Great Expectations

America has become a nation of cynics.

We often go through our days thinking that the worst may happen to us that day and probably will. We worry that everyone is out to screw us over, emotionally, financially, academically, and vocationally.

We roll over, punch the alarm, then roll over and punch the snooze button two more times because we just don’t want to get up and face another day.

We expect the worst, and you know what? With that attitude, that’s often what we get.

Shift gears with me now.

I had a little financial crisis this week. Not earth shattering. Not one that would have kept me from eating. Not one that was going to derail Christmas. One that was just annoying, was (truth be told) my own fault to a large degree, and which might have delayed my anticipated and longed-for mini Christmas shopping vacation to Beaufort, my recharge town.

When this little crisis happened I was, to say the least, extremely annoyed with myself. There was nothing to do but face it head on, talk to some people, try to fix it, and hope for the best.

Reference paragraph number four above. Try as I might, I just knew fixing this problem was going to be a pain in my posterior. I knew it could be fixed, there was no worry about that, but I knew it would not be the way I wanted it done, on my timeline, or as fast as I wanted it to be resolved.

Enter Jessica, a senior level branch employee at the bank.

After I was greeted by a smiling employee who was shepherding each visitor to the bank through the line and to the proper person, I was asked to sit and wait.

Jessica came to retrieve me shortly. She was very warm, welcoming, professional, and she listened attentively to my tale of woe.

Immediately, she jumped on her computer, typed and scanned and clicked and entered and reviewed. She then told me the likely scenarios for solving my problem, the possible timelines for each, and how she might circumvent delays and speed up the resolution to my satisfaction.

This impressed me.

A big bank, wanting to solve a problem with my best interest at heart (pun entirely intentional). Unheard of, right?

A few more clicks, a signature or two, a couple of trips back and forth from her office to the front, and I had a very large cashiers check in my hand.

Jessica smiled.

I smiled.

We shook hands.

I had ordered a Christmas flower arrangement for her, to be delivered to her office by the end of the day, before I made it back to my office.

Sometimes, someone surprises you with exceptional customer service. Sometimes, you know that they have listened to you, that they really know what you need to get from your interaction with them. Sometimes, they do everything they can to make that happen. To delight you. To make you smile.

I wanted very much to make sure that Jessica knew that she went above and beyond in meeting my expectations, solving my problem, and making the rest of my week much more pleasant than it might have been.

How can we surprise and delight someone today?

How can we go above and beyond in solving a problem?

How can we make a difference in someone else’s life?

Have an excellent day, dear readers, and make someone smile.

Old Man River

So I’m thinking yesterday about milestones and changes and how life flows like a river.

I’m thinking about how I read on Facebook and Twitter about the lives of all my family, friends, coworkers and acquaintances, how they are always churning and moving and relocating and promoting and transporting and loving and growing and dying and teaching and learning and experiencing.

I’m watching my granddaughter, not quite one year old, her face glowing with the reflection of family and celebration all around her, reaching for the salad and mimicking a smile and watching her big sister, actively coaching her. I watch her clap, clap, clap, smile, smile, smile, by rote at first, but then sensing that this is pleasurable, this is fun, this is something that I can do for myself. I marvel at the way a life starts, helpless, tiny, pink, soft, and then, in less than a year, learning and soaking up the ways of world and actively communicating without yet saying a single word. I revel not just in the birth of another child, but the incarnation of another personality, another change agent in this world that we sometimes think is irretrievably broken, save this.

I’m thinking about how wonderful it is to be young and in love, to see and feel the wonder of the birth of that small child and then a career and then a family. To feel the tug and pull and stretch of life as it grabs you by the throat and says, c’mon now, you got yourself into this now pull yourself up by your bootstraps, by God, and feed these children and finish that degree and put yourself out there and get yourself promoted and make your mark in the world. Work as a team, work as a unit, be a family, because that’s the way the world moves on.

I’m loving the way it feels to teach my oldest granddaughter to play tic tac toe, the little gears in her head turning as she begins to grasp strategy and that this little child’s game, this little exercise played out with green crayon and paper, is a connection, no matter how fleeting, that is learning at its best. A playful assimilation of how things work. A tiny declaration of independence written in colored wax.

I’m thinking that this family gathered around is so very different from that family that was, in so many ways. We laugh, we talk, we remember. We cry, not here of course, but in private. We all know about that, those private struggles and quiet tears shed away from the celebrations and the holiday lights. We all know.

I see aging before my eyes. I see time’s inexorable march in flesh and bone, the weight of decisions made and a life lived sitting on the shoulders and bowing the back so that the vantage point of the eldest among us is both studied and stooped. I wonder what it must feel like to hear these joyous celebrations, as if from the bottom of a well, muffled and distant but close enough to touch.

I see the march of time.

Relentless. Giving. Exacting. Unforgiving. Heartless. Cold. Cruel.

I see the promise of the future.

Smiling. Bright. Energetic. Hopeful. Creative.

I see what all before me have seen.

A river of time that runs deep with the tears of sadness, the eddies of regret, the rapids of anticipation, and the sun-dappled, warm, mossy shallows of joy.

I see life as it runs its course before me, and today I am content.

Child’s Play

Dr. Kenneth Azar, a mentor of mine at the old Georgia Regional Psychiatric Hospital in Augusta, Georgia, told me something once that has always stuck with me.

He told me that in the early years of his practice, when he was living and working out in Idaho, that he was one of a very small handful of psychiatrists who served the whole state. If an adult with psychosis needed to be stabilized, he would write orders for medications and restraints. If a probate court hearing came up and needed testimony from a psychiatrist about the need for further inpatient treatment versus release to outpatient follow up, he would oblige. If a child was mentally ill and needed to be assessed for depression or trauma or sexual abuse, he was called on. If a forensic case could not go forward without an evaluation by a mental health professional, he would get that call too. He was basically, in this early part of his career, a jack of all trades and a master of none.

Fast forward several decades, when Dr. Azar had been on the faculty of the Medical College of Georgia School of Medicine, Department of Psychiatry and Health Behavior for a few years. He was teaching me, and a steady stream of medical students, interns and residents, all about acute inpatient psychiatry. The North Unit, as we used to call our stomping grounds in those days, was the perfect backdrop for real world learning about mental illness, its diagnosis and treatment. No textbook could have ever provided the rich tapestry of mood disorders, psychosis, substance abuse, personality disorders and rapid-fire triage of mental disorders that this unit did. I probably learned more there, when I think about it now, than I did anywhere before or since in my long association with the field of psychiatry and mental health.

In those early days, I developed my love of the treatment of severe, chronic mental disorders such as bipolar disorder and schizophrenia. I have gravitated towards jobs and positions that allowed me to continue interacting with and caring for patients who have those disorders. Even on the days that I was stressed to the max, wondering how I was going to pull it all off and get the work done, I was happy in that element of chronic illness. I really did, and still do, enjoy learning more about the progression of illness over decades, how we treat it, and how we try to limit the debilitation that often comes from a lifetime of major illness that affects the brain.

Now, fast forward a few more years, past my own stints as associate faculty and mentor and teacher and lecturer to my current duties as the medical director of a busy mental health center, a clinician for four days a week during the daylight hours, and a phantom telepsychiatrist another two or three nights a week on top of that. I am still in my element, seeing chronic illness in some of my clinics that has allowed me to see how depression and psychosis and substance abuse can play out through the years and through multiple generations of the same family, all of whom I have treated.

The twist?

I am now, as Dr. Azar once was those many years ago in Idaho, a child psychiatrist by default.

Now, I did my four years of residency in general psychiatry, to be sure, including a rotating internship year and a chief residency year. I learned about psychiatry as a field, including the treatment of adults, children and adolescents, mood disorders, personality disorders, substance abuse and trauma. I am certified by the American Board of Psychiatry and Neurology. I am well trained, and I have decades of experience in systems as varied as local family counseling centers to Veterans Administration hospitals to state hospital systems to the private sector.

All that being said, I have never seen so many children with so many mental health problems in so many venues presenting with such severe disease.

Children do not scare me. I do not feel uncomfortable around children. I have helped raise three of my own, I have three grandchildren now, and hope to have more in the future!

Even so, there is something quite distressing and disconcerting to me about the fact that I, and many other psychiatric clinicians like me, must now, in 2014, see, evaluate and treat children as young as two-yes, TWO- who might present with symptoms as disparate as mild separation anxiety to florid psychosis. I am humbled by the fact that as I get older, I know what I do not know, and I am striving to increase my knowledge base daily so that I can provide the best care I know how to my charges, adult and child.

It breaks my heart when a child tells me stories of being bullied mercilessly by his peers because he is thin or fat or smart or talented or effeminate or likes to color his hair orange.

It makes me angry to hear stories of abandonment by fathers who are nothing more than biological and care not at all for the fragile lives they help bring into the world, leaving them to flounder with overwhelmed, poverty stricken mothers ignored by political systems that simply don’t care about them.

It makes me physically ill when I hear stories of sexual trauma, rape and molestation that go on for years, with other family members turning a blind eye or simply accepting that this is how it is.

It brings tears to my eyes when the little eight year old girl in front of me tells me that she attacked her teacher because “the voice of the bad man in my head told me that I should kill her”.

I never considered myself a child psychiatrist. That was not my first love clinically. I did not seek my Board certification in that specialty area. I never solicited patients who rode skateboards instead of cars and rocked Beats headphones and iPads instead of printed newspapers and transistor radios.

If I look at my schedule for the past week and read over the consults I’ve done in the emergency rooms all over the state of South Carolina in the past week, though, the picture is pretty clear.

I am a child psychiatrist whether I chose to be one or not. It’s a big part of my job and my professional life at this point, and with the shortage of child psychiatrists coming out of training programs around the country, I don’t see it changing anytime soon.

My take on this state of affairs?

I will never stop learning to be a resource to my patients, especially the small ones. I will never stop growing professionally. I will always pay special attention to the stories that the children tell me, because after all, they are our future.

I know that by seeing children who suffer from mental illness and trying my best to help, I can change the world, one little child at a time.

Is there really any more awesome reason to get up and go to work in the morning?


Two of my grandchildren, when they were first learning to use an iPad mini.

Thunder Lizard

Okay, so I had this thought, not for the first time I’ll admit, but today at any rate.

I acknowledge that I am a dinosaur.

Now wait, wait, don’t get all up in arms and start spouting stuff at me about being so young and handsome and witty and smart and all that (well if you must, go ahead. I’ll give you a few minutes to get that off your chest, then we can move on.)

I’m actually three dinosaurs, a hat trick for my hockey loving readers in Canada, a trifecta for you gamblers out there. And this is not necessarily a bad thing, but something that I’ve just had to come to terms with, starkly and unavoidably, in the last few weeks as things change in the world of medicine in general and psychiatry and mental health specifically.

My first dino-personality fragment is the Deny-o-pod.

You see, I trained in what I now know and wistfully acknowledge was a golden age for young psychiatrists. We were young and idealistic and had the best of both worlds in our books, our patients, our supervisors and professors. We learned all about psychodynamic theory and we were on the cutting edge of the “new” age of psychopharmacology. We had it all, loved it all, discussed it all in a haze of cigar smoke (yes, Dr. McCranie, I’m thinking of you, wherever you are) and good feelings that made our training class feel more like a very small, tight cadre of lifelong friends than wet-behind-the-ears psychotherapists.

The Deny-o-pod in me wants to think that that time and that feeling will never change, when in reality that train left the station many, many years ago. Oh, we still see the faintest of glows from the tiny red taillights on the caboose, but the freight train that carried the likes of Anna and Sigmund, Adler and Jung, Skinner and Kernberg is fast approaching the roundhouse and will not be sent back. I like to think that I can still take three hours to see a new patient, write my notes at my leisure anytime in the next day or two or three after the visit (or better yet just jot down one sentence, sign it and be done) and have plenty of time to read about the things I see and think on them for a time.

That never happens any more. Visits for new patients are crammed into thirty minutes if that, follow ups can be as little as ten minutes, and the new collaborative documentation standard looming by the new year says that notes are typed while the patient is in the room, with input from the patient and buy-in for the treatment plan in real time. This is supposed to make mental health workers happier, healthier, have loads more hours free to see loads more patients and spend more quality time outside the consulting room doing other things. Time will tell. Deny-o is skeptical at best.

Delay-o-saurus is the second of the Jurassic trilogy that lives in my head and heart.

Even when I think of the fact that times are changing, radically, and that we will never go back to those golden days, and even if I tell myself that I must change along with everyone else if I want to keep working, I manage to tell myself that it is perfectly fine to delay and stall and do things the way I’ve always done them until someone, most likely my boss, drags me kicking and screaming into the next decade with a new set of standards and expectations. This is fallacy, of course, and I know it. I have to get on board just like everyone else, especially my staff, who I must motivate to change too.

The third scaly and lithe beast is one who flies, the screeching, soaring Dive-o-dactyl.

That part of me knows that the only way for me to really get my head in the game when change like this happens is to dive right in and go for it. I know what I have to do. I also know that I don’t like being told what to do! That doesn’t matter in this kind of situation. The change is coming, and it cannot be ignored. It’s time to put my head down and dive right into it.

I’m fifty-seven years old. I would like to work at least twenty more years if I stay healthy.

I know I must change and adapt, or I won’t survive.

At least I know my fate won’t be the same as the dinosaurs of old.

There are no asteroids in South Carolina to my knowledge, and I don’t smoke.


Cartoon by the one and only Gary Larson.

Inspiring Steve Jobs Quotes on Passion, Life and Technology

Originally posted on Let's Reach Success:

Steve Jobs changed the world.

Most of us enjoy his legacy every day, but what more we can do is learn from what he had to say, read his thoughts on important stuff and try to think about it, pay attention to what truly matters and see life, death, time and technology through his eyes.

Here are some of the deepest, wittiest and wisest things Steve Jobs has said about the world we live in:

  1. Your time is limited, so don’t waste it living someone else’s life. Don’t be trapped by dogma – which is living with the results of other people’s thinking. Don’t let the noise of others’ opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition.
  2. If you haven’t found it yet, keep looking. Don’t settle. As with all matters of the heart, you’ll know when…

View original 1,014 more words

‘Tis the Season

“Mom, will it ever get here? It seems like it takes months and months for it to get here!”

“Yes, dear, the day will come soon enough. I know you’re very excited. Color another picture for me maybe? Use lots of bright colors. Okay?”

“Yes, ma’am. I can’t wait, Mom. It’s my favorite day of the year.”


“Does this one look okay, Dad? I want to make sure I have something nice to give her, you know? I mean, she does so much for us every day. She never rests, does she?”

“Hardly. She’s always loved giving to people, Sport, you know that.”

“Then this has to be perfect for her. Do you like the foil inside or just the silver seal on the outside?”

“Why not both? She’d like that.”



“Oh, come on, Mom, just one! Can’t we open just one tonight? It won’t hurt nothin’!”

“Anything. It won’t hurt anything. Grammar, young lady.”

“Just one little one, Dad, please?”

“Your mother has spoken, guys. Besides, we haven’t had the first mouthful of turkey yet. You can wait until tomorrow morning, I’m sure. Now, come get your supper.”


(First light)

“Shhh. Quiet!”

“What time is it?”

“Zero dark thirty, kid. Too early for parents to wake up without a severe attack of the pre-coffee grumpies. Quiet!”

“Look! A stack for you and a stack for me. There! On the coffee table. Cool!”

“Mom’s got the biggest stack. Look. There’s my silver foil one, right on top.”

“We’d better start making a little noise in the kitchen or they’ll never wake up.”



“And here’s the next one for you, Mom. Very pretty! Fancy writing on the outside.”

“Oh, how sweet. It’s from Mrs. Jones next door. Thank you so very much for the casseroles you made and placed in my freezer after my surgery. Here it is November, and I haven’t even eaten them all yet. I owe you a great debt. Sincerely, Betty.

“Open one of yours, Junior!”

“Okay, here’s a neat one with Ninja Turtles on the outside. Thank you for cutting my grass this summer. I had the prettiest yard in the city because of your good work. See you soon, Mr. Peebles.

“See, Sam, I told you he appreciated you and your diligence. People notice, son. You may not think so, but they do.”

“Now, I know we have more notes to open, but who wants turkey and dressing?”

“And cranberries!”


“Sam, as the eldest, would you please do the honors and say a blessing for us?”



“Thank you, Sam.”

“No, thank you, Mom.”

“Whatever for, son?”

“I want to thank you and Dad for teaching us the reason for the season. The meaning of Thanksgiving.”

“Yeah!” the twins chimed in. “This is the most awesome turkey day ever!”


“Here, now who’s ready for pumpkin pie?”

Thank you, God, for gifting me with my children and grandchildren, and for the life I am blessed to lead.

Happy Thanksgiving to you all.