Singing on the Brain

I love to hear people sing.

Somtimes, when I’m at many desk at work, I hear a co-worker coming down the hall, and she is singing a song, or a thought, or a response to a question she’s just asked herself, or her frustration at something that just happened. She sings when she gets to work in the morning. She sings during the work day. She sings a little song when she closes her door and leaves for home at five. 

My oldest daughter, who still sings, and dances, and acts, started singing as soon as she could talk-maybe sooner. She would sing a pretty little song, complete with gestures or costumes or acting as the case might be, then stop, look up and sweetly ask her audience, “Again?”

People sing as they walk. They sing in the shower. They sing in the car, with the sunroof wide open or the ragtop down, every window open and the music blaring from car speakers or into earphones. They sing from mountaintops. They sing in valleys. They sing alone, in choruses, in ensembles, in opera choruses and in glee clubs. They sing responses to online questions. They sing into their phones, along with their televisions, to their loved ones or in front of millions of live and beamed-in viewers at the Met. 

What do they sing?

Scales. Arias. Rap. Blues. Rock and roll. Torch songs. Ballads. Gospel. Pop. Oldies. Love songs. They scream. They croon. They whisper. They speak. They parrot. They parody. They emote. They let go. They hold back.

Why do they sing? 

To tell us that the times they are A-changin’, like Dylan.

To remind us to love the one we’re with,  like Stills. 

To give us some of that old rock and roll music, like the Beach Boys.

To love us tender, love us sweet, like Elvis. 

To take us to Carolina in our mind, like J Taylor. 

To say goodbye to love, like Karen Carpenter. 

To take another little piece of our hearts, like Janis. 

To remember that the first cut is the deepest, like Sheryl.

Just to say Hello, like Adele. 

To  know that all we have to do is dream, like Glenn.

And….

…because its just something they must, must, must do.

They thrill us, like Michael. 

Why do we listen?

To be distracted. 

To remember how to love.

To forget the pain.

To learn from our mistakes.

To feel happy. 

To relive those magic moments.

To say goodbye.

Singing,  like nothing else in this world, ushers us in, picks us up when we’re down, and gives us hope.

Singing makes us think, keeps us from thinking too much, focuses us, and distracts us. 

Singing accompanies us while we fall in love, helps us make babies, then helps us raise to those babies and, when it is time, helps us to tell them goodbye.

Singing celebrates milestones with us. It soothes us when we cry. It makes us laugh. It makes us proud. It makes us strong, as a nation, and as individuals. 

Singing takes words, notes, melodies, phrasing, and breathing, and turns all of our darkest fears, our finest ambitions, and our strongest commitments into something fearsome, something lovely, something that arches upward and spirals on the air and floats and frees and makes manifest that which we could never in a million years say on our own.

Singing makes us think about yesterday, keeps us fully in today, and never lets us stop thinking about tomorrow. 

Sing. 

Sing a lullaby to your sweet baby.

Sing a love song to your beloved.

Sing your patriotic allegiance to your country. 

Sing praises to your God.

Sing. 

Do the Right Thing

It’s a fine line that we walk as physicians. 

I went into medicine because I wanted to learn about the craft, become proficient at healing disease and easing suffering, and because I genuinely liked getting to know more about my patients and hearing their stories. These reasons for going into medicine as a career and staying in medicine as a vocation have not changed significantly through the last three decades. 

The problem we are faced with pretty often nowadays is this: the demands that patients (and through them insurance companies, pharmaceutical companies, families, and other third parties) make are often at odds with what we were taught to do. I’ll give you a few examples. 

Patients will come to me and ask for a specific diagnosis. Why? Because sometimes their insurance will not pay for a less severe diagnosis (an adjustment disorder versus a major depression, for example), they do not want to be perceived as being in treatment for an alcohol or other substance abuse problem (no matter how valid it is), or they need to be seen as having a particular problem because their attorney told them that it “would look good” for their disability case or other lawsuit. 

Patients will come to me asking, or sometimes outright demanding, that I prescribe a particular drug for them. Telling them that I do not presribe narcotic pain medications in a mental health clinic is easy enough. When they ask for benzodiazepines like Xanax, Ativan, Valium, Librium or Klonopin, the area might be grayer. Some patients might benefit from those drugs or even need to be on them long term, but they are the exceptions nowadays. “If you won’t given them to me, then I’ll just go to Dr. Jones down the street!” they exclaim, thinking that this is somehow a threat to me. Or, “I know that you give them to Ms. X from across town. Why won’t you prescribe them for me too?” 

Direct to consumer advertising on television has not made this any easier, since patients will come in asking to be prescribed powerful antipsychotics for insomnia or pain medication for panic attacks. What they are asking for often makes little sense clinically, but of course since they saw it on television it must be true and I should get out the RX pad. 

Some patients come in demanding a particular kind of treatment that they think makes the most sense for them. Aunt Sara may have told them to ask for it, since of course she took Psychology 101 in college and has the power of the Google search behind that vast amount of training, or they have read about it in Vanity Fair, or a friend of a friend of a friend had the particular treatment years ago and it worked for them. Some will want long term therapy when it makes little sense to drag things out for years when weeks or perhaps months will address the problems at hand. Some will want outpatient treatment when it is quite clear that they need to be admitted to the hospital. Others, already on an inpatient unit, will want to stay there for weeks, when the right thing clinically is to discharge them to an outpatient clinic. Some will ask for “counseling” when it is imperative that they enter drug rehab for a heroin problem that they do not want to acknowledge.  

Some patients want a specific kind of relationship, that is, they would like to consider the doctor their special friend, not their physician. Others like to consider themselves the medical, diagnostic and therapeutic equal of their physician, since they can and do research everything online, sometimes in real time on a smartphone while they are sitting in the exam or consulting room! Some of course want a clinical relationship to move to a friendship and then perhaps an even more intimate relationship, which is never appropriate in my opinion. I was taught, once a patient, always a patient, and I still subscribe to that maxim today. 

It is hard to do the right thing, in medicine and in life.

So what is a conscientious and well-trained and compassionate doctor to do?

Establish a professional doctor-patient relationship first, before doing anything to treat any malady. This means seeing the patient, getting a thorough history, doing an examination as indicated, establishing a diagnosis and coming up with a treatment plan. No shooting from the hip, sidewalk consulting and doing something for a friend. These will come back to bite you. Although some would not agree with me, I have not made a practice of treating my own family over the years either. If my children were ill, I figured a well-trained, trusted pediatrician was a much better option than a slightly frazzled, worried parent who happened to also be a doctor. 

As far as medication treatment goes, I have always been very conservative. If a mother is pushing for a three year old child to be put on stimulants for “ADHD”, I will balk. If a woman pregnant in her first trimester is pushing for Xanax to help her deal with the marital conflict with her husband because of the pregnancy, I will recommend counseling, not benzodiazepines. If someone who is not psychotic is having trouble sleeping, I will be much more likely to give them a two week course of a sleeping pill than put them on the small dose of a major antipsychotic that they heard about on television. What you’re treating, and not treating, is important. Efficacy and potential side effects are important. 

It is very important to tailor the treatment to the illness diagnosed, the symptoms that are being targeted and the outcome that is expected. 

Lastly, as alluded to above, the relationship between doctor and patient must be held to the highest standard of all. It should be professional, respectful, and collegial. We are partners, but by definition we are not equals in the process. You know yourself better than anyone in the world. You have information that you must impart, and I have decades of experience and learning and training that I must share with you in order to help you get better. 

If we are honest and work together, treatment happens, illness is managed, and patients recover. 

It is only then that it is much easier to do the right thing. 

Monkey in the Middle

Keep away.

Monkey in the middle.

Urban Dictionary defines “monkey in the middle” as the person who is in the middle of two fighting sides. This person is friends with both arguing sides and wants to stay neutral but is eventually dragged into the fight, and one of the fighting sides becomes mad at them. 

I will be fifty nine years old next month. I grew up loving to read. I read everything. I was thrilled when the new Scholastic Book Club circular, or anything like it, came home with me, to be lovingly perused and marked up with all the paperback books,  Dell crossword books and dinosaur books that my parents would allow me to order. I was more thrilled when the shipments came in, giving me hours of pleasure like no other activity I enjoyed at the time. I was ecstatic when my parents bought the complete set of the Collier Encyclopedia, complete with annual updates, though I can now come clean and say that I wish they had bought the World Book Encyclopedia instead. Colliers seemed a bit too stodgy to an elementary schooler. 

I simply loved the feel of the page. I loved the color glossy pages. I loved doing crossword puzzle after crossword puzzle. I loved the feel of the spine of a book nestled in my hands, the way new pages stuck together until you riffled them the first time, opening up the whole new world that was hidden in the infinitessimal spaces between the papers. I loved that tipping point that came when you knew by feel, without even looking at the page numbers, that you were just over halfway through a novel, and that it was all down hill from here. A race to the finish, the climax, the denouement, the satisfying completion of a mind journey that could have transported you anywhere in the universe.

I still love to buy books, to keep books, to shelve books that I just know I will read one day (sometimes do, sometimes don’t, let’s be honest). I still like to peruse the colorful pages of magazines, especially when I am tired and just want to kick back and do something familiar, something comfortable, something comforting. 

I am a product of my age, my upbringing, my schooling, the modeling of my parents and mentors and teachers. I am an analog man in an increasingly digital world. 

Now, I love my technology. 

I have bought more iPads that I care to admit to. I have owned every desktop and laptop computer from a Micron to a Dell to an HP to a Radio Shack to Apples. I have lusted after the newest Sony PDA, upgraded to a Treo with a stylus, and was fascinated when I first heard about the marvelous little machine that was to be the first iPhone. “I’ve GOT to have one of those,” I remember saying when seeing the image of the prototype on my laptop screen. I have owned virtually every model of iPhone since 2007. 

I get excited when thinking about moving next month and setting up a new wireless system in the condo. I am already salivating over wireless security systems and what might best serve our needs. I am constantly looking for the next excellent podcast, digital newspaper, newsletter, or blog to read. I love audiobooks. I listen to music on three streaming services, only one of which I actually have to pay for. I watch movies on my iPad, which has more pixels and a much better picture than my widescreen television. 

I am a product of my age. I am a digitally connected man in a world that is watching analog constructs fade slowly into history. 

I am the monkey in the middle. 

I am listening to a fascinating audiobook right now that I would recommend to everyone. The Inevitable, by Kevin Kelly, looks in some detail at where we are headed, and why, in the next three decades. While I do not delude myself into thinking that I will still be around forty or fifty years from now, thirty is definitely doable. I get very excited when I think about the world that my grandchildren will be running, of which I may still be an active, though peripheral, part. The book speaks to the way that society and all its wonderful parts is morphing and continues to change over time, cataloging and saving and curating and dispersing and sharing and annotating knowledge and creativity and thought of every conceivable kind. It also speaks to the generation, MY generation, that finds itself squarely in the middle of two camps, one whose tenets are inscribed on cotton paper, and one whose bits and bytes are blinking and beeping into the future. 

I am friends with both sides. I want to remain neutral. 

It is going to be a fun ride for the next two or three decades, that is certain. I want to keep up, to remain relevant, to learn, to continue to produce and create and to learn to access the new technologies and the new paradigms as they present themselves. I very much want to keep working, to keep helping people through my vocation, to educate myself continually about advances in my field. I want to enjoy music and art and books and the vast amount of information that is the collective knowledge of our increasingly connected world. I do not want to become an old man who is too intimidated to reach out and try something new out of fear or ignorance or apathy. 

I don’t mind being the monkey in the middle, as long as the game of keep away does not turn into a game of dodge ball. 

PurposeĀ 

There are a lot of people telling us 

what to be, 

who to be, 

what to do, 

who to love, 

how to work, 

how to vote, 

what to think, 

what to believe, 

what to revere, 

what to revile, 

what to fear, 

what to exhalt, 

what to say, 

what not to say, 

what to raise up,

 what to despise, 

what to eject, 

what to retain,

what to wall off,

and what to seal in.

So.

Why are YOU here?

What is your daily purpose?

What are your goals?

What do you hope to accomplish tomorrow?

Next week?

Next month?

Next year?

Before you die?

Do you have a manifesto?

Do you really believe in anything, really, or do you love being spoonfed?

Are you a maintainer?

An innovator?

An influencer?

A game changer?

A world beater?

Is your life stagnant, or fluid, or changeable?

Have you already built your own wall?

Who paid for it?

Who are you keeping out, and…

what are you deparately trying to keep in?

Why Wait?

They’re new, sort of. 

They  load easily onto your phone. They look slick, with nice colorful interfaces and easy to navigate menus. They help you create an account, sign in, and even give you the opportunity, strongly suggested, to add a method of payment to your account so that you’re always ready to go in an instant. 

What are they?

Dedicated apps. 

Apps that serve one finely tuned purpose and have only one mission in life. To separate you from your money. Well, that’s not exactly fair. They do help you buy things, avoid lines, hurrying you on about your busy day. Read on. 

I have used three of them most recently. One is a local app for Groucho’s Deli, a wonderful establishment that I frequent fairly often especially when I need a big salad for dinner as I’m starting a telepsychiatry shift. The other two are Starbucks, which is not new by any means, and Chick-Fil-A One, which is. 

They are all slick, pretty, functional, easy to figure out and use. They all promise rewards of food or other goodies if you use them enough, tempting you to, you guessed it, come back in to buy more stuff. How do they serve you?

First they allow you to order ahead and pay ahead. You can review your potential purchases on the app, and it even learns your most common orders and allows you to order them again with just one or two clicks. Genius, right? When you get to the store, you just walk in, and in Starbucks you simply pick up your order and walk out. At Chick-Fil-A and Groucho’s you have to speak to a real live person, albeit three words and five seconds at most. 

There is no waiting in line when you get there. In and out. Boom. Done. You may even have your own designated pick up zone. There is no need to see the rest of the store, to browse, or any chance to change our mind as you go by all the goodies at eye level at the register. 

This is perfect, right? Order early, come in, no waiting, no mandatory human contact, out the door. 

Well…

Why wait?

Hmm.

Well, you might enjoy talking to some other people at Starbucks in the morning. I mean, there may be some other readers or writers or Bible Discussion group folk or singer/songwriters or just simply the one other person in the state, other than you, who orders a tall non-fat half caf latte with cinnamon and sugar light whip and two ice cubes. You might (gasp) meet new people. Make a friend. Learn about somebody else and why they also get to Starbucks at five AM. 

You might get to browse product lines and find something you really are interested in and might buy. Who knew you would like coconut milk in your coffee or that you really did look that cool with a double walled stainless steel travel mug that just happens to be lime green? 

You would get to people watch if you hung around more than the forty five seconds it takes to come in, grab your chicken and cluck. For a wonderfully funny take on this, see Jeff Gamet’s blog Fresh Brewed Tales. It’ll make you snort chai though your nares. 

Finally, you might get to come in, take a load off, sit a spell, think, plan your day or your week, read a little, listen to a podcast, or have a very pleasant conversation with that neighbor you never knew came to this place!

Yes, I keep saying it and I know you’re tired of it. I LOVE my technology. I really do. 

But, the older and wiser I get, I am also coming to love the idea of reconnecting with people, experiencing new things, trying new tastes, and having to pull my good old leather wallet out to pay with rumpled green (or orange or purple or whatever the heck the colors of paper money are nowadays) cash.

You might try it sometimes.

By the way, I have deleted everything but my Starbucks app. It still has money on it, but it’s not set to actively and automatically reload. 

When it’s empty, I’m going to nuke it too. 

Looking for a Cure(ation)

When my girls were young, we had piles, then stacks, then boxes full of tapes. Audiotapes and videotapes, by that time the ubiquitous VHS format tapes that required parents to learn to master their VCRs, even knowing how to set the time and the timers on the infernal machines. Yes, there were piles, and more piles, and even more piles of Disney tapes, beloved and classic movies and musicals, and later the newer crop of Disney creations which has morphed now into Pixar animations. It seems to me that we bought them all, some of them more than once, because we would wear them out. We had our favorites. I think that I have been told that I loved Little Mermaid the best, but I also liked Lion King, Cinderella, and others. Which brings me to the point of this post.

How, in today’s modern digital world, does one possibly pick out what to listen to, what to watch, what to read, and what to  learn from?  How does one figure out where to go to dinner tonight, where to shop, and which vacation spot to book? 

At our fingertips and via the machines on our desks, laps, and in our pockets, we now have access to millions of songs, videos, books, blogs, essays, newspapers, magazines, online courses, chats, messages, TV shows, and movies. There are thousands of reviews of everything from standing desks to barbecue to scotch whiskey to motorcycle helmets. Pundits and podcasters want to have our ear (as do their sponsors, of course) for thirty minutes to over two hours, just to convince us, educate us, or entertain us. 

Speaking of sponsors, we are still very much in a marketing driven economy. The message is clear. Whether it’s buying, listening, reading,traveling, or doing, the answer is always MORE. 

Buy more. Rent more. Stream more. Listen to more. Watch more. Read more. Browse more. Click more. 

The reality for most of us? 

The one thing that we have a finite amount of, that we cannot truly create more of, that we must manage and use wisely, is time. 

When I look at my ideal day, one that I strive for even though I don’t always hit the mark, it breaks down like this:

Sleep: 7 hours

Meals: 1.5 hours

Work: 8 hours

Travel: 1 hour

Exercise: 1.5 hours

Personal hygiene: 1 hour

This adds up to 20 hours in my 24 hour day that are pretty much allotted to things that I think are important enough to carve out a place in my day for them. Almost every day. 

This leaves four hours, just four short hours a day, to do anything else that I think is important. 

This might include worship, conversation, developing or maintaining relationships, learning new hobbies or activities or skills, spending quality time with those closest to me, making phone calls, meditating, or just sitting and watching a sunset. 

We only have so many hours in the day, and like it or not, very few of those are open for us to manage as we wish in most cases. So what to do we do? Three things.

1) Prioritize. 

I am getting married in November. I have been living by myself for almost four years now, and I have a pretty routine schedule that I follow, within the the framework I shared above. I have a feeling that come the end of November, when I have a band of gold on the fourth finger of my left hand, that my priories and how I choose to use my expendable time might change  just a little! This will be a good thing, in that my beloved will be one of my most treasured relationships, I’ll choose to spend time with her, and I will want my day to reflect that commitment to her. Will I stop going to the gym or listening to podcasts? Absolutely not, but the time I spend, the time of day that I do these activities, and what comes first will change. I will prioritize these activities to reflect what (and who) is most important to me.

2) Choose

We must pick what we do, where we go, where we eat dinner out, and what movie we see. As I mentioned above, we have literally millions of choices. It’s overwhelming! We must learn to choose what we feel is best for us. How? read on. 

3) Execute

Once we have prioritized and made our choices, we must follow through. We must stick to our guns and execute. There will always be something shiny that comes along that will tempt us away from what we thought was an ironclad schedule or a training regimen that could not fail. We must be strong and resist it, and keep to our well thought out choices. Otherwise, we will be hopelessly spinning like tops, trying to respond to marketing messages, requests from work and family and the lure of the exotic, new and exciting. 

But wait, how do we cut through the cacophony? How do we blot our the trivial, the mundane, the boring, the too-expensive, the time-sucks? Nowadays, our problem is that too many people want to do the curating for us, instead of letting us decide for ourselves. It is easier to be lead than to evaluate and choose. How did we do it before, in the days of Disney VHS tapes and plush toys and Pet Rocks? 

We listened to people that we lived with, spent time with, shared interests with and respected. In short, we got personal references for things, activities, and products that we thought might be right for us. 

We focused on the bang for the buck in those days. If we could buy one Disney VHS tape that cost, say, $20, but we knew that it would be played in our home at least a hundred times, that was worth it. What you learned from, what you craved, what you loved, drove your experiences. Now, we crowd source everything, follow the hoards out into the street to play Pokemon Go just because is the biggest thing of the moment and that is what we are supposed to do. (No, I have not, and never will, download that app!) We run headlong from one fabulous experience to the next, not thinking about how this will affect us, if we will truly love it, and if it will make lifetime memories for us. 

When Steve Jobs introduced the very first iPod, arguably the most beloved music player ever invented, one of the catch phrases that he used was that now we could have ” a thousand songs in our pocket”. This was unheard of. It was fantastic, fabulous, ingenious and music to people’s ears. Literally. 

Now, in 2016, we can have millions of songs in our pocket, on at least three or four different music streaming services. We don’t even have to own them or buy them. 

We can access millions of books, including the classics, on reading devices no bigger than the old paperbacks that we all used to carry around when we read one story at a time. 

We can think, out loud into a tiny remote control device, about a movie that we once watched and would like to see again (Little Mermaid comes to mind) , and fifteen seconds later it is playing on our flatscreen television in gorgeous high definition, 4K color. 

Now, those of you who read me know that I love my technology. Of that there is no doubt. But I challenge you to think about this.

Does it really help to have a thousand, or ten million, songs in your pocket, if none of them are good? If they don’t move you to tears or make you shout for joy or make you play them over and over again because the artist just gets you? 

Isn’t it better to have talked about that Beatles album with an old friend or remember the time that you first watched Jaws in the theater or the first time that you were scared out of your ever living mind by a Stephen King novel? 

Isn’t it that much sweeter to have found that song or that book or that movie through someone who knows you and cares about you and shares space in your head, good space, good memories of really good stuff that is worth four hours per day?

Let me know what you think. 

Would You Like Sides With That?

SIde effects are weird things. 

Now, when I prescribe medications for patients, one of the things I always do, after talking about the reason for the med, the dosing, the cost and the the like, is to discuss the most common side effects that I expect they might experience. Why? Because they are likely to have one or more of these obnoxious effects, and if I predict them in advance it makes me look like a smart guy. 

I was taught in medical school that “if you hear hoof beats, look for horses, not zebras”. Or, stated another way, “common things are common”. 

I always tell patients NOT to go home and Google the drug I have prescribed for them. They will be hit with every side effect in the book, legalese out the wazoo, and they will come away afraid to take not just that medication, but any medication that anyone might prescribe for them in the future, ever! I ask that they trust me to give them the lowdown on how the medication should work, how long it will take, and what very common side effects they are likely to see. 

Dry mouth, dizziness, weight gain or weight loss, hair loss, dry skin, sedation and confusion are all side effects that I might mention to a patient. 

Note that these are side effects of the medication itself

But what about side effects of another kind? Side effects of the treatment as a whole? 

By this I mean, what if the patient, after adequate treatment, starts to evidence behavior that he or his spouse or family is not expecting, and even dislikes? What do I mean by this?

Well, if a very depressed woman starts to get better, feels like going out and demands that her couch potato husband take her to dinner and a movie once a week, when he’d rather stay at home, that might be a problem. Her treatment has been very successful, she is more energetic, her interest in doing things has picked up and she is more assertive in asking that her spouse accompany her to do these things that she wants to do. He got used to the “old” her, the person who was lethargic and passive and never made demands on him. He does not like this “new” less depressed wife he now has. This is a side effect of the treatment that is unwanted, in the husband’s opinion.

What if a young woman who has schizophrenia is put on medications and in therapy groups that begin to slowly help her get out of her social isolation and enjoy being around others, even members of the opposite sex? Once again, her parents have gotten used to her being at home,  watching TV on the couch all day, for the last decade. Now, she wants to get out and go places, see people and even date. They are worried that she might even want to have (gasp!) sex! To them, she seems manic, out of control, hyperactive, when in fact she is now able to act like a normal young woman her age and experience things that she never expected to again. 

Side effects can come from medications, from the treatment as a whole, and sometimes can be seen as negative, even when to the patient thinks things are going much better. 

As in many aspects of mental health care and treatment, communication about these kinds of effects and behavioral changes should be attended to early on so that doctor, patient, and family are all on the same page.