Those days.

The 26th Law of Psychiatry (The Law of Therapeutic Charity): Give yourself credit for being the one in the room.

I had one of those days.

I haven’t written about it much so far, but I spend a lot of my time helping people with a nasty genetic condition. It’s called sickle cell disease (SCD).

SCD is very high on the list of things you do not want to have. It’s caused by a defect in hemoglobin, but the main problem it causes is pain. Early on, it’s episodes of bonecrushing pain called crises. Later, for reasons nobody really gets, the pain tends to turn chronic. Chronic pain is not an easy thing to treat.

Most of my patients were told they wouldn’t live to adulthood, though now they have a 50/50 chance of making it past their mid-40s. With longer life comes more cumulative complications. Strokes, joint and bone damage, all sorts of organ injuries, blood clots, and on and on. Not everybody gets all that, of course. The disease is amazingly protean considering how uniform the cause is. That said, it’s a bad disease. Where there is brain injury and chronic pain, there is depression. Of course, it’s depression that’s harder to treat.

I have really, really good days. Walking three inches off the ground good days. Days when I see the first smile of the patient who’s been miserable for months. Days when, after uncountable complicated, ambiguous decisions; I push my head up over the waves and realize my patient has been out of the hospital for a solid year when he used to be in every month. Days when somebody who was utterly gorked on pain meds and in godawful pain finally comes out of the haze and gives me that stunned, “I think my pain’s actually better,” speech. Days when I’m pretty sure somebody’s way better off because of me.

Most days aren’t like that. Usually I don’t know if what I’m doing is working.

Part of that is just plain ol’ statistics. Clinical trials can tell you that if you do the thing for a large group of people, more of them will get better than if you don’t do the thing. They can’t tell you if the particular patient you’re doing the thing for will get better, or if he would have gotten better with time, with or without you. (If you just started singing a U2 song, shame on you. This is a serious post, you Philistine.)

Clinical trials also don’t enroll my patients. You can find a randomized trial with bajillions of people with major depressive disorder (north of 5% of the population). You aren’t going to find a single one with people with SCD (around 0.03% of the population), two strokes, bone infarction, bad kidneys, iron overload from multiple transfusions, chronic pain, and depression. There may be a dozen of those people in a given state, and they’re probably going to be in my waiting room.

I know that what I do works. I seldom know if what I’m doing is working. Such is doctoring.

With uncomfortable regularity, I find myself in a room with someone and we’re three tricks deep into my bag, digging around for numbers four and five. Thus it was on the day in question.

He’s been one of my flock for years now. Since then, he’s developed various painful complications, and his insurance is crap, so he can’t get some interventions that might help. He’s lived about three decades longer than he ever expected to live. He’s also got a grinding chronic depression, and partly due to all the dirt SCD does to your insides, our options for medications are limited and we’re already pretty deep into that bag of tricks. Some things are better – his mood has lifted some, he’s not holed up in his room all the time, he’s spending more time with his kids, and he’s more active than he used to be. Still, better ain’t great; and we both know it.

He and I share a certain sense of humor. We get on, he and I.

To wit:

“How’s it going?”

“Well, I haven’t thrown myself out a window yet.”

“That’s good. It would certainly reflect badly on me if you did.”

“I would hate to inconvenience you.”

Like I said, we get on. Aside from all the bad jokes, we’ve also had some serious conversations about suicide, and we’ll have another one at the end of this session. He’s been straight with me about what he’s thinking. He’s decided to stay alive, come what may. I’ve told him I’m never going to give up on him. That’s the understanding. He’s an honorable guy, with a lot of integrity under his rough edges. Or perhaps in his rough edges. I have decided to believe in him. He has decided to show up. So, on we go.

This particular day, he was dealing with an ongoing problem with his family. Underneath that problem is that he depends on them, and he’s not the sort who likes depending on anybody else. We talked it through, came up with some concrete things to try to improve his interactions. As he walked out, he said, “All right. I’ll give it a try.”

Then, “Thanks.”

There are times people thank you, and there are times people thank you. This was the latter. My chest ached. I watched him struggle out of the chair and limp out to make the next appointment. Everything I haven’t been able to do for him hit me, hard.

I had to give myself that talk. The one I give supervisees who are stuck between the simultaneous realities that you can always find another way to help, and that you never quite know if anything’s going to work until it does.

You are the one in the room with him. 

It might be that there are dozens of other docs out there who know stuff I don’t know, and who would have made a bigger difference. They’re not here. I still am, and I’m hoping if nothing else, that makes some difference all by itself.

So, on we go.


The advantage of being the stupidest one in the room.

CODE ALERT: U.S. Preventive Services Task Force says women should be “screened for depression” during and after pregnancy. Their answer, of course, is to “find the right medication.” And how many on the “Task Force” are on big pharma’s payroll? Follow the money on this one. Hormonal changes during and after pregnancy are NORMAL. Mood changes are NORMAL. Meditation helps. Prayer helps. Nutritional support helps. Love helps.

Recently on social media I came across this gem.

I’m not going to specifically cite the author here – she’s all over social media so you should be able to find it easily if you’re interested. I prefer to avoid signal-boosting such Froot Loopery any more than necessary to make a point.

As far as I’m concerned, the recommendation is long overdue. I have to say I’m disappointed they didn’t specifically recommend paternal screening as well. I don’t think there’s anyone in the medical profession who really takes ownership of care for fathers in the way our obstetricians look after mothers. All that’s aside from what I want to say here, though.

There is a lot to say about the current crop of science denying “purity cults.” These folk act as if there was no such thing as disease in the Neolithic, when everything was all organic and non-GMO and we didn’t have any of those terrible, terrible medicines and vaccines that are steady killing folks. I’m not going to say most of that stuff.

Here’s what I’m going to say: Science is going to win, over and over, because science is intentionally and stubbornly stupid.

Let me illustrate by contrast. Take a look at this slightly enhanced version of that quote:

CODE ALERT: U.S. Preventive Services Task Force says women should be “screened for depression” during and after pregnancy. Their only answer, of course, is to “find the right medication.” And how many on the “Task Force” are on big pharma’s payroll? Follow the money on this one. All hormonal changes during and after pregnancy are NORMAL. All Mood changes are NORMAL. Meditation always helps. Prayer always helps. Nutritional support always helps. Love always helps.

Yeah, she never really came out and said meditation always helps. She damn sure doesn’t use sometimes much, either. You see, she knows.

Back when I was applying to college, in between chucking authentic artisanal spears at the antibiotic-free, free-range cave bears wandering about at the time, I was introduced to my good friend Joe Bloggs.

Joe Bloggs, according to my SAT prep books, was a guy of approximately average intellect. Joe got easy questions right, middlin’ questions about half the time, and was usually wrong on the hard stuff. To his credit, Joe B. knows his own strengths.

Joe B.’s cognitive capacity was the key to a very meta test-taking strategy. First you looked at a question to figure out how hard it was. Then you asked yourself, “What would Joe Bloggs do?” On an easy question, no need to overthink; just write down the answer. On a hard one,  the most immediately appealing answer is probably wrong.

One thing Joe Bloggs had nailed down was this: always and never statements are usually false. Very few things are so simple as to be universally true – for heaven’s sake, even a second doesn’t always last a second. Among the universe of possibilities, always and never can only be true in exactly one circumstance, whereas sometimes can be true under several.

So, our not-too-bright-but-not-too-dumb friend Joe Bloggs might look at such statements and think, “Is there never such a thing as an abnormal mood change? Is there nothing that prayer, meditation, and food can’t help?”

What our boy Joe Bloggs lacks in straight-up horsepower, he makes up for in wisdom. To paraphrase another deeply wise man, Joe knows what he doesn’t know.

Some would make science out to be a monolithic entity that spouts unquestionable truths from on high, and only a small dedicated group can see through it. In fact, the way of science is rigorous, corrosive, unrelenting doubt.

Real, no-kidding scientific conclusions tend to look like this: Under these circumstances, when you do X, Y happens more often; however, it doesn’t always happen and we haven’t looked at some circumstances. So, to the best of our knowledge, X probably contributes to Y.

Science starts out from a position of ignorance about anything, thinks up several possible explanations, and then immediately starts obsessively tearing each one of them apart. Science is pretty much one giant Woody Allen monologue.

Knowing is a lot easier. It’s a lot more pleasant to be smart, to know better than other people.

Except when you’re smart, when you know; you stop looking. For example, you might not look at the actual guidelines since you just know that those @#$%ers are in the drug company’s pocket. If you did, you might find something like this:

They found evidence that cognitive behavioral therapy and other talk therapy are effective treatments and have little risk of harm for the woman or baby. The Task Force found that antidepressants can cause serious harm for a fetus, but the risk of this happening is small. Clinicians and pregnant or postpartum women are encouraged to work together to identify the best approach for treating depression that will meet the woman’s individual needs.

What? Clinicians acknowledging that scientific evidence shows there are both risks and benefits to medications? Pointing out non-pharmacologic treatment options? Encouraging rational discussion and individualized decision-making? It’s even more sinister than we thought! It’s not Big Pharma, it’s BIG PSYCHOTHERAPY!

No, that can’t be it. Must be reverse psychology. They’re trying to misdirect those sheeple into thinking they’re not up to what they’re up to. We could look for actual evidence of their conflicts of interest. Why bother, though? We’re the smart ones. We are the enlightened. We know.

Me, I’ve had most pretense at knowledge beaten out of me. I’ve got some evidence to go by in what I do. Despite the fact that so much has been discovered, I’m still deep in the weeds a lot of the time. There are plenty of medicines that improve the chance somebody will get better, they all have side effects, and they will fail lots of people. The same can be said for all other therapies.

Most of what I’ve got now is some hard-won humility, persistence, and a sharp sense of what I don’t know.

I would rather tell somebody, “I don’t really know what to do, but I can think of some things we can try. Let’s think about which one is worth a shot” than blow smoke. Of course, I got no books to sell.

I’m Joe Bloggs, MD.

Still, I think I’m smarter than some.