I was talking with my wife the other day about different times in our lives and asked her this question: “What is the period or era in your life that you feel most impacted or influenced you?”

I guess the fact that we have been living through a time of such upheaval in the last year has had me thinking about such things. We have seen the worst medical crisis in one hundred years, political unrest, economic instability for millions and racial tensions that have been escalating and boiling over with the deaths of black men in multiple cities. Now in my early sixties, I am at that point in my life that I know there are fewer years ahead of me than there are behind, and I am trying to make sense of who I really am and why.

I think back to the grammar school years, with the early crushes and football practice and idyllic days of riding bicycles exploring nearby woods on a hot summer day. I remember the many visits to my grandparents. My mother’s parents had a farm in middle Georgia, a wonderful place for a small boy to grow up in the bosom of a loving family. I will never forget finding box turtles in the sandy ditch in front of the farmhouse, swollen with runoff after a monster rain storm. I remember spending hours in the porch swing on the front porch of that same farmhouse, back and forth and back and forth as I traveled in my mind to foreign lands, piloted a plane, captained a ship. Many, many dreams had their origins in that rhythmic motion at the far end of the porch. Butchering hogs, gathering watermelons, fishing at the pond, and taking rides in the back of the old truck to the country store to fetch small paper sacks of candy are indelible memories. Christmases were magic, with the floorboards on Christmas morning so cold that your feet would be numb after jumping out of bed before the gas heaters were lit for the day. Food, so much food, and visits by all the aunts and uncles and cousins, light and laughter and love through the ages.

I have been many places and done many things since that time on the farm as a little boy. I navigated the treacherous waters of the teenage years and high school, went to college, lived overseas with my family in Italy for two years, and then achieved my dream of admission to medical school, with residency to follow. I have had many different groups of friends and associates, professional partners and teachers and mentors. All have shaped me, taught me, buoyed me up and at times torn me down (albeit for my own good, I suppose). I have loved it all. But which time in my life has had the most influence on me, given me the most fuel to move forward, taught me the most about moving through the world and being a productive citizen of the planet?

I think you can see by virtue of the structure of this musing that the time that was most important to me was the early times, the formative times, the times that a young boy learned how to be a teenager then a young man. The time that pulls at the man the most is not the college years, the medical school training time spent in the anatomy lab or the first time I treated a patient on my own as a young doctor. The time that has stuck with me the most is the time that I spent with family before I knew about racism,economics, pandemics or politics.

I have a swing at my house today. It waits at the far end of the front porch, and I sit in it only sporadically. It means a lot to me, not because I spend hours there flying planes or captaining ships and sailing to foreign lands, but because I could do that if I needed to. It is a bookmark in time for me, a stained wood reminder of my past, a clear and present comfort in these uncertain times, a place that I can always retreat to any time I need to feel a connection to those who who have gone before, those who have molded me and shaped me in ways that no other periods in my life could have.


Pride goeth before a fall. 


: a feeling that you respect yourself and deserve to be respected by other people

: a feeling that you are more important or better than other people

: a feeling of happiness that you get when you or someone you know does something good, difficult, etc.


Photo credit: Katherine Oliver Birkbeck

We have all had reasons to be proud. 

We grow up, graduate high school, then maybe college, then maybe professional school. We learn a skill, a trade, a profession, gain experience and take it out in the big wide world and find that we are really proficient at something. Reason to be proud, no doubt.

We buy that car we’ve always wanted, or that house, or that boat. We’re proud when people comment on our physical possessions. 

We take care of our bodies, age well, stay in shape, work out, wear nice clothes, get our hair done, wear shiny jewelry. We are proud of how we look. 

We are proud of our work record, our involvement in our church, our community activities or our political dealings. We “run on our record” in so many ways as the years roll by. 

I think Webster may have been thinking about all of these with that first definition above. We accomplish things, learn things, do things,  possess things that help us respect ourselves, and then we expect that respect to be forthcoming from others. All well and good, within reasonable boundaries. 

We cross over into that second definition when things get just a little out of hand. When we think that we are better then others, that we are more fortunate, that we deserve more, that we are more special than others, that we have a higher purpose or place then they do. This kind of pride can swell and fester and putrify and lead us to the brink of destruction, sometimes giving us that last little nudge, that gentle push, that sends us over the edge into the dark abyss of narcissism from which there is no voluntary turning back. 

Now, I have made my fair share of mistakes. 

Some of them have been tiny ones, almost unseen. Some have been known only to me and God. Some of them have been more public and visible and embarrassing. Some have been big, so big that I will rethink them from time to time, and probably will for the rest of my life. 

My mistakes, collectively, may have diminished my ability to feel proud of myself sometimes.

However, nothing has shaken my pride in one thing, actually three people, who I love and care about very much. 

My daughters have grown to be the kind of young women that I can truly be proud of. 

They were all good children, no doubt, energetic and funny and creative and spunky and playful. 

They all grew and branched out into different areas of interest, activities and circles of friends. 

They all finished college, persevering through good times and bad to complete this milestone. 

They now are blossoming even further as adults. 

They teach little children (a job I hold in very high esteem, as they literally shape our future in their classrooms every day). 

They give others the opportunity to grow and learn.

They sing, and dance, and act, and create.

They have pets!

They (or at least she, for now!) have children of their own, something that still amazes me every day.

They love and learn and live and they are making their marks upon this broken world, which gives me great hope that one day it will be whole again.

This kind of pride, this sense that my children are very special and wonderful and lovely and gifts to the world they live in, surely will go before a fall. 

A fall in my hurt and disappointment in myself, because I know I have been a small part of creating three wonderful lives that matter. 

A fall in my anxiety about the craziness of this world, because I know that the generation that follows mine is smart and strong and willing to figure it all out.

A fall in my constant sense of worry (if you are a parent, this needs no explanation), because I know that even though they don’t need me in quite the same way they always used to, they are fully capable of taking care of themselves. 

Yes, this third kind of pride is marvelous. 

It makes all the hurt and pain and doubt and fear fade into the background, and leaves room for nothing but bright hope and joy and celebration.

I love you, girls. 

White Noise

It was a sound that should not have been there.

I arrived at work about the same time as usual, unpacked my things, sat in my chair, and prepared for the day ahead. It was quiet on the far end of the hall where my office is in the mental health center. Quiet, still, and until folks from the parallel hallway start to go back and forth to the bathroom or the ice machine or medical records, mostly devoid of people at that time of day.

It took me by surprise. You might say it startled me.

Dr. B had died less than a week before, just ten days after leaving us for another job that he was very much looking forward to. He had planned to live in a house by the lake, have his wife and dogs come to stay with him while he worked, and enjoy the holidays with his family. I had told him goodbye when he left, carting the last of his office furnishings out to the Prius in preparation for the journey back to Georgia. I had told him goodbye, but not goodbye.

Yes, there was no mistaking it. That low, tuneless drone in the hallway. It was there, all right, but why? It should not have been. He was not here, after all. Or was he? I felt a little involuntary shiver go up my spine.

“Stop it,” I heard someone that sounded suspiciously like me tell me. “Get up and see where it’s coming from.”

Dr. B came in each morning, backpack or satchel or bag of some sort with food, golf clothes or other such items in tow and plopped them on the desk. He then immediately retrieved his white noise maker, a little off-white, round, plastic disk that was plugged into the wall inside  his office but that lived outside in the hallway, one door over from my office, every day. It happily provided the screening soundtrack for his day, and by extension for mine on the days I worked in that office. He set it outside the door, less than a dozen feet from mine, and the day began.

I heard that noise maker this particular morning, clear as day.

I thought of him, and of us, and of the fleeting nature of working relationships, and of life.

I got up, poked my head out into the hallway and halfway expected him to be standing there, scowling at me.

Then I saw it. The little off-white box was  outside the door, whirring away as it always had. Not outside, his door, but the door of a new telepsychiatrist I had hired just before Dr. B’s death, up the hall to the right.

I stopped, smiled to myself, and turned to sit back down.

Holiday seasons tend to bring all sorts of reminders to the forefront for us. Sights, sounds, and smells reactivate thoughts and feelings and emotions that we thought were long-since dead and buried. Memories, both good and bad, come flooding back. We are sometimes overwhelmed at how fresh and raw the emotions are as they wash over us like a cold winter rain. We feel them, we breathe them in, we dance with them. They take us over for that brief time that is memory, that is re-experiencing.

Then, just as the visible vapor that is our breath on a cold shopping day, they swirl and fade away, as quickly as they came.

Holidays of old, partners, children, spouses, teachers, work associates- we know then that they are really gone. That we will never see them, speak with them, give them gifts, argue with them, make up with them, or look for their return again.

Of course, that does not mean that we will  ever stop caring about them, remembering them, smiling at the thought of them, or loving them.

That will never change, no matter how many holidays come and go.

They will always be a part of our memories, just as we are all, now, a part of the future memories of those we cherish.

Happy new year, dear readers.

Make this the best year ever.



I guess there are just times that you have to write about joy, you know?

It’s Thanksgiving week in the United States (yes, I have at least two other readers in foreign lands, count ’em, I do indeed, so they may not get all this turkey and cranberry stuff), and that means giving thanks for the people and the things in our lives that make us truly grateful. Now, I’m not one of the sentimental mushy types who will throw a bunch of fluff at you and see how many times I can make you cry. That’s not my style.

However, after this weekend of food, friends, family, football, and all other manner of things that go fffft as you say them, I simply must thank the Universe and God as I understand him for the abundant joy in my life. Sometimes, stubborn as I am, I don’t let myself see it and experience it fully, but that’s my problem to sort out, not yours.

In the meantime, I am very thankful for:

Food to eat, a warm bed to sleep in, and worthwhile work to do.

Family who love me no matter how many times I disappoint them. My grandkids have that special gift of lighting up like Christmas trees, smiling and running to me every time I come to their front door. That feeling is like no other in the world.

Old friends who are there even when I neglect them, give me honest advice and feedback when I ask for it, a listening ear when I need it, and the promise to help me re-engage with my own life at the pace I need to do so.

New friends who are as dear as old ones, who challenge me, call me on my BS, and love me unconditionally even after they know about some of my worst flaws.

The warm, comfortable glow of tradition, music, liturgy, and ceremony. Without these, our institutions would not stand the test of time, and we would be poorer for that fact.

Like many of you, I will have a short work week. I look forward to the holiday and being with my family. I look forward to slowing down, even for a few short hours.

I look forward to reconnecting with joy.


It Takes Five Senses to Say Goodbye

The first things I think about, and remember so viscerally and physically, are the smells. Somehow, smells always seem to be directly connected to memories, don’t they?

In the springtime, the earth in the backyard garden plot, back behind the pool, had that fresh, fertile, loamy smell, especially after a spring rain that always made me itch to get out and plant something. My mother told me that I did, after all, have farming in my blood, as my grandfather tilled the earth and mom always liked her yard and flowers and vines. I suppose she was right, because the feel of the dirt running through my fingers and the smell of it just felt really good somehow.

Summer brought the fragrant white gardenia blooms on the shiny green plant right beside the back door, the old entrance to the back of the house before the wholesale renovation that moved it around to the back and added more glass and a big back porch that later expanded to an even bigger back deck, built to accommodate the big shade tree that dominated that part of the yard. That little plant put out more perfume per bloom than any other we ever had. One of the particularly bad winter storms did a number on it, and it never fully recovered, but it gave great olfactory joy for many summers.

Summer also brought lawn mowing, and with it the fragrant smell of fresh-cut grass, hearkening back all the way to my boyhood. The fragrant vines, the pungent chlorine of the backyard swimming pool, all smells that made the season what it was.

Fall and winter were no different. Outside, deadening trees and turning leaves had their own smells, and smoke from chimneys carried the acrid smells of families moving indoors to huddle against the cool and pretend that we all “needed” to be by the fire, though that was hardly ever imperative in the south. The best smells of the latter year, the absolutely best smells of all, were the ones around the holidays. The candles, the smell of roasting turkeys and puddings and rolls and cakes and spices and the smell of cold air rushing into a warm kitchen as family with gift-laden arms piled in from outside, ready for another feast day.

The sights of that time were nice as well. Twinkling lights on the Christmas tree were always my favorite. The absolute best time of day after the tree was decorated was late, late at night, when the house was still and most everyone was already abed, when I could sit by the fire, drink in hand, and just bathe in the glow of the season.

The sight of children, little at first, floatties on chubby arms, splashing about in the pool, later so much older, with friends and parties and groups of kids and teens and adults gathered in sweaty knots about the pool, toasting with bottles of beer and sodas, eating hamburgers and talking about the events of the day.

The sounds of the house were as varied as the smells and the sights. Piano playing, by memory or off sheet music or simply banged out under tiny fists that figured out that noise, wonderful noise, came from these black and white things that one could bang on without end. The music from upstairs, passing through phases from Disney musicals and soundtracks from every kids movie that we ever bought and wore out on VCR tape to contemporary pop to rock to rap. Funny how kids will find things you’ve never heard of to listen to, but then will sneak on one of your old favorites from time to time, never thinking that you’ll hear them playing it. The drone of the television, the whining of the mixer, the beeping of the microwave and the harsh buzz of the dryer. The symphonic soundtrack of the life of a family in the house that they called home for almost two decades.

Tastes, oh my, the tastes. Watermelon and ice cream and fresh-baked cookies and chocolate and coffee, lots and lots of coffee, strong and black for some and brown and sweet as molasses for others, but coffee nonetheless. Pumpkin bread and casseroles and hot chili on cold days and beer. Wine at dinner and champagne to bring in the New Year. Sparkling apple cider for the little ones. Tastes of days and tastes of nights and holidays and birthdays and comfort food after 9-11. Sweet and tart and salty as tears. Toxic as jimson weed and bitter as quinine, the tastes left in the mouth when all was said and done. But before that, it was all warm and pleasant and easy on the tongue.

To live in the house was to feel it, the warm earth in the spring, the grass clippings in the summer, the leaves in the fall, the fire wood in the winter. The smooth edges of the island countertop and the warm fluffiness of the blankets and throws around the house were reassuring, familiar. The feel of the worn knob on the back door. The click of the glass door on the shower as it closed. The heat from the oven and the blast of cold from the freezer. The solid, heavy smoothness of teak in the dining room. The nubbiness of raw silk in frames in the living room.

Yes, it took five senses to live in the house and love it for two decades.

It has taken five senses to say goodbye.

Photo by Tricia Ray Smith

Photo by Tricia Ray Smith

Thanks for the Memories




It happened out of the blue, as such experiences often do. 

I had parked my car and was walking a short distance from the public parking deck on a covered concrete sidewalk, past the open expanse of lawn and twinkling Christmas lights in front of the hospital. I was going to visit a friend who had just had surgery, and it had been quite some time since I had been in this hospital for any reason, personal or professional. As I walked, I happened to glance off to my left, and it hit me. 

This is where we used to take my oldest daughter (who is now twenty-nine years old and has kids of her own) to daycare when I was in residency and my wife was working as a pediatric nurse. 

It was a very brief, very concrete thought, attached to nothing, triggered by nothing more than the sight of a brick building. I was struck by how visceral this memory was, how it instantly transported me back to a simpler time when I was in school, had been married but a few years, and had one child. 

I’ve had memories and thoughts like this hit me before, and I’m sure you have too. It seems that at holiday time, these kinds of memories bubble up to the surface more often than at other times of the year. Why, you might ask?

Memories that are associated with our senses are some of the strongest, most tenacious memories we make. Think about how one whiff of Christmas cookies takes you back to your grandmother’s kitchen in a way that feels so vivid you can almost feel the hot stovetop. If you close your eyes, you can taste the icing that you licked off your fingers after they swept the glass bowl once, twice, three times around to catch all the sweetness left there. Think about the perfume your mother wore on Christmas day when you went to church as a family. Anyone can wear that perfume, but only your mother smelled the way she did when she wore it. Smell the evergreen goodness of a freshly-cut and fresh-bought Christmas tree and you are back in your living room, a kid on a mission to shake, rattle and roll every wrapped present until you either knew what was in it or got caught and told to stop. 

Taste cranberries and you remember your aunt’s favorite way to make them. The first bite of turkey this year will remind you of the first Christmas you came home after starting college. How good that bird tasted, because it wasn’t about the turkey. It was about coming home

Touch the tinkling glass ornaments, hear them make that little musical sound, and you instantly remember the story of how they came to hang on your tree. See the lights on the tree and remember the year that all of them were strung before you realized that one string was completely dead and had to be replaced. 

Sensory memories are the absolute best. You can think all you want about the holidays and what they mean to you and your loved ones, but nothing can replace the feeling you get when you hear, see, taste, smell or touch something that instantly brings joy to your heart and a tear to your eye.

Merry Christmas.

And thanks for the memories.




Thanks and Giving

I can read articles and blogposts very early in the morning, which I am wont to do. I can pitch them as retweets on Twitter or shared posts on Facebook, and  maybe throw a little comment or question in there. Then, do you know what happens? 

I can sit back and watch the growing, changing, idea-inspiring stream of comments, rants, supports, challenges and new ideas that come, always, from my friends and family. 

In this season, I am very thankful that I live in a country where I can express myself in writing for all the world to see.

I am thankful for smart friends and supportive family members who have marvelous ideas. 

I am thankful that those very same friends and family will call me on the carpet when I write crap, or when my logic is faulty. 

I am thankful that even when we disagree, sometimes vehemently and fundamentally, we still remain friends and keep the dialogue open.

I am thankful that I learn something new every single day. 


That’s all the sentimentality you get from me today.

Yeah, right. You know me too well. 

Happy Thanksgiving season, my friends. I love and appreciate you all.


I originally posted this on Facebook today, but I wanted to make sure all of my readers saw it. I mean what I said. I love and appreciate the time we give each other, the support, and the time it takes to read, absorb, discuss and challenge each other. Here’s to a great season of thanksgiving and celebration of the year fast coming to a close, and the hope that we all have a wonderful 2014. 

Weekend Wakeup

So, I learned or re-learned some things this weekend while taking a one day hiatus from the workaday world. 

I can sing. Granted, I’m no Placido Domingo, but if Bruce Springsteen or Aerosmith pop up on my playlist with one of my favorite songs, I might just take the melody for one verse.

Road trips clear out cobwebs in my head. Roll the windows down (don’t you just love to keep using terms like that long past their viability, just because you can?), crank up the music, and enjoy the scenery. Costs you nothing but gas money.

Family is best. If you want to be around people, why not let it be your people? Getting to be around my daughters and their families as adults is a wonderful thing. 

Grandchildren are some of the best people to be around-ever. If you’re a grandparent, I don’t need to say more. If you’re not, I hope you will be someday.

Watching movies on the iPad with your granddaughter makes all your problems go away for a while. 

Cupcakes are meant to be shared. Especially the gourmet ones, and especially especially the chocolate peanut butter cream ones. OMG.

Chili is comfort food, even in the summer. Add a good beer, and it’s like whoa. 

Candyland, the game, can teach you more about dealing with life’s frustrations than any other experience I’ve had lately. I mean, how many times can you get thrown back to start again without losing your freakin’ mind?

Having your grandson smile and yell, “Chase me!” makes you feel like a little kid again. 

A hug from your granddaughter is one of the best things in the whole world. 


Yeah, it only takes a day to get back to what really matters. 


It’s a Family Affair


Is there a place for family members in the emergency department?


“Go down the hall, take a right, go through those double doors, behind the vending machine, against the far wall. There’s a double row of hard plastic blue seats where you can sit. Coffee machine down the hall from there. Gift shop on the first floor. We’ll call you when you can see Aunt Mary.”

Of course. We’ve all been there, done that. I’ve spent some time in those egg-shaped butt-numbing receptacles, as have you. That’s not exactly what I’m talking about, though. 

How do families fit in when mental health patients come to the ED seeking help for the suicidal thoughts, the voices, the depression that plague them?

First of all, right out of the gate, family can be invaluable in providing information that the mental health patient cannot or will not give up themselves. 

Some patients are simply too distraught, too disorganized and too psychotic to give any meaningful narrative of how and why they showed up. They are too preoccupied with seeing dead people to speak with live people. They are too deeply focused on themselves and their pain to turn their focus outward on the doctor who is asking what seems like an endless stream of silly questions. 

I can’t make a meaningful diagnosis or recommend anything helpful to an ED attending physician if I have incomplete information. This is why my consult procedure more often than not involves making at least one phone call after I finish the patient interview. A spouse can give me insight into this new-onset psychosis in a seventy year old. Mother knows best when separating acting out from mental disturbance in a six year old. A father has a different perspective on a teenager’s angst than a mother does. 

Families can be calming in times of crisis. 

The ED is a scary place, full of hustle and bustle and lights and portable x-ray machines and lab techs and white-coated scary people. Having one’s clothes and valuables taken away, given air-conditioned scrubs to don, and being placed on a gurney and told to stay there and not move can be very uncomfortable and downright upsetting to a person who is already panicking and contemplating suicide. 

A family member at the bedside, when allowed and appropriate, can be better than Q 4 hour injections of Haldol and Ativan any day. A kind word from mom, a firm hand from dad, or confirmation from a spouse that everything will be okay are balms for the raw nerves and grating irritation that is the emergency department. 

Now, you know as well as I do that this is not always the case. Supportive, loving families are wonderful and helpful in the ED, but there are other times that having family members in the vicinity of the mental health patient is nothing but trouble. Sometimes, it can be a disaster. 

Take for example the nine year old who presents with abdominal pain. Workup is negative. There is nothing “wrong” physically with the child, but the ED doc, rightly so, feels one of those gut checks that tells her to go further. The child is anxious, fearful, more so than would be expected in a normal ED encounter for belly pain. She is anxious, scans the room, cowers and shrinks away when touched. She has a couple of bruises, incidental findings on an otherwise completely normal physical examination. 

The doc calls for a mental health evaluation and a social work consult. During this process, the child’s father, nowhere to be found on initial presentation, shows up at the triage desk demanding to see little Suzy. He is big, scary, belligerent and smells strongly of alcohol. He demands that she be released and says that he is taking her home. There’s nothing wrong with her, he insists, a little too forcefully. 

You know where this is headed. Social services, psychiatry and child advocacy get involved as afternoon turns to evening to night and shift change in the ED comes and goes. This little child, who came in complaining  of belly pain, has a pain in her heart and an injury to her soul that her abusive father does not want made public in this place of healing. While a sanctuary to the abused little girl, the ED points an accusing finger squarely at the man who is the abuser. He knows, even in his intoxicated state, what it will mean if this history sees the light of day. So does the ED staff, who are charged with keeping the child safe.

I have seen other family members abuse the system of mental health evaluation by taking out what are nothing more than false probate court orders to have a patient picked up and brought to the ED for certification for admission to a psychiatric hospital, even when they clearly don’t need it. This might be because of a deep-seated family feud over money or land. It might be a controlling husband looking to have his wife “put away” in a mental institution (something that thankfully doesn’t happen today as it did years ago). This abuse of power by one family member over another, whether or not they have a true mental illness that needs treatment or not, can be frightening to the patient and eye-opening to the hospital staff, who are not accustomed to being pawns in this kind of game.

As a second-year trainee many years ago, I had a supervisor in the outpatient clinic who was a child analyst. Dr. Finch told me something one day that has stuck with me for almost thirty years. 

“Dr. Smith,” he told me in his gruff but smooth bass voice, “you cannot, you will not see this child for therapy unless the family agrees to be here, to be active, and to be involved in his treatment. Period.” 

That lesson from my old clinic supervisor is just as valid for me today as I see ED patients as it was when I was learning to do play therapy with emotionally disturbed children. 

I can talk to families and glean valuable information, good and bad, positive and negative, and do a better job of helping the suffering soul in front of me.

Or, I can ignore input from family members, tuning out the very people who know my patient and her struggles the most intimately. 

I do the former because it is good practice and is best for my patient.

I do the latter at my peril.