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.

Gratitude Again

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NaBloPoMo 2017: Field Notes from a Life in Medicine

I generally dislike cold, damp, cloudy weather.  I have survived this in Chicago the past 26 years, somehow, by grace.  Usually the second half of fall just feels dreary, wet, and lame to me.  And yet this season, on this drab day, I feel warm and happy inside more than last year.

Can’t say why, really.  Another year older and wiser, perhaps?  Maybe because the kids seem to have crossed some magical threshold on this side of which they seem suddenly much more mature and self-sufficient?  I’m entering my fourth year in my current practice, which is the magic number for really settling in, it seems.  With the patients I only see once a year, the third and fourth times bring a familiarity and rapport that can only come with time.  It’s like catching up with old friends.  I’m grateful for another year of watching my family grow and flourish.  I’m grateful for my work, and the immense personal and professional fulfillment it affords me.

Two years ago for my first NaBloPoMo, I wrote November Gratitude Shorts.  It was a spinoff from a Facebook trend in which my friends and I posted gratitude for something every day.  Writing a couple sentences a day was fun and easy; converting those ideas to full-fledged blog posts proved more daunting than I had anticipated.  It felt like a slog much of the time, though I did write some pieces that I’m still proud of.  Last year I felt more relaxed, less pressured to write profound things.  This year I’m actually having fun, though I can still only rarely make myself sit down to write before 10pm.  That will be the challenge next year.  I am grateful for the chance to practice my writing and share with a community of readers, writers, and friends.

I feel the holidays coming on, a little more acutely this year than last…  It’s been a tumultuous year, no doubt, in so many realms.  And yet we are all still here, relationships intact for the most part.  And many of us, happily or begrudgingly, have learned a little more about our biases, our emotional triggers, our friends’ and families’ hidden beliefs, and similarities and differences we did not know we had before.  The conversations continue, then maybe stop for a while.  Emotions heat up, cool down, heat up again—and hopefully the connections remain or even grow stronger.  I have hope that we can continue to do better, and I’m grateful that the trials of the past year have shown me what courage and resilience we have.  I am grateful for the holiday season every year, and the chance to reflect and advance.

A friend told me recently about marriage advice he received when he was young.  We get beyond infatuation and on to real love, he was told, through commitment.  This past year I have seen myriad examples of people making meaningful commitments—to their families, to their core values, to their ideals, their aspirations, their fellow humans.  The examples are everywhere, if we are open to seeing them.  I am grateful for the persistence of humanity, and for our innate drive to connect.

The holiday season is upon us, and truly, I wish us all peace, love, and joy.  I’m grateful to have so much to celebrate, so many to celebrate with, and so much to look forward to.  May you feel and be moved by all that holds you up, this season and for all seasons to come.

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.

 

It’s a Bad Day, Uncle Groper

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What if your favorite uncle, whom you have always regarded as funny, warm, loving, and virtuous, if a little odd, were accused of sexual harassment or assault?  This is what it feels like to learn of Al Franken’s assault on Leann Tweeden in 2006.  I feel nauseated, embarrassed, disappointed, and confused.  I have liked Al Franken for a long time, ever since his Stuart Smalley bits on Saturday Night Live.  It wasn’t until I listened to his recent memoir, Al Franken, Giant of the Senate, that I learned more about him and liked him even better.  He’s a little too sarcastic and biting for me sometimes, but after hearing his stories of how he became a Democrat and what motivated him to run for office, his family’s emotional journeys and how things work in the Senate, I came to see him as a respectable public servant with the interests of his constituents and all Americans at heart.  I have recommended his book to many of my friends.  I have regarded him as a champion for all things progressive, including women’s rights and equality.

And now all of that is thrown in the blender with allegations that I assume are true.

How do I reconcile this?  How does a person, whom I still believe respects women at his core, behave like this?  Ever?  Do I throw away everything about him that I believed was virtuous, everything he has said and written that I agree with, his decades-long marriage, and relabel him as a misogynist because of this one revelation?  Do I assume that because now we know of one, there must be dozens of others?

I am forced to compare my response to allegations against him to that of allegations against Roy Moore.  I don’t know anything about Roy Moore, but he’s an ultra-conservative Republican (I am a heavily left-leaning independent), so if he goes down for sexual assault, I’m not that bothered, and I’m judgmental of people who defend him.  I must concede that neither party can claim moral superiority.  Just this week at least three articles examined the precedent set by Bill Clinton’s sexual escapades from which he plainly escaped a rightful accounting; the precedent his (and Hillary’s) dismissal of all allegations set for everything we see now, and why he should have resigned after admitting his abuse of power.  And today Nate Silver laid out an excellent case for Al Franken to resign now.  I agree that that would be the epitome of Walking the Talk, aside from not having committed the groping in the first place.

My inner conflict now churns on two levels.  First, I must decide what I now think and feel about Al Franken, whether I can still trust him, and how I will interpret any of his words or actions hereafter.  I feel betrayed, and the positivity needle in my mind has how swung a few degrees more toward cynicism, which I hate.  Second, I must examine my immediate reactions when such allegations are made against my political opponents.  I think we can agree that there are some cases of flagrant misogyny, based on years of evidence of poor principles and lack of respect in multiples realms of a person’s life, and we are not concerned with their political leanings—assholes are assholes regardless of party.  But if and when a reputable conservative were to be accused, would I give him the same benefit of the doubt that I wanted to give Al Franken today?  Shouldn’t I try harder to be both objective and compassionate, and rise above my political biases?  Is it appropriate to say we all make mistakes, and that we should give people a chance to prove that they now know better?  If I am willing to say that for Franken today (and I’m not sure I am), will I be willing to say it for, say, Jeff Flake tomorrow?

We all need to decide for ourselves how much we are willing to abide by the standards to which we hold others.  It’s easy until we find ourselves in hot water. So do we lower our standards or rise to the occasion?  Perfectionism and shame loom heavy when we aspire to live a virtuous life, and we can also become arrogant and judgmental.  Then again, looseness with integrity is no way to lead, either.  I wonder what I would do if I were in Al Franken’s shoes tonight.