Silent No More

"Fear is the path to the dark side.  Fear leads to anger, anger leads to hate, and hate leads to suffering" -Yoda

We put too much stock in blaming inanimate objects or other people or oppression or [enter whatever you want here] as the reason why hate toward others is still so prevalent.  We blame guns for deaths and statues for racism.  We focus on the thought, "if we just tear down x it will make the world a better place" or "if we just control y it will change everything".  Why don't any of us stop and realize that it's our own internal fear that drives the interactions we have with others?  It's fear that leads to "us versus them" mentality.  It is fear that is truly the path to the dark side.  Fear deafens us.  We all scream and shout at each other thinking that if our voice is heard the loudest we'll change other people's beliefs.  Just stop talking!  Stop shouting!  Stop silencing everyone around you!  LISTEN!!

First, listen to the silence.  Listen to what can be heard when you aren't ranting.  What does nature sound like?  What is the Earth telling you?  What sensation does this cause?  Does the silence make you angry?  Does it bring you peace?  Do you feel like laughing or crying?  What is the message in between the silence?

Then, turn to the person you have been shouting over, the people silenced because they are afraid of speaking over you.  What do they have to say?  Learn what is important to them.  We all have something that makes us feel important, that is more valuable to us than anything else.  We all have hopes and dreams and fears.  We all have worries.  We all have a purpose.  What is the purpose of your interaction with the person next to you?  What makes them who they are?  And when you are done with this listening, realize that you only know that one person.  You cannot generalize what you learned from them to anyone else.

Now, listen to the next person and the next and the next.  We are all connected to one another in one way or another.  We all have families, we all have dreams, we all have hopes for the future.  If you think that tearing down one statue or removing all guns from non-military/non-LEO homes is what will change the story-line, then it will be a long road ahead.  You have only asserted your beliefs.  You have done little to hear the beliefs of the people around you.  You may be contributing to the fears of those around you, and that does not make you any better than what that statue stood for or what guns can do if used carelessly.

I applaud people who are willing to stand up for what they believe, but blaming today's bigotry on a statue from 1913 does not really make any sense.  Whether that statue is there or not, the history of the university has not changed.  You cannot change the past.  You cannot change history.  By trying to ignore history, you run the risk of repeating it.  What matters now is how you decide yourself, today, to make the world a better place.  Keep in mind, that world may just be a small piece of the planet we live on.  It may only be the few people you touch in your lifetime.  How are you going to make things better for that small sliver, and how are you going to show them how to pay it forward?  What is more important for your future children: telling them you pulled down a statue once and continued your life as it was or show them how you cared for other people throughout your lifetime?  What is going to have an indelible mark on them: a one time instance of disrespect for public property or a continual show of love toward others regardless of how society sees them?

I choose the latter.  I want my children to see me truly love my neighbor as myself.  I want them to see me sit with other people in their suffering and hear their story.  I want them to know that judgement was set aside, and true compassion for human life shown through.  I want them to understand that we are all equal, that we all experience joy and pain and sorrow.  I want them to know we all laugh and smile the same, we all seek comfort when we are lost or hurt, we all cry in the face of deep sorrow.  I want them to know what anger feels like and know that it is okay to be angry, but that it should never be directed toward another person or creature.  I want them to be curious and have a thirst to better know themselves and their world on a grand and small scale.  I want them to know love, deep passionate love, the love of the simple things in life, and the love that makes us want to care for others.  It doesn't matter how we look or act, we are all part of the same family.

Keeping that in mind, how can you change the world today for the person sitting next to you or in front of you or behind you?  You can listen to the story they tell and know that it is a beautiful thread in the cloth of humanity.  You know where that thread is and can marvel in its beauty.  You can let them know that you have seen and heard them and love them for who they are in whatever way you are capable.  This is what I want my legacy to be.

Days 356-362: The End and The Beginning

June 29, 2018 was the official last day for my hospice and palliative medicine fellowship as well as my status as the trainee.  In August, I will start as the trainer.  What a daunting task.  Sometimes, I'm not sure I'm ready to be in that role.  I feel like I still have so much to learn myself.  I realized that there is always going to be this sense of need to learn as much as I can.  I am excited for my new role and to know that I am not going to have to do too many weeks of back-to-back consults.  I will have medical students, residents, and fellows working with me.  I will be working to make the home calls a more cohesive group.  I will be working on my narrative medicine expertise as well as my role as a mentor.  I will be teaching bioethics for the brand new medical students.  I am nervous and excited.  Before I get too far ahead of myself, though, I have six weeks of rest and relaxation.  Or at least not going into work and packing to move to a new house.

Days 331-355: An end and a new beginning

Today marked my graduation from my hospice and palliative medicine fellowship and the end of my time as the trainee.  In one week, I will be officially done with fellowship.  I get six weeks off before starting as faculty, the moment I have been waiting for since I was a medical student.  In the meantime, I will be packing since LOML and I will likely be moving into a new house before I start my new position.  It's been quite the crazy series of events to get the house we are currently under contract on.  We looked at a group of houses in the neighborhood where we thought we wanted to buy, only to find that the layouts of the houses were not what we liked.  When then started again with a new search, and had two houses we liked at the end of the day: newer construction with vinyl siding and an all-brick house with great updates but on a septic tank.  We went with the newer construction, had everything ready for the offer, and were told it went under verbal contract.  So we looked at another house in the same neighborhood that was the plan we liked.  We put in an offer, only to have the sellers back-out and decide they didn't want to sell.  Finally, I convinced LOML that we really did want the all-brick house because it had everything on our list other than a screen-in porch.  We put in the offer, and it was accepted immediately.  We are now getting the inspections and appraisals scheduled, and will hopefully close the beginning of August.  We've shoved as many big events into one year that we can.  We are excited.  I can't wait to start my new job as daunting as it feels.

Days 318-330: Silence

I have forgotten to focus on my own self-care recently.  I have spent so much time trying to do so many things, I have forgotten about myself.  I have not exercised.  I have not blogged.  I have not written for fun.  I have not painted, meditated, knitted, crocheted, or sewn anything.  The last thing that resembled self-care that I did was the honeymoon.  Prior to that, it was almost back into February, maybe March.  Even then, it was just exercise for maybe 15-minutes first thing in the morning.

When I don't take care of myself, I don't have the energy for pretty much anything else.  I never feel refreshed.  I don't have the tolerance for BS that I normally do.  I barely have the ability to keep it together for a patient visit.  I lack my normal, bubbly, positive personality.  I can't remember the last time I felt care-free.  I can't remember the last time I didn't care what other people think of me.  I constantly second-guess myself because I don't have the energy to overcome and maintain my self-esteem.  LOML is the only person I feel normal and safe around.  He's the only one that I feel is 100% supportive no matter what the situation.  He is simple in that, as long as we are together, that's all that matters.  Even when I lack the ability to show my love as well as he shows his, he knows that we are a team and supportive of each other.  I love him more than I will ever be able to say or show.

My sensitivity level is way too high right now.  I take any comment or critique that could possibly be construed negatively as such.  The general feeling is that I cannot do anything the way I am supposed to.  Even though it shouldn't really matter what anyone else thinks (so long as I don't cause other people physical, emotional, or psychological harm), I feel like I have obligations I am not meeting.  I want to get to a point where I am not phased by what other people think about me.  I want to not care about it.  Certainly if it is going to cause harm, I would like to know, but otherwise, I want to be able to feel like I have support for the decisions I make.

Days 300-317: Absentee

I have not blogged in a long time.  I haven't had the energy to.  The wedding on April 29th was picture perfect.  The weather was amazing.  It was a full moon.  Everyone is still talking about how much fun they had.  The honeymoon was more than anything I could have imagined.  LOML and I hiked every day, explored the upper part of NC and the lower part of VA.  I can't wait to disappear into the mountains with him again.  It has been tough to try to get back into the swing of things at work.  I am emotionally exhausted from the wedding and it's myriad emotions, the deep relaxation of the honeymoon, and then a week after getting back from the honeymoon, on a plane to my grandfather's funeral.  I thoroughly enjoyed getting to see all my family.  I was glad to get to speak at his funeral when I wasn't able to go to Grammy Lou's funeral.  I got back Sunday, and turned around on Monday to start on the palliative care inpatient consult service.  While I realize from a billing standpoint the attending can bill more if they are with me, but it also doesn't make me feel like I am actually ready for faculty if I have to have the attending with me on everything.  Some attendings are better than others at allowing me to continue to run the conversation, but the particular one that I am with is not.  She is well-meaning, but sometimes she cuts in while I'm still thinking about my next move.  It makes me feel like I look like an idiot to the patient.  I'm sure that's not the case.  It probably doesn't help that I haven't emotionally recovered from the previous two weeks.  I'm hoping I'll be in a better place mentally next week after a weekend off.  Unfortunately, it is my last weekend off until I finish fellowship.  Granted, then I have six weeks to get mentally ready for faculty.  I'm excited and nervous for that time.  For now, to make it through the next week and a half...

Days 283-299: Celebration and Sadness

Today is the day before LOML and I get married.  It has been a frenzy of activity leading up to today.  There has been some stress.  Family dynamics are always interesting when you add stress to the mix.  I am trying to stay calm, and I am trying to get excited.  I know this is monumental and a wonderful event in LOML's and my life.  I just hate that I'm stressing out about everyone else behaving.  I need to just let it go and enjoy each moment as it comes.  Tonight is the rehearsal. Tomorrow is the wedding.  I wish, sometimes, that it was just LOML and me.  I know the family is excited to be involved.  I need to get some of that energy!

I also can't believe that I will be at the two month mark for the end of fellowship the day after the wedding.  

Unfortunately, some of the excitement is tempered by the loss of my grandpa Jack.  He had been suffering from dementia for several years now.  I am glad he is no longer suffering.  I have not had time to fully process the loss, and likely won't until after the wedding and honeymoon.  I will be able to go to the funeral and am glad that we can remember him for the good times.

Days 265-282: Humbled

Today during debriefing, the facilitator made a profound comment.  He said, "the healthcare providers with the highest emotional intelligence hold a double-edged sword.  They have the highest work satisfaction and are the most likely to have severe/catastrophic burnout.  It's the difference between PTSD and PTS growth."  This came after my presentation of a really tough situation I've been managing (almost completely on my own) since Monday.

Before we go there, the facilitator is amazing.  He is joining the palliative care team in May that I will be joining in August.  He is a surgeon from a former life, converted to palliative care, and also has his MDiv.  He is an incredibly positive person, and is good at instilling confidence in the people he works with.  I almost want him on my mentor team just for the continued confidence boost I would get.

At any rate, I have had a really difficult case that I picked up on Monday.  The family requested transitioning to a focus on comfort.  The caregiver that had been living with the patient for the last year was concerned that the family was forcing the patient into an earlier death than she would have naturally had.  The anxiety levels and lack of sleep led to an incredibly frustrating night and early morning for them on Tuesday, which resulted in me being blamed for the situation because I had not put in enough medication to manage the patient (despite the fact that I am in training, and should have someone to double check my orders as part of education to provide feedback).  I felt terrible because I felt like I had let the patient, the family, and the team down by not asking for recommendations on medication management.  We got the patient on a PCA which significantly helped her pain and the family's anxiety, along with my staying with them to observe what she was doing that was concerning and provide guidance on what to look for.

This morning, the patient was more alert and comfortable.  Her caregiver was in a better place.  And then the surgeon came in upset that this had transpired, and didn't understand why the family had been allowed to do this.  This got the caregiver riled up again about how things were moving too fast, and the children were forcing her death too early.  I was brought into the meeting between the surgeon and the daughters.  The daughters explained their position.  The surgeon backed down and apologized, and then continued to pour his heart out.  He reported his stress over whether the surgery should have even happened.  He felt such remorse, and was looking to the grieving family to help him work through his existential crisis about his career as a surgeon.  It turned out he had several recent surgeries that had ended similarly.

The facilitator was able to note that for many surgeons, their excellence in their career was intimately tied to their identity.  The second was that I was looked on as the expert in communication, and was needed to validate the emotions in the room while delicately moving the focus forward to future care.  The facilitator was in awe at the amount of genuine care I had for the patient, her family, and the surgeon.  Despite my frustration in the room, I was able to step back afterward and see the situation for what it was.  I now have the chance to hopefully reach out and try to support a colleague who is going into a tail spin and looking for someone to provide a parachute.  I hope I have the strength to do what needs to be done to acknowledge the surgeons suffering.  I hope I can see when I reach a point where I might end up in a tail spin and know how to reach out to my colleagues for that parachute rather than the patients and families who are already in their own grieving process.

259-264: Exhaustion

This week has seemed so long comparatively.  It probably doesn't help that it followed the conference in Boston last week.  It also probably doesn't help that it's the first time I've really worked since January, other than my one week on hospice back in February.  Between both my and the attending's crazy schedule, I have felt that I can be more efficient than I give myself credit for.  To see 4 people between 11 and 3, get notes done, eat lunch, and get stuck in an elevator for 20 minutes on Friday, I might be able to be an attending in September.  Am I intimidated? Yes, but I will be able to do it.

This week has seen a full clinic on Tuesday, academic half-day on Wednesday followed by Boris's appointment at the vet, taking Boris back to the vet on Thursday morning and acupuncture in the afternoon, and food tasting on Friday for the wedding.  We will dissect the parts that are important.

First, Tuesday's clinic.  We still finished at 1.  We still had 2 no shows.  The difference was we were double booked for the schedule, so usually we are seeing 4ish patients.  Tuesday, we had 6.  I saw both news, and two of the follow-ups.  I am trying to do better about not spending too much time with the patients to hold us up.  It hasn't helped that people are showing up or getting roomed late.  When we start 30min behind in a palliative care clinic, it's near impossible to make that time up.  But I feel like I'm doing better with what I have some of the time.

Wednesday academic half-day was interesting.  Part of it was supposed to be an hour discussion of "what we learned at the AAHPM conference".  It turned into a 50 minute presentation of what the program director learned with 10 min for me to present.  I didn't present much because I still had to check-out with the attending I was working with and then leave in time to go with LOML to take Boris to the vet.

Boris is my oldest cat.  He will be 12 in June.  We have been through a lot together with his dietary restrictions and weight issues when I first adopted him.  A couple weeks ago, he developed a swelling on his chin.  We thought he had been bitten by Alex, but the vet was concerned about cat acne.  We changed out the bowls, as recommended, and used to wipes as directed.  Unfortunately, his chin worsened.  On Wednesday, the vet couldn't tell the extent of the mass.  He went back in Thursday for his dental and a more in-depth evaluation as well as a biopsy.  The vet felt like the mass only involved the dermis, and did not extend into his mouth or jaw.  We won't know the results of the biopsy until next week.  We are switching him back to the food he used to eat out of concern that the new food is triggering the reaction.  It seems to be mildly better at this point, but still swollen.  Our hope is that it isn't cancer.  It is reassuring that it is not effecting his eating in any way, and he hasn't lost significant weight (even though he needs to).

Acupuncture was interesting.  I spent the better part of Thursday telling myself I would believe in its ability to work.  I went into the office (which is a doctor's office) but the room is set up like a massage spa.  We talk, and I explain the areas of concern, and then was told to strip down to my undies and get under warm blankets.  Next, sewing needle-size needles are placed along appropriate meridians: ear for relaxation, wrist for sinuses, back and feet to help with my neck pain.  A heat lamp was placed over my upper back, and I lay there for about 20-30 minutes.  I was unable to move due to concern that the needles would dig in deeper and cause pain.  So all you can do is listen to the calming music in the room and rest.  I think that may be part of why it works.  It doesn't completely explain why the knots I've had in my neck for the last 3 months are gone.  That was really nice.  I realize that there is more to acupuncture, and I would likely do it again in the future.  It helps knowing that our patients have to be able to lie there for 20-30 minutes to be able to reap the benefits of the procedure.

Friday was interesting for two reasons.  The first was getting stuck in an elevator.  My attending and I were on the 8th floor in one of the hospital towers and trying to get to the 4th floor.  We got on the elevator along with two med techs who were going to the 7th floor.  The elevator doors closed and then momentarily, we sat at the 8th floor before going to the 7th.  The med techs got off, and the doors closed and then reopened.  That should have been my cue to get off, but we didn't.  As the doors were closing, the buttons wouldn't work, and I knew we were in trouble, but it was too late.  I thought maybe it would start again, but it didn't.  We sat for a minute, I told my attending that I didn't think we were going to get out without help, and I called the help phone.  The help phone, coincidentally, connects to the 911 operator, so imagine the joy of telling them I was stuck in an elevator in the hospital.  I'm thankful it was during normal working hours.  Security got there relatively quickly as both my attending and I talked about our issues with claustrophobia before talking about the wedding.  They were able to finally get us out without the elevator becoming the "Tower of Terror" ride.

The second thing that made Friday interesting was learning that LOML and I had been shuffled on to our third event coordinator at Graylyn.  It explains why we had so many issues with communication with the second coordinator as "life was taking her other places" despite her thinking she would be at Graylyn long-term.  Needless to say, the current coordinator is very on top of things and great with communication, so I'm hoping we keep her through our wedding.  The food for the wedding was delicious.  I am very excited for that.  We also did a quick walk-through with just the three of us before the full walk-through with everyone tomorrow.

We met with the DJ today who I am very impressed with.  He has a calm demeanor, and seems very dependable.  He met us when he was coming in early for a wedding reception he was doing, and was worried about the weather.  He also is very receptive, and is going to be very good with helping to keep everything moving smoothly.  I am thankful to have a strong team working with LOML and I for this.  It is helping alleviate some of the stress, even if there is still some to be had.

Obviously, the week has been eventful.  I don't foresee quieter weeks any time soon.  I am looking forward to the honeymoon when we can relax for a little while.

Days 245-258: Compassion Refueling

I have not had the desire to blog in quite some time as noted by only posting about once a week until the two week hiatus.  I was tired and stressed.  There has been a lot going on, and not all of it super positive.  I got to hit the reset button last week at the AAHPM annual assembly in Boston, MA.  The annual assembly is the yearly conference for hospice and palliative medicine practitioners.  I say practitioners because it is more than just doctors.  It's social works, NPs, PAs, RNs, chaplains.  Anyone who has an interest in HPM.  I think having the interdisciplinary approach improves the conference greatly.  You get a variety of perspectives and approaches to the care provided to our patients.  There also is an understanding that to provide great care, you have to foster the creative side of each of us.  I got to color with crayons, play with therapy dogs, write poetry, go to book club, escape a room with a team of other HPM practioners by completing many different puzzles.  It was the best conference I have ever been to.  There was a perfect balance of education and wholesome fun.  We laughed and learned together.  It was a sharing of ideas across disciplines that allows for a more holistic approach to patient care.

It also gave me a break from wedding planning, trying to figure out taxes, and the drama that comes out around the time of a wedding.  It was a welcome break.  I have been stressing about how I was going to get my taxes done because I have additional taxes thanks to my moonlighting.  There are several forms that I have needed to complete in preparation for the wedding.  We haven't taken the time to complete any of them, and then the number of emails to keep straight has been unreal.  I got to forget all of that for a little while.  I got to refuel for my job.

Today has been spent listing out what I needed to get done now that I'm back in Winston.  LOML and I are at the 6 week mark for the wedding.  We finally submitted the form for the ceremony musicians.  We emailed the DJ about dates to meet but are still working on the plan for the reception.We have completed the form for the photographer but need to send the picture planner and the timeline.  We have a tasting date, but need to double check the date for the walk-through.  We are still waiting to hear back from the officiant regarding the ceremony LOML and I created.  It's so funny how the little details take over at the end when LOML and I should be focused on supporting each other as we prepare to become man and wife.  I am so excited to be his wife.  I have to keep focusing on the importance of that statement.

Days 240-244: Dysfunction

Today was a day of interesting encounters.  The first was of a lady who used to be quite ornery until she declined and became non-verbal.  She still wasn't very happy with us today as we moved her around to complete her exam.  She is dying, and while she has very loving caregivers, they aren't able to give her medications if she can't swallow.  We ended up having to move her into the hospice facility to be able to receive liquid, oral medications for symptom relief.

Next was the patient who just wanted to stay in her room.  Her family kept talking about how crazy she was.  She was the most sane of the group.  She clearly was not in a happy marriage.  The nurse and I listened to a sermon from her husband, who then had the audacity to tell her, "you may be good but you sure aren't pretty" when she responded to the nurse's question about how she was doing with a "pretty good".  The daughter did not stop talking, and did not want to rescind control of the patient's care.

Then we went to the top of the mountain to see a third patient whose symptoms are worsening as his disease progresses.  His wife needed coaching on medication administration, but was kind and present for her husband.

Finally, we had the guy who was actively dying, and had a sweet and doting family who had really helped provide the best care possible for him in his situation.  They asked questions about his presentation, if he appeared uncomfortable, and what the best options were for his care.  It really was a good end to an interesting day.