Thursday Thoughts From the Throne

Thomas Fuller quote over NYC bridge

If you will recall my corny post from last month, Twindaddy of Mental Defecation correctly deduced that I had written that post while sitting on the toilet. Truth be told, I do a lot of blogging from the potty. Clearing the bowels tends to clear the mind. In the comments Twindaddy graciously offered to allow me to use “Thoughts from the Throne” which was a recurring feature on a previous blog. I love alliteration. Alliteration is sexy. 

So I am going to try to make this a recurring feature. It may not be every week, but from time to time you may see this title and I wanted you all to know where it came from. 

Also, you should know the above image was created using Pixlr. Desley Jane at Musings of a Frequent Flying Scientist did a post on this recently. I have found that it is addictive…. 

Infertility 

Ellis Island hospital

Graciously bestowing 
You spilled your precious seed
Upon my barren ground
Ignorant and unknowing
An unfulfilled wanton need
Your attempt at marking 
A territory unfound
Traversing the open sea

The ownership unclaimed
My body left untamed
Believing you were deceived
I’m naked beneath the gown
Empty loss echoes down 
Long abandoned corridors
Infertility finally decreed
By the sterile orators 

Devoid of progeny 
The solemn sodomy
Repeats itself again
Another painful bleed
An unwelcome visitor
Testifing silently
Before the Inquisitor
Sounding the final amen

A viscous self loathing
Clogs the rusted plumbing
Magnified through your eyes
Value is forever drowned
Held down by a flood of lies
I’m merely something to breed
A conduit for birthing
Your immortality 

Worn

Interior, Metropolitan Museum of Art

Every year around this date I especially find myself marveling at love…

Love that is gained and lost, and found again. Love that is unrequited and unrewarded and yet still persists. Love that claws its way through the heart and lodges itself there against all logic and stays regardless of physical presence or absence. Love that endures despite being utterly spent, never quite reaching the point where it simply cannot love anymore. 

Lonely love.

Brilliant love.

Eternal love.

For over twenty years I have loved this love. At times gingerly, even tentatively, and at other times fiercely and with conviction. Is it more valuable for bearing all of the scars and scuff marks, the wear and tear of time and hurt? Is it more precious for simply surviving?

Perhaps….

But then, all love is precious. 

Emergencies 

Sunset reflected in a road puddle
“I want a wart removed this Friday”

“The doctor does not have any openings for a procedure this week. We are short staffed and she is completely booked. We can get you in on Monday if you like.”

“I am going on vacation next week. The doctor always accomodates me! You tell her I want to have this removed on Friday.”

I do try hard to get people in when they need it. But sometimes…

Honestly, it has been a rough week. 

With one of my partners out, our nurse practitioner out, AND it being the week before school starts back for many kids in the area… the clinic has been crazy. Finding time to blog/breathe/pee has been hard to come by.

“Fine! You tell her I am finding another doctor.”

It is like this every year. 

Next week it will be a ghost town around here but for now those emergency wart removals are killing us. 

Getting the Worm

Flowers in the NYC Metropolitan Museum of Art

“Mommy? Can I go potty?” 

Her voice pulled me out of a deep sleep in the midst of a nightmare about a movie set with Nicole Kidman and a patient who ran a telephone ministry dial-a-prophetess line. The movie was to be a psychological thriller. The prophetess had just robbed me of money and souvenirs I had pilfered from the set. I am not sure what a dream like that says about my life right now…

“Sure, baby. You don’t even have to ask, you know.” I have lost count of how many I times I’ve said this to her. 

“Ok!” 

I heard her skip down the hall to the bathroom. I glanced over at the clock. 3AM. I would have groaned out loud but that would have taken too much energy.

A minute or two later…

“Mommy, I wiped but I didn’t flush because I didn’t want to wake anyone up.”

“Thanks, sweetie. Go on back to bed.”

“Ok!”

And I heard her skip back down the hall to her bedroom.

Sleep? For me, it was gone. Just like that I was turned into the early bird. Too bad I don’t like worms.

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.

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…