Christmas parties in the first two years of medical school tend to be few and far between, or so it was in Jessie's experience. There just wasn't the time. The last week before the holidays was dedicated to exams and if you had time to party, you slept instead. It's tough and everyone knows it.
Actually being able to put on a dress or at least something other than scrubs and spend a social evening -- unless she was on-call -- with her "working family" was one of the perks Jessie loved about Maine Med. She'd gone through residency with several of her classmates and established friendships among the medical staff that she cherished. A rumor circulating about an attending position opening up once her fellowship was complete had been confirmed by the departmental director, and she was considered a shoe-in for the job. Christmas parties at Maine Med promised to be a feature in her life for years to come.
This year was going to be special for a lot of reasons, not the least of which was an occasion to formally announce her engagement to Bob. The truth is, there was scarcely a soul who didn't know already, thanks to the hospital grapevine. Good news travels like wildfire, especially when Halley Henry is the one with a match. Jessie and Bob spent the afternoon following his proposal with the twins and gave Halley the "Go" command she'd been waiting for. By the following Monday, neither one could walk the hospital hallways without running a gauntlet of congratulatory handshakes and hugs.
Fresh powder had fallen in the White Mountains off and on the week before the Saturday evening event, so Bob and Jessie drove up to Pleasant Mountain ski area near Fryeburg. Jessie skied while Bob spent the morning learning the ins and outs of snow boarding. After a few runs alone, she joined him on the beginner's slope.
"Why, if it isn't Shawn White!" she said, teasingly. "Can I have your autograph, pretty please?"
"Baby, you can have my autograph and anything else you want. I am footloose, fancy free, and all yours!"
She laughed and said, winking, "I can think of a lot of ways to take that."
"I'm sure you can, but this is the bunny slope and that means G rated. With the twins around, you better start getting used to that, Dr. and almost Mrs." he said, winking back.
"Only during the early evening hours -- after they're asleep, anything goes." she said, sidling close and raising her eyebrows.
"I think...I've created...a monster," he said, eyes wide.
"You have no idea. Now come on, you hot snow rider you, show me your stuff!"
Yogi Berra said it, this is like deja-vu all over again.
(Creative Commons image of Shawnee Peak by bobtravis via Flickr)
I hate moving. I used to think I was good at goodbyes, but you want to know the truth? I
suck at it. It doesn't matter whether there's a really good reason for riding into the sunset, I still find reasons for wanting to stick around long past closing time. Days I couldn't wait to resign my job in Colorado turned into days I loved it, even though I was leaving for medical school at last.
It's the same way now, even though I'm leaving to begin residency, also at long last. Only this time, I don't have to look for reasons, they're all around me. For instance, about ten minutes ago, the dogs and I were making our afternoon rounds along the edge of the hayfield when my big dog pulled up suddenly. I looked down and he was nose to nose with either a big woodchuck or an equally large beaver. They resemble one another and despite my friendly greeting, he didn't seem inclined to introduce himself, so we hurried on.
But things like that make it hard to move. Cool, quiet, starlit nights, immune to the sounds of the city. and breezes off the freshly mowed hay, later in June, are things I'll miss. Yes, I'll get to see the Detroit Zoo and perhaps hear the Detroit Symphony, but my roots are in the country and I'd gladly trade the zoo for the porcupine that lives under the barn or the woodchuck in the hayfield.
I know this is my "big chance," as they say in show business, and I'll
be glad to settle in and get to work. Time passes quickly, I learned in medical school. Residency will, too,
and sooner than I imagine, I'll be packing again, to come home. In the meantime, though, warm days
and woodchucks make me appreciate the life I've had, here on the farm, that
much more.
(Photo copyright 2014 by the author)
"Nite train!" he called, waving with one hand and holding his daddy's with the other, as they walked out the door. I'm guessing he was probably four years old and he'd been playing so quietly, it wasn't til he spoke that I realized what held his attention.
I was wandering through my favorite toy store, Tree Top Toys, in the Old Port. The Old Port is a gentrified section of downtown Portland that abuts the harbor (hence, the name) and could easily be mistaken for the backdrop for A Christmas Carol, especially during the Holidays. My attention was held by a Schilling display of wonderful classic tin toys that echo a time before batteries, when toys were wound up by keys and ran on pure imagination.
The store was crowded, though not so much you couldn't move, and he stood in a corner, near the entrance. His father watched from a few feet away, holding baby sister in his arms and ensuring both daughter and son were kept occupied, freeing mommy to play Santa. I noticed them at first just in passing, like I'd noticed other shoppers, picking up puzzles or stuffed bears, turning them over to look for prices or stroking their soft fur and turning into children as if on que. Some items go to the cash register right there and then, others wait for dreams of sugar plums and a jolly old man with a sleigh to find their way "home."
Like a fictional doctor of my acquaintance, a four foot tall stuffed giraffe resting high on a display rack with a smaller one planted between his hooves and a smaller one yet, between his, caught my eye. The clerk told me she'd recently sold one exactly like the tallest to a little girl who saw him last Christmas, fell in love, and saved her allowance the entire year to raise the purchase price. I brushed away tears at the thought of her carrying him home. Christmas brings out the magic of the heart in ways we rarely anticipate.
Working my way back to the entrance, I heard a small voice call, "Nite train!" and looked over to see him leave with his parents and wave as though the cars and engine understood. And maybe for him, riding the night train to Christmas, they did, indeed.
(Photo of horse-drawn carriage in the Old Port copyright 2013 by the author)
The snow started so timidly last night, I could count the flakes drifting cautiously past the shadow of my CRV, as though they felt self-conscious being seen. By midnight, their courage having grown in proportion to their numbers, enough had gathered for me to shovel an inch off the front patio; by morning, they reached, shamelessly, halfway to my knees.
Depending on your inseam, that can be a lot or a little. Mine's 36 inches, so this was a lot. The dogs, by the way, agreed with me. When we went out for morning bathroom break #1, my Yellow Lab took one step, then looked at me and intuited, "Where did all this come from?"
"From the sky, big guy," I responded, aloud.
Now, if I was a kid, an arguable point on days like this, I'd be torn between anticipation and lament. Anticipation because it snowed and that meant play, lament because it fell on Sunday and not Monday, guaranteeing a snow day. Overall, though, I'd be gladder than sadder since this much, this close to Christmas, ensures this year it will be white.
We didn't spend much time shoveling snow when I was younger, certainly not in comparison to what I did today. My father would clear off the back walk to enable my mother to reach her car, but otherwise, we'd trudge through the drifts to the barn to feed the horses. If we'd had a snow thrower, it would have been different, but as they hadn't been invented yet, it makes no difference. Besides, dad was raised on a ranch where knee-deep snow was common and no one thought twice about it.
I probably wouldn't think about it either, but for the fact that snow accumulates in Maine. At the foot of the Colorado Rockies, where I grew up, snow is like a relative, just passing through. Back here, the snow moves in and sets up housekeeping. I can count on the fingers of one hand the number of snow days I had in high school. Back here, it takes both hands and a few toes to keep track of them.
One thing is incredibly similar, though, between the snows of my older youth and those of the younger one I discovered as a medical student, and that is, any snowfall is a chance to play. My new snow brush -- the one I use on the car? -- has a movable head that lets me pull the snow off the car in sections, creating little avalanches as I move from the hatchback to the windscreen.
With snow flying in all directions and oblivious to the cold, it came to me: I cleared the cars the same way as a kid. All I had then was a straw broom, so my avalanches had to move away from me. The push broom from my father's shop was okay, but the brush was too soft to work very well. My new one is perfect and as it was then, creating avalanches is still, so very much fun.
Am I ever glad.
© 2013 All Rights Reserved (text and photo) by the author.
We were taking a late afternoon walk, my dogs and I, around the hayfield, trying to make the most of its company before snow buries it for another winter. We were three quarters the way around, counterclockwise, on the eastern side when I caught whiff of the familiar scent of Velvet pipe tobacco and the sound of a Maine accent I'd heard before, following it.
"So, how does it feel, bein' done and all? Ya ah a doctah, now, aintcha?"
He stepped out of the trees as he spoke, not an old man, but older than me, wearing a red and black buffalo plaid jacket, rubber boots, and a crumpled brown fedora. His took his pipe out of his mouth and gestured, "Nice dogs."
We'd met a couple of years ago when my yellow Lab and I got off the beaten path in the early twilight. He must have recognized the old man as well, because he made no move to growl. The black one, too, was uncharacteristically quiet and both sat, also uncharacteristically, as if on command. "Thanks," I said, "and yes I am, got my passing scores this week. I can't do much with it, though, since I'm not licensed, but that'll come. As to how it feels, I'm not sure. I can't quite figure it yet."
"Makes sense," he said, kneeling down to pat the dogs, who wagged the tips of their tails in response, back and forth across the leaf-strewn stubble. "Fer all ya put inta this, it has to feel kinda strange, kinda like maybe ya don't know how to feel. That's understandable."
He's got good therapeutic technique, I thought, showing empathy and paraphrasing what I say while being non-committal. "To tell the truth, I'm a bit afraid to feel. In the past, whenever I've gotten this close, something always came up to get in the way. It's hard to believe there's nothing 'out there' lying in wait for me. Though there is finding a residency. Still, it's a little anticlimactic."
He nodded, stood up, and looked away to the west. A cloudless winter sky passing into sunset was his view. He puffed on his pipe in silence a moment or two before he spoke again. "How could it not be? Ya been doin' this, med school, what, seven years now? It's been more yer life than an education." The way he said it, sounded like "edgikayshun."
"Yes, it has, with all the good and some of the bad associated with it. Not everyone I know expected me to finish. I never had any doubt, I just didn't know when. Oddly, it feels like something I want to keep to myself instead of shouting from the rooftops. Almost like it's too...too..."
"Too personal? Kinda like havin' a baby? Ya tell ever'one after it comes, but ya don't mention anythin' 'bout how ya made it in the first place. I think that's 'bout right. Shows respect fer what ya been through." He turned his pipe over, knocking ashes onto the ground, and refilled it.
"Listen," he said, "some things you gotta respect, things that make ya who ya'ah, what ya pay fer in ways you can't imagine when you staht out. You didn't know it would take seven years, you couldn't. Nobody could. What matters is, ya did it. Faced down all the demons and come further than ya evah thought ya could. Yuh've done what ya were s'posed to, what ya always been s'posed to. Time'll come fer shoutin' -- right now, just love it. Love it and respect it, cuz things like this don't come 'long ever day."
Before I could reply, he reached down and patted the dogs once again, "You take care uh this fella, ya heah?" They looked at me and wagged, leaves flying as though caught up by a breeze. "As fer you," he said, straightening up and looking me in the eye meaningfully, "Residency'll come too, don't worry, maybe where ya least expect it. Been good seein' ya." Then he nodded and walked back into the trees.
"You, too," I said, watching the angel in the hayfield vanish as he was swallowed up by the woods.
(Photo copyright 2013, by the author, all rights reserved)
Like most kids raised outside of New England, I suppose my earliest tour guide through Colonial America was Walt Disney. Televised reruns of classic films like Johnny Tremain (1957) and the animated Ben and Me (1953) coupled with my imagination to turn me into an idealistic young member of the Sons of Liberty or Benjamin Franklin's collegial churchmouse, depending on the moment. By the time college rolled round, I was a prime candidate for a major in history and when 1776 (1972) was released, I fell in love. With the movie, that is. There was a girl at the time, but that's another story and love wasn't destined to be the key player in our plot line.
Independence Hall is another matter. When Benjamin Gates was there, in National Treasure (2004), I was still in the throes of seeking medical school admission. It was the second of a three year process that ultimately led me to Maine and a farm on the banks of the Saco River in a town founded in 1772. But medical school is time consuming and Philadelphia miles away. It wasn't until this past week that the spin of fate's roulette wheel dropped me into place within a stone's throw of the building in which the Declaration of Independence was debated and signed.
As I wrote yesterday, I'd been in Philly for a day -- actually, two, one to settle in and get a decent night's rest, the second to repeat a medical board exam. I wasn't sure when I'd be finished, so I scheduled my flight home for late in the evening. Done at three, there was time to drive by Independence Hall, if nothing else. At least I could say I'd seen it. Well, you can guess the rest. Once I saw it, I had to find a parking space that wasn't reserved for carriages, and get as close as I could.
A skeleton crew of park rangers or police, I never quite figured out which they were, had everything cordoned off, but it was still possible to walk along South Fifth St. and place my hand on the outside wall of Philosophical Hall, that adjoins Independence Hall on the north. Philosophical Hall is where Benjamin Franklin founded the American Philosophical Society. Immediately across the street is the Library Building, the site of the first public library in America, also founded by Franklin, whose statue adorns the facade over the entry.
I wasn't prepared for how it would feel, seeing Independence Hall for the first time. It's different from Boston and Patriot's Day or Maine and First Parish Meeting House, where the Declaration of Independence was first read aloud in this part of the Colonies. After the battles of Lexington and Concord, the war moved south. One of my neighbors, or he would have been had I lived in 1775, Lieutenant Samuel Merrill (his restored farm is Jessie Livingstone's dream house in Pink Hats), fought at Bunker Hill. I'd have been there with him, if I could. But what I mean is, there is a comfortable quality, almost an ordinariness in the best sense of the word, about the Revolutionary period up here -- it seems less formal, cozier, more familiar. It's everywhere you look. It's like visiting an old friend.
Independence Hall is surrounded by downtown Philadelphia. It's an urban environment and it was back then, too. As urban as you could get in 1776 when street sweepers cleaned up horse manure rather than cans and candy wrappers. Once you get past that, there's a feeling that virtually seeps out of the cobblestones. It was as though I was part of something electric, exciting, on the brink. There's a tension in that historic square mile that hasn't dissipated one bit in three hundred years. Visit City Tavern and you're certain Jefferson and John Adams will be there, plotting Revolution over a pint. One sight leads to another and before you know it, you're reaching for your flintlock, itching for a fight.
I liked Philadelphia. It's a young city and a friendly one. The residents drive like bats from hell on the highways, but meet them anywhere else and they're pleasant and easy to engage. It's a city, nevertheless, and Portland is big enough for me. I loved Independence Hall and the Liberty Bell, but I love our homespun version up here even more. I'm sure Lt. Merrill must have felt similarly, when he left Boston behind for his farm on the banks of the Saco River.
(Photo copyright 2013 by the author. Additional images of Independence Hall may be seen here.)
Well, as of yesterday, surgery is over. I passed my exam, packed my bags, and said adios to the little two story house on the banks of Long Pond in central Maine, that has been home away from home since mid-October. Thursday marked my last shift on the surgical unit and it felt wistful, saying goodbye to people who've become coworkers as much as teachers these past six weeks.
Technically speaking, my instructors have been surgeons: general surgeons, urologists, obstetrician/gynecologists, orthopedists, and neurosurgeons. Quite a range when you consider the size and scope of the hospital. But the nurses and surgical techs were teachers, too, and good ones. And I ought not forget the anesthesiologists and nurse anesthetists. Together, they taught me how to behave as a member of a surgical team.
It has to be difficult, being regular staff and having a newbie walk through your doors eight times a year. Friday, one leaves and Monday, another shows up. Friday's guy has finally figured out how to find the bathroom without having to be shown and Monday's doesn't know what a bathroom is yet. It's not quite that bad, but you get the idea. There's a constant flow of change. Students are a "complete unknown," as Dylan put it, rolling stones gathering as much moss as they can before rolling on.
When I began this rotation, it was with the understanding that a community hospital wasn't exactly the best place to learn about surgery if I wished to become a surgeon. Opportunities for observing and participating were, of necessity, directed toward the ordinary or the mundane. I suppose that's true, but I gained a great deal in spite of the presumed limitations. One of my pastoral mentors reminded me, as I was leaving for seminary, "You can learn something from every preacher, so pay close attention." That advice holds true for rotations and this one was no different.
For instance, I learned how to intubate, i.e. insert a plastic tube into the mouth of an anesthetized patient, past the epiglottis, locate the vocal folds, and slide the tube between them, ensuring an adequate airway during surgery or at other times when a patient needs ventilatory support to breathe. I learned how to place a laryngeal mask airway tube when intubation wasn't necessary. And I learned how to start an IV line. All good tools to stow in my doctor's bag alongside the reflex hammer and stethoscope.
I learned how to take a leap of faith, not once but twice, by incising a patient's belly with a knife sharp enough to cut just by looking too closely at the blade. I also learned the cost of hesitation. Surgical time is billed to the tune of twenty-five bucks a minute. With a mere 60 seconds constituting each minute, one second wasted in unnecessary indecision is accompanied by the sound of 42 cents clinking down the drain. Standing alongside my patient I had 84 cents max to decide whether I had the guts for this kind of work or not. You wouldn't think faith could be thus quantified, would you?
I think my father would have enjoyed talking about this rotation. He knew some experiences have to be lived to understand, but he'd encourage me to try, anyway. Just the effort, sometimes, takes us places we'd never visit otherwise. Incising a half inch long swath into a belly that had held children cut deeply into my own fears. Of what, I'm not sure, but I came out of the surgical suite feeling braver than when I went in. e.e. cumings wrote, "It takes courage to grow up and turn out to be who you really are." While I make no claims to courage, I do think I managed to do some growing up the last few weeks and I have a lot of people to thank for it.
(Photo of Long Pond at sunset copyright 2o11 by the author. Like a Rolling Stone, words and music by Bob Dylan, copyright 1965)
When and where I grew up, a person rarely heard the sound of gunfire. In fact, I can only recall a single occasion when I heard it within the county limits. My father was boarding a horse for a friend of his who was an avid hunter. One afternoon, concerned his new horse might be gun-shy, he and my father led the horse into our pasture and the friend fired his pistol into the ground. His horse just stood there, apparently unimpressed, waiting to be released so he could return to grazing. Why shoot into the ground? Well, despite the fact that terrorists are always firing automatic weapons into the air on film, in reality that's not a wise practice because what goes up will inevitably come down, including bullets.
So, that was the only time. Hunters eager for deer or elk had to go up into the mountains to find them and those who sought ducks or pheasant, to eastern Colorado. The fact is, there were laws prohibiting the discharge of firearms near populated areas which, if you think about it, is a wise practice. Every year there are stories in the news about someone mistaking a partner, cow, or dog for deer or moose. How you get a moose from a dog, beats me, but maybe at distance Snoopy looks that big. Anyway, s/he hears a rustling of leaves, the snap of a twig, they turn and squinting through the trees, spy a shadowy figure. The thrill of pursuit coupled with the release of adrenaline takes over and you can guess the rest.
When I relocated from Maine's seacoast, I was informed, "Oh, now and then, you might hear a gunshot or two," since this is fairly open country and Maine law permits shooting on private land. To put it another way, were I so inclined (which I'm not), I could sit comfortably in my lawn chair on the front patio with my father's western-style .30 caliber carbine across my lap and wait for the deer who gobbles up my apples to wander into the crosshairs. Either that, or I could purchase a shotgun on the internet for next to nothing and sneak up on the flock of turkeys that also feed freely on my apples to provide next year's Holiday meals. It would all be perfectly legal and conveniently culturally-sanctioned.
Except for that darned, interfering Super-Ego (Freud's term for moral and personal conscience) of mine. I don't generally shoot at friends unless they really, really, really, piss me off and then I prefer to throw pies at them. I'm joking (even about the pies). Truly, I am. Please, pretty please with maple sugar on it, don't call the FBI ("Honest, Agents Sculley and Mulder, it was only a literary device, you know that from the lines the two of you have to memorize, right?"). Well, while we're not exactly what you'd call "friends" -- I haven't invited him in for coffee or tea with late season apples lately -- I do like seeing Bambi wander through the hayfield, munching freely at will. I also like the turkeys, porcupine, and the other wild critters who seem to think this is their farm and they permit my presence, not the other way around. Maybe I'm softheaded in a hardhearted world, but it seems only reasonable to live in consideration of those who were here long before me and, no doubt, will continue to be once I'm gone.
Now, fair is fair and I don't want anyone to think I have something against my neighbors or anyone else who hunts, because it's not like that at all. True, I'm still not fully accustomed to being awakened on weekend mornings by what I'm convinced is an M-16 going off within walking distance of my house. If it was 1772, when this community was founded, I'd take my trusty long rifle down from over the fireplace and like any other responsible farmer, parson, or whomever with a family, head for the woods imitating Hawkeye from Last of the Mohicans. But this is 2011 and, like I say, I'd rather not shoot at friends or a reasonable facsimile thereof. As things stand, I'll wear orange as a precaution while cutting firewood or walking the dogs, that's not a problem. It's nearing January, it will all be over soon.
(Creative Commons image and Bambi and Thumper by Jaded Jeremy via Flikr)
St. Francis of Assisi knew gratitude was good for us long before this month's Harvard Mental Health Letter added its two cents, but isn't that the way it usually goes? Evidence follows intuition. Well, according to my friends at Harvard, gratitude helps make us resilient. In fact, it's one of many things that have that effect. For instance, working at something you love rather than working less, having a sense of life purpose, giving for no other reason than because you can, forming and maintaining meaningful relationships, and possessing the confidence to steer your own course, also render a person more resilient in the face of whatever life throws at us along the way.
Resilience doesn't mean resistant, it means durable. Resistance can carry the connotation of immunity to injury. Resilience and durability are fluid concepts that describe those who endure what Hamlet called, "the slings and arrows of outrageous fortune," and come through scathed and scarred, perhaps, but not embittered. Resistant, to me, is a wall; resilient is a membrane, tough and tender, alive, open to experience.
Thinking about gratitude and the resilience it engenders, on this Thanksgiving eve, I'm grateful for a young woman who became the first live human in whose body I've inserted a scalpel to make an incision. She was unconscious at the time, "thanks" to the wonders of anesthesia, but I was sufficiently aware for both of us and so grateful for the privilege she'd granted, I was close to tears when the final sutures were in place. It felt as though I was incising something from my own life (a topic for another post) as much as something from hers.
I feel grateful for my entering medical school class, a group of people, all of them younger than me by months to years, in whose company and because of whose support, I've somehow managed to come this far. They play hard, work harder, each having sojourned in at least one of Dante's Twelve Circles of Hell, and survived with hope and heart intact. It's a privilege to be numbered among them.
I'm grateful for the snow that began falling overnight, the plow that woke me at 4.06 AM and the hunger that followed in its wake, dragging me from the warmth of bed to face the chill of my upstairs room. I'm glad I raked the leaves crowding close to the kitchen door and straying carelessly onto the driveway last night, so that shoveling snow this morning was easier. It was dark in central Maine, dark and cold, and the drive to my hospital slickly hazardous. I'm grateful my CRV takes little note of the weather, embracing ice and snow as a challenge, instead of a threat.
I'm even grateful for the fuse that blew in the kitchen this morning. Power outages in the forecast, I made coffee last night and put it in the fridge -- cold coffee being better than none. Warming it in the microwave was too much too early, it seems, so I had to take flashlight in hand and brave the depths of the cellar I've considered the ghastly realm of goblins, spooks, and creatures unspeakable. It was nothing of the sort, but gazing into the black basement of our creakily ancient temporary housing, my imagination ran rampant. Yoo hoo, Stephen King, are you down there?
Some things only a fool or a madman would be grateful for, but it's the trivial we most often overlook. Those insignificant moments of inconvenience over a blown fuse teach us how to draw upon gratitude when we need it the most. Those moments that remind us that faith, hope, and love can be found anytime, anywhere, and not merely the one day of the year we remember to give thanks. Whoever said, it's the little things that count, wasn't kidding.
Happy Thanksgiving!
(Creative Commons image of St. Francis of Assisi via Wikipedia)
I was four years old when my love affair with fire trucks began. At the time, it was a pumper with a hook and ladder truck and an ambulance that caught my eye just before Christmas. I still have them, battered and scarred with parts missing from good times. I wish I'd taken better care of them since they're worth many times more than what my parents paid on the collector's market. Not that I'd sell them, because, well, you know, they're a part of my childhood. For everything else there's MasterCard. You can't buy memories -- not like these, anyway.
On that Christmas morning, though, I was in for a bit of a disappointment. The only sets left on the shelf were ones without the ambulance and I really wanted the ambulance most of all. How else can you rescue the people, I thought? Someone has to take them to the hospital because they've been hurt in the "fire." It was a childhood fantasy I later fulfilled as an adult when, in my first pastorate, I volunteered as an ambulance driver. Little did I know, either then or as a four year old, I'd end up a medical student seeing patients in a hospital. The most amazing things creep up on you when you're least expecting them.
Kind of like another little boy's dream, the one you see in the photo. It's a 1936 Chevrolet I saw a few nights ago, parked in front of the Knights of Columbus in Old Town, Maine. Of course, I had to stop and take pictures. How could I not? My guide for the best tour I could have asked for, was a tow-headed little guy about seven or eight years old who happily indulged me by climbing into the back to ring the bell. He was able do that, you see, because his daddy, as he proudly informed me, owned it.
Old Town has a special connection for me which I discovered the same evening, when I noticed a sign on its outskirts identifying it as the home of Old Town Canoes. We paddled Old Towns when I was a Scoutmaster on white water canoeing trips in Southeastern Oklahoma. And there I was, driving through the place where they were made. I don't know, it just struck me as sweet, and it brought back very pleasant memories of sunburns, campfires, and friends far away.
Anyhow, back to the fire truck. Walking around it I noticed a plaque that told me everything I needed to know about the person who owned it and why. If you look closely you can see it, right there on the passenger side. It reads simply, A Little Boy's Dream. Yeah, you guessed it. Daddy wanted a fire truck when he was was young and promised himself one day, when he was all grown up, he'd have one for his very own. And now he does and he shares it with his son.
Who shared it with me.
(Photo copyright 2011 by the author)
Well, spring certainly came late to the farm this year. The past few weeks have been chilly, wet, and dreary -- more reminiscent, I imagine, of the northeastern coast of Wales, whence my ancestors came, than coastal Maine. The upside of all this has been my yard no longer looks like August in Colorado, brown and bone dry. The downside is, mowing the grass yesterday was more like harvesting the autumn hay crop.
I'm not complaining, though, nor am I disgruntled because spring decided to take the slow train from wherever. I've wrestled enough with my own "tardiness demons" to be empathetic when the clock runs behind for someone else. Rather than giving spring a good spanking for dragging its heels, I'm welcoming it with open arms. The Prodigal Son has come home at last.
Besides the rain, this means there was a blanket of fog draped over the hayfield when I crawled out of bed this morning, awakened rudely by the sound of water, a steady stream tinkling from my puppy's bladder onto the towels in his crate. Oops. That's what towels are for, right? And it was only his first night and I'd probably pee, too, if it was me, or have to or want to. Something I think he'd like to do again, as a matter of fact, so pardon us while we step away from the computer for a minute and go outside.
False alarm -- he's gone back to sleep, a momentary reprieve. Crate training is a grand experiment. I tried it with my big dog and he did well with house-breaking. Since the little guy has been in a shelter, I thought a crate would make him feel more at home and give him a place all his own. Thus far, it seems to be working; he's slept through most of this post. I can only hope readers don't take the hint and follow his example.
Getting back to spring and grass-growing, it's possible you're wondering why I waited so long to begin mowing, aside from the fact that it's rained almost daily. Well, there was my rotation for one thing. Twelve hours a day at the hospital doesn't leave much time for yard work and that includes repairing the flat tire on my lawn tractor. When I finally had a day free, I discovered it was virtually impossible, with the tools I had, to get the rim off the tractor.
I was, as my late father would say, stuck. I couldn't drive the tractor to the garage because it had a flat and couldn't trailer it because I don't have a trailer. So, I did what any self-respecting future physician should do, namely, phone a colleague and ask for assistance. And that's what I did. I rang up my mechanic, a down-to-earth, easy-going type who is fond of referring to himself as the Car Doc, at least when he's repairing my car, and asked if he'd make a house call. I figured it had to come with the territory.
Now here's what I love about rural Mainers. Not only did the "doctor" take me seriously, though he's probably never had a case quite like this, he actually sent help. A friend of his came over and together we manhandled the tire and rim free. He followed up by insisting on taking it for repair and refused to take a dime in payment. I've never met the man before but he treated me like his next door neighbor.
Driving home -- turns out, the tire was fine, by the way, just a little low in oxygen saturation -- I reflected on what had happened. I've got a graduate degree, nearly two more, and the fellow I'd just met graduated, maybe, from high school. Yet, the measure of his kindness exceeded that which I've experienced from persons who are far more socially adept as well as academically accomplished. He was simply an ordinary guy who enjoyed doing something good for someone else and today was my day to be that person. If spring hadn't been late, if my tractor tire hadn't gone flat, if I hadn't been working so much, think what I would have missed.
(Creative Commons image via Wikipedia) 
"I think Beggar sort of 'adopted me' after his mother passed away," my late aunt said. It was a warmish autumn Sunday afternoon and my female cousins composed her audience. I was in the living room and they were in the kitchen, where my family has always congregated whenever they're together. Only when you can't move without bumping a glass and baptizing it's owner, do we slowly sift, one or two at a time, out the door onto the patio. But not for long. The vacant kitchen is a vacuum, sucking us back inside, unaware we're like pieces of driftwood, floating out to sea, drifting up the shore, riding the tides onto a Maine beach, floating out again.
When I overheard her, I smiled, thinking she was the one who'd adopted me after my father, her younger brother, passed away. Maybe it went both ways, each of us trying to fill an empty space no one else could. Marion the Librarian, my uncle, her youngest brother, christened her because she literally was the librarian for a small, northwestern Colorado town. Though not it's founder, she was certainly it's builder, and it grew steadily, like children, as long as she held her post.
My aunt was a large woman. I don't mean obese, just big. Tall. Buxom. A woman born to be mother who was a good one to one and all. She loved how I lived near Maine's "stern and rocky coast," (The Last Gasp of Summer) though she never saw it for herself. When I think of her, I can't help but see her tall, dark-haired, matronly frame with a gingham apron knotted at the waist. I remember visiting the library once, when I was younger, and being startled when she walked out of her office without that apron. Most days, she tied it on in the morning the same way some women put on makeup -- she didn't quite feel dressed without it.
The truth is, my father's passing was hard on her. To him, she was "Sis," and she missed hearing it. His last years, spent fighting off the disease that could only lay claim to him in his final second at the very end, they spoke regularly by phone. I was never privy to those calls but the way she described them, they were the kind we have when we're acutely aware time is short, and we dare not waste the briefest of breaths speaking words expressing nothing. The kind we have when we fear we'll never have another and what we say will have to last us for eternity. The kind we have when we don't want to leave anything unsaid and regret what we do.
I did try to step into my father's shoes, to the extent I could, since at last we lived close and a visit was so easy you'd be embarrassed to call it a drive down the road. We were both glued to the tube on 9/11 when I began punching in her number. You remember how it was, how you reached for the phone, ringing up mom or dad to tell them you loved them because it was the moment drawn close when tomorrow may not come. You didn't know for sure and couldn't take the risk. She was wearing mom's shoes then and was a comfort I still feel.
As you can tell, I'm thinking about Mother's Day and have been all week, how it was for the women I've known and how different it will be for the women I've intimately met in the birthing room. I saw them the very instant each became "mom." The same instant some lucky slug of a guy became dad. Until this weekend, the first-timers, at least, experienced the day as a daughter, wishing their mothers happiness. Now, I imagine those mothers calling their daughter-mothers, offering them the same wish. It's really quite something.
Happy Mother's Day.
(Creative Commons image by JoshBerglund19 via Flickr)
The things that unite us are greater than those that divide us, as President Barack Obama is fond of saying. The trouble is, I sometimes have a problem believing it. People seem prone to allow everything from the petty to the profane to come between them in the name of ideological purity. But that's one of the qualities I most admire about him, he believes the best even when I'm in doubt.
For instance, take the guy in a pickup truck a couple of days ago -- there were two guys in two trucks, actually, one and then the other. Both got my attention by surprise. You see, all day I'd been encouraging patients to control their cholesterol levels by losing weight, altering their food choices, and getting regular exercise. Sure, there are medications we can prescribe for high cholesterol, but those are mostly for levels that can't be readily controlled by other means. The idea is to get busy doing the things that eliminate the need for medications later on.
On my way home, thinking about a nap, I realized I ought to be practicing what I'd been preaching, so I drove down a nice, quiet country lane, pulled off to the side, set the emergency flashers, and headed off on foot. It was chilly but I had my gloves and jacket and figured I'd work up a sweat soon enough. I'd barely gotten a couple of blocks when I was startled by a horn honking and turned around to see Pickup Truck Driver #1 slowing down and lowering his passenger side window.
"Do you need a ride? Is that your truck back there?" he asked, gesturing with a thumb hooked in the direction of my CRV.
"No, I'm just walking for exercise, but thanks for stopping to ask," I replied. He gave me a curious look, as though he wasn't sure he'd heard me correctly, or if he had, was it time to call the police and have me delivered to the local looney bin. I smiled and did my best to look like a sane, harmless tree hugger who didn't know any better than to walk when I could have easily driven. It apparently worked, because he shook his head and drove off, waving pleasantly. It really was considerate of him to stop, you know? I couldn't help feeling appreciative for small town Mainers.
About two minutes later, another truck stopped and its driver, a white-haired fellow in his 60s with a great smile, asked if the vehicle he'd seen on the side of the road back yonder was mine (sound familiar?). I said yes, and he also offered me a ride. There I was, a complete stranger, and in less time than it takes for the average commercial break on television, I'm offered assistance by two guys, neither of whom apparently gave it a second thought that I might be Jack the Ripper in Polartec. Stephen King, on the other hand, would have a field day.
What is remarkable about all of this is the fact that I've got an Obama campaign sticker displayed on my rear bumper and the second guy stopped anyway. What's remarkable about that? Well, as he drove away, I saw a sticker on his rear window that read, "Don't blame me, I voted for the American." I guess Barack was right, after all. On this country road, at least, ideology be damned. What matters isn't the flavor of your politics, but being willing to help if someone needs it.
(Photo of a dairy farm near Skowhegan, ME copyright 2011 by the author)
I'm home again after another amazing week in rural Maine. I gave my first tetanus shot yesterday and identified, if not actually diagnosed, my first case of outpatient pneumonia. The latter was a biggie for me since we didn't have a chest x-ray to rely on; instead, it was a matter of taking a careful history and listening to our patient's breathing, then asking what was the most likely explanation for their presentation. As I've mentioned previously, I can't get over how much more akin to internal medicine this rotation is turning out to be.
In part, this is due to the fact that my preceptor's patient population is, by and large, an older one, so the colds, flu, measles, and chickenpox that show up in family medicine don't walk through his door too often. It also stems from his comfort level, dealing with difficult and challenging cases. He won't admit it -- something I admire about him -- but he's a careful and astute diagnostician. He takes his time with patients and encourages me to do likewise and make certain I offer well-reasoned and thorough explanations for what we're doing and why.
More than accurate explanations, he wants to make sure we provide ones that are comprehensible. This appeals to me strongly because it's the same principle my friend Dr. Lynn Smith and I followed when writing our book. We wanted to communicate effectively, not impress readers with the extent of our vocabulary, something that often characterizes academic writing. "It's not what you say or do," my preceptor reminds me over and again, "it's what people think you said," that matters. For this reason, you want to make certain what they think is the closest approximation of what you actually said, as possible.
So, for example, when urging a patient to take a complete course of antibiotics and not stop once they begin feeling better, he'll say, "It's like wolves who attack the weak and sickly in a herd of deer and then go after the strong." An antibiotic kills off the weaker members of a bacterial population in the initial few days of taking it, but you've got to finish the prescription in order to get the ones that remain after you've started to improve. Makes a lot of sense, doesn't it?
I'm three weeks down in what's usually a four week rotation but I've been offered the chance to extend it by another two, and that's what I'm doing. I'm learning too much and having too much fun in the process to turn down the opportunity. Of one thing I'm certain, when I graduate, whatever kind of physician I'll become, it will be strongly colored by the weeks I've spent with this guy and his gal Friday in north central Maine. Am I ever the lucky one.
(Creative Commons image of the Kennebec River Valley by jimmywayne via Flickr)
Before settling in to write, I'd like to offer a word of thanks to everyone who's come by to read this week. I'm up to my neck in family medicine and by the time I get back to my temporary digs for the evening, my brain is swimming with diagnoses, treatment options, and reading assignments I've got to complete. Despite all my good intentions, writing has had to take a back seat the past few days, whether I like it or not.
Aside from that, however, the week has gone incredibly well and once again, I've seen conditions that one rarely sees, if ever. For instance, I've gotten to chat with a patient who has Whipple's Disease, an extremely rare condition that has been diagnosed only about five hundred times since its discovery. Most students never have an opportunity like this and I'm extremely grateful for the chance to have heard what it's like from one who's clearly suffered a great deal with it.
Patients are truly the best instructors and today, one of them was a five year old with hair as red as Ron Weasley's. His mother came in for an exam and while she was ensconced with my preceptor, "Junior" and I went out into the waiting room and looked at story books and talked about great adventures. When it came time for his wellness check, I was his pediatrician. It was my first time at bat doing a physical on a child and he was wonderful. I couldn't have ordered a better instructor if I'd had a list to choose from.
And then, there was an opportunity to do some osteopathic manipulative medicine on a patient complaining of back pain. Face-on, he was standing a bit crookedly; when turned around, his spine imitated the "S" on Superman's jumpsuit. His story was typical for this time of year. He was shoveling snow, leaned down, twisted, and yikes! It was his sacroiliac, as osteopathic students are probably guessing, and I was once again glad for a month of OMM practice and review before coming to northern Maine.
Anyway, now you know what I've been doing when I'm not writing, and hopefully, I'll make up for it fairly diligently this weekend. In the meantime, thanks once again.
Image via WikipediaWant to know what the hardest thing is about family medicine -- for me, that is? Explaining to family doctors why I want to be something else. And doing so in a way that doesn't hurt anyone's feelings or give the impression I'm not interested in medicine. Trust me, this is no mean task, especially when doing a family or internal medicine rotation. You see, as a student, I want to get the best education I can. But this tends to create confusion because, somewhere along the line, psychiatry has gotten the reputation of being the discipline for those who don't have the hots for medicine. Making it tricky for those of us who do.
Like most generalizations, this one doesn't hold true in every case. Still, it holds true in enough of them that it becomes necessary for the rest of us to try to overcome the stereotype. But here's the rub: if I act motivated to learn physical medicine, it calls my commitment to psychiatry into question. If I act like all I'm interested in is psychiatry, then I may not be taken as seriously as the student who identifies with Marcus Welby, Ben Casey, Doug Ross, or Alex Karey, MD or DO, depending on which generation of television doctors you follow. Damned if I do and damned if I don't.
To be fair, I'm sure it must be the same for students whose stated intention of becoming "doctors" is complicated by an interest in patients' psychiatric conditions. Both/and isn't the easiest thing to cope with on the best of days. Now, it's entirely possible that those appear medically-ambivalent might actually be happier with advanced degrees in psychology. I don't know, I'm just saying. You can definitely count on medicine involving you with patients in ways you don't have to think about as a psychologist.
Take this past Thursday, for example. The only other time I've performed a male (why do we call it that? I mean, is there any other kind?) prostate exam was in lab one evening a little over a year ago. On the same occasion, I did my first female breast and uterine exam, both with actor-patients to whom and for whom I will be eternally grateful. As you may know first-hand, exams like these are a very intimate, for doctors and patients alike. And they're things a psychologist doesn't ever do.
It's true, psychiatrists don't routinely do prostate exams or pap smears, but that's not the point. They receive this kind of training because they're in training to become doctors and therefore, approach the brain-mind-behavior interface from the standpoint of one who practices medicine, not psychology. As an aside, this is one of my objections to allowing psychologists to prescribe psychoactive medications, but that's for another day. Call me narrow-minded, but I don't think one can be a competent psychiatrist without being a competent physician for the very reason that psychiatry is the medical discipline whose task is to tread the no-man's land between mind and body.
St. Augustine, Bishop of Hippo (not of hippopotamuses, though I certainly have no objection to the idea -- ever attend a blessing of the animals on the Feast of St. Francis of Assisi?) in Northern Africa during the fourth century, prayed, "God, deliver me from the need to justify myself." I guess I'm not there, yet, but God knows my heart and I think my preceptor in rural Maine does as well, because he surely gives my desire to learn physical medicine the same attention he does my interest in psychiatry. It's just a matter of coping with the stereotype in subsequent rotations and I guess that involves being gently and respectfully honest and letting the chips fall where they may. It's nice to know Augustine struggled, too. I feel like I'm in good company.
(Fair use of a copyrighted image of George Clooney as Dr. Doug Ross from "ER" claimed for the purpose of identifying the character in question with no commercial intent and in the absence of a similar, free image)
I thought there would be lots of colds, flu, and diarrhea in my rural medicine rotation, remember? Ordinary, boring pathology that mom could treat as well, if not better, than the doctor. This week, I've seen shingles (a burning, painful rash that sometimes hits on those who've had chickenpox), polycystyic kidney disease, a transient amnesia that I thought represented a transient ischemic attack and may still prove to be, and a boatload of psychiatric issues couched (no pun intended) in the guise of daily life. To my friends in family medicine, I can only say, you were right and I was wrong -- family med is anything but boring.
It's easy to create the impression that "rural" automatically means "country," especially when referring to communities like the one I've been describing. Well, it does and it doesn't. My preceptor practices in a small town of about 1200 persons but his patients come from miles beyond the town limits. It is country, no doubt about it. But rural really means under-served more than anything else. For instance, in a community that numbers, including outlying farms and communities, a population closer to 12000, the yellow pages lists one psychiatrist.
True, patients could drive to Augusta or Bangor or even Waterville, but that's hardly a realistic expectation when gas is $3.19 a gallon and the average family limo is a four-wheel drive truck that drinks gas faster than you can put it in the tank. Even if they have insurance, considering the limits placed on psychiatric care by most policies as well as sky-high deductibles, having insurance doesn't simplify the problem of paying for ongoing care.
That's what "rural" really means. Limited access as well as limited services to begin with. It's almost easier for a dairy farmer to make a living in these more remote areas than it is for a mental health clinician. For that reason, because doctors also have to put food on the table and payment can be uncertain, it's difficult for a community to keep a psychiatrist in practice even when they find a willing victim.
So, what do you do? You either keep your depression, anxiety, tormenting internal voices, or suicidal thinking to yourself until they get out of control or you go see the family doc who takes care of your high blood pressure. But, lest this sound like a good deal, it's not really. Family doctors function by necessity as default psychiatrists, but their training has its limits, as does the psychiatrist's. It has to be that way because no one can possibly learn everything. Not even doctors.
One solution involves dual-tract medical education: family or internal medicine slash psychiatry. If you're fortunate enough to match in one of these highly competitive residency programs, you're ahead of the game because at least you can count on physical medicine to help subsidize the psychiatric care you deliver. But Maine doesn't have a dual residency program and students tend to practice near their training site and that leaves us, once again, out in the cold.
It's a dilemma that needs serious attention. And we've got to do something because the needs of patients in outlying areas for psychiatric care are overwhelming and as things stand, there just aren't enough of "us" to go around.
(Photo of a park in the snow in Skowhegan, Maine copyright 2011 by the author)
I wish the sun had been shining when I took the photo accompanying this post, because things aren't nearly as bleak as they look, but this is north central Maine, it is winter, and the sun doesn't shine all the time. That doesn't seem to make a great deal of difference to the residents of this little community on the Kennebec River. Five miles away lies Skowhegan, where student housing is located in a private home. Skowhegan leads the state in maple syrup production. Fun facts about New England to know and tell.
The storm paralyzing the mid-West at this moment, gets a matter of fact greeting this far north. The closest we'll come to recognizing the weather is to show up for work tomorrow in boots and jeans instead of slacks. And forget about wearing a tie. People who aren't born here, move here because they want to live as far away from anywhere a tie might be considered normal attire.
Five miles separate the comfortable basement where I sit writing and the first floor doctor's office in the yellow Victorian above (photo). "Welcome to Grady," I said to myself yesterday morning as I walked into the waiting room. Grady is the fictional location for the film Doc Hollywood -- this was the first of many Michael J. Fox moments I think I'm going to have over the course of the next four weeks.
I mentioned Sunday I hoped eventually to have the chance to see patients, relatively speaking, on my own. Eventually came twice yesterday and was repeated as many times today. It may have been a while since I've done a physical exam, but apparently I haven't forgotten nearly as much as I feared. And nearly every day, I'm grateful for Dr. Francis and the PASS Program, as my patients reiterate something he taught and real life imitates.
A rotation like this is a gift. Seriously. How often do you get to drop into someone else's life? But that's essentially what I've done with my preceptor. This is his town and I'm a visitor. He lives here and I'm passing through. That he, his nurse, and their patients treat me as though I'm anything but just another student is pretty darned amazing, because they sure don't have to. And yet, that's exactly what they do.
(Photo copyright 2011 by the author)
So, tomorrow begins my rural community health rotation, which basically means private family practice in a rural area. I've always thought that was a bit of an inside joke since the entire state of Maine is classified as rural, but I'm probably splitting hairs. From the standpoint of population, my last rotation was actually more rural, since tomorrow's is only six miles from a town of eight thousand. I'm probably splitting hairs, again. I think the idea is to get me somewhere off the beaten path.
You might be wondering why I'm doing a rotation like this in the first place. The most obvious reason is because, well, I have to. While rural medicine is an elective at other medical schools, mine requires it. We train mostly primary care physicians and the average patient, if we decide to practice in Maine, will likely resemble those we see on this rotation. It's also a way of getting students out of their comfort zone, though for me, rural life is like biscuits and gravy. I was raised in the country and practically learned "down home" before English.
As to what I'm expecting, it's going to be family practice. Lots of colds, flu, and diarrhea. There may be opportunities to learn how to suture cut fingers and I suspect, like most family docs, my guy is also the local shrink. That will be fun. I'm hoping for a chance to get my physical exam skills back up to speed and use the OMM skills I've been practicing the past month. And I hope my preceptor eventually feels comfortable enough to allow me to work up a few patients on my own.
For most students, rural medicine seems to come along later in the rotation cycle, so they've had a chance to learn a few things before showing up at "Doc Hollywood's" front door. Because I had to retake boards, my cycle is slightly different, so rural medicine is my opportunity to get into shape before diving into the hospital madhouse routine. I'm not sure one way is better than the other, it's simply the way things are. I'm just glad to have boards behind me and be seeing patients for a change.
From the perspective of my dog and cat, this will be a lot easier than the PASS Program. Last fall, as you may recall, I was in Champaign, Illinois for eight weeks and the three of us chewed up the phone lines every night. This time, I'll be out of town four days out of seven, but it's only a two hour drive away, and I'll be home on the weekends. We'll go for walks, watch movies, have morning snuggles with the cat on my lap, and bake cookies before I head back on Sundays. Pretty much life as usual. Considering subsequent rotations may send me further afield and for longer periods, this will be a good transition for them. And for me.
Anyway, there will be more to come and we shall all see how it goes. Oh, and yes, I'll take photos.
(Creative Commons image of the Kennebec River by qnr via Flickr)
Well, the snow has stopped for now, but the wind continues to howl, imitating the sound of a passenger jet flying low overhead. Or the sound of traffic on the highway from the patio of my apartment in Champaign this past fall. It's funny how one thing triggers the memory of another. Oh, it's started again -- snowing. We had a couple of inches before Christmas, enough to qualify for a white one, and I have an idea Maine has seen the last of the soil until spring.
This is the kind of snow I loved and hated as a kid. Loved because my gloves didn't soak through while playing, hated because it was too dry to pack. No snowballs or snowmen will be forthcoming from this one. The wet snows were my father's bane. First, my gloves would get wet, so I'd come inside and tell my mother. She'd produce another pair, usually my dad's, and I'd go back out and play until those were too wet and cold to wear. Once again inside and "Mom!" Another pair of my father's, and you guessed it, he'd come home later to find all of his, side by side with mine, dripping in front of the radiator. This did not make him happy.
"Son, I needed gloves so that I could do some work in the barn and feed the horses."
"But I needed them to play." I felt badly -- really, I did. While I was playing, though, it was hard to see further than the next snowball.
"Mm. Well, do me a favor, next time leave me at least one pair, okay?"
"Okay." The lessons of my youth.
I think about those days when it snows because, as soon as it stops snowing, I'll go out and start digging my way from the door to the driveway, and then from the barn door to the street. My polartech gloves will be the first to dampen, then my old wind-proof gloves I got at REI in Boulder, and finally, if it comes down to it, my leather work gloves.
Thankfully, if all else fails, I still have a pair of my father's in a drawer. I guess I could always resort to those. Psst. Don't tell him, okay?
(Creative Commons image by Grant MacDonald via Flickr)
