Category Archives: angels

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Shades

This is for RonovanWrites Weekly Haiku Challenge #73, prompt words black and white. I was thinking of the shades in between and all of the stances on the internet: this is true, this is false, this is horrible, this is wonderful. We only seem to be able to agree about cute cat photos and videos. I keep hoping that the loss of privacy on the internet will teach us gentleness and peace and tolerance: entertain strangers for they might be angels. Peace, all, and work to end all discrimination.

 

white light darkening
hark angels black and white sing
black tract lightening

 

I took the picture at the start of a rain storm at Lake Matinenda, Ontario, Canada in August.

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at the end of the massage

at the end of the massage
I was dreamy and he put a warm towel over me
and said that I was not to get up until
my body had absorbed all of the heat from the towel
and he left the room

and I thought dreamily that it was so nice
to have my armor removed and muscles unlocked
and to just be assigned to let warmth seep in to me
until I held it all

and I thought dreamily that if all of the archetypes
are in each of us and I am learning to love all of mine
and even and especially the most horrific ones the ones
we all want to reject, not mine, the monsters, oh, poor monsters
that howl in the wilderness that howl in the dark that howl
to be loved

and I thought dreamily that if I love all of the archetypes
inside me then they aren’t a group that is around a table
in my mind, when they are all loved they come together and I
am one and everything is one

and I thought dreamily that how surprising that I felt one
quite suddenly and with no warning and with warming and oh
Beloved all connected

and I thought dreamily that was I really feeling healed as if
all of the splits and breaks and damaged are healed just by
love and I can add to the love in the world loving the inside
terrible parts of myself oh and the monsters long to be loved so
their weeping is terrible

and I thought dreamily blessings monsters blessings Beloved and
love to all and I lay there until I had absorbed all of the warmth
from the towel

and I got up slowly

and returned to the world

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Cindy gets real and skips the ball

We had a lovely dinner with family and friends. I look at the tablecloths and napkins that I have inherited and I am glad that I live in a time where I can work as a female physician and am not embroidering elaborate tablecloths and napkins. Some of the ones that I have WERE done by female relatives. Amazing and work that is currently not very valued.

So my centerpiece was an acknowledgement of the changes: Cindy is not going to ride in the coach. She has a canoe and paddles and a backpack, sleeping bag, stove, water bottle and GPS. She is going to find her own way and paddle her own canoe.

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Adverse Childhood Experiences 8: Social cues

I am thinking about social cues for people with high Adverse Childhood Experience scores. With crisis brain wiring the response to social cues may be very different than what is considered the acceptable “norm”.

I always miss the cue when someone says “see you later”. I think “When?” Then I realize it’s a social comment and they do not in fact plan to see me later. I have a moment of disappointment. I do the same thing when someone says, “Let’s get together for dinner.” or “Let’s have coffee some time!” or “I will call you back!” or “Why don’t you come to our cabin some day?” Yes, I think, when?

And then I think “Liar.”

So I fail social cues….. or do I? Maybe I am not responding to the “correct” or “conventional” or “nice” social cues.

My father drank too much and especially while I was in high school and college. And my mother would enable and cover up and pretend nothing was happening. Children in this situation, which is way too common, develop special skills.

My sister was three years younger. As adults we discussed the stages of drinking and which one we hated most. We would both walk in the house from school with trepidation. In the door and almost feeling the air: what is happening? Am I safe? Do I need to hide? How dangerous is it? How much will it hurt?

I walked in once during high school and missed the cue. I was thinking about something. I thought my father was asleep in the kitchen. I went in to get something. I was very quiet so as not to wake him. I made a cup of tea.

He was not asleep, or else he woke up. And it was the worst stage, or the one I hated most.
Not physical violence. But he started talking. One of things he said was “You can tell me anything.” Now, he meant it. But he was crying by then and I knew I did not want to tell him anything and all I wanted was desperately to leave the room. And neither my sister or my mother was home. Finally I was crying too, because I said “I just want to go read my book.” and he was more crushed and maudlin and emotional and crying. And I tore out of the room and up to my room, as my mother walked in.

I did not cry much. Ever.

I refused to talk to my mother about it.

The next day she said to me, “Your father told me that you were talking about Lamont.” Lamont Cranston was a very beloved cat, The Shadow, who was missing now. Dead, we thought.

I said nothing. Because we had not talked about Lamont. So either my father was lying or else he’d had a blackout, didn’t remember and was making shit up. And if I told my mother the truth, she would back him and deny what I said or make it into a joke.

The stages my sister and I identified were:
1. sober
2. a little bit
3. goofy/silly/makes no sense
4. crying
5. asleep

We were ok with 2 and 5. I don’t think we saw 1 for years. We disliked 3 intensely, especially in public and especially when our mother was doing a cover up dance. And 4 we hated.
And yet I loved my parents and mostly miss them now that they are gone. Except when I remember things like this.

So, what is the point?

I miss “social cues” because that is NOT what the crisis brain, the ACE score brain, pays attention to. I am paying attention to far more intuitive things: body language. Whether what the person is saying matches what I know about them and what they have done in the past. I am looking for whether this person is telling me the truth.

I don’t trust instantly. Why would I?

I said to a counselor once that reading the “cloud” around the person was terribly useful in medicine but made me a social misfit. “I don’t know how to turn it off.” I said. She grimaced and said, “Why do you think I went into counseling?” She said, “I can’t turn it off either but I have learned to ignore it during social situations.” I was in my forties before I realized that there are people who don’t sense this cloud, who trust people until the person is dishonest, who understand that it is just fine to say “Let’s get together.” and not mean it.

Because actually, when someone says “I’ll see you later.” and they don’t mean it, they are saying an untruth. They are not planning to see me later. They don’t mean it. And my brain automatically files that under evidence that this person is not trustworthy. To them it is a social cue that is polite. To some of us, it is clearly something that is not actually true. I pick up on a cloud of social cues, but not the ones that are acceptable or conventional. And I am not the only one.

my sister on the left and me on the right, in the 1960s

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It’s about caring

I described helping a woman bring her bad LDL cholesterol down from 205 to 158 with two clinic visits the other day, and someone said, β€œI can replace you with a teacher who is much cheaper. Why should you go to medical school to talk about the things people already know? Let’s free you up to do heart surgery or something important.”

Well? What about that? Is my career as a doctor wasted because I am in primary care? I am in Family Practice and I spend tons of time counseling people about diet, exercise, lifestyle choices.

My work is not wasted.

If all we had to do was give people information, we have the information. Every magazine and newspaper screams at us: β€œObesity! Stop smoking! Exercise for health! Eat right! Don’t eat junk food!”

Why do two visits with me make a difference?

People do not feel valuable and do not feel cared for in our culture. In the same magazine with articles about losing weight, getting organized, shouting β€œYou can do it!” there are multiple advertisements for sugary desserts and things to consume. My spouse used to joke, β€œIf I get (whatever he wanted at that time) then I’ll be a better person.”

I see pregnant woman who can stop smoking while pregnant, to care for the baby on board, but who often can’t extend the same caring to themselves after the child is born.

The history is often listed as the most important part of a clinic visit. I agree, but not just for diagnosing illness. I am listening to the person, and now with a laptop, I am recording their history. Why are they here today, what medical problems have they had, allergies, surgeries, do they smoke, are they married, do they have children? I want a picture of the person and I must listen hard. What do they reveal about their trust in medicine, about favorable or unfavorable medical interactions in the past, about what they understand or believe about their health? The visit is a negotiation. I need their view of what is happening and their questions.

The physical exam is often an interlude for me. I look at the persons throat, in their ears, listen to their heart and lungs. And part of me is collating the information that I’ve gathered, so that we can move to the next step: analysis and plan.

If I am doing a preventative check, a wellness visit, a physical, whatever you want to call it, I name the positives and negatives. Are they exercising regularly, have they stopped smoking, are they trying to eat a good diet? I name these. Are they lucky enough to have four grandparents who lived to 102 or do the men in their family die at 52 of a heart attack? A 55 year old man who has lost multiple relatives in their early 50s is surprised that he’s alive, and starting to wonder if it might be worth attending a little to his own health. He is a bit shy about hoping that he might not die tomorrow, and ready for encouragement in taking care of himself.

The visit is really about caring. Many people in our culture do not feel cared for. Moms are supposed to care for everyone else. Parents are very very busy, trying to take care of children and have jobs. People are afraid that they will lose their job, their insurance, their homes. We try to do the tasks of adulthood: have the career, find the true love, raise the children, achieve the lifestyle, home and place in our society. And many people feel that they are failing or fear failing. They have not gotten the job they hoped for. They have a house, but it is a huge amount of work. They are working very hard, but there are still so many things they would like to do or see or have. They have become overweight, they have gotten hooked on tobacco, their children are not turning out as they’d planned, the ungrateful wretches. And their parents’ health is crumbling, and in all the chaos, why would the person attend to themselves? The cell phone rings, the computer beckons, it’s time to work, to cook, to clean, to stay on the hamster wheel of life.

In clinic, for a few moments, this person is the center. They explain their health to me. They are painting a picture of their life. A patient will say, β€œI’ve been worrying about my mother, my son, my spouse, and I don’t take the time to exercise or eat right.”

And I say, β€œI hope that your mother, son, spouse does better. But you are important too. It is wonderful that you have stopped smoking, excellent! But we’re both worried about your cholesterol, right? It is too high. How are we going to take care of you? What can you fit in?”

Most people do not want to start with a medicine. They want to take care of themselves, too. They are willing to make lifestyle changes. They need encouragement and permission and to come back to see how it is going. What they need is my caring. And I do care.

I used to think that somehow complex patients would gravitate to me. But that is not true: the truth is that everyone is complex. Each person has layers and thoughts and feelings: fears and joys. I barely scratch the surface. It is the caring that is most important and each person that I see is important.

At the end of the visit, I print my note. I give it to the person. β€œCheck it. Tell me if something is wrong. I cannot change the note, but I can put an addendum.” I see that people are shy and often show some confusion. Two pages? Single spaced? About me?

Yes. About you.

written in 2010 and published first here: http://everything2.com/title/It%2527s+about+caring?searchy=search

I took the photo in 2004, a school overnight trip to explore settlers 100 years ago….

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Rural medicine crisis: Job offers

One of the signs that we are entering a worse crisis for rural medicine is job offers.

I am starting to keep the email job offers: so far the record is from Texas, a random out of the blue job offer for $500,000 yearly.

One half million dollars for a Family Practice job. I won’t take it. I like my clinic and anyhow, the pace they would set me to work is burning out physicians. They are quitting, though some die instead. A recent article said that this year a physician poll reports the number at burnout this year has risen from 40% to 50%.The job offers roll in. I get phone calls, emails, mailing and now my cat is getting rural family medicine job offers. Really. Desperate times.

Years ago I read that only 30% of family practice doctors are willing to take a rural job and that only 30% of those are willing to do obstetrics in a rural area. I did obstetrics as part of my practice from 1996 to 2009. I stopped when I opened my own practice, because the malpractice price tag is three times as much and my rural hospital was grumpy at me. Starting in my third year of medical school, I did deliveries for 19 years. During my nine years here, the cesarean sections were done by the general surgeons and we did not have an OB-gyn. I called Swedish Hospital Perinatology when I needed help. I got to know them well enough that if I had someone in preterm labor I would call and find out who was on call BEFORE I chose a medicine, because I knew which perinatologist liked terbutaline and which one would rather I would skip it and use procardia. They were fighting out the research: I didn’t know who was right, but it is a huge benefit to have your consultant be happy with your choice if you have to lifeflight the patient by helicopter at 3 am. With a 25 bed rural hospital, we try not to deliver a baby under 35 weeks, and it’s better to fly the baby in mother if you can’t stop the labor.

Back to the numbers: so 33 out of 100 family practice doctors will take a rural job and only 11 of those are willing to do obstetrics. Our first day of medical school, the faculty said, “Shake hands with the person on your right. Shake hands with the person on your left. At least one of the three of you will be sued for malpractice in your career.” Oh, goody, let’s start training with paranoia. Or is it just being realistic and prepared?

I worked for five years between college and medical school and took the GREs first. I thought I was going to get a PhD. However, I did not want to write a thesis and did not want to be one of three world experts in anything. I had a friend who was one of three world experts in honeybee behavior. I asked what happened when they got together. “We argue.” he said. I also did not want to publish or perish, tenure was becoming more of a problem and anyhow, I did not want to be tied to a university. I got a job working as a lab tech in the National Cancer Institute at NIH in Bethesda. Two years there gave me my answer: primary care is the ultimate generalist. I could work anywhere in the world, in a city, in a small town, and there is endless lifelong learning. I took the MCATs and got into medical school, determined to do primary care.

Back to the job offers: 450K for Iowa. 310K, 350K, signing bonus, paid move, 6 weeks “off” (As far as I can tell it’s always unpaid leave. No sick leave, no paid holidays, no paid leave at all. Do factor that in.)Production bonus. No call or phone calls only. Near a city! In a city! Cheap houses! Excellent schools for your children and 6 stellar golf courses! FP job in Texas, 315K, 4 day work week, signing bonus, loan forgiveness!

The most that I’ve made in a year, I think, is less than half the listed average income for family doctors, though that has risen by nearly 1/3 in the last ten years. And that was enough and I didn’t see enough of my two children and the next year I worked less. I have never made the “MGMA average” for what a family doctor makes and it was more than ten years ago. I am below average in income but I think I am above average in personal happiness and way below average in burn out! I made way less last year, because I was out sick for 6 months. Ok, I lost money. However, my clinic still nearly covered expenses and stayed open, with no provider from early June to November 15, thanks to my receptionist, my patients, the PA who stepped in in November and the other independent practitioners in town. The hospital system refused to help except that they took over my 18 patients on controlled substances… after I threatened to complain to the state that they were refusing care. How nice.

I have an old house and old cars. I have a son finishing college and a daughter about to start. More money to retirement seems like a good idea. I now have 25 years as a member of the American Academy of Family Practice and I am an “old” doctor, because I didn’t retire at 50. I told a younger partner at the hospital that I was deliberately being “below average” because I was going for a career with longevity and wanted to avoid burning out. He left town last year….

From the American Academy of Family Practice paper http://www.aafp.org/about/policies/all/rural-practice-paper.html : family practice providers are 15% of physicians in the US, but do 23% of the visits each year. And in rural areas about 42%. “In the U.S. as a whole there is 1 Primary Care physician per 1300 persons while in rural areas the ratio is 1 Primary Care physician per 1910 persons and 1 Family Physician per 2940 persons. In the most rural counties, those with a community of at least 2500 people but no town over 20,000, close to 30,000 additional Family Physicians are needed to achieve the recommended 1:1200 ratio.” I have patients driving from over an hour away because it takes months on the waiting list to see a primary care doctor in their area, and now I am seeing veterans too, because we are more than 40 miles by road from the nearest VA hospital.

This article:Β  http://doctordrain.journalism.cuny.edu/the-broken-system/family-practice-just-doesnt-pay/ makes me laugh. The student says that 90% of family practice visits are probably coughs and colds. Uh, I would say that less than 5% of mine are. Half of my patients are over 65 and what I do is care for chronic disease with some acute disease thrown in. Diabetes, hypertension, coronary artery disease, rheumatoid arthritis, stage III renal failure, opiate overuse syndrome, depression, PTSD, and the average patient has 4-5 chronic diseases, not one. So the complicated ones have 9 chronic diseases. If they have walking pneumonia and diabetes and are 80, what was their last creatinine so I can adjust the antibiotic dose for their stage three renal failure? My oldest current patient is 98, has diabetes and still is out haying…. rural medicine is never ever boring and some days I think, oh, I would pay to see a simple cold. In the last two months one patient had a four vessel bypass, two have hepatitis C, one has hepatitis B and last month I found one with pertussis: whooping cough. And one has to go to the Big City to see the gynecologist-oncologist….

Rural family medicine is the ultimate generalist. I have to know a little bit of everything and know when to call and ask questions and who to call. Once I had an obstetrics patient with severe and confusing back pain after an epidural. I knew it was something peculiar because we could barely control it with opiates and her back exam was fine. I started calling specialists: ob-gyn didn’t know. The nurse anesthetist. My local internist. An orthopedist. A neurologist, the closest one 90 miles away. Then I got it: I called an anesthesiologist in Denver, 250 miles from where I was. He said it was an inflammatory reaction to the epidural medicine and to give her steroids, which would fix it. It did… but it was my being sure that I had something different on my hands and the stubbornness to keep calling until someone knew the answer….

A friend from college got a PhD in genetics and then went to medical school at the same time as I did. We talked when we picked our specialties. She chose pathology. I chose Family Practice. “Not Family Practice!” she said. “Why not?” I asked. “You can’t know everything!” she said. I said, “Well, no one knows everything. Put three top specialists in a room and they argue about the research. The trick is knowing what you know and what you don’t know.”

We need more primary care physicians and more rural family doctors. And it’s only getting worse.

http://www.aafp.org/about/policies/all/rural-practice-paper.html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071163/
http://healthleadersmedia.com/content/COM-208773/Physicians-Offer-Insights-on-Practicing-Rural-Medicine.html
http://www.siumed.edu/academy/jc_articles/Distlehorst_0410.pdf
http://doctordrain.journalism.cuny.edu/the-broken-system/family-practice-just-doesnt-pay/
https://www.aamc.org/newsroom/newsreleases/358410/20131024.html
https://www.washingtonpost.com/news/to-your-health/wp/2014/05/22/how-many-patients-should-your-doctor-see-each-day/
This blog post helped inspire this article: https://theridiculousmrsh.wordpress.com/2015/11/03/why-i-hope-my-doctor-is-off-having-a-cup-of-tea-as-seen-on-the-huffington-post-yup-actual-huffpost/

The picture is some of the madashell doctors on our first trip stumping for single payer health care in 2009.

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Walk away

I used to carry my phone around
hoping you would call me now
I walk away

my house is three stories and
I can’t hear the phone and still
I walk away

I long to hear your voice I send
a hopeful query to you then
I walk away

I leave the phone plugged in the wall
and go up the stairs and down the hall
I walk away

I listen in the quiet to hope sighing
in my heart and maybe dying as
I walk away

I took the photo at the National Junior Synchronized Swimming Competition in 2009.

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Songs to raise girls: Long Black Veil

 

This and The Fox are what I think of as the two core family songs. We sang this from as early as I can remember and my father played the Band’s version on the record player all the time. I taped his records to take to college…

This is the song my parents chose to raise girls on? Oh, and I do have it memorized….

Ten years ago on a cool dark night
There was someone killed ‘neath the town hall light
There were few at the scene and they all did agree
That the man who ran looked a lot like me

Ok, it starts with a murder. Someone is killed, in the town, at night. Be careful, little girls, bad things can happen at night.

The judge said “Son, what is your alibi?
If you were somewhere else then you won’t have to die”
I spoke not a word although it meant my life
I had been in the arms of my best friend’s wife

It is about infidelity and not only infidelity, but infidelity with his best friend’s wife. This song is a morality play. He doesn’t speak. I see the magazines at the counters in the grocery store and think about how different this song is from our current culture. Divorce and splashed all over the papers, that’s what the celebrities do today.

She walks these hills in a long black veil
She visits my grave where the night winds wail
Nobody knows, no, and nobody sees
Nobody knows but me

So she doesn’t speak either. She remains faithful to him in visiting his grave, but the marriage must continue, because she only goes at night.

The scaffold was high and eternity neared
She stood in the crowd and shed not a tear
But sometimes at night when the cold wind moans
In a long black veil she cries over my bones

She watches him die for what they considered a sin. This song is about ethics, really. The two of them had broken their code of honor and paid the price, which was that he died for a different crime. And did the man who really killed the person in the first stanza then go free?

Why wouldn’t they speak up? Perhaps she had children and he couldn’t support them. Perhaps they truly considered it a sin, a dishonor, a horrible mistake. Perhaps honor and honoring his best friend was more important than love…. Our current culture seems to think that love conquers all, but it doesn’t in this song. Did they do the right thing? This is a song to discuss and to think about and yes, a song to raise girls.

Though I think the husband and any children would know that there was something…. a parent and partner can’t really hide that deep sorrow….

It was written by Danny Dill and Marijohn Wilkin in 1959 and originally recorded by Lefty Frizzell.

Lefty Frizzell: [https://www.youtube.com/watch?v=50k18gL76AU]

The Band, 1968

Johnny Cash, 1968

Lots of others…. and us.

The photo is me and my sister, probably in 1993 or 1994.