Starting telehealth, and some thoughts on tasks vs. “thinking big thoughts”

After three months working on the inpatient psychiatry unit at UCSF (August – December), I switched to my six-month block of outpatient psychiatry at the SF VA hospital.  I still take call shifts at all three hospitals (UCSF, San Francisco General, and the VA), but now the bulk of my time is spent doing psychiatry by phone and video.  I’m told that the VA system converted its outpatient appointments to telehealth with remarkable speed last spring, in part because it already had a telehealth infrastructure in place (though for much lower volume) including its own video interface (called Veterans Video Connect).  Certainly this expansion of telehealth has allowed us to reach patients who might ordinarily have considerable difficulty coming to San Francisco for an appointment.

For the first time since before the pandemic started I am primarily working from home, and not commuting certainly feels like a luxury.  Another perk: I am far better hydrated than I used to be.  Thus far, I think I am enjoying outpatient work, even through telehealth. It’s too early for me to compare it with inpatient work, so the jury is still out on whether I see myself more as an inpatient or outpatient psychiatrist in future. That aside, I am also finally learning about the downsides of staring at a screen all day, and have wondered how many cumulative hours will be spent toggling audio sources and headphone/earbud connections between different applications.  

I do already miss the casual but fortifying in-person interactions that, during on-site work (which now that has to be distinguished from “work”), happen as a matter of course.  Throughout 2020, I felt lucky to still work on-site, making actual eye contact with patients and colleagues.  During our four months at the General last spring, the spacious resident workroom felt like a college dorm as we each faced a different direction on our computers, but shared commentary and chatter throughout the day, and we bolstered each other through the fear and uncertainty that the pandemic had brought.  By the summer, wearing a mask felt as normal as wearing my ID badge, and when we weren’t speed-walking around the hospital to see patients, my co-resident and I sat back to back in the consult workroom, frequently swiveling to update the whiteboard’s to-do list, reading messages off the pager, occasionally griping or sighing to each other.  In the fall, the inpatient unit sometimes created an illusion of normalcy: as I walked into the unit and interviewed patients I could, for brief moments, forget that we were in a global pandemic, though this illusion was interrupted by the spectre of COVID anytime someone coughed.  The co-resident working next door to me would regularly knock on my door to check in, and we turned the spacious hallway into our water cooler.  Now, these same coworkers are boxes in Zoom meetings or faceless bubbles in a text thread.  It’s not the same.

The past couple of weeks have felt tense, though fortunately I have a light month in terms of call shifts.  I need to sort out my clinic and schedule preferences for the entire PGY-3 year (July 2021 through June 2022).  For the first time in residency, we have some opportunities to choose sub-fields of psychiatry in which we want more training, and this planning task feels daunting.  Intellectually I know that the point of electives is to gain exposure to particular clinical areas, and so our elective experiences can help inform our future career interests.  On an emotional level I am thinking of this the other way around: I feel pressure to decide a priori what my career goals are, so that I can pick the electives that connect most clearly to those goals…but I’m not certain what those goals are. If anything, as I mentioned in my previous post, I feel increasingly aware of how much more I have to learn.

While this has been swirling around in my head, last week I found myself shifting rapidly between telehealth appointments with my patients, talking with a mentor about my academic priorities, didactic sessions during which I was simultaneously on the phone with IT (who was remotely installing some missing software on my work computer via a temperamental VPN connection), and reading news about the recent assaults against Asian-Americans in the Bay Area, including some elderly individuals who look like they could be my own relatives.  I felt the urge to cry several times but was also somehow physically unable to do so until two days ago, when I broke down fuming that I’d wasted half of a Saturday by watching old episodes of “The West Wing” instead of working on various projects that I hadn’t had time to get to during the week.  That cry was cathartic, as was the jog that I eventually persuaded myself to go on.

During my jog I listened to a podcast interview with Celeste Headlee, the author of Do Nothing: How to Break Away from Overworking, Overdoing, and Underliving. Headlee talked about on our society’s increasing prioritization of efficiency, which certainly rings true in that I’ve lost count of how many times I’ve said to an advisor or supervisor that I’m trying to work on being more “efficient” (generally meaning that I want to get faster at reviewing patient charts and writing clinical notes). The irony of listening to this interview while exercising (so efficient!), after I had berated myself for doing nothing during a weekend day during my residency training, was not lost on me.

The interview also mentioned the distinction between checking off checkboxes and doing work that actually moves us toward a goal and/or aligns with our values.  This continues to be a point of tension for me.  I will always be one of the first to stand up for the importance of task completion, and it matters to me that I am conscientious and organized in my work. Part of why I like inpatient work is that it is a complex dance between countless individuals in different roles and departments, whose individual efforts (and checkboxes) all weave together at a rapid clip.  It’s often the resident’s job to get a large number of tasks done in a small amount of time, tasks which are clearly necessary in order to move the patient’s care forward.  So we write the notes, order the labs, follow up the results, call the nurse, call the other team who paged about X, page someone else about Y, order the medications, get a page about the orders, change the orders, call someone to let them know we changed the orders.

As a medical student, learning to complete some of these tasks was a big part of each clinical rotation, and could provide plenty of gold stars, little dopaminergic reinforcements that could easily be interpreted as signs that I was a good fit for that particular specialty.  At some point during my third-year clerkships, though, I came to recognize that there was a difference between feeling satisfied by task completion and feeling satisfied (or intrigued) by the actual medicine that those tasks were intended to implement.  I had great experiences on many clerkships, but in the end what tipped me toward psychiatry was that nearly every day on that rotation, I felt a sense of fascination. Eventually, I expected to get good at checking off the checkboxes in my work.  I believed that once this happened, I would still need to be compelled by the particular type of doctoring in my specialty: getting to know that specialty’s patients, their backgrounds, and their clinical presentations; and thinking through the specialty’s range of diagnoses, differentials, and treatment options.

Sometime in the past six months, I think that transition happened for me. I got comfortable enough with the tasks that merely completing them stopped being anywhere near enough, that in order to feel satisfied with my work, I needed enough of the actual doctoring. I’ve been reassured, if not surprised, to find that even without the same amount of dopaminergic feedback from checking off my checkboxes, psychiatry definitely still feels like the right choice: it is still fascinating, even more so now that I’m 19 months into residency.  At the same time, I am also even more aware now that there are often so many tasks, and getting through them can be so burdensome at times, that what gets shortchanged is the actual doctoring, as well as the bandwidth for fascination and for what one of my attendings refers to as “thinking big thoughts.”  It is frustrating and even angering to realize that because the healthcare system sometimes requires me to perform so many tasks, time spent with a patient is often shortchanged. I doubt anyone ever went into residency thinking that they would have great work-life boundaries or plenty of free time in which to ponder, but I still chafe at the realization that often, time spent thinking deeply about how I am caring for a patient (or thinking about how we should be caring for our patients, or reading and learning so that I can better care for my patients) must be directly deducted from my own “time off.” 

I intentionally used quotations there because, as everyone else has already discovered but I am now discovering with telehealth, the boundary between work and life has only become more porous. I don’t have an answer for this tension yet, and I suspect it’s a challenge that will continue to be present throughout my training and afterward. I also suspect that as long as I have the good fortune of finding the core of my work fascinating, the answer may involve accepting a fluidity of boundaries. I’d like to accept that my efforts at efficiency and optimization drive me to try and optimize my so-called work-life balance, but that this optimum only exists as an unattainable abstract.

Some thoughts on C/L, performance vs. growth, and “pager anxiety”

At the start of October I switched from my three-month Consultation/Liaison (C/L) rotation to the Adult Inpatient Program rotation, which will run through the end of December.  I found the C/L rotation challenging in multiple ways.  There was so much interesting psychiatry that I got to see and learn, with many clinical situations I hadn’t encountered previously, and I admit that there was a certain level of excitement that came with the pace of the service.  At the same time, I had to come to terms with the fact that I really don’t like to work at the behest of a typically-busy and always-unpredictable pager, and I very much don’t like to feel rushed.  

As an example of unpredictable and rushed: one afternoon the service pager stopped working without us realizing it.  Fortunately there was a workaround that involved forwarding the pager number to a personal pager.  But after the service pager got reactivated the next day I simultaneously fielded pages—including a couple of “We tried to consult yesterday but never heard back” calls—while exchanging emails with IT to figure out why the pager had stopped working in the first place.  Put another way: I found this work quite stressful.  There were more than a handful of nights where I woke from a vivid dream that I hadn’t finished a note or clearly signed out a to-do, and would have to convince myself that it had simply been my anxious subconscious and not an actual daytime lapse.  

It’s not that I didn’t have enough support or encouragement during this rotation; in fact, I was grateful to receive feedback that I was adapting to and handling the work well enough, and I discussed my qualms with both faculty and older residents.  But on a deeper level, my anxiety in trying to adapt to this workflow still made me question my own competence.  I intellectually understood that it was ok if this particular style of work wasn’t “my thing,” and that it was ok if I didn’t feel a sense of equanimity (to say nothing of mastery) when holding the consult pager.  Realistically, how could a resident at the start of their PGY-2 year be expected to have or feel mastery over anything in their specialty?  But I was afraid—and when on a call shift, especially, I am still afraid—that if I were to become overwhelmed, I would make a mistake that would affect patient care, or would not get everything done during my shift and would need to sign too much out to the next resident, or would need to stay far too late to finish my work.  What this all adds up to, in my head, is that I might be insufficiently efficient or effective, that I might be the weak link on my team.  I think that at the root of my “pager anxiety,” a fear of being overwhelmed connects with a fear of failure.

At some point in the past I read that residents go through several stages of growth which I loosely recall as 1) not knowing how much they don’t know; 2) knowing more than they did at the start but also realizing how much more there is to know, and so feeling discouraged and less confident than they should feel; 3) thinking they know more than they actually do; and thus feeling overconfident in their knowledge/abilities; and 4) realizing that they know a certain significant amount, but balancing that with the need for ongoing learning, and therefore calibrating confidence more appropriately.  Recently I joked to my therapist that stage 3 sounded nice because I was definitely still in stage 2, and very much worried about how much I have yet to learn.  Six months of psychiatry during intern year and three months on the C/L service felt like a mere scratch on the surface of this enormous field.  

In thinking about my “pager anxiety,” I’ve been thinking about the difference between a “performance mindset” and a “growth mindset,” which was a contrast drawn for us at the start of residency by one of our program directors.  As medical students, it’s impossible to avoid the performance mindset, as we are in fact constantly being evaluated and our future trajectory (i.e. residency prospects) depend in large part on those evaluations.  As new residents, we were encouraged to shift into a “growth mindset,” since we now have the opportunity to focus on patient care and our professional and personal development as clinicians / scholars / scientists / public servants / teachers / etc, without the same pressure of performance evaluations every couple of weeks.  

At this stage of residency, I can certainly look back on the start of intern year and recognize the considerable growth that has occurred, and anticipate much more to come.  I know I am still susceptible to the performance mindset, and on some level I don’t know that I will ever be able to entirely set it aside.  It does matter to me to feel like I am delivering “good” or even “excellent” clinical care, and also that I am meeting or exceeding expectations for my role as a trainee.

But what does it mean to be “excellent” in this work?  Hospital quality metrics aside, I’m starting to realize that on a personal level there is a risk to chasing the feeling of “excellence” if it is tied to a sense of surety, mastery, or ideal patient outcomes, when the very nature of residency training is that we are learning how to do this job, and especially when the nature of psychiatry is that our patients’ presentations and trajectories are multifactorial and often unpredictable.  On top of that, even without the COVID-19 pandemic, the system simply doesn’t allow me (or anyone else) to deliver perfect care.  There are too many patients and not enough providers, and so I simply can’t spend as much time talking with each of my patients, poring over their histories, or pondering their formulations as I would like.  To do so, I would need to routinely work until 10pm or later every night (not even taking into account those call shifts!).  

As such, I have to balance my own high expectations with what is realistic and sustainable.  I have to continue to ask for help when I need it, and to believe that I will continue to become more knowledgeable, efficient, and effective as my training progresses.  I need to keep working to build my internal locus of control and confidence, while keeping faith that my threshold for feeling overwhelmed will continue to rise.

And, if all else fails, the beauty of shift work is that each shift eventually comes to an end, and then comes a time to rest, reflect, and prepare for the next.

Anti-racism check-in

A case vignette I wrote back in the spring, “A Racial Enactment Amid COVID-Focused Anxiety and Mania,” was published this month in Psychoanalytic Dialogues.  The vignette focused on some racially charged interactions and I and a colleague (who is also of Chinese descent) had with a Black patient, “Iris,” in the inpatient setting. The full vignette is behind the journal paywall, but below is the closing paragraph:

Also present was another internal object that is both insidious and impossible to ignore: the reality that we psychiatrists, no matter our own ethnicities, are part of a mental health system with a long history of pathologizing and criminalizing Black anger as a symptom of mental illness (rather than a reaction to centuries of oppression and intergenerational trauma), supporting the shattering of Black families, and over-diagnosing Black individuals with learning disabilities or schizophrenia while underdiagnosing them with depression. This institutional racism continues to haunt our present systems of care, and has understandably wrought mistrust of psychiatry. I may be a well-meaning and even idealistic resident psychiatrist who sought to connect with and understand Iris. However, within the setting of involuntary hospitalization, I represent an institution of racial and social power, eliciting caution, deference, and fear. I am discomfited by two coexisting truths: I am a physician of color whose own ethnicity, especially during the present pandemic, leaves me vulnerable to racial enactments; and at the same time, I occupy a position of privilege and power within a system that can retraumatize patients, even as I seek to treat their illnesses.

One of the [long-overdue] changes I’ve made in my practice over the past few months is that I’m trying to be intentional about naming and validating structural racism (particularly structural anti-Black racism) as a factor in my patients’ experiences, whether longitudinally in their lives, during the past few months in context of national events, or as it affects their relationship with the mental health system.  Some of my patients have brought up race and racism of their own accord, which has led to some unexpected conversations and interactions that were deeply meaningful for me. Sometimes, I have tried to name race and structural racism as being present in the room with me and my patient, and to openly acknowledge my own role within the power structure of the mental health system.

These interactions haven’t always been graceful or effective. The stumbles are real. But, stumbles and all, it feels necessary to continue learning from my patients’ perspectives, and for me to be able to broach the topics of race and the pain of racism as determinants of health. The work continues.

Staying put, for a change

Being on the Consultation-Liaison service feels like everything is in constant flux: a patient list that is different every morning, walking all over the hospital, encountering different clinical questions, and seeing patients with different attendings. Over the course of a day I put on hats ranging from psychopharmacology non-expert (who is nonetheless trying to offer some semblance of expertise or authority), to therapist (for the patient) to therapist (for the patient’s family member) to therapist (for the primary team), to amateur ethicist, to legal hold writer, to student, to teacher, to note-writer, to team manager.  At any given moment, I’m probably trying to wear more than one of these hats.  None is comfortable yet.  One thing that is unchanging is the constant reminder that inherent to residency, and to being a physician, means never getting completely comfortable.  I read once that if I stop feeling all fear or uncertainty, then I need to change something about my job.  Right now there’s plenty of both.

This past week I was on vacation, i.e., staycation.  It started off with several days of sleeping poorly and feeling generally anxious and grumpy, which made me feel upset about being anxious and grumpy, which made me additionally upset about how I wasn’t enjoying my vacation the way I wanted to and the precious days were just ticking by, poorly spent.  Then I felt even worse that I was feeling bad at all, when so much of the state is literally on fire and so many people have lost their homes, are afraid of losing their homes, have lost loved ones or are afraid of losing loved ones due to COVID or structural racism or both, and/or don’t even have the option of taking time off because of financial insecurity.  In short: I have so, so much to be grateful for, so who am I to complain?

When I’m at work, certain core elements of that work have remained relatively unchanged from pre-pandemic, and that too is a blessing.  I’ve been consistently working in inpatient settings since February, and so I’ve acclimated to the masks, face-shields, and Zoom teaching sessions.  When I have time off, it’s much harder for me to ignore how disrupted our world has become (first by a pandemic, and now by fires and air pollution), that this is our new reality, and that we cannot predict a return to “normalcy.”

What ultimately unfolded this past week was that I let myself mope, to some extent.  I watched “Indian Matchmaking” and the latest season of “Selling Sunset,” ate some pastries, and drank some wine.  I also had regular meals with protein and vegetables; talked with my therapist, who helped me put words to the negative emotions I was feeling; and talked with one of the chief residents, who helped me come up with different ways to approach some of the challenges I have been encountering in my current clinical rotation.  I did some online exercise classes, and even went on an outside jog with friends.  I chatted in person with some of my residency classmates, and felt slightly (but tangibly!) less weighed-down afterward. My husband and I went to Ocean Beach and found some intact sand dollars, watched a seagull battle with a crab (the seagull won), and stared in horror at the apocalyptic ridge of smoke stretching from the North Bay to the horizon.

I finished Isabel Wilkerson’s “The Warmth of Other Sons” (in a word, awe-inspiring) and Frances Cha’s “If I Had Your Face,” and started and finished Molly Wizenberg’s “The Fixed Stars.” I started Jonathan Metzl’s “The Protest Psychosis” and Kara Cooney’s “When Women Ruled the World: Six Queens of Egypt,” and started listening to the audiobook of Isabel Wilkerson’s “Caste.”  Last night Andrew and I finally watched “Parasite,” during which I alternately laughed and squirmed, and nearly cried at the end.

Tomorrow morning I head back to work. I’m trying to keep in mind that it is simply impossible to be confident and excellent in everything that I do, that being resilient does not mean being emotionally impervious or without anxiety, and that a certain degree of emotional permeability allows for empathy. Accepting uncertainty and constant change has never been a strong suit of mine, but it’s an area of ongoing growth.

Other update: A little while ago I was honored to work with the expert storytellers heading up Stories Behind The Mask, which is a fantastic project focused on highlighting perspectives from healthcare workers on the fight against COVID-19 and racism. My video is here:

The Masked Asian Psychiatrist

My story “The Masked Asian Psychiatrist” was published in Pulse last week! I started writing it several months ago when I was on my inpatient psychiatry rotation in the last third of my PGY-1/intern year. By the end of the spring, much had already been written about the pandemic’s effect on mental health, and there were some incisive pieces reflecting on the pandemic’s effect on Asian healthcare workers (see this piece by Dr. Sojung Yi). I hadn’t seen much written, if anything, about the particular experience of Asian mental health workers, and that motivated me to write my story.  The process of doing so and then editing it with input from friends and colleagues, and then with Pulse’s editor, was both therapeutic and stimulating for me.  Seeing the story out in the world, and subsequently with an intriguing and ultimately heartening series of reader comments (on the story page), has been a thrill.

I highly encourage anyone interested in narrative medicine and perspectives from healthcare providers and participants, both poetry and prose, to subscribe to Pulse (both free and donation-based subscriptions are available) and help them continue editing and publishing.

For me, a large part of becoming an antiracist physician and an ally means reading and learning from the lived experiences and wisdom of BIPOC colleagues, friends, writers, and more.  It also means learning to talk about how my own cultural identity—Chinese-American, immigrant, Northern California college town-raised, upper middle-class-raised, non-white, and non-Black, as well as cisgender, heterosexual, and able-bodied—and the privileges and complexities therein, have shaped my life and affect my work with patients.  This Pulse story was the first time in my professional/adult life that I’ve “spoken” publicly about this.  There is so much more that I wasn’t able to cover this time, but am still unpacking and writing about, and there is much more reflection and self-critique ahead.  

I am grateful to all who have encouraged and supported me in venturing into this new space.

PGY-2 so far

Part of my houseplant collection, with the most recent additions being the feathery fern and the large dracaena on the right side.

First day on the Consultation-Liaison (“C/L” or “Consult” for short) service last week: a surprisingly manageable easing-in for me and my co-resident, with our chief resident and multiple attending physicians (i.e. our supervising physicians, “attendings” for short) orienting us to the service.  Started getting familiar with the long patient list.  Spent significant time getting lost in this hospital, where I’ve only worked for a week in the past.

Second day: Long and overwhelming. This was in part because I was still getting physically lost and didn’t know my patients well yet, but also because I hadn’t yet learned to titrate the number of follow-ups seen in the morning before getting some of their corresponding progress notes done (this is key so I’m not super behind come mid-afternoon).

Thanks to the July 4 holiday I had some time to recover before my third day, a weekend call shift, during which I was covering the Consult pager (albeit at the very familiar hospital where I worked the prior four months), as well as supporting new interns who were getting used to covering the inpatient psychiatry pager.  It was a packed day but ultimately felt manageable, and made me appreciate the growth that happens over the course of one year of residency.  Knowing I needed to periodically check in with an intern and review some how-tos with them actually helped me stay focused on my tasks and try to be as efficient as possible.  As a bonus, it was wonderful to watch the interns give a clear and organized sign-out to each other at 8:00pm.

4th through 8th days: Varying degrees of “busy” ranging from comfortably busy to “we just got six new consults in two hours, yikes!!” but ultimately doable with the support of our attendings, senior residents, fourth-year medical student, and nurse practitioner.  We were getting lost far less frequently, and managed to eat lunch more days than not.  As the cognitive load of finding the right room numbers and simply keeping track of my to-dos lessened just a tiny bit, I found myself again able to recognize some moments of satisfaction and even joy in the work. My co-resident and I are alternating weeks of holding the pager, and he did a great job this past week.  It is also heartening that when one of our consult patients gets admitted to inpatient psychiatry, one of our residency classmates often becomes the primary physician.

Looking ahead at the coming weeks, in addition to my work-related goals and psychiatry learning goals, my secondary goals include:

  • staying hydrated as much as possible
  • remembering to pack a snack every day
  • aiming for 10+ minutes of strength- or mobility-targeted exercise most days, in addition to my 12-min daily walking commutes
  • continue to keep my houseplants alive
  • continuing with music and non-psychiatry reading, even if sporadic.

Currently reading/listening:

  • Isabel Wilkerson’s “The Warmth of Other Suns”: I started this while on vacation three weeks ago and it is such a gorgeously written and overall epic book. It also feels particularly timely and thought-provoking now.
  • Ibram Kendi’s “How to Be an Antiracist”: Almost finished listening to the audiobook (read by the author), though I expect to return to it later as well. Part of my self-assigned educational curriculum as it is for many others.
  • Anna Solomon’s “The Book of V”: audiobook, I’m 30% of the way into it, but I think it might be better read in a couple longer sittings instead of listening in short spurts.
  • Kevin Kwan’s “Sex and Vanity”: fluffy fun, though unsurprisingly, not as good as the “Crazy Rich Asian” series.

From intern to resident

I took this photo at the end of a night shift in early April 2020. From the seventh floor I could see the long line of socially-distanced hospital staff waiting in line for pre-work infection screening.

As of a few days ago, I am officially a second-year psychiatry resident, or PGY-2 (see end of post for a quick primer on the quirks of residency year naming). When I began my intern year in June 2019 I was excited to practice medicine, but was also apprehensive about whether I would find the work fulfilling, or whether I would experience burnout.  Both turned out to be true: it was an incredible year wherein I’ve truly enjoyed [finally] getting to be a doctor, and I’ve also learned invaluable and sometimes unexpected lessons that include how to choose and adjust antipsychotic doses, but also how to more accurately recognize and then mitigate burnout.  I’ve had the enormous privilege of learning from patients, fellow interns, senior residents, attendings, nurses, technicians, social workers, nutritionists, psychologists, and occupational therapists at the VA, at San Francisco General, and at Benioff Children’s Hospital; in different specialties (psychiatry, medicine, neurology, pediatric neurology, and adolescent medicine); and in a variety of different clinical settings.

At the start of residency I had hoped, but certainly hadn’t expected, that my fellow residents might become close friends.  My fear that I would be terribly unsuccessful in making new friends turned out to be unfounded; in fact, some of the senior residents have described our residency class as notably cohesive, which bodes well for the coming years.  Our camaraderie certainly helped when, two thirds of the way through the year, we unexpectedly faced the specific challenge of working in healthcare during a pandemic with various unknowns.  From February through June I worked on the same psychiatric units at the General, and it was at turns fascinating, stressful, and educational to watch the city, our institution, and our department adapt to this public health crisis.  Amid bouts of uncertainty over whether the curve would be flattened or if we would end up with a terrible outbreak on our units (which, thankfully, did not happen), the overall consistency of my schedule during these past months gave my life structure.  Together with my colleagues I settled into the new normal of daily pre-work screening questionnaires and surgical masks all day.

Then, toward the end of the year, we all found ourselves grappling with the role of structural racism and police brutality in our communities and our medical fields, and the impacts (both acute and chronic) on our patients, colleagues, and friends.   As part of this long-overdue collective reckoning, we have had to rethink what it means to be supportive of each other, to hold each other accountable as allies, and to advocate for each other and for the patients we serve.

During orientation for the incoming interns, a classmate and I each shared a couple sentences about our cultural backgrounds and how they affected the start of our residency.  I shared that I am a Chinese-American immigrant who grew up in a relatively liberal and well-educated college town, and that while during medical school I was involved in some equity-focused advocacy efforts, it was during intern year that I finally began unpacking my intersectionality and privilege in earnest.  I believe a necessary step in becoming an anti-racist physician is understanding one’s own cultural intersectionality, that we are each at a different stage in this process, and that wherever we are is a fine place to start.  Just as this chosen career path requires that we hold space for our patients’ emotions and inner conflicts, so too do we need to hold space for our own uncomfortable truths.  And so, I am reading, listening, writing, and thinking.  

My second residency year (PGY-2, or post-graduate-year 2) will start next week with three months on consultation-liaison psychiatry at UCSF, followed by three months on adult inpatient psychiatry at UCSF, and then six months of outpatient psychiatry at the VA.  Throughout the year we take call shifts at the General, VA, and UCSF.  Each residency year brings new expectations and challenges, and just as I did a year ago, I again find myself feeling both apprehensive and excited.

***Summary of residency year naming schemes: each year, or title for a resident in that year, is often named as “Post-Graduate Year” followed by the number: PGY-1, PGY-2, etc. Another informal shorthand for residency years or residents is R1, R2. Thus, a second-year resident could be referred to as “a PGY-2” or “an R2,” and is in their PGY-2 or R2 year. The first year of residency (PGY-1) is colloquially called “intern year” because some medical specialties, such as radiology or neurology, require that their residents first complete a general medical internship (which may or may not be at the same institution) before starting specialty training in PGY-2. Psychiatry residency is one that begins in the PGY-1 year. Regardless of these differences, across specialties, the completion of the PGY-1 year is thought of as the transition from internship to residency.

Looking back: Scrubbing in and suiting up

This was a short piece I originally posted on my old blog in May 2018, when I was a third year medical student halfway through my 12-week surgery rotation. On re-reading it now, this piece transports me back to a time when I had already decided to pursue psychiatry, but was also acutely aware that this surgical rotation was the only one I would have. As such, it represented a brief but memorable immersion into a dramatically different arena of medicine.

There is a unique desperation that arises during the medical student surgery clerkship, when the student is confronted with ostensibly simple tasks – such as finding a roll of paper tape, or opening the correct dimension of gauze, or holding a retractor with the right amount of tension – that have suddenly become staggeringly challenging.  Great attention must be paid to the placement of one’s hands when one is doing nothing but standing and observing.  The differentiation between what is light blue (the color of sterility and safety) and not light blue is now the most salient, if one wants to avoid the justified wrath of the scrub technician, to say nothing of keeping alive the chance that one will get asked to hold an instrument or possibly even, if lucky, help close an incision. 

It is safest to keep one’s arms crossed, or forearms folded over one’s stomach, or, ideally, resting on a draped area that is away from the operating field, if the surgeons or a particularly thoughtful scrub tech invite one to step closer.  It is definitely not safe to begin to doze off while sitting on a stool between a patient’s [draped] legs, while watching the surgical proceedings on the screens around the room, to then realize that one has just contaminated one’s gloves by touching the stool.  This may or may not have happened to me in my second week on the inpatient gynecology service, during a six-hour surgery, during part of which I had been told to push in various directions and then isometrically hold an instrument placed in the uterus, while the surgeons used the Da Vinci robot to manipulate parts of the pelvic organs through the abdominal wall.  One of the more surreal moments in my life: being told “Harder!  Push to the right!  No, the patient’s right!,” contorting my shoulder into increasingly uncomfortable angles, seeing on screen the uterus move with my clumsy adjustments, while the surgeons stared into their arcade-like consoles and used carefully calibrated movements of the control knobs to trigger precise adjustments of the articulated robot arms.  For obvious reasons I was extremely alert during that part of the surgery, but all bets were off once my physical and intellectual involvement was over and I was left to watch.

It took well over a week – and if I’m being honest, closer to two weeks – before I felt comfortable scrubbing in, and then just to be a minimally invasive component of the OR milieu.  By the fourth or fifth week, I started appreciating the rhythm and routine around me.  The structure-seeking part of me did find comfort in the repeated ritual of being gowned and gloved by the scrub technician:

After scrubbing for upwards of three minutes, walk into the OR with hands held up in front of you, elbows away from your chest, water dripping downward onto the floor.  Take a sterile towel and, still keeping your elbows up, dry the hands and forearms on one side, then use the other (clean) side to dry the other arm.  Place your arms into the gown which has been held open for you, extending your arms under the arms of the scrub tech with only a slight back bend, and immediately straighten with your hands once again held in front of you, fingers together, so that the arms of the gown can be pulled down just enough.  When the first glove is held open for you, slide one hand down into it, then use those now-sterile fingers to help hold open the second glove that is proffered.  The back of your gown has already been closed by the circulating nurse, but you now ask him or someone else to take the paper card tethering your waist ties, then spin counter-clockwise and pull the other waist tie off with a subtle flourish, so that you can fully close your gown.  You are now enclosed in cleanliness, and you have only to avoid messing it up.  

This sequence of actions, repeated at the start of every surgery, armors the surgeons – and wide-eyed medical students – in a papery, synthetic, fluid-proof, and anonymity-granting suit.  When everyone who has scrubbed is gathered around the draped patient, with only the operating field exposed, they coalesce into a nucleus around which the outside world, the non-sterile and chaotic and hazardous, recede.  Despite interruptions by pages or phone calls, or episodes of chatter regarding weekend plans or how the family is doing, there are always stretches of collective scrutiny on the task at hand.  Sometimes it seems to me that in the OR, the patient’s personhood and humanity are intentionally deemphasized, tucked into the background by the blue drapes.  And yet I also see that in the OR there is a unique dimension of respect for the human body and its natural variations in anatomy and [patho-]physiology, which create the potential for surgical challenges that are not always forseen by imaging studies.  I sensed that the haptic unpredictability of surgery, as well as the monastic focus that must result, is part of what surgeons love about their work.  As an observer and intermittent participant, scrubbing in provides a memorable glimpse into this unique cognitive realm.

Looking back: Grad school lessons on how gender matters

This was the second in a pair of posts from early 2015, when I was a PhD student in Neuroscience. Now that I am working in a medical specialty that is quite balanced in terms of gender, the disparities that were so apparent in my graduate training are less present in my day-to-day clinical work. However, within academia, the same discrimination is present and relevant, to say nothing of even more pervasive and toxic structural injustices toward BIPOC individuals.

Lesson: Gender matters sometimes, even for grad students in a generally supportive environment.

A professor once gave my class some excellent advice on scientific presentation.  He said that every time one gets up to speak in front of colleagues, even in a casual setting like a lab meeting or small seminar, one should be as well-prepared and professional as would be expected for a job talk.  His point was that each presentation reflects on the speaker’s reputation as a scientist and scholar, and I try to keep this in mind.

Some months after hearing this advice, it also occurred to me that if a woman happens to be working in a field that is skewed toward men, her gender might already be a more salient factor as soon as she steps to the front of a room to speak.  A scientist’s presentation skills, confidence level, and quality of work are obviously important regardless of gender, but these metrics might be evaluated more stringently for a female scientist giving a talk (even on a subconscious level, because I believe that most scientists are not consciously sexist).  Furthermore, what is assumed about her overall competence as a result of these metrics might have a greater impact on her career than if she were a man.  In a male-dominated field, a female speaker’s public presentation could even impact what others assume more generally about Women In This Field.

I don’t intend for this post to be a manifesto, but I do think what I just said deserves some consideration of the broader context.  There is plenty of evidence demonstrating that perceptions of competence can differ based solely on gender.  To cite some primary sources, one study in which subjects performed a contrast sensitivity test showed that men and women are held to different standards of competence (Foschi, Social Psychology Quarterly, Sep 1996).  There was also that memorable 2012 PNAS paper highlighting how, when faced with two hypothetical applicants with identical profiles except for name (Jennifer or John), science faculty members of both genders were more likely to offer John a laboratory manager position, and with a higher salary than would be offered to Jennifer (Moss-Racusin et al., PNAS, Aug 2012).

In 2014, another PNAS paper confirmed and enhanced the 2012 findings by showing that in choosing a candidate for an “arithmetic task” based solely on the candidates’ physical appearances, employers of both genders were twice as likely to choose a male candidate (Reuben et al., PNAS, Jan 2014).  The degree of individual bias correlated with the Implicit Association Test (IAT) score, which in this study measured the degree to which the subject associated an individual’s sex with his/her science-related ability.  Even after receiving objective information about the candidates’ actual performance on the task, “suboptimal hiring decisions” (i.e. hiring the candidate with lower performance) tended to favor a lower-performing man over a higher-performing woman.

A meta-analysis published earlier this month concluded that overall “women may be more likely to face discrimination in male-dominated environments, whereas, on average, neither gender has an advantage in female-dominated or integrated environments” (Koch, D’Mello, and Sackett, Journal of Applied Psychology, Jan 2015).  Encouragingly, these authors also found that gender-role congruity bias (i.e. preferential selection of men for male-dominated jobs) is reduced when the applicants are shown to be highly competent, when the decision-makers are “motivated to make careful decisions,” or when the decision-makers are “experienced” with “organizational decision-making” and are not simply pulled from, say, the frequent psychology study population of undergraduates.

Now, I am fortunate to be in a gender-balanced lab and relatively gender-balanced training program on a campus that is enormously collegial.  I have mentors and instructors of both genders who actively promote the advancement of women in science.  I also emphasize that I have not, as far as I am aware, experienced any instances of overt gender-based discrimination that have affected my educational opportunities.  That said, I am also a trainee in a subfield of neuroscience – imaging and analysis of cortical network activity – that is male-dominated, which probably has some association with the topic’s heavy emphasis on technology development, hardware, and computational techniques.  I love and believe in my project, and there is no other scientific topic in which I’d rather train. However, my intellectual excitement for my research doesn’t blind me to the reality that my field is still gendered.  I certainly have experienced, witnessed, and heard about episodes of subtle or inadvertent sexism, which can still be impactful.

As part of this reality, I’ve had to learn that men and women often assert themselves and/or respond to negative interactions in very different ways.  At one point, I sought out the advice of a female mentor because I was having difficulty navigating a particular research-related situation.  The situation involved some interpersonal dynamics that I thought might have something to do with gender, but didn’t necessarily want to label as such.  The mentor practically read my mind and told me that in this circumstance I should in fact “act more like a man,” i.e. be more aggressive in advocating for my point of view.  It was slightly jarring to hear a female faculty member so matter-of-factly confirm the gender differences I had suspected, but her attitude was also reassuring, and her advice certainly proved effective.

About three months later, another faculty member and I unexpectedly started discussing the issue of gender differences in science, and in particular how men and women respond to negative interactions in the workplace.  This faculty member pointed out that many men tend to “call B.S.” readily and then promptly move on, without giving it much more thought, whereas women – irrespective of competence, confidence, or ability to be aggressive – sometimes tend to ruminate about what happened.  This struck me as being an uncanny reflection of how I responded to unexpectedly negative interactions or inappropriate comments: briefly freezing with surprise, trying to exit the interaction in an uneventful and often non-confrontational way, and then obsessing afterward about all the things I should have said in the moment.

Goals: To be a more assertive or aggressive self-advocate, when constructive; to recognize when a situation is “B.S.” and point out when it is problematic or inappropriate; and to let go of negative interactions afterward instead of ruminating about them.

The aforementioned conversations echo other discussions I’ve heard on “The Broad Experience” by Ashley Milne-Tyte, a podcast I highly recommend.  One particular episodefocused on gender differences in workplace communication and quoted Barbara Annis, an expert on gender intelligence: “So women tend to worry more.  And as I mentioned, ruminate more, that internal dialogue that goes on. And I always say to women, think about this, is there any cheese down that tunnel [i.e. a real problem], first of all, to worry about this?  Or is it time to, you know, say OK, I’ve handled it to the degree that I can, and now I’m going to let it go. [….] Now there are some things that it’s really important to worry about, so I’m not saying dismiss on things that are really vital.  But the small things, if they are on your worry list I would strike them off and create a clean slate.”

Having some lactose intolerance myself, I find the cheese analogy particularly resonant.

Looking back: Grad school lessons about confidence

I originally wrote this piece in January 2015, when I was a second-year PhD student in Neuroscience. The same lessons still ring true now that I am in residency, including: “I am trying to redefine my conception of competence to include the effort I expend and the progress I make, and to hold more confidence as a result.”

Now that I’m halfway through my second year as a PhD student, and recently submitted a fellowship application describing My Thesis Project and My Intended Scientific Training, I’ve been reflecting on the first 1.5 years of grad school and making a list of What I’ve Learned So Far (and/or Am Still Learning).  Some of the items on my list were unsurprising, such as:

1) Developing some broad understanding of neuroscience and a more in-depth understanding of my narrower research field;
2) Two-photon imaging (which, by the way, is awesome), some MATLAB programming, and various other experiment-related techniques;
3) How to read papers more efficiently and critically;
4) Grant-writing;
5) Presentation and teaching skills;
6) The importance of strong mentorship;
6) The necessity of unwavering support from family and friends, plus lots of tea and dessert (and some wine).

But as generally happens in life, several other lessons were unforeseen, and gave rise to new personal goals.  I thought I’d write about them as a series of blog posts, this being the first.

Lesson: The power of confidence is very real.  

In my years before grad school, it repeatedly struck me that because I tended to be comfortable speaking in group settings (in med school, those were typically the Problem-Based Learning or Doctoring groups), I was frequently perceived as being a highly competent student.  In reality, my comfort level with participation in discussions or with public speaking didn’t necessarily reflect my mastery of lecture material.  Even so, it was clear to me how an appearance of confidence could create an assumption of competence.

During both college and med school, measures of progress and achievement are frequent and often externally defined in the form of exams, essays, or short-term projects (such as preparing a piece of music for performance).  But in grad school, competence is less concretely defined on short time scales.  There are classes, sure, and having a knowledge base in neuroscience is clearly important for becoming a neuroscientist, but successful completion of classes isn’t remotely sufficient to make a good scientist.  Instead, scientific competence has much more to do with creativity and innovation, ability to understand the literature and also see beyond it, ability to design and re-design experiments, project management and trouble-shooting skills, ability to work well with colleagues and advisors, and a whole lot of perseverance.  In theory, one develops and/or solidifies these attributes over the course of a PhD and then further develops toward being an “independent investigator” during a post-doctoral fellowship.

It turns out that although these metrics of competence may be very different from the metrics before grad school, the connection between outward confidence and perceived competence – and the potential disconnect with actual competence – is just as strong.  If you asked me whether I am a competent scientist, my answer would be “Not yet, but I’m working on it.”  I am reasonably sure of my potential for becoming a productive and capable scientist, but I’m also near-constantly and sometimes painfully aware that I still have so much learning and growing before I get there.  My self-doubts about being very much “in training” can seep into what I project externally, and since confidence and self-advocacy often go hand in hand, my doubts could definitely affect not just how I am perceived, but also the opportunities that I seek or am offered.

Especially when it comes to rectifying a weakness or learning a skill that is very necessary for my research, such as MATLAB programming, I tend to feel insecure until I feel that I’ve achieved enough competence in that skill.  But how would I define “enough competence”?  In the past year I’ve had to recognize that I may never achieve the level of mastery that I would ideally possess for any given skill, that there will always be scientists who have years more experience and ability than I, and that my own benchmark of competence will constantly shift as my training progresses and my research pursuits evolve.  That the target is moving doesn’t mean that I’m not making solid progress, progress about which I should be confident, because my incremental progress will still enable me to produce solid science in my own right.  Thus, I am trying to redefine my conception of competence to include the effort I expend and the progress I make, and to hold more confidence as a result.

Goal: To develop greater confidence in my abilities and progress, while working hard to constantly improve my competence as a scientist.

P.S. Based on what I’ve heard from other grad students, this process of navigating our scientific and personal development is fraught with insecurities for everyone, whether we are outwardly assertive or not, and so I sense that this first goal is shared by many of my peers. 

There have also been some interesting media discussions related to this subject.  The specific topic of how confidence and competence relate to gender, and possibly to success, was explored in-depth in a fascinating and provocative article published in The Atlantic last May: “The Confidence Gap” by Katty Kay and Claire Shipman.  More on gender in a future post.