Wednesday, December 20, 2017

Christmas eve

It’s Christmas eve. Outside, the sun is setting under a sky that could pass for cotton candy.

The air is frigid but still. The street is busy with people hurrying home to begin celebrating the holiday. You, yourself, are looking forward to getting home to a crackling fire on the hearth and a traditional Christmas eve meal. The kids are home from college. Their gifts are wrapped and piled under the tree. You breathe a sigh of relief and gratitude.
It was a busy day. Among the patients you admitted through the emergency room were a child with asthma complicated by fever and pneumonia, an elderly gentleman who fractured his hip when he slipped on the ice outside his garage, an OD, and an out-of-state trucker with chest pain and an abnormal EKG. Orders have been written, tests scheduled, and rounds finished. Your patients are settled for the night. Your job for the day is done. It’s time to go home.

Except that part of you never goes home.
You remember the expression on the child’s face when he learned he would be spending Christmas in the hospital. He’d asked for a blue bicycle and he couldn’t stop crying because he wouldn’t be there to get it…and he wasn’t well enough to ride it, anyway.
You recall discussing her husband’s injury with the elderly man’s wife. She would be alone for Christmas now, and for weeks to follow. She couldn’t imagine how she would manage by herself.
The OD was not accidental. You are reminded of the most recent studies debunking the long-perpetuated myth that suicide rates peak around the holidays. In fact, suicides reach a statistical nadir in December. Still, opioid contamination keeps no schedule and leaves no clues. It will be a long vigil for this victim’s family overnight.
You learned that the trucker’s family was stuck at Chicago’s O’Hare International Airport because of blizzard conditions. They wonder if he will survive this latest heart attack. They wonder if they will get there in time.
It’s Christmas eve. You get to go home. Your patients don’t.
This is a bi-polar time of the year, a time that highlights the irreconcilable discrepancies, emotional extremes, and divergent realities that prevent some people from celebrating the spirit of the holidays. There is poverty in contrast to wealth, sorrow instead of joy, cruelty as opposed to compassion, and of course, illness instead of health.
For those of us in the medical field who are taking our patients’ medical histories, exploring their symptoms, and fielding their pain when the rest of the world is celebrating joy and peace, it is a bittersweet season. Many of our patients will experience pain rather than comfort, grief instead gratitude, anger as opposed to joy, and anguish instead of peace. It won’t be merry or bright at all. They will be stuck with it…and in many ways, so will we.
If Christmas eve with your family is happy, loving, and peaceful, I wish you a merry one.
If not, I wish you hope for something better. Courage. Friendship. Beauty. Time. Snow if you like it…sunshine if you don’t.
Dickens could have been describing Christmas as he wrote in “A Tale of Two Cities":
“It was the best of times,
it was the worst of times…
it was the season of light,
it was the season of darkness,
it was the spring of hope,
it was the winter of despair.”
It was Christmas eve.













Tuesday, December 12, 2017

revisit. revise. recover.

 “I write because
I don’t know what I think
until I read what I say.
~Flannery O’Connor~
This observation by author Flannery O’Connor rings true to anyone who harbors a vague feeling of anxiety for no identifiable reason.
“Worrying is like
walking around with an umbrella
waiting for it to rain.”
~Wiz Khalifa~
Even though they are living in a comfortable rut—let’s say, they are financially secure, their health is good, their family is intact—they can’t deny the knot in their gut or the dull ache in their chest that suggests something is wrong. Or, maybe they wake up every day with a sense of dread, exhaustion, sadness, or withdrawal that screams “depression”, even though, as people tend to remind them, they have nothing to be depressed about. After all, they have a steady job and a nice home, their children are doing well, and their bills are paid. They should be happy.
Still, the feeling is always there…uncertainty, fear, emptiness, hopelessness. They just don’t know why.
“These mountains you
are carrying,
you were only supposed to climb.”
~Najwa Zebian~
This is where storytelling comes in. Writing enables us to seek out and sort through memories, and to locate them in time and space. It encourages us to name the gremlins that stalk us, to label our fears, acknowledge our wounds, and reimagine our lives. We are no longer the victims of some obscure fear or unacknowledged sorrow. We can claim it and conquer it.
“The act of putting pen to paper
encourages pause for thought.
This, in turn, makes us think
more deeply about life…”
~Norbet Platt~
Physicians do this for every illness—from diabetes to heart disease to cancer. We ask about symptoms. We search for causes and encourage our patients to do what they can to avoid or eliminate them. We name the disease and suggest a course of treatment. If we have done our work well, we alter the course of the illness. We take control of it. We change the patient’s narrative.
This is storytelling at its finest. It is also the goal in clinical practice and in narrative medicine. When we write about illness, we revisit the initial injury. Perhaps it was a childhood rape, or a tragic accident, or the loss of a friend or family member we couldn’t face. By naming it, we confront it. The road to recovery leads us to a new perspective or understanding of it. Then, when we read what we’ve written, we finally know what we think.
Storytelling is the very process by which we revisit, revise, and recover.
Revisit. Revise. Recover.

Wednesday, November 22, 2017

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~

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
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.~






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.
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~

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~






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 (
“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?

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~


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.”
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.”
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.”
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~