Incomplete Thoughts on Suicide

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Not selfish

Not thoughtless

Simply belief beyond shadow that no one will mourn you, people will be better off without you

Unimaginable for those who have not lived it

Most who try once don’t try again

So better to keep guns away

——————–

One of my high school classmates killed himself when we were seniors.  He shot himself in the head at home.  He was the vice president of our Students Against Driving Drunk chapter (I was president).  He was a member of the National Honor Society.  He was well-liked, always friendly, generous, smiling, encouraging.  He was a nerd, and so was I, so I thought nothing of it.  I did not know him well, and I never asked him about his life, that I recall.  I have no idea whether he was bullied or what drove him to take his own life.

The morning we found out, our calculus teacher had to sit down in the middle of the lesson. She was overcome.  One of my other classmates got up and hugged her.  She had more presence of mind than I.  I can’t remember if it was that moment or later, or if it was our teacher or someone else altogether, who said something like suicide is ultimately a selfish act.  That it was inconsistent with our classmate’s character to cause so many people so much pain.  That if he had known how much he would hurt people by this act, he never would have done it.  I can’t say I had thought anything about suicide before then, and I have probably not thought enough about it since, but her words stuck with me.  I’m not sure I would have ever come to this conclusion.

The way I understand (think I understand) it today, suicidality is such dark state, a place so far removed from where we connect with our true selves and others, including (especially?) loved ones, that people really do believe that everybody else will be better off without them, that there is nothing worth living for.  I cannot fathom that kind of disconnection and loneliness.  It feels almost too scary to even contemplate.  I feel totally incompetent to address this kind of pain and suffering.

I saw this video recently and it moved me.  A young man jumped off the Golden Gate Bridge and survived; he tells his story of instant regret for the attempt, and gratitude to be alive.

I pray tonight that if anyone in my circle is feeling suicidal, I may say or do something to help them know they are loved, wanted, and connected, and to keep them with us long enough to get help.

 

I’m the Doctor, You’re the Doctor

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NaBloPoMo 2017: Field Notes from a Life in Medicine

“I’m the doctor, just do what I say.”  I don’t think doctors actually say this anymore, but I wonder how many of us think it?  It’s probably not even a conscious thought, but rather an attitude—paternalistic and directive, a relic from the old days when patients had no power or voice in the relationship because the doctor held all the information and all the expertise.  Today patients are empowered by culture and the internet to participate in shared decision making , and it’s a good thing.

The problem with the “I’m the doctor” attitude is that it inhibits the patient from owning their own healthcare choices.  Then if and when the care plan goes badly, they feel rightly justified blaming the doctor, because they were just following orders.  Sometimes it’s necessary, like in the case of trauma or serious surgery, where the doctor is truly in charge and must make life or death decisions according to their expertise and judgment.  Thankfully this is not my work.

In primary care, if I take this attitude, I miss an opportunity to forge a collaborative and rewarding relationship with my patients.  If I simply issue orders, people don’t feel seen or heard, and they may withhold important information that would help me make a better, more relevant diagnostic and treatment plan.  And if they defy my advice (edict), as they are more likely to do when our relationship is transactional and cookbook, and things go well, then I lose credibility and they are even less likely to follow my advice in the future.

“You’re the doctor,” on the other hand, is something I hear often.  It usually comes up when patients (and I) are faced with decisions involving competing interests or vague risks and benefits.  An example is prostate cancer screening.  Guidelines over the years have ranged from screening every man, every year, starting at age 50, for life, to don’t screen anyone ever.  Most physicians and professional societies agree currently that the best approach is to discuss risks of screening (over-diagnosis, harm from testing in patients without disease) and not screening (missing early cancer, delayed diagnosis, possibly leading to preventable negative outcome), and make decisions based on patients’ individual values and goals.

When a patient in this or a similar situation says to me, “You’re the doctor, just tell me what to do” alarms ring my mind.  What I intend to be a shared decision suddenly falls to me to make unilaterally.  In this scenario, the patient essentially cedes responsibility for the treatment plan, and if it goes badly then it’s my fault “because you told me to.”  Or the patient may choose to ignore my directive and also blame me because “you told me to but I disagreed.”  Either way a patient may then feel justified to blame me for any negative outcome, even though I gave them what they said they wanted.  I understand that this is not how the scenario necessarily plays out, but somehow I’m wary of it.

I had my teeth cleaned today.  The dentist recommends x-rays every year; I politely decline most of the time.  I just don’t understand (or accept?) the rationale and benefits of annual radiation to my face, and I’m cynical about the fee-for-service structure in which providers make more money for ordering more tests (which is a legitimate concern in medicine, also).  Without explaining why it’s recommended for me particularly (it was explained later), I heard, “Well, it’s okay if you don’t do it today, but you have to do it next time.”  [Expletive, not stated out loud.] I am emotionally triggered when people try to tell me what to do without asking me what I think about it first (see my post from 2 days ago).  So I bristle when I witness colleagues doing it, or when my patients demand it from me.

I don’t see my job as telling people what to do—I am not a surrogate.  Rather, I think of myself as consultant and guide, expert, counsel.  It’s my job to discuss, explore, explain, review, consider, negotiate, compare, assess, debate, explain and discuss again, and then make a shared decision.  This includes follow-up and contingency planning, setting expectations, and reassurance about my commitment to the person, regardless of the problem.  I’m the doctor, you’re the patient, we are a team.  We are in this together.

Bring It

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NaBloPoMo 2017: Field Notes from a Life in Medicine

Had my knee MRI yesterday.  I had been looking forward to it for over a week, trying to predict what it would show.  I was thinking a serious meniscal tear, since I have had crackling in my knee for so long and I surely must have arthritis by now, from all the falling on it I did in my youth.  I lay perfectly still and started to get sore where I expected to feel medial meniscus pain.  I could not wait to know the results.  I just wanted to know what I’m dealing with, so I can figure out next steps, get moving.

Since it’s a weekend, I won’t know the radiologist’s report until tomorrow.  Suddenly part of me doesn’t really want to know.  What if it’s really bad and the only option to regain function is surgery?  What if it looks like I’ll be permanently disabled in some way, never able to get back to my previous level of activity?  What if that prognosis totally throws me off and I let myself go, become a sedentary lump, weigh over 300 pounds, and die in five years from heart disease and depression?  Truly, this could end my life, some poisonous voice hisses in the recesses of my mind.

But hubs is the ordering physician and he looked at the images with me tonight.  Lots of fluid/swelling.  Bruises on both bone ends of the joint.  Good news, the menisci are intact and look normal!  Woo hooooo!!  Posterior cruciate ligament also looks normal—thick, uniformly black (swelling and inflammation are light on this image), well-positioned.  Can’t find the ACL.  Huh.  He says 10% of people don’t have one.  That’d be cool, because if I never had one then it couldn’t be torn.  But the bone bruises alone are not enough to explain the swelling and pain.  So either it’s so inflamed that the fluid obliterates it on the MRI, or I have completely ruptured it and the little stumps have retracted out of view.

I had wondered which I would rather have, a serious meniscal or ACL injury.  I had leaned toward the latter, because the ACL can be fixed.  Meniscal tears really don’t heal; the body smooths them over somewhat with time, but the end result is just less cartilage, faster wear, and more tear.  The problem with an ACL injury, however, is that it increases the risk of future meniscal tears.  So either way, the knee will never be the same and now I have to deal with it.

We will wait for the official report, and I may see the sports orthopod.  Here’s what I don’t want from that appointment: For him to tell me, “Cathy, you should stop playing volleyball or anything that requires jumping, sudden movements, or the like.  You’re too old and your knee will just be hurt again.”  I will be polite, but in my mind I will think, “You can’t tell me what to do, I’ll play f*ing volleyball if I want to, and I will do it with or without your help.”  What I would love for him to say is this:

“Cathy, here is what’s going on in your knee.  It’s likely that these factors contributed to the injury (lists possible risk factors that he knows from my history), and also it was a freak accident that can happen to anyone, especially jumping female athletes (which is true).  It’s a good thing you’re pretty healthy to start with, and that you had gotten fit these last few years.  What do you want to do now?”

I’ll tell him that I really want to get back on the court and play.  I’ll tell him I want to keep doing all the training I’ve been doing: elliptical, Kangoo running, TRX, pistols, golf, and Betty Rocker workouts.  I want to take up new things like Orange Theory, kickboxing, martial arts maybe, and who knows what else?  I want to be the most active person I can be, and I want to JUMP.  I’ll tell him that I want to be responsible about it; I’m not going to ignore the risks and be stupid.  I want to know the risks, the evidence as it applies to me as specifically as possible, the 44 year-old mom with lax ligaments and super-flat feet.

Then I hope he tells me, “Okay then here’s the plan.  We gotta rehab the knee really well.  Ya gotta be patient.  Keep up with your trainer, strengthen all the muscles around your knees, continue working on core, posture, and form.  When you start jumping again make sure you know better how to land, train that muscle memory and get it down, own it.  Take your time, and take it easy when you start again.  There are braces you can use when you play that will help keep the knee stable.  And you still might hurt yourself again, there’s no way to predict what will happen. But if that’s what you want to do, I’ll do my best to help you get there.”

Because here’s the deal, my friends:  I own my decisions, but I need help to make them in the most responsible and informed way possible.  I don’t need someone paternalistically telling me what to do, how to live my life.  I need the doctor to explain to me the risks, benefits, and costs of what I may want to try.  Then I need to him to trust that I will make the best decision for myself, based on my own core values and goals.  I understand that nobody can predict the future.  But I also have a clear vision of the future I want.  I want to live a very active life, able to try new things and connect mind with body with spirit, and with other people.  I want to look back in 10, 20, and 30 years and say, “I did what I wanted to do, I made my decisions with the best information I had at the time.”  I may hurt myself again.  I may end up with a knee replacement before age 60, and never run or play volleyball again after that.  But if I get there having thoroughly assessed the risks of my actions, having taken all reasonable steps to proceed safely, and having continued to have fun and enjoy my mobility as long as I could, then hopefully I will regret very little.  I would much rather live this scenario, than get to that age wondering, “What more could I have done?  Did I sell myself short?”

This is how I discuss decision making with my patients, particularly when it comes to screening.  Their decisions must originate from their personal values and health goals, not mine or anyone else’s.  How do they understand the risks, and which worst case scenario of screening or not screening, treating or not treating, will they regret less?  A very athletic yet osteoporotic 65 year-old woman really does not want to take medication.  So we review her daily dietary calcium, vitamin D, protein, and vitamin K intake.  We make sure she continues weight bearing exercise every day.  We pay attention to balance, flexibility, strength, vision, and fall risks.  We reassess her risks and goals every year to make sure that we are still on the path she chooses for herself.  I present her with as much evidence as I can, for efficacy of medication, her personal fracture risk, and potential consequences of fracture.  In the end the decision is hers and hers alone; I serve as consultant and guide.

Meanwhile, knowing what’s likely happening in my knee gives me peace and confidence.  Now I can make a plan.  I’m convinced this is why my knee feels better tonight than it has in days, although the ibuprofen I took this afternoon probably also helps.  I have a new compression sleeve that fits under my dress pants.  I can get back to my workouts, and maybe add on a little every week.  My motivation to eat healthy just got a fierce boost (Betty Rocker really helps with this—I have no financial interests in her business, I just really like what she does and how she does it).  I’ll start physical therapy soon.  No volleyball for likely 6 months.  But I got this.  Bring it.

Thanks

…to the six people who came to my talk today. It was a pleasure to present to you. You were engaged and attentive, which I very much appreciated.  I’m disappointed that more of our colleagues did not join us, as this was the best iteration of this talk yet!

The best part was when we exchanged questions and ideas at the end.

I hope you got something out of the presentation that will help you and your patients.  If that’s true for any of you anytime after today, then it was totally worth it. “”

Seek the Stories

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Do you have time in your doctors’ appointments to tell the story of your problem?  Do you even think of it as a story?  More and more I find myself saying to people, after they have given a list of symptoms in no particular order, “Tell me the story, starting from when you last felt well/normal.”  Then it all comes out in an interesting narrative, often with new insights as to causes, connections, and exacerbating factors along the way.

Do you read more fiction or nonfiction?  I have always been a non-fiction gal.  I appreciated The Grapes of Wrath and devoured the Harry Potter and Percy Jackson series, but usually I avoid novels.  My favorite books this decade are The Art of Possibility, Rising Strong, Big Magic, Start With Why, and Give and Take.  I realize now that these books are also full of stories—just real-life ones.  I have tried to incorporate more stories in my writing, and I find it challenging and awkward.  But I will keep trying, maybe take a creative writing class someday.

I have heard some amazing stories recently, and I will get some details wrong, but I want to share them with you, in case they touch you as they touched me.

A doctor attends a mindfulness workshop because he is interested in mind-body medicine and always looking for new methods to explore his inner world.  Part of the workshop is a professional quality of life survey, on which he scores very high for compassion satisfaction and low for burnout.  He says it’s because this is a second career for him.

He always wanted to be a doctor growing up.  He was accepted to medical school in his home country, but his family could not afford it.  So he stuck with science and went to school the cheapest way possible, and graduated with a biology degree.  Over the years he got married and immigrated to the United States.  He never forgot his dream of being a doctor, but progressed nevertheless in his graduate basic science studies.  When he applied to allopathic medical school here in the 1980s, he was told that since his BS was from abroad and the class was already ‘culturally imbalanced,’ he would not be admitted.

He was offered a spot in an osteopathic school, however, and grabbed it.  Meanwhile his wife was pregnant with their first child.  He had to move away from her and his parents for residency, and while he was away his father died.  Sometime in there his wife also started medical school, and they made it through training and the births of two children (with two weeks maternity leave each for her) intact.  They are now both well-respected primary care physicians in a small outlying community.  He is a physician educator and leader.  They sit side by side at the dining room table on Sunday nights catching up on notes.  They call these their “Epic dates.”  [Epic is the name of a widely used electronic health record.]  Both of their children are doctors.  He never feels burned out; he is living his dream.

Another doctor, a leader in his field and his institution, and a black man, described everyday racism that most of us cannot fathom.  A neighbor approached him on the beach of his own lake house, accusing him of trespassing.  Passing drivers backed up to confront him at his mailbox, suspecting him of stealing some white person’s mail.  A cop pulls him over around the corner from his suburban home in a nice neighborhood, asking, “What are you doing around here?”

A man in his 50s breeds guppies for fun.  It started with his 5th grade teacher, who was his mom’s best friend.  He used to go over to her house with his mom, and got interested in her guppy tanks.  Now he has hundreds of his own tanks, and he knows everything there is to know about inbreeding, crossbreeding, guppy circadian rhythms, and where the world’s experts on guppy breeding live and work.  Now I know this is a thing.

Mr. Rogers is quoted as saying, “There isn’t anyone you couldn’t learn to love once you’ve heard their story.”  I wholeheartedly agree.

 

Because This Is Who We Are

 

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Followers of this blog may know of my interest in and passion for physician health and well-being.  I was immersed in this world last couple of months, with two amazing conferences and multiple conversations with fellow physicians at work.  As often happens, I was moved to articulate a vision/mission statement of sorts, mostly to solidify my own intentions and also to share with like-minded colleagues.

I love that I enter this arena from the world of executive health.  Corporate leaders, physician leaders, and physicians on the ground share so many attributes that everything I learn from patients translates seamlessly to my own professional development.  This is exactly the right space for me to inhabit today, and I am forever grateful for the integrative experience.  Physicians are care team leaders by default, and we miss opportunities to improve all of medicine when we forget or ignore this fact.  I’m interested to know your response to the words below—the more visceral the better (but please, if possible, refrain from spitting, vomiting, or defecating your own words here):

Why do we advocate for physician health and well-being? 

Because we believe we can only lead well when we are well ourselves.

Because leading can be lonely and leaders need support.

Because leaders need metrics of our own performance, both related to and independent of the performance of those whom we lead.

Because health and leadership intersect inevitably and who we are is how we lead; the more awareness and active, intentional self-management we practice, the more effective leaders we will be.

Because people follow our example, like it or not, so we owe it to ourselves and those we lead to model Whole Physician Health.

What Is Whole Physician Health?

Whole Physician Health is an approach to health and well-being which defines physician as both clinician and leader, both healer and vulnerable.  This approach focuses on the 5 Realms of Health: Nutrition, Exercise, Sleep, Stress, and Relationships.  We explore how these realms intersect and overlap, affecting the individual physician, those whom the physician cares for and leads, and the entire medical profession.  We apply principles from health and sports psychology, communication, leadership, mind-body medicine, and myriad other disciplines.  We value openness, curiosity, critical analysis, and collaboration.  Our mission is to create a resilient medical culture in which all members—physicians, patients, all caregivers and support personnel—thrive and flourish.

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The Whole Physician Health Advocate:

*Values self-awareness and self-exploration.

*Understands and accepts his/her position as role model and culture setter for the team.

*Wishes to broaden the skillset in cultivating positive relationships

  • With self
  • Between self and immediate colleagues
  • Between colleagues themselves
  • Between physicians and staff
  • Between teachers and learners
  • With extended family of colleagues and institutional entities
  • Between institution and the patients it serves

*Sees the physician health and well-being movement as an opportunity to learn, see from a different point of view, connect to fellow physicians, and form new tribal bonds that will hold us all up.

*Wants to contribute to the creation of a global professional vision and mission of the 4 WINS:

WIN 1–You

WIN 2–Those you lead

WIN 3–Your whole organization

WIN 4–All those whom your organization touches

Of note, one need not be a physician to advocate for Whole Physician Health.

Stability is Strength

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The holidays are coming.  People will be bustling up and down Michigan Avenue with large shopping bags and puffy coats, fuzzy hats and determined gait.  If someone knocked into you on the sidewalk, would you be stable enough to hold your space and not get pushed over?

I asked this to a friend today, a woman about my height and twenty pounds lighter, ‘bird-boned’ by her own description.  I swear, she looks like a feather to me.  We were talking about our habits, what seems to be changing as we approach menopause, and how we envision our best selves in old age.  I thought about the elder women in my family, who are all healthy in general, but not necessarily fit.  What if someone knocked into them this holiday season, would I be dealing with a hip fracture over Christmas?  The mortality rate for people over 65 in the year after a hip fracture is somewhere on the order of 25%.  My friend and I definitely do not envision this for ourselves.

So what needs to happen in order for me to stand my ground in the face of some external force?  I need a stable foundation, my feet in firm contact with the ground.  I need a low, massive center of gravity.  I need fast reflexes to contract and relax opposing muscles groups to bear the sudden and unexpected load.  I cannot be rigid and brittle; rather I must exert flexibility, to absorb enough force to move with it and away from it on my own terms.  I need to stand tall and face the force head on, with openness and grace, firmness and self-assurance, ready to assess instantly whether it was inadvertent or intentional, benign or malicious.  And then I need clear-minded judgment to determine how to respond to either condition.

This may come naturally and easily in our 20s.  Today, bum knee notwithstanding, I feel confident that I could meet such a force with appropriate strength and stability.  My friend and I agreed today on a shared vision: STRONG OLD LADIES.  We understand that this will not just happen because we will it; we need to fuel and train, rest and recover, and cultivate our mind-body connections, as well as our connections with others.  Small habits, sustained over time, positive or negative, will yield predictable results.  So the time is now to pay attention and establish some excellent patterns.

It occurs to me that this idea of stability and strength relates our physical to our mental and emotional well-being.  While Amy Cuddy’s research has recently been called into question, I still adhere to the idea that power posing and physical posture can enhance or diminish confidence and self-efficacy. Wide stance, low center of gravity, elongated spine, and open arms:  Stand strong, feel strong, think strong, speak and act strong.  I have practiced power posing before presentations since 2015 and I believe I am better for it.  And if it’s a placebo, I’ll take it—the benefits so far have outweighed the risks and costs.

Lastly, I think we can also apply this stability and strength awareness to our inner lives.  Here I refer to our integrity.  Our world changes ever faster, technology offering capabilities we had not dreamed even a decade ago.  It seems every interaction these days is shorter, more ‘efficient,’ less personal.  That is the default goal—low cost, high speed above all else.  Change is often good.  But we must also exercise judgment, and practice taking the long view, casting light from our core values onto a cautiously optimistic future, attending to and addressing the shadows.  We should gut-check, with ourselves and one another.  What are we really getting here?  How will we use it mindfully? How can it serve us, rather than us serving it?  When we are stable and strong in our shared humanity and collective goodwill, we arrive at the best answers to these questions.  Then we can all be stable and flexible, and stronger as we age together.