The Small Things

I have a patient with schizophrenia who I take out to lunch about once a month. Seeing as it was his birthday recently and he verbalized a desire for Chinese food, I took him somewhere different for a special treat.

Sitting for the first time with him in a real restaurant---not just a pizza place or delicatessen---I was struck by the normalcy of what we were doing. Here we were, two people talking about our families, making comments about the weather, the food, the Red Sox, passing the soy sauce, pouring tea. Given his somewhat different way of relating to the world (schizophrenia being essentially a personality and thought disorder), this gentleman's conversational skills can be somewhat lacking in the strict sense of social decorum and "normalcy", and his personal brand of logic can sometimes be challenging to follow. That said, our time together was lovely, relatively comfortable, and very satisfying for us both on several different levels.

During the course of the meal, he looked me squarely in the eye and said, "Y'know, I appreciate this more than you could ever imagine. I look forward to our outings (his word) so much, and it's such a breath of fresh air to go out and do this." He added later, "I wish there was a way I could repay you." I responded that he could repay me by taking the best care of himself that he possibly could. We shook hands heartily and he got out of the car.

This interaction reaffirmed for me the therapeutic value of this monthly tradition, as unconventional as it seems. I don't do this with any other patients, although I have been out for coffee with a few here and there. There's a technique in psychological treatment called "therapeutic use of self" which refers to the professional individual disclosing personal information in a nonmanipulative way in order to normalize the patient's experience, perhaps helping the client to see that the clinician can empathize based upon actual personal experience. I've practiced this technique by disclosing the fact that I take antidepressants, for instance, or that, yes, my cholesterol is also high and my reflux is out of control when I forget to take my medication. When convincing a patient to use a weekly pill-box, I'll often comment that I could never remember my meds without using one (a very true statement, indeed).

While I can't afford to pay out of pocket to take all of my patients to lunch every month, the value of my decision to do this regularly with this particular individual is worth much more than the actual cash value of said expense. It has become something that I simply plan on, and today exemplified for me the fact that the benefit is both therapeutically measurable and personally meaningful. The interpersonal connection and trust that's been created in this "clinical" relationship is something that I can see is a valuable tool in the therapeutic kit which I employ with this gentleman.

Today I acknowledge that it is often the small things that pay the largest, most meaningful dividends.

Where Does the Time Go?

Seems like it was only yesterday that I posted on Tuesday night. My, how the week does fly. Working only three days, seems like I did the same amount of work I would normally do in five. Maybe I did.

Rose, mentioned in previous missives, is now in the hospital, deemed legally incompetent, and awaiting what comes next.

Another patient called me begging for prednisone for her worsening asthma. I declined and sent her to the ER. She's admitted now and I knew in my gut that prednisone wouldn't cut it. Looks like pneumonia. Sometimes I think about my nursing license when I make such decisions. Must think clearly and not just try to save the patient the inconvenience of an ambulance ride.

Another patient was in the ER today---brittle diabetic, alcoholic, eschewing his insulin and other self-care, sticking to his bottle instead. I don't foresee a happy ending there.

A medical student followed me on my rounds today and we were able to visit three very diverse and interesting patients in their homes: an alcoholic with Hepatitis C and bad pulmonary disease, just out of the hospital; a lovely older man with cancer who takes such good care of himself that I offered to pay him as a consultant to teach my other patients his secrets of success; and finally, a transgendered man (of whom I am exceedingly fond) with more life-threatening diagnoses than you can shake a stethoscope at, and he is still filled with joie de vivre and a strong will to live. Sometimes work can be inspiring, especially when someone takes such responsibility for their life and personal self-care.

That said, work fatigue is definitely weighing on my eyelids this evening, while my old nemesis "compassion fatigue" is nowhere in sight. The weekend is for the recharging of the batteries, and I'm so very pleased that my batteries aren't disposable.

Narcotic Nightmare

It seems that more and more of my time at work is taken up by patients in need of narcotic medications. As the "middle-man" between my patients and their providers at the clinic, I negotiate contracts around the use of narcotics and monitor patient's side effects, pain levels, and adherence to our agreements. While many people are sincerely in pain and certainly need narcotics to ease their suffering, there are always some whose motivations seem slightly dubious and cause confusion and difficulty for their providers. A history of substance abuse also complicates the picture and makes treating pain more challenging. It's times like these that I give thanks that I'm not a Nurse Practitioner and have no prescriptive authority. Put into the position of listening to a patient's complaints and assessing their needs, I know that I would be a soft touch, always erring on the side of believing a patient, even if my intuition led me to think otherwise.

Pain is widely under-treated in this country and I'm happy to assist in managing patients' pain, but it is admittedly a confusing and trying ordeal at times. While pain advocates in the medical world are pushing for more recognition of pain as the "fifth vital sign" (after temperature, pulse, respirations, and blood pressure), it is still not always clearly seen by providers and is treated with less than germaine levels of attention.

Many of the docs at the clinic only work part-time, so I often find myself negotiating for narcotic prescriptions when my patients call for refills. Add to that the fact that patient's charts are often MIA at the the clinic, making documentation and double-checking of doses even harder. I think I can say that this is my least favorite aspect of my job, one which causes me endless distress and cognitive dissonance. The fact that I started writing this entry just before midnight on a Friday underscores the notion that it weighs heavily on my mind.

I'd like to write about this some more in future, but send this missive out into the cyber-ethers to allow myself to let it go for my long, four-day weekend. A short vacation is in order and I must clear my mind of static.