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.

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.




Keeping Your Face Hidden

 

 

 

 

 

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.

An Advent Paradox: Glory in the Darkest Place

 

 

O come, thou Dayspring, come and cheer
our spirits by thine advent here;
dispel the shadows of the night,
and turn our darkness into light.
~from O Come O Come Emmanuel

 

 

 

Moonless darkness stands between.
Past, O Past, no more be seen!
But the Bethlehem star may lead me
To the sight of Him who freed me
From the self that I have been.
Make me pure, Lord: Thou art holy;
Make me meek, Lord: Thou wert lowly;
Now beginning, and alway:
Now begin, on Christmas day.
~Gerard Manley Hopkins

 

 

 

 

I leave home in darkness to go to work and come home in darkness in the late afternoon.  It seems for days on end the sun never shines as I’m tucked away with patients in clinic consult rooms hearing their own struggle against the darkness.

Where is the light that I promise to each of them if I can’t feel it myself?

Yet Glory is present in the darkest place and the Light has come.

I will remember His promise.
Even in the darkness I know His face.
He knows I know.

 

 

 

[Verse 1]
Out of the depths of silent night
Immanuel, come hear our cry
Our grief is strong, our burdens great
The night is long and hope is faint

[Verse 2]
You came to set the captives free
A Morning Star of joy and peace
Why does this darkness feel so deep?
Why can’t our weary spirits see?

[Chorus]
Glory, glory
Glory in the darkest place
Glory, glory
Glory, let Your mercy reign

[Verse 3]
Out of the depths of silent night
A Savior born, a mother’s sigh
The darkness trembled at this Star
A beam of hope for troubled hearts

[Verse 4]
You came to make Your blessings known
And bear our curse of death alone
You came to share our suffering
So in our sorrow, we could sing

[Chorus]
Glory, glory
Glory in the darkest place
Glory, glory
Glory, let Your mercy reign
Glory, glory
Glory in the darkest place
Glory, glory
Glory, let Your mercy reign
Brittany Hope

An Advent Paradox: Filled Because I’m Emptied

horsehairvase

 

“I am the Lord’s servant,” Mary answered. “May it be as you have said.”
Luke 1: 38

 

…to bear in her womb
Infinite weight and lightness; to carry
in hidden, finite inwardness,
nine months of Eternity; to contain
in slender vase of being,
the sum of power –
in narrow flesh,
the sum of light.

Then bring to birth,
push out into air, a Man-child
needing, like any other,
milk and love –

but who was God.
~Denise Levertov, from “Annunciation”

 

annunciation
The Annunciation by Henry Tanner, Philadelphia Museum of Art

 

I want it to be the way I want it:
my plans, my timing, my hopes and dreams first and foremost.

And then life happens and suddenly nothing looks the way it was supposed to be. I feel abandoned and completely emptied.

Yet only then, as an empty vessel, can I be filled. How am I to respond to such a paradox?

In my work in a University Health Center, I see this struggle in the lives of young adults: a tremendous lack of resiliency, an inability to ride the waves that crash and overwhelm. One of the most common responses to the unexpected is to panic, facing uncontrollable anxiety that interferes with eating, sleeping, working, studying. A common response to anxiety is to self-medicate in any way easily accessible: alcohol, marijuana, nicotine, sex, a friend’s prescription drugs. A little isn’t working so a lot might be better. The anxiety is compounded and descends into deepening depression.

The sadness and hopelessness, even anger –is a discouragement stemming from the lack of control of circumstances, feeling there is no way out, being unable to find another path to a different future. This leads too frequently to thoughts of ending one’s life as it seems too painful and pointless to continue, and more rarely, taking others’ lives at the same time in an attempt to make sure everyone else knows the depth of the pain.

There is an epidemic of hopelessness among our society’s young people that I’ve never before seen to this extent in my forty years of clinical work. To them, their debts seem too great, their reserves too limited, their foundations too shaky, their hope nonexistent, their future too dim. They cannot ride the waves without feeling they are drowning. So they look for any way out.

In the annunciation of the angel approaching a young woman out of the blue, Mary’s response to this overwhelming circumstance is a model for us all when we are hit by a wave we didn’t expect and had not prepared for.

She is prepared; she has studied and knows God’s Word and His promise to His people, even in the midst of trouble. She is able to articulate it beautifully in the song she sings as her response. She gives up her so-carefully-planned-out life to give life to God within her.

Her resilience sings through the ages and to each one of us in our troubles:
may it be to me as you say.

May it be.
Your plans, Your purpose, Your promise.
Let it be.
Even if it may pierce my soul as with a sword so that I leak out to empty.
You are there to plug the bleeding hole and fill me.

So I sing through my fear, through my weariness, through my tears.

 

“Like Mary, we have no way of knowing… We can ask for courage, however, and trust that God has not led us into this new land only to abandon us there.”
~Kathleen Norris from God With Us

 

Matthias-Stomer-Annunciation-Painting
Matthias Stomer’s Annunciation

 

 

 

Everything inside me cries for order
Everything inside me wants to hide
Is this shadow an angel or a warrior?
If God is pleased with me, why am I so terrified?
Someone tell me I am only dreaming
Somehow help me see with Heaven’s eyes
And before my head agrees,
My heart is on its knees
Holy is He. Blessed am I.

Be born in me
Be born in me
Trembling heart, somehow I believe
That You chose me
I’ll hold you in the beginning
You will hold me in the end
Every moment in the middle,
Make my heart your Bethlehem
Be born in me

All this time we’ve waited for the promise
All this time You’ve waited for my arms
Did You wrap yourself inside the unexpected
So we might know that Love would go that far?

Be born in me
Be born in me
Trembling heart, somehow I believe
That You chose me
I’ll hold you in the beginning
You will hold me in the end
Every moment in the middle,
Make my heart your Bethlehem
Be born in me

I am not brave
I’ll never be
The only thing my heart can offer is a vacancy
I’m just a girl
Nothing more
But I am willing, I am Yours
Be born in me
Be born in me
Trembling heart, somehow I believe
That You chose me
I’ll hold you in the beginning
You will hold me in the end
Every moment in the middle,
Make my heart your Bethlehem
Be born in me

Francesca Battistelli

The Turmoil of Thinking

stoneweep

 

chardfrost5

 

 

Flee for a while from your tasks,
hide yourself for a little space from the turmoil of your thoughts.
Come, cast aside your burdensome cares,
and put aside your laborious  pursuits.
For a little while give your time to God,
and rest in him for a little while.
Enter into the inner chamber of your mind,
shut out all things save God
and whatever may aid you in seeking God;
and having barred the door of your chamber, seek him.
~Anselm of Canterbury: The Major Works

 

 

oakleaffrost

 

fairyfrost

 

Yesterday I needed to leave work early;
near tears, physically spent, too fried
to keep listening, problem solving, comforting.

I needed to feel something other than needed.
I needed neediness myself —  a sorry place to be.

It’s happened before, many times:
middle of the night mothering a vomiting child,
middle of the night mothering a frail mother,
middle of the night worried about the world.

Yet morning comes because God never left,
maybe not bright and shining and wondrous
maybe a weeping rock,
but if I gently close the door to all that is not God,
I will find Him looking for me.

 

 

morning1116181

 

morning1116183