Well, I made a mistake. In "Medical School Hopscotch," I said Chuck had virtually no medical training prior to beginning his pediatrics rotation with Dr. Bob Z and in yesterday's post, he suddenly has six weeks of internal medicine and two of radiology behind him. Oops!
So, which is it? "Hopscotch" has the record correct, pediatrics is Chuck's first rotation and will be followed by internal medicine, a radiology selective, obstetrics and gynecology, and then, his long awaited psychiatry rotation. The purpose of yesterday's post was to reveal how his experiences with Bob, Jessie, and the twins, as well as his other patients, have triggered the desire to blend psychiatry with children and their parents. He thought his life was planned out nicely, but the past four weeks have introduced a change and now child-adolescent psychiatry is apparently on his horizon.
Chuck's role in Pink Hats has been twofold. First, he provides some necessary continuity with the events of chapter one. As time went along, it struck me as incongruous that we should only encounter him once, particularly since, without him and his dog, we wouldn't have a story at all. Second, he's given me an opportunity to talk about psychological issues that would naturally surface with Bob's desire to adopt the twins. For instance, why would a 62 year old man wish to put himself through everything having children entails? Chuck's an unbiased observer, allowing you and me to see how things look inside the male mind from the perspective of an outsider.
At the same time, being an older student, Chuck is far more likely to develop a relationship with Bob that smacks of peerage and thus, permits us to see Bob in a different light. With Chuck, he can be a teacher as well as a man who asks questions about himself and his motives. In a sense, Chuck is the closest thing Bob has to a male friend and confidante, though in fact, this is not the case. Bob has friends, but with the exceptions of Halley and Ted, none of them have made an appearance and since we're nearing the climax of the story, I doubt any of them will. We're getting to the point where introducing anyone other than very minor characters would be confusing.
So, my apologies for failing to keep track of the details. Although the Holidays are over for us in the real world, they're just around the corner for Bob, Jessie, and everyone else, and I think they're going to be a lot of fun. If it all works out like I hope, you'll want to have a hankie or two handy.
(Creative Commons image of The Book of Changes by Nikki L via Flickr)
After-hours coffee and Danish from the Nook and Cranny had the earmarks of becoming a ritual between friends. Despite his pediatrics rotation having been complete around mid-September, Chuck continued drop by Bob's office throughout the first of his two required six-week internal medicine rotations and now an elective two weeks in radiology. On the other side of four more in OB/GYN lay psychiatry, at last. What he didn't expect was the residual effect of his initial month with Bob, Jessie, and the twins on his future.
"I keep thinking about that child-adolescent fellowship and it's all your fault," he said, hanging his head and faking misery.
"I've been blamed for a lot of things," Bob replied, ruefully, "including a baby when I was seventeen that I had absolutely nothing to do with -- and couldn't have even if I'd wanted to because I was on a Scouting trip during conception -- but this is a new one. Tell me."
They were sitting in Bob's office with their feet propped up on opposite sides of a massive roll top desk he'd inherited ten years ago from his pediatrics instructor who, at 80, decided it was a good time to retire and sail around the world. He made it, by the way, and now, he and his wife were trekking in Nepal, in celebration of his 90th birthday.
"Well, I thought I had everything planned out. Adult psychiatry was my bailiwick. Sure, I loved kids, just like you, but I enjoyed psychotherapy so much it was hard to see myself in another role. Then you came along -- and Jessie -- and the twins -- and the next thing you know, I couldn't get enough of pediatrics. Especially the kids with ADHD and parents who're going nuts trying to cope, the occasional bipolar disorder we've seen, and the substance-abusing teens. And frankly, I miss them. I feel like saying, along with the prophet Isaiah, 'Woe is me, for I am undone.'"
Bob pursed his lips and nodded, as though he had anticipated the news. "I had a feeling we were going to be a bad influence. It's even worse when the kids like you, and clearly, they do -- that's a trap waiting to be set. Top it off, when you can get teenagers talking -- well, all I can say is, you are in way wicked trouble, my friend." He broke into an appreciative smile.
"Looks like it. I don't know all the details yet, but I've got plenty of time -- see? You can't get rid of me, can you? Now, about the dream you mentioned a couple of days ago in passing, the one you had on the way home from Concord --"
"-- yeah, what did you think of that?" Bob asked, interrupting.
"It was a good one, especially coming on the heals of meeting Jessie's father."
"You're saying a dream's timing is as important as its content?"
"From the perspective of interpretation, yes. Dreams are one thing, the way we view them afterward, is another. My impression is, this one is suggesting you have your own rhythm. Kind of like Thoreau's comment, 'If a man does not keep pace with his companions, perhaps it's because he hears a different drummer.' In your dream, the bass drum was a stethoscope -- you're maintaining the 'beat' of the music all right, but in your way. Timing enters the picture because, from what you've told me about Jessie's dad, it sounds like he's inclined to do similarly. It's probably another one of the benefits of you being older, allowing the two of you to establish a more mature connection."
"I agree, but that didn't make it any easier. Sure, we were more likely to develop a peer-type relationship than would have been possible if I was nearer Jessie's age, but he's still her father and truthfully? I felt like I was 22 once again, sweaty palms included. I guess none of us are as 'together' as we'd like to believe."
"That holds true for me, I'll tell you. One thing you can definitely count on is your relationship with her father making life a great deal easier for Jessie."
Bob was in mid-bite on his Danish. He stopped, put it down, and said, "I would assume that's a 'given.'"
"It is, but there's more. It tells her she doesn't have to love one of you at the expense of the other. It gives her a deep, abiding sense of security about two of the most important relationships a woman can have with men. And a woman like Jessie, who clearly wants someone with more maturity than a guy closer to her own age might possess, has the unspoken expectation that whoever she brings home, should be someone her father can respect as well as one who respects him. You already know this, but she's really an extraordinary woman -- I hope I get half as lucky." With a gleam in his eye he added, "Wait a minute. Didn't you tell me she has a sister? Anyhow, looks to me like you hit this one out of the ballpark. When are you going to pop the question?"
Bob laughed, "One at a time. First, yes I did and she's available, but I think it would look better if Jessie played matchmaker. A professor setting up a date might appear as unfair advantage. As to the second, I haven't quite decided, but I'm thinking around Christmas. It's our favorite time of year and even a romantic moron like me can pick the right place. I need to find a ring and I haven't figured out how to get her size without coming out and asking. I could do that, I suppose, but then the cat would be out of the bag and I'd like this to be a surprise. Not that we haven't talked or at least alluded to it. I just want very badly for her to have the 'fairy tale,' you know?"
"Yes, I do, and she'll love you for it."
(Creative Commons image by Allie's Dad via Flickr)
In August of this past year, the House of Delegates of the American Osteopathic Association passed a resolution supporting the use of osteopathic manipulative medicine (OMM) for the treatment of psychiatric and neurological patients. In some circles, this might be viewed as a controversial decision and for non-medical readers, I need to explain why.
To begin with, we're not really talking about neurological patients since OMM has long been used in their treatment. With psychiatric patients, however, it's another matter. You see, psychiatry has traditionally been the one medical discipline in which practitioners, apart from a polite handshake, generally tried to refrain from touching patients as a matter of principle. Psychiatric relationships are already complicated due to their subject matter, why risk complicating them further by introducing physical contact into the mix?
Not all psychiatric writers agree, however. Irvin Yalom, MD, for example, argues physical contact shouldn't be rigorously avoided; rather, when touch has been appropriate, the next step is to talk about its meaning for the patient (The Gift of Therapy, 2003). There is a wise saying, Everything is grist for the therapy mill, which means everything that takes place between doctor and patient should be discussed as a natural part of the patient's psychotherapy. But OMM involves more than placing a comforting hand on the shoulder of a grieving patient, which is why the decision to employ it has the potential to generate controversy. From my perspective, the issue has as much to do with history as with theory.
The practice of psychiatry as it's usually conceived can be traced to the work of individuals who were adherents, so to speak, of The Indiana Jones School of Psychiatry, i.e. they made it up as they went along. That's legitimate, by the way, when you're quite literally going where no one else has gone before. You sort of have to find your own way because there isn't anyone who's done what you're about to and can advise you to take up a hobby instead, or better yet, just get a dog.
In those days, psychotherapy was the psychiatrist's primary, if not only, tool -- it would be years before lithium became the first psychiatric medication on the scene. I studied under a psychiatrist who completed her training prior the advent of psychiatric medications and I asked her what that was like. She said being thrust into a ward filled to the brim with actively psychotic patients with nothing to use but psychotherapy was a hopeless endeavor, but as they had nothing else, what else could they do?
According to the pioneers in the field (Jung, Freud, and others), the cure to neurosis was found in the resolution of the transference (the idea that a therapist unconsciously reminds a patient of another key figure in their lives, a parent for example, and by working through their feelings toward the therapist, they are actually working through painful feelings toward the parent; past and present meet in the transference). I can't say that psychiatrists and patients didn't ever touch because there are records to the contrary; it just wasn't a formal element in the process because it was feared touch might interfere with resolving the transference. The relationship between patient and doctor, therefore, was primarily cerebral and words were relied upon to render it incarnate in flesh and blood.
For the most part, the osteopathic community has focused its interests on the application of OMM to promote wellness and treat physical illness, especially in the context of primary care medicine. There are references to its use with psychiatric patients in the literature, but these are few and far between. Many, if not most, osteopathic (D.O.) psychiatrists have been trained in the traditional hands-off model and hence, experience a natural reticence about using touch to any great extent as a treatment modality.
Now, here's the problem. If osteopathic medicine represents a similar but also different approach to medical practice, it only makes sense that osteopathic psychiatry should represent a similar but also different approach to the treatment of psychiatric illness. As long as our methods are identical, however, it's kind of hard to see how anyone can point out a distinction between us and our MD colleagues. If you want to claim your degree confers a measure of "something else," it's only fair to ask what that might be.
In response, many have been inclined to say, we're interested in the whole person. But here's where I run headlong into my own experience. I've trained side by side with M.D. psychiatric residents and witnessed how much they care about their patients. They may not use the mind-body-spirit terminology that is the heart and soul of osteopathic medicine, but they care and that's what matters above all. What I'm getting at is, whatever differences exist between us, they have to be real, measurable, and not based solely on a well-worded principle, as critical as it may be to osteopathic identity (see Mission Impossible, 2/5/2014).
I realize I may be treading on thin ice and not all my osteopathic colleagues are going to be comfortable with the prospect of introducing therapeutic touch into the psychiatric mix. But times change. Physicians can undergo sub-specialty training in alternative medicine. The diagnosis and treatment of psychosomatic illness has its own subdivision within the American Psychiatric Association. The landscape of psychiatry is becoming far richer and far more complex than our forefathers and mothers could ever have imagined when they invented the talking cure. I think the House of Delegates is telling us it's time we woke up and smelled the roses.
(A follow-up essay may be found here)
(Public Domain image via Wikipedia)
There's no question about it, I'm definitely enjoying this rotation. For one thing, as a friend reminded me yesterday, the techniques tend to come back once we start using them. I think muscle memory plays a role here, the hands remembering things the mind thinks it's forgotten. An understanding supervisor makes a tremendous difference, her ability to recall what it's like being in shoes similar to mine drives away the tension. Forgiving patients who tolerate my fumbling efforts and offer thanks when leaving, make me think there's hope for me yet.
Something I'm noticing more and more is how common some types of dysfunction tend to be. One patient has a rotated pelvic bone and then another and another after that. In lab we see this sort of thing in isolation from daily life. They're exercises rather than the lived experience of someone in pain. And for the most part, a rotated pelvis isn't the primary consideration, but addressing it enables a person to walk with less stress and strain, placing fewer demands on the rest of the body to compensate. When my supervisor tells me to examine and treat what I find and then returns later to check my work and responds with a pleased, "Mm," it's gratifying to say the least.
I've mentioned at least a few thousand times before that I'm a psychiatric guy. I see patients with physical problems and can't help but look at their facial expressions and listen for the energy or the lack of it in their voice and speech patterns. How does pain affect a person in ways we can't see? And how do these signs change as treatment progresses? I love the friendly banter my supervisor engages in with patients and encourages from me. It's a chance to loosen tight muscles by drawing personality into the mix.
The beauty of working in an established practice is you get to work with patients who aren't new to OMM. They're accustomed to having relative strangers touch them in really quite intimate ways and I marvel at their trust. I'm grateful for this, especially, because it helps me think of myself as a medical clinician, doing the best I can to help them feel better, while learning as I go. Their willingness to allow my unfamiliar fingers to probe and manipulate is turning each day into one marked by self-discovery, by the process of finding the healer within me that I have so frequently admired and sought to emulate within others. I don't know how they do it but I'm very glad they do.
(Creative Commons image entitled "M is for Muscle Memory" by stuant63 via Flickr)
Image via WikipediaWell, I've completed the first day of my first clinical rotation and I almost feel a little guilty because things went so well. My instructor/supervisor and I seem to enjoy working together and all of our patients left feeling better than they did when they arrived. All in all, I think we can call this one a success. So far, that is. I still have plenty of time to screw up, though, believe me, that's not at all my intention.
The setting for this rotation is a private practice in neuromuscular medicine utilizing osteopathic manipulative therapy. Unlike one in family medicine, for example, where I'd see patients with a variety of medical as well as psychiatric conditions, most of the patients in this rotation have some kind of somatic, i.e. physical, pain resulting from injury, repetitive use/misuse, or age-related degeneration. OMT involves using one's hands to apply prescribed techniques for the relief of pain and restoration of normal functioning.
The good thing about starting off with a neuromuscular rotation is, I'll get a solid basis for using OMT in other clinical settings, something I've wanted very much. At the same time, it's a reminder that I've been so focused on boards the past few months, I've forgotten some skills and need a serious refresher.
Even better is getting immediate satisfaction for your work. In psychiatry, we learn to defer gratification because psychological change occurs incrementally over time. With OMT, patients often show visible improvement at the end of a treatment session and it feels good knowing I've had a "hand" in that.
Best of all, the awareness that I'm not simply in the office for a day, but will be around the entire month is wonderful. It means I'm not asleep, I'm not dreaming, and I'm not going to wake up in the morning to find boards still looming in the distance. And that feels really, really good.
(GNU Free Documentation image via Wikipedia)
Besides the noble art of getting things done, there is the noble art of leaving things undone. The wisdom of life consists in the elimination of non-essentials.~ Lin Yutan
In medicine, we call it triage, the process of prioritizing patients according to the severity of their condition. Around New Year's, we use the term "resolutions." For me, it comes down to rotations beginning tomorrow and the painful recognition that, once again, time is going to be a precious commodity. I had hoped Pink Hats would have been done by Christmas. Fat chance. Well, I had good intentions, anyway.
So, now, seeing as how my days are going to be taken up by working with patients 40 miles and an hour's drive away, I think it's probably reasonable to say Pink Hats entries are going to more likely appear on the weekends. In between, I'll try to focus more on what it's like, doing a clinical rotation, show you some photos of the countryside, and get back to life in general. At least that's a workable plan. Like all the best laid ones of mice and men, things frequently go awry, and if they do and it's fourth down, we'll punt.
Unless we're close enough to run the ball into the end zone, in which case, who knows how things will turn out?!
(Creative Commons image entitled "Triage" by lamont_cranston via Flikr)
When I was a kid, New Year's meant the Tournament of Roses parade and football afterward. It also meant Christmas break was almost over and I'd have to face the prospect of going back to school. It was really hard to get excited about a holiday with that kind of baggage. I've never been one to "party hardy," so as an adult, I tend to spend New Year's Eve at home, explaining to my dog and cat why New Year's is such a big deal. They usually end up falling asleep somewhere in the midst of my soliloquy and I don't blame them.
Last night, however, I got an unexpected treat when the 2006 film Rocky Balboa showed up on commercial television. I hadn't seen it in quite a while and all I could recall was, Rocky is an older, retired fighter who has a chance to come back and tackle a younger and presumably, hungrier opponent. I'd forgotten some of the things that made it such a moving film the first time.
Mostly, I'd forgotten Rocky's impassioned speech when his son appeals to him to turn down the invitation to fight the reigning world heavyweight champ on the grounds he has felt eclipsed by his father's name and reputation. "The world ain't all sunshine and rainbows. It is a very mean and nasty place and it will beat you to your knees and keep you there permanently if you let it. You, me, or nobody is gonna hit as hard as life. But it ain't how hard you hit; it's about how hard you can get hit, and keep moving forward. That's how winning is done. Now, if you know what you're worth, then go out and get what you're worth. But you gotta be willing to take the hit, and not (be) pointing fingers saying you ain't where you are (or wish to be) because of him, or her, or anybody."
Listening to Rocky's character, I couldn't help but think about people I've known (and know, by the way) who've had experiences that lead others to ask, "Haven't you had enough? Isn't it time to rethink your options?" And instead of rethinking anything, they find a way to keep moving in the direction they've chosen. Not stubbornly, mindlessly, without regard for life or limb, in the name of an overblown sense of pride. But out of commitment to something larger than themselves, a dream, a vision of their future they're unwilling to abandon simply because the way has gotten tougher than they thought it might.
I'm impressed by their determination, but especially by their integrity. When they've called or written to say they've taken a hit, they don't talk about how they've gotten a bad break or who's to blame for their situation. They consistently tell me what they've done and how their actions have resulted in what they're facing now. If they blame anyone, it's themselves, but not in an off-handed way that suggests they think someone else is responsible after all.
These are the people who keep me going. When I'm tempted to feel sorry for myself or think I'm all alone in a big blue sea of things that didn't go right, they're out there, swimming against the tide instead of treading water. The waves wash over their heads, they sputter, clear their faces, take another breath, and keep on going. They know land is ahead whether they can see it or not and refuse to quit until their feet touch solid ground. If they can do it, so can I.
From my dog and cat, Dr. Bob Z, Jessie, and all the rest -- including me -- Happy New Year!
(Creative Commons image by Lord Henry via Flickr)
