“When a newspaper posed the question, ‘What’s Wrong with the World?’ the Catholic thinker G. K. Chesterton reputedly wrote a brief letter in response:
‘Dear Sirs: I am. Sincerely Yours, G. K. Chesterton.’
That is the attitude of someone who has grasped the message of Jesus.” ~Timothy Keller, The Prodigal God
O lovely apple! beautifully and completely rotten hardly a contour marred–
perhaps a little shrivelled at the top but that aside perfect in every detail! O lovely
apple! what a deep and suffusing brown mantles that unspoiled surface! No one
has moved you since I placed you on the porch rail a month ago to ripen.
No one. No one! ~William Carlos Williams “Perfection”
I am what’s wrong with the world and so are you.
Not one of us escapes the rottenness that lies not-so-deep beneath our shiny surface. We are full of wormholes, inviting the worms of the world to eat us alive.
One look at the news headlines of the day is enough mar the most perfect surface. No one moves to save us from our over-ripening fate; we sit untouched, withering and shriveling.
We are the problem and the problem is us.
We need rescue by a Savior who is the one good apple among a barrel of contagiously bad apples. We are so tainted, it takes Someone who truly is Perfect to transform us from the inside out, from worm-holes back to wholeness and on to holiness.
May we fall to our knees, weeping and grateful, that Christ, who is the Leader of all in His Kingdom, will grant us a grace and sanctuary we emphatically don’t deserve.
May He pick us before the worms do. We are in this together.
Sometimes when I watch trees sway, From the window or the door. I shall set forth for somewhere, I shall make the reckless choice Some day when they are in voice And tossing so as to scare The white clouds over them on. I shall have less to say, But I shall be gone. ~Robert Frost from “The Sound of Trees”
There is a thing in me that dreamed of trees, A quiet house, some green and modest acres A little way from every troubling town, Al little way from factories, schools, laments. I would have time, I thought, and time to spare, With only streams and birds for company, To build out of my life a few wild stanzas. And then it came to me, that so was death, A little way away from everywhere. ~Mary Oliver from “A Dream of Trees” from New and Selected Poems
As I wind down my work load, for once sharing the calls at night, and allowing others to manage the day time urgencies,
I wonder if I shall have less to say, and whether I will become less myself.
A life of non-stop doctoring means having little time for anything else. Soon I will have time and time to spare.
I wonder about the trees and how To build out of my life a few wild stanzas.
The thing to cling to is the sense of expectation. Who knows what may occur in the next breath? In the pallor of another morning we neither Anticipated nor wanted! … we live in wonder, Blaze in a cycle of passion and apprehension Though once we lay and waited for a death. ~Carolyn Kizer from “Lines to Accompany Flowers For Eve”
Over seventy years ago my maternal grandmother, having experienced months of fatigue, abdominal discomfort and weight loss, underwent exploratory abdominal surgery, the only truly diagnostic tool available at the time. One brief look by the surgeon told him everything he needed to know: her liver and omentum were riddled with tumor, clearly advanced, with the primary source unknown and ultimately unimportant. He quickly closed her up and went to speak with her family – my grandfather, uncle and mother. He told them there was no hope and no treatment, to take her back home to their rural wheat farm in the Palouse country of Eastern Washington and allow her to resume what activities she could with the time she had left. He said she had only a few months to live, and he recommended that they simply tell her that no cause was found for her symptoms.
So that is exactly what they did. It was standard practice at the time that an unfortunate diagnosis be kept secret from terminally ill patients, assuming the patient, if told, would simply despair and lose hope. My grandmother passed away within a few weeks, growing weaker and weaker to the point of needing rehospitalization prior to her death. She never was told what was wrong and, more astonishing, she never asked.
But surely she knew deep in her heart. She must have experienced some overwhelmingly dark moments of pain and anxiety, never hearing the truth so that she could talk about it with her physician and those she loved. But the conceit of the medical profession at the time, and indeed, for the next 20-30 years, was that the patient did not need to know, and indeed could be harmed by information about their illness.
We modern more enlightened health care professionals know better. We know that our physician predecessors were avoiding uncomfortable conversations by exercising the “the patient doesn’t need to know and the doctor knows better” mandate. The physician had complete control of the health care information–the details of the physical exam, the labs, the xray results, the surgical biopsy results–and the patient and family’s duty was to follow the physician’s dictates and instructions, with no questions asked.
Even during my medical training in the seventies, there was still a whiff of conceit about “the patient doesn’t need to know the details.” During rounds, the attending physician would discuss diseases right across the hospital bed over the head of the afflicted patient, who would often worriedly glance back and worth at the impassive faces of the intently listening medical student, intern and resident team. There would be the attending’s brief pat on the patient’s shoulder at the end of the discussion when he would say, “someone will be back to explain all this to you.” But of course, none of us really wanted to and rarely did.
Eventually I did learn how important it was to the patient that we provide that information. I remember one patient who spoke little English, a Chinese mother of three in her thirties, who grabbed my hand as I turned to leave with my team, and looked me in the eye with a desperation I have never forgotten. She knew enough English to understand that what the attending had just said was that there was no treatment to cure her and she only had weeks to live. Her previously undiagnosed pancreatic cancer had caused a painless jaundice resulting in her hospitalization and the surgeon had determined she was not a candidate for a Whipple procedure. When I returned to sit with her and her husband to talk about her prognosis, I laid it all out for them as clearly as I could. She thanked me, gripping my hands with her tear soaked fingers. She was so grateful to know what she was dealing with so she could make her plans, in her own way.
Forty years into my practice of medicine, I now spend a significant part of my patient care time providing information that helps the patient make plans, in their own way. I figure everything I know needs to be shared with the patient, in real time as much as possible, with all the options and possibilities spelled out. That means extra work, to be sure, and I spend extra time on patient care after hours more than ever before in my efforts to communicate with my patients. I’m not alone as a provider who feels called to this sharing of the medical chart – the nationwide effort is referred to as Open Notes.
Every electronic medical record chart note I write is sent online to the patient via a secure password protected web portal, usually from the exam room as I talk with the patient. Patient education materials are attached to the progress note so the patient has very specific descriptions, instructions and further web links to learn more about the diagnosis and my recommended treatment plan. If the diagnosis is uncertain, then the differential is shared with the patient electronically so they know what I am thinking. The patient’s Major Problem List is on every progress note, as are their medications, dosages and allergies, what health maintenance measures are coming due or overdue, in addition to their “risk list” of alcohol overuse, recreational drug use including marijuana, eating and exercise habits and tobacco history. Everything is there, warts and all, and nothing is held back from their scrutiny.
Within a few hours of their clinic visit, they receive their actual lab work and copies of imaging studies electronically, accompanied by an interpretation and my recommendations. No more “you’ll hear from us only if it is abnormal” or “it may be next week until you hear anything”. We all know how quickly most lab and imaging results, as well as pathology results are available to us as providers, and our patients deserve the courtesy of knowing as soon as we do, and now regulations insist that we share the results. Waiting for results is one of the most agonizing times a patient can experience. If it is something serious that necessitates a direct conversation, I call the patient just as I’ve always done. When I send electronic information to my patients, I solicit their questions, worries and concerns by return message. All of this electronic interchange between myself and my patient is recorded directly into the patient chart automatically, without the duplicative effort of having to summarize from phone calls.
Essentially, the patient is now a contributor/participant in writing the “progress” (or lack thereof) note in the electronic medical chart.
In this new kind of health care team, the patient has become a true partner in their illness management and health maintenance because they now have the information to deal with the diagnosis and treatment plan. I don’t ever hear “oh, don’t bother me with the details, just tell me what you’re going to do.”
My patients are empowered in their pursuit of well-being, whether living with chronic illness, or recovering from acute illness. No more secrets. No more power differential. No more “I know best.”
After all, it is my patient’s life I am impacting by providing them open access to the self-knowledge that leads them to a better appreciation for their health and and clearer understanding of their illnesses.
As a physician, I am impacted as well; it is a privilege to live and work in an age where such illumination in a doctor~patient relationship is possible.
Tired and hungry, late in the day, impelled to leave the house and search for what might lift me back to what I had fallen away from, I stood by the shore waiting. I had walked in the silent woods: the trees withdrew into their secrets. Dusk was smoothing breadths of silk over the lake, watery amethyst fading to gray. Ducks were clustered in sleeping companies afloat on their element as I was not on mine.
I turned homeward, unsatisfied. But after a few steps, I paused, impelled again to linger, to look North before nightfall-the expanse of calm, of calming water, last wafts of rose in the few high clouds.
And was rewarded: the heron, unseen for weeks, came flying widewinged toward me, settled just offshore on his post, took up his vigil. If you ask why this cleared a fog from my spirit, I have no answer. ~Denise Levertov “A Reward” from Evening Train.
~Lustravit lampade terras~ (He has illumined the world with a lamp) The weather and my mood have little connection. I have my foggy and my fine days within me; my prosperity or misfortune has little to do with the matter. – Blaise Pascal from “Miscellaneous Writings”
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 from Hannah Coulter
Worry and sorrow and angst are more contagious than the flu. I mask up and wash my hands of it throughout the day. There should be a vaccination against unnamed fears.
I want to say to my patients and to myself: Stop now, this moment in time. Stop and stop and stop.
Stop needing to be numb to all discomfort. Stop resenting the gift of each breath. Just stop. Instead, simply be.
I want to say: this moment, foggy or fine, is yours alone, 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 just as rain can clear the fog. Stop holding them back.
Just be– be blessed in both the fine and the foggy days– in the now and now and now.
When I lay these questions before God I get no answer.
But a rather special sort of “No answer.”
It is not the locked door.
It is more like a silent,
certainly not uncompassionate,
As though he shook his head not in refusal but waiving the question.
Like, “Peace, child; you don’t understand.”
Can a mortal ask questions which God finds unanswerable?
Quite easily, I should think.
All nonsense questions are unanswerable.
How many hours are there in a mile?
Is yellow square or round?
Probably half the questions we ask –
half our great theological and metaphysical problems –
are like that. ~C.S. Lewis from A Grief Observed
I know now, Lord, why you utter no answer. You are yourself the answer. Before your face questions die away. ~C.S. Lewis from Till We Have Faces
And now brothers, I will ask you a terrible question, and God knows I ask it also of myself. Is the truth beyond all truths, beyond the stars, just this: that to live without him is the real death, that to die with him the only life?
~Frederich Buechner from The Magnificent Defeat
And that is just the point… how the world, moist and beautiful, calls to each of us to make a new and serious response. That’s the big question, the one the world throws at you every morning. “Here you are, alive. Would you like to make a comment?” ~Mary Oliver from Long Life
Some mornings it is impossible to stay a silent observer of the world. I demand answers to the unanswerable.
Overnight, wind and rain have pulled down nearly every leaf, the ground carpeted with the dying evidence of last spring’s rebirth, dropping temperatures robing the surrounding foothills and peaks in a bright new snow covering.
There can be no complacency in witnessing life in progress.
It blusters, rips, drenches, encompasses, buries.
Nothing remains as it was.
And here I am, alive.
Called to comment.
Dying to hear a response.
Vast whisp-whisp of wingbeats awakens me and I look up at a minute-long string of black geese’ following low past the moon the white course of the snow-covered river and by the way thank You for keeping Your face hidden, I can hardly bear the beauty of this world ~Franz Wright from “Cloudless Snowfall”
A psalm of geese labours overland
cajoling each other near half…
The din grew immense. No need to look up.
All you had to do was sit in the sound
and put it down as best you could…
It’s not a lonesome sound but a panic,
a calling out to the others to see if they’re there;
it’s not the lung-full thrust of the prong of arrival in late October; not the slow togetherness
of the shape they take on the empty land on the days before Christmas:
this is different, this is a broken family, the young go the wrong way,
then at daybreak, rise up and follow their elders again filled with dread, at the returning sound of the journey ahead. ~Dermot Healy from A Fool’s Errand
We are here to witness the creation and abet it. We are here to notice each thing so each thing gets noticed. Together we notice not only each mountain shadow and each stone on the beach but, especially, we notice the beautiful faces and complex natures of each other. We are here to bring to consciousness the beauty and power that are around us and to praise the people who are here with us. We witness our generation and our times. We watch the weather. Otherwise, creation would be playing to an empty house. ~Annie Dillard from The Meaning of Life edited by David Friend
I am overwhelmed by the amount of “noticing” I need to do in the course of my work. Each patient, and there are so many, deserves my full attention for the few minutes we are together. I start my clinical evaluation the minute I walk in the exam room and begin taking in all the complex verbal and non-verbal clues offered by another human being.
How are they calling out to me as they keep their faces hidden?
What someone tells me about what they are feeling may not always match what I notice: the trembling hands, the pale skin color, the deep sigh, the scars of self injury. I am their audience and a witness to their struggle; even more, I must understand it in order to best assist them. My brain must rise to the occasion of taking in another person, offering them the gift of being noticed and being there for them, just them.
This work I do is distinctly a form of praise: the patient is the universe for a few moments and I’m grateful to be watching and listening. When my patient calls out to me, may they never feel they are playing to an empty house. May I always look for the beauty in their hidden faces.
Like the stretching light of the river?
And did you feel it, in your heart, how it pertained to everything?
And have you too finally figured out what beauty is for?
And have you changed your life?
~Mary Oliver from The Swan
This laboring of ours with all that remains undone,
as if still bound to it,
is like the lumbering gait of the swan.
And then our dying—releasing ourselves
from the very ground on which we stood—
is like the way he hesitantly lowers himself
into the water. It gently receives him,
and, gladly yielding, flows back beneath him,
as wave follows wave,
while he, now wholly serene and sure,
with regal composure,
allows himself to glide.
~Rainer Maria Rilke, “The Swan”
This is the time of year when we look at making changes in how we live our lives. We want to start fresh as the calendar turns over; we want to become “new” too. Maybe it is giving up an old destructive habit or adopting a new healthier routine, but it means giving up something familiar and becoming uncomfortable, at least for a while.
I seek out the graceful gliding part of life and not the lumbering awkward part. I’d like to say I live out equal measures of both, but I don’t – I’m lumbering and awkward too much of the time due to my own choices. It is difficult to navigate the waves of life when in “lumbering” and “laboring” mode, as wave follows wave, some gentle and lapping, others overwhelming and crashing.
I know what grace looks and feels like, floating atop whatever wave hits me, to stay on the surface and not get soaked through.
I pray that whatever comes, this stretching light over the waves, will fill me with its beauty and grant me grace to glide.