Loneliness Lab

It seems fitting to talk about loneliness now. Some things are opening but the COVID19 pandemic continues to close many social spaces and requires people to not only stay home but to physically distance themselves from those who live outside their home. It’s been interesting to watch the Facebook and Instagram evolution of my online network. The pandemic started with cutesy mask photos, ebbed into anger, and now includes random questions to spark online conversation and exercise videos.

There are those who have been gravely affected by the financial toll of losing work or of illness during COVID times. But setting more extreme circumstances aside, I’ve noticed that those who seem most impacted by social distancing are those who are very extroverted, those who live alone, and those who were lonely before the world shut down. I think for many, the slowed pace of life during a pandemic has unleashed an uncomfortable amount self-reflection. I imagine many are grappling with questions like: How do I occupy myself? And, how do I feel connected to those I care about if I can’t see them?

I think the silver lining of widespread feelings of loneliness during mandated social isolation is understanding. You or I may feel isolated today, but it took the extreme circumstances of a pandemic to get us there. Many are unluckier. They feel isolated daily, on normal days, or for long stretches of their lives. Many of those people are our family and friends. I think the pandemic has shown us that people feel loneliness at different thresholds and endure the feeling in varying ways.

We can observe the evolution of our own feelings during COVID, especially if they are new feelings, in the hope that they will provide greater insight into the feelings others in our lives may have at different times.

Thinking about my career as a physician and my role as a member of a community and family, I will always know and meet people who are lonely. I think it is easy to forget how common loneliness is. It is not something that is always worn outwardly and loudly like a football jersey. Often it is subtle. And while we might not be able to drive the loneliness someone else is feeling away, each of us can be an encouraging force for others. We can be present to listen when someone else needs to share. We can be a connection in their lives.

The nice thing about pandemics is they usually end. For many, the end of this COVID shutdown will be a return to normal. It will be easier to travel and socialize again. The feelings of isolation and stress and sadness many feel now will magically lift when social distancing is no longer required for public health. But, for those who feel isolated for other reasons, the struggle will go on. You and I should remember that. Not to be negative and pessimistic but, rather, to remain in touch with people beyond ourselves. Loneliness is a powerful force. If we are feeling it now for the first time, we should take note. We should take note so that we might be more empathetic later when we are not feeling isolated and someone in our network is.

When do we need heroes?

In movies and books with simple plots heroes have capes and big muscles. They drive decked-out cars and never compromise their morals. They are always good. The problem is, creatures like that don’t exist.

Heroes do exist though. They just aren’t as straight forward and flashy as blockbusters make them seem. We don’t usually notice them. As the saying goes, “A job well done goes unnoticed.”

Heroes use their precious time in selfless acts. Those acts need not be large, but sometimes are. Heroes don’t seek acknowledgement. They don’t expect thanks. They are driven by something within. They are driven by a belief that the world can be better and that helping others is worth some personal loss.

Being a hero always comes with a price. The price isn’t always steep, but sometimes it is. No one is always a hero. None of us are like superman.

Everyone has opportunities to be a hero at different points throughout their life. Those who become heroes step up and take those opportunities to help others more often than they let the opportunity go untaken. Those who can’t act on those hero opportunities aren’t bad—they’re just human.

Few can dedicate most of their time to others. Life is more complicated than that. Personal need is real. That’s why it’s amazing when someone goes out of their way to help others often. Being a hero doesn’t come with a job title. Becoming X doesn’t mean you are selfless. Becoming X may afford you more opportunity than becoming Y does to be selfless. Some jobs are centered around helping others, but only doing the job well achieves that goal. The bigger point is that we all can be heroes. Regardless of what profession we do or place we live or activities we undertake, choices are made every minute of every day in terms of how we act and treat others. What makes some people exceptional on the hero scale is how often they take a loss and lend a hand.

I think it is important to be grateful for acts of kindness and service. Not just now, but always. I also think little acts pile up. It’s worth noticing small acts just as it is worth acknowledging something large like a life saved. We can always thank those who are kind. We can always strive to be kinder. Times like these, when so many folks are sick, make it easier to notice how others are sacrificing for us or our family. But, truth be told, people are heroes every day. Just like someone could use our help always.

The circumstance of COVID19 remind us that we can make a difference in other’s lives. But, the need for heroes will not end with COVID19, just as it did not begin there. COVID19 has given us a window to view our inner strength. It has made us pause and observed those around us. I think hard times renewed our reverence for helping. Let’s keep the value of others sacred long past when the pandemic fizzles. Because, when the pandemic ends, all of life’s other troubles will continue.

People Get Sick – Some Rise and Some Fall When Faced With That Reality

As the COVID19 pandemic continues, it’s brought out the different sides of people directly and indirectly in my life. I continue to be impressed by the many folks who fearfully, yet generously, show up to work at the grocery stores, the hospitals, and the other businesses of service that we can’t live without and can’t be run remotely. I am equally surprised by those who had the opportunity to help and instead fled. Fear is powerful. It makes those who consider themselves generous selfish.

I’ve seen great efforts of humanity from handmade protective equipment to online hangouts bringing people who haven’t talked in years together. I’ve seen folks put on fitness, meditation, and medical school classes virtually—I’m amazed how much can be done over online video chat it a pinch.

I’ve also seen people lash out at people who are sick but not dying, in anger and fear. It is easy to blame those who are sick for their illness and label them as a threat but, like everything in life, it isn’t that simple. It’s worth remembering that pandemics are not the work of individuals; they are the work of collectives. What is more, viruses and other microbes are perfectly simple and wonderfully complex. Nothing made by humans can be quite as clever as they are, so no need to find human scapegoats to blame for a disease they could not have made.

The idea of not knowing if someone has an illness you can catch is scary. But, that’s the nature of many infectious diseases, not just COVID19. And while many of us born in America do not necessarily think of potentially deadly infectious diseases often, that is a luxury people in different parts of the world do not have. It helps give perspective to remember that millions of people die of infectious diarrhea and malaria, for example, each year. And their plight isn’t one the larger world community has committed to ending. It will go on…perhaps as long as humans exist.   

We are strained by social distancing today. Yet, we carry on because we have a sliver of hope that by limiting our interactions we can end COVID19. We believe that we can limit the number who die or get sick. As we hold on to these ideas, we should also remember that social distancing need not make us less compassionate for others. Protecting ourselves does not require that we compromise kindness. I would hope that we all see this time as an opportunity to discover creative ways to help those who are sick while also protecting those who aren’t yet. The infection count is not a numbers game of distant people we don’t know, it is happening right here, today, and to real people with families and a story. Just remember that those numbers you’re refreshing are humans. Don’t forget that, because if you do you just might become apathetic. We have a pandemic to end. It will take the actions of each of us to be successful. Stay engaged.

Why I Go Back for Each Shift

Not long ago, I walked into an emergency department room (a cube defined by some walls but mostly curtains) to place an IV. An elderly man was on the hospital stretcher. He was there with his son. I began my normal banter—introducing myself, explaining why I was there, and narrating what I was doing as I went. The man might have asked me about my name, about 30%-50% of patients do because it’s unique. He might have asked about my necklace, it’s a wolf and about 25% or so of my patients ask about it.

“I’m going to raise the bed so I don’t have to stoop,” I said. “I need my back for many years to come.”

The patient and his son laughed. “You know what you need, music. Do you listen to music?” the patient asked.

“Not here, it’s not the right place. But, I like to dance, so I do listen to music,” I said.

“My wife liked to dance. She died a year and a half ago,” the patient said.

“I’m sorry to for your loss, sir,” I said.

“We were together 60 years,” the patient said.

“That’s amazing! I don’t think I’ll be with anyone for 60 years at this point. Did you take her dancing?” I said. I maintained a jovial tone because he seemed merry when he mentioned his wife and dancing.

“I did,” the patient said. I looked down to find him crying. I paused and put a hand on his forearm. Giving him a squeeze. I’d recently visited my grandmother. A big part of our visit was discussing how my grandfather, who’d died 2 years prior, was still with us.

“How lucky she was to have you take her dancing! How amazing it must have been to have had so many years together,” I said.

“Sorry, I always cry when I think of her,” the patient said. He half-shrugged and looked away.

“It’s okay. She’s with us still and you’ll see her again, sir,” I said.

“I hope so,” the patient said.

“I know you will,” I said.

The patient and his son nodded. The tears ebbed. I placed the IV. All humans have stories. Sometimes they find space to share them when they visit us in the emergency department.   

Below the Surface

A pre-holiday Paraguay visit is to blame for the blogging hiatus this December. It had been 2 years since I last visited Paraguay, the country where I lived for 27 months while serving as a Peace Corps volunteer. My Paraguayan friends were amazingly generous. They fed and housed me. They brought me on adventures around their lovely country. We spent hours chatting and eating—recalling old times, catching up on times spent separately, and dreaming about the future. I was reminded of how easily Paraguayans show affection—through food and time given to others. I was reminded, as I’ve been hundreds of times, of how lucky I am to have stumbled upon my Paraguayan community and how spoiled I feel to enjoy the company of my Paraguayan friends.

During this visit as I walked back from church one evening, after attending the celebration that marked the closure of the Christmas in Families (which is where people go to family homes to share passages from the Bible and prayer for 9 days in the month leading up to Christmas), I was reminded of a story shared at my favorite Paraguayan mass years ago. I don’t remember the occasion for the mass or who gave the sermon, but I remember the story the priest shared. I think, regardless of religious beliefs, it reminds us that we must look carefully and patiently to see what’s hidden below other’s facades. It’s what was hidden below the surface that made me fall in love with Paraguay. It was the journey of looking deeper at the land of Guarani that taught me resilience and showed me how to find hope no matter the circumstances. Here’s the story from that mass:

A Ride in a Car

There once was a young man whose rich brother gave him a fancy new car. The young man was so proud of his car, he loved to drive it all around town. One day, the young man had to park his car in a poor neighborhood while he was running an errand.

As the young man walked back to his car after finishing his errand, he noticed a boy circling his car. The young man worried that the boy was trying to find a way to enter or damage the car. The young man hurried to his car and asked the boy what he was doing by the car.

“I’m just looking at your car! It’s so nice. I’ve never seen one like it. I hope one day I will have a car like this one!” the boy said.

The young man explained that his brother had given him the car. “Wow!” the boy said. The boy and the young man talked about the car at length. The young man scolded himself for thinking the boy had been up to no good.

“Since you don’t have a wealthy brother to give you a car, would you like to take a ride in my car with me?” the young man asked the boy after they had talked for some time.

The boy jumped with excitement and jumped into the car. They drove a little way, then the boy asked if the young man could pause in an alleyway because the boy had to deliver a message to someone. Once they stopped, the boy asked the young man to wait for him to return, promising to be right back. The young man agreed to wait for the boy, but again had doubts. He wondered if the boy was getting someone to help him steal the car. The young man waited nervously, thinking of all the bad things that could happen. He thought about leaving before the boy returned, but something made him wait.

After several long minutes, the boy appeared in the doorway of a building in the alley. The young man squinted, the boy had something in his arms. The boy approached the car. Once the boy was close to the car, the young man noticed that the boy had a sickly, disabled child in his arms. “Sir, this is my brother! Can he take a ride in the car too? I want to show him the car. I have just promised him that one day when I am rich, I will buy him a nice car just like yours.”

The young man agreed to take both boys for a ride. The young man scolded himself not only for distrusting the boy, but for thinking the boy was envious of his car.

On Not Becoming Jaded

One night a coworker in the emergency department, who also aspires to be a doctor, asked me if I was worried about becoming jaded as I worked in health care. I answered confidently that I wasn’t worried about becoming jaded, my hope for humanity waning, or burning out like so many medical professionals do. He was skeptical, but I am certain of only that one aspect of my future.

Defining Jaded

Especially late at night when most patients are tired and grumpy, the drunks roll in after exhausting the bars, and the patients held for mental health evaluations decide to spend the early morning hours holding yelling matches that involve nonsensical accusations against staff, it’s easy to see how one can grow tired of working in a hospital (and specifically the emergency department). In medicine, we take care of everyone, even if they’re jerks to us, because the fundamental principle of health care is that we serve all people.

Not so long ago I was greeting patients in the waiting room at the emergency department. We had around 20 folks waiting for rooms, the rooms weren’t changing over, and the wait times for many were over 2 hours. That’s a recipe for an unpleasant experience as a greeter, and the recipe was rich that night. I had a parent repeatedly insult the staff, including me, and ask why we hadn’t brought her child to a room yet. That was annoying, but manageable. What got to me was when she stormed up and demanded to know why we brought back “a drug addict” (her words, not mine) before her child. Her argument was that her child had a bright future while that person was a lost cause. Of course, I couldn’t tell the hysterical mother just how awful it is to watch a person go through withdrawal shakes and then seizure. That’s something you can only understand once you see it. I couldn’t tell her about the alcoholic who came to us one night shaking so badly he couldn’t drink water from a cup. I couldn’t tell her how he had looked me in the eye and told me he wasn’t human anymore. That mother was choosing to believe him, but I knew that that patient was human even if he didn’t feel like he was. That angry mother in the waiting room clearly had never seen a person beat an addiction—winning the daily fight to not give in to a drug or alcohol for years. I have.

It’s not the job of medical professionals to pass moral judgment. Sometimes we are weak and tired, and we do judge our patients’ life choices. But if we were to slip into a world where we used our personal morals to decide who should receive care, we would betray the heart of medicine. Medicine was never meant for only a select few.

In my view jaded is another way to describe losing empathy. There are many presentations—impatience, anger, and hating work to name a few. These feelings come when we are too tired and too worn out to see patients as humans. They come when we no longer find joy in the small things about the job that are awesome. And jaded becomes the norm when we give too much. It’s easy to work hours no one else would dream of working when you’re in health care. Each hour is rewarding because we help someone feel better, but the hours take a toll on the giver.

Considering all the above, how am I so certain I won’t become jaded?

  1. My empathy comes from selfish sources, so I don’t expect that it will fizzle. The first source is curiosity and the second is a love for stories and puzzles. Each human has a story. Each sick person is a puzzle. The curious mind can’t help but wonder about the story plot and the answer to the puzzle. These two factors are some of the main reasons I veered down the medical path in the first place.
  2. I know that I’m brave enough to step away and recharge as well as to shake things up when caring for patients under specific conditions becomes wearisome.

How do I know I am brave enough? Paraguay. While living in the land of Guarani, I cultivated an ability for self-reflection and the bravery to face fears because they were required to survive the Peace Corps. Paraguayans also showed me the value of letting yourself be still. In America, we are so determined to be productive we schedule every moment. I think running around all the times makes everyone miserable no matter what their profession. I also think those who become jaded forget to reflect and change. They fail to see that their job is draining them until it’s too late and, then, they lack the courage to change their work so it’s fresh again. It comes down to the best professional advice I was ever given. When I asked a presenter in one of my undergraduate classes how she knew when it was time to leave a job (she had an awe-inspiring, lengthy job history) she said, “You’ll know. You know when it’s time to leave.”

She was right. We do know when it’s time to mix things up. The hard part is taking the steps to act upon what we know. But, if we do take those steps, then jadedness can never catch us. The moment she gave me that advice, years ago now, I promised myself I’d be strong enough to change my course whenever I “knew” it was time. That strength sent me to Paraguay and brought me back to Vermont. So, no, I’m not worried about becoming jaded. I’m just excited to see where my adventures in medicine bring me.

Human Side of Medicine

Not so long ago I worked a code (cardiac arrest = patient’s heart stops and they neither have a pulse nor are breathing) in the field. The patient was middle-aged and had a complex medical history. The patient’s father, visiting from out-of-town, found him unresponsive, started compressions, and called 911. We did all we could—did compressions, ventilated, pushed epinephrine and other medications, and analyzed for a shockable rhythm. As we worked the father knelt at his son’s head. The patient’s fiancée sat outside the house. As it became clear that we were not getting our patient back, my crew chief reviewed, outload, all we had done. She asked us if we could think of any other interventions we hadn’t yet done and then she engaged the father, explaining why we were going to stop resuscitation. Once we had stopped she went outside to talk to the fiancée.

As heartbroken as the patient’s family was, they were calm when we stopped CPR. They had seen us sweat over their loved one, try everything we could, and ask for suggestions. We included them in our decision to stop our efforts. We lingered after our care was done to answer questions and offer condolences. This call showed me how it is within the pauses between action that we connect with our patients.

The human side of medicine comes through when we take time to ensure our patients understand what is happening and our plan for treatment. It comes when we include our patients and, when appropriate, their family in decisions about their care. And it’s completed by taking a moment to share their feelings, whether of relief after a successful procedure or sorrow after the loss of a loved one, before we scurry on to our next case.

Amid medical histories and assessments of signs and symptoms that lead to differential diagnoses it can be easy to let the presence of a disease or condition consume our attention. We can focus so intently on the disease that we forget humans bear the illness. But, below the clammy skin and wheezing is a person with a family and life experience just like you and me. And, what the patient will remember from their time during the flurry of a medical crisis is how someone treated them. It’s the offering of a kind word or an act of kindness on the worst day of someone’s life, not just the hope and likelihood that we have a cure, that defines good medicine. I try to remember to take advantage of the pauses by offering a blanket or bit of conversation to my patients. There aren’t always many pauses in my day, but when there are I don’t like letting them go to waste. It’s in the shared moments between points A and B that we build our humanity, but we must be attentive or we’ll miss the opportunity.

Prayers

Trying to get into medical school is a bit of a slog at times. I’ve been lucky to have people support me during each leap through the hoops of fire. Recently, I’ve had a few folks tell me they’re praying for me, and then qualify their statement by saying they know not everyone believes in God. I was surprised that they felt the need to acknowledge I may not believe in their God.

In Paraguay, my adopted mothers prayed for me almost every time I left their house for mine (so almost daily). I am and was always thankful because of the sentiment. I believe it’s tremendously generous and kind when a person cares enough to think of me, to support me, and then to ask for help on my behalf—whether they communicate with their God or simply wish me luck.

In America, I think we publicize the extremes. I see politics radically divided. Political opinions are often based on extreme visions of how things should be or a rebellion against others’ interpretations of right and wrong. These hardline stances don’t allow for more than one opinion to thrive. To me, holding an unweaving “I’m right and they’re wrong” stance is limiting because it creates rigid definitions of aspects of life that neither the State nor another individual can interpret for me or you.

I attended church often in Paraguay because the church was the center of everything in my Paraguay community. I did not and still do not believe in the God of that church. But, I could feel how strongly my Paraguayan friends and family believed in their God. To them, their God was not only the source of life and reason for living but also the definition of love. Going to church allowed me to better understand how they saw the world. The Paraguayans who welcomed me into their lives knew our views of God were different, and they still embraced me as a dear friend. They included me in their secular and religious activities, answered my millions of questions that began with “Why?”, and they accepted it when I sat out from certain rituals because they were “too much for me.” What these shared experiences taught me was that we do not need to have the same definition of life and love to build friendships. We just need to be comfortable knowing that even though we see eye-to-eye on some things and share some history, we also hold very different views of certain aspects of life.

My hope is that someday the US won’t just be tolerant, but that each of us will be comfortable standing side-by-side with folks who are different from us, be strong enough to ask questions to learn more about how those different people see the world, and be proud enough of our belief system to follow it without expecting others to pledge allegiance to our view.

When I think of those who prayed for me before I took the MCAT, I’m thankful. Perhaps their prayers didn’t mean to me what they meant to them, but I think we share the knowledge that what I was doing was hard and whatever assistance they gave would be part of my success.

Christof

There’s a guy, Christof, in my neighborhood who collects returnable bottles from the recycling we put out on the corner for the city each Friday. One day when my father was visiting me, he struck up a conversation with Christof. One of Christof’s daughters went to college and the other didn’t–Christof joked that the daughter who finished college doesn’t have a job while the other one does. He collects bottles to help both of them.

I don’t often drink anything that comes in a redeemable bottle, but since chatting with Christof, my father started saving his seltzer bottles…he drinks a lot of seltzer. My father brings the bottles to my house (even though I live about 2 hours away) when he visits so I can give them to Christof.

I work nights, so it’s challenging to put out the recycling before Christof passes. One morning I saw him, though, collecting from the neighbors. As he walked by, I ran out and asked him to wait a moment. He paused, a smile lighting his face. I handed him 2 huge trash bags of bottles I’d squirreled in the garage for a few weeks. He thanked me a million times, wished me a blessed day, and was on his way.

At first, I thought my father was ridiculous for saving bottles for Christof. But, that morning when I saw Christof’s face after I handed him our bags of bottles, I realized that my father was right. We can get so caught up in all the big things we should do that we do nothing. Christof reminded me that it’s the small things that add up in the end. And, luckily, life is full of small things.

Empathy – Critical and Elusive

Helping others is dependent on your ability to be empathetic, not just your knowledge and skill. In the world of health this may seem obvious, however empathy often gets lost in the complexity of the health care system.

I began pondering the sometimes dire absence of empathy in health care after watching Peter Attia’s TED Talk “Is the obesity crisis hiding a bigger problem?.” In his talk Attia discusses the practice of blaming obese patients for their health and questions the current way we think about obesity. He starts the talk with a story about a patient whom he treated. He explains that he provided exemplary medical treatment but failed as a person. He says he failed as a person because rather than being empathic he subconsciously blamed the patient for her condition.

In today’s U.S. culture it’s easy to blame people for health conditions like their weight; it’s easy to blame them for all their unhealthy choices. But, what does blaming achieve?

A large portion of my current work is in substance abuse prevention. Empathy is sometimes so hard. When I read the latest horror story about drug use, it’s hard to stop thoughts like “How can ANYONE start meth? There’s just no upside.” But, thoughts like that don’t help prevent anyone from using drugs and they certainly don’t help people trying to recover from addiction. Again, it’s so easy to blame people for using drugs. But if we want to help we must get beyond the finger pointing. We must acknowledge that we are trying to help individual humans, and that those individuals are struggling. Their struggle is their own, but we do not have to be another barrier, we can be a positive force.

I was struck by the power of empathy after watching Eleanor Longden’s TED Talk, “The voices in my head.” She talks about her struggle with schizophrenia. When she was first diagnosed it seemed her world would end. However in her fight for peace she got help from someone who told her she could work with the voices in her head. He believed in her and her ability to lead a safe and happy life. He was right. She was able to master the voices in her head. By simply offering support and understanding he changed the course of her recovery.

Health is charged. Health is mysterious. Empathy is simple. But in its simplicity it is easy to overlook. Don’t.