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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.

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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.

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

bigstock-Business-Man-Sleeping-On-The-F-97521389-300x300

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.

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