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”

Partly Cloudy

Today is one of those excellent January partly cloudies
in which light chooses an unexpected part of the landscape to trick out in gilt,
and then the shadow sweeps it away.
You know you’re alive.
You take huge steps,
trying to feel the planet’s roundness arc between your feet.

~Annie Dillard from Pilgrim at Tinker Creek

After years of rarely paying attention,
too busy with whatever household or clinic or barnyard task needed doing,
I realized there are only a finite number of sunrises and sunsets left to me
and I don’t want to miss them, so now I stop, take a deep breath
and feel lucky to be alive, a witness to that moment.

Sometimes they are plain and gray
just as I am,
but there are days that are lit from above and beneath
with a fire that ignites across the sky.
I too am engulfed for a moment or two,
until sun or shadow sweeps me away,
transfixed and transformed, forever grateful for the light.

Our Plodding Resistance



If that’s what he means,’ says the student to the poetry teacher, ‘why doesn’t he just say it?’ 

‘If God is real,’ says the parishioner to the preacher, ‘why doesn’t he simply storm into our lives and convince us?’ 

The questions are vastly different in scale and relative importance, 
but their answers are similar. 

A poem, if it’s a real one, in some fundamental sense 
means no more and no less than the moment of its singular music and lightning insight; it is its own code to its own absolute and irreducible clarity. 

A god, if it’s a living one, is not outside of reality but in it, of it, 
though in ways it takes patience and imagination to perceive. 

Thus the uses and necessities of metaphor, which can flash us past our plodding resistance and habits into strange new truths. 

Thus the very practical effects of music, myth, and image, which tease us not out of reality, but deeper and more completely into it.
~Christian Wiman, My Bright Abyss: Meditation of a Modern Believer

We are an impatient and unimaginative people; we want proof of God and we want it now. Yet we plod through our days blind and deaf to His presence in our lives, with little awareness of Him walking beside us.

So each day I try to take the blinders off and look for Him, listen for Him and wait on Him to make His presence known.

I will call Him by Name.

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.

Clearing the Fog

 

 

 

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.




Unanswerable Questions

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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,
gaze.

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

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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

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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

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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.
Awed.
A witness.
Called to comment.
Dying to hear a response.

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Best of Barnstorming Photos Summer/Fall 2018

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I walked

on New Year’s Day

beside the trees

my father now gone planted

evenly following

the road

Each

            spoke

~Lorine Niedecker (1967)

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With what stillness at last
you appear in the valley
your first sunlight reaching down
to touch the tips of a few
high leaves that do not stir
as though they had not noticed
and did not know you at all
then the voice of a dove calls
from far away in itself
to the hush of the morning
so this is the sound of you
here and now whether or not
anyone hears it this is
where we have come with our age
our knowledge such as it is
and our hopes such as they are
invisible before us
untouched and still possible

~W.S. Merwin “To the New Year”

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The object of a new year is not that we should have a new year. It is that we should have a new soul.
~G.K. Chesterton
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No one ever regarded the First of January with indifference.
It is that from which all date their time, and count upon what is left.
It is the nativity of our common Adam.

~Charles Lamb 

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We come to this new year
naked as dormant branches
in the freezing night.

Mere potential barely budded,
nothing covered up,
no hiding in shame.

A shared and common birthday of renewal,
a still life nativity in a winter garden,
a roaring fire refining what is no longer of use,
another chance to make it right.

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Grant, O Lord,
that as the years change,
I may find rest in Your eternal changelessness.

May I meet this new year bravely,
secure in the faith that,
while we come and go,
and life changes around us,

You are always the same,
guiding us with Your wisdom,
and protecting us with Your love.
Amen.

~William Temple (1881–1944)

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