when the truth is pure fiction

 

One of the goals in narrative medicine is to unearth the patient's whole story, including missing details that point to the correct diagnosis and lead to an effective treatment plan. These details are easy to overlook when time is short. When the health care provider is staring down the barrel of the proverbial productivity gun and is under pressure to get on with it. When his own anxiety propels him through the day. It takes time to elicit the patient's story, to understand the real source of his pain, to recognize the oscillations between identification and detachment, between truth and denial...and to act on the patient's behalf out of sincere empathy and compassion. The provider's job is tricky and difficult under the best of circumstances.

 

In addition to the productivity conundrum, there is this: patients sometimes lie. Yes, they do. They don't always mean to be misleading, but it happens.

 

"The most dangerous lies

are the ones we tell ourselves."

~Honey Sanaa~



Let's say the patient has been sitting in the waiting room for almost an hour and is running late to pick up the kids from school. When she finally gets in to see the doctor for her checkup, and he says, "How have you been?", she replies, "Fine. Things are good." This lets him off the hook. He breathes a sigh of relief. Never mind the fact that she has been exceptionally tired lately. That she gets winded carting the groceries into the house. That she feels a little lightheaded when she stands up too fast. She doesn't have time to go into all that today.

 

Never mind the fact that she looks so pale, and her blood pressure is running low. She says she feels fine, and that's all the doctor has time for today, anyway. 

 

Never mind the leukemia that already has a head start but could have been stopped in its tracks if only there had been enough time that day. Enough time for the doctor to mention her BP, to comment on her pallor, and to ask if she was feeling tired or weak...which might have led him to order the blood count that might have saved her life.

 

"The greatest obstacle

to discovering the truth is

being convinced that you already know it."

~Ashleigh Brilliant~

 

Besides the ever present problem of time constraints, patients may lie out of shame. They're not likely to admit to the sexual encounter that left them with a rash or discharge. They'll tell you they tripped over the dog and ended up with a broken wrist, but they won't mention that it happened after night of heavy drinking.

 

Out of a sense of guilt. They'll try to convince you that the infant with the fractured femur fell off the changing table in the split second it took to fetch a clean diaper.

 

Out of denial. They blame their chest pain on indigestion or a muscle strain even though they know better. Their cholesterol is out of control and their BP is sky high.

 

"A diagnosis is burden enough

without being burdened by secrecy and shame."

~Jane Pauley~

 

So...even though the goal of narrative medicine is to get to the truth, sometimes it will inevitably be pure fiction. 



 jan

 

 



the difference between caring for our patients and caring about them

Today

~How is it, I wonder, that the universe we know to be cold, dark, and dangerous

drapes itself around us in shades of baby blue?~

The motivating principle behind the practice of narrative medicine is the conviction that, in clinical medicine, storytelling is a healing practice. The concept of training health care professionals in narrative medicine originated under the direction of Rita Charon, M.D. at Columbia University. She recognized the fact that patients need to be encouraged to tell their whole story in order for the clinician to come to an accurate diagnosis and to develop an effective treatment plan. A complete medical history reveals not just what symptoms patients are experiencing, but how their illness affects them emotionally, how it impacts the people they love and care for, what fears they harbor, and what expectations they hold.

"Everyone has a story that

will break your heart.

And, if you're really paying attention, 

most people have a story

that will bring you to your knees."

~Brene Brown~

hey learned the skills necessary to elicit and interpret the patient's history, to pick-up on missing details, and to understand the patient's illness in the context of his life and community. As a result, patients under their care felt as if someone was finally listening to them. That someone cared. When they felt heard, they did better. They coped more effectively. They were more receptive to therapeutic intervention.

Did they heal because of it? That, of course, depends upon how you define healing.

 

"Your pain will transform you.

Your story will enliven the world.

Your truths will magnetize your tribe."

~Tanya Markul~



The motivating principle behind the practice of narrative medicine is the conviction that, in clinical medicine, storytelling is a healing practice. The concept of training health care professionals in narrative medicine originated under the direction of Rita Charon, M.D. at Columbia University. She recognized the fact that patients need to be encouraged to tell their whole story in order for the clinician to come to an accurate diagnosis and to develop an effective treatment plan. A complete medical history reveals not just what symptoms patients are experiencing, but how their illness affects them emotionally, how it impacts the people they love and care for, what fears they harbor, and what expectations they hold.

It might be a stretch to say that a narrative approach to patient care speeds wound closure or prevents the spread of cancer. Antibiotics are probably a better choice for pneumonia. You need surgery if you have appendicitis.

 

Nevertheless, the empathetic connection that develops between the physician and the patient when the patient is heard in a caring, receptive and holistic manner can improve his prognosis.  

 

No illness is free of emotional fallout. Fear. Shame. Anger. Heartache...none of which the patient may want to admit or express. These feelings may, however, be the most amenable to the healing power of storytelling in the clinical setting. Only if the patient is encouraged to express his frustration, fear, and sense of loss can we know what kind of support he needs. Perhaps he simply needs facts to help him understand and embrace his treatment plan. Maybe he needs constant reassurance and encouragement. Maybe she needs assistance arranging for help at home. Some patients welcome prayer at the bedside. Others may not. 

We can't know what the patient needs unless we ask. Then, it is up to us to respond empathetically.

 

"It is more important to know

what sort of person has a disease 

than to know what sort of disease 

a person has."

~Hippocrates~

For those of us involved in patient care, the operative word is "care." This involves more than tending to the tasks required to treat our patients. It means caring about them. Caring enough to frame the impact of their illness on their emotional and psychological wellbeing, and its impact on their family and friends. On their futures. On their souls. All the hidden places pain lingers.

 

"Cure sometimes.

Relieve often.

Comfort always."

~Hippocrates~  

jan

 

the happiest day of the year...or the saddest

 

Happy Mother's Day

A couple of years ago, a childless friend of mine stopped me after Mass on Mother's Day. She confided to me about how sad she was because she couldn't stand up in church to receive the special Mother's Day blessing. 

So...this post is for her, and for YOU...if you are a mother or hope to become a mother some day.

This is also for you if you have been unable to become a mother, or if you have decided that motherhood is not right for you.

This is for you is you have lost a child through illness or injury, an act of gun violence...or, God forbid, because of a drug overdose or by suicide.

If you are a mother who has been entrusted with the care of a child with special needs, this is for you.

If you have suffered a miscarriage...or opted for an abortion...this is for you, too.

If you are estranged from your children...if you wish you had done better...if your maternal heart is broken, this is definitely for you.

If you are trying to do it alone, this is for you.

"Behind every great kid is a mom 

who's pretty sure she's screwing it up."

~attribution unknown~

This is for all the meals you prepared, all the laundry you washed, all the miles you drove, all the sleep you lost.

~Anne Taintor magnets~

If you are a woman, this post is for the comfort, encouragement, patience, kindness, and love you have shown for any child, anywhere, ever...

It's for the frustration, worry, sorrow, anger, and sacrifice you have borne just trying...because Mother's Day may be the happiest day of the year for you...or the saddest.

www.scientificchicago.com

*

Remember:

"Treat Mom to a bottle of wine

this Mother's Day.

Remember: You're the reason she drinks."

~From "Your Lighter Side"~

jan

protect kids, not guns

 Here are the facts:

Firearm-related injuries 

are the leading cause of death among

children and adolescents in this country.

~https://www.nejm.org/doi/full/10.1056/NEJMc2201761~

~https://www.cnn.com/2023/03/29/health/us-children-gun-deaths-dg/index.html~

This is a public health crisis. A societal and cultural tragedy. A monumental failure to protect the health and well-being of our children.

Those of us who are in healthcare can justifiably celebrate the gains we have made over the years in the successful treatment of other killers...childhood cancer, congenital heart disease, infectious diseases, and diabetes, among others. For this, we can thank the well-funded research programs and the men and women who dedicate their lives to the pursuit of elusive cures. 

When it comes to gun violence, though, it seems all we have to offer are thoughts and prayers which, so far, haven't worked very well. And never will. The same can be said for marching in the streets to protest the failure of elected officials to act on behalf of the innocent victims of gun violence, and it holds true for those of us who write to our representatives and senators for help. It hasn't worked. It never will.

"It takes a monster to kill children.

But to watch monsters

kill children again and again and do nothing

isn't just insanity--it's inhumanity."

~Amanda Gorman~

Interestingly, right-leaning politicians and their supporters who understand and defend the right to life of the unborn apparently do not apply the same standard to toddlers, preschoolers, or school age children. They don't seem to understand the connection between easy, and often illegal, access to firearms and the loss of young lives. Instead of citing the role of firearms in these deaths, they assign blame elsewhere. They place responsibility on a failed mental health system, or with lawless immigrants. And they can't be convinced otherwise.

Which leaves us in a bind. Those of us who recognize the horror and the urgency of this crisis feel an aching imperative to act. A sacred duty to act. But...what can we do? Our leaders have nothing to suggest. Our priests and pastors have nothing to add. We are left with little more than wishful thinking.

"Maybe this is crazy,

but I think the right to own a gun 

is trumped but the right not to be

shot by one."

~Andy Borowitz~

Death by gunshot is an agonizing process. Imagine it. Go ahead. Try. Imagine the bullet tearing through your flesh, into your lung, or your gut, or your brain. Bleeding out. Suffocating for lack of oxygen. Now take a moment to imagine your child or grandchild suffering like that. No...no, you can't. It is unthinkable. Unbearable. Impossible. 

Unless you are able to somehow acquiesce to the loss of your own child's life by gunshot, you must take a stand against it no matter which side of the political spectrum you favor. You must speak out. You must act to pass strict gun control laws. To disempower the NRA. To prioritize mental health services. You must put your own guns down. To ignore or deny or vindicate this problem is to invite disaster into your own life and the lives of those you love.

"Protect kids, not guns."

~attribution unknown~

jan

"writing to heal"

 

In an earlier post, I talked about the ACE (Adverse Childhood Experiences) Score and how childhood trauma can cause epigenetic changes in the young brain that trigger an overactive inflammatory response. This has been shown to lead to disease states in adults, such as autoimmune conditions like lupus and rheumatoid arthritis, heart disease, diabetes, stroke, depression, and PTSD-like anxiety and reactivity. Luckily, epigenetic changes can be reversed. Healing is possible.

"What is the source of our first suffering?

It lies in the fact that we hesitated to speak.

It was born in the moment when we

accumulated silent things within us."

~Gaston Bachelard~

Among the practices that have been shown to promote epigenetic healing is writing to heal. Researchers at Carnegie Mellon found that the simple act of writing and reporting on an emotional state had a significant effect on the body's physical state. It improved measures of immune function even in patients battling life-threatening diseases. It reduced markers of the stress response by lowering the heart rate and blood pressure. It lowered rates of depression, addiction, anxiety, and PTSD. The damaging effects of ACEs can last a lifetime, but they don't have to. 

"I write because silence is a heavy weight to carry.

I write to remember.

I write to heal."

~Andrea Gibson~

Bernie Siegel, MD, uses "writing to heal" in his workshops. He prompts students to write on the topic of  "why you love yourself." Then he asks them to write about why they might want to end their lives. They are usually surprised to see that the compilation of pages they have written about why they should commit suicide is many times greater than the collection that considers why they should love themselves. Whether their stories are about emotional pain or physical pain, Siegel encourages them to break the silence that has been wreaking havoc on their minds and bodies all their lives without their awareness or understanding.

In another study, one group of participants was asked to write about a personally traumatic experience for 15 minutes daily for four days in a row, while another group wrote about an emotionally neutral topic. The first group reported improved mood, improved memory and sleep, reduced pain, fewer intrusive negative thoughts, and reduced blood pressure compared with the second group.

It is hypothesized that writing exerts its positive physiological effects by reducing the levels of inflammatory substances that accumulate when traumatic or painful thoughts and emotions are denied, repressed, or otherwise silenced. Acknowledging, describing, and releasing those feelings through writing may allay anxiety, reduce stress, and promote healing.

Hence, my interest in the practice of narrative medicine.

If you would like to give it a try, or if you want to offer this tool to your patients, here are a few general guidelines for getting started:

• Find a time and a place to write without distraction or interruption.
• Try different modalities, such as writing long hand in a journal, tapping it into your laptop or phone, or dictating and transcribing your story.
• As you write your first draft, do not worry about or let yourself be sidetracked by correcting grammar, spelling, or usage.
• Forget what you imagine others will say about your writing.
• If what you are writing about makes you increasingly anxious, set it aside. Focus, instead, on self-care. Take a walk outside. Take a nap. Have something good to eat. Call a friend. Return to writing when you are ready.

"Self-care is a divine responsibility."

~Danielle LaPorte~

The simple act of putting our stories into words can help us heal both psychologically and physically. When we share our story with others, it can help them heal, as well. And isn't that what we are here to do? To help others heal.

"The healing that can grow 

out of the simple act of telling our stories

is often quite remarkable."

~Susan Wittig Albert~

jan