And what have you done?

In other news... first off, go have a look at FW's diary - would do the link to the particular post but am too stupid. Warning, may cause spontaneous cheering. That's pretty damn fine writing.


Secondly, Sarah continues much as she was, but thanks all for the well wishes. She uses a walking stick and I am trying to order her a sword-cane through the internet, but have grave doubts on our ability to get it through customs. In the interim, there are walking sticks tastefully carved in the shaped of women's lingerie-clad legs. If I buy her one of them I'd better hope she doesn't also have a sword-cane.

Anywy - this will be a brief letter because I'm writing it from the coast where we are attending a family Christmas - more of which later. I mentioned a while back a change in careers and here 'tis: I have given up on Emergency and a few weeks ago sat the interview of the psychiatry training programme - in fourish years I am not going to be an emergency doctor, I am going to be a psychiatrist.

In a way I think this is like coming out, admitting what kind of person you are after years of denial trying to be something else... but it's that special kind of coming out where you've had your arms and legs and torso out of the closet for years and only your head halfway in and then you pull your head out and say "Prepare yourself, people, I have an utterly amazing announcement" and everyone says "we know already."

If there is a "type of person" who does psychiatry, rather than emergency medicine, a way of interacting with people and looking at stuff and thinking about things, I am that kind of person*.

It appears, by the way, that I have already been practicing some startlingly efficacious pyschotherapeutic techniques for many years, albeit in my kung fu class. As stated, this simple technique can be used to treat many mental illnesses that otherwise require time-consuming therapy, costly and dangerous pharmaceuticals or green-house-gas unfriendly electroconvulsive therapy. I am looking forward to using this technique to cure drug dependency, and will start tomorrow on my larger straight-out-of-prison patients. Quick slap and they're cured. I'll have to be careful not to knock over the ones standing on one leg holding a rose.

I was thinking about denial the other day and how someone at my (basic) level of medicine treats it and thinks about it, and I've worked out I don't treat it or think about it in the right way at all. Denial is one of the things we assess in the basic mental state exam - it is related to questions like "does the patient have insight?", "does the patient believe they are sick?", etc. On bad days I think of it as a scorecard for how much the patient agrees with the doctor.

Denial is generally seen as bad. When I first started out I think I had the idea that part of your job is stripping away the denial and getting the patient to "face facts", which was obviously the first step to healing and so on, because if you don't believe you have a terrible and frequently fatal disease, why would you take the horrible medications doctors prescribe for you?



Nowadays I think that this is not the case. I was wrong about denial.

The wonderful thing about medicine is it is at its heart so simple. Whatever helps the patient become healthy is good medicine. Whatever distracts you from that is... well, it's a distraction.

And denial, in the short term, in inescapable situations, might be part of good health, often a crucial part.

Basic example - you know those horrible moments when you catch a glimpse of yourself in the mirror unawares, and realise how fat/balding/otherwise scombroid you look, those faintly sickening feelings? Thats the stuff that you deny momentarily emerging from the ocean, a barnacled kraken, dark, streaming with seaweed from the deep, profoundly threatening. That basic level of denial is what keeps us going day to day.

And above that there's the other useful kind of denial, situation-specific rather than background denial - the denial that you are working yourself to an early grave, that your partner has been emotionally unfaithful, or that your job and life and friendships are not what you'd hoped them to be. That denial can be an internal armour, the intrapersonal equivalent of the more commonly encountered interpersonal white lies of "how are you going?" and "that's nice, dear".

Of course, whether going on, keeping a marriage together, using your internal resources to maintain said job and life and friendship at all costs, rather than seeing things for what they are and moving on - that's another thing, of course. In those cases denial can be fatal to happiness. But if you don't have the courage, or imagination or whatever it is best called in that particular situation, denial becomes essential. If I had been diagnosed with some horrible cancer, for example, maybe a couple of days of denial would be a good thing.

Anyway. Here endeth the lesson. I am meant to be packing for Christmas, instead of lying here wide-eyed, open-mouthed and inert, like some kind of enormously elongated anchovy.

Lots of marine imagery this post, maybe it's high tide or something. I wonder if there is a belief that creativity pulses with the tides - writers scribbling ferociously under a (say) full-moon perigee, struggling to produce anything under apogee.

Anyway. Off to pack before Sarah does it all.

Thanks for listening,

John

* *Obviously, it's not a particularly eloquent person.

The Picture

Hail,
Mid morning here, Sarah has just left for work, (I have evening clinic) and I am worrying. This is how things are going.

Without rehashing the whole timeline, Sarah's got relatively advanced joint disease. It's worst in the hips, worse on the right. She's been to an orthopaedic surgeon and he has recommended surgery. That can only happen in April, and surgery itself may be difficult, because to intubate people for surgery they have to bend their neck about, and she has joint disease in her neck as well.

In the meantime she is in considerable discomfort. I know this via deduction - when the day begins she walks with difficulty, almost stiff, like a poorly animated marionette. She moves more freely once her medication kicks in - the dextropropoxyphene lasts maybe two or three hours, the transdermal buprenorphine all day, but only at low levels. She is sleepy during the day - partly a medication effect, partly because pain affects the quality of sleep, erodes its complex architecture.

Towards the end of the day she may wince, or falter, or stop in the middle of a sentence, once or twice she has momentarily paled, and sat for a while.

Joint pain is bad. It's a combination of two or three different kinds of pain - the sharp pain of a fractured joint - (this is what is going on, the radiologist points to where the bony spurs, the steophytes on Sarah's hips have broken off), the dull pain of constant inflammation, occasionally the horrible burning ache of neuropathic pain. The acetabulum, the cup in which the ball of the hip twists and turns, is supplied with nerves that also supply the lower limb - she gets a dull ache in the muscles of her thigh, pain in her knee. The joint itself is corroded and fragile. Looking back - and reading about this - it may have been that the joint has been mis-shapen and weak from birth.

As I said, I know this via deduction, and weak induction, but I do not know this via her testimony, because she almost never mentions it. The reasons for this are, as far as I can work out, complex.

Sarah is afraid that everyone will think she is whining if she complains at all.

She is afraid of being self-pitying, or of allowing her illness to dominate her life, of becoming an illness wrapped in the skin of a person, someone who is their pathology, rather than a successful and fascinating and wonderful person in her own right, a person who has an illness.

At some level, despite my best efforts (and possibly because of my worst) she remains afraid that I will somehow get irritated by this and leave her for a Russian gymnast.

She remains deathly afraid of becoming one of her own patients, and imagines herself toothless and torpid, her life a flat, featureless plane, surviving on the disability support pension.

All of this combines to make her attitude to pain relief deeply stingy, and her mental attitude a curious mix of determined, unrelenting optimism that very occasionally dissolves into glimpses of terror.

I don't know. I am in awe of her, not for the first or last time in my life. It's odd that at a glance I am a lot stronger than her, I can carry her around the yard whereas she can't unload even small bags of cat-food from the car, but there is no way I have her strength. I can kick hard at head height and bench press a reasonable amount and do CPR on a big man for a long time, but there is no way I could last a day doing what she does.

I think that before cliches became cliches there must have been a time when they were new and young and fresh. The first person who said "All flesh is but grass", or "her eyes were as blue as the sky" or "I will love you til I die" must have felt that thought like lightning, as something pure and limpid and true. Now that experience is lost to us, because there is no way, unless we are particularly skilled, that we can express thoughts like that in that way, with that potent combination of truth and immediacy.

Anyhow. I will love her till I die. I wish I could take the pain for her. Her eyes are as dark as the night.

Enough of this. The thing is, that picture that Sarah keeps in her head of her after the operatrion, her better, her healed, is something we are going to be focussing on. It's not the only thing, we are going up to the zoo later on for one of those behind the scene things where you look at baby cheetahs and so on. I have been trying to buy her surprise presents, trips overseas and cats and so on, which is a difficult thing to do when you have joint accounts, and so far every attempt has run into some kind of organisational portcullis or another. But overall it's just a matter of organising stuff so that she doesn't ave to do as much, so that we spend the maximum amount of time together.

See, from that point of view it's not all bad. Everyone's a winner.

Anyway, time to get my act together for tonight, which is seafood and something, and then a romantic DVD or something. Hopefully a more romantic DVD than my last choice, which was actually a horror movie.

Will post soon,
John

How about seventy two relatively sexually inexperienced people?

Hail,
Been reading and thinking - and this will alarm some of you - about religious belief and faith and stuff. And just to cause more alarm, this comes after reading something our new Prime Minister wrote about the subject a few years back.

First off, I should point out that I have been thinking about this subject in isolation for a while, and like all people who sit alone and think obsessively about a limited range of topics, I've probably gone a little crazy. Some of this, I suspect, may not make a lot of sense to anyone else, whereas to me it has All Become Perfectly Clear. But anyway, here goes.

I don't talk to my friends about religion. I seem unable to do it with any degree of success, the times I have tried the discussions have either wound down blind alleys which are of little interest to either of us, or turned into mutually distressing arguments, or stalemated into mutual incomprehension. And by sheer weight of numbers, it can't be them who is consistently daft about the whole thing, it's probably me.

I think some of the problem comes down to meanings of words. To my friends, religion means some sort of active believing in the supernatural, whereas when I don't mean that. I don't know that anything supernatural has ever occured to me in my life.

To some of my other friends, being a Christian means hoping and wishing and believing that there is a God watching over you who is going to somehow bend the rules for you - cure your medical problems, for example, when He lets others suffer, or change the lights to green so I can be on time to a meeting that maybe I should have left earlier for. I don't believe in that, either.

Some others suspect it's powered by the Afterlife, the whole promise of seventy two virgins . To be honest, I'm not that good at the whole delayed gratification thing at the best of times, and anyway, the way I was taught, that stuff's all theologically iffy anyway. Plus, and nothing personal to any virgin readers, being a virgin doesn't mean things are going to work out between us, or make us mutually interesting or anything.

You know, there's a great story waiting to be written there. Some guy wakes up in the afterlife and there's the seventy two virgins, and things encomplicate. Something this guy could write about.

Just to confuse my friends, when I'm talking about religion I mean a couple of different things, too. The one I talk about least is the most real, the most important, the core thing. I've written about this in this blog occasionally, I suspect it's deeply boring to anyone who hasn't experienced it, and it's something I have no faith in my ability to put into words.

The meaning of religion I've been thinking about most recently is more a cognitive thing. I have been thinking of it as a sort of mental cookie-cutter, a way of thinking we are all born with - some to a greater or lesser extent, but something we've all got. I call it a cookie cutter because it carves up the otherwaise inchoate and unknowable and mercurial universe into handleable, useful shapes, makes it something we can use. This cookie cutter is something evolution put there because it works, because it's a successful method of dealing with stuff. A "way of thinking about things" - lots of things, not necessarily or even most often supernatural things - that you start seeing in a lot of places once you know where to look.

This actually gets quite interesting once you look at it.

Okay. There are certain things a "way of thinking about things" has to have to get called religious. There have to be a division of the world into the Saved and the Damned. There has to be a belief in prophets, in some sort of Received Wisdom. There has to be a vision of Paradise and therefore of Hell, there has to be a Gospel and an urge to spread it, and following on from that a desire to convert the masses, persecute heretics and especially apostates and so on.

Now, this is all pretty obvious, but the weird thing is where you see it. One of my best friends - and one of the smarter people I know - has read Richard Dawkin's latest book, the God Delusion, which is about pretty much what the title says. In terms of a belief in the supernatural, a hope that God will change the traffic light colours for him or an envisioned rendezvous with the seventy two virgins, Dawkins is a deeply and openly non-religious man.

But in the sense I have just outlined above, he is profoundly religious. He's a True Believer.

This friend of mine says that if atheism is a religion then not playing chess is a hobby. To me, that sounds more like a bumper sticker than a hypothesis, and it doesn't apply to Dawkins. If you don't play chess you... just don't play chess. You don't write a bloody great book on it, appear on television denouncing those who do play chess, equate parents who teach their children the Sicilian Opening with child abusers, and dedicate a large proportion of your time that could otherwise be spent writing excellent books on areas you know a lot about to trying to stop people playing chess, denouncing the unbelievers and prophesying the Hell that will follow if your exhortations fall on the deaf ears of this thankless generation and the paradise that awaits the Elect who throw away their chessboards and be free.

This may sound like rhetorical points, but I believe that there is a deeper truth behind them. Dawkins, for example - and he wrote two or three of the best science books of the last twenty five years - is like the rest of us: a man with a religious cookie cutter in his head, a man given to thinking in religious terms. I remember reading The Selfish Gene - and if you haven't, go now and do so, I'll wait here - and being stunned at how this one man had taken the whole popular understanding of evolutionary theory and rotated it ninety degrees, so you could see how it made sense that way too, what a truly great idea Darwinian evolution was too.

And then, perhaps troubled by what he could see would be done with the idea, on the last page he wrote "We, alone on Earth, can rebel against the tyranny of the selfish replicators".

I read that and thought "Thank God" and then later on, a couple on months later, driving down the hill to the ED, I remember thinking "well, I don't see a lot of evidence of that happening", and a few months later I realised the reasons for that.

I don't see any evidence for that because there isn't any. It's not an evidence-based statement. It's a faith statement, one that arises de novo in your head, a function of your conceptual tools and emotional needs, put there by evolution because believers like Dawkins and me fought harder and fucked faster than our more skeptical neighbours. Dawkins has a faith in human nature or the human capacity to rebel or whatever where other people have a faith in the seventy two virgins.

Another example of religious thought in Dawkins' writing is his moral absolutism. To Dawkins, religion is bad ab initio. No matter what comes out of someone's religious (in the traditional sense of the term) beliefs - feeding the poor, visiting those in prison, that kind of thing - to Dawkins, those beliefs are still crap. None of this "by their fruits shall ye know them" stuff, it's all bad because... it's all bad. Religion is brainwashing. Religion is stupidifying. Religion is child abuse.

Now these are pretty strong terms, and to a certain extent obviously he's chosen them to shock, but the thing that struck me when I heard them was their familiarity. We've all heard this kind of stuff from religious people before.

Examples from my own inglorious past. When I was an atheist, religious believers were morons and butchers. When I became a fundamentalist Christian, pretty much everyone other than the Few - the men and women beside you on the bus, the Catholics, the Jews, the North Melbourne Football Club - all were destined for the Hell they so richly deserved. When I became a (comparatively) radical socialist, advocating separatism for women and justifying the overthrow of the state by any means that didn't actually involve me doing anything more than talking, Capital and those who had it were bathed in the blood of the workers. If I'd been into Amway, I would have thought Omegatrend was Satan's child.

Anyway, I could go on about this and I know I have a tendency to do so, but I'll stop now. This was less somethign I wanted to get out there for public consumption than something I wanted to put into some kind of order in my head, some thoughts I wanted organised. And I'm not trying to defend stuff, I'm not saying "my way is the right way" or "religion makes people better" or even "hey, seventy two virgins. That's seventy two!". I'm just trying to explain something I feel. Thank you for indulging me, and apologies to anyone I've offended - it was inadvertent.

Anyhow. I have much to write about besides this - patients and psychiatry and Sarah and so on - and this weekend I will. And I'm not going to post anything more until I've replied to comments, this weekend.

Thanks for this,
John

Briefly

Hail all,
A very brief catchup note.

Thanks vast amounts for the well-wishings. Sarah is still not well, hence the fewer posts than usual - I have a lot I want to write about and not a lot of time to do it. She is now on some relatively hard-core pain relief. It is difficult to tell if this is working because tragically, Sarah was born without a whinge gland and physiologically almost cannot complain, whereas my whinge gland is the size of a cantaloupe and pulses rhythmically several times a day.

However, we know that good pain relief means good mobility means good recovery from surgery, so there is a functional reason for her to take her medication, an "excuse", and that seems to be working.

In other news, the Great Socialist Dawn (that's an event that I am referring to, not a person) continues here. Oddly, it seems almost exactly the same as the previous administration - and God, that term suited the previous lot, because they weren't a government because they didn't govern and they sure as Hell weren't a leadership because they didn't lead. Things seem unaltered, whichever way you look at it.

Anyway. With Sarah trying to exercise pre-surgically, I have been doing martial arts stuff (sorry about the "sexy women want to meet you" pop-ups, but it's worth looking at) and have managed to give myself sciatica from muay thai. These are possibly sympathy pains, i.e.: pain that you get so you can say "hey, I need some sympathy!", but still it's a real pain in the gluteofemoral region. In the mornings it's coffee, black with two naproxen and some panadol.

Speaking of drug-popping doctors, if anyone's seen "House", how many people reckon he's Sherlock Holmes? House --> Holmes, Wilson --> Watson, isolated, misanthropist, opiate dependent, impossibly keen diagnostic eye. He even plays a musical instrument. Can't remember if I've mentioned that before.

Anyway, work is going moderately well, and I have much more I want to write about, but now I am on call and must go off and work. I am looking forward to writing tomorrow.


Thanks for listening,
John