Nuts R U

I so suck at small talk. Some people are masters of the lingo and I truly admire their facility. Even with friends, sometimes I end up babbling like the little fishy dude in The Return of the Jedi. Remember him? Lando Calrissian's co-pilot on the Millenium Falcon in the final, epic battle against the new Death Star? When he spoke, it sounded like he was saying, "Blabbada, blabbada, blabbada." Well, that's me.

If only social situations were like writing. Not texting, because my fingers are so big and the keyboard on my iphone so small I have to hunt and peck with one finger. Even with text shorthand, "hi how r u?" takes so much time that my co-communicant has gone on to "nice 2 see u bye" before I'm halfway through the conversation. I mean real writing where nouns are nouns and verbs are verbs and they follow one another in the sweet company of polite punctuation. Not likely, huh?

I don't know if I freeze up inside or what, but when confronted by situations where a dissertation is inappropriate and a few choice words are poetry, my brain goes blank and my mouth takes on a mind of its own. And that's where writing would help because I could always backspace and erase a comment before hitting "enter." Not that this guarantees anything but it does allow editing. The other way, where what you say is what they hear, it's anyone's guess whether I'm going to come off like a nice guy or a goof ball.

Now, it's very true that asking other people questions, giving them an opportunity to talk about themselves, is generally a safe bet. If you can listen well, and therapists are usually pretty good at that, you're covered. Inevitably, however, there comes a point when you run out of questions or they'd like to hear about you, and then the good ship and crew are in peril.

Occasions like these make me wonder about the extrovert business. On any given day, that's me, energized by interaction, eager to engage. In casual social settings, Mr. Introvert takes over and even Forest Gump would have a better chance of making a good impression. Maybe I should memorize some of his better lines? When someone asks how I'm doing, respond, "Well, life is like a box of chocolates, sometimes you get a smooth center and sometimes it's nuts." Just so long as they don't walk away thinking the nuts r u. That would probably be bad.


(Public Domain image via Wikipedia)

Omega Thinking Revisited

A little over a year ago, I wrote a post entitled, Omega Thinking, describing my journey to medical school and the changes that have taken place in my life along the way. Since then, I've shared this concept with a number of people, some older, some younger, and all of them have found it a meaningful explanation of experiences they've had, and I've been encouraged to believe I may be on to something.

Let me give you a brief overview to get us all on the same page. In the photo you'll notice two Greek letters, alpha on the left, and omega on the right. While nobody's life proceeds in a straight line, for the sake of simplicity, let's say the left leg of the omega represents mine as a young man. At some point, I'm guessing about age 25, I took a left turn. I didn't realize what I was doing at the time nor did I make the turn intentionally. It just happened, like a lot of things.

For the next twenty or so years, I wandered, for lack of a better term, around the loop, attending graduate school, running a business, going through life trying to figure our where I fit in, if I did at all. Exactly when I took the second left, this time onto the right leg of the omega, is also uncertain. I think it was 1998, the year my mother died, my father was diagnosed with pre-leukemia, and I began premedical studies. In depth psychology, "left" symbolizes the unconscious and I've come to interpret the first left turn as a sidestep ultimately leading to self-discovery. The second left integrated the person I had been with the one I was becoming, and perhaps, ought to have been all along. This sounds easy; in reality, it was far from, though the details will only muddy the water, so we'll leave them out at the moment.

The complicating factor in all of this is the arrangement of the legs of the omega. Notice the point at which they are nearest one another. When someone undertakes a process like the one I'm describing, once they've come full circle, they're going to be more like the person they were when they started out. Yes, they're older, and hopefully, more mature, but that doesn't change the fact that they're closer to the starting line than the end of the race. It seems to me, for reasons only the unconscious knows and each of us has to fetter out, some of us need time in the loop in order to truly run our race to the best of our ability. Or to find out which one is our race to begin with.

In either case, once a person has exited the loop, they may find themselves out of step with members of their age-group generation in terms of interests and life tasks. While you were "in the loop," those who weren't, moved on ahead, and now, in a very real sense, your generation is not the one you were born into, but one you dropped into when you stepped out of the loop. Sounds like a time warp, doesn't it? But that's how people I've talked with describe it.

It can be genuinely confusing, when you find yourself in a position like this, and for most of the past year, I've wondered if there was a corollary to Omega Thinking that might verify I was on the right track. Something more than the validation I'd received from others who liked the idea. This week, I found what I was looking for. It surfaced while chatting with someone in recovery from alcohol dependence. The nature of recovery forces a person to confront issues that have been hidden for years, blunted by their drug of choice. Doing so can be difficult, painful, and yet, have the effect of creating the feeling that one is alive for the first time. Once you dare draw the curtains wide, there's no telling what you'll see. Although our histories were different, the pattern we followed was extraordinarily similar.

Was my initial left turn a mistake? Was it like this man's first drink as a teenager that made him feel like an adult and kept him drinking for thirty years? I'm inclined to say it wasn't because of the value I've come to place on the things I've learned and the relationships I've established along the way. The unconscious leads us where we need to go, even when we think we're in charge. I certainly thought I knew what I was doing at 25. If there was a mistake involved, it stemmed from trusting an omniscience I never possessed and relying on judgment that was untested and unproven.

I'm not about to say I'm older and wiser, now. Older, yes. Wiser is still ahead, somewhere down the road, or at least I hope so. But even the "older" piece of it is relative. It helps, having a grey hair or a wrinkle here and there, when trying to convince a patient to take better care of themselves. But I'm still a student -- 25 or 50 plus, it doesn't matter -- and I must come across as one because some of my patients treat me as though I've got a lot to learn. And they're absolutely right, I do. What I've learned already, by sidestepping into the omega loop, is how to pay closer attention to what life has to teach.(Creative Commons image by Leo Reynolds via Flickr)

A Word of Thanks

Before settling in to write, I'd like to offer a word of thanks to everyone who's come by to read this week. I'm up to my neck in family medicine and by the time I get back to my temporary digs for the evening, my brain is swimming with diagnoses, treatment options, and reading assignments I've got to complete. Despite all my good intentions, writing has had to take a back seat the past few days, whether I like it or not.

Aside from that, however, the week has gone incredibly well and once again, I've seen conditions that one rarely sees, if ever. For instance, I've gotten to chat with a patient who has Whipple's Disease, an extremely rare condition that has been diagnosed only about five hundred times since its discovery. Most students never have an opportunity like this and I'm extremely grateful for the chance to have heard what it's like from one who's clearly suffered a great deal with it.

Patients are truly the best instructors and today, one of them was a five year old with hair as red as Ron Weasley's. His mother came in for an exam and while she was ensconced with my preceptor, "Junior" and I went out into the waiting room and looked at story books and talked about great adventures. When it came time for his wellness check, I was his pediatrician. It was my first time at bat doing a physical on a child and he was wonderful. I couldn't have ordered a better instructor if I'd had a list to choose from.

And then, there was an opportunity to do some osteopathic manipulative medicine on a patient complaining of back pain. Face-on, he was standing a bit crookedly; when turned around, his spine imitated the "S" on Superman's jumpsuit. His story was typical for this time of year. He was shoveling snow, leaned down, twisted, and yikes! It was his sacroiliac, as osteopathic students are probably guessing, and I was once again glad for a month of OMM practice and review before coming to northern Maine.

Anyway, now you know what I've been doing when I'm not writing, and hopefully, I'll make up for it fairly diligently this weekend. In the meantime, thanks once again.

Coping with Both/And

Image via WikipediaWant to know what the hardest thing is about family medicine -- for me, that is? Explaining to family doctors why I want to be something else. And doing so in a way that doesn't hurt anyone's feelings or give the impression I'm not interested in medicine. Trust me, this is no mean task, especially when doing a family or internal medicine rotation. You see, as a student, I want to get the best education I can. But this tends to create confusion because, somewhere along the line, psychiatry has gotten the reputation of being the discipline for those who don't have the hots for medicine. Making it tricky for those of us who do.

Like most generalizations, this one doesn't hold true in every case. Still, it holds true in enough of them that it becomes necessary for the rest of us to try to overcome the stereotype. But here's the rub: if I act motivated to learn physical medicine, it calls my commitment to psychiatry into question. If I act like all I'm interested in is psychiatry, then I may not be taken as seriously as the student who identifies with Marcus Welby, Ben Casey, Doug Ross, or Alex Karey, MD or DO, depending on which generation of television doctors you follow. Damned if I do and damned if I don't.

To be fair, I'm sure it must be the same for students whose stated intention of becoming "doctors" is complicated by an interest in patients' psychiatric conditions. Both/and isn't the easiest thing to cope with on the best of days. Now, it's entirely possible that those appear medically-ambivalent might actually be happier with advanced degrees in psychology. I don't know, I'm just saying. You can definitely count on medicine involving you with patients in ways you don't have to think about as a psychologist.

Take this past Thursday, for example. The only other time I've performed a male (why do we call it that? I mean, is there any other kind?) prostate exam was in lab one evening a little over a year ago. On the same occasion, I did my first female breast and uterine exam, both with actor-patients to whom and for whom I will be eternally grateful. As you may know first-hand, exams like these are a very intimate, for doctors and patients alike. And they're things a psychologist doesn't ever do.

It's true, psychiatrists don't routinely do prostate exams or pap smears, but that's not the point. They receive this kind of training because they're in training to become doctors and therefore, approach the brain-mind-behavior interface from the standpoint of one who practices medicine, not psychology. As an aside, this is one of my objections to allowing psychologists to prescribe psychoactive medications, but that's for another day. Call me narrow-minded, but I don't think one can be a competent psychiatrist without being a competent physician for the very reason that psychiatry is the medical discipline whose task is to tread the no-man's land between mind and body.

St. Augustine, Bishop of Hippo (not of hippopotamuses, though I certainly have no objection to the idea -- ever attend a blessing of the animals on the Feast of St. Francis of Assisi?) in Northern Africa during the fourth century, prayed, "God, deliver me from the need to justify myself." I guess I'm not there, yet, but God knows my heart and I think my preceptor in rural Maine does as well, because he surely gives my desire to learn physical medicine the same attention he does my interest in psychiatry. It's just a matter of coping with the stereotype in subsequent rotations and I guess that involves being gently and respectfully honest and letting the chips fall where they may. It's nice to know Augustine struggled, too. I feel like I'm in good company.


(Fair use of a copyrighted image of George Clooney as Dr. Doug Ross from "ER" claimed for the purpose of identifying the character in question with no commercial intent and in the absence of a similar, free image)

Family Doctors -- The Default Psychiatrist

I thought there would be lots of colds, flu, and diarrhea in my rural medicine rotation, remember? Ordinary, boring pathology that mom could treat as well, if not better, than the doctor. This week, I've seen shingles (a burning, painful rash that sometimes hits on those who've had chickenpox), polycystyic kidney disease, a transient amnesia that I thought represented a transient ischemic attack and may still prove to be, and a boatload of psychiatric issues couched (no pun intended) in the guise of daily life. To my friends in family medicine, I can only say, you were right and I was wrong -- family med is anything but boring.

It's easy to create the impression that "rural" automatically means "country," especially when referring to communities like the one I've been describing. Well, it does and it doesn't. My preceptor practices in a small town of about 1200 persons but his patients come from miles beyond the town limits. It is country, no doubt about it. But rural really means under-served more than anything else. For instance, in a community that numbers, including outlying farms and communities, a population closer to 12000, the yellow pages lists one psychiatrist.

True, patients could drive to Augusta or Bangor or even Waterville, but that's hardly a realistic expectation when gas is $3.19 a gallon and the average family limo is a four-wheel drive truck that drinks gas faster than you can put it in the tank. Even if they have insurance, considering the limits placed on psychiatric care by most policies as well as sky-high deductibles, having insurance doesn't simplify the problem of paying for ongoing care.

That's what "rural" really means. Limited access as well as limited services to begin with. It's almost easier for a dairy farmer to make a living in these more remote areas than it is for a mental health clinician. For that reason, because doctors also have to put food on the table and payment can be uncertain, it's difficult for a community to keep a psychiatrist in practice even when they find a willing victim.

So, what do you do? You either keep your depression, anxiety, tormenting internal voices, or suicidal thinking to yourself until they get out of control or you go see the family doc who takes care of your high blood pressure. But, lest this sound like a good deal, it's not really. Family doctors function by necessity as default psychiatrists, but their training has its limits, as does the psychiatrist's. It has to be that way because no one can possibly learn everything. Not even doctors.

One solution involves dual-tract medical education: family or internal medicine slash psychiatry. If you're fortunate enough to match in one of these highly competitive residency programs, you're ahead of the game because at least you can count on physical medicine to help subsidize the psychiatric care you deliver. But Maine doesn't have a dual residency program and students tend to practice near their training site and that leaves us, once again, out in the cold.

It's a dilemma that needs serious attention. And we've got to do something because the needs of patients in outlying areas for psychiatric care are overwhelming and as things stand, there just aren't enough of "us" to go around.


(Photo of a park in the snow in Skowhegan, Maine copyright 2011 by the author)

A Real Country Doctor

Image via Wikipedia
Well, I'm home for the weekend, having gotten away early, following a short day in the clinic, and I've got to say I'm enjoying this rural medicine rotation immensely. In part, I'm sure it has to do with the fact that I'm personally getting to see at least a couple of patients each day on my own before we're joined by my preceptor, and today there were three, all in a row.

I can't begin to tell you how good it feels to do this once again, after such a long dry spell. It's been four years since my little cubbyhole of an office in Denver where I sat with patients, argued with managed care, and dreamed of being a doctor. Walking into an examination room, now, and greeting someone I've never met, asking them what brings them to the clinic, is so much like coming home it's almost beyond words.

What has surprised me about the experience thus far is how much fun I'm having. Previously, my encounters with family medicine have been so-so. Not bad, but not great, either. This time, I can hardly wait to get to the office at 8.30, about the time the nurse-receptionist-office manager-cheer leader in residence and anything else you want to call her, arrives. She's got a wry sense of humor that is wonderful and she knows medicine inside-out. I told her today that when her boss retires, she may as well forget about retiring herself, because I'm hiring her next.

By nine, my preceptor arrives, and the first patient shortly thereafter. If we having breathing room, we'll see this one together. If it's like this morning, the nurse has one lined up for both of us and I'm in heaven. Thirty minutes later, I report to him what I've found and we round on the patient together. There is always a teaching moment somewhere in the mix and I'm amazed at how much he knows and how much I'm learning. And this has only been the first week.

I'm glad to be home, to have a chance to walk my dog and cuddle with the cat, to clear the fresh snow away from the barn and dig out my mailbox that's buried forty inches deep with more snow on the way. But you know? I honestly can hardly wait for Monday to come. I'm seeing diseases I've only read about the past few years, evaluating patients with a growing confidence, and learning about medicine in a way that makes me wish I could scan my preceptor and his nurse into my iphone and carry them with me right through residency. He's a real country doctor and I'm a country boy who's having the time of his life.


(Pubic Domain image via Wikipedia)

Rural Medicine Rotation: Welcome to Grady

I wish the sun had been shining when I took the photo accompanying this post, because things aren't nearly as bleak as they look, but this is north central Maine, it is winter, and the sun doesn't shine all the time. That doesn't seem to make a great deal of difference to the residents of this little community on the Kennebec River. Five miles away lies Skowhegan, where student housing is located in a private home. Skowhegan leads the state in maple syrup production. Fun facts about New England to know and tell.

The storm paralyzing the mid-West at this moment, gets a matter of fact greeting this far north. The closest we'll come to recognizing the weather is to show up for work tomorrow in boots and jeans instead of slacks. And forget about wearing a tie. People who aren't born here, move here because they want to live as far away from anywhere a tie might be considered normal attire.

Five miles separate the comfortable basement where I sit writing and the first floor doctor's office in the yellow Victorian above (photo). "Welcome to Grady," I said to myself yesterday morning as I walked into the waiting room. Grady is the fictional location for the film Doc Hollywood -- this was the first of many Michael J. Fox moments I think I'm going to have over the course of the next four weeks.

I mentioned Sunday I hoped eventually to have the chance to see patients, relatively speaking, on my own. Eventually came twice yesterday and was repeated as many times today. It may have been a while since I've done a physical exam, but apparently I haven't forgotten nearly as much as I feared. And nearly every day, I'm grateful for Dr. Francis and the PASS Program, as my patients reiterate something he taught and real life imitates.

A rotation like this is a gift. Seriously. How often do you get to drop into someone else's life? But that's essentially what I've done with my preceptor. This is his town and I'm a visitor. He lives here and I'm passing through. That he, his nurse, and their patients treat me as though I'm anything but just another student is pretty darned amazing, because they sure don't have to. And yet, that's exactly what they do.


(Photo copyright 2011 by the author)