What's A Poor Doctor To Do?

I was skimming through a recent issue of the Journal of the American Medical Society this morning and I came across an article analyzing trends in prescription drug use in adults from 1999 until 2012. It initially caught my attention because I misread the title and thought it was an analysis of prescription drug misuse, which is something I encounter frequently as a psychiatrist. On closer reading though, it was simply an analysis of prescription drug use, which has increased by 8 % over the two time periods in the analysis (from 51% of adults to 59% of adults). The prevalence of polypharmacy (use of five or more prescription medications) increased from 8.2% to 15.0% between the same two time periods.

The article itself was factual and neutral but I started to get hot under the collar as I read it. Polypharmacy is considered a negative thing in medicine. It exposes patients to more side effects and drug drug interactions, and it’s considered dangerous. And I’ve read many news articles about how doctors prescribe too many drugs for too many conditions, and how it’s terrible and expensive and dangerous. At the same time, there are multiple published standards for treating different conditions. There are specific, numeric goals for screening and treating hypertension, diabetes and high cholesterol, just to name a few. There are standards for screening for and treating depression and pain; to remain accredited with certain quality agencies you have to document that you are doing both.

The publication of specific standards for treating conditions and the publication of critiques of polypharmacy and overutilization of prescription medication creates a double-bind for physicians. A double bind is a situation in which no matter which option you take, you fail. You are given two conditions that you must meet, but they are mutually exclusive. There is no possible way to succeed.

For example, when I was a primary care doctor, I might have a patient come in who had hypertension, diabetes, high cholesterol and depression. Many of these illnesses run in packs, so that’s a pretty common scenario. I evaluate the patient and talk to her about treatment. My treatment is likely to be medication based, because even though I encourage her to exercise regularly (which would help all of her conditions) and to change her diet (ditto) and to reduce stress and get more sleep, my patient lets me know that these kinds of changes just aren’t realistic for her. So I start to work with prescriptions. Chances are, it will take two or three medications each to control her diabetes and hypertension and one or two each to get her high cholesterol and depression under control. Not to mention the “add-ons” like prescribing a baby aspirin a day for certain age and risk groups that are published as standards of care. I might succeed brilliantly in controlling her medical problems, but I’m a failure because my patient is taking 5 or more medications.

Double binds are incredibly bad for your psychological health. They create pain, depression and confusion because when you are in a double bind you are always wrong. The only way to “win” in a double bind is to stop playing the game; to refuse one or the other of the conditions that have been placed on you. However, double binds occur in situations in which you can’t just leave the problem; the classic example is between a parent and a child (the parent is the one inflicting the double bind on the child) and of course the child can’t just leave the parent. I would suggest that after the amount of money, time and energy most doctors spend acquiring their professional credentials they are equally unable to leave medicine. So what’s a poor doctor to do?

Most of us seem to muddle along focusing primarily on the patient in front of us at the moment, the one who needs multiple medications to get their chronic health problems under control. We keep our heads down and try to ignore all the criticism, implicit and explicit, that we get for trying our best to do our jobs. I notice though, that there seem to be more and more depressed doctors around. So that strategy doesn’t seem to be working. 

I don’t know if we, as doctors, can speak up for each other and ourselves. I don’t know if we can begin naming and refusing the double binds that are placed upon us. I’m starting to think that we need to try.

To See A Universe in the Changing Of The Clock

I was walking in to work this morning with a colleague, and she commented that the sunny weather had put her in a good mood.

“It’s nice.” I agreed. “It’s one of the things I enjoy about the end of daylight savings time. It’s going to be nice and bright and easier to get up in the morning for a few weeks.”

She looked at me in surprise. “A few weeks?” she asked.

So I explained that it is nice and light now when we are getting up and driving in to work but that as we get closer to the winter solstice it will be darker and darker in the morning. Then as we move towards spring it will slowly become lighter in the morning, but only for a little while until daylight savings time comes along. Then we move forward an hour and it’s dark again in the morning until we get closer to the summer solstice.

My colleague listened to this politely and with an appearance of interest until we reached the turnoff for our respective hallways. We wished each other a good day and moved on into the flow of work.

I walked off down the hall puzzling. This changing of the patterns of light at different hours of the day matters a lot to me. I’m not a morning person in any sense of the word and waking up in the dark is really challenging. If I had the choice I’d always sleep until past sunrise, but my job is not so flexible and so I often have to wake up before I’m ready. So I pay attention, roughly, to the seasonal patterns of light and how our cultural pattern of clock changes interacts with that. I can’t tell you when sunrise will be tomorrow, but usually by sometime in January I’m desperate enough for morning sunshine to have looked up a sunrise table in order to figure out when I’ll have the light back. (Yes, I’ve tried a sunrise alarm clock, and no, it didn’t work for me at all.)

Yet this pattern, which means so much to me, was apparently news to my colleague. At least it seemed that way to me. Maybe she knows all about it and was just being extra polite in listening to my pedantic chatter. I read an article recently that talked about how bad we humans are at interpreting what other people are thinking and feeling (We are very bad at it but we think we are good at it. This is bad news for me as a psychiatrist, although I think it’s true and it explains a lot). So I could be completely wrong. Still, she seemed surprised to me.

Conversations like this make me realize that we really do live in our own universes. The things that matter to me, the details I notice, the patterns of my thought and experience, the way I interpret events, is completely unique to me. Other people don’t care about how much light there is in the morning because it doesn’t affect them. It’s not even part of their world. They don’t even know about it unless I happen to mention it in passing.

No wonder we all have so much trouble understanding each other.

The Intriguing Mystery of A Child

One of the interesting things about parenting a kindergartener is that you get these strange little windows into what they are thinking, without much in the way of explanation or discussion.

For example, the other night I am sitting on the couch reading and my daughter is playing in her play area. She comes over to show me something she’s built, and helpfully tells me it’s a scooter for her doll. 

“Nice work!” I tell her.

She then explains that she is buying new safety equipment for her doll and that she buys her new safety equipment every year (because she outgrows it, like my daughter does her bathing suits).

“What kind of safety equipment?” I wonder. “Helmets?”

She tells me that it’s helmets and knee pads and elbow pads. This is strange, I think. As far as I know, my daughter has never worn knee or elbow pads. Where did this idea come from?

“Don’t you think that’s a bit much for scooter riding?” I ask.

“She’s my sweet girl and I don’t want her to get hurt.” she tells me.

That’s pretty much the end of the exchange, and I am left puzzling. “Sweet girl” is one of my pet names for my daughter, so I see where that came in. I do tell her that I don’t want her to get hurt, usually in the context of her doing something really foolish like standing on a kitchen chair and pushing on the back of it to tip it. (I caught her before she fell, but I wasn’t pleased.) In things like bike riding I actually encourage her to be brave.

In fact, this is not a kid who’s terrible sheltered when it comes to physical activity. She climbed a 20 foot climbing wall a month ago (in a harness, on a belay, but she was still 20 feet up in the air climbing the wall). She dives head first into the deep end of the pool. She gets bumps and bruises and scrapes and we talk about “the good kind of scrapes and bruises” meaning the kind you get because you were doing something really fun.

On the other hand, she really doesn’t like getting hurt. Not that anyone does, of course, but she is very intense in her reaction. I think it’s partly her age and partly the dramatic personality she inherited from my side of the family. Minor scrapes are often accompanied by loud wails, tears, and insistence that “It hurts me very much!” and “I want this scrape to go away right now!” Which makes it hard to keep a straight face sometimes while trying to comfort her.

So maybe she wishes we were protecting her a little more? That her mommy was doing a better job taking care of her sweet girl? Or maybe she saw a TV show or read a book featuring a kid wearing elbow and knee pads and wanted to try the idea out with her doll? Who knows? I can’t really ask her, because I don’t think she really knows either. Trust me, I've tried. Either her explanation doesn't really make sense to me or she gets bored with the conversation and veers off in another direction altogether. She’s just playing, and her game makes sense to her even when she can’t explain it to me. It hammers home that this kid I adore, this child who shares my home and my genes and my water bottles, this girl I think I know so well, I sometimes don't know at all.  Like any other human being, she’s forever an intriguing mystery to me.

Phonetics Blues

“I before E except after C and when it sounds like A as in neighbor and weigh. Weird, right?” says my husband this morning as we engage our daughter in yet another discussion of how to spell a particular word.

My daughter’s kindergarten teacher tells us not to spell words for her anymore. She wants my daughter to listen to the sounds and figure out the letters. The same principle applies when my daughter is trying to read. She is supposed to be sounding out the letters to figure out the words. The school uses a mixture of phonics and sight words (high frequency words that are simply memorized) to teach reading. In theory, it all sounds fine. It should help my daughter be more confident and independent in her reading.

In practice, English doesn’t seem to work well that way. Take the word “knight.” My daughter wants to be a knight for Halloween. My husband has made her a knight costume complete with shield and sequined “chain mail” armor. Public schools no longer celebrate Halloween, but they do have “Storybook Character” day on October 30^th in which the children are requested to bring a storybook to school and dress up as a character from the book. My daughter is quite excited about this idea, plans to wear her knight costume to school, and really, really wants to be able to read at least part of the book to her teacher if asked.

We have a cute little storybook about a Knight and a Dragon who are dismal failures at fighting each other and open up a restaurant together instead. (The Knight and The Dragon by Tomie dePaola).  We were practicing it this evening before bedtime. My daughter was trying to read it by sounding out the words. Unfortunately, if you sound out the word “knight” you get “k-nig-hit” which is adorably Monty Python but not particularly helpful to a five-year-old trying to make sense of a story. It took about five minutes for her to struggle through the first sentence (which also contained the words “fought” which comes out “f-o-uh-g-hit” and “castle” which comes out “s or k, mom? – k-a-s-t-lee”).  I’m not sure she had any sense of the meaning of the sentence because she was working so hard just sounding out the words. After she finished I told her that was enough practice for the evening (because frustration + five-year-old + bedtime = a more explosive combination than dynamite) and I read the rest of the book.

I confess, I’m still spelling words for my daughter, despite her teacher’s instructions. If the word makes sense phonetically I’ll get her to spell it, but I just can’t stand it otherwise. It just doesn’t make sense to me to teach her wrong ways of spelling and reading that she’ll have to unlearn later. I’m balancing between encouraging her to read and keeping reading fun by making sure she still gets the stories she loves. The phrase “yes, we know, sorry, English is strange” has become quite frequently heard around our house. I know I must have gone through the same thing as a child. I have dim, recently awakened memories of being taught about helper vowels and silent letters. So I know it all works out, because I started reading competently around the 2^nd or 3^rd grade. And I do believe that once it is learned English is a lovely, flexible, powerful language. I just feel sorry for the kindergarteners.

Being A "Nicey"

My daughter’s kindergarten class has read a book titled “The Meanies Came To School” (written by Joy Cawley). I presume with some guidance from the teacher, the children have all decided that they don’t want to be “meanies" and that instead they will all be “niceys.” This has become quite the topic for discussion around our house, as my daughter explores the question of being mean or being nice and what that implies for her behavior.

In the car one day, she announced that she thought that my husband and I were “niceys.” I was flattered and I thanked her. Then, of course, she follows the butter up with the tough questions. “Why are you a nicey?” she wants to know.

The question reminded me of a conversation I had with a colleague earlier that week. I had been very pleased about a particular patient who was doing well and who had mentioned during their visit that they had used something I told them to help someone else. I mentioned to my colleague how happy I was, and how I always hope that what I say will be helpful and will be passed along from person to person. My mental images is like the wave that happens at sport stadiums, but rather than arm waving, I’m hoping for a wave of good health. My colleague agreed and mentioned she’d like to see a wave of kindness as well, which sounded really good to me.

I answered my daughter’s question with one of my own, in approved Socratic fashion. “What would happen if I wasn’t a nicey? How would you feel?”

She responded immediately that she wouldn’t like that, that she’d feel bad. “How would Daddy feel, if I was a meanie to him?”

Again, she responded quickly that Daddy wouldn’t like that.v“Do you think that if I were a meanie then you and Daddy might end up being meanies too?”

That was more challenging (hypothetical contingencies are tough for grown-ups, let alone five-year-olds) but she came to the conclusion that yes, she and Daddy might be meanies if I was a meanie, and she was able to extend it and observe that her grandparents and aunts and uncles might all be meanies as well.

“Right. So, I don’t want to live in a world full of meanies. That’s no fun. I’d rather live in a world of niceys, so I try to be nice. Plus, when I’m nice to someone whose mean to me, then sometimes their meanness stops.”

Then, because I didn’t want to leave her with the idea that she couldn’t speak up for herself or do something to stop someone who was treating her badly, I elaborated. “When someone is mean to me I can use my words and say ‘Please Stop. I don’t like that.’ and then if they don’t stop I can walk away and get help. I can tell them to stop while still treating them kindly and speaking in a respectful voice. And my kindness and respect reminds them to be kind and respectful as well."

The conversation went off on a tangent then, as conversations with five-year-olds have a tendency to do. It was probably too much at once, anyway. But it pops up again here and there. I know my daughter, so I know we’ll keep talking about it until she gets it settled in her mind. And I’ll keep trying to get my point across.

I’m a “nicey,” a kind person, because I truly do want to live in a world that is filled with kindness. I would love to see waves of kindness spreading around the world. I do believe that kindness can absorb and stop the spread of meanness and can set limits at the same time. How about you?

Healthy Relationships

I work with a lot of people who have experienced toxic, negative, hurtful relationships. Often they’ve been through an entire history of them. Whether these were romances or friendships, eventually a person who is getting healthier will ask the question “How can I have a healthy relationship in the future? or “How can I keep this from happening again?”

I’ve given my stock advice. Things like “learn to value and care about yourself. know what is important to you. don’t put up with people who treat you badly, even in small ways.  know your own limits and insist that others respect them. do things you enjoy for their own sake, and be friends with the people you meet there.” I do think all of that is pretty good advice, but I recognize that it hasn’t been completely satisfactory for many people. So I was pretty excited recently, while reading the book Simplify by Bill Hybels, to find a chapter (chapter 7, if you’re interested) on friendship. He outlined some common sense things to look for and some others to watch out for and some ways to go about making friends. I liked his list, but since he is a Christian writer and a pastor, his was very spiritually focused. I wanted something that was more general that I could share with people I’m working with. So, inspired by Mr. Hybels, here are some thoughts about forming healthy relationships.

First of all, for any of these characteristics, look for patterns. Anyone can have a good day or a bad day, but try to keep the overall pattern of a person’s behavior in mind. And look not just at how the person is treating you but at how they interact with everyone around them. Look at the small details that can be very telling. Many people can be charming when they are trying to win a new friend or romantic partner. How they treat the people they aren’t trying to impress can be much more revealing. How they behave when they don’t know anyone is watching is most likely to reflect the core of who they are.  

Characteristics to look for include having a positive attitude. Look for someone who appreciates the good in his own life and isn’t complaining all the time; someone who when faced with challenges says “ok, we can do this.” It’s also good to look for someone who is truthful and trustworthy. Honesty in small things, like admitting small faults or letting the cashier know he gave too much change is a great sign that a person will be honest in larger things. A person who is patient and kind, who doesn’t get upset or angry easily and who shows consideration for people around her, will likely be patient and kind with you as well. A self-disciplined person, who can say “no thanks, that’s not good for me” about an extra piece of cake, a late night, a drink, or an impulse purchase will encourage you to be healthy as well. A person who can respect his own limits is much more likely to respect yours. A person who keeps small promises, like showing up when she says she will, is more likely to come through on the big promises.

On the other hand, watch out for a person who is arrogant or entitled, someone who views themselves as better than other people. In particular, watch out for someone who is perfectly nice to you but is rude to people who she is categorizing as “not important” or “just there to serve me.” Sooner or later the person who berates the waitress, the bus driver, or the clerk is going to see you as an object as well. When you fail to meet her needs you’ll be in for the same treatment. Don’t get too close to someone who rants, trantrums, whines, sulks or pouts when things don’t go his way.  Being able to handle disappointment and even adversity with grace and class is the mark of a true grown-up, and relationships with people who are emotional children in adult bodies are often exhausting and painful. Someone who is habitually dishonest in small things is not likely to be honest in large things like faithfulness and commitment keeping. Someone who is constantly gossiping about others is probably going to gossip about you when you aren’t around. A person who complains about someone else’s behavior to you is probably not going to be able to work out problems with you in a healthy and relationship building way. A person who is mean and hurtful, who breaks the confidences of others, or causes trouble between other people is showing that they are toxic. Don’t put up with unkindness disguised as humor, no matter who the target is. That’s a form of bullying. And stay away from careless friends, people who are inconsiderate or thoughtless about other people’s time, energy, and feelings.

Finally, step into new relationships slowly. I hate to be a buzz-kill, but relationships that seem too good to be true probably are. I recommend being very wary of anyone who appears to completely understand, love and connect with you on the first meeting. Romantic ideas of soul mates or love at first sight aside, usually that kind of intense initial connection is much more about the holes and wounds inside each person and the fantasy of rescue than any kind of honest, adult connection. Relationships aren’t and can’t be a short cut to avoid doing hard emotional work. Instead of dumping your entire history and all of your emotional pain on someone at the first meeting, take it slow. Give it time. Developing a relationship is a dance of small, mutual steps, a process of growing give and take. Confide a little piece of information, something you don’t tell everyone, and see how she handles that. Try out trusting him with a little vulnerability and see if he is able to reciprocate. See how the two of you are able to navigate an area of disagreement or difference. Make sure you can talk about the tough, important topics (money, sex, politics, religion, families) bit by bit, and that you can do so with respect even when you don’t agree.

This can be a tough list to follow. Often the people who give you a thrill are the people who have more of the negative characteristics than the positive. They can seem sophisticated, funny, and exciting. The people who are honest, kind, patient, self-disciplined and positive can seem hopelessly dull. I get it. But I have to ask you this. If you’ve been chasing thrills for years and you’re now at the tail end of a string of painful relationships, how’s that working out for you? Is it time to try something else yet?

Friendship at Four is Hard

My daughter came home from preschool yesterday upset because two of her friends were playing on the playground and they wouldn't let her play. Today she came home distressed because she was at the playground with another friends and a third little girl was trying to intrude on their play. I wasn't there but my husband tells me that our daughter got so upset he had to take her home.

"I was afraid she'd take <friend's name> away from me." she told me as we cuddled on the couch.

I get it. My head knows that kids this age don't play well in groups of more than two, that someone will always be the odd girl out. My head knows that my daughter has been both one of the two girls playing and the third girl trying to get in on the fun. My head knows that the third little girl today probably felt a whole lot like my daughter did yesterday. My head knows that there is a good chance that the kids will work all this out themselves, eventually. But oh, how my heart aches for my precious girl. I wish, so deeply, that I could protect her from this. Failing that, since I my head knows that I can't, I wish I had more wisdom to guide her through this.

The truth is, I wasn't very socially competent as a child. I wasn't picked on or bullied but I was ignored and excluded a lot of the time. I was too smart, too quiet, too bookish, and too well behaved. So I spent a lot of time feeling left out. It wasn't until college that I really felt I had true friends, friends I could count on and who really liked me, not just my ability to help them with homework. And I'm not asking for pity or sympathy, but I still feel the effects of being excluded today, when I'm all grown up and successful and competent. I still tend to be quiet and retiring; I don't push myself forward. I try not to intrude on conversations and I look for signs that what I have to say isn't wanted. I feel rejected and hurt pretty easily and have to spend time talking myself back into good common sense. Somewhere inside, that lonely eight year old girl still lives inside me. So I really, really wish there was a way to spare my daughter all this.

I cuddled my daughter this evening. I empathized and let her know that I cared. "It sounds like you felt jealous. I know that's hard." I said. "It's scary to feel like someone might take your friend away."

She snuggled into me and said "Why?"

"Why does it feel hard and scary when you think someone might take your friend away?" I clarified.

"Yes." she agreed.

"I don't know, baby." I told her. "That's just how we are."

I do know, sort of, but I'm not going to tackle psychology, biology, and evolution this evening when we're all tired. And in another sense, I don't know why all my experience and knowledge, all the love I have from my family and friends, all my faith in my identity as G-D's child, doesn't overcome those things. I don't know why it's still so very scary as an adult to think someone might take my friend away. So I just hugged her and was grateful for preschool attention spans that quickly moved on to other topics.

Then after she went to bed I went online and bought some books about friendship for preschoolers. I talked to my husband, although his memories are different and I'm not sure little boys do this stuff, or at least not in the same way or at the same age. If I don't have wisdom in this area, and I don't think I do, I can at least have knowledge. I can at least equip her with the understanding of how to be a good friend. That way, even when her friends wander off, I can hope they'll always wander back.