I've been spending the last few days reading a book on motivational interviewing. One of the main problems I see in medicine is communication, and one of the things in which we aren't trained enough. In medicine and in my own life I've seen the weight of words. I have personal biases too, because having spent years writing essays about the choice of particular words and their context, I'm inclined to feel the nuances of everything that's said. This book is founded on the idea that while change must happen from a source internal to a person, the facilitation of the change very much depends on external factors, like how you talk to them about the change. I think this is all very true, that people are consciously and subconsciously affected by tone, syntax, vocabulary.
For that reason I try to take care with words; it's one reason I find it easiest to write rather than converse, when I have more time to consider. I've been told that this is a mode of filtering, that I'm being less honest because I don't just say what comes to mind. But for me I don't feel that my immediate words reflect my immediate feelings, mostly because I've barely figured out how I feel, not nearly enough to explain why I feel that way, and to explain it to convey it.
But it is hard, because language, even the same one, doesn't overlap from person to person. There are subtle differences in connotation and meaning for each person, and not only do you have to process what it means to you, but also what did the person mean, and which is more meaningful? Since I give it so much thought, I often forget that most people don't. And so, I shouldn't take things this way or that; that's not what was intended, and then following that things are said with clear meaning but that aren't meant. Too much care can be ultimately detrimental, and so balance is a goal in even something like that.
Friday, December 17, 2010
Wednesday, December 8, 2010
talking to each other
A very rough retrospective summary of happenings at the end of October, beginning of November--
*
When we first learn how to interview patients, we are taught to center our conversation around the patient’s chief complaint, with subsequent questions designed to elucidate its source and nature. Because people aren’t naturally inclined to speak following such structure, we’re taught to set an agenda early on in the conversation, to prevent unnecessary ramble and distracting tangents. Emphasize the main points and shed the rest to the sidelines. When a person comes in with a long list of concerns, we’re advised to ask the patient what is most personally important, while we silently also consider what may be most medically important. In this way we cut down and narrow for efficiency, but in doing so sometimes we also dilute, and make murky the source that we develop such intricate formulas to discern.
I’d seen several patients with chronic pain with Dr. McGarvey, and they often have multiple issues both within and outside the realm of physical pain. It can be overwhelming, and unrealistic, to address all of them. One woman, followed by Dr. McGarvey for pain and depression, comes to the clinic with concerns about head pain radiating down her arm, bilateral feet cramping, an episode where she felt sweaty and “drunk,” and sinus tenderness. These are what she names as most important to her, when asked to narrow her initial multitude of issues. She brings all her medications, and narrates a lengthy story about having stopped certain drugs after attributing her drunken sensation to her medications, and recent additions to her medications, and then having stopped all of them after visiting a native medicine healer, and not knowing where along this line lay the cause of her symptoms.
Armed with her bottles and stories, she is someone who may be quickly considered difficult and unreasonable by a healthcare provider meeting her for the first time, or one who has seen her often. But Dr. McGarvey uses his several year history with her to delicately untangle the threads of her state of health, taking each one in turn and stopping to examine the intersections where one crossed another. He translated the sweating and drunkenness that she described in association with her medications to diaphoresis and altered mental status, symptoms of a process called serotonin syndrome that may have been precipitated by a recent addition of trazodone to her usual sertraline, both drugs acting to increase serotonin in her system. This may also account for the cramping in her feet.
When she says that occurrences like these make her feel like she is taking too many medications, because she can never be sure what is acting on what, he doesn’t present the removal of trazodone as the only solution. Instead, he works with her to rework her medication regime. He groups them into drugs for pain, depression, and prevention and maintenance. He points out the few medications he felt were very necessary, and points out others that are more for long-term that may not be as crucial to take at this current moment. He knows her well enough to know to not overwhelm her now, and to know that she will be open to restarting these medications later. With the drugs for pain, he listens to which ones she feels help and which don’t, and rearranges things accordingly. The doctor having often talked through her medications before, the patient understands the details of her medications, and asks intelligent, thoughtful questions.
This is a routine that may be recurring, and that will never eradicate the continual pains and problems, but his care helps her take care of herself the best she can. For her there is no chief complaint, but a general sense of non-well-being, and a person in such a place often benefits from us broadening our view.
She pushes us to do so when she asks for a referral to the native medicine healer in the hospital. After checking in with the pharmacy to begin filling her prescriptions, I take her to the hogan where Larry, the native medicine healer, is working. A hogan is a traditional Navajo building, where families live and host ceremonies. It’s built in the shape of an octagon, and you enter the hogan in one direction and leave in the other, clockwise, to mimic the rotation of the earth around the sun. This one has a fireplace in the middle, rendering all the dimensions of the chimney completely visible until it reaches the roof.
Larry sits in one chair without a back, she sits on another chair with a back and so do I. While the light is still on in the hogan, he asks her what is plaguing her, and she tells him about her head pain radiating to her arm and her feet cramping. Then he takes out a small zippered pouch containing three crystals, a feather, an arrowhead, and a longer item I can’t identify. He’d received the set of three crystals from his grandfather, who had been a medicine man. He can’t say where they are originally from or how they came to be in his possession other than that they’d been passed on in the family for years and years. As a child, Larry followed his grandfather as he healed others, and when Larry was thirteen he perceived the light of the crystal while crystal gazing, the process which he is commencing now.
He lays out two square white cloths. One behind him, one in front of him. The one cloth behind him holds the items he will later place in his hand, and in her hand. On the one cloth in front of him, he places a small round glass bowl. He pours water from a water bottle into the bowl, and places one crystal and the arrowhead in the bowl after the water.
The feather he places in front of this cloth. He holds one crystal in his hand, gives one crystal for her to hold, as well as the item I couldn’t discern. He turns off the lights, turning to me and saying, “This is like an X-ray. It must be dark so that I may see through the body.”
They begin conversing in Navajo for a few minutes, and then he stares for a long time into the crystal. He speaks to her again for another few minutes. In the crystal he sees that in several years ago she had cut and burned the cactus around her home. This disruption of natural surroundings seeped into her body, and I wonder in what spaces—blood, bone, mind?
“You must communicate with all the elements: the sun you feel, the animals you eat, the trees you cut down to make a hogan. You tell them what you are doing with them, you ask permission. They talk to you too, if you listen.”
When there is a rearrangement of the state of things without conversation, the disorder is carried inside and manifests itself as illness. Other happenings like lightning and tornadoes can bring upon a person the aches of arthritis or a silent rise in blood pressure. I’m not sure if these natural occurrences are sources, or reflections, of disturbance.
Like others, this patient will need prayers, one which Larry chants now, and a ceremony in the future to fully recover. In her case, it will entail an offering to cacti and stages of placing sand paint, white for the new dawn and yellow for the closing evening, on her face and chest.
Ceremonies are performed for intervention in times of sickness, as well as for shaping in times of health. When girls experience their first menstrual period, they undertake the process of a kpuberty ceremony. Because a girl’s body is in a phase of change, everything about it is considered sacred; her spit is saved and used as medicine. Everything about it is also malleable. The ceremony lasts four days, and the girl runs at dawn and noon every day, each time going a bit further, to imbibe stamina for the rest of her life. She bakes a large cake for everyone from corn, which she is to grind herself from kernels to powder, using grindstones (one long stone and a bigger slab of stone), and she hand weaves the carpets and baskets used in the ceremony. These movements provide form, and she is also shaped by others in a process called molding, where she lays atop blankets as her skin is massaged by older women.
At the end of this ceremony, the patient drinks the water from the round glass.
“Where water comes together is birth; everything comes from water,” Larry explains.
I am a witness, as someone other than the giver and recipient of prayer must be present. If I had not been there, Larry would have used a long wooden stick he calls a ladder, as a witness. He would communicate with the ladder before beginning the crystal gazing, and then throughout the process, explaining what he sees and feels, just as he did with me.
Everything requires communication. When Larry offers to give me a travel prayer when I leave Arizona next week, I ask whether that it’s all right for someone from another culture to receive a prayer. With a short, light laugh he says, “Yes!”
“Before we start the prayer, I will tell the elements who you are, how you grew up, what your culture is. For those who believe in a Christian God, I will include this in the prayers too; for those who don’t, I don’t. I myself go to three different churches. I was raised Catholic by my mother, I go to Protestant church for the songs, and to Mormon church because my wife is Mormon. I feel the belief is all the same thing.”
“How important is belief to whether the prayer will work?”
“It works sometimes even for those who don’t believe. Belief is the thing, though.”
And so, on my last day on the Navajo reservation I’m blessed by Larry for safe travels. He uses a feather that was a gift given to him in Canada, where he took his wife once when she was feeling badly about her father’s death. At that time, seeing her grive, he had said to her, “Let’s drive North,” and that’s what they did. He brought back this feather that he uses often for prayers. He sings a travel song, and then prays, all in Navajo. The only thing he says in English is: “going to drive to Connecticut.”
He burns wheatgrass atop a burning coal. He gathers the smoke in the air with the feather, using the feather to wave the wafts around my body, then touching the feather lightly to my body: my feet, shins, knees, thighs, arms, chest, shoulders, cheeks, back.
When he says goodbye, he gives me a gentle hug sideways, stooping very slightly to meet me.
*
When we first learn how to interview patients, we are taught to center our conversation around the patient’s chief complaint, with subsequent questions designed to elucidate its source and nature. Because people aren’t naturally inclined to speak following such structure, we’re taught to set an agenda early on in the conversation, to prevent unnecessary ramble and distracting tangents. Emphasize the main points and shed the rest to the sidelines. When a person comes in with a long list of concerns, we’re advised to ask the patient what is most personally important, while we silently also consider what may be most medically important. In this way we cut down and narrow for efficiency, but in doing so sometimes we also dilute, and make murky the source that we develop such intricate formulas to discern.
I’d seen several patients with chronic pain with Dr. McGarvey, and they often have multiple issues both within and outside the realm of physical pain. It can be overwhelming, and unrealistic, to address all of them. One woman, followed by Dr. McGarvey for pain and depression, comes to the clinic with concerns about head pain radiating down her arm, bilateral feet cramping, an episode where she felt sweaty and “drunk,” and sinus tenderness. These are what she names as most important to her, when asked to narrow her initial multitude of issues. She brings all her medications, and narrates a lengthy story about having stopped certain drugs after attributing her drunken sensation to her medications, and recent additions to her medications, and then having stopped all of them after visiting a native medicine healer, and not knowing where along this line lay the cause of her symptoms.
Armed with her bottles and stories, she is someone who may be quickly considered difficult and unreasonable by a healthcare provider meeting her for the first time, or one who has seen her often. But Dr. McGarvey uses his several year history with her to delicately untangle the threads of her state of health, taking each one in turn and stopping to examine the intersections where one crossed another. He translated the sweating and drunkenness that she described in association with her medications to diaphoresis and altered mental status, symptoms of a process called serotonin syndrome that may have been precipitated by a recent addition of trazodone to her usual sertraline, both drugs acting to increase serotonin in her system. This may also account for the cramping in her feet.
When she says that occurrences like these make her feel like she is taking too many medications, because she can never be sure what is acting on what, he doesn’t present the removal of trazodone as the only solution. Instead, he works with her to rework her medication regime. He groups them into drugs for pain, depression, and prevention and maintenance. He points out the few medications he felt were very necessary, and points out others that are more for long-term that may not be as crucial to take at this current moment. He knows her well enough to know to not overwhelm her now, and to know that she will be open to restarting these medications later. With the drugs for pain, he listens to which ones she feels help and which don’t, and rearranges things accordingly. The doctor having often talked through her medications before, the patient understands the details of her medications, and asks intelligent, thoughtful questions.
This is a routine that may be recurring, and that will never eradicate the continual pains and problems, but his care helps her take care of herself the best she can. For her there is no chief complaint, but a general sense of non-well-being, and a person in such a place often benefits from us broadening our view.
She pushes us to do so when she asks for a referral to the native medicine healer in the hospital. After checking in with the pharmacy to begin filling her prescriptions, I take her to the hogan where Larry, the native medicine healer, is working. A hogan is a traditional Navajo building, where families live and host ceremonies. It’s built in the shape of an octagon, and you enter the hogan in one direction and leave in the other, clockwise, to mimic the rotation of the earth around the sun. This one has a fireplace in the middle, rendering all the dimensions of the chimney completely visible until it reaches the roof.
Larry sits in one chair without a back, she sits on another chair with a back and so do I. While the light is still on in the hogan, he asks her what is plaguing her, and she tells him about her head pain radiating to her arm and her feet cramping. Then he takes out a small zippered pouch containing three crystals, a feather, an arrowhead, and a longer item I can’t identify. He’d received the set of three crystals from his grandfather, who had been a medicine man. He can’t say where they are originally from or how they came to be in his possession other than that they’d been passed on in the family for years and years. As a child, Larry followed his grandfather as he healed others, and when Larry was thirteen he perceived the light of the crystal while crystal gazing, the process which he is commencing now.
He lays out two square white cloths. One behind him, one in front of him. The one cloth behind him holds the items he will later place in his hand, and in her hand. On the one cloth in front of him, he places a small round glass bowl. He pours water from a water bottle into the bowl, and places one crystal and the arrowhead in the bowl after the water.
The feather he places in front of this cloth. He holds one crystal in his hand, gives one crystal for her to hold, as well as the item I couldn’t discern. He turns off the lights, turning to me and saying, “This is like an X-ray. It must be dark so that I may see through the body.”
They begin conversing in Navajo for a few minutes, and then he stares for a long time into the crystal. He speaks to her again for another few minutes. In the crystal he sees that in several years ago she had cut and burned the cactus around her home. This disruption of natural surroundings seeped into her body, and I wonder in what spaces—blood, bone, mind?
“You must communicate with all the elements: the sun you feel, the animals you eat, the trees you cut down to make a hogan. You tell them what you are doing with them, you ask permission. They talk to you too, if you listen.”
When there is a rearrangement of the state of things without conversation, the disorder is carried inside and manifests itself as illness. Other happenings like lightning and tornadoes can bring upon a person the aches of arthritis or a silent rise in blood pressure. I’m not sure if these natural occurrences are sources, or reflections, of disturbance.
Like others, this patient will need prayers, one which Larry chants now, and a ceremony in the future to fully recover. In her case, it will entail an offering to cacti and stages of placing sand paint, white for the new dawn and yellow for the closing evening, on her face and chest.
Ceremonies are performed for intervention in times of sickness, as well as for shaping in times of health. When girls experience their first menstrual period, they undertake the process of a kpuberty ceremony. Because a girl’s body is in a phase of change, everything about it is considered sacred; her spit is saved and used as medicine. Everything about it is also malleable. The ceremony lasts four days, and the girl runs at dawn and noon every day, each time going a bit further, to imbibe stamina for the rest of her life. She bakes a large cake for everyone from corn, which she is to grind herself from kernels to powder, using grindstones (one long stone and a bigger slab of stone), and she hand weaves the carpets and baskets used in the ceremony. These movements provide form, and she is also shaped by others in a process called molding, where she lays atop blankets as her skin is massaged by older women.
At the end of this ceremony, the patient drinks the water from the round glass.
“Where water comes together is birth; everything comes from water,” Larry explains.
I am a witness, as someone other than the giver and recipient of prayer must be present. If I had not been there, Larry would have used a long wooden stick he calls a ladder, as a witness. He would communicate with the ladder before beginning the crystal gazing, and then throughout the process, explaining what he sees and feels, just as he did with me.
Everything requires communication. When Larry offers to give me a travel prayer when I leave Arizona next week, I ask whether that it’s all right for someone from another culture to receive a prayer. With a short, light laugh he says, “Yes!”
“Before we start the prayer, I will tell the elements who you are, how you grew up, what your culture is. For those who believe in a Christian God, I will include this in the prayers too; for those who don’t, I don’t. I myself go to three different churches. I was raised Catholic by my mother, I go to Protestant church for the songs, and to Mormon church because my wife is Mormon. I feel the belief is all the same thing.”
“How important is belief to whether the prayer will work?”
“It works sometimes even for those who don’t believe. Belief is the thing, though.”
And so, on my last day on the Navajo reservation I’m blessed by Larry for safe travels. He uses a feather that was a gift given to him in Canada, where he took his wife once when she was feeling badly about her father’s death. At that time, seeing her grive, he had said to her, “Let’s drive North,” and that’s what they did. He brought back this feather that he uses often for prayers. He sings a travel song, and then prays, all in Navajo. The only thing he says in English is: “going to drive to Connecticut.”
He burns wheatgrass atop a burning coal. He gathers the smoke in the air with the feather, using the feather to wave the wafts around my body, then touching the feather lightly to my body: my feet, shins, knees, thighs, arms, chest, shoulders, cheeks, back.
When he says goodbye, he gives me a gentle hug sideways, stooping very slightly to meet me.
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