doctor-patient relationship

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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.

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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.

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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.

 

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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.

Related articles

 

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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

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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.

 

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Confidence and Humility Go Together

Here is the good and the bad news.  There will always be something we can do better.

The Bible has a group of books called, the books of prophets.  Two of these are Hosea and Amos, named after the men who are narrating them, i.e. the prophets.  They say,

1.  You have a problem
2.  Recognize Me (God)
3.  Come after Me (God)

Amos talks about a roaring lion that is about to consume us.  Apparently sometimes it is not easy to get our attention and it calls for A Roaring-Lion-Intervention.

(Flip page.)

In the culture of the practice of medicine, the physician is expected to know what is going on including anything and everything that can possibly go wrong involved in the treatment offered.  When things do go wrong, what is worse, knowing it was going to happen or not knowing?  Things will always go wrong.

Roaring Lion

Roaring Lion (Photo credit: Martin_Heigan)

It is what it is that a physician finds herself in the position to work with confidence and direction, knowing that she will be wrong.  Does she need a prophet to tell her?  A lion to roar?  Stop!  Look out!  You have a problem! Well if the Israelites needed it, we can sure as not know that she will too.

Sometimes patients get upset at their treatment and roar on behalf of insight and common sense to their practitioner.

We in medicine, on either side of the white coat, will find it is most friendly to know we, (patient: physician: patient: physician…,) have a problem.  We need to know that we are not God and recognize Who is.  Then know that going on humbly does not mean without courage and confidence.  Who ever faced a roaring lion without?

Question:  Have you heard a lion roaring?  How do you grasp confidence and humility simultaneously?  Please tell us your story.

Self-Care Tip:  Go into practice and treatment with confidence and humility.  Be a friend to yourself.

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How to Trust Whom You Serve and Whom is Serving You

Michael E. DeBakey, world-famous cardiothoraci...

Much of what we do in medicine is elementary. I wouldn’t know how to quantify the amount of plainness involved with our goings-on. Behind the writing of controlled substances on pricey government controlled paper, behind our, “Hmm’s”, our flow of learning and teaching, and more (or less) than the laying on of professional hands, we are… we are common.

To say it simply, physicians are dealing with themselves. In medical practice, separating the self out, effectively breaking the emulsion of the physician from their personal journey leaves many of us suspiciously grouped into the numbers of old and lonely but practically excellent. Some medical specialties are infrequently bested by anything other than 80+ hour work-weeks, knowledge retention and steady hands. The imminent peril and the literal moment by moment of life-saving interventions helps the rest of us understand.

Even so, I’ve known some who have been “the best” and still managed to be connected to their personal. I imagine some other dimension is forced open by all the space that that kind of nearly fictional human occupies: Cardiothoracic surgeon, Anees J Razzouk, M.D., at Loma Linda University, for one; Gisella Sandy, M.D., critical care specialist, general surgeon and medical missionary in Peru, for another. We are all happy to say that the list is long here. We think of the ordinary physicians planted around our planet who are heroic enough to do the simple. After all, how much can a physician offer to her patient if she hasn’t taken care of herself first?

Those of us who seek medical care from a physician will be interested to know that the physician as well as the patient can only carry so much before things start to fall out of their arms. Before a sack tears on our way from the car to the kitchen, before there is spillage and things go unnoticed, we want to know that they thought about it. We want for them what they want for their patients in other words. Accountability to Me.

Wanting this for others, because we are afraid, is understandable. But it’s not at the aorta where life pumps and freedom flows. Each of us, regardless of fancy prescription pad or paper gown, to trust the other, we must have their own wanting. Wanting this for themselves. For Me. That is the pulse on trusting each other.

Questions: How has being a better friend to yourself improved your trust in those who are serving you? How has being a better friend to yourself improved your ability to trust those you hope to serve? Please tell us your story.

Self-Care Tip – Follow the thoughts that bring you back to Me where you will healthily grow your accountability, wanting and trust. Be a friend to yourself

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An Introduction to Self-Care | Journal of Participatory Medicine

logo

I thank the talented editor and friend, Sarah McGaugh of birdinyourhand, for her untiring interest and excellence in helping me develop this journal entry.

An Introduction to Self-Care | Journal of Participatory Medicine.

Please join us in celebrating publication in this wonderful Journal.

“Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.”

Kathleen O’Malley, Managing Editor, turns out to be wonderful as well.

Keep on.

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The Struggle in A Doctor-Patient Relationship To Not Get Personal

Conversation between doctor and patient/consumer.

Image via Wikipedia

In a patient doctor relationship, one of the realities is that our roles limit us from personal relationships.  Do things get personal?  I suppose inevitably as long as we are both human they will.  But we do our best to stay professional and use the standard of practice and the guidelines presented by our profession’s specialty board to help counsel us.  Because of years of increasing litigant awareness on both sides, patient and physician, this has culturally become important.

Each physician must decide what defines their ethical boundaries in their practice of care.  Each patient at some point must understand that there is a difference between what they are receiving and what they are giving in this relationship.  The patient doctor relationship is different from a friendship in part because there is an unequal level of power between them that opens up a huge index of interpretations on motives, intentions and fair play.  It also robs the patient of receiving what is considered a more objective level of treatment.  When things are personal, it’s more difficult to be objective.  It’s more difficult to do our job.

When I was in medical school, the psychologist I saw became intensely special to me.  She was the one who saw my vulnerabilities in every color.  Even though I cried regularly, brought her gifts that, thank God she accepted, and felt affection toward her, she somehow reciprocated without making me think I’d ever hear about her personal life, see her cry, receive gifts from her nor affection beyond what was appropriate for our professional exchange.  I learned so much from her but wish I could learn more.

Physicians do different things to help themselves learn and practice professionally.  It isn’t easy.  After all, we have feelings.  Some of us have temperaments that are naturally what culture would consider professional; temperaments that predispose for cognitive processing, naturally not personalizing what isn’t about us and have needs outside of interpersonal relationships.  Other physicians are designed to bring people into our inner space, and when that is not considered ethical, have an ongoing degree of struggle to maintain distance.  It is an important skill for anyone who plans on practicing outside of prison to learn quickly.

In psychiatry, historically when we used to do more psychoanalysis, it was accepted practice to collect all fees at the beginning of the session.  The patient placed the money on the table where it stayed throughout the hour as a reminder that this is a professional relationship.  I have chosen to maintain a variation of that practice where I try to collect the fees in cash from patients rather than my staff.  Sometimes when I’m behind or such I’m not able to but I try.  My hope is that Freud got something right and that the patients, at some level, register that I am hired for a medical service which is perhaps more than friendship.  You can imagine how this is less obvious to some seeing their psychiatrist rather than their podiatrist.

I have other support to help also, such as through my malpractice insurance, CAP-MPT.  They are wonderful.  They are available any time for a phone or email consultation on any question I have.  (I believe they know my name by now.)  They also send out regular newsletters on related topics to their clients which I read seriously and try to implement.

Before writing FriendtoYourself.com, I was much more guarded.  I never treated friends or family and felt isolated from my community which I thought I was doing to maintain patient confidentiality issues.  I’m so glad that has eased up a bit inside of me.  I’m a better physician because of it.  I will continue to learn about this dynamic balance in patient doctor relationships from my patients and from experience and welcome the growth.

Self-Care Tip – Give yourself the benefit of keeping a professional in your life who knows their role.

Question:  What is your opinion about the patient doctor relationship?  Do you ever struggle with boundaries?  How do you see those boundaries as being in your favor of getting better medical care?  Please tell us your story.

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Please Get Back on Your Meds!

Please get back on your meds!

Pretha explained that her mom had done better on her medication.  It was the irritability that isolated her.  That and the boredom.

It’s just boring, her daughter said.  It’s boring because there’s just so little there before she falls into her fray.  The venere is so thin.  It’s just boring.  

Pretha’s mom who had taken her medication didn’t see what it was doing for her.  Every day it had hurt her a little, knowing what she knew.  She was better now that she had given it over to God.  Her life without medication was a testimony to the power of God.  She had not been faithful taking medication.

What do you think, doctor?  How am I doing?  Aren’t I doing well?

Pretha’s mom was difficult to maintain eye contact with.  I wanted to please her.  That’s not easy for a physician.  At least for me.  It was more uncomfortable because my thoughts had already skated down the path of what if’s.  Whatever I said, Pretha’s mom wasn’t going to get back on her meds.

Where’s the self-care in this?  Pretha?  Mom?  Physician?  You, reader?  Do you identify with any of us?

Pretha and I have similar jobs.  Keep what is about Me, right there.  Be present with ourselves first and subsequent to that more able to be present with Pretha’s mom.

Pretha’s mom has her job of sifting through her distortions, using her same organ that is diseased to understand her disease.  Pretha’s mom’s job is large.

What is your self-care job reader?  Please tell us your story.

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No One is Choosing For You – Know Your Choices For Health

Yesterday we asked some pithy questions re: Why Psychiatry?  Your responses were received with gratitude and humility.  It takes courage to understand our connection with psychiatry considering ongoing stigma.  Today we’re reviewing that some and taking it one bit further.

When referred to a psychiatrist for medical care, we can feel confused.

Why is my physician sending me away?  Does this mean I’m at my last resort?  Does this mean I’m that sick?, or,

Does he think I’m crazy?  I’m not insane!, or personalizing with,

Does my physician not want to work with me?  I’m that bad of a patient?  Cast off?

Our expectations when we first see our psychiatrist are often also similarly reactive.  Maybe,

I’ll give this one chance but if she doesn’t fix whatever it is that’s going on, I’m out of here. 

I am not going to be dependent on medications!

I do not want to be made into a zombie!

Are we looking for a cure?

Also, we might be confused by the amount of time that she spent with us the first appointment as compared to our follow-up appointments.

I need to talk about my problems!  I need time!

There’s a lot to take in.

Unfortunately, when we are referred to a specialist, often our referring physician hasn’t effectively communicated as to why we are being sent there.  This is for many possible reasons, including Me not hearing him.  Many other reasons are also understandable with insight but we aren’t always given the opportunity to hear the inside story of why our physician does what he does.  That doesn’t mean we have to accept it.  But if we do, we did and it’s our choice.

Choice

Image by Scarygami via Flickr

We have choices.  Before accepting the referral, we can ask, Why?  Keep asking why until we are satisfied with our level of understanding.  Schedule a follow-up appointment with the referring physician if necessary to gain more time if we think we need it.  Sometimes, despite our physicians best efforts, we won’t understand as well as we’d like and we have to make our choice with the information we have.  We can read up on our symptoms ourselves.  I read in Twitter from @NathanBransford,

The 11th Commandment: Thou shalt not ask someone a question thy could easily Google thyself.

That’s ridiculous although I cracked up.  The World Wide Web comprehensively and including Google or any other source within that World Wide Web are not designed to practice medicine.  When we read something, we need to ask for qualifications behind the author of the print, references and so forth.  The Internet is a tool worth our attention but you decide how far you are willing to take what you read before you consult with your own physician.  I think if Doctor Seuss were alive today, he’d write a book (or many) about health care; Oh The Tools We Can Use!  (Maybe Carl and Thysleroux will do a series or a post on this?  Should be fun.  – Asking, “Why?”  Becoming our own friend.  Connection.  Going towards shame, pain, anxiety.  Growing bank – and more.)

And so that brings us to today’s questions:  What choices do you perceive you have in referrals like these?  In your continuing medical care?  In your ability to collaborate with your physician?  In obtaining an understanding of your illness(es)?  Please tell me your story.

Self-Care Tip – Grow your understanding of your choices for your health and medical care.

Related Articles:

  1. Stay Connected For Your Sake and For Theirs
  2. Connecting To Others Is a Condition of Freedom
  3. Safety in Connections
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Reworking Choices With Your Physician as Part of Your Team

What do you want? 

It is one of my challenges as a physician when someone comes to see me for reasons I’m not able to accommodate.  I can’t validate them.  I can’t tell them what they want to hear.

What can I do?  Help them “realize” that they came to see me for another reason.  Another way to say it is to help them “choose” another agenda.  A part of them realizes their need for help; they came.  A part of them believes I am a person that can help; they came.  A part of them.  A part that I and the patient are responsible to find and shift agendas deliberately or by any wiles possible.

Hands touching

Image via Wikipedia

We are an unusual team in this.  How often do you find another so awkwardly paired?  Yet these are some of my best patient-doctor relationships.

What do you want?

When there is a meeting up, a connection and everyone is working for the same “want,” both presence and movement are natural responses.  It’s like we’re standing still in the moment, senses taking it in, and moving all the while.  The process of moving itself brings pleasure and healing.  It is not always about arriving.  It is not always what we think we want.

Self-Care Tip – Enjoy your re-choices and what you will get from them.

Questions:  Have you every found yourself being “helped” to have a different agenda that improved your presence and movement in your personal journey?  Please tell us your story.

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Stop! Don’t Stop! – Affecting Our Practice Of Medicine and Other Agendas

Self-Care Tip #281 – Be aware of how your “Stop!  Don’t stop!” behavior is interfacing with your agenda.

One of the challenges in practicing medicine is the inevitable “Stop!  Don’t stop!” petitions.

stop & go

Image by Joseph Robertson via Flickr

It’s similar in a few ways to being a shoe cobbler who receives clients that don’t want her to use leather.  Ms. Cobbler spends 40-60% of her time with clients persuading them of her capacity to use leather, the objective and subjective evidence behind the use of leather and empowering her clients to wear their leather shoes despite public opinion.

This sounds silly and is not meant to be disrespectful to patients, including myself as a patient of physicians and my own difficulties being a patient.  It is only to describe the forces we are all working with when we work together in medical care – physician and patient.

Quenn came in reminding me of this.  Quenn was a 32 year-old married mother of three, who complained of trouble swallowing, sleeping and ability to feel pleasure over the past two months.  She had struggled with this after her mother died nine years ago, but the problems went away over the following year.  However nine years-ago, Quenn was not a mother.  Nine years-ago, Quenn could shake, stay in the house with the shades down, silent or crying loudly, not eating lying in bed for days and if she wanted, nine years-ago no one would know.  This time however, Quenn told me she was desperate.

I have to get better!  This time, I’ll do anything!  But please start with something natural.  I don’t want to get addicted!  I’m someone who never does meds.”

Quenn, why are you seeing me?  

This is challenging for everyone.  Together, the physician and the patient work with this influence on their agendas.

My brothers and I used to play a game on each other when we were kids.  Maybe you did this too.

Stop!  No don’t!  Stop!  No don’t! Stop!  Don’t!  Stop! Don’t! Stop! Don’t stop! Stop! Don’t!  Don’t Stop!  Don’t Stop!

And for some reason that was hilarious to us.  I like to remember this when I’m in the office and smile despite being played by the “Stop!  Don’t stop!” behaviors and emotions.

Questions:  How about you?  How are the “Stop!  Don’t stop!” behaviors and emotions playing on your agendas?  Please tell me your story.

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Our Patient-Doctor Relationship Improved by Self-Care and Back At You!

NICU Nursery

Image by EMS Shane in Portland via Flickr

I am writing a series of blog-posts outlining self-care in which we examine the tenets of self-care:

Self-Care Tip #265 – Use your connections to help yourself and use your self-care to improve your connections (such as your patient-doctor relationship.)

Damaged and premature, my niece was born needing help to live. Now, one year later, I am playing ball with her on the floor. Her intelligent smile, thriving body, and especially the lovely nape of her neck with that baby-curl of hair lipping up makes remembering her near death-dive into life surreal. I don’t want to remember it anyway. But when I can’t help myself, what I like to think of is how my brother and sister-in-law were treated.

The clinicians at UCSD were unbelievable, my brother said. They included him in their decision-making and informed him of medical study results. If you don’t know, if you’ve never been sick or been in a medical setting otherwise, this doesn’t always happen. It isn’t traditional to share medical information directly with patients (such as x-rays, laboratory results, differential diagnoses, and to ask their opinion. Can you imagine?!  “…Um. Yes PLEASE! Can I be your patient!?” Sounds like fantasy.)

I’ve also struggled to collaborate. Hovering over charts and laboratory results, many of us practitioners behave as if our patients were at any moment going to throw us into court. It’s embarrassing, even though the truth is, too many of us clinicians are stalked by litigious intentions, whilst the truly awful practitioners seem to sail away on unsinkable malpractice without pursuit.

I have not enjoyed myself when I’ve done this. When I’ve acted suspicious of the very people I’m meant to team up with, work was not good for me. I don’t think my patients felt comfortable with the doctor-patient relationship either during those times. Hearing my brother talk about how he was treated has emboldened me to engage with more trust in the care I offer patients. Moreso, being friendly to myself has helped me be a better physician.  It’s tail chasing but with productive and enriching effects.

Making a choice to choose trust and transparency with patients and clinicians, even being present with the fear, is self-care although high pressure. With people’s lives on the line, clinicians and patients know mistakes will happen. The self-care will grow our ability to forgive each other.

My journey with self-care has brought me to see people differently. I look at them from the self-care angle. I look for those sticky bits where we can connect and collaborate. I expect things from them. I ally myself with their self-respect, with their intuitive desire to be friends with themselves. I am bored at work when I don’t do this. I am bored at work when my patients don’t do this too. Without self-care for myself and without my patient’s interest in self-care, medical practice becomes everything that the negative reputations advertise about the physician and the patient.

Yes. My quality of practice has definitely improved.

Who isn’t blessed when she sees the courage to face stigma, shame and bewildering illness? Who isn’t more informed every time someone chooses the freedom to do self-care, chooses to live, fights hard like my niece did and shows what that fight is worth?

Who doesn’t learn from that? When someone loses her identity to the defacing ravages of disease but still knows she is worth the fight, like PattyAnne, working beside her is one of the best places in the world to be. For Me. It starts and ends with Me.

Building trust in a patient or a clinician starts with us staying connected to others in our personal circle and along the ripples as the circle widens. We have to have a voice and hear their voice and we do this by maintaining a community of people.

Connection is part of self-care for both clinician and patient. In the case of PattyAnne, (yes, she’s still in our story,) she could take an action toward her self-care with the intention of gaining stronger connection to her community and to me. She could ask herself about her intentions. In fact, we both would do better self-care approaching each other this way.

Connection via the patient-doctor relationship is self-care and then back the other way too!

It starts and ends with Me.

Questions: Has your patient-doctor relationship been a friendly part of what you’ve given yourself?  What are some examples or in what ways have other connections you’ve chosen improved your self-care?  How has self-care inversely improved your patient-doctor relationship?  Please tell me your story.

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Trusting our Clinician, or Not

Free Fall Image

Image via Wikipedia

I am writing a series of blog-posts outlining self-care in which we examine the tenets of self-care:

Introduction to self-care
self-knowledge 
presence 
moral neutrality
trust (Today’s topic)
patient-doctor relationship/connection

Question:  How do we trust ourselves when we choose to trust our clinicians?  What is your answer? Please tell me your thoughts.  These are some of mine.

…Enters experience, temperament, and personal self-care/readiness to practice of the clinician.

Self-care does.  Self-care is our tool.

The clinician living her own directives is university.  Going to work in a state of readiness is instructive.  At some level, her patient sees that self-care allows the clinician to go to work after personal needs have been attended to.  The clinician then is able to give over space in time, place and emotion and make room for her patient.  Who wants to go see someone for help but instead finds a clinician in role confusion?  The opposite can also be true.  The patient might mistake their own role and try to leave their real illnesses hidden, protected in the safety of their own expertise.

…Re-enters PattyAnne.  Remember her?

PattyAnne was pretty sure that getting an ADHD diagnosis would explain to the people she had hurt a better why for why she hurt them.  It would give PattyAnne a name for the chaos.  Having a diagnosis that comes from a figure of perceived authority, say a Doctor of Medicine, offers this.  It is like a judge who pronounces us innocent and another guilty.  This is not a bad or good motive.  It just is.  To want to get away from negatively perceived labels, is.

As a practitioner, it’s not simple to resist the lure of treatment, when it would be easy to make our patient happy.  It also takes a lot more time in patient education and building a trust relationship if we don’t agree with the patient’s self-diagnosis. Considering these pressures, many have wondered if the frequency of prescribing is affected by it.  For example, it is estimated that 73% of clinician visits for sore throats result in antibiotic prescriptions, but over 90% of sore throats don’t respond to antibiotics. (I know.  That’s robbery!  Those poor other patients who got nothing for their copays!  Not even a prescription!)

So in comes PattyAnne, diagnosis and treatment already in place. All she needs is my signature.

Being a patient is not always easy.  It improves some with insight or at least the ability to receive insight, a vulnerable pose, humility, courage, self-respect and so much more.  Maybe PattyAnne was thinking, “Oh boy.  Now I got this woman who doesn’t know that I’m ADHD!”

We have each other and begin the adventure of patient-doctor relationship, an alliance and a connection.

Self-Care Tip #264 – Trust to improve self-care, and take care of yourself to improve your trust.

It starts and ends with Me.

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Presence Encourages Self-Care

The Forgetful Professor

Image via Wikipedia

I am writing a series of blog-posts outlining self-care in which we examine the tenets of self-care:

Self-Care Tip – Sit back and listen to the emotion to be present in your own life.

There are two terms we’ve used in psychotherapy since before Freud and Jung were around:

  • Transference – putting our feelings on the clinician.  For example, my clinician looks like my father.  I will transfer onto him my feelings about my father and subconsciously think he is like my father.
  • Countertransference is the opposite.  The clinician thrusts her own memories and associations on her patient.

These can be positive or negative.  Of course they do not stay in the clinic.  Transference and countertransference happen between all of us all the time.  Often it is healthy.  It helps us grow, model others, fantasize and move towards fantasies long enough to make them true.

Remember PattyAnne from yesterday?  …In PattyAnne’s and my case, PattyAnne could be said to have transferred her fear of being treated as a lesser person.  But what was my reaction and what is yours in similar situations?  What is our countertransference?

I have often been guilty of negative countertransference in situations like this.  I remember feeling dirtied by people’s prejudices and fears.  Almost like I needed to bathe afterwards.  The truth is, though, we don’t have to feel this way.

When people are afraid of us, we do not have to be afraid of them.  We do not have to anger, agitate, or feel “soiled.”   We can just be with them.  Let it be about them and not run away.  Be present.

Clinicians can be open to hearing this song.  When any patient starts in again, this time, sit back and listen to her fear rather than worry about what words carried it.  Patients will be better for it.  Maybe clinicians will be, too.  And that is key.  The gift we give first is to ourselves.  By just being with someone in her fear, we can just be with ourselves too, and vice versa.  Quite friendly to us both.

Presence encourages self-care.  It helps guard us against the temptation to see ourselves as victims.  When we do not realize that our emotions and behaviors come from us, were not imposed upon us from external sources or realize more specifically the transference or countertransference that we are responsible for – we can feel like victims.

Any time we do not own our emotions and behaviors, this is a quick path to losing our connection to our personal journey and become “absent” rather than present with ourselves.

Still, many wonder: at what point does “too much self-care” become part of the symptomatology?  This concern will resolve when we see how emotions are not moral implications.  “See” you tomorrow!

Questions:  How has feeling like a victim disconnected you from others and yourself?  How have you collected your absent self and come together again?  Please tell me your story.

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Introduction to Self-Care

Questions:  How do we collaborate with our patients, or with our clinicians, to take action on behalf of health?  What can we as clinicians or patients do to teach, learn and practice the tenets of the field of self-care?

Self-care is living consistently with the belief that the success of our health (emotional, physical, spiritual) begins and ends, not with “me,” but with “Me.” To teach and practice self-care comes when we understand that the essential self, the Me, is always worth fighting for, always worth the journey, always of value even in the throes of mental illness.  Here at FriendtoYourself.com, we work to define and teach self-care daily, we attack guilt, we stand up to shame, we live as we choose despite stigma and we work harder than we ever have on perhaps the hardest job of our lives.  Self-care is not weak but rather courageous.  It brings us to humble accountability for our lives, not seeking to erase our history but still reminding us that we are free to start over any time.

I will be writing a series of blog-posts outlining self-care in which we will examine the tenets of self-care: self-knowledge, presence, moral neutrality, and connection. We will look at self-care as an essential practice for both clinician and patient, examining the ways in which a self-caring clinician may, in turn, provide better care to her patients, and patients take better care of themselves.

Self-Care Tip #260 – Clarify what it means to be your own friend.

By the way, check out a still unknown glorious writer at ASkirtAWeek.com.

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Choose The Learning and The Teaching You do, and That is Done To You: Patient-Doctor relationship

I'll Give You All I Can...

Self-Care Tip – Choose the learning and the teaching you do, and not be passive to it, when in your patient-doctor relationship.

Hearing a physician tell us when we can and cannot take medications is somewhat private.  In our culture in our “advanced” and liberated age it isn’t so easy to feel handled like that.  But feeling handled verses helped is our choice.  It is all the more reason to dig in our fears and see what scares us.  If what we find there is that our fear is playing into keeping us from receiving this information, and decide actively if that is really in our best interest.  Emotion has it’s own activity, different from a muscle in our arm.  When we respond to the emotion, and especially if we respond before we do this kind of digging into the fear, we might not actually be doing protective behavior, like our fear would have us believe.

We have talked a bit in previous blog-posts about the patient-doctor relationship being a team effort.  It quickly became apparent that some of us don’t perceive that we have the luxury of working with a physician who see’s their patient as a person to learn from and influence their treatment decisions.  But it is still important to know that this exchange is critical for us and then to let that knowledge progress to a wanting in us to have this dynamic relationship with our physician.  The knowledge and the wanting will have their way in us and in our communities subsequently.  We do not know how long that will take but it will happen.

The marvelous scientist, Deb Roy, from MIT talked about his research on language development.  It was of course extremely endearing as it began with his work with his own infant baby and hooked us both by the intimacy of it and the marvelous discoveries.  Then after we were oohing and ah’ing (most appropriately because this is AWESOME stuff!) he moved us into our cities and media and showed us with his data and eloquence that in order for learning to happen, the professor and the student, the sales rep and the client, the physician and the patient, the parent and the child, both learn and teach simultaneously.  Whether it is subconscious or conscious.  The baby teaches the parent to teach him better and the parent learns this from the baby.   The physician teaches the patient and the patient teaches the physician to teach him better.

Both roles of instructor and student you see requires humility to learn and teach.  They both push into private spaces of the other.  Without consent, either conscious consent or subconscious consent must be there, it will not happen.  So this is consensual, even when we do not realize it.

Now what do you think the friendly thing is for us to do for ourselves, considering this growth in our knowledge?

Of course.  We will be more effective if we embrace this knowingly, willingly, humbly.  Move this learning process from the subconscious to the conscious level.  Make it as deliberate as possible.  For both physician and patient, this is good self-care.  Accept that when we engage in a patient-doctor relationship, we are giving that other person admittance, by our will and choice, admittance to that private space inside of us and not feel the victim when they enter.

Questions:  How has feeling like a victim sabotaged your patient-doctor relationship?  How have you worked past it in a positive way for both of you?  Please tell me your story.

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