Tuesday, August 28, 2007

Don't Shrink Me

I was surfing the NY Times website and came across this article by Ronald Pies, a psychiatrist in the Boston area. Dr. Pies talks about a wonderful nurse he worked with in the psychiatric emergency room and his surprise when he walked on to the inpatient one morning to find this same wonderful nurse, now admitted as a patient with a severe major depression. Dr. Pies talks about wanting to save his colleague, and recounts how over the course of an 8-week admission, the patient's symptoms didn't respond to two different anti-depressants. He later runs into the patient, now cured of his atypical depression by an outpatient doc who recognized his atypical symptoms and more appropriately treated the patient with an MAOI (an older type of anti-depressant). Dr. Pies laments that he missed the diagnosis because the patient was a VIP of sorts, that he didn't get approached in the same way, with the same freshness and thoroughness, that a stranger would be, and he refers to Jerome Kroopman's book, How Doctors Think, as a reference for the celebrities-get-worse-care phenomenon.

We've talked about these issues here at Shrink Rap, asking whether
docs as patients fare worse, and we even discussed a New Yorker article by Dr. Kroopman a few months ago. Here at Shrink Rap, we do it all.

I thought: I should write a blog post about this NYTimes piece. There's a lot to write about-- we could talk about Atypical Depression, missing diagnoses, the use of MAOIs in treatment today, treating people we know. Oh but it's August, I'm feeling lazy, I let it go. And then today, I was reading Clinical Psychiatry News, kind of psychiatry's version of a tabloid, and I saw a letter by the same Dr. Pies. He wrote to discuss how the term "Shrink" is demeaning, how we shouldn't use it. This, of course, inspired me to write this post, I'm still not sure what it's about.

There are some words that feel very powerful, some that squeeze me. Shrink isn't one of them (obviously). I don't generally refer to myself as a shrink--- except in Shrink Rap posts where it flows out pretty easily-- but when others do, I don't cringe. If it's supposed to be a derogatory term, demeaning, hurtful or vengeful, laden with stigma and rife with belittlement of my chosen profession, none of that has jelled in my heart. The term evokes nothing in me, it's not what I feel when I hear people utter racial or religious slurs. Should it be? Did I miss something big? I know Roy isn't nuts about the term "shrink." ClinkShrink, I'm guessing, has incorporated the word as part of her internalized identity.

I don't know Dr. Pies. I wonder if he'd like Shrink Rap, of if he'd just cringe at the title, shun the three psychiatrists who use a derogatory term so lightly, ducks and all. Gosh, are we just a bunch of quacks?


ClinkShrink said...

Hmm...nope, 'shrink' doesn't affect me at all. I've been referred to by many more obviously derogatory terms so this is pretty benign. Others are: sickotrist, psycho doc, nut doc, head doc, etc. Funny how no one writes a sick call slip to the 'gorgeous smart doc'. Still waiting for that one.

Gerbil said...

Only a bunch of quacks would post popularity contest for SSRIs! ;)

Rach said...

hey... at least you have some light-hearted term to describe yourself! why do I call myself "unstable mental illness patient?!"

(sorry bad day... don't mean to take it out on you)

(ps: word verification: oemonxea - sounds like a case of bad hair day)

Kaliki said...

I am not a shrink, but when I use the term, it has a flavor of affection to it. I have been very blessed to have good shrinks.

Rach said...

Btw, i think your poll needs to be extended! I don't have a favorite SSRI, but I have favorite other drugs! (aren't people with bipolar disorder not supposed to take SSRI's because it greatly increases the risk of acute mania?)

Roy said...

I don't like the term, as it seems to miscommunicate what we do. What do we shrink? It does not have a positive, growth-promoting connotation. Reminds me of the movie, Beetlejuice, and the tall African dude in the waiting room with the tiny head. We're not Shaman (Shamen?).

But, it's not something I think or fret about. We did name it Shrink Rap, afterall, but that was because Psychiatrist Rap didn't roll off the tongue. I generally prefer one-syllable words to polysyllables, and shorter words to longer words. You can call me lazy (2 syllables, but short), but I prefer to think of it as efficient. (Hence, my preference for "folks" versus "people" (saves a letter AND a syllable... sweet!) or (God forbid) "individuals".

Shrink that!

The Silent Voices in my Mind said...

I didn't realize "shrink" was a deragotory term. I think of my therapist as my shrink and refer to him that way in conversations with friends/family/blogs/etc. and it is anything but ill-meant.

But if it's offensive - what do we use instead? "therapist" doesn't work because I am also in physical therapy so that leads to confusion. "psychologist" seems so formal (and long to type) so... what the PC word?

BTW - we CAN'T leave messages or anything for "super-gorgeous psychologist doc" - you know, the whole boundaries thing. I happen to think my therapist is incredibly drool-worthy but I could (and would) NEVER say that to him!! LOL

Should I ask him if the term offends him? How do you approach a topic like that?

Dr. Rob said...

I have a psychiatrist friend (and I admit it!) who likes the term "Expander" instead of "Shrink." Most people don't get it.

Otherwhys said...

I do not like any SSRIs. I do not like them in a house, I do not like them with a mouse.They make me MANIC!!! So, I never take them.
This question makes me wonder what peoples' favorite poisons might be. Arsenic, ricin?

NeoNurseChic said...

I don't like the word "Shrink" in terms of psychiatry, but it doesn't personally bother me. I just don't like it. I've said before that there are words I just don't like. Usually there's a whole story and reason behind that (even if I don't know it at the time), but I have no reason not to like the term "Shrink" - I just don't. (Unless this is yet some other unknown story-related term that I'm just not thinking hard enough about!) haha I simply refer to my psychiatrist as "my psychiatrist"... - Sure it takes a few more sylLABles to say, but it just sits better with me. When I want to refer to him in a general sense so that people don't know I'm talking about psychiatry at all, I just say, "my doctor." This comes up when I say that "my doctor" moved his office to NJ. I don't really feel like saying WHICH doctor or "my psychiatrist" so I just say "my doctor." Works for me!

On the topic of doctors or celebrities get worse care... In almost all cases, I agree. But I just wanted to comment from a personal perspective. I became a bit of a VIP/celebrity in my own treatment because of the fact that I worked, was a student, and a volunteer, and a researcher all at the same institution. I started off there always as a patient first, but before long, I was all of those things at the same time. Also, I became personally very knowledgeable about the field for which my condition belongs to. This generally lended people to working harder around me. I noted that they spoke to me as if I was intelligent and informed about my condition and included me more in making choices about my treatment, instead of just saying, "OK we're going to try this" without asking how I felt about it. What I thought actually mattered. I know one radiology fellow actually got nervous when I had my arthrogram done once he found out I was a nurse at the same hospital. He kept doing silly things like dropping stuff and having to have the techs bring him new equipment. I could tell by his mannerisms that he was nervous - but this didn't start until after he learned that I was a nurse in that hospital.

I've used the fact that I am (was - due to a clerical error, I am not currently) a member of the American Headache Society and worked in headache research for awhile when going to the ER. They take me more seriously. Instead of treating me like "just another migraine patient" (aka in ER terms - just another whiner/drug seeker/hypochondriac/insert negative derogatory term here), they treated me as a legitimate patient and took me seriously. Before I could say that I worked in headache research and all those things, I was treated like the former.

All of that being said, I won't say that being so close to the field hasn't had its downsides. It has. When I had the anticholinergic toxicity reaction to mexiletine (which, as it turns out was not to mexiletine solely - but the combination of mexiletine mixed with other meds I was taking), this was a huge issue. I went on the med and called the office 3 times/gone in twice in 8 days to tell them of problems and side effects I was having. I finally went to the ER due to dizziness/palpitations/tachycardia/blood pressure issues/cognitive problems and ended up in full blown anticholinergic toxicity - with psychosis and all (I know I've said this story many times before). When I woke up from all of that, one of the NPs from the neuro's office was there. She said that sometimes doctors will put a health care professional (I was a nursing student at the time) on a more dangerous med and give them a little more free reign just because they know that someone like a nurse would recognize a more serious side effect versus a more mild or transient one. Therefore, they may not monitor quite as closely/be as anal retentive about the med. For example, mexiletine is supposed to be started while still under cardiac monitoring of some sort. I was in the hospital on continuous IV lidocaine for 12 days. I was discharged from the hospital and the pharmacy could not fill the mexiletine prescription for another 3. I was not given a first dose in the hospital. I was not given a first dose while under any kind of monitoring whatsoever. I took the first dose 3 nights later, at dinner at my parents' house. I then contacted them numerous times when I started to have strange symptoms (I had just suffered 4 days of anticholinergic toxicity during the hospital stay, so I knew when the symptoms were seeming kind of familiar. The first thing I said was 'I'm having trouble thinking again' and started laughing.).

My gripe with all of that was that if they were going to trust a nursing student with more free reign on a dangerous med (well, now I know more a dangerous combination of meds), then they also should have LISTENED to me when I started saying that I was having serious problems on it. I just kept being told to continue to take it and the side effects would go away. I didn't know any better, so I trusted them. For this situation to go well, it's fine if the doctor gives the health care professional as patient more free reign within certain parameters, but then there must be some sort of feedback loop. When said healthcare professional comes to the physician, the physician really needs to listen.

When I brought this up to my neuro at the time, I was told that perhaps I was too angry to continue my treatment there and that it was time I was sent out to the headache center in Michigan. So it was a lose/lose situation for all. And for the record, I still see the same neurologist and now we get along great. So I consider this story a past major bump in the road, but it's in the past.

Sorry for the length - I just can see both sides to the coin of being a "VIP" patient of sorts - at least in terms of being a nurse who is also a patient.

Take care!
Carrie :)

Sarebear said...

I think of it as, they help me shrink my problems. 8^D

Road Warrior said...

"Expander" *gag!* I think your use of the term shrink shows that you have a sense of humor about yourselves.


Ron P said...

Hi, Dinah and Other Writers--I happened to find "Shrink Rap" while surfing on line today, and could not help but notice the my recent NY Times piece was mentioned, as well as my recent letter on using the term "shrink."

Dinah, first of all, let me say that I appreciate your citing both of these pieces. I'll also say that my letter in Psychiatry News would not have appeared, had I not been responding to a column in that paper, by Dr. Steven Moffic.

Re: the term "shrink"--truth be told, when asked how my practice is going, I have sometimes been known to reply, "Business is shrinking!"

I do think that keeping a sense of humor--about oneself and one's profession--is a good and healthy thing. And let's face it, there will always be psychiatrist jokes!

I certainly bear no animus toward anybody for developing a website called "Shrink Rap". It looks like you folks deal with some important and informative issues, and that's all to the good.

That said, I do feel that the term "shrink" has a certain, well...funny odor about it. At its best, it might be compared to the term "Yankee Doodle". As you may know, this was originally a term of derision that the British applied to the colonials who dared to rebel against the mother country. The "rebels" decided to co-opt the term, and soon, it became a kind of badge of honor. (That, at any rate, is the story I've heard). So--considering that the term "shrink" is supposed to be a short- hand version of "head-shrinker", I suppose I can see something gutsy in appropriating it and turning it in to a sort of honorific--or at least a playful form of self-deprecation.

At its worst, though, the term reminds me a bit of how the characters on the show "The Wire" refer to each other...these are African-American youths who constantly refer to one another using the "N" word.

I do not mean in any way to analogize psychiatrists to those who have suffered in the way blacks have in this country. I am simply describing the same sort of queasiness I feel when I hear the "N" word being used in this way, and when I hear psychiatrists refer to themselves--even playfully--as "shrinks". On some level, it feels like a very subtle form of self-hatred or self-flagellation --or maybe a preemptive attempt to deflect criticism from those who otherwise would demean and attack the profession.

I may be wrong about this (I have been known to err on occasion) and I'm sure many feel this is "much ado about nothing."

Maybe so. There are bigger problems in the world to tackle, for sure.
Nobody should lose sleep over this one. And yet, and yet...do we ever find surgeons referring to themselves as "Saw-Bones"? I wonder why not.

With all best wishes for expanding our horizons, rather than shrinking--Ron Pies MD

Roy said...

Hi, Ron. Thanks for visiting. For those of you who don't know, Ron Pies writes some of the most clear and understandable articles about issues in psychiatry that are written today. So, thank you for visiting.

I think you touched on some of the very reasons why we have come to accept this term. As stated elsewhere, I hate the term "shrink". But I have warmed up to it some, in part because it is easier and shorter to say or write (somehow, "saw-bones" seems like more work than "surgeon"). It is different than the N-word, which is used intentionally to harm. I think the S-word is used more out of misunderstanding what we do.

I have come to appreciate that, like many of the commentors above noted, some folks do not see it as a derisive term. But, more importantly, to use it in a self-deprecating manner, and always with some humor, allows us to be seen as "more human" (as some of our readers and listeners say). This is the value. We need regular folks to be able to "get" psychiatry, to understand how we think and take some of the mystery out of our specialty. Only when people can start to understand us and relate to us can they begin to see psychiatry as a medical subspecialty, rather than some weird, mumbo-jumbo, psycho-babble sh*t.

Ron, please stop by any time. I know it can be difficult to mix up static media and dynamic media, but you strike me as someone who doesn't shrink from a challenge.

Ron P said...

Hi, Roy--Many thanks for the kind words on my writing. It's nice to know that somebody outside my family actually reads it!

I appreciate your--well, ambivalence?--about the word "shrink", Roy. I think we are all aware of its "double edge"; on the one hand, a playful and maybe useful tool for helping "humanize" psychiatry; on the other hand, a potentially insulting and demeaning
word that doesn't seem to have its analogue in references to other medical specialties. (Ever hear a similar term applied to a neurologist?). So, if we want to convey that psychiatry is one medical sub-specialty among other (co-equal) specialties, is the best way to do that via a self-deprecating moniker? I don't know, but I am dubious.

Well, so be it. To borrow Keats' phrase, perhaps we all need to develop our "negative capability"--living with ambiguity or contradiction.

In any case, I agree with you that we have our work cut out for us, vis-a-vis helping the general public (and many of our medical colleagues) understand what it is we do, and do not do. There are many ways to do that, I think, and humor of some type is undoubtedly one way.

I have sent a brief note to Dinah (who was good enough to write) indicating that I may, indeed, stop by from time to time...after all, I am no shrinking violet! There, I gave in. Now maybe I can get some sleep!--Best, Ron

Otherwhys said...

I really want to know whether the use of the term shrink, as applied to psychiatrists,is found to be offensive to any of the descendants of those people who at one time in history were honest to goodness head-shrinkers.
I think that it is a bit of an over-reaction to be so offended. Many other professionals are subject to a certain amount of ribbing. Politicians of all stripes are called all sorts of names. Lawyers are called crooks, rats etc. Oh, but those monikers reflect reality while shrink does not reflect any reality? Of course you don't shrink heads.Everybody knows that. There is no parallel to be drawn between shrink and the N word; that is really pushing it way too far. If psychiatry does not feel it is taken seriously as a medical sub-specialty (assuming here that psychiatry can "feel" independently of it's practicioners whose views on the subject vary)one should be asking why that would be. One of the bloggers mentioned the fact that there is a trend towards more "scientific" research in the field and that one day the pendulum might shift back towards a more humanistic view. Others would argue that a pure medical model (yes you are all M.D.s, we know)fails to take into account that you are treating people ,not merely brains, and that those people are far more than the container for their brains and that there are interesting concepts (such as resilience which Dinah wrote a post on) that may not be getting looked at in such a shift.

toni said...

This "shrink" thing makes me feel really icky. During my last session, I referred to my therapist as a shrink. I didn't intend anything negative, but now I am obsessing over it.

If I offended her then I won't be able to face her again. I might have to cancel my next appointment.
Another option would be to show up and apologize. That might be good for me if I can do it. Otherwise I'll just let it ride and obsess in the private confines of my mind.

Oh can someone please help me shrink this ever expanding problem?

Dinah said...

Much ado about nothing, if you ask me.

Ron P said...

A quick note to Toni--Please don't trouble yourself! I'm sure your therapist has heard worse than "shrink"! All of us have learned to shrug and smile, and we know that the term is often meant affectionately or at least without any intent to offend. Your overall relationship with your therapist is much more important than a word here or there...but if the issue bothers you, you can certainly raise it with her.
I think I've said enough on this topic, as there are many more pressing ones for all of us--as clinicians and patients--to deal with! --Best regards, Ron Pies MD