Slumber Undisturbed

Blazing sun bakes a lichen crust
atop a stone so feverish to touch
it becomes hearth without fire
reaching hot fingers deep
into soil supporting a box
that knows no warmth.

When windstorms rage
lightning crack and thunder clap
trembles anew the hole filled ground
as dying leaves spin and swirl
through arcing cascade into
settled and spent.

Till crisp hoarfrost clings
in glittering crystalline coverlet
from gray sky that throws down
soft cotton batting gently
fluffed to protect a slumber
undisturbed and silent.

Soon vernal raindrops bring
promise of quenched thirst
for dry bones lying suspended
between the welkin sky
and earth’s deep pit
to blossom finally in fullness.

Following the Path

photo by Nate Gibson

Twice each day I walk the same downhill path to the barn for chores.  Sometimes I’m half asleep, sometimes weary from a long day at the clinic, sometimes sliding on icy snow, sometimes slipping in mud from unending rain, sometimes wading through a sea of overgrown grass.   The constant in this twice daily journey is the path itself and where it takes me– no matter what time of year, the state of the weather, or how temporarily difficult to discern.   My feet have learned the way by feel as much as by sight–the twist here, the dip there, the curve around the septic tank lid, the aromatic stretch through the stand of wild mint, all while trying to avoid stepping on the swerving barn cat perpetually underfoot.

I prefer to take the demarcated path to the barn as it keeps me focused on the task ahead of me.  If I happen to deviate,  I will surely find weeds to pull, a bird to admire, a cluster of cherries to eat, or a sweet pea blossom to smell.  The distraction may bring me momentary pleasure but so much work remains to be done.   I find my way back to the path and stick to it.

As a teenager, I was a trailblazer, bushwhacking my way through brambles to see what might be on the other side, or to discover a new favorite place in the woods, or simply to prove I was stronger than the brush that yielded to me.  In my middle age, I now tend to stick to the familiar.   I like knowing where my feet will land, what work my hands will touch, and where my head will rest.  The adventure of the unknown, so attractive in my youth, is less appealing now.  The visible path, even when difficult to follow due to cover of snow or abundance of overgrowth, is reassurance that I have a purpose and a destination.   I know where I am going and I know where I’ve been.   I know I’m needed both places and the path I take is my bridge between house and barn.

We tread many paths during our time on this soil–some are routine and mundane, leading to the barns and chores in our life, and others a matter of the heart and spirit.  As tempting as it is to deviate, the path is there for good reason.  It doesn’t have to be a super highway, or lined with gold or even paved with good intentions. It may not be straight.  But it must be true, steadfastly leading us to where we are called and back again to where we belong.

It’s time to pull on my boots.

Solemn Silence

photo by Josh Scholten

The moment of waning night before
the first bird sings-
a solemn silence holds its breath
about to be broken

Like a full breast tingles
with readiness to flow until empty-
a wave rises highest before
toppling forward to withdraw

Like a nose tickles and builds
to uncontrolled sneeze-
a conductor’s baton raises to
ready the chorus

The anticipation rises
for unrealized potential-
cascades tonight’s stillness
into tomorrow’s dawn

Whose Life Is It Anyway?

Sixty five 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 was gone 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.

Thirty years into my practice of medicine,  I now spend a significant part of my patient care time in 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.  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 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.   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.

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.”   I have never felt more empowered as a healer when I now can share everything I have available, as it becomes available.  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 unrestricted access to the self-knowledge that leads them to a better understanding of their health.

And so I am impacted as well, as it is a privilege to live and work in an age where such a doctor~patient relationship has now become possible.

Just My Luck


“Therefore keep watch, because you do not know the day or the hour.”
Matthew 25:13

I’ve been keeping quiet about the rapture predicted for tomorrow at 6 PM.  It is a complete embarrassment that anyone would presume they could calculate and predict the exact moment of the beginning of the end of the world.   The whole point of the Second Coming is that we won’t know it until it’s in our laps and then it won’t be subtle.  It’s kind of like a surprise kitchen inspection by the Department of Health. Either you are always ready, with things spic and span, or you are toast.  Now THAT is something to think about.

This whole idea of rapture is new to me as I didn’t grow up in an “end times”  kind of family.  Even so, my very pious Bible-reading grandmother was certain if she lived to be 102 (in the year 2000),  the trumpet would sound and in a twinkling of an eye she’d be gone at the stroke of midnight.  It’s just as well the Lord took her home in 1970 as she would have been sorely disappointed that the millenium didn’t change a thing.  We are still trying to keep watch, now without Grandma.

So not knowing when it is going to happen, it would be just my luck for the trumpet to sound at a very inopportune moment–like when I’m on the toilet, or when I’ve just said something really cranky, or I’m fast asleep and miss the whole thing.   I’d like to think I’m trying to live every moment as if it were my last on earth, but reality is something different.  I think we all become a little ADD when it comes to preparing for the end of the world.

If this May 21 doomsday prediction has done anything, it does remind us:  when we’re behaving badly,  let that not be our last moment on earth.  In anticipation, we need to clean up what we think, say and do.

Otherwise we’ll be caught with our pants down,  and not even given a chance to flush.

Z-Pack Pas de Deux

I’m really miserable and need that 5 day antibiotic to get better faster.

Ninety eight percent of the time it is a viral infection and will resolve without antibiotics.

But I can’t breathe and I can’t sleep.

You can use salt water rinses and decongestant nose spray.

But my face feels like there is a blown up balloon inside.

Try applying a warm towel to your face.

And I’m feverish and having sweats at night.

Your temp is 99.2. You can use ibuprofen or acetominophen.

But my snot is green.

That’s not unusual with viral upper respiratory infections.

And my teeth are starting to hurt and my ears are popping.

Let me know if that is not resolving in a week or so.

But I’m starting to cough.

Your lungs are clear so breathe steam, push fluids and prop up with an extra pillow.

But sometimes I cough to the point of gagging.

You can consider using this strong cough suppressant prescription.

But I always end up needing antibiotics.

There’s plenty of evidence they can do more harm than good.  They really aren’t indicated at this point in your illness.

But I always get better faster with antibiotics.

Studies show that two weeks later there is no difference in symptoms between those treated with antibiotics and those who did self-care only.

But I have a really hard week coming up and I won’t be able to rest.

This may be your body’s way of saying that you need to evaluate your priorities.

But I just waited an hour to see you.

I really am sorry about the wait; there are a lot of sick people with this viral thing going around.

But I paid $20 co-pay today for this visit.

We’re appreciative of you paying promptly on the day of service.

But I can go down the street to the walk in clinic and for $95 they will write me an antibiotic prescription without making me feel guilty for asking.

I wouldn’t recommend taking unnecessary medication that can lead to bacterial resistance, side effects and allergic reactions. I think you can be spared the expense, inconvenience and potential risk of taking something you don’t really need.

So that’s it?  Salt water rinses and wait it out?  That’s all you can offer?

Let me know if your symptoms are unresolved in the next week or so.

So you spent all that time in school just to tell people they don’t need medicine?

I believe I help people heal themselves and educate them about when they do need medicine. 

I’m going to go find a real doctor.

A real doctor will first do no harm.  I wish you the best.

There is no joy

"Eye of Sauron" star with rings via Hubble telescope

Bin Laden’s death is not like the death of Darth Vader, Sauron, or Lord Voldemort: a neat and tidy ending of a classic tale of good and evil.   It took courage and persistence on the part of many over a decade to seek him out and stop him before he could orchestrate more suffering on this earthly soil.   Yet as much as we wish it were so, evil is not forever buried in a shroud at sea within the decaying flesh of bin Laden.

Jubilation is premature.   How can there be joy when evil continues to live and thrive in the hearts of men?

His death marks a turning point for thousands of family members who mourn the death of loved ones lost to bin Laden’s wicked reach for power, or in the efforts to stop him and his minions.

But there can be no joy as the lost are still lost.

The end of this man’s life illustrates how humanity’s separation from God is so wide a gap that the only hope for joy is the Son specifically sent to bridge that gulf.

Evil was buried forever within His cast-aside shroud, no longer needed to cover the stench of death.  Evil, pervasive as it is, will never overwhelm His living breathing body.

As surely as I live, declares the Sovereign LORD, I take no pleasure in the death of the wicked, but rather that they turn from their ways and live. ~Ezekiel 33:11