Archive for October, 2010

The return of proprioception and recontact with friends from the 60’s

October 15, 2010

Consider the means and the ends,

The time that goes by, and the trends

    To the folk we belong

    If you’re right or you’re wrong,

 Always make time for your friends

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year, 30-mile non-compete clause ticks out, I’m taking a sabbatical and having adventures.  My close college friend, Bob, is recovering from surgery in San Diego, following the explosion of a disc in the mid back.  He still faces some possibility of paraplegia.  I took a week to visit.

 

Last night I called Al.  Bob, Al, and I lived together off-campus with five others in 1970-71 and three others in 1971-72. 

By dint of hard work and innate talent, Al holds a position of prominence at the National Institutes of Health.  He took the news about Bob’s medical condition with shock, as did I.  Currently in the Washington, D.C. area, he has a business trip planned to San Diego in about a month.

This morning I checked out of my hotel early, drove through harrowing San Diego traffic, and stayed with Bob till 1:30. 

Before I left for the airport I saw the toes of his right foot move; as of yesterday his left leg is moving well.  I grasped his right second toe, moved it a couple of times and had him tell me whether the position was up or down.  He now has position sense (proprioception), at least in the right foot.  In a few more days he might be a candidate for rehab.

While we talked, our close friend from the 70’s, whom we knew as Toni but now goes by Talia, called. She plays and teaches violin professionally now. 

She had a career on television in the ‘50’s and early ‘60’s, playing violin with Jack Benny (I realize that most people who recognize the name Jack Benny don’t read blogs; suffice it to say that Talia has been a very good musician for many years). 

Talia and I played music together during my New Haven days.  She benefited from the lessons and practice I didn’t get and would do.  Over the last forty years I’ve often quoted her observation, “There’s no substitute for doing your homework.”  Because she knew me as a saxophonist back then she could appreciate my observations about my current level of musicianship.

She can also remember that I couldn’t sing back then; most people who have known me for that long have suppressed the memory of my voice searching for the right note.

She plans to come to see Bob during his convalescence.

I filled her in on Bob’s recent medical problems and my recent career move.  We talked about what freedom means.  It doesn’t mean nothing left to lose, it means everything to live for.

Of long awaited punch lines, Rolling Stones, and fresh-faced volunteers

October 13, 2010

After thirty-five years in the priming

And planning and laughing and rhyming

    Our scene much rehearsed

    From the better to worst

The punch line comes down to the timing.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year, 30-mile non-compete clause ticks out, I’m taking a sabbatical and having adventures.  My close college friend, Bob, is recovering from surgery in San Diego, following the explosion of the disc in the mid back.  He faces the possibility of paraplegia.  I’m taking a week to visit and advocate for him (Bob insists I add  ..and be his consiglieri).

Bob and I have talked writing with each other for more than thirty-five years; he’s been my sounding board while I’ve crafted novels and stories.  When we were in our mid 20’s we dreamed up what we thought would be a great scene for a movie.  What will it be like, we thought, when our generation of rock ‘n’ rollers gets old?

Imagine the day room in a nursing home.  We, the aged (in our youth, we imagined our senescence) rock in chairs.  In one corner, opposite the door, stands an upright piano, painted an amateur gray.

A youthful female volunteer, her blond hair in a ponytail, her cheeks with a healthy peaches-and-cream complexion glow, wearing a candy-stripe uniform, steps in.  She carries sheet music and book music.  She takes three confident strides into the room, and feels the leering gaze from the dirty old men we imagined ourselves to become.  She takes three more hesitant steps, looks around, stops, panics, and runs out of the room.  The tough, mature (but younger by twenty years than us in our film) charge nurse stops her in the hall.  There follows an indistinct but passionate conversation for several seconds.  She comes back into the room hesitantly; when she turns to panic, the nurse stands in her way, arms akimbo. The volunteer, fighting tears, faces the piano, and summoning all her courage, seats herself.  She takes out a music book titled “Songs of Love and Inspiration,” with a cover featuring rays of light coming through dark clouds, over a placid sea.  She strikes a major chord for a church hymn and starts to sing.

Bob and I, in our imaginations aged to dirty old men, rock in synchrony, for three or four bars, till one pounds on the ground with his cane and demands, “Play Sympathy For the Devil.” 

We’ve described this movie scene to each other and most anyone who will listen, almost every time we’ve gotten together, for the last thirty-five years.  In the anthropology of humor, this story as inside humor helps define and distinguish us.

Fast forward from 1975 to 2010.  Bob lies, for real this time, in a sunny new hospital room in a high-tech hospital bed.  I sit beside him in a steel tube-and-nylon mesh chair, designed for comfort and washability.  A smiling, fresh-faced young Asian woman in a blue volunteer smock, enters the room carrying a guitar.  “Hi,” she says, “My name is Romy, and I’m a volunteer.  Would you like to hear a song?  Something mellow?  Something light?”

With a straight face, I say, “Play Sympathy For the Devil.” 

Romy hasn’t heard the song, has barely heard of the Rolling Stones, and doesn’t know who Mick Jagger is.  Timing is everything in humor; it’s rare that I get to put the punch line on a gag three and a half decades in the making.

Romy does a Leonard Cohen number.  She has a beautiful voice.

Cycles of hope and disappointment: life and death for the economy, function and movement for a friend, and employment in December.

October 12, 2010

 

Turning from disappoint to hope

An agency is trying to cope

    Opportunity friction

    The economy’s malediction

A depression has started down slope

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  While my one-year, 30-mile non-compete clause ticks out, I’m taking a sabbatical and having adventures.  My close college friend, Bob, is recovering from surgery in San Diego, following the explosion of the disc in the mid back.  He faces the possibility of paraplegia.  I’m taking a week to visit and advocate for him (and Bob insists I add ..and be his consiglieri).

Bob got moved from the rehab hospital to the acute medical hospital yesterday.  Corticosteroids for the spinal swelling make his blood pressure labile and his blood sugars run out of control.  He developed diarrhea, possibly because of medications, diet, or infection.  His MRI showed a possible abscess near the surgical site, he’s getting high potency, broad-spectrum antibiotics.  So much happened medically that he couldn’t benefit from therapy.  The set back was hard on him.  Still, the motion in his left leg is improving though he still lacks feeling.

We’ve talked about writing.

Win Blevins, a friend and a real writer in Wyoming, said that the people who should write are the ones who have to write.  I’m one of those.  I’ve always written, sometimes better than others.  Bob has written sporadically over the years, convincingly and cogently.  We’ve served as sounding boards for each other’s writings for decades.  Bob is making plans now for more writing in the future, and I think he’d be good at it.

I’m negotiating in the hospital here as a civilian, not as a doctor.  I get to suggest a thyroid panel here and a probiotic there, but I don’t write orders and I don’t mind.  I have to enter the hospital by the afterhours entrance near the ER and ask directions to get to the elevators; I park half a mile away and walk past the lots that require a card or a sticker to get in or ward off the tow trucks.  I get to see the health care system from the consumer’s point of view, not the doctor’s.

With Bob’s life-and-death drama playing out foremost in my attention, I’m still trying to arrange work in the background.  Locum tenens agencies (the folks who get docs who want to work short term in touch with the people who want to hire them) vary in quality, and the recruiters who work for them vary in professionalism.   I’ve accepted fifteen jobs so far, and all but three have conclusively fallen through.  I accept the uncertainty inherent in the business, but the roller-coaster ride of hope and disappointment continues.

One of the Nobel Prize Winners in Economics announced today won his honors by studying “opportunity friction” and its effect on the economy; his area of expertise covers the problem of getting willing workers to appropriate jobs.  One would think in the Information Age such difficulties would have disappeared.  (Bob here is quite emphatic I mention that we’ve started into another Great Depression).

Having missed out on an opportunity in Alaska, I’m hopeful for a place for in December in the rural Midwest.

Death, unconditional love, and a really bad case of enlightenment

October 10, 2010

You know, it’s not that I pried,

 But Bob said, “Last night I died,

    It wasn’t a frightenment

    But a bad case of enlightenment

I was willing to take it in stride.”

My friend Bob almost died last night

Bob controlled his diabetes well for the last ten years, before a disc in his mid back exploded and necessitated surgery about ten days ago.  He faces a very real possibility of paraplegia. Standard of care in these cases includes steroids.  I’ve been in California for the last few days visiting him in the rehab hospital.

Doctors throw the term steroids around more carelessly than two-year-olds throw rice at a Chinese restaurant.  The word refers to any molecule built on a cholesterol skeleton, including testosterone (the main male hormone) and estrogen (the main female hormone).  In this case, “steroids” mean things like cortisol or cortisone or prednisone, properly called corticosteroids.  They’re widely used in dermatology, asthma, emphysema, and cancer chemotherapy.

They are the body’s main stress hormone; we use cortisol levels to measure the stress of an episode.

My personal experience with the class of drugs goes back twenty years, when my rheumatologist decided to treat my flaring ankylosing spondylitis (spinal arthritis related to rheumatoid arthritis) with prednisone.  My back felt great, I felt even better: creative, energetic, and invulnerable.  I talked so fast that my wife and daughters had to tell me to slow down.  I slept four hours a night and awakened rested.  I wrote another novel.  But steroids exact a price, I started to get irritable, I could hear repetition in my speech, and I lost so much strength in my shoulders I couldn’t string my bow.  My rheumatologist tapered the dose down and started methotrexate (a very nasty drug); I’ve not been on prednisone since—I found it too seductive.  In retrospect, it put me into hypomania (a state near mania, part of bipolar disorder), a known side effect of the drug. 

Steroids like prednisone powerfully inhibit the body’s inflammatory response.  Post-surgical swelling in the area of the spine can put enough pressure on the spinal cord to strangle it; thus the corticosteroid therapy.  Predictably, they wreak havoc with blood sugars, but not in a linear fashion, and physicians play a balancing act trying to avoid the adverse consequences of sugars too high or too low. 

Bob has been on Decadron or dexamethasone; compared to prednisone it’s a steroid, well, on steroids.  The doctors on the case have been appropriately prescribing insulin, but corticosteroids bring chaos to diabetes.  His sugar crashed last night.  His blood pressure, blood sugar, and oxygenation fell below levels that sustain life.

He doesn’t remember seeing white light or darkness, and he calls the experience “a really bad case of enlightenment.”  He no longer fears the pain of death.  He loves his freedom.

But he’s alive today and better than he was yesterday.  He has minimal movement in the left leg and a trace on the right.  Between the steroids, motion in his legs, and his new-found freedom, his spirits are soaring, his thoughts are racing, and he relishes the feeling of unconditional love he has for the people around him.

Stood up for the eleventh time

October 10, 2010

On an exciting adventure I’ll go

Out where the wild winds blow

    Sending by fax

    Sheets piled in stacks

Until the recruiter says “No.”

Teachers get substitutes, administrative assistants get temps, and doctors get locum tenens.  During this year I’m doing some locum tenens work. 

I am getting better and better at filling out applications for locum tenens agencies.

The process goes like this:  I contact a recruiter and tell them I’m interested; the call goes well and the recruiter sounds enthusiastic.  I talk about the year I’m taking to Do Other Things, I explain about the one year non-compete clause.  Pretty soon they ask me how much I want to get, and I say, “It’s not about the money anymore,” and I explain that I’m looking for adventure.  Then we talk about my availability.

Shortly afterwards my email has a form for me to fill out, anywhere from four to twelve pages. 

Over the following couple of days I procrastinate about the form, and finally fill it out.

I get together a copy of my Continuing Medical Education certificates, all my licenses (I have 8), my med school diploma, my internship/residency certificate, my driver’s license, an explanation of the lawsuit I was dismissed from, a list of my traffic tickets, and copies of my ACLS and BLS cards.

Then I babysit my new fax machine while the stack of sheets goes over copper telephone wires.

I scanned those documents into my computer but, for some reason, the files won’t send.  If this process keeps up much longer I’m going to find out why.

The recruiter calls me back a few hours or days later and pitches an assignment, asking if I’m interested.  Most of the time I say yes, and the recruiter says he or she will present me to the Client.

Recently a position came open to do house calls to hotel rooms in a very expensive, glamorous ski resort.  I stopped the recruiter in mid pitch.  “That’s not me,” I said.

I’ve sent my materials out to eight agencies so far; the first time the process consumed me for the better part of a month.  Now it takes about two hours.  I’ve said yes to fourteen placements so far, of which three have panned out.

Even if I’ve made my mind up not to get angry, one can’t get stood up eleven times without some negative feelings.  

Still, life is all about tradeoffs, and in this case it’s time here versus time elsewhere; it’s the experience of staying home versus the experience of going new places and doing new things.  It’s not about the money.

Drama and irony hit too close to home

October 10, 2010

The experienced nurse we call Rickie,

Faced a transport every so tricky.

     She said with a sigh,

     “You need MRI,

“Shit happens, and sometimes it’s sticky.”

Drama and irony hit close to home when I got a call about one of my college friends.

Bob and I met in the fall of 1969 at Yale, fresh from trips to Antarctica and Barrow, he’d worked with the Naval Arctic Research Lab.  We lived in the same house off campus in the two years before I graduated.  We’ve kept in contact since though Bob has stayed coastal and I’ve been inland.

We saw each other through the roller-coasters of college dating, and the difficult years of career takeoffs.

He  provided a shoulder to weep on during the emotional case-hardening of medical school; I attended his first wedding.  When I graduated I visited him and his wife in the east, and he sold me my first car.  He danced at my wedding, too, and I supported him through the agony of his divorce. 

In the decades when I did my continuing medical education (CME) in Pennsylvania I stopped and visited; when he worked for a year in Minneapolis he came to my house most weekends.

Our kids regard us as uncles.

Five years ago, his mother fell and broke her hip.  Despite a relationship that at best can be called difficult, he moved home to care for her, and has been the main caretaker since.  We’ve talked about the difficulty of honoring your father and mother, which Bob has done while his mother aged from 85 to 90.  It has not been easy for him.

He celebrated with me when I started my sabbatical, my year of going walkabout.  I chose Barrow partly because of Bob’s stories.

Ten days ago Bob, networking with my youngest daughter on Facebook, had abrupt onset of severe lower body pain, accompanied by ascending paralysis and loss of sensation.  He received the cogent, emphatic advice:  “Close the computer.  Call 911.”

A disc had ruptured in the lower part of his mid back, putting pressure on his spinal cord.

In the poetry of illness, Bob describes the feeling of being the Atlas who didn’t shrug so the weight of the world broke his back.  Now physically unable to take care of his mother, he feels free.

Having worked so hard to get his freedom, he faces the very real possibility of paraplegia.

This year offers me the only time when I would have the flexibility to take a week to visit him during such a critical time.  Since Thursday I have spent most of my day advocating for him at Sharp Rehabilitation Hospital in San Diego, California.  We’ve been coping by writing limericks for the staff (see above).

There but for the grace of the Grand Designer go I.  I’ve seen too many times the bitter irony of the person who works hard for most of their life, only to be denied the sweetness of retirement at the end.

Every day, every moment that I don’t know bad news is a better day or moment, it’s one to be relished.  I embrace the uncertainty.

Pathology stalks the people I run into; in a restaurant, airport, sports shop, or grocery store

October 7, 2010

I suppose I could do it for free,

Diagnose whatever I see.

    Unsolicited, intrusive

    And sometimes elusive

Advice I’d give without fee. 

Thirty-two years ago, in the winter of 1978, I walked into the Chinese restaurant in Saginaw, Michigan with another medical student.  As we sat down, my classmate observed, “It’s funny, you know, as soon as you start doing clinical work, people start talking to you about their medical problems.  Whether they know you’re in med school or not.”

“Maybe,” I said, “We just got more attuned to listening for it.”

 As we munched our mini-egg roll and spooned our egg drop soup, we overheard the couple in the next booth talking about a parent’s recent surgery.  We looked at each other and we ate, two not-quite doctors, listening to public conversations about very confidential matters.  After a while I said, “Coincidence?”

My classmate shook her head.  “Karma,” she said.

I expressed my doubts, but while we stood in line at the cash register a man was talking to his friend about a recent doctor’s visit.  We could tell there was a great deal he hadn’t understood, and we two students made eye contact and, without saying anything, decided to let the moment pass.  When we layered our clothes up and stepped out into the shocking cold of a Michigan winter evening, I said, “Maybe it is Karma.”

Such events riddled my days and nights ever since.  Whether I admit I’m a doctor or not, the drama and irony of medicine’s interface with the human condition accompanies me wherever I go.

“My husband’s doing better,” I heard the woman say this afternoon, “With that new drug, I don’t know what you call it, it grows new veins and such, well his stumps have healed up real good and he’s started to grow hair there ‘n’ the doctor says that’s a sign of healing, like he’s getting his circulation back.  And it’s hard on me.  Beer ‘n’ cigarettes, beer ‘n’ cigarettes I tell him, that’s my therapy.”  I didn’t point out the irony.

“So I went to the dentist,” the man said in a public venue, “And he did x-rays and everything, well, come to find out there’s nothing wrong with my teeth, no abscess or nothin’.  And he put me on penicillin like I asked and I’ve been taking it for a week, a week, and I’m better, the pain is gone but there’s still swelling.”  I nodded.

In an airport on the slidewalk I diagnosed the person ahead of me with scoliosis, osteoporosis, and neuropathy; I wondered about deficiencies of B12, folate, vitamin D, and thyroid.

On the airplane I saw the lion-like facial features of acromegaly, the consequence of a pituitary tumor in adulthood.  I wondered how it affected the person and the family.  Again, I didn’t say anything.

I don’t give unsolicited advice to people who aren’t my patients.

It’s none of my business

Jamming with my nephew, much easier after I practiced scales

October 5, 2010

In the meld of the horn and the strings,

Ah, the joy that harmony brings!

     In past times I failed,

     Then I started scales.

Not only do I play but I sing.

I grew up in Denver, and going back for the American Academy of Family Practice Scientific Assembly brought back a lot of memories.

When the conference finished I prowled my way through the traffic to the house of my sister, Ilise, for a family gathering. 

I got to catch up with another sister, Hava,  and her family and meet my twin niece and nephew.

After supper, the two toddlers melted down (normal for age) and went home.  I got out my saxophone and jammed with my teenage nephew, Ilise’s son.

Unlike mine, his musical talent hasn’t been hampered by a lack of lessons nor a deficiency of desire to practice basic exercises.  He plays well, he’s gotten a good sense of rhythm and he learns quickly. 

I’m not sure if he composed the two numbers we played, I am positive I hadn’t heard them before.  Keeping up with contemporary music requires a lot of listening and cannot be rushed.  I have had little time to just sit and listen to music for the last forty years, it has always formed an accompaniment to doing something else, like bicycle repair or driving or cooking or sweating over a hot elliptical machine.

I put my horn together, tuned up, and said, “OK, what key are we in?”  I received a blank look and asked, “How many flats?” 

Let me explain that my soprano saxophone is in the key of B flat; a piano is in the key of C.  In order to get onto the same musical page I have to transpose everything in my head.  In the beginning, my brain rebelled against such cognitive dissonance, but since my experience in Barrow, Alaska (see my posts on musicianship from June and July) the exercise has become more like dance and less like calisthenics. 

When I had my head wrapped around what musical neighborhood I should play in, I said, “You start, I’ll follow.”

A youth in his mid-teens doesn’t expect such a statement from an uncle with a markedly grey beard, particularly if he’d never heard me play. 

Now in contemporary American Cinema the protagonist walks into musical group, picks up an unfamiliar instrument, says, “OK, C minor,” and immediately the group turns out a highly polished number, leading the audience to believe that you don’t really need to practice scales to sound wonderful.  Such was the illusion I labored under for a very long time.

But I have been playing scales, and I have improved my musicianship.

He started with a very compelling rhythmic structure under a (thankfully) simple harmonic.  With my new-found ability to play scales, I enveloped his melody with good, solid counterpoint.  Our right hemispheres melded.  We sounded great.

And we had a great time.

Bipolar, sandwiches, CME, and intellectual honesty

October 4, 2010

Genetics are mostly to blame

For bipolar chemical change

    Despite volume loss

    The amygdala’s boss

Of structures all over the brain.

To maintain licensure and certification, doctors have to complete a certain amount of Continuing Medical Education, or CME.  My state license requires 30 hours, my board certification demands 50.  Most years I stop counting at 200 hours. 

Audio Digest, a subsidiary of the California Medical Association, records CME lectures around the country and provides credentialing for the activity with a pre test and a post test; I listen to one of those lectures a week in the car.

I attended the American Academy of Family Practice Annual Scientific Assembly in Denver last week, and I finished with about 20 hours.  In other courses I’ve walked away with 54 hours in 5 days and an overloaded brain.  I decided to enjoy the lectures this year.

Arcane regulations govern what counts as CME and what doesn’t.  Yesterday, over the noon hour, I went to a lecture about neurophysiology in bipolar disease.  (We used to call bipolar disease manic-depression; people cycle from really high highs to really low lows.  Most of my best friends have been bipolar.)  No CME credits were offered.  I confess that if the lecture hadn’t come with a sandwich I probably wouldn’t have attended.  (On the other hand, CME might have been offered if there weren’t a sandwich.)

A drug company sponsored the talk and bought the food.  I expected biased information about a drug.  I depend on the data from Big Pharmaceutical being biased; certainly a company won’t tell the whole truth about their drug but the competition will fill in the gaps.  Such is the nature of capitalism.

I do not remember the name of the sponsor, and the only drug mentioned, lithium, has been off patent for decades.

The lecturer was dynamic and passionate about bipolar disease.  He does research on the problem using the functional MRI; he showed himself to be quite knowledgeable.  During the lecture, the docs kept turning to each other and saying, “I didn’t know that.”

Every attack of bipolar mania leaves structural changes in the brain; the more attacks one has, the more attacks one gets and the harder stabilization becomes.  Getting the illness to symptom control decreases structural changes but not as much as bringing the disease to remission.  The left amygdala (funny how that brain structure keeps popping up; see my post entitled “Rage, Hunger, Lust, and Sleep”) shrinks in bipolar disease, proportionate to the severity and number of attacks.  While the left amydala loses volume, the activity increases, but the right amygdala doesn’t change.  The centers which govern impulse control change in size and activity, as do a number of other structures.  Treating with lithium, still the most potent bipolar drug, reverses the volume loss changes but not completely.

I find no moral dilemma in accepting food from a pharmaceutical company, as long as I maintain a similar relationship with their competition.  The current ban on small gifts to doctors such as pens and notepads insults the intelligence and integrity of the medical community but it cuts down on the clutter and junk in my office.

A doctor living with cancer gives me tips on how to slow down; the same conclusions I’m coming to

October 1, 2010

If you feel the crush of time’s press,

Don’t make of your life a big mess.

     Don’t blame others instead

     Just start with your head

As the place to manage your stress.

The first lecturer of the morning lives with metastatic cancer, and talks about finding a life balance as a physician.

Doctor’s statistics are terrible.  Half of all physicians live in advanced stages of burnout.  Half of family physicians report inadequate sleep at least half the time. 

He asks questions about good sleep, spiritual satisfaction, children, and burnout.

Patients listen to satisfied doctors more than they listen to burnt-out doctors; doctors who find the right balance are better doctors. 

Doctors tend to work to avoid home stressors.  Docs with a spiritual life are 25% happier than docs without.  But docs tend to become organizers in their spiritual communities; the lecturer tells us to quit being in charge when we leave the office. 

Physicians with more than two children are happier than the ones with two children; children teach you efficiency in the face of loss of control; they show us unconditioniality and survival of the cutest.  They bring their adults into communities. 

Intelligent and sensitive,  doctors tend towards opinionated and judgemental.  We’re inquisitive and we’re obsessive and perfectionistic and competitive, we crave recognition. 

A five-minute break twice a day manages stress better than a week’s retreat every seven years.

Physicians have trouble delegating, and the lecturer gives tips on empowering staff.

Selection of medical students biases towards the obsessive-compulsive and medical education enhances the behavior.  Normal behavior for doctors meets the DSM IV criteria for pathology.

Cutting back hours doesn’t do as much good as working on the doctor’s personality. 

Without business training we try to be businessmen. 

Keeping up with the literature is impossible, but we access data easily. Better reactive, looking up the information you need than ineffectively proactive, keeping a stack of unread journals. 

We, the physicians, are change-averse people in the face of increasing speed of change.

The lecturer says if you’re lost admit it, it you are still lost, stay put.

No one stands between us and what we want more than ourselves.  Lose the BMW, he says: bitching, moaning, and whining.  It wastes catecholamines.

At the end he shows the same video clip twice.  The sequence shows a man taking a taxi into New York and the things that he sees; the first time accompanied by strident, discordant music.  The second, identical series of visuals has a string quartet playing in the background.  The perception of the scene changes dramatically with the change in music.

Stress management starts in the head, changing one’s perception of the world.

He talks about how to deal with toxic people: do your best to find something good and concentrate on that; he calls it amygdaloid substitution. 

(For more about the brain’s amygdala, see my previous post: https://walkaboutdoc.wordpress.com/2010/03/08/rage-hunger-lust-and-sleep/)

He advises us to add gratitude to our day: write three things to be grateful for at the end of each day.

It’s difficult to find acceptance of anything if we aren’t will to let go of control.

His words ring true.  I left my prior practice at the right time.