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OfficeOnce in a while I sit across from a long time patient with still active symptoms looking at me to ‘do something’ despite years of attempting to do so. What to do? For these types of cases, I have made ‘cheat sheets’. These are timelines written by hand on foolscap paper, which I keep in a folder unofficially titled ‘the rock-and-rollers”. At a glance can see all that has gone on before me. They are time consuming to make but they frequently come to the rescue when I am in the ‘what on earth am I do here?” position – which happens often. Thanks to them I can make logical recommendations based on history and trends and patterns rather than micromanagement or (worse) random guessing.

The folder needs periodic tidy-up, so every season I go through the ‘active’ pile and sort out the patients who have dropped out. Those not seen in over twelve months I move to another file with the precise if not too imaginative name of ‘Inactive’.  Like The Flying Dutchman some of these will come back but the majority will not.  Yesterday as I put the sheets in order, I wondered (as is my wont) why they didn’t return. Patients drop out all the time.  I don’t know if this happens more or less in psychiatry compared to other specialties. I don’t have the data to how my dropout rate compares to other shrinks. There are many possible reasons why patients drop out and don’t return:


They move away

There is a loss or change of insurance

There was a dissatisfaction with the clinic or with me.

They got better.*

Whatever the reason[s] the inactive pile always evokes thought. Since these patients were challenging (thus the need for a cheat sheet) most of them quickly come back to my memory. I sometimes recall their story but more often they disappeared without explanation.

The patients who died are the ones are the ones who evoke in me the most thought. I am seldom privy to how they died. The news mainly comes from a telephone message from a relation ‘Joe’ isn’t coming in anymore as he died last month.  Sometimes Joe’s death is announced via fax from the county medical examiner they have his body and please supply notes to help them with their inquest. Many of the inactive patients were old, sickly, and they didn’t take care of themselves. People with mental illness tend to not live as well or as long as people without such conditions.

The death of a patient evokes all sorts of emotions including angst about suicide. Most patients I see are at some risk for such. I can speak for most psychiatrists when a patient commits suicide the doctor becomes anxious about that what-ifs: had they missed something or should they had done things differently etc. Truth is when a patient in intent of killing themselves nearly nothing can stop them.

Regardless of the cause behind a long time patient going from the ‘active’ to the ‘inactive’ folder each one makes me wonder if I really did anything lasting for them while we were together. Mind, some were with me for years if not  nearly a decade. It was my task to be with them on their Journey as they moved through life, hopefully better for our interaction. I never know – and I seldom if ever get a thank you either. I have to take satisfaction in knowing I tried while our paths converged.


*The scientist and the businessman elements of me really wants to know this stuff. If people are dropping out due to dissatisfaction, I would like to know ‘why’ to try to fix problems.  Negative reviews online are of little help. Those I have read were either not going to be happy no matter what OR upset I didn’t do what they wanted me to do. “He didn’t listen or take care of me needs” is code for “I wanted valium but he caught me doctor shopping”.


I am dismayed but not at all surprised to be up to my oxters in post-vacation paperwork. It’s been nonstop. However it calms down.  Things will settle in time. 


In med school we were taught to always touch the patient in some way, even if they were coming in merely for forms or a shot from the nurse.  In internal medicine this is easily done by taking the pulse or listening to the lungs.   Touch heals; touch is therapeutic – most of the time. In psychiatry, the  patients often have issue with touch.  There is controversy about psychiatrists touching patients at all.

Today a long time patient came in,  this time with her spouse. After the appointment concluded I shook his hand out of habit of male to male custom. I then shook her hand, in the presence of the mister. She remarked that in the many years of coming to see me this was the first time I had ever reached out to shake her hand.  There was a mild chastisement in her voice.

She wasn’t wrong. I don’t shake hands with the female patients. This is a conscious but not comfortable decision. Many of my female patients have PTSD and a history of trauma from men. Touch is often a trigger to upset or flashbacks. I have a handful of patients who still look like they have entered an abattoir when they come to see me, despite years of service.  Once I had a female complain I had come on to her when in fact I had merely shaken hands hello and good bye.



New male patients I don’t usually touch (lest they have OCD germ phobias or social anxiety) but I can sense ‘mistake’ and make sure at the end of the appointment I give them a shake.

This bias is not something I feel comfortable with.  I suppose I can err on shaking everyone’s hand and if this results in emotional upset it is hoped patients will politely decline my offered hand, but in truth they don’t speak up.*

There is a flip side: female patients who want to give me a hug. Then it is my turn to feel uncomfortable and have troubles figuring out a way to say no.  Male patients (straight ones anyway) never want to hug me.  Sometimes when a gay patient is leaving they want a hug; common sense tells me to put out and not hide behind the APA bylaws.

By the way, I see the female counselors at work regularly hug their female clients hello and goodbye.I don’t see them hugging the male clients.  The male counselors don’t hug anyone.

On Thursday I see my own physician.  When The Good Doctor enters the room he and I always shake hands and later again at the end of the interview.  When he examines me I sneak in a therapeutic jolt that this is healing and not just finding the edge of my liver.  After a decade of his care and service I want to give him a bear hug – but I don’t. I wonder how many of my patients long to do likewise with me.

I wish touch wasn’t so politically charged or tainted by anxiety.



*This parallels their trauma history viz. feeling helpless to say no to a man in power and she feeling powerless to resist.


Once in a while I sit across the desk from a long time patient with again active symptoms who is looking to me to ‘do something’ despite years of treatments and interventions. What on earth is next to do? For these types, I have my ‘cheat sheets’ to consult. I sometimes make a handwritten timeline summary on a patient. This allows me to see at a glance all that has gone before. These papers are time-consuming to compose but they have come to the rescue on many occasion. Thanks to them I can make logical recommendations rather than resort to micromanagement or (worse) random treatment proposals.

Once in a while I go through the ‘active’ pile of cheat sheets to realize some patients have dropped out. Those not seen in over twelve months I move their cheat sheets to the ‘inactive’ folder. I never through them away. Some folks will come back, sometimes years later. The majority who go to the inactive file do not come back.  As I tidy up the folder, I often wonder what happened and why they didn’t return.  Patients drop out all the time in Medicine in general. I don’t know if this is more or less the same in psychiatry as in other specialties, nor have I the data to know if this happens more or less than me compared to my fellow wizards.

There are many possible reasons why patients drop out/don’t return:


A move

Insurance (a loss or change thereof).

A dissatisfaction with me or the clinic.

They got better.

Whatever the reasons the inactive pile members makes me wonder. Since these patients were long timers and challenging too nearly all of them come quickly back to my memory. Some I remember they told me moved away; some I know have died.

The patients who have died are the ones that evoke the most thought. Many of the inactive ones were old, sickly, and didn’t take care of themselves. People with mental illness tend to not live as well or as long as people without such conditions.  I am seldom privy to the reasons how and why they died. The news of their deaths mainly come from a relative’s telephone message Joe isn’t coming in anymore as he died last month.  Sometimes I am told via an ominous fax from the county medical examiner office; they have Joe’s body and please supply the latest progress notes to help them with their inquest.

A patient’s death evokes all sorts of emotions, including anxiety of  a possible suicide. Most patients I see are at some risk for such. I think I can speak for most psychiatrists when a patient commits suicide the doctor wonders had they missed something or should they had done things differently. Truth is when a patient in intent of killing themselves nearly nothing can stop them.

Regardless of the cause of the transfer from ‘active’ to the ‘inactive’ status each one makes me wonder I my endeavors made a difference. Mind, some of these patients were with me for years, if not a decade. It was my task to be with them on their Journey, if only for a little while, hopefully better for my contributions. I never know – and I seldom if ever get a thank you either. I have to take some satisfaction in knowing I tried my best.


Every January I see the same sordid situation at work in Medicine which I call ‘The Change” . This is a collection of disrupting alterations patient insurances and co-pays. Most people’s deductibles again kick in now and Rx regiments are suddenly altered usually without warning.  To top it off, the clinic where I work insists all patients fill out up-to-date insurance forms even when they insist nothing about their insurance information has changed.  More than a few patients come to clinic for their appointment only to learn their insurance is no longer taken here. (either the insurance pulled out or the clinic pulled out from the insurance).  Oh the pain. It is all quite predictable and repetitive every January.

“The Change is coming” says The Wonder Receptionist every mid-December. Alas, there is no way really to prepare for it.

It’s Wednesday night and I am pooped from it all – and I am only two days into it!  As I see most patients every 3 months ‘The Change’ usually lasts that long then is drops off to relative quiet until next January.

On the positive, lots of patients now bereft of coverage get quite upset they are losing me. For once I hear I am valued; it is rather sweet. I will be getting soon a bunch of new patients in need of a new shrink; the majority seem surprised and pleased I do a better job than the quack they just came from hohoho.

Less jolly are the patients who feel they can’t afford their medications anymore despite the fact the meds were working and sometimes they were the only Rx that worked. We spent a year getting them right only to learn they can’t continue.  It is curious to see what a patient is willing to continue or let go.  I believe if all tranquilizers became ‘not covered’ every one would sell their grandmother to pay for pills rather than give them up for $ sake.

I wonder in more civilized nations if they have all similar January chaos. Perhaps universal or governmental coverage has no yearly square-dance of changing doctors, medications, and coverage.  I dare say if Americans were to vote on health care issues  in January when deductibles are active more people would go for a new system.

Oh well. We all bitch about the system but never enough to demand real change. People seem to accept “The Change” as an unalterable truism rather than a sign of a system that needs overall.

Well that’s enough ranting. I need to get my beauty sleep to face another round tomorrow.  In my day schedule patient types are color coded.  As of yesterday my schedule is awash in lavender, the color of  thems who need insurance updates. This is rather pretty compared than the dull beige of patients without bills or issues.

Unknown  Urs Truly is in the faraway kingdom of Las Vegas, attending a three-day long seminar, pow-wowing with his fellow wizards. The sponsors of the soiree are a group I am not usually one to attend. This conference has some minor differences to my usual one but overall it is the same set up and style.  The attendants are the same. Indeed- the types of birds who fly in for these shing-dings never seem to vary.

In every psychatric conference there are a groups of Asian women doctors. They travel in together; they are never alone. They are Indian, Phillipino, and Korean. Usually there are all three. They sit with each other and they never mingle.  They tend to talk in native tongues.  They also go through the lunch lines together and move too slow doing it.

Men in suits. These are  the presenters, the pharmaceutical representatives, or doctors over 60.  Psychiatrists over sixty years old still dress up to go to conferences. Indians doctor birds of the male type are always in suits, even at 6AM. Indian doctors dress as if they are going to an interview for some coveted position at Yale.

In contrast are the old hippies type of shrink birds. The males have their balding hairs back in ponytails or little buns and the females are in Birckenstocks with brightly coloured organic looking sun dresses.

There are a few youngsters (residents) but they are rare birds indeed. There are many theories why the young doctors don’t flock to seminars but the chief one is they find it silly to travel and sit in a lecture hall for days on end when you can get credit and information on-line.  How old-fashioned! How mono-tasking! How boring!

Lurkers.  There are always a few in the back who look like they might be patients who have crashed the party to hear about the topics.

I am sure Spo-fans want to know if there are any birdies light in the loafers.  I used to scan the audience playing the game we all know: “who’s gay/who’s not gay”.   Nowadays we have apps for that sort of thing. Yesterday while I should have been listing to the lecture I was texting “Profdad” on Scruff who was sitting (so he said) in the back row.  I asked to meet him at the coffee break – it’s always nice to know a queer colleague. He said sure and then he stood me up and I was ghosted.  I was highly annoyed but also comforted in the fact even psychiatrists are jerks on pick-up apps.


When I came to the Mesa office today I was greeted with an appalling chemical smell, as if someone had just finished the walls using a cheap brand of paint. When the staff arrived they explained the next door office yesterday sealed their floors with epoxy and the fumes are coming in via the air system. Apparently Monday the Mesa office air so toxic many counselors called and canceled their Tuesdays.  The boss-man set up a series of fans to blow the bad air out one door while the outside pollution of Mesa was sucked in through another. Overall this did little good; by noon the two receptionists had called it quits leaving Urs Truly to and two intrepid counselors to fend for ourselves.

While I am writing about toxic work environments I might as well mention the fridge. The staff at Mesa are mostly female. I have long thought women were more fastidious than men but lord love us they leave lots of dirty dishes in the sink as if someone is going to clean them. Worse, the fridge is full up with have consumed leftovers in paper bags and white take-home boxes.  Today a saw the Boss-woman had taped on the freezer door ala Martin Luther a collection of theses tersely telling people for heaven’s sake clean out your crap your mother doesn’t work here.  Fat chance of that.  My Swiss-German genetics took this as permission to adopt a scorched-earth policy and take charge. I first limited my toss-outs to things with brown and green fuzzy growths on them and containers with expiration dates of 2016. It’s a slippery slope and soon I had most unmarked half-consumed totes and bottles out and into the rubbish. As the staff were too sick from asphyxiation no one really noticed.

I am in the Phoenix office tomorrow and the cupboards are calling. The drawers are full up with napkins, plastic utensils etc. leftover from endless pharm-rep lunches just waiting for Urs Truly to clean house andput all the spoons, forks, and Splenda packets in taxonomic order. No one will thank me and I dare say it enables the problem but I will feel much better.

If someone should question my sanity I can blame it on expoxy exposure.


A Spo-fan some time ago asked me to write how does the brain think. I’ve been putting this off for it is a lofty topic. A promise is a promise so here it is. Spo-fans afraid of the learning-kooties should skip this one – although to do so would be ironic given the topic and conclusion.  So pay attention and learn, dammit. 

The thinking brain model is divided into two modalities with the unimaginative names of System I and System II.  For my little  lecture I will refer to them as “Spo” and “Michael”. I will also use myself as the model although this applies to all people.

“Michael” nee System II is my conscious self. He is who I think I am.  He is in charge of conscious decision . If you ask me to multiple 367 by 2 without a calculator Michael is the one to do it. Michael is lazy; Michael slow; it takes effort for him to do anything. If there is something to do he likes to conveniently vanish.  Thinking is an uncomfortable task;  it takes effort. It’s easier to ‘think’ quickly and make fast conclusions rather than stop and work. However he is the careful one capable of catching error.

“Spo” A.K.A System I is Michael’s quick counterpart who processes all the information flooding into your senses. Spo has to be quick for he is dealing with a lot.  Quick as a quarter-note Spo discards the irrelevant bits (which is most of them) for the deemed needed stuff.  Spo works without Michael knowing he is doing it.  The quick and unconscious Spo makes up his mind even before “Michael” attends to the matter at hand.

Spo is made possible by your long term memory.  “Michael” is my working memory, capable of working with a few things only at a time. Example: a string of random numbers or two tasks to do at once.

Michael wants to pass things over to Spo for long term reference, but to accomplish this Michael has to work consciously and repeatedly (and that takes effort!) to get Spo to accept into his realm that matter.  At its onset it is tedious to memorize a poem or learning how to chop an onion, or they directions to the dentist. When Urs Truly was learning to dance, I had to consciously memorize what steps went where next until it became an effortless flow done without thinking. ‘Getting it into my muscle memory’ my teacher called it. but it really isn’t going into the muscles but into Spo.

Michael and Spo make a good team. As Michael has limited capacity and needs time and effort Spo has to be doing the majority of thinking.  Think how much your typical day’s doings are done ‘without having to think about it”.

On the downside, Spo quickly tells Michael what to do based on quick intuitive conclusions that may not be right at the moment.  To Michael’s ear what Spo says sound reasonable and the lazy bum will go with it without checking on it first.  Opps. This can be a bad thing.  Ironically by making something a tad difficult or complex makes Spo upset enough to pass the problem onto Michael who is obliged to ‘stop and think’ – and more likely make the right decision.

I see a lot of “Spo” mentality in politics. Simple incendiary statements don’t evoke “Michael”  to stop and think and what was said is truth or rubbish.  Alas, I like to stay with ‘what I already know’ so I don’t have to think – which is time-consuming, slow, and uncomfortable.  The paradox is by being out of my Spo-run mentality and making  my Michael work is the only way to learn and enrich my Spo-based knowledge base.

The Boss-woman announced she will be ‘moving in’ to my office (the one in Mesa) to work on the days I am in Phoenix. When I went to work today I see she already brought in better furniture (finding my chair untenable) and some knickknacks that give the room a slight feminine touch. I don’t really use the desk drawers other than to store paper, rubbish, and tea things, so I was planning to clear out some space for her in the desk. I see she has already placed in one of its drawers some sort lotion bottle of which I am unfamiliar.  Having grown up with four brothers I am unaware of the feminine mysteries of cosmetics etc.

In the upper left drawer of said desk, in the tray among the pen, is a red-wrapped ‘Lifestyles’ condom. When I moved into the office it was in there and I haven’t ever moved it. I have never deduced what on earth is it doing there. It has an expiration date of 2/2012 so it is not usable. I should probably throw it out before The Boss-woman finds it and makes sordid presumptions about my probity.

In the lower right-hand drawer is a brain. You can take it apart to reveal the neural pathways used in the treatment of depression and anxiety.  This large slightly off pink plastic goober was left behind by the previous psychiatrist, perhaps with the condom. Set on a stand on the desk, it give the patients the heebie-jeebies so I’ve kept it in the drawer and out of sight.  I should probably throw it out but how?  I am somewhat sheepish to put it in the recycling bin lest the poor sod at the other end finds it and has catalepsy.

The upper right-hand drawer is a bricolage of teaspoons, Stevia packets, and some sriracha chili sauce, along with whatever mugs are at hand. Sometimes I shove into the drawer half-consumed sandwiches or nasty bags of chips if I suddenly have to do something. Sometimes I actually remember to retrieve it at the end of the day, but not always.

The port side middle drawer  has a ‘secret compartment’ in the back so secret I forgot it is there. I found some JAMA journals from the 2010 – 2011 apparently saved for vital reference. Now the contents are as obsolete as floppy discs.

I think I will use the arrival of the Boss-woman as a good reason to commit ‘danshari” and leave nothing behind but the stationary, prescription paper, and the tea things. What more does one need in a modern office anyway? The model brain I might deposit in a mail box, having seen that in a movie once. I think I will keep the condom as sort of a ‘grandfathered in’ object. By now I don’t have the heart to throw it out.


OfficeI came to work today to discover someone new sitting at the receptionist window. She wasn’t too much of a surprise, for I had seen her sitting with the other receptionist last week for what looked like ‘training’.  As usual, no one tells me these things. I had to introduce myself. Yes, she was hired as ‘new staff’, apparently to help with billing and here and there as well.

I’ve lost track of the all the receptionists the clinic has seen over the years. I am never privy to ‘why’ one suddenly disappears and is replaced. Being curious (and nosy) I want to know ‘why’ – were they dissatisfied or had they found better jobs or did the bosses deem them busts. Asking the existing staff is no use. They either do not know or are discreet to demur the reason.

Pharmaceutical representatives are even more transient. Worse, they tend to look alike. I ask ‘Jill” how she is doing and “Jill” responds no she is “Jane”, the replacement.  I feel like Sir Galahad at the Castle Anthrax.  Another challenge is they sometimes represent one company and then another.

The counselors are work are less likely to flip like houses. Many of them work in the other branches of the clinic, where I am not. I knew of  a“Cheryl” but never met her – only to hear a few months ago “Cheryl” had moved on.

People come and go so quickly here.

Then there is Urs Truly. I took this job in 2005 and I’ve been here ever since. In the movie “Young Victoria”  the young monarch is walking and talking with her aunt about the prime minister.  Auntie reminds her: “Prime ministers come and prime ministers go – you stay” – and she did for over sixty years.   It’s good to be queen. 🙂


Doing things you are fearful to do is sage advice. The dreadful action often isn’t as bad as you fear it will be and doing so gives one a sense of accomplishment. I’ve never gone on line to the ‘Rate your doctor’ sites to read what people have been writing about me – until last night.

Before I tell you the findings, let me reflect on these sites. If one is feeling OK about a service, restaurant etc. one generally doesn’t go on line to say so. In contrast, if one is mad, frustrated, or disappointed, one is more likely go write a negative review. This is done  to ventilate upset or elicit sympathy but sometimes it is done out of spite.  Responding to negative reviews on line is difficult as this blows confidentiality. A doctor can’t easily the patient who wrote ‘He didn’t listen or took care of my needs” was a crafty drug seeker whose request for Valium was declined on the sensible grounds the person was caught doctor shopping.

I suppose the authors hope their reviews will cause others to think twice about going to said physician resulting in the doctor losing business and feeling remorse.

I’ve never been worried about negative reviews on line. Patients wait months to see me; I do not lack for business.  I can’t please everybody. Always doing what the patient wants is bad medicine. Sometimes I have to tell them their ways/requests are not good. If they leave in a huff and write on line how bad I am so be it.  Conversely I never read on-line reviews about professionals knowing what is written is probably not reliable.

With that said I thought to go on line and have a look-see.

The majority of my reviews are good ones at ‘4-5 stars”. However there were a handful of ‘1s’ as well. There were little if any in-between reviews.  I am described as either brilliant or the worst doctor there ever was.

Like most people I zeroed in on the negatives. Most of them were tirades with little logic or point. Some of them were amusing in a way. Here is my favorite:

“Freakin (sic) bow-tie guy, dressed to the nines, very uppity butt crack kind a guy. Wants you to relate everything to him and he types it all down on his laptop and asks you personal information that isn’t any of his business.”

Fascinating! I don’t use a laptop at work, so that was an eye-raiser. On the other hand the writer isn’t wrong I do ask a lot of personal questions about the condition of their periods, bowel movements, sexual functioning, and troubles at home. It’s something I picked up in medical school, I suppose.

Rather than merely dismissing all negative reviews as rubbish, I am analyzing them for any tidbits that sound like genuine criticism upon which I can improve. Here are some possible valid lesson:

I need to keep vigilance to make adequate eye contact and not get lost on the computer screen.

Overall people see the bow-ties as distancing rather than making me seem dapper.

I think I will continue to ask nosey personal questions.

Someone described me as “pompous arrogant and godlike” . I will leave off the eye patch and keep the two ravens at home.

I am going to interpret the butt crack kind of guy comment as a callipygian; my work outs are paying off.

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