#neveragain

 

 

If you practiced medicine back in the 1970s, you witnessed a dramatic change in the practice of pediatric primary care. By then, advances in medicine had reduced the incidence and toll of many deadly childhood diseases, including infectious diseases (through vaccination, antibiotics and improved hygiene/sanitation), pediatric cancer, asthma, and heart disease. Instead, the emphasis turned toward disease prevention, behavioral pediatrics, and safety. We saw major public health initiatives emphasizing automobile safety (the use of seatbelts and approved car seats for children), prevention of accidental poisoning with the use of child-resistant packaging and safety caps, SIDS prevention, and the use of smoke detectors…all calculated to reduce the incidence of the number one cause of death in childhood: unintentional injuries.

“The safety of the people

shall be the highest law.”

~Marcus Tullius Cicero~





But then, of course, there were still the guns. Headlining the February 2, 2018 issue of Newsweek magazine is this:

“Kids and Guns:

Shooting now the 3^rd leading cause of death for US children.”

 

Which brings me to this true story:

A boy was accompanied to my office by his mother for his well-child exam. I took his past medical history, family history, and social history before examining him. I asked about school, what sports he played, whether or not he wore his seat belt, whether or not there were smoke detectors in the house…routine questions, among others, that covered preventive/safety issues in the home.

Then I asked whether or not there was a gun in the house. Did he know where it was kept and if it was locked and/or loaded? Well, to my surprise, his mother became irate at these questions. It was as if I were accusing her of a crime. Prying into something that was none of my business. As if I was trying to shame her for having a gun in the house. In fact, she was so offended, she wrote a letter to my office manager and left the practice.

Not long afterward, there was a deadly accidental shooting in our community. A young boy died.

 

~from Townhall

February 20, 2018

Beth Baumann~

 

This story serves to illustrate the explosive (no pun intended) nature of the gun control debate. No other safety issue has generated such a heated response. This is a concern that all health care providers must confront. It is a huge personal, political, and public health problem. It belongs to all of us.

#NEVERAGAIN

jan

we've come a long way

 

 

Yesterday—February 3—was National Women Physicians Day. Who knew there was such a thing? This is proof we’ve come a long way since I decided medicine would be my path in life…since the days when women in medicine were regarded with suspicion, disdain, and even mockery.

 

“If society will not admit

of woman’s free development,

then society must be remodeled.”

~Elizabeth Blackwell~

My journey into the practice of medicine started with my hospitalization for rheumatic fever when I was just three years old. Even at that young age, the experience shaped my sense of self. I never lost my appreciation for the suffering illness creates in a person’s life. I learned to harness the power to heal, and to revere the people who made it possible.

When I was in high school, I volunteered at one of the largest and poorest hospitals in Buffalo, NY. I majored in medical technology in college. I applied to medical school when there was still a 10% quota on women who were admitted—just ten in of a class of one hundred. Today, more women than men go on to study medicine.

“Every woman who heals herself

helps heal all the women

who came before her, and all those

who will come after."

~Dr. Christine Northrup~

I hope that more than just the numbers have changed.

I hope that young women who pursue the study of medicine are openly welcomed into the medical community, mentored, and encouraged to stay with it. I hope they are able to maintain high standards of medical ethics, selflessness, and dedication to patient care. That their male colleagues do not confront them with the disdain, disparagement, and arrogance that sometimes greeted us. That their female colleagues—nurses, therapists, aides, and support staff—feel connected with them in the art and science of patient care.

“The trained nurse has become

one of the great blessings of humanity,

taking a place beside

the physician and the priest.”

~Sir William Osler~

I hope they feel supported by their spouses, children, and friends. That exhaustion doesn’t do them in. That they practice balance in their lives. I wish them enough time and energy to embrace their creative nature, to enjoy their leisure, and to seek spiritual sustenance.

Because...

“Wherever the art of medicine is loved,

There is also a love of humanity.”

~Hippocrates~

jan

 

 

 

 

 



revisit. revise. recover.

 

 

 “I write because

I don’t know what I think

until I read what I say.

~Flannery O’Connor~

This observation by author Flannery O’Connor rings true to anyone who harbors a vague feeling of anxiety for no identifiable reason.

“Worrying is like

walking around with an umbrella

waiting for it to rain.”

~Wiz Khalifa~

Even though they are living in a comfortable rut—let’s say, they are financially secure, their health is good, their family is intact—they can’t deny the knot in their gut or the dull ache in their chest that suggests something is wrong. Or, maybe they wake up every day with a sense of dread, exhaustion, sadness, or withdrawal that screams “depression”, even though, as people tend to remind them, they have nothing to be depressed about. After all, they have a steady job and a nice home, their children are doing well, and their bills are paid. They should be happy.

Still, the feeling is always there…uncertainty, fear, emptiness, hopelessness. They just don’t know why.

“These mountains you

are carrying,

you were only supposed to climb.”

~Najwa Zebian~

This is where storytelling comes in. Writing enables us to seek out and sort through memories, and to locate them in time and space. It encourages us to name the gremlins that stalk us, to label our fears, acknowledge our wounds, and reimagine our lives. We are no longer the victims of some obscure fear or unacknowledged sorrow. We can claim it and conquer it.

“The act of putting pen to paper

encourages pause for thought.

This, in turn, makes us think

more deeply about life…”

~Norbet Platt~

Physicians do this for every illness—from diabetes to heart disease to cancer. We ask about symptoms. We search for causes and encourage our patients to do what they can to avoid or eliminate them. We name the disease and suggest a course of treatment. If we have done our work well, we alter the course of the illness. We take control of it. We change the patient’s narrative.

This is storytelling at its finest. It is also the goal in clinical practice and in narrative medicine. When we write about illness, we revisit the initial injury. Perhaps it was a childhood rape, or a tragic accident, or the loss of a friend or family member we couldn’t face. By naming it, we confront it. The road to recovery leads us to a new perspective or understanding of it. Then, when we read what we’ve written, we finally know what we think.

Storytelling is the very process by which we revisit, revise, and recover.

Revisit. Revise. Recover.

jan

 

 





perception vs reality

 

The medical history can difficult to obtain for many reasons. A patient’s description of his illness can be affected by his perception of it, his experience with it, and what he imagines about it. By his expectations. By fear or denial. Or he may simply lack the language to express it.

“Perception is reality.”

~Lee Atwater~

For example, if I had to tell you what has been going on in my left foot for the past six weeks, I would be hard pressed to describe it. You would be left scratching your heads. It all started with localized pain during weight-bearing (but no tenderness to touch). It started to swell, and then, after four weeks, I noticed bruising. I don’t recall any injury. It’s hard to know what triggers the pain because it seems worse at night for some unknown reason. I have no idea why it is getting worse despite the fact that I have been faithfully resting my foot like I know I should. It frustrates me because I can’t exercise. It worries me, too. What if I need surgery? What if I can’t take care of myself?

Even though I’m a physician, and I know all about strains and sprains, overuse injuries and stress fractures, tendonitis and arthritis…I can’t really describe the discomfort. And because I don’t remember injuring my foot, I can’t make sense of it. This is weird.

Imagine how difficult it must be for patients to describe their symptoms or to make sense of their illnesses when they have neither knowledge, experience, nor language for what is happening to them.

“Write hard and clear

about what hurts.”

~Ernest Hemingway~

Most people are not used to thinking about their symptoms in the kind of descriptive terms physicians depend upon to narrow the diagnostic possibilities. For example, they might not realize that the difference between a headache that is generalized, dull and steady rather than unilateral and throbbing may distinguish a tension headache from a migraine. They may not be able to distinguish between the kind of pain caused by heartburn and myocardial ischemia. They might not use those terms to describe it at all. The patient is more likely to view his symptoms in terms of lost wages, his inability to provide for his family, or his own impending decline rather than the onset, character, and duration of his symptoms.

“Every sickness has an alien quality,

a feeling of invasion and loss of control

that is evident in the language

we use about it.”

~Siri Hustvedt~

Severity is especially tricky to assess. It depends to some extent on the patient’s innate tolerance for pain. Is he a stoic or a whiner? His perception of pain depends upon how his symptoms affect his mood, his ability to carry on, and his fears which are largely based on what he has heard, what he imagines, or what he has witnessed in others.

Take it from me, under the best of circumstances, the medical history can sometimes remain a mystery.

“One day I will find the right words

and they will be simple.”

~Jack Kerouac~

jan



you too?

 

*

 

 

...especially when your story involves a history of sexual assault.

 

Witness the proliferation of stories about sexual abuse that have corrupted America’s dignity over the past few years…beginning with the Church, then shaming the military and Hollywood, and now erupting at every level of government. Affecting even our Olympic athletes.

 

Witness the “me, too” movement rising from every corner of the country, voices that went silent years ago out of shame, fear, and guilt. Men and women alike.

 

The first time it happened to me, I was twelve years old. It happened again in high school and in college. Then in medical school. Then as a medical resident.

 

“People talk about sexual assault like it’s a

bad habit that men have.”

~Jon Stewart~

 

These were not just dates run amok. They were not consensual affairs. They were uninvited, unwelcome, intrusive encounters.

 

“It’s not consensual

if you make me afraid to say no.”

@hannahsnead5

National Sexual Assault Hotline

888~656~4673

 

I was lucky, though. None of these incidents was especially frightening or painful or traumatizing to me. In every case, I knew the person. They were all men who, until then, I had come to respect and admire…one, a relative. One, a fellow student. The others…physicians and colleagues.

 

The problem is I have no idea where these men ended up or what they are doing today. That means you might actually know one of them. Your child’s coach or teacher or pastor could be one of them. Perhaps one of them is your own physician, surgeon, or counselor.

 

Interestingly, we haven’t heard much about sexual assault among members of the medical community yet. God forbid patients should speak up. Imagine the stories they could tell...

 

“Our lives begin to end

the day we become silent

about things that matter.”

~Martin Luther King, Jr.~

 

jan

 

 

 

 

 

the best of circumstances, and the worst

 

 

 

Under the best of circumstances, it can be difficult for a health care provider to obtain a thorough and accurate medical history from a patient. Whereas the provider wants to hear about the onset, timing, severity, and nature of his symptoms, the patient may be focused on the fact that he had to miss work to keep his appointment, or that he can’t afford whatever tests or medications he may need. He may be ashamed to admit that he fell because he’d been drinking, or that he was coughing because he smokes, or that his sugar is high because he ran out of pills and can’t afford to refill his prescription. Or, he might simply have forgotten the details—for example, when his headaches first started, or how often he gets them, or what sets them off. All of which makes it hard to arrive at an accurate diagnosis.

 

“Diagnosis:

It is every doctor’s measure

of his own abilities;

it is the most important ingredient

in his professional self-image.”

~Dr. Sherwin Nuland~

 

And then there’s this:

 

We all have a friend or relative who can only be described as talkative. You know the kind-- mired in detail, obsessed with accuracy, insistent. A conversation with this person might go like this:

 

     Doc: So, when did the headache start?

 

     Pt.: It started last Tuesday. I remember because I had breakfast with my friend Barbara, and it started when I was driving home. No, wait. Maybe not. Maybe it was later that day, when I was in the grocery store. Or…did I go to the store on Wednesday? (pause) I don’t remember, but when I got home, I realized I didn’t have any Tylenol, so I took two Advil for it. Or…was it Aleve?

 

And so it goes, on and on and on in painstaking but inconsequential detail. And you only have fifteen minutes to coax the whole story out of this patient…

 

“Our lives begin to end

The day we become silent

About things that matter.”

~Martin Luther King, Jr.~

 

Or, you might meet up with this patient:

 

     Doc: I understand you’ve been experiencing some headaches.

 

     Pt.: Yup.

 

     Doc: When did they start?

 

     Pt.: A while back.

 

     Doc: Weeks ago? Months?

 

     Pt.: I guess.

 

You can’t pull a meaningful answer out of him if you kneel down and plead for it.

 

“I have learned now that,

while those who speak about

one’s miseries usually hurt,

those who keep silence hurt more.”

~CS Lewis~

 

In the first case, you wish you could shut the flood gates long enough to pull a few pertinent facts out of the overflow. In the other, you want to open the gates and net a few relevant answers before you move on.

 

The medical history challenges both of us, patients and providers alike. We’re in this together, and whether we are doing the speaking, or the listening, the correct diagnosis is our goal.

 

“Listen to your patient.

He is telling you the diagnosis.”

~Sir William Osler~

jan





a sigh of relief

 

 

 

True story:

 

When the nursing home called, my mother was already on her way to the emergency room. She’d been experiencing a deep cough and increasing shortness of breath for two days. When her oxygen levels fell to dangerously low levels, her doctor ordered her off to the hospital.

 

I left as soon as I got the call, hoping to get there ahead of her because you see, by this point in her decline, my mother had lost the ability to speak. She didn’t suffer from dementia. Rather, her inability to communicate was the cumulative result of multiple small strokes. I knew she would be scared and confused, and ultimately frustrated by her inability to express herself. As sick as she was, she would be unable to give her medical history or answer questions. Nevertheless, I had no doubt she would receive excellent care—the ER staff would start an IV, administer oxygen, get a chest X-ray (and a scan if needed), draw her blood, and monitor her vital signs. She would receive antibiotics, or medications for her heart, or anticoagulants depending on the test results (pneumonia vs heart failure vs pulmonary embolism). If worse came to worse, she would be intubated. The doctors and nurses would do everything they could for her automatically and efficiently, without a second thought.

 

Without knowing a thing about her.

 

“You treat a disease: you win, you lose.

You treat a person: I guarantee you win.”

~Patch Adams~

 

When I got to the emergency room, Mother was sucking down oxygen via IPPB. She was weak and pale, but alert. The minute I pulled the curtain back and stepped to her bedside, she relaxed. A faint smile of recognition and relief appeared. She closed her eyes and squeezed my hand as if to say healing could now begin.

 

“A kind gesture can reach a wound

that only compassion can heal.”

~Steve Maraboli~

 

I kept an eye on the monitors that surrounded her bed while I sat with her and explained what was happening and why. I requested an extra blanket for her. I answered the nurses’ questions. I ached to know the results of the tests the doctors had run, what her diagnosis was, what was in store for her. Through it all, I kept a smile on my face while all the worst-case scenarios played out in my imagination.

 

“Isn’t it fascinating

how long a few minutes can seem

when you are completely alone

with not a familiar face in sight?”

~Kirby Larson~

 

Imagine the relief I felt when the ER physician returned to check on her…when he drew the curtain aside and I recognized a trusted colleague, a man I knew to be compassionate, gentle, and wise. Like my mother did when she saw me, I relaxed as soon as I saw him. I smiled with a deep sense of relief and gratitude. I could talk to this man and I knew he would listen. He would treat my mother like his own, and me like a sister. As if we were family. I felt as though healing had already begun.

 

*

 

This story is intended to convey the healing power of the personal relationship between the physician and the patient…the sense of relief a familiar face can bring when everything else is foreign and frightening to the patient. It speaks to the importance of trust and confidence in the healer’s character and expertise. It should remind us to regard every patient with compassion, and to treat every patient with the same respect, kindness, and care we would extend to our best friend, and to our own family members because:

 

“I’ve learned that people will forget

what you said.

People will forget what you did,

but they will never forget

how you made them feel.”

~Maya Angelou~

 

jan