Thursday, July 22, 2010

Thursday Morning Workday

I like Thursdays. I'm over the hump of Wednesday and on the downhill of the work week. Thursday night I have a men's meeting that's always a source of humor and inspiration. I look forward to seeing the guys and hearing how they've fared in the week. I like the camaraderie. We've gone through recovery together. It's a kind of flip side of the bond that military guys talk about. Some of the guys are military and describe the similarities. Here the war was with ourselves or the negative aspects of ourselves. Together we changed ourselves and our lives from the unhealthy to the healthy. We embraced the spiritual and found community. Each Thursday night we check in with each other and see how it's going. We're survivors who frankly are thriving in the new roles but still remember. Seeing the faces of friends keeps the faith alive.

I'm older too. And talking on Facebook with friends I like keeping in touch and hearing how they're managing. When I was a teen ager I wanted to know what choices my friends were making. Who was going to university. What job were they getting. It's that way again. It's always been like that in some ways but now the information seems so much more important.

Talking with a Transylvanian friend about motorcycles and her saying she sometimes feels possessed by her things. She's bought a new house and I'm thinking of an upgrade in vehicles. Perhaps she needs another hidey hole while I need another escape vehicle. But I know what she means. Things take care. Walden Pond by Thoreau always comes to mind. The simplicity. Maybe if I didn't have 'stuff' I could just travel some more. Become the wanderer again.

Bicycling across Europe began to be it's own 'work' after 3 months. I'm liking where I am now. Part of me wants to set out sailing again but I'm just as happy to putter at bringing the boat back to expedition standards. Pirates scare me. I don't want to kill someone. I suppose I don't want to get killed either but I seem more concerned about having to kill someone dropping from the skies to board my boat or coming up behind me in a fast tobacco boat. I read of these things now in Blue Water Cruising Association's Currents and Seven Seas magazines. Confrontations off Yemen. There was a kidnapping and killing off Nicaragua when I was cruising down that way still in Mexican waters. It bothered me then but now I think life is even more precious. Perhaps because there's less.

Then too Canadians are hated as readily as Americans. I didn't like being seen as 'easy money'. I didn't like the sullen anger I encountered in the poor any more than the drunken party stupidity I saw in the partying NorthAmerican and European set. There's something so sad about seeing a rich jet setter young American surfer kid drunk and stoned throwing around money in Cabot San Lucas while a Mexican family living in poverty works all day to meet subsistence needs. I see the same rich and poor in Vancouver but its not quite so in one's face. I was afraid in Morocco. I liked Hong Kong and Japan for the feeling of safety as a tourist. But overall I'm not as enamored by 'passing through' experience or 'fellow travelers' as I once was. It will come again. It's always just a matter of time. I'll take a vacation and be satisfied for a time with just that. Travels with Charley, may well wait till i'm retired. My friends are fishing and shrimping and I most envy them their time on the water, not having schedules. There are so many books I want to read and courses I want to take. Adventures internal call as much as adventures external.

Right now Gilbert is a going concern. He's so busy mouthing everything, chewing everything. It's 5 months and it's let up a whole lot but I'm told it's likely to go on till the end of this year at least. I like the way he wakes me up now. Jumps on the bed and comes over and licks my ear. He's telling me he wants to be let out to pee and it's a leisurely show. We can cuddle. He can wait for me to chuck him under the chin and scratch his back. And eventually I can let him out. There's no fear of him letting go on the bed. That's no way to wake up yet twice these last months that was the start of the day. Before that he'd scratch at the door and I'd rocket to let him out hoping I was in time. And before that he'd just happing piss and poop any old place so my bare feet could find it. I loved the puppy napkins that served as the earliest container and re director.

Thursday work day. It's always full. Lunches are forever lost to emergencies. An American College of Specialists did a study that showed that we were required to do 90 minutes of activities for every 15 minutes of an office visit even before the patient's complaint was clear. Further the Canadian Medical Protective Association has recommended because of the increasing limitations of judges and the changing laws of litigation that doctors record equal time for the time they're seeing patients. 5 minutes for the patient and 5 minutes for the potential judge. Administrative bodies have their own demands which are sometimes right out of left field or some bizarro comic strip that make sense in some board room but have absolutely no consideration of what goes on in the real world. Add to that the ever present ivory tower. The result is that I and every doctor I know, the finest and brightest, are complete and utter failures before they start their day. The patients aren't pleased because the politicians have taken all their money in taxes and promised them universal health care only to tell them that they'll have to pay for everything they want.

Daily now the patient is coming having read the internet story on their illness and expecting to get what the academic or vested interest says their condition deserves only to encounter a doctor who has been told by their College or by the Ministry that they have to 'ration' health care. "I know it says in that New England Journal of Medicine article that you should have an MRI and we should rule out lime disease and that it's possible that that the mosquito bite was the vector for your feeling tired today, however I don't think the "odds" justify a million dollar workup. Your blood test shows you're 'anemic' because you've not been careful with your vegetarian diet and that's sufficient reason for your being tired."

It's always a war. Those that are a million miles from the trenches write how they think saying no to somebody should go. Reading their papers and brochures and protocols you know only too well that you were where they were a decade or two ago some thousand patients before you really learned 'desperate' patients don't take kindly to 'no' and there's no guaranteed way to safely say 'no'. And the fact is that most people 'avoid' that equation. Passive aggressiveness is the cornerstone of these 'professionals'. Words like 'addiction', "suicidal", "borderline", "litigionous", "entitled", "angry", "demanding" get their files put at the bottom of any pile of politically correct doctors concerned most with themselves and not "universal" health care. Since you get paid as much to see a clean and rich one, in fact you get paid a whole lot more, there is no incentive to see the dirty and ugly ones. It's like dating and the cherry picking is ubiquitous now with no one wanting to take the risks that go with seeing the sickest people. Really sick people aren't at their best when they see the doctor and tend to be paranoid, touching, demanding and sometimes quite frankly dangerous. If you have to say 'no' be prepared to duck. So mostly these patient's are 'lied' to. It's a 'white lie' in that the doctor is afraid of their reaction so does anything but say 'no'. I say "no". It's my job. The buck stops at my door. It used to be I got a lot of support but these days there is none. One of my friends in the police told me he felt the same way. A judge in Canada said the same. The "cancer of nice" and the 'sugar coated" "maybe no", or 'a little no'.

The fact remains "no" offends people. Ironically people want all of me and threaten me with death or whatever to get all of me. The various agencies, not to mention the tax man have gnawed me to the bone even before I get out of bed. Apparently the HST task is sucking the blood out of everyone working now too. Soon there will be no incentive to go to work. "Beatniks are out to make it rich, must be the season of the rich." Mostly I hear of the underground economy. It's well over 50% in BC. Even 'awards' are made out in 'tax free' dollars. The dollar is nothing if it's not 'tax free'.

Easy to think like this. Some days I'd succomb. It's what I hear day in and day out in the office. All the dross of civilisation. All the negativity. Every day another wounded walking comes in the door and tells a tale of how the system or some supervisor or superior or spouse betrayed them and ruined them. It's usually the case that the person is telling the truth too. Broken promises galore. I listen and eventually I create a tiny 'resistance' of my own, suggest a different viewpoint, put forward that the police, or the boss, or the spouse, or the government or the aliens, or the Ku Klux Klan or the Black Panthers, Jews or Nazis, Moslems or Buddhist might have a different point of view. It's then that the mild manner woman or man who has been solely your friend and really understanding and frankly 'nice' turns on you and the dogs of hell are unleashed, they're screaming that you don't understand, you're just like them, you're a male chauvinistic pig, police love, establishment, priviledged, antisemetic, Indian lover, moslem hater, whitey......I can't remember the list of a hundred or more labels I've been called when I asked "Is it possible and suggested that the person might look at the 'event' only 1 or 2 degrees off from their own perspective'. This is a classic test of a patients capacity for "psychotherapy'. If the patient fails it they simply 'lack' the capacity of 'psychological mindedness' so therefore are not candidates for depth psychotherapy , the kind that psychiatrists are trained to do. If the person 'considers' that their may be an alternative viewpoint to theres they are sufficiently 'open minded' to engage into an investigation into how they might change to maximize their interpersonal experiences. Most people are 'paranoid' or 'arrogant' and simply are not amenable to true psychotherapy. They merely want 'allies' and 'advocates'. They really need a lawyer but mostly just want money and power and possibly a gun. They wear suits and because of the rapid changes in society can frequently get to high positions even in government bodies. They seek control because sadly they're not terribly in controll themselves. They are often "parental' in their interactions yet think they're being adult but lack that fine balance of creative child that comes with the expansion of personality and character.

I do a lot of consults. In the days of long term psychotherapy the analyst , getting paid $100 an hour for 5 days a week and expecting to see the patient for 3 years said "no' at about one year. That's when the analyst made an 'interpretation' that suggested that the patient needed to change. The Therapeutic alliance was established over that first year and supposedly would protect pateint and analyst from the frustration of the having to change. Frequently the patient said 'screw you' and the analyst had a year of income but failed the case. So Brief and Focal Psychoanalytic studies were done and found that therapy of a sort could be done in 10 to 20 sessions and this 'confrontation' should occur in the first 1 to 3 sessions with a view to identifying who would warrant this kind of 'depth' therapy. Depth psychotherapy is 'anxiety' provoking and most people want 'counselling' which is by nature non conforntational and 'agreeable' and 'educational' and doesn't change 'core belief's' and works best if 'advocacy' is warranted. It's also been likened to psychic massage. My patient wants to kill someone and this is not uncommon in my practice, they want to kill themselves or someone else and all that 'nice' therapy hasn't worked.

Now the patient doesn't want to take medications because they don't want to weaken their paranoid resolve to kill someone. So they want 'psychotherapy' but really they want advocacy.

I've noticed that colleagues rarely do this anymore. It's easier to prescribe an antipsychotic to everyone and assume they're paranoid. It works. It's safer. Mostly my patients have seen so many counsellors and psychologists and psychiatrists and we try to do what hasn't been tried. So I frequently suggest the 'cops" or "judge' or 'wife' or 'ex husband' might have been right. That's what makes my practice so dangerous. Ironically it's also what gets me the great successes. Whether they're 'burnt out' with all the 'love' and 'niceness' or they're just tired of hating, more often than not a person at that moment show a 'crack' in the character armour and we can beginn really life changing therapy. I'm still exhilerated to hear of the patients getting back to work, getting married, having kids, writing poetry, taking a trip home or whatever it is that was utterly impossible before.

Their eyes clear. The light that had gone out comes back on. They've done the work of psychotherapy and made real progress. They've given up addiction and let go of the thanatos. They've moved out of the dark side to the light. They're building again and no longer tearing down.

Thursdays I can see the light of the weekend where rest is waiting and the work of psychiatry seems worth it. I'm glad to see the patients and look forward myself to getting together with the guys. Often I get through to my dad and talking to him in his 90's makes going on seem even more worth it. I like those who've gone before me. I've got a few older psychiatrist colleagues, really giants of the mind and soul. Often I call them on Thursdays or email them and it's possible to get through the week. There's hope on Thursday.

Time to get Gilbert ready to ride on the back of the motorcycle.

- Posted using BlogPress from my iPhone

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