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
888~656~4673
 
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.~
 
jan

 

 

 

 

 

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.
 
“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~
jan



Tuesday, October 31, 2017

a sigh of relief


 
 
 
True story:
 
When the nursing home called, my mother was already on her way to the emergency room. She’d been experiencing a deep cough and increasing shortness of breath for two days. When her oxygen levels fell to dangerously low levels, her doctor ordered her off to the hospital.
 
I left as soon as I got the call, hoping to get there ahead of her because you see, by this point in her decline, my mother had lost the ability to speak. She didn’t suffer from dementia. Rather, her inability to communicate was the cumulative result of multiple small strokes. I knew she would be scared and confused, and ultimately frustrated by her inability to express herself. As sick as she was, she would be unable to give her medical history or answer questions. Nevertheless, I had no doubt she would receive excellent care—the ER staff would start an IV, administer oxygen, get a chest X-ray (and a scan if needed), draw her blood, and monitor her vital signs. She would receive antibiotics, or medications for her heart, or anticoagulants depending on the test results (pneumonia vs heart failure vs pulmonary embolism). If worse came to worse, she would be intubated. The doctors and nurses would do everything they could for her automatically and efficiently, without a second thought.
 
Without knowing a thing about her.
 
“You treat a disease: you win, you lose.
You treat a person: I guarantee you win.”
~Patch Adams~
 
When I got to the emergency room, Mother was sucking down oxygen via IPPB. She was weak and pale, but alert. The minute I pulled the curtain back and stepped to her bedside, she relaxed. A faint smile of recognition and relief appeared. She closed her eyes and squeezed my hand as if to say healing could now begin.
 
“A kind gesture can reach a wound
that only compassion can heal.”
~Steve Maraboli~
 
I kept an eye on the monitors that surrounded her bed while I sat with her and explained what was happening and why. I requested an extra blanket for her. I answered the nurses’ questions. I ached to know the results of the tests the doctors had run, what her diagnosis was, what was in store for her. Through it all, I kept a smile on my face while all the worst-case scenarios played out in my imagination.
 
“Isn’t it fascinating
how long a few minutes can seem
when you are completely alone
with not a familiar face in sight?”
~Kirby Larson~
 
Imagine the relief I felt when the ER physician returned to check on her…when he drew the curtain aside and I recognized a trusted colleague, a man I knew to be compassionate, gentle, and wise. Like my mother did when she saw me, I relaxed as soon as I saw him. I smiled with a deep sense of relief and gratitude. I could talk to this man and I knew he would listen. He would treat my mother like his own, and me like a sister. As if we were family. I felt as though healing had already begun.
 
*
 
This story is intended to convey the healing power of the personal relationship between the physician and the patient…the sense of relief a familiar face can bring when everything else is foreign and frightening to the patient. It speaks to the importance of trust and confidence in the healer’s character and expertise. It should remind us to regard every patient with compassion, and to treat every patient with the same respect, kindness, and care we would extend to our best friend, and to our own family members because:
 
“I’ve learned that people will forget
what you said.
People will forget what you did,
but they will never forget
how you made them feel.”
~Maya Angelou~
 
jan

 

 

 

 

 

Monday, October 23, 2017

a doctor's touch

 
 
 
This week, I planned to provide a few prompts for physicians and healthcare providers who are blocked for whatever reason from telling their stories, perhaps because of constraints on time and energy, self-doubt, or lack of encouragement and support. I had planned to offer words by Julia Cameron (http://www.theartistsway.com)
 
“Writing is medicine.
It is an appropriate antidote to injury.
It is an appropriate companion
for any difficult change.”
~Julia Cameron~
 
…and by mindfulness meditation leader Jon Kabat Zinn:
 
“Cultivate wisdom and equanimity
~not passive resignation~
in the face of the full catastrophe
of the human condition.”
~Jon Kabat Zinn~
 
Then a friend of mine (she knows me too well...) sent me a link to a YouTube video by Abraham Verghese, titled "A Doctor's Touch.”
 
 
“The most important innovation
in medicine to come in the next ten years:
the power of the human hand.”
~Abraham Verghese~
 
Suddenly a whole new set of questions arose. This video emphasizes the therapeutic effect of the laying on of hands by the physician...the healing roles of ritual and expectation...the importance of time spent with patients. It undermines the glorification of the ten-minute office visit…the game of "Beat the Clock" that doctors are required to play in order to meet productivity quotients. Don't get me started...
 
“The life sciences contain spiritual values
which can never be explained
by the materialistic attitude
of present day science.
~Sherwin B. Nuland~
 
These trends in the practice of "modern" medicine, among others, are what led me to bow out of practice out of fear of the inevitable: that the day would arrive when I would miss something important because there simply wasn't time to do the job well.
 
These are the questions I still can’t answer:
 
--Should I have taken a stand against the system and what I perceived to be the erosion of my wisdom and authority as a physician in the care of my patients
 
--How could I have done it...without risking my job?
 
--Would it have made any difference?
 
--Is it too late now?
 
Thankfully, there are physicians like Abraham Verghese who are able to speak eloquently on our behalf while the rest of us scramble to collect our thoughts and yet fail to act on what we know to be true.
 
"What moves men of genius,
or rather what inspires their work,
is not new ideas,
but their obsession with the idea
that what has already been said is still not enough."
~Eugene Delacroix~
 
Is there an issue that you need to confront? What is holding you back? What kind of a difference can you make? When will you begin?
jan
 
 
 


Tuesday, October 17, 2017

living in awe


 


One of the perks of being a physician is that you get to live in a state of perpetual awe. It starts with the first pass of the scalpel on your first day in the anatomy lab. It continues as you tease out every organ, blood vessel, and nerve in the body you’ve been assigned to dissect. A sense of wonder punches you in the gut the first time you hear a beating human heart, and you realize that your own heart has been beating steadily and predictably without any effort on your part since before the day you were born.
“Stay in a state of
gratitude and awe.”
~Wayne Dyer~
You’d have to be a toadstool not to be mystified by the anatomy, physiology, and psychology of your very own body. You’d have no choice but to believe in miracles if you understood the way a broken body heals, what it takes for an open wound to close, how a lifeless heart can pick up the beat again. Don’t even ask what happens during sex.
I studied medicine for seven years and practiced for over three decades so I understand how the body heals. I know what it takes to keep it up and running. Most of the time, I know how to fix it when something goes wrong. Most people don’t. They get out of bed in the morning and expect their bodies to work.
The problem is sometimes they don’t. We take good health for granted until something goes wrong. The cancer comes back. The paralysis turns out to be permanent. The depression won’t lift. Sometimes the afflictions of the body go beyond its ability to heal. Beyond the physician’s ability to help.
“Every patient you see
is a lesson in much more than
the malady from which he suffers.
~Sir William Osler~
For example, Pat’s son has undergone forty operations to correct the disfiguring wounds caused by the explosion that blew the side of his face away. At first, the doctors didn’t think he would live. Now he’s not so sure he wants to. Each time he goes back for the next stage in reconstruction, the incisions heal. Not so his spirit. The hospital scares him. His reflection repulses him. He wants this to be over—the repairs, the rehabilitation, the pain. Life itself. His wounds may heal but he still has a hole in his heart.
Pat would gladly take on his pain, frustration, and despair if she could spare him a lifetime of misery. She would do anything to restore him to the brave, handsome young man he was before his deployment. If his lot in life is physical and mental anguish, hers is paralyzing heartache. He feels abandoned and she feels helpless.
Helpless—the way a doctor feels when a patient under his care gets worse and there is nothing he can do about it. When he has tried everything and nothing has worked. When he feels like a failure—so not God, as is sometimes still expected of physicians.
And that’s a problem. The downside of doctoring is that sometimes the patient gets worse despite your noblest efforts. The cancer spreads. The heart fails. The wound won’t close. There is nothing more you can do. You concede that it would take a miracle for the patient to recover. All you really have left is prayer.
But what if you don’t believe in prayer?
What would it take to change your mind?
Brenda was forty years old when she went in for her first routine mammogram. Yes, she performed regular breast self-examination. No, she hadn’t felt anything unusual, nor had her husband, a breast surgeon who would have known something was wrong had his highly trained fingertips come up against a lump there. Nor did she have a family history of breast cancer that put her at risk. Nothing.
Which is why the X-ray report came as such a shock. A large mass occupied most of her left breast and the calcifications in it looked suspicious. While she explained to her children why she had to go into the hospital, her friends and family stormed the heavens with prayer. You can imagine the collective sigh of gratitude and relief that went up when the surgical reports came back negative. When they failed to turn up a single cancer cell.
“Impossible,” the doctors said. They re-examined the X-rays. They pulled the slides out and went over them again in excruciating detail, searching for even one abnormal cell. They were left to shrug their shoulders in disbelief. She was healed. Her surgeon couldn’t explain it, but her friends and family hailed it as a miracle and they attributed it to prayer.
“Be patient toward all that is
unsolved in your heart
and try to love
the questions themselves.”
~Rainer Maria Rilke~
On the other hand, the doubting Thomases explained it away based on the limits of technology. After all, they insisted, not every X-ray is accurate. It might have been caused by human error. Perhaps the planets were aligned in her favor that day. They would accept any explanation but they would not acknowledge the triumph of a medical miracle. In cases like this, the faithful celebrate while skeptics ramp up arguments to explain it away, and doctors are left to shake their heads in disbelief.
Or in awe, depending on how you see it.
“I think this is how
we’re supposed to be in the world~
present and in awe.
~Anne Lamott~
jan
 
 
 

 
 

Monday, October 2, 2017

how stories bring us to wisdom

 
 

 
 
To really understand a story, you have to know something about the person who is telling it.
 
“It may take a doctor
to diagnose someone’s disease,
but it takes a friend
to recognize someone’s suffering.”
~Unknown~
 
Picture this: a four-year old is enjoying an ice cream cone on a hot summer day. But the ice cream is melting faster than she can lick it off. Suddenly the whole thing just gives way and ends up a pool of sticky sweetness on the hot sidewalk. She starts to cry. She is unconsolable because her ice cream is gone.
 
If she could tell her story, she might describe how happy she was when her mother bought her the ice cream cone, and how her heart was broken when it fell to the sidewalk. She might blame herself for being careless and feel guilty about having ruined it.
 
Depending upon her personality, her mother might see it two ways. It might upset her to see her child’s disappointment and to hear her crying. Or, she might be angry because her daughter was careless with it and her money was wasted. Two different stories.
 
Her bratty brother might describe his perverse delight in her predicament.
 
Everyone would tell the story differently.
 
Likewise, patients tell their stories from different perspectives depending on the situation. This can be misleading for the physician. Some people panic at the slightest ache or pain. Some people ignore a serious problem out of fear. A good example is rectal bleeding. Everyone knows it can be a warning sign of colon cancer…but no one wants to have a colonoscopy.
 
“Fear of illness
accounts for more deaths
than illness itself.”
~#marvinthegreat~
 
Others may be in denial about their symptoms. Chest pain is blamed on indigestion when the patient is actually having a heart attack. Or heartburn is blamed on stress when the problem is an ulcer. They try to convince themselves it isn't serious.
 
Stoic patients may minimize their symptoms. My mother was a stoic woman. I called her one Sunday evening, like I did every week, and I noticed her speech was slurred. When I asked her about it she said, “Oh, I think I might have had a slight stroke a couple of days ago.” Did she call the doctor? No. She didn’t think it was severe enough to bother him about.
 
“Listening is often
the only thing needed
to help someone.”
~Unknown~
 
The medical history, then, can be misleading. To get the whole story, the physician has to listen to the patient’s story while also observing his expression and body language. It helps to know what is going on at home and at work. It takes time to explore his beliefs, his fears, and his experience of illness.
 
It helps to know the patient. It helps us know his disease.
 
“Facts bring us to knowledge,
but stories bring us to wisdom.”
~Rachel Naomi Remen~
jan



Monday, September 25, 2017

no contest



 
 
I’m pretty sure Mother Earth wobbled on her axis last week after three epic hurricanes, raging wild fires, and a catastrophic earthquake disfigured the face of the planet we call home. The urgent and passionate stories that erupted in the aftermath of these disasters held us spellbound…horrified…as tragedy unfolded before our eyes.
 
We witnessed accounts of terror, helplessness, grief, and pain. We heard stories of courage, strength, compassion, and faith.
 
I don’t know about you, but those stories silenced me. The worries I harbor, the sadness I feel, the losses I face in my life pale by comparison. Who would want to hear about them?
 
“Writing is a struggle
against silence.”
~Carlos Fuentes~
 
For example, I could tell you about a friend of mine who missed a step in the middle of the night a couple of weeks ago. She tumbled down a flight of stairs and suffered a brain hemorrhage. Her family and friends have kept a bedside vigil ever since, even though the  prognosis for her recovery, short of a miracle, is nil. It’s a tragic story…but it is dwarfed by the magnitude of suffering we witnessed in the aftermath of the disasters that wracked the world last week.
 
“Write what should not be forgotten.”
~Isabel Allende~
 
Perhaps the same thing has happened to you. You went mute because your story sounded dull or ordinary or immaterial by comparison. It was unworthy. Unnecessary.
 
It doesn’t take a natural disaster or a missile launch or a violent uprising to shut storytellers down. We do it to ourselves all the time. We trivialize the course of our own lives, lock away our memories, and dismiss our thoughts, feelings, and convictions because we doubt ourselves. We tell ourselves our story isn’t important.
 
“Write hard and clear
about what hurts.”
~Ernest Hemingway~
 
In fact, everyone’s story deserves to be heard. Storytelling is not a contest to see whose narrative is the scariest or saddest or most horrifying. Rather, it’s the pathway to truth as each of us understands it. 
 
“You can’t make this stuff up.”
~Lee Gutkind~
jan