Well, I had my 100th post last May, and after reading it today, it is unfortunate to note not much has changed, so I will be a bit lame and cheap in efforts to just replicate it now for this 400th post milestone, but, I hope if you haven’t read it, you will now and perhaps appreciate what I note I have endured in my career.
Here it is:
Someone I work with recently said this at a meeting, and I had to write it down and consider using it at an upcoming blog. I think it fits well here:
COMMON SENSE IS AN EXCEPTION THESE DAYS.
Wow, that just hit home for me, and on so many levels. For those who have been reading here for some time, maybe since the inception of the blog back after Thanksgiving last year, you know that I write about topics not just mental health in general , but more specifically about personality disorders, addiction, and politics. Ironic all three seem to have an incestuous relationship, to those who are aware of what those topics mean by themselves.
I have given much thought what to write about for this 100th blog, and I came to the conclusion it should be about my past, present, and future as it stands now. So, for any and all interested to what I have to say, here is what I see as a psychiatrist regarding my past, my present, and what I hope to see myself doing in the future, sooner than later. I hope as well you will see that comment above will have applicability to at least some of what I write about below.
I finished my residency the end of June, 1993, not a minute too soon. I had “issues” with the hierarchy of the residency program during my third year, and in the end, I was fortunate to finish my fourth and last year completely off site from the program and work with people at a community general hospital who showed me how psychiatry was to be practiced, not indoctrinated back at the “U”. At that time, I really hoped to be working a combination of Consult-Liaison psychiatry at a hospital, maybe some community mental health clinic work, and private practice. I really liked variety, and for at least the simple reason so I could be available to everyone who needed to access a psychiatrist, and make sure I kept up with my influences from both undergraduate and residency that reinforced the Mind-Body connection role to medicine in general.
Well, I am not going to detail my travels, except to say I have practiced in 4 different states, doing inpatient, outpatient, partial hospitalization, urgent care, and even some correctional/forensic work. My longest tenure at a site was 6+ years, my shortest was just 3 months for a job NOT involving Locum Tenens work. For those who know the movie “Blade Runner”, at the end when the Rutger Hauer character sits in front of Harrison Ford and says “I have seen things you people would not believe”, well, that is applicable to my travels as a psychiatrist, and not just directed to the public at large, but to colleagues who still think that the field is largely filled with clinicians who care and maintain appropriate boundaries.
Don’t misread me, there are good people in this profession, and that needs to be read and heard before you read further. People who go to Med School and read the Hippocratic Oath at graduation more often do understand and accept the premise to the oath, but, I wish I could say it is at least 50% of people practicing, at least in psychiatry. And I have said this before, probably not here in so many words, but will say it now so people have some idea of what I have dealt with:
there is something not directly said, nor secretly asked of incoming doctors to sign some type of oath to follow upon starting in a psychiatry residency, but in my dealings, especially with more older colleagues than not, I have to wonder if there is some unspoken expectation that psychiatrists have to have a level of patriarchal, non negotiable directorial attitude not only with patients, but with colleagues who are viewed as juniors or substandards.
I have seen and heard things you people would not believe. Doctors who don’t give a damn about patient care, administrators who have not only embraced the business/customer model of running health care sites, but would sacrifice a clinician in a heartbeat solely to maintain the alleged good standing of a health care site. Irregardless if the clinician was in fact clinically and ethically right in a conflict with a patient or outside source of dissent. I have met therapists who have no clue what psychotherapy is about, yet, crave and covet my training abilities just to have an advantage. I have worked with patients who have no interest in care, some in fact not even in the office as a patient, but would take advantage of my abilities and standing just to get a drug, a “get out of jail” pass, other outs for court related/legal issues, and even try to get me to tell another person in the room with the patient that overtly inappropriate, immoral, if not illegal behaviors and choices were allegedly right.
Oh, and my interests in C-L work, well, those died within a few years after residency when it became painfully evident not only were consulting psychiatrists not appreciated, but were woefully under-reimbursed and inappropriately utilized.
I have seen and heard things you people should not believe. I could write many more paragraphs of things I had to take a stand against that were greeted by administrators like I was having a Tourette’s vulgarity outbreak. People running programs to help patients who were in fact asking or doing things that did nothing to genuinely benefit patients. And I can say, with cautious appreciation, I have maintained a level of practice handled responsibly and ethically as trained by supervisors and mentors I knew were directing me appropriately during my training. That met standards of care, that encouraged collegiality, that was respected by peers of equal concern.
20 years of the past is not the main point of this post. We can’t undo what we have done, what we have experienced, what we have endured. But, we can use the past to help us make the present, and the foreseeable future as appropriate and responsibly sought as we can possibly pursue. I tell that to patients, I write this now, and I hope to practice it onwards after this post.
I currently work solely in a Community Mental Health Clinic 3 days a week, I have openly noted I left a private practice opportunity over 6 weeks ago for the better, per what I see private practice is as of now, with insurance continual interferences; the alleged continuity of care roles of therapists, other psychiatrists in hospitals and other referring sources; what PCPs and other non psychiatrists are doing with patients dealing with mental health issues prior to referring to psychiatrists; and, as well as what the average patient is willing to pay for psychiatric services that are fair and reasonable costs. Quite the run on sentence there, eh? So has been the run on effort to have a private practice these past 10 years at different sites, with different groups, as well as on my own.
I have to say I learned interesting things while working as a Locum Tenens doc for about 2 years from late 2009 to 2011. Some of it was fun; I was in Maine for a summer working for a pseudo private practice involved with a hospital, and while I was separated from my family which was unpleasant, I had the beach as a comfort, thank god for that! And that relates to the present, because I think I have finally learned it is important to have outlets to maintain sanity in what is a more insane world of late, based on what Einstein so well put: to do the same things over and over and expect different results is insanity.
I see that more clearly now, I can’t expect to find majority acceptance and reassurance with people who are not fully focused on the patient care model I embrace. It’s not about money first. For me, it has always been about a variety in patient load, the people I work with both as clinicians and support staff, the physical plant of the office, and then money/benefits/other concrete details. You have to be comfortable in your own skin, and that has been an ongoing pursuit for me. It is one of the reasons I started this blog, because I saw the blog as an outlet, as an ability to express my personal beliefs and feelings, after just being a commenter for several years at other sites that control the input. I realize now having been commenting as a blog author and reading what others write, hopefully more validating than not in their comments, it is important to tell people what you think, IF the audience wants to hear it, and gives you feedback you have a valid opinion.
This won’t be a long section of this post. What is my future, as well as the future of psychiatry as I would like to see it offer to the public? I know a few things that are essential elements for this profession succeeding and righting some serious wrongs incurred the past 15 or more years, at least what I have actively participated in that time period:
>First, dump this stupid “biochemical imbalance” garbage that has been erroneously propagated by so many false leaders and alleged advocates. Gee, there’s a surprise from a site that has as the mission statement “…if you want to get it right, face the truth” and not just take a damn drug! Why psychiatry allowed managed care to hold us at proverbial gunpoint and disallow us to be therapists, well, whoever signed off on that attitude, go to hell, there is no other way to respond to that sell out!
>Second, psychiatrists are not tyrants, but, we are leaders, and we do have a reasonable directorial role in the mental health system, and all those non psychiatrists who think they are equals, well, you are not! You are not servants or slaves either, but, you don’t prescribe if you aren’t adequately trained, you don’t have diagnostic equivalency if not well versed, and you don’t have seniority if you don’t have the clinical experience to validate such a position. Frankly, I really know in my heart there is an inversely proportional equivalency to people who have positions of power in mental health programs but who have little if any real training in mental health, or have allowed their experience to be so far removed they have forgotten what the demands and realities are of the hands on care.
>Third, patients need to realize once and for all that mental health disorders are multifactorial causes in creation, so, require multifactorial interventions to successfully impact on improvement. How many medication trials that have had no successful resolution must one endure to finally make one realize it isn’t about a biochemical imbalance?! Are those Axis 4 stressors going to magically go away just because one takes a pill, or pills? And those interpersonal skills that not only have alienated the alleged significant others in one’s life, maybe one needs to hear from an empathetic and invested provider(s) that the countertransference issues elicited in the office have validity in being a factor to the symptoms. And it is time for people who have comorbid addiction issues to hear and accept the basic premise: if you don’t get clean, maintain abstinence off ALL risks of dependency and be in treatment with credible sources to handle the addiction matter at hand, then you are wasting EVERYONE’S time who are trying to help you!!
>Finally, one thing I personally have to start utilizing more in my practice is the role of music. I am a big fan of movies, and I have realized over the years that one element of the theater experience has been the role of music as the soundtrack. I won’t go into much detail what I will try to do, but I do know this, it is time for those who have the ability, the sophistication, and interest, to figure out ways to use music to motivate, to soothe, to empower, and to embrace change and efforts to improve.
Look at it this way, we all have what I deem “THE SOUNDTRACK OF YOUR LIFE”, and I will hope to find creative and therapeutic ways to use it to help people help themselves.
Hey, isn’t that what it is all about at the end of the day as a provider in mental health, we are catalysts, and we help people get better, to change, without it dramatically altering ourselves the providers as a whole?
Well, I hope those of you who have made the time and effort to read this post have found something of interest. I know it was worth the time and energy and effort I put into writing it!
So, to me Joel, happy 100th blog, I hope the next 100 are of fun and worth as I have found these first 100 to be. Yeah, some were easy as copies of pictures or handouts, but, everyone has outs at times.
Genuinely, thank you out there for being a reader. I don’t take peoples’ time for granted. I hope I can help people in some way by writing this blog. Hey, I read other peoples’ stuff, and I know that most of them are not just doing something that takes a couple of seconds to print.
BE WELL, BE SAFE, AND HELP OTHERS AS YOU ARE ABLE!!!
BACK TO TODAY APRIL 20 2014: At other blogs there are ongoing discussions about what the APA is now advocating for integrated/collaborative care by psychiatry and other disciplines. Here are at least two of those posts to give perspective:
Be sure to read the comments section of those posts, I think you will find some colleagues’ perspectives of interest. And not mine, as I think I wrote something in each, but the reference is NOT about me.
Integrated/collaborative care has always been there; it is just, to me, so dishonest and disingenuous of not only the APA, but of my psychiatry colleagues who are claiming such collegial dialogue needs to resume when in fact our non psychiatry peers have just taken over our role in health care, and now have realized that playing psychiatrist is no easy task. And the APA wants to reinforce this non psychiatric game show out there! Did you fellow psychiatrists forget that the APA is clamoring for a Somatic Provider version of DSM 5? What the hell is that geared for, or do I have to ask in the first place??!!
So, sorry if you feel this 400th post is a bit of a cheat, but I like the 100th post and am glad to repeat it now.
Happy Easter, Passover, any Muslim holiday occurring around now, and don’t forget the big one on Tuesday, EARTH DAY!
May the Force be with you, and be at one with your karma, and Carl Sagan, wherever you are, may the Cosmos give us all peace, without an oncoming asteroid to blast us into pieces!
End of line. (for you Tron fans)