Friday, April 19, 2013

The locked inpatient psychiatry unit: What’s it really like? (KevinMD, 4/19/2013)

As I walk onto any one of the locked psychiatric units at our hospital I am immediately struck by the hum of intense activity. It’s like the startling feeling of stepping out of an air-conditioned apartment into the steamy height of a New Haven summer. Across from the nurses’ station, a psychologist interviews a patient retelling the story of constant childhood molestation as rivulets of mascara run down her cheeks. A confused nineteen-year-old man recently diagnosed with schizophrenia talks to an unseen critic telling him he should just “end it all.” In the heavily-fortified clinical station nurses enter vital signs, psychiatric technicians rapidly discuss overnight events and psychiatry resident physicians like myself collect all this data in order to present our patients’ clinical profiles on morning rounds.

While this bustling environment might suggest a power differential in which patients are at the mercy of their treatment providers, such an interpretation could not be further from the truth. The days of psychiatrists wantonly admitting patients against their will has been replaced with a legal procedure that firmly puts patients’ rights first. The question of whether a patient possesses “psychiatric disabilities and is dangerous to himself” is reexamined daily to ensure that the patient can be treated in the least restrictive environment possible. Just as the patient’s commitment criteria are constantly being reevaluated, long-term management strategies run alongside. Psychological and pharmacological therapies are used together to stabilize patients and transition them into outpatient treatment where their long term psychological needs can be met. Additionally, as many of our patients are in dire financial straits, housing and vocational opportunities are aggressively pursued by the treatment team’s social workers.

Perhaps you’re saying yourself, “This all sounds way too normal. Where are the screams? The shackles? And where, oh where, is ‘Nurse Ratched’?!” These are questions that have plagued the perception of psychiatric inpatient treatment since Ken Kesey’s seminal work One Flew Over the Cuckoo’s Nest and the classic movie adaptation. Certainly the screams occur. I wish I could say there weren’t situations in which patients need to be forcibly restrained. However, these events happen far less often than might be expected.

Just as our colleagues in surgery and emergency medicine note that fiction wildly dramatizes certain elements of their fields, inpatient psychiatry is also a victim of such inaccurate portrayal. In fact, much of inpatient psychiatric care involves a lot of routine work, like any other medical unit. We admit patients, treat them, and discharge them. That’s not to say incredible things don’t happen, of course. The reality of a locked inpatient ward is less outwardly dramatic than fiction but perhaps even more potent. True transformations occur during psychotherapy, medication management sessions, and art therapy classes. When a patient who has been kicked around his entire life finds an empathic ear, the click of connection is almost audible during a session. When just the right medication or psychological therapy falls into place, the heart and soul of inpatient psychiatry emerge. These moments don’t photograph well and similarly don’t move books or sell movie tickets. Pictures of cruelty sell better than the truth, unfortunately.

Despite the well-worn image of the inpatient made into a zombie by mind-numbing agents, I’m pleased to say that our patients, on balance, do well. And they are doing better with every passing year. Emerging medications have made patients’ lives outside of the hospital less encumbered by severe side effects such as drooling and confusion that previously served to isolate and stigmatize. Long-acting forms of our medications have been developed to help patients who are unable to manage having to take pills on a consistent basis. While celebrity rapid-detoxes and costly boutique psychotherapy treatments seem to command widespread interest, I am more excited to hear everyday people tell me that they have been admitted to an inpatient unit during a crisis and our now able to return to the satisfactions of life and work while managing their illness through a combination of therapy and medications. Although images from Cuckoo’s Nest and the like persist in the minds of many, I think the future holds an intense change in perception of the inpatient psychiatric ward. As our government has now recognized the increasingly high cost of lost productivity due to mental illness, perhaps the average inpatient stay will increase, the funding for outpatient care will similarly climb, and patients will have a greater shot at wellness. Such an outcome may not make for a great movie but is high drama nonetheless.

This piece originally appeared in HUM Magazine.

Sunday, April 7, 2013

The Liberal Arts: Stealing from Peter to Pay Paul (Hum Magazine, April 2013)

“You know, we don’t need a lot more anthropologists in the state. It’s a great degree if people want to get it, but we don’t need them here. I want to spend our dollars giving people science, technology, engineering, math degrees. That’s what our kids need to focus all their time and attention on. Those type of degrees. So when they get out of school, they can get a job.”
 -Florida Governor. Rick Scott  (The Marc Bernier Show, 10/11/2011) 

Since late 2012 to present, Mr. Scott, pursuant to his statement above, has been pushing the Florida legislature to consider freezing state university tuitions for three years in “strategic areas” based upon supply and demand in Florida’s job market. Effectively, this means that the tuition burden for those obtaining degrees in science, technology, engineering and mathematics (STEM) would remain stable while the tuition for those choosing liberal arts degrees (such as anthropology) would climb to fill the financial gap. In other words, under his proposal, a liberal arts degree would be more expensive than a STEM degree.

Despite having pursued a STEM degree myself, I am perplexed by this logic. I knew that by going into medicine I would be well compensated; shouldn’t I have paid more than my liberal arts colleagues and not the other way around? As a psychiatrist-in-training I am confused in other ways: how am I to understand the underpinnings of behavior without the work of anthropologists? How am I to appreciate the depths of human misery without the work of those who have devoted their lives to literature, the stage, and the screen?

I can imagine Mr. Scott’s reply, “I’m not saying the arts aren’t important. But we only need a dozen musicians to fill our iPods, a few artists to deck our walls and a handful of actors to grace our stages. So why are we investing in so many?” The reason is this: art, like science, is not based on a one-to-one ratio. Investing in one artist or scientist does not translate into a piece of work that “legitimizes” the funding. Artists and scientists alike all stand on the shoulders of those who came before. The Beatles did not create Sgt. Pepper’s Lonely Hearts Club Band by themselves. John Lennon and Paul McCartney were informal students of American blues and rock luminaries upon whose work they built their own masterpieces. Similarly, Albert Einstein’s photoelectric law was not a singular creation but rather a work deeply influenced by Max Planck’s quantum theory developed years earlier.

According to Dale Brill, who chairs this task force on academic funding, when it comes to liberal arts majors, “There will always be a need for [liberal arts graduates]. But you better really want to do it, because you may have to pay more” (Sun Sentinel, 10/12/2012). Given the similar nature of artistic and scientific progression, such a proposed funding structure reeks of hypocrisy. If there will “always” be a need for liberal arts graduates, then why are we disincentivizing their education? The answer lies between the lines of Mr. Brill’s policy: while we need the liberal arts they are inherently less valuable than the sciences.

Bizarrely, despite his overt support of producing STEM students, Mr. Scott fails to address what actually happens to STEM majors while in college. According to a study released in October 2011 by the Center on Education and the Workforce at Georgetown University, 60% of STEM students end up leaving the major prior to graduation. This figure begs the question: if these careers are so lucrative and necessary, why are students switching? Elaine Seymour’s and Nancy Hewitt’s Talking About Leaving: Why Undergraduates Leave the Sciences (Westview Press, 1997) established that poor teaching was found to be the most significant factor. The Wisconsin Center for Education Research is currently working on a study entitled Collaborative Research: Talking about Leaving Revisited: Exploring the Contribution of Teaching in Undergraduate Persistence in the Sciences in order to further address the issue. The Wisconsin group posits that a mere 10% reduction in the transfer rate of STEM students would produce three-fourths of the one million STEM graduates that President Obama announced last year as a goal over the course of this decade.

I do not believe that Mr. Scott has a grudge against the liberal arts. I think he, in good faith, is searching for a solution to the problem of our lack of STEM graduates to fill the increase in STEM jobs. He is looking to bolster Florida’s economy and incentivize the pursuit of a college education in an era when tuition has spiraled out of control. However, his approach is at best merely shortsighted and at worst completely unnecessary. While using financial resource allocation to incentivize STEM majors may create more STEM students in the short-run, research suggests that these students may not even graduate with these majors and therefore fail to fill STEM jobs in the long-run. The solution to this problem lies in a reallocation of funding which reaps rewards on a much longer timescale but with a far less headline-capturing strategy: revamping the ways that we educate those students already motivated to pursue STEM majors so that we can bring them to graduation and subsequently into STEM careers. Unfortunately, investments in improvements in teaching style frequently requires a large investment up front with long-term rewards only reaped long after the lawmakers who championed them are out of office.