Care Of Vulnerable Adults: Balancing Independence and Safety

Last night, I watched ProPublica and Frontline’s excellent documentary, Right to Fail, about New York’s struggle to find the balance between independence and safety in the care of people with disabling mental illness.

Finding this balance between independence and safety is something that I struggle with in primary care frequently. Most of the time, you can find a balance by bringing family members into the conversation and focusing on harm reduction and quality of life. But sometimes it’s not enough.

I took care of a gentleman in the emergency department the other day whose blood oxygen was dangerously low because of a condition called aspiration pneumonitis that he got because he was choking on the food that he was eating. He had neck surgery a couple months prior and the muscles that coordinated his swallowing reflex had not fully recovered. I advised him to come into the hospital until his lungs recovered enough that he wouldn’t need supplementary oxygen or we could arrange to have an oxygen tank delivered to his home. I told him I was worried that with prolonged low oxygen levels, his brain, heart, and kidneys may start to be damaged or fail. He declined admission, but couldn’t really repeat back to me an understanding of the risk he was taking by leaving against medical advice. I offered to call a family member on his behalf, but he didn’t want to worry them. I was stuck…

As someone with a strong professional and emotional drive to protect people from physical harm, it hurts me to see people suffering because of a limited capacity to take care of themselves. I often feel the impulse to say, “well let’s just have someone else take care of you.” I’m not alone in that. I think most people, when they seem someone on the street who is clearly unwell and in distress, feel suffering on that person’t behalf.

Many people with disabilities are glad to have assistance when that assistance is provided with compassion not condescension and supports of positive sense of self. I strongly believes that we need much better programs to support people with disabilities to maximize their capacity to live independently. But for those who who expose themselves to significant harm by rejecting assistance while having a questionable capacity to understand the risks and benefits of that decision, it gets difficult.

Institutionalizing someone against their will can be traumatic and harmful and must be a last resort. That being said, I do think it is sometimes the right thing to do, and it needs to be an option on the table.

In summary, 1) watch Right To Fail, 2) support programs that help people with disabilities live independently with dignity, and 3) consider that there are (rare) situations where loss of agency can be a net benefit to an individual with severe mental illness.

Closing the Racial Wealth Gap

The Samuel DuBois Cook Center on Social Equity and the Insight Center for Community Economic Development put out a great report titled “What We Get Wrong About Closing the Racial Wealth Gap.

You can read a short editorial summarizing a few of the findings here.

The report presents ten myths regarding the racial wealth gap and then gives the evidence again each of these myths:

  • Myth 1: Greater educational attainment or more work effort on the part of blacks will close the racial wealth gap
  • Myth 2: The racial homeownership gap is the “driver” of the racial wealth gap
  • Myth 3: Buying and banking black will close the racial wealth gap
  • Myth 4: Black people saving more will close the racial wealth gap
  • Myth 5: Greater financial literacy will close the racial wealth gap
  • Myth 6: Entrepreneurship will close the racial wealth gap
  • Myth 7: Emulating successful minorities will close the racial wealth gap
  • Myth 8: Improved “soft skills” and “personal responsibility” will close the racial wealth gap
  • Myth 9: The growing numbers of black celebrities prove the racial wealth gap is closing
  • Myth 10: Black family disorganization is a cause of the racial wealth gap

Pertinent both to our discussions on theft of black wealth and the conversation about reparations in Seeing White, the authors in this report give a detailed argument about why behavioral interventions to close the racial wealth gap are doomed to fail.

“We challenge the conventional set of claims that are made about the racial wealth gap in the United States. We contend that the cause of the gap must be found in the structural characteristics of the American economy, heavily infused at every point with both an inheritance of racism and the ongoing authority of white supremacy.

“As a result, blacks cannot close the racial wealth gap by changing their individual behavior –i.e. by assuming more “personal responsibility” or acquiring the portfolio management insights associated with “financially literacy” – if the structural sources of racial inequality remain unchanged. There are no actions that black Americans can take unilaterally that will have much of an effect on reducing the racial wealth gap. For the gap to be closed, America must undergo a vast social transformation produced by the adoption of bold national policies, policies that will forge a way forward by addressing, finally, the long-standing consequences of slavery, the Jim Crow years that followed, and ongoing racism and discrimination that exist in our society today.”

Questions to consider
  • How many of these myths are only plausible due to racist prejudice against black people?
  • Why are explanations of inequality that “blame the victim” more appealing than explanations that place some burden of responsibility on me? How can I counter-act this bias?
More reading on the racial wealth gap

Social Media for Doctors

This is a meant to be a bit of a “starter kit” for doctors looking to explore social media for the purposes of continuing medical education or advocacy. It’s certainly not a conclusive list, but it includes some of my favorites. I’ll continue to add to this over time.

Twitter

Free Open-Access Medical Education (#FOAMed)
Physician-Advocates
Other

Podcasts

I use Overcast for listening to podcasts, but most phones will have a native app you can use.

Anti-Racism Reading Group #6: Race and Gun Policy

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read summaries of previous discussions here.

The topic of this month’s anti-racism reading group was inspired in part by the Parkland shooting and the resulting public demonstrations for better public policy to prevent future gun violence.

Given that one of the main purposes of this reading group is to improve our capacity to understand the impacts of racism, this seemed to be a good opportunity to explore how racism impacts the gun control debate in our country. The following readings were sent out in advance:

  1.  “The simple, surprising factor that explains America’s gun problem” by Jason McDaniel and Sean McElwee
  2. “Racism, Gun Ownership and Gun Control: Biased Attitudes in US Whites May Influence Policy Decisions” by O’Brien, et al.
  3. “Racial Resentment and Whites’ Gun Policy Preferences in Contemporary America” by Filindra and Kaplan
  4. “The Secret History of Guns” by Adam Winkler
  5. “A researcher explains how racial resentment drives opposition to gun control” by German Lopez

While people went through these readings, I asked them to consider the following questions:

  1. What are the ways in which race and racism influence how people perceive gun ownership and gun control?
  2. How has the politics of gun regulation varied with the politics of race in American history?
  3. Philando Castile was a gun owner who had a concealed carry permit. He was explaining to Officer Jeronimo Yanez that he had a legal weapon on his person when Yanez shot him to death. How does he fit into this story of race and gun ownership?

Continue reading “Anti-Racism Reading Group #6: Race and Gun Policy”

Anti-Racism Reading Group #5: Seeing White

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read summaries of previous discussions by following these links: one, twothree, four.

For the fifth anti-racism reading group, we listened to Seeing White, an excellent podcast hosted by John Biewen at the Center for Documentary Studies at Duke University. In it, Biewen and regular guest Dr. Chenjerai Kumanyika explore the history and consequences of White racial identity in a way that is both extremely accessible and intellectually rigorous.

This was a particularly ambitious project because the podcast series is fourteen episodes long, meaning there were many hours of material to discuss. For the purposes of our discussion group, we focused on the first three episodes which cover the history of Whiteness and the last two episodes on anti-racist action. However, I encouraged the group (as I encourage you) to listen to the full series, because every episode is worth your time.

Given the expanse of the source material and the conversation, I don’t have a thorough summary of the discussion, but rather three items of conversation that I found particularly interesting. Continue reading “Anti-Racism Reading Group #5: Seeing White”

Anti-Racism Reading Group #4: White Fragility

In an effort to hold myself accountable to better anti-racism theory and practice, I’ve started hosting an anti-racism reading group for health care practitioners in the Seattle area. In this series, I’d like to share both these readings and some of the discussion. You can read part one here, part two here, and part three here.

For the third reading of the anti-racism reading group we focused on White Fragility. Our reading was the article White Fragility from the International Journal of Critical Pedagogy which you can download here. Supplementary materials were Dr. DiAngelo’s White Fragility and Rules of Engagement and this comedic White Fragility Workplace Training Video.

What is White Fragility? In Dr. DiAngelo’s words:

White Fragility is a state in which even a minimum amount of racial stress be- comes intolerable, triggering a range of defensive moves. These moves include the outward display of emotions such as anger, fear, and guilt, and behaviors such as argumentation, silence, and leaving the stress-inducing situation. These behaviors, in turn, function to reinstate white racial equilibrium.

Continue reading “Anti-Racism Reading Group #4: White Fragility”

Do No Harm: A Doctor’s Case For Single Payer

In 2013, Drs. Ubel, Abernethy, and Zafar published “Full Disclosure — Out-of-Pocket Costs as Side Effects” in the New England Journal of Medicine. In this essay, the authors grapple with the ethical responsibilities of physicians when it comes to the enormous cost of modern medicine. If a surgery or a course of chemotherapy is likely to bankrupt a patient, what is our duty to warn them, to ensure that they have considered both benefits and harms? A larger question, however, was left unasked: “How do we as physicians ethically operate within a medical system that forces people on a regular basis to choose between health and financial stability”

To grasp the extent of the issue, consider that even after the passage and defense of the Affordable Care Act, 27 million American remain uninsured. An additional 41 million Americans are underinsured which is to say that their out-of-pocket expenses (such as deductibles and copays) are enough to cause financial duress, despite having health insurance. And as health insurance deductibles increases faster than wages, the proportion of Americans who are underinsured continues to grow.

The consequences of this are grave. Three out of ten American adults report forgoing needed medical care due to cost concerns. One in four were unable to pay for basic necessities like food, heat, or rent because of medical bills. One third spent down all of their savingsContinue reading “Do No Harm: A Doctor’s Case For Single Payer”