a huge, heartbreaking problem

I spent a good chunk of my weekend completing the mandatory child abuse recognition and reporting course I am required to submit in order to renew my (retired) medical license every couple of years. If you are reading this blog, and you are a healthcare provider or a therapist in any field licensed by the state, you know what I'm talking about. You have to complete a couple of hours of required child abuse CME before you can renew your license. This is because you are, by definition, a mandated reporter.  You are obligated by law to report any incidence of child abuse or neglect whether you witness it yourself, it is shared with you, or it is something you otherwise remotely suspect...even if it occurs outside the scope of your practice, in the grocery store or on the playground, for instance. 

"The true character of a society

is revealed in how it treats its children."

~Nelson Mandela~

  

The reason we do this over and over again is that the process changes over time. The laws change and our awareness of the problem may dwindle. And...because child abuse and neglect are so damaging to our culture. To our future. We aren't required to update our understanding of heart disease, the newest treatments for cancer, or our grasp on mental illness to maintain our professional license. We are required to understand the nature, magnitude, and recognition of child abuse.

This is a huge, heartbreaking problem. It is estimated that a report of suspected child abuse is made every ten seconds in the United States. Over four million referrals are made every year. On average, five deaths occur every day due to child abuse/neglect. Even so, this may represent a gross underestimate given the problem of under reporting.

This is the thing: you may be reading this blog even though you're not a healthcare worker, therapist, or other mandated reporter. (This includes childcare workers, teachers, coaches, even librarians, among others). Perhaps you're a friend of mine, an on-line acquaintance, or even a previous patient of mine. So what does this have to do with you?

Whether you realize it or not, you are identified as a permissive reporter, meaning you are encouraged to report suspected child abuse even though you aren't required by law to report your concerns. While mandated reporters can file their reports through an on-line process, permissive reporters must contact Childline directly to register their concerns:

CHILDLINE

1-800-932-0313

AVAILABLE 24 HOURS/DAY

7 DAYS/WEEK

This is what you need to know. Your call will be kept confidential. Your call can be made anonymously. You do not have to prove that abuse did, indeed, take place. That's for the experts to determine. Your suspicion of possible abuse justifies your call. You will never face legal retribution for placing it. 

"Child abuse casts a shadow

the length of a lifetime."

~Herbert Ward~

I have written about Adverse Childhood Experiences (ACEs) before. (See "take this test," November 23, 2021). These are potentially traumatic events that occur in childhood (ages 0-17) and they include violence, abuse, and neglect, parental substance abuse, mental health issues, and household instability. ACEs are linked to long term, chronic health problems that manifest in adulthood, including heart disease, immune disorders, and mental health problems. These long term effects should compel all of us to take the problem of childhood trauma seriously. Personally. We should do all we can to identify it. To prevent it. To mitigate it. For more information on this important topic, this is a good reference:

https://www.cdc.gov/violenceprevention/aces/fastfact.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fviolenceprevention%2Facestudy%2Ffastfact.html

Remember this:

"You can spend a lifetime

trying to forget a few minutes

of your childhood."

~www.HealthyPlace.com~

If you're interested in learning more about how to recognize and report possible child abuse, this is an excellent course:

https://www.reportabusepa.pitt.edu/

*

"Give me your past,

all your pain,

all your anger,

all your guilt.

Release it to me and

I will be a safe harbor for the life

you need to leave behind."

~Jewel E Ann~

jan

https://www.reportabusepa.pitt.edu/

the transfiguration

THE TRANSFIGURATION

Impotent: how you feel when a patient under your care is dying, and medical science has nothing more to offer. When you’ve tried everything, and nothing has worked.

You feel like a failure—so “not God” as is sometimes still expected of physicians. It haunts you, especially when the patient is a child, or someone you know, or your own parent.

My father, for example, died a perfectly modern medical death, and there was nothing I could do about it. Post-operative complications of failed vascular surgery compounded by chronic lung disease took him down even though he was surrounded by life support paraphernalia of every description. Even though he was attended 24/7 by bright, dedicated doctors and nurses throughout the entire ordeal.

In the end, he died alone in the Intensive Care Unit because people were too busy to notice when he took his last breath. If the alarms hadn’t called them to attention, no one would have known. He died alone while I frittered the moment away with my mother in the visitors’ lounge down the hall where we’d gone for a cup of coffee. No one came to get us. No one drew us to his bedside in time to say one last good-bye. And by the time we were summoned, it was too late.

The truth is that doctors come to expect this kind of thing. Family members do not. Right from the start medical students are warned about it, and then they are trained to deal with it. For me, the seeds of indoctrination were sown on the very first day of medical school when the dean of the College of Medicine stepped up to the podium, and one hundred eager students, terraced like rice paddies on a hillside, snapped to attention.

He congratulated us on our academic achievement and our noble aspirations. He spoke about tradition and honor. He went on and on about dedication, self-sacrifice, excellence, courage, and the ethics of exhausting work. But the bottom line was, “Do no harm.” And in the next breath he declared in no uncertain terms, “The day will come when a patient under your care will suffer or die because of something you did, or something you failed to do, and it will be your fault. You will have no one to blame but yourself for having been careless or hurried or ignorant or, God forbid, arrogant or indifferent. You will bear the burden of guilt for the rest of your life. You will never get over it.”

He surveyed the blank expressions arrayed in front of him, and then he went on. “If for a moment you doubt what I am saying, you are invited right here and now to gather up your belongings and leave. Go. Depart.”

He paused, stepped away from the microphone, and waited. He scanned our fresh young faces row by row as if he knew exactly who among us would be unable to bear it when—not if, but when—a patient died under our care. I remember locking eyes with the man as if he were able to judge strength of character and depth of devotion by the size of one’s pupils. He was waiting for the fainthearted among us stand up so everyone could get a good look at what it meant to be a coward. He might just as well have asked those of us who had dropped acid over the weekend or those of us who preferred unprotected sex to stand up in front of everyone so we could hang our heads in shame as we shuffled out the door. But no one left. A few of us shifted nervously in our seats, but who would admit it? 

When he stepped back up to the microphone he sounded incredulous. “No one?” He paused. “Then God help you.” And with that he doffed his glasses, picked up his notes, and left.

One hundred fledgling medical students responded with stunned silence. Then someone in the back row chuckled, as if to say, “What the hell was that?”

That, we would learn, was the power of prophecy. It was inevitable that patients—even children who were critically ill or injured—would die under our care, in the emergency room or on the operating table or in the intensive care unit. Despite our best efforts, patients would slip away from us. We were warned to expect it, and we were taught how to deal with it.

In medical school, when a patient died, we learned to tell ourselves there was nothing we could have done to prevent it. We were not to blame. It was the incubus of exhaustion, the sophistry of the gods at work. Put it out of your mind, we were told. Better yet, pretend it never happened. We were told to move on. We had work to do. Hope to instill. Trust to inspire. Destiny to ordain.

For four years the men of medicine took hammer and chisel to us until compassion fell away like dross—a smoldering pile of words that longed to be spoken, of hands that begged to be held, of tears that never fell. And out of it we emerged transfigured—tireless, dispassionate, infallible. Or so we were led to believe.

Over the years, though, experience taught me otherwise. When I knew a patient was dying, I learned to stay at the bedside. To check for a pulse myself. To place my stethoscope on the patient’s chest and listen for a heartbeat even though the monitors had already gone silent. I met with the patient’s family and explained what had happened. I did my best to answer their questions.

"We touch heaven

when we lay our hand

on a human body."

~Novalis~

I didn’t make up excuses. I didn’t turn the situation over to the nurses, or the hospital chaplain, or to someone from social services. I finished the job.

I believed in the healing power of the physician’s presence and the importance of his touch, and I still do. We all did. We respected the roles of ritual and expectation in healing, and we honored the importance of compassion and human connection in patient care. Of course, this was in the day before the exaltation of the ten-minute office visit. Back when we still made eye contact with patients. When we enjoyed a holistic relationship with them, a trusting kinship that helped them heal. Even when healing was beyond our grasp, we stayed with our patients to provide support, comfort, and hope.

Today’s overwhelmed health care provider may suggest this is what we have nurses, social workers, psychologists, pastors, and family and friends for. But by disengaging himself from the patient's psychological, emotional, and spiritual life, the physician sacrifices his connection with his patient, and with it, he surrenders his calling. His passion. His sacred duty.

Looking back, I realize that to deny the truth is to ignore a festering wound, a disfiguring blemish on the snow-white complexion of the soul. You can slap a bandage over it so it doesn’t show, but still, you know it’s there. The truth is that guilt aches and throbs even out of sight. It is as contagious as fear, as pernicious as anger, as deadly as pride. And it never heals. 

I was twenty-three-years old when I started medical school. I practiced Family Medicine for over thirty years. It took me that long to acknowledge the truth. You can put fear and doubt behind you. You can move on to other things, but when a doctor attends a patient's death, he bears the loss forever in his heart.

"Nobody cares how much you know

until they know how much you care."

~Theodore Roosevelt~

jan

memories are made of this



 

As a physician, I am awash with memories. Some are biggies…like the five-hour ambulance ride it took to transport a fragile premie from a rural upstate hospital to the medical center where I was a resident in Family Medicine. Lights and sirens the whole way. Or running a clinic out of a tent in the African bush without electricity or running water. Or prepping a patient who was sent to the OR by the emergency room doc for an appendectomy in the middle of the night…when my pre-op exam revealed a leaking aortic aneurysm instead. That got things moving!

On the other hand, some memories are brief, isolated moments that punctuate the middle of a busy day…a dousing with pee during a newborn exam, a spontaneous embrace or word of gratitude from an appreciative patient, a smile or a grimace or a groan.

 "We don't remember days.

We remember moments."

~Cesare Pavese~

Monumental or trivial, happy or sad, some memories stick with us. When you consider the number of patients we see over the course of our careers, all the details we tend to, all the information we process, it’s amazing we remember any of it.

Imagine, though, what it must be like for your patient. You may already have seen twenty patients that day. It’s all a blur. Each patient, on the other hand, sees one physician or provider that day—you—and will be totally focused on this particular encounter. Years later, he may still recall the fear or dread that tempted him to cancel his appointment. The impatient sigh that escaped when you glanced at your watch. How cold your hands were, or how warm. How hurried you were, or how patient…

 "You will never know the value

of a moment

until it becomes a memory."

~Dr. Seuss~

 …when you don’t remember the patient at all.

Whether you’re a provider or a patient, if you’re interested in narrative medicine, you have to tap into those memories. Relive those moments. Reflect on your experience. And share what you have learned.

"One day you will be just a memory

for some people.

Do your best to be a good one."

~unknown~

jan

psychedelic-assisted psychotherapy

 

 

Last summer while I was attending a writing workshop at Omega Institute, a MAPS (Multidisciplinary Association for Psychedelic Studies) group was also on campus for the week, so I had the opportunity to speak to a number of psychiatrists and therapists who are beginning to integrate the use of psychedelics into their practices. 

"With psychedelics, 

if you’re fortunate and break through, 

you understand what is truly of value in life.

 Material, power, dominance, and territory 

have no value. 

People wouldn’t fight wars, 

and the whole system we have currently 

would fall apart. 

People would become peaceful, loving citizens, 

not robots marching around in the dark 

with all their lights off.”

~Gary Fisher~

I especially like the part about no more wars.

The therapeutic use of psychedelic substances, including LSD, psilocybin, and MDMA ("ecstasy") to modulate certain aspects of consciousness has attracted renewed interest and enthusiasm in recent years. Clinical investigations have targeted depression and anxiety, alcoholism and other addictive disorders, and PTSD, among others, with unprecedented success. LSD has demonstrated palliative effects on the anxiety, fear, and dread experienced by patients with terminal illness as they approach death. Many people experience a mystical or spiritual awakening that leaves them calmer, gentler, and more loving. And it sticks. As long as it's done correctly.

"Patients reported that their psychedelic sessions

 were an invaluable experiential training for dying.”

~Stanislav Grof~

The problem is that research into the use of psychedelics has a stormy history. Research protocols are notoriously difficult to design and to control when the end-point is subjective. Because these drugs are illegal, they are difficult to procure. And there are reports of adverse experiences. Entire departments have been shut down out of fear that their work may be more harmful than helpful. This has forced dedicated scientists and doctors to continue their research underground, jeopardizing their reputations and the results of their studies. 

"By banning psychedelic research 

we have not only given up the study 

of an interesting drug or group of substances, 

but also abandoned 

one of the most promising approaches 

to the understanding 

of the human mind and consciousness.”

~Stanislav Grof~

From those clandestine efforts, however, there eventually emerged a systematic plan and therapeutic process that addressed some of the concerns raised by the naysayers. A code of ethics emerged, and a charter was established. Questionnaires were developed, and guidelines for therapists were published. With this new sense of order and accountability, psychedelic-assisted psychotherapy is finding its way into mainstream practice...although it has a long way to go.

The history of psychedelic use in psychotherapy is fascinating, and it spans many decades. If you read up on it, you'll encounter names you may recognize but not associate with psychology or scientific studies: Aldous Huxley, Andrew Weil, Allen Ginsberg, Walt Whitman, Ken Kesey, and of course, Ram Dass and Timothy Leary...names we associate with literature, art, and the search for enlightenment, all of them curious about consciousness and creativity. 

Experts in the field and proponents of the practice suggest that it provides a new perspective on consciousness and the role of the ego in accessing memory, emotional response, and learning. Its potential is literally mind-boggling. If you'd like to know more, I recommend you start with this book:

Or, you can attend the largest gathering of psychedelic researchers and practitioners ever assembled next summer in Denver at the 2023 Psychedelic Science Conference: https://maps.org/

Seriously...I'm thinking about it.

jan

everything we need to know

 

Where there's a will, there's a way.

It seems as though everything we need to know is right at our fingertips. How to change a flat tire. How to set a beautiful table. How to potty train a toddler. All available with a click on a keyboard.

This week alone, the following titles popped up on my social media feed:

• How to master a life transition
• How to make the best of life
• How to be perfect
• How to reprogram your subconscious mind
• How to access superhuman abilities

And my favorite:

• How to finish your book.

Although some of these sound like impossibilities, this is not a joke. The authors and presenters are all serious. Among them are authors, life coaches, researchers, spiritual leaders, and world famous teachers and gurus. 

They did, however, miss a few topics of interest to me. I'd also like to know:

• how to convince people to take care of their health
• how to get people to complete their Covid vaccinations and get their flu shots
• how to make it safe to vote
• how to eliminate child neglect and abuse
• how to rescue every animal on the planet that is sick, injured, hungry, or lost

 And my favorite:

• how to do away with conspiracy theorists and their followers and believers

Maybe something will come up for me next week.

What impossibilities interest you? If you could do anything at all to help humanity, what would you do? How would you explain the process? How would you change people's minds?

"People who think they know everything

are a great annoyance to those of us 

who do."

~Isaac Asimov~

jan

how telling your story can help you heal

It doesn't take a stretch of the imagination to understand how hearing or reading just the right story at just the right time can help with healing. For example, you might gain a new perspective on an issue that has been troubling you. Perhaps you've been struggling with guilt after a friend committed suicide. You pick up a book like "The Ticking Is the Bomb" by Nick Flynn whose mother took her own life. His story looks at suicide differently. He considers the inevitability of it given the course of his mother's life. After reading it, you might see things a little differently. Maybe it wasn't your fault your friend found life unbearable. Perhaps you didn't miss the clues because there were none. A layer of guilt falls away.

Healing.

"The book I read after my mother died,

the how-to-deal-with-trauma book,

had failed to say when change could resume,

when one could go on."

~Nick Flynn~

~"The Ticking Is the Bomb"~

 

Or maybe your friend has been diagnosed with cancer, and it doesn't look good for her. You have no idea what to say or do for her, no clue how to help. Then you pick up a book like "Talk Before Sleep" by Elizabeth Berg, and you learn all the ways you can comfort and encourage her, and even bring a touch of humor to the situation. 

 

Healing. 

 

It may be a bit harder to grasp the idea that telling or writing your own story can also be a healing practice. But it is.

 

Maybe for you, anger sometimes erupts without provocation. Perhaps you feel anxious even when life is going well. Maybe despair blankets everything you do for reasons you don't understand. Or a particular song always brings you to tears. You can't help it. Why?

 

"We don't write what we know.

We write what we wonder about."

~Richard Peck~

 

Intrusive thoughts and feelings are the shadows of traumatic memories. Remember the time your father hit your mother in a fit of rage? You were so angry you wanted to hit him back, so scared you didn't dare move, and you couldn't run away. You felt helpless as a child, and now you feel worthless as an adult.

 

Perhaps, in your family, you never knew when the front door would open and your father would come home drunk, and even if you were already in bed, he'd find you there...

 

Maybe that was the song you listened to so you didn't have to hear your parents argue.  

 

Your anger, or sadness, or fear needs to find a time, or a place, or a name to explain it. You need to know its identity, its source, and its setting in order to renegotiate your relationship with it.

 

Telling your story puts you in control. It helps you think about what happened. It helps you understand why. You get to decide how it ends. And that can help you heal.

 

 "At any given moment

you have the power to say,
'This is not how my story is going to end.'"
~Christine Mason Miller~

 jan

 





 





the concussion conundrum

Concussion care made big news this week when the NFL called for new guidelines for the management of players who sustain a head injury during the course of play. The NFL has agreed to make changes to its concussion protocol mandating that concussed players be removed from the game whenever signs and symptoms appear. The problem is that a concussion can be hard to diagnose accurately on the field. Symptoms can mimic orthopedic conditions (ie. when ataxia is misdiagnosed as a limp). And some symptoms, such as nausea and vomiting, blurred vision, numbness, dizziness, and seizures may not develop until hours, days, or weeks later. Some symptoms are relatively vague, including moodiness, irritability, memory loss, and sleep disturbance. The first concussion is serious enough, but if the player sustains a second concussion, even a mild injury before he recovers from the first one, it can be deadly. (Second Impact Syndrome) And we all know that repetitive traumatic brain injury increases the risk of dementia (Chronic Traumatic Encephalopathy)

~"If in doubt, sit them out."~

~Sydney Children's Hospital Network~

The protocols that guide concussion diagnosis and management have been under study and revision for as long as I have practiced medicine. Most of the early research concentrated on childhood injuries without establishing clear guidelines for adults. So, while this effort to mitigate the toll traumatic head injuries exact on professional football players sounds like a good thing, it seems to me a case of too little, too late. It does nothing to prevent concussions. By the time the problem is recognized, diagnosed, and treated...it is too late. The damage has been done. And if you are willing to acknowledge the fact that many players sustain hundreds, even thousands, of blows to the head over the course of their careers, you might wonder why we allow it. Encourage it. Cheer it on...

"The millionaire players of professional football

are suiting up for the new season

with a startling caution on their locker room walls.

A poster headlined “CONCUSSION” warns players

that lifelong brain damage can result

if they persevere with macho gallantry

through multiple head injuries."

~NYT Editorial quoted by Michael Craig Miller, MD

in Harvard Health Publishing~

It's a tragedy that the sports culture in this country refuses to protect young men who are conditioned to become macho millionaires at all costs. 

"(American) football is not a contact sport.

It is a collision sport.

Dancing is a contact sport."

~Vince Lombardi~

jan