The Medical Paper Gown

I recently got an email from a reader that included this bit:

I just left the hospital last night after a small cut needed 7 stitches. Nothing big, just obviously a self inflicted wound. The nurse tried to force me to put on a gown in the middle of the ER while no other patients were wearing one. I realize now it was to see how many other cuts I had. She yelled at me when I refused.

Which led me to realize that a good topic for a post would be “What’s up with those hospital gowns?”

About gowns in general, I assume the reader is in North America.  The whole gowns thing is an American thing. Sometime in the 1950s, some efficiency expert decided that doctors could work faster if patients were all naked when they came in the room. But naked seemed too awkward, so the NOT-awkward paper gown was invented. And they tell you to get in it before the doc comes in, presumably to save time! There’s no real medical reason. Most doctors today probably don’t know this. Incidentally, there’s tons of discussion online between medical professionals about what is more sanitary/cheaper/classier – paper or cloth gowns, but no one seems to question much the whole necessity of the things. Check out this article, and don’t miss the comments! They go over and over when to gown, what kind, how to put it on, but NEVER ask why to do it at all.

Nakedness/gowning never caught on in the rest of the world. I suspect this might have to do with cost of either disposable gowns or laundry. I’ve never worked anywhere where those gowns even exist. Our ER has pajamas for people who come in covered in blood or whatever – but they’re just pajama pants and button-up shirts with a hospital logo. There are robe-type tops for people who are having heart attacks or something and might need very quick access to their chests…but nothing like the American hospital gown (except in labor and delivery, and those are also cloth nightgown type things and everyone brings their own clothes anyway).

So, when the reader asks, “Is this normal protocol for a forearm wound?” I have no idea. For someone who finds him/herself in that situation, what I’d recommend doing is just saying Ok to the nurse, and not changing. I seriously doubt anyone would notice.

I personally don’t think that any time saved by undressing a patient beforehand is worth causing discomfort/awkwardness. Every country I’ve worked in other than the US seems to agree. In most of the world, the standard practice is for a patient to come in the room and sit down and talk first, and then move to the exam table.

If we are on the subject of medical culture, I’ve also found that medical office rooms look weird in the US – most other places, the room is divided into the office part and the exam part, with a curtain or screen around the exam part and a locking door. The doctor sits at a desk, and the patient on the other side of the desk at first, moving to the exam table only later. It’s like walking into basically any other kind of office in the world. I have no idea what’s up with the weird rolly chairs and patients sitting on exam tables there.

To examine a patient, AFTER we’ve discussed what’s going on, we ask him or her to move to the table if necessary; if I only need to check their throat or something, I’ll just do it in the chair. No getting naked. They go to the table, and I either put my hand under the shirt or pull it up to listen to heart and lungs, pull pants/skirts down to the hip and shirts up to the ribcage to examine a stomach, whatever. It is NOT the world standard to do the whole gown thing or ask a patient to strip down to begin with. I guess sometimes, if I need to check feet or something, I wait a little for someone to take off their shoes…but I doubt it’s a significant amount of time. Not worth having every patient come in with shoes off.

I don’t do a lot of gynecological exams, but usually the standard is to just undress from the waist down, or pull a skirt up, and use a regular sheet to drape over the patient. I don’t give instructions, so some women wrap themselves with the sheet more like a towel after a shower, which is fine with me. If I know that the complaint is not likely to require a full internal exam (likely a yeast infection or something), I usually don’t even do this, I just have her lie on her back and slip her pants down to her knees and look like that while I stand at the side of the table. I think it’s less invasive if I stand there than between the legs, and it feels better to have pants around your knees than totally off. I do not use stirrups at all, just have them put their knees on the table and spread. I’m not even sure if most of my exam tables even have extendable stirrups. I think that the ass-hanging-off-table and feet floating in the air in stirrups is a much worse feeling than just lying down on the table.

Of course, I’d probably fail a medical school exam if I were seen doing this. And I don’t often do a really comprehensive gynecological exam where I need “full access.”

Other times I can think of where I need more exposure is during an orthopedic exam if I think legs might be different lengths or I want to check for scoliosis (both can be done in underwear or even with pants pulled down a little and shirt off, bra for the ladies), a full skin exam (which can be done in parts), rectal exam (which I do by just lowering the pants as little as possible while the patient lies on his side with knees bent, which I think is better than bending over, but if you’ve been through it, let me know if I’m wrong). Believe me, it feels better to have your underwear half pulled off or lifted than to sit around naked in a gown.

While we are on the topic, another practice that seems uniquely American in my experience is for the doctor to be running between multiple exam rooms at once. I’ve not seen another country where patients are briefly seen, asked to undress while the doctor leaves and sees another patient, and then returns. Most doctors have their own office where they sit all day, and patients enter, finish everything, and leave. Offices are therefore more personal as well, because they belong to a specific doctor and all of her shit is in there (well, especially if you are like me), not a clinic where doctors are bouncing all around looking for open rooms. I can’t wait to finally be settled in my own permanent office, where I can paint in warm friendly colors, and put in nice furniture and curtains and normal lighting rather than overhead.

One more thing: chaperoning! I personally hate this. My family doc is a man (I used to have only women doctors until I went to medical school and then realized that 1. it didn’t matter, and 2. I would be pretty pissed off if someone didn’t come to me just because I was a woman) and despite knowing me for years, he lately has started calling the secretary in for even simple exams.

I do understand why and all that, but on the other hand I find it kind of offensive – like, does he really think I’m going to sue him? It bugs me every time, messes up the basic trust of the relationship. And of course, it makes me wonder that if I weren’t a psych patient too, would he do it?

Thoughts? Do you want the chaperone or not?

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Enough

I finally wrote what I thought was a reasonable letter to the shrink, since he never seemed to hear what I said…about how I can’t live in the dark about what is wrong with me or how to fix it, that I was deeply hurt and concerned about the borderline thing, etc. I hoped that we could work something out.

But today, we met. True, I knew I was in a bad mood going in. But on the other hand, he claimed I had nothing to be upset about, accused me of splitting between him and the GP (I knew from the minute they started “coordinating care” that sooner or later I would be accused of this and tried to be so careful not to say anything negative about either of them), said he couldn’t understand why I would be upset, that he was so sure I’m just trying to push away. It felt like always – I say and mean one thing, and he sees it through his filter. Refused to tell me why he thought I was borderline (and then later, when I was angry, said, “See – that’s classic borderline. You’re upset, so you’re trying to make me upset.”), what he thought my problems were, or how we planned to work on them together. (“Part of your problem is needing to just trust me.”) In short, it was the classic psychoanalytic bullshit – the shrink is always right and the patient is always crazy.

To top it off, I requested my medical records and was refused.

The whole scene was incredibly upsetting – to be so totally invalidated. But I had spelled out that I just am not interested in paternalistic care, where my problems and how they will be treated are hidden from me. That if this is the care he gives, I’m not interested…not interested in his diagnosis and not interested in buying a treatment that can’t even be explained to me. That I need collaboration, I want to change, but need the direction on how.

No good. “I can’t understand why you are so upset.”

I left, finally. It was sad, and it was scary. I’m now without a safety net and badly medicated, though I did meet a hippie clinical psychologist I sort of liked (woman).

I drove home and cried a little, felt like throwing up. It was so humiliating, invalidating. But – I also drew my lines in the sand. I can’t say I was totally calm; in fact, I was angry. But I spent months examining myself closely to see if what he said could be true, if there was justification in my anger. I decided there was, and that I needed some acknowledgment of that. I really didn’t expect not to get it at all. But I didn’t.

And that’s just not ok with me. No matter how sick I am, how bad I feel, how much I need help…I don’t need it that bad, bad enough to believe that I am so crazy that I am totally out of touch with reality.

So, through my tears on the way home, I reminded myself that I can save myself, that maybe only I can save myself, that I’ve done it before, and that I can do it again. That I’m somehow going to be ok. That I am a decent person, despite how broken I may or may not be.

I might go re-read The Color Purple. I think that is the message that I need to hear – remember Celie? Raped as a child, beaten, cast-away, unloved by anyone, half-literate…she knew somehow that she was a human being of intrinsic worth, one of God’s creations, one of the things that is included in the phrase “God love everything you love–and a mess of stuff you don’t.” That even if she was poor and ugly and a woman…the universe had created her with love. That God loved her, even if nothing and no one else did. That she existed, just as lovely as a wildflower.

I may suck at being happy. At being patient. At controlling my temper. I even may suck at loving the people I love. But I can do some things – I can comfort people and I, on a good day, can write words that mean something, that capture something real that happens to people. I can forgive. On a good day, I can be grateful, and on a great day I can pray, or at least I used to be able to. I can be part of the universe sometimes, and of the human race when I am not sick. I can overcome my fears. I can see the color purple. I can survive the dark night. I am a living, breathing part of the universe, and sometimes, that is enough.

I just need to remember that, to remind myself that during the moments when it seems like everyone is trying to tell me to the contrary.

  • * *

Note to self for next post – remember to post the thoughts about chronic depression, the idea of depression as an addiction, why some people can’t seem to give it up, and the Buddha.

Crying at the shrink

I did cry at the shrink’s the other day, and that was strange, because I’m usually so hard and in control. But I was so strung out by anxiety and three days of no sleep from the bupropion that it took me a few minutes to even calm down enough to talk (this kind of hysterical shit is very unlike me). In an ominous tone, from him, “You NEED a mood stabilizer.”

He wanted to send me home then and there with an injection of phenergan so that I would sleep a few hours before being on call; I declined. Not a fan of the sleep aids. Last time I took zolpidem, I was fine and awake in the morning, but almost got in a car accident, which had never happened to me before. (And while on call, I saw yet another acute dystonic reaction, so there about the phenergan.)

But at least the massive anxiety from this drug, as well as the calming of the affective storm, for once made me feel both stable enough and uninhibited enough to actually talk to the guy about something that happened in my life that was very meaningful to me, that happened a long time ago, advice that someone gave me that let me move on from grief and heal tremendously from a big wound.

Without going into a long and sort of irrelevant story, the gist of it was that an older woman knew me well, and gave me permission to grieve about something when I was a teenager, to acknowledge a severe loss and hurt. She was one of my mother’s friends, artist-spiritual type, and gave me a concrete ritual to do to give myself permission to grieve, and maybe open doors to a grief I didn’t fully realize I had, or was entitled to. I remember thinking the idea was silly at first, but I went home and tried it (starting by looking at old pictures and just thinking about the people in them), and it unleashed a tremendous flood of tears.

Let me state that the “ritual” she recommended wasn’t an exorcism or supposed to work on some bullshit supernatural plane; I think it was pretty sound psychological advice, if phrased in terms of spirituality. It allowed me to realize a loss I hadn’t acknowledged because it came at such a horrible time in my life anyway, and to free me from the past by letting me discover various feelings of anger, injustice, and ultimately, mourning. It was not “out there” by any means. It wasn’t like she told me to draw a crop circle so aliens could come heal me. It was just something to formally mark a loss, which gave me the opening to feeling it.

And sometimes even today, years later, maybe once every couple of years, I revisit those photos and what she told me, and I cry again, hard. But it is different now, in the way that grief changes. I look at the pictures, and it’s not this raw gaping wound, it’s just sort of a nostalgia, a sense of being sorry that things didn’t go the way that they would have in a perfect world. A love for times and people past, with all the imperfections.

She gave me the gift of being free from something that could have torn me down, destroyed any potential I had to be other than numb or in shock for the rest of my life. She gave me the gift of healing.

When I think about it…no, that’s not right, when I feel it, really let myself remember and feel, I can’t help but cry. And that’s what happened at the shrink. It wasn’t like I was sobbing hysterically and out of control. It’s just that the story opens in me some very bittersweet emotions – of the loss, of the gratitude of being able to let go, of the magic of healing, and of a million other things, too.

I noticed also that for the first time with the shrink, I was talking in terms of how I really think, how I used to be, because it took me back to so long ago, to a time when I was in my core state, when I was really ok. I spoke in terms of ritual and feelings and symbols, which is a reflection of how I see the world, how I grew up, in a world of artists.

I think I concluded the story by saying something like, “That’s what I think I need now…a priestess. An older woman who knows what happens to women, how they get so hard and cold, the way I’ve gotten to be. I wasn’t like this then. I was warm, and loved everyone, and was so idealistic and compassionate and forgiving. I wasn’t ice like I am now. I need someone who understands how that happens to women’s spirits, how they get lost in the woods and meet so many monsters that they start building up armor, and how to set me free again.”

I’ve said to the shrink many times, “We don’t speak the same language.” I don’t think he ever quite got what I meant. It became clear to me. I have always spoken to him in medical language, the language I’ve learned, the language of pathology and death. But that isn’t my real language. I think that I had forgotten my real language a bit, and speaking in it, of ritual, magic, symbols and signs.

After I said all this, the contempt was all over his face. Then he said, “Sure, she just gave you a magic solution.” Obviously he also wanted to say that he thought that she had probably done me psychological harm. But it wasn’t a “magical solution” and it didn’t solve anything overnight.

He thinks that at the core, there is something wrong with me that it will take expert reparenting or whatever (naturally, by my submission to his worldview and acceptance of it, by letting him be daddy). I think that at the core, I am actually healthy, and just need to be freed from a lot of things that happened to me along the way. I need to find my way again.

And that is what became so clear to me sitting in front of him. For once, I didn’t give a shit that he was so dismissive, so utterly un-understanding, because I know what is wrong now. I need my language back, my self back. I need to get rid of the chains that medicine has wrapped around my soul and return to the path. I don’t need to fix what is broken; I need to find what is whole.

Suddenly I could see a chain of events, a period of time, in which I became hard, and cold, and unrelenting, began to speak in a foreign and cruel tongue.

I saw that he didn’t get it. So I started to say something like, I just think I need to see a woman…because I just hate men too much. It was my way of letting him off the hook. It isn’t his fault he’s a man. It’s easier and kinder to say that than to say that it is his fault that he hasn’t seen me, not really, not once, in all these years. That managed to set off a huge argument over whether it is normal or not to hate men. Which was missing the point, but that’s ok. I finally see it: he’s just not going to get the point.

But I do. And that’s a start.

* * *

When I asked her what I/we could/should do, she took up her walking stick and walked expressively and purposefully across the room. Dipping a bit from side to side.

She said: Live by the Word and keep walking.

– Alice Walker

The Rest of My Life

I’ve been writing kind of heavy stuff lately, and I think it has skewed what this started out to be, which was a chronicle of how people who are crazy live in the normal world, how we are mostly invisible to everyone. Lately, you’d think that all I ever am is crazy.

Which is understandable. This last year my mental health has been perhaps the worst in my life (or second worst). And the Wellbutrin is making me anxious which makes me write. (Student loan panic set in tonight, which is always a symptom.) And I have been thinking a lot about my mental health, which I don’t usually do when I am well. It is the main thing on my mind, sad to say. I’m afraid many more important things have been forgotten in the mess, like the people I love.

So I thought I’d put in some balance of the perspective. Despite having an awful morning due to various symptoms, I pulled it together and worked a night shift last night that was perfectly fine. While working, or writing, or engaged in conversation, I am able to selectively ignore a lot of symptoms, just feel them less. I think it’s like sometimes when you have a flu or something, you really do feel better when you are up and moving around rather than lying around thinking about what hurts.

I thought I’d make a scattery list of things that happen in my average life, which are far underrepresented here.

1. I usually meet friends a few times a day. Having stayed more or less in the same medical system where I went to medical school, there is no shortage of acquantances and a few very close friends around all the time. Sometimes when it is very hard for me to go to work, knowing that they are there helps a lot.

My best friend is a friend from medical school who also stayed on at the hospital. We can often catch a few minutes to chat outside the building while he smokes. He’s tried SO hard to quit, and even tried taking the bupropion for that, but guess what – it gave him panic attacks and made him paranoid! He can’t believe I’m sticking with it. It does give me panic attacks (witness yesterday morning) but I find them infinitely preferable to depression.

He has a new baby and is utterly in love with her and shows me pictures on his cell phone. I haven’t been good about going to see her; haven’t given her the baby gift (partly because I can never find anything quite special enough). I am happy that he is so happy.

I’m afraid I haven’t been a very good friend lately, since all I can think or worry about is how crazy I am…and no one wants to hear about someone’s mental health, shrink problems, med problems etc forever. He has been very good about always coming to talk if I need to, though. And sometimes we just talk about normal stuff, laugh at ridiculous senior doctors, the fucked-up system we are in, and so on. If another friend joins us, it’s better sometimes because I can’t talk about crazy and it just rolls over into small talk.

2. My partner and I spend domestic time together, which is very quiet and pleasant. I tend to be something of a homebody, and he humors me. We spend a lot of nights watching DVDs of comedies (I can’t stand to watch anything sad or serious on TV. If I wanted reality, I could go to work.) We laugh a lot. We curl up and read. We are both nerds. Sometimes we talk about physics or other science topics one of us has read about. We had this weird discussion of Descartes and Maxwell after something he read a few days ago, lasted late into the night. We got into this discussion about whether mathematics is something that exists intrinsically, or something we made up.

3. I love my house. It isn’t anything fancy, and is really a rented apartment, and nothing in it is expensive, but it has my things in it, and I have set it up to be a shelter for me, a quiet place with warm colors. I think that sometimes this isn’t so good because I don’t invite people over much. But sometimes I curl up on the sofa with a book or a blanket and feel overwhelmingly content. I am surprised at how nice this feels. I guess when you grow up in a stormy, violent place, the thought of home is a strange pleasure. I’m surprised to have found one. I am overwhelmingly grateful to live so comfortably, to be safe and warm and sheltered.

Of course, because I am crazy, this can lead to worry that it will all be taken away from me somehow. But I know I can survive that too. I have been in very bad places, poor places, alone in life, and that taught me that really a human being needs very little to survive. You don’t need a bed, or a roof, or a change of clothes, or internet. You need food, and that is about it. I can be thankful for what I have now while still knowing that I could survive without it, have survived in scarcity, in violence, not knowing where I would lay my head. I love what I have and would hate to give it up, but I wouldn’t die from that.

4. Though it stretches my budget immensely, is my single biggest expense after rent, I can pay for my mental health care, for what I need to keep a job, to avoid the “bottom of the barrel” public mental health system. This makes me luckier than people thrown at the mercy of the public system. Unfortunately, this is also self-perpetuating: I am able to work because I can afford at least partial medical treatment for my condition, which is not covered by insurance. People who can’t will never get the quality of care they need to get better.

5. When I work in the emergency room, I sometimes pass through the pediatric ER just to see what is going on. Pediatricians are the nicest people in the world and I’m always able to say hi and smile. There are sometimes funny kids in there too, and they make me smile too, even though kids aren’t my thing. The best break room in the whole ER complex is in the pediatric ER and when I eat I go in there and make tea (they have the water cooler) and see nurses and staff I haven’t seen since I stopped working there. The hardest work I did was there, but also the nicest environment. And everyone there always says hello to me and smiles.

For someone as shy and introverted as I am, it is wonderful to know I have a place like that, a place where “everybody knows my name.” And not in the way the internal med docs or ER docs do – as the freak one who always was in a rage and never got along (last time I worked with them I was in a very bad state). The pediatricians know I didn’t like pediatrics and didn’t like working there much, but they like me anyway. For someone like me, it is very nice to have people who are happy to see me. Especially after this bad year, when I ruined so many working relationships.

6. Since I’ve lived in the same place since med school, the local businesses know me. I can walk in to grab quick take-out food, and see familiar faces. The nearest neighborhood with amenities is of a lower middle class to working poor area, and people haven’t gotten into the ideas of having cars for everything, so they walk and use local business. There is a sense of community that people don’t have in wealthier areas. And they know me by sight when I walk in, too.

7. I always can call someone on the phone from my cave. (Not that I usually would, but that’s a different issue altogether.) Somehow, I don’t know how it happened, I ended up having friends. I’m afraid I haven’t been as good a friend as I should always, but I am fortunate to say that I’ve never felt truly lonely. Alone, certainly, but I have received far more love in this life than I ever deserved. We don’t get together that often, but we chat, we see each other at work. Sometimes I feel guilty that I’m sick, sometimes I can’t love them back as well as I’d like. But I know that for a lot of the mentally ill, they drift out of society into increasing isolation and that loneliness is a huge factor in suicide. I think that I may have spread a lot of pain amongst the people who have loved me, but I never meant it, and I was never really left alone.

Last time I was really depressed, it was last spring. One friend, I didn’t tell him details at the time, just that I was not feeling well. Despite having a house full of kids and being a busy doctor too, he called me at least every other day to see if I was ok, and let me vent without asking for details. Since at the time I was pretty much confined to the sofa, those phone calls were incredibly meaningful to me.

He always invited me to a weekend dinner with his family and I always declined, but once when I started to feel a little better, I went. Of course, I was nearly non-reactive, and when I did speak it was a huge faux-pas with his mother-in-law. But no one ever made me feel strange about anything. Even though it wasn’t a particularly memorable evening, it marked a lot of coming back to life for me. I felt horrible, was minimally groomed, but I was out of the house and back among the living.

This incredibly kind gesture, those daily calls, which must have been miserable, for no reason, was something that stays with me until today.

And I know that if I ever really flip out and end up in a hospital, I wouldn’t languish there at the mercy of some fucked up psychiatrists. A few close friends with connections in the med world would come to my aid and beat them down from over-drugging me. I’d die of embarrassment and probably try to keep them from even knowing, but I wouldn’t be alone at the mercy of the system.

8. I read a lot, though since these episodes have been so out of control, it has been a lot harder to focus. But this month I finished two books. Not my normal rate, but better than before. It used to be a big part of my day, especially when I was a kid. It is probably some escapist coping mechanism that isn’t so healthy, but I enjoy it. In my bedroom, on my side of the bed, I have a big pile of books and note papers. My partner calls it “my world.” Whatever I’m reading, which is usually one or two new books, and a lot of old favorites for when the mood strikes, are there. There are lots of books on the edges of the sofas too, and all over the house.

9. Food: not much of a cook, when I do cook, it is healthy fare, or something that goes together quickly. A grain and a legume. I don’t cook with much that “you can’t tell where it came from.”  Often, as I said, it is takeout from a local place. There is only one that is close by. Too much fried shit, but it is quick and good. On call, I eat at one of the many coffee shops in the adjacent shopping center – salad or pasta, usually. Usually I go with whoever I happen to be working with that day, but not always.

I hate all this Atkins shit. I love carbs – pasta and potatoes and bananas and grains. I’d rather give up fat than my carbs.

I can’t cook that well, but I’m a really good baker. I make all kinds of wonderful cookies and cakes. Nothing flashy or pretty, but the kind of thing you just can’t stop eating, out of simple ingredients. I haven’t in a while because of being busy and also not wanting to eat a whole batch, but it’s my secret skill.

10. I have a ton of makeup. Nothing expensive, but I used to be a sort of punk ass kid and I still have a lot of stuff left over from high school. I don’t get to wear it anymore much, but when I’m off work, I do. I wear my long hippie dresses, my slightly gothic looking black velvet stuff, my Wuthering Heights collar jacket. I guess some of it could pass at the hospital, especially if I wore just one piece, mixed with mostly business looks. But I hate having the clothes I like “contaminated” by work. The problem is that I don’t go out a lot to other places where I can wear them.

One of the books I’m reading is a pop culture version of a book on Schema Therapy – basically cognitive therapy that people with deep problems have them from deep assumptions rooted in childhood about themselves and the world. The pop culture book tells you all these signs of which false beliefs you might have. One of them was “Dressing more conservatively than you would like.” I think that was supposed to point at an “outsider” belief: that you feel like you don’t fit it, are somehow different. This can be a “defective” belief; you feel that you are somehow basically flawed, and damn well better hide it.

And damn if I don’t feel that way in medicine a lot. Most docs come from a very different background than I do, with very different social rules. Very upper middle class and conformist. I always feel like I’m trying to ape a look that they have…and I hate myself for sticking out because I don’t ever quite like them, and I also hate myself for trying so hard.

I remember in med school, there was this one girl from a very affluent city. She was a bitch, shallow, mean, basically obnoxious. Spoiled brat, rich parents who divorced and just threw money at her. She sort of pretended to be my friend, but always with an air of, I don’t know, like she would be my social guide. I didn’t really like her, but she terrified me because she was so mean. She always criticized my makeup, my clothes, whatever. One day I was wearing fishnet stockings (probably with Doc Martens but I don’t remember; certainly not with fuck-me-pumps or anything) and she came up and rolled her eyes so hard, and said to me with a snort, “God, don’t ever wear those again.”

This girl was a caricature; she was ridiculous, and no one else ever took her seriously. But she was from “the right side of the tracks” and this rich town and seemed to know the rules that I didn’t. And every time I let her do that to me. In high school, I would have gotten into a fistfight with someone like that. And I would have taken her down.

And I never wore fishnets to med school again.

Somehow I think that story is symbolic of what med school and the doctor world has sucked out of me.

And once again, I digress into psychological topics.

But I guess I can tie that in to this post, because it is something that, apart from my crazy, is prominent in my inner world lately. I am slowly coming to the realization of just how much I have let medical school and being a doctor kill my soul. How different I am from when I started. And I think back to all the times I should have said, “No. This far, and no further.” Years ago, in maybe the second year of medical school, with the animal experiments. And a million other examples. Right now, I am working very hard to recover my soul, my woman’s wild soul, from inside the soulless monstrosity that is modern medicine.

A funny thing happened lately…I have been so depressed off and on that I finally let my meticulous makeup go and have been going to work without it, with just a little bit. And looking generally disheveled, hair uncombed, because I just can’t deal with it. (I have finally grown a half-meter of hair, which I love, but it’s just so hard to wash it all after 30 hours on my feet, and I know I’ll probably cut it, but still, I worked so hard to grow it out.)

And I’m not sure, maybe I’m just imagining it, but it seems like I’m getting less disbelief when I walk in and say I’m a doctor. Most of the girl doctors look like that.

I’m not sure what bothers me more, that I am letting myself go like that, or that no one can imagine a doctor who doesn’t look like C. Everett Koop (and even he had some goofy facial hair going on).

I also hate how many comments I’ve gotten about how I look so much more “professional” without the makeup. (One from that attending who tore me down.) Even the shrink said I was “prettier bare,” that I didn’t need to “hide behind all that.” (Was that a borderline inappropriate comment? I’m never sure.)

If I want to wear it, none of their fucking business. Women have played with masks and veils since the beginning of time. Why can’t I?

At home, though, I immediately change into sweats, warm, cozy things that I’ve had forever.

But – I love playing with makeup and looking slightly like I stepped out of the wrong time century. Even if now I just do it in the bathroom alone before I get into the shower.

11. Other things in my life every day: sometimes I promise myself a good cup of coffee on the way into the hospital and that is the thought that keeps me going as I get out of bed, get dressed in the cold bathroom, sitting on the bath mat as I brush teeth because I’m too tired and down to get up. I feel like a little kid, bribed with candy. But sometimes, that’s a big part of my day.

12. I worry about money a lot. Not paying the rent and bills and all that; and I never run up the credit card. I’ve always managed to live within my means, which at times were ridiculously meager…except for one thing: my massive student loan debt. I have no idea how I will ever pay this off. Or even make payments that make a dent in it. Once the deferments and all that are up, the payment alone will not leave me enough for rent. Hoping for a miracle. I guess I’m just like everybody else in this. I obsessively read the “get out of debt” stories, and “America’s Cheapest Family” and all that. But the thing is, there’s not much more I can cut. I don’t buy clothes, I don’t go out to bars or to eat much (the takeaway is cheaper than buying enough basic stuff to cook for me), really the only thing I do buy is books, and even most of them are used. I would try to cut back, but part of the problem with libraries is that what I read is always too obscure, or in the wrong language. No one ever thinks, when they move to another country, how much they will want to read in their native language – and how expensive it might be to find imported books.

My credit card statement is funny – it breaks the charges down by categories. All I ever have are groceries, gas, insurance payments, pharmacies, and books. Every time I open it in front of someone, they just laugh.

I guess I could go carless. I don’t really need one. Local mom and pop grocers deliver, and, while it does cost money, it’s less than a car. But after my contract is up, I don’t know where I’ll be working, and then I might need one, so I don’t want to get rid of one just yet.

13. I always keep a bus pass in my wallet, and sometimes I take the bus to the hospital. The walk to the stop is nice, and it is quicker than having to park there. The hospital is toward the end of the line, so the bus by then is usually full and I stand up. It is nice not to drive and worry about when my car is going to die.

14. I take something to write with everywhere. Often I get writing ideas that fly through my head, and if I don’t get them down immediately, they’ll go away, be forgotten. My life is full of the backs of receipts, of ticket stubs, of gum wrappers, on which are written things like the perfect end to my novel. My close friends laugh at me because they can see when I zone out into an idea, and sometimes laugh or am otherwise altered by the words that run through my head, how my attention is both in the conversation and far gone. People like that girl above think I’m weird. But the people who love me think it is just another part of me, a quirk.

* * *

I think I wanted this post to be even more about minutiae, things not concerned with my mind or medicine. I’ll try to let some more ideas come to me as I go about my day over the next few days. Maybe if I ride a bus.

* * *

Next time: remind me tomorrow to write about how I cried at the shrink’s a few days ago. I didn’t think I had tears left, I thought I was too cold. I think he kind of had contempt for what I cried over…but that’s ok, it reminded me of something important, pointed the way to me to the things I need to be able to cry about again, the things that I can’t, ever since becoming a doctor.

Cyclothymia as a personality disorder; hormones and moods

I have had a partial response at least to the bupropion. Because of the anxiety it causes, I haven’t been overly eager to up the dose so I am still on half a normal dose. I can’t get anything done and feel bad a lot of the time, but I am not wallowing in my misery nonstop. I suspect I need a little serotonin, but as I have been told many times, it is not my job to be my doctor. I don’t even want to suggest anything anymore.

* * *

Things That Make Me Sad

I have done a few calculations that make me sad; these are calculations that probably should not be done.

For two weeks of every month, I am nearly symptom free.

Then ovulation hits and I have 2-3 days of misery, which slightly abate, but then I have two weeks of slowly mounting depression, darkening of the world.

That means that half my life or so is erased.

Add to that my twice yearly or so major episodes – usually one in September-October (depressive) and one in late March-April (manic).  Each lasts about 2 months.

Where exactly am I supposed to live in between all of this? How much time of being normal can I enjoy? Most of it gets eaten up trying to compensate for the things I ignored during the episodes, cleaning up messes I’ve made, trying to forgive myself.

Then, just as I think I might be alright, it begins all over again.

Is it any wonder they accuse me of having a personality disorder? I think the shrink is sort of right about that, but none of them fit because it’s one that has been taken off the books. I checked. I’m not borderline, I’m sure. Maybe some narcissistic traits, but I don’t lack empathy completely. Histrionic, well, no, I’m too shy for that.

When I was doing the reading on borderline to see if it could be, I was quickly relieved that it wasn’t. I read everything in the medical library, including pulling the original Krapelin and Kernberg out of the archives. There was a book from the 1950s or so that described borderline as something slightly different than today (more in psychodynamic terms and with more of an emphasis on the “psychosis” parts), and I was greatly relieved all around by my reading that the shrink was wrong.

(Please, if you are carrying a BPD diagnosis, don’t get offended, I mostly was happy that he was wrong, not that it’s the end of the world to have it. Also, after a horrible year getting used to the idea of being manic depressive, I didn’t think I could take having to go through that again to something else.)

The relief I felt was visceral – the descriptions just didn’t “click” with me the way that the bipolar ones did when I first read them.

When I first realized what was happening to me, that I was in the midst of a terrifying full manic episode, and steeled myself and went and read all night about manic depression (for about 36 hours straight, mania anyone?), something I didn’t know much about. After a few articles, every time, I was nearly physically ill, had to remove myself from the library to just breathe before passing out.

I saw myself described in such perfectly accurate, pathological terms. Shock – someone who had never seen or met me could so clearly describe my life – I knew in my gut that it was right, that as much as I wanted to, I couldn’t argue with it.

When I went to investigate borderline, I started in the big Kaplan and Saddock (I own only the small one) and then went backwards in time. I did some paper in med school on a psych topic and at that time, I’d read a lot of Krapelin and Bleuler and all of the older psychiatric writings, and I remembered that they were far better observationists of phenomena than we are today. Much of what they realized is forgotten in neurotransmission and the pharmaceutical industry, colored by what we are just starting to know about biology, and often gets bogged down in details while missing the big picture of a disease. They had far better intuitive understandings of various mental states and illnesses than anyone living today because they were scientists, observers, not trying to fit a dopamine theory or a serotonin theory or any other theory to what they saw.

So I had found some old, old book, probably translated from German, on borderline states. Hunched over that dusty volume, I turned page after page on borderline, interested out of curiousity, but after hours losing interest because it didn’t speak to me, wasn’t grabbing me by the heart and shaking me around like first reading about the bipolar syndromes did.

And then I turned a page, and the thing facing me was a chart, this: “Cyclothymic Personality” and I don’t remember  if they called it “disorder,” I don’t think so. I think then they were calling it “Personality Structure.” And I read it. And I got that sick feeling again.

The new thinking in psychiatry separates personality from mood, and cyclothymia has been popped over to mood (from what I can tell, this happened in DSM-III), and you can no longer have a cyclothymic temperament and full-blown mood episodes; having a major mood episode bumps you into the realm of “bipolar” somewhere and “erases” the cyclothymia diagnosis, at least as far as I can tell.

But that seems fairly arbitrary; because listen to this description (which supposedly is validated, see Akiskal’s writings in the late 1990s, and also, for BPDers who are reading along, his writings on BPD as an extension of a mood disorder with bad coping features are also very good, and a thank you to that psychiatrist I met once in New York who gave me Akiskal’s name to read up on).

The Cyclothymic Personality:

  • Lethargy alternating with eutonia
  • Shaky self-esteem alternating between low self-confidence and overconfidence
  • Decreased verbal output alternating with talkativeness
  • Mental confusion alternating with sharpened and creative thinking
  • Unexplained tearfulness alternating with excessive punning and jocularity
  • Introverted self-absorption alternating with uninhibited people-seeking

Then, the non-validated but often cited ones, in Akiskal’s rules of thumb for identifying BP in a depressed patient:

  • frequent shifts in line of work, study, interest, or future plans
  • irritable-angry-explosive outbursts that alienate loved ones
  • extravagant, colorful, unusual dress
  • frequent changes in residence or geographical location

Is it any wonder I look like a personality disorder? I am all over the place, this is what he sees, that sometimes I never shut up and can’t stop joking (and believe me, I grossly overestimate how funny I am), yet other times can barely speak for shyness. Or “I know every single thing in medicine better than anyone else,” versus “I’m terrified and can’t handle anything.” Or, the astounding self-centeredness of something like this blog versus my feelings sometimes of a vast and shattered love and compassion for everyone and everything in the universe.

What about on an existential level? My alternating nihilistic atheism with my sense of magic and wonder and unity and ultimate gratitude and worship at the universe?

No wonder one would think something is inherently unsettled in my self-concept. I always try to explain that it is the mood that is the problem, not me, but no one hears. I don’t feel like I change at my core, rather that the core is filtered through the mood. The mood grabs me and shakes me and twists me around, building me up, tearing me down, over and over again. It is exhausting. But it doesn’t erase who I am, though over time, I’m sure it has changed it some.

I don’t have identity issues. But I think that might be kind of hard for someone on the outside to see, especially someone who trained in the times of DSM.

If I remember correctly, that same book said that most of the way to distinguish between borderline and cyclothymic is that borderline has additional sine-quo-non attributes:

  • the abandonment issues and fear of such, the behaviors that go with that
  • disturbances of self-image: the sense of not knowing who they are/emptiness/fear of disappearing
  • splitting and the black/white worldview

The rest of the criteria can be or not be in either disorder. There are some that tend to be more common in one or the other (big ones: seasonality and sleep changes, more in cyclothymia; rejection sensitivity and unrelenting suicidality in borderline). Mood lability, interpersonal conflict, impulsivity, seductiveness, bisexuality, rages…any of these can appear in either disorder, maybe in slightly different forms, but they aren’t distinguishing characteristics.

* * *

I don’t know where I’m going with this post. I started this post wanting to update on how things are going before I go work another all-nighter, but also wanted to add some content. I doubt it is that informative for anyone – if you’re a shrink you probably already knew it, and if you are a patient, not sure what it could possibly do for you. Maybe I just wanted to point out that who we are is a tricky subject. Or that in psychiatry things need to go back to science and observation, not have theory dictating. Maybe that a system that catalogues pathology without normal workings is problematic in medicine.

I have been on a light schedule since January 1, and it has been both good and bad. Physically, I’ve been able to catch up on sleep, eat a little more healthily, but in a way, the sleep deprivation, while making me terribly unstabile and volatile, kept me out of the worst of the lows. I wanted to ask other women out there what to do about the mood stuff – I’ve tried every hormonal birth control type thing available, and all of them just made things worse. I’d do an oopherectomy in a second if I knew it would make this stop.

So that is the current state – floating, not really sick, not really well. Faith isn’t quite back, worry is still hanging around. Trying to rally some of that enthusiastic energy that has been gone or in rage form for so long to enjoy patients tonight. Not sure I’ll get there by tonight. Sending love to the universe as best I can, hoping some of it will come around to you, and maybe back to me. Until next time…

* * *

* Note: I used the term “borderline” without any qualifiers for several reasons. I find the whole “diagnosis” terribly subjective (and I think it has been shown to be fairly nonreliable though I don’t have a reference on hand), often a result of dislike for a patient, offensive as a woman, and unfair to the patient, who is pathologized, while the person who raped/beat/molested her is left with no stigma. I see patients with the patterns described, but once I let myself see them as “borderline,” I become free to ignore or brush off what they say, to shirk my duty to them. While the syndrome described exists, it is also perpetuated by treating physicians who treat patients as less than responsible adults.

Other reasons: One, in my opinion, “personality disorder” is a perjorative phrase. Two, it looks like the disorder is going to push over to the affective disorders. Three, I didn’t use “emotional dysregulation disorder” or any of these newer terms because they are not yet widely used enough to be easily recognized. Four, I am also discussing historical uses, which did use that phrase in a very different way than it is used now but nonetheless used it for similar phenomena.

I think the suggestion I like best for a new term will never catch on: Mercurial disorder. It’s catchy, one-word, poetic, and descriptive while not proposing a root cause, which we really and truly don’t know. (Emotional dysregulation disorder sounds nice, but do we know that that is the disorder and not an effect of it? Is that the central defining feature? Far from certain.) I used the word myself in a previous post without knowing it had been proposed as a replacement name.

Link

Things here are mostly the same, maybe slightly better since I’m working back at my main hospital, mood more or less stable, but in a slow decline. Physical health also taxing and on top of it, a massive viral infection (winter in the ER, joy to the world), but whatever. I can deal a lot better with that than the brain stuff.

But for your reading enjoyment, here’s a great post over at BipolarLawyerCook. The third paragraph is exactly what I think about having kids.

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.

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