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.

fungaltree

lundetree

 

Only Human

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photo by Nate Gibson

                                                                                                                               above photo by Nate Gibson

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They work with herbs
and penicillin.
They work with gentleness
and the scalpel.
They dig out the cancer,
close an incision
and say a prayer
to the poverty of the skin.
They are not Gods
though they would like to be;
they are only human
trying to fix up a human.
Many humans die.
They die like the tender,
palpitating berries
in November.
But all along the doctors remember:
First do no harm.
They would kiss if it would heal.
It would not heal.

If the doctors cure
then the sun sees it.
If the doctors kill
then the earth hides it.
The doctors should fear arrogance
more than cardiac arrest.
If they are too proud,
and some are,
then they leave home on horseback
but God returns them on foot.
~Anne Sexton “Doctors”

 

Decades ago, essayist, journalist and storyteller E.B. White advised, “Be obscure clearly.”

As a physician, 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.  There is much that is still 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, hardly pristine and clear.

Let’s face the lack of facts of the plethora of shifting, changing facts.  Our conceit about our clinical work is ready to unseat us and plunk us in the dust even on the best of days when everything goes well.  We hope our patients communicate their concerns clearly and comprehensively, 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, advertised by our training as so solid and reliable,  is quicksand much of the time even though our patients trust we are giving them advice based on a foundation of truth learned over years of education and experience.   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.

Over thirty years of doctoring in the midst of the mystery of medicine — learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with constant 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 will be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The patient shares responsibility for maintenance of their medical records and assists the diagnostic process by providing online symptom and outcomes 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 clearly.   Lives depend on it.
And maybe we can stay on the horse and out of the dirt a little while longer.

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Prepare for Joy: Repairer and Restorer

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Then your light will break forth like the dawn,
    and your healing will quickly appear;
then your righteousness will go before you,
    and the glory of the Lord will be your rear guard.
Then you will call, and the Lord will answer;
    you will cry for help, and he will say: here am I.

11 The Lord will guide you always;
    he will satisfy your needs in a sun-scorched land
    and will strengthen your frame.
You will be like a well-watered garden,
    like a spring whose waters never fail.
12 Your people will rebuild the ancient ruins
    and will raise up the age-old foundations;
you will be called Repairer of Broken Walls,
    Restorer of Streets with Dwellings.
Isaiah 58: 8-9, 11-12

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Medical science is realizing there is less benefit (and possible potential for harm) in healthy people requesting an “annual physical”  than previously believed.  Too many people hold off on very real problems, hoping they are insignificant, and expect the doctor might discover what’s wrong during a cursory physical exam.

As healers, we are tempted to look too hard for “something wrong” to fix, at the risk of creating illness where there is none, all at a hefty price tag.

Give us the sick and tired and we doctors feel right at home, with problems to solve and a job to do.

Jesus, as the Great Physician, understood there is “something wrong” with each of us needing His unique healing art.  He hangs out His shingle as the place to come, triaging the most troubled and distressed to move first in line.   When we cry out for help, He is on call full time, a certified, licensed and bonded Strengthener, Rebuilder, Restorer and Repairer.

No more waiting for the annual check up.  The time has come to cry out our brokenness, our desperate need of restoration.

It is not the healthy who need a doctor, but those who are ill.
Luke 5: 31

A Recipe For Good Medicine

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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 from Dandelion Wine

Most days in clinic we see tears, lots of them.  We keep boxes of tissues strategically placed in the exam and consult rooms,  as well as the waiting room.  Life can seem overwhelming, fear and worry proliferate unchecked and floodgates spillover occurs when just one more thing happens — maybe a failed test, a fight with a family member, a lingering fatigue that just might be some dread disease.

We underestimate how therapeutic a good cry can be, almost as helpful as deep and heart felt laughter.  Stress and tension is dissipated, endorphins are released, muscles relax.  Holding back tears, like trying not to laugh (think Mary Tyler Moore at Chuckles the Clown’s funeral service) is hard work and cab only make things worse.

So I hand out kleenex like candy and tell my patients to just let it go and flow.  I’m an easy crier myself, and will cry at the drop of a hat with very little provocation — a certain hymn in church, a beautiful word picture, a poignant memory, or sometimes in exhaustion and frustration.  Tears are a visible tangible connection with what is happening to us and around us and to others.   They can be more honest than what we say and do.

When the weeping wanes,   I always recommend a good night’s sleep.

And chocolate.

Good medicine without a pharmacist.

fogdrops2

My Own Usefulness

hand

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 from “What I Learned From My Mother”
When my clinical responsibilities top out at 14 hours a day and there is still more to do,  when I’m weary and grumbling about work load, I need reminding that my usefulness is completely dependent on others’ suffering.
No illness, no misery, no suffering and I’m out of a job.
If only. What bliss that would be.
If I’d known it could help you, I’d have baked a cake…

Definitely chocolate.

Startle and Wonder

photo by Josh Scholten

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

As a physician, I’m trained to notice the exceptions.  Ordinarily I’m not particularly attentive to everything that is going well with the human body, instead concentrating on what is aberrant or could be made better.  This is unfortunate; there is much beauty and perfect design to behold in every person I meet.

Instead I am looking past the every day miracles to find what’s wrong.

To counter this tendency to just find flaws, I’ve learned over the years to talk out loud as I do physical assessments:  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 a stress and your tears are completely appropriate.  I want to acknowledge what is working well, as it should, as it was designed to be.  I want a wonder of the human body and mind to extend to the person who inhabits it as well.

When the exception occurs, it is likely to startle and frighten the patient but I don’t want it to surprise me.  We must tackle it with everything we’ve got.

What gives us the strength to deal with the exception is how much in every person is right and wondrous.

Just as it was meant to be.