the downside of doctoring

 

 

One of the perks of being a physician is the fact that you get to live in a state of perpetual awe. It starts with the first pass of the scalpel on your first day in the anatomy lab. It continues as you tease out every organ, blood vessel, and nerve in the body you've been assigned to dissect. A sense of wonder punches you in the gut the first time you hear a beating human heart and realize that your own heart has been beating steadily and predictably without any effort on your part since before the day you were born.

 

"There is nothing worse than

thinking you are well enough...

Don't turn your head.

Keep looking at the bandaged place.

That's where the light enters you.

And don't believe for a minute

that you are healing yourself."

~Jelaluddin Rumi~

 

You'd have to be a toadstool not to be mystified by the anatomy, physiology, and psychology of your very own body. You'd have to believe in miracles if you understood the way a broken body heals, what it takes for an open wound to close, how a lifeless heart can pick up the beat again.

 

Don't even ask what happens during sex.



I studied medicine for seven years and practiced it for over three decades, so I understand how the body works. I know what it takes to keep it up and running. Most of the time, I know how to fix it when something goes wrong. Most people don't. They get out of bed in the morning and expect their bodies to cooperate with their plans for the day. They have to get their children off to school. They have to get to their jobs. They don't have time to be sick.

 

But what if you woke up in the morning and you couldn't move the left side of your body, and you speech was garbled so you couldn't tell anyone what had happened? What if you woke up to find the infant you rocked to sleep the night before pale and lifeless in her crib? What if everything that was familiar and predictable to you changed in a heartbeat?

 

We expect our bodies to work, but sometimes they don't. We think our children are safe, but we can't guarantee it. We take health and happiness for granted until something goes wrong. The cancer comes back. The paralysis is permanent. The depression won't lift. Sometimes the afflictions of the body go beyond its own ability to heal, and beyond the physician's ability to help.

 

What then?

 

When a patient under his care gets worse and there is nothing he can do about it, a doctor feels helpless. When he has tried everything he knows and nothing has worked, he feels like a failure. So not-God as is sometimes still expected of physicians.

 

And that's the problem. The downside of doctoring is that sometimes the patient gets worse despite your noblest efforts. The cancer spreads. The heart fails. The wound won't close. There is nothing more you can do. You concede it would take a miracle for the patient to recover. All you have left is prayer.

 

"The greatest force in the human body

is the natural drive of the body to heal itself,

but that force is not independent of belief...

What we believe is the most powerful option of all."

~Norman Cousins~



 

But what if you don't believe in miracles and you've given up on prayer? Your sense of awe comes into question. Your sense of wonder falters. Hope fades away. Where do you turn?

 

You might try this. Study the night sky. Watch for the first signs of spring. Feel the pulse in your own wrist. And teach your patients to do it, too.

 

"The human body experiences

a powerful gravitational pull

in the direction of hope."

~Norman Cousins~

jan



 

 

 

 

 

 

 

 

 

 

 

 

 

 





the disorienting dilemma

Unless you're an educator, you may not be familiar with the term "transformative learning". The theory of transformative learning was developed by Jack Mezirow, a sociologist and Emeritus Professor of Adult and Continuing Education at Columbia University. It refers to the ways we adjust our thinking based on the acqusition of new information. Nothing special about that, but the thing that sets transformative learning apart from, say, what we learn from reading is the fact that transformative learning always involves what is known as a "disorienting dilemma". 

 "You can't resolve a dilemma

with the very same mind

that made it."

~Albert Einstein~

A disorienting dilemma can be described as an experience that does not fit our expectations or make sense to us without a substantial change in our world view, our conditioned assumptions, our previously held beliefs, or our tightly held convictions. It leaves us stunned. Disoriented. Our dilemma forces us to ask several questions:

• What have I been thinking all this time? Why?
• What am I really committed to?
• What is important for me to accomplish?    
• What is preventing me from accomplishing what I am committed to?
• What path will I take going forward?

While Mezirow's theory was intended to reference learning in adults, it is applicable across a broad spectrum of behavior and experience. And it is especially relevant to health care providers.

A disorienting dilemma for me evolved gradually with the changes in the health care system...the erosion of the physician's authority by self-proclaimed intermediaries who had neither knowledge of nor concern for patients’ well-being...attorneys, auditors, insurers. A system whose number one priority was corporate profit rather than compassionate care. The imperative to see more patients, faster in order to generate more revenue...which I believed put patients at risk. I worried about missing a diagnosis, or bungling a procedure, or prescribing the wrong medication in my rush to stay on schedule...in my efforts to appease corporate administrators, while struggling with an oppositional-defiant electronic medical record system, a baffling coding and reimbursement system, and the ever-present threat of litigation. It scared me.

Medicine was my passion, but my sacred duty was to patient well-being and safety, hence, my dilemma: Should I stay and fight the system? Did I have a duty to engage in that battle? Or should I go? 

"Sometimes you change your mind...

sometimes your mind changes you."

~Binyomin Scheiman~

Long story, short: I abandoned the practice of medicine. After thirty years in Family Medicine, I told my patients and colleagues I was retiring…when I meant I was quitting. I didn’t put it quite that way, of course. It wasn’t as though I simply got fed up with things, turned in my stethoscope and tongue blades, and slammed the door on my way out of the office. I wasn’t impulsive about it at all. I agonized over my dilemma for years. My decision had nothing whatsoever to do with my patients. Caring for them was my passion. Nor was I defeated by the perpetually long hours. Nor was I discouraged by the fact that I’d been running behind schedule all day, every day for thirty years with no chance I’d ever catch up. That wasn't the problem.

I simply deferred to what I considered to be my sacred duty, my true calling...and I did what was necessary to honor it.

"Sacred duty is the thing that

if you do not do it, you will feel

a profound sense of self-betrayal."

~Stephen Cope~

Sooner or later, most of us will come up against a dilemma that requires us to re-evaluate our deeply held beliefs in life, to question our assumptions and opinions, and perhaps, to change our minds. Then we will be confronted with the imperative to act on what we have learned in the process, or to betray ourselves.

The important plot points in our lives tend to involve disorienting dilemmas. They punctuate our professional narratives as well as our personal lives. And they unfold among our patients. For example, whether or not to terminate an unplanned pregnancy. Whether or not to place Mom in an extended care facility. When and if to discontinue life support.

Are you facing a life-changing decision? Are you ready to learn? Are you prepared to act?

"Two roads diverged in a wood

and I--I took the one less travelled..."

~Robert Frost~

jan

a battle worth fighting

If you have dedicated your life to work in the field of health care, chances are it was more than the prospect of a secure income that motivated you to spend so many additional years studying and preparing when your friends were already out in the world. Earning money. Cultivating a social life. Even starting a family. Perhaps you come from a long line of nurses or doctors and felt the pressure of expectation to continue the tradition. Maybe you were attracted by the prospect of authority and prestige. Perhaps you pursued medicine or nursing out of a heartfelt desire to do good in the world. To help people heal. Or because you felt called to this line of work.

"The two most important days in your life

are the day you are born

and the day you find out why."

~Mark Twain~

If medicine is your calling in life and you know it, good for you! But if your purpose in life is not yet clear to you, if you're not sure what you were put on Earth to do, or who to be, or why it makes any difference, you might want to start thinking about it. Otherwise you may find yourself wandering through life without a clear path forward. Chasing after someone else's expectations for you. Investing time and effort in something that offends your sense of right and wrong. Striving for something that is meaningless to you or harmful to others. 

If you have been contemplating your sacred calling in life but still feel lost, or you've been avoiding the issue because you don't know where to start, I highly recommend Stephen Cope's new book, "The Dharma in Difficult Times".

In it, he illustrates the teachings of the great Hindu text, the Bhagavad Gita, through the lives of dedicated visionaries including Gandhi, Thoreau, Sojourner Truth, and Marion Anderson, among others, all of them committed to non-violent resistance/activism. How did they discern their sacred calling? What were they willing to sacrifice to achieve their goal? How did they apply the principles of non-violence to their efforts? What was the outcome?

Why is this important? Because we all have a sacred calling, a duty to ourselves, to others, and to the planet, whether we care to embrace it or not. Sooner or later each of us will be confronted with a dilemna that will require us to discern right from wrong, truth from untruth, whether to follow the crowd or to stand up for what we believe and value. Each of us needs to decide if this is a challenge we are willing to accept. A goal worth pursuing. A battle worth fighting. 

"Tell me,

what is it you plan to do

with your one wild and precious life."

~Mary Oliver~

I believed medicine was my sacred calling in life. I ignored the naysayers who insisted women weren't meant for it. That I would regret my decision. That I would fail at it. Instead, I made the sacrifices that were necessary to do the work I chose. Diligently and without fanfare. For over thirty years.

What about you? Where are you on your journey? To what cause do you feel a sacred duty? Cope states: 

"Sacred duty is the thing that

 if you do not do it,

you will feel a profound sense of self-betrayal."

~Stephen Cope~

 

Is it health care? Climate change? Racism? World hunger? Cruelty to animals?

All of the above?

How will you make a difference?

"Be the change you wish to see

in the world."

~Mahatma Gandhi~

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how to know if you have what it takes

The day I went to my first medical school interview was a day just like today...a sunny but frigid day in mid-January. I had a three-hour drive ahead of me that I negotiated in my father's dilapidated Corvair...the one with the gaping hole in the floor boards under my feet that allowed me to gaze at the pavement when I grew tired of the scenery. It lent new meaning to the expression "cold feet", as I speculated about what questions I would parry when I met with the Dean of the College of Medicine and his team of decision-makers, fate-sealers, and heart-breakers. Early in the morning, I wrapped my legs in a warm woolen blanket and headed for I-didn't-know-what.

I don't remember much about the rest of the day. I have only a vague recollection of the interviewers, my tour of the hospital, the lecture halls and labs, and the drive home, but one question still haunts me some fifty years later:

"What would you do if a classmate

offered you a joint?"

Wait a minute. Really? Why don't you ask me what books I'm reading. What my favorite subject is. Whether or not I have any experience with illness or with people who are dying. Don't ask me about pot! I don't remember how I answered, but I'm pretty sure that whatever came out sounded awkward, naive, and very uncool. I was sure my application ended up in the trash that day.

The next interview took place in Philadelphia. It turned into a road trip with my BFF, who didn't think it was safe for me travel alone overnight. She insisted on coming with me, so we hopped on a Greyhound bus in Burlington, with a midnight transfer at the terminal in Albany...notorious for sheltering every kind of drunken, drug-addicted, and mentally deranged poor pathetic soul imaginable on cold winter nights. I remember every detail of the Albany bus terminal...but I don't remember one moment of our stay in Philadelphia, and nothing of the interview, or the trip back up North. I do, however, remember what it felt like to stay awake all night before one of the most important interviews of my life. Good practice for all those nights I would eventually spend on-call.

"Nothing fixes a thing so intensely

in the memory as the wish to forget it."

~Michel de Montaigne~

My last med school interview also involved an overnight bus ride and another stopover in Albany on my way to NYC. Alone. In Manhattan, I landed in the Port Authority terminal at 6:30 AM, where I was forced to wash up and change in a germ infested public restroom. Where I had to fight my way into a taxi during morning rush hour...against men in three-piece suits carrying alligator briefcases for protection. Where I remember touring the hospital at Flower and Fifth, as if a country girl like myself could possibly survive there. 

Looking back, I think each interview was an adventure, each one a test...each one a challenge in its own way. Nerve-racking. Exhausting. Scary...much like the practice of medicine itself. Still, the idea of driving a car with a hole in the floor in the middle of January with just a blanket for warmth still brings a smile to my lips today. I will never forget the characters who entertained me at the Albany bus terminal while I cowered on a bench in disbelief. I still cringe at the thought of washing my face and brushing my teeth in the Port Authority rest room, and I smile to think how I fought my way into the cab that carried me to the hospital at Flower and Fifth.

Proof, I think, that I had what it takes to become a...

"DOCTOR"...

because bad ass miracle worker

is not an official job title."

~unknown~

jan

 

the real test of courage

What is the bravest thing you've ever done?

If you're a healthcare provider, courage is required just to get through an average day. Emergencies arise. People depend on you. Your knowledge and expertise can make the difference between life and death for your patient. More than a couple of times, I've pulled over at the scene of an accident before an ambulance could be summoned. I've performed CPR in the front seat of a patient's pick-up when he went into cardiac arrest before he could get into my office. I've ventilated a newborn premie in the back of an ambulance for three hours on the way to the hospital.

"Be brave my heart.

Have courage my soul."

~www.weheartit.com~

Friends comment about the courage it must have taken to run a makeshift clinic in the African bush for a week without electricity or running water. To make a house call in the middle of the night to a patient with a loaded rifle next to his bed. To take a drill to a patient's skull.

The way I see it, though, that kind of thing didn't require courage. It was all part of my job. I trained for years to handle situations like these. It didn't take bravery, as much as practice and resolve. You don't think of yourself as a hero or a god when you're just doing the job you pledged to do.

"Courage is grace under pressure."

~Ernest Hemingway~

Still...the work of the healer has its frightening moments. Problems arise that you can't anticipate or prepare for. That's when courage kicks in. When you're asked to sign the DNR order for a patient you can't save. When you have to confront a colleague about a mistake he made. When the mother dies during childbirth, but the baby survives. 

It is the difficult conversation, the tough confrontation, the tragic loss that uncover real courage.

"Courage is found in

unlikely places."

~J.R.R. Tolkien~

So, what is the bravest thing you've done? Have you comforted a sobbing child? Rescued a puppy? Forgiven an enemy?

Each of us is summoned differently. Where do we find the courage to help others heal?

"You never know how strong you are

until being strong is the only choice you have."

~Bob Marley~

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trauma is the great silencer

The practice of narrative medicine encourages healthcare providers to explore the patient's whole story, not just the timeline of their symptoms. It allows time and space for patients to reflect on their lifestyle, cultural roots, socioeconomic status, religious beliefs, and the presence or absence of supportive relationships...whatever might have had an impact on their health, and their ability, or lack of ability, to heal.

"It is more important to know

what sort of person has a disease

than to know what sort of disease a person has."

~Hippocrates~

 

There's just one problem with this approach. We never learned about the problem of trauma and how it affects memory. How it affects the way we process and navigate terrorizing or horrific events--the emotional and physical aftermath of war and natural disasters, serious injuries, difficult hospitalizations, domestic violence and child abuse, among others. How trauma can trigger intense emotional reactions years later so that even early childhood trauma can lead to physical, psychological, and emotional disturbances in adulthood. Why it is sometimes impossible to access those memories, and what makes it so hard to put them into words. In other words, unless you recognize the sign and symptomss of trauma, an important part of the narrative will still be missing.

"Traumatic events are almost impossible

to put into words."

~Bessel van der Kolk~

Trauma is the great silencer. As demonstrated on fMRI images, trauma activates the limbic area, or emotional brain which includes the body's alarm system. Years later, when people encounter images, sounds, or thoughts related to their trauma, it triggers a cascade of stress hormones that raise blood pressure, heart rate and oxygen intake, preparing the body for fight or flight, even though no current threat exists. At the same time, trauma decreases activity in Broca's area, one of the speech centers of the brain. When Broca's area shuts down, you cannot put your thoughts and feelings into words. Years later, traumatized people have enormous difficulty telling the story of what happened to them.

"You'd be surprised what lengths

people will go to

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

~unknown~

This is the missing piece in narrative medicine training, the part of the patient's story that will never emerge, because it can't. Memory is shut down. Speech is cut off. 

The bad news is most physicians don't know this, so they can't help their patients heal from it. They aren't trained to recognize and explore the signs and symptoms of remote trauma, nor do they know how to treat it. The result is that these patients end up with a multitude of inaccurate diagnoses including, but not limited to depression, anxiety, ADHD, oppositional defiant disorder, and borderline personality disorder. Then they are prescribed a slew of medications in a futile effort to regulate their behavior and responses.

The good news is it can be treated. Patients can be taught to access painful memories and to assemble them into a coherent history without being emotionally overwhelmed. Only then can healing begin.

If you, or someone you know, or a patient you are treating tends to fly into a rage for no justifiable reason, or is anxious even when things are going well, or shuts down in social situations, or has been in therapy but hasn't made any headway, the cause may relate to unresolved trauma, and it may take a topnotch specialist to crack the case, and to work through the problem.

If you're interested and would like to learn more, there are plenty of resources available. Check out "Developmental Trauma Disorder" online. These are books that helped me a lot:

• "The Body Keeps the Score" by Bessel van der Kolk

• "Childhood Disrupted" by Donna Jackson Nakazawa

• "The Beauty of Breaking" by Michele Harper

Be sure to check out their websites, online courses, and references because:

"The most important part of a story

is the piece of it you don't know."

~Barbara Kingsolver~

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who are the real superheroes?

This is not a picture of me, but it could be. The ward I was in looked exactly like this.
The bed is the same, and it is in exactly the same spot as mine was. This could be the little boy who was in the bed next to me. 
It is uncanny. 
I wept when I first came across this picture.

Truth:

An ugly scar. A permanent limp. A weak heart. The aftermath of childhood illness can last a lifetime. You think you’re over it when the sight of a little blood or the thought of getting a shot catapults you back in time to a place you’d rather forget. One moment you’re a fully functioning adult. The next, you’re a sobbing three-year-old.  Like a stain you can’t get out, like fog that never lifts, it stays with you.

Trivial details rise up out of nowhere with perfect clarity. An aide unloading the lunch cart. The “No Smoking” sign by the door. The pile of Little Golden Books stacked on your nightstand. 

Moments you’d rather not remember surface uninvited. Your mother in tears at your bedside. The mingling smell of antiseptic and stale urine. The jab of a needle and the dull ache that lasted until the next shot was due. You still feel it.

Even if you recovered completely, memories of the ordeal can shadow you all your life. Perhaps as an adult you still use a night light to dispel the fear you felt when visiting hours ended and the nurses turned down the lights in the children’s ward. Maybe you struggle with asthma because of the way the nurses held you down to draw your blood. Smothering you. Maybe your gut still cramps up the way it did when the doctors lined up around your bed and insisted on pushing on your belly right where it hurt worst. Every last one of them.

Or, maybe you still have trouble swallowing pills because you were too young to get them down when you were sick. Instead your mother crushed them and slipped the powder into applesauce or pudding in a failed attempt to mask its bitter taste. Maybe your favorite threadbare teddy is still packed away in a chest in the attic. All visceral reminders of the ordeal you endured as a child.

Traumatic memories can release an outpouring of emotions that can stop you in your tracks. Something as simple as getting your flu shot, or having your blood pressure taken, or hearing an ambulance in the distance with its siren wailing can set the whole thing off again. Palms sweating. Heart racing. Hands shaking.

I was three years old when I went into the hospital. How is it I remember the exact arrangement of the beds in the children’s ward? The pattern of the afternoon sunlight reflected across the wall? The name of the girl in traction across the room from me? Alice. Ten-years old.

How does it all come back to me in technicolor detail when some days I can’t remember what I ate for breakfast?

*

"Sometimes real superheroes live in the hearts

of small children fighting big battles."

~unknown~

jan