A Poet Reborn

Sometime in seventh grade (~2003/2004), I remember writing somewhere around 40 poems in 2 weeks for 2 english/reading/literature classes. From English sonnets, to free verse, haiku's, it was simply too much for a middle school mind to handle. Fast forward over 10 years and it seems the seeds of the poet planted by my amazing grandfather have finally be watered and are starting to grow. There has been nothing better than writing a thoughtful poem after a long day at the hospital, or better yet, on the walk into work in the crisp summer morning. I have provided a few of my more mindfully oriented pieces below and will continue to add at least one poem each week. Maybe a weekly Saturday poem is just the thing to share with the welcoming world.

Photograph

 6-3-2015

What is a photograph but a poem without words

Cursed without a voice, but blessed by the majesty of sight

The colors dancing upon my eyes, speaking a different language

Shadows, contours, reflections whisper in my ears

It takes more than silence to keep a picture from speaking

 a thousand words

Compassion

6-25-2015

Gratitude

We share our thanks

Positivity

We share our optimism

Caring

We share our thoughtfulness

Truth

We share our honesty

Acceptance

We share our understanding

The recipe for compassion is rather simple

All it takes is a little belief

Into how beautiful

The human connection

Can truly be

The Flame

7-16-2015

We all carry a single torch

At the center of our being

It is our eternal flame

Forever burning

Even after our physical form

Has passed

Nurture your fire with friendship

Let the light show you

What it truly means

To be nourished

Give from your source

And receive the gifts from all those

Willing to connect

Eternal being is not the same as

Always giving

Or

Perpetually receiving

We must seek to be

The wick when another is burning out

The light when a torch goes dim

The strength when only smoke remains

Blessed we are

To have courage

To let our fires burn

Under the care of another

Let vulnerability and compassion

Be the sustenance

To your flame

And you will never be worried again

By the question

Of when your embers

Will finally go out

Pediatric Medicine for Adults?

         Having recently completed a 6 week rotation for Pediatrics, in which I saw numerous children from the 2-hour newborn to the 18 year-old needing a sports physical, I was quite impressed with the depth of knowledge required to be a pediatrician. I often joke with my brother's girlfriend, who is a veterinary technical assistant, that being a doctor should be simple, you are just responsible for one species. When it comes to taking care of kids, however, the idea that they are all Homo sapiens somehow is just too hard to believe. Developmentally complex, children can be categorized by certain physical and cognitive milestones, but in reality, this is just a snap shot reflection of the person they currently are, and may have no bearing on the adult they will become. Nurturing and caring for our youth is something near and dear to my heart. Having grown up with all younger cousins, I literally saw the growth of my relatives from diapers, to tricycles and rec soccer, to finally graduating high school and moving on to college. If I were to tell you that the most important part of their physical maturation was constant oversight from a pediatrician via well child checks, sports physicals, the occasional visit during a tough cold, or getting comfort for some bumps and bruises and that really weird rash, you might think this to be a grand overstatement. But take a closer look and what you might find instead is a relationship of trust whereby the pediatrician or family physician nurtured the growth of a child by being a positive presence, someone who cared.

         After observing several visits with UVa general pediatricians, it became very obvious that the majority of our discussions revolved not around an illness or presenting complaint (even if there was an acute problem), but on how a kid was doing in life. What sports did they play, were they involved in dance or art, how much were they sleeping, did they have any problems with their diet- too much candy, food intolerances, not eating enough vegetables, binging on ice cream and Chinese food, how was life at school, did they have close friends, if they had siblings what was their relationship like, did they get to travel to another state or country, what did they want to do when they grew up, what was the coolest thing they had done in the past week? Taking a history was so far removed from asking about quality, duration and onset of pain, or reciting a laundry list of questions for a complete review of systems. Even when these components where required as part of our visit, it was accompanied by discussions about total well being: social, spiritual, physical, and emotional.

         As vulnerable as I have become during my years of medical school, I often tell people that I see a psychologist every 2-4 weeks for an hour at a time to simply talk about my life, review my well-being and make sense of any thoughts or doubts that are going through my head. While this relationship works for me, what I encourage of everyone is to find that person in your life with whom these types of discussions can occur, completely safe, secure and free of judgment. It certainly does not have to be with a trained psychologist or even a family member or friend, the arrangement and sense of true acceptance are all that matters. In thinking about the pediatric visits, it became clear to me that maybe this dynamic was being shaped without even the child, family or doctor being aware of the development. Through thoughtful and meaningful interaction over a period of time, the pediatrician could become a trusted presence in a child’s life such that the cultivation of positive well-being and the adoption of self care practices could actually develop. We all want to be happy, healthy and at peace with our true nature. Sometime illness, negative thoughts, and unexpected life events can cause upheaval in this balance. While I always want to know that I have people in my life that I can turn to when times are difficult, I ultimately want to know that I have the tools and personal resiliency to face any challenges, all the while with my support team waiting in the wings to catch me should I stumble.

         Being a pediatrician can be so much more than simply being the kid doctor. As physicians of adult patients, it can be rather difficult to see where we fit into the patient’s idea of wellness and day to day self-care practice. Often we get derailed by discontinuity or lack of communication/connection with our older patients, yet this is not an excuse. A recent Ideas and Opinions piece from the May 19^th, 2015 issue of Annals of Internal Medicine entitled “Balloon Animals, Guitars, and Fewer Blood Draws: Applying Strategies From Pediatrics to the Treatment of Hospitalized Adults” sought to showcase how we can improve care in the hospital for adult patients by utilizing a pediatric approach. While the article was creatively original as well as practically relevant to our current health care system, it got me to thinking: “What if we combined the pediatric approach with the holistic model of personal well-being and applied this in the outpatient, functional environment, away from the hospital? As I have said many times before, the hospital is all too often the home of sick care while true preventative holistic medicine conducted at the home is healthcare, so why not spend more energy changing the way we care for adult patients outside the home, than continuing to reform and revamp an institution that routinely fails to provide health and vitality to the majority of people seeking aid. I am never one to discredit the value of hospitals, and certainly do not want to come across as someone who views the thoughtful Annals article as misguided, I merely want to suggest an alternative use of our time, energy and resources. Sure, my kind of hospital would look a lot like the one described by Michael R. O'Brien, MD; Marjorie S. Rosenthal, MD, MPH; Kumar Dharmarajan, MD, MBA; and Harlan M. Krumholz, MD, SM, but I also see something more, a new frontier for medicine, a replacement for the hospital when one needs just a little more care than what is realistically achievable while living strictly at home. Just maybe, with the help of a few friends and many years of hard work, we might just see the creation of a new healing institution that truly embodies what it means to provide Healthcare.

The Abbott Way: Goal Directed Treatment Plan

Part IV: Goal Directed Treatment Plan

            In the penultimate post for this 4 part series, we will delve into the idea of the Goal-Directed Treatment Plan with regards to healing for our patient. Now, any doctor or medical student will be very aware of the treatment plan, and will certainly attest to the fact that all patients receiving care ultimately receive a treatment plan. I argue, argue, however, does this standard treatment plan actually address the desired goals, the true needs and most importantly the “Nourishing Review” conducted previously in our 4-step medical encounter. Even with my optimistic attitude, I am hard-pressed to believe that this is actually the norm. Now critics may say that the treatment plan implemented by the doctor is perfectly sufficient for the majority of illness and I would reluctantly agree. My hope, however, is that even if you arrive at the same ultimate treatment strategy, regardless of whether one intimately discusses ideas, goals and desires with the patient, the fact remains that in one instance YOU ACTUALLY GARNERED PATIENT INPUT. In this age of health care, empowering the patient and allowing them to dictate his or her course of healing is the PRIMARY GOAL OF CARE, not simply prescribing a drug or implementing a temporary intervention.

            Here is where I may begin to sound a little crazy, but I am not afraid to say, in my mind, if I was able to have a patient choose to spend 30 minutes less each day on his or her cell phone and replace those minutes with family time, yet do absolutely nothing to change diet, exercise, or drinking habits, I would consider that a successful completion of a goal as part of our adopted treatment plan, You see, this is completely independent of any changes or improvements to the individual’s physical health that can be quantifiably determined. If at the end of a visit I have a patient leave without taking any drugs to modify HTN, DM II or HLD, and they are unable to commit to any dietary or lifestyle changes, yet they choose three activities identified from his or her Nourishing Review to implement on a daily basis, I am entirely satisfied. Investment into one’s own health is the first step to positive changes and improved well-being, not drugs that artificially improve blood markers of metabolic health. Patients that improve their happiness and feel satisfied with their lives will ultimately be in the right place to adopt healthier lifestyle habits, this is a simple truth.  I like to tell people all the time, humans are generally only good at attempting one task or changing one habit a time. Add even one additional change or modify up to three habits, and invariably nothing happens, and we simply feel worse for it. So with this in mind, I encourage patients to conduct the Nourishing Review, cultivate happiness in their lives and spend at least 5-10 minutes a day practicing mindful self care- whether that is meditation, gratitude, a body scan, journaling or simply deep breathing, all of these mindful activities can center the mind and put us in a place where we can actually think and act on lifestyle changes.

              Like I say time and time again, my job as a physician is not to make you better or solve all of your problems, my job is to engage in a positive discussion of what may be your current roadblocks to optimal health, and what may be the best strategies for achieving your goals. I can support and prescribe medicines, supplements, or herbals to help you achieve these improvements, however, I cannot live your life or tell you what to expect along the way. A world of empowered patients will ultimately make for healthier patients, regardless of what treatments you actually utilize. The reality is that proper nutrition, adequate sleep, positive social and human connection, spending time outdoors in nourishing sunlight, engaging in regular movement/exercise and practicing routine mindful activities/stress reduction are the cornerstones to optimal health. This will never change and anyone that tells you of a perfect cure that does not involve these principles is downright wrong. The resources, apps, online tools/protocols used to successfully modify behavior and allow one to successfully adopt new habits following these fundamentals will always vary, and this is exactly what a capitalistic economy/society provides. 

              Gary Kraftsow of the Viniyoga Tradition used to say frequently during our RYT training lectures, one method/sequence is never right for everyone, however, one method/sequence is always right for someone. So I encourage everyone to create a nourishing list, use this as your guide for a treatment plan with your physician, and engage in a positive discussion regarding the lifestyle principles outlined above. As doctors we want to believe we are doing right by engaging in shared decision making, however, if the decisions still ultimately revolve around only our understanding of the potential treatment options, what good is it to be considered “shared?” Whether you are a patient or a healer, we can all benefit from the understanding that shared decision making isn’t the perfect answer, but that cultivating an active discussion regarding what nourishes the patient, in addition to following our fundamental lifestyle pillars, all within the context of addressing an individual’s primary presenting complaints, will provide healing and vitality to all willing to invest the time and energy to find it.

The Abbott Way: Healing Touch

Part III Healing Touch

            We all are quite familiar with the physical exam, and what would a doctor’s visit be without a proper physical? The problem comes; however, when 1) we forget entirely about doing any form of physical exam and simply stick to questions regarding history and presenting symptoms 2) we walk through the motions, simply engaging the patient in what we may feel is only a necessity in terms of charting for the EMR or 3) (more relevant to healers in training like myself) in the midst of being so concerned about acquiring and practicing a “skill” we entirely remove ourselves from the reality that we are a human touching another human, whether it is for a specific purpose or not. While these 3 reasons are not exhaustive, they readily come to mind when I think about the pitfalls when approaching a physical exam within the context of the medical encounter.

          

          In the spirit of adapting language to modify our intentions and overcome cognitive biases, this is where I suggest replacing  “Physical Exam” with “Healing Touch.” Simply taking a moment to pause, breath and re-center myself with the intention of not only eliciting a potential sign towards pathology, but providing a healing human connection through touch has been critical for me during my medical school training. If anything, I realize that my actual physical exam technique is certainly not of the caliber of a family doctor with 30 years experience listening to hearts and lungs, so why not take the opportunity to truly provide a soothing touch? With both a resident and attending physician also conducting a physical exam on nearly all patients that I see in the hospital, I am not overly concerned that the patient is being inadequately cared for in terms of the physical examination.  Now, while I have specifically pointed out encounters from the medical student perspective, the truth is that all healers, those training and who have practiced for numerous years can stand to benefit from reframing their intentions when it comes to patient contact.

            Danielle Ofri of NYU School of Medicine and Bellevue Hospital has become one of my favorite authors and speakers within the medical field and it is no surprise that in July 2014 she wrote an article for the NY Times entitled “The Physical Exam as Refuge” that got more than a few gears churning in my head when it came to changing my approach to the physical exam. To put it succinctly, her article is pure magic, and I suggest to anyone willing to change his or her perspective on the physical exam to follow the link below to read her piece.

Ofri “The Physical Exam as Refuge”

http://well.blogs.nytimes.com//2014/07/10/the-physical-exam-as-refuge/

            Her primary point in the conclusion sums it up perfectly, “So while the utility of the physical exam for diagnosing illness may not be quite as refined as it once was (though certainly still quite useful), it has become a tool of a different sort, a refuge from the intrusion of technology, a moment of only touching and talking.” Ask anyone in medicine today and the first thing that most will complain about are EMR’s and the amount of time spent dictating notes or typing and sitting in front of a computer monster. Just this past week, during Pediatric Grand Rounds at UVa, our speaker spent the entire 60 minute lecture discussing how to go about tackling the monster that is EMR and modify our hospital workflows such that we can actually be more efficient and improve patient care. While this post is not focused on the technological modifications that we could implement to allow us to operate outside of the “monolithic EMR system,” we must realize and take any opportunity to engage our patients without involving a computer screen.

            To wrap up and bring this post to a hopefully cheery and more practical ending, I will share with you a recent patient encounter of mine that was precisely what I think of when it comes to “Healing Touch”. I was seeing a young 7 year old boy with Type 1 Diabetes in our Pediatric Endocrine/Diabetes clinic. The boy had some serious energy, yet was polite beyond imagination. It became quite clear as I started talking to this young boy that his enthusiasm for life was certainly not restrained by his chronic illness. From baseball to swimming, to playing adventure games outdoors, this little guy was living life to the fullest. In addition, he told me in the most genuine manner I have heard to date- including adolescents and young adults, that he wanted to be a doctor and go the UVa School of Medicine. So I said, “Well, if you want to be a doctor, how about we start your training right now?” I had already seen him playing with the otoscope and ophthalmoscope on the wall and clearly he wanted to have these tools of the trade in his hands. So I started with him and said, “We are going to do a head to toe exam and after I do each of my parts of the exam on you, you will get a chance to do some of the same things on me, how does that sound? Eager beyond belief, he was already lying upright on the table ready for me to look at his eyes, feel his neck and listen to his heart. Step by step, I went from looking at his pupils to shining a light up his nose and in his mouth to listening to his heart and lungs, and finally gently pressing to feel the pulses in his arms and legs. While I explained to him that he would have to have more training to look at someone’s ears and at the back of the eye, he was overjoyed to listen to my heart beat, feel my pulses and watch my pupils dilate with a shining light. It was by the far the most enjoyable “Physical Exam” I have performed during my training up to this point, and amazingly enough, likely the most accurate and effective. My heart had be stolen by this one little boy, and through the course of the visit, with the attending speaking with the mother and I engaging with the 7 year old patient, we had broken down, together, the barriers of EMR and the temptation to simply go through the motions of a physical or type endlessly into the computer aka: the pit of despair. “Healing Touch” is not just an optimistic expression for an approach to human contact, it is truly a manner of providing therapeutic relief to our patients that goes far beyond diagnostic relevance. And in the end, we all might find that, as doctors and medical students, we might just benefit from a little “Healing Touch” ourselves.