Startle and Wonder

photo by Josh Scholten

We should always endeavour to wonder at the permanent thing, not at the mere exception. We should be startled by the sun, and not by the eclipse. We should wonder less at the earthquake, and wonder more about the earth.
~ G.K. Chesterton

As a physician, I’m trained to notice the exceptions.  Ordinarily I’m not particularly attentive to everything that is going well with the human body, instead concentrating on what is aberrant or could be made better.  This is unfortunate; there is much beauty and perfect design to behold in every person I meet.

Instead I am looking past the every day miracles to find what’s wrong.

To counter this tendency to just find flaws, I’ve learned over the years to talk out loud as I do physical assessments:  your eardrums look just as they should, your eyes react normally, your tonsils look fine, your thyroid feels smooth, your lymph nodes are tiny , your lungs are clear, your heart sounds are perfect, your belly exam is reassuring, your reflexes are symmetrical, your emotional response to a stress and your tears are completely appropriate.  I want to acknowledge what is working well, as it should, as it was designed to be.  I want a wonder of the human body and mind to extend to the person who inhabits it as well.

When the exception occurs, it is likely to startle and frighten the patient but I don’t want it to surprise me.  We must tackle it with everything we’ve got.

What gives us the strength to deal with the exception is how much in every person is right and wondrous.

Just as it was meant to be.

Inherited Specks

photo by Josh Scholten

Skin was earth; it was soil. I could see, even on my own skin, the joined trapezoids of dust specks God had wetted and stuck with his spit the morning he made Adam from dirt. Now, all these generations later, we people could still see on our skin the inherited prints of the dust specks of Eden.
~Annie Dillard from An American Childhood

A goodly portion of every clinic day is spent looking at my patients’ skin.  Most of the time, it is a quick assessment of color, moisture and texture before I go on to concentrate on the chief complaint that brought the patient in.  However, skin concerns frequently are the chief complaint — perhaps as straight forward as an abrasion or laceration, or a puzzling bump, an oozing sore, a total body itch, or an ominous pigmented lesion.

I feel like Sherlock Holmes when I focus on a patient’s outer covering in magnified detail.  I assume the identity of detective, inspector and archeologist all at once, trying to discern what is taking place on or beneath a piece of dermatologic geography.

No matter what the diagnosis or the treatment plan, I’m continually awestruck by the topography of skin.  This supple landscape is made up of trapezoidal specks connected one to another, just like the soil upon which I tread.   Skin cells are in a state of constant renewal, the dead and discarded falling off to rejoin the dust from which it came.

This elaborate matrix of collagen and keratin is the foundation for our scaffolding and our shroud.

His spit provides the superglue: the rivets, the bolts and the nails that bind us together for a lifetime.

We are created to be far more than a mere pile of random dust specks.

Lenten Grace — Washed Clean

Jesus washing the feet of his disciples by Finnish artist Albert Gustaf Edelfelt

What e’er the soul has felt or suffered long,
Oh, heart! this one thing should not be forgot:
Christ washed the feet of Judas.
~George Marion McClellan
from “The Feet of Judas” in The Book of American Negro Poetry 1922

As an aide in a rest home caring for the crippled feet of the elderly,
as a medical student in an inner city hospital seeing the homeless whose socks had to be peeled off carefully to avoid pulling off gangrenous toes, as a doctor working with the down and out detox patients from the streets who had no access to soap and water for weeks,

I’ve washed feet as part of my job.

People always protest, just as Peter did when Jesus started to wash his feet.
We never believe our feet,
those homely gnarled bunioned claw-toed calloused parts of us,
deserve that attention.

We are ashamed to have someone care about them, care for them, when we don’t care enough on our own.

I have never washed the feet of someone about to betray me, leading me to my death.

I have never had my feet washed by someone who understood my heart needed cleansing even more than my feet, who loved me that much.

Until now.

This one thing should not be forgot:
Kneeling, He wears the humility and towels of a servant as His only raiments. He gently cups our heels in His palms, washes and dries our soles and arches and toes, but our hearts are held, still beating,  in His loving hands.

sculpture by Mark Greine

Good Medicine

photo by Josh Scholten

A good night sleep, or a ten minute bawl, or a pint of chocolate ice cream, or all three together, is good medicine.
~Ray Bradbury

If there is anything I’ve learned in 35 years of my medical career, it’s that I still must “practice” my art every day.  As much as we physicians emphasize the science of what we do, utilizing “evidence based” decisions, there are still days when a fair amount of educated guessing and a gut feeling is based on my past experience, along with my best hunch.  Many patients don’t arrive with classic cook book symptoms that fit the standardized diagnostic and treatment algorithms so the nuances of their stories require interpretation, discernment and flexibility.    I appreciate a surprise once in awhile that makes me look at a patient in a new or unexpected way and teaches me something I didn’t know before.   It keeps me coming back for more, to figure out the mystery and dig a little deeper.

I’ve also learned that not all medicine comes in pills or injections.  This isn’t really news to anyone, but our modern society is determined to seek better living through chemistry, the more expensive and newer the better, whether prescribed or not.  Chemicals have their place, but they also can cause havoc.  It is startling to see medication lists topping a dozen different daily pills.  Some are life-saving.  Many are just plain unnecessary.

How many sleep without the aid of pill or weed or alcohol?  Fewer and fewer.  Poor sleep is one of the sad consequences of our modern age of too much artificial light, too much entertainment keeping us up late, and not enough physical work to exhaust our bodies enough to match our frazzled and fatigued brains.

How many of us allow ourselves a good cry when we feel it welling up?  It could be a sentimental moment–a song that brings back bittersweet memories, a commercial that touches just the right chord of feeling and connection.  It may be a moment of frustration and anger when nothing seems to go right.  It could be the pain of physical illness or injury or the stress of emotional turmoil.  Or just maybe there is weeping when everything is absolutely perfect and there cannot be another moment just like it, so it is tough to let it go unchristened by tears of joy.

And without a doubt, the healing qualities of chocolate are unquestioned by this doctor, however it may be consumed.  It can fix most everything that ails a person. at least for an hour or two.

It doesn’t take an M.D. degree to know the best medicine.  It just takes a degree of common sense.
Time for bed and time to turn off the light.  A good bawl and chocolate will wait for another night.

 

What the Soul Is

photo by Nate Gibson

“I believe I will never quite know.
Though I play at the edges of knowing,
truly I know
our part is not knowing,
but looking, and touching, and loving,
which is the way I walked on,
softly,
through the pale-pink morning light.”

~Mary Oliver from Bone

This morning I got up in the middle of the night to head south to Seattle for a conference on “Transforming Health Care: Improving Quality and Lowering Costs”, traveling in the dark pre-dawn and arriving at a very busy hospital campus. Even at 6:30 AM this place is bustling with shift workers coming and going, doctors and patients arriving for a day of procedures and caregiving. Though I spent a decade of my life training and working on this city hill, I always feel out of place, a fish out of water when I return.

However estranged I feel from the busy city, I feel in familiar surroundings when I see patients, their anxieties and fears plain on their faces as they wait their turn. This is the life I chose, to serve those in need however I can, with whatever resources I have. It is the look, the touch, and love I have to give. It is all I have, far more than my knowledge which pales when compared to everything there is to know, far more than the ultimate skill and expertise. We are souls in mutual need, moving into the pink light of dawn on a winter morning, trying to leave behind the darkness of our fears of mortality.

I am here for you. And there will always be more of you, waiting, worrying, wondering if someone will care for them with more than knowledge–someone who will see you for who you are, touch you with gentle skill, and love you, really love you–no matter what.

Cat-Like Observation

photo by Nate Gibson

Even doctors must become patients eventually, and often challenging patients at that.  We know enough to be dangerous but not enough to be in charge.  We want to question everything but try not to.  We can tend to be catastrophic thinkers because that is how we are trained to be, but fear being alarmists.  We want our care providers to actually like us, when we know they inwardly cringe knowing they are dealing with another physician.  We wouldn’t want to take care of us either.

Due to intermittent changes in vision in one eye, I have recently been getting some practice at trying to be a model patient.  Unfortunately, I have become an ‘interesting’ patient, something no patient really wants to be.  That means the symptoms are not classic, the diagnostic tests not straight forward, the exam findings not clear cut, the differential diagnosis list very long.   It also usually means a visit to a tertiary care center for a visit with a sub-subspecialist to try to pick the brain of one of the handful of living physicians who thoroughly understands one aspect of complex human physiology and anatomy.  As a primary care physician who always sees an entire forest when I approach a patient, it is a unique experience to watch a colleague at work who truly concentrates on understanding one leaf on one tree.

A public academic training institution’s subspecialty care outpatient clinic is a fascinating place to spend a few hours.  The waiting room was packed to capacity with people from all walks of life sharing our afternoon together because of a shared concern about one small but crucial part of our bodies — our retinas.  We were all told the average time spent in clinic could be three hours or more and we all knew it was worth the wait so didn’t mind a bit.   Despite the long wait, not one of us would have thought to object when a couple of sheriff deputies accompanying a shackled county jail inmate dressed in his orange jumpsuit were escorted right into an exam room, rather than taking the only empty seats in the waiting room next to several elderly ladies.   We figured he was more than welcome to jump to the head of the line.

Finally my turn came to be seen first by a technician, and then a resident physician, then more testing with more technicians, and finally by the subspecialist attending physician himself.  I appreciated his gracious greeting acknowledging me as a colleague, but also his unhesitating willingness to be my doctor so I could be his patient.  His assessment after his exam  and review of everything that had been done:  there was no clear cause for my symptoms,  so my diagnosis would carry an “undifferentiated” label rather than the currently less preferred “idiopathic” label.   In other words, he didn’t know for sure what was up with my retina and as an expert he didn’t like to admit that, but there it was.

He then smiled and said “so for now we’ll treat you with MICCO.”

MICCO?  I knew there are many new unique pharmaceutical names that I have not been able to keep up with, but this was a brand new one to me that I figured only a sub-subspecialist would know about and be able to prescribe.

So he explained: Masterful Inactivity Coupled with Cat-like Observation.

In other words, do nothing for the moment but keep a close eye on it and be ready to pounce the minute something changes. Watchful waiting.

I am relieved to only be under watchful surveillance for now even though my diagnosis, its etiology and prognosis is unclear.  I realize it is a treatment strategy I need to use more in my own clinical practice.    It helps solidify that doctor/patient partnership, especially when the patient is a doctor;  I am content to do nothing but watch for now,  knowing I’m being watched.

It was an afternoon well spent in the sub-subspecialty world, as I come away with a commonsense piece of advice very appropriate for some patients in my own primary care practice:

Right now it might appear I’m doing nothing, but doing nothing makes the most sense and is the least risky option.  I’m keeping my unblinking eye on you, ready to spring into action if warranted.

Treatment plan: MICCO prn

photo by Nate Gibson

photo by Nate Gibson

photo by Nate Gibson

Open for Business

photo by Josh Scholten

Astonishing material and revelation appear in our lives all the time. Let it be. Unto us, so much is given. We just have to be open for business.
~Anne Lamott from Help Thanks Wow: Three Essential Prayers

I have the privilege to work in a profession where astonishment and revelation awaits me behind each exam room door.

In a typical clinic day, I open that door 36 times, close it behind me and settle in for the ten or fifteen minutes I’m allocated per patient.  I need to peel through the layers of a person quickly to find the core of truth about who they are and why they’ve come to me.

Sometimes what I’m looking for is right on the surface: in their tears, in their pain, in their fear.  Most of the time, it is buried deep and I need to wade through the rashes and sore throats and coughs and headaches to find it.

Once in awhile, I can actually do something tangible to help right then and there — sew up a cut, lance a boil, splint a fracture, restore hearing by removing a plug of wax from an ear canal.

Often I find myself giving permission to a patient to be sick — to take time to renew, rest and trust their bodies to know what is best for a time.

Sometimes, I am the coach pushing them to stop living sick — to stop hiding from life’s challenges, to stretch even when it hurts, to get out of bed even when not rested, to quit giving in to symptoms that can be overcome rather than overwhelming.

Always I’m looking for an opening to say something a patient may think about after they leave my clinic — how they can make better choices, how they can be bolder and braver in their self care, how they can intervene in their own lives to prevent illness, how every day is a thread in the larger tapestry of their lifespan.

Each morning I rise early to get work done before I actually arrive at work,  trying to avoid feeling unprepared and inadequate to the volume of tasks heaped upon the day.   I know I may be stretched beyond my capacity, challenged by the unfamiliar and stressed by obstacles thrown in my way.  It is always tempting to go back to bed and hide.

Instead, I go to work as those doors need to be opened and the layers peeled away.  I understand the worry, the fear and the pain because I have lived it too.   I am learning how to let it be, even if it feels miserable.  It is a gift perhaps I can share.

No matter what waits behind the exam room door,  it will be astonishing to me.

I’m grateful to be open for business.  The Doctor is In.

photo by Josh Scholten

Now and Now

photo by Josh Scholten

And so you have a life that you are living only now, now and now and now, gone before you can speak of it, and you must be thankful for living day by day, moment by moment … a life in the breath and pulse and living light of the present…
~Wendell Berry

My days are filled with anxious people, one after another after another.  They sit at the edge of their seat, eyes brimming, fingers gripping the arms of the chair.  Each moment, each breath, each rapid heart beat overwhelmed by fear-filled questions:  will there be another breath?  must there be another breath?   Must this life go on like this in panic of what the next moment will bring?

The only thing more frightening than the unknown is the known that the next moment will be just like the last.  There is a deficit of thankfulness, no recognition of a moment just passed that can never be retrieved and relived.   There is only fear of the next and the next so that the now and now is lost forever.

Their worry and angst is contagious as the flu.
I mask up and wash my hands of it throughout the day.
I wish a vaccination could protect us all from unnamed fears.

I want to say to them and myself:
Stop.  Stop this.  Stop this moment in time.
Stop expecting some one, some thing or some drug must fix this feeling.
Stop being blind and deaf to the gift of each breath.
Just stop.
And simply be.

I want to say:
this moment is ours,
this moment of weeping and sharing
and breath and pulse and light.
Shout for joy in it.
Celebrate it.
Be thankful for tears that can flow over grateful lips.

Stop me before I write,
because of my own anxiety,
yet another prescription
you don’t really need.

Just be–
and be blessed–
in the now and now.

Obscurity in Medicine

photo by Josh Scholten

Be obscure clearly.
~E. B. White

As a family doctor, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  To begin with, there is much that is still unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, not at all pristine and clear.
Let’s face the lack of facts.  A physician’s clinical work is obscure even on the best of days when everything goes well.  We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Over thirty years of doctoring in the midst of the mystery of medicine — learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done will be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The patient shares responsibility for maintenance of their medical records and assists the diagnostic process by providing online symptom and outcomes documentation.   The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure clearly.   Lives depend on it.

Realm of Briar

photo by Josh Scholten

Far from Love the Heavenly Father 
Leads the Chosen Child, 
Oftener through Realm of Briar 
Than the Meadow mild.

~Emily Dickinson

I know folks being dragged through the realm of briar right now.  They are dealing with life-threatening disease, disintegration of relationships, significant mental health challenges or the results of random tragedy.  The cruelty of so much earthly suffering cannot be easily explained nor dismissed.  It feels “far from love” to be chosen to walk through a place that rips and tears away at one’s very flesh and spirit.  Yet many of us are chosen to experience such trials rather than allowed to live life in the mild meadow.

The only consolation is that we are not alone on this path of pain.  The Chosen Child, sent to walk alongside us through the realm of briar,  bleeds with us, bleeds because of us, bleeds for us, bleeds when we have nothing left, ultimately bleeds so we no longer have to.

To be everlastingly filled, we must first be emptied.

To find our forever home, we must admit we have lost our way and need rescue.

Accompanied through the realm of briar, we suffer wounds that only Love can heal.