are you a superhero?

 

 

True story:

 

It happened again today. I was in the grocery store when one of my patients from way-back-when rushed up to say hello. She went on to tell me how much she missed me as her doctor, and then she told me her story. She had recently visited our office for some minor problem that had nothing to do with her heart. In fact, she didn't know she even had a heart condition. But then, out of nowhere, she suffered a major heart attack while she was in the bathroom. She was rushed to the hospital where she underwent surgery that saved her life.

 

She couldn't say enough about how grateful she was for the care she received...immediate, thorough, and skilled. Also, compassionate and caring. She still couldn't get over how lucky she felt to have been in the right place at the right time. I told her it wasn't the first time that something had happened in our practice. One patient collapsed in the parking lot as he was getting out of his car...and lived to tell the story. Another time, a patient's heart stopped beating as I was taking his pulse.

 

 

Another patient was complaining of indigestion when, in fact, he was experiencing a heart attack in evolution.

 

"Having a heart attack felt

nothing like I how

I thought it would feel."

~www.myheartsisters.org~

 



The point is that, as health care providers, we take incidents like these in stride, while our patients literally take them to heart. It's gratifying to be able to help, but we don't see ourselves as heroes or gods. Patients sometimes do, though.

 

If you don't think of yourself as a superhero, think back. Whose life did you save? How did it happen? How does it make you feel? Tell us the story.

 

"You are braver than you believe,

stronger than you seem,

and smarter than you think."

~Winnie the Pooh~

 

jan



 

 

 

 

 





get something down...anything

 

 

I've been posting a lot about the importance of telling your story...the one that needs to be told, the one that won't go away, the story others need to hear. But have I mentioned how hard this can be to do? Have I told you how hard it is to get started? How long it can take? How confusing it can be?

 

"If I'm gonna tell a real story,

I'm gonna start with my name."

~Kendrick Lamar~

 

The story I need to write has been nagging at me for over 65 years...since I was three years old. That's when my brother and I both went into the same hospital with the same illness at the same time. The story explores the divergent paths we took through life in the aftermath of our shared experience. And how long it took to share our separate truths.

 

It begins:

          "The aftermath of childhood illness can linger for a lifetime. You think you’re over it when, out of nowhere, you remember the way the nurse rolled you onto your side and bared your little buttocks. First came the jab, then the dull ache that lasted until the next shot was due. One moment you’re a fully functioning adult. The next, you’re a sobbing three-year old.

          Like a stain that won’t come out, like a fog that never lifts, it stays with you. It can send you down a path you never intended to follow. It has the power to transform you into someone you never wanted to be. The memory of it catapults you back to a time you'd rather forget."

I started working on this project in earnest six years ago. This is as far as I've gotten. The details are vivid in my mind, the story arc is clear, and I already know how it ends. What, then, is so difficult about it?

 

I think the hardest part is convincing yourself that your story is worth telling. And after that, engaging the reader. Convincing him that your story is also his. Compelling him to read on in order to make sense of his experience in light of yours. Finding meaning not so much in the recitation of events, but in their cause and effect, in your process and outcomes, in the truth you summoned the courage to share.

 



"When you stand and share your story...

your story will heal you

and your story will heal somebody else."

~Iyanla Vanzant~

 

 

For reasons that will take a full-length book to explore, my brother spent most his adult life battling the anxiety, fear, shame, and insecurity that followed his hospitalization, as well as the addictions that helped him cope. His story is an epic quest for healing.

 

I went on to study medicine.

 

If you are mystified by the way your life unfolded as it did, if you have spent sleepless nights reflecting on the people, places, and circumstances that shaped you as a human being, if you have ever wished things had been different, you have an important story to tell.

 

"Other people are going to find

healing in your wounds.

Your greatest life messages

and your most effective ministry

will come out of your deepest hurts."

~Rick Warren~

 

If you are discouraged about telling your story because you don't know where to begin, start by writing something. Anything. Start with your name.

jan

 

 

 

 

 

 

 

 



a story that needs to be written

This week I'm dog-sitting for these two gentle giants:



 

 

It's pouring outside, and it's chilly...a good day to curl up on the couch between two big dogs with my third mug of coffee while I share the wisdom of some brilliant writers and caring physicians. 

 

Sometimes we need to be reminded that medicine embraces both science and the humanities. It requires factual knowledge and technical expertise, but first and foremost, it depends on our relationship with the patient. A healthy doctor-patient relationship (no pun intended) is built upon mutual respect, trust, compassion, and intimacy...physical, emotional, and psychological. The healer must know the patient. The patient cannot be separated from his story.

 

There is a softer side to medicine than what can be delivered by a laser or through an endoscope. There is more to healing than what can be achieved by the latest innovation in drug therapy. There is more to the patient than what can be checked off on a bulleted EMR. The study of narrative medicine involves training in techniques that enable the provider to elicit, process, and respond to patients' concerns. It encourages healers to explore the patient's whole story. It requires patients to become storytellers, themselves.

 

In other words:

 

"It may take a doctor

to diagnose someone's disease,

but it takes a friend

to recognize someone's suffering."

~unknown~

 

"The good physician treats the disease;

the great physician treats

the patient who has the disease."

~Sir William Osler~

 

"Writing and humanities studies produce better physicians...

because doctors learn to coax hidden information

from patients' complaints."

~Rita Charon~

 

"Stories are not material to be analyzed;

they are relationships to be entered."

~A.W. Frank~

 

"Write hard and clear about what hurts."

~Ernest Hemingway~

 

"Every patient you see

is a lesson in much more

than the malady from which he suffers."

~Sir William Osler~

 

"Wherever the art of medicine is loved,

there is also a love of humanity."

~Hippocrates~

 

"It has become appallingly obvious

that our technology has exceeded our humanity."

~Albert Einstein~

 

"Dancing, singing, storytelling and silence

are the four universal healing salves."

~Gabrielle Roth~

 

"Writing is medicine.

It is an appropriate anecdote to injury.

It is an appropriate companion

for any difficult change."

~Julia Cameron~

 

 

My coffee mug is empty. The rain has stopped for now so it's time for us to stretch our legs. I plan to spend the rest of this week working on the opening pages of a memoir that needs to be written. Wish me luck.



"If a story is in you,

it has got to come out."

~William Faulkner~

jan

 

 

 

 

 

 

 

 



 



 

 

what the patient needs

Programs in Narrative Medicine, like the one at the College of Physicians and Surgeons of Columbia University, train health care providers (physicians, nurses, and therapists of all kinds) to recognize, absorb, interpret, and to be moved by stories of illness--the patient's chief complaint (CC), the history of the present illness (HPI), and the past medical history (PMH).



It is no longer sufficient to scroll through a bullet list of symptoms, ie. low back pain and stiffness. Check. Lower extremity weakness and numbness. Check. Calf swelling. Check.

The patient needs more from his provider than a diagnosis, and a referral or prescription. He needs to know that his provider hears him, understands him, and addresses all the ways he is suffering:
               ~physically because of the symptoms of his illness...pain, exhaustion, weakness, etc.
               ~emotionally because of anger, shame, guilt, or despair
               ~spiritually when there is no hope for recovery
               ~financially if he becomes disabled because of his illness or injury

"The good physician treats the disease:

the great physician treats

the patient who has the disease."

~William Osler~

Ten minute office visits do not suffice to expose all that must be said, nor do they permit the kind of longitudinal relationships that are so important to understanding and responding to illness. This process takes time.

"Medicine practiced without a genuine

awareness of what patients go through

may fulfill its technical goals

but it is an empty medicine,

or at least, half a medicine."

~Rita Charon~


 

The whole other issue in narrative medicine is the patient's ability to tell his story. Patient's are not born knowing the language of medicine. They don't know what the provider needs to hear in order to understand their illness. Fatigue is not the same as weakness. Tingling means something different from numbness. Stabbing pain means something different from aching pain.

"If storytelling is important,

then your narrative ability to put into words,

or to use what someone else

has put into words effectively,

is important, too."

~Howard Gardner~

 

Patients may be ashamed to admit to unhealthy behaviors that put their health at risk. They may be reluctant to share the emotional impact of their illness on their marriage, children, and co-workers. They sometimes lie in order to deny or minimize the seriousness of the condition, saying the crushing pain that accompanied their heart attack felt like "a little indigestion," or the fungating mass in their breast just appeared "a week or so ago." An attempt to assuage their worst fears.

Medical history taking is a collaborative effort. For both the storyteller (the patient) and the listener (the provider), it requires a shared language, common purpose, and mutual effort. It is never too soon to begin...to learn...to change.

"People hear facts,
but they feel stories."
~Brent Dykes~

jan



a recipe for disaster

 

Bye-bye, summer.

 

 

I retired after thirty years in 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 physical 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.

Curiosity has its own reason

for existing."

~Albert Einstein~

 

Last week I told you about the mysterious case of frostbite that was only diagnosed after the provider went back and reviewed the whole story with the patient. 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.

jan

 

 

 

 

 

 

 

 





how to save time and money

 

"Why, certainly. Help yourself..."

 

This summer, I enjoyed a brief writing hiatus that included a week away at Kripalu Center for Yoga & Health for the third annual conference on Narrative Medicine. Of course, I came back ready to share what I learned about compassionate listening, cognitive coupling and dissonance, and the interpersonal neurobiology of storytelling...and how all of that relates to patient care and healing. No small task.

 

But it wasn't until I got home and was enjoying a cup of coffee with an old friend, a nurse practitioner, that the point was driven home. She presented me with this photo of a patient's foot and dared me to make the diagnosis:

 



 

This was the patient's history: She'd been seen in the emergency room several days earlier with an injury to the foot. She said she'd twisted it. X-rays were negative for fracture and she was discharged with instructions to elevate the foot and apply ice for pain and swelling. A few days later she saw my friend for follow-up because her foot had gotten so much worse. This is a picture of the foot at follow-up.

 

What do you think was going on?

 

"There is need of a method

for finding out the truth."

~Descartes~

 

I ran through a quick differential in my mind. Was it a crush injury? No. Necrotizing fasciitis from "flesh-eating bacteria"? No. Disseminated intravascular coagulation? No.

 

My friend, too, had been puzzled because the history did not fit the findings. So she'd gone back to the patient and asked again what had happened. If she hadn't taken the time and made the effort to uncover the whole story, she never would have made the correct diagnosis. The patient would have undergone expensive and unnecessary testing, and misguided attempts at treatment.

 

This is a case of frostbite.

 

To ice her foot, the patient had purchased an icing boot. It numbed her foot to the point that she left it on for 48 hours and didn't realize what was happening until she took it off. With this bit of additional history, the diagnosis presented itself. The patient underwent extensive treatment and rehab, and eventually recovered.

 

 "Listening constitutes the very

heart and soul of the

clinical encounter."

~Mary T. Shannon~

 

This is a perfect example of the importance of narrative in medicine. Taking the time to hear the patient's whole story promotes accurate, efficient, and effective evaluation and treatment. And, for all the CEOs and CFOs out there...that saves time and money.

jan

 

  

 

the untold story

 

If you follow the news, you may feel overwhelmed right now. I know I do. My heart aches for the victims of the recent school shootings and their families and friends. It’s an outrage to witness the cruel treatment of immigrant families at the most vulnerable time in their lives. I worry about climate change and environmental issues given the perversion of the EPA. And I cringe to think how close to nuclear war we may have come because of the impulsivity of a few corrupt and evil men. It’s a lot to think about. I’m scared. I’m angry. I’m sad. But mostly, I feel helpless. I think we all do.

“The good news is that

Jesus is coming back.

The bad news is that

He’s really pissed off.

~Bob Hope~

And now there’s this to think about: suicide. This past week we lost two renowned, respected, and seemingly successful souls to it. Even though they lived in the public spotlight, no one saw it coming. Even close family and friends were blind-sided by it so no one intervened to prevent it.

Now we will never hear their untold stories. We will never know what demons stalked them, what internal battles raged, what was missing in their lives…how they ended up on this path and followed it to the end.

“At any moment you have the power

to say this is not

how the story is going to end.”

~Christine Mason Miller~

The thing about suicide is that, unlike some of the other political, environmental, and humanitarian challenges we face, we can do something about it. Timely intervention can save lives. But first, you need to understand who is at risk. You need to know the warning signs that suggest someone is suicidal, and then be courageous enough to act. If you are worried about a potential suicide, say something. It has been shown over and over again that talking about suicide to a person who may be contemplating it does not trigger the suicide.

The warning signs of suicide are indicators that a person may be in acute danger and may urgently need help.

·                     Talking about wanting to die or to kill oneself even in a casual or joking manner;

·                     Looking for a way to kill oneself even if it’s just an online search

·                     Talking about feeling hopeless or having no purpose; 
·                     Talking about feeling trapped or being in unbearable pain;

·                     Talking about being a burden to others;

·                     Increasing the use of alcohol or drugs; 
·                     Acting anxious, agitated, or reckless;
·                     Engaging in reckless or dangerous behaviors or activities;

·                     Sleeping too little or too much;

·                     Withdrawing or feeling isolated;

·                     Showing rage or talking about seeking revenge; and

·                     Displaying extreme mood swings.

(This list of Warning Signs for Suicide was developed by an expert review and consensus process that included SAVE’s Executive Director and was informed by a review of relevant research and literature.  Additional information about the warning signs can be found in the following published article: Rudd, M. D., Berman, A. L., Joiner, T. E., Jr., Nock, M. K., Silverman, M. M., Mandrusiak, M., et al. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36(3), 255-262.)

In some cases, an individual who has appeared to be depressed or agitated may suddenly seem unusually calm and relaxed. This may mean they have settled upon and are at peace with their decision to carry out their plan…not that they have decided against it.

You can learn more at https://save.org/about-suicide/warning-signs-risk-factors-protective-factors/

“If you want a happy ending,

that depends, of course,

on where you stop your story.”

~Orson Welles~

 jan