cutting a line

My brother is a Surveyor. As in cutting lines through the backwoods of VA. No hacking through jungles. No, rather he has a desk job, now. And not Upton Sinclair, though he reads Upton, I'm sure. (most surveyors, don't, FYI, but he is smart). But sometimes he cuts the line. I think that's what they call it, when you go out and hack through the Kudzu, et al. You cut the line.

Sometimes I think I'm supposed to cut the line.




    

No Exit Strategy

Dear Pristiq,

I know I shouldn’t blame you that your parents must have named you due to extraordinary proximity or ana-mana-pia to the word prestige.

I get it.

Pharmaceutical company birthed you in some effort to compete with the Wyeth family's Effexor XR. I suppose somebody got paid boo-koo bucks to spin your Robin hood like effort as reversing the stigma of depression. As in not merely helping but even going so far as to impart prestige in a world of mental health stigma. As in one might have prestige being on this drug. As in, look what we’re doing to help the depressed and anxious of the world—altruistic company that we obviously are.

Doing your part, little cash baby—only one hundred fifty dollars a month coming out of that small disability paycheck. 

I shouldn't blame you, that there is no exit strategy. That you only come in unbreakable, extended release tablets with your 11 hour half-life. Ready to ensure yo-yo symptoms in those who try to crawl out of your web with every other day dosing strategies.

There is no exit strategy.

But that’s not your fault. You’re just an enteric-coated baby released from the Pfizer mother-ship. I shouldn’t be angry that there is no smaller pill—no dosage available less than the 50 milligram suicidality inducing therapeutic dosage. I shouldn’t blame you that your mother tells us that we must taper the dosage to avoid withdrawal—I’m sorry, discontinuation syndrome side effects, when there is nothing smaller to taper to. No smaller pill has even been a twinkle in the mother-ship's eye. And then when the withdrawal effects manifest, pompous arguments can be made about depression relapse. When suicidal thoughts appear, fear motivation can be harnessed for further entrapment campaigns.

No. I shouldn’t blame you. You’re just the greed-powered-wind-up-doll-drug mechanically going through the motions, screwing patients on cue.    

most insincerely,

a physician

thanks Denny

Everyone needs a Denny. Some character, perhaps a little rough around the edges that introduces you to the idea that, sometimes, Typhoid only disappears with the disappearance of the sewer. Some character that helps you see the reality of small towns laden with bureaucratic, red tape. Some character that tells the truth—raw and painful though it may be to hear that your new employer isn’t actually going to be able to teach you much from his deathbed. Some character that tells you how things are actually done in the real world.

Especially in medicine, everyone needs a Denny.

Sometimes that Denny role turns out to be played by a different actor than the one you thought you cast. You know—the mentor who seems polar opposite? It turns out that therein lies the balance for your stage play where other characters foil you and end up teaching you something, precisely, because they aren't like you at all.

Everyone needs a Citadel. A shelter or stronghold to which one goes during battle. A place from whence you retrieve your soul stored under a big rock.

Sometimes that Citadel is an old novel from the 1930’s, written about some green doc establishing a medical practice in a coal mining town across the sea. A far away tale of medicine travelling your own soul back to you. An old tale curiously parallel and strangely relevant to your own little world.

on writing as physician

Somehow, writing takes on an almost hazardous tone, in the role of physician. HIPAA protects patient confidentiality even down to the seemingly mundane details. Are you scheduled for Wednesday or Thursday? Protected. Are you my patient? Protected. What are you being treated for? Protected. Etc. Sure the goal is to minimize the information leakage. And in the day to day running of a medical practice, you might see Joe Blog’s name on the sign-in sheet above yours because you arrived 30 seconds after him. Some of these security breaches are unavoidable. The point of HIPAA is to minimize them to the extent reasonably possible.

Guarding the sacred space of doctor-patient relationship, HIPAA cozies up, seeking to embody trust. Of course, trust isn’t something easily embodied, especially when it comes to mental health. And of course, HIPAA regulates only one side of the relationship—the physician’s side. It is a somewhat one-sided venture, since as patient, you can share whatever the hell you want about your health with whomever you choose. It’s your business, after all. The spirit of the law is to essentially regulate trust. Of course, information has to be shared sometimes, for insurance purposes, or to foster high quality care, and in a general way it can be shared for educational purposes, as long as it is divorced from any identifiers, with relevant details changed.

But following the spirit of HIPAA is easier said than done. Sometimes it feels paralyzing from the Physician side of things. A significant part of one’s life, one’s being, the core and soul of what one does every day, always needs to be sifted through a HIPAA sieve of perpetual censorship.  In constant flux, one vacillates, share this, not that.

Complicated by people’s perceptions, falsehood or truth matters not. As patient, you know not that one in four people has a mental illness. You know not that depression is the “common cold” of mental illness. You know not how many people have suicidal thoughts or intense anxiety. You know not that everybody bleeds this way, just the same. To you, these are the intimate details of your story—not humanity’s. And this is how, even amidst mutant sifted details on a blog, you might see yourself in the story. In the composite, with the humanity peering out through the words. Hey that’s me you are talking about. And therein trust gets snuffed out. The sacred space darkens, as it warps and twists into something a bit different.

Even if HIPAA hasn’t been thwarted at all, the fact that you think it might have been, undermines one of the most critical elements of the doctor-patient relationship. Next time, you might struggle to tell what needs telling. Because of a perception—a false one at that. Something uttered might snake its way into the ether regions of your story. Your experience of life. The words said might be lifted from context, or might be misunderstood as some personal message. Across my desk, this thought is sometimes both frightening and inspiring.

I’d love to write more directly about my healed patients. How they don’t really recognize themselves anymore. How so much of the old has slid away. How we’ve avoided mood episodes of deep darkness. Or just how life feels so different gliding through it with a homeopathic Gortex suit. I’d love to emote for hours on just how beautiful a person can be when healing via Tuberculinum,

Stramonium 

Natrum Mur

Belladonna  

Sulphur  

Sepia    

Ignatia  

Carcinosinum  

Thuja 

Staphysagria 

and Nux Vomica.  These remedies and many others, foster an almost nostalgic feel in the prescribing physician. They are like old friends as Margaret Tyler used to refer to them. Even their names roll off the tongue and hang in the air, like the art that they make out of life. I suspect with my going on about remedies, I've waded away from the point. Which is simply that these miracles aren't exactly my stories to tell. Sure, I can tell unidentified snippets and fragments. Sure, I can tell pieces while ever conscious of my pet snake, HIPAA. And truth is, you probably won't believe me, anyhow, dear reader. For the stories almost sound made up. Hyperbolic. Ridiculously exaggerated. As Tim O'Brien once wrote, Fiction is often more honest than the truth, and the truth often rings false--something to that affect.  

In this case, the facts seem false. Such as the fact that somehow Patient C can’t remember the time when she didn’t have Problem X. All my life, she says in the intake. And there it is gone. Almost insulting. Can she really have had that symptom gone away in a few months with a few sugar pellets under tongue? I don’t think so. Can he really be feeling that much better? You must be exaggerating, Jenn.

Except that I try quite hard not to exaggerate. To be accurate. To understate. I lean so hard into that wind of transparency and attempted honesty that sometimes I think I might fall over. One of my mentors says I’m too honest.

And this puts things in a quandary when it comes to writing, in this role, as I see it. The intersection of HIPAA, transparency, and trust unfolds. I am left to struggle with the balance: how to reach toward the catharsis of writing. How to share the powerfully inspiring stories that remind me of the joys of being a physician, yet protect the sacred space of doctor patient relationship. Above all, I struggle in holding the sacred trust tightly enough so as to not drop it, yet loosely enough so that it doesn’t wrap around and strangle the very relationship it is supposed to protect. Easier said than done.

ode to ignatia

Ignatia amara is the name of a homeopathic remedy often given to those that grieve. I wrote this piece a while back as a student… My apologies to those that have read this before.

Oh healer of closet weeping,
bulging doors
holding at bay suppressed avalanches
issuing forth
at inopportune moments
burying recipients in old sorrows.

Shaking trees of endless anguish,
rooted deep in the dry, crystallized earth
shattering time forever.

Oh Sire of desired loneliness,
choking back pain
pretending ease of speech
while bearing apple-sized lumps in throat.

Cloaker of sadness heavy and long,
Oh that You should be needless
disappointment ailing none
death
mere figment in the minds of men.

miles

It was the middle name that he dutifully carried like a good son for 22 years. Not an easy task when the namesake you bear lived life as mythical character, as in Herculean sized standards. Named for Dad's mentor--a bald, little spitfire of a guy wielding Bible verses on street corners, holding a small college together by the seams, inspiring many even into his 80th year. The shoes were definitely big.

We needed for him to be epic. To back up the carrying on of the family name after a decidedly long line of X chromosomes. The even longer line of five older siblings claiming niches in life complicated matters for my brother. He needed to be epic and distinct. We needed a knight.

Did our needs and expectations somehow contribute to the creation of the epic adventures? To the creation of this Bipolar Disease as foe? No. But sometimes my mind wanders there. To the place where guilt and shame and blame throttle you and wrestle you to the ground.

In particular, I wonder sometimes at how mania made him larger than life. How the mania granted the opportunity to be epic. Grandiose. O Fortuna. It was the mania that birthed the Knight, or the Phantom of the Opera, or the Prophet, or Jason Bourne and his identity crisis. It was the mania that made him invisible as he danced around the block on the run from the government conspiracy.

The Knight.

I'm not sure he ever knew that the Latin word for Knight is Miles.

And he'll never know that my medical practice names him as it treats mental health patients.

Miles.

His namesake. Favored piece on the chess board, L mover, plunderer of Queens and Kings alike. Good at chess, because he knew how to use the knight to such advantage. And because he studied to the point of obsession.

Miles. Suggestive of a journey. Travels. Epic. Knight. Brother.

What's in a name?

A memory. History. The boy that never ages finally reaching knighthood.

how the story goes

I spend a lot of time hearing stories. Leaning back in my chair, I listen for clues of emotive content steeping beneath the surface--the song beneath the song. Waiting for the pieces that make sense of it all. The pieces that tie all the lines on the face together, wrinkling seamlessly into one another. The pieces that make my patient’s choice seem, the most logical thing of all to do. The point in the story, where I think I might have done the same thing, responded in some similar way, that place where I’m caught up in the moment of the story and thoughts of what-to-have-for-dinner, or if-I’ll-make-it-to-the-bank-before-closing, recede into the background. The place where I stop having to say, tell me more about that, because the story spills out like the yolk of an egg, my patient and I seemingly second string teammates on the sideline, watching the game. Almost as if the story breathing a life of its own, flows like current toward the falls.

This is the place, I intuitively struggle towards. The place where all the psychologists say good blending occurs and one manages to catch understanding. For me the moment is about finding the features that fit an appropriate homeopathic medicine.

But I’d be amiss to say that the moment is only about finding the most appropriate medicine. In many ways, the moment is part of the medicine.

Telling your story is powerful.

Most of my patients tell me so and mental health literature bears this idea out. Many of them tell me, I've never told anyone this... Much of the time, they feel better just telling the story out loud. If the story is particularly dark or messy, the telling of it seems to be even more valuable.

Indeed, telling your story is powerful.

A good friend of mine recently wrote on her blog about the act of writing, itself. Wondering aloud on the feed, she asked,  why do I  write, anyway? Not ready to quit her day job, and not really wanting to she blogs her own unique story. She doesn't think she's all that good at writing. Incidentally, she is--but that isn't why her story is so powerful. I think her story is powerful precisely because she writes to sort out the messiness of life on the page. To process honestly, sometimes painfully, the details of a struggling daughter or an elderly, Alzheimer toting adult with erased memories.    

James Pennebaker wrote a book entitled, Opening Up: the Healing Power of Confiding in Others. In it he discusses research demonstrating that talking about your problems—or not talking about them as the case may be—can have profound effects on your physical health. That’s right—physical health. According to Pennebaker, talking, even writing about our problems, our struggles, our traumas heals us.  And conversely, not talking about our junk harms—not merely psychologically—but physically. Of course, we know it's all connected, anyway. Chronic inhibition and suppression of our emotions and feelings, in particular anger, leads to increased risk of all sorts of physical diseases—heart attacks, hypertension, cardiovascular problems, asthma, diabetes, and cancer.  

For some of us, letting go and telling our story is more difficult. Parading our shadowy sides scares us. Climbing into the boat and letting the current take us places, makes us feel vulnerable. What if my friends think I’m complaining? What if I’m labeled “whiny?” What if they think I have a mental illness? What if my children don’t like who I really am?

And so we bind ourselves up. Thinking somehow, that we are protecting ourselves from the inevitable isolation of rejection. Telling ourselves that it’s the good, Christian thing to do. Telling ourselves we’re becoming better people by hiding our struggles, our griefs, the badness of our story wrought with flaws.

The truth is we do manage to protect ourselves. We do manage to cut ourselves off from venues of possible rejection. We do manage to protect ourselves from something that might get out of control--something that might take on a life of its own--sticky, messy, and difficult. In not sharing our story, we effectively cut ourselves off from the larger communal story, with its unique power to transform and shape our own story into something more. And that's how the story goes.