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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by mair on June 23, 2001, at 22:08:03
I had an appointment with my pdoc the other day - I see her only about once every 6-8 weeks. In the course of talking about my meds, I told her that I had, on my own, decreased the dosage of one of my meds. While I had a fleeting thought when I was doing this that maybe i should let her know, that thought passed I guess because it was sort of my own experiment. This is a drug I've taken for quite awhile and have made previous decisions to go up or down on it.
This pdoc is about as soft spoken and mild mannered as they come, but she definitely let me know that this was not a cool move. If I understood her correctly (and my therapist too) it's not so much of a matter of playing around with these drugs as it is passing up opportunities to collaborate with my pdoc in making joint decisions. This supposedly has alot to do with my tendency to isolate myself when depressed. I respect boundaries to an unhealthy degree and I guess I'm the antithesis of the Bill Murray character in What About Bob? Thus my therapist and pdoc have talked to me alot about the advisability of calling them at home if they're otherwise not reachable. Basically I guess I was given an opportunity to demonstrate that I had gotten better about working collaboratively and was found sorely wanting. I didn't seize the opportunity because I didn't even recognize it as one. Having all this explained to me made me feel pretty discouraged. I've tried to imagine circumstances where it might be appropriate to call my therapist or pdoc other than at their office, and unless I'm fearful that a suicide attempt is very much in the immediate offing, I just can
't see the point. Am I missing something here?Mair
Posted by lissa on June 23, 2001, at 23:38:20
In reply to When do you consult your pdoc?, posted by mair on June 23, 2001, at 22:08:03
Here's what I think:
You seem to have enough common sense about your medication regimen and I don't think you should feel discouraged about the ways your doctor and therapist have, in my opinion, speculated (rather speciously) about your psychological motives. If there were an emergency, you would call your pdoc immediately, right? And you wouldn't, say, take the whole darn vial at once, right? I think these are the relevant questions to be asking. I'm not sure how safe it is to be tooling around with whatever you're on, but having the tendency to isolate yourself and your style with "boundaries," as I see it, are pretty irrelevant to your medication regimen. Why did your pdoc choose this event to make an example out of your help-seeking behavior? Your doctor does not seem to respect your intelligence very much. Some pdocs are into psychological theory, others really aren't. Maybe you'd feel more comfortable sticking with your therapy (if it works) and finding a pdoc who is more interested in the scientific side of things. That way, you have two different perspectives and you might feel more comfortable. (Please note that this is just an opinion from someone totally unqualified to be giving advice about this sort of thing ... :)
Posted by judy1 on June 24, 2001, at 2:51:50
In reply to When do you consult your pdoc?, posted by mair on June 23, 2001, at 22:08:03
Dear Mair,
I don't see how you can have a trusting open comminication with a pdoc you see once every other month. How can she reasonably expect you to communicate your needs under those conditions? I see my shrink every week, talk to him several times outside (by phone or e-mail) and partner in my choice/level of med unless I'm psychotic (it happens). that is the only way i am able to work with and respect a pdoc. i suspect her ego was injured- tough. I agreed with my pdocs on emergencies- suicidal impulses (not thoughts), serious cutting, hallucinations- all things i'll call day or night. I'm sorry you were made to feel discouraged, i think it's important that she understand that she made you feel that way and discuss why she reacted the way she did without her being defensive. kind of hard, but important if you want to continue your relationship with her. i wish you the best- judy
Posted by Wendy B. on June 24, 2001, at 10:48:03
In reply to When do you consult your pdoc?, posted by mair on June 23, 2001, at 22:08:03
> I had an appointment with my pdoc the other day - I see her only about once every 6-8 weeks. In the course of talking about my meds, I told her that I had, on my own, decreased the dosage of one of my meds. While I had a fleeting thought when I was doing this that maybe i should let her know, that thought passed I guess because it was sort of my own experiment. This is a drug I've taken for quite awhile and have made previous decisions to go up or down on it.
>
> This pdoc is about as soft spoken and mild mannered as they come, but she definitely let me know that this was not a cool move. If I understood her correctly (and my therapist too) it's not so much of a matter of playing around with these drugs as it is passing up opportunities to collaborate with my pdoc in making joint decisions. This supposedly has alot to do with my tendency to isolate myself when depressed. I respect boundaries to an unhealthy degree and I guess I'm the antithesis of the Bill Murray character in What About Bob? Thus my therapist and pdoc have talked to me alot about the advisability of calling them at home if they're otherwise not reachable. Basically I guess I was given an opportunity to demonstrate that I had gotten better about working collaboratively and was found sorely wanting. I didn't seize the opportunity because I didn't even recognize it as one. Having all this explained to me made me feel pretty discouraged. I've tried to imagine circumstances where it might be appropriate to call my therapist or pdoc other than at their office, and unless I'm fearful that a suicide attempt is very much in the immediate offing, I just can
> 't see the point. Am I missing something here?
>
> Mair
In my opinion, if you come out of therapy feeling worse about yourself than when you went in ("was found sorely wanting"), then the therapy isn't very good. Like Lissa & Judy said, sounds like an ego problem for the therapist, not a problem with your "not being able" to consult. Sheesh! Especially since you've adjusted the dose on other occasions. You weren't questioning her authority, but that seems how she has taken it. A little infantile, IMHO.I also know that I wouldn't call my shrinks at home unless it was a total emergency, like I did once when I thought I was cracking up. Otherwise, I really want to respect their privacy... how can that be turned around and made into a negative quality? Sorry you had to go through this, and hope if it doesn't get asnwered satisfactorily in the next session (don't wait 6-8 wks), then you should consider moving on, if you have some other options.
Best wishes,
Wendy
Posted by shelliR on June 24, 2001, at 22:36:00
In reply to When do you consult your pdoc?, posted by mair on June 23, 2001, at 22:08:03
Hi K.I guess it's respectful to let your pdoc know when you are changing meds or even dosages, since she's the one prescribing them. I don't think it's a major deal, but I often got criticized when I used to change things on my own with my last pdoc. So I starting faxing her any changes, or if I was feeling discouraged, and she would always call me at the end of the day or early evening, even though I hadn't asked or expected a call back.
In your case,maybe your therapist used that as an example of how you are trying to do this all by yourself (or mostly by yourself) and maybe as a reminder that both she and your pdoc are there for you. I think it's appropriate to call your pdoc and therapist at home when you are feeling that you need immediate support. I've called when I am feeling utterly hopeless, but not necessarily actively suicidal. Maybe this is less about when exactly to call them and more about accepting their collaboration and support as a stepping stone to accepting support from others in your life. Since I know that has been an issue with you. Anyway, just a guess and a chance to connect with you.
Shelli
Posted by stjames on June 24, 2001, at 23:19:44
In reply to When do you consult your pdoc?, posted by mair on June 23, 2001, at 22:08:03
I always inform my doc of dosage changes. That is what you doc is asking you to do. So it is simple, if you want to change, call. Period.
james
Posted by medlib on June 25, 2001, at 0:28:12
In reply to When do you consult your pdoc?, posted by mair on June 23, 2001, at 22:08:03
Hi Mair--
Thanks for your thought-provoking post--it generated all sorts of useful musings for me. At one level, I think the tendency to isolate oneself when depressed is perfectly understandable--after all, it's a survival instinct of all mammals to hide themselves from potential predators at times of greater vulnerability. I know that I "roll in the sidewalks" when feeling down; it takes energy to initiate contact with others and to prepare to defend oneself against potential misunderstandings and hurts--energy I just don't have when depressed. It also seems reasonable to keep a "stiff upper lip" around others you cannot expect to be willing or able to be "on your side."
I've found it useful to examine if and/or how my decisions re mental illness differ or would differ from my decisions on other chronic physical ailments (such as diabetes, arthritis, or heart disease). For example, I take medication for hypertension and hypothyroidism; would I adjust those med dosage levels without prior consultation? My answer is "Yes", I would and have--if there's objective evidence to support a change and I'm confident my doc would concur. It's "No", if I can envision a case for reasonable alternatives, or if I have no data to back up my preferences.
On the other hand, I've had enough severe depressive episodes to realize that my judgment during those times may be impaired. Pain and exhaustion cloud my ability to evaluate objectively, and skewed perception prevents me from being able to see beyond the immediate moment to glimpse a bigger picture or discern repeating patterns of behavior. Rather like learning to take responsibility for recognizing when you're too drunk to drive, I've had to try to become aware when I'm too depressed to decide. Under those conditions, I need to at least share the control.
Some people want not to be ill (physically or mentally) so much that, with the first signs of improvement, they reduce or eliminate medication--often with quite negative long-term consequences. Others wish to remain in control so strongly that they cannot perceive the small signs of an impending mood shift in time to make the minor adjustments which could prevent a crash.
I guess what I'm trying to say, in my typically long-winded ( and possibly redundant) fashion, is that determining when to decide, and when not to, may be as important as the decisions themselves. A good therapist could be a valuable sounding board in evaluating one's judgment, decision-making patterns and biases--but only if s/he can manage to be both objective and supportive. Do you think that yours can?
Re pdoc appointments: IMO, 6-8 weeks between appts. is fine if your med cocktail is reasonably satisfactory and has been stable for awhile. The appointment interval is too long if you are still actively searching for the best fit medically; it's too difficult to maintain momentum and avoid mid-course course corrections under those circumstances.
I had to declare an "emergency" in order to speak with my pdoc in person (during office hours) 3 weeks ago--the first time I'd had to contact him between appointments in the 20 months I've seen him. So, at my most recent appt., I asked him to modify his office SOP for me; I also obtained his email address. (If he hadn't been willing to make those changes, I would have begun seeking help elsewhere.) I see him monthly; if I decide to make a change between appts., I'll email him what I'm doing and why. If he disagrees with my decision, he can let me know at his convenience. Would something like that work for you?
I envy your ability to stay functional while depressed; obviously, you have a great deal of inner strength. It seems to me that all you need is a bit of "tweaking" to enable you to better recognize when that strength is working *for* you, and when it may be working *against* you.
If you're still reading this, you must have great patience, as well. I hope that I haven't said some of this before (some of it sounds distressingly familiar). And please pardon the unsolicited 2 bit analysis; usually, I'm not quite so presumptuous.
Well wishes---medlib
Posted by Chris A. on June 25, 2001, at 14:17:44
In reply to When do you consult your pdoc?, posted by mair on June 23, 2001, at 22:08:03
Personally I tend to worry about bugging my doc inbetween appointments. I don't want him to view me as a pain or the boy who cried "Wolf," so get a bit paranoid and hesitate to phone, especially when my mood is off. He has always been very good about calling me back, so it isn't his problem. We also have an arrangement where we work as a team and I can titrate meds to a certain extent when early warning signs arise or side effects are intolerable. Sometimes I do lack judgement as to when I need to call.
Even in a relationship where trust is strong it can be a difficult decision. One idea is to go over with the doc what they consider as appropriate times to contact them. If they've given you their home phone number, I would consider that an encouragement to call. Afterhours I talk to the pDoc on call, as that is the arrangement. There are six pDocs in the practice, so this gives them uninterrupted time with their families.Please don't feel bad. Most pDocs should realize that it's difficult to know when to consult them first. Some apparently don't allow the patient to make any changes him or herself. I wouldn't like that.
Take care,
Chris A.
Posted by Jane D on June 25, 2001, at 14:46:07
In reply to Re: When do you consult your pdoc? » mair, posted by medlib on June 25, 2001, at 0:28:12
Mair
I don't think you did anything wrong in adjusting the dosage without consulting. Lots of us have done it. You've done it in the past. There is no way that you could have been expected to anticipate that she would object and I wouldn't take her speculations about your underlying motives that seriously. Just write it off as a misunderstanding and insist that she do the same. If she believed that you isolated yourself it was up to her to be explicit about when she expected you to contact her. Now that she has been explicit I think you should comply. It's obviously important to her and respecting this will make it easier to work with her. I also wouldn't waste a lot of time trying to second guess her motives in making the request. I would, however, consider HOW she made it. If you thought she was rude or condescending or made you feel too much like a scolded child then you may want to object to that.
I also can't imagine calling a doctor at home. I barely call the office. But I have never had difficulty getting through when I do. Perhaps your doctors know that there can sometimes be difficulty reaching them. Maybe they are both workaholics or maybe they think that you don't always recognize how serious your condition is. Ask them to explain to you when they want to be called and why. This is another thing you should not have to guess about.
Jane
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