Monday, February 28, 2011
Sometimes, I treat people who have the same problems I have in my personal life. It's hard. Oh, it's really hard. If I'm really distraught about something and a patient calls seeking treatment with a similar life circumstance, I will sometimes turn them away and recommend another shrink. But I don't always screen so carefully on the phone, and often "I'd like to make an appointment," will simply get a time and date.
The feelings get really complicated here.
If I feel I've had a role in creating my circumstances, then I wonder as my patients seek my counsel, Who am I to be making any suggestions, much less giving advice? Why are you looking to me, I've screwed up the same situations. Oh, you say, Dr. Jeff said on KevinMD that Psychiatrist's Shouldn't Give Advice, but you know, some of us do, and even when we don't, our feelings are often relayed through the questions we ask or the comments we make or don't make, or perhaps by the expressions on our faces, even if we don't say "You should do X." I told a friend once that I feel uneasy, guilty even, in these situations, and he replied, "How do you think I feel?" Did I mention he does family work and was in the midst of a stressful divorce? And I have yet to ask a colleague who also does family work how he managed during the years his own children wouldn't speak to him. Oy, life can be tough, for shrinks just like everyone else.
So perhaps I listen to someone talking about his most personal feelings about a situation, and you know, if I've been there before, perhaps it's good that I can empathize. If I'm in the middle of it, sometimes I listen and the patient's words seem so unreasonable, so unjustified, and yet I recognize them as being exactly my own--it's like having my own anxieties bounced off a wall only to ricochet straight back into my face.
Do I tell the patient that I've been in the same place before? Generally, no. Therapy is about his problems, not mine, and I think in these situations my empathy is clear. I say things that are more poignant and resonant than I might in circumstances where I feel removed. And patients never ask if I've been in the exact same place. On some of the harder things-- things that have no precise quick and easy answer-- I've taken to saying, "Not only don't I know what will fix this, I don't know anyone else who does have the answer." This I can say because I've done my own searching.
I hope I'm reassuring and comforting to people who find themselves in the same places I dwell. Certainly, tripping over a few stones on the path makes one walk a little more gingerly and judge a little less harshly those who walk more slowly. Mostly, though, I worry that I'm a little bit of a fraud just for being in the room.
Thursday, February 24, 2011
Ben is an expert on Deep Brain Stimulation. We like him.
I read today that Eastern Ontario has started a bed registry to keep track of where open psychiatric beds are available. This is something I've long advocated. The United States now has less than 10% of the beds it used to have 50 years ago. Granted, treatment has improved and community resources are enhanced. But there are still areas that often do not have a sufficient number of hospital beds for folks needing acute inpatient psychiatric care.
The Ontario story described in the Ottawa Citizen states that six of the area hospitals have been connected to a computerized "bed board" that provides real-time information on who has an appropriate bed available. This saves time in the ER and gets patients to needed treatment more quickly. Otherwise, calls need to be made to each individual hospital, which is very time-consuming.
And it is not uncommon for all the beds to be full. Last July there was an EMTALA complaint against a hospital in Maryland because a patient sat in the ER all weekend, and this hospital said they had no beds to admit the patient to. The Department of Health and Mental Hygiene investigated the complaint and found that, indeed, the hospital was full that weekend. The ER's record indicated that all the hospitals (except the state hospitals) were called that weekend and all indicated their beds were full. So, DHMH visited every hospital (about 28, I think) thinking that surely one of them had an empty bed they were hiding. What they discovered was that every single psychiatric bed in the state was full.
Unfortunately, we have no way of determining how often this happens, but we know if happens often enough. A "bed board" like this would be very helpful in (1) quickly finding beds when needed, and (2) keeping track of the extent of this problem. Having patients wait in ERs for days is unsafe and is even discriminatory. How many people with stroke or uncontrolled diabetes sit in ERs for days waiting to find a bed for treatment? I'd like to hear others' thoughts on how this problem can be addressed.
[Note: my apologies to our readers for not blogging or commenting much over the last year or so. I plan to be more engaged again in Shrink Rap going forwards. I'll never talk as much as Dinah does, but I'll get some words in :-]
Tuesday, February 22, 2011
KevinMD has a post up today by Tobin Arthur called
Arthur also refers to a post on the AMA's website back in October by Amy Lynn Sorrel,
Good timing because I wanted to post a vignette about a friend who is distraught about the on-line reviews he's gotten from patients. To protect both the innocent and the guilty, I'm confabulating the details & demographics, but the gist of the story is real and I'd like to hear your comments.
Dr. Tom Shrinky (not his real name) is a friend of mine who practices in Sanetown, PA (not a real place). He's an excellent psychiatrist with a great reputation, a packed practice with a long wait for new patient entry, and he's as conscientious as they come: he carries his cell phone everywhere and he returns all calls within the day. Plus, he's a nice guy, though I may be biased because we're friends.
One day, a patient says to Dr. Shrinky, "Doc, you know, I Googled you, and it wasn't pretty." Alarmed, Tom goes to Google himself and discovers that he's got a patient review up on one of these rate-your-doc sites. The comments are strangely personal, they comment on his recent weight loss, and say that he's in bed with the drug companies. There are a couple of other reviews, all 5 star, all saying how he's the best shrink in the world, but his overall rating is 3 star, and you'd wonder if he wasn't dying from the comment.
Okay, you hate a restaurant, you zing it on Yelp and you don't go back.
But Tom believes he knows who put these comments up. He has a patient, a lawyer he sees for weekly psychotherapy sessions. The patient is often hostile towards him, often treats him in a demeaning fashion, and this relationship does not feel good. The patient left treatment once briefly, years ago, but returned because, "You shrinks are all nuts and you're better than Dr. Cashew." Why Tom took him back, I'll never know. Tom tries to get the patient to focus on his hostility as part of the treatment.
So, a drug rep did stop by the office once to drop off samples while the patient was in the waiting room, and the patient had made a comment about this. And Tom had lost a lot of weight recently-- he'd taken up running and before he knew it, he was doing half-marathons. He cut back on carbs, beer and soda, and 60 pounds had dropped off him over 14 months. He looked great, and everyone commented including his patients. This particular patient, however, had said nothing, and one day walked in, looked Tom up and down, and said, "Have you got cancer or AIDS?" So the comment on the review about how he'd lost a lot of weight recently and looked like he had cancer. Tom could think of no one else who was unhappy with him or who would do this.
Unlike the restaurant patron, Tom's patient continues to show up weekly for psychotherapy. Tom feels a bit intimidated by him (this is not new) and is always happy when he cancels. So far, Tom hasn't asked if he wrote the review, but it bothers him. Others have put up counter-reviews, but there is a second bad review, and Tom thinks this is also the same patient. A colleague mentioned that a patient he tried to refer would not see him because of the reviews.
So, my thoughts, and then please do add yours:
--It seems to me that sometimes people have negative feelings in the course of a psychotherapy (ah, we might call this transference, but it would be dismissive to attribute all negative feedback to negative transference). In this case, it's no longer a doctor-patient issue, but one that has potentially included the entire world via the Internet.
--Should Tom ask his patient if he's put up the reviews? What does that get him? The patient may become embarrassed or defensive, or he may say he didn't do it (and maybe he didn't?) and be angry at the accusation.
--How does a psychiatrist (or any doctor) continue to treat someone who publicly struck at their reputation?
--And here's another problem for the doc--- a patient who would do this might also go to the physician licensing board and complain, and so Tom may worry that to terminate this patient's care may incite the patient's anger and result in a complaint and investigation of his practice. The patient is a credible professional and a complaint from him would likely be taken quite seriously. While Tom is certain he's provided responsible care and has not violated any standards of practice, he's well aware that a Board investigation (if a complaint did progress to that) takes years and causes a great deal of expense and agony, and so he may well be worried about fanning any flames.
--And finally, Tom is worried about upsetting the patient. He's been taking care of this patient for years, and he doesn't want this to end badly.
So what should Dr. Tom Shrinky do?
Monday, February 21, 2011
Sunday, February 20, 2011
In yesterday's New York Times, Alan Schwarz wrote about the tragic suicide of football player Dave Duerson this past week. Schwarz notes that prior to shooting himself, Duerson texted family members that he wanted his brain examined for Chronic Traumatic Encephalopathy, a condition we've discussed before in our post Brains, Behavior, and Football.
Doctors, N.F.L. officials and even many players denied or discredited the links between football and such brain damage for months or even years. The roughly 20 cases of C.T.E. that have been identified by groups at Boston University and West Virginia University were almost always men who had died — most with significant emotional or cognitive problems — with no knowledge of the disease. Now, for the first time he knows of, Stern said, a former player has killed himself with the specific request that his brain be examined.
I'm left to wonder, did this former football player have this problem? Sometimes depression alone causes memory problems and sometimes people with depression worry that they have Alzheimer's disease, or any number of other illnesses for that matter. Treating the depression may help the memory problems, and may alleviate the fears of other illnesses. And we don't know much about the Chronic Traumatic Encephelopathy induced by repeated head injuries: is the course of the dementia altered by early intervention with medications? Does the depression respond to the usual treatments for mood disorders? Could Mr. Duerson have been saved, at least for a while?
Here's an article on the treatment of chronic brain injury with hyperbaric oxygen in animal models:
And here's an emedicine article on treatments for repetitive brain injuries (not necessarily specific to CTE) with medicine recommendations, but no mention of antidepressants or medicines to slow the course of dementia:
Here's a medscape article on CTE and dementia:
And, finally, here's a shout out to my friend and med school classmate Robert Morrison, M.D., Ph.D. whose paper for our public health class was published in JAMA back in 1986 as a state of the art review of boxing and brain injury: http://jama.ama-assn.org/content/255/18/2475.short
Is it worth it in the name of sports?
Could I ask a huge favor of the next football player who considers suicide? Instead of completing the act, could you have your depression treated and then write about the results? It would be an enormous contribution. Sure, it would be an anecdote, and not a controlled trial, but perhaps it would add something to the field. And we'd be happy to publish your story here on Shrink Rap.
My heart goes out to the family of Dave Duerson.
Clinical Psychiatry News sends out 40,000 tabloid newspapers a month to the nation's shrinks. Last week they launched a website with news feeds, on-line versions of their columnists' stuff, podcasts, videos, and more. Check it out at http://www.clinicalpsychiatrynews.com/home.html
Thursday, February 17, 2011
In today's New York Times, David Tuller writes about a study that shows that psychotherapy is an effective treatment for chronic fatigue syndrome. In Psychotherapy Eases Chronic Fatigue, Study Shows, Tuller writes:
The new study, conducted at clinics in Britain and financed by that country’s government, is expected to lend ammunition to those who think the disease is primarily psychological or related to stress.
The authors note that the goal of cognitive behavioral therapy, the type of psychotherapy tested in the study, is to change the psychological factors “assumed to be responsible for perpetuation of the participant’s symptoms and disability.”
In the long-awaited study, patients who were randomly assigned to receive cognitive behavioral therapy or exercise therapy, in combination with specialized medical care, reported reduced fatigue levels and greater improvement in physical functioning than those receiving the medical care alone — or getting the medical care along with training in how to recognize the onset of fatigue and to adjust their activities accordingly.Interesting. Generally, I like to stay away from the "it's all in your head" debates. I'll let our commenters do the talking here.
Tuesday, February 15, 2011
As our publisher was designing the cover for our book, we put in a request. We'd like a duck on the cover. No Duck, we were told. As we dusted ourselves off, our editor came back and said the design department had agreed to put a duck on the spine of the book. We rejoiced! Here and there, Roy would mutter about the duck. Remind them, don't let them forget about the duck. As the cover was finalized and the galleys were finished, we received a note from our beloved editor. Are you sure? Of course! People will think you are quacks. But we're not quacks, anyone who reads our book will know that. Roy was convinced that it would add to the idea that this isn't just another dry reference textbook, it's an easy to read, ducky kind of book. I thought a little duck would be fine. Our editor sent the picture of "our duck:Now let me tell you.
I did not like this duck.
I did not like this duck at all.
The duck had long lashes, looked way too happy for a psychiatry book, and looked like a toddler's bath toy. We're shrink rappers, but we don't squeak! Oh, and we're not quacks.
Here is the duck I wanted. Very small, very subtle. Think of the penguin logo for Putnam Books.
Only think of it as a duck. Here is the duck I wanted. Our editor agreed, I think, that it was a better duck:
And happy with our duck (though ClinkShrink thought the first duck with the flirty eyelashes was fine)... I get an email from the marketing department. It is a very serious email about how well they think our book will do, and how packaging is important to the overall product. The upshot: there will be no duck. Our opinions were not wanted, the duck was gone, it was a done deal.
Oh, the duck would have been just fine....
Monday, February 14, 2011
My mother and father and the dreaded psychiatrist definitely believe I am schizophrenic.
Now here's a Shrinky book I haven't read. Or at least not yet?
In yesterday's New York Times Book Review, Darin Strauss reviews a father-son memoir by Patrick Cockburn and Henry Cockburn. Henry's Demon's is the story of Henry's battle with schizophrenia.
Did Strauss like the book? I couldn't say. He spent a fair amount of time picking apart the writing of the father/war correspondent. I think he wished the son of a novelist had become schizophrenic for the sake of fewer cliches.
What about Amazon, how do it's reviewers feel? No reviews yet. If you read this book, by all means, tell me what you think! Here's the father-son dual on the Diane Rehm Show if you'd like to listen to their tale.
Thursday, February 10, 2011
Oh, not really.
In this episode, we talk about parenting. Now why do we talk about parenting: this is a psychiatry podcast, did someone forget to tell us that?
We talked about parenting for a few reasons:
It started with the tie in between trying to understand how mentally ill people become violent and we mentioned the very poignant article that Susan Klebold wrote on Oprah.com called "I Will Never Know Why?" about her son's role in the Columbine shootings and the awful toll this has taken on her. Somewhere, as a society, we've decided that parents are responsible for how their children turn out, and parenting topics are frequently addressed by patients in psychotherapy. We hear from patients who feel wronged by their parents and from parents who worry about doing right by their children. Ah, if only we had crystal balls!
This led us to talk about Amy Chua, the Yale attorney who wrote Battle Hymn of the Tiger Mom and whose article "Why Chinese Mothers are Superior" in the Wall Street Journal has gotten everyone talking about parenting styles of the East versus the West. Is this a good thing or does it contribute to student suicide?
We also mentioned Dr. Richard Friedman's article from the New York Times, "Accepting that Good Parents May Plant Bad Seeds" and Susan Reimer's article in the Baltimore Sun, "Blame Jared Loughner's Parents--It's the Easy Way Out."
Mostly we talk about the uncertainty of it all and mention issues related to good-enough parenting, lousy parents who get resilient kids, and good parents who get lousy kids.
Thank you for listening. Please do write a review on iTunes!
Send your questions and comments to: mythreeshrinksATgmailDOTcom
Wednesday, February 09, 2011
Electroconvulsive therapy, or ECT, is considered to be a highly effective treatment for depression. The story goes that roughly 90% of patients respond. The down-side is that it requires general anesthesia with all it's attendant risks, and patients may suffer from headaches, and memory loss. The memory loss is often mild, but there are cases where it is profound and very, very troubling. As with any psychiatric treatment ---or so it seems-- there are those who say it saved them and those who say it destroyed them. Because the risks aren't minor, the procedure is expensive and often done on an inpatient unit, and people generally don't like the idea of having an IV line placed, being put under, then shocked through their brain until they seize, only to wake up groggy and perhaps disoriented with a head ached, it's often considered to be the treatment of last resort, when all else has failed. This makes the 90% response rate even more powerful.
I'm no expert on ECT. I haven't administered it since I was a resident and I don't work on inpatients where I see people before and after. I've rarely recommended it, and then I've been met with a resounding, "NO." My memory of it was that it worked, and that most people didn't complain of problems. One woman read a novel during her inpatient stay. I asked if she had trouble following the plot (ECT in the morning, novel reading in the afternoon) and she said no.
The FDA has been looking at the safety and efficacy of the machines used to perform ECT. It's a fairly complex story where the FDA advisory panel was considering whether to keep ECT machines categorized as "Class III" machines which would now require machine manufacturers to prove their efficacy and safety. A reclassification as Class II (and therefore lower risk) would not require this stringent proof.
On Medscape, Fran Lowry writes:
If the FDA decides to follow the advice of its Neurological Devices Committee, it means that the 2 companies that currently manufacture ECT machines would have 30 months to submit a premarket approval to show that the devices are safe and effective.
ECT has been in use since before the FDA enacted new, more stringent laws for device approval, and psychiatrists fear that the logistics of conducting new trials will pose insurmountable problems for the manufacturers.
They also doubt whether data from any new trial would be sufficient to convince a subsequent advisory panel of the efficacy and safety of the devices, long considered by the APA to be life-saving.
"It hasn't been yanked from the market right now," said Sarah H. Lisanby, MD, head of psychiatry, Duke University, Durham, North Carolina, and chair of the APA Task Force to Revise the Practice of Electroconvulsive Therapy.
"But the continued availability of this life-saving treatment in the long term lies in the hands of the FDA right now. We're pleased it wasn't taken off the market instantly, but if new trials are going to be required, it's not clear who will fund them and whether they will in fact even be done. This is the concern," she told Medscape Medical News.
David Brown has an excellent article in the Washington Post-- see "FDA panel advises more testing of 'shock therapy' devices."
(As an unrelated aside, since Roy claims that "everyone" is my neighbor , I'll mention that David Brown is also my neighbor. )
In surfing, I found a strong anti-ECT sentiment on many blogs. There were also those who said it helped them, but theirs was a quieter rant. I particularly enjoyed Electroboy's rendition of his treatment for mania.
If you have thoughts or stories, by all means....
Thanks to Bob Roca for the heads up on the FDA hearings.
Sunday, February 06, 2011
Sometimes in my real life it becomes obvious that a friend or acquaintance is having a problem. Either they are wearing obvious signs of mental illness or they just show signs of being 'stuck' in life or, worse, of moving backwards. Often they don't see it. I suppose there is the outsider's vantage point of making a judgment that may reflect my own value system and not their reality: to me, I may see someone who has family and job and connections who sees leaving those things as a healthy escape and their withdrawal as a good kind of comfort with keeping their own company. Usually these aren't my close friends, but what do you do when you notice that someone in your life is changing and might possibly benefit from help?
In general, I've found that "You need help" is not helpful. People hear this as an insult, not as a kind suggestion from a concerned friend. And from a psychiatrist friend it may be worse and easier to blow off---shrinks think everyone's crazy, they push drugs, they think everyone needs therapy, they see the world in a skewed way (at least this is how the commercial runs).
So I wondered: how do people let their friends know they need help in a way that inspires them to get it in the absence of a crisis? If you're in treatment because someone else suggested it, what enabled you to hear the suggestion without being wounded or insulted?
Friday, February 04, 2011
From yesterday's mail:
I work with FINS.com, a career resource site owned by The Wall Street Journal. We are launching a new national ad campaign starting this week. We produced a series of videos about failed job interviews and what “not to do” tips. The fourth video in the series called “Strengths” (at http://www.fins.com/Job-Interview-Tips) and is set to begin airing early next week. A couple of us over here enjoy . We thought that because the video is related to psychiatry, that it would be really cool to get your feedback and other reader’s feedback on the video prior to air date.
Thanks for your time in advance.
----So I watched the video and I thought, "Hey no one ever asks me to go their job interviews!" I watched a few of them: they are cute, and make a quick point, but you know, there is one with the tip Leave your Pets at Home. It shows a guy on an interview with a half dozen sweet dogs and cats, and I did wonder, "Well what about the support duck?" The Silence Your Cell Phone flick was so outrageous, but I don't doubt it happens at all. And Proof Your Resume....well maybe she should have gone with the flow when the interviewer was so impressed with her 'passion for finance' and not said she meant it to read 'passion for her fiance!'
So what do you think of the Strengths video? Are they poking fun of patients and shrinks, or is this something that has really happened and is it a valid tip? Yeah, it pokes fun, but so do all the others. Does it annoy you? Does it increase stigma? Is it cute with a reasonable point to make about how not to advertise one's weaknesses during a job interview?
Well those Wall Street Journal affiiliated folks want your input. Go for it!
Thursday, February 03, 2011
Thanks to Peter for bringing this article to my attention.
Have I ever mentioned that I hate forms? Oh, it's not just Medicare forms, it's all medical forms.
In private practice, there's not much paperwork. I see patients and I jot down a note for their charts. Sometimes I type a formal evaluation for their primary care doctor. Sometimes I need to fill out treatment plans or preauthorization forms for medications or forms for disability insurances. And these things are a pain in the neck, but most days there are no forms. I see patients, I turn off the phone, and I'm with them fully.
In the clinics where I've worked, the notes go on forms. There are simple questions to be filled out, nothing that exciting, but it pulls my attention. There's a line for the date. Oh, I do that anyway. Diagnosis. Usually I know that. Time I started. Oh, who cares? Usually I'm talking with the patient and realize I forgot that. I turn to look at the clock and record the time. First zap away from the patient. Age: ? I look at their birthdate. I subtract from the current date to get the year. Why do I have to calculate the age of every patient I see everytime I see them? There are computer labels on every page with the date of birth. If someone wants to know, why can't they do the math? Medical Diagnoses and Medications: I look that up. Date of last physical: ? I look that up or ask the patient. If it's been a while, I tell them to have a check up: Maybe that's useful, but every patient, every visit? I check the box that says they aren't suicidal and that I've discussed the risks and benefits of the medications and how often they come for therapy and what the goals are and if they are getting labs done. I update the medications on the log sheet and in the electronic record. I send a letter to their primary care doc listing their current psych meds: this is required even if their current doc is at the same hospital and can access the updated medications on the EPR. Time ended? I glance at the clock and record it. Duration of appointment: ....Oy, someone else can't subtract the minutes? I've taken to writing 17.3 minutes. Oh, and in there, there was lots of time to hear about the patient's life.
Okay, I'm ranting, but I felt vindicated when Peter sent us all Teresa Brown, R.N.'s article in the NYTimes Well Blog, "Caring for the Chart or for the Patient." Nurse Brown writes:
Because that’s my real concern: the effect on patients of incessant record-keeping. Each of these individual initiatives has merit and is worthwhile, but together they become a mishmash of confusing and oppressive paperwork.
Wednesday, February 02, 2011
Enough meditation. Let's move on to what people really talk about in psychotherapy: Football.
And no, I'm not kidding.
Here in Baltimore, the hype's died down as the fans remain catatonic. The purple lights have fadded and the only energy left is that which remains to cheer against the Steelers. Oh, something tells me that on Sunday, there will be lots of energy for Steeler hatred.
I don't really get it-- it's a bunch of too-big, way-too-old, guys in silly outfits chasing balls and charging at each other and they get paid millions to do this. I suppose it's an escapist thing, but I've learned never to say aloud that I don't get it, or worse, that it's just a game.
So SuperBowl Sunday, and the fans are psychiatric patients waiting to happen....the beer and the beer and the beer and maybe the fights will break out and they'll all end up on line to see ClinkShrink. Oh, and the angst and the panic, and the pre-game anxiety and the post-game euphoria/depression.
New York Times report Benedict Carey talks about treatment options in A Home Treatment Kit for Super Bowl Suffering. Mr. Carey suggests:
Breathing exercises are highly recommended and become increasingly important as the football contest nears the fourth quarter, when events on the field are likely to prompt strong physiological reactions, like a pounding heart, hyperventilation, even dizziness. These internal cues, as they’re called, can escalate the feeling of panic, a self-reinforcing cycle resulting in groans and cries that can be frightening to small children, pets and sometimes neighbors.
In the final minutes of the game, be forewarned: Many patients will move beyond the reach of therapy. Their faces may change, their breathing appear to stop. Researchers have not determined whether this state is closer to Buddhist meditation or to the experience of freefall from an airplane. All that is known is that, once in it, patients will fall back on primal coping methods, behaviors learned in childhood within the cultural context of their family.
Like emitting screams. Or leaping in an animated way, as if the floor were on fire. Or falling on their back and moving their arms and legs like an overturned beetle, in celebratory fashion.This post is dedicated to my husband and son.
Tuesday, February 01, 2011
On my post on meditation, Guzman from Montevideo, Uruguay left us a joke. I mentioned in that post that my mother took me to learn Transcendental Meditation when I was 10. Odd coincidence, but my mother also worked at the US embassy in Montevideo, long ago. Did you know her Guzman? It was many decades ago.
So I took Guzman's joke and I modified it to suit us three Shrink Rappers because it kind of suited our personalities:
Jiddu Krishnamurti telling a joke...
“There are three shrink rapping monks, who had been sitting in deep meditation for many years amidst the Himalayan snow peaks, never speaking a word, in utter silence. One morning, Roy one of the three suddenly speaks up and says, ‘What a lovely morning this is.’ And he falls silent again. Five years of silence pass, when all at once a bird flies over and pulls the duct tape off monk Dinah's mouth and she speaks up and says, ‘But we could do with some rain.’ There is silence among them for another five years, when suddenly ClinkShrink, the third monk says, ‘Why can’t you two stop chattering?”