Why do I Keep Living? – Chronically Suicidal.

trainwrecklife

Carl D’Agostino is a retired high school history teacher. His interests include woodcarving and blogging. Cartoon blog at carldagostino.wordpress.com.   Cartoons published in book, “I know I Made You Smile, Volume I.”

Marvin lived hard for years, used up his bank, his talents used up like putting a flame to his wick.  He was wired to live in the moment. Living that way, when he had gifts galore freely given, living was different than when those gifts were used, diminished, and broken. Marvin was smart enough to rationalize his way into a chronic suicidality thereafter.

What is the point of living, after all? Marvin asked this question, answered it, and asked it again, to the point that it separated itself from Time and place. It is a question that is infinite anyhow.

Sometimes Marvin, with this infinite question, this question that occupies the time of God, kings, and beggars, Marvin would sit in my office with this infinite question in his nicotine-stained and inked fingers, and he would in this bring together the infinite with the finite. I remembered that the whole point, the meaning of the infinite and finite, is increased in value by the other. Marvin, living in the moment, even now years after his coin was thus reduced, was living in the infinite.

Why do I have to keep living? I just need someone to tell me it’s going to be ok if I die.

Marvin, If you are looking for a doctor to help you die, you need to go somewhere else. I will always choose life.

(It seemed like that “FYI” was in order.)

“We” made a plan …that Marvin wasn’t entirely in agreement with. I told him he could not come back to my clinic if he wasn’t engaged in that plan.

Marvin, we are just going to do what the data tells us will work. We don’t have to feel it or even believe it. We have the data at least.

Every time I have ever seen Marvin, I took a hard look, memorized him, knowing this may be the last time. Setting boundaries with him was freaky. It felt like trying to hold broken glass. Would Marvin be back? If not, I knew I’d be hurt.

The patient-doctor relationship is unique to each patient. It is unique to each doctor. For me, in my patient-doctor relationships, if it wasn’t for the hard grip I keep on the seat of my chair, I’d have too many of my patients in a big, but likely awkward, (and my Academy tells me, “Inappropriate”) hug.

This flashed through my mind in fair warning again. I compromised, saying instead,

You matter to me, Marvin.

I think Marvin’s lip actually curled and his canines grew. And I quote,

How can you say that? I just don’t get it.

This was a moment of road’s diverging, 31 Flavors, coins in your hand in front of a mother-loaded vending machine. I could see philosophers, all over the now and then of the ages, slobbering like they were at a nudie bar.

Once, when I called 911 on behalf of a patient who needed to go into the hospital for safety, the police person looked like that, bouncey even, on her toes. I had to check her feet to see if she was actually standing on a pedestal, she sermonized my poor patient so thoroughly. I think she was even eating a candy bar as she left my office, satisfied, (without my patient, by the way. Apparently she thought her tonic words had medicinal powers.)

Marvin was fishing me. There were so many ways to lose with that question. He was hoping I’d flop around with straining gills sucking air for hours while he tugged on the hook.

I’ve done that often enough, and will do it many more times. We can count on mistakes. What took me by surprise was, this time I did not.

Well, I’d guess it has something to do with me and something to do with you.

Yup. It surprised me. The surprise brought a wave of gratitude. “Thank you God.”

And if you aren’t as surprised or grateful by that liner, I can only explain that it was right at the time. Marvin lost his handlebar lip curl. I lost my grip on the chair. Marvin’s still alive, (I know everyone’s worried about the “for now” part of that.) And our universe cares, finitely and infinitely.

To the Marvin’s of the world, the wasted, the used, and the squandered, work your programs.

To the lonely and distorted, to the ones who have tried to die, to you who don’t know why you keep living, follow what the data offers by way of direction.

To you who may not get the same freely given gifts in this life that are now gone, you have good things coming.

We choose to live with you, than without. We choose you again. We choose, every time, what Love will bring. Keep on.

Questions: Have you ever asked yourself and/or others, “Why do I keep living?” What has your answer been? What is your answer now? For yourself. What would you tell your own Me?

Self-care tip: …I think I waxed on and off enough already with that – smile.

Love to Pee

peeThe little boy was standing in the tennis court by the fence, facing out.  Doing what?  Sure enough. 

“I’m nature peeing,” he said.

Have you ever seen as much happiness than in the faces of little people peeing?  Well, I love to pee, too. I think most of us do. That is until we pee inopportunely. Or poo. Ahem. 

I’m getting older and realize that my happy peepee-ing days are numbered.  Three kids later, into my forties, and like the garden faucet outside with minerals crystallized around a corroded fixture, dripping “will,” (ahem,) start. Soooooooo, sooooooome day, …urine will yellow my underwear. Kids, without discretion, will announce that I smell. And for the innocent, and a once happy pee gone horribly wrong, I will be ashamed.

The pelvis is like a woven basket. Muscles criss-cross in a wonderful design between a supportive frame, like plant fronds and wood. 

When I was an eleven-year-old, I travelled to the African continent.  It wasn’t every country, wink, but a few on the southern side. I don’t remember enough of my childhood. Who knows why. But I do remember, in every African market place, I looked on women and children weaving leaves and grasses. They didn’t even have to watch their projects. Their fingers had memory of their own.  Instead, their eyes were watching us watching them. Brilliant more-than-white smiles in chocolate black skin, turned their curious faces up.

My Mom, a lover of all things lovely, looked. She loved them all – the people, the baskets, the freedom of being in Africa, and more. Then the blood of generations of hagglers and market yellers whipped through her Lebanese veins with increasing energy, distracting her from a bigger picture.  She wished mightily for baskets.  She would have purchased every one and made us carry them all back to our home, eleven hours by airplane, if she could. (Those were the days when people smoked inside airplanes. You and I understand what that meant. That air inside airplanes was the same air everyone inside breaths. It was a long flight.)

A decade-plus later, World Market opened. I wondered about all the faces and fingers it must have taken to make all those gorgeous creations, now for sale in Temecula, CA, for twenty some dollars a piece.

How could I be so clueless as a twelve-year-old, but I was, and I didn’t know about the fingers that deftly moved, the brilliant plant dies, the tight strength that remained in a basket, like hands clasping, between each fiber. The baskets held memory.

These are the baskets I think of when I think of the marvel that the pelvis is.  These are the baskets I think of when I think about how much I will despise losing continence. When losing continence, I will also remember that little guy making “nature pee.”  I will pull the backing off another panty-liner and say, I used to really like to pee. 

Our emotions and behaviors are similar to the joy of peeing and the pelvic basket. We at one point in our life may have loved to live, loved to speak with friends, loved our hobbies and our stamps, and our cooking pans. Some day later, we wake up, and people notice the difference, like the urine smell in incontinence, people notice our emotions and behaviors “leak.” Kids point, even, “Mommy, why does Bridget’s Mom always wear those sweat pants? She’s in the same sweat pants every time we see her!”

It’s awkward. People don’t know what to expect from us. Our emotions and behaviors are not what is socially acceptable and they stop knowing how to speak to us. Our professionals who are supposed to help us don’t even know how to speak to us. They shorten their visits with us. They tell us how to feel, “Just decide. Make a choice. Choose to be happy.”

When people don’t know what to expect, it divides us and separates us and is uncomfortable for all. This discomfiture, (less often consciously aware,) is a barrier in knowing how to speak to a psychiatric patient. It takes a heck of a lot of self-awareness on each party’s side to look inside ourselves and figure out where our discomfort is coming from.

What will you think of when you “wet your pants?” Or of someone you are with? Feel your energy get sucked into the earth by a depressed colleague? Notice acid escaping your stomach into your throat when an angry child’s emotions fill a room? Your thoughts start to buzz when the white noise of anxious Dad comes around.

Remember the pleasure that came back in the day, see into our Me, identify the nidus of discomfort, and then let it lose it’s power over us – then the unexpected with be an encounter of mutual respect.

Knowing how to talk to a psychiatric patient, means that we are okay not knowing what to expect, not personalizing what isn’t about us, and allowing for a context that is in many ways unknown. With this, we will pull the backing off a panty liner and get on with it.

Questions:  How has the unexpected behaviors of your, or of others you know, been treated by your medical providers? How have you treated yourself in those scenarios? Please tell us your story.

Self-care tip: See into your Me to be better at speaking with the unexpected.

What to do!? On-Line Physician Bullying.

I’ve been to this great APA meeting, great that is, because of the people!  Wow!  The fellow attendees, the exhibitors, the speakers – just, WOW.

I’m going to try to share content with you but it will take me time.

bully

For today, “Are You a Sitting Duck Online?,” reminded me of our earlier discussions on the doctor-patient relationship and a previous post, on July 11, 2012, that went like this:

Hello Friends.

Please tell me how I’m doing on this.  Just out,

Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice

This is important to me as I treasure both my medical practice and our community, connection, exchanges on-line.   I don’t want to do anything that jeopardizes either, nor the implication that if I did, that means I would have mistreated a patient.

Thank you for this, what I call, a “good problem” to have – the joy of medical practice and participation in social media/networking.

So many of you resonated with this and engaged.  I am still super grateful.  I’d love to continue with you in further discussion and with your comments!

For me, one of the many reasons I was so excited about this recent talk at the APA is because of the mucho online stuff connected to my name that affects my patients and the dynamics in our patient-doctor relationship.

In my practice, these are just a few sites that have wrong information (demographics) on me:

  • healthgrades.com
  • vitals.com
  • betterdoctor.com
  • ucomparehealthcare.com
  • insiderpages.com

They didn’t ask to clarify my demographics.  They didn’t ask me if I wanted them to become an on-line reference on my behalf.  They use my practice information to drive “eye-balls” to their site so they can get advertizing money and more.  They impose incorrect information about my practice, knowing that in so doing, I will be pressed, (I call it bullied,) into contacting them with my correct information.

If I don’t do this expensive effort, (money, time, emotional expense – all in limited supply, to correct what they post incorrectly,) patients will continue to tell me that they couldn’t find my contact information.  When they Google me, instead of my website coming up, these other sham pages pop up.

Some patients call dead numbers or even drive to incorrect locations to find treatment.  Instead of whomever is behind these websites being held responsible, the medical providers are.

These are the notes I took from my colleagues, as I heard them say.

Unfortunately, I was late to the meeting so I missed two of the four speakers.  Even so, this is worth it.


Dinah Miller M.D., Author of “Shrink Rap” and writing regularly for Clinical Psychiatry News.

Dr. Miller told us about the difficulty of “patient” (or nonpatient, i.e., sham-patient) reviews online.

Who can review the physicians?

  • your patients
  • Friends and lovers
  • enemies
  • trolls – a negative internet stalker

Every practitioner has an idea that they are a pretty good doctor.  So it isn’t easy for any of us to hear otherwise ;).  After getting unsolicited feedback from a person who took the time to write a comment on a site that listed her, a site that listed her profile without asking her, Dr. Miller chose not to play the victim.  She decided to call “Health Grades,” and with her persistence, they took her information down.

On “Vitals” – she got an answering machine with a person’s voice mail and no name and number.  So she called CEO, Mitch, who stated she wasn’t able to take her profile down.  She didn’t ask to open herself up to trolls.

Dr. Miller asks, what shall we do, as physicians?

  • do nothing
  • write a response
  • try to call the company

There are many whose livelihoods depend on public opinion.  For example, waitresses/waiters – many lose their jobs if they get even one negative reviews.

The practitioners in the group responded with resonance with Dr. Miller’s ideas.  They also had thoughts that if left alone, the democratic process would win out over time, truth would come out and such.  (Maybe the nearby statue of Liberty played into our thoughts :).)


Paul S. Appelbaum, MD, Dollard Professor of Psychiatry, Medicine & Law, Columbia University

Principles that Might help physicians Identify Constructive Responses

  • Responses should be Effective
  • Practical
  • Compatible with medical ethics
  • Positive rather than negative consequences

Problematic Responses by Individual Physicians

  • Request removal by website – typically declined.  Saying you’re writing a public article on it might help.
  • Contact the patient who wrote a negative response to request removal – Patient not likely to remove response, many patients post anonymously, most websites won’t allow patients to remove them
  • Flood site with fake positive reviews – deceptive, embarrassing if discovered, ? inducing a person to rely on a statement that may be used to their detriment (fraud)
  • sue patient for libel – identify patient might be difficulty, people have a right to their opinions – would have to prove statements untruthful and not merely opinion, $$ in money/time/and emotion

Encourage Satisfied Patients to Post Reviews?  We could refer to a firm to do this.  $$

Some sites, similar to “Vitals” offer the option to the practitioner to respond to a posted review.

Negative Reviews:

If we do respond – how?  We don’t want to come across arrogant or insulting.  We fear violating patient-doctor confidentiality. In the end, we recognize we don’t have the last word.  We may respond with a soft word of concern.  “If you would call my office, I’d be happy to schedule at no fee to speak with you about this and see if I can help.”

Can Patient Reviews Be Controlled?  There once was a company that tried this.  “Medical Justice” developed a form that gives control over of copyright of all reviews to MD.  – Didn’t work.  See article, “Company tries to stifle online reviews with patient ‘gag orders’.”

Another idea is that medical practitioners help themselves by coming together to develop an internet ombudsman.  This would be a medical/mental health professional not involved in care of patient.

  • Independent (unrelated party) investigation of physician about the case.  A successful investigation may give a third party opinion.  There’d have to be a reason for the world to trust this opinion.

It is difficult for healthcare professionals to protect themselves from inaccurate complaints about their care.

Positive Reviews

Does it put undue pressure on the patients?

A sign in waiting room perhaps.  Make the information available w/o practitioner knowing if they have or have not commented.

There is a dissonance between the position of being a business person that says we must practice democratically and compete fiscally, yet stay in congruence with what tradition holds us to.


The issues addressed in the talk weren’t specifically about being bullied by sham-websites, but it included that idea, along with other difficulties physicians are experiencing in the rapid transition of 3000 years of tradition as a healthcare providers to spending the majority of their time serving patients first to now, the reckless $ burden of running a media vulnerable business.

In the practice of psychiatry, a traditionally extreme-private practice, this is dissonant to many.

Q:  How do we treat the extremely delicate practice of psychiatry as a business when we are held to currently minimally defended standards like this?  Please speak out and let it flow!  We need to hear from you!  …and, Keep on.

Self-Care Tip:  Deal with internet sham-sites and reviews in a method that is consistent with Me, and temperament, while doing the least damage to oneself. It will be better for oneself as well as others.

 

Sequestering Physicians from the Muggles

muggles

When in the exam room, we do not want it to be about the physician.  However many of us don’t want it to be about the patient.

Some of us want it to be about the system, whatever system we are in, so that the system can run as smoothly as possible and get all our protocols met. Are we are making physician-robots?  We isolate them and ourselves. There is a pressure when working in a system to sequester the physicians, such as wizards from the Muggles.

As physicians, we care better for our patients when we realize what we are getting out of the relationship.  We give much better when we know what we are hoping to get and perhaps hoping not to get.  We give better even with medical care.  Is it comforting to think that when it is medical, it is objective, about data?  More safe, perhaps.   However, this binary logic, is false.  We do not practice in such.  We practice in a place where people smile and cry and bond and connect and receive from us and give to us.  When we practice, it is personal.  It is obvious that it is professional.  The delusion is that professional is an either/or condition.  Either professional or personal.  Not both.  Never both.  That is a buttered wall to grip before sliding into patient doctor sexual relations.  Sneeze.

There is a term called, Grace, you may have heard of.  Grace is the condition of receiving without purchase.  Having been gifted and celebrating in the gift without qualifying it.  Perhaps getting a great review from a patient on-line you are expected to respond to, and just saying, “Thank you.”  We have a hard time with this in our world.  “Getting” well.

I struggle with “getting.”  I cannot describe yet how to get well.  How to receive.  When a patient gives to me, I struggle not to qualify what I am getting in the same way I qualify taking a trip to Hawaii, “Oh, I’m going to a medical conference.”  Or, “Look at this new patio set I got from Home Depot!  It was totally on sale.  I got a great deal.”

In practicing medicine, we need to grow to an acceptance of what we receive, and receive with Grace.

I am sure being a patient is better when we realize what we are getting from the exchange too.  We get more, or perhaps differently, than what the insurance and copay gives purchase to.  I hope the patient-doctor relationship is more than what can be had on the street of a Turkish bazaar.

Question:  What are you getting from your patient-doctor relationship?  What is your clinician getting from you?  How can you receive with Grace?  Does this affect your accountability to yourself?  Is this an act of friendship to Me?  Please tell us your story.

Self-Care Tip:  Get you some Grace, with Grace.

Psychiatrist is In

Psychiatrist is In

Lucy’s psychiatry booth

Did you notice?  In this picture, the patient became the psychiatrist.

Question:  Have you ever felt like your psychotherapist or psychiatrist blurred their boundaries with you?  Have you ever struggled with your own boundaries with him or her?  Please tell us your story.

Self-Care Tip:  Enjoy your boundaries and let them lie.

 

A Note of Thanks For Collaborating

typewriter 1

June 30, 2013

You
Friend to Yourself
Colleagues
Practitioners
Referral Sources

Hello,

I just wanted to send a note of “Thanks!!!!”
Thank you so much for including us in the care of your patients.  I hope we continue in your and their trust.

Practicing variety psychiatry brings me toward my quality of life experience and I am grateful.  I am not alone in this but blessed to be included in a fantastic team and community of treatment providers.

We believe passionately that our own quality of practice experience is the first step to engaging in a patient-doctor relationship.  Connection brings change and so our patients become a changing force in our lives with their courage.

Our patients work through multiple modalities, pressing toward healing and presence with electroconvulsive therapy, treatment-options awareness groups, medications, psychotherapy, and homeopathic remedies.  If there is more we might benefit from in practice, please let us know.  This is a life-journey we are honored to share.

Keep on.

Dr. Q

951-677-2333 ECT Centers, Medical Director
PrimeTelepsych.com Personal cell available, Concierge Telepsychiatry
951-677-2333 Treatment-Options Awareness Community Groups
800-670-4960 Pharmaceutical Research, such as, for those who cannot afford care otherwise – Principle Investigator
PatientFusion.com or (951) 514-1234 Outpatient Psychiatry Clinic
FriendtoYourself.com Us, you and I, Writing and Public Speaking

Patient-Doctor Relationship

shoes

Tonight I pulled together all the posts we have on the patient-doctor relationship into one page.  Please let me know your reactions.  This is a journey I am really grateful to travel with you.  Keep on.