Monday, May 22, 2017

off topic...but not really

A friend of mine recently returned from a trip to Machu Picchu, one of the “new” seven wonders of the world. In my humble opinion, the self-proclaimed experts who, back in 2000, voted to rename the Seven Wonders of the World, missed the point. They were looking at manmade monuments and structures of lasting beauty and grandeur while overlooking what I believe to be the Seven True Wonders of the World. I was reminded of them last week with the arrival of my newest grandson. This is what was so extraordinary about it:

Oh, and sex…where it all begins.
When you consider all the changes the body has to orchestrate flawlessly in order for a healthy baby to enter the world—the timing of the hormonal and anatomical changes, the electrochemical shifts, the first breath—it astounds me that it ever goes according to plan. So much can go wrong…and often does. If you want to hear inspiring stories…as well as sometimes tragic stories…listen to a group of women sharing their birth experience.
“The mind of a woman in labor
is power unestimated."
They will tell you how excruciating pain leads to immense joy…or, when the process fails, to deepest sorrow. They will describe fear, even panic, at the slightest suggestion of trouble. They may reflect back on how hard it was to get pregnant…or how easy or even unexpected it was. How they learned the meaning of longing and of love.

“Story is the umbilical cord
that connects us to the past, present, and future…
Storytelling is an affirmation of our ties
to one another.”
~Terry Tempest Williams~
There is nothing new in the history of childbirth, but there are an infinite number of unique stories about it. Birth narratives are packed with sensory and emotional detail, victory and defeat, courage and cowardice, mystery and manifestation. Each story is epic in scope…part fantasy, part mystery, part thriller, part love story. Something for everyone.
Every birth is a wonder to behold.

“There are no seven wonders of the world…
There are seven million.”
~Walt Streightiff~


Wednesday, May 3, 2017

ten reasons to join a writing group...or start one

Here are ten good reasons you might be interested in joining a narrative medicine writing group:
1.      You are a health care provider or a therapist in any field. You have been a patient at some point in your life, or you know someone who is. Trust me: you have plenty to write about.
“Anybody who has survived his childhood
has enough information about life
to last him the rest of his days.”
~Flannery O’Connor~
2.      People keep telling you, “You really should write a book…” because of all you have endured and overcome, or because of your special expertise, or exceptional courage, or unique perspective.
3.      You keep telling yourself, “But I’m not a writer,” even though there’s a story chiseling a hole in your heart…something that caused such sorrow, or anger, or despair you can’t bear to revisit it, or such relief, or gratitude, or inspiration you can’t imagine how you would put it into words.
“There is no greater agony
than bearing an untold story
inside of you.”
~Maya Angelou~
4.      You keep telling yourself, “I wouldn’t know where to begin,” even though you’ve been over the details in your mind a thousand times.
5.      You keep telling yourself, “My life (or work or experience…) is so ordinary, I have nothing interesting to say, nothing new to add, nothing helpful to share.”
“Write what disturbs you, what you fear,
what you have not been willing to speak about.
Be willing to be split open.”
~Natalie Goldberg~
6.      You like to write, but convince yourself you’re not good enough at spelling, grammar, or punctuation to share what you have written.
“If you hear a voice within you saying:
you are not a painter,
then paint by all means, lad,
and that voice will be silenced…”
~Van Gogh~
   The same can be said for writing.
7.      You think you’re too busy. (You’re not.)
8.      You’re afraid you’ll offend someone if you write the truth…the surgeon who botched your operation, or your uncle who abused you as a child, or the colleague you don’t trust.
“All you have to do
is write one true sentence.
Write the truest sentence you know.”
~Ernest Hemingway~
9.      As a patient, you sometimes feel like giving up. If you’re a provider, you sometimes feel like quitting.
10.  You harbor questions you can’t answer…doubts that won’t go away…pain that nothing can heal.
“While medicine creates material for writing,
perhaps even more important is that
it also creates a psychological and emotional
need to write.”
~Daniel Mason~
If you’re still not sure writing is for you, I’d like to recommend a couple of good books for beginning writers, especially those who are reluctant to get started:
·         The Artist’s Way by Julia Cameron
·         If you Want to Write by Brenda Ueland
·         Writing from the Heart by Nancy Aronie
If you’re interested but can’t find a narrative medicine writing group near you…think about starting one.

Sunday, April 23, 2017

physician, advocate, friend


As a retired physician, I sometimes find myself in a role I am passionate about. I am sometimes invited to accompany friends to their appointments with specialists.
I took a friend with neuro-sarcoidosis to see a physician who specializes in this rare condition at Hopkins. I went to the oncologist with a friend who had a rare retro-peritoneal sarcoma to learn what options were available to her.
“The good physician treats the disease.
The great physician treats the patient
who has the disease.”
~William Osler~
To me, this is a great honor. They are asking me to listen with expert ears to the medical-ese--a foreign language to them--that specialists tend to use when discussing rare or life-threatening conditions. They count on me to help them make difficult decisions. They haven’t studied anatomy. They don’t have access to clinical trials. They don’t understand morbidity and mortality statistics. They want to know how long it will be until they feel better. When they can get back to work. Whether or not they will live to see their first grandchild.
Not only can I provide a “second set of ears” to help them recall important information…but I am able to interpret what we are told, and to translate it into a language they can understand.
True story:
Last week I sat with a friend who was seeking a second opinion from a specialist about complications that arose following surgery to reverse a gastric bypass. That was two years ago. She has undergone 6 procedures since then in a failed effort to close fistulas that developed at the operative site and never healed. One of them has opened out to the skin and drains continuously. No matter what she eats or drinks, some of it ends up draining out through the opening…coffee, ice cream, noodles, corn.
“We don’t know how strong we are
until being strong is our only choice.”
~author unknown~
Her surgeon had nothing else to offer so he referred her to one of the top bariatric surgeons in our area for her thoughts on how to proceed.
The technical details were only part of the problem with this discussion. Honestly, my friend doesn’t much care about the details. She just wants to be healed, whatever it takes…which in her case would be a “miracle” according to this doctor. She described a risky and complicated procedure which would involve a whole team of surgeons, each lending his/her own expertise…and still there was no guarantee the fistula would close. Things could get worse instead of better. My friend could die.
Or…she could consider doing nothing. As hard as it is to imagine, she is still working. She maintains her home and yard by herself, and she gets around on her own. It’s just this awful, foul drainage that gets her down.
So now that she understands her situation, her treatment options, and her prognosis, the hard work begins. Facing reality. Surrendering to it. Pushing through. Maintaining some semblance of the resilience and determination that have kept her going these past two years.
As a physician, my job is done. I listened. I understood. I translated.
As an advocate and friend, though, my job is just beginning…
“Some patients,
though conscious that their condition is perilous,
recover their health simply through their contentment
with the goodness of the physician.”
PS: Every week I contemplate a topic for this blog. For inspiration, I sometimes read up on the field of narrative medicine. Sometimes I look into medical research. I often reach back into my own memory and experience. Last week, though, this story was hand-delivered to me by pure chance. It would be gratifying if, after reading this woman’s story, someone were prompted to offer a prayer for her. If someone found the strength and courage to continue his own medical battle, or to reach out to a friend who is facing a life-threatening illness. Each one a step on the journey toward healing. Thanks for listening.

Wednesday, April 12, 2017

how storytelling reopens the wound

If you are reading this blog, you probably have some familiarity with or curiosity about the concept of storytelling as a healing practice. If you are a health care provider, a therapist in any field, or a caregiver—or if you have ever been sick yourself—you may have an untold story wreaking havoc in the back of your mind. Perhaps it reflects a difficult, sad, or frightening episode in your past…something you’d rather not resurrect. Maybe there was a time of such joy or relief or healing you can’t imagine putting it into words so you haven’t even given it a try.
“A writer is someone
for whom writing is more difficult
than it is for other people.”
~Tomas Mann~

Or…perhaps you’ve started the story again and again and gotten nowhere with it. It turns into a rambling description of places, persons and events that fails to capture the emotions that made the experience meaningful to you.

This is where a good writing prompt can be helpful. That and a supportive reader who knows how hard this is for you and heaps praise upon you just for trying.
If you need a little nudge to get you started, here a of couple of writing prompts for health care providers that may help:
·         Write about “expectations” you’ve embraced (or rejected).

·         Tell us what it feels like to work without sleep, on an empty stomach in the middle of the night.

·         What goes through your mind on the way to work in the morning…or on your way home at the end of the day.
If you were sick, or caring for someone who was ill, try these:
·         Write about your hands.

·         Tell us what you fear the most.

·         Tell us what you do to care for yourself.

When you begin, don’t worry about grammar, spelling, or punctuation. That’s the easy part. It comes later.
Instead, write about the first thing that comes to mind.
“When in doubt,
tell the truth.”
~Mark Twain~

Give yourself 15 minutes or so at it, then rest. Wait a couple of days and then try again. Write until you come up against the piece that is hardest to write…a time when you were so sad or scared or angry you still hesitate to commit it paper…or so comical or comforting or inspiring it leaves you groping for words.
“The most important things are
the hardest to say,
because words diminish them.”
~Stephen King~

When you write, include details even if they seem insignificant. The missing tile on the ER wall. The overflowing trash can in the visitors’ lounge. The ladybug that made its way into the OR. These familiar images connect the reader to your story. Use the senses to bring the scene to life. The sight of blood pumping out of a tiny artery after the other bleeders were all tied off. The taste of cold, black coffee in the middle of the night…and why you sometimes need it. The smell of stale urine.

“To create something exceptional,
your mindset must be relentlessly focused
on the smallest detail.”
~Giorgio Armani~

An untold story can leave us with a vague sense of frustration, anxiety, or confusion that we don’t understand, and can’t dispel until we put it into words. Until we set the scene, name the players, and face the feelings that have festered out of sight for so long.
Storytelling unmasks the wound so healing can begin.
“There is no greater agony
than bearing an untold story inside you.”
~Maya Angelou~










Tuesday, April 4, 2017

more than meets the eye

I called my best friend last night. We don’t get to see one another very often, but we talk every week. After we catch up on all the things that keep us busy, the conversation turns to friends and family.
Here are a couple of the stories we shared this week:
·        My friend described the plight of a woman who has undergone eight operations in a futile effort to eliminate a recurring MRSA infection post-total knee replacement.
·        She expressed her concern for a neighbor in her seventies who took a tumble and broke her hip, and then, a few weeks later, fell again and suffered a subdural.
·       We discussed the story of a woman from her church who is losing her battle against metastatic breast ca.
·        I told her that a friend of my daughter’s, recently married, had suffered a miscarriage over the weekend.
…not one happy moment among them.
The thing is that these occurrences are not uncommon. We encounter them every day. In fact, stories like these are so commonplace we are tempted to dismiss their gravity and to overlook the emotional devastation that remains in their aftermath.
“Under the look of fatigue,
the attack of migraine, and the sigh
there is always another story.
There is more than meets the eye.”
~W H Auden~
But what if we knew those details? Are we interested, empathetic, compassionate or simply curious enough to ask? Is there more to the story?
·       The woman with the recurring MRSA will be going off IV antibiotics in a week or two. Every time she does, the infection recurs…seven times, so far. If it happens this time, she will be staring down the barrel at an amputation…
·        Several months earlier, the neighbor who fell and her elderly husband became foster parents to their grandson who was 9 months old at the time…
·       The woman with the metastatic breast cancer had entered hospice care. The question that arose for my friend was whether or not it was too late to give her a call. What could she possibly say?
·       The young woman, who under her doctor’s direction miscarried at home, described herself as feeling like a “monster” for having to flush her baby down the toilet.
There is always more to a story than first meets the eye. It pays to go deeper. To draw out the most painful details. How else will we know what a person needs? How to help? What to say?
“Everyone you meet is fighting a battle
You know nothing about.
Be Kind.
~various attributions~
Last night I spent an hour on the phone with another a friend whose autobiography should be titled, “Anything That Can Go Wrong, Will…” Her story is one of multiple oversights, erroneous assumptions, and mistreatment during a recent hospitalization that would give Stephen King nightmares, I kid you not. Untreated hypertension and untreated pain complicated by complacent nursing care. Today, she thanked me just for listening.
It turns out that narrative medicine is alive and well in every community, in every neighborhood and around every kitchen table. What is your story?
“Tell me your story,
show me your wounds,
and I’ll show you what Love sees
when Love looks at you.
Hand me the pieces,
broken and bruised,
and I’ll show you what Love sees
when Love sees you.”
~from “When Love Sees You”~
~lyrics by Mac Powell~



Monday, March 27, 2017

irresistible communication


If you’re interested in storytelling as a diagnostic and therapeutic tool, you should get a copy of the book, “Irresistible Communication” by King, Novik and Citrenbaum. (It’s out of print but still available “used.”)
Image result for irresistible communication
In this book, the authors discuss subtle communication techniques that encourage and facilitate storytelling in the clinical setting, for example, when delving into a patient’s medical history. These techniques operate on a subconscious level to engage the patient/client in ways that relax him, and affirm the fact that he is being heard and understood. They enable the clinician to read the patient’s body language and to understand how the patient accesses and processes information—whether he is a visual, auditory or kinesthetic learner—and how this affects memory, receptivity and comprehension.
“Seek first to understand,
then to be understood.”
~Stephen Covey~
Some of this is accomplished by simply mirroring the patient’s posture, respiratory rate, eye movements and positional changes. If the patient is anxious and breathing rapidly, the clinician can begin by matching the patient’s respiratory rate and then gradually slowing and deepening his own breathing. When the patient is engaged, his breathing will begin to slow and deepen, enabling him to relax. His anxiety will then lessen.

Observing the patient’s eye movements can tell a lot about how the patient processes information. Whether his gaze is directed upward to the right, upward to the left, or to one side or the other suggests the predominate sensory pathway by which he accesses memory.
Let’s say the patient was involved in a car crash. You can get a good idea of how he remembers it by the direction of his gaze and the language he uses to describe the scene. For example, he may say, “I heard the tires squeal right before the truck slammed into my car,” while gazing sideways and to the right, where the impact occurred. He is processing the accident according to what he remembers hearing. If you ask him, then, “What color was the truck?” this will take him out of his story. His memory will blur and important information may be lost, whereas if you ask him, “What else did you hear?” he may recall the sound of crumpling metal, broken glass, the voices of people coming to help, the sirens…all in accurate detail. He may never remember the color of the truck if he doesn’t process memory visually.

A visual person might recall the way the blood splattered on the windshield or way the lights were flashing in the ambulance. His gaze may be directed up and to the left or right as he recalls the details.

A kinesthetic learner might describe the shards of glass striking his face, or the sharp pain in his neck at the moment of impact.
The same traumatic experience can be recalled differently according to the patient’s predominant sensory processing pathway.

“To effectively communicate,
we must realize that we are all different
in the way we perceive the world and
use this understanding as a guide
to our communication with others.”
~Tony Robbins~
Interestingly, the clinician can put this information to use when treating the patient. The visual learner may benefit from written instructions or diagrams. The auditory learner may do better with a CD or audiotape. The tactile learner may constantly want to touch the injured area. Ask the visual learner, “Do you see what I’m saying?” Ask the auditory learner, “How does that sound to you?” Ask the kinesthetic learner, “How do you feel about that?”

Repeating or rephrasing what the patient says is another way to improve effective communication. Asking the patient to repeat instructions is also useful. How many times has a patient gone home with written instructions when he can’t read…
This, of course, is an oversimplification of a complex and intriguing approach to communication techniques. Since “Irresistible Communication” was published almost 35 years ago, a vast amount of research into the neurophysiology of sensory processing pathways has been published.

It reminds us that a lot more goes into narrative than telling a story, and listening involves a lot more than just hearing.
"I know that you believe you understood
what you think I said,
but I am not sure you realize
that what you heard is not what I meant.”
~Robert McCloskey~

Thursday, March 23, 2017

memories are made of this


As a retired physician, I am bursting with memories. Some are biggies…like the five-hour ambulance ride it took to transport a fragile premie from a rural upstate hospital to the medical center where I was a resident. Lights and sirens the whole way. Or running a clinic out of a tent in the African bush without electricity or running water. Or prepping a patient who was sent to the OR by the emergency room doc for an appendectomy in the middle of the night…when my pre-op exam revealed a leaking aortic aneurysm instead. That got things moving!
On the other hand, some memories are brief, isolated moments that punctuate the middle of a busy day…a dousing with pee during a newborn exam, a spontaneous embrace or word of gratitude from an appreciative patient, a smile or a grimace or a groan.
“We don’t remember days.
We remember moments.”
~Cesare Pavese~

Monumental or trivial, happy or sad, memories stick with us. When you consider the number of patients we see every day over the course of our careers, all the details we tend to, all the information we process, it’s amazing we remember any of it.

Imagine, though, what it must be like for your patient. You may already have seen twenty patients that day. It’s all a blur. Each patient, on the other hand sees one physician or provider that day—you—and will be totally focused on this particular encounter. Years later, he may still recall the fear or dread that tempted him to cancel his appointment. The smell of cigarette smoke on your clothing. The impatient sigh that escaped when you glanced at your watch. How cold your hands were, or how warm. How hurried you were, or how kind…
“…You will never know the value 
Of a moment
Until it becomes a memory.”
~ Dr. Suess~

 …when you don’t remember the patient at all.
Whether you’re a provider or a patient, if you’re interested in narrative medicine, you have to tap into those memories. Relive those moments. Reflect on your experience. And share what you have learned.
“One day you will be just a memory
For some people.
Do your best to be a good one.”