Sol Duc and I made it home on Thursday, 325 more miles, arriving happily to the house in Grand Junction. I got ready to take her for a walk later and stepped outside: snow! We went over 7 passes driving from Port Townsend to Grand Junction and some smaller peaks that did not have the altitude marked, but didn’t get snow. On the last night a big storm was rolling in from the south east in Colorado and from the west in Utah. I thought, whew, I may just make it.
We did and I took the photograph yesterday morning before driving to work. Just a sprinkling, more as I got to Palisade, but not on the roads. It warmed up and melted through the day.
People have told me that Grand Junction does not get that much snow. That may be relative, that it might not be much compared to Denver, but a lot more than Port Townsend. I have no clue! We will see.
Sol Duc and I went for our walk together yesterday. This is a yard across the street, with the grass all pressed down where someone slept recently. Local deer or Sasquatch?
Meanwhile, I think the nearer we get to the election, the more bizarre I find our culture. I don’t suppose Make America Great Again has anything to do with modeling courtesy, kindness, setting a good example, lifting others up. It’s more like the drama of a “reality” show, where all the boring bits of life are edited out and it’s all drama and people getting frustrated with each other and confrontation. And speaking of discourtesies, the other party sent me a text and email, “Earth to Katherine”, wanting more money. I am offended, deleted and blocked that one. What IS this? Are we so addicted to action movies, “reality” shows, drama, violence and video games that our politics imitates them? When will people grow up?
I hardly watch movies or television series any more because honestly, no one on any of them is any more mature than Elmer Fudd. At least Bugs Bunny is funny. And the things “based on a true story”. Right, let’s add some more dramatic moments and more conflict.
The Ragtag Daily Prompt today is identity. Yesterday I went to work an hour early so I could attend the Friday morning Continuing Medical Education. It was about adult ADHD and the positives and negatives.
I do not have a diagnosis of ADHD. I have one friend who insists that I have it, but I don’t much care. However, the speaker started talking about masks and authenticity. She said that we are told to be authentic at work, but that people with ADHD often find that their authentic self is not welcomed and they learn to mask.
I asked, doesn’t everyone mask somewhat at work? She said, “Good point, and yes, people do.” It got me thinking about identity and masks. I pretty much clammed up in Kindergarten because I was too much of an outlier and culturally wrong. We did not have a television and television was pretty much what the other children talked about. I knew songs and poems but these did not interest my peers. I was interested in science, too, but that was also not popular. I think I was a geek before it was named and as soon as I learned to read, I became a bookworm. I am not sure if having a television would have made any difference, either.
Fast forward to after high school. I went to Denmark as an exchange student my senior year and then needed to make up credits to graduate. Another high school student was in my Community College classes. After a bit, she said, “I thought you were shy in high school.” I said, “No, I just didn’t talk.”
Currently I am more authentic in the room with patients than with the rest of the staff. Corporations are very weird hierarchical places. My authentic self always questions authority but I am trying not to do it all the time. At least, not out loud. The patients seem to be fine with it. I had a very difficult conversation with an elderly couple this week about memory and planning, now, before they can’t. I got hugs at the end of the visit even though we’d gone into frightening and difficult territory. They did very well. Yesterday was my last day at that clinic and next week I am in another one. Even after just four months in this clinic, I will miss many of the patients and hope they do well.
Yesterday I really did Urgent Care. My schedule only had a few people and then six more sick ones were added on. We had to call an ambulance for one, the first time I’ve had to do that here.
What is authenticity and what is our identity? Is the work mask less real than the self in our minds?
I took the photograph at a small hot springs resort. A friend that I’ve known since high school and I met there. I love the bookworm rabbit. I think she represents the happy bookworm part of me. I read about 7 novels a month, haunting the library here. Maybe I will get to know some more people over the next 6 months.
I ran my own small clinic from 2010 to 2022, working somewhere else, got Covid, was on oxygen for a year and a half, did some healing and then came back to work.
There has been a culture change in medicine that feels very strange to me. I did not notice it because I was in a solo clinic and not “part of the system”.
All the doctors, providers, are more isolated. I got a compliment yesterday when I was doing a “warm hand off” of the most sick or complicated patients, three new diabetics, a person with cancer, a person with a genetic heart problem. The doctor who I was handing off to is in the same clinic but we have barely talked since May. I don’t know her at all. She complimented me on excellent care “and calling specialists”.
I thought, huh. But I think that is a dinosaur doctor thing. I think mostly people communicate through the electronic medical record email, send messages about patients. For the decade that I was solo, I had to call other specialists because I was on a different electronic medical record. The email didn’t connect. The hospital reluctantly gave me a “link” to their system, but it was only a link to look. I could not write or send anything.
About two months ago I got an echocardiogram result. I read it and thought, ok, it’s not normal but what does it mean? Outflow obstruction by the thickened heart wall. Hmm. I called cardiology and spoke to the cardiologist who read it. He sounded surprised and said, “Idiopathic hypertrophic cardiomyopathy, most likely. It’s a classic echo.” “So, what do I do?” “Send him to me.” “Anything that I should change meanwhile?” “Yes,” says the cardiologist. He had me stop one medicine and start another. “No vasodilators and the beta blocker slowing the heart rate should help decrease the outflow obstruction.” “Got it.” I said. He also gave me two more tests to order.
I referred the patient to cardiology but it was a month before he got in. The two tests were done and they ordered more. If the diagnosis is correct, he’ll be sent to a special clinic in Denver. I called my patient while we were waiting for the cardiology visit. The medicine change had not made much difference as far as he could tell.
I was also told when I got here that I would never get a local nephrologist to see a patient, they were two busy. However, I have called two nephrologists about two patients and both took the patient and again, gave me instructions.
Two specialties have been very difficult to contact: orthopedics and gastroenterology. I have no idea why they are so difficult.
I can see that email feels faster. But there is no human contact, asking follow up questions is difficult, I don’t get that bit of further helpful education: this is what you do next. I have learned so much over the years by touching base with specialists. Once I fussed at a patient to go to hematology oncology about their high platelet count. The patient didn’t want to. He came back and said, “Apparently I have this newly found genetic problem. They put me on two medicines, not expensive. And I feel better than I have in 20 years.” I asked the oncologist about it the next time I called. He lit up, excited, and told me about the JAK-2 mutation. It is so exciting to learn about new areas in medicine and my patient says, “I have to thank you for pushing me to see the oncologist. I feel so much better.” Wow and cool.
Clinic feels like I am mostly isolated, a silo, an island, rarely talk to the other physicians unless I go to find them. I think hospital administrations like this, keeping the physicians in line by having their schedule be so packed that they almost never talk to each other. What a good way to keep physicians from interfering in the money making production! Ugh, I think it is quite horrible and unhealthy for the providers and for our countries medical system in the long run. I was seriously less lonely in a solo clinic.
The prognosis for our current medical system is very poor. The patients say to me, “Why do my doctors keep leaving?” They aren’t attached, they are isolated, I don’t think the physicians know what they are missing. Colleagues. Not silos.
Honey is older, nearly thirty years since that first feeling of being bitten by ants. She is back in corporate medicine, as a temp. Temporary, short term, maybe that will work better.
It is a joy to go in a room and be alone with a person and their monsters. Theirs and hers. Sometimes the younger ones haven’t experienced it, they are terrified if one of their monsters becomes a little bit visible, they hate seeing them. Honey tries to be gentle. If they only want to talk about the sore shoulder and not the stress and violence, well, she leaves the door open a crack. Sometimes the monsters cry.
Older people may be stiff to start with, but when they realize their monsters are seen, acknowledged, this isn’t another robot doctor in to say increase your diabetes medicine, lower your diabetes medicine, tell them a plan without ever connecting, the older ones lean back, sigh, and relax. The monsters play on the floor, Honey’s monsters playing with theirs, happy, engaged.
The hard part is the clinic staff. Honey is with them daily. The medical assistants are young. They kick their monsters aside as they walk down the hall. It is terribly hard and heartbreaking to work at her desk, with the medical assistants’ monsters cowering under their desks, kicked, abused, silent tears and holding bruises. Honey’s monsters mind. They climb into her lap and hide their faces in her shirt, under her jacket, peer over her shoulder. They don’t understand! Why can’t she be nice to THESE monsters?
Honey whispers to her monsters when the medical assistants are rooming patients. “I am so sorry, loves. If I acknowledge these, the monsters of the women working, I become a demon. It is very hard to share an office, no wonder I worked in a clinic alone for eleven years.” Honey has been through that. It is still inconceivable that some people don’t see the monsters at all. Is it learned blindness? Or just not developed unless someone had to learn it? Unless someone grows up in terror and seeing the monsters is the only way to survive.
Honey thinks some people learn to see them as adults, at least their own monsters. Hard enough to do that, without seeing the monsters clinging to other people.
Honey is tired of her monsters crying in sympathy with the staff’s monsters. She thinks maybe there are small crumbs that she can leave for these demons. Little gifts. Her monsters can creep under the desk when she is the only one in the room and leave something. A flower. A dust bunny. A crumb of a crisp. A small rock. A little gift to let them know they are seen and loved. A poem. A prayer. Just a tiny bit of love.
It did not even occur to me that yesterday’s dream could be taken as complaints about patients! That was not my meaning!
I wrote the dream out because I wanted to know what it was trying to tell me. And I look at it from the perspective of all the people in the dream being aspects of myself.
So who is the whiny guy (me) who won’t cooperate with authority (me) and who wants attention and is difficult? That’s not a very nice aspect of myself!
First of all, he reminds me of my father. My father really did not like authority and did not like most men. When I was quite small, I announced that he would have to die first, because he couldn’t live without my mother, but she could live without him. I was wrong as well as being an awkward child. My father’s dislike of authority interfered with his employment and he was mostly underemployed. He finished a Master’s in Mathematics, but never wrote the thesis for his PhD. I asked him why once and he said, “I was bored.” I don’t know how much alcohol interfered with his working.
I am not brilliant with authority either, though I am trying. I notice systems and often annoy authority by asking why something is run a certain (foolish and unproductive) way. I used to study whatever system I was in and then say, “Here, I’ve thought up a solution for this problem.” Then I would get in trouble for suggesting that there was a problem and I would be the problem. I learned to go to authority first and ask, “So is this (huge problem) a problem? I find it difficult. What is your advice?” Priming the pump, so to speak.
As a temp, the authority problem is weirder. I am an outsider, short term, no one really has to be nice to me. That fast trip home and back made me realize that I am lonelier in a group clinic than I was in a solo clinic. In my solo clinic there was me, my receptionist and the patients. In this group clinic I have less people to talk to and it is lonely. My problem, not theirs. They are about to move me to another clinic and I will see what approach I can take to this. The system might have a Balint Group or I may be able to start one.
What about the frozen looking spouse? Ha, I think that’s the part of me that is trying to keep my mouth shut with authority. The kids? Some days I want to pull the system apart and fix it, but I am not in authority to do that here. The grumpy nurse? I am running behind and I can’t fix everyone. Some people don’t want to be fixed, including me.
I could go home and try another place. However, I think that the cracks in the US medical system are in the whole system. As a country, we built this. I hope that I see single payer healthcare in my lifetime, but I may not. And Martha is right too: I thought that this place was doing better handling a chronic illness than where I worked in 2021, but they aren’t, really. They apply a formula, but the patients don’t get much out of it. They just get shuffled in once every three months. I did upset that apple cart by spending more time with those people and talking to them, but I do not know what the next physician will do. Sigh. The patients are already my patients and are saying goodbye.
Facing a wall or lying in bed
breathe slow: four seconds in
one two three four
four seconds out
one two three four
keeping count
or facing a wall sitting
on a zafu, bell rings to start
how can forty minutes be so long?
fall asleep and body weaves
waking me up OH don’t hit the wall
adrenaline then slithering down
towards sleep again
zen mind, blank mind?
my mind wanders off again and again
what is for dinner? grocery list?
that annoying thing or person
at school or work
the mind busy as a squirrel
burying nuts and digging them back up
bring the mind back again
again again again
to the breath the wall letting go
of this well trodden mind trail
only to have the mind wander off
down another: this with briars
and falling into a pond
that has ice and cold
back shake like a dog
shake it off
focus on the breath the wall again
vivid multicolor cats
with paisley and stripes and spots
there is the BELL
forty minutes
Bow to the wall
and stretch
get up
ready zafu for the next time
meditation
mind
they are neglected, you know, by most
the worse self, the worst self, the dark
the impulse to yank the moon from the sky
when she slides down the stair, to see who’s there
there are few poems written to the dark impulses, the demons, the underside of our hopes and dreams, the nastiness, the grief, the anger we are kept in the dungeons below the basement
below the belt we band together huddle
in a pile of claws and unfeathered wings and teeth
wishing for a blanket, to be held, rocked
loved, wishing for the mothers who left us
the fathers who denied us, pushed us away
so that we knew and know what to hide
what to deny, what part of ourselves to kill
we try and try but few do
and then they are mourned, people say
they don’t understand but ask the demons below
and oh, they do, they do! maybe the next plane
will be kinder and love the demons
the bitter self, the dark self,
that longs so badly to be loved
that longs forever to be loved
that is not loved this round
I call a friend yesterday and sing, “Happy Day Before Your Birthday to You”. It sounds silly. She has just gotten Covid and this cheers her up.
She is telling me about her summer and about a class at a camp. Some for adults and some for children, but one where people really dropped their masks and just got to be themselves.
What identity is your deepest self? She is talking about her nine year old self. I think mine is more like four and rebellious and skeptical of adults, adulthood and all of their rules. I don’t think I am ever out of touch with this identity, though I don’t let it talk out loud in clinic. Mostly. A rebellious four year old informed by medical school and years of experience is a pretty frightening thought, isn’t it? Or the basis for a great cartoon.
That part of me is very observant and quite smart. It does not care what we are supposed to see or the cues people give. Growing up in an alcohol household, it looks for what people do not say. This can be terribly helpful in clinic and also a bit weird. It is body language and tone of voice and what questions a person shies away from answering and the puzzle pieces that do not fit.
Last week I see a small child with her parents for vomiting and coughing and fever. I am interviewing the child and asking if things hurt. “Do your ears hurt?” I ask. She shakes her head no. I point to my throat next and she nods. Yes, that part hurts. Her toes do not. I include toes or something silly to find out if the child is saying yes to all of it. I tell the parents that we will do a strep test, that mostly people don’t cough with strep except when they do. The strep is positive. My medical assistant grumbles, “They didn’t tell me that,” but I think the parents were more worried about the vomiting and she may not have complained about her throat.
Are the masks we wear always bad? I don’t think so. I think it is frustrating if we believe our mask or never ever get to drop it. There is some formality to my role in clinic and I tend to get more formal when I am worried about someone. That has been interpreted as anger or brusqueness, but it isn’t. I am wearing a real mask with all patients because we are seeing at least one person with Covid every week. The literal mask does not help me connect with people, but sometimes I can anyhow. I have to take it off for the 90 year olds because most of them are hard of hearing and lip reading helps.
Sometimes clinic feels a bit like Sisyphus must feel. Rolling the stone of illness up the hill but it is eternally rolling back down. I can’t stop it. People age and people die and otherwise there would be no room for young ones.
The last two weeks of clinic has worn me out a bit. A friend says that I take too much of it home, worrying about people. How to let go of this?
I make connections in clinic. Not all the time. Sometimes I fail. I made a connection with more than one person with diabetes this week, but one was funny. The connection is that he mentioned that he is an elk hunter. Oh, and flies to California to fish and has a very lot of fish. I said that I’ve had elk and like it. That was when the connection engaged: he was very pleased that I am not horrified by hunting. Hunting elk is not at all easy or cheap and cleaning the animal and carrying it out, well. He is coming back about his diabetes and left cheerful.
If I go home trailing those connections and spend my time worrying about this people, I’ll wear out. I don’t want pneumonia number five. So how do I connect but let it go when I go home?
I will think of the connection as much smaller than the boulder that Sisyphus deals will. Not a boulder. A small piece of the rock. I can suggest how the person can lighten the load a little. Then I must stand aside and let them go. They have to decide what to do about their health. It is between them and the Beloved, they can try what I say or not.
Now it is not a boulder that I am trying to keep from rolling down a mountain. Each person has their own mountain to climb in their life, their own habits and histories, good or bad, trailing them like Marley’s Ghost in A Christmas Carol. I can suggest a tool to loosen a link of diabetes, or a slightly different trail up the mountain. Then it is up to them. I can’t carry them and should not carry them. Maybe they are approaching a patch of scree and I can suggest an easier or safer path. And then stand aside, stand down, let the people go.
Now I am not pushing a huge rock. I am standing on my own mountain, quiet, and looking at the path behind. I am resting a little and on my own path. I don’t know what will be around the next bend in the path. But I love the mountain and the forests and the birds and the ocean. All of it.
Discover and re-discover Mexicoβs cuisine, culture and history through the recipes, backyard stories and other interesting findings of an expatriate in Canada
Engaging in some lyrical athletics whilst painting pictures with words and pounding the pavement. I run; blog; write poetry; chase after my kids & drink coffee.
Refugees welcome - FlΓΌchtlinge willkommen I am teaching German to refugees. Ich unterrichte geflΓΌchtete Menschen in der deutschen Sprache. I am writing this blog in English and German because my friends speak English and German. Ich schreibe auf Deutsch und Englisch, weil meine Freunde Deutsch und Englisch sprechen.
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