Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Sunday, February 10, 2008
My Assorted Thoughts on Tara Parker-Pope's Wellness Blog Today
I feel this funny kinship with The New York Times Wellness blogger, Tara Parker-Pope. I don't know her, probably never will, and I'm jealous that her blog is so much more widely read than mine. Why hasn't The New York Times hired me?? Maybe it's because she's a blogger, I think she's a mom, and "Tara" is the name of my college roommate who has journeyed around the country collecting advanced degrees and remains a beach-ball of energy (there's something 'round' about my Tara, I don't know why, she's petite, slim and runs miles a day, but she's energetic and hard to grab on to, nonetheless). More simply, though, Tara Parker-Pope often writes about things we like to address on Shrink Rap, and for the second time recently, we've "known" in some sideline way, the same people. Not long ago she wrote about headaches and referenced my neighbor, the Johns Hopkins migraine king-- a man with beautiful gardens, a lovely wife, who run circles around our neighborhood for exercise, but my conversation with him has been limited to mutual nods.
So the Wellness Blog of 2/8 came to my attention this morning because it's on When Doctors Become Patients. That was ClinkShrink's post!! There Tara Parker-Pope goes, stealing from Shrink Rap again. We got to do something about this!
So I click over and there's a photo of Bob. Who's Bob? you say. Well Robert Klitzman certainly wouldn't remember me, but he pops up in the media now and then so I remember him. When I was a third year medical student doing my much-anticipated psychiatry rotation (for Bob's sake, I won't say where), Bob was one of the four PGY-2 residents on the fourth floor unit I was assigned to. Only I wasn't assigned to work with him, I worked with Beth. Beth was great, the thing I remember most about Beth was she told me she didn't like to go to the movies on a first date; she wanted a chance to meet a guy, get to know him a little, so she could dump him right away (she eventually married a musician, don't know what happened to the marriage, but my feeling towards Beth remain fond).
Bob wrote a book about his residency training experience: In a House of Glass and Dreams. I stumbled upon it in a bookstore. I knew the author so I bought it, and while he never named the program, I knew all the details. I remembered the lock that stuck outside the hallway to my supervisors office. He talks about his first day going to therapy, and I remembered being in a conference and a bunch of the residents saying "Where's Bob?" and someone replied "Bob went to therapy!" "Bob went to therapy???" I didn't really know Bob but I assumed that wasn't expected. This was in an institution where the chief resident posted on a black board what times he'd be psychoanalysis, don't beep me then. At some point, many years ago, I chatted with Bob briefly when I accidentally ended up at the wrong reception at APA, and I told him how much I liked his book. I think he was flattered. The book, which I read well after completing my own residency at an institution where one certainly didn't announce that they were going to psychoanalysis, resonated with me and and left me feeling understood-- it was during a time in my life where I was having a hard time feeling like anyone understood. I'd had enough wine to be at the wrong reception, so who really knows what we talked about, maybe 15 years ago.
At some point, and I'm not sure why, I learned that Bob's sister had died in the September 11th attacks. My heart went out to a man I hadn't ever really known, and the Wellness blog is about Bob's experience of being a psychiatrist with depression in the aftermath of his sister's death, and how his own journey has made him a better, more considerate doc. I don't doubt it.
I guess the other thing I wanted to comment on, since this NYTimes post hit on so much for me, is that Bob initially experienced his depression as physical symptoms and didn't recognize them as a mental illness. This is not uncommon. I've had patients lose tremendous amounts of weight (50 pounds anyone?), have severe pain (usually GI) and have extensive cancer workups. One tells me frequently "No one ever told me this could be depression." Another is only now getting to be a little better after his zillion-dollar work up. When I heard of the case, as he was being referred, I said to the internist, "Hmmm, sounds like cancer." He agreed, said they were continuing to look for the elusive tumor. One look at the patient and I rethought, "Looks like depression." Patients, unfortunately hear this as "Your Pain Is All in Your Head." I' rephrase this as "Sometimes depression is expressed as pain. It doesn't mean the pain isn't real." I want it to not be insulting, but the reality is that the prognosis for pain as a symptom of depression is a whole lot better than the prognosis of pain as a symptom of lots of other things that people are wishing will be found.
Posted by Dinah on Sunday, February 10, 2008
Labels: blogging, depression, diagnosis, pain, patient care
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Very interesting, as usual. Very well-written, as usual.
I'm particularly interested because my two colleagues and I, as sufferers of second trimester miscarriage, breast cancer and stroke, signed up to give a talk on Doctor as Patient.
Then, when we went to actually prepare the talk, it turned out there were no formal studies of the topic in the literature. We ended up just telling our stories and opening up the floor for people to discuss their experiences. It worked, sorta.
Now, even though I'm not in academic medicine anymore, I want to do the study. I think providers need to know in one formal and peer-reviewed study, how doctors want to be approached when they (or their loved ones) are sick.
Haven't really thought about the specifics, nor have I decided which of my five waking and non-working hours a day do I want to give up to do this project, but if you or any of your readers want to co-author, we should hook up. :)
Thanks, Fat Doctor.
Looks like Dr. Klitzman has written a book about this:
Personally, I don't even like to think about the topic.
This comment: " the prognosis for pain as a symptom of depression is a whole lot better than the prognosis of pain as a symptom of lots of other things that people are wishing will be found" depends on who you are, how depressed you are, how long you have been depressed and whether treatments have worked for you.
Personally, I would rather have had anything else, even if it was terminal, than the 6.5 year, treatment resistant MDE I've been in. Chronic Major Depression is like being trapped in hell forever.
Yes, treatment-resistant depression sucks.
I guess I'm thinking that if your choice is a) disseminated cancer versus b) never-before treated depression, the odds are better for depression.
I hope you feel better...
I took care of my Mom for three months after she was diagnosed with pancreatic cancer. It was a horrific three months, but both of us knew her pain would end. I loved her so much, but when she passed away I felt relief for her. Relief that her suffering ended. I do not see that ever happening for me. I know the prognosis for many with depression is good, but what I know of my illness is that even if i do get well, the chances I will become ill again are extremely high because of how many depressive episodes I have had before this one. Honestly, I wish I had died instead of my Mom.
FD - If you make it about health care providers as patients, which includes nurses, then I'd be happy to work with you! You may or may not know that I was a patient before becoming a health care provider, but I also have quite a bit of personal experience in this area as at varying points, I have been an employee, patient, student, and volunteer all within the same institution. I see being a nurse and a patient as two-fold: What it is like to be a patient having the knowledge of a nurse and also What it is like to be a nurse with chronic health problems. That last bit there can also be split into several components: compassion of fellow nurses when one of their own gets sick, physical/mental demands of the nursing job when one has complex chronic health problems, and emotional component of caring for the sick when one has chronic health problems. When it comes to being a patient and having the knowledge of a nurse, I feel that my knowledge allows me to ask more complex and insightful questions at times, but that I would like to be spoken to like I am the average Jane, so that nothing is missed in the assumption that "of course a nurse would know that." It's a VIP patient syndrome since usually doctors and nurses, when patients, are treated a bit like VIPs and then corners may be cut when assumptions are made. It is best if we are treated in the same way as anyone else with respect to medical workup and explanation, as therefore we can be sure that nothing is lost in translation. I like having the knowledge that I have (although I didn't gain my knowledge about headaches from nursing school! But rather from hours of personal research, asking questions, knowing the right people, and working as a volunteer in headache research for a summer), but I still like it when the physician/NP/whoever takes the time to explain things to me.
As an example - I am preparing to get my occipital/supraorbital nerve stimulator implant anytime after mid-April when the new battery comes out for the company I have chosen to work with. I have really enjoyed the fact that they have spoken to me on their terms and allowed me to view a DVD on surgical techniques for implanting stimulators that is meant for doctors to see. They know that I will understand what it is they are showing me. I also have asked a number of questions that I know for a fact I wouldn't have asked had I not been working in health care. However, at the first appointment with the neurosurgeon and my parents, the neurosurgeon asked us if we knew exactly how the process worked, and we all said no. He then proceeded to draw us a picture and go through a quite decently lengthed explanation of the procedure and how it works. When I first met with various physicians along the way in this process, I held off on telling them that I was a nurse at first so that they would explain every detail to me. Now I feel like I have the best of both worlds.
Dinah - WRT pain as a symptom of depression. This comes up from time to time in my therapy as a point of perhaps disagreement between my psychiatrist and myself. I see my headaches as originating in some biological disease process - one moment I was fine, and then next, I got this headache that will not leave. And cluster headaches? Well speaking of those implies knowledge that CH most likely comes from a faulty hypothalamus, which is a physical thing. However, I'm pretty sure my psychiatrist feels that my headaches are of some psychological origin, and therefore can be alleviated best by working through therapy as opposed to taking medications that have harmful side effects. He's asked me repeatedly if I feel that having headaches be some psychiatric disorder makes them "less real." No - it doesn't, but it's just a matter of belief. I go in and out of depression - I know that. But I don't go in and out of headaches. They were not there one minute, and they were there the next. I know what physical symptoms were associated with them. How then, are they psychiatric?
But yet, I see what he (and you with your explanation) are saying. That pain can be a manifestation of depression in and of itself. No, it doesn't make the pain less real, but perhaps easier to treat. I, however, have tried several antidepressants for headache alone, including cymbalta which is supposed to help with the "pain" of depression, with little or no success. He once speculated that perhaps my headaches were better one particular month because of my willingness to discuss more difficult things in therapy. Mmm... Maybe. I think the jury's still out on this one. I see what he is saying when he says this, but I don't see how it makes it easier to treat - and if he does believe it to be of some psychiatric origin, then why does he not put me on an antidepressant to try to treat this "symptom"? Clearly therapy alone has not knocked back this 7+ year beast in my head, but neither have the majority of meds tried, either. I can't quite figure what his angle is on this, even though we do discuss it periodically.
Anyway - I know you weren't talking about me, personally, but the topic of pain and depression hits home to me. And the topic of doctor/nurse as patient, too. Well, all my life I wanted to be a doctor until my health problems took away that option from me, and so I decided to become a nurse instead. I don't regret that choice, although I often do feel sadly that I didn't continue down the path to medical school, even though I see that it wouldn't have been a good path for me. These topics are very personal to me, and have haunted me for over 7 years now, no matter how hard I have tried to shake them.
re: depression and pain.
The problem is that it is a vicious cycle. Many of us with chronic intractable pain have had docs diagnose us as being depressed and therefore we have pain rather than because we have chronic intractable pain we experience depression. Treat the chronic intractable pain and we may well no longer feel depressed as our ability becomes greater to be more able and involved in the world.
Carol Jay Levy,
author A PAINED LIFE, a chronic pain journey
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