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.