Wednesday, February 14, 2018

illness, inside and out


Illness can be understood by its impact on the patient both inside and out.

Within, it interrupts normal physiology and function. It alters anatomy. It causes pain. Traditionally, this has been the domain of the healer: diagnosing and treating the illness or injury by asking about symptoms, examining the patient, ordering diagnostic tests, and formulating a plan of treatment. It can all be done at the bedside.
But illness also triggers a cascade of intellectual, emotional, and psychological responses. It affects the patient’s relationships, his capabilities, his expectations, and his role in the family and community. Positive mental and emotional changes have been shown to support the ability to heal. On the other hand, negativity is believed to impede recovery. Unless we take into account the patient’s sense of self when tending to his illness or injury, we may neglect one of the most important determinants of his ability to heal.
“It may take a doctor
to diagnose someone’s illness,
but it takes a friend
to recognize someone’s suffering.”
For example, when the family breadwinner is laid off because of illness, he loses wages. It’s possible he will lose his job. He worries how he will support his family. Fear and uncertainty aggravate the illness. His self-respect and confidence take a punch to the gut. That’s the thing that really hurts. But he won’t tell you about it unless you ask.
“To me the ideal doctor would be a man
endowed with profound knowledge
of life and of the soul,
intuitively divining any suffering
or disorder of whatever kind,
and restoring peace by his mere presence.”
~Henri Amiel~
Or perhaps your patient is a mother with young children at home. Who will take care of them while she is in the hospital? She worries about them. She feels guilty because she can’t be with them. She may actually lie to you in hopes of being discharged from the hospital, denying the pain she still has, or pretending to be stronger than she actually feels. Her narrative is misleading.
The patient’s story extends beyond the bedside. It embraces more than his illness. One person will be crippled by it while another is healed.
We can’t understand a patient’s illness unless we understand how it affects everything around him—his family and friends. His hopes, dreams, and plans for the future. We can’t treat the patient until we hear his whole story.
“The doctor may learn more
about the illness
from the way the patient tells the story
than from the story itself.”
~James B. Herrick~

Sunday, February 4, 2018

we've come a long way


Yesterday—February 3—was National Women Physicians Day. Who knew there was such a thing? This is proof we’ve come a long way since I decided medicine would be my path in life…since the days when women in medicine were regarded with suspicion, disdain, and even mockery.
“If society will not admit
of woman’s free development,
then society must be remodeled.”
~Elizabeth Blackwell~
My journey into the practice of medicine started with my hospitalization for rheumatic fever when I was just three years old. Even at that young age, the experience shaped my sense of self. I never lost my appreciation for the suffering illness creates in a person’s life. I learned to harness the power to heal, and to revere the people who made it possible.
When I was in high school, I volunteered at one of the largest and poorest hospitals in Buffalo, NY. I majored in medical technology in college. I applied to medical school when there was still a 10% quota on women who were admitted—just ten in of a class of one hundred. Today, more women than men go on to study medicine.
“Every woman who heals herself
helps heal all the women
who came before her, and all those
who will come after."
~Dr. Christine Northrup~
I hope that more than just the numbers have changed.
I hope that young women who pursue the study of medicine are openly welcomed into the medical community, mentored, and encouraged to stay with it. I hope they are able to maintain high standards of medical ethics, selflessness, and dedication to patient care. That their male colleagues do not confront them with the disdain, disparagement, and arrogance that sometimes greeted us. That their female colleagues—nurses, therapists, aides, and support staff—feel connected with them in the art and science of patient care.
“The trained nurse has become
one of the great blessings of humanity,
taking a place beside
the physician and the priest.”
~Sir William Osler~
I hope they feel supported by their spouses, children, and friends. That exhaustion doesn’t do them in. That they practice balance in their lives. I wish them enough time and energy to embrace their creative nature, to enjoy their leisure, and to seek spiritual sustenance.
“Wherever the art of medicine is loved,
There is also a love of humanity.”

Sunday, January 28, 2018

variations on a theme

Let’s say you have three patients who are battling cancer.
One is devastated by the diagnosis. She is overwhelmed by fear and dread. Convinced her situation is hopeless, she resists starting chemo. She just wants to die. Her doctor suggests an anti-depressant.
“Once you choose hope,
anything is possible.”
~Christopher Reeve~
One is a man of deep faith. He is convinced that God has the power to cure him even though his prognosis is unfavorable. He devotes himself to prayer and sacrifice because he believes that will earn him God’s mercy. Even when his cancer spreads, he clings to his faith. It gives him hope and a sense of optimism right up until he is forced to surrender to the disease. His doctor tries to be respectful of his faith, but he can’t shake off his own doubts about it.
“Cancer didn’t bring me
to my knees.
It brought me to my feet.”
~Michael Douglas~
The other patient is f***ing pissed off about it. She is not about to lose this battle. After all, she has a husband and children at home. It isn’t fair to them. She agrees to an aggressive plan of treatment that includes surgery, radiation and chemotherapy. She begins a program of exercise, diet, and meditation, and she adopts a practice of loving self-care. She is determined to beat this thing. Her doctor encourages her even though he’s not so sure about self-care, himself.
“You never know how strong you are
until being strong is
the only choice you have.”
~Bob Marley~
Three different patients with the same disease, and three different stories. What difference does it make? There is an abundance of literature concerning the factors that affect a patient’s quality of life during treatment for cancer and how this correlates with his likelihood of recovery. Some factors are immutable: age, gender, and family history, for example. Others are modifiable: emotional and attitudinal factors, dietary factors, level of fitness, faith, and social support.
Given their stories, the physician will approach each of these patients differently, even though each of them has the same fundamental needs: education, encouragement, and support.
When is the last time you had to convince a patient to enter treatment? When is the last time you offered to pray for--or with--a patient?
When is the last time you practiced self-care?
“Self-care is a
divine responsibility.”
~Danielle LaPorte~

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.