People Who Need People

People, people who need people,
Are the luckiest people in the world
We’re children, needing other children
And yet letting a grown-up pride
Hide all the need inside
Acting more like children than children.

People” is a song composed by Jule Styne with lyrics by Bob Merrill for the 1964 Broadway musical Funny Girl starring Barbra Streisand, who introduced the song.

My newly minted son-in-law just started his internship and residency in emergency medicine in Denver, Colorado this summer. I feel for him. The first year is designed to be hell, and it usually is. Once you’re past it, things get better and better in many ways. But first, you have to learn. A lot. You think you absorbed so much in medical school and that you are now a doctor because you have MD after your name. Wrong. You are just starting your journey to being not just a doctor, but a physician.

It starts early, the indoctrination. Living, breathing people who come into your circle of influence, no matter how small it is as an intern, are sick. They’re hurting. They’re wanting something from you. They may be at risk of dying. Your job is to rapidly assess what you see in front of you, make a diagnosis, and fix it. Simple, right?

You learn to run with the numbers, the trends, the evidence base. You know how many symptoms of what severity need to be present to diagnose an acute myocardial infarction or an abdominal ileus or a suicidal depression. You listen, you examine, you rapidly run through a differential, you get labs and studies to augment your thinking, and you decide what to do.

You fix it.

If you’re a psychiatrist, you might do this fifteen times a day. A family doctor might do this fifty times in an afternoon. An ED doc might do it a hundred times in a shift in a busy ED.

The powers that be in medicine these days are trying to turn us all into fast-talking, fast-typing, money-making medical technicians. We evaluate, crunch the numbers and act. Next. Repeat.

Sick people have become patients have become clients have become consumers of medical services have become members have become souls.

We doctors are fast losing touch with what makes us who were are. Healers.

I am learning more about the practice of psychiatry and about myself now than I have ever learned before. I don’t like all of it, but I’m embracing it. As I get older and continue to practice medicine, I learn important things on a more and more regular basis.

One of these is a very simple, back to the basics kind of discovery.

My patients are still people.

In some of my practice settings, I have begun to see the third and even fourth generations of patients from the same family come to me for help. These multiple generations are teaching me about the heritability of depression, bipolar disorder, schizophrenia and substance abuse. They are teaching me about the realities of dysfunctional family dynamics and domestic violence. I hear their stories and I listen. I learn.

I have found that appointments have become visits. Visits have become real conversations. Both patient and doctor look forward to these. This is why I chose psychiatry as my primary specialty all those years ago. I do not want to be the six minute prescription pusher who knows little to nothing about the life of the person he is treating. I can’t practice medicine that way. Never have. Never will.

I look forward to seeing my patients and hearing what they have to say.

I have recently returned to cover a clinic where I have not seen patients for the last seven years. I have changed. Some of my former patients have not. I am seeing many more children than I have ever seen. That may be another post for another day. The return to that clinic, especially following a beloved physician who retired and who practiced similarly but not exactly like I do, has been a lesson in humility, resilience and improvisation.

In the end, the bottom line is that I went into medicine to help people, like many doctors did.

I decided to be a physician because I wanted to get to know people on a level that is almost impossible in any other job or setting. I feel extremely blessed and lucky to be able to do what I do. I am grateful for the chance to reach out, engage, and help.

I’ve told you before that I’m an introvert at the core of it (some of you still don’t believe that), but even introverts need social contact, one-on-one time, relationship.

People who need people are the luckiest people in the world.

IMG_0034.PNG

Shazbat

“I believe I could do dance on ice, or play in a musical of Freud’s life called “It’s Your Mother”- or maybe one for the symbolists: “Jung at Heart”. There’s always the one about India: “The Ghandi Man Can”.

Robin Williams

She was the coroner for the county I came to when I started my private practice many years ago. She was well known around the area, sister to one of the local primary care physicians, and very active in trying to figure out why our county had one of the highest suicide rates in the entire state. She also started a custom of painting a white cross on the highway at the spot of each traffic fatality her office had to work.

I met her in the course of doing my own work, first as a staff psychiatrist, later as a senior psychiatrist and then as medical director for a two-county mental health center. We talked about the numbers, the cases, the treatments that worked and those that failed. We talked about her task force, and I came to be a more active part of it later, as time went on.

She was passionate. She was loud. She was persuasive. She was dogged. She was unconventional. She was driven.

She got cancer.

She was very sick, in and out of work, finally unable to do any more. We talked, on various levels and in various contexts, about what it all meant. Her work. My work. Her life. My life. Her death.

She died.

I don’t remember all of it, not the details of it, but I do remember one thing very clearly, even today. I remember the gut wrenching feeling I got, deep in my core, when I heard she had died. I was done for the day. I couldn’t think. I couldn’t focus. I couldn’t do anything but go home. I did.

I lay across my bed, in my bedroom at home, and cried. Really cried. I don’t know how long. I just know I cried, hard. I didn’t know then what I was crying about. I just knew that I was tremendously sad. I knew that we had lost something important, somebody important, somebody who cared.

I was driving home today when I got the text from my oldest daughter.

No, I had not heard. What?

No.

No, no, no, no, no, no.

More texts, tweets, posts, quotes, pictures, film titles, Oscar shots, more quotes.

“Apparent suicide.”

I knew him like we all knew him.

Not personally, but as Mork. As the guy behind the mic loudly proclaiming “Good morning, Vietnam!” As the voice behind some of the most beloved characters in film. As one of the voices who made feet happy. As a man who sat and made a fund raising commercial with a little boy from my community, a boy who had defied all odds and survived the onslaught of a horrendous cancer with the help of the staff at St. Jude’s.

I felt the tears coming again, for this man that I had never talked to in person, or sat around a table with discussing suicide and mental health care. I felt the tremendous rush of emotion that comes with knowing that someone is really gone, permanently gone, and that nothing anyone can do will ever bring them back again.

I understand the tears now, though, at least better than I did when my friend died of cancer those years ago.

We weep not because we have lost someone. If we live long enough, ALL of us will lose someone, more than likely several someones.

We weep because we know what they have brought out in us. What they have made us do. We think better because of them. We ask questions. We marvel. We dream. We dance. We sing. We love. We laugh, oh, my do we laugh and laugh and laugh and laugh.

They make us better, and when they are gone we know that we will never quite be the same again.

Robin Williams 1951-2014

Clarity

Sometimes we writers struggle to find things to write about.

Sometimes we sit, an uncompromisingly blank piece of paper in front of us, twirling the Montblanc or the Mirado Black Warrior #2, waiting for the Muse to arrive with the coffee and wisdom that only she can bring. Sometimes she comes, right on time. Sometimes she makes us wait. Sometimes she stands us up.

Today, she came straight at me, holding out a bright orange Jittery Joe’s large Crackacino with three Equals, dark, strong, and good. She made no bones about what I was to write today.

I want to talk to you about clarity.

To be clear, I want to talk to you about three aspects of clarity.

The first is clarity of thought.

We live in a world of too many choices, too many stimuli, too many rules, too many loopholes. We are confronted with ambiguity at every turn. We could do this, or we could do that. We could believe this, or not. We could value this, or not.

We watch screens, three inch, five inch, seven inch, eleven inch, thirteen inch, fifteen inch, seventeen inch, twenty-one inch, twenty-seven inch, God, up to six feet across. They tell us what to think, how to dress, what to buy, how to eat, what to read, and what is popular. They tell us who is rich, who is poor, who is beautiful, who is ugly, who is smart and who is powerful.

We are bombarded with cues, clues, and mandates. We are told what to do and how to process. The result is, of course, that we are nothing more than confused. Horribly confused. Awash in what ifs and how tos and maybes and somedays and if onlys.

We have forgotten how to think.

We all need to sit with ourselves, just with ourselves, and think. We need to be clear and honest with ourselves about what we think. Why we think the way we do. What we believe to be true and why. We need to do this today more than we ever have before.

The second is clarity of action.

Any good practitioner of cognitive behavioral therapy knows that one may not change actions before one changes thoughts. Clear thoughts lead to clear actions.

Be honest with yourself today. Why do you do what you do?

Is it to feel good? Is it to impress someone? Is it to provide for your family? Is to achieve fame or notoriety? Is it to become rich? Is it to manipulate someone else, or to make them suffer? Is it to become more in touch with yourself, your own emotions and feelings and aspirations?

My friends, I don’t care what you do. I would never offer advice about what you should do. It’s simply not my place to do that. The choice to take an action or not, to follow through on something or to let it go, to seize an opportunity or to let it slip by is completely up to you. To each of us. You must make that decision for yourself.

I would just ask that even as you try to think more clearly, that you also act out of a sense of clarity as well. Know what you are doing. Choose it, actively. Decide that it is the right thing, the right path, the right direction for you. Don’t let anyone or anything make that choice for you. Act from a position of strength.

The third is clarity of motive.

We all fool ourselves. We do it every day. We tell ourselves that we think this way and act that way because of our religious beliefs or our upbringing or our sense of responsibility to the greater good.

Bullshit.

We know exactly why we do the things we do and what drives us. We are just too embarrassed or afraid to be honest with ourselves and own our own thoughts and actions. I see it every day in my professional work. Patients want me to validate and sanction and explain their thoughts and actions away.

A large part of my day to day work is helping people to see that they are not victims, they are not powerless and they are not doomed to the present state of affairs. They can change.

Why do you do what you do?

Why do you stay in a job that you hate? Why do you live with someone who abuses you? Why do you repeatedly make poor choices? Why do you drink or use drugs? Why do you see yourself as a victim? Why do you let others have so much control over your life? Why do you resist making the changes that will alter your life in profound ways, mind-blowing ways?

Let’s be clear.

Your thoughts are your own. Sit down and be honest about them. Hash them out. Explore them. Flesh them out. Let them expand. Own them.

Your actions are your own. You decide to do something. Or not. You make the choices, every day of your life. Own them.

Your motives are yours alone. You know exactly why you think and feel the way you do. You know exactly why you act the way you do. Are you brave enough to be honest with yourself and own that, too?

Clarity of thought.

Clarity of action.

Clarity of motive.

Think, do, and understand exactly why.

Your life will be much simpler and much richer for it.

Waffling in The House

(Hey, you got one!)

“How are ya, hon?”

“I’m fine, thank you.”

“What can I get you, sweetie?”

“Cheesesteak omelette, tomatoes, no grits, no toast, black coffee, please.”

“Pull a cheesesteak, tomatoes, don’t drop one, no bread!”

“You want that coffee in a big to go cup, hon?”

“Yeah, that would be great, thanks.”

“Where you headed?”

“Up to see the Berry football team’s first game tomorrow.”

“Oh, are they any good?

“This is their very first year having a football team. I hope they’ll be good.”

“Wow, those tomatoes were makin’ me sneeze!” (Washes hands vigorously)

“Here’s your change, Louise.”

Mumble mumble mumble.

“Hey, Tex, you’re early! Is this even the right day for you?”

“New route. Be here Tuesday, Wednesday, and Friday.”

“I’ll guess you’ll see me, then, if you come back on Tuesday.”

“If he lets you out of the bedroom. That’s where I hear you been holin’ up lately.”

(Blushing furiously)

“Everything okay with you hon?”

“Yes ma’am. Good stuff.”

“John’s not here anymore, huh?”

“No, he went over to the Cartersville store I think. Over there with Margaret I think.”

“He was a good one.”

“Yes, he was.”

“You want your usual, or you want to wait until you have a couple cups of coffee in you first and then decide?”

“Yeah, coffee first.”

“May I use your bathroom?”

“Sure hon, right down that hall.”

“Good night, Ms. Louise. See you on Wednesday.”

Mumble, mumble, mumble.

“At least we made a little money.”

“Yeah, a little I think.”

“You need anything else, hon?”

“No, I’m good, thanks.”

“Good luck to your team tomorrow!”

“Thank you.”

“Hurry back.”

I love to travel.

I love to eat on the road.

I love to people watch.

It’s all good.

(Reposted from 9-6-13. Hope it gives you the same chuckle it gave me.)

Ghosts in the Machine

I took the shortcut via a backroad from the local college to the mental health center the other day, just for kicks. In doing so, I did a drive-by past my old private practice office. It’s a nondescript, low, one-storey brick building that now houses a primary care clinic that sees a lot of my patients for their hypertension, diabetes and chronic low back pain. As I zoomed past (hey, my new car likes to hug the curves in Sport mode), I could feel myself in that building.

I could see myself booting up the old Mac LC that held the records of my professional life in the early 1990s. I could feel and hear the little squeak of my dark maroon leather executive chair as I leaned back, crossed my legs, and took notes as I listened to a new patient tell her story. I could hear my administrative assistant answering the phone in the next room. I could feel the scratch of the gold nib of the fountain pen that I used to write my very brief notes in those idyllic days of dark inks, real paper, and color coded charts. I could see myself returning phone calls after the last patient had left at five PM, anticipating the consults that waited in the ER and the rounds on my half dozen patients on the inpatient unit in the hospital.

Now, dear readers, before you all tell me to take a dose (a very large dose, preferably by injection) of my own antipsychotic medications, hear me out. I don’t really think I’m out of touch with reality, though some of you who know me very well might disagree.

I could feel myself there in that squat, plain, brick office building because I think I left a part of myself there, all those years ago. I spent many hours in that office, pouring over schedules, reading textbook and papers, helping many people through hard times in their lives, personal and professional. I also spent hours agonizing over the suicides of patients, some mine, some those of my partners, and wondering what we, what I could have done differently. What did I miss? What did I not know that I should have known? How could I set the losses right with the next hundred, five hundred, thousand patients? All of this entered my brain at light speed as I went past my old office in my new car in my old(er) body.

This is not the only time this has happened to me, and I’ll bet my last drachma that it’s happened to you too. I’ve written in this very space about going back to the mill village of my childhood and visiting the ghosts around the central field where Christmas lights glowed, the now-empty field where football teams played and I blew trumpet at midfield, and the mound of earth that used to be the community swimming pool. Part of me is there too, just as surely as I sit in this coffee shop on this rainy day and tap tap tap these words.

Part of me still hangs out at the fishing pond that used to belong to my grandfather Jack, a beloved place of sun and heat and crickets and Catalpa worms and bream and that one humongous largemouth bass that I could never catch.

Part of me will always, and I do mean always, live on the front porch of my grandparents house, sitting in the squeaky wooden swing there, whiling away the hours as happy as any kid could ever be.

Part of me will always be sweating in the sun at the beach, any beach, but especially my beloved South Carolina coast, a magical, mystical place of marsh and blue crabs and spectacular sunsets and drinks on the dock.

When we pass through the places of our lives, do we leave parts of ourselves behind?

Do we let a little of our essence, our being, stay behind as place holder, a signpost, a guide for those who follow? Is it a physical thing, some almost invisible DNA in manifest form that becomes a forever part of that place, adding to how it is seen by others who zoom by in their own new cars?

Is it a spiritual thing, a puff of our essential smoke, our invisible but tactile self that cannot be seen by others but can be felt by those who love us, long after we leave this world?

Is it an attitude, a thought, an imprint, a bit of influence imprinted upon someone who then passes it on to someone else years later?

I would argue that it is all of these.

I would also argue that in this age of change in the world, in this time of uncertainly for so many, abuse of power and misuse of humanitarian possibility, that the essence of all of us, the good in all of us, must be left in places where it will be seen.

We must, if humankind is to not just survive but thrive in the centuries to come, leave markers to remind others that follow us what is right, what is true, what is real, what is enduring, what is truly important and what is worth preserving and passing along to the next generations.

How do we do this?

How do we leave our essence, the thing that makes us human?

We can leave money, endowments, marble edifices with our names engraved for all time. We can teach, write books, guide students in the ways that will make them successful and happy members of society. We can give our time. We can create, with words, and art and music and the things that stir men’s souls.

Yes, we can and should do all of these things.

But above all else, dear readers, we must leave these traces of ourselves, this essence of humanity and what is good in the world, everywhere we go, every day, by caring and being seen and making a difference in the world.

It is only by being passive, by not caring, by hoping to pass through this life without being noticed or leaving a trace of ourselves that we will insure just that.

A world that does not remember, does not know, and does not care.

Faith, Hope and Love

I don’t usually crowd source my blog posts. As a matter of fact, I never do. First time for everything, right?

I published this status update in Facebook yesterday as I was having a late pre-fishing trip breakfast, and over sixty people have already liked it. There have been many good comments and personal takes on the situation that prompted the post. I would like to expand on my feelings in this blog post, and I would like to share some of what you said to me that made me think even more about the topic at hand (thank you for that!). Here is the post from yesterday:

Just saw a very sweet elderly couple quietly enjoy a large breakfast, smile at each other, and talk very respectfully with their nice waitress.
Then, he got up, unfolded her walker with the dayglo yellow tennis balls on the back legs, gently helped her up, steadied her, and slowly walked with her to the door and into the parking lot.
Love, real love, is patient and kind.
Respect only grows stronger with time. It does not see class, color or infirmity.
Devotion is dogged. When challenged, it only becomes more tenacious.
Well done, sir. Well done
.

First off, some of you might remember that I talked about another couple I saw in another setting, two people who looked tired and sad and said not a word to each other as they ate their meal. Watching them, I felt sad, defeated, worn down. The futility I felt while watching them felt very real to me.

This elderly couple was different. They had to be in their eighties, both a little feeble, he a little kyphotic but still tall and relatively strong for his advancing age. She, obviously post-stroke or some other event that necessitated the walker, but with a sweet face and a look in her eyes when she made eye contact with him that spoke love in a way that was unmistakeable. They enjoyed a hearty breakfast, eating more than I did! They didn’t say much to each other, but in this case I don’t believe they had to.

His attention to her was slow, measured, careful, loving and supportive. He never pushed her, never scowled at her, never hurried her at all. She made an obviously difficult effort to rise, balance herself and walk. He never wavered, supporting her arm at the elbow, guiding and letting her shift her weight onto him as she needed to.

I had no doubt that he was always that way with her, that he loved and cherished her, and that he would do anything to make her life easier. No words were needed. He didn’t need to explain himself. It was all so clear, so very clear in his actions.

One of you told me that what mattered was that this was their reality and their life. Sometimes, we don’t get to choose what happens to us. We do, however, choose who to spend our lives with, who to love and cherish and who to support. We also choose who to show our vulnerabilities to. This loving companionship, this caring and sharing and supporting, work both ways in a good relationship. A relationship cannot last, not in any meaningful way, when these bonds are not real, not strong.

Another reader told me that she had spent a lot of time “unfolding the walker” for her dear husband. She said more in that one little comment than I could ever write in a thousand words.

One reader asked if I thought this was the exception. I certainly hope not, though I think the world likes to hear more about the sensational, the negative, and the outlandish much more than it does about the quiet humbleness of a man acting out his humility and servitude in the context of love and devotion.

One of my friends commented that love and resilience are two qualities that must be present in a successful marriage, and she is so right.

Another friend reminded me that love and respect go hand in hand. The former is not real without the latter.

I was very humbled by the likes and responses and opinions shared on Facebook about this tiny little status update as I sat there drinking coffee and eating eggs. There is so much sensationalism in social media these days that sometimes we forget to sit quietly, observe our world, and allow ourselves to think, observe and learn.

For those of you who have this kind of relationship with someone, cherish it, please. Work on it. Nurture it. Feed it. Let it grow and grow as the years go by, so that when the inevitable storms come and the stresses mount up and you feel lost and unable to cope, you can look across the table at the love of your life and know that everything will be okay.

For those of you who have never had this, I hope you find it. At twenty or forty or sixty or eighty. I hope you find it and it knocks your socks off.

For those of you who have had it, or even a part of, and lost it, take heart. Never give up. Miracles, true miracles, happen. Love blossoms and grows in the most unlikely places. Old loves come back. New loves spring up.

Never stop looking.

“For there are these three things that endure: Faith, Hope and Love, but the greatest of these is Love.”

Aramaic Bible in Plain English