Wednesday, June 29, 2011

Psychiatric Help is Five Cents, Please

"I just needed a little psychoanalysis -- did I say that right?"

"Yes, Jake, you said it fine."

"It's my first big word, you know. Will you take me out to the bathroom now?"

"Sure, hop down and let's go."

Having a patient sit on your lap probably isn't quite what Dr. Freud would approve, but neither did he have patients with fur. Then again, the potential for soiled trousers may been precisely the reason why he insisted on sitting behind patients while they reclined on a couch. And all this time we've thought it was to avoid contaminating the transference. I mean, who knew?

Furthermore, under most circumstances the idea of taking a patient out to the bathroom is questionable, rather like taking one out to the ballgame, except there are conditions where that could be considered therapeutic. You think I'm kidding? Not at all. Exposure therapy for what most clinicians call Baseball Stress Disorder. It happens a lot in cities with major league teams, though more cases are reported in Boston and New York, depending on whether the Yankees or Red Sox won the pennant any given year. Actually, the DSM-IV labels it Post-Pennant Syndrome (PPS) -- I'm sure you've heard of it, it's been in all the papers. This morning however, since my patient was Jake the Puppy, a visit to the front yard was hardly a boundary violation.

It all came about because Jake has been thinking about a behavior problem that troubles us both. It concerns his proclivity for growling and barring his teeth when he's sitting, contentedly, on my lap and I happen to move. I thought it was a dominance issue, his answer to the age-old question, Who's the boss? But he said it wasn't that way at all.

According to Jake, he spent most of his early life scratching and clawing for his share of the food, blanket, and play toys at various adoption centers between Arkansas and Maine. It wasn't horrid, he said, but it was dog eat dog and since he was a little baby puppy, he had to learn to be tough. Now, things are different. He has his very own crate, food and bowl, a big brother, the Cat and me, and he's very happy. But when he growls, he says it's because he feels like he's back at the animal shelter. I told him not to worry, it was an unconscious response, and now that it's out in the open, he'll be more able to regulate his behavior. And since he wants to be a "good dog," like his older brother, the motivation for change is already built-in to his character structure.

It was a good session and Jake accomplished a lot. Naturally, there was the question of fee, since the therapeutic frame must be maintained. "Jake?" I asked, stopping for a moment at the door.

"Mm? Are we going out or not? You know what happens when we don't."

"I know and we are, but first, I need to be paid for my services. Psychiatric help is five cents, please."


(Photo copyright 2011 by the author)

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Sunday, June 19, 2011

Dreaming About My Father

Well, he did it again, waking me at dawn's early light to go Number One -- Jake the Puppy, who's internal alarm goes off with a regularity rivaling the Royal Observatory's "Baby Ben" at Greenwich. I wonder who winds that one? Probably quartz by now. Anyway, more or less two minutes passed and he was back in his crate and I was back in bed with the big dog curled against my leg, hoping the rest of my night's sleep was still within striking distance.

Fat chance. Ten minutes and we're outside for Number Two. You'd think I'd have learned by now, wouldn't you? Yesterday, at least, I was sufficiently conscious to snap a shot of fog rising from the hayfield with the moon setting overhead (photo).

Seconds later it seemed like, he's barking again. Now, I try to let these things go until he stops; part of crate training is figuring out that the human -- most days that's me -- isn't going to come running at every beck and call. But our typical pattern is becoming pee, poop, then dog food and he knows it. The third time's the charm and being soft-hearted (or soft in the head) about such things, I'm finally up for real. The coffee's made, the dogs and cat have been fed, and following an energetic post-prandial romp through the house, both canines, naturally, are dead to the world. Not me, of course. Oh, no.

While moderating their usual "I want his food" debate, I watched a bit of Inception (2010) on HBO. If you haven't seen it, it's worth a rental, but be prepared to have your brain twisted and squeezed. The theme revolves around interactive dreaming and the possibility of manipulating a dream from within the dream itself. This can be done at three levels. First, you're asleep and dreaming. Second, dreaming you're asleep and dreaming. Third, you're dreaming you're asleep and dreaming, and in that dream you're asleep and dreaming. It's like a box within a larger box within an even larger one. I did say the film's a brain twister, right?

While trying to unravel the film in a mildly caffeine-deprived state, it hit me once again how little we know about mind-brain interactions. Strict reductionists consider the brain's electrochemical processes as end of the story. Brain functions equal mind operations. But the best neuroscientists can't figure out how the mind ends up floating along like oyster crackers in an electrochemical soup. If you conceive of dreaming as the mind talking to itself, mind-brain interactions become still more baffling.

I dream about my father sometimes, like the other night. I don't recall the details but he was there, alive and vibrant, though he will have been gone eleven years this coming November. I'm always glad to see him but it's funny how I never seem to remember the things I wish we could talk about over the phone. You'd think I would, since that's one of the things I miss the most. Whenever he appears, however, I always seem to feel grown up, as if the dream is a reminder, even though he's not with me in any physical sense, he did a pretty good job while he was.

Happy Father's Day.

(Photo copyright 2011 by the author)

Saturday, June 18, 2011

First Lessons

I almost became a veterinarian. A horse doctor, as the cowboys called them when I was a young teenager, distinguishing between the large and small animal variety. Back then, I'd occasionally drop the "doctor bomb" on my parents, testing the waters to see if anything had changed in their perceptions of my future. For reasons I never understood and she could never quite explain, my mother felt my severe needle phobia disqualified me for human medicine but made me a perfect candidate for vet school.

Perplexing as her logic was, it provided the motivation to hang closely with the veterinarians who came to treat our animals, particularly Charlie Vail, DVM. who not only taught me how to administer sub-cutaneous injections (a skill that translates directly to human medicine) but to understand the mind of the horse as patient. A positive treatment outcome can depend as much on the doctor-patient relationship as the nature of the treatment.

You might think it's harder to establish a connection with an animal than a person because animals can't express themselves verbally. In point of fact, not all humans can either. For example, some who are in pain will only tell you, "It hurts." If you ask where their pain is located, how severe is it on a scale of 1-10 (not a very accurate measure, by the way), when did it start, what makes it better or worse, and does it refer to other parts of the body, they respond, "I'm telling you it hurts. What more do you want?" They can no more refine their complaint than a horse could put it into words in the first place. Excepting Mr. Ed, of course.

In psychiatry, you'll hear, "I'm depressed." When you inquire how your patient knows they're depressed, they'll say, "I just am, I know it, that's all." Explain how depression shows up with sleep disturbance, changes in appetite, concentration, memory, or the loss of interest in pleasure, and they'll look at you as though you had three heads. What's perfectly obvious to them ought to be to you. Verbalizing the nuances of feeling is not always within the realm of their possibilities and some of them think it's unnecessary. I'm depressed is equivalent to I'm sick, now fix me. Times like this, you envy the horse doctor.

Speaking of whom, I ought to write Charlie and tell him how his eager student is finally becoming a doctor. He probably won't remember -- it's been years -- though I'm sure he'll remember my father. Everyone from that era remembers dad. Maybe that's why I'm thinking about Charlie this morning, because tomorrow is Father's Day. Because my father was willing to spend the family vacation to make certain I had a horse. Because it was a veterinarian who gave me some of my first lessons in what it means to be a doctor.

(Creative Commons image by Peter Gene via Flikr)

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Saturday, June 11, 2011

Looking Forward to Monday

I've thought about writing all week and while it's been a good week, my best in recent memory, it's also been a long one and I'm glad today is Saturday. Admittedly, my weariness can be traced, in part, to the distance I'm driving, nearly fifty miles from farm to hospital parking lot. In itself, that's really not a big deal. The landscape is pretty, the traffic minimal, and there are zero speed traps, but it's another couple of hours tacked onto an already busy schedule. There's student housing on site -- taking advantage of it, however, means not coming home in the evenings to find the dogs and cat waiting at the door. I'll take the drive.

The days themselves are fast and furious. My attending is known for the rate at which his long legs propel him down the hallways; I find that refreshing since mine do similarly.
We go from patient to unit, upstairs, down and back, crisscrossing St. Mary's as though Guinness is timing our attempt to set a land speed record. With luck, I'll arrive at mid-July having shed those five stubborn pounds I've been working on the past few months.

The very best part of this rotation is waking up every morning, even if it's been a short night, with the anticipation of being scarcely able to wait until I get to the hospital. Walking onto the psych unit on Monday was everything I'd hoped it would be. The staff was cheerful and friendly and the routine as comfortable as a well-worn and obviously well-loved pair of Sketcher Shape-Ups (the best all-round footwear for the hospital, in my humble opinion). By the time my cohort, another medical student whom I've known from school, and I finished our tour of the premises, I was so charged if they'd plugged me into a light socket I could have powered the unit for a week.

One thing I've discovered in previous rotations, was how much I actually enjoy physical medicine. I think I may have mentioned how concerned I was when beginning medical school, that things might not turn out that way. Based on experience I knew I loved psychiatry but had nothing comparable when it came to listening to hearts, lungs, or palpating prostate glands. In particular, my rotation in pediatrics had me wondering if I hadn't misread my calling. My first morning in psychiatry, the clouds parted, the sun was shining through, and I swear I heard a heavenly choir under the direction of John Denver singing, "Hey, it's good to be back home again..."

It wasn't just the familiarity, though, it was the atmosphere, the sense that this was the here where I'd always belonged. A dear friend of mine struggling with choosing between psychiatry and internal medicine for residency, got it right when she said, she wasn't ready to hang up her stethoscope, like Gary Cooper hanging up his guns and riding off into the sunset with Grace Kelly in High Noon (1952). Physical medicine is where her heart lies and once a person finds that place, it's time to stake their claim. For me, nowhere else have I been even as remotely happy as I've been the past week. I am so looking forward to Monday.

Yesterday, while chatting with an internist on the chemical dependency unit, I used the phrase, "our patients," referring to the ones my preceptor and I have been working with. On strictly medical rotations, I've always tended to think of patients as under the care of my attending while I tag along, wearing shoes too big for me to fill. Yesterday, rounding on my own, I knew I had something of my own to offer, something I'd made my own by hours and days, weeks and months of hard work, and my shoes were a perfect fit. That, I can tell you, is an incredibly good feeling, indeed.

(Creative Commons image "Line Study at St. Mary's (Lewiston ME)" by Jody Roberts via Flikr)

Sunday, June 5, 2011

Leave the Light on for Me, Mom

I feel like I've been far away and coming home, I'm not sure what to expect. I know what home is like, having lived there, and I know what the people are like, having grown up with them, but I'm still a little nervous. It's been a while. Living and learning among those who speak a different language and have different world views, well, it changes a person. There is an African saying I've quoted before, He who never travels, thinks mother is the only cook. What I'm wondering is, how's mom's roast beef and apple pie going to taste now?

Probably as good as it always did, maybe better. Having gotten accustomed to the equivalent of curry, jalapeno, oregano, and a pinch of sea salt, picking up on the nuances of her spice list will resemble listening to a symphony in stereo instead of the old monaural clock radio by the bed. A unitary sound exchanged for multiplicity, becoming complexity, yielding to sublime simplicity. That's the beauty of mom's cooking. I don't know if she ever read the manual or not and it's debatable how much of her efforts are science or art, but what comes out of the mix, sometimes, is pure magic.

She's a tough cookie, all right, no pun intended, and a demanding taskmaster. She may start out a little later in the morning and punch out a little earlier at night, but there's sweat pouring off her brow in between. If you're going to keep up with her, you'd better be prepared to have your preconceptions challenged and your previous experience called into question. She'll have your head spinning with recipes you're certain she's made up out of thin air and when you try to take a short-cut through the micro-wave, she'll firmly remind you that anything good takes time.

Working in mom's kitchen isn't for everyone and not everyone likes to be reminded of it. Some think once you've been exposed to her way of doing things, the fat lady's come onstage and you'd best pack your bags. Some genuinely appreciate her contribution and wish they'd paid her closer attention when they had the chance. And some just scratch their heads, wondering what's a nice boy like you doing here when the whole world could be at your feet?

If you haven't yet guessed, all this is metaphor. My mother is years gone and I have no immediate plans to head for Colorado. I'm not even contemplating a quickie flight out to Dallas for a warm visit with close friends and some real Mexican food, pleasant prospect that it is. No, I'm talking about beginning my long-awaited rotation in Psychiatry tomorrow. Six weeks of inpatient, outpatient, adults and children, coming home in a place I've never been before. It's going to be interesting, it's going to be fun,
and because I'm not the same person I used to be, it's going to be new.

Leave the light on for me, Mom.

(Creative Commons image by lux increscis via Flickr)

Thursday, June 2, 2011

Like Cheech and Chong

The past few days have been early ones -- on the order of 5.00ish AM -- because the puppy's potty alarm is set to go off the instant dawn's dim drapery settles over the tips of the tops of the trees in the hayfield. If he's got a snooze button, I haven't found it. "'s...early," I'll groan, pulling cargo shorts over a left knee that lately, aches like an old war wound, and creep out the front door grateful that few venture down the lane at this hour and any who do, look as bleary-eyed and brain-dead as me.

About my knee, I tore a medial meniscus (the cartilage pad that serves as a cushion between femur and tibia) and medial collateral ligament one evening about seven years ago when training my big dog who was then a puppy. I wish I could say it was a college football injury resulting from a game-winning quarterback scramble John Elway would envy, but alas, it wasn't. The ligament is fine but it just occurred to me, this ache feels like that ache, the meniscus. I know, restrict motion, apply ice prn, take ibuprofen, and call my doctor if it worsens. Sigh.

Anyway, what I was going to tell you, before my knee so rudely interrupted, was a discovery I made while sipping coffee this morning and watching a bit of Sneakers (1992), one of my favorite films, starring Robert Redford. The dogs were engrossed in a post-breakfast game of Dino Dogs, imitating the T-Rex and Velocoraptor in the closing scenes of Jurassic Park (1993). Dino Dogs, by the way, is distinguished solely from its oriental martial arts cousin, FangWa, by the absence of sneezing. Both entail vigorous play, but FangWa intersperses play with episodes of vigorous sneezing. Don't ask me why, I didn't make up the rules.

In the midst of all this sensory overload, I noticed Redford was wearing a light blue chambray or denim shirt and khaki slacks. That's when the lights came on, my jaw dropped open, and the caffeine kicked in. Aside from the fact that I'm six inches taller, from the neck down, Redford and I have virtually the same body. Cut off our heads (metaphorically speaking, please), dress us in slacks and a loose fitting shirt and by golly, we're like Cheech and Chong. Well, not them exactly, but you get the idea.

It would be my luck, of course, to have the resemblance halt at the neck. I mean, how many women do you know who are going to smile and bat their eyelashes, their pupils having suddenly and uncontrollably dilated larger than silver dollars, if I were to attempt this as an opening line at a cocktail party: "Ahem, Robert Redford and I have similar body types." That's what I thought, not very many. I may as well scribble the word "boring" across my forehead right now in indelible black Sharpie. Nope, about the best I can do is write about it and let sleeping dogs lie -- which, by the way, they're both doing, at last.


(Creative Commons image by jb2.0 via Flickr)

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