Monday, May 05, 2014

Dragon-slaying is Overrated: Treatment, Tradition, and Taming the Tarasque



Fairy tales are more than true: not because they tell us dragons exist, but because they tell us that dragons can be beaten. –GK Chesterton, in “Orthodoxy”

 Most of us are familiar with the phrase, “Here be dragons.” In the days of yore (what does yore even really mean?) it was included on maps to indicate the outer bounds of what was known; the dangerous and unexplored territories beyond the limits of the cartographer’s knowledge. In a psychological sense, too, dragons may fill this function in fairy tales, myths and legends: something dangerous, something unknown or unknowable, something that must be battled in order to move on to the next stage of whatever quest is underway. One of the clinicians at the treatment center, in fact, has the GK Chesterton quote prominently displayed in her office. Perhaps that is why, over the last several weeks of my own questing—sometimes frantic, sometimes paralyzed, almost always overwhelmed—dragons, and the beating thereof, have been very much on my mind.

I, like most people I know, am most familiar with the story of St. George and the dragon: this is my understanding of how dragon-beating is supposed to go. Not just dragon-beating, in fact, but dragon-slaying—an important distinction to which we’ll return. St. George came upon a distressing tableau as he was riding through the Libyan countryside: A fell beast arching out of the water, teeth bared! On further examination, the beast was ready to devour a princess who was standing on the shore in all her finery, an offering for the good of the village (from a feminine and feminist perspective: SNORE. Again with the damsel in distress thing? Oy). At any rate, St. George charged the beast on his white horse, lanced it through the side, “wounding it grieviously,” and lo, the dragon was killed. Ta-da! No more princess-munching, no more havoc-wreaking. The dragon had been disposed of, once and for all. 

In our own lives, whether struggling with our own dragons or (as helping professionals) attempting to rid others of theirs, we often adopt this Western, militaristic, once-and-for-all approach; and, I would argue, to our detriment. True, there is something inspiring and intoxicating about the idea that our personal dragons—eating disorders, addictions, depression, etc.—could be slain at one fell swoop, over the course of a single (though no doubt draining and arduous) battle. After a month of treatment, we’re on a meal plan and regaining some weight, so the dragon of anorexia must be vanquished! After starting Zoloft and a few therapy sessions, we’re feeling better, so we have smote depression to the ground and it will never rise again. We’ve abstained from alcohol for six weeks, or six months, or six years. We have a sponsor. Surely the dragon of addiction has been pierced to the heart! 

Similarly, the treatment methods that exemplify modern profit-driven medicine, even psychiatry, are often of this type. Treatment for anorexia, for instance, focuses on behavioral methods (are you eating X calories a day? Are you gaining X pounds per week?) and once these goals are met, even if only for a few days, insurance is unlikely to continue to pay—there is no time for the investigation of the trauma, shame, or perfectionism that fed the disorder in the first place. The dragon need not be known; it must simply be killed (as shown by normalized lab values and vital signs). It is assumed that with normal blood potassium and borderline normal blood pressure comes relief from what is actually the most painful part of the illness—the incessant calculation of calories, obsessive body-checking, endless drive to exercise, the profound and heart-rending self-loathing. Unfortunately, this is rarely the case. Dragons have a way, like their cousin the hydra, of sprouting new heads and resurrecting themselves in new places if we take St. George’s hit-and-run approach. Yet what other option presents itself? If killing the dragon isn’t the way to peace, what is? 

This past week, leafing through one of the approximately six books I’m currently reading (a bad habit, as I now can’t remember which book I found it in) I stumbled upon the legend of St. Martha and the Dragon. My first thought was, “No, not THAT Martha,” but in fact it WAS that Martha, familiar from the Gospels. The domestic scold, or the faithful servant, depending upon your feelings—was apparently sent out from Bethany in Judea, and ended up (as so many characters in mediaeval hagiography do) in France. She came upon a small village near Avignon where the people were being tormented by a huge beast, part dragon, part bear, part lion, which lurked in the rivers. This monster was known as the Tarasque. It would regularly run ships aground, or sink them and gobble all aboard. Once again, it is interesting that dragons seem to situate themselves underwater or in caves—dark, inaccessible spaces rife with wild and shifting shadows, where they cannot be clearly seen. This is the quintessence of the dragon: in Jungian terms it would be allied with the Shadow self, that part of us that is neither ego (the way we experience ourselves, from behind the various shields of our defense mechanisms) nor the persona (that mask which we present to the world). This is the darkness that stands behind us, yet is attached inextricably to us, the part which not even we—and certainly not our compatriots, if we can help it—fully know.

St. Martha went to the people of the town, who promised to convert to Christianity if she could rid them of this danger. With this charge she strode out to the dragon’s lair armed not with a shield and sword, but with holy water and an armamentarium of holy songs. She did not go on a dashing, ethereally white steed, as St. George is so often pictured; she walked, connected to her earthiness, at the Tarasque’s level. She sprinkled the Tarasque with holy water, fended it off with the sign of the cross, and calmed it with her mellifluous voice. Thus becalmed, the dragon allowed her to wrap her girdle around its neck like a leash, and she walked it back to the village, tamed. This is the more feminine, Eastern, approach to beating a dragon, a counterpoint to the martial Western method exemplified by St. George. The dragon is not slain, but rather tamed; it is not hacked to bits, but is coaxed and seen and known. 

Though this method of beating a dragon—taming rather than slaying--is not the one we are most familiar with, I believe in the long term it offers the best chance for true healing and change. Violence against the shaded, reptilian parts within us is still self-inflicted violence; hating hate does not lessen it. Rather than charging bloody-mindedly at our injuries and addictions with lance in hand, perhaps it would behoove us to sing to them, tame them, get to know them. Note that this is not the same as agreeing with the dragon’s agenda. St Martha didn’t go to the Tarasque and say, “All right, let’s go eat some more fishermen. And how about attacking the village? You haven’t set fire to it in several weeks, from what I hear.” Rather, I imagine her saying, “I know you; I see what you are. I see what you’re doing, and why. However, you still have to get on this leash. You can’t hurt people anymore.” Similarly, our own dragons require understanding if they are to be tamed. What is a person struggling with alcoholism actually thirsty for? What is she trying to forget or numb? And most important: what non-drug experience could provide her with that same sense of heady intoxication, or comfort, or release? From there, the roots and functions of the addiction can be parsed, and healing can begin. What is a woman with anorexia really afraid of (mayonnaise, let’s be honest, is not inherently frightening)? As she begins her second hour racing around the track, what is it—in her past or in her present—that she’s running from? If her motivation is to have ironclad control, what in her life has been out of control, and how can that be addressed? If her motivation is self-punishment, what does she believe she needs to be punished for, and how can compassion and forgiveness replace that drive for self-destruction? 

In a way, St. Martha’s path is more difficult than St. George’s. The splatter and shimmer of a single, epic battle is replaced by the far more fraught work of dialogue and contemplation. It is a process rather than an event. It is (sigh) a journey. It is relatively easy to stay on a white horse, slashing at those parts of us we have labeled ‘the enemy,’ never bothering to learn their stories or their names. What requires true courage is venturing into the shadowy glade by the river, barefoot and afraid, and meeting the dragon eye-to-eye.

Friday, January 24, 2014

I am NOT pro-abortion. No one is.

I happened to have the afternoon off on the anniversary of the Roe v. Wade decision this year. Hooray, you say, afternoon off (and so did I)! Then I made the mistake of going to the gym and parking myself on the treadmill stationed in front of the TV that is perennially tuned to Fox News. Oh no, you say (and so did I)! Maybe subconsciously I wanted to watch something that would enrage me and make me anger-run faster; I don't know.

In any case, over the course of my workout I was treated to an endless parade of pundits discussing the evils of the 'pro-abortion' movement, and it was all I could do not to snatch the earbuds out of my iPhone and lob it through the TV (instead I increased the speed on the treadmill a tick each time something new and enraging was said; I nearly set a personal record on one of the mile repeats). Because here's the thing: I am as staunchly feminist as anyone I know, and I move in a sphere of other powerful, kick-ass women fiercely committed to reproductive rights--and I am NOT pro-abortion, and don't know anyone else who is. I would venture to say, in fact, that NO ONE  IS--at least no one who is sane, and passionate about women's autonomy and well-being. What I am, as the bumper sticker on my Prius proudly proclaims, is "Pro-Faith, Pro-Family, Pro-Choice."

In a perfect world--the world I would wish for--abortions would happen rarely, if at all. Everyone who didn't want to get pregnant would use contraception 100% of the time, and it would be 100% effective (right now even the most effective methods, like IUDs, have a ~1% failure rate). Rape would never happen, nor would incest. All pregnancies would be healthy, with no life-altering fetal anomalies; no woman would ever suffer complications that made continuing the pregnancy damaging or life-threatening. However, in case it's escaped your notice, we don't live in a perfect world (I personally was alerted to this by the fact that I was not kissed awake by Mariska Hargitay this morning). Fifty percent(!) of pregnancies in the United States are unintended. One in four US women is sexually assaulted in her lifetime. Condoms break, pills fail, women develop life-threatening complications of pregnancy, some fetuses develop without brains or with life-limiting genetic illnesses that would make even their short time on earth a maelstrom of pain. At that point, in that place, there must be a choice; and for one in three US women, at some point in their lives, that choice will be to terminate the pregnancy. Do you know three women? Six? Nine? Unless you have lived the entirety of your life in a monastery (and maybe even then), you know someone who has had an abortion.

Life happens. I wish abortions were never necessary, but sometimes they are. I wish all women had access to the financial, medical and social resources that would make preventing an unplanned pregnancy possible, or carrying to term an emotionally, socially, and spiritually viable option, but it's not reality. Not right now. And until and unless you are the one staring in dismay at the positive pregnancy test while trying to imagine how you'll feed another person, you don't get to make that decision. Until you're the one doing the mental math and realizing that yes, it's been six weeks and the emergency contraception failed and your rapist made you pregnant, you don't get to make that decision. It's not your body. It's not your life. And the best thing you can do, as a person whose choice it ISN'T, is to compassionately and humanely support the person whose choice it IS.



Tuesday, January 14, 2014

On Food, Faith and Flesh

Of late, in the process of trying to vanquish the demons of body-hatred and self-negation that have once again reared their ugly heads (strange how they can slumber, or appear to, for months or years, then resurrect themselves at a moment's notice), I've been looking at the ways in which eating disorders are not just emotional or psychiatric maladies, but spiritual ones. Some of my thoughts--more or less coherent--follow.

I grew up in a church where "the flesh" was shorthand for all the evils of humanity's fallen nature. In our teen Bible study we read Galatians, where Paul exhorted us, "Those who belong to Christ have crucified the flesh with its desires..." and "Now the deeds of the flesh are evident, which are immorality, impurity, sensuality..." Simultaneously, of course, I was teetering on the cusp of adolescence, with all its associated bodily chaos. For a variety of reasons I was intensely, painfully self-conscious, and my body especially frightened me. I was able to keep the rest of my life in order; I made straight As, played first chair flute, captained the  volleyball team. My body, however, resisted my attempts to force it into line. Of their own volition (and it seemed specifically to spite me) my hips spread and my thighs thickened. Flesh appeared where none had been before, complete with untidy appetites and shameful desires. Struggling in an unwinnable fight--but no less valiantly for that!--I tried to bring my body, "the flesh," under control through epic deprivation and exhausting exercise. My body shrank, true. Yet the hunger, that base desire, that fleshly weakness, persisted. I could never be good enough; I could resist temptation, but I could never not want, never not need. This is the self-flagellating attitude of false piety and misguided contrition that I think drives many eating disorders, especially among those influenced by Western Christianity. The idolization (a carefully chosen word) of self-abasement and starvation--particularly for women--has a long history, particularly in the church. St. Catherine of Siena, for instance, starved herself to death and routinely forced herself to purge with an olive branch. St. Angela Foligno and St. Margaret of Cortona both subsisted on little more than Communion.

However, this idolization of self-punishment, of restriction, of penance, is just that--a false lionization of our own power. It is based on an assumption that we have to be good enough to be loved, that we have to save ourselves, that we have to earn grace. In fact, not only are none of these things required, they are impossible. If humanity could attain salvation on its own, a Savior would be superfluous. Grace, by its very nature, is extravagant--it is not earned. In theory, this relentless pursuit of self-negation (in the presumed service of piety) places us at the center of the universe rather than The Divine. We imagine that we can suffer our way into acceptance or into Paradise. Like the mirror image of the narcissist who declares himself a VIP because he feels secretly, deeply inadequate, we--in our abject self-loathing, our desire to make ourselves holy, to make ourselves good--have strayed dangerously close to hubris.

 And speaking of hubris, there is something to be said for eating disorders--whether they manifest as over- or under-eating--as sin. Not 'willful' sin, not intentional misdeeds, not something more to feel guilty about, but as a marker of profound alienation: from Divinity, from others, and from ourselves. I remember a long-ago conversation with a Jewish friend who stated that smoking was a sin. Curious about his particular perspective (and hoping to compare it to the reasoning I'd grown up with, which could be summed up: If it's fun, like drinking, dancing, smoking or sex--it's probably a sin), I asked why. "It's an abuse of the body God has given you," he said. "Your body is entrusted to you, but there is an expectation that you will cherish it and use it to do good in the world." Not castigate it, not starve it, not engineer its destruction one calorie at a time--Cherish it! Imagine that.

Beyond that, Christianity, or the Episcopalian sect to which I belong, is in fact a powerfully embodied faith. Jesus was incarnate--"enfleshed"--as human. He ate and drank (quite a bit, in fact; he was decried more than once as being a "glutton and a drunkard" in the Gospels). We use our bodies in worship, kneeling, standing, crossing ourselves. There is the spicy-sweet smell of incense in our nostrils as we pray, and hymns and chants echo in our ears. Most important, the beating heart at the center of it all--the center around which everything holds--is a meal. We come together as a family around a table to share freshly-baked bread and experience the dusky tang of wine on our tongues. It is difficult to lose yourself in the Paschal Mystery if you are wondering how many calories are in a mouthful of bread. It is difficult to reach out your arms and enter the embrace of that family when you are clutching your private, painful secret to your chest. It is difficult to come to the table for solace or strength when the very phrase "come to the table" fills you with panic. Yet it is for precisely those reasons that it is essential to lose oneself, to reach out. It is for the healing of ills just such as these that we come to the table of grace.

Intellectual understanding is one thing; living it is another. To quote Paul again, "For I do not understand my own actions, for I do not do what I want, but I do the very thing I hate...so now it is no longer I who do it, but sin that dwells within me."

Sunday, June 23, 2013

Three not-valid excuses for using the N-word

Goddamit, Paula Deen. I liked you. I really liked you. Granted, sometimes your giant, beyond-whitened smile made me afraid you might come through the television screen and devour my soul (I have this same fear of Suze Orman--I think it's the huge, unnaturally white teeth combined with what we psychiatrists call 'the crazy eye'). I'm also relatively certain every meal at your restaurant should come with a 50% off coupon for coronary bypass surgery, or at least a referral to an endocrinologist. BUT. You seemed 'sweet,' in absolutely the best Southern-fried sense, and your accent made you sound EXACTLY like my beloved high school history teacher, an aging Southern belle...and now it turns out you throw around the n-word like a float captain throws beads at Mardi Gras (flash your tits and I'll call you a disgusting racial slur!). Dammit, Paula. If I knew how to make gifs, there would be a big one right here of me sighing and shaking my head. Your father and I are so, so disappointed in you.

In the aftermath, I've heard a lot from people on both sides(?!?!) of the 'Do we damn Deen for her dastardly deed' issue (alliteration for the win!). The best, hands-down, reply for the 'It's 20-freaking-13, of course it's not OK to say that' camp, otherwise known as 'The Reasonable, Sane Human Beings' comes from the Daily Show. Go watch it. No, seriously, go watch it right now. I'll wait. BEST LINE: "You know what else is a lot of slaves? ONE, PAULA DEEN. ONE."

So, here are some excuses I've seen trotted out for use of racial slurs (the n-word in particular) in the last few days.

1) "But it's not directed at all Black people; it's just used to describe low-class, thuggish Black people." Variant: "It's not a race thing at all. It's just a word for no-good, low-class people with no manners." Disingenuous at best. Why have I never ever ever heard this word directed at anyone but African-Americans, then? Why is it used to describe Barack Obama, who as the Leader of the Free World (TM) is surely the farthest it is possible to be from "thuggish and low-class"? If that's the case, why is the phrase "uppity [n-word]" even a thing? Even if this were true (which, duh, it's not) the classist BS inherent in these 'explanations' would still be seriously problematic. Next.

2) "It's just a part of Southern culture," or "It's what things were like in the South when I/he/she was growing up." You really think bigotry deserves to be called a part of Southern culture? Like, not in 1865 or 1920 or even 1960, but today? I'm not saying racism isn't still an issue (it is, and not just in the South), but come the hell on. Sweet tea is part of Southern culture. Big porches, the Kentucky Derby, trees festooned with Spanish moss, saying "Oh, bless your heart" when you mean "Please go directly to Hell." Mint juleps. Kudzu. An almost genetic, visceral distrust of anyone with the last name Sherman. Do you really think so little of the South that you'd call vitriolic hatred part of the culture (and Southerners, do you think so little of yourselves)? As for the "When I was growing up..." argument: When my mother was growing up she didn't have air conditioning, a color TV, a computer, or an iPhone. She's adapted pretty well to having all those things, because people adapt as things change--if they want/need to. She also saw the integration of her high school and wasn't a total dick about it, because my mom is a basically good human being. Things change, kids. Get with the program.

3) Last, and perhaps most frustratingly frequent: "But they get to use that word!" 'They,' of course, referring to African-Americans. Oof. Where to begin--especially without 'whitesplaining.' So, there's still a robust debate among Black Studies scholars (and everyday folk) whether anyone should be using the n-word, or a derivative thereof, at all. Here's are pro and con articles that explain it better than I ever could. But to sum up, there's a difference between the word 'nigga' and the alternate, hard-r-at-the-end, much more venemous version. Two African-American guys saying hello to each other might say "Hey, nigga." This is worlds away (obviously? I hope it's obvious?) from a person from the historically dominant culture shouting the n-word at someone from a historically oppressed culture while driving by, or in a face-to-face interaction, or even (as in Deen's case) in a discussion with another member of the dominant culture.

 Reclaiming language is always tricky, and always makes some people uncomfortable. I know it's not exactly the same, but para ejemplo: I'm a woman who identifies as lesbian/queer and has no problem with either of those words. I have some LGBT friends who are fine with those words too, and we call each other 'queer' or even 'homo' sometimes, endearingly. However, if anyone I didn't know, gay or straight--or even some of my straight friends--called me 'homo,' I'd be righteously pissed. I have some friends who really don't like the word 'queer' because it has negative connotations to them, and so even though I kind of love it, I don't use it around them or to describe them. Similarly, I absolutely can't. stand. the word 'dyke,' even though I know some lesbians have 'reclaimed' it, and my friends know not to call me that.

Which is a circuitous way to say, just because an oppressed group is reclaiming certain words for use among themselves doesn't give you the right to use them. There's an entire, complicated social and historical context surrounding these words, and saying things like "But why do they get to say it then?" makes you look like an uninformed, entitled, petulant little kid who's pissed off someone else is getting to play with something you want. The truth is, that word is NOT YOUR TOY. You're not entitled to it, and you never were. Get over it and go play on the swings or something.

Saturday, June 01, 2013

The Friendzone

It's not a TV series hosted by Rod Serling. It's not the place at the end of the gridiron where you make a touchdown and do the victory dance that makes you look like a chicken with a neuromuscular disorder (in fact, there's a conspicuous absence of scoring). It's...the Friendzone, a much-lamented but nevertheless completely bullshit concept, a not-so-subtle outgrowth of (mostly male) privilege and entitlement. For those of you not in the know, let me explain the Friendzone by giving you an example (or you could just look it up on Wikipedia--whatevs). Names have been changed to protect the innocent--and the guilty. I'm going to assume for the purposes of this post that a woman is the 'friendzoner' and a man is the 'friendzonee,' not because I want to be sexist or homophobic but rather because 99.99% of the time I've seen it play out, that's been the dyad involved.

I know a guy named Bob from, I don't know, those nights when the moon is dark and evil menaces Metropolis and we put on our capes and masks and fight crime together. Yeah, that's it. Anyway, Bob has a thing for another member of our superhero squad, Julie. They go to movies and bars together on weekends. He helped her move into her new apartment a few months ago. He brought her ice cream and the first two seasons of Golden Girls when she broke up with her old boyfriend Evil Evan, and held her while she cried about what a jerk he was. Now, Bob would looove to be in a relationship with Julie--or at least to get into her skin-tight-leather crime-fighting hot pants. BUT. Bob has never said a thing about it. He's never asked her on a date (and CALLED it a date), he's never told Julie he's into her, he's never gone in for a kiss while they were watching a movie...nothing. Finally he works up his courage and tells her he's interested in being 'more than friends' (Bob's corny like that, but at least it's more romantic than 'Let's bone,' which I swear to Jeebus I heard at a frat party once). Julie tells him she loves him--he's the best friend she's ever had--but she's not in love with him, not that way. In common parlance, Bob has been Friendzoned; and in this example, as in so others I've heard of (in person, on the internet), Bob is PISSED.

So Bob and I grab a beer the next day, and he starts spilling his guts. I feel for him at first; unrequited love is painful, after all. Then he goes into attack mode.
 "She's just a bitch. She totally used me--to move her stuff, to be her shoulder to cry on! Shit, I even went shoe shopping with her. What straight guy goes shoe shopping with a girl he's not screwing? She totally exploited me, and I was such a nice guy [this will be an important phrase later--ed.], and I totally got friendzoned. Women are just users. They only go for assholes."


Now, let's analyze this. Bobs of the world, I'm going to speak directly to you. Everyone else, feel free to listen in.
1. If you befriend someone with the sole intent of getting in their pants, and you aren't honest about it (instead keeping your plans to yourself and thinking, "Oh, but if I go with her to this John Mayer concert/Sex and the City movie/do what the hell ever other 'nice guy' things, and never ever pressure her romantically, surely she will see that I'm the perfect guy for her and jump on my manhood like a starving dog on a bratwurst"), you aren't actually a 'nice guy.' I hate to break it to you, but you're misguided at best and a manipulative jerkface at worst.

PS--If you really think there should be a sort of contract, where you agree to act friendly and she agrees to give you a chance at a relationship, make that explicit at the beginning--ie, "Hey, I'm just helping you move and listening to you talk about your utterly boring friends in hopes that you'll eventually let me do unspeakable things to your awesome breasts. So let me know if we're a go on that, 'cause otherwise you can move this shit yourself, mmmkay?" Wait--you think that sounds totally awful and would probably get you kicked in the unmentionables? Yeah, exactly, because it lets her know what you yourself are incapable of seeing--you're kind of a self-centered, disingenuous git and not a 'nice guy' at all.

2. Being nice to a woman doesn't entitle you to her body. This idea that hanging out with/doing favors for a woman (you know, like actual FRIENDS do for each other?) means you should have a shot in bed is as old as it is ludicrous. It's like a lite version of the old date-rapey "I took her out to dinner, how dare she not sleep with me!" outrage. She didn't keep up her end of the contract, that frigid friendzoning bitch! Yawn. So twentieth century.
Look. Women are not agency-less sex-vending automatons whose legs spring open after you insert enough 'niceness tokens.' Believe it or not, women are people! Just like men! And they have thoughts and preferences and desires, just like men! And sometimes those desires don't coincide with yours, and that doesn't make either person's desires wrong. You're allowed to want her to sleep with you, and she's allowed to say no.

3. If your ego/emotional equilibrium is so fragile that someone telling you they aren't romantically attracted to you is enough to send you into paroxysms of rage and despair and misogynist Tourette's, you probably aren't ready for an adult relationship anyway. You don't need a girlfriend; you need a therapist.

4. Lastly, what's wrong with being friends with a member of the opposite sex? Friends are awesome--friends of all genders. Viewing every interaction with a member of the opposite sex in terms of humpage potential is limiting and sad. Don't be limited and sad.

For more awesome takes on this issue, try here or here or here.

Thursday, May 30, 2013

Size matters.

So I recently came upon this post discussing the existence of weight-related bias in the medical profession, and was...sadly, not terribly surprised. In medical school alone, I've seen countless instances of body-shaming and downright hatefulness related to people's (usually patients') size, including a discussion of childhood obesity that somehow devolved--while led by an attending physician I otherwise greatly admire--into a youtube-comments-worthy, riffing free-for-all on the themes of "Why can't fat people just not eat fatty fat all day," "God, why are fat people so gross?" and "If they weren't so lazy and would just exercise..." Interestingly, now that I think about it, my medical school class of 125 had...5 people I can think of who might qualify as 'obese' (ie, BMI >30, which is totally arbitrary, but whatever). That's 4% of my class, as opposed to 36% of Americans as a whole. Not drawing any conclusions (cough, education and socioeconomic status, cough) just...thinking.

 It was around the time that someone suggested drawing attention to a child's obesity at every single office visit (to 'inspire them to change,' of course) that I started getting truly angry. I stuck my hand in the air.
"Don't you think," I said, "That's somewhat shaming for the kid? Don't you think it's overdoing it to mention size not just once a year at physicals but during every visit for every runny nose and earache? Don't you think these kids are already aware that they're fat? Don't you think their peers already remind them every day?"
"Well, if shame acts as a motivator..." Her voice trailed off and she smiled.
"No," I said, "Shame is an awful motivator. Shame doesn't lead to healthy changes. Ok, I hear you, more than a third of American youth are overweight or obese. But you know what? Between a quarter and a half of young women in the USA have disordered eating patterns--or outright eating disorders--that put them at much greater physical and emotional risk. And do you know what drives eating disorders? Shame."
And then I sat down and tried not to look at anyone, because I could tell my voice had gotten a little growl-y at the end and I didn't want to be known as 'the girl who flipped her shit during that obesity talk'...but it was already too late. In hindsight, I'm kind of proud of it.

College was a rough time for me, body-wise. I started college weighing 170 lbs, which for my height put me--just barely--in the 'obese' BMI category (the vagaries and vicissitudes of BMI is a topic for a whole different post). I also had some rip-roaring bulimia going on, for which I sought help at the Student Health Center. However, because of my weight, my eating disorder wasn't deemed 'serious.' It wasn't until it morphed from bulimia to anorexia, and I dropped 70 lbs in the space of a year, that I was suddenly granted the label of someone with a 'real' eating disorder. I remember very distinctly coming back to school August of my sophomore year and seeing my physician at Student Health for the first time in several months. At the time I was in the low-normal BMI range, and creeping ever-downward.
"Look," she said to me, suddenly very stern, "You're at a normal weight now. A little low, even. You can stop doing this now."
As if everything that had come before had been legitimized. As if it were OK to starve myself and purge and overexercise while I was "overweight" (because everyone knows fat people can't have 'real' eating disorders). As if an iffy weight-loss technique suddenly became pathological when I crossed that magical line of 'healthy' BMI. As if self-loathing and body hatred and abject despair over what I saw in the mirror were totally fine, even expected--as long as I was fat.

I've heard doctors mock their obese patients in private, and I've heard them rake patients over the coals for their weight face-to-face (mostly the former, thank God--for the patients' sake). Which is sad, really, for a lot of reasons--but primarily because doctors are DOCTORS--professionals with a duty to do no harm and provide the best possible care, which doesn't include shaming. Shame, as mentioned previously, is a terrible motivator. How on earth is telling someone that their body is ugly and disgusting and unacceptable supposed to motivate them to take care of it? People don't take care of things they hate.

I'm not saying physicians shouldn't discuss weight with their patients--far from it. There are certain health problems that are more common among overweight/obese folks, and losing weight can sometimes help clear them up. It would be foolish at best and malpractice at worst not to tell an overweight patient with PCOS that losing weight could help her improve her fertility. The same goes for patients with diabetes, or osteoarthritis, or high blood pressure. However, focusing on weight as the sole metric of a person's health is not only myopic, it can be counterproductive. There are numerous studies that indicate focusing on behaviors instead--increasing intake of produce and whole grains, getting more exercise, reducing stress--is more effective in improving outcomes.

Para ejemplo: a relative of mine makes occasional attempts to lose weight. He's what would be called, somewhat melodramatically, 'morbidly obese.' It all starts well--he'll begin eating more fruits and vegetables, checking his portion sizes, and getting more exercise. For a few weeks, or even months, this 'works,' in that he loses weight. He starts feeling more energetic and less depressed. Then the numbers on the scale plateau, and because that's the only thing he and his doctor focus on (rather than how his new regimen makes him feel, rather than the fact that his blood sugar and blood pressure are improving, rather than the fact that his stamina has grown by leaps and bounds), he gets discouraged and impatient...and he stops. What was an opportunity for him to feel stronger, healthier and happier gets derailed because people (himself included--it's hard not to do as 50-odd years of socialization have trained you) are only looking at the numbers.

People aren't numbers. They're people.

Friday, May 24, 2013

Things Medical School Has Taught Me

Sorry for the long interlude without a post--things have been busy, what with the graduating and commencementing. And now that med school is all over, and I is officially a doctor, I thought I'd post a few of the things I've learned in the last five years--some technical in nature, some more to do with matters of the heart. A quick run-down, in no particular order.

1. To quote an anesthesiologist colleague, "It's pretty hard to kill a breathing patient." That's why the ACLS algorithm (Advanced Cardiac Life Support, for those wondering about the abbreviation--don't feel bad, I had to look it up myself) goes Airway, Breathing, Circulation. I don't know why, but I find this oddly comforting--as long as they're breathing, and you keep them breathing, things are (relatively speaking) pretty good. Which leads into our next point--

2. What doctors mean when they say someone's "sick" and what everyone else means are COMPLETELY different--and it varies a little bit from specialty to specialty. From what I've gathered from ER and surgery/trauma folk, their "sick" means "this person is going to die within the next hour unless someone does something." Internal medicine folk are a little more liberal with it, and as long as someone's basically OK at baseline (ie, doesn't have kidney failure, heart failure, diabetes, AND hypertension), someone can have a pretty gnarly pneumonia or acute liver failure and still not be "sick." Psychiatrists' "sick" has more to do with whether someone's talking to people who aren't there and smearing feces on walls.

3. Speaking of feces. One of the main things I learned during my time on labor and delivery is that, while childbirth is a beautiful, natural, ethereal experience in theory, in practice there is a lot of grunting and screaming and, now that I think about it, literally every secretion the female body is capable of producing. This is not a soft-filter Lifetime Very Special Event with gentle lilting flute music in the background. There is sweat and blood and vomit and feces and don't even get me started on meconium. And there's nothing wrong with that, because pushing another human being out of your body is miraculously awesome and I think entitles you to do pretty much whatever while it's happening. It also taught me that, while I do want kids, I think I probably want my wife to have them, or that if I do any child bearing, I want an epidural early (like, the beginning of the third trimester would be nice).

4. Also from my time in OB/Gyn land: lots of women are allergic to something in Always pads, and Kotex (or another non-Always brand) will often work better, and by 'better' I mean 'not cause a painful, itchy rash in the lady regions.' Also, there is no reason to douche, ever, and most of the products sold for 'feminine refreshment' (I don't understand--does my vagina want a glass of lemonade?) actually make things worse by mucking up the natural pH balance and allowing yeasts, unhealthy bacteria and other interlopers to set up shop. I don't completely understand why anyone thinks women's bodies are supposed to smell like a summer's eve or a spring morning or a dog day afternoon, but they aren't. If things are getting kind of...malodorous in the region, you don't need to be spraying Febreze down there, you need to go to the doctor. If things smell just fine, you don't need to be fancying things up with new car smell anyway.

5. As for psychiatry, I've learned a ton, but the most interesting is that ECT is actually not a scary, mediaeval procedure. In fact, it's one of the safest and most effective procedures in all of medicine, especially for people who are seriously depressed and who need a quick response to treatment. For out of control psychosis, Haldol can be like a magical elixir. For folks with dementia, unfortunately, medications like Namenda and Aricept do virtually nothing. Also: for people with pretty much any mood or anxiety disorder, a companion animal (in conjunction with an SSRI or mood stabilizer, of course) can be just what the doctor ordered. If my cat hadn't come to me with a name, I probably would have named her Zoloft--Zoe for short, of course.

6. To quote an internal medicine colleague, "Often the shortest road between despair and hope is a good night's sleep." This is true not just for overworked, hyper-stressed interns and medical students, but for everyone.

7. Drinking caffeine in little bits throughout the day is more effective at keeping you awake and functional than chugging a large coffee all in one go. Eating a little protein snack will also help you stay alert. Avoid processed carbs like the plague. At least for me, a bag of Cheez-Its from the vending machine might as well be cheddar-flavored Ambien.

8. Never pass up a chance to eat, sleep or pee. It may not come again for a while. As for sleep, I learned during my surgery rotation that it is most definitely possible to fall asleep standing up--and during rounds, no less. In fact, it's probably easier than falling asleep in a call room bed (which is often only a bed in the loosest possible sense of the word). I'm sorry to disappoint all you Grey's Anatomy fans, but call rooms are approximately as romantic as that Motel 6 out by the highway, with the added possibility that someone could come in the door at any moment. I can't imagine anyone ever having sex there. Then again, I can't imagine anyone having sex in a hospital room, but I've definitely heard of patients who have managed it.

9. On a more serious note, it's OK to cry with patients sometimes. It's OK to cry with colleagues sometimes. And sometimes it's OK to find the nearest bathroom, lock yourself in a stall and have a good sob. I've done all of these things, and from what I've gathered, so have a lot of other doctors (especially the crying in the bathroom).

10. Everyone wants to feel heard and to feel validated. "Tell me more about that," "I can understand why you feel that way," and "I hear what you're saying" will almost never go amiss. This isn't only true for patients--it works with families, with other healthcare professionals, hell, even with yourself.