Observations Reading Reflection

Year in (partial) Review.

One of my goals in 2015 was to post something here at least once a week, for a total of 52 entries. Including this one, I posted 48 entries this year. (I did not have a similar goal in 2014 and, as a consequence, I posted only 25 entries last year.)

The post I wrote this year that received the most views discussed whether people choose to be homeless.

The post from this year that came in second place for most views discussed the experience of grief.

The post that received the most views this year wasn’t even a post I wrote this year; it was a post from 2013 about the DSM-5 criteria for schizophrenia.

Another goal I had for 2015 was to read more books. I didn’t keep track of the number of books I read in 2014, but I think I read more books this year (23) simply because I had a goal. In addition to the books listed in the footnote here, I also read:

Stitches (Lamott)
Bossypants (Fey)
The Practicing Mind: Developing Focus and Discipline in Your Life (Sterner)
I Know Why the Caged Bird Sings (Angelou)
Boundary Spanning Leadership (Ernst) – not yet finished

I do recommend all of them, with the exception of the last one, only because I have yet to finish it.

Thank you for reading my writing this year, particularly those of you who have been reading my words and sentences for over ten years. See you in 2016.

Lessons Medicine Nonfiction Reflection

Repost: Control.

I wrote the post below over ten years ago during my last year of medical school. I was on an elective hospice rotation. This came to mind this weekend after I visited a mentor who is dying from cancer. Someone from a hospice service also visited him while I was there.

I will miss him.

We all die.

Really. We all die.

And people know this. Sort of. Kind of. Maybe.

Some people accept this fact that yes, we all die, with calm grace. Some, indeed, genuinely welcome death and look forward to shedding this mortal coil. Some don’t necessarily want to die, but they recognize the inevitable fact and actively choose to spend the rest of their days living, not dying.

And then there are people who fight death. Or maybe it’s not death itself that they fight; they fight their mortality. They struggle with the fact that life will end. They don’t want to relinquish control over their existences. They want to know how much time they have left, what exactly will happen, and how things will progress between this moment and that last breath.

Family members of dying people (but really, aren’t we all dying?) seem to feel more—sadness? anger? frustration?—whatever; they often seem to feel more than the patients. The Type A’s get super Type A, jumping all over the place, asking How? When? Why? What? How much? How often? How quickly? How slowly? Can I do this? What about this? And that? The angry people get angrier, but I don’t think the core emotion is anger. The sad people try not to feel more sad, but their cheery smiles are obviously superficial. And the crazy people just get crazier.[1. I wince at what words I used to describe people in the past. I hope the wincing means that I’ve gained some wisdom over the years.]

It’s not fair to say that this grief is entirely selfish, but in a way, it is: If the loved one dies, it is a theft from the person in question. There will no longer be any shared moments, quiet glances, bursts of laughter, or shouting matches. And if the loved one dies, it only reminds us of our own mortality.

Because we all die. We just don’t believe it.

A hospice nurse and I sat in a family’s house for nearly an hour this afternoon. The patient, an aging woman, lay on the gurney in the living room. She’s had multiple strokes and doesn’t interact with the world. Her eyes fix upon yours, but she’s not looking at you. Her pale lips, smeared with Vaseline, are parted. Her left foot writhes in the bed, as if forming cursive letters on the white sheets. Her skin is cool and she doesn’t really react to the touch of another human hand.

Her daughters keep extensive notes about her: How much did she pee? poop? sleep? Has her skin changed color? Is she throwing up? How much morphine has she gotten? (They won”t say “morphine” in the room; they call it “M”.)

They don’t want to give her too much morphine because they fear that they will kill her. And yet they want her to be comfortable—and the grimaces on her face suggest that she is not. The daughter who is administering the morphine will not—cannot—give her any more.

“It’s about HER comfort, not YOURS,” her sister said, trying not to shout at her.

“Well, you don’t want to give it to her, so I am, and this is what I’m comfortable with,” the sister replied.

“I know she’s declining… I know she is…” and yet she cannot accept this fact completely and buries herself in her dying mother’s urine and fecal output, her blood pressure and pulse measurements, the dosages of her medicines.

It’s about control. Lack thereof, really. And to sit there, actively listen, and be present with these patients is exhausting. You literally feel what they feel, and yet you also feel what you feel in response to their feelings, and your brain is running through the algorithms of disease. So you monitor yourself while you monitor them, staying in the moment, completely unsure of how the next moment will unfold. Part of you wants to comfort them and part of you wants to scream in frustration. Part of you wants to run away and enjoy the gorgeous world outside and part of you wants to give everyone in the room a big hug. Part of you wants to give up completely and part of you wants to fight for the life that remains.

God, it is so beautiful to be alive.

Consult-Liaison Education Lessons Observations

More About Questions.

Last week I riffed on the importance of “what is the question“. This week I will riff on a related topic: “How will the answer affect what you do next?”

If the answer to your question won’t change what you will do, then perhaps you don’t need to ask the question.[1. This I definitely learned in medical school. It was usually phrased, “How will this affect your management?” If you’ve made the decision to prescribe an antibiotic for pneumonia, then there’s no reason to get a chest X-ray. It doesn’t matter what the answer is to the question, “What will we see on the chest X-ray?” Thus, don’t order the X-ray.]

If you know that you friend isn’t the biggest fan of cake, but you’re going to serve cake at the party anyway, there’s no point in asking your friend, “Do you like cake?” or “Do you mind if I serve cake?”

Sometimes we ask questions not because we want to learn the answer, but because we want to say something. In the above example the question “Do you mind if I serve cake?” may actually mean “I hope you won’t feel angry or disappointed that I am serving cake”.

Consider meetings or conferences where audience members have opportunities to ask the speaker questions. Sometimes the people who raise their hands to ask questions either (1) never ask an actual question, or (2) ask a question that they then answer themselves, whether the group wants to hear it or not.

To be clear, I’m not saying that we should never ask questions unless the answer will influence our next actions. Asking questions is how we learn about ourselves and the world around us.

When I first moved to New York from Seattle, many of my colleagues in New York asked me about how much it rains in Seattle.

It actually rains more in New York than it does in Seattle,” I would reply, sometimes with unnecessary smugness.[2. I do like the Merriam-Webster definition of smug. It makes it clear that it is always annoying and never necessary to be smug.]

The question was, “Does it rain more in Seattle than it does in New York?” The answer was “no”, but it didn’t change anything anyone did. No one moved from New York to Seattle to experience less annual precipitation. It didn’t stop me from moving to New York. I still wore trench coats in both cities (though got one with more style in New York) and covered my head as needed. That there is more annual precipitation in New York is just interesting.

It is nonetheless worthwhile to consider the reasons behind questions you ask. Sometimes the answers to your questions will affect what you do next. Sometimes your questions help you learn more about other people or phenomena in the world. Sometimes your questions address only your own psychological needs, which often has bad outcomes for everyone involved in the conversation (e.g., “Do I look fat in this?” or “Are you getting your period?”).

Be careful what you ask for.