Doc Season

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It may not be rabbit season or duck season but it definitely seems to be doc season, especially as the next version of the American Health Care Act is unveiled today. This (and the Affordable Care Act which preceded it) is not about patients — it is about how to keep doctors and the health care industry under reasonable cost control and maintain some semblance of quality service.

Physicians are lined up squarely in the gun sights of the media, government agencies and legislators, as well as our employers and coworkers, not to mention our own professional organizations, our Board Certifying bodies, and our dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim. It’s not enough any more to wear a bullet proof white coat. It’s driving doctors to hang up their stethoscope much earlier than they expected just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too over-committed, uncaring, egotistical, close-minded, inflexible, and especially, and most annoyingly – perpetually late.

One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule. Doctors do run late and patients wait. And wait. And wait some more. Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character as well as their salary compensation.  It is considered basic Customer Service 101.

I admit I’m one of those late doctors. I don’t share the reasons why I’m late with my patients as I enter the exam room apologizing for my tardiness. Taking time to explain takes time away from the task at hand: taking care of the person sitting or lying in front of me. At that moment, they are the most important person in the world to me. More important than the six waiting to see me, more important than the several dozen emails and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message from my daughter from school or the worry I carry about my dying mother.

I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources. I don’t earn more by seeing more patients. There is a work load that I’m expected to carry and my day doesn’t end until that work is done. Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch. I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.

The patient who is angry about waiting for me to arrive in the exam room can’t know that I’m late because the previous patient just found out that her upset stomach was caused by an unplanned and unwanted pregnancy. Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair. Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection is showing signs of a pulmonary embolism caused by oral contraceptives. Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men, or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to a suspicion of undiagnosed chronic hepatitis.

Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs. Quite the opposite. We strive to make our patients feel respected, listened to and cared for. Most days it is a challenge to do that well and stay on time. For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time. The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”

Patients need to bring a book or catch up on correspondence,  bring knitting, schedule for the first appointment of the day. They also need to bring along a dose of charitable grace when they see how crowded the waiting room is. It might help to know you are not alone in your worry and misery.

But your doctor and health care team is very alone, scrambling to do the very best healing they can in the time available.

I’m not hanging my stethoscope up anytime soon though some days I’m so weary by the end, I’m not sure my brain between the ear tips is still functioning. I don’t wear a bullet proof white coat since I refuse to be defensive. If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed to the needs of the “most important person in the whole world.”

And that human being deserves every minute I can give them.

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A Crack in Everything

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The birds they sang
At the break of day
Start again
I heard them say
Don’t dwell on what
Has passed away
Or what is yet to be

Ah the wars they will
Be fought again
The holy dove
She will be caught again
Bought and sold
And bought again
The dove is never free

You can add up the parts
but you won’t have the sum
You can strike up the march,
there is no drum
Every heart, every heart
to love will come
but like a refugee.

Ring the bells that still can ring
Forget your perfect offering
There is a crack, a crack in everything
That’s how the light gets in.
~Leonard Cohen from “Anthem”

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Our cracks expand with age:
do they not heal as quickly
or are we more brittle than before?

I know how my eyes leak,
my heart feels more porous.
The events of the day break me open even wider.

Let the light pour in
and illuminate our wounds old and new.
Let the world know
that from the hurt comes healing.

May we become the perfect offering.

 

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One at a Time

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They know so much more now about
the heart we are told but the world
still seems to come one at a time
one day one year one season and here
it is spring once more with its birds
nesting in the holes in the walls
its morning finding the first time
its light pretending not to move
always beginning as it goes
~W.S.Merwin “To This May”

 

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Each morning is a fresh try at life,
a new chance to get things right
even if all our yesterdays are broken.

So I drink in the golden dawn,
take a deep breath of cool air
and dive in head first
into light and blossoms,
hoping I too just might
stay afloat today.

 

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Supposing It Didn’t

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“Supposing a tree fell down, Pooh, when we were underneath it?”

“Supposing it didn’t,” said Pooh after careful thought.

Piglet was comforted by this.
~A.A. Milne

 

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It is the final week of a very long academic year and tension is running high.

Among those students to whom I provide care,
there are many who dwell deeply in “what if?” mode,
immobilized in their anticipation of impending disaster.

I understand this line of thinking,
particularly in this day and age of
“in the moment” tragedy
played out real-time in the palm of our hand
and we can’t help but watch as it unfolds.

Those who know me well
know I can fret and worry
better than most.
Medical training only makes it worse.
It teaches one to think catastrophically.
That is what I do for a living,
to always be ready for the worse case scenario.

When I rise, sleepless,
to face a day of uncertainty
as we all must do at times~
after careful thought,
I reach for the certainty I am promised
over the uncertainty I can only imagine:

What is my only comfort in life and in death?
That I am not my own, but belong
—body and soul, in life and in death—
to my faithful Savior, Jesus Christ.

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“Supposing it didn’t” — He says to reassure us.

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The Dearest Freshest Deep Down Things

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THE WORLD is charged with the grandeur of God.
It will flame out, like shining from shook foil;
It gathers to a greatness, like the ooze of oil
Crushed. Why do men then now not reck his rod?
Generations have trod, have trod, have trod;
And all is seared with trade; bleared, smeared with toil;
And wears man’s smudge and shares man’s smell: the soil
Is bare now, nor can foot feel, being shod.

And for all this, nature is never spent;
There lives the dearest freshness deep down things;
And though the last lights off the black West went
Oh, morning, at the brown brink eastward, springs—
Because the Holy Ghost over the bent
World broods with warm breast and with ah! bright wings.
~Gerard Manley Hopkins “God’s Grandeur”

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Unless the eye catch fire,
Then God will not be seen.
Unless the ear catch fire
Then God will not be heard.
Unless the tongue catch fire
Then God will not be named.
Unless the heart catch fire,
Then God will not be loved.
Unless the mind catch fire,
Then God will not be known.
~William Blake from “Pentecost”

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Today, when we feel we are without hope,
when the bent world reels in blood and violence,
when faith feels frail,
when love seems distant,
we wait, stilled,
for the moment we are lit afire ~
when the Living God is
seen, heard, named, loved, known
forever burning in our hearts deep down,
brooded over by His bright wings
we are His dearest, freshest
in this moment
and eternity.

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All Things Frail and Imperiled

 

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Here, I place
a blue glazed cup
where the wood
is slightly whitened.
Here, I lay down
two bright spoons,
our breakfast saucers, napkins
white and smooth as milk.

I am stirring at the sink,
I am stirring
the amount of dew
you can gather in two hands,
folding it into the fragile
quiet of the house.
Before the eggs,
before the coffee
heaving like a warm cat,
I step out to the feeder—
one foot, then the other,
alive on wet blades.
Air lifts my gown—I might fly—

This thistle seed I pour
is for the tiny birds.
This ritual,
for all things frail
and imperiled.
Wings surround me, frothing
the air. I am struck
by what becomes holy.

A woman
who lost her teenage child
to an illness without mercy,
said that at the end, her daughter
sat up in her hospital bed
and asked:

What should I do?
What should I do?

Into a white enamel bath
I lower four brown eggs.
You fill the door frame,
warm and rumpled, kiss
the crown of my head.
I know how the topmost leaves
of dusty trees
feel at the advent
of the monsoon rains.

I carry the woman with the lost child
in my pocket, where she murmurs
her love song without end:
Just this, each day:
Bear yourself up on small wings
to receive what is given.

Feed one another
with such tenderness,
it could almost be an answer.
~Marcia F. Brown “Morning Song”

 

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I am comforted by rituals, as are we all.
The feeding, the cleaning,
the washing, the nurture,
the smoothing of the wrinkled and ruffled,
the sacred time of rest.

It is those small things that get us through the day,
that create holiness in each breath, each moment.

What should I do next? What should I do?

No need to wonder. I am led to what is needed.

 

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When the Storm Passes

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This has been a wild weather month on the outside:

heavy winds at times, damaging hale storms, snowfall covering the foothills, sweaty sunny middays, torrential unpredictable showers, ankle-deep mud.

And inside my cranium:

words that flew out too quickly, anxiety mixed with a hint of anger, too easy tears, searing frustration, feeling immobilized by the daily muck and mire.

The unpredictable month of May needs no explanation for acting like October, December and August within a span of a few hours.  I am not so easily forgiven or unburdened.  I end up lying awake at night with regrets, composing apologies, and wanting to hide under a rock until the storm blows over.

But in the midst of all the extremes, while the storm is raging, a miracle takes place:
it can only happen when brilliant light exposes weeping from heavy laid clouds, like the rainbow that dropped from heaven last week to touch the earth right in our backyard, only a few feet from our barn.

God cries too.  His wept tears have lit up the sky in a promise of forgiveness.
He assures us: this storm too will pass.

He assures us because He knows we need it.

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