Too Big for My Glitches

He was a small but very intelligent and articulate young man. I had seen him before, but it had been quite a while. He came to me complaining (as did his family) that he was having some trouble controlling his anger, dealing with quarrelsome students at school, and not always getting his assignments inside or outside of school completed in a timely manner.

We discussed the usual ways to approach this, I asked him about his goals that he wanted to work on with his counselor and we established that he was not in need of any medication from me.

When I asked for triggers for his troublesome times, like the  times that his assignments went missing in action, he told me that he had the most trouble right after someone made him angry or slighted him in some way.

“I call those times my glitches,” he stated matter-of-factly.

Glitches.

We all have them, don’t we? I know I do.

When I have been up for too many nights until too late, have been working too hard, or have neglected to exercise or eat right, I am prone to be glitchy.

How do my glitches show up?

I am (more) forgetful. I might forget a name, which doesn’t mean much for me since I did NOT inherit the gene that allowed my father to remember someone’s name, the number of children they had and what all their shoe sizes were, twenty years after he first met them. I might let an important piece of an assignment slide, then remember it the next day. I might think about something I need to do, but then forget to put it on my master to do list.

I get fearful. I worry about things that I have no control over, that might not even concern me, or that I have no business fretting over in the first place. If my guard is down, and my worrying is up, look out glitches!

When I am overwhelmed emotionally, look for a glitch or two to be in the mix. I wrote previously about a week when “I had all the feels”. That kind of week, with its stresses good and bad, its changes big and small, and its uncertainly about the future, is a glitch magnet.

If I have too many tasks on my plate, too many projects to finish easily, or too many interactions that will be stressful for me, I tend to not pay close enough attention to the things that are important.

If I say yes too often, even knowing that I have no more time or energy to possibly do what I just told Mr. Jones I would be happy to do, glitches are coming.

Yes, my friends, sometimes I am just too big for my glitches.

How about you? Are there times that you forget, don’t complete something or that you are not thorough enough?

 

 

No Excuses

I attribute my success to this-I never gave or took any excuse.”

Florence Nightingale

 

I was publically thanked today for doing my job. No, really. By two of my coworkers, actually. It sort of took me aback just a bit.

Over the Christmas holiday a couple of patients, being human like we all are, forgot to get their medications squared away before the clinic was going to be closed for a total of five days running. They panicked, thinking that if they ran out of medications it could come to no good (probably an accurate assessment showing some degree of insight), so they contacted the clinician on call. She, doing her job, texted me, asking if I would consider calling in the medications for these folks.

I was in Atlanta, probably in my bathrobe or at best a pair of shorts and a t-shirt, but reach me she did, and respond I did in kind.

It took a little finagling (it was Christmastime, after all), but the scripts were duly called in, the clinician relayed that to the patients and everyone was free to go forth and celebrate.

This was no onerous task. It was no superhuman feat. It was good care provided when asked for, best practice response, and the kind of support that builds trust not only between team members but between providers and patients as well. Why would I not respond exactly like this, every time the scenario occurred? Nowadays, I try to do just that. A few short years ago, that might not have happened. Why? Come back in time just a few years with me and let’s take a look.

In the days of yore, the old paradigm saw us working pretty standard 8:30 AM to 5:00 PM clinic days, with a half hour to an hour off for lunch. We were on site then, everyone knew that everyone who worked there was in the building,  and it was not really very hard to find people.

There were phones on site, but they were the most basic back then, having two lines, maybe three if you were lucky. It was not uncommon in those days to have to wait for all the little lights to go off so that you knew you had a line open to make a call. There was no voicemail. There were pads of various sizes of yellow sticky notes that were used to leave messages everywhere, from doors to desktops to coffee cup handles.

Communication in the office was largely word of mouth. In other words, if you wanted to speak with someone, you actually had to (gasp) go find them and talk to them! Oh, you could also write a letter or a formal memo that had to go through the office courier to get to the party you sought.

The key thing was, the hours were 8:30 to 5, and that was when most of the work got done. If you did not reach your party and state your case and get your business done within those hours, chances are nothing was going to happen before 8:30 the next morning.  When quitting time rolled around,  most folks headed out toward home, and they did NOT want to be found or hassled or hounded before they came back to the office the next business day.

As you might imagine, this lead to frequent missed contacts, unfinished business, lost sticky notes, and poor outcomes sometimes.

Flash forward to 2017. The new paradigm. Meet the new boss, same as the old boss, but with a few technological and logistical enhancements.

We now have much more flexible business hours, with some folks working until seven or eight at night, and many jobs requiring weekend hours. It is hard to define “after hours” now, especially if you work two very different  jobs like I do, one of which involves shifts of six to thirteen hours and can last until one in the morning.

Our phones are now internet based, meaning that I can have a physical phone on each of my four desks in three separate offices, but all I have to do is sign in with my number and a passcode and all my previously programmed information and my voicemails follow me wherever I am, with little work on my part.

I have had an iPhone since 2007, and my life lives on and in that little pocket computer. All of my contacts, my to do list, my calendar, my schedules all live on that phone. It is with me from the time I wake up until I lie down to sleep at night.

For that reason, voicemails are now ridiculously easy to leave, in multiple places if necessary.

I now have Skype for business open on my computer desktop all day long, so I have yet another way to communicate in real time with my coworkers. I can send a message in real time and chat with someone, instead of sending an email and waiting perhaps all day for a response.

Word of mouth and actual productive conversations are still necessary and effective, but one must be more proactive to make them happen now. Memos and physical letters among coworkers hardly exist anymore.

We are living an “always on, always connected” life in 2017. I am almost always accessible, but it quickly becomes apparent that if I do not decide on what the appropriate limits are for that availability, it will most assuredly be abused. Limit setting is key.

So, the bottom line is, in this day and age, to say that I never got the message from my coworker about the patients who needed medications called in, or that I had not checked my voicemail one single time during the Christmas holiday would simply not fly.

If I put myself out there as available and willing to respond, then I must make good on that promise, build trust that I will do what I say I will do, and allow my patients and coworkers alike to benefit from the trust that builds over time.

In 2017, there is simply no good excuse to do otherwise.

 

Why Do We All Want to Die?

I use an ongoing spreadsheet to keep track of and to report my demographics and stats for each telepsychiatry consult shift I do.  I’ve done thousands of consults in over two dozen South Carolina emergency departments over the last half-dozen years. We have now gone over thirty thousand consults as a group.

It never ceases to amaze me, as I fire up my computer, log on to my systems and bring up that spreadsheet for the shift ahead, that one column is remarkably uniform and consistent, sometimes for days at a time. It is the column that asks for an abbreviated reason for the consultation request. It usually looks like this:

SI

SI

SI

SI

SI

SI

SI stands for suicidal ideation, and that is one of the most common chief psychiatric complaints that we see in the emergency department.

Sometime I am simply so busy trying to see all of these people (there was a multi-day stretch recently that we had up to thirty different consults queued up waiting for one of us to see them) that I cannot afford the luxury of slowing down, looking for trends, trying to analyze why we might be so busy during that particular weekend, and the like. There is just not time. However, it is hard not to see the obvious pattern created by the number of people who come into the EDs and state to a staff member that they want to kill themselves.

Why do we all want to die?

Sure, the world has its ups and downs and stresses, but there seem to be so many people who are bent on their own destruction lately that it is mind-boggling.

Allow me to posit some reasons for this disturbing trend.

We do not feel that we belong.

I heard something on the way to something else the  other day that stated that folks who are forced to check that box called “Other” on standard forms do not feel special when doing so. They actually can be made to feel apart, cast out, cut off from the mainstream, in that they do not fit any of the standard groups listed on such forms. To be “other” is to be different, odd, not a part of the group. It is socially and emotionally ostracizing. It means that we do not belong. That hurts.

We do not feel loved.

Okay, okay, I know that is shrink talk and too touchy feely for some of you, but hear me out. I hears over and over from folks in the ED that they do not feel loved by their parents, their spouse, their children, or anyone else. Once again, whether it is feeling like the “other” or not loved by anyone at all, it is a massive cause of self loathing, isolation and hopelessness that will drive someone towards not wanting to exist at all.

Everything seems too hard these days. Nothing is guaranteed.

It used to be if you went to school, graduated, kept your nose clean and played by the rules, you would almost certainly succeed in life. You would be able to find a job, you would have a place to live, you might find love and even raise a family. Today, it seems that none of this is guaranteed, and that for some it all seems just out of reach. Sometimes, people who appear at first blush to be lazy are just depressed, unmotivated, not well-trained, not educated, and simply down on their luck. They see little hope for success no matter how hard they try, so they don’t try. It is sometimes easier to just give up, find someone or something to blame, and give up, rather than really working to make things better.

We feel hopeless.

Hope keeps us getting up in the morning. Hope keeps us going to school, working our way up the ladder, doing the jobs that no one else wants to do, taking on challenges that we are afraid of. If we lose hope, we have lost our will to challenge ourselves. We have lost our dreams for the future. We have lost our ability to see ourselves in the distance, happy and healthy and successful.

What exacerbates these core states and feelings? What makes it hard to fight back and move past them? What do I see most often in the emergency department when someone has come in after cutting, swallowing a bottle of Tylenol, or drinking themselves into oblivion?

Relationship problems are always in the mix. A teenager breaks up with the love of her life and now thinks that life is over. (She cuts herself on the arms and legs where no one can easily see her attempts to deal with her pain). A middle-aged man is a raging alcoholic but has no insight into how this is devastating his family. His wife leaves him, taking their three small children with her. He comes in with a blood alcohol level five times the legal limit. An elderly man has just lost his wife of sixty years to cancer. He is quite literally lost without her, and he does not want to go on. He is a retired police officer, owns several handguns, and knows how to use them.

Financial problems and reversals can produce high levels of anxiety that seem insurmountable. Some folks are almost paralyzed by just not being able to buy gas for the car or groceries for the kids this week. Others may be more well to do, but the shock of losing value in their retirement portfolios or not being able to make the mortgage payment on a huge house that they really cannot afford leads to guilt and shame and feelings of failure. Both can feel like the easiest way out is to simply not be here any more.

Some patients are dealing with chronic mental or physical conditions that they are simply tired of. The ups and downs of bipolar disorder, the pain of congenital spinal malformations, the physical and emotional trauma of cancer and its treatment can all lead to feelings that it would just be better to end things on your own terms rather than waiting on the  diseases to decide when it is time for you to die.

Perceived failures and disappointments (both disappointing yourself or others) often leads to the mistaken notion that if you kill yourself, the problem goes away for not just you, but everyone involved with you. The thing that most of these folks have not thought about to any degree is the pure devastation that is left in the wake of a suicide. The family members, spouses and friends who must live on after you are gone must ask all the hard questions, the “what ifs”, the whys. The guilt and emotional suffering they feel is tremendous and it never really, truly goes away.

Fear and anxiety drive many suicide attempts. Odd, in that most people think that only those who are severely depressed kill themselves. Anxiety, severe and unrelenting, actually leads more folks to actually successfully complete an attempt than depression. The underlying shame, guilt, or other emotions that drive the anxiety are often not discovered in time, or are so well hidden by the patient that it is only after the successful suicide that these are uncovered and better understood, often from the note or other communication left by the deceased.

What is the common feeling that weaves its way through it all? Hopelessness. If you think that there is no way out, that there are no viable solutions left, that you have exhausted all reasonable possibilities for making your situation better, then that gun or bottle of pills or telephone pole look like rational and logical answers for your unanswerable questions. You give up. You quit looking for answers. You feel lighter, happier, more confident because you have made that decision to just let it all go. If there is no intervention, swift and appropriate, you will die.

What are all these stresses and problems complicated by, as if it could get any worse?

One of the most common accelerants for suicidal ideation and attempts is intoxication with alcohol and other drugs. Decreased inhibitions, poor judgment, impulsivity and poor decision-making all lead to potential problems when one is already contemplating self harm. If you are already stressed, at the end of your rope, and contemplating ending it to escape the anxiety and pain you feel, reach out and get help. Drinking, smoking and popping pills rarely makes things look better.

Poor social support is another major deficit that exacerbates suicidality. I see countless patients who truly do not have family, friends, church or anyone else they can call on in time of need. They are really, truly alone. Isolation and disconnection from other people kills.

Lack of access to care also makes things worse just when the help is needed the most. The shrinking of available mental health resources in this county has lead to a dearth of programs that address acute illness and this does not bode well for someone who needs help now, not three weeks from now or at the next available appointment time.

Concomitant mental and physical illnesses can spell disaster. Those dealing with longstanding cardiac disease, severe diabetes, metastatic cancer, and other devastating illnesses may be overwhelmed with the emotional counterpart of the illness and if not noticed or addressed, it may steadily worsen and become malignant itself.

What to do if you find that you are one of those people who is thinking that death looks like your only option?

Call 1-800-273-TALK.

Talk to your family, your girlfriend, your husband, your minister or priest.

See a psychiatrist or other qualified mental health professional right away. If you are turned away when you call, call somewhere else. Don’t accept anything less than an option for immediate assessment. This is your life in the balance, and it is important.

Suicide kills over forty-four thousand people in the United States every year. For each completed suicide there are twenty-five attempts. On average, there are over one hundred twenty suicides per day in the US.

There are many reasons that many of us really want to die.

The job for the rest of us is to convince those folks on the edge that there is help.

There is treatment.

There is hope.

 

 

Too Ill to Treat

rAn article posted in the Augusta Chronicle newspaper on January 13, 2017 by Bianca Cain Johnson, Staff Writer, has left me no option but to write this blog post today. I would like to quote some parts of the article, then address some of the comments in turn, as they are provocative or distressing to me.

I should say right away that this is my personal mental health musings blog, and that my opinions are my own, in no way reflecting the policies or procedures or opinions of my employer. I should also state that there was very little factual or historical information in this article about this particular case, but for me it just brought up several broad issues of the treatment of mentally ill persons, our approach to violent behavior and other broader issues that I wanted to address.

From the article:

“According to a sheriff’s office incident report, the 31-year-old had been at the hospital for several days, but because of his mental illnesses and history of being violent, the hospital was having trouble finding a mental institution to take him.” (italics mine)

“A doctor re-evaluated him on Tuesday morning and determined he could be released.”

“…the patient stated, “the only way to get attention is to show out”.”

After he had allegedly injured a guard and nursing staff, “the patient was restrained and given medication to calm down, (and) employees heard him comment “this is what I wanted”.

Remember “too big to fail“, as it pertained to banks or motor vehicle manufacturers? Well, in mental health nowadays we run up against admission and placement issues for those patients who are “too ill to treat”. It may be because they have some element of intellectual disability. It may be that they are floridly and actively psychotic. They may be actively suicidal with access to a lethal method and a serious, specific plan. It may be, like the patient in this article, that they have a previous history of violence. For these and other related reasons, what you find is that some facilities among our dwindling number of mental health hospitals now cherry pick the patients that they want to take. If patients are too sick, too acute or too potentially violent towards themselves or others, they are denied admission and treatment, and are often stuck in emergency departments for days or weeks.

Can you imagine the outcry if a patient with chest pain that was too severe was denied admission to a cardiac care unit, or if a patient with a stroke that left him prone to emotional outbursts was denied neurological treatment?

A doctor re-evaluated the patient and made the determination that he was ready to be released. We do not have nearly enough information about that determination to be able to comment on it all, but we can say that we as physicians are notoriously bad at using our (non-existent) crystal balls to predict violent behavior. Of course, there are known risk factors, characteristics, static points of history, and previous episodes of violence that might sway one towards thinking that there was a better than average chance that some violent behavior or acting out was coming, but to be able to predict that with any significant degree of certainty is fraught with problems.

Please see this article on mental illness and violence for more detail about these related issues.

The issue of the patient knowing or learning or figuring out that in a busy emergency department the best way to be heard or to get drugs or to be assessed is to act out is another huge issue. This involves separating out acutely ill patients who act out unwittingly or because of lack of control, versus those persons who know exactly what they are doing and plan to be violent or agitated with a specific goal in mind (to be separated from the general population or to be given injectable medications, for example).

The comments about this article, which I will leave you to read on your own if you wish, were predictable. This issue is politicized, psychiatric patients are called nuts and commenters express nostalgia for the days when they could just be locked up “for a long time”. One commenter stated that the evaluating doctor should have his license pulled immediately. In my opinion, none of these kinds of comments is helpful.

What do I see going on here as a medical director for a mental health center, and even more so as a telepsychiatrist who sees patients in over two dozen South Carolina emergency departments? What did this particular case make me think about?

First of all, we know that deinstitutionalization was a real thing. Hospitals were closed, patients were discharged to their families, to supervised living situations, or to the streets, and the local mental health centers were supposed to pick up the slack and treat them as outpatients, all in the name of streamlining care and saving money. When I started medical school thirty eight years ago and did my very first psychiatric rotations as a junior and senior student, state hospitals, VA hospitals and mental health nursing homes were still very full of patients who were too ill to function well in society. Many were there for long term stays of weeks, months or even years.

Gradually over my career I have seen many inpatient facilities cut back and close beds and finally close their doors entirely. The ones that survive are much smaller, treat patients for much short length of stays, and are run via much more stringent business models than ever before.

Many patients now get their medical care and most of the psychiatric care in an emergency department, not from their own personal doctor. Once admitted there for evaluation, it can sometimes be a very difficult and complicated ballet to assess the patient for his primary illnesses or presenting problems, available resources, need for inpatient versus outpatient treatment, payor sources and requirements, and family involvement. Add to that the hospital administration’s take on treatment, as well as pressure from ED doctors to get patients in and out as rapidly as possible, and it becomes somewhat overwhelming.

In those past years, patients who were truly psychotic or actively suicidal or a danger to others could simply be committed to the state hospital and held there as long as necessary to achieve remission, or as close to it as possible. This is not nearly as easy or smooth a process now as it once was.

As I mentioned above, we do not have crystal balls, but we do have fairly detailed screening procedures for harm to self or others, for example. We can assess, apply evidence based guidelines, offer the best recommendations we can based on these parameters, and decide if a patient must held or can be released. Recommending and treating based on numbers alone, administration goals, or by algorithm rarely work well.

If a patient is acting out of his own volition, is cognitively processing things appropriately, is not overtly psychotic  or in withdrawal from substances, and he still destroys property or intentionally  hurts others on the staff or other patients, then he should be charged for these actions accordingly and would perhaps be better served in the county jail than the emergency department.

I would welcome stories of  your own experiences in this area, your opinions and ideas for how to make these tense situations more rewarding and beneficial for both staff and patients.

 

 

 

 

Fox News

Now, the chickens were happy. Happy as clams, you might say, but you would of course be wrong, because they were chickens after all. Dozens of them, running around and scratching and making noise on the wide yard, their coop behind them. Happy as chickens could be. Scratching out a living, never leaving the safety of the yard, laying an egg or maybe two a day, nothing awfully strenuous, and relying on the farmer to throw them something to eat and keep them in water every day.

Chickens have small brains. They don’t really worry much, unless they think the sky is falling or some such. They don’t really fly. They squawk when upset, and they might peck you if cornered, but that would take a lot. Now, if a whole yard full of chickens got upset, that could be exciting to watch. The feathers might fly. Otherwise, on a normal day in a normal month in a normal year, I’d most think of a coop full of chickens just sitting there brooding.

Sam the farmer loved his chickens. He was like a father, no, maybe an uncle to them, keeping them safe and warm and dry, feeding them and keeping the predators away. It was sure easy taking care of a yard full of chickens, or so Sam surmised. The problem was, you see, that Uncle Sam was a good man, a decent man, but he was dumb as a post. He could not see beyond his small white farmhouse and the yard and the chickens he loved. He never ever looked towards the dark woods, just past the open fallow field, just paces from his dirt yard. He liked to pretend that the dark woods were not there at all.

There were foxes in those dark woods. Sly, cunning, beautiful, sleek foxes. Exotic animals, they were, when compared to the chickens. Red foxes, with bottle brush tails and sly little grins on their whiskered faces. Perked ears that heard all, especially at night, under cover of darkness. Brains that never stopped thinking of chickens and dirt yards and farmhouses that didn’t belong to them.

The foxes never came out in the open during the day, not during broad daylight, because even the farmer, who was dumb as a post you might remember, could usually believe his own nearsighted eyes when something was amiss in broad daylight. No, the foxes were stealthy creatures of the night. They only came probing when it was pitch black out and the farmer was sitting in his rocker, full of supper and snoring the late evening hours away.

The foxes began to pick off the chickens one by one, so that the farmer might not notice. First, the Rhode Island Reds. Then the Guinea fowl. Then the Cubalaya. Then a Bantam breed or two. The foxes cared not a whit for different colored feathers, or top knots or wings or funny shaped beaks. They picked them off slyly, not in overtly foxy ways at all. Sam did not even notice at first, as he had a problem with numbers and counting you see.

One day, Uncle Sam decided to count all his chickens, even the ones that had not yet hatched. He enlisted his wife Libby to help him. She was older and smarter than Sam. She loved him without question, always had, but she sometimes grew tired of his simpleton ways and inability to see things as they really were. She soon realized that they were losing their prize chickens, the ones that had come to the farm from very far away and were valuable. She related this assessment to Uncle Sam, who spat loudly into the dirt and promptly denied that this was happening. An argument ensued, and Libby threatened to leave the farm, and Sam if things did not change for the better, and soon. The foxes, listening just inside the tree line in the dark woods, heard every word, and smiled.

Time went on, more chickens were lost, ones of every color and variety, prized chickens that Sam and Libby had sacrificed to bring to the farm. The borderland between the farmyard and the edge of the dark woods seemed to be blurring. Libby grew more upset, then angry, then depressed, then despondent, then lost all hope. She moved away, never to return to the white farmhouse.

One night, Sam was awakened by a clatter in the yard out by the chicken coop. He grabbed his shotgun and went outside into the darkness. Hearing commotion, not having any idea what it was, and feeling very afraid now, he fired his gun into the darkness, one time, twice, three times, until all his shells were spent. The noise continued. He reloaded and fired again, blindly responding to the threat that he did not understand but was very frightened by. The noise stopped. “There,” he said out loud to no one, “that’s better. Nothing to fear. Nothing to see.” Satisfied that he had done his duty, he went back into the white house and fell asleep.

The morning after, Uncle Sam came out of the house, got a pail of feed for the chickens and prepared to distribute it to them as he had for many years. As he approached the coop, the site of all the commotion from the night before, he saw blood and feathers everywhere. “The foxes,” he said out loud. “Libby was right, it was the foxes that did this awful thing.” Then he noticed that the dozens of chickens had not been torn apart or dragged away by foxes at all. They had all been shot. In his denial and blindness and panic, Sam had wiped out his entire  chicken coop in the dead of night.

Distraught at his own foolhardiness, he returned to the farmhouse, packed a small, battered suitcase, and left the farm behind. He thought of his wife, many days gone before him now. “Liberty,” he said (he always called her Liberty when things got serious between them), “I’m coming to find you. If it takes me ten years, I swear I’m gonna find you. We need to be together. We have to be together.”

As darkness fell that night, there was no soft clucking or rustling as hens got comfortable on the roost. There was no cheery whistling or singing as Libby made an apple pie in the kitchen. There was no snoring as Sam slept through the changes that had cost him his way of life.

There was only the softest rustle of fur on fencepost and a fast-moving glint of red in the moonlight as the next occupants of the little white farm house moved through the dooryard.

The Buck (Naked) Stops Here

Well, it was time to head back to my doctor’s office today for that most favorite of pastimes, the annual physical examination. I know, I know, some folks say that this is one medical procedure that is not needed anymore, that every other year or less is okay as long as you are healthy. It still makes me feel good to go down there and get humiliated into paying attention to my own wellbeing once a year. Kind of a swift kick in the pants, you know. Doctors need to stay healthy too.

The initial procedures, of course, included getting weighed, having my temperature taken and getting the bejesus squeezed out of my right arm, (my prescription writing arm, damn it) by an automatic contraption akin to a boa constrictor with a streak of Velcro on his belly. My blood pressure was fine, but darn if I don’t miss the days of having the nursing assistant or tech personally squeeze my arm until it’s blue. Medicine is losing its personal touch, for sure.

You know what happened next. I got herded into my own special room, complete with exam table, unused computer monitor, assorted tongue depressors and hard chairs. It’s usually cold enough to hang meet in this room, but today there were no hams or sides of beef in sight. Yippee. Global examination room warming is real, my friends.

“Since this is an annual examination thing, I’m going to have to give you a gown, you know,” the cute thirty-eight week pregnant assistant told me, looking back almost apologetically.

“Oh, yeah, sure, I know,” I answered lamely.

“Everything off except for underwear, and you can keep your socks on if you like,” she said, deadpan. Something about this whole interaction was just, well, so wrong.

She left the room and I dutifully disrobed, donning the backless gown like so many before me, wondering if it made my butt look big. (Of course it does.) You know that if you tie the thing you’ll tie it too tight and never be able to get it untied without asking for help from the pregnant assistant, but if you don’t tie it the darn thing keeps sliding off your shoulders like dead skin off the back of a Walking Dead zombie. No win scenario here.

I went with the fashionable, confidant choice and left things untied. Then I sat on one of the hard chairs and waited, ridiculous gown, black socks on feet, reading an article on my iPhone until Dr. H walked in.

Shortly, he did just that, chart in hand. He shook my hand, welcomed me genuinely and asked how I was. He is a very good doctor, thorough and competent but compassionate as well. When you are a doctor, seeing your own doctor like this is sort of like looking into a mirror.

You’re a doctor. He’s a doctor.

You know what he’s going to do. He knows what he’s going to do.

You’re basically naked and cold. He’s wearing khakis and a warm fleece sweater vest with the practice logo on it.

You have no tools of your trade at hand. He has rubber gloves and KY.

Somehow, no matter how kind the practitioner, you sort of feel that you are at a huge disadvantage here.

Now, once upon a time, way back when I was a fledging physician, routine annual histories and physical examinations might take from sixty to ninety minutes. The doc would sit and chat, scribble and write, take more notes, go back and ask more questions, then take another twenty to thirty minutes or so to do a complete physical exam checking cranial nerves, doing tests of reflexes, checking you for vibratory sensation, and watching to see if you could walk and chew gum at the same time. Not to mention the usual checking of heart, lungs, ears, mouth, teeth, belly, extremities and pulses.

My physical exam time with the doctor today was probably less than fifteen minutes total. Time with ancillary staff added another fifteen to thirty minutes to that of course. He does not have time to mince words in this fast-paced medical environment that we all labor in.

A side note: when updated information is obtained at my doctor’s office, such as my weight, height, medication history and the like, it is now entered into a patient portal, which I have access to on my iPhone via a secure app. By the time I got back to the exam room today and was undressed and seated waiting for the doctor, my most recent info was already entered and I was getting an email alerting me to check it out. I have to admit, that’s pretty impressive.

Now, speaking of info and numbers and data, they do not lie. No matter how many leather oxfords I slip out of or how many keys or phones I take out of my pockets before I step on the scale, my weight is going to be what it is. In my case, my weight is too high for my height. My BMI, which is a calculated number that speaks to that weight per height ratio, is also too high according to actuarial tables that speak to such things. Not terribly so. Not dangerously so. But it could be better. I know that. My doctor knows that. We discussed weight set points and aging and activity level and sedentary time and other issues that are real influencers of this height/weight/BMI thing.

I realize that it is not my doctor’s obligation or job to make me feel better about being unhealthy, but he is also responsible for helping me to interpret the numbers and other data including my labs (results of these pending at this writing) to help me be the healthiest, most active, happiest person I can be.

What does this all mean?

Well, if I was 7′ 6″ tall, my current weight would be absolutely at the lowest end of the “normal” weight range for that height, according to those tables I mentioned. Put another way, I could be at a perfect weight for my height and could 1) be cast as an extra in the next Avatar movie, or 2) be the starting center for any NBA team I chose. I have not lost heart or resolve. I could hit a major growth spurt in my sixties. It could happen. You don’t know.

The last part of any red-blooded American male’s annual physical is that most wonderful of experiences, the DRE. Now, I won’t offend those of you with weak constitutions by telling you exactly what that means, but suffice it to say that it is to check to make sure you 1) don’t have an easily identifiable (and hopefully highly treatable) rectal cancer, and 2) that your prostate is still behaving itself as you age gracefully in your backless gowns.

It is not a fun experience for either doctor or patient, but in all honesty it is one of those brief screening exams that can literally save your life. It’s worth doing. If you are a guy getting a physical, don’t skip this one. There is only one thing that makes this brief little exam even more awkward than it already is by default.

Trying to answer your doctor’s questions about bowel habits or urination flows or similar stuff while “assuming the position” is like trying to explain your theory of global exam room warming to your dentist with a suction hose, four metal instruments and two sets of hands in your completely numb mouth.

And that’s all I’m going to say about that.

I am happy to say that my blood pressure was good, my exam was normal and I left my doctor’s office reasonably healthy and happy for another year.

It was almost lunchtime when I headed back towards my own office for the afternoon’s work. I decided that I would stop for lunch before driving back.

There is nothing in the world like getting naked in front of your doctor for a physical examination to make you really think hard about what you are going to order for lunch immediately afterward. You’re thinking about weight, blood pressure, blood sugar, cholesterol, sleep, food, exercise and all the rest as you stand in line to place your order.

For me today? A market salad with fat-free Italian dressing and a large black coffee. Did I want to reward myself for my good results with a cookie or brownie or something else? Damn straight. Did I ? Not a chance. Not today.

My resolve should last until the next time I open the pantry and spy the last of the Christmas white chocolate bark with crushed almonds, dried cranberries and a touch of orange. Will I eat it?

Nah.

I’ll save it for my lovely wife, who has much more resolve and will power in her pinky than I have in my whole 7′ 6″ frame.

Did I mention that I seem to have had a recent growth spurt?

 

 

 

 

 

You

I have been enjoying an hour of reading each morning before work, and Thomas Friedman’s Thank You for Being Late is my latest fare. It is a fascinating book that addresses the many different types of accelerations that we are experiencing in the world right now, and how we had best conceptualize and cope with them in order to survive and thrive.

One thing that Friedman makes very clear, and that other writers are echoing, is that our assumptions, the things that we have always taken for granted and have counted on to be eternal, have started to erode. We have always assumed that if we played our cards right, kept our noses clean, and played by the rules, that life would turn out pretty well for us. We were always told that if we worked hard, went to school, got an advanced degree and met the right people, we would land that nice job with benefits in a company that was too big to fail and that would see our careers through until we could take a retirement package that would let us ride softly and gently into the sunset of old age.

The world is changing. Rapidly. Fundamentally.

Previous assumptions do not hold true any longer. Previous plans, tried and true, that everybody followed, do not work. Traditional training, preparation and thinking that used to get us firmly attached in industry and the world of work now provide little except for artificial trappings that say what we should know and what we should be able to do.

Tradition, once the bedrock of our predictable lives, is changing faster than most of us can keep up.

This is the age of You 2.0, or maybe even 3.0.

You are now the startup. You are the company of one that is making the pitch out in the world. You are the one trying to convince someone important that you have the knowledge, skills, training and flexibility to perform, to produce.

There is now the need not only for a specific amount of schooling and training, but for continuous learning throughout your working lifetime. Finite training and degrees, static and sterile, are entering a phase of obsolescence. Continuous self assessment, pivoting to meet the current needs, retraining and skill acquisition are the watchwords of You 2.0.

You must not only be prepared and properly trained, but you must have fully developed emotional intelligence, the skills necessary to handle groups of people, exemplary communication skills, and flexibility. You must be willing and able to turn on a dime, to meet new challenges and take on new projects that in years past you would have thought were out of your league. Continuous self assessment will be your watchword, and adaptation and skills acquisition will be your goals.

As Friedman said in a previous book, the world is flat. It is also fast and furious, changing at the speed of Moore’s Law and then some.

Those of us who are overwhelmed by this rapid change will fade away, some fast, some slowly.

Those who embrace change, who thirst for knowledge and who adapt to different landscapes and environments will be successful and drive the next wave and the next and the next.

You 2.0 will look nothing like the prototype.

Then again, did we really expect it to?