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I routinely encounter patients who are afraid of the wrong things. An elderly patient announced  he won’t be getting his covid19 vaccine as he heard tell three people in England died after receiving theirs. This same person smokes cigarettes at a pack a day. Patients are not the only ones afraid of the wrong things, out course. One of my brothers refuses to take medication for high cholesterol on the (rare) chance it could cause side effects but he regularly buys lottery tickets hoping that pays off.

You get the picture. People are notoriously lousy at assessing risk. 

I hear the number of people who die each year from shark attacks can be counted one or or two hands, but we had to be dragged kicking and screaming into wearing seat belts to safeguard us from the far more likely chance someday 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 I do 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. 

One may not be able to stop being afraid of the wrong things but with some logic one can lay off the Lotto tickets and use the saved money to buy more vegetables. 

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. 

I must hold my tongue to ask the mask-less man on the street if you are not wearing a mask as you are putting your trust in G-d, why then do you feel a need to carry a gun? 

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

Wear a seat belt!

Stop smoking!

Wear a mask and wash your hands after using the restroom!  

Get exercise!  

And stop eating crap !


*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 Trump supporters, at least by how they look anyway. They often look heavily armed and grossly obese.  

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. 

If you think I’ve paused blogging because I am composing a profound and erudite entry you will be disappointed. The reason is I’ve been up to my oxters in work.  The week between Christmas and New Year’s Eve is a hectic one. There are a lot of calls from frantic folks wanting something done prior to 1 January when their insurance changes.  It happens every year.

Yesterday was all ‘med checks’ consisting of fifteen minute appointments, which in theory go smoothly along the line of ‘I am still good, the meds are good, I just have to check-in for your sake, and see you in another three months”.  This did not happen.  Many patients were quite emotional from loss, loneliness,  and physical maladies for which there is no relief.  I also got a lot of patients telling me they had covid19 since they last checked in. It feels like I’ve heard more cases in the past fortnight than in the past four months. 

The ostinato to these cases is nearly all of the distraught had a sense of being trapped. They can not get out of that awful situation/marriage/relationship/financial/medical/legal situation.  I try to get them to examine what is truly a trap vs. what is only feels like so.  Alas, I have little success, not because people are stupid but due to human nature.  Your brain wants your life to be predictable; your emotions want life to be stable.  We are wired to want to feel safe; we avoid uncertainty and the unpredictable.  It is scary to let go of the familiar, even when you know it is killing you, to go to – what?

For better or worse freedom and uncertainty are linked.

Sometimes I imagine I am looking at a caged person miserable therein and so wanting out.  When I point out the proverbial cage isn’t locked, or the bars are breakable, this doe not evoke relief but panic. “Yes, but…” often follows. These are based on fears, often quite legitimate, of what happens next.

Yesterday ended as days sometimes do with me feeling I did little or nothing to help anybody.  My patients don’t need pills but resources that I cannot provide.   They also need courage – courage to act and to give up the need to know how things will turn out.

The work week is a series of Blursdays but for Tuesday. On Tuesday I go to the office and work from there.* This is to have a break from working at home. There are always forms and labs sitting on my desk for my inspection. I pick these up and I drop off the ones I took home last week Tuesday.

Going to office as early as I do (I arrive about 6AM) allows me to make a hot cup of something and dictate charts or write forms in peace. After 8AM the receptionists come in (they do not work from home) and they tend to pop in and out of my office with forms to sign and fires to put out.

Some of the pharm representatives have deduced I am in office on Tuesday so they tend to show with samples and wanting my signature and attention. I find it bewildering why they bother as I do not see patients face-to-face and therefore Rx samples sit untouched in the cabinet. They probably have some data knowing this but making me aware they still exist must have some pay off for them. Why else would the tread about town doing what they do?

On Tuesday there are three counselors here as well. Some of them actually see patients face-to-face. I know this as I see them going past my open office door. They are all properly masked I am glad to say. All the same it makes me wonder why they do this as their offices are cozy things; sitting for an hour with someone even in masks sounds not safe to me. My bosses have not asked me to do likewise.  I don’t think they will.

The office is a more comfortable place for me to maneuver all the gadgets needed nowadays to shrink heads from afar.  I have the work screen, the laptop with the Zoom, and the two telephones (my cell and the office).

A bonus to work at the office is there is no dog sitting behind me just out of arms reach making low growls of sharpened famine asking me to get up and go to the kitchen yet again for something to eat. Whenever I feel annoyed by the pharm rep shenanigans I merely remember the trade off and I feel better.



*This has some risk of a patient showing up in person and understandably asking to be seen since I am here anyway. I picked Tuesdays as this is usually “Mesa” day and I go to the Phoenix office rather. Mesa patients would sooner eat rats at Tewkesbury than drive into Phoenix, so the chances of patients dropping in is lessened by this ploy. I still get calls on Tuesday from the Mesa office the patient has just shown there expecting me to be there too.

The other day The Other Michael sent me an article titled “Why didn’t gay rights cure gay loneliness?”.  It was a sad but unsurprising read. My fellow wizards have been beating the drums telling the tribesmen the news at the conferences for some years now on the ill effects of loneliness. I remember one lecturer showing stats saying loneliness was more hazardous for old men than smoking and lack of exercise.“They don’t need Lipitor, they need a buddy.” he commented.

Our monkey brains need touch and proper interactions. Alas, the isolation of 2020 sharpens our starvation for real social intercourse. It’s quite grim. Social media outlets have paradoxically worsened loneliness by enhancing the shadow sides of socializing. It emphasizes judgment, condemnation, and ostracism and it heightens our neuroses of ‘am I good enough?” and “will they like me?” crap must of us are glad to be rid of when we left high school.*

The majority of Spo-fans are either older gay men and straight and gay women.** These types grow up with a hyper-sensitivity towards rejection. They can sense such with a sharpness like a dog’s sense of smell. We reach out but when there is a slight redolence of disappointment emanating from the other we tend to withdraw lest there is worse to come.  This primitive reflex combines with the 21st century technology into an equation making new bonds almost impossible and loneliness to continue almost unstoppable. 

So much of my speciality’s pathology is based on social stuff. Prior to 2020 I was trying whatever I could to get people to do something about their loneliness.  Whatever the means it was mostly about learning to get through the pained perception of rejection to keep trying.

Covid19 has thwarted the usual channels and loneliness is more prominent and painful than ever – especially for old men. Poor sods. I wish I could do more for them. They don’t need prozac, they need a pal. 


*One writer comments social media has taken our brains back to the value of junior high school days. Oh the horror. 

**All are fine folks well over four feet. 

Note: this draft was written a few days ago and then I put away. I wondered whether or not to post it. I decided yes I would, as it is a ‘slow news day” and TBDHSR members who bothered to read it thought the essay shows my vulnerable side. I am not certain if that is a compliment or a critique for the only vulnerable sides that interest them is where to aim the axe.


Today I had to tell a patient ‘no”.  Prior to the 8AM appointment I read the chart notes: X has had years if not decades of anxiety and X has seen nearly a dozen psychiatrists apparently to no lasting benefit. I wondered if I could do any better. I sent out the Zoom invitation; I got no response.  I sent out another – nothing.  Around 820AM I called X who became anxious explaining they had the appointment down for 10AM and no they haven’t received any Zoom invitations. I sent out a third. Around 830AM there was still no response and the appointment was from 8-845AM, so when X called again for help I said alas this was a bust and we will have to reschedule. In the chart I saw X is getting medication from somebody else and in counseling with someone at our place. X became agitated saying their panic/anxiety was sky-high and had to be seen today.  Indirectly X conveyed if X was learning coping tools/different ways of dealing with the anxiety this wasn’t working or being applied for the present situation. X pleaded for me to start the appointment now over the phone (we have a policy all new patients must be ‘seen’). I said no and X went into hysterics. I repeated the plan to reschedule ASAP and hung up.

Physicians find it painful not to help patients more than they can but it is also painful telling patients ‘no’. Doctors are mostly ‘nice’ people, who are not good nor comfortable telling patients what they want or need isn’t going to happen.* Parents feel something similar with their children. Kids are always asking for things which parents must say ‘no’. Children usually up the ante by crying or by throwing a fit or through nagging – hoping to wear down the parent by attrition.  Everyone knows it is important to set limits with kids as giving them whatever they want does them no good but makes them into horrible human beings, who learn being nasty ‘pays off”.  

Saying ‘no’ to a patient seems harder to do nowadays. Back in the bad old days doctors if your doctor told you not to do something you did so without question.  Nowadays patients see their doctors more like waiters who will bring them want they want and if they don’t they will leave a bad tip in the form of a negative Yelp review, usually along the line ‘my doctor doesn’t listen to me”.

I regularly remind myself I cannot help everyone. I am not a bad person nor a bad doctor telling people no. As I’ve aged this is becoming easier to do but I have lots more to go. I try to explain the ‘no’ and what we will do otherwise. This doesn’t always go well of course. It gets down to being comfortable with someone angry/hurt/feeling let down by me.

As for X, X will probably reschedule and be seen sooner than X feared would happen. I might point out the lesson that waiting a week shows her anxiety although uncomfortable is not the end of the world.  I’m pretty certain the previous twelve shrinks tried something similar.

At some point one has to give up the illusion one can fill a black hole and there is no point to cross the event horizon into one  – painful as this feels.


*SIL #3 is an ER physician. She would find this notion absurd as most of her job  is doing just that viz. telling folks coming to the ER they are not getting certain medications or procedures as if they had walked into an all you can eat buffet.


Alas Babylon ! My medical secretary A.K.A. Bubble A.K.A. Mr. Humphries announced last Friday afternoon at closing he is quitting suddenly to take an dream-post with WHO.  I wish him luck; I will miss him. Besides being bright and obsequious he was pleasant conversation.  He likes tea, so we often made a pot in the mid-afternoon to shar.

On the negative I now have to work today/this week/for some time now without an assistant until The House Manager finds a replacement. Oh the pain. He was the third assistant in five years or so. They don’t stay long. I suspect the bosses don’t pay them enough; the last three incarnations all left to get better paying jobs. I have to remind myself the role and responsibility of the medical assistant is the house manager’s job, not my own.

My work has become a lonely endeavor.  For four months I’ve worked from home with hardly any interactions with the bosses or the therapists; they are all working from home too. It’s been nearly five months since I went to The Mesa Office; by now I cannot remember the names of the current crop of clerics who work there.

It seems there are so few personnel left at the clinic – the therapists come and go too. A few of them recently retired. Today Monday there will be one counselor who comes into work; she will close her door and work all day and I won’t see her at all.   It all makes me wonder if the place will endure. Goodness knows I have no lack of work to do and perhaps more if The House Manager calls on me to chip in in the interim until there is aa new Medical Assistant.

Well that’s all the news prior to the 8AM first appointment. So far I hear no one entering the door (counselor or receptionist) and the office feels like a ghost town. Yesterday I wrote about the joy of solitude and silence. This version doesn’t feel so nice.

Along with an increase in covid cases comes an increase in worry and anxiety*. The number one issue at work these days is “how do I deal with this?” As a public service announcement I will tell you. Pay attention: people pay me big bucks for this sort of stuff.

The first step in dealing with stress is to not try whitewash or deny things but recognize these are tough times. Anxiety is like an unwelcome family member Thanksgiving – in this example I will personify a/w as Uncle Joe. You wish he weren’t there but he is; the task is to keep Uncle Joe’s dinner table shenanigans to a minimum and not let him to run and ruin things. 

The second step is to remember bad things and times always happen; the current set is indeed a nasty one but this isn’t unique. You have more strengths than you realize. 

The third step is learning and applying something called mindfulness. Mindfulness is paying attention to what you are experiencing/what is happening in the present moment without judgment. Mindfulness takes time to practice but it is simple to learn and it has one of the best track records for dealing with the Uncle Joes of life. Mindfulness has four general parts:

#1 – Recognizing what your are feeling/experiencing. “I am experiencing sadness/anger/panic/confusion” puts you at a little but crucial distance to not immediately act out on these feelings**

#2 – Allow the feeling to happen. This advice is often met with aghast as most patients want the anxiety/worry/panic/confusion to go away or not to have happened in the first place. Yes it feels bloody awful and certainly you would rather not have it but it’s there. Like Uncle Joe if you try to eject him he becomes more dominant and ensconced.

#3 – Examine it. Start asking the questions: Why now? What is contributing to it? What things from the past are playing into it and coloring it?  

#4 – Disengage from it. Anxiety is not ‘you’; it is what you are experiencing. You are not Uncle Joe nor are you responsible for his being there or for his shenanigans. You can do something about his influence on him. This is where the patient’s individual strengths and approaches are applied. Perhaps your best method is take time out/walk away; perhaps it means applying the approaches you know have helped in the past. 

Through recognition, acceptance, examination, and action one can get through a lot including these worrisome times.




*’Worry’ is a state of mental agitation while ‘anxiety’ is worry with somatic symptoms such as shortness of breath, palpitations, and restless. This is straw-splitting but I like the discrimination. 

**Feelings vs. emotions. This is another psychobabble straw-splitting maneuver. Feelings are conscious while emotions are not conscious.

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January 2021

Spo-Reflections 2006-2018