body – MARY PAN

Narrative Medicine Monday: Throat

November 18, 2019 No Comments

Gabriel Spera writes of how our body changes in sinister ways in his award winning Bellevue Literary Review poem “Throat.” Spera speaks of how aging can alter a previously cherished reality, in this case, a love of food: “… life takes or twists what we hold most dear, / the heart’s fire of youth swapped for the heartburn / of middle age, which ends each feast at the medicine chest.”

In the midst of these bothersome symptoms, Spera’s friend gets difficult news: “She spoke bluntly, the doctor, as though hiding her chagrin / at all the time they’d wasted chasing red herrings— / ulcers and reflux, bacterial infection. They’d begin / with the chemo right away…” This is a constant fear, a threat with any ailment. During a visit, I often ask patients what they are most concerned about to ensure I’m addressing whatever issue weighs heavily on their own mind. Sometimes I’m surprised at their response, their occupation with a worry I would not have considered in the differential of likely, or even possible, causes. Often there are concerns about the least likely but most serious cause of a symptom: a headache is a brain tumor, a cough is lung cancer, a skin change is melanoma. Most of us have a tendency to worry about the worst case scenario.

In this case, the man is eventually diagnosed with that worst case —cancer. Spera’s lyrical descriptions of the ensuing treatment are infused with detail. The IV bag of chemo: “The tube: a string gone slack without a puppeteer / to tug it, a sleeping viper, a vine, a spill / of vermicelli, a nematode keen to disappear / into the cool earth of his arm…” The radiation is “like a cluster bomb / of atom-sized suns. Then the fallout, the scorched earth / of his flesh, the fatigue, the itch of skin too numb / to scratch.”

The reader is transported into this suffering body, the treatment itself causing “A backlash, a body blow: What stunted the tumor stunned / his muscles, his neck’s whole scaffold rigidized / like leather left to the mercy of the sun…” Within the details of this devastating illness and its treatment lies broader truths. Spera reflects that “Sometimes, what leaves us frees us, and what remains / holds soul enough…” Ultimately, the conclusion is that “despite conflicting evidence, / even the least life is worth what it inflicts.”

Writing Prompt: When there is a recurrence of cancer, the patient questions if “He’d had enough, or rather, no longer had / enough to keep losing chunks of himself, ill-equipped / to envision any future worth suffering further for.” Have you had an illness that caused you to question if you’d had “enough?” Have you had a patient who told you that they’d had enough? What does “enough” mean? Write for 10 minutes.

Narrative Medicine

Narrative Medicine Monday: History Taking in the Anatomy Lab

May 13, 2019 No Comments

Bethany Kette writes about “History Taking in the Anatomy Lab” in the latest issue of JAMA. Kette describes how in medicine we almost always start with the history of the patient, then move on to the physical exam. Kette notes though that “there is one time in our medical careers when we are instructed to perform the most thorough physical examination possible without learning so much as the patient’s name:” that of dissecting a cadaver in anatomy lab.

Now, fifteen years removed from that anatomy lab and ten years into my primary care medical practice, I can attest to the value of history-taking in a relationship developed over time: “It is a closeness and privilege that can provide purpose and meaning to routine acts of medical care.” Yet as medical students learning anatomy through the very intimate process of dissection, we receive very little information about our donors, only their age and cause of death.

In order to better understand the life of the woman who donated her body, Kette created the Obituary Writing Program at Georgetown. Kette developed the program with input from the Literature and Medicine Track director (how great that this is a track in a medical school!) and an obituary writer for the Washington Post. The result allows interested medical students to craft a real narrative about their donors, discover stories “that reveal a life.”

Kette interviews her donor’s son and learns that the woman was a “small-town farm girl” who graduated from Georgetown University School of Medicine: “She had literally stood in my footsteps in the same formaldehyde-scented labs in which I had spent the past year with her as my teacher.” The woman eventually retired from medicine to become a painter and was a “devout Catholic;” her faith informed her drive to help others. The medical students who participated in Kette’s program read the obituaries they had written during a ceremony at the end of the year, part of expressing gratitude to the donors themselves and to their loved ones for the gift of the donor’s bodies.

Kette’s program puts “history in its rightful place before the physical— students now interview the families of their donors before making the first cut in anatomy lab.” It also serves as a reminder to those of us well into medical practice that a person’s rich history, their life lived outside the hospital bed or exam room, is what we’re striving in medicine to help them return to, and what matters regarding their health, in the end.

Narrative Medicine

Narrative Medicine Monday: Leaving the Body

January 7, 2019 No Comments

Author Lisa Knopp shows how we can be drawn to the presence of a body even following death in Hospital Drive‘s “Leaving the Body.” After her mother dies, Knopp lingers in her hospice room, asking to stay as a woman enters to wash her mother’s body and ready her “for the people who are coming to pick her up soon.”

Knopp initially wonders about “the point of bathing my mother, since her body will soon be ash.” The nurse’s aide speaks to Knopp’s mother as she wipes her face and arms. Knopp finds this “comforting, this informing my mother of what’s about to be done to her, since I can feel that something of her is still here.”

When the aides remove the woman’s gown, Knopp is filled with wonder at her mother’s naked body. “Even though she would feel shamed by my scrutiny, I want to savor and memorize the details.” This body holds memories for Knopp, the substance of a mother-child relationship, connection: “I know their shape so well: large knee bones, slightly bowing calves, like those of her mother, and thick ankles. Just below her right knee on her inner calf is a blue vein, an inch or two long that has been there as long as I can remember.”

In these moments right after her mother’s death, Knopp finds herself “starving for her physicality” and tells the aide she’d like to touch her mother. She kisses her forehead and strokes the top of her head and wonders, “What is it that I’ll be missing now that my mother’s heart has stopped beating, and she’ll soon be turned to ash?” Her mother has died, but Knopp is still drawn to her physical body, the familiarity of her mother’s form that will cease to exist. Knopp shares that her greatest regret will be that “we didn’t spend more time in each other’s physical presence” and that this final sponge bath is her “last chance to see and touch and smell my mother, flesh of my flesh, my first home.”

Knopp recalls all of the beautifully mundane things she and her mother chatted about on the phone, though they rarely discussed her cancer or the grander questions Knopp yearned to ask her dying mother. The loss Knopp highlights in her essay isn’t so much about the flesh itself, but more about her experience of her mother that was contained in that body: her “voice, words, thoughts, laughter, and silences.”

Knopp reflects on the waning importance of physicality in our modern world, how the dean of her college encourages faculty to have more screen time and less face time with students, how so many interactions with friends are via social media and not in person.

At the end of the essay, Knopp combs out her mother’s hair, braids it with care and cuts a lock of hair as a token. Knopp is unsure what she will do with the lock of hair, but the gesture seems satisfying in the moment, keeping “more than just memories of her body” before they wheel her away.

Writing Prompt: If you’ve been present with a dead body, either a loved one or a patient, what did you experience while in that space? Was it difficult? Healing? Both? Did you feel drawn to touch the body, as Knopp did? What are your thoughts about Knopp’s observation that we spend significantly less time face-to-face? How do you think spending less time in the physical presence of others might affect us? Write for 10 minutes.

Narrative Medicine

Narrative Medicine Monday: Titanium Seed

June 25, 2018 No Comments

Poet Judith Skillman’s “Titanium Seed,” published recently in the Journal of the American Medical Association, describes the new “part of flesh inside” that is hers “to carry through / airports, not setting off / any alarms, they assure me, / not anything other than / a placeholder for cancer.”

She depicts the experience of getting a breast ultrasound, “the technician rubbing her wand / over and up hills of black / and white.” Skillman’s poem illustrates the anxiety associated with waiting for a diagnosis, the uncertainty of the pause that occurs after an aberrancy is found but before a definitive answer is revealed.

The seed represents an alteration of Skillman’s body, this reality of the possibility of cancer she harbors in her flesh unseen. She outlines how the patient is at the mercy of the medical diagnostician, describing how she lies “between two triangle pillows – / placed like an offering / to this Demi god who may / or may not find what appeared / on his screens.”

Writing Prompt: Think of a time you had a biopsy or lab test or imaging done and had to wait for the results. Sit in that space of uncertainty. Describe the experience. Did colors return, as they did for Skillman, when she receives a benign diagnosis? How did knowing contrast with the period of waiting? Try writing about this space of waiting from both the patient and medical provider’s viewpoint. Write for 10 minutes.

Ramblings

Free Write Friday: Trapeze

June 8, 2018 No Comments

I arrive first, check in. Dark paneled walls open into a large central space. Elevated platforms flank either end, steel ladders climb toward the beamed ceiling. A roped net cradles the entire space, bordered by a balcony for onlookers. I imagine a medieval theater, a galley of spectators, gaping at the show below. It reminds me of Shakespeare’s Globe Theatre, remade in London along the Thames, just meters from the original.

It is a show, after all, a novel experience. I see a group of girls taking turns, climbing the ladder, swinging on the suspended bar, hanging upside down by their knees, then letting go, trusting they will be caught by the professionals mirroring their trajectory. My friend appears at my side. We watch them in awe for a moment, then agree: they must’ve done this before.

Our turn. We line up with our fellow students, five of us inching into middle age: mommas and businesswomen, divorcees and professionals. On the wooden bench in front sit five preteen girls, emerging into adulthood, a Girl Scout troop on the rise.

They fit us with belts, like corsets. (“You wouldn’t want to slip out of it,” the instructor warns as she pulls the belt tighter.) I can’t breathe but I can’t tell if it’s the mental anxiety or the physical constriction causing my respiratory distress.

The women make nervous chatter as the girls listen attentively to the instructors. Why didn’t we just go wine tasting? We haven’t swung on monkey bars in decades. “Listen up!” One of the teachers admonishes us. They review how to hold onto the platform scaffolding with one hand and grip onto the trapeze bar with the other. We stand barefoot on a wooden beam a foot off the ground to simulate the platform. We learn to lean forward, bend our knees, take a leap at command.

“As soon as we say ‘hup,’ you jump.” I wonder why they don’t say “go” or “jump,” but “hup” does seem fitting somehow. It’s how I feel: a quick inspiration, like I’m about to dive underwater, like I’m sucking in to get that corset on, like I’ve just been frightened or surprised to an extent that breathing in and out in normal cadence is no longer possible. “Hup.”

She explains that really all we need to do is follow their commands. Do the right action at the right time and all’s well. “Hup!” We jump, we swing. “Knees up!” We pull our knees up and over the bar. “Hands down!” We let go, arch our back, squeeze our legs to the bar. “Hands up!” Grab the bar again, swing our legs back through. “Then you just tuck your knees when I tell you and you’ll naturally go into a backflip, landing in the net.” I think: natural and backflip are not two words I’ve ever used in the same sentence.

We shift nervously from side to side, glance up to the net, to the platforms above as she speaks. It seems unlikely that we’d accomplish all she suggests with the right timing, the correct cadence. “If you do everything at the right time, in accordance with our prompts, you’ll hear this sound.” She rings a cowbell attached to a large beam. The sound reverberates through the hall. My mouth is dry. “If you get a cowbell before the last half hour of class, then you can try for a catch with the instructor.” One of her colleagues, wearing a T-shirt and short leggings waves her hands at us amicably.

“Well, that’s it. Let’s get started.” We look at each other, confused, mouths still gaping from the prospect of “catch.” We’ve had about five minutes of training. They want us to just get up there and do that?

Thankfully, they’ve already assigned a lineup, with the Girl Scouts going first. I figure, we’ve given birth, we’ve survived medical school, we’ve cared for multiple tantruming toddlers; we can do this.

I thought the height would be the issue, looking down from above, the prospect of having to let go. But it’s not the height that gets me; it’s the performance, the need to listen, to follow directions, to do what she says – the expert – holding the rope far below, tethered to the belt that constricts, that saves.

I climb the ladder, sweaty palms, beating chest. I make small talk with the instructor on the platform who unhooks the carabiner attached to my belt from one rope and secures it to another. She hands me the bar. It is weathered, wrapped in white tape, frayed all around from gripping hands over months, maybe years.

“Lean forward.” She’s holding onto my belt from behind. I’m to grab the bar with my other hand, let go of the platform scaffolding. Trust. I hesitate, then follow the command. “Good, now belly forward.” I protrude more, the safety belt digs in.

“Okay, now bend your knees… Hup!” Knees bent, I hesitate. Can I do this, just jump? “Hup!” She says it again, into my right ear. I hear her. It doesn’t compute. Something doesn’t compute. I look down at my red toes, freshly pedicured on an outing with my seven year old daughter the day before.

“Hup!” This time I leap, free flying, not falling. I’m soaring forward, arcing across the air.

“Legs up!” I hear it from below but I’m already moving, too early. I jumped the gun, didn’t wait for the command. I did that at track meets sometimes in high school. Spiked shoes aligned just so in the starting blocks. At the ready, all set, then GO! Too fast, too jittery, I anticipated and missed.

In trapeze, anticipation is to your detriment. The timing off, the trajectory all wrong, I struggle to get my legs up and over. Finally I do, muscles burning. “Okay, hands off!” My hands loosen, then drop unceremoniously. I am a wet noodle. I am hanging, undone.

“Okay, grab the bar again. Legs down. When I tell you, you’re going to tuck your legs and you’ll backflip into the net.”

Still skeptical, I consider rebelling, like one of my predecessors. Just let go and fall straight down, as if into a river from a rope tree, feet first, nose plugged. But instead I follow directions this time, tuck in my knees and, wonder! I’m flipping! I fall back into the net with a smile on my face.

***

I’m one of only four to achieve the coveted cowbell, the last of the group to do so. One of the instructors quickly pulls me aside to go over the drill. All the same sequence, but after I let go of the bar with my hands I arch my back, thumbs out, hands shaped like an “L,” and look behind me, towards the instructor who is swinging from the other platform, ready to catch. When she says so, I straighten my legs and fly. No reaching for her, nothing left for me to do. All I need is to follow instructions, release from the bar when it’s time.

It sounds so simple, so elementary. And when I watch the girls before me do it, arms chalked up, faces eager, it is. As I climb the ladder, I sense eyes on me, I sense heart pounding, I sense performance, a desire to succeed.

My first attempt I fall. I don’t arch my back enough, I’m looking down, not behind me where I should. My left calf hits the bar on the way down. Instead of grasping me, the instructor’s hands splay open, empty and reaching. I fall into the net, disappointed.

“We have time for one more try each.” I rub my sore Achilles as I tumble off the net. I have to try. Just one more.

As I climb the ladder, I think: Is this stupid? What if I’m really injured? What if it’s my Achilles? I have a long-planned trip to Europe, leaving the end of the week. What if I need surgery? But I can’t let it go.

I empty my mind. Everyone is watching. I’m the last one. One of the Girl Scouts yells from the galley, “Go, Birthday Girl!” I let it all go. I listen. “Hup!”

And it’s seamless, the flying. “Knees up!” “Hands off!” “Legs off!” I don’t reach. I don’t worry. She catches me and I soar.

Narrative Medicine

Narrative Medicine Monday: Anatomy Lesson

January 8, 2018 No Comments

Poet Nellie Hill illuminates the process of learning anatomy in her Bellevue Literary Review poem, “Anatomy Lesson.” She notes that to “understand the heart you’ve got to memorize…” I remember searching for ways to memorize, as one professor put it, the “firehose” of information required as a new medical student. Anatomy is especially daunting, with all the blood vessels, nerves, muscle origins and insertions. Dissecting cadavers in anatomy lab is a rite of passage for every medical student, but we also drew pictures, color-coded organ systems, made up songs and stories to help us remember the essential information that is the human body. Hill starts with memorization, but takes the reader on a journey down the “snake path” of the body “to where thoughts become memories or dreams.” I like the imagery of “anatomy stacked like a ladder from your toes” and how Hill hints that the functional organ itself may also hold an intangible purpose.

Writing Prompt: Think about when you first learned anatomy. Even if you’re not in the healthcare field and never took a more intensive course in the subject, we all learn about basic bones and organs as children. Did learning about anatomy help you to see the body, and your own body, differently? When was the last time you thought about anatomy? What are your thoughts on how the physical body or certain organs might be connected to a greater or hidden purpose (acupressure points, the mind-body connection)? Write for ten minutes.

Narrative Medicine

Narrative Medicine Monday: The Permanent

September 4, 2017 No Comments

In “The Permanent,” Amy Burke Valeras takes us back to the 1980s when perming your hair was a thing. In the first half of the poem, Valeras opens up about her struggle with her hair; I could relate. I similarly begged for an ill-advised perm the same year, the same age as the author. I like how Valeras makes her hair a central character of the poem. We battle along with her preteen self as she tries to tame the “frizzy poof.” We can understand when, two decades later, she is told she has cancer but all she can think of is: “My hair!”

Writing Prompt: Think of an every day aspect of your life, of your body, that you took for granted or had a different relationship with until you became ill. Consider level of energy during a bout with the flu, walking with a sprained ankle; maybe you have lost your hair to chemotherapy or a breast to invasive cancer. Write about your relationship with this aspect of your body before you became ill and after. How did things change? Write for 10 minutes.

Ramblings

Free Write Friday: Pain

June 16, 2017 No Comments

I notice it gradually, while exercising one morning. It’s a familiar routine, but that day bending over to touch the floor, leg lifted behind, I can’t hold the pose and my back gives way. The pain is insidious, then persistent. I go to work, hobbling throughout my day. Coworkers ask: What happened? Do you need something? Then they suggest: Try my chiropractor. Try downward dog. Here’s a hot pack. This is the only thing that helped my sciatica years ago. They’re all trying to be helpful but I can only wince. I can hardly walk. The pain is shocking, debilitating.

As a physician, I see people in pain every day. Pain from overexertion, pain from chronic illness, pain from medication side effects, pain from heartache. But to experience it myself, the slowing of body, the unexpected twitch of muscle with a movement, the limitations imposed by a body that isn’t working as it should, by a body that is a conduit for pain rather than a vessel for function: it’s humbling.

I don’t exercise for a week, then two. It’s hard to explain to others who only see me as able-bodied. They don’t realize. I shuffle as I cross the street; my husband and children walk casually ahead, so far ahead, on the crosswalk. I feel slow, I feel invalid. I get massage therapy, apply heat therapy, ingest ibuprofen religiously. The pain, initially searing in my back, flares unpredictably, shooting through my hip as I rise from sitting, as I twist to respond to a question, as I bend to pick up my baby from her crib.

A week into the flare, I just want to lie in bed, not get up, not go out. Though I am loathe to just lie there. I resent the creeping sluggishness. I want to defeat the lethargy and, simultaneously, be enveloped in it. I can suddenly see how people succumb: to numbing medications, to despair. Pain steals all functionality until the pain is all that’s left. And then it becomes your only companion. It is a cruel tease. One day or moment might feel a bit better, hope rises. Then, cruelly, it dissipates as the pain roars back.

One day I wake and can sit up without wincing, can walk with only a slightly antalgic gait. Everyone asks: How are you feeling? I feel tentative. I feel better. I feel anxious that it might come back, might return to level me again. I’ve learned now, it’s taught me. Pain is a presence, but also a thief.

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