I don't know about yours, but with the advent of Thanksgiving my Facebook news feed turned saccharine. Everyone suddenly experienced a burst of gratitude for their families and friends, their comforts in life, their health, their spiritual practices, their work, and their confidence in a bright future. Thank goodness it's but a one-day holiday closely followed, if not eclipsed, by Black Friday, when grateful people can descend en masse on department stores to slug it out with each other over the right to be the even more grateful owners of brand new big screen TVs, because I don't know how much more of the sickeningly sweet gratitude I could have taken!
Gratitude is in vogue these days. We're exhorted to keep gratitude journals, count our blessings, and focus on the positive. Some believe that the objects of their thoughts and energy grow and multiply, and so spew forth affirmations of gratitude like lava from a volcano, thereby putting the universe on notice that with thanks duly rendered even greater good and bigger gimmes now are past due.
There's an elephant in the room with all this gratitude. Its name is Narcissism, and its language, simply put, is nothing more than the wolf of old-fashioned boasting clad in sheep's clothing of appreciative verbiage. Tedious at best, this big old elephant expends its energy trumpeting about its good life, leaving the rest of us bored while the actual I.O.U. due from the elephant to the universe remains outstanding.
True gratitude is awestruck. Overwhelmed by the magnitude and/or timing and/or convergence of forces for good, true gratitude stands still and small in the face of bounty. And when true gratitude begins to feel its power, that feeling emerges as a call to service. The truly grateful respond to that call, and are much too busy, too enthusiastic, and too outwardly focused in their efforts to deal with, much less become, elephants.
"I am so grateful that my days of roadside breakdowns are over, and for the people at MegaMotors who will deliver my new Porsche tomorrow," or "I thank God for guiding me to the perfect house and for helping me negotiate to buy it for only $3 million," or "I'm filled with gratitude to be the owner of a thriving, successful business that dramatically surpasses growth projections every month" all are clarion calls of the elephant. The elephant in the room indeed would have us believe that as long as it's expressed in the language of gratitude, it's ok to say, "I have have arrived in the world, and in a new Porsche!," or "I'm so well off that I just bought a multi-million dollar home!," or "I'm such a huge success that I exceed even my own expectations every month!"
The elephant, I'm afraid, is not well. Even if its proclamations are modest (a gift or compliment received, a nice vacation), when the elephant trumpets, "Look at how good I have it!" one must suspect that such noise masks underlying, unmet need. There is no shame in needs; everyone has them. But it is sad when genuine need is tamped down and hidden instead of guided gently to the light where it can be met and transformed.
Decades of work in human services, and even longer living in a human body, have taught me that growth cannot be forced or hurried. There first must be willingness to consider that there might be another, better way, and then courage to reach out, to tell the truth, and to try something new, whether it is a new oven cleaner or giving up crack cocaine.
An old friend called early one morning not long ago, waking me up. "Hey, how're ya doin'?" I asked, attempting a cheerfulness to mask both my grogginess and my concern that a call at that hour portended something amiss.
"I'm grateful!" he responded. "My business is doing great. I have a nice home, a wonderful dog, great friends, and good health. How could it be any better?"
Doubting that many people awaken a friend to explain how grateful they are for their perfect lives, I suspect there is an answer to his question, rhetorical though it may have been intended to sound.
While true gratitude need not hide its face, it is not boastful or showy. It finds expression in a combination of humility and service, it tends to be quiet, and it unleashes powerful forces for good. It is the antithesis of cheap thanks, which is focused on the self and expressed as thinly veiled bragging. Cheap thanks tends to be manipulative and deceptive of self and others, and it deprives everyone of the fruits of the full creative potential generously bestowed by a benevolent universe. It is cheap thanks that is
What's Wrong with Gratitude
Sunday, December 1, 2013
Tuesday, June 25, 2013
It's Obvious
It seems obvious that the way to achieve better health outcomes is to solve problems patients actually have, rather than try to make patients have the problems we best know how to solve. Yet so often the obvious is overlooked, and then we wonder why patients don't improve or are "noncompliant."
"Rose" is 89 years old. She has diabetes, heart disease, chronic back pain, and wounds on her feet. One foot has an open ulcer that just won't heal; a toe was amputated from the other foot, and now not only is the surgical site not healing well, but the adjacent toes are showing signs of breakdown. The foot with an ulcer is hooked up to a machine 24 hours a day; this gently sucks drainage from the wound bed and into an attached canister and stimulates growth of new tissue. Rose carries the machine around in a shoulder bag, being careful not to trip over the tubing attaching the machine to her foot. She also requires two canes to walk, one in each hand. So while she isn't getting much worse but certainly isn't getting much better either, every time Rose wants a drink of water or needs to use the bathroom or seeks a sweater to ward off a chill or anything else, day or night, she must hoist the bag-with-machine onto her shoulder, grab one cane with each hand, carefully adjust the tubing so she neither trips nor pulls it loose, and slowly grunt her way through the little apartment she shares with her husband. Many times I have sat in the living room waiting for Rose to make her way to and from the bathroom, listening to her rhythmic grunt. grunt. grunt., one grunt for each step, because her back hurts when she moves, and she is carrying a machine, avoiding long tubing, and leaning on first one cane and then the other as she goes. A trip to and from the bathroom is grueling exercise for her.
Rose needs to see her vascular surgeon, and I need her to see him, because our treatment no longer is working and we need to adjust the plan. More robust but equally elderly, Rose's husband is confident he can get her down the stairs, into the car, and to the big university medical center where her doctors practice, but he's worried about what will happen once there. In the past they have waited up to forty minutes for a transporter to bring Rose a wheelchair, but now Rose barely can stand for four minutes, much less forty. In the past after appointments they have had equally long waits for a transporter to rescue them again and wheel Rose back to the parking garage. Unless they can get a wheelchair, Rose's husband explains, she can't go to the doctor.
The medical center is full of wheelchairs. I know this. I've been there many times; I've seen them. But I also know Rose's husband is sharp and a straight-shooter not given to exaggeration or fabrication. So I called the social worker whose job is "transitional care," that is, helping people span the gap between the hospital and home, seeing that they have the resources they need to manage safely and well when they are discharged from the hospital, and that they are properly "connected" to doctors and other providers for their follow up care.
The social worker didn't know, she told me, what the situation with wheelchairs was, but she would look into it. With Medicare now exacting significant financial penalties when patients are re-admitted to the hospital for problems that could have been prevented, there is particular emphasis on being sure follow up appointments are kept and that post-hospital care goes smoothly.
A short while later the social worker called me back, startled to have learned that there were only five (5!) wheelchairs and transporters assigned to cover that entire area of the medical center. Patients indeed often had to wait some time for a wheelchair to be available. And, yes, this could have a significant impact on follow up "failures," i.e., patients missing appointments because it was too difficult to get to their doctors' offices when they were tired, hurting, sick. . . and most in need of being there. If they waited until they were sick enough to need to be taken by ambulance to the Emergency Department transportation would be assured: EMS will deliver patients directly to the treatment area, and there are plenty of wheelchairs in the ED to take patients to their hospital beds, yes indeed, more follow up failures turned into re-hospitalizations.
The social worker had seen that a concern about wheelchair availability had been duly registered and was making its way upward through the administrative hierarchy. Meanwhile we remember that Rose is 89 years old. The chances of her living long enough to see administrative resolution of this issue are somewhere between the proverbial slim and none.
So there we were, the social worker and I, on the phone together talking about an elderly patient who needed to see her doctor and who could get to the medical center, but once there could not get to the doctor's office. The social worker wanted to help. Under a special program, Rose qualifies for Medi-car transportation from home to the medical center; the social worker could arrange for the Medi-car. I reminded her that Rose and her husband have a car and can drive themselves. The issue was getting her to the doctor's office once there. The social worker could contact the doctor's office and make an appointment for Rose, she said, and even try to make an appointment with the endocrinologist for the same day. Rose and her husband can dial a phone, I noted; they didn't need help making appointments. They needed help getting from one part of the massive medical center to another. The social worker would see what she could do and get back to me.
Later that day she called with her ultimate resolution: An appointment had been made with the vascular surgeon, and a second appointment a month later with both doctors on the same day. I reminded her again that the problem was transportation from the parking garage to the doctor's office, and she told me curtly that there were only five transporters available and people would have to be patient and wait.
Rose's problem was transportation within the medical center; the medical center's solution was transportation outside the medical center and assistance making appointments that Rose was physically unable to keep. Unable to solve the problem Rose actually had, the social worker provided "help" that wasn't needed, or helpful. But although solutions to problems Rose didn't have and not solutions to her actual problem, this "help" was something the social worker knew how to do. And so that's what she did.
And I'm afraid this happens often.
I could retire comfortably tomorrow if I had a dollar for every time I've been asked to see patients because they were "noncompliant" with their medication regimens and needed "teaching." Information and instruction are proper responses to lack of knowledge or misunderstanding. But patients don't take their medications correctly for a host of reasons, most of which have little to do with knowledge.
They may not be able to afford medications, or medications may have unpleasant side effects, real or imagined. Patients may object to the very idea of taking medicine, or may believe they have too many medicines to take. They may simply forget. The prospect of taking medications may leave some patients feeling "old" or "sick" when they prefer to think of themselves as healthy and vibrant. They may hide medications from their families in order to keep their health issues secret and then miss doses because family members are present and would ask questions, or because in effect they have hidden the medicines from themselves, too. Regimens may be too complicated, or interfere with other activities. People may worry about appearing to be "junkies." They may fear needles or not be able to remove protective covers or child-proof bottle caps. Small pills may be too difficult for arthritic fingers to handle, or may be invisible to eyes with fading vision. Patients may believe their medications don't work, or that doctors prescribe them only so patients will have to keep going back for refills, generating more billable office visits for the doctors. They may understand that while taking some medications they need to give up other things they enjoy, ranging from drinking grapefruit juice to driving, and decide that they'd rather "drink and drive" than take pills. Patients may feel too sick to go to the pharmacy to have prescriptions filled. Large pills may be hard to swallow, liquids may have an unpleasant taste, tablets that need to be broken in half may resolutely refuse to break.
And yes, sometimes, people truly don't understand what they should take, when, why, how, and what the consequences should and could be. This latter group is the one needing "teaching." Yet time and time again I see a nurse or other provider explaining medication names, actions, purposes, administration, and possible side effects, and then considering the job done, and calling patients "noncompliant" and the task of teaching them not do-able when patients continue not to take their medications as ordered. The fact is that such teaching is easy; we know the information and can spew it in our sleep, and then we can feel justified that we have done our work and it is the patient who has failed to take proper advantage of our largesse.
In fact, we have taken the easy road, assuming patients all have the problem that we are best prepared to solve, "knowledge deficit," rather than asking, probing, listening, and comprehensively assessing to ascertain what the real issues are in any individual situation, and then figuring out with the patient how best to address them and move forward. I remember a time when patients were expected to follow "doctor's orders" blindly and were not taught; since then it seems we have come to suppose that imparting information is the solution to all problems with health behaviors. But there's not one of us who never fails to act in accord with what we know to be best: We overeat and underexercise,we sleep too much or too little, we smoke or tan or text while driving, . . . and not for want of "teaching." Providing information is what we healthcare providers know how to do; solving the messy problems of complex human lives is a dicier undertaking. So we assume that anyone who doesn't do what we want him or her to do needs to be taught, less because we have identified real learning needs, and more because teaching is something we know we can provide.
I am working to get Rose her own little wheelchair that can be folded and placed in the car; she and her husband aren't yet sure they want one, but it would make her much less a prisoner in that little apartment, and I have a hunch we'll come to an accord. Failing that, perhaps the vascular surgeon will agree to see her in the medical center's parking garage, if only to call attention dramatically to a simple problem that could be resolved expeditiously if the right people were motivated to do so. And if all else fails I can offer Rose the services of a physician who makes house calls and would evaluate her at home.
Yet through all of this, and in so many similar instances, I am struck by the amount of time, energy, money, and frustration expended by so many providers when by assumption and action, deliberately or not, they try to fit patients into the molds of problems they know how to solve (as by teaching, ordering Medi-cars, and making appointments, whether or not patients need those things) rather than identifying and solving the problems patients actually have. And when patients don't respond by changing their behavior and/or getting better the costs are great, the outcomes poor, and everyone dissatisfied and wondering why. But although challenging, it's no mystery. In fact,
It's Obvious.
"Rose" is 89 years old. She has diabetes, heart disease, chronic back pain, and wounds on her feet. One foot has an open ulcer that just won't heal; a toe was amputated from the other foot, and now not only is the surgical site not healing well, but the adjacent toes are showing signs of breakdown. The foot with an ulcer is hooked up to a machine 24 hours a day; this gently sucks drainage from the wound bed and into an attached canister and stimulates growth of new tissue. Rose carries the machine around in a shoulder bag, being careful not to trip over the tubing attaching the machine to her foot. She also requires two canes to walk, one in each hand. So while she isn't getting much worse but certainly isn't getting much better either, every time Rose wants a drink of water or needs to use the bathroom or seeks a sweater to ward off a chill or anything else, day or night, she must hoist the bag-with-machine onto her shoulder, grab one cane with each hand, carefully adjust the tubing so she neither trips nor pulls it loose, and slowly grunt her way through the little apartment she shares with her husband. Many times I have sat in the living room waiting for Rose to make her way to and from the bathroom, listening to her rhythmic grunt. grunt. grunt., one grunt for each step, because her back hurts when she moves, and she is carrying a machine, avoiding long tubing, and leaning on first one cane and then the other as she goes. A trip to and from the bathroom is grueling exercise for her.
Rose needs to see her vascular surgeon, and I need her to see him, because our treatment no longer is working and we need to adjust the plan. More robust but equally elderly, Rose's husband is confident he can get her down the stairs, into the car, and to the big university medical center where her doctors practice, but he's worried about what will happen once there. In the past they have waited up to forty minutes for a transporter to bring Rose a wheelchair, but now Rose barely can stand for four minutes, much less forty. In the past after appointments they have had equally long waits for a transporter to rescue them again and wheel Rose back to the parking garage. Unless they can get a wheelchair, Rose's husband explains, she can't go to the doctor.
The medical center is full of wheelchairs. I know this. I've been there many times; I've seen them. But I also know Rose's husband is sharp and a straight-shooter not given to exaggeration or fabrication. So I called the social worker whose job is "transitional care," that is, helping people span the gap between the hospital and home, seeing that they have the resources they need to manage safely and well when they are discharged from the hospital, and that they are properly "connected" to doctors and other providers for their follow up care.
The social worker didn't know, she told me, what the situation with wheelchairs was, but she would look into it. With Medicare now exacting significant financial penalties when patients are re-admitted to the hospital for problems that could have been prevented, there is particular emphasis on being sure follow up appointments are kept and that post-hospital care goes smoothly.
A short while later the social worker called me back, startled to have learned that there were only five (5!) wheelchairs and transporters assigned to cover that entire area of the medical center. Patients indeed often had to wait some time for a wheelchair to be available. And, yes, this could have a significant impact on follow up "failures," i.e., patients missing appointments because it was too difficult to get to their doctors' offices when they were tired, hurting, sick. . . and most in need of being there. If they waited until they were sick enough to need to be taken by ambulance to the Emergency Department transportation would be assured: EMS will deliver patients directly to the treatment area, and there are plenty of wheelchairs in the ED to take patients to their hospital beds, yes indeed, more follow up failures turned into re-hospitalizations.
The social worker had seen that a concern about wheelchair availability had been duly registered and was making its way upward through the administrative hierarchy. Meanwhile we remember that Rose is 89 years old. The chances of her living long enough to see administrative resolution of this issue are somewhere between the proverbial slim and none.
So there we were, the social worker and I, on the phone together talking about an elderly patient who needed to see her doctor and who could get to the medical center, but once there could not get to the doctor's office. The social worker wanted to help. Under a special program, Rose qualifies for Medi-car transportation from home to the medical center; the social worker could arrange for the Medi-car. I reminded her that Rose and her husband have a car and can drive themselves. The issue was getting her to the doctor's office once there. The social worker could contact the doctor's office and make an appointment for Rose, she said, and even try to make an appointment with the endocrinologist for the same day. Rose and her husband can dial a phone, I noted; they didn't need help making appointments. They needed help getting from one part of the massive medical center to another. The social worker would see what she could do and get back to me.
Later that day she called with her ultimate resolution: An appointment had been made with the vascular surgeon, and a second appointment a month later with both doctors on the same day. I reminded her again that the problem was transportation from the parking garage to the doctor's office, and she told me curtly that there were only five transporters available and people would have to be patient and wait.
Rose's problem was transportation within the medical center; the medical center's solution was transportation outside the medical center and assistance making appointments that Rose was physically unable to keep. Unable to solve the problem Rose actually had, the social worker provided "help" that wasn't needed, or helpful. But although solutions to problems Rose didn't have and not solutions to her actual problem, this "help" was something the social worker knew how to do. And so that's what she did.
And I'm afraid this happens often.
I could retire comfortably tomorrow if I had a dollar for every time I've been asked to see patients because they were "noncompliant" with their medication regimens and needed "teaching." Information and instruction are proper responses to lack of knowledge or misunderstanding. But patients don't take their medications correctly for a host of reasons, most of which have little to do with knowledge.
They may not be able to afford medications, or medications may have unpleasant side effects, real or imagined. Patients may object to the very idea of taking medicine, or may believe they have too many medicines to take. They may simply forget. The prospect of taking medications may leave some patients feeling "old" or "sick" when they prefer to think of themselves as healthy and vibrant. They may hide medications from their families in order to keep their health issues secret and then miss doses because family members are present and would ask questions, or because in effect they have hidden the medicines from themselves, too. Regimens may be too complicated, or interfere with other activities. People may worry about appearing to be "junkies." They may fear needles or not be able to remove protective covers or child-proof bottle caps. Small pills may be too difficult for arthritic fingers to handle, or may be invisible to eyes with fading vision. Patients may believe their medications don't work, or that doctors prescribe them only so patients will have to keep going back for refills, generating more billable office visits for the doctors. They may understand that while taking some medications they need to give up other things they enjoy, ranging from drinking grapefruit juice to driving, and decide that they'd rather "drink and drive" than take pills. Patients may feel too sick to go to the pharmacy to have prescriptions filled. Large pills may be hard to swallow, liquids may have an unpleasant taste, tablets that need to be broken in half may resolutely refuse to break.
And yes, sometimes, people truly don't understand what they should take, when, why, how, and what the consequences should and could be. This latter group is the one needing "teaching." Yet time and time again I see a nurse or other provider explaining medication names, actions, purposes, administration, and possible side effects, and then considering the job done, and calling patients "noncompliant" and the task of teaching them not do-able when patients continue not to take their medications as ordered. The fact is that such teaching is easy; we know the information and can spew it in our sleep, and then we can feel justified that we have done our work and it is the patient who has failed to take proper advantage of our largesse.
In fact, we have taken the easy road, assuming patients all have the problem that we are best prepared to solve, "knowledge deficit," rather than asking, probing, listening, and comprehensively assessing to ascertain what the real issues are in any individual situation, and then figuring out with the patient how best to address them and move forward. I remember a time when patients were expected to follow "doctor's orders" blindly and were not taught; since then it seems we have come to suppose that imparting information is the solution to all problems with health behaviors. But there's not one of us who never fails to act in accord with what we know to be best: We overeat and underexercise,we sleep too much or too little, we smoke or tan or text while driving, . . . and not for want of "teaching." Providing information is what we healthcare providers know how to do; solving the messy problems of complex human lives is a dicier undertaking. So we assume that anyone who doesn't do what we want him or her to do needs to be taught, less because we have identified real learning needs, and more because teaching is something we know we can provide.
I am working to get Rose her own little wheelchair that can be folded and placed in the car; she and her husband aren't yet sure they want one, but it would make her much less a prisoner in that little apartment, and I have a hunch we'll come to an accord. Failing that, perhaps the vascular surgeon will agree to see her in the medical center's parking garage, if only to call attention dramatically to a simple problem that could be resolved expeditiously if the right people were motivated to do so. And if all else fails I can offer Rose the services of a physician who makes house calls and would evaluate her at home.
Yet through all of this, and in so many similar instances, I am struck by the amount of time, energy, money, and frustration expended by so many providers when by assumption and action, deliberately or not, they try to fit patients into the molds of problems they know how to solve (as by teaching, ordering Medi-cars, and making appointments, whether or not patients need those things) rather than identifying and solving the problems patients actually have. And when patients don't respond by changing their behavior and/or getting better the costs are great, the outcomes poor, and everyone dissatisfied and wondering why. But although challenging, it's no mystery. In fact,
It's Obvious.
Sunday, May 12, 2013
It's Nurses Week!
It's Nurses Week, and also the feast days of several minor saints, and perhaps the time to commemorate uncommon species of rodents or obscure varieties of peppers. As holidays, all warrant about the same degree of observance. But my Facebook news feed does show the annual bump in nurse cartoons, nods of appreciation of nurses that for the most part miss the mark, and a few truly humorous tales about Life with Nurses. One of the latter that hit both Facebook and my inbox more than once is said to have been offered up by the spouse of a nurse: Could be, but if so it's questionable that they actually have been married for 25 years, or that she has been a nurse that long. Or perhaps he's just a lovable slow learner, as many of the fine points and much of the true genius of what we do are missing from his piece. Regardless, in honor of this august occasion (Nurses Week. See, you forgot already), this crone from the Land of Nightingale (that would be Florence. She started all of this. At least in the modern era) is offering a p.s. for those married to nurses, friends and family of nurses, and those otherwise personally involved with nurses:
Don't even think about trying to deceive nurses. They routinely get complete strangers to strip naked and reveal intimate details within three minutes of their first hello. They have treated cheating spouses; criminals; people who don't want their closest intimates to know The Truth (whatever that may be in a given situation); ingenious souls who do anything to get more drugs, or fewer; executives and socialites more concerned about their Image than their lives, much less their health; and even teenagers. And they see all of these in their most vulnerable moments. Nurses go into homes, bedrooms, workplaces, schools, and they keep. going. back. (Facades can be sustained only so long.) Nurses see the cracks in the veneer of carefully crafted public personae, and have uncanny ways of inspiring people to let down their guard and get real. Nurses have a spidey sense like none other. If they haven't discerned exactly what your game is it's because in the overall scheme of things your piddly problem just isn't important enough to warrant the effort. But nurses know when something's off, when people are disingenuous. And God help you once you've triggered that alert.
Don't expect endless sympathy and comfort. Nurses want those they serve to be whole and strong, healthy and self-responsible. This means they dispense Tough Love generously and often. They won't do for you what you can do for yourself, although they may spend hours helping you learn. If you have a symptom or a problem they'll ask what you did to contribute to it and what you can do to make it better. You'll emerge empowered, not coddled. Nurses will help. They'll provide resources, encouragement, referrals, and kicks in the backside. They'll be your loudest cheerleaders and harshest critics. But they're not likely to tuck you in and bring you milk and cookies if you're more than ten years old. And those bedpans and shots so common in nurse jokes? Forget it. Nurses will have you walking to the bathroom under your own power and administering your own injections before you know it.
Odd as it may seem, nurses aren't always looking for more ways to help more people, more tales of woe to hear, or more problems to solve. You have your own family and friends; use them. There is someone in your doctor's practice who actually is being paid to take your call at 2 AM; if you truly need attention at that hour, make him or her earn his or her money. The Emergency Room and EMS are for emergencies; you pay for them with your taxes, your insurance premiums, and your hard-earned pocket money. When you need them, use them. If you call your neighbor or friend or fellow church/PTA/club member, or whoever, who happens to be a nurse, and that person chooses to respond and help you, it is because she or he is a true friend, Good Samaritan, and decent human being (and you should reciprocate in kind). It is not because nurses are limitless givers, doormats, or pathetic, bored souls glad for your giving them something to do on Saturday afternoon.
It's Nurses Week. While I can't speak for the saints, rodents, or peppers, if you're inclined to make an appreciative gesture to nurses you're correct in realizing that there is no thank you big enough for lives saved, medical mishaps averted, wisdom dispensed, confidence inspired, small changes caught early enough to prevent big problems, or the sense that someone who understands somehow knew how to get inside your head and body and guide you back to equilibrium and to new levels of self-care such as you never knew were possible. Empty platitudes, jokes about sex, and caricatures straight from the 1950s don't do it. Safe working conditions, opportunities to practice on the cutting edge and to the full extent of our ability and license, and compensation that reflects our value would help. But for one not in a position to effect those? Be a straight shooter, a respectful fellow citizen, and a self-responsible human being. And you'll find nurses will do the same for you.
P.S.: We also accept Starbucks gift cards, spa days, soft robes, spring flowers, and great dinners! After all,
It's Nurses Week!
Don't even think about trying to deceive nurses. They routinely get complete strangers to strip naked and reveal intimate details within three minutes of their first hello. They have treated cheating spouses; criminals; people who don't want their closest intimates to know The Truth (whatever that may be in a given situation); ingenious souls who do anything to get more drugs, or fewer; executives and socialites more concerned about their Image than their lives, much less their health; and even teenagers. And they see all of these in their most vulnerable moments. Nurses go into homes, bedrooms, workplaces, schools, and they keep. going. back. (Facades can be sustained only so long.) Nurses see the cracks in the veneer of carefully crafted public personae, and have uncanny ways of inspiring people to let down their guard and get real. Nurses have a spidey sense like none other. If they haven't discerned exactly what your game is it's because in the overall scheme of things your piddly problem just isn't important enough to warrant the effort. But nurses know when something's off, when people are disingenuous. And God help you once you've triggered that alert.
Don't expect endless sympathy and comfort. Nurses want those they serve to be whole and strong, healthy and self-responsible. This means they dispense Tough Love generously and often. They won't do for you what you can do for yourself, although they may spend hours helping you learn. If you have a symptom or a problem they'll ask what you did to contribute to it and what you can do to make it better. You'll emerge empowered, not coddled. Nurses will help. They'll provide resources, encouragement, referrals, and kicks in the backside. They'll be your loudest cheerleaders and harshest critics. But they're not likely to tuck you in and bring you milk and cookies if you're more than ten years old. And those bedpans and shots so common in nurse jokes? Forget it. Nurses will have you walking to the bathroom under your own power and administering your own injections before you know it.
Odd as it may seem, nurses aren't always looking for more ways to help more people, more tales of woe to hear, or more problems to solve. You have your own family and friends; use them. There is someone in your doctor's practice who actually is being paid to take your call at 2 AM; if you truly need attention at that hour, make him or her earn his or her money. The Emergency Room and EMS are for emergencies; you pay for them with your taxes, your insurance premiums, and your hard-earned pocket money. When you need them, use them. If you call your neighbor or friend or fellow church/PTA/club member, or whoever, who happens to be a nurse, and that person chooses to respond and help you, it is because she or he is a true friend, Good Samaritan, and decent human being (and you should reciprocate in kind). It is not because nurses are limitless givers, doormats, or pathetic, bored souls glad for your giving them something to do on Saturday afternoon.
It's Nurses Week. While I can't speak for the saints, rodents, or peppers, if you're inclined to make an appreciative gesture to nurses you're correct in realizing that there is no thank you big enough for lives saved, medical mishaps averted, wisdom dispensed, confidence inspired, small changes caught early enough to prevent big problems, or the sense that someone who understands somehow knew how to get inside your head and body and guide you back to equilibrium and to new levels of self-care such as you never knew were possible. Empty platitudes, jokes about sex, and caricatures straight from the 1950s don't do it. Safe working conditions, opportunities to practice on the cutting edge and to the full extent of our ability and license, and compensation that reflects our value would help. But for one not in a position to effect those? Be a straight shooter, a respectful fellow citizen, and a self-responsible human being. And you'll find nurses will do the same for you.
P.S.: We also accept Starbucks gift cards, spa days, soft robes, spring flowers, and great dinners! After all,
It's Nurses Week!
Saturday, October 6, 2012
Don't Poison It
I have taught wound care for years, to university students, to practicing clinicians, and to patients and their caregivers. Here's my lesson, adapted with apologies to the one from whom I learned it, presented so succinctly years ago. At the time I never knew how timeless and universal her teaching would be, and I've long since forgotten the proper citation for my inspiration. Somehow I feel sure she wouldn't mind:
* If it's dirty, clean it.
* If it's broken, protect it.
* If it's dry, moisten it.
* If it's wet, absorb it.
* If it has a hole, fill it up.
* If it's dead, remove it.
* If it's infected, treat it.
* Whatever it is, don't poison it.
That's it. Memorize those,and you can care for any wound, whether you nick yourself shaving, impale yourself on a garden tool, come out on the losing end of a bad car accident, or have the unfortunate experience of surgery gone wrong. Oh, I can turn those eight lines into an hour lecture or an entire course or series of courses, but, bottom line, those simple points are the essence of wound care.
Wounds can't heal properly around dirt, dead matter, and/or infection, so when those are present we need to get rid of them. It's common sense that most anything that's broken benefits from protection until it can be repaired, be it a cracked windshield or a broken heart, and broken skin is no exception. This is why God created bandages. And we know that things function best when they're in optimal condition, be they car engines, the bodies of Olympic athletes, or wounds trying to heal themselves. If those wounds are drowning in excess exudate ("leakage") or are cracked, hard and dry, it's mighty hard for the body to do its healing work. And an empty hole is a flashing neon "Vacancy" sign beckoning infecting organisms to a warm, welcoming place to settle in and have a good meal, so we want to shut down that sign by filling the vacancy, i.e., filling the hole.
We who care professionally for wounds and who have an admittedly bizarre fascination with how the healing process works and how we best can support it can spend years studying the fine points, and we do sit for days in conferences considering the latest data about how best to fill a hole, treat an infection, clean dirt, protect something vulnerable, and create the best possible environment for the body to do its work. But be not confused: We heal nothing. The patient's body does the work, and our job is to give the body the best possible working conditions and then get the heck out of the way.
My patients with wounds often think the purpose of my encounters with them is to change their bandages. It is not. A chimpanzee can learn to change most bandages and doesn't need a professional license to do so, and if a chimp can do it, so can a patient and/or family member or other caregiver. I'm happy to show them how. The only reason they need me is to help them know when a change in the way a wound looks portends healing or a complication, whether a wound is becoming too wet or too dry as it heals and so needs a change in therapy, and if they safely can relax confident in the knowledge that they're doing everything right. Truly, with a little help from his/her friends, the patient does all the work.
And here's the dirty little secret big pharma and insurance companies don't want you to know: In all of healing, not just wound management, the patient does the work. We with our licenses, degrees, and certifications just shine light down the path to wholeness and smooth the way for the body's efforts. Truly: Master light-shining and road-smoothing and you can have yourself a medical degree.
But as an industry we've come to the point of keeping our light under a bushel and of creating more roadblocks than we remove. The body's natural tendency is towards wholeness, yet at every turn we invade it, cut it open, place alien substances inside it, and douse it with chemicals, creating ever more new obstacles for an already challenged body to overcome. We're not evil nor mean-spirited; we're just good science run amok the same way cancer is good cells gone haywire and taking over their host until they kill it. Heaven knows antibiotics and other drugs have saved millions and truly turned the tide of human existence. And so have surgery and angioplasties and CT scans and more. In fact, these have proven to be so good that we look to them more and more . . . more than is necessary, more than is helpful, and more, to the point of being harmful. As with so many things, if a little is good, more isn't always better.
Big pharma's ads on TV say, "Ask your doctor" if you're depressed, impotent, sneezing, sleepless, diagnosed with one disease or another, anxious, headachy, lame, or merely human, yes, ask your doctor if the latest pill won't help you. Usually it won't, bottom line, or your doctor or other provider already would have prescribed it. Trust me: Your doctor watches TV, too, and knew all about those latest pills long before those ads ever ran. S/he doesn't need Madison Avenue to consult in your treatment.
What I long for ads to say is, "Listen to your body and give it a chance." Your doctor is doing his/her job when you walk out of the office without a prescription. Another x-ray, another blood text, another cardiac catheterization may not tell us anything more than your own inner knowing and the wise judgment born of your healthcare provider's years of experience examining and listening to people much like you.
What I long for ads to do is quote one of my old pharmacology professors: "There is only one drug that has no side effects: Arsenic. It just kills you." Sometimes, many times, less is more. That grocery bag full of pill bottles that Grandma carries around may be doing her more harm than good, and when she 'asks her doctor' if she doesn't need the latest pill advertised on TV and the doctor, pressed by financial imperatives to see 15 patients an hour (like Bill Clinton, I like arithmetic: That's four minutes each, folks, including the time to write prescriptions and document in the medical record, with no potty breaks or phone calls allowed), yes, the doctor figures it probably won't hurt and will make her happy and so writes another scrip. Then poor Grandma may go away feeling satisfied that her doctor has done something for her . . . and may add one more toxic substance to a body already processing everything else in that grocery bag of pill bottles, pills to treat the side effects of the side effects of pills, until her kidneys, her liver, or her soul simply says, "Enough."
Can't we say, "Enough" now, before Grandma, or any of us acquires the surgical scars, the stents, the tests, the pills, and the bills? Enough. "Enough" ≠ "none." Enough is enough, that is, enough is what one needs to heal and be whole, nothing more, nothing less.
A riveting, compelling, completely engaging portrayal of the issues in healthcare in America just has hit the big screen, and I cannot endorse Escape Fire enthusiastically enough. Do yourself a favor and go to the movies this weekend: http://vimeo.com/27450676
That last point in my wound care lecture bears revisiting: Whatever it is, don't poison it." Not all that many years ago, in an effort to serve point #1 and clean a dirty wound or avoid infection, we doused wounds with various forms of iodine, hydrogen peroxide, alcohol, and good ol' soap. These do clean wounds and kill bugs all right . . . and they also kill the new, healthy tissue trying to grow and heal. They're poison, albeit used with good intent, but far more toxic than is warranted in vast majority of situations (there are rare exceptions, rare). The rule of thumb now generally is not to put something into or on a wound that one also wouldn't put in one's eye. Truly. So we cleanse with normal saline (salt water), plain water, or wound cleansers formulated to mimic the body's own fluids and tissues.
Would that we reach the point of doing the same in all of healthcare. Would that providers have time and discernment to say, "Let's just watch this and see what happens; the body is working well to right itself. Let's support, rather than confound it. And I will be here for you to evaluate the process as it unfolds, and intervene if necessary. Yes, I have time, yes, I will, this is what I do." Would that the day comes when attending physicians, and other providers, are able truly and simply to attend, to be present.
Would that we prescribe nutrition (now absent from most medical schools' curricula) before pills, would that our research dollars be invested in natural healing and comprehensive approaches to wellness as much as in disease management and medicine, would that insurers pay for and promote health care instead of merely illness care, would that we teach proper exercise, stress management, sleep hygiene, the art of self-knowledge, and good, old-fashioned play. Would that we prize healthy relationships, work settings, and communities, and stop poisoning our air, water,and soil. Would that we consume real food instead of processed, nutrient-poor, chemical-rich pseudo-foods.
Would that each of us, before asking our doctors for the latest pill, ask our own body what it needs to be whole and require that our healthcare providers and policy makers supply this,and our insurers pay for it. May we each cherish the body we have been given, be supported in caring for it, and, yes, in every way see that we
Don't Poison It.
* If it's dirty, clean it.
* If it's broken, protect it.
* If it's dry, moisten it.
* If it's wet, absorb it.
* If it has a hole, fill it up.
* If it's dead, remove it.
* If it's infected, treat it.
* Whatever it is, don't poison it.
That's it. Memorize those,and you can care for any wound, whether you nick yourself shaving, impale yourself on a garden tool, come out on the losing end of a bad car accident, or have the unfortunate experience of surgery gone wrong. Oh, I can turn those eight lines into an hour lecture or an entire course or series of courses, but, bottom line, those simple points are the essence of wound care.
Wounds can't heal properly around dirt, dead matter, and/or infection, so when those are present we need to get rid of them. It's common sense that most anything that's broken benefits from protection until it can be repaired, be it a cracked windshield or a broken heart, and broken skin is no exception. This is why God created bandages. And we know that things function best when they're in optimal condition, be they car engines, the bodies of Olympic athletes, or wounds trying to heal themselves. If those wounds are drowning in excess exudate ("leakage") or are cracked, hard and dry, it's mighty hard for the body to do its healing work. And an empty hole is a flashing neon "Vacancy" sign beckoning infecting organisms to a warm, welcoming place to settle in and have a good meal, so we want to shut down that sign by filling the vacancy, i.e., filling the hole.
We who care professionally for wounds and who have an admittedly bizarre fascination with how the healing process works and how we best can support it can spend years studying the fine points, and we do sit for days in conferences considering the latest data about how best to fill a hole, treat an infection, clean dirt, protect something vulnerable, and create the best possible environment for the body to do its work. But be not confused: We heal nothing. The patient's body does the work, and our job is to give the body the best possible working conditions and then get the heck out of the way.
My patients with wounds often think the purpose of my encounters with them is to change their bandages. It is not. A chimpanzee can learn to change most bandages and doesn't need a professional license to do so, and if a chimp can do it, so can a patient and/or family member or other caregiver. I'm happy to show them how. The only reason they need me is to help them know when a change in the way a wound looks portends healing or a complication, whether a wound is becoming too wet or too dry as it heals and so needs a change in therapy, and if they safely can relax confident in the knowledge that they're doing everything right. Truly, with a little help from his/her friends, the patient does all the work.
And here's the dirty little secret big pharma and insurance companies don't want you to know: In all of healing, not just wound management, the patient does the work. We with our licenses, degrees, and certifications just shine light down the path to wholeness and smooth the way for the body's efforts. Truly: Master light-shining and road-smoothing and you can have yourself a medical degree.
But as an industry we've come to the point of keeping our light under a bushel and of creating more roadblocks than we remove. The body's natural tendency is towards wholeness, yet at every turn we invade it, cut it open, place alien substances inside it, and douse it with chemicals, creating ever more new obstacles for an already challenged body to overcome. We're not evil nor mean-spirited; we're just good science run amok the same way cancer is good cells gone haywire and taking over their host until they kill it. Heaven knows antibiotics and other drugs have saved millions and truly turned the tide of human existence. And so have surgery and angioplasties and CT scans and more. In fact, these have proven to be so good that we look to them more and more . . . more than is necessary, more than is helpful, and more, to the point of being harmful. As with so many things, if a little is good, more isn't always better.
Big pharma's ads on TV say, "Ask your doctor" if you're depressed, impotent, sneezing, sleepless, diagnosed with one disease or another, anxious, headachy, lame, or merely human, yes, ask your doctor if the latest pill won't help you. Usually it won't, bottom line, or your doctor or other provider already would have prescribed it. Trust me: Your doctor watches TV, too, and knew all about those latest pills long before those ads ever ran. S/he doesn't need Madison Avenue to consult in your treatment.
What I long for ads to say is, "Listen to your body and give it a chance." Your doctor is doing his/her job when you walk out of the office without a prescription. Another x-ray, another blood text, another cardiac catheterization may not tell us anything more than your own inner knowing and the wise judgment born of your healthcare provider's years of experience examining and listening to people much like you.
What I long for ads to do is quote one of my old pharmacology professors: "There is only one drug that has no side effects: Arsenic. It just kills you." Sometimes, many times, less is more. That grocery bag full of pill bottles that Grandma carries around may be doing her more harm than good, and when she 'asks her doctor' if she doesn't need the latest pill advertised on TV and the doctor, pressed by financial imperatives to see 15 patients an hour (like Bill Clinton, I like arithmetic: That's four minutes each, folks, including the time to write prescriptions and document in the medical record, with no potty breaks or phone calls allowed), yes, the doctor figures it probably won't hurt and will make her happy and so writes another scrip. Then poor Grandma may go away feeling satisfied that her doctor has done something for her . . . and may add one more toxic substance to a body already processing everything else in that grocery bag of pill bottles, pills to treat the side effects of the side effects of pills, until her kidneys, her liver, or her soul simply says, "Enough."
Can't we say, "Enough" now, before Grandma, or any of us acquires the surgical scars, the stents, the tests, the pills, and the bills? Enough. "Enough" ≠ "none." Enough is enough, that is, enough is what one needs to heal and be whole, nothing more, nothing less.
A riveting, compelling, completely engaging portrayal of the issues in healthcare in America just has hit the big screen, and I cannot endorse Escape Fire enthusiastically enough. Do yourself a favor and go to the movies this weekend: http://vimeo.com/27450676
That last point in my wound care lecture bears revisiting: Whatever it is, don't poison it." Not all that many years ago, in an effort to serve point #1 and clean a dirty wound or avoid infection, we doused wounds with various forms of iodine, hydrogen peroxide, alcohol, and good ol' soap. These do clean wounds and kill bugs all right . . . and they also kill the new, healthy tissue trying to grow and heal. They're poison, albeit used with good intent, but far more toxic than is warranted in vast majority of situations (there are rare exceptions, rare). The rule of thumb now generally is not to put something into or on a wound that one also wouldn't put in one's eye. Truly. So we cleanse with normal saline (salt water), plain water, or wound cleansers formulated to mimic the body's own fluids and tissues.
Would that we reach the point of doing the same in all of healthcare. Would that providers have time and discernment to say, "Let's just watch this and see what happens; the body is working well to right itself. Let's support, rather than confound it. And I will be here for you to evaluate the process as it unfolds, and intervene if necessary. Yes, I have time, yes, I will, this is what I do." Would that the day comes when attending physicians, and other providers, are able truly and simply to attend, to be present.
Would that we prescribe nutrition (now absent from most medical schools' curricula) before pills, would that our research dollars be invested in natural healing and comprehensive approaches to wellness as much as in disease management and medicine, would that insurers pay for and promote health care instead of merely illness care, would that we teach proper exercise, stress management, sleep hygiene, the art of self-knowledge, and good, old-fashioned play. Would that we prize healthy relationships, work settings, and communities, and stop poisoning our air, water,and soil. Would that we consume real food instead of processed, nutrient-poor, chemical-rich pseudo-foods.
Would that each of us, before asking our doctors for the latest pill, ask our own body what it needs to be whole and require that our healthcare providers and policy makers supply this,and our insurers pay for it. May we each cherish the body we have been given, be supported in caring for it, and, yes, in every way see that we
Don't Poison It.
Tuesday, July 24, 2012
Small Courtesies
One who ignores another's milestones and major life events is not a friend. Failure to acknowledge serious illness or death, marriage, or achievement of an important life goal is but affirmation of the obvious: An acquaintance is no more than that, and is lacking in the social graces as well. Most likely one doesn't much care, or understands such disregard as a clear indication that the relationship itself merits being disregarded.
But what of the small things? The birthday greeting that is days, weeks, or months late. The small favor forgotten. The overlooked invitation. The gift that isn't: A lukewarm "Let me know where you want to go out to celebrate your promotion," with no offer to treat or of a date or of a plan, or "It's so hard to shop for you that I haven't gotten around to buying your present [although the occasion has passed and I haven't made much effort]."
Few of us need another birthday card, social obligation, material object, or free meal, and it's easy to reason that careless friends mean well but are busy or disorganized. But both parties lose when we accept that sad conclusion.
It's true that timely birthday and holiday greetings, casual favors, little "just because" gifts, acknowledgments of small triumphs and setbacks, and celebrations no matter how modest are small courtesies, not major life needs.
But good friends are worthy of small courtesies.
Anger and fear abound these days, appearing as road rage, sullen silence, passive-aggressive manipulation, endless self-justification, prolonged seething that suddenly erupts into violence, malignant sadness, compulsive fault-finding, adamant self justification, and defensive isolation.
I wonder if more birthday greetings carefully delivered on time, more I-thought-of-you-when-I-saw-this-and-wanted-you-to-have-it small gifts, more flowers and home-grown vegetables handed over the back fence, more come-for-tea-Sunday-afternoon or I'd-like-to-gather-a-few-friends-next-Friday-to-celebrate-your-new-job, more invitations reciprocated, in short, more simple, small courtesies, if these might be a larger-than-expected step towards peace on earth, and if they might make a significant dent in the epidemic of "cardiodiabesity" and other lifestyle diseases characterized by people trying to fill and comfort themselves in a world that may feel colder and more empty than an observer might suspect.
It seems an experiment worth trying: Indifference, convenience, habit, and self-preoccupation, or
Small Courtesies?
But what of the small things? The birthday greeting that is days, weeks, or months late. The small favor forgotten. The overlooked invitation. The gift that isn't: A lukewarm "Let me know where you want to go out to celebrate your promotion," with no offer to treat or of a date or of a plan, or "It's so hard to shop for you that I haven't gotten around to buying your present [although the occasion has passed and I haven't made much effort]."
Few of us need another birthday card, social obligation, material object, or free meal, and it's easy to reason that careless friends mean well but are busy or disorganized. But both parties lose when we accept that sad conclusion.
It's true that timely birthday and holiday greetings, casual favors, little "just because" gifts, acknowledgments of small triumphs and setbacks, and celebrations no matter how modest are small courtesies, not major life needs.
But good friends are worthy of small courtesies.
Anger and fear abound these days, appearing as road rage, sullen silence, passive-aggressive manipulation, endless self-justification, prolonged seething that suddenly erupts into violence, malignant sadness, compulsive fault-finding, adamant self justification, and defensive isolation.
I wonder if more birthday greetings carefully delivered on time, more I-thought-of-you-when-I-saw-this-and-wanted-you-to-have-it small gifts, more flowers and home-grown vegetables handed over the back fence, more come-for-tea-Sunday-afternoon or I'd-like-to-gather-a-few-friends-next-Friday-to-celebrate-your-new-job, more invitations reciprocated, in short, more simple, small courtesies, if these might be a larger-than-expected step towards peace on earth, and if they might make a significant dent in the epidemic of "cardiodiabesity" and other lifestyle diseases characterized by people trying to fill and comfort themselves in a world that may feel colder and more empty than an observer might suspect.
It seems an experiment worth trying: Indifference, convenience, habit, and self-preoccupation, or
Small Courtesies?
Saturday, November 19, 2011
What's is Like to Be You?
For a standing room only crowd at the National Museum of Mexican Art last night, a group of fiesty Chicanas unveiled their new book, Chicanas of 18th Street, and spoke of their more than forty years of activism in the Chicago Hispanic community. There were cheers and tears in the audience, spontaneous expressions of heartfelt appreciation from a number of men (!), and an embarrassing shortage of tamales for a turnout that was three times what had been expected. The authors' overriding theme was that the "struggles" (this word was used often) continue and these women write and speak to teach and inspire the generations that follow.
But the previous day one of the most thoughtful, dedicated, and articulate Hispanic advocates I know posted an essay on Facebook raising the question of why the Hispanic community in Chicago seems to have lost momentum in its activist movement. He teaches at a local college where most of the students are of Mexican heritage, and asked this question of two of his classes. The response was that they were unwilling to give up the twenty or thirty dollars they would earn working in order to attend a demonstration or other activist activity. Is the issue money, the author/teacher wondered? Or fear? Or something else? He invited comments; as of this morning there has been only one.
He is asking the wrong question.
The Chicanas inspired an overwhelming turnout. Young women rose from the audience to ask tearfully what they could do to help, how they could become more involved. Discussion was halted after two hours or the crowd might still be there this morning. In fact, they may indeed yet be there! I briefly perused a couple of poster displays while consuming my one lonely tamal, signed up for the mailing list, picked my way through the milling crowd that clearly was going nowhere soon, and took my leave in order to go home to dogs much in need of walks. Who knows what time the museum finally emptied of that crowd?
Hispanic activism clearly is alive and well in Chicago, indeed, in the very same barrio where turnout had been so poor for a demonstration two short weeks ago. How is the difference to be explained?
The easy question to ask always is, "Why don't others do what I believe they should?" Why don't they march in the streets for a good cause, why don't they take their medicine, watch their diets, keep their medical appointments, exercise regularly, turn off the TV or computer and read a book, sit down as a family for dinner at night, and make love, not war?
But the question that yields meaningful answers and suggests where discussion and action need to begin if behavior change is to be inspired is, "What are they doing instead of what I believe they should?" Because it is in actions that values and priorities are reflected, and until a recommended behavior change serves those values and priorities as well as or better than current practices and habits, change won't happen. Jack Glidewell, a professor with whom I studied at the University of Chicago years ago, used to emphasize that when seeking to make change in any organization or group it is imperative to remember that any behavior or practice that has persisted for a long period of time has done so for a reason, and unless that reason is understood and continues to be satisfied, the proposed change will not be embraced.
So, if workers have functioned for years in a punitive environment where mistakes were punished instead of corrected and order was maintained with threats rather than reason and discourse, sudden introduction of a new manager or, worse!, "consultant" who announces that an "open door policy" and shared governance now are the order of the day is likely to meet with mute disregard and heightened suspicion. If the Sunday School class followed by the worship service followed by the church supper for decades has been the anchor and highlight of an old woman's week, counsel that she must take a "water pill" that will require her to run to the restroom every twenty minutes or have" accidents," and that she may not eat the foods served at the supper because they contain too much salt, fat, and sugar is likely to cause cognitive dissonance at best, and almost certainly to be ignored over time. Understanding the historic context of the work setting and the values and needs served by longstanding personal habits are key to improving both the workplace and personal health. Any anything else.
I don't know why the Pilsen community packed an auditorium last night but did not appear for a march two weeks ago. I don't know why "Mr. Brown" missed his doctor's appointment last week. I don't know precisely why any one of millions of Americans will overeat and make unwise food choices this holiday season. But I do know that asking why they don't do something other than they do will not give me the answers I need to inspire them to make different choices. Instead I need to ask, "Where were you the day of the demonstration? What were you doing? What was that like for you; how was it important? Did you know about the demonstration; how does/doesn't it matter to you?" and "What happened last week, Mr. Brown? Where were you and what were you doing the day of your doctor's appointment? How was that important to you? How do you feel about going to the doctor? What makes it easy/hard for you to go?" and "Tell me about your holidays. What do you do and with whom? What are your fondest memories? To what do you look forward? What is most special to you, and what do you most enjoy? Are there aspects of holidays that are difficult for you, and, if so, how do you manage that?"
Knowing that one is comfortable sitting in an auditorium but not marching in the streets, or that the comfort of the church community and of longstanding habits is greater than the discomfort of any exacerbated health problem, or that mindless consumption of cherished traditional foods in the company of too-rarely seen loved ones and a good televised football game brings greater joy than seeing a two pound weight loss on the scale the next morning tells me where to begin if I hope to bring change.
When we were divorcing many years ago my soon-to-be-ex husband looked at me with pained eyes and asked, "Why can't you be who I want you to be?" My answer might have been, "For the same reason that you can't love me for who I am." Just as a marriage based on projecting a fantasy onto one's partner is not likely to succeed, so efforts to bring behavior change, whether by inspiring a community or a single patient, are likely to be sorely misguided when they proceed from the question, "Why don't you do/be/think as I want?" Instead may the question always be,
"What's It Like to Be You?"
But the previous day one of the most thoughtful, dedicated, and articulate Hispanic advocates I know posted an essay on Facebook raising the question of why the Hispanic community in Chicago seems to have lost momentum in its activist movement. He teaches at a local college where most of the students are of Mexican heritage, and asked this question of two of his classes. The response was that they were unwilling to give up the twenty or thirty dollars they would earn working in order to attend a demonstration or other activist activity. Is the issue money, the author/teacher wondered? Or fear? Or something else? He invited comments; as of this morning there has been only one.
He is asking the wrong question.
The Chicanas inspired an overwhelming turnout. Young women rose from the audience to ask tearfully what they could do to help, how they could become more involved. Discussion was halted after two hours or the crowd might still be there this morning. In fact, they may indeed yet be there! I briefly perused a couple of poster displays while consuming my one lonely tamal, signed up for the mailing list, picked my way through the milling crowd that clearly was going nowhere soon, and took my leave in order to go home to dogs much in need of walks. Who knows what time the museum finally emptied of that crowd?
Hispanic activism clearly is alive and well in Chicago, indeed, in the very same barrio where turnout had been so poor for a demonstration two short weeks ago. How is the difference to be explained?
The easy question to ask always is, "Why don't others do what I believe they should?" Why don't they march in the streets for a good cause, why don't they take their medicine, watch their diets, keep their medical appointments, exercise regularly, turn off the TV or computer and read a book, sit down as a family for dinner at night, and make love, not war?
But the question that yields meaningful answers and suggests where discussion and action need to begin if behavior change is to be inspired is, "What are they doing instead of what I believe they should?" Because it is in actions that values and priorities are reflected, and until a recommended behavior change serves those values and priorities as well as or better than current practices and habits, change won't happen. Jack Glidewell, a professor with whom I studied at the University of Chicago years ago, used to emphasize that when seeking to make change in any organization or group it is imperative to remember that any behavior or practice that has persisted for a long period of time has done so for a reason, and unless that reason is understood and continues to be satisfied, the proposed change will not be embraced.
So, if workers have functioned for years in a punitive environment where mistakes were punished instead of corrected and order was maintained with threats rather than reason and discourse, sudden introduction of a new manager or, worse!, "consultant" who announces that an "open door policy" and shared governance now are the order of the day is likely to meet with mute disregard and heightened suspicion. If the Sunday School class followed by the worship service followed by the church supper for decades has been the anchor and highlight of an old woman's week, counsel that she must take a "water pill" that will require her to run to the restroom every twenty minutes or have" accidents," and that she may not eat the foods served at the supper because they contain too much salt, fat, and sugar is likely to cause cognitive dissonance at best, and almost certainly to be ignored over time. Understanding the historic context of the work setting and the values and needs served by longstanding personal habits are key to improving both the workplace and personal health. Any anything else.
I don't know why the Pilsen community packed an auditorium last night but did not appear for a march two weeks ago. I don't know why "Mr. Brown" missed his doctor's appointment last week. I don't know precisely why any one of millions of Americans will overeat and make unwise food choices this holiday season. But I do know that asking why they don't do something other than they do will not give me the answers I need to inspire them to make different choices. Instead I need to ask, "Where were you the day of the demonstration? What were you doing? What was that like for you; how was it important? Did you know about the demonstration; how does/doesn't it matter to you?" and "What happened last week, Mr. Brown? Where were you and what were you doing the day of your doctor's appointment? How was that important to you? How do you feel about going to the doctor? What makes it easy/hard for you to go?" and "Tell me about your holidays. What do you do and with whom? What are your fondest memories? To what do you look forward? What is most special to you, and what do you most enjoy? Are there aspects of holidays that are difficult for you, and, if so, how do you manage that?"
Knowing that one is comfortable sitting in an auditorium but not marching in the streets, or that the comfort of the church community and of longstanding habits is greater than the discomfort of any exacerbated health problem, or that mindless consumption of cherished traditional foods in the company of too-rarely seen loved ones and a good televised football game brings greater joy than seeing a two pound weight loss on the scale the next morning tells me where to begin if I hope to bring change.
When we were divorcing many years ago my soon-to-be-ex husband looked at me with pained eyes and asked, "Why can't you be who I want you to be?" My answer might have been, "For the same reason that you can't love me for who I am." Just as a marriage based on projecting a fantasy onto one's partner is not likely to succeed, so efforts to bring behavior change, whether by inspiring a community or a single patient, are likely to be sorely misguided when they proceed from the question, "Why don't you do/be/think as I want?" Instead may the question always be,
"What's It Like to Be You?"
Sunday, April 3, 2011
Mouse-Eared Princess Brides
Walt Disney World didn't seem an ideal venue for a professional symposium last month. Throughout every phase of managing my travel, the Disneyites referred to my trip as a "vacation," which hardly seemed appropriate as I hauled my jet-lagged backside to obscenely early meetings and lectures. Further complicating the jet-lag was the irksome practice of ending every day with a late night parade, complete with rousing renditions of patriotic music that certainly left one wanting to march to the beat . . . except when one wanted to clamp a pillow tighter over one's ears instead. Unless short-order fast food seemed appealing, breakfast was a boat-ride away. This entailed extracting one's bleary-eyed, post-nocturnal parade self from between the sheets at an ungodly hour, in order to hike to the dock and wait in the cold - and at that hour of the morning central Florida was cold in March! - for the boat, and then shiver in gratitude for the fly-back-to-Chicago clothes which, although not quite warm enough, surely were salvation from what felt like threatening frostbite as morning winds whipped over the open vessel making its way across the lake. I never had attended a professional meeting in jeans and fleece before, but, hey, Disney is good for nothing if not new experiences! Even if the mercury pushed its way into the seventies by mid-afternoon, there's no way my decorous skirts and blouses with coordinating light sweaters, were going to cut it on that boat!
Then there was the matter of timing: early to mid-March. Read: Spring break. Disney World no doubt is a magnet for children and families any time, but with many schools and colleges out of session for break, that week the place was a veritable wasp's nest of youthful revelers, everywhere, every hour, day and night. And Disney World is all about the children. A nap by the pool was punctuated by enthusiastic loud-speaker entreaties to join in a hula hoop contest. Every meal in every restaurant had a make-believe theme. Staff often were in costume, and those who weren't wore uniforms that looked like costumes. And wherever one turned, the landscape was ripe for acting out some fantasy. Indeed, each of the Disney World resorts has a theme, and expressions of that theme and opportunities for immersion in it and for absorbing play are everywhere. There are subtle and not-so-subtle suggestions and props at every turn, and everything a child would need to become the adventurer of his or her dreams.
And become adventurers and act out their fantasies they did. At about age three, "Pocohontas" stood next to me on Main Street of the Magic Kingdom, calmly taking in stride the sudden halt of a trolley-like vehicle, from which emerged colorful Victorian-era performers singing and dancing . . . even when one of them left the revue, danced up to little Pocohontas, greeted her by name, and engaged her in conversation. And although wide-eyed and a bit shy, Pocohontas not only did not back away from the attention, but instead gradually allowed herself to be drawn into it. Disney World is a safe place to be a child. And childhood is embraced, understood, and celebrated there.
A number of times I noticed a variation of the same ironic being: A little girl, with the trademark skull cap and mouse ears that characterize Disney, but also sporting a tiara in front of the cap, and a bridal veil behind it and down her back. Yes indeed: A mouse-eared princess bride. Princess costumes were everywhere, and mouse ears of course were ubiquitous. Interesting combinations of regalia from various Disney characters and individualized versions thereof popped up all around. But the mouse-eared princess brides were my favorite. And judging from the looks on the faces under this headgear, this look was the be-all and end-all for them, too. Such happy little girls!
In fact, the entire place was brimming with happy, happy children. I witnessed a rare, mild, fatigue-induced fuss now and then, but no tantrums, no whining, no aggression or violence, . . . only an extraordinary degree of patience, wonder, and sheer delight. Hundreds and hundreds of over-excited children in a strange place with their daily routines turned topsy-turvy, and little other than a large measure of happiness to show for it. And never once did I hear anyone tell a mouse-eared princess bride that she, in fact, could not be a mouse, or a princess, and certainly not all three, that she might not ever be, or actually want to be a bride, or that the other two options were out of the question entirely, thanks to immutable biology and heritage. No, if a little girl wanted to be a mouse-eared princess bride, then a mouse-eared princess bride she was, with the essential trappings provided and nothing but unassuming acceptance all around.
There's a lesson here. I have lived the better part of six decades, and have yet to encounter an adult who thought she was or wanted to be a mouse-eared princess bride. Maybe, just maybe, it isn't necessary, or desirable, to help children understand that their fantasies aren't real, to tell them that some dreams won't come true, or to admonish them to be realistic and grow up. And maybe the Disneyites have it right: If children are encouraged and supported in their creativity, they will tend to be happy, content children . . . and perhaps continue to create, begin to ask "what if?" and "why not?", and experiment and understand the world around them in ways that we in our paradigms, protocols, and evidence-based obsessions would never consider. Confident and brave, instead of doubtful and neurotic, perhaps these children can grow into adults who see ways out of the complicated mires previous generations have left them, and they might even be kind and generous enough to look kindly on their feeble and misguided elders, and protect us from ourselves.
Children don't need to be taught or told to grow up; it happens naturally (although we do have the wherewithal to make the process smooth or miserable). I suspect dreams and fantasies do the same: Supported, and then left to her own devices, the mouse-eared princess bride evolves into a new version of her dream, and then another, and another. Each one fits the circumstances of the child's life and level of maturity at the time, and if we try to mold, correct, or guide them, we produce only a damaged child and a lifeless dream with nowhere to grow and no empowering spirit.
Walt Disney World seemed a poor choice for a professional symposium, where experts from around the world would come together to understand and explore what is to be done to halt the epidemic of cardiovascular disease raging through our society and worsening alarmingly every year . . . while a giant, over-the-top, perpetual birthday party raged outside the meeting room doors. It seemed a poor choice, until I met the smiling, shining-eyed mouse-eared princess brides. And until I saw that if a little girl dreamed of being Mickey or Minnie Mouse, a princess living in Cinderella's castle, and a beautiful bride who would grow up to be just like Mommy, altogether, all at once, then she could do it, she could be it, with acceptance, support, and everyone around her eager to join in the game. Maybe, just maybe, we would solve the problems of cardiovascular disease, and poverty, and obesity, and cancer, and bad hair days, and all the rest, much more easily, much more creatively, much more effectively, and much less expensively, if we were allowed and encouraged to dream, to assume for awhile that the impossible is possible after all, and to ask "what if" and then act out the answers. Maybe our science would be better, and we would be a tad more effectively human, if we began our days with a boat ride to breakfast, lived our days in the spell of magical castles where anything is possible, expected people to pop out of vehicles on Main Street and break into song and dance, and never went to bed without a parade to celebrate all the good that the day had wrought.
I came home, in my fly-back-to-Chicago clothes, with a suitcase full of reports and samples, a bit of sunburn, and a wistfulness about the lack of a parade that night, and about there being no boat ride on the agenda for the next morning. Walt Disney World had not afforded me many quiet corners to have intense conversations about Important Matters with colleagues from across the country, and I was a bit sleep-deprived and overstimulated by days of being surrounded by throngs of excited children. I still haven't sorted through all those papers in my suitcase, and the volume of email generated from that conference is daunting. I'm worried about the toll to be exacted by the epidemic of "cardiodiabesity" that is upon us, and rue the lack of immediate answers. But I have a sneaking, smiling suspicion that even as we conference attendees go back to our laboratories, classrooms, and clinics and do our best to help those we serve and to advance the science that will help that process, the best ideas and most profound solutions may yet come a bit farther along in the future, from eager, insightful, creative, and confident clinicians and scientists who today are fortunate to be embraced and encouraged to be who they are and become who they will, beginning right now as
mouse-eared princess brides.
Then there was the matter of timing: early to mid-March. Read: Spring break. Disney World no doubt is a magnet for children and families any time, but with many schools and colleges out of session for break, that week the place was a veritable wasp's nest of youthful revelers, everywhere, every hour, day and night. And Disney World is all about the children. A nap by the pool was punctuated by enthusiastic loud-speaker entreaties to join in a hula hoop contest. Every meal in every restaurant had a make-believe theme. Staff often were in costume, and those who weren't wore uniforms that looked like costumes. And wherever one turned, the landscape was ripe for acting out some fantasy. Indeed, each of the Disney World resorts has a theme, and expressions of that theme and opportunities for immersion in it and for absorbing play are everywhere. There are subtle and not-so-subtle suggestions and props at every turn, and everything a child would need to become the adventurer of his or her dreams.
And become adventurers and act out their fantasies they did. At about age three, "Pocohontas" stood next to me on Main Street of the Magic Kingdom, calmly taking in stride the sudden halt of a trolley-like vehicle, from which emerged colorful Victorian-era performers singing and dancing . . . even when one of them left the revue, danced up to little Pocohontas, greeted her by name, and engaged her in conversation. And although wide-eyed and a bit shy, Pocohontas not only did not back away from the attention, but instead gradually allowed herself to be drawn into it. Disney World is a safe place to be a child. And childhood is embraced, understood, and celebrated there.
A number of times I noticed a variation of the same ironic being: A little girl, with the trademark skull cap and mouse ears that characterize Disney, but also sporting a tiara in front of the cap, and a bridal veil behind it and down her back. Yes indeed: A mouse-eared princess bride. Princess costumes were everywhere, and mouse ears of course were ubiquitous. Interesting combinations of regalia from various Disney characters and individualized versions thereof popped up all around. But the mouse-eared princess brides were my favorite. And judging from the looks on the faces under this headgear, this look was the be-all and end-all for them, too. Such happy little girls!
In fact, the entire place was brimming with happy, happy children. I witnessed a rare, mild, fatigue-induced fuss now and then, but no tantrums, no whining, no aggression or violence, . . . only an extraordinary degree of patience, wonder, and sheer delight. Hundreds and hundreds of over-excited children in a strange place with their daily routines turned topsy-turvy, and little other than a large measure of happiness to show for it. And never once did I hear anyone tell a mouse-eared princess bride that she, in fact, could not be a mouse, or a princess, and certainly not all three, that she might not ever be, or actually want to be a bride, or that the other two options were out of the question entirely, thanks to immutable biology and heritage. No, if a little girl wanted to be a mouse-eared princess bride, then a mouse-eared princess bride she was, with the essential trappings provided and nothing but unassuming acceptance all around.
There's a lesson here. I have lived the better part of six decades, and have yet to encounter an adult who thought she was or wanted to be a mouse-eared princess bride. Maybe, just maybe, it isn't necessary, or desirable, to help children understand that their fantasies aren't real, to tell them that some dreams won't come true, or to admonish them to be realistic and grow up. And maybe the Disneyites have it right: If children are encouraged and supported in their creativity, they will tend to be happy, content children . . . and perhaps continue to create, begin to ask "what if?" and "why not?", and experiment and understand the world around them in ways that we in our paradigms, protocols, and evidence-based obsessions would never consider. Confident and brave, instead of doubtful and neurotic, perhaps these children can grow into adults who see ways out of the complicated mires previous generations have left them, and they might even be kind and generous enough to look kindly on their feeble and misguided elders, and protect us from ourselves.
Children don't need to be taught or told to grow up; it happens naturally (although we do have the wherewithal to make the process smooth or miserable). I suspect dreams and fantasies do the same: Supported, and then left to her own devices, the mouse-eared princess bride evolves into a new version of her dream, and then another, and another. Each one fits the circumstances of the child's life and level of maturity at the time, and if we try to mold, correct, or guide them, we produce only a damaged child and a lifeless dream with nowhere to grow and no empowering spirit.
Walt Disney World seemed a poor choice for a professional symposium, where experts from around the world would come together to understand and explore what is to be done to halt the epidemic of cardiovascular disease raging through our society and worsening alarmingly every year . . . while a giant, over-the-top, perpetual birthday party raged outside the meeting room doors. It seemed a poor choice, until I met the smiling, shining-eyed mouse-eared princess brides. And until I saw that if a little girl dreamed of being Mickey or Minnie Mouse, a princess living in Cinderella's castle, and a beautiful bride who would grow up to be just like Mommy, altogether, all at once, then she could do it, she could be it, with acceptance, support, and everyone around her eager to join in the game. Maybe, just maybe, we would solve the problems of cardiovascular disease, and poverty, and obesity, and cancer, and bad hair days, and all the rest, much more easily, much more creatively, much more effectively, and much less expensively, if we were allowed and encouraged to dream, to assume for awhile that the impossible is possible after all, and to ask "what if" and then act out the answers. Maybe our science would be better, and we would be a tad more effectively human, if we began our days with a boat ride to breakfast, lived our days in the spell of magical castles where anything is possible, expected people to pop out of vehicles on Main Street and break into song and dance, and never went to bed without a parade to celebrate all the good that the day had wrought.
I came home, in my fly-back-to-Chicago clothes, with a suitcase full of reports and samples, a bit of sunburn, and a wistfulness about the lack of a parade that night, and about there being no boat ride on the agenda for the next morning. Walt Disney World had not afforded me many quiet corners to have intense conversations about Important Matters with colleagues from across the country, and I was a bit sleep-deprived and overstimulated by days of being surrounded by throngs of excited children. I still haven't sorted through all those papers in my suitcase, and the volume of email generated from that conference is daunting. I'm worried about the toll to be exacted by the epidemic of "cardiodiabesity" that is upon us, and rue the lack of immediate answers. But I have a sneaking, smiling suspicion that even as we conference attendees go back to our laboratories, classrooms, and clinics and do our best to help those we serve and to advance the science that will help that process, the best ideas and most profound solutions may yet come a bit farther along in the future, from eager, insightful, creative, and confident clinicians and scientists who today are fortunate to be embraced and encouraged to be who they are and become who they will, beginning right now as
mouse-eared princess brides.
Subscribe to:
Posts (Atom)