The wind, one brilliant day, called to my soul with an odor of jasmine.
“In return for the odor of my jasmine, I’d like all the odor of your roses.”
“I have no roses; all the flowers in my garden are dead.”
“Well then, I’ll take the withered petals and the yellowed leaves and the waters of the fountain.”
The wind left. And I wept. And I said to myself: “What have you done with the garden that was entrusted to you?” ~Antonio Machado “The Wind, One Brilliant Day” translated by Robert Bly
This garden bloomed with potential, entrusted to me for 32 years: the health and well-being of 16,000 students, most thriving and flourishing, some withering, their petals falling, a few have been lost altogether.
As the winds of time sweep away another group of graduates from my care, to be blown to places unknown, their beauty and fragrance gone from here.
I marvel at their growth, but also weary weep for those who left too soon, wondering if I failed to water them enough – or is it I who am parched in this garden with a thirst unceasing, my roots reaching deep into drought-stricken soil, ever so slowly drying out?
A new book from Barnstorming available for order here:
Nothing seems to please a fly so much as to be taken for a currant; and if it can be baked in a cake and palmed off on the unwary, it dies happy. ~Mark Twain
Today I will wrap up 45 years of uninterrupted training and doctoring. Most of that time, I have worried I’m like a fly hiding among the black currants hoping to eventually become part of the currant cake.
Maybe no one has noticed. These days we call it the “impostor” syndrome. Mark Twain knew all about currant cake and how easy it was for a fly to blend into its batter.
Even while bearing three children and going through a few surgeries myself, I’ve not been away from patients for more than twenty consecutive days at any one time. This is primarily out of my concern that, even after a few weeks, I would forget all that I’ve ever known. In fact, half of what I learned in medical school and residency over forty years ago has evolved, thanks to new discoveries and clarifying research. I worried if I were to actually to step away from doctoring for an extended time, then return to see patients again, I would be masquerading as a physician rather than be the real thing. A mere fly among the currants palmed off on the unwary.
If being truly honest, those who spend their professional lives providing medical care to others always share this concern: if a patient only knew how much we don’t know and will never know, despite everything we DO know, there would really be no trust left for us at all.
Of course, some say, didn’t the COVID pandemic prove our ignorance? Physicians started at Ground Zero with a novel virus with unclear transmissibility and immense potential to wreak havoc on the human body … or cause no symptoms whatsoever. We had no collected data to base prevention or treatment decisions: would masks just protect others or would they only protect ourselves, or maybe they protect both? Could a common inexpensive anti-inflammatory/antimalarial drug be beneficial or would a parasitic wormer medication be somehow effective to fight the devastation of the virus?
Effective treatments are still being sought all these months later; others have been debated, studied and discarded as worthless.
Or would this pandemic finally resolve thanks to effective yet controversial public health mandates while rapidly distributing highly effective vaccines developed from many prior years of carefully performed research?
During the past 16 months, your next door neighbor, or the loudest tweet on Twitter proclaimed more expertise than the average medical professional and definitely had a stronger opinion. At least we doctors knew how much we didn’t know and how much was simply guess work based on experience, good intentions and hopeful prayer. Gradually, while lives were lost, including too many of our own, real data began to trickle in so decisions could be made with some evidence backing them. But even that data continues to evolve, day by day, as authentic medical evidence always does.
That doesn’t stop all the “quack” flies out there from climbing into the batter pretending to be currants. With so much rapidly changing medical information at everyone’s fingertips, who needs a trained physician when there are so many other resources – sketchy and opportunistic though they may be – for seeking health care advice?
Even so, I am convinced most patients really do care that doctors share the best information they have available at any point in time. None of us who are doctoring wants to be the “fly” in the batter of health care.
As I meet with my last patient today, I know over forty years of clinical experience has given me an eye and an ear for the subtle signs and symptoms that no googled website or internet doc-in-the-box can discern. The avoidance of eye contact, the tremble of the lip as they speak, the barely palpable rash, the hardly discernible extra heart sound, the fullness over an ovary, the slight squeak in a lung base. These are things I am privileged to see and hear and about which I make decisions together with my patients. What I’ve done over four decades has been no masquerade; out of my natural caution, I am not appearing to be someone I am not. This is what I was trained to do and have done for thousands of days and many more thousands of patients during my professional life, while passing a comprehensive certification examination every few years to prove my continued study and changing fund of knowledge.
The hidden fly in the currant bush of health care may be disguised enough that an unwary patient might gobble it down to their ultimate detriment. I know I’ve not been that doctor. I’ve been the real thing all these years for my patients, even if I’ve seemed a bit on the tart side at times, yet offering up just enough tang to be exactly what was needed in the moment and in the long term.
And someday, hopefully not too soon, I will die happy having done this with my life.
A new book from Barnstorming is available to order here:
You can’t say you haven’t been warned: there are creepy crawlies in this post
Things I will never like: 1. Drying off with a cold, damp towel. 2. The feeling of seaweed wrapping around my legs. 3. Anything that was popular in the 70’s. 4. Licorice, yam, or raisins. 5. That high-pitched screech that babies make. 6. Writhing maggots. ~Bill Watterson from It’s A Magical World: A Calvin and Hobbes Collection
A few weeks ago, I had a bit of home-made potato corn chowder left over that I added to our compost bin in our barnyard. It isn’t often that much animal protein makes its way into the bin so when I checked on the compost a few days later, I was amazed to see it teeming with fly maggots in the midst of their Thanksgiving feast. Ordinarily pictures and videos of maggots would not find their way to this blog. People might be looking at this blog while eating their breakfast or lunch and writhing maggots are not something you are expecting to see. My apologies in advance and now is the time to delete delete delete.
Therefore: a trigger warning. Don’t scroll down further if you would rather avoid seeing (and hearing) creepy crawly things.
My first medical exposure to maggots came while examining the leg and foot wounds of the homeless folks I helped care for when training in an inner city emergency room. Peeling off old ragged stockings and socks would often reveal more than dirty feet – in fact, the maggots may have been somewhat beneficial in those cases yet we were quick to dispose of them.
Maggots are, in fact, fascinating creatures with potential therapeutic value, notwithstanding their gross-out factor. This week in a brief Atlantic article found here, there is a summary of a recent study in France comparing typical surgical debridement of venous ulcers of the skin with maggot therapy. Maggots were faster in cleaning the wounds but didn’t enhance eventual healing any more than traditional surgical care. There wasn’t a difference in the discomfort level as long as the patient didn’t know which therapy was being used. For those who had been randomly assigned to maggot therapy in one study, an astounding 89% said they would opt for the insects over surgeons if faced with needing wound care in the future.
I’m not sure what that says about surgeons, but it is a great compliment to maggot larvae!
Here is a formal cross-referenced evidence-based summary from UptoDate.com about wound treatment with biologic methods:
Biologic — An additional method of wound debridement uses the larvae of the Australian sheep blow fly (Lucilia [Phaenicia] cuprina) or green bottle fly (Lucilia [Phaenicia] sericata, Medical Maggots) [42,43]. Maggot therapy can be used as a bridge between debridement procedures, or for debridement of chronic wounds when surgical debridement is not available or cannot be performed . Maggot therapy may also reduce the duration of antibiotic therapy in some patients .
Maggot therapy has been used in the treatment of pressure ulcers [45,46], chronic venous ulceration [47-50], diabetic ulcers [42,51], and other acute and chronic wounds . The larvae secrete proteolytic enzymes that liquefy necrotic tissue, which is subsequently ingested while leaving healthy tissue intact. Basic and clinical research suggests that maggot therapy has additional benefits, including antimicrobial action and stimulation of wound healing [43,47,53,54]. However, randomized trials have not found consistent reductions in the time to wound healing compared with standard wound therapy (eg, debridement, hydrogel, moist dressings) [55,56]. Maggot therapy appears to be at least equivalent to hydrogel in terms of cost [56,57].
Dressing changes include the application of a perimeter dressing and a cover dressing of mesh (chiffon) that helps direct the larvae into the wound and limits their migration (movie 1). Larvae are generally changed every 48 to 72 hours. One study that evaluated maggot therapy in chronic venous wounds found no advantage to continuing maggot therapy beyond one week . Patients were randomly assigned to maggot therapy (n = 58) or conventional treatment (n = 61). The difference in the slough percentage was significantly increased in the maggot therapy group compared with the control groups at day 8 (67 versus 55 percent), but not at 15 or 30 days.
The larvae can also be applied within a prefabricated “biobag”, commercially available outside the United States, that facilitates application and dressing change [58-61]. Randomized trials comparing “free range” with “biobag”-contained larvae in the debridement of wounds have not been performed.
A main disadvantage of maggot therapy relates to negative perceptions aboutits use by patients and staff. One concern among patients is the possibility that the larvae can escape the dressing, although this rarely occurs. Although one study identified that approximately 50 percent of patients indicated they would prefer conventional wound therapy over maggot therapy, 89 percent of the patients randomly assigned to maggot therapy said they would undergo larval treatment again . Perceived pain or discomfort with the dressings associated with maggot therapy may limit its use in approximately 20 percent of patients.
The STARZ show Outlander (a show and series of books by scientist Diana Gabaldon I thoroughly enjoy) used real maggots in the fifth season of the show when in 18th century America, wife (and surgeon) Claire successfully treats her husband Jamie’s snakebite wound with the larvae. Actress Caitriona Balfe describes her co-starring maggots in this brief video:
So there are still things to learn about medical therapies we used in the past which have been sidelined or forgotten in our push for modern treatment modalities. The days of leeches and maggots may not be over after all.
And now for video, complete with little maggotty sound effects — scroll down
Maggots in our compost bin – enjoying corn and potato chowder leftovers
A new book from Barnstorming is available to order here
And so you have a life that you are living only now, now and now and now, gone before you can speak of it, and you must be thankful for living day by day, moment by moment … a life in the breath and pulse and living light of the present… ~Wendell Berry from Hannah Coulter
~Lustravit lampade terras~ (He has illumined the world with a lamp) The weather and my mood have little connection. I have my foggy and my fine days within me; my prosperity or misfortune has little to do with the matter. – Blaise Pascal from “Miscellaneous Writings”
I laughed in the morning’s eyes. I triumphed and I saddened with all weather, Heaven and I wept together, and its sweet tears were salt with mortal mine. Against the red throb of its sunset heart, I laid my own to beat And share commingling heat.
Rise, clasp my hand, and come. Halts by me that Footfall. Is my gloom, after all, Shade of His hand, outstretched caressingly? Ah, Fondest, Blindest, Weakest, I am He whom thou seekest. Thou dravest Love from thee who dravest Me. ~Francis Thompson from “The Hound of Heaven”
My days are filled with anxious and sad patients, one after another after another. They sit in front of their screen and I in front of mine, so close yet so far from each another – a wilderness of unexpressed emotions.
They struggle to hold back the flood from brimming eyes. Each moment, each breath, each heart beat overwhelmed by questions: How to take yet another painful breath of this sad life? must there be another breath? Must things go on like this in fear of what the next moment will bring?
The only thing more frightening than the unknown is the knowledge that the next moment will be just like the last or perhaps worse. There is no recognition of a moment just passed that can never be retrieved and relived. There is only fear of the next and the next so that now and now and now is lost forever.
Worry and sorrow and angst are more contagious than any viral pandemic. I mask up and wash my hands of it throughout the day. I wish there was a vaccine to protect us all from our unnamed fears in the wilderness.
I want to say to them and myself: Stop this moment in time. Stop and stop and stop. Stop expecting this feeling must be “fixed.” Stop wanting to be numb to all discomfort. Stop resenting the gift of each breath. Just stop. Instead, simply be in the now and now and now.
I want to say: this moment, foggy or fine, is yours alone, this moment of weeping and sharing and breath and pulse and light. Shout for joy in it. Celebrate it. Be thankful for tears that can flow over grateful lips and stop holding them back.
Stop me before I write, out of my own anxiety over you, yet another prescription you don’t really need.
Just be– and be blessed– in the now and now and now.
There are three kinds of men. The ones that learn by reading. The few who learn by observation. The rest of them have to pee on the electric fence for themselves. ~Will Rogers
Learning is a universal human experience from the moment we take our first breath. It is never finished until the last breath is given up. With a lifetime of learning, one would think eventually we should get it right.
But we don’t. We tend to learn the hard way especially when it comes to matters having to do with our (or others’) health.
As physicians in training, we “see one, do one, teach one.” That kind of approach doesn’t always go so well for the patient. As patients, we like to eat, drink, and live how we wish, demanding what interventions we want only when we want them – this also doesn’t go so well for the patient. You’d think we’d know better, but as fallible human beings, we may impulsively make decisions about our health without actually using our heads (is it evidence-based or simply an anecdotal story about what “worked” for someone else?).
The cows and horses on our farm need to touch an electric fence only once when reaching for greener grass on the other side. That moment provides a sufficient learning curve for them to make an important decision. They won’t try testing it again no matter how alluring the world appears on the other side. Humans are smarter sentient beings who should learn as quickly as animals but unfortunately don’t. I know all too well what a shock feels like and I want to avoid repeating that experience. Even so, in unguarded careless moments of feeling invulnerable (it can’t happen to me!), and yearning to have what I don’t necessarily need, I may find myself reaching for the greener grass (or another cookie) even though I know better. I suspect I’m not alone in my surprise when I’m jolted back to reality when I continually indulge myself and climb on the scale to see the results.
Many great minds have worked out various theories of effective learning, but, great mind or not, Will Rogers confirms a common sense suspicion: an adverse experience, like a “bolt out of the blue,” can be a powerful teacher. As clinicians, we call it “a teachable moment.” None of us want to experience a teachable moment — none of us, and we resent it when someone points it out to us.
When physicians and patients learn the hard way, we need to come along aside one another rather than work at cross-purposes.
What shall I say, because talk I must? That I have found a cure for the sick? I have found no cure for the sick but this crooked flower which only to look upon all men are cured. This is that flower for which all men sing secretly their hymns of praise! This is that sacred flower! ~William Carlos Williams from “The Yellow Flower”
The nail of each big toe was the horn of a goat. Thick as a thumb and curved, it projected down over the tip of the toe to the underside. With each step, the nail would scrape painfully against the ground and be pressed into his flesh. There was dried blood on each big toe.
It took an hour to do each big toe. The nails were too thick even for my nail cutters. They had to be chewed away little by little, then flattened out with the rasp, washed each toe, dried him off, and put his shoes and socks back on. He stood up and took a few steps, like someone who is testing the fit of a new pair of shoes.
“How is it?” “It don’t hurt,” he said, and gave me a smile that I shall keep in my safety deposit box at the bank until the day I die.
I never go to the library on Wednesday afternoon without my nail clippers in my briefcase. You just never know. ~Richard Selzer from “Toenails” from Letters to a Young Doctor
I know for a while again the health of self-forgetfulness, looking out at the sky through a notch in the valleyside, the black woods wintry on the hills, small clouds at sunset passing across. And I know that this is one of the thresholds between Earth and Heaven, from which even I may step forth and be free. – Wendell Berry from “Sabbath Poems”
Whenever I lose perspective about what I’m trained to do and who I am meant to serve, when I wallow in the mud of self-importance rather than in the health of self-forgetfulness~
I wash out a plug of wax from a deaf ear and restore hearing or remove a painful thorn in a thumb or clip someone’s crippling toenails so they can step forth in freedom or I simply sit still as someone cries out their heart’s pain.
I cling to the crooked flower of healing and forgiveness I was handed over forty years ago in order to share its sacred sweetness.
I’ve been given these tools for a reason so need to continue to use them.
Our job is to love others without stopping to inquire whether or not they are worthy. That is not our business and, in fact, it is nobody’s business.
What we are asked to do is to love, and this love itself will render both ourselves and our neighbors worthy if anything can. ~Thomas Merton from Catholic Voices in a World on Fire
This is a time of too many seriously ill people and too few resources to care for them intensively, therefore doctors and nurses are placed in an ethical dilemma: they must decide who receives the critical care needed to save them and who doesn’t. It is an awful and awe-filled dilemma – no one wants to be in the position of deciding who is “worthy” of the only ventilator available, or the scarce medication, or the only empty ICU bed. Yet medical professionals are trained in triage to assess who is most likely to survive thanks to an extreme and immediate intervention and who would be unlikely to survive – essentially, who is “worthy.”
Thankfully, God doesn’t have to triage His children, deciding who gets His intervention and who must wait or go without care. God is not faced with limited resources. God has no dilemma about our worthiness: we are worthy because He loves us and we are His.
So should we love one another as best we can, even in times like these. We share, we give, we serve, and yes, we will sacrifice.
No less than what God has done for us.
This year’s Lenten theme for Barnstorming:
God sees us as we are, loves us as we are, and accepts us as we are. But by His grace, He does not leave us where we are. ~Tim Keller
1 O Love that wilt not let me go, I rest my weary soul in thee; I give thee back the life I owe, that in thine ocean depths its flow may richer, fuller be.
2 O Light that follow’st all my way, I yield my flick’ring torch to thee; my heart restores its borrowed ray, that in thy sunshine’s blaze its day may brighter, fairer be.
3 O Joy that seekest me through pain, I cannot close my heart to thee; I trace the rainbow thro’ the rain, and feel the promise is not vain that morn shall tearless be.
4 O Cross that liftest up my head, I dare not ask to fly from thee; I lay in dust life’s glory dead, and from the ground there blossoms red, life that shall endless be.
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.
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 MertonfromMy 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.
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.