Feb 23

Red Dress Gala for Womens Heart Health

WexlerPsychRedDressGalaby Dr. Micaela Wexler

This past weekend, I once again had the privilege of speaking at the Alpha Phi Foundation Red Dress Gala to raise awareness of women’s heart health. I was on a panel with Dr. Lee McKinley, a pulmonary critical care specialist who confronts severe heart disease on a daily basis. He gave us some harsh facts about heart disease. It is the number one killer of women each year in the United States.

The following factors contribute to this: obesity, sedentary lifestyle, fatty diet, smoking and hypertension. Only 3% of Americans adhere to ALL four of the following healthy habits which have been found to prevent heart disease: 150 minutes of exercise per week; 5 fruits and vegetables per day; normal weight; no smoking.
While I acknowledge that it is important to hear these hard facts, as a psychiatrist, I opt for a more light hearted approach to motivate people to adopt healthy habits. So, here is a fun filled day of cardiac health.

Upon waking up, while you’re still in bed, take a few cleansing breaths. Deep breathing lowers blood pressure. Try a breath now: breathe in slowly, into your stomach, hold and then slowly let your breath out. Do this a few times.

When you get to the bathroom, read the post it note you left on your mirror last night telling you something wonderful about yourself. If all it says is “you’re awesome!” That’s enough. WexlerPsychToilet

Then, as you sit on the toilet with your phone in your hand, read a joke or look at a funny video.
WexlerPsychLaughter

Laughter really is the best medicine. A 2006 study in Maryland showed that laughing 15 minutes a day dilates your vessels 22 percent. This lowers your blood pressure, and putts less strain on your heart.

Now it’s time to crank up your favorite dance song, or two. Something with a beat, and start dancing. Dancing improves heart health. Listening to rhythmic music 30 minutes a day lowers blood pressure and heart rate. I recommend Grenade by Bruno Mars. Played 10 times in a row.

When you get to work, hug your boss.

A study in North Carolina showed that hugs reduce heart disease, and women benefit more than men. And it doesn’t matter if the person is close to you or a casual acquaintance. You still get the benefit. So hug someone every day, several times a day.
WexlerPsychHug

If you have to sit for your job, get up and walk around at least once an hour. I take a big container of water and take a huge drink right when I get to work. An hour later, I go to a bathroom far away from the clinic. Fewer people use it, which means fewer germs. And, more movement.

While you’re in the bathroom, think about your beautiful body. This beautiful body that brought you here today. Women, we are COMPLICATED! We don’t have typical symptoms of heart attacks. If you feel anything funny from your neck to your pelvis, call your doctor. WexlerPsychMirror

Walk during lunch. It doesn’t have to be a long walk. Walking 10 minutes a day twice a day every day significantly reduces heart disease.

Middle of the afternoon: time for some more cleansing breaths. Check out your mood. Are you stressed out? Taking those deep breaths will relax you.

If you find you have trouble relaxing, or that your mood is depressed, think about getting help. Untreated depression carries a high risk of a heart attack, especially for women. You have to be happy: you heart depends on it.

Don’t forget to hug people during the day! Every day during Womens heart month.
WexlerPsychWomenDance

After work, treat yourself to some more dancing while you change out of your work clothes. You earned it!

Then, it’s time for a glass of red wine. Studies have shown that a daily glass of red wine is good for your heart.
After dinner, treat yourself to some dark chocolate for dessert. Again, you’re doing this for your heart. Chocolate with 65% cacao is good for your heart. WexlerPsychRedWine

Then just before bed, grab that blank post it, and write something awesome about yourself and put it on your bathroom mirror.
WexlerPsychPostIt

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.

Appointment information for Dr. Wexler: wexlerpsych.com

WexlerPsychLogo

Logo Copyright Debby Bloom

Nov 02

Is Dr. Lisa Tseng a murderer?

DrLisaTsengWexlerPsychiatryby Dr. Micaela Wexler

On February 5, 2016, Dr. Lisa Tseng, a Los Angeles area physician, was sentenced to 30 years to life for killing three patients who overdosed on pain pills she prescribed.

Prosecutors charged Tseng with murder for the deaths of Vu Nguyen, 28, of Lake Forest; Steven Ogle, 25, of Palm Desert; and Joey Rovero, 21, an Arizona State University student who prosecutors say traveled more than 300 miles with friends from Tempe, Arizona, to obtain prescriptions from Tseng at her California clinic. The prosecution made the case that she recklessly prescribed large amounts of narcotic pain killers to people who did not need them, and the jury agreed.

Her defense team has made the claim that this was a case of malpractice, not murder, that Dr. Tseng was deceived by her patients, and that physicians should not be held responsible if their patients abuse their medications, and that her patients should have known not to take large amounts of narcotics, and not to mix them with alcohol or benzodiazepines.

It’s difficult to make a case for malpractice given these facts. Malpractice is generally reserved when great harm is caused by a physician’s mistake. But, Dr. Tseng’s actions do not fall under the definition of an error. She did not accidentally prescribe the wrong medications; she intentionally prescribed opioids, Soma, and Xanax. Habitually. Approximately 25 times a day.

On her very first meeting with this out of state patient, she allegedly quickly prescribed Rovero more than 200 pills, including nearly a hundred 30-milligram doses of Roxycodone, a potent and addictive painkiller. Nine days later, he was dead, joining the approximately 100 Americans per day who die from a drug overdose. The investigation showed that in addition to the three deaths for which she was convicted, eight other patients died from overdosing on her prescriptions. Numerous others overdosed, including one in the clinic bathroom shortly after his appointment. Her staff and patients testified she spent just minutes with each patient, did not perform physical exams, and did not verify they had a true need for these medications.

I believe responsible prescribing is the duty of every physician. Having said that, what exactly does this mean?
How is one physician guilty of malpractice while yet another is guilty of manslaughter, while Dr. Tseng is the first physician to be convicted of murder for the death of patients to whom she prescribed medications?

Losing patients is the reality of being a physician. Patients routinely die even when physicians do everything possible; death can result even when a patient has been prescribed a medication that is not controlled and considered low risk, such as a patient with asthma inadvertently prescribed a beta blocker. Then we have the issue of suicide by overdose: we do not hold physicians responsible when a patient decides to ingest the entire bottle.

As a psychiatrist, I have found it extremely challenging to treat patients who request narcotic pain medications. It is difficult to determine which ones have a pain issue and which ones have an addiction. I have learned the hard way that a patient with a true pain disorder can be just as violent as one with a narcotic pain pill addiction.

I have decided that for ME responsible prescribing of narcotic pain medication means VERY limited prescribing. I do not prescribe narcotic pain medications for any patient longer than a few days, for the simple reason that I am not trained in pain management. I prescribe controlled substances such as benzodiazepines and stimulants only to patients who will be under my care long term. I educate patients about this as early as possible.

If a patient enters my care on an acute psychiatric unit while prescribed a narcotic pain medication, I advise the patient the pain medication will be continued overnight and will be discontinued if I am not able to verify that they have a legitimate prescription. To ease their discomfort I will taper rather than abruptly discontinue opioid medications. If a patient presents to an outpatient setting requesting pain medication, I advise that I am not skilled in narcotic pain prescribing, and as such, I am not able to keep them safe, so I will not be writing a prescription for narcotics.

I’ll be the first to admit: this is much more complicated than what I have just described. Most patients requesting opioid pain medications are not content with my limits. The most mild reactions are those in which they try to persuade me to give them a prescription “for a few days worth to get me by until I find a doctor.” They launch into a detailed description of their medical issues, and explain how their pain is contributing to their depression and suicidal behavior. Some will go so far as to say, “if I don’t get my pain meds (or Valium, or Xanax), I’ll go kill myself.” I have hospitalized such patients involuntarily.

These are the “easy” patients. What happens far too often is that patients become aggressive. Their behavior ranges from verbal threats, “I know where you live” is the most common, to physical aggression. I have been spit on, kicked, shoved, had books thrown on me, had my hair pulled and, in one case I was beaten up by a patient who then attempted to strangle me. I have learned I am far from alone in these experiences, so much so that I now teach a class on coping with these types of patient situations.

I have encountered numerous physicians in the rural Midwest who, as Dr. Tseng was known to do, prescribe large amounts of opioids to patients they know little about. The Drug Enforcement Administration says Dr. Tseng wrote more than 27,000 prescriptions in just three years, at an average of 25 a day. By the time Joey Rovero, a college student in Arizona, visited her California office in December 2009, Dr. Tseng had developed a reputation as a “candy doctor,” a name given to doctors who “give you whatever you ask for.”

As a medical student and intern, I delivered approximately 70 newborns. I loved delivering babies. I loved the excitement; I loved holding their slimy bodies, stimulating their faces until they cried, watching their color change from blue to pink. I loved being present as a new family was formed. So great is my love of this, that I have remained active in providing breast feeding support, because of the proximity it affords me to this process.

If I happened to be the only person around, I would certainly deliver a baby if needed. However, I would never consider putting myself in a position where I would routinely be expected to participate in deliveries. It would be horribly irresponsible, and if a baby died under such circumstances, I’m not sure it would be considered malpractice.

This is the analogy from my life which most closely matches Dr. Tseng’s situation. There is no evidence to suggest Dr. Tseng had the proper training or technique to prescribe such large numbers of opioids. Her prescription of opioids in such large amounts would be similar to me running to women’s homes to get there before the midwife, knowing that in her vulnerable state, a woman in labor might actually prefer a physician over a midwife.

While it is true that Joey Rovero was an intelligent young adult, a college student just months away from completing college, unlike Dr. Tseng, he did not have a medical degree. Like Dr. Tseng, I also attended an osteopathic medical school. I was trained that the physical exam is of utmost importance when treating physiologically based medical conditions. In addition, all osteopathic medical students learn osteopathic manipulation technique (OMT). We are encouraged to turn to OMT as much as possible, especially in treating pain.

I don’t know what motivates physicians to run what are known as “pill mills.” Prescribing opioids in such large amounts turned out to be very lucrative, as reports indicate Dr. Tseng made $5 million in three years. A couple of years ago, I discussed this issue with a friend who happens to be a malpractice attorney. He advised me these cases never make it to court because the patients are unsympathetic due to their addictions. “We always find something in their background that will make them look bad in court.”

Joey Rovero was not someone with “something bad” in his background. He grew up as a good student and athlete in a close knit family. Rather than being shamed by the circumstances of their son’s death, his parents filed a complaint against Dr. Tseng. The following year, April Rovero started the National Coalition Against Prescription Drug Abuse. She has worked tirelessly to educate students, parents and lawmakers on the dangers of narcotic prescription drugs.

Dr. Lisa Tseng’s conviction and prison sentence is a wake up call that the manner in which we treat pain, as well as how we address the problem of prescription medication addiction needs to be addressed.

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.

WexlerPsychLogo
Appointment information for Dr. Wexler: wexlerpsych.com

Logo Copyright Debby Bloom

Jun 04

Thank you, Caitlyn

by Dr. Micaela WexlerVanity Fair July 2015 Cover

As both a parent and as a psychiatrist, I was filled with hope and joy by the introduction via Vanity Fair of Caitlyn Jenner. I have been involved in advocating for transgender rights for several years. When I was in my psychiatry residency at Kansas University Medical Center, I did my scholarly project on transgenderism. My research involved a review of the literature as well as “field work.” I interviewed transgender individuals in various settings: Navajo Nation, San Francisco, Kansas City, among others.
I learned about embryological gender development, and how this can lead to both intersex disorders and transsexualism. My training as a physician made it quite easy for me to understand how a discrepancy between genital differentiation and brain sexual differentiation can result in transsexualism.

I learned the horrifying statistics with regard to violence against transgender individuals. While the average American has a one in 18,000 chance of being murdered (which to me is a deplorable number), a transgender individual has a one in 12 chance of being murdered. I think of that statistic every time I give one of my elderly patients a clock test for dementia. I learned how Gwen Araujo was brutally murdered on October 4, 2002, just shy of her 18th birthday. The four men who killed her were found innocent due to their “gay panic deception” defense.

The grim statistics with regard to suicide in the transgender community are inescapable to me as a psychiatrist. A staggering 41% of transgender individuals in the United States have attempted suicide. For transgender youth, that statistic jumps to over 50%. When Leelah Alcorn died from suicide in December 2014, I was haunted by her plea left behind in her suicide note: “The only way I will rest in peace is if one day transgender people aren’t treated the way I was.”

How was Leelah Alcorn treated? In a note she wrote prior to her death, she makes it clear she is committing suicide “because life isn’t worth living as a transgender.“ She acknowledges that her peers and school were supportive, but not her parents. Her mother “reacted extremely negatively,” and she urges other parents to be more accepting. Her mother’s lack of acceptance, on many levels, persisted after her death, when she posted on Facebook that her “sweet 16 year old son” was hit by a truck when out for a morning walk.

Given the realities faced by the transgender community, Caitlyn Jenner’s public act of courage, which is accompanied by widespread acceptance, including that of her family, is cause for celebration. It is so refreshing to see the word “transgender” NOT followed by the word “tragedy” or suicide.” While it is true that she comes from a tremendous amount of privilege, with the accumulation of resources made possible by capitalizing on a male persona for several decades, it is wonderful that she is using her celebrity as a vehicle to help others, especially members of an extremely marginalized group.

Research shows that the younger a transgender individual is when she or he transitions, the greater positive effect this will have on his or her mental health. They suffer less bullying, discrimination and isolation the younger they are when they assert their true identity. Treatment with hormone blockers to prevent unwanted physical characteristics allows for a more complete social development.

Given these findings, I can’t help being sad that Caitlyn had to wait until her 60’s to assert her true identity. This is tempered by the fact that by giving a positive public face to transgenderism, more transgender youth will be able to transition and live their lives to their full potential. We are much closer to having Leelah Alcorn rest in peace.
Thank you, Caitlyn.
WexlerPsychLogo

Appointment information for Dr. Wexler: wexlerpsych.com

Apr 20

Why was Natasha McKenna Tasered?

by Dr. Micaela Wexler

WexlerPsychiatryNatashaMcKenna

On February 3, 2015, Natasha McKenna, a 37 year old woman with a diagnoses of schizophrenia, who was being detained in the Fairfax County, Virginia jail, stopped breathing after a stun gun was used on her. She had been restrained in her cell by six deputies with handcuffs behind her back, leg shackles and a face mask prior to being shocked four (some reports say six) times. She was taken to a hospital, placed on life support, and died several days later, leaving a seven year old daughter.

Why was Natasha McKenna tasered? Tasers are not recommended for use in the mentally ill. McKenna’s mental health challenges were well known to involved parties. She was diagnosed with schizophrenia at the age of 12. She had no history of serious criminal convictions, but was known for her erratic behavior. She had been arrested on January 15, 2015 by Alexandria, Virginia police after creating a disturbance at a Hertz car rental location. She ran from police, resisted arrested, and was combative with officers. That incident resulted in hospitalization at a psychiatric facility. By the time she was restrained at the Fairfax County jail and tasered, she had already spent eight days in the jail’s mental health unit. During that time she had engaged in bizarre behavior indicative of her deteriorating mental state: she had urinated and defecated in her cell and had been combative with deputies.

Why was a felony warrant for assault obtained for a person well-known to have mental health challenges? During her public disturbance on January 15, she punched a cop, bit another cop. She was not arrested, however; she was transferred by the Alexandria, Virginia police to a psychiatric facility where she was hospitalized for several days. Despite this transfer, the police issued a felony warrant for assault. By January 26, she had been released. On that day, she called police to report an assault. Workers at the store where she borrowed the phone reported she was dressed in hospital patient attire. When she was picked up by Fairfax County sheriff deputies, she was taken to jail rather than to a hospital, in large part because of the warrant for her arrest. She was viewed as a criminal rather than a person with mental health challenges.
Treating people with mental health challenges like criminals while denying them care hurts all of us. This was tragically demonstrated in 2007 when Seung-Hui Cho, who had been recognized as being severely mentally ill and briefly hospitalized, was not treated and went on to kill 32 people at Virginia Tech.

While providing CIT training for all law enforcement personnel is a useful goal, more basic steps can be immediately taken, such as not using a taser on a person who is already restrained and not using one on a person who is emotionally unstable. Widespread recognition of mental illness for what it is, a medical condition which renders the person vulnerable, would go a long way to preventing unnecessary tragedies like the death of Natasha McKenna.
WexlerPsychLogo
Appointment information for Dr. Wexler: wexlerpsych.com

Mar 31

It was NOT the depression

by Dr. Micaela Wexler

As a psychiatrist who treats people with depression on a daily basis it is disheartening to see news story after news story referring to depression in relation to the Lufthansa Germanwings Airbus crash. The latest news story I’ve seen is one titled “Lufthansa’s Deadly Confession,” and it reveals that Lufthansa (gasp) knew Andreas Lubitz was depressed and continued training him.

People do NOT murder because of DEPRESSION. People do not do much of anything because of depression. That’s the problem with depression: it prevents people from taking actions, from accomplishing, from participating. People with depression are unable to do things they could previously do before a depressive episode. They lack interest, energy, concentration. People with depression do not suddenly get an urge to go out and do something evil that takes a great deal of skill and planning.

Perhaps there is confusion about what depression is. If so, then it is up to people like me, a psychiatrist who is intimately acquainted with depression, to educate about what depression is. The mnemonic device DIGSPACES (Depression, loss of Interest, Guilt, Sleep disturbance, Psychomotor agitation/retardation, Appetite changes, loss of Energy, Suicidal thoughts) is a helpful way to remember these key symptoms of Major Depressive Disorder. To be diagnosed, the person has to have had FIVE or more present over the previous two week period, and it has to reflect a change from the previous level of functioning.

Does any of this sound like someone is focused and energetic enough to go plan the murder of 149 people?

It is stigmatizing to the many people I see who courageously struggle with their depression to see the media continuing to relate this tragedy to depression. I am not saying Andreas Lubitz did not suffer from depression at some point. Evidence shows that he did, and that is very sad. What I am simply saying is that the depression is not why he did what he did. Yes, depressed people can be capable of evil things, they are capable of hurting others, of causing damage, of lying, stealing, just like anyone else. But, it isn’t the DEPRESSION that makes them do this. Their motivations would be the same as anyone else committing evil, violent acts.

It’s hard enough to get people who struggle with depression to get help. Let’s not make it worse by stigmatizing them. This will not only serve to further marginalize the mentally ill, but it will do nothing to get to the root of what really caused Andreas Lubitz to crash a plane full of innocent people. And, both of those situations hurt all of us.

Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Nov 26

Comparing Ferguson to the OJ Simpson case

by Dr. Micaela Wexler

In the days since the tragic events in Ferguson Monday night, I have seen an appalling number of Facebook posts comparing the Michael Brown case to the OJ Simpson case. Judging by the wording of the posts, the posters consider themselves quite clever as they point out that “white people didn’t riot when OJ Simpson was acquitted.”

First, it is disappointing to see how quick people are to judge when they have not walked in another person’s shoes. I don’t know if Officer Wilson was right or wrong in what he did, I wasn’t there, it is not my place to judge him. It is also not my place to judge how a people responds to deep psychic pain. Second, to compare the Michael Brown case to the OJ Simpson case is irresponsibly ignorant. OJ’s acquittal says more about how we devalue women and over value celebrities then it says about race.

In addition, whether one agrees with what Officer Wilson did or not, what happened in Ferguson is a monumental tragedy. First, an 18 year old man lost his life after doing what I have witnessed countless teenage boys do: shoplifting and walking in the street. His body was left to bake in the hot sun for four hours before it was removed. This loss tore open a deep wound in that community.

What happened in Ferguson Monday night is a large scale of what I see every day as a psychiatrist: people who are so angry and wounded they give up and destroy themselves. That community committed a form of collective suicide. It is as morally repugnant for us to use these events as a form of entertainment as it would be to make an individual who died from suicide an object of derision.

Early diagnosis beneficial in AD
WexlerPsychLogo
Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Oct 14

Talking to your teenager about Ebola

by Dr. Micaela Wexler
wexlerpsychiatryEbola

As the Ebola epidemic continues to grow in West Africa and begins to spread to other countries, it is natural for teenagers to become distressed. One teenager asked me yesterday, “Are we all going to die from this?” Even though I am a psychiatrist who treats teenagers daily, I did not have an immediate answer.

I decided to do some research and share my findings and ideas on this blog.

First, be calm when talking to children of any age about Ebola. Don’t panic. Don’t give in to hysterics. If you harbor fears or conspiracy theories, share them with other ADULTS. There is no need to share ideas not founded in fact with teenagers.

Stick to established facts. After consulting the CDC web site, I not only had some answers, but I was reassured that it is very unlikely, maybe impossible that we are all going to die from Ebola.

Share with your teenager how Ebola is transmitted. According to the CDC web site, Ebola is transmitted through direct contact (through broken skin or mucous membranes in, for example, the eyes, nose, or mouth) with:
- blood or body fluids (including but not limited to urine, saliva, sweat, feces, vomit, breast milk, and semen) of a person who is sick with Ebola
- objects (like needles and syringes) that have been contaminated with the virus
infected animals

Ebola is not spread through the air or by water. In the United States, it is also not spread by contact with food. In West Africa, handling wild animals used for food also poses a risk for Ebola transmission. There is no evidence that mosquitos or other insects can transmit Ebola virus. Only mammals (for example, humans, bats, monkeys, and apes) have shown the ability to become infected with and spread Ebola virus.

Point out to teenagers their low risk for Ebola. People at highest risk are healthcare providers caring for patients with Ebola and close friends and family members of patients with Ebola. So, unless your teenager is a healthcare provider, her or his risk is almost non-existent.

Ebola Symptoms

Teenagers benefit from having concrete facts. It doesn’t hurt to teach your teenager the signs and symptoms of Ebola. Signs and symptoms include: fever, severe headache, muscle pain, weakness, diarrhea, vomiting, abdominal pain, unexplained bleeding or bruising.

Give your teenager a plan for coping with Ebola. I was happy to note that for non-healthcare workers, it is pretty easy to avoid acquiring Ebola. Practice personal hygiene, such as frequent hand washing. Avoid contact with bodily fluids, such as vomit or saliva, of people with signs of infection. Avoid travel to areas of the world, namely West Africa, with Ebola outbreaks. Avoid contact with bats, rodents and non-human primates known to carry the virus.

Ask your teenager to share her or his ideas of how the Ebola outbreak should be controlled. Remember, teenagers will soon be tomorrow’s leaders; let them know we value their ideas.

Finally, point out our healthcare system is one of the best in the world. Yes, tragically, the first person to be diagnosed with Ebola in this country has died and a nurse who cared for him has contracted Ebola. However, we have the capability to learn quickly and implement changes.

The same day a nurse caring for Thomas Duncan was diagnosed with Ebola, the University of Kansas began treating a patient who arrived with a high fever and had been working on a medical boat off the coast of West Africa. KU Medical Center immediately implemented CDC guidelines. The patient called the hospital and was met with staff wearing protective equipment. The patient was immediately isolated in an area of the hospital with its own ventilation system. The staff caring for the patient will not care for any other patients until Ebola is either ruled out, or the patient no longer requires treatment. (Update: initial tests are negative for Ebola.)

As with any crisis, it is important to remain calm, get the facts, and focus on scientifically backed methods to cope with the crisis. There are many other dangers which our teenagers face. For example, it is estimated that every year 2 million adolescents attempt suicide. Teenagers face a great number of risks which do not have easy solutions, such as hand-washing and avoiding vomit. Let’s keep things in perspective as we communicate with our teenagers, and let’s not let hysteria distract us from their very real needs.

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.

WexlerPsychLogo

Logo Copyright Debby Bloom

Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Aug 13

Paul Fleiss, MD, September 8, 1933 – July 19, 2014

By Dr. Micaela Wexler
image

In 1997, I was the young mother of two daughters, an infant and a toddler. I was an unemployed playwright, with no marketable skills. I was married to a working actor who struggled to support our family so that I could be home with our daughters instead of working menial jobs. Central in this decision was our fervent wish that I breast feed our daughters “on demand.”

We had a pediatrician at the time who had not been supportive of me breast feeding my first daughter while pregnant with my second daughter. I had attempted to educate this pediatrician with research articles showing there was no harm in breast feeding while pregnant, but this had led to an acrimonious debate in her office during which she warned me my daughter could be removed from my home if I did not stop “harming her.”
I was aware that as a dark skinned minority woman without a college degree, I could not afford to fight with a pediatrician, that this could very well lead to my losing custody of my daughter. In my hormonal state, I began to have nightmares that I was sent to prison and my daughter soon forgot who I was.

I didn’t stop breast feeding. My husband and I simply lied to our pediatrician. We also lied to our obstetrician. I continued to breast feed throughout my pregnancy and then, when my second daughter was born, I started to “tandem feed,” all the time concealing my breast feeding practice from the person, who after my husband and me, was most responsible for my daughters’ health.

I shared all of this one day with my writing group. During the lively discussion that ensued, I was told about a pediatrician who was a champion of breast feeding, including tandem feeding. He was active in La Leche League, and did not turn anyone away, regardless of their ability to pay. His name was Dr. Paul Fleiss.
At that point in my life, I was still shy and timid. One of the women present surmised that I didn’t have the courage to call him, so she went to the phone and called him herself. It was late evening, but Dr. Fleiss answered his phone and listened as she told him my entire story. She got off the phone and told me I had an appointment the next day. When she gave me directions, I realized I had been walking by the cozy craftsman house he used for his practice the entire time I had been a mom.

During my initial appointment, Dr. Fleiss asked me questions in his soft voice, and as I gave my history of my daughters, he praised me, telling me what a great mother I was. He gently examined both my daughters, letting my toddler play with his stethoscope and place her finger on the end of the ophthalmoscope.
He was impressed I had found research articles about breast feeding while pregnant. He invited me to the La Leche League meeting held every other week in his office. He also invited me to join him and other people from the neighborhood in a morning hike in Griffith Park they took every morning at dawn. “Bring the babies,” he said. “They’ll love it. We’ll help you with them.”

Thus began a friendship that lasted until Paul died July 19, which happens to be my birthday. Paul became a friend, mentor and father figure to me.
I began hiking with the group, and developed several close friendships with other hikers. During one of our hikes, Paul shared that he did volunteer work in the Latino community, and could always use a fluent Spanish speaker. I accompanied him on one of these excursions, and my professional life began to take form.

For reasons that are no longer important I was not raised with the stability nor was I taught the skills one needs to pursue a career of any magnitude. During our many hikes I shared with Paul the story of my childhood and he took it upon himself to fill the paternal void in my life. He gave me advice as we climbed the hill in Griffith Park. He supported me in all my endeavors with the same enthusiasm he had for breastfeeding and pediatrics. Paul brought a group of friends to see each of the productions of my three plays.

One day I shared with him my desire to become a doctor, and my fears that I was too old. Whereas many well meaning friends advised me to consider nursing or physician assistant school, Paul never once said a discouraging or negative word about my desire to become a doctor. He gave me nothing but support in every way possible. He assured me that I was not too old, and then he said, “It’s better to be a good doctor for five years than a bad doctor for 20.” He gave me advice on where to take my pre-med classes, and how to make my resume more competitive. He allowed me to shadow him for countless hours in his office. He regaled me with stories about women who had become physicians after having children.

When I received my medical school acceptance letter, Paul was overflowing with pride. He then suggested a way for me to afford medical school: applying for the National Health Service Corp (NHSC) scholarship, a program that pays the entire cost of medical school (tuition plus a monthly stipend) in exchange for four years of service in a primary care specialty in an underserved community. “You’re exactly what they’re looking for,” he said.

During medical school, I did one of my pediatric rotations in his office. He risked our friendship for the greater good of pushing me hard as a medical student. He never passed up an opportunity to share one of his pearls of wisdom. A constant refrain was “always listen to your patient. If you listen long enough and carefully enough, the answer will come to you. The patient will tell you what you need to know.”

My second year of residency took me out of Los Angeles to Kansas City in 2007. The excitement of starting a new life was tempered by leaving Paul. Not only was I leaving an amazing pediatrician for my children, but I was leaving my mentor, father figure and close friend. Paul softened this blow by suggesting that I fly to Los Angeles with my daughters for their annual physicals. “Many people do it,” he said. For the first three years, that’s exactly what I did, and each time we saw him, he treated us as if we had never left.

My NHSC service obligation took me to a small town in Southwest Missouri where I was the only psychiatrist providing outpatient care. I also staffed the inpatient unit. The hours were long, and it was challenging to find coverage so I could take time off. My last trip to Los Angeles to see Paul was in 2011, for a short, impromptu weekend. Despite the short notice, Paul made time to see me. We went on a hike, and I had two of my three meals in town with him. I shared with Paul the challenge I faced in rural Missouri: the patients had come to expect doctors to write them multiple prescriptions for controlled substances. This expectation was especially high when patients saw a psychiatrist. My visit with Paul strengthened my resolve to “listen carefully to the patients,” and not just give out multiple medications.

My job in Southwest Missouri became more demanding as the months passed. The poverty there is brutal; the incidence of substance abuse is staggering. I was physically attacked on several occasions for various reasons: my dark skin, my refusal to dole out narcotics, my reluctance to place patients on disability until all avenues had been exhausted, and on two occasions, when parents became convinced I was the one who had called child protective services.
In the summer of 2012, I called Paul. “I can’t go on,” I told him. “I’m not going to make it through my contract.” We discussed the enormous financial penalties I would face if I didn’t complete the contract: 3 times what it had cost to attend medical school plus 18 percent accrued interest.

“I’m going to have to move to Mexico,” I concluded.

“That’s a wonderful idea!” Paul said. “my son went to school in Mexico. He loved it. You could teach in the medical school.” Always the dreamer, his mind was always brimming with possibilities. His reaction was perfect, it lifted my burden, giving me the freedom to think of other possibilities myself. I began to indulge my desire to treat children with developmental challenges, which became my plan to pursue a child and adolescent fellowship after completing my contract.

That plan fueled me for the rest of my service obligation. In September 2013, I got in touch with Paul to wish him a (late) happy birthday. When I expressed my fears that I would not be accepted into the program, he promised me he would hire me to do child psychiatry in his office. “In my eyes, you’re already a child psychiatrist.”

A month later I was accepted into the fellowship program at KU Medical Center, to start immediately upon completion of my NHSC service. I completed my service July 18, at midnight. Paul died the next day. My mentor and friend saw me through to the end.

There have been many moments since Paul died that I have been overcome with grief. It’s hard to believe I will never hike up the hill at Griffith Park with him, that I will never “talk shop” with him about my work with children. It’s difficult to accept that his seemingly endless energy really has stopped. To me, he will always be that thin man hiking next to me, his mind sparkling with ideas, showering me with flakes of hope and possibility. I get through these sad moments by taking comfort in the many gifts he gave me. Each time I think about Paul, I remember to “listen to the patient, and the answer will come to you.”

Dr. Micaela Wexler provides child, adolescent and adult pscyhiatric services in Kansas City.

Please visit Wexler Family Psychiatry to schedule an appointment.

WexlerPsychLogo

Logo Copyright Debby Bloom

Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Jul 17

My rural medicine adventure

By Dr. Micaela Wexler

Tomorrow my four year adventure in rural medicine will come to an end. It will be bittersweet. I will complete my four year service obligation for the National Health Service Corps (NHSC). The NHSC is a federal program that provides scholarships and loans to physicians and nurse practitioners willing to provide primary medical care to under served communities. I was in their most competitive program, the Scholar Program for Physicians: the NHSC paid for me to attend medical school in exchange for providing psychiatric care to a community on a “critical need” list.

I decided to pursue medicine after my two oldest daughters were born, and without the NHSC, I would not have been financially able to attend medical school. I was thrilled to discover that my area of interest, psychiatry, was on the list of required specialties. The financial support from the NHSC felt like a luxury: they paid my medical school tuition and fees up front along with a monthly stipend. This made medical school extremely enjoyable for me. I didn’t have the shadow of mounting student loans looming over me, which made me almost giddy as I immersed myself in anatomy, pathophysiology and clinical rotations. It wasn’t until I was in residency, exposed to critically underserved populations that I began to consider the rigorous job options that awaited me.

At the beginning of my last year of residency, I learned that psychiatrists in my cycle of service would be required to serve in remote rural communities. This had a profound impact on my family. There were absolutely no rural communities which had a Jewish community. My best option was to be placed in a community one and a half hours from a Jewish community. I chose Southwest Missouri, 85 miles away from where my children would be living. This meant I would be living alone as I completed my service obligation.
This turned out to much more difficult than I ever imagined. When I arrived, I was convinced the commute would be easy, that this would be no different than when I did my rotations during medical school in Los Angeles and regularly did 3 hour round trip commutes due to traffic. Well, it’s a completely different story when you’re the only provider and 20 to 30 people need your care on a given day. You can forget about making that commute. And, when you do make that commute, be prepared for something worse than traffic: no other cars at all. No one to help you if you hit a deer or get a flat tire, or, worse, you fall asleep and fly off the road. All of those things happened to me at least once.

When I arrived in my community, I assumed I would pursue multiple hobbies with all my “spare time.” I had hopes of making a quilt, joining the gardening club, riding with the local cycling group. Well, again, that huge patient load made all of that impossible. I never even had time to go inside the quilting store, something that still makes me sad. I rode my bicycle alone in the pre-dawn hours.

I spent many days when the only people I had conversations with were my patients and the nursing staff. I ate most of my meals alone, while I completed charts. I engaged in stress eating, which caused me to gain weight.
While I did manage to visit my children at least twice a week for the entire four years, I did miss quite a few parent teacher conferences, school performances, and even a couple of birthdays.

So, why am I not absolutely ecstatic that my service is over? The patients. I was able to start an outpatient psychiatry clinic from scratch, and provided face to face care to people of all ages. I provided inpatient care to patients from all over the state who typically arrived in a state of crisis. I never had even one hour when I felt I was useless or superfluous. I learned about the brutality of rural poverty and the devastating effect it has on children and adolescents. This knowledge focused my efforts in a profoundly meaningful manner.

My work in the clinic afforded me the opportunity to treat entire families: children, parents, grandparents, and in a couple of cases, great grandparents. I acquired deep knowledge of their hopes and struggles, of the fierce family loyalty which survived substance abuse, incarceration, chronic unemployment and severe mental illness. I witnessed the miracle of children growing and thriving despite their many obstacles.

I fell in love with my patients. I will never stop being inspired by their admirable struggles to overcome the challenges of mental illness. Their hope and optimism in the face of considerable adversity will inform my practice of medicine from this time forward.

Apr 28

Talk to your kids about sex . . . and love

By Dr. Micaela Wexler
This is an important topic parents have a hard time discussing with their children. Too often I find that my adolescent patients have never had an in depth discussion about sexuality with their parents. In the best case scenarios, they have been told about pregnancy and STDs, but usually sex has been presented as a forbidden activity, in an atmosphere of discomfort and embarrassment. There is rarely any discussion about relationships, intimacy, sexual expression, body image, masturbation and acceptable behavior. Parents seem to be oblivious to the fact that according to the Guttmacher Institute, 46% of teenagers age 14-19 report having had sex at least once.

Failing to talk to your teenager about sexuality puts him or her at grave risk for a variety of dangers ranging from the obvious – pregnancy – to others that are less obvious but potentially more life threatening, like depression and relationship abuse. Depression is the greatest risk factor for teenage suicide. Romantic break ups are a common trigger for depression in teenagers. Teenagers most at risk for depression following a relationship break up are those who have limited support and poor coping skills. Parental support is a potent protection against teen dating violence.

It is never too early to talk to your child about sex. Ideally, the “sex” talk should begin at birth. Use correct words for genitalia when changing diapers or giving your child a bath. Make positive statements about their body (and yours) throughout their childhood. Early childhood is when boundaries should be taught, that their private parts are their own and no one else should touch them. The same is true about other people’s private parts. Introduce the physiological aspects of sexuality in the elementary school years, with anatomy lessons, including the different processes that occur, such as hormonal and physical changes, pregnancy and orgasms.

I recommend that birth control and STD protection issues be brought up during elementary school years, even if you are a strong believer in abstinence before marriage. Hearing about both birth control and abstinence at the same time does not lead to children engaging in sexual activity earlier. Parents should remember that children hear alternative, even conflicting views about many topics in their lives. Presenting children with choices teaches them decision making skills.

Children are being exposed to sexual topics outside of the home at an earlier age, and they will be safer if they have heard about them from you. In addition, talking about birth control and STDs helps children open up about other sexuality related topics; they are less shy about sharing what they have been exposed to at school and in the media. Don’t be afraid of letting them know the meanings of words they hear, ie blow jobs, fuck, cunt, etc. These are valuable opportunities for parents to express their views on acceptable sexual behavior.

Explore your own thoughts and feelings about sexuality. If you are uncomfortable discussing the topic of sexuality, try to figure out why. Are you unhappy with your own sex life? Are you disappointed with the level of satisfaction you are achieving? Maybe you have a history of domestic abuse or childhood sexual abuse. Were you taught negative views about sexual expression during your own childhood? Or, perhaps you are mourning the loss of a relationship. Getting in touch with your own emotional feelings regarding your sexuality will help you address the emotional impact sexual expression has on your teenager.

Studies show that most parents do not discuss the emotional aspects of sexuality with their teenagers. They do not discuss intimacy, relationship conflicts and violence in relationships. Teenagers are left to navigate the confusing world of dating, relationship building, sexual expression without any skills and with no one to turn to when problems occur. Whether they are engaging in sexual activity or not, teenagers experience very strong emotions when it comes to relationships. Due to their raging hormones, every aspect of the relationship is magnified. This is a dangerous time to withdraw parental support.

Once you have talked to your child about all the concrete aspects of sexuality, you have set the groundwork to talk about the complex emotional issues surrounding sexual expression. It is important to approach the topic in a non- judgmental and non-threatening manner. Open the discussion by asking if their friends are in relationships. Rather than focusing on sex, focus on issues like trust, mutual respect, friendship and honesty. Guide your teenager through a relationship conflict. Be on the lookout for signs of teenage violence. Do not trivialize their feelings. Teach your teenagers that their sexuality is a gift that should be treasured, and that it should never be used to hurt them.