make me care

The art of storytelling is as old as the spoken word, and it's just as powerful. It entertains, informs, and connects mankind across culture, race, and creed. It has the power to heal, and in medicine, it can be a life-saving skill.

Most people enjoy reading or listening to stories at their leisure. The health care provider, on the other hand, listens to stories all day long because it's part of his job. This is how he obtains the "history of the present illness," perhaps better described as the "story of the present illness." It forms the basis of all that follows: performing the physical examination, tracking down the diagnosis, and formulating a treatment plan.

The clinical encounter begins when the health care provider takes the patient's history. He listens for specific details that lead him to the diagnosis. If the problem is pain, the provider wants to know where it's located, and whether it's sharp or dull, steady or throbbing, constant or intermittent. He wants to know how long the patient has had the pain--for a day? For a month? For years? What makes it better? What makes it worse? These details guide him through a maze of possibilities.

"The shortest distance

between a human being and the truth

is a story."

~Anthony de Mello~

The problem is that patients don't know what the provider needs to hear. They don't arrive at the office prepared to rattle off a list of relevant signs and symptoms. It's the provider's job to ask about them, but he only has so much time to get to the bottom of the patient's problem. Nowadays, the written or dictated clinical note has been largely replaced by the electronic medical record (EMR), so rather than listen to the patient's history, the provider navigates his medical record with a series of clicks that pull up an array of bulleted lists, complicated charts, and sketchy details. This is intended to expedite what has been ruthlessly abridged to a ten-minute office visit.

Because time is limited, doctors often redirect the patient who appears to be getting off track or is slow coming up with answers. In fact, one frequently quoted study found that physicians interrupt and redirect the patient when they are as few as 18 seconds into the interview. Frequent redirection leads the patient to believe that what he wants to say isn't important or relevant, so details go missing.

This is a problem. Healing, or failing to heal, occurs in the context of a person's relationships with his family and friends, his surroundings, expectations, and perceptions, as well as his emotional, psychological, and spiritual life. If the patient is denied the opportunity to tell his whole story, part of him may never heal.

"Healing yourself is connected to

healing others."

~Yoko Ono~

Let's say, for example, that the patient presents with abdominal pain. He answers all of his doctor's questions. The pain has been present for four days. He describes it as constant. It started in his upper abdomen, but now it radiates into his back. Eating makes it worse. In fact, the patient says he hasn't been able to keep anything down for the past twenty-four hours. After a focused physical exam and a few tests, the physician correctly diagnoses the problem as acute pancreatitis. But that doesn't explain why the patient develops a headache, has trouble keeping his balance, and becomes confused the day after he is admitted to the hospital.

What the doctor doesn't know is that the patient has been drinking heavily because his wife walked out on him recently. In fact, he blacked out a couple of days ago and woke up on the floor next to his bed. He didn't mention it because he was busy answering the doctor's questions about his abdominal pain. So, the doctor missed the small subdural bleed his patient sustained in the fall until days later when he had his first seizure.

This scenario highlights an important problem. Obtaining an accurate and thorough medical history takes time. Given the imperative to see more patients faster, the provider may have little time to explore the details of the medical history with every patient. Perhaps he's running behind schedule, or an emergency interrupts him. In some cases, the patient can't bear to disclose the sorrow, or fear, or shame that underlies his symptoms, so he doesn't mention it. It takes time to invite, enable, and encourage some patients to share the story that brings them to the office in the first place.

"Storytelling is the essential human activity.

The harder the situation, 

the more essential it is."

~Tim O'Brien~

When the patient is constantly redirected in order to satisfy the provider's agenda, important parts of the story may be overlooked. This reinforces the importance of hearing the patient's full narrative. When we reach into their cholesterol laden hearts to understand why they are poisoning themselves with food, we need to know more than what they are putting into their mouths. When a patient is noncompliant, we need to consider what he is afraid of, or angry about, or grieving over. When we allow the patient to speak, we may discover that the 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.

"The greatest story commandment is:

Make me care."

~Andrew Stanton~

jan

why you should take this test

 

Rotsund, Norway

The last time I saw my primary care physician for my annual wellness exam, I was handed a clipboard and instructed to answer page after page of questions. They included updates to my demographics, my insurance information, my family medical history, and a "health risk assessment" that included questions about lifestyle (exercise, diet, smoking, and alcohol/drug use), about my mood and stress levels, current and previous health conditions, dementia screening, recent falls, and my ability to perform daily activities such as feeding myself, dressing, and bathing. It may be annoying to fill out the same questionnaires year after year because it's time consuming and redundant...but it makes sense from a health maintenance perspective. This line of questioning helps the physician identify problems that predict poor health outcomes. It provides information he can use to institute preventive strategies, as well as timely interventions to correct or compensate for developing problems. 

"A facility that asks you to fill out

a health screening form is a sign of one

that really cares about its members."

~Kathi Davis~

Back when I was in practice, we didn't use screening questionnaires like these very much, but now they're considered an important part of the patient's medical record...which makes me wonder why the ACE (Adverse Childhood Experiences) Survey is not included in the paperwork we submit to our health care providers. This questionnaire addresses childhood trauma and its effect on the development of chronic disease in adulthood.  

A growing body of evidence supports the link between childhood adversity and the development of physical disease and mental health disorders later in life. Childhood tauma includes physical, emotional, and sexual abuse, physical, verbal, and emotional neglect, living with a depressed, mentally ill, or addicted parent, witnessing domestic abuse, and losing a parent to separation or divorce...among others. Chronic adversities like these actually change the architecture of the child's brain, altering the expression of genes that control stress hormone output. This triggers an overactive inflammatory response that leads to adult disease states, notably autoimmune conditions like lupus and rheumatoid arthritis, heart disease, and PTSD-like anxiety and reactivity.

You can take the quiz here. Answer yes or no:

Before your 18th birthday:

1.      Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you, or act in a way that made you afraid that you might be physically hurt?

2.      Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you, or ever hit you so hard that you had marks or were injured?

3.      Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way, or attempt or actually have oral, anal, or vaginal intercourse with you?

4.      Did you often or very often feel that no one in your family loved you or thought you were important or special, or that your family didn’t look out for each other, feel close to each other, or support each other?

5.      Did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you, or that your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6.      Were your parents ever separated or divorced?

7.      Was your mother or stepmother often or very often pushed, grabbed, slapped, or had something thrown at her, or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard, or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

8.      Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

9.      Was a household member depressed or mentally ill, or did a household member attempt suicide?

10.  Did a household member go to prison?

Add up your "yes" answers. This is your ACE score. If yours is greater than 0, you should be concerned.

The bad news is that the higher your ACE score, the more likely it is that your health and well-being are under assault. People with an ACE score of 4 are twice as likely to be diagnosed with cancer than someone with a score of 0. Each "yes" response increases the likelihood of hospitalization for an autoimmune disease by 20%. Someone with an ACE score of 4 is 460% more likely to face depression as an adult than someone with a score of 0. An ACE score of 6 or higher shortens an individual's life-span by almost twenty years. This is a big deal. 

The good news is that these early changes in the brain, and their subsequent effect on inflammation and the immune system can be mitigated. Epigenetic changes are reversible. There is a path to healing. 

Some of the practices that have been shown to promote epigenetic healing include:

• writing to heal
• drawing
• mindfulness and loving-kindness meditation
• tai chi, qigong, and yoga (moving meditation)
• dietary changes to promote a healthy microbiome in the gut
• guided imagery
• hypnosis
• neurofeedback
• EMDR

The problem is that childhood trauma is notoriously shrouded in secrecy, and very few healthcare providers are aware of these associations so they don't ask about them. Most physicians see several patients with high ACE scores every day, but all too often the underlying trauma that plays a role in the patient's illness goes unidentified. The opportunity to intervene therapeutically is, therefore, lost.

If you're interested in the relationship between adverse childhood experiences and their effect on health outcomes in adults, I would recommend you check out the book, "Childhood Disrupted" by Donna Jackson Nakazawa, or visit her blog online at www.donnajacksonnakazawa.com.

If you're curious about the role of epigenetics in illness and healing, check out "The Biology of Belief" by Bruce H. Lipton, PhD.

At the top of the list is "The Body Keeps Score" by Bessel van der Kolk, M.D.

"As the ACE study has shown,

child abuse and neglect is the single most common

cause of drug and alcohol abuse,

and a significant contributor

to leading causes of death such as

diabetes, heart disease, cancer, stroke, and suicide."

~Bessel van der Kolk, M.D.~

It is a shame to withhold this vast body of knowledge from patients when it offers an effective pathway to healing that has, so far, been largely ignored.

jan

unspoken forces at work

  

Hippocrates is the one who advised physicians, "First, do no harm." Cicero proclaimed, "The safety of the people shall be the highest law"...lofty principles that, to this day, both challenge and inspire health care professionals.

It was Paraclesus, though, who declared, "The physician should speak of what is invisible...He becomes a physician only when he knows that which is unnamed, invisible, and immaterial, yet has its effects." He was speaking, of course, about the impact of the patient's thoughts, feelings, and emotions on his experience of injury and illness. These include his fears, expectations, and hopes...all invisible, all immaterial. 

"O, what an untold world

 there is in one human heart."

~Harriet Beecher Stowe~

In his book, "The Wise Heart," Jack Kornfield reminds us that the key to healing has to do with the patient's understanding of his illness. What is he fearful about? Why? What does he think will happen to him? How will he support his family? Who will take care of her children? It turns out making the diagnosis is sometimes the easy part. Uncovering the patient's hidden fears can be harder.

"You'd be surprised

what lengths people will go to

not to face what is real and painful 

inside them."

~Rae Earl~

For example, let's say a patient presents with breast cancer. She is forty-four years old, the same age her mother was when she was diagnosed. But her mother died following surgery and a full course of radiation and chemotherapy. This is what scares her. She jumps to the conclusion that this is her fate as well, despite the fact that her mother's cancer was far more advanced when it was detected. Despite the fact that treatment has improved in the twenty years since her mother's diagnosis. The patient's initial reaction to her diagnosis may be to give up right then and there...her unnamed, invisible, and immaterial thoughts, feelings, and emotions left unchecked.

"Your body hears everything

your mind says."

~Naomi Judd~

Or let's say the patient is a middle-aged man who schedules a ten-minute appointment with you so he can get something for his heartburn. But he isn't simply experiencing indigestion. He describes symptoms that suggest he is having angina, and it's getting worse. He has convinced himself that it's just his stomach because the thought of a heart attack scares him. His brother had one last year and ended up with a defibrillator. His ten-minute appointment includes an EKG and blood work, and it stretches into a forty-five-minute dialogue about unstable angina and the need for hospitalization. He tries to laugh it off, but beneath his cavalier manner, he fears for his life. His family. His business. All of it unspoken, invisible, immaterial.

"A physician is obligated to consider

more than a diseased organ,

more than even the whole man.

He must view the man in his world."

~Harvey Cushing~

Clues to the unspoken forces at work in the patient's life include refusal of, or noncompliance with treatment. Denial, anger, impatience, or resistance. Reticence. Despair. 

As providers, we should handle these patients with special care. We should ask about their fears, expectations, and perceptions. We should confront whatever misinformation they may have picked up on-line. Whenever possible, we should offer hope.

We have to explore what we intuit to be unnamed, invisible, and immaterial before healing can begin.

"Anything will give up its secrets

if you love it enough."

~George Washington Carver~

jan