Ramblings

Free Write Friday: Rocks

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One day, before the cancer resurfaced, before the papery pale skin that transformed her into a childhood memory, she told the young girl that stones with a complete circle were special. She taught her how to search for them along the rocky shore, barnacles and seaweed camouflage carpeting like a mold.

They’d stroll along the Sound, down a woodsy steeped path, down from the musty cabin, faces groundward, searching for the wishing stones. Sometimes a clear white ring signaled upward, demarcated from the the concrete grey base of an oblong rock.

Decades later she teaches her own daughter: look for the one with the ring, the sign of infinity round and round. Hold it in your hand, warm it, keep it. Or return it to the ocean; give it a new life among the rolling waters.

They like to collect the different stones, squat and oblong, granular and smooth. Such varied colors from the surface of the earth. They turn them over in their hands, so different. One small and delicate with a child’s tensile skin; the other spotted, weathered from decades of existence. They each make a wish, the girl tossing into the sea, the woman holding on, relegating her hopes to her pocket.

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Narrative Medicine

Narrative Medicine Monday: The Bright Hour

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I first came across Nina Riggs’ book, The Bright Hour, because of its comparison to another popular memoir, physician author Paul Kalanithi’s When Breath Becomes Air.

Riggs was a poet, and her writing style reflects this; short chapters with descriptive elements and a musicality to the sentences that leaves us wanting more. She is honest and funny. Diagnosed with breast cancer in her thirties, a life just hitting its stride with two young boys in tow.

In describing Atul Gawande’s book Being Mortal, Riggs illuminates the heart of her own memoir “of living and dying.” She notes the attempt “to distill what matters most to each of us in life in order to navigate our way toward the edge of it in a meaningful and satisfying way.”

Riggs navigates the world of oncology and the process of dying with candor and a clear sense of self. When her oncologist discusses her case with colleagues she bristles at the standard name for the meeting of minds: “Tumor board: the term kills me every time I hear it. You’re just saying that to freak me out, I think. What is actually a group of doctors from different specialties discussing the specifics of your case together around a table sounds like a cancer court-martial or a torture tactic.”

She takes her young sons to her radiation oncology appointment in the hopes of getting them interested in the science behind the treatment. In the waiting room, she becomes acutely aware of how, taken as a group, her fellow cancer “militia” appear: “Suddenly I am aware of so many wheelchairs. So many unsteady steppers. So many pale faces and thin wisps of hair and ghostly bodies slumped in chairs. Angry, papery skin. Half-healed wounds. Growths and disfigurements straight out of the Brothers Grimm. So many heads held up by hands.” Have you ever been entrenched in a world of medicine or illness and then suddenly seen it from an outsider’s perspective?

Riggs ushers the reader into her new world as breast cancer patient. In a particularly striking scene following her mastectomy, she goes to pick out a breast form from the local expert, Alethia. “‘Welcome!’ She says. ‘Let’s find you a breast!’ She tells me that according to my insurance, I get to pick out six bras and a breast form…. The one she picks comes in a fancy square box with gold embossed writing: Nearly Me.” As Riggs’ contemporary, I could see the grave levity in the situation; Riggs is a master at sharing her experience, heartache and humor alike.

In the end, this is a memoir of a young woman who is dying. She acknowledges this and realizes that, near the end, there is a metamorphosis of light: “The term ‘bright spot’ takes on a whole new meaning, more like the opposite of silver lining: danger, bone pain, progression. More radiation. More pain medicine. More tests. Strange topsy-turvy cancer stuff: With scans, you long for a darkened screen…. Not one lit room to be found… not one single birthday candle awaiting its wish. No sign of life, no sign of anything about to begin.”

Writing Prompt: If you’ve read Kalanithi’s When Breath Becomes Air or Atul Gawande’s Being Mortal, how does their approach to writing about dying compare with The Bright Hour? Riggs comments on a kinship with the “Feeling Pretty Poorlies” she meets during her radiation treatment but because of HIPPA privacy regulations, never knows if they finished treatment or if it was “something else” that caused them to disappear. Did you ever participate in a treatment where you saw the same people regularly? Did you wonder about them after that time ended? Think about the privacy rules set in place to protect patients’ privacy. What are the benefits? Do you see any drawbacks? Write for 10 minutes.

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Narrative Medicine

Narrative Medicine Monday: Lessons in Medicine, Mortality, and Reflexive Verbs

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I “met” Dr. Robin Schoenthaler through an online group of physician writers. Schoenthaler has been universally encouraging to our growing community of novice and accomplished writers and offers practical and helpful advice. Her kind of wisdom and support is so needed in both the literary and medical worlds.

This article by Schoenthaler, published in the New England Journal of Medicine, describes her use of Spanish during her medical training in Southern California. Schoenthaler learned much of the language from her patients, notably a “young woman named Julia Gonzalez” who, admitted with acute myeloid leukemia, taught the young Schoenthaler “considerably more than Spanish nouns and verbs.” After several rounds of chemotherapy, Julia improves and is discharged. This, along with Schoenthaler’s progress in Spanish, bolsters the young doctor.

Schoenthaler recalls that in medical school she fell in love with, “of all things, reflexive verbs. I loved the concept of a verb that made the self the objects.” Schoenthaler found that reflexive verbs gave her what seemed to be a “kinder, gentler way of speaking to patients in those early, awkward days of training. It felt so much more graceful to say to a stranger, ‘You can redress yourself’ rather than ‘Put your clothes back on.'” I too remember the awkwardness, in words and in deeds, of being a new physician. So much is foreign; the medical jargon and culture, the intimacy of illness and body each patient entrusts us with.

Schoenthaler finds that trying to discuss a topic as challenging as cancer tests her Spanish language skills. Near the end of medical school she attends a language immersion school in Mexico and her Spanish improves dramatically. When she returns, her patient Julia is readmitted with a grave prognosis. Distraught, she calls her mentor and he advises: “‘Now, you concentrate solely on her comfort.'” The new doctor translates his words into Spanish, “with its reflexive verb: ‘Ahora nos concentramos en su comodidad’ (Now we concentrate ourselves on her comfort). We, ourselves, all of us.”

Schoenthaler makes it their mission, instead of a cure, to provide comfort for Julia in her last days: “I held her hand and rubbed her wrists and used my reflexive verbs. We were both speaking a foreign language.” After Julia dies, Schoenthaler calls Julia’s mother, using the Spanish words she’s learned to convey the worst of all news: “‘Se murio’ — ‘She herself has died.'” The mother’s response needs no translation.

Writing Prompt: When you were first starting to care for patients, what words or phrases seemed most awkward? As a patient, have you had medical providers use phrasing that seemed detached or confusing? If you speak multiple languages, think about the different ways sentences are formed. What gets lost or jumbled in translation? Alternatively, think about a time you had to tell a patient’s loved one they died. What words did you use? Write for 10 minutes.

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Ramblings

Free Write Friday: Beach Run

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I step onto the sand, fine and sinking under the weight of my upright frame. Feet imprint as sand spills over my running shoes, mesh fabric not immune to the elements. I hurry to where it is more compact, recent tide receding to give way to damp beach, level and accepting to the jogger.

A quarter mile down, I reach my stride, rushing Pacific to my left, chilly and predictable in the June morning fog. I like that the sound lures me to its wake, wary seagulls, dormant sand dollars waiting just ahead. The Pacific teases with its name, as if it would be peaceable, cooperative. Instead, it is a force to be adhered to, to acknowledge fully.

I nod at other joggers as we pass, feet wet, gait off from the usual city asphalt run. I don’t wear headphones, don’t rush my cadence. Running on the beach is a gift to the senses, to the muscles, sinewy body substance aligned with nature.

Ridges appear from waves past, uneven ground bumpy beneath my feet. Shallow water from recent tides remains in places. I’m used to hopping over puddles, formed after a midnight Seattle rain. But this is different, diffuse, a slight impediment, a refreshing coolness.

I pump my arms, lift my legs, admire the burn of the muscles, the arc of the tree line in the distance, knobby evergreens gesturing to the sky. At a mile and a half I turn, make my way back down the coastline. Salty sea air igniting my lungs, the gentle cushion of compact sand accepting my footprints, my mark as I travel back from where I came.

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Narrative Medicine

Narrative Medicine Monday: Titanium Seed

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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.

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Ramblings

Free Write Friday: Vaporetto

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I crane my neck to see the plastic sign mapping out the boat’s destinations as it pulls up to the dock. Circular markers dot stops marching along a primary color, like a linear road. It takes me a day to realize the N line only runs at night, the 5.1 and 5.2 don’t always drop me off at the stop closest to my hotel.

I climb aboard, daypack pulled snugly to my side, and finesse my way to the opposite railing. There is seating down below, past the nook reserved for large suitcases, for strollers. But I prefer to stand above, let the wind whip my face, my wide brimmed straw hat. Down below the sticky air suffocates, bare legs adhere to the plastic seafoam green seats. Summer vacation is no time to confine oneself to the bowels of a water bus.

Tourists on the deck lean over to capture a selfie, to catch a glimpse of the picturesque narrow canals, balconies brimming with wisteria, with dangling vines. It’s a dying, decaying city, a vestige of extravagances past. The city is sinking, its permanent inhabitants driven out by high costs and impracticalities. There’s beauty and sadness in the grandeur, in the loss, in the transformation into a spectacle for outsiders.

The more helpful attendants announce the stop as we arrive, shouting “Zattere!” “Ferrovia,” maybe even a helpful “San Marco” or “Piazzale Roma – Bus Station!” for the tourists. Usually, though, you simply have to scan your way through the crowd to find the bright yellow banners, black lettering painted on each stop, indicating the location. Much in Italy is charmingly lackadaisical. This is both refreshing and irritating to high strung Americans.

I read in a guidebook that in the evenings the vaporettos thin out: less people, less tourists as visitors return to their massive cruise ships in the harbor. But I found crowds at almost all times of day and night, the sticky sardine feeling of being packed in with weary travelers, shimmer of sweat trickling down their backs, each odor distinct but difficult to pinpoint. The evening breezes at least provide relief from the glaring sun, from the thick air. The lights of the baroque buildings bounce off the Grand Canal, reflections disrupted by gliding vaporettos.

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Narrative Medicine

Narrative Medicine Monday: Curiosity and What Equality Really Means

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Atul Gawande’s recent commencement speech at U.C.L.A. Medical School, published in The New Yorker, begins with a story. He describes an Emergency Room encounter with a prisoner who had slit his own wrist and swallowed a razor blade. Gawande found himself caring for this person who had alienated himself from many others, who experienced many preconceived expectations, given his status, as well.

Gawande warns the graduates that “wherever you go from here, and whatever you do, you will be tested. And the test will be about your ability to hold onto your principles. The foundational principle of medicine, going back centuries, is that all lives are of equal worth.”

He asserts that there is a gap in the care that people receive, whether that disconnect be due to “lack of money, lack of connections, background, darker skin pigment, or additional X chromosome.” Have you noticed this in your own medical practice, in your own life? How did this injustice make you feel?

Do you agree with Gawande that, as medical professionals, we have a “broad vantage” of this issue? Do you also agree that “[w]e all occupy our own bubbles?” How have you seen this manifested in individuals and society as a whole?

Gawande argues that we should regard all people as having “a common core of humanity.” In order to put ourselves in others’ shoes, we need to have a certain curiosity, as Gawande does about his prisoner patient. Despite the way the patient threatens his chief resident, Gawande engages with the patient. He learns that “[i]n medicine, you see people who are troublesome in every way: the complainer, the person with the unfriendly tone, the unwitting bigot, the guy who, as they say, makes ‘poor life choices.’ People can be untrustworthy, even scary… But you will also see lots of people whom you might have written off prove generous, caring, resourceful, brilliant. You don’t have to like or trust everyone to believe their lives are worth preserving.”

In my ten years in practice, I have certainly found this to be true. I agree that, above all, remaining curious about others is the key to understanding, the “beginning of empathy.” As medical professionals, we are “given trust to see human beings at their most vulnerable and serve them.” That trust is sacred, should never be forgotten and should inform our every attempt to serve “all as equals” and cultivate “openness to people’s humanity.”

Writing Prompt: We all train, and many of us work, in hospitals. Gawande notes that hospitals “are one of the very few places left where you encounter the whole span of society.” Think of two encounters you’ve had in a hospital with people of backgrounds from different ends of a spectrum. Write about your interactions with each of them. Alternatively, think about what gives you status, or lack thereof, in society. How have you been treated by medical professionals? Do you think your experience would be different if you were a C.E.O. or a cabbie? Why or why not? Write for 10 minutes.

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Ramblings

Free Write Friday: Campo San Polo

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Young children scamper across the square chasing balls, bold pigeons and unsuspecting tourists. I sit on a lacquered red bench under a low leafy tree, oblong salmon colored berries just beginning to sprout from its branches. The cover from the high afternoon sun is welcome.

Tourists stroll past with their Burano lace fans, their high-end shopping bags. A man with a walker all dressed in white leans forward as if about to fall over, as if about to kneel in prayer. A child sleeps in his mother’s arms as she reclines on the steps, a yellow bike leaning against the stone structure.

I should move on, get going. But it’s pleasant here, if a bit too noisy. I hear Italian and Russian dialects, I think. The occasional English words from a British or American tourist are too distracting but a foreign language doesn’t have the same effect; the musicality of their native tongues almost a background nicety.

Grey stones of irregular shapes make for uneven ground. The two boys jostling for a soccer ball, bouncing it against the sepia brick buildings, don’t seem to mind.

An elderly man shuffles across the square wearing cushioned sandals, a sky blue plaid cap. He turns, just barely, and shakes his head at something, I don’t know what. Maybe the crying child, maybe the rushed tourists. Maybe his own arthritic knees that are clearly causing him pain. He pauses for a moment as he looks over his shoulder, as if he’s taking it all in, as if he’s remembering something. Then he straightens, and hunches, and realizes it’s time to move on.

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Free Write Friday: Trapeze

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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.

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Narrative Medicine

Narrative Medicine Monday: Narrative Humility

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“Telling and listening become an antidote to isolation, a call for community.” – Sayantani DasGupta

Dr. Sayantani DasGupta is a leader in Narrative Medicine and faculty at Columbia University. What is narrative medicine? DasGupta explains it this way:

“Narrative Medicine is the clinical and scholarly movement to honor the central role of story in healthcare. Long before doctors had anything of use in our black bags—before diagnostic CAT scans, treatments for blood loss, or cures for tuberculosis—what we had was the ability to show up and to listen; to stand witness to birth, death, illness, suffering, joy, and everything else that life has to offer.”

In this TEDx talk at Sarah Lawrence College and in an essay in Creative Nonfiction on the same topic, she expands on the concept by describing narrative humility:

“Narrative humility means understanding that stories are not merely receptacles of facts, but that every story holds some element of the unknowable.”

DasGupta asserts that “listening to another person is an act of profound humanity; it is an act of profound humility. This is particularly true at those charged moments of illness or trauma, change or suffering.” Have you found this to be true, either as a patient or as a medical provider?

In a healthcare system plagued with burnout, DasGupta argues that narrative humility, learning to listen well to patients, can “deepen medical practice, bringing satisfaction and joy back to an ancient profession that is so much more than a business.”

Writing Prompt: Do you agree with DasGupta that we need to “once again train clinicians to elicit, interpret, and act upon the stories of others, that we hold in equal stead multiple ways of knowing—the scientific and the storied, the informational and the relational?” Why or why not? How can we do this? If you’re a medical provider, were you taught how to listen in your training? Have you considered the concept of narrative humility? Do you think it’s possible to practice this way in today’s healthcare system? Write for 10 minutes.

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