It's the night before the elections. By all predictive accounts it's not a good time for Democrats. If you're supportive of what the Democrats stand for, of what has been accomplished in the last 2 years, of the overall job our president has done (even though you might disagree with some of his stances), it would be easy to feel very discouraged tonight. Anonymous donations are creating a flood of negative political messages now that the Supreme Court has decided that money and profit-driven corporations have the same rights of free speech as individuals. The possibility of a return to a monied plutocracy from a representative democracy looms. The first major steps toward health care coverage for all seems threatened. Angry epithets are hurled publicly. The media has created a business model based on inflammatory distortion and simplification of our major societal problems rather than participating in helping to educate us about the difficult choices that are needed to ensure our future. And on and on.
However, it felt really good to stand in line for an hour to vote on Saturday. Everyone was civil. Sample ballots were passed down the line. No one seemed angry. Kids were with their parents, purposefully brought along for this community civics lesson. Maybe I was projecting, but I felt a sense that everyone was taking their opportunity to participate as a serious obligation. I left feeling pride in our system and hope for its ability to balance my worries about the specific outcomes tomorrow. And with the knowledge that --should all the possible concerns I mentioned start to materialize --I'd have the opportunity to stand in line once again in two years to do my part to help set the country on the right path.
Monday, November 1, 2010
Saturday, October 16, 2010
Defense, Defense, Defense
With the football season well underway, stadiums and TV screens are filled with chants of support for the home team. A common cheer is 'Defense, defense, Defense'...often accompanied by the inane defense sign; a 'D' in the right hand, a picket fence in the left.
True football fans know that, while spectacular plays on offense, a long pass, a field length kickoff return, are exciting, it is defense, often quite boring, that wins games and championships.
With this an an analogy, I often tell my patients that once they turn 50 it is time to play defense with their health. Here are some examples of what I mean:
-taking a baby aspirin a day unless you have a specific reason not to
-keeping your weight from going up 2-3 pounds a year
-exercising every day, 45 minutes, not just weekends.
-keeping your blood pressure and cholesterol numbers low. Don't be satisfied with 'borderline'. If you have high numbers, it will take SIGNIFICANT AND CONTINUOUS diet and exercise efforts to change them. Don't be afraid of medication if you need it.
-play defense in your community...volunteer doing something that makes you feel good.
-laugh out loud at least once a day.
-watch your step...stand on one leg
-keep striving for the elusive work/life/spiritual balance
I think you get the idea.
Here's another sports analogy:
Most games are won or lost in the second half. You can make up for a slow start with a terrific fourth quarter.
So start playing some good defense...the outcome of your game may depend on it.
True football fans know that, while spectacular plays on offense, a long pass, a field length kickoff return, are exciting, it is defense, often quite boring, that wins games and championships.
With this an an analogy, I often tell my patients that once they turn 50 it is time to play defense with their health. Here are some examples of what I mean:
-taking a baby aspirin a day unless you have a specific reason not to
-keeping your weight from going up 2-3 pounds a year
-exercising every day, 45 minutes, not just weekends.
-keeping your blood pressure and cholesterol numbers low. Don't be satisfied with 'borderline'. If you have high numbers, it will take SIGNIFICANT AND CONTINUOUS diet and exercise efforts to change them. Don't be afraid of medication if you need it.
-play defense in your community...volunteer doing something that makes you feel good.
-laugh out loud at least once a day.
-watch your step...stand on one leg
-keep striving for the elusive work/life/spiritual balance
I think you get the idea.
Here's another sports analogy:
Most games are won or lost in the second half. You can make up for a slow start with a terrific fourth quarter.
So start playing some good defense...the outcome of your game may depend on it.
Sunday, August 1, 2010
It's never what you think it will be
I have the 'advanced directives' discussion with my patients every day in the office. What I usually hear is some variation of: "if I get to the point where my life is not worth living, I will not want to keep living". (Or, more actively, "I will have a plan for ending things"). They want to be certain that I understand.
What I have really come to understand is that the future never plays out exactly as you anticipate. The most definite, strongly held views today will be different in the future. Relationships change, unforeseen circumstances occur, life never follows a predictable path. The moment of decision so clearly anticipated in the abstract is never quite so definite in reality. The feeling of surety today, even when placed in legalese on the living will, is often quite ambiguous at the real moment. What seems to be a single point of decision is blurred and not completely clear. The definition of 'a life worth living' becomes a moving target.
I've begun to incorporate these thoughts into my discussions of living wills with patients. I've come to believe that the term 'living will' is not just a will that is made when one is living, but also a will that lives...that represents a process, not just an abstract statement of intent for a set of circumstances that may not happen. A conversation that is ongoing, not signed and sealed in the lawyer's/doctor's office.
My mother-in-law is one of strongest life forces I've known. Her mind is a tour de force. She has had 2 husbands unfortunate enough to develop Alzheimer's dementia. She has always said that if her mind goes, she will end her life. She is a member of the Hemlock Society. She's had a full tank of helium in her home for years, a stash of barbiturates in her freezer ready for 'the day'. At 93, lonely and with all of her friends and contemporaries dead, she met someone she knew 75 years ago. He, too, was a lonely life force with no living contemporaries. They are like the two last survivors on the island. Now 96, she worries that her mind is going. She has trouble remembering, and doing her beloved crossword puzzles. But the helium and barbiturates remain in the closet and freezer. She wants to spend each day, and each next day, with her companion.
My father had a severe stroke 3 months ago. His life has changed radically. He can no longer swallow and depends on a tube for nutrition and medication. Years ago we had the discussion I referenced above. I'm the doctor in the family. He wanted to be sure that I would not let him exist the way he is currently existing. But he since remarried. He fell deeply in love... perhaps the deepest of his entire life. His definition of a life worth living changed. Now, if he can awaken tomorrow and see Rosie, his wife, one more time, his life is worth living. If, 10 years ago, he could see the facts of his existence today, he would say 'No." Today, in the evening, Rosie gives him a kiss goodnight and says "See you in the morning", and he says:" I hope so".
What I have really come to understand is that the future never plays out exactly as you anticipate. The most definite, strongly held views today will be different in the future. Relationships change, unforeseen circumstances occur, life never follows a predictable path. The moment of decision so clearly anticipated in the abstract is never quite so definite in reality. The feeling of surety today, even when placed in legalese on the living will, is often quite ambiguous at the real moment. What seems to be a single point of decision is blurred and not completely clear. The definition of 'a life worth living' becomes a moving target.
I've begun to incorporate these thoughts into my discussions of living wills with patients. I've come to believe that the term 'living will' is not just a will that is made when one is living, but also a will that lives...that represents a process, not just an abstract statement of intent for a set of circumstances that may not happen. A conversation that is ongoing, not signed and sealed in the lawyer's/doctor's office.
My mother-in-law is one of strongest life forces I've known. Her mind is a tour de force. She has had 2 husbands unfortunate enough to develop Alzheimer's dementia. She has always said that if her mind goes, she will end her life. She is a member of the Hemlock Society. She's had a full tank of helium in her home for years, a stash of barbiturates in her freezer ready for 'the day'. At 93, lonely and with all of her friends and contemporaries dead, she met someone she knew 75 years ago. He, too, was a lonely life force with no living contemporaries. They are like the two last survivors on the island. Now 96, she worries that her mind is going. She has trouble remembering, and doing her beloved crossword puzzles. But the helium and barbiturates remain in the closet and freezer. She wants to spend each day, and each next day, with her companion.
My father had a severe stroke 3 months ago. His life has changed radically. He can no longer swallow and depends on a tube for nutrition and medication. Years ago we had the discussion I referenced above. I'm the doctor in the family. He wanted to be sure that I would not let him exist the way he is currently existing. But he since remarried. He fell deeply in love... perhaps the deepest of his entire life. His definition of a life worth living changed. Now, if he can awaken tomorrow and see Rosie, his wife, one more time, his life is worth living. If, 10 years ago, he could see the facts of his existence today, he would say 'No." Today, in the evening, Rosie gives him a kiss goodnight and says "See you in the morning", and he says:" I hope so".
Saturday, May 15, 2010
My phone vibrated as I walked into the Salt Lake City airport to catch a connecting flight home. The name on the phone screen
could only mean one thing: bad news. The details would come in the conversation to follow, but I had certain knowledge that in some way everything would be different from now on as soon as I saw that particular name on the screen.
I think that our lives are punctuated randomly, without warning, with these instances: good or bad, happy or sad, encompassing the entire spectrum of human emotion. Our personal blink moments, a la Malcolm Gladwell
The blink moment described above was the news that my father had had a stroke. His life, and our relationship would be forever changed.
Other blink moments for me have been:
-that moment in September when the feel of the air instantly announces autumn.
-looking down at both Coert and Emily as I delivered them
-the instant I smell the perfume my grandmother wore
-the first 2 notes of the sound track of 'Out of Africa'
These are all emotional 2 x 4's, and don't happen often. I often feel that life is passing by in the 'blink of an eye'. Perhaps with attention and mindfulness more of life can become a personal blink.
could only mean one thing: bad news. The details would come in the conversation to follow, but I had certain knowledge that in some way everything would be different from now on as soon as I saw that particular name on the screen.
I think that our lives are punctuated randomly, without warning, with these instances: good or bad, happy or sad, encompassing the entire spectrum of human emotion. Our personal blink moments, a la Malcolm Gladwell
The blink moment described above was the news that my father had had a stroke. His life, and our relationship would be forever changed.
Other blink moments for me have been:
-that moment in September when the feel of the air instantly announces autumn.
-looking down at both Coert and Emily as I delivered them
-the instant I smell the perfume my grandmother wore
-the first 2 notes of the sound track of 'Out of Africa'
These are all emotional 2 x 4's, and don't happen often. I often feel that life is passing by in the 'blink of an eye'. Perhaps with attention and mindfulness more of life can become a personal blink.
Sunday, April 25, 2010
Walking in New york
I'm always telling my patients that no matter what their problem might be, exercise is part of the answer. I have activity and exercise themes among the pictures, slogans and books in each exam room. It's an uphill battle. Living in the car dependent West, exercise for me and my patients tends to be something apart from the rest of our day, something separate in time. I'm visiting my daughter, who lives in Brooklyn, this weekend. We're walking everywhere. day and night. THe streets are crowded with people walking. Sure, there are a few overweight people on the streets, but nothing like the obesity epidemic I see at home. Of course, at home I don't see anyone on the streets. I thought I was in pretty good shape before this weekend, but I obviously need to do much more walking. I'm revising my bias that living in a city like New York would make it difficult to exercise. And before my next visit I'll definitely go into training.
Friday, April 23, 2010
“Oh, by the way?"
Hand on the door. Office visit thought to be completed.
These words are code, which every physician understands to mean: “Here is what I really want to talk about.”
On your best days you sit back down and say, “Yes?” -- knowing the line of patients not yet seen will now be pushed back 20-30 minutes more. These ‘best days’ are, more and more, a casualty of the 15-minute-or-less time allotment now ruling the doctor-patient encounter, thanks to managed care.
“Oh, by the way,” Larry said. “I’m worried I might have AIDS.”
Larry was an acquaintance who had become a patient, a political science professor whose life had taken an abrupt turn when he found the courage to admit that he was gay. He had left his 20 year marriage, and was determined to maintain a healthy relationship with his adolescent son.
I arranged for him to be tested.
When the tests came back positive, I suggested that I refer him to the AIDS clinic at the University (the easy solution for me). He objected.
Larry was my first AIDS patient and I was afraid. I was afraid I wouldn’t be able to give him good enough care. I was afraid I’d make mistakes. I was afraid that this disease was more than a Primary Care doctor could handle. Part of me was also struggling with the irrational fear of the disease itself.
“You are my doctor, “ he said “You know me. I don’t want to go through this with a stranger, as a number. I’ll help you. We’ll do this together.“ And we did.
Once we got started I realized that this was exactly where his treatment should be managed: in a family physician’s office. He’d been my patient for years. I could get whatever consults were needed for him through my network of specialty colleagues. I could study. I could learn. Most importantly, I had a relationship with him that preceded his disease, so he remained essentially Larry – not an AIDS patient who happened to be named “Larry.”
For 10 years. We both learned. We both watched each other grow. We both asked for help when we needed it – he from his family and friends, me from my specialist colleagues. Just before his death, when the final course was clear, we both agreed we would not have done things differently.
I know this experience was a gift to me. A gift that began the moment I heard the code words.
Hand on the door. Office visit thought to be completed.
These words are code, which every physician understands to mean: “Here is what I really want to talk about.”
On your best days you sit back down and say, “Yes?” -- knowing the line of patients not yet seen will now be pushed back 20-30 minutes more. These ‘best days’ are, more and more, a casualty of the 15-minute-or-less time allotment now ruling the doctor-patient encounter, thanks to managed care.
“Oh, by the way,” Larry said. “I’m worried I might have AIDS.”
Larry was an acquaintance who had become a patient, a political science professor whose life had taken an abrupt turn when he found the courage to admit that he was gay. He had left his 20 year marriage, and was determined to maintain a healthy relationship with his adolescent son.
I arranged for him to be tested.
When the tests came back positive, I suggested that I refer him to the AIDS clinic at the University (the easy solution for me). He objected.
Larry was my first AIDS patient and I was afraid. I was afraid I wouldn’t be able to give him good enough care. I was afraid I’d make mistakes. I was afraid that this disease was more than a Primary Care doctor could handle. Part of me was also struggling with the irrational fear of the disease itself.
“You are my doctor, “ he said “You know me. I don’t want to go through this with a stranger, as a number. I’ll help you. We’ll do this together.“ And we did.
Once we got started I realized that this was exactly where his treatment should be managed: in a family physician’s office. He’d been my patient for years. I could get whatever consults were needed for him through my network of specialty colleagues. I could study. I could learn. Most importantly, I had a relationship with him that preceded his disease, so he remained essentially Larry – not an AIDS patient who happened to be named “Larry.”
For 10 years. We both learned. We both watched each other grow. We both asked for help when we needed it – he from his family and friends, me from my specialist colleagues. Just before his death, when the final course was clear, we both agreed we would not have done things differently.
I know this experience was a gift to me. A gift that began the moment I heard the code words.
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