Tuesday, September 29, 2015

Gone to Carolina.

image credit
"Can't you see the sunshine?
Can't you just feel the moonshine?
Ain't it just like a friend of mine to hit you from behind? 
Yes, I'm gone to Carolina in my mind."

For thirteen days straight, I've asked the same questions. "Where are we this morning? Do you know where you are?"

Most days, it's something vanilla like, "We are right here." You point down at the sheets on the bed. "Right, right, here." You look up at me hopeful. And on some days fretful.

"Where is here?" I press.

"Right over here. Not yonder, but here."

Which is technically true. But false at the same time.

Is this delirium or dementia? Or is it both of them stacked on top of one another? Your mental distance is yonder. It saddens me so I keep trying and asking the same questions over and over again. Hoping I'm wrong.


Your family says that you're pretty much "back to how you normally are." And at an age too young to even qualify for Medicare, I wish they were all wrong. So I keep asking.

As of this morning, you were better with regards to what had you hospitalized. Your heart failure exacerbation had improved. The swelling in your legs had dissipated and the oxygen requirement caused by the fluid filling your lungs had waned. From a medical perspective, you could return home. And even though I'd already told your loving family, I still felt the need to tell you, too.

And so I did. You just looked through me with a vacant stare, smoothed out the covers, and sighed. A little hopeful but mostly fretful. I didn't really know what to do with that so I returned to the basics.

"Where are we this morning? Do you know where we are?"

"Oh. We here. We right, right here."

I rubbed your cheek with my hand and smiled."Where is here?"

This time you smiled back. "Greensboro, North Carolina."

My eyebrows raise. This was new, on the last day no less. I'd never heard you say that answer before. Instead of following it up with my standard, "We are at Grady Hospital in Atlanta, Georgia," I left it be. Because this time your eyes were dancing and your expression was so sweet, so innocent.

And, for once, not vacant. Or fretful.

I'd later learn from your daughter that this was where you'd been raised. Milking cows and running through fields with your siblings. The simplest time of your life had been there. Right, right there.

And so. Upon your discharge I left you there. And for the first time since you'd been hospitalized, some piece of me found solace in knowing that you were there. Gone to Carolina in your mind. Instead of here. Right, right here.


Happy Tuesday.

Now playing on my mental iPod one of the best songs ever by one of the best artists ever. When I hear it, I will now think of you every time.

Saturday, September 12, 2015

I know what you did last summer.

"You've always had the power, my dear. You just had to learn it for yourself."

~ Glenda the Good Witch

I acquired a new small group of medical student learners in July. First year students fresh out of the layperson's world and still in those bumpy stages of trying to make sense of this new culture. My group is a mixture of students just months outside of four year universities and others who'd worked for a few years before coming to medical school. Either way, I'm fortunate to have eight earnest, insightful and seemingly emotionally mature students in this new crew.


For the last couple of weeks, we've been on the part of the curriculum where we introduce our students to the patient interview. They've been taught all of the elements of how to take a medical history and determine the narrative of a patient's present illness. Readings outlining nonverbal cues and ways to facilitate a conversation have been assigned and handouts posted on their electronic blackboard site explaining the right and wrong ways to build rapport with patients. And while all of it is good and true and well-meaning, any person studying these materials would probably discern quickly that it doesn't seem like rocket science. Then again, maybe it does sound a little too much like rocket science (even though it isn't) which is why the students get so tripped up about these early patient encounters.

At least that's what I think.

So yeah. I guess whenever I look at literature about how to talk to patients, I almost always instinctively wrinkle my nose and squint one eye. "Why are we making this so academic?" I always mumble to myself. And again, I am taking nothing from the experts who've devoted their medical career to this. Instead, I'm just thinking that, just maybe, all of this would be much, much easier for our students if they could just remember one thing and one thing only: Patients are people.

Simple, right?

I mean, actually? Yeah. Right. Patients are people. And people are not something that should be foreign to a high achieving college-educated person beyond the age of 21. What makes it even easier is that our students are people, too. So they already have a point of reference.

Does this sound confusing? I'm sorry. Let me be more clear.

So check it. I was tasked a few weeks back with helping my students take a medical history. They'd learned the elements and I was supposed to have them interview each other in pairs with a mock chief complaint that had been provided in the assignment. And yes, those simulated complaints were good ones that, I'm sure, would offer great practice to these budding young student doctors.


The focus was supposed to be fluidity and asking open ended questions. Fighting the urge to do what 100% of doctors in nearly every patient-doctor communication study I've ever read does to their patients--interrupt. Yeah. So the point was that and not so much those complaints. And the students knew what they were supposed to be doing and were ready to give it a try.


So the truth is that I've been doing this long enough to know that somehow, some way all of the academicism of the exercise causes even the best communicators to forget simple tenants of interpersonal skills. Being told that you're "in a clinic" instead of "in Starbucks" creates this weirdness that more often than not morphs into these staccato yes-no questions that fly out of mouths without rhyme or reason.

And so. This year, I decided to try something different for that first session. Since I knew that we'd have enough time, I started the session off by going over all of the assigned material. We talked about ways to have a good interview and tips for encouraging the patient to speak. I told them that we were going to do the mock chief complaints but first we'd do something else. Something very different yet pretty much the same.

I paired them up and then gave these instructions instead:

"You are in a coffee shop. Your task is to find out about the very best thing the person did this summer. Get as much detail as possible because you'll have to tell us about it. Why was it the best thing? Who was there? What did they do? What experiences did they have?"

You know what happened? They relaxed. They listened. They didn't interrupt or interject with their opinions. They nodded their heads in the places one would nod a head and asked the kinds of questions that convey genuine interest. And, of course, the person being interviewed opened right up and gave even more information.


It was so awesome, man. They were laughing and enjoying one another. Reacting to the remarkable parts of the stories and gaining clarity on the aspects that didn't make sense. And, because those conversations were light and the "patients" felt heard, it was easy. No one had to explain to anyone "how to be"--it came natural.

Sure did.

I had them swap interviewer and interviewee but changed the instructions a bit. This time they had to find out about the most frustrating or disappointing thing to happen to them in the last year. Similar to the last one, it was the job of the person asking to find out  what happened and why this particular incident was identified as the one so significant that it got this label.

You know what happened? The empathy came right on out. Facial expressions conveying regret and automatic shifting of intonation. Softer voices, gentler eyes. And all of it happened naturally.


Immediately after, we moved into the those medical complaints and did the same exercise.  And you know what? It went great. It really did.

You know what else about this was so cool? After each of those first interviews, I asked the interviewer to tell the group what they'd learned. Without fail, every single one of them broke out into these elaborate story lines chronicling summers in Barcelona, rides on very, very big roller coasters, and long summer days in New York City. No one took a single note. Yet, somehow,  they got all of the most important parts. Just from listening and not jumping ahead. And conveying through body language and voice that they were there precisely for one reason--to get that person's story.

I guess what I loved so much about that part was that I believe that when one person is allowed to speak while the other carefully listens, it's usually easy to remember most of it. I think getting too many rules thrown at you on how to do this takes away from our ability to listen. Any time a person is trying to remember the steps to something, hearing gets interrupted. Like, totally.

Honestly, I wish someone had told me all of this when I was a medical student or an intern. Like, I wish they'd simply reminded me that patients are people and that I'd already gotten quite far with the communication skills that I have. It would have been great to have it explained to me that I wouldn't need to overhaul my complete personality to be a doctor. I'd just need to acquire some knowledge to help guide my questions.


Somewhere around my third or fourth year of residency, I started realizing all of this. It dawned on me that having only one version of myself that adjusted only slightly depending upon the patient and the setting required less memory. And it felt more authentic. On top of that, I got far more from my patients when I just told myself, "This is a person who needs to be heard. And I am a person who is here to listen so that they can."

I still tell myself that to this day.

So, I guess my approach now is simpler. I come out of the gates telling them that any person who cares about other humans is already qualified and able to take a kick ass, non-awkward, and completely thorough history. I spend more time discussing the art of listening--which is an art indeed--and try as hard as I can to model that for them.

You know what? Every day I'm realizing more and more that being tasked with guiding brand new medical students into what is arguably the most critical aspects of who they will be professionally is huge. More than huge--it's ginormous, man. But the more I do this, the more I am seeing my role as more like Glenda the Good Witch than the Wizard of Oz. That is, my job is to simply shine a light on the person that is already there and give them the courage to click their heels and trust who they are.

And the best part? Every lesson for them is a lesson for me. 

Yes, ma'am and yes, sir.

Happy Saturday.

Monday, September 7, 2015

Life in iPhone Snaps: Images of This Fast and Furious American Life.

Life moves so quickly sometimes. Capturing it in images slows it down for me and helps me savor it. Here are a few random iPhone snaps from the last few weeks in this little life of mine.

Like to see 'em? Here they go!

My boys are getting big. Fast. Sometimes I walk behind them listening to their conversations and they morph into 16 and 17 year old young men. I shake my head and wipe my eyes and they go back to this size. It's crazy. But in this bittersweet and beautiful way.

The "baby god brothers" are now kindergarten aged. Look how protective my boys look of them. I remember posting their births on this very blog. Dang.

My nephew is now a freshman at Emory. What's super awesome is that his dorm is literally across the path from where I teach and right along where I walk in and out to the med school. This was from a day that I ran into him. It made my week.

Fortunately my nephew wasn't present for these dorky photos that I talked the family into taking on move in day.


I love it that we get to see so much of David now. This was yesterday when he popped by our house. He was Zachary's age when he was the ring bearer in our wedding.

Le sigh.

Went to L.A. for JoLai and Joe's big post wedding soiree last weekend. Because JoLai is the friend hoarder, there were friends representing every single phase of our lives. It was awesome.

We were all so awkward in middle school. I love seeing how much we've all come into our own.

My best friend, Lisa D., joined me for the trip. We had a blast.

LOL how awesome is this? This woman, Sandra V., graduated from high school with me. We tied for 6th in our high school class down to like 5 decimal points. I'd forgotten that until she reminded me. I told her, "Oh well. It just means we were both smart girls."

Road trip to Savannah for Zachary's football tournament. It was hot as FISH GREASE, do you hear me?

I am in love with these two boys.

He asked me if we were close to the equator. I told him, "That or hell."

I love when the BHE helps get Zachary situated. It really is quite appealing in a strange way.

If my skin looks like it is melting off it's because it probably was.

I bought this big ass umbrella on Amazon. They laughed at me. Until it rained cats and dogs in Savannah. Mmmm hmmm.

Awesome day with Small Group Epsilon. We had lunch then took a field trip to look at social determinants of health in two neighborhoods. We visited two different grocery stores and it was really eye opening to see how poverty can affect access.

This store had 17 different types of apples. And they all looked amazing.

Have you ever heard of a "Rockit" apple? I hadn't.

When your grocery store is this affluent, you run out of organic apples.

I had to ask two different people to help me find the organic apples in the other store. This was from the lonely pile they had. The kind man in produce told me, "They cost a lot so they don't sell."

This affordable display, however, was more affordable. And also prominently situated at the very front of the store when I walked in.

The first store had a Starbucks. This one had beauty supply, pawn shop, and a number of predatory lenders. What did they learn? That achieving your full health potential is some complicated shit.

Especially if you have limited income and uninspired surroundings.


This was cool:

My former Small Group Alpha advisee, Alanna S., is now on the Grady faculty with me. How crazy is that? This was taken on the first time we ever precepts residents in the clinic together. So awesome.

Speaking of Small Group Alpha:

Antoinette N. was in town last week for her Family Planning fellowship interview. She's finishing up her Ob/Gyn residency and is ready to take her next step. It's like no time passed at all since I've seen her last.

Our goofiness immediately comes out. 

Same day, different learner. This was from an awesome lunch pow wow with Robbie G. She's not in one of my small groups but I've secretly adopted her. (Don't tell her advisor.) Love her.

Might as well keep my "selfies with med students" thing going, right? This is Mike E. I took him out to breakfast to celebrate him winning the Medical Student Teaching Competition. He is such a talented and enthusiastic teacher!

Hmmm. What else? Oh. This:

I keep this in my office. It is pretty much the main rule of my office. And my life. Yeah. Pretty much.

Visited my godson at his preschool the other day. He was so happy to see me. I love when little kids that I love show love back. Everyone knows how fickle preschoolers can be.

Mmm hmmm.

I run a race every August now in Deanna's memory. I call August the "Deanna month." Now it's the JoLai month, too. She got married in August so I REALLY needed to get a race in. I just made the cut with this 10K on August 29. Woke up early and did it alone but it was good.


I pass this sign every day when driving from Decatur (where the kids are in school) back into my neighborhood. On this day I was in traffic so rolled down my window and snapped a photo of it.

I saw this sign below hanging on a wall while walking into my friend's loft apartment. It names all the intown Atlanta neighborhoods. Atlanta has the interstate 285 going in a circle around it and is intersected by interstate 85 vertically and interstate 20 horizontally. Everything inside of the circle we affectionately refer to as "ITP"--that is INSIDE THE PERIMETER.

I think an ITP snob is responsible for this sign.

This was from a lovely evening stroll with some of my Small Group Delta advisees. I truly love them.

Man. Have y'all peeped the five dollar movies at Target?

Our latest acquisitions are "Goonies" and "The Princess Bride." Two of my favorite movies that have now become two of my kids' favorites, too.

I think this green grill shows the level of dedication I have to my son's team. I'm just sayin'.

Had an awesome brunch at my favorite brunch spot with my best friend. I love that when it's just us two we can speak so freely. Our twenty three year old friendship just gets better with time.

More Prosecco?

Yes, please!

And then today:

Started it off with a 10K for breakfast with two great friends, Stephanie M. and Ishan M.

It was a merciful course and the weather was equally kind to us.

Yeah. So that was a cool way to start my day.

Especially since it was my birthday.

I spent the whole day lazing around with my three favorite guys. The big one wasn't feeling my camera so kept hiding.

Zachary detests cake but Isaiah happily polished off my complimentary flourless chocolate cake the minute the candle was blown out.

Harry and I both had on white pants. You know they have all these rules about white below the waist in the south (after Labor Day.) That wasn't a thing in California. But when in Rome.. . . . 

And lastly this photo taken by the BHE after the guys took me to dinner. Nope. It wasn't a rager of a birthday for me at all. But it was perfect.

Truly perfect indeed.