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Spo-fans will find it amusing if not downright ironic I wrote this on my laptop at 930PM. 

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Lord love us I just read another study linking – again – a good night’s sleep to just about everything good and a bad night’s rest causing or worsening all our woes. The brain is the ultimate luddite; it is fixated in a time prior to the invention of the electric light. It wants a long night’s rest above all else and (like a peevish spouse) when it doesn’t get its way it will make your life miserable until it does.

The study comes down to advising our patients with all sincerity they should turn off the TV and all technical objects at 8PM and don’t dare touch them until morning – or face a series of demons of shortcomings and sorrow. This oh so sensible advice will get the same ‘St. Anthony preaching to the fishes’ nods I get from my patients whenever I tell them to lay off junk food and avoid coffee for their nerves.  Fat chance of that.

Foolish people. We don’t want to turn off our texts, not even to drive safe. We like fries to salad and Netflix marathons to working in the yard.  Female patients freak out most over the notion of breast cancer, yet it is cardiovascular disease that is more likely to hit and knock you into your grave.

Can I nag my patients into prudent living? Alas, that breed of doctor authority died out long before I arrived on the scene, more’s the pity. History shows vice laws and prohibitions do not enhance virtue and maybe more likely to undermine it.

Even to Urs Truly a ‘healthy lifestyle’ sounds a bit dull: rise every day at 5AM even on the weekends; no bacon but eat oatmeal and yogurt for breakfast. Avoid meat. Watch no more than 30 minutes of TV. Keep moving. Drive with the cellphone turned off. Abjure processed foods and strong drink.  No techie toys after 7PM but read a paper book. Bed at 9PM and repeat.  This may extend life by a decade but is it worth it?  It all sounds like Midwest Protestant Work ethic, which was/is code for suspicion for things pleasurable.

Oh well, there is no better way to lead others than by example. I shall do better at getting sufficient sleep, at least.  As summarized in the study mentioned at the beginning, it is the ultimate cornerstone upon which to build one’s health. Try to tell as many people as you can in town why don’t you.

Office  Last Monday my lower back muscles when into a paroxysm of pain and they refuse to loosen up. Yesterday the left lower psoas muscle went into a spasm severe enough to make it near impossible to get up without evoking a vice-like grip in my lower back. It is not a sharp or radiating pain; it is not sciatica. All the same I have never been in so much pain other than the time I had  migraine headaches. I couldn’t do much last night. Even putting on and off my clothing was hellish and horrible. Taking massive amounts of Motrin and Ben-Gay have done little if any good.  My only comfort is the knowledge I’ve had this before and it passes – eventually.  Until then life is miserable and limited.  It effects my cognition and my moods.

I see a lot of patients with pain; theirs are far worse than mine. For such an important and ubiquitous topic pain is not much addressed in medical school. Doctors in general aren’t keen on treating patients with pain. I don’t disclose a secret to say patients with pain are not the types doctors like to deal with. Pain is subjective; pain makes people needy and wobegon. What patients want and what doctors are willing to do for pain are often at odds. A common complaint of my patients is their pain is not being taken seriously nor is it being addressed adequately. With the current national worry about opiate medication abuse, doctors are becoming less willing to prescribe such or even deal with pain, asking the patient to ‘see a specialist” which rivals getting an audience with The Pope.  When a patient is fortunate to find a physician willing to address their pain, they often feel they are looked upon as drug-seeking manipulative whining cranks.  By the way, data supports chronic pain is best treated NOT with opiate-based medication but with other Rx and non-pharmaceutical routes. Alas, these take time, energy, money, and explanation to do,  and patients often don’t ‘buy it’ – they want drugs – now – and effective ones. It is hard to think rationally when your mind is poisoned by pain. I my current status I would be willing to debase myself for something stronger than ibuprofen.

I know what I need to do for my pain: stay put, take regular Motrin, apply heat, and wait patiently. Perhaps get a massage and for goodness sake do some stretches. No valium  or hydrocodone is needed.  That’s a slippery slope.

But what about my patients, the ones who have active/chronic pain not being properly addressed? It is tough to treat depression/anxiety when pain is active. It’s like trying help a patient improve their sleep when they live in an apartment with the neighbor’s music  blaring all night.

Pain is a complex problem and the solution is likewise. The treatment is also complex. I wish I had a simple solution.

There is a ritual catching on in medical schools called The White Coat Ceremony. I’ve not seen one myself, nor was I in one.  Apparently the schools welcome their incoming students with a presentation of their short white coats. My school has reached out to its alumni to sponsor a student via purchasing his or her lab coat. The recipient of this medical munificence gets a card with the donor’s name. We donors are encouraged to write a few words as well.

Urs Truly always has a desire to write great or witty prose; I am first in line to do so. I’ve decided to forgo brevity and wit so I won’t write such things as  “Don’t bother” or “It was hell” but write a proper letter.

Here is the first draft for Spo-fans entertainment and input.

Dear student,

Welcome to the wonderful and wacky world of Medicine. I wish you well. I am nearly thirty years ahead of you. I would like to share with you some sage words for you to keep in mind as you fall down the rabbit hole.

First of all, keep an open mind. The dirty secret is hardly anyone ends medical school with the same vision they started with. Practically everyone changes their specialty and some do so a few times. Most of what you will learn in med school will be either obsolete or useless by the time you hang out your shingle. Yes it’s important to pass the tests but the real point of school is to learn to think like a scientist with a critical eye. Learn to learn.

It will often seem overwhelming and tedious; many times you will doubt your sanity why the hell did you get into this when everyone else your is making money, having fun, and getting sleep too. It all seems tiresome while you were in training but from my view looking back it is a blink of an eye in one’s lifespan.

You will run into many doctors who will complain and discourage you. They will make you wonder if Medicine was a mistake. Shun them and seek out positive role models.

Above all else: take care of yourself. Even caretakers need care-taking.  You will be no good to others if you are no good to yourself.  If you need guidance – or just a shoulder to cry upon – page.  Despite it all it is a marvelous Journey. I’ve had no regrets; I hope you have the same.

I think it is in ‘Alice in Wonderland’ where someone says something about believing six impossible things before breakfast. It seems I am believing improbable things rather. As The Firesign Theatre says: “Everything you know is wrong”.

I am reading rawhter rancorous research about the brain that isn’t reassuring.  Our ability to accurately remember things is not even close to what we think it is. Rather than being a like a CD to replay when we want it,  our long term memory is composed of past and present elements; the mind puts it all together each time in a slightly altered memory, making objective memory nearly impossible.  It is kind of like making the same dish that never comes out exactly the same way. There is bad news for attention too; we are deluding ourselves how good we are at being minding traffic, hearing something important while in a noisy room. Worst of all are cellphones which basically destroy any other cognitive endeavors while we operate them. Even hands-off cellphones diminish our ability to attend to traffic.

Some curious research suggests when we try to talk to people who are set in their beliefs (ex: trying to talk reason to an anti-vaccination parent, a Trump supporter, or a non-believer in evolution/global warming etc.)  their brains light up in the same areas and in the same way as being physically attacked. This means attempts at dialogue/reason have about the same chance as telling a person to thinks sensibly when they are being lunged at by a lion.

Cognitive bias is so strong and subtle it sheds doubt on our abilities to see anything objectively.

The cerebral cortex has conned itself into thinking its in charge and make all the decisions. Meanwhile the emotional parts of the brain run amok making up rubbish and basically running the show.

Oh the pain. Oh the discouragement.

My science training tells me to be open to changing my beliefs when the facts say otherwise, even when I want to hold onto cherished dogmas and comforts. This stings, but even more  when you feel you’ve been conned.  Enough says my hummingbird brain for all this ‘everything is relative” nonsense. Give me some simple black or white convictions. Alas, more research says when facing ambiguities or pointlessness we create ersatz solids and make meaning out of nothing.   Oh well.  I can take comfort in some simple Truths like tea is lovely and I can refrain from going on to prove black is white and perish in the next zebra crossing.

I got a request from a Spo-fan (who is well over four feet) to write about bipolar depression. Here are some basics.

Clinical depression comes in various types. “Unipolar” depression is the mood condition in which people go between states of depression and feeling OK/normal (rather than feeling happy). “Bipolar depression” as the name suggests means sometimes the moods go up and beyond ‘OK” into what is sometimes referred to as mania. In a manic mood state the person often feels euphoric with high energy; they sometimes feel they can do anything. They often do reckless activities such as driving too fast, spending money, or sexually act out – all in ways they would not do in a calmer mood. In a bipolar depression there is often irritable and labile mood swings, talking too loud a/or too fast, and little or no sleep.

The old term for bipolar depression is manic-depression. Either term is used by patients but clinicians tend to use the former.

Discriminating unipolar from bipolar depression is quite challenging, for the mood conditions fall on a spectrum rather than in clear either/or categories. I spend a lot of my job trying to figure out a patient’s depression type. Sometimes it takes years before someone is properly diagnosed with a bipolar depression, having had first a long time of being diagnosed and treated as unipolar. It makes a crucial difference to get the right diagnosis, for the treatments  are different. If I give a person with bipolar depression the wrong type of medicine, the prescription could actually make them worse or manic.

Alas, people don’t fall cleanly into clean either/or categories; bipolar depression is seldom clear cut. When I was trained only thems with ‘classic’ manic periods – followed by depressive states – were diagnosed ‘bipolar’. Now we know the majority of bipolar patients do not fit into this classic definition.

Sometimes a patient tells me once upon at time they took an antidepressant and it made them worse. This is a sign for me to sit up and consider the possibility of a bipolar type depression.

Lithium used to be the one and only Rx for bipolar depression. There are many others now, although lithium remains the ‘gold standard’. It’s a tough medication to take, and thems with ‘atypical’ or ‘mixed states’  or ‘rapid cycling’ types of bipolar depression don’t respond to lithium as well as ‘garden-variety manic depression” viz. clear and clean manic episodes.

It used to be people with bipolar depression were missed and underdosed. Now the pendulum has swung the other way and too many moody/irritable unipolar depressed folks are being diagnosed with bipolar type depression. Ironically, thems with true bipolar depression are still not being identified and treated.

There are no good physical exam findings or brain scans or blood work tests to make the diagnosis easy (at least not yet). There are some relatively good screening tests a doctor can do to help screen for such. In the end it is the history and timeline – and an expert like Urs Truly (hohoho) – to make the diagnosis. Even then I have to be mindful do I have the proper diagnosis or not.

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This one was written in piecemeal as I sit through a weekend conference. It was mostly written during the talk on pediatric movement disorders.

I am glad to be in a medical specialty that is ever-learning and ever-changing. It is a bit humbling to learn much I believed tried and true is no longer so. It’s the Firesign Theatre slogan: “Everything You Know is Wrong”. It stings a bit, but it feels good to learn and grow, which is a sure sign of being alive.

I work in isolation so I don’t know any local colleagues. One of my goals of this conference was to meet and hob-nob with my fellow wizards. I’ve faced my social anxiety fears and attended the Friday night mixer, made. I purposely wore one my more loud and colorful Spo-shirts. This forbade me to stand in the corner unobserved. People approached me to ask about it. This gave me a sort-of springboard into dialogue. I met a handful of shrinks; I feel a sense of accomplishment. I emade a few business contacts. The President of the Arizona Psychiatric Association invited me to ‘get involved”.  Good for me!

Speaking of colleagues I am struck how diverse is my speciality. Surgery, for example, tends to be all white males (and pompous ones at that). Shrinks are male, female, old/young, and seem to come from all ethnic backgrounds. I like that.

Do I sound like a wicked old screw to write the psychiatric residents are beautiful? The young male doctors attending the lectures are all drop-dead gorgeous. Many of these lads have whiskers, all worthy of a Fearsome Beard post. I guess one of the admission criteria to residency nowadays is being woofy and handsome. I am grateful I was ‘grandfathered in” both literally and figuratively.

During the lecture breaks there is coffee and tea (albeit rubbish) and buns and things and pharmaceutical representatives. Many of them I recognize from Wednesday luncheons at work. As a group they change products and companies like participants in a fast-paced square-dance.

My liability insurance company also has a representative present. She is well over four feet. She told me she is pleased I am not afraid to call them with worries when my colleagues fear to do so lest they be labeled as a ‘problem doctor’. She gave me some notepads (the pharm reps no longer do so). On each sheet is a ‘tip’ how not to be sued. The top page suggests  I keep my prescription pad under lock and key so it isn’t pinched by the patients.  I will try to tell as many people as I can in town.

A Spo-fan asked me the other day (or was it a few weeks ago?) please write out my thoughts on the topic of Introversion vs. Extroversion. I was about to write a most-fascinating entry about the drainpipes but this topic topic sounds more vital. There is a lot of rubbish about on I. vs. E. and perhaps I can banish some ignorance.

If you get one thing out of reading this, it is the following: the difference is “where do you go to get recharged?” [1] When you feel drained do you prefer to be to yourself or do you prefer doing something with others?  That’s it. That’s all that matters. That’s the difference.

Jung wrote a lot on the topic. He saw the two modes of operation as how does one process the world, internally (introversion) or externally (extroversion). His goal for mental well-being is always to get one’s psyche in balance as much as possible. One finds out which is your ‘major’ and go to work on the other.

It is nonsense to see these two terms as black and white, or it’s one or the other. “I’m an introvert!” I hear someone say in a bar or at a party. I have to hold my tongue to respond so what are you doing here.

Urs Truly has a predominate introverted psyche. There is nothing so pleasing to me as spending a day to myself reading and doing chores only to realize I haven’t spoken to anyone all day. Some friends find my statement hard to believe, seeing me mingle and interacting well with others in social settings. After all, I am in the blogging community for pete’s sake – that’s a very extroverted endeavor. Introverts do not lack social skills, nor do they hate socializing etc. It’s just if given a choice between happy hour or staying home with a good book they find more ‘charge’ in the latter.

People who predominately relate to the world through extroversion [2] often  find the other kind a bit bewildering. Es are more likely to encourage/push Is “out the door’ as it were. [3]  However even Extroverts see value in ‘down time’ and peace and quiet – at least the more balanced ones.

There is no war between the two types.

One is not ‘born one way’ and one is not destined to be just one way or the other.

Do not try to put yourself as one or the other.

Goal of learning this: balance out as much as possible while keeping an eye on what recharges your battery – a book or a telephone call.

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I thought I would put up one cliche summary picture.

Get the gist and now discard. 

 

[1] If you like more fancy words: in what setting does The Ego find replenishment for spent Libido (viz. psychic energy).

[2] I purposely don’t use the words Extrovert and Introvert as they enhance labels. Nevertheless it is hard to avoid the lexicon.

[3] Thems mostly introverted seldom bother to try to make extroverted types stay more at home.  It’s an iniquitous arrangement.

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I get to work around 7AM although the first patient is not scheduled until eight. 7-8AM is a pleasant time and at this time of the year the rising sun shines on my side as I sit at my desk; it feels as pleasant as a cat in a sunbeam. I get a lot done in these serene sixty minutes. Best yet, I can write out a blog entry while having a nice hot cup of morning tea. There are no interruptions or phone calls to mar my meditation. It is a lovely way to start the day.

It’s Wednesday, which have been christened ‘Wacky Wednesday” for most of the week’s shenanigans happen on today. I get more calls/reminders and fires to extinguish than on any other day.**

I’ve just learned today’s pharm representative has called to cancel lunch. I have some backup protein drinks which will do me no harm. I worry I am scaring the reps away. I don’t think I am ‘mean’ to them but I do not buy their song and dance at face value but ask questions for which they often don’t know or exposes jiggery-pokery. Oh well. I never was happy having them.  Pharmaceutical representatives are only doing their job of course, but as a group they come across as rug salesmen trying to sell me something I already have or don’t want.  They move around like Bedouins: one day Sally Sue is working for “A” and next week she’s with “B”.  It is hard to get them straight as who does what.

I’ve scanned my day’s roster and did not have any “Frau Blucher” responses to the drama personae on my dance card. It’s nearly starting time. I can hear some mild commotion coming from the lobby. Mr. 8PM has arrived; it sounds like he is not in a good mood and having his crisis de jour. It looks to be a long day, as is the wont on Wednesday.

Happy Hump-day to Spo-fans far and wide. Don’t stick no beans of your nose. And always ask who was excluded in the double-blind trial of your medication.

 

**I may be at ease now but I won’t be so jolly by 3PM. Happily, my track record for getting through Wednesday’s Woebegones is so far 100%.

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Not long ago I had a patient with symptoms that occurred only in the middle of the night. He would wake with chest tightness and a sense of foreboding. A creeping sensation took over him and develop into partial paralysis. His theory was not depression or panic attacks but the house was bewitched. He tried to exorcise the alleged ghost(s) with some sort of cleansing ritual but no luck: the symptoms continued. His PCP sent him on the possibility he was off his rocker. I didn’t think him ‘crazy’ but I wasn’t going with his hypothesis of spooks. I got him to have his place checked for black mold and the like. It turns out carbon monoxide was seeping in to his room from the near by garage. I thought the man would be grateful but he wasn’t. He was downright disappointed the explanation wasn’t supernatural. You’re welcome. People believe in a lot of mumbo-jumbo about illness and treatment. Because of my training in Jungian psychology patients expect me to be full of dungeons and dragons and they are dismayed when I cut through their rubbishy theories about every little fiddle-faddle. They want me to agree with their beliefs and take umbrage when I don’t

On the other hand I’ve learned if a patient is gung-ho about something for their treatment I go with it so long as their modest proposal does no harm. The placebo effect is a strong and useful medicine. If their way works, great; if it doesn’t, then next time it is my way.  It is important to be neutral about these things. A patient recently returned after a year of trying a myriad of non-pharmaceutical means to alleviate her depression, only to sheepishly admit (with a touch of rancor) only the zoloft works and would I please give her another prescription. OK is the answer, not I told you so you silly person.

Patients with paranoid delusions are particularly tough nuts to crack. I’ve learned not to butt heads yes it’s true no it’s not but to go with the affect.  “Gee, that must make you (angry/scared/frustrated) to have that happen to you” not only does this mirror the affect but it dodges the debate about the truth of it all.

I see Thursday’s roster has “Joe” coming in. He doesn’t want treatment per se but seems to be showing up solely to wear me out through attrition and get me admit I am wrong and affirm his belief about the supposed nightly break-ins. My two comments  a) how the hell can I know for sure and b) it sounds not likely and give it a rest neither appease or cause him to dismiss me as a quack and go elsewhere. He is determined to get me to confess yes he’s right. It’s all rather tedious. I am half-tempted to tell him his house is bewitched. It may actually raise his low opinion of me.

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The Other Doctor called in sick today and The Wonder Receptionist is taking time off for a family matter, so things are a bit quiet here at the office. I sense the former’s absence will create ‘cover’ work, while the absence of the latter will mean the phone calls won’t get through. Today’s pharmaceutical lunch may be canceled due to lack of attendance. I will have to run out in mid-day traffic to find something to eat as quickly as possible between noon and 1230 in time to get back to the helm. For all my wool-gathering, I am never asleep at the switch.

The clinic has lost another potential new prescriber. For some time the bosses have been trying to get a 3rd doctor but no such luck. A physician or RN gets oh-so-close and then they bail. I am told this last one went a little off the deep end just before starting. Apparently she was appalled to learn part of the job of working with anxious or ADHD patients means sometimes prescribing controlled substance Rx. Worse, she has to cover her patient’s phone calls. It was probably good to find this out prior to her being on board.

I am clearing out my files of ‘clippings of interest’ and ‘patient resources’. In my field things come and go so quickly; last year’s research and recommendations may already be outdated. While it is exciting to be an ever-growing branch of Medicine, it is rawther difficult to keep up. Sometimes it is easier just to go to Youtube than read JAMA, which I read mainly for the lovely art history articles that illustrates the front covers.

I am practicing my Spanish lessons on the clerical staff. They are too polite to tell me my Spanish is god-awful, so getting feedback is faulty. My formal grammar is politely corrected to everyday vernacular, which I appreciate. I can’t seem to remember the who/what/where/why words but the swear words have landed safely into my lexicon. Cabron is my new favorite, probably because it isn’t clear to me what it means exactly.  For all I know I am getting the Spanish version of “The dirty Hungarian translation book”.

 

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