The Difference Between Pain and Suffering

At 3pm each day on the Hematology/ Oncology Service we attempt to rip ourselves from our wards work to take in a teaching session. It was during one of these sessions that our presenter made this provocative statement: “Pain is not the same as suffering. We can take away a patient’s pain but she may continue to suffer. We may not be able to take away a patient’s pain, but she may yet find a way not to suffer” 

This statement stopped me in my tracks. Each morning we evaluate our patient’s pain, especially important on the cancer service. There is usually a number involved between 1 and 10, giving us a nice clear target to shoot for. When we get that number down to zero, we feel good that the patient is not in pain. And yes, that is a worthy target. But how do you quantify suffering? The presenter offered this definition of suffering “To not feel whole.” 

Patients suffer by being reduced to an illness; they feel less than whole. I once had trouble getting through to patient until I walked into his room without an agenda. We just talked, person to person, not doctor to patient. A doctor can inadvertently cause suffering, the very thing our oath compels us to avoid. At the end of the classic Greek play, Oedipus, the title character is in a great deal of pain, having just gouged his eyes out after realizing he had, despite his best efforts, fulfilled the prophecy of killing his father and marrying his mother. It is a horrific realization and yet he is finally complete in the knowledge of this truth. He is in pain, but he is emerging from suffering. 

The challenge is how we ease not just pain but suffering in others. Or put another way, how do we contribute to another’s sense of wholeness? 

Stump By the Sea: Grappling with Lost Glory

One of the toughest emotions to deal with is a sense of lost vitality. I witness this emotion when working with sick patients and their families. We all must individually confront this question through the arc of life at some point. While walking along the beach (quickly, it was cold!), I noticed a single tree stump which may offer a thought for us in such moments:

Stump By The Sea:

Been a long time
Since sap flowed through my veins

Since I fed vibrant leaves

Since I showed off my perfect bark

People don’t look at me 
Like they used to

When I was alive

But I’m still here-not dead

I have a great view

Of my friend the ocean

Who swims right up to me daily 

My other friend, the sun

Still flashes that amazing smile each morning

So maybe I am more fragile

Than I once was

But I am surrounded by beauty

And so, somehow, stronger. 

Residency as Dance: (Gradually) Replacing One of Your Left Feet

Image Credit: Pinterest.co.uk

There are many reasons to love 90’s hip-hop and R & B. Only recently, I offered a brief lecture to my ward team in which I deconstructed the iconic music video “Motownphilly” by Boys II Men. The exercise provoked teenage memories of working on synchronized high energy dance moves with one of my good neighborhood friends, Martin. The moment when your conscious effort fades away and the music takes over your body as you execute the moves to the building cheers of friends at a party is one of those great life feelings. 
Residency feels like learning a dance . . . 

But, I don’t always learn the steps in order.

There are many steps! 

I can be asked to perform at any time “What do you want to do for the patient?”

The music is always changing, from the steady mid-tempo of the wards to the upbeat Emergency Room to the slow dance of clinic (of course, the music can instantly change within all three settings as well). 

I can’t lead all the time- sometimes I only get to the best part of the room by letting my patient lead. 

I sweat, I get tired, I wonder how many minutes are left in the song. Can’t I leave the dancefloor for a minute? Then, this little dancer in clinic shows me a new move: It’s called “Hug the Doctor.” It’s a great move and easy to learn. It also gets me to the end of the song . . .

And sometimes, the music skips. I can’t figure out the problem or what to do next or how to get past an impasse of opposing lyrics. 

And sometimes, I’m back on the dance floor with Martin. The patient presentations flow with energy and purpose. Everyone recognizes the beat of a good plan. The steady drum of knowledge is overlaid with a couple of compassion tracks and we have a hit. The team may not be dancing on the desks of the nursing stations, but they’re thinking about it . . .

Doctor Who? From Medical School to Residency

May 13th, graduation day, seems like a generation ago. I am now a resident physician in Pediatrics at Seattle Children’s Hospital.   I am 4 months in and the big question, of course, is “What is residency like?”
Residency is like a whirlwind- a lot of activity, direction not always clear.

Residency is like an intense championship game- you are surprised by what you and you team can do under pressure

Residency is like a great cup of coffee- when you can sit down and actually appreciate it, there is a lot to savor

Residency is like a power cord- sometimes your best efforts still fall short

Residency is like a great meal with a good friend- you walk away feeling more complete, more alive

Residency is like a murder mystery- never seen this before

Residency is like an assembly line- seen this too many times

Residency is like dawn- new possibilities abound each day

Over the next 3 years, I will tell the story of residency, right here, in weekly posts.

Of course, I am not on this journey alone; I have an extraordinary group of co-residents at work and my home team, the family. I will let these pictures tell the rest of the story:

Camz taking a nap with Snow and Storm, our first pets!

Camz, set for football practice

Christian and friends, first Homecoming at Shorecrest High School

Anne, taking it all in at Richmond Beach, Seattle

Celebrating Anne’s graduation from her Architecture program

Day off at Richmond Beach

The Dream Team, my co-residents

Downtown Seattle and Mt. Rainer , from Kerry Park

Donning the long white coat for the first time

Flashback to graduation

With Anne at BMA senior banquet

With “Mom-Kenya” and “Mom-USA”

What Can We Learn from Hamilton for 2017?

“God help and forgive me . . . I wanna build something that’s going to outlive me” Aaron Burr, Hamilton

I will admit it: I am unashamedly and unabashedly in love with the musical Hamilton. Earlier this year, an old and dear Theatre friend and I reunited after 15 years and she completely surprised me with tickets to Hamilton, which was everything it is hyped up to be: a great story, clever lyrics, rich characters, dynamic acting, evocative music and truly captivating staging. But more than simply giving you a performance high, Hamilton also leaves you thinking. One thought has continued to linger as I contemplate entering into 2017 . . . it is captured in the Act II song “Room Where it Happens”

In this song, Aaron Burr- President Thomas Jefferson’s vice president- expresses his desire to be part of the decision making that was taking place behind closed doors. He was frustrated at only hearing about the results without being part of it. As we enter 2017, what is the room where it will happen. Will we be in it? It is easier to show up to the building than it is to show up in the room. Whether that building is the home or the office building, it is possible to keep showing up to a building but never really entering the room where it happens.

I experienced this difference recently with my two boys. Usually, when they get going with video games in the living room, I exit quickly to find a quiet spot in the house. This time round though, I stuck around and half-listened in as Christian was playing a combat game. At one point, he was having trouble winning a battle and repeatedly blamed the other character, the game system, the lighting- everything but himself. I asked him to pause the game and we talked about owning wins and losses, not making excuses and focusing on how to get better instead of blaming everything else. It was one of those father-son moments that only happened because I was in the room. 

Getting in the room has a price though. Being in a room is more intimate than simply showing up at the building. You can hide in a building, much harder to hide in a room (Also, unless you’re 5 years old and playing hide and seek, it’s a little awkward to be discovered hiding in a room). But in the room, you can be heard; you can be seen; you can contribute; you can change things. This is what Aaron Burr wanted to be a part of-what we can all be a part of. But Hamilton also warns that when you choose to be in the room “you get love for it, you get hate for it, you get nothing if you wait for it” 

So, in 2017, will we be in the room where it happens?

BLOG EXTRA!😉 While on the topic of Hamilton, here is a recording (link) I recently made of “Dear Theodosia”, Burr and Hamilton’s tribute ballad to their children as they contemplate their future .  . . Enjoy and have a blessed 2017!

http://www.smule.com/p/485830569_829501433

Light Through Tears . . .

Photo Credit: HealingwithDrCraig
The look was the same . . . trembling lips, searching eyes, streaming tears, furrowed brows. The only difference between the grieved face of the father of slain officer, Patrick Zamarippa, and Alton Sterling’s son was the hue of their skin. The pain was identical. This was a harrowing week in America and I won’t cheapen the moment by offering political viewpoints on how we find ourselves here. I have appreciated the calls by both black and white people to love not hate, but I think we all know that Facebook statuses alone are not going to change the situation. In medicine, when patients present with medical conditions that are years in the making, a diseased lung following years of smoking, we understand that no medication no matter how powerful will simply erase the problem. The most effective solution is twenty years past its time. So, I humbly submit that the most potent forces for change were the babies born on each of the days that these men died and left holes in their families. Death can only be overcome by life. These babies do not yet know hate; we can teach them something different. We can dare to move past the natural discomfort we all feel with unfamiliarity and connect. 

And what about the rest of us? Can we change? Absolutely. But it will take something radical, beyond ourselves. When our heart has a major physical problem, we recognize that we need expert help in the form of a cardiologist or cardiothoracic surgeon. Why then would we think that spiritual heart defects are do-it-yourself projects? I realize that not all who read this may agree with my spiritual framework, but I have realized that real change in my heart requires God, who called himself “the great physician.” There is a wonderful verse in the Bible in which the Word of God is referred to as able to “pierce to the division of soul and spirit, joints and marrow.” Sounds like a surgical instrument to me. In fact, one translation describes the Word as a “surgeon’s scalpel.” I recognize that I am a surgical candidate, requiring both the operation that can transform my heart as well as the supportive care of people of goodwill thereafter. Change is possible.

I want to leave you with an image that came to me as I was praying this morning for the families of those lost. I imagined light challenging the darkness of violent acts, a light we can call carry. But I remembered that even those carrying light may still be carrying pain. So perhaps there are tears streaming down the face of light. But the light shines through those tears and, as physics teaches us, a rainbow is created. Not only is darkness dismissed, but color as beauty, not as color as divider, is introduced. This is our opportunity . . . 

Hide the Suitcase

How slowly can I make the door close
To catch one last glimpse of your face in the dark?

Softly saying “Goodnight daddy, have a safe flight”

Your “I love you” echoes in my ears as my legs, like lead

Walk slowly down the hall

In this moment

Every ambition, every purpose, every goal

Pales in comparison to the anticipation 

Of hugging my little (and not so little) champions again

And then how quickly will I make the door open 

To clear the path for your sprinting embrace

 

Learning from Sherlock Holmes . . .

Alicexz.deviantart.com

One of the interesting things about being in medicine is that friends and family consult you with all kinds of medical questions at any time. The questions span speciality (I was asked about a brain tumor, cramping and a bad cough in the same week!) Honestly, I enjoy it: it’s like an unplanned case of the day, and it’s a chance to be helpful. In many cases, I can simply put someone at ease. The movie “Dead Poet’s Socity” spoke about two kinds of professions, the “life sustaining” ones like medicine and engineering and the “life enriching” ones like literature, music and the fine arts. My reward in Acting was to (ideally) give my audiences a meaningful emotional experience by the end of the play through the life of my character, that is enrichment. In medicine, my reward is to use medical knowledge and skills to help patients feel better, sustainment. So, I appreciate the inquiring phone calls and texts and I would like to take you back to one in particular . . .

Last week, my sister texted me, concerned that her daughter (my ridiculously cute niece:) had a high fever and a cough. As I gathered the history and started working through the mental algorithms for what could be wrong, I happened to catch my niece’s voice in the background. She simply asked “What is that?” I think I have may have gotten more information from that audio signal than almost anything else in her story. Why? People who feel very sick are not curious. One of the things we learned in evaluating pediatric fever is that the exact tempertature is not as important as how the child appears. That takes observation, attention. I appreciate that because it feels clinical. A computer can work through algorithms but a only a clinician can be a medical Sherlock Holmes and notice personal, intangible atrributes that crack the “case.”

Paying attention matters not only in diagnosis but treatment. While on a neurosurgery service last year, I encountered a patient who required an operation to remove a brain tumor. Due to the tumor size and location, the patient had a devastating choice, to either lose the ability to read or to hear on that side, depending on which surgical approach was taken. Losing hearing or reading is more than a medical choice, it is a human one. One must ask the difficult question of which option would reduce one’s sense of self more profoundly. This question is approached by a patient who pays real attention to who she is, as well as family members and yes, doctors, who have done the same. No matter our profession, we will learn the same algorithms: law students learn the law, pharmacy students learn the drug mechanisms, but effective decision making in the grey areas seems to reward those who pay close attention to the nuances that no curriculum can adequately capture. Even in the enrichment professions, the actor who not only knows the lines but pays attention to the demands of the performance moment will respond with that spontaneous artistic choice that we recognize as brilliance . . .

By the way, I think we made the right call on my niece. She is doing well . . .

 

3 Stories from Liberia, Pakistan and the US: A Changed Afternoon in Ann Arbor

 

Garmei Sumo, Body Team 12, Monrovia, Liberia [image source: mountainfilm.org]

Listening to these stories was hard. The first was the accounting of Garmei , the only female member of the one of the teams charged with picking up the bodies of Ebola victims in Liberia during the height of the epidemic. The second story featured Saba, an 18 year old woman shot in the face by her father as part of an attempted honor killing in Pakistan. While still recovering from these two, I heard about Manny Bobbit, executed in California in 1999 for a 1982 murder, a case complicated by his history of PTSD and a bungled defense. I left the theater drained having experienced three of the short documentaries nominated for the Oscars in 4 weeks . . . and all three stories left me with tough questions . . .

What is the point of us in Ann Arbor, far removed from the cultural contexts of all three stories, witnessing these tales? Is it so we can shake our heads somberly and say “That’s terrible” Surely, there is more to hearing such stories than well-meaning sympathy . . .

Are such stories a call to action? Should we engage in an educational effort in communities like those in Monrovia, Liberia where Garmei was deserted by her friends for taking on the gruesome but necessary task of collecting victims’ bodies? Perhaps join an activist group to draw attention to the ongoing issue of honor killings in Pakistan? Take a Criminal Justice course to learn more about the flaws within the system in securing justice for the vulnerable?

I will admit I am susceptible to the call for action interpretation. Such stories are so harrowing and so heartbreaking, that my natural inclination is to want to “fix.” It’s hard to sit with pain. But perhaps such stories are asking us to do something even more challenging. To examine afresh our own experiences and relationships where we are in light of these seemingly “foreign” experiences. Before we jump on a plane to Liberia to volunteer, or join that campus activist group to draw attention to honor killings, what about an internal taking stock? Garmei talked about joining the body team because many men were afraid to confront death. How well do we confront end of life issues here? How can we, like brave Garmei, walk into dark, hurtful places where people are afraid? Her daughter called Garmei the “Ebola hero” each day when she came home. She was willing to confront the unpopular, the uncomfortable and yes, the dangerous. Perhaps, we don’t need to be on a plane to Liberia yet. There is enough around us to confront that is unpopular, uncomfortable, and perhaps even dangerous. Will we do it?

Saba was shot in the face by her father for marrying outside the family without permission, as part of an attempted honor killing. She survived after being dumped in a  river and somehow managing to emerge for help. The incident tore her family apart as her mother and sisters were caught in the middle. She was estranged from her mother and didn’t talk to her for months. Are there not many families in disarray right here in the USA or where you may be in the world? If a mother and child are not talking to each other, do the specifics of the conflict really matter? The end result is the same, a lost relationship. Can we really categorize the pain of the mother whose son’s body was picked up by Germai, or Saba’s mother when she first saw her daughter’s disfigured face, or Manny Babbit’s mother when she got the phonecall confirming her son’s death by lethal injection? Or our own?

Stories don’t need to have an agenda, but they should provoke reflection. The tears I witnessed on those three faces today whether in Monrovia, Lahore or Sacramento all looked exactly the same . . .

 

 

 

 

The Power of One: Rethinking New Year’s Resolutions

http://www.pulpypics.com

It’s that time of year again, the time when we take a moment to reflect on the past year and look forward to self-improvement in the next year. The usual suspects are trotted out: nutrition, exercise, spirituality, finances and family with ambitious goals articulated for each. Anecdotal evidence suggests that the success rate for this bold list is less than ideal. But the alternative, an unexamined stroll into the next year is just as unpalatable. So, perhaps a shift in approach is needed . . .

What if we pick ONE substantial target? Sounds reasonable. But how do we make that choice when there are many things we would like to change? I’d like to share a process I went through recently and propose that it may provide a model for you to frame that choice.

My family and I had an extraordinary experience during a family visit this Christmas. One of my favorite cousins visited us for Christmas with her husband and three children and the usual pleasant visit became much more. Toward the end of the visit, we gathered together and asked the kids to share school tips with each other (my two boys, aged 7 and 13 and her 3 kids, two boys aged 12,15, and a 19 year old woman). So the college student (my niece) shared her insights with the  high schooler who then shared his tips with the middle schooler (my older son) who then shared with the elementary children (my nephew and other son). These tips provoked some questions from us, the adults, which led to much more personal revelations about their individual challenges with school. I was blown away by how much more complicated their school lives are because of social media, cyberbullying, fitting in, skewed perceptions of female beauty and more. I learned more about my nieces and nephews in that one session than in all previous visits combined. No therapy could have yielded the rich insights and sharing facilitated by having cousins who looked and sounded like each other share their struggles and victories. It was the kind of moment that was both frustrating and beautiful. Frustrating because these moments are so hard to consciously reproduce but beautiful because you KNOW they are transformative when they happen. I saw the power of relationships firsthand and knew what my focus would be in 2016: building richer relationships.

A few days later, I watched a TED talk focusing on the most comprehensive study on happiness in history. Several men were followed for as long as 75 years and the data revealed that the single strongest predictor of health and longevity was satisfaction with personal relationships. And so building stronger relationships has become the entirety of my “list.” Perhaps, resolutions should not be a list of “ought to’s” but a single “have to”. There should be both an urgency and timeliness to what we pick . . . I think that leads both to a greater chance of success and meaningfulness to the accomplishment. And so, as we all enter 2016, I will leave you with that question, what is your “thing”? May you reach it.

Happy New Year!