Feeling of Rightness

     “The transient vacuities of … success, peace, happiness, and distraction – pale before the question of whether or not one experiences this life as meaningful. Moreover, the test of meaning is not a cognitive decision, so one should not suddenly quit this present life for any quixotic mission. Meaning is found, over the long haul, through the feeling of rightness within.”
     Hollis J. “Finding Meaning in the Second Half of Life.” Gotham Books, NY, 2005.
 
     “Wisdom traditions, the paths followed by our patients and our own experiences suggest that a sense of integrity comes through establishing healing connections. That’s not quite it. It wasn’t that the wave needed to establish connections. It was connected — part of a greater whole. Its challenge was to recognize the connectedness that was already there.”
     Mount BM. The existential moment. Palliat Support Care 2003; 1(1): 93-6.

Connecting

     “… practice sharing the fullness of your being, your best self, your enthusiasm, your vitality, your spirit, your trust, your openness, above all, your presence. Share it with yourself, with your family, with the world.”
     Kabat-Zinn J. “Full catastrophe living. Using the wisdom of your body and mind to face stress, pain and illness”. Dell Publishing, NY, 1990.


     "I don't help everyone [in terms of cures] ... I help them to show their true humanity, their true spirit, despite adversity ... Each of my patients told me what a difference I had made in their lives. All I did was to recognize their true selves and coax those to the surface, despite everything else that was happening ... Hope - not despair, not denial, not giving up, not demanding success ... It comes from knowing that the Universe cares about us, even when our desires are not possible ... The peacefulness of integrating these apparent contradictions is truly a miracle."                                                                                                  Lewis Mehl-Madrona MD

      “Meaning is, broadly speaking, the awareness of connectedness, importance, and felt significance among perceived objects both external and internal; narrowly speaking, it is the attribution of positive value to a particular configuration of attitudes, ideals, and connections that stand close to the center of one’s identity and are the key to judging importance in relation to time, persons, events, and the natural world.”
     Parks SD. “Big questions, worthy dreams. Mentoring young adults in their search for meaning, purpose, and faith.” John Wiley & Sons, San Francisco, 2000.

Honesty

     “At the outset the focus was, in true medical tradition, on the patients. What was wrong with them? What was this ‘unhappiness’ within them and how could it be defined, captured, and nailed into a scientific classification? I soon realized that the phenomenon coexisted in the doctor and in the doctor-patient relationship.
     What about the unhappy doctor? Only after a while in general practice did I vaguely begin to feel that I was dealing with something more than physical and mental illness, something that was part of my and the patients' existence. I found there was no ‘cure’ in the frame of reference in which I had been trained or was working.
     My negative feelings centered, broadly speaking, on a negative premonition (heartsink), irritation, anger, and frustration. These reactions were not necessarily all present at each consultation and were of varying intensities and subtleties, ranging from mild impatience to intense dislike.”
     Ellis CG. Chronic unhappiness. Investigating the phenomenon in family practice. Can Fam Physician 1996; 42: 645-51.

       Mindfulness practice is “not a mental struggle – it is not about thinking differently; rather it comes from getting out of our heads and into our bodies – that is, into the physical experience of the present moment.”
     “With whatever arises, whether it’s pleasing or not, try to remember that all we can do is experience and work with whatever our life is, right now. No matter what life is and no matter how we feel about it, all that matters in practice is whether we can honestly acknowledge what is going on, and then stay present with the physical experience of that moment. This is the way we come to experience true appreciation for our lives.”                       Ezra Bayda

     “… practice sharing the fullness of your being, your best self, your enthusiasm, your vitality, your spirit, your trust, your openness, above all, your presence. Share it with yourself, with your family, with the world.”
     Kabat-Zinn J. “Full catastrophe living. Using the wisdom of your body and mind to face stress, pain and illness”. Dell Publishing, NY, 1990.

International Conference on Physician Health 2012

The 2012 AMA-CMA-BMA International Conference on Physician Health will take place in Montreal, October 25-27, at the Westin.

Send your proposals for an oral, poster or workshop presentation using the new online abstract management system

Stay tuned for registration details coming in July. For more information, please email physicianhealthconference@cma.ca or visit www.cma.ca/physicianhealth.

Quality of Life

     Movement on the quality of life “continuum toward an experience of integrity & wholeness may be thought of as healing, (while the movement) toward suffering & anguish (may be thought of) as wounding.”
     Mount BM et al. Healing connections: on moving from suffering to a sense of well-being. J Pain Symptom Manage 2007; 33(4): 372-88.

     “The key to self-development … is the experience of … a state of relaxed concentration in which the individual neither freezes out of fear nor clings due to desire. … the free flow of vital energy within the body and between the body and the universe.”
     Sayama MK. “Samadhi. Self-development in Zen, swordsmanship, and psychotherapy.” State University of New York Press. 1986.

 

Emotions are adaptive

     “Many doctors have difficulty handling their own emotions — sorrow, guilt, identification, and feeling a failure are just part of the range of emotions reported. There is little evidence that these difficulties get easier as doctors become more experienced.
     Doctors are unaware that a failure to disclose information honestly to patients might be an attempt to protect their own emotional survival as much as to help protect the patient.”
     Fallowfield L, Jenkins V. Communicating sad, bad, and difficult news in medicine. Lancet 2004; 363(9405): 312-9.

     Research shows that “some emotions … will be painful and unpleasant but will promote healing. This makes it impossible to separate positive and negative emotions as if they were healthy and unhealthy, respectively. Assuming that unpleasant or negative emotion is unhealthy overlooks the primary function of emotions as being adaptive. … none of the affective-meaning states are inherently pathogenic. ... getting stuck or persistently ‘repeating’ any one of these components will cause emotional disorder … (Whereas) a healthy self-organizing trajectory reaches its completion as a meaningful, emotionally differentiated, and integrative experience. … it may begin as a sense of intense, poorly regulated, and ill-defined global malaise.”
     Pascual-Leone A, Greenberg LS. Emotional processing in experiential therapy: Why 'the only way out is through.' Journal of Consulting and Clinical Psychology 2007; 75(6): 875-887.

     Suffering begins with a perceived threat of destruction and ends either when the threat has passed, or a sense of integrity is otherwise restored.
     Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982; 306(11): 639-45.

Photo: ju_ju   www.dpreview.com

A journey

     “dying patients forced me to move from doing to being. Forced me to enter their experience, not observe their disease.
     I learned that the art of medicine represents the hero’s journey of awakening to the calling, a journey to the unknown, painful transformation and a return to service in the community.”

     Duffy J. Rediscovering the meaning in medicine: lessons from the dying on the ethics of experience. Palliat Support Care 2004; 2(2): 207-11.

When we had winters ...

 

Authenticity

     “Michael Kearney, an Irish psychiatrist and hospice physician, defined suffering as ‘the experience of an individual who has become disconnected and alienated from the deepest and most fundamental aspects of him or herself.’ Psychiatrist, Victor Frankl … asserted that: ‘Man is not destroyed by suffering, he is destroyed by suffering without meaning.’
     Coulehan J. Compassionate solidarity: suffering, poetry, & medicine. Perspect Biol Med 2009; 52(4): 585-603.

     “authenticity (is) the unimpeded functioning of one’s true self in daily life … is positively related to such important outcomes as self-actualization, self-concept clarity, and self-esteem.”
     Schlegel RJ et al. Thine own self: true self-concept accessibility and meaning in life. J Pers Soc Psychol 2009; 96(2): 473-90.

     One definition of spirituality is … “every person’s inherent search for ultimate meaning and purpose in life … including a relationship with … transcendence; relationships with others; as well as spirituality found in nature, art, and rational thought. Critical to the definition is that spirituality underlies the very nature of the relationship with our patients and each other.”
     Puchalski CM. Spirituality and medicine: curricula in medical education. J Cancer Educ 2006; 21(1): 14-8.

     “If we want to grow as teachers -- we must do something alien to academic culture: we must talk to each other about our inner lives -- risky stuff in a profession that fears the personal and seeks safety in the technical, the distant, the abstract.”
        Parker J. Palmer, The Courage to Teach: Exploring the Inner Landscape of a Teacher's Life 

Optimal adult development

     "Adult development is not merely a product of biology and social adaptation, but also involves individual choice and personal commitment to change. Indeed it should be viewed almost as the antithesis of childhood development. Throughout childhood and adolescence, one develops complex schemes and habituates to specific stimuli, until advanced levels of biological, cognitive, and social / emotional development are reached – physical maturation, abstract thinking, and autonomy. The liberative perspective requires that, for optimal adult development to occur, the individual must deconstruct the existing framework or at least not be constrained by expectations about how one should act or feel. Ideally, one returns to a state of receptivity or child-like openness to experience.”
      Levenson MR, Crumpler CA. Three Models of Adult Development. Human Development 1996; 39: 135-49. 

     “many elderly people exhibit (a form of self-transcendence called) gerotranscendence … characterized by a loss of traditional role-based definitions of the self. With increasing age, one experiences losses of friends, family, jobs, youthful looks, and so on, and thus the definition of the self becomes less dependent on externals. The boundaries between self and other also become more permeable, and one may become more aware of the unity of experience … called nonegoistic morality. … the progress of gerotranscendence can sometimes be hastened by crises.” 

     Aldwin CM, Levenson MR. Commentaries on Posttraumatic Growth: A Developmental Perspective. Psychological Inquiry 2004; 15(1): 19-92.

     Am I still caught-up in the momentum of childhood coping strategies in an endless losing battle to keep an unfriendly universe at bay - OR - can I enjoy a better quality of life – with actual joy, by choosing, moment-by-moment, to open up to reality as it is, warts and all, and live an authentic life?

Photo: BlackCorvid   www.dpreview.com

The Sight of Blood

     In first year dentistry, medicine, and other health-care professional programs, some students feel faint or actually keel over at the first sight of a cadaver or the first sight of blood, etc.

     Some students come up with every imaginable excuse to delay seeing their first patients.
     Some students "vote with their feet" ie skip lectures and seminars that involve behavioral sciences or medical humanities.
     Too many graduate health-care professionals when dealing with medically-unexplained symptoms will tell these patients that they "found nothing wrong," intentionally avoiding the psychosocial elephant in the room.
     The "hidden curriculum" arises, at least partially, due to our personal discomfort with the full breadth and depth of our disciplines.
     Indeed, a key element of leadership in health care is the "ability to inspire people to move to areas to which they don't want to go." Hudson AR. HealthcarePapers 2003; 4(1): 4-12.
     Avoidance comes very easily to many of us, while approach is challenging. Don't health-care professionals tend to avoid continuing education courses on topics about which they feel least competent, and thus clearly need the most?
     It's hard to imagine a seasoned health-care professional remaining uncomfortable at the sight of blood, yet too many of us continue to avoid addressing the very basis of this primal fear - fear of our own death. It's impossible to become knowledgeable and competent in this important area, if we persistently avoid it.

     "If all of us would make an all-out effort to contemplate our own death, to deal with our anxieties surrounding the concept of our death ... perhaps there could be less destructiveness around us."      Elizabeth Kubler-Ross 

       Niemiec CP et al. Being present in the face of existential threat: The role of trait mindfulness in reducing defensive responses to mortality salience. Journal of Personality and Social Psychology 2010; 99(2): 344-65.

     See also: http://mindfulnessforeveryone.blogspot.ca/2012/03/65-embracing-full-catastrophe.html

Photo: Andre Gallant   http://www.andregallant.com/

Unacceptable? Fear of Death, not Death, Ruins Lives

     I've had two different senior health-care professional colleagues emphatically tell me that their own death is "unacceptable." One of them became so upset from drawing up his will, that he abandoned the effort.

     "wise individuals evince less despair and greater equanimity because they (are) more likely to grapple with existential dilemmas and paradoxes that give life more meaning."
     Le TN. Life satisfaction, openness value, self-transcendence, and wisdom. Journal of Happiness Studies 2011; 12(2): 171-182.

     “The denial of impermanence, aging, and death is a big problem. It leads to a fundamental tightness of spirit and a fearful, reactive approach to life. The more we are willing to face that which we usually avoid, and even fear, the more we begin to relax at a fundamental level with ourselves. It is futile to fight with reality. It just doesn’t feel right. What a relief it is to stay with our experience fully, even when it is painful, and in turn be more fully present for others.” Judy Lief

Photo: Patty Capps   www.dpreview.com

Healing & Personal Disarmament

               “Hard to be soft
               Tough to be tender”                       “Help, I’m alive” song & lyrics by Metric

     “With understanding and compassion you will be able to heal the wounds in your heart and the wounds in the world.”                              Thich Nhat Hanh 
 

      “As compassion increases, we build bridges instead of borders; we move from hubris to humanity, from isolation to involvement.”                   Linda R. Douty

      “The ultimate metaphysical secret, if we dare state it so simply, is that there are no boundaries in the universe. Boundaries are illusions, products not of reality but of the way we map and edit reality. And while it is fine to map out the territory, it is fatal to confuse the two.” 

         Wilber K. No boundary. Eastern and Western approaches to personal growth. Shambhala, Boston, 1979.


Boundaries vs Psychological Defences: http://www.guidetopsychology.com/boundaries.htm

Photo: Lenthall   www.dpreview.com

 

Communication

     “Most of us believe the nonverbal message first and the words only if they match.”

     “The most important thing is that we let ourselves be as present as we can. Out of that we will have a better sense of what might be helpful right now.”

     Wegela KK. “How to Be a Help Instead of a Nuisance. Practical Approaches to Giving Support, Service, and Encouragement to Others.” Shambhala, Boston, 1996.

Photo: Andre Gallant   http://www.andregallant.com/

 

Being Helpful

     “… in order to be capable of benefiting others, we need first of all to deal with our own confusion – our own lack of confidence, our lack of clarity, and our fear of pain. To be helpful to others, we need to begin by working with ourselves.

      … the most valuable help we can give to another begins with developing our ability to simply be.”

       Wegela KK. “How to Be a Help Instead of a Nuisance. Practical Approaches to Giving Support, Service, and Encouragement to Others.” Shambhala, Boston, 1996.

     See also: http://healthyhealers.blogspot.ca/2012/12/self-knowledge-depth-and-healing.html 

Photo: BlackCorvid   www.dpreview.com

Approach-Avoidance Dichotomy

     “In contrast to many nurses and psychotherapists, physicians (and dentists) rarely learn to attune to their negative feelings. Yet evidence suggests that taking a few moments for self-awareness can reduce errors, improve decision-making, and resolve conflict. Basic psychology research shows that once people recognize their negative emotions, they readily correct their negative appraisals and actively seek more information about their situation.” 

     Halpern J. Empathy and patient-physician conflicts. J Gen Intern Med 2007; 22(5): 696-700.

Photo: Curtis Steele   http://www.cheerfuleye.com/

Intrinsically valuable

     "By ignoring expressed existential matters, doctors disregard their patients' humanity, which is a moral offense that is often perceived negatively. At the core of the conception of morality and human dignity is the idea that individuals are not reducible to objects, but intrinsically valuable."

       Agledahl KM, Gulbrandsen P, Forde R, Wifstad A. Curteous but not curious: how doctors' politeness masks their existential neglect. A qualitative study of video-recorded patient consultations. J Med Ethics 2011;37:650e654.

     But health-care professionals tend to derive our sense of acceptance primarily from external praise for ability and performance. We thus tend to be perfectionists, compulsive, needing to be in control, and tend to be emotionally fragile. We feel loved only while performing our professional roles perfectly.

       Fredrickson RE. Nova Scotia Dentist. Aug/Sept 2005.

 

     If you disagree with the last sentence above, check in with how you feel at other times.

     We treat ourselves no differently than we treat our patients. Patients, illness, ourselves - are all objectified, reduced to a simple, efficient, hollow formula.

     Until we first realize that the way in which we relate to ourselves is morally offensive, we'll continue to assume that we're good, caring clinicians.

A physician on burnout & self-care

 

"Medical processing" - our failure to deal with suffering

     Why do we systematically avoid the personal and human dimensions of our patients' - and our own - suffering?

Recorded medical appointment:

     The doctor greets the patient, a middle-aged man, inviting him to sit. He says he now has recovered from what was probably just an infection. The doctor turns to the computer, nodding occasionally while attending to the screen. 

     The patient suddenly speaks up: 'I have really been physically healthy all my life, right until my wife died three ... three years ago. Three years ago.' 

     The doctor looks at her computer, showing no reaction: 'Yes.' 

     Patient: 'And ... and then a great deal seemed to happen ... and so the last three years there has been a lot concerning my heart and so, but ... otherwise ... I guess I am ... relatively ... ' 

     The doctor: '... But otherwise you have been healthy, yes?' 

     Patient: 'Yes ...' 

     The doctor pulls her chair over to the patient and smiles: 'Then there is the big question that is asked of everyone who comes here: Do you smoke?'

       Agledahl KM, Gulbrandsen P, Forde R, Wifstad A. Curteous but not curious: how doctors' politeness masks their existential neglect. A qualitative study of video-recorded patient consultations. J Med Ethics 2011;37:650e654.

Disenchantment

 
     "We see the world not as it is but as we are."        Anais Nin

     “The great religions consider our usual mindless meandering through life to be a tragedy. They also worry that we are blind to the sacred – in the world, in others, and in ourselves.

     This blindness is particularly dramatic in the modern Western world, largely due to the power of science. So potent is the impact of science on our lives, so often are we bombarded by its descriptions of the universe as a great, meaningless machine, that this view can easily seem the natural and only way to look at things.

     The result is that we look out on what philosophers call a ‘disenchanted world’: a world seemingly stripped of meaning, significance, and spirit, and we see ourselves as equally barren. No wonder our society seems adrift, without a higher goal or vision. No wonder so many people feel their lives are meaningless and hunger for something more sustaining. This something more is freely available to us all. The problem is that very few people see it, since it requires cultivating a different way of knowing.

     Science is a superb method – the best humankind has ever found – for learning about physical objects and their properties. But it can see and say nothing of nonphysical things, such as meaning and purpose, values and spirit.” Roger Walsh MD, PhD

       Walsh R. “Essential spirituality. The 7 central practices to awaken heart and mind.” John Wiley & Sons Inc, NY, 1999.

Photo: Andre Gallant   http://www.andregallant.com/

 

Compulsive triad

     “The compulsive triad of doubt, guilt, and (an exaggerated sense of) responsibility can have an enormous impact on physicians’ professional, personal, and family lives.

     Diminished awareness of one’s physical and emotional needs leads to a self-destructive pattern of overwork. A psychology of postponement takes root, in which physicians habitually delay in attending to their significant relationships and other sources of renewal until all the work is done or the next professional hurdle is achieved.”

       Kearney MK. et al. Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival." Jama 2009; 301(11): 1155-64, E1.

     “The mass of men lead lives of quiet desperation. What is called resignation is confirmed desperation. ... A stereotyped but unconscious despair is concealed even under what are called the games and amusements of mankind. There is no play in them, for this comes after work. 

     But it is a characteristic of wisdom not to do desperate things.”                Henry David Thoreau

Photo: Brigitte Lorenz   http://www.brigittelorenz-photography.com/

To Burnout or Engage?

     "The key dimensions of burnout include emotional exhaustion, feelings of cynicism and depersonalization (detachment from the job), and a sense of ineffectiveness and lack of personal accomplishment. Emotional exhaustion refers to feelings of being overextended and depleted of one’s emotional and physical resources. Exhaustion prompts efforts to cope by distancing oneself emotionally and cognitively from work. Depersonalization refers to negative, callous, or excessively detached responses to various aspects of the job and is another distancing mechanism.

     The greater the mismatch between the person and the work environment, the greater is the likelihood of burnout. 

     A better match or fit is associated with greater engagement with work.”
       Kearney MK. et al. Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival." Jama 2009; 301(11): 1155-64, E1.

     "We tend to approach pleasurable opportunities to promote well-being and survival, and conversely avoid or withdraw from painful experiences as protection from harm. This biological approach-avoid dichotomy underlies all motivational tendencies, forms the basis of emotion and promotes adaptation.

     We're biologically and culturally programmed to seek pleasure and avoid discomfort."

     But life includes not only pleasure, but also pain, as well as uncomfortable periods of growth that take "place beyond one’s comfort zone - in liminality *** - a state of in-between-ness & ambiguity.
     Avoidance of liminality is the basic obstacle to engagement. Mindfulness practice cultivates acceptance of, and the ability to work within, liminality, and should therefore improve engagement."
     Lovas J, Gold E, Neish N, Whitehorn D, Holexa D. Cultivating Engagement through Mindfulness Practice. Poster Presentation, American Dental Education Association annual meeting, March 19, 2012, Orlando, FL.

     *** See: http://www.johnlovas.com/2013/06/liminality-insight-into-emptiness.html

Photo: Brigitte Lorenz   http://www.brigittelorenz-photography.com/

Self-awareness as a physical reality

     If asked "point to where you are", most of us would point to our temples - we're in our heads most of the time. Or more accurately, we're off in future plans or anxieties, or off in past embellished memories or regrets - in other words, we're rarely here, in our bodies, in real time.

     Our own illness brings our attention back, at least for a time, to reality - the fact that we have a body - that we live as a physical entity.

     We depend on body-awareness (the original, direct biofeedback) to manage not just our physical, but total health - we are after all one indivisible package. We also need to develop body-awareness, as part of self-awareness, to effectively interact with the external environment.

     Learning to self-manage diabetes involves "a sequential process integrally related to awareness of and attention to an understanding and interpretation of one’s body … ‘body listening’ … ‘tuning into my body’ "

       Price MJ. “Exploration of body listening: health and physical self-awareness in chronic illness.” ANS Adv Nurs Sci 1993; 15(4): 37-52.

Photo: Brigitte Lorenz   http://www.brigittelorenz-photography.com/

Healing ourselves first

     “Although ours is a healing profession, we do not always experience healing interactions within our ranks. We … must intentionally focus on healing ourselves from within. As we begin healing ourselves, we will have the potential to make a greater impact on the healing of others.”

      Jackson C. Healing ourselves, healing others: third in a series. Holist Nurs Pract 2004; 18(4): 199-210.

Photo: CJ Lan   dpreview.com

Faith?

     “… faith must be emancipated from its too-easy equation with belief and religion and reconnected with … matters of truth, reality, & ultimate importance. … personal, affective, visceral, and passional dimensions of being and knowing.

     If faith ( meaning-making in its broadest sense ) is discounted, the human landscape becomes arid, and hope and commitment wither; the human spirit grows parched, and not much more than a prickly cynicism can be sustained.

      if faith is understood as static, fixed, & inextricably bound to a particular language or world-view, it must be discarded as obsolete, if the integrity of intellect and soul is to be maintained in a dynamic world.

      Cynicism functions as a kind of armor against disappointment and despair. Skepticism combines the power to question with an openness to being convinced. Skepticism can be a healthy form of doubt, or it may reflect the loss of a once-shared trust in a universe of meaning, however that was defined. It may also function as a thin veneer of public sophistication, glossing over a private, lonely void that neither the rational mind nor economic success can fill. 
     In our time, we have become at once scientifically informed, philosophically relativistic, and disappointed & disillusioned in many quarters. Yet ironically (meaning) can come alive in an engagement with radical uncertainty.” 

         Parks SD. Big questions, worthy dreams. Mentoring young adults in their search for meaning, purpose, and faith. John Wiley & Sons, San Francisco, 2000. 

     See: http://www.johnlovas.com/2013/11/out-of-fearful-pessimism-we-isolate.html

Photo: cia  www.dpreview.ca

 

Self-concept Maturation

     "There are three aspects to the development of self-concept, which refer to the extent to which a person identifies him or herself as 
     • an autonomous individual, 
     • an integral part of humanity or society, or 
     • an integral part of the unity of all things as one independent whole, such as the universe. 

     Each aspect of self-concept corresponds to one of three character dimensions: 
     • self-directedness, 
     • co-operativeness and 
     • self-transcendence, respectively. 

     ... the well-balanced maturation of (these) character traits appears to be essential for the development of intrinsic academic motivation in medical students."

     Tanaka M. et al. Personality traits associated with intrinsic academic motivation in medical students. Med Ed 2009; 43(4): 384-7.

Andre Gallant   http://www.andregallant.com/

Epiphany

      Isn't it great to be surprised by how wonderful small events can be? Is this happening less and less frequently to you? It's not aging - it's an attitude thing. We need to be receptive - like being able to laugh spontaneously and wholeheartedly at jokes. We need to cultivate an open heart to be porous enough for these simple yet truly wonderful everyday blessings to enter our lives.

     “An epiphany is the conscious recognition that the mind’s edge has dissolved and a discovery is in the making. You see something about the world you had not seen before, and … you see something about yourself.”

       Jauregui A. Epiphanies. Where Science and Miracles Meet. Atria Books, NY, 2007.

From Luke's blog: http://crashinglybeautiful.tumblr.com/

Photo: Jean-Philippe Charbonnier (1921 – 2004)