A year ago I had two grandchildren, Ezra and Liam. Now I have 9!  Three more have been born this year and my eldest son married a wonderful woman with 4 children.  We had all but one in town for Easter holiday and we spent three glorious days together around good meals, dying Easter eggs, hunting Easter eggs, laughing hard and loudly, and basking in unexpected sunshine.  There was possibly a bit more noise and action than I’m used to so there is some frazzle in the aftermath and certainly some sadness in their leaving.

Kathleen made some amazing food:  Easter ham and potato and sweet potato au gratin; fresh green beans and cole slaw with Ging’s amazing boiled dressing, and then the Heavenly Pie.   Gingie was the name for Kathleen’s grandmother, given to her by her first grandchild an attempt to say Grandma.  Saturday we had our traditional family breakfast: corn meal waffles with melted butter, warmed maple syrup and fresh strawberry puree with whipped cream – a breakfast my sons and I discovered on a trip to Glacier Park twenty five years ago.  And one we make every time we get together.  Each family has a waffle iron and knows the recipe and the routine.  Lori insists we make a cherry pie for at least one meal and I insist on vanilla ice cream to get with it.  For breakfast on Saturday when we dyed the eggs we had a brunch of egg casserole, hot link sausages on the griddle and fresh fruit compote.

Did I tell you about the Heavenly Pie?  Thick meringue baked to sweet melt-in-your-mouth-crunch and then topped with a small mountain of lemon mousse. This pie is tart to make your salivary glands squirt and sweet to bring you back. The kids were playing in the background of the kitchen cooking scene with a soft rocket toy.  You squeeze the handle and the rocket shoots up and hits the ceiling–lots of laughter with each launch.  I told one 3-year-old that when she tasted the Heavenly Pie she’d need to watch out she might go into orbit, like a rocket, the pie was so glorious and celestial. She wasn’t sure she wanted to taste it until her father showed her it was alright. More than alright in my book.

The Easter egg hunt included hardboiled and pastel dyed eggs – some from our little flock of 5 hens. There was also a treasure trove of plastic eggs filled with treats – candies of all sorts. We had some other friends for the hunt so there were a lot of kids from 2 to 8 out hunting.  I note that not a lot of hard boiled eggs got eaten yesterday.  Alas.

Sweets and holidays, family vacation and dessert–how does this family celebrate its loving times together?  Like many others I think.  We take a break from our restraints and limits.  We enjoy these treats as a way to declare our joy of being together – our happiness that we can afford to live it up with a bit of excess and letting go.  There is a sweetness in our attitude towards each other – a way to say that the more disciplined life of work and routine is not something that owns us but something we choose – just like we choose to be together and to accept our different political tastes in favor of relishing our uniform appreciation for Ging’s passing these recipes down to us.  Like we will pass them down to Liam and Ezra, Lucas Michael and Riley.  These things tie us together.  Now for 5 generations and more.  Joy.

As some of you know, I spent many years teaching medical students at the School of Medicine in Chapel Hill. There was an interesting phenomenon I observed over and over again. When the students entered School in their first year they had what I’d call patient-centered values by and large. They were sympathetic and sensitive to the feelings and needs of patients and these values didn’t need much encouragement. They were good patient advocates. Somewhere along the way there was a switch. As they became more focused on their roles and the heavy responsibilities of becoming a doctor their sympathies often migrated too. As stories would go around of patient encounters that involved some level of conflict or disagreement, they were much more likely to want to defend or justify the needs of the physician.

Growing into the role of the physician is difficult. It involves learning many skills, and an almost impossibly large amount of knowledge. The risks in making mistakes are as high as they come. As a student takes on these responsibilities it is not surprising that their sympathies for the patient might wane. Sympathies lose out in favor of the importance of facts.

In this landscape of the doctor-patient relationship, one earth-shaking consequence of the digital revolution is the patient’s access to facts.  No longer does the doctor own them all. And I observe that this shift is not necessarily bringing a kind of balance to the nature of the interaction that might occur. On the contrary, the new access to good information on the web may and can raise the defensiveness of both roles. I think I see in some of my patient relationships a tendency to hold the cards close to the chest.  An ‘I’m not going to show you my cards (what I know) until you show me yours (what you know)’ kind of dynamic.  Or worse, the initial relationship-negotiating may seem to center on who knows the most. If I know more than you do, I win and call the shots. Not so good I think.  I guess this is not unexpected since so often in the past, the physician and patient have both assumed that how much you know is the most important thing.

If the egoic need to know more than the other can be dismissed, perhaps this new level of knowledge by each patient might introduce a wedge of mutuality into the equation. An equation might be created where facts are recognized as important and relevant but one where other factors take on more value; factors such as the experience of the physician, the values of the patient and a kind of mutual regard. I value your facts, values and want to help. You value my facts, values and want to help. We are in this together. Colleagues! Too much to hope for?

As I work on my patient relationship skills I am increasingly appreciating the importance of another aspect of what lies between us: Kindness.

Have you been hearing or reading about the importance of Adverse Childhood Experiences (ACEs)? This is a large study begun 17 years ago to study the effect on the health of individuals who had been exposed to abuse, neglect or other trauma. The findings of this study are mind-blowing to me. The more ACE’s a person has had, the unhealthier they will be as they grow up.  It is perhaps not so surprising that these children will have more trouble with their emotions, learning, addictions and relationships. But  they will also have problems of their heart, digestion, sleep and autoimmune diseases. The more ACE’s, the more health problems.

Having observed the difficulty of the medical student to maintain the patient’s perspective I am sensitive to this issue in my own practice and as I write this column today I am reminded about the complexity of the doctor-patient relationship. As I think back over the years of my practice I realize again how the distance between us can interfere with not only communication and understanding but also the quality of the care and the effectiveness of the outcomes. I’ve known of and observed the importance of mutual respect as in important factor in this relationship and now as I think about the effects of trauma on my patients I begin to realize the importance of kindness. Here’s to kindness.  Let us all embrace it as a key to our wellbeing.

To Your Health.

[published in Health and Healing in the Triangle, October 2012 issue on Surgery]

I’ve been cut.  Couple of times, actually.

Mostly I remember Kathleen’s presence. She goes in with me. She holds my hand when I talk with the pre-op nurse and the anesthesiologist and she waits for me to come out. She listens to the surgeon and later tells me what he said. I get better. I believe one of the operations saved my life.  Seven operations. I’m a frequent flyer.

I’m very lucky.  In most of the instances the surgeon has been a professional colleague.  One time it was a medical school classmate and friend.  Mostly I know the anesthesiologists too.  If I have the chance, I handpick them.

I’m not necessarily proud of this.  If anything I’m a little embarrassed to admit it. I don’t want to want to be treated as special.  I’m guessing that the possibly excessive care I took getting connected to the team in charge is in part testimony to my need for control.  Or more likely my anxiety.

I like to think I’m not afraid, but I am. I don’t like the idea of scalpels opening me and retractors holding my tissues apart.  I don’t like the idea of someone else reaching inside me.  I suspect there is a part of me (which part I wonder) that monitors this invasion and declares an emergency – both in anticipation and in recovery.  Only my civilized self says it is OK.  My primitive or perhaps my higher self tells me “this is very dangerous”.  There are voices inside wanting to know that this will be done in the spirit of healing rather than something else.  It is my experience that these voices pay close attention to what is said in preparation for the time of the cutting.

Fear is not a good thing. It does bad things to my head and my body.  I don’t sleep.  I don’t eat the right things.  I don’t say the right things and I retreat.  I go inside my head.  This makes things worse.  I create possibilities with my mind that aren’t healthy.  I pretend I am not worried.  I don’t tell Kathleen. This distances us.  She understands and holds my hand anyway.  An acquaintance just last night told me that fear is praying for bad things to happen.

Just what you want for a major operation, right?

Now I realize how good it has been that I knew the people that surrounded me when I was cut.  I remember in some detail how well and how important it was that the surgeons explained the procedures and what it would be like.  It helped calm and prepare me when I met other people that would be in the room with me when the procedure was carried out.  I remember now how important it was that the surgeon acted in a kindly and warm manner towards me.  These actions and the feelings they transmitted quieted the inner voices that were warning me of danger.  The inner voice heard healing instead of trauma.  I remember one surgeon was able to convey so much to me about his concern for me–simply by asking if I was ready.  This communicated to me that he was not so much doing something TO me, rather something we were doing together.  It was also important to me when another surgeon clearly bonded with Kathleen, and by his attentiveness communicated to me how well he understood her importance to me and to the outcome.

In my mind Kathleen was the warrior protecting me, sending me off and waiting for my return. I wasn’t actually crossing the river Styx but perhaps my spirit was. I needed a powerful reason to come back and she was it.  It was unsaid but by her presence she declared herself and her expectations.

So this is what I say.  If you’re a patient and you have a chance, pick your surgeon by his bedside manner.  Onetime when I was having a technically complex procedure I picked a surgeon that had a bad reputation in his relationship skills but was considered brilliant technically. I told my friends that if I needed someone to help me through this illness emotionally, I’d find a social worker. In retrospect I think that was a bad idea. I lost a lot of blood and it took me a long time to recover. Maybe these were not related but I think they were. If you’re a surgeon and you want good results remember that your patients are scared even if they don’t act it.  Speak to their fear.

And if you can arrange it, have a warrior by your side throughout.

Oh yeah.  One more thing. The pain meds they give afterwards cause horrible constipation and you need to start taking something for that before the operation.  ‘Nough said.

To your Health.

Popular wisdom holds that those of us with addictions have a problem with will power. We don’t know how to resist urges so we over-indulge in things that make us feel good.

Of course everyone wants to feel good.  And some people can gamble, have sex, eat, drink, and work to their enjoyment and satisfaction.  Then there are those of us that can’t.

Instead of feeling good, addicts sometimes do bad things like ruin marriages, or relationships with mothers, fathers, and children.  Some lose it all. I know people who began life with every advantage and became penniless and incarcerated.  It is not uncommon in recovery circles to meet people who are accomplished and working responsible jobs (sometimes very responsible jobs) with good marriages and admirable civic behaviors who spent time sleeping under the bridge when they were using.  Most who know them now would never believe it.

Another common assumption about active addicts is that there is some element of choice at play. Very bad choices would be a description of their behavior, and of course that wouldn’t be wrong but it wouldn’t be right either.  In my experience, addictions are way more powerful than intentions, self-discipline and self-imposed rules.  In my case, while my will power had a lot of inner resources and did some good things on behalf of others, it was no match for the thing that made me feel good.

I believe most of us who succumb to addictions have a couple of things pushing us in those directions. Most of us have a family history of addictions.  My family, for example, is filled with alcoholics. I hear this from most (but not all) of the people I know who have gone into the fire.

I believe that most of us also have a deep discomfort, and that our drugs of choice stake their claim on our souls by virtue of their power to release us from our demons.   And then they are in charge.  Chief Demon.

How do we get from “taking our comfort” to ruining our lives?  Where does the Chief Demon gets its power?  I think addictions get their power from our pain.  Losing control over things that make us feel good is not so much about an absence of will power.  Rather, it is the degree of the pain and the inability to find better solutions than escape.

What stands between us and finding better solutions?  My guess is pride.

Most of the people that I know with addictions, inside and outside of recovery, have a history of working hard, worrying about details, making plans, analyzing mistakes, committing to do better. In fact, it is my impression that those obsessions often rule us tyrannically.  The addictive behaviors and substances can help us forget.  And then the obsessions return with new fuel:  guilt about our misbehavior.

So we try harder. We amp up the control techniques. We recommit. We try different combinations of white wine and vodka, rationalizations, a different race track, or we move.  It’s the job, the wife, the children, the sheriff who is to blame and if they would get right, so would we.

I know and listen to a lot of people who are in recovery. I always listen carefully when they tell me about how they got sober or clean or stopped using. There seem to be a couple of what might be essential elements: 1) got sick and tired of being sick and tired, 2) asked for help, 3) surrendered to the source of help.

There is a pivotal moment in my life. I was in a treatment program in Pinehurst, and the therapist said to me, “it’s OK Michael. I’m in charge now and I’ll tell you what to do. Just follow these steps and you will find a peace that you don’t now know and it will change your life”. And I did, for the first time in my life.

Surrender.  The absolutely last place I thought to look. This was contrary to my upbringing, ethics, nature and self-esteem. It was contrary in the extreme to my pride. I mean contrary in the extreme.

I’ve been following this counselor’s advice now for almost 18 years.  18 years in 32 days to be precise.  I still want to take control, my inner voices still berate me, I rehash old slights and anticipate new ones.  I obsess on my mistakes, harshly judge myself and others, especially those I love and call my own.  But underneath it all lays a belief that it is better if I am not in control.  It is better if I turn it over.  As Reg said last week, Higher Power is in charge and all is well. Peace.

To Your Health,

Dr. Sharp