Doctor, no offense but I don’t want to see you

Doctor, no offense but I don’t want to see you

It was already close to the end of the workday in my clinic but there was still a new consult to see. It was the usual – a recent heart attack with diabetes, metabolic syndrome and hypertension. Pardon me, I meant to say – there was a new patient named Mr Lowry with the above-mentioned medical conditions.

I went through the chart quickly – some of the medications could be further optimized, blood pressure could be better controlled, the weight would have to come down. I asked the patient the usual questions – no, no recent chest pain; yes, he can walk for couple of blocks until his knees start hurting; yes, he quit smoking; no, he has not been able to lose weight. Mr Lowry answered the questions readily enough though he did not offer additional information or ask questions.

I asked him to take off his jacket and get on the exam table for a quick physical. As I leaned closer to help him push the T shirt up to listen to his heart, I could see there was writing on the shirt. I could only make out the word “today” as the shirt was riding up on Mr Lowry’s generously sized belly. “What’s written on the shirt?” I asked, curious. I received the first smile of the visit, and Mr Lowry pulled the shirt down so I could see. I DIDN’T WANT TO BE HERE TODAY, the shirt read. As I puzzled, my patient burst out laughing. “This is my hospital shirt”, he explained. “I wear this to all my doctor visits. My wife knows that it needs to be washed every time I have an appointment”.

The smug joke masked a deeper truth – my patient was trying to set his own narrative for his medical appointments. He didn’t want to be “recent non-ST-elevation MI, diabetes, obesity”. He was “Mr Lowry who doesn’t want to be sick”.

There is something freeing in naming the negative emotion. It is now out there and identified. In regards to Mr Lowry, it made it easier for me to find the motivation for lifestyle change – “you need to take your medications, lose weight, etc – so that you don’t have to see me anymore”.

Over the next day, I kept going back to the shirt. Is it somehow more powerful to elicit a negative emotion rather than positive one? Politicians certainly know that fear moves people to vote more than a desire for a positive change. The generic “you should exercise to be healthy” is less motivating than “you should exercise so that you wouldn’t get a heart attack”. It is especially motivating if the heart attack has already happened once – now the fear has teeth. When I ask my patients what is the most important thing I can do to help them, the answer often comes in negatives: “I don’t want to be short of breath”, “I don’t want to be tired after walking 10 steps”, “I don’t want to be in the hospital”, “I don’t like the hospital food”.

Few weeks ago, Mr Herkel was admitted to my hospital service. He was an epitome of a healthy 53-year old – slim, fit, didn’t smoke, exercised regularly. Part of the reason he had kept himself healthy was his bad genetic lottery – most of the men on his father’s side of the family had already had heart attacks or died by his age. And now, when he had developed chest pain that refused to go away, he anxiously checked himself into the emergency room. The type of chest pain he had was not especially worrisome – but due to the significant family history, we did a thorough workup nevertheless. His careful lifestyle had counteracted his genetics – the tests showed no heart disease. Mr Herkel’s relief was palpable. “No offense, doctor,” were his parting words, “but I sure hope I will never have to see you again!”

As for Mr Lowry, I am waiting for him to come back one day with a different T-shirt. The one that says, I DIDN’T NEED TO BE HERE TODAY.

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Self-care tip: Sometimes, a powerful negative emotion may be a motivation for positive changes in your life. But you have to name the emotion first and evaluate it. Be smart.

Question: Have you had a negative emotion change your life for the better?  Tell us your story.

Blue Corvette and Cowboy Boots

Blue Corvette and Cowboy Boots

Some people love their cars and some people don’t.

I drive a Honda Civic – a perfectly serviceable car. It hasn’t been washed for half a year – after all, there is water restriction in California, or so I tell myself. There is a dent in the back bumper from that time when I tried to parallel park and a post magically appeared behind my car. I haven’t bothered to fix that dent nor the scratches that the car got when I fearlessly drove through a felled tree on the road. It’s not that I don’t love my car. I just love its functionality more than its appearance.

Several years ago, as I was walking to my job at the hospital, I saw a colleague getting out of an electric blue Corvette. The car was beautiful – compact, sleek, sparkling in the sunlight. My colleague happens to be not only a very tall but also a somewhat heavy man, so he had some difficulty getting out of the car – the Corvette was not made for his body habitus. Nevertheless, he looked positively radiant. I asked him later, “Why did you spend so much money on an expensive car that is too small for you and does not have that much functionality?” (perhaps I haven’t mentioned that I am not a very polite person). His answer surprised me. “It makes me happy”, he said. “When I get up in the morning and think about facing the day in front of me, I know there is always a bright spot in the beginning – I get to drive my Corvette to work. And that makes me happy.”

I pondered this. There was no way any blue Corvette was going to make me happy. Even a bright orange Aston Martin couldn’t make me happy. And I like orange. But I had to admit that I could not judge my colleague or somehow downplay his joy over something I didn’t understand. People are different. Happiness is relative, and in the eyes of the perceiver.

Over the years, I have had many conversations with my patients about what makes them happy. I have started looking at it as part of the treatment for their heart disease. People who can name sources of their happiness are usually more motivated to take their medications and to follow the lifestyle advice. Additionally, there is a small secret that the physicians may not tell their patients – and I just exposed it in case any of my patients happen to read this blog – tying the lifestyle advice to the sources of happiness makes it more likely to work. It doesn’t have to be a big thing – more often than not happiness comes in small packages. It can be a father, now less short of breath, able to play catch with his son. It can be a chronically ill patient now able to take an airline trip to see a new grandbaby. It can be singing a solo in church, making a trip to the grocery store, walking around the block.

Just recently, a patient I had not seen for few months, literally skipped into the room for his clinic appointment. “Are you seeing this?” he asked triumphantly, a big smile on his face. Well. Sometimes patients forget that I see dozens of them every day, and expect me to remember everything that was said at their last visit. I searched my brain as I was looking at him. Ah. The cowboy boots. Mr Golnach was wearing beautiful patent-leather ornately decorated boots that might as well have walked down from an expensive store window display. This had been his dream – to get his leg swelling down so he can finally put his beloved cowboy boots on. Clearly now, between better diet and regular medications, his heart failure was compensated well enough where the boots had become a possibility. “Isn’t this great,” he sighed happily. “Now I can die”.

Self-care tip: Find sources of happiness in your life, small and big. Naming them will add quality to your life, and keep you motivated to live better.

Question: Tell us your story about an unexpected source of happiness. 

Sparks of Joy

Sparks of Joy

The emerald green color had faded. The hem was somewhat frayed. The sleeves were a little tight. The old shirt stared at me as I was working my way through the closet and picking out things to give away. I knew there was no point in trying the thing on for the hundredth time – it hadn’t gotten less tight or old with the years. I had really liked the shirt at one time and worn it a lot but it really should have gone to the ‘give-away’ pile years ago.

I tried to figure out why the shirt was still in my closet. I had read about home organization guru Marie Kondo and her approach to cleaning and tidying – so I thought I would try. Kondo maintains that foundationally, we have relationships with our belongings, and we should spend some time figuring out which ones elicit strong feelings in us and which ones do not, so our lives don’t become cluttered. She calls it “sparks of joy”. I closed my eyes and held the old green shirt in my hand. I envisioned myself wearing it. No sparks of joy. Ok then, easy – throw-away pile it is. My hands were strangely reluctant and nudged the shirt back toward the closet. Interesting. I closed my eyes again and ran my fingers over the shirt. Ragged edge, stitching…slightly different stitching. I opened my eyes. There it was. My Mom had mended the shirt when she was visiting me, perhaps 10 years ago.

It’s not like I never see my Mom – I talk to her on Skype all the time, and I see her when I visit my home country every couple of years. We have a good relationship. She sends me things, so there is no need for the old shirt to remind me of her.

When I thought about it further, I realized there was more to it. My Mom, while still in relatively good health, no longer likes long travels. She has told me on more than one occasion that she doesn’t expect to undertake another trans-Atlantic journey from Europe. It has made me strangely sad. I don’t think it will change the frequency of me seeing her. But she will never again go through my closet and give her opinion on the clothes I wear. Or pick oranges from my tree. Or mend another shirt that I like but has loose stitching. Or plant new flowers in my garden.

I miss the thought of my Mom in my house. So, I compensate. I take my iPad to the garden when we Skype so I can show her how my avocado tree has recovered from the frost and how big the rose bush has gotten this year. I call her from the store to ask if I should buy a particular piece of clothing. I hold up the phone if she happens to call me when I am out with my friends so she can say hi (she really hates when I do that).

At the end of the day, I put the green shirt in a different pile in my closet. This is the pile that I keep for my nieces – in case they want to wear anything from there in the future. And I am keeping my own stitching skills alive – so I can offer to mend their clothes when I visit them.

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Self-care tip: Allow for things in your life to have a relationship with you. They don’t replace people but may paint richer shades to your life.

Question: Have you noticed that some things you own have more meaning besides their functionality? Any objects that attach to a special person in your mind? Tell us your story.

Links:

Identity that refused to fade

Identity that refused to fade

“Who is changing this TV channel to cooking shows?” a nurse was asking, exasperation evident in her voice. “Every time I turn around, someone changes it, and I am sick of it.”

The voices from the ICU patient room were audible in the hallway. I stopped to listen before I entered the room.

“But the patient…” – the nursing student couldn’t quite get the word in. “What about the patient?”, the nurse interrupted. “I am sure the patient doesn’t want to watch some boring cooking show; here, I am changing it back to the news.”

I’m a hospital based cardiologist who does a lot of consultations. Today, 88-year old African American Mr Jaafir, very sick all over, including lungs and heart. A ventilator had been breathing for him for about a week and it didn’t look like he would be able to get off any time soon. Still, he was mostly awake; when people asked him questions, he was able to write the answers on the paper – the ventilator kept him from talking. During one of my earlier visits, I had run into his large family at the bedside – a younger stylish wife and several verbose sisters, all of them clearly attached to the patient, and eager to pass on his life stories.

The family had told me what the current nurse Marcy did not know – Mr Jaafir had been a chef, and a famous one at that! I had listened as they told me of his famous dishes – the ones that people traveled distances to sample, and were featured in local newspapers and TV shows. Not only was he well known for his restaurant cooking but his home was a central location for the whole neighborhood. I had also learned that being the center of attention had resulted in an interesting life with several marriages and numerous children and grandchildren.

I told all of that to Marcy.  She knit her eyebrows for a second to think and then chuckled, “So, Mr Jaafir, this is why you have been banging on the bedrails when the channel was changed?” The patient glared. Having been an authority figure to numerous family members and friends all his life, he did not take kindly to the loss of control. The cooking channel stayed on for the rest of the day. And for Marcy, Mr Jaafir now had an identity apart from being a random patient on the ventilator.

Over the next couple of weeks, the family and friends came and went. Mr. Jaafir stayed opinionated – the bedside table was littered with sheets of paper,  his directives with exclamation marks and triple underlines readily visible. However, his strong opinions could not sway his weakened body, and it finally gave up. He knew it before it happened, and his writing changed from “I want to go home” to “let me go”.

I stood at attention with the rest of the staff and his family when his body, covered by the American flag to honor his service to our country, was taken away to the morgue. I had admired the way this man had lived – with a strong sense of self, touching multiple lives on his way, taking care of his family, commanding strong respect in his career. Even more, I admired the way he had died. The formidable sense of self had accomplished a rare feat – retaining his identity while helpless in the ICU. He died as he had lived – strong, surrounded by family, firm in his insistence to choose his own path.

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Self-care tip: You are you. Don’t let people change that. Keep your identity.

Question: Have you felt your identity fading in difficult life situations, such as depression, sickness, and/or stress? Tell us your story.

Desolation cries for company

Desolation cries for company

There was a new bounce in his step. Mr. Stefani stood a little straighter, and his face expressed an almost smile. Intriguing.

I had treated elderly Mr. Stefani, suffering progressive heart failure, for approximately a year. It was an exercise like table tennis. I told him how important it was to take medications on a regular basis – he kept forgetting. I told him it was important to avoid salt in his diet – he said he was a poor cook and it was easier to heat up instant meals. I told him it was important to get out and be part of social activities – he said he didn’t have a family, and didn’t really care.

“Why care?” he said.

He was sick, and, as he put it,

“What was there to look forward to in the beginning of each day anyway.”

This is a common story. When people develop heart failure, proper food and self-management of the condition is as important as taking correct medications. This may make a difference between being able to manage the disease at home or several hospitalizations in a year, ending up in the nursing home. Elderly patients, especially men, who do not have family support, are faced with a “triple whammy.” There is no-one who cooks proper food for them. Wham! No one reminds them to take their medications. Wham! And no one motivates them to want to live better and longer. Wham! Wham! Wham!

So what had happened to Mr Stefani?

After we went through these preliminaries –

“Have you been more short of breath?”

“No.”

“How much can you walk?”

“About a block.”

“Are you taking your medications?”

“Yes.”

“Are you keeping away from the salt?”

…we finally arrived.

“Yes, much better now,” he announced, “I have a new friend who cooks for me”.

Well, in all fairness he had said, “I have a new girlfriend.” I just interpreted it as a “new friend”. He went on to explain that there was now a young woman in her late 20s living with him, and she had taken over his kitchen and was helping him out in general. Hmmm. I wasn’t sure if I should ask anything further, something along the line of “Where did you find her?” However, Mr Stefani was more than happy to explain.

“I was driving along the road one day, and there she was, standing on the edge of the road. I stopped and asked if she needed a ride. She said she had nowhere to go. I asked if she wanted to come home with me, and she said yes. That’s how it happened.”

My patient seemed happy. His grooming was better. His feet were no longer swollen. I suggested that he bring his new friend to his next appointment.

The next appointment came in 6 weeks. Mr Stefani walked in with a young woman who beamed at me. I started asking questions about his health. Yes, he was feeling a lot better. She proudly presented his medication list. He told me how she was after him to walk every day. She told me how she had changed her Chinese-style cooking to be salt-free. He told me how he helped her look for a job.

There were questions I didn’t ask. Was she really his girlfriend? Was she an illegal immigrant? Was she hiding from someone? What did she get out of this arrangement? Was he paying her?

Looking at the two people in front of me, these questions all of a sudden did not seem so relevant. People at their heart need connections, and those two had found one.

Endless Rhythm by Robert Delaunay

Endless Rhythm, by Robert Delaunay

 

Self-care Tip: Be open to human connections wherever they occur. It may just save a life – yours or someone else’s.

Question: Have you made a connection with a person that was unexpected? Was it challenging? Fruitful? Embarrassing? Eye-opening? Tell us your story.

 

Introducing our new co-author at Friend to Yourself

Finally!

I’ve been hoping, asking, looking, waving awkwardly in the hospital hallways, trying to find someone who would join me in this great blogging experience with you on self-care. And, finally.

Please join me in welcoming Dr. Helme Sivet! You will love getting to know her, and she will love, as I do, sharing space with you. Keep on.


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Helme Silvet, MD, MPH, FACC
Loma Linda University School of Medicine
Chief of Cardiology, Jerry L. Pettis VA Loma Linda Healthcare System

Hello!

 

My Blog Journey

Sana (or Dr Q) and I have known each other for two decades or so (and yes, we have lived that long). We have spent hours talking about what makes us excited to be physicians, what gets us up in the morning, and what makes us upset. Finally, we decided that it was time to share some of these thoughts together. Taking care of self is a principle that we both try to teach our patients, but also practice ourselves in order to be effective parts of our families, communities, and humanity. The goal of this blog is to attempt both from the, perhaps, somewhat unique perspective of biology, and medicine as the starting point to self-care.

My Professional Journey

My medical experience started in the “old country” behind the Iron Wall – I grew up in Estonia and graduated from medical school there. After the Soviet Union opened its borders, I made my way to the U.S. and finished an internal medicine residency at Loma Linda University and cardiology fellowship at Brigham and Women’s Hospital/Lown Cardiovascular Center. Starting in 2003, I have worked at the VA system as a cardiologist. Along the way, I also graduated with an MPH degree from Harvard School of Public Health. I am passionate about making people get better – this includes preventing, treating and managing heart disease as a cardiologist – but also helping my patients make sense of their life journey. One cannot treat and prevent disease without caring for the whole person.

My Life Journey

Between my two sisters and myself, we have lived in 5 different countries – this has made for interesting holidays! Seeing different parts of the world up close has given me plenty of experience, but has also come with a certain sense of displacement. It has been a continuous struggle in my life to figure out where I fit in the wide world in general, and in my little microcosm of a world in particular. In this context, it has been fascinating to learn different things from different cultures, and observe how people with different life experiences can effectively communicate with each other. And I noticed that somewhere along the way, my quest for truth and knowledge is giving way to a quest of understanding and compassion.

Disclaimer

The thoughts on this blog are my own and do not represent entities I belong to in a professional capacity. The stories that I tell are true in principle but the details may have been changed to protect people’s privacy. The blog is not meant to offer professional advice or treatment advice for specific medical conditions; the goal is to share ideas, general principles and stories of a personal journey.