Change

So, I've been away from the blogosphere for a while. Lots of happenings in the interim; the largest of which is returning to school. Crazy? Maybe! But, in the spirit of making my little corner of the world better for the people in it, I could no longer listen to the stories of patients and families in the hallways of my clinic day after day, and not respond in some larger way. So, after jumping through the many, many hoops that a nationally ranked graduate program requires, I am into my first semester of a Master of Public Health program, with a focus on Health Policy and Management. (And, yes, one of those hoops included taking the GRE again after 30 years. And, yes, I was the ONE person in the testing center wearing bifocals that day!)
So, the juggling of work, school, and just the daily minimum "life maintenance" is challenging. It's budget season at work, hours and hours of stats homework, multiple policy articles to read, and somehow it seems right. Oh, and I learned very quickly that statistics homework is no longer completed (as it was 30 years ago) with a calculator, formulas, and t-tables to reference. It is all done in Excel. The times have changed!

Sunday's 3 BT

1. Awakening sans alarm
2. iTunes DJ
3. Laundry fresh from the dryer

3BT

1. Pachelbel's Canon in D
2. Watching baby robins feed in the yard
3. Fiery pink azaleas in full bloom

5000 Steps

My employer, a healthcare system, is promoting wellness for bothemployees and our patients. As part of that initiative, we have all been given the opportunity to wear a pedometer that logs our steps, individually, and collectively. As a group, our goal is to reach 1 billion steps this year. Our executive leadership team reached 1 million steps last year.

Well, a few weeks ago, pedometers arrived in my department, and after registering them online, and having an electronic "reader" connected to one of the desktop computers, I was set to go. Knowing that the recommended steps per day was 10,000, I was curious to see where my baseline might be. Keeping in mind, that in the last 2 1/2 years, I had a couple of freak falls and broke my right tibia, and then a year later had a complex fracture of my left knee cap, I have "just" made it to walking on smooth terrain c-a-r-e-f-u-l-l-y, I was expecting my daily steps to be around 5000 or so. Well, I was far, far short of that mark.

I have come very close to hitting and breaking 5000 steps in a day, but have just fallen short. My "best" days (in the 4500-4800 range) have occurred on days when I have been in a shopping mall. Sad - isn't it? I think I hear a treadmill calling my name.

The therapeutic dance of lifelong learning

The article below appeared in today's New York Times in their 'Cases" feature. I thought it a lovely vignette describing the dyadic learning and relatedness that occurs during the therapeutic "dance" – even at a Life's ending.

 

October 6, 2009

Cases

A Final Round of Therapy, Fulfilling the Needs of 2

By HENRY GRUNEBAUM, M.D.

Some years ago I was consulted by a psychologist, a man in his 60s who wanted help with relationships and in thinking about his life, which was threatened by heart disease. At the time I was in my 70s, and his condition had special resonance for me: my father had died of congestive heart failure, and I have feared I will die in the same way.

 

"Do I want to work with a man who may die, and who may be closer to death than I am?" I reflected. If we have a good relationship, I will have to experience grief. If I do not come to care about him, the therapy will not be helpful. On the other hand, I might not outlive him, and losing a therapist is painful. Should he be subjected to that loss too?

 

But I liked the new patient and thought that in his situation, I would want someone to have the courage to be with me. So we began meeting from time to time.

 

Over the next few years, he continued to see his clients, teach and write. We talked about how to improve his relationships, but mainly we talked about how to live when life seems likely to be short. I shared my own thoughts and experiences, and without identifying the patient, I discussed the situation with my wife (who is also a therapist, and a helpful editor), as I do when confronted by an ethical or otherwise challenging clinical problem.

 

As the patient's heart failure worsened, I worried about him often and called if I had not heard from him for a few weeks. At the time, I was facing my own aging — cataract surgery and a knee replacement — and while I felt fine, I also felt keenly that time was passing too rapidly. I felt fortunate to be alive and well, enjoying my wife, my family, my friends and my work — but not a day went by that I did not think about my own death.

 

Then my patient took a sudden turn for the worse. I should not have been surprised: my father's terminal hospitalization had seemed sudden, too, and to my lasting regret I had put off going to see him, not thinking it could be the last time.

 

Determined not to make the same mistake this time, I called my patient and asked whether he might want me to come see him. He said he would. So I began a series of visits over a number of months to nursing homes and hospitals. He talked about his writing, his regrets about botching a prior marriage and his shame at being in a nursing home.

 

I was improvising a kind of therapy I had never done before with a dying patient. While he did talk about death, he focused on how difficult his life was now. Knowing his love of writing, I suggested that he borrow a laptop and put his thoughts and feelings into words. He smiled and seemed pleased at the idea.

 

Then a colleague who heard me talking about this intense emotional work lent me "Momma and the Meaning of Life: Tales of Psychotherapy" (Piatkus, 1999), by Irvin D. Yalom, a psychiatrist and author. In particular, Dr. Yalom writes about a patient of his who had metastatic breast cancer and who taught him what living with and dying of cancer was like.

 

When we next met, my patient had begun needing oxygen and was besieged with paperwork. He needed to transfer to the Medicaid rolls to pay the costs of his nursing home, and he complained that someone so sick should not have to put up with such a burden. I agreed that it was Kafkaesque; even when you are dying, I thought, there is no respite from bureaucratic hassles.

 

After a bit I said: "You have always been a teacher and consultant, and you are going through something I will soon face. What can you teach me about it?" His face lighted up.

 

"The first thing you need is a sense of humor," he said, as I recall. "And then you need something like my writing, which gives your life some meaning. And finally you need to be able to put up with a lot. You have to deal with lots of people who cannot do simple things right, such as putting in an IV or bringing you edible food."

 

I replied with a favorite Woody Allen line: "It's not that I'm afraid to die. I just don't want to be there when it happens."

 

And he fired back: "Woody Allen also said: 'We know there is an afterlife. The question is what times is it open and is it close to Midtown?' "

 

He was soon transferred to another hospital, where I found him looking very weak. I stayed for a few minutes, held his hand and told him and his wife they could call me anytime, day or night. Three days later his wife called to say visits were now limited to his immediate family, adding, "I know you mean a lot to him."

 

I then learned that he had been withdrawn from medications and was being "kept comfortable," which meant that the end was near. I became very sad, preoccupied with the thought that we had not had a chance to say goodbye. I also knew that I needed this farewell more than he did.

 

At his memorial service, where there were many heartfelt tributes, his wife approached me and said she had asked him, "Why does Henry see you, since you are not paying him?"

 

His answer, as she recounted it, made clear that though on the verge of death, he had felt affirmed as a teacher, a person and a fellow professional — that dying need not be merely a matter of letting go, of disengaging from those most dear to us, but of giving meaning, hope and a vital part of oneself to those whose lives we have touched and have touched us.

 

"He comes," my patient had told his wife, "because he is learning from me."

 

Henry Grunebaum is a psychiatrist and clinical professor at Harvard Medical

Beautiful Bride by the Sea

Calendar Wisdom

Quote from my calendar today: "To appreciate the beauty of a snowflake, you have to stand in the cold."