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

 

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Be obscure clearly.
~E. B. White

 

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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.

 

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You Are Worth Profound Care

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You can change the world with a hot bath,
if you sink into it from a place of knowing
you are worth profound care,
even when you are dirty and rattled.
Who knew?
~Anne Lamott from Small Victories

 

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As a farmer, I spend at least a part of every day muddy and up to my elbows in muck.  I call my barn life “the real stuff” when the rest of my day is spent dealing with “virtual stuff ” which leaves me dirty and rattled nonetheless.  I prefer the real over virtual muck although it smells worse, leaves my fingernails hopelessly grimy and is obvious to everyone where I’ve been.

The stains of the rest of my day are largely invisible to all but me and far harder to scrub away.

It is so much easier to deal with the barnyard over bureaucracy; what soils us can be washed off and we’re restored for another day of wallowing in our muck boots.  On the farm is the grace of drawing up clean warm water, soaping with the suds that truly cleanse, a sinking down into a deep tub of renewal.

God knows well what a washing we need.

 

 

 

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damppups

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A Deep Fear of Emptiness

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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).

 

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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.

 

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To Thank the Light

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Now a red, sleepy sun above the rim 
Of twilight stares along the quiet weald, 
And the kind, simple country shines revealed 
In solitudes of peace, no longer dim.
The old horse lifts his face and thanks the light, 
Then stretches down his head to crop the green. 
All things that he has loved are in his sight; 
The places where his happiness has been 
Are in his eyes, his heart, and they are good.
~Siegfried Sassoon from “Break of Day”

 

 

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I am growing older along with my horses. I think of them out to pasture throughout my workday as I continue to climb in the harness to pull the load as fast and hard as I can muster, returning home in the evening sore and weary.

I think of them with the morning sun on their withers, the green blades under their feet, as they search for the sweetest tender patch to munch.

They remind me to bring the calm of the pasture inside to balance the noise and bustle and troubles found in the clinic.  There still is peace and light to be found; I have only to look for it.

 

“To practice medicine with good spirit does not mean to be in a place where there is no noise, trouble or hard work. It means to bring your calm and loving heart right into the midst of it.” from www.theheartofmedicine.org

 

 

 

wallysunset

 

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A Moment of Peace

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It had happened many times before, but it always took me by surprise.

Always in the midst of great stress, wading waist-deep in trouble and sorrow, as doctors do, I would glance out a window, open a door, look into a face, and there it would be, unexpected and unmistakable. A moment of peace.  

The light spread from the sky to the ship, and the great horizon was no longer a blank threat of emptiness, but the habitation of joy. For a moment, I lived in the center of the sun, warmed and cleansed, and the smell and sight of sickness fell away; the bitterness lifted from my heart.  

I never looked for it, gave it no name; yet I knew it always, when the gift of peace came. I stood quite still for the moment that it lasted, thinking it strange and not strange that grace should find me here, too.   Then the light shifted slightly and the moment passed, leaving me as it always did, with the lasting echo of its presence. In a reflex of acknowledgment, I crossed myself and went below, my tarnished armor faintly gleaming.
~Diana Gabaldon – Claire’s observations from Voyager

 

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I’ve known this moment of peace in the midst of my work; it comes unexpectedly after a day of immersion in troubles and anguish.  As I leave the clinic and breathe in a sudden rush of fresh air, and as I drive down our country road as the sun is setting, I remember that for all of us, the sick and the not-yet-sick, there still are moments of grace and beauty.

It isn’t all sad, it isn’t all anxious, it isn’t all anguish. The moment may be brief, it may be elusive.

But it is there. And I seek it out every day.

 

 

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(written with gratitude to author Diana Gabaldon for her insights into the complex workings of an innovative physician’s mind in her Outlander series of novels, for Caitriona Balfe‘s insightful characterization and understanding of Claire and for Sam Heughan‘s sensitive portrayal of the man who loves her beyond the boundary of time in Starz’ Outlander  – if you don’t know these stories yet, you should.)

 

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The Damp Pewter Days

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5.
Here, what’s made, these braids, unmakes
itself in time, and must be made
again, within and against
time. So I braid
your hair each day.
My fingers gather, measure hair,
hook, pull and twist hair and hair.
Deft, quick, they plait,
weave, articulate lock and lock, to make
and make these braids, which point
the direction of my going, of all our continuous going.
And though what’s made does not abide,
my making is steadfast, and, besides, there is a making
of which this making-in-time is just a part,
a making which abides
beyond the hands which rise in the combing,
the hands which fall in the braiding,
trailing hair in each stage of its unbraiding.

6.
Love, how the hours accumulate. Uncountable.
The trees grow tall, some people walk away
and diminish forever.
The damp pewter days slip around without warning
and we cross over one year and one year. 

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The calm of a daily rote task,
the over under over under
following twists and turns
of moments weeks years
Return of rain
balances the dry days
we all have
I keep on plaiting lives
over under over under
to braid up something stronger~
a making which abides
wwutangle3

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Enter Autumn Cautiously

autumnleaf2

 

squirrellayers

 

Enter autumn as you would 
a closing door. Quickly, 
cautiously. Look for something inside 
that promises color, but be wary 
of its cast — a desolate reflection, 
an indelible tint.
~Pamela Steed Hill  “September Pitch”

 

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Today is a rainy gray start to the University’s academic year:  we enter autumn cautiously with no little trepidation about what comes next.

Once we’re on the other side of the closing door, we search for what enriches and envelopes  —  that which is unforgettable and indelible.

May we find the color midst the gray.

 

redsquare

 

redleaf1

 

alittlecolor

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