take this test

 

A couple of weeks ago, I saw my primary care physician for my annual wellness exam. As usual, I was handed a clipboard and instructed to answer page after page of questions. They included updates to my demographics, my insurance information, my family medical history, and a "health risk assessment" that included questions about lifestyle (exercise, diet, smoking, and alcohol/drug use), about my mood and stress levels, current and previous health conditions, dementia screening, recent falls, and my ability to perform daily activities such as feeding myself, dressing, and bathing. It may be annoying to fill out the same questionnaires year after year because it's time consuming and redundant...but it makes sense from a health maintenance perspective. This line of questioning helps the physician identify problems that predict poor health outcomes. It provides information he can use to institute preventive strategies, as well as timely interventions to correct or compensate for developing problems. 

"A facility that asks you to fill out

a health screening form is a sign of one

that really cares about its members."

~Kathi Davis~

Back when I was in practice, we didn't use screening questionnaires like these very much, but now they're considered an important part of the patient's medical record...which makes me wonder why the ACE (Adverse Childhood Experiences) Survey is not included in the paper work we submit to our health care providers. This questionnaire addresses childhood trauma and its effect on the development of chronic disease in adulthood.  

A growing body of evidence supports the link between childhood adversity and the development of physical disease and mental health disorders later in life. Childhood tauma includes physical, emotional, and sexual abuse, physical, verbal, and emotional neglect, living with a depressed, mentally ill, or addicted parent, witnessing domestic abuse, and losing a parent to separation or divorce...among others. Chronic adversities like these actually change the architecture of the child's brain, altering the expression of genes that control stress hormone output. This triggers an overactive inflammatory response that leads to adult disease states, notably autoimmune conditions like lupus and rheumatoid arthritis, heart disease, and PTSD-like anxiety and reactivity.

You can take the quiz here. Answer yes or no:

Before your 18th birthday:

1.      Did a parent or other adult in the household often or very often swear at you, insult you, put you down, or humiliate you, or act in a way that made you afraid that you might be physically hurt?

2.      Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you, or ever hit you so hard that you had marks or were injured?

3.      Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way, or attempt or actually have oral, anal, or vaginal intercourse with you?

4.      Did you often or very often feel that no one in your family loved you or thought you were important or special, or that your family didn’t look out for each other, feel close to each other, or support each other?

5.      Did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you, or that your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6.      Were your parents ever separated or divorced?

7.      Was your mother or stepmother often or very often pushed, grabbed, slapped, or had something thrown at her, or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard, or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

8.      Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

9.      Was a household member depressed or mentally ill, or did a household member attempt suicide?

10.  Did a household member go to prison?

Add up your "yes" answers. This is your ACE score. If yours is greater than 0, you should be concerned.

The bad news is that the higher your ACE score, the more likely it is that your health and well-being are under assault. People with an ACE score of 4 are twice as likely to be diagnosed with cancer than someone with a score of 0. Each "yes" response increases the likelihood of hospitalization for an autoimmune disease by 20%. Someone with an ACE score of 4 is 460% more likely to face depression as an adult than someone with a score of 0. An ACE score of 6 or higher shortens an individual's life-span by almost twenty years. This is a big deal. 

The good news is that these early changes in the brain, and their subsequent effect on inflammation and the immune system can be mitigated. Epigenetic changes are reversible. There is a path to healing. 

Some of the practices that have been shown to promote epigenetic healing include:

• writing to heal
• drawing
• mindfulness and loving-kindness meditation
• tai chi, qigong, and yoga (moving meditation)
• dietary changes to promote a healthy microbiome in the gut
• guided imagery
• hypnosis
• neurofeedback
• EMDR

The problem is that childhood trauma is notoriously shrouded in secrecy, and very few healthcare providers are aware of these associations so they don't ask about them. Most physicians see several patients with high ACE scores every day, but all too often the underlying trauma that plays a role in the patient's illness goes unidentified. The opportunity to intervene therapeutically is, therefore, lost.

If you're interested in the relationship between adverse childhood experiences and their effect on health outcomes in adults, I would recommend you check out the book, "Childhood Disrupted" by Donna Jackson Nakazawa, or visit her blog online at www.donnajacksonnakazawa.com.

If you're curious about the role of epigenetics in illness and healing, check out  "The Biology of Belief" by Bruce H. Lipton, PhD.

Next on my list is "The Body Keeps Score" by Bessel van der Kolk, M.D.

"As the ACE study has shown,

child abuse and neglect is the single most common

cause of drug and alcohol abuse,

and a significant contributor

to leading causes of death such as

diabetes, heart disease, cancer, stroke, and suicide."

~Bessel van der Kolk, M.D.~

It is a shame to withhold this vast body of knowledge from patients when it offers an effective pathway to healing that has, so far, been largely ignored.

jan

finding a way forward, without a map

 

Last weekend I was speaking to a friend of mine who is thinking about retiring from medical practice... prematurely, like I did. Not because he can no longer keep up with the demands of patient care or the new technology. Not because of ill-health, or exhaustion, or forgetfulness. The problem is a health care system that subscribes...alas, surrenders...to the demand for power, speed, and profit at the expense of excellence, compassion, and human connection.

"America's health care system

is neither healthy, caring, nor a system."

~Walter Cronkite~

When I gave up after thirty years in Family Medicine, I told my patients and colleagues I was retiring…when I meant I was quitting. (Don't get me started.)

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 the decision for years.

"You can quit your job,

but you can't quit your calling."

~Lissa Rankin~

It had nothing whatsoever to do with my patients. Caring for them was my passion. I wasn't defeated by the perpetually long hours, nor 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.

No. What finally got to me was the erosion of my authority as a physician by self-proclaimed intermediaries who had neither knowledge of nor concern for my patients’ well-being. When I started out in medicine, the problem was oppressive paperwork; now-a-days it’s an oppositional defiant electronic medical record system. A baffling coding and reimbursement system. The ever-present threat of litigation. A pharmaceutical industry that invests as heavily in marketing as it does in service. A health insurance industry whose number one priority is corporate profit…not compassionate care. Aggravations that follow physicians through life like a swarm of angry bees.

In my friend's situation, mismanagement stoked by poor judgement and lack of foresight had propelled his department to the brink of disaster. They were understaffed. Plagued by scheduling errors. Preoccupied with plans to expand into something bigger, faster, and more profitable while they were mired in confusion and frustration...all problems he could have remedied if he'd had the go-ahead from leadership. Instead, his concerns and suggestions were met with disregard. He felt he had no choice but to resign. To explore a different path forward. Without a map.

"You are never too old to set

 another goal or to dream a new dream."

~C. S. Lewis~

Reflecting on his predicament, I put a series of rhetorical questions to him:

• What happened to the drive for excellence in health care? 
• What actually constitutes excellent patient care?
• When did our priorities as providers shift in favor of speed, power, and profit?
• Is it possible to restore the sanctity of the doctor-patient relationship?
• Is there any role for compassion, communication, and mutual respect in patient care?  

He met my gaze with a blank stare.

Health care providers and patients alike should be worried. I'm afraid we are lost, some of us forever.

"The best way to find yourself is

to lose yourself in the service of others."

~Mahatma Gandhi~

Don't you think it's time we restored rightful autonomy and authority to physicians and health care providers…to men and women who have dedicated their lives to delivering compassionate and capable health care to their patients? To clinicians who are not derailed by the promise of wealth or power? To healers who still believe they have a sacred duty and calling?

"We touch heaven when we lay our hands

on a human body."

~Novalis~

jan

the wound that still needs to heal

 

You don't have to be a healthcare provider to share a medical narrative with the world. If you have ever been sick or injured, or if you have cared for someone who was ill or injured, you have a story to tell. Why should you? Because people everywhere are experiencing some iteration of the same ordeal...pain, fear, shame, anger...and no one knows how to navigate it. They need to know how you made it through. Where you found the strength and courage to heal. How you overcame obstacles to recovery. How many tears you shed...and how you learned to smile again. 

"Healing yourself is connected with

healing others."

~Yoko Ono~

Perhaps you recall the time you had to remove the splinter from your child's foot. It seemed like a trivial enough incident...until you are reminded of her pain, her fear, and what you did to ease her through it. Or maybe it was the day you learned your newborn needed open heart surgery...when your fear and your dread outweighed his. Perhaps your narrative started with nothing more than the bruise you tried to ignore, until it morphed into leukemia. Maybe it began when the doctor missed the diagnosis, or botched the operation. Oh! You have a story to tell, all right. Emotions to explore. Sorrow to express. Anger to release. These things happen every day, and people never stop struggling with them. They need your help. What will you tell them?

"The final stage of healing is using 

what happened to you to help other people.

That is healing in itself."

~Gloria Steinem~

If, on the other hand, you are a healthcare provider--a physician, nurse, EMT, or therapist in any field--your narrative may have different layers, each emerging from your unique perspective as a healer and/or caretaker. When and why did you decide to enter your chosen field? What was the hardest thing about your training? About your practice? Is it what you had hoped it would be? Your story embraces your victories and defeats, successes and failures, your motivation and your frustrations, your determination and your insecurities, your joys and your sorrows. If you have ever been seriously ill or injured, you can also write from the perspective of the patient, in light of your special insight and expertise. What will you reveal? What still needs to heal?

"The healing that can grow out of

the simple act of telling our stories 

is often quite remarkable."

~Susan Wittig Albert~

Oh! It's in there, all right. We all have a story to tell because we all embody a wound that needs to heal. Won't you tell us about yours?

"Write hard and clear 

about what hurts."

~Ernest Hemingway~

jan

the hardest thing

Healthcare providers are, by nature, driven by the desire to serve as helpers and caretakers, healers and comforters, empaths and sympathizers. Both on the job and off...

...which is why last week was so hard. There was a death in our family, a call to be present. An appeal for connection and support. An invitation that tested both spirit and belief.

Hundreds of people--family, friends, coworkers, and acquaintances--dropped everything in an effort to gather to "celebrate" (actually, to mourn) the life that had passed. They took time off from work, and made arrangements for childcare, travel, and accomodations. They ordered flowers, and delivered food. They knelt in prayer, or sat in meditation. They embraced one another and wept openly, or they mourned silently. They did all they could.

"Look for the helpers.

You will always find people

who are helping."

~Mr. Rogers~

Navigating grief is difficult, but it isn't the hardest thing we are called to do. When we arrive at the graveside, we are asked to check everything else at the gate...our expectations, our fears, our anger, all the sorrows we hold in our hearts. Disappointment. Shame. Guilt. Blame. We are asked to come with open arms and caring hearts.  

"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~

This may be hard...pretty much impossible for some of us...but it's not the hardest thing. You could be left out...as a friend, as an anchor, as a wellspring of comfort and consolation. Perhaps you couldn't get time off from work, or your flight was cancelled, or bad weather kept you away. You wanted to be there, but you couldn't.

Still, it could be even worse...

...if you simply cannot leave your own burdens behind. If you arrive weighed down with old resentments, disappointments, and misunderstandings. When you don't have the strength or desire to reach out. You arrive without flowers or food. You cannot manage a song or a prayer. 

When you are needed the most, you are helpless, and that is the hardest thing. 

"Grief does not change you...

It reveals you."

~John Green~

jan

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~

jan

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~

jan



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~

jan