When A Patient Gets Political

Disclaimer: This blog post reflects the author’s present recollection over time. Characters and dialogue have been recreated and rearranged. Events have been fictionalized and any resemblance to actual persons, living or dead, is purely coincidental.

A well-groomed, middle-age woman walked into my office and said, “Doctor, my anxiety is shooting through the roof!”

I expressed dismay and asked her what has changed since our last visit.

“It’s this damn fake election!” she exclaimed. “The Democrats are going to undo all the great things that Trump has done for this country. I can’t stand seeing these BLM rioters and Muslim invaders and Antifa terrorists on television. And now they’ve stolen our democracy! It’s terrible! And so many businesses are still shut down because of this stupid Chinese virus. I felt safer with Trump as president.”

Okay. I felt my heart pounding. I heard a low buzz in my ears. My body was entering fight-or-flight mode. I repressed the urge to stand and leave the room.

This puzzled me. Why was I feeling so afraid?

It made no sense. My patient was sitting in a non-threatening posture and more than six feet away, the result of social distancing precautions. She spoke at a moderate pace in a mildly anxious tone. She was even smiling at me as if she expected me to agree with her.

In my role as a psychiatrist, I take care of people who are intoxicated, delirious, and emotionally labile. This happens, especially in an emergent setting. Many of my patients had been brought to the hospital against their will, and they are usually afraid. Fear leads to irrationality, irrationality leads to unpredictability, and unpredictability leads to violence. I have tolerated a lot of verbal abuse from patients. I’ve endured misogynistic comments and racial slurs. I am trained in verbal de-escalation. I have talked many, many people down from screaming at me to thanking me. Despite these measures, I’ve had several patients attempt to physically assault me. One actually did.

Any front-line healthcare worker understands. As a group, we are remarkably prone to encountering verbal and physical abuse. Nationwide, 78% of emergency department physicians reported being targets of workplace violence (Behnam 2011). 82% of US nurses have been assaulted at least once during their careers, and 73% believe that assault was just part of their job (Speroni 2014). Verbal aggression is just as serious. In a 2016 review article, Phillips writes, “The importance of recognizing verbal assault as a form of workplace violence cannot be overlooked, since verbal assault has been shown to be a risk factor for battery. When verbal abuse and low-level battery are tolerated, more serious forms of violence are invited.” Verbal violence affects not only the victimized individual but also the entire health care system. Verbal violence can lead to demotivation, poor job satisfaction, early burnout and compassion fatigue. Overall, workplace violence affects the delivery of health care, decreasing quality and accessibility (Watson 2020).

I can handle that. But this smiling woman in my office was different. This felt new, in a strange, subtle, gut-twisting way. Maybe it was because this patient was not intoxicated or psychotically delusional and was speaking with a linear thought process. Maybe it was because this took place in the ostensibly safe space of my office. Maybe it was the inflection in which the word “Chinese” is said – with an elongated and emphasized sound of “chai” followed by the derisive sneer of “neez”. Maybe it was because I never expected this type of hate speech from this particular patient, who I had formerly thought of as a friendly, pleasant lady. Or maybe it was because I was vividly reminded of past hurts, of the childhood peers who would smile to my face and then make fun of my “chinky” eyes behind my back.

I took a slow breath. She seemed to sense my emotional turbulence. We looked at each other silently. I wondered what she saw.

My physical presentation is as a petite, Asian-American female. Would she think of me differently if she knew that I was not born in the United States? That despite my adopted American accent and soft southern drawl, my mother tongue is Mandarin Chinese. Or would she tell me that, oh no I’m not racist, you’re one of the good ones, without thought of how that implies the opposite – that in order for me to be different, the rest of my peer group must share common negative traits.

As a rule, I don’t bring up politics with patients. But what do I do, when a patient gets political?

“I don’t agree. I feel less safe,” I said. “You know, it has been really difficult being an Asian person in this pandemic.”

To my relief, she offered an olive branch.

“I’m sorry for talking about politics,” she said. “I don’t mean to bring all that negative energy in here.”

And we talked about it. I told her that I want my office to be a safe place where she can bring her worries. That I wanted to hear about the triggers for her anxiety, so that I could better understand her and be a better doctor for her. At the same time, I told her that her words can be hurtful. That although she was certainly not responsible for my feelings, perhaps she could be a little more mindful and understanding about what she says and how she says it – because I am a person, too.

Then we moved on to discuss her medical care.

Although it may be uncomfortable, I think that it is important to think about how race and politics can color interactions between health care providers and patients. As we seek to understand each other, these conversations need to be ongoing and authentic. NBA player Jeremy Lin spoke out earlier this week as a guest on “Race in America: A Candid Conversation.”

“I feel bad for somebody who harbours hate for somebody else, who they’ve never met, just based on skin colour,” he said. “That makes me want to do something. It makes me want to educate people… speak out and find ways to make a difference. Honestly, it goes from anger to just heartbreak.”

He also posted on his Instagram: “Being an Asian American doesn’t mean we don’t experience poverty and racism. Being a 9 year NBA veteran doesn’t protect me from being called ‘coronavirus’ on the court. Being a man of faith doesn’t mean I don’t fight for justice, for myself and for others.” (Didion 2021)

There has also been a rise in hate crimes against people of Asian descent. Recent data released in major cities show a shocking growth in the number of racially-motivated attacks (Wells 2021, Sturla 2021). As I discussed above, serious physical assault does not occur in a vacuum; it is frequently preceded by verbal abuse and low-level battery. I strongly suspect that there are numerous unreported events of verbal abuse and microaggressions. Knowing this, I can begin to understand why I felt the way I did. My feelings of danger have root in truth.

What happens out in the world gets brought into doctors’ offices. And when this happens again – when, not if, because problems of hate and intolerance do not simply fade away – then I can be better prepared for it.

More Information

Behnam M, Tillotson RD, Davis SM, Hobbs GR. Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. J Emerg Med 2011;40:565-579

Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218-228. doi:10.1016/J.JEN.2013.05.014

Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. PMID: 27119238.

Watson A, Jafari M, Seifi A. The persistent pandemic of violence against health care workers. Am J Manag Care. 2020 Dec 1;26(12):e377-e379. doi: 10.37765/ajmc.2020.88543. PMID: 33315330.

Didion, A. Warriors’ Jeremy Lin Reveals He Has Been Called ‘Coronavirus’ on Court. NBC Sports Bay Area. February 26, 2021. Accessed February 27, 2021. Link: Warriors’ Jeremy Lin Reveals He Has Been Called ‘Coronavirus’ on Court – NBC Bay Area

Wells, N. Anti-Asian Hate Crimes Are Up 717% In Vancouver. Canadian Press. February 18, 2021. Accessed February 27, 2021. Link: Anti-Asian Hate Crimes Are Up 717% In Vancouver | HuffPost Canada (huffingtonpost.ca)

Sturla, A, et al. Anti-Asian attacks are on the rise in NYC. The city is pushing to combat it. CNN. February 27, 2021. Accessed February 27, 2021. Link: Anti-Asian attacks are on the rise in NYC. The city is pushing to combat it. – CNN

Inside Asylum Walls

“Nobody will ever convince me that the splendor of individual courage cannot triumph over all the fates. Neither family death, nor personal illness, nor “hard times,” nor heavy responsibility solely borne, nor hazards met without warning can defeat one man standing alone who refuses to relinquish his courage. I knew such a man. He was my father.”

– Dorothy Powers, In Tribute to My Dad.

About a year ago, I visited a small bookshop in Spokane, Washingon. As an independent book store for nearly four decades, 2nd Look Books was full of second-hand treasures and local history. A bright red book caught my eye. Boldly titled: “Dorothy: POWERS TO THE PEOPLE”, it contained a collection of columns written by journalist Dorothy Rochon Powers for the pages of The Spokesman-Review.

The inside cover had a hand-written note from the author dated September 16, 1989. It was addressed to a dedicated reader, perhaps the author’s friend. “I wish you many happy memories in these pages. Thank you for reading my column! – DRP”

As per my usual habit, I flipped open the book to a random page. To my surprise, the book fell open to an article titled, “Inside Asylum Walls: The Patient’s View.” It must be fated for this book to land in the hands of a psychiatrist, I thought, and so of course I purchased the book.

Published in December 1957, the article by Powers reported on conditions at Eastern Washington State Hospital. As part of her research, Powers repeatedly visited the institution and conducted interviews with members of the staff. Then with the assistance of officials, she got herself “committed” and spent time there disguised as a patient.

What she found was disturbing. The institution was overcrowded and understaffed. “To a state mental hospital with 2,064 patients — and facilities for 1,861; to a staff of 13 doctors, where the American Psychiatric Association standards show 28 are needed; to an institution with 20 nurses instead of 166,” Powers wrote (pg 99). This was shocking. In comparison, the institution where I am currently training as a resident physician can provide services for up to 99 patients, with four attending psychiatrists on-site every workday and a half-dozen resident psychiatrists serving as helping hands. The physicians are supported by a robust staff of nurses, techs, and social workers.

In 1957, there were too few hands on deck at the Eastern Washington State Hospital. Members of the staff did their best, but the amount of work was overwhelming. Not only were they outnumbered, but they also cared for some of the most severely mentally ill people in the state. There would have been people who were diagnosed with debilitating illnesses such as chronic schizophrenia or catatonia. Some would be so paralyzed by their minds that they depended entirely on caretakers for basic functions, such as eating, bathing, and toileting. Powers described their despair. “‘It’s all we can do to keep them clean,’ sighs an attendant, ‘much less spend any time working with them'” (pg 101).

Remember, this was before the advent of psychopharmacology, before antipsychotic medication such as chlorpromazine and haloperidol and clozapine revolutionized psychiatric medicine. This was before the 1960s, when the social movement for deinstitutionalization of the chronically mentally ill gained momentum and lead to the replacement of long-stay psychiatric hospitals with an outpatient care-focused model and the goal of reintegrating patients into the their community. Powers’ article, among many others across the nation, helped instigate change. Today, Eastern Washington State Hospital has a patient capacity of just over 280 beds, according to Wikipedia. The changes over the years are reflective of our society’s evolving attitudes and growing understanding towards mental health.

The picture that Powers’ paints may seem foreign and strange, as the landscape of behavioral healthcare has transformed so drastically. But some things remain familiar. As I read, I was vividly reminded of people I have met in my current work in psychiatric wards. The 1950s were not so long ago – some of these patients may still require care today. Powers provided powerful quotes: “‘You keep wondering why you’re different, what the people at home are saying. Right now, I worry whether the neighbors will still let their children come see me, when I get home… if I get home'” (pg 100).

People in the past as they do today still yearn for home, fear rejection, and desire healing. They have hopes and fears and dreams that, though clouded with their illness, remain deeply, unconditionally, and essentially human.

The remainder of the book is a fascinating documentary of life in the eastern side of Washington State. Powers captured the highs and lows of the human experience. She flew in a giant Air Force refueling jet at 40,000 feet in the air at 600 miles an hour. She mingled with inmates in Washington State Penitentiary. She climbed a 15-story bare steel scaffolding. She reported on the thunderous eruption of Mount St. Helens. Throughout it all, she described people with understanding and compassion.

When I travel, I love these pieces of local history. Upon my next visit to Spokane, I plan to return the book where I found it so that someone else can also discover its treasures. May the next lucky person also find inspiration in Powers’ stories!

More Information

Powers, DR. Dorothy: Powers To The People. Cowles Publishing Company. 1988. Print.