The Physician as Storyteller & Poet: Quick Writes from East Bay Writers’ Workshops

Kaiser Permanente, The Permanente Medical Group, The Permanente Federation

 

Tom Janisse, MD; Betty Lin, MD

Winter 2012 - Volume 16 Number 1

https://doi.org/10.7812/TPP/11-181

Story to Stay Alive

An Oregon naturalist, Barry Lopez, wrote in his Native American tale, Crow and Weasel, "The stories people tell have a way of taking care of them. If stories come to you, care for them. And learn to give them away where they are needed. Sometimes a person needs a story more than food to stay alive. That is why we put these stories in each other's memory. This is how people care for themselves."1

Writing Story

In this issue we publish 15 original stories and 2 poems written in 10 minutes with minor edits for clarity by physicians and practitioners at 2 writing workshops in Oakland, CA in 2009 and 2010. The workshops explored the use of reflective writing to support and sustain a satisfying medical career. The prompt was simple: recall a meaningful moment in your practice with a patient or colleague; it could be connecting, uplifting, sad, even traumatic, or enlightening, and previously unexpressed in writing.

Why do physicians and practitioners write stories? And why tell them to a group of unfamiliar colleagues? People write to learn from their experiences, to express the meaning of their life's work. Although we remember our stories, we may not understand them until we write them on paper, and move them out into the world.

Relevance of Story

Underlining the original premise for these workshops—that supporting physician health and overall well-being has never been more important—numerous studies indicate that approximately one of three physicians experiences burnout at any given time.2 In addition, growing evidence supports the importance of physician wellness above and beyond the benefits to the individual physician. Links to improved patient outcomes3 and increased physician retention4 are two examples. Writing is a powerful tool to discover meaning and to promote self-understanding, and because psychological conflicts are linked to specific changes in our bodies, narrative writing can be of therapeutic value to physicians.5,6

This two-part program focused on the use of creativity as a means of dealing with the stress of a medical career, enhancing coping skills, increasing job satisfaction, strengthening the ability to attend empathetically to a patient's experience of illness, and improving overall general health and well-being. One must first care for oneself before being able to care for others. The agenda for the first workshop focused on the techniques of reflective writing, observational experiences, and experiential exercises using the visual arts to complement and expand our familiar forms of written communication. The second workshop was designed as a train-the-trainer for those interested in advancing the technique of reflective writing and bringing workshops to their respective medical centers in Northern California. Used together, these workshops resulted in new insights, appreciation, and acknowledgment as validated by participant comments, such as: "I was surprised by uncovering the importance of unconscious memories," "The stories were compelling, and I enjoyed hearing them," and "Great connection, and great stories." Of note, as a result of these workshops, an East Bay Writing Group was established and has met several times.

The Permanente Press Workshops

The Permanente Press (TPP) has now led over 1000 physicians and practitioners across the country through a writing workshop where each wrote and shared a story. Many of these have been published in one of several TPP publications: The Permanente Journal; Soul of the Healer: Art & Stories of The Permanente Journal;7 a medical literary-arts e-journal, leaflet;8 and previously published stories have been collected together in an anthology: Narrative Medicine Anthology (available from The Permanente Journal Web site: www.thepermanentejournal.org). Comments from participants at these other workshops include: "This workshop affirms the work we do as clinicians." "Elucidates the value of the story in clarifying issues and meaning of clinical encounters." "Inspirational. Rediscovering what is human and meaningful in our daily lives and careers is a very good antidote to becoming jaded and cynical." "This workshop opened up my eyes to how important my stories can be." "The training/sharing I had today will help change how I view each patient interaction." "Quite amazing how somewhat emotionally distanced physicians and caregivers can be brought out so quickly and profoundly." "I know the people around my table better in two hours than I know the colleagues I work with everyday."

Tribute to Writers

We publish these stories and poems as a tribute to the writers who opened their hearts and became vulnerable in expressing deeply meaningful moments in their clinical practice, and even personal lives, through writing and sharing with others at the workshops, and who now make their stories public for others to learn from. Enjoy these stories and consider writing one of your own to gain insight, understand an experience, or feel a sense of release and fulfillment. The stories will take care of you and others.

References
1.    Lopez B. Crow and Weasel. San Francisco, CA: North Point Press; 1990.
2.    Cole TR, Goodrich TJ, Gritz ER, editors. Faculty health in academic medicine: physicians, scientists, and the pressures of success. Totowa, NJ: Human Press; 2009. p 29-38.
3.    Janisse T. Relationship of physician's well-being to interactions with patients: practices of the highest performing physicians on the Art of Medicine Patient Survey. Perm J 2008 Fall;12(4):70-6.
4.    Wallace J, Lemaire J, Ghali W. Physician wellness: a missing quality indicator. Lancet 2009 Nov 14;374(9702):1714-21.
5.    Pennebaker JW. Opening up: the healing power of expressing emotions. New York: The Guilford Press, 1997.
6.    Pennebaker JW. Writing to heal [monograph on the Internet]. Austin, TX: University of Texas at Austin; 2008 Oct 9 [cited 2012 Feb 8]. Available from: www.utexas.edu/features/archive/2005/writing.html
7.    Soul of the Healer: Art & Stores of The Permanente Journal. Portland, OR: The Permanente Press; 2005.
8.    leaflet [Web page on the Internet]. Portland, OR: The Permanente Press; 2012 [cited 2012 Jan 30]. Available from: http://leaflet.thepermanentepress.org/.

One Weekend Day During Internship

Lee Ballance, MD – Chief of Alternative Medicine and of Continuing Medical Education, Acupuncturist, and Orthopedist at the Vallejo Medical Center in CA.

One weekend day during my medical internship at Lincoln Hospital in the South Bronx, probably a Saturday, I received an admission. She was a woman in her mid thirties, well known to the medical service, with chronic renal failure. Every few weeks she would come into the emergency room with fluid retention and elevated potassium, and we would hustle around to get her to the ICU where we could initiate peritoneal dialysis.

Our ICU had 7 beds for our indigent population of 350,000 and it was shared by all of the services: Medicine, Peds, Surgery, OB. There was never a free bed, so finding a bed for one patient always required a lot of negotiation and weight-throwing. To make it worse, she came at around shift change when it is always difficult to get anyone moved in or out of a bed.

I have never been very good at weight-throwing and having started my career as an orderly and scrub nurse, I am very uncomfortable about "yelling" at the staff, which was what was required.

Before I could get my patient into the ICU, place the catheter, and start the dialysis, she had a cardiac arrest and died.

I took the full load of her death onto my shoulders. How had I let this woman die leaving her children (two, or three as I now remember) motherless? I had failed when my colleagues had succeeded and why couldn't I have been more forceful and aggressive?

I went home the next day in a dark mood. I felt as if I was a harmful, dangerous person who had no business becoming a doctor. I thought about throwing myself under a bus or at least breaking my leg on a lamppost.

It was all I could do to come in to rounds on Monday. I had to tell my team my story and how I had let them down.

Our attending physician, who was also our nephrologist, listened patiently to my tale of failure then calmly told me that I had not killed the patient. The attending reassured me that the patient was killed by her kidney disease and a social system whose best solution was prolonged dialysis. She also reassured me that she would be happy to yell at the staff, if I ever needed help with that in the future.

Making Dad Comfortable

Roger Baxter, MD – Infectious Disease Specialist and Co-Director of the Kaiser Permanente Vaccine Study Center in Oakland, CA.

Image: Cold winter snowy walk, bare trees, along the Genessee River in Rochester.

My father had been ill with a mystery illness for several years, but still the call that he was admitted to the ICU with pneumonia was unexpected.

My mom had handled things well previously, a woman who always tried to see the bright side of things; now she was terrified. Oakland to Rochester flew by.

I arrived in the ICU at the University of Rochester Strong Hospital. I felt strangely comfortable, at home, in the ICU, from years of attending on ID. The residents approached the doctor-son of their patient. Almost the first words were to see if we wanted a "full code." Seeing my past, and all the family members I had approached with this question, I stopped to consider, and then said, I needed more information. I needed to see the x-rays, talk to the attending, but until then, he was to remain a "full code." As I reviewed the films, the awareness dawned that this was cancer, not pneumonia, and this was truly the end.

We moved Dad to another floor, used CPAP to keep his 02 up, and called the family. The hospital residents ceded authority to me, as did my family, and we set about making Dad comfortable as we gathered around. The responsibility then and now seemed overwhelming, as I had (in my mind) to decide between life or death.

Outside the hospital was the Genessee River, wintery, cold, barren with a large graveyard across the way. I walked through the snow, processing and crying, letting go and remembering, dealing with my needs and those of my family. We're five siblings, all very different, and until then had hardly spoken to each other in ten years. Now we came together to bond again, share and agree; connect.

Bare branches overhang swift water and ice. The bridge was empty.

Bill

Denise Fuson, MD – Medical Director, Medical Weight Management East Bay; Controlled Medication Advisory Panel; Chair, Professional Well Being Committee East Bay; Oakland, CA.

Big, burly, with tears rolling down his face and into his snowy beard, he tried and failed to say goodbye and instead fell back into a story of his mother, her decline, and her gentle death. He included me in the story and placed me central, rather than peripheral. It is our last clinic visit, Bill and I. Our journey started years before with him driving his frail and elderly mother to her appointments with me. His caregiver role connected us—me the doctor, him the son. As she failed, we explored and discussed the most loving strategy for her ending. In that process, he soon filled the empty spot her dying left in my practice. At first, just to share sadness at her passing, then to learn about and care for him.

Now I was leaving and neither of us had words for goodbye. I am struck by his hugeness and strength. An old-time, railroad man, an engineer who dealt with the hard steel, grimy oil, and pervasive grease; these elements of the man I think I know melt away.

As I walk out of the exam room, my parting image is his sobs, his sorrow.

I know he will never leave me—this paradox of strength and softness who has allowed me such an intimate connection.

Rico—My Friend

Louise Glaser, MD, FAAP – Chief of North Valley Communication and Leadership Development, Point West, Sacramento, CA.

I knocked and then opened the door slowly in case he was playing in front of the mirror. He was dancing in the middle of the room, his head of big brown curls bouncing. He turned and his warm brown eyes caught my eyes; he smiled shyly and ran to mom's lap without a noise

"Hello," I said, "Wonderful to see you today Rico. How are you? And how are you Mom?"

Tina had been my patient too when she was younger and now brought her son to me today for his 18-month check-up

"How do you like his hair cut?" she asked, beaming.

I complimented her and him and asked what questions she had for me. I watched Rico; Rico watched me, eye-to-eye, while his mom and I exchanged words. He smiled; he looked away. He smiled; he looked away. We were making friends again.

He was silent.

Mom said, "I am worried he is not talking. He says ‘Mama' and ‘Dada' and nothing else." We talked a bit more about his behavior, his hearing, his health, and a few other things. Rico and I stayed engaged; he looked into my eyes and I into his. I turned on the computer; he came to stand by my side. He looked up and smiled at me.

He was silent.

He sat on Mom's lap for his exam. He watched my every move, from listening to his heart, feeling his belly, to looking at the ear light with either a smile or interest as he followed along. At the end of his exam, I pushed my rolling stool back away toward the computer.

He began to cry.

Mom said, "He thinks you are leaving now." I rolled back over, talked to him some more, eye-to-eye, told him how great it was to see him. I would see him again soon. Mom and I had a plan to make sure he was okay.

Rico made a new noise.

I blew him and Mom a kiss.

When I went back into the same room for the next patient there was a photo of Rico they had left for me. On the back it said­: "Dr Glaser, Thanks for looking out for my health. Love, Rico."

Body of Work

Matthew J Gracianette, MD – Pediatric Hospital-Based Specialist and Northern California Regional KP HealthConnect Lead for Inpatient Pediatrics, Hayward, CA.

We capture, in waveform
what we think is vital.
We replace, in synthesis
simply synthetic replacement
    fluid here, meds there,
    drugging and dragging humanity,
    vital vessels for such critical care and worldly work,
    through our medical mire.
Although we may not always win the battle, all is not in vain, nor merely intravenous.
And even with all advances and eager efforts,
and despite disease's effortless drive to deem a dreaded demise …

The human body, glorious in its minute clockwork coordinated physiology,
remains, somehow, a living, breathing, feeling, thinking
soulful sculpture of what we, both patients and providers, really are,
in mind, heart, and body:

We are flawed perfection.

Every Self We Possess Is Always With Us

Yassamin Hazrati, MD – Orthopaedic and Shoulder Surgeon, Vallejo Medical Center, CA.

I reviewed her history before I went into the room. She was 80 years old and on Coumadin for atrial fibrillation and was referred to me for a shoulder replacement consultation.

I walked in, greeted her, shook hands, and then asked about her medications. She rambled on about this and that and in my short time with her, I tried to capture all that was relevant and update the problem list in the electronic chart.

We talked while I examined her. She was a retired secretary, and was eloquent. She had a sweet chubby face, white hair, and used a walker. It soon became apparent that she did not want surgery. During the update of her family history she asked me, "How do you stay slim, doctor?" For me that week it was a strange question. I had just had a miscarriage and felt like I carried all the "baby fat," so I was not feeling particularly slim.

I said something about portion control and avoiding snacks. Then she teared up: "I am so fat, my mother would have thought I was disgusting. She thought fat people were sloppy. My mother died when I was 7. She would not like the way I look today."

"You are beautiful," I said, but she was not easily consoled. I looked into the mirror of her eyes and found myself staring back, hypercritical, and incorporating my own parents' criticism and lack of acceptance of me.

The encounter did not take more than 25 minutes. She seemed happy about having an alternative to surgery and perhaps that I had heard her. The 7 year old who had lost her mother was also in the room that day.

I find myself fearing distraction from my more important work of "fixing" things when I take the time to listen, but that work seems to be equally if not more important to the patients and on this day it was equally important to me.

It Was Amazing

Shahnaz Iqbal, MD – Internist, Assistant Chief of Medicine, Chair of Recruitment Committee in Medicine, Chair of Credentials and Privileges, South Sacramento Medical Center, CA

On a commute in India, I hired a driver to take us from Delhi to Agra. It was hot, humid, even the air conditioning in the car was hot. Until the excitement of seeing the Taj prevented us from complaining, everything was beige except the gray road. Beige fields, beige dirt side roads, beige mountains.

Suddenly out of nowhere, a truck passed us. It was painted bright red, vivid green, exciting yellow strips with a Christmas decoration garland strung around it.

It honked its horn repeatedly as it passed, greeting us loudly and jolting us out of our trance-like state.

The Taj disappeared as quickly as it appeared. Again beige views. We drove for miles. Every now and then we would see Rajastani women walking along the highway.

It was always just a sight—dark-skinned women in large, solid fuchsia sari or neon green or sun-bright yellow. We couldn't see their faces only their silhouettes and bright colors of the saris, all the same shape, same size, same carrying pots on their heads. There were no houses or villages in sight.
It was amazing. Where did they come from? Where are they going? We continued to drive through the beige landscape. Suddenly, we came upon a gathering of people—lots of people, lots of noise, some type of gathering—no, it was a parade with adults, children, music, chanting. We asked the driver what was going on. He told us but we did not understand. There was a doll—they were carrying some type of statue. Perhaps they were celebrating the birthday of a saint. The driver stopped, so we could join their celebration.

We got out of the jeep and the children rushed to us, chanting, singing, laughing and posing for pictures.

The Day I Knew I Wasn't a Doctor

Tom Janisse, MD – Editor-in-Chief, The Permanente Journal.

When I caught up to the medical student hospital rounding group, they all ignored me. The attending professor, crisp in his white coat with sewn blue name, positions and titles across the front of his pocket of pens, abruptly stopped, turned only his head toward me, and across his shoulder scowled. Everyone eyed me, like eleven lasers. All now displayed intense dissatisfaction. Distressed because I didn't expect this, I stood alone, felt shunned.

Professor said, "You, Janisse! Staging your own show?

"The patient wanted …"

"Now we're behind! This is critical work."

"I stayed with my patient because your questioning upset him, actually, terrified him."

"That's dramatic."

"He was hurt by your open discussion of his case."

"This is rounds. You're wasting more time."

"He didn't understand what you said, and misinterpreted most of it."

"Didn't you prepare him?" The tip of his finger shot out nearly touching my nose.

"Not for an inquisition," I gained courage through anger, "disparaging fat comments, and general inhumanity."

"You're no doctor, or ever will be. Emotion throws you off. You're a scientist, not a therapist. And I'm noting your impertinence."

"He thinks he's going to die."

"He's right. Severe heart failure. He's got to deal with it, not you. He caused it. Your job is to examine, diagnose, and treat him, not hold his hand like a nurse!" He turned, walked through the middle of the group and led them down the corridor.

Stunned, I thought how could that be good doctoring? How arrogant! Do I need to be like that? Cold and calculating, he wasn't even fazed. Why can't I be like that? This objective academic approach was like an intellectual rape of the patient. I must not be the right kind of person to be a doctor. I'm not going to make it.

Will She Turn 20?

Marisa Leto, MS, LMFT – Early Start Specialist/Psychotherapist in Ob/Gyn at the Richmond Medical Center in Richmond, CA.

What will she remember when she leaves here? What will she see if/when she looks in the mirror? Will she remember the reminders about safety; the emphasis on the grave danger she faces if she decides to see him? Will she see the dark circles under her involuntarily tearful eyes, remnants of the bloody, swollen mass he left her in at their last encounter?
Will she remember how eloquently she talked about the chasm between the experience of being beaten to a pulp and the helplessness to stop herself from re-uniting with him once again?
Will she remember her OB's warning about the danger of injury and even death to her fetus if she is beaten again?
Will her digestion eliminate the grave warnings as waste, or will she absorb them as nutrients to sustain her tenuous hold on safety, on life.
Can she create a bridge between the disconnected worlds to take a path away from violence, away from kicks to the face, away from dizziness, unconsciousness, and midnight escapes? Can she transform her hideout in the dark corner to enter the nearby open gate?
Will she turn 20 without discovering what she knows to be true? Will the truth of the danger she chases ring louder than the inexplicable need to be with the one who almost killed her? Will her as yet unborn daughter kick strongly enough to tip the decision in the direction of a lonely birthday and away from the possibility of an early death for both? Will she turn 20?

How Do You Respond to That?

Heidi Larsen, MD – Internist, Oakland Medical Center, CA.

Mary is an artist with white, shining hair, a twinkle in her eye, and a charming mischievous smile. She followed me to Kaiser Permanente (KP) from my private practice on Summit Street. Although I left there only nine years ago, it feels like it was in another life. All I recall from our encounters then was that she had a lot of problems tolerating her cholesterol medications. We tried numerous samples from drug reps before settling on Lescol, a crappy cholesterol medication compared to most, but the only one she could tolerate. I was asked to change it at KP many times but I resisted because of my memory of her experience.

As I have gotten to know her over the years, Mary has revealed more and more of herself to me. She has taken Paxil on and off in homeopathic doses for mild depression with anxiety and a tendency toward panic attacks. I never questioned her self-management and accepted and refilled the prescription when she asked.

On a recent visit, she confided to me that this time she was deeply depressed. Her sister had told her over lunch that she has hated her since she was three. I said, "How do you respond to that?" Mary shrugged. She told her story about how she was sexually abused by a family member and that the denial and cover up of this could cause all sorts of dysfunctional dynamics in her family, and that she was in some ways given special privileges that her siblings resented. Clearly, this was stuff I wasn't trained or prepared to deal with in my 20-minute return visit. She had a bad start with her LCSW in psychiatry who seemed more intent on filling out forms and questionnaires to comply with work expectations than listening to patients unburden their souls.

I explained my suspicions about why the visit went badly and convinced Mary to give it another go.

When she returned a couple of weeks later with a rash, she had her usual twinkle and smile again. She reported that therapy was going well and her medicine was helping. Mary said the thing that helped the most was when I said, "How do you respond to that?" She had thought about that after leaving me and realized that she wasn't responsible for her sister's feelings, and that her sister would have to work on her own rage and maybe she just needed to stay clear of her until she did. Mary felt she was a mentor to the other women in the depression group she attended, as she had been depressed so many times over the years. She was indeed almost enjoying this passage in life. Mary thanked me for my profound question, but I don't think it was that profound. I was just curious.

I Don't Know

Betty Lin, MD – Physician Satisfaction and Wellness Chair and Women's Health Liaison and Ob/Gyn at the Richmond Medical Center, CA.

End of a long week
Dusk is just setting
Where is it from?
I don't know
My friend and I approach
Is it a cat or is it a dog?
I don't know
It is a dog
Frantic, searching—where is home?
I don't know
We call it—it comes
"Safely" in my friend's arms
Now what?
I don't know
Two some years have passed—
he is mine
His name is Richmond
What would have become of him that fateful night if he had not found me?
I don't know

Mortality, Motherhood, and Milk

Andre Ramos, MD – Pediatrician, Hayward Medical Center, CA.

Looking at me, she said, "Dr Reyes, I think I know what it is." I was finishing up a visit with Imogene and her mother, one of several routine well checks I would be doing that day. Imogene was 15 months old, doing very well by my assessment. She was part of a family of 4 daughters, all my patients. As a result, I had gotten to know her mother very well and had lowered my professional guard more than usual; she was one of the few parents with whom I had shared my wedding photos. She was very certain in her belief that having only daughters was much more challenging than all sons with respect to child rearing. On one occasion, she even had the courage to ask me a personal question at the end of a visit. "Do you have kids, Dr Reyes?" Nervous about the implication of the question and its answer, I hesitantly answered that I had no children. She looked at me seriously and deadpanned, "Don't have too many."
I learned about Imogene at a visit for her sister. Her mother had volunteered that she was pregnant—with Imogene—and it was clear from her exasperated expression that the pregnancy was not planned. Like many of my patients' parents, she was strong, focused, and never betrayed this disappointment again.
At her 15-month visit, Imogene displayed only one issue—she was not interested in weaning the bottle. An unsurprising trait, as was her mother's slowness to expedite the transition. I perfunctorily described the dangers of continuing, the certainty of success with determination, and felt confident a plan was in place. As I returned to the room with paperwork and fully intent to close the visit with all details reviewed and assessed, her mother answered the question I had not asked. "Why? Why are you slow to wean the bottle?"
She said, "Dr Reyes, I think I know what it is. I know I was not happy to be pregnant. I thought I was done having kids, but now I do have her. And I feel like if she leaves the bottle behind, then she's not my baby any more, and I really will be done."
Her child-rearing days were far from over, but the impact of this particular transition foretold the end of those days, as well as the end of her days. Mortality, motherhood, and milk all in the same bottle.

Re-Story Her Life

Julie Rogers, PsyD – Clinical Psychologist in the Department of Psychiatry at the Richmond Medical Center in CA.

I brought her in late. I don't remember why I was late, but she accepted my apology, for this third session. In the first, I'd felt frustrated. She was so focused on complaining about her husband, how he had been pursuing another woman, and the proof she had.
I don't remember now what helped her shift, something I said. No, I think she said just being able to tell me. But she shifted so much by the second time and then the third, so much stronger, so much more centered.
She was very grateful, and expressed much appreciation. Why was it hard to take it in? I helped her. I helped her re-story her life, to find power, agency, where she had felt none. She took the ideas and ran with them. I remember now telling her that she did more in that moment of time than most people; she used the process well.
How quickly I moved on to the next person I have to "worry" about. That was quite a day. Ending with another amazing session—someone upset with me, disillusioned, realizing I'm not "one of us [Latino]." And I was so there.
In the first session, I was present, except for not taking in her gratitude. I took it in some, maybe more than at other times.
I helped her. I helped her. I helped her. And what an experience for her, and for me, to experience change, to experience empowering her so quickly, even with sessions spread far apart.
The connection of disillusionment was just as rich—maybe even more so. Someone I knew much more, and that felt like "real" energy—therapy that includes talking about the relationship. Just being there with her and her feelings. Just listening, and acknowledging, and asking questions to understand more. Letting her cry, tears that dropped to the floor. Because I'd returned her gift to her. So real. Her complaints, her criticisms, her pain. My mistakes. My responses. So human.

Pretend to Listen or Hear Her Words

Rashel Sanna – Senior Project Manager for The Permanente Medical Group Wellness Coaching in Regional Health Education in Oakland, CA.

Such an interesting woman, although she didn't seem like it upon initial view; seemed like any other patient to walk through my door. Asking her about her situation, assuming, thinking I already knew what I needed to know but allowing her the privilege of telling her own story, more as a courtesy than a necessity. For having counseled one after the other, so many times the stories would run together, blend into sameness.

Not today, not this woman. She spoke generally at first of the edema in her legs. She spoke of the many doctors who would pretend to listen but would not hear her story. She looked at me longingly, surely attempting to discover if I would be yet another who would only pretend to listen. Or if on this day she would find a soul willing to hear her words. She began describing her situation, the conclusion she'd come to about the size of her legs. She felt there was a man in her legs. I found myself stunned, caught off guard, confused. Had she seen someone in Mental Health? What is my role here? Eat less salt lady (my brain recalling the key factors in edema), drink more water. She wasn't listening. She was talking. Interrupt her, call her therapist? Why was she here? Who sent her to me? What is the right action here? What is my role—my scope? My brain was spinning—and then, somewhere amidst the chaos and confusion, my soul opened. My ears perked up. I fully allowed myself to enter her world. I began to ask questions, to engage, to hear her story. I was compelled to allay judgment, to be present, accepting, compassionate. I noticed a tear running down her cheek. I wish I had asked her why. Were they happy tears—someone listening brought a certain level of satisfactory joy or tears of loss, confusion, or fear? So often I find myself making assumptions about my patient's stories. So often I allow myself to believe that their story is the same, the same as others—not unique, not individual—alas unworthy of allowing the time and effort it takes to truly listen for the uniqueness of their story, the individuality of their journey and how it is they have landed here before me today.

The Code

Rena Tacdol, MD – Family Medicine, Pinole Medical Offices, CA.

I did my family medicine training at an unopposed county hospital in Salinas—where Spanish was heard just as often as English and underserved and poor was the norm. In this hospital, the residents on call were in charge of it all—the adult medicine ward, pediatrics, labor and delivery, ICU, the psych ward, and Emergency Department (ED) admissions. Three residents every night ran the show. It was terrifying.
The only thought that I had was to keep everyone alive until 6:30 am when the day crew—the other residents and attendings—came in to pick up where I had left off. During those days, I was basically numb—tired, sleep-deprived, lonely, just trying to get by. It took a lot to faze me and to make me feel.
One event sticks out in particular for me. It was in my second year of family medicine training. I was the one resident in our ED working with the one lone ED attending. After seeing broken bones, suturing, giving Lasix and breathing treatments, another "code" was about to come in. The charge nurse corralled the troops into order: lab tech, nurses, radiology tech, doctors stood by in our crash room. Seconds and then minutes ticked by. Everyone got their gloves out and stood at the ready. Finally, we heard the siren of the ambulance and our "code" was wheeled in.
I had assisted in these codes before, but I really wasn't prepared for what I saw that day. The girl lying on the gurney could not have been more than 15. Her long hair was mousy brown. Her fingernails were painted black. Her blue eyes were rolled back and up. They transferred her to the table and we all took a deep breath and sprung into activity—lines, labs, tubes, monitors. She was stripped of her clothing and then I noticed or it was pointed out the markings on her neck.
"She hung herself," said someone around me. "Her father found her. We did CPR on the way over."
The young Emergency Medicine doctor told me to do chest compressions while he took care of the line. I was familiar with the routine—compressions, medications, airway, and look at the monitor—again and again. I had seen this time and time again, but this time I was afraid to look. She was so young, I thought. We tried again, and finally, eventually, the ED physician "called it."
The flurry of activity ceased. Everyone backed away and disappeared. The ED doctor mumbled and said he had to speak to the family.
The girl was left on the table—naked and alone. Her head was to the side as if in sleep. I had this big urge to weep … such wasted life. I took a deep breath, and tucked the sheet around her—as if I was tucking her into bed—and turned away.

You Made My Life

Farah Toloui, RN – Extended role RN, PHN, Drumming Facilitator in the Family Medicine Department at the Richmond Medical Center, CA.

His last name started with P. He came to my office because of a cough. His eyes didn't want to look at my eyes or my face. His nose was red, bulging with alcohol. His hair was oily and ungroomed. He smelled like an ashtray. His voice was uncertain and angry. His vital signs were abnormal—his blood pressure was high. He refused to start the healthy lifestyle, quit smoking, drinking, and eating junk food. He said, "I will die anyway." Then I told him what
was in my heart; what I could see in him, maybe a hard childhood, abandonment, neglect, and discouragement.

I shook him with my sentence, "Yes, you will die someday, but do you want to choose dying with integrity and a smile on your face or do
you want to have a miserable death?"

He decided to take meds and reduce his selfabusing lifestyle. Many months passed. I called a patient in, his last name started with P. He sat in my exam room, a smile on his face, wellgroomed hair, still smelled like cigarettes but not the ashtray. He looked in my eyes and smiled.

His blood pressure was NL, his PSA was way down, then at the end he told me how he felt, which is now engraved in my heart. "I was never loved and cared for. I see you in my dreams; you made my life."

He doesn't believe I feel appreciation toward him. He said, "Goodbye—see you again," smiling and walking away.

He helped me to believe in my intuition, my love for patients, and my bold and creative approach. His image and words open a smile on my face.

His Eyes Said It All

Gloria Yu, MD – Pathologist, Fremont Medical Center, CA.

What struck me were his fading blue eyes and gold-rimmed spectacles. He was quiet. In fact, he did not say anything the whole time. He was a good-looking man about 30 years old. I was asked to do a liver biopsy on him. His abdomen was swollen with an enlarged liver and ascites. Even without a word, I knew he understood that he was a hopeless case. His eyes said it all. Later, after I made the deadly diagnosis of high-grade lymphoma, I found out that he died the previous evening.

TPJ20Years

 

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