Category:

Medicine

Thankful Thursdays

{Venice Beach, California}

For this week’s Thankful Thursdays, I would say that I am very thankful for one of my best friends from medical school, who flew into town for a quick visit. My resolution for the remainder of the year (mentioned in my previous post) included being spontaneous and free to explore. Surprisingly, in all my years living in southern California, I have never experienced biking along the beaches of Santa Monica and Venice, nor have I ever gone shopping on Abbott Kinney (a well-known boulevard located in Venice lined with trendy/urban shops, earthy/cool restaurants, and more). We had a wonderful time catching up, eating delicious food, and discovering new fixtures in the area that we’d never noticed before. I figure that Los Angeles still has a LOT to explore, therefore, to kick off my resolution, I might as well begin locally!

Thought of the Day: What are you thankful for from this week?

For background information of the reasoning behind my Thankful Thursdays posts, check out my 1st post of the series here! (And subsequent posts here, here, and here).

August 20, 2015 8 comments

Medicine Psychiatry

The Other Side

written by freudandfashion

Written on August 11, 2015

My psychotherapy supervisor taught me a tip during residency — to pay close attention to the very first thing a patient says, and more importantly, the last topic they bring up towards the end of session (because it’s likely that the subject weighing most heavily on their mind is too uncomfortable to discuss at the very beginning). I struggled to come up with a topic to discuss on my blog today. At first, I uploaded chipper, smiley pictures taken from a recent spontaneous trip to the coast, but there was something about my grin and carefree expressions that didn’t seem quite appropriate to post today. I try my best to ensure that my blogposts are reflective of my current state of mind, and my current mood is actually quite solemn.

I know that today marks the one-year death anniversary of Robin Williams, yet avoided news articles, tweets, and Instagram posts that paid tribute to the iconic, inspirational actor. While sitting on the couch and staring blankly at the television screen, a short reel of Robin Williams popped up on entertainment news. Not content with the mainstream, flowery piece which strung together brief clips of some of his finest, Oscar-winning work followed by a quick moment of silence in remembrance, I picked up my phone. While scrolling through Instagram, I focused on a long, detailed post written by a young man in which he describes his own personal battle with depression and multiple, near fatal suicide attempts. Robin Williams’ lost battle to mental illness motivated this man to share his story rather than isolate in shame and silence. The words authentically describe the powerless experience of succumbing to the disease. The depression takes exclusive command and overrides any attempt at rationalization. And I know the story to be true because the writer is a dear friend of mine who miraculously survived.

Several of my patients have described similar experiences. Several people living with mental illness whom I follow on social media share similar stories. Every morning that I arrive in clinic, I log on to my electronic medical records and pray not to see a message from the coroner’s office. As a psychiatrist, getting that dreaded phone call from the medical examiner is probably my equivalent to the oncologist receiving a call from a family member or hospice staff. As a young teen, I vividly recall accompanying my family for routine, frequent visits to my grandparents’ apartment, where my grandfather passed away, rid of the suffering he endured from colon cancer. A few years later, my grandmother peacefully died from multiple myeloma. Her last words to me before she passed was that she wished for the opportunity to pay for my education and witness me become a doctor. My other grandfather, as he approached the end stages of his battle with cancer, fulfilled his wish to fly back to the Philippines, where he comfortably spent his final days in his homeland with our large, extended family by his side. When the medical examiner’s call ends, my immediate response is to shut the door and sit alone in silence.

Finally recognizing the mixture of emotions that I suppressed the entire day, I could no longer hold in my tears. Rather than isolating (as clinicians tend to do when it comes to coping with patient loss), I attempted to share my thoughts and emotions on social media, with the goal to make others aware of the difficult emotions that we, as mental health practitioners, face when dealing with patient suicide. The loss not only permanently impacts us professionally in our practice, but also as human beings. I left the post on my feed for 20 seconds, then immediately deleted it. Shame, embarrassment, and fear of judgment overrode my hope to break the norm of silence and connect with others too afraid to open up about their own experiences losing a patient to suicide.

As you can see, I waited a few days to publish this post after much contemplation. The truth is that the fear of losing a patient to suicide weighs heavily on my mind almost every day.

August 13, 2015 16 comments

Medicine Psychiatry

The Drug Rep Dilemma

written by freudandfashion

I attend pharmaceutical dinners every once in awhile because: 1) I like to stay up to date with all the new drugs (or just a slightly modified version of the generic, but with a much fancier name and packaging); 2) Though I’m several years out of med school/residency, one thing I have maintained from those formative years is the mentality where I’d never pass up a free meal. I know that pharmaceutical sales representatives (also known as drug reps) have been banned and limited in several institutions, and I completely understand the reasoning (it has been shown that drug reps’ marketing tactics influence physicians to write prescriptions they typically would not write, thus boosting pharmaceutical sales). However, I also think it’s important for physicians to be self-aware of their existence and influence in order to make conscious decisions on their own.

A few months ago, I attended a pharmaceutical dinner sponsored by the manufacturer of one of the newest psychiatric medications. These dinners always feature a physician, who describes the medication (the pharmacology, indications, side effects, etc), explains the existing research in support of the medication, and leads a discussion and answers clinical questions. My initial impression of the night’s presenting physician: charming, and since his introduction boasts the research he conducts at a prestigious university, he must be highly reputable and intelligent. But, as his talk progressed, I realized how narcissistic and full of sh** he was. I sat in the very front, yet chuckled to myself and assumed every other clinician in this room picked up on his suave, yet unconvincing tactics. I mean, who was this guy trying to fool by flaunting his European accent and stories of trips around the world??

However, I looked around the room and the entire audience of doctors and other clinicians were laughing and smiling in awe. I tried to hide my disdain and cringing facial expressions, but I sat at the very front of the room, so I’m sure others noticed. Or maybe not…I mean, everyone in the room was mesmerized by this guy! I figured that I should refocus my thoughts and give him another chance and caught up just in time to hear about his trip to Europe. I shook my head and thought to myself, “wow, can you believe this guy? And he gets paid tons of money to attend this dinner and talk about himself?” I smirked and assumed his current, pointless story-telling (aren’t we supposed to be discussing the medication?) would be convincing enough to prove his bullsh**, fake persona, so I turned to look at the audience assuming others would catch on. Still, all smiles.

At the end of the dinner, I found myself in a dilemma as I had to pass this man on my way out as I left the dining room. I contemplated whether I should act just as fake as his schmoozing and say something along the lines of “hey, great presentation” or should I challenge some of the comments he made? I settled for a more neutral comment and told him “thanks, you are very entertaining” as I shook his hand and smiled.

Then, I realized at that very moment I became just like everyone else in the audience who commended and complimented him. For a temporary, quick second I even contemplated prescribing the medication. The thought of prescribing the medication was short-lived, for, after I left the restaurant, I snapped out of it and wished I gave him a piece of my mind.

I thought, “oh well, instead I’ll just stick with my guns and won’t be overly influenced to prescribe the med, unless clinically indicated.” (I’d never deprive my patients of a medication that might possibly help). I now realize even more why pharmaceutical companies used to frequently provide fancy trips, extravagant dinners, and expensive novelties before policies/rules became more stringent. The speakers and drug reps can be quite hypnotic and mesmerizing, but it’s our duty not to be fooled by any marketing tactics.

Or have I already been swayed?

July 2, 2015 11 comments

Medicine Psychiatry

Out of Isolation

written by freudandfashion

{Calistoga, California}

I noticed that my latest posts convey far less emotion than usual. My reserve for tolerating stress had reached maximum capacity, which I realized upon my first day back at work from vacation three weeks ago as exhaustion immediately erased any sense of relaxation from my trip. Perhaps I should have requested two weeks off instead of one? Either way, I’ve felt numb in the past (as I wrote in previous posts), but my current state of numbness also included fatigue and the need for multiple naps throughout the day. At first, I blamed my tiredness on multiple potential causes (overexerting myself during workouts, not eating enough, lack of sleep). I returned to clinic with a massive inbox full of emails, prescription refill requests, and patient messages, but the one message that impacted me the most was a note documenting that one of my patients (whom I least expected to have a suicide attempt) was in the psychiatric hospital due to an attempted suicide by overdose. Normally, I’d breathe a sigh of relief knowing that my patient was alive, safe, and receiving care in a secure environment, however, something triggered me at that moment to feel even more anxious than usual, which led to a massive headache. Did I develop a headache because my mind can’t tolerate the thought of experiencing even more patient loss and grief?

Fatigue continued to hit me on a daily basis. And how ironic that I recently wrote a blog post on tiredness and neither of the reasons I listed seemed to fit my case. However, I neglected two important, plausible causes (one that I even listed in my post) — Burnout & Depression. One of my closest friends asked if I might be depressed and I quickly replied, “no, I just need to eat better.”

I thought to myself, “How can I be depressed? I make a good living, I chose to enter this field, people respect me and tell me I’m a great doctor, I have amazing family and friends…”

Yet, after fighting the idea that I may in fact be burned out and depressed, I became more accepting and relieved at finally pinpointing the cause — yes, I was burned out and depressed. I was experiencing loss of interest, fatigue, poor concentration, lack of motivation, and increased naps during the day. How dumb of me not recognize the signs, especially since I’m a psychiatrist??? (Depression obviously impacts cognitive abilities as well)

Later that day, I randomly thought of one of my patients whom I haven’t seen in clinic for quite some time. He missed his last two appointments with me and never returned follow-up calls. I quickly searched for his name and confirmed my biggest fear once I saw the word “obituary” next to his name. Tears filled my eyes, which led to uncontrollable sobbing. I seriously wanted to quit my job that very moment.

My attempt at self-care and setting healthy boundaries:

Whereas in the past, I would’ve dealt with the news by isolating, throwing myself into work as a form of distraction, or having several glasses of wine once I came home, I knew that I’d eventually hit rock bottom unless I sought help from others. I reached out to my close friends, sought support from my clinic manager, opened up about my issues in my therapy group, and talked to other staff members who knew my deceased patient. I allowed myself to cry rather than holding in the tears.

Feelings of detachment had also replaced my propensity to engage with others, which made practicing psychiatry and being fully present for my patients much harder. I scheduled a trip to visit my family in northern California for Father’s Day because I knew that visiting home would alleviate my detachment and make me feel like myself again. Also, in further effort to prioritize self-care, I requested a two-week long vacation in the following month because I knew that more time off was necessary to fully recover my emotions, energy, and drive.

Why am I sharing my experience? We may read research, statistics, and articles about physician burnout, yet the majority of people in the medical field still do not feel open nor comfortable enough to share due to fear of stigma, criticism, and feelings of guilt and shame. A part of me even feels somewhat embarrassed posting this, but if someone out there can identify with my experience, then why not share? Physician burnout is more common among physicians than other workers in the United States and has been linked with the following: negative impact on patient care, more likely medical errors, depression, and increased risk of suicide among physicians and medical students.

Staying silent about our struggles and trying to cope on our own does not solve the problem, especially since the rate of physician burnout is on the rise. If we can’t advocate and stand up for ourselves, then who will?

June 25, 2015 26 comments

Medicine Psychiatry

Why Am I So Tired?

written by freudandfashion

{Rancho Cucamonga, California}

As I struggled to get up this morning and hit the snooze button multiple times then proceeded to turn off my alarm clock on accident (thus waking up several hours later), I contemplated reasons why I’m feeling so tired today. I’m sure several of us try to diagnose ourselves, and sometimes jump to the worst conclusions as to the causes of our tiredness. But before you start self-diagnosing, here are a few potential causes that I generally explore with my patients before resorting to lab tests and referring back to their primary care doctors:

1. Are you getting enough sleep? Lack of sleep is an obvious cause, but you’d have no idea how many people actually believe they’re inhuman and should be able to get by on less sleep without crashing.

2. Is your schedule constantly changing? Our circadian rhythm acts as an internal clock that guides our sleep-wake cycle. Any disruption as a result of a change in schedule or activity (ie, I have several patients whose job schedules constantly change, such as firemen, dispatchers, etc; or college students studying late night for exams; or recent travel to a different time zone) can disrupt your cycle, thus causing you to feel more tired than normal during the day.

3. What type of food do you eat? If you start your day with a meal chock full of refined carbs (bagel, doughnuts, croissants, etc), your insulin levels skyrocket, thus feeling sluggish. Also, not eating enough food is an obvious reason for low energy levels.

4. Do you rarely exercise? Just turning up your current level of activity up a notch (ie, if you’re sedentary, start walking, etc) has been shown to increase your energy levels.

5. Do your workouts involve exercises that your body’s not quite yet conditioned to? I, myself have tried various types of workouts programs and generally struggled to adjust when I first started, which is to be expected. In the past, I’ve done boot camps and Crossfit, which I truly enjoyed, yet my recovery times were quite long (in addition, I also had to change my nutrition to adequately fuel my body). Thus, I had several days where I’d want to nap or veg on the couch all day (leg days tend to be the worst!). I have several patients who feel abnormal because they’re making great efforts to drastically increase their physical activity, yet don’t realize that feeling tired during the recovery phase is normal.

6. Did you forget to take your medication? Thyroid medications (such as levothyroxine), stimulant medications (such as those used to treat ADHD), antidepressants (such as buproprion) can drop your energy levels if not taken regularly.

7. Is it a medication side effect? If you were recently started on new medications and notice that you’re feeling more tired lately, then check with your doc (or search online as most people do) to check if lethargy is a possible side effect.

8. Did you cut back on your regular caffeine intake? Somnolence is a common symptom of caffeine withdrawal (in addition to headache, irritability, decreased concentration, etc).

9. Did you overexert yourself with activity recently? Work, running errands, planning a big upcoming event, etc — it’s normal to feel exhausted and need time to regroup after a busy day (or days) of activity. Know your limits as to how much activity you can handle, or go easy on yourself if you’re not as productive on subsequent days.

10. Are you working on some difficult material in psychotherapy? Since I am a psychiatrist, I usually explore this possibility. Processing difficult emotions can be draining. I’ve experienced this firsthand and used to take naps after my Saturday sessions with my therapist.

11. Is tiredness a sign of depression? If tiredness is also accompanied with symptoms such as loss of interest in activities you normally enjoy, isolation, sadness, etc, then lack of energy might be a sign of depression. Reach out to your doctor, especially if symptoms don’t improve and start impacting your ability to carry out your daily activities.

If the cause of tiredness is not apparent, then make sure to contact your medical doctor to discuss your symptoms. However, more often the cause of tiredness is not a major medical issue. In my practice, I find that the most common cause of lethargy is related to schedule and unrealistic expectations that we place on ourselves to be superhuman (I’m definitely guilty of this) and accomplish so much in one day without allowing adequate time to rest and refuel, thus leading to excessive stress, insomnia, poor eating habits, subsequent depression, etc. Listen to your body — if rest is needed, allow yourself enough time to reset, relax, and gain your energy back.

Photo by Marlon Santos

June 3, 2015 5 comments

Medicine

What Being a D.O. Means To Me

written by freudandfashion

When approaching the door leading to my office, patients often look at the signage and proceed to ask one of the most frequently asked questions I receive: “What’s a D.O.?”

Several books and articles exist on explaining the background, history, and differences between being a D.O. (Doctor of Osteopathic Medicine) versus an M.D. (Doctor of Medicine). Also, debates on which degree is better persist, though I personally find the feeds quite annoying and amusing at the same time (mostly because I remember diligently reading these forums before applying to medical school, which were predominantly biased towards M.D., but I’m able to confidently say that myself and all of my classmates/colleagues that I know of from my D.O. program turned out just fine). So let me be clear that my purpose is NOT to exacerbate the debate between which degree to choose, but rather convey what being a D.O. means to me.

But first, let’s get the basics down regarding the two degrees (if you’re already aware of the basic similarities/differences, skip to the next paragraph):

What’s the same:
- both undergo four years of medical school education (some schools actually offer both MD and DO programs where students attend the same lectures/classes, such as Michigan State and Rowan University).
- both undergo the same amount of residency training depending on the program
- both are fully licensed to practice medicine in the United States
What’s historically a bit different:
- Different licensing exams: DOs take the COMLEX while MDs take the USMLE
- DOs receive > 200 hours of osteopathic manipulative medicine training; MDs do not.
- DO programs are historically known to accept the non-traditional applicant (for example, the average age of students are a bit older, may be non-science majors, or seeking a second career)
- In 2008, 7% of practicing physicians in the U.S. were DO graduates and 68% were graduates from a U.S. MD schools (I tried to find more recent statistics, but couldn’t find an accurate source)
- Osteopathic medicine is distinct in its philosophy that “all body systems are interrelated and dependent on one another for good health” (American Association of Colleges of Osteopathic Medicine)

I applied to both MD and DO programs for medical school and remained open to attending either one. I interviewed at both types of programs, but only received acceptance letters from DO schools. Perhaps I didn’t have the highest MCAT scores, GPA, or my interview responses weren’t impressive enough? Well, whatever the reason, I was just happy that the DO admissions committee gave me the chance to prove that I’d make a good doctor.

The whole concept of a more holistic approach to medical practice offered by DO programs sounded ideal to me, yet at the time I was more focused on getting through school and graduating rather than on how the philosophies would impact my practice as a physician. After graduating from medical school, I had the option to apply to either DO or MD residency training programs. I applied to both, yet decided to pursue the osteopathic route when I heard about the opportunity to be a part of the first osteopathic psychiatry residency on the west coast. As the oldest of 33 grandchildren, it was inherent of me to jump on the opportunity to help trailblaze a new program (my program director nicknamed me Hiawatha). I knew that my decision posed potential limitations in obtaining a future job since a few organizations still don’t accept psychiatrists certified under the osteopathic board. However, I took the risk because I saw more value in being the first to graduate from and help shape a new, developing program.

For me, being a DO fits my personality and what I’ve grown to stand for in my practice: being integrative, holistic, and preventative. I truly believe that without such an emphasis on integrative medicine as one of the main tenets of the program, I wouldn’t be the physician that I am today. Therefore, it’s no wonder that 50% of the graduates from DO programs become general practitioners (family practice, internal medicine, emergency medicine, etc). I initially despised having to attend osteopathic manipulation classes, and even failed my very first practical exam. Yet, the hands-on approach made me unafraid to touch my patients. Each psychiatrist is different, but for the most part human touch provides a sense of comfort and connection. A few of my patients politely ask for a hug, and if appropriate, I unhesitatingly oblige.

And in some unique way, I feel that being a DO caused me to work harder in a field predominantly filled with MDs to make my presence and way of practicing known. When a large, metropolitan county declined to consider me for a job due to my credentials, I utilized the rejection as motivation to persevere rather than a barrier.

And most importantly, I used to feel bombarded by the numerous, large framed portraits of osteopathic medicine’s founder, Andrew Taylor Still, MD, which hung in almost every corridor of each osteopathic institution. However, after feeling frustrated with several aspects of current practices in medicine, I’m undoubtedly far more appreciative and understanding of AT Still’s motivation in the 1800s as an MD to create a method of practice that rose from adversity (he lost 3 of his 12 children to viral meningitis with no method of saving them even as a physician himself) and frustration (an over-dependence on medications and the sometimes harmful medical practices of the time). I actually wish his story was more widely publicized because he epitomizes successful individuation from mainstream medical practices amidst much scrutiny and opposition.

In the field of psychiatry, where Western medicine can’t always explain nor provide the most adequate treatment via pharmaceuticals, wouldn’t it be great if we had more modern day AT Stills to branch off and create a newer system of viewing and practicing mental health? I’m truly frustrated with the current practices particularly the overemphasis on medications alone. The number of overdoses (100 people die from drug overdoses everyday in the U.S.), medicated children as early as infancy, continue to rise. Medications are only one component of treatment, but greater emphasis should be placed on developing resiliency, acknowledging the individual’s unique traits, and treating the person holistically rather than symptomatically.

AT Still put it best when he said the following:

“An absolute demand for revolution is before us at this date and time, for there is a demand for a progressive step in the line for treating disease. For a number of days I have been haunted by the feeling that we are in danger of getting into a rut unworthy of higher consideration than should fall to mere imitation. Let us not be governed to-day by what we did yesterday, nor to-morrow by what we do to-day, for day by day we must show progress.”

April 30, 2015 23 comments

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