Saturday, November 19, 2016

how will you tell your story?

This week’s post presents a brief excerpt from my novel, The Bandaged Place. It goes without saying that this scene is fictional, but it could just as easily be part of a memoir, it is that authentic. It connects the reader with a moment she may have experienced in her own life--when she had to share bad news with friends, when she needed their support, when she knew how hard it would be for them to come to grips with her predicament. The fact that it is fictional does not diminish its impact, suggesting there is more than one way to tell a story.
In this scene, the protagonist, a physician, has just told her two closest friends she has been diagnosed with breast cancer:

          My kitchen is as silent and as still as any place on the face of Earth has ever been—the deepest cave, the holiest shrine, the eye of the storm. I have just finished explaining to Sophia and Barb why I need them here today. It’s one thing to sit at your desk with a patient and break the news to her, “You have breast cancer.” It’s another thing entirely when you are seated at your own kitchen table with your best friends, saying to them, “I have breast cancer.”
          They’re sitting across from me stunned, expressionless, struggling in vain to access whatever words they need to say to me right now. But there are no words for this. Silence reigns.
          I am tracing the pattern of the grain in the wood on the tabletop. Sophia is looking out the window, her chin resting on her hand, gazing as far away as possible. Barb is staring at me, searching for some sign, some indication that would explain how she missed it, as though she should have known something was wrong. And I am having second thoughts as I watch both of them wrestle with this—as I watch everything change for them—knowing what I just unleashed in their lives.
          I break the silence, “Well?”
          Sophia slowly turns her attention back to the present. “Well what?”
          “Well, what’s going through your heads?”
          Barb turns to Sophia for help with this one.
          “Me?” Sophia sits forward and braces herself as if she’s preparing for turbulence, in full upright and locked position. “If it were my decision, Kate, I’d have them both off. And I wouldn’t bother with reconstruction. I mean, what purpose under heaven do they serve anymore?” She waves her hand as if she were scooting the dog away. “That’s what I think.” She sits back as if the voice-of-reason has spoken. Clearly, she doesn’t understand.
          Barb stares at my chest as though the answer is scrawled in capital letters across the front of my sweater. True to form, she sums it all up, “You know what I think? I think you’re lucky they’re both pretty small.”
          Sophia closes her eyes and wags her head. “You’re impossible.”
          I have to giggle. I can’t help it. Barb would come up with something like that. Why is it, I wonder, that the worse you feel, the better bad jokes sound—silly, stupid, crude—as far from reality as you can get?
          “When I was ten,” I tell them, “I went crying to my mother because I had this little sore bump on my rib, right about here.” I point to my heart. “Mimi had just died and I knew that she had breast cancer so I was convinced that I’d caught it from her. At ten! I was so sure of it—so scared—I waited a month before I said anything. And by then it was even bigger so I was certain I was doomed. But Mother just smiled and told me, ‘It’s part of growing up, is all. It’s perfectly natural.’”
          “That was natural,” Barb quips. “This is not.”
          Nor is it fair. Nor is it even conceivable.
The fact is that scenes like this unfold all the time in real life. If you’ve ever shared bad news with your closest friends, you know how hard it can be.

The point is that each of us has a story to tell. If you write, you can translate what you experience, think and feel into a memoir. But if what has happened is too painful or too difficult to chronicle, try wrapping it up in a story or a poem. If you are an artist, you may be able to express yourself better on the canvas. If you compose, in your music. If you act, on stage.

There is more than one way to tell a story, but tell it you must. Which way is right for you?





Saturday, November 5, 2016

a needy character

I've been off the grid for a couple of weeks because I've been downsizing and moving. This process taught me a couple of things I'd like to share with you.

I learned to ask for help…putting furniture together, setting up a new internet server, installing electrical fixtures, lifting and carrying…the list goes on.

Retro-Fans Blog

But, asking for help isn’t easy for me. I don’t like to inconvenience people or burden them when they already have more to do than they can handle. I feel better about myself when I know I can manage on my own. And, I’m never sure who to call. Who’s reliable? Honest? Thorough? Nevertheless, because I’m pretty helpless when it comes to hi-tech changes and to mechanical and electrical upgrades, I had to ask for help.

Then it struck me.
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For over thirty years, I met day after day with people who had turned to me for help. I was a healer, a pillar of hope for them.

If you’re a health care provider, you know what I’m talking about. Our patients’ health and well-being are at stake. Sometimes their survival is in our hands. They come to us with heart disease, cancer, broken bones, depression…unable to care for themselves. They need the help of an expert, someone who is careful, compassionate and wise, but they don’t always know who to turn to. Imagine what it must be like for the woman who discovers a lump in her breast. For the parent whose child can’t breathe. For the trucker having dizzy spells. Imagine not knowing what to do or who to call. Who you can trust. Who you can depend upon.

When I moved I was anxious about calling for help just to install a kitchen fixture, assemble a desk and repair an appliance, trivial matters compared to one’s health. Nevertheless, it was a huge relief when family members, friends, and friends of friends responded promptly. Every single one of them was happy to lend a hand. Total strangers treated me with respect and kindness.

I would consider myself a success as a physician if I could be as cheerful, as skilled, as attentive and as considerate as the people who helped me when I needed them this week—the plumber, the electrician, my new neighbors. My friends. My family. All of them ordinary people acting with extraordinary character.  

Image result for character is how you treat those who can



Sunday, October 9, 2016

why we need to hear your story

True story:

Almost twenty years have passed since I was sued for malpractice.
It was a classic case of a “missed diagnosis”—colon cancer in a young woman with no personal or familial risk factors for the tumor. In her case, it lurked just out of reach of the flexible sigmoidoscope, back in the days when flexible sigmoidoscopy was considered the standard of care for young, low risk patients with minor rectal bleeding. In this population the most likely culprits were hemorrhoids, fissures or small inflammatory polyps. Colonoscopy was considered overkill in cases like this. It was expensive and insurers were reluctant to cover it. Out of pocket expenses for the patient could run into thousands of dollars. In addition, it entailed the risks associated with anesthesia and perforation. 

So I performed a "flexi" on her.

I felt confident in my skill and thoroughness when I explained to the patient that she did, indeed, have internal hemorrhoids which were the likely cause of her bleeding. Nevertheless, I gave her careful instructions to follow up with me for further evaluation if the bleeding persisted or worsened. In fact, I provided her with three test kits to run at home for what is referred to as occult bleeding—blood in the stool you can’t see but can test for. In either case, she would need a colonoscopy.

I never heard from her again. In fact, her name never came up until two years later when I received an official summons that began: “YOU HAVE BEEN SUED IN COURT.”
By then, she had undergone surgery, radiation, and chemotherapy to no avail. She died after a long, painful struggle with the disease, leaving behind three teenage children and her husband.

To make a long story short, the case was settled out of court with the help of a topnotch expert witness. Serendipity may have been on my side as well. Before he went into malpractice law, the prosecuting attorney had been a friend of mine. We attended the same church, our children played sports together, and we had entertained him on more than one occasion in our home. I have always wondered if he went easy on me. Fortuitously, the day of the deposition, he was suffering from a back injury making it impossible for him to grill me for ten hours without food, water, or bathroom breaks as was his customary practice. My malpractice carrier handled the out-of-court settlement. Things could have been much worse for me.

But that’s not the point of this story.

The point is this: my patient’s fate found a permanent home in my heart. Today, for example, I thought about her when I drove to a nearby state park and hiked the lakeside trail through the woods…under a ridiculously clear blue sky, in the warm sunshine, against the gusty wind. I think of her when the snow falls, turning the world soft and silent. I think of her, her children and her husband on the very days I am most grateful to be alive. I am reminded that she’ll never enjoy another sunrise at the beach, another sip of wine or another good strong cup of coffee. She didn’t live to see her grandchildren come into the world...

...which probably explains why, twenty years later, her spirit lives on in my heart. Whenever I feel gratitude or joy or pure pleasure I think of her and all that she has missed. It never fails. It keeps me mindful. It keeps me humble. It makes me sad.

That’s my story. What’s yours? If you are prompted to share it with us, you can use the comment field below, or contact me and we’ll work something out.


Sunday, October 2, 2016

why you can't make this stuff up

Don’t let the term “narrative medicine” intimidate you. This is a broad and inclusive writing niche. You don’t have to be a physician to practice it. In fact, you don’t have to be a health care provider at all to share your story with the world. Nor do you have to be a patient who survived a serious illness or encountered a life changing injury to engage readers with your experience, thoughts and feelings about it.

Perhaps you work in the hospital laundry and never have direct contact with patients at all. What if you were sorting through the surgical scrubs that came down from the OR one day when a half-burnt joint fell out of a pocket? Which bleary eyed surgeon did that come from? Or, imagine you’re a janitor called to fix a leaky faucet in the middle of the night. When you walk into the room, the patient is breathing quietly. Then you hear a groan and his breathing stops.

Oh, you have stories to tell all right.

If you’re a patient, tell us what went through your mind the day the chest pain started. What worried you about it? Why didn’t you go to the ER sooner? Tell us what it was like to wait in the ER for hours before someone came to set your child’s broken wrist. What did you see there? An angry drunk in handcuffs escorted by the police? Drops of blood drying on the floor? The surreptitious pinch on her behind the doctor gave the receptionist when he thought no one was looking?

What is it we like to say? You can’t make this stuff up.

Now, let’s add another layer.

What if the surgeon who is scheduled to replace your aortic valve in the morning was up all night because that afternoon his son totaled the car on his way home from school? What about the ICU nurse who found the cigarette burn on the shirt her ten year-old wore to school yesterday? What about the single mother who works in food service with the dull ache in her low back and unpaid bills collecting on her kitchen counter? What are their stories?


Sunday, September 18, 2016

never underestimate the healing power of storytelling

This week I came across an article in Psychology Today (you can read it here) that alerted me to yet another show-stopping demonstration of storytelling as a healing process.

It told about an elderly patient with dementia who had become increasingly confused and combative at home. When her condition deteriorated following a fall, her family took her into their home to care for her. Then, following a seizure, she was hospitalized and underwent a battery of tests including blood tests and brain scans that frightened and confused her. She experienced hallucinations that intensified her fear. Because she didn’t understand what was happening to her, she created a narrative in her mind that made sense to her. She convinced herself she was the victim of terrorists, and that she was being tortured. She became increasingly fearful and angry with her family because she believed they had allowed it to go on.

Instead of trying to convince her she was wrong, the family offered her a different story to explain her situation. Instead of taking offense at her accusations, trying to change her behavior, or medicating her, they created an illness narrative. They helped her understand that she had a disease called Alzheimer’s that was causing her confusion and forgetfulness. They reminded her of her fall and the seizure, and what tests she had endured. Little by little it all started to make sense to her and her anger and fearfulness subsided. Once she understood what was happening to her, she was able to accept her family’s care and to make peace with her prognosis.

Image result for terry pratchett quotes about alzheimers

The authors conclude:

A narrative is a powerful thing. A narrative not only makes sense of the past, but also allows one to see the self in the future. The problem is that we all know the future of the Alzheimer's narrative: gradual decline and the expectation of future difficult episodes. We know that we will have wonderful moments as well. Having this narrative, even with the known end to the story, has been a blessing. The narrative provides an understanding and a feeling of resolution. In addition, this shared narrative improved and repaired our damaged relationship.”

Never underestimate the healing power of storytelling.

Monday, September 12, 2016

plot points in retrospect

There is some truth to this observation:

We were reminded of this last weekend as we commemorated the lives that were lost as a result of the terrorist attacks of 9/11. I was at work that day so it was hard to keep up with events as they unfolded and reality set in. You probably remember exactly where you were and what you were doing that day, too.

The same is true for many of us when the space shuttle, Challenger, exploded. I was in the drugstore, at the checkout when I heard the news. When we learned that President John F. Kennedy had been shot, I was sitting in 9th grade algebra class.

Some memories stay with us because they are tragic, some because they are inspiring, or funny, or scary. Some moments in time stay with us for reasons we may not understand while others are lost forever. One hectic day blends into another until whole blocks of time fade from memory. All we know of our past are the moments we can recall.

A lifetime in medicine is no different. The years we dedicate to patient care—the unending procession of patients, the emergency admissions, and daily hospital rounds—leave us little time for reflection. We don’t purposefully commit each day’s events to memory. Nevertheless, some moments survive as vivid images that flash back to us uninvited years later, each one a glimpse back in time, back into the story of our lives.

Here are a few moments in medical practice that are forever chiseled into my psyche:
  •  A gentleman presented to the office with chest pain. His wife was seated next to him in the examination room as I placed my stethoscope on his chest. Suddenly, as I listened, his heart simply stopped beating. He slumped to the floor as his wife looked on. CPR failed to revive him. His story ended that day, while his wife’s story changed forever.
  • A “Code Blue” (cardiac arrest) summoned us to Labor and Delivery where a young woman had hemorrhaged following the delivery of a healthy baby. Her story ended there while, waiting in the visitors’ lounge, her husband poured himself another cup of coffee in joyful anticipation of the birth of their first child.
  • A patient was admitted through the emergency room for what was described as an unsuccessful suicide attempt. He thought he’d ingested rat poison from an unlabeled bottle in his garage. Instead, it turned out he’d actually swallowed sulfuric acid. Rat poison ingestion is treatable. Sulfuric acid ingestion is not. He was placed in a medically induced coma as his mouth, throat, and esophagus disintegrated. Life support measures gave friends and family just enough time to say goodbye before the doctors pulled the plug. His depression came to an agonizing end that day, while theirs was just beginning.

Looking back, I don’t remember how any of those days started for me. I forget what happened later on. But I do remember the look on his wife’s face when that first patient slumped to the floor. I remember watching the young woman’s husband cradle his newborn baby in his arms as the doctor explained what had happened to his wife. And I remember keeping the suicidal patient alive, if unresponsive, while his family confronted the unthinkable tragedy that, in fact, ended his life.

Oh, I could go on.

If life is a story worth telling, these are the plot points that change the story arc. 

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They have the power to turn comedy into tragedy, reality into mystery and hope into despair. 

Where do these memories hide, and why do they return?

Do long-forgotten memories ever intrude upon your thoughts? What triggers them? How will you use them to tell your story?


Monday, September 5, 2016

an outpouring of stories

If you want to hear an outpouring of stories about medicine, start a conversation about childbirth with a gathering of women or about sports injuries among men. Ask a group of doctors about their most difficult cases. Listen to any cancer survivor describe her diagnosis and treatment. Ask a child about the band aid on his knee. You’ll find a story there.

These stories serve us in several ways:
  •  By narrating our experience, we organize our thoughts about it. No longer are we plagued with a vague sense of fear or dread or uncertainty. We come to understand what our fear is based upon. The pregnant woman confesses, “I thought I did something wrong to cause the bleeding.” The basketball player says, “I thought I’d never play again.” The doctor admits, “I had no idea what to do next." 
  • Storytelling is an attempt to understand the cause and timing of an illness. Why me? Why this? Why now? What did I do, or fail to do, to bring this on?
  • It enables us to understand the role illness plays in our lives. How it affects our family and friends, our team, our job, our finances. Our future. It all comes out.
  •  It forces us to ask some difficult questions. What could I have done differently? How much pain can I bear? Who will take care of me? How long do I have to live? 

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This is a big deal. Illness disrupts our lives at the same time it grounds us. It forces us take a good hard look at what we value. Shared stories of recovery and healing dispel fear and give us hope. Stories of loss deepen empathy and help us confront denial. Stories of courage and faith strengthen us for our own battles.

The importance of storytelling in medicine cannot be overestimated. Most of us are bursting with stories, about to explode with the untold narratives we stuff inside because no one invites us to tell them.


Sunday, August 28, 2016

listen up

Storytelling isn’t easy. Even the best authors sometimes struggle to put their ideas into words, and emotions can be hard to express.  Ask any writer.

So it shouldn’t come as a surprise that patients have trouble telling the stories of their illnesses. When they try to tell us about their symptoms, they may not have the language for it. The fellow having a heart attack may describe his pain as indigestion, when the doctor is looking for words like dull, heavy, or tight to describe the discomfort. The patient who is lightheaded may  describe the feeling as dizziness rather that fainting. The provider then has to determine if the patient is experiencing presyncope or vertigo. The patient who complains about pain in his sinuses may be experiencing a migraine headache. Patients don’t know what we need to hear from them about their symptoms, so sometimes the obstacle is language.

Sometimes the problem is denial. The fellow having the heart attack may know exactly what is happening to him, but be so scared by the prospect he unconsciously tries to make a case for something less ominous. He describes his problem as indigestion, hoping the doctor will say, "It sounds like reflux. Nothing too serious."

Fear, then, is another confounding factor. When a patient describes a symptom, the provider has a long list of details he needs to know in order to diagnose the cause of the patient’s distress. However, the patient might be more frightened by the symptom than he is suffering from its severity. Perhaps a coworker recently suffered a disabling stroke. The patient is having some tingling in his right hand so he’s convinced he’s about to have a stroke, too. Carpal tunnel syndrome doesn’t cross his mind. The tingling isn’t severe, but his fear of having a stroke is off the charts. Once the doctor addresses the patient’s unfounded fears, treatment has a better chance of success.

It’s up to the provider to figure out what is what. This explains why health care providers must be excellent listeners. We have to make an accurate diagnosis by listening clinically, and we must understand how the illness affects the patient by listening empathetically.

Listening clinically involves getting the details right. Encouraging the patient to tell us about the onset of his symptoms (sudden or gradual), the duration (hours, days or months), the severity (mild or excruciating), and quality (sharp or dull, constant or intermittent, localized or generalized). A thorough and accurate history of the patient’s symptoms is fundamental to making an accurate diagnosis.

But there’s more to it than that. Empathetic listening enables us to understand how the illness affects the patient, what it means to him, and why. Why is he in denial? What is he afraid of? How will his illness affect his job, his family, his faith? It includes:

  • Reading facial expressions and body language. For instance, if the patient brings his fist to his chest when he is telling you about his heartburn, you need to think heart attack instead. It’s a classic gesture. 

Image result for patient describing a heart attack with clenched fist in chest

  • Understanding the patient’s emotional state. I once had a young woman come in with a swollen black eye. She laughed it off. “I’m so clumsy,” she said. “I was jumping on the bed and hit my eye on the corner of the TV.” In fact, she had a blowout fracture of the floor of the eye socket. When I asked her what really happened, she described the blow she took from her boyfriend’s fist, the fear she felt for her life. She not only needed medical care, she needed social services.
  • Listening between the lines for what the patient may be leaving out. I used to ask my teenage patients whether or not they were sexually active. Invariably, the answer was, “No.” That let me off the hook. I didn’t have to ask about STDs or contraceptive practices. It saved time…but I knew it wasn’t always true. So I started to ask instead, “How many sex partners have you had?” Eight, twelve, twenty-five! I was flabbergasted. But it enabled me to begin a meaningful discussion about body image and the patient's sense of self-respect. We went over the dangers of and prevention of STDs. And I was able to offer reliable contraception. 
What difference does empathetic listening make? It gets us closer to the truth. It connects us with our patients in a meaningful way. It improves patient satisfaction and that by itself helps promote healing. It enhances diagnostic accuracy and the efficacy of treatment. It decreases the physician’s sense of frustration and ineffectiveness. And by strengthening the physician-patient bond, it decreases the rate of physician burnout.

If good storytelling is an art, effective listening is a craft. In these efforts the physician-patient partnership is forged. Health care becomes a mutual endeavor, and everyone benefits from it.
“You are so brave and quiet
I forget you are suffering.”
~Ernest Hemingway~

Sunday, August 21, 2016

a conversation that matters

True story:

Just yesterday a friend and former patient of mine stopped me after church to tell me how much better she was feeling since my husband—the consummate family physician—had seen her at home the previous Sunday. It's true. He made a weekend house call even though he wasn’t on-call that day.

She’d been suffering from incapacitating neck pain and headaches for a couple of weeks, but hadn’t called my husband about it because she was in palliative care for an oppositional defiant malignancy that nothing could stop. She didn’t call him about the pain because her oncologist and hospice nurse had already called in prescriptions for narcotics that hadn’t touched it. She understood the concept of palliative care to mean that nothing more could be done for her so she assumed the pain was part of the process.  

Nevertheless, even though her specialists were not treating the cancer anymore, the goal of my friend's medical care was to keep her as comfortable and functional as possible, for as long as possible. I reminded her that incapacitating pain is not considered by most patients to be comfortable. When a patient who is otherwise still independent becomes housebound because of it, she is not really functioning. She deserved to be treated for the pain.

Her husband was the one who finally called my husband who then took time out of his weekend off to listen to her story and examine her. Based on what he found, it was apparent that her problem was muscular. It had nothing to do with the malignancy. After one day on a muscle relaxant and low dose steroids, the pain subsided. She slept through the night for the first time in weeks. And to her relief, the pain has not recurred, which explains why she was able to get to church this weekend. Why her appetite came back. Why she was smiling despite her generally poor prognosis.


Rita Charon, in her ground-breaking book, “Narrative Medicine—Honoring the Stories of Illness,” presents an unconventional approach to gathering information from the patient. She simply invites the patient to “tell me what you think I should know about your situation.” Then she listens. She doesn’t scribble down notes or tap away at her keyboard while the patient is speaking. She listens.

Had my friend’s oncologist or nurse used this approach, I think she would have told them, “I’m having severe pain in my neck. I can’t move it when the pain comes on. Then I get a severe headache. It’s so bad I can’t leave the house. I can’t eat. But they said nothing more could be done for me so I didn’t want to bother you about it." 

That miscue resulted in weeks of unnecessary suffering for a woman who had already suffered enough.
“Be brave enough
to start a conversation that matters.”
~Author Dau Voire~

Thursday, August 18, 2016

can you hear me now?

Clearly, storytelling is important in the practice of medicine. All day long patients tell us their stories. During hospital rounds colleagues discuss interesting and difficult cases. This often continues over lunch, after office hours, even on the golf course…wherever health care providers convene.

We tell stories hoping that someone will listen, and by listening, understand…and by understanding, come to care. This helps patients make sense of their illness, find meaning in it, and begin the healing process. Storytelling helps answer the questions: Why me? Why this? Why now? It enables providers to share information and experience, to celebrate when patients recover, and to bear the loss when they don’t.

We all benefit from telling our stories…but who benefits from hearing them?

In fact, listening connects us in extraordinary ways. Not just cognitively and emotionally, but physiologically. This is a measurable phenomenon. Yay for technology!

Functional MRI scans detect changes in blood flow and oxygen uptake in different regions of the brain. It has been shown that when listening to a story, changes occur in the listener’s brain that coincide with or mirror the pattern in the teller’s brain. This is called speaker-listener neural coupling. The greater the coupling, the greater the understanding. The extent of speaker-listener neural coupling predicts the success of the communication. (Here is a link to a highly technical paper on this subject for any skeptics out there: )

The concept of neural coupling has enormous implications for narrative medicine. If we want to understand a patient’s illness, we need to listen to his story. Not interrupt his narrative. Not redirect him to satisfy our own agenda. Not fix our gaze on a computer screen and check off boxes.

Miscommunication between patients and health care providers can lead to misdiagnosis, and misdiagnosis can lead to inappropriate treatment. The patient’s condition can worsen because the doctor doesn’t understand the patient's illness. He didn’t listen to the patient’s story.
"Histories must be received, 
not taken."
~Sir Richard Bayliss~

Sunday, August 7, 2016

primum non nocere

I learned something new today. This is a good sign because some people like to joke about my incipient dementia. At least, I hope they’re joking.

I was toying with the topic for today’s post when the phrase “primum non nocere”—first do no harm—came to mind. I learned that the Hippocratic Oath is not its source. It actually comes from Hippocrates’ writings in “Epidemics”: “The physician must…do no harm.” These words are the bedrock of medical ethics and practice. Hippocrates is regarded as “the father of medicine” for good reason.

In fact, many of the traditions that influence the way we practice medicine today were passed down to us by men. Not because women were excluded from the practice of the healing arts in ancient Greece. On the contrary, women were highly respected as physicians and healers. Even Plato held them in esteem. Though they were few in number, patients sought them out. They were regarded as the “wise women” of the community. Their “soft hands” were considered to be “healing hands.”

But as the science of medicine advanced, the feminine ethic lost credibility. Its wisdom and power to heal were dishonored in favor of dispassionate technical expertise—testing, procedures, and proofs. Today speed and efficiency reign, and reimbursement issues drive the system. Over time, tradition has suffered. As a result, patient care has suffered, and even physicians have suffered.

One of the time-honored traditions that survives today expressly prohibits the physician from entering into a personal relationship of any kind with his patients. This, of course, is an impossibility. It disavows the emotional intimacy that is the inevitable fruit of shared suffering. It contradicts the compassionate physician’s experience and denies him a powerful tool.

Today, the physician is taught that it is unprofessional to share personal experience, insight, beliefs or values with the patient. This rule of non-engagement is hammered into our heads during training when we’re still easily moved to empathy, at a time when connectedness with other human beings is still something to be desired and defended.

Sadly, this means that patients may know more about their hairdresser or mechanic than they know about their doctor—the person they trust with their health and their children’s health. With their lives. Most patients know nothing about him but what they can gather from the plaques and certificates displayed on the walls in his office—what schools he attended, when he graduated, what honors he earned…which speaks to his intelligence but what about his inspiration, his motivation, and his conduct?

This can be troubling for patients. They have little choice when it comes to selecting a physician and, except for the credentials hanging in his office, they may know nothing at all about him. They worry about it, and they should. Is he competent? Is he caring? What motivated him to undertake years of grueling study and training? What sustains him? How does he manage it all?

This precedent distances us from our patients at times in their lives when what they may need from us more than anything else—more than another prescription or another test or another procedure—is our presence with them, our strength, compassion and support especially at times of serious illness and suffering. At times when fear and grief cut deep. At times when they may need to understand that nothing more can be done for them…or for someone they love—a friend, a spouse, or a child. When our patients need us the most—that is, when there is no hope for them—we are trained to turn their care over to the nurses, or the family, or their pastor.

We leave the bedside the way we approached it—as strangers, not storytellers.
“Some patients, though conscious that their condition is perilous,
recover their health simply through their contentment
with the goodness of the physician.”
~Hippocrates (460-400 BC)~

Saturday, July 23, 2016

when to think outside the box

Last week I talked about the history of the present illness, or more appropriately, the story of the present illness. This cannot be adequately recorded using a bulleted list of oversimplified prompts (What are your symptoms? When did they start? How often do they occur? How long do they last? What kind of treatment have you tried?). The story also needs to take into consideration the patient’s expectations for recovery, his fears, the misconceptions he may have about his illness, and the effect it may have on his family and friends, his ability to work and his willingness or reluctance to engage in treatment.

As if that weren’t hard enough, the standard medical record goes on to explore three other histories that influence the patient’s illness:


Here the provider is looking for a history of previous illnesses, surgery or injuries that might have led to the patient’s present illness or have predisposed him to problems later on. Perhaps he was treated for a childhood cancer that increased his risk for a second malignancy later in life. Maybe it was an accident that required surgery for abdominal trauma that predisposed him to the occurrence of a bowel obstruction later on. Maybe a case of rheumatic fever as a child damaged a valve in his heart leading to heart failure years later. The possibilities are endless.

The past medical story may sound a little different, though. In my brother’s case (see my previous posts), he suffered bouts of anxiety and depression all his life but no one understood why. He was ashamed to tell his story so no one could help him. It didn’t seem possible that his anxiety and depression had anything to do with the episode of rheumatic fever he experienced when he was five years-old. Not until he told me about the fear, dread, and hopelessness he suffered way back then did we uncover the truth together…that, as a child, he misunderstood what was happening. He was sure he was going to die, and the fear of death had stalked him all his life. Once he understood the disease and how it was treated back then, once he accepted the fact that his heart was healthy, recovery from the emotional and psychological aftermath of the illness was possible.


This is important for the provider to explore because some conditions tend to run in families. Some problems are passed on from generation to generation. Genetic disorders come to mind, but so should alcoholism, certain cancers, and some mental health problems. Their occurrence in a relative may raise the risk for other members of the family.

The family story, though, may be more complicated. In her landmark book “Narrative Medicine—Honoring the Stories of Illness,”

...Rita Charon sites a patient who presented with abdominal pain, weight loss and diarrhea. Because his uncle had died of pancreatic cancer he assumed he had the same thing and he believed that death was imminent. Having watched his uncle suffer through the terminal stages of the disease, the patient chose to die of it as quickly as possible. What surprised him was the ease with which he made this decision and how complacent he was about the end of his life. When testing revealed a benign and easily treatable condition, he was forced to confront his masked depression and passive suicidality.


Here the provider is looking for a history of smoking, drug and alcohol abuse, dietary habits, exercise, domestic violence, sexual preferences and habits, and occupation, all of which can adversely affect the patient’s health.

This is where the patient’s story gets complicated. He may be ashamed to admit to unhealthy habits and practices. He may feel guilty if his health has suffered because of them. He may lie about it. For these reasons, it may be harder to pull this part of the history out of the patient, and even harder to motivate him to change.

I had been seeing a patient for years, trying unsuccessfully to lower her triglyceride levels. We discussed her diet and exercise routine in detail at every office visit. Even medication didn't help. It was a mystery until she admitted to consuming a bag of chocolate chips every day.

Every. Day.

I was flabbergasted. Had she failed to make the connection? Was she in denial? The truth can sometimes be hard to come by.

It’s a monumental task just to take a good medical history. Then you still have to conduct the physical examination, order tests and create a treatment plan. And that takes time.

Nowadays, for speed and convenience, the medical record allows the provider to simply click on a little box next to the problem:
                                                          tobacco use
       alcohol use
       illicit drug use
       caffeine intake

But this doesn’t give you the real picture. Sometimes you have to think outside those little boxes and color outside the familiar lines to get the patient's whole story.

“It is more important to know what patient has the disease
than to know what disease the patient has.”
~William Osler~

Sunday, July 17, 2016

the story of the present illness

The story of my life during the years leading up to my retirement could have been recorded in ten-minute sound bites, patient after patient, day after day. This was in keeping with the trend toward abbreviated discourse, 140 character tweets, and snarky comebacks that have come to replace the leisurely, thoughtful exchange of ideas that human beings have always enjoyed, and sometimes depended upon.

In medicine, the written or dictated patient note has been largely replaced by the electronic medical record (EMR). Nowadays, rather than narrating the patient’s story, you navigate his data base with a series of clicks that pull up a confusing array of bulleted lists, complicated charts, and sketchy details.

This is intended to expedite what has been ruthlessly abridged to a ten-minute office visit. After all, as physicians, we have productivity quotients to meet and income to generate. That forces us to see more patients faster and to learn less about them at the same time.

It wasn’t always this way, though. There was a time, not many years ago, when I could scan my schedule for the day and envision every patient I was scheduled to see. I knew them that well.

With a quick glance at the chart I was able to recall who was getting ready to start chemo. She’d presented with palpitations and chest discomfort that could have required an extensive cardiac work-up. Instead, we discussed the anxiety she felt having watched her mother die of the same cancer despite having consented to the same treatment. My patient’s heart was fine. Her family history (a.k.a her story) made the diagnosis. Try teasing that information out of an EMR.

I knew instantly whose intractable headaches began the day she discovered the cigarette burn on the sweater her ten year-old wore to school that day. I could have run every test under the sun and prescribed every medication known to mankind, but unless we addressed the problem she was having with her child, nothing would have helped.

I remembered it because I'd asked about her family, she'd told me the story, and I'd written it into the chart.

This isn’t just idle chit-chat. It’s not a waste of time. In medical jargon, it’s called “the history of the present illness” but it could just as well be called “the story of the present illness.” And it should interest more than just writers. Research has shown that patients require fewer medications and fewer follow-up appointments when they are allowed, indeed encouraged, to tell their whole story. Patient satisfaction improves. And it improves the odds of getting the diagnosis right.

This should appeal to the CEO’s and CFO’s of hospital health systems because in the long run, it saves time and money. (More on that pet peeve later...)

Good history taking is the key to excellence in medical care. Every patient is embedded in a family, a community and a culture, each of which affects their health. All patients experience illness in terms of their expectations, beliefs and hopes. They know all about fear, shame, anger, guilt and despair. Every one of them deserves our attention, respect, expertise and honesty.

Each and every one of them has a story to tell and a lesson to teach. And that takes time.

"You are not your illness.
You have an individual story to tell.
You have a name, a history, a personality.
Staying yourself is part of the battle."
~Julian Seifte~