Sunday, November 8, 2009

"Changing the Narrative"

We're all telling ourselves a story. This is not so much reality as it is the deliberate choices we make about how to respond to reality. Splicing it, spinning it, shaping it. Owning it.

That's what this blog is, really. Forcing myself, despite the burdens of time and resources, to tell myself the evolving story of my road to 'doctorhood.' It doesn't have a beginning, a middle, or an end exactly. But, so far, it's a pretty sweet story.

I wrote some time ago about story-telling in patient care, and how I saw narrative medicine -- the thoughtful, collaborative weaving of the themes and values that make up the broader context of a person's life (of which their illness is only one part) -- as a major influence in the way I hope to one day care for people. The symbols, the irony, the various devices to layer awareness and reflection -- all designed to empower people to heal themselves through the tools that doctors, patients and the characters of their lives all work together to develop.

Narrative medicine, of course, is just as powerful a vehicle for me as a trainee -- and will continue to be, for the rest of my life. Writing allows me to construct and reconstruct the formative events of my world, to give them meaning -- to frame it all in a way that teaches me as I go, and will continue to teach me as I look back upon it. Tapping into recurrent, intersecting themes is comforting for me -- the power and confidence of consistency is enormously gratifying. Last year, I had a "thing" about what I called "practicing commitment" (which is how my immunology course director used to describe the process of building confidence in coming to a diagnosis and standing behind it -- which I extended to apply to EVERYTHING that ever happened...). I found my "champion" symbol in the hematopoetic stem cell (en route towards various paths of differentiation -- unlimited possibilities, yet unable to turn back the farther along it proceeds). I practiced "practicing commitment" as an athlete, as a coach (HOW many training sessions have been specifically themed around commitment -- to a specific intensity, to a specific challenge, to a specific breathing technique, to an awareness -- over the past year? Hundreds. Commitment for the sake of commitment, even. The idea of demonstrating one's ability to husband all of one's resources upon a specific task -- how gratifying that can be.), as a medical student. As a human being.

As it turns out, we revisited hematopoesis last week in school. As slides of myeloblasts and lymphoblasts, and dozens of genetic translocations that result in their failure (that I'm magically supposed to encode for life -- or at least, for my Boards) flashed before my eyes, I was comforted by associating these "characters" with the way I conceptualized my life story. Or something like that.

Ironically, this coincided with quite a few epic developments to said "life story."

First, the process of TELLING it. At clinic on Wednesday, I had a fascinatingly subtle discussion with my preceptor about self-narrative. I am so lucky that I have a mentor who spontaneously slips into casual evaluations of self-narrative (what?!). His premise was how it's futile to deny how much of the stories we tell ourselves are inextricably linked to our biases, our expectations, and our dreams. We project aspects of our stories onto other people; we see what is consistent with what we want to see -- what we tell ourselves that we're seeing. I wanted to tell him that he was wrong. I wanted to tell him that I was confident in my objective analysis of reality at all times. But he wasn't wrong. I reconciled my dissonance relatively quickly. I came home and told Scott "my story," and heard his. In so doing, I 'owned' every single one of those projections, biases, and distortions. And it was a pretty sweet story, indeed.

The week continued. It was Primary Care Week, so I had the opportunity to attend a bunch of family medicine-related talks and interact with a number of characters who are starting to make quite the impact on me. I also set myself up to attend another family medicine conference, this one the Vermont state professional organization. I'd attended this group's meeting last year, as my first introduction to the community I'd come to experience as "my people."

Yesterday, I met with my advisor (one of the coolest human beings on earth). I found myself comfortably, casually recounting the past 6 months of my life. When summarized and editorialized (i.e., crafted as a story), I felt really "together." Even recounting my flop of a study (that I'm SERIOUSLY going to work on this week!) felt pretty good. He was amused by all of my masochism (i.e., three Centuries, deliberately seeking out awkward/unbearable/AWFUL experiences in order to get comfortable being uncomfortable). He observed my hyper-self-awareness (which I didn't exactly have the sort of relationship where I really should have felt comfortable reflecting at the level I was reflecting -- but I suppose he experienced my candidness as refreshing). Our discussion left me really proud of the story I'd pieced together. It may not have felt so fluid in real time -- but the version that lasted was a useful one.

Then, last night I went out to the clinic to have dinner with my preceptor, the PA who treats me like a daughter (she MET my mother a few weeks ago - it was pretty epic), and another friend. We got to talking about prostate exams (I do them all the time, unsuccessfully -- my fingers are too short!) and pelvic exams (I've done four now...) -- both of which I haven't been formally taught how to do at school, yet am regularly invited to practice at clinic. While I can comfortably discuss my history of anxiety and panic attacks, my love for my boyfriend, and my self-narrative style with my preceptor -- what I blurted out next was somehow outside of my comfort zone. I've written about it a ton. But blog fodder is not necessarily "say out loud to your hero"-appropriate.

"I feel so guilty every time I do a pelvic exam. I feel like I haven't done anything to earn this privilege. There's no reason that someone is being so generous. So I just want to get in and get out and get them done with being vulnerable to me. I don't spend time really learning."

With no more than 5 seconds passing, my preceptor responded:
"So change the narrative. Tell yourself that this patient made this choice because they wanted you to learn as much as you possibly humanly can -- and it's your job to honor that underlying basis for her choice."

Whoa. This man is BRILLIANT. That is an entirely crafted, distorted narrative. It's a version of reality that gets me to adapt my behavior, my attitudes and my emotions. It's a version of reality that's TOTALLY going to work for me. Is it exactly true? No. Is it false? No, actually. Is it more true than it's false? Yes. Is it going to make me a better doctor? Damned straight.

So, today was the conference. I woke up with a reprise of my lung-hacking cough. I had no appetite. My GPS got me lost. There was a country song on the radio, and I found myself kind-of LIKING it -- just because it seemed so movie-esque to be driving down a dirt road as the sun rose, en route to a symbolic event to mark "my future."

Turns out, I was the only medical student there. I didn't know anyone. I was awkward. Irony: it was held at the hospital where I deliberately accompanied my preceptor those nights over the summer, for purposes of "owning my discomfort." HA. I owned my discomfort for 9 hours today!

I didn't want to network. I just wanted to crawl in a hole and not be alone and out of place. But, at intervals, I changed the narrative. I was confident. I belonged. I had useful things to say. So I started... saying them. I met a handful of people who were really eager to encourage and support me. I talked with someone I'd heard speak a year ago, who really inspired me -- and there she was, eating lunch with me. There was another character, a junior doc, who probably recognized a lot of my young, naive, overly eager idealism. She inspired such comfort that I was able to ask her genuinely useful questions, and learn a ton from her experiences (i.e., elective choices, geographic options, etc).

Then, I had an idea.

A board member from the national umbrella organization for this state chapter was there, giving a talk on the future of family medicine. He started off with statistics about how very few people are choosing to go into family medicine and how it doesn't pay as well as x and y and z and blah blah blah. He then went into all of the mechanisms for reform under way, but completely omitted a discussion of efforts to increase the workforce (which tons of other speakers address). The difference is that this guy didn't expect a medical student to be in the office. But you know what? I was a medical student in the office. And suddenly, I felt compelled to be useful.

I spent 45 minutes during this talk plotting my next life event. My heart was pounding, unresponsive to breathing techniques. My legs were twitching. My vision started to blur. Own your discomfort. You don't need to make the anxiety go away. You just need to own it and keep going. You practiced this.

"Any questions or comments?"
Show time.

I raised my hand and in front of 60+ strangers, introduced myself as a second-year medical student for whom there was a 0% chance that I would do anything else with my life besides practice family medicine. I offered that I didn't know if my perspectives were useful, but that I felt compelled to speak up as the only student in the audience. I wanted them all to know that the reason I'm so committed to family medicine is because of experiences I've had with people like themselves -- the stories, the intangibles, the generosity of making time to give me the opportunity to learn from them and their patients. That I know they're busy and overworked, but that they should know that the time they make is invaluable to the future of family medicine -- that it means so much, that it goes so far.

I didn't stutter. I didn't cry. I didn't have a panic attack. And a few people came up to me afterwards and thanked me.

I got in my car and drove off, literally, into the sunset. I put "Who Knew?" by Pink on repeat for 45 minutes straight. Not because the lyrics mean anything to me -- but chords just kept striking the absolute perfect 'place' for me. I was tearful. Proud. Self-enamored. Peaceful. I even drove the speed limit the whole way home.

'Who knew' that I'd be telling myself THIS story? Or any of the stories that have directly led up to it? Every story of the experiences I sought to prepare me to do what I did today. The uncomfortable bike rides, the embarassing questions, the deliberate exposures to looking like an idiot -- just to get good at it.

Who knows what I'll be telling myself next?

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