choices

This one chance
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This one chance

My morning clinic had been hectic but not very interesting. I felt bad for the student who had been assigned to me – we had not seen any unusual cardiac pathology. Instead, we had heard a long litany by a patient with a recent heart attack who for the life of him could not stop smoking, and been forced to listen to a tirade by an anxious wife who was unhappy with her husband’s nursing home and wanted to take him home for end-of-life care. A large part of that visit had consisted of calming the wife, and hunting down a new oxygen canister to replace the empty one that the nursing home had forgotten to check on when they sent the patient on his way to my appointment.

I sure hoped the next case would offer something more exciting for the student. It was a new consult, an elderly man, wheeled into the office by his wife. When I asked him if he could get out of the wheelchair, he easily acquiesced though I could tell his wife was uneasy. She didn’t say anything, though – it seemed that this was the custom, defer to the husband. He tried to flop onto the exam table, steadying himself with the cane – and almost fell. The student jumped to catch him, eagerly – he was a freshman, in the beginning of his first year, and had not seen a real patient until that day, so to him, catching a patient from a fall was new. The patient grumbled that he was ok, and the wife rolled her eyes.

As we talked further, I couldn’t quite figure out why this patient had been sent to a cardiologist – he had some nonspecific complaints that I could not entirely make sense of, either because he was a bad historian by nature, or had become one after his stroke. His wife tried to supplement the history but due to her language barrier and her general reluctance to take the center stage in the storytelling she was not much help either. In the end, I decided that an objective cardiac test would help alleviate everyone’s concerns, and ordered it. I then spent another half of the visit going over heart-healthy lifestyle, and addressing other, not-heart-related safety and preventive issues that I thought were important for him, such as walking safely, getting physical therapy and doing regular exercises to prevent falling.

After the visit, I helped to wheel the patient back to the waiting room, and saw a little girl jump up from the chair and run over to take the wheelchair away from me. “Our grand-daughter”, the wife said. Oh.

I turned toward the girl: “How old are you?” She proudly extended all the fingers on one hand: “Five!” Somewhat surprised that the little girl had been left all alone in the waiting room, I nevertheless tried to make some conversation.

“So,” I offered somewhat lamely and predictably, “what do you want to be when you grow up?”

“A cop!” came a self-assured and unhesitating response.

The girl then looked at me, pondering, her brunette curly mop shaking, gold earrings glittering, and then offered somewhat less confidently, “And a doctor.” After a moment, the curls bounced again. “Yes, a cop, AND a doctor”.

I smiled. The student laughed. We said our good-byes to the patient and his wife and returned to the exam room to finish the paperwork.

As I stood at the desk, however, I found my attention wandering. I saw other little girls in my mind – myself at age five, uncertain and shy, my little niece at the same age, more confident in what she wants but not sure yet of her place in life. My feet took me back to the waiting room.

“Here,” I offered the ears of my stethoscope to the little girl who was still guiding her grandfather’s wheelchair, “Do you want to hear what your heart sounds like?”

“YESSS!” the enthusiastic reply came quickly.

“Ok, here is your heart – ‘tick-tock, tick-tock’ … and here are your lungs, ‘whoosh-whoosh’ – can you hear it?”

The curls bobbed up and down again as the girl turned to her grandmother, spell-bound: “That was my heart! Gramma, I could hear my heart!”

After I had retrieved my stethoscope from the small hands, the student and I parted the second time and went back to the exam room. While I was trying to make some teaching points about the case, the excited squeals were still very audible from the waiting room, “The doctor! My heart! It went tock-tock! I could hear it!”

The student laughed again. “And just like that, you changed this girl’s career trajectory for life,” he offered, jokingly.

Well. Probably not. But who knows? One chance is all it takes sometimes.

Maybe the little girl will become a doctor. Maybe the man with a heart attack will stop smoking. Maybe the wife of the seriously ill patient will be less distraught, knowing she can call on my help. Maybe the elderly man will not fall at home.

Maybe.

***********

I never got the name of the little girl. I don’t remember the name of her grandfather. By next week, I will not remember the name of the first-year student who spent the day observing my clinic. They will likely not remember my name. I got this one chance with all of them.

One chance. Every day, filled with one-time chances.

That is a lot of maybes.

***********

Self-care tip: Watch for one-time chances in your everyday life. It may make a change – albeit small – in your life or in someone else’s.

Question: Do you recall a time when you took a one-time chance, or missed one? Tell us your story.

 

It’s not my fault
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It’s not my fault

The new on-call resident – Jonathan, I think was his name? – was trying to present another admission to me. He was visibly annoyed.

“…so, the ER calls me and says, you have a patient with chest pain, and I say, what kind of chest pain, and they say, oh, we don’t know, but the patient needs to be admitted, and then I go down and try to talk to this guy, and he is just the worst historian in the world and just stares at me, and says I don’t understand him, and…”

I cut through the never-ending sentence. “Let’s just go down and see him together, hm?”

The light was on in the ER urgent room but I couldn’t really see the patient. The gurney had its rails pulled up, and I could make out a small lump breathing heavily under the blanket. We stepped closer and I called out,“Mr Jones? We came to see you, can you come out from under the blanket?”

The top of a knitted cap made an appearance, with two dark eyes peering out from under it. “Mr Jones?” I tried again. “I hear you were having some chest pain? Are you still having any now?”

The eyes got suspicious. “Ahah,” came a noncommittal reply.

“Well, can you tell me more about it?” I persisted.

“I waited until the morning”, was a cryptic response.

“What do you mean, you waited until the morning?”

The resident interrupted. “He was actually here last night and was sent home, and he came back today morning saying he has chest pain.”

I looked at Mr Jones again. It is not uncommon for patients who have no place to be, to complain about chest pain as they know it is a sure way to get admitted. This guy really did look sick, however. After some grumbling, he sat up for an exam. Clearly, he was in decompensated heart failure, and had been for a while. I motioned to Jonathan to step outside the room. “Is there anything about heart failure in the chart?” I asked him. “Yes, he has had heart failure for a while now – methamphetamines,” he added quietly under his breath, “EF, ten percent, but noncompliant with treatment, still meth positive last month though he denies using”. EF stands for ejection fraction – the normal being 60 percent – the lower it is, the weaker the heart muscle. I glanced at the monitor – heart rate at hundred and ten, blood pressure 80 systolic – he really should have been admitted last night. The ER attending had completely missed the heart failure part. I suppose Mr Jones didn’t make it easy.

I tried to get a little more information. “Mr Jones, when you say you waited until the morning, where exactly were you waiting? Did you go home?” The patient was evasive. From the bits and pieces of his broken sentences, it became obvious that he had somehow hid himself on the hospital grounds all night and come back to the emergency room when he thought the shift had changed and he would get a chance with a new physician. I decided not to press him further until he had gotten a little better.

As the day progressed, more wrinkles appeared in Mr Jones’s case. It turned out he had been diagnosed with a lung mass two years earlier and biopsies and surgical follow-up appointments had been scheduled that Mr Jones had not kept. He had not seen a health care provider other than the emergency room for at least couple of years. His heart disease was thought to be related to his drug use – initially, he had admitted heavy methamphetamine and alcohol use that he now denied. Unsurprisingly, his urine drug screen still came back positive.

****

The next day, Jonathan and I went to see our patient again. He was breathing a little better but had an expressionless look that was speaking louder than any words. I decided to press for words.

“Mr Jones, what do you know about your cancer?”

Blank eyes turned toward the wall.

“Well, they said I had one but then that’s the last I heard about it, couple of years ago.”

“Why didn’t you keep your appointments then?”

The eyes blinked rapidly. “Well, I didn’t know I was supposed to keep them, did I? They didn’t tell me what I was supposed to do…” The tail-end of the sentence ebbed away as Mr Jones was feebly trying to come up with a justification. The defense was half-hearted, as if he knew there was really nothing to say, and nothing he said changed anything anyway.

Jonathan at my side was struggling to remain silent. As a young physician, he was taught to help people, and it was frustrating to him that the help had not been accepted. Mr Jones was a veteran – all the healthcare for his cancer would have been free. Now it was too late. For Jonathan, it seemed like a failure, and what young physician likes that?

****

In the end, we were able to stabilize Mr Jones’s heart failure but his cancer was already spread to most of his body and could not be treated. He was no longer able to take care of himself, and was packed off to the nursing home for the rest of his short days.

It had been a good learning case for the residents – not because Mr Jones had presented a medical challenge – but because he had taught the limitations in our communication skills. We had never been able to engage Mr Jones in any meaningful way, and he remained as absent on the day of discharge as he had been on admission.

As an attending physician, I struggled to make sense of it to myself, so I could explain it to my residents. Was it supposed to make sense? Had we failed somehow, or was the outcome already determined before we got involved?

I tried to put myself in Mr Jones’s shoes, knowing for years that he had cancer but putting it out of his mind. Was he sorry now? Or was the current indifferent attitude merely an acceptance of his fate, knowing deep down that he would rather have chosen those carefree years again, living alone in his trailer, drinking, smoking cigarettes and weed, and allowing himself a hit of meth whenever he could spare the money? He had missed countless procedures and surgeries, doctor visits, blood draws, and lectures by the likes of me about his drug habit. Now in the end of these years, the choice was no longer his.

Remembering the vacant stare, I suspect Mr Jones may not have known himself.

****

I told Jonathan that he had done well, and that he should not give up on people. I suspect there will be time for more cynical life lessons later.

 

Self-care tip: Good intentions do not always result in good outcomes. Recognize when your help is not accepted – it is not your fault.

Question: Have you felt helpless in a face of suffering or personal struggle, and found yourself unable to help? Tell us your story.

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Your Life. Your Choice. Why Are You Still Negotiating?

 

 

Self-Care Tip #102 – Take what is yours and live.  Be a friend to yourself.

Cheri came, still dressed in work scrubs, with her 2 daughters, 8 years old and 3 years old.  Having finished their dinner date, they were swinging by for her appointment before going home.  Cheri told her kids, “Get out now and go sit in the lobby!  If you don’t listen to me I’ll….”  Turning to me, she said, “It’s never enough!  I just took them to dinner and they do this to me!  No matter what I do…!”

1.  Cheri tells me she’d like to cope better with simple stressors such as redirecting her kids

2.  We talk at length about her perception of her kids abusing her.

Cheri is married.  Her husband laughs at her for “…having to take those drugs to be normal!”  “…But he just sleeps his problems away.  He doesn’t deal with them like I do.  He has no idea!”

3.  We talk more about her perception that her husband is responsible for her place in life.

Cheri believes if she doesn’t take more than 2 pills a day, she is less “dependent” on drugs.  She says, “I don’t want to go on like this!”  Her tears continue talking when her voice stops.  She is ashamed.

4.  The concepts supporting taking care of yourself as being the kick-off point to caring for anyone else comes up.

5.  We talk some more about who is “The Why” for what we do or don’t do.

Cheri feels less shame, but it’s still there.  She is willing to give a new medication a try but clearly doesn’t buy it all yet.  She’s going home with her girls to her husband with new pills.  And hope?  Yes.  It is all connected.  It all pulses together and is a living negotiation of sorts.

Disease <–> behavioral/emotional negative symptoms <–> victim role <–> self-neglect <–> greater crisis <–> seeking help <–> responsible self-care <–>  healing <–> fewer behavioral/emotional negative symptoms <–> emotional abuse from husband may continue but is no longer seen as responsible for personal choices and self-care <–> less shame <–> further healing and so on….  (Lub-dub…Lub-dub…)

 

hbofamily.com

 

Cheri is still negotiating her deal in life.  She doesn’t realize that it’s already hers for the taking.  Her life.  Her choice.

The deal is already made.  Take it or leave it.  Your life to live.

Question:  How are your negotiations?  Do you see them as still in progress or settled.  Please tell me your story.

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Choose Your Prophesy

A woman today with a frank quick smile found out I wrote FriendtoYourself.com.  She swung open the door to her story.  People like her never bore me.  In brief, she was sad after many life losses.  Then when she made some changes in her life she got better.  “I didn’t know how bad I felt!”  (And who does?)  Now every day has activity she loves.  She gets tearful just telling me about all the gratitude that took her by surprise.

In psychiatry, the way she felt when she was sad is called an Adjustment Reaction.  An Adjustment Reaction doesn’t last long, it is in response to stress, and it goes away when the stressor is removed.

Stress is dangerous to us.  It can affect us for different amounts of time, like measuring cups.  During that time, it can affect us to different depths within ourselves, like a scuba diver exploring a coral reef.  If the sad time in this woman’s life went longer, and if she had gotten more sick, it might have become a Major Depressive Episode.  In that case, medication therapy would be appropriate.

Stress affects different intersecting paradigms that make us into who we are, like storm water over farmland.  It crosses over our biology, our genes, what is done to us in life, what we do to ourselves, what is put in our bodies, and how we cope.

Stress can pass over us like a Jewish holiday or it can stay, working, changing, reshaping, adding and taking away bits, always active and busy.  Ants in the walls of our house.  Most often we don’t know what it is doing, for how long, or where it is at work in us.  Stress mutates our cells, turns sleeping genes into loud cancer, depression, anxiety, heart attacks, dementia, old and wasted faces.

But what to do?  Do we avoid stress?  Do we end it?  Do we cure it?  All of that, of course.  My dad told me, “Everyone has problems.  The difference between you and somebody else, is what you do with your problems.”  Not the number of them.

No.  This woman’s story didn’t bore me at all.  The opposite does.

In the film directed by Adam Shankman, “Bedtime Stories,” the character played by Adam Sandler thinks choices have little effect on inevitable negative outcomes. “Life has no happy endings.”  He lives consistent with that belief, until love finds him.  A happy life story can be chosen.  His fantasies are freed to cross the boundary from imagination into the material world where love was waiting, in the shape of family and strangers.  Love showed him that his life had been a self-fulfilling prophecy.  He hadn’t even realized how unhappy he was.  (And who does?)

Self Care Tip #38 – Choose to go towards your fantasies.  Be a friend to yourself.

Question:  What do you think?  What is your story?

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Fewer Choices

We have infinite choices in life but they aren’t necessarily the same choices. I don’t know at what age that starts making sense. It reminds me when J.K. Rowling‘s 9y/o Luna Lovegood witnessed her mother killed, which enabled her to see Thestrals. In story form, saying suffering brings sight. Choices can bring us suffering, which in turn might bring us sight. It’s true that we always have a choice but it’s not true that we can choose the same choice again. Nor is it true that we will have the same quantity of choices.

My sister-in-law Joana Johnson, neuroscientist, says we recruit more areas of our brain as we age but use less brain matter to problem solve and think creatively. We can generally multitask better than we could when we were younger although our short-term memory is less available. It is a biological example of renewed options all the while earlier options are no longer available.

As we mature, the beauty is that we have a greater capacity to work with our options. It is obviously not that we have a greater number of options. But isn’t that marvelous!

Scott Anthony, president of Innosight writes, “You can’t do more with less unless you understand what more means.” Hopefully there comes a time when each of us will look into our choices daily for all they can become. Think plate of chocolate lava cake in front of you. Will we get the gift of sight? Anyone can.

Self Care Tip #25 – Get the gift of site. Be a friend to yourself.