Flying Blind

Posted on May 26, 2012 by

Driving down the road to work the other day.
It’s raining very lightly.
Across the river, up the little hill, past the Waffle House, memorial park and gas station on my left. On autopilot, you know?
Red light. Stopped. Impatient. I’m important. Places to go, people to see, things to do. Red lights. Bah. No time.
Glance to my left.
Blind man.
Cane tapping.
Tapping in the rain.
Mentor behind him holding an umbrella over his head. He can’t see it, no, but he can feel what he does not feel no? Yes?
The mentor is talking to him, lips moving slightly in the dry space inside the rainy dark world where his cane is tap tap tapping on the rain-slick pavement of the street.
The street that must be crossed.
Mentor never touches blind man. Never takes him by the hand or guides his cane or pulls him in one direction or another. Never makes contact but is always in contact. Always supportive, pushing, encouraging, pushing, guiding but not guiding, pushing.
Raining.
Dark in the blind man’s world. Always dark. No promise of a rainbow today.
He steps off the curb.
Tap tap tap.
The mentor follows, umbrella lifted like a beacon that the blind man cannot see but can feel.
My light is green.
Places to go.
People to see. See.
Not as important as I thought, and yet…

Who will I mentor today?

Who will I guide out of the rainy darkness?

Who will I touch without ever touching?

Who?

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F = (Sx – Dx) X Tx

Posted on May 22, 2012 by

There is a lot of buzz in the mental health community right about now. It concerns the upcoming revision of the Diagnostic and Statistical Manual that most all psychiatrists, and many other mental health practitioners, use when trying to make a diagnosis in the field. This will be DSM V, and it
promises to make waves in ways both good and bad. Our field has always argued and fought over whether or not someone with behavioral problems or sexual orientation problems or relationship problems actually had a diagnosable mental illness or not. We have embarrassed ourselves, looked foolish in the eyes of other medical practitioners, and had to backtrack and revise more than once when these discussions got out of hand. We have argued over the exact wording that would best describe mental and physical changes that occur just before, during, or after a woman’s menstrual cycle. We have tried to legislate whether or not someone who is gay is sick and needs treatment or has a personality flaw that needs to be expunged or has an alternative lifestyle that needs to be managed. We wax eloquent at our meetings and in our journals about esoteric criteria and symptoms and complicated diagnostic criteria that our trainees must memorize and regurgitate to their examiners in order to be Board certified. Some of us sit in ivory towers and pontificate and argue over the placement of commas and over how many angels can dance on the head of a pin.

Some of us get up every morning and see patients. Lots of patients. An overwhelming number of patients. So many truly sick people that our broken systems cannot address all the problems they bring. So many unemployed people, so many people without health insurance, so many people who cannot buy the newest expensive medications, so many people who are more anxious after coming to the emergency room for treatment because they are already drowning in debt and cannot take on one more hospital bill. We try to see them all. We try to listen to them. We try to help them and make an impact on their lives. In the midst of this we are asked to fit these wretched masses into neat little boxes of five out of nine symptoms and illness for greater than two weeks but less than one month and psychotic symptoms that meet this threshold but not that one. We are asked to pigeonhole. We are asked to make the diagnosis of the month, or the year, or the decade. We are asked to make people fit the book, whether it’s the first edition or the fifth revision.

You know what? Virtually all of the sick, down and out, hurting people that I see do not read the book. They don’t give a shit about the number of diagnostic criteria they meet, for how long or to what degree or severity. They don’t care if the qualifier after the decimal is a two or a three or a four. They come to see us because they are in pain. Their lives are broken. They have no jobs, no money, and no self esteem. They are drinking too much and smoking dope and popping pills because it’s the only way they can make it through their miserable lives day to day. They are trying to survive. They are trying to feel something. They are trying to be human. They are desperately trying to get someone to understand.

Freud was wrong about a lot of things, but the love and work things, those two are important.

Functioning equals symptoms minus diagnosis times treatment.

Listen to the patient. Hear what she has to say. Figure out where it hurts. Figure out a good treatment to make it better. Treat it. Watch her get better, feel better and function better.

Help her to have a life that satisfies her in the real world, not a diagnosis that fits a book whose diagnostic criteria will only change, again, in five more years.

That is my battle cry. I’ll leave it to those much smarter than me to continue to revise the books.

Posted in mental health, mental health treatment, mental illness | Tagged | 5 Comments

Documentation Doldrums

Posted on May 20, 2012 by

I’ve had a few days off and now I’m getting ready to make my reentry into the world of work. For the most part I look forward to this, although I must admit that sleeping a little later, walking a little more and taking lots of pictures of lots of beautiful things is a daily pattern that I could get used to. I look forward to talking to patients again, interacting with real people and trying to make myself useful in the real world.

The one thing I absolutely do not look forward to is the documentation.

We doctors are a busy lot. We like to do things and solve problems and talk and fix and plan and complete procedures and take things out and put things in and change people. When we finish doing that with one person we like to move on to the next one, and the next one, and the next one. We do not like to slow down to fulfill someone’s idea of writing for writing’s sake, or dictation to complete a chart or completing a discharge summary to avoid sanctions from the Medical Records police. We do not like to be just busy. We like to be productive. There have been more than a few articles in the last few months addressing the actual speeding up or slowing down of physician productivity when an electronic medical record is injected into the mix and the exam room. Surprise surprise, but some doctors are actually slower and don’t perform as well when saddled with the requirements of an EMR.

I have two very fond memories of practice past.

One was my old private psychiatric practice. I might see someone for a fifty minute hour, as it was called, of psychotherapy, enjoying the back and forth of that enterprise. After goodbyes were said, I would pick up a thin manila folder with the patient’s name and number on it, flip to the notes section, pick up my favorite Mont Blanc, and write this simple entry:

“One hour psychotherapy. Issues of abandonment and anger addressed. No medication changes made today. Follow up appointment in two weeks.”

Boom. Done.

The second memory is of my time on the Gulf coast after Hurricane Katrina. I was deployed via the Red Cross and was initially attached to an ERV (emergency response vehicle) team that served meals and drinks to thousands of displaced people in the countryside in Mississippi. My job was to make contact with as many stressed people as I could every day. Talk to them. Soothe their fears. Help them find medications or listen to their stories of evacuation and loss and pain. I loved it. It was connecting and communicating with humanity at its best and worst all at the same time. It was being so real that you could taste the interactions with people like you could taste the dust in your mouth after a long day on the country back roads. It was gritty. It was exhausting. It was exhilarating. My documentation requirements for the Red Cross? A tick mark for every person I spoke to that day in a little spiral bound notebook I kept in my back pocket.

Some days I came home to a meal and a hot shower at the church that was my base with over five hundred check marks in my notebook. Five hundred.

Do you think I cared any less or made any less effort to help people when my documentation was sparse? Do you think I enjoyed or paid attention to my work any less when I had no burden of electronic documentation or insurance forms or written checklists?

Doctors want to help people. We want to be busy and productive.

We want to make a lasting record of what we do, but we don’t want the act of record keeping to keep us from being the doctor of record.

I’ll go back to work tomorrow. I’ll try my best to remember that the reason I’m there is not to write a novel, but to change someone’s life for the better.

Posted in mental health, mental health treatment, Telepsychiatry, work | Tagged , , | 5 Comments

Perspective

Posted on May 19, 2012 by

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I write this from the dining room table in the beach house that my family has enjoyed for the last twenty three years. When I look up I see the dunes, the low scrub brush, sea oats and other plants that make up the fragile coastal ecosystem that many birds and animals call home. Just a scant few yards past that I see the white caps of the St. Helena Sound, breaking merrily over the sandbars a few dozen yards off shore. Except for subtle yearly shifts in the pattern of the dunes and the height of the vegetation, this view has been remarkably consistent over the last quarter century. Some times consistency is good, but sometimes looking at the same landscape from a different perspective can be helpful.

Today I drove the short distance over the bridge to the next island, an island that is designated a state park and for that reason is much wilder and less developed than many others that join it to make up the Sea Island chain.

I enjoyed a long walk on the beach there, a place that reminds me of prehistoric times and almost makes me think some huge dinosaur will burst from the green vegetation and chase all the tourists to the breaking waves of the shoreline. I took pictures on that walk, and I made a special point of looking down, as far down on the beach as I could, straining to see what tiny animals made their homes there among the fallen trees, broken concrete piers and old sea walls. I saw some of the most beautiful sea creatures, small and nondescript at first glance, iridescent and glowing on further inspection. I marveled at how much life there was below the usual plane of my vision, how much of the world went about its business out of my sight and consideration. The more I looked, the more I saw. There were hundreds, even thousands of them, clinging to life through tide after tide, hanging on for dear life cemented to plants that had once been alive, but now served as odd apartment houses and residential villages for these little citizens of this island world.

After the beach walk I climbed the spiral stairs of the island lighthouse, rising one hundred forty feet above the park. As I exited the metal door at the top of the structure, a very stiff wind met me and threatened to rapidly decrease my bravado as I hung over the single iron railing to take more pictures of the tiny people below. I looked out from the black and white tower, circling to get the full three hundred sixty degree perspective it offered, and was again (for I had been here a few times before) amazed at how far and wide ones view of the surrounding coastline was extended by having this simple advantage of height. I could see Edisto Island, just as I can see it now sitting at this table and writing this piece, but it looked oddly different from that angle. I could see two and a half miles more of the state park off to my right, and past that I could make out the silhouette of Fripp Island, its many fine homes lined up like colorful boxy soldiers along the beachfront. People below, people off in the distance frolicking on the beach out from the campsites on the far left end of the island. A whole coastline of islands, people, beaches, houses, and activity. All places I had been before. All places that were almost as familiar as home. And yet, very different when viewed from this vantage point.

We tend to get used to our surroundings and see them the same way, day in and day out. For the most part, that is a comforting thing for us. However, sometimes looking up and out, or down and closer, helps us to see that there are other perspectives than just our own.

What can you look at in your own life from a different perspective?

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Posted in life | Tagged , | 4 Comments

All The News That’s Fit to Toss

Posted on May 18, 2012 by

Okay, every once in a great while I try to do something nice for my wife. Something small, granted, but something that I think she might notice. Something that I think might impact her life starting right away in the morning. When I leave the house I unlock my car, toss my bag in the back seat, then walk over toward the street. Almost every weekday morning, it’s there. Lying there, almost invisible, holding itself flat against the ground as if it’s trying to become one with the gravel and camouflage itself to delay the inevitable. I bend down and pick it up.

The local daily paper, such as it is, has arrived.

Now, once upon a time, in the age of print media dominance, papers had weight. They had substance. They felt good in your hand. You could grab one, balance it just right, cock your arm at the elbow, take aim, and let it fly. With any luck and a timely release, the paper would fly beautifully toward the porch or the steps or the base of the back door. It would hang just right, like a Piper Cub executing a flare before landing, and almost float to the spot you intended it to occupy. There it would sit until the owner of the house came out, bathrobe tied at the waist and fuzzy slippers halfway on, grateful to you that they had only to poke one arm out of the house to fetch the document that would bring them the news of the day, the details of the triumphs, tragedies and travails of the big wide world beyond their threshold. Papers occupied space as well as time. They had heft as well as headlines.

Nowadays, I take the thin slip of newsprint that finds its way to my backyard, pinch it between thumb and index finger, account for trajectory, wind speed, humidity, solar flares and El Niño, and try my best to aim for somewhere near the back of my house. Invariably, despite my best efforts, the Document that Shall Not Be Named takes a hard right and finds the rosemary bush in the pot, a harder right and lands in the cedar mulch under the window, or makes a crazy left turn and ducks under the deck. I’ve grown immune to these shenanigans, and usually get in my car and drive away, knowing that my wife may or may not find the Easter egg that is the Op-Ed section peeking out onto the brick patio. Some days I come home and she’s outfoxed the newsprint. Other days, I see it sticking out of the rosemary like some pale handless arm. On rainy days, it looks nothing short of pathetic if it’s been left outside, the headlines running down like sweet green icing in MacArthur’s Park.

Is today’s news less weighty than stories of old? Is there less to tell us? Less that we really care about? A shortage of newsprint or ink? Why does my local printed news float like a butterfly instead of stinging the deck like a bee when it falls heavily to earth after being tossed from the car that brings it in the early morning fog?

I’m not sure, but I am sure of one thing.

I for one no longer get my news from a rag. Where do I get it?

I read multiple RSS feeds religiously, sending things that I want to give more time to to Instapaper or Pocket on my iPad. I get regular email notifications from medical news sites, prompting me to
peruse headlines that grab my attention or interest me. I see a constant stream of news, breaking stories and trending topics on Twitter. I read blogs. I listen to podcasts, including one that keeps me up to speed on the local arts scene and one that gives me a summary of world news in less than twenty minutes. I have friends and acquaintances who act as personal curators, sending me links to articles, videos, books and other media that they think I might be interested in. I return the favor, linking to things that interest me and that I think others might like to see.

My iPad, only a pound and a half, now outweighs the local daily.

Some might say that it is much more impersonal than my local paper, but it will never end up in the rosemary bush, and I have never yet let it sit outside all day in the rain.

How do you get your news?

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Smiles per Mile

Posted on May 17, 2012 by

This week I’m taking a much needed break on the South Carolina coast. This place can recharge me like no other. The salt air, high humidity, killer sunsets, great food, and a beer or two on the deck go a long way in getting my head screwed back on straight after months of grueling clinics and stressful consulting.

Then of course, there’s the walking. Twice a day if I push myself a little. Fourteen miles the last three days with another 3.5 when I get home, afternoon thunderstorms permitting. Good, wholesome, sweaty, tiring, muscle stretching exercise. Time to think. Time to listen to music. Time to catch up on my podcast queue.

Time to wave and smile.

Now I’m not sure what happens on your island, but on this one people are exceedingly friendly. I know a few of them personally, but most of the people who pass me on the paved roads going to and fro are complete strangers. Just this morning, there was the island security employee in his little golf cart, the construction worker delivering a pickup load of long boards to a house under construction, and a man wearing a shirt and tie who, in this setting, surely must have been heading to work. There was the overweight man walking out toward the gate as I was coming back, huffing and puffing under his too tight white tee shirt but throwing his hand in the air and calling out to me anyway. There was the couple, elderly and frail in their late model American sedan, she sitting with hands in her lap as he raised one finger off the steering wheel in that way we all learned to do as soon as we learned to drive. Last evening there were the three guys manning the grill, one of whom had just come in driving a candy apple red Corvette with Indiana plates. They nodded in unison, manly “heyhowyadoin” smiles from all three.

There’s something about driving, walking, working, grilling, patrolling, and building on an island in the sun that just makes people want to smile.

I think my level of stress must be going down just a little. My negativity must be lessening just a bit. My hope for the future may be inching back up just a notch. My humanity may be restored yet.

A climb up the lighthouse tomorrow, a panoramic look at the spectacular view toward the Atlantic, a nice lunch and a good cup of strong coffee may just do it. I may break into a grin in spite of myself.

After all, this is a place with more smiles per mile than any other I know.

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Prescriptive Prognostication, Part Finis

Posted on May 2, 2012 by

I lost two patients this week.

I have seen both for some time now. I wrote about one of them in a post in January, and with your indulgence I would like to repost it here as a tribute to him. The other patient I have known for years. Her death was not an altogether unexpected occurrence, but was still a shock.

In psychiatry, we don’t expect to say final goodbyes to too many patients. A friend of mine on Twitter said today that “usually saying goodbye means things are better”. Sometimes, it just means that things are over. Relationships are broken, ended, forcefully terminated without consent. For me, just like for you, it is a painful experience. It reminds me that I should do my best every day, that I should make a difference where I can, when I can. I am not guaranteed another chance.

I want to thank both of these patients publicly for allowing me to be a part of their lives. I want to thank them for trusting me to treat them and help them through bad times. I want to thank them for teaching me and making me a better psychiatrist. In sickness we find hope. In struggle we find resolve. In weakness we find strength we never knew we had. In death, we leave behind the wonderful gift that was our life, magnified a thousand fold through those we touched. Both of these people touched me, and I am a better man for having known them.

Rest in peace. Your struggles are over.

I have seen him on and off for several years. He has had the various problems dealing with issues that many of my outpatients have, with some mild anxiety and depression thrown in from time to time for good measure. He has come in to see a counselor, and he has seen me for medication management. He is like the thousands of other patients I’ve seen over my career thus far. Mostly the same as all the rest, except for one thing.

He is dying.

Psychiatrists don’t usually have to deal with death that much, thank goodness. Oh yes, I would be remiss if I told you I’d never had to deal with it. I have had patients die of physical illnesses that were not related to the reason they were seeing me, sometimes from longstanding maladies and sometimes unexpectedly. I have had patients leave me when they were shot and killed or otherwise murdered by others, even in the medium-sized city I live in. And yes, I have had my share of patients who committed suicide. If you are a practicing psychiatrist and you see patients, you will see some of them die by their own hand. I remember every single one of them. Sometimes their faces or their stories or the way they died pop into my head and my thoughts almost intrusively. Sometimes I feel that long, slow, building wave of guilt about their deaths. Sometimes I realize that what happened to them was tragic but altogether unpredictable, and I learn from it and move on to help the next person sitting in front of me. Yes, in psychiatry we are lucky in that we usually deal with illnesses that might be lifelong but that do not kill their victims, at least not in the acute sense of the word.

This man, however, is dying. He knows it. I know it. It is not an elephant in the room. We talk about it. He volunteers sometimes. I probe at other times. He shares. I listen. He teaches. I learn. He has pretty much maxed out his therapies. His body has absorbed all the poison and the rads that it can. His doctors have told him what to think about, and how to prepare. He has resigned himself to the fact that this illness is what is going to end his life. He is still fully engaged, although some days in slow motion, in his life and the lives of his family. He still wants to see me. I still want to see him.

At the end of our last visit, something very strange happened to me. We were talking and wrapping things up, and the natural course of things lead me to ask him about his need for a new prescription for his medication and a new appointment time to see me. He hesitated just the least little bit (or did he?) before answering me. Something in my brain commented very softly, but loudly enough to bother me tremendously.

Do you think he’ll live until his next appointment with you?

How many refills will you put on his prescription?

I suddenly felt a little panicky, very unnaturally so. Of course I did not show this outwardly, but inside my gut tightened and I was a little light-headed and I felt a little nauseous. It was almost, for a crazy, wild, awful, weird, unnatural moment, as if I could influence the future, his future, by deciding how many refills I would put on his prescription or how far out into the future I decided to schedule his follow-up visit with me.

It’s hard to say goodbye to those we love, to those we care about, to those we enjoy talking to. It’s hard to lose emotional connections that have been forged over months or even years. It’s hard to move on when death comes. Spouses have to do it. Children have to do it. Parents have to do it. Psychiatrists have to do it.

I have learned a lot from my patient about impending death. I have learned about the absolute necessity of maintaining a positive attitude, about staying fully engaged with children and grandchildren and about the importance of calm and serenity. I have learned about giving in without giving up. I have learned about making good choices based on science, emotions, reality and practicality. I have learned about seeing life as it is, not as we wish it could be.

The fleeting moment of panic left me as quickly as it had come. I wrote out the prescription for my patient, told him when I would like to see him again, stood up, shook his hand, and walked with him to the door and out into the hallway. He smiled. I smiled.

“I’ll see you soon,” he said, as he turned and stiffly walked toward the exit.

“Yep, I’ll see you soon,” I replied.

The number of refills on the prescription? Well, I can tell you that for patients I know and have been seeing for a while, I usually put five.

I’ll let you guess what I did that day.

Post script:

As many of you have already guessed, I gave him five refills that day in January. I knew he would not live to see me again in June. He knew it too. Neither one of us spoke that thought aloud.

Reality is what it is, but hope springs eternal, does it not?

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