Tyra Lee: Student Researcher and Dedicated Advocate in the Field of Medicine
December 18, 2023
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Hi! My name is Alister, I am an ER physician, and I am a faculty member at the MGH Center for Social Justice.
The center has a fairly straightforward mission, which is, figuring out how to make the care of vulnerable patients better and take better care of our patients in general, and it’s about how to take the opportunity with vulnerable patient groups in the emergency department and do something sensible with them.
Back in 2015, I was taking care of a patient on an overnight shift on Friday, around 2 a.m. The patient was a 20-something-year-old female, that had two kids, who about two months before seeing me, had a really big surgery and she was sent home with oxycodone for pain control. Over a couple of weeks, she felt like she couldn’t get back to normal without this medication. Once she ran out of the prescription, she started taking an opioid painkiller left in the home from her husband’s prior surgery. She started asking her friends and family, and then eventually when none of those things worked she got a dealer. Over the course of six-day weeks, things escalated to a point where she never, ever would have dreamed of.
That night when she came to the emergency department she had made a decision, she was determined to stop and get her life back. So, she texted the dealer and she said to him: “look, I am going to get help, so don’t ever text me again”. She later showed me the text and the dealer basically responded: “no problem, have a good life”. But about an hour later the dealer came knocking on her door and she went downstairs and he said “look, recovery is hard, and I think you are going to need some help” so he gave her about ten pills for free, oxycodone.
Her husband saw this, intervened and they both decided that night; they had to do something about it. They spent about two hours online, trying to find treatment centers, and there was nowhere open, so she came to the emergency department, and basically, I’m hearing this story and I’m like “What? Yeah, of course, we are going to help you”. I was a doctor for barely less than a month and I had no idea what helping her meant. So I went back to my attending doctor, who was the boss, who decides what the plans are, and I said “look, here’s the plan that I have to get her admitted to the hospital and get her the help she needs” The attending, who is a kind and compassionate doctor said nothing could be done by the emergency department and she had to be discharged without help.
That for me was the beginning of it, it was the realization that the vast majority of emergency departments treat patients like her, in the way I just described. We miss these opportunities to actually get people their lives back. If we did something, while they were here, that was productive; we might help them get one step closer to recovery. We may not be the ultimate solution, but we can get people along the road to recovery.
In order to actually start with a patient like her on the road to recovery, she needs to be put on the gold standard in addiction medicine for patients struggling with opioid addiction. The issue is that there’s an anomaly in our legal system, and that is that we still have a wall on the books called the Harrison Narcotics Tax Act, passed in 1914. This basically means that physicians can never use medications to treat addiction. In 1914, that made a lot of sense, but in 2021, the science has changed quite a bit, and the data demonstrate that medications work for addiction. Just like medications work for diabetes and for infection.
Basically, this law mandates that physicians should not use medications. In order for me to start that patient who came in that night on the correct medication, I need to have something called “DEA X-waiver”. Which is a ridiculous concept, that in order for me to prescribe buprenorphine, I must have a waiver. To get this waiver, you need to take an 8-hour course, you have to pay $200, and you need to wait about 4 weeks. Busy physicians in the middle of a pandemic don’t have the time nor the bandwidth to be doing something like that. As you might imagine, less than 5% of all physicians across the country have this waiver, and in the middle of an opiate epidemic and the middle of a virus pandemic, it’s all making the opiate epidemic worse.
We need to dramatically increase the number of physicians that have this waiver immediately. GetWaivered really is an attempt at trying to do that: getting people this waiver as quickly as possible, in a way that is as easy as possible, so they can get started treating patients. The work through our grant awarded for our efforts in opioid recovery has allowed us to really scale the model of waiver training courses, so we can get thousands and thousands of people wavered, and that’s what we’ve been doing.
The core of this work is really founded in behavioral economics, which is the idea that you can influence decision-making without using financial incentives. Back in that story that I told about that took place in 2015, I realized that in order for me to make an impact on this problem in my hospital, I had to start with helping all physicians get waivered, get this DEA X-waiver.
So I went back to my mentors at the Kennedy School, and my professors who are really experts in the field of behavioral economics. These are folks who have applied these concepts to nudge decision-making and political behavior. Having folks vote for one candidate or another or helping folks make decisions with regard to consumer behavior theory. My stance has always been: “Why are we using these tools to get politicians elected or to get people to buy products when we should use these tools to save people?”. This was the first experiment of trying to use behavioral science and economics, to influence decision-making on physicians to get this waiver.
A few of the things that we did, that I’d say are really part of behavioral science, are:
Number 1: We addressed hassle bias, which is, if the behavior is hard to do, you might have all the motivation in the world, but you just don’t follow through with it. Here we have this system, where you have to sign up for the waiver, there’s no clear website or place to do that. You need to figure out if your schedule even fits with the upcoming courses, and you also need to figure out what course you take, since there are three different versions. There are a lot of decisions that make it a hassle waiving process, so GetWaivered made it really simple: click this button on this website, get it added to your calendar, and you’re on the course.
Number 2: Social norms around the concept of treating opioid addiction. Back in 2015, I was looking around to see what other people were doing in my department, and I would come to the conclusion that no one was treating opioid addiction, so “I was okay not treating it too”. That lack of a social norm really works against the change we want.
For GetWaivered, we started at the top, we recruited the Vice-Chair and the Chair of the department. They were the first people who announced they were going to get waivered, and they announced so at a faculty meeting. In that meeting we had five well-regarded doctors, people who folks respected, stand up and say “I am also joining the Chair and the Vice-Chair.” So that’s just one example of what social norms look like.
Number 3: The concept of saliences that, really emotive, eye-catching, or memorable stories/experiences, actually influence the way that we make decisions because we remember the story, and it stays with us. When you are thinking about ER physicians, we only see, and hear the stories of patients who have, in our eyes, “failed”. The only patients with opioid addictions that we see are the ones who have overdosed, who have relapsed, or the ones who are still struggling with their addiction and can’t get a handle on it. So what story do we tell ourselves? We create this scenario: the patients who have an opioid addiction, don’t get better, they just overdose, and relapse. So “why should I care anyway?” “Why should I make the extra effort?” “Because these people don’t get better”. This is called an availability heuristic; our worldview is made up of the things that are most available to us, in terms of the data.
We had to counteract that. During our GetWaivered sections, we brought back some of the frequent flyers, the people who are physicians struggled with, and thought they were dead, who came in overdose after overdose. We showed them, not only that they were not dead, but they were in a suit, telling you about how they finished their degree and were now an accountant/professional.
Yeah, right. In 2018 we had a hospital focus for GetWaivered. In 2019 and 2020, we took the show on the road and started partnering with states. We partnered with the state of Texas, with the University of Texas, and also with the state of Nebraska through the department of mental health. Really, those two experiences were like, we know these nudges and these interventions worked in a hospital, in the individual department. But what about if we were to do this on a larger scale? So we did roadshows in the state of Texas and we helped to set up waivered training courses in the state of Nebraska. That’s when the NIH (National Institutes of Health) and the NIDA (National Institute on Drug Abuse) basically, spotlighted the GetWaivered program and put forth a model for how states can implement programs like this.
We were just about to really hit our stride thanks to the fore-grant and then the pandemic came. We had these plans of doing these humongous auditoriums with hundreds of people getting waivered, but we couldn’t do that because of social distancing and the limited large crowd gathering restrictions. So we decided to try and pivot and do this work online and we found that we were about three times more successful than we thought we were going to be. Altogether we got about 3500 people to do the waivered training course throughout all of the different GetWaivered stations.
The reason why it’s more successful with Zoom is that it comes back down to hassle bias, it’s easier to set up and take a course on Zoom rather than getting in your car, paying gas, driving to a convention, etc.
Sure, it’s a little bit like a rollercoaster, honestly. The Trump administration announced it was going to be making changes to the X-waiver, and in the last waning hours of the Trump administration they released the news that they were going to remove the X-waiver, which is actually good, good news. Myself and a couple of my other colleagues had written a letter to the Biden transition team, basically recommending the exact same thing.
Saying something like: “the waiver has to go, particularly now, when we are seeing an overdose spike because of the pandemic”. So we were pretty hopeful that when the Biden administration came in, they would not only continue with the X-waiver removal process but add to it, and make it even easier for patients to get into treatment. But it’s been pretty unfortunate that the Biden administration backpedalled in this situation. My hope is that it’s temporary, but it doesn’t look like it, so we’ll see.
I wake up really early in the morning, not because I am a morning person actually, but because it’s the only time I have to myself. So I wake up around 5 a.m. and then I work out because I realized that I really need a face-change, and that process of working out shifts the face of my brain from my sleeping and being relaxed mode to “Go mode”.
After that, I try to meditate for anywhere between 7 to 10 minutes, and then I start working. I am focused on my own individual projects until about 11 a.m. and that’s when I start taking meetings. The rest of the day is just basically taking meetings and responding to requests, and things like that. But that protective time in the morning, about 4 to 5 hours, is where I get the most creative work done. Then after a full day of meetings like until 6 or 7 p.m, I do emails and try to go to sleep around 10 p.m.
Yep, so my shifts are all over the place, which is just part of the job.
I have a different routine everytime I approach my shifts. For me, I think, there is this sort of pattern that maybe you can see developing in the job that I took. In emergency medicine it’s all really about responding to crises, right. It’s about being flexible, and adaptable and trying to solve problems in the moment. In my schedule, when I look at my calendar there’s a similar pattern that develops: I have my daily routine, and then I have my ER shifts, which are just kind of random and so I have to adapt to them.
Similarly, in the projects that I work on, I have my approach, which is what I think we are going to do and what I expect that could occur. But then life happens, and we have to adapt and be flexible and address the problems that arise. As a physician my internal state in the emergency room is about being responsive to challenges and using the adversity as a springboard.
A mentor of mine also said: “if you can’t find 10 minutes in your day to relax/meditate, that means you probably need 2 hours”. Meaning, your day is so packed to the brim that you are not making time for yourself, that means you have a lot of work to do in order to regulate your internal space and get things under control. At least that is my interpretation of it 🙂
Besides Slack, and Google Suite, I would very much recommend learning something called AutoHotkey, which is basically a script that lets you automate things on your computer, and it’s super helpful. Another one I’d recommend is Dragon Anywhere, which is a speech-to-text software that is very accurate and I think there’s benefit to being able to sort of step aside and write a quick note to yourself, about an idea that you have, or a connection that you made. Writing it down for me is a bit hard for me sometimes, so this app makes it very easy since you just speak into your phone and it types it for you.
Lastly, this is not an app/tool but it’s more of a behavior. There’s very good research that demonstrates that all of the major tech companies (Instagram, Facebook, Apple) have gotten really good at creating addictive products. The applications that we see, the beautiful imagery that we have on these different social media platforms -generally speaking even things as discrete as the color choices that they’ve chosen- all of this really engaging and almost magnetic attraction to our social media, profiles, phones, makes us spend a lot of time on it. And I find that the more time I spend on my phone, the less engaged I am in other things that I need to be, so one really easy thing that I have started doing (I told myself I’d do it for like 2 days at first to see how it is but I am just not going back) is converting my phone to black and white, so there’s no colors, no eye-catching stuff, which makes my phone really boring and less time wasting.
Well, I am a big Audible fan, so I have lots of books in audio format.
There’s a lot of books that teach people new information, but I’d say the ones that stick most with me are the ones that don’t teach me any new information but actually change who I am. Two that come to mind are: Daring Greatly by René Brown, and the other one would be Tiny Beautiful Things by Cheryl Strayed.
I would say that, my research really is all about how to create change, and how do you sort of move people in departments and in medicine in general, closer to where its values are. We say want to take care of vulnerable people, and those who are most in need, and yet our actions often don’t demonstrate that. My work, my research, and my projects, are all sort of into getting us close the gap between action and intention.
So what I’ve come to learn is that the process of managing change is an interesting duality. You have to be committed to your long-term, slow, gradual, shifting away, and the hard work of doing the daily grind. And It can seem like there’s not a ton of change being made on an individual on a day-by-day basis, but that’s one of part of the making change process, you have to be committed to that.
Yet on the other side of the duality there are these moments, these privileged moments, where you can speed up time, and if you seize them, you can buy yourself years. You can catch your sentiment, and move it in the direction of getting things done very quickly. For example, with the opiate epidemic, when I started even in 2015 it wasn’t really a national newsline crisis. When I started sort of trying to mobilize the support around it, I had to bide my time and wait until the moment was right. Then it started coming up in national news headlines, in the Boston Globe, in the New York Times, and it was something that was on the tip of everyone’s tongue. So I could seize my opportunity to move the issue forward, because I knew I had public support, that I didn’t when I first started.
The overall process I am beginning to learn is a lot like -some sort of a weird metaphor but- how the Grand Canyon was made. The Grand Canyon is the biggest natural valley in the world, you can fit the entire city of New York in the Grand Canyon, and it was made by two forces: one, the slow drip of rain and water, and two, by that same water becoming frozen in between the cracks. When that frozen water expands, whole sections of the cliff break off.
Basically, there’s this drip process and also taking advantage of the bigger, and sudden opportunities. Managing the change process means you have to be ready for both situations, the slow gradual work, and also being prepared to seize moments when you have them.
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