Witness

Walking up to a person who looks sad but okay presents an opportunity and a risk. Do I remark that they look sad? Do I have time to engage in the conversation? Would they want me to ask, or am I being nosy? Most of the time, I know that the right answer is to ask. It's to let myself risk looking like a fool for the chance of making a connection.

 After this many years of medical training and parenthood, I am well-practiced at looking foolish. And yet, I still hang back in some kind of attempt to preserve the illusion of dignity - mine or the other person's. This is what prevents me from asking about depressive symptoms in a patient who presents to the ER for some unrelated issue.

 This is also what has kept me from looking at or asking about today's particular Jewish holiday, now some years into this project in interfaith living.

 Last year, in Jerusalem (*not* on Tisha B'Av, just while we were there), I couldn't even approach the western wall, couldn't bring myself to come close to that broken structure, that enormous symbol of loss. I could see, but not really look at that symbol of broken relationships with God, with the earth and between neighbours. I was trying so hard to hold onto my shaky vision of family wholeness that I could barely discern; it seemed far too threatening to look directly at the fractures and divisions between us:

Male and Female

Queer and Straight

Married and Unmarried

Jewish and not...

 Let alone the other divisions that I could sense in that space: divisions swirling around definitions of orthodoxy and legitimacy of conversions, recognition of spiritual expression, and the claims of so many voices to such a small piece of earth.

What is the right way to be in relationship with someone's sadness? With their loss? When do I name it, and when do I choose to allow people to just survive it by going on to the next thing? When do I take the time to look grief in the eye and let it be, and when do I mentally note the depth of the pain I cannot explore and move onto the next patient, the next task, so that the rhythms of this day don't get derailed by yesterday's losses? How do I stay in relationship with another who is in pain? How can I better set aside my own cowardice and really be present for people mourning a loss?

To look at that loss directly, to just be in the sadness of it. Not to look ahead for the healing, not to look obliquely for the silver lining at the edges, but to look directly at that pain and acknowledge it. Not to try to fix it, but to really be present for the person who mourns. To risk the chance that I will be derailed by empathy, or by my own pains. To hold them aside for later and just be present.

 I can only hope to be Winnicott's "good enough doctor". The world is so broken. I am so broken. Even if I don't feel the loss of ancient temples or a husband or mother as my own, I can see the brokenness of God's world in the cracks where grief flows through. I can be reminded to just feel that brokenness. To be present with grief, and to offer my wish for wholeness into the work that I do at home and in the world.

I can't rebuild temples, I cannot rebuild lives, I cannot even heal bodies. I can only surrender my self and my work to the faith that healing can happen amidst such brokenness. So I will send love home to my family, promise myself to listen, and to listen some more. Pour myself another cup of coffee, and sit down to learn how best to just allow for the rebuilding of broken people. (i.e. read more textbooks).

where I puzzle out some thoughts on alternative medicine **

Before medical school, I was a dramatherapist. Healing with the arts. I never believed that art cured anything, not diabetes, not ADHD, not even depression or anxiety. What I liked about it was that it's pretty. That people I worked with had a bit of time when they actually enjoyed themselves, and that it gave folks some tools to use, and some skills that they could come back to in their lives.

What sucked was parents who had been on waiting lists for years to have their kid assessed for autism, or who had been diagnosed with something or other, and who would come to me all hopeful when they either couldn't get into see a doctor or psychologist, or when the treatments offered were unpalatable or ineffective. Hoping that I had some special magic that the doctors had overlooked.

I hate to burst anyone's bubble, but improv games have no special powers.

I do think that "because it's pretty" is a good reason. I think that art is worthwhile. Folks will disagree on what's pretty, but I'm glad that there are people out there who do art. (I'm also very glad that it is no longer me).

I told myself that when I got to be a real doctor, I'd be patient and empathetic with people who wanted gentle care and alternative medicines. I was sure that I would be the hippy doctor who knew both the herbal options and the drugs.

I have 2 vegetarian kids, both of them were supposed to have been caught by midwives.

But something happened at medical school. I learned things. Like evidence. And I now agree with Joe Schwartz's claim that "If it works, it's not alternative; and if it doesn't work, it's not medicine"

And I now have a thin tolerance for woo.

Not that I am uncritical of medicine. It's screwed up in several ways:
* Diseases/conditions that rich white guys suffer from are researched and funded to a disproportionate degree. If you're a middle-aged man with crushing chest pain (or baldness or erectile dysfunction), it is far more likely that you will get excellent care than a girl with depression, or an auto-immune disease. Let alone a kid with malaria someplace else.
* Much of medicine is not actually evidence-based. There are lots of things that are difficult or unethical to study. We rely on evidence from experiments during WWII, and lots of decisions are made based on tradition that has *never* been researched. If medicine were only that which could boast good evidence, we wouldn't do much at all.
* Evidence is routinely ignored. Airline pilots have strict work hour maximums. Driving while tired has apparently been demonstrated to be like driving drunk. And yet, surgeons. WTF? Also: white coats. Grody. But we are still wearing them.
* Doctors aren't always very nice to patients. (see above on work hour maximums)

But most of those criticisms can also be levelled at alternative medicine. There is no research, it's almost entirely based on tradition, and evidence is routinely ignored. I suppose there might be nicer altie practitioners, But some doctors are nice, and if I had more time, I'd be nicer too.

One of the ways a routine disregard for evidence is irritating me this week is in the area of pregnancy and childbirth.

Like people who will eat soft cheese or drink some alcohol while pregnant, but won't get a flu shot.

This baffles me.

Soft cheese caused 6 premature deliveries and 1 stillbirth due to Listeria infections in Quebec during an outbreak last year. Pregnancy causes changes to the immune system that make listeriosis 20 times more common than in healthy adults. -- I.e. it's an infection that is almost entirely seen in pregnant people, neonates, immune compromised folks and the elderly. A stillbirth is a horrible event. Even if it's rare, it's probably worth skipping or heating the brie.

Alcohol is known to cause birth defects, and no safe consumption level can be ethically determined. Natural or no, alcohol causes birth defects.

Flu shots during the third trimester have never been correlated with anything negative for either pregnant people or fetuses. They have been shown to decrease complications from the flu in young infants.

I get that "maybe it'll make it more likely I'll get cancer or my baby will be autistic" are scary thoughts. Cancer and autism are terrifying prospects for many people. But influenza and listeria are somewhat preventable and sometimes fatal.

Death didn't used to be something that happened to old people from cancer and heart disease. Back when everything was natural, organic, traditional, spiritual or whatever, it was young women and children who did lots of the dying. Of infection. Of things that are treatable and preventable now. Dying of cancer and heart disease at a ripe old age (or even at 50) is a fantastic achievement. Way better than dying of an infection from some soil bug at a week old.

And the anti-vaccination thing. How is risking that your kid is going to die of complications of chicken pox, measles, whooping cough or even HPV (it happens, even in Canada) somehow less scary than autism, or vague "bad things"? Even if the crappy study linking autism to MMR vaccination had been good and not faked, autism just makes you weird. Tetanus will make you dead.

So what's the problem? Why do people understand that some things are too risky during pregnancy/birth, but that others are risks worth taking? Why do so many people take the bigger risks? I'm genuinely curious about the thoughts, fears, desires behind the thinking that things are good if they are "natural". Where is the disconnect between evidence and patient decision-making? How can information be communicated in a way that actually impacts choices? How can that be done without having to send everyone to medical school before they become parents? (If I'm any indicator, it just makes for neurotic parents anyway)

Coming back to the dramatherapy, I suspect it may be about stories. The emotional impact of stories about people we feel like we know influences us in ways that data isn't going to. Doctors don't hear the amazing and empowering stories about altie treatments/procedures going well. But neither does the public hear about how horribly wrong things can go. I'm open to suggestions about how things can be better communicated. With the hope that informed choice can be more often both and not neither.

** I don't have all the answers, obviously. But I can use google to check my stats if you insist. I may be very very wrong. Feel free to do my research for me if you're into that sort of thing.