Christmas eve

Imagine that tonight is 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.

"I will honor Christmas in my heart

and try to keep it all the year."

~Charles Dickens~

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 can't forget 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 learn that the trucker’s family is stuck at Chicago’s O’Hare International Airport because of blizzard conditions. They wonder if he will survive this latest heart attack. Will they get there in time?

It’s Christmas eve. You get to go home. Your patients don’t.

"When you're sick, 

it's nice to know there are people

who await your recovery

as they might a holiday."

~Anton Chekhov~

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.

"Illness is the night-side of life,

A more onerous citizenship.

Everyone who is born holds dual citizenship

in the kingdom of the well

and in the kingdom of the sick."

~Susan Sontag~

If Christmas eve with your family is happy, loving, and peaceful, I wish you a merry one.

If not, I wish you hope. Courage. Friendship. Beauty. Time. Snow if you like it…sunshine if you don’t.

Dickens could have been describing Christmas eve when 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.

jan



choosing the path that feeds your soul

Have you ever walked into a bookstore or library and pulled some random book off the shelf just because the title interested you or the cover attracted you? And then, when you got home and started to read it, you discovered to your surprise that it was exactly what you needed at that moment in your life. Something inspiring, or validating, or transformative. You were stunned by the wisdom of the author's words. You fell in love with his prose. You wanted to learn more.

This happened to me recently. I picked up Stephen Cope's book, "The Great Work of Your Life--A Guide for the Journey to Your True Calling." On page 9, he describes what can happen when we hit a crossroads in our lives. Perhaps we lose a loved on, or lose our job, or retire, or divorce. The last child leaves home. Illness strikes. Everything changes. We can't see the way forward because we have no idea where we want to go or what we want to do. Everything that is familiar, and secure, and predictable shifts. Cope writes:

"They came to this crossroads and found themselves rooted there, with one foot firmly planted on each side of the intersection. Alas, they never moved off the dime. They procrastinated. Dithered. Finally, they put up a folding chair smack in the middle of that crossroads and lived there for the rest of their lives. After a while, they forgot entirely that there even was a crossroads...forgot that there was a choice."

That's what happened to me. At some point I found myself contemplating which rocking chair I should set up in the middle of that intersection, unable to decide which road I should take going forward, and whether it was worth the effort.

"When faced with a decision,

choose the path that feeds your soul."

~Dorothy Mendoza Rowe~

Cope's book led me to tackle this stack of books:

...and this stack:

...several of which I read years ago and intend to revisit, as well as several I recently read cover to cover. Twice. In rapid succession.

Why? Because Buddhist psychology and practice fascinate me. Because the authors are brilliant and authentic. The writing is fluent and lyrical. Which makes me a bit jealous. It discourages me from beginning something new at this late hour in my own life. But it also inspires me...

...the same way I am inspired by a friend who was recently invited to display one of her paintings at an art show, for the first time in her life. Her talent astounds me.

...the same way I am carried away by music that has the power to transform my mood and ignite my energy. I can't imagine how anyone can orchestrate such melodies, such beautiful harmonies, such touching lyrics.

I am in awe of what these writers, artists, and musicians can create...when I have trouble putting my thoughts into words, and commas still confuse me. When I can't really draw a decent stick figure. When I can barely carry a tune.

"Creativity is intelligence

having fun."

~Albert Einstein~

Then, I remind myself that, after college, I devoted seven years of my life, 24/7, to the study of medicine...and thirty years to its practice. That was my path in life. Now, I'm writing about it. It turns out that I won't be needing that rocker after all. I've already chosen the road I plan to take.

Or, perhaps, the road has chosen me.

"Wherever you go,

 go with all your heart."

~Confucius~

jan

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 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.

"One of the most valuable things
we can do to heal one another
is to listen to each other's stories."
~Rebecca Falls~

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 going to need a puppy. And lots of wine. Red wine. For medicinal purposes."
          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.

*

And so the narrative begins with the physician as the patient.

"Stories are not material to be
analyzed;
they are relationships to be
entered."
~A.W. Frank~

The fact is that scenes like this unfold all the time in real life. If you have shared bad news with your closest friend, you know how hard it was. If someone made you smile on the worst day of your life, you witnessed a miracle of sorts. If you have a friend who was willing to sit quietly and patiently at your side, she helped you heal.

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 words. But if what 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?

"Everybody's got a different way

of telling a story, and 

has different stories to tell."

~Keith Richards~

jan



excuses...excuses

The healing power of storytelling emerges when four conditions are met:

• when we listen to what our body is trying to tell us
• when we feel an insistent urge to put our story into words
• when we find a safe place to share it
• when our story is received and understood by someone we trust

I hear this from people again and again:

"I've always wanted to write..."

This is usually followed by a litany of excuses for not getting started:

• ...but I wouldn't know where to begin. 

I simply tell them, "You begin in the upper left hand corner of the first blank page."

• ...but I don't have the time.

The truth is nobody has the time to write. We sometimes have to lie, cheat, and steal to carve out the time for it.

• ...but I don't have anything important to say.

Oh, really? Let's say you have a child with special needs, meaning you had to learn how to feed her through a tube, and tend to her skin, and run through a whole set of exercises with her every day. Don't you want the rest of us to know how you manage it all? Or maybe you have to go in for chemo every week, but you're still trying to hold down a job so you can afford it. Don't you want to add your voice to the outcry against health care inequality? Oh! You have something important to say, all right! Something the rest of us need to hear.

If opening lines come to you when you're driving to work, or a memory sneaks up on you while you're mowing the lawn, or snatches of dialogue come to you in the middle of the night, your story may be begging you to please, start writing. If your voice has been silenced for too long, now may be the time to begin writing as a healing practice.

"When you stand and share your story

in an empowering way, your story will heal you

and your story will heal somebody else."

~Iyanla Vanzant~

jan

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 inspiration and support. I had planned to offer words of encouragement by Julia Cameron (http://www.theartistsway.com ).

 

"Writing is medicine.

It is an appropriate antidote to injury.

It is an appropriate companion

for any difficult change."

~Julia Cameron~

 

…and by mindfulness meditation leader Jon Kabat Zinn:

 

"Cultivate wisdom and equanimity

~not passive resignation~

in the face of the full catastrophe

of the human condition."

~Jon Kabat Zinn~

  

Then a friend of mine (she knows me too well...) sent me a link to a YouTube video by Abraham Verghese, titled "A Doctor's Touch.”

 

https://www.ted.com/talks/abraham_verghese_a_doctor_s_touch/transcript

 

"The most important innovation
in medicine to come along 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 because 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 you need to confront? What is holding you back? What kind of a difference can you make? When will you begin?

jan

 

 

 



wash your spirit clean

The mountains were calling...



I was lucky enough to have spent the past two weeks hiking in Sequoia and Yosemite National Parks under cloudless blue skies with people I love. It would be impossible to put such magnificent beauty and grandeur into words, so I took hundreds of pictures. When I got home, though, I realized that none of the pictures really captured what I saw or communicated what I felt out there. You have to stand on a mountain top, or hike to the base of a waterfall, or look up at a Sequoia to appreciate what that feels like and how it can affect you.

 

"I only went out for a walk, and finally concluded

to stay out till sundown, for going out,

I found, was really going in."

~John Muir~

 

 



I imagine this is what it must feel like for patients when we ask them to describe their illness. How hard it must be for them to express what they feel. To help us understand what they are experiencing and how it affects them physically, psychologically, and emotionally. All of which we need to know in order to help them heal.

 

"Between every two pine trees

there is a door leading

to a new way of life."

~John Muir~

 

 

How does the patient describe the fear he feels when his doctor pronounces the word "cancer"? What does it feel like to survive a major stroke or heart attack? What sadness blankets a parent whose child is suffering?

 

The tests we order, and the x-rays and scans we review help us make the diagnosis but they don't reveal a thing about the patient's experience. Like my pictures, they don't capture the patient's feelings or reactions to his illness. To his treatment. To his sense of helplessness, or, God forbid, his sense of hopelessness.

 

"The clearest way

into the Universe is through

a forest wilderness."

~John Muir~

 

 

 

You have to climb the mountain to see the view. You need to hike in the woods to appreciate the trees. You have to wade in the river to enjoy the water.

 

What do you think it takes to understand a patient's illness? What does it take to heal? 

 

"Keep close to Nature's heart...

and break clear away once in a while,

and climb a mountain or

spend a week in the woods.

Wash your spirit clean."

~John Muir~

 

 jan

 

tell us what you think we should know

 

 

If you are a health care provider or therapist in any discipline, you may find yourself frustrated from time to time when a patient does not respond to treatment. You find yourself questioning the diagnosis. You ask the patient about his symptoms over and over again, re-examine him, and order additional tests without getting anywhere. Something doesn’t add up. There must be a missing piece. Too often, the patient is labelled as uncooperative, difficult, or mentally ill...when you may not have heard the patient’s whole story.

"The simple yet complex act of listening is,

in and of itself,

a clinical intervention.

Listening constitutes the very heart and soul 

of the clinical encounter."

~Mary T Shannon~

Some days there just isn’t time to explore the details of his illness with every patient. Perhaps you’re running behind schedule, or an emergency interrupts you. Some patients can’t bear to disclose the sorrow or fear or shame that underlies their symptoms. Some remain in denial for reasons we don’t understand.

Rita Charon, MD pioneered the practice of “narrative medicine” almost twenty years ago as a path to help clinicians uncover the missing piece in their patients’ histories. It trains the healer to recognize the fact that the problem exists, and then to elicit the patient’s untold story—to listen, receive, interpret and apply what the patient reveals.

This is how she begins with a new patient. She simply invites the patient to "tell me what you think I should know about your situation." Then she listens to the patient without interrupting, clarifying, correcting, or taking notes. Instead, she focuses her attention on what is revealed and how it is communicated...paying attention to the patient's posture and gestures, images and metaphors, facial expressions, and the characters who play a role in the story. This approach may take more time in the beginning, but in the long haul,  it saves us from revisiting the history again and again, from ordering unnecessary tests, and from wasting time and resources on ineffective interventions because of what we have missed. 

“I am, by calling,

a dealer in words;

and words are, of course,

the most powerful drugs used by mankind.”

~Rudyard Kipling~

When we reach into our patients’ cholesterol-laden hearts to understand why they are poisoning themselves with food, we need to know more than what they putting into their mouths. When we let the patient talk, we may discover that the real reason for this one’s fatigue or that one’s intractable headache is end-stage disappointment or anger or shame that has festered for years.

 

Only then can we help them heal.

"Histories must be received, not taken."

~Sir Richard Bayliss~

jan

 

 



where does your story begin?

 

 

 

 

?? Chapter One ??

 

An ugly scar. A permanent limp. A weak heart. The aftermath of childhood illness can last a lifetime.

 

You think you're over it when the sight of a little blood or the thought of getting a shot catapults you back in time to a place you'd rather forget. One moment you're a fully functioning adult. The next, you're a sobbing three-year old. Like a stain you can't get out, like a fog that never lifts, it stays with you.

 

Trivial details rise up out of nowhere with perfect clarity. An aide unloading the lunch cart. The "No Smoking" sign by the door. The pile of Little Golden books stacked on your nightstand.

 

Moments you'd rather not remember surface uninvited. Your mother in tears at your bedside. The way you cried yourself to sleep at night. The jab of a needle and the dull ache that lingered until the next shot was due. You still feel it.

 

Even if you recovered completely, memories of the ordeal can shadow you all your life. Perhaps as an adult you still use a night light to dispel the fear you felt when visiting hours ended and the nurses turned down the lights in the children's ward. Maybe you struggle with asthma because of the way the nurses held you down in order to draw your blood. Smothering you. Maybe your gut still cramps up the way it did when the doctors lined up around your bed and insisted upon pushing on your belly right where it hurt worst. Every last one of them.

 

Or perhaps you still have trouble swallowing pills because you were too young to get them down when you were sick. Instead, your mother crushed them and slipped the powder into applesauce or pudding in a futile effort to mask its bitter taste. Maybe your favorite threadbare teddy is still packed away in a chest somewhere in the attic. All visceral reminders of the ordeal you endured as a child.

 

Traumatic memories can release an outpouring of emotions that can stop you in your tracks. Something as simple as getting your flu shot, or having your blood pressure taken, or hearing an ambulance in the distance with its siren wailing can set the whole thing off again. Palms sweating. Heart racing. Hands shaking.

 

I was three years old when I went into the hospital. How is it I remember the exact arrangement of the beds in the children's ward? The pattern of the afternoon sunlight reflected across the wall? The name of the girl in traction across the room from me? Alice. Ten-years old.

 

How does it all come back to me in technicolor detail when some days I can't remember what I ate for breakfast?

*

"Nothing fixes a thing

so intensely in the memory

as the wish to forget."

~Michel de Montaigne~



 

Your comments are welcome...

jan

 

 





 

 













the power to heal

The motivating principle behind the study and practice of narrative medicine is the conviction that storytelling has the power to heal, not just psychologically and emotionally, but physically, as well.

“Dancing, singing, storytelling and silence

are the four universal

healing salves.”

~Gabriella Roth~

It is easy enough to understand how an uplifting story can raise one’s spirits. Let’s say you have been diagnosed with cancer. Hearing the stories told by people who have faced the same thing and have healed can offer hope, optimism, and strength for the journey you are about to embark upon. Ok, so you feel better emotionally and psychologically. The question is, does this shift in the psyche translate into physical healing?

Consider the vast literature concerning the mind-body connection. One simple but compelling case in point: the disappearance of warts with self-hypnosis. Pretty straightforward. We are also aware of the accumulating research on neuroplasticity and the effect of meditation and visualization on the course of illness. We have learned about the neural connections that modulate the release and function of stress and growth hormones, and how those processes influence our physiology.

“The purpose of storytelling

is not to tell you how to think,

but to give you

questions to think upon.”

~Brandon Sanderson~

In addition, there’s this: the demonstration of neural coupling on functional MRIs during storytelling. Researchers scanned the brains of storytellers and their listeners before and during storytelling. While different areas of the brain were active before the story began (maybe the listener had skipped breakfast and was focused on where he would go to pick up lunch, while the storyteller was worried he might leave something out), as the listener became engaged in the story, the scans changed. They came to mirror one another. The same areas of the brain started to light up in both the storyteller and the listener…proof that the person sitting across from you has the power to affect you physically by how he engages with you mentally.

This is no great secret. We have all experienced a racing heart while watching a thriller on TV, or shed a few tears during a sad interlude at the movies. And, who hasn’t lost track of time while reading a good book? Something happened to our bodies while we were engaged with the story.

In the medical setting, the storyteller is the patient. The listener is the physician or provider. Their brains come into synch by virtue of their mutual engagement in the process of obtaining the medical history. Their physiology changes. We can measure changes in hormone levels and we can scan for changes in electrical activity in the brain. They become connected.

“There isn’t a stronger

connection between two people

than storytelling.”

~Jimmy Neil Smith~

If a story can bring us to tears…or to laughter…it doesn’t take much to imagine that it can affect our health and wellbeing…whether through a mindful change in our attitude or behavior, or a beneficial surge in certain hormones.

This is why narrative has a role in the practice of medicine. Both the patient who is telling his story and the physician who is listening to it are affected not only cognitively, but physically, as well.

“Storytelling is the essential

human activity.

The harder the situation,

the more essential it is.”

~Tim O’Brien~

jan

layer upon layer

 

Like most of you, I was horrified to awaken on Sunday morning to news of a second mass shooting in less than two days this weekend. El Paso and Dayton. As reality started to sink in, it occurred to me how many layers there are to these stories.

"Man is unique in

organizing the mass murder

of his own species."

~Aldous Huxley~

The unfathomable grief blanketing the friends and families of the victims. The shock. The anger, fear, and sorrow they will shoulder for the rest of their lives.

"No one ever told me

that grief felt so like fear."

~CS Lewis~

The aftermath of trauma the survivors face. The pain. The scars. The horror.

"I'm standing in the ashes

of who I used to be."

~Mallika Dodeja~

 

You have to wonder if the courage and resolve it took for first responders to act at the scene didn't falter just a bit. Maybe, a lot. You have to wonder how those images are carved into their psyches. Into their hearts.

 

And who doesn't want to know what drove two young men to commit mass murder in the first place? Not to excuse them or to forgive them, but to understand how something like that takes root in a human heart. To fathom what it takes to plant the seeds of hatred, violence, and dispassion in the mind of someone who was born an innocent child?

 

What about the parents and families of these two men? Mystery abounds. Speculation grows. Will we ever know the truth? Will we ever hear their stories?

 

"There is no greater agony

than bearing an untold story

inside you."

~Maya Angelou~

 

What about the nurses and doctors who dropped everything to tend to the mass influx of trauma patients on short notice. How did they get through it?
 

Does it help those of us who practice narrative medicine to tell our stories? Does anyone benefit from hearing them? What can we learn from victims and patients? What can killers teach us?

 

SUDDEN

~by Nick Flynn~

 

If it had been a heart attack, the newspaper

might have used the word massive,

as if a mountain range had opened

inside her, but instead

 

it used the word suddenly, a light coming on

 

in an empty room. The telephone

 

fell from my shoulder, a black parrot repeating

something happened, something awful

 

a sunday, dusky. If it had been

terminal, we could have cradled her

as she grew smaller, wiped her mouth,

 

said good-bye. But it was sudden,

 

how overnight we could be orphaned

& the world become a bell we'd crawl inside

& the ringing all we'd eat.

 

jan