This burnout

Is your medical provider seeming snippy? Impatient? Cranky?  Do they have a faraway look in their eye that looks like they may be wishing they were gouging their eyes out rather than talking to you?  Do you feel like they have checked out and aren't listening?  Follow this simple checklist to see if you are the reason your psychiatric prescriber has compassion fatigue!

Do you regularly make appts and then simply forget about them and no show, so the provider gets yelled at by their boss for reduced productivity?

Do you regularly wander in 15 mins late for appointments and then loudly demand to be seen, completely uncaring of the 15 clients whose appts are after yours who your provider now has to run to catch up with because they will yell at them for making them wait in the lobby?

Do you show up late and then complain at your provider for making you wait in the lobby for 10 mins because of the other 5 people who didn't bother to show up on time?

Do you demand controlled substances by name and then when your provider agrees but has to give you a urine drug screen because our bosses require it, do you yell indignantly at them about how this is unfair before peeing a stream of pure molly and Jack?

Do you come in to your appointment dressed in pajamas you have been wearing for 3 days straight without having showered or used deodorant while chain smoking tobacco and cannabis so that when you leave the office the miasma of your body odor perseveres?

Do you insist on giving your provider a hug as if we're friends rather than understanding that this is a job they are being paid to do?

Do you try to find and friend your provider on social media and then get mad when they decline?

Do you track down your provider's home address or number and contact them to ask for refills?

Do you refuse to take simple advice like engaging in therapy but at the same time say hyperbolic things like "My anxiety is through the roof off the charts out of control" when you actually mean "I get tense sometimes at work" and then insist that the only thing that works is controlled substances?

Do you insist you need sleeping pills and then argue with your provider when they say that perhaps instead you should cut back the 3 energy drinks you have every day because you think that could not possibly be the problem?

Do you insist on getting benzos and then argue that you have no need for therapy "because I've done it all before" and thus it can't possibly help because of course two different therapists could not possibly have different approaches?

Do you whine to your provider about how the only reason you got a domestic violence charge is because you're a subjugated cishet white male and if you were female you would have been treated better by the courts for giving your partner a black eye?

Do you insist on interrogating your provider about their gender presentation and then make a big deal of how annoying you find gender neutral pronouns, and then insist that they engage in that conversation with you rather than let them focus on their actual job of medication management?

Do you change your med dosages on the fly without consulting your provider first and then yell at them for not releasing early refills when you increase your dose on your own?

Do you miss appts and then request early refills of controlled substances via email?

Do you complain about how hard it is to manage your trust fund/inheritance, while not having to work or go to school, and having no real social responsibilities while being a cishet white male?

If you answered yes to any of the above, yes, you are part of the problem and yes you are part of why we burn out and seem calloused and uncaring.  Don't take it wrong or personally, it's just that we are burnt out because of you specifically and how you are and the things you do and say, that's all.  Thanks for listening.

This Gender Affirming Surgery Letter

For the sake of allowing folks to have a copy of a generalized, boilerplate psychiatric gender affirming surgery recommendation letter, here then, in all it's gatekeepy glory, is a blank copy of the letter I have used and curated for years successfully. Feel free to use, share, copy, give helpful feedback, etc etc. 

Date: today

Re: John Q Lastname (the Q stands for queer)

DOB: 26 June 2019 

To Whom It May Concern:

I am writing this letter of support on behalf of John Q Lastname in his pursuit of medical treatment and evaluation for gender reassignment and affirmation surgery.  He is a 28 year old Black trans male, assigned female at birth.  He first met with this clinician on your mom’s birthday for a comprehensive psychosocial assessment that included an evaluation of gender dysphoria history, support network, awareness of risks and benefits related to said procedure, and for an assessment of his ability to give informed consent.

After the comprehensive psychosocial assessment detailing past experiences and gender identity, it became evident that John Q Lastname meets the criteria for Gender Dysphoria, as set forth by the World Professional Association for Transgender Health in the seventh edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, and as defined by the American Psychiatric Association in the DSM 5.

The goal of the psychosocial assessment is to provide a holistic client portrait, gauge the client’s readiness for medical treatment, and to inform a treatment plan from a behavioral health perspective.  The purpose of the psychosocial assessment includes the following six factors:

1. To facilitate the wellbeing, empowerment, and support of the client;
2. To highlight the diagnostic criteria for Gender Identity Disorder, that is met by the client, as defined by the DSM IV-TR or for Gender Dysphoria, as defined by the DSM-V;
3. To facilitate appropriate referrals for mental health, psychiatric, medical and/or surgical interventions as indicated, and if client is seeking medical intervention, to make assessment of the client’s mental health and readiness for these interventions;
4. To rule out the presence of psychiatric or psychosocial stressors which could interfere with the client’s ability to engage in treatment, or be able to describe how these are controlled;
5. To assess the client’s ability to make informed decisions about her/her/their care; and
6. To identify with the client any issues which could be addressed in on-going behavioral health treatment.

The assessment process generally includes, but is not limited to: childhood development, gender identity, sexual orientation, trauma history, prior mental health treatment and/or hormone replacement treatment, social support and finances, substance abuse history, and the client’s understanding of medical intervention as part of the transition process.

John Q Lastname has a long history of cross-gender identification and gender dysphoria. This has impacted work, school, and social functionality historically.  He has been living socially under his preferred name of John Q Lastname for approximately 5 years, which also has contributed to reduction in gender dysphoria.

This clinician believes that he is able to provide informed consent in pursuing or engaging in any prescribed medical treatment to alleviate gender dysphoria.  He has a more than adequate social support network in place to support him during the recovery process as well.

John Q Lastname has been undergoing hormone replacement therapy for 4 years under the supervision of Dr Jacob Feelgoode at this clinic.  John Q Lastname has been living fulltime as his identified gender for over 5 years.  He has been binding his chest off and on to reduce feeling of dysphoria as well as wearing oversized clothing to obfuscate his figure.  Avoids binders only due to the discomfort they cause and the exacerbation of feelings of claustrophobia and difficulty respirating.  Further medical/surgical gender affirming intervention, including chest reconstruction surgery, would seem to be the logical next step in relieving any remaining gender dysphoria symptoms.

John Q Lastname is both able to assess and is aware of risks and benefits associated with medical intervention to relieve gender dysphoria including surgical procedures.  Judgment and insight have remained intact and unimpaired consistently as have mental status exams overall.

In all, I am confident that John Q Lastname understands the implications of surgical treatment.  It is my clinical opinion that pursuing further reduction in feelings of dysphoria will greatly improve his quality of life.  I support his decision to pursue medical intervention related to gender identity/dysphoria.  If you have any further questions, please contact my office at 503-460-0405. I would be happy to discuss the matter further, with the client’s written consent.

Sincerely,

Jacob Balinky, PMHNP-BC 

This corpus horror

In which I recount the Epic Saga of the last month. Here's the thing, intellectually you always know that you can become really sick, or even disabled, but on some level you never really believe it until it throat punches you.

Diabetes runs all through my family, so I always knew that it was coming for me, slowly but surely, like a fucked-up vampire sloth. A couple of months ago I noticed that I wasn't able to read the item descriptions in my inventory on Mass Effect, and had to have my partner read them for me even though he was just about as far from the screen as I was. So I went to the eye doctor and found that I needed glasses despite the fact that I only had LASIK surgery a few years ago, and quite successfully too. As an afterthought we decided to go ahead and test my blood sugars just to be certain that I wasn't running high, because that's a thing that can sometimes drive reductions in vision.

Turns out my sugars were through the roof, cue metformin. A rare side effect of Metformin turns out to be something called lactic acidosis. I was one of the lucky ones.

Cue Glipizide. This was not bringing my sugars down however, even at top doses, cue insulin. For those of you unfamiliar, this is not the way this usually goes. Typically you have a lot of time before you have to start insulin, and usually diabetes doesn't slam into you like a freeway truck. However even with this cocktail, my sugars were uncontrolled and I wasn't really able to eat much, for some reason I couldn't deduce at the time. I also was having trouble with dizziness, stumbling around like I was drunk despite painful sobriety, and general weakness and fatigue, and not the Monday morning after a late Sunday kind.

As it turns out, my liver was attempting to jump out of my navel. This was uncovered after a blood test revealed that my liver enzymes were just about on level with someone who had Advanced hepatitis. To be clear, I don't have hepatitis. I know because that's the first thing we tested for. By this point I was on Zofran, a medication to keep me from Technicolor yawning all over the house. It wasn't really working, but it was trying hard. We took my blood again and found that my liver was continuing to be pissed off and so we did an ultrasound. This didn't show anything except for, surprise, a liver with anger management issues. This type of thing drives up blood sugars a lot, so mystery solved there at least.

You know, you can go your whole day and not really think about what your liver is up to. That is, of course, until it starts getting an attitude.

My doctor's verdict? I had some mysterious virus that was pissing off my internal organs and was going to run its course and then I would magically start feeling better? I hadn't much hope by then. By this point it had been about 2 weeks since I'd been able to work, thank all the deities for Aflac.

Eventually, the universe took pity on me and my liver just started to chill out as this unnamed mystery virus got bored and wandered off. My doc doesn't believe that we'll ever know what infectious process was slapping my liver around, and frankly I don't care as long as it doesn't take an interest in me ever again.

I've never been truly disabled since I started working as an adult. I mean, aside from the occasional respiratory infection, however those have a really well defined course and you know roughly how long they're going to last. The worst I'd experienced as an adult was bronchitis taking me out for a week or two, or the odd surgery that took me out for a week or two. But here it was three weeks in and I still wasn't sure how much longer this was going to last. The biggest stressor for me was the nebulousness of it all. How much longer was I going to have to miss work? How much longer was I going to have to sit in this recliner? Just how long before I could eat something besides dry toast before I kill someone? I haven't even gone into the details of what liver dysfunction does to your bowel movements, but trust me, it ain't pretty. I'm fairly certain we're going to need a rabbi to bless my bathroom before it can be safely used by humans again. But I digress.

Today marks the fourth week of my being off of work, and it looks like I'll be fit to be re-released into the work force next Monday. This has been without a doubt the most terrifying, most uncomfortable period physically and emotionally of my adult life. I was sick a lot as a kid, but when you're young, you don't really have a sense of mortality, or at least I didn't. All I know is that there's no amount of emotional preparation that I could have done that would have made this any easier to process. When you're that sick, the most simple cognitive processes become intense uphill struggles. The next time one of my clients comes in telling me that they have trouble thinking or concentrating because of pain or nausea or any physical problem really, I'll have a whole new understanding of what they're talking about.

I cried every day of this ordeal. Every. Day. And now, the simplest of physical victories, like leaving the house for something other than another blood test or eating something other than toast and not throwing it up make me feel like Rocky Balboa beating a Russian twice his size.

Yesterday, I went out wearing real clothes, and got 2 oz of sugar free frozen yogurt, and sat like a person eating it with my family at a table and watched random humans go by. After weeks of going to Kaiser an average of 4-5 times a week, it felt like going to Disney World.

The point of all this, if indeed I have one other than to record this experience as a means of upload to external memory, is as a reminder. Both to appreciate any moment of good health that you have, and to be as kind and patient as possible to those who have less of it than you do. Because that, I assure you, will be you someday, and you will not be ready, and you'll need all the kindness and patience you can get.

Meanwhile, that thing that you were really wanting to do but were putting off until you had a little bit more money? Go do it. Because you might not have the spoons to do it tomorrow.

Dat fourth reich tho

Chuck Wendig recently, and super no-scopedly, called this the epoch of syphilitic dipshittery. (I had to spell check syphilitic omg am I a nurse?)  And it got me Thinking About Stuff. Specifically, it made me think about why I keep having sweat-and-pee soaked dreams about all the body politic.  I'd been questioning my reactions to the persistent, hyperspeed onslaught of news, each byte more freaky than its predecessors.   Was I being melodramatic? Was I just losing my teflon-coated Daedric armor of positivity?  The news kept calling me a snowflake, were they right??? Holy shit, it's June, snowflakes don't historically last long in these kind of heatwaves... I better figure this socio-political angsty shiz out, and that right quick.

I'm quite stereotypically Ashkenazi. Like so many of my peers at my heeb school growing up, lots of my family branches had been burned during WWII.  (Yes, literally.)  My great Aunt told me stories about growing up in the Warsaw ghetto while her sister, my grandmother, got gently drunk on white Franzia and turned off her hearing aid so that she couldn't hear my mom squawk at her to put the box down.  I hadn't dredged those stories to mind in a long time, but recently, they started fluttering limply back from the 'ol hippocampus like Exxon Valdez birds. 

So many of my aunt's stories sound vein-chillingly familiar to some of the news stories of the last 6 months.  Stories of the gestapo being helped by local militant groups, or just conservative randos who were nearby, to herd and incarcerate the Jews of the area when they were moved to the ghetto, or, more specifically, when they resisted being moved. Jews being shot by law enforcement just for talking back or walking down the street.  My aunt hated telling me these stories, though my dad and I always pressed her to.  She was beaten pretty badly once as she was on her way to school when she was 8 by some older teens while being called (screamed) the equivalent of kike, just before her family moved.  That particular story she never told me, my grandmother recounted it because, as she put it, "it's too hard for her to talk about, but it's important you never forget it, where we were, and what we did, and why we're here instead.  Now eat some ruggelach, you're too skinny."  

Baked crumbly Jewish delicacies aside, she was right, it was.  I think, looking back on it now, she meant that this moment right here is why it was important to remember.  It was important to remember what impact the news can have on a populace, and how that populace can feel empowered to be monumental prolapsed anuses to any group they don't like if those in power encourage it.  It was important to remember how to identify the warning signs of an impending autocracy. It was important to remember how it looked and felt as empathies, and rights, were degraded by centimeters and eventually parsecs.  They tried to trust the law, the government, their non-Jewish neighbors, wanting to keep to the high road and assuming it would all work out because, c'mon, these were their neighbors.  But, eventually it all exploded in a long, heavy shit shower, and the country eventually disappeared entirely up it's own asshole and then imploded.  And that's how I ended up here.  Blogging at your face. About how this all feels way too familiar.  My aunt and her family didn't march or protest, they feared, and they ran.  To be vodka transparent, I ain't mad at them for self preservation.  BUT.  I can't help but wonder what my aunt's stories would have sounded like if she, and all of the other amcha and righteous (or just middle of the road) gentiles at the time, would have loudly taken to the streets.  

My point, if indeed I even have one in all of this fappery, is this: TAKE TO THE GAWDSDAMNED STREETS.  I'm tired of despairing, I'm tired of feeling like there's a heavy inevitability to all this syphilitic dipshittery.  Cussing a lot helps, so cuss up a fucking storm.  Yeah, I'm still sad, it's unavoidable.  But I'm rapidly finding that the best tonic for sad is RIGHTEOUSLY FUCKING PISSED OFF.  It's important you never forget it, it helps when you're where we are, doing what we're doing, here instead of someplace better. Now go eat some muthafucking resistance ruggelach. 

This pain

WHY YOUR PAIN IS NOT BEING TREATED

Hi. I'm your friendly neighborhood NP, here to talk to you about how THE WORLD IS GOING TO END  ARG ARG ARG RUN RUN RUN THE OPIOIDS ARE COMING FOR US ALL.

At least, that's apparently what this, er, let's call it "measured and thoughtful" letter from our US Surgeon General, Vivek H Murthy, is trying to tell us.  By us, I mean every practitioner with a prescription pad or, more to the point, a DEA number.  Yesterday I walked into my office and saw this little number waiting for me on my desk, enjoy. My opinions follow.  No, there will be no jumpcut. Read it.

"August 2016
Dear Colleague, I am asking for your help to solve an urgent health crisis facing America: the opioid epidemic. Everywhere I travel, I see communities devastated by opioid overdoses. I meet families too ashamed to seek treatment for addiction. And I will never forget my own patient whose opioid use disorder began with a course of morphine after a routine procedure. It is important to recognize that we arrived at this place on a path paved with good intentions. Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely. Tis coincided with heavy marketing of opioids to doctors. Many of us were even taught – incorrectly – that opioids are not addictive when prescribed for legitimate pain. Te results have been devastating. Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly – almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed. Now, nearly two million people in America have a prescription opioid use disorder, contributing to increased heroin use and the spread of HIV and hepatitis C. I know solving this problem will not be easy. We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic. As cynical as times may seem, the public still looks to our profession for hope during difficult moments. Tis is one of those times. Tat is why I am asking you to pledge your commitment to turn the tide on the opioid crisis. Please take the pledge at www.TurnTeTideRx.org. Together, we will build a national movement of clinicians to do three things. First, we will educate ourselves to treat pain safely and effectively. A good place to start is the enclosed pocket card with the CDC Opioid Prescribing Guideline. Second, we will screen our patients for opioid use disorder and provide or connect them with evidence-based treatment. Third, we can shape how the rest of the country sees addiction by talking about and treating it as a chronic illness, not a moral failing. Years from now, I want us to look back and know that, in the face of a crisis that threatened our nation, it was our profession that stepped up and led the way. I know we can succeed because health care is more than an occupation to us. It is a calling rooted in empathy, science, and service to humanity. These values unite us. They remain our greatest strength.
Thank you for your leadership."


Well then.  And thank you, Vivek, Vivvy, may I call you Viv? Viv. Thank you, for alerting me to this "urgent health crisis that threatened our nation."  Naturally, as a conscientious practitioner, I wish to be up on the latest data and, hey, if prescription opiates like Norco and Vicodin are killing people in droves, quadruple the deaths since 1999 sounds super scary after all, I better take your advice and make sure I'm as educated as I can be, right? Of course right.  So, off I surf to CDC.gov, to fill up on data, omnomnom delicious data.  I mean, the last thing we'd expect is to find is that this kind of vague, inflammatory language isn't... *reads opioid overdose stats page* isn't based on actual facts that... *reads some more* facts that.... *re-reads*....
....
*re-reads again*
....
Gawddamnit, Viv.
Turns out, according to the CDC, "Changing the way deaths are analyzed seems to result in a decrease in deaths involving prescription opioids."  Huh. What does "changing the way deaths are analyzed" mean, I ponder. Turns out, this means that while deaths from opioid overdoses have indeed increased over the last several years, this means deaths related to ANY opioid, including such best selling titles as frakking heroin (which is NOT a prescribed opiate, just to be painfully clear) and bootleg Fentanyl cooked in a bathtub and cut with who knows what.   Apparently, overdoses from NON prescription sources, specifically heroin alone, accounts for most of this uptick.  Also, given that Oxycontin wasn't even INVENTED until 1996, it makes sense that the deaths from this medication have, you know, increased, since before it existed.

Viv, from the bottom of my prescription pad and from the bottom of my heart which belongs to two amazing partners who struggle with chronic pain every damn day, please go fuck yourself vigorously with a cheese grater. And do it, obvis, without pain meds.  Because years from now, I want us to look back and know that, in the face of reactionary ableist tripe, it was our profession that stepped up and looked critically at said tripe and led the way to ripping it to shreds.

This paradigm

Hey there.  I'm Jake.  I have a lot of discomfort related to neuralgia in my left femoral area, due to nerve root impingement.  In English, I gots pains, yo. Pins and needles that shoot pretty constantly from my left hip down to the knee.  High doses of turmeric help. I'm a PMHNP so I can't take anything that might intoxicate me or hinder my judgement while I'm prescribing, though to be fair, pain can hinder your judgement pretty profoundly too, so, yeah.  (and no, don't @me about that unless you have some fucking experiencing being in consistent, cringing discomfort for months on end while having to make important day to day decisions which significantly impact other people's wellbeing all the while just wanting to punch a baby square in the cutes)  I only have one functional kidney, so I can't take NSAIDS on the reg, gotta baby that thang.  Which brings me to the point of all dis glorious tmi:  HOW DO I TREAT DIS SHIZ BEFORE I KILL SOMMUN????  Glad you asked.  Since I live in Portland, I know what you're gonna ask, and no, I don't smoke weed.  I vape cannabis.  SEE WUT I DID THAR? Here's the thing, I get my curls in a twist when I see the dominant thoughts about cannabis being amplified by, well, most platforms.  Even the platforms that are pro-cannabis are hit and miss when it comes down to it, because eventually at least 50% of the sites I go to for information degrade into the all-to-familiar tropes most associated with cannabis.  Yeah yeah, that joke about Chong was hilarious, sure sure lacing that article about anti-inflammatory effects of cannabidiol with stoner-talk euphemisms is super cute, and original af too, never seen it done before, now please just render unto me my relevant medical information. *disappears in a puff of vapor*

This muphu right here

Please enjoy this copypasta of an actual chat I had with customer service, trying to find the missing tech who was supposed to repair my internet line which had been cut by the FD after the ice storm. The snark is real.  Note: My name. Is not. Jennifer. However, that's how they had it on my account so that's what showed.  Note the last line, I imagine he was rubbing his nips while moaning as he typed that line.

Jennifer : at 11:05:19

he was supposed to be here today between 8 and noon I think

no luck yet

Albert: at 11:05:43

I see. Let me check the technician. 

Jennifer: at 11:05:50

repair reference number is VP217129

Albert: at 11:06:21

Thank you

Jennifer: at 11:07:20

I appreciate the help?

Any luck?

Albert: at 11:10:13

Thank you for waiting. I'm, reaching out to the technician assigned to the job right now.

What's your best callback number?

Jennifer: at 11:10:35

503-867-5309

So do we have an ETA for the tech's arrival?

Albert: at 11:13:59

Thank you for waiting. I've sent an immediate message to the technician to update you since he is been running late on the schedule appointment visit. Base on his status that I can see here, he is still working a job before your location.

Jennifer: at 11:14:41

uh huh.

soooooo, he's going to be at my place when?

Albert: at 11:16:05

My apologies, there is no Estimated time of arrival, however, he should be updating you any time soon about the appointment.

Jennifer: at 11:17:52

so, to sum up, he's running late, not sure how late, he should be updating me about when he may be showing up, but that definitely won't be within the pre-arranged 4 hour window, is that right? And I should expect him to call me in how long?

Albert: at 11:20:05

Unfortunately, that is right Jennifer, the update from him should be within an hour or within the day.

Jennifer: at 11:21:35

uh huh. you know, I'm curious why we bother scheduling 4 hr windows days in advance if they're not something the techs can honor. Just saying.

Jennifer: at 11:23:08

So to also sum up, I'll need an adult at the house for the rest of the day if we want the wire repaired. I can't authorize the repair here?

Albert: at 11:23:09

I understand your frustration Jennifer, rest assured your feedback about this scheduled appointment will be escalated.

Jennifer: at 11:23:41

Also, before I forget, I've changed my name and I'd like to do that officially.

In your records.

Albert: at 11:24:29

You want to update the account holders name is that right?

Jennifer: at 11:24:37

Correct

Jennifer: at 11:25:52

Can we do that?

Albert: at 11:27:32

As much as I wanted to do it for you, only Care department can update the information for you as we are in charge of technical concerns.

Here is their direct number: 800-244-1111 They are open from Monday to Friday 8AM-6PM. Saturday CLOSED.

Jennifer: at 11:30:06

Ah ok. Thanks.

Albert: at 11:30:54

Again, I'm really sorry you are having these issues but for the mean time, is there anything else that I may assist you with?

Jennifer: at 11:31:37

else? you haven't really been able to do anything at all, so, no, I guess not.

Thanks for trying.

Albert: at 11:32:31

Your welcome Jennifer, Thank you for choosing CenturyLink, have a good day!