The Mere Exception

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We should always endeavour to wonder at the permanent thing, not at the mere exception. We should be startled by the sun, and not by the eclipse. We should wonder less at the earthquake, and wonder more about the earth.
~ G.K. Chesterton

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As a physician, I’m trained to notice the exceptions – the human body equivalent of
an eclipse or an earthquake,
a wildfire or drought,
a hurricane or flood,
or a simple pothole.

Ordinarily I’m not particularly attentive to everything that is going well with the human body, instead concentrating on what is aberrant, out of control or could be made better.

This is unfortunate; there is much beauty and amazing design to behold in every person I meet, especially those with chronic illness who feel nothing is as it should be and feel despair and frustration at how their mind or body is aging, failing and faltering.

To counter this tendency to just find what’s wrong and needs fixing, I’ve learned over the years to talk out loud as I do physical assessments:
you have no concerning skin lesions,
your eardrums look just as they should,
your eyes react normally,
your tonsils look fine,
your thyroid feels smooth,
your lymph nodes are tiny,
your lungs are clear,
your heart sounds are perfect,
your belly exam is reassuring,
your reflexes are symmetrical,
your emotional response to this stress and your tears are completely understandable.

I also write messages meant to reassure:
your labs are in a typical range
or are getting better
or at least maintaining,
your xray shows no concerns,
or isn’t getting worse,
those medication side effects are to be expected and could go away.

I acknowledge what is working well before attempting to intervene in what is not.

I’m not sure how much difference it makes to my patient.
But it makes a difference to me to wonder first at who this whole patient is before I focus in on what is broken and what is causing such dis-ease.

I just might be astonished.

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A Furry, Finned or Feathered Treatment Plan

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Due to changes in Fair Housing Act laws, clinicians are experiencing a significant increase in requests from patients for medical documentation to keep emotional support animals with them in “no-pets policy” rental housing. On a college campus, this leads to far more than just two-legged mammals inhabiting dorm rooms.  There has been an animal explosion on our University campus with over seventy animals of various types approved as an “ESA” in the residence halls and unknown dozens more who live with their owners off campus yet still frequent campus.  Only a small minority of these animals are actually trained and certified as service animals with the right to accompany their owner on public transportation to any public place, including classrooms and eating establishments.  The rest are approved only for housing purposes, yet they are regularly showing up in airplane cabins and grocery stores, dressed in little jackets that are easily purchased along with “certification letters” for big prices on the internet.  ESAs have become part of the campus and community landscape.

As a relatively outdoorsy, green and tolerant northwest University campus, the presence of animals on our campus has yet to seem like a big deal, but as the animal numbers inevitably increase due to 25% of the college student population nationwide currently eligible for an animal due to a mental health diagnosis, it is becoming a big deal as individuals insist on exercising their civil rights along with their dogs.

And it isn’t always dogs.  There are cats, along with the occasional pocketed rat, hamster, guinea pig, flying squirrel, and ferret not to mention emotional support pot bellied pigs, tarantulas, and various types of birds.  And at least one snake.

Yes, a snake.

As a physician farmer concerned with stewardship of the patients I treat and the land and animals I care for, I’m emotionally caught and ethically bound in this treatment trend.  The law compels clinicians to provide the requested documentation to avoid  potential law suits alleging discrimination, yet I’m also concerned for the rights of the animals themselves.   I’ve loved, owned and cared for animals most of my sixty two years and certainly missed my pets during the thirteen years I was in college, medical school, residency and doing inner city work (my tropical fish and goldfish notwithstanding).  I neither had the time, the money, the space nor the inclination to keep an animal on a schedule and in an environment that I myself could barely tolerate, as stressed as I was.   That is not stopping the distressed college student of today from demanding they be able to keep their animals with them in their stress-mess.

As a clinician, I’d much prefer writing fewer pharmaceutical prescriptions and help individuals find non-medicinal ways to address their distress.   I’d like to see my patients develop coping skills to deal with the trouble that comes their way without falling apart, and the resilience to pick themselves up when they have been knocked down and feel broken.   I’d like to see them develop the inner strength that comes with maturity and experience and knowing that “this too will pass.”  I’d like individuals to see themselves as part of a diverse community and not a lone ranger of one, understanding that their actions have a ripple effect on those living, working, eating, riding and studying around them. Perhaps corporate work places, schools and universities should host a collaborative animal center with rotating dogs and cats from the local animal shelter, so those who wish to may have time with animals on their breaks without impacting others who aren’t animal fans, or with potentially life threatening animal dander allergies.

So I find myself reluctantly writing a prescription for a living breathing creature perceived by the law as a “treatment” rather than a profound responsibility that owners must take on for the lifetime of the animal.   With great gravity, I always let my patients know an animal is not disposable like a bottle of pills (or a human therapist) when no longer needed and must have a lifelong commitment from its owner beyond a particular time of high personal stress.

Pardon me now while I go take care of my dogs, my cats, by birds, and my horses and yes, my goldfish.  They are my joy to support for decades and for as long as they need me.

josekelsy

A Z-Pack Pas De Deux

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I’ve been really miserable for three days and need that 5 day antibiotic to get better faster.

Ninety eight percent of the time these symptoms are due to a viral infection and will resolve without antibiotics.

But I can’t breathe and I can’t sleep.

You can use salt water rinses and a few days of decongestant nose spray to ease the congestion.

But my face feels like there is a blown up balloon inside.

Try applying a warm towel to your face.

And I’m feverish and having sweats at night.

Your temp is 99.2. You can use ibuprofen or acetominophen to help the feverish feeling.

But my snot is green.

That’s not unusual with viral upper respiratory infections.

And my teeth are starting to hurt and my ears are popping.

Let me know if that is not resolving in a week or so.

But I’m starting to cough.

Your lungs are clear so breathe steam, push fluids and prop up with an extra pillow.

But sometimes I cough to the point of gagging. Isn’t whooping cough going around?

Your illness doesn’t fit the timeline for pertussis.  You can consider using an over the counter cough suppressant.

But I always end up needing antibiotics. This is like my regular sinus infection thing.

There’s plenty of evidence they can do more harm than good.  They really aren’t indicated at this point in your illness and could have nasty side effects.

But I always get better faster with antibiotics. Doctors always give me antibiotics.

Studies show that two weeks later there is no significant difference in symptoms between those treated with antibiotics and those who did self-care without them.

But I have a really hard week coming up and I won’t be able to rest.

This could be your body’s way of saying that you need to evaluate your priorities.

But I just waited an hour to see you.

I really am sorry about the wait; we’re seeing a lot of sick people with this viral thing going around.

But I paid a $20 co-pay today for this visit.

We’re very appreciative of you paying promptly on the day of service.

But I can go down the street to the walk in clinic and for $130 they will write me an antibiotic prescription without making me feel guilty for asking.

I wouldn’t recommend taking unnecessary medication that can lead to bacterial resistance, side effects and allergic reactions. I truly believe you can be spared the expense, inconvenience and potential risk of taking something you don’t really need.

So that’s it?  Salt water rinses and wait it out?  That’s all you can offer?

Let me know if your symptoms are unresolved or worsening in the next week or so.

So you spent all that time in school just to tell people they don’t need medicine?

I believe I help people heal themselves and educate them about when they do need medicine and then facilitate appropriate treatment. 

I’m going to go find a real doctor who will listen to me.

A real doctor vows to first do no harm.  I know you want something different than I’m offering you and I wish you the best as you recover.

Now and Now and Now

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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

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My clinic days are filled with anxious people, one after another after another.  They sit at the edge of their seat, eyes brimming, voice shaky. fingers gripping the arms of the chair.

Each moment, each breath, each rapid heart beat overwhelmed by fear-filled questions:  will there be another breath?  must there be another breath?   Must this life go on like this in panic of not knowing what the next moment will bring?

The only thing more frightening than the unknown is the known that the next moment will be just like the last.

It seems a serious deficit of acknowledgment of NOW, 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 the now is lost forever.

Such worry and angst is more contagious than the flu virus rampant in the waiting room.
I mask up and wash my hands of it throughout the day.
I wish a vaccination could protect us all from our unnamed fears.

I want to say to them and myself:
Stop wishing away your life.
Stop wanting this moment, this feeling, to vanish.
Stop expecting some one, some thing or some drug must fix it.
Stop being blind and deaf to the gift of each breath.

Just stop this moment in time
And simply be.

I want to say to them and myself:
this moment is ours,
this moment of weeping and sharing
and breath and pulse and light
and yes, sometimes despair.

Shout for joy in it.
Celebrate it for what it is.
Be thankful for tears that can flow over grateful lips.

Stop me before I write
out of my own anxiety,
yet another prescription
you probably do not need.

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

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A Calling Out

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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;
~Dermot Healy from A Fool’s Errand

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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

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By the time Saturday rolls around, I am overwhelmed by the amount of “noticing” I needed to do in the course of my work that week.  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 sometimes offered by another human being.

How are they calling out to me?

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.

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Send Our Roots Rain

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Justus quidem tu es, Domine, si disputem tecum; verumtamen
justa loquar ad te: Quare via impiorum prosperatur? (Jeremiah 12)

Thou art indeed just, Lord, if I contend
With thee; but, sir, so what I plead is just.
Why do sinners’ ways prosper? and why must
Disappointment all I endeavour end?
    Wert thou my enemy, O thou my friend,
How wouldst thou worse, I wonder, than thou dost
Defeat, thwart me? Oh, the sots and thralls of lust
Do in spare hours more thrive than I that spend,
Sir, life upon thy cause. See, banks and brakes

Now, leavèd how thick! lacèd they are again
With fretty chervil, look, and fresh wind shakes
Them; birds build — but not I build; no, but strain,
Time’s eunuch, and not breed one work that wakes.

Mine, O thou Lord of life, send my roots rain
~Gerard Manley Hopkins  “Thou art indeed just, Lord”

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As I look out through a tear-streaked window at the beginning of this dark day,
I feel inadequate to the task before me.

Parched and struggling patients will line my schedule in weeks to come;
they are anxious and already weary and barren, seeking something, anything
to ease their distress in a hostile world.
Preferably an easy pill to swallow.
Nothing that hurts going down.

While others thrive around them,
they wilt and wither, wishing to die.

Lord of Life, equip me to find the words to say that might help.
May it be about more than
genetics, neurotransmitters and physiology.

In this dry season for young lives,
send your penetrating rain to reach them
and those who guide them.
Reach down and shake our roots fiercely
to slake our continual thirst.

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When to be Glad

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Well I know now the feel of dirt under the nails,
I know now the rhythm of furrowed ground under foot,
I have learned the sounds to listen for in the dusk,
the dawning and the noon.

I have held cornfields in the palm of my hand,
I have let the swaying wheat and rye run through my fingers,
I have learned when to be glad for sunlight and for sudden
thaw and for rain.

I know now what weariness is when the mind stops
and night is a dark blanket of peace and forgetting
and the morning breaks to the same ritual and the same
demands and the silence.
~Jane Tyson Clement from No One Can Stem the Tide

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Soon to arrive, a wave of 15,000 young people
with such potential to grow,
their health needs entrusted to us
as if we tend them as gardeners:
most thriving and flourishing,
yet some already withering,
their roots thirsting.

As the winds of time bring
new thousands to our care,
blown in from places unknown,
I weary weep for those who may not bloom,
wondering if I will fail to water or care enough~

or is it me with thirst unceasing,
my roots drying from each new morning’s
same ritual and same demands unceasing,
as if I’ve forgotten how to be glad for this work,
being met with the silence
of my own gardeners.

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