don't quit your daydream

 

This week I started reading “Writing from the Heart” by Nancy Slonim Aronie for the third time.

This book is intended to encourage and inspire reluctant or disheartened writers to trust themselves, to take the risk of living from the heart, and to embrace the art of writing from the heart. I think all of us, writers or not, can learn from this book.

I know the author's words ring true to my experience. My inner critic is always beating up on my inner child, discouraging the poor kid from trying new things, nit-picking every unintentional goof-up, bullying her until she’s ready to give up completely. First, it was the dream of going to med school:

“The competition to get in is fierce.”

“Maybe nursing would be a better choice.”

“They don’t take many women, you know.”

Even now, later in life, I have to turn a deaf ear to all those other voices, the self-appointed experts who claim to have my best interests at heart as they rattle off disparagement:

“Start writing at your age? Really??”

“But you’ve never written a thing in your life.”

“Why would anyone give up a career in medicine? Why now??”

It’s no wonder we get discouraged as children when our creativity, curiosity, and energy levels are at their highest. The problem is that these same voices stalk us into adulthood. They can stop us in our tracks.

Which is why we all need encouragement, not just to write, but to live from the heart. As I read this book again, it occurs to me that we can all benefit from Aronie’s words, especially when we start to think about beginning something a new, when we still cling to a dream we once abandoned because we were told it was unrealistic, or unproductive, or unattainable.

Maybe you’re thinking about going back to school, or taking up piano. Maybe you’d like to try sky diving or scuba diving. Perhaps you’re drawn to carpentry or improv theater, but something inside you is holding you back.

“It’ll take too long.”

“It costs too much money.”

“I’d just be wasting my time.”

It may be time to raise your voice. Stand up to that inner critic. Stick up for the child who was bullied out of following his/her heart. Make sure the same thing isn’t happening to you now.

Whatever you do...

"Don't quit your daydream."

~attribution unknown~

Have a great week!

jan

narrative vs visceral memory

A few years ago, I was working on a project through a site called "Storyworth." Every week they sent a writing prompt and I submitted a short piece in response, usually a brief memoir or autobiographical ditty. At the end of the year, I had 52 stories that they assembled into a book I gave to my children and grandchildren for Christmas. It included topics like "What was your favorite candy when you were a child," and "Did you have any pets when you were a child?" Nothing too deep.

One week, I tackled this one: "What Is One of Your Earliest Childhood Memories?"

I'd been avoiding the topic because my earliest memories date back to my hospitalization with rheumatic fever when I was three years old, not a happy tale to tell. I've written about it before. In fact, I published a brief memoir about the ordeal a couple of years ago. I have analyzed the experience in detail from every perspective over the years. I thought I was at peace with it.

I jotted down a few lines and then I went on-line to search for a couple of pictures. I found an image of The Children's Hospital of Buffalo, where I spent two weeks when I got sick. 

Then I found this:

www.ECMC.edu

This is a photograph from the Acute Scarlet Fever Ward at the hospital, and it made me catch my breath. It is exactly as I remember the ward I was in. Except that it was taken many years before my admission there, that little girl could be me. That was where my bed was in the ward. In the bed next to me was a boy about five years old. Back then the nurses wore stiff white uniforms, and they were proud to wear the official nursing caps they worked so hard to earn. I remember it all, but I did not expect the gut-punch I took when I saw this picture. It brought me to tears, it was so uncannily real to me. 

It made me wonder where that emotion has been hiding all these years, and why I felt it so viscerally when I saw this image.

It turns out we store memories in different ways. Narrative memory is the story we tell about what happened to us. Visceral memory expresses the sensory and emotional experience of the story without using words. It's what we feel, physically and emotionally, when the memory emerges. Fear. Sorrow. Anger. A racing heart. Sweaty palms. Nausea. 

"Trauma comes back as a reaction,

not as a memory."

~Bessel van der Kolk~

It's important for health care providers to understand the difference. I can describe the ward where I was hospitalized in great detail. I can tell you about the other children who were there with me. I remember the toys and books I kept at my bedside. I can tell you the whole story calmly and accurately, as though it were no big deal. In fact, I can narrate my entire medical history without blinking an eye. But there's more to it than that. Apparently, something else is still stored away inside, unwilling to be acknowledged and released. Something that still needs to heal.

When a patient presents with anxiety or depression that doesn't seem to fit the picture, or his symptoms don't respond to treatment, think about unresolved childhood trauma. When he senses a racing heart but his EKG is normal, or his headaches won't go away, go back in time with him. What triggers it? A certain song? The scent of his mother's cologne? The sight of a needle? Or like me, a random photograph I came across on-line? 

Narrative memory may be clear and accurate while visceral memory lurks in the shadows. Without warning, an innocent trigger can release a lifetime of unexpected emotion that can wreak havoc on the body. If you're a healthcare provider and things don't add up, go back. Try again.

"I may look peaceful,

but don't provoke the beast."

~Gautham Balaji~

jan

narrative medicine~not just for doctors

 

The program in narrative medicine that was conceived, developed, and implemented at Columbia University under the leadership of Rita Charon, M.D., PhD. teaches medical students and residents to reflect upon and to write about illness as it affects their patients.

 



 

This goes beyond traditional training which is satisfied with arriving at an accurate diagnosis and effective treatment plan. It involves much more than clicking the bullets on an EMR. Exploring the patient's narrative provides insight into the ways illness/injury changes every aspect and every relationship in their patients' lives. Their sense of self. Their ability/inability to fulfill their perceived role in the family and in society as a whole. Their fears and sorrows. Where they find strength. What gives them hope. This process enables doctors to see their patients as more than interesting or challenging cases. It empowers them to tend to the whole person--body, mind, and spirit.

 

"Stories are not material to be analyzed;

they are relationships to be entered."

~A.W. Frank~

 

This practice improves the physician's sense of engagement with his patients. It deepens empathy. It has been shown to improve physician satisfaction and to lessen the likelihood of burn-out.

 

"Writing improves clinicians' stores of

empathy, reflection, and courage."

~Rita Charon, MD, PhD~

 

But narrative medicine isn't just for doctors.

 

Everyone who works in a health care system carries untold stories with them. Nurses and aides, EMTs and first responders, and therapists in every field have important stories to tell. Even staffers such as receptionists, orderlies, and even maintenance and food service workers all have stories they could share with us.

 

"While medicine creates material

for writing, perhaps even more important

is that it also creates

a psychological and emotional

need to write."

~Daniel Mason~

 

But narrative medicine isn't just for them, either.

 

The book on narrative medicine begins with the patient's story...a story almost everyone can tell. If you have ever visited a doctor's office or an emergency room, or been admitted to the hospital, or been a caretaker for a friend or family member, reflecting on the experience can help you organize your thoughts about it. It encourages you to sort out and name your feelings about it. It clears away confusion, and that eases fear. When you tell your story and someone hears it, you both learn from it. When you write your story and someone reads it, you leave part of your burden on the page.

 

Storytelling applied to the practice of medicine is more than helpful. It is a healing process.

 

"Writing is medicine.

It is an appropriate antidote to injury.

It is an appropriate companion

for any difficult change."

~Julia Cameron~

 

jan

 

 

a doctor's touch

Tanzania 2012

This week, I planned to provide a few prompts for physicians and healthcare providers who are blocked for whatever reason from telling their stories, perhaps because of constraints on time and energy, self-doubt, or lack of inspiration and support. I had planned to offer words of encouragement by Julia Cameron (http://www.theartistsway.com ).

"Writing is medicine.

It is an appropriate antidote to injury.

It is an appropriate companion

for any difficult change."

~Julia Cameron~

 

…and by mindfulness meditation leader Jon Kabat Zinn:

 

"Cultivate wisdom and equanimity

~not passive resignation~

in the face of the full catastrophe

of the human condition."

~Jon Kabat Zinn~

  

Then a friend of mine (she knows me too well...) sent me a link to a YouTube video by Abraham Verghese, titled "A Doctor's Touch.”

 

https://www.ted.com/talks/abraham_verghese_a_doctor_s_touch/transcript

 

"The most important innovation
in medicine to come along in the next ten years:
the power of the human hand."
~Abraham Verghese~
 

Suddenly a whole new set of questions arose. This video emphasizes the therapeutic effect of the laying on of hands by the physician...the healing roles of ritual and expectation...the importance of time spent with patients. It undermines the glorification of the ten-minute office visit…the game of "Beat the Clock" that doctors are required to play in order to meet productivity quotients. Don't get me started...

 

"The life sciences contain spiritual values
which can never be explained
by the materialistic attitude
of present day science."
~Sherwin B. Nuland~
 

These trends in the practice of "modern" medicine, among others, are what led me to bow out of practice because of fear of the inevitable: that the day would arrive when I would miss something important because there simply wasn't time to do the job well.

 

These are the questions I still can’t answer:

 

--Should I have taken a stand against the system and what I perceived to be the erosion of my wisdom and authority as a physician in the care of my patients?

 

--How could I have done it...without risking my job?

 

--Would it have made any difference?

 

--Is it too late now?

 

Thankfully, there are physicians like Abraham Verghese who are able to speak eloquently on our behalf while the rest of us scramble to collect our thoughts and yet fail to act on what we know to be true.
 

 "What moves men of genius,

or rather, what inspires their work

is not new ideas,

but their obsession with the idea

that what has already been said is still not enough."

~Eugene Delacroix~ 

 

 

Is there an issue you need to confront? What is holding you back? What kind of a difference can you make? When will you begin?

jan

 

the role of awareness and expression in recovery

This week I came across an article titled, "A New Psychotherapeutic 'Gold Standard' for Chronic Pain?". (The question mark suggests more study is needed...) It described a technique called emotional awareness and expression therapy (EAET) which, to me, sounds a lot like training in mindfulness and storytelling. In this study, it out-performed traditional CBT (Cognitive Behavioral Therapy) in reducing pain, depression, and anxiety in a group of injured and traumatized veterans.

"Awareness is the first step in healing."

~Dean Ornish~

In CBT, patients are taught to use guided imagery, relaxation techniques, and other techniques to change the way they think about pain.

In EAET, patients are asked to recall a difficult or traumatic memory, to re-experience how the related emotions felt in their body, to express those feelings in words, and how to release or let them go. They learn that the brain's perception of pain is influenced by their emotional reaction to it, the big culprits being grief, fear, anger, and shame. In this study, the researchers concluded that "the evocation and expression of emotions is superior to the mere cognitive discussion of these emotions in therapy..."       

Some time ago I listened to a program on NPR about the factors that influence the perception of, response to, and recovery from a painful or traumatic injury or condition. It focused on the differences in perception between persons who feel victimized by an injury, for example, a car crash, as opposed to soldiers who are hailed as heroes when they sustain injuries on the battlefield. 

In a futile attempt to revisit the program for the purposes of this blog, I reviewed a mountain of research and literature on the topic. It astounds me that so much academic effort is devoted to a topic that seems intuitive to me. We witness it all the time. Athletes who play through or continue to compete despite injuries that would sideline most of us. The fact that any woman would put herself through childbirth again, after the first ordeal. This is in contrast to the person who seizes on his injury or pain to excuse himself from work, or to gain sympathy.

"Pain is inevitable; suffering is optional."

~Haruki Murakami~

Many factors affect the way a patient responds to a painful injury or illness. In addition to gender and age, there is a role for:

• social and cultural norms and expectations
• past experience and conditioning
• the sense of victimization vs heroism
• the patient's motivational state
• his emotional state
• his spiritual inclination
• his social support system

"Often it isn't the initiating trauma

that creates seemingly insurmountable pain,
but the lack of support after."
~S. Kelley Harrell~

The easy part for the health care provider/therapist is to diagnose and treat the injury. The hard part is to understand the patient's attitude toward his pain, and how it affects his recovery:

• Is he angry, fearful, ashamed, or depressed?
• Who does he feel is to blame for his injury?
• Will he be able to work? Does he want to work?
• Where can he turn for support? Will he accept it?
• How will she take care of her children? Who can she turn to for help?
• Is he using his injury as an excuse or escape, or as a way to gain sympathy?
• Are his family and friends supportive or dismissive?

These dynamics suggest themselves when the patient fails to respond to treatment as expected, or is non-compliant with the treatment plan.

If you suspect this is happening, it may be time to put your laptop to sleep, look your patient in the eye, and sort through some of the other issues that complicate recovery from an injury, issues you won't find bulleted in the EMR. If you're the health care provider, you must explore the patient's whole story.

If, on the other hand, you're the patient, you must be honest and compassionate with yourself. It makes sense that awareness and storytelling can play a significant role in recovery.

"Self-care is a divine responsibility."

~Danielle LaPorte~

jan

here

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~

jan

 

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~

jan