Tuesday, January 16, 2018

who we remember and why it matters

I practiced family medicine for over thirty years. I cared for thousands of patients with everything from common colds and itchy rashes, to life-threatening chest pain and end-stage cancer. From birth to death. From morning to night. Like all of you.
As health care providers, we record our patients’ stories. We invade their privacy and probe their bodies. We formulate a differential diagnosis and subject them to sometimes painful testing and treatment. Through it all, we provide encouragement. We embody hope. We offer solace. We confront suffering. We celebrate healing.
“The best way to find yourself
is to lose yourself
in the service of others.”
~Mahatma Gandhi~
It’s no wonder, then, that we carry their stories with us. That, years later, we still remember people we encountered only briefly, not because their stories were particularly gruesome or traumatic or heartbreaking (although many were), nor because their recovery was so extraordinary (sometimes miraculous), but because we took our time with them. We learned from them and we used what they taught us for the rest of our careers. Or, perhaps, we failed them and still can’t forgive ourselves.
Trust me…for any but the most trivial office encounter, patients remember us, too. How we dressed. If our hands were cold. The smell of cigarette smoke on our breath. Whether or not we made eye contact. They read the expression on our faces and our body language. They sensed when we were hurried. They knew if we were listening.
“Give whatever you are doing
and whomever you are with
the gift of your attention.”
~Jim Rohn~
I remember certain patients because I was touched by the suffering they endured, or by the strength they demonstrated, or by wisdom they embraced. I hope they remember me because of the time I spent with them, the compassion I felt, and the knowledge I shared.
Which patients do you remember?
“There is no such thing
as an ordinary human.”
~Stephen Moffat~
How will they remember you?
“I’ve learned that people will forget
what you said,
people will forget what you did,
but people will never forget
how you made them feel.”
~Maya Angelou~

Saturday, January 6, 2018

the power to heal


The motivating principle behind the study and practice of narrative medicine is the conviction that storytelling has the power to heal, not just psychologically and emotionally but physically, as well.
“Dancing, singing, storytelling and silence
are the four universal
healing salves.”
~Gabriella Roth~
It is easy enough to understand how an uplifting story can raise one’s spirits. Let’s say you have been diagnosed with cancer. Hearing the stories told by people who have faced the same thing and have healed can offer hope, optimism, and strength for the journey you are about to embark upon. Ok, so you feel better emotionally and psychologically. The question is, does this shift in the psyche translate into physical healing?
Consider the vast literature concerning the mind-body connection. One simple but compelling case in point: the disappearance of warts with self-hypnosis. Pretty straightforward. We are also aware of the accumulating research on neuroplasticity and the effect of meditation and practice on the course of illness. We have learned about the neural connections that modulate the release and function of stress and growth hormones, and how those processes influence our physiology.
“The purpose of storytelling
is not to tell you how to think,
but to give you
questions to think upon.”
~Brandon Sanderson~
And then, there’s this: the demonstration of neural coupling on functional MRIs during storytelling. Researchers scanned the brains of storytellers and their listeners before and during storytelling. While different areas of the brain were active before the story began (maybe the listener had skipped breakfast and was focused on where he would go to pick up lunch, while the storyteller was worried he might leave something out), as the listener became engaged in the story, the scans changed. They came to mirror one another. The same areas of the brain started to light up in both the storyteller and the listener…proof that the person sitting across from you has the power to affect you physically by how he engages with you mentally.

This is no great secret. We have all experienced a racing heart while watching a thriller on TV, or shed a few tears during a sad interlude at the movies. And, who hasn’t lost track of time while reading a good book? Something happened to our bodies while we were engaged with the story.
In the medical setting, the storyteller is the patient. The listener is the physician or provider. Their brains come into synch by virtue of their mutual engagement in the process of obtaining the medical history. Their physiology changes. They become connected.
“There isn’t a stronger
connection between two people
than storytelling.”
~Jimmy Neil Smith~
If a story can bring us to tears…or to laughter…it doesn’t take much to imagine that it can affect our health and wellbeing…whether through a mindful change in our attitude or a beneficial surge in certain hormones.
This is why narrative has a role in the practice of medicine. The patient who is telling his story and the physician who is listening to it are affected not only cognitively, but physically, as well.
“Storytelling is the essential
human activity.
The harder the situation,
the more essential it is.”
~Tim O’Brien~

Wednesday, December 20, 2017

Christmas eve

It’s Christmas eve. Outside, the sun is setting under a sky that could pass for cotton candy.

The air is frigid but still. The street is busy with people hurrying home to begin celebrating the holiday. You, yourself, are looking forward to getting home to a crackling fire on the hearth and a traditional Christmas eve meal. The kids are home from college. Their gifts are wrapped and piled under the tree. You breathe a sigh of relief and gratitude.
It was a busy day. Among the patients you admitted through the emergency room were a child with asthma complicated by fever and pneumonia, an elderly gentleman who fractured his hip when he slipped on the ice outside his garage, an OD, and an out-of-state trucker with chest pain and an abnormal EKG. Orders have been written, tests scheduled, and rounds finished. Your patients are settled for the night. Your job for the day is done. It’s time to go home.

Except that part of you never goes home.
You remember the expression on the child’s face when he learned he would be spending Christmas in the hospital. He’d asked for a blue bicycle and he couldn’t stop crying because he wouldn’t be there to get it…and he wasn’t well enough to ride it, anyway.
You recall discussing her husband’s injury with the elderly man’s wife. She would be alone for Christmas now, and for weeks to follow. She couldn’t imagine how she would manage by herself.
The OD was not accidental. You are reminded of the most recent studies debunking the long-perpetuated myth that suicide rates peak around the holidays. In fact, suicides reach a statistical nadir in December. Still, opioid contamination keeps no schedule and leaves no clues. It will be a long vigil for this victim’s family overnight.
You learned that the trucker’s family was stuck at Chicago’s O’Hare International Airport because of blizzard conditions. They wonder if he will survive this latest heart attack. They wonder if they will get there in time.
It’s Christmas eve. You get to go home. Your patients don’t.
This is a bi-polar time of the year, a time that highlights the irreconcilable discrepancies, emotional extremes, and divergent realities that prevent some people from celebrating the spirit of the holidays. There is poverty in contrast to wealth, sorrow instead of joy, cruelty as opposed to compassion, and of course, illness instead of health.
For those of us in the medical field who are taking our patients’ medical histories, exploring their symptoms, and fielding their pain when the rest of the world is celebrating joy and peace, it is a bittersweet season. Many of our patients will experience pain rather than comfort, grief instead gratitude, anger as opposed to joy, and anguish instead of peace. It won’t be merry or bright at all. They will be stuck with it…and in many ways, so will we.
If Christmas eve with your family is happy, loving, and peaceful, I wish you a merry one.
If not, I wish you hope for something better. Courage. Friendship. Beauty. Time. Snow if you like it…sunshine if you don’t.
Dickens could have been describing Christmas as he wrote in “A Tale of Two Cities":
“It was the best of times,
it was the worst of times…
it was the season of light,
it was the season of darkness,
it was the spring of hope,
it was the winter of despair.”
It was Christmas eve.













Tuesday, December 12, 2017

revisit. revise. recover.

 “I write because
I don’t know what I think
until I read what I say.
~Flannery O’Connor~
This observation by author Flannery O’Connor rings true to anyone who harbors a vague feeling of anxiety for no identifiable reason.
“Worrying is like
walking around with an umbrella
waiting for it to rain.”
~Wiz Khalifa~
Even though they are living in a comfortable rut—let’s say, they are financially secure, their health is good, their family is intact—they can’t deny the knot in their gut or the dull ache in their chest that suggests something is wrong. Or, maybe they wake up every day with a sense of dread, exhaustion, sadness, or withdrawal that screams “depression”, even though, as people tend to remind them, they have nothing to be depressed about. After all, they have a steady job and a nice home, their children are doing well, and their bills are paid. They should be happy.
Still, the feeling is always there…uncertainty, fear, emptiness, hopelessness. They just don’t know why.
“These mountains you
are carrying,
you were only supposed to climb.”
~Najwa Zebian~
This is where storytelling comes in. Writing enables us to seek out and sort through memories, and to locate them in time and space. It encourages us to name the gremlins that stalk us, to label our fears, acknowledge our wounds, and reimagine our lives. We are no longer the victims of some obscure fear or unacknowledged sorrow. We can claim it and conquer it.
“The act of putting pen to paper
encourages pause for thought.
This, in turn, makes us think
more deeply about life…”
~Norbet Platt~
Physicians do this for every illness—from diabetes to heart disease to cancer. We ask about symptoms. We search for causes and encourage our patients to do what they can to avoid or eliminate them. We name the disease and suggest a course of treatment. If we have done our work well, we alter the course of the illness. We take control of it. We change the patient’s narrative.
This is storytelling at its finest. It is also the goal in clinical practice and in narrative medicine. When we write about illness, we revisit the initial injury. Perhaps it was a childhood rape, or a tragic accident, or the loss of a friend or family member we couldn’t face. By naming it, we confront it. The road to recovery leads us to a new perspective or understanding of it. Then, when we read what we’ve written, we finally know what we think.
Storytelling is the very process by which we revisit, revise, and recover.
Revisit. Revise. Recover.

Wednesday, November 22, 2017

perception vs reality

The medical history can difficult to obtain for many reasons. A patient’s description of his illness can be affected by his perception of it, his experience with it, and what he imagines about it. By his expectations. By fear or denial. Or he may simply lack the language to express it.
“Perception is reality.”
~Lee Atwater~
For example, if I had to tell you what has been going on in my left foot for the past six weeks, I would be hard pressed to describe it. You would be left scratching your heads. It all started with localized pain during weight-bearing (but no tenderness to touch). It started to swell, and then, after four weeks, I noticed bruising. I don’t recall any injury. It’s hard to know what triggers the pain because it seems worse at night for some unknown reason. I have no idea why it is getting worse despite the fact that I have been faithfully resting my foot like I know I should. It frustrates me because I can’t exercise. It worries me, too. What if I need surgery? What if I can’t take care of myself?
Even though I’m a physician, and I know all about strains and sprains, overuse injuries and stress fractures, tendonitis and arthritis…I can’t really describe the discomfort. And because I don’t remember injuring my foot, I can’t make sense of it. This is weird.
Imagine how difficult it must be for patients to describe their symptoms or to make sense of their illnesses when they have neither knowledge, experience, nor language for what is happening to them.
“Write hard and clear
about what hurts.”
~Ernest Hemingway~
Most people are not used to thinking about their symptoms in the kind of descriptive terms physicians depend upon to narrow the diagnostic possibilities. For example, they might not realize that the difference between a headache that is generalized, dull and steady rather than unilateral and throbbing may distinguish a tension headache from a migraine. They may not be able to distinguish between the kind of pain caused by heartburn and myocardial ischemia. They might not use those terms to describe it at all. The patient is more likely to view his symptoms in terms of lost wages, his inability to provide for his family, or his own impending decline rather than the onset, character, and duration of his symptoms.
“Every sickness has an alien quality,
a feeling of invasion and loss of control
that is evident in the language
we use about it.”
~Siri Hustvedt~
Severity is especially tricky to assess. It depends to some extent on the patient’s innate tolerance for pain. Is he a stoic or a whiner? His perception of pain depends upon how his symptoms affect his mood, his ability to carry on, and his fears which are largely based on what he has heard, what he imagines, or what he has witnessed in others.
Take it from me, under the best of circumstances, the medical history can sometimes remain a mystery.
One day I will find the right words
and they will be simple.”
~Jack Kerouac~

Monday, November 13, 2017

you too?

There is no greater agony than bearing an untold story inside you.
...especially when your story involves a history of sexual assault.
Witness the proliferation of stories about sexual abuse that have corrupted America’s dignity over the past few years…beginning with the Church, then shaming the military and Hollywood, and now erupting at every level of government. Affecting even our Olympic athletes.
Witness the “me, too” movement rising from every corner of the country, voices that went silent years ago out of shame, fear, and guilt. Men and women alike.
The first time it happened to me, I was twelve years old. It happened again in high school and in college. Then in medical school. Then as a medical resident.
“People talk about sexual assault like it’s a
bad habit that men have.”
~Jon Stewart~
These were not just dates run amok. They were not consensual affairs. They were uninvited, unwelcome, intrusive encounters.
“It’s not consensual
if you make me afraid to say no.”
National Sexual Assault Hotline
I was lucky, though. None of these incidents was especially frightening or painful or traumatizing to me. In every case, I knew the person. They were all men who, until then, I had come to respect and admire…one, a relative. One, a fellow student. The others…physicians and colleagues.
The problem is I have no idea where these men ended up or what they are doing today. That means you might actually know one of them. Your child’s coach or teacher or pastor could be one of them. Perhaps one of them is your own physician, surgeon, or counselor.
Interestingly, we haven’t heard much about sexual assault among members of the medical community yet. God forbid patients should speak up. Imagine the stories they could tell...
“Our lives begin to end
the day we become silent
about things that matter.”
~Martin Luther King, Jr.~






Thursday, November 9, 2017

the best of circumstances, and the worst

Under the best of circumstances, it can be difficult for a health care provider to obtain a thorough and accurate medical history from a patient. Whereas the provider wants to hear about the onset, timing, severity, and nature of his symptoms, the patient may be focused on the fact that he had to miss work to keep his appointment, or that he can’t afford whatever tests or medications he may need. He may be ashamed to admit that he fell because he’d been drinking, or that he was coughing because he smokes, or that his sugar is high because he ran out of pills and can’t afford to refill his prescription. Or, he might simply have forgotten the details—for example, when his headaches first started, or how often he gets them, or what sets them off. All of which makes it hard to arrive at an accurate diagnosis.
It is every doctor’s measure
of his own abilities;
it is the most important ingredient
in his professional self-image.”
~Dr. Sherwin Nuland~
And then there’s this:
We all have a friend or relative who can only be described as talkative. You know the kind-- mired in detail, obsessed with accuracy, insistent. A conversation with this person might go like this:
     Doc: So, when did the headache start?
     Pt.: It started last Tuesday. I remember because I had breakfast with my friend Barbara, and it started when I was driving home. No, wait. Maybe not. Maybe it was later that day, when I was in the grocery store. Or…did I go to the store on Wednesday? (pause) I don’t remember, but when I got home, I realized I didn’t have any Tylenol, so I took two Advil for it. Or…was it Aleve?
And so it goes, on and on and on in painstaking but inconsequential detail. And you only have fifteen minutes to coax the whole story out of this patient…
“Our lives begin to end
The day we become silent
About things that matter.”
~Martin Luther King, Jr.~
Or, you might meet up with this patient:
     Doc: I understand you’ve been experiencing some headaches.
     Pt.: Yup.
     Doc: When did they start?
     Pt.: A while back.
     Doc: Weeks ago? Months?
     Pt.: I guess.
You can’t pull a meaningful answer out of him if you kneel down and plead for it.
“I have learned now that,
while those who speak about
one’s miseries usually hurt,
those who keep silence hurt more.”
~CS Lewis~
In the first case, you wish you could shut the flood gates long enough to pull a few pertinent facts out of the overflow. In the other, you want to open the gates and net a few relevant answers before you move on.
The medical history challenges both of us, patients and providers alike. We’re in this together, and whether we are doing the speaking, or the listening, the correct diagnosis is our goal.
“Listen to your patient.
He is telling you the diagnosis.”
~Sir William Osler~