aging

Family is Family
by

Family is Family

She must be in her mid-thirties, I thought. Kids – it looks like she has kids. She was well dressed, with a pleasant, kind face. Everyday Mom – a person who is easy to like, a person next door who everyone wants to be friends with.

Just right now though, she was spouting angrily, full of righteous indignation.

“And just to think that they could have easily killed him, I just could not believe it.” Her eyes were flashing. “I told them right then and there, I will never take him back to this doctor. He almost died and ended up in the intensive care for DAYS!”

The reason for the outpouring, my new patient, was sitting quietly, fondly looking on as she continued. He looked to be around eighty, which I knew was about 10 years more than his actual age. Recently diagnosed heart failure, stroke last year – this would make anyone look older.

The daughter was at the end of her rant. “So, we just decided to come straight here and find another cardiologist.” She pulled out a large binder. “Here are all his records – we want you to take over now.”

Usually I try to be understanding of my own profession and not be quick to join in the blame game. After reviewing these records, however, it was difficult not to be blunt in my judgment. Her father’s case had indeed been poorly handled – he was prescribed two medications at the same time with predictable life-threatening interactive side effects. His daughter’s diligence likely saved his life – when his mind started slipping, she had checked his blood pressure, found it extremely low, and immediately called for help.

After some painful experiences in my career, I had learned that instead of pronouncing judgment, it was best to find things to praise.

“You are quite lucky to have such a devoted daughter, sir,” I remarked. “If you are not aware, I can tell you – research shows that men with daughters live longer, so you have an edge there.”

The patient smiled. His daughter looked pleased.

*************

As I was going through his medical records, I was relieved that this new patient had been scheduled into an hour-long slot – there was a lot to cover. Making notations in the chart, I asked follow-up questions – what other medical problems he had, what were his habits, when was he first diagnosed with heart disease. The daughter answered most of the questions – not unusual when the patient is elderly; younger people tend to have better memories.

Working through the records, I noticed a condition the daughter had not mentioned.

“So, the prostate cancer – when did you have that?” The daughter looked confused for a moment and then turned to the older man. “When was that, Dad? This must have been a long time before I met you.” They started discussing the possible dates – the patient did not have the best memory.

This snippet in the conversation caught me off guard. First I thought I had misheard the word ‘met’. Surely one would not use that word for one’s own father? Should I ask? Social history is an important part of the medical exam. Also – let’s face it – I was curious.

“That was an unusual word choice,” I started carefully. “So, I assume you are adopted then?”

“Oh no,” the woman answered cheerfully. “As biological as can be.”

The utter confusion must have shown on my face. She decided to have pity on me.

“Well, of course, I didn’t know who he was.”

…. That did not make things any clearer.

“My Mom refused to tell me who my real father was – so after she died, I started looking for him. Went through as many genetic tests as I could – and I finally found him!”

There was an unmistakable triumphant note in her voice.

The patient just smiled and continued looking at her fondly.

She went on. “So, then I asked him to come visit us last year. That’s when he had the stroke. Of course he would be better off here, so I just asked him to stay and he lives with us now.”

I tried not to react. To be perfectly honest, I wasn’t sure how one would react. The commitment she described was flabbergasting… and to a father who had never been in a picture. This woman had taken a virtual stranger into her home and into her life and acted not only as a forgiving daughter but as a caregiver to an elderly man with multiple medical problems.

“Family is family,” she announced. “I am so happy I could finally be with my Dad.”

*************

I must confess that there was a small suspicious part of me wondering if she will stick to it. The old man was not healthy and with the recent stroke needed a lot of help. After the initial euphoria of having a father wore off, would she think it too much?

On the next scheduled visit, the daughter was there, with the same updated binder. The father was looking better – the combination of optimized medications and stable home care had done wonders for his health.

On the visit after, the granddaughter had joined them. She was a bright-eyed little thing, curious about everything and intently looking at her new grandfather’s heart pumping on the ultrasound screen I was showing them. The daughter was making notes about medication changes. While I talked to the her about the home care, the granddaughter was trying to talk the grandfather into playing a game once they got home. The whole visit had an atmosphere of care and contentment.

*************

I never asked more questions about their history. Why had the mother refused to talk about the father? What skeletons were in that family’s closet?

She probably would have told me. But it was not my place to ask. As a physician, I was happy enough that my patient had good social support.

Family is family. In this case, family that almost wasn’t.

 

 

Portrait of an Old Woman
by

Portrait of an Old Woman

It is New Year. Another year.

Another year older. I hate getting older.

I joke about it – about forgetting a name here and searching for a word there, about new wrinkles, about an age spot, about the difficulty of getting rid of a flab around the stomach. But it bothers me. It feels as if somehow every day I am getting closer to being a smaller, weaker me with less ‘me’ in it.

Couple of days ago, I stumbled onto a new app on the phone that ages your picture for you. Supposedly, this will make you friendlier towards your future self, so you will take care of it better. Well, ‘it’ being me, really. Obviously. I knew that.

I found a picture of me on the phone I thought looked like ‘me’. The ‘me’ I know. The ‘me’ I like. I hit the “aging” button on the app…

****************************

I had come to visit Mrs Beren.

Her face looked small and fragile against the white hospital sheets. Old. Quite a bit older than her fifty-nine years, in fact. With so many chronic diseases, it was no wonder.

She had put on lipstick, I saw. Not a bright garish red I would have expected from someone who was vain enough to bother with makeup while being in the intensive care unit. No, it was a tasteful light pink that did not clash too strongly with her tired and pale face, wrung out from endless nights on a hospital mattress.

She was a strong woman, I knew. Not her body – that was weak – but her mind. I had always been fascinated by it for the years I had known her.

Strictly speaking, I didn’t have a reason to be here, monitoring her progress with the disease that had landed her in the hospital, for the umpteenth time. She had everything wrong with her. She could no longer walk due to neurological damage and depended on her husband to lift her from the chair to bed at night, and back to the chair in the morning. Her kidneys had failed her and her husband brought her to dialysis three times a week. Just this year, she had been in the hospital with pneumonia, urinary tract infection and now again with fever and sepsis that the doctors had not found a reason for yet.

Mrs Beren was not my patient.

Her husband was.

I had no reason to be here.

But her husband had asked me. I had run into him unexpectedly in the hospital hallway, looking out of place and out of sorts. I had been surprised to see him – he was one of my healthier patients, with a minor heart problem, who I saw for routine visits only once a year. He always came with his wife who drove herself into the room in a motorized red wheelchair. I had been confused by it at first – why bother coming to her husband’s appointments when clearly she was so much sicker than he? But after a few visits, I realized that this was their life. The edges of individual lives had blurred. It was a unit, with her being the guiding force. It had always been the two of them, all their lives since they were teenagers. When I asked questions from Mr Beren, the wife answered half of the time. They joked about how the new reliance on a wheelchair for transport no longer allowed them to enjoy traveling that they had been fond of in the earlier days of marriage. When I asked for a report on his exercising, it was the wife who proudly told me how she pushes him to go for a walk each evening – with her driving her motorized wheelchair, right next to him. They told me about the adjustments of their house they had to make, about the new car they had to buy. The life in their little unit had changed to accommodate her increasing disability but at the core they were still the same people.

I had not asked for their life story. It had just naturally flown out of them, piece by piece, over the years’ worth of visits.

So here I was, staring at Mrs Beren’s pink lipstick.

“I ran into Roy in the hallway”, I started. “He told me you could use a visit.”

“Good old Roy”. She looked up, pensive. “How did he seem?”

Confused by the question, I hesitated slightly. “He seemed … well. Worried, of course. About you. I know you have not had it easy lately.”

“No.” I could see she was testing the words before speaking. “I don’t think it will get any better, frankly. And I am pretty tired of being sick. I just don’t know what will happen to Roy when I’m gone. He is not strong.”

Implications were heavy between us. Not strong like her, getting herself to all her husband’s appointments in a wheelchair. Not strong like her, worried about her husband while lying deathly ill in the intensive care. Not strong like her, making herself pretty with lipstick on what she thought may be the last days of her life.

***********************

After I first hit the “aging” button, I slammed the phone down. The woman who had looked back at me from the picture was old. Heavily wrinkled, with saggy skin and grey hair.

Also, unmistakably me. It was chilling. Unnerving. A little nauseating.

I picked up the phone again and tried to look past the wrinkles. The confident pose I had liked on the initial picture was still there. The sparkle of enjoyment in the eyes was still there. The smile of general happiness with life was still there. It was me. Old – yes, but still ‘me’.

It made me feel better. The woman on the picture wasn’t smaller or lesser. Just different.

I don’t have a choice in getting older. But as a colleague and friend likes to point out frequently, the alternative is far worse. So, I can choose how I get older. I can choose to be the “me” I like even when old. I can choose to be strong even when sick.

I can choose to put on the lipstick.

 

Screen Shot 2018-01-01 at 2.22.09 PM

Portrait of an Old Woman, by Guido Reno

by

Live Imperfectly, Dad is dying, and I Have no Power.

wilted flower

Living with someone like tomorrow might be their last is much harder to do when it is actually the case.

My dad told me, after my nine-year old niece died, that a parent should never outlive their child.  When I look at my own children, I know that is true. But with my parents aging process, my dad’s long and difficult past twenty years, and now near end of life condition, I just don’t know how I’d order things, if I could, between us.

When God, (Morgan Freedman,) told the complaining Bruce Nolan, (Jim Carey,) that he could have all of his powers, the audience of “Bruce Almighty” projected both a positive transference and a schadenfreude. Bringing the viewer into the character’s identity is every actor’s aspiration. And we went there. Up. “Yay! Bruce can answer everyone’s prayers with a ‘yes’!” And then down, down, down. The multidimensional disaster’s created by misplaced power, power without wisdom, love, or altruism, was just painful to watch. Power does not God make.

My Dad is dying. Not likely from cancer. Not likely from a failed liver, floppy heart, or baggy lungs. He is just dying.  He’s confused on and off. His spine is failing so he can barely walk. He has repeated blood clots. And he’s recently risen out of a deep depression. Rison right into a confused grandiosity, full awkward, awkward like pants ripping when you bend over type of awkward, and inter-galactic soaring thought content.

The first “word” Dad played in Scrabble last week was “vl.” He explained, “vl, like vowel.” …Okay? For thirty minutes Dad played without playing one actual word. I started crying when he finally stopped connecting letters. The letters floated on the board like California will look after the “big earthquake” finally hits and it falls into the ocean. (We’ve all been waiting.) Now he tells me he called and spoke to Obama and Magic Johnson. Reference point. This is bizarre and out of his character.  He’s been delirious with waxing and waning level of consciousness for a month and a half. He’s dying. Sheez.

Living well while Dad dies is not easy. Would I use power to restore him to his healthy twelve-year old self, like Elli’s seventy-year old grandfather did, in “The Fourteenth Goldfish,” by Jennifer L. Holm? Would I use power to change the order of death? Would I do anything more or less or different, while my dad is dying?

Power does not God make. I am not God. (Ta-da! It’s out of the box now.) But both of us are watching Dad die. I trust that She, with the power, wisdom, love, and altruism, is living with him well, during this time.

In Life and Other Near-Death Experiences, by Camille Pagán, Libby Miller decides to live, just live, rather than die perfectly.  And maybe that’s my answer to this unasked question. Living with someone dying will not be perfect for me.

Self-Care Tip: Live imperfectly to live well, like this is your, his, or her last day.

Question: How do you “live well?”

Keep on!

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Memorial Day – My Graduation Thank you

IMG_3342My Mom saved a bunch of “stuff” from years gone by (sniff) and I came across this. I was moved to snuffles. Thank you Mom for valuing my life.

I remember it so poignantly, working on these words with my brother Cam, and laughing a lot. Then before I knew it, there was the after graduation party, standing at the mike and those many faces. I blubbered mostly. Mortifying. But I do remember who I saw.

You! You! You! It’s all about you! We’ve done this together, and it’s God in you people that got me through. Thank you.

Medical School was hard for me. All that book work was as exciting to me as my acne, one of those things you hope just sort of goes away. I found that whenever I had some book in front of me, I suddenly became the best conversationalist. In fact, I learned to start taking them on dates. I started having a lot more success… with dating.

But still, all those years of book work were a form of security. There’s security in book work.  When third and fourth year came round, I got a little nervous. You know. You’ve got to perform.  By now I’ve learned if flirting doesn’t work, hey! I can always cry! I can do that because I’m a girl. Being a woman in medicine is neat like that. The only problem I really ran into with being a woman in medicine, is that guys are soooo competitive!!! Aren’t they!!! In med school especially. But you know what I like? I like to just CRUSH THEM!!! No I’m just kidding. I wouldn’t crush anyone …irreparably.

Growing up with Dad being a doctor was inspirational. From him, I thought what you mainly learned in medical school was that if it hurt, all you needed to do was put ice on it. Now I know you have to use tape too.

But on bad days, it was Jesus and Jesus in you that got me through.  You my friends who sent notes, you my family, brothers, Mom and Dad, who know me so well and survived my selfish demanding life, who kept me laughing and smiling and inspired, you all, you who prayed.

And I know this is just the beginning of a lot more practice of depending on God and God only for power. So here we go, together. You and me and Jesus. Thank you. You you you. It’s really all about you.

And 18 years later, even without the security of book work, the distance between me and medical school could still not get far enough! Thank you for trolling down that lane with me. May you all celebrate your history. Happy Memorial Day!

Keep on!

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I’m peaking in my career

  
Supposedly, I’m peaking. And this isn’t about egg yolk and marenge pie. I’m 43 years old, have been in medical practice for fourteen years, and am looking at a canyon in 360-degrees from where I stand. That’s what the data says. I wonder if I am going to do the electric slide or how I’ll boogie through the next years of medical practice. I try to think, “This is the best moment of my life, right now,” any time self stigma and fear of mortality creeps in. (That’s not saying, “This is as good as it’s going to get!” Ha!) I want to cherish the gift of practicing medicine, for however long I am blessed with it. 

It’s a popular discussion amongst my colleagues these days, about how long a physician should practice. There’s a newer’ish respected program called, PACE, that evaluates physician competency to practice as they get old.  This is a huge shift in the culture of medicine. It’s meant to respectfully assist rather than discriminate with ageism. I try to imagine what it might feel like if I were approached and asked to take the test. 

So what does a psychiatrist rocking her best jeans have to show for herself anyway, you may ask. Well, (tapping the mike), “I’d like to first say thank you to my sponsors….” Wink.  I mean my patients! Thank you. 

…Hey! This peak is crowded! Give me some room!

Ahem. But at my “peak,” at the best of my career, I thought it would be fun to play around with, “Why?” What’s in my doctor’s bag that is so special?

  • Ask, “Why do you want to be alive?”
  • Start all work-ups with a medical work-up. 
  • Give full informed consent with the 5-Treatment Paradigms of Psychiatry: 
  1. chemical (medication), 
  2. psychotherapy, 
  3. hospitalization (inpatient and outpatient), 
  4. alternatives (such as acupuncture, massage, sleep hygiene, lifestyle change, etc.), 
  5. stimulation therapies (such as ECT or TMS).  There’s nothing else (that I know of 🙂 ) that anyone is going to offer you in psychiatry, no matter who’s clinic you go to. 
    • Push to full treatment response. 
    • Work toward quality of life, not cure, not perfect.  Ask again, “What makes like worth living for?” Design treatment toward those goals. 
    • Routinely and deliberately consider the flow of patient’s treatment agendas with physician treatment agendas. 
    • Mood journal. Nobody believes they were “that bad” after they feel better. Everyone wants to stop treatment when they feel better. (This is why there are so many repeat pregnancies, for example!). We all need our own voice (mood journal) to look back on and speak the truth. 
    • Fight for oxygen. If your patient has sleep apnea, don’t stop working toward treatment compliance. There are no medications that can take the place or make up for oxygen to the brain. 
    • Community. More community. 
    • The third eye – a therapist. None of us can be a mirror into ourselves. We all need someone outside of the “triangle” to speak.

    I’ll be thinking of more as I try to go to sleep tonight, but it’s bed time. I’m off! Sleep hygiene! Arg!

    Self-care Tip: Evaluate your position in your lifeline, and treasure where and who you are with deliberation. Keep on!

    Questions: Where are you in your lifeline? Are you struggling with ageism? What gives you value? Please speak! I, and the rest of us, really need your voice. 

    by

    How Do We Age Well?

    photo

    Ella Rose

    In preparing for retirement, for aging, we put money away like Smaug The Dragon who knows his coin.  We imagine we will gain freedom, retain vitality, interest, and motivation, perhaps enjoy the affection of those we served through life.  But do we prepare for what is really coming?

    I’ve been asked, how do we age well?  And guess who asked.  An aged man.  I tugged on my chin a little to hide my discomfiture.  After all, I would like to sit at his table and listen in on his story of doing what he had inevitably done, grown old.  I’d like to hear what he is pleased with.  And what he regrets.  I’d like to hold up the memories, like picture slides to the light, and see if I recognize anything.  Maybe something I might relate to.  Something I might more deliberately emulate.  I might feel more secure, knowing what he has done before me.  Maybe I’d think I am safe.

    Remember that song,

    A foolish man built his house upon the sand, A foolish man built his house upon the sand, A foolish man built his house upon the sand and the rains came a tumbling down.  The rains came down and the floods came up, The rains came down and the floods came up, The rains came down and the floods came up and the house upon the sand went splat!

    (The hand motions make the song.)

    But why ask me about aging?  Do I look so old already?  What the!?  Fine then.  I’d like to say, grow old continent and stock full of Botox.  Nah.  That wasn’t it.  (Mind wandering already you see.)

    Or maybe, we who are aging wonder quietly if this person, or that might have a trick of doing it better.  This person wants to hold up my picture slides to the light and gather security to them.  That person wants to do more than hoard coin, and another doubts the vitality and wonders if she’d know what to do with it if it were waiting there for her after all in the end any way.  “How do we age well?”

    Start with Me.

    Me, where there is freedom to choose, the chance of change, the place where cause begins.  (The 3 C’s done our way at Friend to Yourself :).)

    As a psychiatrist, it’s easy for me to think first of the biology of aging of course – brain health over time and to recall that the brain is connected to rest of the body.  I could tell this aged man that he’ll be wanting to get oxygen to his brain at night and use his cpap regularly.  I could speak of motility and exercise, of caloric intake and sleep hygiene.  We might spend some time on medical care for psychiatric illnesses common in again, depression, dementia, anxiety, and so forth.  We might speak of the inevitable process of losing friends and family, aging past a child or losing pets.  But as many so often remind me, psychiatrist’s only have the truth that their perceptions allow.  😉

    A dear Obstetrics and Gynecology specialist told me the other day that she has become more convinced than ever that the processes of coming into the world and that of leaving the world are the same.  Having delivered countless souls into life, she has been marked, as if the luminescence of so many branded her.  She carries the knowledge of their entry and of those who have already died.

    I remember my niece who died at 9 years and 28 days.  Not so old.  Not so aged.  Some how we think of death when we think of aging, not when we think of nine-year-olds.  However my niece did age well.

    I suppose aging is like any system, as strong as its weakest member.  The wonder is that if we believe in aging, we believe our lives run on a line, on Time, which is after all, a human construct, a philosophy and based on Magic. Aging well as implied by my OB-gyn colleague, is looking at it from both ends, looking at what is in between, and looking at what is outside of birth and death.  Aging well includes exploring the essence of Me, what bit of Magic came before Time and before zero and numbers and philosophy turned into math.

    How do we age well? Does aging imply disease? Aging is linear. They’re different but definitely paired… Help me on this?

    keep on.