Seeing Inside

inside of tree

In the welcome page to my blog site, I write the following: “moving from youthful illusions of invulnerability to embracing the fullness of loss and love, I realized when I could be still, medicine and leadership brought me back to my starting point- the shared human condition”.

Crabbit Old Woman, an initially anonymous poem later attributed to Phyllis McCormack, paints a poignant image of our shared human condition. I inserted my name, David, where the word “nurse” appears in the original text. This facilitates the old woman speaking directly to me but more importantly it transforms the old woman into me. I encourage you to substitute your name as you read the poem. The poem touches on the person inside each patient; more importantly, it connects us with our shared human condition—the person inside experiencing joy, change and loss.


An Old Lady’s Poem

What do you see, David, what do you see?
What are you thinking when you’re looking at me?
A crabby old woman, not very wise,
Uncertain of habit, with faraway eyes?
Who dribbles her food and makes no reply
When you say in a loud voice, “I do wish you’d try!”
Who seems not to notice the things that you do,
And forever is losing a stocking or shoe…..
Who, resisting or not, lets you do as you will,
With bathing and feeding, the long day to fill….
Is that what you’re thinking? Is that what you see?
Then open your eyes, David; you’re not looking at me.

I’ll tell you who I am as I sit here so still,
As I do at your bidding, as I eat at your will.
I’m a small child of ten …with a father and mother,
Brothers and sisters, who love one another.
A young girl of sixteen, with wings on her feet,
Dreaming that soon now a lover she’ll meet.
A bride soon at twenty — my heart gives a leap,
Remembering the vows that I promised to keep.
At twenty-five now, I have young of my own,
Who need me to guide and a secure happy home.
A woman of thirty, my young now grown fast,
Bound to each other with ties that should last.
At forty, my young sons have grown and are gone,
But my man’s beside me to see I don’t mourn.
At fifty once more, babies play round my knee,
Again we know children, my loved one and me.
Dark days are upon me, my husband is dead;
I look at the future, I shudder with dread.
For my young are all rearing young of their own,
And I think of the years and the love that I’ve known.

I’m now an old woman …and nature is cruel;
‘Tis jest to make old age look like a fool.
The body, it crumbles, grace and vigor depart,
There is now a stone where I once had a heart.
But inside this old carcass a young girl still dwells,
And now and again my battered heart swells.
I remember the joys, I remember the pain,
And I’m loving and living life over again.
I think of the years ….all too few, gone too fast,
And accept the stark fact that nothing can last.

So open your eyes, David, open and see,
…Not a crabby old woman; look closer …see ME!

Use comments below to describe how this poem helps you connect with our shared humanity.

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Wounded Story Tellers II

michael bischoff

Written by guest author Michael Bischoff

David and I recently talked about his post, Wounded Story Tellers.  In that post, David described four types of illness narratives (restitution, chaos, quest, and clinical). David and I talked about another narrative that is related to the quest narrative, but also a distinct story and approach to healing.

Opening narrative

While transformation of one’s self might be a part of the this story of illness, that personal transformation is a part of a larger story of releasing into a larger flow of life. This narrative includes cultivating non-attachment to the outcomes of one’s individual health and life, and an acceptance of mortality as a part of the cycle of life.  Death is seen not as a failure, but a stage in opening, releasing the small self we thought we were into the largeness of life.

Those of us with life-threatening illnesses might be more drawn to this narrative, but this narrative can also be applied to minor illnesses.

While remaining engaged with relationships and healing, this story includes a choice to focus on the quality of one’s presence and a non-judgmental acceptance of the emotions and conditions that arise.

This narrative can be expressed in religious terms, such as welcoming God’s healing power to move through me or in terms of accepting what is and trusting the body’s natural healing tendencies

An example of a statement from the opening narrative could be:

“How long I live isn’t the most important thing to me. Living as fully as possible in the reality of love in every moment is what is most important to me.”

Michael Bischoff is currently experimenting with ways to contribute to community well being from the perspective of a patient with brain cancer.

Michael Bischoff CaringBridge Site

Consumers or Patients?

Patients. Families. Members. Consumers. Customers.  Communities. Clients. Healthcare uses many words to describe those we serve. We also use various terms such as experience, healing relationships, service excellence, satisfaction, reputation, brand and top-of-mind awareness to describe the perceptions of those we serve. How do we make sense of this word salad?

Words evoke emotions and frame thinking. In the past, I bristled when I heard “consumer” or “customer” used in place of “patient.” The terms “consumer” and “customer” felt corporate and seemed to demean the near sacred nature of healing relationships conveyed to me by the term “patient.”

Over time I lost my emotional response to “consumer” when I realized in my own health care experiences I often viewed myself as a patient, consumer or both depending on circumstances.

Imagine examples outside of health care in which you consider yourself a consumer. You stroll into Caribou for a cup of coffee, order a book from Amazon or buy milk from a grocery store. You pay for the transaction with some combination of time and money, and expect hassle-free service or an item that performs as advertised. The hallmark of your consumer role is a sense of your own power as you feel in charge of your time and money. And as a consumer, you think about service excellence, rather than trusted empathic relationships and a healing experience.

In contrast, the hallmark of being a “patient” is your feeling of fear and vulnerability. You want trusting and empathic relationships to provide guidance and comfort in a strange and foreign land. Being a patient involves interactions between human beings, rather than consumer transactions. You likely think about healing and empathic experiences, rather than service excellence.

The day I lost my vision I felt afraid and vulnerable. During my recent transient ischemic attack (TIA), I sensed I was in a strange and foreign land “on other side of the bed.” In both instances, I could not possibly feel in charge, and I desperately needed the empathic trusting relationships that come with being a patient. I did not want to feel like a consumer and did not think about “service excellence.”

Over time, these events have shifted into periodic visits to physicians to check my blood pressure, eye pressures and receive medication refills. During these encounters, I feel in charge and want hassle-free service. I appreciate the relationships, but I don’t have the same need for them as I did during the first few days of the acute episodes. In both instances, healing involves my transformation from a vulnerable and frightened patient to feeling like an empowered and in-charge consumer. Additionally, I feel like a consumer in health care when I receive a flu shot or when my children needed a strep screen. In these examples, my time trumps an empathic relationship, and I think about service excellence rather than a healing experience.

Similarly, I encountered a variety of needs and roles in my involvement with the legal profession. When I was sued for malpractice, I felt very vulnerable in the strange and foreign land known as the courtroom. I didn’t feel much like a consumer and preferred to be called “client” by my attorneys. However, years later when I was working on my will, I actively shopped around for an attorney, felt in charge of the process, and returned to the comfortable “consumer” role.

The in-charge role of “consumer” and the vulnerable role of “patient” are not on opposite ends of a spectrum; we can experience both roles simultaneously and the balance may shift in the blink of an eye.

The graphic below depicts a useful way to think about the roles of patient and consumer.

patients or consumers

The y-axis represents the empowered and in-charge consumer seeking hassle-free service and value, while the x-axis marks the fearful and vulnerable patient needing empathic, healing relationships. An individual can be in any of the four quadrants one moment and shift to another quadrant in the blink of the eye.

When I lost the vision in my left eye, I started in the lower-right quadrant (vulnerable and fearful patient), and over several weeks as I adjusted to the change in my life, I shifted to the upper-right quadrant (I wanted regular follow-up visits that fit my busy schedule, yet lingering fears remained). Now, more than 12 years later, I am solidly in the upper-left quadrant as I fully accept my loss and want follow-up eye checks to be as convenient as possible.

Consider some illustrative vignettes which demonstrate movement within the quadrants. A young woman named Rita is visiting her dentist for a routine check-up and cleaning. She senses no vulnerability, feels in charge and wants to get in and out of the office as quickly as possible. She decides to ride her bike to the appointment. She feels like a consumer. Unfortunately, on the way home, she falls off her bike and shatters four teeth. She is worried about the damage to her mouth and wonders when she can return to work and how she will tolerate the pain. In the blink of an eye she has changed from in-charge consumer to a vulnerable patient needing an empathic caring relationship.

Kathy is 35, married and has two young children. She is in charge of the health care decisions for her family. She feels like a consumer when she chooses her family’s health plan and takes the kids to their well visits. The evening after she selects the health plan through her employer, her youngest daughter is hospitalized with respiratory failure from influenza. She and her husband find themselves in a strange and foreign called the Intensive Care Unit. They need guidance and empathic relationships to navigate the world of ventilators, heart failure and kidney failure. In a blink of the eye Kathy shifts from an in-charge consumer to a scared and vulnerable family member.

Many individuals with chronic disease are in the upper-right quadrant, similar to where I was a few months after my vision loss. They live every day with their chronic disease, and as a result, feel empowered and in charge, yet also may harbor lingering fears about complications.

Our work requires understanding the needs of those we serve at any given moment and understanding that those needs may change in the blink of an eye. The work of healing relationships includes supporting individuals to move from fear and vulnerability to feeling empowered and in charge.Paradoxically, healing relationships support the process of patients becoming consumers.

Please use comments below to describe your thinking about the role of patient and the role of consumer.

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The Cracked Pot

cracked pot

The Welcome Page of Between Two Waves of the Sea and the post Wounded Healers describe  caregiver (healer) and patient sharing a universal human wound (uncertainty, change and loss are inevitable; love is a choice). Additionally, they describe our “shared human condition.”

In his book The Dog Says How, Kevin Kling, a local storyteller and playwright, retells the following parable that deepens our understanding of woundedness and our shared human condition:

Back in the days when pots and pans could talk, which indeed they still do, lived a man

And in order to have water, every day he had to walk down the hill and fill two pots and walk them home.

One day it was discovered one of the pots had a crack, and as time went on, the crack widened.

Finally, the pot turned to the man and said, “You know, every day you take me to the river, and by the time you get home, half of the water’s leaked out. Please replace me with a better pot.”

And the man said, “You don’t understand. As you spill, you water the wild flowers by the side of the path.”

And sure enough, on the side of path where the cracked pot was carried, beautiful flowers grew, while the other side was barren.

“I think I’ll keep you, “said the man.

Leonard Cohen paints a similar image in the song Anthem:

“There is a crack, a crack in everything
That’s how the light gets in.”

The parable and the song indicate that beauty, represented by flowers and light, flows from our cracks – our woundedness. All humans carry wounds. Each one of us has our share of unique wounds beginning in childhood, and as we mature we accumulate additional unique wounds. These wounds are left by broken hearts, disappointments, death of loved ones, fears and illness. Additionally, we all share the universal human wound: on the one hand, we are born, we age, we experience loss and eventually we die and on the other hand we don’t want to accept this truth for our loved ones or ourselves.

Empathy and compassion flow like water from the cracked pot as we recognize that every human being nurses unique wounds and we all share the universal wound. Shared humanity emerges from our cracks.

Please use comments below to describe your thoughts about shared humanity and woundedness. Please consider using the share buttons to forward via social media or email to your colleagues and friends.

Anything Worth Doing is Worth Overdoing

“ Anything (huff) worth (puff) doing (heavy breath) is worth (wheeze) overdoing (gasp).” I heard these words for the first time at the Chequamegon Fat Tire Festival, an off­road bicycle race in Wisconsin. A cyclist, a man in his 60’s, uttered the phrase as he passed me. I was in my late thirties, and felt humbled and inspired as the older rider overtook me. The words captured what I was unintentionally doing with my riding and running.

If running a 10k was admirable, then a marathon was superior. If riding 50 miles was good, then certainly a century ride (100 miles) was better. If exercising at a heart rate of 145 was recommended, then 155 was preferred. If eating oat bran for breakfast (a 1980’s fad) lowered cholesterol, then a diet consisting of nothing but oat bran would really do the trick (it did—my total cholesterol went to 120 without the use of medications).

If Nordic walking 2 miles a day was healthy, then increasing to 6 miles a day over the course of a few weeks had to be better. I assumed the instructions to increase mileage over a minimum of 8 weeks applied to other people, but certainly not to me. This arrogant assumption resulted in a stress fracture of my hip.

The fracture forced me to slow down and ponder the “more is better” story that I told myself, and that contributed to the “overuse” injury. I realized over the years I used exercise to attempt to out ­run, out­ bike, and, most recently, out­ walk the reality that I was not immune to the passage of time and the randomness of events. Like many of us, I felt restless discomfort and a lack of control in simply living with this reality. Instead, I preferred constant movement, compared to the sublime but frightening stillness of seeing life as it is. I used exercise to avoid the unavoidable: life is uncertain and change, aging and death are inevitable. I know other people who use frantic schedules or acquire possessions to avoid sitting with this truth.

And how often do we use prevention and treatment narratives to try to outrun the reality that we cannot make our lives and the lives of our loved ones completely safe? How often do physicians try to avoid the necessary pain of diagnostic uncertainty by ordering more and more tests that at times generate additional uncertainty of incidental abnormalities or false positives?

I overhear the “more is better” illusion in the snippets of healthcare conversations that permeate restaurants, coffee shops and walking trails. Recent examples include the following:

“There must be a reason I am tired. I only sleep 5 hours per night, but other people do fine with 4 hours. I am going to ask my doctor for another battery of tests.”

“Food labels contain only the minimum daily requirements of vitamins. I take megadoses to be healthy.”

“I know my cholesterol is normal, but I like to get it checked every 6 months—just in case. You know, you can’t be too careful.”

And in my case, the “more is better” approach to exercising created the illusion of control over my health but the reality of a stress fracture.

What do you do to outrun life as it is?

 

 

 

 

Ghosts

Over the years, the memories of ten specific patients float like ghosts through my mind. Nurses and other physicians tell me certain faces also haunt them. Recently, I conjured all of these ghosts in order for me to understand what they have in common. The answer surprised me.

The key to understanding the puzzle of why these 10 patients, and not others, haunt me came from two of them, Shirley and Sophie (names changed to protect privacy).

Let’s start with Shirley

Shirley, a 79-year-old patient hospitalized patient taught me the meaning of healing on a Saturday many years ago. On that particular weekend, I drove to the hospital resentful and feeling sorry for myself for being on call and missing family activities.

As her physician for the past few years, I recalled her history as I perused her chart outside the room. I remember her daughter committed suicide earlier in the year. Sometime after the suicide, Shirley underwent a hip replacement complicated by multiple admissions for dislocation of the prosthesis. She had a history of an artificial aortic valve and recently developed acute endocarditis (bacterial infection) of the valve seeding the prosthetic hip with an infection. During the current admission, the hip was splayed open enabling drainage and antibiotic irrigation of the hip as she received intravenous antibiotics to calm the heart valve infection. Her only chance for survival involved risky replacements of the infected valve and later the hip. I knew I needed to talk with her about the valve replacement. Given her condition, the surgery carried grave risk, but without surgery, she had little chance of leaving the hospital.

As I walked into the room, I saw she was covered with blisters, most likely a reaction to the antibiotics. She whispered one phrase: “I feel like Job.”

I held her hand and cried with her about the events of the last few months. My self- pity about being on weekend call evaporated. We talked about replacing the valve and the hip and she stated calmly she wanted to live despite her suffering.

Shirley taught me that healing is not the equivalent of cure. Healing occurs when we acknowledge life as it is and exercise personal choices in the face of reality. Healing may occur with the dying process. Healing may result from grieving.

On that Saturday in Shirley’s room two human beings healed.

I knew Sophie, a friend of my parents, from my childhood. I became her physician when she was quite old and I was in my thirties. During the specific visit that haunts me, I asked what her secret was for aging so gracefully. She said, “David, in order to age gracefully you have to live gracefully.” It was my first glimpse that aging gracefully could not be initiated when you are old. It begins with how you live now.

Shirley made me face my petty crankiness about being on call during a weekend. As I opened myself to her suffering my pettiness evaporated and on that day I became a better human being. Sophie gave me a life map to follow.
Gathering together memories of the ten patients clarified what they have in common. They are not ghosts. They are guides who taught me important life lessons. They made me whole, and thus healed me.

As healers we can heal alongside our patients when we open ourselves to our humanity. By being in touch with our own core human wound of the finiteness of our own lives and the potential loss of loved ones and losses associated with aging, we open ourselves to receiving the gift of healing from our patients as we stand witness to their courage and wisdom facing the same ultimate human wound.

 

Wounded Healers

ascleius

Between aging baby boomers, health care reform, genomics, value based purchasing, nanotechnology, “big data,” artificial intelligence, population health, work force retirement and countless technological advances, healthcare promises ever quickening change.

Given the changes, what has not changed? What should never change?.

From the dawn of recorded history we know that human beings long for healing.  The word “healing” implies a return to wholeness. Humans feel a fundamental need to be in harmony with themselves and with their worlds. In response to the deep need, formal healers occur in every culture across the vast expanse of time.

The deep human need for healing-for wholeness and harmony- has not changed. With the certainty of ongoing changes in health care, what should never change is our role within modern medicine as healers.

Carl Jung, a famous early psychoanalyst, described  “archetypes”– constantly recurring themes and symbols in dreams, literature, paintings and mythology. These archetypes, etched in prehistoric cave paintings and embedded in Greek Mythology, appear in disparate and completely separate cultures and today in movies like Star Wars (hero archetype). Jung wrote about the healer as an archetype evident from prehistoric times across dispersed cultures. Interestingly, he called this archetype the “wounded healer“ implying that the archetypical healer needs to be in touch with his/her own woundedness in order to be effective. Thus, the typical initiation of a shaman healer involves the shaman embarking on an internal (and sometimes external) journey to experience and come to terms with their pain- their woundedness.

Jung described the centaur Chiron from Greek mythology as a “wounded healer.“ Chiron became a healer after sustaining an incurable wound from one of Hercule’s arrows. Chiron mentored the orphan Asclepius who became a famous wounded healer. The picture above shows Asclepius with bare chest suggesting vulnerability and carrying a rod with a single serpent. This rod became the “rod of the physician” Thus the rod, as a symbol of medicine, is the wounded healer.

Karolyi Kerenyi, a colleague of Jung, elucidated the wounded healer archetype as the capacity “to be at home in the darkness of suffering and there to find germs of light and recovery…”

Pema Chodron expressed a similar sentiment in “The Places That Scare You: A guide to Fearlessness in Difficult Times,” She writes:

Compassion is not a relationship between the healer and the wounded. It’s a relationship between equals. Only when we know our own darkness well can we be present with the darkness of others.

The “wounded healer“ archetype implies that we need to be in touch with our woundedness in order to effectively support other humans in healing- moving to wholeness. What does it mean to be a wounded healer in modern medicine?

Although we each have our unique wounds, the universal wound is that life is impermanent and changing- we are born, we live and then die. And we have limited control of what happens in our lives. I know I carry a veil over the fragility of life- I can’t constantly face the reality that my life may change in an instant and my loved ones may suddenly suffer and even die. I did not wake up to my woundedness until my mid-thirties when I went through a divorce. Until that time I carried a quiet illusion that somehow I was different from other human beings in that I was fully in charge of my life and magically protected from suffering.  Even though my mother died a few years before my divorce, her death felt like the natural course of life and failed to alter my magical thinking. My divorce, however, shattered the illusion of special protection from suffering. I lifted the veil covering life’s reality and saw with relief I had the same fundamental challenges as all humans- how to make sense and find joy in a world I could not control. After a while I accepted the only thing I could control was the kind of person I chose to be (and even that is not always easy).

I know I became a more effective healer after facing my illusions. I moved from being a doctor who was good at diagnosing and occasionally curing, to a physician who embraced the role of healer. And my practice became more satisfying as I opened myself to the privilege of being healed by my patients as I stood witness to their courage, grace and integrity.

I believe the challenge for modern healers in healthcare is greater than ever. We have the same challenges as healers throughout the ages- to help other humans find some sense of wholeness and harmony in the face of loss and eventual death. But additionally we have the challenge of helping people come to harmony and make decisions based on the scientific model of what is effective.

Please use comments below to provide your thoughts about wounded healers. Please use the share buttons to forward to friends and colleagues if you found this post valuable

 

 

Wounded Story Tellers

night camping under the stars Mountains

I don’t intend to eaves drop on conversations, but it’s unavoidable sometimes in public places. Wherever I go, restaurants, coffee shops, grocery stores, airports or parks, health care stories waft through the air. The snippets go something like this:

My husband was hospitalized with chest pain. He had the “widow maker” kind of plugged artery. Fortunately, they opened it right away…

I have been feeling so run down and fatigued. I think I need to go in for a full physical…

My cancer came back. Fortunately, my oncologist knows about an experimental treatment to try…

My back hurts. I saw the doctor and had an MRI. It showed some wear. I can’t work anymore. I lost my job. I don’t know how we will pay the mortgage. The physical therapy hurts even more. I am afraid my wife will get fed up with me. The pills don’t help…

Today is the tenth anniversary of being cancer free after surgery, radiation and chemo. The experience changed me into a better person. I don’t take life for granted anymore and I am grateful for every sunrise and sunset…

It would be easy to dismiss the continuous hum of these dangling conversations by saying that health care is 17 percent of our economy, so of course the topic will frequently surface. But I wonder if the prevalence of medical stories has more to do with how we all use narrative to make sense of our lives. We understand and relate to events and people by weaving happenings, heroes, villains and circumstances into coherent sequential stories.

The book “The Wounded Story Teller” by Arthur Frank, a sociologist and survivor of testicular cancer, provides insight into illness stories.

Frank describes the need we have to predict and control how our bodies will perform in situations. A few months ago during Flu season, I experienced a trivial problem that illustrated this idea. I developed a hacking cough that would occur without warning as I was speaking or trying to listen to others. Suddenly, I could not trust my body to perform as expected and I needed to set new expectations for my workday. Though irritated, I kept a sense of humor about it and told myself a comforting story – that the disruption was temporary and insignificant.

In contrast, serious illness represents a loss of the personal story and expectations that previously guided the ill person. The central problem becomes how to avoid living a life that is diminished by illness or by the reactions of others to it. Medical stories turn illness from fate into experience and enable the storyteller to create bonds of shared suffering and vulnerability between themselves and their listeners.

According to Frank, each story is unique to the storyteller, while at the same time falling into one of three common patterns: restitution, chaos or quest stories. I would add a fourth – the clinical narrative, when we health care workers act as the storytellers.

Restitution stories

Restitution (cure) stories are the most common narrative. The primary goal is to permanently restore a normal life; illness is viewed as a temporary detour. Whatever happens can only be understood as a necessary step toward the achievable goal of health. Restitution positions physicians and modern medicine as heroes and relegates the patient to the object of that heroism. At their best, restitution stories portray patients as the fortunate beneficiaries of modern medicine; at their worst, the stories depict patients and families as victims of a dehumanizing modern medicine bureaucracy.

These stories reflect the deeply-held longing of some of us, especially in western societies, to use science and technology to explain, control and “fix” lives. The restitution narrative is often useful and accurate in the short term, but fails as a long-term story of life – we cannot outrun the inevitable losses of aging.

My first three examples of overheard conversations represent restitution. In the first, the husband’s life is saved when “they” (physician heroes) open his plugged coronary artery. In the second example, the storyteller assumes that the fatigue represents something fixable. In the example of the cancer relapse the storyteller hopes an experimental treatment suggested by the oncologist hero will restore health.

Chaos narrative

Individuals living in chaos lack a sense of viable future. Disconnected sentences pour out of the storyteller as a rapid-fire jangle of present assaults. This narrative is more common at the onset of a serious illness.

The conversation I overheard about back pain feels chaotic with one misfortune begetting another.

Quest narrative

The quest narrative views the illness experience as an opportunity to transform oneself into a better person through overcoming adversity, re-learning what is important in life and sharing with, and supporting, others who are suffering.

The last example of overheard conversations conveys gratitude for what illness taught the cancer survivor.

The clinical narrative

Consider the medical record as a restitution story told from the perspective of those of us working in healthcare. After prompting patients to tell their stories in a way that we can find meaning (“Please describe your pain. Is it sharp or dull? Did it travel anywhere? What brought it on?”), we capture a portion of the story in words, pictures and numerical data that may to help us discover something fixable, or at least explainable.

As we pursue our own storytelling to identify what we can control, we may overlook the chaos the patient is experiencing, or minimize how the patient feels about losing their personal story and life expectations because of the re-writing the illness is causing.

The excerpt below, describes a clinical summary for my hospitalization in May 2013 for a Transient Ischemic Attack (TIA).

This 62-year-old male noticed the sudden onset of imbalance while browsing in front of the refrigerator… On arrival he displayed staggering gait, inability to tandem walk and perhaps mildly slurred speech. A code 99 (possible stroke) was called. CT scan of the brain and a cerebral Magnetic Resonance angiogram (MRA) did not show an acute cerebral hemorrhage or infarct (stroke). The symptoms improved greatly during the first 3 hours and completely resolved within 12 hours. He was discharged to home on low dose aspirin therapy for presumptive diagnosis of Transient Ischemic Attack.

 Note that the summary is useful and concise for medical purposes, but lacks any trace of what the experience meant for me and how I would need, over time, to tell myself a story that would help me navigate vulnerability.

Please use comments to describe your thoughts about story-telling an illness. How can we strengthen our ability to hear the various narrative themes and help people look at the stories they are telling themselves?