Sanity vs Insanity, Part II

During our lecture today, we spent a long time discussing the paper I wrote about yesterday. It was a great discussion, led by an instructor who's obviously used this paper to teach his points for years. I'll see if I can recap a few of the different views I now have about the paper.

1) (This analogy was given by the instructor) If you were to walk into a neurologist's office and complain of crushing, throbbing unilateral headaches accompanied by photophobia and phonophobia, and you were to be admitted to a hospital for workup, at the end of which they found nothing wrong with you, and you had no headaches in the hospital (and indeed, never had headaches), wouldn't their diagnosis still be migraine? And if they found you out to be lying in the first place, wouldn't their diagnosis be malingering? So, if you come to a psych ward and lie about your symptoms to get in, then have no more symptoms inside, you are actually technically meet a diagnosis of malingering. Therefore, instead of "sanity versus insanity", what we're actually having a tough time diagnosing is "psychosis versus malingering", which apparently is true. It's pretty easy to fake psychiatric symptoms (Oh, I'm hearing the voices now!) and then when you get what you want, not hear them anymore. I worked on a "forensic unit" in a psych hospital, which accepted patients from the local jail. It was amazing how many of them heard voices in jail, but not in the hospital, at least not until the night before they were to be discharged.

2) The study really isn't very rigorously scientific. It is, however, a fascinating social experiment, which I think still renders it valid. It also gives us fascinating insights into the treatment of patients within a psych hospital, which were some of the most appalling points of the paper.

3) Today, you would not likely be admitted just for saying "I hear voices." 35 years ago, the diagnostic criteria for schizophrenia were much broader. I'm still not sure why that symptom alone was enough to get all these people admitted--a patient needs to be unable to take care of themselves, or decompensating rapidly, or a danger to self or others usually to be admitted like that. Maybe that's a difference with time? I'm not sure.

4) The author's claim that the pseudopatients acted "normal" in the psych ward wasn't entirely true. They never told the doctors they'd lied, they never told anyone they were in an experiment, etc. As far as the doctors and staff knew, these patients had honestly heard voices (eg, exhibited psychotic symptoms) and were currently asymptomatic. The doctors weren't given all the information, and certainly psychotic patients can hear voices one day and not the next.

5) Finally, the author's conclusion was essentially that the category of insanity is bogus because we can't reliably tell it apart from sanity (although he really meant we can't tell psychotic from non-psychotic). Is hypertension a bogus diagnosis, even though you might get a reading that is 135/85 and some books say "normal" and others say "pre-hypertension" and others say "hypertension", and some authorities urge you to treat it and others say don't worry? (I exaggerate in this example, but you get the point.) I personally think, and thought yesterday, that he's throwing the baby out with the bathwater, so to speak. Perhaps it's easier to recognize abnormal, maladaptive behavior in the "sane" world than vice versa, but this is the world most of us live in, where such behavior gets us in trouble.

The important take home points of the article, according to the instructor (and I touched on this briefly yesterday, but not in a very organized fashion):

1) It's very important to have reliable categories of diagnostic criteria that lead to valid predictors of outcome (which was the point of the lecture).

2) The second experiment, where the doctors rated whom they believed to be pseudopatients, likely shows either a high rate of malingering patients or a high rate of very high-functioning patients (or both) who weren't particularly bothered by their symptoms, although that begs the question why were they in a psych hospital.

3) The way patients were treated by staff was a valid observation by the pseudopatients. They were able to take detailed notes without anyone caring, because they were believed to be crazy. They were able to document abuse by staff of some of the patients, when said abuse would stop when physicians entered the unit, because they were not "credible witnesses"--after all, who'd believe a psych patient? They also experienced the depersonalization that happens on a psych ward--there's little to do but watch TV and wait for meals, you're not in your own clothes, you can't go to the bathroom in peace because there's often no door, you can't have your own belongings with you, and your room and personal items may be searched at any time. Also, the segregation of staff and patients holds true today, for sure. Most of us get a little prickle of fear the first time we walk into a locked psych ward. After all, if we lock them in, these guys must be dangerous! But how, then, do we strike a balance between keeping the patients safe (and keeping those few patients who are dangerous safe) and allowing personal freedom and rights?

It may sound like a non sequitur, but I'd like to conclude with an observation I made in China in a locked psych ward. The air was fresh, because small windows were open to allow air circulation. I'm not sure if the building had central air conditioning, as the majority of buildings in Beijing did not. It was just so refreshing to enter various hospitals and find open windows allowing in fresh air. In America, I doubt there's more than a handful of psych hospitals that have windows which open. As a result, the air quality on most psych wards is ridiculously stale--rather like the jail I worked in last year on OB. The air in this Beijing psych ward was fresh (or as fresh as air in Beijing ever is!) Perhaps one small difference we could make for our patients is a little fresh air. After all, they're not inmates (usually), they're just people with problems that they wear on the outside where everyone can see them, as opposed to inside.

Chinese Medicine

This is the essay I turned in to complete my China rotation. It's a little long, and wordy, but hey, that's me.

I really didn’t know what to expect of the Chinese medical system. Consciously, I didn’t think much about it; I was more concerned with what I needed to pack for a month overseas than what I would actually do when I got there. Subconsciously, however, I think I had more stereotyped ideas. China is a Communist country, and that brought up sensations of drab ugliness, poverty, dirtiness, and an inability to change. After all, I was raised during the Reagan era by Republican parents, and I think I internalized some of those expectations. I know I carried some of those stereotypes to China because I felt surprise when I entered the first few hospitals; even though I thought I hadn’t expected anything, they weren’t what I expected. During the month, we saw so many hospitals in so many specialties that I not only changed my expectations, but I can actually compare my experience in China with my American medical education and draw some conclusions.

The first hospital we visited, T, was known for neurosurgery. Our first morning at T we visited the operating rooms. I was surprised that the inside of the OR looked like any OR in the States. The CT and MRI films on the wall were high resolution; the anesthesia cart looked familiar, and the surgical equipment was advanced. In fact, the only shocking thing in the OR was the appearance of OR sandals (we were all given pairs ourselves), which seemed dangerous (OSHA would have thrown a fit).

In the afternoon, we visited the wards, where the difference was much more striking. Each room held eight to ten patients, plus several family members for each patient. There were no curtains or privacy walls, and the restrooms were down the hall for the use of the entire floor. They appeared to be less than sanitary. Each patient had a water jar or a baby bottle at the bedside; I assumed the baby bottles were for patients who were bedridden and couldn’t sit up. Each patient had a folder at the foot of their bed containing their films, which we could go pull out and examine at the bedside. Patient privacy laws must be less stringent than HIPAA, because we would discuss the case in the room in front of all the other patients and all the families.

The next day at T we visited the ICU. The ICU attending was very interested in American end-of-life ethics, and we talked for quite a while. We gathered that there are a limited number of ICU beds in a Chinese hospital, like ours, but they don’t seem to have LTACs or other places to send patients needing high-level care, so those patients simply remain in the ICU. Then, the family takes ultimate precedence over what happens with the patient. Thus, if a physician wants to transfer the patient out of the ICU (I assume because care is futile), the family may request that the patient stay. Every bed was full while we were there, and he seemed upset that families may request a patient to remain in the ICU even while other patients need that bed more. This is a situation that is at least similar to ones most of us have faced in the States, as there are never enough ICU beds for everyone who needs them (or so it seems). It did seem, from speaking to that attending, that few Chinese have any kind of DNR or Power of Attorney paperwork (or family discussion), which complicates the situation.

The most interesting difference is that they recognize brain death, but it is not a legal criteria of death. Therefore, if a patient is brain dead, they still have to convince the family to remove life support, whereas in the States (at least in those states that recognize brain death without qualifications) once those criteria have been met, that patient is legally deceased. Life support is withdrawn because the patient is not alive; it is a different situation for us than a patient in a vegetative state where life support is withdrawn from a patient who would continue living on it. I remember how much relief the brain death standard gave to the physicians when I was on neurology, because there were no tough decisions to make at that point; the patient was brain dead, therefore they were dead. It was much harder if the patient retained one brain stem reflex but otherwise had no cortical function, because then the family must make a terrible decision. All in all, the situations doctors face in ICUs regarding end-of-life are fairly similar in China and the United States.

At F Hospital two weeks later, another interesting situation arose. We were rounding on general surgery patients, and we met a patient who had arrived at the hospital with a small bowel obstruction. A CT of her abdomen showed a large sigmoid tumor which had caused her obstruction. As we took her history (translated through the resident), we asked if she knew her diagnosis (since we’d seen her case presentation before examining her). The resident explained that she had not been told, as most patients with cancer did not want to know. We were all shocked. Then who makes decisions? The resident replied that her family would be told of the diagnosis, and they would make decisions in her case. This was totally foreign to us, and several students were made very uncomfortable by this situation. Next, we examined two women with very large breast masses (in front of the other seven patients in their room), one of whom had large palpable nodes in the axilla. We asked the resident if these women knew their diagnoses. He replied yes, because it is “more obvious” when the problem is in the breast. All of us in that group have read the case in ethics where the family requests that the patient not be told her diagnosis, and the correct answer is of course to ask the patient how much they want to be told. When we asked the Chinese residents about this, they were puzzled; why would the patient want to know? I think they were easily as confused by our views as we were by theirs.

The biggest difference between our health care systems took the majority of the trip to elicit. We asked this question at every hospital, of every resident and attending, and received varying answers. Finally, at A Hospital at the end of our third week, a cardiology attending answered our question in a startingly truthful manner: what happens if the patient doesn’t have insurance and can’t pay? Answer: they don’t receive treatment. She was incredibly honest with us. She told us that even acute patients having a STEMI come to the emergency room and are required to pay for their stent before receiving it. If they do not, most hospitals can/will do nothing, so that patient simply does not receive treatment. If the patient has no means, the family will be pressed; this might work better in China than here because the family structure is very tight. As one might imagine, demanding cash up front delays the time before the patient goes to the cath lab, which had been confirmed in studies this attending had helped conduct. Now, in the States, money is a huge issue in our medical system, and I have watched many back-boarded, c-collared patients in the ER trying to sign insurance forms held above their heads while they lie flat on their backs. However, because of the EMTALA law, if a patient is in need of emergency care, they will receive it (at any hospital which receives Medicare funds). A truly private American hospital might refuse to stent an uninsured patient, or deliver their baby, but most hospitals are bound by EMTALA. China does not seem to have such a law. The hospitals we visited in China were all public hospitals (there are some private hospitals), and surely a public hospital should be required to treat the public (at least in my understanding of the word).

The Chinese system is much more capitalist than ours regarding payment for service. Much of the work American hospitals do is unpaid; in China, that hospital must receive a fee for their work. The fees charged are very low by American standards, because we tend to float the unpaid bills off those that are paid. So the price of a blood test is several hundred dollars, because the hospital will not be paid for everyone’s test. In China, the fee is lower, but everyone has paid for their test. In our system, we’re running into escalating costs because of the price of paying for the uninsured (among many other things); in theirs, their population just keeps growing. Rural areas are terribly underserved there (as in America, only worse), so there are always more patients who need the care than there are hospitals or doctors to care for them, but on a scale that most of us could not comprehend. After all, our system administers to 301 million people; theirs, 1.3 billion. Our system is overloaded; theirs must be bursting. Is it any wonder that we saw many paying Chinese patients receiving “extra” tests because those are cash tests? Of course, that kind of thing happens in the States, too, but we call it fraud. There, it was normal.

Overall, I learned many things about the Chinese health care system, and by contrast, many about our own. I saw the differences between Chinese and American medical education, and I am very glad I don’t have to learn medicine in Chinese (but Chinese doctors have to learn medicine in English). I learned a bit about Traditional Chinese Medicine, if only enough to know the terms to look up for patients in the future. I witnessed a living example of an ethical situation that had been only abstract until then. The Chinese system would be an excellent system to study here in America in the near future, when our health care system will be scrutinized and changed after the presidential election. Whoever is elected, I hope they can take some of these lessons to heart, because their system modeled interesting features of both capitalist and socialist health care systems, and in some cases, the worst features of both. Perhaps the most important thing I learned, though, was how similar our systems really are—far more alike than different. I’m much more conscious of my beliefs about the Chinese health care system now, and I’m no longer surprised by what I saw there.

Home Again, Home Again, Jiggety Jog

My plane arrived home today after an 11 hour overnight train ride from Xi'an to Beijing, an 11 hour flight from Beijing to San Francisco, and a 5 hour flight from San Francisco to the Gulf Coast. It's now 8:39 pm here, but my body kind of thinks it's 9:39 am tomorrow morning in Beijing. I didn't really have jet lag too badly on the way to China, but I'm so confused right now I'm amazed I'm typing. I will shortly go to bed and pass out, and hopefully wake up when tomorrow is truly tomorrow, not some strange half day where the sun sets and rises but the date doesn't change.

It was a great trip. I'm thoroughly sick of Chinese food, and I'm sooooo happy to be back in my house, with my own soft bed, my own clean Western toilet, unlimited toilet paper, clean hand towels, and soap (all luxuries). In the airport, I could actually read all the signs, and understand the directions of the officials guiding me through multiple lines of Customs checks and security searches. You get homesick for little things you didn't even think about.

After leaving the airport, we drove immediately to a mexican restaurant, where I had (in this order) iced tea, a margarita (on the rocks, no salt), chips and salsa and queso, enchiladas (chicken and beef) with refritos and rice, and vanilla bean cheesecake. Every bite was heaven.

I now speak a few words of Mandarin. I can say hello (nihao), thank you (xiexie), how much is it? (duao shao chen?), count to three (ee, er, sun), this and that (jega and nega), doctor (ishung), please (ching), and you're welcome (bu ku chi). (All spellings are TS-ized pinyin and I just made most of them up). It is weird now not to be greeted at a restaurant with Nihao! but I guess I'll get used to it.

Travel is fun, and I really, really loved my month, but I'm so glad to be home.

Hello From Sunny Beijing

I've been having Internet difficulties here, but I might be able to sneak in a short post before going to bed. It's 2143 here in Beijing, and 0743 back home, so I'm having a very difficult time getting in touch with my husband. Email is just not satisfying, but even though my cell phone is working here it costs $2.29 per minute to call home. We've just downloaded Skype but haven't had time where we could attempt calling each other. Ai.

I've already done many of the tourist-y things here, like Tianenmen Square, Forbidden City, and Temple of Heaven. This weekend, we might go to the Summer Palace and the Ming Tombs. And, of course, the shopping. Meccas of cheap goods with fake American or European labels for which you have to barter like crazy. These shopworkers are GOOD. I got taken for an enormous ride for my "authentic" North Face jacket, but I did a lot better on my "Seven" jeans and "Max Mara" short red trench. I'd put in pictures, but my internet connection will not let me upload photos to blogspot right now, which sucks.

We've seen a neurosurgical hospital (very impressive) and a psychiatric hospital (nicer than my county one) so far. Thus far, most of the doctors I've talked with are very well-educated, very smart, and eager to learn from us (and we them). One interesting phenomenon is that most of these doctors very much look down on traditional Chinese medicine--they're not taught it in medical school or residency, and aren't really sure what training those practitioners receive. I think we visit a TCM hospital later in the trip, so I'll learn more. I'll also try to discuss the differences between our health care systems further, but I will say that they are probably more same than different, which is surprising to me.

And now, to prepare for bed, adieu. I would say good night in Chinese, but I can't. Adios, then.