what to expect when you recover... if you recover

 

At a writing workshop I attended recently, we were asked to respond to specific prompts. We wrote for 15 minutes or so, and then read what came up for us to the group. One of the prompts was to write about a time someone lied to us. I wasted a good five minutes trying to recall a story-worthy episode to write about. This is it:

True story:

Telling a lie can have life-threatening consequences.

My shift in the Emergency Room was almost over, and I was already counting the minutes until I could head home to my tail-wagging, cheek-licking puppy and my own warm bed.

Just one more patient to see.

I pulled the curtain aside to find a young woman with a tear-stained face, pressing an ice pack against her right eye, her boyfriend holding a bloodied towel.

"We were just having fun jumping on the bed," she explained, "but I lost my balance and hit my eye on the corner of the nightstand. Right, Kevin?"

"One thing more shocking than the truth 

are the lies people tell 

to cover it up."

~Author Unknown~

It occurred to me that they were rather old to be jumping on a bed for fun. And he looked like a bodybuilder, suggesting the bed must have been made out of reinforced steel and concrete.

"Let's take a look," I said...thinking it would just take a few quick stitches and I'd be done for the day.

But under the ice pack, her eye was bruised and swollen shut. Blood oozed from a cut above her eyebrow, and her nose looked a little crooked, too.

The technical term for her injury is a blowout fracture of the orbit, or eye socket, and it represents a medical emergency. It's like a skull fracture, and it can result in blindness. You hardly ever see this kind of injury except in a car crash, or an industrial accident, or a major league baseball game. It takes a lot of force to cause a blowout fracture.

I got to work. I ordered Xrays and summoned the surgical team while they prepped the OR. I started an IV, drew her blood, and convinced her to sign the consent form.

One of the nurses escorted her boyfriend out of the room as chaos erupted. When he was safely out of earshot, I tried again.

"Linda," I said. "Tell me what really happened."

"Trust your instincts.

Intuition doesn't lie."

~Oprah Winfrey~

A direct blow to the eye by a fist is a terrible injury, and it adds layer upon layer of extra work. You have to summon the police and file a report. You may have to obtain a protection from abuse (PFA) order. You have to consult someone in Social Services to secure a safe place for her to shelter when she recovers. 

If she recovers. 

Because, in medicine, telling a lie can cost you your life.

"In the long run,

the most unpleasant truth

is a safer companion than a pleasant 

falsehood."

~Theodore Roosevelt~

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variations on a theme

 

Let's say you have three patients who are battling cancer.

One is devastated by the diagnosis. She is overwhelmed by fear and dread. Convinced her situation is hopeless, she resists starting chemo. She just wants to die. Her doctor suggests an anti-depressant.

"Once you choose hope,

anything is possible."

~Christopher Reeve~~

One is a man of deep faith. He is convinced that God has the power to cure him even though his prognosis is unfavorable. He devotes himself to prayer and sacrifice because he believes that will earn him God’s mercy. Even when his cancer spreads, he clings to his faith. It gives him hope and a sense of optimism right up until he is forced to surrender to the disease. His doctor tries to be respectful of his faith, but he can’t shake off his own doubts about it.

"Cancer didn't bring me

to my knees.

It brought me to my feet."

~Michael Douglas~

The other patient is f***ing pissed off about it. She is not about to lose this battle. After all, she has a husband and three children at home. It isn’t fair to them. She agrees to an aggressive plan of treatment that includes surgery, radiation, and chemotherapy. She begins a program of exercise, diet, and meditation, and she adopts a practice of loving self-care. She is determined to beat this thing. Her doctor encourages her even though he doesn't indulge in self-care, himself.

"You never know how strong you are

until being strong is

the only choice you have."

~Bob Marley~

Three different patients with the same disease, and three different stories. What difference does it make? There is an abundance of literature concerning the factors that affect a patient’s quality of life during treatment for cancer and how this correlates with his likelihood of recovery. Some factors are immutable: age, gender, and family history, for example. Others are modifiable: emotional and attitudinal factors, dietary factors, level of fitness, faith, and social support.

Given their stories, the physician will approach each of these patients differently, even though each of them has the same fundamental needs: education, encouragement, and support.

When is the last time you had to convince a patient to enter treatment? When is the last time you offered to pray for--or with--a patient?

When is the last time you practiced self-care?

"Self-care is a 

divine responsibility."

~Danielle La Porte~

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a grand tectonic shift

I spent last week at a writing workshop at Omega Institute for Holistic Studies in Rhinebeck, NY. Usually, when I go to Omega, I spend an inordinate amount of time in the bookstore, and I come home with a small fortune in books I can't wait to read. But something changed this time. I walked away empty-handed again and again. It dawned on me that I had read what I wanted to about Buddhist psychology, meditation, healing, and consciousness. Of course, what I know is barely the tip of the iceberg, just a smattering of the literature, the teachings, and the practice. But leaving the bookstore with nothing, it struck me: It's time for me to start writing my book. 

"If there's a book

you really want to read,

but it hasn't been written yet,

then you must write it."

~Toni Morrison~

I felt a twinge of panic. This is going to be hard.

"Write about disturbs you,

what you fear,

what you have not been willing to speak about.

Be willing to be split open."

~Natalie Gildberg~

What will I write about? This is about those tectonic shifts that dismantle the foundation our lives. That make us question what we have always believed, or been taught is true, or have tried to live by, and where we go from there. Sometimes it concerns physical healing...when cancer strikes, or the heart gives out, or a disabling injury occurs. Sometimes it requires emotional, psychological, or spiritual healing...from trauma, or abuse, or shame, or guilt.

"If you never heal

from what hurt you,

you'll bleed on people who

didn't cut you."

~various attributions~

When did it happen to you? How did it change you? How will you heal? When will you begin writing about it?

"We write out of revenge against reality,

to dream and to enter

the lives of others."

~Francine du Plessix Gray~

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a change of mind, a change of heart

 

 Anyone who knows me, or reads this blog, knows that I am fascinated with the human mind. How little we understand about how it works. How thought is generated. How memories are retrieved. So it's no wonder I am intrigued by the concept of neuroplasticity--the property of the brain that allows it to change structure and function in response to changes in the environment, our personal experience, and our intentions. It accounts for how the brain changes over time, and specifically, how we can consciously generate those changes. In other words, it allows us to rewire our brains. We can change our minds.

"Nature has given us a brain

that survives in a changing world

by changing itself."

~Norman Doidge~

This came into focus for me in light of the Covid-19 pandemic. While most of us are compliant with the simple mitigation practices that have been shown to contain the spread of the virus, and are eager to get vaccinated, not everyone agrees. Some people are skeptical of the science behind Covid research, and the physicians who are trying so hard to explain it to them. There is an oppositional-defiant edge to their attitude and behavior. They cannot, or will not, change their minds despite the proven efficacy and safety of such simple measures as masking and social distancing. They refuse the vaccine. Their defiance puts their lives at risk, and it threatens the rest of us.

"The highest form of ignorance is

 when you reject something

you don't know anything about."

~Wayne Dyer~ 

As a physician, this frustrates and angers me. There is a tiny voice in the back of my head that keeps telling me that people like this deserve to get sick. To suffer. To die. To watch their children get sick and die. It was the choice they made, and nothing we have said or done so far has had any effect on them. They don't care about us, so why should we care about them? And on and on...

This little voice is not one I welcome. This is not me speaking. It is social media exerting its pull. It is political commentary pushing back. It is, in fact, human nature going down its well worn path. But it is not what I know in my heart to be true, so I'm making an effort to change my conditioned and deluded mind about it...

"It is not the strongest 

of the species that survives,

nor the most intelligent that survives.

It is the one that is most adaptable to change."

~Charles Darwin~

...because I hate to see anyone suffer. Certainly, not a child on a ventilator. Not his mother in tears at his bedside. Not even a turtle stuck on its back, or a robin with a broken wing. I wouldn't wish Covid-19 on anyone. No one "deserves" to suffer, and if the decisions they make cause them pain, my intention for them is comfort, solace, and healing. If I could speak with them, I would tell them that they'd made a mistake. That people lied to them. That there's a lot of misinformation out there.That they didn't understand how viruses are spread, how they replicate, and mutate. How vaccines work. 

Then I'd teach them about neuroplasticity. I mean, if I can learn to change my mind, maybe they can learn to change theirs.

"Sometimes you change your mind...

sometimes your mind changes you."

~Binyomin Scheiman~

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the moose in the mud

 

"The clearest way into the universe is through a forest path." 

~John Muir~

I was lucky enough to have been invited to spend last week in a cabin in the Maine woods. My "bucket list" item for the trip was to spot a moose, and I did. But not in the way I had hoped.

My daughter and I set out one evening for a bog that was known by the locals as a good place to watch for moose. We pulled off the road and waited...and waited...and waited. We thought we were seeing a bird flapping its wings every so often, until we realized we were seeing the ears and tail of a moose twitching as she lay in the mud. 

We pulled up closer, and sure enough...there she was, lying in the mud, barely visible. It occurred to us that she might be sick or injured, but she wasn't struggling, or calling out. So we concluded that, like all good mamas, she just needed a little time to herself, and what better place for a moose on a hot day than in a nice cool mud bath. Still, we didn't think it was too much to ask for her to stand up and take a few steps for us, so we whistled at her, clapped our hands, called out to her, and honked at her. We pleaded with her and cajoled her...all to no avail. We gave up as darkness closed in...

"Until one has loved an animal,

a part of one's soul remains unawakened."

~Anatole France~

...but the next morning we were on the road at 5 AM to see if she was still there. Again, it was hard to make her out, but there she was! We stayed with her for an hour, but except for those twitching ears, she didn't move. 

So, we went back that evening, and we were actually relieved to see that she had moved on...that she was OK...until we pulled off the road to turn around. That's when we found her. Dead, in a clearing, with two broken legs. How she managed to get out of the mud and through the underbrush to the clearing I will never understand. The pain. The suffering. We were stunned. Heartbroken. And so, so sad for her.

"May all that have life

be delivered from suffering."

~Buddha~

Why am I sharing this story on a narrative healing blog?

I can't get her off my mind. Perhaps telling her story will help me accept it. Maybe it will serve to caution inattentive or careless drivers. Maybe it will honor her suffering, in some way. 

It makes me wonder how I will bear my own  pain when the time comes. What if I go into heart failure? Or I develop cancer? Or I fall and I can't get up? Will I bear it quietly? Courageously? Patiently? How will I prepare my family for it? 

~Ilan Shamir~

As health care providers, we all witness pain and suffering. We are trained to do whatever we can to relieve it. We all witness death. In some cases, we have time to prepare our patients for it. We are sometimes called to break the news to their families. I held my mother's hand during her last hours, and stayed with her until she took her last breath. She didn't die alone, in pain, to be discovered too late by some passerby.

It makes me wonder how, in that vast wilderness, a solitary moose and a rare passing vehicle happened upon each other that day. Why? What are we meant to learn from this disasterous stroke of synchrony?

It reminds us that we don't always know when someone is suffering. Like the moose in the mud, they may not let it show. 

We are reminded to seek them out. To be patient with them. To be kind and gentle always.

To hold space for them in our hearts when there is nothing we can do to help.

I'm pretty sure the moose just became my spirit animal.

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why you should question everything

As a health care provider, I'm accustomed to dispensing advice. I tell my patients how they can lower their cholesterol levels. How much exercise they should get. Why they should definitely get the Covid-19 vaccine. And colon cancer screening. Patients, even friends and relatives, expect it.

"If it's free, it's advice.

If you pay for it, it's counseling."

~Jack Adams~

Now that I'm older and wiser, I have one more piece of advice to impart:

Save your money,

and invest it wisely so you can retire early. 

Why? Because it can take a long time to unlearn what you were taught that has become obsolete, or been proven wrong, or was outright false to begin with. It isn't easy to undo all that contradicts your sense of what is compassionate, fair, and true. It isn't easy. There's a lot to do, and it takes time.

Think about it. We now have access to information we couldn't imagine when we first entered medical practice. We didn't have MRIs or PET scans. We were just learning about the applications of radioactive isotopes in diagnosis and treatment. Laparoscopic and cryosurgery weren't options. Immunotherapy wasn't even on the horizon back then.

It's disconcerting to realize that the care we thought was top-notch proved to be ineffective, or worse, harmful to our patients. We know now that we were doing CPR all wrong. We were abusing antibiotics. We didn't recognize the existence of the human biome and its role in health and illness. Our understanding of epigenetics has changed the way we view the transmission and inheritance of DNA. We dismissed the importance of the mind-body-spirit connection in illness and health. 

The fact that we know better now...that we have learned over time...is a good thing. But this is the point:

"The important thing is

never to stop questioning."

~Albert Einstein~

This pertains to everything in life...to all we have been taught, or want to believe, or have been coerced into accepting as truth...about evolution, about the natural world, about cultural norms, about religion, and about science itself.

Question everything...and then,

when you think you have it figured out,

question yourself. 

As the Buddha put it:

"Believe nothing,

no matter where you read it

or who has said it, not even if I have said it,

unless it agrees with your own reason

and your own common sense."

~Buddha~

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how to play "stop the clock"

 

I retired after thirty years practicing Family Medicine out of fear.

I didn’t leave because of the long hours, or the fact that I’d been running hopelessly behind schedule all day, every day for three decades. I didn’t leave to take an easier position or to make more money. I didn’t ask to be excused because of fatigue, or forgetfulness, or ill health.

 

What scared me was the inevitability that I would miss a critical diagnosis, and because of it, I would subject the patient to unnecessary and inappropriate testing and treatments...all because I didn't get the patient's full history. I didn't know the whole story. Who had time to listen? Who had time to search for hidden clues to the diagnosis?

 

"I think of my patients as

body AND mind;

the more I understand about both of these,

the easier it is for me to help."

~Dr. McKenzie Mescon~

 

This fear reflected, in part, the trend toward productivity requirements that link complexity with compensation. Briefly...a doctor generates more money by seeing more complicated patients in less time, and by utilizing fewer diagnostic resources in their care. This is a sure recipe for disaster.

 

Let's say a patient presents with a sore throat and fever. His health care provider checks his throat and ears, and feels around for swollen submandibular lymph nodes. A throat swab is negative for Strep. But because he's running behind schedule, and only has ten minutes to see the patient in the first place, the provider fails to palpate the enlarged supraclavicular node that would have tipped him off to the real diagnosis...the lymphoma that was simmering out of sight. The lymphoma that was causing the patient's night sweats, fatigue and weight loss that no one asked about. It has happened. 

 

"The important thing is

not to stop questioning."

~Albert Einstein~

Details go missing all the time. 

Health care providers have to deal with time constraints. There simply is not enough time in the schedule to invite every patient to elaborate on the details of his medical history or symptoms. The provider gets the basics down, but then he is left to jump to conclusions or to dismiss further input that might otherwise affect the patient's treatment and prognosis. For example, it's bad enough when a patient presents with a broken arm after falling off a ladder at work...but it gets complicated if the patient fell because he was drinking on the job. That's a whole different problem.

The provider is also tethered to a coding and reimbursement system that doesn't compensate him for the time he takes with his patients. The EMR does not reflect psychosocial, emotional, or relational complications of illness or injury, all of which affect the patient's ability to heal.

In addition, people are busy. They're in a hurry. They may have to squeeze in a quick visit to the doctor between meetings or other commitments. To save time, they may minimize or dismiss their symptoms. For example, the patient may not want to stick around while you run an EKG for what he wants to believe is a case of indigestion. If the doctor has taken the time to explore the symptom, though, he may suspect angina...it gets worse when the patient climbs a flight of stairs, or he sometimes feels it in his jaw, or it makes him dizzy. It's not just a little heartburn.

 

Another problem is the fact that the patient may not have the language to describe his symptoms. To a doctor, there is a difference between lightheadedness and dizziness, episodic pain and steady pain, fatigue and weakness. They mean different things and imply different illnesses, and that may take some sorting out.

 

"It can be argued that

the largest yet most neglected

health care resource, worldwide,

is the patient."

~WV Slack~



Patients may also withhold information out of shame, fear, or guilt. Alcohol, tobacco, and drug abuse are prime examples. STIs  are another. Any behavior, or practice, or habit that contributed to their illness, or heartbreak, or regret is part of the story that needs to be told before healing can begin.

 

It can be as much of a challenge for patients to tell their whole story as it is for physicians to ask about it. 

Some time ago I related the history of a patient who claimed her left orbital blowout fracture was the result of a fall causing her to strike the corner of her TV...when in fact, it was the result of a blow from her boyfriend's fist that required me to secure a PFA and to find safe shelter for her. That took time, but it may have saved her life.

 

Isn't that what physician productivity is really all about? Time constraints, reimbursement issues, and productivity aside...we are here to deliver high quality, compassionate, and complete health care to our patients...not to play "stop the clock" with them.

"You define what is important to you

by what you dedicate your time to."

~Vishwas Tiwari~

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