“Don’t die with the music still in you..!”


“History teaches us that men and nations behave wisely once they have exhausted all other alternatives. ”   –  Abba Eban”

Let’s hope so…..!

To grasp the broader meaning of  “spoon” or “spoon theory” lets start to say this is sort of a disability metaphor used to explain the reduced amount of energy available for various and productive tasks.  Spoons are features of measurement. They are used to check how much energy a person has throughout a given day. We can’t live on one teaspoon sugar, so to say. Let’s agree this is very different on the spectrum of human diversity. That’s easy to understand. Energy levels are different, likewise the energy levels we can sustain.

When you are affected in your mental health either through depression, excessive anxiety or being “burnt out” of sorts, the energy available for a healthy “output” may be reduced at various degrees. That’s what we may call in broader terms “lost spoon”.

How far your “spoon” is lost is a different story. The most important thing is that when you lose your spoon that you try to find it again.

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But mind you, there are many “lost souls” on this planet unable to find back what they lost. Damaged and living on the other side of the spectrum…Surely, I am unable to say as how to find what you lost again and certainly this is different for anyone involved in issues affecting mental health.’ But.. without generalisation, it is true that even the greatest on earth did know the battle of the mind at times. The struggle to compose oneself and radiate a sense of normality whilst conflicting emotions and feeling low or anxious at times play a role at the background.

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Abraham Lincoln, together with more famous sufferers of depression like Winston Churchill and Mark Twain, used humour as an antidote to depression. To boost his spirits, Lincoln told jokes and funny stories. Lincoln once said, “If it were not for these stories—jokes—jests I should die; they give vent—are the vents of my moods and gloom.” Joshua Wolf Shenk (In ” Lincoln’s Melancholy: How Depression Challenged a President and Fuelled His Greatness”) concludes that “Humour gave Lincoln protection from his mental storms. It distracted him and gave him relief and pleasure . . . Humour also gave Lincoln a way to connect with people.” In addition to humour, Joshua Wolf Shenk ( the writer of above book) discovered that Lincoln utilised other major depression antidotes, including his love of poetry and a strong belief that his life had an important purpose. As you see, and without adding too many examples, many did lose their “spoon”, but some of them had also the means to help themselves. When Lincoln e.g started to speak, started to connect with people, – his often somewhat sombre face did relax into an embracing smile. Very different than e.g Donald Trump, but that aside.

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Just one other example:

Before becoming the Buddha, he was Siddhartha Gautama. According to traditional biography, he was born into royalty, his father a king who attempted to shield Siddhartha from knowledge of human suffering by removing the sick, aged and other suffering from his view. However, Siddhartha was said to have seen an old man, a diseased man, a decaying corpse, and other suffering, and then to have become deeply depressed by these sights. And at age 29, he began his journey to seek wisdom as to how to overcome suffering and despair. His spiritual journey took six years, with Siddhartha ultimately rejecting popular “treatments” of his day that included asceticism, deprivation, and self-mortification.

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Siddharta’s Antidotes: At age 35, after 49 days of meditating under the Bodhi tree, he attained Enlightenment and became known as Buddha, the “Awakened One,” and one of the world’s greatest antidotes to the suffering of depression was born. Buddhism begins with understanding truths about suffering. Specifically Buddhism’s Four Noble Truths are that (1) suffering is an inherent part of existence; (2) suffering is caused by attachment and craving, and our ignorance about this; (3) we can reduce suffering by letting go of attachment and craving; and (4) this can be done by following the Noble Eightfold Path of the right understanding, thought, speech, action, livelihood, effort, mindfulness, and concentration. For the remaining 45 years of his life, Buddha travelled and taught extensively. Compassion and the truth about suffering were his major antidotes to depression and despair—antidotes for himself and for others.

It would not be wise  to romanticise all depression sufferers and to celebrate all non-medical solutions. As a medical professional myself I would be against it, however those examples give some comfort perhaps. Comfort in a sense that you may loose your “spoon” but that in compassion through suffering you may give back one way or the other. Is this wisdom?  Not so sure about this. Aeschylus once said that he who wants to learn has to suffer. For sure he did not mean the type of learning we do at school or at Uni. He meant the learning of the soul in the pains we may encounter. There might be a pain we can’t forget. An agonising wordless feeling hanging as a cloud upon the mind. What can we say about this? He said that “the” wisdom may come from a different calming dimension. Not as an instant cure, but through a long lasting process. Yes, he said:” Even in our sleep pain which can’t forget falls drop by drop upon the heart, and in our own despair, against our will, comes wisdom to us through the awful grace of God”. He reflects on the supporting dimension of God.

I think I lost 2 times in my life “my spoon”. Sort of!.. The first time ( I don’t count my departure from being a “tropical doctor” in Africa), was when I moved from Scotland to Australia.  It was a very busy and stressful time. Firstly to sort out my practice where my partner left me on my own with a cottage hospital pending to close down. For the last reason,  I could not attract a new partner because I could not promise a growing income. This seems to be important for doctors. Almost one third of our income was generated from this hospital. There were issues with the practice building as well, in need to be sorted out as the premises were in the name, still, of the previous partner. I had not signed a contract as yet, and was not willing to do so once I knew he was going to leave. For sure, there were background reasons. His wife worked as a practice nurse and could not get along with our Practice Manager. He wanted “to sack” her but as the Practice Manager was both competent and reliable I did not want to go ahead with this..Anyhow, big time!.. Legal issues related with this…. The Grampian Primary Care Trust was prepared to take over the practice, – which was great, as they did. My legacy, if any, was that I was able to secure the practice with this Trust. But for various reasons I did not wish to work under them. It would be an understatement that I worked very hard at the time… When they asked for a “free spirit” in South Australia – and after plenty of consideration with my family – , we all went ahead and moved from Scotland to South Australia and started in a rural area some 250 km from Adelaide. I was tired, for sure, and staying the last 5 months in a “mini” house after selling our house and waiting for the paper work to be sorted (all related with emigration to Australia) was a big time as well.

Starting in Australia, I did not sleep at all anymore. Not good. A challenging time again. But I recovered and did adopt. Had to do so as I had to look after my family and was  the solo GP for both the practice and a hospital with an A&E, apart from both acute and long term patient services. Yes, I recovered well, – which was good.  A blessing actually.. I had various plans for a multidisciplinary practice, being a “free spirit” of sorts and being used to a fair degree of independence in Scotland.

Besides this, what good that there was a Royal Flying Doctor Service to get those patients transferred  to one of the specialist hospitals in Adelaide. Those  who were really critical ill or at risk to die. Great nursing staff in this country hospital.The Director of Nursing was not that great. I had a great team in my practice, both reception staff and Practice Manager. But when they arrived in tears during my holidays at our house next to the practice, as they were “bullied” by the EO/DON,.. it was again “big time”… I wrote to the  Hospital Board and raised my concerns but before I knew, our portable family swimming pool was emptied by this EO/DON. Not good at all… They claimed I had no Council permission but I asked the hospital permission beforehand (which I got!) and for a portable swimming pool at the time no permission was required. Mind you, a swimming pool of that kind was nice. One Summer we had days of 47- 50 degrees Celsius, pretty warm…Anyhow,..to make a long story short, working for this community was great. We had many contacts. But working with this EO/DON was an affliction. It did screw up all plans to start a multidisciplinary practice as the best Practice Manager I had resigned due to the “bullying nature” of the EO/DON, who wanted to have control in everything..I will refrain from more details as this person had good things as well. And.. “every sinner has a soul” , so to say…. I am not perfect either and perhaps we learnt from each other.

In all this, however, we need to realise that people are often far more than their expression at one stage of their lives, and that lots of goodness not always appear to the surface. Being gentle therefore bears more fruit, I guess.

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Finding the right balance is not always easy, but there is always  a learning curve.

At some stage,though, I had not that much energy anymore. Being more or less permanent on-call, a busy family life and counter productive dynamics at senior hospital management level, – have not been the best ingredients for “recharging” the batteries  through rest – which was not there. Besides this it was hard to work things out as hospital management claimed control over the practice. They asked for a “free spirit” to start with, but when they got one they did not like to change the status quo. Undermining tactics were part of the domain of the EO/DON at the time, – felt by many.

We moved in 2004 to a town close to Port Macquarie where after one year I got an associate partnership. Nice teaching practice but at some stage also somewhat dominated by not so fruitful dynamics on which the youngest doctor decided to start for himself elsewhere. Great GP.. and a good person ..and sad to see him go.  But actually I went before him as the other associate partner was not very pleased in general with his dynamics, nor happy with my dynamics of more (and less rigid!) change in the practice. For sure, perhaps, I was a bit full on with a strong drive,  but along this I recovered nicely (as well) from twice an ablation procedure on my heart. The last due to very fast heart rate (coming and going), – which on its own was really not very comfortable… By the way, I left at the point where it seemed that I would be possibly left with the practice on my own, as the longest staying GP wanted to seek a different endeavour as well… Mind you, I was not keen to have the experience in Scotland repeated.. No way!

To make a long story short, after I left, –  the doctor who wanted to start on his own again, despite some financial odds against him, established a very successful practice and took the Practice Manager with him along with other practice staff. Perhaps in some ways a reflection on the last and longest remaining GP. It is not always good to think to be right all the time, –  as sometimes this works counterproductive… But also this GP took a successful different direction with both courage and determination. And all that’s good, I admire this! In a way both great people, but better in different entities.

As I said, people are often very much more than their expression at one stage of their lives. And being mindful of this, bears perhaps more fruit in our response to matters or circumstances where human dynamics are involved.  That’s the reason I like what Abba Eban said about history and exhausting alternatives: “History teaches us that men and nations behave wisely once they have exhausted all other alternatives. ”

There are always people though, who are stubborn, thinking that they are always right and not willing to change their mind where this is at times required.

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But people who “run out of spoons” have no choice but to rest until their spoons are replenished. For me there was not much rest, so to say.  But let it be said that there are many people on this earth lacking rest or sleep. Nothing unusual. My return (longer ago) from Africa to Europe was “a sad one”, not being that tired though. It was of a different nature. I left “my spoon” there in terms of “meaning in life” which could not be continued the way I hoped for. Different reasons. But to come back on the experience in Australia’s east coast:

After working in New South Wales in a sort of  suburban type practice, by coincidence, I returned to South Australia with my family for a job with SA Health at the Tailem Bend Health Service. It was (as I said) a coincidence as my preference was to go to a practice up north in Tweed Heads. Various family dynamics, however, steered the direction of going back to South Australia, – where we started initially in Australia some 16 years ago,

Tailem Bend, again, was full of adventures and endeavours. Last but not least because working with SA Health made you as a GP less in charge of choosing the doctors to work with. SA Health was in charge. Contracted with SA Health provided, for sure, some benefits but where it comes to “involvement” in critical choices, there was not much choice. The workload could be fairly unforgiving at times, with both the cover for the practice, A&E, the acute end of the hospital and the long stay elderly department. For the last reason doctors more often did not stay that long. Obtaining the Royal College exam (called the FRACGP) was not rarely one of the motivations to stay  and then: moving on again! Fortunately I did this exam in 2004. But the variety of doctors coming and going had their challenges for the practice and hospital in Tailem Bend as well. In between I worked often, at large, on my own, with regularly  the required support lacking. Support  in terms of “back up locum cover” for this busy place. Surely it was not always easy to secure locum support for both the entity of cover for both the practice, hospital and A&E. Not everybody likes it. But for some reason I managed to sustain. For both myself and my family, however,  with only small holiday breaks, –  not including weekends.  Not good, actually. Long term retention for GP’s in rural areas do really require sufficient time to recuperate from the strains of working under totally different circumstances than city GP’s, and this failed to be implemented in my case. If you work for more than eight and half years in an area like I did, with coming and going of GP’s (all being “fat up”), it’s a warning signal for those who should take the retention of rural GP’s at heart and provide really sufficient breaks and recovery time, Even if it was only once in 3 years..

So for sure, not enough time to recover with hardly enough breaks. That’s clear. It did surprise me that Government positions have the entitlements of “long service leave” and others, –  whilst in healthcare, doctors being contracted by SA Health have different arrangements, – and not always in line with a certain normality, so to say…

Besides this, with being that busy, it is not always possible to make friends as being on-call was a quickly occurring repetitive event. The last doctor with SA Health in Tailem Bend working with me, did not get his contract extended as due to the type of conduct not being favourable with both SA Health and the Medical Board. Hence again, it left me with a challenging situation working very long hours and (often) on my own between the end of March 2016 and December 2016. Having explored all options (see last article), I left this health service for a practice in Aldinga.

Undeniably this almost nine years journey in Tailem Bend had an impact on both myself and my family. Not always for the better. However…. a learning experience…For sure!

Arriving in the new practice in Aldinga:..

What a change! .. Nice group.

I guess that after some months the aftermath of Tailem Bend did hit back. Not sleeping…  in ways I experienced twice in the past. Not great… And proper sleep is the way to restore the batteries, as we know.  I failed actually to take a proper break in between the 2 jobs. Not very sensible the last. But a misguided sense of duty is perhaps not always helpful. Feelings of despair are not strange to me and at times I learnt the hard way. In my “isolation” in Tailem Bend, by the way,  some simple human encounters were very helpful on some occasions.

In Aldinga, working at a lower pace and variety was almost a shock for “the system” as I was not used to this, but I appreciate it now. However, in some ways I am further away from my original aim when I studied Medicine in Maastricht. Just actually before a significant pending endeavour. which would have brought me close to my aim (despite some dangers), I had to leave Africa (long ago) for reasons not within my control. That’s life at times. As a doctor in those areas you are responsible for your family as well..

We try to make decisions within the best context of both duty, care for family, and…”meaning” perhaps – but we do not always get what we want.

Often we have to balance on what life asks us to do in a particular set of circumstances.

The search for meaning goes on and on. It never stops and every time you need to reinvent, embrace life for “belonging” and change, and keep in mind what Aeschylus once said. And for sure, .. it’s all part of: > “not to die with the music still inside of  you”<.

And that it may be agonising at times may be part of life. For some more than others.

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Through the awful grace of God we may forget history and live with the music in us, and embrace the last in full for the benefit of others. But “rest” we need at times. It is also a matter of the right sense of direction and the right sense of discipline – and.. heart over matter.

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Yes – heart and imagination over matter – if we are able to allow not to be defeated in our own souls..

Thank you so much!
Paul Alexander Wolf

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