Thursday, March 27, 2014


Sometimes, as a physician first, and a psychiatrist, now, I see some one, a friend of a friend, a family member of a friend, the patient of a colleague, and the person doesn’t return or I hear they were upset about me.
I worry and wish I could have ‘acted’ differently, ‘been better’, ‘reassessed the situation’, shown "more sensitivity’.  Other times I think why did I disrupt my schedule, work late, miss lunch, allow someone to jump the queue only to be treated like this by an ‘ingrate’.  It fluctuates depending on mood and hours of lost sleep, missed lunches.
I’m older now and still ‘worry’ as much, but accept more.
What I notice though is that there’s something ‘missing’.  More often the person who was ‘depressed’ and ‘suicidal’ and really in ‘need’ was doing something specifically they were not telling their family, friends or doctor about.  Then I realize that they were upset with me most likely ,probably, because I was doing my job and doing my job very well.
I have patients come in with a ‘rehearsed’ ’spiel’.  This ‘story’ that they tell others doesn’t ‘ring’ true to me so I ask specific questions, like doctors do, and this ‘derails’ this sort of patients ‘routine’. They’ve got their ‘poor me’ down pat and want me and everyone else to ‘see’ things their way. They don’t want to ‘learn’ what I’ve got to say or ‘hear my opinion’. They principally want me to rubber stamp their bullshit.
But their friends and family don’t know a critical detail.
One of the most common is ‘drugs or alcohol.’  One man remains furious at me a decade later. I know his friend who referred him to me. The man drinks 80 oz of vodka a day and called me a quack when I told him that alcohol was a chemical depressant.  “I am sure I could treat your depression but you’d have to stop drinking’.  "You're nothing but a quack, I don't have a drinking problem".
A man saw me recently and he was smoking pot all day long and everyone was concerned he wasn’t motivated.  No one had a clue as to just how much pot he was smoking and how much money this was costing.
My gambler wasn’t telling anyone about his losses.  If I owed those people what he owed I’d be depressed too.
There’s no ‘magic’ pill in medicine. If you are cutting your wrists and bleeding a good doctor is going to tell you to stop cutting your wrists, take away the knife, and bandage your wrist.
But today you can get a lawyer to sue me for telling you to stop cutting your wrists claiming I didn’t ‘respect your rights’. Further a human rights commission will insist that my first obligation was to refer you to a doctor who does euthanasia.  Already the millionaire abortionists insist we pimp for them so it’s only days before the euthanasia folk will have their own financial future legislated such that suicidals are given their  ‘choice’.  No one considers the conflict of interest that a State Health Insurance creates.  
Further, you can complain to the College of Physicians and Surgeons that I wouldn’t cut your wrists for you. The poor College of Physicians and Surgeons will be obliged to berate the doctor who took an oath to do no harm.
The other thing people don’t tell people about is their illicit sexual lives. Even as a gp I was seen usually only once for treatment of gonorrhoea or certain types of bugs or warts best not discussed in ‘polite’ society.  After I’d successfully treated a person they would go to another doctor so their ‘file’ was not ‘tainted’ by their nights of forgetting their marriage.  Increasingly the insurance companies and courts are destroying medical 'records' and increasing the costs of health care exponentially because patients will go to extremes including multiple doctoring to conceal their 'dirty secrets'.
The common theme is that when people   say the ‘doctor wasn’t that good’ or ‘they didn’t like the doctor’ it may not be so 'simple'.   No one tells their mother or father, husband or wife, I didn’t like the doctor because he told me stop doing crack cocaine.  They don’t even tell their family physicians often.
A week doesn’t go by that a family physician doesn’t learn something critical about their patient after they’ve been sent to a good psychiatrist, when I say good I mean thorough conscientious or maybe just plain 'curious' about their patients.   Hundreds of times I’ve been told by collieaques, “I never knew”.
Yes, I can learn to be more ‘diplomatic’. I can learn to ‘speak more softly’. I can learn to go quicker or slower or be less intrusive or wait longer.  Yet, I’m paid for by my time and addicts especially want to do their whole ‘routine’ on you. There are people these days who want to talk to the doctor for years before telling them what the real problem is.  They want to ‘work’ you like they have ‘worked’ their family and friends. They want to do their ‘sales pitch’ on a professional.  What they don't want me to do is weigh them if they're obese, ask for a release of their records from the hospital if they're a hustler, or ask them 'has anyone questioned your drinking or drugging' rather than asking them 'how much' so they can lie by saying 'only two drinks' .
The sociopaths are even better. The fact that most people don’t know that their friend or a family member is a sociopath isn’t surprising. They chameleon. These are most often the girlfriend or boyfriend who comes along on a visit. The ‘loved’ one thinks the person is there for ‘support’ and doesn’t know that they’re a ‘hostage’ and that the ‘loved’ one wants to be there to ‘control’ them more.
There is innocence.
There is purity.
There is truth.
 There is ‘good intentions’  But where there is disease there are commonly ‘secrets’.  We are as ‘sick as our secrets’.  I learned that harsh one in physical medicine when people would come in late in the course of disease of cancer and ‘share’ ‘too late’ that they’ve had this ‘lump’ in a breast or a gonad or a pelvis or an anus and it’s hurting too much. When I’d examine the lump I’d know it had been growing for months sometimes years but the person, ashamed, usually didn’t want to tell anyone. Often it was too late.  
There is so much people don’t tell their family, friends, and colleagues. They tell their doctor and often their way of returning to the safety of silence and to the illusion of lies is to simply say “I didn’t like the doctor’.  Then they go looking for another one hoping for better 'news'.
When patients tell me they didn’t “like" a doctor 90% of the time I learn by careful concerned questioning what exactly the doctor ‘said’ or ‘did’ that disturbed the person. This is true even when it’s said about a doctor I personally think is an ass.   10 % of the time the complaint is true. The doctor was an idiot but mostly it’s because they focussed the patient on something they didn’t want to address.
The search for second opinions is commonly a search by a person for a doctor who will support them cutting their wrists while accepting the duty to bandage.  Life was a lot easier and lucrative for doctor swhen they didn’t practice ‘prevention’ and we knew less about the fact that most diseases, especially any of the chronic ones, are ‘lifestyle diseases’.
Working now in addiction I most commonly face someone who wants to convince me that anything from heroin to marijuana to obsession with pornography isn’t the problem. Mostly sons want to tell me their mother is the problem, husbands that their wives are the problems and everyone that its ‘stress’ from the boss or work.  Just ‘stress, Right?  Everyone wants the problem out there, not in here.
It’s so hard to be an artist, a physician, a school teacher. “I just need a pill, doctor.”  " I really need medical marijuania to take the edge off the crack hangover.”
A lot of people don’t want to hear the truth.  As a physician I’ve enraged, thoroughly enraged, elephant women in my practice, by stating frankly ‘you’re obese’.  Mostly though these days it's the marijuana addicts who want their 4 joints a day but also want happiness and motivation to get a job. So many of the single children in their 30's and 40's who see me don't want to leave the tit and are angry that the parent won't pay for their increasing expenses.
People want to have ’symptom relief’ and yet if we ignore the ‘disease’ and just treat the symptoms we’re not good doctors. The smokers want ‘ventolin’ inhalers to breath better, the alcoholics want valium for hang overs and percocets for headaches.  The list is endless.
I am such an amazing clinician that I could be the physician to the emperor and live making the emperors life of debauchery comfortable but the insurance companies would be furious with me and the College of Physicians and Surgeons might yank my licence. Like Michael Jackon’s doctor I could get sued or lose my license. The most demanding and critical of my patients never have the millions it would take for me to do ‘celebrity’ practice medicine for them alone. Increasingly everyone is angry with me because I won't order an MRI and a complete 'battery of tests' for any truly minor concern.  Hypochondriasis is truly common and thanks to Dr. House everyone cold is now a rare disease that stupid doctors are missing. None of my patients do statistics.  But who am I to judge, the moment I get a fever, I'm calling the morgue. The only difference is I don't want to have 'unnecessary' tests done because I know that 'unnecessary' tests almost invariably lead to more 'unnecessary tests' and even more 'unnecessary procedures'.
I loved the doctor who told me that rubbing my eyes after picking my nose was causing my recurrent conjunctivitis.  I was a university student studying all night and had several episodes of conjunctivitis. I’d seen several doctors before that. Personally I lost respect for them when the real Dr. House in my personal life truly solved my real problem.  There was no more return business. I’ve not had conjunctivitis since.  I still pick my nose but I don’t rub my eyes after I do.
Now I go to work and do the best I can and tell people what my teachers taught me and say the truth as nicely as I can knowing nothing angers and upsets people more than the truth.
I didn’t like talking about my nose picking with that doctor who had the smarts to ask.  I certainly didn’t tell anyone I had red eyes from nose picking. For maximal sympathy I told everyone it was because I was studying all night.  Some things you only share with your doctor.

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