A Bad Day

It's been seven months now, and I have an inkling of what I'm doing (ha). Sometimes days go by and I don't need advice - really. And I'm starting to see some things differently. For one thing, suicide is such a big deal. I end up talking about and dealing with this way too much. Two of my patients now have made attempts and been hospitalized, both were overdoses which, frankly, we providers classify as low-lethality. It usually doesn't kill you. If you want to die, you should jump off a high place or get a gun. And now I feel like I should backspace over all that and erase it, but no, it's the truth. I need to say these things so that I don't cry. And I guess that's the point - this is heavy stuff. There have been days I leave my office and feel as though my body is full of mercury. And I'm not the one that's suicidal! I can only imagine...and I do, I imagine because I think that's important. And at the same time, I realize that I can't truly fully experience what they do. I have no trouble getting up and feeling good about lies before me each day. They go weeks, months, without a single day feeling that way. I am just surprised by how many times each day I discuss suicide with a person. As in, do you feel suicidal? Yes, I do. How often? What's in those thoughts? While I listen, I'm toting up their past in my mind - have they felt this way before, have they attempted before, what did they use, etc. Then we get to the really ugly parts - Have you thought, gee I'd like to do this next Tuesday? (and that sounds like planning a dinner party, which absolutely makes me go cold) and finally, Do you have a gun? Have you looked for spots to jump when you drive over Pennybacker bridge? I have one patient that I asked to remove a gun from the house.

This is exhausting. I can't seem to do this and shake it off. And I want to quickly say, I'm not whining. I love my job, and I intend to keep doing it and get better at it. It's just, JFC, I am slayed by how much I have to deal with suicidality and how difficult it is emotionally. Sometimes I wonder, gee, is it me? Is is some quirk that I ended up with these people? I kind of thought this would be easier....you know, the perception those of us that have been in the trenches of mental hospitals have is that private practice is the easy route - the mildly depressed and anxious. And you know what? That's just totally screaming wrong. People out in the community have significant issues. This is no small potatoes - let me just say Robin Williams. I heard on the radio driving home that he had killed himself. Oh god, we didn't save him. Think of everything he could've done if he'd stuck around.

I had a particularly bad day recently. Let me describe it. I'm going to change up a few details to protect identity. First of all, one of my patients came in manic. A manic person is dangerous, they are impulsive, make poor choices (have unprotected sex, buy new cars, walk alone at night) and if they have suicidal or self-harm tendencies, that can be a bad mix. So the first order is cool them down and protect them. That's hard in an outpatient environment. I need them to use good judgement to follow my instructions, and they don't have that now. What I try to do is hand them a sample medication to knock the mania on its ass - a good stiff antipsychotic usually does the trick. Don't really trust them to get to the drug store. But that messes up the day - they take more time than a 30 minute followup. So I start the day behind already.

Then I have a new evaluation that was a borderline personality. Fit it to a T - the history of drama-filled relationships, F'ed up childhood, the dependency and poor coping in life, the rushing from this to this to this to fix her. It was hard to listen to, and then there's the thought in the back of my mind: these patients rarely make any improvement. I have only an hour for new evals and it's hard to cover everything in most cases. This person was killer - I had to interrupt several times, "Gee, I'm sorry, but I have to move on and ask you some questions or we won't finish". Frankly, she wasn't capable of following that simple instruction. Finally I wrap things up and discuss a few medication options and she then reveals, Tah-Dah! - she already knows what she needs! She read about it in a magazine and sounds like it's just the drug for her. And it's a new antipsychotic. Funny, when I say that word, most patients don't react too well, they hate the idea of psychosis. I explain to her that none of her diagnosis fits the criteria for that drug. But, but...she protests. It sounds like it would help me. I said, it's not FDA approved from your diagnosis. It's unethical for me to prescribe it and I won't. You are free to leave and see another provider, no charge. Jesus. She decided to go with what I recommended. As I'm checking her out, our receptionist tells me that she got a strange call and had to refer him to me. A guy goes thru the process to book an initial eval, gives all the info (which is a lot), then at the tail end - Tah-Dah! - reveals that it's actually for his wife, not him! And she doesn't want help, so he's going to trick her into coming to the appointment! Of course, Angela tells him we won't accept that. He'll have to get agreement from me to have the appointment booked. I listen to this rambling voicemail, and this is the ridiculous part - he won't say what's going on. I suspect that his wife is using drugs or alcohol but JFC if you want help, at the very least tell me what's going on. I call him back and leave a message saying, look I suspect she has a substance abuse problem and you need to consult with an interventionist, not with me. I refer him to two places that have interventionists on staff. Luckily, he doesn't call me back. I am always highly suspicious when an adult calls to make an appointment for another adult - even if it's a college student - it just immediately tells me that the person isn't really motivated to seek treatment for themselves. Let mommy do it. And that never goes well.

Alright. Think that's enough? Well, the day goes on and three of my follow-ups are struggling with suicide so we have to talk about that in some detail. See the first paragraph of this blog. That alone would be enough for one day, but there's more. I have another new eval at the end of the day, and he's pretty much in crisis. Panic attacks, can't sleep, missing work. Cries thru much of the hour. We get about 1/3 of the way in, and he starts asking me rather strange questions. Would you stop writing things down? Can you keep a secret? I explain the limits of confidentially - namely, if I believe you are at risk to harm yourself or others, I can call the police, and if you are abusing a child or elderly person, I have to turn you in. OK, not a show-stopper yet. He keeps hinting around, finally spills it. He did some illegal activities in the past. And we move on.

So there it is. That's what a bad day looks and feels like. I think next time I'll explain what a good day is like - I have those too. Really.

Overdose

Working a lot. Learning a lot. One of my patients overdosed last night, so maybe I'm not learning the right stuff. Nah, this was a high-risk situation from the outset and I knew that. It's interesting, one of the things that Dr. S. used to tell me when I trained with her my last semester was that some providers play it safe. They only accept patients that haven't been in mental hospitals, patients that have never made a high-lethality suicide attempt, patients that are not in the "CMI" category (chronic mental illness). I really pride myself on not doing that - I want to help people, even the ones that scare me and that I worry about. And this patient was one of those; 3 recent suicide attempts, one of which landed him in the ICU and 2 hospitalizations in the past six months. And I saw him twice last week, as we tried to head off some incipient mania, but obviously it just didn't work. One of my colleagues was on-call over the weekend and talked to ER doc, and he's still with us, outcome seems pretty good. But it's a wake up call. If they didn't admit him, first item of business is serious discussion about exactly how to take meds and when and maybe you don't get a whole bottle of sleeping pills now.

So, it's hard to follow that with some light remarks but I'll try. Some friends of ours from Baton Rouge made their annual pilgrimage to Austin and had a party at Dart Bowl. Nile, Dani, and I went and all of us bowled this time. Know what? That was really some fun. Makes me want to go bowling again. It's such a cool retro bowling alley, not exactly close to us, but worth the drive. www.dartbowl.com Here's a photo of my handsome son and his friend.

Here's something amusing: almost all the correspondence I get from pharmacies, insurance companies, and therapists all address me as "Dr." I cross it out and write Provider, or NP. But jesus, NPs have been prescribing for many years, decades in fact, in the US. And it's not like we are hard to find, there's actually more than 200,000 of us in this country. And Physician's Assistants can prescribe too. One patient asked me recently why I didn't go to medical school and I said, jeez, I like being a nurse. I like being an NP. It may sound corny, but we see the patient holistically. You are not a diagnostic puzzle to me (like Dr. House), I think about all parts of your life and how that helps or hurts you. I'm not afraid to ask if you have a dog or cat (pets are great for mental health) or what your exercise routine is.

I've gotten a lot of substance-abusing patients lately. Another thing that many providers just won't touch. And let me quickly say, that I appreciate my doc not restricting my practice so that I can't accept those clients. But do they scare me? Yes, mostly because I feel that I can't truly help their mental health problems (usually depression and/or anxiety) if they don't either stop or cut way way back on their drinking or drugging. And every single person, when I bring up the subject of rehab or detox, starts with the song and dance to the tune "I Can't Do That", it just won't fit in my life right now, my job's too important, my husband will freak out, blah blah blah. OK darlin'. But you know what they call it when you keep doing the same old thing and expect different results. Yes, I'm a little fatigued by the excuses. It can wear me down. I try hard not to lecture, that's really one of my core principals. I'm not your mommy. But I will speak my truth, especially when I hear baloney, I'll simply point out that's what it is. I'm not going to smile and say "Sure, you get high three times a day, I'll throw 3 different pills at you, and you won't feel any better. Let's keep doing that."

Today a patient walked out on me. In tears. No fun, and that's why I'm up at 2 AM writing this. It was an initial evaluation, and at the end of the hour I tell her what I believe can be helpful in terms in medication. And she didn't like that. You can probably guess why (if you've read previous posts); yes, she wanted Xanax. Such a screamingly awful drug, I must say. And for multiple reasons, that was a very bad idea. I said no, I didn't want to do that, and I even said I wouldn't shut that down forever, just that I wanted to try some other things first that didn't have the serious potential problems that Xanax has in her case. So then she got angry, and insisted she needed relief now. Oh darlin', I said, mental health recovery doesn't work that way. This is a long, slow process and I can't make it all better today. Especially, in my opinion, with that medication. But hey, you're free to go, get a second opinion, and no charge for today. And that's what she did. I'm relieved, so why is that keeping me up? I think two things: I was surprised (usually I see that one coming) and I almost made the wrong call. In fact, I was going to go along with the Xanax until I stepped out of the room at the end of the hour and reviewed it with my doctor. He immediately advised against it, and it wasn't hard to persuade me, he just reminded me of the elevated risks for the situation, which frankly is one I don't see very often (very specific disorder). I am deep in rumination on all the choices I made today,  I am a real champ at anxiety it seems. I know it well. God, that learning thing....how many months in on this gig am I? Oh that's right, only five. Five!

Yep, you're wondering what the hell I'm doing in this profession. Ha. Really, it's freaking amazing when it works. So how often is that? Well, sometimes you get dramatic results and boy does that feel good. I have 3 of them right now and I'm so, so pleased to see them in my office. One has postpartum depression (talk about scared the bejesus out of me), one has an eating disorder, one has suicidal depression. All three are basically back to normal after treatment. Happy and able to take care of baby and returning to work this month, gaining weight and no more feeding tube, and happy, productive and back at work after 3 months off. It's hard not to hug them and cry, it's just such an honor to be part of their good work and recovery. And yes, it is mostly them, just a little bit of me. I tell them that, too. You did this. You.

Wicked and Meh

It's been a month since last post. New job sucking all my time. I ostensibly have 2 days off each week, but seems like I can only keep up if I go in the office those days too. Now, on those "off" days, it's not my usual thing where I'm driving home in the dark, but still. And I'm not complaining - whining about how busy I am is so lame and boring - I'm happy that I'm busy and I absolutely have the best job in the world.

And now the 2 days off disappear. As of a week ago, I'm an official provider with one of the big insurance companies. I'm happy about that, although it's a pretty steep discount between my published rates and what they actually pay me. I realize however, that people should be able to use their insurance benefits and I want to be part of that solution. If money was a big concern for me, however, I may not be making this choice. But regardless of what I'm paid, I've finally been there long enough I've seen some patients really do better with my help and that's quite rewarding.

So I have some pretty pictures from Art Erotica from AIDS Services about a month ago. The event was actually disappointing however - for several reasons. Seems like it was just so much smaller-scale than last year. Just not as much entertainment, not as much art, not as many people. We did get to see some fun sexy art, a set of 3 artists demonstrating their craft as a tableau of models posed - that was my fave thing of the night, and do some people-watching. One guy came in with his partner half-nude, on a leash with a tail sticking out of his....yes, really. I should have photographed that, but I didn't have the nerve. The other thing that made the evening less than spectacular was the modification to the venue - it was open-air and we had a weird cold front that evening, so it was windy and rainy. I was cold and was thinking about how I could warm up the whole time. And the last reason, which is a huge drag....I fell off my heels and really hurt my foot. It's still not right, a month later. I can finally walk on the treadmill again and I only missed 2 days of the gym but I was a limping fool for weeks. Thank goodness I could still spin or my brain would've stopped working. And those shoes....they are Anthro red suede heels on a platform, must be at least 4", maybe more.  Sob - I can't in good conscience wear them again. Oh the tragedy.

I went to a yoga studio near my office today and it was way fun. They've been in Austin for many years - one of the first places - and it will be a nice option to sneak over there. It's literally less than 5 minutes from my office (I timed it). YogaYoga Austin It's a pretty different crowd, though, I have to say, from the gym. Not to be snarky, but the people at the gym are much fitter and stronger physically. It's funny, I was worried about not being able to really do it "right" since I take classes at a gym regularly, not a studio, but I was able to do all the advanced options that were taught today. Of course, it was not an advanced class so we'll see when I take one of those. But it sure was good for my head. And I need that. I'm starting to feel the effects some days of what I do. Sometimes the things I'm told just stay in my head, particularly when I get to the Trauma section and ask the question, "Has anyone ever hurt you or abused you?" Let me just say, human beings are some twisted creatures. We don't need a devil, he's among us. He is us. And as far as the sexy erotica AIDS thing being bad and wicked? Good grief, I couldn't disagree more. Just keep it safe, folks. Human sexuality is a wonderful thing to behold, in all its variations and themes.

Looping

I am learning so much. I'm finding that much of the work of a new practitioner is hidden, however. When you're not full of experience, research is needed as you encounter new patients and new problems. It's also important to stay abreast of current developments. For example, over the weekend a new study was released that shows an increased risk of pre-term birth when pregnant women are on antidepressants. And not a small risk, I might add, something in the nature of 20-30%. I have two patients in that exact category now, and I will certainly be having a discussion with them. Also, there's this hidden correspondence with other providers. When a new patient comes to see me, they usually have a history with another provider and/or they have medical issues being managed separately. They may be seeing a therapist for just talk therapy. I obtain releases and contact all of them, review records and sometimes call them too. When you're prescribing medication, you need to know exactly what's going on with a person. Beyond just providing better care, it's a safety issue. Many drugs interact. So when does all that work take place? Whenever I'm not seeing patients. And since I'm new, time's pretty short. I'm finding that I need the full time to see a patient, which leaves charting to the end of the day for everyone. That takes several hours usually, for a day's worth of patients. Eventually I'll get faster at this. It's sucking up all my evening yoga right now.

Yesterday was a trying time. I had a suicidal patient that I was very concerned about with means to end things at home. I had to ask him to take steps to ensure that those means were disposed of and then prove that to me. My doctor helped me make all that happen, but I got terribly behind and my afternoon was a wreck. And the patient is furious with me and may never return. That's OK, I did what I needed to do in my small way. Did that fix things? No, but I (may have) prevented a terrible outcome on my watch, and that's all I can control. I couldn't sleep last night after all that -- endlessly charting in my mind. Oh, did I chart that I called the therapist? Did I specify that I requested next visit in 3 days? Did I outline verbatim what the patient said about intent? You see how it goes...I get stuck on a jag while I lie in bed. Which is so close to what my depressed, suicidal patients tell me their experience is like. Is that not ironic? Their minds are often in a loop of rumination over events and choices -- the abusive ex-husband, the shy boy that they used to be and now constrains them so much socially, the perceived shortcomings they possess. We all have these from time to time. Did I really screw up my charting? No, I'm actually coming along with that pretty well. But I couldn't stop obsessing over it. It's like if I get an unusual stimulus big enough that day, it really screws up sleep. It takes a while to come down. And I think patients experience the same thing. (by the way, details changed/obscured to protect confidentiality above)

So I tweeted something today: Good news! Texas gives Nurse Practitioners full practice authority, and joins16 other progressives states. #hell #AprilFool
And of course, the followup: Reality is that Texas is among the 13 most-restrictive states where we are squarely under a doctor's thumb. #changeiscoming
We will see how long that takes, of course. I wrote a big check to CNAP (Coalition for Nurses in Advanced Practice) this year to help move it forward. It's interesting, I am already starting to have some ... constraints ... with my supervising physician. Who in general is one of the good guys, helpful, respectful, smart and not in my face at all. However, he lacks experience and knowledge in eating disorders, which is exactly my area of specialty and that I obviously expected to bring with me to this practice. I have about 3 ED clients right now, and recently he asked me to limit it to just that. I about fell out of my chair. Apparently, he believes that they pose an extra risk (I don't agree) and he lacks experience with them. We talked and agreed on a plan to get him informed but he expects that to take a couple of months. And I'm not happy about that. I wish now that I'd thought to bring it up before we signed our contract -- I didn't. But all of a sudden, I see the allure of those 16 states. Beyond the financial boost (yes, the physician takes a cut of what we earn), there's a freedom to use your skills and experience as a professional. Here's a map of those states if you're interested. Map for NP Restrictions

Nile and I are back at the Animal Shelter. We go every other Sunday evening for 3 hours. It's good for both of us, and it's really fun to be so surrounded by the cats. Bonus: it's not kitten season yet! Because of the prolonged "winter" here, the feral cats bred less. And maybe all that spaying and neutering is paying off. Fix your pets!

I gave a lecture to my old psych NP class at UT, along with the former COO from my previous job. We talked about eating disorders, of course, for about an hour. It was nice to be back, but strangely didn't even felt like I left. I guess it's been a little less than a year. I am amazed at how much I have learned in this short time. The human brain is such a great thing. And it was fun to dress up like a professional - I used to wear my yoga clothes to class as I was always trying to squeeze in a class either before or after being at school. Here's a pic of the retail therapy that provided the cute new dress that I got to wear from Anthro - a definite perk to not being a student any more - making a little (very little right now) money. And hey - I got the word yesterday that one of the insurance plans accepted me! This is the one that initially said they won't accept anyone - even physicians - without 3 years experience. Our savvy office manager then sent in a letter outlining what they should make an exception for me, and they DID. Way cool.

Magical

And it's March. Halfway through, actually. It's still mostly cold which is just frankly weird for Austin.  I'm starting to get the hang of things at work, mostly learning my way around the electronic charting system and all the little special stuff. Things like, I finally had a patient that needed labs drawn and I didn't know where the forms were. I wanted to refer another for a sleep study and didn't know who was preferred for that. One of the quirks of this practice (which is actually smart) is that the initial meeting is always a consultation and we haven't entered into a treatment relationship yet. This gives us the option to decide that we don't accept a client. That finally happened to me. Basically, I was out of my league completely - no specifics, but quite severe and chronic illness, many attempts to get help, many medications tried, all to no avail. So a new grad can help you? I asked. The client gave me a nasty laugh -- oh, I'm only here because my parents insisted. Well, that kind of clinched it. There's no therapeutic alliance present, and this is simply doomed. Oh, and I almost forgot...the only drug that's ever worked is something highly abused. Right. Let me whip out that Rx pad, just a min. But interestingly, it still bothered me. This person clearly needs help. And I can't provide it.

My daughter is in New York for Spring Break. It's an interesting feeling to have a child so grown up she can can plan and execute a trip alone to the City. I'm really glad that she's kept in touch with her NYU friends. And she's staying with my fantasy son-in-law, a nice Jewish boy whose dad is a producer/screenwriter in Hollywood. He stayed with us for a week last summer for the Austin experience. Alas, she says they're just friends. She rented a little Soho apartment and then cooked dinner for her friends. Look. Yep, that's Turkish/Lebanese food. Our favorite.

I went to a retirement party for a woman I worked at Exxon with for years. She had the office next door to me for about the last 5 years I was there, when she wasn't traveling the globe. I think she was one of only 3 systems architects for the entire Refining division. Very successful, and single, no kids. It was a lovely party, at Damien's in Houston. Great food, I had scallops. I saw people I had not seen since 2005, when I left to become a nurse. And yes, most of them had not aged well. Exxon does not have a culture that encourages self-care - one of the reasons I left - but some people looked remarkably the same and still others seemed really happy (some of those were retired!). I'm not real big on reunions -- but Suzanne was special to me and I wanted to see her.

And speaking of reunions, I had a great meeting with the office of UT's employee assistance program, and I think I'll be able to partner with them to see their patients that need medication. They are looking for a provider who can see people promptly and collaborate with them, and that is something I'd like. We'd have monthly meetings to go over cases and that would be a little something extra that I'm not getting in private practice. Oh, I have been calling the therapists of some of my patients to compare diagnostic impressions, but those little doses of collaboration are brief. This would be more. I remembered something when I was there, meeting with all the therapists - when I was a freshman Business student at UT in 1980, I got a work-study job at the Counseling Center. And here I am, back again, as a provider. I never could've predicted that. Isn't life surprising? Wonderful. Magical. When a patient looks at me alone in my office, with tears in their eyes, and admits to me their deepest wish, or secret they've never shared....I feel that magic.

L'Wren Scott killed herself. I saw it on the twittersphere last night and just could not believe it. Such a young talented person who seemed to have this charmed existence. A celebrated designer, wealthy (apparently), Mick Jagger's girlfriend by god....how does that add up to miserable? Well, it's certainly an example of how mental illness doesn't discriminate. In my opinion, almost every suicide is in a severe depression. There are a few other instances where people choose that route, but in most cases it's the deep, dark pit. It made me intensely sad. I thought of Alexander McQueen, an even larger talent when he decided to end things. Dani got to see his Met exhibition and she had the glossy book of photographs of his creations....such incredible beauty. And often fragile, not of this world. As he was. And L'Wren.

Yesterday I had a suicidal patient so that pretty much ruined my day. Not that I minded - I never mind doing what's needed in such cases - but there's a great deal of extra work involved. On top of a very busy day. So I was at work until 7:45, long after everyone else had left. Then a comedy of errors began. I wouldn't have believed it, but here's what happened. I had left my phone at home, which was weird but oh well. My office has no place to store my purse securely so I lock it up in the front office. I often leave patients alone on my couch as I run down the hall to consult with my doctor, and it's just foolish to leave valuables sitting there. So, yes, when I finished up alone, so late, I discovered everyone had left, locked up the front and I didn't have my purse. Great. I didn't have my phone, didn't have anyone's number to call. Who memorizes numbers any more? Not me. I finally figured out I could call the answering service for our office and the other NP, who is on call this week, would answer me. I'd ask her to come back and help me. And know what? They F'ing suck. I called them, they refused to give me any information like home phone numbers, guess they thought I was a liar or something, said that they would just pass the message on. I called them back 3 times, got a different person every time who knew nothing. Finally I gave up and called my momma (really) -- and I hear the cleaning people next door. They let me in with their master key. It's 8:30 by now but I can leave. JFC. So many procedures that need to be fixed. Guess things ain't perfect after all. And guess what? The other NP finally texts me back at 11:30 last night. What the hell?


There's this guy at the gym, I call him Tattooed Love Boy, like the Pretenders song, he is older, big and muscular and bald and yes, heavily tattooed. Good looking guy. He is not a newbie, he's not there every morning with us regulars, but several times a week. And he does his dumbbell sets right in front of the rack, effectively blocking me from getting the weights I need while he grunts and sweats. He should know better - such a breach of gym etiquette. But I finally figured something out. He does it when I'm there by the rack, doing my sets. He steps back when it's just guys around, but when one of the women are there, he's all up in our grill. He's doing it on purpose. I guess he thinks it's a way to spark conversation. He must be shy or something. But know what? It just annoys me. I think if he worked up the nerve to say something, I would snap at him: "What the hell is wrong with you?" Somehow, I doubt that's what he's hoping for.

And in the end

Valentine's Day weekend 2014 was a way-terrific experience. Ken and I went to Park City to see Duncan Sheik perform live and to try cross-country skiing. And both were top-notch. The skiing was good - it is much easier to get up and going than downhill. Of course, years of downhill experience I'm sure helped. The first day, we took a lesson in the morning and then went back in the afternoon and did our own thing for about 3 hours. It was a nice day, if anything too warm. Ah but the next day-- totally different deal. A storm was blowing in, dumping snow as we started. By the end of our second run, I couldn't even see the tracks and my face hurt from all the needles of snow the wind pushed in my face. But it was so beautiful. Gorgeous. And, yes, it's safer than downhill. It's not an adrenaline rush, it's more your body being one with the outdoors. It's such a steady-state cardio workout, I ended up just hearing my breath and feeling the snow. I like it.

My new job couldn't be better. Here's how great they support me -- every day I'm there, the office manager comes by and asks if I have any questions or need anything. I mentioned off-hand that I could use a clipboard. Oh, she says, I'll get you one tomorrow. What color? What style?  This after I opened my desk drawer on the second day and found it had a nice set of supplies arrayed. They asked if I'd like a painting to go over my couch, and then brought in an assortment for me to choose from. We have Starbucks K-cups, cream and milk, and La Croix water in the break room, all free. It's so first-class.

And then there's the stuff that really matters. My schedule is already as full as I want it. I have 7 appointments for Thursday. Already, folks. In two weeks. It's because I can see insurance patients right away. And get this, one of my contacts is a fellow NP that is closing her practice because she's pregnant with her third child. (She plans to resume but not for at least a year or two.) She has hooked me up with UT's employee assistance program, and now I'll get a bunch of those clients referred to me. I'm meeting with UT next week. The best part: I really like it. It's challenging, it's fascinating -- I mean, I'm the shrink, people tell me things that they have never spoken aloud before, and it's a puzzle and an art. Especially prescribing. Which medication to choose? So much less cut and dried than antibiotic or cholesterol meds. And much more critically, is medication even warranted? My supervising physician is so different on that front -- he's so non-meds oriented -- frankly, it's been a little hard to get used to. When I bring my cases in to review with him, he spends much more time on that question and always, always about the therapy. With my previous doctors, it was all about med selection. We got to that very quickly. It's nice to have the opposite, because I like to always be conservative with medication.

My sort-of last day at the old place was Friday. I'm returning on Tuesday to write up a bunch of discharge summaries that I got behind on. It was a typical day there - so busy I barely had time to pee. I had an intern with me all day, and they planned a little cake party for me, but of course, something came up and I had to see a patient and the party turned into a 5 minute deal. So no tears because there was no time. I did an exit interview with some suit up in St. Louis and it was just stupid and pointless. I don't need to bitch and moan to her, and I didn't. But this has been, oh god, such a stressful time. I'm not sleeping well, and my pants are all baggy because I've lost weight. Part of it is just the stimulation of the new job - when I wake up at 3:00 am, I'm running through all the decisions I made about my patients that day - did I pick the right antidepressant? Did I note in the chart that she had seizures as a kid? Did I remember to block my lunchtime meeting next week? Didn't help that my Doc at the old job took a day off this week AND our census popped up. It was a terrible week. And it's over. And I'm going to yoga three times this next week, because I can now. Hoo hah.

So Dani casually mentions to me she's going to the movies. Oh, I say, with who? She says "my boyfriend". My eyes pop out of my head - What boyfriend? Oh yes, she has one of those now. His name is Rakan. Computer Science major at UT. His parents are from Syria. Can't wait to meet him.

Quit

I had a brand-new experience on Friday. I got angry and quit my job. Well, yes, I did give two weeks notice - I mean, I'm trying to do what's responsible for my patients - but after sitting through the ridiculous meeting with the owner where she failed spectacularly to reassure us that the place isn't falling apart,  I said enough. But allow me to back up a few days - so Tuesday, the COO and the Clinical Director quit. The Administrative Head quit the week before. And I quit Friday. Maybe that tells you all you need to know. 

My life has changed considerably. I'll be able to focus much more on my new private practice and I'm full of good feelings about that. I had my first day on Thursday and saw two new patients for evaluations. Of course, both were very complex, what we call "special" populations. The second one I reviewed with my collaborating psychiatrist and agreed that even he didn't have the expertise for the case. But both of them wanted to continue seeing me, and I have two more scheduled for Monday already. This is growing quickly. And I am finding that the staff there are as good as I'd hoped - I am getting the orientation and support that I need. They are smart, capable people. As Ken says, they seem to realize that both process and environment are important. 

Here's a pic of my new office. Every item in it is new - how cool is that? It's so nice after my crummy previous office with the stained carpet, the holes in the walls, the broken handle on the desk, and no window. So obvious they were saving every nickel and dime. I like this so much better. It aligns more with my personality - frugal is not me. Since we only go around once, it better be good. 

Nile took his next step in black belting. This was the most assured that I ever saw him before a test. And he broke his board on the 2nd try. He is assisting with the little kids on Thursdays now, and surprise...he likes that. He's always grumbled about being around them before, but turns out being the teacher is OK. 

I'm looking forward to having a much calmer life. After last week, I was already quite worried about how to fit in both of my jobs. I worked very late on Tuesday, and then they were peppering me with questions from the new job (Did you read that email? Have you turned in this form to Blue Cross? When you check your schedule, you need to look at this.) I could see that it was going to be out of control soon. Now that won't happen. So right now, their expectation is for me to be there two days a week. As soon as I have enough clients, I'll add another day and then another....until I'm at all 5 days. But here's the sweet part: I don't have to work Friday afternoons. I can use that time to catch up on administrative tasks or I can leave. Totally up to me. 

Friday was a really intense day. I walked out of that awful meeting with the owner - and she insulted me personally by the way, implied that I wasn't running my CBT group properly (which I strongly disagree with; and I wasn't the only target of her insults) - went straight to my office and typed out my resignation letter. I think it was 2 sentences, just the facts with no emotions. I'm leaving on this day, thank you for my time here. Then I walked up to the Clinical Director and handed it to her. She read it quickly and said "I totally understand." Then I walked away. And you know what? The owner was there the whole rest of the day and she never said a word to me. Telling. I was in the front office about an hour later, and our PhD Psychologist said to me, "Hey, I just want you to know how completely inappropriately I thought you were treated in that meeting." and this is the only time that day I really allowed things to leak out, I just blurted out "I quit". There were three other people in the office, and their heads snapped around. Late in the day, an announcement went out. It was a difficult day, I had a full slate of patients to see, insurance companies to call. I even had two doc-to-doc calls that I had to do (which is what they call an insurance appeal. I have to talk to the insurance company doctor, instead of just the clerk.) And I lost both of those appeals. I have to say, that's usual. I had a good track record of usually winning. So I'm going to take that as a sign that it's time to move on. 

L'aissez les bons temps roulez

Two big things to talk about. First, I have a new job. I'll be working in private practice with a local psychiatrist. He has one NP and now he's adding me. It's a truly innovative office, they emphasize therapy as much as medication, and his primary technique is psychodynamic. That's right up my alley, with my love of Jung and appreciation for his philosophy. The psychiatrist's wife is also a key player in the office, and she has an ivy league MBA, and they are very focused on data and best practices. But the most remarkable aspect is basically there is no churn. Unlike most other practices, it's not how many billable hours can you cram in a day, it's more how can we do good and feel good about our work. Education and collaboration is a planned, scheduled weekly thing. And he really means all this -- here's proof: he expects 30 billable hours a week, which is lower than most other practices, and I can do 4-6 therapy-only clients a week. That's really different, and it happens to be what I want. I am so lucky. Maybe it will help me heal from the storm that ran through my life when things I loved so much left me. The signs are good. I start Thursday. There will be an overlap period with my other job, but only as long as I want that (per contract, up to a year). Ken is actually urging me to just quit, but a part of me isn't ready. (I have a great husband, just FYI.) It's going to be emotionally very difficult to leave, to admit that I can't fix this. But more proof seems to happen every day; just this week I found out that they've started a new, expensive initiative that basically is just moving deck chairs around. Can I tell you how angry I am that they have money for this ridiculousness, yet my position was cut in half? It's going to be quite a chore to hold my tongue in the two stupid special management meetings I've been asked to attend, never mind the fact that I'm not management anymore. I mean, hell, I'm PRN, how can that be management? I have to drum up some patient emergency that will require my attention.

The other thing to talk about is Carnaval. Www.sambaparty.com. We went last night and it was one of the most fun events I've been to in ages. It was like an indoor Mardi Gras parade, with the creme de la creme of dancers. I was blown away by the quality of the hour-long drum and dance show by Austin Samba School. (and you better believe I'm going to Zumba tomorrow night, ha) The costumes that the attendees wore were incredible -- I was so both over and under dressed. Dani did my makeup and said "Mom, you look like a hooker." False eyelashes are way fun. Well, that really wasn't enough, I had a mini skirt, fishnets and boots with a Lulu top, but man, I needed to show waaaaay more skin. I lost count of the topless women, the ass-less chaps, the thongs (male and female), the innovative body paint....what a feast for the eyes. I'll definitely be spending more time on my costume next year. It's not a time to be classy, let's just say.

One of the things I really liked about the experience, and you'll see this from my pics, was that people of all shapes and sizes were included among the performers (attendees, too -- all 5,000 of us). There were so many women who weren't rail-thin, just full of happiness and great dancing ability, and did they ever strut their stuff. It was impossible not to smile and feel amazing watching it. Made me wish I could have a field trip with my anxious little anorexic patients, so convinced that the scale determines their worth. Oh baby, it does not. All bodies are beautiful! Just watch and learn.

Up

Things are looking up. I don't have a lot of news, but I mostly just want to get that rant off my homepage. Ha. Felt good to do it, but now I am uncomfortable with it being the first thing seen. I had an interview, and it went really well (in my opinion). It's an innovative practice with a psychiatrist that really emphasizes therapy. Already has one NP and seeks another, so I won't have to break any new ground. Lots of experience to learn from. Excellently run, with an office manager that's been there 7 years. The office is simply gorgeous - in a lovely park-like setting, the building is quiet. Obviously been professionally decorated with no expense spared. I would have an office with a window. The only downside is the commute, but it's bearable. And he was amenable to working flexible hours. They asked the magic question near the end: How soon can you start? Anyway, I'm providing them with all my license numbers, diplomas, etc. It's definitely going on to the next step. We haven't talked money yet, but I've already heard that he's reasonable. I must confess, the idea of seeing a wider range of patients with a variety of issues does interest me. This practice only sees adults now, but perhaps I could broaden that - I'm so comfortable with adolescents at this point, as they've been the majority of my patients.

It's a snow day in Austin. A rare event. My gym opened about 45 minutes late, but I got over there and my wonderful spin instructor did two extra songs for the three of us there. Love her. And no work today! Of course, no pay today either! This part-time thing....not gonna work. I'm really trying to put on my big girl panties and smile and have a positive attitude there. There is only one person at work I've bitched to, and I'm going to keep it at that. But the signs continue to be quite negative. I was told that I need to start meeting in person (instead of calling) with parents of adolescents on admission day - which is great, I think it's a good idea, but I'm not there every day. Nobody thought of that. Another example: I had 4 insurance reviews to do today, which won't get done because of the snow. And I'm not there on Monday. Someone else will have to do them that day, or patients could get denied for coverage and we have to eat the cost. Hope that gets done (said in a bitchy voice). I asked how situations like that would be handled when we were discussing this part-time schedule, was told "we have a lot of things to work out" and that was it. Just like the contract I was supposed to sign on Tuesday. Never saw it.

Um, this is turning into a rant again. Damn.

So what else is going on? Running is going really well. My rule is that I run one song, walk one. I'm up to 40 minutes doing that, wearing a knee brace. No more pain than before I started this, so = success. My gym is strangely deserted for a January, and it's because the new location opened in Westlake. A lot of people are going to that one, it's brand new and has a pool. I'm going swimming today, for sure. And yoga, and oh my...it'll be a fantabulous workout day. It's nice not to have a jammed resolutioners crowd, but I'm also worried that they may cut some of the spin classes for poor attendance. And I must, I mean must, mainline my spin every morning or I go into withdrawal. Nothing else quite does it for me, I think it's the intervals. Working so hard you can't catch your breath, drenched in sweat, cranking it up to the nth degree, screaming inside when will this stop?! And then slow down, breathe, recover, and do it again! For 45 minutes! Yeah baby. This may completely be TMI, but it is a lot like sex. You're in a dark room, building up to the climax, breathing hard, focused, straining.... especially when we reach the top, folks sit down on the bike and everyone sighs and squeals. Sometimes I just have to laugh. Yes, it's a spin orgy.

My ham planet cat has learned how to open doors. We have hook door knobs, and he stands on his hind legs, reaches up and opens it. He really likes to do this to the bathroom and then destroy the toilet paper. His girth facilitates this - ha.

I just finished The Goldfinch by Donna Tartt. It's a novel about love, art theft, tragedy and PTSD, and the losses that all of us face in life; the unfinished nature of how things turn out, the missed connections and the way that love actually doesn't conquer all. But still... there remains beauty and meaning, if we are brave and face things. It takes place in New York, Las Vegas, and Amsterdam. It's hard to put in to words why it's so good. It's well written, it surprises, it is deep. And it's absolutely not trite. I guess that's what I value most in a novel. If you want to read more about it, here's a link. I can't recommend it enough. http://books.google.com/books/about/The_Goldfinch.html?id=T2CA83gbtM8C

OK, yoga in an hour.

I'm not crabby, I'm just really bitchy.

This is going to be a bitchy rant. If that's not your thing, walk on by.

As I've often mentioned, I love my job. I work at a small specialized treatment center that I feel really makes a difference in people's lives, especially those of girls and young women. Most of the clinicians there are so capable and there's this wonderful collaboration. It's a stimulating environment to work in, and when I look back on the 5 months I've been there, it's quite stunning how much I've learned.

Can you hear the "yes, but..." coming? Our break-even census number is 11 patients, and since about late summer, we have not consistently been at that number. I've still had plenty of work, at first it was because I was learning so much, but I've taken on other tasks. I am the liaison to all the insurance companies, so I have to interface with them for each patient about every 4 days and get authorizations for continued stay. It takes time to collect the data from everyone on our team and build the story of what that patient needs. I also do three therapy groups each week and work with two different interns on separate days. I revised all of our medication management policies, which basically was non-existent. I was busy in spite of the low census, and I definitely worked more than 40 hours a week. I went in every Sunday afternoon, and frequently I had to meet with patients who were struggling over the weekend since none of the therapists were there. Sometimes I left early because of that, but not lately. In spite of all that, I knew that the organization was worried about the low census. In the past month, they laid off our HR person and our PR person. And guess who was next? Well, I'm their third-highest dollar employee, right behind the COO and the clinical director. But here's the deal, they really can't lay me off. Nobody else can do what I do - they aren't licensed to diagnose, treat, and prescribe. Only the doctor can, and he works only 8 hours a week, and half of those are meetings. I was thinking that they might consider dropping me to work only 4 days a week, or expanding my role to take on more of the therapist tasks. But they had something else in mind. And it didn't go down well.

So the delightful day before my birthday, the director tells me that they are dropping me from a salaried employee to only 25 hours a week, and keeping all my duties intact. I would work 3 days a week, and they propose that I see patients in a private practice using my office on the other days, and use a 60/40 split for the money I make on those days. The only problem with this is they were "too busy" to get me credentialed with the insurance panels all this time, so I've been billing under the doctor's name. I can't take any insurance patients on my own. And that's a ridiculous split - I would never agree to it. The going split around town is between 20 and 30, and that's with providing billing and insurance processing. They want 40% of my money just for me to use an office that's empty anyway? They also asked me to propose an hourly rate. So  I went away and started thinking about this.

The next morning, I see the COO in the coffee room and say, oh by the way, I forgot to ask when you guys want to implement this. He says, next week. My mouth falls open. I can't stop myself. I say "you are kidding". He says, oh I'm under a lot of pressure from Dr. M (our "headquarters" organization is a treatment center in another city; the doctor there owns both facilities). That's just peachy. You expect 2 weeks notice from me, yet you give me 5 days. That's just great. Later, in the weekly leadership meeting (and that they nicely inform me, I'll no longer be attending) our administrative head tells us that she worked all weekend on a proposal to fix financial problems that have recently been uncovered at HQ. Seems that their census has been low for months too, and they had been very sloppy about billing and record keeping when times were flush. Now they're not, and discovering that they have huge problems. Hmmmm. Could there be a connection to their sudden decision to cut my job to the bone?

Anyway, I calculate a rate that basically turns my salary into an hourly rate, I don't add on anything for the lost benefits. I am generous. I tell them the next day what I want, and that I want a 70/30 split and want to be credentialed. I offer to help with that process, filling out forms, making calls, whatever. Reasonable, no? I do this without being pissy, either, in spite of how I feel. And then I wait. And wait. So it's Friday, and all of this is supposed to start on Monday and fucking finally, he meets with me and counters my hourly rate with one dollar below that and they won't compromise on the 60/40 split. I say nicely through clenched teeth, I decline your offer. I can stay for the 3 part-time days but at my original rate and I'll find something else to do on those 2 days off. And incredibly, he says Well I have to run that by the owner. Great. Let me know by the end of the day. I'm not showing up to work without us coming to terms.

And at 2:00, they come back and agree to that.

I'm incredibly sad about all this. I really was doing work that fed my soul. But I can't stay at a place that feels they need to humiliate me. One dollar less? What is wrong with you people? I've had uncomfortable, strong signals for a while that our COO isn't very competent, and this just confirms it. Throughout all this, he kept saying this was not his choice, it was all coming from HQ, it was out of his hands. You fucking ballless wonder. So what exactly do you do here then? And the serious financial mismanagement is not trivial. I don't believe these people are good businessmen and women. I see reaction, I don't see strategic thinking.

I have a job interview Thursday, at an office with a psychiatrist that I've heard wonderful things about. The only downside is the drive. He's up 360 on Spicewood Springs, but that's reverse traffic so I don't think it will be bad. And it avoids Mopac, which is about to become a disaster area for years when they start building the toll road. My plan is to start working there on the 2 days I'm off, he can start getting me credentialed, and then I'll quit and go over there once my practice on those 2 days fills up. Actually, a pretty good deal because many times the first 6 months of a private practice are pretty lean as you build your clientele.

And I'm closing with a picture from the hot sauce fest this past summer. It allows me to do what I wanted to do all week. I look pretty happy.

More Naps

I'm at work. Seems like I could just say that at any moment and it's correct. Not too big a whine, but seems like lots of parents thought that they could "cure" their teenage daughter of her eating disorder in the two week break for the holidays. Ridiculous, sad, so misinformed. And then they are angry at us when we don't pull that rabbit out of the hat. My doc has worked only a total of 4 hours over the last 2 weeks, and numerous people have been on vacation. What I'm trying to remember is that I can only do what I can do, and that all of this is a choice. And people covered for me when I took a week off (of course, they have a PRN NP that has to come in for me. Nobody but the doc can actually do what I do; unfortunately that's not true for me. I can step in and do the therapist work and I have been.) But honestly, I've had some fantasies about finding another job. That bothers me. My boss returns Tuesday and we will be having a chat. I've decided that I need to set some limits on the time I leave the office. The actual patient work is quite rewarding, it's worth it to make a big effort to fix the problems.

They opened a new Gold's gym less than a mile from my office. It's pretty sweet, all brand-new equipment and .... a POOL. I've swum laps there twice now and I have all the excitement for the beginning of a long term relationship. They have a nice sauna too. I suspect that will become attractive for me, stop there a few times a week after work. Swimming has always been such a meditation activity for me, it would be perfect after a long day to "process" as we say. Their spin room is big too, I'll have to try that out. Brand new bikes. I've started running again. My knee really felt better after that week in Holland with just walking for exercise. Took away all the weights, yoga, spinning and rowing. So I've started VERY slowly. I run one song, walk one. And I stop after a cycle of 3. After two weeks, I'll let myself increase. This is so NOT what I did last time. I think in less than a week, I was running 30 minutes straight. Through the knee pain. Don't do that.

Ken and Dani are in Taos. They skied yesterday, I'm waiting to hear a snow report. And it's supposed to be a super-chilly day here. I should have some great snowy pics for my next post. They ate at Tecalote Cafe in Santa Fe, one of our favorite places. Blue corn pancakes.

Ken and I are going to Carnaval Brasileiro www.sambaparty.com this year. I figured no Mardi Gras, this'll stand in. And I bought the VIP tickets, so we'll have a nice little area to chill when we get out of breath from dancing. And baby, I sure plan to do that. I'm working on my costume, so far I've settled on freaky stockings and boots. Maybe a Lululemon top, I need some extra support for all my jumping up and down. Ha. Can't wait. From what I read online, this is a real feast for the eyes as well as the legs.

The holidays are over and I'm so ready. Not my favorite time of year, and I think with the work issues it was particularly bad this year. It's funny, I spend much of my days being somewhat of a cheerleader to my patients -- "What skills could you have applied in that situation? What things work for you to improve your mood? What's standing in your way of making those choices?" and I catch myself thinking, maybe (just maybe) I should apply them to myself. Certainly it's easier to tell others than to do it yourself when you're blue. Or stuck in the black and white of it all, technicolor gone missing.

Over the holiday revelry, here's something interesting that came up in the dining table conversation this year. We were all sharing the most interesting thing from our year's work. My brother owns a vintage furniture store in Austin called Modern Salvage www.royt.com and as part of his inventory acquisition process, he buys foreclosed storage units. One of the units he bought was owned by a great-grandson of Jack and Rose from the Titanic story. Yes, the movie. Those were actually real people, although they weren't that young, and they had children that were not with them on the boat and survived. So yes, most of the movie's plot line was fiction. Anyway, this guy that owned the storage unit has had a difficult life. Lots of money handed to him (the family was wealthy) but he was a sucker for con men with schemes. Lots of detritus in that unit from failed deals that he was involved  in, and also lots of expensive, little-used things he bought (great for my brother). One of the items was this beautiful Movado pocket watch that you slide apart to see the lovely little clockface - pic below. And here's the real kicker - there were Krugerrands in the unit too. Why would you put such a thing in storage and then stop paying the rent? Isn't that an interesting question.

I've been reading some of my friends' New Year's resolutions on Facebook, and so far my favorite one is "take more naps". I kind of hate the whole idea of setting goals, usually not realistic, at some arbitrary point. Maybe it stems from my distaste with my ridiculous overcrowded gym for the month of January. Yesterday I had to place my yoga mat right smack at the front mirror so that people who only stayed for 3 songs could have the primo spots. I'm serious, Erika even remarked "where did everybody go?" ARRRGGG. Lots of people with no sense of gym etiquette - muddy shoes, doing their sets right in front of the rack, using F'ing cell phone on the machines..... But on the other hand with resolutions, few of us take the time to stop and take a breath and evaluate our lives. So yes, I've taken a few moments to do that, need to do it some more. I heard a great thing on NPR this week about this by Two Guys on Your Head. I love them. It's locally produced by KUT and exactly the kind of stuff I think about constantly anyway. Here's a link. http://kut.org/post/how-make-effective-changes-new-year-0 So what are your resolutions? I am toying with the idea of taking a drawing class but wrestling with the reality of having to drive through traffic at the worst time of day to make that happen. I think I would love it but the truth is that my time is limited and precious. If only I could find something close - I'd be all over that. (Austin friends  -- any art classes in the Westlake/Lakeway area?) The other thing is meditate more and get in at least 2 yoga classes a week. Odds just went up on that one with that delightful Westlake gym.