From Clinic to Senate

Last week at the dog park, the mother of a poodle-mix wrestling my furry four-legged friend asked me what I did for a living. Internally, I sighed. Never before has this question elicited such difficulty for me to answer or for the person who inquired to understand. The short answer is that I am a psychiatrist who works in the Senate. Inevitably, this response leads to more questions and the longer, more complicated answer.

In April of 2018, I was working as an Assistant Professor in the Yale Department of Psychiatry. I spent one day a week hiring actors, writing scripts, and designing programs for standardized patient workshops across the Yale School of Medicine. Another day or two was spent extracting rich knowledge from university professors in interdisciplinary subjects, clinical faculty in the School of Medicine, and New Haven community leaders to build a residency curriculum in social justice. The remainder of my time was dedicated to treating patients with serious mental illness, complex psychosocial issues, and limited socioeconomic capital as an outpatient attending in a community clinic.

However, the most taxing job of all—that which led to my seeking a different position—was managing social dynamics as a faculty member with intersectional identities. I worked in a Department with over 500 affiliated members: roughly one of five were women, one eighth were queer, and one twelfth were Black. I was one of the very few (likely only) who was all three. While I am conscious of the way all of my identities shape my perspective, my identity as a Black person was most acutely salient during this time due to the tense sociopolitical context.

I was a 33-year-old who had navigated various institutional landscapes as a multiple minority, but had never felt so far on the margins of belonging, socially, to my academic community. Much of this dynamic was influenced by my efforts in support of inclusive treatment of minority patients, students, or faculty. I grew accustomed to being the only person in the meeting to voice disagreement about decisions that could impact those not represented at the table. I grew accustomed with being the only Black person at staff meetings, at the upscale restaurants, or doctor on duty. But being the “only” in many settings started to become upsetting as I perceived increasing barriers for others who were Black, in particular patients.

The long standing impact of institutional inequality on the lives of my marginalized patients, students, and members of the medical workforce infiltrated my psyche. The aura of discouragement was palpable in the clinic, classroom, or coffeeshop. In addition to daily life struggles, my patients now expressed worry about large scale problems like getting shot by the cops because of their race, not knowing if family survived the aftermath of Hurricane Maria, or getting off the waiting list for public housing after three years. The same conversations about social justice that I had been having for years now contained a stronger undertone of suffering: colleagues expressed more exasperation with caseloads during quick chats at the water fountain; black and brown trainees sighed more heavily when I asked how they were doing as we crossed paths in the hospital; and the standard “good morning” pleasantries with the clinic custodian turned into “I’m surviving.” I began feeling like my advocacy efforts to support others fell short. Worse, I started to believe that nothing I did would ever be enough.

In an attempt to hold on to my faith in advocacy, I chose to leave. I wanted leverage my privilege as a physician and look for new opportunities to influence change on a larger scale. Therefore, in August of 2018, I began working as a health legislative fellow through the American Psychiatric Association in the Office of U.S. Senator Christopher Murphy. In this role, I interface with bipartisan congressional staffers, constituent groups of various backgrounds, and draft memoranda from a perspective that values my experience as a staffer socialized in a clinical, not political context.

In my time thus far working with the Senate, through meetings with constituents, Congressional briefings, review of proposed or enacted legislation, I have been able to connect the policy implications leading to the inequity I witnessed as a psychiatrist. Due to the barriers of implementing mental health parity law, I see why my patients only had access to a psychiatrist who practiced 1.5 days a week yet had a caseload of over 100 patients. I understand how the lack of funding and coordination of agency efforts for the disabled contributed to a deficit of functioning braille machines or trained interpreters for my blind or deaf patients who went months without communicating with another person who really understand them. It is clear how the millions of dollars to combat the opioid crisis rarely reach those in recovery whose only housing options pose the risk of stolen medications, infestation with bed bugs, or relapse triggered by watching housemates use drugs. When someone asks me what I do for a living, I have no idea how to explain all this. Perhaps what is more anxiety provoking, is what to do with all this knowledge when my experience ends in June 2019.

What I do know is that as a physician, an individual with multiple minority identities, and currently as a Congressional fellow, I am even more motivated to be an agent of change. However, to be honest, I am not the most confident that lasting political change is possible.

Despite the uncertainty of whether change is possible, I can’t stop trying. But I will need help from other physicians and members of the health care workforce because true progress in access to care, effective treatment, and more equitable outcomes will only come through efforts outside of the clinic.

I need your help.

First, and most importantly, it is imperative that our efforts start in our own medical communities. During my time in the Senate, I have seen many leaders advocate for national change in the absence (or deliberate neglect) of making those same changes locally. We need to advocate not just for diversity, but also for norms that reinforce social inclusion of all types of people who may or may not carry ID badges to enter our institutions of medicine. Academic institutions (and academics) need to prioritize sharing resources (all types i.e.: land, labor, capital, entrepreneurship) to bring individuals from the margins to the center of their communities. We cannot improve the health of our patients if we do not pledge to improve conditions mandatory to fostering improvement. We should capitalize on the brilliance of our thought leaders to develop evidence-based strategies for resource distribution that could be widely disseminated.

Specific examples include:

1.) Investment in the surrounding community infrastructure to benefit individuals outside of the university whose lives are affected by the institutions’ presence.

2.) Investment in hiring employees (especially in leadership) from backgrounds forced into the margins by historical discrimination.

3.) Investment in hosting courageous conversations with all members of your community about changes to practice including innovative, institutionally mandated education rooted in social justice and ethical responsibility; Effective development of safe harassment reporting and response protocols that are transparent to your community; Thoughtful treatment standards rooted in patients’ access to social determinants to extend inclusion in equitable ways; Investment in having critical conversations that may result in negative feedback, demotion, or loss of privileges to important stakeholders that foster hostile work environments; Promises to ensure that conversations about the above do not continue to be conversations, but lead to action so that those in the margins do not have to rely on faith, or lose hope, or give up.

Second, we as providers need to feel empowered to share our experiences in policy arenas. Since my time on the Hill, I have often been one of two physicians in a room while discussing changes to physician payment structure, which specialties need loan repayment, and prescribing requirements. As a physician, I have been able to share concrete examples about the lack of access to buprenorphine providers or difficulty in deciding how to code patient encounters to balance affordability with reimbursement. As healthcare providers on the front lines, we need to be present during these conversations.

Specific examples include:

1.) Contact your city (city council members, city staffers, local health department), state (state health department, district representative or state Senator), or federal officials (U.S. Senator or Representative) directly about policies that create barriers for your patients.

2.) When patients describe encountering a bureaucratic barrier to obtaining resources, research the etiology of the legal policy, then contact that office directly via email, written letter, phone call, or attend an event hosted by the office and do not be afraid to approach the official in person!

3.) Get involved with your state medical society who can keep you updated on opportunities and strategies to maximize your contribution.

3A.) State medical societies can provide guidance on how to write letters about specific issues and laws being considered that may impact you or your patients.

3B.) Look into opportunities to advocate through specialty professional organizations.

3C.) Professional organizations have a dedicated team of individuals who meet with government officials (also known as lobbyists) and are often looking for physicians to accompany them or share experiences which bolster advocacy goals.

3D.) Encourage your colleagues to get involved; there is strength in numbers.

3E.) Apply to fellowships offered to medical providers to work in Congress. These are offered by professional specialty organizations or other health advocacy foundations.

4.) We as providers must practice self-reflection, self-interrogation, and self-empathy. We cannot advocate for others unless we advocate for ourselves. As clinicians, we want to take on tasks to help others, often to the detriment of our physical and mental health. Feel empowered to say no, ask for help, or ask for time off. When we risk burning out, we run the risk of impacting other individuals who rely on our efforts. We also risk burning out our family and friends who are keeping us emotionally afloat. Strengthening your understanding of why advocacy is important can help motivate and direct efforts. Seeking out educational resources (i.e.: books, podcasts, films, talks about social justice, empathy, morality, inequality) and introspection strategies (psychotherapy!) can bring clarity.

Most importantly, remembering that change takes time can relieve the immense pressure that many of us high-achievers put on ourselves.Remember that advocacy does not have to mean changing legal precedents; it can also be taking a mentee out for coffee, giving feedback about your colleague’s stereotyping of a patient, or not patronizing restaurants with unfair wage practices.

Finally, in order to advocate, we must accept uncertainty and doubt. I have no idea if equity in access, treatment, and outcomes for those at the margins is possible. In fact, most of the time I doubt it is possible. However, mobilizing members of my medical community to be leaders in changing policy is well worth trying. At least the next time someone asks me “what I do,” I can say, “I’m advocating, want to help?”