The Best of…. Creative Writing by Family Physicians 2003 Award Winners Presented at the 2003 STFM NorthEast Region Meeting By the Family Medicine Education Consortium www.fmec.net Sponsored by the Family Medicine Education Consortium The FMEC Creative Writing Project In 2002, the Board of Trustees of the Family Medicine Education Consortium, Inc. created an award to encourage and recognize creative writing by Family Physicians. The idea was to promote the writing of prose and poetry that draws upon the experience of teaching/learning or practicing Family Medicine. The criteria for the awards process are as follows: * The submission must derive from the experience of teaching/learning or practicing Family Medicine. * Faculty, residents and students and all Family Medicine clinicians in the northeast region of the US were eligible to participate. * Stories, poems, and other forms of unpublished fiction or non-fiction writing were welcome. * A panel of reviewers composed of Family Medicine faculty and creative professionals experienced in manuscript evaluation was established. * Each submission was evaluated with an eye to its critical reflection, emotional honesty and technical merit. A blinded review process was followed. * Submissions could be no longer than 1500 words. Pieces previously published at a national level (magazines, journals, books with a national circulation) were not eligible for this award. * An author could submit a maximum of one poem and one prose piece. Creative Writing Award Project 2003 Review Committee Julie Schirmer, MSW (Chair) Maine Medical Center Family Medicine Residency Portland, ME Bertie Bregman, MD Columbia University, Center for Family Medicine New York, NY Andrea Gordon, MD Harrisburg Hospital Family Medicine Residency Program Harrisburg, PA Paul Gross, MD New York Medical College Department of Family Medicine New York, NY Ms. Diane Guernsey New York, NY Ms. Courtney Spencer Portland, ME Richard White, MD Burlington, VT Administrative Support Laurence Bauer, MSW, MEd Ms. Lisa Schwieterman Ms. Vicki Battin Questions about this project can be Directed to Julie Schirmer, MSW at schirj@mmc.org or Laurence Bauer, MSW at Laurence.bauer@sbcglobal.net The Best of . . . Creative Writing by Family Physicians 2003 Award Winners Table of Contents Page Prose Winners 4 - 8 1st Place: Pay Attention . . . . . . . . . . . . . . . . 4 2nd Place: Learning About Death . . . . . . . . . . . . . . . . 6 Honorable Mention: Suspended Animation . . . . . . . . . . . . . . . . 8 Poetry Winners 10 - 11 1st Place: Anatomy Lesson . . . . . . . . . . . . . . . . . . . . 10 Honorable Mention: Mr. Hannah . . . . . . . . . . . . . . . . . . . . . . . . 10 Honorable Mention: Transplant . . . . . . . . . . . . . . . . . . . . . . . . . 11 Prose 1st Place Winner: Pay Attention Our patient sat on the table curled around a big ball of a belly cradled between her short legs. She wore her gray hair long, straight and limp, in the same style she’d probably worn for thirty years. Her fingers were adorned with a multitude of rings, each gouging into her flesh. Alice not only gave off the strong odor of cigarettes, but also emitted a subtle smell, acrid. Her skin looked slick. When I introduced myself, her hands felt damp. Her bare feet, peeking out from under the sheet, puffed up so her toes looked as if they’d been pinned on. “What brings you in?” I asked. “I can’t breathe.” Alice demonstrated this with a wheeze. “How long has this been going on?” “One week.” “Any asthma?” “I haven’t been to a doctor in 28 years.” “I noticed you smoke. How much?” “Pack to two packs. Depends.” “Any alcohol or other drugs?” Her son’s girlfriend, who stood at the head of the table, behind Alice, nodded vigorously. “I’ll have a beer or two after work.” “OK. Let me take a look at you.” I washed my hands and thought at the sink: anxiety; depression; alcohol abuse; chronic bronchitis; something cardiac. That belly could be ascites. I turned and faced Alice. She looked scared. “I’ll tell you everything I’m going to do, before I do it. I’m going to start at your head. First, I’ll...” “I don’t need a tour.” “OK.” I felt her scalp and neck. No lumps. Each cheek, where it merged with the bridge of her nose, bore the tattoo of an alcoholic. “How long have you had these?” “What?” “These little red blood vessels on your face?” “Hadn’t noticed them.” Her lungs sounded congested, with generalized wheezing (cigarettes) and coarse breath sounds (fluid) in the lower fields. Her arms were thin, compared to the rest of her. Her palms had deeply etched red creases—“palmar erythema”–symptomatic of liver disease. When I asked Alice to hold her arms out in front of her, her hands shook in a fine resting tremor. I asked her to put her wrists up, as if she were a police officer ordering me to stop. She did: no liver flap. If her liver were far gone, her hands would flap uncontrollably. Did I have her do it the right way? “Could you do that again?” “I could, but I won’t.” “Fair enough. Can I look at your belly?” Fine. I’m not lying flat, though. I can’t breathe when I lie flat.” “How about if I raise the head a bit?” She lay back wearily. “I really appreciate your cooperation.” 4 Alice exposed her globe of a belly. She had caput medusa, raised veins in the wild array of Medusa’s snake hair around and above her belly button. I tried to elicit a fluid wave; I couldn’t. But her skin looked tight, the way it does when expanded by fluid. When expanded by fat, it looks softer, like dough. I thumped on her belly to find her liver edge, but I couldn’t. Was fluid in the way? Had the liver already shrunken? Alice’s legs appeared withered. Had her body used its own protein to fill in nutritional gaps? Her feet were edematous. Was her heart inefficient? Did her liver fail to produce enough albumin? Both? “OK. I’m finished. We’ll need to get some blood work. I’ll be back.” I relayed my findings to the resident, who repeated parts of my exam: her heart and lungs, her liver. Alice wouldn’t look at him. “OK, Miss Dunne. We are going to admit you,” Matt said. “We need to work up your liver. We also need to check your heart. Since you haven’t seen a doctor in more than 25 years, we need to begin at the beginning. How does that sound?” “Like a bad idea. I only agreed to the ER. I didn’t agree to be admitted.” “Miss Dunne,” I added gently, “I feel confident we can figure out why you haven’t been feeling well. We can get you some medicine, find a doctor for you to see regularly—“ “Who says I want to see a doctor regularly?” Her son’s girlfriend stepped forward from behind the table. “Mom, I think you should give it a try. You’ll feel better.” “OK. Fine. I can tell you all are going to gang up on me until I agree. So admit me. Go ahead,” Alice said, her face looking a mixture of resignation and relief. “Do you know the most important order we need to write for Miss Dunne?” Matt quizzed, then answered: “CIWA protocol. And if you don’t put her on CIWA, what happens?” “She can die. Alcohol withdrawal can kill patients who go cold turkey.” “Ten points. And the other things we have to worry about? That she might leave AMA. And that we can’t talk a nurse into taking care of her.” Miss Dunne stayed with us for 10 days. She hated her roommate, so we found her another. She hated the food, so her son brought in McDonald’s. She hated Matt, whom she called a Nazi, even though he was Latino. I visited her whenever I could. She would motion for me to sit on the side of her bed instead of in the visitors’ chair, so I did. I was “managing” her nutrition. Alcoholics are renowned for terrible nutrition, forgoing food for booze. We tried to get protein into her in various ways, but other than Big Macs, she wouldn’t eat any. She’d ask if I wanted the yogurt off her lunch tray, because she wouldn’t eat that “granola shit”. I would take the yogurt, eating it as a late-night snack. I felt it made things more equal between us: I helped care for her, and she, by feeding me, helped care for me. Her abdominal ultrasound proved that her belly was full of fluid. A CT scan of her belly revealed no tumor in her pelvis or liver, “just” cirrhosis. We made plans to discharge her. I tried to hook her up with Alcoholics Anonymous, or a therapist who specialized in substance abuse. Alice would have none of it. She was furious 5 with her son’s girlfriend, refusing to see or even speak to her, after she told Alice that she’d thrown away all Alice’s booze. So we were releasing her back to her old life, with minimal support, no promises from her that she would do anything to improve her health. We had to let her go. I went in to say good-bye. Alice gave me her phone number and a stuffed dog, holding a heart. “This is for you, for giving me your heart,” she said. I hugged her and wished her well but I refrained from giving her my home number; some basic instinct told me not to. The last day of the rotation was upon us. One last meeting and we were done. As I was going in to the conference, Matt motioned to me. “I have something to show you,” he said. “A letter from Miss Dunne.” I followed him down the hall, imagining a letter full of praises for my heartfelt care. Matt handed me the letter, typed on yellowed paper. He stepped away from me while I read. The letter was addressed to Matt. I can’t remember the exact words. But I remember the gist of them: I was deceitful, untrustworthy, unfit to be a doctor. I had misled her, stood in the way of her getting better. The attending called out into the hallway for me to join them. “Why?” I asked Matt. “Why did she write this? And why are you showing it to me now?” I turned to go, crushed. What had I missed? Even though my rotation was over, I tracked down Matt the next day. I needed more closure than those few phrases in the hallway. “Why did you show me that letter then? What did you want me to learn?” I asked. “Don’t get too close to patients. Keep a professional distance at all times.” Sit in the visitors’ chair, not on the side of the bed. “But what if I don’t want to?” “Then be prepared to receive letters like this. Or have your supervisor receive them.” “What do you make of the letter?” “It confirms my medical opinion. She has borderline personality disorder, as well as alcoholism. This letter is an example of ‘splitting’, which is what people with BPD do. When a patient tells you they hate the resident, but they love you, pay attention.” He was right. I was vulnerable particularly then, when I was always coming up against Matt’s seemingly vast medical knowledge compared to my paltry collection of facts. He had knowledge; I had compassion. And now that I’m a resident? I ask to care for alcoholics. I remember best Alice’s fear, her isolation. I distilled Matt’s advice to this: Pay Attention. And I still sit on the side of the bed. Mary Ready MD, Main-Dartmouth Family Medicine Residency, Augusta, Maine ???????????????? Prose 2nd Place Winner: Learning About Death Clearly all patients die, but somehow that wasn’t obvious to me when I started my training. During the first two years of medical school, the facts came at us with blistering speed and the answer to every question was either a, b, c, d, or e (including what to have for dinner). Then came the autopsy. 6 It was one of the many assignments in our physiology course. I was neither looking forward to it nor dreading it - just one more thing to do. A check box with the words ‘attend autopsy’ next to it, a vague sense of annoyance that this activity could not be neatly scheduled into my already too busy existence. The pager went off and I headed to the morgue with my classmates. What I experienced there will be forever indelibly imprinted deep within me. As I entered the room, the first thing I saw was a naked dead woman my grandmother's age having her chest sawed open. I remember the curve of her hands draped off the gurney and the exact color of her chipped pink fingernail polish. I remember the smell of death and burnt bone that was so different from the formaldahyde stench familiar from gross anatomy. I remember wanting to leave or pass out or cry or vomit and expending absolutely all of my energy to do none of the above and pretend that the person lying there was just a body and an interesting learning experience and not a woman with a family who had been alive that morning. I remember that her name was Madeleine and being oddly disappointed knowing that I would never be able to use this name that I loved for any of my future children. I remember being so overwhelmed and underprepared that I considered leaving medical school for good that day. Soon after came my dream. In it, I had to do a rotation on the death ward. To get there, I had to go through many sets of double doors. The halls were dark and deserted except for a lone, silent, stone-faced guard at the last set of doors. Beyond him was a brightly lit room (the same room where we had attended the autopsy) filled with many people working industriously. Someone opened a huge freezer on one wall and I saw rows and rows of heads and feet - dead people lying down, waiting for anatomy class. I fled back down the dark hall. In a room off the corridor, there were four beds with very sick, very old people sleeping. Some of them were in large plastic garment bags. Depending on how sick they were, the bag was placed at the bottom of the bed or it was up around the waist or at the neck of the person/patient. They all had very sweaty legs in their bags. A tall female doctor in a long white coat was working there. She was envious of me that I could leave and she could not. After that, I became scared of even being in hospitals, which was problematic as an about-to-be third-year medical student. I was truly afraid of seeing dead people and was on the watch for them everywhere now that I knew there was a morgue in the basement. I remember my racing pulse and sweaty palms outside the gift shop in the lobby of the hospital when I spotted a stretcher with something on it covered by a white sheet, my relief when it turned out to be linens. My first funeral. I remember sitting by the little girl's open casket with her doctor and hundreds of others, all of us crying. I cried for Madeleine, for me, for this girl and her family, for her doctor, and for my future patients who would die while I was their doctor. Those patients have since been numerous and each has given me a gift in their passing. How to do a paracentesis, eight times in eight days. How to gracefully accept a gift of gratitude, to feel very uncomfortable that it was cash, and to buy a plant that I still have and to donate the rest to charity in the patient's name. How to open the window so a soul can leave. How to call a stranger in the night and tell them that their mother has died. How to teach students and residents to do these things well but to never neglect themselves the way I had at my first autopsy. When my grandmother became gravely ill, I was a new attending and that dream from medical school came back to me. Only then, after many more years caring for many more patients, could I understand it. The doctor in that room had been me at the end of my training. Anxious and afraid. Would I be able to handle the immense responsibility of caring for dying patients? How was I going to balance seeing all this death with leading my own life? I found out when my grandmother died. 7 She was scheduled to have a CT-guided biopsy to get a tissue diagnosis for the mass on her lung. She had her IV in, the radiologist there and had actually climbed up on the table in her gown before she decided that she did not actually want a biopsy or any further treatment. She climbed back down, thanked everyone for coming, apologized profusely for taking up their valuable time, and went home. Then, after years of reminding my family that I was a doctor and in the hospital because that was where I worked and not because there was something wrong with me, suddenly I was the expert. My patients, in their own dying, had given me gifts to then give to my other patients and to my own family. During my training, I had gone from being terrified of death to being awed and comforted by its many blessings and celebrations. My nana died two months later in her own bed surrounded by family including my own infant daughter who loved to play with her oxygen tubing. Some of her last words were “Thank you all for coming.” Nana shared the end of her life with us. Out of respect for my medical education, she donated her body to a medical school. At the beginning of her death, I’m sure that she was someone else’s ‘attend autopsy’. Julie S. Taylor MD, MSc, Memorial Hospital of Rhode Island, Brown Medical School, Pawtucket, Rhode Island ???????????????? Prose Honorable Mention: Suspended Animation Early last year I celebrated the third anniversary of my kidney transplant. I knew even then that the kidney donated by my brother was failing rapidly due to chronic rejection. Three months later I missed my first presentation at a national STFM meeting in order to start peritoneal dialysis for the second time. When I finally adjusted to dialysis, the vomiting started. All summer long, I spent two or three days each week vomiting. Just when I would start to feel better, it would all begin again. I could believe the significant mortality statistics for end-stage renal disease. Dying seemed a reality. Each time I stood up, the world faded to gray. I endured it until my nephrologist and I identified an unusual reaction to erythropoietin. Finally the vomiting stopped. Now I am regaining my strength. I can even walk with my ten-year-old daughter without constantly searching for the next place to sit. Yet I retire early to bed to begin my nightly dialysis marathon. After years of sleep deprivation, I never expected ten hours each night confined to bed on dialysis to be such a difficult task. Still my light burns on for hours as I read book after book. I am becoming once again the late night person I had always been. My commute to the hospital takes me past a state park and several lakes. The drive through woods and fields allows me time to plan for the day or to relax and prepare for the return home. In spring, the flowers in the apple and peach orchards are breathtaking in the moonlight after a late evening at the office. Now I travel those roads as I visit my own physicians. The scenery remains the same, yet the destination represents a dramatic change. Instead of being back to work, I am on “The List.” I carry my beeper although I have not been on call for over a year. I am aware that at some point the phone will ring or the beeper will sound and it will be “The Call.” I am burdened by the thought of the future tragedy to be suffered by my donor and my donor’s family. I am grateful for their ability to consider others at a time of such great personal loss. I am conscious of the fact that the daughter of a patient had the same operation that I await and she never woke up from surgery. I look at the statistics. I know that should not happen to me. And so I wait. I continue to lead a resident Balint group with one of my former colleagues. Week after week the cases seem to involve patients on disability. I sense that the residents are struggling with the idea of me being disabled. I 8 am sure I look the same and I try to maintain my usual positive demeanor. Yet I struggle with the concept of disability myself. I worked the entire year I was on dialysis before my first transplant. Now on a very good day I feel dishonest for not being at work, but the very good days are rare. On a typical day I can manage one medium task before pausing to rest. A simple trip to the grocery store exceeds my limits. A one hour Balint group is both preceded and followed by physical rest. Hospital rounds or a session in the office is an unattainable goal. My physical body is unreliable for the demands of my job no matter how capable my mind feels. And so I wait. How do I plan for such an uncertain future? The average wait for my type of transplant was four months when I was placed on the transplant list. I was on the list for three months before I could no longer continue working. At that point, I envisioned surgery in the near future and a quick return to work. It has been a year since I left my practice, but my professional life will stay on hold a little longer. I hear stories of people who waited five, seven, or ten years and I wonder. And so I wait. When I was so ill last summer, I was desperate for a transplant. It was essential for my survival. Now that I have reached a state of equilibrium, the decision seems less clear. I could almost continue life on dialysis indefinitely. The transplant will mean a better quality of life and a longer one as well. Or will it? And so I wait. Another summer is coming. The hospital wants an update on the anticipated length of my medical leave of absence from the staff. My extended family is holding a reunion in a distant state. The health insurance from my former job extended through COBRA has less than a year remaining. My daughters want me to take them camping with the girl scouts. I need seventy hours of CME this year to qualify for re-certification in my specialty. And so I wait. It is the day-to-day planning that is getting complicated. Should I do my midday dialysis exchange before or after lunch? Do I have enough energy today to attempt leaving the house? Will I last through the meal if I go out to dinner with my husband? Should I sign up to give that lecture next month? Should I make the trip to visit relatives out of town? Should I register to attend that CME course? What if I get my transplant? What if I do not? And so I wait. I feel life rushing forward all around me and yet I do not feel myself rushing forward with it. I am waiting. Another day passes. Another dialysis bag empties. Another night is spent on the machine. Another week is marked on the list. Another month of my life goes by. And still I wait. The spring weather outside is warm and inviting. The orchards are in bloom. I find myself alive, yet not able to live fully. How long will I remain in suspended animation? Suzanne VanDerwerken MD, Underwood-Memorial, Family Medicine Residency, Woodbury, New Jersey ???????????????? 9 Poetry 1st Place Winner: Anatomy Lesson You think you have seen death before, how the dead look so dead when they’re dead, but pulling back the stainless cover, you are unready for that form as gray and cold as a late November day, wet, with limp brown stems of day-lilies, like lifeless hair hanging over unhearing ears into the silver trough. Perhaps it would be easy to begin to view yourself as a doctor here, in a Rembrandt pose, bending over unbeckoning fingers, but the smell of formaldehyde is overwhelming, and you feel you are only pretending, violating the only part of this person still left on earth. And where does all this fat come from? Globules stick to your instruments and stain your atlas with greasy smudges, so although you take care to wear your apron, you find one of the yellow bastards on your sock as you cross your legs hours later, after lunch in the cafeteria. Is that your respect for the dead? Or does it come years later, after you have filled a couple of graveyards with corpses in silent decomposure? Their spirits visit you in quiet times, as you sit alone in your car, waiting, or awaken, sweating, just after three. The hairs on your neck arise, tingling, as the dead tell you things, and you listen. Robert S. Fawcett, MD, MS, York Hospital Family Medicine Residency, York, Pennsylvania ???????????????? 10 Poetry Honorable Mention: Mr. Hannah You’re breaking my heart every time we go in to draw your blood put in a line change your ET tube And your blue rimmed eyes leak tears you are unable to wipe (unable to breath, eat, move) So angry when we cannot understand words mouthed over the tube in your mouth down your throat You pull your hand away in disgust When I sometimes caress it for comfort (as I pull from my lover’s touch when it seems more for the feel of my soft skin than me) I don’t know, Mr. Hannah what we are doing, If you will thank us one day or continue to curse us, unheard, a grown man reduced to diapers and tears Jessica Small MD, Tufts University Family Medicine Residency Program, Brookline, Massachusetts ???????????????? Poetry Honorable Mention: Transplant The week after her daughter’s transplant surgery my patient came to the office. Her daughter was dying. She held my hand as she wept and told the story of the operation that led to her daughter’s death. I held her hand as I silently wondered where I was on the list of patients who awaited the same operation. She finished her story as I sat and held her hand. Suzanne VanDerwerken MD, Underwood-Memorial Family Medicine Residency, Woodbury, New Jersey 11 11