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Note: this draft was written a few days ago and then I put away. I wondered whether or not to post it. I decided yes I would, as it is a ‘slow news day” and TBDHSR members who bothered to read it thought the essay shows my vulnerable side. I am not certain if that is a compliment or a critique for the only vulnerable sides that interest them is where to aim the axe.

 

Today I had to tell a patient ‘no”.  Prior to the 8AM appointment I read the chart notes: X has had years if not decades of anxiety and X has seen nearly a dozen psychiatrists apparently to no lasting benefit. I wondered if I could do any better. I sent out the Zoom invitation; I got no response.  I sent out another – nothing.  Around 820AM I called X who became anxious explaining they had the appointment down for 10AM and no they haven’t received any Zoom invitations. I sent out a third. Around 830AM there was still no response and the appointment was from 8-845AM, so when X called again for help I said alas this was a bust and we will have to reschedule. In the chart I saw X is getting medication from somebody else and in counseling with someone at our place. X became agitated saying their panic/anxiety was sky-high and had to be seen today.  Indirectly X conveyed if X was learning coping tools/different ways of dealing with the anxiety this wasn’t working or being applied for the present situation. X pleaded for me to start the appointment now over the phone (we have a policy all new patients must be ‘seen’). I said no and X went into hysterics. I repeated the plan to reschedule ASAP and hung up.

Physicians find it painful not to help patients more than they can but it is also painful telling patients ‘no’. Doctors are mostly ‘nice’ people, who are not good nor comfortable telling patients what they want or need isn’t going to happen.* Parents feel something similar with their children. Kids are always asking for things which parents must say ‘no’. Children usually up the ante by crying or by throwing a fit or through nagging – hoping to wear down the parent by attrition.  Everyone knows it is important to set limits with kids as giving them whatever they want does them no good but makes them into horrible human beings, who learn being nasty ‘pays off”.  

Saying ‘no’ to a patient seems harder to do nowadays. Back in the bad old days doctors if your doctor told you not to do something you did so without question.  Nowadays patients see their doctors more like waiters who will bring them want they want and if they don’t they will leave a bad tip in the form of a negative Yelp review, usually along the line ‘my doctor doesn’t listen to me”.

I regularly remind myself I cannot help everyone. I am not a bad person nor a bad doctor telling people no. As I’ve aged this is becoming easier to do but I have lots more to go. I try to explain the ‘no’ and what we will do otherwise. This doesn’t always go well of course. It gets down to being comfortable with someone angry/hurt/feeling let down by me.

As for X, X will probably reschedule and be seen sooner than X feared would happen. I might point out the lesson that waiting a week shows her anxiety although uncomfortable is not the end of the world.  I’m pretty certain the previous twelve shrinks tried something similar.

At some point one has to give up the illusion one can fill a black hole and there is no point to cross the event horizon into one  – painful as this feels.

 

*SIL #3 is an ER physician. She would find this notion absurd as most of her job  is doing just that viz. telling folks coming to the ER they are not getting certain medications or procedures as if they had walked into an all you can eat buffet.

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Alas Babylon ! My medical secretary A.K.A. Bubble A.K.A. Mr. Humphries announced last Friday afternoon at closing he is quitting suddenly to take an dream-post with WHO.  I wish him luck; I will miss him. Besides being bright and obsequious he was pleasant conversation.  He likes tea, so we often made a pot in the mid-afternoon to shar.

On the negative I now have to work today/this week/for some time now without an assistant until The House Manager finds a replacement. Oh the pain. He was the third assistant in five years or so. They don’t stay long. I suspect the bosses don’t pay them enough; the last three incarnations all left to get better paying jobs. I have to remind myself the role and responsibility of the medical assistant is the house manager’s job, not my own.

My work has become a lonely endeavor.  For four months I’ve worked from home with hardly any interactions with the bosses or the therapists; they are all working from home too. It’s been nearly five months since I went to The Mesa Office; by now I cannot remember the names of the current crop of clerics who work there.

It seems there are so few personnel left at the clinic – the therapists come and go too. A few of them recently retired. Today Monday there will be one counselor who comes into work; she will close her door and work all day and I won’t see her at all.   It all makes me wonder if the place will endure. Goodness knows I have no lack of work to do and perhaps more if The House Manager calls on me to chip in in the interim until there is aa new Medical Assistant.

Well that’s all the news prior to the 8AM first appointment. So far I hear no one entering the door (counselor or receptionist) and the office feels like a ghost town. Yesterday I wrote about the joy of solitude and silence. This version doesn’t feel so nice.

Along with an increase in covid cases comes an increase in worry and anxiety*. The number one issue at work these days is “how do I deal with this?” As a public service announcement I will tell you. Pay attention: people pay me big bucks for this sort of stuff.

The first step in dealing with stress is to not try whitewash or deny things but recognize these are tough times. Anxiety is like an unwelcome family member Thanksgiving – in this example I will personify a/w as Uncle Joe. You wish he weren’t there but he is; the task is to keep Uncle Joe’s dinner table shenanigans to a minimum and not let him to run and ruin things. 

The second step is to remember bad things and times always happen; the current set is indeed a nasty one but this isn’t unique. You have more strengths than you realize. 

The third step is learning and applying something called mindfulness. Mindfulness is paying attention to what you are experiencing/what is happening in the present moment without judgment. Mindfulness takes time to practice but it is simple to learn and it has one of the best track records for dealing with the Uncle Joes of life. Mindfulness has four general parts:

#1 – Recognizing what your are feeling/experiencing. “I am experiencing sadness/anger/panic/confusion” puts you at a little but crucial distance to not immediately act out on these feelings**

#2 – Allow the feeling to happen. This advice is often met with aghast as most patients want the anxiety/worry/panic/confusion to go away or not to have happened in the first place. Yes it feels bloody awful and certainly you would rather not have it but it’s there. Like Uncle Joe if you try to eject him he becomes more dominant and ensconced.

#3 – Examine it. Start asking the questions: Why now? What is contributing to it? What things from the past are playing into it and coloring it?  

#4 – Disengage from it. Anxiety is not ‘you’; it is what you are experiencing. You are not Uncle Joe nor are you responsible for his being there or for his shenanigans. You can do something about his influence on him. This is where the patient’s individual strengths and approaches are applied. Perhaps your best method is take time out/walk away; perhaps it means applying the approaches you know have helped in the past. 

Through recognition, acceptance, examination, and action one can get through a lot including these worrisome times.

 

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*’Worry’ is a state of mental agitation while ‘anxiety’ is worry with somatic symptoms such as shortness of breath, palpitations, and restless. This is straw-splitting but I like the discrimination. 

**Feelings vs. emotions. This is another psychobabble straw-splitting maneuver. Feelings are conscious while emotions are not conscious.

I recently had a first follow-up appointment with a patient who was pleased his ‘refractory’ depression was lifting with the new treatments and for the first time in ages he was had some hope of feeling better. He asked me how long have I been doing this sort of thing as I seemed to know what I was doing. I had to get out the calculator to do the math. If I count the years of residency I’ve been shrinking heads for nearly thirty years. Patience above! Thirty years! How is this possible? He saw me as some sort of genius while most of the time I feel somewhat a sham. This is called ‘the imposter syndrome”: it is a common emotion when you feel not as good in your role as others deem you to be. Despite thirty years doing this work I still often feel bewildered along the line of “what on earth am I supposed to do?”  I am in a profession where the older you become the more wise you are perceived to be. Having grindled whiskers and graying hair makes on look sage-like. In contrast I often feel nonplussed no different than when I was in training back in the early 90s. It is hard to be Dumbledore when you are feeling a ‘first year’.

Feeling helpless is different than feeling an imposter although they often go hand in hand.  Wednesdays have the sordid reputation of being the ‘worst’ day of the work week when it comes to workload and clinical challenges. “Wacky Wednesday” I call the day. Before writing this I had a look-see at the day’s roster and I am slightly horrified by its contents. I have four new people (two with sordid reputations) and a handful of “Zorgenkinder”*.   I feel unable to help them. You would think folks who are no better would eventually go away on the grounds I am not helping them but they stick to me like bumper stickers continually turning to me to ‘do something’ and I have no answers. After 30 years I’ve become only slightly more at ease to admit I don’t know how to help you any more/this is as good as I can get you”.

Mind! Lots of Medicine isn’t getting people ‘better’ but witnessing their pain and going with them on their Journeys. “Don’t just sit there, do something!” needs to be continually translated to “Don’t just do something, sit there!”

This Wacky Wednesday will probably be  a long difficult day and at times nasty. I will probably end in exhaustion with a pile of notes to write. They nearly always do. No doub I will feel helpless and a bit of an imposter too.I’ve managed to get through nearly thirty years of Wacky Wednesdays so I will get through this one as well.

 

*Zorgenkinder: a German word meaning ‘child of woe”, a stormy gloomy emotional type, sort of like Wednesday Addams without the charms.

In Charles Dickens’ “A Christmas Carol” under the robe of The Ghost of Christmas Present lurks two terrible entities named Ignorance and Want. If you’ve never read this scene run don’t walk to do so. It is one of English Literature’s greatest metaphoricial warnings – and in the middle of a Christmas tale! There is another couple of shadow human emotions less known but arguably just as sinister. I don’t know under whose robe they reside but let me introduce you to the nasty children called Reactance and Pluralistic Ignorance. 

Reactance. 

Reactance is a psychological phenomena of becoming motivated to resist something when there is a perceived threat of a loss or of a freedom.  When people feel ‘forced’ into a certain behavior they bristle and this resentment manifest in doing the opposite of what the authority figure(s) desired. Wear your helmet; put on your seatbelt; you can’t come in without a mask – these are recent examples although the phenomena is as old as time. It is the ‘you are not the boss of me” emotion.  People are generally neutral until someone forces them to do so then they resist. This is why government mandates often backfire.

What gets people to do the right thing is often accomplished by a different route than rules. I have a patient who refused to wear a mask in public until his daughter a nurse got him to change. He changed his behavior because someone he trusts told him so. 

Pluralistic ignorance.

This is a group psychology dynamic. Officially everyone in the group publicly believes something but the individuals do not. Group members privately refute what the is the majority outlook of the group. The individuals believe no one else in the group thinks like they do because no one is saying so. I once had a girlfriend who was a member of a protestant church with strict rules against going to the movies. She confided nearly everyone secretly went to the shows but as a congregation they all voiced disapproval of such. In Pluralistic Ignorance people don’t speak out and get others to agree with them. Sometimes a brave soul does this and the charade quickly falls ala “The Emperor’s new clothes”.  Alas, what often happens when someone tries to speak up they are trounced by the members of the group even though many secretly agree.  I think this is what is happening with the GOP.  I suspect many in the GOP think Trump is awful but they are fearful to say so publicly lest their colleagues turn on them. Certainly Trump keeps the dissenters in check by his lashings out at those who question him. This is often how tyrants keep people in check.

When there is a manifest group consensus you disagree with chances are others feel the same way. Questioning things publicly or with others privately helps reveal the Emperor’s new clothes for the nakedness it is. 

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I often deal with grief. I regularly have a lot of patients stating they have depression when in fact they have grief. Depression and bereavement are not the same (although they overlap) and I spend a lot of professional time discriminating them and giving counsel accordingly.  Being a Jungian I extol ritual but not when it comes to bereavement. How and when we grieve – and for how long – are as individual as fingerprints. You would think we would give each other slack on grief styles but we do not. People and societies get terribly judgmental towards the bereaved on how it ought to be done.  Often the grief-stricken get should-statements. “You need to get over it” vs. “wow you got over that quickly” or “You need to let it out” vs. “you should compose yourself’.  Sometimes the bereaved is given contradictory advice.  We tend to use our own means of grieving as the proper way while holding others’ ways as wrong or radically selfish.  

“He hasn’t shed a tear since she died!” 

(Code: he should be crying or he didn’t really love her). 

“She’s been wailing for over four months now” 

(Code: I have moved on so why can’t she?) 

Societies tend to be even more judgmental than individuals. Public Opinion often dictates how to dress and what one cannot do. This often comes with a fixed period (say, a year) as if afterwards things suddenly become OK.  In “Gone with the wind” there is a scene where everyone is scandalized when Scarlet dressed in her widow’s weeds is having a good time not at all doing what she is supposed to be doing ‘in her grieving time”.  

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In the opera ‘Orpheus in the Underworld’ Public Opinion literally hounds the widower Orpheus to retrieve his wife from Hades although he has no desire to do so. 

I often counsel grieving patients to be wary when someone criticizes their mode of grieving. On the other hand I try to get them to figure out a ritual and time to do it so their grieving time has a finite ending. A ritual marks the end of something and the beginning of something else.  In a ritual one can say to his or herself “I have grieved enough and I will close this chapter; I may not be able to move on but I choose to move forward.”

As Mother’s health declined I initiated my individual grieving process early on. When she died it wasn’t the start of my bereavement but the end of one chapter and onto a new one. My means to grieve is through writing. 

Today I feel OK.  I feel a closure. Public Opinion would be outraged but Mother would not. 

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I recall a Spo-fan once asked me to make a list of what nuggets of wisdom I say to patients that do the most good. I’ve been hesitant to do so as these chestnuts are seldom numinous when said on their own out of context. No patient has ever heard them , opened the eyes in amazement and left the office transformed.  Were it that easy!  However I wanted to keep my promise so here it is. These are the truisms that seem to come up the most; I believe them to be right if not always helpful. Alas Babylon! The Spo-fan who requested the list doesn’t seem to be reading my blog anymore.

 

There is no progress without struggle; there is no wisdom gained without pain.

If you want to know what the future maybe like look at what you are presently doing. 

Learn to say no without having to justify or explain yourself. 

If you were to do one thing to better your well-being give up your need for certainty.

Don’t cry for a person who doesn’t know the value of your tears. 

This too shall pass. 

Being with someone who has something deficit in you will not fill your void. In time you will reject them for the same trait that drew you to them. 

When you are wrong admit it; when you are right – keep it to yourself. 

The key to a good life is not fame nor fortune – it is community. If you have nothing in life but friends you are truly rich. 

A clear rejection is better than a fake promise. 

Happiness is a by-product or a consequence; it is not a goal.

While you have little or no control of things, situations, or others you have control of your reactions.

If you want health you first have to be willing to give up that what is making you sick. 

You can’t always be strong but you can always choose to be brave.

Do things without expectations of returns. 

You don’t have to live your life the way other people expect you to.

Don’t talk, act; don’t say, show; don’t promise, prove it. 

 

And –

My favorites – 

 

Life has no meaning other than what you make of it. 

Laughter is the panacea. 

Question everything. 

Remember to enjoy life. You only get one. 

 

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I am back to work now after a week off  for (non) vacation. I am back in the saddle as it were. Some have questioned this viz. why the mental health clinic hasn’t shut down. I may be a psychiatrist but first and foremost I am a physician. I took an oath to help others so here I am.* On the positive I don’t physically examine patients and I can put a good enough distance between my and the patient’s chairs.

 

Most of the patients are coming in as usual; there are not too many no-shows or cancellations. Even the evaluation patients (newbies) are making their appointments. The medical assistant tells me the bosses have OK’ed some ‘telepsychiatry” and I am trying this out.  The ones down to do this are highlighted in lime green on my roster. There aren’t many so far. Curiously no one is complaining they were obliged to come in. Rather some are conveying gratitude I haven’t closed down.
The therapists are working – some of them anyway. They’ve been interpreted as ‘medical’ so can keep working if/when Arizona goes into more stringent circumstances.

The patients aren’t especially anxious/depressed about the what-ifs.). No one has come in in hysterics or seemingly gone off the deep end although I’ve heard about some patient’s loved ones buying up months of tinned meats and ammunition.

The ‘chief complaint” seems to be having ‘cabin fever’ being at home with the spouse and the kiddies who are already rambunctious and bored. Only a few patients are agitated/anxious about pending doom situations but these sorts tend to be agitated/anxious about anything and everything so this isn’t greatly different.
Few seem worried about loss of income/work; I wonder if this is because more basic needs are paramount (food and supplies.

 
I myself don’t feel particularly anxious. I don’t shake hands or physically examine my patients. The patients sit a reasonable distance away from me. I’ve had training in Infectious Disease and I treat OCD-types so I know what to do about touching things. I open the doors using paper napkins and a regularly wash my hands and wipe down the keyboards etc. I’ve gone on the conclusion it is not if but when I get the damned bug I only hope that when I do I am one of the 80% who will have a ‘mild case” only.**

 
I am writing this at 3PM during my 15 minute mid-afternoon ‘break’. The place is relatively quiet. I don’t hear much activity in the adjacent rooms although the receptionists managing the phone calls sound as busy as ever.

It will be curious to see what happens next. The number of corona cases will increase before it dissipates. I will probably go to more ‘on line” lime green patient appointments and less face-to-face ones. Maybe we will shut if the business drops. Who can say.  So much of life is based on the notion we don’t know what to expect next. We will take this one day at a time and find out.

 

Post-script written at 330PM:  my 315PM patient said he’s glad I was here and I do important work. That made my day.

 

*I did not take the Hippocratic oath as it required one to swear by the Greek Gods. At the time I was an active WASP and to do so violated the first commandant. Rather I took The Declaration of Geneva of the World Medical Association. I forget which version it was; it’s been updated a few times.

**Even that sounds horrible and nasty.

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Urs Truly has been a busy boy what with work matters. The Other Doctor announced he is leaving the practice. He is going to a part-time job which will take patients who only will pay out of pocket. His patients dote on  him enough I suspect many will go with him. However not all will be willing or able to do so. They will be probably be coming my way. Hot puppies.

The incorporation of another’s physician’s roster is a tedious endeavor but it isn’t anything I haven’t done before – many times. I’ve lost count of the number of shrinks and nurses who have retired, died, or disappeared only to have their clientele come crowding to me. I am like The Statue of Liberty for the anxious and depressed: give me your tired, your poor, your huddled masses yearning to have their prescriptions refilled. Maybe a better simile is I am like Queen Victoria: prime ministers come and prime ministers go but I stay.

It’s an ill wind that blows nobody good. There are some positives to this avalanche of newbie neurotics. I will have the medical assistant (A.K.A. “Bubble”) all for myself and he will have more time to do my capricious biddings. I can cancel all the pharm representative lunches, something I’ve been wanting to do for some time. * I had good job security; now it is iron-fast. It’s good to be King** – especially when there are no rivals to the throne. I’m thinking it’s time for new furniture and a computer hohoho.

Patients are usually unhappy about having to see a new doctor. It feels like ‘having to start over’ and there is the dreadful anticipation ‘will we click’. At my end it is challenging to live up to the deemed reputation and skill of the now-departed doctor. Some may find me marvelous; others will see me as not a proper doctor not like Dr. Kildare/Hoffmann/Frankenstein/Houser or whoever they were seeing.

I find out next week how many of The Other Doctor’s clientele go which way. I am fortunate to have good bosses who appreciate my cooperation in this endeavor. Perhaps next Christmas I will get not one but two bonus bottles of bourbon. That would be groovy.

 

*There were no pharm reps here until The Other Doctor brought them with him. I sense some will leave me before I tell’em to depart. They won’t see much advantage to schlepping in food and brochures if it is just Urs Truly.  It is hoped they all go with The Other Doctor.

**Or should that be ‘Queen’?

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Last Wednesday at lunch a pharmaceutical representative presented a ‘new’ medication which is really an old medication (long time in generic form costing ~ 15-20$/month) repackaged with some sort of substance or microchip which, once swallowed, a tracking device (a patch to the ribcage) monitors if the patient has taken the daily dose. The information is transmitted to the patient’s app  “and to three or four others as they wish” including the doctor. In his/her copious spare time the physician gets to monitor adherence via an app or through the pharmaceutical website. Presumably one of these watchmen contacts the noncompliant patient to inquire why aren’t they taking their medication and do so now. The medication/system isn’t prescribed like other medications but requires an application (ironically a paper one) and the Rx can only be filled at specialty pharmacies not with the usual pharmacies the patients are already using for their other meds. By the way, the price of this system is 1,700$/month.

What could possibly go wrong?

It took a lot of composure for me not to choke on my sandwich as I listened to this Orwellian situation. I distilled all my questions into one simple inquiry: is there any evidence this system improves adherence compared to setting a daily alarm (as I do) to take your meds. There isn’t any. Ah well.

This is why we can’t have nice things. Once in a while I read about some effort to ‘reduce the rising cost of medication’ like capping the price of insulin or epi-pens but these are quaint band-aids that don’t address the real problem: advances in medications are driven by private industry and they based on profit to please the stockholders not patients. In their defense pharmaceutical companies spend billions on creating meds so they want their money back. The makers of medications lose their patents and have come up with these sci-fi situations and send out salespeople to convince me it is something groovy.

In the USA we are bedazzled by technology and think applying it makes things better. How long though before Rx adherent app information is hacked or sold to others like advertisers or insurance companies. There is something Borg-like about walking around with a patch on monitoring what’s in us. On the other hand we seem OK to walk around with our phones shouting our whereabouts and goings-on to anyone who wants it.

While I am ranting about medications and the machinations mated to them let me add here I have enough money to retire. But if I stopped work I would lose health insurance particularly prescription coverage. I’ve down the sums: the amount of money I would have to pay per month would skyrocket making retirement unaffordable.

Sadly the main reason why this medication won’t be used much isn’t the cost or concerns about privacy but the doctor’s emotional sensation ‘this is going to be more work for me”. They imagine a clinic-full of patients’ electronic information coming in daily and feeling obliged to watch/record it all.  And they are not wrong.

When The Other Doctor at our clinic retires I plan on pulling the plug on pharmacy lunches and samples. The patients will howl like an orchestra of scorched cats not to have samples I suppose, but the set up contributes to the national problem of outrageous costs and pharmaceutical shenanigans.

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