Baking Bread

 
Anyone who bakes their own bread probably knows this and I'm a late comer, but King Arthur Flour has an awesome web site with some pretty incredible recipes. In particular, I'd like to offer praise for their Vermont whole wheat, oatmeal, and honey bread. If you follow the proportions, you get two one-pound loaves that beat Sara Lee by about a buck a loaf and the grocer's bakery by two. Not only that, it tastes better (sorry, Sara, nothing personal) and you've got total control over the calories, fat, and salt.

Now, KA says to use maple sugar but I've substituted 1/4 cup of maple syrup and it comes out fine. Maple sugar's expensive and relatively hard to come by, so substitution is the order of the day. They also call for cinnamon, which is a nice addition. but I held off this week and used only maple syrup plus 1/2 teaspoon of Frontier Natural Products maple extract and it came out wonderfully sweet and tasty. I'd love to try a maple essence but thus far all I've been able to find is orange, but add that to chocolate chip cookies and you'll die happy.

I can also give five stars to their Classic Apple Crisp recipe, having made that this past week, as well. With both big apple trees going postal, I've had to be a little more creative than the usual apples and peanut butter.  

This isn't an especially literary piece; I just thought I'd pass along my good fortune for anyone else who loves the aroma of home-baked bread in the kitchen. 


(Creative commons image of King Arthur Flour types by gabster_ro via Flickr)

Like Apples off the Tree

 
I was reading an older post this morning, in which I mentioned hearing the sound of apples falling onto the garage roof from the Black Oxford tree that stands next to it. They've been doing it again lately, dropping like fist-sized bombs and sending my youngest dog running for the window to see what or who's threatening his territory. He's a sensitive little guy, though little is not the best word to use, I suppose. He's almost the height of the big dog, a 90 pound yellow Lab, but half his weight and twice his nerve. I won't say he's fearless, but he does his best to act like it. 

I have four apple trees growing on this parcel of heaven, fifteen or so miles west of the Maine coast. All of them are ancient varieties, the offspring of seeds brought to the Colonies by European immigrants, as are most native Maine apples. You can go to commercial orchards and pick ancients as well as the familiar red and golden delicious and Macintosh. How these four came to be planted here, I have no idea, but I'd wager the largest, the Black Oxford, has been around at least a hundred years, from the diameter of its trunk.

The next largest is a Moses Wood, named for a Winthrop, Maine, farmer who was an early grafter of the tree, and the others are either Summer Sweet or Winter Sweet -- I don't know for sure what they are, to tell the truth -- and produce yellowish-green fruit that are better for cooking than eating from the tree. The Oxfords are a winter apple and really need a frost to bring out the flavor. The Moses Wood, if I've identified it correctly, that is, has had a difficult few years, but it bounced back this month as though trying to make up for lost time. It's been so prolific, I've had to give bags of tangy-sweet apples to my neighbors before they went bad. The apples, not my neighbors.

The little yellow trees are full this year, too, but the fruit are so small that by the time they're pealed, there's little left but the core. They're better for throwing, anyway, or so I imagine a younger version of myself thinking and then doing, trying to see how far he could launch them down the long grassy slope that leads to the hayfield. Much to the delight of the deer that have been feeding there in the evenings.

My tenant, Freddy the Porcupine, who lives under the barn. has taken to munching apples in front of the garage at night. Most mornings I'll find the evidence of his nocturnal snacking inches from the door -- a half-chewed apple -- as though he feels he should leave it for me to finish. I guess it's his way of paying rent. Two years ago, when he moved in, he had the habit of snoozing in the flowerbeds, snuggled up against the house in the afternoon sun. I saw him the other night and he's no more afraid of me now than he was then.

I've been like the little apple trees, it seems, for a long time. Ideas a plenty but none juicy enough to write about. Now, I feel more like the Moses Wood, if not prolific, at least more productive. Pink Hats has been on my mind and like Freddy's apple, "someone" needs to finish it off. Reading over the chapters, a couple of things have caught my attention. We've never really gotten a glimpse of Jessie's inner process, how she got to the place in her life where marrying Bob and becoming an adoptive mother straight off was doable. I've been working on that as well as a post about the conversation between Bob and her father in Untarnished and in Uncharted Territory. I hope, like apples off the tree, they're worth sitting down and biting into. In the meantime, have a wonderful Labor Day weekend.


(Creative Commons image of ancient apple trees by gemteck1 via Flickr)

Behind the Scenes with Dr. Neal Cross

Like many medical schools, fairly early in the first term mine presents a memorial service for families whose loved ones donated their bodies as cadavers for Gross Anatomy. While I've referenced our service in another blog post, I've never revealed how I came to be one of the student speakers for the service celebrated by my entering class, the UNE Class of 2010. 

It came about in the late evening chill of September 17, 2006. September usually acts like summer in my native Colorado, unless it gets a wild hair and decides to imitate winter with an early season snowfall, as it did in 1997, dropping 30 inches overnight. Here in Maine, there's no denying September is autumn, especially in the evening and especially near the coast. My school is within walking distance of the Atlantic Ocean and even though days are comfortably warm, when the sun goes down so goes the temperature. 

For our service, the new class is positioned on the east side of the staging area. They're really present as witnesses, but because they constitute a wall protecting the celebrants and families from intrusion, I like to think of them as Guardians of Reverence. The previous year's class, the one for whom this service is most meaningful. is seated with the family members and faculty. An honor guard, led by a piper, opens the ceremony. Clad in dark blue Yankee uniforms from the Civil War and bearing Old Glory and the state flag of Maine, they are a sight to see.

Why the Civil War and not modern uniforms? This is New England and history is honored here. Our service and the internment of ashes takes place on the rim of a cemetery on campus that dates from the 1600s. Old slate gravestones mark the names of those whose sons and daughters gathered at First Parish Meeting House that used to stand on this very spot (it has since been relocated a mile away) and listened as the Declaration of Indepedance was read aloud in 1776. I stopped once on my way home, and at the invitation of a groundskeeper, stepped inside. It is plain and simple, with white wooden pews covered with black velvet seat pillows. Along the back walls are photos of veterans dating from 1861; the smells of must and dust and time are as vivid as the afternoon sunlight that streams through old, single pane windows. In the silence, you can't help but hear, "We hold these truths to be self-evident..."

Following an introduction by the Anatomy faculty, two or three students take the podium to speak on behalf of their classmates and try to put into words what it's meant to work so intimately with the bodies of persons we've never met. There are words of thanks and appreciation that we hope become words of comfort to family members who've waited a year to see their loved ones laid to rest, here, at the end of the world.

After the service is over, people mingle and chat, the first years leave early because Gross Anatomy for them is far from over and it seems there's always an exam pending. I wandered over to Dr. Neal Cross, our professor and the director of the anatomy program, and we talked about this and that. I was struggling in anatomy, despite having done well as a premed, and he and I had discussed my situation in detail. The truth is, I was afraid my first term in medical school would be my last. Somewhere in the mix, Dr. Cross said to me, "You should be a speaker next year." 

I responded, "You really think I'll still be here?" I resisted adding, "Are you nuts?"

"You'll be here," he said, nodding, "though I may not be. In either case, I'll make sure you're on the list of student speakers." He asked me to keep it to myself, which I did, but he was contemplating accepting another faculty position elsewhere and mine proved to be his last year teaching in Maine.

I went home with a small, dim but real, glimmer of hope that helped get me through the rest of the term, despite the fact that I'd have to repeat anatomy the following summer. Dr. Cross was right. I made it to next year and the years following, all the way to graduation. I don't know what he saw in me or what he knew. I didn't ask and he didn't say. Some things, I guess, are best left where they lay, behind the scenes. 

This past weekend, Dr. Neal Cross passed away, far too young and far too soon. I'm told a motorcycle accident was partly to blame. Though we never had any contact after he moved on, I've never forgotten the faith he gave me that night and I never will.

Thanks, Neal.  


 (Photo of Dr. Neal Cross courtesy of the University of New England, all rights reserved)

Osteopathic Psychiatry, the Forest, and the Trees

You remember the 1998 film, The Horse Whisperer, don't you? Robert Redford riding the range of Montana. Kristin Scott Thomas the intense New York magazine editor. Her daughter, Scarlett Johansson, reeling in the aftermath of an accident involving her, her horse, and an 18 wheeler. Music by Thomas Newman, recalling redemption at Shawshank Prison, sets the tone (no one scores redemption like Newman).

Kristen Scott wants Redford to fix her daughter's horse. It's pretty simple, she says, do whatever it is you do, take my money, and I'll be on my way. I'm busy, my life is full, I don't have time for distractions. He's an animal, not a person, fix him, like my car. You live on a ranch, you fix things, fix this.

But Redford can't and neither can anyone else. Not with a snap of the fingers, anyway. Some things take time, he replies, and your horse is one of them. You should also know, I don't treat symptoms in isolation. Your daughter will be involved and very likely, so will you, before all is said and done. The forest is as important as the tree.

Osteopathic Psychiatry is like that, or it ought to be. 

When I published Osteopathic Psychiatry: Time to Smell the Roses, I had no idea it would become as popular as it has, suggesting other people are as interested in the subject as I am. Curiously, that particular post was inspired by a problem I had researching osteopathic psychiatry. Apart from chapters in the seminal osteopathic textbooks and scattered journal articles, there wasn't much out there. Google "psychiatry" and you'll be busy reading til the next millennium. But a body of literature, devoted specifically to the theory and practice of osteopathic psychiatry, eluded me. I was reminded how unexplored territories are labeled on old maps. No roads or rivers, just the phrase, "Beware, there be dragons here."

Sometimes I wonder if this "empty book shelf syndrome" stems from uncertainty about whether there is such a thing as a peculiarly "osteopathic" psychiatry? What if psychiatry is nothing more than a purely allopathic endeavor that osteopathic physicians practice in imitation of their M.D. colleagues? If that were truly the case, we could stop right here. End of discussion. 

On the other hand, what if the diagnosis and treatment of mental distress and disease, its biophysical underpinnings, and behavioral expression, is a sub-field of medicine, independent of theoretical orientation or professional degree? I believe this is precisely how we should think about psychiatry, much as we do with the other forms of practice that make up the fabric of medicine as a whole. 

Now we're in the position to ask, is there any justification for an osteopathic approach to psychiatry? Are there identifying marks rendering it unique? Suggesting clinical activity is "osteopathic by association," i.e. osteopathic by virtue of being practiced by a DO, doesn't work as well as it sounds. That's too much like saying a wedding ceremony is Baptist (or Jewish or anything else) because a Baptist minister performed it. You can take my word for it, I've performed enough weddings to know, the minister's denominational affiliation means very little. The character of the rite itself must reflect the tradition the minister represents. 

Taking a clue from DOs who practice physical medicine, one of at least two key elements in the "rites" of osteopathic psychiatry should be the insistence upon a person-centered framework for diagnosis and treatment. In my experience, MD physicians almost universally describe DOs as whole-person oriented in contrast to their own problem-based focus. Put simply, and perhaps too simply, MDs are trained to evaluate the tree; DOs to evaluate the tree and the forest as a single entity. Superior is not how I'd describe the difference; complimentary is far more accurate. Our medical house is big enough for each of us to have our own room and share the common spaces without feeling cramped.

A second key element, which could actually turn out to be the defining feature of osteopathic psychiatry, is the way it attends to the mind-body interface. We're physicians, not psychologists. We learn how to perform physical examinations, treat physical illness, and use Osteopathic Manipulative Medicine (OMM) in patient care. Whether we do these in the clinical setting or not, the training and experience are still there. At the core of osteopathic medical training is the explicit understanding there is no artificial distinction -- no disunity -- between mind and body. If the triad of mind-brain-behavior represents the tree, the body, at bare minimum, represents the forest. Mind-body integration lies at the heart of everything we do. How this will work out in terms of philosophy and psychiatric practice guidelines is the direction I think we're moving.
 
The way we're accustomed to thinking about medical practice is changing rapidly. Integrative care, involving psychiatrists who function as consultants within primary care settings, may become increasingly common. A new generation of osteopathic psychiatrists has begun applying OMM to alleviate the somatic dysfunction accompanying, compounding, or in some cases, even leading to symptoms associated with psychiatric illness. DO and MD psychiatrists alike may find themselves monitoring medical conditions their instructors customarily referred to the Internist. Our generation of psychiatrists -- particularly osteopathic psychiatrists -- may eventually be known as the one that took the stethoscope out of the desk drawer and placed it back round our necks, where it belongs.

(Creative commons image by takomabibelot via Flikr)

Medical School Without a Doubt

"Regrets, Eric, that you're not down there with them?"

"Yeah...no doubts, though."

These words pass between coach Sandy McGrath and runner Eric Liddell in the film Chariots of Fire (1981).  Sitting in the stands, they're watching the 1924 Olympics event in which Liddel refused to participate because it was held on Sunday. 

As you may recall, Liddell was firm in his religious convictions, including keeping Sunday as the Lord's day. Adherence to his beliefs brought him into conflict with the Olympic Committee whose members found it incredible anyone would place God above King and Country. Seeing his teammates run without him, he wishes he was among them -- even with strong convictions, he's still human -- but it's a wish unaccompanied by doubt. In his final race, a competitor says of him, "He has something to prove. Something personal. Something guys like (our) coach would never understand in a million years."

Probably the second most common question I get about attending medical school at my age relates to whether I have any regrets about my decision. "Now that you're here, has medical school lived up to your expectations? Would you do it again, knowing what you know now? Is the pursuit and presumed attainment of a dream everything it's cracked up to be?"

Truthfully, it depends on the dreamer. For me, it certainly has been, and continues to be, as fulfilling as I hoped it would be, and in ways I couldn't have imagined what seems like a lifetime ago. In part, this is because I haven't been aiming at achieving a distant goal nearly as much as I've been engaged in a daily process of achievement. 

Life is a terminal illness for everyone and waiting to live is folly. Sure, like the rest of my classmates, I can hardly wait for the day I get my first paycheck as an attending physician, but delaying enjoyment of what I'm doing until then is like carrying a dream around in a bucket that has a hole in it. You wake up one morning to find your dream has dribbled away when you weren't looking.

This is why I try to take every day as another chance to work at being a doctor, even one in training, though may I forget, as we all do. Distracted by a mistake or worried about my performance, I stumble over my own frailty, and then a nurse asks me what she should do next or a patient smiles after we've discussed her upcoming procedure and I remember. Doctor is who we are on the inside, long before our names are punctuated by the initials D.O. or M.D. on our white coats.

Would I do it over again, knowing what I know now? I've probably answered that one already, but let's just say a person can arrive at the point where living authentically is more important than playing it safe. You bet I'd do it again, though, with the virtue of hindsight, there are a few things I'd do differently along the way. For instance, I'd make the acquaintance of Francis Ihejirika, MD, much sooner. Francis is the founder of the PASS Program in Champaign, Ill., and even more than successfully preparing me for board exams, he taught me how to think as a medical clinician. Eight weeks of being challenged, encouraged, patted on the back and kicked in the pants were life changing. "Thank you" is scarcely enough.

I'd also be less afraid, if that's possible and maybe it isn't when you're trying to swim against fifty-foot waves that drown the biggest ships as though they were the tiniest toys. But that's what medical school can seem like. We start out feeling vulnerable -- much like we do in those crazy dreams where we're naked and everyone else isn't. You've had those, too, huh? Funny how I never manage to have Daniel Craig's physique (Casino Royale, 2006), despite what Freud said about dreams representing wish fulfillment. Anyway, we end up finding out the individuals we thought were the smartest, the most gifted, and presumably, the most invulnerable, have have been battered by the waves, too. 

Medical school is a huge undertaking; it's the hugest thing most of us have ever attempted. I can't stress this enough. Honesty forbids me from coloring this truth in anything but black and white. Nothing I know of can adequately prepare a person for the volume of material they're going to face, the hurricane force at which it strikes, or the feelings of aloneness that surface in the wee hours before exams. It's something you have to experience to know. But looking back, I can see how I've grown in the confidence surviving brings and without a doubt, I'm braver because of it.

(Creative Commons image of Eric Liddell via Wikipedia)

Medical School at My Age

 
A week ago, a few days before graduation, I was asked the question I hear more frequently than any other: "Why did you choose to attend medical school at this time in your life?" My questioner went on to say he’d graduated in the late 1970s and couldn't imagine doing it "at my age." 

You'd think after six years I'd have gotten enough practice that answering questions like his wouldn't require much reflection. To a certain extent, that's true, except over time my understanding of why I undertook this process has grown, and along with it, the way I respond to questions related to age. 

Now, to be fair, some of it does have to do with how I read the the other person. What do they really want to know and how much time have they got? Is it polite cocktail party curiosity or are they contemplating a course correction in their own career? In this case, the question was posed by an attending anesthesiologist I'd just met and we scarcely had any time at all, so I talked briefly about pursuing a dream. As I walked to my car a bit later, it occurred to me how impossible it is to imagine myself not  being a medical student at this point in my life and how very little age has had anything to do with it.

Admittedly, that isn't entirely true. Before I undertook medical school, I argued vociferously against it, considering age my most salient point. I wanted to become a doctor and, particularly a psychiatrist. I always had, but the circumstances of life took me in other directions and it seemed ridiculous to suppose anyone would take me seriously now. Obviously, I eventually lost that argument and what I've realized over time is I never had a chance of winning in the first place. Something was afoot in my life that neither reason nor common sense nor anything else had the power to effectively counter, as I hope the following story reveals.

It was a Sunday night and my shift as a substance abuse therapist at a Boston hospital was 30 minutes away from being history when I was paged to the nursing station to handle an admission. My patient was an older, intoxicated gentleman, accompanied by his adult son. They were pleasant, intelligent, lived out on the Cape (Cod), and despite grumbling to myself about having a new admission so close to sign-out, I immediately took a liking to them both. A few moments later, while meeting with the father to sign his paperwork, he said to me, "Doctor, I want to tell you how all of this began..."  I ought to have told him I was only his therapist, but hearing the title, "doctor," honestly it felt so good, I just couldn't. 

I told myself I'd explain the next day and I did. I wasn't trying to mislead him, but it felt like unfaithfulness to something I didn't quite understand, to correct him. You might say he was under the influence and simply mistook me for his physician because I was an older male. I say in vino veritas. Unknowingly, and probably unconsciously, he saw into a deep and private place and called me by the name nobody, not my parents, my friends, or anyone else, had ever spoken. For the first time in my life it seemed as though someone knew who I was. How could I deny that?

Back then I wasn't so much thinking as feeling. Drawing near the end of this leg of the journey, I've done a great deal of thinking and I've begun to realize how very much it's been like growing into a father's shoes. When we're young, we slip into them and they're huge, so huge we can't walk without stepping out of them. One day, they've grown smaller and then smaller still until they fit us as well as dad. Why attend medical school at my age? I guess you could say, that's when the shoes finally fit.

In another life, to borrow from Katy Perry, whom I love, I might have gone to medical school "on time." The tricky thing about other lives is they don't come into being unless we find a way to make them. I didn't have the keys to a Delorean (Back to the Future) in my pocket, so reversing the time-space continuum wasn't an option. All I could do was be like the proverbial turtle, who never gets anywhere unless he sticks his neck out. Yes, I was older and by definition, that meant attending medical school as an older, rather than younger, adult. Age was a piece of my puzzle. But it was only a single piece and nowhere near my biggest one. Had I been born someone else, it might have been gender, race, or national origin. We all have something we can't change.  

George Eliot (pen name of Mary Anne Evans), author of Silas Marner, said, "It's never too late to be who you might have been," to which I'd add, until it's too late for everything but that final breath.  What has become clearer and clearer to me is how much medical school and now, residency, have come to mean immeasurably more than simply fulfilling a long cherished dream. They mean being true to what I've learned about myself as this process has unfolded and there really are very few things quite as important. They mean acting on the freedom to make choices of my own rather than making up excuses for denying them and then, trying to live with the consequences. They also mean, considering everything that lies behind and whatever lies ahead of me, there isn't anything to make me regret coming this way.


(Photo copyright 2013 by the author)

Newtown, Connecticut: The Streets of Heaven

"The streets of heaven are too crowded with angels tonight..." ~ President Josiah Bartlet, The West Wing

Following a tragedy such as took place yesterday in Newtown, Connecticut, one often hears the statement, "Let's not politicize this." But failing to recognize its political implications is as irresponsible as attempting to use them for political gain. Remaining silent on the pretense of respect, renders the needless, senseless deaths of children meaningless. Can there be anything worse?

In the latter days of the war in Iraq, when it had become clear there were no weapons of mass destruction, when the Bush administration determined a "war of liberation" would play better in the media, families of soldiers killed in action relied on those three words to assuage a loss no parent should ever have to face. The alternative was a sacrifice without meaning, and that was unthinkable.

We flirt with meaninglessness, however, when a murderer rips our loved ones from us and from the public stage we hear, "I hope no one uses this as an excuse to talk about gun control." What we've witnessed in Connecticut is neither an excuse, nor is it evidence we need an armed electorate to take the place of those we've empowered to protect us against violence and mayhem. What is is, is evidence of our national refusal to listen to the voices of victims at Columbine High School and a theater in Aurora, Colorado.

If we could tune down the noise of our own convictions, we'd hear a voice shouting from the periphery of those convictions, "For the love of God, please, don't let this happen again." But we do. The gun lobby argues, "guns don't kill people, people kill people," and there's an element of truth in that. I've never seen an M-16 walking down the street, creating havoc. Not without a person at the butt end, pulling the trigger. Then again, what if they couldn't get hold of a semi-automatic weapon with a 30 round magazine in the first place? Would that really impinge on anyone's Second Amendment rights?

We treat gun ownership like pornography. We put up with Hustler because we want to be free to purchase a copy of The New Yorker or Road and Track at the grocery. We also regulate Hustler to keep it from falling into the hands of children. We presume the right to own an assault weapon secures our right to own the 12 gauge we take bird hunting in the fall. Maybe it does, but that doesn't mean anyone who wants one should have one. Mutual responsibility in a free society requires us, at key times, to limit the exercise of our freedoms for the sake of the common good. 

We regulate pornography better than we regulate guns. If we're going to honor the memory of those who've died tragically, we've got to change and we've got to start now.

(The West Wing citation from 20 Hours in America, (2002); GNU free documentation image of the Columbine High School Memorial via Wikipedia)