stubborn goats

With frustration, I learn to practice acceptance and compromise.

Context:
I chose medicine not for fame and fortune. Sure it crossed my mind several times that it would be a financially secure career path, but only in the setting of a strong desire to take care of my parents when they are older. Anything above that is cherry on top.

So when I meet/work/come across people that blatantly tell me that their primary goal in medicine is having power and influence through the development of specialized knowledge, it is jarring. I understand the important of legacy…after all, I work with patients on a daily basis in which when their health turns south, hospice talks can consist of what we desire to leave behind. However, when this goal is combined with domineering phrases and minirants about how having knowledge puts you at an advantage over others, it’s a bit uncomfortable to me. I think it’s just worrisome to me to think of physicians (or soon to be physicians) that seem to crave the power dynamics of the medical world. I’ve never been one to back down from an argument but I also know when to step back to try and understand where someone is coming from. That’s just who they are.

Nonetheless, stubbornness is different than perseverance and I hope that people realize that the beauty of medicine is that you will never know everything and you’ll always be learning. And that’s why I love it.

cyclic thoughts in primary care clinic

A repeat patient in clinic reminded me of how much I enjoy continuity. That sense of familiarity that comes with seeing a person, getting to know what their issues are, and then seeing your recommendations take effect. Not only do we touch base on health concerns, but life events too. Did you end up enrolling in those math classes? Are you still staying with your friends? I enjoy learning the details of a person’s life that makes them who they are. My initial draw into medicine was for the stories.

However, the back of my mind rings with frustration. I am given half an hour with my patients, more than most primary care clinics offer to their physicians. The VA system is generous that way. 30 minutes to combed through health problems lists long, yet each one so important. But there’s an understanding that this is “med student” clinic. The exception rather than the norm. In the real world, I’d be working with 10/15/20 minute time slots and piles of insurance forms. How realistic is my experience here? How cynical have I gotten…

“Internal medicine is intellectual masturbation”, one of my physician mentors told me today.

A crude but accurate terminology that lets me reflect on why Internal Medicine has been such a fascinating specialty to me. My inpatient internal medicine experience can be sold as the “core” of medicine easily. Patient gets really sick, they go to the hospital where if they get admitted, they see a team that closely manages their care, they get better (finger’s crossed), and then they leave. The doctors that help them in the hospital that they see the most? Internists. But when a person thinks of medicine at it’s root, is it the internist we think of? Or the family physicians that are reliable, dependable, and….there through thick and thin. Front line of defense. Right?

I struggle with where my passions lies and as I go through with third year, I am utterly swayed by every specialty I come across. I loved loved loved surgery. The operations! The technical skill! I loved loved loved internal medicine. The complexity! The management and detective work!

Now what?
Who am I?
What do I do?

As I continue learning medicine, I guess I’ll learn more about myself.

I’m writing my personal statement for Surgery and I wrote this paragraph. I took it out because I’m already in medicine and should be focused on why surgery instead but I thought it’d be a good post here for future’s sake 🙂

Act I. During college, I wanted a career that was not only highly dynamic and intellectually challenging, but also allowed me to serve every population I came across. I harbored an innate desire to reach across cultural barriers and build trust with someone whilst working toward a common goal: their health. This most likely developed from my upbringing. As a child of immigrant parents, I understand the complexity of cross-cultural care and the barriers that often arise between patient and physician. I knew I could make a difference with my cultural and bilingual background. Medicine ended up being a field that satisfied my thirst for knowledge, my dedication to service, and my love for the intricacies of the human body.

“Not just a methadone clinic” – How ETS has flourished

Evergreen Treatment Services is located on Airport Way in Seattle’s SODO district, close to many of the homeless encampments along the busy I-5 corridor. It is an obscure building with a faded awning in the front. When I arrived at 3PM (after dosing hours), the inside of the building felt like a cold maze, with areas sectioned off with crowd dividers. I met with Michelle Peavy, a psychologist at ETS, who told me about the history of the program. It has been around for over 70 years and serves over 1300 clients, with more than 40% of those clients being homeless. It predominantly serves as a medication assisted treatment provider, handling both methadone and buprenorphine prescriptions. Clients can come in at various time day, check in, and line up to go into a small and private room where they receive their daily dose from a dispensing window. During check-in, a screen will tell them if they need to leave a urine sample or not. Michelle talks about how the program recently started prescribing buprenorphine and methadone regardless of whether the patient is using other medications or not. This approach is based upon the philosophy that it is better to have points of contact between provider and patient rather than none at all. The daily dispensing of medication is an intersection point that is a valuable opportunity to reach out to the individual and “check-in”.

There are also additional resources available for patients. There are psychologists on site that do peer-to-peer counseling, an approach that Michelle feels is more effective than group counseling. There are also weekly health clinics on-site, staffed by physicians from Harborview Medical Center. During these clinics, patients can be screen for HIV and hepatitis C. If positive, patients are hooked up to a treatment program and in the case of hepatitis, they can receive their weekly medications at the site.

An interesting resource ETS provides is their acupuncture room. Although Michelle is unsure if the approach is evidence-based to help with substance use, she believes that the quiet relaxing room provides a type of “getaway” from the chaotic lives that some of their patients have. Many patients report feeling decreased stress levels and less cravings with these treatments.

I appreciate that ETS provides something of a “one stop shop” for those who are on medication-assisted treatment programs. Their bare-bones building may not look like much, but that was their goal- to not stand out as a treatment facility, but to normalize it.

Assisting mothers and babies: PCAP + Swedish Hospital’s Inpatient Addiction Program

Parent-Child Assistance Program (PCAP)

The Parent-Child Assistance Program was started in 1991 in the state of Washington as a pilot project to help substance-abusing mothers build healthier support systems and obtain resources that will enable them to maintain healthy independent lives. This is done through a “home visitation case-management model” in which mothers are paired with a case manager who will serve as their advocate. PCAP helps mothers obtain alcohol and drug treatment, stay in recovery, and work through issues related to their substance use. There are currently 12 sites in Washington with talks of expanding to 15 sites in July 2017. The King County site is one of the largest sites and I was grateful for the opportunity to meet with its site supervisor, Charlene (Lena) Takeuchi who has been with the program for over 18 years.

The KC site recently moved to a simple office building off Lake City’s busy Aurora Ave. As a result, the location is still working on unpacking and making it feel like home. Upon entering, there is a living room-like area filled with toys for all ages to welcome the families. There is a computer for mothers to use if they need to access any materials. It’s a simple setup where they meet with case managers to talk about their situation, but I imagine that most of the magic occurs during these interactions. The site’s most important possession is a whiteboard that shows where the case managers are for that day if they are out in the field and what vehicles they are using. Lena stresses the importance of having her case managers check in every couple of hours so she can make sure they are safe and accounted for.

Lena and I talked about the logistics of the program and the difficulties they have encountered. A lot of the women have significant trauma, either from family, friends, significant others, or the shame associated with substance abuse and pregnancy. This prevents them from seeking a lot of the care they need. She recalls a patient who was successfully enrolled in a treatment program at Swedish and on the day they had sent an advocate out to pick the patient up, the advocate was late. This led to the patient becoming worried and deciding to opt out of being admitted to rehab.

It was clear that PCAP has made an amazing amount of progress is gathering data about the role of traumatic events and substance abuse in pregnancy. This allows for continued funding as well as policy changes to help these mothers get the help they need.

 

Swedish OBGYN Chemically Using Pregnant Women’s Program – Ballard Campus

Swedish’s OBGYN treatment program specifically focuses on admitting pregnant women with substance use. It is led by Dr. Jim Walsh, an efficient yet compassionate and empathetic gentleman who entered the field of addiction by opportunity and chance. Having visited PCAP the day before, I was told that Dr. Walsh is an amazing presence in the field of OBGYN and addiction and is a valuable asset to the community.

The setup of the program is unique. For inpatient treatment, there are only a certain number of beds available. They prioritize women who are later in their gestational age and are at higher risk of having complications. During inpatient treatment, women eat together in a communal dining room, do several recovery classes together, and are given medication-assisted treatment. Dr. Walsh stresses the important of having medication-assisted treatment and points out the overwhelming evidence the shows that it works. He has seen countless times that simply believing in yourself (“having confidence”) is not enough because the stigma against those who abuse drugs during pregnancy is so strong that it often leads to isolation and relapse. He believes the program works because they take provide a supportive non-judgmental environment for women who are undergoing similar circumstances. This is particularly important in recovery groups when having someone who is not pregnant discussing their substance use disorder can make those who are pregnant feel more ashamed of their actions.

Swedish also has an outpatient drop-in clinic for those who are undergoing substance use but are not of high risk enough to be admitted. The clinic, located on Swedish’s First Hill, is open Tuesday afternoons and is fully staffed to provide treatment care. Here, women can learn about resources such as PCAP and look into addiction treatment programs that may be available to them in an outpatient setting.

When asking about how women find out about the Swedish program, Dr. Walsh talks about the close-knit community of women and the power of word of mouth. As someone who is interested in Family Medicine, OBGYN, and community health, I hope that this program at Swedish is still around when I am practicing so I can also recommend it to others.

Creating community at the RecoveryCafe

As Seattle’s hypergentrification continues, a plain brick building on the corner of Denny and Fairview sticks of like a sore thumb with it’s plain brick façade against a glass and steel building complexes. The RecoveryCafé serves as an oasis for the recovering addicts community in a city that is building a new wall every other second- physically and metaphorically. The café strives to be an “alternative community” that celebrates sobriety by providing community base, non-religious but spiritually-led care. Its format is similar to a community center where people who are in recovery can become “members”. As a member, you are served 2 meals a day buffet-style, a variety of classes ranging from yoga to painting, computer and phone access, and the opportunity to enroll in classes to learn how to be a barista or yoga instructor. The only requirement to continue membership is to attend a recovery group (Recovery Circles) once a week in which you discuss your progress on maintaining sobriety or path towards sobriety. Additionally, members are required to be sober during the time they spend at the facility.

I met with Carolyn, the program manager, who gave me a tour of the cafe. It is a bright and warm one level layout with certain areas designated as living room space(books and couches), a media center with computers and printers, and a café in the middle with tables surrounding it cafeteria-style. Off to the side is the kitchen where volunteers are using whatever they received that day from local food banks and restaurants to prepare over 200+ meals.

The RecoveryCafé focuses on creating a space that focuses on building community and support. Using the Recovery Oriented System of Care (ROSC) model, they acknowledge that the pathway to recovery is different from individual to individual but the common thread is that most people are unable to do it alone. Carolyn has been at the café long enough to know individuals on a first-name basis and their personal stories. She encourages sharing and support between everyone and states that an essential part of Recovery Circles is giving feedback to those around you. I attended an orientation session led by Jason, the Director of Operations, in which new members were given an introduction as to what the RecoveryCafé could do for them. Members at the table came from a variety of socioeconomic backgrounds, different stages of recovery, and different levels of familiarity with the RecoveryCafé. Post-orientation, I talked to Jason about his philosophy towards medicine and it boiled down to “building support so individuals can be self-advocates”. He has a history of substance use himself and brings personal experience to the table in understanding that recovery alone is an extremely difficult pathway. He hopes that the relationships made here will at least serve as a constant in the often chaotic lives of those who walk through their doors.