hunting for zebras

~





theearthorganization.org

 

When we were studying the art of clinical diagnosis in medical school, we were cautioned not to look for "zebras"--those rare, exotic diseases and conditions we studied but were unlikely ever to encounter in clinical practice. In other words, when a child presents with fever and rash, Fifth Disease or chicken pox should come to mind before you think about less common causes, like Rocky Mountain Spotted Fever or rubella. When a patient comes in with abdominal pain, rule out appendicitis and cholecystitis before you start to worry about Familial Mediterranean Fever. If the problem is dehydration and diarrhea, consider viral gastroenteritis or food poisoning before you think about cholera.

 

"If it looks like a duck,

and walks like a duck,

and sounds like a duck...

chances are it probably is a duck."

~unknown~

 

Not always, though.

 

True stories:

• The patient was a woman in her sixties. She was admitted from the ER directly to the OR with a diagnosis of "acute appendicitis." She'd had increasing pain and tenderness in the right side of her abdomen for two days. The intern on call (me) was summoned to the OR to perform a quick pre-op physical while the OR team waited impatiently. On examination, instead of deep RLQ tenderness, my fingers came up against a tender, pulsating mass in the patient's RLQ, consistent with a leaking aortic aneurysm. Zebra #1.

• A twenty-two year-old man presented with a several week history of fever and malaise. Two weeks earlier, he'd seen a doctor who diagnosed him with a non-specific viral illness. Upon careful examination, he now had a soft (barely audible) diastolic heart murmur and mild enlargement of his spleen, classic findings for subacute bacterial endocarditis. Zebra #2.

• A sixteen year-old presented to his PCP with a two week history of a cold and sore throat. Everyone in his family had had the same symptoms and had recovered uneventfully. The patient's sore throat, however, persisted and was getting worse. Long story short, what sounded like a straightforward case of pharyngitis or Strep throat in a healthy adolescent, turned out to be gonococcal pharyngitis in a closeted gay teenager. The sexual history is not something most of us routinely obtain when we're seeing a patient for upper respiratory symptoms. Zebra #3.



"Medicine is a science of uncertainty

and an art of probability."

~Sir William Osler~



 

Today, more than ever before, physicians and other health care providers are under intense pressure to see more patients faster. It's tempting to jump to conclusions. To rush through the patient's history and to gloss over portions of the physical exam in order to save time. Sooner or later, though, you're likely to miss an important detail in the patient's story, or to overlook a subtle finding on examination that points to the diagnosis. 

 

What you think is just another pony over there in the field, may turn out to be a zebra, after all.

 

"The intuitive mind is a sacred gift,

and the rational mind is a faithful servant."

~Albert Einstein~

 

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the missing piece

 

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 at 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 we can help them heal.

"Histories must be received,

not taken."

~Sir Richard Bayliss~

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why you should join a writing group...or start one

 

 

 

Here are ten good reasons you might be interested in joining a narrative medicine writing group:

1.      You're a health care provider or a therapist in any field. You have been a patient at some point in your life, or you know someone who has been. Trust me: you have plenty to write about.

 

"Anybody who has survived his childhood

has enough information about life

to last him the rest of his days."

~Flannery O'Connor~

 

2.      People keep telling you, “You really should write a book…” because of all you have endured and overcome, or because of your special expertise, or exceptional courage, or unique perspective.

3.      You keep telling yourself, “But I’m not a writer,” even though there’s a story chiseling a hole in your heart…something that caused such sorrow, or anger, or despair you can’t bear to revisit it, or such relief, or gratitude, or inspiration you can’t imagine how you would put it into words.

"There is no greater agony

than bearing an untold story

inside of you."

~Maya Angelou~

4.      You keep telling yourself, “I wouldn’t know where to begin,” even though you’ve been over the details in your mind a thousand times.

5.      You keep telling yourself, “My life (or work or experience…) is so ordinary, I have nothing interesting to say, nothing new to add, nothing helpful to share.”

 

"Write what disturbs you, what you fear,

what you have not been willing

to speak about.

Be willing to be split open."

~Natalie Goldberg~

6.      You like to write, but convince yourself you’re not good enough at spelling, grammar, or punctuation to share what you have written.

 

"If you hear a voice within you saying:

you are not a painter,

then paint by all means, lad,

and that voice will be silenced."

~Van Gogh~

The same can be said for writing.

7.      You think you’re too busy. (You’re not.)

8.      You’re afraid you’ll offend someone if you write the truth…the surgeon who botched your operation, or your uncle who abused you as a child, or the colleague you don’t trust.

 

“All you have to do

is write one true sentence.

Write the truest sentence you know.”

~Ernest Hemingway~

 

9.      As a patient, you sometimes feel like giving up. If you’re a provider, you sometimes feel like quitting.

10.  You harbor questions you can’t answer…doubts that won’t go away…pain that nothing can heal.

 

"While medicine creates material for writing,

perhaps even more important is that

it also creates a psychological and emotional

need to write."

~Daniel Mason~

 

If you’re still not sure writing is for you, I’d like to recommend a couple of good books for beginning writers, especially those who are reluctant to get started:

"The Artist’s Way" by Julia Cameron

"If you Want to Write" by Brenda Ueland

"Writing from the Heart" by Nancy Aronie

If you’re interested but can’t find a narrative medicine group near you…think about starting one. I am.

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unlock the power of storytelling

 

~Burlington, VT~

💜

 

Last week, I enjoyed the privilege of attending the fourth annual conference on narrative medicine at Kripalu Center for Yoga and Health in Stockbridge, MA. This year the conference was reimagined and renamed "Narrative Healing~Unlock the Power of Storytelling." The program was more experiential this year, focusing on practices that generate stories, facilitate storytelling, and promote healing.

 

Buddhist teacher and author, Ethan Nichtern, taught us that storytelling is a meditative process, and that meditation is a creative and generative practice.





 

 

Ethan Nichtern, a senior Buddhist teacher primarily trained in the Shambhala tradition, is the author of The Road Home: A Contemporary Exploration of the Buddhist Path, which made multiple lists of the best books of 2015, and has recently published The Dharma of The Princess Bride: What the

Coolest Fairy Tale of Our Time Can Teach Us About Buddhism and Relationships.







Activist and publisher, Jamia Wilson, spoke about owning our authentic story, and connecting with one another for universal good.



 

Jamia Wilson is the executive director and publisher of the Feminist Press. She is the author of Young, Gifted, and Black and Step Into Your Power, coauthor of Road Map for Revolutionaries, and wrote the introduction and oral history to Together We Rise: Behind the Scenes at the Protest Heard Around the World. She is the recipient of the 2018 NYU Graduate School of Arts and Sciences Distinguished Alumnae Award, the Planned Parenthood Southeast "Legend in the Making" award, and her work has appeared in numerous publications, including the New York Times, Essence, Rookie, Refinery29, CNN, the Washington Post, Elle, and more.

 

 

Communications coach, Leah Bonvissuto, taught us about listening to our authentic voice and the embodiment of language. She challenged us to think in terms of the story our bodies are trying to tell us, and how to communicate it to others.





 

 

Leah Bonvissuto is a Communication Coach + Founder of PresentVoices, where she helps professionals communicate consciously and be powerfully present when speaking. She builds on her experience as an award-winning theater director to help leaders and teams at LinkedIn, Facebook, Bank of America, Indivisible, AIG, PayPal, among others, improve executive presence, defuse public speaking nerves, and advocate for themselves in the workplace. Leah is passionate about helping her clients speak with conviction and without apology. Leah coaches professionals one-on-one, designs custom workshops for teams at corporations and speaks about communication whenever possible. She pulls from the worlds of theater, mindfulness and movement to help people feel confident and in control of their communication.

 

 

Poet and teacher, Holly Wren Spaulding, introduced us to the healing and transformative power of poetry.

 



 

Holly Wren Spaulding is the founder of PoetryForge, where she empowers writers to explore the fullness of their humanity through the practice of poetry. A passionate teaching artist, collaborator, and editor, she works across disciplines to expand the definition of what it means to be a poet in the world. In 2018, the National Endowment for the Arts supported her role in the conception of a residency entitled the Long Memory Project. Her writing has appeared in the New York Times, The Nation, Michigan Quarterly Review, Witness, Poetry Northwest, The Ecologist and in Elemental: A Collection of Michigan Creative Nonfiction, among other places. She is author of If August, Pilgrim, and The Grass Impossibly, and is a member of the creative writing faculty at Interlochen Center for the Arts, where she began her education more than 30 years ago.

g’s poems, articles

And, finally, Lisa Weinert, founder of the Narrative Healing program at Kripalu and dedicated yoga instructor, introduced us to a restorative yoga practice, and shared writing prompts that connected us with our authentic story, and with one another.





 

Lisa Weinert, RYT 200, is passionate about powerful voices and the potential for storytelling to heal and transform lives. She has worked with authors as a publicist, editor, and agent for 15 years, and is the curator of the Narrative Healing program at Kripalu. She is committed to empowering authors with the tools to create and launch their work. Lisa established an online course called the Age of the Storyteller with the Authors Guild, teaches a publishing course at Wesleyan University, and offers literary book coaching to select clients.

*

 

If there is something in your past that emerges again and again and brings you to sorrow, anger, remorse, or shame, it may hold the story you need to tell. If you keep tucking it away, out of sight and mind, this might be the time to summon it, embrace it, and then, send it out. Ask yourself, "Who will benefit from hearing my story?" Then, tell it.

 

"Start where you are.

Use what you have.

Do what you can."

~Arthur Ashe~

 

 

And, remember: The next Narrative Healing conference is less than a year away.





jan