Why I Don’t Fire the Shrink, and follow-up

I’m sorry to drop the last post down because I think it is one of my more important ones and would like it to get as much traffic as possible. Maybe I’ll make it a page or something, but I wanted to write a little more today.

Tony White over at Graffiti left me a beautiful post with a deep answer to a question about what constitutes a “characterological” or “personality” problem. I guess I asked since I have been accused of the same, though I don’t agree.

I have been trying to draft further questions to him but his website isn’t working. He did, however, inadvertently answer sort of what I guess this shrink is trying to get to do with me – make a connection that will be stable and somehow “heal” whatever is fucked up. Whether I believe in this or not – sounds like one step away from alien healing to me, well, that’s another story.

But I thought I’d give some follow-up to the shrink-related part of this post. I thought that if I’m so curious that I’m writing about it in depth, fairly eloquently, I may as well ask him. I did not go and say, “Hey, buddy, aren’t you kind of useless?” Instead, I phrased the question, “Do you think that maybe at this point, the right thing to do would be to stop trying to make me better and shift into working with the condition I’m in and getting me to a point where I can live with this?” After all, I am functional, I’m not in a state where I’m homeless or actively suicidal or beating my partner. It could be worse.

His answer was an emphatic no, that it is definitely doable to get me to better health.

Leaving me to wonder who in the room really has the denial problem.

* * *

I did call in sick, I think maybe for the first time in my life, the day after that post. I really was sick from whatever drug was doing that to me, had been writhing around and vomiting since 3 AM, but I felt incredibly guilty, and am waiting for the universe to punish me. I did make an appointment with the shrink that day, arrived pale and sweating, and he flipped out and tried to send me to the emergency room (shrinks don’t deal well with physical illness). But still, I’m waiting to be punished.

The worst part is, it doesn’t really matter if I’m there or not. The exact same work still gets done. That’s the bind of this job – it is an incredible amount of work with an incredible amount of responsibility, pay below minimum wage, and yet you are utterly expendable. I did call in, but no one even noticed I was gone the day after.

On the up side, I have started investigating other possibilities for employment when I finish. I think this is a positive sign; instead of helplessness and despair at the world of medicine, I’m being proactive and looking for solutions. Not depressive thinking at all.

* * *

I realize I’m down on the shrink a lot and a lot of the things he says are horribly insensitive and sexist, that everyone I know encourages me heartily to fire him. So for anyone who cares, here are the reasons why I haven’t.

1. He is basically a decent person and is trying to help. I realize that this argument could be made for, oh, say, Sarah Palin, but after seeing psychiatrists from the other side in med school, I know that there are some truly Machiavellian types out there. I could do so much worse. He means well, though our views on what is wrong with me, let alone how to fix it, are worlds apart. It is sad that this is an important point, but it really is. At least I can be fairly certain he’s not out there making jokes about me with colleagues.

2. He has seen my episodes on both ends of the spectrum. I can’t say that he really “knows” me, not at all. But I just do not want to have to start the whole history thing over somewhere else. I don’t want to have to go through admitting to manic behavior. And he has seen it, at least glimpses of it, what I don’t manage to hide, so he has a firsthand clinical impression. That counts for something.

3. He is available. He understands the vagaries of a junior doctor’s schedule and is incredibly flexible about seeing me when I can, including sometimes 7 or 8 at night. He can see me on short notice and understands when I disappear for weeks at a time. I know this also sounds like a dumb reason, but I had to quit the counselor I liked best since starting med school (one of those tough, New York feminists) because we simply could never find a time to have an appointment. Others have demanded a set hour every week, which is impossible for me. I also see this as an extension of reason number 1 – he really does care and is trying to help, even at his own inconvenience.

4. He understands the brutality of medical training. This is the first time I’ve had any kind of therapy with an actual psychiatrist, and one thing that is nice is that I don’t have to explain the concepts of on-call, of how it feels after 30 hours, etc.

5. He picked my good meds. This gave me 4 years of normal, good life. I guess in retrospect he fell onto it more out of luck than talent, but still, I am immensely grateful to him for those four years, in which I lived like a normal person and managed to build a decent life for myself, even if it is all going to shit now, and might actually be crueler to have had and lost than never had at all.

6. About anything not related to my mental health, we get along well. Though here it may sound like a lot of angry silences and friction, whenever we are just chatting about something, we mostly get along. We share an unusual hobby and can chat in a friendly way. Just as long as we don’t drift into points where his basically bourgeois or sexist views come out, but mostly they are only a problem when discussing my life and its twists and turns, which he can’t really understand, being from such a middle class boring place. This is a big issue – he misses a lot of what is culturally normal for me and sees it as psychopathology. We come from the same ethnicity, but grew up in different parts of the world – he in a very conformist (though not necessarily right-wing) place and me as a hippie liberal. He’s the kind of man who pays lip service to liberalism but sees marriage and 2.5 kids and a mortgage as normal and anything else as deviant.

But, as I said, if we stay away from that, it’s ok. Light banter is always pleasant.

7. He doesn’t fall for my manipulation. This is also a big one. For whatever historical reasons, I’m a master manipulator of men – by anything from mental gymnastics and rhetoric to sex appeal, I always get my way. I do get furious when I don’t with him, but I think somewhere deep down, it’s good for me.

8. He recognizes that I’m wasting my life and talent. In fact, has made that very comment to me. This is one of the hot spots of what is bothering me. Unfortunately, most counselors I’ve seen see that feeling, the feeling that I am wasting my talents, as pathological, and try to address it, because on paper I look like I’ve done a lot for my age. He once, unprompted, told me I was wasting my life…and I thought it was one of the most insightful things anyone had said – that he sees through my impressive resume to see the dilettantism behind it.

* * *

But the main reason is #1 – I know I could do so much worse. If it’s all bullshit, I may as well stay with someone who means well.

And no, none of this excuses his obvious countertransference-gone-wild issues, the sexism of calling me borderline because I am an angry female, the utter unwillingness to discuss what he sees as the problem and how he plans to therapeutically fix it, the dismissal and blaming of the patient…but still, at least he’s nice. And that means a lot. Do I really want to go find someone with all that same shit, who also is mean or cold?

* * *

Edit: Tony White read this and pointed out a reason number 9, one of which I was not consicouly aware, but of course, he’s right. It made me laugh to realize that I hadn’t realized this, when it was so obvious to someone else.

On mental illness and stigma in medicine

Today I saw a patient for a pre-operative evaluation. This is a consultation for a patient that needs surgery, but who has other medical problems that make the surgeon nervous, and the surgeon basically wants someone like me to sign that I evaluated the person so that I can be blamed if something goes wrong. At least that’s my semi-cynical version of it. My fully-cynical version of it is that surgeons make relatively little money seeing a patient in clinic (though a lot more than a family doc or internist does), and they don’t want to waste time evaluating a patient when they could be operating and billing for the real benjamins.

Of course, I’m messing with the details of the story, but it went something like this: this woman was elderly, but under 80, and had the usual medical problems that go with that age, but not more – mild diabetes, mild high blood pressure, a few other things like that, but no history of smoking, no lung disease and no significant heart disease.
I think that over time I’ve collected a few doctor readers, so I’ll add this list of meds, more or less: some vitamins, a beta blocker, metformin, maybe there was an ACE inhibitor in there, can’t remember, a statin, a laxative, a bisphosphonate and some ranitidine, and a few other drugs, which I will get to in a minute.

She also had a recently discovered cancer, which was the occasion for the operation. The operation is a large one, but not “heroic” or the kind of thing they call people to come sit in the balcony to observe. It’s not a Whipple or anything close, but it’s not a lumpectomy either. It probably will not lead to a cure, but will almost certainly lengthen her life considerably, and will definitely prevent at least some of the uglier complications in the future. It is the standard of care.

Now, the rub: one of her diagnoses was “Depression.” No further explanation. In addition to the above, she also receives lithium at a healthy dose as well as paroxetine. This was the first time I saw her and she is an immigrant who does not speak any language I speak, so we had to speak through her son translating. But she was perfectly pleasant, totally coherent (able to give full medical and surgical history since childhood) as far as I could tell without speaking her language. To my shame, I didn’t ask what her profession had been. (I just didn’t think to while trying to sort out a complicated medical history.) I had never seen her before, and she came with almost no written medical information other than the recent imaging and investigations that were directly related to this cancer. I have no idea how her depression presented, why lithium was added, how long she had been stable or ill, or anything about that particular illness other than what I saw. To be fair, I also had no information about the history and control of her diabetes or blood pressure, though all three issues were controlled during my examination – blood pressure was good, sugars fine as well as HBA1C.

And then this: among all of her documents, I come across a paper that is a statement by a consultant psychiatrist that she is competent and able to both consent to and undergo the operation.

The surgeon and anesthesiologist had both refused to treat her without this evaluation. The surgeon’s referral put the demand for a full psychiatric evaluation (at the family’s expense) above cardiac, geriatric, oncologic, or functional evaluation, and refused to proceed or even make a tentative statement on her suitability for operation without this.

The surgeon, for that matter, does not speak her language either. But I assume he saw a similar patient to the one I did, as he had seen her less than 3 weeks before.

Just the fact that she came in taking certain medications, with a psychiatric diagnosis, one that, for that matter, has no bearing on her ability to decide how to live her life or to comprehend information, could have caused life-prolonging, standard-of-care treatment for cancer to have been withheld, to have been considered “inappropriate” or “unnecessary” or “unsuitable.”

In her case, fortunately, the psychiatrist did not write a full three page summary of her personal flaws (as I have seen sometimes in these types of evaluations), but rather summed it up with a line something like, “Patient understands implications of illness and treatment options and is competent to make any and all judgments blah blah blah.” But how many of these cases never make it that far? How many times, when surgery is an option, do surgeons see a diagnosis like that, or a drug like lithium and decide that the patient simply isn’t a candidate for surgery, or decide not to present all of the options?

I also wonder, if it had been an older man with “depression,” whether he would have been put through this humiliating evaluation, or whether only hysterical women need to be qualified as competent. Or if it had only been the paroxetine and not the lithium? What was it that pushed her into questionable incompetence? Does the referring doctor understand the implications of demanding an evaluation like that – that they are essentially calling into question a person’s sovereignty over their own body? I am hard-pressed to think of any kind of mental disability, including those conditions that include intellectual disability, in which a person cannot be presented with options in a manner fitting their understanding.

I don’t know whether to be angry, or to want to cry, or what. But I think mostly I’m afraid that someday I will be that little old lady with an ugly diagnosis on my chart, whose life is seen as only questionably worth saving.

Does long-term, non-remitting mental illness need a psychiatrist?

Over at Vicarious Therapy, Aqua is really upset about an article by the Canadian Psychiatric Association. She says that it basically justifies dumping chronically mentally ill people out of the system.

I’m not sure I agree with her interpretation of the article, but I can see why she is offended. But I’m  not. I think they have a point. Maybe it’s just seeing things from the side of limited medical resources, how people with adjustment disorders and so-called mild crises can’t receive services. These are people who are easily “cured.” They would greatly benefit from a short time with a psychiatrist, whereas someone like me, well, all my time and effort has been a waste at best, and may have left me worse off than I started.

At some point, my shrink should just point out he isn’t helping/can’t help me and stop taking my money and time and giving me false hope.

I’ve been thinking a lot about that lately – that I need to quit going to him, but he insists that whatever voodoo he thinks he’s doing can help, so I keep going. At some point, it’s fraud. And it’s hard for me to give up, for obvious reasons –  who in my situation wouldn’t be a sucker for hope of a better condition, even a cure? But doesn’t he have some responsibility to just tell me what that article says? That I probably will never be well, probably will never be what I was with the ideal drug combo. Shouldn’t he be “emancipating” me at some point to learn to deal with this sub-par life?

It’s a huge issue in medicine – the public’s perception of what can be done (everything can be treated/cured, resuscitation on 95 year old grandpa is malpractice if he doesn’t live). But this time, I’m seeing it from the patient side. It is hard to accept that nothing further can be done, that I will probably never be alright again. But I thought we were moving away from the paternalistic view in which the doctor doesn’t tell the patient about the bad stuff, the bad prognosis, offering endless treatments to keep the patient hopeful and busy, when there’s really nothing that can be done.

And then, of course, in this case it’s complicated by the fact that shrinks get all wound up about failure too. As mentioned at the end of the article, not being able to fix me gets me tossed into “personality disorder,” which is a blame-the-patient stunt if I ever heard one. (The worst part: I almost believed it.)

So I do think the article has a point. (Though I highly disagree with the recommendation to send them back to their GP, as if family docs are a catchall system.) If a medical treatment can no longer help someone, doctors are obligated to stop providing it. It burdens the system, puts false hope into the patient, and is paternalistic. Why is psychiatry exempt?

On the other hand, I am starting to understand why people keep going to faith healers and alternative treatments for cancer. Sometimes they promise hope, when we no longer do. Is my continuation any different?

* * *

Here’s a Shrink’s Line of the Day in the same vein. Last time I was there, I brought up how one of the drugs, either the lithium or the Wellbutrin or the combination, was making me vomit incessantly. (Most likely a creeping-up lithium level, but I had no time to get it checked.)

The backstory: one of the completely unsuccessful new fancy drugs he put me on a few months ago caused, as a rare side effect (one that I did not know existed until it happened) massive hematomas on my whole body. I just wanted to quit the drug, since it wasn’t doing me any good anyway, but he insisted on sending me to a hematologist friend of his, who said she’d never seen anything like those bruises (the drug itself was too new for her to comment). So I ended up undergoing a massive clotting factor and platelet function workup (ristocetin, anyone?) which found nothing. Eventually I stopped the drug because it was useless, and one of those weird reaction reports was filed with the company. There were other cases on file.

At my last appointment, I mentioned the vomiting (I lost 2 kg in about 10 days). His line of the day: “Well, all these side effects, right out of the textbook, somewhere in your mind, you’re making an opening for your body to react that way, expressing your feelings toward the drugs.”

Isn’t that yet another phrase that is worth firing? Blame the patient 101. And I’d like to point out that I didn’t even know that the other could do bruising (neither did he, and the company only admitted it after it was reported). And I also pointed out to him that my great drug combo had worse side effects than any of these combined, but I never complained because at least I felt good.

I am scared that I will never be really ok again, back to where I don’t have to think about my mood every day, to being to where I can’t understand how I ever considered suicide, to where I’m not concerned with sleep and anger. But on the other hand, as more and more time goes by, maybe he should be transitioning to pushing me out and learning to live like this. I wouldn’t tell a new-onset diabetic that one day it would all go away; why should he be telling me the same?

My Answer to the Commenters

I started to put this in the comments and then just decided to post it as a regular post, because it was turning into one in length.

Thanks for writing, everyone. Thank you especially 5150 for reminding me that it will fade. I kept telling myself that during the worst of it…that it wouldn’t be forever like this.

I have zero benefits or anything. The one private disability insurance I bought probably wouldn’t cover this as a pre-existing condition and it only replaces about $700 a month of income anyway (a percent of what I am paid by the hospital and not the government – and the government pays most of my salary). Jjunior docs have no benefits at all – we are almost hourly wage employees – do not even have personnel benefits at the hospital that the cleaning staff has.

The option would be another job. I constantly remind myself that approximately 99.999999% of the jobs in the world are something other than “physician.” But it seems like such a shame, when I am so close to finishing training not to just suck it up and pull through.

On the other hand, when I find myself on the roof again and again, I keep telling myself, just walk away. You have a choice. You do not need to do this.

And the worst part of it is that it isn’t the practicing medicine that is killing me. It’s the bickering with the nurses who walk all over me, the paperwork, the phone hassles to get tests done. It’s not the essence of the job itself. Sometimes I even think that being decent to people and helping ease their way through something is what is keeping me going.

Another thing is that I quit taking the Wellbutrin and the lithium a few days ago and feel immensely better. One of them was doing something bad to me. I’m not sure which one…but I could feel it physically – shaking, throwing up, feeling drugged and surreal. You’d think that that was a creeping up lithium level, right? But it also came with a terrible agitation and that unreal feeling was never something I got from lithium. It felt like that first time I took the Wellbutrin and flipped out. Lithium, even at its worst, always chilled me out. I semi-wanted to call the shrink and ask what he thought but never managed to have a free moment to do that while it was a decent hour. And don’t even think about getting to a lab to have lithium levels done during business hours. I’ll probably slowly restart the lithium today.

The other thing I am slowly coming to accept are some limitations. While the idea of leave scares me, I realize that I just can’t keep up with my peers with the no sleep thing. They consider a day after call a day off. I can’t even move, and if I don’t sleep through until the next work day morning, I’m crazy. This saddens me. I used to be unstoppable, so ambitious, wanting to take care of everything, be the best at everything.

And I’m also coming to accept the idea that since my good cocktail is gone, I just may never feel totally well again. It’s been a year now, or almost a year…and nothing is any better than when I first started. That’s what sort of fucks up the idea of taking leave to fix the meds – the meds may never get fixed. I may never be what I was.

I think I could be okay with that if I could do a few things that are really important to me. First is to write – which I can’t really do in this state. Others are a creative habit that I can no longer do because my hands shake too badly, and flying, which I can’t do because I’m always on the edge of vomiting anyway. My three passions in life have been stripped away, which is hard. Maybe I just need to throw myself into medicine, which is something I can still do well, and find a real life in it, which is something I never have been able to do. Satisfaction, sometimes. Purpose, yes. Pleasure at using a skill for the good of others, yeah, I guess.

But passion…never.

Yes, I am a tremendous whiner, compared to so many people whose lives have been much more devastated than mine, I’m bitching about having a job as a physician. But still, a dream lost hurts, no matter how grand or small, and I dreamed of something so very different than this squalid sleepwalking broken-down life I am left with.

Hello, World

Sorry I haven’t posted, if anyone is still reading after the massive amount of traffic from the obesity websites.

My mental health has crashed lately. Partly because of the drugs, I think, and partly because of the sleep deprivation experiment that is my job. I am not sure where I am going from here, whether a leave of absence or quitting altogether. Will let you all know when I have time. In the meantime, go on over to Secret Life of a Manic Depression for the Six Reasons post. It’s a great read.