Demograffiti

Way back in the day, when I was going to medical school and my beloved Mac computer was but a gleam in its creator’s eye, we were taught to think about and to present medical cases in a very circumscribed and conventional way. After reviewing all of the pertinent medical records (which were all written down on paper and required transport from nursing station to workroom on small but sturdy wheeled carts, of course), we proceeded to the patient’s room (if hospitalized) or to the clinic exam room if outpatient and proceeded to take a history. Yes, my friends, we actually sat down, SAT DOWN, I tell you, and spent minutes if not an hour or two with the sick person at hand and actually talked to them, a la William Osler, giving them ample opportunity to tell us what was wrong with them, and then to gregariously yet sanctimoniously let them in on the secret, as if we had actually figured it out ourselves. (Most of the time, it is quite true, patients have a pretty good idea what is wrong with them and will tell us of we will only take the time to listen) Yes, the whole review and history taking process could be as long…as that last sentence was.

Now, after that was done, we of course did the requisite physical examination, which might include judicious use of a reflex hammer to the knee and a sticky wheel to test for sensation and a tongue blade applied at just the right angle to view whatever was lurking down the gullet. We came. We looked. We saw. We diagnosed.

Then we reported. To the chart. To our attending. To the nurses. To our less bright counterparts who were slow on the uptake and couldn’t tell the difference between a whiteout from pneumonia on chest X-ray and Aspen, Colorado in a February snowstorm. Our discourse almost always began as follows.

“This forty-two-year-old alcoholic white male presented to the emergency room with acute chest
pain of two hours duration accompanied by nausea, diaphoresis and pain radiating down his left arm.”

“This sixteen-year-old sexually active white female presents with new onset abdominal and pelvic pain and a moderate fever, with elevated white count and a left shift.”

“This fifty-year-old obese black female presents with abdominal pain, anorexia, listlessness and depression over the past three weeks.”

“This eighty-five-year-old male, a former aerospace engineer, presents with irritability, forgetfulness, wandering behavior, and inability to find words or name routine everyday objects.”

Now it is funny to me that in this day and age, when Google knows our whereabouts and Amazon can deliver things to us in two hours before we even knew we needed to order them, some folks take great exception to the routine practice of calling attention to one’s age, sex, race, color, creed, sexual proclivities or activity, body habitus, or other defining personal parameters and characteristics. Somehow, this is seen as invasion of a person’s privacy or is knowing too much about a person’s private information.

Really.

Well, when I was taught medicine, it was very important for me to know your sex, your age, whether or not you were HAVING sex, your weight, your alcohol and drug use habits (including the use of needles), your eating habits, your stress level, what kind of job you did, how much time off you took, your complete family history, and so forth. I needed to know those things, because in order to differentiate heartburn from heart attack, ectopic pregnancy from eructation, psychosis from neurosis and flatulence from petulance, I needed all the information I could gather, and then some. I might even have to speak with your spouse (with your permission, of course) or (God forbid) your mother to find out the things that you conveniently left out and did not want me to know.

Yes, today we who work in the healthcare industry are in the business of safeguarding privacy, and I am all for that. HIPAA (a 1996 Federal law called the Health Insurance Portability and Accountability Act that restricts access to your private health information) is king. However, I am not the enemy. Your other doctors are not the enemy. Your physician assistants, nurse practitioners, counselors, psychologists, nurses, phlebotomists, and lab techs are not the enemy. We are not Facebook. We are not Google. We are not Alexa. Okay, I think you get the point. We need to know these things because we know that dementia rarely strikes eight-year-old girls and sarcoidosis might be a little more common in a middle aged African American woman. An overweight man with chest pain who tries to keep his case of beer a day habit from me when I admit him to the hospital for depression will make treatment of his ensuing alcohol withdrawal that much more difficult as we work him up for his third heart attack.

In order to give you the excellent care that you deserve, we need to know everything that pertains to your health, including habits, mental health issues, and pattern of substance use. Please help us. Because you know, some of your demographics are written all over your history and physical and are easy for me to see. Other bits of vital information are hidden in your head. Unless you let them out, that is where they shall stay.

I’m a psychiatrist, but I’m not a mind reader.

Balance

There have been a lot of reasons to think about the past in the last few weeks and months. We have lost music legends, astronauts, family members, friends, and some might argue that we as a nation have just lost our innocence and are in for the ride of our lives beginning in January 2017. At any rate, I think that all of us have had to deal with some kind of loss recently, and that tends to make us look back. Sometimes fondly, sometimes sorrowfully, sometimes with malice in our hearts and venom on our tongues.

But look back we do. We can’t help it. We are drawn to history, the fascination of it, the mystery of it, the supposed good old days that we are always wishing for but can never seem to find.

I love history. I love reading biographies of great men and women and trying to figure out how they did it, how they kept it all together, how they made their marks on this world. I love reading about grand armies and governments and founding fathers and technology breakthroughs and all of it. I love to look back.

Funny thing is, the older I get, the more I see that my looking back is taking away time from my looking forward to what is left to me. Time. Experiences. People. Loves. Challenges.

There has to be a balance. How do we find out just what that balance is? How do we differentiate between studying,  learning from and enjoying the stories of the past from looking to, living for, and planning for the future?

I am starting to build a framework for this level of analysis for myself, and I thought I would share it with you. It’s a work in progress, and it may not fit your own personal framework for looking at the world at all. That’s okay. If it spurs contemplation, then I’ve done my job for this evening and you may take it from there.

I am looking at the progression from birth to death, and the associated looking back versus looking ahead, as a series of dichotomies.

Sadness versus Joy

We have all lost friends and family members, and we have endured changing relationships, shifting alliances, and the loss of stepping-stones, milestones and cultural icons. When these losses occur, we are sad. Why? Because we have lost the familiar, the bedrock of our lives that has always anchored us. We have lost our foundation, and that feeling that we are standing on shifting sand and trying to maintain our balance is not a good one. For me personally, and for many of you I wager, we also start to feel that we are moving ever more rapidly along that continuum of generations, that we are becoming the older generation much faster than we expected to. We get the feeling that, by default, barring miracles, we are next. We have lost our youth, no matter how valiantly we try to hold onto it.

Is there joy in this state? Yes! Knowledge and wisdom (they are not the same) increase as we age. Generativity becomes almost second nature. We begin to realize that the memory of these people, places and experiences will never be taken away from us (notwithstanding the development of dementias and the like), no matter how many losses stack one atop the other over the years. We begin to realize that we are all a very small part of a very large rushing river of time, and how awesome it is to have even existed and been here at all. We begin to develop a sense of unity with something much larger, and much more intricate, than ourselves.

Grief versus Hope

We have all experienced grief. We know what it feels like to lose a pet, a teenaged beau, a friend, a parent, a spouse, a sibling. We begin, as we age, not to just deal with the loss of others, but to deal with the loss of ourselves. Our physical stamina lessens, our sexuality, dexterity, eyesight, hearing, all begin to change and often not for the better. We lose friends, jobs, responsibilities. We are acutely aware that with the passing of each dear friend or loved one, that we could possibly be next. We come to understand in a very real way that we will all die. None of us escapes.

Hope in all this? Of course! Hope that we learn by losing that we need to fully and deeply experience our ongoing relationships, job duties, and activities each day to the maximum degree possible, given time and circumstance and motivation. There is hope in that with each passing there is new life, new birth and a renewal that we may make a part of ourselves. We are making impressions on others all the time, and we have more influence over how the world around us is experienced by others that we often give ourselves credit for. In a very real sense, the way we live on in the future is directly proportional to how much we give in the present, how invested we are in our own lives.

Acceptance versus Anticipation

Do we simply accept that we get slower, more overweight, mentally dulled, boring or incapable of learning just because we are closer to the death part of the graph than the birth part? Of course not. Do we accept that deaths and losses define us, put us in a perpetual state of sadness from which we can never recover? Do we get lulled into thinking that the last half of life is not supposed to be as fun, stimulating or challenging as the first? Do we look back at the past and mutter to ourselves that this is the best it is ever going to be?

If so we can learn to better anticipate what is coming. We can train ourselves to seek out new ways of doing the same old things, to learn new skills and to look for trends that will likely affect us as we age. We cannot predict the future, but we will have a pretty good idea based  on those lessons learned from the past what is likely to trend as time goes on, and rise to meet it instead of having it crash over us like a wave.

Retention versus Sharing

There is a tendency, is there not, to circle the wagons, load the guns and pray when things look bleak around us. When we see that things are getting tight, that there is not enough, then we gather our stuff to ourselves (be it money, time, expertise, ideas, or energy) and retain as much of it as we can for as long as we can. We feel satisfied that if we can just hang on to everything that we will be okay. We look to the past, to the things that we have always had and the way things have always been. We close our eyes tightly and hope that when we open them that nothing will have changed at all. This is folly.

Paradoxically, as we age and mature, we find that this is the wrong approach all together. Gathering everyone and everything we love to ourselves and holding on as tight as we can guarantees control in the short-term, but in the long-term it is suffocating and stifling and leads to an artificial sense of safety. Sharing our time, talents, expertise, money and our own physical presence is so much more satisfying. Giving to others, hearing of the experiences of others away from us is more enlightening and instructive to us than holding onto old patterns and ways.

Control versus Freedom

Control. I often feel that I have it, don’t you? If things make it onto my calendar or my to do list, then they exist, they are real, and I can manipulate them. They will happen as I want them to happen, when I want them to happen. Today, next week, next month, next year. If I choose a path to take or a project to finish, it will be so. I run my life. So it is that I get up every day, or I used to, and tell myself that. It only took one course in college that I almost flunked (after making all A’s my entire life up to that point), one out-of-control clinic day that shot my perfect schedule all to hell and back, one sudden death of someone I thought would always be around, to show me, brutally convince me, that I have very little actual control over my life. I control the store front, the façade, the window dressing. My actual life, the things that happen around me and to me and inside me, are wild and untamable and uncontrollable by me or anyone else.

How wonderful then, how absolutely marvelous, to experience the freedom that comes with letting go the need to control our own lives. I’m talking about the big picture here. I know that I do still have some control over my choice of life partner, what kind of work I will do and when I will do it. But control over life in the grand sense, in the overall scheme of things? None of us have that. We cannot repeat or redo past events, no matter how we’d like to. We cannot fully atone for past mistakes. (Now, before you get started, please understand that these are philosophical ramblings, not religiously based ideas that need fleshing out. That is the job of my friends who are ministers or who are in seminary) We certainly cannot control events that have already happened. If we cannot even control these events from the past that we already know about, how can we delude ourselves into thinking that we have any modicum of control over future happenings that we have no inkling of yet?

I can plan ahead all I want, but I must stay flexible.

I can chart my own course, but I must be willing to change directions.

I can maintain a sense of personal values, religious beliefs, political positions and the like, but I must be willing and able to pivot.

The moment you give up the need and the drive to control and the artificial sense of power and influence that comes with it, that, my friends, is the moment that you are truly free.

Loss versus Accumulation

I think back on my life, and through a certain kind of filter, what do I see? A long, seemingly never-ending string of losses. My own personal trail of tears. Childhood. Innocence. My father. Teachers. Mentors. Bosses. Classmates. Relationships. Loss upon loss, rapidly escalating as I age. Loss portends diminishing returns, decreasing value, shrinking assets, and the very real sense that we are rapidly fading away to a state of irrelevance and obsolescence. The past is slipping away-or is it?

Each loss, though acutely and immensely painful at the time, adds to our overall life experience. The richness of life is increased not just by our acquisitions, not just by our successes, but by our losses and our abject failures. Our reaction to loss, our adaptation to it, the way we decide to go on in spite of it, is what makes us stronger. We accumulate memories, experiences, emotions, and bonds that inform our daily lives, sometimes imperceptibly but always actively. Our present is informed by our past. How could it not be?

We should not carry our past losses and sadness as baggage too heavy to bear, but we should wear our past lessons as a bright garment woven with the golden thread of love and experience. Only then will we be able to feel hope in the face of transition.

Frustration versus Calm

If only I had…

If only she had…

I tried over and over to…

I told you so…

I get so frustrated when…

I should have…

I would have…

I could have…

I wish…

I look back at all those times, and I know, I really know, that I did the best I could with the skills I had, the information I had at the time, the temperament that I possessed, and the logic and reasoning that I could bring to bear on each situation that frustrated me so.

I will not get do overs.

I can’t blame myself.

Today is already here and tomorrow is coming fast.

Hanging on to frustration will not make me any more ready to face tomorrow, my task at hand.

If I remain calm, I have a chance to get it right this time. I truly believe that, and you should too.

Idealization versus Deglamorization

Like many of us, I have a tendency to look back at the past and see it as an idyllic time, a perfect time, a joyous and stress-free time. “The good old days” were not always that, I’m afraid. Life was simpler, yes, we were not so materialistic, we were not plagued by the double-edged burdens of technology, and we always seemed to have enough. I do not remember arguments about gender, who was going to use which bathroom and who could or could not get married or serve in the military. Politics seemed simpler. (I know, I know, they were just as bad then as now…) There were the good people and the bad people, and as long as you stayed away from the latter you were safe. There were wars to be fought, to be sure, but they were against real, flesh and blood enemies with different uniforms and the conflicts were winnable. We expected to win, every time. It was a simple time, right?

No.

Stop.

Not true.

Remembering and learning from the past is fine, but all was far from perfect in those idyllic times of our youth. All it takes is listening to a book like Churchill’s The History of the English-Speaking Peoples to realize that we have always treated each other very badly, we have always killed each other and plundered and raped and stolen and intrigued and schemed. We are human, and we have always been human. I don’t expect that part of the great flowing river of time and history to change that much over the next few thousand years.

Looking at the present for what it is and moving forward with the intention of improving it is admirable. Stripping away the glitz and the glitter of fond memories may not be the most comforting thing to do, but it is the way to lean into tomorrow with an attitude that will get you through the day.

Blaming versus Acceptance

One of the main things that we do in the twenty-first century to justify our anger, frustration, and angst is to blame others for our circumstances. We’re too fat, too thin, too rich, too poor, too black, too white, too liberal, too conservative. You name it, whatever it is, we can find someone to blame for it. Our sense of entitlement is so bloated these says that we think someone else is bound to be responsible for the state we find ourselves in, and we could have no direct responsibility for it ourselves, could we? Furthermore someone else must do the hard work of fixing the problem, whatever it might be. I have to say this, and I hope you know what I mean.

History is an enlightening teacher, but she does not grant absolution.

In order to balance our love for, allegiance to, and fascination with the past with our need to survive and thrive in the present world, we must accept our current state. We must make peace with our history, embrace our present, and faithfully welcome our future.

I really think that is the crux of it.

We must forgive ourselves and others.

We must own our own actions, including our mistakes.

We must take responsibility for our words, our plans and our interactions.

If we can do this in the present, taking cues and learning lessons from the past, only then can we positively and confidently face tomorrow. Getting lost in a dusty past or hiding from an unknown future will not work.

We have life to live.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Institutional Memory

Institutional memory is a collective set of facts, concepts, experiences and know-how held by a group of people. As it transcends the individual, it requires the ongoing transmission of these memories between members of this group. Elements of institutional memory may be found in corporations, professional groups, government bodies, religious groups, academic collaborations, and by extension in entire cultures.

Wikipedia


On Wednesday, I met a group of peers, friends who I work with in the South Carolina Department of Mental Health Telepsychiatry Program, in Columbia for a different kind of day. We met at the flagship mental health center for the system downtown, sitting around a conference table and chatting with the state medical director for mental health as well as an administrator friend of mine who has been with the Department for half a century. With those two people sat the Telepsychiatry director, my friend and colleague of over thirty-five years, me, and then four younger people, three of them just recently out of residency and fellowship training. 

We came together this week, in real time and face to face as opposed to meeting with each other via the video technology we’ve all gotten used to, to visit and tour physical sites, to talk about the state of affairs in our program, to hear stories about the history of these sites and programs, and to learn. To learn not only about how telepsychiatry works in South Carolina, but to learn about systems and their evolutions, about some of the original founding fathers of the state mental health system, about the old and new buildings themselves, and to get to know each other better as people. 

We came together to ride around in the already sweltering heat of a South Carolina summer, to get closer and listen to the whispers of the ghosts of the old buildings, to enjoy the air conditioned comfort of the brand new buildings, and to swap tall tales. A large part of what we did was pass along institutional memory.

As you see in the definition above, institutional memory is a collective set of facts, concepts, experiences and know how. It is something that is static but fluid at the same time, changing with the years but always building on its base. One of the key characteristics of IM is that it transcends individuals. Memories can be carried by official historians, who write things down, record things for posterity, or maintain computer files of a system’s information. It can also be carried by people like my friend Ed, who was able to drive the younger set among us on Wednesday around Columbia and describe buildings, programs, and people he had experienced personally. He was the only one of us that day who could relate personal conversations with William S. Hall himself, the first state director of mental health in SC and the man who our current child and adolescent inpatient facility is named for. 

Institutional memories may be recorded as above, but they may also be memorialized by placing plaques, planting trees, establishing scholarships or endowed academic chairs, or naming buildings or facilities. Anniversary celebrations are times when people, programs and milestones from the past may be recognized and revered. 

As we saw on our journey around the old state hospital grounds on Wednesday, beautiful buildings age and crumble. Programs change as knowledge about treatment changes through the decades. Founding fathers pass away. Even though this is true, the underpinnings, the original ideas that gave rise to those buildings and programs remain in the hearts and minds of those of us who come afterwards. It is our responsibility to pass along these institutional memories to our younger counterparts, so that the spirit of the founders never dies. 

Loss of these memories and ideals that form the bedrock of our current systems and programs,  whether it be family groups, professional groups, or governments, leads to unnecessary reinvention of core ideals, rediscovery of mission, or sometimes total reconstruction of the group. 

If you possess some of this history, knowledge, or expertise in your family, in your church, in your work group, or other peer groups, it is your obligation, no, it is your privilege, to pass this knowledge and history along to the generations following behind you. 

As Sir Isaac Newton said, “If I have seen further, it is by standing on the shoulders of giants.”

We owe a great to debt to those who have come before. To let their hard-won knowledge and struggles lie fallow in the spring fields of history is to guarantee ourselves a poor harvest in the fall.