Monday, August 29, 2005

Sugar Busting, Salad Shootings: Dietary Drama in New Haven

It was a dark and poor-me night, the Thursday before last. I was upstairs in my room, sprawled out on my bed, websurfing by the flickering light of my powerbook screen. My inner monologue was trying to convince my outer monologue to get up and do something productive. It wasn't working. I couldn't understand why I'd been feeling like such a physical and emotional lump those last few weeks; maybe it was the depressing rotation at the veteran's hospital, maybe it was those doggone monthly hormones...or maybe, it occurred to me in a momentary olfactory hallucination of the brownies sitting on our kitchen counter, it was my worsening sugar addiction.

Thinking back on the previous week of meals, I realized that I'd been consuming more and more of the insidious white stuff--at least at every meal, plus snacks and dessert every night. I'm not saying I was a hardcore addict--I hadn't gotten to the point of dipping my baby carrots in corn syrup, or rubbing the Orbitz wrappers on my gums for the extra kick; but I do have a history of abuse (I once attempted to snort pixie stix in 7th grade) and I could see that I was well on the road to being consumed by the empty calories I was consuming.

I thought about the upcoming few weeks. The most exciting thing on my calendar was my dad's Israeli movie screening benefit, set to take place on Aug 31st at the legendary West Hampton Synagogue. Apparently, the WHS is a ritzy shul founded by Steven Spielberg, frequented by all the big shots Jews who spend their summers in the Hamptons. From my brief google search, I get the sense that it's the kind of synagogue known more for how much its congregants pay than how much they pray. I calculated that it was exactly 12 days until the event...hmm, 12 days...12 steps...sugar addiction...and that's when I decided to go cold turkey and avoid refined sugar for the next 12 days.

Today is Day 10. I'm happy to report that I have been largely successful, aside from some illicit Heinz ketchup that I put on my eggs yesterday, and the organic gum (that I incorrectly assumed to be sugarfree) that was ironically the first thing I ate on Day 1. Mostly, I've been eating a lot more fruit, to avoid feeling such an intense sweet craving that I cave in and dive into one of the many taunting ice cream tubs in our freezer. I've even been going over to the dark side -- last week one of our professors hosted a going away party for a visiting resident on her way back to Mexico. Rather than leave myself vulnerable to cake attack, I proactively had one of the delicious chicken chimichangas and a few shots of tequila; by dessert time, my tummy was all too happy to stick with watermelon only.

At this point, I have no doubt that I will be able to push on until Wednesday. And, I've realized, it has nothing to do with willpower or discipline per se. Instead, I think there is an art of neural negotiation inherent in making changes to one's life. We all have habits and thought patterns that don't serve our highest good; say, for example, eating too much sugar, or procrastinating because I don't feel like expending the effort to get something done. In each of these, it might seem appropriate to say that what is needed to overcome these obstacles is more willpower or discipline. But actually, I would argue, the fact that I can procrastinate so effectively, so consistently, and so powerfully *must* be representative of *some* sort of willpower--just not directed at the goal that I consciously say I want. I would say that these behaviors have just become part of a mental short circuit in my brain, a sort of rut carved out in my neural path by the habit of doing this same thing over and over. Therefore, the best route to behavior change (in my experience) is to start laying down an alternate neural path, brick by brick slowly convincing my brain to believe that newer is better.

If you try to change a behavior just by not doing it, it's like doing construction on a highway without installing a detour. Car after car approaches the barrier, and with nowhere else to turn, the angry drivers get into such a tizzy that they inevitably plow through the barrier back onto the old road, sometimes with even greater strength than before. In this metaphor, "willpower" and "discipline" are the lone construction workers standing at the barrier trying to singlehandedly direct oncoming cars to turn around and go no farther. What an impossibly difficult job! Whereas, if there is a detour in place, all Mr. Willpower and Ms. Discipline have to do is hang out and point their orange flags towards the big detour sign, reminding the sometimes absent-minded commuters that they'll make it to their desired destinations much quicker if they follow the detour.

I've told a few people about my sugar busting endeavor. One person suggested that I embark on a 100-day eating experiment, trying a different "fad" diets every 10 days, and then write a book about my experiences. If I can come up with 10 reasonable diets to try, I'd do it.


In other, more dramatic news, there was trouble down at the med school lunch carts last week. When I went outside to grab lunch one day, there were cop cars in the street between the two rows of food carts, and the waiting lines were abuzz with rumor: apparently, the Vietnamese guy at the American grill cart had just made a death threat to the Vietnamese guy at the authentic Vietnamese cart. Yes, a death threat! According to some, he had even walked right over and punched the guy to prove that he was serious about his threat. The offense? Authentic Vietnamese cart had started selling salads of the same variety as those that were already a hit at the American grill, and Mr. American grill was feeling violently possessive of his salad selling monopoly. Could it be true? By the time I got out there, Mr. Vietnamese cart had already graciously packed up for the day, to avoid further provocation, but it was said that the American grill would be deported permanently if there was any more funny business when Vietnamese returned. While waiting for my burrito, I engaged in typical rubbernecking gossip with my fellow burrito hankerers; I've never personally been to either of the carts in question, but I found it pretty amusing to hear others already taking sides, especially since their opinions were obviously based solely on their total of several 10 second interactions with either of these guys, as well as how much they liked the food. I imagined the whole situation escalating to the point of lunchtime war -- a West Side Story of the culinary variety, including spontaneous song and dance, flashy costumes indicating whose side you were on, and of course the symbolic struggle of assimilation vs. cultural identity, represented so poignantly by the central theme of salad bowl (instead of melting pot) as a metaphor of our multicultural American society.

Monday, August 22, 2005

What's in a Name?

Reading the latest issue of American Family Physician, chock full of ads highlighting the latest magic bullets for common complaints like anxiety and insomnia. My eyes lingered on the one for Ambien...suddenly, it hit me! Ambien = A.M. Bien, "good morning"! Awesome. It's almost as clever as the treatment for onchocerciasis, infection by the worm that causes river blindness: Ivermectin = I ver (i.e., "I see"). I get such a kick out of those eureka moments.

As much as I despise the pharamaceutical industry for its relentless pursuit of profit through advertising, I can't deny my appreciation of smart wordplay. I've always thought that if medicine turned out to be not my bag, I would go into advertising.

My First Cuddle Party!

Cuddle (kud'l), v.: To hug tenderly, hold in the arms, embrace.
Cuddle Party, (kud'l par'tee), n.: a non-sexual, judgment-free space to explore touch, intimacy, affection and choice, where your boundaries will be respected. A rave for lazy people. An opportunity to get out of your comfort zone--and into someone else's. A fun way to spend a Sunday afternoon.

The Official Cuddle Party Scout Report, by Rachel Friedman:
1. It really isn't a euphemism for group orgy. Sorry to those who were hoping it was. There was no sex (rule #1), removal of clothing (rule #2), or dry humping (rule #7). Not really any kissing either, although it's technically allowed as long as a verbal request is offered and accepted. There was, however: massage giving, hugging, spooning (both with and without intertwined legs), back scratching, leaning against one another, holding, neck nuzzling, and other various enjoyable types of pj-to-pj contact. Yes, with people who I did not know before arriving there. No, it did not feel weird or skeezy (sp?) or gross. On the contrary, it felt wonderfully refreshing to be able to experience some physical intimacy without having the usual flood of racing thoughts--does he like me do I like him what are we doing where is this going what's the next step should I stop but wait I like this am I doing it right am I really attracted to him is he attracted to me what does this mean for us--preventing me from being fully in the moment taking place outside of my crazy head.

2. It *is*, however, a euphemism for "opportunity to practice being completely open and honest about how you communicate your desires for physical intimacy". During the Opening Circle, we all had to turn to a partner, pick an A and B, and A had to ask B, "Rachel (for example), may I _____ (insert kiss, hug, hold, etc.) you?" To which B had to respond, "No." Then we switched sides and practiced again. And then again one more time. Even though it was just a silly role play, I was surprised at how difficult I found both roles--it wasn't easy to do the asking out loud, and it was nearly as hard to have to say no without any explanation, qualification, or lame excuse. At the end of the exercise, we were all instructed to notice that (1) despite having just been flat-out rejected, we were all still quite alive and well. From now on, my self-imposed cuddle party homework is to be boldly and honestly expressive when it comes to pursuing my attractions and desires.

The bottom line: I fully endorse Cuddle Parties. Sure, it's a rather bizarre notion for all of us who live in this culture where physical affection among adults is assumed to be sexual; but although they are contrived environments, cuddle parties are proof that in the appropriate context, cuddling can truly be just that, and no more. I left the party feeling more refreshed, happy, and connected to humanity, and also bit dazed and loopy; it reminded me of the feeling of stepping out of the dark theater into the bright sunlight after having just seen a gripping, yet heart-and-soul-inspiring movie.

Saturday, August 20, 2005

Two Movie Recommendations For Those Wishing To Get In Touch With Their Inner Teenage Boy

1. The 40-Year-Old Virgin. Very funny movie, though quite crude, and sometimes bordering on offensive. Not appropriate for small children, those who get queasy at the sight of vomit or nipples, or your grandma. At times I thought they might just be improvising--seemed very real. You *will* laugh out loud.

1a. One of the characteristics of said 40-year-old virgin is that he drives a bicycle instead of a car. I also highly recommend, and believe in, the practice of using a bike as primary transportation. Of course, this is highly enabled by things like warm, dry weather and a Point B that is less than 5-10 miles from your Point A. Nevertheless, one of my most favorite things about New Haven is the fact that I can get around fine without driving for days on end--it's also much cheaper in the imminent $3/gallon gas era. For those actually in New Haven, I also highly recommend participating in Critical Mass -- it's like being in a big speedy bicycle street race, except without the speedy race part.

2. Wedding Crashers. Also very funny, less crude, but far more contrived. You will likely laugh out loud at this as well, and my grandma reports firsthand "I liked it. It was very funny. There was quite a bit of cursing, though." We saw this movie together the last time I visited her in Lakewood (NJ), two weekends ago. I spent well over six hours driving that weekend to spend just over four hours with her, but it was one of those perfect afternoons that you remember for a long time. Well, I will at least--my grandma has Alzheimers. She doesn't always remember our visits after the fact, but she definitely enjoys them a whole lot, and she still remembers that I'm her favorite granddaughter....seriously, though, the fact that I only get a few hours with her at a time has, over the past few years, significantly upped the quality of the time we do spend together.

2a. Grandma only had $2 in her purse when I picked her up at the nursing home, so I told her that I'd be thrilled at the opportunity to pamper her for the day. Little did I know at the time that I'd be pampering her in more ways than one; when we arrived at the movie theater after lunch, I was helping grandma out of the car when her face clouded over with that look of surprise with a touch of embarrassed horror that one gets when one has suddenly lost control of one's bowels in public. I won't bore you with the details, but let's just say that we were lucky grandma was wearing a diaper, even luckier that the movie theater had a spacious bathroom that stayed virtually empty during our 25 minute stay in it, luckier still that we had (in typical grandparent fashion) gotten there 30 minutes before the movie started, and luckiest of all that I'm a medical student who is paying a lot of money right now for the very privilege of learning how to do things like manage bodily fluids and creatively problem solve. (Note to self: if someone is wearing a diaper, that's your first clue that the situation might arise that would requiring needing to change it--always bring extras!) Afterwards, we got Rita's gelati, another recommendation, which we ate peacefully in the car parked at the shore of Lake Carasaljo, the quiet warmth of the Saturday afternoon wafting in through the open windows and sunroof.

Thursday, August 18, 2005

Words of Wisdom From A Former Seatmate

I decided to attempt productivity this evening at my old stomping ground, Starbucks, so I drove over and parked before realizing that I should have brought some blank paper for taking notes. While scrounging around in my trunk for a blank notebook, I found a blue spiralbound "fat lil' notebook" (their name, not mine) that I used back in 2001, the summer I graduated from college and made the big decision to move to Greensboro, NC for a job at the American Hebrew Academy.

Before the official move from Boston that August, I had been flying back and forth between the two cities every weekend in order to participate in faculty orientation in NC while finishing up my Sparknotes editing (along with other "hot" summer activities...) in MA. During one such plane trip, I found myself sitting next to a uniformed man with a warm, deep gaze, who immediately struck up a conversation with me. Very soon, I realized that this was no ordinary seatmate; indeed, when I asked what he did for a living, he revealed himself to be the prince (or chancellor, or some important title that I no longer remember but was impressed with at the time) of an African country (the name of which I also don't remember, but it's not important; he gave me his business card, so I knew he was legit). We proceeded to converse--chat would be too light of a word--for the rest of the flight, and as soon as we landed and parted ways I whipped out my little blue notebook to scribble down as much as I could remember from our talk. Well, mostly his words of advice, which comprised most of the talk. Here are some excerpts:

* Everyone is a messenger. We just don't all know what our message is.
* You have to be crazy--Einstein was crazy.
* Ask yourself: Does this lead to more self actualization for me? Is this fulfilling? Is this something that I could do 24 hours a day and not get tired?
* What are the beacons in your life? When you were most happy? When you were at your lowest? Summing up your life like this, you begin to see patterns emerge, threads that weave through.
* What we remember, what we cherish most are the moments when we make a difference in other people's lives.
* Don't sell yourself cheaply. Wait for the best. (I asked: How do I know when the best comes along?) You'll know. You feel it in your bones.
* It's not arbitrary--you see hundreds of people walk by, and then three come along and you say "Well, *who* are *you*? I want to know *you*"
* Make sure your needs are met. Not your wants, your needs.
* Sex is overadvertised. If you like it, then do it. If you're just doing it to please someone else, then don't.
* You seem like a two boy, one girl kind of person. (I laughed, thinking he meant some sort of threesome, but turns out he meant as in children. Seems like a good plan to me.)
* I don't have friends--I know a lot of people. Some people need friends, need someone to talk to every day. I'm more alone. Look at lions. They go about alone most of the time.
* I learned a lot from my lowest point--that if I had just had the confidence to know that I could succeed, I could have done extraordinary things.
* Life is short. Live each moment to its fullest. Make every moment *unusual*. Live *unusually*.
* Don't be ordinary. Be extraordinary.

Tuesday, August 16, 2005

Chasing the Sunset

It was somewhere (or sometime?) in the vicinity of 7:30 as I arrived home today and walked up the steps of my front porch. Before putting my key into the front door, I happened to glance up behind my left shoulder, and wow! The sky was full of sunset: ruffled strips of white clouds arranged against the baby blue like layers of ruffles on a little girl's party dress, tinged pink by the streaming hot rays of the setting sun. It had all the colors of a nursery, and I could imagine the air up there smelling like baby powder. Very different from the intensity of a powerful purple and orange sunset...sweet instead of striking.

I had been planning to eat dinner upon home arrival; but before I had finished turning my key in the lock, I knew what I had to do. Sprinting up the stairs, I dropped my stuff in the dining room and ran through the kitchen, stopping just long enough to blurt to Allison (now my roommate of two years, friend and classmate for three) and Heather (our new fourth roommate) "sunset beautiful, going to change, biking up to see it" before sprinting up the second set of stairs to my room. Within seconds, I was out the door and on my bike pumping the pedals towards East Rock.

Within minutes, my lungs were burning. With all due respect to Billy Blanks, my new infatuation with his Bootcamp videos did nothing to prepare me for the pain I was about to experience (sidenote on Ultimate Bootcamp: the first night I tried preparing for Ob night float by staying up all night, I got suckered into the first infomercial I saw when I turned on the TV at 4am--I promise it's the only time I've *ever* bought something off an infomercial; and until today, I thought Billy was the man. As he says, "who I am today is where my mind put me, and who I'll be tomorrow is where my mind put me"--ok, so he don't speak so good grammatically, but I like how he thinks).

Back to the ride up East Rock--the cover of trees and the shadow cast by the rock itself seemed to suck all the light off the eastern path I was using to wind my way up to the top. I huffed, I puffed, I shifted gears several times; I almost turned back, but the slivers of pink I could occasionally glimpse through the trees when I rounded the western corners kept me going, evidence that my trip might not be entirely futile.

At last, I broke through the treelined path onto the road and gave one final push towards the edge overlooking the city. Did I make it? Suddenly, after the sound and fury of my race against time, time stopped. Sound stopped, except for the muffled thump of my heart (which, thankfully, did *not* stop). All that remained of my brilliant pink sunset was a quiet blanket of washed out blues and grays spread over the hills west of New Haven. Gazing over the individually discernible houselights of a small coastal city at dusk nestled between those hills and the washed out gray of the Long Island Sound, I felt content and peaceful...the first time in a long while.

I rode slowly up the rest of the way to the tip top lookout, where Allison and Heather were waiting. They were impressed at how quickly I made it to the top. I was impressed at how much my lungs still felt like lobsters being boiled alive for dinner. One more ragged deep breath of the now moonlit dusk, then I hopped back onto my bike for the second race of the evening, this time against the impending darkness. Coasting down the road, I could barely make out the edge of the shoulder, let alone any potholes or more serious obstacles. For a moment, I wondered if maybe I haven't been eating enough carrots and had developed a slight vitamin A deficiency night blindness. But no, it was just plain getting pitch dark. I felt a surge of adrenaline-laced fear as I realized that I could at any moment hit a rock and go careening over my handlebars...luckily, I didn't. Just as the edges of the shadows began to disappear entirely, help miraculously arrived in the form of Allison's silver PT Cruiser to illuminate my path all the way back home. We all arrived back at the house safely, at which point hunger kicked in. So I made teriyaki tofu and steamed baby spinach for dinner. Yum.

Conclusion: I really like tapping into the part of me that is a spontaneous person willing to take some risks and make adventures out of everyday events. Life's more interesting that way, and far more fun. And, I definitely feel better now (referring to my previous post); hopefully it will last at least til tomorrow's sunset. The End.

Monday, August 15, 2005

Counterproductive Countertransference

I haven't written much over the last two weeks, i.e. ever since I started psychiatry. Strangely, I have had far more sleep (avg 7 hrs from avg 5) and free time (avg 5 hrs/day from avg 2) than I had on ob/gyn; yet I've been feeling less happy, less energetic, and less motivated to write or do other things that I enjoy. It's not so severe that I can't laugh and have fun with friends, but the key for me is that my default mood and default thoughts--the state I fall back into in those in between moments--seems more sluggish than the usual Me. Also, my appetite's been a bit less than normal (in itself a *very* abnormal event, though not entirely unwanted), and I've had some difficulty staying focused on completing the items on my non-hospital to-do list.

In short, I think I've come down with an acute case of dysthymia, or mild depression.

Although I'm not happy about this recent bout of generalized not-as-happy-ness, I am--like a good doctor-in-training--determined to explore other differential diagnoses as well as possible etiologies (causes) of my current state. So here goes:

DDx (Differential Diagnosis):
1. Mild Depressive Disorder With Seasonal Pattern: there's something about the imminence of autumn that wraps me in a blanket of back-to-school dread. Even though I've been working through the entire summer, the thought of September still gives me olfactory hallucinations of rubber erasers and freshly copied worksheets; tactile hallucinations of gusty leaf-laden winds whipping through the space between my back and my backpack, and auditory hallucinations of the teacher saying "close your books--pop quiz".

2. Cyclothymic Disorder: This is where you get numerous periods of hypmanic symptoms (increased energy, excitement, racing thoughts and speech) with depressive symptoms over a few years. I did have a two week period back last September when I was on hyper-overdrive and needed less sleep than usual, so if I were to seriously self-diagnose, this would probably be my best guess.

3. Countertransference: The pace of psychiatry--a slow amble through the day, with multiple stops to smell the roses and analyze our emotional response to them--is quite different from the sprints, hurdles, and night float marathon of ob/gyn. And I already know from exercise experience that I get far more endorphin release from a hard run than a quiet stroll. Moreover, like the phenomenon of countertransference (the subjective responses of a physician to particular patient personality traits or behaviors) I tend to subconsciously mirror/absorb the environment or people around me. So it's no wonder that while on the high energy surgical floors, I was diagnostically hypomanic (less than 4 hours of sleep a night, talking/writing more effusively than usual, excessive involvement in pleasurable activities like delivering babies and risk-taking activities like doing surgery); and now on psych consult I've developed many of the depressive symptoms of the depressed patients I spend time talking to every day. Hopefully for my own sanity, I won't get assigned too many floridly psychotic patients...

And last but *certainly* not least...

4. Hypochondriasis: "Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms". The most likely diagnosis of them all. I probably just liked the feeling of making a difference so prominant in ob/gyn, so I'm less excited about just sitting and talking to my psychiatric patients, and thereby have less to look forward to each day; and now that I can get in later I stay up later for no good reason, so I'm more tired in the morning; and now that I have more free time, I go out more in the evenings and therefore make less time for writing or other work tasks; and given that I haven't lost any weight, the reduced appetite is probably just wishful thinking. Sigh.

We really need a separate section in the DSM-IV (the official psychiatric diagnostic manual) for conditions specific to medical students.

Friday, August 05, 2005

Out of Pysch: Out of Mind

On Monday I reported to the CT Veterans' Association hospital in West Haven (aka "the V.A.") for the start of my psychiatry rotation. It's quite a culture shock from Ob/Gyn. They didn't do much psychologizing (or psychiatrizing, as it were) on the obstetrics floors--my only real psychiatric experience there was listening to one of my residents tell a story about a woman who had given birth during her intern year: as the doctors swept Baby away to the bassinet to clean it up from its messy journey, the new mother had apparently looked on with fear in her eyes and became increasingly agitated. Finally, one of the doctors asked her what was wrong, and she asked anxiously, "Is my baby an alien?" Without exploring this bizarre speculation further, the medical team went into a flurry and quickly secured their patient into an inpatient psych which point a real psychiatric evaluation was done (i.e. a doctor actually took the time to sit down and talk to her about more than just her pain, vaginal fluids, and vital signs.) To the embarrassment of the obstetric team, it was discovered that the poor woman, a recent Mexican immigrant, had merely been trying to ascertain the citizenship status of her child! Oops.

It's been a little disconcerting, the sudden switch from an entirely female, largely under 35 patient population to an entirely male, largely over 65 patient population. Also, the switch from barely talking to my patients but probing deeply into their most intimate body parts, to barely touching my patients but probing deeply into their most intimate mental parts.

I guess the common factor on both is that they inspire me to do my own personal sort of probing--last month, thinking more seriously than I ever have before about my position on abortion: I always considered myself pro-choice by default since I consider myself a liberal democrat, but now after actually participating in terminations, prenatal care, and deliveries, I can say that I actively and unequivocally support a woman's right to make decisions about her own body.

Now, I'm thinking about the idea of insanity. I've read a lot of books in my day, but one of the novels that made the most impact on the way I think about the nature of society and reality was _1984_, which I read for the first time when I was in 7th or 8th grade. There was one line in that book that really hit me hard, and I still remember it to this day: "Insanity is a minority of one." I'm learning now how to do a comprehensive psychiatric interview, how to screen someone for things like depression, anxiety disorders, personality disorders, psychosis. A key feature I'm always supposed to be looking for as a sign of psychosis is thought content that seems "delusional." According to current consensus, a delusion is defined as "a fixed, false belief" that is not bound by culture or religion. But what if the culture believes something false? It seems to me that Copernicus and Galileo were clearly delusional, since they were essentially minorities of one in their own time. Doesn't every successful trendsetter or visionary have to go through a period of seeming delusion before others begin to agree with and catch on to their brand new idea? I'm not trying to deny that there are a lot of people out there suffering from disabling schizophrenia, because there are. But given the high correlation between certain mental illnesses and creative genius, and what I see as a ridiculous overuse and overdependence on psychoactive drugs by the medical profession...well, I don't know exactly, but I'm going to continue probing.

And finally, a new marketing idea from your favorite failed inventor (Danny Katz and I invented the Camelbak in 1990, long before it came on the market; we called it "water-to-go", made our prototype out of neon orange fabric, a hot water bottle, and the end of a fleet enema; it was entered into the NJ invention contest for children, and we didn't win; I'm convinced that the judges stole our idea, or maybe there was an EMS secret agent prowling about; I'm still bitter about the whole thing):
Alcoholism is, as you know, a huge problem in this country. One of the worst side effects, or sequelae, of chronic alcoholism, is a terrible encephalopathy due to the deficiency of the B-vitamin thiamine. Apparently, thiamine is an incredibly cheap vitamin, and is present in so many staple foods (bread and cereals, for example) that it's near impossible to acquire a deficiency in it unless you're truly not eating much of anything, which can happen when severe alcoholics replace almost all of their daily caloric intake with alcohol.

So it occurred to me today--why not supplement beer and other alcoholic beverages with thiamine? Or else start a new Budweiser campaign called "Bread--it's what's for dinner." There are enough bad things that end up happening to people with alcohol dependence; there's just no reason why we can't do something to help reduce this ridiculously easily preventable, yet potentially fatal, complication.