only time will tell

 

 

 

As a physician, and at times as a patient, I enjoy the advantage of knowing, before I see a doctor, what questions he will (or should) ask concerning the reason for my visit. This saves time and effort because he doesn’t have to tease out the diagnostic clues that are part of the “history of the present illness.” I hand them to him in perfect order.

 

“It is much more important

to know what sort of patient

has a disease

than what sort of disease

a patient has.”

~William Osler~

 

Likewise, I already know what the physical exam should include and how it should be performed. I can predict what tests he will order, and he doesn’t have to go into detail about the treatment he is recommending. I know what he is going to say before he says a word.

 

Unfortunately, this means I pick right up on it when my own physician slacks off. When he fails to ask the right questions. When he neglects parts of the physical examination. When he fails to follow-up on X-ray findings or blood tests.

 

This is how mistakes are made…and I know why it happens. Not because he lacks expertise in his field. Not because he is uncaring. Not because he is lazy or unmotivated. (I know him better than that…).

 

No, there are other forces at work. He is seeing a patient every 10-15 minutes, so he is usually running behind schedule. The history and physical exam must focus solely on what he suspects is wrong. There simply isn’t time to be as thorough as he would like to be.

 

“It’s not about having enough time.

It’s about making enough time.”

~Racheal Bermingham~

 

Perhaps he's falling behind on his “productivity quotient” and risks losing his job if he doesn’t pick up the pace.

 

Or maybe the EMR he is using doesn’t have a bullet for the information he wants to include, so it goes unrecorded.

 

All the health care mandates and initiatives in the world will not solve the problem of TIME. Time spent with the patient. Time to reflect on his illness. Time to help him heal.

 

Now is the time for change.

 

“Lack of time

is actually

lack of priorities.”

~Tim Ferriss~

 

jan

 

 

 





true story

 

True story:

A friend of mine has been in terrible pain for over a year. She has orthopedic problems and degenerative disc disease in her back resulting in unrelenting sciatica. She also has a rare autoimmune disorder that requires her to be on chronic steroid treatment. Her initial workup, several years ago, found nothing operable so she has been taking substantial doses of opiates daily since then in a futile effort to control her pain. She can’t drive. She can barely make it up the stairs to her bedroom. She is experiencing a deepening depression because of it.

“You can avoid reality

but you can’t avoid the consequences

of avoiding reality.”

~Ann Rand~

 

Why hasn’t she gone back for re-evaluation?

 

Because, as she puts it, “They’ll think I’m a whiner.” She doesn’t want to take up the doctor’s precious time when other patients are worse off. She doesn’t have the language to describe her pain…not the nature of it, not the severity of it, not the timing of it. She tells herself she’s a sissy, that other people wouldn’t complain about it so she shouldn’t, either. She is convinced the doctor won’t find anything wrong and he’ll laugh her out of the office, or worse, he’ll assume she’s seeking drugs. Or, worse yet, he’ll decide she needs surgery after all, and she definitely doesn’t want that.

 

Her situation illustrates some of the obstacles patients encounter when trying to tell their story--the chief complaint and the history of the present illness.

 

What happens in situations like this is that the patient lies. He minimizes the severity of his symptoms because he doesn’t want to sound like a complainer or weakling. He may be embarrassed to admit that he can’t keep up with things anymore because he’s afraid he’ll lose his job. Even if he suspects the gravity of the problem, he may be reluctant to learn the truth. For example, the patient with chest discomfort may describe it as indigestion or heartburn in an attempt to dissuade the doctor who is sure he has CAD.

 

“You’d be surprised

what lengths people will go to

not to face what’s real and painful inside them.”

~unknown~

 

These are some of the obstacles that serve to confound the patient’s narrative: denial, shame, fear, ignorance, and dread.

 

To make a long story short, at my insistence my friend scheduled an appointment to see her pain management specialist. I’ll be going with her that day because, as a physician, I know what she's up against. As a writer, I think I can help her tell her story.

 

“One day I will find the right words

and they will be simple.”

~Jack Kerouac~

 

jan

 

 

 

 

 



where brilliance abounds

Kripalu  Center for Yoga & Health



 

I learned three great truths at the conference on narrative medicine at Kripalu Center last week:

 

            ~Storytelling is an act of raw courage.

 

“It takes courage to grow up

and become who you really are.”

~e. e. cummings~

 

~Brilliance abounds.

 

“That was brilliant!

Brilliant!!!”

~Nancy Aronie~

 

            ~ “The news from the mountains is good.”

 

“These mountains that you are carrying

you were only supposed to climb.”

~Najwa Zebian~

 

…that, and a little bit about the root of all suffering and how to alleviate it, how the mind has the ability to change the brain, and how listening can be a healing practice. I learned about dismantling the walls that surround issues of ethnicity and race, about poetry as a storytelling tool, and how meditation can fuel creativity. I watched skepticism morph into curiosity, curiosity lead to connection, and connection grow into trust.

 

If you noticed a slight jolt around noon on Friday, it was caused by the release of energy, intention and wisdom by fifty or so students of narrative medicine as we returned to our lives inspired, encouraged, and supported as storytellers, as listeners, and as healers. We learned that:

 

“There is no greater agony

than bearing an untold story inside you.”

~Maya Angelou~

 

Deepest gratitude goes out to Rita Charon, MD for sharing her work in the practice of narrative medicine, to Stephen Cope for helping us embrace our calling in life as a spiritual practice, to poet Marie Howe, to Rev. Jacqueline J. Lewis for her efforts to abolish the artificial constructs of ethnicity and race, to Lisa Nelson for introducing us to the neurobiology of listening, to Nellie Hermann on memoir, to Judith Hannan and Nancy Aronie for inspiring us to write, to Jillian Pransky for connecting us in mind, body, and spirit, and to Paul Morris for moderating our “open mic” in the tradition of The Moth.

 

Many thanks to Lisa Weinert and her staff for orchestrating, choreographing and conducting this conference. But most of all, thanks to everyone who dared to share their own stories with the rest of us.

 

“You are braver than you believe,

stronger than you seem,

and smarter than you think.”

~Christopher Robin~

 

jan

Ps: Your thoughts and comments are welcome and encouraged.

 

 



a random rant

Tanzania, 2012

 

Today’s post is a random rant in keeping with my conviction that the American health care system is headed in the wrong direction. This issue came to my attention after my daughter gave birth last month. She reminded me of this outrage:

Back in October, 2016, a couple in Utah learned that, after the birth of their baby, the hospital charged them $40 for immediate post-partum skin-to-skin contact, a practice widely believed to be beneficial to the newborn who has just been unceremoniously propelled into a hostile environment, and to the mother whose life has just changed forever and ever, amen. This is considered the standard of post-partum care, unless it is contraindicated for medical reasons…for example, newborn resuscitation.

 

www.quotemaster.org



The couple was flabbergasted at this charge. Their post went viral. It was explained to them that, nowadays, so-called “kangaroo care” is considered to be an intervention. It has its own billable code, and therefore, incurs an extra charge. It also requires supervision by an additional nurse whose salary has to be covered…for supervising a mother cradling her baby on her chest.

“I just want to lay on your chest

and listen to your heart.”

~www.beat-it2.blogspot.com~

It makes one wonder. How many mothers have dropped their babies in the delivery room? Since when did an age-old, cross-cultural, intuitive and nurturing post-partum practice become an intervention?

What is the price of maternal love?

“Nowadays people know

the price of everything

and the value of nothing.”

~Oscar Wilde~

jan

 

check your assumptions at the door

 

 



The same illness can be understood in different ways by different people. Nowhere is this more troubling than in the doctor’s office. The unspoken biopsychosocial elements that distinguish the physician from the patient pose a real obstacle to effective communication.

“I know that you believe

you understand what you think I said,

But I am not sure you realize

that what you heard

is not what I meant.”

~Robert McCloskey~

 

The physician may see illness as a puzzle to solve, or a challenge to overcome. He understands the problem in technical terms. He can describe how the anatomy and physiology have gone haywire, recite the tests that need to be done to prove it, and rattle off the latest peer-reviewed protocols for treatment. He may be doing a bang-up job of caring for his patient, so it confuses him when his patient doesn’t respond.

On the other hand, depending on his beliefs, the patient may see his illness as a punishment, a failure on his part, or a random manifestation of universal injustice. His clinical course can be aggravated by guilt. He tells himself he should have quit smoking sooner, or watched his diet more carefully, or kept up his exercise program. But because now he has a spot on his lung, or a stent in his heart, he thinks it’s too late. Why start now, he wonders.

Illness can also be complicated by grief, as in the case of a woman who relives her mother’s losing battle with breast cancer when she discovers the lump in her own breast. She may be skeptical about her treatment options, or reluctant to begin therapy, having watched her mother suffer to no avail.

Some people cling to the belief that prayer is the answer, even when it doesn’t work for them.

Patients make certain assumptions about the nature and course of disease based on observation, experience, belief, hope, and expectation that can affect their motivation, and even their ability to heal.

“Check your assumptions.

In fact, check your assumptions at the door."

~Lois McMaster Bujold~

The physician is unlikely to take these factors into account unless he anticipates them and asks about them. The patient is unlikely to bring them up on his own out of shame, or guilt, or grief, or fear unless he is invited and encouraged to share them.

Doctor/patient communication is difficult enough without the specter of false assumptions. They are, nevertheless, a clue to the patient’s history. They are an important a piece of his narrative.

“Nobody cares how much you know

 

until they know how much you care.”

~Theodore Roosevelt~

jan

 

off topic...but not really

 

A friend of mine recently returned from a trip to Machu Picchu, one of the “new” seven wonders of the world. In my humble opinion, the self-proclaimed experts who, back in 2000, voted to rename the Seven Wonders of the World, missed the point. They were looking at manmade monuments and structures of lasting beauty and grandeur while overlooking what I believe to be the Seven True Wonders of the World. I was reminded of them last week with the arrival of my newest grandson. This is what was so extraordinary about it:

Ovulation

Fertilization

Implantation

Gestation

Labor

Delivery

Oh, and sex…where it all begins.

When you consider all the changes the body has to orchestrate flawlessly in order for a healthy baby to enter the world—the timing of the hormonal and anatomical changes, the electrochemical shifts, the first breath—it astounds me that it ever goes according to plan. So much can go wrong…and often does. If you want to hear inspiring stories…as well as sometimes tragic stories…listen to a group of women sharing their birth experience.

“The mind of a woman in labor

is power unestimated."

~www.thejoyofthis.com~

They will tell you how excruciating pain leads to immense joy…or, when the process fails, to deepest sorrow. They will describe fear, even panic, at the slightest suggestion of trouble. They may reflect back on how hard it was to get pregnant…or how easy or even unexpected it was. How they learned the meaning of longing and of love.

“Story is the umbilical cord

that connects us to the past, present, and future…

Storytelling is an affirmation of our ties

to one another.”

~Terry Tempest Williams~

 

There is nothing new in the history of childbirth, but there are an infinite number of unique stories about it. Birth narratives are packed with sensory and emotional detail, victory and defeat, courage and cowardice, mystery and manifestation. Each story is epic in scope…part fantasy, part mystery, part thriller, part love story. Something for everyone.
Every birth is a wonder to behold.

“There are no seven wonders of the world…

There are seven million.”

~Walt Streightiff~

jan

 

ten reasons to 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 are 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 is. 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 writing group near you…think about starting one.

jan