Prognosticrastination

I was listening to a neat little podcast called Ctrl-Walt-Delete the other day. Those of you who are computer nerds will understand why that name is so perfect. 

The two podcasters, Walt Mossberg and Nilay Patel, are smart, funny and witty, and I always learn something new or rethink something I thought I knew when I listen to to them. 

The April 28th episode took a long look back at the tech predictions made by Walt when he wrote for the Wall Street Journal back in the day. It was fascinating to listen to how he had very carefully schooled the readers of that paper on exactly what a CD-ROM was, how the hardware of the day worked, and most interesting of all, what he saw coming in the next couple of decades. He was remarkably spot on with some of his thoughts about the future. 

Other famous tech folk, Steve Jobs foremost among them, were said to be able to see what was coming fifteen or twenty years before it was a gleam in anyone else’s eye. Jobs was famous for saying that his company, Apple Computer, was in the business of making products that people didn’t even know they wanted or needed yet. Think back to the time just before the launch of the iPhone around 2007, and recall the delicious irony as wide-eyed technology worshippers lined up around the first publically displayed iPhone, under glass no less, and snapped picture after picture of it- with digital cameras. Now, walk down the street in any locale and try your best to find a digital camera. People’s phones are their cameras in 2016. 

It’s fun to look back at how we looked forward. 

I remember very well indeed the day I stood at the island in my kitchen ( some things never change-I’m standing at the bar  in my kitchen as I write this), white plastic MacBook open and humming along, surfing websites. I had been told that there was a rumor that a small, handheld device was coming. It would be a multifunction device, one that was connected like a phone or computer, but wirelessly. It would be able to run little programs called apps and it might even (gasp) do a pretty good job at playing music! No way. I found a picture of the prototype. 

No matter how much it cost on release, I knew I would buy one. It was that simple. The lure of holding the future in my hands was just too powerful and strong. 

I have long since lost count of how many iPhones and iPads I have owned since 2007. 

There is talk recently, after Apple’s quarterly earnings call this week announced the first year over year decrease in income for the first time in thirteen years, that the iPhone, indeed the smart phone cycle is now on the downside. Much like the iPod before it, all the rage when it debuted as “1000 songs in your pocket”, the smartphone may have tricked itself out as much as technologically possible, and have little else to wow us with. Not that it is dead, mind you. I count my iPhone 6 as my primary computing device today in many ways. However, we may all be waiting, and holding our breath for, the next big thing. 

Will it be virtual reality? I don’t know about you, but dealing with actual reality taxes my aging brain more and more these days, and excites me often enough that I’m not sure I need to know how virtually happy I might be in another dimension or time. 

Augmented reality, then? I might meet you halfway there, as I love to travel, experience new places and things, and that type of input might just make my trips and activities that much more enlightening and entertaining and educational in the bargain. 

Will we roll up our screens and put them in our pockets as we head out the door each morning? Will we visit our great-grandchildren holographically, or will we instead be whisked in real life to their door in a driverless, automatic car?

Will we wear our computing chips, or have them implanted in our arms? 

Why do some of us put off thinking about the future? 

What do we hope for? Immortality?

What do we fear? Obsolescence? 

Do we think that there is nothing left for man to invent? (We should certainly know better by now)

How much can we absorb, and how fast? 90% of the world’s data has been created within the last two years. It is conceivable that all current knowledge could cycle and change and renew itself in months, weeks, even days before too many more decades. Fascinating, and scary as hell. How to keep up?

I will be eighty-four years old, God willing, in late 2041, just twenty five years from now. 

My current grandchildren (Yes, of course I’m hopeful for more!) will be thirty-one, twenty-nine, and twenty-seven. 

What will their world, or the world of their children, be like? 

How will my world, my personal existence, have changed? 

We talk, we guess, we dream, we scheme, we plan, we design. We try to make ourselves believe that we hold the future in our hands, that we control it, that we fashion it and create it and bend it to our will. 

I’m not so sure about that. I think we know, deep down, that we have little control, really. 

We are fascinated by and drawn to the future, while we so very desperately cling to the past. 

Happy 2041! 

I hope to see you there. 

Unlevel Playing Field

From the New York Times this week:

“Police departments around the US are turning to crisis intervention training in response to high-profile shootings of people with mental illnesses. Twenty-five percent or more of people fatally shot by the police have had a mental disorder.”

We all learned about power differentials at a very young age. At first it was our parents who made the rules, told us what to do and when to do it, and inflicted punishments on us if we did not learn and obey. 

Next it was teachers, or Scout masters or football coaches or a myriad of other people, usually adults, who were in authority and could therefore hold sway in most any situation. 

We learned that there was a hierarchy,  and that we had a definite place in it. As we got older, wiser, and more skilled, we took our places higher up the ladder of responsibility and power. Hopefully, we learned to use our places and our skills wisely, compassionately and fairly. 

Now, that being said and that general background being clear, in medical school and residency training, spanning eight years of my life, I learned that this went even further than I was originally taught. 

Once you have MD after your name, you are (and should definitely be, in my personal opinion) held to a higher standard. You are privy to information, secrets, confidences that run the gamut, and it is your sworn duty to honor those confidences and do your best to make your patient whole again. You know a lot of things about medicine and the healing arts, yes, but you are also expected to work in tandem with, and in collaboration with, your patients to search for and find the best treatment that will lead to the best outcome. This has never been more important than today. 

Another thing we were taught, that was drilled into us in many ways, was that we were NEVER to abuse this relationship, this partnership, this collaboration. Now, some of you will balk at this next point, but it’s true nonetheless. Physicians were taught, and should still be taught, that there is a definite power and influence differential in the therapeutic relationship and the consulting room. Advocates, especially in mental health, may talk about being on equal footing with physicians and being partners in their treatment and the like. I’m not saying that this is wrong. What I AM pointing out to you is that the physician has a power over his patient, given to him by centuries of history and practice and backed by law to a large degree, that can never be equaled on the other side of the stethoscope. 

Any time I can sign a piece of paper that takes away your right to walk out of a hospital emergency room of your own accord, there is a power differential. 

Any time I can, with proper consultation from other licensed physicians, decide to give you a powerful medication for your obvious psychosis, even against your will, there is a power differential. 

When I have the obligation to break confidentiality and report certain actions that you have taken to the police, the department of social services, or other agencies, even though you beg me not to, there is a power differential. 

A well trained physician will always be very aware of this and use this power and influence wisely, for the good of his patient. 

A poorly trained one, an impaired one, or a physician with another goal other than his patient’s well being, will not.

In mental health, infractions might be as simple as saying negative things to a vulnerable patient, as bad as giving potentially lethal amounts of medication to a patient that has a known risk for suicide, or as terrible as coercing a patient to have a sexual relationship with the doctor. 

You see, when our patients are ill, they may be moody, depressed, manic, or indifferent. They might actually be psychotic, or suicidal, or homicidal. They are sometimes impulsive. They make bad decisions and their judgment may be impaired. They might be very angry at us, or even afraid of us. They might run from us, literally run out of the office or the ER. 

Might this happen, has this happened when a mentally ill person is confronted by a uniformed police officer, much as it might happen when confronted by a white coat wearing doctor?

Of course! 

A well trained police officer, much like the doctor, would much more easily recognize the limitations in judgment, the poor decision making, the rage or the fear, or the potential for harm to self or others in a distraught, agitated patient. He or she might be aware that allowing the person to have more space, talking them down, using de-escalation techniques, calling for backup, utilizing family members, or using other techniques might prevent escalation and the potential for harm to suspect or officer. 

The high profile cases alluded to, alas, usually show us by shaky cell phone video how someone with  a gun, and an obvious power differential, might be prompted too quickly to resort to deadly force short of trying other methods to get the situation under control. 

Crisis intervention training would be a wonderful way to begin to teach police officers, EMS workers, and other first responders to adequately assess a situation that might involve a person with mental illness. I have no doubt that lives would be saved. 

Any of us who have this power differential with those we serve should remind ourselves of these simple principles:

1) WE are responsible for the actions we take in a crisis or urgent situation involving a person with mental illness. 

2) WE are responsible for adequately assessing the situation and the state of mind of the person we are dealing with, to the best of our ability in any given situation. 

3) WE are responsible for using our very best judgment, falling back on rigorous training that was done looking to this very day. 

4) WE are responsible for continued training and self assessment so that we can accomplish the above.

5) WE are responsible for always acting in the best interest of the person we are trying to serve, even if that service involves involuntary commitment, detention, medication, or incarceration. 
Having a license to practice medicine, or carry a gun, or make arrests does not give any of us the right to abuse our power, and believe me, it is real and actionable power. 

On the contrary, it creates an obligation and a sacred trust that demands our very best in the very worst and challenging of times. 

Be safe out there, friends. 

Terms and Conditions Apply

You’ve all heard it. Those ads about that wonderful product that will change your life. The new kind of mattress that will finally give you a good night’s sleep every night. The new electric car. The superfood. They go on about them for thirty seconds or a minute, you are enthralled, and you dream of going right out and purchasing. Ah, marketing, how powerful you are. How much we want to be swayed. 

Then they say the last little bit. Very fast. Almost an afterthought. We hear it, but we don’t think about it. 

Terms and conditions apply.

That new medication that will fix your aches and pains does seem wonderful, miraculous even, but it has its downsides. It happens to be toxic to your liver, even at therapeutic doses. 

That relationship with the perfect guy seems like one you waited for your whole life. He’s handsome, rich, has a good job, and everybody loves him. You do too. Problem is, he drinks way too much, and when he does, he hits you. 

The author you have always loved to read, the one who used to write just one more book because, in all honesty he needed the money, the one whose bucolic, breezy salt in the air prose you craved, finally tried to get himself fit. He tried to eat right, exercise a little bit, and decrease his girth to fit the national standards. He was headed in the right direction when suddenly, quietly, the pain in his gut sent him to the doctor. Three weeks later, he was dead. Cancer is no fan of good fiction. “Healthy living will kill you,” he quipped, joking to the end. 

The singer was only fifty seven. A medical emergency, shadowed details. The end was the same. He left no spouse, no children, no living parents. His fortune will most likely  be in the hundreds of millions of dollars. He has songs that have not even been released yet. Someone will make the tough decisions for him. Someone will process the wealth, the leavings of life. Is that sad, really? Not for him. He has no need of gold any longer. 

He sometimes knows who you are, but most days he doesn’t remember you any more. He is still reasonably healthy,loves to eat, to sneak sweet snacks like a little child. He can be irritable, irascible, demanding,  aggressive. She is getting tired, worn out by it all. You watch, you help. You love. It is a terrible, tragic, unnecessary disease, all the more difficult because of its slowness, its insidious march towards madness and loss of all connection with life as we know it, love it, need it. 

I am told how to practice now, many days. In spite of good training and better experience through three decades of practicing my craft, someone with less formal education, less real world patient time will look at a script, a series of numbers, an outcome paradigm and will say yes or no to my treatment plan. But this works, I tell myself, tell them. I’ve seen it work a thousand times. Doesn’t matter, they say. It’s not evidence based. It’s too expensive. It takes time. We won’t pay for it. 

And that’s that. 

You will bear the pain.

You will stay with him, because he’s the best guy you’d ever want to meet when he’s sober.

I will re-read Prince of Tides and South of Broad and travel to the Lowcounty and remember him.

Every time it rains, it will be purple. 

Your Daddy will be here until he is not. You will go on helping your Mama, because that’s who you are. Someone will love you all the more for your compassion and your strength. 

I will go on treating patients, because that is what I know. 

That is what I love.

That is what I do. 

Terms and conditions apply. 

Relation,  Not Rendition

We all have expertise in some area. We all know things, some of which it’s nice to share with others. 

Many of us who know things have books or manuals or guidelines that help us put what we know in a specific framework, all the more easily to share that knowledge with others in constructive ways. For me, and and others in the mental health field, that would be the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. Published in 2013, this large book is the go-to resource for doctors, therapists, insurance companies and even patients themselves as we try to figure out what is wrong, name it, code it, bill for it, and get paid for making it right. 

Others like ministers might turn to the Bible (the real one, not the DSM-5) for source material. Information technology professionals would look to coding manuals for the same reason. Electricians might use schematic diagrams, and architects would pore over plans and drawings and blueprints. Writers would refer to Strunk and White. 

The bottom line is that we all have our areas of expertise, and we usually have an adjunctive tool or two that helps us articulate what we know and pass it on to someone else in a credible fashion. 

We do this because we want someone else to know what we know. We want to tell them something that we think will fix a problem, make them feel better, or save their soul. There is a need, real or perceived, to share. The most expedient way to do that, of course, is to give them the book, let them read it, copy parts of it, email attachments, cut and paste. Easy enough, right? Tell them, and let them work out the whys and wherefores. 

That’s not the best way.

One of the best ways to share real knowledge with others is face to face. Talking.  Processing. Back and forth. Questioning. Answering. Challenging. Exploring. Refuting. Explaining. Disagreeing. Agreeing. 

As I grow older, both in age and experience, I have found that it is much more important to share knowledge than simply to impart it. 

No one likes to be lectured, have boring details read to them, be preached to in a condescending manner, or sterilely instructed. 

People like to be included, made part of the process, given options, challenged to make their own decisions and draw their own conclusions. They like to be asked for their opinions. They like to give feedback. They like to matter. 

How can we use this very important principle every day, no matter what our job or life circumstance?

Relate to the people you come in contact with. Don’t simply recite things to them.

Share your knowledge and expertise. Don’t be afraid or feel put upon or personally challenged if you find they have done some research of their own and want to make you justify or explain your reasoning or principles. They will learn, but you will too. 

Do not read, recite, lecture, or browbeat. 

Engage and empower others to be the best they can be, no matter the circumstances or tribulations they struggle with daily.

If you do this and truly share your expertise, knowledge and experience, not only will you be helping another human being, but you will grow and be a more effective disciple in your field. 

Abdication

Mom came into my office followed by five little stair-stepped children, each of them immediately scanning the room for toys, games, or edibles. The oldest of the bunch was the identified patient this go round. The little ones roamed the sparse floor space . The eldest sat in the chair to the left of my desk, motionless, wide-eyed, lips slightly parted. 

“She is the worstest child in the world, Doctor. She never minds, she’s always back talkin’ me, and she get in trouble in school. ”

More vitriol followed. The little ones played, sparred, talked, cooed. They found the Inside Out gang on my bookshelves. 

They also listened. 

“The worstest child I’ve ever seen. Worstest. She need a pill to keep her quiet, to make her mind. A powerful pill.”

And then, the worstest.

“I’m just about to sign over my rights, Doctor, sign her away. Give her to somebody who thinks they can handle her, ’cause I sure cain’t. I’d just rather give her up. I don’t have no problems like this from the rest of these children.”

——–

“How did you find out?” I asked.

“She was texting with friends, and I was trying to talk to her and she wouldn’t put the phone down. I finally told her, look, just put the phone down for a minute and talk to me, please!”

My patient rolled her eyes, noticeably and for effect, heavenward.

“Yes, and then…”

“Then it buzzed again, and I picked it up, you know, just to see who she was talking to.”

My patient looked away, not out of embarrassment, but in a rage that her mother was even telling me any of this. 

“I couldn’t believe what I saw. She was sending…”

“Go on…”

“She was sending sex pIctures of herself to this other girl, and they were sharing them, sharing them. With boys.”

A pause. 

“May I ask how long ago you bought your daughter her first iPhone?”

Mom looked sheepish. 

“I can explain. You see, she was going to her grandmother’s after school…”

“How many years ago?” I asked gently.

“Two years ago,” said mom. 

My patient was ten years old.

——–

We are abdicating responsibility for the proper upbringing of our children.

You know, the fact is, you trade a few minutes of mind-blowing sex for a lifetime of mind-blowing hard work.

You make the decision to create  this child, and give birth to this child (I use that phrase inclusively to bring fathers into this conversation as well) , and with those decisions comes almost two decades of other decisions, one on top of the other about car seats and diapers and formula and highchairs and t-ball and swimming lessons and school districts and pets and clothes and vacations and church and college and weddings and on and on. 

You cannot just simply sign away your parental rights, voluntarily give up your sacred responsibility to this child. You should not and you cannot do it. It is immoral and against all the laws of nature and man to do so. 

You cannot quit just because it is hard. 

You also cannot expect to put one of the most advanced pocket computers in the history of man in the hands of a pre-teen and not expect that they will get into trouble with it. It’s like putting a live hand grenade into those same eight year old hands and saying,  “Now, go play with this grenade and have a good time, but whatever you do, DON’T PULL THE PIN!”

Parents used to be very comfortable (too comfortable if you grew up in my generation) with laying down the rules and enforcing them to the letter.  There were chores around the house that had to be done. There were curfews that had to be observed.  There were expectations of behavior in school and church and other places outside the home. Infractions, failures to observe these rules and abide by these conventions from a very early age brought not only punishment swift and serious to the child, but embarrassment and likely a parental apology on the other end. Children were not allowed to drive a car until they could physically and emotionally handle the pressures, much less have indiscriminate sex.

I see so many parents today who feel impotent, powerless,  out of control. Society, the Internet, clubs, gangs, all have taken over as all powerful parental surrogates, leaving the biological parents to scratch their heads and wonder what they did wrong. 

Most of the time, the answer to that is NOTHING.

It is often not that parents are doing anything wrong, but that they do not feel strong enough to do what they know is RIGHT. 

All of us, parents and grandparents and great grandparents, must re-learn how important we are in the raising of our children. We must be strong, model our chosen values, teach positive habits and behaviors, and never miss a chance to show and to say how very proud we are of our kids. 

We do have a choice. 

We just have to make it. 

Passing On

My father worked as a middle manager in the textile industry for many years after he graduated with a degree in textile engineering from Georgia Tech in Atlanta, Georgia. As far as I know, he was the first to graduate from college in his family. I can only imagine how exciting it was for him to leave the little middle Georgia town of Cochran, travel to the big city of Atlanta, work and study to get a college degree, and then go out into the world of work in the early 1950’s. Business was booming, jobs could be had, and an ambitious young man could go far if he just put his mind to it. 

Things went well, I came along, as did my brother four years later, and my family was clearly living the middle class dream. A nice though small brick home, two cars (one new, one used), food on the table, and new school clothes from Sears every fall. I remember being very happy then, as happy as a kid could be in 1960s America, I think. 

Something happened later on. When my Dad was clearly and firmly middle aged he was essentially laid off, or downsized or rightsized or whatever they would call it nowadays. I only have vague memories of that time, but I don’t think my father was ever quite the same. The textile industry was pulling out of America already, shipping machinery, raw materials and the jobs that put them together to foreign countries, where labor was plentiful and cheap and from where they would never return. 

My father would work various jobs until his untimely death at the age of sixty two, but I can only imagine the pain he felt when he saw his beloved vocational framework slipping away. He was powerless against the tide of offshore industrial development. 

Another community hospital closed its doors a few weeks ago in the small town of Barnwell,  SC. We have a mental health center satellite clinic a stone’s throw from the hospital parking lot, and there was a freestanding medical clinic affiliated with the hospital twenty yards from our office. There are various stories and rumors about how the hospital got into trouble, but the fact remains that it could not longer afford to operate, and the decision to close came fairly precipitously, at least from the perspective of those of us who live or work in the community. 

It was not the first, and it will not be the last community medical facility to close. The fact that it did threw the town into a mini crisis, leaving it to figure out how to manage medical emergencies, what to do when there is no emergency room to go to, and  how to establish new methods of caring for the needs of its citizens. Mental health was not immune to this, as we often used the hospital to evaluate, stabilize, or refer mental health patients in crisis. The nearest hospitals for referrals are from seventeen to thirty five miles away. Law enforcement, medical providers, ambulance services, probate court and other parties have had to get busy creating new processes and lines of communication to insure that services are provided when needed, even without a hospital. Telepsychiatry has become an active player. 

It’s hard not to draw parallels between the textile industry of the 1960s and the medical industry today. Our services and institutions are not being shipped overseas for the most part, but small players are being swallowed by larger ones, the weak links are being forced to close, and managed care is moving in to tightly regulate what remains. It is definitely a challenging environment to be working in, but I would certainly not call it fun. 

As many small mill villages like the one I grew up in relied very heavily on that large manufacturing plant for jobs, security and a sense of community, many communities have been accustomed to having decent medical care close to home,  sometimes within walking distance. When providers leave and hospitals close, the sense of security and safety often leaves with them. Communities are forced to think outside the box, come up with new links between the providers left behind or fashion completely new protocols. 

I do not, like my father before me must have, worry about my job security.  There are plenty of patients and plenty of positions in the mental health field and I do not see those going away any time soon if ever. However, I do mourn the loss of the small town family doctor, the local clinic, and the community hospital. Some of these, once closed, will never come back. 

Healthcare in this country is going through tremendously stressful changes and passing on to a new system of health care provision.

I only pray that we never lose sight of why we all do this- to help the patients who need us. 

To paraphrase Sir William Osler, one of the best physicians to ever practice the healing arts, maybe we should “listen to the system, and it will tell us what is wrong with it”. 

A Penny For Your Thoughts

“Could I have a large coffee with three Equals, please?” 

“Yes, sir. One large hot coffee with three Equals but no cream. Correct?”

“Yes, ma’am, thank you.”

“Come on around to the window, please.” 

I fished out two singles from my wallet, then felt in the little pocket in the armrest for whatever coins might still be in there. I usually just drop my change right into that little ready made coin holder. Thank you, Mazda.

I made the tight turn, straightened up and sidled up to the drive through window. The little screen was black, but within thirty seconds it read $2.49. 

I folded the ones in half, then placed two quarters on top.

She came to the window, young and fresh-faced even at this early  evening hour. She smiled, took my money but held the cup of coffee for a couple of seconds. 

“I just wanted to ask you a question,” she said, innocently enough. 

“Sure,” I said.

She looked at the large cup of steaming coffee in her hand almost quizzically. 

“How does this taste? I mean, does it just taste like black coffee, or, you know, does it taste sweet or something?” 

I blinked. 

“Uh, yeah, it’s got three Equals in it, so , you know, it tastes kinda sweet. I like it black but a little sweet. No cream usually.” 

She then released the cup to me, satisfied that it was really what I wanted. 

“Oh , okay. Thank you. I had just been wondering about that.” 

She turned to ring up the sale, putting my $2.50 in the cash drawer. The Dunkin Donuts uniform connoted a minimum amount of expertise in this particular area, I mused. 

“It’s okay,” I said. “You can keep the change for your drawer.”

Penny for your thoughts, I said in my mind, and drove away.