…Then how his muffled armies move in all night And we wake and every road is blockaded Every hill taken and every farm occupied And the white glare of his tents is on the ceiling. And all that dull blue day and on into the gloaming We have to watch more coming.
Then everything in the rubbish-heaped world Is a bridesmaid at her miracle. Dunghills and crumbly dark old barns are bowed in the chapel of her sparkle. The gruesome boggy cellars of the wood Are a wedding of lace Now taking place. ~Ted Hughes from “Snow and Snow”
I wish one could press snowflakes in a book like flowers. ~James Schuyler from “February 13, 1975”
It’s true that three snow days in a row is unprecedented in our part of the world. Being snowbound by driveway-blocking drifts has its advantages until it isn’t fun any longer and means even more work to be done both on and off the farm, especially for a physician stranded from her closed clinic.
I’ve been doing my best taking care of our clinic’s patients via messaging, text and other media, but there is a limit to my virtual reach: I can’t palpate a tender belly, or feel swollen lymph nodes or listen to someone’s palpitations, though it is a little easier to discern despair, anticipate anxiety and work out someone’s worries from afar.
But I do have a view of the wedding lace of our woods and the sparkling chapels made of our tired old barns and buildings on the farm. I’m reminded that even I can be dressed up with a covering as white as snow. So lovely to look at, if only to be preserved for the long summer days that lie ahead — a wilting snowflake pressed into a book like a flower remembered, its fragrance still attached.
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 only human trying to fix up a human. Many humans die.
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” from The Awful Rowing Toward God.
Let me not forget how humbling it is
to provide care for a hurting person
and not be certain that what I suggest
will actually work,
to be trusted to recommend the best option
including tincture of time,
wait and see,
try this or that.
Like other physicians who tumble off
at a full gallop, having lost balance
between confidence and humility,
I sometimes find myself unseated and unsettled,
returning on foot to try again to make a difference.
It may not be rabbit season or duck season but it definitely seems to be doctor season. Physicians are lined up squarely in the gun sights of the media, government agencies and legislators, our health care industry employers and coworkers, not to mention our own 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 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 overcommitted, uncaring, egotistical, close minded, inflexible, and especially– 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.
I admit I’m one of those late doctors. Perpetually 20-30 minutes behind.
I don’t share the reasons why I’m late with my patients as we sit down together in the exam room but I do apologize for my tardiness. Taking time to explain why takes time away from the task at hand: taking care of the person sitting or lying in front of me. At that moment, that is the most important person in the world to me. More important than the six waiting to see me, more important than the dozens of emails, electronic portal messages 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 of concern from my daughter or the worry I have about a ill relative.
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 three patients before them I saw a woman who 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, but is showing potential 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 suspected 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, 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 is very alone, scrambling to do the very best healing he or she can in the time available.
I’m not yet hanging my stethoscope up though some days I’m so weary by the end, I’m not sure my brain between the ear buds 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 for that moment to the needs of the “most important person in the whole world.”
And that human being deserves every minute I can give them.
Astonishing material and revelation appear in our lives all the time.
Let it be.
Unto us, so much is given.
We just have to be open for business. ~Anne Lamott from Help Thanks Wow: Three Essential Prayers
I have the privilege to work in a profession where astonishment and revelation awaits me behind each exam room door.
In a typical clinic day, I open that door up to thirty plus times, close it behind me and settle in for the ten or fifteen minutes I’m allocated per patient. I need to peel through the layers of each person quickly to find the core of truth about who they are and why they’ve come to clinic that day.
Sometimes what I’m looking for is right on the surface: in their tears, in their pain, in their fears. Most of the time, it is buried deep, often beneath a scar I must search to find. I need to wade through the rashes and sore throats and coughs and headaches and discouragement to find it.
Once in awhile, I actually do something tangible to help right then and there — sew up a cut, lance a boil, splint a fracture, restore hearing by removing a plug of wax from an ear canal.
Often I find myself giving permission to a patient to be sick — to take time to renew, rest and trust their bodies to know what is best for a time.
Sometimes, I am the coach pushing them to stop living sick — to stop hiding from life’s challenges, to stretch even when it hurts, to get out of bed even when not rested, to quit giving in to symptoms that are to be overcome rather than become overwhelming.
Always I’m looking for an opening to say something a patient might think about after they leave my clinic — how they can make different choices, how they can be bolder and braver in their self care, how they can intervene within their own finite timeline to prevent illness, how every day is just one thread in the larger tapestry of their lifespan.
Each morning I rise early to get work done at home before I actually arrive at my desk at work, trying to avoid feeling unprepared and inadequate to the volume of tasks heaped upon each day. I know I will be stretched beyond my capacity, challenged by the unfamiliar, the unexpected and will be stressed by obstacles thrown in my way. I know I will be held responsible for things I have little to do with, simply because I’m the one who often acts as decision-maker.
It is always tempting to go back to bed and hide.
Instead of hiding, I go to work as the exam room doors need to be opened and the layers peeled away. I understand the worry, the fear and the pain because I have lived it too. I know the limitations of a body that wants to consume more than it needs, to sleep rather than go for a walk, to sit rather than stand.
Even now in my seventh decade of life, I am continually learning how to let it be, even if it is scary. It is a gift perhaps I can share.
No matter what waits behind the exam room door, it will be astonishing to me.
I’m grateful to be open for business. The Doctor is In.
A good night sleep, or a ten minute bawl, or a pint of chocolate ice cream, or all three together, is good medicine.
If there is anything I’ve learned in over 40 years of practicing medicine, it’s that I still must “practice” my art every day. As much as we physicians emphasize the science of what we do, utilizing “evidence based” decisions, there are still days when a fair amount of educated guessing and a gut feeling is based on past experience, along with my best hunch. Many patients don’t arrive with classic cook book symptoms that fit the standardized diagnostic and treatment algorithms so the nuances of their stories require interpretation, discernment and flexibility. I appreciate a surprise once in awhile that makes me look at a patient in a new or unexpected way and teaches me something I didn’t know before. It keeps me coming back for more, to figure out the mystery and dig a little deeper.
I’ve also learned that not all medicine comes in pills or injections. This isn’t really news to anyone, but our modern society is determined to seek better living through chemistry, the more expensive and newer the better, whether prescribed or not. Chemicals have their place, but they also can cause havoc. It is startling to see medication lists topping a dozen different daily pills. Some are life-saving. Many are just plain unnecessary.
How many people sleep without the aid of pill or weed or alcohol? Fewer and fewer. Poor sleep is one of the sad consequences of our modern age of too much artificial light, too much entertainment and screen time keeping us up late, and not enough physical work to exhaust our bodies enough to match our frazzled and fatigued brains.
How many of us allow ourselves a good cry when we feel it welling up? It could be a sentimental moment–a song that brings back bittersweet memories, a commercial that touches just the right chord of feeling and connection. It may be a moment of frustration and anger when nothing seems to go right. It could be the pain of physical illness or injury or the stress of emotional turmoil. Or just maybe there is weeping when everything is absolutely perfect and there cannot be another moment just like it, so it is tough to let it go unchristened by tears of joy.
And without a doubt, the healing qualities of chocolate are unquestioned by this doctor, however it may be consumed. It can fix most everything that ails a person, at least for an hour or two.
No, it doesn’t take an M.D. degree to know the best medicine.
6 Then he told this parable: “A man had a fig tree growing in his vineyard, and he went to look for fruit on it but did not find any.7 So he said to the man who took care of the vineyard, ‘For three years now I’ve been coming to look for fruit on this fig tree and haven’t found any. Cut it down! Why should it use up the soil?’
8 “‘Sir,’ the man replied, ‘leave it alone for one more year, and I’ll dig around it and fertilize it.9 If it bears fruit next year, fine! If not, then cut it down.’” Luke 13:6-9
As a farmer, I spend over an hour a day cleaning my barn, and wheel heavy loads of organic material to a large pile in our barnyard which composts year round. Piling up all that messy stuff that is no longer needed is crucial to the process: it heats up quickly to the point of steaming, and within months, it becomes rich fertilizer, ready to help the fields to grow grass, or the garden to produce vegetables, or the fragrant blooms in the flower beds. It becomes something far greater and more productive than what it was to begin with, thanks to transformation of muck to fruit.
That’s largely what I do in clinic as well.
As clinicians, we help our patients “clean up” the parts of their lives they really don’t need, that they can’t manage any longer, that are causing problems with their health, their relationships and obligations. There isn’t a soul walking this earth who doesn’t struggle in some way with things that take over our lives, whether it is school, work, computer use, food, gambling, porn, you name it. For the chemically dependent, it comes in the form of smoke, a powder, a bottle, a syringe or a pill. There is nothing that has proven more effective than “piling up together” learning what it takes to walk the road to health and healing, “heating up”, so to speak, in an organic process of transformation that is, for lack of any better description, primarily a spiritual treatment process. When a support group becomes a crucible for the “refiner’s fire”, it does its best work melting people down to get rid of the impurities before they can be built back up again, stronger than ever. They become compost, productive, ready to grow others.
This work with a spectrum of individuals of all races, backgrounds and creeds has transformed me.
As Jesus says in Matthew 25: 40–‘I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me.’
It’s crucial to fertilize those who otherwise may be cut down. Only then can they bear fruit.
May my eyes see, my ears hear, my heart understand. He prepares me with parable.
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
Be obscure clearly. ~E. B. White
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 clearly. Our lives depend on it.