In reply to: Denial...

Gah, I just wrote a long reply to my friend's blog post here, and then realised I'd written more than the original post... Time to copy paste.

Cam's original post deals with a workmate who had an affair with a married woman, and tries to justify it.

My reply:

Oh dear. Yes, I agree completely on both counts. Denial of the truth occurs on so many levels, ... although it is usually the complexity of the situation which allows denial, justification and moral dilemmas in the first place.

Although I would add a qualifier to your first statement: Denial seems to be a way for the guilty to remain sane without learning anything from the experience. Don't worry, Cam, once we give up the false shield of denial, we "guilty" don't necessarily go insane all the time! (Although hey, some of us already have.) I hold out hope that a person can learn something from each time they do something they know is wrong ... even if they only thing they learn is "I'll never do that again." And admitting and atoning for the wrongdoing? Well, that takes it a couple of steps further, although whether it helps is debatable.

As for marriage ... by goodness, people are so complicated and wrapped in their own little world of desires and attitudes. It should be established fact that trust and mutual support are the basis of a good marriage, but hey, nobody's done the randomised controlled trials. People like that man and woman obviously choose to believe otherwise, or at least act like it. And I guess there are other people who go along with society's norms without really thinking about it, so plenty of marriages hold.

But it takes a certain degree of empathy to think about a situation like this before it is actually upon you. To say to yourself that no, you wouldn't like it if you were in the husband's shoes. And it takes a bigger leap of empathy to decide that the husband deserves to have what you would want - unbroken trust in his wife. I have a feeling that that particular level of mutual 'thinking about each other' is the basis of most happy marriages.

That first step, of making people think about these situations? Hey, that's why we tell each other stories like this. That's why I keep reading this blog.

Hang in there, Cam.

The rest of my day...

Speaking of theory and practice, my attempts at writing concisely have obviously just failed me and it's past midnight. So here's a quick summary of what else happened today, without baggage:

I got my midterm assessment, and realised that I've been leaving my angel side with the patients and not with my colleagues;

I let myself get ambushed by tasks too many times, and missed out on a clinic and a lecture I would have loved to attend;

Smith and I went to dinner with some good friends, and met a friend's new girlfriend, who seems friendly and interesting and mature (and young, at the same time);

We all saw Mary and Max (Margaret and David review here), which has to be one of the best films I've ever seen, and claymation to boot.

More on each later, I guess. On that note, goodnight!

Theory and Practice

At 11am I was close to having an argument with a patient's granddaughter. At that point my registrar deflected the conversation, and I realised just how far I have to go in my communication skills.

Since I started university, for some reason I have considered myself to be an excellent face-to-face communicator. I knew I wasn't as good at writing, or at confrontation, but when it came to day-to-day interactions, it seemed to go more smoothly for me than for others. Now, I'm no charmer. I will never say anything just because it's what someone wants to hear. But by that token, people get to know that when I say something, I mean it. When I was young, I read a book about conflict resolution and active listening*, and so I try really hard to listen and understand people in return. And combined with the fact that I have a nice smile and (I thought) a good attentive manner, and my eagerness to say things in a way people will understand ...

... well, it seems to work. People like me. People smile at me when I smile at them. I have gone up to people and made bald-faced unusual requests, and had them granted out of the goodness of their hearts (in a good cause). And patients and their families love me.

Actually one of the positive thinking slogans I made for myself when I was down, was related to this: "The world smiles at me when I get things done and go out!" I really do have all the luck sometimes. I used that as my screensaver, so that when I got paralysed in front of a computer I might think about moving.

Being a doctor ... well, I certainly had a lot of skills to learn when I started - case presentation, handover, ward rounding, informed consent, explaining things to patients and their families. But it's been two years now, and these days I feel pretty confident, especially with the last one: explanations. I really put some thought into finding a simple way to explain what's happening and why we need to do certain things. But maybe I'm over-confident. It's come to the point where I do interrupt my registrar and at times even my consultant, in order to clarify things for the listener. Maybe I'm backing them up, or maybe I'm getting in the way and being inappropriate. I don't know how to tell.

Anyway, today ... we got a call to say the patient's granddaughter was upset and wanted to speak to us. Now, we hadn't met her before, but we were already having problems dealing with the patient's medical issues - mainly pain and agitation - and her son's distress. So on the way in we caught up with the nurse, who said the granddaughter's main concern was that the family hadn't been informed when the patient was moved into a windowless single room overnight. (Ahh, treatment rooms. Another story for another time.) And that the reason for this was that the patient had been agitated overnight, but now she was quite settled in the new room.

Now, we hadn't been informed either. Actually, we'd come in that morning and gone "where's the patient?" "Oh, she's on [a ward on another floor]". So I was all set up to go in and sympathise - after all, we would have preferred her not to be removed from her familiar environment either. But boy, did that conversation take a turn in the opposite direction.

She started by expressing her severe disappointment with the system, and her wish to speak to someone senior. Fair enough. We talked about the bed move, and the fact that yesterday she had specifically asked that the family be informed about any changes in treatment. Obviously that message and its scope (including 2am phone calls about bed moves) hadn't got through to us. Anyway, she thought her grandmother would have been further agitated by the move, and the language barrier wouldn't have helped, as her grandmother now didn't know where she was. I tried to explain that people had tried to speak to her in two of her native languages last night with no success - because she had been confused. She didn't agree.

But then she took a completely unexpected direction. She was concerned that her grandmother was drowsy, and expressed her opinion that she was on too much medication. At this point, I'm not sure, but I think I did no more than frown, I don't think I said anything. The response: "Don't question me." (I was standing facing her with my registrar between us half-facing her, so he couldn't see my face.) So I said nothing further, and she continued along her line - her grandmother was drowsy and not herself. Obviously this was true even if I didn't agree with her over the cause, and my facial expression at that point was (or should have been) of "concern". Suddenly her tone changed, and she looked like she was going to get angry with me. My registrar sensed it too, and quickly changed the subject slightly.

(As I later did manage to explain to her, we had cut her medications by two-thirds the day before, and she had had hardly any that night.)

Later in the conversation there was another flashpoint, where she had questioned the prescription of a medication a couple of nights before - the nurse had needed to tell the doctor a medication he was about to write had already been given. I tried to point out that the doctor was on the evening shift and wouldn't have known the full situation. She didn't respond well to that - she told me not to defend something that was wrong. (Later we pointed out that he had already asked for advice from a senior doctor before making that decision.) Anyway, I guess I scored myself another aggravation point with that one.

My registrar is a very experienced doctor, who worked in Palliative Care last term, and it's to his credit that he was able to defuse the whole situation. He acted swiftly to protect me from becoming a focus for her anger. Later, he explained that he could see her misinterpreting what I was saying, and he was afraid that she and I would get into a proper argument. Overall, his competence with the situation made me feel I should just keep my mouth shut and learn from the way he dealt with it. He did give me a few tips afterwards - on what parts of a conversation I should actively let go, and how to emphasize just the necessary facts.

It's funny, I always thought I was good with families. Now I realise that there are two categories I've learned to deal with. Anxious and worried people, I'm good at - I can give them enough information, and reassure them that I believe in what I'm doing. People who are just upset for no good reason and don't listen - I learned long ago that they're a lost cause. But there's at least one type that I don't respond to adequately - the angry argumentative person who listens to what I'm saying in the wrong way, and throws it back in my face. I get defensive, just like I tried to defend the intern from the other night. Those sorts of things, I need to learn to actively listen to, acknowledge, and then let go, and wait for the right time to provide correct information. And despite my reading, I've never practiced active listening and it's not in my skillset. More practice needed.

And there are probably myriad other situations I haven't yet come across or learned to deal with ...

Oh, and we did manage to explain everything to her in the end, and she agreed with the plan, and we encouraged her to take some of her concerns to a higher level. Later that afternoon, though, we were told she was planning legal action against the hospital.

*bibliography: I'm almost sure the book I read was We Can Work It Out, but it's way too recently printed... I've been trying to find which book I actually read. Any suggestions?

To begin with....

Way too much happened today.

So, in the interests of getting to bed before midnight, I'm going to change my posting style tonight. Instead of getting the whole train of thought, you get random passengers showing you their luggage. Then they get to go their separate ways, like they normally would.

Why? Well, I wonder sometimes about whether my essay style has too much of a wall-of-text effect. It's the only writing style I've ever trained myself to follow. In English class I started out being really poor at filling out each paragraph, but left to my own devices and topics it starts turning into lists, which can get really long. These days all I want to do is tell a story anyway.

Motley crew coming right up... possibly in chronological order...

The Mentality of the Culicidae

It's 3am, and I'm awake. Again.

I used to be the type of person who would lie awake at night thinking about things. I have this goal of "understanding", so puzzling things out is a natural instinct. And hey, I used to have things to think about. The MUD, for instance. Why on earth did this player say that? Was that what he thought of me? Why would he think that, did they really think I was so selfish? How could I make them all see the person I really was? Et cetera. Or when I had a crush on a boy when I was fourteen, now, that really gave me something to think about. But that was long ago, and it's not why I'm awake tonight.

No, tonight there's a mosquito in my bedroom. Again.

Now, I like to think of myself as a nature-lover. Some of my fondest childhood memories are of visiting the Botanical Gardens with my family, being taught about the different trees and flowers, feeding the ducks. When I was lonely in primary school, there was a patch of buttercups far across the field from where everyone played, and I would retreat there when the age difference got too intrusive for me, and keep the bees company. And I like cute and cuddly animals as much as the next girl.

Actually, I've probably quite a bit more tolerance for the wildlife than your average person; too much David Attenborough as a teenager, I suppose. (No, you can never watch too much David Attenborough.) So, in accordance with his enthusiastic attitude, I find it all interesting, curious and worth preserving (although I haven't gone vegetarian). This means that I don't mind large spiders, because the big ones we get here are harmless; in a safe environment, I wouldn''t mind handling a snake. To me, ants' nests are a marvel of nature, as you can see in this video, although obviously they're best left alone. I like earthworms, in theory, although I've never bothered digging them up to go look at them. By a weird extension, I like colorectal surgery. (Seeing the patient's innards spread out on view... Pink and wriggly? Happy guts. Ooh, that bit looks sick, poor thing. Let's cut it out. The rest of them still happy? Happy guts.)

But well, mosquitoes are the lone exception. They spread malaria, causing a worldwide disease burden. Not to mention myriad other diseases. They don't support any ecosystem, as far as I know, because they're a pest feeding on humans and animals. They seek me and my mother and sister out preferentially, and we get huge welts that last for days and sting at night. I don't believe in "evil" in the malignant, people-hating sense, but ... mosquitoes are the enemy and must die.

Which brings us to The Hunt.

The door is closed. The lights are on. All wooden surfaces get checked. Then Smith gets covered in blankets up to his face, and my arms and head are free to act as bait ... and to smack them out of the air. I used to be reasonably good at it. When I was on rotation on the North Coast, in a house with broken fly-screens, I'd sit for an hour before bed and get about six or seven of them each night. Then I could sleep knowing that with the door shut, no more would come in.

These days, though ... I don't know what it is. Maybe I'm older and slower. Maybe I'm tired more often. Maybe the mosquitoes are faster, where we live now. But many hours over many nights have been fruitless, and I usually end up just putting a blindfold on and going to sleep with the lights on. I don't think I've caught a mosquito this year, and there have been plenty.

So I've had plenty of time to think about the intelligence of the mosquito. Obviously it's not on a par with the human mind. I must be some kind of animist, because I usually like to think of things as having a personality - trees, germs, guts (as above), supermarket trolleys, you name it. But well, I don't even like to dignify a mosquito by giving it its proper gender (only the female ones bite). No, this is not your average gravid female looking for nourishment for her eggs, and this is not a bitch-slap fest. It is an IT. Kill it.

There used to be a catchy television advertisement for insect spray, that featured an anthropomorphic, singing housefly. I'm Louie the fly, Louie the fly, straight from rubbish tip to you! Spreading disease, with the greatest of ease ... But when you're in a room with a mosquito ... well, it's not exactly a planning genius.

"Right, we go around the bedpost here and between the slats, and they'll be straight ahead. Ignore the golden-haired one, the Asian one has a better blood group, taste that carbon dioxide on her breath ... So we're going to zoom over the face, we don't want her to wake up, focus on the hands, arms, anything but the head, you got me? And do not, I repeat, DO NOT land on the hair - it's a trap. They're not called hair triggers for nothing. Okay, you ready?"

No, I like to think of a mosquito more as a machine. In its nervous system and what counts for a brain, it has, what, ten thousand neurones? A hundred thousand? I don't really have a clue, although I bet it's not in the billions. And there are probably only a few basic impulses - eat, mate, hide. Each one would have excitatory and inhibitory factors, and you can kind of predict what they are.

Anyone who's done neuroscience probably knows what I mean by that, but here's an analogy. Mating aside, let's say that 'hide' and 'feed' are at opposite ends of a dial. What the mosquito does depends on where the dial is at a particular time, and that depends on the environment. The time of day is one factor pushing the dial towards one end or another - feeding at dawn or dusk, and hiding the rest of the day. The presence of food pushes it towards feeding - I've just looked it up, and apparently carbon dioxide and oct-1-en-3-ol in breath and sweat are strong attractants. I used to watch them come up to me, mesmerised, tracking along the trail of my breath - conveniently, right in front of my face so I could smack them between my hands.

Obviously being swatted at is a fast swing towards the "life-preservation" end of the dial, but also, the presence of a good place to hide will attract it. I've learned that mosquitoes like to hide on dark wood-grain surfaces, and I used to be able to go hunt them down on my bedroom door or the bookshelf. (Now my bed is wooden and there's an underneath for them to hide. Grr.) And, to my despair, having the light on (so I can see it!) seems to be a strong push towards the 'go hide' end. Maybe having a 35 watt fluorescent for sewing and reading as the top light (100W incandescent equivalent) wasn't such a good idea.

Other than that, I'm guessing. I suspect that while light is a fast swing to the hiding end, darkness is only a slow push in the other direction. I wonder if the strength of the light is a factor in the speed. Sometimes I wonder if they're tempted to hide on my hair, being a dark, grainy surface. I haven't yet gone as far as digging out my tiny stash of acupuncture pins and opening a vein to attract it despite the light, but tonight I'm tempted. It did come out when I had a nosebleed earlier tonight, after all.

That only accounts for about fifty neurones in total, so obviously a mosquito is more complicated than that. But I've got a hundred billion ... I win, right? Well, that's what I'm hoping...

neeed ... sleeeep.....

People will forget what you said
People will forget what you did
But people will never forget how you made them feel.

Maya Angelou

Of course, this is true even when people have completely misunderstood what you said and don't know what you did.

Ordering a Life

What do you do when life leaves you with nothing to do, and all the time in the world to do it in?

For some people, this is called a holiday. It may be a welcome break from the constant demands of working life. But for others, it can become a lifestyle. And it gradually becomes a hole that is very difficult to get out of.


In August last year, I took extended sick leave from my job. I found that the pressures of being a first-year doctor required a lot more energy than I had. Don't get me wrong, I loved my job. But after five months of working, my energy levels were low to the point that I would take at least a day off every fortnight because I couldn't get out of bed, and at work every afternoon around lunchtime I started feeling exhausted and by 3 I would need a nap. Hardly compatible with full-time work. So, despite the fact that I got an excellent report from the last team I worked with, it was decided that I would take leave until I felt better. (I think the excellent report was something to do with the fact that when I was there, I was doing my job as well as replacing other people who were supposed to be there but weren't. :P)

We'd already planned to take a holiday in early September - went off skiing. But after that, and after Smith went back to his job, there was nothing much for me to do. As far as I knew, my job was to get better so I could go back to work. But what would that involve? I didn't know.

Medical investigations had been organised to work out if there was any medical reason for my exhaustion. All I had to do was wait for them and then wait for the results. (In the end, there was no convincing medical reason.) In the meanwhile ... I slept. Seemed like the right thing to do, when I was so tired.

September, October, November ... I think I lost three months of my life.

I certainly can't remember doing anything worthwhile. I wasn't particularly enjoying myself, either. A lot of the time I would sleep until midday, or 1pm. I'd get up, mooch about on the computer a bit, maybe go back to bed. Computer time was spent reading webcomics, playing Insaniquarium or LOTRO, and doing puzzles. In the afternoon I'd nap again, wake up when Smith made dinner, and then sleep; or stay up late playing LOTRO. To tell the truth, I don't remember much about that period. It wasn't much of a life.

Nice work if you can get it, you might say. A life of leisure, with a job to go back to when I was ready (but how would I know I was ready?). Loving husband. Every need met. Capable of doing anything I wanted to do. No time pressures. No financial pressures, thanks to my husband's job. No obligations.

From another perspective, I was a bum. A highly privileged one, to be sure, but still a bum, leeching off my husband.

Of course, I'm not what you'd think of as your typical bum. You know the kind: the guy who lives in his mother's basement, on the computer all day (or all night, doesn't matter which) but doing nothing productive, doesn't cook, clean, wash or take care of himself, baulks at the idea of getting a job or even studying. In the 50s he'd be hanging out on street corners, 'bumming' cigarettes off his friends, in the 80s he'd be at the garage talking about all the cars he'd love to do up. But your privileged bum of the 21st century ... well, I sure acted like it. A female version, at least. You couldn't even call me a housewife, I wouldn't have met that standard by any stretch.

Naturally, I didn't recognise it at the time. There aren't many bums in medical circles :P And of course, nobody thinks of themselves as a bum, because the concept that comes to mind when you think of a bum is of how unfair it is on the people around him, that he isn't pulling his weight. Nobody likes to think of themselves that way. Even my husband was kind enough to think of it as me being ill, and that one day I'd get better; he'd support me until then. He knew I was capable of much more, and he figured I'd get back to it one day.

And the way it looks from the inside ... of course there's that nagging feeling that you're not being a productive member of society, and you're not even really enjoying yourself. For some people, I imagine that feeling is easily overruled by the simple ego-feeding thrills of whatever it was they're spending time on - World of Warcraft, or an addiction like gambling at the poker machines. For others, it is strong, the sense that you're a dead weight on the people around you, and that you really could be doing more with your life ... if only you knew how, or what. But it also feels like there are insurmountable obstacles in your path. For me, I knew there was more to life, but I didn't feel I had the energy, or the motivation, to do anything. It was all just too hard. This inner struggle in itself weighed down on me, the feeling that I couldn't do anything I wanted to do, I didn't know what would become of my career ... a cloud constantly in the background dampening my mood, blunting my emotions.

---------

If you recognise this as a picture of yourself ... well, I'm writing a series of posts for you. I've gradually, very slowly, pulled myself out of that hole, using nothing but willpower I didn't know I needed, didn't know I had, borrowing strength from the people around me. I think it's time to detail how I did it, because when it comes to a hole like this, only you can pull yourself out, no matter how many hands are reaching in to help you. But know this: There is a way out.

There is a way out.

Don't expect any startling revelations from me, though. Everything I am going to say has been said many times before. I'm not advertising any miracle product or ten-week program (You too can be shiny and successful!) No, it is all common sense that you have heard from your parents and from society ... you might even be sick of hearing it by now. The big surprise is: it works.

You don't need money. You don't need any special powers of the intellect. You don't need any special circumstances (although, come to think of it, this would be kind of difficult if you didn't have a place to live, even temporarily). Your tools are a watch, maybe a pen and paper, and the wherewithal to get out there and take care of yourself, and then others. And while it won't be easy - I plan on detailing as many pitfalls as I can think of - it can be done.

The key word, of course, is 'done'. This is a process that you must do, you cannot simply 'become' (although popular culture would love to tell us you can!) No, you must act.

Currently these are the steps I have taken:

1: Realise that you could be doing something worthwhile. (This step took the longest.)
2: Take steps to obtain the energy you would need for doing it. In other words, take good care of yourself.
3: Seek support, and recognise support when it is being offered.
4: Actually write down things you could be doing.
5: Try to do some of the things you want to do.
6: Recognise the barriers in your way, and find out which ones are within yourself.
7: Realise that everything takes time, but only a certain amount of time.
8: Plan your time concretely, and realistically.
9: Endure your first big relapse into old habits, and come out of it realising why it happened and how to limit or avoid it next time.

Of course, this isn't a complete list; I'm not yet where I want to be. In fact, I've just come through my first big relapse into amotivation and fatigue. (I didn't go back to LOTRO, but there was a lot of Insaniquarium. I did do something every day, though.) But eventually - on March 31, to be exact - I will be going back to work. And by then, I plan to be ready. I'll keep you posted on how I go.

In the meantime, though, I will be going into each of the above steps in more detail. I hope that, one day, someone finds this useful (although I don't have that many readers just yet). Just remember:

It can be done.