Learning from the ATM

On our way to school, my younger daughter and I stopped at the credit union to deposit my first pay check from my new job. The credit union was conveniently located and a new job was a convenient time to switch financial institutions. 

I put my bank ATM card in and the machine would not accept it. I pulled it out, pushed it back in and double checked that it was rotated correctly. Eventually, the ATM grabbed the card and asked for my PIN. I gave it and the ATM said, "Incorrect PIN." I tried a different number. It didn't work. Another different number didn't work. Finally in desperation, I tried my bank PIN. It worked. That was odd. I was pretty sure that the credit union didn't use as many digits as the bank allowed for PINs, but clearly my memory was faulty. Next the ATM wouldn't allow me to deposit. I chose "balance inquiry" thinking that maybe it would give me a "more options" screen eventually. It gave me my balance (which was wrong) but never allowed me to deposit. I gave up and figured that I would be spending a lot of time on the phone with the credit union later that day to sort everything out.

It was then that my daughter pointed out I was using my bank card at the credit union. The balance was correct for my bank account.

I reflected as I drove away that whenever something goes wrong, my immediate instinct is that I have screwed up. I didn't put the card in right. I forgot my PIN. Once I have settled on the fact that I have screwed up, I stop searching for an explanation for what is going on. This is an example of the mental inflexibility that I have been appalled and shocked to recognize in myself recently. I remarked to my daughter, "I immediately think I am so stupid that I forgot my PIN rather than realizing the problem is that I am so stupid I am using the wrong ATM card. I need to be more flexible in labelling my stupidity."

She said that it was not stupid to use the wrong ATM card. That I was switching banks and used the bank card at least ten times more often than I used the credit union card. This stopped me in my tracks.

For me the external world is an often bewildering morass of sensations and inputs that come rushing and screaming at me. I cannot possibly attend to everything I am aware of and I take all kinds of mental short cuts to help make sense out of it. I have learned in life that if something, especially something mechanical, is not working, it is because I am doing something wrong. If there is an explanation for the circumstances that involves "Mary has screwed up yet again" or "Mary doesn't understand the way the world works as usual," my mind sighs in the sweet relief of a world that makes sense and I can continue without having to think very hard.

Not only is that not fair to me, it becomes a self-fulfilling prophecy. Instead of working to solve the problem, I relax into the comfortable world I have lived in for years, assume I’ve screwed up somehow, and stop trying to solve the problem, proving that I screw up and problems don’t get solved.

Assuming something else had gone wrong, casting my problem solving net further and working to solve the problem would allow me to live in a world where that problem was solved, and where I would be propelled forward just a little harder into my next problem because I had solved this last one.

I wonder what would happen if I vowed to assume I was minimally competent in the world. What if I defended myself against my own critical judgement? Would this model be more likely to produce good outcomes for me as I make my way in the world? Would I be happier?  

A lesson from the ATM this morning. Totally worth the $5 my bank charged me for using my bank card at a credit union ATM.

Coxsackie In an Otherwise Healthy 53 year old Woman

I never could get good enough at blogspot to use more than one picture in a post.
Starting from the top: There is lots of reflection in the first two, but I do not have my tonsils so everything you see that looks like tonsils is inflammation of the tonsillar pillars. It feels about like you'd expect.
My gum are not usually that purple color of the third photo.
Fourth photo shows multiple lesions on the end of my tongue yesterday or maybe this moning.
Fifth one shows the most painful ones on my left buccal mucosa.
Sixth one shows one of the lesions having bloomed quite impressively.
Last picture is not so useful, but if you can magnify it you can see my poor posterior oropharynx.

Now you've had your medical geek moment for the day. Thank you for joining me.

Death's fashion moment

It's not just us palliative care folks who think a lot about aging and death these days. "Bucket list" is a thing that everyone knows about, movies like "The Fault in Our Stars" are popular and lots of famous people are dying. I've been thinking that our society has had several decades with less than an average amount of death and is now headed for some time with more.

Something ocean's waves something something life something very deep.  

The way I see it, the folks coming of age around the time of WWII, who have been called "the greatest generation" popularly, have ended up with a very happy intersection of events: growing old with improvement in health care and growing up without serious environmental degradation. We have figured out a lot of key things about heart failure, strokes and cancer in the past 20-30 years so anyone lucky enough to make it to the 1990's has had the benefit of catheter driven cardiology, a daily aspirin, less toxic and more effective cancer therapies, beta blockers and statins. In the 1990's, people coming of age at the end of WWII were around 65, just the perfect age to get the advantages of those advances. These advances caused folks who otherwise might have died to survive their heart attack or their early breast cancer that would not have been survivable a generation before. Thus they were more likely to live past 65 and into their next decades. Postponing of death cannot go on indefintely, however. None of us lives forever and the human body eventually wears out. Folks born in the 1920s and 1930 are in their mid-80's now and are getting to the point where even the best science runs out of rabbits in the hat. Essentially, I think there are a lot of people in their 80's who are still alive who probably would not have lived to their 80's if they had lived their lives out twenty years earlier, but they are getting to the point where there are no more tricks to keep them going. Thus there is an uptick in deaths among the "greatest generation" set.

I think there is also starting to be an increase in deaths among the boomer set as well. The oldest boomers are in their late 60's and are approaching the age when people start dying. It seems that perhaps because of a combination of increased smoking rates and environmental degradation, the boomers are going to be dying a little younger than their parents, thus leading to an uptick in death rate among the boomer set.

These two trends colliding has lead, it seems to me, to an increase in the rate of dying. I don't think it's our imagination; we're busier. I think our society will be thinking more about death for the next twenty years because we will all be experiencing a lot more death than we have for the previous twenty years. Hospice is such good work; it's always a good time to be in it, but it might be a particularly good time to be in it. I think we will also notice a huge uptick in the amount of popular culture that will be devoted to thinking about death and dying.

May we all live long and prosper.

A virtual speech

I didn't "get to" give a speech, but I did have a nice time last night after I got home writing an acceptance speech. I hope you like it. I do. 

Friends, thank you for this wonderful honor. When I was nominated for it, I was honored, of course, but surprised, too. I feel that what I do is take the best care I can of the next person in front of me. That doesn't feel innovative, but I see what you are saying in the letter and I guess would have to agree with your point. To win feels an incredible, astonishing honor. Thank you.

I'd like to thank my teams at Home, Health and Hospice Care: the advanced illness management team, the hospice at home team and The Community Hospice House team. Also, my Dartmouth team, my friends, my bosses, my teachers and my family. All of you, thank you for your daily love, support and affection. I could not even get out of bed in the morning without you, never mind take loving care of the sickest and most vulnerable patients in the system. You make me better every day. Thank you.

It seems that today a theme has emerged: that we have a choice regarding our stance towards the future. We can look at the regulatory changes and view the future with fear or we can view it as an opportunity to really live our missions. What is each of our missions? Fundamentally, to love our communities. As with everything else in life, we are offered the choice between fear and love. Michael Leunig says (and copying from John McPhee, I'll read it twice):

(please note, I have asked for copyright permission to put the poem here, and until it arrives, here is a link to it)

When I consider the choice in my own life between love and fear, it strikes me that every time I chose love, I was choosing to be my better self. I'd like to tell you about some of those times.

As Carla has already noted, today is June 13. June 13 is my youngest brother's birthday. He turned 56 today and I called him on my way in this morning and sang to his answering machine. Keith was 41 and I, 35 when I first met him and my other three brothers and my sister. Our father had already died before I got to meet him. Making the decision at 35 to track down and meet half of my family of origin was a real choice between love and fear. I was afraid that they would say that they had not contacted me all these years on purpose and they really didn't want me in their lives at all. That fear held me back from the time I learned of them at about 22 until when at 34, I finally paid $19.95 to do an internet search and found my Uncle Frank. It has turned out well. Keith lived with us, in fact, for a number of years and we have been a tremendous force for good in each other's lives. Happy birthday and I love you, Keith.

June 13 is also the day I was diagnosed with leukemia. It was exactly two years ago today that my secretary came running down the hall, frantic, "Dr Braun! Dr Braun! I'm looking for a doctor to talk to the pathologist, but it can't be you because he's calling about your labs!" It has been a million dollar experience I wouldn't pay two cents for. I have learned so much from it. I thought I was empathetic before, but I get so many things now that I didn't before I got sick. I am a much better doctor than I was before. The "kill the cancer" mentality is easy to fall into, but it never felt right for me. My leukemia was, well, mine. It was truly flesh of my flesh. I feared the leukemia, because I did not want to leave my children motherless, but the fact that fear was not my main emotion allowed me to be open and to receive what the leukemia had to teach me. I love you, my beautiful tiger, and am sorry I had to kill you in order to live.

Today is also the day I got this award. Those of you who are clinicians know the push/pull between fear and love that we feel with patients daily. In palliative care, where our patients are so fragile, the fear is so much stronger for me than it was in primary care. If I screw up, I could easily kill a patient. If I make a mistake, I could suggest a course that would ruin a number of the precious days of their last month. Then there is the fear that they are going to die on me, even if I do nothing wrong at all because that is what very sick patients do. Every day, with every patient, I have to adjust diuretics, pain meds, anti-epileptics, decide if we are going to treat this infection and if so how, choose nausea meds, make decisions about bowels, really think, really care, knowing that this patient for whom I am wracking my brain in all likelihood will be dead before my next day off. Over and over, I have to overcome my fear for them, my fear for my pain at their death and love them enough to apply my knowledge and experience to their specific situation, to really understand them. My patients all know this in their hearts, but I will say it outloud to you: I love you, my dears. Thank you for trusting me.

I have often said to people that if one were giving a life to someone with the intent of making them a palliative care clinician, one would have given them my life. It is nice to see my leukemia and my family of origin braided in with this award through the date of June 13 and I want to thank you again for honoring me with it. I am touched and humbled by your belief in and love of me.

I will close by saying again, we have a choice for the future: love or fear. Let's be our best selves and choose love. Thank you.

A real award

Yesterday, June 13, 2014, I received a wonderful honor at the annual NH Hospice and Palliative Care Organization meeting. I was the 2014 winner of the Ira Byock and Yvonne Corbeil award for innovation in palliative care. From the email notifying me I was nominated:

The criteria for the Annual Ira Byock and Yvonne Corbeil Award is: to recognize an individual, team or organization in Northern New England who has demonstrated innovation and collaboration to:

• Improve quality

• Expand access, and/or

• Increase efficiency

in delivering the best end-of-life care possible to New Hampshire residents.

I was honestly surprised to have been nominated and even more surprised to have won. Janice was reading off the nominees' names and bios and I was actually really interested in them: I didn't know Dr. Saunders done that or that Shawn LaFrance had all those intersting jobs or o my gosh, that was name and it seems to be in the same sentence with "the winner of this year's award." I went to the front and got some (hopefully) nice pictures taken with Janice and Carla. If they will allow, I'll post them later. Here is a picture of the award:

I will be hanging it in my DHC office. I am very proud and happy, appreciative of those who nominated me and did all the work of writing the letter, the committee who voted for me, the patients who allow me to take care of them, Steve and Barbara who point me in the right direction, my friends and family who support and love me so well. I promise to work hard to deserve this honor this year and going forward!

NH Fiddle Ensemble

New Hampshire Chronicle came to the Fiddle Ensemble and filmed a little bit of our rehearsal and concerts. Here is the video. I can't figure out how to control it at all so you may have to watch the whole thing in order to see this, but my 0.15 minutes of fame are at 6:20.

May we all make beautiful music.

How long the road?

When I was in the hospital, some one told me that if I had an auto-transplant, that it would take about six months to get back to normal and if I had an allo-transplant, that it would take about a year to get back to normal. Fortunately, I needed no transplant of any variety, but it is safe to say that I did not felt back to normal six or even twelve months out from treatment. I am now about sixteen months out and I think I started feeling normal at about fifteen months. I say "I think," because feeling normal does not arrive with an announcement; about one month ago is my best memory of it.

If someone was going to recover quickly from their leukemia, you would expect it to be me. I was pretty young (47-48 years old) and in good shape physically (I ran a five K the weekend before my diagnosis--I was slow, but still). I had lots of resources, support and help. It seems highly unlikely that most patients are going to recover from a larger intervention than I had more quickly than I did. I mentioned this to John at my last visit and he said that it didn't surprise him--that he would have guessed that I went back to normal about sixteen months ago when I went back to work. We talked about the questions he asks usually and what different questions might elicit that information (if he wanted it). He told me he would change his standard thing that he says to patients because he thinks it's probably not true. I certainly can attest to the fact that it's not useful.

Budapest looking its normal gorgeous self, hopefully feeling it, too.

So, now that I'm back to normal what does it look like? Lots of different things, but today it looks like me running five miles in under an hour. I am so happy because it is the best I've run since before my leukemia.

May we all be the selves we would like to be--our normal self or not.