Be Obscure Clearly



A wind has blown the rain away
and blown the sky away
and all the leaves away,
and the trees stand.
I think, I too,
have known autumn too long.
~e.e. cummings




Be obscure clearly.
~E. B. White




As a family doctor in the autumn of a forty year career, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  That is hard work for my patients, especially when they are depressed and anxious on top of whatever they are experiencing physically.

There is still much unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, not pristine and clear.

Let’s face the lack of facts.  A physician’s clinical work is obscure even on the best of days when everything goes well.  We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Forty years of doctoring in the midst of the mystery of medicine: learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done can be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The time has come for the patient to share responsibility for maintenance of their medical records and assist the diagnostic process by providing online symptom and outcomes follow up documentation.

The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure clearly.  Our lives depend on it.



Taking a Moment (or a day) to Rest



As we drown in the overwhelm of modern day health care duties, most physicians I know, including myself, fail to follow their own advice. Far too many of us have become overly tired, irritable and resentful about our work load.  It is difficult to look forward to the dawn of the next work day.

Medical journals and blogs label this as “physician burn-out” but the reality is very few of us are so fried we want to abandon practicing medicine. Instead we are weary of being distracted by irrelevant busy work from what we spent long years training to do: helping people get well, stay well and be well, and when the time comes, die well.

Instead we are busy documenting-documenting-documenting for the benefit of insurance companies and to satisfy state and federal government regulations. Very little of this has anything to do with the well-being of the patient and only serves to lengthen our work days –interminably.


Today I decided to take a rare mid-week day off at home to consider the advice we physicians all know but don’t always allow ourselves to follow:

1) Sleep. Plenty. Weekend and days-off naps are not only permitted but required. It’s one thing you can’t delegate someone else to do for you. It’s restorative and it’s necessary.

2) Don’t skip meals because you are too busy to chew. Ever. Especially if there is family involved.

3) Drink water throughout the work day.

4) Because of 3) go to the bathroom when it is time to go and not four or even eight hours later.


5) Nurture the people (and other breathing beings) who love and care for you because you will need them when things get rough.

5) Exercise whenever possible. Take the stairs. Park on the far side of the lot. Dance on the way to the next exam room.

6) Believe in something more infinite than you are as you are absolutely finite and need to remember your limits.


7) Weep if you need to, even in front of others. Holding it in hurts more.

8) Time off is sacred. When not on call, don’t take calls except from family and friends. No exceptions.

9) Learn how to say no gracefully and gratefully —try “not now but maybe sometime in the future and thanks for thinking of me”.

10) Celebrate being unscheduled and unplanned when not scheduled and planned.

11) Get away. Far away. Whenever possible. The back yard counts.


12) Connect regularly with people and activities that have absolutely nothing to do with medicine and health care.

13) Cherish co-workers, mentors, coaches and teachers that can help you grow and refine your profession and your person.

14) Start your work day on time. End your work day a little before you think you ought to.


15) Smile at people who are not expecting it, especially your co-workers. Smile at people who you don’t think warrant it. If you can’t get your lips to smile, smile with your eyes.

16) Take a day off from caring for others to care for yourself.  Even a hug from yourself counts as a hug.

17) Practice gratitude daily. Doctoring is the best work there is anywhere and be blessed by it even on the days you prefer to forget.



The Doctor is In

waterfall 3


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


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 me.

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 and 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 can be overcome rather than be 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 better choices, how they can be bolder and braver in their self care, how they can intervene in their own lives 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 “in charge” as the 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.  Even now in my seventh decade of life,  I am 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.



When the Wind Blows Hard

photo by Starla Smit
photo by Starla Smit

Let us not be surprised when we have to face difficulties.
When the wind blows hard on a tree,
the roots stretch and grow the stronger,
Let it be so with us.
Let us not be weaklings,
yielding to every wind that blows,
but strong in spirit to resist.
~Amy Carmichael

And so the government and its people are at an impasse–the winds of change are pummeling us all and everyone has entrenched more deeply in order to stay upright.

As a U.S. health care provider who has worked for over 30 years as a salaried physician, in non-fee-for-service health care settings providing patient care that meets the need when need arises without profit motive, I am flummoxed by this impasse.  Policy makers could not come up with a more simplistic solution than what is contained in 2000+ pages of complex regulations that are already creating bureaucratic havoc in all health care settings, distracting health care providers with electronic and telephone paperwork that pulls us away from the bedside. The patient and the provider no longer partner together without a dozen other entities dictating the choreography of their dance.

A potential solution to the problem of affordable access to all who need it already exists in the form of the Public Health Service Commissioned Corps with incentive scholarships for medical and nursing training in exchange for work in under-served areas.   An expansion of such a system, requiring funding at a much lower cost than the billions of dollars required by the current health care reform act,  would address the challenges of the uninsured and the uninsurable.

As a medical student in training, I  spent many months providing patient care in Seattle’s exemplary Public Health Hospital and its associated clinics.  Patients traveled hundreds of miles to see the specialists who worked there; the best and the brightest clinicians saw the poorest of the poor inside those walls, but there were a number of physicians and their families I knew who received their care there as well because they knew the people who worked there were devoted to the patient, not to profit.

When the Executive, Judicial and Legislative branches of government refuse themselves to participate in a health care system they have constructed for the people, then it is not created of the people, by the people, for the people for they are people who get sick and injured just like the rest of us.  What is best for them must be best for us all.

All citizens, and non-citizens inside our borders for whatever reason, should have easy access to affordable health care.   All health care providers should have opportunity to work off the costs of their training to keep the debt load from crushing them for decades to come.

I am grieved that health care has come to this impasse, with government now in a take-no-prisoners mode that clear-cuts us all down to the bare roots.
We need to lean in together for support and quit the fighting that only creates more injury.

We need look no farther than our own commissioned corps of health care officers.  It is an idea whose time has come.



Palmed Off on the Unwary


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

Returning to clinic after time off for a summer break, I worry I’m like a fly hiding among the black currants hoping to eventually become part of the currant cake.  Just maybe no one will notice I don’t quite fit back in.

In thirty three years of practice, even after bearing three children and going through several surgeries, I’ve not been away from patients for more than twenty consecutive days at any one time.  This is primarily out of my fear that, even after a few weeks, I will have forgotten all that I’ve ever known and if I were to actually 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.

Those who spend their professional lives taking care of others also share this concern if they are truly honest: 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 need for us at all, especially in this day and age of accurate (and some terribly inaccurate) medical information at everyone’s fingertips.  Who needs a physician when there are so many other options to seek health care advice, even when there are a few flies mixed in?

As I walk back into an exam room to sit with my first patient after my time away, I recall over thirty years of clinical experience has given me an eye and an ear for subtlety of 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 fullness over an ovary, the slight squeak in a lung base.  These are things I am privileged to see and hear and make decisions about together with my patients.  This is no masquerade; I am not appearing to be someone I am not.  This is what I’m trained to do and have done for thousands of days of my life.   No need for the unwary to fear.

The hidden fly in the currant bush of health care may be disguised enough to be part of the cake that an unwary patient might gobble down to their ultimate detriment — but not this doctor.  I know I’m the real thing, perhaps a bit on the tart side, but offering up just enough tang to be what is needed.

And I will die happy doing this.



What’s Beneath the “Chief Complaint”

Any primary care clinic has a schedule that lists the appointments of the day in incremental time slots.   There is a column for the name of the patient, the patient’s age, and always there is a place for the reason for the visit–the “chief complaint” according to medical parlance.

A quick review of the “chief complaints” for the day gives the physician a sense of how clinic will flow.   There are the seemingly “quick” concerns, like a blood pressure check, sore throat or ankle sprain, and then there are those that will predictably take longer such as fatigue, trouble sleeping, back pain, or headache.

All health care providers are aware that the chief complaint may not be what the patient really wants to talk about.   Finding out the real concern can be part of the detective work the physician must do.  Sometimes it doesn’t actually reveal itself until the physician’s hand is on the door knob, ready to say goodbye and move on to the next patient.

So I can’t depend on a seemingly routine and straight forward chief complaint to be what it appears on the daily schedule.   When I knock on the exam room door, I need to expect the unexpected.  Otherwise,  I’ll have failed my patient and not done what I’m trained to do–look for what is “beneath” the chief complaint.


“itching” – a patient who reports 2-3 months of daily itching, worse at night, with no other symptoms and no apparent rash.  Treatment for scabies showed no benefit, there has been no significant relief from antihistamines or topical corticosteroids.   Examination is unremarkable with no skin findings other than the excoriations from scratching.  Lab work reveals mildly elevated liver function tests.  Additional labs reveal no acute or chronic infectious hepatitis but further work up confirms primary sclerosing cholangitis.

“back pain” in a patient who had been seen with similar low back pain six months previously, but it has been intermittent up until a week prior to this visit when the patient’s legs feel heavy when going up stairs.  Exam reveals an abnormally “stiff” gait but no leg swelling or neurologic abnormality.  Sed rate is elevated and subsequent MRI scan shows bilateral iliac thrombosis due to a congenitally absent inferior vena cava.

“memory lapses” in a patient who notes two weeks of feeling that it was a struggle to remember something that had happened only a few moments before.  Significant recent stress with fatigue but mental status exam and physical exam appears entirely normal.  Screening lab work reveals a significantly elevated calcium, with subsequent testing showing hyperparathyroidism.  Surgery to remove the offending parathyroid gland reveals incidental papillary thyroid cancer as well.

“constipation” in a patient who has noticed bloating in her lower abdomen for several weeks.  She has had normal cycles on birth control pills, has a negative pregnancy test, and a rock hard 18 week size mass in the pelvis.  Subsequent surgery reveals a rare non-metastasized ovarian malignancy requiring aggressive chemotherapy.

“fatigue” in a patient who is puzzled about having slept for almost 20 hours straight.   General disheveled malnourished appearance and smell suggests issues with being able to do basic self care and an examination reveals needle tracks on both arms.  Admits to daily heroin use but doesn’t think it is connected to the excessive sleep need since drug use has not changed over several years.

“fever” with headache, myalgias, and nausea for two days in a patient whose rapid strep and influenza screen is negative, lab showing normal white count with a left shift.  Blood cultures eventually grow strep viridans from subacute bacterial endocarditis on a previously undiagnosed bicuspid aortic valve, presumably from a dental cleaning a few weeks before.

“rib pain” in the left lower anterolateral chest wall of a patient with a week of dry cough, congestion, and low grade fevers.  Vital signs and pulse oximeter readings are normal, as well as a plain chest xray, a urinalysis shows some red blood cells. Scan of the abdomen rules out kidney stone but suggests a subtle infiltrate in the left lower lobe.  D-dimer is mildly elevated and scan of the chest shows multiple infarcts most likely related to use of combination oral contraceptives.

Any of these routine “chief complaints” could have led me to conclude an every day diagnosis, forming a treatment plan based on standardized clinical guidelines with prediction of an uncomplicated recovery.   But complacency in a primary care setting would be disastrous.

My job is to peel down through the layers and find what lies beneath the symptom that was the patient’s reason for seeking help.   It is that every day mystery that keeps me coming back, day after day, wanting to know what will happen next when I open the exam room door.