Saturday, December 7, 2013
We were taking a late afternoon walk, my dogs and I, around the hayfield, trying to make the most of its company before snow buries it for another winter. We were three quarters the way around, counterclockwise, on the eastern side when I caught whiff of the familiar scent of Velvet pipe tobacco and the sound of a Maine accent I'd heard before, following it.
"So, how does it feel, bein' done and all? Ya ah a doctah, now, aintcha?"
He stepped out of the trees as he spoke, not an old man, but older than me, wearing a red and black buffalo plaid jacket, rubber boots, and a crumpled brown fedora. His took his pipe out of his mouth and gestured, "Nice dogs."
We'd met a couple of years ago when my yellow Lab and I got off the beaten path in the early twilight. He must have recognized the old man as well, because he made no move to growl. The black one, too, was uncharacteristically quiet and both sat, also uncharacteristically, as if on command. "Thanks," I said, "and yes I am, got my passing scores this week. I can't do much with it, though, since I'm not licensed, but that'll come. As to how it feels, I'm not sure. I can't quite figure it yet."
"Makes sense," he said, kneeling down to pat the dogs, who wagged the tips of their tails in response, back and forth across the leaf-strewn stubble. "Fer all ya put inta this, it has to feel kinda strange, kinda like maybe ya don't know how to feel. That's understandable."
He's got good therapeutic technique, I thought, showing empathy and paraphrasing what I say while being non-committal. "To tell the truth, I'm a bit afraid to feel. In the past, whenever I've gotten this close, something always came up to get in the way. It's hard to believe there's nothing 'out there' lying in wait for me. Though there is finding a residency. Still, it's a little anticlimactic."
He nodded, stood up, and looked away to the west. A cloudless winter sky passing into sunset was his view. He puffed on his pipe in silence a moment or two before he spoke again. "How could it not be? Ya been doin' this, med school, what, seven years now? It's been more yer life than an education." The way he said it, sounded like "edgikayshun."
"Yes, it has, with all the good and some of the bad associated with it. Not everyone I know expected me to finish. I never had any doubt, I just didn't know when. Oddly, it feels like something I want to keep to myself instead of shouting from the rooftops. Almost like it's too...too..."
"Too personal? Kinda like havin' a baby? Ya tell ever'one after it comes, but ya don't mention anythin' 'bout how ya made it in the first place. I think that's 'bout right. Shows respect fer what ya been through." He turned his pipe over, knocking ashes onto the ground, and refilled it.
"Listen," he said, "some things you gotta respect, things that make ya who ya'ah, what ya pay fer in ways you can't imagine when you staht out. You didn't know it would take seven years, you couldn't. Nobody could. What matters is, ya did it. Faced down all the demons and come further than ya evah thought ya could. Yuh've done what ya were s'posed to, what ya always been s'posed to. Time'll come fer shoutin' -- right now, just love it. Love it and respect it, cuz things like this don't come 'long ever day."
Before I could reply, he reached down and patted the dogs once again, "You take care uh this fella, ya heah?" They looked at me and wagged, leaves flying as though caught up by a breeze. "As fer you," he said, straightening up and looking me in the eye meaningfully, "Residency'll come too, don't worry, maybe where ya least expect it. Been good seein' ya." Then he nodded and walked back into the trees.
"You, too," I said, watching the angel in the hayfield vanish as he was swallowed up by the woods.
(Photo copyright 2013, by the author, all rights reserved)
Saturday, November 30, 2013
Some time back I wrote a post about tailgating that included the lyrics to a song I'd written while still in Colorado. It came about one afternoon while trying to deal humorously with a BMW whose driver apparently decided my late father's beautiful '88 Cadillac was so fascinating he had to get as close as he could. My car was naturally flattered, but at 65 miles an hour, the attention wasn't exactly welcome.
Later on, I wondered about him, what motivated his behavior, was he thinking at all or was his mind far away on a beach? Why are some drivers unwilling to keep a reasonable distance? If they want to go faster, why not take the option to pass, especially if the dashed white line clearly says, "Go for it"? I think the same questions may be on the minds of those who've graciously read the first post and I'd like to offer a follow-up that errs less on the side of levity.
There are a lot of factors involved, I'm sure. A driver's attention is drawn away by a cell call as their foot depresses the accelerator proportionate to the intensity of the conversation. This is why you don't want to talk to your ex while the car is moving; tempers flare. Some drivers have psychiatric disorders that make it difficult to manage emotions, particularly under stress and driving can be stressful. Anyone who's ever been late for work knows there are times it's just hard to keep your emotions in check. Before you know it, you've forgotten other people have concerns besides yours and you're doing to them what you hate to have done to you. We're all human, every one of us.
But there's another issue I've observed, or think I've observed, since it reflects an attitude or personality trait and therefore can only be inferred. Some drivers behave as though their vehicle is a symbol of superiority and owning the road is their right and privilege. The presence of another car ahead of them sets off an intriguing cognitive process. If the car appears of comparable value to theirs, they are less likely to tailgate. Instead, they'll keep a respectful distance before accelerating around it. They'll glance at the other driver for recognition, nod and drive on. Strangers and clearly social equals passing like ships in the night. A car of lesser value or vintage, however, represents an imposition their self-importance won't tolerate.
Now, why is that? Well, the presence of a lesser vehicle in front of them can be understood as triggering feelings related to shame. Not in the way we normally think of it, i.e. being embarrassed or ashamed because of something we've said or done. This is shame in the sense of feeling "less than," of being inferior. This experience may seem minor to you and me, but it's anything but minor to those who've oriented their entire lives around the idea they're deserving of preferential treatment. If you've been whispering to yourself the word, "narcissism," by the way, you get an A+.
Obviously, I don't think everyone who tailgates is narcissistic, but the behavior of some drivers leads me to think it's not uncommon. Consider how narcissistic individuals tend to be exquisitely sensitive to anything suggesting they aren't naturally superior to everyone else. We imagine them possessing the biggest house, newest car, and the most attractive of spouses. The reality is more diverse, though narcissism, generally, is characterized by almost a passion for control and a strong sense of entitlement. To the narcissist, our car constitutes a threat to their self-esteem; it's taking up space that rightly belongs to them. Finally racing past is their way of reminding us of the fact.
It takes very little to set off narcissistic rage, sometimes almost nothing at all. The thing to remember is, on the road or in daily life, it really is all about them, in the sense you aren't to blame for their misbehavior. You aren't inferior and they aren't superior. Accelerating dangerously or giving them the middle finger salute, only puts you at risk because your emotions have taken over your better judgment. They probably wouldn't get the point anyway. As easy as it is to become angry, it's far healthier to switch lanes or pull off the road briefly -- literally and metaphorically -- when it's safe to do so. No one's narcissism is worth an accident, or worse, becoming a statistic.
(Creative Commons image by Eleventh Earl of Mar via Flickr)
Thursday, November 28, 2013
On this chilly, breezy, sunny Thanksgiving morning, my gratitude list is topped by the mundane: I'm grateful to have power. Out here in the country, trees are plentiful and as you can see in the photo (pardon last winter's snow), they sometimes lean rather precariously close to the power lines. These particular ones are New England White Pines and are some of the oldest trees in the area, dating from the time of the Revolution. I'm very happy they resisted the forces of Nature once again and stood firm in the face of high winds.
I'm also grateful the hayfield wasn't completely under water when the dogs and I went out for their morning business. It rained yesterday, in case wherever you are isn't close to where I am and you came through the day dry. It rained enough that the Saco River estuary I call a stream, flirted with overflowing onto the west side of the field. It didn't and we only tramped through shallow ice-encrusted puddles instead of an ankle-deep pond.
Lately, the awareness I've completed medical school creeps up on me at odd times and I feel incredibly grateful. Watching 60 Minutes the other night, the lead story concerned veterans in treatment for post-traumatic stress disorder. If you happened to see it, too, you may recall one of them saying he missed the camaraderie, the feeling of brotherhood, that developed within his unit. It was a closeness he was certain he'd never feel again, a closeness you had to experience to understand. I immediately identified with what he was saying, having gone through my own version alongside the members, especially, of my entering medical school class.
Maybe it's because I'm slightly older or prone to reflection. Maybe it's because it took me so long and entailed so much to become a medical student and then remain one to the end. Maybe it's none of these. I do know that because of all we shared, I'm not the same person who walked into our first year classroom in August 2006. Looking back, I was insecure, unsuspecting, and thoroughly wet behind the ears. So we all seemed, one way or another. We grew up together, facing death in Gross Anatomy and crawling on our bellies across a no-man's land strewn with disease indices and day-long exams, the like of which we couldn't ever have imagined.
I'm not sure whether it's the nature of our experience or the company we keep in the midst of it. For me, the company was as important as the landscape in which we found ourselves and found each other. Sitting in my comfortable chair with one dog stretched between my legs and the other curled up beside us, looking back on it all is a luxury I once only dreamed about. Now I dream about those who struggled by my side and I'm grateful to have come this far.
(Photo copyright 2013 by the author, all rights reserved)
Monday, November 25, 2013
In psychiatry, a great deal depends on timing, including the correct diagnosis. For instance, while you may have experienced or witnessed a traumatic event or may have had prolonged exposure to highly stressful, traumatic, or abusive conditions, you can't be diagnosed with PTSD unless your symptoms have persisted longer than six months. Under six months, we call it acute stress disorder. PTSD symptoms can persist a long time.
Looking back, I definitely think 9/11 resulted in the semblance of a nation-wide case of PTSD from which we've done a fairly good job of recovering. We're more alert to danger but less likely to shut down the entire country over an isolated, local threat. We're no longer quite so eager to send in the troops at the sound of gunfire on the far side of the world. Life has begun to approximate "normal," though we're more aware of our vulnerability and the memory of tragedy is still there and always will be. Even the extreme political right seems more intent on defeating the president's health initiative than tackling terrorism. I don't think we've done as well with November 22, 1963.
I've often thought the free love, abundant drugs, and Tune-In, Turn-On, and Drop-Out mentality of the 60s was more an expression of anger -- acting out -- than typical adolescent rebellion. For the first time in our history, almost an entire generation gave the establishment the middle finger. Its hero was dead, LBJ had taken office, the Warren Commission was established, there was a national day of mourning, and now, it was time to move on. But this generation wasn't ready yet, and we would all have to wait for Kubler-Ross (On Death and Dying, 1969) to inform us the funeral was only the beginning.
Watching the 50th anniversary of the Kennedy assassination programming the past few days, I've been struck by how often someone uttered the phrase, "People don't want to think Kennedy could have been struck down by a single individual, acting alone. The magnitude of his personality as president seems to demand much more." I'm not certain this is accurate. I don't believe his personal magnetism or his role as the nation's leader are nearly as important as the magnitude of his loss. Ongoing conspiracy theories and the tendency of 2/3 of Americans to doubt the findings of the Warren Report symbolize the depth of grief many still feel, as well as an abiding need for it to be recognized. Mistrust of government may have burst into full flower with Watergate, but it is rooted in the mismanagement of national grief over the death of a president.
This is likely an unfair generalization, but there is still some truth in the statement that Lyndon Johnson's generation was more accustomed to putting tragedy behind them than paying close attention to what it means and mourning its significance. Anyone who's watched the HBO presentations of Band of Brothers (2001) or The Pacific (2010), or talked at length with veterans from the Great Generation knows how exceedingly reticent they are about digging up old wounds. The idea that the country as a whole needed time and leadership in the matter of grieving was unheard of in 1963. In a very real sense, we needed a president who understood and embraced his role as nation's chaplain as well as it's chief executive. Unfortunately, this was not one of JBJ's strengths, in contrast with our current president who has been known to take hours comforting the victims of gun violence.
I was also struck by the numbers of interviewees who commented on how America had changed, subsequent to the assassination. They lamented a loss of optimism, hopefulness, and the belief anything was possible. Whether those feelings are shared by all is debatable. There were and still are, sectors of the population that make no secret of their hatred of Kennedy and the causes he and his brothers championed. Nevertheless, his loss was felt by far more and the feelings associated with it have lasted far longer than anyone might have imagined.
Grief isn't resolved, if it's ever truly resolved, by assigning blame, getting even, and nursing the satisfaction gained from a moment of passion. We learn to deal with our losses, to live with them, making them part of ourselves, by refusing to play down their impact and brush them away like crumbs from the table. Grief has to be honored and mourning respected if we're ever to regain the optimism, hope, and sense of the possible that seems forever out of reach when we feel bereft. If there are lessons worth learning from the past 50 years, this is one to take to heart.
(Creative Commons image of eternal flame at grave of John F. Kennedy by Tim Evanson via Flickr)
Friday, November 22, 2013
They say days like today, you always remember where you were when you got the news. I was in my classroom, it was lunchtime, and a fellow student rushed in, out of breath, and announced, "Kennedy's just been shot." I was too young, I suppose, to understand what that would mean, though I recall going through the rest of the afternoon with a feeling of tenuousness in my stomach and I couldn't wait to get home.
Two years earlier, during the presidential campaign, an older teacher admonished our class that if JFK was elected, "we'll be under the Pope." Obviously, that never materialized but it reflects the mindset of some at the time. Change was difficult for them to envision and embrace, not unlike it seems now. All I knew was, my parents voted Democratic, they liked Kennedy's youth and energy, and neither cared whether he was Catholic, Baptist, or Jewish. He served in the military as had my father and we watched PT-109 (1963) with pride.
That night, though, we watched the news all evening long. The information was mixed and we weren't certain from one minute to the next whether he'd survived or not. All I really remember was midnight and the screen flashing the American flag. The national anthem played, my mother wept, and so did I. Dad, as always, was the pillar we leaned on, but I vaguely remember him wiping his eyes as he led me down the hall to bed.
Days later, I stayed home from school and we watched the funeral. Everything and everyone moved so very slowly, to me it seemed endless. I had met death twice by then, my dog and pony both having passed away two and three years earlier. But I'd never encountered it in human form and seeing John Jr. and his sister, I was so glad it wasn't my father we were laying to rest.
In November 2000, it would be, replete with military honor guard, the firing of rifles, and a bugler playing "Taps." I wasn't thinking of John Jr. and Caroline then, nor was I thinking of their father. Not until later, when Barack Obama was running for president and I felt the same optimism and hope my parents talked about in 1963. Not until a snowy day in Portland when I met John's brother, Ted, campaigning for the president. And not until today, when I remembered where I was and how I felt and why.
(Creative Commons image by the smuggler via Flickr)
Wednesday, November 20, 2013
Is it even possible anymore, healthcare without politics?
I don't know, but I hope so. I'd hate to think the only place it could exist was Disney World. I hope we can reach the point midst all the maneuvering and jockeying for power and influence where our concern for those who need healthcare exceeds its value as political capital. Sadly, we're not there yet.
Back in the day when, for the average person, Blue Cross/Blue Shield was pretty much the only health insurance game in town, coverage protected in case of catastrophe, i.e. hospitalization. I've described in other posts my own experience of kidney stones necessitating two major surgeries. My family paid out of pocket for outpatient doctor visits and prescriptions, grateful our Blue Cross policy meant the cost of my hospital stay wouldn't hit us with the force of a tsunami carrying the threat of bankruptcy in its wake.
At the time I was recovering from kidney stones and for a few years thereafter, doctors were reimbursed by insurance for services rendered. It was called a fee-for-service system. More services meant greater reimbursement. Eventually, managed care firms came into existence and in the effort to control the costs of operation, they established criteria that must be met, justifying tests and procedures, before insurance claims would be paid and doctors reimbursed. Soon it became necessary for providers and/or policy holders to obtain authorizations for treatment before managed care considered itself obligated to pay. If you think about it from a business perspective, this makes sense. A company can only pay out so much before it is unable to pay at all.
The road to hell is lined with good intentions, as the saying goes, and while management of healthcare costs was doubtless a factor in the evolution of managed care, we have to remember, healthcare insurance is still a business and the first priority of any business is to make a profit. To accomplish this goal, a business has to increase revenues and/or reduce expenses. Determining which procedures or medications were clinically indicated, ostensibly based on empirical evidence, was one way of setting limits on expenses. Refusing to cover pre-existing conditions was another. Over time, decisions of medical necessity were taken over by managed care and stories of treatment denial, some of them truly horrible, started surfacing. You've heard them on the nightly news as have I.
Despite public outcry, doctors' frustration with a growing insurance beuracracy, and the efforts of congressional leaders like the late Senator Ted Kennedy, insurance reform lagged. Ours is a free-market economy, it was argued, competition lies at the heart of the American Way. Socialized medicine in Canada and Europe, opponents declared, provided poorer quality care and ours was the best in the world. The reality, however, failed to live up to the evidence even as the arguments proliferated.
Families on the verge of collapse because of alcoholism or drug abuse may resort to performing an intervention, confronting the substance abuser who is unwilling or unable to get treatment themselves. Not dissimilarly, someone had to intervene if healthcare insurance was going to obtain the "treatment" it had long needed. Relying on competition to even the field failed to yield more affordable coverage and the number of uninsured Americans continued to grow. Either free-market theory was wrong or the industry discovered how to prosper in spite of it. Although many believed there were good reasons for reforming the system, there was insufficient motivation for the system to reform itself.
Enter the Affordable Care and Patient Protection Act, the function of which is to enable one to obtain affordable healthcare insurance and provide protection against potential abuses by the insurance industry. Under its umbrella, patients can no longer be denied coverage because of preexisting conditions. The determination of medical necessity has been placed back into the hands of those who are committed to serve the needs of patients. Doctors now have the right to review private insurance company files that identified physicians with high utilization patient populations and directed new referrals to those whose patients were regarded as healthier and therefore cheaper to insure.
It's not a perfect solution but imperfection doesn't automatically render it a bad one. If anything, we're discovering it's a work in progress and we'll need to adjust and adapt it as we go. I don't think it represents a step toward socialism anymore than the Selective Service represented a step toward a police state. Most of us are too smart to believe that line, even if politicians aren't smart enough to find a better one.
The Affordable Care Act is an attempt to reform a system sorely in need of reform, not only for the sake of patients and policy holders, but for its own sake as well. As with any intervention, the insurance industry finds change painful and naturally responds with anger, disbelief, and a desire to bargain, hoping to retain something of the status quo. Over time, acceptance will ensue and the industry will find itself better off for the changes that have been made. In the meantime, we're past the point of no return; pretending the good old days were the best days is a fantasy and Fantasy Land is for cartoons. We live in Tomorrow Land and the future is now.
(Creative Commons image of Walt Disney Politics by sbwoodside via Flickr)
Thursday, November 14, 2013
On the premise one agrees spirituality is important to medicine, as I argued in yesterday's post, that's only where the story begins. There are even more questions to be raised about its management in the clinical setting. For example, who is best qualified to inquire about spirituality and, besides, isn't it an end-of-life issue? What if a patient asks their physician to pray with them and s/he is an atheist? These are real concerns and as a minister on the cusp of medical residency, I'd like to offer a perspective.
Customarily, religious or spiritual preference is noted in the intake interview and becomes part of a patient's chart. Whoever does the intake should ask, at least generically, about the significance of religion, faith, or spirituality. During times of stress, changes of life, or when treatment decisions can be affected by religious beliefs, it's especially appropriate for the physician to broach the subject. When patients come to the clinic, they anticipate seeing a doctor they know and have come to rely on. The doctor-patient relationship provides an ideal basis for talking about what health or illness means to them, personally. As I define it, such conversations reflect "spirituality" in its most basic sense.
Naturally, you'd assume spirituality to be an end-of-life concern but it surfaces at other times as well. For instance, couples who have been relatively uninterested in religion often express a desire to reconnect with family religious traditions when a newborn enters the picture. As a first-time pastor, I discovered young children in the home was associated with parents attending church regularly. Family atmosphere, the potential for children to learn moral principles, and social contact with other parents were important factors in the decision to become involved. Midlife is another time when spirituality may take on new significance. The point to remember is, spirituality and relating -- intrapersonally and interpersonally -- go hand in hand, and most of us are best at both while we're still breathing.
The question of qualifications is one that has far less importance for spirituality than the practice of medicine. Doctors are accustomed to referring patients when a specialist would be better qualified to be of help. Spirituality, however, doesn't require technical expertise to be addressed meaningfully. Patients don't expect their physician to be a theologian. What they expect is consideration, respect, and empathy. If we can't provide these qualities, we've got far bigger fish to fry than whether we can explain why bad things happen to good people. And for the record, even ministerial folk have a hard time with that one, if they're honest about it. As long as we stay in touch with our humanity, we've got all the qualifications we'll ever need.
Well, then, what about physicians counseling with integrity when their own convictions concerning spirituality are at odds with patients'? While statistics indicate physicians who are fairly comfortable bringing up spirituality tend to be persons of faith, there's absolutely no reason why this should be considered necessary or even advantageous. For one thing, it's not about what we as physicians believe or disbelieve, anyway. For another, there are a number of potential points of disagreement with patients, including music, politics, caffeine or decaf, none of which require us to alter our convictions to be medically effective. In any case, introducing spirituality into the conversation is never an occasion for us to persuade, convert, or pontificate.
Admittedly, possessing a spiritual orientation may seem helpful, but it can also create problems. The innocent presumption that you know what a patient is talking about since you're able to identify with their experience may result in failing to ask follow-up questions. Conversely, patients may withhold information believing a common experience tells you all you need to know. In situations like these, having no spiritual orientation or one that differs from your patient can be an advantage because it requires us to explain ourselves rather than err by relying on assumptions.
Finally, in the matter of praying with patients, I'm reminded of a wonderful line from the film, Oh, God (1975). John Denver's character asks God (George Burns) if they might just talk now and then, to which God says, "You talk, I'll listen." If a patient should ask their doctor to pray with them, whether or not they are persons of faith, offering to listen reverently while the patient prays is spot on. If they should ask you, as their doctor, to pray on their behalf, there is no harm in gently explaining your convictions should they differ from your patients'. By telling the truth you maintain your integrity and confirm your trustworthiness. Furthermore, your honesty tells your patient that you value them too much as persons to pretend to be someone other than who you are. The result could very well be a much stronger bond between you.
Admittedly, in this essay I haven't gone anywhere near the truly difficult and painful spiritual/ethical issues of blood transfusions and Jehovah's Witnesses, abortion, or faith-based objections to teenage birth control and HPV vaccination. My interest has been on what you might call "bread and butter" spiritual concerns, but demonstrating respect, empathy, and truthfulness is essential in any situation involving religion or spirituality. We struggle, do our best, make mistakes, fall down and get back up, mindful that where spirituality is concerned, nothing is etched in stone.
(Creative Commons image by john-norris via Flickr)