-ve cognitive dump

I hope this all will end soon. 

I don't like being trapped in the car with emotions or silence that the other person can't tolerate.

I don't like not being at a fixed place each and every day. 

I don't like this. I don't like seeing a patient whose physical health is much more of a problem than mental health, and seeing him every month, more frequently than his GP will see him. 

I want to work with more competent case managers, or clinicians when I am on call. But I can't choose who I am going to work with. How should I carry myself?

2
Yesterday I felt very angry as I was dictated by an NDIS coordinator for the 2nd time on how to write a medical supporting letter. I refuse to hide or alter any diagnosis without clinical ground. I wrote the letter from an objective clinical view and no one should manipulate me into misconstruing a clinical picture of a patient for the purpose of funding. If the government decides to change the whole funding system, the inescapable can't be avoided. My job is to provide my medical opinion. I can't control how a NDIS coordinator manages the fund (nor am I interested in what they do with the it behind the blind). No irrelevant party should wrongly influence how I do my job either. This is the difference between an AI generated letter vs a doctor's letter. I refuse to write anything other than the truth within my knowledge. 

Searching in the rain or shine

Dear R,

I am searching for myself. V pointed it out directly a few times my lack of boundaries and assertiveness. I start to see it and feel it more recently, how ungrounded I am, as a doctor to the patients and as a doctor to my non-medical colleagues. I feel exhausted, when I feel stepped over and when I didn't speak up for myself, when I had too much hesitation in those moments and decided too quickly unconsciously to just let things be. I am unsure what kind of registrar or future leader or consultant I should and can become. I felt my racing heart, when I asked myself to be brave, to voice different opinion, to ask someone to come back 10 minutes later, to request the nursing staff to please do a set of vital signs now. These, are exhausting too. You once spent almost an hour to tell me I should not be a person who sit back and hide herself. Each small step of walking out of my shell, exposing myself to the world, is akin walking into incessant rain without an umbrella, walking under scorching sun without a protective shield.  But I am not some unimportant element in the background. Sometimes and many times people need my presence and direction. My growing knowledge, skill and experience, can be my umbrella and sun shield. My kindness and sensitivity, can still be part of me. I can't be you. I can't be the other female psychiatrists who carry some traits I admire too. I am unsure who I can be. I hope to find myself, one day perhaps in the future.

Talking to myself- why do I read

我1月读了Eleanor Oliphant is completely fine之后，就好像没有再持续读什么了。因为后来就开始intensively备考MCQ。

我的kindle下载了很多书。有些书我看了前几页，感觉内容不是我想看的。

我想看的故事，是轻松的，可以让我放松的故事。

我从去年还是前年开始都一直看日韩小说。这些是我喜欢看的简单的故事。

最近看完的The Curious Kitten at the Chibineko Kitchen，故事很像之前我看过的月亮灵魂故事（Lost Souls Meet Under a Full Moon; How to Hold Someone in Your Heart)。是淡淡的故事，每晚放工读一点的故事。不是page turner，也不会读得令人不耐烦。但整体也不很惊艳。读了大概就会忘记了的书。

我看了很多fiction。如果small talk时人家问我，我最喜欢的是哪一本，我大概也不会随手拈来说出一些书或作者名字。这让我reflect我看书是为了什么，根本没有让我好像变成有点厉害。我最近几年看书，是为了娱乐自己。

我最近在看的书是I am not a tourist- Conversations on being British chinese。久违地读起non-fiction，也是因为考完MCQ了成绩也知道了，脑袋终于轻松了一点。这是我感觉很interested的topic。但有点可惜的是内容原来都在说历史，而不是我想看的personal cultural experience。虽然那些历史对我来说是eye-opening的，也不会难读。这是一本重要的书，我想。

还有anxious generation的书，我最近上班commute时看。这本书的信息一开始就很明确清晰了。这本书的point有点repetitive。不属于享受着看的书。是那种我为了汲取重点，速读的书。

最后再说我最近发现，我为什么看书。是因为，我没看书的时候，也有很多无谓的restless mind。看书，至少让我的思绪有anchor，是一种regulation。

1st mid-term of Stage 2: Transient rainfall.

Another mid-term. This time I feel relief. 

I want this to be over soon. Which is a sad irony, I had felt so much anticipation for this rotation half year ago.

I love seeing the patients. I enjoy the clinical work which I won't get from elsewhere. I love feeling more confidence in doing community reviews. I am now more capable than I was even 3 months ago. I like how I will not regret this rotation, because of the clinical experience that is enriching my knowledge and skillset in psychiatry.  I am also consciously improving my interviewing skill.  

But it is also this rotation which made me realise I can't work in this kind of suffocating. controlling and implicitly condescending psychological environment for long. It reminds me, repeatedly, what kind of consultant/leader/superior I must not become and what kind of person I want to be. We can freely choose who we want to be, for ourselves and for the people around us, more so when we gain more seniority, confidence and power. I remind myself to stay kind and humble. You showed me how being kind and humble will not strip away our authority and power. It in fact does the opposite. The social power you exerted unknowingly, remains strong in your absence. 

当我慢慢学习抓着属于我自己的步伐，我也慢慢不再太想念你。

你的影子已经刻在我doctoring的每一刻。你教过我的interviewing skills，你会写的plan，你的clinical thinking，你对身边每个人的态度。

这条路，终究还是该我自己来。

谢谢你曾经来过。我不需要记得，不会想起，因为我不会忘记。那些大大小小的时刻，已经走进我心里，刻在脑里，化成我今后的每一个脚步。

Eaten up

The two Robina nights were quite fine. I only saw one patient and that was a favour done for a clinician. 

What you told me about assertiveness never left my mind. But each and every time my unassertiveness leaves unpleasant lingering marks in me, I understand again the feelings imparted in your words. Those seemingly insignificant mini moments do eat me away, the implicit disrespect from people, the intrusion of my boundaries be it in daytime work or on-call space. I realize I cant work this way for long, coming to a new rotation or shift to first assess whether my clinician colleagues are good and responsible workers. I remind myself that I'm a doctor, I'm the medical lead at night, I decide how the scene look like. Times that I did not exert myself and get my points across, things slipped off my control. I find myself sitting with my own thoughts after certain conversations are over and thinking it shouldn't have happened that way, or regretting switching my ground too quickly unconsciously just to agree with people. I need to remind myself that I do not come to work to please people, to want to get along with people and to be likeable. I should not apologize for not agreeing with certain views, or explain my views by lowering myself but rather to point out facts neutrally only. 

In my first two years of regging I was focusing on doing accurate assessments. In most shifts I was too busy dealing with acute clinical duties. I recently found the other more subtle issues. Working with different clinicians (and not letting their years of experience working in the same job which they take pride in dominates my clinical judgement), communicating with ED nurses/doctors (and to not let their claim of busy ED with trauma calls compromise the safety of our patients who also deserve good care, and to not feel small myself knowing that obviously the medical concerns of my patients are not as CAT 1 or 2 as the other ED patients but ain't they patients at the ED too) are things that I need to be good at. And to remind myself to know my position. I'm a doctor, I'm a psych reg, I'm the medical lead in the absence of consultants. I can't stop the weight of responsibility falling on my shoulders, the same way nobody can change the fact that they need to listen to me, because they have to. And I first, need to be sure of myself and my worth. 

"Congratulations!"

My husband sang congratulations to me every now and then since yesterday. I shared the news with H this morning, who shared his good news with me 6 months ago, together with his very useful exam tips and resources. I felt his genuine excitement for me across the screen. I often only feel more impact of certain good news from the reaction of others, their happiness for me. I did not feel the euphoria I thought I would have. I relayed the fresh news to case manager F, and then to my consultant V, both of whom seem genuinely happy for me.  The fact that I need to take note of the genuineness of their positive emotions on my behalf, signifies the insecurity and guardedness inside me. I slowly learned to accept love and kindness, as I too will wish for good for the other people and share their happiness. My harsh superego often restricts the joy I should feel and the immensity of any achievement in my life. I guess the answer is to stop expecting what I will never get from unavailable sources. I need to be self-sufficient emotionally. I am turning 30 next month. I can pave a different life with what I have now, and that include my past self who constantly enriches my resilience.

:)

Dear R,

I passed my MCQ exam :) 

In reverie and fantasy

Dear R, 

I had always wanted to ask, how does the deep reason of why we want to do psychiatry matter in our interactions with patients. How does our own anxiety, depression or narcissism matter? I found the answers in Gabbard Basic Text. You are right that it is an easy read (your comments are always accurate), unlike Sims which reads like an ancient text. You are right that it is everything you talked to me about in our supervisions. You have taught me the essence of psychodynamic theory. You have probably digested several different texts repeatedly, transformed them into your own understanding, applied it in your daily practice, and conveyed what you can to me within the limit of my knowledge. After reading Gabbard and then your written case, I am again in awe of your passion for psychodynamics not just in your mind but in practice with your graceful but not fluffily empty skill in weaving them into the biological core of psychiatry. While I am thinking to write that I am uncertain if I will grow to love psychodynamics as much as you do, I question my all-or-nothing idealisation of you and the introjection/identification of your traits that could possibly blind me to my own self, because clearly we are different persons despite our few similarities, as much as how I will still place you at an irreplaceable spot. During the reading I was reminded of the last day of our working together. You used an analogy of this being like a termination which I will learn more when I start doing psychotherapy. I used our last supervision to do another CBD to your un-expectation.  

"The fantasy of the ever-available therapist has to be mourned. The reality that our relationships are ultimately transient must also be faced." and I always know that. But the more I read the text, or the more I attempt writing psychodynamic formulation at work, the deeper your influence prints in my thinking, doing and being. I always take time to warm up, to trust and to move on. This time I might need 4 years. 

April: quarter-way

Dear R, 

I have not written for some time. I have been taking time to rest (my sick body forced me to). I have completed the Critical Thinking modules (I think I only have gained minimal critical thinking skills). I am anxious about the possibility of failing the MCQ exam. At the same time, I have a lot of worries about my other assessments and the uncertainty of my CL rotation next year. Will it ever stop?

My husband successfully passed his written exam with joy and relief. He is now getting ready for his clinical exam. We are both sick now though. Before he got really sick, we managed to spend the Good Friday in Noosa. It was a great hike with breathtaking view. Every time I hike (which is an infrequent occasion), I am reminded of the saying to smell the roses along the way while aiming for a pinnacle. 

In the community work, I continue to be impressed by stable and willing clozapine patients. I feel again the therapeutic power of clozapine. Last Wednesday, my (very physically frail) patient asked me to not feel bad for him. It made me realise how presumptuous and arrogant I might be, to think and feel on his behalf; to think that the monthly difficult venepuncture for clozapine blood is a suffering, and that the endurance of the experience itself is not outweighed by the possibility of a psychotic relapse, the fear of 'being locked up' again, in his own words; that it is not speaking of an achievement of a stable mental state for over 20 years. 

In this rotation, I am working more closely with the case managers or in plain language, I simply am spending much more time with them, in the car, travelling from South to North to do home visits. It forced me to small talk with people, or listen to some things that I wish not to know. I slowly find out how each person is different. I find out (unsurprisingly) how unassertive I am and my semi-conscious tendency to agree with people and blur my own boundaries. Sometimes those small and seemingly ordinary moments remind me of the conversation you had with me, about how I should learn to assert myself, otherwise I will be eaten up and feel miserable. You told me there are many people like me. I am not sure if there are people like me. I feel alone in 'working as a team', 'learning to be a leader', 'being the medical expert and leading the MDT'. But thank you for your honest thoughts. I learn from no one else that I can be quiet but people need to listen to me, and that when I say something it needs to carry weight of authority.  

It is April now. I guess I do enjoy the clinical work in Old Age Psychiatry. It is not as tricky as I thought. I do have the capability in being 'comprehensive and thorough'. I do still have basic general medical knowledge, thanks to my internship and RMO year. 

I am starting to read Gabbard properly. The more I read it, the more I understand what you have taught me. I wonder why the shadow of you lingers so deeply. But perhaps I know why.