Can You Hear Me Now?

“I feel like a little girl at Christmas!” my almost eighty-five year old mother said, from an appropriate social distance, after she received her new iPad earlier this month.
My middle daughter, ever the organizer and planner, asked if her grandmother knew how to FaceTime or otherwise communicate by video in this new world of COVID-19 and social distancing. Her great-granddaughter is growing up in Colorado and she, like the rest of us, has not been able to see the little one, or any of her other great grandkids, for some time now. Something needed to be done to remedy that. My daughter had the marvelous idea that we should get her Grandma an iPad and teach her how to use it. I agreed and ordered one right away.
The look on her face when I saw my mother talking to me by video on the tablet was simply priceless. She quickly learned how to use this wonderful little piece of tech, and connected swiftly with her grandchildren and great grandchildren in Denver and Chattanooga. Something so simple lead to almost immediate joy. A silver lining in this dark gray Coronavirus cloud for sure.
We have found that we can all stay connected pretty easily to friends and family in this time of social connection crisis, but what about connections between patients and providers? What do you do when you have physical symptoms and have been told to stay away from doctors’ offices and emergency rooms? What happens when your depression deepens, your anxiety flares and the voices that were under pretty good control start to scream at you again? What happens when your resolve to stay sober is dashed by the fact that AA meetings are not meeting at all? How do you connect when mental health centers, doctors’ offices and clinics are not seeing people physically due to the worry about coronavirus transmission?
We have found that there are several very good apps and services that help us to do just that. Most of us in the local mental health center world are now working from home the majority of the time but we still have full schedules of people to assess, check for medications, and to do counseling sessions with. I thought I would share some generalities and specifics of this new world with you. It might help as you pursue your own mental health treatment, and you might find that it also goes for other medical care that you might receive as we navigate this new normal.
We communicate with you by phone call or by video calls of several kinds. This is a wonderful addition to our therapeutic arsenal, but it does come with some caveats. First and foremost, you must understand that while these ways of communicating with your doctor or therapist are quite private and secure, they may not be considered 100% HIPAA compliant. As you might remember, one of the primary jobs of the Health Insurance Portability and Accountability Act of 1996 is to safeguard your private personal and healthcare related information. Speaking with me in my office with the door closed and no one else around is about as safe as we can make things. Talking to me on our iPhones via FaceTime not so much, though it is a wonderfully vivid way to see and talk with each other in real time. You see the tradeoff there.
What are some of the other options for communicating in this new way that are being used by the local mental health community? Doxy.me is a video or audio telemedicine platform that is free to use, though it does have a paid tier with a little more functionality. I can send you a link that allows you to be in my “waiting room” until I call you for the session, which can be video or audio only. This service works well but the quality seems to be a little spotty at times, with freezes and restarts and other issues. If you have a Google or Android phone and have Google Duo, I have found that both the audio and video quality with that app are quite good. Google Voice is my go to for regular phone calls, as the connection is usually quite good and the quality of the call is quite nice as well. I have already mentioned FaceTime above, and some folks specifically asked to be contacted via that platform since they have an iPhone and trust it to be secure.
When we see you using these apps and services, we make sure that we tell you why we are doing this, that it is not the same as being seen in the office and that you give us permission to speak with you using these platforms. Most everyone I have seen over the last two or three weeks has been completely fine with these new ways of having a mental health visit. Some of the upsides? Patients do not have to waste time, gas money or effort getting to the clinic from their homes, paramount during this time of social distancing. When I call and you answer, we can get right to the point, cutting out much of the time walking to and from the waiting room, gathering paperwork for labs, etc (I can do most all of that electronically, as well as electronically prescribing most of your medication right from my laptop keyboard as well) and actually finishing many of these sessions in less time than at the center in person.
Lastly, may I leave you with some tips to help make this a smooth process on both ends of the phone screen? Understand that video or phone appointments are still appointments. They are set at specific times, and we expect to “see” you at those times. These are not casual or social calls. That means that you should be set up and ready to receive the call at the time specified, so that everyone may be seen on time for that day. I have called some patients this week, only to have a parent roust them from bed to speak with me, or having to wait for them to complete a task in the kitchen or bathroom before they can come to the phone. Consider your surroundings, as I do. I have had virtual tours of many backyards and decks, and met several cats and dogs on screen this week, which is certainly fun but may make it harder for us to really hear each other well enough to get our business together completed. Find a quiet, private spot for us to talk, just as we would if we were in the mental health center. One more thing. Remember to dress like you are going to talk to your doctor or counselor. I have been quite surprised and frankly startled a couple of times these last few weeks by what folks will wear while FaceTiming on the phone.
We are very unlucky in that we are all living through the first world pandemic in the last one hundred years. We are also quite fortunate to have at our disposal some of the most useful, easy to master technological tools for communication in our history. I am so glad that we still get to carry our work forward, maintaining our mental health even as we strive to stay physically healthy in these challenging times. Stay safe and thanks as always for reading.

Come Hither: Random Covidisms for Sunday 4-19-20.

  1. One of my superiors in the Department of Mental Health sent out an encouraging email to us the other day. One of things she said that really hit me was that in our current state of personal uncertainty, anxiety and turmoil, maybe we were all experiencing just a little of what our patients experience throughout much of their lives. That stopped me in any tracks mentally and emotionally. How right she was. Thanks, Deb, for making us take the time to exercise our empathy muscle.
  2. I am now working from home four days out of five, as far as my regular clinic job goes. I go into the office on Fridays, as part of the need to have a medical doctor on site for billing purposes for Medicare and other random reasons I suppose. After getting sort of used to being home and having a completely different physical and mental workflow, I went to the office this past Friday as instructed. I drove around to the portico for my pre-admission screening, passed that, parked, and went inside the building. There were probably a dozen people actually working at the office that day, most of whom I did not see the whole time I was there. I went directly to my office, mask in place, then closed my door (mask comes off) and worked most of the day without leaving that small space. I did walk to the medical records area to drop off signed items (mask goes on), left a couple of things under the doors of coworkers’ offices, but spent most of that time in my own space (make comes back off), physically and head-wise. Once, I was out in the hallway (mask back on) and saw another masked staff member walk around the corner and up the hallway. I gave them plenty of space, kept my social distance and only said hello. Nothing more. Odd this felt, in so many ways, this day at the office that felt like more of a punishment than a reprieve. I did not really want to be there. I am now used to working at home (funny how the new normal takes hold so fast) , I did not want to make obligatory small talk (I normally love the little random daily interactions that make up office life and relationships) and I was mentally prepared to just work by myself for that day. This was not a bad day but neither was it a fulfilling day at work. I miss the old way.
  3. I am not one to remember my dreams, if I dream at all. I know I probably do. There is more time lately to actually reach that stage where dreams may come, but I wake with that vague semi-remembrance that feels like wisps of cotton brushing my brain. Not so last night and this morning. My wife gets up earlier than me on most mornings that we are at home together, and so she did today. I decided that as I seemed to be dreaming, I would give myself a little more time to complete these elusive thoughts. As I am not a Freudian (even though I trained with mentors in a program that was hanging on to psychoanalytic principles with everything it had) I will let you interpret these as you will. In the first part of my dream, I was sitting at an airport bar, Dell laptop (yes, this is the work machine if that has any importance in your interpretation of my nocturnal strivings) on the bar in front of me, drink at the side (a no-no, of course!) struggling with some project or note or problem. Distracted by something that I do not remember, I turned back to face the mirrored surface and multiple bottles of booze only to realize that the laptop had been stolen. Gone, it was. Crap. So what did I do but of course go the bathroom to relieve myself, telling myself that I had my bag containing my personal MacBook at the foot of my barstool, and that I could continue my work on it when I returned. You guessed it, when I got back to my unattended bag of technology, it too had been pilfered. I went home. I then realized that my Lexus (I do not own a Lexus) was showing that its oil level was perilously low to the point of imminent engine lockdown. I went into the house and asked my wife where she kept the cases of extra motor oil, as one does, and she promptly brought out five quarts of Costco’s finest. I drank half of one bottle to make sure that it passed muster, which it did. I then went out and filled my Lexus (I do not own a Lexus) with motor oil, knowing that I was not going to be driving anywhere for the next God knows how many months due to the Coronavirus lockdown. I then decided, as the hour was unseemingly late in the morning even for a Sunday, that I could wake up and start the day.

Happy Sunday.

It is Sunday, right?

Or am I dreaming?

Certainty

“Have you ever heard a story like mine before?” she asked me, a pleading look on her face that both begged me to say no, making her special, and to say yes, alleviating her fear that she was so unique that there was no help for her.

“Why, yes, I have, many times,” I answered.

She slumped, her body releasing the tension of years of not knowing, of fearing the worst, of thinking that she was beyond help.

“Please, tell me. Tell me. What do I have? What is my diagnosis? What is wrong with me? I just want to know that someone knows what this is called, what my symptoms mean. I want to know. To be clear. To be certain.”

I told her what I thought, while at the same time telling her that not much in the field of mental health is absolutely certain. The brain is a fascinating organ, but when something goes wrong deep inside it, it may neither be as easily diagnosed as a fractured femur, nor as easily repaired.

Many of my patients come to me with anxiety, with fear, with uncertainty. They feel things, they experience things that frighten them and make them feel that their world is out of control. They are hesitant at first to uncover these feelings and thoughts and impulses and changes in mood and thought that they think will label them as crazy or weird or not normal. Can we blame them? Absolutely not. We all want to appear, to feel, and to be normal, at least in the eyes of our family, friends and peers. We crave normality. We crave the usual, the mundane, the predictable. Of things that can be known and explained, we crave certainty.

Now, these past few weeks have been different, wouldn’t you say? We are told to distance ourselves from our loved ones and coworkers. We communicate via FaceTime and Doxy.me and Zoom and Skype. We wear masks. We wash our hands many times per day. We look askance at the person approaching us in the aisle at the grocery store. We have developed an intimate relationship with Netflix. Some of us have lost our jobs, and with that has come a rise in anxiety, insomnia and fear that I have not seen in my patients for quite a long time. All of this is stressful enough, but it is bearable, at least for the short term.

Enter the lack of certainty.

Humans can bear almost anything for a finite period of time. Think of previous pandemics, the fall of empires, the great wars, and natural calamities. We have faced much, and we have survived much. We are able to bear the most painful hurts and atrocities, as long as we know there is an end in sight. As long as we know there is an end to the suffering, the pain and the uncertainty. This is one of the reasons that our current situation, battling the unseen enemy that is the coronavirus that causes the illness COVID-19, is so difficult for us to bear. We simply do not know exactly how and when this is all going to end.

We are told to get out but keep our distance. We are told to go to work. We are told to stay home. We are told that we can work in a modified way, then we are unceremoniously handed a pink slip or a furlough notice. We are told that we must  stay in our homes for six or eight weeks, then we are told that the churches will be gloriously full of people on Easter Sunday.

How do we respond to this? We are anxious. We are stressed. We do not sleep. We hoard things that we think might be in short supply soon. We obsess over how we will pay our bills, care for our children, and check on our elderly relatives. We get depressed. We lose hope, that most precious of commodities that fuels recovery from any disaster. We worry needlessly, because as one of the nation’s top scientists said, we do not make the timeline. The virus makes the timeline. What to do?

How can we protect ourselves? The key is to recognize that we cannot be certain about this virus, this illness or the resolution of this pandemic. Even the medical scientists who know everything there is to know about these things are not in agreement about how this will all play out. We must let that go. What we can be certain about is how we live out our own life in the middle of this event, choosing to be positive and proactive instead of responding to the growing reports of illness and death.

Sleep. Sleep enough and rise and go to bed at the same time each day if possible. Eat healthy foods. Do not overindulge. Exercise. Meditate. Read things other than the news. Journal. Create. Connect with friends and family in any acceptable, non-risky ways you can. We are social organisms, and we do not do well with long term isolation and emotional and physical deprivation. We just don’t. Learn new skills that help you navigate this crisis. Do not expect to do things the same way because “that’s the way it has always been done”. Keep an open mind, learn new techniques and skills, participate and be a part of life as it is today, not as it was three weeks ago.

This pandemic will pass. I don’t know exactly how or exactly when. I just know that I am certain about a few things right now. I can still see my patients from a home office that did not exist until last week. I can get outside and take a walk and eat lunch in the warm sunshine on my front porch. I will go to the river and fish this weekend. I will read and listen to music. I will connect with my family in technological ways that were only vague dreams when I was my grandchildren’s age. This is the life that I can lead right now, and I am going to embrace it with everything I have. Of that, I am certain.

I hope you choose to do the same in your life. Be well and stay safe.

Lend Me Your Ears

Okay, so I made it clear in my last post that I do not like really big, long term change. That’s just me. That being said, I have been in a maelstrom of rapid, relentless, major, workflow altering change, much as many of you have, over the last two weeks now. Sort of like that frog in the pot of water that is unaware that the temperature is rising until he starts to boil, we have been the recipients of a slowly gathering storm, pushing a tidal wave of change on us from way out at sea, knowing that it is coming but not having a clue exactly when it will hit, how much damage it will do, or whether we will survive it.

On top of that, we are now seeing reports of people actually dying from this COVID-19 infection and disease, not just getting sickened or inconvenienced by it. A young lady. A middle aged media executive, a child, an infant, a renowned neurosurgeon, a country music artist. In other words, people like us or people that we love and care about. Ouch. Much too close to home. Anxiety, More stress. Worry. Paranoia. Enforced isolation which leads to functional isolation which leads to real isolation even at home. Not good for the psyche. Not good at all.

I can handle this, I tell my bad self. I will not get sick. This could never happen to me. I’m too young to die. I’m in my prime. My brain, smart as it is in the area of fact assessment and reality testing, is also super duper good at deception. The person it is the best at deceiving is me. I do not feel sick, therefore I cannot get sick. I am able to handle this stress, and even more stress, without feeling it physically. I will not notice a thing, not one little thing that will give me a clue that maybe my physical or emotional systems are overloaded. Right.

A couple of weeks ago, my left ear started to feel a bit stuffy. Annoying, but not terribly debilitating. I chalked it up to the myriad allergens in the air in the southern United States at this time of the year. I had felt this before, sometimes saw it turn into a mild cold, and had developed a way to cruise through it. Daytime and nighttime cold medicine at the very start of this syndrome, plus nasal spray to keep me breathing enough to work and be productive, all for about a week or so, had always worked before. Dutifully, at that first little feeling of stuffiness and discomfort, I embarked on my standard regimen. I thought little more about it.

A week later, things were worse. The ear was more stopped up, I could not hear well on the left side, and there was an uncomfortable feeling of having one side of my head in a barrel. I knew best, I told me, and I continued to doggedly prosecute my tried and true regimen. More liquicaps, more spray, more time. Nothing doing, my ear said, we will not budge. The left side of my head, down onto my neck, around to my cheekbone, got numb. When I would talk to colleagues, albeit from six feet away, I felt that I was shouting. Conversations at the island in the morning with my wife were unsatisfyingly one sided unless I turned my head towards her and practiced a mixture of something like torticollis and lip reading. “This is one bad allergy season!” I pontificated. All the while, this was really starting to drive me nuts, with the changes at work, schedules upended, my wife getting back on planes to fly germs, I mean passengers, around the country.

Then I remembered an episode a few years ago when a similar thing happened, but a time that I felt that I lost ALL the hearing in the same ear. Total hearing loss. Nothing. Scary. I ended up going to an urgent care center that time, and as you may have guessed by now, I had a monster, hard, obstructive impaction of cerumen, that’s ear wax to you and me, in that ear canal, completely and utterly obliterating any path for air or sound to travel one way or the other down my ear canal. A little soaking and a splashing shower of irritation, I mean irrigation into a small metal pan, and I could hear! I had never felt that happy in my entire life.

Fast forward to this week. No hearing, numbness in my face, unsteady on my feet, oh my God do have a tumor somewhere kind of angst running amok among the COVID-19 particles , I finally remembered that episode. I go to Walgreens, buy some ear wax nuking stuff (No, they still don’t have hand sanitizer), and get to work. I won’t bore you with the tedious details, but after three nights of this intervention, one evening in the midst of a showering royal flush, out came an ugly piece of wax that had bugged me for days. I could hear! I was no longer numb! It was a miracle!

Funny thing, though, the right ear, the one that had felt pretty normal through all this, felt a little stuffy itself once the left one was crystal, drive a gondola down the ear canal clear. Oh, no, migratory aural tumor, I thought to myself, and had to smile. Really? Really? More wax nuking drops, two more days, then blessed relief. I am virtually normal now, if I ever was.

So, I quipped to my wife at breakfast the next morning, sitting at the island, and NOT turning my head as I could already hear her replies, I wonder if increased stress and anxiety can cause one to create more ear wax? Ever at the ready to end wanton ignorance in our little world, she snatched up her iPhone and searched for an answer.

I’ll be damned.

Turns out, increased stress and fear can cause the body to produce more cerumen.

WHAT?

PRODUCE MORE CERUMEN!

SEASON WITH CUMIN? WHAT?

NO! EAR WAX. EAR WAX!

Oh……

We are all overloaded right now. We are frogs in a pot. The temperature is rising, and we are in jeopardy of boiling if we are not careful. We think that we have seen it all, done it all, figured it all out because we are smart, successful, resourceful people. We have all the answers. We are large and in charge.

Wrong.

This is bigger than us. Tiny viral particles, too small for us to see, have brought our world to its knees. Our economies are reeling. Our social institutions are paralyzed. Some of us are sickened. Some of us are dying. Our bodies know this, the ancient parts of our bodies and those cells and systems that really HAVE seen it all and survived, they know this, even if our younger, smarter, more resourceful brains cannot accept it.

Listen to your body. It will tell you when you are maxing out your biological credit line. It will tell you when to slow down, when to meditate, when to eat, when to rest. If you do not heed it, it will find a way to get your attention.

Thanks for lending me an ear while I waxed eloquent.

Yes, I really went there. Be well.

COVIDISMS: Change

I don’t like change. Never have. Never will. That is, big change that impacts me in big ways for long periods of time. Little changes, maybe okay.

That being said, this COVID-19 crisis sucks.

As soon as we knew at work that this was a real disaster, that it would almost certainly affect us locally and all of our coworkers and patients, we began to plan and to act. Almost immediately, we began to scheme how to put at least six feet between us, how to open doors with door stops so that no one would have to repeatedly touch them to go in and out of the various hallways in our buildings. How to sanitize fixtures and other touchable surfaces multiple times each day to keep us safe. The physical cleaning and distancing and separations came almost naturally as a first step to keep us healthy and safe. I dealt with that okay. Wash my hands even more times than usual. Don’t cough or sneeze openly. Use Kleenex, handkerchief, sleeves. Don’t touch stuff and then touch your face. Got it.

Next came how to distance ourselves from each other while all working in the same building, and how to keep patients from coming in and out, potentially cutting down on exposures for all of us. Six feet of distance. No staff meetings. All info exchanged by email, text or other non personal ways. Screening tent set up outside, signs diverting folks coming to the property to that area for the now ubiquitous interrogatory. Injections given outside in the tent by scrubbed, bescarved, masked nursing staff. The first ever, to my knowledge, management team meeting at our place that was completely done by Skype for Business. Most of us were still in the same building, but we were not dropping by to stand in each other’s doorway to chat, we were not doing sidewalk consultations, and we were not having routine meetings in the mornings or any other time. This was a major departure from business as usual for mental health types, who are used to presenting cases, asking questions, getting feedback and working in a team model.

The next step, pressure from the governor’s office to work from home. Not just a few of us. All of us, or as many as practically possible. This meant rapidly, and I mean in a matter of days, prepping everyone to pull up stakes, take everything needed home, learn to connect with a laptop, cell phone or tablet and access all the tools that we use to do our jobs every day, but in a completely different setting with completely different hardware. In addition to that, to speak with patients by video chat or phone (video encouraged) instead of face to face. This changed in less than a week. Hard to describe in words how monumental this is for many of us, who have sat face to face with patients for decades, looking for clues from odors, mannerisms, movements, gait, speech, expressions and other ways of assessing people and their behavioral problems. Suddenly, our world jumped online. Almost totally.

There are still a few of us literally in the building. I am still doing my Telepsychiatry emergency room work at the office since I have all of my technological rig in place there to do high quality video, etc. I am not set up to do that from home. I do, however, have a new laptop that is about halfway set up to do everything I need to do to run my clinic job from home, bolstered by video access that I can get with my MacBook or iPad. I have about sixty patients scheduled for the clinic this week, so I am not sure where the time is going to come from to make these major changes in workflow while work is flowing, but it will come to pass somehow. Soon, I may be asking for permission to share my wife’s art room studio space for a makeshift office in the corner for me, my Dell, my Mac, my iPad, my iPhone and my virtual patients. Major. Major. Major. Change.

Are there changes outside work? Are you kidding me? As I settled in to do my Telepsych shift in the EDs this morning, I got a FaceTime request from my daughter in Denver. Did not have to think twice about answering it immediately. There was my granddaughter, with a smoothie popsicle breakfast in her little hands. She has been in the habit lately, according to her mother, of calling someone that she wants to check on. Today, she wanted to call her Papa. Well, melt me and wipe me up with a Quicker Picker Upper. This is radical. This is heartbreaking. This is fabulous. This makes me laugh hysterically and sob at the same time.

So. Much. Change.

Such a short time to take it all in.

Has this changed my relationship with my wife? Not fundamentally, not in the least. She is my rock, my confidant, my support when I need it most. I try to be hers and return the favor. So are we both stressed? Absolutely. I work in health care. She works in the airline industry. Enough said. Might one of us be exposed to this little particle and infect the other? Of course. Might we get sick? We’re both over sixty. Yep. Might we have to quarantine? Yep. Can she work from home? Nope. We are okay, but we have had conversations. We will have more.

How am I dealing with all of these fundamental and profound changes?

On the negative side, by obsessing way too much (I do that anyway, on a good day!), by updating, organizing, re-reading, trying to concentrate, trying to stay focused on the task at hand and actually finish it in a timely way.

On the positive side? Listening to music, lots of music, uplifting music. Listening to podcasts. Writing. Journaling. Sleeping when I can. Eating good food. Connecting with family by email text, FaceTime and phone calls. Trying my best to be supportive of my friends and my staff at work. Getting advice and help and guidance when I need it. (I still need it.) Making time for my marriage and my relationship with my wife. Noticing that it is indeed a beautiful springtime outside and marveling at the beautiful colorful flowers in our courtyard, my Japanese maple that has miraculously resurrected itself from the winter doldrums to sprout dozens of delicate red feathery leaves, and the azaleas that are shouting at us, “Look! Look! We are gorgeous! It’s spring!” Watching the doves who sit patiently on their nests at the top of the courtyard’s brick wall under a marvelous cascade of tiny yellow roses. Sitting, blinking, soft and beautiful brown-gray and wondering what all the hullabaloo is about.

I do not like change.

I do not like it in my house.

I do not like it for my spouse.

I do not like it at my work.

Out of my routine I am jerked.

I do not like this viral spread.

I do not like the many dead.

I wonder when it all will end.

I wonder if our paths will bend?

I wonder if we all will learn

That viruses our worries spurn.

They set their own trajectory

And care not one small whit for me.

How has your life changed in the last two weeks? How is it likely to change this next month? How will you cope and stay happy and healthy and productive until this pandemic ends?

Stay safe, isolate, wash your hands and we’ll get through this together.

Music Notes and Covidisms

Music is always a good thing, no matter the mood. If I am down, sad, angry, irritable or just flat, music can be the background that either confirms my emotional state or lifts me out of it.

I was pleased to open the music app on my phone yesterday to see that Apple had gifted me with a new curated music list called Get Up! I usually like to play my Favorites Mix, the Chill Mix and sometimes get wild and crazy and listen to the New Music Mix. The Get Up! Mix was especially welcome in light of all the stress I have been feeling in at work this past week. From the opening bars of Drivin’ With Your Eyes Closed by Don Henley (one of my favorite artists) to Elton’s John’s Sleeping With the Past to You Might Think by The Cars, I was immediately transported to a better, more mellow place.

Whether Dan Fogelberg is riffing on democracy or Chicago is making me smile, this music is a throwback and an anchor to times before middle age, viruses and crazy politics. I find myself singing along, tapping my feet, humming, and just letting a tiny bit of the stress flow out of me and back to wherever stress goes when it leaves us.

Like the bands tell me, If my Paper(is)late and I am stressing over deadlines, music can Take It Away. A look to the Western Skyline does Open Soul Surgery on me and, like Tom Petty (may God rest his soul) I Feel A Whole Lot Better. Amen.

What does COVID-19 do to you, even if you’re not infected? Well, from my chair at work, it makes me anxious, it has tripled my workload and it leaves me wondering when this will all end. Any good things, positive things it has done? Yes.

I am concentrating on communicating my needs and the needs of my staff and patients more succinctly. No time for mincing words these days. Formulate the thought, get it out. On to the next thing. It has made me appreciate touching base with my peers. A lot of decisions and plans can be made in a very short amount of time in a crisis situation. I knew this from having worked hurricanes and other natural disasters, but this is different. It is affecting everything from staffing to leave time to employee health to childcare to scheduling to clinic procedures to supervision to patient care to technology to time management. Boom. In a matter of days, the way we did things is no longer the way we DO things. You have to keep up. It’s exhilarating, excruciating and exhausting.

I have had more direct contact with my family members by phone and FaceTime in the last few weeks then in the last year. I checked on my uncle last evening after hearing from my mother that he had sustained an injury in a fall. He sounded the same to me on the phone. A little mischief and humor in his voice, an even tempered assessment of the world, a positive take on what had happened to him and how he was going to deal with it. It made me smile just to hear his voice. Why had I not called him sooner? There is no reason; there is no excuse. Just a loss of routine connection that a tiny virulent particle has prompted a course correction for.

Thanks to Tom Petty for giving me the right thing to say to you, Coronavirus.

I’ll feel a whole lot better when you’re gone.

Updates

Well, as often happens, it takes a while for the dust to settle on a new idea or project to really find out what you were thinking in the first place. I was going to have a spin off blog about growing older that would be separate from my longstanding blog Musings. I realized a couple of things. One, it is as difficult to multi-blog as it is to truly multitask. We fool ourselves into thinking that we can do it, but in reality we only find ourselves ping ponging back and forth between competing ideas and projects, half doing both, completing little and feeling frustrated. I found that as I was growing older I was simply musing, and in the time I was musing I had indeed grown older. The solution? Merge the blogs. Done. If you missed any of the first dozen and a half posts on Growing Older, they are here to be found and enjoyed. Now, back to musing, the thing that I like to do and most likely do best in this space and format anyway.

Coronavirus has changed my life. Has it changed yours too? It seems like years ago since the first inklings of this unfolding tragedy hit out consciousness, but it’s only been weeks. In just weeks my home life, work life, travel, recreational time, and professional view of the world has changed. It’s here. I don’t like it.

Specifically, what do I not like about this virus-filled world? I do not like the fact that I now am sitting at my desk, isolated, cut off from my patients, all of whom I now communicate with by cellphone or video. I do not like the fact that my wife is unnerved, unsure, and at loose ends, not knowing if she will fly, where she will fly, with whom she will fly, and if she has a better then even chance of contracting this COVID-19 and then bringing it back home. I also worry that even though I see everyone artificially and sterilely now, that I may have had a chance or three to pick up that same virus in the weeks before we even knew it was stalking us. I do not like the fact that I spent many hours thinking about and working on a presentation for a conference that is now canceled. I do not like the fact that my wife and I were planning to go to Italy in April, the first time I would have been back to that country since I lived there as a seventh grader in 1970, and now that dream is many months if not years down the road. I do not like the fact that I cannot joyfully get on a plane and fly anywhere I want to seek adventure or excitement, because each trip is possibly contaminated and scary and potentially disease-ridden. I do not like the fact that I had to physically rearrange my office to better telepsych and type and talk and Skype and document. A little thing, but enough to make me not know exactly where to put my hands and at what distance to sit from each screen and how to best situate myself to hear and see and type and complete other tasks at hand. Just enough change to make me strain at the viral tether that now is attached to all of us, invisible and inevitable.

Which part of all this makes me the most cranky, feel the most sad, the most sorry for myself? None of it.

What hurts the most about this kind of game changing, world shrinking, mind blowing natural event is how it impacts the ones I love and care about. I already mentioned my wife. What hurts her hurts me and vice versa. Her confusion and questions are mine, my physical and emotional exhaustion are hers. We support each other the best we can and keep moving forward.

Our mothers, both in their eighties, should not have to worry about this. They are the young old, at least in our eyes, energetic and sharp and happy and smiling. They enjoy Silver Sneakers, volunteering at the hospital, spending time on the back deck, tending to flowers, watching the myriad birds they attract with feeders, visiting with neighbors, seeing pictures of great-grandchildren on FaceBook and living the life that the old should be entitled to without question. They should not have to worry about a cough, some congestion, a fever.

My children. No, they are not young anymore, I know that, strange as it still seems to me. They are courageous and daring and outspoken and informed and energetic as they attack this new problem that has decided to pop up in their lives at this particular time. They must handle relationships and jobs and raising children and sending spouses off to work. They have this newfangled internet and FaceBook and Twitter and Instagram stories and all the ways they can connect to friends and family, and they wield them like flaming swords, daring this little be-crowned viral particle to deconstruct their worlds. I marvel at their energy, their drive, their curiosity, their willingness to challenge norms and speak out and change their world. Virus be damned.

Yes, all the inconveniences are just that. They are not insurmountable. They may be fleeting. They are adaptations, mild kinks in the otherwise relatively smooth rope of time that we all cling to and slide along until we reach the frayed end that allows us to quietly slip off into history.

The big things, the important things, are how this little virus is changing our social fabric, our emotional, physical and financial security, our ability to reach out and touch each other, to comfort each other, to hold each other up. It is painful to watch, to experience, to feel. It is isolating. It is depressing. It feels almost insurmountable.

But it is not forever. The wonderful line in one of the shows that my oldest daughter starred in last season in Chattanooga, Avenue Q, says it best.

It’s only for now.

Wash your hands. Pick up the phone. Call someone. Wash your hands. Telecommute if you can. Cook at home. Have wonderful conversations. Wash your hands. Do it, because you must. We must all pitch in, if not for ourselves, then for our mothers and fathers and children and grandchildren,

It’s only for now.

Productive Anxiety

Mind Matters

Monday, March 23, 2020

Productive Anxiety

“I can’t quite explain what it is,” I told my wife a few days ago. Seems like weeks ago, actually.

“I agree,” she replied. “I can’t put my finger on it either, but something is not quite right.”

We were having what now seems like the first of dozens of conversations about the latest threat to our stability and wellbeing. Of course I am talking about the coronavirus scare that we have all been grappling with over the last few months. The threats posed by COVID-19 have inserted themselves into our vernacular, our school systems, our places of worship, our nursing facilities and our workplaces. We have read newspapers, listened to television reports, made toilet paper and canned goods runs on Costco, and washed our hands more in the last few weeks than ever before. What is it about this latest threat that makes us so uneasy?

Things that we do not fully understand make us anxious. I hear about anxiety virtually every working day from my patients but this is different. None of us know what to expect. Someone told me last week that this is like knowing that the tsunami is coming but not knowing how big it will be and how much damage it will do. All of us, patients and families and caregivers and healthcare providers alike, get anxious about this kind of threat. This is a novel virus. Most of us do not like novelty, change, things that are different and are likely to disrupt our routines. We fight against things that we can see, touch, or manipulate. This is different. This is an invisible threat that will not kill most of us, or even make many of us really sick, but may potentially sicken or kill the most vulnerable among us if we do not act now, and decisively so. This kind of anxiety is normal. Let me repeat that. This kind of anxiety is normal. It helps to make us more attentive, more attuned to the things around us that will help us not only survive, but prosper and move forward. Anxiety can be a catalyst for positive change. It is both a warning and an energizer. It slows us down but propels us to action at the same time.

Now, what happens if we do not stay abreast of the science and the rational warnings being offered by those who know how best to do this, but fall prey to rumors, speculation and frenzy? If that happens, our normal, adaptive, productive anxiety turns to fear. If we touch anything we will get sick. If we do not wear a mask we will breathe in something horrible. If we do not buy up everything in sight, we will run out of something vital. Anxiety turns to fear, which can lead to further speculation which leads to more false information being internalized which leads to more fear and on and on. As you might surmise, this is not adaptive, positive or productive. It makes us circle the wagons, cuts us off from sources of legitimate information, and erodes trust. Anxiety can be motivating. Fear can be paralyzing.

Some of my patients describe going up one more rung of this anxiety ladder, all the way up to panic. If fear is paralyzing, panic is even more isolating and disruptive. Rational attempts to socially distance oneself from large crowds or potentially infected people becomes absolute isolation. Panic makes you feel the most anxious and out of control you have every felt. You feel, literally, as if you might die. Your heart races, your pulse quickens, your palms are sweaty and you feel that you must run out of the room immediately. Panic keeps you from taking in new information, even if it is rational and useful, makes it hard to concentrate and keeps you from making good decisions for yourself or those in your care.

Panicked is not where we need to be at this time of crisis. Afraid is not where we want to be. Anxiety? Now, that is another thing. If I told you I had not been anxious about how COVID-19 was going to affect me, my practice seeing patients in a busy mental health center, my eighty four year old mother or my six grandchildren and their families, I would be lying to you. Of course it makes me anxious. That drives me to seek out good, useful information, make good, safe decisions and take care of myself and those under my care the best way I know how.

How can you keep yourself in a state of productive anxiety, not fear or panic?

Connect with others, but in a healthy way.  Write letters, text and make actual phone calls to those you want to check on. FaceTime with family. Skype with business associates. You do not have to weather these kinds of stresses alone. We are truly all in this together and we are stronger when we support each other through the stressful times.

Educate yourself. Know the facts about COVID-19 and issues related to it. It is very true that knowledge is power, and from my perspective, it is a pretty darn good treatment for anxiety as well. Check out cdc.gov and scdhec.gov for timely and ongoing updates on the state of the virus outbreak and related topics.

Know yourself. Do you have underlying health issues that put you at risk? Are you over age sixty? Do you need to be careful with routine exposure to crowds, avoid sick people, or avoid going out at all unless absolutely necessary? Do you have support from family, friends or neighbors who can run errands or accomplish tasks for you that might be too risky for you right now?

Reframe any mandatory time away from school, church, work or social contacts as time for you. Read. Paint. Put together a puzzle. Take a nap. Watch comedies. We are all guilty of being too busy and never taking enough time for ourselves to just be still, meditate or relax. This is the time to retrain ourselves and understand just how important that time is.

Wash your hands often, use hand sanitizer if you need to in between scrubbings, avoid shaking hands and practice good respiratory hygiene.

Remember, anxiety can be a productive, adaptive, healthy response to stress.

F5s

F5
Incredible tornado.
261-318 mph.
Strong frame houses lifted off foundations and carried considerable distances to disintegrate; automobile sized missiles fly through the air in excess of 100 meters; trees debarked; steel reinforced concrete structures badly damaged.

tornadoproject.com

 

We had a strong storm front come through the southeastern United States last week. Of course, this was not the first time this happened, and it will certainly not be the last. It was fascinating to watch it march inexorably across the country, showing up on my weather app as a ragged green diagonal slash from Gulf to heartland to northeast, moving slowly and relentlessly across the landscape. In the center of the ragged slash was a well defined hard bright yellow-orange-red line of destruction. Pretty on the screen, destructive on the ground. Destroyer of worlds.

Texts began to trickle in from my daughter, who lives in Spartanburg, of an apparent tornado that touched down not five miles from her house and destroyed a shopping center. A coworker who sees patients at the mental health center by telehealth connection also reported frightening noises that drove her to her basement to hunker down until all warnings were lifted later in the day. Both reported the loud, surreal wail of tornado warning sirens, something that I have never heard in real life, but that I am sure must be quite distressing in the midst of gray skies, howling winds,  pouring rain and lightning flashes. Not an F-5, but terrifying nonetheless.

When I hear about such stressful situations and see evidence of the destruction they bring,  I think of my friends, family, acquaintances and patients have who struggled with cancer, financial stress, persecution for various reasons, and other stresses that lead to anxiety, fear and emotional upheaval. My aunt who succumbed to ovarian cancer when I was a boy. My mother, who is a breast cancer survivor. My friend, who tragically committed suicide. My patients, who tell me stories of unbelievable trauma, neglect, abuse and hopelessness. Like an F-5 monster tornado, these life circumstances can drop on any of us unexpectedly from the sky. Pretty colored X-rays and scans reveal the destructive power of the cancer underneath. Sirens go off. The mind screams take cover, take cover! The body sometimes is only grazed, shrapnel cutting but not killing. Other times, the impact is devastating. Nothing looks as it did before the storm. The landscape is flattened and only rubble is left. We return to a place, time or set of circumstances that we expect to be familiar, only to realize that all of our old landmarks are gone, destroyed. We do not know whether to drop to our knees and cry, run headlong into the pile of rubble, or turn and walk away.

Is there anything good about F-5s, cancer, abuse, trauma, and destruction?  What an odd question, I hear you asking me.

These scourges, while leaving city blocks, body parts, and psyches in absolute ruin, are often coldly surgical in their devastation. That is, a few hundred yards away, or a few inches outside the margins, or in some other part of the emotional us, the sun is shining, the tissue is healthy, the coping is reasonably good and life goes on. Friends rush to help. Prayers go up. Communities, wonderful , supportive, dynamic communities form. Support is not only offered but insisted upon. Rebuilding begins immediately in the aftermath of the siren’s wail, the surgeon’s knife, and the abuser’s fist.

When the horror and the shock and the denial and the anger and the tears and all of it subsides, victims become empowered survivors.

Strong!

The chorus goes up.

We will rebuild.

Life will go on.

We’re still here.

The Doctor Is In. Sometimes.

I grew up in a small mill village in northwest Georgia. When things did not go right, someone got sick, or we had an accident, or we needed a sports physical, we would head around the circle to the entrance to the mill complex, just across the grassy field from my house, and see Dr. Harry Dawson. Dr. Dawson was that old omnipresent breed of physician who had a small self-contained office, seemed to me to always be there anytime he was needed, and could treat anything. He got kids through the measles, mumps, chickenpox, broken arms, flu, the common cold and of course that time I dropped the hammer on my brother’s head when we were climbing the tree in the back yard. It was an accident, I swear. He’s fine, thanks.

There are a few Dr. Dawsons left nowadays, but not that many. Same goes for psychiatrists. It is getting harder and harder to simply think, I want to go see my psychiatrist, call for an appointment and actually get one in less than a few weeks if not a few months. There are a few good reasons for this. According to a February 25, 2018 Forbes article Psychiatrist Shortage Escalates as US Mental Health Needs Grow, there are twenty-eight thousand psychiatrists practicing in the US, but three out of five of them are age fifty-five or older. (Here’s looking at me, kid.) As we face more and more angst, shootings and the escalation of completed suicides, the number of psychiatrists who actually see patients face to face and deal with crises individually in their practices, modern-day Dr. Dawsons, are very hard to find. My patients tell me all the time that they don’t want to come in to see a counselor, a nurse, a social worker, but that they want to see their doctor. I understand this, but as you shall soon see, what I and many of my colleagues are doing in 2020 is far different than what we trained to do in the seventies and eighties. If you need mental health care nowadays, you may see any one of a dozen people who are part of a treatment team of health care providers. Your doctor may be in, at least physically, but he or she may not be available to see you personally.

My workflow, and that of my colleagues, has changed dramatically over the last thirty years.

While in medical school and residency training, my schedule of activities was pretty much set for me. I had simply to show up at the appointed time and place and work and learn. Training, classes, meetings, patients, all were set by a scheduler or training director. I had very little input. There was little autonomy during training.

Flash forward to early practice in the late nineteen eighties, when I was a junior faculty member of the Department of Psychiatry and Health Behavior at the Medical College of Georgia. I was an attending physician at the state hospital, in charge of residents barely younger than me, attended faculty meetings, and had a practice life that was still fairly regimented. I still spent a lot of my time working directly with people, around people, talking with people. Psychiatry at that stage of my life was still a people profession, driven by conversations, interactions and face to face meetings.

Go forward still to private practice, which I did for about five years. There were personal interactions with my staff and my patients in the office all day long, visits to inpatients in the hospital, and consults sent for patients on the medical and surgery floors. I was still doing most all of my clinical work myself, making my own decisions, and deciding how often to see patients.

Next came work at the mental health center that started as a part time job in 1991 and then became my primary job in 1993. I loved it, and I have never looked back. Oh, I have done work in crisis units and I have now been doing telepsychiatry for ten years, but my primary mental health center duties are still my most loved ones. The funny thing is, with time, my duties to see patients one to one in the clinic have taken a back seat to myriad other duties, especially since I have been serving as medical director of our center. Individual work (“I want to go see my doctor!”) has morphed into leading a team of other mental health professionals, and even more recently serving as a co-provider in these groups, not even officially leading them anymore. Now in 2020, I supervise a medical staff of thirteen other people, the most we have ever had in my time at mental health. Oddly, though in the past we had as many as five or six psychiatrists working at the center, there are only two of us among these fourteen staff now. I have many very talented advanced practice nurses, nurses, administrative staff and part time, locum tenens and other providers who have helped us take care of patients over the last decade or more.

The thing that I noticed when engaged in a conversation with some of our senior staff last week is that now I do not simply see a limited and finite number of patients, as many as today’s schedule will allow. I do much more indirect and direct supervision, answering dozens of emails each day, talking in real time on Skype, and otherwise making decisions for patients who I am not seeing directly, at least most of the time. I am relying on the eyes, ears and assessment skills of the medical staff as they multiply my ability to hear your stories, assess your symptoms and come up with a reasonable treatment plan that will help you recover. This is both sad and exciting for me. I miss the days of seeing one patient after another, my patient coming in to see their doctor, that most pure of doctor-patient relationships. However, this new paradigm of care allows me to have a much broader reach and treat more people than I ever could alone. That is good. When you need to come in for treatment of mental illness, you may not see the doctor initially, but you will be seen by someone on the team that the doctor is intimately connected with.

What does the future hold? Telepsychiatry is making inroads in hospitals, prisons, jails, schools and even patients’ homes. Mobile crisis teams go out into the community and meet patients where they are, giving care at that point, not relying on visits to a clinic. Traveling RVs staffed with teams of providers scour the backroads for people who need help. More and more, care is becoming collaborative, as mental health workers are embedded with law enforcement and medical clinics, and medical providers set up shop in mental health facilities. Psychiatrists are learning that they can teach, supervise and function very well as part of a larger team, reaching far more souls than they could ever do in their simple solo practices.

I think Dr. Dawson would be proud.