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!)

 

Preparing Through Parable: Fertilize…

empressfruit

 

Then he told this parable: “A man had a fig tree growing in his vineyard, and he went to look for fruit on it but did not find any. So he said to the man who took care of the vineyard, ‘For three years now I’ve been coming to look for fruit on this fig tree and haven’t found any. Cut it down! Why should it use up the soil?’

“‘Sir,’ the man replied, ‘leave it alone for one more year, and I’ll dig around it and fertilize it. If it bears fruit next year, fine! If not, then cut it down.’”
Luke 13:6-9

 

horse manure composted garden

 

As a farmer, I spend over an hour a day cleaning my barn, and wheel heavy loads of organic material to a large pile in our barnyard which composts year round.  Piling up all that messy stuff that is no longer needed is crucial to the process: it heats up quickly to the point of steaming, and within months, it becomes rich fertilizer, ready to help the fields to grow grass, or the garden to produce vegetables, or the fragrant blooms in the flower beds.  It becomes something far greater and more productive than what it was to begin with, thanks to transformation of muck to fruit.

That’s largely what I do in clinic as well.

As clinicians, we help our patients “clean up” the parts of their lives they really don’t need, that they can’t manage any longer, that are causing problems with their health, their relationships and obligations.  There isn’t a soul walking this earth who doesn’t struggle in some way with things that take over our lives, whether it is school, work,  computer use, food, gambling, porn, you name it.  For the chemically dependent, it comes in the form of smoke, a powder, a bottle, a syringe or a pill.  There is nothing that has proven more effective than “piling up together” learning what it takes to walk the road to health and healing, “heating up”, so to speak, in an organic process of transformation that is, for lack of any better description, primarily a spiritual treatment process.  When a support group becomes a crucible for the “refiner’s fire”,  it does its best work melting people down to get rid of the impurities before they can be built back up again, stronger than ever.  They become compost, productive, ready to grow others.

This work with a spectrum of individuals of all races, backgrounds and creeds has transformed me.

As Jesus says in Matthew 25: 40–‘I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.’

It’s crucial to fertilize those who otherwise may be cut down.  Only then can they bear fruit.

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

 

 

compostjanuary

Lost Inside This Soft World

morning113159

 

 

goldenhaze3

 

Everyday
I see or hear
something
that more or less

kills me
with delight,
that leaves me
like a needle

in the haystack
of light.
It was what I was born for — 
to look, to listen,

to lose myself
inside this soft world —
~Mary Oliver from “Mindful”

 

foggymorning13115

 

dawn7253

 

Some days I’m the needle
and other days I’m the pin cushion

Today I may be both,
probing into people’s lives and feelings,
moving beyond their sharp edges
to find the source of their pain.
They don’t realize I wince too,
remembering how it feels.

I choose the softness of the light
that floats close to the ground,
that reaches out with cloudy grasp.

This is what I was born for:
delighted to be lost
and then found.

 

reflecting1

 

foggyfrontyard

When Worry is a Terminal Disease

kitty2

 

Considering myself a Dr. Doolittle of sorts, always talking to the animals, I reached out to pet a stray cat sitting quietly outside our barn one evening while doing barn chores.  This is a grayish fluffy cat I see around the barns every few months or so–he doesn’t put in frequent appearances and reminds me of a kitten we raised on this farm a few years back, though his markings are a bit different,  so I know it is not our cat.

We have 6 cats to pet here who claim “us” as their home and family, so there is no lack of fur balls to love.  There are probably that many more who hang out,  now and then,  considering our farm fair game and looking for an occasional free meal.  This cat just seemed to need a reassuring pat at that moment or maybe I needed the reassurance.  Wrong.

I found myself with a cat attached to my wrist by teeth and claws.  It took a bit of an effort to shake him off and he escaped into the night. I then surveyed the damage he inflicted and immediately went to wash my wounds.  They were deep punctures near my wrist joint–not good.  Lucky for me I was up to date on my tetanus booster.

By the next day the wounds were getting inflamed and quite sore.  I know all too well the propensity of cat bites to get badly infected with Pasteurella Multocida, a “bad actor” bacteria that can penetrate deep tissues and bone if not treated with aggressive antibiotics.  After getting 6 opinions from my colleagues at clinic, all of whom stood solemnly shaking their heads at my 12 hour delay in getting medical attention,  I surrendered and called my doctor’s office.  I pleaded for a “no visit” prescription as I was up to my eyeballs in my own patients, and he obliged me.  I picked up the antibiotic prescription during a break, sat in the car ready to swallow the first one and then decided to wait a little longer before starting them, knowing they wallop the gut bacteria and cause pretty nasty side effects.  I wanted to see if my own immune system might just be sufficient.

So the bacterial infection risk was significant and real but I was prepared to deal with it.  For some reason I didn’t really think about the risk of rabies until the middle of the night when all dark and depressing thoughts seem to come real to me.

I don’t know this cat.  I doubt he has an owner and it is highly unlikely he is rabies vaccinated.  My own cats aren’t rabies vaccinated (and neither am I) though if I was a conscientious owner, they would be.  Yes, we have bats in our barns and woods and no, there has not been a rabid bat reported in our area in some time.

But what if this cat were potentially infected with the rabies virus but not yet showing symptoms?  Now my mind started to work overtime as any good neurotic will do.  Last summer a rabid kitten in North Carolina potentially exposed 10 people when it was passed around a softball tournament, no one aware it was ill until it died and was tested.  Lots of people had to have rabies shots as a result.

This cat who had bitten me was long gone–there was no finding him in the vast woods and farmland surrounding us.  He couldn’t be kept in observation for 10 days and watched for symptoms, nor could he be sacrificed to examine his neural tissue for signs of the virus.

I called the health department to ask what their recommendation was in a case like this.  Do they recommend rabies immune globulin injection which should have been done as soon as possible after the bite?   I talked with a nurse who read from a prepared script for neurotic people like me.  Feral cats in our area have not been reported to have rabies nor have skunks or raccoons.  Only local bats have been reported to have rabies but not recently.  This cat would have had to have been bitten by a rabid bat to be rabid.  This was considered a “provoked” attack as I had reached out to pet the cat.  This was not a cat acting unusually other than having wrapped itself around my arm.  No, the Health Dept would not recommend rabies immune globulin in this situation but I was free to contact my own doctor to have it done at my own expense if I wished to have the series of 5 vaccination shots over the next month at a cost of about $3000.   Yes, there would be a degree of uncertainty about this and I’d have to live with that uncertainty but she reassured me this was considered a very low risk incident.

I knew this was exactly what I would be told and I would have counseled any patient with the same words.  Somehow it is always more personal when the risk of being wrong has such dire consequences.  I could see the headlines “Local Doctor Dies From Rabid Cat Bite”.

This is not how I want to be remembered.

Rabies is one of the worst possible ways to die.  The cases I’ve read about are among the most frightening I’ve ever seen in the medical literature. Not only is it painful and horrific but it puts family and care providers at risk as well.  It also has an unpredictable incubation period of a up to a month or two, even being reported as long as a year after an exposure.  What a long time to wait in uncertainty.  It also has a prodrome of several days of very nonspecific symptoms of headache, fever and general malaise, like any other viral infection before the encephalitis and other bad stuff hits.  I was going to think about it any time I had a little headache or chill.  This was assuredly going to be a real test of my dubious ability to stifle my tendency for 4-dimensional worries.

I decided to live with the low risk uncertainty and forego the vaccination series.  It was a pragmatic decision based on the odds.  My wounds slowly healed without needing antibiotics.  For ten days I watched for my attacker cat whenever I went to the barn, but he didn’t put in an appearance.  I put out extra food and hoped to lure him in.  It would have been just be so nice to see his healthy face and not have to think about this gray cloud hanging over me for the next few months, as I wondered about every stray symptom.  No gray kitty to be seen.

Almost a month has gone by now and he finally showed up last night.  I could have grabbed him and hugged him but I know better now. No more Dr. Doolittle.

He is perfectly fine and now so am I, cured of a terminal case of worry and hypochondria which is not nearly as deadly as rabies but can be debilitating and life shortening none the less.

From now on, I’ll be contented to just “talk to the animals” like any good Dr. Doolittle.  I don’t need to cuddle them.

 

kitty1

catlikeobservation
photo by Nate Gibson

Foggy and Fine Days Within Me

fog101926

 

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

 

fog1228141

 

~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”

 

foggyfield
photo by Nate Gibson

 

Is my gloom, after all,
Shade of His hand,
outstretched caressingly?

~Francis Thompson from “The Hound of Heaven”

 

supermoonbarn

 

My days are filled with anxious and sad patients, one after another after another.  They sit at the edge of their seat, struggling to hold back the flood from brimming eyes, fingers gripping the arms of the chair.   Each moment, each breath, each heart beat overwhelmed by questions:  will there be another breath?  must there be another breath?   Must life go on like this in fear of what the next moment will bring?

The only thing more frightening than the unknown is the knowledge that the next moment will be just like the last or perhaps worse.  There is no recognition of a moment just passed that can never be retrieved and relived.   There is only fear of the next and the next so that the now and now and now is lost forever.

Worry and sorrow and angst are contagious as the flu.
I mask up and wash my hands of it throughout the day.
I wish we could be vaccinated to protect us all from these unnamed fears.

I want to say to them and myself:
Stop this moment in time. Stop and stop and stop.
Stop expecting someone or some thing must fix this feeling.
Stop wanting 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
and stop holding them back.

Stop me before I write,
out of my own anxiety,
yet another prescription
you don’t really need.

Just be–
and be blessed–
in the now and now and now.

 

sunset15183

Be Obscure Clearly

thanksgiving20173

 

A wind has blown the rain away
and blown the sky away
and all the leaves away,
and the trees stand.
I think, I too,
have known autumn too long.
~e.e. cummings

 

thanksgiving20172

 

Be obscure clearly.
~E. B. White

 

thanksgiving20177

 

As a family doctor in the autumn of a forty year career, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  That is hard work for my patients, especially when they are depressed and anxious on top of whatever they are experiencing physically.

There is still much unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, not pristine and clear.

Let’s face the lack of facts.  A physician’s clinical work is obscure even on the best of days when everything goes well.  We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Forty years of doctoring in the midst of the mystery of medicine: learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done can be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The time has come for the patient to share responsibility for maintenance of their medical records and assist the diagnostic process by providing online symptom and outcomes follow up documentation.

The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure with clarity.  Our lives depend on it.

 

thanksgiving20174

A Deep Fear of Emptiness

dawn7251

 

marshmallowglow2

 

Wheels of baled hay bask in October sun:
Gold circles strewn across the sloping field,
They seem arranged as if each one
Has found its place; together they appeal
To some glimpsed order in my mind
Preceding my chance pausing here —
A randomness that also seems designed.
Gold circles strewn across the sloping field
Evoke a silence deep as my deep fear
Of emptiness; I feel the scene requires
A listener who can respond with words, yet who
Prolongs the silence that I still desire,
Relieved as clacking crows come flashing through,
Whose blackness shows chance radiance of fire.
Yet stillness in the field remains for everyone:
Wheels of baled hay bask in October sun.
~Robert Pack “Baled Hay” from Rounding it Out: A Cycle of Sonnetelles (1999).

 

mayfieldbales

 

marshmallows51116

 

Each day I am called to see and listen,
to open fully to all that is around me.
From the simple stillness of the fields
surrounding our farm,
to the weeping of those who sit with me
day after day
in their deep fear of emptiness,
their struggle with whether to try to live
or give up and die.

Their deep fear of emptiness renders me silent;
I struggle to respond with words
that might offer up a healing balm
assuring them even in the darkest time
hope lies waiting, wrapped and baled,
radiant as fire,
ready to spill out fragrant,
to bear us silently to a new morning,
to a stillness borne of grace.

 

lookingnortheastoct

 

centralroadoct