Aunt Rachel’s Blessings

My friends, it’s been an intense couple of weeks!  So much so that I have fully neglected the news headlines—this must be why I’m still in a reasonably good mood.  Another is that I have rediscovered Dr. Rachel Naomi Remen, the wise and benevolent matron of medicine whose gentle and gracious example I aspire to follow.

I first read her books, Kitchen Table Wisdom and My Grandfather’s Blessings, at least ten years ago by now.  They felt like my favorite plush blanket, draped over my shoulders with that welcome, comforting weight, and tucked under my feet, warming me with stories of love and belonging.  Life was just as hectic then as today, but in a different way.  The kids were little, and I had few if any responsibilities at work outside of patient care.  Aunt Rachel’s stories calmed me and gave me peace in that young chaos.  I had meant to reread them, but, well, life.

I perused the shelves and stacks of my personal library recently, searching for a book that my friend might like.  Both avid readers, we share and discuss titles on leadership, philosophy, and personal development.  The search this day felt different from browsing Amazon or my local book store.  A deeper part of me knew exactly what I sought for my friend, even as my conscious mind had only a vague idea.  I wanted to share something different with him, something less cerebral.  As soon as I saw it, I settled on My Grandfather’s Blessings, no question.  But after a day or two, as often happens with instantaneous intuitive decisions, I did question.  So I sat down with the Aunt Rachel and her grandfather one evening, as if meeting old friends in a cozy, familiar café.  After some years of listening to books rather than reading them, I find quiet sitting with a paper book so comforting now.  I am called to slow down, to be still, more than I have been (have allowed?), for a very long time.

By page two of the introduction, my doubts vaporized.  This is it, I thought.  Stories of humanity, history, culture, medicine, healing, perspective, and how we humans are intertwined with one another and nature in the most beautiful and cosmic, inescapable and daunting ways.  As I reread her grandfather’s wise sayings, his subtle yet unmistakable messages of reassurance and unconditional love, that familiar warmth enveloped me again.  I could almost feel my blood pressure drop, my oxytocin level rise.

So much love and connection—the book is really all about relationships, which my friend and I both hold as the key to a meaningful life.  As I continue to read this week, it occurs to me that perhaps I was not actually looking for a book for my friend, but rather for myself.  For many years I have hunted ravenously for books to teach me, to elevate my performance in parenting, doctoring, leading.  But Aunt Rachel’s books simply soothe me.  They acknowledge and give credence to that still small voice that advocates for and validates the need for deep personal connection, in a world that values it less and less.

I wonder if reading Aunt Rachel’s books so early in my career helped me more than I knew.  Looking back on the past decade, I feel proud to have resisted the pressure of 15 minute clinic visits, to have made the effort to relate as personally as I could with every patient, even if my bids were rejected.  Aunt Rachel’s books honor that heart center in me that holds true to what I value the most, which is connection with people.  Perhaps I have her to thank for watering the strongest, deepest roots of my doctor soul before they could dry up and later require excavation to revive?

I still think my friend will enjoy Aunt Rachel’s book.  Her stories resonate with the humanity in all of us, not just doctors and patients.  I look forward to hearing his feedback, and finding more books to share.  And I must remember to bless our friendship.

May we all acknowledge and share the blessings in our lives, every chance we get.

How Reunions Feed Us

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It was July 1997.

Maria C. and I had just started our third year of medical school, rotating on general surgery.  We stood on evening rounds–it was already dark outside on this balmy summer night.  The hospital hallway was quiet and half the lights were off.  We visited a little old lady who had had surgery in the prior days.  She looked frail, but also like she had been spry once.  Her lips protruded the way my grandmother’s did when she took her dentures out at night.  She wore a round fuchsia sleeping bonnet, a little askew atop her head.  She looked half asleep, barely aware of our presence, and had slid down in the bed such that the pillow and blankets had effectively swallowed her.

We were tired, Maria and I.  It was not a fun rotation for me.  I had witnessed our attending throw a bloody sponge across the OR that month.  He was not particularly interested in us, I don’t recall any direct teaching (but there could have been), and the sleep deprivation was killing me.  But I had Maria.  She always had a smile, always an encouraging word, and she loved surgery.  Her energy held me up.  We stood dutifully, trying our best to pay attention and learn something.

As we listened to the discussion of the nice lady’s plan of care, suddenly I heard a loud, resonant, and prolonged PPPPPPPTHTHTHTHAAAAAARRRRRRRRTTTT.   Our somnolent charge had just passed the longest breath of colon gas I had ever heard, before or since.  And it didn’t phase anybody.  The team continued to discuss her plan of care as if nothing had happened.  I don’t know, maybe they were encouraged, as flatulence is the first step to oral feeds and eventual discharge after abdominal surgery.  They forged on without acknowledgement.  I wondered if I had imagined it.  But when I caught Maria’s eye, within seconds we could both barely contain ourselves.  Maybe we were just slap happy from too little sleep, or we just needed something to break the tension.  But it was too much, we had to step out.  Back out in the dim hallway we laughed out loud as quietly as we could, to the point of gasping for breath, hanging onto the wall and each other to keep from falling down.  Even today, 22 years later, I cannot help but smile at that moment.  Either we went back inside after composing ourselves, or the team emerged eventually, I don’t remember.  Rounds continued and I tucked away this little memory as one of the best bonding experiences of all my years in training.

*****

The Class of 1999 returned to The University of Chicago this past weekend to celebrate 20 years since graduation.  I had only signed up for a couple events, in my usual non-committal way.  I arrived at the breakfast venue, a building that did not exist when we were students.  I glanced over at the tables and saw only people much older than me, and my heart sank a little.  Where were my peeps?  Then at a back table an old friend stood up and waved, and my spirits lifted instantly.  We ate and laughed, and shared photos and anecdotes of surly teenagers at home.  As I had made no other plans that day, I met people again for lunch and we walked through campus, which I had not done in years.  The peonies in the quad burst with color and fullness, welcoming us all back.

I’m so proud of our class.  We are general internists and pediatricians, hospitalists, cardiologists, allergists, emergency medicine doctors, and orthopaedic surgeons.  We do neurologic interventional radiology, microvascular plastic surgery, and private equity.  We are medical directors, section chiefs, and NIH researchers; we teach medical students, residents, fellows and colleagues.  We advocate for immigrant health and lead international research teams to win the war on disease.  We are parents of toddlers and college students, single, married, and divorced.  But mostly we are just older versions of our younger selves, in love with the science of medicine and driven by something deeper within to care for our fellow humans, relieve suffering, and make the world better for our having lived.  This weekend gave us the opportunity to reconnect deeply on that level, to recall and relive those bonding memories tucked away all these years.  I had a chance to catch up with classmates whom I had always wanted to know better in school.  What a blessing.

Our specialties are widely diverse, as are our life experiences, before and since medical school.  But we also share so much in common.  Many of us have had painful experiences as patients or family of patients, and that has impacted our attitudes as physicians.  We collectively recall the stages and transitions of training as both trial and reward.  And everybody has something to say about the current, broken state of American healthcare.  But the overarching feeling of the weekend was camaraderie and love.  Emails poured in from classmates across the country and around the world who could not make it back; I count almost 60/100 of us included in our communications thus far.  We were just waiting for the chance to find one another again.

*****

In our current geopolitical climate of division, competition, and polarization, reunion is the antidote.  In this vital ritual of humanity, we reconnect with those who knew us in a more innocent phase of life, when we bonded through shared struggle, with whom our diversity and shared experience are paradoxically complementary in the best ways.  Our souls are fed by one another, in person, surrounded by food, back at our first professional home.  Relationships long dormant stand revived, and we are lifted.

It occurs to me, in this lovefest of reconnection:  How can we leverage this energy?  What if we could sustain these bonds, reforged and hot in this moment?  If we connected like this more often or regularly, across specialties, geography, and practice structure, how much better could we all be at what we do every day?  How much more empathy could we have for those who don’t do what we do, whom we see as competing for resources or otherwise trying to undermine us?  How would our patients feel in our presence?  Our support staff?  Our hospital leaders?  Gatherings like this prove that we have the capacity to just be together, appreciate one another, and support each other with generosity and grace.  So much potential for positive synergy among this group.

We have big plans for our 25th reunion, but I have a feeling our renewed relationships will find powerful expression long before then.  So stay tuned, my friends.  We are Pritzker Class of 1999, and we’ got work to do.

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A Community of Champions

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Spoiler Alert:  Big Bang Theory Series Finale!

* * * * *

When was the last time you felt totally safe, at work, to address the central relational challenges that hold you and your team back from your best performance?

How often at work can you really assess and evaluate your own interpersonal skills, their impact on those around you, and on the organization as a whole?

How much time and energy do your teams waste being stymied by relational issues, stuck in redundant, dysfunctional power struggles up and down the organizational hierarchy?

How do you feel in your body just reading these questions?  Perhaps tense and frustrated?

* * * * *

We, the eight participants and two faculty members of Leading Organizations to Health Cohort 11, reported palpable heaviness upon convening for our second training retreat last Tuesday.  Despite the Colorado spring bursting with blooms, wildlife, and vast clear blue skies, dark clouds hung over our collective consciousness, each for our own reasons.  Throughout the week we shared stories of successes, challenges, conflicts, power and powerlessness.  We practiced appreciative inquiry and relational coordination, and explored the insidious impact of unearned privilege.  We spent three days in intense skills training, supporting one another through viscerally gnarly role plays and open, honest feedback about how we impact the group.

In the midst of all this deep work, we also shared meals, walks, a horseback ride, and life stories around a fire pit and drippy s’mores.  As we debriefed around the circle on the last day, something had shifted:  overall we now felt refueled and energized.  The air buzzed with the anticipation of learners on the verge of integrating our emerging skills, excited to bring it all home to practice.  The clouds had parted.  We will keep in touch through peer coaching groups—our newly established, intense-support network.  In my heart, I feel we are really becoming a family.

 

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I headed to the mountains straight from the session, for 24 hours of processing and decompression (and more washi tape card-making).  More and more I marveled at what a rare opportunity I have in LOH, to be led and learn to lead in this relationship-centered way.  For these ten months I am immersed in a professional learning lab, experimenting with different ways of speaking, acting, and being, safe among fellow professionals also grappling with this skill set.  It just does not get any better than this!

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On my way down from the mountains, I listened to an interview with Bonnie St. John on Ozan Varol’s podcast, Famous Failures.  She is the first African-American to win medals in Winter Paralympic competition as a ski racer; she is a lower extremity amputee.  She is also an author, an entrepreneur, and a former member of the Clinton administration.  Her story is inspiring, please take a listen!  At the end of the interview she describes asking a former coach about how he built champions.  He said he never built individual champions; rather, he built communities of champions.  You can only push one person so far, he said; but an allied group of people will hold one another up, push each other harder, make each other better, take one another farther.

That is exactly how I experience LOH—my best self is challenged and called forth in the most loving and professional way.  We hold space for all our struggles, allowing the learnings (epiphanies, in my experience!) to emerge.  It is deeply and literally inspiring.  Though I already do so much of this inner work on my own, there is a profound and unparalleled synergy from learning in this group—we serve as one another’s pit crew for the journey toward our better selves at work and in life.

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Nobody succeeds alone.  In the series finale of The Big Bang Theory (my favorite TV show of all time, which I missed while at LOH!), Sheldon (the obliviously self-centered genius) finally realizes this.  During his Nobel Prize acceptance speech, he acknowledges his sudden and profound appreciation for his family and friends, crediting his success to their unconditional love and support, and recognizing them in front of an international audience.  LOH made this finale even more meaningful to me than it already would have been.

It is always through the struggles that we grow.  When struggle together, any and all successes are amplified exponentially.  My nine new friends will make me immeasurably more successful, both professionally and personally, than I would ever be without them.  God bless them all, and may the work we do together ripple out for the benefit of all whose lives we touch.

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Elephant to Elephant:  How to Change People’s Minds

 

Friends!!  If you read only one thing today, stop here and click on this link to James Clear’s essay on why facts do not change minds.  It’s very similar to Ozan Varol’s post of a similar title from last year.  That piece prompted a prolonged conversation on my Facebook page two months ago, which I described and shared here.

The Trigger

I’m thinking hard again about facts and changing minds now, as the number of new measles cases skyrockets not just in the US but around the world.  I’m so angry that we have to fight his war again—a war we had won as of 2000.  I’m so frustrated that because of the actions of a relative few, the health and safety of the very many and vulnerable are once again at risk.  I know my colleagues and many in the general public share my sentiments, and we often end up shaming and deriding our ‘anti-vaxxer’ peers.  We hurl facts and statistics at them, incredulous at their intransigence to the truth of science.

In the end everybody digs in, feelings get hurt, relationships suffer, and the outbreaks progress.

There is a better way.

James and Ozan (I imagine them as friends and so refer to them by first name) explain it eloquently in the posts I share here, and I really encourage you to click on those links.

The Metaphor

Personally, I return often to Jonathan Haidt’s analogy of our mind as an elephant (the emotional, limbic brain) and its rider (cognitive, rational brain).  We think, as rational beings, that our riders steer our elephants.  But psychology research and evidence tells us that the elephant goes where it wants; the rider rationalizes the path.  That is why facts do not change people’s minds—they are the rider’s domain.

Chip and Dan Heath, in their book Switch, take Haidt’s idea further in their formula for behavior change:

  1. Direct the rider (provide the facts, rationale, and method),
  2. Motivate the elephant (make the message meaningful on a personal, emotional level), and
  3. Shape the path (shorten the distance, remove obstacles).

It occurred to me recently that when I flood you with facts about measles and vaccines, I speak only through my rider.  You listen (or not) as both rider and elephant.  But as Simon Sinek describes eloquently in Start With Why, the elephant limbic brain has no capacity for language.  And facts, conveyed in words, have no emotional meaning or context.  So unless your rider is somehow really driving in this moment, my rider’s appeal will not move you.  Your elephant does not understand my rider, thus I cannot steer you where I want you to go.

The Approach

So how can I motivate your elephant?  If I’m using words, I can tell a story.  But the words of any story matter far less than the emotions the story evokes.  If I can relate with your own past experience, point you to a loss, a gratitude, or some shared connecting experience between us, then your elephant may hear me.  If I tell my story with honesty, authenticity, and humility, then my rider serves as translator for my elephant, communicating directly with your elephant.

But the most important connection between our elephants, if I really want to change your mind, is my presence.  Researchers agree that a vast majority of communication, up to 90%, occurs non-verbally.  Even if my rider interpreter tells a great story, my attitude carries the real message.  This manifests in my tone of voice, facial expressions, posture, stance, and all kinds of other subtle, nonverbal, subconscious cues—all seen and understood by your elephant, because they emanate from mine.  Even if my story tugs at your heart strings, you will defend your position if you feel me to be righteous, shaming, condescending, etc.  Elephants are smart; they know not to come out if it’s not safe.  And if my elephant is at all on the attack (see anger and frustration above), your elephant knows full well not to show itself.

It’s not the words we say or the things we do—it’s not the method that counts.  It’s how we are, how we make people feel—the approach—that gains us access to people’s consciousness and allows us to influence their thinking (which is really their feeling).

So I calm my rider and elephant first.  Deep breaths.  Then instead of my rider jumping off my elephant and charging at you with a wad of sharp verbal sticks, she sits back in her seat.  My elephant humbly ambles alongside yours on the savannah of community and (humanity), shares some sweet grass, points to the water hole where we both want to go.  I invite your inner pachyderm lovingly on a shared adventure toward optimal health for us all.  Rather than rush, berate, or agitate you, I wait.  I encourage.  I welcome.

James Clear writes, “Facts don’t change minds.  Friendship does,” and “Be kind first, be right later.”

My elephant fully concurs.

 

Some Facts, because I’m a doctor after all:

  • As of last Friday, May 3, 2019, there were 764 known cases of measles in the United States. According to the CDC, “This is the greatest number of cases reported in the U.S. since 1994 and since measles was declared eliminated in 2000.”
  • About 2/3 of patients are unvaccinated; 1/10 have been vaccinated, and the vaccination status of the rest is unknown.
  • 44% of patients are children under 4 years of age.

See this article in the Washington Post from today for more statistics.

For answers to frequently asked questions about Measles, please refer to the CDC measles FAQ webpage.

Please talk to your doctor if you are unsure about your risk.

 

The Optimist and the Cynic

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Are you an optimist or a cynic?

I consider myself to be, wholly and without question, an Optimist—with a Big O.

In The Art of Possibility, Ben and Roz Zander describe a cynic as a passionate person who doesn’t want to be disappointed again.

By this definition, cynics are not altogether hopeless and negative; they are simply wary and cautious based on past experience.  Still, I judge cynics and find them tiresome.  I reject their gloom and doom outlook.  Sometimes I really just want to throttle them.  In their presence I turn up my outward optimism to happy headbanger volume.  I can tell this makes them a little crazed—they see me as Pollyannish, idealistic, and naïve—and likely wish to strangle me, too.

And here’s the thing:  I also possess a deep cynical streak; one that can really overtake my consciousness sometimes.

Every day I campaign ardently to empower myself and those around me, pointing to all the ways we can claim our agency and effect positive change.  I advocate for using all of our kindness, empathy, compassion, and connecting communication skills, in every situation—take the high road!  Be our Best Selves!  And yet at the same time, a darker part of me, my shadow side, silently tells a contemptuous story of the forces we fight against.  I paint a sinister picture in my mind of impediments made of ‘the other’ people—the small minded, the pessimistic, the underestimating, unbelieving, rigid, unimaginative, distrustful, conventional, supercilious, and condescending themThey are not like usThey are the problem.

Of course this is not true.  It’s just a story I tell—a counterproductive and self-sabotaging story.  How fascinating.

Sometimes I tell this unsympathetic story aloud, out of frustration, impatience, and exasperation.  Sometimes I actually name people and label them all those negative things I listed.  It feels justified and righteous.  But then I feel guilty, as if my worse self kidnapped the better me and held my optimism hostage until I vented against my better judgment.  I wonder when my words will come back and bite me in the butt?  What will I do then?

I suppose I can only claim passion and disappointment.  Sometimes I let the latter get the best of me and allow shadow to overtake the light.  It happens to the best of us; I can own it.  There is no need to disavow the disappointment and disillusionment, the dissatisfaction with what is.  If I didn’t care so much—about patient care, public policy, physician burnout, patient-physician relationship, and relationships in general—I would not suffer such vexations.  And it’s because I care so much that I fight on, to do my part to make it better.  I stay engaged in the important conversations, even if I have to take breaks and change forums at times.

Yes, I, the eternal optimist, harbor an inner, insubordinate cynic.  While most of me exclaims, “Humanity is so full of love and potential!” another part of me mutters subversively, “Also people suck.”  Some days (some weeks) the dark side wins, but it’s always temporary.  The Yin and the Yang, the shadow and the light, the tension of opposite energies—that’s what makes life so interesting, no?  We require both for contrast and context, to orient to what is in order to see what could be. 

The struggle for balance is real and at times exhausting.  And it’s always worth the effort.

Reconnecting to Mission, Patients, and Colleagues

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What’s the most personally fulfilling aspect of your work?  In times of uncertainty, threat, and transition, what holds you up?

This past week, I had the privilege of standing alongside giants in the fight against physician burnout.  In a series of presentations at the annual meeting of the American College of Physicians (ACP), we did our best to acknowledge and validate the current state of physician burnout (about half of all physicians in all specialties report at least one symptom), and then present as many strategies to reduce it as time would allow.  We showed how changes in workflow, task distribution, and technology, such as pre-visit labs and scribes, have been shown to improve physician satisfaction, team morale, and patient experience.  My role was to attempt to inspire my fellow internists to claim their individual agency, model a culture of wellness, and advocate for systems change in their home institutions.

The content felt dense but manageable, and the audience appeared engaged.  Our colleagues from all around the country approached us afterward to clarify studies of efficacy and ask about local representatives for advocacy in the ACP.  In the end, I think we achieved our primary objective of having most attendees leave with just a little more hope for our profession than they came in with.

Over the four day conference, however, what consistently grounded me in professional mission and meaning, not only in our own presentation but in others, were the personal stories.  That is how we humans relate to one another, after all—through narratives.  And connecting to mission and colleagues is key to maintaining a healthy and productive workforce, physician or otherwise.

Our attendees participated in two practices that I’ll share here.  Both were “Pair and Share” activities, meant to stimulate reflection both internally and externally.

Who In Your Life Really Changed You?

First we asked our colleagues to think of a patient who changed them, how, and to what end.  I know there have been many patients who changed me, but I always think of one particular woman.  She was middle aged, obese, diabetic, depressed, and severely disabled from osteoarthritis.  She lived alone and had a sparse social network, and her life partner had died unexpectedly a few years before I met her.  At every visit we struggled through the same fundamental challenges of weight loss, glucose control, and pain management.  How could she take her diabetes medications more regularly?  How could we control her pain without having to take opioids every day?  How else could we manage her depression, as some of the medications were raising her blood sugar?  She may have cried at almost every visit; wailing was not uncommon, and once she even vomited from cumulative distress.  Our relationship was good overall.  I overcame my impatience with her non-adherence to the treatment plan as I understood her life situation better.  But for four of the five years we knew each other, I saw few if any indicators that her thought, emotional, and behavior patterns would change.

Then things started to turn around.  She started coming consistently to appointments, no more no-shows.  She got online and found a community center that was accessible by bus.  She connected with a knitting group and started going to art fairs to sell her creations.  She started taking her medications more regularly, and lost enough weight to have her knee replaced.  By the time we parted ways, she had transformed from a weeping victim of circumstance to a woman with agency, self-efficacy, and goals, dammit!  And most of this had nothing to do with me.  I simply had the privilege to witness and support her intrinsic revolution.  From her I learned what perseverance looks like; I learned about hope and self-redemption; I learned that I should never make assumptions about anybody’s future.

Who Supported You in a Time of Vulnerability?

They said do the hardest thing that you know you don’t want to do for a living as your first rotation.  So I chose surgery.  In July of my third year of medical school, my days started around 5:30am and could end the next night at 10pm if my team was busy post call.  Most faculty physicians were kind and wise, or at least non-abusive.  Some, however, not so much.  What buoyed me most through that rotation was always the support and protection of the residents on my team.  I would watch them get abused by our attendings, but that sh*t never rolled downhill when the boss left the room.  I did not fully realize until years later what a gift that was and how much it spoke to the character of these men (they were all men).  This was in the 1990s; verbal abuse of medical students and snide comments about one’s appearance, gender, and just about everything else were simply to be expected.  But my favorite residents always pulled me aside and asked how I was.  They always made sure I felt confident about my role on the team, and they taught me basic skills with conviction and encouragement.  As I was about to insert a patient’s bladder catheter in the operating room, my elder brother in training told me firmly, like he really believed I could do it, “Don’t be afraid, hold it (the penis) like a hose.”

As we did this reflection exercise at the meeting last Wednesday along with our audience, I was so moved by these memories that I looked up one of my old residents that night and sent him a thank you card.  I bet he won’t remember at all who I am, but he will hopefully feel validated that he is in exactly the right position now as program director of a surgery residency.

*****

Recalling stories like these, and then sharing them with a person who truly listens, receives them generously, and simply helps you hold them (that was the instruction to the group—when it’s your turn to listen just do that, no interruptions, no jumping in), reconnects us to our calling in medicine.  It’s not just about the patients or the science.  It’s about all of the relationships and how we tend them.

We will not solve the immensely complex problem of physician burnout overnight.  It will take a concerted effort at all levels of healthcare, and physicians cannot and will not do it alone.  And it’s not that we are stoic, arrogant, and somehow intrinsically flawed, and thus dissatisfied with our work and leaving the profession in record numbers.  It is a systems problem, no question.  And, while we call our congressional leaders and professional advocacy groups to change policy, while we lobby our hospital administration to hire more support staff and move the printers closer to where we do our work, we can all take a few minutes each day and reconnect to the core meaning and purpose in that work.  Let us all remember a cool story and share it today.

Pain and Desperation

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When was the last time you used any narcotics?  I think I took some of my mom’s cough syrup with codeine over a decade ago, when I felt like I might actually cough up a lung.  Before that it was one dose of Darvocet after having four impacted wisdom teeth extracted at age 18.  I don’t really remember much after swallowing the pill and lying down on the sofa.  I was given multiple opioids during knee surgery last year, but needed only Tylenol and Advil afterward.  Looking back on the post I wrote about that experience, I realize even more how I was influenced by this piece in the New York Times just a month before my surgery.  In it the author is reminded that pain serves an essential purpose, and it’s better that we not necessarily seek to obliterate it at every turn.

* * * * *

Four or five times in the last two weeks, I have received calls from local pharmacies to confirm opioid prescriptions that I did not write.  They were all paper prescriptions for patients I have never met, caught by astute pharmacists who suspected fraudulent activity.  This is the first time it has happened to me, and I know many of my colleagues have experienced the same.  Pharmacies in the area have now flagged my name and license number, and they know not to fill any controlled substances without direct confirmation from me.

What a morass.  How did we get here?  It’s a rhetorical question, really, but not a simple one by a light year.  When I started my training, we were taught to consider pain the ‘5th vital sign.’  Every patient assessment included the cartoon face pain scale.  Anesthesiologists’ prioritized rubrick for pain control started with long acting opioids around the clock, then regular anti-inflammatories if no contraindications, then short acting opioids as needed for breakthrough pain.  In the hospital I never questioned this method, especially since I almost never interacted with these patients after discharge and was oblivious to follow up issues.

It was not until I started in practice that I experienced the multidimensional challenge that is pain control and opioid prescribing.  After 15 years I am still learning the layers of complexity, unique for every patient, and I see that even if we understand it (which I think we do not), most of us feel helpless to address it.

The pharmacist I spoke to today told me that his store’s standard procedure is to inform the patient that the prescription was proven to be fake, advise the patient not to attempt such an act again, and let them know that the prescriber is aware and the police will be contacted.  It was that last part that made me pause.  Because even as I intend to file a police report (as advised by my institution), the answer to the problem is not, in my opinion, rounding up patients with chronic pain and throwing them in jail.  In order of importance, I think the opioid crisis is first a social, then a medical, and only then, a criminal problem.

* * * * *

Increasingly, we have become a society of immediate gratification and entitlement.  We want and expect a magic pill for and complete relief from whatever ails us—because it’s the twenty-first century for crying out loud, how could we not have that already?  Also, medicine has become increasingly transactional.  We, patients and physicians alike, experience ‘care’ in predetermined packets of protocol and procedure, and spend considerably less time in conversation, education, expectation setting, and actual caring.  The advent of the internet has accelerated this immediate gratification expectation.  It also gives many of us an illusion of connection through social media, when in reality, we are actually less and less connected to one another.

Pain results from myriad causes.  We all have varying thresholds for feeling and tolerating pain, which vary themselves depending on circumstances, mindset, expectation, and meaning making (think childbirth versus bike accident).  There are so many factors that impact our pain experience, including dehydration, sleep deprivation, low mood, and emotional and/or mental stress.  Loneliness, depression, anxiety, sleep disruption, suicidality, and substance abuse are all on the rise.  And all of these conditions lower our thresholds for pain and the harm it does to us.

For many, opioids are indeed the immediately gratifying magic pills.  But the magic wears off faster and faster, and both pain and the desperation for relief accelerate in the wake of short and long term withdrawl.  As physicians, we feel an intense desire to alleviate suffering.  Once a patient has experienced the profound relief (both physical and psychological) from opioids, it feels cruel for us to withhold them, even when we understand fully their risks and the long term harm they cause.  And we have less and less time to explore with and educate patients about adjunct pain management practices, such as mindfulness, biofeedback, and movement.  Everybody feels despairing and impotent, and this drives people to do things they might not otherwise do, like make a fake prescription for hydrocodone and try to get it filled.

I know there are real criminals out there, people not really in pain, who do this to make money—to take advantage of people in real pain.  I don’t know who’s who.  But the story I tell myself is that this is not most people.  What we need is a stronger infrastructure to address chronic pain at multiple levels—individually, in community, with policy, and culturally.  As I write this, even as a physician with a leadership title, I feel powerless and a little hopeless.

But maybe a good start, at the individual level, that we can each do the next time we look ourselves in the mirror or meet another human being on the street, is to just exercise a little compassion and generosity.  I assume that those patients presenting the fake prescriptions, if they are real patients, are not criminals at their core.  Pain makes us do unthinkable and unbelievable things.  I hope we can all help one another find better sources of relief and support.