Changing Times

Fall colors on the water

I love the fall. I love the colors, the pumpkins, the hint of cooler weather. I love the baking, wearing sweaters, fires in the fire place. I do not, however, love the time change.

Who likes it? That’s what I want to know. And if everyone hates it so much, why the hell hasn’t anyone changed it?!?!!??! Every year we all complain. There are news articles decrying the needlessness of it. And yet, it still happens. 

The dreaded “Fall Back”…

So, the time change alone is bad enough by itself but this year I also forgot to turn back my kids’ clocks so their alarms went off an hour too early yesterday morning. Gah. Who can remember to turn back ALL of their clocks? Worse? It was dark by the time I left work to go pick them up from school. 

Cranky kids. 

Cranky mom. 

For the next few months I will exist in a disorienting cave of darkness, a fugue state of sorts, confined to a building during daylight hours. My brain does not like this. It craves the feeling of sunlight on my skin, the deep red glow of sun filtered through closed eyelids. I find that this matters more and more to me each fall and winter. 

Bottom line? Gaining an hour of sleep is a farce. We don’t get more rest. We don’t have more energy. It is all a sorry pack of lies we tell ourselves every dang year. 

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The Apple and The Tree

I don’t usually post on Mondays anymore because the clinic is usually crazy but I did want to reblog this post from Twindaddy at Mental Defecation. Typically I don’t get a ton of people popping over to read reblogs but I would encourage you to hit the link on this one.

Mental Defecation

The apple doesn’t fall far from the tree, the old saying goes. It’s an obvious statement, of course. Unless an apple tree is at the top of a hill any apple that falls from it isn’t going far at all.

My tree has dropped three apples, so to speak. None of them have fallen far from the tree. To be frank, I’d bet money the genetic engineers of Jurassic Park cloned my “apples” directly from me if I didn’t know better. I can see my likeness in their jokes, their intelligence, their behaviors, and their personalities. But nothing quite dissected how similar we are until I read a short essay today.

I was talking with Baby B about meds and school when he mentioned he’d finished an essay he needed to turn in for English tomorrow was finished. I inquired more about it and found out that the topic he’d…

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Lift

Bomber

There are times when the anxiety overwhelms. Pressure on my chest. Can’t breathe. A dysphoric and irrational sense of impending doom falls like a curtain, separating me from the rest of the world.

I need to move, to escape. 

But I can’t. 

Why? Why now?

It comes in phases. There are times when I fly through the day, a smile inside and out. I feel the joy. I am the joy.

And then? The darkness descends.

You aren’t good enough or smart enough. Someone is going to figure it out. Then everyone will know your secret. You don’t belong here.

I can’t focus. I type words that aren’t right and don’t make any sense. I cannot follow the conversations people try to have with me. My brain is paralyzed. No. My brain is in overdrive running from one imagined catastrophe to the next. I cannot sleep because I cannot make it stop.

“Doc, it’s like you know me. How do you understand it so well when I am not even sure how to describe everything?”

Because I am you.

Sometimes there is good reason for it, an event which serves as trigger. Like a supoena to testify in a patient’s lawsuit against an multi billion dollar international corporation. Sometimes there are dozens of good reasons for it. Being on call, stressful patients, behavior issues at school with my kids, extended family conflict, pressure from the suits, my virtual desktop at work is overflowing, the WordPress app reader is frizzing out again and I am missing posts, … Very often, though, there is no good reason at all.

It is then that the pill calls to me.

Die to live another day…

I keep a bottle with my name on it. Not to literally kill myself. Just to make life easier. Kill the anxiety. End the suffering. A pill a day to make the anxiety go away.

But I am a coward it turns out. I am not good at taking pills. I try to do other things. I take a hike in the woods. Being among the trees often helps. Instead, I get a bad case of poison ivy. I try attending an opera, but I can’t enjoy that because of the itching from the poison ivy. I buy a new skirt but it doesn’t fit because of the steroids for the poison ivy. I want to hug my kids…. hugs from my kids often helps… but good squeezes set off the itching again.

All I can do is laugh. There is nothing else left to do.

Suddenly I am rising up out of the abyss. 

Thursday Thoughts From the Throne #7

Clock feature in a small park in NYC

Is the day over? No?

Phew!

Made it. 

My colon has been awfully out of whack this week. So has my running schedule, come to think of it…

So, most of the time I try to avoid talking politics and religion with my patients and my friends. There are only a few trusted people I feel I can have a rational conversation with. Today, though, I ran across one of those people who was trying to convince me that my theology was misguided and that abortion was wrong in all circumstances. Even in the case of an 11 year old girl who was molested by her uncle.

Don’t get me wrong, I like this guy. He is a good man, even if we fundamentally disagree. However, he made a comment about prayer in school that got my dander up. Specifically he said that Christian prayers only should open every school day and that more of it probably would have prevented the Las Vegas shooter from killing all of those people.

Um. No.

I am going to skip the theology question and the abortion issue and hit on that school prayer statement.

Being prayed at is not the thing that prevents hurting people from lashing out. Love does. Good parents who try to do right by their kids and their spouses, fellow human beings who show kindness…. these are the things that prevent damaged people. 

Loving people who need it is awfully darn hard. 

I am not saying don’t pray. Go ahead and pray. I pray. Prayer is powerful. Prayer can help you love, help you find kindness when you don’t think there is any left inside of you. Here’s the thing, though: Don’t you ever think for one minute that your prayer means you have done your duty and your responsibility to other people stops there. No. You have to physically reach outside of yourself and help those around you or you are just saying empty words. 

I used to be that person, the one for whom the world was black and white. No amount of arguing or reasoning could change my mind. I was so full of anger back then. Why doesn’t everyone see the logic that I see? Life had to show me the all of the other shades of gray and the myriad of vibrant colors that make up this world. It had to show me that I am not as smart as I thought I was. 

Life is still teaching me.

Kind of makes me wonder what I will think of this post in ten years…

Stretched

Dinosaurs in the American Museum of Natural History

“I want to change doctors.”

Reviewing her chart before entering the room I could see that she had been asking for this for months. The medical assistant had warned me that she was going to bring it up again.

“Why?”

“Well, I never get to see her when I need to. She’s always out or I have to see the nurse practitioner because she’s too busy. Besides, you were the one recommended to me by several coworkers but you weren’t taking new patients.” She stared at me, accusation in her voice. 

“Well, the reason I stopped taking new patients is because the ones that I did have could not get in to see me when they needed it.”

Some days I have open slots that don’t fill. It makes me antsy but I try to remind myself that not overloading the schedule ensures that people can get in if they need to. I want to be able to see them, have a relationship with them, even if it hurts my bottom line. THAT gives me joy.

“….But you should also know that I have kids. Sometimes they get sick. Or I get sick. Or some other emergency pops up…”

“Well, she doesn’t have kids. At least not that I know of.”

In truth she is undergoing a fertility work up, hoping to have kids but it was not my place to tell a patient this without her permission. A woman should have the right to have a child if she wants one, shouldn’t she, even if it inconveniences others.

I agree to take her on as a patient. The very next day:

“Uh, mom?”

“Yes?”

“I just puked.”

The smell of vomit began to waft through the car. I cracked a window.

“Block my open slots until I can get to the clinic and see what is going on.”

“You don’t HAVE any open slots.”

As my daughter retches again into the plastic sack I know I don’t have a choice. They will all have to be rescheduled. There is no one else that can watch her.

“He’s going to have surgery. I’ll need to be out for at least a week….” 

It makes me nauseated to think about it, rescheduling that many people, but it just cannot be helped. 

He needs me.

No doubt someone, somewhere is asking to change doctors. Knowing that bothers me on some level but being a mom also brings me joy. My kids deserve a mom who can be present for them. It strikes me that this sort of issue is unique to female physicians. It is partly why we make less money. It is partly why we don’t hold as many leadership positions as our male counterparts. 

I choose my kids. 

I choose my family.

Meanwhile, I am sitting in a hospital room with my laptop, trying to do as much as I possibly can from here.

That doesn’t make me better. Or worse. Just different. 

Or maybe the just same. 

Blow

Sailboat in the Hudson Bay

“How much time are you spending on social media?” 

“Well, I stopped completely until about a week ago. I’m easing back into it.”

“Really? You stopped it all? Completely?” I tried to keep the suspicion out of my voice.

“Yeah. For about six months.”

“Why?”

“I didn’t like how it made me feel.” There was real, actual eye contact, no phone in sight. 

“Now that you are back at it, what do you think? Does it make you feel good?”

“No.”

“So what do you think you are going to do?”

“We’ll see.” She shrugged. “Maybe I’ll pull the plug again.”

That, folks, is a kid who is going to be all right…

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…