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“I am half inclined to think we are all ghosts…it is not only what we have inherited from our fathers and mothers that exists again in us, but all sorts of old dead ideas and all kinds of old dead beliefs and things of that kind. They are not actually alive in us; but there they are dormant all the same, and we can never be rid of them. Whenever I take up a newspaper and read it, I fancy I see ghosts creeping between the lines. There must be ghosts all over the world. They must be as countless as the grains of the sands, it seems to me. And we are so miserably afraid of the light, all of us.” – Ibsen (from his play “Ghosts’)

Sometimes when one of us proposes we do something different than the usual way it is reclined along the following dialogue:

“I got an idea, rather than going to Kobalt on Friday as we always do, let’s try going to Bar-1”

“No thanks”

“Why not?

“It is custom” (translation: I don’t want to change what we usually do).

This expression is a tongue-in-cheek reference taken from a book (I forget which one) about a man visiting a country in which he encounters a lot of questionable if not downright dysfunctional attitudes and actions. When he asks ‘why’ or suggests alternative ways of doing and thinking he is told over and over the way things are done are done as ‘it is custom’. No one is willing to think outside the box let along alter the status quo.

“It is custom” is one of mankind’s greatest impediments.* Most of the time we are so enmeshed in cultural norms we don’t question them. It is sort of like a fish being asked how’s the water and it thinks what is water?” A lot of my professional and personal life is getting folks/ myself to recognize what they are immersed in isn’t an absolute truth nor is it unchangeable.

Speaking of my own culture (America), a lot of misery and disease here derives from it. If a person fails it is their own damned fault. Public shootings cannot be stopped. Health care is not a public service. Many in the land are beginning to question these so-called truisms. They either try to alter things and are met with the resistance of thems in charge who are all too ready to say ‘it is custom’ or they devolve into dropping out of society. The rise of depression/anxiety in the land (especially in children and adolescents) is correlated with the consequences of ‘it is custom’ thinking. They are immersed like fish in the foul waters and do not thrive. Society addresses problems with pat answers and band-aids and the usual point-the-finger-at ‘them’ who are the scapegoats.

I don’t know have answers to fix things, but I can do my part by constantly challenging ‘it is custom’ beliefs whenever I sense one. Given our negative bias towards things we tend to think ‘it is custom’ ways cannot be altered. This is not so. When enough folks do what was considered written in stone can change. Let us hope so.

I wrote this on a Monday morning before the work week began. I will challenge patients with depression and anxiety to look at the context and their surroundings for contributions to their symptoms. “It is custom” can questioned at home/at work/in the nation and maybe make a difference.

*Other impediments include our tendency to split folks into ‘us vs. them’, to obtain more than is necessary, and build strip malls.

Psychedelics are the talk of the town these days. Plenty of patients are coming in to their appointments having heard of them or read something on line that they are the new miracle cure for whatever ails them. I wish I had a shilling* for every time there is a new and exciting treatment that gets into the public press before the details are sorted through only in time for the promising pill to fall flat. Medicine Road is paved with disappointing discards. This is especially so in psychiatry. I’ve heard all sorts of supplements and such patients hope will be something to help them when other things failed. Alas, Babylon! these are usually are a bust, worse luck. Remember Saint John’s Wort and SAMe? Once upon a time patients were agog about both. In time these two supplements turned out to be duds. It wasn’t that they didn’t ‘work’ but SJW isn’t regulated (or covered) and it only helps in mild cases of depression and it doesn’t like to play with other medications especially birth control pills. Oh the horror. SAMe, at least in The States, in an expensive supplement that by the time the patient gets to the dose that shows promise they are shelling out of pocket hundreds of dollars per month for something that was fair at best. It’s a disappointment.

Which brings us to the newest rising star: psychedelics. Once upon a time LSD, ‘magic mushrooms’, and the like showed genuine medicinal potential. Then the hippies and party boys got hold of them and the straight-laced types were horrified and thems in charge made these drugs illegal no-nos with reportedly no medicinal value. Now we know more about how they work in the brain so they are rising from pariah status towards possible treatments for depression and PTSD.

For thems curious how they work, read on; for thems not interested, skip over this next paragraph why dontcha.

Psychedelics work by interacting with certain neurotransmitter receptor sites in the brain that the conventional medicines don’t. Glutamate and some subtypes of serotonin neurons are the main ones activated. These creates connections not easily done otherwise. Think of airplane hubs and connections. You are in San Diego and you want to go to North Dakota, but there are no direct flights. You have to go to Houston then to Chicago then catch a flight to Bismarck. Psychedelics allow all city hubs to connect directly to the others, allowing connections years of conventional counseling often are needed. In this near-numinous removal of impediments one can do therapy work that otherwise is very difficult or too emotional to do. Another metaphor is finally getting the right-shaped key to open doors to hallways in the brain the usual keys could not open. Groovy.

Trying to sort through the rubbish for genuine worth is a challenge. Research is working on the science of ‘how much’ and in what form and context might these substances actually work and not cause harm. For thems who have never done psychedelics there is the possibility of a ‘bad trip’ and thems doing these drugs often do so with a ‘guide’ nearby to help them in the newly dissociated state of being. These are not to be done likely; do not try this at home. I suspect if/when they become bona fide FDA-approved treatments their use will not be a simple prescription ‘take this daily’ pill but done in a supervised setting with a counselor/supervisor. That will require time and effort on the part of the patient, and this demand may make this a ‘rich man’s drug’ as not many folks will be able to afford taking a few hours off from life/work 2-3x a week to trip in a psychiatrist’s office. **

There is a lot of potential with psychedelics in psychiatry. I hope society doesn’t spoil it the way we did withcannabis. Cannabis has probable treatment benefits, but society voted to make it legal before there were proper tests done on it, so now it is the wild west in terms of amounts/dosages, mixtures etc. Pharmacies don’t distribute these things but merchants who are keen on selling things for profit. When a patient asks my advice on ‘medicinal marijuana’ I tell them it is buyer beware as I can’t tell them ‘how much and how often’ and even if I could there is no guarantee they will find it as nothing is regulated for purity. Now in public domain, no one is going to do the costly research needed to find evidence-based data. For all I know cannabis is mostly placebo effect.*** Thems who try it swear it works, but they were excited to try it in the first place. That sort of set up nearly always works. Oh to have a double-blind study! This won’t happen.

I am excited to someday have psychedelic-based treatments for my patients. What I have now to offer often doesn’t work well or is intolerable. New means of treatment are always welcomed. However I won’t count my chickens. I want to see proper data no rubbish that assure me and my patients psychedelic Rx really works and how to use it and what dangers/drawbacks it could have in the long run. Until then I tell my patients to wait – and don’t do this on your own. For one thing it is still illegal and I hate seeing people deluded by shysters out of their money and hope for miracles that aren’t there.

*This bet amount is based on the pre-15 February 1971 money system. Overall a headache system but more interesting really.

**Presently ketamine indicated for the treatment of depression. This involves going to a certified center 2-3x a week to start with where they administer this psychedelic sprayed up the nose and then you have to be watched for psychoses/dissociation for an hour so. There must be a designated driver to take you to/from your appointments. I tell my patient referred for ketamine to think of it like kidney dialysis in time and effort. Few folks have the time and driver for this sort of thing. Stinko.

***Think of it for a moment. I have heard cannabis lauded as treating almost everything. What drug actually does this? I smell a rat when someone is trying to sell me something that is a panacea of all ills.

I finally threw out my ponderous collection of “The green journal”, which is the official journal of the American Psychiatric Association. It has a dark verdant cover like that of a pine tree. It is the psychiatric equivalent to JAMA or The Lancet or The New England Journal of Medicine.* After I receive and read one I put it on a shelf at work at work to use as reference, but mostly for decorating. Patients see and associate them with knowledge. Truth be told I never open them and after quickly after skimming one ita contents are forgotten. The articles are very complicated, difficult to read, and most important hardly ever applicable to patient care. Here’s an example:

Aberrant developmental patterns of gamma-band response and long-range communication disruption in youths with 22q11.2 deletion syndrome.

Another factor about these journals is they become quickly obsolete. Articles become outdated after a few years.

I feel sheepish throwing them out. Thirty years of Medicine has ingrained in me a large ‘should statement’ about the importance of journals. This is what one does to stay abreast of the news and be a good physician. The dirty secret is medical journals are obsolete and a case of the Emperor’s new clothes. If I need something I go online. I get my news and updates from apps, lectures, and audio-lectures. Reading ten-page journal articles – who has time for that? I bet in any lecture hall if you got folks to be honest nearly everyone would raise his or her hand to confessing they don’t read them either.

There are so many journals. Urs Truly subscribes to a half dozen, and the ones I read are the ‘fun ones’ that are short, practical, and easy to digest – like my men. I skim through the JAMA headlines at bed time to get the ‘gist’ of what’s happening in Medicine In General and other what’s happening in other specialties, knowing I don’t need to know the latest is surgery or pulmonology or the newest protocol how to work up hematuria.**

Some of this is being ‘old man’ thinking. It feels like sticking with LPs or CDs when it isn’t how things are done anymore. However most of my reluctance is letting go of ancient lofty ‘should statement” to admit I don’t read journals and that’s OK, I am not a bad doctor for doing so.

With this relief I have to figure out what to put on the newly emptied shelves at the office. Once upon a time medical textbooks served similar signals of study and sagacity. Medical textbooks are even less read nowadays than medical journals.*** Perhaps I will fill up space with rocks and tasteful art pieces. No books or journals in the office may be off-setting to the oldsters but the young ones won’t care. And there is less clutter, which pleases me very much.

*All very lofty and prestigious journals indeed. If you get your paper published in any of these you are a on the “A” list of Medicine.

**Blood in the urine.

***About five years ago or more I bought the 22nd edition of Cecil Textbook of Medicine, traditionally the Bible of Internal Medicine. I cannot recall the last time I opened it. It sits next to the PDR which I believe they stopped publishing after decades, not unlike the Telephone Book.

“Remembrance of things past isn’t necessarily the remembrance of things as they were” – M. Proust.

At the heart of insight-oriented psychotherapy is the belief something from the past is mucking up the present and holding you back from going forward. Symptoms signal you to look back in life at what happened and with insight (catharsis) you can go forward less neurotic. [1] This approach is based on the proviso memory is accurate to do this sort of work; something may be suppressed or unconscious but once realized the memories are correct. More and more data shows memory is not that good in fact it can be downright terrible. We tend to forget a lot both good and bad. Even the process of remembering something can alter the memory itself. There is the added trait memories are malleable, altered through persuasion, as seen in ‘false memory’ and ‘gaslighting’. I was recently saw a production of Ibsen’s ‘Hedda Gabler’: [2]

Judge Brack: Did you not leave the room while he was here?

Hedda Gabler: no.

JB: Think again. Were you not out of the room, even for a moment?

HG: Yes, perhaps, for a moment, out into the hall.

This is unsettling stuff as we want to believe what we remember is true. Our legal system (as illustrated above) rests on our recall of ‘what happened”. We want to believe our memories are objective, not just a “Roshomon’ experience constantly evolving. Folks with dementia are pitied most for having lost their memory viz. who they are. Oh the horror. This is particularly upsetting in precarious times when uncertainty makes us covert certainty even more. The claptrap “Make America great again” touches upon this anxiety/need for a mythical time when ‘life was good not like now’. [3]

I think things would go better and we wouldn’t be so angst-ridden if we altered our expectations of memory. Rather than seeing a faulty or failing memory as an awful loss, consider ‘why’ this happens. Our brains are wired to go forward not backwards. We retain what is important to go on. Once upon a time I knew lots of trigonometry, anatomy, calculus, and how to dance the two-step. No more. I can see this as sad or as something that was important at the time but not now as I need to remember relevant things like my gym lock combination. It’s OK to ask my second cousin once-removed how we are related. If needs be I can relearn things.

Back to counseling for a moment. If a patient identifies something from the past is holding them back by all means we work on it – knowing:

a) their memory of it may change as they work on it.

b) it may not be ‘objective’ but subjective.

c) they may never know the truth of what happened. [4]

Rather than seeing memory as the iCloud, think of it as a cozy room with so much space that discards old things to make room for more useful things. It does throw out things you wanted to keep but in general it keeps the good things and discards the bad ones. It’s not ideal but it is doing its job well enough.

[1] In contrast, Cognitive Behavioral Therapy (CBT) and its subset Dialectic Behavioral Therapy (DBT) don’t focus on the past but the present way of thinking and behaving. They argue – and quite successfully too – one doesn’t need to spend time in the past to work on the present.

[2] It ends badly.

[3] This bias goes by a lot of names, such as Rosy retrospection. Egocentric bias is changing a memory to make us look better than we were. (think of Smeagol in “The Lord of the Rings”).

[4] These cases can be tragic. Imagine a patient who vividly remembers they were hurt in childhood but there is no one alive to confirm this. Worse, none alive recall the event as happened or not in the way the patient remembers it. Folks want certainty (often with confession and justice), and it isn’t going to happen.

This one was inspired by a conversation I had in the locker room today. Spo

While dressing for exercise the gym, I told Someone about a recent podcast I heard exploring the so-called modern complaint that ‘people nowadays don’t want to work anymore” and it’s due to folks being lazy and demanding. It turns out this exact belief and complaint has been said throughout time, many times throughout U.S. History, and even earlier – almost back to the beginning.* He read letters to the newspapers and articles going back to the early 1800s. The real matter is whenever there is a change in how people work, people want to work but they want to work in the new system/mode. Folks fixed in the old ways can’t see or won’t see this. “People don’t want to work anymore’ really means “People don’t want to work how I want them to work”. It is a reflection of changes in the work settings and workers’ wants.

As I talked, a man next to us, I think he was in his 70s, heard this, and chimed in. He remonstrated young people are indeed lazy and no good and they just don’t want to work. He cited several friends with restaurants who can’t hire dishwashers and wait staff because… people don’t want to work anymore. I tried to repeat a summary what I had just said; he repeated his conviction his way of thinking was right. Oh the pain.

Recently, a belief of mine fell apart and become invalid. It was a long-time cherished belief one, based on year’s of experience. Then some new data came along. It was presented by someone with whom I don’t have an overall good relationship and it was given to me in a less-than-supportive way. My ego had a triple-attack:

a) being told it was wrong.

b) told by someone I didn’t care for being ‘right’.

c) her style was not one in which I like to hear to make me open to learning.

I said to the person presenting the matter she was right and I was wrong.

It is human to bristle and go defensive – or ballistic – under these situations. It’s no fun being told you’re wrong, especially by someone who is a jerk. Hopefully my Ego isn’t so rigid or fragile to react badly to these emotional onslaughts. I was recently reminded this has been called ‘the totalitarian ego’. It’s as if there’s a miniature dictator inside, trying to keep out threatening information that could topple its control. When it isn’t on the attack mode, it protects us with comforting lies and rationales. In some cases we becomes hostile at the mere thought of being wrong:

“The totalitarian ego leaps in to silence counterarguments, squash contrary evidence, and close the door on learning” – Adam Grant.

It keeps away/out others that threaten its mode of action; the totalitarian ego keeps around it only the people who validates it.

Mind! We all do this to some degree. The point isn’t not have it but to pause between reaction and response to try to ‘hear’ for genuine critique and that our way of thinking might be wrong. Alas, Babylon, Americans have a grown away from the once-upon-a-time thought ‘admitting you were wrong’ was a sign of manly virtue. Now the opposite is lauded: being implacable if not downright pig-headed in light of all reason and data. One can not learn and grow if you feel you are right. Unfortunately it seems fewer people want to grow, they want to be right and certain. Sad.

I thought the podcaster’s history and examination of ‘why people don’t want to work anymore’ was valid. If I were an employer I would try to go with what attracts workers now: more flexible hours and home/office time balance. I would advocate for employees obliged to deal with the nasty public – and not try to force folks to ‘take it or leave it’ which to their surprise but no one else’s they ‘leave’.

I practice saying with my patients I was wrong, and what we tried wasn’t the correct way after all. When a patient points out an error I try to say yes that is so and what can I learn from this? I hope this is seen as a strength and not a weakness. Doctors often are frightened to admit to an error.

I am curious to see if the mentioned female patient will return after our last encounter. If she does, I hope our bond is strengthened for it. If she doesn’t return, so be it. I learned something anyway.

*Examples from post bubonic plague England in the 1370s-1380s were sighted. Laments in documents remonstrate the peasants don’t want to work anymore.

A few days ago I wrote about a patient who wished to transfer from Urs Truly to the nurse, who is female, on the reported grounds she prefers a female. [1] This is a regular request in Medicine and in Psychology: a preference to someone more like yourself. I wish I had a shilling for every time a gay male patients has asked me for a ‘gay therapist’ who is male too. I often tell them there isn’t one like there here but Dr. So-and-so is excellent, so how about he try her/him but this is often declined. In a similar vein, female patients often ask for seeing a female provider.

In my field if a patient requests a certain type of someone folks try to oblige them.** However the opposite is considered not good viz. a patient requesting they see a white doctor or ‘someone not gay’. [2]

There is good data that shows children in grade school who are put in a class where the teacher is ‘like them’ do much better for it. However, no one flips it around to say to little Dicky Purdy (who is black in this example) “because you are black we are putting you in Mr. Penno’s class, because Mr. Penno is black.”

I have a very WASP-sounding name. I know I’ve received patients (new and transfer types) of white folks hearing/seeing my name and thinking ‘he’s white and not a foreigner”. I always ask a new or transfer patient ‘what were the matters with the previous psychiatrist that you are looking to find a new one?” What’s often said is “He/she was OK but I couldn’t understand his accent’. I smell a rat on this. This is more likely the previous was doctor was Indian and they want a white dude. Imagine their dismay/dissonance when they get one – but not of their political views or (worse) sexual orientation! I sometimes see the dismay in their faces in the evaluation as they connect the dots. I see them wondering whether to return to their previous shrink or stay with me, or figure out where on earth can they find a straight white conservative psychiatrist. [3]

Urs Truly is no exception. The Good Doctor was specifically picked as he is ‘like me”, done on the superficial joke he would understand my Better Midler references, but really because I feel more at ease to talk about some matters without having to stop and explain things. In my defense, this is a preference not a necessary. When he retires I hope I am OK with anyone so long as he or she is good and not judgmental. [4]

There is something in the field of psychology/therapy called ‘goodness of click’: yo have an at-ease emotion with your provider/physician. Unfortunately you don’t know until you meet up; all the rave reviews and credentials are no use if you don’t feel a rapport with your counselor. The bottom line is if you don’t feel comfortable enough with the person before you, better to go elsewhere – at least in Medicine or Psychology.

A counselor or a physician wanting to be rid of a patient they don’t especially like or isn’t like them – that’s a different topic.

Do you have a preference to the type of physician or counselor you see, based on who you are?

“I don’t like him” they are both thinking perhaps.

[1] This is how it was explained to me anyway. It may be a euphemism she thought me an old goat or she couldn’t manipulate me into giving her what she wanted.

[2] It’s true seeing a counselor like themselves makes the patient initially at ease, but this sometimes delays the actual therapy. The connection gets them ‘in the door’, but then the work isn’t so obvious. A female patient with PTSD/issues with men may feel not at ease for seeing a male therapist, but the transference issues are obvious and in the long run more likely to work.

[3] Fat chance of that. As the old while male analytically-trained psychiatrists retire they are being replaced with a diversity of types, predominately female.

[4] My pediatrician Dr. Helen Nutting was the one who inspired me to go into medicine. Later on I learned Lorraine her office manager was actually her long time companion. Well !

Note: This tongue-in-cheek entry is another one that puzzled The Board of Directors Here at Spo-reflections. They were worried I was being serious; I assured them it was a bit of nonsense, other than the Planet-in-Virgo influence which is quite true. They are ones to talk! My annual review with them is worth an entry onto itself. Spo

The Boss sent an email the other day to all the employees announcing we are going to do annual reviews now. No doubt this is a decree handed down from The Overlords. Corporations do love their annual evaluations. The last time I had one of these things was over twenty years ago when I worked in a state hospital.*  I haven’t had one since I joined my current post in 2005; The Bosses felt no need for such apparently.  

I am OK with this, for I am curious to know where I need improvement. In my natal chart, some busybody planet (I forget which one) is in Virgo, which apparently means I am always keen on self-improvement. “How am I doing?” I regularly ask The Bosses, legitimately curious for any critique. Their replies were/are always a general ‘Oh you’re fine”. This is nice but isn’t there anything I could do better?  Vague but assuring positive feedback is sweet but risks one developing a Dunning-Kruger complex or worse megalomania.   Oh the horror. 

Truth be told I am more interested in what are the metrics to which I am measured. What defines ‘a good doctor’ is continually debated.  I wasn’t the brightest bulb in my med school, but I caught on quick if:

  1. I explained everything.
  2. Kept on time and didn’t make people wait.
  3. Gave people options. 

I got and still get good reviews.  

I wonder what happens if my seventeen years of Mary Poppins-like feedback** doesn’t hold up to proper scrutiny. The three traits mentioned above may be not what The Overlords see as a‘good doctor’. Perhaps what they want to see is something different like do I bring in enough money. The mind boggles.

Of course I could be shocked to get gobsmacked with strong criticism and be placed on – what do they call it? – a plan of action to improve my deficits. I remember working in the state hospital any annual review less than stellar wasn’t met with vows to improve but hissy fits and threats to go to their union for action against management’s slander. Bottom line is if my first annual review is a bad one I can go elsewhere.***

All of this is rubbish really. I sense The Boss (who is not a doctor) has no great desire to tell this doctor employee how to do his job, but she is obliged now to do so.  I confess it will be a bit of a letdown to get “Oh you’re fine” as the official review.  My Virgo planet will be disappointed. 

Do you get annual reviews where you work? Tell me about them. 

*They were good, I recall. 

**Practically perfect in every way. 

***If they say in their best Joan Crawford voice “No Spo-shirts ever!” I’m walking.

Today is the last day for the The Other Psychiatrist. I don’t know why he is leaving. After meeting him in the interviewing process I never saw him again. He was scheduled to work in the PHX office on the days I was at MESA. This makes sense but it meant I never interacted with him. That’s too bad and now he is leaving. People come and go so quickly here. The Overlords had plans to expand services somewhat based on having him around; I wonder if these proposals are aborted.

I am peeved with the staff at the MESA office. Compared to the PHX office, it is a smaller space with more staff who sit closer to each other. I am only one of two people who regularly wear masks at work. Last Friday, when I was working in PHX, I was told many in MESA went off sick with something. Of course I am thinking covid. I am scheduled to work there tomorrow and I am half-tempted to work from home. You bet your flaming knickers I am keeping my mask on.

Technically what I am doing isn’t therapy but what do should always be therapeutic. I carry around in my head a handful of quick-to-say-I-hope-this-sticks statements that I give onto the med-check folks who could use some counseling. My latest one:

“Between the stimulus and your response is your humanity.”

This captures the sage advice not to immediately act on quickly-erupted emotions but to pause/think/evaluate before saying or doing anything foolish or regrettable. Indeed, most counseling is trying to convey this in some form or another. It may also result in something noble. No one can be judged for instantly feeling the impulse to run away, but maybe you will not do so but stay where you are to help others.

Another at-work item: I am about to take my first holiday and not lose income for doing so. The proviso at work has always been I can take off as much time as I wish but I won’t get paid for it. I know this is a factor towards me not taking time off when I should. Now I have two weeks paid vacation. Hot puppies! I will still have to call in/get messages/renew prescriptions etc. That hasn’t changed. I hope in time it will.

I’ve been at the same job since 2005 and there are many patients from that time still ‘active’. When charts get thick I sometimes make something called a ‘cheat sheet” on which I draw a timeline of what meds/events have happened over the years. All the information is in the chart, but it is tedious to open and close years of progress notes to find this sort of stuff. A single 8.5 x 11 page, a handwritten, with a timeline, allows me to see in one glance patterns and forks in the road. I get a ‘forest for the trees’ view. When a long-time patient announces a change is needed, I pull out their cheat sheet for direction towards what’s next. I carry these dog-eared pieces of paper around in a file that I keep on my desks, handy if they should be needed.

There is another file, similar to this one, kept in a drawer in the desk. These are the ‘closed patients” cheat sheets. Sometimes I realize I haven’t seen ‘Dicky Purdy’ in awhile, and look him up only to discover he hasn’t been in since 2019 and there is no follow up appointment on the books. I move his cheat sheet from the ‘active’ to the ‘closed’ file. I keep them in case Dicky Purdy should return.* The cheat sheets are kept in alphabetical order. This means when I transfer one into the ‘closed’ file, I see the names of the ones no longer with me. Many I remember just by seeing their name.

When a patient goes away they often don’t tell me; they just drop out without explanation. The usual reasons are as follows:

They have moved away.

There was a change of insurance or an economic restraint.

They have died.

They didn’t want to continue.


They were unhappy with me or the place or both.

I would like to know how many fall into which categories. If they fall into the fifth one, I would have liked to know if there was something I could have done differently or learn from, but I don’t.

Patients are color-coded. Light-blue means an evaluation, a new-comer. Green is a med-check; dark blue is for a patient already in the system but I haven’t met. There is another category, orange, which means “a patient you haven’t seen in ages who is coming back in”. I pull out the cheat sheet from ‘closed’ and put them back into the ‘open” (again) and get ready to hear their tale. The usual reason for returning: they have been ‘living off of refills” or the GP has floated them some – or grandmother died and they were taking her meds. These have run out and they were obliged to return.* Sometimes they explain ‘they felt good so they decided to stop treatment’ followed with ‘I was doing OK for awhile but not now”. These types often feel defeated and sullen for not being able to ‘do it on their own’. **

Many in the ‘closed’ file I know have moved away or have died. Last week I fellow I’ve treated since 2006 announced he was moving east and this was our last appointment. I did the ‘exit’ interview to tuck him in with enough refills to get him through his move enough to find a local doctor to carry on.

I would like to know how many patients I have seen over the years and compare this to the current number and how many ‘are long timers’. People come and go so quickly these days. I do what I can for them and hope that whatever I do makes a difference they are better people for it.

I keep in the ‘closed’ file the cheat sheets of patients I know are dead. There is no logic to this, other than when I see the cheat sheet I remember them. It serves as a sort of gravestone. They and their loved ones don’t know I do this that, that I still think of Dicky Purdy after all these years, even if our time together was tumultuous. Over time the ‘closed’ file grows in volume, but the ‘open’ one doesn’t shrink. This week alone I have five new patients – and three ‘orange’ ones. The Circle of Life? It’s the Circle of Medicine anyway.

*Although down for 45 minutes, this sort of thing usually only needs 15-20 minutes to ascertain all is OK they merely need refills.

**I point out sometimes this is like me and my blood pressure medication. Despite non-pharmaceutical means to keep it down, every time I skip meds I nearly have a stroke from hypertension, so I stay one them.

*This happens too. I may not see someone for years, only to have them return, usually there is a change of insurance or they have moved back to the area. Sometimes they have ‘using up the refills’ or getting the Rx from others but this has run out, obliging them to return.

Throughout my work day I hear people’s concerns that are basically the same things. After thirty years of listening to such, I find I give out the same pseudo-sage advice. They seem cliche, but they are truthful and they are practical. Folks tell me they are useful and they help. I sometimes think to myself I should just write them all down onto a sheet of paper (suitable for framing) and give a copy to everyone who comes in as a fabulous parting gift. Last Friday, when I should have been paying attention to a patient telling me for the umpteenth time how much a bum is her spouse*, it dawned on my to scribble down these tips once and for all. Rather than distribute them to the patients I would post them here.

Pay attention; people pay me big bucks for this sort of stuff. Spo

Urspo’s 10 tips for better living.

1- Learn to say no and say it often. This is especially true for the gals who are more often than the men-folk to automatically say ‘yes’ to things lest they be seen as not nice. I sometimes advice as an exercise to not say ‘yes’ to anything for a week, even if it is a mawkish thing such as ‘do you want fries with that?” to discover people don’t hate you for saying no to them. Another tip is to say to the person asking you to volunteer to be in charge of the church rummage sale: “(after a pause) Let me get back to you on that”. Then give them a time, say a day, you will do so. This gives you space to develop a ‘no’ answer or perhaps a ‘yes’ with limitations and conditions. I’ve learned to say a simple ‘no’ has saved me from countless regrettable actions.

2- Pause before action. I wish I had a shilling for each time I have given the advice to find some way to prolong the time between feeling something (anger/rage/panic) and reacting to it. Count to ten; take five deep breaths; remember what happened last time you ‘popped off like this one’. Just enough delay to hopefully thwart action you will lately regret.

3- I can think; I can wait; I can fast. I forget which divine sage said this (Buddha?) but is summarizes nicely one’s assets. I can think: I won’t let emotions dominate my actions. I can wait: before I rush into something I have patience to think it through for the right time for action. I can fast: I can go without this, that, or the other for now.

4- Be curious. “Nothing in life is to be feared, but understood” Marie Curie. So much anxiety, so much avoidance, and so much grief would be thwarted if we took the approach of curiosity to our fears. What is this? Why is it happening? Can I learn about it to better cope with it? I go so far as to define a ‘good life’ as having nonstop curiosity about the self, others, the world. I plan to write an entire entry on this one.

5- Genetics is not destiny. Many patients assume that if something ‘runs in the family’ they are destined to get it and unable to prevent it or do anything about it – so they don’t try. I point out on average only 40% of most conditions is genetic; the other 60% is something we can do something about. A crude metaphor I use is you may have inherited the family gun but you determine to buy and put in the bullets. Yes, you have depression/blood pressure/migraines like your mother, but YOU ARE NOT YOUR MOTHER. You can do something.

6- Do something. When feeling helpless and hopeless we often shut down, crawl into a hole, throw up our hands. To these states of emotions I say ‘do something’. ‘Do what?’ they tell me. ‘Something, anything so long as it is not nothing.’ Gandhi, Dr. King, Luther, Milk – all the great movers of history – they didn’t start with massive revolution, they started by doing something. Even if it is a concrete concern like cleaning out the Aegean stable of a garage. Rather than see it as an all or nothing project, everyday for 5 minutes (preferably at the same time) go there and throw out something. If you want to keep going, do so. Iin time the garage project is done. “But that will take a long time!” True, but it is less time than doing nothing.

7- Do not confuse causation with correlation. This sound scientific approach is worthwhile to apply to ourselves and to others. Many things are associated but not necessarily cause and effect. It allows us to look for other reason(s) for what’s going on.

8- Choose the positive. In all bad scenarios there is the ability to learn, to grow, to better yourself. By searching for it and nurturing it this doesn’t deny the awfulness of the situation. It makes the event something more than meaningless sorrow. The habit of choosing the positive builds resilience. It can make a trauma less likely to become PTSD (post traumatic stress disorder) and more like to PTGD (post traumatic growth development).

9- Accept ambivalence. One of my professors defined mental health as the acceptance or ambivalence, meaning in all relationships and situations we will have mixed feelings. Getting married has some doubt; having a baby has some regret/unhappiness about it; the death of a loved one has relief as well as sorrow. Even in a fight when we are very angry at someone we still love them. The ability to allow mixed feelings to co-exist and not let one deny the other makes for stable Self and stable relationships.

10 – Avoid curried snacks. OK, I don’t tell patients this one. I tell Spo-fans rather. It couldn’t hurt to do so.

*Every three months for the past ten years or so Patient X comes in for a med-check. The meds are reported as OK/no matters with them. I ask (as is my wont) what’s news in her life. She replies (as is her wont) how her no-good husband fails to do this, that, or the other, and she has to do everything and this makes her miserable. Every once in a while, I mistakenly break from this agreed-upon ritual and suggest ways for her to change the situation, including getting out. She looks at me aghast, as if I asked her to grow wings and fly to the moon. I usually say something along the line of ‘dear me!’ and see you in another three months.

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November 2022

Spo-Reflections 2006-2018