Hopin’ to Move Up!

Associate Clinical Professor of Psychiatry sounds pretty good, I think, but apparently, I am eligible to apply to become a Clinical Professor of Psychiatry (voluntary), and so I did. I wrote about my various and sundry teaching experiences, supervising, case conferences, journal clubs, along with my administrative work of representing the sole female on the Voluntary Clinical Faculty Board of Directors. Most uncomfortably, I listed ten folks who could affirm my work, and yet, I was told I was not to give them a heads up. Now, I wait many months as the committee forms an ad hoc committee to decide whether I qualify for a new title, which, in point of fact, means a lot and a little at the same time. It means a lot in that my peers will be evaluating me, and I would like to think that they think highly of me. It means a little in that my daily life remains. I see patients and I teach. That combination is independent of my title, for the good and bad of that. Many of my posts have my rant about the lack of transparency in mental health. The public does not know what they get when they walk into psychotherapy. That I am affiliated with UCLA may impress some, but the exact nature of that affiliation hardly seems to matter, as the nuances of my title are not relevant. In a way, that makes sense. Patients and students should evaluate me based on how I make them feel, and not necessarily where I went to school or whether I got honors or not. On the other hand, my academic record demonstrates a hard-working value which has lasted over many decades. This potential advancement is further evidence of my commitment to teaching, to giving my time, to help the next generation of psychiatrists hold on to the old notion of the value of history-taking and the doctor-patient relationship. I want to pass this on, both with my blog postings and my face to face contact with my students. Luckily, this is not threatened by this application. Volunteering seems to be an open position, at least for now. Still, I hope I pass.

Why Be A Psychiatrist?

Who becomes a psychiatrist? Many would say those that can’t stand the site of blood. I always took issue with that half-joke, half-truth comment, because for me, I really really like blood. I like organs. I liked my surgery rotations. I liked drawing blood. I became a psychiatrist because I never wanted to get bored. At the time, all other specialties were following algorithms, meaning that once these were mastered, there seemed to be little challenge. With psychiatry, talking to people, is always new and different. I like that. I wonder if that same principle applies to my younger colleagues. Were they drawn to listen to stories, or were they drawn to the fun of psychopharmacology? Psychopharmacology is fun, in that people get better from medication and this, of course, is very satisfying. Still, I wonder how young people decide their specialty these days. A psychiatry rotation in medical school deals with chronic mental illness. It would be hard to extrapolate from that, my daily life as a private practice psychiatrist. I am sure there are the practical considerations of paying back loans, controlling one’s hours, and the amount of overnight call. I think I should ask my students. Stay tuned.

Anniversary Reaction

A reader writes:” My brother and I were like twins growing up: 14 months apart and inseparable. When I was 25 and he was 26, he died of cancer. At the time, I didn’t grieve hardly at all, as I was raised not to talk about intense feelings much. So…I put a lot of these painful feelings away, and didn’t realize until this past year, when I was going through other stresses, that there was even something called delayed grief. The pain has been overwhelming. I am going through counseling with a really good therapist who is helping, but I am dreading my brother’s death anniversary date that is coming up next month. It is always an extremely difficult month for me. I am especially dreading it this year. I had been doing better lately but the past two days I started crying just thinking about my brother. I miss him so much. He was my best friend in the world and no one can ever replace him. On top of everything else, I have guilt feelings that I didn’t do enough to help him get diagnosed earlier. It has been so many years since he died but it feels like just yesterday.”

 

From…http://www.griefhealingblog.com/2012/05/coping-with-anniversary-reactions-in.html

 

In cruising the internet, I found this tale, helping me pinpoint my curiosity about this idea of the “anniversary reaction.” There is something, for some folks, like this reader above, that I will call Zach, in which the anniversary becomes the focal point for grief. It is almost as if Zach’s mind has given him permission to grieve around the anniversary time, whereas at other times, he would feel foolish or “too sensitive”. On the other hand, maybe the anniversary, the time of year, the length of the days, the holidays, bring back a flood of memories which bubble up causing this psychological pain. Either way, and of course, it could be both, Zach expresses this sentiment that “the pain has been overwhelming,” leaving us, the reader, to wonder what he means by that. He is “dreading” his brother’s death anniversary, but what is he afraid of? One imagines that he is afraid of the despair, the heart-wrenching feeling, of helplessness that he cannot bring his brother back. What is “overwhelming,” I think, means that he is fearful that his ego will be taxed beyond it’s typical coping skills, leaving him with no means to soothe himself. In the event that he cannot soothe himself, he fears he will be left feeling agitated and alone, perhaps with a temptation towards conscious or unconscious self-destructive behaviors,  in order to help him escape from his psychological state. All egos, no matter how strong, or well-developed, can face circumstances which exceed it’s ability to find healthy coping skills. On this level, Zach’s fears are understandable. His “good therapist” can help him understand his fears, but by no means, can this “good therapist” protect him from his anticipated need to escape his psychological state. On the other hand, maybe understanding that the ego might, in fact, be stressed in ways that it has never been stressed before, might help Zach be more thoughtful about developing new, and deeper ways of managing, what at this time, seems to be an unbearable reality. Maybe that is what I do.

What Do You Do?

In trying to explain what I do for a living, I am acutely aware how inarticulate I become. “Well, I try to help people sort out their psychological issues and the points in their lives that lead them to feeling confused and bewildered.” I say, not quite happy with this answer, but unable to say it in a better way. “Sure, I prescribe medications and I think that is very important, but that is incorporated into a bigger picture of trying to listen and understand how the person has made important decisions in his life.” I continue, still not satisfied with my answer. As a psychiatrist, some folks imagine my practice to be filled with the chronically mentally ill, and, of course, I do see these folks and I have the skill-set to help them. Yet, in addition, I work with many people who do not meet criteria for a mental illness, but still benefit from medication and psychological exploration. My listener often looks confused as I talk about this. I try again to encapsulate my work, but I feel that my response does not capture the variety in my work. I work with kids, families, couples,  and individuals of all ages.  I work with people who have spent time in psychiatric hospitals, as well as those who will likely never need those services. I prescribe medication to many, but  not all of my patients. My work is varied and customized to each client. How do I communicate that? I need to think more about this.

What Do Psychiatrists Do?

Private practice, county jobs, VA jobs, academic jobs, are all examples of how psychiatrists jump into a career. As I have ranted in this venue before, most psychiatrist jobs, these days, are what I call “psychopharm” jobs, meaning the institution hires the psychiatrist to be a “pill-mill”. “What’s wrong with this?” My imaginary readers ask, to help me launch into my current post. What’s wrong, is the psychiatrist should be the thought leader, the one who designs programs for the mentally ill or creates systems of care in which problems such as homelessness and substance abuse can be approached in a comprehensive, and compelling way. Checklists are not the answer, and yet, there is a large push, particularly in the public sector, for the practitioner to check off boxes, signaling that important issues are discussed. Yet, the issues of the mentally ill, be they anxiety or psychosis, is that the individual needs to feel deeply understood, and then there needs to be services which connect with their underlying pathology. Psychiatrists are in a unique position to both understand patients, as well as help other mental health professionals understand the deeply disturbing experience of mental illness. As such, psychiatrists understand the kind of social services that patients need. They also understand the kind of individual work a patient needs. Putting these two skill-sets together, creates a thought leader who should run agencies, direct programs, or design curriculum. Yet, in most institutions, those jobs are done by non-MDs. The psychiatrists fill the check-box of “psychopharmacology evaluation” and that is usually all they do. This is the big picture/small picture issue. We, as a field, have bought into the ‘small picture,’ without feeling the responsibility of the ‘big picture.’ For this, I think, my field needs to reflect and re-group.

Changing Face of Medical Care

 

There is change mentioned at every lecture I attend, every lunch time discussion, every committee meeting. I hear these discussions in primary care and in psychiatry, but I think it is likely that every corner of health care is struck by the feeling that we have reached a pivot point. Today’s angle was delivered from an esteemed Duke primary care physician, director of the Family Medicine Residency, and a former student. Family Medicine, he says, will no longer focus on why patient A does not take his blood pressure medication, but the physician will look at a bigger picture of how can he/she implement a system which facilitates compliance. We changed the name from compliance to adherence and back to compliance, but that is another story. This system is going to involve using technology, nursing and administrative staffs, wellness groups and community outreach. It sounds like Kaiser to me. In fact, it is the Kaiser model. Have lesser trained folks work on the patient interface, while the physician does what he is trained to do; decide what the problem is and how to treat it. After that, the can gets kicked down the road, and the health care team deals with the details of implementation. Theoretically, this makes a lot of sense. Practically, Kaiser, as the model, does a good job, mostly. My issue, as my readers have heard before, is that the reward system for the physician has changed drastically. It used to be that the implementation of the details, understanding why patient A does not want to take his medication, his resistance, if you will, to making his life better, was where the deep relationship developed, and hence the career satisfaction. Now, unless a physician “goes concierge,’ as my colleagues like to say, that connection is lost, leading to a more technical job of diagnosis and treatment recommendations. More technical means that patients, on average, will get good care, but the physician will only be using his left brain. The integration of the right brain, the understanding of how human emotion interfaces with disease management, will no longer be in the physician’s scope. As a policy maker, this makes sense. As a physician, well, the world is changing.

Graduation Time

 

Tonight the UCLA Child Psychiatrists are marking the end of their fourteen year journey to professionalism. There are eight 30ish men and women who will begin careers for the first time, without the mandatory supervision of faculty members. Many folks see this as a prolonged adolescence in that despite their age, they have yet to experience the responsibilities of adulthood. Although they are licensed physicians, and perhaps board certified in adult psychiatry, they have never had the experience of being an employee. Thus far, they have been in this in-between land in which they are working under supervision, similar to an apprentice, while still learning their trade. They are graduating at a time in which the Affordable Care Act will soon change the landscape of medical practice. Access to mental health care will explode, leading to a high demand, but at the same time, the providers of this care will likely be primary care physicians and nurse practitioners. Psychiatrists, the experts project, will be consultants, helping those on the front lines deal with the issues of mental distress. Yet, their training has not been embedded in primary care so the jobs they jump into will not resemble their apprenticeship. This reminds me of my training where psychotropic medications were yet to explode, so I launched into a world of “psychopharmacologists” thinking that word was for those with PhDs in psychopharmacology and not clinicians. As I have often said in these posts, I was caught in a world in which my younger colleagues became great enthusiasts for the wonders of medication, whereas  my older colleagues had deep skepticism, and I could see both sides. This is the dynamics of medical training, where the embryonic development is so long, that the field one enters is not the field one exits. Excitement and apprehension ensue. These folks have had multiple graduations, from college, medical school and residencies, but “this is the one that matters” I tell my students. “This graduation means you are entering into a world in which you are now responsible for your own career.” I say, remembering the weight of this crossroads.

Fungible

 

Health care is moving to assembly line medicine which means that physicians are completely interchangeable, or fungible, entities. This does not mean that people will get poor care, but it does mean that the role of the physician has changed from cultivating relationships to following algorithms. In the long run, those attracted to a medical career will be a different personality type than those in the past, as following algorithms is a different skill set than feeling the pleasure of healing relationships. I understand the value of fungibility, yet I am sad about this change.  Adapt or die, comes to mind, and so I will adapt.

 

 

 

 

Fungibility is the property of a good or a commodity whose individual units are capable of mutual substitution, such as crude oil, shares in a company, bonds, precious metals, or currencies.

It refers only to the equivalence of each unit of a commodity with other units of the same commodity. Fungibility does not describe or relate to any exchange of one commodity for some other, different commodity.

As an example: if Alice lends Bob a $10 bill, she does not care if she is repaid with the same $10 bill, two $5 bills, a $5 bill and five $1 bills or bunch of coins that total $10 as currency is fungible. However, if Bob borrows Alice’s car she will most likely be upset if Bob returns a different vehicle–even a vehicle that is the same make and model–as automobiles are not fungible with respect to ownership. However, gasoline is fungible and though Alice may have a preference for a particular brand and grade of gasoline, her primary concern may be that the level of fuel be the same (or more) as it was when she lent the vehicle to Bob.

 

http://en.wikipedia.org/wiki/Fungibility

 

 

CS Lewis: Known as “Jack”

 

According to Wikipedia, “at the age of four, shortly after his dog Jacksie was killed by a car, he (CS Lewis) announced that his name was now Jacksie. At first, he would answer to no other name, but later accepted Jack, the name by which he was known to friends and family for the rest of his life.” This vignette intrigues me, as I continue to prepare for my upcoming Talkback. My contention is that CS Lewis and Freud are each representing different aspects of their own belief systems. In essence, they agree with each other, they maintain conflicting opinions, but, for the purposes of a writing career, for the purpose of establishing a place in history,  they articulate only one side of the argument about G-d, sexuality and the meaning of life. Given that point of view, I take from CS Lewis, insisting on being called the name of his suddenly deceased dog, is a way in which he lives out  his belief that death is not permanent, so long as someone keeps your memory alive. So much of the discussion about the meaning of life, stems from one’s view of death. If death is final, then fear might ensue. If death is one step on a longer journey, then perhaps one can relax into life. If CS Lewis could think about his dog every day, as he is called by his dog’s name every day, then Jacksie is still alive, yet in a different way then before he was hit by a car. As February represents a month of memories for me, of a particular person that I was close to, who is no longer with us (or me), I, too, am aware of how important it is to keep the discussion, and hence the person, long away from our living world, alive in a way which still has meaning for me. I imagine telling others to now call me by the deceased person’s name. I can feel how special this would make me feel. I can feel that I was not just living my life, but theirs as well. The name would represent a “containment” as Winnicott  would say. In this “containment” there is peace. CS Lewis, Jack, was on to something psychoanalytic; a fact he may take issue with. May he rest in peace.

Unknowable

Trina, fifty-six, a physical therapist in private practice for twenty-two years does not understand how her business works. She has great referral sources, but the flow of her practice changes “wildly,” she says. “Sometimes I have no time to myself, whereas other times I think I am going out of business,” she says, with palpable anxiety and uncertainty about her future. “I have many colleagues and they have the same experience, except for them, they make these false attributions, like blaming the economy.” Trina says, explaining that her perspective is that her business plods along at a rate which is not simply explained by market forces. “There is no way to get a handle on the supply and demand aspect of what I do,” she says, with a sound of frustration that she cannot control her world. “Well, let’s assume it is unknowable, what does this mean to you?” I ask, wondering how she manages this anxiety. “It means to me that I have to understand that my business is vulnerable in a way that I may never fully comprehend.” Trina says with resignation. “When you hear your colleagues talking about how the economy is hitting their practice and you don’t see it that way, how do you cope with that?” I ask, wondering about how she deals with not finding colleagues who share her point of view. “First, I think they are saying that to make themselves feel better. Maybe their practice is down because someone is guiding them to someone who they feel is doing a better job. That is always a possibility. It is hard to go down that road. It is hard not to take it personally and feel that a low practice is secondary to poor work, so it is comforting to know that the force is external instead of internal. No one ever says that their practice is down because they are not good at what they do, but I am sure many people feel that. We, in private practice, get so vulnerable because training programs that offer additional certification can seduce us into believing that if we just could use one more machine then our practice would flourish. Of course, that may be true, but it may also be a way for these training programs to make more money. It is so hard to know. Other people feel the key to building a practice is marketing, so they spend a lot of time and energy trying to package their practice, but it is not possible to know if that is helpful, or the tides are turning on their own. You cannot do a randomized control trial to see what the key ingredients to building a practice. I think this is why a lot of physical therapy students are looking at a place like Kaiser, where there are no business worries. I could not do that because then I would have a boss, and you know me enough to know, that as much as I hate thinking about how vulnerable I am, I also do not like the idea of working for someone else.” Trina explains to me why she copes with this uncertainty. “So, living with the unknowable in private practice seems better than living with the knowable of having a boss while being employed.” I say, articulating her dilemma. “That is exactly right. Life is unknowable. This is just one more thing,” Trina says poetically.