You are currently browsing the category archive for the ‘Shrink Stuff’ category.

Office

All doctors think they are smart enough not to be swayed by sweet-talking pharm reps but the research supports the opposite: we are far more likely to prescribe something when a salesperson drops by to schmooze and give out samples and (best yet) something to eat. As a consequence I try to be vigilant towards these devious drug dealers. Most of the time I do a good job (I hope) sticking to evidence-based and science-supported statistics. The representatives who drop in at the office have learned not to talk rubbish or push things. There is one exception. A particular pharmaceutical representative is being especially insatiable in her pursuit to get me to make her product my number one prescribed medication. Unfortunately the prescription is very expensive, seldom covered, and causes side effects (despite her insisting it does not). There are cheaper alternatives that do just as good so why use it? Brand name medications are more expensive than generic meds; patients often complain these are not affordable.

Perhaps she is under pressure from her bosses to produce sales. Maybe it’s a personal matter; she sees me as a challenge like the Duke of Edinburgh award. I have to get on board and prescribe it. Whatever her motives she pops in a lot like a nefarious jack-in-the-box to inquire if I am using her product.

So far her means of persuasion have fallen flat. Someone didn’t do her homework that feminine charms and flattery may work well for on my colleagues but not with Urs Truly. The standard graphs and charts she presents I see right through (all of them produced by the same folks who make the drug). Poor reasoning and straw man arguments make my eyes cross. Her point ‘so many others use it as their main drug” does not move me onto the bandwagon.

Sorry lady but your product just isn’t my favorite. It isn’t as clean as you report and ny patients find it ‘too expensive”* It’s not a bad drug it’s just at the end of the line of my choices.

The Wonder Receptionist informs me said rep is bringing to her next luncheon** a physician to talk to me about the medication. The manifest reason is for me to ask a colleague any questions off-label something she is not allowed to do. Fair enough. The real reason to bring in Dr. Bigwig is for me to be dazzled so I too will want to be just like Dr. Bigwig and be swell too via using the product.

I could ask the Boss-man and Boss-lady to tell her and her ilk to go away but The Other Doctor likes having them in. I like the samples they provide; I use these for patients who can’t afford “X” when “X” is the only thing that works for them.

Salespeople come and go quickly as they are frequently sacked or reassigned to other areas. Ms. Persistence is more likely to be transferred than succeed. Perhaps someone higher up the food chain will connect the dots and replace her with a big burly bear-type salesman. I hope I am up to the challenge.

 

*In reply she asked me to ‘define expensive”. I explained when my patient says their medication is too expensive for them they want something cheaper I take this at face value and not argue.

**Poor thing. She always brings in the same food, not my favorite. If she brought in something better / something I liked perhaps her sales would go up?

I am not a fan of Robert Heinlein. There are many reasons for this but one of them is about the traits of his novels’ heroes. They are often ‘The self-sufficient man’. The fellows could do everything themselves thus never needing help from others. Mr. Heinlein extols his readers (mostly boys) to be likewise and he castigates thems who do not. Asking for help is a sign of failure. The truth is the opposite: we continually need help. We are a species that evolved to live in groups and cooperate to achieve our survival. All day long we seek assistance from others.

Throughout my workday I listen to patients’ fears. There are usual ones like public speaking, flying, and animals with nasty pointed teeth. “Asking for help” is a subtle but ubiquitous anxiety for most, which is odd as we all do it and need to. Many people avoid asking for help as they fear rejection or the judgment of others for doing so. I think men suffer most from the Shadow side of the Self-sufficient Man archetype.*

I try to teach patients it is OK to ask for help. To better their chances of getting results and feeling good about the process I give’m a few tips. We tend to ask for help badly, You would think by now we would be good at it. Many ask do so in an apologetic manner (I’m sooo sorry to bother you) and don’t communicate the specifics.  We often ask for help via text or email thinking this is the best way. Studies support the opposite: we are much more likely to get a ‘yes’ reply if we ask for help face to face or a phone call. Another matter to consider: we are awful at registering a person wants or needs help, yet people often assume our loved ones can sense we need help so they don’t directly ask and become upset when the others don’t pick up on our allegedly obvious vibes. I can’t remember the exact term for thi, but it is based on the illusion of transparency. Bottom line: you have to ask, even those you think should be able to read your mind.

When I need help I first tell my Self-Sufficient Man Complex shaming me yeah, I hear you but buzz off. Then find the person I want to ask and do so face to face. “I need your help” I say. Then I state in simple, realistic, and clear words what I want. “I need you to call this patient back for me to say she needs to come in” or “I want you please to call Hector (the groundskeeper) to come tidy up the yard” or “Thank you! I can’t get into my account I want you to help me figure out why not”.   Another tip: if there help was helpful, tell them about it later. “I wanted to let you know your help was really helpful, thank you”.

Let’s stop giving The Self-Sufficient Man more libido (psychic energy) than he needs or deserves.

mohandas-gandhi-leader-interdependence-is-and-ought-to-be-as-much-the

 

*The cliché of men not asking for directions touches spot-on this archetype.

office

So-called truths are often not so. I recently heard a podcast debunking the concept of ‘alpha-males’ in wolf packs.* The Firesign Theatre strikes again: “Everything you know is wrong!” When I pull back the curtain on something to reveal the great and powerful Oz is a humbug I often feel a sense of being had. The alpha-male wolf nonsense evoked relief. The clap-trap behind this concept has done a lot of damage and it can be thrown out for the rubbish it is.

I grew up always at the other end of the hierarchy of alpha-males. Only at home did I have some clout. As the oldest of a bunch of brothers (fine fellows all, well over four feet) I am still  called upon to take the role of time-keeper whistle-blower referee. On the other hand they are all taller than I which sort of lowers (pun intended) my role as ‘big brother alpha-male’.

My nerdy wimpy self now has a board-certified double specialty connected to it. I forget I am the ersatz alpha-male. Being the ‘M.D.” at work puts me in the alpha-role more than I realize. I am not one of those bossy a-hole doctors barking orders at the minions. Despite my jovial nature and polite manners (think Lily Tomlin in “Big Business”) everyone at work addresses me as ‘doctor’ even though I’ve tried to make it OK to call me by my first name. The thralls all seem to do my bidding without question. I’ve noticed when I cut people off they shut up and let me go on not call me on it. It’s good to be King but it needs careful consideration when to pull out such archetypal energy.

In the bad old days when doctors = god patients did things without question. Nowadays the doctor/patient relationship is dialogue and consensual process (good!). All the same there is a part of patients that wants/needs me to be the alpha;  too much laid-back interactions makes them uncomfortable.  It is hard for me to conjure me-big-doctor alpha-male dressed in loud brightly colored aloha-style shirts. It’s like seeing your pilot wearing T-shirts and cut offs in the cockpit. You know he/she can fly the plane but you want to see a uniform.

It is hard to be The Great and Powerful Oz when you are more like Judy Garland.

male-doctor-looking-powerful-strong-flexing-arms-expressing-power-56354338

 

*Turns out the actions of the ‘alpha-male’ wolf is more of less doing the ‘dad role’ to his family. That’s it. Even the author of the seminal treatise on the topic can’t seem to shut it down.

Back when I was smaller and people were taller the ability to change your mind was considered a sign of maturity and wisdom. If you connected the dots you were wrong about something you were adamant was ‘true’ you were either sheepishly or  matter of fact admitted you were wrong.  Either way you moved on with your new and improved state of being.  If your hypothesis was incorrect you discarded it for something better – and you were looked upon as good for doing so.  I’ve been trained in the scientific way to test hypothesis and if they fall flat to reject them even if “I really wanted them to be true.”

Or so I remember.

Perhaps this openness and plasticity of the past wasn’t so stellar as I remember. My recollection is probably colored by the human propensity to make the past a more ‘golden age’. All the same the 180-opposite direction approach people have these days is refusing to admit they were wrong and let alone change. Presented with data that challenges paradigms makes people dig further into their convictions. Changing your mind is looked upon as a sign of weakness.* What was once considered a sign you were being pig-headed is now admired as a sign of strength. Oh the horror.

In my profession (medicine) new stuff comes up all the time. There is a continuous parade of “Everything you know is wrong” findings that oblige me to discard cherished beliefs to what work with what the data actually supports.  My specialty has so many turnovers it makes my eyes cross. Public Opinion may say this is a bad sign but I see it as quite good – and proper.  I want to throw out the rubbish. Otherwise I’d still be prescribing psychoanalysis for the treatment of OCD (which is caused by suppressed anger towards your parents) and sending ‘perverts’ to conversion therapy.  Oh the embarrassment.

You will be shocked shocked shocked to hear doctors are no better than anyone else that when confronted with data telling them to think and do differently they often than not just keep doing what they have always done.  “Time-honored treatments’ don’t bow readily to ‘evidence-based medicine” I am sorry to say.

And of course, thems who want things to stay status quo don’t take kindly to thems who challenge things  Just think of Galileo, Corpunicus, Darwin to name a few.

I will continue to be open and welcome changing my mind as needs arise and see this as a virtue not a sign of spinelessness. Thems who are recalcitrant in their beliefs in are not ‘strong’.

“You see, the point is that the strongest man in the world is he who stands most alone.”
Henrik Ibsen, An Enemy of the People

 

 

*I have a vague memory of a candidate running for public office being ridiculed on TV for changing his mind on something. The ad conveyed he was therefore not to be trusted and he was ‘weak’ for being so. I recall thinking he ought to be elected as a sensible fellow open to new ideas and self-correction.  I believe he lost.

I recently read genetics is only ~ 25% of what makes a long-liver from a short-timer. Thems who live to be 100 don’t do so just because they have ‘good genes’. This is good news for folks who want to make such a goal. It turns out the key(s) to achieving 100 gets down to five factors. Happily four of them aren’t too difficult to do if you are determined to do so.*

First of all let’s get rid of the rubbish, the things 100 year old folks did NOT use towards seeing your one hundredth birthday cake:

Complicated/zany diets

Mega doses of vitamins

Supplements

Antioxidants

Goop advice

Going to the gym

Money

Abstinence from alcohol

‘Success’ in life

The world’s communities with lots of 100-year-olds members were interviewed and they consistently don’t do anything of these things.  What a blessing to know!

Here be the five: 

1] Be active.  None of these folks went to the gym or ran marathons.  Rather they had active lives. Their work kept them moving. They walked to places; they took the stairs. 

Advice #1 – take the stairs, park further away and walk a bit to the store. Get up and move lots. Get in a daily dose of thirty minutes of action. 

 

2] Take time to chill. On the other hand they did not work themselves to death, double tasks or freaked out over a wasted minute. They all had some sort of ‘down time’ each day to take a siesta, have a tea break, gab whatever. They also got enough sleep, valuing  sleeping time over getting one more thing done.  Their vacations were the type for sitting and reading and talking – not running amok trying to do a lot and see all the sights.

Advice #2 – Take some time off each day to unwind in meditation, prayer, whatever. And turn off the techie things to get some sleep.  Forgoing sleep from ‘fear of missing out’ is bad bad bad. 

 

3] Eat right and eat less.  These sages never did silly diets; they had a dietary lifestyle. They did not stuff themselves; they would eat just enough to start feeling full and then they would stop. They ate little meat (not none!) and what they ate is mostly plants.  Nobody abjured butter or booze or bread; they just ate little amounts. They also spent time to eat – and with others. No drive-through dining here.  

Advice #3.  Common sense eating (type and amount) consumed slowly with friends and family is the best diet there is. 
4] Belong to something.  The 100 years folks did not live alone or in a vacuum. They lived in communities that helped each other out and tended to each other’s welfare.  They had privacy and personal times but they also ‘us’ times and places. 

Advice #4.  This is the one of the five that is most difficult to remedy. Somehow you need to be part of a family, a community, a church, or a club. Don’t do Life alone. 

 

5] Meaning. “What am I waking up for?” sort of questions. None of them lived cosmic or fabulous or infamous lives, but their lives had meaning. This was in their work or their art, or what they do for their family, friends. 

Advice #5. Make meaning in your life. I can not tell you how I can only tell you it is vital. 

There. Long life isn’t complicated or bedazzling. The list isn’t in line with todays’ society belief it is fame, power, and money that will get us long and happy life. 

Even it you don’t live to 100 you are likely to live well. 

100-Year-Old-Birthday-Cake.jpg

*It is a fair question whether or not making it to 100 years old is a good goal. This is not the point of today’s entry. 

Office

While you all are no doubt goofing off or sleeping in or raiding hamlets* Urs Truly at a two day weekend long conference, powwowing with his fellow wizards, learning the latest on this, that, or the other.

Today’s topic is pain. We will hear the latest on what is it, how to properly diagnosis and address it, and the updates on the controversies around opioid analgesics A.K.A. as pain pills. Unless you’ve been hiding under a rock you know the latter topic is a hot topic A.K. A. ‘The opiate crisis.’  Society and medicine are trying to come to grips with ‘how on earth did we get here” situation we are in and what to do about it. As is often the case, people/politics/physicians all want simple scapegoats and solutions.  Fat chance of that. It’s a morass of awful gunge consisting of many, many factors. Frankly it’s a tangle and will take time to sort through the matters.

I don’t specifically treat pain but I see a lot of psych patients who are dealing with chronic pain. Most folks with pain also have depression/anxiety; it’s like a coin with two side: pain and mood. Overall they are not doing well.  Most come in to see me quite remonstrative and disconsolate** about their pain management physician.  There are four common themes to suggest they are not just whining or seeing things wrong:

1. The management of pain is inadequate

2. They are treated/seen as manipulator drug seeking scoundrels rather than patients.

3. The doctors are more concerned about them not taking pain meds than how they are doing.

4. The system went woefully wrong and they are the ones being ‘punished’ for it viz. can’t get proper treatment viz. can’t get pain meds. 

I find it hard to polish my side of the coin when the other side is not being well addressed.

One of my greatest challenges for pain-full patients are thems taking long time opioid-based pain medications and tranquilizers now being told by their pain docs ‘it is one or the other”  viz. get off the valium or they will no longer prescribe the Percocet, that sort of thing.  Ironically, it often would be a very good thing for chronic pain/anxiety sufferers to lay off these types of medications in favor of alternative treatments that show better help – but you try telling them that.  They resemble an orchestra of scorched cats as they lament these four matters listed. Poor sods. They too have to redo their paradigm and approaches as do the physicians. 

The three hour lecture on these matters is about to commence. After it concludes I will add a post-script for thems interested in updates and news and such. 

Spo-fans who are dealing with chronic pain: I am curious to hear from you if you find it difficult to get help with such. 

 

*Guess who’s doing that today. 

** Many are positively irate. 

Note: The Board of Directors Here at Spo-Reflections thought this entry rawther altiloquent. The told me to expunge the similes and smarty-pants words. Nerts to them. I left’em as they are.   After all this article is about control.   – Spo

In my line of work I see a lot of stress. One of the most frequent and most upsetting emotions people have is the feeling of not being in control. “I have control issues” they tell me. They quickly go into a horrible fantod when they feel not in control. They spend a lot of time and energy etc. trying to be in control.  For folks with ‘control issues” the poor dears never seem to have any control. It’s like being a perfectionist who can never get anything right.  The gods seem to find the vow for control comical; they like to surround thems with control issues lots of thing uncontrollable.

After thirty years of encountering this issue I’ve come to these conclusions:

There isn’t much you can control.

Control is overrated.

Letting go of needing control paradoxically helps you feel more in control.

Alas, these truisms are seldom comforting to these poor unfortunate souls. Rather than feeling relief to hear their ponderous yokes can be thrown off patients with control issues double down and up the ante in their agitation to become more in control. Oh the pain.

One of the reasons they fare so badly is they continuously confuse things they can control with what they can’t control.*  In ‘The Serenity Prayer’ people ask for the knowledge to know the difference. Not so my patients.

Alas, Babylon! One can’t control Life – or most of it. In the proverbial Pandora’s box of Life’s uncontrollable elements there is hope. There are few things we can control, and happily they do a lot of good. In Life’s game you don’t have many cards but you hold a few trumps.

– Things you CAN’T control –

Other people  (what they do and what they think of you)

The weather

The past

Random bad events  – which are not due to God’s will/Fate/destiny etc.

 

– Things you CAN control –

Diet

The company you keep

How you treat others

Asking for help

Your choice in beliefs and attitude

Saying ‘no”

The philosophy of Stoicism rests upon the axiom Life is not a field knee-deep in buttercups and daisies but full-up with sorrow and disappointments. One can not control things yet we take comfort knowing we will be OK enough.

Spo fans are welcome to put into the comments additions (and disagreements) what you think we can/can not control.

*This in itself is a problem viz. control-types don’t want to sort out what they can’t control; they want to control everything.

 

NOTE: this one was written without too much careful thought or editing. It is more catharsis than careful prose. I thought to store it away until I could carefully comb it for errors and such. I decided to post it as it is.   

When I was a newbie shrink I was filled with enthusiasm and psychoanalytical theories; I was ready to shrink heads and assist others in their exploration towards awareness and better being.  Thirty years later I am not so excited in that way. I now know many (most?) people don’t want to ‘get better’ or they lack the courage and/or resources to do so even when they want to.  A lot of my nowadays work it trying to do what I can; I try to alleviate some pain and keep major bouts from blossoming.  The vast majority of my patients aren’t looking for self-achievement; they are looking for a means to keep their symptoms from dominating their lives so they can function. Medications often work better than insight-oriented analysis when it comes to helping agoraphobia or manic reckless behavior.  For folks with intrusive ruminating thoughts it’s better to give them Prozac than to explore their alleged unconscious violent ideation towards others, which was the standard approach in psychoanalysis for the treatment of OCD.  What I professionally do, and the tools and paradigms I use have little resemblance to what I had in the early 90s. It’s like looking back in your photos to how your dressed in the 70s. Oh the embarrassment.

Sometimes I think this is a bad thing viz. being mostly someone who writes prescriptions to treat a conglomerate of symptoms. I no longer deal with patients more personal problems. It feels a bit soulless. After all Psyche is the Greek word for soul. I hear tell psychiatry residencies no longer teach psychotherapy other than the basics of how cognitive behavioral therapy works (the one therapy with data to back up its efficacy).  Having psychiatrists learn psychoanalysis has been compared to astronomy students being obliged to learn astrology.

One the positive what I do is more and more ‘evidence-based’ and not based on theories without good data to back it up.  I feel more like a proper physician. Funny how my field was once criticized for being mumbo-jumbo and now it is accused of pushing pills.

All the same it is a field constantly growing as we learn more about the puzzle that is the human brain. It’s exciting to be continually learning   albeit a bit discombobulating to have all my beliefs redone every decade or so.

It’s late and I am tired. I’ve been dealing with patients and their matters all day and into the night. It’s been a rather tough week with each day ending with a sense I don’t think I can or want to keep going.   Perhaps I will feel better about it all tomorrow after a rest. It will be another full day as I try to juggle objective scientific data with human empathy and compassion.  May my efforts do someone some good.

 

office

The Other Doctor (TOD) and I have different approaches when it comes to seeing patients who are associated with existing patients. If TOD has “X” for a patient, he will not see X’s spouse, children, siblings, etc. Even distant relatives are declined.  I take the opposite approach:  I subscribe to the ‘Family Physician” style of shrinkdom in which the doctor sees relations to appreciate all that’s happening at home, work, and family.

My style as a drawback I have to retain patient confidentiality. This is no small task. I have to remember who said what. Mr. R sometimes asks me will I see their spouse, child, parent, coworker, or friend. This is a compliment as he must feel good about my services to ask me for such. I explain yes I am willing but on the agreement despite my attempts to keep boundaries inevitably I will bungle.  I give an example of asking Mr. R about so-and-so only to see him raising his eyebrows and asking me how do I know about so-and-so as he hasn’t ever brought it up. Inside (I explain) I am thinking “Drat, it was Mrs. R who told me that”.  If Mr. and Mrs. R don’t mind these human mistakes then make it so.  I don’t remember a time when this dissuaded them from both seeing me.

Getting different views and perceptions of what’s happening can be curious. The missus comes in with remonstrations about the mister. A few weeks later when I see the mister I ask how are things at home he replies oh everything is fine really no matters.  Is one of them ‘right’ and the other ‘wrong’? Are both ‘true’ from a subjective point of view? I have to maneuver around these Roshoman moments all the time.

The ‘family practice’ style of psychiatry has a harder issue than merely keeping tabs on who gave me what or different points of views. I wrestle with ‘secrets’ the other one doesn’t know but ought to. The Other Doctor doesn’t have to contend with these matters, which is probably why he does not do the family practice approach. Recently I had a new patient who was horribly depressed in his relationship. He felt stifled to speak up his partner about the many miseries in their marriage. A few days later I saw his partner who remonstrated his partner the new patient is depressed but he can’t figure out why when all is so well at home and they are groovy.  I remember a case I saw the mister who was having hook ups unbeknownst to his wife my other patient.  Do I tell her?  I am allowed to break patient confidentiality if there is an immediate threat to self or others. If someone says they plan on killing themselves this weekend but don’t tell anyone you bet your knickers I am going to call someone. However what if they are voicing thoughts of suicide without immediate plans or intent and the spouse doesn’t know. That’s not as clear.

As for complaints about the other, I often sense A is telling me things as A doesn’t trust B is forthcoming with me. I try to get A’s permission for me to talk to B. When they so no, I point out how the heck am I supposed to bring up something?  Often I have to find some way of discussing a topic with B without letting on I know the scoop because A said so. Once in a while B smells a rat; I remind B this happens when A and B see the same shrink.

You would think these matters would be enough for me to take TOD approach. I too should tell folks I won’t see their friends, family, and coworkers – but they don’t. The benefits of seeing the bigger picture outweigh the drawbacks.

Office  I spend a lot of my professional life trying to figure out ways to get people to do things they don’t want to do. In Medicine this is called “nonadherence to treatment’; in classic psychiatry lexicon this is ‘resistance”. Really though it is just human nature. We are wired to seek the immediate reward as ‘the future’ was tentative at best. Our monkey brains like food and sex and avoiding unpleasant situations. They aren’t designed to think of retirement planning and cardiovascular disease. I plead, coax, and (sometimes) threaten patients to improve via long time plans often to no avail. Patients – humans really – want short time immediate fixes and results.

I often channel The Cassandra Complex, on which I have written. Cassandra (for thems who don’t know her and/or too lazy to look up that entry) was a Trojan princess cursed by Apollo to always speak the truth but no one would believe her even when she was spot-on correct again and again. I was recently reminded Cassandra had impediments that made the situation worse. If she could have worked on them things might have been more communicative.

1. She spoke in cryptic metaphor. I recently reread some of her wailings and it is no wonder no one could deduce what the hell she was trying to say.

2. She spoke of things too far in the future. People couldn’t connect the dots to what was happening now in their immediate lives to faraway consequences

3. She asked too much of people.

4. She didn’t have any authority.

IMG_0975.PNG

I keep these Cassandra-mistakes in mind if I want my patients (and myself) to overcome the propensity to procrastinate and avoid anxious endeavors.

#1 is easy. I try not to speak ‘psychobabble”. I move between lexicons depending on the abilities of the patient before me. I need to be clear with my words and what I am trying to communicate.

#4 used to be a sure thing. When doctors spoke it was with an authoritarian-don’t-question-me voice. Those days are over (and probably for the best) but I still hope I have some clout. I am up against what’s on the internet, often pointing out to patients their Google search does not surpass my expertise.

#2 and #3 are more difficult. They are the Scylla and Charybdis of the medical odyssey. Let’s start with #2:

With few exceptions my patients are not dumb. They ‘get it’.  They know if they continue smoking and eating Oreos instead of oranges they are going to have trouble. But the human brain makes long term abstract thinking (and consequences) hard to make happen. This is especially true for folks in their 20s and 30s who all too readily believe they are invincible and they won’t be like their parents (remember thinking that way?).

Defining what is “asking too much” in #3 and how to circumvent it is an ongoing art. I think this is where Medicine as a ‘practice’ gets its namesake. Rome wasn’t built in a day and Naples wasn’t rebuilt in a year. People are more likely to start with – and succeed -with one specific task than a cosmic transformation.  “Give up sugary drinks” is more likely heard and done than ‘stop sugar for the rest of your life”.   “Start walking 15 minutes each day” is better than ‘lose 30lb or else”.  Sometimes if a person travels the sensation-based route of life I entice them via that road. Rather than telling a man with a drinking problem he will die of cirrhosis if he doesn’t stop swilling gin I tell him he will lose easy weight and look better and get better hard-ons. (Hot puppies!).

Being a Cassandra is a frustrating job but with some more careful approach and wording some things may be heard and heeded and I won’t end up with an axe between my shoulder blades.

Blog Stats

  • 1,651,955 Visitors and droppers-by

Categories

August 2019
S M T W T F S
« Jul    
 123
45678910
11121314151617
18192021222324
25262728293031

Spo-Reflections 2006-2018