Prescribing Good Medicine

 

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 over 40 years of practicing medicine, 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 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 people 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 and screen time 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.

No, it doesn’t take an M.D. degree to know the best medicine.

Just remember: sleep, weep, reap (chocolate!)

 

Breathing In and Out

What is there beyond knowing that keeps
calling to me?  I can’t
 
turn in any direction
but it’s there.  I don’t mean
 
the leaves’ grip and shine or even the thrush’s
silk song, but the far-off
 
fires, for example,
of the stars, heaven’s slowly turning
 
theater of light, or the wind
playful with its breath;
 
or time that’s always rushing forward,
or standing still
 
in the same — what shall I say —
moment.
What I know
I could put into a pack
 
as if it were bread and cheese, and carry it
on one shoulder,
 
important and honorable, but so small!
While everything else continues, unexplained
 
and unexplainable.
 
….mostly I just stand in the dark field,
in the middle of the world, breathing in and out…
~Mary Oliver from “What is there beyond knowing”
I’m reminded daily about how little I know and understand.  I work with people who are suffering, whose symptoms may fit prescribed diagnostic criteria but yet defy explanation or reason.  They care about what relief I might offer rather than a label that names the illness.
Like so much in medicine, what I witness daily is unexplained and unexplainable.  What I do know I carry with me, small and honorable and shareable.   I offer it up to each patient, one after another:  here is what I think might help.  here is your next step to take.  here is the hope that goes with taking each breath, the next and the next.
Even when standing in the dark, as we all do at times in our life, we just keep breathing.  In and out.  In and out.  We are filled even when empty.

The Darkness is Wisdom’s Way to Light

 

By these three days all the world is called to attention.
Everything that is and ever was and ever will be,
the macro and the micro,
the galaxies beyond number and the microbes beyond notice –
everything is mysteriously entangled with what happened,
with what happens, in these days.…
Every human life,
conceived from eternity and destined to eternity,
here finds its story truly told.
In this killing that some call senseless
we are brought to our senses.
Here we find out who we most truly are because
here is the One who is what we are called to be.
The derelict cries, “Come, follow me.”
Follow him there?
We recoil.
We close our ears.
We hurry on to Easter.
But we will not know what to do with Easter’s light
if we shun the friendship of the darkness that is wisdom’s way to light.
~Richard Neuhaus from Death on a Friday Afternoon

 

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So many recent killings of innocents — needless, heartbreaking death at the hands of others — people abruptly wrenched from their routine lives, their families left with empty arms and eyes filling, spilling endlessly with tears.

Such senseless tragedies, we say, recoiling and withdrawing as if we can close our ears to more bad news.  Some take to the streets to march in protest.

How to make sense of deaths that arise from the darkness found in every soul?

This is the day in between when nothing makes sensewe are lost, hopeless, grieving.

Yet we are brought to our senses by this one Death, this premeditated killing, this senseless act that darkened the skies, shook the earth and tore down the curtained barriers to the Living Eternal God.

The worst has already happened, no matter how horrific the events that fill our headlines.

This Holy Saturday we are in between, stumbling in the darkness but aware of hints of light, of buds, of life, of promised fruit to come.

The best has already happened. Happening now even when we are oblivious to its impossibility.

We move through this Saturday, doing what is possible even when it feels senseless.

Tomorrow it will all make sense: our hope brings us face to face with our God who does the impossible.

 

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The Holy Saturday of our life must be the preparation for Easter,
the persistent hope for the final glory of God. 

The virtue of our daily life is the hope which does what is possible
and expects God to do the impossible. 

To express it somewhat paradoxically, but nevertheless seriously: 
the worst has actually already happened; 
we exist,
and even death cannot deprive us of this. 

Now is the Holy Saturday of our ordinary life, 
but there will also be Easter, our true and eternal life. 
~Karl Rahner “Holy Saturday” in The Great Church Year

 

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The Unstilled World Still Whirled

 

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If the lost word is lost, if the spent word is spent
If the unheard, unspoken
Word is unspoken, unheard;
Still is the unspoken word, the Word unheard,
The Word without a word, the Word within
The world and for the world;
And the light shone in darkness and
Against the Word the unstilled world still whirled
About the centre of the silent Word.

O my people, what have I done unto thee.
~T.S. Eliot from “Ash Wednesday”

 

In my beginning is my end. Now the light falls
I said to my soul, be still, and wait without hope.
~T.S. Eliot from “East Coker”

 

 

On Maundy Thursday, I arrive back to the beginning,  six weeks later returning to Eliot:
“the unstilled world whirled/About the centre of the silent Word.”

This day:

a day of disquiet and silence,
of Christ taking towel and water to disciples’ dirty feet,
of bread broken and fruit crushed and consumed,
of anguished prayer and the kiss of betrayal,
of stilling the sword,
of watching those He loved run off in fear
and deny they ever knew Him.

In my beginning is my end.
And now the light falls and the darkness begins.
We wait, sorrow-filled, our unstilled souls stilled
by our betrayal, our denial, our hopelessness without Him.

 

He Emptied Himself

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Christ Jesus, who, though he was in the form of God,
did not count equality with God a thing to be grasped,
but emptied himself, by taking the form of a servant,
being born in the likeness of men.
And being found in human form,
he humbled himself by becoming obedient
to the point of death, even death on a cross.
Philippians 2: 6-8

 

[The Incarnation is like] a wave of the sea which,
rushing up on the flat beach,
runs out, even thinner and more transparent,
and does not return to its source but sinks into the sand and disappears.
~Hans Urs von Balthasar from Origen: Spirit and Fire

 

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This is a week of emptying. It is impossible to approach tomorrow’s supper and His anguished prayer without feeling hollowed out, our empty spaces then filled to the brim with grace. More over, through commemoration of these historical events, God on earth once again empties Himself onto our earthly soil and into our fleshly souls. He washes our dirty feet, feeds us at His table, and pleads for our forgiveness when we deserve none of it. He loses Himself in us. Through Him, we are welcomed home, whole and holy.

Hollowed, then hallowed.

 

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Let him kneel down, lower his face to the grass,
And look at light reflected by the ground.
There he will find everything we have lost.
~Czeslaw Milosz from “The Sun”

 

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Preparing Through Parable: Knock Like You Mean It

 

 

Then Jesus said to them, “Suppose you have a friend, and you go to him at midnight and say, ‘Friend, lend me three loaves of bread; a friend of mine on a journey has come to me, and I have no food to offer him.’
And suppose the one inside answers, ‘Don’t bother me. The door is already locked, and my children and I are in bed. I can’t get up and give you anything.’ I tell you, even though he will not get up and give you the bread because of friendship, yet because of your shameless audacity he will surely get up and give you as much as you need.
“So I say to you: Ask and it will be given to you; seek and you will find; knock and the door will be opened to you. 10 For everyone who asks receives; the one who seeks finds; and to the one who knocks, the door will be opened.”
Luke 11: 5-10

 

 

 

…we are faced with the shocking reality: 
Jesus stands at the door and knocks, in complete reality. 
He asks you for help in the form of a beggar, 
in the form of a ruined human being in torn clothing. 
He confronts you in every person that you meet. 
Christ walks on the earth as your neighbor as long as there are people. 
He walks on the earth as the one through whom 
God calls you, speaks to you and makes his demands. 
Christ stands at the door. 
Will you keep the door locked or open it to him?
~Dietrich Bonhoeffer from an Advent Sermon “The Coming of Jesus into our Midst”

 

 

Over ten years ago a young woman I’d been seeing for several weeks in my clinic for depression called unexpectedly on a Friday afternoon and canceled an upcoming appointment for the following Monday and did not reschedule. The receptionist sent me a message as is our policy for patients who “cancel and do not reschedule”. It gave me a bad feeling that she was turning her back on her treatment plan and I was uneasy about the upcoming weekend without knowing what was going on with her.

I could have just put on my coat and headed home at the end of that long Friday but decided to call my patient. She didn’t answer her phone. I mulled over my options, looked up her apartment address and drove there. As I approached her door, I could hear someone moving around in her apartment, but she didn’t respond to my knocks or my voice.

I decided to stay right there, talking to her through the door for about 15 minutes, letting her know I wasn’t leaving until she opened up the door. I finally told her she could decide to open the door or I would call 911 and ask the police to come to make sure she was okay. She then opened the door, tears streaming down her face. She had been drinking heavily, with liquor bottles strewn around on the floor. She admitted an intent to overdose on aspirin and vodka. The vodka was already consumed but the unopened aspirin bottle was in her hand. I was the last person she expected to see at her door.

I called the mental health unit at the local hospital and they had an open bed. I told my patient that we could save time and hassle by heading over right then and there, and avoid the emergency room mess, and the possibility of an involuntary detainment.

She agreed to come with me and be admitted voluntarily for stabilization. I went the following day to visit her and she greeted me with a hug and thanked me for not giving up on her when she had given up on herself. In sobriety, her eyes were brighter and she was more hopeful. She never expected anyone to care enough to come knocking on her door looking for her, and to stand firm when she was rejecting all approaches. She was astounded and grateful, and frankly, so was I.

Four years later, a small card arrived in my clinic mailbox on a most challenging work day, from an unfamiliar address two thousand miles away. The name looked vaguely familiar to me but when I opened and read the contents, this time it was my turn to let tears flow:

“Dear Doctor,

I am not sure if you will remember me considering you see a number of patients daily; however, I am a patient whose life you changed in the most positive way. I never truly THANKED YOU for listening to me and hearing my silent words of grief and hearing my cries for help. If it had not been for you, had you not knocked on my door, I would not be writing this letter to you today. I don’t know exactly what to say to the person who saved me from hurting myself fatally. You were a stranger in my life, but a dear friend in my time of need. THANK YOU, for everything that you did for me. You have a permanent place in my heart, you have given my spirit hope, you have reminded me that a life is worth living. Thank you, thank you, thank you! Sincerely, L_____”

I’m grateful so many years ago I had the sense to go knock on her door, the stubbornness to stay put until she responded, and most of all, I’m appreciative for her gracious note letting me know it made a difference. Later, on a most difficult day, she made a difference for me.

She kept knocking on my door and I opened it, awash in my own tears.

 

May my eyes see, my ears hear, my heart understand.  He prepares me with parable.

When Flesh and Heart Shall Fail

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(Ten years ago this week, this healthy young college student came to our clinic stricken with seasonal influenza complicated by pneumonia.  His family gave permission for his story to be told.)

 

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Nothing was helping.  Everything had been tried for a week of the most intensive critical care possible.  A twenty year old man, completely healthy only two weeks previously, was dying and nothing could stop it.

The battle against a sudden MRSA pneumonia precipitated by a routine seasonal influenza had been lost.   Despite aggressive hemodynamic, antibiotic, antiviral and ventilator management, he was becoming more hypoxic and his renal function was deteriorating.  He had been unresponsive for most of the week.

The intensivist looked weary and defeated. The nurses were staring at their laps, unable to look up, their eyes tearing. The hospital chaplain reached out to hold this young man’s mother’s shaking hands.

After a week of heroic effort and treatment, there was now clarity about the next step.

Two hours later, a group gathered in the waiting room outside the ICU doors. The average age was about 21; they assisted each other in tying on the gowns over their clothing, distributed gloves and masks. Together, holding each other up, they waited for the signal to gather in his room after the ventilator had been removed and he was breathing without assistance. They entered and gathered around his bed.

He was ravaged by this sudden illness, his strong body beaten and giving up. His breathing was now ragged and irregular, sedation preventing response but not necessarily preventing awareness. He was surrounded by silence as each individual who had known and loved him struggled with the knowledge that this was the final goodbye.

His father approached the head of the bed and put his hands on his boy’s forehead and cheek.  He held this young man’s face tenderly, bowing in silent prayer and then murmuring words of comfort:

It is okay to let go. It is okay to leave us now.
We will see you again. We’ll meet again.
We’ll know where you will be.

His mother stood alongside, rubbing her son’s arms, gazing into his face as he slowly slowly slipped away. His father began humming, indistinguishable notes initially, just low sounds coming from a deep well of anguish and loss.

As the son’s breaths spaced farther apart, his dad’s hummed song became recognizable as the hymn of praise by John Newton, Amazing Grace.  The words started to form around the notes. At first his dad was singing alone, giving this gift to his son as he passed, and then his mom joined in as well. His sisters wept. His friends didn’t know all the words but tried to sing through their tears. The chaplain helped when we stumbled, not knowing if we were getting it right, not ever having done anything like this before.

Amazing Grace, how sweet the sound,
That saved a wretch like me.
I once was lost but now am found,
Was blind, but now I see.

Through many dangers, toils and snares
I have already come;
‘Tis Grace that brought me safe thus far
and Grace will lead me home.

Yea, when this flesh and heart shall fail,
And mortal life shall cease,
I shall possess within the veil,
A life of joy and peace.

When we’ve been here ten thousand years
Bright shining as the sun.
We’ve no less days to sing God’s praise
Than when we’ve first begun.

And he left us.

His mom hugged each sobbing person there–the young friends, the nurses, the doctors humbled by powerful pathogens. She thanked each one for being present for his death, for their vigil kept through the week in the hospital.

This young man, now lost to this life, had profoundly touched people in a way he could not have ever predicted or expected. His parents’ grief, so gracious and giving to the young people who had never confronted death before, remains unforgettable.

This was their sacred gift to their son so Grace will lead us home.

 

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