Category Archives: grief

by

small child

my small child was locked under rock for years

she came out shy reluctant distrustful

you are special, the first adult in whom
she recognized another small child
locked in and called you
out to play

and we played hard

now she stomps her foot at me
“He does not play fair! He won’t come to my house!
He makes all the rules! He doesn’t listen!”

yes, bear, I know

time to go home, small child
you have had your first playmate
since you were locked away
but he is still locked in a dungeon
of monsters and zombies
you unlocked him for a little while
just a tiny bit

but he has decided not to play
he is locked down

come, small child

she is in my arms, head on my shoulder
sucking her thumb, crying
until she is too tired
and falls asleep

she will always love you, you know

anything, to have someone to play with
she let you make all the rules
for a long time

but now she wants
someone who will play fair
and share the rules
and love her back

 

12/2015

by

Loved

It’s ok

I just want you to know

even if I never see you again
even if I never touch your hand
even if I never hug you again
even if you don’t answer
even if you don’t let me in
even if you are deaf to anything I say
even if you forget the moment you stop reading
even

I just want you to know

you are loved you are loved you are loved

always

even if

for my lost ones, living and dead 9/15/16

The photograph is from 2004, in the Hoh Rain Forest.

I am submitting this to the Friday Night Music Prompt #62 : Never too late for love & Keep me in your heart

 

by

Fraud in Medicine: Heartwood

Here in my neck of the woods, people are continuing to quit medicine. Two  managers who have worked in the clinics eaten by the hospital are leaving on the same day, after 30 years. And another woman doctor, around my age, is retiring from medicine. She is NOT medicare age.

Meanwhile, the Mayo Clinic is publishing articles about how to turn older physicians into “heartwood”.

http://www.mayoclinicproceedings.org/article/S0025-6196(15)00469-3/fulltext

“As trees age, the older cells at the core of the trunk lose some of their ability to conduct water. The tree allows these innermost cells to retire…. This stiffened heartwood core…continues to help structurally support the tree…. Here a tree honors its elderly cells by letting them rest but still giving them something meaningful to do. We non-trees could take a lesson from that.” Spike Carlsen

Oh, wow, let’s honor the elderly. Even elderly physicians. Instead of what, killing them? Currently we dishonor them, right?

But what is the core of the issue? Skim down to “Decreased patient contact”:

“Already, many physicians are choosing to decrease their work to less than full-time, with resultant decreased patient encounters and decreased institutional revenue. Prorating compensation to match full-time equivalent worked will aid in financial balance, but the continued cost of benefits will remain. However, when that benefit expense is compared with the expense of recruiting a new physician (estimated by some to approach $250,000 per physician), the cost of supporting part-time practicing physicians becomes more attractive.”

Ok, so the core of the matter. “Decreased institutional revenue” and the employer still has to pay BENEFITS. NOTHING ABOUT THE QUALITY OF CARE FOR PATIENTS.

Again, the problem is still that you can’t really “do” a patient in twenty minutes, and that full time is really 60 or more hours a week. To be thorough, I  have to absorb the clinical picture for each patient: chief complaint, history of present illness, past medical history, allergies, family history, social history (this includes tobacco, drugs and alcohol), vital signs, review of systems and physical exam. And old records, x-rays, pathology reports, surgical reports, laboratory reports. I fought with my administration about the 18 patient a day quota. I said: ok, I have a patient every twenty minutes for 4 hours in the morning, a meeting scheduled at lunch, four hours in the afternoon. When am I supposed to call a specialist, do refills, read the lab results, look at xray results, call a patient at home to be sure they are ok? The administration replied that I should only spend 8 minutes with the patient and then I would have 12 minutes between patients to do paperwork. I replied that they’d picked the Electronic Medical Record telling us that we could do the note in the room. I could, after three years of practice. But it nearly always took me twenty-five minutes. I would hit send and our referral person had so much experience that she could have the referral approved before my patient made it to the front desk. BUT I felt like I was running as fast as I possibly could all day on a treadmill. Also, the hour lunch meetings pissed me off. I get 20 minutes with a patient and they get an hour meeting? Hell, no! I set my pager for a 20 minute alarm every time I went into a meeting and I walked out when it buzzed. I needed to REST!

After a few weeks of treadmill, I dropped a half clinic day. But of course that didn’t go into effect for another month and I was tired and ran late daily. And every 9 hour clinic day generated two hours of paperwork minimum: nights, weekends, 5 am when I would not get interrupted and could THINK. Do you really want a doctor to review your lab work when they are really tired and have worked for 11 hours or 24 hours? Might they miss something? It might have been best if I had been quiet and just cancelled two people a day, since the front desk knew I was not coming out of any room until I was done, but I argued instead.

The point is, you would like to see a doctor who listens and is thorough. You do not actually want a medical system where there all these other people who read your patient history forms and enter them in to the computer and your doctor tries to find the time to read it, like drinking from a fire hose. If we want doctors and patients to be happy, then doctors need time with patients and we need to off the insurance companies who add more and more and more complicated requirements for the most minimal care. One system, one set of rules, we’ll fight over the details, medicare for all.

by

Choosing love

My sister and another writer posted essays under the title Choosing Love here: http://everything2.com/title/Choosing+Love. My sister’s was written in 2002. I posted mine there last November.

Choosing Love

I choose love
I have no enemies
I hold you close in my heart
and hug you close if I can
and if you hurt me over and over
I can still love you
I choose love
I have no enemies
I hold you close in my heart
from far far extremely far away
I choose love
I have no enemies
I hold you close in my heart
I hug you from a safe distance
I choose love
I have no enemies
I hold you close in my heart
even if I will not allow contact again
I choose love

The photograph was on the beach. The gull and the crow were interacting. After I watched for a while it was clear that the gull was following the crow and trying to take things from the crow. They were not friends.

 

by

Diagnosis is only half the job

In clinic I have two jobs.

The first job is to diagnose. Chief complaint, history of present illness, past medical history, allergies, review of systems, medications (and vitamins and supplements and herbs and any pills or concentrated substances), social history including addictive substance use, family history, physical exam. What is my diagnosis? A clinical portrait of the patient.

The second job is to communicate and negotiate. I have to get a snapshot of the person’s medical belief system, their past experience with MDs, their trust or lack of trust, whether they are willing to take a prescription medicine. I have to try to understand their world view at this visit, at this moment in time. And it’s not static and may change before I see them again. If I can understand the person well enough to communicate with respect, with concern, with understanding, then we may be able to negotiate a treatment.

In clinic the other day I had a new patient who said, “I am not going to be pushed to take prescription medicine.” I responded, “That’s fine. I am not going to be pushed to do medical testing that I think is inappropriate, either.” She actually laughed and said, “Ok. That’s fair.” This is a patient who is coming from alternative treatment but wants medicare to cover her tests. After the visit she called and said that her provider wants a certain test before they feel comfortable proceeding with a therapy. I responded that I need a note and an explanation of the planned therapy before I will order the test. (Honestly, it’s an increasing trend that I get calls from patients with messages like “My orthopedist wants you to get my back MRI prior authorized.” and “My physical therapist wants my hand xrayed.” Our new office policy is: the provider has to communicate themselves, not via the patient. Also, it ain’t always so….)

I had patient once in the emergency room who said, “I have an antennae in my tooth. Get it out.” Her roommate nodded, looking terrified. This was after a fairly confusing complaint of tooth pain. I needed to think about an approach. I said, “I need to check on another patient. I will return.” I left the room in the emergency room and considered approaches. I went back in and said, “I am not a dentist. I can’t take out the tooth. BUT I can call a doctor to help with the sounds that you are hearing until we can deal with the tooth. The doctor is a psychiatrist.”

“Ok. Call them.” said the patient. The roommate practically collapsed with relief. Psychiatry said, yes, looks like psychosis and we have a safety contract and she will come in Monday. People HAVE actually had metal in their mouth that picked up radio sounds, but psychosis is much more common. Also, if you can say the station call sign that is a lot different than voices that are telling you to harm yourself.

I thought about my approach carefully. I did not want to argue about the tooth. I wanted her to agree to talk to psychiatry. So I told the truth: I can’t fix the tooth. It’s Saturday night. Here is what I can do. I never said, hey, I don’t think it’s the tooth, I think it may be a psychotic break. She may have known that it was not the tooth but been too terrified or too disorganized to tell me. And there was a small chance that in fact, it WAS the tooth.

It is not worth trying to “fix” or change someone’s world view. If they trust their naturopath more than me, that is ok. But it’s a negotiation: I am a MD and I will do treatments that I think are appropriate and safe and I may or may not agree with the naturopath or chiropractor or physical therapist or accupuncturist or shaman. But the goal in the end is NOT for me to be correct: it is to help the patient. Half the therapy is respect and trust and hope. And kindness.

The biggest problem with ten minute visits and the hamster wheel of present day medicine in the US is that the second job is often not possible. Complex diagnoses are missed or patients leave feeling unheard, not respected and frustrated. Time to make the connection and to understand is very important and is half the job. Physicians and patients are frustrated and it is only getting worse.

 

The photograph is my daughter and her wonderful violin/viola teacher, right before my daughter played for a music competition.

 

by

Rain on water

My sister wrote Rain on water and posted it on everything2.com in 2009. Here: http://everything2.com/title/Rain+on+water

She was writing about going to Lake Matinenda. Our family has had land with cabins since the 1930s and now the fifth generation has gone there.

My sister died in 2012. I wrote my own version while I was there last summer.

____________________________________

What are you doing?

nothing

outwardly nothing

Inwardly, I am on a journey. I am back at the lake. It’s been three years. I am at the lake when the family is not there. I take old friends who have never been there. One knew my sister as I did and has known me for thirty years.

He and his wife and his six year old love the lake. And the six year old wants freedom as we all want but there are rules and you must wear your lifejacket on the front rocks until you can swim and can swim a certain distance and we never get in the canoe when it is on the rocks, it must be in the water or the canoe will be hurt and my uncle’s shade is over my shoulder and I can hear him yelling about the canoes as his parents yelled at him. The birchbark canoe that he and my mother destroyed still awaits repairs. And I demonstrate how to tip a canoe over when we go swimming and how fast it goes. “You may try it, but first you must practice jumping in the water. Do you want to?” No, he shakes his head, no, the small canoe went over so fast.

They leave and I am alone. I am not alone. The dead are there, their ashes, their words in the log, their voices in my head, their heights marked on the wall of the Little Cabin, my sister’s clothes, a marker for my uncle, my grandmother’s bed has been taken apart and is now a bench and I grieve about change and loss but it goes on. My sister is a sea otter but there are no sea otters at the lake and she is at the lake with me because she said, “How will I find you?” and I told her how and she was satisfied. No sea otters, but there are river otters, they come, a family, three, playing and fishing. I sing to them, Pie Jesu and they watch me curiously and go back to fishing and I think of my father my mother my sister and that I think they would be happy to be river otters in the lake together and fishing. I am with them almost and crying. My grandmother is a white pine and in the mink, my grandfather is a dragonfly, my uncle is the snapping turtle, I wonder what my friend’s son is, dead at 22, and the next animal I see is a merganser, the hooded merganser with two babies and she is leading me away from them while I am in the canoe, they are hidden I know about where and she circles back to say that now they can come out and are safe and I think yes, that would be right, a child who grew to a young man and was lost, he might choose to be a mom next caring for these young and careful and nurturing them, protecting them, hiding them, leading danger away.

Loons call and I answer and my voice lessons have helped my loon calls, I can hit the high notes now. A long conversation with a loon with me in the blue canoe and the loon wondering, do I have a loon trapped in my boat or am I in fact a loon, yes, I think I am, I will be a loon not a human any more

I can’t swim for long, not yet strong enough, the taste of the water is ingrained, layers of memory back to five months old and beyond, in the womb, has the lake marked my dna in three generations, I don’t know but I am in the water I am of the water I am water tears and water

written 8/29/15

by

I will marry only he who defeats me in battle

he
I am not really that attached to gender.
I’ve always thought that love is love
and who cares what birth sex or chromosome arrangement
people have
since nature’s diversity
is beyond insane

marry
I am not sure I would marry again
there is so much attached to the archetype
of a married couple
and no two are alike
in their conscious
much less unconscious
and then project the unconscious expectation
it makes me tired just thinking of it

battle
I agree that we are all fighting a battle
but I think it is always with ourselves
avoid avoid avoid
things that we fear
when we should go towards them
and embrace them
for our fears are the demons
we’ve chained in our unconscious

defeat
what is defeat?
loss of money?
loss of power?
the only defeat I have
is when I try to avoid myself
my true self
my dark self and my light self
there is no defeat
except my own failure
to admit my true self

I love who I love

whether they love me back

or not

 

I took the title from here: http://everything2.com/title/I+will+marry+only+he+who+defeats+me+in+battle and published there as well

 

by

Black lives matter

My family moved from upstate New York to Alexandria, Virginia when I started high school. My mother, Helen Burling Ottaway, took life drawing classes at the community college to meet other artists and because she would have a model. More than one.

She met Michal Platt and took classes with him. He pushed her. My mother did tiny etchings and fantasy drawings and big drawings and watercolors. Micheal wanted her to do powerful drawings. So she did. When he had to be gone for a day from the class, he would have my mother fill in teaching.

I have this picture hanging in my clinic. The title is “One fist of iron”.

The stages of grief for the recent deaths include denial, anger, bargaining, grief and acceptance. It is not a series one goes through. We do them over and over, going from one to another, like a spiral, a whirlpool, a tornado. Black lives matter, police lives matter, I wish my mother were still alive.

 

 

by

Beast Cthulhu and bone metastases

In 2011, when my sister wrote  Beast Cthulhu and bone metastases,  about her breast cancer being a treatable chronic illness, I was so sad…..

….because it was not true, even though I wished it was.

The perils of being the doctor sister.

It was clear that her cancer was progressing. Yes, she could request to continue treatment. Yes, they would keep treating her….

….but it wasn’t working.

The hematologist-oncologist chooses the best treatment first. Chris Grundoon was 41 and very strong and healthy so they hit the cancer as hard as they possibly could. Chemotherapy, mastectomy, radiation therapy, a second degree burn on her chest wall. It was stage IIIB to start with. Cancer is staged 0 to IV. Zero is “carcinoma in situ”, cancerous cells that have not even invaded their neighbors. Stage I is very local. Stage IV is distant metastases. Stage IIIB of ductal breast carcinoma means multiple lymph nodes, but not the ones above the collarbone, and no cancer in bone, brain, lungs or liver.

She had two years in remission.

The cancer recurred with a metastasis above the collarbone. The cancer had morphed as well, as it often does. Most, most, most of the cells were killed… but those that survived… were different. Now she was estrogen receptor negative, progesterone receptor negative and her2 negative. All genetic markers which help decide which treatment is best and how to target the cells. More and more are being found.

Our mother died of ovarian cancer. I went with her to her oncologist only once. My mother said that her CA 125 was rising, and of course she could do more treatment if she needed to. The doctor said something positive. I followed her out of the room. Once the door was shut I said, “My mother is talking about another clinical trial! She can’t do that, can she?”

“No,” said the oncologist, “Of course not. She is too advanced. But we will treat her for as long as she wants.”

Whether it works or not. Because she wants to be treated. In spite of diminishing returns.

My sister passed her five years from the day treatment ended. So technically she is in the five year survival group even though then she died. When she was diagnosed, the five year survival for her type of breast cancer and stage was about 5%. It had improved to 17% by 2011.

Her oncologist told her “I am referring you to hospice.” in the spring of 2012. She went to San Francisco to talk to another group about a clinical trial. But it was too far and too late. She refused hospice until about two weeks before she died. Fight to the end, she was willing to fight even when the oncologist said, “You are dying.” She had promised her daughter and promised her husband.

I saw her three times in the last two months before she died. She seemed angry to me on the last visit, glittering, knife edged. I tried to sing a lullaby, but she wanted something else. “Samuel Hall?” I guessed. She smiled and I sang it. My name is Samuel Hall and I hate you one and all. To the gallows I must go, with my friends all down below. Hope to see you all in hell, hope to hell you sizzle well, damn your eyes, damn your eyes. Then she trusted me to be present whether she was angry or sad or confused or once even happy, glowing, transported, transformed….

Some people do not go gentle. That is their right. It is their death, not ours, not mine.

The photograph is from the memorial here… My father had end stage emphysema, on steroids and oxygen, and I was hospitalized with strep sepsis the weekend of her first memorial in California. We could not go. Many people from our chorus Rainshadow Chorale came and we are singing the Mozart: Requiem Aeternum. My father died fourteen months later.

by

Unconditional 2

I think the hardest thing in the world is to love unconditionally. And we can’t love unconditionally unless we love ourselves in that too. Including our faults, our mistakes, our dark corners, our anger and grief, pettiness, unkindness, stupidity, jealousy, greed lust… if we only love our “good” side then we will attack others when they show the same weakness and faults that we know, deep inside, that we are capable of or have acted on. If we cannot love someone who is a sinner, we cannot love anyone, because we are all guilty. Love people anyhow and wholly and yourself too.

I went through a period after my mother died, where I felt I’d entirely failed. My marriage was disintegrating, and I was looking at myself very carefully. How had I gotten here? What mistakes had I made? I felt unlovable and stupid.

I found a letter from my mother written to herself when my father asked me to clean out her clothes. It was two or three years after she died. Here is the letter, with a few things left out for the privacy of the living:

____________________

Sept 18, Friday
1987
Seattle

I don’t want to go home. I want to stay here in Seattle. With the mountains that lift my heart. And clear air and only good memories. What is there to go home to? Struggling with X and his alcohol. I don’t want to try to do something about it. I don’t think it will work if I do. I think will only go on as it is and trying to get help will only lead to fight. I don’t think I have the strength, the courage or the wisdom to help myself or him.

What else am I going to? A house that needs a great deal of work that I only moderately like. A climate I loath. A landscape I find boring. I’m tired of living in a crowded suburb. And that house needs so much work.

People. What people do I go home to? Nearly all have problems. Y, wounded bird, so foolishly enamored of Z or thinks he is. And I have little sympathy or patience with it. And his propensity to failure which I’m tired of also.

A who I dearly love but her household is such chaos with those ill-behaved children and one crisis after another.

B who I like very much but really have so little in common with. I fear all that spiritual stuff may eventually bore me. Maybe not.

C. Another wounded bird, really. And not dependable.

D, barely around, anymore.

Mother, older and frailer. Who needs my care and patience.

E. There is one person to go home to. Thank God she’s there. Not wounded anymore. But so busy and it isn’t fair or wise to dump my troubles on her.

Who else? Why don’t I know any successful (in the best sense) sane people. People who are intellectuals, interested in ideas. F is. But not a fully successful human being and not when G is with him. Ugh. Besides he lives far away and he and X don’t like each other.

I don’t really want to have that show at H’s Church. I don’t like H very well. Oh dear.

I maybe have a job which if I get will be very hard work and if I don’t will be a great disappointment.

Winter’s coming and things cost more and we don’t have quite enough to live on. So that means digging into my inheritance.

I am sick of D.C. I am sick of being a struggling, unsuccessful artist. I am sick of worrying about X, about his moods, his acting the fool when half drunk and acting cruel and crazy when fully drunk. I’m sick of being afraid, of his depression, of his refusal to talk to me about anything of importance.

Of doing dishing. Of all the mess in our house. The mess on my desk, the mud room, the kitchen, the study, the basement. The dirty paint. The back yard. Oh God! How can I change things? Well there are a lot of bad things.

Oh, & I’m sick of being anxious, 10 lbs overweight, biting my nails, having bad teeth/gums. Life get tedjous, don’t it?

Any good stuff?

____________________________

For me, this letter was the key to finding myself lovable. My mother wrote to herself because she felt that she could not share these feelings with anyone. Terrible feelings. And I thought about it for a long time: I thought: my mother was charming, loved and an entertainer. But a child knows the parents’ hidden feelings. So I knew about my mother’s darkness and the letter confirmed it. And I thought, my mother didn’t need to hide that because I knew about it and I loved her anyhow. I love her more knowing that she was human too.

And if she is lovable whole, so am I. So are you. We all are. And we all make mistakes and are guilty of anger (sometimes appropriate but sometimes not!) jealousy, greed, lust, sloth and pride. Love people anyway and wholly and yourself too.

 

I have a view of Puget Sound if I stand in the road in front of my house. I took this with a zoom lens on solstice morning at sunrise.