Split 

Room in the Metropolitan Museum of Art in NYC

Shadows watched from the corners of the room… ever present, ever vigilant. 

She waited.

Footsteps in the hallway. Raucous laughter. 

The door flung open and he stumbled in, drunk, clinging to the arm of a woman.

Who was it this time? 

It was hard to see clearly in the dim light. 

Her.

Their eyes met for a long moment. Silent words passing between them. Then she turned her attention back to him, allowing him to undress her. He fumbled. The process took much longer than it should have. 

Naked.

She glanced at the mirror again, seeing the other woman once more, the one who looked like her but was more charming, the one whose laughter came more easily. She was the one who was not ashamed of being naked, the one who demanded love and attention from everyone.

The drugs made her beautiful and charismatic. She knew the flame could not burn this high for very long. It would go out soon, extinguishing her in the process.

But it was worth it. 

Every day was worth the price to avoid the loneliness again.

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Depressions

New York Public Library entrance

“I see from the medical assistant administered PHQ-2 that you have been feeling down lately. Tell me about that.”

“Uh, I am here for my knee. Why was she asking me about depression?”

“Well, we want to put a focus on mental health, you see…”

“What about my knee?”

“We’ll get to that at your next visit. Right now all we have time for is delving into this positive two question depression screen.”

“You guys never did this before.”

“I know. But here we are. Better late than never. So are you thinking about killing yourself?”

“NO!”

“Should we put you on medication?”

“I don’t like drugs.”

“Counseling then! Good choice. I’ve got a list of counselors in the area…”

“I am not paying for counseling and I haven’t got time for it in the first place. My knee is what is getting me down.”

“Yes, well. Come back in two week’s time and we can talk about the knee.”

*****************************************

That wasn’t real. But it could be….

The healthcare organization I work for is now measuring my quality based on my medical assistant asking patients questions about depression once a year right before they check the blood pressure. 

I have yet to have a patient say this was a good addition to their rooming procedure but that is beside the point. Why are we focusing on this in the first place?

To save lives.

Personally, I hate questionnaires. They are an attempt to oversimplify a very complex problem. Can we really put depression into a box? Should we?

If the PHQ-2 is positive it should be expanded into the PHQ-9. The PHQ-9 should be used to monitor response to treatment. 

I much prefer a conversation with a patient to reviewing a questionare. I can tell, usually, when a patient is having a hard time but even if I can’t I still ask once a year at the physical as part of my review of systems. And if they say they are having problems I pry, by golly. Are we talking about a chemical imbalance or did their mom just die? Is it affecting their ability to hold a job? To take care of their family? My medical assistant shouldn’t be the one asking the questions. It should be ME. That is my job. Which then brings me to documentation. Make it easy for me. Don’t hide it on a different screen. My review of systems documentation should be sufficient shouldn’t it?

It frees the physicians up to do other more important things.

What is more important than mental health? But then, I wonder, are we perhaps overemphasizing it on some level, too?

When we made pain into the “fifth vital sign” we created a whole population who became focused on feeling no pain, a pharmaceutical industry happy to create addictive drugs that prevented anyone from feeling pain, and physicians caught in the middle. Ultimately, the prescription narcotic addiction crisis was the unintended consequence.

So I worry that we will over diagnose depression. I am not sure that assigning labels like that is all that helpful for most people. I worry that those who are truly ill, who need the most help, will be pushed out of an already failing system that becomes glutted with everyone else. I am already seeing this trend. Making my very ill patients wait three to six months for an appointment with a reputable psychiatrist is unacceptable but it is par for the course nowadays.

The mental health system in the US sucks and that’s the truth. It especially sucks around here. There is a dirth of good psychiatrists in my area. Same with counselors and psychologists. What are we supposed to do? Should we as primary care just push drugs on everyone? Drugs that have side effects and risks and which are not appropriate for all patients? Who then will manage those drugs? Me? With very minimal training? And if we push drugs but cannot effectively pair it with counseling support, what have we accomplished? We are supposed to help, to make people better aren’t we?

I’d really like to know YOUR thoughts…

The Troll Under My Bridge

Bridge partially obscured by rays of sunlight

“Hey, Doc?”

“Ummmhmmm?” I was trying to figure out what button to push to get his tetanus booster to propagate into the right field of his health maintenance screen. I had a cuss word on the tip of my tongue that really wanted to get said…

“Are you happy?”

That made me stop what I was doing and look up at him. 

People don’t often ask me that question. Most people just assume that I am super happy. I mean, I do have that nice looking fake wedding ring, right? Plus, there is the fact that I work hard to project joy and happiness for my patients. They don’t need me dragging all of my baggage into their office visit. 

But now that the question had been asked I took a momentary inventory of my happiness quotient. Am I stressed? Sure am.

But, am I happy?

Then it hit me. Yes, yes I am happy. Very happy. You know how I know? Generally, I dislike the holidays but this year I find myself looking forward to them. The sound of Jingle Bells does not make me want to strangle some innocent, unwitting fluffy creature. 

I do my best writing from dark places but right now, I don’t want to go there.

So I say all of that to say that while you may read dark things, like yesterday’s mediocre medical poetry, I am not writing them because I am some shell of a person paralyzed by grief who spends the day curled up in a corner thumbing through a lifetime of regrets. Hardly. I have better things to do. And when I do go to dark places it is not because they are my places. Often I borrow them. And I don’t live there. Not for long, at least! Not anymore.

Today, I am happy. 

Today I am thankful. 

Say Wat?*

Cambodia 041

So, something that I have noticed is this:

Adopted people seem to often carry around a lot of baggage. 

Sometimes it’s obvious from childhood. There are times, though, they don’t even know it is there until they are all grown up.

I have seen this clinically and personally and throughout the blogging world. Even under the best of circumstances, with the best adoptive parents, there is a profound amount of baggage that accompanies adoption.

Who am I, really?

Where did I come from?

Why did she give me away? Didn’t she love me?

Now, let’s say it is an adoption situation where the child was adopted as a baby but the birth mother died and the father was never known. What would be the best approach? When do you tell the kiddo, who has only known you as a parent, about the death? 

It is easier in some ways to simply avoid the topic altogether, isn’t it? There is that temptation to not say a word about adoption and death, let that child go through life thinking they are 100% yours. Decades ago that might have been possible, but in the advent of DNA testing, these secrets never stay buried. I cannot tell you how many times I have had conversations with devastated patients about the seemingly innocuous DNA test done for fun that uncovered a few half siblings or even different parents. 

I have been thinking about this for some time. Maybe the point is not that there is a “right” way or a “right” time to have that discussion. There is no point in time that would make it all OK and would prevent subsequent life turmoil, so much as simply understanding that life sucks… sometimes it really sucks… and when you cannot make it better you just do your best to support them as they work through it all. Working through the grief and anger and abdandoment issues can be a lifelong process and that is OK.

What are your thoughts?

*This is a wat in Cambodia. A wat is a Buddist temple or monastery.

The Pregnant Pause

IMG_6322

When I was pregnant with my son, I ran away to Switzerland. 

I rode the trains all over the country and climbed to the top of the Klein Matterhorn, keeping track of all of the public toilets along the way.

To be honest, I was terrified. I thought it might be easier in some ways to just die. Not that I had a plan but if I could just die, it would all be over.

Fall asleep and not wake up….

I was not prepared at all for being pregnant. It was the last thing I wanted at that point in my life. I was under a huge amount of personal stress and I worried about whether or not I should even carry on with the pregnancy. As I sat around wracked with indecision, the weeks ticked by…. It was clear I was not going to have a miscarriage.

Then, an early ultrasound determined that the baby might have something wrong with the kidneys and something snapped.

Suddenly, I wanted a baby. I wanted that baby more than I wanted anything else in the entire world.

To get him, though, I was going to have to make some other very major, very painful sacrifices and rather than make them right then, I ran away. 

To Switzerland.

Away from everyone. Away from the pressure, the shame, the fear. Away from everything.

It was the best time of my life. 

So, Belladonna Took asked about the meaning behind my moniker, my gravatar name…. Victo Dolore. In truth, it has many meanings and I struggled with what to write about it.

There is the Latin meaning: “Pain Conquered.”

There is the historical meaning. Victo Dolore was written on the family crest of Dr. James Simpson. He discovered chloroform and was the first to use it in childbirth. Anesthesia in childbirth is something that is near and dear to my heart.

There is the historical implication. Many opposed the use of anesthesia during childbirth, arguing that women should suffer as much as possible in childbirth as it would bring them closer to God. Some argued that without the great pain involved in bringing babies into the world, mothers would not love their children as much. (It should be noted that these were arguments posed by men.) 

And then, there is the personal meaning. Life is about conquering pain. Sometimes that pain is physical. Sometimes the pain is something more. 

Much more. 

Switzerland helped get my feet back under me. There are plenty of things that have happened in my life that have caused me great pain. There are just as many things that have helped me find my center again. I write about some of those here. If I wait long enough, I can always get up again. Pain diminishes, it never goes away, but we can learn to control how much influence it has on our lives. 

Victo Dolore.

Comparing 

zinnia in black amd white

Life is made of joys and sadness. Ignoring the sad, painful times neutralizes the joyful ones.

One of my office managers keeps insisting that we not talk at all about the negatives of our job. He would prefer that the staff and physicians only project happiness, sunshine, and roses at all times. I am not sure that is entirely healthy.

This is the way of life lately. No one wants to hear or even acknowledge the negative. Sadness makes us uncomfortable. It is painful. It is a natural thing to want to avoid it.

Why can’t you just be happy?

The problem is that completely ignoring it promotes isolation. It keeps us from recognizing who is suffering, who is at risk, who needs help. This is a tough job for all involved. What is wrong with acknowledging that so we can all work through it together? 

Am I the only one who feels this way? What is wrong with me?

And it takes away the drive to get better. 

If everyone is happy, why do I have to do it right?

The worst part is that it takes away the celebration of the real triumphs. 

What? Can we BE more happy?

It is OK to feel fear, doubt, sadness, frustration. It is what we do with those emotions that is the key. How do we respond and use them constructively?

I see this in patients, too. So many believe they should not have to feel any negative feelings, that such feelings should be avoided at all costs. 

I know I should still be happy. I am going bankrupt, my wife left me, and my son is in jail, but I should be happy. Everyone tells me I should just be happy. Make me feel happy.

Doc, I am really, really trying to stay positive. I have metastatic cancer and I am in pain all the time and chemo is kicking my butt. Everyone tells me I should stay positive or I won’t beat this but I really just want to cry. I need to cry.

You know what? Being sick sucks. Having cancer sucks. Sometimes life just sucks.

And it should be OK to say it sucks. It should be OK to grieve and be sad and to cry if need be, even if it makes others uncomfortable. 

What we need is balance. Not a cult of happiness.

Punishment 

IMG_3414

I stared at the scarf in my hands. Silk. Embroidered. A soft bluish gray. I bought it in Italy a few weeks prior for a stupidly expensive sum.

He owed me. I wanted to make him pay.

I had not worn it even once but now I found myself staring at a gaping hole in the fabric. The damn thing was never as perfect as I had thought. I felt sick. Revenge shopping. It was not worth it.

I deserved that.

In medicine you see the price that is paid for bad decisions. They are paraded before you day after day. You think you are smart enough to learn from it, that it will never happen to you.

Until it does. 

You realize too late, while in the ER staring at a loved one, how close you really are to tipping over that ledge yourself.

Just one more drink, right? It won’t hurt anything, he said, and I wanted to believe it. Another glass was always placed in my hand and I never, ever said no.

I liked you better after you had a glass of wine. Or two. Or three. Hell, I liked myself better, truthfully.

The perfect life, the perfect spouse, the perfect kids, the perfect house, the perfect job…. Utterly unattainable. No matter how much you want them, they simply do not exist. So much of depression is actually disappointment, not being able to accept this reality.

This is not supposed to be MY life…

All of the anger I carried around for so long? Wasted. Just like all of that money on the stupid scarf. I never told him but his fall probably saved my life, too. 

Well Crafted

 I came across an article the other day that encouraged knitting as therapy. In fact, there are knitting therapy groups popping up all over the place. It is even being advocated for weight loss.

Here is the article if you are interested: The Health Benefits of Knitting

All of this made me laugh out loud because, being a knitter myself, I have recommended knitting to patients as therapy countless times over the years and have pondered starting my own knitting circle at the clinic to teach those who are interested. I would call it my Stitch And Bitch group, because of the history behind the name. 

AND because profanity by itself can be a bit therapeutic in its own right. 

In fact, though, it is not just knitting. I have recommended crafting of all sorts. “Find a constructive hobby where you create!”

It will help. 

Maybe?

To be honest I have only had two people to my knowledge ever take my advice. I taught one how to knit a basic scarf during office visits. It did help, they said, at least it helped until they had made all of their extended family Christmas scarves by July and then gave it up, not wanting to try more complicated projects. Often I get the argument that they don’t know how to start or that they don’t have time or that they could never possibly be any good at it.

No worries. We have pills for that….

I have connected with countless crafters/artists here on WordPress. Knitters, crocheters, woodworkers, photographers, quilters, painters, costumers, artists in other mediums… And I wonder, would they consider it therapeutic for them?

Crafting of various types has gotten me through super rough patches in my life. Making jewelry. Knitting and crochet. Sewing and quilting. I enjoy learning new skills and looking back on the beautiful things that have come from the negativity. The sense of pride I get from finished projects helps lift me up. I wonder if Lego would count as a craft?

Do you craft for therapy? If so, what do you craft? If not, if you were going to pick a crafting therapy, what would you want to try? 

Inebriated 

 Black and white cemetery. 

Brought to my knees
Soulless and diseased
A parched, dark hole
No longer in control
Succumbed to you

Mind no longer sees
Ears deafened to my pleas
Bitterness burning
Always yearning
For a taste of you

Thirst never slaked
Heart forever staked
Eyes sightless and blind
Look for love I’ll never find
I am drunk on you

Cold 


I stare at your sleeping form on the bed, your head hidden by the linens and the multitude of fluffy hotel pillows.

You cried out my name but no one heard.

The cold window ledge brought out the goose flesh on my naked skin. I shiver involuntarily. I could go get a blanket but that would mean getting closer to you.

I would rather die.

I focus on the scene beyond the window glass. The lights of the city glow below, creating an artificial twilight reflected in my ghostly shadow. I can see for miles from the twenty-second floor.

Syncopated skyscrapers.

Cold fingers and the clinking of ice cubes against the thick glass of the tumbler as my shaking hand bring me back to this room, this ledge.

You knew that sound, didn’t you? 

I take a sip of the drink. The taste is watered down from the melted ice but still cloying. You didn’t want anything that tasted like alcohol and always made fun of me for liking scotch and extra dry olive martinis.

So we had this pansy drink instead.

What was the point? 

There was not enough left to get drunk from. I put the glass down, letting the condensation pool in a damp circle around it, weeping.

We were over.

There was no yelling.

Still, we both knew.

We assaulted each other over the years so thoroughly that love was obscured by pain. You still held my hand when we would cross the street in daylight, still endevoring to protect me. It was endearing but we could neither of us bear the intimacy of darkness any longer.

Kiss me once more like you mean it. For old time’s sake…

Your lips didn’t even move.

So the out of practice fumbling and grunting and an early abort left us both even more frustrated and more distant. You rolled over without a word and fell asleep.

Even after all of these years you can still make me feel like an unwanted whore.

Maybe that is what I am but come the light of day I will be so much more….

———-

I listen to patient stories all day. It is an honor and a privilege to get to hear those stories just by itself, but it is also great for creative writing. I take little bits of people’s stories, put them together, and mix them with mine. The things that I hear, the heart break that I am witness to… 

I am going to smatter in some more creative, fictional vignettes and see how it goes. Let me know what you think.