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office

My work day officially starts sharp at 8AM when I see my first patient. However I usually start working around 6 to 630AM. I am always the first one into the office. When I arrive I make a pot of tea or coffee (the latter, if I know The Boss Man will be in that day), I sit down to the computer, and I get to work.

I like this twilight time. It is quiet and I am by myself. What I do in the early morning hours is helpful  later on when I want to stay on time. It has a certain peace. I am able to work uninterrupted by calls and staff matters. I turn on music or a podcast. There is a pleasant low-key industry to renew prescriptions and set up the progress notes for the pending work day.

There is a sort of virtue to this time of the day . People tend to respect and admire you.  I daresay this is a hangover from medieval times when getting up early to work was a necessity. Perhaps we made it a virtue to compensate for the misery of long work days.  Over time the sure sign of ‘success’ was NOT working but having long leisurely days initiated by sleeping in. History has come full circle and long hours are again a sign of success. Being busy is the new status signal: “I work 12-14 hours a day I am very important”.

It’s nearly 8AM here at work. The secretaries and billing staff are coming in. There is a sense the place is ‘waking up’. I will see nearly thirty patients today between now and closing time. These are long days. I don’t mind really. On the other hand, my interest starts to wane around 3PM but the work ends at 5. I pity the patients coming in after 4: they are getting the last bitter drops out my gray matter grapefruit that has been squeezed a bit too many times today.  🙂

office

Some folks have jobs in which they move about; they are constantly on foot at the workplace or driving/flying to interact with clients. My job is the opposite: I sit still and my clients (A.K.A. patients) travel to see me. Some of them (the dears!) travel a long way. Some come from other states rather than find some local doctor. I listen to peoples’ comings and goings while ensconced and sessile in my chair.

This iniquitous arrangement makes me sometimes jealous. This was apparent the other day when “Peer” showed up for his appointment. He pops in every 3-4 months for a routine check-up. As usual he’s a bit late to return to clinic as he’s been vagabonding.  As I escorted Peer into the office it seemed to me he’s aged – not in a bad way but simply I’ve watched him grow older. Peer reported he was fine and he feels a fortunate fellow. He is retired; he has a cabin in northern Arizona that he adores. When he isn’t there he is traveling – a lot  – for he loves it so. After a few formalities to convey he’s steady and the meds are worth continuing I asked what’s coming up. Oh, he replied, he’s traveling to Chile ‘for the millionth time” to hop a cruise ship to NYC. Maybe afterwards he may visit Canada, he isn’t sure, or perhaps he will just relax at said cabin.

On his way out he joked he’s seen me growing old which makes sense as ‘I’ve been coming here for five years or so”. I looked this up: we first saw each other in 2005 – 14 years ago.  This made him laugh and he doubled his gratitude for my care taking. Well, see you after I get back from South America and he waved good-bye.

I went home that night feeling a bit melancholy. We have watched each other grow old and the years have flown by. The difference is he’s circled the globe countless times while I, Solveig-like, have stayed home. In a way it seems a disappointment to spend one’s life growing old in chair watching others live out their lives.

A lot of my success at being a shrink and as a physician is being constant. In a world of perpetual change my patients appreciate I’ve been there for nearly fifteen years and counting. I hang in with them while they go on their peripatetic tumultuous Journeys. I’ve received many thanks for ‘doing well for me’ based not so much on making them better but just being there.

All the same, I don’t want another 5-10 years of watching patients grow old. It is very difficult for me to take time off from work but it isn’t impossible. I don’t want to see Peer in another ten years under similar circumstances. It’s time for me to get out and be more than everyone’s rock.   I can be both Peer and Solveig.

journeys

office

A while back a Spo-fan emailed me the question: “What causes depression?” I wrote a response; I decided to post it here for other’s edification.

We humans like simple ‘A causes B’ explanations. Unfortunately this approach seldom if ever properly explains anything. I won’t dwell on the cliché (albeit true) explanation depression arises from of a complex multi-factorial gunge ranging from genetics to what you are eating nowadays. Here is a simple enough (and hopefully accurate) explanation.

There are two main causes of depression:

The main one comes from the perception of loss: loss of status, resources, companionship, leverage or independence.

The other main cause of depression is from sickness. Chronic conditions, especially chronic pain, are greatly correlated with depression. Either the sickness leads to depression or an underlying factor (inflammation) creates the physical and mental conditions. Some say sickness is just another variation of loss viz. loss of health. Therefore the perception of loss is the main cause of depression.

Depression and loss are linked as the consequence of evolution. We evolved as social creatures. Being involved and connected helped us relatively naked and defenseless animals to stay alive – alive long enough to reproduce. We had to anxious battler fronts to win: beating the bugs and keeping in good standing with The Tribe. To lose connection with the latter meant you were ‘on your own’ and at risk of death.

Notice I wrote ‘perception’ of loss. Back in the bad-old days if you got infected or booted from society both usually led to death. The mind developed depression as if to say ‘You have inflammation! or You are on your own! You’re doomed! Shut down and die!” Nowadays we have treatments for infections and losing your group, job, or status doesn’t lead directly to death – but the body/brain still reacts the same.

Unless depression is purely a ‘brain disease” like a stroke, the treatment for depression involves mostly treating the body and the mind not the brain. The treatment depression addresses improving general health thorough regular exercise, good diet, and sleep to diminish stress hormones and general inflammation.  Connection to others is vital via social network and ‘talking about it’; avoid isolation which the mind sees as a death-kneel.  Improving autonomy and removing things that trap you (bad job, bad relationships etc.) help depression.  Talk therapy often looks at and challenges our negative thinking viz. the loss of a relationship, a job, etc. is not really ‘the end of the world’ as our monkey brains like to go to in a loss situation.

Office

After 13 years of working where I do, I finally have ‘M.D.’ after my name on the letterhead. I’ve never been one to flex my medical muscles but I think it is appropriate to include my credentials whenever I am writing pompous letters to insurance companies or pow-wowing with my fellow wizards. All it took was a simple request to The House Manager. Who would have thunk it?  This revelation was like the radiance of a brilliant sunrise so I asked her to send me the other templates for coiffing. All the forms are updated and nifty looking.* I’m pleased as punch.  I arranged the sentences and such to accommodate my left-handedness. I added ‘please’ to some of the imperial-sounding instructions.  Manners count!

Alas, I won’t be attending the annual office holiday party this weekend for I am away on a medical conference. Each year at this party I get a modest cash stipend which I immediately use to buy a good bottle of scotch I am too cheap to buy with my own cash. I wonder if I will get it given my absence. Let us hope so. I have the bottle already picked out.

One of the counselors is quitting work this week. I am sad to see him go for he did a good job and the patients liked him. A new one started this week but I haven’t met him yet. Glancing at him in the hallway he looks a bit overwhelmed. Let’s see if he stays.

Where am I going this weekend Spo-fans may be asking? I go to Lost Vegas for a medical conference. Last night I received an email from the Conference asking me to clarify which of the two seminars am I attending: “Updates in substance abuse disorders” or “The pelvic anatomy and gynecological surgery symposium”.  Dear me! I suspect the latter would be more intriguing – and probably with better luncheons. Shrinks tend to feel guilty being fed by pharm reps so they don’t eat lavishly, but surgeons have no such scruples – and they demand only the best, baby.  I will attend the one on ketamine, opioids, CBD oil etc. as sooner I’d eat rats at Tewkesbury than sit among surgeons. If my group becomes dull I can tiptoe across the hall and go have a look-see at the newest in prolapse uterine repair – or at least to swipe me a proper sandwich.

 

*It’s always the queer one to make things fabulous.

I want to share something recommended to people with depression; may you find it thoughtful and perhaps useful.

The awful axiom of depression is it clouds ones entire being and outlook in dark and dismal despair. Nothing has hope; all who could be helpful are believed to be useless and actually uncaring. In times of improvement people can see in hindsight the lie of their depressive delusions. Alas, when back the depths of depression it is all forgotten. 

People with depression sometimes are asked to compose a certain list. This roster consists of the names and telephone numbers of people who are meaningful and helpful to you. These are the folks you can turn to at times of despair, for they genuinely care and see you worthy. They pass the test of those you can call at any time when feeling down or even suicidal. I tell patients not only to include names and numbers but ‘why’ they are important. 

Perhaps you know someone from church who thought you funny. Maybe theres was a teacher from college who thought well of your prose. Is there an aunt who always saw you as clever? It is important to list the ‘whys’ because in moments of depression you don’t remember this stuff or if you do you doubt their truthfulness.

 “I, who have written this in a time of wellness, remind you these people and the reasons listed are genuine. They really said to call when you feel bad. Do so.” 

It is important to get the permission of these lifelines, so they (and you) know if you enter despair you can count on them even at 2AM. 
I do not have clinical depression but there have times I feel bad enough I yearn to reach out just to someone to assure me I am not as bad as I feel and someone loves me. Yes, I plan on doing this very soon. I hope I can find a few willing to be on my blessed list. I may not ever use it but I see myself in dark moments pulling it out to read to comfort me and stiffen my spine.

Circle

 

officeThroughout each day we are continually asked things to which we need to respond with yes or no. There is a careful craft to knowing which response is right. In my line of work I see a lot of people who don’t do well with this viz. they often say yes when they should say no and vice versa. They blurt their response without pause or thinking.  Some learn to ‘play it safe” by responding nearly always with “yes” as“no” as panacea for all inquiries. Both ways are bad.

Thems who say ‘yes’  often are sometimes too impulsive: “Would you like try smoking this?” The ‘yes’ people often believe succumbing to another’s wants will make the other(s) like them or say yes to avoid friction/keep the peace.

Thems who use ‘no’ a lot often do so out of fear. “Wanna try something new this weekend?” “No” often deprives us of new opportunities.

I try to train patients to pause whenever they are asked anything, from a small request like “Do you want fries with that?” to the more ubiquitous “Will you do this for me?” In the pregnant pause they should do some self-analysis. I want them to consider the pros/cons of saying either answer. I am keen on intuition and ‘gut-responses” but these are raw and usually driven by habit and neurosis. Adding a bit of thinking before speaking can help us not walk into a regret.

When we say ‘yes’ to something this means saying no to something else. We should ask ourselves what am I indirectly saying no to here and is the trade-off worth it?

Does saying yes personally excite me or am I saying so for some external reason like ‘people will like me if I say yes”.

Is this opportunity wasn’t handed to me would I spend time creating it myself?

I think the propensity towards saying no is less nuanced. When we are confronted with something new, unknown, and out of our comfort zone we become wary or fearful.  To avoid such we often just say no. Our monkey-brains are wired this way. Before saying ‘no’ to someone ask yourself am I afraid of something here? If fear isn’t a factor would I say yes?  Is there a change to the opportunity to make it a yes?

Ok Spo-fans listen up. I am going to give you free advice on how to achieve mental and physical wellbeing. This is the best way I know to live well and happy if not as long as possible.  People pay me big bucks for this stuff so take notice.

The treatment of mental illness and the promotion mental health are like two sides of the same coin. Western Medicine tends to focus on the ‘heads’ side of the nickel: symptom alleviation. This is important but for total health you need to polish the other side of the coin as it were: enhancement of wellness. 

There are five things you ought to do. Happily they are free, not difficult , and they don’t need any fancy equipment or have complicated formulas. For thems who are skeptical or want ‘evidence-based’ medicine I am glad to say there is scientific evidence to back each on of them up. Some of you will read this and think “Duh, just a lot of common sense”, True, but isn’t it assuring to find out the research supports them as legitimate and efficacious?  

So here are five things with the most ‘potency’ to help with mental and physical well being.  They are nicknamed ‘The five pillars”.  I write a ‘prescription’ for you. More maybe better but this is the minimal dose is enough to do some good. 

MENSS is the acronym. 

Mindfulness  This is not woo-woo. This is serious salubrious treatment. I won’t bore you with all the data (of which there is plenty). Taking time off in the day to clear your head does lots of lovely things to our souls and cells. 

Rx: Meditate, pray, tai-chi etc. Just sitting still work. Do this for 15 minutes. Do this daily. 

Exercise – when we move, all sorts of good things happen to our bodies.  Doing something does a lot and is better than nothing. 

Rx:  Go for a walk x 3o minutes; do daily. Try to make this regular viz. in the morning before going to work or right after dinner. This is even better when done with somebody. 

Nutrition – Shocking I know but eating properis correlated to less general inflammation in the body and makes the wee-beasties in our bowels happy. When they are happy we do better. 

Rx:  No easy prescription here but it boils down to eat proper food, small portions, mostly plants.  You know what’s good for you. Cut out the crap. 

Social Connection – More and more data supports our monkey brains need social intercourse. Loneliness turns out to be 2x worse on our mortality than obesity. Social connection occurs while talking to someone on the phone or gabbing over drinks/a game/a task.

Rx:  15 minutes daily interaction with others. On-line social media does not count.  You need proper ‘in the flesh’ interactions. 

Sleep – Despite our desires to do as much as possible in 24 hours our antediluvian brains and bodies need sleep. We play a hazardous game to give up sleep for another hour on-line Scrabble. 

Rx: Cut out activities in the evening for the sake of sleep and not the other way around.  Look up sleep hygiene and do them. 

So there you have it. Make a daily check list and ask yourself each day have I tried to get my daily allowance of Meditation, Exercise, Nutrition, Sleep, and Socialization.

 

office

It seems youngsters these days think of themselves as a mere walking bag of neurotransmitters. A young man recently came in with the ‘chief complaint’ he has DDA. Not recognizing this acronym,  I asked him to expand. ‘Dopamine deficit disorder’ said in a way that resembled a frustrated parent who has to explain for the umpteenth time to a dull child why the night is dark. Sometimes patients bring in brightly coloured brain scans or reams of genetic tests to support they need this or that medication to correct the alleged chemical imbalance.  I’m seen as a glorified waiter from whom they expect to place an order and have the order served without question.  I like to tell them please don’t confuse your Google-search for my medical degree, but I this effects my tip. 

The Other Doctor soon goes to a four day work week and the nurse practitioner retires next month leaving me the sole Rx-pusher on Mondays. This will be a disappointing surprise for the pharm reps who are scheduled for luncheons on that day; they will only have only Urs Truly to feed and entertain. I am getting the sordid reputation among the reps of a smartypants who asks intelligent questions that cut through their dog and pony shows rather than just siting there eating and taking in their data without question. I supposed I will should ask the office manager to cancel Monday luncheons. I will miss the Thai food but the thirty minutes of peace and quiet sound worth it. 

I am behind on my CME* credits. I usually keep on top of them on my car trips to and from work.  Hum-drum medical lectures simply can’t compete with my daily deluge of podcasts.  Podcasts tend to be last less than half an hour which fits nicely into my commute. Medical lectures last over an hour. I’ve decided Tuesday mornings will be ‘CME day’ where I forgo “The Daily”, “Lore”, “Myths and Legends”, and “Hello from the Magic Tavern” for the latest Audio-digest. Tomorrow’s topic is on the treatment of trichotillomania.  Oh the pain. 

 

*Continuing Medical Education. 

Office

After a few tedious weeks of experimenting with ‘classical radio as background noise’ the Mesa office hall sound system has gone silent. I was just in the process of preparing some politic email to ask thems in charge to turn it off or even back to the ‘classical rock’ station when it happened. The quiet hallway is now quite peaceful. On the downside I sometimes hear through the walls the more boisterous therapy patients bemoaning issues of Love  but this is a small price to pay.  I don’t know which I now hate more, Journey or Telemann. Brother #2 recently reminded me The Nephews have hours of the most horrible cacophony and I should count my blessings. I have no idea who the hell is making music these days but it all sounds dreadful.

I realized just before they pulled the plug on the classical rock station nearly every song was about Love. I don’t often think of Love but what to make for dinner and what to do about the car door. Perhaps these topics are not suitable for singing but I am in favor of songs other than about Love.  In my profession I don’t meet many made happy by Love. Rather it drives them crazy. No one has ever come into my office dancing for joy about Love but many have come in to cry about it. The smitten one often is of two opinions about Love: the loved one should either devout all his/her life to the smitten one or should drop dead. I don’t hear this in the classical rock station songs. Sometimes they admit Love is over and now it’s time to move on with dignity after conveying they have made complete fools of themselves on social media.  They don’t sing about that either.

I am on pins and needles waiting to hear if the office music remains off or goes back to the Scylla and Charybdis of rock and roll vs. classical music or it goes on to some new sort of horror-show.  I suggest if we merely want sound to drown out the lamentations of the smitten ones we try some sort of new-agey sort of songs, which are easily dismissed and they never have Love in them.

A friend of mine was recently the victim of a horrible crime. He was assaulted. He is now dealing with the medical, legal, and psychological consequences of such an event. I recently wrote to him. I want to post a copy of what I wrote.  I’ve removed some of the personal bits. I decided to do this on the hopes its contents can do more than help heal a specific person. Perhaps it may help someone else who needs to hear this. Urspo. 

My dear Friend,

Like everyone else who knows about your matter, I too want to reach out and say something – anything – to help you. I am glad to see on Facebook you are surrounded by Love. I thought I would add something else along my area of work. I treat trauma patients; here are some thoughts I hope bring you comfort and hope. 

From what I read on Facebook you are probably having what we shrinks call an Acute Stress Disorder. This is psychobabble to say the obvious: you’ve had a nasty traumatic event which has left you are feeling raw. You seem to be having the usual emotions and behaviors: scared, anxious, despondency, and withdrawn from others, along with poor sleep and paranoia. 

Most people with ASD recover. Really. The symptoms suck and it’s painful but for the majority it all passes other than a bad memory. There are no good studies to predict who is prone to developing ASD after a trauma, or who recovers soon, late, or not at all.   

ASD is not PTSD (post traumatic stress disorder). Both can have nightmares, flashbacks, triggers, hypervigilence, numbness and startles easily. The difference between the two conditions is straw splitting of time. If ASD lasts more than six months it is renamed PTSD. In PTSD the event ‘haunts you’ still despite time and treatments.  

No one really knows why some with ASD go onto to develop PTSD.  None of the variables – trauma type, intensity,  baseline character of the patient – predict who comes out of a trauma relatively unscathed. 

So do not assume the emotions you are feeling now will be permanent. The majority of people ‘get over it’.  Keep hope. 

With that said, there are some things you can do now to better your chances of recovery and to ward off ASD/PTSD. 

1 – Keep in touch with the support network you have. Social support has the most correlation to recovery, wellness, and resilience. Accept all support offers, from someone to cry to at 3AM to the person willing to come in to walk the dog or fix the yard. 

2 – If you are having insomnia or anxiety/panic, avoid tranquilizers. They immediately help but they get in the way of the healing process. If medications are needed, there are others more likely to help in the long run. 

3 – Although it is awful to do, don’t avoid things. Avoidance is understandable but it leads to a slippery slope of isolation.  Get out and get around. Some day – I hope sooner than not – go back to the scene of the crime. Go with friends and go in the day time. Make it a ritual. Call  back your energy and proclaim the place/the bar will no longer dominate you. Perhaps a poem or a reading  may help. Maybe a primal scream is what’s called for , or something along the line “As God is my witness, I shall never go hungry again!” figure it out. 

4 – Avoid Victim energy.  Yes, you were a victim of a legitimate crime which demands Justice, but don’t let it take over. Channel instead Warrior Energy towards social advocacy and awareness.  

5- I know this sounds corny/cliche and it is easier said than done but when given a choice of action or thought choose the positive option. Choice-less, you have a choice now : get better or get bitter. I have no good advice on how you are to do this. It may take a very long time. Take comfort you are not alone on this Journey. 

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