This Notable Thing

Chunky and noisy,
but with stars in their black feathers,
they spring from the telephone wire
and instantly

they are acrobats
in the freezing wind.
And now, in the theater of air,
they swing over buildings,

dipping and rising;
they float like one stippled star
that opens,
becomes for a moment fragmented,

then closes again;
and you watch
and you try
but you simply can’t imagine

how they do it
with no articulated instruction, no pause,
only the silent confirmation
that they are this notable thing,

this wheel of many parts, that can rise and spin
over and over again,
full of gorgeous life.

Ah, world, what lessons you prepare for us,
even in the leafless winter,
even in the ashy city.
I am thinking now
of grief, and of getting past it;

I feel my boots
trying to leave the ground,
I feel my heart
pumping hard. I want

to think again of dangerous and noble things.
I want to be light and frolicsome.
I want to be improbable beautiful and afraid of nothing,
as though I had wings.
~Mary Oliver “Starlings in Winter” from Owls and Other Fantasies: Poems and Essays

Out of the dimming sky a speck appeared,
then another, and another.
It was the starlings going to roost. 
They gathered deep in the distance,  flock sifting into flock,
and strayed towards me, transparent and whirling, like smoke.
They seemed to unravel as they flew,
lengthening in curves, like a loosened skein. 
I didn’t move; they flew directly over my head for half an hour. 

Each individual bird bobbed and knitted up and down
in the flight at apparent random, for no known reason except
that that’s how starlings fly, yet all remained perfectly spaced.
The flocks each tapered at either end

from a rounded middle, like an eye.
Overhead I heard a sound of beaten air,

like a million shook rugs, a muffled whuff.
Into the woods they sifted without shifting a twig,
right through the crowns of trees, intricate and rushing, like wind.

Could tiny birds be sifting through me right now,
birds winging through the gaps between my cells,
touching nothing, but quickening in my tissues, fleet?
~Annie Dillard from Pilgrim at Tinker Creek

…yesterday I heard a new sound above my head
a rustling, ruffling quietness in the spring air

and when I turned my face upward
I saw a flock of blackbirds
rounding a curve I didn’t know was there
and the sound was simply all those wings,
all those feathers against air, against gravity
and such a beautiful winning:
the whole flock taking a long, wide turn
as if of one body and one mind.

How do they do that?

If we lived only in human society
what a puny existence that would be

but instead we live and move and have our being
here, in this curving and soaring world
that is not our own
so when mercy and tenderness triumph in our lives
and when, even more rarely, we unite and move together
toward a common good,

we can think to ourselves:

ah yes, this is how it’s meant to be.
~Julie Cadwallader Staub from “Blackbirds” from Wing Over Wing

Watching a winter starlings’ murmuration is a visceral experience – my heart leaps to see it happen above me.  I can get queasy following its looping amoebic folding and unfolding path.

Thousands of individual birds move in sync with one another to form one massive organism existing solely because each tiny component anticipates and cooperates to avoid mid-air collisions.  It could explode into chaos but it doesn’t.  It could result in massive casualties but it doesn’t.  They could avoid each other altogether but they don’t – they come together with a purpose and reasoning beyond our imagining. Even the silence of their movement has a discernible sound.

We humans are made up of just such cooperating component parts, that which is deep in our tissues, programmed in our DNA.  Yet we don’t exercise such unity from our designed and carefully constructed building blocks.  We are frighteningly disparate and independent creatures, going our own way bumping and crashing without care, leaving so much body and spiritual wreckage behind.

To where has flown our mercy and tenderness?
We have corporately lost our internal moral compass.

We figuratively and literally shoot each other in the back, trampling over and suffocating one another, in a reach for justice that seems right in our own eyes. 

We even watch the daily death count rise in ever-increasing numbers, and still some resist doing what it takes to protect themselves and one another.

The sound of silence is muffled weeping.

There comes a time in every fall
before the leaves begin to turn
when blackbirds group and flock and gather
choosing a tree, a branch, together
to click and call and chorus and clamor
announcing the season has come for travel.

Then comes a time when all those birds
without a sound or backward glance
pour from every branch and limb
into the air, as if on a whim
but it’s a dynamic, choreographed mass
a swoop, a swerve, a mystery, a dance

and now the tree stands breathless, amazed
at how it was chosen, how it was changed.

~Julie Cadwallader Staub “Turning” from Wing Over Wing

Caught in Our Own Careless Wreckage

I believed only air
stretched between the dogwood

and the barberry: another
thoughtless human assumption

sidetracking the best story
this furrow spider knew to spin.

And, trying to get the sticky
filament off my face, I must look,

to the neighbors, like someone
being attacked by his own nervous

system, a man conducting an orchestra
of bees. Or maybe it’s only the dance

of human history I’m reenacting:
caught in his own careless wreckage,

a man trying to extricate himself,
afraid to open his eyes.
~Jeff Worley from Lucky Talk

It was an uneasy feeling opening my eyes this morning, waking up to a world where the election results are still uncertain. We are suspended in a sticky web of our own making and will be for some time, dangling…

Twenty years ago, I woke up not feeling well after a long night of waiting for election results to come in. I thought it was from the tension of not knowing when the outcome would be finalized but no… It ended up being appendicitis that day — my 2000 post-election surgical solution to take my mind off Bush vs Gore. It worked. I simply ceased to care about anything but my own healing, my priorities clarified by post-op recovery.

I’m not looking to resort to that remedy today in Trump vs Biden. I’d like to keep myself out of the ER and the OR and just go about my clinic day as usual. Yet in the dance of human history we badly want to determine who our leaders will be in a clear-cut and clean-cut process, something this campaign season has lacked. So why we would expect clarity now?

Instead, we are covered in a sticky-wickety web, spread all over our faces, unwilling to open our eyes to the reality of our divisive messiness, and attacked by our own nervous systems.

Today, I will open my eyes, take a few deep breaths and I hope you will too. And tomorrow and the next day. And avoid radical surgery if we can.

Maybe the dance is something we can do together — coordinated, cooperative, choreographed, and united — rather than flailing about in our careless wreckage of human history.

How It’s Meant to Be


There comes a time in every fall
before the leaves begin to turn
when blackbirds group and flock and gather
choosing a tree, a branch, together
to click and call and chorus and clamor
announcing the season has come for travel.

Then comes a time when all those birds
without a sound or backward glance
pour from every branch and limb
into the air, as if on a whim
but it’s a dynamic, choreographed mass
a swoop, a swerve, a mystery, a dance

and now the tree stands breathless, amazed
at how it was chosen, how it was changed.

~Julie Cadwallader Staub “Turning” from Wing Over Wing

…yesterday I heard a new sound above my head
a rustling, ruffling quietness in the spring air

and when I turned my face upward
I saw a flock of blackbirds
rounding a curve I didn’t know was there
and the sound was simply all those wings,
all those feathers against air, against gravity
and such a beautiful winning:
the whole flock taking a long, wide turn
as if of one body and one mind.

How do they do that?

If we lived only in human society
what a puny existence that would be

but instead we live and move and have our being
here, in this curving and soaring world
that is not our own
so when mercy and tenderness triumph in our lives
and when, even more rarely, we unite and move together
toward a common good,

we can think to ourselves:

ah yes, this is how it’s meant to be.
~Julie Cadwallader Staub from “Blackbirds” from Wing Over Wing

Out of the dimming sky a speck appeared,
then another, and another.
It was the starlings going to roost. 
They gathered deep in the distance,  flock sifting into flock,
and strayed towards me, transparent and whirling, like smoke.
They seemed to unravel as they flew,
lengthening in curves, like a loosened skein. 
I didn’t move;
they flew directly over my head for half an hour. 

Each individual bird bobbed and knitted up and down
in the flight at apparent random, for no known reason except
that that’s how starlings fly, yet all remained perfectly spaced.
The flocks each tapered at either end from a rounded middle, like an eye.
Overhead I heard a sound of beaten air, like a million shook rugs, a muffled whuff.
Into the woods they sifted without shifting a twig,
right through the crowns of trees, intricate and rushing, like wind.

Could tiny birds be sifting through me right now,
birds winging through the gaps between my cells,
touching nothing, but quickening in my tissues, fleet?
~Annie Dillard from Pilgrim at Tinker Creek

Watching the starlings’ murmuration is a visceral experience – my heart leaps to see it happen above me.  I feel queasy following its looping amoebic folding and unfolding path.

Thousands of individual birds move in sync with one another to form one massive organism existing solely because each tiny component anticipates and cooperates to avoid mid-air collisions.  It could explode into chaos but it doesn’t.  It could result in massive casualties but it doesn’t.  They could avoid each other altogether but they don’t – they come together with a purpose and reasoning beyond our imagining. Even the silence of their movement has a discernible sound of air rushing past wings.

We humans are made up of just such cooperating component parts, that which is deep in our tissues, programmed in our DNA.  Yet we don’t learn from our designed and carefully constructed building blocks.  We have become frighteningly disparate and independent creatures, each going our own way bumping and crashing without care.

We have lost our internal moral compass for how it is meant to be.

The rustling ruffling quiet of wings in the air is actually muffled weeping.

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.

‘Tis Hay Time

haybarnfull

haywagon

Tis haytime & the red complexioned sun
Was scarcely up ere blackbirds had begun
Along the meadow hedges here & there
To sing loud songs to the sweet smelling air
Where breath of flowers & grass & happy cow
Fling oer ones senses streams of fragrance now
While in some pleasant nook the swain & maid
Lean oer their rakes & loiter in the shade
Or bend a minute oer the bridge & throw
Crumbs in their leisure to the fish below
—Hark at that happy shout—& song between
Tis pleasures birthday in her meadow scene
What joy seems half so rich from pleasure won
As the loud laugh of maidens in the sun.
~John Clare “Hay Making”

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haymaking5

haying2012

Every hay crew is the same
Though the names change;
Young men flexing their muscles,
A seasoned farmer defying his age
Tossing four bales high,
Determined girls bucking up on the wagon,
Young children rolling bales closer,
Add a school teacher, pastor,
Professor, lawyer and doctor
Getting sweaty and dusty
United in being farmers
If only for an evening.

Stacking
Basket weave
Interlocking
Cut side up
Steadying the load
Riding over hills
Through valleys
In slow motion
Eagles over head
Searching the bare fields
Evening alpen glow
Of snowbound
Eastern peaks

Friends and neighbors
Walking the dotted pastures,
Piling on the wagons,
Driving the truck,
Riding the top of hay stack
In the evening breeze,
Filling empty barn space to the rafters,
Making gallons of lemonade in the kitchen.
A hearty meal consumed
In celebration
Of summer baled, stored, preserved
For another year.

Hay crew
Remembered on
Frosty autumn mornings before dawn
When bales are broken for feed
And fragrant summer spills forth.
In the dead of winter

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sunset811153

puffsunset2