It's That Time of The Year Again!

Seriously? Why?  Why is it almost October already again?  If you are a Psychiatry resident or any kind of medical resident for that matter in a U.S. residency training program, you don't equate fall with changing colors and crisp in the air; after a long hot smoldering summer.  Fall is literally fall.  Fall from the snoozing horse of daily routine and realizing it is time to hit the MCQs and flashcards.  Even if just for 3 weeks prior to your in-service but now the panic is setting in since "it's practically here."  I almost feel like the Grinch.  Where is my sleigh and dog with the reindeer horns?

Just saying, I have an excuse for being gone for so long.  I am studying or at least am trying to.  I feel like I am stretched too thin with having to read more and more ever since I started outpatient.  I love being in out patient.  To me it is the Utopia that isn't anymore.  I love seeing patients everyday and seeing patients actually get better and show up for appointments.  The never ending cycle of rinse and repeat that is called the inpatient is like a distant memory.  I don't feel stressed out like I used to but I feel more pressured to read more and stay updated more.  Of course this is not to say that while inpatient you shouldn't read but you have more time or luxury to watch your patient and make adjustments to titrate treatment.  Not so much in outpatient.  You have to make decisions based on a limited amount of time you have with them and then see them in a few days, sometimes weeks; depending on your calendar.  So the need to know more and know it then and there is more pressing than when I was a second year.  Now I am having to add prepping for the PRITE and with kids being back in school, shorter days and the need to have some down time in the evening; I feel like I don't have enough hours in the day.  I am never with just myself anymore.

Outpatient is also emotionally more demanding esp. if you decide to take more therapy patients; which I have done.  As much as I love therapy it does takes it toll on me.  Some days I am really beaten down because of what I hear and process all day.  On top of that, as a newly minted 3rd year who is doing therapy; there are many many days I am just not sure what I did or said was even the right thing to say.  I doubt myself and at times I am proud of myself for containing my patient's emotions but it is hard work.  I have to depersonalize at times so I can empathize but stay objective as well.  Thank God for my supervisor.  The importance of a therapy supervisor is actually more clear now even though I had one since I was a second year and had some therapy patient.

But for the time being this PRITE is sucking the joy out of my life as a 3rd year.  It falls in the candy month which is no help because how I will do on PRITE might be a mystery but what it would do to my waistline is no rocket science.  So it is that time of the year again and until the 2nd week of October I probably won't pop in again.  Of course the aftermath will be a post in itself.

So here is to a few more weeks of prep until I check back again.
Stay tuned!!!

Oh Captain, My Captain

"Life is your restaurant 
And I'm your maitre d' 
C'mon whisper what it is you want 
"You ain't never had a friend like me."
I wonder if the genie had a friend when he decided to throw away the lamp forever and take away the magic he had promised Aladdin.  It must have been dark inside esp when he had to light the way for the master without a flicker for himself.
Mrs. Doubtfire is no more, Garp is gone, Dr. Nielsen has left; Dr. Malcolm Sawyer gave up, Alan Parish is lost in Jumanji; may be the hunter got him finally.  Patch Adams isn't laughing anymore, Dr. Maguire and Will don't meet anymore and John Keating won't be in class again.  I never realized until now that how often he was the doctor, the therapist; the teacher, the husband; who was dealing with the pain of suicide and darkness.  He had such passion and vigor as if it was real life.  Little did I realize that in a way it was.
I wish it wasn't true but the reality is that it is.  I had hoped that it was a hoax when the text appeared on my phone but this one time - there was no hoax.  Only the harsh realization that darkness doesn't distinguish between a genius comedian or an ordinary person.  It doesn't leave any doors open when it creeps in the nooks and crannies of a mind, no windows to let the air in; and no secret passages to escape either.  It comes in and takes what it wants and leaves nothing but disaster and confusion in it's wake.  
I am at loss for words so I will just say, 
RIP Genie.  May you finally have the vacation you always wanted.  May you have a friend who has the magic you were giving us and I hope your ship has finally set sail for open seas.  

Oh Captain, my captain - smooth sailing and calm seas.  You will be missed forever.  

Hiatus II

Just popping in to say Hi.  I will be back after July.  Middle of the fasting month, transitioning to PGY-3 and tons of things to do both at home and work.  This is not my ideal state of mind to write.  Stay tuned for more regularity after July is over.

Until than happy summer and happy fasting (to those who are following the fasting)

Willy Wonka and the Golden Ticket

I watched Charlie and the Chocolate Factory with my 8 and 5 year old over this past weekend.  I was having a hard time deciding if it was Johnny Depp or Micheal Jackson dressed as Willy Wonka?  The resemblance was uncanny at various times, yet at times it felt like Lady Gaga was playing some parts of Willy Wonka as well.  I had to keep reminding myself that the movie said Johnny Depp, so my mind must not wonder and focus on the movie.  Unfortunately I haven't watched the Gene Wilder version of the movie but I read somewhere that Mr.Wilder wasn't thrilled about the remake.  I will have to watch the original to compare but for the time being I can safely say I didn't terribly mind watching this one.  

On the other hand the psychiatrist in my head ruined it for me as soon as Willy Wonka started choking on the word "Parents".  It is safe to assume that Willy has daddy issues and daddy had control issue along with obvious inability to express love, care and affection in a more child friendly way, well at least in the movie adaptation.  Enter the five lucky children with their parents and one grandparent.  Charlie Bucket and grandpa Joe, Veruca Salt and her dad, Mike Teevee and his dad, Violet Beauregarde and her mom, and finally, Augustus Gloop and his mom; are the children who found the Golden Ticket hidden in the chocolate bars.  

The eccentric yet quirky Willy Wonka takes his guests on a trip around his chocolate factory with edible grass and chocolate waterfalls and one by one by one all but one child become victims of their own traits.  The last one standing was neither rich nor special with any talents and at the same time he was neither spoiled nor selfish.  

Why did I start thinking about this today other than the fact that I have eaten more candy since the weekend than I did in last 2 years i.e. at least 8 pieces.  Technically it is a lot of candy if you haven't eaten any in 2 years.  I like to keep things in perspective.  But other than the candy dilemma at my hand I think I saw the movie more as a lesson in parenting.  

Parenting is probably the hardest job universally.  It doesn't matter what race, ethnicity, political affiliation or religion you are, being a parent is one of the hardest and most consequential jobs you will ever have.  To make matters worst there is no training, no manuals and there are no do overs or 30 day money back guarantee.  All sales are final and all items are delivered without a warranty.  The flip side of this holds true too.  Children do not get to pick what kind of parents they get nor do they make the choice to be born.  We as their parents make that decision or the decision is made for us when birth control fails. 

No matter how we become parents, by choice or by accident, the moment it happens; life as we know it changes.  The child mother dyad is the foundation of all parenting scenarios.  In cases where mothers are unavailable, for any number of reasons, the dyad has to exist somehow with another attachment figure.  Harlow's mesh wire mother experiment with infant monkeys demonstrated clearly that attachment is not simply driven by internal drives as hunger or thirst.  At the same time it also showed that the soft doll was not a substitute for actual contact with other monkeys.  Monkeys raised in isolation had abnormal social and sexual development, and were eventually neglectful and abusive towards their own offspring.  John Bowlby and Mary Ainsworth have demonstrated that the roots of love lay well above and beyond toys, gadgets and deeply in the realms of mother/caregiver and infant bond.  

Through out the movie there are multiple themes of parenting and for the most part parenting gone wrong.  From Willy Wonka's own longing for acceptance from his harsh and unapproachable dad who forbade Willy a single taste of his Halloween candy loot to overly indulging parents of Veruca Salt and from the avoidant parents of a defiant Mike Teevee to an equally self absorbed and narcissistic mom to Violet Beauregrade.  Let's not ignore the minimally effective mother of the glutton and greedy Augustus Gloop, there is an array of parenting styles or lack thereof. 

On the other hand Charlie Bucket who belongs to a poor family of 4 grand parents and working class mother and father living in a crooked little house, seems to have it all; yet he doesn't seem to have anything tangible to his name, standing among the group of 5 lucky chosen ones. 
The little boy who has nothing turns away from everything when it is offered to him on a platter because he can't fathom to lose what has been his golden ticket all along i.e. his family.  

What is different one might wonder?  Turns out that being a parent is more than providing your children with whatever your resources and wealth can buy, because Veruca Salt is headed right for a life of being a self absorbed individual and an equally unavailable parent.  Parenting won't appeal to her instant gratification need.  It is certainly more than just allowing them to be themselves without discretion or direction because Mike Teevee is learning nothing about self control and definitely nothing about reliable and assertive support a parent provides.  It would be a miracle for him to provide this to his children.  

Parents shouldn't live vicariously through their children because it teaches their children to set themselves up for disappointment, when they learn to follow dreams that aren't their's; without learning how to dream for themselves. Violet Beaurgrade isn't learning to allow herself to follow her passion because life is being modeled as vain and narcissistic, serving a purpose to her mother's need for perfection projected onto her daughter.  Parenting would be a tough challenge because it demands tolerance for complete disruption of normalcy and perfection of life, until the disruption becomes the new normal.  A normal that is not perfect anymore but just right.  That will never be enough for her.  
Being a parent demands being able to be critical of your children without being unkind and setting boundaries without suffocating them.  Augustus Gloop is unfortunate because he parents are too afraid to be critical of his gluttony and are unable to set boundaries while Willy Wonka faced unkind criticism and suffocating boundaries.  He somehow built an empire out of that but Gloop doesn't seem to have that kind of self discipline but he is lucky that dad has a sausage business so Gloop won't have to worry about building an empire.   

Parenting is kindness, love, affection, encouragement and freedom while allowing disappointment, dejection, criticism, anger and above all reliability.  A child who is parented with love that is often tough yet always kind learns to accept, expect and express love the same way which in turn allows tolerance for disappointments and mistakes.  Encouragement doesn't mean anything if there is no room for failure and freedom doesn't teach self discipline and control if it comes without boundaries of critical thinking and at least a small moral compass.  Look where it got Charlie Bucket!!

May be the Golden Ticket Willy Wonka had dispatched was to work the other way around.  May be it was him who needed the final big prize all along and ended up being the winner.  After all he was sitting at a dinner table with a family of his own size and one that seemed to be able to fill his need to finally grow up the way he wanted to.   


I leave you with this thought since this sums up so perfectly what I took so long to write.  

"What a child never learns, he seldom gives back."  P.D. James

Choices Choices

I will be a 3rd year in just two more weeks.  Ack! Time has flown and this means I have two more years left to finish training.  This also means I have to pick a track for the next two years of my training.  Third year of training spans over 12 months of outpatient clinic for all Psychiatry residency training programs.  Outpatient is a different breed.  This is where residents learn to work with patients who are functioning and are able to participate in treatment.  These patients in so many ways help put the inpatient work in a new perspective by shifting the dismal and seemingly hopeless inpatient work to a more stable and predictable one.  Inpatient training teaches residents the art of managing acutely unstable patients from admission to hospital stay and culminating at discharge.  At the same time like any other medical model it seems to have a slew of repeat patients, many admitting multiple times in short periods of time.  That is what sometimes makes many physicians jaded.  I think 3rd year is the perfect time to switch to outpatient so residents can break the cycle for themselves and re-energize before making career decisions moving into 4th year and beyond.  

Like many programs this past year we started assigning PGY-2 residents at least two patients for long term therapy.  I have found therapy to be challenging, at times scary and very rewarding.  What makes it somewhat easier when it seems so hard, is having a supervisor who helps you explore your own emotions and guide you along.  I have to pick a track for 3rd year and I have decided to pick Psychotherapy as my main track, which means I will have at least 9 therapy patients, along with my regular clinic through out the year in addition to the group therapy.  It is daunting and I am not sure if I will be able to handle this but the only way to move forward is to dive in deep and see what happens.

No matter what happens, the bottom line is that I am excited about moving up the ladder, changing work environment and taking up what I love most about psychiatry - healing through words.

Happy PGY-3 to me!!   

Mental Health - The New Boogie Man!

I have contemplated writing and then not writing about this.  To some extent may be I am desensitized, since Dec 2012 when a bunch of elementary school kids went to school to never go home again.  Part of me really went numb that day because it hit so close to home.  As a mother of two very young children living in today's America, my drive from work to school that day was very hazy because I couldn't see through my windshield and it wasn't even raining.  

The pain is very palpable and I remember breaking down inside my car outside their school just thinking about, how I am about to go hug my children and am going to take them home safe and sound, while somewhere in rural America many parents just like myself won't get to do that.  If you are a parent you know what strings that pulls.  You also know what I am referring to because it has happened multiple times after NewTown around schools, malls, temples and college campuses across America.  At the same time the outrage on FaceBook and social media has gradually just dwindled with each incidence after NewTown.  May be people are just numb or may be this is the new way of living in America.  I tend to think losing elementary school children has really just numbed us, especially because they have just died in vain and nothing has changed.  

Memorial day weekend this year, familiar bangs went off in Santa Barbara, again followed by TV and Media coverage, analysis of what went wrong and why and who and when?  Missed opportunity and what nots.  

But the fact of the matter is that there still is no answer for the father who lost his 20 year old because he was in the wrong place at the wrong time.  Because in today's America you cannot be just going about your daily business, without taking the risk of being in a bullet's way.  

And as always focus has gone to mental health.  People talk with conviction because he was seeing a therapist.   Like that is a certain criteria for dx of mental illness.  A NY Times article says it all and is basically the epitome of what the gun control debate has essentially now become.  It starts from mental illness assumptions, to the role of medications in inciting violence without any regard for the possibility of considering that some people, inherently are capable of committing mass crimes just because they want to and can do so easily, given the ease of access to multiple legally bought firearms and arsenal of bullets and rounds.  

Are we really that naive? Am I saying that psychotic/mentally ill people can’t be violent? Of course not.  But I am absolutely going to oppose the definitive "mental illness causality" so to speak.  An acutely psychotic patient for the most part is not sitting around and planning a NewTown, Aurora or Santa Barbara style murder.  There is months of planning, preparation, and vendetta in those plans.  If you have treated even 5 schizophrenic or psychotic patients, you will know that their biggest targets are mostly themselves or people they already know.  Less than 1% of violent crimes are committed by SMI and even less by firearms.  

It is simply irresponsible to punt the blame on mental health or medications and ignoring the fact that antisocial and pathologically narcissistic human beings do exist and are incapable of feeling remorse or regret, in their rage and anger.  By far these mass murderers have willingly chosen to become monsters and have planned and executed their vendetta successfully. Yet we refuse to address the issue of anyone being able to buy multiple weapons and 400+ rounds without being tracked.  Cough syrup purchase is tracked (for good reason) but go ahead and buy arsenal and post You Tube videos, your second amendment protects you.  

I am not saying that a mentally ill mind is not unwell, au contraire it is very unwell.  In fact so unwell that these people can't take care of basic daily life.  Hence the admission criteria "unable to care for self" along with other admission criteria does exist for psychotic patients.

People throw examples of Boston or OKC, while neither of these incidents were carried by psychiatric patients. So while there are incidents carried by other weapons of destruction but to that effect, we do have tracking on simple fertilizer too and really how many people have committed mass devastation using bombs and this regularly?  

The grandiosity SB murderer exhibited is not because he was mentally ill, say psychotic (actively psychotic patients don't have those well-kempt appearances) but there is no room left to consider possibility of his personality, with his sense of entitlement that everyone owed him something because “look at me” and that he saw nothing wrong with his way of thinking.  Or that he is a loner with a twisted disturbed way of thinking who is angry, full of rage and vengeful and is incapable of containing his anger and rage.  

The is no attempt to distinguish disturbed minds from ill minds and at the very core of this debate that needs to be distinguished.  Most disturbed angry people don’t seek treatment nor do they believe they need it and that in itself doesn't make them psychiatric candidates.  They might very well be far off the center of what is socially productive but that alone doesn't justify lumping them with mentally ill individuals because it ignores the basic idea of neutrality and objectivity and essentially allows society to dust off hands from accepting gaping holes in social responsibility towards the common good.   

That takes me to the medication conundrum that is in this mix.  The fact that there are side effects on labels and that they will happen in certain % of people, doesn't trump the fact that for millions of people on these medications for proper indication, do not have those side effects and have their symptoms well under control.  So whether FDA has crossed all the Is and dotted all the Ts doesn't mean that the data supports the warnings.  Hence they are warnings, not contraindications.

I do not deny SE and warnings because I prescribe these drugs but I really do not think that not treating ill people is an option and any warning takes precedence over benefits of treatment, when empirical and final data on harm is open to question at best.  For the most part, regardless of what and why something was prescribed, in majority of these cases these people were not even taking the medication.  My basic point still remains, are we really just so sure that all of these people are just mentally ill?

There is overwhelming epidemiological evidence that the vast majority of people with psychiatric disorders do not commit violent acts. Only about 4 percent of violence in the United States can be attributed to people with mental illness. (Fazal 2006)

I quote from the NY Times what I cannot say any better: 

"All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group. But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force."

As a provider I am just frustrated with how comfortable as a country we are, with just not doing anything but going after a small group of individuals, who are already not well served anyways.  

Simply focusing on mental health and medications, for something of this magnitude will not solve this problem but really only stigmatize the treatment even more. 
  

How long can we hide behind this boogie man to avoid addressing the real problem of our inability to fight the real fight?

Let It Go!!

Is Elsa singing about empowerment, liberation and accepting yourself or is this one of the all times, most reproduced, re-sung, reposted expression of the anger we as human beings carry around all the time?  Anger, rage, fury, incensed, irate, pissed off, livid, there are over 75 synonyms out there for this very basic yet one of the most consuming human emotions.

Anger like sadness is not socially appealing, accepted or appreciated.  We don't like to deal with sadness and we don't like to face anger, be it personal or not.  At one point or another all of us have come across these emotions beyond what is normal and necessary for daily ho hum of the life, yet for the most part I personally am responsible for not handling it right when it happens to me.    

Why am I talking about this today?

Our process group had to deal with this question yesterday.  

"How do you deal with people who are angry or make you angry?"  We couldn't answer this.  Not one of us offered to confront the anger nor we suggested setting boundaries to protect ourselves from the rage others would displace onto us.  That in itself said a lot about us as a group.  Why is it so vital to address this and yet we don't or we can't?  

First off as a group of residents who have various roles in the span of our residencies ranging from over time to day to day role transformations like brand new intern to different roles from one rotation to another and more frequent role changes of on call doctor after hours to the resident on unit or clinic during the day, we are required to switch hats frequently.  

In the bigger picture of training this is completely normal and actually required for us as residents to be able to switch between decision makers on call to an active learner in normal duty hours, so we can eventually be able to work independently.  But the fluidity and flexibility also leads to confusion among ancillary staff leading to conflict and many times residents are front and center of attention in such conflicts.  The concept of physician autonomy is at times hard to apply to residents because they are still under training and therefore are easier to be put in the middle of such situations.  At the same time being residents we also feel obligated to make everyone happy and play nice mostly to get over with the day, call, rotation and residency in general.  

We all beat around the bush yesterday, some of us tried to see the other side and tried calming the negative feelings we were having and so on.  We were unable to allow ourselves to be angry and were uncomfortable with expressing that anger even in the safe and contained setting of our group.  Not because we can't get angry but because we worry about the natural consequences of expression.  But it doesn't help the fact that the longer you don't deal with your feelings the worst it gets.  Again so easy to tell your patients yet so hard to apply to self.  

We will deal with angry bosses, angry administrative staff, abusive supervisors and loud and obnoxious staff who will talk over us and yell at us because for the most part such people do get away with their behavior because we fail to protect ourselves from their rage.  People who express anger in socially and at times blatantly disrespectful way are at ease with it because most people want to get over with it and go back to business but it doesn't address the issue nor does it avoid a repeat.  A simple "you are yelling and I am sorry I cannot talk with you like this." was so hard to produce yesterday from all of us that I was taken aback by how we would allow this to happen to ourselves.  I realized yesterday why we were lucky to have the group leader we have because he pointed out the basic flaw in our approach.  We are two extremes of responders, too angry to engage and too avoidant to disengage from our therapist role for the aggressor even when we are the victim.   

Anger doesn't dissolve when it is pushed back and denied it's existence.  It is consuming and drains us of energy while we try to tell ourselves it doesn't bother us that much.  It piles up with each occurrence and makes us anxious because of how uncomfortable we are with the conflict.  Avoidance of setting boundaries doesn't resolve conflict but actually gives way to passive aggressive even more toxic conflicts.  

I hope yesterday's process taught us that it is okay to protect ourselves from abrasiveness and set limits.  We have to let go off the anger in ourselves to continue to maintain fluidity our roles as residents and for us to be able to say "I do not appreciate your tone." without being afraid of it's impact and be able to disengage ourselves.    

The only way to "Let It Go." is to actually stop and deal with it because your anger is almost always a sign that you have been quiet for too long and besides Elsa didn't save Arendale by running away from it.  

From Gatsby To Rhett Butler

Lately I have been thinking about the destructive nature of love.  I had read Wuthering Heights many years ago before I started working with patients as a psychiatry resident.  Heathcliff and Catherine seemed like nothing out of ordinary other than what was apparently out of ordinary.  Then a few months ago I read The great Gatsby, and this time Daisy Buchanan and Gatsby seemed more than just cross eyed lovers; who were dealt a bad hand by luck.  Daisy's power over Gatsby is no coincidence just like Catherine's effect on Heathcliff now seems more than the great love story of all times.  The need for one human being to completely dissolve themselves into another, and blur or almost obliterate the boundaries of self identity, has deeper roots than just an exaggerated need for love.

I come across people who love very deeply and without any reserve.  They cling to other human beings who are more or less like them.  There is a greater distinction to be made between loving passionately and loving pathologically.  One must understand that passion can become pathological when it can't be contained even in the face of suffering to self.  Just because it seems agape, doesn't necessarily mean it is.  I don't see Gatsby as a selfless lover who was willing to move mountains to create a life with Daisy after the train had left the station.  I however, am inclined to say that he had clearly crossed into; what some people have described as pathological passion.  He ignored bull horn warnings and refused to see that Daisy in her own narcissism and equally strong materialism was incapable of reciprocating the reality he was dreaming.  Left at the climax of his utopia he crumpled under the weight of his life around him and couldn't recover in the face of reality.

I call these kind of relationships destructive because of the enormous power one party has over the other.  The disequilibrium of loyalty and caring, eventually translates into disequilibrium of power in such relationships.  When the object of affection realizes his/her place in the relationship; the rinse repeat cycle of use and discard can be very hard to break.

For people who grow up in chaotic households, where the chaos is more than a mere occasional occurrence in the daily grind but the very fabric of existence, and probably a means to survival; love doesn't take center stage as a grounding force.  It rather peeks from behind closets and doors, never materializing into something tangible but always a fantasy.  

Children who grow up with neglectful and/or abusive caretakers, know love in it's inherently violating nature so often and so pathologically, that they never learn to contain and tame it.  For an abused child, an abusive mother, father or caretaker, models a love that doesn't respect boundaries and doesn't nurture nor comforts.  They learn to live with it to survive the force of it's blows day after day.  Freudians often talk about Identification with the aggressor in abused children and how it serves as a coping mechanism against fear and impotence the victims feel, as Mcwilliams puts it.  If not corrected early on these experiences lead to reenactments of the trauma in adult relationships over and over.

I have seen that for some of my patients, it is so natural to handle relationships that resonate with the kind of love I described above.  It may seem odd but for them the idea of dealing with a constructive, caring relationship is full of fear.  The fear of losing a caring relationship is the kind of hurt they are not equipped to deal with, while staying in a relationship that consumes and eats at it's very core, is a familiar territory.

The art of loving and being loved is taught at a very young age and is life long.  From the moment we are born till the moment we die, we are the lucky ones, if we have been held, fed, hugged, kissed, loved and re-loved in the face of good moment, not so good moments, bad fights and good laughs; without judgement and reserve but with respect for our boundaries and limits.

My goal as a therapist is to make sure that the patients that I see have an opportunity to learn the art they were denied and deprived of, for whatever reasons.

The road from Gatsby to Rhett Butler might be long and at times scary but in my humble opinion often necessary and therapeutic to the effect.  There is nothing more empowering than being able to walk away from the marble staircase that showcases the object of one's affection, knowing deep in your heart that it was tainted all along, and that you deserve better.

  

What's In A Job?

T minus 19 days to APA MEETING - HELLO NYC !!  It is going to be a busy week starting with 75 years after Freud and then leading into APA conference plus the chief meeting, before I come back home.  Last year when I was about to start my chief year, I had the opportunity to go to TARRYTOWN for the chief retreat.  As I think about wrapping up one year of this job leading into year two, I cannot help but realize how I have changed in this job from one year to the next.  The natural progression from a newbie to a more confident chief has come on it's own terms and in it's own time.  It has pains and gains and moans and groans.  Well more groans and pains at times, but nonetheless there it is.  Part of this also comes from the fact that transitioning to a 3rd year is terrifying at so many levels that I can't help but be aware of the need to expand my vision, not only as a chief but also as a resident who in 2 more years; is going to be an independent physician and may be also an attending physician to work with new residents.

When I started last year and went to Tarrytown as a spring chicken, I had no idea how over the span of the year with all the experiences and events; I will have a totally different view of what my job actually is.  Rewind to this post and I see how much I have grown up in just four months as well.
While for the most part the post I referred to above still holds true, esp the part where I talked about my amazing residents and how much I love being around these people.  But I have also learned that I do have a role besides being a liaison between residents and the program.  I do play a role in decision making with my boss and I do have a role in working with him to ensure program integrity.  There are times when I worry about the lines of authority i.e. should it come from him or me?  At times it is a fine line but at other times I know what to do.  I do believe that managing physicians is a very hard task.  

By nature we are annoyingly narcissistic with the added necessary devil of the learned and mostly productive autonomy needed for our jobs.  I am sure I do not need to elaborate.  If I have to choose the hardest part of my job, I would choose schedules any day, closely followed by the every day resident issues specific to our setting.  But many of those issues are beyond my scope and fan my own frustration as well.  I have learned to pick my battles carefully just so I can keep myself sane.

Back to the oh so lovely schedules.  I have lost count of how many hours I have spent on creating, recreating and tallying call hours and numbers.  Sometimes I look at the folder on my desktop at home and I become nauseous because I remember nights when I have mixed up master tally with master master tally and DONOT ALTER tally and still have altered the tally even though it was named specifically "DONOT ALTER" in ALL CAPS.  I have it all corrected now but I have had close calls bad enough to give me a heart attack.  Part of me is very proud that I have kept the Tuesdays, Thursdays and Fridays, fair and square between all of us because for our call purposes those days really do matter a lot for every one.  I have anxiety regarding giving up the call schedule duties in a few months but I will get over it because I have to.

I have also learned that I have gotten better at having a thicker skin to criticism and have learned to really choose my words wisely.  I advice everyone who wants to be a chief in any residency training program, work on being careful about what you say.  You are under a microscope and you will need to be able to absorb a lot of anger directed towards you directly or indirectly.  You cannot make everyone happy, not as a resident and certainly not as a chief.  What I can do is, be fair and approachable.  People for the most are aware of your fairness and availability even when a few won't acknowledge it.  At the end of the day that is all that matters.

If you plan to hold the chief's office start to expand your vision from a perspective 2-3 years beyond your current training year.  I have been guilty of tunnel vision and not seeing the bigger picture because residency is tough, tough, tough but these years no matter how tough, are still protected by the shield the program provides compared to when you are out and about on your own and have to be responsible for all and everything.  I do realize now that people are positioned from the beginning mostly unconsciously but at time consciously to hold positions of responsibility, either by themselves or by their superiors.  So if you have inclinations of doing the hard job of managing your peers, position yourself maturely.  It helps.

What's in a job you ask?  The maturity, ability and willingness to go above and beyond what is needed to get things done and understanding that your role; should you pursue this path, is vital for your program whether you realize this or not.  It's not as much as being a good or bad doctor in this role but really about being able to be a manager/leader.  Being effective without being insensitive and being available without being a push over.  What I have really learned is to finally realize that I am not a union leader but rather a resource for both sides to work through issues and concerns.  What I am is really a position that is able to voice frustration, concerns, at times anger from my peers to my program with the intention to resolve that frustration, with handling issues that need to be addressed to diffuse the frustration.  But I do see now that a big part of this job will be to present better vision and goals to better the program and consequently ourselves as physicians and role models for the next generation of residents.

Here is a great piece to read regarding what other chiefs found out and learned about their jobs.  What chiefs learned!

Until next time I leave you with this thought:

A genuine leader is not a searcher for consensus but a molder of consensus.

Martin Luther King, Jr.

WWW.Brainyquotes.com

Through Ups And Downs

Took me long enough to return here.  What can I say?  A lot has happened since the last post.  

Last time when I took a leave from writing was when I was about to leave for the Forensic Center.  It was an incredible experience with a minor hitch that I would rather not get into.  I had the opportunity to work with an incredible attending physician who is now running our resident process group.  First time I sat through the treatment team with him, I was in for a surprise.  I found out about my own hang ups and anxieties that came into play in a different way with this teacher.  He is all about interpersonal dynamics.  You would think it is a given because I am training in a program that is more and more geared towards that but we still have ways to go and having this one week with him just opened my eyes to what I/we could learn from him.  So of course I put my chief hat on and am immediately thinking about how to have more access to him for other residents.  It would be great to have him as our own attending rather than just a week in one month but that is not happening.

I always wanted a process group for our residents and have a fairly decent amount of backing from my program director to go ahead with this.  Eventually with some discussion and persuasion residents agreed to have a twice a month group with his help.  I will have more thoughts about that when we have a few more of those.  I also had an opportunity to rotate at the county jail with another great attending.  What I found great about this month was that not only I had a good pool of patients to observe but I also had physicians who were eager to teach and were involved in making sure I got the best of the limited time I had with them.  I however did recognize that even though I enjoyed the rotation, I have no desire to pursue forensic psychiatry as my future once I graduate.

One of the star events of this month has to be having Pat Pantone come talk to us.  I am always amazed at these incredible teachers who come and talk to us and always leave us wanting more.  There are not many people other than my children for whom I won't mind staying up a Saturday morning after a "No shut eye" Friday night call.  This came neck to neck to the above.  Dr. Pantone is associated with William Alanson Institute, NY and provided us with an amazing two days of discussions, case presentations and provided much appreciated analysis of two of our own cases, including one of my own current therapy patients.  I did end up realizing that I do not suck as bad as I thought I did.  Of course having the Director of Clinical Education of WAI validate that, did help a lot.  


And then there was the chief election last month.  I didn't get fired and got to keep my job for one more year.  The election process in itself was rather anxiety provoking.  In the process I also had some not so pleasant days which I now realize come with the territory.  The invisible cloak I had referred to here doesn't seem to be just a novel product of my naive beliefs about being a chief before I was one myself.  I didn't coin this idea because it exists in other minds too.  I however now know after a year in this position that it doesn't exist.  

I titled this post "Through ups and downs" precisely because with all my ups this past month I had downs that dragged me down and caused a great deal of anguish.  I did make the mistake of giving the downs too much attention.  I always tell my patients that how they react when something or someone bad happens to them depends on how much value they put on their own time and energy.  I needed to remind myself of my own mantra.  Isn't it so easy to sit on the chair and talk to the person on the couch?

What I have learned over the last month is that my job as a chief is valuable to my fellow residents and I cannot lose the sight of that value because they did choose me one more time.  The ups and downs I face in this position are learning points just like in any mid management or management position.  I can't let the ups disconnect me from the normal and I certainly cannot let the downs make me lose my focus from what I do every day i.e. be there for the residents as their support and guide them when they need me to, while balancing that support with the role I have to play for the program.  I have another year before I turn my hat over to the next chiefs and I have a lot of work to do in this year starting with our brand new PGY-1 class starting in July.  So while I still have to be mindful of triggers that change a good day to a bad day for me, I have to keep the bigger picture in mind and learn to look at it with more focus rather than thinking about "At this time and point in time."  I think it is time to read Spencer Johnson, M.D. again.

So here is to becoming even better this year and continuing to work the very important job I was elected for, for one more year.  Because through valleys only you get to the peaks.  

Of Hiatuses And Such

I do realize I have been less than punctual about my writings but don't you know the dog ate my homework!  Incidentally I don't have a dog.  You get the picture right?

In the meanwhile I have finished most of my off campus rotations and am very happy to be back to the mothership.  PGY-3 is oh so close.  There was the vacation that now seems so far away and almost dreamlike.  I felt like January was the mandatory slow down month and a must have hiatus when the general trend is to start new year resolutions and start it with a bang so to speak.

So this is it for today.  I leave next week for part of my forensic rotation for 3-4 days.  Should be interesting since I am not sure what to expect.  Hopefully I will have some thoughts to reflect on afterwards.