can you hear me now?

 

What good is a story without someone to tell it? What happens to it if no one is around to hear it?

Communication is both crucial and sometimes difficult in health care. This week I was reminded of the importance of listening to what our patients have to say...and what a complicated process it is to be able to hear, much less understand what it is they're trying to tell us. I was reminded that the process of communication between us is tenuous and delicate. It is mind-boggling that it works at all. 

I am re-reading "The Road Home~A Contemporary Exploration of the Buddhist Path" by Ethan Nichtern, founder of the Interdependence Project, who teaches meditation and Buddhist studies across the country.

He talks about mindful listening--listening as a meditative practice--which might, or might not resonate with you, but then he describes the process. He notes that when a person speaks:

"...the vibrations (tiny movements of air that carry sound across physical space) funnel into these cute, weird-shaped little holes on the sides of the other person's head called "ears." At that point, the other person's brain (the listener's) determines what these vibrations mean based on her own past associations and experiences, experiences that are incalculably distinct from your own, encapsulated within the subjectivity of a very different human experience. Then, the other person has to reach down into, and somehow connect with her own soup of feelings, memories, and emotions to see if what your vocal cords just emitted resonates with her own lived experience. If, somehow, this has all gone well and succeeded, the other person nods at you approvingly and says something like, "I know what you mean!"

Think of it this way. Imagine you are lying in bed at night and you hear the rumble of thunder in the distance. It might be five miles away, or ten, or twenty. If it were close enough, you might actually feel the vibrations that carry its sound. But not only has it travelled for miles, it has passed through rain and fog, through the trees in your yard, through the panes of glass in your windows, and into your funny little ears...where it sets your ear drum vibrating exactly as it must if you are to hear its deep rumble. The ear drum then transmits the vibration to three tiny bones in your inner ear, and they stimulate the auditory nerve in a way that somehow preserves the "rumble." The auditory nerves then transmit the sound to the auditory center in the brain. Voila! You realize you are hearing the sound of thunder from far away, not the dog snoring at the foot of the bed. Not the garage door closing when your teen misses curfew. Not your own stomach rumbling.

"Can you hear me now?"

~attribution unknown~

But it doesn't stop there. You might experience a strong emotional reaction to the sound. If you were scared of lightening and thunder as a child, you might still experience fear. Your heart races and your hands sweat. If your area needs rain, you might feel relief and gratitude that a storm is on the way. Or, perhaps you're annoyed because your sleep has been interrupted.

All this because of a rumble of thunder. Imagine what goes on in your brain when you're listening to the story your patient is telling you! When a Mozart symphony brings you to tears. When your partner whispers, "I love you."

This has always been one of my favorite meditations: contemplating the process of hearing and how sound waves seem to contradict everything I know about physics. When you break it all down, when you understand all that has to happen with accuracy, precision, and perfect timing for you to receive, experience, interpret, and react to what you hear, it is mind-boggling. Unimaginable. Seemingly impossible. The thought that what I am experiencing can't possibly be happening strikes me as absurd. It makes me laugh every time! And that's just hearing. Imagine what vision involves! Reflect for a moment on the processes involved in retrieving remote memories, in imagination and creativity. In experiencing grief. In feeling love.

"The quieter you become,

the more you can hear."

~Ram Dass~

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obstacles to storytelling in medicine

 

"Obstacles to the Application of Narrative Medicine

in Clinical Practice"

 

The impetus behind the use of narrative in patient care has to do with understanding the patient's whole story. Not just the time line along which his illness developed, or the severity of his symptoms, but the root causes of the problem, how it affects his quality of life, and how it impacts the people around him...all of which affect his ability to heal. The problem is that not many providers practice narrative medicine, and not all patients are good storytellers.

 

One issue involves the time constraints that health care providers confront daily. 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 reward him for the time he takes with his patients. The EMR does not reflect psychosocial, emotional, or relational complications of illness or injury. In addition, the practice of narrative medicine requires certain skills that are not traditionally covered in medical school and training. "Deep listening" and "close reading" are foreign concepts to most health care providers. Most providers are unfamiliar with the importance of neurocognitive resonance and dissonance when caring for patients. Expertise in technology is valued over connection with the patient.

 

"Patients don't care how much you know

until they know how much

you care."

~unknown~

 

While numerous studies have demonstrated the healing power of storytelling, the system is stacked against it. 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. But, if you take the time to explore the symptom, you may suspect angina...it gets worse when the patient climbs a flight of stairs, he sometimes feels it in his jaw, it makes him a little 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, throbbing pain and steady pain, fatigue and weakness. They mean different things and imply different conditions, 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. Rape is another. Shame can shut a patient down. Any behavior or practice or habit that contributed to their illness or heartbreak or regret is part of the story that needs to be addressed 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 sort it all out.

 

"People will forget what you said.

People will forget what you did.

But people will never forget

how you made them feel."

~Maya Angelou~

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feel the pulse beating in your own wrist

 

I started medical school in 1970. There, I studied traditional Western medicine for seven years, and I went on to practice according to its principles for thirty years. I knew the structure and function of every organ system and the signs and symptoms of the diseases that affect them. I learned how to examine patients, which diagnostic tests to order, and how to treat the patient's problem. For the most part.

It turns out, that was the easy part. Most of it made sense. How oxygen gets into the bloodstream. How the kidneys know what to excrete and what to recycle. How food is broken down and absorbed, and what we are left to deal with in the aftermath. In the healthy state, every process is carried out with precision, perfect timing, and uncanny coordination. And, for the most part, it all happens without any effort, attention, or awareness on our part. The fact that the body body knows what to do to keep us healthy is incomprehensible. The fact that it knows how to heal itself is beyond imagination.

"There is more wisdom in your body

than in your deepest philosophy."

~Friedrich Nietzsche~

1970 was also just about the time the mind-body-spirit connection was catching on among forward thinking healers and energy workers. Timothy Leary and Ram Dass were experimenting with hallucinogenic mushrooms in their quest for enlightenment. Quantum physicists were eyeing the nature of consciousness. We started to hear about the therapeutic applications of acupuncture, hypnosis, meditation, massage and therapeutic touch, Reiki, and yoga...all dismissed by the medical elite as malarky for lack of randomized, double-blind, placebo-controlled trials that proved their worth. All of it 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.

Nevertheless, these so-called "alternative" therapies intrigued me. The scientific community rejected the concept of the mind-body-spirit connection, but I knew better. I'd seen it work.

When I was a medical student, I shadowed an orthopedic resident who had earned 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 nothing more than a brief hypnotic induction, sparing her a dose of general anesthesia with its lingering after effects, and a night in the hospital. I was sold. I studied self-hypnosis, and submitted to surgery under its spell 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.

"Your body hears everything

your mind says."

~Naomi Judd~

The quest to connect with my own mind, body, and spirit led me to a mysterious, theoretical, and fantastical world of untold potential. Of waves and particles, of infinitesimal smidgeons of time, and never-ending stretches of space. I learned that our genes express themselves differently depending on our environment and experience. That we have the ability to modify the traits we pass on to future generations. That ultimately, the mind is in charge of what transpires within and even around us. All because of the incomprehensible complexity, interconnectedness, and precision of all that sustains life.

In the meantime, I continued to see patients in my office every fifteen minutes. I whittled their medical histories and examinations down to a few bullet points in a new-fangled electronic medical record system, and sent most of them off with a prescription or two, in keeping with my training.

To be fair, not everyone believes that cell biology is connected with our thoughts, emotions, and experiences. Not every biologist supports the idea that the brain affects the biochemistry of cells down to their molecular structure and function. But then, not that long ago, many scientists dismissed the idea that blood pressure, heart rate, and even body temperature could be modulated by meditation. They had to transport groups of Tibetan monks to research laboratories in the US, and hook them up to monitors to record the very phenomena they so vigorously questioned. They were mind-boggled by what they observed. The monks were able to lower their heart rates and blood pressure, and to raise their body temperature even in sub-freezing conditions. Just by thinking about it...

"When nothing is certain,

anything is possible."

~Mandy Hale~

...which is jaw-dropping because it touches on the greatest mystery of all: the origin, nature, and function of consciousness, including thought, memory, and imagination. Science has fully explored the anatomy, molecular structure, electrophysiology, and biochemistry of the brain, but we haven't quite figured out how it works. We don't know how thought is generated in the first place, or how it is translated into something as easily experienced and observed as tears, or laughter, or fear. We don't exactly understand how a thought can raise the heart rate, or make us sweat, or leave us shaking. How a remote memory resurfaces, and where it has been hiding.

I practiced medicine for over three decades without giving either the body or the mind credit for its genius. It's a shame to have spent so many years memorizing, studying, and analyzing information that has since been proven to be inaccurate, or incomplete, or totally untrue. It unnerves me to realize how much time and effort I devoted to learning what has already become obsolete, or been proven wrong, or been questioned anew. It is amazing to contemplate the myths we embraced, the mystery that continues to unfold, and the masterpiece it reveals.

"Your body's ability to heal

is greater than anyone has permitted

you to believe."

~attribution unknown~

You may not understand the science of cell division and differentiation, or what drives it. It may be hard to grasp how it affects your health and well-being, and it might seem absurd that you have any control over it at all. It's interesting to contemplate one's own thoughts, and to speculate on their origin, nature, and power. 

Physicists, biologists, physicians, philosophers, and quantum theorists are hard at work trying to figure out exactly what it is that makes us who we are...while our bodies are mysteriously, silently, and predictably doing what they do best: making us who we are.

If this doesn't astound you, try this: study the sky at night. Watch for the first signs of spring. Feel the pulse beating in your own wrist.

"Imagination is more important

than knowledge."

~Albert Einstein~

jan

the key to the universe

 

It happened again this week. I finished another almost-300 page book, much of which I didn't understand. It was about the origin and evolution of the cosmos. Quarks and neutrinos. String theory. Dark energy and dark matter. And how we know what we know about it.

"The more you know,

the more you know you don't know."

~Aristotle~

My friends tend to respond with a blank stare or an eye roll when they ask what I'm reading this time...because, usually, I can't explain it. This is true of much of what I choose to read about. The interface between science and spirituality. Eastern psychology and practice. Quantum theory. Consciousness studies. 

Perhaps this month's record setting heat wave propelled my attention to the ravages of climate change and the fate of our planet. To our place in the solar system. To our dependence on unpredictable and as yet unknown cosmic forces, because the book I just finished is "Cosmic Queries" by Neil deGrasse Tyson, an astrophysicist at the Hayden Planetarium in NYC. He not only describes the origins and evolution of the universe as we know it, but he tackles the big questions. How old is the universe? What is it made of? How did life begin...and how might it end? Who figured it all out and how did they do it?

"The universe is under no obligation

to make sense to you."

~Neil deGrasse Tyson~

It fills me with deep reverence for anyone who understands mathematics like this, not to mention the person who came up with it:

~from Mostafa Elhashash @ Praxilabs.com ~

So, why do I bother reading books that are so difficult to understand when I could be reading romance novels, cozy mysteries, thrillers, or dystopian fantasies? When I could be meeting with friends over a glass of good red wine or simply watching home renovations on TV? (Not that there's anything wrong with any of that...)

For me, the answer is AWARENESS. 

I may not exactly understand what I'm reading about, but it helps to be aware of it. To know that it exists. That someone, somewhere understands it.

"Imagination is more important

than knowledge."

~Albert Einstein~

Before I tackled this book, I'd never heard of Lagrange Points, the Heisenberg Uncertainty Principle, or the WOW signal. I didn't know what a "singularity" referred to, or what a Higgs boson was. I didn't know that Yellowstone National Park is situated on a supervolcano that last erupted 664,000 years ago. It's so massive that, if it erupted today, it would bury much of North America under volcanic ash. I'd never heard of Mount Krakotoa in New Zealand. When it erupted in 1883, seawater rushed in to fill the gap, causing an explosion heard in Australia, 2,000 miles away~the loudest sound in recorded history. Imagine that! I still don't really understand the BIG BANG...but I have a clearer awareness of it now.

Does knowing this make life any better? Easier, or happier, or safer? No. Does it make any difference whether you're aware of any of this or not? 

As a matter of fact, it does. It leaves me in awe. It fills me with wonder. It reminds me that there is so much I don't know I don't know...which inspires me to read, to reflect, and to wonder. It humbles me. It compels me to ask if we are witnessing an unfolding mystery or a genuine miracle.

"I do not believe in miracles.

I rely on them."

~Yogi Bhajan~

My advice is this:

Don't wait (like I did) until you retire to pursue whatever stokes your curiosity. To explore whatever fuels your sense of disbelief or skepticism. To embrace the thing that makes you wonder.

Never stop imagining. Never stop questioning. Never abandon the search.

"The most interesting questions

are the ones we don't yet know to ask."

~Neil deGrasse Tyson~

jan