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)

Medical School Without a Doubt

"Regrets, Eric, that you're not down there with them?"

"Yeah...no doubts, though."

These words pass between coach Sandy McGrath and runner Eric Liddell in the film Chariots of Fire (1981).  Sitting in the stands, they're watching the 1924 Olympics event in which Liddel refused to participate because it was held on Sunday. 

As you may recall, Liddell was firm in his religious convictions, including keeping Sunday as the Lord's day. Adherence to his beliefs brought him into conflict with the Olympic Committee whose members found it incredible anyone would place God above King and Country. Seeing his teammates run without him, he wishes he was among them -- even with strong convictions, he's still human -- but it's a wish unaccompanied by doubt. In his final race, a competitor says of him, "He has something to prove. Something personal. Something guys like (our) coach would never understand in a million years."

Probably the second most common question I get about attending medical school at my age relates to whether I have any regrets about my decision. "Now that you're here, has medical school lived up to your expectations? Would you do it again, knowing what you know now? Is the pursuit and presumed attainment of a dream everything it's cracked up to be?"

Truthfully, it depends on the dreamer. For me, it certainly has been, and continues to be, as fulfilling as I hoped it would be, and in ways I couldn't have imagined what seems like a lifetime ago. In part, this is because I haven't been aiming at achieving a distant goal nearly as much as I've been engaged in a daily process of achievement. 

Life is a terminal illness for everyone and waiting to live is folly. Sure, like the rest of my classmates, I can hardly wait for the day I get my first paycheck as an attending physician, but delaying enjoyment of what I'm doing until then is like carrying a dream around in a bucket that has a hole in it. You wake up one morning to find your dream has dribbled away when you weren't looking.

This is why I try to take every day as another chance to work at being a doctor, even one in training, though may I forget, as we all do. Distracted by a mistake or worried about my performance, I stumble over my own frailty, and then a nurse asks me what she should do next or a patient smiles after we've discussed her upcoming procedure and I remember. Doctor is who we are on the inside, long before our names are punctuated by the initials D.O. or M.D. on our white coats.

Would I do it over again, knowing what I know now? I've probably answered that one already, but let's just say a person can arrive at the point where living authentically is more important than playing it safe. You bet I'd do it again, though, with the virtue of hindsight, there are a few things I'd do differently along the way. For instance, I'd make the acquaintance of Francis Ihejirika, MD, much sooner. Francis is the founder of the PASS Program in Champaign, Ill., and even more than successfully preparing me for board exams, he taught me how to think as a medical clinician. Eight weeks of being challenged, encouraged, patted on the back and kicked in the pants were life changing. "Thank you" is scarcely enough.

I'd also be less afraid, if that's possible and maybe it isn't when you're trying to swim against fifty-foot waves that drown the biggest ships as though they were the tiniest toys. But that's what medical school can seem like. We start out feeling vulnerable -- much like we do in those crazy dreams where we're naked and everyone else isn't. You've had those, too, huh? Funny how I never manage to have Daniel Craig's physique (Casino Royale, 2006), despite what Freud said about dreams representing wish fulfillment. Anyway, we end up finding out the individuals we thought were the smartest, the most gifted, and presumably, the most invulnerable, have have been battered by the waves, too. 

Medical school is a huge undertaking; it's the hugest thing most of us have ever attempted. I can't stress this enough. Honesty forbids me from coloring this truth in anything but black and white. Nothing I know of can adequately prepare a person for the volume of material they're going to face, the hurricane force at which it strikes, or the feelings of aloneness that surface in the wee hours before exams. It's something you have to experience to know. But looking back, I can see how I've grown in the confidence surviving brings and without a doubt, I'm braver because of it.

(Creative Commons image of Eric Liddell via Wikipedia)

Medical School at My Age

 
A week ago, a few days before graduation, I was asked the question I hear more frequently than any other: "Why did you choose to attend medical school at this time in your life?" My questioner went on to say he’d graduated in the late 1970s and couldn't imagine doing it "at my age." 

You'd think after six years I'd have gotten enough practice that answering questions like his wouldn't require much reflection. To a certain extent, that's true, except over time my understanding of why I undertook this process has grown, and along with it, the way I respond to questions related to age. 

Now, to be fair, some of it does have to do with how I read the the other person. What do they really want to know and how much time have they got? Is it polite cocktail party curiosity or are they contemplating a course correction in their own career? In this case, the question was posed by an attending anesthesiologist I'd just met and we scarcely had any time at all, so I talked briefly about pursuing a dream. As I walked to my car a bit later, it occurred to me how impossible it is to imagine myself not  being a medical student at this point in my life and how very little age has had anything to do with it.

Admittedly, that isn't entirely true. Before I undertook medical school, I argued vociferously against it, considering age my most salient point. I wanted to become a doctor and, particularly a psychiatrist. I always had, but the circumstances of life took me in other directions and it seemed ridiculous to suppose anyone would take me seriously now. Obviously, I eventually lost that argument and what I've realized over time is I never had a chance of winning in the first place. Something was afoot in my life that neither reason nor common sense nor anything else had the power to effectively counter, as I hope the following story reveals.

It was a Sunday night and my shift as a substance abuse therapist at a Boston hospital was 30 minutes away from being history when I was paged to the nursing station to handle an admission. My patient was an older, intoxicated gentleman, accompanied by his adult son. They were pleasant, intelligent, lived out on the Cape (Cod), and despite grumbling to myself about having a new admission so close to sign-out, I immediately took a liking to them both. A few moments later, while meeting with the father to sign his paperwork, he said to me, "Doctor, I want to tell you how all of this began..."  I ought to have told him I was only his therapist, but hearing the title, "doctor," honestly it felt so good, I just couldn't. 

I told myself I'd explain the next day and I did. I wasn't trying to mislead him, but it felt like unfaithfulness to something I didn't quite understand, to correct him. You might say he was under the influence and simply mistook me for his physician because I was an older male. I say in vino veritas. Unknowingly, and probably unconsciously, he saw into a deep and private place and called me by the name nobody, not my parents, my friends, or anyone else, had ever spoken. For the first time in my life it seemed as though someone knew who I was. How could I deny that?

Back then I wasn't so much thinking as feeling. Drawing near the end of this leg of the journey, I've done a great deal of thinking and I've begun to realize how very much it's been like growing into a father's shoes. When we're young, we slip into them and they're huge, so huge we can't walk without stepping out of them. One day, they've grown smaller and then smaller still until they fit us as well as dad. Why attend medical school at my age? I guess you could say, that's when the shoes finally fit.

In another life, to borrow from Katy Perry, whom I love, I might have gone to medical school "on time." The tricky thing about other lives is they don't come into being unless we find a way to make them. I didn't have the keys to a Delorean (Back to the Future) in my pocket, so reversing the time-space continuum wasn't an option. All I could do was be like the proverbial turtle, who never gets anywhere unless he sticks his neck out. Yes, I was older and by definition, that meant attending medical school as an older, rather than younger, adult. Age was a piece of my puzzle. But it was only a single piece and nowhere near my biggest one. Had I been born someone else, it might have been gender, race, or national origin. We all have something we can't change.  

George Eliot (pen name of Mary Anne Evans), author of Silas Marner, said, "It's never too late to be who you might have been," to which I'd add, until it's too late for everything but that final breath.  What has become clearer and clearer to me is how much medical school and now, residency, have come to mean immeasurably more than simply fulfilling a long cherished dream. They mean being true to what I've learned about myself as this process has unfolded and there really are very few things quite as important. They mean acting on the freedom to make choices of my own rather than making up excuses for denying them and then, trying to live with the consequences. They also mean, considering everything that lies behind and whatever lies ahead of me, there isn't anything to make me regret coming this way.


(Photo copyright 2013 by the author)

Newtown, Connecticut: The Streets of Heaven

"The streets of heaven are too crowded with angels tonight..." ~ President Josiah Bartlet, The West Wing

Following a tragedy such as took place yesterday in Newtown, Connecticut, one often hears the statement, "Let's not politicize this." But failing to recognize its political implications is as irresponsible as attempting to use them for political gain. Remaining silent on the pretense of respect, renders the needless, senseless deaths of children meaningless. Can there be anything worse?

In the latter days of the war in Iraq, when it had become clear there were no weapons of mass destruction, when the Bush administration determined a "war of liberation" would play better in the media, families of soldiers killed in action relied on those three words to assuage a loss no parent should ever have to face. The alternative was a sacrifice without meaning, and that was unthinkable.

We flirt with meaninglessness, however, when a murderer rips our loved ones from us and from the public stage we hear, "I hope no one uses this as an excuse to talk about gun control." What we've witnessed in Connecticut is neither an excuse, nor is it evidence we need an armed electorate to take the place of those we've empowered to protect us against violence and mayhem. What is is, is evidence of our national refusal to listen to the voices of victims at Columbine High School and a theater in Aurora, Colorado.

If we could tune down the noise of our own convictions, we'd hear a voice shouting from the periphery of those convictions, "For the love of God, please, don't let this happen again." But we do. The gun lobby argues, "guns don't kill people, people kill people," and there's an element of truth in that. I've never seen an M-16 walking down the street, creating havoc. Not without a person at the butt end, pulling the trigger. Then again, what if they couldn't get hold of a semi-automatic weapon with a 30 round magazine in the first place? Would that really impinge on anyone's Second Amendment rights?

We treat gun ownership like pornography. We put up with Hustler because we want to be free to purchase a copy of The New Yorker or Road and Track at the grocery. We also regulate Hustler to keep it from falling into the hands of children. We presume the right to own an assault weapon secures our right to own the 12 gauge we take bird hunting in the fall. Maybe it does, but that doesn't mean anyone who wants one should have one. Mutual responsibility in a free society requires us, at key times, to limit the exercise of our freedoms for the sake of the common good. 

We regulate pornography better than we regulate guns. If we're going to honor the memory of those who've died tragically, we've got to change and we've got to start now.

(The West Wing citation from 20 Hours in America, (2002); GNU free documentation image of the Columbine High School Memorial via Wikipedia)

Can You Cuss a Little?

I must have been around seven, seven or eight, though it could have been nine -- certainly no later -- when I met my paternal grandfather the first time. If he held me as a baby and surely he must have, I'd be hard-pressed to dig the memory out of my distal recesses. The other first time, however, is as vivid as this morning's frost on the grass. 

He lived in Oklahoma, my parents and I in Colorado, and he'd come for a short visit. More like a stopover than a "visit," he was gone the next morning. I sat in a brown or green -- I never knew which -- overstuffed relic from the 1940s with short, fat wooden feet and a flowery pattern that rose off the fabric like continents on a globe. It was big enough to curl up in while he talked with my parents about people and places they knew and I did not. After a while, he turned to me and suddenly young blabbermouth Beggar was at a loss for words. Particularly, the ones he wanted to hear.

"Have you learned how to cuss yet?" 

For the record, I wasn't really at a loss for words -- by then I'd acquired a vocabulary of two bad and two really bad words and combinations thereof, thanks to my father's verbal creativity. I just wasn't supposed to say them. Ever. And now, here's my father's father, asking me to do what would ordinarily result in my catching the word that began with an "h" and ended with me wishing I'd said "heck," instead. I looked from my mother to my father, hoping for permission. They may as well have been playing poker for all the help I got from their expressions. Hell -- I mean, heck -- of a time to enforce the rules.

"Come on, Beg, you must know one or two. Let me hear you cuss," he said with a truly conspiratorial glint and grin. Let's play a good one on your folks, I read. Talk about caught between "the devil" and the deep blue sea. I wanted to, oh, how I wanted to, the blood rising to my neck and then flowing like a flood over my face. 

The clock was ticking, he was waiting, they're silent, and all I can think is, "Damn it, Grandad, you know I'll get in trouble if I do!" If there was ever a time I needed a Get Out of Jail Free card. 

"Well, I can see you'd rather not go against your folks and that's good. We can save the cuss words for later," he said, winking, after my shirt had nearly soaked through with nervous sweat. 

I felt relieved, but also felt I'd let him down. I wanted to do both, be good (and incidentally, avoid a lickin') and be grown up at the same time. It's funny how these things go. Eventually, you do find out how to be both at once and true to yourself in the bargain. Back then, all I knew was, that's the night I began to love my grandfather. 

I sure hope he knows.  


(English: New Year's Day postcard. Reads: "A New Year's Resolution / Jan. 1st / To Gossip, Slang and Cuss words / I'll bid a last "Adieu" / And place a bridle on my tongue / And thoughtless actions, too!" Photo credit: Wikipedia)

The Sighing Thing

"Oh, God!" he sighed, heavily. So heavily I thought he and the ancient, paint-stained,  ladder back chair he was sitting in were going to sink through the scraped and scratched wooden plank floor to the soil beneath. I waited for the thunk! -- it never came. His eyes were closed, but he wasn't sleeping. Nor was he being profane.  

"It's all right, Beggar, he's just praying," my grandmother said, overhearing him. I wondered if she knew how many times I'd heard him before. So many I'd lost count.

I looked at her and smothered a smile. Did she really believe that or was she trying to preserve my youthful innocence, the very thing my grandfather -- her husband -- had done his best to turn into good judgment, something he considered eminently more practical.  

He did the "sighing thing," as I came to think of it, mostly while sitting in the shade near our bunkhouse door. It wasn't really a bunkhouse, but we called it that, just the same. It was a detached single car garage that had never housed a car, at least in my memory. My father converted it into a saddle shop at one point and I've written about cutting firewood for his stove. Summers, it was the bunkhouse where my grandfather stayed. Those months, I've realized since, were a journey in character development.

"If you absolutely have to point a gun at someone to protect yourself or your family," he said once, "it's too late for threats. Indecision at a time like that can be deadly." He spoke from experience. Another summer night, years before, he stared down a neighbor who had the nasty habit of occasionally firing his gun in the general direction of my grandfather. "The man's crazy," he said, refusing to get dragged into something he knew he'd have to finish, "and besides, he can't shoot worth a damn." Only this particular evening, it was different. The man had shot at my father who was about my age and I was thirteen. 

Why not call the police or sheriff, I imagine you're thinking. That would have been the thing to do, if they'd had a phone. Forty miles into barely civilized northwestern Colorado, the ranch was a two or three hour drive by Model A Ford from the nearest town. There were no phones, nor were there corner stores or gas stations. I'm not even sure there was electricity. It wasn't that you took the law into your own hands, there just wasn't anyone else who could take it into theirs.   

So, father and son rode out to address the situation. Watching the scene unfold, my father was fearful, certain he was going to witness my grandfather meet out justice just as his father had fifty years earlier. In my imagination, reliving those long seconds, I see my grandfather with a look in his eye that left no doubt, as his hand strayed to the pistol at his side, that he fully intended to use it. The neighbor must have seen that look, too, because he backed down and that was the end of it.

Grandchildren are a second chance for parents to get it right. Those summers, I was my grandfather's trusty teen sidekick, Cowboy Toby to his Roy Rogers (photo). I listened, learned, and hopefully digested far more than I actually remember. I've never forgotten the "sighing thing," though, nor the day I finally asked him what it meant.

I'd really been hoping he'd tell me himself when he was good and ready. That's how things usually went between us, though I never knew from day to day where his mind would lead. But it was nearing the end of summer and he'd said nothing, so I screwed up the courage one day and asked what was he thinking about when he sighed so deeply. He was surprised I'd noticed. How could I not? 

"You live as long as I have, Beggar, you're going to make a few mistakes. Don't be afraid, everybody makes a few and so will you. Some, maybe most, don't matter, least not as much as we give them credit for. People who know you, forgive like you forgive them. Some mistakes do matter -- maybe more than they should, but that doesn't change the fact. Problem is, you either don't realize it or you're too stubborn to admit it, until it's too late. I think about those."

"So you don't make the same ones again, right?" 

"No, because I made them the first time." 

I was too young to understand regret. Sorry, wish I hadn't said or done this or that, oh yes -- plenty. Regret was something else, something -- I don't know -- bigger, something I hadn't lived long enough to become acquainted with. Something that only comes about with experience, with trying to do what you think is right even though you don't and can't know everything but you have to try anyway because it's all you can do and it's really all anyone can do. Don't worry, we all make mistakes, so will you. It's okay. My grandfather said so.

Happy Thanksgiving.


(Creative Commons image by vintagecobweb,com via Flickr)

Advising Mitt

 
I sort of feel sorry for Mitt Romney. He did what most of us have done, or I have anyway, and wished almost immediately we hadn't. Opened our mouths and watched as the unspeakable came out seemingly of its own accord. Maybe we were angry or afraid or eager to be viewed as acceptable and be embraced by others. At the time, it might have seemed innocent enough -- we thought we were in a protected environment -- and of course, we weren't, as demonstrated by the fallout we're unable to duck no matter how deep we dive into the shelter. Now, we're left, picking up the scattered remnants of our self-esteem, detritus from stepping on one of our own land mines.

Have you ever noticed how easily, on such occasions, a person  says, "But that wasn't me"? Well, if it wasn't, then who was it? It sure looked like me, it sounded like me, people say it was me. I haven't been cloned lately, so far as I know. It sure wasn't Robin Williams doing his best Beggar imitation. I "inhaled" in high school but my sensibilities have long since moved in other directions. I can't blame alcohol -- with my limited tolerance, slurred words are far more likely than misspoken ones. True, at least this way I'll never have to explain how "what made Milwaukee famous, made a loser out of me." (Thanks, Jerry Lee Lewis -- wish I'd written that line.)

So, basically, it was me, or you, or in this case, Mitt. Now, in retrospect, I'm sure he wishes he'd never said anything about the 47%, but it was caught on tape and splattered onto the news, so there's no denying it. The problem is, he's attempting to do what anyone would under similar circumstances, i.e. try to dissociate himself from the image he just created. That's normal -- we don't want people to think of us in terms of what we say or do when we wish we'd said or done something else -- and would if, please God, just this once, is it okay if we turn back the clock?

On the other hand, I sometimes wonder if a better strategy might be to simply own up and admit the truth. Instead of trying to convince us that he really is empathetic, state for the record, "Yes, I'm an elitist. I have a strong preference for associating with wealth, I don't relate well to the working class, I disapprove of welfare and those who depend on it, I'm opposed to government restrictions on business and given the opportunity, I'll lower taxes on people like me and if you want to see my tax returns, watch how fast hell freezes over."

You don't think that's going to get him elected. Well, you're probably right, I suppose it is asking a bit much. But trying to pretend he's someone he's not is even worse. The unconscious has a nasty way of making itself known and frequently does when least expected or welcomed. We all have an inner trickster who absolutely delights in making us appear foolish and the harder we try to keep her/him locked in the closet, the more determined s/he becomes to make us regret it. So, Mitt, if you still aspire to the presidency and you don't mind my unsolicited advice, admit you need to change. Trust me, it won't hurt. Okay, it will, but only your pride and most of us can use a little bit of that now and then.  


(Creative commons image, "Trickster Tales Sketch" by Amanda Schutz via Flickr)