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.

A Very Busy Day

I am up early on this day that is to be another scorcher. They say it will not quite reach ninety today, which is good. A heat index of one hundred is not my friend. I don’t tolerate the biological steam, outside and in. I grow weak and faint sometimes. I get angry. My temper gets short. Things irritate me. It happens.

Breakfast would be nice. It may be the most important meal of the day, but for me it’s the hardest to come by. The kitchens and churches are not open yet. Lunch, ah, yes, lunch will be no problem if my feet don’t fail me. If I can make it down the hill-wheeeeeee-pushing the cart that contains everything tangible, touchable in my life, I’ll get lunch. A hot lunch on a hotter day in a numbingly cold room. Why do churches think common areas have to be so freaking cold? Am I complaining? No, not really. It’s a mini-respite from the baking air. Sit in the corner, back to the wall, always know my exit. Keeping my ear to the ground, scouting out dinner. Always looking for the next meal. It’s part of the job.

I see the same cars come down this hill every day. Same cars. Some shiny and new. Some old and battered. Some middle-aged, slow and barely functional, like me. I wonder if they see me, those cars and their people. I stand right here, like I do every morning, one hand on the cart to balance me, stretching, stretching up to the lightening sky, stretching out the kinks that come from a night on the ground. The other hand clutching the tattered cardboard sign, my calling card, my resumé as I apply for one more day of life on the street. It’s getting warmer already. Calisthenics make me hungry.

My appointment book is full today. Social services, paperwork to fill out, deadlines to meet. Church, via the back door of course, never the front door, oh, no, never the front door. Discretionary funds can be lifesaving. I wonder if they are ever afraid of me, these pious friends and benefactors of mine. I read the papers. You’re surprised at that, aren’t you?  I know about shootings at mosques and churches. I carry an old backpack everywhere I go. Do they look at me and wonder? Do they see Jesus in me, or do they see Dylann Roof? Do they cringe when I open it? Do they expect a gun? A bomb? A half rotten banana peel all mottled brown and musty smelling?

Soup at the kitchen for lunch, but I’ve already told you about that. Sorry. I like the soup and the company. The cooks see me and talk to me. My downtown stroll in the afternoon. The air is cooler by the river some days. The river is always peaceful. The shade under the old bridges is nice too. The stench not quite so. But the shade. In the heat of the day, the shade is cool gray friendship in a bright world of hurt. Mental health before closing time at five if I can get a ride there. Two strikes and I’m out. Can’t afford to miss this appointment. No show, no meds. They have their rules, I know. I like my counselor. My doc is all right. The one who knows the most about me at the mental health center? I’ll let you figure that one out.

I’ll have a dinner date on the square tonight. She’s usually there, and she shares. Oh, mind you, it’s just platonic. What? Are you surprised that I know that word? Via Latin from the Greek, I think. I’m not so different from you, in that way. My mind works just fine most days, if I take my meds. It’s just my community that fails me sometimes. You know.

It will be a very busy day. You’re surprised again, aren’t you?

Ah, my friend, don’t lose a minute’s sleep over it.

I’m not homeless, really.

Like my blue mental health center sticker says, I’m just a Visitor here. A wanderer. A wayfarer.

We’re not so different, you and I.