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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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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”.

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[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.

“Always do what you are afraid to do” – Emerson. 

A Spo-fan recently asked me what sort of patient is ‘the hardest’ type for me to deal with. The usual guess is someone who has schizophrenia or a borderline personality. It is the patient with anxiety who challenges me the most.

At the base of all anxiety is discomfort. When we worry or experience anxiety*  it makes us uncomfortable. We are wired to be on the lookout and ever vigilant for threats to our well-being. Alas, the lizard-parts of our brains do not discriminate between a scorpion and a deadline.  Anxiety only becomes a ‘disorder’ when it is too frequent and intense – and problematic.  Anxiety makes a good servant but a lousy boss. Treatment is geared towards reversing the role.

Over the years of treating anxiety I’ve seen a shift in thems with anxiety -and it is not good. The real treatment for anxiety is a gradual exposure and rethinking of the anxious person towards the realization the anxiety is over-rated and unfounded. One learns to lower the level of discomfort and/or live easier with your worries. “Yes, I am still uncomfortable, but it isn’t as intense, and I can deal with it”.  That is a good outcome.

What a lot of anxious people want nowadays is the unrealistic goal of NO anxiety. Any little amount is seen as overwhelming and unacceptable. In summary, people are finding it harder to manage discomfort.  It is human nature to want to avoid things that cause anxiety and discomfort.  But by going into it rather than away paradoxically deals with anxiety. In the cave you most fear to enter lies the treasure you seek.

Urs Truly tries to lead by example. Often when The Timorous Tim within me says ‘No, go, turn around” I pause and proceed. Here is a simple example. Yesterday at the gym The Personal Trainer wants me to do ‘lunges’ something I do not like (as it causes intense physical discomfort) and they make me anxious, so I often quit long before the assigned length.  I took the approach a) Yes I will feel short-winded and b) I will probably fall over but both are not the end of the world nor as bad as I imagine them to do be. So I did them. I did not fall and I yes I was quite exhausted. I felt exhilarated. I had faced my fears and done well enough. I still don’t like doing lunges, but I am going to continue doing them.

I try (not very successfully I might add) to get patients to practice doing  what makes them anxious, whether it is making eye contact or going back to visit the place where they felt anxiety.  What they want of course, is Valium to simply lower their anxiety.

This week I have made a little list of things I’ve avoided doing or confronting out of avoidance of anxious discomfort. Like The Mighty Hercules I will address them one by one and be victorious, realizing these labors weren’t that laborious – or scary – as they claimed to be.

 

*”Worry” is technically the anxiety we imagine while ‘anxiety’ is the physiological elements of the condition. I worry about my mother; in my anxiety I have palpitations and shortness of breath and pacing. This is straw splitting; most of the time the words are interchangeable.

Office

At work I often encounter patients who have extraordinary circumstances or just bad luck between appointments. I call this “The Helen Syndrome”, which is named after a patient or mine who was named – wait for it – Helen. Helen seemed to have the worst luck. I kid you not I would see on January 1st and we would start a medication, let’s say Prozac.  She would return on February 1st and I would ask how the medication is going. She would reply it was hard to tell for on January 3rd the house burned down with all their possessions and they had to move in with that bitch sister-in-law who I can not stand and iI am so close to knocking her teeth out and oh by the way I got pneumonia about mid-February I was so sick I had to be hospitalized.  She  would finish she had only been discharged home a few days ago and the bitch sister-in-law still hasn’t done anything in her absence and now the insurance company is doubting the story.

“So you see, Dr. Spo, I can’t tell if the Prozac is doing any good.”

Oh the pain.

When this happens I change over from listening if the Rx made her feel better to Helen despite it all did you go off the deep end and crack up?  She admitted she hadn’t gone postal on the insurance agent and she hadn’t axed her sister-in-law. Normally she wigs out in hospital, but she took it in stride. Perhaps the Prozac was helpful after all.

The Helen Syndrome happens a lot. People are forever having unexpected events most unpleasant occur while they are out and about.  One patient astutely questioned the phenomena. “Gee doc, isn’t what you are calling The Helen Syndrome, just, you know.. life?”  Good point.  Life is full of random actions and surprise appearances. One definition of mental health is how well we deal with life’s surprises and roadblocks.  However, it’s the humdinger happenings that really test our mettle (and the meds).  Interesting: most patients  who worry they had snapped a tether since that random comet annihilated their house are comforted by my feedback they did OK under the circumstances. Seldom do they want ‘more meds’ but are willing to see if the next month is a bit more mundane.   This follows the sage advice of Hippocrates who defined all of Medicine as the careful craft of entertaining the patient while the body heals itself.

Neurotics don’t trust good times; they just know the shoe will drop soon and they are not wrong. What they don’t consider is during Helen Syndrome-like down times it is equally true the shoe will pick up.

It is a bit giddy for me to forever wonder what is going to walk in my door next, a patient spitting blood or one worshiping my intervention ‘you saved my life mister’.  The Helen Syndrome and Life itself keeps me on my toes. It is never dull. It sure beats cardiology.

When The Lovely Neighbor moved away she left behind a computer monitor the size of an IMAX screen. Alas I couldn’t use it at either of my offices for it blocks my view of patients (and everything else). I gave it to The Wonder Receptionist who loves it so. Apparently she has poor vision and this large screen is superior to the previous one. She is pleased as punch.  If she is happy the clinic is happy.

Office

Rumor has it the bosses hired a nurse practioner so there will be three pill pushers on the premises. Let’s see if she shows. Hiring a third prescriber has been a challenge; at the last minute the change their minds and don’t show up. My experience with psychiatric RNs is not good but I am going to keep a neutral opinion on this new one. The past ones often lauded ‘they are just as good as the doctor’ but when they were faced with a challenge they told the patients ‘Oh, I am just a nurse you need to see a doctor’ and give them to me.

The current crop of pharmaceutical representatives has arrived. They come and go so quickly here. It looks like the pharmaceutical companies haven’t done their research well as this lot doesn’t have any particularly handsome ones of the sort Fearsome Beard would post on his blog as “Beard of the day”. The 401K man recently came to visit, bringing with him a companion. They weren’t bad on the eye. Alas I have no legitimate excuse to have him back for a private examination of my mutual funds.

After years of threats from the Boss-man he vows it is really going to happen viz. his plan to knock down my office wall to divide the room into two. This will allegedly happen when I am away later this month. I don’t mind really. My office is quite capacious and I prefer a more cozy setting. I retain the better half, the one with the windows and the view.

The Mesa office refrigerator remains messy and cluttered with leftovers long forgotten and other things hard to identify. The users are 95% female; I thought women were more fastidious than men.  My Swiss-German genetics wants me to clean it all out and perhaps I will.

 

What do patients expect of me?

Walter (mon cher!) recently asked: “what do patients expect of you?” I thought I would reply in an entry.

The culture has changed. It used to be the psychiatrist was seen as a cliché analyst with whom you share your dreams and inner-most thoughts. He tells you what it all means and through this insight you feel better. Nowadays (at least in the States) the psychiatrist is the ‘guy who prescribe the meds” while others deal with your personal problems. Based on this ersatz job description, most folks who come to see me nowadays are looking for me to prescribe them something.

In my office are two pottery jars. One is labeled “Eye of Newt”; the other “Fairy Dust”. Patients fear I will give them something sinister that will turn them into zombies or werewolves while simultaneously hoping for magic pills to take away all their ills.

First-timers are often not at ease if downright skittish. They often look around for ‘the couch” and are relieved and disappointed to find none. Rather, I am sitting upright and writing on a pad but typing on a keyboard. I do a lot of explaining what we are doing; they seem assured I am ‘always looking for the most conservative methods’ to treat what ails them.

Many patients still look to me for help with their personal problems. I have a handful of patients who regularly check in with me to get grounded and hear sage advice. Their meds are stable; they are coming in for a talk. Some of them want advice/support but most of them just want me to listen.

Alas, I have many patients who should be in counseling but won’t go. The usual explanations are they don’t have time or money to do so. They often come in for 15 minute ‘med checks’ and spend it venting their woes and then want me to do something about it – with medication. I butt heads with these folks the most. They often spend a lot of energy/time – and money in this way.   At best I can get them somewhat better.

I learned in school not everyone wants to grow. The majority of people just want some symptoms alleviated and just enough to function. However there are still few, the lucky few, who are interested in learning about themselves; they want to be on The Journey.  I do what I can for them. Most of the time they need to do that elsewhere with someone who has sufficient time (and coverage) for it. I was trained in Jungian Psychology – great for Self growth but not good for panic attacks and general anxiety etc.

And then there are the folks who want pills – pills to sleep; pills to calm; pills to focus and give them energy. I have to be careful with these folks as they can be black holes of need which no amount of medication appeases. “Give me more (fill in the blanks)” These folks needs education – and limits.  People often think psychiatrists push pills when in reality they spend a lot of time trying to get people to do/try non-pharmaceuticals rather.

I like my job for I never know who and what matters  will next come through the door.  Mostly I go on The Journey with my patients,  sometimes as Guide but more often as Companion.  I may not be able to always heal but I nearly always influence. That in itself is nothing to sneeze at – and better than Fairy Dust or Eye of Newt.

imagesUrs Truly is not often invited to shing-dings and parties. This is a pity as I have so many Spo-shirts to show. On the other hand the lack of bacchanals etc. saves me from the dreaded cocktail conversation called “So, what do you do?” Unless this is a party of ill-repute this means what do I do for a living.  I try to avoid this question in general; putting people into (occupation) boxes is not a good way to really know another.  In my case, the question is even more ticklish. There is nothing like saying the “P” word at a party to change the mood.   I used to lie and say I am an actuary which got most people to leave me alone.  Sometimes I reply I am a doctor (true) but this is “P-light” viz. I get a lot of sudden changes good and bad.

When I say “I am a psychiatrist”  many (the majority?) of party people do one of the following:

  1. Run away.
  2. Pick a peeve and try to get me to defend it.
  3. Ask for (free) medical advice.
  4. Start telling me their dreams.

Let’s start with 4).  There is nothing more boring to a psychiatrist than being asked to analyze a dream given impromptu and without context. Sometimes I cut the dreamer short by asking them to first provide their co-pay. Sometimes if I am tipsy (or the speaker handsome) I pretend to listen and after they are done rambling I reply with some generic chestnut or I tell him he and everyone in his life needs to take medications as soon as possible.

3) ain’t so bad as I always stick to general knowledge and I do like to shoot my mouth off. If they keep pressing for more freebies or specific advice I start asking personabl questions about their bowels, menstrual cycles, or sexual functioning, usually in a louder voice so others can listen in to benefit from my font of wisdom.

Under the right circumstances 2) can be jolly good fun. “Why should I have to defend that?” is usually not accepted.  Then I channel The Dark side of Psychiatry and pull up my Inner-Hannibal-Lector and cat-like before a cornered mouse I toy with them long enough to get them to leave in a huff or take route a).

Which leads us to 1).  This really happens. I was once at a party being sized up by a young woman (so much for her judgment) until I said I was a psychiatrist. Her eyes widened and she turned around and ran quickly out of the room and was probably never heard from again.  I sure know how to clear a room.

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