“One is the loneliest number that you’ll ever do.”

Three Dog Night

Well, dear readers, we have passed another holiday season, one that was magical for many of us, sad for others and downright lonely for a few. I was already thinking about this annual state of affairs the other day when I happened upon an article in the Dec 19/Jan 20 AARP Magazine, of all places, called “Is There a Cure for Loneliness?” It got me thinking more about some observations that apply to many of my patients, and perhaps to all of us to varying degrees. Please allow me to share some of these with you.

One of the last observations in the article, and I think one of the most important, is that loneliness is the difference between what we would like to have in our relationships and what there is in reality. This is a key idea, in that the rest of the article was predicated on the fact that it is very hard to nail down just exactly what loneliness is and how to best measure and study it. According to this article, it is fairly well known that older Americans are at risk for social isolation and that this can sometimes lead to physical illness, depression, even dementia. The piece tried to explore causation for loneliness, wondering whether there exist medical causes for and treatments for loneliness.

Louise Hawkley, a senior research scientist at the University of Chicago, stated that “Loneliness is a universal human experience, and being the social animals that we are, there must be implications when these social connections are not satisfied.” Steve Cole, Professor of medicine, psychiatry and biobehavioral sciences at UCLA School of Medicine, studied biological effects in lonely people. He found that blood cells in such folks “were in a high state of alert, as if responding to an infection”. Ms. Hawkley stated that “we humans have a need to be embedded, connected, integrated in a social network”. Ah, I can hear you right now, as you read this column, saying, “Well, I am embedded in Facebook and Twitter and Snap Chat! Of course I am connected to other people!” Alas, is that a truly fulfilling connection? Is it enough to ward off isolation, illness, mental health problems? See my previous columns and those of others over the last several years. What kind of connections do we desire, need, thrive on? Is it different one person to another? Of course it is. We are all human, but we are profoundly different from each other in many ways, the need for socialization and connection being one of them.

The one thing that does seem to be more and more clear, however, is that if we do not have some sort of meaningful connection to others, that we are adversely affected both physically and mentally. A friend of mine, who is a physician and also an Episcopal priest, was trying this holiday season to reconcile the religious and the secular in his life. He spoke of worship versus parties, as it were. He said that for him, it would be very important to spend worshipful time in quiet reflection about the mysteries of the season, but he also resolved to “accept every invitation to go to every party and gathering I am invited to!” He was always a wise man when he was my surgery attending in medical school, and he is still wise in the ways of social interaction. We do not need false, fake or superficial social networks and connections, but real, substantive connections with other human beings. That is why real time gatherings can be so satisfying and fulfilling. We need deep conversations; letters (not just texts, LOL); groups that support art, therapy, learning, and self-improvement; shared activities; and shared experiences that allow us and others to feel fulfilled and whole.

Is there a financial cost related to loneliness? According to the AARP article, people who live in social isolation add about seven billion dollars to Medicare costs due to longer hospital stays and lack of adequate family and social support at home. Loneliness is a killer. It may worsen heart disease, may make us more vulnerable to cognitive illnesses such as Alzheimer’s Disease, may worsen hypertension and may leave us vulnerable to infections. Loneliness may be more dangerous than obesity and the equivalent to smoking fifteen cigarettes a day. But wait, I hear you saying now, how can an emotion, a very abstract one at that, shorten a life?

Is it the loneliness itself or the social isolation, disconnection in a variety of ways that is fueling this problem? Again, per the AARP article, there are more people living alone these days as shown by census data, the marriage rate has declined, and the number of children has also decreased. Julianne Holt-Lunstad, professor of psychology and neuroscience at BYU, was co-author of a study that looked at three groups: those who were socially isolated from other people, those who described themselves as very lonely, and those who lived alone. The study included pooled data from seventy studies that followed 3.4 million people for seven years. Each group had about the same risk for early death, 29%, 26%, and 32%, respectively. The study data was independent of health status. It is a fact that people who live alone are not necessarily lonely, and it also follows that some who are surrounded by family and friends do indeed feel very lonely. One thing that seems clear, however, is that people who are socially connected live longer.

Can you definitely measure and quantitate something like loneliness? The UCLA Loneliness Scale, according to this AARP article, is the gold standard for research purposes. It is a twenty item questionnaire that asks about the feelings associated with loneliness, without asking about the thing itself.

How to approach loneliness? First, like many illnesses and conditions, this article states that we must recognize that there are likely multiple etiologies for what we see. These can include genetics, social situation and family environment. We must also try to look at this problem from the point of social connection, not loneliness per se. Why? Because like obesity and other conditions, people who are lonely often are subject to stigma and may be looked on as social failures. We can encourage those who are lonely to volunteer, help others, and encourage activities that qualify as life experiences that build connections and memories. Another concept mentioned in this article, that I like to think of as crowd sourcing care, is that we can ask that people who are in the arena (postal workers, healthcare providers, hairdressers and many others who come into contact with many people every day) to watch out for the needs of others and spot those who are struggling. Finally, we can stay abreast of the research that is being done on inflammation, pain and other issues that might be biologically related to loneliness. There are not many hard and fast guideposts for the medical aspects of loneliness yet, and no medical treatments that are panaceas, but more knowledge is sure to come as we learn more about this problem that can affect us all, not just at holiday time.

Happy New Year!

Selling Out?

I do not watch the Golden Globes, or many other awards shows for that matter, but it was almost impossible to escape from some of the recent press about Ricky Gervais and his non-caring (his words, not mine) diatribe towards modern tech giants and other companies and people he had disagreements with. I leave you to peruse YouTube or other sources for more details.

On thing that struck me about all this was that he was jumping all over Tim Cook, stating that if Apple did indeed win any Golden Globes for their new Apple TV+ content (they did not) that they should not use the acceptance speech as a platform for platitudes of any kind. He was intimating, no, coming right  out and saying actually, that because Apple ran “sweatshops” overseas to make its millions of iThings and billions of dollars that they would be hypocrites if they did anything more than simply walking up on stage, saying thank you and exiting stage left.

That got me thinking even more that I usually do about the government, the companies that we usually trust, the businesses that we buy from, and the people that we normally look to as embodiments of at least a modicum of good will and morality.

As a kid, I always looked forward to the fall, when my mother would take my brother and me to the local Sears store to buy school clothes and that wonderful new pair of sneakers. (PF Flyers, if memory serves) . Sears was America packaged in a fairly nice store with friendly people and had the bonus of a cool Christmas Wish Book that we all loved to page through to make our Christmas lists. Who didn’t like Sears, for God’s sake? As I grew up, given that retail background, guess where I always bought tires for my car? New appliances when one wore out? A new and better lawnmower when the time came for that? Sears. I didn’t know a thing at that time, even in my early adult life, about their overseas business practices, their stand on religion, how they felt about gay people, or any of the things that we gnash our teeth about today. They were a decent store that had decent people that treated us well and sold us a good product that gave us something lasting  for our money. Period.

Flash forward to Apple. I ran my first solo practice on an Apple computer. It was much more expensive than I could afford, but I bought it and a companion software program that I knew would work, would serve my needs and help me take care of my patients, and that was that. Ten years or so ago, I bought my first iPhone, and I have had almost every one that Apple has built so far. (I did not buy an 11, as I will wait for this fall’s 5G offerings to see if they are worth the money) I remember being on my white MacBook reading about this newfangled gadget that was going to come out that would be a phone and let you listen to music and send emails and on and on. No way! Way! I knew that I would buy one of those as soon as it came out, no matter how much it cost. Early adopter, I am. Separated easily from my money, I am. At any rate, back then, I also did not know one thing about Apple’s stance on overseas production or tariffs or child labor or outsourcing or gay rights or any of it. I just know they made cool stuff that would help me do what I needed to do, I liked cool tech stuff and I would buy what they were selling.

Are you hungry? Do you like Chick-fil-A? I do. They have good food, excellent food.  I like the superfood salad, the chicken soup, the grilled nuggets. The kids that work there are always nice, respectful, say please and thank you and have smiles on their faces. I have always enjoyed eating at this restaurant. I still do. They have angered a lot of people with their stances on gay rights, religion, other issues I suppose, so some folks have boycotted them. Okay, I get that.

Then there’s Amazon. I spend a lot of money and buy a lot of stuff from Amazon. I would have to say it’s my go-to online place to get stuff. I assume I am not alone in this. A lot of people do not like Amazon, Jeff Bezos, his world view, the way his marriage has gone, the fact that he owns a newspaper, how Amazon is purported to treat its workers, etc., etc. Two hour delivery of some items in urban areas is crazy, I know. What do I really need in two hours? Not much. The convenience, the sheer number of available items, the ease of returns, the ease of ordering, all of it tends to make our lives so much easier than they used to be in a lot of tangible ways. I am not opposed to this. I like it in many ways.

Are Sears in its current iteration (bless them), Apple, Chick-fil-A, Amazon and others perfect companies? No, of course not. Are they paragons of virtue, using best practices while paying their workers top of the line wages and benefits and caring primarily for their welfare? No, I think not. Do they use their retail bully pulpits to foist their opinions about religion, gay rights, marriage, guns, free speech, and other major issues of the day on others, unbidden? Yes, sometimes, yes. Do I always agree with their public stances on these and other issues when I hear about them in the news or on television shows or podcasts? No, of course not.

That being said, am I going to go over every balance sheet and news article about laborers in China and fret over records of gay marriages in all fifty states before I buy grilled nuggets or my next iPhone or order a gift for my granddaughter’s birthday? No, I am not. I absolutely am not.

I may be wrong about this, or I may be too uncaring like Ricky Gervais, or too naïve or whatever, but I’ll be damned if I am going to restrict my purchases of food, phones and happiness at this stage in my life just to do the politically correct thing. I am not going to vet every single day to day decision I make based on the societal correctness of its context, whether or not it offends a particular group, or whether it butts up against the minimum wage in a foreign country.  Don’t get me wrong. There are ways to deal with these real life issues, and they should be dealt with. But I’m sorry, Mr. Gervais, what Tim Cook says or does not say when his television shows win or do not win a Golden Globe is not going to be the deciding factor next fall when I decide to buy an iPhone or its Samsung counterpart.


And Speaking of Exercise

Further thoughts after my pain post.

When we are very young children we are flexible, energetic, tough and resilient. We run, jump, pull up, dive under, crawl around, and skip merrily about in that most frantic of ways that is known only to youngsters and those who watch out for them. We have little fear, none that I can remember personally! The exercise, the movement, the physicality of it all is for the sheer joy of the activity itself.

We can move, therefore we do move. We must move.  We enjoy the movement.

Fast forward to those junior high and high school years, when movement and activity and exercise get more regimented by the year. We join sports teams. We learn what it means to be part of a team, a team that wants not only to participate and play, but that wants to win. We train, we strengthen, we drill. Yes, it’s fun, of course, but it’s also regimented and with one goal in mind. Excelling. We train, we practice, we drill, all in the service of victory.

We are told to move. We will move better than anyone else. We will be celebrated for our movement.

A little further. College, graduate school, professional school. For some of us, the rigors of academics and study and preparation started to severely cut into our physical time, our recreation and competitive sports and training and working out. Yes, I still played quite a bit of tennis and ran and competed in races as I have written about already, but it was becoming that thing that I had to find and make time for, not the thing that came first and gave me the most joy. Having fun was becoming more of an obligation, something to be scheduled. The spontaneity was fading.

We wanted to move. We tried to find the time to move. We knew we should move. It still felt good to move.

Adulthood. We’ve made it. School is done. We have a job, a relationship, maybe a marriage, maybe children, a home, a mortgage, bills to pay. We go to church. We join social groups. We go to ballgames. We shuttle the kids around. We do dishes. We clean house. We work in the yard. We clean the pool. We plant a garden. We are tired and stiff and sore some nights, but we fall into bed and sleep and get up and do it all again the next day, because that is the drill.

We must move. Movement is required to keep the schedule going. We resign ourselves to the need for constant movement.

Now. I am sixty two years old. Firmly middle aged, I do not feel old at all. That being said, I do have days when joints hurt, feet hurt, I strain a muscle I never even knew I had, and I have a hard time bending over to tie my shoes. (Now, take this with a grain of salt, because I was diagnosed with Polymyalgia Rheumatica several years back, and although it is not active, I still think it affects me in little ways from time to time) As we age, we find that the little day to day things that we have always taken for granted are sometimes more of a challenge than they should be. Carrying a load in from the car. Reaching for the dryer sheets in that cabinet up above the washer. Going up and down long, steep flights of stairs. Sitting at a desk for long periods. All of these routine daily actions can sometimes take us by surprise and feel uncomfortable or even hurt! Have you ever reached for something or twisted around suddenly and pulled that tiny muscle under your shoulder blade, that then hurts like the devil for about three days before it settles down? Yep, that’s what I’m talking about.

We still need to move. Some movements are now challenging. If we do not move, our quality of life will begin to suffer.

So, what to do as we age?

Continue to move daily.

Get up, stretch, walk, garden, do the laundry, take the stairs and not the elevator, bend down to tie your shoes. Do not sit more than an hour at a time, if that. Get up, walk up and down the hallway, bend over and touch your toes a few times to loosen up. Use a standing desk. Get outside and walk around the block. Hike.

As long as we are moving, we are living.

No Pain, You Must Be Dead

I have always liked to be physically active. Raised in the south, I was no stranger to exercise.

I participated in the usual pee wee football, JV football, basketball, softball thing as I grew up, then settled on tennis as my favorite competitive sport, which kept me occupied all through high school and college and beyond, at least on a fun, non-competitive basis.

Several, I mean several years ago, I blew out a gastrocnemius muscle while stretching for a screaming wide shot off to my left on an asphalt tennis court, and felt like someone had sneaked up behind me and hit me in my left leg with a baseball bat. Think Nancy Kerrigan, although when I turned around there was no Tonya Harding to be seen anywhere. I don’t think I’ve ever had a more painful sports related injury, as I felt a searing white hot heat go up my leg into the depths of my brain and immediately felt like I would never walk again. I did, of course, but to this day I have not stepped back on a tennis court for anything more than a very slow, easy volley.

Have I ever stopped exercising? Of course not. Humans like to move, stretch, and challenge themselves. I am no different from my brethren.

In the distant past, I got into the whole running thing, bought the Jim Fixx books, kept a running journal and spent Saturdays with buddies running up and down hills in Augusta, Georgia preparing for races. We ran 10Ks, ten milers, half marathons, and I even managed to complete one marathon in Augusta back when that was a thing. I have never been so happy to cross a finish line and complete a task in my life. I was happy to be there in the early years of the Peachtree Road Race, back when only ten thousand of your closest running buddies participated. I have fond memories of trudging up the 3/4 mile stretch of road called Cardiac Hill, culminating at the juncture of Peachtree Road and Collier Road, conveniently located just across from Piedmont Hospital, in case you needed to duck in for a quick cath or ablation before you finished this always searingly hot and humid race.

The jewel in the crown of my running days was the completion of the Steve Lynn triathlon on base in Savannah, Georgia. This half Ironman race consisted of a 1.2 mile swim, a 56 mile bike ride and a 13.1 mile half marathon, back to back. I trained for it by running around Augusta, riding my bike up to Clark Hill lake and back on many weekends and swimming laps in a backyard pool. I had a good support team to help me with the logistics of that race, I was in the best shape of my life and I proudly finished it in a respectable time. It was exhilarating and exhausting.

More recently, I have been into hiking. It is as strenuous as you want it to be, as easy and relaxing or as hard and taxing as you choose and gives you the opportunity to get outside, breathe the fresh air, see wildlife and test your skills in nature. I have hiked the Augusta Canal trail at home, the multiple trails at Sesquicentennial Park in Columbia, SC, and the trails at Mistletoe State Park just up the road. I have hiked solo at ten thousand feet in New Mexico on a ridge so high that it felt like I was on top of the world. My wife and I have walked past Mount Rainier in Washington State, enjoyed a walk through Okichisanso Gardens in Kyoto, Japan, and summited a pretty falls in Rocky Mountain National Park. Last January I hiked and up and down Camelback Mountain in Phoenix, Arizona, one of the most difficult hikes I have ever done. My heart rate approached 150 as I made the summit after scrambling up a boulder field. The hike was more a rock climb, and I was glad I brought leather climbing gloves instead of poles for that adventure. I had never been more physically exhausted than at the bottom of that mountain, but it was also one of the most technically challenging and satisfying treks I have ever made.

Last March, as my wife and I descended from the summit of a mountain in Table Rock State Park in Pickens, South Carolina, I had a wake up call. I had hiked this trail several times previously and knew it pretty well. I had not brought poles for this hike, which in retrospect was a huge mistake. Roughly halfway down, following my bride as she lead us back to the car, my hiking boot caught the edge of a rock at the top of a large section of rock steps leading to a lower section of trail, bordered on the right by a ravine. Although the fall is not as terrifying to recall now as it was for weeks following the accident, I can still vividly remember my thought pattern as I went airborn.

“Uh oh.”

“I think this is going to hurt me very badly.”

“I’m afraid this fall might kill me.”

“I don’t want to die like this.”

It was one of those accidents that happens very fast but is strung out in your mind in slow motion. As I tripped, I had the sensation that one always has in that situation, that I could put out my arms, regain my sense of balance, make sure my other foot came down squarely on the next step, speed up a little until my center of gravity was okay again, and proceed on down the trail. Unfortunately, this was a real fall, completely in the air, out of control, immediately disorienting to the point that I did not know up from down, right from left, path from stairs from ditch. I was cognizant of the fact that I was tumbling, that I had not yet hit the ground, and that when I did, it was not going to be good. Something would break. I would hear a snap. I might hit my head. I might be rendered unconscious, with a head injury that would be no joke.

“Uh oh.”

My wife told me that I flew past her (thank God I did not take her down with me, for that would have been truly unbearable) pitching and rolling. I remember her calling out, but not what she said. I had the sensation that I was going to hit a rock step, the ground, or tumble into the ravine sometime very soon. I did not have time to figure out how to brace myself, how to hold my arms to break my fall, how to orient myself for minimum damage when I hit. It was all just too fast. I was at the mercy of gravity and inertia.

“I think this is going to hurt me very badly.”

Seconds that seemed like minutes went by, and I knew this was it. I was going to come to ground soon. I did not know if I was going to be okay. This scared me very badly. What was going to happen to me. How could this happen? This is not supposed to happen to me. It was then that the fleeting thought that scared me most of all came into my spinning head.

“I’m afraid this fall might kill me.”

What would it feel like to die on this trail at this time after this fall? Would it be painful? Quick? Would I know, at the bottom of this tumble, that I was dying? Would I see nothing but black and not wake up again? How would this affect my wife? My God, how would she get me off this mountain? How would she do that?

“I don’t want to die like this.”

I know that I am going to die. I started this blog a while back to deal with my feelings about being sixty two, thinking about my father dying at more or less this same age, and how I was going to move on into the next thirteen years and beyond. I wanted to explore how it was going to feel to become an old man, crotchety and opinionated and feisty and relatively fit (I hoped). I knew all that, but at the moment of this horrendous fall my brain was facing, at what seemed like the speed of light, what it would feel like to experience my own death, an accidental death, a traumatic death for me and for my wife. It was at the same time surreal and vividly real.

I did finally stop tumbling, and came to rest (that is a very soft way to say crashed painfully to earth) on the right side of my head, my right wrist and forearm and right leg. I was stunned and disoriented but I knew I was alive. I tried to pull myself up as my wife scrambled down to assist me. I was off balance, felt nauseated and very sick, and could get no further than on my knees, wobbling, swaying, my brain saying get up, idiot, you’re fine, and my body saying, man, that was really, really, really bad, dude. I was bleeding but I did not know where from. Turns out, a couple of small chunks had been torn from the top of my right ear, and there was stray blood on my hands. My right leg was on fire and numb at the same time. I did not know if anything was broken. In true injured physician fashion, I began to assess myself through my wife’s eyes!

“Is my head bleeding anywhere? Any cuts? Anything else malformed, bleeding? Are my pupils reactive? Are they the same size? Am I making sense? Are my words slurred?”

I can easily say that in all these times that I have played sports, participated in races, hiked, and otherwise done something physically taxing, this spring’s tumble on a mountain trail was the most frightening injury I’ve ever had. I got away with mild abrasions and contusions to my head, ear, hands, and wrist, and had one hellacious deep bruise over most of my upper right leg that took months to heal and that is numb and intermittently  uncomfortable to this day. I did not break any bones. I had no open bleeding wounds. I did not lose consciousness. I did not have a concussion.

My wife swears that two of my guardian angels, always vigilant, swooped down at the first sign of danger and gently laid me to rest (thanks guys) at the bottom of that pile of rocks with only minimal injuries. (Oh, did I tell you that my glasses were still on my face, not a scratch on them, my backpack was still securely in place on my back and I was still wearing my cap when I was finally able to stand?) A fall like this could have easily fractured major bones, lead to compartment syndrome in my leg, caused a head injury, a broken arm, loss of consciousness or death. At minimum, it should have put me in the ER if not in the hospital. At worst, it could have killed me.

Ten months later, I am writing this.

So, no pain, no gain, right? Not exactly. As you get older, if you stay active, you WILL have pain, discomfort, sadness, illness and injury. As a nurse told me one time in the emergency room after I had broken my leg sliding into second base, “Hey, it’s the active people who get out there and do stuff every weekend that get these kinds of injuries!”

As for me, I have plans to fly to Arizona two weeks from today. My wife and I will be hiking on a big ridge just south of Phoenix, as I glare back at that mountain that resembles a camel, and start planning the next adventure.

Let’s face it. If you don’t wake up tomorrow with some pain somewhere, well, you must be dead.


Hindsight is Always 20/20

It’s another new year.

January 1, 2020, and I have already been up for a while, read the headlines, had my first coffee of the day, been to the gym and contemplated what to do with the rest of my only day off for the next ten days. Holidays at home are the best. There is work to be done, taking down Christmas lights, organizing thoughts and workflow for the coming year, but there is also the feeling if being at peace, being one with home, one with light and life and relationship and that feeling that this is that one place on earth where I can be myself, for better or worse.

I am munching on pears and cheese lovingly prepared by my wife, who bustles about the kitchen readying the collard greens, black-eyed peas and cornbread for our feast later today, before we watch the Bulldogs play the Bears. The game starts at 8:45 PM which means 9 PM which means way too late for a sixty two year old man who is going to try to sleep at least seven hours per might this year come hell or high water. No, I do not make New Year’s resolutions, but I resolutely recognize that not getting those seven hours of sleep per night is not going to lengthen my life any and therefore doing so is a worthy goal. I will watch the game to the end, unless it is a blowout either way.

The Christmas holiday was a good one, with travel, visiting family and friends and giving and receiving gifts. We got to see the grandkids, growing and learning and getting much too big much too fast. When you are growing older yourself, you do not necessarily feel older until you see your grand children. It is then that you know that your place in the family tree is changing, that you are becoming one of the lower, founding branches and that the little shoots before you are the future. I am becoming not only the older, hopefully wiser present, but I am slipping inexorably into the past. I’m not usually sad about that. It’s just a fact.

The new year for me always means re-evaluation of what works and what does not work. I have a set way of approaching the big things in my life, and for the most part this approach works well for me. Each January, I look at all of it with fresh eyes, and a small dose of skepticism. Did my plans come to fruition last year? if not, why not? Where was the loose connection, the miscommunication, the laxity, the laziness on my part that did not let a thing happen that I wanted to see happen? Where can I fine tune, tweak, let go, add, and change the flow of planning, execution and progression in my personal and professional life that will make 2020 better in some tangible way from 2019?

I spend a fair amount of time thinking about this every year. As  I mentioned in previous posts, I know that time is a finite commodity, and that every year it gets more precious and valuable. Of course, I never know how much if it I actually have left, so it is hard to plan accordingly. I don’t just think about this, truth be told. I obsess about it, as I do about many things. For better or worse, I plan, rejigger, write down,  list, reconfigure, reorder and rethink every part of the plan for life in the coming year. How and when to write? Books by audio or held in hand? Paper or screen reading? More or fewer podcasts? How to make more time for exercise? How to make better and more satisfying connections with spouse, family and friends? Work more, work smarter, or work less overall?

Yes, the new year brings 20/20 hindsight. I know what happened in 2019. I know what worked well and what did not. I revel in my successes and make peace with my failures as best I know how. I vow not to repeat them. I am optimistic about the future. I remember the past, but I do not want to wallow in it or get mired and immobilized.

I do not know the future, but I embrace it proactively as an old friend.

I am older. I am trying to be wiser. I am trying to be kinder, gentler, and more forgiving of others, as well as myself. Will I have succeeded on January 1, 2021?

By then, hindsight will, as always, be 20/20.

Search Ingenuity

I recently came upon an article on the site kevinmd.com, a place on the internet where some of my own work has been published in the recent past. The piece, entitled “Don’t judge patients for researching their health issues” was written by Suneel Dhand MD, an internal medicine physician. In it, he started his musings with “it’s difficult to imagine a world now without Google and the internet. It’s also strange to think that most people alive right now received the bulk of their education in the pre-internet era.”


I can remember that all through my formal education, up to and including college, medical school and residency, I always had written notebooks full of information, copied handouts given to me by professors and notetakers, and stacks of heavy books containing the latest information at the time of their publication. These reams of paper notes could literally fill dozens of large plastic binders and take up a lot of space on bookshelves and tables. The textbooks were large, ponderous, heavy and expensive. One internal medicine book might cost more than one hundred dollars, a fortune for a medical student with very little expendable income. The goal of collecting all of this written material, of course, was to have the most up to date knowledge of the time, the cutting-edge information that was going to make you a better student, resident and doctor. It was an effective strategy, of course, until the next set of notes came out or the next edition of that expensive textbook was published. You were then immediately behind the curve, not up to date and worried that you might not know enough about the latest and greatest theorem or procedure or medication.


Enter the internet.


According to Dr. Dhand, “one of the most important ways we are now using the internet is to make informed health choices and read up around our illnesses. Unfortunately, this hasn’t always been met with enthusiasm by all members of the medical profession. “Another saying that I have seen on cartoons and coffee cups goes something like this: “Don’t confuse your Google search with my medical degree and thirty years of experience.” Patients have been quick to embrace this new firehose of all things information, but some doctors, especially from a generation or two ago, are sometimes threatened by their patients Googling diagnoses, treatments, medications, and other medical information that in years past was the intellectual property of their physician who would dispense it as carefully as he did medicine. The days of Marcus Welby MD have long since passed, I’m afraid, and that doctor with his closely guarded secrets does not exist any longer.


Dr. Dhand also writes, “If there’s any physician who gets annoyed, intimidated, or frustrated by patients and families who Google search and ask them questions, that doctor should take a long hard look at their internal belief system. I, for one, always welcome questions and challenges to what I’m saying, and see this as a natural part of being a professional. “I agree with this view, with a few caveats that I will outline below.


First, a relationship between doctor and patient should be a collaborative one. Physicians have worked long and hard to study and learn as much as they can about the practice of medicine so that they can help you when you come to see them for a specific ailment. Good doctors have your best interest at heart and want to give you the best advice and share the most up to date knowledge with you that they can. They expect you to trust that this is the case. By that same token, a good doctor will welcome your opinions, your knowledge about your own body and how it is reacting to a disease state and your own research and thought into what might be helpful to you in treating that disease.  You may have come upon some of that knowledge by searching the internet, reading books and magazines, hearing the opinions of friends and family, or relaying the opinion of another doctor. As long as doctor and patient respect each other and collaborate on the best course of action, no one should be frustrated, intimidated or annoyed by that process.


Second, it is the patient’s responsibility to use good judgment and due diligence when looking for information about their own health. One of the downsides of the ubiquity of the internet is that there is much bad information to be found, in addition to quality knowledge. Patients can up their search game and get the best info to be found by going to respected sites when they need information about diseases, medications, and other treatments. A few of these might include: http://medlineplus.gov/ for general information about diseases and medications; http://drugabuse.gov/, which gives substance abuse information for patients, families, parents and providers; http://nami.org/, for general support related to severe mental illness; and http://dbsalliance.org/ for information on depression and bipolar disorder. I am also partial to https://www.mayoclinic.org/, which has wonderful searchable databases full of info that can be printed out and shared with others.


Third, physicians must be open to hearing what their patients have to say. In his article, Dr. Dhand states that a good patient comeback to the physician meme above might go something like this: “Don’t confuse your 1-hour lecture on my condition with my 20 years of living with it. Yes. Doctors, we are here to serve, answer questions, and show empathy. Not judge our patients for researching their own health issues.” I am so very fortunate to care for a patient population that is wise about illness, what works, and what does not. I also work with a wonderful, caring staff who share my concern for our patients and want very much to help them recover.  I learn something new almost every day I have a clinic because of the willingness of my patients to share their lives and struggles with me. It is one of the most rewarding things about practicing psychiatry.


In summary, a doctor patient relationship should be collaborative. Patients bear some responsibility to use due diligence when educating themselves about their illnesses. Physicians should be open to listening to others so that they might continue to learn and grow.


Together, we can search for the right questions, the correct answers and the best path to recovery.

Area 51

“51-year-old female presents today with…”

Many of my clinical notes begin with that phrase, give or take a year or two. Women in their fifties who see me in the clinic, who I speak to in an emergency room via television in my telepsychiatry practice, or who I interact with in some other way. It strikes me as odd that so many women of similar age come to psychiatric consultation. Mental health practice is funny that way. Groups of people, age clusters, diagnostic groups-they all tend to show up in bunches and herds and gaggles. Could be the full moon (No, there is no empirical evidence for that that I am aware of). Could be environmental toxins. Could be nothing.

At any rate, I have some thoughts about the whole woman in her fifties thing.

Women in their fifties are caught squarely in the middle of I’m-grown-and-I-don’t-need-you-to-take-care-of-me-any-more children and I’m-old-and-I-need-you-to-take-care-of-me-constantly parents. They are conflicted. They are pulled and torn and exhausted. They want to be mothers to their children, who they see slipping away into adulthood and not needing them anymore. They want to be adult children to their parents, not quite ready to take on the mantle of the oldest generation themselves but knowing that the time to do so is rapidly approaching. They are worried about empty nests and nest eggs and quiet and emotional vacuum and nights with worries about globetrotting children and cognitively impaired parents who left unattended will walk out the front door in nightgowns and slippers. They are the glue that holds their world together, acting as a resonating resin that is pulled and stressed and taken to the limits of its ability to bend but not break. They are stressed, but they feel that this is the place they must be. If they let themselves be pulled too far in one direction or the other, someone they love will be short changed. The only option is to plant both feet firmly on the ground, stretch each arm out, and hold on tight until something gives. It is a precarious place to be.

The problem is, the thing that often gives is the fifties woman herself. She suffers from it all, sometimes quietly, sometimes noisily, but she suffers just the same. She has the OCD that has never been diagnosed. She has panic attacks every time she sets foot in Walmart. She has the wild mood swings of bipolar disorder, making the best use of her hypomania while trying not to kill herself when in the doldrums of a deep depression. She is the mother who never gets over the baby blues and feels uncomfortable every time she picks up a kitchen knife when her baby is within arm’s reach. She would never hurt herself or her child, but those obsessive thoughts…

She is the closet drinker who could never drink anything but the best wine and the most expensive liquor, though more of it than anyone in her family ever knows. She suffers from unprocessed guilt and rage and disappointment and sadness that her busy life affords no time to deal with.

The fifties woman feels guilty for being ill, so she tells nobody. She constantly tells me, her psychiatrist, that she is the rock of her family, the matriarch, the strong one, the one that everybody else comes to when they need help or solace. She works a fulltime day job, washes the clothes and cooks the meals and bakes the cookies and drives the carpool and goes to the appointments with her frail parents. She keeps her schedule in her head or on her phone. She is a caretaker, a people pleaser, a model woman, at least in the eyes of the world. In her own eyes, in her own heart, she is a miserable failure. She feels a burning shame that no amount of work will fix. This makes her go faster and try harder and take on more. This eats at her and erodes her physical and mental health.

The good news?

The woman in her fifties has many, many reasons to get better. She has the love of her children and her parents, who may not tell her often enough but feel it intensely just the same. She has grandchildren coming, or maybe already here, and they open up a whole different world of love and reason for being. She has a home that she has worked on and built and crafted for years, a place of comfort and safety for her and her family that anchors the emotional lives of almost everyone she loves. She has the rest of her life ahead of her, a whole new chapter of being a woman who has run the race, stayed the course, and is now ready to learn new skills, experience new things and find out who she really is.

I’m always glad to see these women. They are strong. They are resilient. They teach me lessons they have hidden from themselves for years. We explore and learn together, and our eyes are opened wide to new reasons to live, to thrive.

They know where they’ve been, they know what they’ve accomplished, they know what stands in their way and they are ready to take the next step and grow.



On a Wing and a Prayer

I live in a conservation community near the Savannah River. Since moving here,  I have walked out my back door and seen many things that nature has on offer. A sleek black snake draped from a tall plant over the edge of a wooden boardwalk, luxuriously sunning himself and oblivious to me. A Cooper’s hawk, silently settling into the tree in front of my kitchen window, then picking off an unsuspecting baby mockingbird with deadly accuracy, snuffing out its life with a powerful clawed foot, then soaring away with him as I watched agape. A fat beaver, lazily sloshing about in the shallow water of a creek tributary, looking up at me, inquisitive, then swimming slowly off toward the creek, broad leathery tail rippling the water behind him.

I saw a beautiful sight early one morning on the way to work. It is one that always makes me smile.

There they were, two beautiful creatures with compact heads, long, straight, thin necks, plump bodies and powerful wings. They flew side by side, wings almost touching, like the pairs of Marine Corps fighter jets I’m used to seeing rocket by overhead when I’m at the beach on the coast of South Carolina. Less than thirty seconds later the main body, the vee formation we’re used to seeing at change of seasons, chased the pair and no doubt were trying to get the whole group back together.

Geese fly in this characteristic formation for very specific reasons. Among them: the ability for all of the geese in the formation to see each other, to watch each others’ backs, as it were; the need for only one member to bear the brunt of flying point, against the most wind resistance, at a time, allowing others in the party to expend less effort; to provide for an easier “middle ground”, the center of each arm of the vee, where members can expend the least energy and rest a bit; and the ability to rotate from one of these positions to the other and round again, working hard at your turn but then regaining strength and preparing oneself for the next round of effort.

This flying formation, copied by squadrons of fighter jets, allows these beautiful birds to fly for hundreds or even thousands of miles, helping each other along the way, attaining a common goal. Now, what happens if a bird gets sick or injured, such as by a hunter who wings it? That poor fellow must sometimes turn away from the formation, banking and descending and heading for the ground to a safe haven, where he will either get well and rejoin his fellows, or where he will die. Does he do this alone? Of course not. One or two of his fellows follows him down, never leaving him. They are there for him to help him rejoin the group at full steam, or they are there to help ease him out of the world. If the latter occurs, they rise back up and catch up to their kin, ready take their places back in the formation and keep flying. Even when one is lost, the group sustains itself, and life goes on.

I know that many of you who read Musings are hurting today. Some of you have seen friends and family leave the safety of formation, follow their loved ones, only to deal with the awfulness of death. You may be trying to help them rejoin the group and fly again. Some of you have been that injured member who must stay behind. Some of you have been shot out of the sky by life’s cruelties, grounded for good and dealing with pain and suffering. You are hurt, angry and wondering why. Some of you are crippled in mind, some in body, some in spirit.

The things we can learn from nature in these times of trial are elegantly simple and profound. We can learn to take our turn at being the one who must face the gale force winds head on, cutting the sting of the rain and making it just a little more bearable for the ones who follow behind us. We can learn that there is a time to let go of the control and drop back to the safety of the bosom of the formation, letting the ones who fly point and the ones who bring up the rear do most of the hard work, while we regain our strength in the center. We can allow ourselves to heal. We can learn that there is a time to be close and to support a fallen comrade, but that there is also a time to say goodbye and to let go. It is after that goodbye, in its hushed quiet or in its regal and terrible pomp and circumstance, that we must decide to once again spread our own wings, rejoin the group that still labors, and fly on. We cannot stay on the ground. That is not our nature. We are built to soar. We are built for community.

It is programmed deep within these beautiful birds to cut drag and resistance to a minimum, and to experience life to the maximum.

In their misty morning flight they silently teach us, if we will only listen.

The End

My cousin’s fifteen-year-old son committed suicide.

Caught up in activities with school friends that got out of hand, he had made a promise to do some things that did not go the way he planned. Sick and afraid, at church with his family, he had his mother take him home. She put him to bed, then went downstairs to get him some water. A single shot rang out. He had been so afraid of disappointing his parents, getting into trouble with them, that he made a decision to take his life rather than to face what seemed like insurmountable troubles. His devastated parents, who were so proud of him and loved him unconditionally, would never have the chance to explain to him that a parent’s love is not predicated on perfection, but on a bond so strong that even death could never break it.

Halfway through the year in Aiken County, we had already had twenty-one suicides. Twenty-one people who decided for myriad reasons that life was unbearable, that there was something better, that they were too ashamed to go on, that the hurts were too harsh or the damage too deep. Some probably left notes. Some probably left clues pointing to what was about to happen. Some probably made the decision, told no one and carried out a plan that they saw as redemption. I don’t know the stories behind the decision to end each one of these lives, but I’m sure there were stories to share.

Who were they? Nineteen of them were males and two were females. Their ages ranged from sixteen to ninety-five years old. Nineteen were white, one was black, and one was Hispanic. Eleven of them had alcohol or other drugs on board at the time of death. Overwhelmingly, they killed themselves with guns. Fifteen males decided to end their lives using guns.

Do these numbers, our numbers, mirror the national ones? According to an article in the Wall Street Journal, “To Lower Suicides, Methods Matter”, by Jo Craven McGinty, 47,173 people killed themselves in 2017. This was up from 29,350 people in the year 2000, according to the American Foundation for Suicide Prevention and the Centers for Disease Control. Suicide is the tenth leading cause of death, according to the CDC. Those at greatest risk are white males, middle aged white males. People like me, and probably like a few of you reading this column, folks. In 2017, white males like me accounted for seventy per cent of all suicides. White women accounted for nineteen per cent. Men of color made up eight per cent, and women of color only two and a half per cent.

Firearms are the most common method of suicide used by men. In 2017, fifty-six per cent of males who committed suicide killed themselves with a firearm. Do our Aiken County numbers mirror the national ones? I think that is easy to see.

One thing that I found fascinating about the Wall Street Journal article was that whether someone acts on the urge to commit suicide may hinge on having access to their preferred method in a moment of crisis. Because of the percentage of suicides involving guns, wrote Ms. McGinty, the American Foundation for Suicide Prevention and the National Shooting Sports Foundation are working together to encourage the safe storage of firearms. I am not personally against guns by any means (I do not own guns at this time, but I have a younger brother who has been an avid hunter all his life), but the bleak statistics involving firearms and deaths by suicide are simply too awful to ignore. If someone is struggling and has access to an unsecured and loaded gun at the time of their most severe crisis, tragedy is simply too often the result. Blocking access to this most lethal of methods may indeed save lives.

In the world of mental health treatment, we already do a fairly good job of screening for issues including suicidality and plans to harm oneself. However, given the statistics above, we must do better. Eighty three percent of those who die by suicide have seen a health care provider in the year before their death. Aiken-Barnwell Mental Health is using the Zero Suicide initiative (www.zerosuicide.com) to address this terrible problem. This system uses evidence-based tools, systematic practices, and embedded workflows to strive for continuous quality improvement in the assessment, screening and addressing of suicidal ideation in everyone who walks through our doors. It involves systematic changes and improvement in training, identifying those at risk, engaging in a meaningful way, treating suicidal thoughts and behaviors, and making good transitions to ongoing care and follow-up once the acute crisis has passed.

What can you do?

Remember this number for the National Suicide Prevention Lifeline: 1-800-273-TALK.

Secure your guns if you own them.

Listen. Ask questions. Respond. Act.

Consider participating in the Out of Darkness Walk on November 10th at 2 PM at the H. Odell Weeks Activity Center in Aiken.

I have lost patients, family members, neighbors, and coworkers to suicide. I wager that many of you reading my column this week have had similar experiences and losses. It will take all of us working together to bring about meaningful change that leads to the end of suicide.