Posts Tagged ‘addiction’

Perfect people don’t come to see me.

May 1, 2019

When it comes to the way patients flow,
You could call this gig a bit slow.
But the patients expressed
They’ve been pretty impressed
At the warmth that I can show.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania, western Nebraska and Canada. I have now returned to southern Alaska. Any identifiable patient information has been used with permission.

I currently deal with low patient flow on a daily basis. Yesterday I had, for the second time, 5 patients in one day; all the other days have gone more slowly. Yet with 5 patients, each scheduled for ½ hour appointments, I kept busy. My electronic inbox never gets to empty. I review lab work and incoming consultation results. In fact, my in box would keep me busy for about 2 hours a day whether or not I saw patients. Thus the electronic version of paperwork flows so fast that it has acquired a life of its own.
Still I have a good amount of time to spend with each patient. I impressed each one so far with my patience. I nod, I listen, I take notes. I get to ask the patient their agenda. The vast majority have been over the age of 70; the youngest so far this week was 48.
But I interrupted one patient. Within 2 minutes, I knew my trouble following his story came from his shifting focus. The numbers in his narrative didn’t add up. After a while I asked if he were having trouble focusing, which he was. Eventually, that one piece of information, more than any data from the telling, gave me the diagnosis.
One patient, who gave me permission to write this, has ankylosing spondylitis, a disease I myself have struggled with since 1967 (or maybe 1963). The best I could do during that visit came down to running a chronic pain support group with two people. We turned out to have a lot in common.
Addicts lie. This truth comes so consistently that, when I find a liar, I look for an addiction. However fun and charming the addict, their words cannot be trusted, especially when it comes to what drugs they use. I have not yet found a way to figure out when an addict stops lying.
But I listen to the addicts and alcoholics as patiently as I listen to the overeaters and the smokers. Perfect people do not come to see me. Everyone who brings illness through the front door comes with a back story of drama and irony, and I have the time here to dig for the patient’s agenda.
The patient’s agenda always wins. Asking what they want in 5 or 10 years uncovers that agenda better than anything else, but does not do so perfectly. Some people don’t know what they want. But asking what they want makes them think.

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Taking call as an addictive process

November 10, 2013

Let me talk about my predilection,

Which looks a lot like addiction

I keep taking call

After I’ve hit the wall

But improvement is my prediction.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and 4 days In Mexico for our daughter’s wedding.

In 2001 a government Task Force declared pain the 5th Vital Sign that needed to be assessed at every visit along with temperature, pulse, blood pressure, and respiratory rate.  In the aftermath, pain management did not improve.   But the unintended consequences marched forward, with non-suicidal lethal overdoses of prescription opiates quadrupling in the course of ten years, until last year those drugs killed more than traffic accidents did.

Since September I’ve logged more than 70 hours of CME; about one-fourth of those hours have concerned addictions, pain management, and narcotics.

All addiction processes share certain characteristics.  The behavior continues despite adverse consequences, and occupies time to the detriment of other important activities.  Loss of control strongly indicates a pathologic behavior, where, for example, a person might say at the beginning of the night, “I’ll only have two drinks,” but loses count.  Or the runner who, intending to just do a quick 5 miles, ends up doing 14.  Loss of control counts even if it happens rarely.

The part about the addictive behavior robbing time from family hit home when I thought about my years taking call.  When I have call, my family knows they can’t depend on me.  I need increasing amounts of time to recover afterwards, both because I am aging and because the call burden has grown.

I have had adverse consequences.   About a year ago I started having palpitations corresponding to runs of atrial tachycardia from the stress of staying up too many nights in a row.

And I have lost control.  In residency, one can understand the naïve young doctor volunteering to help another resident out, but I failed to learn.  Recently I found myself working at 2:00PM though my call had ended at noon.

Yes, my employment depends on my taking call.  But I also have a friend in the wine and spirits business, who drinks for a living.  That he does it professionally does not negate his alcoholism.

To the best of my knowledge no one has examined taking call as an addictive process, but it sure looks that way to me.

I have only two bad nights of call until my clinic hands over our hospital business (with the exception of patients under the age of 18) to the hospitalists.

I wonder if I’ll backslide when I can’t find (or start) a Calloholics Anonymous meeting.

DOCS: The Distant Obstreperous Child Syndrome

January 13, 2013

Even when long, life is brief

From the tree one must drop, like a leaf.

For those left behind,

We’re all of a kind,

Love is paid for with grief.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Weekend call comes with a theme; this weekend I keep foundering in the shoals of familial dysfunction in the wake of parental alcoholism.

I do a lot of explaining from my own family story.  “It does something to you,” I said far too many times this weekend, “to watch someone you love killing themselves.”

Terrible ambivalence devolves upon the only child of a self-destructive parent, that same anguish spread through a larger sibling cohort pushes children into emotional roles that come to dominate their lives.  From experience, the most geographically distant child moved the furthest away emotionally; having left the most unsaid, when the final hours of that parent come that child has the least emotional preparation for the ultimate separation and will make the most trouble for the health care team and the entire family.  At the Practice Formerly Known As Mine we called it DOCS, the Distant Obstreperous Child Syndrome.

In those cases, I point out to the other siblings that the one child making the most noise really can never be ready for the parent to depart, and takes upon him or herself the feelings of unfinished business of all the brothers and sisters.  Thus the observation than under the best of circumstances a split in the siblings follows the death of a parent and that split seldom heals.

The child who has had the most involvement, who sees clearly the limitations of the human condition and knows that the time has come to embrace the grief and then move on, rarely makes a show out of their internal emotional state.

The same things happen in families without dysfunction but alcoholism or any other addictive behavior magnifies the drama and multiplies the irony, especially if the mechanism of death comes from the addictive behavior.

If a parent firmly places a finger on the self-destruct button, and has only one child, all those sociologic and emotional roles get concentrated into one psyche, and the whole grieving experience will increase by orders of magnitude.

Things only get worse in the absence of advanced directives.  If a person puts first things first, and, seeing the end coming, makes out a clear will, pre-arranges funeral plans, and attaches a Do Not Resuscitate form to the refrigerator, they probably didn’t indulge their destructive addictions at the expense of their families. 

By the same token, addicts, alcoholics, and adulterers maintain a steady stream of chaos and leave behind a mess of unfinished business when they go.

If people could live forever, we wouldn’t love the way we do.  Human love remains an undeniable force even in the face of bad parenting and addictive behaviors.

If a split comes between you and your siblings, I say, it can only continue if maintained, and don’t you be the ones who puts more energy into the maintenance than everyone else.   And if you have no siblings, don’t isolate yourself in your grief.

 

At last, the geographic cure worked once.

July 18, 2012

We wonder where the time went

And thinks of the hours we spent

I always guess wrong

About just how long.

Nothing’s a hundred percent.

 

I tell my smoking patients not to try to quit by cutting down, first because it doesn’t work and second because it constitutes a slow torture.  Physiologically, a gradual nicotine dose reduction prolongs the agony of withdrawal while it makes the smoking habit stronger.  And people who want to ‘cut down’ haven’t made an emotional commitment to quit.

Observation confirms theory; in the 30 years since I finished residency I have met 3 people who quit smoking and stayed quit by cutting down, but I’ve met tens of thousands who failed. 

Thus I can’t say categorically that cutting down doesn’t work, I can say that other methods offer a much higher chance of success.

Recovering alcoholics and addicts will speak derisively of the geographic cure.  Active substance abusers will, sooner or later, try to blame their addictive behaviors on their surroundings and companions.  Thinking that the problem resides externally, they try moving to another place to make a fresh start.  On arrival at the new destination they find new connections and bars, and their abstinence collapses less than three months later.  No more than a year passes and they return, generally with their dependency having moving forward a notch or two.

Those people in recovery say the first person you need to fix is yourself.

Yesterday for the first time I met a person for whom the geographic cure had worked.  For reasons of confidentiality I can’t give details, but later that evening I mentioned the case to a nurse, declaring that every day I see patients I find at least one thing I’ve never seen before.  The nurse blinked and, deadpan, told about caring for a patient who survived a fall after a parachute failed to open.

Every known malignancy has at least one miraculous survivor; people who go decades with metastatic lung cancer are common compared to those who exit airplanes without a parachute and live.  Yet we now have dozens if not hundreds of cases of people who survived falls of hundreds or thousands of feet.

Over the weekend a family member asked how much time a patient had; I refused to give a number because I guess so poorly.  I recall one patient I looked at and thought, “Just hours now”’; yet another patient I firmly believed had months died in less than two days.

We never know how much time we have in this world, and in the last 8 days (including 5 twenty-four hour shifts) I have repeatedly run into the fallout of people with terminal diagnoses deciding to tell or not to tell their families.  I advise the patients that if their loved ones would spend more time with them, knowing that the end was near, that they should by all means spread the knowledge. 

Most listen.

Confessions of a chocoholic

September 12, 2010

Dark chocolate brings love at first bite,

In moderation I suppose it’s alright

     The stuff in the cocoa

     Won’t drive you loco

But it might keep you up all the night.

Having failed to take my own advice about chocolate, my sleep suffered last night. 

I’m probably a chocoholic.

Any person who can tell you that they like dark chocolate and specify, for example, that optimal cocoa content is between 70% and 78% is a chocoholic.  I suppose that would be me. 

Anything more than two bites will bring heartburn and reflux and disturb my sleep.  Half a bar will give me a visible tremor, a whole bar will make my heart race.

When I went to Barrow I deliberately failed to bring chocolate with me, but while I was there I found Dove Promises selling for the princely sum of five bucks a bag.  I bought them.  I confined myself to two a week.  When I ate them, I did it right: I didn’t do anything else but sit and let the chocolate melt in my mouth.  I did well with moderation.  If I weren’t a chocolate addict, I would lose control.

Such loss of control, even rarely, distinguishes moderation from addiction.  Five ounces of wine, five days a week, will add years to your life but putting away five or six drinks in a night, even occasionally, will cost you years.  If you use caffeine occasionally, it will be your ally; if you use it regularly you will be its slave.

I actively lobbied to bring no chocolate on the moose hunting trip to Kalgin Island; if it’s dark enough to satisfy my craving, it’s got enough caffeine, theobromine, and theophylline to make me shake, and thus impair my shooting. 

I hadn’t bought any since my return to Sioux City until Friday afternoon when Aliya and I went to the grocery store.  I lost control.

The worst chocoholic I ever met ate two squares of baking chocolate a day with the following philosophy:  chocolate is so good that if you add anything to it you just dilute it, and why would you want to do that?

Still, caffeine is the most benign of the addictive drugs.  If I have a patient who has sleeping difficulty and is drinking, for example (I’m not making this up) sixty-four cups of coffee a day, I’ll tell the patient that the caffeine is murdering sleep and to try going without the caffeine for two weeks.  When I do that, I don’t meet denial, minimization, or projection.

When I tell a patient that alcohol is causing their medical, social, or legal problem, the most common response is denial.  Denial is usually followed by minimization (it doesn’t happen that often, I know a lot of people who drink more than me, that arrest could have happened to anyone) and projection (don’t you drink, Doctor?  Then you don’t have any business talking to me about my drinking.). 

I’ve been advising patients for thirty years not to smoke, drink, or use caffeine.  In all that time no smoker has been able to achieve control over nicotine.  Fewer than a dozen alcoholics have been able to maintain normal drinking without losing control.  In contrast, exactly two caffeine addicts, having successfully withdrawn from high-level daily use backslid.

Caffeine and its cousins, theophylline and theobromine, make chocolate addictive; without those three it just doesn’t taste the same.