how to know if you have what it takes

The day I went to my first medical school interview was a day just like today...a sunny but frigid day in mid-January. I had a three-hour drive ahead of me that I negotiated in my father's dilapidated Corvair...the one with the gaping hole in the floor boards under my feet that allowed me to gaze at the pavement when I grew tired of the scenery. It lent new meaning to the expression "cold feet", as I speculated about what questions I would parry when I met with the Dean of the College of Medicine and his team of decision-makers, fate-sealers, and heart-breakers. Early in the morning, I wrapped my legs in a warm woolen blanket and headed for I-didn't-know-what.

I don't remember much about the rest of the day. I have only a vague recollection of the interviewers, my tour of the hospital, the lecture halls and labs, and the drive home, but one question still haunts me some fifty years later:

"What would you do if a classmate

offered you a joint?"

Wait a minute. Really? Why don't you ask me what books I'm reading. What my favorite subject is. Whether or not I have any experience with illness or with people who are dying. Don't ask me about pot! I don't remember how I answered, but I'm pretty sure that whatever came out sounded awkward, naive, and very uncool. I was sure my application ended up in the trash that day.

The next interview took place in Philadelphia. It turned into a road trip with my BFF, who didn't think it was safe for me travel alone overnight. She insisted on coming with me, so we hopped on a Greyhound bus in Burlington, with a midnight transfer at the terminal in Albany...notorious for sheltering every kind of drunken, drug-addicted, and mentally deranged poor pathetic soul imaginable on cold winter nights. I remember every detail of the Albany bus terminal...but I don't remember one moment of our stay in Philadelphia, and nothing of the interview, or the trip back up North. I do, however, remember what it felt like to stay awake all night before one of the most important interviews of my life. Good practice for all those nights I would eventually spend on-call.

"Nothing fixes a thing so intensely

in the memory as the wish to forget it."

~Michel de Montaigne~

My last med school interview also involved an overnight bus ride and another stopover in Albany on my way to NYC. Alone. In Manhattan, I landed in the Port Authority terminal at 6:30 AM, where I was forced to wash up and change in a germ infested public restroom. Where I had to fight my way into a taxi during morning rush hour...against men in three-piece suits carrying alligator briefcases for protection. Where I remember touring the hospital at Flower and Fifth, as if a country girl like myself could possibly survive there. 

Looking back, I think each interview was an adventure, each one a test...each one a challenge in its own way. Nerve-racking. Exhausting. Scary...much like the practice of medicine itself. Still, the idea of driving a car with a hole in the floor in the middle of January with just a blanket for warmth still brings a smile to my lips today. I will never forget the characters who entertained me at the Albany bus terminal while I cowered on a bench in disbelief. I still cringe at the thought of washing my face and brushing my teeth in the Port Authority rest room, and I smile to think how I fought my way into the cab that carried me to the hospital at Flower and Fifth.

Proof, I think, that I had what it takes to become a...

"DOCTOR"...

because bad ass miracle worker

is not an official job title."

~unknown~

jan

 

the real test of courage

What is the bravest thing you've ever done?

If you're a healthcare provider, courage is required just to get through an average day. Emergencies arise. People depend on you. Your knowledge and expertise can make the difference between life and death for your patient. More than a couple of times, I've pulled over at the scene of an accident before an ambulance could be summoned. I've performed CPR in the front seat of a patient's pick-up when he went into cardiac arrest before he could get into my office. I've ventilated a newborn premie in the back of an ambulance for three hours on the way to the hospital.

"Be brave my heart.

Have courage my soul."

~www.weheartit.com~

Friends comment about the courage it must have taken to run a makeshift clinic in the African bush for a week without electricity or running water. To make a house call in the middle of the night to a patient with a loaded rifle next to his bed. To take a drill to a patient's skull.

The way I see it, though, that kind of thing didn't require courage. It was all part of my job. I trained for years to handle situations like these. It didn't take bravery, as much as practice and resolve. You don't think of yourself as a hero or a god when you're just doing the job you pledged to do.

"Courage is grace under pressure."

~Ernest Hemingway~

Still...the work of the healer has its frightening moments. Problems arise that you can't anticipate or prepare for. That's when courage kicks in. When you're asked to sign the DNR order for a patient you can't save. When you have to confront a colleague about a mistake he made. When the mother dies during childbirth, but the baby survives. 

It is the difficult conversation, the tough confrontation, the tragic loss that uncover real courage.

"Courage is found in

unlikely places."

~J.R.R. Tolkien~

So, what is the bravest thing you've done? Have you comforted a sobbing child? Rescued a puppy? Forgiven an enemy?

Each of us is summoned differently. Where do we find the courage to help others heal?

"You never know how strong you are

until being strong is the only choice you have."

~Bob Marley~

jan

trauma is the great silencer

The practice of narrative medicine encourages healthcare providers to explore the patient's whole story, not just the timeline of their symptoms. It allows time and space for patients to reflect on their lifestyle, cultural roots, socioeconomic status, religious beliefs, and the presence or absence of supportive relationships...whatever might have had an impact on their health, and their ability, or lack of ability, to heal.

"It is more important to know

what sort of person has a disease

than to know what sort of disease a person has."

~Hippocrates~

 

There's just one problem with this approach. We never learned about the problem of trauma and how it affects memory. How it affects the way we process and navigate terrorizing or horrific events--the emotional and physical aftermath of war and natural disasters, serious injuries, difficult hospitalizations, domestic violence and child abuse, among others. How trauma can trigger intense emotional reactions years later so that even early childhood trauma can lead to physical, psychological, and emotional disturbances in adulthood. Why it is sometimes impossible to access those memories, and what makes it so hard to put them into words. In other words, unless you recognize the sign and symptomss of trauma, an important part of the narrative will still be missing.

"Traumatic events are almost impossible

to put into words."

~Bessel van der Kolk~

Trauma is the great silencer. As demonstrated on fMRI images, trauma activates the limbic area, or emotional brain which includes the body's alarm system. Years later, when people encounter images, sounds, or thoughts related to their trauma, it triggers a cascade of stress hormones that raise blood pressure, heart rate and oxygen intake, preparing the body for fight or flight, even though no current threat exists. At the same time, trauma decreases activity in Broca's area, one of the speech centers of the brain. When Broca's area shuts down, you cannot put your thoughts and feelings into words. Years later, traumatized people have enormous difficulty telling the story of what happened to them.

"You'd be surprised what lengths

people will go to

not to face what's real and painful inside them."

~unknown~

This is the missing piece in narrative medicine training, the part of the patient's story that will never emerge, because it can't. Memory is shut down. Speech is cut off. 

The bad news is most physicians don't know this, so they can't help their patients heal from it. They aren't trained to recognize and explore the signs and symptoms of remote trauma, nor do they know how to treat it. The result is that these patients end up with a multitude of inaccurate diagnoses including, but not limited to depression, anxiety, ADHD, oppositional defiant disorder, and borderline personality disorder. Then they are prescribed a slew of medications in a futile effort to regulate their behavior and responses.

The good news is it can be treated. Patients can be taught to access painful memories and to assemble them into a coherent history without being emotionally overwhelmed. Only then can healing begin.

If you, or someone you know, or a patient you are treating tends to fly into a rage for no justifiable reason, or is anxious even when things are going well, or shuts down in social situations, or has been in therapy but hasn't made any headway, the cause may relate to unresolved trauma, and it may take a topnotch specialist to crack the case, and to work through the problem.

If you're interested and would like to learn more, there are plenty of resources available. Check out "Developmental Trauma Disorder" online. These are books that helped me a lot:

• "The Body Keeps the Score" by Bessel van der Kolk

• "Childhood Disrupted" by Donna Jackson Nakazawa

• "The Beauty of Breaking" by Michele Harper

Be sure to check out their websites, online courses, and references because:

"The most important part of a story

is the piece of it you don't know."

~Barbara Kingsolver~

jan

who are the real superheroes?

This is not a picture of me, but it could be. The ward I was in looked exactly like this.
The bed is the same, and it is in exactly the same spot as mine was. This could be the little boy who was in the bed next to me. 
It is uncanny. 
I wept when I first came across this picture.

Truth:

An ugly scar. A permanent limp. A weak heart. The aftermath of childhood illness can last a lifetime. You think you’re over it when the sight of a little blood or the thought of getting a shot catapults you back in time to a place you’d rather forget. One moment you’re a fully functioning adult. The next, you’re a sobbing three-year-old.  Like a stain you can’t get out, like fog that never lifts, it stays with you.

Trivial details rise up out of nowhere with perfect clarity. An aide unloading the lunch cart. The “No Smoking” sign by the door. The pile of Little Golden Books stacked on your nightstand. 

Moments you’d rather not remember surface uninvited. Your mother in tears at your bedside. The mingling smell of antiseptic and stale urine. The jab of a needle and the dull ache that lasted until the next shot was due. You still feel it.

Even if you recovered completely, memories of the ordeal can shadow you all your life. Perhaps as an adult you still use a night light to dispel the fear you felt when visiting hours ended and the nurses turned down the lights in the children’s ward. Maybe you struggle with asthma because of the way the nurses held you down to draw your blood. Smothering you. Maybe your gut still cramps up the way it did when the doctors lined up around your bed and insisted on pushing on your belly right where it hurt worst. Every last one of them.

Or, maybe you still have trouble swallowing pills because you were too young to get them down when you were sick. Instead your mother crushed them and slipped the powder into applesauce or pudding in a failed attempt to mask its bitter taste. Maybe your favorite threadbare teddy is still packed away in a chest in the attic. All visceral reminders of the ordeal you endured as a child.

Traumatic memories can release an outpouring of emotions that can stop you in your tracks. Something as simple as getting your flu shot, or having your blood pressure taken, or hearing an ambulance in the distance with its siren wailing can set the whole thing off again. Palms sweating. Heart racing. Hands shaking.

I was three years old when I went into the hospital. How is it I remember the exact arrangement of the beds in the children’s ward? The pattern of the afternoon sunlight reflected across the wall? The name of the girl in traction across the room from me? Alice. Ten-years old.

How does it all come back to me in technicolor detail when some days I can’t remember what I ate for breakfast?

*

"Sometimes real superheroes live in the hearts

of small children fighting big battles."

~unknown~

jan

the cure for new year's resolutions

I'm not a fan of making New Year's Resolutions. It's a time-consuming process that smacks of self-discipline, grim determination, and Herculean effort...and it often ends in failure. I prefer to think of it as wishful thinking. This has a more optimistic ring to it. It suggests we believe...or hope...that the new year holds limitless possibility for us...the possibility that good will come to us, that our burdens will be lifted, that help is available. It enables us to envision a world at peace, to imagine an end to poverty and hunger, to hope for an elusive cure, to pray for an end to suffering. 

"Now is the accepted time 

to make your annual good resolutions.

Next week you can begin paving Hell with them."

~Mark Twain~

Last year, I resolved to embrace practices that are said to raise cellular telomerase levels. Telomerase is the enzyme whose function is to lengthen telomeres. Long story short, telomeres are stretches of DNA that prevent the double helix from unraveling so the entire length of the helix can be duplicated prior to cell division. This increases the vitality and reproducibility of stem cells, enhances health, and extends life. Meaning, you want your telomerase levels to be as high as possible if you hope to live a good long life!

"Bad news: A lot can change in a year.

Good news: A lot can change in a year."

~Rohit Hooda~

The bad news is that telomerase activity can be inhibited by common environmental stressors such as exposure to adverse prenatal conditions, childhood abuse/neglect, domestic violence, PTSD, nutritional deficiencies, and isolation or lack of love. 

The good news is that certain practices can raise telomerase levels. Good nutrition, exercise, meditation, yoga, a positive outlook on life, dwelling in happiness and gratitude, serving others, and love, especially self-love, all enhance telomerase activity. Telomerase lengthens telomeres, and long telomeres promote a long and healthy life, so that's what I worked on all year long.

The problem is there's no way for me to know if I succeeded. Unless you're a cell biologist, you can't simply measure your telomerase levels to see if they're improving. I have, however, been told that I seem to be happier and more peaceful, so something must be working.

This year, in keeping with my pro-telomerase practice of mindfulness meditation, I have decided not to look back at the year that has passed, with its shortcomings, goof-ups, and defeats...that lead me, inevitably, to feelings of inadequacy, shame, and sadness.  

"Don't look back.

You're not going that way."

~Mary Englebreit~

Likewise, I am not looking ahead. I won't be inviting frustration and failure with broken promises, misguided intentions, or impossible goals...meaning, I won't be making New Year's Resolutions this year.

Instead, in keeping with my mindfulness practice, this year I plan to focus on the present. What it feels like to be in the moment. Literally. If you're interested, the meditation goes something like this:

Begin by bringing the breath into focus.You may close your eyes or keep them open. Because I tend to hold tension in the abdomen and throat, I make sure I'm breathing correctly, inhaling with a soft belly, and feeling it tighten on the out-breath. I relax my tongue and throat until I can feel the in-breath all the way into my upper airway. I do a quick body scan to acknowledge any areas of discomfort. 

"I think this is how 

we're supposed to be in this world.

Present and in awe."

~Anne Lamott~

When you are ready, turn your attention to the space around you. Notice the temperature. If you're outside, is the air still, or is there a breeze? Take note of the light around you. What do you hear? The birds outside? The TV downstairs? Thunder in the distance? What do you smell? Coffee brewing in the kitchen? Fresh cut grass? Wood smoke? Don't forget to visualize what is behind you and overhead. Fully immerse yourself in the moment. If your mind starts to wander--and it will--return your attention to the breath.

Oh! You caught yourself starting your grocery list? Good for you! Return to the breath.

Oh! You just now remembered where you left the book you've been looking for? Good for you! Return to the breath.

If emotions arise--and they will--simply acknowledge them, and turn your attention back to the breath. Perhaps tears well up. Maybe your heart starts racing. Perhaps your breathing quickens, or your throat tightens. Welcome whatever comes up without judgement, shame, or rejection...then let it go. Return to the breath, to the space you're in, to the sound of it, to the light around you, to its bouquet.    

Training in mindfulness reminds us to let go of our regrets about the past with its frustrations, disaapointments, and defeats. It asks us to release our grip on the future, and to allow it to unfold as it will. It is a sure cure for New Year's Resolutions.

"Whatever is good for your soul,

do that."

~Unknown~

jan

the part of you that never gets to go home

Go ahead. Help yourself.

Imagine that tonight is Christmas eve. 

Outside, the sun is setting under a sky that could pass for cotton candy. The air is frigid but still. The street is busy with people hurrying home to begin celebrating the holiday. You, yourself, are looking forward to getting home to a crackling fire on the hearth and a traditional Christmas eve meal. The kids are home from college. Their gifts are wrapped and arranged under the tree. You breathe a sigh of relief and gratitude.

"I will honor Christmas in my heart

and try to keep it all the year."

~Charles Dickens~

It was a busy day. Among the patients you admitted through the emergency room were a child with asthma complicated by fever and pneumonia, an elderly gentleman who fractured his hip when he slipped on the ice outside his garage, an OD, and an out-of-state trucker with chest pain and an abnormal EKG. Orders have been written, tests scheduled, and rounds finished. Your patients are settled for the night. Your job for the day is done. It’s time to go home.

Except that part of you never goes home.

You can't forget the expression on the child’s face when he learned he would be spending Christmas in the hospital. He’d asked for a blue bicycle and he couldn’t stop crying because he wouldn’t be there to get it…and he wasn’t well enough to ride it, anyway.

You recall discussing her husband’s injury with the elderly man’s wife. She would be alone for Christmas now, and for weeks to follow. She couldn’t imagine how she would manage by herself.

The OD was not accidental. You are reminded of the most recent studies debunking the long-perpetuated myth that suicide rates peak around the holidays. In fact, suicides reach a statistical nadir in December. Still, opioid contamination keeps no schedule and leaves no clues. It will be a long vigil for this victim’s family overnight.

You learn that the trucker’s family is stuck at Chicago’s O’Hare International Airport because of an unexpected blizzard. They wonder if he will survive this latest heart attack. Will they get to his bedside in time?

It’s Christmas eve. You get to go home. Your patients don’t.

"When you're sick, 

it's nice to know there are people

who await your recovery

as they might a holiday."

~Anton Chekhov~

This is a bi-polar time of the year, a time that highlights the irreconcilable discrepancies, emotional extremes, and divergent realities that prevent some people from celebrating the spirit of the holidays. There is poverty in contrast to wealth, sorrow instead of joy, cruelty as opposed to compassion, and of course, illness instead of health.

For those of us in the medical field who are taking our patients’ medical histories, exploring their symptoms, and fielding their pain when the rest of the world is celebrating joy and peace, it is a bittersweet season. Many of our patients will experience pain rather than comfort, grief instead gratitude, anger as opposed to joy, and anguish instead of peace. It won’t be merry or bright at all. They will be stuck with it…and in many ways, so will we.

Dickens wasn't referring to Christmas, but he could have been when, in “A Tale of Two Cities", he wrote :

"It was the best of times,

it was the worst of times...

it was the season of light,

it was the season of darkness,

it was the spring of hope,

it was the winter of despair."

~Charles Dickens~

He was writing in the 1800s, but he could have been writing today. This is the beauty of narrative...the concept and context of great storytelling endure across generations. Common themes repeat themselves. We realize we are connected in our joy and sorrow, victory and defeat, pleasure and pain with the rest of humanity all across time and space. And that is a sacred gift...a gift to each of us.

A Gift To Bring You

~Rumi~

You have no idea how hard I've looked

for a gift to bring you.

Nothing seemed right.

What's the point of bringing gold to the gold mine,

or water to the ocean?

Everything I came up with

was like taking spices to the Orient.

It's no good giving my heart and soul

because you already have these.

So I've brought you a mirror.

Look at yourself and remember me."

*

This Christmas, I wish you enough.

 

jan

 

 

how healing begins

 

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 may see things a little differently. You see it wasn't your fault your friend found life unbearable. Perhaps you didn't miss the warning signs because there were none. A layer of guilt falls away...

...and healing begins.

"Guilt is to the spirit

what pain is to the body."

~David A. Bednar~

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 her. 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...

...so that healing can begin. 

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 any 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. 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.You were 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.

Or perhaps a song comes on. It's the one you listened to so you didn't have to hear your parents argue, the one that still makes you cry.  

 

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