How can we improve the quality of psychiatric care that Americans receive?
I address this daily as a psychiatrist in my primary job at a children’s clinic in San Jacinto that is part of the Riverside University Health System. And I address this more generally by training medical students, residents, and fellows through my position on the clinical faculty in psychiatry and neuroscience at UC Riverside School of Medicine.
I believe that immigrant physicians, nurses, and other health care providers are starting to redefine the way medicine is practiced, simply because so many immigrants have found work in the American health care industry. My hope is that these immigrants, with their experiences of other health care systems, can help to improve the way we provide mental health care. In particular, we need to change the standards of how we define “productivity,” and the way that insurance companies define that for the health care industry. More personally, I think the health care industry ought to define productivity through the quality of the interaction between health care providers and their patients and not by the numbers that came through the door for the day. The relationship between the patient and the health care provider should be seen as sacred, and essential to the practice of medicine.
My approach to medicine, both in my clinic and in training medical students, residents, and fellows, is deeply informed by my experiences in both Nigeria and the US. My parents are Nigerians who were graduate students in San Francisco when they met. They took me back to Nigeria shortly after I was born. We returned to Nigeria during the oil boom (in the late 1970s) and I grew up in the southeastern city of Owerri. I then studied medicine in Port Harcourt, which is the hub of Nigeria’s oil industry.
One requirement of my medical school training was a community rotation. I ended up in a rural town about fifteen miles from Port Harcourt city, an area called Ogoni, which is home to a minority ethnic group in Nigeria. It was also the site of many oil wells. Doing my community medicine rotation in Ogoniland—which had been devastated by the environmental impacts of the oil industry, ongoing violence (from both local groups and the militants), and also by extensive human rights violations—was mind-blowing. With a colleague, I began to study the positive and negative effects on the area’s youth of growing up amidst the oil—and learned that many had traumatic experiences, were not able to go to school, or were seduced by the money available because of the various illicit economies that had sprung up around the oil. I have remained particularly fascinated by the combination of psychological and medical effects of these influences on communities in the Niger Delta, and continue to collect data there.
Shortly afterwards, I relocated to the US. At this point, I had my medical degree from Nigeria; an MBBS. To practice in the US, I had to take series of examinations and fulfill requirements to complete the process of acquiring the doctor of medicine (MD) degree. My interest in medical and public health issues affecting communities has made me a community-oriented provider. Hence as I pursued the MD degree, I also studied for a master of public health (MPH) degree. I eventually completed my general psychiatry residency training at Loma Linda University and then child psychiatry fellowship training at USC. I have remained a community-oriented health care provider and I still stay connected with organizations that advocate for the right of individuals and their communities to quality health care and especially mental health care. These organizations include the American Psychiatric Association as well as National Alliance for the Mentally Ill.
In my job in San Jacinto, I have the opportunity to serve people who have no other ways of getting mental health care. Most of my patients have Medi-Cal. Some of them drive over an hour, from farmlands and very rural areas, for care. In many ways, this community reminds me of where I come from because there is so little access to mental health care.
At my clinic, our team includes psychiatrists, therapists, parent partners, and administrative staff. The average child or teen who comes to me has many psychosocial issues. I have to get through so many layers before I get to the core, and this takes time—time we often don’t have in American medicine. Maybe it has something to do with my Nigerian background or just being raised in a different environment, but—when somebody comes in and says they are depressed I just can’t say “OK, here’s your medication for depression. See you in one month.” I always have to deal with the core issues. I ask a lot of questions. We have Maslow’s hierarchy of needs, with the basics like food and shelter at the bottom and other things at the top. I feel I have to get to the basics first, before prescribing.
In the American system, health insurance companies and billing issues drive the way psychiatrists interact with patients. The norm is that the psychiatrist is the pill-pusher and a therapist does the therapy. While I think that specialization is important, it is also important to take a wholistic approach—especially when it comes to emotional issues or psychosocial issues that could be interacting with mental health issues. I will not shy away from something that is staring me in the face, especially when I know that it is a hindrance to the patient. I am not sure if this mindset comes from my Nigerian background or medical school training or even from the specific experiences that have shaped my life, but I just think that looking at an individual as fragments does not work for me. I believe that we should look at the individual in a more comprehensive way. I have to allow my patients to tell me how they feel in a way that is meaningful to them. My job is to grant them the space they need to explain to me what is going on.
I really believe that my work with underserved communities is my calling. I think of it as a great privilege because I could work just about anywhere. However, to have an impact on someone’s life that truly transforms him or her is just extraordinary.
The fact that I am an immigrant helps some parents relate to me. Parents are a huge part of child psychiatry, which is really more like family psychiatry. They often ask me where my accent is from. Even my Spanish-speaking parents who communicate with me through the help of translators may also identify with me as a parent. I think my young female patients also see me as a role model and someone who might inspire them to achieve loftier goals.
But at the same time, my experiences in Nigeria mean I’ve had to make some adjustments to the way I think. When I first started my residency in a more affluent community, I struggled with accepting people’s stressors for what they were. My teenage patients would get admitted following a suicide attempt and during interviews I would learn, ‘Oh, yeah, my boyfriend put this song about me on his phone and everyone laughed at me!’ I had thought of this comment as trivial and not a reason for a suicide attempt. In my mind, I was comparing this young girl to the kids I had seen during my rotation in Ogoniland. I had judged this girl and a few others as not really having problems. I was judging them in a way that was inappropriate. So for me, the biggest change was the way that I had to transform myself to be ready to work with people and their stressors at their level.
I started working with medical students two years ago. Understanding some of the expectations was initially challenging. I learned that the primary goals of the residents’ rotation were to have them get comfortable around psychiatric patients and be able to take a history.
However, as time went on I realized that the rotation was not just about the students showing up just to fulfill their psychiatry obligation. These students are individuals with different stories and different backgrounds. I have encouraged them to see their own strengths, and see the things that they may take for granted. I have asked them to challenge the status quo about stigmas related to mental illness. I have encouraged them not to be scared of mental illness.
In a competitive field like medicine, medical students and trainees go through grueling experiences—they do rotations, deal with all kinds of personalities and expectations, some of which are quite high-handed. They have high rates of suicide. I have observed some undergo a tremendous transformation as they allow themselves just to open up to the process of what happens in their different interactions with the patients and their families. About a year ago, I was pleasantly surprised when the students named me their favorite psychiatry instructor.
In time, I think perspectives like mine will shape health care. I think that “the checklist thing”— where you treat every patient the same—does not work. I’m not just talking about making patients feel good. Productivity is not just how much money you’re bringing in. Productivity should be measured by whether we are keeping this patient out of the hospital. How are you increasing the productivity of this patient?
When a patient comes to me, I cannot find out in 15 minutes why they have been on benzodiazepine for 20 years. And if I could spend maybe an extra five, ten minutes over the next two or three months, I could get this person off benzodiazepine and get them back to work. How can we stay connected to people so that we can really get to the bottom of the problem and solve the problem in a meaningful way, instead of just this superficial treatment we do all the time that’s not getting us anywhere?