Monday 14 May 2012
Wednesday 25 April 2012
The Iceberg and the Tip
The tip of the iceberg of suffering is when someone kills themselves. Why it is the tip of the iceberg is because for every person who commits the act there are many many others who suffer depression and anxiety, often quietly, and for some, for their entire lives.
We each bring our reasons to the work we do and for me it must in some ways be tied up with my own father's depression and multiple suicide attempts when I was an adolescent. If I look at my motivations for blogging I find that I have the hope that maybe, just maybe, one of these posts might help someone feel less alone and be more open to asking for help if they are feeling depressed anxious or suicidal. This is a lofty goal, and some may say it is even Polyanna-ish- No matter, it has, at the least, the potential to be helpful, and, if you have read this far it is likely that it is not causing any harm.
If you click on the link below you will be brought to short 10 min NPR interview with the MD-author Danille Ofri as she talks about the shocking suicide of one of her mentor's.
Be well,
S.
From Danielle Ofri's website:
Doctors’ Suicide
One of my most beloved mentors from residency took his own life. He seemed so much older to me at the time, but he was only 39 years old. In this interview on NPR, I talk about his loss, and read from the story I wrote about him, “Intensive Care.” This story, from the book Singular Intimacies, is included in a new anthology, Writer MD.
http://danielleofri.com/doctors-suicide/
http://ttbook.org/book/danielle-ofri-suicide-and-medicine
Thursday 29 March 2012
Emotions, intelligence, and medicine
The NYT's article below outlines the conditions in which pretending we do not have emotions and suppressing our own reactions is unhelpful. Rather than seeing emotions as a sign of weakness, there is a lot of good evidence (particularly in the psychology literature) that the best decisions are made when we couple our rational (left-brain) to our intuitive (right-brain) and use BOTH together. I often get the impression that for many in medicine the "ideal" is to be 100% left -brain and to ignore those right-brain emotional messages. My own n-of-1 trial (i.e. my life) thus far has shown me that combining intuition & emotional-awareness in addition to rational cognition makes both me and those around me happier. That is true only of course, when I can actually do all that!
S.
Doctors Have Feelings, Too
By DANIELLE OFRI (in the NYT's)
It was a little bit like looking in the mirror. We were the same height and build, the same age — mid-30s — and both of us had two young children at home. In another world, had we been friends, we could have easily shared clothing. But today it was me with the white coat, and her with the death sentence.
Except she didn’t know it yet.
It was the morning of Julia’s discharge from the hospital, and we were going through the array of cardiac medications stacked on her bedside table. She asked the same question about each bottle: “Will this medicine make my heart better?”
I squirmed painfully around the question, weaving ever more elaborate explanations about controlling symptoms, enhancing breathing, minimizing fluid imbalances, improving exercise tolerance. I told every truth about every medication, but I could not bring myself to tell her the ultimate truth — that a roll of the genetic dice had doomed the fibrils of her heart, that her only chance was a heart transplant, that because she was an undocumented immigrant this was nigh impossible. That her children would grow up motherless.
Last month, an article in the journal Health Affairs made headlines in the news media — “Physicians Are Not Always Open or Honest with Patients.” A vast majority of the nearly 2,000 doctors surveyed agreed that physicians should be fully open and honest in all their communications with patients, as the Charter on Medical Professionalism requires, but more than one in 10 had specifically told a patient something that was not true within the past year. Almost one in five had not revealed a medical error. More than half had framed a prognosis in a more positive light than was warranted.
The authors expressed concern that doctors were not fully living up to the charter; patients worried that they couldn’t trust what their doctors said. I also found the data disturbing, but for different reasons. I don’t think that doctors are generally a dishonest bunch. Yes, there are a few utter miscreants out there, and many more who could use a tune-up on their communication skills. But I suspect that the dishonesty that is being uncovered in a study such as this — and frankly, I was amazed that the number of less-than-truthful instances was so low — reveals more about the diagnosis of being human than anything else.
When Julia walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have “open and honest” communication with her, in a “patient centered” manner. But I couldn’t. I couldn’t bring myself to tell this young mother that she was going to die.
It could be that I over-identified with my patient, or that I let my emotions get the better of me, or that I was an out-and-out wimp. No doubt all played some role, but I wasn’t the only doctor who struggled with the truth. Everyone responsible for her care — intern, resident, medical attending, cardiology fellow, cardiology attending — independently fell short of the Charter on Medical Professionalism. Young, old, male, female, touchy-feely, egotistical, blustery alike — not one of us could say those words to her face.
When it comes to medical error, doctors have an even harder time coming out with the truth. There is, of course, the well-founded fear of malpractice litigation. Momentum is growing for legislation to protect doctors who acknowledge error and apologize. But beyond the fear of malpractice, there is the larger issue of shame at failing at your job, of letting a patient down, that makes you want to hide. It took me two decades to speak publicly about my first major medical error.
I was one week out of my internship at the time, and my patient was admitted nearly comatose with what is called diabetic ketoacidosis, from a severe lack of insulin. After we’d brought him back from the brink and could finally turn off the intravenous short-acting insulin drip, I committed the cardinal error of neglecting to inject him with long-acting insulin. He promptly barreled downhill again. A senior resident rescued him before he had a cardiac arrest, then screamed her lungs out at me in front of the entire emergency room staff.
I never mustered the courage to tell the patient what happened. So great was my shame that it was 20 years before I could begin the “open and honest” communication that the situation deserved.
Are doctors simply cowards? Do our own existential fears paralyze us? Human beings, by nature, prefer to avoid horrible truths, and denial may be our most powerful survival skill. Doctors are no more nor less immune to this, and to the basic human drives of empathy and pity, than anyone else.
By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but the consideration of them rarely makes it into medical school curriculums, let alone professional charters. Typically, feelings are lumped into the catch-all of stress or fatigue, with the unspoken assumption that with enough gumption these irritants can be corralled.
The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the “continuous musical line of our minds, the unstoppable humming ...” This basso continuo thrums along, modulating doctors’ actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions.
Julia did eventually get the truth of her diagnosis, at her first post-discharge clinic visit. The actual moment was — as expected — horrible. It took several tries for us to get the words on the table. Voices choked, eyes brimmed — and that was just the doctors. Julia was more stoic. She nodded slowly, very slowly, as she pieced it all together. The quiet that followed felt like a licking of the wounds for all parties. All wasn’t sunny and optimistic, but there was a sense of reality, and now the planning could begin.
Why did it take us so long to tell her? It might have been that we doctors first had to come to terms with the diagnosis ourselves — however selfish that might sound. Perhaps, unconsciously, we were trying to give Julia breathing room. But all this may have been mere justification to make us feel better. The fact is that we didn’t tell her the whole truth, up front, as we should have.
I’d like to say that I’d handle the situation better now, with another decade of clinical experience under my belt, but I’m not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can’t — and shouldn’t — eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.
Danielle Ofri, an associate professor at New York University School of Medicine, is the editor of the Bellevue Literary Review and the author, most recently, of “Medicine in Translation: Journeys With My Patients.”
S.
Doctors Have Feelings, Too
By DANIELLE OFRI (in the NYT's)
It was a little bit like looking in the mirror. We were the same height and build, the same age — mid-30s — and both of us had two young children at home. In another world, had we been friends, we could have easily shared clothing. But today it was me with the white coat, and her with the death sentence.
Except she didn’t know it yet.
It was the morning of Julia’s discharge from the hospital, and we were going through the array of cardiac medications stacked on her bedside table. She asked the same question about each bottle: “Will this medicine make my heart better?”
I squirmed painfully around the question, weaving ever more elaborate explanations about controlling symptoms, enhancing breathing, minimizing fluid imbalances, improving exercise tolerance. I told every truth about every medication, but I could not bring myself to tell her the ultimate truth — that a roll of the genetic dice had doomed the fibrils of her heart, that her only chance was a heart transplant, that because she was an undocumented immigrant this was nigh impossible. That her children would grow up motherless.
Last month, an article in the journal Health Affairs made headlines in the news media — “Physicians Are Not Always Open or Honest with Patients.” A vast majority of the nearly 2,000 doctors surveyed agreed that physicians should be fully open and honest in all their communications with patients, as the Charter on Medical Professionalism requires, but more than one in 10 had specifically told a patient something that was not true within the past year. Almost one in five had not revealed a medical error. More than half had framed a prognosis in a more positive light than was warranted.
The authors expressed concern that doctors were not fully living up to the charter; patients worried that they couldn’t trust what their doctors said. I also found the data disturbing, but for different reasons. I don’t think that doctors are generally a dishonest bunch. Yes, there are a few utter miscreants out there, and many more who could use a tune-up on their communication skills. But I suspect that the dishonesty that is being uncovered in a study such as this — and frankly, I was amazed that the number of less-than-truthful instances was so low — reveals more about the diagnosis of being human than anything else.
When Julia walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have “open and honest” communication with her, in a “patient centered” manner. But I couldn’t. I couldn’t bring myself to tell this young mother that she was going to die.
It could be that I over-identified with my patient, or that I let my emotions get the better of me, or that I was an out-and-out wimp. No doubt all played some role, but I wasn’t the only doctor who struggled with the truth. Everyone responsible for her care — intern, resident, medical attending, cardiology fellow, cardiology attending — independently fell short of the Charter on Medical Professionalism. Young, old, male, female, touchy-feely, egotistical, blustery alike — not one of us could say those words to her face.
When it comes to medical error, doctors have an even harder time coming out with the truth. There is, of course, the well-founded fear of malpractice litigation. Momentum is growing for legislation to protect doctors who acknowledge error and apologize. But beyond the fear of malpractice, there is the larger issue of shame at failing at your job, of letting a patient down, that makes you want to hide. It took me two decades to speak publicly about my first major medical error.
I was one week out of my internship at the time, and my patient was admitted nearly comatose with what is called diabetic ketoacidosis, from a severe lack of insulin. After we’d brought him back from the brink and could finally turn off the intravenous short-acting insulin drip, I committed the cardinal error of neglecting to inject him with long-acting insulin. He promptly barreled downhill again. A senior resident rescued him before he had a cardiac arrest, then screamed her lungs out at me in front of the entire emergency room staff.
I never mustered the courage to tell the patient what happened. So great was my shame that it was 20 years before I could begin the “open and honest” communication that the situation deserved.
Are doctors simply cowards? Do our own existential fears paralyze us? Human beings, by nature, prefer to avoid horrible truths, and denial may be our most powerful survival skill. Doctors are no more nor less immune to this, and to the basic human drives of empathy and pity, than anyone else.
By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but the consideration of them rarely makes it into medical school curriculums, let alone professional charters. Typically, feelings are lumped into the catch-all of stress or fatigue, with the unspoken assumption that with enough gumption these irritants can be corralled.
The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the “continuous musical line of our minds, the unstoppable humming ...” This basso continuo thrums along, modulating doctors’ actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions.
Julia did eventually get the truth of her diagnosis, at her first post-discharge clinic visit. The actual moment was — as expected — horrible. It took several tries for us to get the words on the table. Voices choked, eyes brimmed — and that was just the doctors. Julia was more stoic. She nodded slowly, very slowly, as she pieced it all together. The quiet that followed felt like a licking of the wounds for all parties. All wasn’t sunny and optimistic, but there was a sense of reality, and now the planning could begin.
Why did it take us so long to tell her? It might have been that we doctors first had to come to terms with the diagnosis ourselves — however selfish that might sound. Perhaps, unconsciously, we were trying to give Julia breathing room. But all this may have been mere justification to make us feel better. The fact is that we didn’t tell her the whole truth, up front, as we should have.
I’d like to say that I’d handle the situation better now, with another decade of clinical experience under my belt, but I’m not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can’t — and shouldn’t — eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.
Danielle Ofri, an associate professor at New York University School of Medicine, is the editor of the Bellevue Literary Review and the author, most recently, of “Medicine in Translation: Journeys With My Patients.”
Thursday 15 March 2012
Medicine with a Heart
There is an entire website and related discussion-groups based on "Remembering the Heart of Medicine" (check it yourself at http://theheartofmedicine.org/finding-meaning-in-medicine-discussions/fmm-email/) that is a call to meaning and re-discovering the depth in the everyday.
This pausing to ask "what matters?" and "where is the heart in this?" is not just for doctors to need to do (although as a group perhaps we need to be reminded even more than most, due to both internal & external forces that lead us away from the heart).
Stumbling across the poem below was just such a moment's pause for me today, and now perhaps for you too?
DESIRE
Alice
Walker
My desire
is always the same; wherever Life
deposits me:
I want to stick my toe
& soon my whole body
into the water.
I want to shake out a fat broom
& sweep dried leaves
bruised blossoms
dead insects
& dust.
I want to grow
something.
It seems impossible that desire
can sometimes transform into devotion;
but this has happened.
And that is how I've survived:
how the hole
I carefully tended
in the garden of my heart
grew a heart
to fill it.
My desire
is always the same; wherever Life
deposits me:
I want to stick my toe
& soon my whole body
into the water.
I want to shake out a fat broom
& sweep dried leaves
bruised blossoms
dead insects
& dust.
I want to grow
something.
It seems impossible that desire
can sometimes transform into devotion;
but this has happened.
And that is how I've survived:
how the hole
I carefully tended
in the garden of my heart
grew a heart
to fill it.
Saturday 3 March 2012
Nothing to do, nowhere to go, nothing to achieve
Why do I write these posts? (Other than to
meet some of my ego’s needs).
My intention is the possibility that
you, dear reader, may come across it at just the time you need to hear it. The
proverb “When the student is ready the
teacher will appear” has been true at important times in my own life. I
remain grateful to many for putting stuff out there so that when I was ready it
was right there for me.
Of course that also means that not
everything is for everybody (and that’s where the delete button comes in real
handy).
What follows is by no means an
explanation of suicide or even of depression. It is rather an attempt to make
sense of things out of my own experiences. So it may not ring true for you and
is not meant as an explanation of anyone else’s behaviour.
Growing up with a depressed and
suicide-attempting dad (he is still alive) has made me ask myself “how can I learn not to end up depressed and
a victim of my own thoughts?” (and keep in mind that I chose to work in
pediatric palliative care!)
Does any of this sound familiar?
·
You get married and
think “I will never be lonely again!”
·
You get a job
promotion and a raise and think “now everything is going to be perfect!”
·
After years of trying
you finally have a child and now “life is finally complete!”
If only.
You know how foolish it is to think that
any one thing is ever going to make “everything just perfect”.
Without the mythic and impossible
promise of “everything will be perfect when…” the advertising industry would grind
to a halt in a heartbeat!
Does any of this sound familiar?
·
You lose your job, and
now your life is ruined!
·
You get a frightening
diagnosis and now your life is over!
·
Someone you love dies,
and now your life will never have a good moment again.
Are any of these thoughts true?
Even if they feel really true at the
time just how long do they last? Forever?
Things happen, we can’t control most of
it, and we decide, on the spot, that they are great or terrible. But when you look back at what you thought was
bad it rather turned out to be good, and what was supposed to great and long-lasting
was not so.
·
“I would not wish this diagnosis of cancer on anyone but it has changed
my life and I have grown”.
·
“Losing everything I had thought I needed to be happy has turned out to
be the best thing that ever happened to me”
What to make of all this?
Not
only do we not know what is going to happen next, but our initial judgements
about what is good or bad are often wrong, or at least it is often more
complicated (the good/bad judgement) than we initially thought.
All these things that happen are
descriptions of our life situation, but not of our LIFE.
Things happen to us and we get buffeted
around by them like a balloon in the wind – Sometimes we are up and sometimes
down – and all that is still not our LIFE but is rather our life-situation.
So what is our LIFE if it is not all
these things that happen?
Is it possible that LIFE is what is
experiencing all these things?
This LIFE (versus life-situation) is
what we sense when an island of calm opens up in those spontaneous moments
where thinking abates and we just are – We all get these moments from time to time –
·
Watching your 8 year
old eat an apple;
·
Diving into a calm
lake;
·
Sitting quietly and watching
the snow falling just outside the window.
So what's the big deal about the
difference between LIFE and life-situation?
If you believe that your life situation
is the same as your LIFE, if you believe that your self-worth is hinged on this
or that, then you are vulnerable to losing your “reason for living”.
Do you really need any justification for
being alive?
Does any form of life need to “do
something” to justify its existence? Does a flower or a bird need to justify
its own existence to itself or to others?
There is no judgment of good or bad in
“LIFE” but lots of judgements of good and bad in “life-situations”.
As far as your LIFE is concerned there
is nothing to do, nowhere to go and nothing to achieve.
By all means go ahead and do, go, and
achieve, just see them as choices to make and not as necessary justifications
for your LIFE.
If
you believe that what happens to you is the same thing as your LIFE, as who you
really are, then the thought “I
do not deserve to live” can become a wrong thought believed.
And
that can be a fatal mistake.
Friday 17 February 2012
I, Me,& Mine = The misery of taking things personally
Case 1- If you get a hit on the back of
your head and then spin around and see that it was caused by a small tree branch
that fell, then how do you feel?
Case 2- If you get the exact same hitting sensation
on the back of your head and then spin around and see that it was because you
were struck by someone holding a small tree branch in their hand, then how do
you feel?
Do you
quickly rub your head and then get on with your day in the first case?
Do you take
the second case personally and does it then result in a rush of intense potentially
long lasting negative uncomfortable feelings compared to the first case?
What does
it mean to take things “personally” and all the unwanted baggage that goes with
that?
“How could she talk to me like that!”
“I can’t believe he treated me that way!”
“I can’t believe he treated me that way!”
“Who do they think they are?!”
Is it
possible that being unhappy/miserable/suffering boils to down to taking things
personally? But how could I not take
things personally when someone just did or said something to ME?
I think
this points to the question of who we think we are (and sometimes we are even told
exactly that (often in a very loud voice) as in; “Who (the hell) do you think you are!” Maybe the best answer to
that is; “Good question!”
Who am I?
- Am I my body? – If so then if certain
body parts are removed or change am I less myself?
- Am I my thoughts? – If so then
my thoughts (and even core beliefs) have changed since I was born – does that
mean I am not “me” anymore?
- Am I the totality of my life
experiences? – If so then would I not be “me” (the me inside that observes
& remembers) if I had had different experiences (e.g. grew up in a
different country)?
- Ask the same question (i.e. “Am
I this, Am I that?) and the answer always comes back as “Well, yes and no”. It seems that nowhere I look
do I find a stable enduring sense of “me” other than just this “feeling”.
Have I said
and done things I never imagined I would ever say or do (answer = for sure!).
So is it
possible that even I myself am not 100% sure who “I am”?
I think so.
If even I
myself am not sure who “me” is then how could anyone else really know who “I am”?
If no one
else can know who I am then how could anything they ever do really be “to me”? Whatever
they do is, at worse, being done to their version of who they think I am, as
opposed to the “real” me – which is not even really knowable anyway.
Add to this
that most of us spend our time worrying and thinking about how everything
relates back to ourselves (the internal narrative that is mostly an ongoing
story of “me”). Given all that then whatever goes on is likely not really about
“me” at all. That does not mean that things are to be ignored but rather that
seeing them for what they really are means seeing that things happen as a result
of all kinds of factors that do not all revolve around “me”.
So if you
come at me with a stick I will still run or turn to defend myself, but I will
do so with trying to see what is happening from an understanding that trying to
hurt me is not so much about “me” and
likely more about what is going on in the other person. Taking things less
personally in this way feels like a path to less misery. At least it has for me
so far as I continue in my “n of 1 trial”
that is trying to answer/live out the question: “How to live?”
What do you
(whoever “you” really are!) think?
Thursday 9 February 2012
Self-compassion=The opposite of being selfish
Although last week's post was about what mindful speaking might look like, alert readers pointed out that my using the term "personal failure" was harsh at best, and they are correct.
So what does it mean to be so self-critical? Is it possible that there is a direct connection between self-criticism/self harshness and judging others?
I think so.
Maybe I need to re-read the textbook chapter on "professional self care" that I co-wrote where i say that "Care of others begins with caring for ourselves".
If we are harsh with ourselves and self judge then why should we expect to be able to be open and non-judgmental of others?
If we cannot laugh at our own foibles and little failures then do we really expect that we can do the same for others?
Wouldn't it be the wiser path to practice being compassionate with the one person we are always around?
Why not be kind to ourselves as a way to practice being kind to others?
Self compassion is not the same as self esteem as outlined by this quote taken from the website of Kristen Neff - her website is a great resource - You can even take a self-compassion quiz to see how you score for yourself! (From Kristin Neff's website - http://www.self-compassion.
"Although self-compassion may seem similar to self-esteem, they are different in many ways. Self-esteem refers to our sense of self-worth, perceived value, or how much we like ourselves. While there is little doubt that low self-esteem is problematic and often leads to depression and lack of motivation, trying to have higher self-esteem can also be problematic. In modern Western culture, self-esteem is often based on how much we are different from others, how much we stand out or are special. It is not okay to be average, we have to feel above average to feel good about ourselves. This means that attempts to raise self-esteem may result in narcissistic, self-absorbed behavior, or lead us to put others down in order to feel better about ourselves. We also tend to get angry and aggressive towards those who have said or done anything that potentially makes us feel bad about ourselves. The need for high self-esteem may encourage us to ignore, distort or hide personal shortcomings so that we can’t see ourselves clearly and accurately. Finally, our self-esteem is often contingent on our latest success or failure, meaning that our self-esteem fluctuates depending on ever-changing circumstances.
In contrast to self-esteem, self-compassion is not based on self-evaluations. People feel compassion for themselves because all human beings deserve compassion and understanding, not because they possess some particular set of traits (pretty, smart, talented, and so on). This means that with self-compassion, you don’t have to feel better than others to feel good about yourself. Self-compassion also allows for greater self-clarity, because personal failings can be acknowledged with kindness and do not need to be hidden. Moreover, self-compassion isn’t dependent on external circumstances, it’s always available – especially when you fall flat on your face! Research indicates that in comparison to self-esteem, self-compassion is associated with greater emotional resilience, more accurate self-concepts, more caring relationship behavior, as well as less narcissism and reactive anger."
In contrast to self-esteem, self-compassion is not based on self-evaluations. People feel compassion for themselves because all human beings deserve compassion and understanding, not because they possess some particular set of traits (pretty, smart, talented, and so on). This means that with self-compassion, you don’t have to feel better than others to feel good about yourself. Self-compassion also allows for greater self-clarity, because personal failings can be acknowledged with kindness and do not need to be hidden. Moreover, self-compassion isn’t dependent on external circumstances, it’s always available – especially when you fall flat on your face! Research indicates that in comparison to self-esteem, self-compassion is associated with greater emotional resilience, more accurate self-concepts, more caring relationship behavior, as well as less narcissism and reactive anger."
Be well,
S.
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