A Multitude of Flashing Torches

And as you sit on the hillside, or lie prone under the trees of the forest, or sprawl wet-legged on the shingly beach of a mountain stream, the great door, that does not look like a door, opens.
~Stephen Graham from The Gentle Art of Tramping

That great door opens on the present, illuminates it as with a multitude of flashing torches.
~Annie Dillard (in response to the Graham’s quote) from Pilgrim at Tinker Creek

When I pay attention
(and usually I don’t),
each day offers up a moment of illumination
like a multitude of flashing torches,
when we sense something beyond what is here and now.

It feels like an unspoken promise.

When I miss it,
this opened door that is not a door~
too busy to notice-
too blinded to see-
having turned my face away,
nevertheless it happens without my witness.

It saddens and gladdens my heart to know that
it will be offered up again tomorrow,
even though I once again may forget.

Opening Up the Medical Chart

The thing to cling to is the sense of expectation.
Who knows what may occur in the next breath?
In the pallor of another morning we neither
Anticipated nor wanted!

… we live in wonder,
Blaze in a cycle of passion and apprehension
Though once we lay and waited for a death.

~Carolyn Kizer from “Lines to Accompany Flowers For Eve”

Over seventy years ago my maternal grandmother, having experienced months of fatigue, abdominal discomfort and weight loss, underwent exploratory abdominal surgery, the only truly diagnostic tool available at the time. One brief look by the surgeon told him everything he needed to know: her liver and omentum were riddled with tumor, clearly advanced, with the primary source unknown and ultimately unimportant.  He quickly closed her up and went to speak with her family – my grandfather, uncle and mother.  He told them there was no hope and no treatment, to take her back home to their rural wheat farm in the Palouse country of Eastern Washington and allow her to resume what activities she could with the time she had left.  He said she had only a few months to live, and he recommended that they simply tell her that no cause was found for her symptoms.

So that is exactly what they did.  It was standard practice at the time that an unfortunate diagnosis be kept secret from terminally ill patients, assuming the patient, if told, would simply despair and lose hope.  My grandmother passed away within a few weeks, growing weaker and weaker to the point of needing rehospitalization prior to her death.  She never was told what was wrong and,  more astonishing, she never asked.

But surely she knew deep in her heart.  She must have experienced some overwhelmingly dark moments of pain and anxiety, never hearing the truth so that she could talk about it with her physician and those she loved.  But the conceit of the medical profession at the time, and indeed, for the next 20-30 years, was that the patient did not need to know, and indeed could be harmed by information about their illness. 

We modern more enlightened health care professionals know better.  We know that our physician predecessors were avoiding uncomfortable conversations by exercising the “the patient doesn’t need to know and the doctor knows better” mandate.  The physician had complete control of the health care information–the details of the physical exam, the labs, the xray results, the surgical biopsy results–and the patient and family’s duty was to follow the physician’s dictates and instructions, with no questions asked.

Even during my medical training in the seventies, there was still a whiff of conceit about “the patient doesn’t need to know the details.”   During rounds, the attending physician would discuss diseases right across the hospital bed over the head of the afflicted patient, who would often worriedly glance back and worth at the impassive faces of the intently listening medical student, intern and resident team.   There would be the attending’s brief pat on the patient’s shoulder at the end of the discussion when he would say, “someone will be back to explain all this to you.” But of course, none of us really wanted to and rarely did.

Eventually I did learn how important it was to the patient that we provide that information. I remember one patient who spoke little English, a Chinese mother of three in her thirties, who grabbed my hand as I turned to leave with my team, and looked me in the eye with a desperation I have never forgotten.   She knew enough English to understand that what the attending had just said was that there was no treatment to cure her and she only had weeks to live.  Her previously undiagnosed pancreatic cancer had caused a painless jaundice resulting in her hospitalization and the surgeon had determined she was not a candidate for a Whipple procedure.  When I returned to sit with her and her husband to talk about her prognosis, I laid it all out for them as clearly as I could.  She thanked me, gripping my hands with her tear soaked fingers.  She was so grateful to know what she was dealing with so she could make her plans, in her own way.

Forty years into my practice of medicine,  I now spend a significant part of my patient care time providing information that helps the patient make plans, in their own way.  I figure everything I know needs to be shared with the patient, in real time as much as possible, with all the options and possibilities spelled out.  That means extra work, to be sure,  and I spend extra time on patient care after hours more than ever before in my efforts to communicate with my patients.  I’m not alone as a provider who feels called to this sharing of the medical chart – the nationwide effort is referred to as Open Notes.

Every electronic medical record chart note I write is sent online to the patient via a secure password protected web portal, usually from the exam room as I talk with the patient.  Patient education materials are attached to the progress note so the patient has very specific descriptions, instructions and further web links to learn more about the diagnosis and my recommended treatment plan.  If the diagnosis is uncertain, then the differential is shared with the patient electronically so they know what I am thinking.  The patient’s Major Problem List is on every progress note, as are their medications, dosages and allergies, what health maintenance measures are coming due or overdue,  in addition to their “risk list” of alcohol overuse, recreational drug use including marijuana, eating and exercise habits and tobacco history.  Everything is there, warts and all, and nothing is held back from their scrutiny.

Within a few hours of their clinic visit, they receive their actual lab work and copies of imaging studies electronically, accompanied by an interpretation and my recommendations.  No more “you’ll hear from us only if it is abnormal” or  “it may be next week until you hear anything”.   We all know how quickly most lab and imaging results, as well as pathology results are available to us as providers, and our patients deserve the courtesy of knowing as soon as we do, and now regulations insist that we share the results.   Waiting for results is one of the most agonizing times a patient can experience.   If it is something serious that necessitates a direct conversation, I call the patient just as I’ve always done.  When I send electronic information to my patients,  I solicit their questions, worries and concerns by return message.  All of this electronic interchange between myself and my patient is recorded directly into the patient chart automatically, without the duplicative effort of having to summarize from phone calls.

Essentially, the patient is now a contributor/participant in writing the “progress” (or lack thereof) note in the electronic medical chart.

In this new kind of health care team, the patient has become a true partner in their illness management and health maintenance because they now have the information to deal with the diagnosis and treatment plan.  I don’t ever hear “oh, don’t bother me with the details, just tell me what you’re going to do.”  

My patients are empowered in their pursuit of well-being, whether living with chronic illness, or recovering from acute illness.  No more secrets.  No more power differential.  No more “I know best.”

After all, it is my patient’s life I am impacting by providing them open access to the self-knowledge that leads them to a better appreciation for their health and and clearer understanding of their illnesses.

As a physician, I am impacted as well; it is a privilege to live and work in an age where such illumination in a doctor~patient relationship is possible.

To Go Home By Another Way

If you could see
the journey whole
you might never
undertake it;
might never dare
the first step
that propels you
from the place
you have known
toward the place
you know not.

Call it
one of the mercies
of the road:
that we see it
only by stages
as it opens
before us,
as it comes into
our keeping
step by

single step.

There are vows
that only you
will know;
the secret promises
for your particular path
and the new ones
you will need to make
when the road
is revealed
by turns
you could not
have foreseen.

Keep them, break them,
make them again:
each promise becomes
part of the path;
each choice creates
the road
that will take you
to the place
where at last
you will kneel

to offer the gift
most needed—
the gift that only you
can give—
before turning to go
home by
another way.
~Jan Richardson from
“Blessing for Those Who Travel Far”

… having been warned in a dream not to go back to Herod, they returned to their country by another route.
Matthew 2:12

The night sky was still dim and pale.  
There, peeping among the cloud wrack above a dark tor high up in the mountains, 
Sam saw a white star twinkle for a while.  
The beauty of it smote his heart, 
as he looked up out of the forsaken land, and hope returned to him.  
For like a shaft, clear and cold, 
the thought pierced him that in the end 
the Shadow was only a small and passing thing: 
there was light and high beauty for ever beyond its reach.
~J.R.R. Tolkien, The Return of the King

The star represented a hope
too long elusive;
so weary and with so much need
they headed out for unknown lands
to follow a light seemingly
beyond their reach.

When they found its source
they could touch His earthliness.
No shadow cast of darkness,
and no iron nails
could quell the beauty
of its brilliance.

Having been so illumined
they could only return home another way~
No longer could they be
who they had been.

Some Blessed Hope

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In a dark time my eyes begin to see…

~Theodore Roethke

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I leant upon a coppice gate
      When Frost was spectre-grey,
And Winter’s dregs made desolate
      The weakening eye of day.
The tangled bine-stems scored the sky
      Like strings of broken lyres,
And all mankind that haunted nigh
      Had sought their household fires.
At once a voice arose among
      The bleak twigs overhead
In a full-hearted evensong
      Of joy illimited;
An aged thrush, frail, gaunt, and small,
      In blast-beruffled plume,
Had chosen thus to fling his soul
      Upon the growing gloom.
So little cause for carolings
      Of such ecstatic sound
Was written on terrestrial things
      Afar or nigh around,
That I could think there trembled through
      His happy good-night air
Some blessed Hope, whereof he knew
      And I was unaware.

~Thomas Hardy from “The Darkling Thrush”

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I watch the long night’s transition to day as the mountain is licked by bright flames of color, heralding our slow waking.

The sun illuminates the darkened earth and we are bathed in its reflected glory and grace.

We work hard to be at ease, to lay down the heaviness of endings and celebrate the arrival of brilliant light in our lives.

The Son is now among us, carrying our load, fulfilling all promises.

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A Mosaic of Leaves

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And then in the falling comes a rising, 
as of the bass coming up for autumn’s last insects 
struggling amid the mosaic of leaves on the lake’s surface. 
We express it as the season of lacking, but what is this nakedness
— the unharvested corn frost-shriveled but still a little golden 
under the diffuse light of a foggy sky,
the pin oak’s newly stark web of barbs, the woodbine’s vines 
shriven of their scarlet and left askew in the air 
like the tangle of threads on the wall’s side 
of the castle tapestry—what is it but greater intimacy,
the world slackening its grip on the veils, letting them slump
to the floor in a heap of sodden colors, and saying,
this is me, this is my skeletal muscle, 
my latticework of bones, my barren winter skin, 
this is it and if you love me, know that this is what you love. 
~Laura Fargas “October Struck” from Animal of the Sixth Day

 

 

 

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Something about the emerging nakedness of autumn reassures that we can be loved even when stripped down to our bones. We do make quite a show of shedding our coverings, our bits and pieces fluttering down to rejoin the soil, but what is left is meager lattice.

But when the light is just right, we are golden, illuminated and illuminating, even if barely there.

 

 

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At the Waiting Window

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Dawn comes later and later now,
and I, who only a month ago
could sit with coffee every morning
watching the light walk down the hill
to the edge of the pond and place
a doe there, shyly drinking,
then see the light step out upon
the water, sowing reflections
to either side—a garden
of trees that grew as if by magic—
now see no more than my face,
mirrored by darkness, pale and odd,
startled by time. While I slept,
night in its thick winter jacket
bridled the doe with a twist
of wet leaves and led her away,
then brought its black horse with harness
that creaked like a cricket, and turned
the water garden under. I woke,
and at the waiting window found
the curtains open to my open face;
beyond me, darkness. And I,
who only wished to keep looking out,
must now keep looking in.
~Ted Kooser “A Letter in October”
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God knows we seek out light
these autumn mornings,
longing for rainbow colors to fill in the lines
beyond a blackened window pane
and in our prayers.Some mornings we can only see our own reflection
mirrored by darkness, startled by time,
wondering what comes next.
God knows we need to feel the light
as we wait.
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An Unexpected October Thing

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After the keen still days of September, 
the October sun filled the world with mellow warmth…
The maple tree in front of the doorstep burned like a gigantic red torch. 
The oaks along the roadway glowed yellow and bronze. 
The fields stretched like a carpet of jewels, 
emerald and topaz and garnet. 
Everywhere she walked the color shouted and sang around her…
In October any wonderful unexpected thing might be possible.
~Elizabeth George Speare from The Witch of Blackbird Pond

 

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On this early morning
gray clouds lay heavy and unrelenting
hovering low over the eastern hills,
when a moment’s light snuck out from under the covers
throwing back the blankets
to glow golden over the mountain.

Only a minute of unexpected light underneath the gray
gone in a heartbeat
(as are we) yet
O!  the glory when we too are luminous.

 

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