the art of holding back tears

This week I found myself holding back tears. Maybe you did, too. Just to make it through the day. This is nothing unusual for me, because I learned not to cry when I was in medical school. We didn't actually have classes in the art of holding back tears. We had to figure it out for ourselves. How to breathe so it didn't sound like sobbing. How to dab away tears so it looked as though something had just flown into our eye. How to keep our voices calm and steady despite the log jam in our throats.

 

"What cannot be said

will be wept."

~Sappho~

Among my medical colleagues, emotional displays were considered a sign of weakness. We were led to believe that patients would lose confidence in us, or worse, they would lose hope if we surrendered to feelings that had the power to erode our objectivity, confidence, or cool.

We were told it was inevitable that patients under our care would die, whether in the emergency room, or on the operating table, or in the intensive care unit. We were not, however, prepared for them to die in the grocery store, or in church, or in their elementary school classrooms. In agony. In horror. Of gunshot wounds. 

We were warned that, despite our best efforts, patients would slip away from us. We were told to expect it, and we were taught how to handle it. In med school, when a patient died, we learned to persuade ourselves there was nothing more we could have done; we were not to blame. Put it out of your mind, they told us. Better yet, pretend it never happened. Be strong.

"If you don't deal with your emotions,

one day your emotions

will deal with you."

~J. Ivy~

For four years, the men of medicine took hammer and chisel to us until compassion fell away like dross--a smoldering pile of words never spoken, of hands never held, of tears that never fell. Out of it we emerged transfigured--tireless, dispassionate, infallible. At least, that was the goal.

Which explains why I didn't cry in the morgue the time I stood over the body of a pale, blond three-year-old who had just lost her battle against leukemia. I didn't cry when I disconnected the tubes and wires from the patient in ICU who had successfully pulled off his suicide at the tender age of sixteen, and didn't leave a note of explanation. Nor did I shed a tear when my own mother drew her last breath, and her suffering came to an end.

"You'd be surprised

what lengths people will go to

not to face what's real and painful inside them."

~unknown~



I stayed strong for my patients and their loved ones. Calm in the face of fear. Cool in the heat of anguish. Silent when so much needed to be said.

Denial of this magnitude would be a great way of dismissing traumatic memory if it worked. The problem is, it doesn't. Sooner or later the log jam will break. The bucket will overflow. Words and tears will pour on out, and another narrative will begin. 

"Tears are words that

need to be written."

~Paulo Coelho~

 

jan



when a book stalks you

 

The curious thing that got my attention this week has happened to me before. I received a book in the mail that I had randomly ordered on-line for no compelling reason...except that I was looking for something light to read after I emerged from the rabbit hole of consciousness studies, mindfulness practices, and epigenetics where I usually hang out. Instead, I ordered a new book about writing, "Write for Your Life" by Anna Quindlen...as if I don't already own a hundred books on writing. This was another case of "just the right book showing up at just the right time" that always amazes me. 

When I purchased the book, I had no idea the author would devote an entire chapter to the importance of Narrative Medicine as it was first conceptualized and taught by Rita Charon MD/PhD at Columbia University...the inspiration for this entire blog.

In it she discusses an exercise Dr. Charon teaches called "parallel charts":

"Parallel charts:

It's not simply an assignment for medical students.

It's a genius way into personal writing.

On one side the data,

on the other a human response

to those things seen in the hospital room,

felt in the hallways."

~Anna Quindlen~

As Charon puts it: 

"If your patient is dying of prostrate cancer, and he reminds you of your grandfather who died of that disease last summer, and each time you go into the patient's room you weep for your grandfather, you cannot write that in the hospital chart. It isn't allowed. Yet it has to be written somewhere. You write it in the parallel chart."

This is how you connect medicine with humanity, and how you connect the rest of humanity with your True Self.

In her new book, Quindlen talks about much more than this. She talks about the importance of personal letters in recording history, not emails that have to be recovered from cyberspace to be read, but handwritten letters, love letters, and thank you notes that are collected, tied with a ribbon, and stored for safe keeping with all the other memories we cherish. Proof we cared. Proof we tried. Proof we existed.

She writes about the difference between the tap-tap-tap of a keyboard and the freedom and beauty of script. She connects feelings with the words we choose to describe them. And how the act of writing helps us discover who we are, and how we fit in with the rest of humanity. She decries the trivialization of the art and craft of writing by hand, from the heart, to the people we respect, honor, and love. 

I love it when synchrony, or coincidence, or just plain good luck sometimes act on my behalf. I am a firm believer that if you are a passionate reader, books will stalk you. They want you. They know what you need...which is why I would recommend this book to anyone who is toying with the thought of writing but is reluctant to begin. Doctors and nurses. Therapists. Patients and caregivers. All of us.

"This is my rock

Where my thoughts fly about

Like small white ships

On a black sea of doubt."

~Anna Quindlen~

~from her first ever poem at age nine~

jan

the first line of the first paragraph of the first chapter

True story:

A patient of mine presented to the office concerned about unexpected weight loss that had started a month or so earlier. She had no other symptoms. She told me she was eating normally. She had no complaints related to her GI tract...no nausea or heartburn, no diarrhea or bleeding...and no swollen glands or fever that might lead you to suspect something more systemic. Initial labs were normal, including her blood count, electrolytes, sugar, liver and kidney function, and thyroid. I ask her to keep a food diary for a couple of weeks. When she returned, her weight was still going down despite an adequate caloric intake. I proceeded to go through the screening questions for eating disorders, depression, and drug and alcohol abuse, but came up with nothing. The diagnostic process went on for over six months. During that period of time she underwent a full GI evaluation. She saw an endocrinologist. Finally she ended up seeing a psychiatrist who, because he was part of the same health system and used the same EMR as we did, went through the same set of questions, checked all the same bullets, and came up empty handed, too.

"Histories must be received,

not taken."

~Sir Richard Bayliss~



The patient must have given up on me because I didn't see her again for over a year. When I did, she had regained her weight and appeared healthy and strong. I asked her what had happened. What had caused her weight loss and how she'd recovered from it.

"I was depressed," she said. "I just didn't realize it."

Wait a minute. I had asked her about depression. The psychiatrist had asked, too. We'd asked if she'd experienced loss of interest in doing things, feelings of hopelessness, sleep disturbance, fatigue, or change in appetite. The list went on. She'd answered "no" to every question, because that wasn't how she experienced her depression. She was feeling shame. Anger. Abandonment. None of which appeared in the EMR.

So how do you get around this? How can you get to the truth?

Rita Charon, professor of medicine, and founder and director of the Program in Narrative Medicine at Columbia University College of Physicians and Surgeons, begins every patient interview with one open ended prompt. She invites the patient to:

"...tell me what you think

I should know

about your situation."

~Rita Charon, MD, PhD~

Then she listens.

This approach opens a portal to the patient's story. It permits the patient to share whatever she knows about her illness, in whatever words she chooses to use. It enables her to tell her truth. My patient might have been spared months of diagnostic miscues and a fortune worth of tests had she been able to tell her story in her own words.

When things don't add up, when you can't arrive at a diagnosis after exhausting every avenue, when you start to feel frustrated, you might try starting over again. Ask the patient what he knows. Start with the first line of the first paragraph of the first chapter of his story.



"The good physician treats the disease;

the great physician treats

the patient who has the disease."

~Sir William Osler~

 

jan









defending our right to write

 

There is no question that women's reproductive rights are under assault, again. Whether you choose to defend the rights of the unborn or to support the freedom of women to choose, the battle lines have been drawn. There will be no surrender. 

If, like me, you harbor strong beliefs about the impending overturn of Roe v. Wade, you may feel helpless to be heard. Political debate hasn't changed anything. Demonstrations haven't changed anyone's mind. Social media has only inflamed the issue. What are we to do?

"The emphasis must be

not on the right to abortion,

but on the right to privacy and

reproductive control."

~Ruth Bader Ginsberg~ 

I don't know what you will do, but I chose to write.

This is a copy of the letter I mailed to every Republican senator this week:

The Honorable…

United States Senate

Washington, DC 20510

 

May 8, 2022

 

Dear Senator …,

I am writing to you regarding my concerns should the Senate move to undermine the reproductive rights of women by overturning the 1973 United States Supreme Court decision on Roe v. Wade.

I am a physician with over thirty years of experience in Family Medicine so I am familiar with the issues that impact the accessibility, efficacy, and safety of women’s health care. I am also the mother of three adult children, and a grandmother to three youngsters, so I know a lot about the sanctity of a woman’s body and her reproductive rights.

As a physician, it is my duty and privilege to assist my patients with the difficult decisions they have to navigate when it comes to health care. Whether or not it is safe to vaccinate their children. Whether or not to sign the Do Not Resuscitate order. Whether to carry an unintended pregnancy to term, especially in the case of rape/incest, or contraceptive failure. I don’t make these decisions for my patients. I educate them. I guide them through a maze of questions and concerns, some of which they might not otherwise have considered. Together we look at the pros and cons, the advantages and disadvantages, and the risk of unfavorable outcomes when we explore their treatment options. I don’t coerce them, or manipulate them, or mislead them to satisfy my personal, political, or religious agenda. I listen to the stories they share with me, and I respect the decisions they make for themselves.

It's not that I don't hold strong beliefs about a woman's reproductive freedom. I do. I am not declaring my support for, or my opposition to abortion. It is not my role, my duty, or my intention to impose my beliefs on anyone. Nor should you.

At the heart of Roe v. Wade is a woman’s right to decide for herself about elective abortion. Most of us will never have to confront this decision, but our daughters may, and our granddaughters may. The next time you give you daughter a hug, the next time you sweep your granddaughter into your arms, imagine her as a victim of rape. If you vote to overturn Roe v. Wade, be absolutely certain you are willing to watch her suffer. To make her suffer. Ask yourself if you will embrace her child of rape with the unconditional love you feel for your own children.

Because this is my fear. I fear for the infants born to these women. That they will be neglected, rejected, and abused because the color of their skin, or the texture of their hair, or their facial features mark them as different. As undesirable. As unlovable. I worry that they will end up in our emergency departments, abandoned on our streets, or cast off into the trash. How will we care for the ones who survive? Who will care for them? You cannot claim to support the right to life of the unborn unless you have a plan in place to protect and care for them after birth. 

I worry, too, that women will, once again, be forced into back alleys and basements in a desperate and dangerous effort to terminate these pregnancies. That we will see a resurgence of the septic abortions and mutilations that compelled us to support women’s safety and well-being by passing Roe v. Wade in the first place. I am afraid the next generation will manifest a whole new class of traumatized, angry, and abandoned women and children.

But that’s not the only problem I anticipate. The decision to revoke the protections and human rights of women will set a new legislative precedent. It will confer authority to outliers and men in power to unilaterally eliminate the protections we have put in place to support immigrants and asylum seekers. To prevent gun violence. To feed the hungry and shelter the homeless. To access affordable health care, and to protect our privacy.

If Roe v. Wade falls, it will bring our constitutional democracy to its knees, a democracy that has flourished not in spite of, but because of, its diversity, inclusivity, and vision for over 200 years. Indeed, we have already witnessed the violation of basic human rights, the corruption of justice, and a surge in violence and fear among our most vulnerable citizens in the name of political power, self-proclaimed entitlement, and hatred.

This is not the America you and I grew up in. It is not the same country that bestowed upon us a path to success, security, and freedom. How can we deny it to others?

As a United States Senator, you are in a position to change the course of history as it is being written. Will you allow yourself to surrender to men who are hungry for power and control over the reproductive freedoms of women they don’t even know? Why are you afraid to stand up to them? Has your heart hardened against the humanity you are part of? What scares you about defending the rights of women? What prevents you from acting out of dignity, purpose, and principle?

When did you fold?

For the sake of all women and children, out of compassion for all who suffer, and in the name of human rights, I implore you to reconsider your support of the Republican leadership on this important issue. Vote to uphold Roe v. Wade. Do what is honorable, compassionate, and just, or explain to us why you refuse.

Thank you for your attention and consideration.

Yours,

Janet F. Cincotta, M.D.

*

I chose to write not because I believe my words will actually make any difference, or change anyone's mind. I don't. It isn't important to me that anyone is impressed by what I have to say. Nor do I judge or condemn anyone whose convictions contradict mine. I wrote because it is the one thing I can do, and I strongly believe each of us should do something--whatever we can--to preserve social justice, defend democratic principles, and sustain the balance of power in this country. 

"The measure of a man

is what he does with power."

~Plato~

jan