#410

On to the topic of behavioral change...

I'm more than fortunate to attend a medical school with a distinct form of medical practice. Yes, my medical school has a "brand," and on the residency interview trail every program director and interviewer so far knows about it. It's kind of flattering to walk into an interview and have the interviewer know where you're coming from (so to speak), even if you're not coming from an "elite" or name-brand school (at least one with a name patients recognize).

Anyway, the first two years of medical school are spent learning the "science" of medicine, and the last two years involve learning the "practice" (or "art" to keep the analogy going). My medical school has a "hybrid" curriculum, which means we blend both science and practice from day one, sometimes well and sometimes not so well. I often feel like my medical knowledge is lacking compared to other applicants, but after all, what is Google for? I feel that my comfort and intuition, directly gleaned from my school's curriculum, allow me to muscle through gaps in my knowledge.

All of this is to say we spend a fair amount of time discussing behavioral change techniques in the first two years, vis a vis the medical issues of smoking and alcoholism. We learn very little about weight loss or nutrition, although our "dynamic" curriculum means that the school works to improve weaknesses every year. Indeed, the three classes behind mine participated in a month-long cooking course in their first year.

We are taught that there are 5 stages of behavioral change: pre-contemplation, contemplation, preparation, action, maintenance, (and relapse). We are also taught the "5 A's" of behavioral counseling, that the physician's job is to: Assess, Advice, Agree, Assist, Arrange. Or, if you have a patient stuck squarely in pre-contemplation, there's a mnemonic with "5 R's" for how you handle that one. Of course, I forgot it, but it goes something like you have to warn them of the risk of maintaining their behavior, etc, etc, etc...

We're taught that the most effective smoking cessation technique is to help the patient pick a "quit date" (the advice and agree portion) and then prescribe whatever pharmacotherapy they need (nicotine replacement therapy vs buproprion vs varenicline) ahead of time (the assist and arrange portion). I like the ideas of quit dates because it makes the office visit tidy. But in reality, I'm not sure they work. In fact, I once read (citation unknown) that the most successful quitters are those who just do. They wake up one day and just run, like Forrest.

There's been a fair amount of chatter lately about the "post-wedding blues." I assumed I'd get it because frankly, that's the way I am. But over the past month I've come to realize that it's not the post-wedding blues after all, but rather an extension of several years of "wedding ills." Being a bride is like no other time in your life, and I've spent a fair amount of time considering and analyzing the energy and attention I devoted to my "one day." Some call this energy "fetishizing," which I find honest if not entirely right. For me, the experience of planning a wedding became a journey in defining myself. It seemed as though all the adjectives conjured up about our wedding style - "vintage," "apothecary," "whimsical," "clever," "inclusive" - were somehow meant to be telegraphed to wedding guests about who I was, who Tom was. Suddenly I not only needed to pick a cake and a dress and flowers, but I needed to choose plates and pans and vacuum cleaners for the home I was to inhabit (one that remains mythical to this day). It was all so much pressure; if you're registering for pots and pans you're supposed to only buy once (because they last), well darn, you better get it right. And with the enormous gobs of money being spent, you really ought to get it right.

I knew throughout planning but was afraid to admit that the focus rested squarely on the materialistic. "Wedding" meant tangibles - cloth, paper, petals, speakers. It meant nothing about the spiritual. Nothing in our wedding defined me in the realm of ideas. Indeed, I got married in a ceremony that had no relation to what I envisioned. Obviously, that's an incendiary statement but it's not one full of anger or regret or negative emotions. It just is. And I had plenty of good reasons why I let things play out the way they did. It just didn't represent me, even though I supported it.

So I was puzzled by the fact that even after the wedding I still sit on the couch for hours (sad, but really true) knitting or researching arcane facts and details on the computer. Often I forget to eat. Can't bring myself to complete work required of me, like writing papers, planning interviews, or writing thank you notes. It's no different than neglecting to study for the boards or my shelf exams because I needed, just had to find the perfect roll of 4" apricot moire ribbon (which I never bought).

And two days ago I had an epiphany, that what I had been feeling for the last month - like a failure because I was still sitting on the couch surfing the web with the tv on - was not so different from what I had been feeling for the past two to three years. But what was different was that I had the time, the mental space to actually change. In the end, I had one of those trite and pat realizations that I could actually focus on my self. In being a better person, those around me might benefit, too. There was a person I once manufactured out of the ashes of a great and terrible depression and I had stuffed her in a closet. Now it's time to air her out.

I'll spare the details about what I've decided to do, though I may begin to talk about them from time to time. And while this is undoubtedly self-involved, maybe someone else feels the same way? I would not go back and change the last several years. I needed to be that person, and I would never discourage another bride from planning with the intensity I did. That's her choice. That's her process. We all get lost in the woods from time to time. It doesn't take a special day or New Year's to change, it just takes contemplation, then preparation, then action...