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

Bad News for The HEADoc

 It troubles the HEADoc to make today's entry. . .

but he must as a matter of principle. A reporter from the local paper was courteous enough to contact The HEADoc before printing information about a Consent Order from the NC Medical Board to run this weekend. Gossip usually doesn't bother The HEADoc for he knows that the truth always wins with enough time. There are always two sides to every story with the truth usually caught up somewhere in the middle. A consent order from a board is equivalent to an indictment in the traditional criminal court but should not be equated with a criminal act. It simply states that it has been determined that there is sufficient evidence for a case to be heard in the appropriate legal forum for the purpose of settling the complaint. The accused could be dealt with any number of ways. It could be determined that nothing further is required to remedy the situation or problem. Sometimes a doctor's license is restricted or suspended for a set amount of time. In the most serious cases a doctor will have his license to practice medicine taken away. The process serves to promote self regulation of the behavior of all members in a profession basically by public humiliation of the one accused of violating or deviating from what has been deemed the norm for that profession. Having information available on a website is one thing but editorializing it in a public newspaper is another. This is why the HEADoc must speak for himself. He has nothing to hide but just wishes to be treated fairly and understood from his own point of view. He will allow his reputation to speak for itself and those who truly know The HEADoc will stand by him because they know his heart and his devotion and intent to strive to do the right thing at all times. Those who don't really know The HEADoc can make up their own minds, if they even care about the matter at hand. The haters can think what they want.

One of the HEADoc's traits that has tended to cause him difficulties in the past has been a tendency to over extend himself for the sake of others. He chose the medical profession and psychiatry in particular because he didn't like seeing people hurt and suffer. The HEADoc is not ashamed to say that he believes himself to be gifted in the area of connecting with those suffering emotionally. He did not learn that in medical school. Even if he weren't trained as a physician, that would still remain. Being a physician has in a sense provided the necessary authority that those in need would have trust. The HEADoc believes in helping patients grow spiritually. Self destructive behaviors and addictions are the greatest hindrance to this occurring. No person can change such behaviors until they decide for themselves they are ready to let the denial go, seek and accept appropriate help, and make the necessary commitment to work toward their goals.

So what does any of this have to do with the Medical Board one might ask? The Board became involved because a pharmacist didn't think The HEADoc should treat chronic pain patients with methadone and made a complaint. The HEADoc knows of multiple cases of chronic pain where the use of methadone has given a much higher quality of life to that patient. The Board itself has encouraged physicians not to undertreat chronic pain due to fear of being disciplined by them. On the other hand, North Carolina is 5th in the nation in overdose deaths from methadone. This problem was major before The HEADoc even knew what methadone was. That's where the Board comes in. The facts are that 80% of the deaths are from wreckless or naive polysubstance abusers who weren't prescribed the drug from any doctor. When tested on autopsy such a person would have at least 3 other drugs of abuse in their system. Who is truly responsible here? Is it the government who continues to cut funding for mental health and substance abuse treatment? Is it society or is it that people should be more accountable for their own behavior? The HEADoc takes accountability that he did not document his treatment in the manner the Board thought that he should. At times addicts have been skilled enough to pass themselves off as legitimate pain patients, which the HEADoc regrets. Is not the more important question why are people so desperate that they would go to any length to obtain narcotics and other mind altering substances? Is The HEADoc responsible for this?

For a period of time The HEADoc found himself amidst a town that was recently voted to be in the top 5 best places to live of the nation. This is perplexing in that illegal drug use seems to be completely out of control and very little done about it in this great town. Is society that blind, that this problem can be that easily overlooked? Maybe The HEADoc is the one who is delusional. So what has the HEADoc done in the name of self accountability? Since everything will be exposed publicly this weekend he may as well speak for himself in regards to this. The HEADoc has got the heck out of Dodge, with Dodge being the town mentioned above that was voted one of the 5 best in the country to live. The HEADoc witnessed mostly despair economically and emotionally for many people. Being the only provider accepting Medicaid or Uninsured may have led to a skewed view but what The HEADoc saw was real. While reporting to the Board since 2005, The HEADoc set up policies in his practice that included a written agreement with patients prescribed narcotic medications for their medical condition. Violation of the agreement would lead to termination of treatment and referral to the appropriate substance abuse treatment facility or pain clinic, none of which really exist in a functional capacity. Well over 150 patients were screened and dismissed from the practice through policy enforcement in the years 2006 through 2008. The HEADoc attended a 13 hour course at Portland State University on appropriate prescribing of controlled medications to please the Board. On his own he did 20+ hours of self study and attended several lectures involving the management of chronic pain. He recently completed training for office based opioid dependency treatment with Bupenorphrine. In the new office all patients with suspected addiction problems receive routine drug screening. The HEADoc knows that discharging those who violate their agreement with referrals to places they won't even go to or won't accept them anyway is a futile gesture but it puts him in compliance with the Board. Those patients will return to that pool of patients doctors have been conditioned to avoid until another doctor accepts the risk of trying to treat one of their many problems.

So let the unofficial record state that no matter what you read in the papers about The HEADoc, he is not a quack. He is not a drug dealer or murderer. He abides by the law of the land. He has made every effort to work with the Medical Board in the past and present. He has tried to make a positive difference and he has done so with many patients. He is learning to recognize his limits and acknowledge that some problems are too big for any one person to tackle and attempting to do so can be self defeating in the long run. The HEADoc knows that the Board is the ultimate authority and will be well aware of that at his hearing on August 20th. He may be ordered to stop treating chronic pain or his license could be restricted or suspended. Whatever happens to The HEADoc will have little bearing on the real problems that have led to this situation. The HEADoc knows that the world is not a perfect place and he feels good about the patients he has helped in the past. Not treating chronic pain patients will actually be a relief for The HEADoc but he worries about many who won't have access to such treatment. From a political standpoint the Board may feel that it has done its job and publicizing this case will certainly put fear into other doctors of what to avoid doing in their practice of medicine.

  War on Pain Doctors http://www.doctordeluca.com