Old Men Throwing a Football…

 

Three days ago – I drove up to my hometown on Lake Superior to visit relatives and some friends that I have had since childhood.  From about 1963 to 1973 we played football primarily but also several other sports in and around the only park we had as kids.  For a few months in the winter, it was a skating rink.  The rest of the time it was an abandoned field.  For about half of those years, the field was next to a ravine with a small swamp at the bottom of it.  Eventually the ravine was filled in and it was an even rougher field to play one.  We stuck to the rink surface, an abandoned lot across the street and in the wintertime the streets lined by snowbanks.  Of course, in the fall and winter we typically played in the dark after school.

And we played every night – in the rain, snow, and subzero weather.  There was no formal start time. Sometimes I would hear a pebble bouncing off my bedroom window and look out and the boys were all there waiting.  Other times I would step out into the alley and two blocks away see one of my friends waving his arms in a crossing motion over his head.  I would reply with the same motion, and we would head to the field. People would filter in when they saw us there warming up.  Quitting time, was highly dependent on when the neighborhood store closed (usually 8:30 PM).  The winner was often determined by that quitting time: “Whoever gets to this score or 8:15 PM”.  Our post game ritual was consuming 16 oz RC Colas at the store, and we couldn’t miss it.  

Most of these games were 2 on 2 or 2 on 3 passing games.  As a result we could all throw well and learned to catch a football very well. What was remembered three days ago was learning how to catch a ball that disappeared above the streetlights in the extreme dark cold of winter when it suddenly reappeared under the lights.  We would say “it came out of nowhere” – but we would catch it. On this day we did not do any kicking or punting, but I also remembered the guy in our group who taught himself to punt a perfect spiral.  It was amazing to see and that disappeared above the streetlights for a very long time before it came into view.

Today we were focused on short passes of 10-30 yards and throwing flat minimal arc spirals. I still recall my high school coach showing us how to throw a spiral with the nose of the ball slightly elevated for more distance and that was what I was going for.  I wondered if we were going to throw for distance like we used to do but that never happened.  The focus was on these short passes and catching the ball in the hands.  The fall detection on my watch was set off by catching a few of these passes. These passes still had a little heat on them. One of my friends talked about having "$1,000 hands" based on what he caught at work and telling the story of how he developed that ability. 

Only a couple of us played organized sports.  I wrote about that in another post. But the caliber of play was high.  Playing a sport every day for 10 years brings with it a high degree of athleticism both in terms of conditioning and coordination.  And it seems hard to believe these days but the only diversions available to us was very mediocre black and white television transmitted through the air and reading. Technical problems were common with the TV and to see a show you had to be there. It seems hard to believe now - but there was no on-demand viewing or recording.  Reading was limited by what you could buy or borrow from the library. At the same store where we drank the RC Colas – a bookmobile showed up every Saturday.  I remember borrowing and reading When Worlds Collide - a novel written in 1933 - and being fascinated by it.  Toward the end of my football period I worked for the library and mailed books out to other bookmobile locations.

That lack of diversions – technical and otherwise may have kept us focused on our game.  Several people commented to me that nobody ever plays in that field anymore.  On some days we had 10 or 20 additional players.  But these days nobody ever shows up and plays every day.  The city baseball and softball leagues have also been decimated far beyond what could be accounted for by a population decrease. It seems that in small town America not many people are playing sports anymore.

As we were throwing the ball around. One of my friends reminded me of a time when I threw him a pass and he dropped the ball.  I told him to take his gloves off so he could catch it the next time and it was 17 degrees below zero at the time. I am certainly not the same guy I was back then – you become a better person with age.  I asked him what he made of that today and he summed it up: “That’s just the way it was back then.”  There were definite periods where we were unnecessarily rough and angry. But I don’t recall any out and out fights.  The roughness of the game when you are a kid is a source of pride.  We were all from the East End and we had a shared "wrong side of the tracks" blue collar mentality. To this day – one of my friends in the photo gives West Enders a rough time.  He told me that he recently asked one of them: “Did you even play outside when you were kids?”  Trash talking is not a new invention.

The shared experience is something I never thought about at the time. I heard a recent piece on This American Life about the importance of camping to some people and how there were campers and non-campers and the non-campers would never understand the emotional importance of camping.  The same thing was true of our football games.  It gave us all meaning at a time in our lives where there wasn’t much. It gave us a chance for intense emotional expression and eventually being able to control that expression.  It helped us through some pretty bad times. I still remember hearing the pebble bounce off my window and telling the guys: “I can’t play today – my Dad died last night.”  I remember the expression on their faces when they heard that news. I remember it as clearly as if it happened yesterday.  All of the homilies that I heard at various sports banquets about the importance of teamwork - rings hollow. It is more important just to be there and share the experience.  Nobody ever tells you that when you are a kid beating yourself up for losing a game. It really doesn't matter who wins or loses.  It doesn't matter how you play either. It just matters that you show up and keep showing up.

This day - it was happier times.  We had all just finished working - as in retired.  School, work, and in some cases military service were all necessary distractions from our game. One of my friends has just completed 41 years of work without missing a day and for some of those days he was working 7 days a week. We had all dodged severe medical problems of one form or another.  We had all survived COVID so far and had the vaccinations. It was a good day to be alive on our childhood playing field.   

We may have lost a step or two but old men can still throw and throw quite well.  But there were no diving catches.

 

George Dawson, MD, DFAPA

Closing In On Retirement

A happy retirement dream:  I am walking along the edge of a canyon that I have walked many times before.  In physical reality this canyon does not exist.  There is a large herd of buffalo stampeding through the canyon and making a lot of noise.  On the opposing ridge there are 5 or 6 wolves trailing the herd.  I see a family to my right and step into their yard to warn them about the wolves.  The father reassures me that everything is under control and there is nothing to worry about.  He has three small children playing behind him.  He introduces me to a friend who I recognize from college and who has not aged well.  I am sure that I remember his name but don't say it just in case I am mistaken.  I realize that I am late and need to take a test, but it is a long way back to town.  I think about asking my brother to pick me up and take me there - but I am already 15 minutes late.....


Closing in on retirement is not what I expected.  I can remember sitting in 8th grade English class and wondering what it would be like to live to the old age of 40.  Now that I am well past that and surprisingly healthy what is the best way to transition?  Many people who retire these days are in a similar position. Chronic illnesses are better managed and most people anticipate a phase of active retirement, before moving on to less activity.  One of the critical questions is how to make that transition as a professional.  Besides feeling fairly healthy and fit, I also feel like I am at the top of my game as a psychiatrist.  At a time when most psychiatrists are over the age of 55, should I try for a more gradual transition from patient care and teaching?  Or should I just walk away?  A lot of people seem to think that they have the answer.  They have observed my work habits that included too many hours and too few compromises and have concluded "You will never retire!"  The psychiatric colleague who I have known the longest has concluded that about herself.  She thinks that she will end up being  carted away some day from the job that she has worked for decades.  I know I could not do that because I walked away from that setting 6 years ago - burned out and fully intending to call it quits.  When you work a job for 22 years, it is easy to lose sight of the fact that there are many more reasonable jobs out there.  Some of us just hunker down in longevity mode and don't see it until a crisis hits.

I put some preliminary communications out there.  I concluded a couple of years ago that the most rewarding and efficient use of my time would be teaching - preferably psychiatric residents.  Residency programs are much different today than when I was a resident.  Business management has basically corrupted them.  Today it is virtually impossible to be teaching clinical faculty anywhere and not have the same productivity expectations as psychiatrists in private practice.  In other words there is the expectation that you can see large numbers of patients and continue be an innovative and creative teacher.  Your salary is "justified" by the amount of billing that is generated.  That has never really worked for me.  I just attached one of my old storage devices to my current network this afternoon.  Sitting there on that drive was a series of 10 PowerPoints on psychopharmacology from 2008.  They were all 2 hour lectures and I came up with them from scratch after meeting with the residency director of a program I was affiliated with.  The residents that year had requested that I teach the psychopharmacology lectures.  I had peripheral involvement with the program until that point - largely due to the administrative restrictions.  She thought it was really important for me to do it and I agreed that I would, but it was a significant time penalty for me.  There was no productivity credit for preparing and delivering the lectures and no additional reimbursement.  It was all done on my own time after taking care of all of the clinical work, billing and documentation.  All done late at night and on the weekends - free gratis.  Despite that, I was confident that I did a good job and the residents appreciated the work.

The point I am at in psychiatry, I am confident that I can teach nearly anything and do a good job of it.  I am not confident at all that I want to transition into retirement seeing 75 - 100 very ill polypharmacy patients and teaching residents how to tweak that polypharmacy.  You really don't need an experienced and knowledgeable psychiatrist to do that.  I know that this is not really psychiatry, but somebody's business model of how to generate revenue and not consider all of the information that merits consideration.  I can't sit by and look at people who have never had a manic episode being misdiagnosed with bipolar disorder, or the endless people with chronic stress in their lives expecting that medication will somehow change that, or the high functioning person with "ADHD" who really wants a prescription for a stimulant so they are not at a competitive disadvantage in college or professional school.  Beyond that - I can't bite my tongue and listen to how they are seeing a therapist who is a "sounding board" and endlessly rehashing either their childhood or what happened last week and how that is supposed to be productive psychotherapy.  I can tell them what they need to do to get better and if necessary do the therapy myself.  And then there are the people with non-epileptic seizures, psychogenic mutism, chronic Lyme's disease, chronic pain, chronic daily headaches, reflex sympathetic dystrophy/complex regional pain syndrome and endless somatic permutations that need psychiatric care but walk in saying they don't: "I am here because my doctor thinks this is all in my head".  There are the people with delirium, dementia, movement disorders, and abnormal MRI scans.  I can see all of those people until my dying day, but it does not make an impact unless what I know can be amplified through current residents.

Before business managers ran medicine there was the kind of room I need at the current stage of life.  Senior staff in those days were the people the house staff and attendings consulted.  The absolute best teaching team that I ever worked on was a Nephrology team at Froedtert Hospital in Milwaukee.  It was my last rotation in medical school.  I recall finishing rounds at 10:30PM on the night before graduation and walking across the county hospital grounds to my apartment like it was yesterday.  That team was staffed by two senior Nephrologists in their late 60s.  The remaining team members included a Nephrology Fellow, two internal medicine residents, an intern and me.  There was no myth that these senior staff somehow knew less or were less relevant.  It was quite the opposite.  We rounded twice a day until all of the consults and hospitalized patients were covered and the senior staff were the primary discussants.  That myth is alive and well today, largely as a means to disenfranchise the tested clinical methods in medicine and make future generations of physicians dependent on organizations run by business managers rather than colleagues.  Organizations that have promoted the idea that tests and arbitrary and unvalidated performance metrics are more important than spending enough time with patients and enough time discussing clinical scenarios with a broad range of physicians including the most experienced colleagues.  It is no coincidence that the myth thrives in non-academic hospital environments staffed by generalists working impossible shifts.  Knowledge and academics seems at its leanest point in the past 50 years.  

At this point I am resigned to do what I can.  I have offered my services but there are a significant number of reasons why none of that may come to pass.  The hardest thing about retirement for me comes down to three issues.  First, there are not nearly enough people to take my place.  Psychiatry is possibly the best example of how a field can be decimated by political and business influences even in the midst an obvious shortage of services.  Throughout my entire career there has been a shortage of psychiatrists and nobody has done a thing about it.  Second, the very inefficient transfer of knowledge.  I was personally taken out of the teaching loop for a long time by business practices that made it impossible for me to teach.  What I know is not written down in texts and if I don't pass it along - it dies with me.  That is counter to the evolution of how knowledge is passed from one generation to the next.  Only American politics and business practices can stop evolution in its tracks.  Finally, being an active part of a person's treatment and recovery from mental illness is important to me.  In every case that involves an internal process on the part of the psychiatrist.  In retrospect, I have attributed it to having great teachers and colleagues, a great memory, a particular personality characteristic, scholarship, or just being compulsive.

Despite what the measurement based people say, the validation of that process is totally subjective.  At the end of the day or years/decades later - it is a person saying that you made a difference in their life and knowing that happened because you gave them the best medical advice that you could at the time.  For me personally, it has also meant seeing people who have the most severe problems.

I won't miss any of the productivity based work any more than if I walked off any assembly line.




George Dawson, MD,  DFAPA




Addendum: 

I realized in the last couple of years that this blog factors into the transition as well.  People have always asked me how I know something when I quote research or suggest a particular treatment or method of analysis.  I think that part of what I am doing here on these pages is illustrating how I know something.  Hopefully fellow psychiatrists, but especially medical students and residents will find it useful.


Attribution:

The graphic at the top of this post was downloaded from Shutterstock on July 4, 2016.











               

A Poem About Grandiosity

I came across this poem as part of the Breaking Bad series on AMC.  It applies to their plot line, but it is also a testament to grandiosity as a reaction to the existential concerns about death and meaningfulness.  As I drove in to work this morning I thought about the fact that the physical monuments to people, especially the ones that are personally erected in one's own honor rarely stand the test of time.  There is imagery at several levels in the poem from the archaeological to the psychological and the impact that culture has on that psychology.

Thoughts, ideas, and deeds are the best way to be remembered.  And the people who are remembered in this way would not be interested in monuments in their honor.  A good example is the focus on Shelley's poem nearly 200 years after it was originally published.

Ashes to ashes........


Ozymandias

by Percy Bysshe Shelley

I met a traveller from an antique land
Who said: Two vast and trunkless legs of stone
Stand in the desert. Near them, on the sand,
Half sunk, a shattered visage lies, whose frown,
And wrinkled lip, and sneer of cold command,
Tell that its sculptor well those passions read
Which yet survive, stamped on these lifeless things,
The hand that mocked them and the heart that fed:
And on the pedestal these words appear:
"My name is Ozymandias, king of kings:
Look on my works, ye Mighty, and despair!"
Nothing beside remains. Round the decay
Of that colossal wreck, boundless and bare
The lone and level sands stretch far away.



Should existential themes be important to a psychiatrist?  I answered that question for myself over 20 years ago when I picked up a copy of Yalom's Existential Psychotherapy.  At that time I was working in a pediatric setting and talking with residents and staff who actually seemed interested in talking with a prospective psychiatrist.  Two of the physicians in the group had the rare experience of seeing motorcycle accidents on the freeway and being first responders and saving the crash victims.  We discussed Yalom's conceptualization of death anxiety and how it might apply and it made sense to both of them.  Since then I have found it much easier to talk about these themes when they occur rather than trying to elicit specific symptoms since they are very important themes associated with anxiety and depression.  The meaning of those symptoms is still important to most people whether that happens from a psychodynamic, cognitive behavioral or existential perspective.

And yes - I have recognized the grandiose adaptation to death anxiety and meaningfulness, many times.


George Dawson, MD, DFAPA

Bryan Cranston's dramatic read of Ozymandias.  The graphics may not mean much unless you have watched the television series.

Jim Amos, MD.  Did Ozymandias Weep?  The Practical Psychosomaticist Blog.  Jim Amos has been thinking about this poem a lot longer than me.  Read his associations to it at this link.