Paranoia

"Paranoia strikes deep.
into your life it will creep..."
~ Stephen Stills

Of all we could say about paranoia, one thing is pretty clear: it's a symptom of something gone wrong. When we're coping well with life, we aren't generally suspicious or mistrusting without reasonable cause. Even under stress, when we are compensating, as we say in "shrink lingo," we're able to distinguish between real and imagined threats. True, we may not be able to cover every single solitary possibility imaginable -- no one's perfect -- but we do our best. And most days, in most situations, that's good enough.

In extraordinary situations, however, things can change rapidly. With good coping skills and a healthy ego, we're okay, maybe even better than okay. With poor skills or a weak ego, it's not so good. It may even get scary once in a while. Especially to those of us who are on the outside looking in. 

I'm referring specifically to the rash of paranoid ideations that have found their way into video and print in response to the terrorist attack in Paris. Don't let those Syrian refugees into America, they say, you can't tell the good guys from the bad guys. Well, maybe not, but haven't bad guys been able to enter the United States for a long time? What self-respecting, evil, scheming bad guy is so stupid that he'd masquerade as a refugee and expose himself to serious scrutiny, when he could simply walk through customs with a legal passport on any other day?

That's the problem with paranoia, especially the socially-acceptable kind. It checks its brains at the door and starts shouting about the sky falling when the issue is actually much closer to the ground. It becomes irrational even when couching its rhetoric in rational terms. It is true, America has endured terrorist attack before and it only makes sense to be prepared. Once burned, twice cautious. To become obsessed with the possibility to the point we abandon our leadership role on the world stage isn't caution. It's more like crazy.

These are times for brave, sensible people. People like the Parisian father who explained to his young son that memorial flowers and candles were there to protect them from bad people with guns. He's too young to grasp the concept that flowers and candles represent the collective will of good, solid, brave people who refuse to give in to terror. Someday he will, though. When he does I hope he also understands that paranoia is a warning, not a watchman to be heeded.


Creative Commons image by Katlew via Flickr.com.

The White Coat Brigade

Although I wasn't running late, it still felt that way. It was my second day of residency and a meeting with the psychiatry training director had me intent on arriving early. At my hospital, residents have access to a parking garage, unlike lowly medical students. Having been one of them for so long, the garage looks to me like the Taj Mahal. Anyway, after driving round a couple of minutes and coming up empty-handed, I spied an empty space marked, "Physician Parking Only." Wouldn't you know it? I thought, may as well have Dirty Harry guarding it. I started to drive past when the lights came on. 

"Wait a minute, that means me."

If there was a single thing typifying the impact of residency thus far, this incident depicts it. Over and over something happens -- entering the resident's lounge for the first time, hearing my name called with the title "doctor" appended to it, having other residents smile in greeting -- something happens to remind me I'm not in Kansas anymore. Medical school really is finished, I really did graduate, and I really am here, at long last.

It's kind of funny, when you think of it, the way reality creeps up and sinks in. I don't know if it affects other people like this, but I can't help thinking about how everything feels. Maybe that's why I'm in psychiatry: just being here isn't enough; I have to take it in and digest it. And unlike some third year rotations I was glad to bid farewell to, I want these first six months of inpatient psychiatry to poke along at pace that would make a snail impatient.

It's weird, though.  I feel like a buck private who's been given a battlefield commission. Only a few years ago I was an enlisted man, now I'm at the opposite end of the food chain -- or chain of command, as the case may be. Sort of. As a first year resident, I'm little more than a medical student with a title. But the people I work with didn't know me back then or in my life before that, on the front lines of mental health care. They only know me as I am now, a member of the White Coat Brigade. It's up to me to let my behavior spell out what I learned while serving on their side of the coin. 

Nothing is automatic, but it's all as pleasurable as it is satisfying. Especially sitting down with patients for therapy knowing it's partly what I'm getting paid for. I'm here to learn everything I can, but I'm also here to work and at this point, psychotherapy is something I can do quite legitimately. It's one of the tools I've had rattling around in my backpack the past few years, waiting for its time to come.

(Creative Commons image by Kids_Safari2 via Flickr)

The Secret Life of Walter Mitty

 
Beauty doesn't ask for attention. ~ Sean O'Connell

My friend and co-author, Dr. Lynn Smith and I used to talk at length about what we called the "Walter Mitty personality type." Risk-aversive, detail-oriented, traditional (though not necessarily conservative), and inclined to play by the rules. Good, solid people like Bilbo Baggins, who aren't likely to rush out their front door in pursuit of adventure. Their secret is, they'd like to. They dream about it, but they can't let go. Until they have to.

This is the story line for the marvelous film, The Secret Life of Walter Mitty (2014), starring Ben Stiller. By day, Mitty is a quiet, unobtrusive supervisor in the photographic negative department of Life magazine. At any other time, his imagination may have him miraculously rescuing damsels in distress or besting arrogant, narcissistic asses like the one in charge of transitioning Life from a print to online format. In daydreams, he's everything he's not from 9 to 5: creative, brave, articulate, and appealing. In life, he can't even bring himself to speak to the woman who's stolen his heart.

Whatever author James Thurber originally intended, this particular film version depicts a journey of the soul. Mitty is an ordinary guy who's become a worker bee. He contributes, he's efficient, he does his job very well. His life has purpose but no passion. He'd like it to and his daydreams are filled with it, but he's ambivalent. Even his e-Harmony profile is incomplete. He's at a crossroads and needs a guide, a mentor, someone who can show him how to make his own choices and live his own life.

Enter Sean O'Connell, played by Sean Penn. O'Connell is a photographer of the old school. He still uses film and submits his photos for publication by snail mail. He doesn't own a cell phone and would probably misplace it if he did. He's unpredictable and follows his own rules. As it happens, he sends Mitty a roll of film with instructions indicating the last negative on the roll is his preferred photo for the final cover of Life. 

The problem is, Mitty can't find it. It wasn't enclosed in the packet containing the rest of the negatives. Nearly at wit's end, he notices a photograph of O'Connell and imagines him beckoning for him to follow. Without warning, Mitty dashes out the building and boards a plane for Greenland, O'Connell's last known location. No baggage except a briefcase, no clothes except for what he's wearing on his back. 

Unable to hook up in Greenland, he follows O'Connell to Iceland, and on to ungoverned Afghanistan in the high Himalayas, where he stumbles upon him, photographing the elusive snow leopard. O'Connell explains the negative was in a wallet he sent Mitty as a gift. Ironically, the negative was in Mitty's possession all the time, but he was so focused on where it ought to be he couldn't consider where it might be.

O'Connell thought he was being "playful," assuming his partner would get the joke. Mitty saw it differently. Sixteen years and millions of negatives made him good at his job but lousy at spontaneity. In the course of things, he'd forgotten how to play. He's not alone; a lot of us are like that. The pressures of life and work build until we take everything so seriously. We turn to alcohol or drugs to unwind, but they don't help, not really. They disinhibit, that's all. Play is something more basic, more in touch with what makes life worth living.

Observing O'Connell refuse to take a shot of a snow leopard because the moment itself is too precious, Mitty realizes some things are too special to be captured. They can only be experienced. Moments later, playing soccer with a group of young Sherpas, he learns that play and transcendence are linked, and both can find expression in the work we do. Mitty knew all about work. What he needed to learn was how to play once again.

On returning to New York, Mitty confronts the arrogant narcissist in a way that, unlike his earlier fantasies, doesn't involve physical violence. Having rediscovered himself in O'Connell's company, he is able to speak as a mature man with a secure and certain center, to a spoiled and self-centered child. No longer fearful and timid, being with the archetypal "wild man" has changed him. He commands respect and his words carry weight. 

Does Mitty ever get the girl? You have to see the film to find out. Sorry, I'm only willing to leak so much. Besides, you do want to see why that bloody negative was so important, right? Most of all, The Secret Life of Walter Mitty is worth seeing for a contemporary glimpse at the ultimately spiritual journey to earn and achieve maturity, to become confident, to feel truly capable as a human being. It's a study in contrasts, too, between Mitty, who is willing to undertake the journey, and an arrogant narcissist who for all his posturing, has not and probably never will. 

(Creative Commons image by Sheng Wang via Flickr)

Narcissist or Antisocial?

 
Following-up on my last post, "Mirror, Mirror," a reader wrote and asked if I might address Antisocial Personality Disorder in contrast to pathological narcissism. There was a time when I thought doing so was pretty straightforward since antisocial personality disorder was usually associated with a criminal history. I've since realized that's too simple because narcissists who become violent can end up with criminal records and antisocial types can be attractive and charismatic in the same way we usually think of narcissists. 

The picture becomes even more complicated when you think about other features they may have in common. For instance, both are well-known for being manipulative, self-centered, and resistant to feelings of guilt and remorse or responsibility for the damage they cause. "Lack of empathy" is how we describe this professionally, but in simpler terms, it means they can't imagine how it feels to be on the receiving end of their behavior. If a person's ability to empathize is impaired, they tend to act without considering the impact of their actions on others. The way this is expressed gives us an idea about how the narcissist and antisocial type differ.

Despite their belief that they are independent and need no one, narcissists really are very dependent upon others. The arrogant type needs admirers and the covert type, someone to use as a resource for self-esteem. As a consequence, in the initial stages of forming relationships, these individuals are seductive, conveying the image of the perfect friend,  colleague, or significant other. What they want is something else. Like the vampire's victim who willingly exposes her neck again and again, they want your trust, availability, and eager compliance. Only when you've been finally worn out, do they toss you aside like a wrinkled, faded newspaper.

Antisocial types can be seductive, too, but their goal is to obtain something specific and move on. Once they have it -- your money, property, virginity -- the relationship is over. You could say the narcissist invests for the long-term and the antisocial for short-term, immediate gains. A classic example is the retirement scheme that drains seniors of their financial resources, operated by the "pleasant young man who was so eager to help" and has skipped town with the money. Antisocial types consider people too much trouble to spend a great deal of time on them -- it's what you have that they find interesting. Narcissists want you and that's why they are so appealing.

Notice how both types can use people freely without the inconvenient interference of Freud's Super-Ego or conscience. Covert narcissists may be vaguely aware that others consider their behavior wrong or hurtful, but ultimately, how others feel doesn't matter to them. Arrogant narcissists and antisocial types simply don't take morality or conscience into account; they are ruled by pure self-interest. 

All three types are inclined to excuse their behavior on various grounds and criticize their victims for any negative consequences. Instead of internalizing blame and feeling guilty or ashamed, like most of us, they externalize these feelings and try to make it sound as though you're the one with the problem.  Techniques like "gaslighting," making up information in order to prompt a victim to doubt their perceptions or sanity, are commonly used to cover their true intentions. The antisocial type doesn't care whether their behavior violates the law; the idea may even be exciting to them. Arrogant narcissists can't imagine being held responsible for their actions since their natural superiority places them above culpability. Covert narcissists are convinced no one would even consider thinking of them as blameworthy in the first place. 

The reason covert narcissists feel immune to blame is due to their adeptness at creating a facade of innocence and using it to conceal their ulterior motives. Many find it hard to believe such a sweet, caring and ethical person could be deliberately deceptive. And, of course, this is precisely what the covert type is counting on. Their carefully-crafted, false persona enables them to operate surreptitiously, sometimes going undetected for years. Publicly, they don't wish to appear bothersome; privately, they are extremely high maintenance, intentionally draining others of their energy and well-being. 

In a sense, antisocial and narcissist exist on a continuum with the antisocial type lying more towards the asocial extreme and arrogant narcissists on the extroverted, social end. More introverted, yet also socially-oriented, the covert narcissist lies somewhere toward the middle. All of them exhibit an absence of regard for the thoughts, feelings, and values of others. All of them find it easy to lie and all of them are predatory to some degree. 

Predatory is a strong word but it gets to the heart of the matter. The individuals we've been describing are serial users. Whether they appear innocently grandiose or intentionally deceptive, they view others as resources, as means to an end. Adulation is just as important to an arrogant narcissist as ill-gotten gain to a criminal antisocial type. A covert narcissist plans his emotional ambush as carefully as a master thief. To them, the rest of us are sheep waiting to be sheared or resources waiting to be tapped. That we might be anything else never crosses their minds.   

(Creative Commons Image of Narcissus by Tiago Costa Nepomuceno via Flickr)

Mirror, Mirror, On the Wall

 
Bond:  "You're cleverer than you look."
Q:  "Mm, still, better than looking cleverer than you are." ~ Die Another Day (2002)

As most readers already know, I'm a fan of 007. For several years, Timothy Dalton was my favorite -- he possessed a certain darkness that rendered the "killer" aspect of Bond's character believable. Well, move over, Timothy, Daniel Craig does it even better and with a conscience thrown in for good measure (Skyfall, 2013). I like that best of all: Bond is capable of empathy, he is not a narcissist.

He is brutally honest; he's willing to do pretty much whatever he has to in order to get the job done, but looking clever means nothing to him if it's not real. Were he a narcissist, on the other hand, looking clever would be everything. Furthermore, he would think himself exceedingly clever, even though he was not. It's difficult for me to imagine Bond gazing dreamily at himself in a mirror and saying, "Mirror, mirror, on the wall, who's the cleverest of them all?" He hasn't got time for such nonsense; a narcissist has nothing but time for it.

That's one of the many problems with narcissists: they believe their own press. They think they're far more intelligent than the rest of us, true or not. They're wise, we're foolish, they're cosmopolitan or sophisticated, we're naive or impressionable. If a narcissist appears to admire someone, it's because they covet what the other possesses. Admiration is a cover for competition and narcissists are poor losers. 

Ironically, the narcissist's intelligence tends to be less lofty than they'd have us believe. Engage them in a discussion and you'll discover their knowledge base frequently represents a collection of disconnected assumptions and quotes selected from sources they consider influential. Original thinking is not their strong suit. They're like Mockingbirds, whose song is a chaotic repetition of all the other birds in the sky. What matters is not what they think but how impressive they sound, citing statistics and references, and leaving you breathless in their presence. At least this is the case for the arrogant-type narcissist.

Covert narcissists are less willing to risk their fragile self-esteem by trying to impress you with how much they know. Instead, they prefer to listen, treating you like an amazing conversationalist who has them hanging on every word. In the process of winning your trust, they're actually searching for those points at which you are most vulnerable. The time will come when they'll use those points to your detriment, revealing themselves to have been a cunning adversary clad in the guise of a friend. 

It probably sounds terribly unfair, if not unkind, to draw attention to the predatorial aspect of pathological narcissism, but it's necessary in the same way we have to recognize the killer aspect of the James Bond character. The difference lies in the fact that Bond doesn't kill indiscriminately. He's not a cold-blooded murderer despite the numerous notches he might carve into the handle of his Walther PPK. He only shoots (or stabs or drowns or blows up) those who have it coming. There's either justice or necessity in his sights.

Narcissists are rather indiscriminate. Anyone is a good enough target if they're vulnerable and nearly all of us are, to some extent or another. Narcissists wish to demonstrate their self-assumed superiority and doing so is their ultimate value. We are either their privileged audience or an unwitting resource for supporting their self-esteem. We are never individuals worthy of respect and dignity. We are things and for a narcissist, one thing is as good as another, as long as our life blood lasts and we don't realize what's happening to us.

Prevention is the best defense and discovery our key strategy. Learning to recognize the wolf in sheep's clothing is hardly a waste of time. You can't avoid a predator if you don't know what one looks like or how s/he behaves. My four-footed neighbor, Freddy the Porcupine, has only one natural enemy, but you can be certain he knows who that is and how to steer clear of his habitats. In the same way, learning how to identify pathological narcissism and its practitioners is the way we sidestep being reduced to the level of "things" and retain our humanity. Trust me, this is definitely worth the effort.     

(Creative Commons image of Bond and Q by Andrew Becraft via Flickr)
  

Like Walking on Water

 
Walking on water is easy; it's when the waves turn into giants that things get sticky. ~ Beggar

I don't usually quote myself but since there was no one else to blame for my opening line, I figured I'd best come clean. Walking on water, metaphorically speaking, isn't hard, as long as the water's quiet and glassy smooth like the surface of a Colorado mountain lake on a summer evening. The storms that come from out of nowhere in late afternoon, however, before the evening calm, those are what separate the men from the boys.

That image has been running through my mind almost daily, the past few weeks. Walking on water, trying to "keep the faith" when all around the waves are lapping and a glance at my feet tells me I'm going under. Walking on water is precisely what seeking a residency position has felt like, walking on water without a life-jacket.

On March 9, 2010, I wrote a blog post entitled, "Medical School Through the Back Door," describing my experiences as a psychotherapy intern in the company of a group of  psychiatric residents. Back then, I was a street urchin off the pages of A Christmas Carol or Oliver Twist, my face pressed against a restaurant window, gazing hungrily while patrons dined sumptuously. The memory of that internship kept me going through medical school. I knew residency was out there, or at least I believed it was, it was just a matter of reaching it. That was in 2010.

2011 was different, or it looked to be, when I began clinical rotations. The basic sciences were behind me and board exams and I had battled it out, sword on shield, sometimes tooth and nail. Starting rotations in mid-cycle meant I wouldn't have a predictable schedule, resulting in graduation being pushed back a year. 2012 brought an unexpected gap between rotations and once again, I watched graduation skip away with the alacrity of a child playing hopscotch.

In 2013 I received my degree at long last and applied for residency. The Match came and went, leaving me without  "a date for the prom." I'm not sure there's much worse news for a fourth year medical student or recent graduate than, "We're sorry, you did not match with a program." As with any loss, your first reaction is shock and disbelief, followed by anger and frustration, and then despair sets in and you start wondering how you'll ever pay student loans. Hopefully, acceptance comes along soon, enabling you to regroup and get busy chasing available positions and contemplating Plan B or C.

The truth is, I was up and down. One day I felt optimistic, based on nothing more substantial than a phone call with a polite departmental secretary, and the next felt certain I was totally screwed. All the years I'd spent loving and learning psychiatry were circling the drain and there wasn't a single thing I could do to stop them. My Plan B involved a family medicine residency for a year and then reapplying for psychiatry. It had been done before, successfully, by others, why not me? If that failed, I'd go to Plan C: finish family medicine and see psychiatric patients. It was a good strategy, it was workable, but it really did feel lousy. It was like giving up and that's what hurt most of all.

Still, I had to face reality, painful or not, and so I began contacting family medicine programs about openings. Then a call came from the Midwest. I tried to sound casual and friendly, but I could scarcely contain myself as the voice on the other end said, "I'd like to offer you a position in our psychiatric residency program." Talk about the cavalry riding to the rescue. I even think I heard bugles blowing. Until that point, my "best day" was a Saturday morning in January, 2005, when I learned I'd been accepted to medical school. Now it had a contender.

I'm not sure what it's like to "walk on water" that's calm and placid. I'd like to find out. The past few years, though, it seems there's always been a storm brewing, either because of my own frailty or stupidity or because that's what storms do. I'm not complaining; it's better to have to negotiate a storm than sit on the bank, watching others make their way to the other side. That I've managed to come this far is a testimony to good people who stepped onto the water alongside me when the sky was at its darkest. Thanks in no small measure to them, when someone finally opened the door to a psychiatric residency, I was standing on dry land, free to walk through.


(Creative Commons image of Trout Lake, near Telluride, Colorado by Mountain Belle via Flickr)

Michael Palmer. Any Age is Far Too Young

 
For years I'd entertained the fantasy of crossing the Colorado state line from wherever I happened to be, with the windows rolled all the way down and Rocky Mountain High blasting on the stereo. It was going to be my fanfare, like the opening bars of the Star Wars theme or Superman, announcing to the world I was home at last. 

On a warm Indian Summer day in October, 1997, I did that very thing, driving my Ford pickup truck across the invisible boundary between Wyoming and Colorado, leaving the East Coast behind, little knowing in a few years I'd find myself on the same highway, retracing the miles back. Also little knowing that in forty eight hours, I'd be awakened by a story on NPR's Morning Edition with news I never wanted to hear. John Denver had been killed in a plane crash. I felt like I'd crashed with him. 

It was the same autumn I met author Michael Palmer in print. Michael and I never met in the same way John and I had, but we corresponded briefly, discovering how our experiences dovetailed by email. He'd been involved in the Massachusetts Physician's Health Program, working with physicians, like himself, whose lives had been affected by psychiatric illness and/or substance abuse. As a psychotherapist, prior to medical school, I also worked with doctors enrolled in the Colorado Physician's Health Program. Michael was in recovery, as he revealed years earlier, and I was attempting to recover a life I'd never known. Michael was a writer, I was trying to become one, and he offered me generous encouragement.

I found his books while prowling the Boulder Public Library, looking to feed a growing interest in medical fiction. At the time, I wasn't convinced it was even remotely possible to include medical school in my future, though I wanted to, quite badly. Reading about medicine was becoming a kind of therapy, much as writing had been for Michael, and his books helped overcome my fear that, not only had I missed the bus marked "medical school," it was gone for good. I had yet to learn there is no optimal time for going after what matters most to us, there's only now and what we do with it.

Michael was my companion during the months preceding premed coursework, when I hung onto to the ridiculous fantasy that a doctorate in clinical psychology would be enough. He helped me face the inevitable truth that nothing would ever substitute for my becoming a psychiatrist and I'd best get on with it. I learned from him how recovering a life is just as grueling and just as rewarding as what he'd gone through himself.

I'm glad I shared some of these things with him, especially now. We never know how tenuous life is, not really. We go through the daily grind with the unconscious assumption time is on our side. We do this a lot when we're younger or at least I did. We think only older people die, whatever "older" means, and if it happens to a peer, unless we know them personally, we conveniently overlook the obvious fact it could easily have been us, had the cosmic tumblers turned up our numbers instead of theirs.

The reason I'm glad I shared those things with Michael is this afternoon I learned he passed away, quite suddenly, a few months ago. He'd been in Africa, on safari, and had barely gotten back to the States when he experienced a heart attack. I can't help but think how appropriate it was for him to have been on safari; for reasons I don't quite fathom, I've always associated him with Hemingway. Michael was 71 and far too young. I feel certain he would agree, any age is far too young.

(Obituaries for Michael Palmer, MD, may be found here: New York Times and Boston Globe. Michael's final novel, Resistant, can be accessed via michaelpalmerbooks.com)

(Creative Commons image by cdrummbks via Flickr)

Nowhere Else But Here

 
In recent months, I've been preparing for residency interviews, thinking about questions I'd likely be asked and those I should ask of programs. One question sure to come up is, Why do you want to be a psychiatrist rather than some other kind of doctor? I've thought a lot about this, especially in light of third and fourth year rotations, the medical school version of a Baskin-Robbins ice cream shop (or any other, since I've discovered we don't have B-R in Maine) where you get to sample the flavors before deciding to buy.

Prior to rotations, my heart was set on psychiatry. I'd worked and trained in the field, coauthored a book related to a psychiatric sub-field, and truly loved every minute of it. My background set the stage to do well in residency; why do anything else? 

The trouble was, it was like being raised on chocolate ice cream (not a bad thing, by the way) and considering it my favorite. Never having tried any other flavor, how could I be so sure? Maybe it was just familiarity. Medical students often find their plans for residency change after third and fourth year rotations for that very reason. 

In order to deal with the matter fairly, I decided to approach rotations with the intent of evaluating them on their individual merits. If I still loved psychiatry best, by keeping an open mind I'd learn more and be better able to make an informed choice, come Match time. 

The outcome was surprising. I liked surgery, as do many psychiatrists, and I encountered nearly as many surgeons who'd seriously considered entering psychiatry. Why this was true and whether there's a connection between surgery and psychiatry, is unclear. Maybe that would be a good topic for a psychiatric residency research project? 

So, that was surgery. Being involved in delivering babies was wonderful and pediatrics was every bit as enjoyable as I expected it to be. Rural family practice was a warm, nurturing experience and emergency medicine was hard work and a ton of fun. A fourth year sub-internship in internal medicine showed me how much I had yet to learn and at the same time, gave me a boost of confidence about beginning residency. They were all great in their own ways, but eventually you have to make a decision. You can only sample so many flavors before the person behind the counter gets impatient.

What do you want to spend the rest of your life doing? I asked myself. This is not a casual question. No one knows how long "the rest of your life" is going to last. Could and hopefully will be a long, long, long, long time, but none of us is born with a warranty. For me, the various considerations boiled down to a second, more important question, Where have you been the happiest?

Coming up with an answer wasn't as easy as you might think. Never having had children, obstetrics and pediatrics teetered close to the front burner. But obstetrics entailed short-term relationships with patients and my interest in pediatrics was mainly directed toward child/adolescent psychiatry. Reflecting on my experiences, there was only one rotation where it was impossible to contain my enthusiasm about getting to the hospital every morning. It was the same one that made it ridiculously easy to ignore the clock at the end of my shift and the only one I had no reservations building a life around. Turns out, "chocolate" really was my favorite flavor, after all.

A few years ago, after a long day at the hospital in Denver, I took the dogs out and looked up at the stars. It was a chilly fall evening and after finishing their business, I'm sure they were both wondering why we didn't rush back inside to get warm. It had been a good day and at the moment I was caught up in the sudden awareness I was better at psychiatry than I'd ever been at anything else. What I mean is, I worked harder, felt like a better person, was more fulfilled, and more effective. More than anything, I was happy, truly and deeply happy, from the top of my head all the way down to the holes in the heals of my socks. That feeling has never gone away, it's just gotten stronger.

There are a lot of reasons to love something and I don't fault anyone for not loving psychiatry, though I freely admit when someone says they don't like chocolate ice cream, that does give me pause. Continuing to love it, after third and fourth year rotations, probably makes me a hopeless case, which is okay because I'm a happy one. And for me, happy like this is found nowhere else but here.  

 (Creative Commons image "Happy" by Rickydavid via Flickr)

More Than Just a Piece of Paper

 
That's what we say, sometimes, when we're tired, when burning the candle at both ends seems to have done little to bring the end of a long academic journey into view. "___ more months, ___ more rotations," we say, "I'm going to get my piece of paper and I -- am -- gone."

I've said it. After slamming into another obstacle that meant I'd graduate another year later than my entering classmates, I've said it. On good days, I tried to act a reasonable approximation of my age and call such things "character-building." On bad days, they were miserable. The truth is, the good ones really did outnumber the bad by several factors of ten, no whitewash -- except on bad days and then they seemed to multiply as fast as zits on a teenager's face.

Medical education is a group effort and a personal one. We begin in community, like runners in the Boston Marathon, and we string out along the way. I lived off Beacon Street in Boston for a while and stood within inches of the Marathon as it passed by. First came elite runners, like the Kenyans I got to know in Boulder while walking my dogs, some in training for Boston. Long after they were out of sight, came local runners, wheelchair athletes, and those for whom a personal best was the point.

Every year there are runners who, for reasons of their own, cross the line at Boylston Street, where the bombing occurred, way late, maybe after midnight. A father, pushing his wheelchair-bound son, someone else who was injured and refused to quit. It could be anyone. There have been times in this process, when I felt like that, hell-bent on crossing the line whether anyone was there or not, and not really expecting anyone to be, certainly not at that late hour. The virtual presence of more than a hundred cheering friends on Facebook showed me how wrong a guy can be and how amazingly good it feels to discover them waiting for you.

But that's how things can go. All the potential in the world can't ensure the medical education master plan is carried out without a hitch. Something happens, then another, and before you know it, you've had to stop and regroup. Most students make it by the clock (four years), some say they made it by the grace of God and maybe they did. Maybe that's how all of us make it, even when it seems like sheer, dumb luck.

Anyway, yes, I called it a "piece of paper," especially when circumstances and/or my own frailty conspired to raise the bar -- and right when I was starting to get good at reaching it! One of my favorite Robert Browning lines goes, "A man's (person's) reach should exceed his (their) grasp." Well, gee, thanks, Bob, bet you never went to medical school, huh?!

Eons ago, when I was a kid watching classic movies about doctors and psychiatrists on our black and white TV, medical school was something other people did. To me it was as far away as growing up. Eventually, however, I did grow up or at least got taller, and found my way to medical school. When my diploma finally came in yesterday's mail, I can tell you, it was much more than just a piece of paper.

A friend, on his graduation day in 2010, waved his diploma in its protective cardboard mailer and shouted to me, "Don't forget, Beggar, there's one of these with your name on it!" I thought about him as I walked back to the house, carrying mine the same way he had. I thought about him again, opening the package and seeing my name. He was right; there was no mistake.

How does it feel, having finally crossed the elusive finishing line with my diploma in hand to prove it?  It feels empowering. Better than all those other times the bar was raised and I cursed and swore and stretched and strained and reached with all my heart and realized I could reach higher and farther still. It feels right. Residency is fast approaching (Please, God, let it be psychiatry) and it feels like I'm in the starting grid at Indy, waiting for that cute little country singer to finish the National Anthem so I can hear the words I've waited a lifetime to hear: "Ladies and Gentlemen, Start Your Engines!"

Varoooooooooooom! 

(Photo copyright 2013 by the author)

The Psychology of Tailgating: Part Two

 
Some time back I wrote a post about tailgating that included the lyrics to a song I'd written while still in Colorado. It came about one afternoon while trying to deal humorously with a BMW whose driver apparently decided my late father's beautiful '88 Cadillac was so fascinating he had to get as close as he could. My car was naturally flattered, but at 65 miles an hour, the attention wasn't exactly welcome.

Later on, I wondered about him, what motivated his behavior, was he thinking at all or was his mind far away on a beach? Why are some drivers unwilling to keep a reasonable distance? If they want to go faster, why not take the option to pass, especially if the dashed white line clearly says, "Go for it"? I think the same questions may be on the minds of those who've graciously read the first post and I'd like to offer a follow-up that errs less on the side of levity.

There are a lot of factors involved, I'm sure. A driver's attention is drawn away by a cell call as their foot depresses the accelerator proportionate to the intensity of the conversation. This is why you don't want to talk to your ex while the car is moving; tempers flare. Some drivers have psychiatric disorders that make it difficult to manage emotions, particularly under stress and driving can be stressful. Anyone who's ever been late for work knows there are times it's just hard to keep your emotions in check. Before you know it, you've forgotten other people have concerns besides yours and you're doing to them what you hate to have done to you. We're all human, every one of us.

But there's another issue I've observed, or think I've observed, since it reflects an attitude or personality trait and therefore can only be inferred. Some drivers behave as though their vehicle is a symbol of superiority and owning the road is their right and privilege. The presence of another car ahead of them sets off an intriguing cognitive process. If the car appears of comparable value to theirs, they are less likely to tailgate. Instead, they'll keep a respectful distance before accelerating around it. They'll glance at the other driver for recognition, nod and drive on. Strangers and clearly social equals passing like ships in the night. A car of lesser value or vintage, however, represents an imposition their self-importance won't tolerate. 

Now, why is that? Well, the presence of a lesser vehicle in front of them can be understood as triggering feelings related to shame. Not in the way we normally think of it, i.e. being embarrassed or ashamed because of something we've said or done. This is shame in the sense of feeling "less than," of being inferior. This experience may seem minor to you and me, but it's anything but minor to those who've oriented their entire lives around the idea they're deserving of preferential treatment. If you've been whispering to yourself the word, "narcissism," by the way, you get an A+.

Obviously, I don't think everyone who tailgates is narcissistic, but the behavior of some drivers leads me to think it's not uncommon. Consider how narcissistic individuals tend to be exquisitely sensitive to anything suggesting they aren't naturally superior to everyone else. We imagine them possessing the biggest house, newest car, and the most attractive of spouses. The reality is more diverse, though narcissism, generally, is characterized by almost a passion for control and a strong sense of entitlement. To the narcissist, our car constitutes a threat to their self-esteem; it's taking up space that rightly belongs to them. Finally racing past is their way of reminding us of the fact.

It takes very little to set off narcissistic rage, sometimes almost nothing at all. The thing to remember is, on the road or in daily life, it really is all about them, in the sense you aren't to blame for their misbehavior. You aren't inferior and they aren't superior. Accelerating dangerously or giving them the middle finger salute, only puts you at risk because your emotions have taken over your better judgment. They probably wouldn't get the point anyway. As easy as it is to become angry, it's far healthier to switch lanes or pull off the road briefly -- literally and metaphorically -- when it's safe to do so. No one's narcissism is worth an accident, or worse, becoming a statistic.   

(Creative Commons image by Eleventh Earl of Mar via Flickr)

The Death of a President

 
In psychiatry, a great deal depends on timing, including the correct diagnosis. For instance, while you may have experienced or witnessed a traumatic event or may have had prolonged exposure to highly stressful, traumatic, or abusive conditions, you can't be diagnosed with PTSD unless your symptoms have persisted longer than six months. Under six months, we call it acute stress disorder. PTSD symptoms can persist a long time.

Looking back, I definitely think 9/11 resulted in the semblance of a nation-wide case of PTSD from which we've done a fairly good job of recovering. We're more alert to danger but less likely to shut down the entire country over an isolated, local threat. We're no longer quite so eager to send in the troops at the sound of gunfire on the far side of the world. Life has begun to approximate "normal," though we're more aware of our vulnerability and the memory of tragedy is still there and always will be. Even the extreme political right seems more intent on defeating the president's health initiative than tackling terrorism. I don't think we've done as well with November 22, 1963.

I've often thought the free love, abundant drugs, and Tune-In, Turn-On, and Drop-Out mentality of the 60s was more an expression of anger -- acting out -- than typical adolescent rebellion. For the first time in our history, almost an entire generation gave the establishment the middle finger. Its hero was dead, LBJ had taken office, the Warren Commission was established, there was a national day of mourning, and now, it was time to move on. But this generation wasn't ready yet, and we would all have to wait for Kubler-Ross (On Death and Dying, 1969) to inform us the funeral was only the beginning.

Watching the 50th anniversary of the Kennedy assassination programming the past few days, I've been struck by how often someone uttered the phrase, "People don't want to think Kennedy could have been struck down by a single individual, acting alone. The magnitude of his personality as president seems to demand much more."  I'm not certain this is accurate. I don't believe his personal magnetism or his role as the nation's leader are nearly as important as the magnitude of his loss. Ongoing conspiracy theories and the tendency of 2/3 of Americans to doubt the findings of the Warren Report symbolize the depth of grief many still feel, as well as an abiding need for it to be recognized. Mistrust of government may have burst into full flower with Watergate, but it is rooted in the mismanagement of national grief over the death of a president.  

This is likely an unfair generalization, but there is still some truth in the statement that Lyndon Johnson's generation was more accustomed to putting tragedy behind them than paying close attention to what it means and mourning its significance. Anyone who's watched the HBO presentations of Band of Brothers (2001) or The Pacific (2010), or talked at length with veterans from the Great Generation knows how exceedingly reticent they are about digging up old wounds. The idea that the country as a whole needed time and leadership in the matter of grieving was unheard of in 1963. In a very real sense, we needed a president who understood and embraced his role as nation's chaplain as well as it's chief executive. Unfortunately, this was not one of JBJ's strengths, in contrast with our current president who has been known to take hours comforting the victims of gun violence.

I was also struck by the numbers of interviewees who commented on how America had changed, subsequent to the assassination. They lamented a loss of optimism, hopefulness, and the belief anything was possible. Whether those feelings are shared by all is debatable. There were and still are, sectors of the population that make no secret of their hatred of Kennedy and the causes he and his brothers championed. Nevertheless, his loss was felt by far more and the feelings associated with it have lasted far longer than anyone might have imagined. 
 
Grief isn't resolved, if it's ever truly resolved, by assigning blame, getting even, and nursing the satisfaction gained from a moment of passion. We learn to deal with our losses, to live with them, making them part of ourselves, by refusing to play down their impact and brush them away like crumbs from the table. Grief has to be honored and mourning respected if we're ever to regain the optimism, hope, and sense of the possible that seems forever out of reach when we feel bereft. If there are lessons worth learning from the past 50 years, this is one to take to heart. 


(Creative Commons image of eternal flame at grave of John F. Kennedy by Tim Evanson via Flickr)

Healthcare Without Politics: The Future is Now

Is it even possible anymore, healthcare without politics? 
I don't know, but I hope so. I'd hate to think the only place it could exist was Disney World. I hope we can reach the point midst all the  maneuvering and jockeying for power and influence where our concern for those who need healthcare exceeds its value as political capital. Sadly, we're not there yet.

Back in the day when, for the average person, Blue Cross/Blue Shield was pretty much the only health insurance game in town, coverage protected in case of catastrophe, i.e. hospitalization. I've described in other posts my own experience of kidney stones necessitating two major surgeries. My family paid out of pocket for outpatient doctor visits and prescriptions, grateful our Blue Cross policy meant the cost of my hospital stay wouldn't hit us with the force of a tsunami carrying the threat of bankruptcy in its wake.

At the time I was recovering from kidney stones and for a few years thereafter, doctors were reimbursed by insurance for services rendered. It was called a fee-for-service system. More services meant greater reimbursement. Eventually, managed care firms came into existence and in the effort to control the costs of operation, they established criteria that must be met, justifying tests and procedures, before  insurance claims would be paid and doctors reimbursed. Soon it became necessary for providers and/or policy holders to obtain authorizations for treatment before managed care considered itself obligated to pay. If you think about it from a business perspective, this makes sense. A company can only pay out so much before it is unable to pay at all.

The road to hell is lined with good intentions, as the saying goes, and while management of healthcare costs was doubtless a factor in the evolution of managed care, we have to remember, healthcare insurance is still a business and the first priority of any business is to make a profit. To accomplish this goal, a business has to increase revenues and/or reduce expenses. Determining which procedures or medications were clinically indicated, ostensibly based on empirical evidence, was one way of setting limits on expenses. Refusing to cover pre-existing conditions was another. Over time, decisions of medical necessity were taken over by managed care and stories of treatment denial, some of them truly horrible, started surfacing. You've heard them on the nightly news as have I.

Despite public outcry, doctors' frustration with a growing insurance beuracracy, and the efforts of congressional leaders like the late Senator Ted Kennedy, insurance reform lagged. Ours is a free-market economy, it was argued, competition lies at the heart of the American Way. Socialized medicine in Canada and Europe, opponents declared, provided poorer quality care and ours was the best in the world. The reality, however, failed to live up to the evidence even as the arguments proliferated.

Families on the verge of collapse because of alcoholism or drug abuse may resort to performing an intervention, confronting the substance abuser who is unwilling or unable to get treatment themselves. Not dissimilarly, someone had to intervene if healthcare insurance was going to obtain the "treatment" it had long needed. Relying on competition to even the field failed to yield more affordable coverage and the number of uninsured Americans continued to grow. Either free-market theory was wrong or the industry discovered how to prosper in spite of it. Although many believed there were good reasons for reforming the system, there was insufficient motivation for the system to reform itself.

Enter the Affordable Care and Patient Protection Act, the function of which is to enable one to obtain affordable healthcare insurance and provide protection against potential abuses by the insurance industry. Under its umbrella, patients can no longer be denied coverage because of preexisting conditions. The determination of medical necessity has been placed back into the hands of those who are committed to serve the needs of patients. Doctors now have the right to review private insurance company files that identified physicians with high utilization patient populations and directed new referrals to those whose patients were regarded as healthier and therefore cheaper to insure. 

It's not a perfect solution but imperfection doesn't automatically render it a bad one. If anything, we're discovering it's a work in progress and we'll need to adjust and adapt it as we go. I don't think it represents a step toward socialism anymore than the Selective Service represented a step toward a police state. Most of us are too smart to believe that line, even if politicians aren't smart enough to find a better one. 

The Affordable Care Act is an attempt to reform a system sorely in need of reform, not only for the sake of patients and policy holders, but for its own sake as well. As with any intervention, the insurance industry finds change painful and naturally responds with anger, disbelief, and a desire to bargain, hoping to retain something of the status quo. Over time, acceptance will ensue and the industry will find itself better off for the changes that have been made. In the meantime, we're past the point of no return; pretending the good old days were the best days is a fantasy and Fantasy Land is for cartoons. We live in Tomorrow Land and the future is now. 


(Creative Commons image of Walt Disney Politics by sbwoodside via Flickr)

Doctors and Spirituality: Nothing is Etched in Stone

On the premise one agrees spirituality is important to medicine, as I argued in yesterday's post, that's only where the story begins. There are even more questions to be raised about its management in the clinical setting. For example, who is best qualified to inquire about spirituality and, besides, isn't it an end-of-life issue? What if a patient asks their physician to pray with them and s/he is an atheist? These are real concerns and as a minister on the cusp of medical residency, I'd like to offer a perspective.  

Customarily, religious or spiritual preference is noted in the intake interview and becomes part of a patient's chart. Whoever does the intake should ask, at least generically, about the significance of religion, faith, or spirituality. During times of stress, changes of life, or when treatment decisions can be affected by religious beliefs, it's especially appropriate for the physician to broach the subject. When patients come to the clinic, they anticipate seeing a doctor they know and have come to rely on. The doctor-patient relationship provides an ideal basis for talking about what health or illness means to them, personally. As I define it, such conversations reflect "spirituality" in its most basic sense.  

Naturally, you'd assume spirituality to be an end-of-life concern but it surfaces at other times as well. For instance, couples who have been relatively uninterested in religion often express a desire to reconnect with family religious traditions when a newborn enters the picture. As a first-time pastor, I discovered young children in the home was associated with parents attending church regularly. Family atmosphere, the potential for children to learn moral principles, and social contact with other parents were important factors in the decision to become involved. Midlife is another time when spirituality may take on new significance. The point to remember is, spirituality and relating -- intrapersonally and interpersonally -- go hand in hand, and most of us are best at both while we're still breathing.

The question of qualifications is one that has far less importance for spirituality than the practice of medicine. Doctors are accustomed to referring patients when a specialist would be better qualified to be of help. Spirituality, however, doesn't require technical expertise to be addressed meaningfully. Patients don't expect their physician to be a theologian. What they expect is consideration, respect, and empathy. If we can't provide these qualities, we've got far bigger fish to fry than whether we can explain why bad things happen to good people. And for the record, even ministerial folk have a hard time with that one, if they're honest about it. As long as we stay in touch with our humanity, we've got all the qualifications we'll ever need.

Well, then, what about physicians counseling with integrity when their own convictions concerning spirituality are at odds with patients'? While statistics indicate physicians who are fairly comfortable bringing up spirituality tend to be persons of faith, there's absolutely no reason why this should be considered necessary or even advantageous. For one thing, it's not about what we as physicians believe or disbelieve, anyway. For another, there are a number of potential points of disagreement with patients, including music, politics, caffeine or decaf, none of which require us to alter our convictions to be medically effective. In any case, introducing spirituality into the conversation is never an occasion for us to persuade, convert, or pontificate.

Admittedly, possessing a spiritual orientation may seem helpful, but it can also create problems. The innocent presumption that you know what a patient is talking about since you're able to identify with their experience may result in failing to ask follow-up questions. Conversely, patients may withhold information believing a common experience tells you all you need to know. In situations like these, having no spiritual orientation or one that differs from your patient can be an advantage because it requires us to explain ourselves rather than err by relying on assumptions.

Finally, in the matter of praying with patients, I'm reminded of a wonderful line from the film, Oh, God (1975). John Denver's character asks God (George Burns) if they might just talk now and then, to which God says, "You talk, I'll listen." If a patient should ask their doctor to pray with them, whether or not they are persons of faith, offering to listen reverently while the patient prays is spot on. If they should ask you, as their doctor, to pray on their behalf, there is no harm in gently explaining your convictions should they differ from your patients'. By telling the truth you maintain your integrity and confirm your trustworthiness. Furthermore, your honesty tells your patient that you value them too much as persons to pretend to be someone other than who you are. The result could very well be a much stronger bond between you.

Admittedly, in this essay I haven't gone anywhere near the truly difficult and painful spiritual/ethical issues of blood transfusions and Jehovah's Witnesses, abortion, or faith-based objections to teenage birth control and HPV vaccination. My interest has been on what you might call "bread and butter" spiritual concerns, but demonstrating respect, empathy, and truthfulness is essential in any situation involving religion or spirituality. We struggle, do our best, make mistakes, fall down and get back up, mindful that where spirituality is concerned, nothing is etched in stone. 


(Creative Commons image by john-norris via Flickr)

Osteopathic Psychiatry, the Forest, and the Trees

You remember the 1998 film, The Horse Whisperer, don't you? Robert Redford riding the range of Montana. Kristin Scott Thomas the intense New York magazine editor. Her daughter, Scarlett Johansson, reeling in the aftermath of an accident involving her, her horse, and an 18 wheeler. Music by Thomas Newman, recalling redemption at Shawshank Prison, sets the tone (no one scores redemption like Newman).

Kristen Scott wants Redford to fix her daughter's horse. It's pretty simple, she says, do whatever it is you do, take my money, and I'll be on my way. I'm busy, my life is full, I don't have time for distractions. He's an animal, not a person, fix him, like my car. You live on a ranch, you fix things, fix this.

But Redford can't and neither can anyone else. Not with a snap of the fingers, anyway. Some things take time, he replies, and your horse is one of them. You should also know, I don't treat symptoms in isolation. Your daughter will be involved and very likely, so will you, before all is said and done. The forest is as important as the tree.

Osteopathic Psychiatry is like that, or it ought to be. 

When I published Osteopathic Psychiatry: Time to Smell the Roses, I had no idea it would become as popular as it has, suggesting other people are as interested in the subject as I am. Curiously, that particular post was inspired by a problem I had researching osteopathic psychiatry. Apart from chapters in the seminal osteopathic textbooks and scattered journal articles, there wasn't much out there. Google "psychiatry" and you'll be busy reading til the next millennium. But a body of literature, devoted specifically to the theory and practice of osteopathic psychiatry, eluded me. I was reminded how unexplored territories are labeled on old maps. No roads or rivers, just the phrase, "Beware, there be dragons here."

Sometimes I wonder if this "empty book shelf syndrome" stems from uncertainty about whether there is such a thing as a peculiarly "osteopathic" psychiatry? What if psychiatry is nothing more than a purely allopathic endeavor that osteopathic physicians practice in imitation of their M.D. colleagues? If that were truly the case, we could stop right here. End of discussion. 

On the other hand, what if the diagnosis and treatment of mental distress and disease, its biophysical underpinnings, and behavioral expression, is a sub-field of medicine, independent of theoretical orientation or professional degree? I believe this is precisely how we should think about psychiatry, much as we do with the other forms of practice that make up the fabric of medicine as a whole. 

Now we're in the position to ask, is there any justification for an osteopathic approach to psychiatry? Are there identifying marks rendering it unique? Suggesting clinical activity is "osteopathic by association," i.e. osteopathic by virtue of being practiced by a DO, doesn't work as well as it sounds. That's too much like saying a wedding ceremony is Baptist (or Jewish or anything else) because a Baptist minister performed it. You can take my word for it, I've performed enough weddings to know, the minister's denominational affiliation means very little. The character of the rite itself must reflect the tradition the minister represents. 

Taking a clue from DOs who practice physical medicine, one of at least two key elements in the "rites" of osteopathic psychiatry should be the insistence upon a person-centered framework for diagnosis and treatment. In my experience, MD physicians almost universally describe DOs as whole-person oriented in contrast to their own problem-based focus. Put simply, and perhaps too simply, MDs are trained to evaluate the tree; DOs to evaluate the tree and the forest as a single entity. Superior is not how I'd describe the difference; complimentary is far more accurate. Our medical house is big enough for each of us to have our own room and share the common spaces without feeling cramped.

A second key element, which could actually turn out to be the defining feature of osteopathic psychiatry, is the way it attends to the mind-body interface. We're physicians, not psychologists. We learn how to perform physical examinations, treat physical illness, and use Osteopathic Manipulative Medicine (OMM) in patient care. Whether we do these in the clinical setting or not, the training and experience are still there. At the core of osteopathic medical training is the explicit understanding there is no artificial distinction -- no disunity -- between mind and body. If the triad of mind-brain-behavior represents the tree, the body, at bare minimum, represents the forest. Mind-body integration lies at the heart of everything we do. How this will work out in terms of philosophy and psychiatric practice guidelines is the direction I think we're moving.
 
The way we're accustomed to thinking about medical practice is changing rapidly. Integrative care, involving psychiatrists who function as consultants within primary care settings, may become increasingly common. A new generation of osteopathic psychiatrists has begun applying OMM to alleviate the somatic dysfunction accompanying, compounding, or in some cases, even leading to symptoms associated with psychiatric illness. DO and MD psychiatrists alike may find themselves monitoring medical conditions their instructors customarily referred to the Internist. Our generation of psychiatrists -- particularly osteopathic psychiatrists -- may eventually be known as the one that took the stethoscope out of the desk drawer and placed it back round our necks, where it belongs.

(Creative commons image by takomabibelot via Flikr)

Letting the Chips Fall

I was getting some work done on my car and enjoying a visit with the mechanic when it happened, but I'll get to that in a minute. I like talking to mechanics and it's unusual for them to allow customers in the auto bays -- liability, you know. But this fellow's doubled as his waiting room, which, by the way, says a lot about the size of his operation. Anyway, since one of the two chairs was occupied by a morbidly obese collection of tools, greasy parts, and half-empty cans of WD-40, I sat down in the other.

I'd actually brought a book along to keep myself from distracting him with questions, but he wanted to talk and so talk we did, mostly about this and that. In which of the neighboring towns did I live, had I been there long enough to know his sister, when is the next snow coming. The kinds of things that make up life outside medical school and are common to small-town Maine. Probably small-town anywhere, for that matter.

Then he asked what I did for a living. If not the first question men ask one another, this is certainly the second or third. Men talk about work, what we do, how long we've done it, have we done it all our lives and where. It's how we size each other up, determine if we're responsible, reliable, if we can be taken seriously. I thought he handled my answer, that I was a medical student, rather well. It only took him about ten seconds to recover from the initial shock -- he did, however, turn around sharply and look at me like I'd just offered him a thousand dollars for a job he'd bill at ten -- before composing himself to ask what I'd done before. A guy my age must have done one or two somethings, maybe a few more, before sticking his neck out.

"I was a psychotherapist," I said in the most benign tone I could conjure. He picked up the theme like it was a favorite wrench he kept near at hand and related tales of family members who'd engaged the county mental health service, saying how he'd love to "get outta this garage" and do something with his life, while there was still time. Before standing on an uninsulated concrete floor in the dead of winter crippled him like it did his father. He reminded me of the bartender in Billy Joel's Piano Man.

He walked away from the window he was repairing in my passenger side door, shattered late one night by small-time crooks too stupid to realize a 2001 Honda was too old to have a navigation system they could pry free and fence for drug money. If they'd taken time to look in the window before throwing a brick through it, they'd have known. He stepped through the maze of tires and boxes, found a radio sitting on an oil drum, and switched from classic to alternative rock to country, listened a moment or two, and returned to my window. Watching him, I ducked my head and smiled; it was the same thing I would have done.

"Have you always been a therapist?"

Here it comes, I thought. No, I said, I'd also been a minister since about 19 aught 3, or so it seemed on weekends when I came home from rotations, dog tired, with two days to catch up on a week's sleep deprivation. Trying to salvage the situation, I added, but medicine had always been simmering on the back burner and just before my dad died, I finally gave myself permission to move it to the front. Too late, his demeanor had shifted as subtly as the tectonic plates and as noticeably as the Richter Scale identifying a tremor. Some things never change.

Up til then, we'd been two relatively ordinary guys talking about life and limb; a stranger would have sworn we'd known each other for years rather than 30 minutes. All that vanished so quickly it felt like it had never been there in the first place. I was a minister now and he was on his best behavior.

I didn't say it then, but I really haven't spent my adulthood with my head buried in the sand, fearful seeing the world as it was would sully my spiritual sensibilities. If I ever had them, and I feel sure I must have, they've been knocked down, brick and stone, by my own fallibility. A religion that's only good for Sunday morning rarely has much value the rest of the week. Some clerics like the interpersonal distance a collar or title provides; I like risking honesty. I like people who are sufficiently real to swear and not give a damn whether I notice.

In any case, I wasn't eager to put on my minister's hat quite yet and my friend couldn't see me wearing anything else. It's going to take some time. I'll go back to get my snow treads installed, and we'll talk again. Maybe eventually we can find a middle ground, one where he's him, I'm me, and we let the chips fall where they may.


(Creative Commons Sharealike image via Wikipedia)

Door Number Three

Five days ago, six if you count Monday and orientation, I walked onto the obstetrics unit, knowing little more than Prissy (Gone With the Wind, 1939), who freely admitted she knew "nothin' about birthin' babies." I guess that means I knew next to nothing, which is okay; if I knew at the beginning of this rotation what I hope to know at the end, there wouldn't be much reason for what comes along in between, would there?

As it stands, I've already learned a few things, among them that I'm not inclined to drop a slippery newborn despite the fact, as a kid playing Little League, "Butterfingers" could easily have been my nickname. There's something about holding a baby who's just taken its first breath, that makes you hold on for dear life. Maybe it's parenting instincts kicking in, but the thought of losing your grip doesn't cross your mind. Holding them close with a quick, welcome-to-the-world snuggle in the crook of your arm, while passing them to the NICU (neonatal intensive care unit) team, you bet, but letting them slide through your fingers? Uh-uh.

And then, there's the matter of learning about the mess. Childbirth really is messy business. Television prefers spit and polished, shiny clean new babies who don't make anyone squeamish. Not so Mother Nature. There may be some blood, especially if junior's exit from the womb produces a tear in mom's vagina. There's amniotic fluid when her water breaks, though that usually occurs earlier, unless she's having a C-section, in which case the flow of amniotic fluid is more like a flood. To top it off, there's meconium -- baby poop -- mixed in for good measure. Martha Stewart would cringe.

Honestly, though, I don't mind the mess. Life is messy. Personally, I think trying to eliminate the messiness nudges more people toward neurosis than the other way around. It certainly is a driving force in narcissism, where the appearance of perfection is all-important. Babies have an entirely different perspective. Forget all that other stuff, okay? Mom was toasty warm, will someone please wrap me in a blanket? Ah, there we go, that's better. Mm. Thank you very much.

What I'm particularly enjoying about this rotation thus far is the tacit understanding that some things can only be learned here. Internal medicine teaches you how to write a good clinical note, surgery how to behave in the OR, pediatrics how to deal with kids and parents, psychiatry how to manage things going wrong, and then rural and family med puts it all together. None of them, however, specifically target birthing, prenatal care, or women's health (gynecology). So, in a sense, it's expected that a student is literally starting over at the bottom. You can use skills gained elsewhere to a certain extent and yet, so much is totally new. Every day is pregnant (pardon the pun) with possibilities and you never know what's waiting behind door number three.


(GNU Free Documentation image of a brand new newborn via Wikipedia)