the story of the present illness

The story of my life during the years leading up to my retirement could have been recorded in ten-minute installments, patient after patient, day after day. This is in keeping with the trend toward shorter and shorter sound bites, 280 character tweets, and snarky comebacks that have come to replace the leisurely, thoughtful exchange of ideas that human beings have always enjoyed, and/or depended upon.

It wasn’t always this way. There was a time, not many years ago, when I could scan my schedule for the day and envision every patient. I knew them that well. With a quick glance at the chart I knew who was getting ready to start chemo, who had just welcomed her first grandchild into the world, whose mother had been transferred into the dementia unit. I knew because I asked about it, the patient told me the story, and I noted it in the chart.

“Wherever the art of medicine is loved,

there is also a love of humanity.”

~Hippocrates~

Nowadays, rather than dictating a note about the patient encounter (a.k.a. narrating the patient’s story), you open an electronic medical record. This is intended to expedite the ten-minute appointment. After all, as a physician you have productivity quotients to meet, and income to generate. Whether you recognize your patients or not.

The EMR presents you with a confusing array of bulleted items, complicated charts, and abbreviated details. You can tell what symptoms were problematic at the last visit, when they started, how often they occurred, and how long they lasted. You know what tests you ran and what treatment you ordered, but you might not remember the patient because nothing else about his or her story is recorded there. He looks like any other older patient with diabetes, or heart failure, or COPD…because you missed the fact that he’s a decorated Vietnam veteran. You can’t understand why your pregnant patient is so anxious because you failed to ask about her sister…who had three miscarriages in a row. You don’t know because you didn’t record the whole story. There just isn’t enough time for that in a ten-minute slot, and there is virtually no place to enter it into the EMR.

You don’t realize that the patient’s intractable headache started when she discovered the cigarette burn on the sleeve of the sweater her ten-year old wore to school last week. You can run every test under the sun and prescribe every medication known to mankind, but unless you address the problem she is having with her child, nothing will help.

You have no way of knowing that the patient’s heartburn and indigestion have been a problem because of the pile of unpaid bills collecting on the kitchen counter. Until he has some help with them, nothing is going to help his heartburn.

Unexpected details like these rarely emerge as part of the history taking process. When the patient is seeing you for a straight-forward problem, these details are often missed. They are dismissed as unimportant or extraneous when, in fact, they may hold the key to the diagnosis, and to the patient's response (or his failure to respond) to treatment. 

“You are not your illness.

You have an individual story to tell."

~Julian Seifte~

jan

 

 

 

may the force be with you

Last week I tuned into the on-line Science of Healing Summit where I learned about bioenergetic fields, epigenetics, the flow of consciousness, resonance, coherence, entrainment, intuition, and the power of music/sound/vibration to heal. All taught by brilliant and forward thinking researchers and practitioners. 

I may have posted a few tongue-in-cheek comments on facebook because, frankly, I'm miffed. This constellation of concepts and insights first emerged in the seventies, which is when I started medical school...and it was all dismissed by "real" doctors as so much hocus-pocus. Snake oil. Those of us who were curious about it were belittled for our naivete, and shamed for our gullibility.

But I knew better. When I was a medical student, I worked with a resident who had gained a reputation as something of a maverick when he underwent an inguinal hernia repair under self-hypnosis. No anesthesia, thank-you-very-much. When I worked with him in the Emergency Room, he reduced a patient's dislocated elbow after a brief hypnotic induction, and I was sold. I studied self-hypnosis myself. I squandered my vacations on meditation and yoga retreats. I connected with energy healers. I learned to chant, to visualize auras, to breathe. I understood energy. It all made sense to me.

"There is more wisdom in your body

than in your deepest philosophy."

~Friedrich Nietzsche~

So...this is the question:

If you are a hands-on healthcare provider, how do you "see" your patients? As an orchestrated system of organs, muscles, bones, nerves, and flesh that can be distinguished by their structure and function? What is that structure? And how do they function? When something goes wrong, do you immediately think of a pill or a procedure?

Are you willing to see things differently? 

Imagine seeing your own body on a microscopic scale. Imagine the little blood cells coursing through your arteries and veins. Watch the fibers in your muscle contract and relax. Now get smaller. See it on a molecular scale. A subatomic scale. It might surprise you, from this perspective, that there's not much to you but space. On this scale, the distance between the molecules that make up your body is as vast as the distance we are familiar with...the distance between the stars in our own galaxy. Bone feels hard to us because the electromagnetic force between those distanced molecules is so strong. Flesh feels soft because the force that attracts its molecules to one another is weaker.

So...we are pretty much pure space and energy. 

Now look in a mirror. What do you see? That annoying mole on your forehead? Those sagging wrinkles on your neck? Teeth you wish were whiter? All the things that make you less perfect than what you were hoping for? 

Now get smaller. Go inside. That heart in your chest? It's like a perpetual motion machine. It just keeps beating without any attention or awareness on your part...as it has been since before the day you were born. Amazing!

That scar on your belly? The skin healed, the muscle closed, the fascia mended, and the wall of the uterus healed completely after they pulled the baby out...squirming, squealing, and breathing all by itself. Unbelievable!

Do you remember the song that made you cry at your grandmother's funeral? The solo you sang at the spring concert in sixth grade? The first time you heard a Kirtan chant? You have sound waves to thank for that...your whole complicated auditory system, your memory, and whatever made you sad, or happy, or amazed when it all came back to you. All connected across time and space...all vibrating in sync, all resonating, all coherent. In you!

"May the force be with you."

~Obi Wan Kenobi~

The next time you glance at yourself in a mirror, or lay hands on a patient, or make a wish, or shed a tear, remember:

"You are braver than you believe,

stronger than you seem,

and smarter than you think."

~a.a. milne~

You are pure potential.

jan

the science of health summit

 

This week I'm tuning in to the Science of Healing Summit. You might think this would be about recent advances in biomedical engineering, epidemiology and vaccine development, diagnostic testing, and the newest therapeutic techniques, but it isn't. This is a 5-day program of discussions by experts in our understanding of the new biology, energy medicine, and quantum healing that connect the mind, body, and spirit. 

Deepak Chopra, MD and Rudolf Tanzi, MD will explore the difference between awareness and consciousness, and how they influence self-healing.

Bruce Lipton, PhD will go into epigenetics, quantum physics, and the role of the mind in health and disease.

There will be presentations about the roles of intuition and intention in the practice of medicine. The effect of sound, music, and vibration on healing. Neuroplasticity. Spirituality. And a forward looking blueprint for allopathic practitioners.

I've already seen a few disparaging critiques of the Summit by people who have already made up their minds that this is all just a bunch of hoopla, all this talk of consciousness, nonduality, microbiomes, and energy fields. To which I say:

"The highest form of ignorance

is when you reject something

you don't know anything about."

~Wayne Dyer~

Gotta go, now. Gregg Braden is about to begin with a discussion of our origins and potential, and how they relate to immunity and longevity. This should be interesting!

jan

why you should take up writing

 

I often find myself encouraging friends and random acquaintances to take up writing. I may have heard their stories over a glass of wine or a cup of good strong coffee, on a hike in the woods or along a riverbank, so I know they can do it. I nag them because I know someone who needs to hear their story. Someone recently diagnosed with cancer needs to hear from a person who has been through it. They need to know the diagnosis was devastating, the treatment grueling, the recovery painstaking, the victory glorious. If you're struggling to work from home while you school your children, or you're a caretaker for someone who isn't doing well, it helps to know how difficult it is for others in the same situation. How they cope. How they keep their spirits up.

"A day will come

when the story inside you

will want to breathe on its own."

~Sara Noffke~

I encourage people to write even though I know how hard it can be to get words on the page. To stick with it. To go back to it again and again. Like meditation, it can be hard to quiet your mind while sitting alone, in silence. Our minds like to be busy, thinking back on things that have happened, thinking ahead to what awaits us, guessing, planning, judging, fretting, when our goal is to stay focused on the work at hand.

In meditation, when our minds wander, we are encouraged simply to acknowledge the interruption and refocus, not to chastise ourselves for getting distracted, or berate ourselves for letting our attention wander. When unbidden thoughts arise, we label them "just thoughts" or "just thinking," and we move our attention back to the breath--in, out, in, out. Letting go of intrusive thoughts helps mitigate the impact of negative emotions such as anger, anxiety, bitterness, and resentment that may have a stranglehold on us.

"You should sit in meditation

for twenty minutes a day, 

unless you're too busy;

then you should sit for an hour."

~Old Zen Saying~

This, I believe, is a practice writers should embrace. We are accustomed to labeling our own negative thoughts as "voices" we hear. It's an interesting metaphor. We are advised not to pay attention to the voices of negativity that discourage our creative efforts. Voices that insist we're wasting our time, that we have no talent for this kind of thing, that we have no hope of success. Voices that make us feel inferior, or guilty for indulging in something we enjoy when others are so hard at real work.

"Tell the negative committee

that meets inside your head

to sit down and shut up."

~Ann Bradford~

The point is that those negative voices are just thoughts. Just echoes from the past, not worth arguing about. They are opinions, and they do not have your best interests at heart. Banish them! Return to the breath. Or take a walk. Or call up a friend, someone who encourages you, and supports your dream. Someone who understands how hard this is, and respects you for trying. Someone whose friendship isn't invested in your wealth or fame. 

Do whatever it takes to stay on the optimistic side. Do whatever it takes to tell your story. Turn your attention to the truth:   

"People start to heal

the moment they feel heard."

~Cheryl Richardson~

jan

when doing your best is not good enough (grumble, grumble)

 

If you're a health care provider, try to imagine a day in the office when you're able to stay on time despite the inevitable delays and interruptions that tend to put you behind schedule. Imagine having time to accommodate the patient who presents with "a little indigestion" that turns out to be angina, or to stitch up the patient who arrives unannounced with the laceration on his hand, or to deal with the teen who thinks she has a UTI, but turns out to have an STD.

"Relax.

Everything is running right on schedule."

~The Universe~

Imagine being able to decide for yourself how much time to allow for each patient, and how much to charge for each visit. Imagine what it feels like to know you've done an accurate and thorough job. Just think how appreciative your patients would be...knowing you took your time with them. Do you remember what it was like to make eye contact with them?

Back when I started to practice this is exactly how we operated, without the superimposed constraints of intrusive hospital/healthcare systems, and insurance behemoths whose #1 priority is corporate profit. Back then (yes, in this lifetime) uninsured patients were likely to bring in a bushel of apples, or a couple dozen ears of corn if that's all they could afford. And we were happy to accept it. If we needed a ten-minute appointment with them for a sore throat, we took it. If we needed thirty minutes, we took it.

"If you are not in control

of your time,

you are not in control of your results."

~Brian Moran~

This issue haunted me this week because two people I know and love recently had surgery. Not long, complicated operations, but short out-patient procedures. That. Took. All. Day. Long. Hours in registration and pre-op. Hours in post-op and recovery. Because the surgeons were running behind schedule, or the nurses were tied up with endless administrative tasks. 

This will happen. I get that. But it reminded me how much I disliked running late when I was in practice. Keeping patients waiting when they had to get back to work, or pick up their children, or get home to milk the cows. Hurrying to keep up, and worrying I would miss something. Always apologizing. Always anxious.

I know a few things about healthcare finance and economics. Still, I question the motivation and logic behind scheduling patients so tightly it keeps the provider under constant pressure to see more patients faster. All day. Every day. While, at the same time, it keeps patients waiting. Impatient and dissatisfied.

This is a problem when it translates into this:

"Sometimes doing your best 

is not good enough.

Sometimes you must do what is required."

~Winston Churchill~

How does that align with excellent patient care?

jan

we are all just stardust

 

One of the best things about being a physician is 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 takes your breath away the first time you hear a beating human heart. Suddenly it dawns on you that your own heart has been pumping steadily and predictably without any effort on your part since before the day you were born. 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. 

But that's just the beginning.

You would be flabberghasted if you understood the complexity and precision of a single cell cycle in your own body. How every cell knows when to pump out the chemicals it takes to defeat an infection, or battle depression, or laugh at a good joke. How it processes the energy it needs to survive, and how it knows when its time is up. How every cell in your body...the body you sometimes abuse and neglect, the one you sometimes detest, the one you overwork...is intimately connected with the entire universe. The majority of the atoms that are present in our bodies today have existed since the Big Bang...the moment the universe came into being.

"The amazing thing is that

every atom in your body

came from a star that exploded."

~Lawrence M. Krauss~

But that's not all. Each and every cell possesses its own DNA. A single strand of DNA is approximately 3 meters long, yet it fits into the nucleus of each cell, into a space of 2-3 cubic microns (1 micron=1 millionth of a meter). The DNA in your body, if unfolded and stretched out like a string, would wind around the Earth over 2 million times, or loop to the moon and back over 130,000 times, or stretch to the sun and back over 300 times. It is estimated that there are some 50 trillion (that's 50 million million) cells in the human body, all cooperating, all communicating, all contributing to the effort to keep you alive and well. And that's a lot of work.

"Be good to yourself.

If you don't take care of your body,

where will you live?"

~Kobi Yamada~

Your skin is entirely replaced every month. The lining of your stomach is replaced every four days. Your skeleton today is not the same one that held you up three months ago. The gaps between the neurons in your brain are bridged by an estimated 100 million million dendrites that make it possible to process an inestimable number of signals at lightning speed. To read this sentence, your brain arranges a precise pattern of millions of signals in just a few milliseconds, and then eliminates them instantly, never to be repeated again.

"We touch heaven

when we lay our hand on a human body."

~Novalis~

Shall I go on?

If we could see our bodies as they really are, we would never look at them the same way again. If we truly understood how the human body functions, and how it is connected to the universe, we would fall to our knees in praise and adoration. We would feed and care for it properly. We wouldn't overwork it, or poison it the way we sometimes do. We would look into the mirror, and see heaven and Earth reflected there.

"We are just stardust, after all."

~Jodi Lynn Anderson~

jan

life support 101

I practiced medicine for over thirty years before I retired a few years back. I saw thousands of patients during my career. How is it, then, that the distant memory of one of them popped into my mind for no particular reason this week? After nearly fifty years.

"A memory is what is left

when something happens and does not 

completely unhappen."

~Edward de Bono~

The patient (I still remember her name) was admitted to my service with a classical case of bacterial endocarditis--an infection of one of her heart valves that resulted from a congenital defect. She was in her forties. Unfortunately, she experienced one of the dreaded complications of the condition when she suffered a stroke that left her unable to speak or move one side of her body. The stroke caused intractable seizures, so we ended up pumping her full of antibiotics for the infection, and antiseizure meds as she lapsed into coma. After a couple of weeks in ICU, the time arrived to make a decision regarding whether to continue life support...or not. Given her dismal propsects for recovery, the decision was made to start withdrawing treatment, little by little, to see what we ended up with. The first meds to go were the antiepileptic drugs. I can still remember the look on the nurse's face when the sedative effect of the antiseizure drugs wore off, and the patient opened her eyes for the first time. Long story, short...once the patient was awake, she made slow but steady progress until she eventually walked out of the hospital on her own. Taking her off life support brought her back to life. Her recovery was so remarkable, it has stayed with me all these years, and it just pops up every so often because it taught me a lesson.

"Somewhere, something incredible

is waiting to be known."

~Carl Sagan~

This is the thing: No one knows how memories are made, or where they're stored, or what they're made of. No one knows why some persist while others fade, or how they arise unbidden, complete with authentic emotion (sadness, anger, joy), and physical reification (shaking, nausea, sweating).

"Embodiment means we no longer say, 

I had this experience;

we say, I am this experience."

~Sue Monk Kidd~

We can, however, codify the context of memory-making and retrieval this way. Memories will be created and stored most effectively:

1. when the experience is associated with:

• fear
• pain
• anger
• sorrow
• joy 
• gratitude
• love

2. when the experience challenges us, or teaches us something new 

3. when the experience changes the course of our life, or our attitude toward it

4. when we are moved by beauty, or kindness, or a sense of calm

5. when the experience causes us to wonder, to question, or to seek an elusive answer or truth

The list goes on.

Memories foster and animate storytelling. They preserve experience, embody emotion, and teach us so we can teach others. Every so often, they re-emerge from no-one-knows-where to surprise us, to remind us where we've been, who we are, and where we're going.

"We are the universe 

experiencing itself."

~Carl Sagan~

jan