A Reconstructer Of Disassembled Parts

To say that William hardly thought about hospice would be an inaccuracy. He contemplated it, from time to time, during his thirty year tenure as a trauma surgeon.  Usually for fleeting moments before dodging the conversation or deferring to one of his more junior colleagues.  Surgeons didn't give up so easily, he reasoned.  He fancied himself a fixer, a reconstructer of disassembled parts.

Mostly, that is what was expected of him.  His patients didn't come because of cancer or chronic illness.  They came after tragedy.  Unwillingly.   Bodies sprawled on metal tables with insides amiss.  And he put them back together.  There was no time for a prolonged conversation of whether the parts should remain disjointed.

It was easier to look at his patients as parts and pieces.  Easier to round in the ICU and figure out how the puzzle fit together again, or even how the motif in the far right corner connected to the shadow in the lower left.  Complex systems no doubt.  But admittedly there was a refusal, subconscious or not, to discern the forest from the trees.

Thus, the irony was not lost on William, when his oncologist shrugged and suggested hospice care.  This was only after all options had been exhausted.  His body could only withstand so much surgery, radiation, and chemotherapy.  Upon hearing the words, William flopped onto the examining room table and thought of the many conversations he had excused himself from over the years.

His oncologist was not much better. After dropping the H word, he handed him a card with a name and phone number, and left the room.  William held onto card for a few days stuck in the pre-contemplation stage.   He then made the call.

Hospice was tolerable.  William's body began to erode under the enormous burden of cancer.  His eyes sunk, and the skin hung from his atrophied skeleton.  The nurses and CNA's were pleasant and tended to his ever increasing physical needs.  The morphine controlled his pain.

William had already made peace with leaving this world.  There was only one problem.   He had expected to die months ago.  Yet, he was still here.

He prayed to a God that he only partially believed in.  He begged and pleaded.  Take me.  Take me.

Yet he woke up every morning, opened his eyes, and loathed that he was still here.

He had long ago stopped living, and now was solely waiting to die.  Death taunted him at times, holding the prize within reach.  A storm of lethargy would be followed by a an ocean of dyspnea.  With nightfall came peace and quiet.  The next morning all would be tranquil once again.

Sometimes William dreamt that death was seeking revenge for all those lives he had snatched back from the abyss during his surgical career.  All those souls whose path and destiny were interrupted by his mechanical hands.  

He fantasized that after a horrible car accident he was rushed to the emergency room with his aorta transected and the pompous surgeon stood over his body, and licked his lips at the chance of letting the scalpel have free range.  As William begged and pleaded, the surgeon removed his mask and revealed his true identity.  And he recognized his own facade and knew that he would be taken to the operating room.

It was then that William came to terms with a reality that had escaped him his whole clinical career.

Like birth, death is just a natural life event.

A natural event, that somehow kept alluding him.

The Ear Game

If I could, I would spend all day cleaning ears.  Seriously,  There is almost nothing I do that makes patients happier.  Not diagnosing a rare disease,  not treating diabetes or heart failure.  Of course, those patients are thankful too.  But very little lights up a face more than the instantaneous relief and the rush of sound that comes when knocking loose a particularly egregious glob of cerumen.

I figure I could set up four or five rooms in tandem.  Each with a its own sink, syringe, and various plastic scooping tools.  I would spend all day excavating.  Sifting through the mud to expose tympanic membranes long buried.  I would deliver every doctors dream-sudden, immediate, uncomplicated relief.

I would spurn insurance.  Each patient would come in with ears full and leave with pockets empty.  There would no longer be any electronic medical record or meaningful use.  MACRA would be a thing of the past.  Instead, I would spend my time doing that which I was most trained to do.

Clean ears.

I would become an expert and be known far and wide.  I would be listed as one of America's Top Doctors.  I could be interviewed on the Today Show and Good Morning America about the sinister danger lurking in those funny protruding orifice (who knew orifice was the plural of orifice?)

And life would be good.

Sure, you might argue that I will miss the struggle and humanity of treating real human disease.  The rush of delving into the bowels of human suffering and trying to lift my fellow man.  I can't argue with you there.

But when you clean ears for a living, you don't get those angry calls.  The family members who are convinced that you harmed their loved ones or the drug abuser who finally met a physician who won't just fill the meds.

You don't have to worry about malpractice.  No one is going to bring a million dollar suit against you because you forgot an ear.  Or left equipment in the canal.  In fact, you most likely can stop paying those crazy twenty thousand dollar a year premiums.

When you clean ears for a living no one cares if you use an electronic medical record.  There are no books for medicare to audit.  No ICD 10 codes or CPTs when you take cash.  There are no late nights combing over documentation to make sure that you remembered to mark off smoking status or that your PQRS data are crystal clear.

You can stop wearing your pager and turn off your cell phone at night.  No more interruptions while your sitting on the toilet, or taking a shower, or god knows what other personal things you are doing when all of the sudden a nurse must immediately report a skin tear.

And when you clean ears for a living you can stop building those damn walls.  You know, the ones you make in those dark times when something hurts really bad.  The ones your fortify day after day, week after week, and year after year.  Because before you got into the ear game, there was a lot of pain and suffering.  There were late nights and honest questions of culpability.  There were those patients you couldn't save.  And those that you could save but somehow didn't.  And those mistakes you made, or didn't make, or maybe are not sure about.

You wouldn't wake up in the middle of the night in a cold sweat.  Or jump every time your daughter texted you because you thought it was the hospital.

And maybe,  just maybe,  you would stop getting up every morning before the alarm went off.

First, Dispense of False Uncertainty

First, dispense of false uncertainty.

Your father is dying.  I'm sorry.  I know this sucks.  It is horrible, and unfair, and heartbreaking.  I have been there with my own loved ones and counseled many patients through similar situations.  Your brain will try to convince you that it isn't so.  That cure is around the corner, or that if you just make the right decision everything will be OK.

Everything will not be OK.  Your father has cancer laced through his bones and inner organs.  He is bound to his bed and can no longer feed or bath himself.  He has lost interest in eating.  Although I wholeheartedly regret this,  I must not mince my words here.  My bluntness is not meant to be unkind or crude.  It is crucial that you understand where we are in order to move forward.

Death is coming no matter how much you or I wish to deny.

So let's not.

Indecision is decisive.

There will be a strong inclination to pause.  These are horrid decisions that no family member should have to make.  Yet doing nothing creates its own set of consequences.  Without actionable breakers, our medical systems can become a runaway train of horrors.  CPR will break your fathers ribs but will not remove the invaders overtaking his internal organs.  Feeding tubes and IVs will deliver nutrients, but those nutrients will more likely feed the raving beast, and less likely provide meaningful benefit to his ailing body.

Ventilators are magical and awe inspiring when they support the respiratory system of someone who will eventually recover, and conversely barbaric when they provide buoyancy to an otherwise porous ship.

You should sign your father's DNR form.  Life support will not save him, it will prolong his death.

Dignity turns process into an event.

In my interactions with your father, he has seemed a dignified and kind man.   My wish is to provide as much dignity in death as he has enjoyed in life.   To do this, we must move away from futility.  Futile medical treatment brings pain and discomfort.  Pain and discomfort turn death into a process.  A prolonged, agonizing, distressing process.

I would like, instead, to think of his life as the process and death as an event.  By treating him with dignity, managing his symptoms, avoiding unnecessary medical treatments, and providing joy in whatever ever mode possible-we can truly help him feel like he is living until the unfortunate moment he dies.

Bring it home.

I want you to know that I not only worry about your father's wellbeing, but also your own.  After his death, despite your best intentions, you will spend much time thinking about his last days.  Let's create a safe and peaceful landing place for him.

I hope to leave you with the memory that at this most difficult and important time of your father's life, you provided him selfless dignity and comfort.

You gave him one last gift.

You will sleep better during those future restless nights knowing this.

We Were There

Jordan?

She peered up at me, her face alighted by the morning haze streaming through an adjacent window.  A soft kind face, she had aged over the years.  A pair of reading glasses sat perched on her nose ready to be squinted through as she turned her attention to the ever shrinking font on the glowing computer screen in front of her.

We had been colleagues once, lifetimes ago.  My first job after residency.  She, being a few years older than I, was less of an amateur back then.  We stumbled and bumbled though those early days of hospitalism.  I remember the practice of medicine felt so raw and new.   I spent many hours traversing those winding hallways.  And it became my home.

It's hard to explain what the concept of hospital means to a physician.  It is the place where we start as novice, move to apprentice, and exist ever after striving towards mastery.  Many of our significant moments have occurred under those sterile lights.  We have seen lives saved and lost, tears shed in both joy and despair.  It is the place where we have been broken down and if lucky, built back up.

So when you happen upon a colleague on Christmas morning after over a decade, it gives you a moment to contemplate.  A funny thing happens over time.  Doctors show all the telltale signs of aging.  Our hair thins, our backs bend ever so gently forward, maybe the waistline expands a touch.  We wear our battle scars unabashedly.

Yet the hospital, our home, our outer shell, no longer reflects these changes,  Floors are remodeled, wings are expanded, computers are upgraded.  Everything new and young.  And the medical students and residents scurry through the newly updated units.  It is their hospital now.

My colleague and I.  Banished from our childhood home.  Visitors in a foreign country. Strangers in a familiar land.  We will be accepted again one day.  Not as healers anymore, but as patients.  

We may die in the place we once lived.  But the signs of our existence will have been long washed away by progress and expansion.

There will be little left of us.  Except the lives of the those we touched.  And their families and children.  And children's children.

On forgetful Sunday mornings and even on Christmas.

We were there.

Streaming From The Mental Netflix

The memory came unexpectedly.  Buried somewhere deeply in the stacks of significant but not often recalled life experiences.  My conversation with my son had dragged it up, pushed it forward, and blasted it out into my embarrassingly small space of wakeful consciousness.   And I remembered.

My son is in sixth grade and goes to the same middle school that I went to as a child.  On the few occasions I have visited, a wave of familiarity washes over me.  Feelings submersed for decades return with smoothness and clarity.  For a few moments, I remember what it feels like to be twelve years old again.

My son's interests are mainly confined to science and electronics.  I, of course, try to talk to him about subjects like politics, art, and the opposite sex.  Recently I asked him if boys are talking to girls? Dating? Holding hands?

While he immediately demurred and squirmed in discomfort,  an uninvited apparition suddenly streamed out of my mental Netflix. And her name was Christina.

Christina was in my sixth grade homeroom class.  Everyday we chatted, joked, and passed the time until the bell rang and we moved on to more serious academic endeavors.  I liked her.  She was kind, and pretty, and funny.  By the middle of the year, boys were beginning to ask girls to form more formal relationships.  They called it "going with".  It was basically equivalent to a childish version of dating.

I finally built up the courage to write Christina a note, and passed it to her during homeroom.  She opened it, read for a moment, and then put it down.  I glanced backed at her inquisitively, hoping to glean some indication of her feelings.  She folded it cleanly, and put it in her backpack.  At the end of the period she took me aside.  She explained that while she liked me, she wasn't ready to "go with" me, and that she preferred to remain friends.  She smiled affably, she laughed, and that was it.

Nothing changed.  She continued to chat with me before class.  We joked.  There was no awkwardness or unkindness.  And she never told another soul about the whole incident.

I can't remember when Christina and I parted ways.  Maybe it was the next year when we changed homerooms.  Or after middle school.  Who knows?

But I will always remember her kindness and maturity. She could have mocked me.  She could have avoided me.  She could have reacted in a thousand other possible hurtful ways which most likely would have marred my own self image as well as my future interactions with the opposite sex.

Instead she was gracious and sincere.

A sincerity that I cherish.

A sincerity that I now often contemplate as I continue the herculean effort of trying to form my daughter and son into compassionate, loving human beings.  

The Data Was Suffering

The notion began early in computer science class during Jason's freshman year.  The professor had noticed a certain elegance and zeal in his work and suggested medicine.  That was in the days of the giants when clinicians were tied to such clunky programs as Meaningful Use and PQRS.  In this antiquated milieu, Jason cut his teeth on basic healthcare architecture.

In those prehistoric years, there still remained a bias toward eye contact and empathic expression.  Thankfully, over time, the technocrats pushed the boundaries.  Jason couldn't be happier.  His hands hovered over the keyboard and his eyes took in each field with accuracy.  Diagnostic algorithms, demographic screens, drug to drug interactions.  By the end of the first year of medical school, he mastered every simulation.

Years two and three couldn't have been easier.  The newly approved glass separators made clinical encounters almost identical to the simulations. Jason was a pro from day one.  He rarely felt the need to look up from the monitor.

By residency, Jason had mastered the new duplex screen modalities.  Instant messaging allowed for multiple simultaneous visits.  Each patient's biometrics were scanned during registration and appeared  on the client visualization window.

The truth was, Jason ignored the biometrics.  He hated to connect a face to the data.  He avoided names also.  Too personal.  Too close.   He preferred raw data.  Each numeric morsel placed in exactly the right box, on the right screen, in the right folder.  Clean as can be, no mess.

Jason spent the next decade honing his skills in practice.  He rose to the top quickly.  His data was entered faster, more cleanly, and with less errors than his peers.  Such accuracy was profitable.  He qualified for almost every governmental bonus, and his year end stipend was among the highest.

Change came subtly at first.  Jason felt mild anxiety when the glass separators were removed.  Then there was the thing about shaking hands.   A new quality indicator, a governmental big wig had suddenly decided that human touch was somehow related to well being.

A few years passed before the new physical exam mandate was rolled out.  Some yahoo decided that stethoscopes were required for each exam.  Jason figured that a crooked politician had a friend who sold the old time relics and needed a new revenue stream.

The changes began coming faster.  First the state sponsored communication classes.  Then the new gowns and privacy policies.  The  yearly clinical exam.

Each mandate cleaved at Jason's soul.  He was a master, and his mastery was slowly being eroded by non technical politicians who barely understood the beauty nor complexity of a clean data input screen.   He was slipping.  He almost submitted an incomplete claim the other day because he was futzing around with a defective sphygmomanometer.

The data was suffering.  The consequences were momentous.  Doctors were working untoward hours to feed a ravenous monster that was no longer connected to any real version of healthcare.  

And Jason was on the internet every spare hour, looking for a posh consulting job.

Screw the government!

Legislated Out

I have a breathtakingly difficult confession to make.  A confession, that on its face, seems rather innocuous, but in many ways shakes the foundations of who I always thought I was.  How I identify myself.

I no longer love being a physician.

There, I said it.  I winced even as I strung the words together to write the sentence.  You see, to admit this is almost inconceivable.  So much of who I was and who I have become is enmeshed in this intricate quilt of a profession. I view most every aspect of my life through this lens.

How could I not?  Wanting to be a doctor is the first cognition I can recall from childhood.  A childhood marked by a learning disability which brought into contention the idea of being a professional at all.  A childhood in which a father's death became a precursor.  A foreshadowing of who I was fated to become.  I would follow in my father's footsteps.  I would finish the work that was prematurely wrenched from his clutches.  There was never a question whether I would succeed.  The calling was too great.  The pull too strong.

To deny my profession is to deny my father's legacy.  To deny my own reflection.

Yet here I stand.  It didn't happen all at once.  Medical school was difficult and time consuming, but it didn't happen there.  Residency was strenuous and terrifying, but it didn't happen there.  My first days as an attending were grueling, and sometimes awful, but also energizing.

I suppose the change happened sometime after we started using electronic medical records.  It happened with meaningful use.  And MACRA.  And Medicare audits.  And ICD-10.  And face to face encounters.  And attestations.  And PQRS.  And QAPI.  And the ACA.  And MOC. And on and on.

What I do today is no longer practicing medicine.  Instead its like dancing the waltz, tango, and salsa simultaneously to a double timed techno beat.  It's sloppy, rushed, unpleasant to look at, and often leaves my partner more confused and anxious then when we started.

I have become ineffective.  Not by the weight of ever expanding medical knowledge or even the complexity of the human body.  Instead, my hard drive is being spammed by thousands of outside servers.

But make no mistake, I'll never leave.  My love for taking care of people is unwavering.

As for the joy and utter exhilaration of what used to be...

Frankly, it's all been legislated out.

In Memoriam

The text was innocent enough.  Eddie died.  Unlike most human beings, there was no dagger of pain or even pang of grief.  Those types of feelings had long been subdued.  Instead there was just a subtle disturbance, a prick.  I found the normal platitudes bouncing through my skull and down the spinal cord, out through the arms into my hands.

He was old.
He lived a good life.
It was his time.
He didn't suffer.

Words I have said aloud so many times that now I forget to halfheartedly mumble them at all. And of course, the last is a lie.  We all suffer.  Maybe not during death, but in life.  Patients and doctors alike.  Pain is neither a blessing nor a menace, it's more like a life long companion.  A fellow traveler.

A traveler that I, overtime, have begun to ignore, to minimize along the way.  I take care of old people.  My patients die.  All the time.   Over and over again.  I have learned to take the phone call, comfort the family, and say goodbye during interrupted dinners and in-between performances at my children's school.

It's a fallacy to think that these are just professional relationships.  Medicine can only be transactional in it's most basic form.  To really care for people, you have to give of yourself.  You need to be present.  Occasionally offering your own struggles, and always your hand, your shoulder, and even your heart.

Healing is destructive, and painful.  It's taking on another's struggles to lessen their burden.  It's removing your own armor and accepting the glancing blow that rips your own skin.

I'm tired of ignoring the wounds.

Eddie was old when I met him ten years ago. He was crass and chewed tobacco.  He was rough and tough and often swore in Yiddish that I rarely understood.  His hands were thick.  They clapped me on the back every time we saw each other.

And he was so proud of me.  Last week I went to see him, he smiled broadly and proclaimed to the nursing aid that was adjusting him in bed.

That's my doktor.  Hey, where ya been?

I'm here Eddie.  I'm still here.

Now get some rest.

Barren Walls; My Thoughts On Selling Artwork

I bought my first house a few days before starting my second year of residency in St Louis.  It was a townhome actually.  Two bedrooms, one and a half baths, hardwood floors, and lots of wall space.  In fact so much wall space, that I immediately began to look for ways to adorn all those barren surfaces.

After visiting a number of local art galleries, I came to two conclusions.  I knew exactly what I liked, and art work was exceedingly expensive.  Expensive enough to not only prohibit me from decorating my house, but also from buying a single piece for my bedroom.

The easy path would have been to obtain a bunch of prints, frame them, and call it a day.

Instead, I scoured the Internet and eBay. Within days, I was able to find similar paintings, by similar artists, for half the price.  After making my first purchase, I took a few extra minutes to chat with the seller.  Over the next few weeks I spent countless hours researching, calling, and interviewing any art dealer I could find.  Some took my phone calls, others hung up.  I even spoke to a few artists themselves.

I quickly learned that there was a secondary art market with a fairly low cost of entrance.  By making a few friends, I could piggy back my purchases on those of much more wealthy buyers and obtain quite a discount.  A discount, in fact, that was much better than the art galleries I had most recently frequented.

Fast forward a few years, and I was running a business buying and selling artwork.  Originally my purchases were driven by passion for the artist, but eventually I learned to buy whatever I could sell at the best margin.  Hundreds of thousands of dollars worth of product came and went through my business any given year.

But that was the rub.  No longer was the canvas an object of my fascination.  It was now fancy paper that I could move along, and be paid in even fancier paper.   Once I bought ten thousand dollars of artwork that I would have previously coveted.  I inspected it, packed it back up, and sent it on it's way to a buyer who offered me double.

I felt nothing.  Well not exactly nothing, but the thrill had dulled.  A spark was still there, but it was deadened.  Smoothed over by years of experience dealing with beauty that came to and slipped through my fingertips with relative ease.

When I began to run my own medical practice, the extra time for such frivolity evaporated.  There was simply no way to take care of my patients, hire and fire, monitor the books, and tend to an extra business.

The memory of the precious paper never quite left me though.

Often people ask what it's like to be a doctor, to save a life, or watch a patient die.  To know that your mistakes carry such weight.

Usually my mind goes blank, and instead, I think fondly of looking at those barren walls for the first time.

Then I sit them down.  I clear my throat.

And I tell them stories about selling artwork.

Connecting Lines

I both look forward to and despise Sunday mornings.  I awake just before the sun and am on the road by 5:15am.  Although I dread being upright so early on the weekend, I rejoice because it is the only trip to work, all week, at a leisurely pace.  I see the new admits at the nursing home, run by the hospital if necessary, and return just as my family is leaving their beds.

The thirty-minute car ride gives me ample time to reflect.  I often think of my father.  A physician, he died well before I was old enough to understand who he was as a doctor, or a man for that matter.  I often wonder about the parallels.

Did he arise early on the weekend so as to come back before his kids noticed he was gone?  Did he have my bedside manner?  Or I his? Was he the kind of husband and father that I am?

Bringing up my own children has made me ponder the equal parts that go into building a young personality.  My father died when I was eight.  Was that old enough to imprint on me this drive to become a physician?  This will to work insane hours? To be relentless?  Maybe it was all genetics and his behavior had very little effect.

These thoughts make me worry about my kids.  I would give them everything they need to be happy successful adults if I just knew how.  Or maybe in the giving, I am causing harm.  Maybe I need to let them run free without direction and let will be the guide.  The possibilities are dizzying and the options endless.

So I plot and plunder as best as I can.  I sometimes dole advice and others hold my tongue. I try to be an example of honesty, and hard work, and integrity.  I fail from time to time. Or maybe often.

I woke up this Sunday morning.  Like every Sunday morning.  Before everyone else.  In order to be a good physician and father.  Driving the same roads, I had the same thoughts.  I returned home to find that my son had crawled out of bed an hour early, slipped his clothes on, and was shoveling the neighbors snow.  Apparently he also had work to do.

And time passes, memories of dad fade, and my children grow forming their own pathways.

They connect the lines between father and child.

Child and father.

Spoiled Milk

There is no use in crying over spoiled milk!

I have been thinking a lot lately about focus.  As a young physician my ability to multitask was breathtaking.  I could answer an emergency phone call from the hospital, change a diaper, and mow the lawn while stopping at the store to buy my wife flowers.  I was able to navigate the roadblocks of each day without losing stride.  Sure I sometimes stumbled, but I was up and running again without cutting precious seconds off my daily wind sprints.

Age has changed me.  Through the years my career has grown, and the number of pressing professional interruptions has exploded. But more importantly, my mental agility has slowed.  My brain is no longer as nimble at managing multiple concurrent situations.  So choices have to be made.  When I am discussing end of life options with the family of an imminently dying patient, I tend to ignore the pulling on my sleeve as my son tries to convince me to buy the latest trinket in the department store.

Choosing becomes a mode of survival.

This weekend was no different.  The holiday season ushers in a  long slog of patient care crises that usually last well into March.  Between phone calls, I tried my best to navigate family activities, errands, and nursing home rounds.

And of course, it was imperfect. I missed the end of my children's violin concert because I was being berated by another physician for the care of her family friend in one of my nursing homes.  Later that night, as my kids frolicked in the newly fallen snow, I sulked at the edges of the park consumed by a patient care issue that didn't go exactly as planned.

My wife awoke to me sitting on the bed Sunday morning charting on a hospice patient instead of chatting affably and yawning away the last remnants of sleep.  We eventually rounded up the kids for a full day of errands, capped off by a trip to the grocery store, before going to my parents for dinner.  Katie had been looking for a special brand of milk that she explained, between phone call interruptions, would somehow be well suited for our children (I was too distracted to put it all together).

When we arrived at my parents, I dutifully put the milk in the refrigerator so as not to spoil.  After dinner, I retrieved the carton and packed it away with the other groceries stuffed into a bag with a bunch of binders for my son to take to school.

That night, during more phone calls, we unpacked the groceries, got the kids settled, and relaxed a few minutes before going to bed.

I woke up this morning at 4am in a panic wondering if I had remembered to unpack the milk and put it in the refrigerator.  After a quick shower, I got dressed and squeaked down the stairs to find that my fears had been realized.  There the milk was, sitting in the doorway, next to the binders, stuffed in a bag, spoiled.

On the way to work, I looked around at the deserted streets as my car whisked through the snow.  It was a little after five and the rest of the world had not yet wiped the sleep from their eyes.  And I began to cry.

Because the wisdom I have gained from years of dealing with sickness and death has taught me that I can't go back and start the weekend over again.

And be a better dad, a better husband, a better doctor.

What's done is done.

The milk has already spoiled.

I'm Sorry

Dear Mrs J,

I would like to express my deepest condolences in the passing of your mother.  A magnificent woman, I had the pleasure of being her doctor for almost a decade.  And it was a pleasure.  During our short visits she regaled me with stories of childhood and often gently sprinkled in advice gleaned from years of experience.  Even as she began to decline, we would sit together in the nursing home and she would reach out to hold my hand.  She was a gift, your mother.  A gift that I in no way deserved.

I'm sorry she got cancer.  As a physician, there is no word worse than the word metastases.  It not only creates fear in the hearts of our patients but cleaves a chunk out of our souls.  We are never as hapless in our calling as when we admit that we are mere unarmed foot soldiers in the face of this raving beast.  We are not helpless.  We can comfort and palliate.  Cure, however, becomes an ever increasing implausibility.

I'm sorry that your mom experienced pain at the end.  Lying in bed in the nursing home, she somehow mustered a smile through the groans as the nurses and I passed through the room. She told  me that she didn't see the point anymore.  We discussed the risks and benefits of morphine, and I dutifully wrote all the orders.

And I'm sorry, most of all, that you stormed into the room that morning and ordered the nurse to stop.  That you somehow convinced your mother, in the last hours of life, that she would get addicted to morphine. That you screamed at her for not participating in physical therapy the day before because she was far too exhausted.  And that she saw you and I arguing in those last precious moments when you should have been sitting at her bedside, holding her hands, and sobbing.

Your mom is now at peace.  She will suffer no longer.

I know that you meant well.  I am all to aware that the next few years will be excruciatingly hard as you try to work through loss and maybe even come to terms with the fact that you willfully denied your mom a peaceful death.  There was probably much sadness, denial, and guilt that led you to make such decisions.

I am no longer angry.

But I'm sorry that I will not be able to be by your side during this arduous journey.  Because above being a doctor, I am an imperfect human being.  And far from above it all, I am right there in the muck with you

I cannot help you at this time.

Frankly, I'm still too disgusted.

Writing and Imperfection

For the first decade of life, I had headaches. Daily.  Every day.  Occasionally they were mild, but often severe.  I saw various doctors.  Suffered through multiple scans.  At the end of the workup, the answers were no more forthcoming than the day we began.  There was never a clear antidote.  Never a divine potion.
  
Then something magical happened.  Exasperated, my parents took me to a biofeedback specialist who taught self meditation. And my life was transformed.

I won't say that my headaches went away completely.  They didn't.  But practicing regular meditation instilled in me a confidence and a calm that revolutionized my life.  At the age of ten, I learned to manage stress, physical discomfort, and visualize the place I wanted to inhabit in the world.  It helped center me.

Although the habit of daily meditation has fallen off over the years, I still return from time to time.  Whether physical illness or mental, there is a safe harbor in times of need.  There are few practices that have been so impactful on my life. 

The last year, for many reasons, has been hard. I have found myself pulled in too many directions.  And my centeredness has skewed.  My balance faltered.

I have been thinking a lot about this balance.  As a child, it was built on meditation and thoughtfulness.  As an adult, I now realize what has been missing in the last year.

Writing.

My daily routine of putting thoughts into words had recently become too overwhelming.  My days were so disjointed that I had neither the emotional energy nor the physical time to place fingers to keyboard.

Because writing, as life, is excruciating.  Filled with psychic pitfalls, it is awkward at best and messy often.  The words come out disjointed and backwards, and rarely reflect the intangible emotion that circulates amongst the fussy neurons in my brain.

I am rarely satisfied with a piece, even after all the edits have been made.  Imperfection pervades my writing, my soul.

Yet somehow this imperfection provides that thing.  That thing which is missing most.        

The Shepherd

Mathew preferred using the more biblical term shepherd.  After all, he labored his flock through pastoral pastures and meandering meadows.  His parishioners, of course, were sheep and not people.  But after years of leading them, he could discern subtle differences.  The slope of a forehead, the stutter of a step, the variation in bleat.  So much so that he had a distinct name for every animal in his flock of thousands.

Mathew preferred isolation.  From humans that is.  But he was far from alone.  He spent his days in constant motion among the animals, and nights still, under the moonlight beside them.  In this way he past many youthful decades.  A quiet, tranquil life, but not one lacking turmoil.

For Mathew grew to love these animals.  And in so doing, he was forced to master a much broader skill set than just moving to to fro.  Sheep got sick, got stuck, or became prey.  So he devoured books on parasitology, mastered the art of disentanglement, and learned to scan the horizon with the eyes of the hunter.

And death came.  From time to time.  Despite his best intentions.  The fox was too wily or the dehydration too severe. Panic could also be an issue.  Mathew knew profoundly that the axiom scared to death could take on a more literal meaning.

At first these deaths were of little concern.  Natural.  Mathew, however, found that as his love for the animals grew, the impact became more sobering.  He worried incessantly about plausible dangers.  He scanned the horizon for predators, he sniffed the air for hazard.  His anxiety grew each time he passed the great cliffs at the Northern most border of the pasture lands.

The cliffs were steep, unforgiving, and unavoidable.  There was no other way to advance through the Northern rim of the territory, and move such a large group of animals to the South.  Mathew approached this part of the journey carefully.  He talked to the sheep.  Cooing quietly as if the steadiness of his voice could paralyze the musculature of thousands of legs.

He had seen it happen.  Once. Twice. Ten times.  A poor ram would take off in the wrong direction.  If Mathew wasn't fast enough, he could lose a hundred head as they followed to their doom.  He almost always lost one.  If he was on his game, he could mitigate the death spiral by stopping the rest from their morbid march.

As the years passed, he felt these losses more profoundly.  Mathew remembered the distinctive faces, the names.  His fear would bubble to the surface days before reaching the horrid place.  Although he couldn't identify it, what he dreaded most was the guilt.

Mathew had blood on his hands.  If he had only been better.  Faster.  He might be able to prevent such catastrophe.  He wandered many lonely evenings with feelings of regret dancing through his psyche and laying waste to his previously held joy.

It ended, one night, on the eve of his fiftieth birthday.  Mathew dreamt that herd was running towards the cliffs. Since they were lambs.  A straight, genetic, preordained path.  He yelled and screamed but all he produced was bleating.

So he ran with them.  Moving some out of the way.  Stopping others in their tracks.  Saving those that he could, and mourning those that were lost.

He woke up from his dream certain that he could no longer hold himself responsible for nature.

We are born and we die.

If we are lucky, we help others make the journey more smoothly. We turn them from the most imminent, and palliate the most severe.

This knowledge gave Mathew comfort.

He could once again love being the shepherd.