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Hey, Spo-fans! I am up to my oxters in hosting family and haven’t had time to write a proper post. Here is one I was working on for later. Spo

It’s been a year now since I started working from home. I know this so by the “Roster” file. At the end of each work day I send to the billing department the daily roster of my day.  I see the first one is dated 3 April, 2020. * What a funny anniversary to commemorate.  

I was fortunate with covid19 my job readily translated to zoom/phone appointments; I can easily shrink heads at home while sitting in my jammies.**  The majority of patients liked the zoom arrangement. Some of my patients have to travel long distances for their 15 minute check up and others felt limited to only be seen in the Mesa office, which had less opportune hours. On zoom, both matters ceased to be an impediment.  Patients could check in from where ever they were. Curious! A year ago at-home/zoom type appointments were not allowed nor covered by insurance programs and it was almost heretical to suggest trying such. Now they are the norm.

The patients and my bosses are beginning to wonder when the offices will return to old-fashioned face-to-face appointments.  Many are also asking if they can continue using zoom anyway. My answer is: who can say. The cynical answer of course is ‘that will depend if your insurance company is still willing to pay of zoom’.  It will be difficult in my opinion putting the genie back in the bottle. Too many folks want zoom-type appointments.  I will be curious to see what happens: will zoom remain an option and in what circumstances?

I wouldn’t mind having a day ‘working at home’ when all I do is zoom appointments, to cut down on driving and help me mind my aging dog and not have to put on pants.**. We shall see.

*This is supported by zoom appointments being done at the Mesa office; patients doing their appointmens from there remark the calendar in my office is at April, 2020.

**The APA secret police: back off this. These are figurative not literal comments.

Medical schools recently discovered a gimmick named “The white coat ritual”. In it, first year medical students don short white coats that have been bought/sponsored for them by alumni. The students like the ceremony; the alumni feel good for doing so; the schools get some cash in the process. Over the years I’ve sponsored a few students; most have had the good manners to write an email thanking me for doing so. When I get one of these correspondences I write back with an introduction of myself and an offer to keep in touch if they need advice. Only one as done this, a young woman named Bo*.

In the past four years, MS (medical student) Bo has sent emails from time to time, telling me about her studies and how things are going. In return I’ve given her sage advice on how to keep sane and not be swindled by the BS-itude of medical school, of which their is plenty. Bo comes across as a bright and excited person, which is good for someone going into Medicine. She’s had the challenge of being trained during covid19 – can you imagine? 

Last week was “Match day” was last week when students discover where they are going for post-school training. She is excited to have matched to some swanky-sounding medical center in Cleveland Ohio- which was her first choice. She will be near her relations.  It is a joy to hear her happiness about all of this.  She asked for some guidance about residency; I wrote my thoughts on how to prepare for the challenges ahead of her.**

I wish there had been someone to have helped me through the trials and shenanigans of my medical training.  I’ve read med students and residents now have more humane work hours and mental health resources to get them through the grueling process that is residency. I hope so. I struggled alone with my depression and anxiety and loneliness which was 1988-1989*** and when I reached out for help it was held against me.  I would not wish my residency experience on anybody.  I hope hers will be more supportive.

Despite the misery and fears that was internship and residency I survived. Bo will survived too. I daresay she will find it hard in her own way. I don’t know for sure but I think she is African-American which means she will be dealing with that challenge too. I hope most she comes out a good doctor and with a good network of colleagues – something I did not yet nor have to this day. I will be curious to see what happens to Bo and I hope to be there to guide her on her Journey.

*Not her real name.

**It is hell.

***I used to joke I was one year younger than I was as “I do not wish to count as part of my life the year lost in internship”.

Philosophy and Psychology have in common the notion of Self-growth as the goal of living. “Man, know thyself” was written over the door at the Oracle at Delphi for folks to see as they came to learn about their fate. Psychotherapy is mostly about looking at what is getting in the way of the patient’s progress in life.  Both have the assumption – perhaps naïf- people actually want to grow.  In my job I’ve learned not everyone wants to grow. In fact this may be the majority; nowadays people want certainty which is detrimental to growth and learning.  Many people are trying merely to survive. Their lives aren’t so much ‘how do I become a better person” but “how the hell to I get through this day?” and repeat again tomorrow.*

I see a specific sort of clientele, so my data is skewed towards the folks not looking for insight or Self-growth but for medication to appease their anxiety or lift their melancholy so they have more strength and stamina to get through the direful situations they are living in/contending with. I try to insert some education about escaping that awful job/relationship/situation; I also try to get them to see growth and survival as not a choice or one or the other. Often this goes over like a lead balloon. I’ve learned lots of my patients aren’t going to grow and to drag them kicking and screaming down The Journey is foolish. They get their meds, they vent/complain about their lot, and back again in three months.

Once in a while (alas not frequent) someone comes in who doesn’t have ‘clinical depression’ but has ‘spiritual depression”.  In psychoanalysis, depression is not a medical condition to suppress like hypertension but a warning sign one’s life is not right. It’s like an engine light coming on in you car.  When this happens one doesn’t ask the mechanic to turn it off, but to lift the bonnet and see what’s wrong inside with the engine. Dynamic depression feels lousy but thems who experience it have been given a prod to do some something about it viz. mend their lives and find what out needs to be done.  My job is to point this out and try to get them going on their path, despite the fears, the uncertainty, and for some the perceived lateness. 

Few recognize this sort of depression and what it is calling them to do, and fewer still are willing to go on the difficult unforeseen Journey.  Psyche has a curios way to ‘encourage one” to do so when you don’t go willingly by creating road blocks in the form of nervous breakdowns or unconscious acting out to lose your status quo. “Finally!” is seems to say when you’ve lost the jobs/spouse/health “It took a lot but perhaps now we can start the real work!”  

Anyone who has ever read a fairy tale or seen an adventure movie knows The Hero does not go alone on their Journey but goes with sidekicks and meets people to help them. My job often serves the role of Friend or Sidekick.  I am honored to be part of anyone’s Journey.  I hope to give assistance even when I cannot show them the Way. 


*I would like to figure out in a Venn diagram two circles, one titled “Those who are just trying to survive” and another titled: “Those not interested in growing” to see if there is much overlap. I used to think thems not interested led to thems just trying to survive, but I know now this is not cause and effect per se.

I routinely ask my patients what’s happening since we last met and if there is anything exciting or ominous in the immediate future. Thanks to covid19, the usual response I receive now is ‘nothing’ and ‘nothing’. This is often said with a grin and the add-on ‘I’m boring!”. I usually reply I like boring; it’s a sign no bad matters are happening.

Most emotions point us to pay attention to something, but boredom tells us what we are doing isn’t worth our while. With the instant availability of cellphone shenanigans, boredom is now rarer than at any other time in history – and more awful when experienced.  We would rather eat rats at Tewkesbury than experience boredom.  I recently heard about a study on boredom involving college kids asked to do nothing but sit and think in a room that had in it a device that would give a small but unpleasant electric shock if touched.  It turns out a sizeable amount of participants preferred shocking themselves – sometimes often – to that of being bored with their thoughts. 

Our monkey brains are wired to learn and grow and do things that have meaning and when this isn’t happening, we become sorely vexed. An element of why folks to do drugs, drink, smoke, eat junk food, etc. is they feel bored and cannot think of anything else to do.  Most job dissatisfaction is based on boredom and the underlying sense what they do has no meaning.  

Urs Truly is seldom if ever bored, simply because I always have something that interests me. I feel fortunate this way. There is nearly always something to do and what I have to do is worthwhile. Like Mary Poppins’ spoonful of sugar, I make meaning out of the mundane.  However, the dark side of this is I don’t allow myself times to be bored. This would be a good thing I reckon. Many authors and inventors relate their ideas came to them during quiet times of boredom when they were not distracted by things.

Covid has many folks feeling bored for the first time in a long while.  Rather than try to escape from it, let’s try to learn something from it. The quote “Be still, and know that I am God” holds truth that when things are quiet we are open to inspiration and insight.   

I never go online to read what is written there about me.  I suspect there is some (a lot?) of negative reviews. In general, people go online to rate doctors when they are unhappy, which makes Yelp reviews etc. biased towards the complainers.  I cannot rebuke and clarify* matters as it breaks confidentiality. Lately I haven’t gone online to see the news either. Only recently I heard about the bad weather in Texas and Mr. Cruz in Mexico.**  Thanks to my avoidance of social media I wasn’t aware Mr. Limbaugh had died. *** 

As I write this, the sun is shining and it is 18C (mid-60s F).  When I don’t’ go onto the internet, life is quiet and pleasant – my life anyway.  The question arises: am I being sensible not going online looking for things or am I deluding myself?  Am I better off knowing what might be said of my online?  If there is a lot of negative reviews online, I see no evidence my business suffers for it.  New patients have to wait weeks, sometimes months, for an appointment with me. 

I always ask new patient ‘how did you find me or this place?”. Many say their GPs sent them (code: their doctors are happy with me to send me more patients) or they read something ‘good online about me’.  Word of mouth seems good enough to keep me gainfully employed, surpassing what may be written in the doctors reviews.

I will leave you with this charming vignette. I once asked the usual question and I got this response: The patient explained he had gone online to get the address where I work only to be taken right to a doctor review site. He states he read a review saying I was

‘Distant, pompous, arrogant, and godlike”

He explained: since he’s heard from his loved ones he is all that, I must be the right doc for him.  I was deeply touched by this complimentary thunderbolt. However, I stopped wearing to work the helmet and the eye patch.


*‘He did not listen to me’ is often code for someone wanted controlled substances and I would not give them.

**I like to go online and give Mr. Cruz a negative review. Stirge. 

***Can we say this is God’s will, and it was his own damn fault for his lifestyle choices? 

A common complaint from my patients they procrastinate.  It is always the same: they ‘know what needs to be done” but do not do it. They are unhappy about it; they do not like this. They usually attribute their procrastination to their mental illness (depression, anxiety, OCD etc.) or ‘that they are lazy’. Another ubiquitous belief is if their low motivation were remedied this would solve the problem.

Happily, most of these erroneous beliefs and assumptions can be changed.

Putting off something is a universal human endeavor: they are not a sign of mental illness per se. Procrastination has at its heart is the desire to avoid experiencing negative emotions.  Making that phone call, starting those taxes, cleaning out the garage etc. all make us face unhappy feelings: fear, anxiety, pain, embarrassment etc.  We are wired to feel good and to avoid bad things. Thus we go towards sitting on the couch eating nasty chips rather than getting up and starting the new year’s resolutions to do a daily walk, as the later puts us face to face with the sad feeling how out of shape we really are.

Whenever I find myself procrastinating, I immediately pounce on what negative emotions I am trying to avoid. I remind myself while these emotions are no fun they are not devastating. Often, I do a 180 and immediately do something about the task I am trying to avoid.

I teach my patients to first stop to acknowledge their feelings behind procrastination; this is the first step. The second step is rearranging the equation. Motivation is not the first step towards action. Rather, it is the motivation is the reward for taking action.

Let’s say the goal is to ‘clean out the office’. By seeing it as one big task this evokes feeling overwhelmed and coming to painful feelings of the long tedious task ahead. Rather than doing it that way do the following:  set your alarm for the same time of day (we are more likely to do something in a structured time) to do the ‘five minutes’ rule.  For five minutes and five only – regardless of your motivation – go to the office and do something, anything. Start with something small like a drawer or putting papers into piles. After five minutes you feel you cannot go on, stop. Most people keep going though, after they get over the speed bump of starting. Always give yourself credit for having done something! Glorify in it!  Do this every day at the same time for five minutes. Over time you develop a sense of accomplishment, and by focusing on ‘the trees not the forest’, eventually the task is done.  Sometimes the patients complain they didn’t develop ‘motivation’ but they admit it feels good to have done it.

I try to lead by example. Rather than having the vague and mammoth goal to “Learn Spanish”  I have the goal to do the five-minutes rule on Duolingo. Every night at 830PM my phone goes off as if to say “whatever you are doing, cut it out. Time for Spanish lessons – five minutes only – and I don’t care how you feel about it.  I’ve done this over 600 days in a row now. Usually around 8PM I start thinking of it, and when I do, I usually start it then.  I’m slowly slogging my way to proficiency.

I’m considering setting my phone for 9PM now, to tackle a closet. But I’ve been putting it off.  hohoho

I routinely encounter people who are afraid of the wrong things. Recently I heard an elderly dame say she won’t be having the covid19 vaccine as she heard tell three people in England died after receiving theirs. I happen to know this same person smokes cigarettes at a pack a day. One of my brothers refuses to take medication for his high cholesterol on the rare chance it could cause side effects but he regularly buys lottery tickets hoping it pays off.  You get the picture. People are notoriously lousy at assessing risk.  I heard recently the number of people who die each year from shark attacks can be counted on or or two hands but we all had to be dragged kicking and screaming into wearing our seat belts to safeguard for the far more likely chance we will be in an accident.*

I think I am pretty good at discriminating neurotic fears from legitimate ones. The biggest fear I ought to have – and do have – is cardiovascular disease.  I am far more likely to have a heart attack or a stroke than being attacked on the street.  This is why I feel the need to exercise and don’t feel the need to carry a gun.**

Don’t think I am above stupid fears. The monkey part of my brain still goes immediate to full panic at the sight of a scorpion in the house before the wiser part (near the front) reminds me no one dies of a scorpion bite and they do not jump, so knock it off. 

Then there are the folks who aren’t afraid of things when the ought to be.Elderly male patients often won’t get rid of their guns even though statistics support they are far more likely to use the gun to kill themselves than on an intruder. 

It is an ongoing process, trying not to be afraid of the wrong things and being fearful of the right things. 

*Seat belts have a grim history that when they were first considered the auto industry was heavily opposed to putting them in cars as it implied their product was hazardous. Later on when they were installed there were ads encouraging drivers to buckle up for their own good.  These ads were a flop. Then it became law, and only then did people buckle up – and the deaths from car accidents plummeted. It is an example of forcing people to do what’s right pays off when simple encouragement fails.

**These fears seem to be flipped in thems of Trump supporters, at least by how they look in the news. They often look heavily armed and grossly overweight. 

I recently watched a YouTube video made by an Icelander titled “Ten questions Icelanders hate answering”.* I thought it would be fun to try this myself.  

“Ten questions psychiatrists hate answering”

1 – Are you a real doctor?  Yes, I went to medical school and after I graduated I did a year of internal medicine and then a year of neurology prior to going into psychiatry. I became a psychiatrist because I wanted to, not because I couldn’t make it as a ‘real doctor’. Indeed, I was headed towards cardiology but it was boring. This is more exciting.

2 – Where’s your couch? This is not your grandfather’s psychiatry. The couch was when the only tool psychiatry had was psychoanalysis. It is like walking into your primary care doctor’s office and looking around and wondering where are the blood letting tools.

3 – Is everything due to my mother? Not even Freud believed everything was due to Mother. People and their psychologies are complex. Those looking for a single matter to explain things are going to be disappointed.

4 – Do you do anything besides prescribe meds? I spend most of my time trying to get people to do things and solve their problems by NOT using meds. The irony is I am usually the one on the receiving end of someone who wants a prescription rather than a lifestyle change “gee, can’t I just take a pill for that?”

5 – If I say something crazy sounding, will you lock me up? Unless you are at immediate risk to kill yourself or others it is nearly impossible to get people committed to hospital. Again there is irony I am often asked by a patient’s loved ones pleading with me to ‘lock him/her up’ for their welfare. It is hard explaining to folks one can be bat-crazy and going to heck in a hand basket and I can not prevent this. There are no men in the white coats with straight jackets.

6 – Do you ever ‘turn it off’? Yes I do. One of the first things you learn in shrink school is do not become a therapist to your spouse/friend/child etc.  It is a sure-fire way to ruin your relationships.

7 – (Asked at party or social setting) Oh! I better be careful! You’re analyzing me, right? I either tell these folks “Not for free I won’t” or (if I am being catty) “Hmmm, I sense you are anxious about something, tell me more about your childhood and your relationship with your mother”.  

8 – Are you in the pay of big pharma? No I am not. If a psychiatrist is being paid by a company to do research or talk about their products these doctors are required by law to disclose this up and front so the listeners know this. In thirty years of doing what I do not once has a pharmaceutical company tried to bribe me. There are no handsome stud reps throwing themselves on me in exchange for me to push their product.

9 – Can you prescribe me my( pain meds/blood pressure pills/birth control etc.)? No harm asking I tell them but I won’t. I am not up to date on the proper protocols of treating high blood pressure or menstrual problems, and I am not a pain specialist.  Get these things for your body docs who know what they are doing.

10 – Will you write me a letter for me to take my python on an airplane as a therapy animal? Oh the pain.  I no longer write these letters as there is little evidence I am aware therapy animals work any better at assuaging anxiety than holding a stuffed animal. The use of ‘therapy animals”  is quite abused. I tell folks for every person I’ve written a letter to take Fido on board a plane I have another patient being treated for PTSD from being cooped up in a plane with said animal towards which they have allergies or flashback memories of trauma.

*For thems interested, the six I remember:

Are you a Viking? no

Aren’t you always cold? no

Aren’t you all related? no

Do you know Bjork? no

Do you believe in elves? no

Do you have igloos? no

It’s been a rough week. 

This week at work a legal matter had me involved in a zoom-interview that was part deposition and part disquisition but mostly felt ‘inquisition’. I suppose I shouldn’t say more about it so I won’t.  It’s been a major source of stress for me, a matter for months, and apparently ‘not over’.   

At home I have some sniffles and aches, which is probably allergies or a mild cold, but of course I am wondering if I picked up covid19 on my travels. I need to be tested. I always ask my patients ‘Did you have any medical matters since I last spoke with you?”; in the past four weeks I’ve heard more reports of covid19 than in the past six months.  AZ resembles 1347 Florence. 

There is one ‘positive” at work: my work EMR (electronic medical record) has a dashboard that tells me how many unsigned documents I have. It feels good to get this down to ‘zero”. For many months it thumbs its proverbial nose at me taunting me I have ‘one” to sign – with no evidence there is any.  The inability to get to ‘zero” was driving me to distraction, enough to call the help line on the matter. They were most empathetic and after some detective work we found the culprit. Last summer I wrote a telephone note on a patient of The Other Doctor. I sent it to him. He left the practice and didn’t ‘sign off”. To remedy this sore, I had to get the house manager to resurrect him from the dead as an active staff member, then I impersonated him to go in and sign the damn thing. Hot puppies! this worked!  Unfortunately by becoming The Other Doctor (even for five minutes) this resulted in me becoming inactive and worse – nonexistent. It was very ‘1984’.  Eventually I was resurrected ala Dungeons and Dragons and I am back in the saddle with a dashboard showing ‘zero’ for unsigned charts.

One gets ones jollies where one can. 

Brother #3 called me on the eve of my travel to ask if I would take our father to the dentist tomorrow so he can attend the house closing.* He warned me Father is quite anxious almost paranoid but me taking him rather than Brother #3. He tells me Father ruminates I won’t be able to do it. Apparently Father is almost agitated and it is over small matters: I won’t know the directions to his dentist; I won’t know how to get a walker in and out of the car.**  Brother #3 is bewildered why these simple things should be so upsetting. I explained to him  as we age changes in our routine and deviations from the usual become harder to handle. Even a simple change like the dinner hour or  the prescription pill is now round when it used to be square can evoke panic and fright. In the aging brain the parts that light up during a deemed deviation are not unlike encountering something life threatening.  Our brains literally become less resilient with age, more’s the pity. 

I remember when I was a boy witnessing this phenomena in ‘old people’ and vowing I would not do so when I was that age. I put ‘old people’ in quotes as at 58yo one could argue my train is arriving at the station and I am already feeling peeved when something upsets the status quo. Last night I foolishly upgraded Firefox on the home computer thus making my at-home access to work inoperable. Yes, I can call support next week to help and I have access on the laptop but this knowledge didn’t prevent me from going quickly into a swivet perfectly imitating an old man in a nursing home not getting his meal at the usual hour. Afterwards I felt bad and vowed to do better. 

Stoicism states life consists of the unpredictable and the unexpected (and often unwanted) so just go with it and chill – you will survive.  I wonder if any of the Stoics ever reached 70 years old. 

It will be an interesting car ride tomorrow taking Father to the dentist while I watch the road and listen to him talk, sorely taxing my hummingbird brain more than my desire for predictably.  I just hope it doesn’t snow or the two of us will arrive at Dr. Walters’ office resembling an orchestra of scorched cats. 



*Father sold the family house. He had the luck a previous neighbor is buying the house. They moved away only to move back and they wanted to stay on the same street. Father and they know each other and the buyers are paying in cash and want in ASAP. He is quite relieved for the unused house was costing him 2K/month. The money on the sale  is going to reimburse Brother #3 for building an annex onto his house.  

**What he really should fret about is my lack of experience driving in snowy and inclement winter weather. Oh the horror. 

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April 2021

Spo-Reflections 2006-2018