“The Five Keys to Happiness”
I chose psychiatry as my career path more than four decades ago. While in medical school I was asked at an interview for a residency training program why I was interested in psychiatry. My answer was I wanted to help people be “happy.” Perhaps a bit naïve at the time yet looking back on that answer I’d like to think that we all could do worse than assisting others in becoming content.
As professionals involved in the workers' compensation system in California we have all become familiar with the processes of Utilization Review and Independent Medical Review of recommended industrial treatment. The concept places an emphasis upon evidence-based treatment guidelines.
I would like to tell you a brief story which involves a recommendation for an unusual form of treatment for an admitted psychiatric injury. Some years ago I evaluated a woman of Haitian origin who had developed phobic symptoms in response to having been physically injured at work. Counseling services had been provided by the insurer with no significant change having come forth. The applicant was wary of taking psychotropic medication.
The injured worker was aware that there was a practitioner of the dark arts located in her community whom she was convinced could help her. A treating mental health practitioner had recommended an additional one dozen outpatient psychotherapy sessions. My recommendation was that the insurer instead pay for three sessions with the voodoo practitioner. Surprisingly the insurer consented to cover such costs with an acceptable outcome coming forth and the applicant’s claims being brought to a satisfactory conclusion.
This vignette points to the importance of cultural issues. I recognize such as the son of an immigrant mother who was born in Italy. My mom though quite intelligent was highly superstitious. Without her ever having read the works of Freud, she placed great weight upon the interpretation of dreams in foretelling the future. I recognized those same beliefs in the applicant who had been born in Haiti.
No doubt the Utilization Review process and the Independent Medical Review assessment of that claim would never have approved the healing intervention that worked. To the extent that it is possible, my advice is for administrators to maintain some flexibility with respect to treatment authorization in light of the characteristics and mindset of each injured worker.
Let us all give some weight to the power of belief systems and the cultural values of fellow workers and our own families.
The Bureau of Labor Statistics keeps data on fatal occupational injuries on an annual basis. Information on non-fatal yet serious injuries is also maintained. Loggers, construction workers, taxi drivers, police officers and iron workers are at high risk for serious if not fatal injury when compared to the average American worker.
Not uncommonly such injury events involve claims for both physical and mental injury. An agricultural worker losing a limb will understandably have some psychological problems. An iron worker impaled by rebar may experience a fear of heights when later returning to a jobsite. A trash collector witnessing a co-worker run over by a garbage truck may well experience high anxiety when working around heavy machinery. The psychological injuries related to serious physical injuries and work-related deaths are real.
In retrospect I now realize that a number of the jobs that I had as a young man were quite risky. In Chicago I witnessed a more experienced dock worker crushed between two trucks. I later worked in research laboratories with chemicals so toxic that if you smelled them you would die. My shortest career path was as a roofer which lasted one day. That work in Florida was hot, heavy and fraught with hazard. In each of these job positions some years ago I earned the princely sum of less than $5.00 per hour.
Exposure to falls, hazardous substances, dangerous machinery and transportation incidents account for many work-related fatalities. Let us not be surprised that there are psychological consequences to those events. For more information go to www.bls.gov/iif/.
Let us all be grateful when someone else is able and willing to take on dangerous work. When considering the most odious aspects of our own work, think about what cops, cab drivers and power line workers deal with on a daily basis.
Roofer at work
Public safety officers represent a population of workers who often come to the attention of mental health practitioners. Police officers, firefighters, paramedics and other first responders routinely are exposed to critical incidents on a singular or cumulative basis.
As an early career physician I spent five years working emergency services at Highland Hospital in Oakland where paramedics, deputy sheriffs and police were tasked with bringing trauma victims. More than three decades ago I accepted the invitation of then Captain Mike Hebel to tour the San Francisco Police Academy. Following the events of 9/11, I met with N.Y. firefighters at a firehouse that lost eight colleagues.
Whether first responders, long term employees or not, I believe doctors should humanely listen to and report the stories of persons with “mental injury” claims. We should be advocates for systems designed to protect workers while maintaining neutrality in complex human stories.
Firefighters at work
Most folks referred to Dr. Bob for evaluation come with some type of bad story. Not uncommonly they are dealing with debilitating physical illness, intrusive recollections of acute trauma such as armed robbery, or burnout from a long career involving high demands and minimal gratification. A frequently asked question is, “Why me?” Perhaps an existential question best left to philosophers or spiritual leaders rather than mental health practitioners. One of my goals in the course of a consultation is to help interviewees ask, “What can I do to make a difference in my situation?”
The point is to move people away from passive victimization and toward active re-involvement in improving their lives. For some they are encouraged to consider pursuing a job transfer with their long-term employer. For others reduction in reliance upon narcotic pain medication is needed. For those who do not see themselves returning to the workforce there are opportunities to volunteer and mentor persons who are even more wanting.
A few years ago my wife and I became victims of identity theft. A parcel containing copies of our bank records, tax returns, and financial statements was stolen before it could reach its intended source. After returning from vacation we learned that purchases had been made, applications for new credit cards had been accepted, and lines of credit had been approved. It took many months before all the banks and retailers involved became a part of the solution and not the problem.
I did not care for having to be labeled as a “victim” of identity theft after filing a report with the San Francisco Police Department. That turned out to be the only way of resolving numerous transactions that had occurred without our knowledge. That whole process gave me some appreciation for what the people that I see at times must feel when labeled by others as merely injured, disabled or victims. However, when we treat others with respect the victim role is lessened. Simply put, hope can take root when we see ourselves as empowered and not victimized.
Take charge to become empowered.
This is a two-pronged message which is both personal and universal. First: We are all more human than otherwise and thus vulnerable. Second: We should all count our blessings, give thanks.
Last month I had the good fortune, in retrospect, to have the same cardiothoracic surgeon who saved my life more than a decade ago do so once again. After contracting a heart infection, i.e. endocarditis, my aortic valve began to malfunction. In 2008 the valve was replaced during a hospitalization at California Pacific Medical Center. Some years went by during which time my cardiac function was periodically monitored. Over time the pig valve which had been implanted began to fail as well. Rather than put things off I opted to undergo open heart surgery once again, only this time at El Camino Hospital. Last month a team led by Dr. Vincent Gaudiani replaced the defective aortic valve and reconstructed my ascending aorta. I am now more bionic than ever. I am doing amazingly well with long walks and bicycling having resumed as regular activities. I plan to be back conducting evaluations at the Center in December.
Like you I am human, mortal and vulnerable. Like me you have things to be grateful for. I know this Thanksgiving I will be counting my blessings when I am with family and friends.
Let me end by wishing you good health, and absent such, excellent healthcare. My advice to patients, family and friends is simple. “Be your own best advocate. Trust your doctor or get a new one.”
By the way, the rumors of my demise have been greatly exaggerated!
We have things to be grateful for.
There is no cheerful way of having a discussion about gun violence.
Unfortunately, the subject does not take a break for the holidays. During the past two decades, gun deaths have increased by 20 percent in our country, according to the U.S. Centers for Disease Control and Prevention. Almost 40,000 Americans will die of gunshot wounds this year, while several times that number will survive with physical and emotional injuries that may never fully heal. The cost to our society is enormous.
Consider the resources that address our epidemic of gun violence. Law enforcement personnel include patrol officers, SWAT teams, crisis negotiators, commanding officers, sheriff’s deputies, detectives, investigators, forensics experts, bailiffs, correctional officers, parole and probation officers and, unfortunately, coroners.
It doesn’t end there. Legal resources become necessary to deal with criminal and civil matters. These include prosecutors and district attorneys, defense attorneys, paralegals, and judges. Ancillary personnel come into play as well. Bondsmen, insurance company representatives, mediators and morticians are part of the labor pool needed to address the carnage.
I and many of my colleagues lend our expertise to victims, dead or alive, and their family, co-workers and neighbors. The medical team involves emergency physicians, trauma surgeons, orthopedists, physical medicine experts, plastic surgeons, internists, pathologists and psychiatrists like me. Other necessary clinical components are paramedics, EMTs, nurses staffing the emergency room, operating room, medical/surgical units and home visits, hospital technicians and orderlies, occupational and physical therapists, prosthetists, psychologists and counselors.
The financial costs to our society are enormous just in terms of the labor needs required to respond to the frequent instances of gun violence. Meanwhile, the politics of firearm ownership divide us into adversarial camps. The lack of political will has left us with a hodgepodge of laws at the local, state and national levels that are often inconsistent and ineffective in dealing with this public health crisis.
Doctors for America proposes a new program to confront the issue of gun violence. A new government agency called the “National Bureau for Gun Safety” should be established. The NBGS would be staffed by experts in public health, medicine, law enforcement, engineering and communications. It would oversee research into behavior, safety technologies and legislative priorities to save lives at risk from gun injuries. The NBGS would work with the Bureau of Alcohol, Tobacco, Firearms and Explosives. A synergistic approach would be brought forth with respect to research, technology, public awareness and legislation.
In 1966, our government responded to the challenge of increasing mortality on roadways by passing the National Traffic and Motor Vehicle Safety Act. The National Highway Safety Bureau was created. The NHSB systematically addressed the problem through research and technology, which brought about seat belts and later airbags. Public education and legislative change were part of that process. The result was a drop in the motor vehicle death rate by two-thirds over subsequent decades. Doctors for America is calling for a similar response to gun violence as was apparent five decades ago to the problem of motor vehicle accidents and associated injuries.
The proposed agency, as currently conceived, would have shared goals with the Second Amendment Foundation and the National Rifle Association, which have a history of advocating for gun safety.
At the same time, doctors and other health professionals must lead the way in protecting the public health. This is our job, our calling and our lane. The NBGS concept can potentially change the national conversation on gun violence by placing the focus upon health. The goal should be preventing violence, injury and death as opposed to dealing with the victims when it is often too late.
Bob Larsen, M.D., is a member of Doctors for America and the National Steering Committee on Gun Violence. He lives in Santa Fe. This commentary also appeared in the "Santa Fe New Mexican" on December 14, 2019