Can I Have a Word With You?

A while back, one of our commenters took issue with the fact that I referred to a patient's complaint. It got me thinking about the way doctors word things, sometimes in ways that may sound pejorative.

So the standard format of medical notes opens with the "Chief Complaint." If the patient comes in saying things are great, the medical note begins, "patient has no complaints." Often the patient's exact words are quoted. To a physician, this isn't whining, it doesn't have a pejorative edge. The patient's problem is what we are taught to focus on, though a complete medical evaluation includes a review of systems (that's the term) where patients are asked, in a systematic way, about symptoms that may be indicative of a health problem apart from those pertaining to the chief complaint.

In describing patient symptoms, doctors also will sometimes use the statement "patient denies" symptoms. It's sometimes felt that this implies the physician doesn't believe the patient-- patient denies hallucinations is a different statement than no hallucinations.

And then, of course, there are the subtleties of sorting out how people interpret our rather unusual questions in psychiatry. We ask if people hear voices, and when I started doing this I was surprised at how many people say Yes. I soon realized that it's not at all unusual for people to occasionally hear the voice of a dead relative calling their name--- this is, I believe, a cultural phenomena, and in the absence of other voices or symptoms of psychosis, it's not necessarily a psychiatric symptom or a marker of psychopathology. And we ask people if they ever have the sense that the TV is talking to directly to them-- a symptom we call Ideas of Reference from the media. People sometimes think I'm asking if something said on TV feels like something they can identify with strongly, which is a different phenomena (one that's not a psychiatric symptom) when what I literally mean is--- is someone on the TV speaking specifically and only to you? And assessing paranoia in a city with a mind-boggling crime rate is a task of it's own. The questions have to get pretty specific, and if you're not a little worried, well, that's a little odd.

Should Doctors Scold?

Okay, first I was scrolling through KevinMD's blog, and this caught my attention:
In Whoa! an Er Doc talks about psychiatric, pain, and obese patients in his ER. Regarding the obese patient in the ER, he writes:

However, many, many people are obese because they simply eat too much unhealthy food and do not exercise enough. Many of these people live in subcultures within America where obesity is not only tolerated (mostly in women), but is praised, despite the well known health hazards. Obese patients are treated with respect in my ER - however, if they are disrespectful to the staff, demanding, and make a nuisance in my shop, they will get rebuked,just like any one else. Additionally, just like with smoking, I feel it is a doctor’s duty to reprimand patients for unhealthy behaviour - and this includes unhealthy eating and subsequent obesity.

I'll refrain from rambling about people who blame overweight folks for their condition. Another post, another day. What grabbed my attention was this doctor's use of the word Reprimand. It's not just that he reprimands, oh my gosh, no, he feels a duty to reprimand. I think I missed that part of medical school.

Perhaps it's just the harsh terminology. He's talking about behaviors here: over-eating, under-exercising, smoking. Can I add drinking alcohol and using illicit drugs to the list? I do, however, sometimes feel a need to remind people that smoking is bad for your health (it seems to be one of the few behavioral issues we're fairly certain of) and it may well be that using illicit drugs makes it harder to stabilize one's mood. So far, very few people have changed their behavior simply because I've suggested it would be healthier. And fortunately, so far, very few people have left treatment when I've repeatedly suggested they change their behavior. Sometimes I add that if they don't do so, I may be limited in my ability to help them.

I do feel kind of obligated to state the obvious from time to time. I don't think I scold, and sometimes I wonder if I was firmer, more insistent, or more threatening, might I be more successful in getting people to change their behavior? The fact is, I don't have that in me, I don't really believe it would make a difference in anyone's motivation to give up their addictions, and I believe a physician's role is to treat illness and be compassionate, not to reprimand.

ClinkShrink, of course, just puts them in Lock Down.

Please Don't Eat Me

The usual discussion revolves around whether those who seek treatment for mental disorders should be called "patients" or "clients."

So Roy and I were at a legislative mental health meeting and one of the people giving testimony kept referring to psychiatric patients as "consumers." Consumers? Okay, it's not the first time I've heard the term, but here it was used over and over (and over) again. Consumers. I suppose I think of myself as a psychiatrist who treats patients, and not as a 'provider' to 'consumers.' This meeting took place around the same time that one of our readers commented it was insulting when I referred to a patient with recent and repeated episodes of dangerous behavior as a "time bomb" after she stopped her medications precipitously. I was thinking about the power of language, the innuendo of words and phrases, and I was struck by the repeated reference to Consumers.

It brings to mind, for me, this odd anxiety that my patients will eat me alive. Doesn't one consume food or fuel? Does one consume psychiatric services? What exactly does one consume during a psychotherapy session? What's there at the beginning that's gone by the end?

Can someone please tell me why anyone would want to be a consumer rather than simply a patient? Please don't pass the ketchup....

Oh, and my graphic of the person eating lobster is in honor of Roy's vacation posts from Maine. Please, please, do consume one for me.

Eat, Pray, Love: One woman's quest to find herself

 Elizabeth Gilbert is a novelist.  In her non-fiction real life, she had a bad spell: a contentious, ugly divorce, an overly needy relationship with a distant rebound lover, a bout of depression.  She goes on a journey to heal, to find herself-- a pre-planned, publisher-financed 4 months of pasta and language classes in Italy, 4 months of meditation at an ashram in India, 4 months with a medicine man in Bali.  It's kind of everyone's fantasy, no?  Okay, parts of it are kind of my fantasy.  Parts of it.

When I read a book, or listen to a lecture, or turn on the TV, grab my popcorn at a movie, I'm looking for something.  Sometimes, I simply want to be entertained (a worthy goal in and of itself).  Sometimes, I want to learn something that will change how I see the world, or how I relate in some small way.  Sometimes, I'm looking for something that resonates, that I can relate to, that holds true.  A great plot will draw me in-- so nothing about 24 or The Sopranos or LOST feels anything like my life, but still, they draw me in.  

I started Eat, Pray, Love, and honestly, the author felt like a patient.  Her life is chaotic, her relationships packed with drama, she spends an awful lot of time sobbing on bathroom floors, and she makes no secret of her love-hate relationship with anti-depressants and what her therapist advises.  Her therapist and her Guru.  At first, I found it hard to relate to her, even though she was running away from her real life.  Does everyone else occasionally have this fantasy, even if real life isn't so bad?

I got to page 154, somewhere in India, and suddenly Elizabeth Gilbert became someone I could relate to.  Now people who don't know me very well sometimes think I'm laid back.  Anyone who does know me knows I'm a worrier, prone to obsessing about....anything and everything.    So Elizabeth Gilbert is talking about Sean, an Irish farmer she's met at the ashram and she's talking about Sean's "search for inner peace through Yoga."  He's home in Ireland, sitting with his serene dairy farmer father in front of the hearth, telling him about the wonders of his spiritual discoveries:  

      Da--this meditation stuff, it's crucial for teaching serenity.  It can really save your life.  It teaches you how to quiet your mind.

      His father turned to him and said kindly, "I have a quiet mind already, son," then resumed his gaze on the fire.

     Gilbert goes on to talk about people who don't have quiet minds, who are restless, and she includes herself in this group.

     The other day in prayer I said to God, "Look-- I understand that an unexamined life is not worth living, but do you think I could someday have an unexamined lunch?"

    In my last post on impulsive suicides, when I mentioned writing about this book, a few readers wrote in asking about the Amazon reviews-- one in particular calls her 'self-absorbed and irritating.'   Self-absorbed, self-indulgent, absolutely.  At some level, aren't most people self-absorbed?  I suppose it's a matter of degree-- since I listen to people's self-absorption all day, it doesn't particularly bother me, it's not a fatal flaw.  I wasn't irritated.  I suppose at some level, I just enjoyed the fantasy of it all.  The journey to self-discovery is, of course, and old and oft-told story.  Now please excuse me while I boil the pasta and recite my mantra for a while.

My Three Shrinks Podcast 45: Guest Ray DePaulo on Treatment Resistant Depression

[44] . . . [45] . . . [46] . . . [All]

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We are pleased AGAIN to have the head of Johns Hopkins Psychiatry, Dr. J. Raymond DePaulo, joining us here to talk this week about treatment resistant depression (TRD), bipolar disorder, favorite quotes, and words we don't like.

Dr. DePaulo joined us on the last podcast (#44) and talked about cosmetic psychopharmacology, among other things.

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April 13, 2008: #45 Guest Dr. Ray DePaulo on Treatment-Resistant Depression

Topics include:

• Treatment-Resistant Depression. How is it defined (~10:00 min into the podcast)? Is there a magic bullet? Treatment strategies (don't give up; remember lithium; use proven agents; get 2nd and 3rd opinions; do psychotherapy).
  
  
• Nellie, the Hypothetical Patient. Let her know what we know about treatment, and what we don't.
  
  
• "Alternative" Treatments. St. John's wort; SAMe (s-adenosylmethionine); omega-3 fatty acids; ketamine; vagal nerve stimulation (VNS); deep brain stimulation (DBS); psychosurgery (cingulotomy).
  
  
• Cognitive Therapy. Many different types.
  
  
• Words which are Unliked by the Podcasters. Alternative treatment. Mood stabilizer. Antidepressant. Antipsychotic. Hallucinogen. Psychosis. Neurosis. Organic. Schizophrenia. Nervous breakdown. Mood Swings.
  
  
• Quotations We Like.
  "There's only two types of music: good music and bad music." Fran Liebowitz
  "Eighty percent of success is showing up." Woody Allen
  "Expect more of yourself and less of others; you'll be disappointed less." Unknown
  "Life is unfair; the sooner you figure that out, the happier you will be." Unknown (Lilya said it in 2003 on a recovery forum)
  "A good clinician is someone who makes prudent decisions based on insufficient information." Ray DePaulo (I think)
  "Experience is what we call it when we were looking for something else." Federico Fellini
  "Good decisions are based on experience. Experience is based on bad decisions." probably Mark Twain
  "'Experience' is simply the name we give our mistakes." Oscar Wilde
  "Science is a process of conjecturing and refuting what is thought to be universal, therefore a theory can only be considered 'scientific' if it is falsifiable," paraphrasing Karl Popper.
  "It's a short step from the penthouse to the outhouse." Unknown (many found)
  "It's a short step from Who's Who to Who's He." Unknown
  "There ain't no such thing as a free lunch," or TANSTAAFL, by Robert A. Heinlein.
  "When Momma ain't happy, no one's happy." Apparently, an old southern saying.
  "For every aphorism, there is an opposite aphorism that's equally true." Unknown
  "Children can be happy when their parents are miserable. But a parent is never happier than her unhappiest child." Laura Lippman
  "Data is not knowledge, and knowledge is certainly not wisdom." Unknown
  
  
• Drugs in the Drinking Water. Brief mention of last month's AP story finding all sorts of pharmaceuticals in numerous municipal water supplies.
  
  
• Books we are reading.
  -Ray: "Saint Augustine", by Garry Wills.
  -Roy: "Valis", by Philip K. Dick. (Ben was reading it on "Lost".)
  -Clink: More listening to an opera about Carmen, a famous female sociopath.
  -Dinah: "How Doctors Think", by Jerome Groopman.
  
  

Dr. DePaulo's most recent book is Understanding Depression.

There are three audiences for this authoritative book: people who think they may be depressed, those whose condition has already been diagnosed and are in treatment, and those who are concerned about someone who is either in treatment or probably needs to be.

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Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.