“So… where are you going?” he asked, stretching his spindly legs out. Underneath his tattered jeans was a pair of blue slacks with cuffs. Dirty white socks poked out from his the multiple legs of his pants and disappeared into tired loafers with exhausted soles. Only the wrinkled collar of his yellow shirt peeked over the dark green tee shirt which hid underneath the two blazers that were clearly two sizes too large for him.
I smiled, anticipating his response.
“I’m going to New York City,” I answered.
“New York City,” he repeated in his Brooklyn accent. He flexed his ankles. Suddenly, an expression of surprise crossed his face. “New York City?”
“Yes,” I said.
“I’m from New York City,” he energetically said, rapidly sitting up. He leaned forward and jabbed his tobacco-stained index finger up into the air. A lock of his greying hair fell into his face. “I saw several psychiatrists while I was there. A few of them good, some of them not so much.”
We both knew that I already knew this. There was a time when he believed that the trees in Central Park were agents of the FBI who watched him travel amongst the boroughs, the pushcart vendors plotted with the MTA staff to push him off of the subway platforms onto the electrified third rails, and the governors wanted to annihilate all homeless people from the city.
“I don’t believe those things anymore,” he had sniffed. “I don’t think I was doing too well at the time. The haloperidol didn’t really help too much, either.”
For reasons that only he knew, he travelled across the country and ended up in Seattle.
“I have a diagnosis of schizophrenia,” he flatly told me at our first meeting. “But I think I’m doing much better now. The trees don’t bother me as much anymore.”
And, for whatever reasons, he persisted in visiting me every week. I never wrote any prescriptions and he never told me where he lived. We simply sat together. Sometimes he shared symptoms with me, sometimes he didn’t. Sometimes he dashed out of the building shortly after saying hello, citing that he had somewhere that he had to be.
And he always showed up wearing the exact same clothes in the same layers.
In the process of termination, I informed him of my pending departure.
“I’m a trainee,” I remarked, “and I’m graduating in June. Thereafter, I will no longer work here and someone else will take over your care.”
“Oh,” he said. “That’s too bad. I like you. You’re a likable person.”
I smiled. I value compliments from people who are psychotic.
I hadn’t told him at the time where I was going; it wasn’t relevant to our discussions. I was not surprised, however, that he had poised that question to me. All of my other patients had done so as well.
His brows furrowed and he looked up into a corner.
“What would you want to know about a city that you’ve never lived in before?” he asked.
Unsure of where he was going with his question, I repeated, “What would I want to know…?”
“Yes; what would you want to know about a city that you can’t read in a book? Things that most people don’t know?”
“Uh…” I stalled, feeling fairly certain of his intentions. I tried not to smile—not yet, anyway.
He watched my face as I considered possible responses.
“Places where I can get good food for cheap,” I finally said.
“You know I’ve lived in New York City, I can tell you all about that!” he exclaimed, waving his arms about in an animated fashion. “I know New York City well.”
For the next few minutes, he expounded upon hot dogs, pretzels, and gyros from pushcarts.
“But more importantly,” he emphatically remarked, “is your safety. Let me tell you how to keep yourself safe in the subway. The crowd moves quickly and you will find yourself pushed around the platform. Always stand near a column when you’re waiting for the subway. When the crowd starts to push you, you can grab onto the column so the crowd can’t push you to the edge of the platform. You should know that the subway cars in the middle are always the most crowded; if you want to stay safe, go to the cars at either ends of the trains….”
And he continued on for the next ten minutes, sharing numerous pearls about maintaining my safety and stability within the subway tunnels. Clearly he was speaking from personal experience.
I watched him and allowed myself to smile.
This was his way of thanking me.
6 May 2008 | 4 comments.
Regarding “Manipulation”:
The word “manipulation” has negative connotations. Usually, its use refers to someone attempting to exert influence or control with a conditional threat. Clinical examples include:
- “If you don’t prescribe that narcotic for me, I’m going to sue you for negligence.”
- “I don’t know if I’ll live or die if you discharge me from the hospital; the only way I know I’ll stay alive is if I stay here.”
- “But I need the full body MRI—what do you think the Local Television Station will report if it finds out that doctors aren’t providing appropriate care?”
Like I had mentioned previously, however, we are all manipulating each other all the time. In its less negative context, the word “manipulation” suggests skill and grace (e.g. “He manipulated the Rubix cube with ease”). We only realize when someone is manipulating us when the manipulation isn’t skillful. People successfully manipulate us all the time. Think of all of those feminine wiles that induce men to pursue women. Consider the tactics children exercise to maximize the likelihood that parents will purchase the Latest and Greatest toy for them. Ponder the strategies advertisements use to seduce those children to nag their parents to buy the Latest and Greatest toy.
You get my point.
Let’s review a non-clinical example, shall we?
Samuel is infatuated with Janet. When she shakes her head, her auburn locks sway across her back like gentle ocean waves lapping against the beach. He curses the physiological process of blinking, for when he blinks, he loses yet another moment to gaze upon her beautiful face. When she blinks, her aquamarine eyes disappear from his view for what seem like an eterntiy. Samuel is certain that her smile is radioactive, as he feels incredibly warm and tremulous when that lovely expression blooms across her face.
Samuel wants to spend time with Janet, to befriend her, to learn more about her, to secure the opportunity to touch her.
However, he’s not sure if she knows he exists.
Scenario 1: Samuel guesses that the direct approach will work best. He accosts Janet, grabs her shoulders, leans in, and hoarsely whispers, “I want to spend time with you. I want to know you. I’m in love with you. I think you’ll fall in love with me, too, and if you don’t, I’ll keep pursuing you until you do.” He then leans in further to kiss her.
We’ll give Samuel the benefit of the doubt. We’ll graciously assume that he doesn’t know how to ask women out on dates (successfully). We can call this a skills deficit.
Just because we know how to do something doesn’t mean that everyone else knows how to do it, too. Perhaps Samuel has never asked anyone out before. Perhaps he’s never learned that grabbing women who don’t know him may not actually be in his best interests. Maybe he’s never considered that women may not want to kiss him as much as he wants to kiss them.
Simply put, he just doesn’t know how to proceed. Women, however, may find his behavior atrocious and “manipulative”.
(By the way, Janet promptly screams, kicks him in the groin, and runs in the opposite direction.)
Scenario 2: Samuel waves at Janet from across the room and, upon her acknowledgment of him, approaches her. She looks at him; he clearly looks like he has something to say.
“Uh, hi, Janet,” he begins, wiping his palms against the pleats of his khakis. His eyes dart from her face to her shoes. She’s so beautiful. Oh. My. God. “I, uh, was wondering—um, actually, I don’t think you know me—my name—I’m, um, I mean, my name is Samuel. Samuel.”
He opens his mouth to continue, but nothing comes out.
Janet looks perplexed and begins to speak, but Samuel interrupts her.
“I almost make a six-figure salary, I don’t have any STDs, and I’m pretty sure that I can make you very, very happy,” he blurts out.
Poor Samuel. He’s apparently anxious and while he can approach women, his delivery is lacking. This might be a skills deficit, but maybe we can be more generous and suggest that he has not yet mastered skills acquisition.
Do you remember the first time you asked someone out? (You, too, ladies—don’t tell me that you’ve bought into the whole “Rules” thing, please.) It takes practice, right? Few, if any, people are “smooth” during that first invitation. (Indeed, few, if any, people are “smooth” upon responding to that first invitation!) Sometimes we know what to do and are motivated to do it… but we just haven’t had sufficient practice to do it skillfully.
Samuel may not have enough practice asking women out. Janet may be his prototype. And he may believe that his money will successfully induce her to accept his offer.
(Janet blinks at him and then curtly comments, “I already have a boyfriend.” She’s lying.)
Scenario 3: Samuel, on his way to the bathroom, spies Janet about to board the elevator and deduces that she is going home for the day. Realizing that this might be his opportunity to make his case, he dashes after her and slides into the elevator.
There are five other people in the elevator. And Samuel really needs to pee.
“Hi, Janet,” Samuel says quietly, hoping that only Janet will hear his greeting. Of course, everyone else hears him, too, but no one makes any eye contact.
“Hi,” Janet replies, smiling at Samuel. Between his full bladder and the radioactivity of her smile, he is sure that he will soon fall down and completely lose it.
“I’m Samuel. I work down the hallway from you,” he continues, shifting his weight between his feet. He feels the sweat pooling on his forehead.
“Oh, yeah,” Janet says. “I’ve seen you around. Nice to meet you.”
Samuel looks around the elevator. No one looks back at him. He curses his luck as he feels the pressure increase in his bladder. The elevator is stopping on every floor and no one is getting on or getting off the lift.
He’s about to pop.
“I’ve gotta go,” he hastily says as the elevator doors open. “Nice to meet you, too, Janet.”
And off he goes.
Samuel gets an “A” for effort, right? He presumably (1) knows the skills to ask a woman out and (2) has proficiency in them, but he’s never asked a woman out in a full elevator when he’s needed to pee. He’s never used these skills in this context.
Context matters. While we would all like to believe that we have integrity and behave in a predictable, consistent fashion across space and time, this is simply false. You didn’t act the same way in front of your parents as you did in front of your peers, did you? And have you ever looked at anonymous comments on weblogs? Do you think many people would leave such brazen comments if they actually confronted the writer in person?
This isn’t the best example of manipulation, but Samuel has at least planted the idea of himself in Janet’s head. That could potentially influence her in the future.
(Janet wonders what prompted Samuel to take off like that. We only travelled four floors….)
So how can we tie these ideas into a clinical context? If we refer back to our patient requesting narcotic medications:
1. He may not have the skills to calmly negotiate with the physician to obtain narcotics.
2. He may not have mastered the skills to calmly negotiate with the physician to obtain narcotics.
3. He might be in so much pain that he cannot exercise his usual calm negotiation skills with the physician.
“Yeah,” you might comment, “but he probably knows EXACTLY how to get narcotics: He probably knows what to say and how to say it. He’s just being willful and refusing to do it. He’s just being manipulative.”
Okay—if someone is fully aware of what he needs to do to maximize the likelihood of obtaining what he wants, why would he do anything else? If people know what they want, they’ll do the best they can to get it. The more important it is, the less likely they’ll schlep along and put forth a suboptimal effort.
Furthermore, it helps no one to describe a patient as “manipulative”. In using that word, you’ll increase the likelihood that you’ll feel angry at the patient, which will likely manifest itself either overtly or covertly in your interactions with the patient. If your patient senses that you’re angry at them (for reasons that may be invalid), that’ll increase the likelihood that the patient will become angry with you. Your professionalism will slide and other people (other attendings, nurses, medical students, residents, patients, etc.) will notice… and some might then infer that it’s totally appropriate and okay to label patients as “manipulative” and treat them as such.
Other people notice what you do. Be respectful.
Consider striking the word “manipulative” from your vocabulary. Just describe what people are doing. “She says that she will kill herself if I don’t give her Vicodin” is a lot more informative than “She’s manipulative”. Furthermore, brainstorming ideas and conferring with others (including the patient) to solve this dilemma is much easier when everyone knows the specific details of the dilemma. How does one solve a problem around an adjective?
And give people the benefit of the doubt. Time (and history) will soon illuminate the motives of others. But, until then, consider that people may simply not have the skills to effectively get what they want from you (or from anyone else). And, as you undoubtedly know, we all get frustrated (if not a little pissed) when we are stymied in achieving our goals.
Okay, off of my soapbox.
3 May 2008 | 2 comments.
Foiled!
For the past three days, I have wrongly concluded that I have successfully completed the gigantic tome of paperwork the fellowship program sent to me for enrollment purposes.
No joke: The postage on the packet was over $10 at the time of receipt. And I have already spent over six hours working on the packet. And there is still more to do. And there will be even more forms to fill out when I actually relocate to New York City. Which is happening in less than two months!
!
And this is when the Muse strikes, of course. She’s a coy creature, she is.
Ideas:
- The concept of “manipulation”. As in, “She’s so manipulative.” There is a psychiatric diagnosis that has lost all useful meaning; instead, people use this label to encompass all traits they dislike in an individual. People also use the word “manipulative” a lot in conjunction with this diagnosis. To be clear, we’re all manipulating each other all the time. When manipulation is done well, no one notices and no one cares. (In some contexts, “manipulation” is interpreted as “charm”.) We only notice manipulation when it is not executed effectively.
- I’ve received a lot of advice about moving to and living in New York. Much of the counsel I have heard is more a reflection of the person than of the city.
- Forgive me, Father, for I have sinned: I recently laughed at a patient. To his face. I tried to suppress my laughter, but my efforts failed miserably. I apologized and lamely explained the reasons for my laughter. He wasn’t offended. Patients are extraordinarily forgiving.
- Sometimes, we get too caught up in what we think we “should” be doing as physicians. Instead of behaving like ourselves, we behave like we believe physicians should behave. What is the role of authenticity in patient care? And why are we so scared of being genuine?
I am hopeful that elaboration will (soon) follow. Wait for me, will you?
On an unrelated note, I also asked Kevin, MD, for his “take” on a specific issue. This is my peripheral brush with fame, people. And I’m hoping that he’ll help remove the word “medblogosphere” from the lexicon. Don’t let me down, Kevin.
1 May 2008 | 4 comments.
Push/Pull.
He had been divorced for many years. Admittedly, I initially felt awkward and a bit intimidated with our arrangement.
This man is old enough to be my father… and I’m a trainee… and he’s seeing me for therapy…?
The moon waxed and waned many times behind the blanket of grey clouds overhead. I progressed in my education; he became more self-reflective. We both learned from each other.
As Winter melted into Spring, his face brightened.
He had met a woman.
“I haven’t felt this way in a long time,” he said. A smile crossed his face as he looked at his feet. His sheepishness was cute.
“She’s got a great sense of humor. I laugh so much when I am with her. She’s beautiful. And very nice,” he continued, more to himself than to me.
“But I’m scared,” he confided. He rubbed his forehead with his calloused hand. “I’m scared of commitment. I don’t want to get hurt.”
He sighed.
“… which is totally normal,” I gently commented.
“Right. That is normal,” he repeated, looking up at me with that sheepish smile on his face again. His body began to quiver and, soon, his face was in his hands as he laughed at the situation, at himself, at this thing called love.
28 Apr 2008 | 2 comments.
Rest in Peace.
I didn’t open the envelope immediately because I noted that the medical school was the sender.
(Medical schools start soliciting alumni for money when alumni are still residents—and I am certainly not independently wealthy enough to start engaging in that level of philanthropy.)
When I finally sliced the envelope open, I was surprised to see that it was from a surgeon. He has a distinctive, memorable name that accurately reflects his warm character.
My surprise blossomed further when I saw that the letter was addressed specifically to me (versus “alumni” or “graduate”) and was signed with a fresh signature (versus a pre-printed signature).
It is uncommon for anyone to receive a personally signed letter these days, whether from surgeons or not.
I gasped audibly when I read the letter:
Many of you have undoubtedly already heard of the recent death of [Popular Surgery Attending]….
Actually, no, I hadn’t heard about his death.
Popular Surgery Attending was my attending for one week. It was my first month as a third-year medical student and surgery was my first rotation.
I was terrified.
Popular Surgery Attending didn’t smile much and he was reticent, but he was relatively young, handsome, and, my, he was clearly devoted to teaching. Here we were, completely naive medical students quivering in the month of July, and Popular Surgery Attending got straight to work. Though he could probably discuss the basics of hemodynamics in his sleep, he delivered his patter with serious enthusiasm. He instilled just enough fear to command respect, but consistently demonstrated affability so we felt comfortable enough to ask our novice questions. He didn’t yell at anyone in the operating room; he didn’t throw things; he didn’t condescend to any staff or students. His focus was entirely on the task at hand and, when appropriate, he would invite and welcome the curiosity of the students and residents.
The surgery residents loved him. They called him “sir” because they wanted to, not because he asked them to. Privately, they fondly addressed him by his nickname, which was the first syllable of his multi-syllabic last name, preceded by “The”.
I’m currently in that stage of life that is marked with generativity. Friends are getting married and starting families. Peers are embarking upon or settling into careers. I’m not sure that we’re exactly in our “prime” (we’re not supposed to recognize that until it has passed, right?), but we are all active. We have the good fortune of standing in the salad dressing aisle of the grocery and experience the overwhelm associated with staring at the eight kajillion types of salad dressing before us.
We have many options.
Those people who have helped us get to this stage in our lives shouldn’t be dying. They shouldn’t already be dead.
There will come a time when I shall be attending more funerals than weddings, when I shall be thinking more about the past than musing about the future. It’s so easy to be anywhere but right here, right now, though, in truth, right here, right now, is all we actually have.
And those moments can pass so quickly, sometimes without our acknowledgment.
Only when I am sufficiently tired am I able to clear my head enough to realize that my time here is finite. My thoughts are indulgent: What do I want to accomplish with the time I have? What’s the best way for me to fill this finite resource? Those are such luxurious questions; many (if not most) people don’t have the time to wonder about such things. They’re too busy trying to get everything done, all of those obligations that may not be theirs.
It is challenging for most of us, while alive, to rest in peace.
27 Apr 2008 | 3 comments.