I plan on sleeping in

That's another Deathcab lyric (actually it's Postal Service, since I was at that concert this week, but I lump them together). It accurately captures my state of mind but certainly not my actual activities. Ha. People that know me, know that I'm always up early at the gym when there's only a select handful of us regulars and almost all the machines are free. There's no weirdos to come up to you, in your face while you're in the middle of a leg press set, with your earbuds on, and stand there yelling excuse me until you remove one of them to (ick) hold a conversation. Which turns out to be some asinine question about the relative advantages of one leg machine versus another. Look buddy, I'm not your free personal trainer. You'd think I hated people, but look folks, I really don't. Just do not interfere with my gym time. I'm not there to socialize. Not one bit. This is exactly what happened to me when I had to be there during regular-person hours recently (oh, the horror). I had this surreal morning the Tuesday after Memorial Day. First, the doofus at my gym is not on time again. This happens a couple times a month, and I have blogged about it before (so no boring rant); I go to Plan B, which is drive to the Gold's on William Cannon. And even though it's a 24 hour place, it's locked up tight too. A woman and I stand there at 4:30 a.m., scratching our heads. Guess they have a doofus that works there too. She said that had never before happened to her, and she's been an early-bird there for years. Know how I got revenge? Oh, I'm so, so evil. Read all about it (sigh...like they even care). Yelp Review

I've been waiting to write this post until I had job news and I got some today. So, yes, folks, I have so much time on my hands that blogging is now something that I have time to do. Ha. I received "the note" from the Doc's office manager that he'd like me to come in for a meeting. I'm pretty sure that it's to discuss the terms of me working in the practice, and I'm ready to make a deal for that. I've done some more checking around, and I'm convinced that this is the best option for me. One of the checks was someone in the know (won't reveal sources) who said in confidence that their plan is to offer me the job. I'm pleased. I feel lucky to have found a private practice job in Austin as a new grad. I'm not going to reveal where I'm working or with whom so that I can continue to talk in my blog about my work, but only in terms that disguise patients completely.

I just read the most disturbing (in a great way) book. It's Gone Girl by Gillian Flynn and it's a psychological murder-mystery thriller. With some huge twists in the middle and end of the book that really threw me for a loop. I spent most of the day Monday reading it. I haven't had a can't-put-it-down day like that since I read Middlesex (another book I'd highly recommend). What an absolute luxury of a day, and in the evening Dani and I went to hot yoga at this little studio that opened just outside our neighborhood.

Anyway, the book paints an excellent picture of a person with borderline personality disorder, I would list it as chronic, severe, with psychotic features (fixed delusions) if I was writing it as a diagnosis. I am not going to reveal which character has this illness, because it won't be apparent for the first 60% of the book (yes, obviously I have a Kindle if I'm quoting percentages). Really sucked me in, I was completely taken in by this borderline. And the book as a whole is a truly excellent explanation for why clinicians dread working with these patients (in fact, the doc I'll be working with says that we should never have more than 2 borderlines as patients). It's almost impossible to sift through the lies and the truth, mostly because they believe their own lies (that's their version of a fixed delusion). Which is quite sad. And the havoc they wreak on the lives around them, in their desperate attempts to fill their wide, bottomless abyss of neediness is painful to watch. I think of the parents I've met of the frequent-flyer young-adult borderlines that I had as patients at the psych hospital. To a one, they looked tired and sad.

I have done basically nothing since I got back from New York, besides read, eat, and go to lots of yoga class. Well, then there's the Anthro trips with Dani. I found a fantastic black top marked down twice that was only $9.95 yesterday! And I'm not talking about some schlubby loose Splendid top, no it's got these nice little ruched shoulders with 3 tiny set-in buttons. What a find. Made up for the full-price items that I proceeded to buy for Dani.

Nile took another step in his black-belting this week, he had testing Saturday and passed to the next level. He'll get his new belt tonight. It's nice that he gets that before summer kicks off. He is going to work for my brother at his used furniture store, Modern Salvage (Store Link), driving his new car. We got him a dark blue Prius, at his request. Isn't my son smart? Dani is still looking for a job and still looking to see if UT accepted her for the fall. One of her NYU friends, a guy from L.A. whose dad is some big-time screenwriter, arrives tonight for a visit. I bet he loves Austin, what do you think? I loved it when I was 19. In fact, that's about the age when I first fell for her, from the Congress bridge bats to the ice cream at Udder Delight, to water skiing on Lake Travis, to concerts at Club Foot, to bowling in the UT Union basement and indie movies at Dobie Mall. OK, I better stop.

I guess I have to start studying for this board exam. It's kind of weird, when I get the Authorization To Test (ATT) from the credentialing organization, it better light a fire under me; there sure isn't a fire yet. Maybe this meeting about the job will do the trick. I seem to be waiting for some magic. So snap your fingers, say a little hocus-pocus for me (thx).

Here's a few pics of the summer fun.

ETA: Thanks for the chant! It worked! I got my ATT in my email this afternoon and scheduled my test for the 18th. Two weeks is enough to study for the most important test of my life, right?

Postal Service concert

Lakeway trails

Black belt time

Significant

I have graduated. It was a pretty decent day, not too hot and had that nice milestone feeling. I thought the speakers were thoughtful and (most important) not too long. This was just for the school of nursing so it was pretty specific, and I liked that. I must say, I was quite glad that I did not wear heels. Lots of walking, traffic was super awful. Apparently different schools had their convocation ceremonies at the Bass Concert Hall all day long, separated by 2 hours, so as people were leaving, we were arriving. I saw all my Psych NP classmates (all 9 of us).

I have to say, this would not have been possible without the support of my husband, Ken. It was quite a luxury to only work on the breaks (& even then, only because I wanted to). This was a successful joint project. I'm finally at the point of doing my life's work. BTW, here's a link to a story that eloquently explains why I feel that way. I want to be the one that makes a difference in someone's life in exactly this way. Modern Love Story

After graduation, Ken and I went to Kerbey Lane (yep, the original one). I've been going there since 1980, when I first came to UT. Yep, 33 years. Feels incredible. There was a loud table of young ones next to us with a few fellow graduates, drinking mimosas. Great way to spend a Texas afternoon. BTW, I just have to mention that I'm wearing two nursing pins on my gown, nurses go through this unique "pinning" ceremony when they first become nurses, one of them is my grandmother May's pin, who was a nurse in Arizona in the 1930's, the first surgical nurse in a small Arizona mining town. A pioneer. The second one is from my original graduation from Our Lady of the Lake College in Baton Rouge, in 2007. Another meaningful day. 

Then we flew to New York to go get our daughter. We had some fun, but it was a super quick trip (only there 4 days). We went to MOMA, wandered around Soho, and saw a Broadway show (Kinky Boots - fantastic, makes me want to be a drag queen for Halloween next year, ha!), and got her and her stuff back to Texas. We had six heavy suitcases and shipped two big boxes of clothes, but we did it. I ate the best Thai food I've ever had at a place called Peep in Soho, and of course, we had to try the vegan falafel sandwiches that Dani has been living on at Taim (it was as good as she said).

Here's some pics from what we did.

So now I'm just waiting for the authorization to take my boards, and I hope that will be soon although I haven't started studying yet. Not sweating it too much. 

This is an interesting time to be entering this profession. The DSM 5 just came out and is pretty controversial. I listened to an interview on NPR a few days ago with the new head of the American Psychiatric Assn. and I thought he explained/defended the viewpoint of the mental health professional community pretty well. NPR DSM-5  People are upset because we have much more detail in this volume - the first new edition since 1990, which is an eternity in science - but many people don't feel that upset about the fact that similar guidelines for physical diseases, such as heart disease, diabetes, etc. have had even more growth in their body of knowledge. We know more, shouldn't we inform more? And no, I don't agree that we are pathologizing normal (which seems to be the main criticism), it's still an individual clinician that is licensed to make an actual diagnosis - no just anyone can do that - and one of the most important things that the DSM stresses over and over is that if you have a mental disorder it should cause you significant distress and impairment in your daily functioning. If those two criteria aren't met, that it should call the diagnosis into question. 

Next up on the agenda: buy our son a car this weekend, and get each teenager a job. No small feat. Hopefully I'll have job news myself in the next post. I talked to the director of Shoal Creek and I've essentially crossed that off my list because they don't anticipate a start date until September. That tells me they really aren't interested in new grads. I'm certainly not going to wait that long.

Perched on the Handlebars

I took my last final exam this morning. As in "last in my whole entire life", unless I'm going to enter a new profession again. Which I guess is not too unreasonable, given that I've already done at least 5 different things. Those would be (in order): accountant/auditor, systems analyst (which includes many different types of jobs, from project leader to software developer), group exercise instructor, RN, and now....Nurse Practitioner. Yes, I know, I still have a pesky little thing called Boards to pass. NBD. I'll take it soon, but not before May 25th -- that's when UT will officially send my degree info to the credentialing organization.

It was the Pecan Street Festival last weekend, and it was perfect weather. It's been such a cool Spring here, makes it more pleasant to be outside. But of course, there's the grumbling I do as I run to my car in my sweat-soaked clothes before it's even light in the morning. Not digging the cool weather then. But that time appears to be over. Anyway, Pecan St. was a real shopping opportunity, which I did not waste. And half the fun of anything in Austin is the people watching. Great city for that!

I'm still figuring out where I'd like to work. Yes, to quote the Shins, it's like I'm perched on the handlebars of a blind man's bike. I am pretty sure that I'm going to work for a psychiatrist in central Austin in private practice. But I did get a call from a large local psychiatric hospital last week, and they are seem very interested because I have a variety of psych hospital experiences, both here and in NJ. There would be advantages to working there, but the biggest downside is the traffic. I would certainly have to be there for morning rounds - probably at 8:00 - and the traffic would be a nightmare. If I didn't want to be late, I'd need to leave an hour before. The advantage would be higher initial pay, full benefits, but mostly the variety of patients (including those serious mentally ill, which I love but won't see in this practice) and working collaboratively with a large team that includes psychiatric residents. And I'd be their first Psych NP, so it would be ground-breaking. But working in private practice, I can shift my work hours -- arrive at 9:00 or even 9:30 -- and voila, no traffic. Yes, the flexibility would be divine. I have spent 2 days with the Doctor and his existing two NP's and I like/respect all three of them - it feels like a good fit. And this morning, I got an email from his office manager basically asking if I was ready to start job negotiation. Still thinking about checking out the hospital.....urggg, but that traffic.....of course, that's only for two years. When Nile graduates, Ken and I plan to move closer in.

Anyway, that's all been on my mind. Here's something funny. Antipsychotic medication (things like Thorazine, Haldol, Risperdal, Zyprexa) are being found useful for more and more things. They work as mood stabilizers for bipolar disorder and work as an augmentation agent for treatment-resistant depression. But when you say the word "antipsychotic" to a patient, they just hear PSYCHOTIC and flip out. What? I'm not taking that drug! So my clever professor advised us to call them.....broad-spectrum psychotropic medication. Isn't that great? You also see that when you tell a bipolar patient their diagnosis - they envision the Hollywood mania and get pretty upset - WHAT? I'm not manically crazy! I haven't spent every penny and had sex with every man on the street!

I have an Ebel Beluga watch that I bought a couple of years ago on Overstock.com. I saved a few hundred dollars on it and figured that was great. The bracelet broke and I took it to be repaired, which the jeweler said that they could not do. All repairs have to be done by authorized Ebel jewelers or I can ship it to Ebel. I went online to get a repair order and ship it....and guess what...it's counterfeit. The serial number is invalid; it's not even the correct number of digits and letters. Now what? So I googled around and found someone that offers to repair any watch -- I sent it to them. But here's the fun part of this story. I dreamed that night about my watch, that I opened it up to see the inner workings and then I ate them. Yep, crunched up all those little delicate metal pieces. Yum. (note to you: don't buy luxury items from that web site)

Graduation is on the 17th. I'm excited but it will basically be a hellish day. Because of the Boston bombings, security will be super-tight and everything will take longer. Graduates cannot bring any bags or purses. Guess I'll stick my lip gloss in my bra. Spectators have been advised to only bring a bag/purse 12" or smaller, and warned that lines for those to be searched will be long. Better to just go through the metal detector and carry nothing. Oh boy. 

I had an interesting conversation with my hairdresser this week. It was the day that they discovered those three women held captive for 10 years. She wanted advice on whether to bring it up with her two young daughters. We talked about the risk of scaring them unnecessarily vs. letting them hear about it on the news, and talked about the relative risks of stranger danger vs. someone a kid knows (stranger is actually quite rare, most common is parents stealing kids in a bad divorce, but behind that is relative/acquaintance). And we talked about the nature of evil, which is the only thing I can call this. I'm an atheist, so I have no biblical beliefs about the devil and what caused such a thing. Is he mentally ill? Well, of course, it would actually be fascinating to do a psychiatric evaluation of him (if he would talk, surely his lawyer is putting the kibosh on that). Deep down in my bones, I know this man is just plain evil. Very few mentally ill people are violent or motivated to do something like this. And here's the thing - you can't really tell. When I worked at a state psychiatric facility in NJ, we had some of what you call "forensic" patients and a few of them had done absolutely terrible things. I can still remember that one of my patients needed to go off-site for some specialized medical test, and in big red letters inside his chart it said "must be accompanied by two mental health officers for any off-grounds appointments". I had seen orders to have one officer, but two? Then I read further in the chart that he had been a serial rapist. Great. (Rule on the first day: never let the patient get between you and the door.) But was there any clue when seeing this patient in the milieu with everyone else? Absolutely not. Just another guy. 

One more pic. These are my fellow UT Psychiatric Nurse Practitioner graduates, professor (far L) and program director (far R) for 2013. We are a small group, there are many more Family NPs and also about six Pediatric NPs. 

Loco Locums

Three exams left. Counting my boards, which I plan to take either in late May or early June. Two finals and then that really big one. I have some study materials lined up, and I can purchase some computerized study aids too. It feels close, picked up my cap and gown, tassel and hood yesterday. Yes, hood, when you are bestowed with a masters, you wear a hood. The get-up is even stranger for the doctoral graduates.

Job quest rolls on. My plan to work for the specialized facility fell through. They said although I was the best person for the job, the locums tenen doctor (the term means "temp" for a practitioner) backed out at the last minute. This was to fill the gap until I was fully credentialed in late June. So their home office required them to fill the position now with an NP already licensed. I was disappointed, they were very nice about it, but what a time sink that was. I met with them three times, did research on their business and population, interview prep, etc. But the nice part is I'm actually feeling pretty happy about my other option now - it's working in a private practice with a local psychiatrist in central Austin. The only disadvantage is the initial lack of income - this is not a salaried position as the other one was. It will take time to build my clientele. But the team there (the doc and two other NPs) is a great bunch and it will be a great place to learn. The variety of patients will be good too - all ages, all different diagnoses. And I can walk to Kerbey Lane Cafe for lunch every day. Yes, the best revenge is happiness (I actually said that to a client today, when he was talking about recovering from a bad breakup). That's a bit of overstatement for me - no revenge intended here. It's all OK. Really.

Kitten season is coming at the Austin Animal Center. If you're thinking about adding to your family, please come by in the next month or so. We will be overrun soon.

I ran across an article at school that completely articulates my philosophy about mental health. Here's a link to it if you're interested. The cool thing is that this practice that I hope to join is completely on board with this. It's so much more than a pill pushing place. I really think I'll be able to put this into action.
Lifestyle and Mental Health

Ken and I go pick up Dani in NYC in late May. We are only staying 3 days, just lots to do and Nile is here, still in school. When Dani gets back, we will be going to yoga together. She's turned into this total flaming yogini freak, which I'm totally jazzed about. You know, it had to happen, I mean she does have half my genetic material. I got this terrific Groupon for us to take classes at a Lakeway studio together all summer long. Then, here's the cool part: in the Fall, she moves into an apartment that is quite close to where I hope to work and there's a yoga place within walking distance. Hopefully we can meet there after work while I wait for the traffic to die down. Mother/daughter bonding experience and get-healthy time, all wrapped up.

OK, so guess where I'm headed? Yep. Yoga. Aaaaahhhhhhh.

Wicked & Divine

Unique ceramic works.

Last night was Art Erotica, AIDS Services of Austin's big fund-raiser for the Paul Kirby emergency fund. Such a good cause, but man such a good time! It was noticeably toned down this year -- kind of wondering why. Here's the scene as we entered: dark, throbbing beats, art along the perimeter. Lots of gorgeous young gay men serving drinks in just their bikini briefs. There's a stage for fun later, and an area set up for three artists to paint/draw with live models with a circle of chairs for spectators. Lots of super sexy party-goers, yes, ass-less chaps and Marilyn Monroe-esque drag queens. Free drinks too, but I noticed that I've never seen someone stumbly-drunk there, never seen out of control behavior. It's just that nice Austin, tolerant chill weirdness.

This is the one we bought.

So some of the highlights: really cool trapeze performers using hoops and lengths of silk, a mini-Mardi Gras parade at one point, a male and female balancing act using just their bodies (I'd like to be that strong), oh and watching artists create from a tableau of 3 models. That was way cool. Two women and a man, the women had these interesting trompe l'oeil paintings on their bodies (pic below). I simply couldn't believe how fast the artists could work - of course, maybe that was the idea. But the finished works looked pretty good. We did end up buying a painting - its got that mystical Southwestern dreamy thing going on that we like.

So that was fun and well worth a night that I could be studying. School is fine, I'm very busy mostly because I spend two full days a week with Dr. Smith and I have 4 therapy clients now. I'm interviewing at two places for a job, and they are both quite different. One I mentioned in my last post, a local psychiatrist but I'm also talking with a small private center. In the interests of privacy, I won't be specific about the place but it serves a niche market of a specific disorder. They are interested in creating a brand-new position, so it is pretty different from most NP jobs, but one that fits well with my previous experience and my interests. Of course, I'd see patients too -- that's essential to me. Can you tell which way I'm leaning now? Ha. There's many different ways to work as an NP - we can be salaried employees, hourly employees, independent contractors that pay a monthly fee for supervision and office support, or pay a cut of our billings. It's a lot to analyze.

My New Year's resolution was to start adding a little running to my activities and I've been succeeding with that, but I started having knee pain. I suspected that I needed a different kind of shoes, so I went to this local running store in Lakeway, Capital City Running (http://capitalcityrunning.com), and they have a treadmill and videocam to analyze your gait, and I was impressed. I needed stability shoes but also turns out my shoes were way too small. A full size too small, maybe that's a female thing, we don't want to have big feet. I bought the shoes and yes, big difference. I love the running, want the knees to stop hurting though. And of course, I did too much too fast. Duh.

I'd love to say more....especially about interesting things I've learned. But I have a big paper to work on and some group members are counting on me. And the gym is calling too.

Three-Letter Acronym

School is zipping along and I'm liking that. In six weeks I'll be done! Of course, there's a final exam and then my board exams, but let's not count those. Just not having the massive reading (but often it's quite informative) and the papers (which are nothing compared to learning how to quickly document every patient visit) will be a relief. This is Spring Break, but I'm pretty busy. I did get to leave Dr. Smith's office early today because she had a meeting at her kid's school. Yes, working moms, we are everywhere. I have a list of 5 things to get done this week: 4 papers and a presentation, and 3 items are done. The presentation is on Alternative Diets for ADHD. I'll save you the trouble of sitting through it - special diets don't work in more than 90% of children. Kids with ADHD need meds. That doesn't mean that diet isn't important - kids with ADHD need good, healthy food (don't all kids?) and in many cases they need extra calories of high-quality nutrition. But it won't take away their symptoms. One of my last tasks is quite daunting - it's a group project to design an IOP (intensive outpatient program) for veterans with PTSD and chronic/serious mental illness. One of the three group members is a veteran herself so we have the inside track to make a truly realistic proposal. It's a lot of work but good learning.

I think I now could do a psych eval (new patient) in my sleep. I can cover your entire life in 40 minutes. Even if you're a talker. That's going to be painful, I'm going to be redirecting you a lot and it will absolutely exhaust me, but I can do it. I've been doing it. And I now have little lists in my head of what meds to pull out for what disorder, and how to tailor them to specific presentations. Are you depressed, sleepless and losing weight? You need Remeron and Celexa! Are you Bipolar II, don't want to gain weight and your manic periods weren't excessive? You need Lamictal! Are you only anxious and it's not too bad? You need Buspar and yoga! The other disorders (schizophrenia, ADHD, OCD, PTSD, etc.) are not as frequent so I don't have those right on the top of my mind. And yes, I know so many acronyms it's kind of ridiculous. You should hear Dr. Smith on the phone with other providers. It's just an exchange of 3 or 4-letter abbreviations.

Reassuringly enough, just in the past week I've started to feel that I could effectively handle most patients that we've seen if they were coming to see just me. But we had a doozy the other day that left me feeling like I was totally out of my league. I'm going to modify details to preserve privacy, but this was a teenager that had a long history of untreated mental illness, two specific disorders that are often co-morbid (meaning they occur together), and now finally, after flunking out of first semester of college, it's time for treatment. Never mind the fact that having one of these disorders untreated has likely resulted in brain damage according to the neurology report. I had to wonder - who was advising these parents? How did they feel about that now? The parents were very into alternative treatments, very against any medication at all, which is something we see frequently in Austin. The problem is that the alternative arena has a wide variety - yes, some things are new and work, but others are downright harmful. They are unregulated. And if you put all your chips on an alternative treatment, that's a big gamble. We didn't have time to cover everything, and we went 20 minutes over anyway. After this complex, difficult patient, I was pretty shaken. I thought to myself, if this teen came to me for help, I honestly would not know what to do. Dr. Smith said that when you're unsure on a complex case, don't make any decisions in the first meeting. Maybe you need another hour with the patient, and that's OK. She said tell them that you need to consult and do research - and that's OK. Call all the other providers that the kid has seen - previous psychiatrists, neurologists, therapists, psychologists, primary care. She said that usually by the end of that, you'll know what you want to do. But if not, call your mentor(s). She said there are a couple of guys that she trained under in town, and she still calls them once in while. I felt oh-so-much better after that.

I have a job interview this week. It's for a psychiatrist in town that works with three NPs in his office. I talked to two of them and both said great things about working for him - he's very available to consult and he enjoys teaching, he encourages work flexibility in terms of hours. Oh, and here's THE most important thing-- there is a yoga studio within walking distance. Can you say noon-time OM? I just want to see if it could be a good fit for me. He does see kids, so  the fact that my license allows me to see them as well (not all Psych NPs see kids) is a plus. I knew all that time on the kids unit at Austin State Hospital wasn't a waste.

My friend Kathy is moving to Colorado. We had lunch and talked about old times working together at the psych hospital here. I will miss her a lot, and I learned a great deal from her. She's one of the best at establishing rapport with very, very ill psychotic patients. Here we are, having lunch together at Hyde Park Grill (a great classic Austin place).

Cover May Not Be Indicative of Contents

This is an interesting, exhausting time. I'm spending two days a week with my precepting psychiatrist (I'll call her Dr. Smith), in class two days and seeing therapy clients the fifth day. I think the exhausting part is the clinical work. But it's so fun. Oh my goodness, if I ever had a doubt that I was meant to do this, it's gone. I read my textbooks for fun. Stahl's Essential Psychopharmacology? Love it. The chapter on depression is brilliant. And my doc is the best -- I mean, I selected her carefully, it wasn't an accident. It just feels so good that it's coming together for me. I have many avenues for work, the hard part will be choosing.

I knew this already, but I feel that it bears repeating -- people are so darn different, unique and surprising. I can't be specific about patients but I've heard such incredible things over this month. Someone really professional, polite, relaxed sits down, you close the door, and they dissolve in front of you as they talk about growing up with an alcoholic father that beat them, their resulting serious drug problems, their failed relationships, and the depression that's hounded them. It's quite something to pull out that little pad and offer relief. But it doesn't end there, of course. One of the reasons I respect Dr. Smith so much is that she pretty much insists patients see an individual therapist. The meds lift the fog so that you can sleep, function, and face your work in therapy. Therapy helps you make changes that last. Do all patients thrill me? No. I particularly don't like it when I sense someone isn't truthful (which happens a lot....sigh). The range of people's responses are so wide. I've heard from a patient, my Dad's friends sexually abused me but I'm in therapy and I'm coping (true) and then another patient will say, I've had such a terrible year, you absolutely wouldn't believe it. What's so bad? Job stress and elderly uncle died. Hmmmm.

The prescribing is starting to come. I did so much on my own today while the doc watched -- three psych evals (new patient intake -1 hour) and three follow-ups. She asked which meds I'd choose for each, and (yay) I was right most of the time. One I missed was recommending Viibryd, it's very expensive. We went with Effexor because cost mattered to the patient. Another big learning is how common sleep problems are. If you have a mental health concern, you probably have sleep troubles. I got to give a sleep hygiene lesson twice today.

Another thing I'm learning is how to confront or "go public" with my internal dialogue to patients. If your story doesn't add up, I say that, "This just doesn't make sense to me, explain why you refuse therapy, won't take your meds, and keep coming to me. How can you move forward?" luckily that conversation doesn't happen often. But it works even with little things - you say you're fine with your marriage but we've spent most of our time talking about your wife's failings.

There's a bill in Texas that loosens some of the restrictions on Nurse Practitioners' relationships with their delegating physician and it looks good to pass. It's very good news because Texas is terribly short on healthcare providers in most locations (especially mental health, that's actually the worst), so now NPs will be able to do more. And we are cheaper. I'm starting to look around and figure out who I want for "my" doc, and this really matters.

I spent 3 days with an NP at nursing homes, seeing demented patients. I like older people, and after working in NJ on a medical unit, I'm used to dealing with ill elders, but this was not my cup of tea. It was the same feeling I had when I worked in ICU -- so many patients can't really communicate with you, it just takes all the fun out of it for me. And it's just plain hard trying to figure out how to treat dementia (short answer: you can't. You end up medicating to control negative behaviors).

So I have often talked about how much people's weird behavior at the gym bugs me (yes, I know, I spend too much time there). But listen to this. At one of the yoga classes I go to regularly, a woman comes in late. She's older than me and very thin, wearing tight little short shorts. She has a strange double-wide mat, which she proceeds to lay out front and center (strike one - if you're late, stay in the back). She brings big hand weights with her, I'm wondering why. She's now way too close to another woman's mat, who looks irritated. We do our first down dog and I purposely don't look at her ass, knowing those shorts are not covering it. Strike two. Things seem OK, until we get to the abdominal work song, then she starts doing strange things with her weights and they are noisy. Guess that's strike three, because her neighbor picks up her mat and moves to another spot. I had never seen someone do that before. (I sure have wanted to.) I thought to myself, wow, lady, you have no no idea how much you're wearing your obsession. Stick-thin, inappropriate clothes, ridiculous efforts to ramp up the ab work, you might as well post a sign saying "Eating Disorder". Future patients, they are everywhere.

The pic is from the Austin Animal Center. Someone must've donated the cat bed. This little fella sure liked it.