Saturday, August 31, 2013

A Mindful Birthday Party


We celebrated my daughter’s third birthday today. Her birthday is actually a little later next month, but we wanted to have a pool party and that means celebrating before Labor Day. This morning I ran out to the grocery store to pick up last minute items (hey, it was a busy week, and my husband and I aren’t always the most organized people!) and on my way home I realized that I was becoming very stressed over making sure everything for the party was perfect. I wanted to be sure we remembered all the different items and had everything set up just so and that everyone would have a good time and that the kids would all share and play well and… and I just made myself stop. Stop worrying about it. It’s a three-year-old birthday party, and it’s at a pool and the weather is good. It’s already a win, and I want to enjoy it. I want to be present mentally as well as physically.

I recently bought a book called “The Mindful Way through Depression” by Mark Williams, John Teasdale, Zindel Segal and Jon Kabat-Zinn. I bought it to read for my job with a few particular patients in mind, because it focuses on preventing relapse of depression once a person is feeling well again. As I am reading through it I am realizing there is quite a lot in the book I can apply to myself. The premise of the book is that we have two modes of thinking. There is doing mode, in which our minds constantly compare where we are with a mental image of where we want to be. This is a great mode for problem solving. For example, this week my husband and I were assembling birthday gifts and we used our doing mode to read the instructions and put the pieces together and compare what we had in front of us with the pictures on the directions. It all worked out quite well. Doing mode is incredibly helpful in our lives, but when we apply it to our emotional experience it doesn’t actually work well.

Emotionally, we all experience transient feelings of sadness, anger, fear, shame and happiness. These feelings come up for various reasons and usually will just subside in time. However when we react to them in a doing mode, treating them as problems to be solved, we tend to make ourselves more distressed, because the more we think about how unhappy we are the more unhappy we become. We get further and further from our goal. The doing mode also activates a counterproductive train of thoughts and behaviors in an effort to force happiness. In contrast to this, mindfulness teaches us to activate a being mode. In being mode we are non-judgmentally aware of our experience in an open, curious way. We notice our feelings, whatever they may be, but we don’t get all excited about them or try to solve them. And interestingly enough, what usually happens is that the feelings usually are transient and do subside in time without any effort on our part. A whole lot of pain and effort and energy is saved. We also have the time and space to notice what’s going on in our life, because we aren’t deafened by the internal clamor of frantic, desperate doing.

I’ve noticed that when I am doing things in my daily life I am often busy in doing mode. I have a certain image in my mind of how I want an event to turn out, and I get so caught up in that mode that I can’t relax and enjoy the actual event. So driving home from the grocery store, I decided I didn’t want that to happen today. I didn’t want to miss my daughter’s third birthday. So during the party I made a choice to stay relaxed and present. And of course things didn’t go exactly according to plan. We ran late getting there and guests arrived while we were still setting up. We forgot the ice cream. I ordered the pizza late so the pizza delivery didn’t line up with the swimming break. The candles wouldn’t light on my daughter’s cupcakes because it was too breezy. Guess what? Everyone had a great time, including me. I actually had time to talk to my friends who came to the party and enjoy the beautiful weather and delicious food. There was plenty of food and no one needed more sugar in the form of ice cream. The pizza delivery kept the kids out of the pool for the longer breaks from swimming that they needed; after all, we’re talking about 3-5 year olds here. My daughter was perfectly happy to blow out pretend candle flames. Later in the day I had time to appreciate my daughter’s style of opening gifts, which is to open one and play with it for a good long while, instead of feeling an impatient need to rush through the pile so that the “goal” of opening presents was accomplished. We had a lovely, calm, connected day. I put my daughter to bed tonight telling her what a wonderful, special kid she is and how much I love her and how happy I am to be her mother.

There is a lot of scientific research going on these days about mindfulness as a treatment or component of treatment for various mental illnesses, most of it very positive. I think this research is interesting and important, particularly as about 46% of the U.S. population suffers from mental illness at some point in time. Some of those people will receive good, helpful, effective treatment but many will not, even if they seek it, because the treatments we have don’t work for everyone. That makes any and every validated new treatment important, because it gives us a chance to help more people than we can now. But I can also tell you that mindfulness is useful and important in day-to-day life. Today it kept me from missing my daughter’s birthday because of my own stress, perfectionism and impatience. I think that’s pretty good.

Monday, August 26, 2013

Hometown Tourist


It’s good to play the tourist in your hometown from time to time. This past weekend we had a close friend from college come in for a visit, and so my husband and I took the weekend off from stress and chores and home maintenance and went out to play with our daughter and our friend. On Saturday we went up to the Maryland Renaissance Faire, which is a longstanding tradition for my husband and I, and something that our friend loves too. Our focus has shifted now that we are attending with an almost three year old and so this time around instead of browsing the market stalls we focused on playgrounds and elephant rides (yes, we rode a real elephant – which is cool no matter how old you are!) and flower crowns. On Sunday we went into downtown D.C. and discovered two new places.

The first find was a restaurant, Hill Country Barbecue, located in downtown D.C. 
Hill Country BBQ 410 7th St NW DC
(http://www.hillcountryny.com/locations.dc) My husband and I have been looking for a barbecue restaurant that we think is good after moving from San Antonio, TX a few years ago. As you can imagine our standards are pretty high, but Hill Country Barbecue did a great job. Their brisket was just right and served with white bread which is the classic way to do it. The german potato salad was cool and tangy and the pinto beans had just the right amount of heat. Their sausage wasn’t quite to my taste (a little too greasy, but I will definitely try the jalapeno cheddar sausage next time) and the tea was way too sweet but overall it felt almost like being back in San Antonio (minus the friends we miss…) The restaurant d├ęcor felt very “cowboy” and the service was friendly and prompt. We will definitely be heading back there, particularly on an evening when there is live music. Which, from their schedule, looks like almost every evening during the week!

Our second find was The National Building Museum (http://www.nbm.org/), which is not new at all
Central Hall, National
Building Museum
but which somehow has just never made our agenda. I’ve been there before attending the Smithsonian Craft Show with my stepmother, but we’ve never gone just to experience the exhibits. Boy, were we missing out. It’s not part of the Smithsonian but the $8 admission fee was well worth it. First of all, they have an awesome indoor play area for kids ages 2-6 called The Building Zone. It’s included with museum admission but they also sell tickets for only this part of the museum. They had more kinds of blocks than I knew existed, plus a play house, toy tools and construction vehicles, train sets and a dress up area. Our friend and I spent a delighted 45 minutes with my daughter building towers and knocking them down while my husband played the indoor mini golf course (which is sadly a temporary exhibit). Their main area, for which admission is not required, features an enormous open space supported by pillars with a central fountain. The museum was not at all crowded and so my daughter, who has recently discovered the delights of running as fast as possible, had a blast racing us from one end of the hall to the other. The other exhibit we particularly enjoyed was a model of a green classroom that explained how green building techniques in school can support learning and save money in addition to protecting the environment.

It’s easy to get caught up in the “busy-ness” of life. Many times our weekends are filled with errands and chores with a little fun crammed in around the edges. Which is not a terrible thing; life requires a certain amount of maintenance and part of living well is learning to enjoy the daily routines and duties as well as the fun. It’s lovely, though, to step back for a weekend and focus on enjoying time with people I love. Whether it’s riding an elephant with my friend, sharing barbecue with my husband or getting lost in blocks with my daughter, sometimes it’s great to just be a tourist at home.

Wednesday, August 21, 2013

Travel by Train


We are a family that loves trains. My daughter, of course, loves trains the way any small child seems to do. I guess there is just something about the rushing sound and speed and the long drawn out whistle that is fascinating. She’s been excited about trains since she was just about one year old. My husband has also always loved trains. He is a very detail oriented, analytical person and he is fascinated by time tables and schedules and maps, so trains are right up his alley. He is also big on caring for the environment, and train travel is less polluting than a car. As for me, I love the romance of the train. Trains in my mind are connected with so many stories and books as well as so many of my own past adventures. After I graduated medical school my husband and I took a cross country train trip, from D.C. to Boston to Chicago to Oakland. Then a week later we came back from L.A. to Chicago to D.C. We slept in a Pullman car with funny fold-down beds and ate our meals in the train dining car. We read books across the Great Plains and saw the Rocky Mountains from the glass observatory car. It is still one of my favorite trips ever, one that I hope we can repeat with our daughter when she is a little older.

So you will probably not be surprised to know that we opted to take the train this past weekend when we had a special event in New Jersey. Our goal was attending a dear friend’s baby shower and the train seemed like the efficient, low stress way to travel for a very short trip. It would take us about 3 hours up, we could rent a zipcar locally to get around town, stay in a hotel room overnight, and get home in about 3 hours the next day. We cashed in some points from a credit card and there we were, tickets in hand. We should have remembered though, that travelling almost always teaches you to be flexible.

The train ride up worked beautifully, just as we had hoped. My daughter sat in her seat (she has to have her own) and watched our Kindle, I sat next to her and knitted and read a few stories to her, my husband sat across the aisle and handed us snacks, and we arrived on time in calm, happy spirits. It was the ride back that got us into trouble. The train broke down about 100 yards out of the station. We sat on the track for about 45 minutes while the engineers tried to fix the problem, and then we backed up to the station and got off the train. We were directed to another train and so we schlepped our baggage (which wasn’t much, but did include a suitcase, some backpacks and our daughter’s car seat) onto the next train. Of course at this point there were not two seats together (there is no assigned seating on a train anyway and people spread out) but a kind woman offered to swap seats so my daughter and I could sit together. Just as the train got into motion the conductor announced that we would have to swap trains again a few stations down the line, since this train wasn’t actually heading to our destination. So we schlepped our stuff back off the train about 45 minutes later and back onto another train, which was much more crowded. This time we could only find two seats for the three of us, and we felt lucky to find those since many people were left standing. My daughter sat in my lap for the rest of the 2 hour ride. We arrived at our destination about 1.5 hours late and made it home a little before midnight.

I had two separate trains of thought myself during this adventure (as opposed to the three trains we boarded to get home…). The first was my usual internal grumbling when I don’t get my way. Growl growl growl… we paid (well, used points up) for my daughter’s seat and she didn’t get one. Why doesn’t Amtrak have extra cars available to connect to trains in circumstances like these? Why isn’t the service more reliable, what’s wrong with their equipment? I’m tired I’m crowded I want to be home already. Why didn’t we just drive? Growl growl growl…

The other train of thought was realizing that my family and I are really blessed. We travelled about 500 miles round trip in two days and still had plenty of time to attend our event and connect with some other dear friends. That’s still pretty amazing to me; I can travel so far so easily. We did this safely and although there was some hassle involved there was no pain, no trauma and we made it home in time for me to get to work the next day. We didn’t have to endure bad traffic (always a major consideration in the northeast US) and instead were all able to relax and engage in hobbies. Our daughter was a super trooper during the entire event, as she almost always is while we are travelling. She smiled at people, said cute things, and sat patiently on my lap watching a movie on the Kindle during the last, crowded part of our journey. She was as sweet as can be. Other people on the train were kind to us, we had some nice conversations with fellow passengers (nothing like a little adversity to bring people together) and we did actually have seats for my husband and I the entire way. We were a little inconvenienced and a little uncomfortable, and there is nothing really wrong with that. In fact, it’s probably good for us.

I am sure we will opt for the train again the next time we travel this route. We love the train too much to switch. And I imagine we will encounter delays and frustrations along the way, since that is pretty typical for travel in any mode, to any destination. Like I said, travel itself teaches you to be flexible, to be patient, to endure. Travelling reminds you that life isn’t about you and won’t arrange itself to your preferences and schedule. That things happen but that you can cope with them and get where you’re going and have a good time anyway. Not a bad set of lessons for a weekend trip!

Friday, August 16, 2013

People Aren't Junk


I was reading an article today about cyber-bullying and harrasment that game fans inflict on game designers. This is an issue that is important to me because it actually happened to a dear friend of mine. One of the points the article made is that somehow online people are separated from their consciences. They become more primitive and aggressive and fail to recognize the target of their invective and threats as a fellow human being. I think this is probably true, but honestly I think the problem is much bigger than that. We live in a culture of self-centered rudeness. I’ve been thinking about this a lot lately, ever since an interaction at work last week left me shocked and dismayed.

One aspect of my job as a consult psychiatrist is to attend medical rounds with some of the other teams in the hospital. Even if they don’t have specific patients for me to see as a psychiatrist, I can contribute something to enough cases that it is worth my time. Additionally, seeing me on a regular basis helps build my relationship with them, so that when they need a consult for a patient I can be more helpful to them and thus also to the patient as well. And to be honest, I think it’s fun. I liked medicine in my training and although I love my specialty, I also love learning from my colleagues and thinking about other aspects of patient care.

So last week I was on rounds with the intensive care unit team, which I try to do weekly. I really like the team in our intensive care unit, which is made up of a critical care doctor, a family medicine resident, an infectious disease specialist, a pharmacist, a nutritionist, the critical care nurses and sometimes a thoracic surgeon. I have a tremendous amount of respect for the doctors on this unit. They are smart, caring, thorough and hard working. If I were ill I would want them caring for me. So when the attending last week was concerned about a patient enough to request an emergency consult from another specialist, I assumed she would be taken seriously.

Unfortunately, what happened is that the other doctor showed up with an attitude. It wasn’t in anything he said, but his tone of voice and choice of words made it clear he felt that the ICU team was wasting his time by asking him to see this patient. It wasn’t subtle. Everyone on the team was aware of it, and the attending in particular was (understandably) very offended although she kept the focus on her concerns for this patient. Fortunately the specialist did actually see and care for the patient who did well and has recovered. But the incident left an unpleasant taste in my mouth. I think we’ve lost something important when doctors no longer grant each other respect and courtesy. The attitude I would hope for in medical professionals is one of collegiality and trust – trust that if a fellow doctor is asking you to see a patient they have a reason and that you should go and see the patient. That isn’t what I see much of 
the time. Instead I see rudeness and condescension. And I think it’s a symptom of a larger societal illness.

You see, I think all these things are related – rudeness to colleagues, cyber bullying, road rage, mass shootings, racism, misogyny, bigotry in all forms, violence in our families and against women… I think we’ve forgotten that we are all human beings. Somehow in our so busy so accomplished so wealthy society, we’ve lost sight of the idea that every human being is precious. Every human being is created in G-D’s image, is a loved and wanted child of G-D, and deserves kindness and respect. Every single one of us. My mother told me something really important when I was growing up. She said G-D made you, and G-D doesn’t make junk. And I believe that’s true. I believe that’s true of me and you and everyone else.

I don’t know how to combat this illness, except with respect and love. The cure has to be different from and better than the disease. So at work I strive to show and model kindness and respect for my colleagues and at home I try to live those values with my family. I teach my daughter what my mother taught me – that G-D made everyone, and G-D doesn’t make junk. And, I hope, by writing about it. By saying out loud that more hatred and more name calling and more division is not an answer. It’s okay to say that something is wrong or someone is mistaken, but it should be said respectfully and kindly. I’m standing up for what I believe in when I write this blog – but I’m doing it with respect and love.

Tuesday, August 13, 2013

Surprise Mommy!


Part of the fun of being a parent is that your child is always surprising you. As a case in point, this evening my daughter and I were downstairs having our weekly movie night. This is what we’ve been doing lately on Tuesdays when my husband has his night out. We pop some microwave popcorn and snuggle up on the couch for a movie together. Tonight we had just finished watching Tinkerbell and were putting the movie away. My mostly empty can of soda got tipped over and a few drops of diet chocolate soda got spilled onto the open DVD case. So, thinking more about wanting to wipe the spill up quickly than about who I was speaking to, I asked my not quite three year old daughter if she could go get me a paper towel. Much to my surprise, she said “yes, I can!” and proceeded upstairs to the kitchen.

My mommy brain quickly caught up with the situation and I said “Wait, I’ll help you!” knowing that the paper towels are up on the counter and she isn’t tall enough to reach them. She continued up the stairs saying “No, I don’t need help.” So I followed her into the kitchen and sure enough, she didn’t need help. She pulled over a kitchen chair to the correct counter, climbed up on it, pulled a paper towel off the roll and handed it to me. I had no idea what to say, so I just said “thank you very much!” and went back downstairs with her to wipe up the spill.

I had several simultaneous reactions to this. One was pleasure at my daughter’s problem solving skills and her ability to be helpful. Another reaction was sheer astonishment, since I had no idea that my daughter had worked out how to reach things off the kitchen counters. It’s just absolutely amazing to be able to ask her to complete a complex task, something that required multiple steps and intermediate problem solving, and see her successfully accomplish it. My third reaction was something along the lines of “uh-oh” since the lesson of “climb on a chair to reach it” has wide applicability and there are quite a few things on the counters and other high surfaces that I certainly don’t want her to reach. It seems we’ve reached the stage when education and rules have to start replacing child-proofing strategies for safety. Either that or I need to lock up everything we own, but since I'm sure she'll work out opening locks soon that's probably not the best path.

Mostly, though, I’m pretty delighted. It’s fun to be surprised like this. It’s a pretty amazing feeling watching this small person become more and more skilled and capable. Sometimes I see myself or my husband in what she says and does or the way she approaches things. At other times though I’m left wondering “how did she learn that? Who taught her that?” as she solves a problem in her own unique way. Either way, I’m so proud of her. I can’t wait to see what she does next.

Thursday, August 8, 2013

Cinderella, Retold


My daughter has fallen in love with Disney’s Cinderella, and it’s all my fault. I introduced the movie to her a few months ago, mostly on a whim because I thought she might like it. Wow, was I right for once. She took to it immediately and it has eclipsed all her previous favorites (Muppets, Sesame Street). Not only is it what she wants to watch on TV, it is also what she focuses her pretend play around and what she wants me to tell stories about in the evening. At this point I’m getting kind of bored with the movie, although I have had fun noticing things about the Disney classic that I hadn’t picked up on before. For example, Cinderella has quite the sarcastic sense of humor in a few places and some of the animated facial expressions are wonderful.

Aside from the tedium of having the same story seen and discussed again and again, I have to admit to a few qualms about the whole adoring Cinderella thing. The story itself is a little challenging, for one thing, particularly as I have a stepmother and my daughter knows it. I've been at great pains to explain that my stepmother is a good and loving stepmother, not at all like Cinderella's mean stepmother. I'm relieved that my daughter hasn't asked yet about what dying is and hasn't seemed to clue in to the idea that Cinderella's daddy died. But mostly my qualms are about Cinderella herself and the overall message of the movie: that just believing in your dreams will make them come true, that if you are beautiful and passive people will help you, and that marrying a prince is a prize worth fighting for. Bleach. But regardless of my opinion, my daughter loves this movie.

I’m trying to take the very wise advice of a good friend, who many years ago when talking about her own daughter and how different her child is from herself observed “You have to parent the child you have.” I couldn’t agree more. I had, as most parents-to-be have, all kinds of ideas about who my daughter would be and how I would raise her. And I’ve learned, as most parents have, that some of those ideas have worked out, some have been worth fighting for, and many have fallen by the wayside because my daughter is who she is and my theories and fantasies weren't worth two pins. For example, over this past year I’ve come to realize my daughter is much more of a frilly, dressy girl than I ever was. I think that’s part of the appeal of Cinderella for her, to be honest – she loves the pretty dresses in the movie. My daughter herself preferentially wears dresses, has mostly reasonable ideas about what clothes match, and delivers clear opinions on her hairstyle. I don’t quite understand where that came from (my husband is color blind and I am clearly a comfort over style kind of gal) but that’s ok. We’ll go with it. I will buy her dresses and do her hair the way she wants and let her pick her clothes and rejoice in her being the person she is.

On the other hand, I don’t want her to think beauty is just pretty dresses or good looks. And I really don’t want her to imitate Cinderella by being passive and waiting for good things to happen and other people to rescue her. So I confess to utilizing some creative license in discussing the movie and retelling the story of Cinderella for my daughter when she asks. I emphasize how Cinderella keeps her temper when she’s mad as opposed to the stepsisters who forget to use their words and rip Cinderella’s dress instead. I talk about how Cinderella is very strong and good at solving problems and learning new things. I point out how hard Cinderella works. I talk about how Cinderella is beautiful on the inside and that’s what makes her beautiful on the outside. I talk about people liking Cinderella for her kindness and goodness, not for her clothing or pretty voice. I think my daughter is getting the point. She told me the other day “I’m a princess. I’m good at solving problems.”

I don’t really think a love of princesses is going to hurt my daughter. As my sister says – she’s not even three. She has plenty of time to develop the character traits I want her to have. As she gets older and better able to tolerate scary scenes I’ll introduce her to some of the other Disney princesses as well, like Merida and Mulan. And in the meantime I will make every effort to balance my teaching ethics and life skills with rejoicing in my daughter being herself, uniquely and preciously an individual.

Wednesday, August 7, 2013

Science Faith and Beauty at the Virginia Living Museum


Beaver swimming at the Virginia Living Museum
I took a little time off earlier this week so I could take my daughter to visit my mother, who lives about 3 hours south of us in the Tidewater region of Virginia. While we were there my husband and I took our daughter to the Virginia Living Museum (http://www.thevlm.org ). This is a much-loved museum I remember from field trips during my own elementary school days, although it was called The Nature Science Center back then. The name changed to the Virginia Living Museum in the late 1980’s, before I started working as a volunteer in the planetarium while I was in high school. The entire museum was expanded and redesigned in the mid 2000’s and now it is an incredible facility featuring not only the planetarium and solar observatory but indoor aquariums, exhibits on different regions in Virginia, touch tanks, classroom space, green living displays, a children’s garden and a ¾ mile boardwalk around outdoor native Virginia animal exhibits. It is an awesome place for a couple of science and nature geeks (the geeks being my husband and myself) to take an almost 3 year old. We had a great time looking at red wolves, beavers and otters. My daughter is able to run around the entire boardwalk (not without pause, of course) and fortunately the space is large enough and un-crowded enough that she can do so without bothering anyone.

The museum also brings in different exhibits on a visiting basis, as most museums do. The rotating exhibit this summer is called Bodies Revealed and features beautifully dissected and preserved human bodies  (from people who donated their bodies to science after their deaths) in a very artistic display that teaches a great deal about how our amazing selves work. That may sound distressing but I promise, it is respectful and beautiful and wonderful. If this exhibit is ever shown near you, please go. Our bodies are truly miraculous and gorgeous. As a doctor myself, this exhibit was a very cool thing to share with my husband and daughter. I had a good time narrating the exhibit for them, and particularly for my daughter. (My husband, of course, can read all the signs for himself!) I showed her different bones and organs and pointed to where they went in her body and tried to explain what they did as simply as I could. I felt very proud when later, in the context of talking about thinking, she pointed to her head and told me that’s where her brains are.

Red Wolf at the Virginia Living Museum

I’m delighted to share with my daughter a place that means so much to me, a place that’s grown and developed throughout my life and I hope will do so through hers as well. I’m delighted to encourage her in a love of nature and science and beauty. It thrills me when she points to the sky and says “look at those beautiful clouds!” I cheer when she begins to grasp different processes, like a catepillar’s transformation into a butterfly. In the end, observing and reveling in the beauty of our world, whether in an animal’s graceful motion or in the artistry of our bodies or a sunlit bank of clouds is a form of worship, of adoration for the Lord who created all of this intricate, extravagant beauty and then invited us to share it. Learning how the world works, how clouds form and how beavers build lodges and how our hearts pump blood is another form of worship; it is a chance to delight in the elegance and originality and cleverness of the structures underlying what we see. In my life, in my heart, science and religion have never been in conflict. Science has always shown me more and more reasons to love my Lord. This has been a precious gift in my life, and now I am honored to pass it in turn to my daughter.

Saturday, August 3, 2013

To Treat or Not To Treat: Medical Uncertainty


One of the most challenging things about being a doctor is that medical science is so often uncertain. This was brought home very vividly to me this week. One of the psychiatric residents I work with, a doctor who I deeply respect as a compassionate, dedicated and thorough physician, raised an outstanding question. She asked if we should be more proactively treating delirium with antipsychotics than is the current practice in our hospital. Delirium is a medical condition in which the brain is functioning but in a disorganized way due to another severe medical illness. It has been termed “brain failure” and compared with heart failure or kidney failure in that a critical organ is malfunctioning and there are many different pathways that can cause the syndrome. I was taught that the mainstay of treatment is addressing and reversing the initial medical illness causing the problem. Antipsychotics might be used to manage agitated behavior that was endangering the patient (for example pulling out catheters and lines) or staff (hitting or biting, both of which I have witnessed) but I had always been told (and had read) that antipsychotics did not have any particular beneficial effect on the delirium itself.

However, my resident had seen things done differently in another hospital. So she sent me four different articles she had found suggesting that treatment of delirium with antipsychotics in general and haloperidol in particular has beneficial effects for delirious patients in terms of time to resolution of symptoms and longer term cognitive outcomes. This was very interesting and important information, because delirium can’t always be completely reversed and significantly complicates medical care. If we were able to directly treat it many people could recover more quickly and with less long-term debility. It’s also interesting because I don’t use haloperidol very often. It’s an older medication and has some acute unpleasant side effects for many people, and I have greater familiarity with some of the newer medications. Which of course also have unpleasant side effects but seemingly less so in the acute setting. So I read her articles with interest and checked a few other sources and was giving thought to revising my current practice. And then I read another article.

I subscribe to several email services that send important medical articles and headlines directly to my email inbox. There is a lot of medical news happening all the time and I want to keep up as well as possible. One of the articles in this week’s email from Current Psychiatry caught my attention immediately, as it was an editorial entitled “Haloperidol clearly is neurotoxic. Should it be banned?” (http://www.currentpsychiatry.com/article_pages.asp?aid=11469#) In the editorial the author, the editor-in-chief of the journal, cites numerous articles from neuroscience journals that describe neurotoxic effects of older antipsychotics in animal models, cell cultures and post-mortem human brain studies. The author states that he no longer uses the older antipsychotic medications and opines that these medications should no longer be used at all.

And this is what makes medicine difficult. In one week, I have read articles suggesting I should be using haloperidol more often as it protects the function of the brain during severe illness and another article suggesting the same drug is a neurotoxin that should be banned. Obviously there is some missing information here. This doesn’t particularly surprise me; in medical school one of my professors told me that about 50% of what I would learn would be eventually turn out to be wrong, it’s just that they didn’t know which 50% it was. But it does leave me with a bit of a challenge for my own practice. I’m not quite sure what to do, so I will probably consult with some colleagues and most likely will end up treating delirium more proactively but perhaps using some of those newer antipsychotics. 

This is often the case in medicine. I have trained and practiced in an era of medicine in which “evidence based medicine,” meaning medical decisions supported by numerous randomized controlled research studies, is considered the holy grail of good clinical decision making. And yet I find that often the evidence is incomplete, contradictory, clinically irrelevant or altogether missing. I end up doing the best I can based on what evidence I can find, supplemented by experience and advice from trusted colleagues. Which is not to say that evidence based medicine is wrong or bad. I believe in practicing according to the best scientific information available. I think it is important though, for medicine as a field and doctors as people to be humble enough to say – “I don’t know. I'm sorry, but I just don't know." I think that might actually go a long way to restoring some trust in our profession.