job changes

I find myself searching for medical jobs on the internet, but to no avail. I think a lot about what an ideal physician job would be for me. I like practicing psychiatry very much. There are not many places where a doctor can spend a full hour with all her new patients. The clinic I work in now appreciates my work, but can offer me only a few hours a week. I am a family practitioner, with 20 years of practicing psychiatry in a primary care context. I'm lucky to have any work as a psychiatrist. Not likely to find other positions like the one I have. So I think about other options, and wonder what an ideal practice might look like.

I like to talk with patients, sorting through their histories, symptoms, needs, desires, diagnostic possibilities, test results and treatment options. I don't care if I never do another pap smear. I don't particularly enjoy doing physical exams. I like to consult with people, reviewing their records, explaining things. Sort of a mendical translator.

But in the end, what stops me from trying to create something like that is that I'm a physician. If I make a mistake I can get sued. In family practice patients get sick, no matter how hard I might try to prevent it. They will die, as we all do, despite the best efforts of any doctor. Angry family who do not know me may sue me, not understanding the kind of relationships I have with my patients. In the end, no matter what I do, I feel like a failure. I would just like to talk, consult, treat the patient like a colleague, educate them about what is going on with their bodies and minds, and let them make their best educated choices. Then I can feel more like a partner and not the boss.

Is there such a thing as a medical decision making coach? One who educates about illness, the way the body works, and treatment options, and then releases the patient back to their physician for their treatment? If there is, please let me know.

Expert Witness

I had the questionable privlege of being an expert witness in court this week. One of my patients wanted me to testify for her in court despite the fact that my testimony would be highly unlikely to improve her chances of winning her case, and would probably harm it. I tried to get out of it. My boss advised me to ingore the first subpoena, which I did. The lawyer threatened to get a bench warrent. I sent him a written statement of what I would say. He tried to talk her out of it. She insisted. He was representing her pro bono as a court appointed attorney. I have to give him credit, he really tried to listen to her wishes, despite her inability to really understand what the consequences of her decision would be. Finally, I still had to go to court.

Although I don't want to divulge much of the details of the case, my testimony, as I expected, was fairly damning to my patient. No, she was not thinking clearly at all when I first saw her. Yes, I prescribed medicine, yes she was much better when she came back a month later. No she never followed up with me afte that, no she would not have enough medicine to last until now, no I don't believe she would have a normal mental state off the medicine, no I don't think she was highly motivated to work hard in therapy, take responsibility for her behavior, or make the kind of changes in her life she would need to in order to win her case in family court.

It was awful to have to look at this patient while saying things that condemned her case to failure. But what bothered me the most was that this woman, who'd had a terrible childhood, and who had a terrible life, who had little education and very few life skills, had actually formed something of a connection with me. She had at least trusted me enough to tell me her story and to ask me to testify for her in court. She had thought of me as a friend of sorts. I suspected she had been manipulating me to get what she wanted, but I'm not sure she realized that's what she was doing, or even that it was wrong. What bothered me was that I was letting her down, I, who she had trusted enough to talk with, to tell secrets to, was hurting her in public, in court.

I left the court room as soon as I was released; I didn't want to witness her anger, see her lash out at me. Her anger alone would spoil her case with the judge, and she certainly had anger seething in there. But I worry that she will have an even harder time ever trusting an authority figure again. A colleague suggested that a good sign of her poor judgment was her wanted me to testify. I wish there was some kind of system, support, something, that this woman could be plugged in to to teach her what she needs to know to survive and thrive in the world. As it is she is lost in the cracks, no stable place to live, using drugs and alcohol, unemployed, uneducated, and far too proud to directly ask for help. And now I fear that even if help is offered (or court ordered, as her appointments with me had been), she will be too suspicious, too afraid of being hurt, to trust it. She needs a mother, has needed one her whole life. Perhaps for half a minute I had been a very pale version of that mother for her.

She expected me to rescue her, to bail her out, to even lie to get her what she wanted. It's probably the fantasy of what a mother should be to her. Perhaps she set me up to fail her, just as her own mother had failed her in the past. And when I did fail her, it reinforced her identity as a survivor who doesn't need anyone, and can't trust anyone anyway.

I know that as adults we are responsible for our own bad decisions. When I look at this patient, though, I see that angry, helpless, and lost child inside. She makes the decisions she needs to survive. The concepts of consequences, of future, of responsibility toward others, mean nothing to her. She figures out where she will sleep tonight, where she will get food, what drug might quiet the voices in her head. And that is enough for a child to accomplish in a day. And is too much for any child to have to do alone.

Living with the past

Tonight I went to a drug company dinner at a fancy restaurant. I never do these things, but ... well, I guess never is suddenly an exaggeration. The doctor presenting was a thoughtful guy who does pain management as well as sub abuse treatment. He talked about how a patient's time orientation was a good predictor of how they would do medically. Those oriented to the past - "I used to be able to X", "I wish I could do Y like I used to" - tended to do poorly compared to those who lived in the present or planned for the future.

That got me thinking about the things that get me stuck in the past. Childbirth is one of them. I had a horrendous experience having my son - 3 days of labor, 24 hours with an epidural, legs swollen beyond recognition, a doctor who didn't want to assert herself at all, and a C section in the end followed by utter and complete exhaustion, a baby who wouldn't nurse, an obstetrician who forgot to round on me at all, well, that was just the start.

Sometimes at night I lay in bed and remember all that, remember the helplessness and the frustration and the inability to say what I needed, and the inability to just trust that my doctor knew what to do. I ruminate on it, and wonder what I might have done differently, what might have improved the outcome for me. I figured out that I should have listened to the faint whisper that "this is a good fit" when I met the obstetrician that did my amniocentesis. That the whisper should have led to a major change in my medical care just didn't occur to me at the time.

I look at my son and know that whatever I may have gone through was worth it to have him. Still, I wish I had been less traumatized, less exhausted, and more emotionally available to him and my husband, instead of only being able to cry and feel like a failure. I wish I didn't lay in bed at night and have all of that awful experience come back to me.

There are a few other things that get me stuck in the past, too, all centering around some kind of traumatic experience. It is hard to pull out of those ruminations, that stuckness. My stucknesses are things I don't share with others. Talking to my husband today and telling him I wished we'd gone to that obstetrician we liked seemed to help me. Talking to my father after my mother's death seemed to help him deal with the thoughts that he should have done something different, seen a doctor sooner, something.

There is a list of things I don't talk to anyone about, though. I don't get stuck on them often, but they do come back to me from time to time. Like the childbirth experience, they all deal with being misunderstood, helpless, silent, inarticulate, overwhelmed. I am a survivor; I've suffered through a lot in my life. I focus on the future to a fault sometimes. But being stuck on the past doesn't help me grow beyond it. Maybe I'm procrastinating getting my mammogram because I don't want to risk another bad medical experience. Maybe I avoid conflict because I can't stand the flood of emotion that is so strong I can't articulate what I feel. Maybe I get stuck because no matter how many times I think about things, there is nothing better I can figure out to have done differently.

The guy giving the lecture today also talked about how past events shape the way patients live their lives. He described a woman who had been sexually abused as a child. This experience came back to her when she married. She wanted to please her husband sexually but couldn't deal with the memories, so she stuffed herself with food to numb the emotions and ultimately became obese and less desirable to her husband, which also allowed her to avoid sex and the recurrence of those memories. Surely there is a better way to live with our traumas. She lives to avoid them. I live despite them. Is there a way to live because of them?

That question sounds logical but I'm not exactly sure why. I read a story in JAMA today about a doctor whose daughter had leukemia and how that experience nudged him to talk to residents and students about the emotional cost of patient care. Because of my experiences with medical trauma as a young child, I've had that orientation all along. I was the only doctor on the family practice faculty that didn't just inquire about the welfare of the patients, but about the welfare of the residents and students as well. I knew the residents couldn't take care of the patients if I didn't take care of them. I teach creative writing to medical students. In return they teach me about their lives, their difficulties, their sorrow and suffering. I hope that having the chance to deal with what is happening to them at the time it happens will keep them from getting stuck later.

Maybe that is what I needed then, those experiences that make me stuck today. Maybe having someone look me in the eye and recognize I was having a hard time and step in and at least let me figure out how to say what I was going through is something that would have prevented stuckness down the line. Maybe getting the story out now, being free to say "I wish", to figure out what might have made the difference, would help me move past it today. Avoiding it surely doesn't work. One of my patients writes short stories about children. In them she writes childhood the way it should have been for her. Maybe she's on to something. Maybe all this stuckness is just a sign that we need a more formal way, a more open way, not of recounting the past, but recreating it. Or maybe we can write about how to keep the same things from happening in the future. Maybe in stead of saying "I wish I hadn't lost something in the past" we can now say "Next time, it will be different."

Manic

My last patient this evening was hypomanic - talking a million miles an hour, super focused on his own train of thought, impulsive, pressured, not sleeping - AND his wife says he's doing better. Our fifteen minute appointment turned into an hour. Only then could all three of us conclude that we were one the right track. We stopped one medicine, tapered another, persisted with another and raised the dose of another. Whew!

My thoughts were getting all scattered just trying to talk to that guy. When I was with a very anxious lady earlier, my leg started to itch like crazy. It took all I had not to pull up my pants leg and scratch it till it bled. Later I was aware of hives spreading across my forehead. Anxiety. My anxiety was triggered by hers. Another lady started talking about taking care of her dying mother, and I flashed back to my own experience with my mother's death. Another woman started talking about her conflict with her husband. I almost asked her if we were married to the same man. A young woman told me about the abortion she had last week. Since then she found a doctor to put her on diet pills. She is fighting with her boyfriend and is getting depressed. What a mess. I watched people cry as they told about the deaths of husbands, sons, brothers, sisters, parents. One lady is on chemo for breast cancer. My mother died of breast cancer. I am due for a mammogram.

I'm not doing a very good job tonight at separating myself from my work. I am overwhelmed by a party we're giving on Saturday; I'm afraid things won't be perfect, people will be disappointed by my garden, the kids will trash the house and then all scream and cry in unison, my husband will get drunk and space out in a corner, and I will be responsible for everything. Oh well. Been there, done that, survived. It will be ok. But my anxiety gets fueled up by my patients' anxieties, and all the old stuff surfaces.

I don't actually have to listen to my patients' stories at all. I could just ask about symptoms, tweak the prescriptions, and send them out the door. An awful lot of psychiatrists do just that. But the stories give me a context, help me see and care about the person in front of me, make it matter to me whether that person gets better or not. I wonder if the young woman with the abortion, who makes really rotten decisions, might actually be bipolar. One of the therapists informed me that another young woman, who seemed to be willfully destroying her marriage, is suddenly better since I treated her ADHD. Maybe if I listen to these stories carefullyI can figure something out. Waht happens in their stories really does matter.

Well, right now my house is quiet. Another day of patients tomorrow, party the next day. Being manic sounds attractive sometimes. I'd get so much done. But being calm is perhaps the better goal. I can take a breath, realize that my patients' problems are theirs, not mine, and I am earnest in trying to help them. And beyond that, it is summer, my lillies are blooming, and Saturday afternoon I fully expect to be attacked by a dozen kids with water balloons. It doesn't get much better than that.