Congratulations, Fat Doctor!

Look! Fat Doctor and her family have a new baby girl. What a cutie.






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On a totally different note, I just read the strangest article in the Sunday New York Times. The author has a very detailed discussion of her sex life, of how she's no longer interested in her husband, of her first orgasm, and she mentions her episodes of depression, though not as a cause of her weak libido. I'm not posting a link, I'm not even comfortable citing the author's name. The detail would have been rather intimate if I'd heard it from a friend, or perhaps even a patient, but to read it in the New York Times--- somehow I felt like I was prying. I can't help but wonder how the husband (the no longer interesting former object of sexual desire) must have felt.

Other People's Lives

Or maybe just this shrink.

I've figured out something about myself: I'm a voyeur, I love having an outside view into the window of other people's lives without participating. In a way, it's sort of what being a psychiatrist is about: we spend all day listening to the things other people have done, the relationships they've been part of, the trips they've taken, the dreams they dream, even the movies they've seen and the books they've read. I spend far more time listening than doing myself and sometimes I feel I'm the master of the vicarious life. Oh, not really.

Running a blog, for example, Shrink Rap, has elements of this. We throw out stories, or ideas, and people write in their thoughts in the comment section. Sometimes they answer each other and sometimes they use the original idea as a springboard to go someplace totally new (Warning: Roy forbids this). I read the comments, I watch it unfold. Sometimes something riles me enough to comment, sometimes a comment inspires a new post, sometimes I feel a need to address a comment or say thanks for a compliment. Mostly I just watch as the next chapter comes in. It's part of why I love reading Fat Doctor, I like sitting back and reading the next chapter of the very colorful life of some person I've never met, never will meet, and still feel some connection to.

Last week, I joined my neighborhood's list-serve. I'm getting maybe 20 emails a day, from people I know or don't, on and on about the most random of things. Our neighborhood has an Obama group. Oops, now we have a McCain group, too. Sarah Palin shoots moose. What to do about incessantly barking dogs, someone found a dead pigeon the other day, Bonnie needs a new microwave, Joan has a large plant to give away, and many people know exactly what you should do with unwanted clothes. And if no one wants that old freezer, Roberto says to donate it to the Goodwill. I wasn't there for it, but I hear people got really inflamed over issues of deer control. I could use a new carpool, and oh, I saw a rat in the alley the other day, but so far, I'm just hanging out watching. I'm not sure I was meant to participate.

Dear Fat Doctor

Fat Doctor wrote a post a while back where she worries that her darling toddler son will some day be embarrassed by her weight problem. I meant to comment, I meant to write her, instead I'll put up a blog letter.

First a disclaimer: all kids are different, they come in assorted shapes, sizes, and temperments and I've learned quickly and painfully that a wonderful kid can become a particularly difficult kid-- this with a six week countdown in my family until such kid moves half way across the country to start college. Last year, I thought I'd have a nervous breakdown when he left, this year, he's making it a bit easier to say goodbye, though I'm well aware that I still may have a very difficult time with this departure. There are more difficult kids, there are easier kids. So with two teenagers, and with many friends (and patients) with teenagers, let me write a letter to our dear friend Fat Doctor in the blogosphere.

Dear Fat Doctor,

Please don't worry that your son will be embarrassed by your weight. He won't be. And because he's a boy, he probably won't care what you wear. Kids don't worry so much about what their mothers look like, oh, except for girls, who are known to yell: You Can't Go Out Looking Like That! Especially not where their friends might on the same planet.

While you don't need to worry about your son being embarrassed by your weight, there are a few things he will be embarrassed about.

• Your mere existence.

• Every word you say.

• Especially words that date you. Gosh darn is probably not real cool.

• References to TV shows, movies, politics, or events from the days of old.

• The music you listen to.

• The songs you hum. Oh, gosh, don't hum.

• The gestures you make.

• The things you say about him, no matter how glowing. Don't talk about him. Ever.

• The fact that you greet his friends. Do you really need to ask how they are and interrogate them about what they are doing and what they'd like to drink?
  

• The fact that you are not invisible.

• Your ideas. Especially if you express them.

• Oh, and your core beliefs, what ever they are, they are embarrassing.

• Your expectations of him.

This is only a partial list, but Son won't care about your weight. I hope this helps you sleep better.

With kind thoughts. By all means, continue to enjoy the next 10 wonderful years.
Dinah

"You're The Psychiatrist...."

First, check out our PODCAST #45 with return guest Dr. Ray DePaulo.
Then, let me tell you about my weekend.

I went away with my husband on a quick trip to my aunt's 90th birthday party. She looks fantastic, her sister was there, her brother-in-law hasn't slowed down any and he had a few too many and was out on the dance floor with his grandchildren. It was a nice time and there were maybe 50 of us there for a nice celebration in a hotel banquet room. Across the hall, there was a wedding. In the adjacent exhibit hall there were....oh, 1600 "guests" there for Extreme Cage Fighting. I've never quite seen anything like this. I'm not sure how to begin to describe it.

Okay, so I tried to go in to check it out. I've never heard of "cage fighting" but apparently it's the ultimate in brutality...two men in a cage trying to beat each other to a pulp. What fun. I was dressed like I was going to my aunt's 90th birthday party. Security stopped me. "May I help you?" I didn't know what to say. "I guess I'm at the wrong event." He looked me over and said, "You're at the wrong event." Everyone else was in wife-beater shirts. My tattoos....well, let's not go there. He let me stand there for a few, I watched as the police dragged out a few people, it was quite the scene.

So the hotel had lost my reservation and we ended up sleeping at another hotel 10 minutes away. I heard from my cousins that this was not a bad thing--- the 1600 Extreme Cage Fighting observers were drunk, rowdy, and raucous through a good part of the night. Someone erroneously reported a fight in my cousin's room and the police came pounding on her door at 4:30 AM, she sent them away saying that she and her 86 year-old mother were not fighting.

Down the road, my husband and I spent a quieter night, away from our teenagers. We chatted, I told him about Fat Doctor's trouble with her difficult Day-Care provider and how she wants to adopt another child. This is what my life has come to.

So everyone I tell about the Extreme Cage Fighters says to me , "You're the psychiatrist, why do people like this?" I guess I could ramble about the baser of human instincts, a pull towards competition and violence. Something Freudian. Honestly, though, I don't get it. I won't be jumping in any cages any time soon. And Roy, count me out for the mud wrestling.

Are You My Patient?

I'm actually blogging (or starting to blog) from our hotel room at the beach, waiting for the kid to wake up so we can check out and catch some final rays and junk food. It's our traditional weekend-after-Labor-Day away with the Camel Family, a final sweet kiss goodbye to summer. With many thanks to ClinkShrink for moving in with Max and the teenager who couldn't miss practice.

So Fat Doctor has up a great (aren't they all?) post about patients who check in to the hospital with abdominal pain and then refuse either the work up or the necessary intervention. There's the guy with acute appendicitis who won't allow surgery ....and if that hot appendix ruptures, the mortality rates are quite high, even I remember that. I read it and wondered, just like Fat Doctor, if you don't want treatment, why go to a hospital? Okay, okay, I'm being harsh, maybe AppyGuy is only refusing surgery and had hoped there was another option for treatment-- maybe he's taking antibiotics and this will help and maybe he won't rupture and will get better. But to refuse a non-invasive work-up? Or to die rather than have a routine procedure?

So here's another good thing about being a psychiatrist: patients rarely die (and even more rarely from their psychiatric disorders) and we Never send patients out thinking there's is the Probability they will die from their psychiatric symptoms. I'm not saying we always get it right...sometimes patients hide their symptoms, sometimes they talk about being suicidal so often that we lose the ability to distinguish when it becomes imminent, but if we think the patient is in danger from their symptoms, we hospitalize them, either voluntarily or involuntarily.

I work in a private practice and in two clinics; I haven't set foot in an Emergency Room for years. It's been a really long time since I've hospitalized anyone involuntarily and I'm happy about this. While in psychiatry, there are moments when it's absolutely necessary, for the most part, I don't like making decisions for other people.

In outpatient practice, people often have very strong opinions about what kind of treatment they want when they walk through the door. It's not uncommon for me to tell people on the phone before I see them that I don't provide the treatment they're looking for and they'd be better served by someone else (--there are lots of psychiatrists in Baltimore, if someone is looking for a doc to prescribe high-dose Xanax, I'm just not it). Other people are pretty set on what kind of treatment they don't want.

Mostly, I try to work with people, I try to give them what they want or help them understand why what they want isn't the right thing to want. So Prozac helped your friend and you'd like to try that? I might think Lexapro is a better choice, and I'll tell them why, and if they still want Prozac, well, perhaps I let that choice be theirs. So Prozac helped your friend and you'd like to try that? Oh, but you have Bipolar Disorder, something totally different than your friend has, and Prozac may well destabilize you, throw you into a dangerous manic episode, shorten your cycle length, and worsen your overall prognosis: I think we should try a mood stabilizer first and only after that's on board should we even think about adding Prozac or any other antidepressant. You get the idea. And yes, I'll tell you why I asked what your favorite SSRI is soon, but in the meantime, if you haven't voted on our sidebar poll, please do.

Sometimes a patient tells me they won't take Drug X. Ever. And if I think Drug X offers the best chance of relief or recovery, I persist in telling them this. My kids can assure you that I'm very good at repeating myself to the point of nagging. Mostly, I convince people to at least try what I think might work best, but I have never, ever, said to a patient, "If you won't take Drug X, I won't treat you." That's just not what this is about.

Thinking about the Fat Doctor dilemma, there is a psychiatric correlate. Mostly I'm either able to talk patients into trying it my way, or I'm able to achieve some level of comfort while they do it their way. Every now and then I have a patient who is really suffering (or is behaving in a way that causes others to suffer) and who repeatedly foils any shot at recovery. They're miserable, and yet they refuse any treatment suggestions--either they argue with every suggestion I make, or they simply don't do it. The don't get blood levels, they won't try another medication, they won't raise the dose of the old medication or even take the old medication that worked for them the last 14 times, they won't try any behavioral changes (regular sleep hours, exercise, stop the substances, give up the boyfriend who beats you), they won't allow me to communicate with crucial significant others in their lives, they call all the shots, leave me standing there feeling helpless. And before you click on the comment button to tell us about the one or two times you didn't do what your doc suggested, that's not what I'm talking about-- I'm talking about the person who comes, pays, says they want help, but doesn't follow ANY recommendations. I'm sometimes left to point out this dynamic and say "Are you my patient?"

Feelings and Stuff

First, I want to share my feelings of the moment with you:

Sad: That Fat Doctor has closed her blog. I actually discuss her life with my husband as though she's a friend or family member.

Annoyed: That an insurance company can't process the claims for one of my patients until I fax them a copy of my medical license. No insurance company has ever wanted this before, Why exactly are they the only one that can't process claims without it. Not quite true: a few weeks ago, an insurance company mailed me a Letter to my office: they couldn't process claims without my address (!--where did they think they were mailing the letter?), a copy of my Tax ID number-- I don't believe I've ever had such a document-- and my license, however I believe this is the same insurance company that called today. How many hoops can they insist I jump through. Okay, okay, I faxed it, time to move on.

Tired: Long day of being mom and doc and still more to do. Currently, I'm procrastinating.

Stuff
Thank you all for your votes and comments on the first chapter of Double Billing. It's still not too late to vote, I was hoping for 50 million responses and so far have gotten....ummm a little over 50.

Did you want the story of that chapter? When I wrote the book, I liked the first chapter a lot. I showed the book to an agent who said "No thanks," and I got a bit paralyzed. I decided to take a grad school course in the hopes of learning something about fiction writing and getting some constructive feedback. I had to apply to grad school, got accepted, took the course, got a huge amount out of it, reworked the beginning of the novel, and incorporated a bunch of the instructor's ideas, one of which was to have the intro chapter look like it was in third person but then have the narrator introduce herself into the story in this way that some of you described as "jarring." I liked it, he liked it. What's wrong with Jarring, anyway? If someone walks into a restaurant to unexpectedly find an identical twin, it might be, well, jarring. But okay, like it, don't like it, let me think about the commas, I am so fond of them.

So now I put up the original version of Chapter One on a new blog, Double Billing: The Interactive Novel. I'd love your vote. So far it's 6 unopposed votes for the original chapter.

As soon as I can get some traffic there, I'm going to stop hogging Shrink Rap for this (though I will post when the other blog is updated), and I'm going to put up the novel chapter by chapter for as long as anyone can stand it.

And ClinkShrink, thanks for your repeated concern, but I'm happy to have the feedback and my feelings just don't get hurt over this stuff. Carrie, that's for you, too!