Writing and Telling Our Clinical Stories to Improve the Art of Medicine
Tom Janisse, MD Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-075Why do doctors and nurses 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, move them out into the world. Spirit full-text PDF Download
Restoring Our Humanity: Our Intention to Heal
Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/06-028Being a doctor can be such a lonely place to inhabit. Our task-oriented approaches to patient care can all too often reduce us to feeling more like two-dimensional characters in someone else's story than three- and four-dimensional people in our own meaningful lives. Never has there been a time in the history of medicine when physicians have had a greater need to find meaning in what they do. When we translate clinical experience into written narratives, we bring to life the physician-patient relationships in which we live. The act of writing helps us to restore our own humanity, and the act of seeing ourselves with our patients on the written page reminds us of what led most of us into medicine in the first place. These stories both humanize the physician-patient encounter and make physicians feel more like the human beings they are than the "human-doings" they sometimes become. And it is only through being more fully human ourselves that we may convey convincingly to patients our intention to heal.
Does Anyone Have a Case? The Balint Group Experience
Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/04-051So begins another Balint group for clinicians. Using a case presentation model in a facilitated discussion format, clinicians are invited to explore the clinician-patient dynamic. The deceptively simple process can enable clinicians not only to learn more about the perspectives of the patient but also to foster greater satisfaction in the practice of medicine. This is one possible method of practice-based learning that we are exploring to reinvigorate our vocation.
Finding Meaning in Medicine
Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-066Since January of 2004, an extraordinary series of physician gatherings has been taking place at our homes each month. Most participants are from the Kaiser Permanente (KP) Oakland Medicine Department, but the group has grown to include physicians from the Oakland community and other KP facilities as well.
Things Happen in the Park
Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-037A boy yelled, "Stop crying!" As I turned toward him, he pushed his sister. She landed, hard, bouncing on the cement. Then she stood, head bowed, facing him.
For Carl
Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/04-027We were in my exam room, where I most always see my patients. This was probably the fourth or fifth time I'd seen Carl. He was always intense, yet despite his intensity, there was a softness to his eyes. I could imagine him having thoughtful discussions with his middle-school students. His voice was soft, but direct and clear and firm.
Life Lesson
Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/04-033By 7:15 am. I am sitting at the nurse's station, getting report on my group of patients for the shift. Oh, no--this one is going to be a challenge: 55-year-old male, admitted with Stage IV decubitus ulcer and septicemia. History: paraplegic x23 years from a gunshot wound to the spine, with subsequent bilateral AKA, multiple surgeries, and colon cancer two years ago with colostomy placement. He has a suprapubic catheter, triple lumen central line catheter, extensive Q shift dressing changes, and is on bed rest in supine position only. God, how awful. I can't imagine any quality of life worth waking up to, day in and day out, after all of that. Life is hard enough as it is. Now, the poor soul has weeks of around-the-clock antibiotics and more surgery to deal with.
Mountain
Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/04-040Everyone who sits on my couch sees a black and white print of the valley I lived in as a teenager viewed from our mountain. It hangs out of my line of sight, behind me and over my head. I forget it is there most of the time, but it was a gift to my Dad toward the end of his life from one of his art students. They were as eager for his praises I was-and less frustrated. Above the print hung a ceremonial eagle feather given to me by a Native American elder. I thought it looked great flying above the aerial view. More importantly, it reminded me of hope and higher powers.
One of Our Stories - Might, Beauty, and Machine Take Flight for "Right" and "Only":
Tom Janisse, MD Spring 2006 - Volume 10 Number 1
"Please do not vandalize this phone booth. I have no place else to change clothes." --Superman Volcano, California, population 100
High over heads at the World Health Congress, beauty dazzles and drugs, as does sleek black tech. Washington, DC
One hour before the green flag Tony's orange, 20, Home Depot Chevy is second pole. A brilliant racer, True Speed author, he wins at Indy, wins the year, and signs my Stewart hat. Michigan International Speedway
"The Sphere," a bronze sculpture in the plaza's fountain buried at the World Trade Center, rises altered, a peace monument awaiting return. Battery Park, NYC
Doctoring My Doctor
Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-060I got the call at sundown on Friday five minutes before walking out the door for my first free weekend in three weeks. The ER doctor on the phone said he had a patient with acute radicular low back pain, and hoped I could help. The patient, he said, was Dr Peter Devereaux, one of our internists, who, on exam and imaging, was free of spine abnormalities. He said he knew that I, as an anesthesiologist, was an expert, and did I think an epidural steroid injection would work? I gulped, more anxious than I would have guessed to perform a spinal procedure, which I had done a thousand times, on a colleague. Afraid for a moment I could hurt another doctor, I wondered what if he was the one-in-a-thousand patient? What if, while he lay helpless on a white sheet in the fetal position I advanced the 14 gauge metal behemoth through the skin and toward the spinal cord in search of the tiny, potential epidural space, and the needle slipped and I lacerated a lumbar spinal nerve, irreparably. “Sure,” I said, “I’d be glad to take care of him.” When Peter hobbled in, I was at once anxious and confident, concerned and certain, of my skill. He smiled, and said he was so grateful I would help, and happy that I was the doctor on-call who would perform the spinal procedure he dreaded. “Well, how was that Peter?” I said, withdrawing the needle. I had performed a flawless epidural puncture and injected dexamethasone and lidocaine bathing the spinal roots to shrink and numb them. He sat up on the gurney, turned his head side to side, looking into the empty corners of the Recovery Unit and out the windows, now black pictures of night lights, and said, “You know, I think I’m starting to feel less pain already. Yes, the pain is definitely better.” “Great,” I said, my heart rate plummeting. “Peter, I have a request.” I had just received a letter at home from our Physician Health Committee encouraging each of our medical group to find a personal physician (like patient, like doctor): “Would you be my personal physician?” I said. “Turns out, I don’t have a doctor. I was one of the 25% of our Health Plan member population who was unassigned and unbonded.” “I’d consider it an honor,” Peter said.
Evanescence
Mason Turner-Tree, MD Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/04-034The cold, damp institutional concrete leapt at me like a prisoner attacking with a fork, ready to extract my radial artery and bite it in half. Fear permeated the minimal throng of people who were just moments before ensconced in laughter, joviality, and irresponsibility. The vague camphor smell went unnoticed until a polyester protector reminded us that the room was last occupied in the early 1960s. Suddenly, as she inhaled deeply, we all followed suit, as if our individuality had been stamped into an 8x8 cell with a regulation coiled, uncomfortable bed and an assaulting jumpsuit. Suddenly, the camphor flowed over me, not in my lungs, but on my skin, across my eyes and through my hair. The collective shudder was more frightening than the camphor. A shared soul is less easy to tolerate than a distant smell leaching from walls that contained such misery. I peered to my companion, hesitant to break the collection of souls marching alongside the polyester protector. It was night. Bleak, cold, wet, and exhausting night. As I broke the camphoria and touched my companion, the bare bulb blew. An echoed scream blinded us, until we realized that it was blackness, not loudness that had burned the retina of our collective. I pulled to the window, and looked at the marshmallow skyline, enveloped by black, moonlit tar. Suddenly, it was 1960-something, and I was trapped. Imprisoned not by concrete walls, but by loneliness and isolation. The smell of chocolate now filled my lungs, but never made it to my brain, stopped on its marginal path by the bleakness of my soul. Snuffed by the camphoria. Blinded by the pale green that I could feel pressing against me. Relief was usurped when a bowl of light fell upon that very same pale green. The polyester protector squashed the collective with her bowl of chocolate-scented fragrance. I stood alone, so close to the moonlit tar that fear permeated my olfactory senses and dragged me, quicksand-like, into the roiling pot of tar, studded with the white, fluffy figures that seemed like heaven. They too, were imprisoned by the sticky filth around us. Suddenly, a solvent hand touched my shoulder, and the collective was gone. The pale green marshmallows were sucked into the moat, and a radiant dragon appeared to damselize me. In the distance, I heard, "That was the room, where Robert "The Birdman" Stroud died ..."
Miracle
Victoria Van Dyke, CNM Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-065"Do you have privileges at the hospital yet?" I looked up from my computer charting to see my colleague, Julie, standing in the doorway. "Yeah, I was on call last weekend, why?" "Well, I'm supposed to be on call tonight and I just found out that the medical staff office didn't finish processing mine. Now it's past five o'clock and it can't get done today." The impact of what she was saying hit me--we had to have someone available for the laboring women who would surely be arriving at the hospital all night. Our obstetric group had just moved from a hospital that closed to a new facility. All of the members of our group were experienced, competent practitioners but all hospitals have a checklist of information that has to be completed before they allow a practitioner to care for patients. Only a few members of our 11-person group had gotten through the process.
1970
Les J Christianson, DO Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-040Verl was born in 1970. He thinks there is something about 1970 that has made him different from his brothers. Not: Oh, isn’t it unfortunate that in 1970 my neurons got scrambled while incubating in my mother’s womb? But rather, What is it about 1970 that made me so different from my brothers? I wish I wasn’t born in 1970. He has said that many times. But who knows whether his neurons were fried in utero or whether my mother simply did not get the Rhogam shot when she should have. My parents were young and scared and this was rural North Dakota. I think all we knew was that there was a new arrival in our house that kept having seizures. Those images are some of my earliest memories. Verl, having one of his seizures next to the TV. Maybe even under the TV with his legs sticking out like the Wicked Witch of the West except that Verl was not crushed because the TV was on four legs. Two months after Verl moved in with me, and my wife, Kris, I woke up one morning at 3 or 4 am to very bizarre sounding noises coming from Verl’s room down the hall. Kris was in Chicago visiting her family so it was just Verl and me. It was April 2000. I went into his bedroom and my first thought was Is Verl possessed by the devil? His breathing sounded very noisy and labored and he sounded as if he were making grunting animal-like noises. One of his arms was stiff and it was extended into the air. He could not respond to me. He seemed asleep but not asleep. I called 911 because I was scared and because I wasn’t sure what else to do other than sit next to him on the bed. When the crew arrived Verl was coming out of it but was still pretty confused and couldn’t walk on his own. We stood him up and half-walked/half-carried him into the hallway where he pissed in his underwear. They took him to Kaiser Sunnyside Medical Center because that’s the location where I worked at the time and because I had enrolled Verl as a KP member when he moved here. I thought it would be better for Verl to be enrolled in the Health Plan where I worked. A nervous control thing on my part. Pulling out of the driveway to follow the ambulance, I couldn’t control my tears crying most of the way there. Twelve miles. Sobbing is probably more accurate. But it’s only a seizure. Seizures don’t seem to kill many people. The threat to life seems to be somewhere between sneezing and a heart attack. But his seizure scared me. I think I was crying because he seemed so helpless and vulnerable and so much like a child—he was starting to seem like my child.
Insight
Kurt Smidt-Jernstrom, MDiV, MA Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-064"I asked to see you over an hour ago!" she complained as I entered her room and introduced myself. Judy looked slightly older than her 44 years with thick gray hair that had been styled short in preparation for the surgery. A volatility that had plagued her most of her life, manifested itself in the furrows on her brow. Annoyed that she was missing work because of her surgery--to remove a tumor that had engulfed an ovary--and aggravated by the pain she was experiencing, she tyrannized the nursing staff activating the call light continuously as if the mere act of pushing on the device would palliate her impatience.
Silence
Laura Morgan, MD Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-051Maggie taught me about silence. Three years ago, with a nasty case of laryngitis, I went to clinic as usual and let patients know that I would be essentially silent during their visit. Most appointments went smoothly, in fact, more smoothly and quickly than usual, which should have been a hint. But Maggie’s visit, to this day, stands out in my memory most powerfully. I knew her as a type 1 diabetic, accident-prone, morbidly obese, self-deprecating woman who lived in a trailer with her chronically ill, demented mother and her troubled sister and niece. Every previous visit with her had brought reports of conflict, injury, frustration, poverty, and sometimes theft. On the day of laryngitis, I resigned myself to listen passively instead of actively trying to make a difference for the better in this unfortunate woman’s life. I indicated to her that I wouldn’t be able to speak during our visit and, with that, she was off and running. For the first time since our first visit, ten years ago, Maggie told me the story of her abusive father, her “silent” mother, her deliberate decision to gain weight in order to repulse her father’s advances after she heard him express an aversion toward fat women. She told me about protecting her younger sister, with whom she was now living, by offering herself as bait to her father until her sister was old enough to defend herself. She imitated the words and voice he used to initiate physical contact and how, to this day, despite his death, she can still hear his voice. I think it took her all of ten minutes to explain her life to me. She expected nothing in return but my attention. She left the office in what seemed a remarkably lightened mood and told me it was the best visit she had ever had with me. Since that day, Maggie is still my patient, now taking two hours to travel by bus one way to my new office. She never complains about the distance and she’s never late.
Harpooning the Vein
Shawna L Swetech, RN Spring 2006 - Volume 10 Number 1 https://doi.org/10.7812/TPP/05-035Are they prominent and soft, or fine like dark thread? Are they hidden beneath spongy layers of adipose? And the skin, is it thick like tanned leather, or thin like a white veil separating the inner and outer worlds? Should I use a tourniquet? Will the vein distend and harden, roll from the needle's probe? Or will binding pressure burst the thin blue line, ecchymosis purpling the tissues. Take a deep breath, I say, imagine your vein is a caterpillar, fat and juicy. I swipe antiseptic across the target, twirl the steel stylette in the cannula. Please, God. Please let me get in, first stick. I can't think of this as real now, can't think of causing pain, injury. The angiocath becomes a harpoon, the arm a lifeless fish. I pierce the flesh -- Don't move now! and wait for crimson flashback in the needle's hub. Score, there it is. I hook up tubing, chevron the paper tape over and under, place a see-through dressing. Blue lights flash, the IV pump beeps to life. Yes. I have been granted the power again.
The Wheezing Cherub, Her Earth Grandmama, and OUR LOSSES
Spring 2006 - Volume 10 Number 1 Natalie is my sonorous Wheezer--The Orchestra in her chest is rarely in Tune--Alveolar Anxiety She will come in with Raucous Cacophony and appear to have just finished a 50-yard dash unsuccessfully I Treasure her serendipitous visits Rosey Cheeks, the Thickest Light Brown Ponytail, Those Gifted Round Eyes The Heavenly Angel Reads to US while being NEBBED with OUR Misty Solutions to relieve the Frothy Rigid PUlmonary MILKSHAKE ... BOOKS Of Joy, OF HOPE, of HUGS and Kisses, of Teddy Bears and Soft, Fluffy Creatures ONE would like to crawl into bed with when our Bones are damp and aching Grandmama is Her most capable Caretaker since the young one's earliest years Such a Tragedy--MOM's death from a Lymphomatous Lecher in her prime The mid-50s SAVIOR is a bundle of nurturing energy, a 60s lady grown wise, mellow, with Rainbow vestments and Iridescent fingernails I unveil the recent Demise of my own Father We weep together and Breath out Long Serene, Unobstructed Exhalations to Placate our Grief ...
The Young Father's Imperfect Gift of Life
Spring 2006 - Volume 10 Number 1 He gave part of his liver to his Infant Son ... I was there at the Start of this Ugly Bilious Disease Unfortunate "Draw of the Straw" plagued by Biliary Atresia Paternal "Fois Gras" Sucked out ... but nurturing the young babe and recapturing this childhood vigor and joy Yet, the Sequellae of the Donor Impairs DAD's life Abysmally Robbing the prime of Paternal 20s HOLES/CAVITIES/Abdominal Fenestrations years after "The Taking" Haunt him Swiss Cheese of the Peritoneum and Rectus Abdominus This Vaporizes his Vitality--Suspends his LIFE Nonetheless, I know you Treasure the Gift you Gave and I honor you In your Ultimate HOLY Sacrifice ...
Hypochondriacal Atopic Derm Adolescent
Spring 2006 - Volume 10 Number 1 His body is like crocodile skin every Angstrom of it A scaley mass of crustaceous keratin A warty six-foot toad of a teen Intense use of fluoridated steroid ointments, Petrolatum baths, antihistamines q4h, and Newer Immunmodulator agents have little effect on his intense pruritis The true cause of his eczema lies not in the superficial layers of his body; but deep in his somaticizing mind The "boy" tortures himself from within Perseverating in his brain about this malady or that "If only there were another blood test," "A Radiographique" "A serum porcelain level to pinpoint my illness!" He stammers/agitates I present this theory "The mind-skin" gap! If you "soothe" your mind, you will surely "soothe" your alligator dermis In theory, he takes it in but never really engulfs the reality of his tortured cerebrum Fitfully, the young lad wallows in his "crustiness" and painstakingly relentlessly scratching as he exits my exam room!
Poetic Moments
Spring 2006 - Volume 10 Number 1 Yellow green leaf drops Thin stalks, white bark, like slow rain Still, no whisper
Light glances red maple leaves Green intertwined with red Not Christmas, just nature
Red maple on burnt coals Dead yet still beautiful A life after death?
Disbelief
Kurt Smidt-Jernstrom, MDiV, MA Spring 2006 - Volume 10 Number 1 Doubting the diagnosis she listened apprehensively for the sounds of marrow exploding deep in her bones, portending the disintegration of her life.
Hearing nothing and buoyed by an infusion of packed cells she insisted that it was a mistake.
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