My Inner Demons and I are on the Same Side – Living in the Now

“I stop fighting my inner demons. We’re on the same side now. T-shirt”

― Darynda JonesSecond Grave on the Left

 

Monday came. I was not ready to tackle the day. I lay in bed a few minutes longer while I started to dread and plan for the day’s appointments, calculating drive times, meals, and accommodate everyone else’s schedules before I had even thought to blink open my eyes.

It dawned on me at some point that I was living out a day that hadn’t even begun yet.

The anxiety of the impending tasks, or the overwhelm that comes with trying to handle everything before it arrives, you know this too? The exhaustion that eventually overtakes us makes us ridiculously absolutely not excited about our lives.

Living in the future instead of now is like sprinting ahead of our own feet, if only we could! The only task we have to do is to actually wake up.

Continue reading

Stigma from Religion

I’m just leaning on God.

Which was her reasoning for stopping her Lexapro.

Nora’s family lashed out angrily at her. “Why are you so horrible!”

Her husband had left her for another woman from their church, a “friend” of Nora’s who used to come to their house for movie nights. He said, “You’re like poison, Nora. I’m not happy any more with you.”

Nora had now lost her job. She couldn’t focus and cried too much at work. Her supervisor told her, “You are not the same.”

Nora decided she wasn’t going to take her medications any longer because what she needed was more faith to be well and to get her life back. Her plan for recovery from debilitating depression and paralyzing anxiety was to be more dependent on God by way of certain practices, mainly not taking her medication. Although she didn’t see her plan for recovery quite so transparently. She thought it was through prayer and sincere intention to be God’s rehabilitation appurtenant.

Nora did say she was still taking her anticholesterol medication. And so we spoke about the important related perspectives between what Nora saw to be “medical” verses “spiritual” illness.

  • First to lead into the matters, “What are you taking your Crestor for?”
  • Where does cholesterol come from in our bodies?
  • Where do emotions and behaviors come from?
  • Is there a spiritual element that has a relationship to high cholesterol?  How about to emotions and behaviors?
  • Is there a medical change that causes the disease of hypercholesterolemia? How about emotions and behaviors?
  • Why be willing to take medication for a spiritual illness of hypercholesterolemia? Wink.

Nora, it turned out, loved where this conversation took her thoughts. It was hard to encounter inconsistencies in her religious beliefs and practices. But she did because she is a woman of courage!

It got me thinking about what role our cultures, related to religion, play into our emotional health. Is there a source of stigma against getting life saving medical treatment for mental illness that we are missing simply from the religious culture we are quietly woven into through life?  Randy Travis’s song lyrics, “I hear tell the road to hell is paved with good intentions…” implies that we in religion justify the collateral damage, such as death and ruined lives by mental illness, by the belief in the greater good. I’m sure I do this too in my own unconscious way. And isn’t that what this post is all about? I want to take a big stick to this glass and shatter it! (Aggressive much? Smile.)

When I think of Nora, sometimes I can’t believe she actually is taking medication and doing so well now in her life journey. It’s a miracle.

Self-Care Tip: Explore the role religion is in your opinion toward medical treatment.

Questions: How does religion interweave into your stigmas? Or those you’ve broken through? 

Or maybe it’s the opposite. Religion has contributed to your self care and medical choices?

Please speak! We need to hear you!

“The devil is talking to me.”Briefly on God and Psychiatry

“The devil is talking to me.”

Her lips shaped words but her voice was like a robot. 

My gorgeous tall black thin framed model-bodied patient looked at me with a face that barely moved. Almost flat. Her eyes rarely blinked, with orbs that seemed to jump out at me when she spoke. 

This is Talia, a 3.8 GPA college grad last year who just started her first job in marketing. She has been a Jehovas Witness for about ten years and is passionate about her God and religion. She has been attending church related meetings lately about 6-7 days a week and loves to read her Bible for hours. However, over the past six months when she reads the devil and his minions cuss loudly in a cacoffany of foul persecutory language. She is afraid all the time and has high inner tension. 

Talia cannot sleep any longer for more than a few hours at a time. She has been losing weight. She has lost her job, and is panicking, terrified to read her Bible or go to church. 

Her family says she is talking to herself, and has “crazy eyes”.  They do not know what to think. Maybe she is possessed as well as crazy. Maybe both. 

Is Talia possessed by the devil? Is Talia crazy?

I was in Los Angeles this summer with my kids, walking on Hollywood Blvd. We passed several people who were responding to internal stimuli. One extremely saddening lady was slumped against a shadowed corner sitting in her own piss leaking down the street, her shirt half open, as she spoke to various targets. My kids were afraid. We were all, frankly, sad. My kids did wonder, too, were these people possessed by the devil?

Have you ever wondered if the devil was talking to you? Or working on you? 

The question is, if you want to ask this, rather ask, “What does this say about the character of God?” Included in all the biology explanations and psychosocial intersections, we bring the magical and spiritual. If you ask about the devil, ask rather about God. What does this say about God?

Talia had been adhering to her treatments and now celebrates that she is able to read her Bible again, go to her religions meetings, and has even driven around a parking lot once with a family member in the seat beside her. She is sleeping through the night, able to enjoy life, the simple and large things like the touch of shower water or taking a walk. 

When Talia hears voices, she no longer believes the voices come from the devil but rather demonstrate that she has missed something bad inside of herself that she hasn’t yet surrendered. I asked her, “What does that tell you about God? The character of God.”

We are so quick to assign nonbiological causality to emotions, thoughts and behaviors. It turns out that when the brain gets sick, emotions, thoughts, and behaviors generally go the direction of bad, rather than “good.” Naturally we ascribe moral value to what we are culturally primed to believe has moral value – emotions, thoughts, and behaviors. The question becomes, “What does it say about who God is when we do this?”

I like to think about the character of God. It is a picker upper. When I get enmeshed in some line of thought that demonstrates a poor reflection on Gods character, I figure at some point that I’m not seeing things clearly. It’s always a relief. I don’t know it all. If it says horrible things about God’s character, than I must have some misinformation or misinterpretation. 

Others may say rather, I am misreading Gods character as good. That’s not a perspective that is friendly to me in the end. One of the reasons I reject it. 

Self care tip: Ask yourself, “What does this say about God’s character?”

Questions: Have you ever wondered if the devil was talking to you? Or working on you? 

Do you ascribe moral value to emotions, thoughts, and behaviors?

What does it say about who God is?

This one chance

This one chance

My morning clinic had been hectic but not very interesting. I felt bad for the student who had been assigned to me – we had not seen any unusual cardiac pathology. Instead, we had heard a long litany by a patient with a recent heart attack who for the life of him could not stop smoking, and been forced to listen to a tirade by an anxious wife who was unhappy with her husband’s nursing home and wanted to take him home for end-of-life care. A large part of that visit had consisted of calming the wife, and hunting down a new oxygen canister to replace the empty one that the nursing home had forgotten to check on when they sent the patient on his way to my appointment.

I sure hoped the next case would offer something more exciting for the student. It was a new consult, an elderly man, wheeled into the office by his wife. When I asked him if he could get out of the wheelchair, he easily acquiesced though I could tell his wife was uneasy. She didn’t say anything, though – it seemed that this was the custom, defer to the husband. He tried to flop onto the exam table, steadying himself with the cane – and almost fell. The student jumped to catch him, eagerly – he was a freshman, in the beginning of his first year, and had not seen a real patient until that day, so to him, catching a patient from a fall was new. The patient grumbled that he was ok, and the wife rolled her eyes.

As we talked further, I couldn’t quite figure out why this patient had been sent to a cardiologist – he had some nonspecific complaints that I could not entirely make sense of, either because he was a bad historian by nature, or had become one after his stroke. His wife tried to supplement the history but due to her language barrier and her general reluctance to take the center stage in the storytelling she was not much help either. In the end, I decided that an objective cardiac test would help alleviate everyone’s concerns, and ordered it. I then spent another half of the visit going over heart-healthy lifestyle, and addressing other, not-heart-related safety and preventive issues that I thought were important for him, such as walking safely, getting physical therapy and doing regular exercises to prevent falling.

After the visit, I helped to wheel the patient back to the waiting room, and saw a little girl jump up from the chair and run over to take the wheelchair away from me. “Our grand-daughter”, the wife said. Oh.

I turned toward the girl: “How old are you?” She proudly extended all the fingers on one hand: “Five!” Somewhat surprised that the little girl had been left all alone in the waiting room, I nevertheless tried to make some conversation.

“So,” I offered somewhat lamely and predictably, “what do you want to be when you grow up?”

“A cop!” came a self-assured and unhesitating response.

The girl then looked at me, pondering, her brunette curly mop shaking, gold earrings glittering, and then offered somewhat less confidently, “And a doctor.” After a moment, the curls bounced again. “Yes, a cop, AND a doctor”.

I smiled. The student laughed. We said our good-byes to the patient and his wife and returned to the exam room to finish the paperwork.

As I stood at the desk, however, I found my attention wandering. I saw other little girls in my mind – myself at age five, uncertain and shy, my little niece at the same age, more confident in what she wants but not sure yet of her place in life. My feet took me back to the waiting room.

“Here,” I offered the ears of my stethoscope to the little girl who was still guiding her grandfather’s wheelchair, “Do you want to hear what your heart sounds like?”

“YESSS!” the enthusiastic reply came quickly.

“Ok, here is your heart – ‘tick-tock, tick-tock’ … and here are your lungs, ‘whoosh-whoosh’ – can you hear it?”

The curls bobbed up and down again as the girl turned to her grandmother, spell-bound: “That was my heart! Gramma, I could hear my heart!”

After I had retrieved my stethoscope from the small hands, the student and I parted the second time and went back to the exam room. While I was trying to make some teaching points about the case, the excited squeals were still very audible from the waiting room, “The doctor! My heart! It went tock-tock! I could hear it!”

The student laughed again. “And just like that, you changed this girl’s career trajectory for life,” he offered, jokingly.

Well. Probably not. But who knows? One chance is all it takes sometimes.

Maybe the little girl will become a doctor. Maybe the man with a heart attack will stop smoking. Maybe the wife of the seriously ill patient will be less distraught, knowing she can call on my help. Maybe the elderly man will not fall at home.

Maybe.

***********

I never got the name of the little girl. I don’t remember the name of her grandfather. By next week, I will not remember the name of the first-year student who spent the day observing my clinic. They will likely not remember my name. I got this one chance with all of them.

One chance. Every day, filled with one-time chances.

That is a lot of maybes.

***********

Self-care tip: Watch for one-time chances in your everyday life. It may make a change – albeit small – in your life or in someone else’s.

Question: Do you recall a time when you took a one-time chance, or missed one? Tell us your story.

 

It’s not my fault

It’s not my fault

The new on-call resident – Jonathan, I think was his name? – was trying to present another admission to me. He was visibly annoyed.

“…so, the ER calls me and says, you have a patient with chest pain, and I say, what kind of chest pain, and they say, oh, we don’t know, but the patient needs to be admitted, and then I go down and try to talk to this guy, and he is just the worst historian in the world and just stares at me, and says I don’t understand him, and…”

I cut through the never-ending sentence. “Let’s just go down and see him together, hm?”

The light was on in the ER urgent room but I couldn’t really see the patient. The gurney had its rails pulled up, and I could make out a small lump breathing heavily under the blanket. We stepped closer and I called out,“Mr Jones? We came to see you, can you come out from under the blanket?”

The top of a knitted cap made an appearance, with two dark eyes peering out from under it. “Mr Jones?” I tried again. “I hear you were having some chest pain? Are you still having any now?”

The eyes got suspicious. “Ahah,” came a noncommittal reply.

“Well, can you tell me more about it?” I persisted.

“I waited until the morning”, was a cryptic response.

“What do you mean, you waited until the morning?”

The resident interrupted. “He was actually here last night and was sent home, and he came back today morning saying he has chest pain.”

I looked at Mr Jones again. It is not uncommon for patients who have no place to be, to complain about chest pain as they know it is a sure way to get admitted. This guy really did look sick, however. After some grumbling, he sat up for an exam. Clearly, he was in decompensated heart failure, and had been for a while. I motioned to Jonathan to step outside the room. “Is there anything about heart failure in the chart?” I asked him. “Yes, he has had heart failure for a while now – methamphetamines,” he added quietly under his breath, “EF, ten percent, but noncompliant with treatment, still meth positive last month though he denies using”. EF stands for ejection fraction – the normal being 60 percent – the lower it is, the weaker the heart muscle. I glanced at the monitor – heart rate at hundred and ten, blood pressure 80 systolic – he really should have been admitted last night. The ER attending had completely missed the heart failure part. I suppose Mr Jones didn’t make it easy.

I tried to get a little more information. “Mr Jones, when you say you waited until the morning, where exactly were you waiting? Did you go home?” The patient was evasive. From the bits and pieces of his broken sentences, it became obvious that he had somehow hid himself on the hospital grounds all night and come back to the emergency room when he thought the shift had changed and he would get a chance with a new physician. I decided not to press him further until he had gotten a little better.

As the day progressed, more wrinkles appeared in Mr Jones’s case. It turned out he had been diagnosed with a lung mass two years earlier and biopsies and surgical follow-up appointments had been scheduled that Mr Jones had not kept. He had not seen a health care provider other than the emergency room for at least couple of years. His heart disease was thought to be related to his drug use – initially, he had admitted heavy methamphetamine and alcohol use that he now denied. Unsurprisingly, his urine drug screen still came back positive.

****

The next day, Jonathan and I went to see our patient again. He was breathing a little better but had an expressionless look that was speaking louder than any words. I decided to press for words.

“Mr Jones, what do you know about your cancer?”

Blank eyes turned toward the wall.

“Well, they said I had one but then that’s the last I heard about it, couple of years ago.”

“Why didn’t you keep your appointments then?”

The eyes blinked rapidly. “Well, I didn’t know I was supposed to keep them, did I? They didn’t tell me what I was supposed to do…” The tail-end of the sentence ebbed away as Mr Jones was feebly trying to come up with a justification. The defense was half-hearted, as if he knew there was really nothing to say, and nothing he said changed anything anyway.

Jonathan at my side was struggling to remain silent. As a young physician, he was taught to help people, and it was frustrating to him that the help had not been accepted. Mr Jones was a veteran – all the healthcare for his cancer would have been free. Now it was too late. For Jonathan, it seemed like a failure, and what young physician likes that?

****

In the end, we were able to stabilize Mr Jones’s heart failure but his cancer was already spread to most of his body and could not be treated. He was no longer able to take care of himself, and was packed off to the nursing home for the rest of his short days.

It had been a good learning case for the residents – not because Mr Jones had presented a medical challenge – but because he had taught the limitations in our communication skills. We had never been able to engage Mr Jones in any meaningful way, and he remained as absent on the day of discharge as he had been on admission.

As an attending physician, I struggled to make sense of it to myself, so I could explain it to my residents. Was it supposed to make sense? Had we failed somehow, or was the outcome already determined before we got involved?

I tried to put myself in Mr Jones’s shoes, knowing for years that he had cancer but putting it out of his mind. Was he sorry now? Or was the current indifferent attitude merely an acceptance of his fate, knowing deep down that he would rather have chosen those carefree years again, living alone in his trailer, drinking, smoking cigarettes and weed, and allowing himself a hit of meth whenever he could spare the money? He had missed countless procedures and surgeries, doctor visits, blood draws, and lectures by the likes of me about his drug habit. Now in the end of these years, the choice was no longer his.

Remembering the vacant stare, I suspect Mr Jones may not have known himself.

****

I told Jonathan that he had done well, and that he should not give up on people. I suspect there will be time for more cynical life lessons later.

 

Self-care tip: Good intentions do not always result in good outcomes. Recognize when your help is not accepted – it is not your fault.

Question: Have you felt helpless in a face of suffering or personal struggle, and found yourself unable to help? Tell us your story.

Doctor, no offense but I don’t want to see you

Doctor, no offense but I don’t want to see you

It was already close to the end of the workday in my clinic but there was still a new consult to see. It was the usual – a recent heart attack with diabetes, metabolic syndrome and hypertension. Pardon me, I meant to say – there was a new patient named Mr Lowry with the above-mentioned medical conditions.

I went through the chart quickly – some of the medications could be further optimized, blood pressure could be better controlled, the weight would have to come down. I asked the patient the usual questions – no, no recent chest pain; yes, he can walk for couple of blocks until his knees start hurting; yes, he quit smoking; no, he has not been able to lose weight. Mr Lowry answered the questions readily enough though he did not offer additional information or ask questions.

I asked him to take off his jacket and get on the exam table for a quick physical. As I leaned closer to help him push the T shirt up to listen to his heart, I could see there was writing on the shirt. I could only make out the word “today” as the shirt was riding up on Mr Lowry’s generously sized belly. “What’s written on the shirt?” I asked, curious. I received the first smile of the visit, and Mr Lowry pulled the shirt down so I could see. I DIDN’T WANT TO BE HERE TODAY, the shirt read. As I puzzled, my patient burst out laughing. “This is my hospital shirt”, he explained. “I wear this to all my doctor visits. My wife knows that it needs to be washed every time I have an appointment”.

The smug joke masked a deeper truth – my patient was trying to set his own narrative for his medical appointments. He didn’t want to be “recent non-ST-elevation MI, diabetes, obesity”. He was “Mr Lowry who doesn’t want to be sick”.

There is something freeing in naming the negative emotion. It is now out there and identified. In regards to Mr Lowry, it made it easier for me to find the motivation for lifestyle change – “you need to take your medications, lose weight, etc – so that you don’t have to see me anymore”.

Over the next day, I kept going back to the shirt. Is it somehow more powerful to elicit a negative emotion rather than positive one? Politicians certainly know that fear moves people to vote more than a desire for a positive change. The generic “you should exercise to be healthy” is less motivating than “you should exercise so that you wouldn’t get a heart attack”. It is especially motivating if the heart attack has already happened once – now the fear has teeth. When I ask my patients what is the most important thing I can do to help them, the answer often comes in negatives: “I don’t want to be short of breath”, “I don’t want to be tired after walking 10 steps”, “I don’t want to be in the hospital”, “I don’t like the hospital food”.

Few weeks ago, Mr Herkel was admitted to my hospital service. He was an epitome of a healthy 53-year old – slim, fit, didn’t smoke, exercised regularly. Part of the reason he had kept himself healthy was his bad genetic lottery – most of the men on his father’s side of the family had already had heart attacks or died by his age. And now, when he had developed chest pain that refused to go away, he anxiously checked himself into the emergency room. The type of chest pain he had was not especially worrisome – but due to the significant family history, we did a thorough workup nevertheless. His careful lifestyle had counteracted his genetics – the tests showed no heart disease. Mr Herkel’s relief was palpable. “No offense, doctor,” were his parting words, “but I sure hope I will never have to see you again!”

As for Mr Lowry, I am waiting for him to come back one day with a different T-shirt. The one that says, I DIDN’T NEED TO BE HERE TODAY.

Screen Shot 2017-07-09 at 3.39.52 PM

Self-care tip: Sometimes, a powerful negative emotion may be a motivation for positive changes in your life. But you have to name the emotion first and evaluate it. Be smart.

Question: Have you had a negative emotion change your life for the better?  Tell us your story.

Blue Corvette and Cowboy Boots

Blue Corvette and Cowboy Boots

Some people love their cars and some people don’t.

I drive a Honda Civic – a perfectly serviceable car. It hasn’t been washed for half a year – after all, there is water restriction in California, or so I tell myself. There is a dent in the back bumper from that time when I tried to parallel park and a post magically appeared behind my car. I haven’t bothered to fix that dent nor the scratches that the car got when I fearlessly drove through a felled tree on the road. It’s not that I don’t love my car. I just love its functionality more than its appearance.

Several years ago, as I was walking to my job at the hospital, I saw a colleague getting out of an electric blue Corvette. The car was beautiful – compact, sleek, sparkling in the sunlight. My colleague happens to be not only a very tall but also a somewhat heavy man, so he had some difficulty getting out of the car – the Corvette was not made for his body habitus. Nevertheless, he looked positively radiant. I asked him later, “Why did you spend so much money on an expensive car that is too small for you and does not have that much functionality?” (perhaps I haven’t mentioned that I am not a very polite person). His answer surprised me. “It makes me happy”, he said. “When I get up in the morning and think about facing the day in front of me, I know there is always a bright spot in the beginning – I get to drive my Corvette to work. And that makes me happy.”

I pondered this. There was no way any blue Corvette was going to make me happy. Even a bright orange Aston Martin couldn’t make me happy. And I like orange. But I had to admit that I could not judge my colleague or somehow downplay his joy over something I didn’t understand. People are different. Happiness is relative, and in the eyes of the perceiver.

Over the years, I have had many conversations with my patients about what makes them happy. I have started looking at it as part of the treatment for their heart disease. People who can name sources of their happiness are usually more motivated to take their medications and to follow the lifestyle advice. Additionally, there is a small secret that the physicians may not tell their patients – and I just exposed it in case any of my patients happen to read this blog – tying the lifestyle advice to the sources of happiness makes it more likely to work. It doesn’t have to be a big thing – more often than not happiness comes in small packages. It can be a father, now less short of breath, able to play catch with his son. It can be a chronically ill patient now able to take an airline trip to see a new grandbaby. It can be singing a solo in church, making a trip to the grocery store, walking around the block.

Just recently, a patient I had not seen for few months, literally skipped into the room for his clinic appointment. “Are you seeing this?” he asked triumphantly, a big smile on his face. Well. Sometimes patients forget that I see dozens of them every day, and expect me to remember everything that was said at their last visit. I searched my brain as I was looking at him. Ah. The cowboy boots. Mr Golnach was wearing beautiful patent-leather ornately decorated boots that might as well have walked down from an expensive store window display. This had been his dream – to get his leg swelling down so he can finally put his beloved cowboy boots on. Clearly now, between better diet and regular medications, his heart failure was compensated well enough where the boots had become a possibility. “Isn’t this great,” he sighed happily. “Now I can die”.

Self-care tip: Find sources of happiness in your life, small and big. Naming them will add quality to your life, and keep you motivated to live better.

Question: Tell us your story about an unexpected source of happiness.