Still dreaming

Still moves me every time I hear it.

Dr. King would be 80 years old this past week. His death was a serious loss for all humanity, not just those Americans of color. I know many saw him as a "rabble rouser" and a trouble maker, but civil rights was something that was - and still is - a place where the pot needs to be stirred. We cannot be complacent, we cannot turn a blind eye. None are free while others remain oppressed.

As I find myself doing every year, I wonder what Dr. King would think of our nation, of our world, if he were still alive. Consider, on this historic eve, this piece of Dr. King's speech:

"We cannot be satisfied as long as a Negro in Mississippi cannot vote, and a Negro in New York believes that he has nothing for which to vote."

Black America had an amazing turnout this year. Actually, several segments of the population who had previously been seriously underrepresented turned out in spades and made their voices heard. We stood up and shouted that we were done with the status quo, were tired of the Old (Rich, White) Boys' Club and tired of not having a sovereign interest. We showed that everyone can have a say. And instead of yet another old white man of privilege, we elected the best man for the job: a mixed-race man, son of a Kenyan, born in Hawaii, who lived many of his formative years in Indonesia. I am proud of us. I venture to say Dr. King would be, too.

Consider also this, one of my favorite quotes from the March on Washington speech: "I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin, but by the content of their character." That was in 1963. Today, some 46 years later, my friend Khalilah went to work. She's one of my friends from medical school. She's a physician, a solid, solid woman, and one of the best people of character I know. Today, at the hospital, dressed down but wearing a name badge that said "doctor," someone saw a black woman and assumed she was part of the housekeeping staff.

::sigh::

Prejudice is insidious. We're set up for it - you constantly make quick, automatic assessments of people and situations, and it serves an adaptive and protective function. What makes us judgmental is not whether or not we judge people, but how rigid we are in those judgments. How much we allow the irrational and unfounded to cloud our lens. Even now, as far as we've come, our lens, as a nation, is still quite foggy. Consider Khalila assumed to be a housekeeper, me assumed to be a nurse. Consider the disgrace that is most of our inner-city school systems. Consider Proposition 8. We've come so far as a people, a nation, a culture, and a race of humanity. But we're not there yet. We still have so far to go.

Now is the time, my friends. Now is the time.

It's 6:45am and I'm already cranky...

Attention patients/families of patients/people who leave me annoying voicemails because they want me to write them prescriptions:

My name is not Miss. Nor is it Kate, or Katherine, and it's really, really not Kathy. No, I am not a nurse. No, I am not a social worker, clinical therapist, or whatever else you've decided for which I went to school for four or five years. No, I do not need to "check with the doctor."

I am the doctor.

When people want to check with the doctor? They could check with me. See how that works?

If I were a nurse, then that'd be great, had I wanted to be a nurse. I'd be debt-free, making a lot more money currently, and working a much better schedule. I could defer and check with the doctor. But, I made a different choice. I did three undergraduate majors in four years. I spent four years in medical school working up to 120 hours per week while taking out ridiculous amounts of loans for the privilege to do so. I spent a year in hell doing an obstetric internship, and then committed another five years of my life to psychiatry residency and fellowship. I work 60-80 hours a week, have ruined my credit because I can't make the $1600/month payment the loan company thinks I should be able to make on a second year resident's salary, and lay awake at night wondering if I'm doing the right thing, if I'm serving my patients well, and if any of them are going to put a gun to their head tonight. It's a job I love, and a choice I made, but it's a freakin' lot of work and comes at a large cost.

The least you can do, here, is call me "Doctor."

Interpretation

You know those therapy sessions where things just come together, and you get to the end, and you can look back on the content and the structure of the session, and like, everything just aligns, and is so profound, and you just kind of sit back all, like, whoa, and it's so about the alliance that you end up sort of vicariously raw and exhausted, and ultimately you look at your patient and you're just, like, wow. Good work. How cool that I was here for that.

I had one of those tonight.

Except I was the patient. And I left and was sort of like, ohhhh. So THAT's what that's like on the other side of the couch.

Cool.

Also, how many years have I been in therapy, and how many therapists have I seen in the recent past, that this is the first time that's really all come together like that? Which, okay, is not entirely true - this is the first time that it's come together like that in the way that I was able to have sort of that directed awareness of the process because I'm in residency and training in psychotherapy. Which makes me wonder why anyone would be in training and not be (or at least have been) in their own therapy.

I've said it before, and I'll say it again: I really think a large part of the key to being a good therapist is having a good therapist. Because some things you just can't learn by hearing about them.

Cycles

Ohh, I'm so glad this week is over. Actually, the week itself wasn't so dramatic (I was home sick Wednesday and Thursday, after all), but, I'm just so glad it's the weekend.

I need some vacation time. Fortunately, I have a week coming up, but I'm not anticipating that to be very relaxing, since I'm going back to Chicago (the week of New Years, for those who might have a vested interest in that). Good, of course, just kind of frenetic.

The coming week is going to be...um, let's go with...interesting. I'm on Walk-Ins Monday through Thursday (there's a long involved story about why Ed and I switched Fridays...so I have four days this week and one day next week, and then I'm on call twice the week of Christmas...). Walk-Ins refers to the Walk-In clinic, which is just what it sounds like - ideally, an urgent care clinic (I need my meds today because I'm about to run out. I'm going to kill myself. I'm going to kill someone, possibly me, if we don't get this depression treated quickly. You get the idea). You also cover the ER during the day. So it's like daytime call. Or as I tend to refer to it, Day Float.

What's nice is that it's 8:30-5. You plan accordingly and you sign out to the incoming call team at 4:30. Done. What's...um, let's go with...interesting about it is that we have this group of social workers and psych NPs and such that's supposed to be doing all this with us. They're part of the "crisis team" and are salaried to do Day Float things. This sounds great in theory, right, because in theory it would free up the physician (there's only one) to do doctor-y kinds of things. You know, stuff clinical social workers can't do (meds) or aren't really trained to deal with (complicating/complicated medical issues, physicals, orders, etc). Problem is, our crisis team tends to be...um, let's go with...inefficient. They're nice people, just sort of...unmotivated. With a different work ethic than residents tend to have. And rather than firing their asses encouraging efficiency (it doesn't have to be the threat of unemployment that's used to motivate them. How about praise? Incentives? A higher standard and expectation?), they're coddled and stroked because we don't want them to leave.

The residents this year have all been like, so let them leave. They either need to get moving, or get out of the way. We...you know, we're a hard-working bunch. We'll get in there shoulder to shoulder and fight through the roughest of shifts. And, fine, so residents in general are more used to hard work and long hours, we're sort of a masochistic group anyway, etc, but, damn it, if we're in there hip-deep, we expect the people who are paid a heck of a lot more than us to do this very job to be in there with us.

We'll see how it goes. There's a new guy, Charlie, who seems promising. We hired him away from one of the community hospitals, and every time I've worked with him on call he seems to be busting his ass. He's been doing this for a number of years, so I don't think he's going to burn out, and he doesn't seem like the type to be lazy just because everyone else is and he can get away with it, so, maybe the rest of the crew will have to step up to keep from looking bad.

A girl can hope...

I went to this talk this morning for the PECC (more about that in a minute), and the speaker was talking about what he referred to as The Lead Rule - do unto others as others have done unto you. It's so simple and obvious (and sardonic), but damn if that doesn't sum up a lot of issues in medical education. We get into these ruts of "this is how it's been" and "if I had to do it, so do you." This is particularly rampant in the surgical disciplines, but, I think it's pervasive. And I think it occasionally translates into, if no one else has to do it, why should I?

Sometimes? Life kind of stinks. Sometimes you have to do things because it's the right thing to do, or they have to get done, or whatever, even if they're unpleasant or tedious or not what you'd rather be doing. But, if we ALL do this, then it tends to mean less unpleasantness for everyone.

Amazing how many people look at that and say, well, too bad. You can take my share of the unpleasantness. I'm going to go over here...

Also at this talk this morning, I met up with one of my colleagues who told me some disappointing things about our current chief class and how unhelpful and minimally mediocre they've been for the intern class. This upsets me. Because, last year? Our chiefs rocked. They weren't always perfect, but, they always made an effort. And we were all interns once. And it sucked, but we got through it, and that support made it so much easier. This year? You know, I think the thing that bothers me most is that their attitude is contagious. Like, I've always jumped in when someone was sick. I took on May's work when she was ill when we were on together at State Hospital. I took calls for Cleo and Fang on less than 12 hours' notice (about three hours, in Fang's case). I dug in and took on some of Mike's work when he was overwhelmed or had a bad night on Family. I was q2 for a week when Peng had dental surgery. You get the idea. We help each other out, you know? Two weeks ago, when I had a 102 temp and needed my call covered? It was next to impossible to find someone to step up (Sparrow = goddess. Have I mentioned that? JD also rocks) and Ruthie said there was a lot of "fighting" about who was going to take it. I just sort of shook my head at this, because I think it's spilled over from the "I don't want to do more than I have to" attitude that's at the top of our pyramid right now. I think the next three chief classes look promising, though. And you know...as much as I rant about things sometimes....

Holy freakin' cow am I glad I'm here.

Yesterday was an interview day. We had I think seven candidates, all in their smart black suits, all on their best behavior. It's cute. They seemed like a nice bunch (one of them reads my blog! How cool is that?!! Hi, D!!). In general, this year, I've been so pleased with the candidates. Anyway, they'd assembled in Corrina's office and got escorted off to lunch, leaving Peng and me and a couple of the other residents to talk about them, er, discuss recruitment. And we were like, I hope they realize we're all pretty much as we seem, here. We get along. We're a quirky but genuine group of overall good people. The interns lost their tiny little office space? A bunch of us stepped up and procured for them what I now like to call the Intern Rec Room. The Child/Adolescent month was too scattered, we got it changed to being just Adolescent. The faculty supports us, the chair is very interested in how we think things are running, and overwhelmingly people are interested in teaching, learning, and being colleagues. We like each other. We respect each other. I can't even express how important that is.

This time of year always leaves me a little retraumatized nostalgic about life at the Emerald Palace. I remember talking to one of the candidates that would eventually become one of the interns in the class after mine, whom I liked a great deal. I remember thinking I should tell her to run screaming (RUN. RIGHT NOW. AS FAST AS YOU BLOODY CAN. RIGHT. NOW), but what I told her was, intern year is a hard year. The dynamics here are difficult sometimes, and you have to watch out for yourself, but if you know that coming in, I suppose it's easier to handle ("But, gosh, the program has so many positives, too." Like...uh...the way our labor deck is set up. And the cool robotic system in the OR. And, uh, the scrubs are free. And working at Student Health (not here). And the off service months (not here). And the ER attendings (not ours)...). Yesterday, I'm interviewing this guy (I got to interview! It was fun), and I was like, you know...intern year is a hard year. Harder here that most places, but gosh, you learn so much. You come out of it so much stronger in your professional sense of self. And the faculty is supportive, and the upper classes are supportive, and people are genuinely interested in you here. And we're social, and we have fun, and we work hard but we're encouraged to get the hell out of here and be well rounded people. And yeah, not everything works perfectly, or even as well as we'd like it to. But even when there's nothing that can be done about that, they hear us.

He asked me if I was happy. I said, without a second thought, "I love it here." And I meant it. And then he commented on what a good research program we are, and I thought about that for a little while, and he said, all nervous, "Well, you may not agree with that, I guess." And I said, no...actually, I do agree with that. But don't think we're just about research...and then we had a nice discussion of how we're very patient centered and we emphasize psychotherapy and how many opportunities we have here.

The Emerald Palace taught me a lot. In my time there, and in the subsequent cleanup, I've learned a lot about myself. I learned a lot about interpersonal dynamics and group psychopathology and systems errors. I learned a lot from them about what I don't want, and a little about what I do. I learned what it means to be "the doctor" - the program might have rarely let me be that person, but my patients did in spades. I even learned how to do a colposcopy and run the cool robotic system in the OR and do a wicked good circumcision. But the best thing they did for me? They got me here.

I wish I was the kind of person that could thank them for that. I'm still going to go with, "Fuck you."

This little PIGgy

Tonight marks the beginning of the 2009 recruitment season. Tomorrow is our first set of interviews for next year's intern class, and so tonight is the traditional pre-interview gathering, affectionately known in our department as a PIG. It's pretty standard - the night before interviews at pretty much every program in every discipline, there's a meet-and-greet with the current residents at a local bar or restaurant, or when I was interviewing here, at one of the residents' houses. It's a nice, supposedly informal way to kind of get to know the people in the program, it gives you a feel for what people are like outside the hospital, and if you're particularly astute, it gives you a excellent way to gauge the dynamics of the people involved - are they snooty and distant? Generally relaxed and happy? Do they talk about work with each other or just when they're giving you their sales pitch (for those playing along at home, remember that we spend roughly twice as much of our awake time at work than not, so, if they're not talking about work at all, something's awry)? Are they snippy about it? Jovial? Excited? Dry? That can tell you an awful lot about peoples' attitudes toward their work and their patients. Do they generally avoid each other, or do they have inside jokes, ask about kids, family, hobbies? Do they volunteer positive information about each other ("Oh! Martha's really interested in community psychiatry, you should talk to her about our AHEC stuff," or, "Kate knit her own socks!" or, "Mike just ran a half marathon two weeks ago, you should talk to him about the running clubs around here")? Now, of course we're all on our best behavior, but, there's still a lot to be learned. And the residents - who often have a say in the rankings - can gather useful information as well. Generally, I like these things, and am hoping to go to as many of them (and the lunches during the interview day) as possible.

You'll notice, however, that tonight, this little piggy is blogging and making pizza.

Let me tell you how my day went...

I got a late start this morning. Way, way later than I wanted to. And I finally get out the door, and I get a table at the Starbucks, and read through some stuff....and then I get this text message from Sparrow:

"Dogs out."

I looked at that a moment...thought, huh? Is she just making a pop culture reference? Does she want to go take the pups somewhere? Is she...and then, it clicked.

Dog's out.

My dog.

Is out.

Shit!

I immediately started packing my stuff up and making a beeline for the door as I called her. Juan, our lawn guy/man Viernes had called her and said that Maggie had made a break for it. They were off to go corral her. I said something along the lines of "i'llberightthere!" Fortunately, Mags was standing right in front of the house (although Juan said she had started off towards Sparrow's house), and was easily redirected into my house, where the dog door was subsequently slammed shut. Sparrow called, and I stopped driving like a felon with a two-second headstart. By the time I got back home, Maggie was like, "Guess what happened! Guess what happened! Guess what...ohhhhhh, wait, I'm in trouble, aren't I? Ohhhhhhhhhh......"

It was cute. I hugged her. Sparrow'd already told her she was crazy.

Near as we can tell she did indeed go over the fence from on top of the air conditioner. Which is a dilemma I hopefully have solved, at least for the moment, as I took one of my old plastic shelving units and set the shelves upside down on top of the air conditioner. And there's a ladder in front of it. Maggie seems disappointed. For the record, I did NOT think she would go over that fence, certainly not more than once. It's a five foot drop, for Pete's sake! But then, Maggie is nothing if not spry and resilient...

I also discovered that there's been a large grey housecat living under my house. The entrance to which is right on the other side of the fence from the air conditioner (and which has again been sealed off). Dollars to donuts Maggie saw her and was all, "KITTY!!!" And, boop, over the fence she went.

(It was particularly amusing watching me try to explain this theory to Juan, I'm sure, given my pathetic command of Spanish and his limited English. It was a lot of me going, "Perro...con gatto..." and making leaping and scampering motions with my hands. The best part of that whole exchange, though, was when he picked up the recycle bin that's sitting next to the fence covering the hole that Maxine dug during their last jailbreak. He looked down and saw the hole, and all I said was, "Perrita Maxine." And he said "Ohhhhhhhh" in that knowing way, and laughed, and put it back down...)

::sigh::

So then I met up with Sparrow and Martha at this little deli in town, and we chatted and hung out and I had really good falafel. I then went to the Lowes Foods, where I suddenly discovered I was not feeling so well. Which perplexed me. Until two things happened: a, I finally got to the point where I felt so awful I was like, crap, I just need to go home, and 2, it finally occurred to me where we were in the month. So I attempted to finish shopping, checked out, and drove home, not yet realizing that I'd forgotten about half of what I'd gone for, including most of the components of tonight's dinner. Like, you know, cheese, and, say, pizza crust.

I curled up into a ball for a while, thinking some nasty things about Eve and bemoaning the five weeks I have left until Larry (my doc) puts in a shiny new progestin-eluting IUD and hopefully remedies a lot of this (have I mentioned that my insurance company is giving me a Mirena for Christmas? I'm so excited. Soexcited. In fact, never have I been so excited about a sharp poke in the cervix. I am hoping, however, this goes better than the last Mirena that Larry and I tried to put in together). But eventually I got up and realized that it was 4:30 and I'd forgotten about half the things on my list. And that this little piggy was going to have to go back to market.

So I got up. Went to Target. Went to Whole Foods. Came home, went to start dinner...and realized I still hadn't remembered to buy mozzarella cheese.

There was a long string of expletives, but fortunately the six cheese Italian blend I'd bought a month ago had a little mozzarella in it, so we converted from Greek pizza (because it turns out I didn't have any non-moldy feta, either) to fancy six cheese pizza (which I forgot to put seasonings on. I just remembered that. The leftovers have been in the fridge for over a half hour). I then started a load of laundry, and started doing the dishes. And promptly ended up looking at the clock, covered in dog hair and dishwater and swearing at anything in sight, and deciding that this? Was NOT the image I wanted to project to prospective interns.

I'm all for realism, and being up front, but, there is a limit to how much crazy I let people see. Even y'all.

I'm giving up and writing this whole weekend off. Tomorrow will be better. Even if I am on call twice this week. And then again next week.

Never mind. I'm going to go hide under my covers and snuggle with my jailbird dog...

Love Friday

No, I don't know why I'm still up. Damn insomnia.

Anyhow....with the new era of change upon us....I must say four things:

1. Love The Onion.


Bush Tours America To Survey Damage Caused By His Disastrous Presidency

2. Love Mariska Hargitay (it's the 9/10/08 blog entry, if you're reading this later).

3. Love America? Make sure you're registered, and vote.

4. If you don't vote, the terrorists win.

Thank you. I am done being political for now.

Not at all painless

So I've been thinking, today, and for a while, about suicide.

No, not my own (so put the commitment papers away, Peng). But, working inpatient psych, suicidal ideation is probably 60% what we deal with; probably 80% of those admitted to the Crisis service. And it always amazes me, the crazy amount of people that think about, or even attempt, suicide.

I don't understand. I don't understand the people that impulsively down a bottle of tylenol because their girlfriend broke up with them or cut their wrists because they had a fight with their boss. I can't comprehend this idea of, I'm having a bad day, I think I'll kill myself.

Death is so final. It's so....dead. We don't know what dead is. Nobody really knows what death is like. Maybe it's just nothingness. Maybe it's heaven. Maybe it's worse than anything we can possibly imagine in this existence.

And beyond that, it's an end. Which, is why I can understand the patients that are super depressed or really traumatized and think of suicide. I'll admit, I've been there. Not actively suicidal, but, in that place where you're just like, if I died, you know? That would probably be okay. At least this would be over. But it never seemed like a reasonable way out, and certainly never like a quick fix. And let me tell you, when I had - transient, brief, evanescent - thoughts like that, whew, I was in the lowest place I've ever been. It was so far down. I could not have been sitting in the dayroom laughing and watching TV the next day if anyone had locked me up. I understand the patients we have that have no hope, that see no possible light at the end of the tunnel; most of the time they barely see the tunnel. That's a black, black place, and I can understand the need for relief.

I had a friend once who told me that, when she was in high school and realized she was gay, she went to her pastor looking for guidance. And he told her that she was going to burn in hell because of who she was. And she left there, and what kept going through her mind was how she was going to continue to be persecuted while she was here on Earth - she lived in Hicksville, Nowhere and they didn't take too kindly to her sort. So she had a life of hell ahead of her, only to be followed by an eternity of hell afterwards.

So she contemplated suicide, because, why increase her suffering by staying alive? Why not bypass that and go straight to hell? That I get. I'm really mad so I'm going to take all of my klonopin? That's the grown up equivalent of, I'm going to hold my breath until I die and then you'll be sorry. Except, holding your breath until you turn blue? Low lethality attempt. By the time we grow up, we use much higher lethality options. Pills, guns, drugs, nooses...you stay blue.

And that doesn't even address the people you leave behind. Even if you have no family, no friends, nobody at all who loves you and would be distraught if you took your life, I guarantee, it'll matter to someone. It'll matter to your doctor. Losing a patient to suicide is something we all face at some point in our careers, but let me tell you, it shakes every one of us to our core. The very idea of it keeps us up at night. And chances are, there's someone out there - a friend, a neighbor, a family member, a pizza delivery guy - who's going to miss you. Who's going to be upset that you did what you did. Who's going to blame themselves for failing you. Who's going to be saddled with that for the rest of their own life. And suppose you do have a spouse, a parent, a child, a sibling left behind? Who does love you, who worries about you? How the hell are they ever going to deal with that?

I'm just sayin'. Think about it.

And for the love of all things holy, enough with the tylenol, people. If you need to kill yourself, there are ways to assure that you die. I'm not going to tell you what those are, obviously, but I can tell you one that WON'T work - a tylenol over dose. All it's going to do is kill your liver. And then you get to die a slow, awful, excruciatingly painful and uncomfortable death. I'm guessing not the quick fix you're looking for.

Seek help. Everyone has emotions that are intolerable; suicide is never the answer. Think about what suicide would really mean. Get to a hospital ER, call a crisis line, or better yet, seek psychiatric treatment before it gets to that point. Tell someone, tell anyone that you're in trouble.

Every state has a HopeLine. Ours, in NC, is 919-231-4525. The Teen TalkLine is 919-231-3626. You can find your state's by Googling "hope line" and your state. They often have toll free numbers as well. Or you can dial (800) SUICIDE. They're anonymous, they're supportive, and they'll let you talk as long as you need to. So if anyone out there finds themselves in that place, where suicide seems like the best - or only - next step, get help, and get it now.

You'll be glad you did.

Sunday, Sunday

So, here I am again...I'm sitting in the little intern office on the women's unit at State Hospital, waiting for my suicidal drunk guy to come in from the local ER. It's stormy and windy and Maggie was not pleased as I frenetically packed up my stuff. I kept having to stop and snuggle the big, wide-eyed, thunderstorm-averse pup. Fortunately, Sparrow came to rescue her and take her over to stay with them right as I was leaving.

I took the Ruthie approach to packing for call and brought a little bag of random things-crackers, dried fruit, an apple, peanut butter, carrots, I don't know what the hell I threw in there. Ruthie usually brings a large grocery bag of randomness whenever she's on call. Consequently, our office here at State Hospital looks like some sort of organic food bomb exploded in it. Followed by a big paperwork bomb. We should really clean this place up, you know?

I've also adopted her habit of not wearing scrubs on call, but rather, comfy clothes. Not, like, flannel pants, but not my "business casual" finest, either. Things in which I can sleep (ha) but still be seen in public. She's an ex-surgeon as well, and makes the very good point that we spent enough time in scrubs in our former life, and, let's face it - scrubs just aren't that comfortable. Plus, both of us are reasonably curvy women, and scrubs are usually cut for men. Who? Aren't curvy. It makes a difference.

I think she's been a bad influence on me...

So it's my last call at State Hospital. From now on, if I'm on call here, I'll be moonlighting, which means they have to pay me handsomely. But it also means that I have to get re-fingerprinted and get new letters of reference (from people who've known me at least ten years. What? I mean, I have plenty of people who've known me for that long, but do they really care what my best friend the lawyer or my grade-school friend the Spanish teacher think about my ability to practice medicine?? The NC Medical Board is weird) and stand on my head while drinking water or some such nonsense. And after I do all that, then I have to wait six months for them to decide if I'm worthy of the privilege of having a permanent medical license. Which, knowing the issues I had with them at the beginning of the year, probably means that I'll have to go sing the entire score of Die Fledermaus at a meeting of the general assembly or something. In German, while patting my head and rubbing my stomach.

Oh, but how I could use the money. To quote Mike, I am just broke as a joke right now. Or alternatively, to use my aunt's phrase, po'. As in, so poor I can't even afford an "r". But, in time, these things will come. By which I mean in time for me to start paying off my med school loans. Remember when doctors used to drive $100,000 cars and every psychiatrist had a house in the Hamptons?

Ah, well. Clearly, I'm not in this for the money, and let's face it, I'm not living in a box, or bunking with my patients in the South Wilmington Street Shelter.

It's interesting, actually...I had lunch with one of my med students today that I worked with earlier in the year. She's going into OB, silly girl (says the one spending her Sunday night in a state mental institution wearing mismatched socks and listening to opera on YouTube...), and wanted some advice. So we had a very nice brunch, and of course I came home and spent the rest of the afternoon playing the "what if?" game.

If I'd stayed at the Emerald Palace...I'd have graduated probably last week, instead of still being an intern for another month. I'd probably have moved back to Chicago for fellowship, or maybe gone somewhere else. I suspect that I might not actually be doing high-risk obstetrics, but possibly minimally invasive gynecology, which is the direction to which I was starting to lean by the time I left. Which is nice, because that's a shorter, if non-accredited, fellowship. I...okay, you know what? Realistically, if I'd stayed there, I'd be dead by now. Or some very different, hardened, torn-down, bitter version of myself that in no way resembles the person I want to be. So let's just take that option off the table right now.

The issue for "what if," I guess, is more what if I'd stayed in OB/GYN? I do miss it from time to time. I miss the procedural nature of things, the adrenaline rush of delivery. I miss the sweet moments as a family is forged. The pulling undertow of fate as lives are changed in an instant. I miss the excitement of the OR. I miss feeling dexterous and that moment of alignment as the counterintuitive movements of laparoscopy suddenly make sense. I miss the comforting repetition of scrubbing, those contemplative moments gazing over the scrub sink through the windows into the OR, mentally prepping for a case. I miss the give of a uterine sound as the internal os concedes and dilates, and the instrument slides in to hit its mark. I miss the solid bite of suturing a uterus, the snap of a hemostat, the rhythm of an imbricating stitch. I miss the satisfaction of the cervix popping into view on the first try. I miss the flow of clinic and the smell of Chlor-prep (although there are a lot of other smells I don't miss from my job, let me tell you).

I love my job, my work, now, in so many ways. And I think it's where I'm supposed to be. I think I can be more useful, my work more meaningful, from this side of things. But occasionally, it saddens me that I had to leave all those things behind. What saddens me more is how I feel like something I loved was stolen from me, with all that happened up north. But, a door never closes without another one opening. And I really do love what I do.

Speaking of which, I have to go admit someone. So maybe I'd better go do what I do...

It's like Lent

Dudes! I'm down to the last 40 days of internship. I'm thinking of giving something up for the occasion. Except, I've already given up free time and sleep...

I'm on call at State Hospital tonight. I was lamenting earlier that I didn't have my camera when I drove over to the adolescent building to put some kid in restraints. The grounds are quite lovely this time of year, and everything is in full bloom. This really is an amazing place, full of history and stories and lives and souls. Although, as I commented to the PA on our unit earlier, when the patient we just started on clozaril (clozaril = big gun antipsychotic) was lying on the floor naked in the middle of the hall and wailing at the top of her lungs in Spanish, this place feels more and more like a "state hospital" every day.

I've got this one patient I admitted yesterday, she's driving me crazy. She apparently was manic and decided it would be a good idea to drive from Manhattan to Florida. And as always happens (you'd be surprised at how many crazy people decide this is a good idea), she broke down in North Carolina. I don't know why they all crash land here. Apparently it's a good halfway point - they can make it through Virginia, but not quite to South Carolina. So she gets lost, starts feeling physically ill, and so what is the logical conclusion to this? She gets out of her car and lays down on the side of the highway.

.....really? That seemed like the best thing to do?

So now she's my problem. Because she got taken to a crappy private hospital where they made five medication switches in seven days, and then her insurance ran out, so they sent her here. And she of course has started refusing to take medications because they're "too strong, too strong!" So I pull her to the side today, and I was like, what gives? And she goes on and on, in full Fran Drescher voice, about how I'm too inexperienced and I don't know my medications and I'm trying to kill her and I'm trying to drug her out I asked very private things about her yesterday and now I'm going to do her like this and she won't take the medication I tried to start because she read about that and it's poison - POISON - and she has a medical background too, you know.

And I'm like, lady, if I wanted to drug you out, you'd be unconscious right now. But now that you mention it, maybe we should give that a try. And two, there's a big difference between being a nurses' aide and being, I don't know, a DOCTOR. What I said out loud was, okay, well, here's the deal. I'm willing to work with you, but, if you continue to refuse your medications, well, the difference between us and ol' Bipolar Hill Hospital (it's an inside joke) is that I can make you take them. WITH A NEEDLE. Don't think I won't. We finally came to an agreement but I so just wanted to duct tape her mouth shut. We'll see if she actually takes anything tonight...

Ohhhh. If she starts with me tomorrow I'm going to kick her in the shins.

I did, however, admit an amazing lady today. She's faced so much adversity I can't even stand it. And she's been working her Twelve Steps for ten years now. She's articulate and insightful and is here because she just got overwhelmed by a life that would overwhelm the strongest of people. She's a breath of fresh air in this place, let me tell you. She's going to be an amazing sponsor some day. I think she's really going to do great things.

She appreciated that I knew about the steps and "the rooms" and could understand phrases like "life on life's terms" and "let go and let God". I didn't tell her that I think the Twelve Steps are...well...I think they're kind of crap.

Okay, that's a giant overstatement - I fully and wholeheartedly support AA and NA and encourage my patients to go and to keep going until they find the right home group. I think it has a lot of solid concepts and the community support from others who've been where you are is invaluable.

I'll tell you one group I can't stand, though, is Overeaters Anonymous. Every OA meeting I've ever been to was like a setup for a hard core eating disorder. Food, weight, numbers, food, weight, numbers. Restrict, banish, eliminate. Seriously, no, that only makes it worse.

I'll tell you a secret. When I hit the end of my rope in NH and had to just let go, my own eating disorder was totally out of control (I've mentioned on here before that I have bulimia). That's the thing about addiction, and eating disorders (bulimia more so than anorexia), and the like - they're not healthy, but they're wicked strong coping mechanisms, and that's why we keep them. The eating disorder is a HUGE repository for anxiety, stress, trauma issues, self-loathing, all of those things. It's a vast, vast hole you can keep pouring your angst into. It was the strongest coping mechanism I had, and I was under so much stress then that even it was starting to fail to compensate. I don't want to know what comes next.

But by the time I got back to Chicago, I was so off-kilter, and I knew that I couldn't just dive back into another residency without making some serious changes in myself. So the program in which I sought help was Twelve Step based, because they treated addiction as well (honestly? Lots of people like to lump addiction and eating disorders together. But when you get right down to it, it's like apples and lug nuts). That's where I learned about the Steps, and that's where I started to feel like they had some serious flaws.

A, so not helpful for eating disorders, let me just say that. The Eight Steps to ANAD? Much better. Particularly Step Two - "Recognize that 'food' and 'weight' are not the real issues, but that other underlying problems in our lives have led to our obsessions with food, eating, and weight."

I cannot tell you the number of times that I scrawled "FOOD AND WEIGHT ARE NOT THE REAL ISSUES!" across the white board when we got off track in our ANAD meetings. Because it really is the whole point.

But B, I think the Steps and the Program are sort of flawed in general. Which, nothing's perfect. But I dislike how, the moment you slip, even a little, you're back to square one. It's a nice idea, but relapse is a part of recovery. You have to accept that and anticipate it, not pretend that it doesn't exist. Because it's going to happen, and the point is to have mechanisms in place to pull out of that nosedive faster every time. To get the point, not to just avoid.

The other thing I couldn't handle was the concept of powerlessness. I had SO much trouble with my First Step (which is the only one I had to do, thankfully), because I couldn't give over to that idea that I was powerless over my disease (some would say that's sort of the point, but, nonetheless). Because wasn't that the very point of being where I was? To gain power over it?

The bulimia, for me, came out of being powerless. It's such a complex entity I can't even begin to explain all the layers to it, but the original point was to distort myself, to become unappealing, in the hopes that it would stop my molester. I was 11 when it began (even though I wasn't diagnosed until my third year of medical school), just starting into puberty, my body was changing, becoming more womanly. This heralded a number of potential disasters. So I fell into this thing, this disease, that accomplished so many of my goals. I was fat and thus disgusting and unattractive, so even if I couldn't keep my perp at bay, at least I could keep other men at a distance to avoid retraumatizing myself (that's about half the reason I'm not a puker, because my other compensatory mechanisms aren't nearly as efficient). It made me look as bad on the outside (or closer to it, at least) as I felt on the inside. It reinforced my negative self image. It was a self-mutilating behavior, in essence. And it helped me strengthen my superpowers of dissociation, it functioned as a place to store all my anxiety, it did all the right things, even if it wasn't so healthy for me. The whole point was taking back some semblance of control over my own body and my own psyche.

Now, of course, where it got me was almost two decades (so far) of being at war with my body and self-loathing and self-punishment and etc, etc. Although, you know, it wasn't the ED that did that. The ED was a symptom of that. But it certainly reinforced things.

So this concept of powerlessness was lost on me. And truthfully, it still is. I'm not powerless over my disease. Neither is my patient. She was telling me about how she found a bottle of gin in her daughter's room last week. She picked it up, she was tempted, but she walked away from it. Because she knew it wasn't the answer, that giving up her ten years of sobriety wasn't worth seconds, minutes, or even hours of gratification. That's a powerful woman, right there. There's nothing powerless about that act. I mean, I understand the concept, you know, but I think the application's all wrong.

And how do you get anywhere if you can't take the first step?

Was that more than you all wanted to know about me?

"If you're not outraged...

...you're not paying attention."
~ Author Unknown

This'll piss you off:



Wow. Wow.

I don't care who you are, or what your politics, or if you did or didn't want to see HRC in the White House, the fact that they can compile a montage like this is just disgusting.

Ow.

Last time I saw my God daughter (she's six), she told me this exact story:

"This summer we went to Mexico and we flew in a big plane and we sat in the back and I sat near the window and I kept asking my mommy, 'Are we in Mexico yet? Are we in Mexico yet? Are we in Mexico yet?' And then my mommy got a headache."

My aunt and uncle came over today. And then I got a headache.

I don't think the two are more than coincidentally related, though, frankly.


(It's a random cartoon I found on the internet while doing an image search for "headache". It really amused me. The only credit I could find was that it was filed under "Ben is a dork." I don't know what that means. God, I love the internet.)

You know those days where you wake up and think, okay. I have a plan today. I'm going to do this and this and this, and it's going to be fabulous. And then the dog vomits on your bed and the light fixture explodes and you end up washing ranch dressing off the ranch dressing. You know those days? Today was one of those days.

Oh, it seemed like such a nice day when I woke up at 6:30. Which is a ridiculous hour to be up on a weekend day, but, whatever. Mags and I lounged in bed and watched an early morning prelude to the SVU Marathon on USA today (God, I love USA, aka the all-Law-And-Order network). And I thought, okay, up, shower, go to Starbucks to work, come back, unpack a little, have lunch with the fam, come back, make some espresso, unpack again, go to the new intern thing, come back again, go to bed. What a lovely day, right?

Ha.

I went into the bathroom, and the light made this weird hissing sound. And I thought, oh, the bulb's about to burn out, whatever. And then all of a sudden, the leftmost socket (the only one with a functional bulb in it) EXPLODES in a loud, popping, shower of sparks. I ducked. And then I made sure nothing was on fire (note to self: She who lives in an old house made entirely of wood should really buy a damn fire extinguisher! Anyhow...). And then I put new bulbs in it and flipped the switch. That socket's blown, but the other two still work. When I go back to Lowes to replace the blinds I bought that are an inch too short, I'll get a new fixture. Because if I wait for the handyman to fix it, it'll never get done. ::sigh::

And then I went to Starbucks, and managed to finish all the outstanding Child discharge summaries I had (I still have a couple from the adolescents, but I'm less worried about those because I really want my attending from Child to like me. Not that I don't want the other one to, but I really liked her, and so I want her to think I'm like the best resident ever, right, so she'll take me under her wing and turn me into a really good C&A psychiatrist and vote for me for a fellowship at Baby Blue. Okay, no, that's all secondary. I thought she was cool and so I want her to think I'm cool, too. It's so...well....adolescent....). And dropped my tea. But I only spilled a little. So then I went to Target and bought a $14 rice cooker (because my $40 one always burned the rice) and some groceries. And spent a lot of time standing in the aisles going, now...what the hell was it that I wanted here? And, um...where was I going again?

It was the first of many times I would ask myself today, what the hell is wrong with me??

I came home. I swore a lot and tried to find a place for the groceries (have we talked about my lack of cabinet/counter space?). I unpacked more of the kitchen. I had to stop several times and go into the other room before I started crying about not knowing where the hell to put the glass bowls or not being able to remember the word for "toaster oven" or being a big spaz and dropping things. So I went into my room and the dog hops on the bed and is all smooches and snuggles and rub my belly until, without warning, she yaks all over the blanket.

Oy.

Fortunately, I was able to locate the OxyClean with minimal swearing and fuss. And I rinsed the blanket out in the bathtub because my uncle hadn't actually come over to hook up the washer/dryer yet. Frack.

So they showed up, with tools and a milk pitcher and air filters for the furnace (because my aunt says to me yesterday, "Have you checked the air filter? If you tell me what size it is, we can pick one up for you on our way" And then I sent her a long email saying EW EW EW EW THAT'S THE GROSSEST THING IN EXISTENCE, EW! No WONDER the place still smelled like cats!). We changed the gross filter of disgustingness and went to lunch at an Indian place in Durham. And then we came back, and my uncle and I spent WAY too much time trying to figure out my new espresso machine.

The Starbucks here had a tent sale last weekend, to clear out their old model coffee makers and make room for the new ones. My $50 Target espresso maker didn't survive the move, so I thought, you know what? This is going to be my congrats-on-surviving-intern-year-AGAIN present to myself. So I bought the Sirena, which was originally $600, marked down to $199, and then got the 20% tent sale discount PLUS the manager's additional 10% employee discount (because he knows me. Because I went to that Starbucks every single morning that I lived down the street). Wow, what a deal! And it's so nifty! And it's made by BMW! WOW! I have the BMW of espresso machines, cool!

Leave it to BMW to turn espresso into a ridiculously complicated process.

Now, part of it was, again, I kept dropping things, and I was just generally like, "what?", and my aunt kept coming in and saying "Where do you want this? Where do you want this? Where do you want this?" and I kept getting all overwhelmed and confused trying to make espresso AND arrange the kitchen. And after we finally figured it out and made some damn good espresso (what do you know? The $600 machine really DOES make a better cup of coffee than the $50 one!), then we hung pictures and moved the TV (because the one in my bedroom chose today to die, ps. Not that I didn't buy it, oh, my first year of medical school, and not like I didn't buy it off the clearance rack, but, nevertheless...) and then my neighbor came over to complain that my empty water bottles outside waiting to be picked up were over the property line (no, really! Way to meet the new neighbor, huh? She didn't even bring cookies!). And then my aunt and uncle left and Maxine came over and she and Maggie sniped at each other a lot (jealous, jealous puppies over here). And I tried to do the dishes and make a salad for tomorrow and discovered one of the neat little single-serving cups of ranch dressing I'd bought this morning had mysteriously exploded all over the refrigerator and the other little cups of ranch dressing (which then became part of the dishwashing extravaganza) and nearly wound up in tears again and for the five hundred eighty fourth time thought, Jesus, Mary, and Steve, what the hell is WRONG WITH ME?!

And then I went...

Wait....what's today's date?

Oh.

Nevermind.

And somewhere in that mess of dropping things and verging on tears and stuff exploding, my catamenial migraine hit. That's what all the clumsiness was about (I have no idea why things kept exploding).

You know, most days out of the month I really like being a woman. And most of the time I don't even mind the monthly ritual of sloughing and end up humming Ani DiFranco's well-stated and empowering Blood in the Boardroom, with it's lines like "I bleed to renew life every time it's cut down" and "Men have all the money, they have the implements of death, but I can make life you know. I can make breath". But every now and then I revert back to the real meaning of what I'm commonly heard to say, "I think God took all the souls that couldn't handle being women and made them men."

Which really means, sometimes? Being a woman totally sucks. Bleh.

It's just what I think

"I asked my mom if I was gifted, and she said they certainly wouldn't have paid for me..."



I've been thinking a lot this week, for reasons that I'm sure are implicitly obvious, about what it means to be a mother. Or, I guess, a parent, in the broader sense. But for all the theories and fuss about equality and co-parenting and all of that, there's something different about being a mother and being a father. It goes beyond, I think, what still are staunchly defined gender roles in our society. I think it's something biological. And it's not that being a dad is any less important, or any less of a biological drive; it's just different.

I do think it's important that children have strong parental figures in both roles. As one of my favorite LMHCs once said, "You learn your role as a woman from your mother; you learn your worth as a woman from your father." I think that's really true. And I think that you learn so many other lessons in kind - how to treat members of the opposite gender, what it means to be someone of your own gender, what your role in society is, what your worth is as a person, a man or woman, an individual, a member of society. I also think you get so much from watching your parents (or surrogate parents) interact.


I was sitting with one of my patients this week, an adolescent who has a horrible father and a stepfather who's just as bad, and I asked him, "what does it mean to be a man?" He had a hard time answering me, and gave me a lot of negative answers - i.e., "It means not treating women badly," "it means not abandoning your family." I praised his insight as far as noticing what seemed wrong that was going on around him. I also had a feeling that he probably couldn't give me a good answer for the questions, "What does it mean to treat a woman well?" or "what are the ways a woman shows you her worth?" because that had never been modeled to him, either. I don't know that I have the answers to those questions myself, at least not in the superlative sense (actually, I totally stumped myself with the last one, but that's my own neurosis). Nevertheless. This kid's at such a disadvantage at the stage he's at now, trying to figure out how to be an adult, what that is. God help him when he tries to become a meaningful parent. It's a rocky, uphill transition regardless, but this kid has a lot holding him back.

Our parents always do. That's part of being what we are; they prepare us the best they can with the tools they have, but it's up to the next generation to come up with a better set of tools. Whether that means updating and adapting for the changing times, or turning maladaptive skills into beneficial ones, or dumping out the toolbox and starting over, it's the way of progress and of the progression of humanity.


It's an endless effort and a huge responsibility to be a parent. No, to be a good parent. There are so many jobs you take on. At the most basic level, you have to keep them nourished, clothed, sheltered. You have to keep them safe, which if you ask me, is both the most taxing and the most important job. And then, you have to nurture and encourage them. Contain them but give them room to grow. You have set limits, hold absolutely steadfast to those, and know when to break them. You have to know, when presented with two absolutely essential needs that have to be met, which one trumps the other. You have to pass on what's important but keep your own stuff in check. You walk a delicate balance.

The hardest thing, I think, is knowing you have to let them screw up sometimes, even when you see them heading straight for the cliff. Because it's important for all of us to fail miserably sometimes. You have to be willing to bite your tongue, and then offer nothing but a hand and a hug when they're sitting in the middle of a royal mess. Because they have to learn how to fix it.

And you know what? You're going to screw up, too. You have to know how to do that with acceptance, humility, and grace.

Kids learn so much through modeling. It's not the latest theory of parenting or the hippest new toy or the most traditional nuclear family arrangement that makes a difference for a kid - it's you showing them what kind of person to be. We joke about the inevitability of turning into our mothers, or opening our mouths and hearing our fathers' words come out, but it's the honest truth.

I do think it's different to be a mother. I've been thinking a lot about my crazy pregnant patient's baby, what biological drive sent me over to the Women's Hospital to hold her, to physically touch her. I think it stems from the fact that we're set up to carry those little lives for their first nine months. Which isn't to say you have to birth a child from your own womb to be a good mother, or that every woman who delivers a child will parent it well (that one gets the big old duh). But I think it's relevant that we're chemically set up to do that. I think it's relevant that, evolutionarily, we've got better sensory perception and processing than men do. That we multi-task better. That the sound of a crying baby will make a nursing woman let down. Chemically, neurologically, hormonally, biologically, we have a different set of parenting skills.

Which, again, isn't to say you have to be a woman to be the nurturing parent (double kudos to the stay at home dad for defying gender conventions both socially and parentally). And it certainly isn't to say you can only parent your biological children well. And while I'd prefer she didn't take the presidency, I have to give Hilary her due for the fact that it does, indeed, take a village to raise a child. Aunts, grandparents, siblings, good friends - have all been some of the best "parents" I know. And it never hurts to have multiple people to learn from, particularly if your primary parents model well taking the positive from every person you encounter.

Mothering is a tough job. And with much respect intended to all those out their raising their own kids, no one has it harder, I think, than the foster parents. Again, I correct that to, the good foster parents. Because there are so damn many who aren't. And why anyone would take on that job if they didn't intend to be damn good at it is beyond me. Because that must be the most difficult thing going. You get these kids who already come to you damaged in one way or another. They already have attachment issues. And you welcome them in, and you have to attach to them and love them and encourage and nurture them just like any other parent, to deal with their problems and genetic setups and poor coping, knowing that all you may have with them is a brief moment before they get taken from you and whisked to someplace else. It's an awesome prospect and it deserves equally awesome respect.

Ultimately, I think being a mother isn't for everyone, at least not in the "direct," having actual offspring of their own, sense. Some people excel at indirect parenting (i.e., being a positive influence on others' kids or taking a strong surrogate role when the main parental figure is lacking), but for some it just isn't in the cards at all. And that's okay. The key is knowing it, I think, before you actually have kids.

What it boils down to, for me, is giving it your best effort and working in good faith for the welfare of your kids. To listening to them and to your own instincts. To understanding that it won't always be perfect. To remembering that the best thing you can do for your children's development into solid adults is to show them how to be one. Whether they're actually "your" children or not.

And knowing that one day, they'll get it.



(PS - thanks, Jenn!)

I must be a bad doctor...

All my patients got crazier overnight. Even crazier than they were.

I spent so much time doing therapy and meeting with people and soothing family members today that I barely had time to breathe. My med student and I had planned to leave at 4. We left at 5:30 and I had to blow off my new patient's bleeding toe (it's a TOE! It can WAIT until tomorrow, crazy nurse woman!!) to bolt out the door. Didn't get a single note written. Came home, wrote two, and then the electronic chart crashed.

Oy.

Watch that woman's toe have fallen off tomorrow.

Things that make you go...ARGH!

So, you might notice that the amount of days on my timer at right has gone up...

Oh, I can't tell you how pissed I am.

So you might remember that little debacle with my licensure after the evil jackasses at the Emerald Palace tried to screw me up. For those of you who don't, well, the evil jackasses at the Emerald Palace continued their two year run of harassment in turn for my treachery of leaving by sending a libelous and distorted "verification" of my training there. Which resulted in my license being delayed by three weeks until I ultimately had to go meet with a board member who was like, why the hell not? It's just a training license.

Well.

Until this week everyone seemed to be conveniently forgetting that three week delay. Which seems fair, because I didn't get any credit at all for the time served up north. Until the new chiefs took over, and so I get this email. Telling me that not only is the start of my second year being delayed for a month because of this, I have to do another month of crisis, and take another month of intern call, AND my "intern" year is being extended ELEVEN DAYS LONGER THAN ANYONE ELSE'S.

Eleven days.

Eleven days longer. Than any of the other interns. This will come out of my last year experience, he says.

So now I've done 10 months of internship in OB/G. I'll have done a full internship in psychiatry. And then I get to take almost two weeks out of my fourth year, so I could do even MORE internship. And they won't make any sort of allowance. They won't let me do clinic part time in July. They won't let me be in the second year call pool instead of the intern call pool (oh, but there'll be 5 interns on that month, so we'll be on every fifth night instead of every fourth. Big conciliation).

And the man behind the curtain wins again.

That's really the issue. Not the extra month. I can do another month on crisis, whatever. I can do the extra call. But I reserve the right to feel jilted about it.

In other news, the pine pollen has arrived in North Carolina.

It runs in sulfuric rivulets with the rain and it coats everything, inside and out. It's like the worst dust you can imagine.

Pine pollen is my nemesis.


My nose is running. My eyes itch. My throat hurts. I'm wheezing and squeaking by the time I walk into the hospital from the parking lot in the morning. I'm not sleeping well. I'm tired, I'm sore, from these puddled masses yearning to be trees.

And apparently, I make terrible puns in response to the pollenosis.



Maggie's dealing with it okay, though.

So. Very. Tired.

What a long damn day. Holy cow.



It was a long day. It was a long call. I just finished all my notes at home. Which means it's time to go to bed, and maybe when I wake up, it'll be a good day. Because today, really, really not so much a good day. Stupid frakkin' really dumbass day.

I hate people.

GDR.

So I'm dull. It's not such a bad life

Apparently Mr. (Ms?) Anonymous hasn't been too thrilled with my opinions in the comments over on the Shrink Rap blog and felt the need to come over here and make a couple of snide remarks. He/she seems to be someone who feels like psychiatrists are misanthropic snake oil peddlers (which seems like a strange sort to be lurking around a blog written by three psychiatrists, about mental health issues).

It's not a unique viewpoint. And you know, in a way, we are. Well, maybe not misanthropes, but a lot of our treatments are based on anecdotal evidence of what works instead of hard biological data. I mean, you can say that about a lot of things in medicine, but it's even more prominent in psychiatry, I think. Each patient is such a unique mixture of chemicals, experiences, conditioning, and genetics, that one size fits all treatments are usually inappropriate. Now, I concede, that doesn't mean there aren't shrinks out there that think the answer to everything is higher and higher doses of Seroquel or that dole out SSRIs like candy. I quite often get patients who are followed by providers outside our system whose med lists leave me scratching my head (or occasionally outraged). I got into quite a battle last week about a patient who has a diagnosis that not everyone believes in, and how everyone then blamed her therapist for destabilizing her with this voodoo instead of admitting they didn't know much about or understand her diagnosis. I had a doctor send me a patient yesterday -on whom he hadn't come close to exhausting all her medication options, who wasn't catatonic, who wasn't suicidal - and more or less tell me that if I wasn't going to give her electroshock therapy, I might as well send her home, because that's the only reason he was involving us.

Which is not to say I'm the best doctor ever. Far from it. I have a lot to learn, but at least my knowledge is sound on one point: these are the lessons I'm going to learn from my patients.

And let me say this...you know, I'm actually relatively slow to medicate people, but I do think drugs are an important adjunct. Otherwise it's kind of like withholding insulin from a diabetic - you can monitor their labs and check their retinas and take meticulous care of their feet and watch their kidney function and they can do everything else right, but if they don't have the chemical that makes things work, things are going to go wrong. And like diabetes, brain chemistry comes in a spectrum of qualitative and quantitative deficits. Also like diabetes, if you supply the chemical but the patient does all the wrong things, then you're still aiming for disaster. Mental hygiene is exactly the same - balance the chemicals to provide relief and remove any biological impairments, and then find the therapy to move things forward. But where mental health veers from the diabetes analogy is in that afore mentioned idiosyncrasy of being human. Despite our best efforts to diagnostically lump patients, each one is a singular event. The choice of which chemical or combination of chemicals to alter, the utility of what kind of therapy is appropriate or potentially harmful....it's as different as a fingerprint. The DSM is useless as anything but a guidebook.

And since I've beaten that to death...I will concede that even I think my posting of late has sometimes been lackluster. I think it's mostly exhaustion and a touch of being compelled to daily blogging by this Blog 365 business (i.e., you get more verbiage, but it's less profound). Blame the pox. Or the not-court. Or the Flu not-A. Or life as an intern. Or maybe I'm just boring. You know, there's something to be said for leading a life that isn't overrun with drama. A life of contentment with what is and little complication.



I wish I felt like I was living such a life right now....

Now back to today's regularly scheduled posting

I have today off. I love a good day off.

Call on Friday was rough, but not nearly as brutal as the last one. We actually managed to evade four admissions, which was handy, because we had six. My new call senior is weird. Very nice. Very knowledgeable. Very religious. Like, Evangelical Catholic, doesn't swear, won't prescribe birth control, can't say "God damn" in front of her. She got very excited when I told her I was Greek Orthodox. I'm not really sure why, because the Orthodox church is, um, old and stoic, but nowhere near Evangelical. And I certainly neglected to mention that I've read the Quran and the Mahabharata and I think Wicca has some good ideas and if the Church wasn't so ingrained in my family and my culture and my damn DNA I'd probably be a Buddhist (but then again, I have this theory that Jesus would be, too). She's also very slow, and overly thorough, and insisted at the beginning of call that I should do all the admissions, even the Green team ones, but that not only did I have to do all the work, she would come in with me to do the interview, like I was some damn medical student that couldn't tie my own medical shoes. Which, I think she's more motivated by her OCD than her mistrust of my abilities, but it still is annoying. And she's really nice. And she did do the 2:30 admission by herself even though it was a Blue Team patient, and I went to bed. Which was lucky because I was about to fall over.

And then in the morning I tried to put an IUD in this patient of mine who needs one for host of reasons that have nothing to do with contraception (she has her tubes tied already). And so we wheeled her allllllllll the way over to the Women's hospital so we could use their procedure room (not a short drive), and tried and tried, but her os was stenotic and it just wouldn't work. I tried. My attending tried. We couldn't get her to dilate enough to get the tiny little uterine sound in (it's about the size of a US3 knitting needle), much less the Mirena introducer. It was very painful for her, and I felt really, really bad. Really bad. So I called gynecology, to see if they had any ideas. Here's an excerpt from our conversation:

Me: So, I have this patient that I'm trying to put a Mirena into because [long, technical description of patient's medical history]. And I couldn't insert it because her os is stenotic

Him (before I could really tell him why I was calling the consult in the first place): Okay, first of all, [long, technical description of why my thinking is wrong. A conversation ensues about why I want to do this in the first place involving a lot of circular logic and me repeating myself].

Me (finally): Okay, whatever, anyway we thought maybe you could offer some ideas about the next step here.

Him: Well, she's bleeding, right?

Me: She is.

Him (chuckling): Well, her os has to be patent, because stuff's getting out. Otherwise she'd have metrometria.

Me: Duh, you dumbass. I said stenotic, I never said it wasn't patent. Okay, fine. Clearly her os is still open, but it's smaller than a uterine sound, which means I can't get an IUD in.

Him: Well, something you could do to make this really easy is to ripen her cervix with some -

Me: I did that. Last night. She got 400mg of vaginal misoprostol.

Him: Oh. Well. Did you sound the uterus?

Me: Of course.

Him: Well what did you use?

Me: Um...a uterine sound?

Him: Oh. Well I always sound the uterus with an endometrial sampling pipelle. It's easier on the patients and you know, you can't create a false passage through the cervix. (My attending's response to that comment when I told him later: "What's he on? You can do that any time you start poking around the cervix. You can do that with a speculum." Not really, but, the point is it's crap)

Me: Okay, whatever. I used a sound.

Him: Well, did you have good visualization of the cervix?

Me: No, I started poking blindly in her vagina with a sharp object. Of course.

Him: Well, did you use a tenaculum?

Me: Of course.

Him: Well, did you pull traction on the -

Me: Of course I did. I used to be a gyne resident. I know how to do this.

(Long pause)

Him: Well, if you know how to do this, do you really need a consult?

Touche.

In other news, I've started knitting up the yarn I got in my yarn swap with Tiny Tyrant.


It's a local (to her) yarn company called Royal Hare, handpainted superwash merino, dk weight (appropriate, no?). The color is Mt. Tam Moss. It's lovely. I'm knitting it on size threes (in the picture, it's on my little tiny Addi dps, but I started it doing magic loop on my Addi Lace that's a little too long - I think it's a 40" cable - and the sock went back on the Lace about ten minutes after this picture. The dps lasted about three rows. They were just too poke-y). I'm using Sarah's basic toe-up pattern, with a broken (moss-stitch) rib on the instep/leg.

I'm debating whether or not I should take my sock to the department Super Bowl party I'm going to this afternoon. That's a lot of prime knitting time. But I'm not sure they know me well enough yet for me to pull out the knitting at this sort of function...

Ooh, do you know what I'm doing tomorrow, though? I'm going to Duke Law school to be a fake expert witness for their trial practice class. Should be a fun time.

Somebody's gettin' on my nerves...

(Missed the reference? Click here. Before I forget that I'm a lady and give 'em what they deserve.)

People are driving me crazy tonight.

Today was a weird ass day. It was Wednesday, so all the Family residents scampered off to their academic stuff all morning. Which meant it was pretty much just me and Mike and a bunch of attendings. We rounded, I got my notes done, and was more or less ready to leave at noon. It was a nice morning, actually. Mike and I got stuff done, Betsy was gone...and then the attendings started talking about how Sarah, my attending from two weeks ago (remember her?) was in the ER and coming on to the Family Medicine service as a patient.

I like Sarah. She's kind of a lot sometimes, but she's a really good person. And we'd already agreed that we needed to stay friends after she relinquished her position of authority over me. So I went down to the ER to make sure she was okay, offer to take care of her dogs, whatever. We got to chatting and I said, Red Team's admitting, but you know they're going to let you decide whatever team you want to be on, so I'm sure you're just as good to go on Green. And she says, can I come to the your team? I said, of course. And promptly called the covering attending and told her that Sarah wanted to come to the blue team and I was already down there, I'd do the H&P and take her on as my patient. Even though, you know, I'm on call and thus the admitting resident tomorrow.

The attendings appreciated it. Sarah appreciated it. I'm not sure the on call residents were as thrilled, but, should they really care? It's an admission they didn't have to do.

And then I discovered my really manipulative patient we discharged last Friday was back. The one who was so freakin' personality disordered and like ate my whole day and then frakkin' Betsy comes in and plays right into the manipulation and triangulation and the next day we discharge her and she wants Betsy to be her real doctor (a-ok with me, sister, even though someone in my line of work is so much more what she needs. But, please, go play dueling Borderlines, with my blessing) and Betsy sends her out the door with pain meds. Wait, let me rephrase: Betsy sent a known narcotic dealer and abuser out of the hospital with prescriptions for oxycodone, oxycontin, and ambien.

My mind boggles at the street value alone of this little hospital stay...

So she's back. First, the on-call resident tries to get me to do that H&P too, even though, um, I'm NOT ON CALL TODAY. And then Mike and I decide that she clearly needs to be Betsy's to follow, because the patient and I do not get along (because I'm a hardass that sets limits), and because she's technically Betsy's primary care patient, Betsy should see her anyway. So I gave B the courtesy of text messaging her this info - she's yours to follow in the am, and oh by the way, we picked up Sarah on our service. The flurry of texting that ensued just pissed me off on so many, many ways. Suffice it to say, I'm seeing the sociopathic patient in the morning, along with my other four patients. Despite the fact that I'm on call tomorrow and thus admitting. Know why I have to see her? Because Betsy has afternoon clinic, and so she can't possibly see ONE FUCKING PATIENT tomorrow.

I'm so ready to be done with her. Which will be Monday. And I have the whole weekend off. Thank God.

And just to add injury to insult to this day, Mike and I escaped the hospital about 3 and went to this cute place in Carrborro for lunch. I fell down. On the way in, before I'd even had anything to drink. In the middle of the street. Tripped over my shoe. In the middle of the street. Boom. Scraped my elbow. Felt like a moron. Mike, fortunately, picked me back up, hugged me, and then plied me with really good alcohol. It was an excellent response to the situation. I still feel like a moron. But at least lunch was good.

Snow and Ink

So I'm driving around doing errands this morning, and I hear this story on the radio. Apparently the chief surgery resident at the Mayo Clinic in Scottsdale just got fired because he took a picture of a patient's penis with his cellphone during a cholecystectomy and then showed it to his friends. Horrible, right?

I'm having a little bit of trouble feeling sorry for this guy.

Yes, that was really unprofessional behavior. Yes, that was a violation of his trust and the doctor-patient relationship. Yes, the surgeon really should've known better than to create evidence. And it was jocular and silly. But...the guy had "Hot Rod" tattooed on his penis.

Not for nothin', but...hmm. Did you not think that would attract some attention? I mean, I have an unusual tattoo, too (different from a ta-tutu), and I knew when I got it that people would comment. And mine's nothing like that. So, come on, bud. What that resident did was wrong, but, really, the way he's carrying on and being all outraged and horrified is a bit...dude, you let a total stranger with a needle tattoo the words Hot Rod on your penis. Not to mention that now everyone in the literate universe knows about your, um, little secret. I? When that doc had called me, would've been like, fine, sir, whatever, let's just never mention this again.

We're not even going to talk about the number of times I photographed women's genitalia during surgery when I was a GYN resident because they had some clinically interesting or relevant finding. A couple of those pictures even got published, I think, in a journal article, of one woman's vulvar cancer. Not the same thing, I know, but, I'm not sure we told very many of those people we'd taken pictures of their cooch. Our ability to take photographs during surgery is in the standard release form. Now, I concede that the "clinical utility" of these Mayo photographs is questionable, and I was either taking them with the hospital's digital camera or a laparoscope, not a cell phone...but anyway...

In other news, it's snowing in North Carolina.

I think it's sort of funny. In the few hours since I started this post we've actually had some accumulation. We're supposed to get more tomorrow. Maybe it will keep people home and make for an easier call night? A call girl can only hope.

And in still other news, Tiny Tyrant sent me some very cool sock yarn in a yarn swap. Which I promptly tied into a great big knot (with the help of my ball winder) that took me two episodes of Bones to untangle today.

It's very cool. I'll post more about it later now that it's in actual balls and I have a tiny bit of it knit up. Maybe I'll have some time to write tomorrow (keep your fingers crossed for me), but right now, I've got to get to bed....

Wired

I have had way too much caffeine today.

But at least I've been productive. I left the hospital, went and picked up the Maggie, and then we stopped at Starbucks. I came home, loaded the dishwasher, swore at the Treo for a while, and then gave up and went to Circuit City, where I hemmed and hawed and was very indecisive for a very long time about what navigator to get. Then I went to the grocery store, stopped and got lunch, came home, took the trash out, swore at the Treo some more, and now, I'm babbling on here. Good times.

Someone said to me, back when I got the VZNavigator on my phone, if you get the navigator, you'll never learn your way around. I said, nonsense. I'll just not get as lost when I do get lost. But I'll know the town just as quickly. It'll be fine.

Now I say, alright, fine, shut up.

I lasted three days, and one of those days I was on call. I got so rip-roaring lost on Friday coming back from lunch downtown that it was ridiculous. Especially considering there was another physician with me, who also works there, who didn't know where the hell we were, either. And "downtown" is neither that big nor that far from the hospital. For all the IQ points in that car on Friday, I'm just sayin'. But alas, no. The only reason we didn't get lost on the way to lunch was because I was following Mike, who, a, gets out more than I do so he knows his way around "out" better than I, and 2, lives four blocks from the restaurant, so, he really ought to know where it is.

So, adding to the gadgetopolous in which I live, came the TomTom.

There was much wailing and gnashing of teeth over this vs the Magellan. Because I can talk to the Magellan. And the sales guy thought it was easier to use overall. But I couldn't get into the interface, and I really like the look of the TomTom maps. And I got the stripped down version, because I concluded that was really all I needed. But, like, it couldn't find the grocery store. So I ended up googling the Fresh Market on my Treo and then entering the address into the TomTom and feeling a little like the bionic woman. Especially now that I've taken to wearing both my phone and my pager on my hip (because I'm not leaving anything as expensive as the Treo in the pocket of my labcoat). I'm wired for sound, baby.

And I had immediate buyer's remorse as soon as I took the TomTom out of the package. D'oh, I should've gotten the Magellan! Except that this was all triggered by my inability to find the Fresh Market, and who's to say that that Magellan would've been able to find it, either?

Once I gave it the address, though, it did find it. And I fulfilled what's become my Sunday routine...go to the Fresh Market when it opens, buy produce and yogurt and other random (usually impulsive) things, then go to the Char-Grill next door, and get a very yummy burger for me with mustard and onions and a plain cheeseburger for the pup. Today's burger was especially good, and they have the best fries in town. I also made three particularly good finds at the FM. One was vanilla chai, which has become my new addiction at the hospital coffee shop. I also discovered that my new favorite wine also comes in a red, and the other...oh my gosh....I was in the cheese section, getting shredded Parmesan to go with the salad fixin's, and I saw this little half-pint deli container with a really white, softer looking shredded cheese, and I thought, huh, I wonder what kind of Parmesan that is....but it wasn't. It was...are you ready for it? Mizithra! Which is this dry, salty Greek cheese that I could live on. No, really, a little butter and some Mizithra on pasta is the best thing going. It's the food of the gods, I'm telling you, Athena herself invented that dish. It has to be new this week, because I look for it pretty much every time I go past their cheese counter. And there it was! I let out an audible gasp in the middle of the cheese section this morning when I discovered it. There may even have been a Mizithra dance. I'm telling you, this is exciting news. Especially after having conquered the TomTom to get there in the first place.

If I could figure out how to sync the effing Treo, by the way, I'd show you a picture of the TomTom taken with the Treo. Because I thought that was funny. But, alas, I still can't get the laptop to talk to the phone. It was a fluke, one-time deal, apparently. At least it worked long enough for me to load a couple good pictures of my dog onto the phone, so I could show her off at lunch Friday.

Technology is my friend...

Lunch, as an aside, was very nice though. Sarah took Mike and me (Betsy was post-call) out for Thai food to celebrate our surviving the past two weeks (the attendings rotate off service after two weeks, so we'll have a new attending tomorrow. I'm hoping this mellows Betsy out, but, none of us are optimistic). It was very pleasant. The food was excellent, we had a very good time, it was very laid back, and I still left early. Very nice. Plus, Sarah and I have intentions for a doggie play date shortly. She has two dogs, one who she picked up at the roadside after he got hit by a car - a German Shepherd who's probably about twice Maggie's size - and a Leonberger she rescued from the shelter who was so little when she brought him home that he used to sleep in the cats' bed...he's now close to 200 lbs, and he's not done growing. He gets his head stuck in the cat bed now because he doesn't realize he doesn't fit there anymore. He barely fits in her car. I can't wait to meet this big furry mountain.

Those two are going to terrify Maggie, though. She likes cats and little dogs. Unlike my old dog, Wolfie, who was this ninety pound Husky-Akita mix and had a heartbreaking, pining crush on the 125-lb older-than-God German Shepherd next door, Bob. Wolf would run over to the fence when Bob was out and just watch him, awed, tail wagging like crazy. And then he'd look over his shoulder at me all excited, like, "It's Bob! Do you see? Do you see?? Oh, Kate, it's Bob, it's Bob!!" But he'd never bark, and he never dared actually approach Bob, who, incidentally, was this very sweet, toothless, grumpy-old-man kind of dog. No, my dog was a groupie.

Bob died shortly after Wolfie did. And then the big mean old Rottie they had got stomach cancer or something (I told my neighbor, it was probably someone he ate), and he was put down. So shortly after Mags arrived, they got this very obnoxious pit bull puppy. Maggie and Kedzie, my roommate's dog (who's like 13 now or something and is a TOTAL grumpy old man) were both sort of like, what the hell did you bring him here for?

The best Wolf story, ever, though, was when one day we were out for a walk. And these six little rat dogs come tearing out of the house down the block, like, in formation, barking and snapping and squealing and they start circling Wolf, nipping at him, barking, huffing, growling. And Wolfie, bless his little poochy heart, stops, and looks down at these little knee-high (to him) annoyances with this quizzical look on his face. And then he calmly looks up at me, completely baffled, like, "Dude. Really. What the hell are these things?" And he kind of watches them for a minute (in contrast to his owner, who's flailing about yelling "Get out of here! Go! Go! Stupid little shit dogs, get!") and then looks at me again like, "These things are stupid, and noisy. Can I eat one?" Fortunately, their owner happened to notice about then that they were missing and called them back into the house. And he - I'm so not kidding - watched them go back into the house, looked at me, shook his head, and then started back down the road towards our house. I totally would've let him eat one.
That's my Wolfie. He was such a good boy.

Well, Mags and I are going to go spend some quality time napping, and then there more dishes to be done and laundry as well and I still have two discharge summaries to write up. Mi vida loca...