Every Morning, So Far, I’m Alive



Isn’t it plain the sheets of moss, except that
they have no tongues, could lecture
all day if they wanted about

spiritual patience? Isn’t it clear
the black oaks along the path are standing
as though they were the most fragile of flowers?

Every morning I walk like this around
the pond, thinking: if the doors of my heart
ever close, I am as good as dead.

Every morning, so far, I’m alive. And now
the crows break off from the rest of the darkness
and burst up into the sky—as though

all night they had thought of what they would like
their lives to be, and imagined
their strong, thick wings.

~Mary Oliver  “Landscape”

photo by Cheryl Bostrom

In gratitude to poet Mary Oliver, who did not wake up this morning on this side of the veil, but did wake up to unimaginable glory on another side:

Even in mid-January,
when endless days drag on dark and damp~
even when I am unconvinced
new life and light will ever return,
these mosses grow with enthusiasm,
requiring so little to stay alive~

they patiently encourage me
to fly with strong wings,
to keep open the doors of my heart
to the possibility
that even now,
especially now when I can’t imagine it,
I too will thrive.


When it’s over, I want to say: all my life
I was a bride married to amazement.
I was the bridegroom, taking the world into my arms.

When it’s over, I don’t want to wonder
if I have made of my life something particular, and real.
I don’t want to find myself sighing and frightened,
or full of argument.

I don’t want to end up simply having visited this world.
~Mary Oliver from “When Death Comes”

A Little Away From Everywhere

I wonder about the trees.

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.

Opening Up the Medical Chart

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.

An Advent Paradox: The Empty Filled

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The world is filled, and filled with the Absolute. To see this is to be made free.
~Pierre Teilhard de Chardin

 

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And God placed all things under his feet and appointed him to be head over everything for the church, which is his body, the fullness of him who fills everything in every way.
Ephesians 1:22-23

 

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My mouth will utter praise of the Lord, of the Lord through whom all things have been made and who has been made amidst all things;
who is the Revealer of His Father, Creator of His Mother;
who is the Son of God from His Father without a mother,
the Son of Man through His mother without a father.

He is as great as the Day of Angels, and as small as a day in the life of men;
He is the Word of God before all ages, and the Word made flesh at the destined time.
Maker of the sun, He is made beneath the sun.

In His Father He abides; from His mother He goes forth.
Creator of heaven and earth, under the heavens He was born upon earth.

Wise beyond all speech, as a speechless child, He is wise.
Filling the whole world, He lies in a manger.
Ruling the stars, He nurses at His mother’s breast.
He is great in the form of God and small in the form of a servant, so much so that His greatness is not diminished by His smallness, nor His smallness concealed by His greatness.
~St. Augustine

 

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How empty was the world before Christ! From Mary’s untouched womb to Joseph’s futile search for a place to sleep in Bethlehem, to the shepherds’ dismal existence on the hillsides, to Simeon’s arms aching to hold the Messiah, to Anna’s long wait in the temple.

In a million ways, seen and unseen, the empty spaces were filled, the hunger sated, the thirst quenched, the rest assured. He joined us so we shall never lack again. He became one with us–all is fulfilled and filled fully.

 

 

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An Advent Paradox: Loose a Heart Bound By Shame

 

Here is the mystery, the secret,
one might almost say the cunning, of the deep love of God:
that it is bound to draw on to itself
the hatred and pain and shame and anger and bitterness and rejection of the world,
but to draw all those things on to itself is precisely the means,
chosen from all eternity by the generous, loving God,
by which to rid his world of the evils which have resulted from human abuse of God-given freedom.

~N.T. Wright from The Crown and the Fire

 

 

We cling to the mystery of His magnetism for our weaknesses and flaws.
He came in love to loose up our hearts ~
hearts completely bound up in shame and guilt.

He willingly pulls our evil onto Himself and out of us, freeing us.
Hatred and pain and shame and anger and bitterness
disappear into the fiery vortex of His love and beauty,
until evil is left in ashes.

We are let in on a secret, this mystery of His incarnation:

by torching the dirty messes of our lives in the refiner’s fire,
we are purified,
we too are wholly reborn.

 

 

 

 

Christ whose glory fills the skies
Christ the everlasting light
The son of righteousness arise
And triumph o’re these shades of night

Come thou long awaited one
In the fullness of your love
And loose this heart bound up by shame
And I will never be the same

So here I wait in hope of you
All my soul’s longing through and through
Dayspring from on high be near
Day Star in my heart appear

Dark and cheerless is the morn
Until your love in me is born
And joyless is the evening song
Until Emmanuel has come

So here I wait in hope of you
All my soul’s longing through and through
Dayspring from on high be near
Day Star in my heart appear

So here I wait in hope of you
All my soul’s longing through and through
Dayspring from on high be near
Day Star in my heart appear
~Christy Nockels based on the Charles Wesley hymn “Christ Whose Glory Fills the Skies”

Thankful for Stillness

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There is a basic lesson that all young horses must learn (and a fewer older horses must relearn) on our farm. It is to stand still when asked and move only when asked. This does not come naturally to a young horse–they tend to be impatient and fidgety and fretful and full of energy. If they are hungry, they want food now and if they are bored, they want something different to do and if they are fearful, they want to be outta there.

Teaching a horse to be still is actually a greater lesson in persistence and consistency for the human handler, which means I don’t always do well in teaching this to my horses and they (and I) lapse frequently–wiggly pushy horses and a weary frustrated handler. It means correcting each little transgression the horse makes, asking them to move back to their original spot, even if there is hay waiting just beyond their nose, asking them to focus not on their hunger, their boredom, their fear, but asking them to focus only on me and where they are in relationship to me. It means they must forget about themselves and recognize something outside of themselves that is in control–even if I move away from them to do other things.

The greatest trust is when I can stand a horse in one spot, ask them to be still, walk away from them, briefly go out of sight, and return to find them as I left them, still focused on me even when I was not visible.

I was reminded of this during Pastor Bert’s sermon on the book of Exodus when he preached on the moments before Moses parted the Red Sea, allowing the Hebrews an escape route away from Pharoah and the Egyptian chariots and soldiers. In those moments beforehand, the Hebrews were pressed up against the Sea with the Egyptians bearing down on them and they lamented they should never have left Egypt in the first place, and that generations of bondage in slavery would have been preferable to dying in the desert at the hands of the soldiers or drowning in the Sea.

Moses told them to “be still”. Or as our pastor said, he told them to “shut up”. Stay focused, be obedient, trust in the Lord’s plan. And the next thing that happened was the Sea opened up. Then the Hebrews rejoiced in thanksgiving for their freedom.

Thanksgiving, as it has developed over the years from the first historical observance of a meal shared jointly between the Pilgrims and their Native American hosts, is just such a moment to “be still and know” about the gifts from our God. Yet in our hurried and harried culture, Thanksgiving is about buying the best bargain turkey (or this year the most free range heritage turkey costing close to $150!), creating the most memorable recipes, decorating in perfect Martha Stewart style, eating together in Norman Rockwell style extended family gatherings, watching football and parades on the biggest flat screen TV, while preparing for the mad dash out the door the next day to start the Christmas shopping season.

Instead of all that fol de rol –  be still.

Like my horses, I need correction when I start to agitate out of “hunger”–wanting to literally stuff myself full, or out of my boredom– seeking the latest in entertainment or satisfaction, or out of my fear–  feeling the threats that surround us all in the world today. I need to be reminded continually that my focus must be outside myself and my perceived needs, and to be still long enough to know God is with us even though we cannot see Him every moment.

I do not do well at this.

My horses learn much faster than I do. I am restless, rarely taking the time to be still and acknowledge God who continually watches, waiting for me to settle down and focus on Him.

May this Thanksgiving remind me of my need for God, and my gratitude for His patient persistence in moving me back into place when I wiggle and fret and stuff myself even when I’m really not hungry.

May I remember that to be still and know God is the greatest gift I can give and that I can receive.

And may His Stillness be with you as well.

 

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An Unraveling Story

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The fence was down. 
 
Led by their bellwether bellies, the sheep
had toddled astray. The neighbor farmer’s woods
or coyotes might have got them, or the far road.
 
I remember the night, the moon-colored grass
we waded through to look for them, the oaks
tangled and dark, like starting a story midway.
 
We gazed over seed heads to the barn
toppled in the homestead orchard. Then we saw
the weather of white wool, a cloud in the blue
 
moving without sound as if charmed
by the moon beholding them out of bounds.
Time has not tightened the wire or righted the barn.
 
The unpruned orchard rots in its meadow
and the story unravels, the sunlight creeping back
like a song with nobody left to hear it.
~David Mason from “Mending Time” in The Sound: New and Selected Poems

 

 

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How often do we, like sheep, wander astray – out of the broken down barn, or through the fallen fence, into the orchards of rotting delights?

And Someone, always Someone, comes looking for us, lost and always hungering and endangered.

We need our Shepherd and we know His voice.  May we be ready to be led home.

 

 

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