Dusted

dustybee

beeweed

 

“Bees do have a smell, you know,
and if they don’t they should,
for their feet are dusted with spices from a million flowers.”

― Ray Bradbury, Dandelion Wine

 

beeblu

bee

 

I admire the honey bee as pollinator and pollen gatherer simultaneously, facilitating new fruit from the blossom as well as taking away that which will become sweet honey tasting of the spicy essence of the flower touched.

As a physician, I can only hope to be as transformative in the work I do every day.  I carry with me tens of thousands of patients I’ve seen over thirty five years of medical practice.  There is no way I can touch another human being without keeping some small part of them with me – perhaps a memory of an open wound or the residual scar it left behind, a word of sorrow or gratitude, a grimace, a tear or a smile.

Each patient is a flower visited, some still in bud, some in full bloom, some seed pods ready to burst, some spent and wilting and ready to fall away.  Each patient carries a spicy vitality, even in their illness and dying, that is unforgettable and still clings to me. Each patient changes me, the doctor, readying me for the next patient by teaching me a gentler approach, a clearer explanation, a slower leave-taking.  Each patient becomes part of my story, adding to my skill as a healer, and is never to be forgotten.

It has been my privilege to be thoroughly dusted by those I’ve loved and cared for.  I want to carry that on to create something wonderful that reflects the spice of living.

Nothing could smell or taste as sweet.

 

beechestnut

cornbee

beebye

wwubusybees

The Vaccination Conundrum

cacti4

 

It is proof of MMR immunity season again.  Students entering school this fall are being asked to prove they have been fully vaccinated against Mump, Measles (rubeola) and Rubella infection as well as other routine immunizations in order to be allowed to enroll.  A small but significant and vehement minority insist they should be allowed a personal exemption from the requirement that the majority willingly comply with.

Concerned, caring parents make the decision every day to forego life-saving immunity by refusing to vaccinate their children, truly believing they are doing the right thing. They do not perceive an imminent risk to their child from the older contagious diseases despite their resurgence in developed countries like the U.S., focusing instead on the low—or often non-existent but ballyhooed—risks of vaccinations.

These are parents—most of them well-educated and on both ends of the political spectrum—who refuse to vaccinate their children, thereby denying a consensus of scientific evidence and increasing the risk for further outbreaks. “Oh my God. Wealthy, white, liberal enclaves are at risk!” declares Daily Show correspondent Samantha Bee, mocking the anti-vaccine bloggers and activists. So too at risk are some conservative Christian church communities where vaccination rates are low.

As clever the satire may be, I can’t bring myself to laugh or crack a smile. Now in my 60s, I remember the illnesses brought on by these diseases before vaccines. As a physician, I’ve seen cases of them coming back with fatal consequences.

Maybe some of us have forgotten or are too young to realize the severity of these conditions. Healthcare providers who haven’t had firsthand experience with these contagious diseases don’t always think of them when confronted with classic signs and symptoms. But it’s only been a little over 50 years since vaccinations became routine for childhood killers like tetanus, diphtheria, polio, measles, mumps, and pertussis, or whooping cough. Americans growing up before then had no choice but to suffer through childhood infectious diseases as they quickly spread through a community.

Most of us survived our illnesses, rewarded for our affliction with permanent natural immunity. Others suffered lifelong consequences: paralysis from polio, deafness from rubella, sterility from mumps. Some did not survive at all. My father nearly died at age 41 from a case of the mumps I brought home from school. As an infant, my sister-in-law almost didn’t pull through when she turned blue from pertussis infection.

Today, I’ve seen healthy people develop encephalitis and pneumonia from chicken pox. A fit college student in my practice died of influenza within a week of the start of his symptoms. Our university clinic just diagnosed a case of mumps during a local outbreak.  Our herd-immunity for many vaccine-preventable conditions has been waning, as reports of pertussis, measles, mumps, and chicken pox reemerge, in affluent countries with robust health care systems.

Parents who opt to leave their children unvaccinated contribute to the recent outbreaks. Well-meaning American parents are convinced they are doing the best thing by protecting their children from potentially rare and often unproven vaccine side effects. Some Christian parents claim vaccine risks are unwarranted, since God will provide the needed immunity if their children gets sick.

Most cases originate overseas, so it’s especially critical that Americans be vaccinated when traveling outside the U.S., even to Europe. (Those who serve in mission fields are particularly vulnerable, and I’ve found it interesting that previously unvaccinated Christians are more than willing to accept immunizations when they know for certain they will be exposed.)

As a physician of faith, I tell parents God indeed provides immunity. But as we’ve seen over millennia, it comes by very real suffering through a potentially fatal disease. In our modern society, God grants us everyday miracles, both pharmacologic and surgical, including the potential of long-lasting immunity in the form of a vial of vaccine. I don’t think these parents would deny insulin for their child newly diagnosed with diabetes, nor would they fail to strap their child into a car seat before starting the ignition. Vaccines are instruments of prevention, too, given to our healthy youngsters in order to keep them (and others) healthy.

“I’m concerned that so many people seem willing to let others carry the supposed burden of vaccination so that they don’t have to,” wrote Rachel Marie Stone in a Her.meneutics post several years ago. “To me, that’s a failure of the commandment to love our neighbors: our infant neighbors, our elderly neighbors, and our immune-compromised neighbors.”

When I was vaccinated for diphtheria, pertussis, and tetanus (DPT) at the age of 4 months in 1954, my mother wrote in my baby book: Up most of the night with fever 104.5 degrees, a good “take” for the vaccine. She was relieved that it had made me sick, as it meant that my stimulated immune system would keep me safe if exposed to those killer diseases that were so common in the 1950s. Our society doesn’t think about immunizations as we did back then and thankfully a febrile reaction like that would be unusual due to significant changes in how today’s more effective vaccines are formulated.

I wish vaccines were perfect in their protection and potential side effects, but they aren’t. I wish medications developed for treatment of some of these illnesses were perfectly effective, but we can’t depend on a guarantee of cure once sickened. I wish our immune systems were perfect in their response to exposure to pathogens, but they too fail and people do die. Even though there will never be perfect prevention or treatment, parents in third world countries who have watched their children suffer and die from completely preventable disease will walk miles, for days, to get their children vaccinated when they learn of a mobile health clinic setting up an immunization center. Undeterred by that harsh reality, some in our highly educated society choose to run, not walk, in the opposite direction from much more easily accessible free state-supplied vaccine.

There will always be a new plague to worry about. Even as we eradicated illnesses through vaccine, we watched HIV, SARS, avian flu, multidrug-resistant tuberculosis, and MERS infect us. Some countries have seen the return of polio, and we remain concerned over smallpox somehow finding its way out of its lockbox in laboratories.

Given these threats and the new pathogens on the horizon, it remains unwise to refuse safe and effective vaccination. By doing so, we invite the old plagues, these killers of yesteryear, back into our homes, our churches and schools, and inevitably, onto our death certificates.

We can and must do better for our next generation.

 

(an earlier version of this essay was published online three years ago with a significant negative reaction from Christian readers.  It bears repetition because anti-vaccination beliefs continue to be an issue in the midst of current rubeola measles and mumps outbreaks in the U.S.)

cacti9

An Audience of Terminal Patients

chelanblooms1

Write as if you were dying. At the same time, assume you write for an audience consisting solely of terminal patients. That is, after all, the case.
~Annie Dillard from “Write Till You Drop”

chelanducklings5

You’re going to feel like hell if you wake up someday and you never wrote the stuff that is tugging on the sleeves of your heart: your stories, memories, visions, and songs–your truth, your version of things–in your own voice. That’s really all you have to offer us, and that’s also why you were born.

~Anne Lamott in a recent TED Talk

chelanspirea

I began to write after September 11, 2001 because that day it became obvious to me I was dying, albeit more slowly than the thousands who vanished that day in fire and ash, their voices obliterated with their bodies.   So, nearly each day since, while I still have voice and a new dawn to greet, I speak through my fingers and my camera lens to others dying around me.

My good friend, Sara, who I’ve known and loved half my life, is fighting for her life in an all day cancer surgery today, having fought a chronic disease and a totally different cancer once before and won.  She knows well the hard cost of winning even when the odds aren’t good,  yet still has a courage in her to fight once again.

That will to fight is heavy on my mind today.

We are, after all, terminal patients, some more imminent than others, some of us more prepared to move on, as if our readiness had anything to do with the timing.

Each day I too get a little closer, so I write and share photos of my world in order to hang on awhile longer.  Each day I must detach just a little bit, leaving a small trace of my voice and myself behind.  Eventually, through unmerited grace, so much of me will be left on the page there won’t be anything or anyone left to do the typing.

There is no moment or picture or word to waste.

 

chelanpoppies

 image1

 

Doc Season

duckchelan2

img_0761


It may not be rabbit season or duck season but it definitely seems to be doc season, especially as the next version of the American Health Care Act is unveiled today. This (and the Affordable Care Act which preceded it) is not about patients — it is about how to keep doctors and the health care industry under reasonable cost control and maintain some semblance of quality service.

Physicians are lined up squarely in the gun sights of the media, government agencies and legislators, as well as our employers and coworkers, not to mention our own professional organizations, our Board Certifying bodies, and our dissatisfied patients, all happily acquiring hunting licenses in order to trade off taking aim. It’s not enough any more to wear a bullet proof white coat. It’s driving doctors to hang up their stethoscope much earlier than they expected just to get out of the line of fire. Depending on who is expressing an opinion, doctors are seen as overcompensated, demanding, whiny, too uncommitted, too over-committed, uncaring, egotistical, close-minded, inflexible, and especially, and most annoyingly – perpetually late.

One of the most frequent complaints expressed about doctors is their lack of sensitivity to the demands of their patients’ schedule. Doctors do run late and patients wait. And wait. And wait some more. Patients get angry while waiting and this is reflected in patient (dis)satisfaction surveys which are becoming one of the tools the industry uses to judge the quality of a physician’s work and character as well as their salary compensation.  It is considered basic Customer Service 101.

I admit I’m one of those late doctors. I don’t share the reasons why I’m late with my patients as I enter the exam room apologizing for my tardiness. Taking time to explain takes time away from the task at hand: taking care of the person sitting or lying in front of me. At that moment, they are the most important person in the world to me. More important than the six waiting to see me, more important than the several dozen emails and calls waiting to be returned, more important than the fact I missed lunch or need to go to the bathroom, more important even than the text message from my daughter from school or the worry I carry about my dying mother.

I’m a salaried doctor, just like more and more of my primary care colleagues these days, providing more patient care with fewer resources. I don’t earn more by seeing more patients. There is a work load that I’m expected to carry and my day doesn’t end until that work is done. Some days are typically a four patient an hour schedule, but most days my colleagues and I must work in extra patients triaged to us by careful nurse screeners, and there are only so many minutes that can be squeezed out of an hour so patients end up feeling the pinch. I really want to try to go over the list of concerns some patients bring in so they don’t need to return to clinic for another appointment, and I really do try to deal with the inevitable “oh, by the way” question when my hand is on the door knob. Anytime that happens, I run later in my schedule, but I see it as my mission to provide essential caring for the “most important person in the world” at that moment.

The patient who is angry about waiting for me to arrive in the exam room can’t know that I’m late because the previous patient just found out that her upset stomach was caused by an unplanned and unwanted pregnancy. Perhaps they might be more understanding if they knew that an earlier patient came in with severe self injury so deep it required repair. Or the woman with a week of cough and new rib pain with a deep breath that could be a simple viral infection is showing signs of a pulmonary embolism caused by oral contraceptives. Or the man with blood on the toilet paper after a bowel movement finding out he has sexually transmitted anal warts when he’s never disclosed he has sex with other men, or the woman with bloating whose examination reveals an ominous ovarian mass, or finding incidental needle tracks on arms during an evaluation for itchiness, which leads to a suspicion of undiagnosed chronic hepatitis.

Doctors running late are not being inconsiderate, selfish or insensitive to their patients’ needs. Quite the opposite. We strive to make our patients feel respected, listened to and cared for. Most days it is a challenge to do that well and stay on time. For those who say we are being greedy, so we need to see fewer patients, I respond that health care reform and salaried employment demands we see more patients in less time, not fewer patients in more time. The waiting will only get longer as more doctors hang up their stethoscopes rather than become a target of anger and resentment as every day becomes “doctor season.”

Patients need to bring a book or catch up on correspondence,  bring knitting, schedule for the first appointment of the day. They also need to bring along a dose of charitable grace when they see how crowded the waiting room is. It might help to know you are not alone in your worry and misery.

But your doctor and health care team is very alone, scrambling to do the very best healing they can in the time available.

I’m not hanging my stethoscope up anytime soon though some days I’m so weary by the end, I’m not sure my brain between the ear tips is still functioning. I don’t wear a bullet proof white coat since I refuse to be defensive. If it really is doctor season, I’ll just continue on apologizing as I walk into each exam room, my focus directed to the needs of the “most important person in the whole world.”

And that human being deserves every minute I can give them.

chelanbirches2

chelanshadows

Supposing It Didn’t

leadogtree

sunset917168

 

“Supposing a tree fell down, Pooh, when we were underneath it?”

“Supposing it didn’t,” said Pooh after careful thought.

Piglet was comforted by this.
~A.A. Milne

 

clouds101143

It is the final week of a very long academic year and tension is running high.

Among those students to whom I provide care,
there are many who dwell deeply in “what if?” mode,
immobilized in their anticipation of impending disaster.

I understand this line of thinking,
particularly in this day and age of
“in the moment” tragedy
played out real-time in the palm of our hand
and we can’t help but watch as it unfolds.

Those who know me well
know I can fret and worry
better than most.
Medical training only makes it worse.
It teaches one to think catastrophically.
That is what I do for a living,
to always be ready for the worse case scenario.

When I rise, sleepless,
to face a day of uncertainty
as we all must do at times~
after careful thought,
I reach for the certainty I am promised
over the uncertainty I can only imagine:

What is my only comfort in life and in death?
That I am not my own, but belong
—body and soul, in life and in death—
to my faithful Savior, Jesus Christ.

stormacoming1

“Supposing it didn’t” — He says to reassure us.

sunsetdogwood

Music Against the Hard Edges

galena

 

waterfalljasper1

 

In all the woods that day I was
the only living thing
fretful, exhausted, or unsure.
Giant fir and spruce and cedar trees
that had stood their ground
three hundred years
stretched in sunlight calmly
unimpressed by whatever
it was that held me
hunched and tense above the stream,
biting my nails, calculating all
my impossibilities.
Nor did the water pause
to reflect or enter into
my considerations.
It found its way
over and around a crowd
of rocks in easy flourishes,
in laughing evasions and
shifts in direction.
Nothing could slow it down for long.
It even made a little song
out of all the things
that got in its way,
a music against the hard edges
of whatever might interrupt its going.
~John Brehm “Passage”

 

waterfall

 

It may be that when we no longer know what to do
we have come to our real work,

and that when we no longer know which way to go
we have come to our real journey.

The mind that is not baffled is not employed.

The impeded stream is the one that sings.
~Wendell Berry “The Real Work”

 

mejierwaterfall

 

Who among us knows with certainty each morning
what we are meant to do that day
or where we are to go?
Or do we make our best guess by
putting one foot ahead of the other
until the day is done and it is time to rest.

For me, I wake baffled each day
that I am allowed
to eavesdrop on heartbeats,
touch tender bellies,
sew up broken skin,
listen to tearful stories
of those no longer wish to live
and those who never want to let go of life.

I wake humbled with commitment
to keep going even when too tired,
to offer care even when rejected.
to keep trying even if impeded.

It is only then I learn that
daily obstacles slow
but cannot stop
the offer of help,
the gift of caring,
the flow of time given freely
which overflows its banks with
uncertain certainty:
my real work and journey
through life.

May I wade in deep~
listening~
ready to raise my voice
for those who hurt
and sing along.

 

poliswaterfall2

The Art of Showing Up

peonyshower
pears1
grapes2
I learned from my mother how to love
the living, to have plenty of vases on hand
in case you have to rush to the hospital
with peonies cut from the lawn, black ants
still stuck to the buds. I learned to save jars
large enough to hold fruit salad for a whole
grieving household, to cube home-canned pears
and peaches, to slice through maroon grape skins
and flick out the sexual seeds with a knife point.
I learned to attend viewings even if I didn’t know
the deceased, to press the moist hands
of the living, to look in their eyes and offer
sympathy, as though I understood loss even then.
I learned that whatever we say means nothing,
what anyone will remember is that we came.
I learned to believe I had the power to ease
awful pains materially like an angel.
Like a doctor, I learned to create
from another’s suffering my own usefulness, and once
you know how to do this, you can never refuse.
To every house you enter, you must offer
healing: a chocolate cake you baked yourself,
the blessing of your voice, your chaste touch.
~Julie Kasdorf– “What I Learned from my Mother”

 

dandydew

lettinggo11

Usually a mom knows best about these things — how to love others when and how they need it.  Showing up with food you’ve made yourself is always a good thing but it is the showing up part that is the real food;  bringing along a cake is simply the icing.

This is a good reminder that as a doctor, my usefulness is completely dependent on others’ suffering. No illness, no misery, no symptoms and I’m out of a job.

If only.
What a world that would be.
And then I can still be a mom even if there is no more doctor work:

….if I’d known it could help, I’d have baked a cake…

 

 

dandydew5