As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician.  I’ve also written in prior posts about my concerns with modern psychiatry.  I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor.  At the very least, such an understanding takes time.  It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias.  Finally, it takes a certain amount of intelligence.  Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.

I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly.  I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.

On the other hand, if one has the time to sit and share small talk, then review the important issues occuring in a person’s life, and then discuss the problematic symptoms that the patient is experiencing…. then ask questions that provide context for the symptoms, and perhaps make a small suggestion or two in order to provide outside insight into the cause of the symptoms…then present the different medications sometimes used for the person’s symptoms, after first discussing whether the person would prefer medication over working on the problem through more ‘mindful’ approaches… then discuss the different side effects possible with each medication, and the likelihood that the medication chosen would be helpful…

If one does all of these things, psychiatry can actualy lead to profound improvement in a person’s symptoms.

I thought about this situation recently, after paying over $500– my deductible– to repair my car, after hitting a deer.  The cost had to be paid, and I found the money and paid it.  I’m not a ‘rich doctor’ for reasons that I’ve discussed elsewhere, so the expense was significant– but I need a car, and it had to be paid.  Likewise, I had to come up with $3000 to repair my septic tank this spring, since the alternative– having disgusting liquid bubble out of my lawn– was not an option.  I had to pay my speeding ticket– I’m trying to slow down now, by the way– and I had to pay for my own health problems.

If I need surgery, the cost will likely run in the tens of thousands of dollars.  Heck, having a couple warts removed ten years ago cost $400, and the doc was in the room for about 5 minutes.  My auto repair bill, paid graciously by my insurer, amounted to $11,000.

Then there is the cost of psychiatric care.  For reasons I alluded to in the first paragraph, I have rejected the insurer’s model of psychiatric care– the 4-6 patient-per-hour, 10-minute med check.  I spend 90 minutes on the first appointment– often more.  And follow–up appointments last at minimum 30 minutes, and for more complicated cases, 60 minutes.  Because I see only a third as many patients, I do not accept the dramatic discounted fee offered by insurers, and patients are required to pay something.

For patients with a deductible, their cost is essentially the same as for an in-network doctor.  For others, insurers pay some portion of my fee, and for some, insurers pay nothing, leaving the burden of the full cost of an appointment– $199– on the patient.  For that $199, the patient receives 30 minutes of my attention, based on an education that cost me over $100,000 (not counting college), and 16 years of my life to complete– not counting grad school.

I see people who are truly suffering;  people with significant anxiety, depression, addictions, phobias– problems that cause much greater disability than would a torn ACL.  So here (finally) is my question.  Why is it that people will roll their eyes and pay their $2000 deductible for the torn ACL, as their insurer pays $20,000 more, yet refuse to spend anything to treat their depression?   Given the effect of social anxiety on a career, why will people pay $3000 for a septic tank, yet consider $400 unreasonable if spent to improve their ability to interact with others?

We all know the importance and value of a close relationship with a friend or spouse;  we all fear being alone at the end of our lives.  So why do we consider a $1000 plasma TV a ‘steal’, yet consider the same amount, if spent to solidify a marriage, a huge expense?

There is so much good that psychiatry can do.  But I am not impressed by the value of fast diagnoses, and rapid-fire medications.  On the other hand, a limited series of visits, to treat targeted symptoms, is one of the most cost-effective areas in medicine.  I often think to myself, ‘I can FIX this person’s problem– but not in 30 minutes!’  I’ll be frustrated that a person does not consider treating their psychiatric symptoms as valuable as purchasing a new car, or a larger house.  Gosh– my entire cost of treatment– enough for plenty of visits– can be covered by ONE monthly mortgage payment.  And while the mortgage bills keep coming, the benefits of treating one’s symptoms can become a gift that keeps giving, month after month and year after year.

Please help me out by answering the poll below– I’ll try to discuss the results on my radio show in a few weeks.  Thank you for helping me understand an issue that’s had me a bit frustrated!

I’ve described my approach to psychiatric care throughout my web pages. In case you’ve missed those comments, I’ll briefly summarize them below. I’m writing this post primarily so that I will have a web address to give people who ask about my practice.

Some background for the goals I’ve set for my practice:

- There are times when medication is a Godsend for psychiatric illness and symptoms, for example in treating moderate to severe depression, REAL bipolar disorder (i.e. not the bipolar label that is tossed on to every teen who is acting out), psychotic disorders, and moderate to severe anxiety disorders. Children and adults with significant ADD also do much better with medication than with treatments that do not include medication.

- On the other hand, there are many cases of over-reliance on medications. Studies have established that the best treatments are those that combine medication with attempts to improve insight into problem behaviors. Recent studies suggest that antidepressant medications do little for mild depression, and that at least some of the benefit comes from the patient feeling understood, cared for, and reassured that things will ultimately be OK.

- I find the practice employed in some psychiatric offices to be utterly deplorable, where people are seen for very limited periods of time, diagnoses are assigned, and potent medications are prescribed– without taking the time to understand ALL of the factors involved in the patient’s symptoms, and to explain all options for treatment– including the risks of each option.

- People do well when they are treated well. People want to be ‘understood’ by their psychiatrist, and that cannot happen if an appointment begins with a 30-minute wait! How, in such cases, can the psychiatrist claim empathy for the patient’s feelings– right after demonstrating the opposite? And how can someone accurately assess the personality traits of a person who has just been forced to go through a dismissive, frustrating experience?

- It takes time to understand a person– for many reasons. When I begin treatment of a person seeking help, I want to know that person’s strengths; not just the strengths that the patient knows about and describes, but the strengths that I witness and hear about as the patient settles into a long discussion. I also need to know the things that threaten the patient; those that the patient is aware of, but more importantly, the things that the patient does not yet recognize. And again, that takes time. People have a way of acting when meeting a person for only 15 minutes, that disguises how that person truly feels inside. It takes time for a person to let go of that presentation, and settle into being him/herself.

My practice

- With these principles as background, my practice is designed create an environment where people feel relaxed, respected, and understood. I set aside at least 30 minutes for every appointment, allowing time for us to truly understand each other. My appointments start on time. My patients wait a couple minutes for a 30-minute appointment– rather than waiting 30 minutes for a 5-minute appointment!

- I provide formal psychotherapy, usually with hour-long appointments that are scheduled for a predefined period of time, in order to tackle a predefined problem. My approach is ‘psychodynamic,’ meaning that I assume that we all have an unconscious part of our minds, where we repress painful and frightening feelings.  I sometimes use tools from cognitive behavioral therapy as well, depending on the particular symptoms and on the patient’s style of interaction and comfort level.  Beyond formal psychotherapy, I use every visit as a chance to understand the person seeking help, and to help that person understand their symptoms and options. Having a full 30 minutes for a ‘medication visit’ allows us to get things right the first time, instead of random trials of medication after medication.

- I do not belong to insurance panels. I realize that by not contracting with insurers, some patients may pay more for care than they would from a participating doctor. Unfortunately, insurance is set up to pay for ten-minute med checks– a form of psychiatry that I find to be worthless, in cases where it is not actually harmful.  I wish that I could be flexible, and accept insurance in some cases, but the insurance industry does not allow that situation.   I encourage people to consider the ‘big picture.’  Recent articles in the Wall Street Journal and the New York Times have decried the loss of traditional psychiatry as a result of the pressure by insurance companies.  The articles describe the problems with the ’15 minute med check’ in a field as complex as psychiatry.

- I do submit to all insurers, and many do cover non-participating doctors, at least in part.  If you have a high deductible, my relationship with panels may have no relevance to your costs.  I do accept charge cards for payment.

- I ask that people consider a couple of factors when choosing a psychiatrist.  You will not wait more than a few minutes in the office when see me, meaning that your time away from work or from home is more predictable.  I answer e-mails, so that I can answer the short questions that invariably come up when starting any new treatment. But most of all, I believe that my approach is more likely to reduce your symptoms, and more likely to prevent recurrence of your symptoms.  Working together we will improve your insight into the causes of your symptoms, helping you become more proactive in maintaining good health.

- The kind comments that I hear most often from my patients is that they feel that they can ‘be themselves’ with me; that I do not judge them, and that I act as if I have been where they are.  Those comments are accurate;  I have been there.  Life is sometimes very difficult, and I have had times of great struggles, as well as times of success.  I make no secret of my own experiences, hoping that my own openness will help to reduce the stigma that people continue to feel and experience when dealing with psychiatric symptoms.

That is my practice, in a large nutshell!  If you have any questions about my practice, feel free to write to me drj@fdlpsych.com .

JJ

A couple months ago the Governor of Oregon, Ted Kulongoski, vetoed a bill that would have allowed psychologists to prescribe medication after completing two years of additional education.  To date only two states, New Mexico and Louisiana, have granted prescribing authority to psychologists despite significant lobbying by psychologists over the past few years.

Proponents of prescribing authority for psychologists point to the shortage of psychiatrists, claiming that granting prescribing power to psychologists would alleviate that shortage and allow greater access to mental health care for patients in need.  They also cite studies that (so far) have not found negative consequences from the granting of such prescribing authority.

I have written a number of times about the problems with the field of psychiatry.  For example I believe that psychiatrists make a mistake when they leave the mind behind, thinking that the symptoms of depression, anxiety, and other disorders can be understood using only the ‘hard sciences’ of physiology, chemistry, and anatomy.  But ‘hard science’ is where the field is going; those without a firm grip on neuroscience blindly follow the leaders on a professional snipe hunt, taking it on faith that there will be answers at the end of their journey.  While much of the training for my PhD in Neuroscience is out of date, I have enough background to know that there is no ‘there’ there.  Understanding the metabolic pathway for paroxetine for specific individuals is NOT going to have profound effects on mental health care. 

Many of the patients who I see tell me horror stories about their prior encounters with psychiatrists.  They talk about appointments lasting several minutes.  They talk about being prescribed medications without any explanation of why they are to take them, what side effects to expect, or what other options are available besides the medications.  Many times they do not even remember their psychiatrist’s name!   All of these issues come down to one thing:  time.  People want more time to explain themselves, more time to hear the options that are available, and more time to learn whether they are ‘normal.’

In a way, I am saying that psychiatrists need to emulate… psychologists.  I find it a bit ironic that psychologists are striving to get the very power that is pulling psychiatrists AWAY from patients!  It will be interesting to see if the psychologists who gain prescribing authority move toward the psychiatry model of the ‘med check’ appointment!

Psychiatrists do not fret over the issue of prescribing authority for psychologists.  Many of them work for health systems on a salary, and if anything they would prefer a lighter load.  So what if a few patients disappear?!  Besides, most psychiatric medications are already prescribed by non-psychiatrists, i.e. family care docs or nurse practitioners.  But I think that such nonchalance is a mistake.  I assume that third party payers are looking forward to the day when the initials ‘M.D.’ no longer command a higher fee schedule than N.P. or even Ph.D.  And I doubt that any leveling of fees will do as much to elevate the fees of non-M.D. practitioners as it will to lower those of M.D. psychiatrists.  There have clearly been efforts to make everyone the same in the eyes of healthcare consumers.  Those efforts are fine and dandy for the person who DIDN’T spend eight years accumulating debt! 

If physicians are ever forced into a position of having to justify their higher fees, they have placed themselves in a bad position in the battle for PR.  If everything else is even close to equal, patients will choose the practitioner who provides TIME over the 7-minute appointment with someone ‘more educated.’  Already, I hear patients talk about ‘Dr. Steve’ or ‘Dr. Betty’ in reference to their APNPs, any difference in training compared to ‘Dr. Thompson’ totally lost on them.

For the sake of the profession, I hope that psychiatrists learn one thing:  slow down.

I’m sorry for the hiatus in posting; I have another blog (related to addiction) plus there always seems to be tons of paperwork this time of year– not to mention getting things together for the tax season.  With taxes in mind, perhaps it is appropriate to write a post that has to do with the FDA. 

I am going to share an e-mail exchange with a patient about a medication that is part of the changing landscape for treating depression.  Since the replacement of ‘tricyclic antidepressants’ like amitriptyline and desipramine by SSRIs (serotonin reuptake inhibitors), the general approach to medication for depression has been SSRI, second SSRI, SNRI, then augmenting the SNRI, then augment with something else, and finally consideration of ECT.  There are other treatment choices in the algorhythm such as psychotherapy, bupropion, or mirtazepine, but the general pattern of SSRI— second SSRI—- SNRI has been the backbone of treatment in the modern era of psychiatry.

At the same time there have been other medications that are thought of as ‘mood stabilizers,’ including a group of medications known as the atypical antipsychotics.  To use their trade names, the medications include Zyprexa, Risperdal, Seroquel, Geodon, and Abilify. Recently two of these medications have received FDA indication for uses other than for bipolar mania or for schizophrenia, and there are indications that the lines between medications thought of as ‘antidepressants’ and medications considered ‘mood stabilizers’ will become more blurred going forward.  This should be a good thing, as we are gaining additional options to treat mood disorders– a group of illnesses that cause considerable suffering in the country and world.  But the new medications have powerful effects, and so like most medications have potential side effects– in this case the risk of increasing blood glucose, cholesterol, and triglyceride levels, and increasing the risk of weight gain and diabetes. 

The e-mail exchange relates to the issue of medication side effects, and when should a person disregard the scary print at the bottom of the advertisement (or the ridiculously-fast-spoken list of side effects at the end of a TV commercial).  The patient has struggled with depressive symptoms for a number of years, and has been treating the symptoms with the ’safest’ medications– i.e. SSRIs– avoiding medications with greater risks and side effects.  I have been her psychiatrist for a short period of time, and we are not yet certain whether her symptoms are part of Major Depressive Disorder or are instead the depressive side of Bipolar Disorder.   I recently suggested to the patient that we look at the big picture– that the depression is taking a toll on her life, that the depression has affected her relationships and career path, and that the depression has even put her at risk for suicide.  I think I will let the exchange finish the point I tried to make.  She is a bright patient who reads up on whatever we discuss, something that sometimes makes my work easier, and other times makes my work more challenging– albeit in way that medicine SHOULD be challenging.

I suggested considering a more potent medication, such as Seroquel.  She sent a message that included the following comment:  

I looked up Seroquel…and get freaked out by things like this:  http://www.usatoday.com/news/health/2009-04-08-fda-seroquel_N.htm  I will let interested readers go to the link on their own, but the link is to an article questioning the wisdom of the FDA in giving Seroquel the new indications.  As I mentioned earlier, I think that more choices are a good thing– providing we have bright doctors who take the time to educate their patients, who take the time to learn enough about their patients, and who make reasoned decisions based on ‘risk to benefit ratios’– assumptions that may or may not be valid.  I have written about my disdain for psychiatric practices that do ‘7-minute med checks’, and I believe that those practices may serve their patients more safely by sticking to the SSRI’s!

My long-winded response to the patient:

I am not pushing Seroquel- only suggesting that when you look objectively, there may be a case for more aggressive treatment of your depression.  I want to point out a couple things in the USA Today article, an article that is clearly written by someone with certain preconceptions.

First, the article correctly reports that the FDA found that the risk/benefit ratio of Seroquel does not favor using the medication as a  first-line agent.  But it is important to note that after reviewing all of the data, the FDA DOES favor approving the use of the medication for treating depression in people who (like you) do not achieve remission of mood symptoms from first-line treatments like Prozac. 

There are a couple comments in the article that I find misleading; for example, the quote of lawyers who said ‘the company knew Seroquel caused diabetes.’  Seroquel doesn’t ‘cause diabetes’.    There is an increased risk of diabetes in people taking Seroquel, but the risk varies with dose and length of time taking the medication.  The drug is used at 600-800 mg for mania or schizophrenia but only 300 mg for depression, and people who take it for a short period of time at a lower dose are at lower risk.  The risk of diabetes in patients taking Seroquel goes from around 3% to around 6%.  For an individual, the risk of NOT getting diabetes goes from 97% to 94%.    The effect can be worded in a scary way—‘the risk of diabetes doubles’- but going from 97% to 94% odds of NO diabetes is less frightening—especially when the odds ratio takes into account the risk and pain of experiencing years of depression.  The risk if diabetes can be greatly reduced, by the way, by monitoring blood sugars and stopping the medication if glucose tolerance changes.

It is important to distinguish between the risk to an individual vs. the risk to a population.  The FDA looks at the latter, but the individual should look at the former.  For example, much has been made of the risk of suicidal ideation in children and adolescents taking antidepressants.  The result of the FDA black-box warning of this issue has been a significant drop in antidepressant prescriptions for children and adolescents, and at the same time (coincidentally?) a significant increase in suicides in the same age group.  The warning came because retrospective evaluation of pooled research data showed that ‘suicidal ideation and behavior almost doubled’ in depressed patients starting antidepressants compared to depressed patients starting placebo tablets.  A ‘doubling’ sounds bad… but there was no increase in actual suicides, and the data may reflect something benign.  For example, perhaps kids on antidepressants talk about their thoughts more.  Looking at the data beyond the ‘doubling’ headline, in the placebo group about 2% of the depressed patients had increased suicidal thoughts.  In the treatment group the number was around 4%.  This is in fact a ‘doubling’ of suicidal thoughts, but we can look at the exact same data in a different way.  In the placebo group, 98% of the patients did not report increased thoughts of self-harm, and in the treatment group 96% had no increased thoughts of self-harm.  This way of looking at the data is much less likely to scare a mother into dumping her child’s Prozac down the drain… but is also less likely to catch your eye in the check-out aisle where the papers are sold! 

I will again point out that no suicides were attributed to antidepressants.  But meanwhile, suicide IS one of the leading causes of death in that age group, and most of those suicides occur in adolescents with untreated depression.  There has been less dramatic reporting of similar increases in suicidal ideation in patients taking virtually any of the anti-seizure medications, and in similar effects from other medications—like Singulair, a medication for asthma. 

Government health agencies look at fractional risk multiplied times 200 million people.  A 5% risk of diabetes means an additional ONE MILLION people with diabetes!  But an individual still has a 95% chance of NOT having the illness.  I remember going through a similar calculation back in med school, when I contemplated giving up the bacon that I loved to lower my risk of heart disease.  For now, I am still eating bacon!

I want to leave this discussion making two primary points.  First, it is important that patients know the true balance of risk to benefit for any treatment or medication, and that they try to learn the truth behind the headlines.  This point is a perfect segue for a plug for my practice.  I see at most two patients per hour for follow-up visits, and find that even the 30 minutes that I set aside at minimum is a short period of time to adequately explain all that the patient should know– particularly when most of the appointment must be used to collect information from the patient, not the other way around.  I have no idea how people gain anything from the typical 7-minute appointment.  If you are a dissatisfied patient, give me a call through my telepsychiatry practice!

Second, at some point it may become time to treat a mood or anxiety disorder or some other psychiatric condition with more potent medication, including medication that has temporary side effects.  When a person develops gallstones, he/she usually ends up with either a number of small scars from laparoscopy or one big scar under the right ribcage from an open procedure.  In either case, the person experiences significant pain for a number of days.  I sometimes think about the different tolerances people have for the treatment of different conditions, from the financial perspective and from the perspective of tolerable side effects.  People think little of spending thousands of dollars for anything involving a scalpel or anesthesia… my teenage daughter’s broken arm took 10 minutes to cast and the orthopedist charge was almost $1000, but I will get nowhere asking an insurer to pay $140 for an hour of my time with a patient!  Likewise, mild nausea from Effexor will keep a patient from taking the medication, even when the illness is so severe that the person is home-bound from panic attacks. After several days of at most mild dysphoria, the medication has a good chance of eliminating the anxiety entirely! 

What are the reasons for the differences?  I have a few guesses, including the stigma of mental illness, the difficult nature of change, and the powerful effects of denial.  In all cases I don’t see significant changes in ‘how things are’ on the horizon… so noncompliance and unwillingness to accept proper treatment will likely remain an issue for psychiatrists to understand and to consider as part of the entire illness.

Thanks, as always, for reading this far.  I wish you all the best.

JJ

I am proud of the space I have created for my psychiatry practice.  I see patients across the country in telepsychiatry, but I prefer— and I think they prefer– coming for psychotherapy ‘in person.’ My office is at the South end of Main Street, within seconds of the highway 151 bypass and Highway 41.

The pictures below were taken with my i-phone so they aren’t the highest quality. The outdoor shots were taken directly out the window of my office.  Yesterday under one of the pine trees there were two fawns, still a bit wobbly on their feet.  A few days earlier a fox sat in the sunny area in front of the trees for 30 minutes, calmly giving himself  (herself?) a ‘tongue bath.’  Now and then a person will interrupt his/her own conversation to say ‘look-  a hawk!’

Some people have even set up a ‘blend’ arrangement, where they see me in person some days, and over the phone on days when the weather is bad or they just cannot fit the trip to my office into their busy schedules.  Whatever works for you– we can make it happen!

My Office:

The Reception Area

Patient Waiting Area

Conference Room

View out Side Windows

My Desk

View out Rear Windows

Patient Interview Area

I have a weekly radio show about psychiatry– you are welcome to check it out either through the links on the home page of my psychiatry practice, or at KFIZ, the radio station that hosts the show.  Yesterday a caller asked about her son, who lives at home but is about to turn 18, and who to her dismay wants to get a large tattoo on his back to commemorate his birthday.  Complicating the matter is the fact that she and her husband are divorced, and (can you see what is coming?) her ex thinks the tattoo idea is just fine.

Don't judge me for how I look! (?)

This discussion can go in many directions;  one thing we discussed on the show is that even at the ripe age of 18 it is a good thing for a ‘child’s’ parents to avoid being split over an issue that involves the child.  Ideally, the parents would discuss the issue in private and come to terms, if not agreement, over how things will be handled–  rather than have one parent put down the other parent for being too lax or too strict, with the son in the middle choosing sides.  As tempting as that sounds to the parent siding with the young man, such a situation will inevitably cause problems down the line when the son uses the ‘split’ to justify all kinds of behaviors.

But that isn’t what I am writing about. I’m writing in response to a comment that came up during our discussion; the mother said that her son accused her of ‘judging people based on appearances’, and she felt that she was appropriately chastised for being that way. But was she?

We all go through life with a certain image of ourselves— with a sense of ‘who we are’. Those self-perceptions come out particularly when we are nervous—say during job interviews or during first dates, as in: ‘I’m a very giving person’ or ‘I’m such a ditz!’ Are these perceptions accurate? I don’t have any hard data, but my guess would be… No. From my experiences working with people, the perceptions have little to do with reality. Well, that isn’t quite right—they have something to do with reality, but they are not an accurate reflection of reality. For example, a person may refer to himself as ‘an idiot’, and even consider himself an idiot, because of the ‘reality’ that he doesn’t like the pressure of high expectations, from either himself or from others.

If self-perceptions and declarations are not a good indicator of ‘who someone is’, what IS a good indicator? In fact, is the question even worth asking? Can a complicated personality be reduced to a few-sentence description? I think that a person CAN be described, but only with great caution. There are many things that throw off one person’s assessment of another; for example projection involves the process of seeing in other people the traits that we don’t want to recognize in ourselves. Or for another example, studies have shown that contrary to public opinion, the behavior of children, even children with ADHD, does not change after sugar consumption. What does change, though, is a mother’s perception of her child’s behavior; mothers who believe their child consumed sugar are more likely to judge the child’s behavior as unruly. When evaluating others, we always peer through a lens made dirty by our own idiosyncrasies.

So getting back to the woman accused by her son of being ‘judgmental’ for thinking certain things about people with tattoos… she must REALLY be off, right? She is making assumptions without even talking to the other person! But wait– in my opinion, she is probably seeing things the MOST accurately out of all of the examples that I have described. How can that be?!

What is she evaluating when she makes an assumption about a person based on a tattoo? Contrary to the mothers watching in horror as their children dismantle a university waiting room, the woman is evaluating the other person’s actions in a much more objective way. In fact, there is little room for observer bias in such an example; the answer to the question in her observation is either true or false, tattoo or no-tattoo. So unlike those other mothers she has risk of making a mistake in what she sees. But similar to those practicing self-assessment, she does risk making mistakes in what she thinks. But by being a person separate from the person being assessed, she is miles ahead when it comes to accurate thinking!

What do we ‘generally’ know about a person with tattoos? I suppose the answer depends to some extent on the nature of the tattoo—large or small, hidden or obvious, happy or dark, colored or ‘blue-dye’, etc. There is a guy in my home town who drives a motorcycle, without a helmet, and who has a spider-web tattoo on his face, wrapping around the sides and top of his bald head. What does his tattoo say, compared to the 40-y-o woman with a small rose on her ankle? Or compared to the 70-y- o man with an anchor on his bicep? I could easily go wrong by assuming too much—that the spider-web guy is a mean jerk, or that the rose-ankle woman is looking for a man. I think that it would be a mistake to try to use the content of the tattoo, as we don’t know the attitude of the person when he/she got the tattoo—was it a joke? Was it sarcastic? Was the person drunk? Plus if we dealt with content we would start getting into our own unconscious thoughts about roses and spiders.

But we CAN tell something from the simple fact that the person has a tattoo, the size of the tattoo, and the location of the tattoo– with the understanding that we are talking about generalities, and that the data we collect is only one piece of data that must be consistent with the other data before it is taken as true. This is not rocket science… what can we suspect about a person who has a tattoo on his face and head—something that is virtually impossible to miss? We can assume that this is a person who wants to attract attention. This is a person who perhaps wants to be identified by something—he doesn’t feel that just being ‘joe’ is enough; he wants to be (joe), THE GUY WITH THE TATTOO ON HIS FACE. Why would that be? Just guessing, but I would not be surprised if there was a history of abuse; perhaps a family of origin with a domineering mother or father, so that he became very insignificant—almost invisible. But he isn’t invisible anymore—not with that big tattoo… or is he? That big tattoo does two things for him—he is no longer invisible, but is still protected and in hiding, as it isn’t really him people are noticing— it is the artwork on his face. This fits him because as much as he wants an identity, wants to be noticed, he doesn’t have a sense, deep down, that he is worth noticing or that he HAS an identity.

Isn’t this fun?

How about the woman with the rose on her ankle? What do we know about her? It would help to know when she got the tattoo; if she got it at the age of 35 I would wonder the reason—finding herself after a divorce? Or a busy career woman who took a step back from all of the ‘responsibility’ to take a second look at life? Or if she got it at the age of 18 I would suspect that she wanted to rebel a bit, but JUST a bit… no pierced nose or pierced lips, just something that is rarely seen, and that is only seen by people close to her. I would think she is a bit more introverted, perhaps even shy.

I suggested to the woman—the one with the son who wants a tattoo—that she ask him why he wants to get the tattoo. Does he want to ‘stand out’? Is he making a statement of some sort? It really is not true, if the person says ‘no reason’… it is something that hurts a bit, costs considerable sums of money, takes some time… so there is SOME motivation. I suggested that she try to determine his motivation and then see if there is any way to accomplish the same thing in a way that is not ‘permanent’. Young people are often not able to verbalize or even realize what is motivating them… but that doesn’t mean that the motivation doesn’t exist.

As I mentioned at the start of this post, my thoughts on tattoos began in response to the idea that it was somehow improper to judge a person based on appearance, specifically based on the person having a tattoo. I have probably voiced a similar protest at some point during my youth; at least it sounds like something I would have said. But I now realize that particularly given the problems with other means of sizing up a person, the best way to assess or learn about a person is to look at the person’s behavior. In my practice, a person may talk for hours about how considerate he is; if I have to cancel because of a sick child and the person calls me an SOB, I see the behavior as a more accurate indicator of ‘what the person is like’. Likewise when a patient tells me that he ‘doesn’t know who he is anymore’, or when someone says that she ‘wants to be a good person’, I suggest that the best way to judge who you are is to take a look at what you do.

The idea fits well with another thing that I often talk about; acting ‘as if’. For example, if a person doesn’t ‘feel like’ doing the right thing, or isn’t the ‘type of person’ who would do the right thing, I suggest that he ‘act as if’ he IS that type of person, or as if he DOES feel like doing the right thing. In a short time, after acting like the person he isn’t, he will find that the person he isn’t is exactly who he has become.

As I have mentioned, I wrote a column for Psychiatric Times during my residency in psychiatry.  My intent was to write about the feelings encountered by a resident training to become a psychiatrist.  Training in any field of medicine includes new experiences, many of which are not encountered by non-physicians, or which are experienced to a much lesser extent.   In the next article I wondered about the effects that those experiences had on my personality.  To take an extreme example, all doctors start their training with three or four months in the cadaver lab;  our group of four students dissected the body of a woman who appeared to be in her 20′s at the time of her death from melanoma.  I recognized at the time that I was changing in some way as I learned to focus on the brachial plexus, a network of nerves that extends from the neck to the armpit, rather than on the dead woman who owned the brachial plexus.  Later in my training I knew that I was changing when I learned to put on a stoic face, as I told a 40-y-o man that he had cancer.  I learned a totally new concept– that I needed to present a persona that provided the right measure of security, compassion, and confidence, so that the man could perhaps experience some measure of comfort and support from me as he heard the horrible news.  A critic would say ‘just be yourself’!  But there are many ways for a person to ‘be himself’.  I wasn’t learning to be ‘fake’;  I was learning that being a doctor carried certain responsibilities beyond simply cutting out tissue or writing prescriptions.  People study their doctor’s face when they are told bad news;  they want to know how bad it is, and whether there is cause for optimism… or whether there is nothing but despair.

I’m getting off track a bit.  The point of the story I am about to post is that those learning experiences, and my ongoing experiences in medicine, do something to my personality.  Clearly there are some doctors who have developed big egos, anger, or bitterness from a life of doctoring.  In the story I wonder whether the bulk of my experiences have had a positive or a negative influence on who I have become today.  The story:

Stepping lightly over boxes of medical experience

A multi-vehicle trauma! This is what it is all about, I thought, as I followed my senior resident to the stairs. While my age placed my training against a St. Elsewhere’s backdrop, my excitement was more consistent with the modern, high-energy ER soundtrack. The emergency room itself inspired excitement, and as a third year medical student I had not yet developed the healthy fear that affected more senior, and more answerable, members of our surgical team. As we approached the cubicle I noted that the patient was small, maybe two years old. Red froth bubbled from his mouth as the emergency room staff frantically removed his cervical collar. I heard the word ‘tracheotomy’, and someone said “hold him down!” as his arms reached into the air. I grabbed his hand and held tight, grateful that I had found a mission that I could handle.

To my surprise, the hand gripped back. And suddenly… time stopped. Small fingers wrapped around my finger, and at once I was sitting with a small boy, stillness around us. I looked beyond the red froth, to see his clear, blue eyes gazing forward. No longer aware of the work to be done, I began to understand a tragic story. Through pieces of conversation I realized that the boy’s mother and father lay dead on gurneys in cubicles behind me, victims of a drunken driver. In a flash I could see all of what our experience on earth offered: life and death, hope and despair, beauty and horror.

After 15 years, I still feel heaviness in my heart as I remember that night. I have not attempted to describe the scene before, but I have sometimes felt the moment’s essence, as a secret part of what has since become ‘me’.

I have many secrets. I remember the 5-year-old girl who I met in the oncology clinic, with newly diagnosed leukemia. I silently winced in pain at the smile on her small face, an innocent unaware of the needle-sticks ahead of her. She sat with her mother, whose expression betrayed the knowledge that her daughter would be forced from the world where she belonged; a child’s world of security and happiness. I remember the seven-year-old child who died of sepsis in our recovery room after hours of attempted resuscitation, and I remember the horror that filled the room as we accepted the futility of our efforts. And I wonder, how have these secret images affected me? Am I a better doctor, or parent, or friend, or do I now carry a seriousness that has driven some of my personality inside, and beyond reach? Will I be a better psychiatrist? Am I more tuned in to pain, or has my exposure given me a resigned, grim acceptance of suffering?

For much of my life, my approach to learning was that all learning was good learning. My goal was to face life’s experiences as a sponge, seeing as much as I could see, and experiencing as much of life as possible. My assumption was that humans had the capacity to keep the wheat and discard the chaff; to assimilate the positive and to disregard the negative aspects of experience. The end result would be a ‘complete’ personality, free of bias, unfettered by misconception, and nourished by the ultimate sustenance of personality, information.

At some point my early opinions about learning became tempered with caution. I began to see that in regards to learning, experience, and personality, at least in my own case, I am what I eat. As much as I wanted to believe that I was capable of learning only the desirable aspects of experience, I saw that my personality was affected in ways that I hadn’t predicted. I remember briefly facing these questions as a college student, when I wondered, in 1970’s fashion, if there was in fact any evidence that people were ‘smarter’ after formal education. I thought more about the topic during a period of my life when I actively meditated, as I became aware of the constant parade of thoughts that drifted through my consciousness, despite my best efforts to limit them. This view of personality as an unorganized collection of experience is more Eastern, more consistent with what I have read of the developing ego, and more consistent with my experience as a parent of teenagers. Some things, once learned, cannot be unlearned. Some bad experiences are unconsciously assimilated and eventually inhibit function, much like adware on a Windows 98 computer. Memories accumulate like boxes of artifacts in a darkened basement. In my own case, half-opened boxes litter the floor, and some emit frightening noises.

As I work toward becoming a psychiatrist, I would like to develop an understanding of the biases that shape my attitudes; biases that have the potential to interfere with neutral observation and reflection. It is easy to identify the obvious examples of personal experience that interfere with the neutrality that I desire. For example, I can easily recognize the barriers that stand in the way of my feeling compassion for the playground bully. And the death of one of my best college friends during the attacks of September 11 undoubtedly affects my opinions of America’s role in the world. But while in psychiatry we learn to identify personal and historical events that have shaped our attitudes, I wonder if work and training experiences are incorporated in potentially prejudicial ways as well, perhaps beyond question because of their endorsement by common medical experience. I would like to identify the ways that my experiences in medicine and psychiatry change my view of the world, in order to have foresight into bias that will develop in the future. Of course, unique character traits result from experience in all professions; as I sit in the auditorium prior to my daughter’s band concert, the principal, oblivious to the ages of the assembled parents, reminds us to remain quiet and respectful during the concert. But with admitted narcissism, I see the experiences faced by physicians as particularly memorable.

The experiences faced in psychiatry training, while less overtly dramatic than the world of CPR and tracheotomies, force one to incorporate a different type of emotional experience. In my short training, I have been moved by the isolation of schizophrenia, by the emptiness and despair of depression, and by the ravages of families wrought by addictions. It is often difficult to come to terms with reactions to psychiatric experience because of the lack of formal resolution. Psychiatric diseases for the most part are not cured, and yet are not fatal by themselves; so there is no exclamation point to treatment successes and failures, and less opportunity to place experience on the opposite side of the line that protects our present world view from the tragedies of the past. There is also a learned frustration that develops as we accept that the will of our patients does not always coincide with our desire to help. And again I wonder, what have I begun to ‘understand’ about mental illness? Can I make a difference? What is the meaning of life in the face of such suffering?

At these moments, I try to find gratitude for the opportunity to seek psychodynamic understanding. The beautiful, horrible experiences of life weave tapestries, unique to each of us and to each of our patients, with fibers visible only to those willing to see them. And in the tapestries lie the questions, and the answers to the questions, and the answers to all of the questions to come. To study the fabric of these tapestries is to study the essence, and the meaning, of life itself. It may be asking too much to weave our own tapestries by design, but one can be aware of the admonition of Aldous Huxley, that experience teaches only the teachable.

And once again, we are back to the original question. Is all learning beneficial, and are all experiences enriching? Is it true that what does not kill us makes us stronger? Perhaps the answer is moot, since no matter our preferences, experience finds us. Maybe I can make an occasional decision as to what to remember, or face life’s challenges and disappointments with the respect required to ease cynicism. Perhaps I can embrace the feelings and the meanings of life events, rather than attempt to diminish their awareness. Perhaps all I can ask for is to find experiences with my eyes open, and to place my boxes in a well-lit room, where I won’t trip over them.

Continuing on the relationship between mind and brain, there was a study recently reported in the journal Psychological Science and described by the New York Times that concluded that people with ‘neurotic tendencies’ are more stressed out by uncertain feedback than they are by unambiguous negative feedback. To illustrate the point, let’s say you are having your in-laws over for Thanksgiving dinner and you really want them to like you. And let’s say, for the sake of the discussion, that they don’t like you—they don’t like your clothes, your personality, or your cooking. Would you rather have your mother-in-law tell you straight-out that she doesn’t like you, or would you rather have no idea whether she likes you or not?

According to this study, the answer depends in part on whether or not you are ‘neurotic’. People with ‘neurotic tendencies’ in the study preferred certain bad news over uncertainty, at least as measured in the study. This is where we come to the ‘mind-brain’ connection; in the study, the levels of misery of the subjects were determined by the activity in a certain part of the brain, called the anterior cingulate cortex. This brain region is part of something called the ‘limbic system’, a primitive collection of brain structures that give rise to emotion.

I found it interesting that instead of just asking the subjects about their level of inner turmoil, the investigators attached electrodes and measured electrical activity in the limbic systems of the study subjects. I haven’t read the original study—I don’t get the journal—but sometimes studies can get a bit too ‘techy’ and miss the point of what they started out investigating. For example, from reading the review of the study, the primary end point appears to be the level of distress of the subjects. I could imagine a researcher stating that the electrical activity is more ‘objective’ than a survey, but what if a person scores high on the electrical activity, but claims to have little actual distress? I could see the researcher believing the ‘objective data’ over the ‘subjective’ descriptions of the subject, but if the end point is ‘distress’, I think the subjective response is the most relevant. But this isn’t what I wanted to write about… so I will move on.

When I read about the study my first thought was: what is ‘neurotic’, anyway? The study talks about measuring five personality traits, including ‘neuroticism’. This led me to Wikipedia, where neuroticism is defined as ‘an enduring tendency to experience negative emotional states’. Woody Allen is the classic ‘neurotic’, of course; not the ‘married to my stepdaughter’ Woody Allen, but rather the Annie Hall or Hannah and Her Sisters Woody Allen. If you haven’t seen those two movies, you should—they are classics, and you will never again wonder what a ‘neurotic’ is after you has have seen them. I have written about ‘Borderline personality’; the ‘border’ is between neurotic and psychotic, and patients with borderline personality disorder or borderline traits will sometimes cross that line, transiently, during times of severe stress.

The Prototypical Neurotic

I continued to read about neuroticism at Wikipedia and other sites on the web. Gotta love the internet—it reminds me of going to ‘Fleet Farm’ in Fond du Lac, a store that carries clothing, hunting supplies, hardware, plumbing supplies, farm and auto supplies… I will go there to buy a screwdriver and come home with cordless drills, laser levelers, epoxy caulk, and my favorite— minimally expansive foam sealant! With the internet I will start out looking for a single definition, and end up reading page after page of barely-related information.

I came across another interesting finding about neuroticism: it has a geographical distribution! There is a higher incidence of ‘neurotics’ among the east coast population than among the population of the western states like Wyoming, Colorado, and Montana. That doesn’t surprise me at all, but perhaps it should. Why would there be a difference? Is it genetic drift? Some conditions, for example schizophrenia, tend to concentrate in cities; there are more support services available, and it is probably easier to be ‘homeless’ in a big city than in rural parts of the country… so over time the genes for schizophrenia tend to be more prevalent in people who live in cities. But why would ‘neurotics’ favor the east coast?

But then, who am I kidding? Personalities and personality traits run in families—they are carried to some extent in our genes—and so the neurotics of today were more likely to have neurotic parents yesterday. And neurotics are not the type of people to jump on a horse and start riding into Indian country! I can imagine the conversation on the trail, bouncing along on the seat of a Conestoga wagon: ‘gee guys, this is HORRIBLE… it’s so HOT! Is anyone else hot here? I don’t want to be difficult, but gee—what if they don’t LIKE us out here!’ So yes, genetic drift likely played a role, where people who were highly neurotic opted to stay behind and read the postcards rather than risk going to battle against ‘savages’.

No place for neurotics!

There is also the ‘survival of the fittest’ influence on population; people with certain personality traits were less likely to survive and have offspring with similar personality traits. I picture a gunfight with a highly-neurotic gunslinger: DRAW! says the challenger, and the neurotic says ‘You’re kidding, right? I think you must have me confused with someone else! I KNEW this would happen if I came out west!’…

The good news, of course, is that there is a place for pretty much everyone.  A neurotic Woody Allen-type guy would be annoying on a cattle ranch;  the prevailing attitude would be ‘shut up and just do it!’  At the same time, the no-nonsense hard-working rancher, completely at ease in a pitch-dark desert, would likely be put down as a ‘simpleton’ in the boardroom– naked Broadway cowboys aside!

There is nothing to say that people should stay where they ‘belong’.  In fact, many people seem to enjoy being in exactly the place where they DON’T belong– the cowboy in the city, or the sensitive worrier on the oil platform. Some people are most comfortable when they are blending in;  others thrive on standing out.  The important thing, though, is for a person to know where he/she stands.  There were times when I worked at the prison when I felt like an alien; the prison where I worked as a psychiatrist was filled with union yes-men and mid-level government administrators, mostly determined to keep their mistakes secret from the ACLU and Justice Department lawyers who were suing them… (no bitterness here!).

From those experiences I learned that when I think I am going crazy, the first thing to do is take stock of my environment and decide whether or not I ‘belong’.  Doing so would have saved me a great deal of heartache during my prison work.  Another way to state my point is to say that it is not worthwhile to strive to fit in, when you don’t respect the people you are surrounded by.

Peace,

JJ

]]> http://patienttimes.fdlpsychiatry.com/2008/11/neuroticism-and-the-wild-west/feed/ 0