I sit in the Nova, the one I’ve lovingly and falsely pimped out to be something it’s not. (No, maybe that was me…) I told him I was going straight to school. Yes, sir. I understand, sir. She tells me it’s okay if I pick her up and take her. Sure. She’s so fine. Dad won’t mind.

He hops, awkwardly, once, twice, three times. Plop. Splash. Little almost-wings beating furiously against not-air. Little head straining upwards against not-life.

I round the curve a little too fast. Over correct. (Oddly, the same thing my furious father will do later) Off the pavement and into the ditch. Teenaged arms straining against the torque. Teenaged brain thinking not that I’m going to die, but that I’m going to survive just long enough for my father to kill me. Thud. Hiss.

We set him down gently, nylon leaf skimmer and all, since he won’t let go. He’s in the bright sunshine. He’s warm. He’s okay. Momma has been circling him with the same fat bug in her mouth once, twice, three times. She gets close, then backs away. She sees him. I’m not sure if she’s confused or delighted by his independence.

“You’ll need to get a job to pay for it,” he says, matter of fact and stoic.
A thousand dollars. Might as well be ten thousand, a hundred thousand.
I’m not sure if he’s confused or delighted by my dependence.

“Bird brain,” I think to my soon-to-be-working-the-graveyard-shift self.

He blinks. I’m sure he feels the bright morning sun on his damp wings and is somehow glad to be alive.

Who will I mentor today?

Who will I guide out of the rainy darkness?

Who will I touch without ever touching?

Who?

Some of us get up every morning and see patients. Lots of patients. An overwhelming number of patients. So many truly sick people that our broken systems cannot address all the problems they bring. So many unemployed people, so many people without health insurance, so many people who cannot buy the newest expensive medications, so many people who are more anxious after coming to the emergency room for treatment because they are already drowning in debt and cannot take on one more hospital bill. We try to see them all. We try to listen to them. We try to help them and make an impact on their lives. In the midst of this we are asked to fit these wretched masses into neat little boxes of five out of nine symptoms and illness for greater than two weeks but less than one month and psychotic symptoms that meet this threshold but not that one. We are asked to pigeonhole. We are asked to make the diagnosis of the month, or the year, or the decade. We are asked to make people fit the book, whether it’s the first edition or the fifth revision.

You know what? Virtually all of the sick, down and out, hurting people that I see do not read the book. They don’t give a shit about the number of diagnostic criteria they meet, for how long or to what degree or severity. They don’t care if the qualifier after the decimal is a two or a three or a four. They come to see us because they are in pain. Their lives are broken. They have no jobs, no money, and no self esteem. They are drinking too much and smoking dope and popping pills because it’s the only way they can make it through their miserable lives day to day. They are trying to survive. They are trying to feel something. They are trying to be human. They are desperately trying to get someone to understand.

Freud was wrong about a lot of things, but the love and work things, those two are important.

Functioning equals symptoms minus diagnosis times treatment.

Listen to the patient. Hear what she has to say. Figure out where it hurts. Figure out a good treatment to make it better. Treat it. Watch her get better, feel better and function better.

Help her to have a life that satisfies her in the real world, not a diagnosis that fits a book whose diagnostic criteria will only change, again, in five more years.

That is my battle cry. I’ll leave it to those much smarter than me to continue to revise the books.

The one thing I absolutely do not look forward to is the documentation.

We doctors are a busy lot. We like to do things and solve problems and talk and fix and plan and complete procedures and take things out and put things in and change people. When we finish doing that with one person we like to move on to the next one, and the next one, and the next one. We do not like to slow down to fulfill someone’s idea of writing for writing’s sake, or dictation to complete a chart or completing a discharge summary to avoid sanctions from the Medical Records police. We do not like to be just busy. We like to be productive. There have been more than a few articles in the last few months addressing the actual speeding up or slowing down of physician productivity when an electronic medical record is injected into the mix and the exam room. Surprise surprise, but some doctors are actually slower and don’t perform as well when saddled with the requirements of an EMR.

I have two very fond memories of practice past.

One was my old private psychiatric practice. I might see someone for a fifty minute hour, as it was called, of psychotherapy, enjoying the back and forth of that enterprise. After goodbyes were said, I would pick up a thin manila folder with the patient’s name and number on it, flip to the notes section, pick up my favorite Mont Blanc, and write this simple entry:

“One hour psychotherapy. Issues of abandonment and anger addressed. No medication changes made today. Follow up appointment in two weeks.”

Boom. Done.

The second memory is of my time on the Gulf coast after Hurricane Katrina. I was deployed via the Red Cross and was initially attached to an ERV (emergency response vehicle) team that served meals and drinks to thousands of displaced people in the countryside in Mississippi. My job was to make contact with as many stressed people as I could every day. Talk to them. Soothe their fears. Help them find medications or listen to their stories of evacuation and loss and pain. I loved it. It was connecting and communicating with humanity at its best and worst all at the same time. It was being so real that you could taste the interactions with people like you could taste the dust in your mouth after a long day on the country back roads. It was gritty. It was exhausting. It was exhilarating. My documentation requirements for the Red Cross? A tick mark for every person I spoke to that day in a little spiral bound notebook I kept in my back pocket.

Some days I came home to a meal and a hot shower at the church that was my base with over five hundred check marks in my notebook. Five hundred.

Do you think I cared any less or made any less effort to help people when my documentation was sparse? Do you think I enjoyed or paid attention to my work any less when I had no burden of electronic documentation or insurance forms or written checklists?

Doctors want to help people. We want to be busy and productive.

We want to make a lasting record of what we do, but we don’t want the act of record keeping to keep us from being the doctor of record.

I’ll go back to work tomorrow. I’ll try my best to remember that the reason I’m there is not to write a novel, but to change someone’s life for the better.

I write this from the dining room table in the beach house that my family has enjoyed for the last twenty three years. When I look up I see the dunes, the low scrub brush, sea oats and other plants that make up the fragile coastal ecosystem that many birds and animals call home. Just a scant few yards past that I see the white caps of the St. Helena Sound, breaking merrily over the sandbars a few dozen yards off shore. Except for subtle yearly shifts in the pattern of the dunes and the height of the vegetation, this view has been remarkably consistent over the last quarter century. Some times consistency is good, but sometimes looking at the same landscape from a different perspective can be helpful.

Today I drove the short distance over the bridge to the next island, an island that is designated a state park and for that reason is much wilder and less developed than many others that join it to make up the Sea Island chain.

I enjoyed a long walk on the beach there, a place that reminds me of prehistoric times and almost makes me think some huge dinosaur will burst from the green vegetation and chase all the tourists to the breaking waves of the shoreline. I took pictures on that walk, and I made a special point of looking down, as far down on the beach as I could, straining to see what tiny animals made their homes there among the fallen trees, broken concrete piers and old sea walls. I saw some of the most beautiful sea creatures, small and nondescript at first glance, iridescent and glowing on further inspection. I marveled at how much life there was below the usual plane of my vision, how much of the world went about its business out of my sight and consideration. The more I looked, the more I saw. There were hundreds, even thousands of them, clinging to life through tide after tide, hanging on for dear life cemented to plants that had once been alive, but now served as odd apartment houses and residential villages for these little citizens of this island world.

After the beach walk I climbed the spiral stairs of the island lighthouse, rising one hundred forty feet above the park. As I exited the metal door at the top of the structure, a very stiff wind met me and threatened to rapidly decrease my bravado as I hung over the single iron railing to take more pictures of the tiny people below. I looked out from the black and white tower, circling to get the full three hundred sixty degree perspective it offered, and was again (for I had been here a few times before) amazed at how far and wide ones view of the surrounding coastline was extended by having this simple advantage of height. I could see Edisto Island, just as I can see it now sitting at this table and writing this piece, but it looked oddly different from that angle. I could see two and a half miles more of the state park off to my right, and past that I could make out the silhouette of Fripp Island, its many fine homes lined up like colorful boxy soldiers along the beachfront. People below, people off in the distance frolicking on the beach out from the campsites on the far left end of the island. A whole coastline of islands, people, beaches, houses, and activity. All places I had been before. All places that were almost as familiar as home. And yet, very different when viewed from this vantage point.

We tend to get used to our surroundings and see them the same way, day in and day out. For the most part, that is a comforting thing for us. However, sometimes looking up and out, or down and closer, helps us to see that there are other perspectives than just our own.

What can you look at in your own life from a different perspective?

The local daily paper, such as it is, has arrived.

Now, once upon a time, in the age of print media dominance, papers had weight. They had substance. They felt good in your hand. You could grab one, balance it just right, cock your arm at the elbow, take aim, and let it fly. With any luck and a timely release, the paper would fly beautifully toward the porch or the steps or the base of the back door. It would hang just right, like a Piper Cub executing a flare before landing, and almost float to the spot you intended it to occupy. There it would sit until the owner of the house came out, bathrobe tied at the waist and fuzzy slippers halfway on, grateful to you that they had only to poke one arm out of the house to fetch the document that would bring them the news of the day, the details of the triumphs, tragedies and travails of the big wide world beyond their threshold. Papers occupied space as well as time. They had heft as well as headlines.

Nowadays, I take the thin slip of newsprint that finds its way to my backyard, pinch it between thumb and index finger, account for trajectory, wind speed, humidity, solar flares and El Niño, and try my best to aim for somewhere near the back of my house. Invariably, despite my best efforts, the Document that Shall Not Be Named takes a hard right and finds the rosemary bush in the pot, a harder right and lands in the cedar mulch under the window, or makes a crazy left turn and ducks under the deck. I’ve grown immune to these shenanigans, and usually get in my car and drive away, knowing that my wife may or may not find the Easter egg that is the Op-Ed section peeking out onto the brick patio. Some days I come home and she’s outfoxed the newsprint. Other days, I see it sticking out of the rosemary like some pale handless arm. On rainy days, it looks nothing short of pathetic if it’s been left outside, the headlines running down like sweet green icing in MacArthur’s Park.

Is today’s news less weighty than stories of old? Is there less to tell us? Less that we really care about? A shortage of newsprint or ink? Why does my local printed news float like a butterfly instead of stinging the deck like a bee when it falls heavily to earth after being tossed from the car that brings it in the early morning fog?

I’m not sure, but I am sure of one thing.

I for one no longer get my news from a rag. Where do I get it?

I read multiple RSS feeds religiously, sending things that I want to give more time to to Instapaper or Pocket on my iPad. I get regular email notifications from medical news sites, prompting me to
peruse headlines that grab my attention or interest me. I see a constant stream of news, breaking stories and trending topics on Twitter. I read blogs. I listen to podcasts, including one that keeps me up to speed on the local arts scene and one that gives me a summary of world news in less than twenty minutes. I have friends and acquaintances who act as personal curators, sending me links to articles, videos, books and other media that they think I might be interested in. I return the favor, linking to things that interest me and that I think others might like to see.

My iPad, only a pound and a half, now outweighs the local daily.

Some might say that it is much more impersonal than my local paper, but it will never end up in the rosemary bush, and I have never yet let it sit outside all day in the rain.

How do you get your news?

Then of course, there’s the walking. Twice a day if I push myself a little. Fourteen miles the last three days with another 3.5 when I get home, afternoon thunderstorms permitting. Good, wholesome, sweaty, tiring, muscle stretching exercise. Time to think. Time to listen to music. Time to catch up on my podcast queue.

Time to wave and smile.

Now I’m not sure what happens on your island, but on this one people are exceedingly friendly. I know a few of them personally, but most of the people who pass me on the paved roads going to and fro are complete strangers. Just this morning, there was the island security employee in his little golf cart, the construction worker delivering a pickup load of long boards to a house under construction, and a man wearing a shirt and tie who, in this setting, surely must have been heading to work. There was the overweight man walking out toward the gate as I was coming back, huffing and puffing under his too tight white tee shirt but throwing his hand in the air and calling out to me anyway. There was the couple, elderly and frail in their late model American sedan, she sitting with hands in her lap as he raised one finger off the steering wheel in that way we all learned to do as soon as we learned to drive. Last evening there were the three guys manning the grill, one of whom had just come in driving a candy apple red Corvette with Indiana plates. They nodded in unison, manly “heyhowyadoin” smiles from all three.

There’s something about driving, walking, working, grilling, patrolling, and building on an island in the sun that just makes people want to smile.

I think my level of stress must be going down just a little. My negativity must be lessening just a bit. My hope for the future may be inching back up just a notch. My humanity may be restored yet.

A climb up the lighthouse tomorrow, a panoramic look at the spectacular view toward the Atlantic, a nice lunch and a good cup of strong coffee may just do it. I may break into a grin in spite of myself.

After all, this is a place with more smiles per mile than any other I know.

I have seen both for some time now. I wrote about one of them in a post in January, and with your indulgence I would like to repost it here as a tribute to him. The other patient I have known for years. Her death was not an altogether unexpected occurrence, but was still a shock.

In psychiatry, we don’t expect to say final goodbyes to too many patients. A friend of mine on Twitter said today that “usually saying goodbye means things are better”. Sometimes, it just means that things are over. Relationships are broken, ended, forcefully terminated without consent. For me, just like for you, it is a painful experience. It reminds me that I should do my best every day, that I should make a difference where I can, when I can. I am not guaranteed another chance.

I want to thank both of these patients publicly for allowing me to be a part of their lives. I want to thank them for trusting me to treat them and help them through bad times. I want to thank them for teaching me and making me a better psychiatrist. In sickness we find hope. In struggle we find resolve. In weakness we find strength we never knew we had. In death, we leave behind the wonderful gift that was our life, magnified a thousand fold through those we touched. Both of these people touched me, and I am a better man for having known them.

Rest in peace. Your struggles are over.

I have seen him on and off for several years. He has had the various problems dealing with issues that many of my outpatients have, with some mild anxiety and depression thrown in from time to time for good measure. He has come in to see a counselor, and he has seen me for medication management. He is like the thousands of other patients I’ve seen over my career thus far. Mostly the same as all the rest, except for one thing.

I’ll let you guess what I did that day.

Post script:

As many of you have already guessed, I gave him five refills that day in January. I knew he would not live to see me again in June. He knew it too. Neither one of us spoke that thought aloud.

Reality is what it is, but hope springs eternal, does it not?

“Yeah, I used to see a counselor years ago. Never really worked for me. Didn’t help much.”

“Oh, really? Why not?”

“Well, I don’t think think he cared that much about me or my problems.”

“What was his name?”

“I don’t really remember.”

“When did you see him?”

“I don’t know. Sorry.”

“How long did you go for counseling?”

“Oh, I don’t know. A month or two maybe.”

“Why don’t you think he cared about you or your problems?”

“Well, doc, this is sort of embarrassing, but…”

“Yes?”

“Well, he used to kinda, you know, fall asleep while I was talking to him.”

“Really.”

“Yeah, for real. I mean, one time he started to snore. I didn’t know what to do, so I just kinda sat there, you know? in a couple of minutes he woke himself up snoring so loud.”

In order to engage people we have to engage people.

Pay attention.

Take your naps at home.

Take care of yourself. You’re no good to anybody if your own body is exhausted.

When someone reaches out to you and shares their most intimate secrets, their most treasured triumphs, and their darkest fears, don’t be caught napping.

I work three jobs by choice, and I love parts of all of them, but there comes a time in each endeavor that something new pops up that severely tests one’s resolve and one’s desire to stay the course. Feel me? This weekend, I was covering a unit that had sixteen patients, one of whom was acting out severely. The atmosphere was already tense, the work hard, the schedule tight. Added to that was the fact that I had to learn a completely new (to me) software system/electronic medical record that was nothing like the one I’ve used for the last five years.

Now, I’m a fairly smart fellow. I love computers and I’m pretty good about figuring out how they work. New software doesn’t usually scare me. This system, on the other hand, rocked my smug little world. The old medical school axiom “see one, do one, teach one” did not apply here. A very very patient IT support person was very kind to me, walked me through it more than a few times, took several semi-frantic phone calls from me, patiently explained the same procedures to me ad nauseum, and then left me to figure out the rest on my own. Smart on her part, in retrospect. A kindly nurse, who I’ve known for decades, also responded to my plaintive cries from my office when a note was accidentally deleted or a bit of text went missing or I couldn’t figure out where the damn print button was hiding. Halfway through the morning, I was panicking. I hated the feeling. Hated. It.

It took me the better part of six hours to get the hang of it, and it felt like six years. The last three or four patients I saw, and the notes documenting the sessions with them, were much easier. I went home mentally and physically exhausted but no longer feeling like I was going to quit the job on the spot. Sunday was light years better, with a feeling of control that is common for me usually, and a sense of mastery of the new system that at least allowed me to get my rounding for that day done long before the sun was setting. I laboriously copied the workflow for the new system in a new orange Rhodia notebook (yes, the copy was legible- the notes from Saturday had barely been), and flipped back and forth to the sequence as many times as I needed to on Sunday to make sure I got it right. I did not lose a single note on Sunday. Everything was printed out, signed and documented per protocol. No animals, patients, or IT people were harmed in the training of this one doctor who had never met his match or felt so incompetent before this Saturday in March.

They say you can’t teach an old dog new tricks.

You can.

You just have to go slowly, teach the dog to write so had can take notes, repeat everything ten times in the dog’s native tongue, field all cell phone calls from the dog’s number, and back away slowly when you see that cornered, hostile, anxious, “I’m going to bite you now” look in his eyes.

I have added a new skill to my pedigree.

Now, if you will excuse me, I have an appointment at the vet.