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

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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).

 

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

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”

 

 

morninglight

 

octpasture

 

 

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

 

sunsettony2

 

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A Soul Set Free

turningred

 

cosmos1

 

We know when we are following our vocation
when our soul is set free from preoccupation with itself
and is able to seek God and even to find Him,
even though it may not appear to find Him.

Gratitude and confidence and freedom from ourselves:
these are signs that we have found our vocation
and are living up to it
even though everything else
may seem to have gone wrong. 

They give us peace in any suffering.
They teach us to laugh at despair.
And we may have to.

— Thomas Merton from No Man is an Island

 

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rain918174

 

For three decades I have worked in a public setting,
my faith checked at the threshold as I walk in the door.

Preoccupied with the needs of the day,
my prayers for patients and co-workers
stay silent but not unheard
as God knows how to find His way in
through the cracks, under the door.

Even where He is deemed unnecessary
He is present, incognito.

I’ll turn a corner and find Him there,
in streaming rays through the window
illuminating a polished tile floor.
He’s streaming down the face of a patient,
or behind the smile of a co-worker.

He will not be turned away
even when we bar the door to keep Him out.

Knowing this helps me laugh
when I need it most.
Knowing this sets my soul free
from worries;
Knowing this, I shall look to find Him
wherever He may be,
even where He is unwelcome.

 

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To Labor and Not Seek Reward

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And then there was St Kevin and the blackbird.
The saint is kneeling, arms stretched out, inside
His cell, but the cell is narrow, so

One turned-up palm is out the window, stiff
As a crossbeam, when a blackbird lands
And lays in it and settles down to nest.

Kevin feels the warm eggs, the small breast, the tucked
Neat head and claws and, finding himself linked
Into the network of eternal life,

Is moved to pity: now he must hold his hand
Like a branch out in the sun and rain for weeks
Until the young are hatched and fledged and flown.

*

And since the whole thing’s imagined anyhow,
Imagine being Kevin. Which is he?
Self-forgetful or in agony all the time

From the neck on out down through his hurting forearms?
Are his fingers sleeping? Does he still feel his knees?
Or has the shut-eyed blank of underearth

Crept up through him? Is there distance in his head?
Alone and mirrored clear in love’s deep river,
‘To labour and not to seek reward,’ he prays,

A prayer his body makes entirely
For he has forgotten self, forgotten bird
And on the riverbank forgotten the river’s name.
~Seamus Heaney “St. Kevin and the Blackbird”

 

yellowmorning2

 

Eternal Word, only begotten Son of God,
Teach me true generosity.
Teach me to serve you as you deserve.
To give without counting the cost,
To fight heedless of wounds,
To labor without seeking rest,
To sacrifice myself without thought of any reward
Save the knowledge that I have done your will.
Amen.

~St. Ignatius’ Prayer for Generosity

 

thistlegrass

 

Heaney shifts from the literal (if “imagined”) physical world to the metaphysical and symbolic. In the midst of burnout and mental detachment, Kevin is somehow returned to and reconnected with his calling at a level deeper than conscious thought. Indeed, in the span of one brief line break, it is as though he has become indistinguishable from his life’s mission itself: he is “mirrored clear” in the pure, deep waters of an empathetic love for the “network of eternal life” into which he is presently and vitally “linked.”

The way Heaney constructs the next two lines calls attention to the paradox of mindfulness he illuminates. Kevin “prays,” which perhaps most immediately suggests that he entreats God to help him “labour and not to seek reward.” But after the stanza break, Heaney reveals that this prayer is not at all what the reader might have expected; Kevin’s prayer is not conscious because he is no longer conscious in the workaday-world way. Rather, Kevin’s is

“A prayer his body makes entirely
For he has forgotten self, forgotten bird
And on the riverbank forgotten the river’s name.

When he can no longer muster the energy to think of the life entrusted to him, his own delights and discomforts in fostering that life, or even the original life force (here, the “river”) that led to his vocation, it is as if a kind of autonomic spirituality kicks in to complement the compassionate detachment with which—or in which—he holds the blackbird. Body and soul and work are one.
~Kimberly R. Myers, PhD, MA from “Mindfulness and Seamus Heaney” from JAMA’s
A Piece of My Mind, Aug.1, 2017

 

hydrangeaaugust

…we have tried to do too much, pretending to be in such control of things that we are indispensible…

…if you’re like me, you take a kind of comfort in being busy. The danger is that we will come to feel too useful, so full of purpose and the necessity of fulfilling obligations that we lose sight of God’s play with creation, and with ourselves.
~Kathleen Norris from The Quotidian Mysteries

 

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Missing the Knock on the Door

barndoor

 

When a great moment knocks on the door of your life,
it is often no louder than the beating of your heart,
and it is very easy to miss it.
~Boris Pasternak

 

 

 

Years ago, a young woman I’d been treating for depression for several weeks in my clinic called unexpectedly on a Friday afternoon and canceled an upcoming appointment for the following Monday and did not reschedule. The receptionist sent me a message as is our policy for patients who “cancel and do not reschedule”. It gave me a bad feeling that she was turning her back on her treatment plan and I was uneasy about the upcoming weekend without knowing what was going on with her.

I could have just put on my coat and headed home at the end of that long Friday after a very stressful work week and even more stressful year. I was discouraged about many aspects of the clinic work load and the after-hours responsibilities only seemed to get heavier.  I was frustrated at how ineffectively I was communicating to administrative supervisors about the need for change.  I was ready to quit and walk away.

Instead I decided to call my patient to find out how she was doing.  She didn’t answer her phone. I mulled over my options, looked up her apartment address and drove the few blocks to get there. As I approached her door, I could hear someone moving around in her apartment, but she ignored my knocks and my voice and when I tried the door, it was locked.

So I stayed right there, talking to her through the door for about 15 minutes, letting her know I wasn’t leaving until she opened up the door. I finally told her she could decide to open the door or I would call 911 and ask the police to come to make sure she was okay. She then unlocked the door, tears streaming down her face. She had been drinking heavily, with liquor bottles strewn around on the floor. She admitted an intent to overdose on aspirin and vodka. The vodka was already consumed but the unopened aspirin bottle was in her hand. I was the last person she expected to see at her door.

Miraculously the mental health unit at the local hospital had an open bed. I told my patient that we could save time and hassle by heading over there together right then and there, and avoid the emergency room mess, and the possibility of an involuntary detainment.

She agreed to come with me and be admitted voluntarily for stabilization. I visited the hospital the next day and she greeted me with a hug and thanked me for not giving up on her when she had given up on herself. In sobriety, her eyes were brighter and she was more hopeful. She never expected anyone to care enough to come knock on her door when she was at her lowest point,  and she struggled to answer, as consumed as she was in her own painfully beating heart.

She was astounded and grateful and frankly, by deciding to do what I knew was necessary and right even though it disregarded every workplace policy, so was I.

Four years later, a small card arrived in my clinic mailbox on another most challenging work day from an unfamiliar address two thousand miles away. The name looked vaguely familiar to me but when I opened and read the contents, this time the knock on the door was to get my attention, to focus the beating of my heart on what was most important – not the stresses of my work place — and it was my turn to let tears flow:

 

“Dear Doctor,

I am not sure if you will remember me considering you see a number of patients daily; however, I am a patient whose life you changed in the most positive way. I never truly THANKED YOU for listening to me and hearing my silent words of grief and hearing my cries for help. If it had not been for you, had you not knocked on my door, I would not be writing this letter to you today. I don’t know exactly what to say to the person who saved me from hurting myself fatally. You were a stranger in my life, but a dear friend in my time of need. THANK YOU, for everything that you did for me. You have a permanent place in my heart, you have given my spirit hope, you have reminded me that a life is worth living. Thank you, thank you, thank you! Sincerely, L_____”

 

I’m grateful 4 years ago I had the sense to go knock on her door when all she could hear was the beating of her own painful heart. I had the stubbornness to stay put until she responded, and most of all, I’m appreciative for her gracious note letting me know it made a difference. When I needed it the most, she made a difference for me that has kept me on the job all these years later.

She knocked, oh so gently, on my door and I opened it, amazed that someone cared, and found me awash in my own tears.

 

 

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

 

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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

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