This morning, I met with my research advisor to go over a transcript of my first interview, which I conducted back in September. My project is qualitative research, speaking with hospice or near-hospice patients about their main concerns during this transitional period that we term end-of-life. My first interview was with a lovely woman from the South, with a subtly sharp sense of humor and generous spirit, who died a couple months after I met her. She's the one who I wrote about previously, who had written a story she'd wanted to publish in her nursing home newspaper. We'd worked on it together, and she died before it could get published; it will be printed in April.
With those strings in mind, I read the transcript with my advisor, who said, isn't it funny to hear her voice coming back? I agreed, and I thought how nice it was that I had the interview on tape, and also how nice it was to see it transcribed on paper. I've been so trained to close-read that when conversation becomes written, I pay attention differently. Words take on much more contextual meaning. And as fresh eyes to the interview, my advisor noticed motifs and word choices and turns of phrases that I hadn't, while speaking to the patient. She also loves telling any story that comes to her mind when something reminds her of it; they're always funny, or touching, or interesting.
Reading the transcript made me excited anew about the project, realizing that there was more than I realized in those conversations. I'd worried that without structure, and with such different people in different situations, it'd be hard to glean anything from the interviews. But even if each transcript turns out to be very different, there are plenty of individual insights into a person's thought process and expression of them, and that's worthwhile.
Much of the reading I've been doing on qualitative research and narrative analysis emphasizes what's lost when conversations are transcribed into script. You lose tone, pauses, faces, and so on; it's true that much nuance is sacrificed. And so I was surprised to see that simultaneously true is that something's gained in this translation. There's something about the act of recording, which inherently must be in a different medium than actual experience, that gives a perspective outside of the experience itself.
*
This afternoon the wife and I continued to labor over our class slideshow, to be shown at our school's annual second-year-show this weekend. Each year the graduating class puts together a slideshow of pictures. Ever since I saw the fourth year class slideshow during my first year here, I've wanted to work on ours.
We downloaded all the pictures sent from our classmates, and because I wanted to give the show a theme and not just be a conglomeration of pictures, we went through them and organized them. Then we laid them out into slides, keeping in mind order and cohesiveness and variety. Then wife and another friend/classmate of ours chose music to correspond to different parts of the slideshow, and had to learn how to splice music to put together a mix. Then we had to sync, sync, sync, and sync again the music to the pictures; there were a lot of transitions in the pictures that we wanted to line up with transitions in the music. Then we embedded a short video to conclude the show.
We probably spent the equivalent of 24 hours over different days in order to piece together this 6-minute slideshow. We had to choose which parts of songs we wanted, decide which pictures to cluster together, find pictures of everyone in our class, learn how to have certain pictures come into view, figure out how to time slides. All of this required learning details, looking up programs, pulling hair, and intermittent/continuous swearing.
It also meant watching the show over 20 times to see whether our piecemeal efforts congealed into solid form. As frustrating as the process could be, watching the product always made me nostalgic. Four years of people and experiences, compressed in two-second segments placed side by side like pages pressed in a book. Each time we would notice new nuances, the way a lyric coincided with an item on the slide or how, small moments of self-pride and love for the images--that won't be noticed by anyone else, but are known to us and after all that work, gives a lot.
It's a representation, but not only a representation--not in the sense that it's something else other than a representation, but that "representation" encompasses more than we give it credit for. It's not a replica of the experiences that give rise to the memories or even the memories themselves, but it's an experience on its own. The process of making this out of things already made, surprises in the way that in how new it is, how much there is still to learn and feel.
There's the personal satisfaction from creating something with your own hands, and also the sense that something's happening to you. This dynamic way of connecting yourself with things outside of you that are also kind of part of you, and of connecting the outside with parts of yourself that are also kind of already part of your environment, is obviously too poignant for me to describe with any sort of clarity. But for all the curses and furrowed brows, it feels damn good (so long as it goes well for the show, too).
*
I'm really grateful for small experiences like these, things no one would pinpoint as reasons to be a medical student. And of course it's more than medicine that led me to having these moments, and of course if I'd done something else I would've been led to others, but I don't think I've been exposed to quite as much compact variety at any other phase in my life. M and I talk a lot about reasons for and against a career in medicine, with the long stressful process being a drawback. But there are also a lot of opportunities to meet things you may never have felt. I'm lucky that Yale is particularly suited to exploring these things, often without much idea of concrete goal. I also feel lucky for being a part of a small community of students for four/five years; for me it's combined aspects of high school and college I liked most (with some of the bad of each thrown in there, too). I don't think I'll ever experience anything like it again, and in remembering and living it, I miss it too. So for that too I want to record.
Wednesday, February 16, 2011
Tuesday, February 15, 2011
free time
We've been so ingrained to work for things, work so hard that we long for free time and freedom, that when there's no immediate goal to work for we feel a little lost. Writing is difficult because the hours don't add up to results; what is put in doesn't correlate to what is put on paper. I don't think I've had anything else in my life that's so painful and so fulfilling at the same time, except for maybe relationships, and it's funny to think of something so solitary to be most like something so connected to people.
I find it difficult to focus, turning to multiple writings to override the block in one (hence the blogging, the emailing). When trying to write things with clearer details and points to the details, it can be relieving to ramble with whatever comes to mind. I go back and forth between the endeavor of writing and the typing of thought, in almost a frenzy.
And I place things in the background; there is always always music and often there's a book. Currently I'm reading about qualitative research--how to analyze narratives, interpret stories. Which is interesting and informative, but also occupies a lot of the same space allotted for writing, and crowds things a bit.
I doubt that there will another time in my life quite like this one, where I can give so much attention to the space and crowding in my mind. It's ungrateful and honest to complain about the difficulty of free time and uncertain pursuits, and it's also necessary to fully portray how lucky I feel to be both so wound-up and unwinding.
I find it difficult to focus, turning to multiple writings to override the block in one (hence the blogging, the emailing). When trying to write things with clearer details and points to the details, it can be relieving to ramble with whatever comes to mind. I go back and forth between the endeavor of writing and the typing of thought, in almost a frenzy.
And I place things in the background; there is always always music and often there's a book. Currently I'm reading about qualitative research--how to analyze narratives, interpret stories. Which is interesting and informative, but also occupies a lot of the same space allotted for writing, and crowds things a bit.
I doubt that there will another time in my life quite like this one, where I can give so much attention to the space and crowding in my mind. It's ungrateful and honest to complain about the difficulty of free time and uncertain pursuits, and it's also necessary to fully portray how lucky I feel to be both so wound-up and unwinding.
Wednesday, February 9, 2011
anniversary
I like anniversaries for the thought of remembering and reflecting, all that's happened between two points in time. Which is a lot, and considering how many days go by without significance--to feel that one year with someone has given you this much to feel and consider and grow, is nice. We went through a long phase of uncertainty, intermittent phases of awkwardness, a phase of closeness through distance, a phase of travel, and are in something good at the moment. I've always thought it was valuable and important to experience different stages, as we're different in different contexts. Through these with him, we've tried to be honest and open, and more than ease or sap, this is what I've loved best.
Saturday, February 5, 2011
hospice (ending)
I just finished my month-long hospice rotation at the Connecticut Hospice in Branford, which both gave more and took more than I anticipated. Perhaps because after a slew of clinical rotations, I've lost a bit of the expectant newness that used to come before each new venture, and so there wasn't much anticipation to begin with. I didn't think much about what hospice would be like before I started. Having had a strong experience that led me to being interested in the rotation in the first place, I think I unconsciously felt that I'd reached a certain level of intensity that would prevent me from being taken by surprise here, even as I approached this rotation as an opportunity for broadening experience, concrete and emotional. I'm glad to have been wrong.
I haven't felt this motivated to write about a medical school experience for a long time, but before doing it in a structured and comprehensive form, it feels nice to sit in bed and ramble about all the things that made it filling, and hard.
On my last day, an APRN asked me what was the most memorable event during the rotation. It would be hard, and probably not accurate, to choose one event or interaction or experience. Instead it was more generalities absorbed that most affected me. I told her that I'd take with me the calmness of the place, the simplicity of the medicine, and the kindness of the people.
Connecticut had the most snow in January on record since years and years ago. We had two two-feet snowstorms, a couple ice storms, and record below freezing temperatures. While I was used to this in Boston where the winter is more harsh than here, I'd never had to deal with the visceral challenges of snow and ice. For the first time in my life, I had to shovel my car out of the snow, had to try to drive it through the narrowly plowed driveway, had to shovel myself out of the driveway that wasn't plowed widely enough, had to shovel piles of snow off the entrance to the street where the tires would just spin in place, had to chip away at inches of ice off every window and off the roof of the car, had to see why getting ice off the roof is important as a I saw sheets of ice slip off cars on the highway, had to steer my car as it slid on unsalted iced roads, had to walk strategically to avoid puddles of slush and piles of iced snow. It was uncomfortable, and tiring to have to work so hard and think so hard about how to simply get somewhere.
There were also incredible vignettes of how pretty harshness can be, in the snowflakes that would freeze on my car windows to create a printed pattern I'd have to scrape away, in the ice that dressed bare tree branches making the forests on my drive looks like crops of glistening gray hair, and in the sheen of clean soft snow hardened on top like creme brulee, by the ice. There were incredible views from the windows, of big flakes falling against warm yellows and cold grays. There were the first falls, untouched, and the old snows, dirtied.
After the trek through all of that, I arrive at a workplace with windows in tandem, bookshelves, and fireplaces. Laid on the beds are crocheted blankets and patchwork quilts. Hand-painted signs of patient's names are hung in their respective spaces. Guitars strum, and every other day there are sweets from families or employees. It seemed to me I was lucky to have done this rotation during the onslaught of winter, to have to confront bitter elements with reason to escape to this cove. It's not often that you think of a workplace as soothing, especially not hospitals.
It's true that this atmosphere is partly due to the way that the rough edges of medicine are worn away a bit by the different goals and mindset of hospice. There is more thought to necessity, and the removal of what's not. In that sense, things feel simpler. There are no fancy tests to order; people often get sicker and instead of embarking on a diagnostic quest for etiology, we acknowledge the worsening condition and continue. There's still a lot of room for creativity in catering to individual needs. My attending pushed us to consider the best options for care, to not get stuck in status quo. But grounding all of that movement is a framework of simple stability. Not to say that dying is simple, but in the face its possible complexities, people's wants and needs become basic and streamlined to the core, without the excess that can often distort. After awhile the pharmacological treatments become routine, leaving more room to focus on non-pharmacological care, and hospice focuses on that much more than other areas of medicine. Its wholistic perception of people is reflected in its interdisciplinary approach to care; doctors aren't at the center, are instead an arm, of the scheme. There is constant, continual communication with the nurses, social workers, pastors, and family. And while there are many factors to consider, the way in which all these people work together to focus on each person's care, gives a simple sense of value.
I imagine that the comforts and simplicity help the staff as much as the patients, because as calming and welcoming a place it is, it is a hard place to be. Because of that, I think it attracts and seeks certain qualities in the people who work there, making for an incredible community. I've never met such a cluster of genuinely warm, kind, and strong people. The nurses, who are the heart of hospice care, made the biggest impression on me, but the kindness is palpable in every person encountered, from the person at the front desk to the person manning the cafeteria.
In the morning, the nurses and physicians round together, going over the care for each patient. The nurses are the ones giving report, which has never been the case for any other rounds I've seen. They make me remember why I want to be good at whatever it is that I do. They take care in the most whole way possible: delicate where people are fragile, tough and honest when needed. They advocate for their patients, they know their stuff, and they all have voice. It's this combination of warmth and strength that I admire most in women who give care, and every day it reinforced goals to work for.
On my last day I told a slightly demented patient of mine that it had been really nice to take care of her. She replied, "It was really nice to take care of you too." Even as her response was a rote one, I appreciate the truth in that. I think that at their worst these patients and their loved ones have given me more than I could give at my best. Each person copes differently, experiences different pains and discomforts. It would be misguided to say that all of them gave the same thing, but as a whole, it was valuable to witness their capacity to give when so much is being taken from them. There is a woman whose body has been distorted and disfigured by tumors, and as she struggles with grace and patience, she makes me think of how deep our reserves run, how much we can face without being torn. There is a man who has accepted that it will be difficult for him to breathe until he no longer has to, and his first thought in conversation is to answer all the questions he knows you'll ask before you ask them, without pause and without rest, with the creases in his face working with effort to give you all he can. There is a man actively dying before the eyes of his wife, who comforts me with stories of him before he was sick--redheaded, singing silly songs in the morning.
In conversation about this, it was pointed out that perhaps it is something about this stage in life, and not something intrinsic to these specific people, that make us that way. It doesn't matter to me too much from where the source stems. To see people in pain, so close to something unknown, be gracious and generous and sensitive gives me faith in the endurance of these qualities and makes me try harder for the patience to endure. And it's not to say that these people weren't struggling, weren't falling back in some ways, but that there seems to be a pull to hang onto the good when things are slipping away.
I can't say that I endured the past month of this rotation with the same kind of grace that I observed in my patients and their families. The rotation was hard for me. I was surprised by how quickly people transitioned from alert to unresponsive, how I could never get used to someone changing so much over hours or days from the way I first met them even for the ones I rationally knew had come to hospice to die. I missed the people they were as they were still breathing, and I wondered how it was for people who had been their lives. While the pace was unhurried and I was never overworked, and I loved most days there, at the end of them I felt tired.
And I was mean when tired, and the emotional stress of seeing and taking in this weighty process manifested in a lot of physical breakdown. Getting sick, breaking out with a cold sore, a couple allergic reactions, and developing various muscle strains, I was told that I was pushing myself too hard, that I needed to listen to my body. I think it is true that we should take care of ourselves, but I also find value in digging for the resilience that lies in vulnerability, and believe that this first means knowing what makes us weak. I didn't plan this of course, and it could be argued that I'm rationalizing the discomforts of the experience. But somehow, an intuitive, inexplicable part of me feels that there is good reason the weather was so harsh, the people so fragile.
I haven't felt this motivated to write about a medical school experience for a long time, but before doing it in a structured and comprehensive form, it feels nice to sit in bed and ramble about all the things that made it filling, and hard.
On my last day, an APRN asked me what was the most memorable event during the rotation. It would be hard, and probably not accurate, to choose one event or interaction or experience. Instead it was more generalities absorbed that most affected me. I told her that I'd take with me the calmness of the place, the simplicity of the medicine, and the kindness of the people.
Connecticut had the most snow in January on record since years and years ago. We had two two-feet snowstorms, a couple ice storms, and record below freezing temperatures. While I was used to this in Boston where the winter is more harsh than here, I'd never had to deal with the visceral challenges of snow and ice. For the first time in my life, I had to shovel my car out of the snow, had to try to drive it through the narrowly plowed driveway, had to shovel myself out of the driveway that wasn't plowed widely enough, had to shovel piles of snow off the entrance to the street where the tires would just spin in place, had to chip away at inches of ice off every window and off the roof of the car, had to see why getting ice off the roof is important as a I saw sheets of ice slip off cars on the highway, had to steer my car as it slid on unsalted iced roads, had to walk strategically to avoid puddles of slush and piles of iced snow. It was uncomfortable, and tiring to have to work so hard and think so hard about how to simply get somewhere.
There were also incredible vignettes of how pretty harshness can be, in the snowflakes that would freeze on my car windows to create a printed pattern I'd have to scrape away, in the ice that dressed bare tree branches making the forests on my drive looks like crops of glistening gray hair, and in the sheen of clean soft snow hardened on top like creme brulee, by the ice. There were incredible views from the windows, of big flakes falling against warm yellows and cold grays. There were the first falls, untouched, and the old snows, dirtied.
After the trek through all of that, I arrive at a workplace with windows in tandem, bookshelves, and fireplaces. Laid on the beds are crocheted blankets and patchwork quilts. Hand-painted signs of patient's names are hung in their respective spaces. Guitars strum, and every other day there are sweets from families or employees. It seemed to me I was lucky to have done this rotation during the onslaught of winter, to have to confront bitter elements with reason to escape to this cove. It's not often that you think of a workplace as soothing, especially not hospitals.
It's true that this atmosphere is partly due to the way that the rough edges of medicine are worn away a bit by the different goals and mindset of hospice. There is more thought to necessity, and the removal of what's not. In that sense, things feel simpler. There are no fancy tests to order; people often get sicker and instead of embarking on a diagnostic quest for etiology, we acknowledge the worsening condition and continue. There's still a lot of room for creativity in catering to individual needs. My attending pushed us to consider the best options for care, to not get stuck in status quo. But grounding all of that movement is a framework of simple stability. Not to say that dying is simple, but in the face its possible complexities, people's wants and needs become basic and streamlined to the core, without the excess that can often distort. After awhile the pharmacological treatments become routine, leaving more room to focus on non-pharmacological care, and hospice focuses on that much more than other areas of medicine. Its wholistic perception of people is reflected in its interdisciplinary approach to care; doctors aren't at the center, are instead an arm, of the scheme. There is constant, continual communication with the nurses, social workers, pastors, and family. And while there are many factors to consider, the way in which all these people work together to focus on each person's care, gives a simple sense of value.
I imagine that the comforts and simplicity help the staff as much as the patients, because as calming and welcoming a place it is, it is a hard place to be. Because of that, I think it attracts and seeks certain qualities in the people who work there, making for an incredible community. I've never met such a cluster of genuinely warm, kind, and strong people. The nurses, who are the heart of hospice care, made the biggest impression on me, but the kindness is palpable in every person encountered, from the person at the front desk to the person manning the cafeteria.
In the morning, the nurses and physicians round together, going over the care for each patient. The nurses are the ones giving report, which has never been the case for any other rounds I've seen. They make me remember why I want to be good at whatever it is that I do. They take care in the most whole way possible: delicate where people are fragile, tough and honest when needed. They advocate for their patients, they know their stuff, and they all have voice. It's this combination of warmth and strength that I admire most in women who give care, and every day it reinforced goals to work for.
On my last day I told a slightly demented patient of mine that it had been really nice to take care of her. She replied, "It was really nice to take care of you too." Even as her response was a rote one, I appreciate the truth in that. I think that at their worst these patients and their loved ones have given me more than I could give at my best. Each person copes differently, experiences different pains and discomforts. It would be misguided to say that all of them gave the same thing, but as a whole, it was valuable to witness their capacity to give when so much is being taken from them. There is a woman whose body has been distorted and disfigured by tumors, and as she struggles with grace and patience, she makes me think of how deep our reserves run, how much we can face without being torn. There is a man who has accepted that it will be difficult for him to breathe until he no longer has to, and his first thought in conversation is to answer all the questions he knows you'll ask before you ask them, without pause and without rest, with the creases in his face working with effort to give you all he can. There is a man actively dying before the eyes of his wife, who comforts me with stories of him before he was sick--redheaded, singing silly songs in the morning.
In conversation about this, it was pointed out that perhaps it is something about this stage in life, and not something intrinsic to these specific people, that make us that way. It doesn't matter to me too much from where the source stems. To see people in pain, so close to something unknown, be gracious and generous and sensitive gives me faith in the endurance of these qualities and makes me try harder for the patience to endure. And it's not to say that these people weren't struggling, weren't falling back in some ways, but that there seems to be a pull to hang onto the good when things are slipping away.
I can't say that I endured the past month of this rotation with the same kind of grace that I observed in my patients and their families. The rotation was hard for me. I was surprised by how quickly people transitioned from alert to unresponsive, how I could never get used to someone changing so much over hours or days from the way I first met them even for the ones I rationally knew had come to hospice to die. I missed the people they were as they were still breathing, and I wondered how it was for people who had been their lives. While the pace was unhurried and I was never overworked, and I loved most days there, at the end of them I felt tired.
And I was mean when tired, and the emotional stress of seeing and taking in this weighty process manifested in a lot of physical breakdown. Getting sick, breaking out with a cold sore, a couple allergic reactions, and developing various muscle strains, I was told that I was pushing myself too hard, that I needed to listen to my body. I think it is true that we should take care of ourselves, but I also find value in digging for the resilience that lies in vulnerability, and believe that this first means knowing what makes us weak. I didn't plan this of course, and it could be argued that I'm rationalizing the discomforts of the experience. But somehow, an intuitive, inexplicable part of me feels that there is good reason the weather was so harsh, the people so fragile.
Tuesday, January 18, 2011
hospice (beginning)
I'm a week into my rotation at Connecticut Hospice, the first hospice established in the States. It's located in Branford, about twenty minutes north of New Haven, and overlooks the Long Island Sound. The water is a wide expanse, with a wide expanse of ground from the building to the water, and every room has this view. Currently the ground is piled upon with snow, and unlike the snow of city and of routine living, this snow has remained white since its fall one week ago. There's little to disturb it other than the few who walk out from the building to the black fence outlining the beginnings of the water, and these steps add not color but a faceless depth. The sun rising and setting seeps into crevices of the water and clouds, in increments of half seconds, such that you get a sense of change without any motion.
With that backdrop, we have morning rounds, where the nurses (the heart of hospice) report on their patients and their daily plans are discussed. With that backdrop, we visit the patients and write notes on those visits. With that backdrop, we watch people die.
I hesitate with that line, hesitate to dramatize, but when thinking of the actual fact of things, that's just what it is. And some of it is as heavy as it sounds, and some of it floats away without much notice. As not just newbies seeing things for the first time, but as students whose role is to absorb as much as possible, the experience as a whole is quite a bit to take in.
In this short time, I've been struck by a number of things. For example, of how scared I was to see someone physically transition from life to death. Not out of empathy for the person who had not much life before that transition than after, but out of an instinctual aversion to seeing it happen and an awkward, sad sense of trivializing something by being there for the last breath of a person I didn't know.
I've been struck too by resilience, by how people give more at their most difficult times than I can at my best. At a time when I imagine people might feel compelled to turn inwards, they are instead touchingly sensitive to others. They continue on as the people they were--they want to take care of the families they've raised, they are insecure about how others perceive them in hospital beds,
And I've been struck by the variety of burdens, in quality and quantity. There's a lot to consider, besides the sufficient issue of absence. There's a man whose wife donated her kidney to him, there's an unresponsive woman whose 14 year old son reads her stories she'd read him, there's a man whose son and wife don't know how to speak to each other about the same thing, there's a 98 year old woman who says she feels full of emptiness like a room where sound echoes on and on, there's a woman whose understanding of her husband's pain is a more meaningful transition than his from life to death, there's an artist whose wife never let him draw her portrait until now and he draws a black and white picture of her face with her eyes closed. There is a 46 year old man who without telling his wife bought a sports car, who then crashed it while speeding, who then dies after months of his family tracking the movements of his left eye.
And I've been struck by the humor, and conventional routes to warmth paved in a place one might imagine as cold. I wrote my first prescription for a daily beer, frailty quickly turns into feist when a woman wants her nails polished and thinks you're the one who promised them to her, and you find that innocence doesn't need to be young, that the sweetness of wanderings renews itself with dementia. And it's things like all of these that bring awareness from knowing logic to feeling realness, like the sense that maybe death is an emptiness but one that's full.
With that backdrop, we have morning rounds, where the nurses (the heart of hospice) report on their patients and their daily plans are discussed. With that backdrop, we visit the patients and write notes on those visits. With that backdrop, we watch people die.
I hesitate with that line, hesitate to dramatize, but when thinking of the actual fact of things, that's just what it is. And some of it is as heavy as it sounds, and some of it floats away without much notice. As not just newbies seeing things for the first time, but as students whose role is to absorb as much as possible, the experience as a whole is quite a bit to take in.
In this short time, I've been struck by a number of things. For example, of how scared I was to see someone physically transition from life to death. Not out of empathy for the person who had not much life before that transition than after, but out of an instinctual aversion to seeing it happen and an awkward, sad sense of trivializing something by being there for the last breath of a person I didn't know.
I've been struck too by resilience, by how people give more at their most difficult times than I can at my best. At a time when I imagine people might feel compelled to turn inwards, they are instead touchingly sensitive to others. They continue on as the people they were--they want to take care of the families they've raised, they are insecure about how others perceive them in hospital beds,
And I've been struck by the variety of burdens, in quality and quantity. There's a lot to consider, besides the sufficient issue of absence. There's a man whose wife donated her kidney to him, there's an unresponsive woman whose 14 year old son reads her stories she'd read him, there's a man whose son and wife don't know how to speak to each other about the same thing, there's a 98 year old woman who says she feels full of emptiness like a room where sound echoes on and on, there's a woman whose understanding of her husband's pain is a more meaningful transition than his from life to death, there's an artist whose wife never let him draw her portrait until now and he draws a black and white picture of her face with her eyes closed. There is a 46 year old man who without telling his wife bought a sports car, who then crashed it while speeding, who then dies after months of his family tracking the movements of his left eye.
And I've been struck by the humor, and conventional routes to warmth paved in a place one might imagine as cold. I wrote my first prescription for a daily beer, frailty quickly turns into feist when a woman wants her nails polished and thinks you're the one who promised them to her, and you find that innocence doesn't need to be young, that the sweetness of wanderings renews itself with dementia. And it's things like all of these that bring awareness from knowing logic to feeling realness, like the sense that maybe death is an emptiness but one that's full.
Friday, December 17, 2010
language
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.
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.
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.
Subscribe to:
Posts (Atom)
