This one chance

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

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.

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.

Screen Shot 2017-07-09 at 3.39.52 PM

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.

I Can’t Make Friends – Anxiety

voyagerMr. Clark stopped talking and walked to the ringing rotary phone on the wall.

We were experts, as 7th graders, in anticipating what phone calls would be about. I’m surprised we never got around to making bets. I missed my chance to be a bookie. When the phone rang, it could mean someone was in trouble and had to go to the principle’s office.

Everyone was quiet waiting to see if their name would be called. No. That wasn’t it.

It could mean there was a school announcement. It could mean there was something wrong with our bathroom plumbing! But it had never meant that a space ship had exploded. Seventh grade was not the time to grasp what this meant. If we couldn’t grasp it, if our perceptions were unable to see it, then it could not actually exist. Right?

We kids had other things we were trying to sort out. Boys and girls. Getting your period or facial hair. Zits. What Melissa said about you when you thought she was your friend. These were space occupying in our minds. There was little room for understanding that this phone call announced the end of 8 lives, a billion-plus dollars blew up, nor especially not what it meant politically! Spouses and children, watching and cheering in the bleachers live, front row and center, witnessed as their own individual loved one exploded into tiny particles.

Mr. Clark walked, white-faced and perspiring, to the radio, asked for silence over the hum that had built up, and we heard. The challenger, the 8 people aboard (one of them a teacher), in 1986, was gone.

A spaceship exploding is about what anxiety feels like. That may sound extreme but it is the truth. And those who have experienced it, as if their were going to come apart, will do anything not to experience it again. This urge to avoid anxiety expresses itself in emotions and behaviors. But often, when anxiety doesn’t reach a full explosion, the afflicted individual doesn’t even know that they are sensing the urge to avoid, nor how they are responding to this avoidance. The afflicted person and those who know him get think that these medical symptoms are actually the afflicted’s personality. “It’s just the way I am.” 

You may be someone who feels inner congruence with decisions. By temperament, you like closure! But even so, against your own hard-wiring, you find that you have trouble making decisions. How you talk is driven by indecision. You’re couching what you say, being careful. Your self-esteem erodes.

Manuel had some similarities to this, but also, on top of his medical condition with avoidance symptoms, his personality was one that got energy from being alone. That doesn’t mean Manuel didn’t like people or interpersonal relationships. It just means that he got energy from being alone. And he did stay alone most of the time. When around others, the energy poured out of him like lemonade through an open spigot. However, he wanted others. Being lonely was not his goal. But there he was, more energy when alone combined with a thrumming buzz of nerves when he tried to make friends, when he tried to date, or when he was approached by someone spontaneously in public who asked the time.

Fudge! She only wanted to know the Blinking! Time! he screamed inside.

Manuel had some friends with whom he was deeply bonded to by shared experiences. But he had gone on to college and his friends had not. It was niggling in whispering thoughts that he might still be hanging out with them because they didn’t disrupt him. Because he came apart. Terror, like a spaceship exploding in the atmosphere after take-off, filled his perceptions, if he tried to hang out with anyone else! And Manuel didn’t like thinking about his friendships that way. They lost value when tattered by that persistent wind. Nor did Manuel like thinking about himself as someone who couldn’t get other friends if he wanted to. As someone who would use the faithful. Friendship by default? No. He felt shame just thinking it and he knew it’s falseness. In his most essential self, he knew he loved them for more than proximity. But he really didn’t know if he was weak. It was a possibility. And besides! What girl would want a weak man?

People with anxiety have barriers to any number of connections in life, like coming up to an energy force field we can’t see. There are interpersonal connections we might have had, but never initiated or explored because the anxiety held you in place. This is what anxiety does to us. Anxiety takes away our freedom to choose. And as the consequences and fruition play out, we live out the related losses.

Manuel came to me because, “Mom told me I better come and talk to someone.” Mom was fed-up with his isolation, hours of video games, and she had noticed that he was spending even less time with his childhood friends. 

Talking to Manuel, unearthing these patterns in his life, his insight grew a bit. But once he looked at anxiety, even with a sideways glance, which was anxiety provoking in itself, he came up against the need to decide,

Should I treat?

Deciding to treat is a decision to make between the patient, perhaps including their support system, and their treating clinician. When there isn’t a clear answer though, like a blood test that shows the vitamin D levels are low, we respond with vitamin D replacement therapy, but in these areas of diagnosis, it often feels nebulus to the patients on what to do.

When the decision doesn’t have clear form, like an undefined space, go toward the data. You may trust your clinician to know that data integrate it into all the information that goes toward deciding on treatment. Or you may choose to spend time researching and evaluating the data on your own and then go forward. Either way, if you stay with what you’ve been doing, you will remain ill and the illness will progress over time.

So either way, going with the data, either via your clinicians recommendations directly, or indirectly. Accept treatment. In fact, run toward it! You will have a much higher quality of life. And… those around you will too.

Self-care tip – Go toward the data!

Questions: What had influenced your choices in treatment or not to treat? Please tell us your story. We need your voice!

Psychiatrist is In

Psychiatrist is In

Lucy’s psychiatry booth

Did you notice?  In this picture, the patient became the psychiatrist.

Question:  Have you ever felt like your psychotherapist or psychiatrist blurred their boundaries with you?  Have you ever struggled with your own boundaries with him or her?  Please tell us your story.

Self-Care Tip:  Enjoy your boundaries and let them lie.

 

Old and Dying – Why We Are Still Alive

geriatric lady

Sweaty, well-worn, in bike-ware, she was eating comfortably with her friend.  I kept trying not to stare and just had to fight it!  I wanted to imprint her shiny wrinkled yet blooming geriatric status and break down what I saw into categories of self-care moves to grow old by.  She looked really good.

I managed to finish eating at, (Oh my word! Yum! My new binge and bolt location,) Zinc Cafe, without ruining her appetite with a big hug and smooch from crazy-staring-stranger, me.  I almost congratulated myself, it was so hard not to do.  Nevertheless, when walking out I did stop and tell her she was beautiful and that I wanted to grow up to be her.  She bloomed even more, right there and then.  It was swell.  Good food.  Good role-model to remember.

We think it is our best years that people will identify us by.  But they do not just do that.  They think of us as how we are now too.  More importantly is how we think of ourselves – of Me.

It is different for everyone.  Why we want to be here.  Understanding why, is a universal interest.  It is the other side of value in the aging process.

My parents are getting old.  I am.  My patients and their parents are getting old.  We are dying.

My dad is old.  He just turned seventy-nine.  He is not wearing bike shorts.  He is not a blooming geriatric.  But I value him and saying why, well, I realize starts with “Me.”  It is not because of him thirty years ago. It is about his life these last thirty years.  It is about his Me, now.

The present does not prove nor negate the past.  Our value is more than that.

Sometimes I visit community practitioners.   Please visualize that all of this is in the middle of their busy clinic day, racing between exam rooms to meet patient needs.  I am standing at a nurses station perhaps, dressed in something über professional, (to hide the gypsy in me as well as I can.  But if it were you, you would not be fooled by the cut of my lapel!)  I catch the eye of the clinician and receive a strained smile, almost hearing her say, “Come on!  I’m dying here!  I have three patients waiting!”  But generally they do not actually say it, generally.  And sometimes, they are snagged by the magic of connection, take my elbow and draw me away into a private space where they can share their story.  In a matter of moments.

We are skilled at shaving moments here and there.  Skilled at putting as few words into a fat minute that can convey the large concept needed just Now!  We learn this over brow-beating years of managed care medical practice, personal choices, convoluted expectations and need to please – self, other, insurance or what not.  When clinicians share stories, we do it like we are late catching the train to heaven.

From these visits, I get more to my quality of practice.  I get known, and get to know.  Awesome.  It is a newer part of my “work,” that I have been doing this, and I am loving it.  I meet the people who are the other side of our patient’s treatment team.  I meet people who are both human and medical clinicians.  Realness surrounds them.  Life stories come from them.  In a fat minute I hear about their past, gain some understanding of their present and from that, I am given much.  One physician told me of his beloved daughter who suicided, another of her husband’s chronic brain illness and how their family struggles.  I shared how my young cousin hung himself and that part of me who is groping toward that space and time before he died.

To know who we are despite our changing emotions and behaviors, our changing identities, improves our understanding of life value.  Somehow, Dad has known that, without bike shorts.  He continues to mentor me in that.  I do not know about the beautiful geriatric at breakfast, but who is to say she does not know her value?  Not Me.  But I am going to explore my own, for my sake.  I am getting old.

Self-Care Tip:  Look and look some more for why you are valuable.

Questions:  What is valuable about you, even though you have lost so much in life?  Why are you still alive?  Please tell us your story.

Related articles

 

Roughly What We Covered With The University Students

Psychiatry logo

Psychiatry logo (Photo credit: Wikipedia)

What is psychiatry?

Components intersecting at cross-point where stands Psychiatry:

  • The practice of medicine
  • The practice of business
  • The practice of one’s personal life
  • The doctor-patient relationship
  • The pursuit of Quality of Life

Who should go into psychiatry?

  • Consider temperament
  • There are areas of medicine that are more procedural based versus more weighted toward patient-doctor exchange.
  • The medical system is incentivized by codes and governed by layers of administration.
  • But the question begins with Me; what am I incentivized by?  Again, consider temperament.  Temperament encompasses perceived moral values, and where pleasure comes from.

What is brain illness?

  1. Biological
  2. psychological
  3. sociological

We are not in this to cure anything.  We enter psychiatry to improve quality of life – through approach of the biopsychosocial model.

Questions for you:  

  1. What is psychiatry?

  2. Who should go into psychiatry?

  3. What is brain illness?

Self-Care Tip:  Approach brain illness w/o expecting a cure, but rather a process.