Love vs Fear (Adventures of The HEADoc)

Nature can be therapeutic. . . and it doesn't cost a dime to benefit. I have made a couple of entries previously about the process of transference and counter-transference. Freud made these two concepts popular in his practice of psychoanalysis. The subject may transfer emotions on to the therapist that are associated with past encounters with significant people. An example may entail the subject subconciously feeling contempt, resentment, or fear for their controlling and emotionally unavailable father since childhood. For the sake of interest, lets say the father recently died with those issues left unresolved which caused enough internal conflict within to motivate the patient to seek therapy. Since the primary issue with such a patient centers around problems with male authority figures this will almost certainly surface repeatedly in sessions with a male therapist. The therapist has three tools to work with: confront ideas and comments made by the patient, clarify ideas and comments, and make interpretations of how the past may be associated with the present. How and when to make such interpretations is crucial in how effective the therapist is in helping the patient to gain useful insights into their behaviors that will motivate positive change. Counter-transference essentially involves what emotions the patient drums up in their therapist. The therapist is able to interpret that if the patient arouses certain emotions within them then chances are they arouse the very same emotions in others they encounter. Since the therapy session is like a laboratory where ideas can be therapeutically dissected, the therapist over time can help the patient see more clearly why others treat them certain ways and the role they themselves play in that process. Most importantly is finding solutions to their unhappiness or other symptoms they may experience. I wanted to write about animals today but I thought the above preface necessary to help put my ideas into context. Three kittens have found loving homes. One I just couldn't let go. I spent less than two months with them but it was delightful observing them nurse and interact with their mother. As babies they just want to be loved and cared for. Some people deprived of such nurturing during their developmental years can become arrested in a psychological limbo and have ongoing issues and inner conflict. Squeaky is the name I chose for my Alpha kitten because of her high pitched meowing in comparison to the other three kittens. Squeaky was always the first of the litter to explore the environment. She was the most aggressive nurser and the first to discover the food and water bowls. She would follow mother around alone at times. Without her siblings as a reference point now Sqeaky seems traumatized. She is withdrawn and doesn't like being touched much. I think she senses the change in environment without the others and fears she may be taken away next. I kept Squeaky because I like her spirit. She was different. Yesterday I encountered a terrapin in the road on my way to my weekend landscaping project. This isn't the first time this has happened to me and as usual I felt the urge to turn the car around and to go back and rescue the poor terrified creature. I knew it was moments away from being crushed to death by a passing vehicle. He thought he was out of danger by retreating to the safety of the shell. Sometimes I have done the same thing metaphorically, thinking that by avoiding a problem that I had ridded myself of the problem, yet rendering myself oblivious to the potential dangers existing in reality. So I rescued another terrapin and moved him to a safe environment. I feel good about that. On the other hand... I have never resolved my irrational fear of snakes. During my raking and burning I came across a freshly shedded skin of a substantial sized serpent. I now knew that it wasn't all just in my head. He was really in the vicinity, probably watching me at that very moment, and I had no idea where he was. I was extremely cautious in my raking expecting at any moment for an aggressive four footer to hiss and strike at me just like on TV.  Aha! Under a pile of moist leaves there he lay almost ten inches in length. He appeared disoriented and confused as if he had been minding his own business and enjoying a peacful Saturday afternoon. Instinctively, I decapitated and violently beat the head with my rake. Feeling victorious, I picked up the evil serpent to examine the deadly hypodermic fangs I so feared. To my surprise there were no fangs. This meant I had killed an innocent and harmless water snake. Intellectually, I understand terms such as harmless and innocent but somehow haven't learned to view the snake the same as I view the kitty  and the terrapin. I do feel bad sometimes about being a snake killer so maybe I can reform and allow some of those poor creatures to live in peace. I did meet paths with a wasp nest in a small cedar tree that I wished to cut down. As a kid, I never got along with wasps very much and was known to pick a fight and end up being stung. So I have had an irrational fear of wasps, hornets, and bees in addition to snakes. This time, the wasp and I fought to a draw. I stopped chopping on the tree and he went back to finish his nesting business. Another day and another time the tree will be mine. I feel like I conquered yet another phobia in that brief encounter with my foe the wasp. My encounters with nature tapped into my emotions in a unique manner. The only true and rational emotions I believe to be the love for the kittens the compassion for the terrapin, the remorse for killing the snake, and the respect for wasp's residence. I'm glad to have this opportunity to work through my issues and misunderstandings with nature.

psychiatrypsychology

I Ain't Scared of You. . .

What's that light at the end of the tunnel?. . .

It could be the daylight of peace and tranquility or it could be the proverbial freight train of more and worse to come, or maybe just another mirage to extend hope a little while longer. I arose this morning to learn that a favorite comedian Bernie Mac was dead at age 50 and Senator John Edwards had confessed to the rumors in The National Enquirer putting his political career in ruins, for the time being at least. These shocking realities saddened me but also caused me to realize how blessed I am. In the past couple of years I have faced the threats and realities of divorce, foreclosure, bankruptcy, death of family, business failure... Every doctor fears the humiliation of being published in the quarterly newsletter of the Medical Board for facing disciplinary intervention. We all understand that is the way the profession polices itself since most physicians are quite conscientious and feel bad when they commit a regrettable act on occasion. For most it would be preferable to secretly spend thirty days in the County Jail than to endure unfair or unwarranted public scrutiny. I had prepared myself for the inevitability of making the Newsletter. I definitely was not prepared for newspaper and television news involvement. I never read the article nor saw what was reported on the evening news. Some who support me described it as B.S. It makes me feel good to know that not everyone is programmed to automatically accept everything they are fed at face value.

In order to move on with my career and my life it is important for me to speak for myself and make sure the record is set straight. Those who really know me are aware of my competence as a practitioner and my caring nature. There is really no power given to any human or group of humans capable of changing those two facts. The Medical Board became involved with my practice of medicine because of complaints from outsiders who drew their own conclusions to how I found it most appropriate to treat opioid dependence and chronic pain patients. Many would comment that you shouldn't have been treating them in the first place. My answer to that would be that if our health care system functioned as it is suppose to I never would have been treating such patients. Maybe so many other doctors would not avoid such patients if the inappropriate patients received appropriate intervention medically and legally. The real problem is not legitimate chronic pain patients. The real problem is the addict who has chosen to willfully engage in unlawful behavior. A person of such character has no regard for anyone but self and they deep down don't really even care for self or they would not choose such a self destructive pathway to live. I have little compassion for a person who is willfully dishonest and deceitful. Many have been discharged from my care once the truth became known. Such people are the other source of complaints and false information supplied to the Medical Board. Aside from that, the Board reviewed five of my charts dating back 1 to 2 years. During previous meetings with them I was told what was deficient in my documentation and what needed to change in the future to continue treating chronic pain patients. The Board left me believing that completing the Continuing Medical Education I took at Portland State would be sufficient to prevent them from going forward with any legal proceedings. They made a compilation of all I had told them in good faith and used charts they already knew were representative of the pre remedial situation to justify a public smear of my practice of medicine.

So what could be the worst possible outcome? That of course is easy to answer. I could lose my privilege to practice medicine permanently. Is that likely to happen? Absolutely not. Most of the Board's leverage comes from embarrassing a doctor publicly when they want that doctor to comply. After that, they tend to show a display of overwhelming force to show that doctor that he or she cannot possibly win against them. They have nothing to do with the actual practice of medicine but everything to do with who is allowed to practice medicine and what their scope of practice can entail. They mask everything behind protecting the public. In my case the main people protected by them are ones who regularly break the law. Others such as legitimate sufferers of pain from chronic conditions will be again told they can't be treated in the most appropriate manner because of intervention by their government agencies.

How much wrong have I really done? First of all, I don't really want to treat a lot of chronic pain patients. For the vast majority of patients I have prescribed an opioid to I think it is for the best for them to be treated elsewhere. Where that elsewhere is, I'm not sure. This catch 22 cannot be resolved by me. The pain clinics can go only so far with them, the orthopods and neurosurgeons would rather not be bothered, family docs don't have the time to address the addictive component associated with many of these patients' condition. A subset of patients found the perfect home with me and have done exceptionally well. They have found adequate relief to have their life back, to a degree. Without such relief some patients would consider suicide. To the Medical Board this would be preferable to me continuing their treatment. I'm sorry but that really bothers me. That's why I encouraged such patients to write the Medical Board themselves to express their feelings about their right to treatment being tampered with for bureaucratic purposes. Some patients simply do need a medication such as methadone to control their chronic pain. I think it is probably unethical to deprive them of the treatment they need in the name of protecting them. As Dr. Deluca with the Pain Relief Network has stated in his video interview, few people in America receive the true standard of care for chronic pain for the simple reason that the average doctor fears the repercussions for attempting to provide such treatment to the degree that may be necessary. I feel if I had never prescribed methadone for chronic pain treatment the Board would never have taken things this far. The DEA is a federal institution and could only charge me for a criminal act or for using narcotics for non medical use or for treating substance abuse disorders without the proper licensing. Physicians usually use certain narcotics for the treatment of a diagnosis of a chronic medical pain condition. This is perfectly legal in the United States. But... the State Medical Boards make the criteria for what is deemed a legitimate medical condition. Most doctors are not aware of the detailed criteria in the policies until it's too late. By that time the Boards can have enough against a particular doctor to use against them in any way they see fit to suit their purposes. In my case, the remediation done as requested was irrelevant but it would give them justification to allow me to continue treating pain patients if that was their desire. They hold all of the cards.

I have been advised against going through with the hearing for it would more than likely be pointless and could make things worse in the long run. However, if I had the legal backing and finances I think the cause is worthwhile to fight for. Without such support no individual citizen can expect to beat the State. That much has become clear to me. The norm in such a case as mine is have a consent order issued that allows the Board to feel it has acted sufficiently on behalf of The People of The State of North Carolina.  Basically, the doctor is ordered to do as they say and the doctor consents. This consent frees the doctor to not have them on his or her back any longer. The doctor's license is usually restricted for a year as a technicality but things go on as usual as long as the doctor stays out of trouble in the future.

All but a few of the patients I have treated for chronic pain seem to be handling the news ok that I will be ordered to no longer treat their condition. At times I wish I had forced myself to cap my chronic patients at the 10 or 12 that I find it most rewarding to treat. Had I done that, I believe that none of this would have happened. I can only hope and pray that they will find one willing and able to provide the treatment they need. Those patients are most dear to me because they constantly remind me that I did do some good in this context and that in principle I have been right. Despite that, there still often comes a time when one must let go because ones limits have been reached for a situation.

Dr. Alex Deluca, Pain Relief Network

psychiatrypsychology

4 Years of HEADoc

 

August 8, 2008 will mark the 4th anniversary of Thoughts From The HEADoc-Quest 4 Sanity. . .

How cool is that? The HEADoc has thought of this journal often as a cry from the wilderness. Such a metaphor tends to speak for itself in that it was known from the start that not every potential reader would hear the messages while still others would hear what they chose to hear. Some would interpret courage and insight yet others would see foolishness or insignificance. Still The HEADoc tried to keep it real and write about subjects rarely mentioned from such a perspective as his own. The Quest was never about the personal sanity of any individual person but mostly about situations in life that can sometimes challenge that personal sanity of essentially anyone. The THOUGHTS have not been specific for Psychiatry but have been generated by one who practices Psychiatry. An effort has been  made to document original thoughts, freely associated, and of interest most of the time. On a rare occasion an entry has been synonymous with pornography as far as what has been shared with readers. In a pornographic film the actors tend to relish in exhibiting a behavior that should be private. The actors know that those seeking what they have to offer will identify. The idea here is not to suggest perverted writing but to suggest that The HEADoc did not alter the writing for the sake of political correctness or attempting to please readers or to make himself look good. Non fiction to The HEADoc is more valuable than fiction.

Readers who are of an ultra conservative right wing world view will never see eye to eye with The HEADoc on much and usually wouldn't read more than one post anyway unless wishing to pursue an argument, which has actually happened before. The HEADoc, believe it or not, is not a bleeding heart liberal as one might be inclined to believe but would identify himself with The Rationalist's party, if such a party existed. The Rationalist's party would take the good ideas from the existng political parties and discard the rest of the B.S. The Rationalist would be seen as a communist by the Right and as too hard to pin down by the Left. A Rationalist would be small on talk and big on action. A Rationalist would not need to lie to the public or mislead the public because he or she would identify with the public. When a policy failed, The Rationalist would be required by conscience to admit that and immediately investigate and begin a rational reform of that policy based on fact and logic. The Rationalist Candidate would win every election because of full undisclosed accountability to the public. The Rationalist Candidate would conform only to common sense and show limited loyalty to political correctness. He or she would not fear stating such beliefs as: Oswald didn't act alone nor did James Earl Ray or Sirhan, that more could be done to stop the flow of illegal drugs across the U.S. borders, that Bush didn't really win in 2000, investigate 9/11 to find out what really happened, the Iraq War was unecessary, there is no gas shortage (yet), Obama really is the better candidate.

Enough of the nonsense. The HEADoc has worked through his grief fairly well and does not wish to be perceived as a victim. He has thought long and hard about the situation with the Medical Board and has tried to see the situation from their pespective. He has accepted the possibility that perhaps they could be right (according to the statutes) and on a technical basis at least, The HEADoc should probably just accept that. In the arena of treating chronic pain patients, the time to throw in the towel is nigh. The HEADoc has begun to see that most of the true pain patients greatly fear having to find another doctor to effectively treat their pain and fear losing the security they have found with knowing someone cares enough to make sure they have what they need. Some of The HEADoc's patients have done exceptionally well with treatment after years of seeking relief. The HEADoc believes this mostly due to the fact their emotional needs were validated and addressed in addition to the physical  state of disease initiating their pain. The most important lesson learned from treating chronic pain conditions has been how the road to true and lasting analgesia is centered in changing how the brain perceives the pain signal. Ridding the body completely of pain is an unrealistic goal for any treatment. Teaching the brain to experience pleasure again is key in the chronic pain patient with depression and anxiety based on the premise that the brain is not constructed to perceive pain and pleasure simultaneously and must choose which to experience at any given time. When chronic and persistent pain becomes the sole focus of ones life the regions of the nervous system that conduct primarily good thoughts and feelings, in a sense, can cease to function adequately. The pain conducting areas of the nervous system then operate unchallenged, thus a vicious cycle of pain, depression, and anxiety persists.

At this time, The HEADoc recognizes that the well being of the patient is what is most important. The Board states the safety and well being of the public as its primary responsibility. The Board's basic stance, in this particular case, is that it is better for many people to live in more pain than they have to than to risk  one more addict getting their hands on a drug they shouldn't have. The HEADoc intends to continue providing quality psychiatric care to the chronic pain patients within the practice while facilitating referrals to a provider willing to treat their pain conditions. This will be an extremely difficult process for some patients and will produce emotional distress.  Many patients have made it clear that the value of the mental health care received has been equal to or greater than the value of treatment of their pain condition and they have no intention of terminating their psychiatric care because of being required to find chronic pain treatment elsewhere. The HEADoc will do his best to help such patients deal with the fear associated with the change. Their treatment has been considered sucessful and if successful in finding effective continuation of treatment for their chronic pain condition the best may be yet to come for them.

psychiatry