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.

jan

 

 





perception vs reality

 

The medical history can difficult to obtain for many reasons. A patient’s description of his illness can be affected by his perception of it, his experience with it, and what he imagines about it. By his expectations. By fear or denial. Or he may simply lack the language to express it.

“Perception is reality.”

~Lee Atwater~

For example, if I had to tell you what has been going on in my left foot for the past six weeks, I would be hard pressed to describe it. You would be left scratching your heads. It all started with localized pain during weight-bearing (but no tenderness to touch). It started to swell, and then, after four weeks, I noticed bruising. I don’t recall any injury. It’s hard to know what triggers the pain because it seems worse at night for some unknown reason. I have no idea why it is getting worse despite the fact that I have been faithfully resting my foot like I know I should. It frustrates me because I can’t exercise. It worries me, too. What if I need surgery? What if I can’t take care of myself?

Even though I’m a physician, and I know all about strains and sprains, overuse injuries and stress fractures, tendonitis and arthritis…I can’t really describe the discomfort. And because I don’t remember injuring my foot, I can’t make sense of it. This is weird.

Imagine how difficult it must be for patients to describe their symptoms or to make sense of their illnesses when they have neither knowledge, experience, nor language for what is happening to them.

“Write hard and clear

about what hurts.”

~Ernest Hemingway~

Most people are not used to thinking about their symptoms in the kind of descriptive terms physicians depend upon to narrow the diagnostic possibilities. For example, they might not realize that the difference between a headache that is generalized, dull and steady rather than unilateral and throbbing may distinguish a tension headache from a migraine. They may not be able to distinguish between the kind of pain caused by heartburn and myocardial ischemia. They might not use those terms to describe it at all. The patient is more likely to view his symptoms in terms of lost wages, his inability to provide for his family, or his own impending decline rather than the onset, character, and duration of his symptoms.

“Every sickness has an alien quality,

a feeling of invasion and loss of control

that is evident in the language

we use about it.”

~Siri Hustvedt~

Severity is especially tricky to assess. It depends to some extent on the patient’s innate tolerance for pain. Is he a stoic or a whiner? His perception of pain depends upon how his symptoms affect his mood, his ability to carry on, and his fears which are largely based on what he has heard, what he imagines, or what he has witnessed in others.

Take it from me, under the best of circumstances, the medical history can sometimes remain a mystery.

“One day I will find the right words

and they will be simple.”

~Jack Kerouac~

jan



you too?

 

*

 

 

...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.”

@hannahsnead5

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

 

 

 

 

 

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





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

 

 

 

 

 

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

 

 

 

 

 

look for the helpers

Like many Americans, especially those of us who have friends and relatives living in Florida, I have been following the course of Hurricane Irma for the past several days—listening to the data that predict the path of the storm, the projected rainfall amounts, barometric pressure, wind velocity, and expected storm surges. I have been watching the preparations for the storm, the course of evacuations, and the availability of storm shelters.

www.usatoday.com

 



But this is not what interests me the most.

Having this data is like knowing a patient’s vital signs—his pulse, respiratory rate, blood pressure and temperature. It tells us how he is doing, but not how he feels.

More than data from the weather watchers, more than updates on the recovery effort, I’m interested in the human narratives behind Irma.

We were horrified by the images of the nursing home patients in their wheelchairs with flood water up to their waists while they waited to be rescued.

www.fox13now.com



We can only wonder what it must be like for people who lost everything. And had no flood insurance. And now, no job to go back to.

“And so rock bottom became

the solid foundation

on which I rebuilt my life.”

~JK Rowling~

 

What if you were in a shelter at the height of the storm and you started to experience chest pain, or unrelenting RLQ pain indicative of acute appendicitis, or symptoms of a UTI? Where would you turn for help? How did the doctors and nurses manage without electricity, without water, without sleep? How many lives did they save? How many did they lose?

 

 

Like the trees that were uprooted and the homes that were destroyed, the injured and terrified children, and lost pets, unspeakable suffering and deep grief are all remnants of Hurricane Irma.

 

The stories that emerge in the aftermath of the storm will be as powerful as the storm itself. They will fill volumes if people can find the words to tell them.

 

“Dance on broken glass,

build castles with shattered dreams,

and wear your tears like precious pearls.

Proud.

Strong.

Unshakable.”

~Anita Krizzan~

 

 

If it were possible to bring strength, comfort, solace and healing to everyone affected by this storm...and (while we're on the topic) Hurricane Harvey...and the wild fires out West, and the floods, famines, and injustices that devastate Mother Earth, we would all embrace the power of hope, compassion, and inspiration.

jan



the time is now



 

Warning! Op-ed:

When I closed my practice after thirty years in Family Medicine I told my patients and colleagues I was retiring…when I meant I was quitting.

“Quitting is leading, too.”

~Nelson Mandela~

I didn’t put it quite that way, of course. It wasn’t as though I simply got fed up with things, turned in my stethoscope and tongue blades, and slammed the door on my way out of the office. I wasn’t impulsive about it at all. I agonized over my decision for years until I knew the time was right.

“The moment you feel like

you have to prove your worth to someone

is the moment to

absolutely and utterly

walk away.”

~Alyala Harris~

It had nothing whatsoever to do with my patients. Caring for them has always been my passion. Nor was I defeated by the perpetually long hours that became interminable as I grew older. Nor was I discouraged by the fact that I’d been running behind schedule all day, every day for three decades with no chance I’d ever catch up.

No. What finally did me in was the erosion of my authority as a physician by self-proclaimed intermediaries who had neither knowledge of nor concern for my patients’ wellbeing. When I started out in medicine the problem was oppressive paperwork; now-a-days it’s an oppositional defiant electronic medical record system. A baffling coding and reimbursement system. The ever-present threat of litigation. A pharmaceutical industry that invests as heavily in marketing as it does in research. A health insurance industry whose number one priority is corporate profit…not compassionate care. Aggravations that follow physicians through life like a swarm of angry bees.

“Be the change you wish to see

in the world.”

~Mahatma Gandhi~

Isn’t it about time we restored autonomy and authority to physicians and health care providers...the men and women who have dedicated their lives to delivering compassionate and capable health care to their patients? Isn't it time to put patient care first, again? 

What do you think? Is this the time?

“The time is now.

The person is you.”

~Nido R. Qubein~

jan

 

 

 

only time will tell

 

 

 

As a physician, and at times as a patient, I enjoy the advantage of knowing, before I see a doctor, what questions he will (or should) ask concerning the reason for my visit. This saves time and effort because he doesn’t have to tease out the diagnostic clues that are part of the “history of the present illness.” I hand them to him in perfect order.

 

“It is much more important

to know what sort of patient

has a disease

than what sort of disease

a patient has.”

~William Osler~

 

Likewise, I already know what the physical exam should include and how it should be performed. I can predict what tests he will order, and he doesn’t have to go into detail about the treatment he is recommending. I know what he is going to say before he says a word.

 

Unfortunately, this means I pick right up on it when my own physician slacks off. When he fails to ask the right questions. When he neglects parts of the physical examination. When he fails to follow-up on X-ray findings or blood tests.

 

This is how mistakes are made…and I know why it happens. Not because he lacks expertise in his field. Not because he is uncaring. Not because he is lazy or unmotivated. (I know him better than that…).

 

No, there are other forces at work. He is seeing a patient every 10-15 minutes, so he is usually running behind schedule. The history and physical exam must focus solely on what he suspects is wrong. There simply isn’t time to be as thorough as he would like to be.

 

“It’s not about having enough time.

It’s about making enough time.”

~Racheal Bermingham~

 

Perhaps he's falling behind on his “productivity quotient” and risks losing his job if he doesn’t pick up the pace.

 

Or maybe the EMR he is using doesn’t have a bullet for the information he wants to include, so it goes unrecorded.

 

All the health care mandates and initiatives in the world will not solve the problem of TIME. Time spent with the patient. Time to reflect on his illness. Time to help him heal.

 

Now is the time for change.

 

“Lack of time

is actually

lack of priorities.”

~Tim Ferriss~

 

jan

 

 

 





true story

 

True story:

A friend of mine has been in terrible pain for over a year. She has orthopedic problems and degenerative disc disease in her back resulting in unrelenting sciatica. She also has a rare autoimmune disorder that requires her to be on chronic steroid treatment. Her initial workup, several years ago, found nothing operable so she has been taking substantial doses of opiates daily since then in a futile effort to control her pain. She can’t drive. She can barely make it up the stairs to her bedroom. She is experiencing a deepening depression because of it.

“You can avoid reality

but you can’t avoid the consequences

of avoiding reality.”

~Ann Rand~

 

Why hasn’t she gone back for re-evaluation?

 

Because, as she puts it, “They’ll think I’m a whiner.” She doesn’t want to take up the doctor’s precious time when other patients are worse off. She doesn’t have the language to describe her pain…not the nature of it, not the severity of it, not the timing of it. She tells herself she’s a sissy, that other people wouldn’t complain about it so she shouldn’t, either. She is convinced the doctor won’t find anything wrong and he’ll laugh her out of the office, or worse, he’ll assume she’s seeking drugs. Or, worse yet, he’ll decide she needs surgery after all, and she definitely doesn’t want that.

 

Her situation illustrates some of the obstacles patients encounter when trying to tell their story--the chief complaint and the history of the present illness.

 

What happens in situations like this is that the patient lies. He minimizes the severity of his symptoms because he doesn’t want to sound like a complainer or weakling. He may be embarrassed to admit that he can’t keep up with things anymore because he’s afraid he’ll lose his job. Even if he suspects the gravity of the problem, he may be reluctant to learn the truth. For example, the patient with chest discomfort may describe it as indigestion or heartburn in an attempt to dissuade the doctor who is sure he has CAD.

 

“You’d be surprised

what lengths people will go to

not to face what’s real and painful inside them.”

~unknown~

 

These are some of the obstacles that serve to confound the patient’s narrative: denial, shame, fear, ignorance, and dread.

 

To make a long story short, at my insistence my friend scheduled an appointment to see her pain management specialist. I’ll be going with her that day because, as a physician, I know what she's up against. As a writer, I think I can help her tell her story.

 

“One day I will find the right words

and they will be simple.”

~Jack Kerouac~

 

jan