It's not that I haven't done anything fulfilling in the past 5 months. Much to the contrary. Fourth year has been intellectually and emotionally fulfilling, beyond all belief. I learned how to manage scary things and be in scary places. I learned how to talk with people about death -- their death. I learned how to actually, legitimately perform brief interventions in psychotherapy. I returned to the clinic where my love of rural family medicine began. At times, I struggled (when least expected, really); at others, I felt so profoundly gratified. But I just never really felt like writing about any of it. It's just one more thing to do -- as though simultaneously preparing for my Boards, writing my residency applications, planning my wedding and subsequent epic travel (all of which will happen within the next five weeks) wasn't enough.
I almost wrote a few weeks ago, though. I've been recruiting patients for a clinical trial I am doing next month, and I received a phone call from a woman who had seen my advertisement. I recognized her name instantly. Because exactly two years ago, she made me feel like I could actually one day be useful to a human being. To excerpt from my July 2009 blog entry on this encounter:
I spent 2.5 hours with this woman. I asked her to talk about what it was like to wake up and move about, and dress and eat and get about her day. I asked her to talk about what it was like to leave the house, to interact with her family. To go food-shopping, to attend church. To process the world around her. To communicate with her doctors, her therapist. To feel alone, discouraged, purposeless. Hopeless.
And along the way, we tapped into issues that I wondered whether they'd seen the light of day before -- her anxiety about how she communicated with imprecision, about remembering certain key things in her day. I didn't know how to manage her meds; she probably really did need all 20 of them. But I knew about her anxiety. I've not had any training -- but I knew EXACTLY what to say, how to prompt her to evaluate her thought process.
Everything out of my mouth was fluid and confident. I knew that I knew what I was talking about, and I just did it. And she did it. She engaged the questions I asked her, engaged the concept of asking herself questions, of rehearsing her coping mechanisms in advance of encountering challenges, of developing an arsenal of experiences to draw upon that demonstrate her strength and confidence.
As each word passed my lips, I line-item compared it to those that have spouted during Spinning rides, blog posts, car rides, and all of the other opportunities I've given myself to practice, inadvertently, for this one moment.
As I deliberately carved each word to empower this woman to motivate herself towards change, with the exact same words that I'd used for so many literal and figurative hills for myself and others, I was so mindful of how directly I was speaking to myself just as intently as I spoke to the woman before me.
This was what I had trained for; this is what I had trained myself for.
I made her a list to take home with her of three skills she had developed and practiced during our time together. Her ammo against her depression that was all of her own active creation, to help the meds work better. Her way of reminding herself that she was in charge, actively constructing her own experience.
She smiled and took my hand.
And I knew that I could and would never practice medicine in any other field besides primary care.
So when I heard this woman's voice on the other end of the line, I flashed back to how truly fulfilled I felt when I wrote all that. I remembered, specifically, about the "list" I referenced. I had assigned her homework that day to go home and ride her horse, which she hadn't been able to bring herself to do for several years but once enjoyed. It was an exercise in "acting opposite" to her mood.
We made arrangements that she would come in to speak with me. But unlike the downcast, tearful woman I met two years ago, here she was with a bright, sunny straw hat making legitimate eye contact. She consulted the planner book in her purse before committing to schedule her study visits with me:
"Well, you see, I simply can't come on Thursdays. Thursdays are the day I ride my horse."
I bit my lip to keep from bursting into tears. I was so proud of her, this woman I hardly knew. And I told her so.
Now flash forward to yesterday. Back at clinic, I was asked to go see a young woman with complicated psychiatric illness who had begun to exhibit some self-destructive behaviors, who had expressed an interest in my study. She didn't qualify for participation, but I thought it might be a good opportunity to practice some of the skills I'd be actually using during study visits -- figuring it was worth a shot to try to help her. Went in, introduced myself, did a little bit of an intro pitch to diaphragmatic breathing, etc. Then I demonstrated her how to practice it, same as I would show someone on a Spinner bike. No big deal. Demonstrating to her how to rest her thumbs on her navel and let her fingertips expand across her lower abdomen so that she could gauge how well she was expending her abdomen on inhalation, I noticed how intent she appeared to learn this "skill." She looked up at me, wide-eyed and timid, with an expression on her face that seemed to be asking for approval.
The dynamic was foreign to me, in a clinical setting at least. I felt some combination of guilty, horrified, and overwhelmingly useful (as in, more so than I really should have been able to be useful) and sad. Sad because the way this girl was relating to me, more reminiscent of a young child, was the result of so many things gone wrong: her neural wiring, her life circumstances, her poor, poor coping mechanisms.
So I thought that I might try to teach her some coping mechanisms. One of the best things I learned on my outpatient psychiatry elective a few months ago was a component of cognitive behavioral therapy, a tool called Coping Cards. The idea was that you teach people, while they're not in crisis mode, to brainstorm coping actions or thoughts that they can look to during a crisis -- so that they don't have to think straight (since they're not likely to do so): the thinking is already done for them, by them, in advance.
I encouraged this girl to come up with a list of five actions she could immediately complete as an alternative to forcing herself to vomit when she got anxious. Without questioning me, she started rattling off a few things she could do to distract herself. I explained the concept of Coping Cards, handed her a few blank index cards that I started carrying around in my white coat pocket lately -- just in case I ever got to do this. And, again without questioning this foreign concept, started writing -- in a handwriting style and content consistent with the other regressive qualities I'd observed -- the following:
"Instead of vomiting, I could draw a picture."
Again, I wanted to bawl.
I didn't know if I was actually accomplishing a darned thing. But even getting to practice this skill that I didn't think most people even knew about, which I only knew about because of a very specific opportunity I sought for myself, with the promise of doing so much good with something so simple -- felt almost as good.