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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.

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office

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.

 brain.jpeg

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. 🙂

Office

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.

office

The APA Secret Police recently sent me an email hoping I will have a good autumn. In it they reminded me there are 47 ways for a AZ physician to be ‘unprofessional’ . [1] The email didn’t tell me what these faux pas were, so I had to look them up. I was quite curious what they could be.

Most of them turned out to be obvious  no-brainers. They were on top, perhaps in case if a physician is only going to read part way he/she should at least view the most important ones.

I should not have sex with my patients; I shouldn’t prescribe oxycodone to my relations. That leaves 45 to go.

I admit I was disappointed find no obscure laws of the type that make you wonder how on earth did they get there in the first place. I’ve been told it is illegal here in AZ to carry ice cream cones in your back pocket; I didn’t see anything similar about being a proper doctor.  There were some no-nos about chelation therapy but these were more about telling patients it doesn’t work rather than trying it for constipation or something.

Happily there is nothing about rolling down grass hills or having to know from memory the counties in Arizona. [2] I was also relieved to see no fashion felonies that forbid me donning my Spo-shirts on Fridays.

The last one, dear #47 is about practicing medicine under a false name. Calling me “Dr. Spo” may be putting me in legal jeopardy. If I am dragged away by the APA Secret Police I will argue while laughter is the best medicine Spo-fans who address me so are patients but blogger-buddies. I am going to tell my patients to stop referring to me as “Space ghost”.

th

[1] – The D.O.s have 49.

[2] – There are 15 counties; some of them larger than the State of Rhode Island.

 

 

The Firesign Theatre had a comedy album “Everything you know is wrong.”  This axiom turns up again and again throughout my life. Going to medical conferences is no exception. Medicine is an ever-changing field. What was true one year turns out to be not so the next.  Some people see this as a sign of a sham but it is a truism of science.

For example, I was trained in the 80s/90s thems who smoke marijuana were all pot heads and nothing good could come from smoking the stuff.  Yesterday I heard the latest scientific-backed evidence-based data to negate all my training and beliefs.**

I prefer Truth to Dogma, so I try to throw off held-fast beliefs when there is good evidence to support such.  This is not as easy as it sounds as we like steadfast truths. To have the rug constantly pulled out from us leaves us with little firm to stand upon. Most people are uncomfortable without some fixed beliefs.  You might have noticed thems who believe Obama was born in Kenya or deny climate change or think the earth if flat are never swayed by reasoning and evidence; they just dig into their beliefs more.  There are few at ease with moral ambiguities (hey it sings) so they pretend they don’t exist.

As a doctor I can’t ethically do this. Imagine I learn after hundred of years of prescribing bloodletting it turns out to have no value but MDs decide their years of experience with it and ‘it has always been that way’ trumps evidence (pun intended) and they keep prescribing it.   Alas, this happens more often than not. Lots of doctors continue to do things which have little scientific backup.  Deny and discard is more often done than not. I try not to be one of them. I know myself well enough I do and prescribe things

I go back to work on Monday with  new perspectives and an up to date knowledge base – some being 180s to what I used to say and do. Some patients will complain ‘you guys can’t settle on what is right and wrong” but I know I am following the path of science – test a hypothesis and discard it if the evidence doesn’t support it.

 

**There is ‘good’ and ‘truth’ to the possible use of cannabis in the treatment of mental illness yes, but it is not at all what my patients believe.  More on this anon if Spo-fans are interested.

I am grateful for my scientific training and mentality for they help cut through the humbug and dazzle that are presentations provided by pharmaceutical programs.  Urs Truly is only partially listening to a pharmaceutical sponsored breakfast in which a product is being flogged. As is the wont, the data/graphs are are jolly and they seem to imply the medicine is safe, clean, efficacious, and preferable to what’s already on the market.  What isn’t being addressed is the Rx is:

This is a repackaged medication of something already on the market in generic form.

The drug is not superior to anything already on the market.

It costs ~ 2,000$ a month to take.

It will be a bitch to get it approved for all these reasons.

Pharm reps are often not allowed to answer what I really want to know.  They are not a good source for knowledge. I’ve learned to hold my tongue asking intelligent questions which poke holes in the data, and my bear-baiting makes them uncomfortable. Rather, I nod and be polite and try not be a jerk about it all.  Still, it makes my eyes cross to see spectacles.

Mind! If you ask any doctor if they are swayed by the razzle-dazzle of pharm-rep symposiums they will say no way.  In my head I hear the host of one of my favorite podcasts “You are not so smart” telling me I am probably led by the nose more than I realize.  One must be always on guard for such.

It’s good to ask questions and be skeptical and take everything with a grain of salt, whether it is a pharm-rep pushing pills or a politician trying to convince you of the need for building a wall and Mexico will be paying for it. When it comes to Hair Furor and his minions, I believe nothing. Someday he might actually say something true and I am likely to miss it as I am so used to dismissing anything he says as rubbish.

Urs Truly is in New Orleans at a medical conference, pow-wowing with his fellow wizards learning new things to become the best shrink possible.  Sitting still and listening to lectures x 3 days is not an easy task. Alas the pharmaceutical booths are not giving out free samples of Ritalin, more’s the pity.  It also doesn’t help The Muses or The Graces or some of that crowd is flooding me with inspiration. Bitches have bad timing and/or a wry sense of humor. I should be focused but my brain is bouncing about blog bits.   When the conference is concluded I may write a bullet-point highlight for Spo-fans of mental health tips.

The first conference is about opiate and canniboid receptors in our brains and why is it we like to take drugs rather than eat broccoli.  Apparently our monkey brains have certain buttons that light up like a christmas tree when pushed with smokes, gin, doughnuts, or that pick up from Scruff.  Our hard-wiring responds to greasy goods and intoxicants.  The “Just say no” approach hasn’t a chance against millennia of evolution. Oh the pain.  Happily, wiring is not destiny; we can do something about it rather than always pulling through the Dunkin Doughnuts or Beer Stop on the ‘what the hell” approach.  I should know more by lecture’s end.

Updates! Bottom line headlines! 

It turns out there are some actual uses of marijuana as treatment in Medicine, but it is not what everyone thinks or wants, but there is something not nothing (as I was trained). 

Inflammation plays a major role in mental illness. Inflammation is probably the key factor in treating depression/anxiety etc. 

Mindful meditation can increase endogenous pain relief so well if you give a opiate-blocker to someone trained in such their pain will return.

Sugar looks to be the worst evil for our well-being. Avoid it at all costs

Opiates can actually cause pain; opiate-based medication can worsen chronic pain especially in fibromyalgia, arthritis, and lower back pain. 

Taking care of you microbiota (the wee-beasties in your bowels) may be the most important ‘job’ you have to manage physical and mental well being. 

There are 5 simple things you can do to make your health so much better – they are easy to do, measurable and have science to support them all.

More anon. 

Never trust trust.

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