Take the Hand You Know Belongs in Yours

I think of the story
of the storm and everyone
waking and seeing
the distant
yet familiar figure
far across the water
calling to them…

…so that when 
we finally step out of the boat 
toward them, we find
everything holds
us, and everything confirms
our courage, and if you wanted 
to drown you could, 
but you don’t 
because finally 
after all this struggle
and all these years
you don’t want to any more
you’ve simply had enough
of drowning
and you want to live and you 
want to love and you will
walk across any territory
and any darkness
however fluid and however
dangerous to take the
one hand you know
belongs in yours.
~David Whyte from “The Truelove” in The House of Belonging

Yesterday was the wrap-up to my thirtieth academic year working as a college health physician.  Despite budget challenges, inadequate staffing, a higher severity of illness in a patient population with burgeoning mental health needs,  our staff did an incredible job this year serving students and their families with the resources we do have.  

Reaching the end of the school year is always poignant: we will miss the graduating students we have gotten to know so well over four or five (or six!) years,  while we watch others leave temporarily for the summer, some to far away places around the globe.

We weep for those who have failed out, given up or fallen away from those who care deeply about them, some never to return to school again, and a few giving up on life itself. They did not take the hand offered to guide them through, even though they tired of drowning.

In my work I have tried to do what is needed when it is needed no matter what time of the day or night.  There are obviously times when I fall short– too vehement when I need to be quiet, too urgent and pressured when I need to be patient,  too anxious to do something/anything when it is best to simply do no harm.

I can only hold out my hand and wait. 

Each year I learn enough from each patient to fill volumes, as they speak of their struggles, their pain, their stories and sometimes hearing, most tragically, their forever silence.

I honor you, our students, on this day, to confirm your courage stepping out from the safety of the boat — not to drown, never to drown — but wanting to live, wanting to love, wanting to move healthier, better equipped and joyful into the rest of your lives.

Just take the outreached Hand that belongs in yours.


Finding Out Who the Patient Is

Portrait by Norman Rockwell

If you want to identify me, 
ask me not where I live, 
or what I like to eat, 
or how I comb my hair, 
but ask me what I am living for, 
in detail, 
ask me what I think is keeping me 
from living fully 
for the thing I want to live for. 
~ Thomas Merton from My Argument with the Gestapo

As a patient waiting to see my health care provider,  I would adapt Merton’s template of personal revelation this way:

If you want to know who I am,
ask me not about my insurance plan,
or what is my current address,
or whether I have a POLST on file,
or whether I have signed the Notice of Privacy Practice,
or whether I’ll accept a message on my phone —
but ask me what I am most concerned about,
in detail,
ask me what I think is causing my symptoms
and what I think is keeping me
from eating healthy, exercising regularly,
and choosing moderation in all things
so that I can live fully
for the thing I want to live for.

As a physician in the midst of a busy clinic day, I struggle to know who my patients are beyond their standard medical history and demographics.  One of my goals in our primary care clinic, now sixteen years into electronic medical record (EMR) use,  is to create a way for our patients to provide their personal history online to us via their password secured web portal.   These are the questions our clinic staff may not have opportunity to ask or record during clinic visits.  Having the patient personally document their social history and background for us to have in the chart –in essence, telling us their story in their own words–can be very helpful diagnostically and for individualizing the best treatment approach for each unique individual.

There needs to be an “About me” section in the EMR that would contain biographical and personal history information the patient could provide online via writing or video.

Tell us about yourself

This is your own personal history in your own words to be added to your electronic medical record in the folder “About Me”. You can edit and add information at any time via this secure patient portal to update it.

We want to know your story.  Only you can tell us what you think is most important for us as your health care providers to know about you.  We may not always have the time to ask and document these detailed questions in a brief clinic visit, so we are asking for your help.  

Why do we want to know your non-medical background as well as medical background?

We evaluate a patient’s symptoms of concern but we also are dedicated to helping our patients stay healthy life long.  To assist us in this effort, it is very helpful to know as much about you as possible, in addition to your past medical history.   It is crucial also to understand your family background and social history.  We want to know more about your personal goals, and what you think may be preventing you right now from living fully for the things you consider most important to you. 

This is your opportunity to tell us about yourself, with suggested questions below that you can consider answering.  This information is treated as a confidential part of your medical record, just like all information contained in your record.  You can add more at any time by returning to this site.

1)      Tell us about your family—who raised you and grew up with you, and who currently lives with you– including your racial/ethnic/cultural heritage. If relevant,  tell us whether you have biological beginnings outside of your family (e.g. adopted, egg donation, surrogate pregnancy, artificial insemination, in vitro fertilization)    Provide information on any illnesses in your biologic family.

2)     List the states or countries you have lived in, and what countries outside the U.S. you have lived in longer than a month.  Have you served in the military or another government entity, like the Peace Corps?

3)      Tell us about your educational and job background. This could include your schooling or training history,  paid or volunteer work you’ve done.  What are your hobbies, how do you spend your leisure time, what are your passions and future goals.  Where do you see yourself in ten years?

4)      Tell us about your sexual orientation and/or gender preference.

5)      Tell us about your current emotional support system—who are you most likely to share with when things are going very well for you and especially when things are not going well.

6)      Tell us about your spiritual background,  whether you are part of a faith or religious community and if so, how it impacts your life.

7)       Tell us what worries you most about your health.

8)      What would you have done differently if you could change things in your life?  What are you most thankful for in your life?

9)      What else do you feel it is important for us to know about you?

Thank you for helping us get to know you better so we can provide medical care that best meets your unique needs.

As our clinic is moving to an updated EMR, I’m interested in hearing feedback from patients and health care providers.  What additional questions would you want asked as part of personal history documentation in a medical record?

Electronic medical records allow us, as never before, the ability to share information securely between patients and their health care providers.
Patients want to tell us their story and we want to know more about them. 

It is time we asked them and truly listen to what they have to say.


Composting

Nature teaches nothing is lost.
It’s transmuted.

Spread between rows of beans,
last year’s rusty leaves tamp down weeds.
Coffee grounds and banana peels
foster rose blooms. Bread crumbs
scattered for birds become song.
Leftovers offered to chickens come back
as eggs, yolks sunrise orange.
Broccoli stems and bruised apples
fed to cows return as milk steaming in the pail,
as patties steaming in the pasture.

Surely our shame and sorrow
also return,
composted by years
into something generative as wisdom.

~Laura Grace Weldon, “Compost Happens” from Blackbird

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. 

That’s what my past clinical work in detox and treatment of addictions was like.

As a physician, I helped patients “clean up” the parts of their lives they can’t manage any longer, that are causing problems with their health, their families and jobs, and most of all, their relationship with their Creator.  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 work,  computer use, food, gambling, 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 rid the impurities before they can be built back up again, stronger than ever.  They become compost, productive, with the wisdom and readiness to grow others.

This work with a spectrum of individuals of all races, professional and blue collar, rich and homeless,  coming from all over the state for help,  was transforming for me.  I worked with incredibly gifted nursing and counseling staff, some recovering themselves, who dedicated their careers to this work.

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.’

Nature teaches that nothing is lost.

God teaches we seek out the lost until they are found and then and only then, the work of transformation begins.

A Wedding of Lace

…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.

Returning on Foot

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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 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.

 

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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
among many~
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.

 

 

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Why I’m Running Late

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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.

 

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The Doctor’s Waiting Room Vladimir Makovsky 1870

This Doctor is Open For Business

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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

 

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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.

 

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