Changes

Today, I drove home from work post-call, crying. I had a busy, largely sleepless night, with the lovely addition of the onset of a head cold. I made it through the call shift, made it through my work shift in the morning, then headed to a feedback session with one of my course directors. The course was "Empathy" and involved interns listening to comments made by patients on tape, then delivering empathic responses back.

Most of us had a hard time with this.

One intern said she felt like she couldn't respond to the happy patient because she only sees suffering or she assumes the patient is manic or borderline--she didn't know how to treat someone who was just happy. My responses felt to me like I was still using them as questions to extract more information, instead of just interjections to let the patient know I was listening and perceiving what they said.

My course director said I had done a good job, and that I had "a practical, pragmatic approach" that she felt would become less self-conscious and improve over time. I started to say something in response and instead tears welled up (I've cried in front of her before, so I doubt she was shocked).

I told her I felt like I used to be better at empathy, at understanding where patients come from and what they're going through, and trying to connect, and that I've lost something this year. That I used to enjoy trying to connect with patients, and now I find it difficult (I didn't tell her that often, I don't bother trying).

As I drove home, I started to cry again. At first, I couldn't tell what was bothering me. I assumed it was tiredness + being sick. It felt too bad to be that simple, though. When I get really upset, I feel a squeezing pressure in my chest that seems to wring tears from me (yes, I'm aware this is psychosomatic). I tried to think, what was bothering me? Then I realized I was still crying over what I'd lost this year. But why am I so burned out, empty? What have I lost?

I think a combination of forces has dried up my empathy well (maybe it wasn't very deep to begin with?). Call it soul, or humanity, or empathy, or sympathy, or "being with"--whatever--I feel like mine has shriveled a little (or a lot) under the blaze of a ferocious burn out.

(A note about burn out: when high school seniors, or college seniors moan about being "so burned out on school right now", that is not the same. This kind of burn out leaves you feeling hollow and empty. It invades your personal life, your marriage, your quiet time, and your dreams, even when not at work.)

I'll point a finger at chronic sleep deprivation. I've been working around 60-65 hours per week (which is not that much, really, by medicine standards; please, surgeons, don't hit me) and taking 5-6 calls per month for the past 6 months. I don't feel recharged between calls, and I think over time my reserves have gotten lower. I've taken some vacation time and tried to catch up, but it seems to only take one call to flatten me out again (I like my sleep, so sue me).

That's not the whole story, though. Part of it is the patient population I treat. On call, the most memorable patients are the substance-using (usually cocaine or alcohol) homeless narcissists (or antisocials) who are in it to get a free bed. I used to fight this, but I've given in to the system where I work. This system pulls these patients in and suckles them for a while. Aww, did you relapse for the 40th time? Was that placement not nice enough for you? You didn't make any of your follow up appointments (often, despite having benefits, bus passes, or special transportation) and couldn't be bothered to take your meds (given out for free), but that's okay, come here baby, I have a bed and a tray for you. I strongly feel that this system thereby encourages these patients to continue this behavior. There's no need to make choices or take responsibility when there's always a cushy safety net. Just say the magic words ("I'm thinking about hurting myself", but don't have a real plan) and you're in. I don't mean to suggest that all my patients are like this, but enough of them are (and they all seem to come in crisis at 3 am, because they know an intern is on, rather than during the day when the attending will send them to outpatient rehab) to be grating. I said in a previous post that there are few true psych emergencies at 3 am, and I still hold that to be true. There are some, and I'm happy to treat those, but most 3 am consults to the ER are for someone who's crashed off cocaine, feeling suicidal, and completely oblivious to the idea that cocaine could make them feel this bad. They want me to fix their sadness, but don't want to give up the high.

Some few of these patients can be verbally abusive, which makes it oh-so-exciting when I get to call the police or security to escort them out.

I hate the stigma against the mentally ill, even though I recognize some of it within myself. I recently treated a patient with delirium tremens who had a CIWA of 21 on my exam. The reason for consult was "rule out other psychiatric issues". My note politely stated that I would reassess other psych issues after pt was more alert and oriented (not A&O x none like on my exam) and that the primary team should consider increasing the lorazepam drip. Agitated patients who cannot give a clear history of alcohol or benzo use are often shuttled to psych while having withdrawal. I've seen patients not receive appropriate treatment of surgical or medical conditions with no other explanation than "due to psych diagnosis". (I also hate inappropriate medicine consults by psych because someone forgot how to look up the dose on a blood pressure med, so I'm perfectly aware that this is a two-way street).

Of course, when I went to the dentist last week and saw that my chart said (in Magic Marker on the front cover) "depression, nervousness, psych problems", I nearly cried in the dentist's office. I mentioned having a history of depression and anxiety during my intake, but I had no idea it would be proclaimed on the front cover of my chart like that, for all the office staff to see. So I understood my patient last night who told me she had lied to her psychiatrist about her previous suicide attempts because she was too ashamed, so she said she'd never done anything.

I believe a lot of my burn out is related to having been an intern for nearly a full year. Internship and residency are tough (yes, even in psych). I also believe that I would be pretty burned out no matter which specialty I'd chosen.

But a part of this burn out is psych itself. It's the overuse of meds, the overuse of diagnoses, the stigma against psych patients and psych doctors (but man, are you glad to see us when you need us!), the massive pharma scandals (Seroquel, Zyprexa, and Abilify all come to mind), the overmedication of children who need appropriate discipline (and the recent revelation that the data supporting stimulant use was oversold to us), and the overwhelming feeling that I'm not cut out for this like I thought I was. I'm not as good at psych as I thought I could be, which is tough for me, as I'm usually good at clinical work (for pete's sake, I won an award for best clinician of my med school class when I graduated!). I doubt I'd be a terribly skilled therapist, and I believe that therapists should be skilled. I have some sensitivity to what people are feeling and am able to read between their words, but I'm finding that doesn't seem to be enough. In other words, I'd probably be a competent psychiatrist, but not an excellent one, and that's not good enough for me.

So for all these reasons, and one other big one (and maybe a few I forgot), I'm switching residencies to internal medicine. The other big one, obviously, is that I like medicine and miss it. I think I'd be pretty burned out right now if I'd just finished a year of medicine internship, so I'm trying to think pretty realistically (although sometimes I'm so desperate to escape my burn out that I get "grass is greener" syndrome and wish for medicine to fix my problem). I wasn't a fan of medicine as a med student, largely due to a certain attending who tore me a new one and then said I should go into medicine (which is a dumb reason to avoid a whole field, really). I clicked with medicine as an intern, though. I was good at it. I was my usual gets-too-flustered-when-paged, OCPD-I-might-have-missed-something self on medicine just like on psych, but I was better there. I was better able to see the big picture on medicine than I remembered, and less able to see the big picture in psych than I thought.

So there, that's my big announcement. Will switching residencies solve everything, or anything at all? Maybe not. It's not that I hate psych, because I don't, despite all the mean things I just said about her. After all, you have to care about something to get angry about it. There's nothing magical about doing internal medicine now (and many of the same problems exist there as well); I still don't know exactly what my career will look like from here (which makes me nervous), but I realized at some point in the fall that I could no longer see myself as a psychiatrist, and in November I realized I could see myself as an inpatient medicine attending, or supervising residents in a clinic, giving lectures to med students--in short, similar plans to what I had for psych, only now in medicine. I'm doing psych consults this month, which is giving me some closure (which I needed). I'll miss psych, especially during the sweet 3rd and 4th years of psych residency when they work 8-5 M-F and I'll be a ward upper level on medicine. I'll miss the intern class I came in with--they're wonderful people, and it has been a pleasure to watch them learn how to be doctors. The psych department is full of people who are special to me and I will miss them.

Fortunately, I'm staying within the same medical college, so the switch is relatively painless. I'll be a PGY-1.5 for 6 months, then start PGY-2 in January. This will put me 6 months behind for medicine, but 6 months ahead for psych. I still plan on doing a fellowship, so I'll be a trainee for a long time ahead.

I've thought about combining medicine and psych, and I think that's a definite possibility. I could run a primary care clinic for psych patients, for example. My psych program has offered to let me come back in the future if I want to do so; I haven't ruled this out (although I do NOT want to be a trainee for the rest of my life).

So now, on to different things. As of next Wednesday, I will no longer be a Tiny Shrink. As I've already changed the handle on this blog a couple of times, I think I'm going to close the blog out and maybe start a new one. If I do that, I'll post a link. As I struggle to find my identity as a doctor, I'm not sure it's fair to make my blog struggle with me. It's kind of like CSI picking a new lead actor when Gil Grissom's character left (or maybe not). So I think this is goodbye for now. I really appreciate anyone who has read this blog or left a comment (or indeed, made it to the bottom of this circumstantial, rambling mess of a post), and I thank you.

Natural Does Not Equal Healthy

http://www.cnn.com/2009/HEALTH/06/16/zicam.fda.warning/index.html

In brief, 3 of the nasally-applied Zicam products (which are sold as supplements, and therefore not regulated by the FDA) may be causing people to lose their sense of smell. The FDA has urged patients to stop taking the products, and has notified the manufacturer that they will not be allowed to market these products without FDA approval.

My favorite part of this article:

On its Web site, however, Matrixx says the allegations are "unfounded and misleading."

The company contends that "there is no known causal link between the use of Zicam Cold Remedy nasal gel and impairment of smell. No well-controlled scientific study has demonstrated a potential cause-and-effect relationship between the use of Zicam and diminished smell function. No court cases have revealed any reliable evidence of any causal relationship."

Well, whaddaya know! They know how to play ball! They may not have to do "well-controlled scientific [studies]" to prove that their homeopathic product works, but they want the FDA to produce one to prove it hurts people!

Does Zicam cause anosmia? I have no idea. Matrixx is correct that there is no current proof of a causal relationship. However, if we regulated these supplementary products, at least for safety if not for efficacy, then we'd likely know the answer to this question. Not that it matters, as I've never used the stuff, but as I like to be able to stop and smell the roses (or at least my gardenias), then I will probably avoid Zicam--just to be safe. One fewer day of cold symptoms or a lifetime of not being able to enjoy eating as much... not much of a choice, in my book.

Vacation Part II

Taking 3 days off to go see my dad and my grandmother. Trying to catch up on my sleep before taking more calls.

Weight Watchers

The other day, I took off a few hours in the afternoon and went to the gym (then came back to work so the other intern could leave early). I was super proud of myself--look at me, I'm being so healthy! I knew my pants were fitting a little tight, but I used the usual lie (they must have shrunk in the wash) and blew it off.

 

Until I got to the gym and weighed in.

 

I was only 1-2 lbs underneath what I'd set as my "maximum" weight. A weight I'd said "I'll join Weight Watchers if I get to that point." While this is only a few lbs above where I'd been a few months ago, it has definitely been creeping upwards. This scared the junk out of me. Often times, I'll see people walking around who are very obese and I'll think "I never want to look like that". I'm well aware that nobody becomes morbidly obese overnight, though; it happens 1-2 lbs at a time, which is why I set a ceiling for myself. Now, I'm almost at that ceiling, and I've decided not to wait.

 

So, I enrolled in WW online.

 

My first few days have been very frustrating. I've been trying to use the online tracker to enter in my foods, and have been totally astonished how many calories I've been eating. My denial voice keeps saying "I usually eat okay..." but the sad truth is that obviously, I don't. In 4 days of entering points, I was something like 17 points behind FOR THE WEEK. AFTER ADDING IN MY WORKOUTS AND GARDENING AND DIGGING HOLES FOR TREES. This is a huge wake up call for me, but I'm left going, what do I do? How do I start menu-planning, when I'm frequently on call and at the mercy of the hospital or eating drug-rep food or eating indulgently because I'm on call? I have so many excuses, some good and some not, but it's hard to get started.

 

My goal is not to lose tons of weight. I could stand to lose 25-30 lbs to really be in the healthy range, but I just don't think I'm ready to do that. Right now, I want to lose 10-15 lbs and be healthier, more aware of what I'm eating. Especially since I do want to have children in a few years, I want to be as healthy as possible before trying to conceive. I also want to pass healthy eating habits on to my children (and I'd be appalled if they ate how I eat now).

 

But sometimes this seems like an insurmountable task, and I'm standing at the very beginning of this--I can't see very far ahead. I have no idea if I'll make it or not. I don't have a really fixed goal, either--but maybe that's a good thing, because if I just thought "I'll lose these 10 lbs and be done" then I'd probably relapse. Who knows how this will go, because I don't.

The Key to Mental Health

I've decided that the one of the best ways to be mentally healthy is to garden. By this I mean I'm tired, cranky, burned out, and counting down my remaining calls, but when I drive home, I get out of my car, go into my yard, and just smile. I keep buying more and more plants to plant because it just makes me happy to putz around in the dirt. Yes, my ancestors were farmers, but I've never felt like I was particularly good at growing things until recently. My flowers are blooming, my trees are finally upright and that lovely dark green, and my herbs are tasty (I bought this the other day and it is AWESOME).I'll be making an announcement at some point on here, but I haven't decided how I'm going to do it yet. No, I'm not pregnant, nor did I get pregnant and sneak off to give birth, nor did I adopt a Malawian baby. For now, I'm just going to put up some pictures of my plants:

FREE=MORE (Some Random Thoughts)

I'm borrowing a line from the Happy Hospitalist because I really appreciated one of his posts today. Go check it out here: http://thehappyhospitalist.blogspot.com/2009/04/land-of-screwed.html. I know not everyone is a huge fan of Dr. Happy, and I don't always agree with him myself (and sometimes when I do agree with him his tone still kind of gets to me), but still, I think the majority of this post is spot on.

 

We are facing a time in this country (and in some other countries as well) where we are going to face more rationing of care. I say more rationing because we already have some rationing in place. Every time an insurance company, Medicare, or Medicaid chooses not to pay for a claim, that's rationing. Currently, our system of rationing is haphazard and doesn't make much sense. 1) If you have money, you can pay for any test you want. CT scan of the heart to check for coronary artery disease? Sure! That'll be $500 up front. 2) Some insurance plans pay for tests that others don't, and it may have more to do with the negotiations between the insurance company and the hospital than whether the test is necessary or how much it costs. 3) Medicare benefits are not even across the country; recipients in one state may be able to get a test that those in the next state over can't. 4) Medicaid benefits are even more uneven, negotiated by each state. 5) The uninsured receive wildly variable care. If they have cash (the self-employed uninsured) they may receive care. If they go to the county hospital, they may receive care. It varies widely, and they may not be paying anything for it.

 

I think many people are afraid that "rationed care" is going to apply to them, personally.

 

Many people with insurance are afraid their care is going to be different, and that they will get less. We expect our MRI's and our expensive back surgeries and our brand name drugs. We expect these things because they're flashy and we're taught they're the best. We resist when we hear they're not the best. PSA testing may not be effective, but by gum I want to know! I think we're basically a nation of hypochondriacs, using our healthcare system to ease our anxieties.

 

And then some of the medical interventions that really make a long-standing difference--for example, vaccinations, exercise, psychotherapy--get ignored, downplayed, vilified, or are not covered by insurance. We want the quick fix. I was asked by a highly intelligent patient (in seriousness) whether I had a pill that would make him happy. He didn't want the medicine "that didn't make me unhappy but didn't make me happy".

 

Everyone is afraid of the long lines we hear about in Europe and Canada. Many of the situations I've heard about, though, requiring months of waiting, are for elective procedures. We want our knee replacements NOW. My back hurts NOW. Never mind that herniated disks may or may not be the cause of that pain, it was on my MRI and I want my picture to be prettier NOW.

 

I don't think there's a single best answer out there; I think all the sides have some truth to them. Patients demand certain things that they shouldn't; doctors prescribe and order willy-nilly because someone else is paying; insurance companies deny legitimate claims to pad their bottom line; government care is fraught with its own perils and problems.

 

I have to agree with Dr. Happy, though, on one thing: when we removed the payment from the doctor-patient relationship, we added a whole new world of problems. "Insurance" should mean a policy to save for a rainy day. I don't call my car's insurer when I need an oil change or routine maintenance; I don't call my homeowner's company when my house needs to be vacuumed or the lawn mowed; so why do we expect our health insurer to pay for our checkups? We really shouldn't call it "insurance". After all, there's no guarantee you'll get care just because you have insurance. Your claim could be denied for any number of small errors, and then you'll get the whole inflated, padded bill all to yourself.

 

A healthcare policy for a group of employees, for example, tries to float the costs of the few unhealthy patients on the premiums of the rest of the healthy; the problem is that the healthy think "$10 copay? I have the sniffles, I should go to the doctor." Or they think "My knee hurts; I could take Advil, or I could get the MRI because the insurance is paying for it." The costs go up and up as people utilize more care (and more expensive care).

 

I guess one of the biggest problems is that so much of the care is unecessary. Back surgeries don't necessarily reduce pain or return you to work. Penicillin for strep may not actually prevent rheumatic fever like we once thought. Cardiac stents don't necessarily work better than taking your aspirin and blood pressure medication, and we don't really have fewer bypass surgeries even though we're doing more stents. PSA testing doesn't save lives; ovarian cancer screening doesn't save lives; and even mammograms are suspect. Giving proton-pump inhibitors in the hospital to prevent rare occurrences of GI bleed may interfere with your Plavix and give you a heart attack. Getting the glucose down to normal in the ICU can kill you. If we truly analyze our diagnostic tests and our medical and surgical treatments according to strict evidence-based criteria, how many would stand up and how many would be no better than "Take two aspirin and call me in the morning"? How much of what we're spending our healthcare billions on is junk?

 

I also think doctors share a large amount of this blame. If the public expects the MRI, it's probably because a doctor ordered it for their sister, or a doctor went on the local news station to advertise, etc. While I think public expectations need to be better managed, I also think our continuing medical education needs to be revamped. How easy would it be, out in private practice, to pick "fluffy" CME courses paid for by drug companies that come with a free steak, instead of intensive and expensive courses that require real learning? I also think we are not good stewards of the healthcare dollars we help manage. Every time I order a full CBC with differential, I could have saved a significant amount of money. Any time I might think "I'll order this possibly useful test, they have insurance", I need to be swatted.

 

Doctors and patients are more money-conscious than ever. Both groups are worried about money constantly. But we're not supposed to talk about it with each other. We placed the insurance companies in between us and then were surprised when our discourse became complicated because someone else was taking and making money off our interaction. Seemingly, the insurance companies are the only ones truly benefiting off this interaction, because certainly the doctors and the patients aren't.

 

Perhaps we could go to some kind of "basic care" model, where our basic checkups and very basic labs are covered by a yearly fee (provided by the healthcare provider themselves), then we have a high deductible policy for true medical emergencies. Patients with long-standing chronic conditions that require the most medications, the most admissions, and the most cost, could be covered by the government; others could be allowed to purchase more care depending on what they think they'd need. Have a kid with asthma? Get a plan with certain types of coverage or a lower deductible. Allow for interstate insurance policies, so that I can shop for insurance in Oregon if they have a better plan than that available to me. Allow for transparency in healthcare interactions: doctors should be able to publish the cost of their office visit on their website (and it should be roughly the same for all comers, whether insured or not; the doctor can then decide to discount if need be) as well as the price of the most commonly used tests. Let patients decide how much elective care they want to pay for, and require emergency coverage (or make it very affordable).

 

Or do something else entirely, but (in the words of Kenan Thompson from SNL) FIX IT!

Still Here

Just haven't felt much like posting lately. Back soon. In the meantime, I'll be watching "Lie to Me", my new favorite show.