Ramblings

Free Write Friday: Cross Country Ski

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The stillness is deafening. I startle to someone coming up behind me until I realize the swishing is from my own skis, legs scissoring across the powder, cutting into the silence-laden air. My quadriceps, my calves burn under layers of cotton, of smart wool. My nose ignites with the chill of exposed skin, nares dripping with shock. I pull my hood tighter, cocooning my half moon ears.

We come to a pond, sheets of ice overlay sections, tempting the foolhardy. A carved wooden sign marks it a “swimming hole.” I try to imagine a sticky summer day when a jump in those waters would be desirable, a welcome cooling. But all I can think about are my fingertips, numb and double-gloved, constantly flexing interphalangeals, willing the circulation to return.

I hear the river’s rush before we see it, the waters churn over smooth rocks, under the precarious bridge. The sound floats on the air, over the snow, down the trail, amplified as if running parallel, overhead, all around, rushing through us as we ski closer to the river’s edge.

The trail forks, we turn right, enter a grove of birch trees, slender white bark complementing the elegance of the silent snow. There’s a muffling to the drifts, an insulation and paradoxical amplification of sound. I like the set grooves in the trail, a designated place to put my slim skis, a comfortable path to follow. They keep me focused, respectable, out of harm’s way.

Today though, it’s too cold – single digit temperatures jolt this moderate-weather gal. We’re unable to enjoy the journey, frozen extremities too distracting. We hurry back to the warming hut, thermosed hot chocolate and a rush of heat greet us.

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Narrative Medicine

Narrative Medicine Monday: Standardized Patient

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Artist Kerry Tribe’s latest installment at the San Francisco Museum of Modern Art, Standardized Patient, brought back memories for me of medical school. The article on Tribe’s work by Hyperallergenic describes her as “interested in memory, language and awkward connections.” The relationship between patients and doctors-in-training certainly consists of awkward connections. I remember the standardized patients we worked with to learn how to take a basic medical history, how to perform a physical exam, even how to do pelvic and rectal exams without as much fumbling and hesitation inherent in such a personal exam. All the standardized patients I encountered were professional and helpful, giving valuable feedback and helping us prepare for a new component of the medical licensing exam: that of a standardized patient interaction. For this portion of the exam we flew down to California (the closest location for those of us training in the Pacific Northwest) and stood outside nondescript doors in our short white coats, much like the medical students in the last photo of this piece. I remember feeling terrified at what this patient, this actor, might judge me on. Was I too friendly? Not personable enough? Did I make enough eye contact? Ask the right questions? Perform the right physical exam? Give the correct reassurance and explanation?

Tribe’s installment “captures the atmosphere of a hospital: that draggy kind of feeling, as though everything is tired and washed out, as if you are waiting for something.” She shows the uncertainty of physicians-in-training: “We can see the tentativeness of the prospective doctor, as they question one SP about how her boyfriend has treated her and see how the doctor tries to comfort her.” I like that Tribe captures the nuances of medical training, that “[w]atching this display of effort creates empathy for the doctors as well as the actors. Seeing the feelings of both — impatience, kindness, concern — flash across their faces, you almost forget they’re acting….”

Writing Prompt: If you’re a physician, recall a particular interaction with a standardized patient during your training. What did it feel like? What did you learn? As a patient, were you aware that your physician trained with actors as patients? Does this seem strange or is it encouraging to you? What kind of focused training on communication or empathy might be helpful for your doctor today? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Of Mothers and Monkeys

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Caitlin Kuehn’s essay “Of Mothers and Monkeys” draws parallels between her research work with macaque monkeys and her mother receiving treatment for breast cancer in the same hospital. As her mother starts chemotherapy, Kuehn “rotate[s] between the animal ward and the human ward.”

Kuehn wrestles with the ethical ambiguity faced in animal research. Thinking of her own mother’s reaction to chemotherapy, she darts off to her work in the research lab, wondering “what animal first shared with my mother that sudden fear of a throat closing in… I realize that I—as a student, with very little power but a whole lot of responsibility—am complicit in a moral choice I have still not taken the time to make. Some days it is hard to remind myself that medical research has a purpose. Some days it is as clear as cancer. Some days I just do not know.”

When Kuehn’s mother needs injections to help boost her immune system after suffering from a serious sepsis infection, though Kuehn “could do a subcutaneous injection in the dark,” she becomes “shatteringly nervous” whenever she has to give her mother injections; the familiar activity takes on a different tone.

Kuehn’s mother begins to rely on her to answer medical questions, but Kuehn’s scientific expertise is limited to “what I have learned in my undergraduate science classes, or here at the lab. All of it applicable only to non-human mammals, or else too theoretical to be of any use for as intimate a need as this. I have no good answers.” I was struck by the fact that often, even for those of us who have extensive medical knowledge and training, we still lack “good answers” to those questions posed by suffering loved ones.

Kuehn has a strong reaction when her mother declares that she’s fighting her cancer for Kuehn and her sister: “She’s pushed her will to persevere off onto my sister and me. It’s too much pressure to be somebody else’s reason.” Have you ever been somebody else’s reason for fighting for survival? Did you have the same reaction as Kuehn to that kind of pressure?

Writing Prompt: At one point Kuehn responds to Domingo’s convulsions in the same comforting way she does when her own mother’s throat begins to swell during her chemotherapy: You’re going to be okay.  When a patient or loved one has been faced with a particularly challenging moment of illness, is there a mantra you’ve repeated to them? To yourself? Did it help? Write about the situation. Alternatively, reflect on Kuehn’s statement that “death is a condition of life.” Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: What Patients Say, What Doctors Hear

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Dr. Danielle Ofri’s latest book, What Patients Say, What Doctors Hear is a call to re-examine the way doctors and patients communicate with each other. Through fascinating patient examples and directed research, Ofri illuminates the pitfalls in the current medical system that lead to miscommunication and, ultimately, worse heath outcomes.

I was particularly struck by Ofri’s call for physicians to become better listeners, and thus “co-narrators” of a patient’s story. This term was coined by researcher Janet Bavelas, whose study shows that how physicians listen to a patient’s story in fact contributes to the shaping of that narrative. Ofri asserts that “medicine is still fundamentally a human endeavor,” that one of the most significant ways we can advance health care is by improving one of our most basic tools: communication.

I’m thrilled Dr. Ofri will be speaking to my medical group this week and I’ll be able to meet her in person. Dr. Ofri has written many books and essays important to the world of narrative medicine and is the Editor-in-Chief of the Bellevue Literary Review.

Writing Prompt: One chapter in Ofri’s book outlines a “Chief Listening Officer” who was hired by a hospital to listen to patients and translate their needs back to the hospital so they could improve care. Ofri notes the value of this, that “being listened to so attentively is a remarkably energizing experience. It makes you eager to continue engaging.” Have you ever had an interaction with a medical provider who listened to you and your story in this way? How did it make you feel? Did that experience benefit your health in any way? Write for 10 minutes.

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Writing

The Artist’s Way

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At the beginning of the year, I stumbled into a group working through Julia Cameron’s prolific The Artist’s Way. The premise is that we’re all created to be creative, that along the way our artistic self becomes “blocked” and, through a process of exercises and exploration, we can unleash our underlying creativity, transforming our own life in the process. It’s an involved undertaking, which I tackled in characteristic too-fast-out-of-the-blocks fashion.

I had heard of Cameron’s book but didn’t know much of what it was about when I agreed to commit myself to the group and the process. I’ve found the “Morning Pages” Cameron endorses a cathartic free-form journaling that does serve to unearth our core stumbling blocks and greatest desires in life. I’m recalling previous passions and brainstorming ways I could incorporate these childhood joys into my adult life: writing and playing music, performing elaborate plays, detailed needlework, making bracelets, dancing.

I have to admit I was skeptical at first. Despite being a life-long journaler with a history of a strong spiritual faith, I initially found some of her observations and suggestions new-agey and impractical. What modern professional parent has time to write three pages every morning and take their inner artist on a weekly date? I’ve since come around, appreciating the thematic chapters and exercises, the encouragement and confidence instilled that we are all creative beings, most content and most ourselves when we find ways to weave artistry into our lives.

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Narrative Medicine

Narrative Medicine Monday: Today, Magda

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Writer Catherine Harnett presents us with Magda in her opening paragraphs, a woman who wears “scarlet velvet shoes with bows, so ladylike” and “sends thank you notes to hostesses the next day.” Magda takes a cab to visit her husband, Conrad, who “cannot place her, though she seems familiar.” Magda notes that with this persona “she can talk with ease about The War, how hard it is to live without silk and chocolate.” Magda and Conrad have tea together and as she leaves she recalls the other roles she’s played. There is a melancholy sweetness to Magda’s character play. She has found a way to have satisfying interactions with her husband despite his progressive and painful memory loss. Her husband has, in fact, disappeared and Magda fills the void with her elaborate personas.

Writing Prompt: What do you think of Magda’s approach to meeting with her husband, who no longer remembers her? Is she taking on the different personas more for his benefit or for hers? Have you had a loved one who has forgotten who you were? How did it feel? If not, imagine someone close to you suddenly didn’t remember your life together. Write for 10 minutes.

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Ramblings

Free Write Friday: California

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The light wanes as we step out of the hotel conference room, eyes blurry from hours of lectures, Powerpoint slides flashing, acronyms swirling, EKGs dancing. The sun has set but the purple light of dusk hovers in the sky. The moon is rising over the palm trees lining the street, thin stems with bushy tops, as if each were adorned with floppy wigs or jester’s caps. The air is cool but not cold in way the sky is shaded but not dark.

We make our way to the cove after dinner, can just discern the rough waves crashing onto the rock face. We want to feel the fine granules of sand between our toes, stow them home in our carry-on bags tucked away in our shoe soles and jean pockets.

We hear the seals before we see them, sharp intonations directed upward, all around. They squeal and shriek their protestation to our presence. We are intruders and suppliers, they must love and hate us. One seal beaches several yards away. We point and exclaim like paparazzi, eager to elevate the novel to a venerated plane.

***

The sand on the soles of my feet, the sudden coolness of the water washing over my toes, the Pacific wild in its winter norm, tame by the time it reaches the California shore.

People-watching is paramount along the walkway that winds parallel to the strip of sand. Surfers haul their boards under their arms as if the equipment is another appendage, wetsuits peeled to their waists, hair dripping to their shoulders. Rented bikes with fat tires and curved handlebars in candy coated colors weave in and out of pedestrian traffic. Tourists unsteady as they cycle, unsure on their winter legs in the foreign sunlight.

Twenty-something revelers pack the margarita bars, sipping slushy neon drinks in oversized goblets. They laugh easily, their cheeks crimson they lean into each other suggestively, throw their heads back into the bright sun. A girl in a green vest pulls a wagon filled with Girl Scout cookies, stacked Samoas and Thin Mints, boxes disappear into eager hands.

Umbrellas and beach towels dot the pale sandscape. Sunday afternoon revelers exult, even here, in a warmer than expected day. I close my eyes and see a glow, rouge-hot, yellow afire.

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Narrative Medicine

Narrative Medicine Monday: Still Not Convinced You Need a Flu Shot?

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Aaron E. Carroll provides a straightforward explanation as to why getting the flu shot is imperative to a healthy community. In his New York Times article “Still Not Convinced You Need a Flu Shot?” he notes we may be passing on the virus without realizing it, to people much more vulnerable than ourselves: “You can infect others a day before you show any symptoms, and up to a week after becoming sick. Children can pass along the virus for even longer than that.”

Carroll points out our lack of concern about the flu virus, so familiar every winter, is illogical: “Because the flu is so common, we tend to minimize its importance. Consider the contrast with how the United States responded to Ebola a few years ago. We had a handful of infections, almost none of them contracted here. One person died. Yet some states considered travel bans, and others started quarantining people.” He argues that we should be much more concerned about the flu, noting that influenza is the “only cause of death in the top 10 that could be significantly reduced by a vaccine. Lowering risks of heart disease, cancer or Alzheimer’s are much, much harder to do.” We have a way to decrease the morbidity and mortality from a common illness yet we choose not to harness that opportunity.

By looking at the history of the varicella vaccination, Carroll illustrates the benefit we gain through herd immunity and the ethical consideration of getting immunized even if you yourself are not at high risk. He notes that babies were dying from chicken pox prior to implementation of the vaccine, but “as rates of vaccination rose, the rates of death from varicella were low…. But more significant, from 2004 through 2007, not one child younger than 1 year old died in the United States from chickenpox. What was amazing about this finding was that we don’t vaccinate children that young for chickenpox — therefore, those babies’ deaths were not prevented because they were vaccinated. Their deaths were prevented because we vaccinated their older siblings.”

In a previous Narrative Medicine Monday post, I highlighted a New York Times article written by Dr. Danielle Ofri that I’ve used when teaching narrative medicine courses to medical professionals. It illustrates the challenge of communication between physicians and patients and why there often is a disconnect. How can we improve the dialogue to better inform the public and, ultimately, save lives?

Writing Prompt: Do you get your flu shot every year? Why or why not? Do you feel that you understand the reasoning for immunizations? What information might help you better understand? If you’re a medical provider, have you struggled to convey such information to patients? Think of such a time and write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Order

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Writer and nurse Catherine Klatzer organizes it all in her poem “Order.” I like that it is written in second person, puts the reader in the space of the patient who is “so civilized / so well-behaved.” I can relate to the narrator, finding comfort in gathering forms and ensuring everything is in order, even in documenting the pain. I can sense the absurd tension in deciding if the papers should be sequenced in chronological or reverse chronological order. The poem hints that there is a kind of respite, however ill-conceived, in controlling what we can control even when there exists an “an impossible rupture.”

Writing Prompt: Have you ever felt that “something is tearing, ripping open” yet you moved forward with assembling order to your life, to your medical records? How is ordering what is tangible helpful when we are bombarded by the chaos of illness? Alternatively, consider medical records. If you’re a provider, what is different about working with electronic records versus paper charts? As a patient, how do you compile your medical records? Are they neat and organized? Is there a sense of confusion or comfort when you read them? Write for 10 minutes.

 

 

 

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Ramblings

Free Write Friday: Dressing

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He brings his stack of neatly folded clothes, procured the night before, into the master bathroom. He likes to dress with Mama in the morning, inky sky evolving outside the frosted windows.

He puts his socks on first, insists they match. So I bought him twelve pairs of athletic socks, all white, identical. He can pull them up and over his calves, a satisfiable stretch.

Next is the underwear, logoed with superhero emblems, bright elastic trim. They too come in plastic wrapping, in neat sets of six or eight or ten. I never understood the “days of the week” underwear until I had children: it’s exhausting for them, for me to watch, to choose what to wear each day, even undergarments.

Next is the t-shirt; can’t be too tight on the neck, on the arms, must hang just so. He likes orange, bright colors. Pixelated hamburgers, paper airplanes, whimsical animals dance on the silk screened front. He pulls them overhead, sometimes his mousy head gets stuck, needing a tug from Mom to help his straining face emerge.

Last, the pants. He likes elastic bands: comfortable, practical. He pulls one leg through, then the other. Doesn’t bother to regard himself in the mirror; instead he rushes off to gather other treasures and accessories from his room.

He shuffles back in, rainbow suspenders in hand, clip-on tie already attached to the front of his waffle t-shirt. “Can you help me, Mama?” His legs shuffle back and forth impatiently; he wants his outfit completed. I clip on the suspenders, straighten his orange necktie. He smiles broadly, proud as he sashays into his day.

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