Saturday, January 30, 2010
It's snowy here in Maryland.
First, let me say that it's never okay to lie to your shrink. Therapy is about having an honest interaction, and a psychiatrist probably can't help someone who is hiding a secret life. This post, however, was inspired by Clink's last piece, Rage Against the Machine where she wails on Electronic Medical Records, in a feeble and failed attempt to engage Roy in a fist fight. There she is a punchin' and he's just skating along oblivious as can be.
Why do EMR's make me uneasy? When I'm in the clinic with patients and I can access their medical records, well, it makes life easier. So why don't I like the whole idea? I talked about some of this in the comment section on Clink's blog post.
With an EMR, it's easier to get records, and any doctor in an institution who treats a patient has access to them (oh, the whole institution has access to them, but only those involved in the patient's care are allowed to "peak"). What if a patient wants to withhold some of their information from certain docs? Is that lying? Is that reasonable? Should that be allowed?
If it's about obtaining prescriptions for controlled substances, it's just wrong. But might there be other reasons a patient would want to control the flow of information?
Let's face it, some docs and some patients don't click. A patient may feel the doctor didn't really listen, saw him much too briefly and jumped to a conclusion without hearing all the information, or was uneasy with the doctor's conclusion. The patient comes for treatment of his headaches, and after a few minutes, the doctor says it's "Stress." The patient wants more tests done, the doc feels it's unnecessary, and the patient would like to get a fresh opinion. Electronic Records may hamper the ability to get a fresh opinion. The next doctor may look at the note and agree with the patient that more testing should be done, or he may see another doc's opinion and go with that. And who knows what the first doc wrote, it may continue to prejudice future care. All sorts of human emotions get tossed in here: What if second doc hates/adores first doc, that may prejudice what side he takes. Any way you dice it, if the question is so much as raised that a patient is malingering or that an illness is factious, medical professionals may shut down.
So how does this pertain to psychiatry? Psychiatric patients are often given sub-par medical care. Their medical symptoms are more likely to be attributed to their psychiatric disorders (and sometimes this is appropriate after a reasonable and thorough work up). Perhaps a patient worries that if he tells a doc he's in therapy, his problems will not be considered as valid. I think this is getting better.
Roy would say that the patient should be involved in the evolution of the record. Maybe Roy should say what he wants to say....
And you didn't really think I was going to say if it's okay to lie to your doc!
So I'm adding this as a next-day addendum: Talesofacrazypsychmajor left us a comment saying that primary care doc who knew of psych diagnosis felt it had to go on every school form that needed to be filled out (presumably for school, work, camp) and perhaps that's a valid thing to reveal to any institution needing medical information. However, it is an example of how the patient is out of control of their information. This example is obviously not an EPR issue alone, but EPR's make the spread of information easier for better or for worse.
Wednesday, January 27, 2010
I'm posting this for ClinkShrink at her request. She's in jail at the moment and they block Blogger. This is in honor of the Apple Tablet announcement today, and she's looking to pick a fight with Roy!
Rage Against The Machine
With the pending announcement of the long-awaited Apple tablet, and on the heels of my new programming project (an iPhone app), I'm thinking about health information systems. This blog post is a blatant attempt to yank Roy's chain, but I know he's smart enough to see right through it. Nevertheless, if he totally agrees with me I'm going to be quite disappointed.
The fact of the matter is, I'm a geek and I love technology but I really really dislike health information systems. I've yet to meet one (other than stuff I've designed myself) that doesn't drive me screaming into banshee land.
I know all the supposed benefits of healthcare information systems: they're supposed to improve care by allowing communication between providers, they're supposed to reduce healthcare costs by improving efficiency, they're supposed to contribute to medical knowledge by collecting aggregate data about diseases for research.
I also am concerned about the downside of health information systems: potential threats to information security, harmful uses of the data that's collected, breaches of confidentiality and loss of independent medical decision-making.
Fine. That's not why I've hated them. The reason I strongly dislike most systems I've used is because they make it harder to figure out what my patient really has.
is a descriptive art. You make a diagnosis through observation and description. You treat people through language and free communication. stifle all that. Instead of being able to document that the patient "believed he was the President so he hopped on a bus to Washington, camped out on for three weeks, then climbed over the fence of the White House", I only get to check a little box that says "delusional". Now, that really loses something.
Even when the computer programmers give me a textbox instead of a checkbox, I run out of room to document the treatment history of a really complicated patient. I could type for ten minutes about the stuff I want the next clinician to know, only to discover that my keystrokes have been brutally ignored and rejected by the $#@!J$#* healthcare interface.
I am a geek. I want my machines to obey me. Instead, I am forced to let the machine convert my prose into categories, to shave off the nuances and color and "flavor" of the people I treat, all because the system is designed by engineers rather than clinicians. I am peppered by little popup warnings about contraindications and medication interactions that only occur in one out of every 10,000 people. I have ignore these so regularly that I fear missing the one that might truly be dangerous.
Will the benefits of a national health information system outweigh the risks? Better yet, will doctors be able to use them without wanting to smash a keyboard over somebody's head? Only time will tell.
So, that's my take on the 'con' side of the national information system. I'll leave to Roy to be the 'pro'.
Tuesday, January 26, 2010
Today (Tue Jan 26) at 12:00 noon Eastern Time, Gregg Masters (@2healthguru) will be interviewing Dirk Stanley, Tim Sturgill, and me about Flower on BlogTalkRadio. Flower promulgates the message that we should control our health data and have universal standards for sharing it.
Here's the blurb about it that Gregg wrote for the hour-long live show on BlogTalkRadio:
What is flower? At this time it’s an abstraction — a placeholder for several concepts centering on what would healthcare look like if....? And, more specifically what would personal health information (PHI) look like if....? A flower was chosen as the abstraction because it is easily and universally understood, regardless of language, anywhere in the world — a flower is a flower. Where a flower is flower carries the additional abstraction that there is a common ground — characterized by property and implementation. While a fluid and dynamic idea, this informed panel will provide both history and context for its genesis and diverse unfolding narrative. Join Dirk Stanley MD, @dirkstanley, http://twitter.com/dirkStanley, Tim Sturgil MD, @symtym, http://twitter.com/symtym, and Steven Daviss MD, @HITshrink, http://twitter.com/hitshrink, as we discuss Flower's granularity and transformational potential to make sense of a complex and moving target: informatics, health care and the patient. For additional context and insights on 'Speak Flower' see: http://speakflower.org/, and the threaded discussion on Howard J Luks, MD, blog: http://hjluks.posterous.com/thinking-about-flower-a-concept-is-born-hcflo
Monday, January 25, 2010
We've been quibbling about a title for our book-to-be for over a year now. We've used a working title of Off the Couch: Three Psychiatrists Discuss Their Work. Clink and I like it, Roy hates it, our editor cringed and changed it to Off the Couch: How Psychiatry Works and How Psychiatrists Think. We've toyed with everything from Beyond the Couch, to Psychiatry Demystified, to Set the Couch on Fire. Then HappyOrganist suggested Behind the Couch in one of the comments. Behind the Couch--- I like it, it has the whole behind the scenes connotation. Oddly enough, Roy liked it. Roy liked it. Wow. It's the first title that all three of us have been able to live with. Editor says "we'll see." She obviously didn't love it. So for the moment, our working title is : Behind the Couch: Three Psychiatrists Explain Their Work. Thank you HappyOrganist!
So I want to know: do you like this title? I know it's a complicated question, there's "do you like it" versus "would you buy it?" versus "would you pick it up in a bookstore" versus "Yuck!" So I'm just going to ask as a yes or no poll. Please vote and thanks for your input.
Okay, picture this: I'm sitting in front of my desktop computer. Swivel to the right and my laptop is there. On the desk in front of me is my cell phone on which I'm arranging a meeting via text message. My left shoulder cradles a phone against my left ear(my home line) where I've been on hold with Medicare for the last 10 minutes because I want to talk about details of the 27 page form that I need to fill out for my office change of address. My left hand holds a second phone (my fax line) to my right ear -- I'm on hold for an insurance company where I'm hoping to talk to someone to help a patient get reimbursement even though I'm out-of-network. My right hand types this blog post. I may explode but I won't have gone down without trying.
Friday, January 22, 2010
Thank you all so much for your input on my Intrusions post. I'm going to sit with the chapter and your comments and try to get it all put together. Soon. I hope.
So I want to talk about a weird social situation. I have to confabulate this one, you'll bear with me and not get too involved with the details, because they aren't real.
There's this woman I know sort of vaguely. We've had a few conversations over the years, and she has always greeted me very warmly. We were never friends, but I like her, and like I said, the vibes between us were good. She called me at work one day and asked if I'd treat one of her family members. She's not a friend--- I said yes-- but I did make the comment to Family Member that I knew Warm Woman and asked if this was a problem. It wasn't. I saw the family member for a while, the treatment was successful and Family Member has left treatment with the understanding that my door remains open. Nothing that was said in the therapy changed my opinion of Warm Woman....Family Member cherishes her and didn't reveal any skeletons in any closets.
Yesterday I went to a small event for a group I belong to. Warm Woman was there, seems she's also a member of this group. She ignored me. I followed suit and did not approach her-- seems as the relative of the patient, it's her call. And I do know she's been in treatment herself, and that she understands all about boundaries. It felt weird though. I wanted to say Hi, and I wanted to tell her to give my regards to Family Member who has not seen me for a while. I almost felt like I was in the room with my own uncomfortable patient, but Warm Woman was never my patient. I even wondered if I should drop out of the group, but I like going, and I joined, in part, at the request of someone else in the group, someone who has no idea this interaction is happening.
Just thought I'd share a day in the weird life of a shrink.
Wednesday, January 20, 2010
I'm working on a chapter for our book. I still like either Off the Couch or Beyond the Couch for a title. Roy wants to name it Set the Couch on Fire. And he's not kidding. What do you think?
Okay, so the current chapter is on real life intrusions-- things that impact care, for better or for worse, in ways we may or may not really understand. So stuff external to the actual treatment. Some examples are--- Money/fees/ not showing up for appointments/ Violence (how does it impact care if you have a suicide attempt? If you threaten or assault your shrink?/ assumptions people make about their patients or shrinks/ drug company influences/ and the media portrayal of psychiatry. A lot of the chapter is about money and insurance companies and fees.
Are we missing anything? The chapter is short---still waiting for Clink to write about violence, still waiting for Roy to chip in. And really, this isn't a real entity in psychiatry, it's something to draw together some unrelated stuff we wanted to talk about and make it cohesive. So is there something you want to know about that might intrude on care?
Tuesday, January 19, 2010
The timing couldn't be more perfect for an article in the New York Times on the genetics of compulsive behaviors in poochies.
In Scientists Find a Shared Gene in Dogs with Compulsive Behavior, Mark Derr talks about the work of Dr. Nicholas Dodman on doberman's who compulsively suck their flanks (hmm, what exactly does that mean?) and a genetic link:
Dr. Dodman and his collaborators searched for a genetic source for this behavior by scanning and comparing the genomes of 94 Doberman pinschers that sucked their flanks, sucked on blankets or engaged in both behaviors with those of 73 Dobermans that did neither. They also studied the pedigrees of all the dogs for complex patterns of inheritance. The researchers identified a spot on canine chromosome 7 that contains the gene CDH2 (Cadherin 2), which showed variation in the genetic code when the sucking and nonsucking dogs were compared.
Should ClinkShrink be worried? Might she adopt a dog with a psychiatric disorder? Should her would be pup have genetic testing? Derr goes on to write:
Recent rough estimates by Dr. Karen L. Overall, a veterinarian specializing in animal behavior at the University of Pennsylvania School of Medicine, suggest that up to 8 percent of dogs in America — five million to six million animals — exhibit compulsive behaviors, like fence-running, pacing, spinning, tail-chasing, snapping at imaginary flies, licking, chewing, barking and staring. Males with the problem outnumber females three to one in dogs, she found, whereas in cats the ratio is reversed.
Ah, but it's not just the poochies with this problem: other critters have compulsive behaviors, and treatment is available. Mr. Derr tells us:
Other domestic animals, notably cats and horses, as well as some of the animals at zoos, exhibit compulsive behaviors, including wool-sucking in Siamese cats, and locomotion disorders like stall walking and weaving in confined horses and pacing in captive polar bears, tigers and other carnivores used to ranging across large territories.
Although antidepressants, particularly selective serotonin reuptake inhibitors and clomipramine, a tricyclic antidepressant, and behavior modification have proved effective at controlling compulsive behavior in dogs and people, they do not appear to correct underlying pathologies or causes, Dr. Ginns said. Those causes are likely to be as varied as the compulsive behaviors and as complex as the interplay of multiple genes and the environment.
Here's the thing:
1) ClinkShrink is allergic to critters and has felt much better since the deaths of her beloved kitties, Elavil and Prozac (aka Zac and Elli, and yes, this was their names).
2) ClinkShrink doesn't want a puppy, or any critter for that matter.
3) A dog would cramp Clink's away-we-go to rappel ourselves down steep cliffs and climb things no one was ever meant to consider climbing.
So why would ClinkShrink get a doggy?
1) A member of her household desperately wants one. Really really badly.
2) They make hypo-allergenic pooches, don't they?
3) She loves my dog Max and takes wonderful care of him when I'm away. (And funny, we've never heard her sneeze).
4) They are sooo cute.
5) Dogs add a dose of passion to life, and passion is good.
Well? What do you think? The puppy in the pic is Roy's, by the way.
Saturday, January 16, 2010
I had this dream last night that begs to go on the blog, so here I am.
I was walking down the street with ClinkShrink, and Roy was with us too, but walking a bit slower. We came across a body in the road, face down, and we went to help, Clink and I right there at the scene. It was a woman, and someone else was there, looking for a pulse. She moved, and then she got up. I asked a few medical questions, and we decided it was okay to leave. Roy thought I should have asked different questions.
Then we were in Boston. We'd flown and I had to get back the same day. I asked Roy if he'd bought my ticket, since I hadn't bought it myself and thought I might owe him money. He hadn't. I also didn't recall ever seeing a boarding pass---how did I get on the plane?
We were at a meeting and there was another psychiatrist there as well as some of my neighbors. I sat down and tried to figure out how I was going to get back to Baltimore that day. I pulled out my iTouch and tried to download an AirTran App.
By the time I'm dreaming about i-Anything apps on vacation, well that's when I know that Roy has gotten to me.
Thursday, January 14, 2010
So I'm writing a blog post when I should be packing. Hours before departure, I asked my husband if they speak English where we're going and he asked me if we can use American dollars. And off to Google we went (:: yes and yes). He's confident he'll be able to watch the Ravens' playoff game which is good----one of the reasons we had so much trouble organizing ourselves over the holidays was that he had Ravens' tickets and there was a push of resistance against leaving town.
Arg! Blogger won't let me put a photo in! Oh, and please do encourage Clink to get a puppy.
Roy and ClinkShrink will hold the fort. See you next week!
Wednesday, January 13, 2010
David B. Goldstein
Over the past decade, powerful genotyping tools have allowed geneticists to look at common variation across the entire human genome to identify the risk factors behind many diseases. Two striking findings will define the study of disease for the decade to come. First, common genetic variation seems to have only a limited role in determining people's predisposition to many common diseases. Second, gene variants that are very rare in the general population can have outsized effects on predisposition.
For example, rare mutations that cause the elimination of chunks of the genome can raise the risk of diseases such as schizophrenia, epilepsy or autism by up to twentyfold. Some researchers view these major risk factors as aberrations. My guess is that as more genomes are sequenced, many other high-impact risk factors will be identified.
If so, here's one confident but uncomfortable prediction of what personalized genomics could look like in 2020. The identification of major risk factors for disease is bound to substantially increase interest in embryonic and other screening programmes. Society has largely already accepted this principle for mutations that lead inevitably to serious health conditions. Will it be so accommodating of those who want to screen out embryos that carry, say, a twentyfold increased risk of a serious but unspecified neuropsychiatric disease?
Some advances will be relatively uncontroversial, such as the development of tailored therapeutic drugs based on genetic differences that are otherwise innocuous. Others will be transformational, such as the identification of definitive genetic risk factors that provide new drug targets for conditions that are often poorly treated such as schizophrenia, epilepsy and cancers. Over the next decade millions of people could have their genomes sequenced. Many will be given an indication of the risks they face. Serious consideration about how to handle the practical and ethical implications of such predictive power should begin now.
Tuesday, January 12, 2010
Mental healthDaniel R. Weinberger
Senior investigator, US National Institute of Mental Health
The search over the past decade for genes behind mental illness has led to the realization that mental disorders are not discrete conditions with specific causes. Rather, they are the result of interactions between risk factors that affect development; psychiatric symptoms can arise from many causes and are more interrelated than current disease models allow. By 2020, this insight, which has been slow to take hold, will have transformed how doctors understand and treat psychiatric conditions.
Finding specific genes for mental illness now seems a pipe dream. A more realistic endeavour for the next ten years is to look for genes that code for basic cellular and brain functions that modulate our responses to the environment and that come together in particular ways in individuals at increased risk. Many hundreds of genes may contribute to raised vulnerability, and such defects may affect brain development and function independently of any specific psychiatric diagnosis. There is no straight road to psychiatric illness, but a highly diverse network of developmental pathways.
This approach will lead to diagnosis and treatment based on a proper grasp of the underlying biology, rather than on an interpretation of symptoms. Psychiatric research is poised to realize Sigmund Freud's dream of a biological psychology, but it will require new applications of old thinking (see also page 9).
Monday, January 11, 2010
I've moved. You know that. The new office is terrific, shabby chic walls and all.
So I'm working on the whole change-of-address thing. I've notified the post office, the bank, sent a zillion notices out. I've notified my malpractice insurance agent so many times that he called to tell me he changed my address weeks ago and I keep notifying him. I called the Controlled Dangerous Substance folks in my state. It costs $50 to notify them of a change of address. What gives with that. And the DEA...no forms, I tried emailing, I guess I'll send a real letter. The hospital gave me a local number, but it's out of service.
And Medicare: have I mentioned the 221 downloadable forms and how to change your address you have to fill out the 27 page enrollment form? I did? I guess I did.
Did I mention that I'm a non-participating Medicare provider? I don't want to 'enroll.' I finally tackled the form, figuring it would have a box at the end where I could check off that I'm not a participating provider....since I have not 'opted out' ...I'm actually participating by not participating. Try explaining this all to a distressed patient.
I surrender. Tomorrow, I'll try calling. I will no longer be blogging. I anticipate the next year of my life will be on hold.
If you have any answers, by all means....
...about The Reasons to go on Living Project, based at St. Joseph’s Healthcare Hamilton (ON, Canada): We are collecting the stories of people who have attempted or seriously contemplated suicide but now want to go on living. The project will study and share these anonymous stories for research, education and inspiration.
Sunday, January 10, 2010
In today's NY Times Magazine, Ethan Watters discusses cultural influences in the etiology and expression of mental illnesses in his article entitled "The Americanization of Mental Illness." Watters is not a big a big proponent of the idea that psychiatric disorders are brain-based diseases, and he points to ways that Western ideas have changed the incidence and thinking in other parts of the world. Watters writes:
Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world’s psyche, and applying it around the world represents simply the brave march of scientific knowledge.
Of course, we can become psychologically unhinged for many reasons that are common to all, like personal traumas, social upheavals or biochemical imbalances in our brains. Modern science has begun to reveal these causes. Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Those stories, whether they tell of spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways. In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.
Watters then goes on to ask if the medicalization of mental illness does in fact lead to destigmatization. He cites a study where college students give bigger shocks to test subjects trying to learn a new task if they believe the test subject has a mental illness caused by a biological problem rather than a childhood problem. I'll skip even thinking about this study, but why do so many studies have college students shocking each other? Shouldn't they just hit each other with baseball bats?
Watters goes on to conclude:
CROSS-CULTURAL psychiatrists have pointed out that the mental-health ideas we export to the world are rarely unadulterated scientific facts and never culturally neutral. “Western mental-health discourse introduces core components of Western culture, including a theory of human nature, a definition of personhood, a sense of time and memory and a source of moral authority. None of this is universal,” Derek Summerfield of the Institute of Psychiatry in London observes. He has also written: “The problem is the overall thrust that comes from being at the heart of the one globalizing culture. It is as if one version of human nature is being presented as definitive, and one set of ideas about pain and suffering. . . . There is no one definitive psychology.”
Friday, January 08, 2010
I like Facebook, kinda sortof. It fits in well with my life as a voyeur, and I get to participate. My friends are my friends (those on FB), I have some random people there--like a carpool mom I don't really know, and I have a lot of elementary/high school folks, some of whom I've found, and some of who have found me.
So some of these people who want to be my friends are high school folks I don't remember. Okay, maybe the name is familiar, or maybe it's not. They have all the same High School friends in common and they live where I grew up, and hey, who wants to hurt anyone's feelings, so I've confirmed pretty much anyone who asks. Why not? I'll tell you why not, because some of these people play all these games on Facebook (Farmville and Bejeweled are particularly popular among my peers) and who cares if they got a new animal? But every time I sign on to FB, my news feed is filled with their scores. Fat Doctor---Oh, she's the best, but I took her feed off my FB page, though we still remain friends.
I decided to Unfriend the people I don't know, don't remember, and who fill up my news feed. FB doesn't tell you if you're "un" friended, right? Only I unfriended some stranger and two days later I got friend request from her, again! No No No No! Go away! Go play Farmville!
You know, I am too old for this stuff.
Wednesday, January 06, 2010
From the LA Times Blog: "Depression Treatment Lacking For Many People"
The post refers to a study in the Archives of General Psychiatry and notes:
Treatment for major depression is abysmal, according to a study published today in the Archives of General Psychiatry. In a national survey of 15,762 people, it found that only half of all people with depression received treatment. And among those who did receive treatment, only 21% were getting care that is consistent with American Psychiatric Assn. guidelines.
Researchers at UCLA and Wayne State University found that nearly 45% of individuals with depression received psychotherapy with no medication. Only 34% received antidepressants. African Americans and Mexican Americans were prescribed antidepressants a third less often than whites.Oh, I'd like to read the full article in the hard copy, but my journals have so far not reached my new office.
The LA Times piece goes on to talk about how more psychiatrists are using antidepressants in combination with second generation antipsychotics, and is critical of this practice. Seems like an entirely separate issue to me:
In another study, also in the Archives of General Psychiatry, researchers found that a growing number of Americans are being prescribed combinations of antidepressants and antipsychotic medications even though there are few studies that support the benefits of such combinations.
The study examined prescribing data from 13,079 psychiatry office visits between 1996 and 2006. Researchers found a growing trend in the use of more than one psychotropic medication, such as combinations of antidepressants and sedatives, antidepressants and antipsychotics or two different antidepressants.
On a separate note: Happy Birthday, Ross!
Monday, January 04, 2010
It's the typical shrinky line, so I'm using it to introduce a new website on Mother-Daughter relationships (and all their angsty stuff). Check it out at Motherrr.com ! Ah, the site is run by my sweet Cousin B and her friend, and no, they aren't shrinks.
I'll leave it to Clink to tell you about the Shrink Rapper holiday dinner last night at Mr. Rain's Fun House. Oh, why not: I threw red sea salt at Clink and Roy ate a gourmet dog biscuit that Clink had brought from the Ben & Jerry's store in Vermont. The food was good, too. Purple soup and cotton candy baked alaska, anyone?
Saturday, January 02, 2010
I sometimes feel like I keep my life compartmentalized (home, family, work, blog, book, friends, chocolate, etc) , and I suppose that works for me. I've been on vacation the last couple of weeks and, you know, the world kind of stops in December-- in a good way-- but I actually do better when life is a series of goals and tasks, and I get restless without an agenda, especially if I feel like I'm supposed to be vacationing. Funny, but I really like vacation better when I go away, put down the laptop, and my connection with my real life is severed. I have a wonderful house and terrific friends, but getting away is crucial. And it's hard to feel like it's vacation with an office move and 27 pages of Medicare forms that I haven't filled out (and won't do on vacation).
The last couple of months, I've felt over-extended and things have slipped. I don't exercise the way I usually do, I haven't been working on the book, I get ideas for blog posts but they just kind of fester and never really form, I want to resume the podcasts but there some issue with a cable and everyone's new laptops. And Clink is skiing down some mountain (soon to return) and Roy says all his docs have quit and we'll never see him again as long as we live except for tomorrow night at the Shrink Rapper holiday dinner. I suppose which ever one of us spills something stinky on ourselves will be the one to write about it. Oh, organizing fun food events has been the one thing I'm not feeling fuzzy about. I still do that well.
So the new year. Do you have any resolutions? I don't have resolutions, but I do have plans to get sequentially refocused. The move is done (that was a big one). My obligations to our professional society will resume at the beginning of the week, I go back to work, there's the book to write, my plans to commit myself to some form of daily exercise, and I do miss our podcasts (especially the chili). Okay, I'm rambling, but that's what I meant by feeling fuzzy.