finish line

     In the wilds of a Colorado backcountry trail this past summer, the soles of my hiking boots decide to separate from their respective shoe bodies.  Thank goodness for duct tape.  It's MacGyver'ed me out of many a backcountry problem - torn tent on a stormy evening, blister on the feet, burn on the foot, ripped backpack, etc. 

     Upon finishing exams - 6 in 10 days, and successfully, I might add - my particular soul also felt its own separation while coping with newly discovered territories of grief.  Ravines, cliffs, and caves of impenetrable darkness that I never knew even existed.  Existential silver, sticky, tensile stuff is holding me together.  Strong stuff, and that's a good thing because I sure need it.  I sure hope it doesn't give out.  But then, duct tape never does give out, does it?  Because you can always whip out more.

     On my way to yet another exam, the traffic was flowing freely, much like the tears that ran down my face.  As usual, they came out of nowhere.  Before my morning tea had even wet my lips, memories of my brother haunted my waking state.  Not just tears.  Gut wrenching sobs with fists full of destructive anger.  No bones broken.  The bathroom tile is sturdy. 
    Exam?  How am I going to take an exam like this?  Ariving early, I am in no mood to be around other students.  Without any conscious thought, I walk over to MD Anderson.  My feet chose the path for me.  I pass through those familiar doors not as a brother, not as a son, not as a doctor-in-training.  Not as anything other than the most broken parts of myself. 
     Where to go where eyes streaked red with tears (and stress) will not garner attention?  The chapel.  I haven't been in there since my brother was offered the choice of "going down swinging".  I sit one seat over from where I sat on that ruinous day, almost as if that old vestige of me was still sitting in vigil behind the phantom of my brother slumped over in a wheelchair while the memory of our mother is crumpled over him. 
     What do I do now?  I scroll through my brother's iphone.  (It will always be his iphone, no matter how much I use it.  It's become a talisman of sorts.)  I come across a guided meditation on grief.  Seems as good a time as any.  Shortly into it, I'm instructed to imagine a guide.  Someone to help me on this path.  Of course, my brother comes to mind.  Thoughts and emotions stream out of me rapid fire.  'How am I supposed to do this?  Why did you die?  Why the pain?  Why did you have to die like THIS?  And finally, I miss you.' 
     And in return, I receive no big brotherly advice.  No words of encouragement.  No solace.  His response is, 'how do you think I feel?  I lost everything.' 
    'Yeah, I know.  I know."  I dry my eyes, take a deep breath, and wander back over to my school to take an exam.

2 down, 4 to go

75 questions over diagnosing diseases based solely on physical findings.  Unfortunately, "I need to run some tests" was not in any of the answer choices.

1 down, 5 to go

Ugh.  101 questions over psychiatry.  That didn't go well.  And I'm going to go out on a limb that the class average sunk right along with mine.  We'll see.

a not so subtle metaphor

     By all conventional wisdom, this monarch caterpillar shouldn't be.  Frost has lightly blanketed my garden on multiple nights, winter starting the decaying process of the butterfly weed upon which it depends for sustenance.  Surprisingly, I saw at least a dozen cats yesterday and figured last night, the coldest yet, would be the one to send them off gently into that cold dark winter night.  Somehow this one endured.  It shouldn't be.  It should be in Mexico overwintering in warmer climes or it should be dead.  But it's not.  It's stuck here in my garden with the dying butterfly weeds.  It's not where it wants to be, if ever a butterfly could want.  It's certainly not where it's supposed to be based on the migratory patterns.  An existential crisis if ever there was one.  It must struggle to endure its dying source of nourishment.  It must find an enclave protected from the elements in which to create its chrysalis.  It must endure until weather warms and favors growth over decay.  And finally, it must emerge out the other side transformed into something else.  But first, to endure.



bereavement

III. Bereavement
     As death of a loved one is filled with anguish and pain it should come as no surprise that grief is one of the most painful human emotions.  It is not clear how long grief should last (even if the category of 2-6 months is currently popular).

     The final lecture from my Behavioral Science class this block was about grief.  How appropriate.  And the above came from the reading.  The two to six months part is laughable to me, as it was to the psychiatrist who gave the lecture.  "My dad passed away during my residency and it takes a lot longer than 2-6 months.  I'm not sure where they got this number," she informed us.  The lecture then delved into how we as physicians need to try to distinguish appropriate grief from a major depressive disorder in our patients.  A very real and substantial part of me appreciates the contributions of a medical model of looking at the darker aspects of moods.  It has utility and it has value.  I've seen what happens when depression goes untreated and results in suicide.
     But as I read more and more about grief vs. depression, I began to think that there's something lacking in substance to the medical model.  Medicine seeks to treat or event prevent diseases.  If there's a broken bone, we reset the bone, immobilize it and allow it to heal properly.  For viral infections, we administer vaccines to eradicate the scurge of polio.  Antibiotics have made rheumatic heart disease a thing of the past. 
     But how does that work for someone's psyche?  The psyche is broken and we seek to fix it.  There's a certain material logic to it.  If someone is suicidal, we'd certainly like to prevent that.  But taking the "fixit" analogy can cut the journey short when 'fixing' equals 'happy'.  There is something quintessentially dark about the human spirit.  Jung called it the shadow side and the older I get, the more I think there's something to it.  Our society places way too much emphasis on being happy or content as the goal of life.  Pain avoidance, I suppose.  There's even a whole body of medicine trying to link positive moods with life extenstion, nevermind the countless self-help books on being happy or positive.  But life is more than the number of days.  Don't believe me?  Name any great story that has endured the test of time.  The overwhelming majority involve soul wrenching pain and suffering.  Very few are happy-go-lucky stories.  Greek tragedies, anything by Shakespeare, you get the idea.  Yes, there may be hope and triumph involved but at the base is still suffering.  There's a reason for that.  Every single human being will be faced with it at some point in their life.  It is part and parcel of the human condition where literature and philosophy have as much to say, if not more than medicine has to say. 
     So I think about that lecture and how I approach that from my own experiences and how I will (probably) approach that with my patients down the road.  And at the end of the day, I do not choose to differentiate between appropriate bereavement and major depression.  They seem one and the same to me, a part of the human condition with artificial labels.

il faut d'abord durer

     Hemingway was known to sign personal letters with the French phrase il faut d'abord durer.  Idiomatically, it translates as "first, to endure".  It's been my motto ever since my brother died.  And it's a hard axiom for me.  I always enjoyed excelling.  Being above average was fun for me.  In football, I played to win.  And you don't get into med school by being middle of the road.  So it's a hard pill to swallow to set my sights at this point on merely surviving.  It feels like I'm settling.  But with the trifecta of med school, death, and my dad's condition.....I remind myself that it's a lofty and noble goal at this point.  If I can just get through all of this intact, that's no small victory.  So entering into the next round of exams, woefully unprepared, I remind myself, "first, to endure."  Go easy on myself and let go of the notion of honors and be content to endure.