Friday, August 31, 2007

Random Notes


* We've gotten some actual rain the past two days in Reno, after more than eighty days without it. The air smells like sagebrush again, and the natives are rejoicing. On campus yesterday, I saw students lying on their backs on the grass of the quad, with their faces turned up to the rain.

* My new meds cost $75 a month. (And that may go up if my dose increases.) My old ones came in a $5 generic. Ack! I'll have to discuss this with my doc. But so far, I've been doing well enough on the new meds that both Gary and I think they're worth it.

* Volunteer chaplains at my hospital will no longer be charting on patients (I never have, since I'm in the ED, but upstairs, we're supposed to). This is all connected with some new paperless computer system that will come in eventually. One of the staff chaplains sent out a carefully worded letter about the issue thanking volunteers effusively for their service and emphasizing how much we mean to the hospital, so I'm guessing that they're trying to avoid any perception that volunteer chaplains are being marginalized. Still, the change definitely emphasizes the volunteer/professional split, and I've been wondering if we'd be seeing more of that with recent management changes at the hospital.

* I'm feeling a little glum, because the folks I was visiting at the assisted-living facility last year have very gently and kindly told me that they no longer need my services. They have eminently sensible reasons -- especially since a new Episcopal Church has been planted right around the corner from them -- but it still makes me sad, because I really enjoyed going there.

* My hospital shift this week was unusually quiet, but nonetheless draining. We had one of those patients whose life story just breaks your heart -- it's the kind of biography that would seem like unbelievable melodrama if it were fiction -- but who was also verbally (and sometimes physically) lashing out at everyone in the vicinity: family members, medical staff, me. The family was amazingly loving and steady through all this, and we all knew not to take any of the behavior personally, but it was still very hard to witness. I asked the doctor to do the patient a favor (writing an order for a nicotine patch, because there was no way we were letting the jonesing-for-a-cig patient outside to smoke, and the patient had enough to deal with without cold-turkey nicotine withdrawal), but then the patient cursed me out, because the patient didn't want the patch. The nurse told me, "I've seen this kind of thing before, so I'm not surprised, but thanks for trying," and at the end of my shift, one of the case managers thanked me for spending time with the family. I doubt I did much good, but I wasn't hurting anything, and at least the relatives had someone else there taking some of the heat. I hope they'll all be okay: it's a very sad situation, although at least the patient's now getting needed treatment.

* There are no classes on Monday. A long weekend: thanks be to God!

Thursday, August 30, 2007

Trust


You're elderly, and you look frail, but you're cheerful. I don't know why you're in the ED. When I introduce myself as the chaplain and ask if you'd like conversation, prayer, or a blanket, you brighten and ask for the blanket. And indeed, it's chilly in here. The staff, always on their feet and running, tend to keep the thermostats turned down to 55 degrees, forgetting how easily patients lying motionless on gurneys get cold.

I crank the thermostat up to 65 and get your blanket. When I give it to you, you beam up at me. "You're a sweetheart! Thank you!"

"Are you warm enough now? I can get you another one."

You hesitate. "Well, I'd like another . . . but I don't want to be greedy, and I know you're busy."

"It's no trouble at all," I tell you. When I give you the second blanket, you look as if you're about to weep with joy.

"You're an angel." I hear this a lot from patients when I give them blankets. Warm cotton makes people feel loved.

We chat about nothing in particular, until you ask me, politely, "Do you live in a hotel?"

"No," I answer, startled. "I don't. Do you live in a hotel?"

"Oh, no. I'm homeless." Your tone is still cheerful, matter-of-fact.

Concerned, I leave the room to find your doctor. Do we need to get you a shelter bed, or call social services? But the doctor shakes his head. "No, that patient lives in a group home. They tell me there are episodes of confusion."

I go back into your room. "You're not homeless," I tell you gently.

You cock your head. "I'm not?"

"No. You live in a group home. They sent you here to see the doctor."

"Really? A group home? What's that?"

"It's a place where people who need certain kinds of care live together, along with the people who take care of them."

"Oh, I see." You think a minute, and then frown up at me, anxious for the first time since I've met you. "Are they honest?"

I don't know any more about your living situation than you do, but you trust me to tell you about your life, for no other reason than that I've given you some blankets and talked to you. And so I find myself saying, "Oh, yes. It's a good place."

"That's good," you tell me, contented again.

But as I leave the room, I wonder if I said the right thing. I don't know if they're honest. I don't know anything about them. I told you what I wanted to be true, instead of what I knew to be true. When I told you that I knew your caretakers were honest, I wasn't being honest.

Why did I offer such facile reassurance? The truth would have been, "I don't know, but I hope so. They sent you here to make sure you were all right, so they seem to care about you and to be taking good care of you."

Why didn't I say that? You trusted me to tell you about your life, and I couldn't bear to seem less than trustworthy, so I lied. I couldn't bear to make the darkness through which you're navigating so calmly even deeper. In your place, I'd be terrified: terrified at not knowing, terrified at having to depend on the kindness of strangers. I marveled at your lack of fear, and I couldn't bear to give an answer that might frighten you.

And so all I can do now is pray that the lie I told you is, in fact, the truth.

Overnight Evolution


Yesterday, I was a Slimy Mollusc in the TTLB Ecosystem. Today, lo and behold, I've made it it up to Flippery Fish. My average daily hits are also now above 200, for the first time ever (although that may not last long).

Thank you, Grand Rounds!

Meanwhile, this morning's paper had a truly scary update on the Judy Calder case, not that they could have written anything that would have been reassuring.

My heart aches for her family and friends.

Wednesday, August 29, 2007

*Whew!*


Well, I got through my perfect storm. Preaching went fine on Sunday, and the first week of classes seems to have gone fine too, and I got Grand Rounds posted and have gotten some good feedback on it. Nick Genes did a nice pre-rounds interview with me on MedScape, but right now, it's subscription-only. I'll post another link when everyone can access it.

As anticipated, Grand Rounds has done wonders for my SiteMeter stats. My average number of daily hits zoomed from 127 to 160 overnight, and today I've gotten over 400 hits, which I believe is a record.

If I ever host Grand Rounds again -- and I'd like to! -- I'll a) do it during the summer and b) be much more organized about setting it up ahead of time. I might even get creative with pictures and stuff, as so many other hosts do. This time, it was all I could do to get the links where I wanted them!

Oh, and: I finally have my TTLB ecosystem status displayed! They fixed a bunch of stuff, so at long last I managed to get to the code and post it. The entire world can now know that I'm proud to be a Slimy Mollusc. One day I hope to make it to Flippery Fish, although I may slip back to the level of Lowly Insect. I just hope I don't devolve back into an Insignificant Microbe!

In much grimmer news, a UNR professor who's been missing since August 10 is now believed to have been murdered (they found a body that matches her description, hundreds of miles from here). I didn't know her, but after what happened to Doug -- although of course, we really don't know what happened to Doug -- this strikes awfully close to home.

Gary's made me promise to be extra-careful on campus, although I always am anyway. I'm sure she was, too. Most of the women I know are: we learn hypervigilance with our mother's milk.

It doesn't always help.

Tuesday, August 28, 2007

Grand Rounds: Volume 3, Number 49


Welcome to this week's edition of Grand Rounds! I'm very excited to be hosting for the first time, and I want to thank Nick Genes, the Father of Grand Rounds, for offering me this opportunity.

I received forty-three submissions from forty bloggers. (I really hope I haven't left anyone out; it's been a very hectic week, so if I somehow deleted your submission e-mail by accident, please forgive me!) As promised, I've selected thirty posts for the body of the edition, the "first cut"; but I've also followed the lead of some recent GR hosts by including the rest of the links at the end, so that anyone who wants to can read the "second cut."

This week's theme is Narrative Medicine. Pioneered by Rita Charon, an internist and professor at Columbia's College of Physicians and Surgeons, Narrative Medicine trains doctors and other caregivers to use careful listening and reflective writing to forge deeper connections with their patients, resulting in better care.

Charon describes three essential components of narrative medicine:

Attention: Listening carefully to patients, which includes remaining sensitive to what they may not be saying, gives the caregiver potentially valuable information and also makes the patient feel more cared for.

Representation: Using writing to reflect on patient interactions helps caregivers understand both their own feelings and those of their patients more deeply.

Affiliation: The process of attending carefully to patients and reflecting on patient stories ultimately makes caregivers stronger and more passionate patient advocates, because they've become more invested in their patients' care.

In this edition of GR, we'll pay attention to Patient Narratives, enjoy the representation of practicing medicine in Provider Narratives, and see how providers use writing to enhance affiliation with patients through Reflections on Advocacy. These categories are, of course, somewhat fluid and overlapping.

Additional, off-topic treats will follow. But enough intro! On to the first cut!

THE FIRST CUT

Patient Narratives

Laurie Edwards, who is both a writer and a patient with chronic medical conditions, uses narrative as a lens to give us a fascinating meditation on how these two roles intersect.

After almost twenty-one years with type 1 diabetes, author Kerri Morrone talks wistfully about her new normal. And Amy Tenderich from Diabetes Mine asks, equally wistfully, Why Did God Make Carbs So Yummy?

Elsewhere on the spiritual front, a thought-provoking post from the blog How to Cope With Pain asks how disability affects patients' relationships with faith communities. Since spirituality and group support are both vitally important to people with chronic medical conditions, this is a topic that merits thought from medical caregivers.

Rachel, who has both SAD and diabetes, reminds herself that the coming of autumn means dusting off the light box. Rachel, I'll be digging mine out of the garage soon, too!

Ileana offers some tips on helping patients with social anxiety.

Mary, a fat-acceptance advocate, tells us about the emotional turmoil -- complicated by her mother's medical history -- that she undergoes when she has to see a doctor, even a "fat friendly" one. We've been hearing a lot about weight in the news lately, and it's important for providers to understand how overweight patients feel in the doctor's office.

Dean Moyer, who suffered for years from back pain, advises fellow back patients which doctor to see first.

Although this next post was submitted by a doctor, I've put it in this section because the main voice we hear is the patient's. Dr. Rima Bishara shares her interview with a patient diagnosed with cancer at age sixteen.

Another cross-category post comes from everyone's favorite Mexican Med Student, who offers a uniquely self-reflective case study.

And, finally, Jon Schnaars from Anxiety, Addiction and Depression Treatments reminds us of the importance of listening to patients in a post about the role of cultural factors in suicide prevention. Since I live in a state with a very high suicide rate and very poor mental-health services, I found this post particularly compelling.

Provider Narratives

Medical student Kendra Campbell muses on the irony of how her training in medicine -- a field often associated with selfless idealism -- has temporarily made her more selfish, and thanks her family and friends for their support. Good luck, Kendra, and hang in there!

Med-Source reminds future physicians of the importance of listening carefully to patients, and addressing quality-of-life issues, in a moving post about a young cancer patient and her family.

For medical students and providers new to practice, encounters with mortality can be particularly wrenching, as our next three posts illustrate. Medical Student AMiB (an American Medic in Britain) tells us about his first code blue. Dr. Val (who actually studied under Rita Charon at Columbia!), shares an entry from the journal she kept during residency, describing Night Float in the Hospice. And Nurse Jane shares a suspenseful tale, from when she was a very New Nurse, about a patient with severe cardiac decompensation.

Experience doesn't lessen the impact of some patient interactions, though. ERNursey, in a poignant post, honors the humanity of one of her former patients, a true gentleman despite initial appearances.

On a happier note, Dr. Emer brings us a heartening story from Taiwan about the survival of extremely premature babies under very challenging hospital conditions.

Challenging patients occur at every stage of life. Dr. Paul Auerbach tells us how, as an intern, he negotiated with a diabetic patient, a young woman, to stay in the hospital. Meanwhile, Jay from UroCanswer ponders the appropriate treatment for an elderly prostate-cancer patient.

If conversations with patients are difficult, witnessing the conversations of other providers can be even more so. Geena from CodeBlog describes her discomfort at witnessing a doctor's inopportune call.

Our final post in this section is a monumentally entertaining epic from Bo, the brave and intrepid Road Nurse, who shares two intertwined stories about danger on the job -- the first posed by a patient, the second by the weather -- and ruefully laments her own rashness in the latter situation. Bo, I think the moral here is to trust your instincts and follow them (and damn the peer pressure). Also, I really hope someone films the story of your life someday!

Reflections on Advocacy

The ever-thoughtful Kim tells us how blogging has made her a better nurse.

The Nurse Anesthetist, Counting Sheep, writes a letter to her patients, assuring them that the short conversations she has with them in no way lessens the quality of her care and concern.

Jeffrey, a medical student in Australia, reflects on how his military training will make him a better doctor. Jeffrey, I'm glad you're putting those old skills to life-saving use!

And, in a characteristically witty post, the blogosphere's beloved Nurse Ratched pens an only slightly tongue-in-cheek updated Nurses' Prayer.

Number-Crunching

We have a trio of posts this week about statistics and the dangers thereof. Sandy Szwarc brings us a rigorous challenge to popular interpretations of data about bariatric surgery. Christian from Med Journal Watch is similarly alarmed about the misuse of statistics to suggest links between risk reduction and weight loss. And in a slightly lighter spin on fun with statistics, Clinical Cases and Images shares the amazing phenomenon of a PubMed article with 600 coauthors.

Virtual Medicine

Because I'm a science-fiction writer, I couldn't resist these two posts about the intersection between medicine and cyberspace (although I guess all medblogging really falls into that category, right?). Tony from Hospital Impact tells us what healthcare can learn from FaceBook, and medical student Bertalan Mesko reports on an intriguing virtual hospital in NHS London in Second Life.

That's it for the main body of Grand Rounds this week. Again, my thanks to everyone who submitted posts. Next week's host will be Parallel Universes.

Below are the rest of the submitted posts, for those of you with the luxury of lots of reading time!

THE SECOND CUT

JC Jones RN shares some of the health challenges facing black men.

Allergy Notes praises immunotherapy as protection against asthma for children with allergic rhinitis.

Alvaro from SharpBrains reviews recent cognitive training research, and also lists The Ten Habits of Highly Effective Brains.

Over at Diabetes Mine, diabetes patients energetically debate the merits of Merck's new drug Januvia.

Adam at NY Emergency Medicine tears into a New York Times Op-Ed piece recommending pay cuts for physicians.

Henry Stern from InsureBlog helps us wise up to Stupid Government Tricks.

Eric Turkewitz discusses the ramifications of Medicare's Medical Malpractice Fix.

Sam Solomon from Canadian Medicine brings us news of an American medical-malpractice insurance firm that promises to help doctors fight RateMDs sites.

From South Africa comes a grim little anecdote about political corruption and liver transplant.

Jolie Bookspan, the Fitness Fixer, gives us two inspirational stories of regained health, here and here.

Sunday, August 26, 2007

Planned Giving


In her comment on my previous post, Jean said:
"When I'm in the United States, I often hear people praising the European welfare states for doing a better job of taking care of their tired, their poor, their sick, and their hungry - but when I am here in France, I still see just as many beggars on the train on my way to work or on the sidewalk on my way to church. I have been coming here for twenty years now, and it seems to me that the number has remained constant through every change of political party in power whether the president was Mitterand, Chirac, or Sarkozy. Sometimes giving feels right, sometimes it feels wrong, and always, always, always the decision itself feels difficult.

"If you or any of your readers happen to have any thoughts about this particular problem, I would be very glad to hear them."
I've been thinking about this problem since at least 1987, when I moved from New Jersey to New York City. I'd encountered beggars before that, of course, since I'd worked in the city for years and lived there part-time, staying with my father and stepmother on weekends, but becoming a full-time Manhattan resident brought the issue into new and sharper relief.

I lived on 110th Street between Broadway and Amsterdam. The subway stop was half a block away. To catch the train to work in the morning, I had to walk past a literal line-up of homeless people, six to twelve a day, all with their hands out.

I couldn't help all of them, and I didn't have the skills or the time to evaluate who needed my spare change most; and at that point in my life, I didn't have all that much spare change, anyway. And there was the ever-worrying "But won't they just spend it on drugs or alcohol?" question.

Important digression: In 1986, when I was still living with my mother, I had -- very, very briefly, which was probably a good thing all around -- dated James Ellroy, the somewhat notorious and extremely colorful noir crime novelist. James, as anyone who's even slightly familiar with his biography knows, spent ten years homeless on the streets of L.A., addicted to speed and alcohol. He wrote his first novel, Brown's Requiem, while he was working as a caddy at an L.A. golf course; he composed the manuscript longhand, standing at a dresser between rounds because there wasn't a desk. By the time I met him, he'd been sober and drugfree for years, and was starting to sell movie rights to his books, a fact he celebrated by buying extremely expensive cashmere sweaters. But whenever he got a royalty check for Brown's Requiem, he sent ten percent to the broken-down alcoholic caddy at the golf course who'd been the inspiration for one of the characters in the book -- and whenever people on the street asked him for money, he gave them whatever he had, no questions asked.

One day we were approached by a young guy who was clearly high as the proverbial kite, and who delivered an incomprehensible, jittery monologue about why he needed money. James, as usual, emptied his pockets. Afterwards, I shook my head and said, "Aren't you afraid he's just going to spend the money on drugs?"

James looked at me and said, very gently, "Susan, I'm still alive today because when I was a drug addict on the streets, people gave me money without asking me what I was going to do with it."

I've never forgotten that, and I didn't forget it on 110th Street, either. But I couldn't afford James' generosity, and that morning gauntlet was intimidating. I was sharing an apartment with several other women, and we spent a fair amount of time agonizing over this. For a while, we favored choosing one guy (they were almost always men) and buying him a meal at the bagel shop on the corner, but picking only one person was hard, and the meals weren't that cheap. One of my roommates took pity on a fellow who always slept in a doorway on the block and gave him a pillow, but was outraged, a few days later, when the pillow was gone. (She was mad at him for losing it; even then, it seemed more likely to me that someone had taken it from him.) One of my roommates became completely disgusted with all the beggars, whom she dismissed as ungrateful charlatans, and stopped giving any of them anything. Various other people I knew decided to give to reputable social-service agencies but not to individuals, and I did a little of that, but it didn't lessen the pangs I felt walking past all those outstretched hands.

I kept agonizing. Someone I knew shared a strategy: figure out how much you can afford to give away that day. Break it down into quarters or singles or whatever, and put it in your pocket. Whenever someone asks you for a handout, give that person one of the quarters or dollar bills. When the money's gone, it's gone, and you've done what you can do for that day.

I did this for a while, but it made the morning walk to the subway even more harrowing, since the regulars quickly figured out what I was doing and eyed my pockets.

I lived full-time in New York until 1990, and the question never got too much easier, although I did figure out a few permanent guidelines:

* I wouldn't give money to anyone who tried to frighten me, guilt-trip me, or engage in any kind of emotional blackmail. For a while, every ATM in the city had a homeless attendant or two who'd open the door for you and then expect a tip. They didn't get any from me, because I could open my own door just fine, thank you.

* If I'd heard a particular story before and realized that the person was lying, that person got no money, either.

* I'd cheerfully give money to anyone who entertained me, or even tried to. I still fondly recall one fellow who worked the #1 Broadway line, and who distinguished himself from the competition by toting around a beaten, bashed-in saxophone. He'd play screeching, ear-splitting noise for a few minutes, stop, grin at everybody in the subway car, and say brightly, "Who'll give me twenty-five cents to stop doing this?" Almost everyone laughed, and a good many reached for their spare change. Anything that made my commute less tedious was worth a quarter or two!

* I was also more likely to give money to people who explained carefully what they did and didn't need. One evening on the subway, a young woman with a toddler came into my car and asked politely for everyone's attention. She needed short-term financial help, she told us. Her baby's father had walked out on them. She had a place to live, and she was signed up with Welfare and would start receiving those benefits in a certain number of days. Once she got her first check, she'd be fine, but in the meantime, here were her expenses. She proceeded to give us a detailed budget breakdown: so much per week for diapers, so much per day for babyfood, so much per day (a very modest amount) for her own meals. Could anyone help?

A lot of people helped. It was a calm, impressive performance. One woman sat down next to her and started talking about housing help, and the young mother said patiently, "Thanks so much, but I have an apartment. That's not the problem at the moment." Because she limited her claim, she got more from her listeners.

In 1997, when Gary and I moved to Reno, I stopped encountering homeless people -- as I had almost every day back East -- because I started driving. Cars are terrific insulation, but that insulation bothered me. I didn't want to become complacent about my own level of privilege. One of the reasons I started going to church was to get more involved in helping people: as a direct result, I began volunteering with our community's Family Promise network -- St. Stephen's was a host congregation for homeless families (parents and children) for quite a few years, and I served on and off as our volunteer coordinator -- and also started volunteering at the emergency room, which is one reliable way to interact with homeless people in a safe environment.

Somewhere in there, I met a very wise Catholic man who responded to the "should we give them money?" issue by saying this: "If someone pretending to be homeless scams you, the deception is that person's sin. If you assume that a person in need is scamming you and refuse to help, your hardheartedness is your sin." This man, like many others I know, favors the "give what you can afford when you're comfortable doing so" approach. I once discussed my Catholic friend's comments with my fundamentalist-atheist father (who's actually one of the most Christian people I've ever met), and he said, "If you aren't being scammed once in a while, you aren't being generous enough." Some of the people out there are lying; many aren't.

I've also now met a number of formerly -- as well as currently -- homeless folks, all of whom report that the most difficult thing about being homeless is feeling invisible. All of them say something like this: "If you don't want to give money, don't; that's up to you. But please, please, make eye contact! Say hello. Treat us like people, because we are."

The homeless person to whom I'm most generous (although not as generous as I promise myself I'll be, or as I wish I could be) is also the homeless person I know the best: my friend A in Berkeley, about whom I've posted at some length. This reinforces the point of my homily this morning: relationship lies at the heart of generosity.

Since moving to Reno, I've noticed that when we visit San Francisco, I'm usually badly startled the first time I'm approached for change, and usually don't have any in my pocket. I don't like taking out my wallet on the sidewalk, so when we go to the city, I try to remember to put change in a pocket so I won't be caught unprepared. When I am unprepared, I usually say something like, "Sorry, I can't help you today," but I try to smile and make eye contact.

I'm not perfect at any of this.

In summary, my recommendations would be:

1. If you can, try to give a little bit of money, as much as feels comfortable, without asking what the person is going to do with it. It's a gift.

2. Even if you don't give money, do make some sort of human contact. It will be as good for you as for the person in front of you!

3. Homeless-service agencies always need funds, but personal involvement is just as generous and far more life-changing (for both sides). There are a number of programs -- Family Promise, local soup kitchens, and so forth -- that provide safe, structured ways to interact with this population.

4. For a superb book on helping the homeless, see Christine Pohl's Making Room: Recovering Hospitality as a Christian Tradition. Among other things, she does a great job of talking about how to set boundaries and recognize burnout.

Oh, and here's a grim cautionary tale. A young security guard at the hospital told me about a friend of his father's, a very scraggly looking member of a motorcycle gang. This gentleman was in San Francisco one weekend and, while crossing the street, was hit by a speeding car, which threw him onto the sidewalk. He landed in a doorway, blacked out for a while, and -- when he came to -- started asking passersby for help.

No one would help him, or even look at him, because they assumed he was homeless and only wanted their money. He lay there for two days, and when someone finally did realize that he was hurt and called 911, the medical care came too late to save his legs, which had to be amputated. They could have been saved if he'd gotten prompt assistance.

Do unto others as you'd have them do unto you. And so forth.

Oh, and: lots of homeless people are kids. You all knew that, right?

Whew! I told you I had a lot to say about this! Would any of you care to add your two cents?

Saturday, August 25, 2007

Under His Nose


Here's tomorrow's homily. This is one of those pesky political ones . . . because faith really is inescapably political, if you're paying attention. What we believe in private can't help but influence what we think should happen in public (although not everybody's as obnoxious about it as the Christian Right).

And no, I have no policy recommendations. I'm just asking the same questions everyone else is. The maddening thing is that the Gospel -- at least as far as I can tell -- points very clearly to answers, but offers no blueprints as to how to make them happen in any reasonable way.

The readings are Jeremiah 1:4-10 and Luke 13:10-17.

*

This morning’s readings from Jeremiah and Luke are both about the triumph of relationships over rules, of love over legality. In Jeremiah, God assures the prophet, “Before I formed you in the womb I knew you. . . . Do not say, ‘I am only a boy.’” God knows Jeremiah intimately -- better than the prophet knows himself -- and therefore knows Jeremiah’s gifts and abilities. This knowledge overrides the general rule that young people have not yet learned enough to speak God’s word, to be effective prophets.

Likewise, Jesus cures a woman in the Temple even though she comes there on the Sabbath, the day when, according to the Law, no work should be done. The leader of the synagogue sees a breach of the Law. Jesus sees the particular, individual woman in front of him, the daughter of God who has been crippled for eighteen years. He doesn’t want her to suffer even for one more day, and he silences his critics by reminding them that they feed and water their livestock on the Sabbath, even though doing so is also, technically, a violation of the Law. We care for those we love whether we have been commanded to rest or not, perhaps because such loving ministry feels much less like work to us than like worship.

Throughout the Bible, love trumps law. Think of how God spares the city of Ninevah, despite Jonah’s indignant protests. Think of how Jesus heals the daughter of the Canaanite woman, even though she is, according to the Law, not someone with whom he or his disciples should associate. Think of Jesus’ commandment at the Last Supper: “Love one another as I have loved you.” The law of God is a law of love, not of unbending rules.

When I was in high school, I babysat for an Orthodox Jewish family who deliberately employed a gentile to watch their children on the High Holy Days. I could do things they weren’t allowed to do, like turning lights on and off and using the phone. The mother of the family explained to me, though, that the very young, the very old, and the sick were exempt from such restrictions. People in these categories were not expected to fast, because that would be harmful to their health; and if a baby, an elderly person or someone who was sick needed care, family members were allowed to do anything they had to do to help the vulnerable person.

I was impressed by how carefully she explained this, and I admired the idea of overriding abstract rules to take care of real people. But the concept didn’t hit home until I was in college.

My family wasn’t wealthy, and I was at an expensive school. My parents were divorced, and for complicated personal reasons, my father couldn’t help pay for my education, despite what looked, on paper, like an impressive income. My mother accepted this, and I’d gotten a very generous financial aid package. For the first two years, everything was fine.

Then, during my junior year, the rules changed. My father had to submit a tax return to the school, and the school decided that he had to pay a certain amount towards my education. My father wrote a letter explaining why this wasn’t possible. My mother wrote a letter explaining why it wasn’t possible. I went to the financial aid office, where a very nice woman listened to me explain why it wasn’t possible, and then told me that the rules were the rules, and that she couldn’t do anything for me. The next week, I went back, and she told me the same thing. The week after that, I went back again, in tears. She patted my back, handed me tissues, and listened sympathetically. She was very sorry, but she couldn’t change the rules.

Terrified that I wouldn’t be able to stay in school, I went back to my dorm. The following week, I found a flyer in my mailbox advertising a scholarship for students planning to go into law or government. Since I had no interest in those careers, I threw the flyer away.

A few weeks later, my phone rang. It was the woman from the financial aid office, asking why I hadn’t applied for the scholarship. “What scholarship?” I asked. When she reminded me about the flyer, I said, “I’m not going into those fields, so I’m not eligible.”

“Just fill out the application, okay?” When I began to protest that I didn’t meet the criteria, she said, “Susan, just fill it out.” I told her I’d thrown it away. She sighed and said, “Okay, come down here right now and get another one, and fill it out! It’s due tomorrow!”

I filled it out. I got the scholarship, for exactly the amount that the school had insisted my father had to pay. Many years later, I told this story to a friend who had worked as a financial-aid officer at another school. She said, “Oh, sure. I did that kind of thing all the time. The students who came in were always scared and angry. They thought we were a bunch of petty bureaucrats ready to recite lots of rules about why we couldn’t give them money. But we were there for the students. We wanted to give them money, and whenever we could find a loophole, we used it.”

It certainly helped that I’d cultivated an individual, if rather weepy, relationship with the financial-aid officer. Like Jesus looking at the crippled woman in the Temple, this university bureaucrat saw me as a person, not as a statistic.

The leader of the synagogue, on the other hand, saw a dangerous precedent. If Jesus healed the crippled woman on the Sabbath, his Temple might be overrun with sick people interfering with rest and worship. When he looked at Jesus’ patient, he saw a generalized threat, not a particular human story. His fear of all the sick people who weren’t in the Temple, but who might be if he bent the Law, kept him from loving the woman who was right under his nose.

We still see that kind of fear today. Debates about public policy are driven by fear of immigrants, of convicts, of the uninsured poor. Debates about church policy are driven by fear of women, of sexual minorities, of change itself. I don’t mean to suggest that these debates have simple solutions; all of them are fueled by complicated factors -- including competition for scarce resources -- and by genuine concern about the wisdom of certain precedents. After Jesus’ miraculous cure of the crippled woman, the Temple may indeed have been overrun by sick people seeking healing. We aren’t told that part of the story. What we do know is that Jesus responded to the need that was right under his nose, and that he calls us to do the same.

Whenever we find ourselves using the law as a reason for excluding or denying someone, we’re called to remember the Law of Love, which replaces unbending rules with individual relationships. This may require us to cultivate relationships with those we fear. Everyone I know who does prison ministry is no longer afraid of convicts as a class; everyone I know who has worked with the homeless -- including the many people here at St. Stephen’s who’ve volunteered with homeless parents and children in the Family Promise program -- is no longer afraid of the homeless as a class. Parishioners who initially feared Family Promise have told me, “Now that I’ve spent time with the families, I know that they’re people just like me.”

In all of our national and church debates about whom to welcome and whom to turn away, we face difficult questions about allocation of time and money, about the best timing and procedures for implementing change, about how to soothe and reassure those who are frightened by the new and unfamiliar. But we don’t face the question, “What would Jesus do?” We know what Jesus would do. The Gospels answer that question, again and again. Jesus would nurture relationships, turning fearsome strangers into beloved friends. He’d respond to the needs that were right under his nose, even if he had to break the rules to do it.

Amen.

Friday, August 24, 2007

Grand Rounds Reminder


Just a reminder that the deadline for Grand Rounds submissions is Sunday at noon (Pacific time). I've already gotten a lot of good submissions, but if you have one you haven't sent me, I want to see that one, too!

And that's my entire post for today, because it's been a very long day and I'm really tired. And tomorrow I have a homily to write.

G'night!

Thursday, August 23, 2007

Yay, Sort Of


My syllabi and other handouts for Monday are finished and photocopied, and I've planned each class. I went to the university bookstore today and splurged on some new school supplies, mainly spiffy, bright plastic folders to replace my ratty paper ones. (Last spring, I devised a system of keeping different categories of papers in different colored folders: this worked very well, but my students warned me never to make the folders the same color, or chaos would ensue.) I think I became a college professor to be able to keep buying school supplies!

I also finally got around to reading my teaching evaluations from last semester, which were overwhelmingly positive. Since spring is usually my toughest time of year, and since one of the classes was thrown together at the last minute when a grad seminar didn't make, that was especially gratifying. My workshop evaluations did have a consistent theme of wanting me to lecture more (!), but I'd already planned to do that this fall, so all's well.

So school stuff's in very good shape at the moment. Other things are pretty chaotic: I have vast towering heaps of e-mail to answer (sorry, everybody!), and I haven't started my homily for Sunday -- although I have a general idea of what I'll be saying -- and since it's Morning Prayer, I also have to figure out what anthems etc. we're doing, which I probably should have done yesterday or today, oh dear oh dear, and I'm behind on revising both my Mythcon essay and the ED Sonnets.

And, actually, not all school stuff is in good shape, either, since I need to work on various committee matters.

Eeeep!

It Will All Get Done Somehow. This is my mantra.

Wednesday, August 22, 2007

Partners in Their Own Care


The other day I saw this photo of a beluga whale calf on the ever-beguiling Cute Overload, a site that does wonders for my mental health. I followed links to the calf's home,
Shedd Aquarium in Chicago, where I found the following description (on this page) of their marine mammal training program:
The emphasis on training goes far beyond putting on presentations several times a day for guests. Training provides the animals with mental stimulation, it gives them physical exercise and, perhaps most importantly, it teaches them to cooperate in their own care. With a simple hand cue from a trainer, a 1,700-pound beluga whale positions itself for a mouth exam or to allow a veterinarian to take a blood sample from its tail. Teaching the animals to participate in their own healthcare makes the regular medical exams easy for staff members. And it’s easy for the animals, too, because all training is conducted like a play session, with food, toys, or verbal praise as frequent rewards.
We've all heard a lot about the importance of people being partners in their own healthcare, but I'd never seen the principle applied to non-human animals! On the other hand, having watched 35-pound children in the hospital vigorously resisting blood draws, I certainly wouldn't want to be in the vicinity if a 1,700-pound beluga whale were doing the same thing.

Now if only Gary and I could train our cats to be happier at the vet's office! Of course, if we could train our cats, our furniture would be in much better shape.

Tuesday, August 21, 2007

Back to School with Grand Rounds!


This week's Grand Rounds is up, with a "Back to School" theme. I'm delighted to be included, even though I'm not close to being ready to go back to school myself next week!

And don't forget that I'm hosting Grand Rounds next week (preaching Sunday, school starts Monday, hosting GR on Tuesday: what was I thinking?). Here's my call for submissions.

Happy reading!

Monday, August 20, 2007

Today's Winning T-Shirt Design


A colleague at work who owns a pit bull, and who's been involved in pit bull rescue, was wearing this today. She has an entire set of anti-Vick t-shirts. You can see a lot of them here.

I know I should be praying for Vick and for everybody else who mistreats animals. I find this very, very difficult. I know someone who tortured animals as a child, and who's grown up to be the kind of person whose favorite vacation is building houses for people living in muddy cardboard boxes in the Caribbean. (Even more miraculously, I believe this transformation occurred without any psychiatric help.) I know that redemption is possible for everybody, and that God loves Michael Vick as much as She loves any of the rest of us, as much as He loves the pit bulls themselves.

But it's intellectual knowledge. I'm having trouble feeling it, if you know what I mean.

Lord, let Michael Vick be healed somehow: but please, please, don't let him keep his job with the NFL!

The Never-Ending Journey


I put Dad on a plane this morning. The security people at the airport couldn't have been nicer: they let him keep his Ensure even though it was in bottles of more than three ounces, helped him back on with his shoes -- and tied his shoelaces for him -- after the security screening, and didn't hassle him about his carry-on bag containing twenty-two (count 'em, twenty-two) containers of daily prescription medication, including heavy-duty pain meds. He boarded the plane early, and it took off early and landed in Denver early.

In Denver, of course, everything got screwed up, although to be fair, that was probably because of horrendous weather in Philly. (Gary and I once had an absolutely hellish experience being stranded overnight in Denver, and now never fly through there if we have a choice; when we booked Dad's tickets, though, we wound up not having a choice.) Dad was supposed to have a layover of several hours, which is bad enough, but the wait grew and grew and grew. He was originally supposed to leave a bit before 5:00 and land at 10:30 Philly time; the plane finally took off a bit after 8:00, and is now due to arrive in Philly after two in the morning.

My poor father. My poor sister, who's picking him up!

But I'm really glad he came out, although he may not be, after the grueling trip back home. We had a lovely visit. He especially enjoyed sitting on our deck, which he's doing in the photo above. We ate out there almost every evening -- Gary and I don't do that on our own, since schlepping a meal outside while keeping the cats from escaping is a bit too much effort -- and went for drives to places like Donner Lake and Pyramid Lake, both of which are gorgeous. My father revels in landscape, so he was very happy.

When my mother and sister visit, we shop. When Dad visits, we drive.

We both got choked up saying good-by at the airport; other passengers watched with sympathetic smiles.

And on a slightly lighter note, here's a nifty photo Gary took of Bali, who'd crawled between the blinds and the window to watch the finches at the birdbeeder. You'll probably have to enlarge it to see it properly, but it's a nice shot.

My father was surprisingly sweet with the cats, given that he likes them less than anyone else in the family. They're glad to be able to get into my study again, since it was off limits when it was serving as Dad's guestroom.

Saturday, August 18, 2007

Grand Rounds 3:49: Call for Submissions


On Tuesday, August 28, I'll be hosting Grand Rounds, the weekly medblogging carnival.

This edition will have a suggested -- but not required! -- theme of Narrative Medicine, which I've explained below. I'll be choosing the thirty best-written and most interesting posts, whether they're connected to the theme or not.

The submission deadline is noon PDT on Sunday, August 26. Please e-mail your submission to SusanPal at aol dot com. Put "Grand Rounds" in the subject line of the e-mail, and please include the URL of the post, a 2-3 line summary of the post, and the name and URL of your blog. If you have questions, please let me know!

So what's Narrative Medicine, anyway?

Pioneered by Rita Charon, an internist and professor at Columbia's College of Physicians and Surgeons, Narrative Medicine trains doctors and other caregivers to use careful listening and reflective writing to forge deeper connections with their patients, resulting in better care.

Charon describes three essential components of narrative medicine, all of which are natural topics for medbloggers:

Attention: Listening carefully to patients, which includes remaining sensitive to what they may not be saying, gives the caregiver potentially valuable information and also makes the patient feel more cared for. So: when have you heard a patient story that surprised or moved you? When has a patient responded with gratitude to your attentive listening?

Representation: Using writing to reflect on patient interactions helps caregivers understand both their own feelings and those of their patients more deeply. What has medblogging, or other reflective writing, taught you about yourself or about your patients?

Affiliation: The process of attending carefully to patients and reflecting on patient stories ultimately makes caregivers stronger and more passionate patient advocates, because they've become more invested in their patients' lives. How has medblogging changed the way you approach or understand patients? How has writing made you a better caregiver, or made you better at caring for yourself in a demanding profession?

Just Imagine


When I was preparing for the med-school seminar on death and dying I taught last week, I read Stephen J. Freeman's Grief and Loss: Understanding the Journey. It's a good book, and I think it would be very useful for medical students, although I wound up not using much of it in the seminar.

One passage from the book, though, really jumped out at me. On page 96, in his chapter on unresolved grief, Freeman includes a section called "Deal with the Fantasy of Ending Grief:"
Fantasies sometimes provide us a glimpse of reality. It might be helpful when grieving has gone on for prolonged periods to have the bereaved fantasize about what it would be like to finish grieving. This exercise should take the form of experiencing both the pros and cons of grieving. Fully examine and experience what life would be like without grief and what the bereaved would be giving up by not continuing to grieve.
This activity might come more naturally to a therapist or other counselor than to a physician; nonetheless, it highlights the role of the imagination in healing. It's much easier for all of us to reach any given place -- whether a physical location or a state of mind -- if we can visualize it first. When we can't imagine better or at least different outcomes, hope has died and chances for healing are diminished.

Medical students and other future clinicians, especially in their first two years, are bombarded with facts and data. Imagination tends to go by the wayside, except perhaps as the component of research necessary to formulate a hypothesis. But good doctors need to be able to encourage patients to imagine themselves in full health, and they also need to be able to imagine a range of explanations for patient or family behavior. They need to be able to imagine the non-obvious, both in clinical diagnosis and in personal interactions.

As a volunteer ED chaplain, I've sometimes seen caregivers leap to the first or most obvious conclusions about patients and their families. The relative obsessing about her own health conditions in the face of a loved one's terminal diagnosis is obviously a selfish hypochondriac; the frail little old lady who's alone in the ED has obviously been abandoned by heartless, unfeeling family; the homeless frequent flyer who lies about combat experience is obviously engaging in a contemptible charade.

I try to remind caregivers that there may be other things going on. Maybe the seeming hypochondriac is really worried about being able to care for a dying relative while also coping with personal illness. Maybe the frail little old lady has behaved so badly to her family that they haven't been able to care for her while also caring for themselves; or, at the very least, surely they have stories they could tell to explain their behavior. Maybe the homeless patient is mentally ill and really believes that he was in combat, or maybe his stories of being in combat are really metaphorical narratives about the difficulties of surviving on the street.

Any given situation can be explained by a range of stories. Reminding ourselves to imagine all of those possibilities helps us stay flexible, caring, and open to hearing the true tale, which is almost always both deeper and stranger than anything we've imagined. Nonetheless, imagination is excellent training for navigating the consensus reality in which we live.

Patients need imagination to heal. Caregivers need imagination to treat patients with compassion and dignity. Although objective test results are essential to medicine, there's much more to human experience than blood values and radiological images.

Thursday, August 16, 2007

Finding the Right Equipment


I drive a 1999 Ford Escort, which we bought used; it had formerly been a rental car. It came with a radio -- with an excellent sound system -- but nothing else. Gary and I have talked periodically about getting a CD player or XM radio, but whenever we investigated those options, the cost was a bit more than we wanted to spend, especially since I really don't do that much driving. Aside from the occasional (maybe four times a year) drive to San Francisco, everywhere I need to go regularly is in a four-mile radius from my house.

But my birthday's coming up in September, and my parents always nag me about what I want, and I can never think of anything. So this year, I decided that I'd mention the car CD-player to my father, who loves music. When we priced the project, it turned out to be even more expensive than we'd anticipated; installing a CD player in a 99 Ford Escort requires replacing part of the dash, in addition to a new wiring harness and the deck itself.

I'd told my father that he might want to split the cost with my mother, and that it would be fine with me if it covered both birthday and Christmas for both of them. Gary and I also offered to pay for part of it ourselves, since my father's on very limited Social Security income. But we got the set installed yesterday, and my father insisted on paying for the whole thing.

We're all very happy. Gary and I love being able to listen to our favorite music in the car; my father's delighted that he was able to get us something we really wanted and will use a lot. Yesterday we went for a drive around Reno, since Dad enjoys the scenery, and listened to folk music. Great fun!

Meanwhile, on Tuesday I'd lost the special magnetic clip-on sunglasses that came with my prescription. I have a tiny head and usually have to buy chidren's frames, and for the past five years or so, I've been getting the ones with magnetic clip-ons, since they're easy to use. The downside is that I lose them a lot, and my optometrist's office wants $100 to replace them. And Reno is not a place where anyone can survive without sunglasses.

So I was very seriously bummed about losing the clip-ons. But while I was waiting for the car installation yesterday, I wandered into a convenience store and found clip-ons that work via springs and only cost $10. I got the pair that fit my glasses best and drove home feeling very pleased with myself.

Yesterday evening, we made a supermarket run, and there I found a pair of the spring-loaded clip-ons that fit my glsses even better than the first pair, although they cost slightly more ($15). So I now have a backup pair of sunglasses! And I'm freed from the tyranny of the optometrist's office! Tra-la!

Wednesday, August 15, 2007

Med School Seminar


It went well; sixteen students and three faculty were there, and everyone seemed to get a lot out of the writing exercise I gave them. It helped that we were working with a really juicy (although very sad) case that raised a lot of questions and offered many possible viewpoints. I also used anecdotes from my own hospital experience.

The students did a great job, and several said that they don't get to do much reflective writing and really appreciated the opportunity. (Various faculty, including the three who were there, are working on ways to incorporate more reflective writing into the curriculum.)

I was dissatisfied with the last forty minutes: the seminar lagged a little at the end, and I could have done a much better job on time management. If/when I teach this seminar again, I'll definitely organize things differently. But for a first effort with a new audience, I'm pleased.

Tuesday, August 14, 2007

Grand Rounds


This week's Grand Rounds is up, and I'm delighted to be included.

Happy reading! I can't believe I'll be hosting in two weeks. Yikes!

Monday, August 13, 2007

Hip Hip Hurray for the Reno VA!


Today I took Dad to our local VA Medical Center. He needed some medication that the Philadelphia VA was supposed to have mailed to my house, but that hasn't arrived yet. He's been out of those meds for three days now, and I'd called the Reno VAMC and been told that he could register at eligibility services with that hospital and get a stopgap supply of pills.

Since I hadn't been to this hospital before, of course I parked near the wrong entrance. When we went inside and I asked a passing man in a white coat -- doctor or tech, I don't know which -- how to get to the eligibility office, he frowned and said, "I'd better just take you there."

And so he did, leading us on a ten-minute trek involving long hallways between buildings, an elevator ride, and lots of baffling turns. We thanked him profusely for being so helpful; we never would have found the place on our own!

The man in the eligibility office was similarly kind and obliging, remaining patient and courteous even when Dad -- who was wearing his anti-war button on his hat -- launched into a slightly scatological and deeply anti-Bush joke. "Um, Dad," I said in alarm, "this might not be the best place for that particular joke."

My father laughed. "Oh, I've discovered that this joke always goes over very well at the VA."

The eligibility fellow gave us a tolerant smile and said, "Even though I'm a dyed-in-the-wool Republican, I always appreciate a good joke."

He got Dad's Philly info transferred into the Reno system, and told us that we had to wait to see a pharmacist on the primary-care team, who'd give us the prescription. But the clerk in the primary-care area told us that the pharamacist was at lunch (it was now 1:00) and would be back at 2:00. We told her that we were going to the canteen to get coffee.

The canteen was near the entrance where we'd parked. We tried to retrace our steps, wishing we'd dropped breadcrumbs behind us, and soon got lost. I saw a courtyard with the building we wanted across the way; stairs led to it, but surely there must be a wheelchair ramp somewhere too?

We went outside to investigate. We didn't find a wheelchair ramp, although we did meet two people with darling teacup service dogs. It was pleasant out there, with flowers and a fountain, so Dad and I decided that I should park him in the shade and go buy him some coffee.

I did that. We sat on a bench in the courtyard, snacking and enjoying the fresh air, and a little before 2:00, we set out for the primary-care waiting area again.

When we got there, the clerk ran to meet us, waving her arms in distress. "The pharmacist came back! She only had one appointment open today, at 1:40! I tried to find you! I sent someone to the canteen to find you! But now it's too late!"

"We were in the courtyard," I told her, touched that she'd gone to all that effort to try to locate us. "Isn't there any way we can get those meds today?"

She frowned and thought for a minute, and then brightened. "Yes, sure. I'll have you go through Urgent Care."

That waiting room looked pretty crowded to me, so we settled in for a good long wait. But Dad's name was called in about ten minutes, and we talked to a very pleasant intake nurse, who told us that we could have gone to the ER this weekend to get the meds. She promised to try to expedite the pharmacy refill, and sure enough, about thirty seconds later, she'd spoken to a doctor and gotten Dad's prescription.

We went to the pharmacy, where we were told that Dad's meds would be ready in about half an hour. In the meantime, Dad wanted a shave, and we'd learned that there was a barber shop next to the entrance where we'd parked. We found our way back there without having to ask too many people for directions.

While Dad was getting his shave, I decided to take his VA card and go pick up his meds, since getting back to the pharmacy was a lot easier without pushing a wheelchair, and since it would be more convenient for Dad to stay close to the car. I didn't see Dad's name on the "your meds are ready" monitor, but I got in the line anyway, to see if maybe they might show up by the time I got to the desk. When I handed Dad's VA card to the pharmacy clerk, I expected to be yelled at for getting in line before our name came up.

Instead, the clerk said, "Let me check on that for you," scanned Dad's card, and said, "That will be ready in about ten minutes." I thanked him and sat down, but Dad's name came up almost immediately, and the clerk handed me the bag with a smile.

When I got back to the barber shop, Dad was sitting outside, clean shaven and beaming. While he was getting his shave, two other men had come in to pass the time. The barber told a joke. Dad told his anti-Bush joke. Everybody laughed. When Dad asked the barber how much the shave was, the barber said, "Don't worry about it; it's taken care of. You told the best joke today."

Of course Dad gave him a nice tip.

On the way home, we couldn't stop talking about how friendly and helpful everyone had been. Dad said that the Gulfport and Philadelphia VAMCs aren't like that, although of course they're also larger. What really stood out for me, and moved me, was how explicit everyone was about the privilege of serving servicemen and women. The eligibility clerk, when the phone rang during our conversation with him, picked it up and said, "I'm serving one of our veterans, so I'll have to put you on hold for five or ten minutes or ask you to call back." The intake nurse at the Urgent Care clinic, when she was telling us how we could have gotten meds for Dad this weekend, said, "That's a service we provide for our veterans."

Maybe this is just rhetoric. When we told Gary about it, he said, "I bet they're doing that as PR after the mess at Walter Reed." But whether it's PR or not, we noticed it, and it impressed both of us. The warmth and flexibility we experienced from everyone there made a fairly tortuous process much pleasanter.

Thank you, Reno VAMC! Keep up the good work!

Sunday, August 12, 2007

Papa Palwick and the Kitties of Doom


Here's my Dad. We're having a nice visit, although he's frustrated by how little energy and appetite he has. He sat in a chair in the family room most of yesterday, but in the evening we sat out on the deck for a while, and he said that did him a world of good, so my goal today is to get him onto the deck earlier (since I'll be at church in the morning, Gary may need to oversee that project). In the afternoon, if Dad's up to it, we'll drive to campus so he can see my new office.

Yesterday before dinner, he lay on our bed for a while. When I take naps, Harley routinely hops up onto the bed to nudge and nag me into getting up: this is part of his Rescue Kitty function, since it's highly unnatural for humans to lie down while the sun is up. (He never does it at night, and in the morning, Bali's the one who wakes me up to be fed.) Sure enough, Harley did the same thing to my father. I tried to get some photos, but they were too blurry. My sister had warned us that Dad is impatient with cats, but so far, he's been very sweet with ours. He did say, "Stop that!" when Harley kept nudging his elbow, but I do the same thing when Harley kneads my ribcage.

I did get a picture of Harley playing his "everything is a cave!" game. He adores climbing into wastebaskets. I don't know why cats glory so in small, confined spaces, but I've never met a cat who didn't. Harley does have a particular fetish for trash receptacles, though.

Red is my father's favorite color, and he kept his red jacket on when we came inside from the deck. Gary hates this picture and claims that it makes him look like a space alien, but I told him it doesn't. So anybody who leaves a comment, please back me up and tell Gary he doesn't look like a space alien!

Here Dad's looking at a photo we took of my mother when she was here. It's a neat picture because you can see the image of her through the paper, and she was wearing red too. (Anyone who was at my Mythcon reading will recognize this as one of the images I used; it was the one that kept falling over!)

And heeeeere's Bali! Because he's all black, it's hard to get good photos of him, so I was pleased with this one. It's a particularly nice shot of his beautiful golden eyes.

So that's the visit report so far. Tomorrow, Dad wants me to take him to the VA so he can try to pick up some medication. (It was supposed to arrive by mail, but hasn't yet.) I hope we can do something fun tomorrow, too -- a little drive, maybe -- especially since I'll be gone much of Tuesday, teaching at the med school.

Saturday, August 11, 2007

Upswing


It's been a bit of a tough week. Wednesday I visited the friends whose baby had died, and Thursday I had a really draining shift at the hospital: two visits with terminally ill patients (one of whom got a grim test result while I was in the room), followed by a visit with a haunted, conflicted combat veteran. I bungled that one very badly, undoing the good work of what had been a positive interaction by asking a singularly stupid question; the patient chewed me out in no uncertain terms, very understandably, and I felt horrible about it. (When in doubt, shut up. As often as I relearn this, I always seem to forget it again.)

I had more than my share of confronting my own limitations this week. This is, of course, a reminder that God can do what I can't, but in situations where one wants to demand of God, "What were you thinking?" that reminder isn't necessarily a comfort.

Yesterday, things turned around. Remember the baby shower I was going to on Wednesday? (It was a really nice party!) My pregnant friend had been scheduled to have the baby by c-section this coming Wednesday, but Friday she went for a routine checkup, and her doctor decided that the baby needed to come out then. Right then. Her doctor's appointment was at 1:00. The baby was delivered by 3:30. Mother and child, a little girl, are doing very well, thank you, and yesterday I visited them in the hospital and got to hold baby Ada, who's just gorgeous.

Holding a healthy newborn was exactly what I needed after the events of the previous two days, and the fact that the obstetrician picked up on warning signs and saved what could have been a dire situation restored my faith in what medicine can do, after a few too many examples this week of what it can't.

Babies: good medicine!

Meanwhile, I had a meeting with my friend Marin at the medical school to go over my teaching plan for the med-school seminar on Tuesday. We had a comedy of errors finding each other, but when we finally did, the meeting went swimmingly. I feel good about what I've planned, and Marin was very enthusiastic. Now I just hope the students like it!

My father arrived safely last night, after another comedy of errors involving delays -- he was two hours late -- and United's dithering about whether they were going to allow me to meet him at the gate or not. They finally decided that they would, after telling me categorically that I couldn't (this after I'd made two separate calls to the airport and the airline and been told that of course I could).

When we got home, I found e-mail from my friend Ann the poet, who'd written a thoughtful and very helpful critique of my ED sonnets. She has a lot of good ideas for strengthening the sequence, but certainly seems to feel that doing so will be worth the effort. So that was heartening.

Oh, on Tuesday I saw my psychiatrist, who's taking me off the nortriptylene -- just in case it contributed to my wonky EKG -- and has begun the process of starting me on Lexapro. I'm still taking the Effexor too, but the ultimate goal is for me to be only on the Lexapro, which supposedly had fewer side effects than other SSRIs. I'm a little nervous, since I couldn't write on Prozac, which is also an SSRI, but my doc assures me that if this happens, I can go back to the current regimen.

Fun with meds! Yay! But I like the idea of only one pill. And I haven't given up on my eventual goal of being off meds, at least for a while, even though my doc's dubious about that.

And, finally, here's the latest batch o' cat pix. I had a quilt and some blankets piled on a chair while I was making my father's bed, and Figgy discovered that they made a wonderful cave. Click to enlarge, and enjoy!




Thursday, August 09, 2007

Carnival of Hope: Volume 1, Number 12


Welcome to the August Carnival of Hope! As I explained in a blog post a few days ago, this will be the last edition. While I've enjoyed working on the carnival, I want to move on and do other things. I'm very grateful to the people who've submitted posts over the year I've been doing this. Thank you all!

My favorite post this month is Tom Gilson's delightful Two Churches, Two Races, One Heart. "Our church, especially our youth, is spending the week ministering in a poor and troubled part of town, partnering with a church that's located right in that neighborhood. Our church is 99.8% white. The other church is just as thoroughly African-American. We have absolutely fallen in love with each other this week." I dare anyone, religious or not, to read this and not feel more hopeful about the possibility of transcending ethnic and cultural barriers!

And on an only slightly similar but still delightful note, here's Mother Jones' Got God?, in which she rewrites the Nurses' Prayer ("God, please get me through this shift in one piece"), adding, "I'm convinced that the only thing that keeps me in nursing is divine intervention." As a hospital volunteer, I can attest to the fact that to patients, nurses themselves often seem like agents of divine intervention! Thanks for your devotion to your profession, Mother Jones.

Not everyone can be a nurse, but almost everyone can follow Vivek Khemka's lead in making a list of Ten Simple Ways to Save the World. We'll probably all have different lists, but even small efforts can have large effects.

If you need an item to start your own list, you could do worse than Roger Carr's idea of Giving Thanks, Love and Appreciation. Roger notes how strangers smile at him when he says "I love you" into his cellphone in public. I always enjoy overhearing that phrase, too -- even though I usually loathe cellphones!

If a chance encounter with a stranger talking on a cellphone can brighten our day, what could a chance encounter with a shaman do? Tupelo Kenyon tells us in Reverence For Life Through Nature.

Tupelo's encounter with the shaman deepened his reverence for the interconnectedness of creation. But how can we reclaim aspects of creation that have been devalued? Bdurfee offers an instructive anecdote in Sharing the Wealth. This post is less personal than most I include here, but I was really struck by the observation that while money is often a taboo subject in our culture, wealth and abundance are celebrated. If money feels dirty or shameful to us, then, the trick is to perceive it as a form of abundance.

Perception is also the key in Karen Murphy's self-deception, and the way out of it, which concludes with her observations about the healing power of writing. Although my approach isn't quite as metaphysical as Karen's, I loved the humor in her writing, especially in the phrase "the Special Extra-Dark Glasses of Half-Emptiness." Hey! I've got a pair of those too! We must go to the same optometrist!

Wouldn't that make a great Boy Wizard Book title? Barry Rotter and the Special Extra-Dark Glasses of Half-Emptiness. Yes! It's perfect!

Dr. Hal describes his own Extra-Dark Glasses prescription, the one that consists of seeing what isn't there rather than what is, in What Are You Looking For? Note: While I love Dr. Hal's story about his and his wife's different perceptions of the lake, I don't agree with his final statement, "Remember, We Live within the Environment Created by Our Choices!" The power of choice is a luxury denied to many people in the world, especially the very poor, the very young, and the very old; while perception and attitude can certainly make a difference in what we do with our circumstances, certain material conditions can't be changed by willpower. Victims of genocide in Darfur didn't choose to die: their environment was created, tragically, by other people's choices.

That doesn't mean that there's no hope, though. It does mean that each of us has to consciously make the best choices we can, and find ways to try to influence others to do the same. We can begin the work of creating a better world, even if we can never finish it. In that spirit, I leave you with Bishop Ken Untener's famous, but always timely, prayer in honor of Oscar Romero:

It helps now and then to step back and take a long view.
The Kingdom is not only beyond our efforts,
it is beyond our vision.

We accomplish in our lifetime only a fraction
of the magnificent enterprise that is God's work.
Nothing we do is complete, which is another way of
saying that the kingdom always lies beyond us.

No statement says all that could be said.
No prayer fully expresses our faith. No confession
brings perfection, no pastoral visit brings wholeness.
No program accomplishes the Church's mission.
No set of goals and objectives include everything.
This is what we are about. We plant the seeds that one
day will grow. We water the seeds already planted
knowing that they hold future promise.
We lay foundations that will need further development.
We provide yeast that produces effects
far beyond our capabilities.

We cannot do everything, and there is a sense of
liberation in realizing this.
This enables us to do something, and to do it very well.
It may be incomplete, but it is a beginning,
a step along the way, an opportunity for the Lord's
grace to enter and do the rest.
We may never see the end results, but that is the
difference between the master builder and the worker.

We are workers, not master builders, ministers, not
messiahs. We are prophets of a future not our own.
May whatever you believe in most strongly sustain you, and may you journey with hope towards a bright future.

Training Spirit-Friendly Doctors


For the past few months, I've been attending meetings at the University of Nevada Medical School of a group of people who have a small grant from the George Washington Institute for Spirituality and Health (GWISH). (I'm now listed on the grant as a research assistant, which involved completing three hours of online Institutional Review Board training. This was quite the adventure, since I have no biomedical training and was taking the biomedical module!)

The GWISH group is going into the third year of a three-year grant, with a charter to work on integrating awareness of spiritual issues into the medical curriculum. For instance, our med school, like many others, uses standardized patients (SPs), laypeople coached to provide specific medical histories, to help train medical students; the GWISH group has been working up an SP case involving spiritual issues, and is also encouraging the students to incorporate FICA questions into the medical history.

But we spent most of the last meeting talking about why the GWISH project has been, in the words of one participant, "a tough sell." The meeting had been originally intended as a welcome dinner for new family-practice interns and residents, who would be invited to contribute to the project. Only three of about eighteen showed up.

The main reason for this, of course, is lack of time and energy; if you're working eighty hours a week in a physically, emotionally and intellectually draining new job, you won't be inclined to spend your limited resources on a topic that might seem extraneous or "soft." So the question for the GWISH group became: How can we make spirituality-and-health issues seem essential, worth taking the time to learn about, rather than irrelevant? Evidence-Based Medicine (EBM) is all the rage these days, and spiritual issues, almost by definition, defy scientific inquiry. So how do we sell them to medical students and new doctors?

The most EBM-friendly doctor in the GWISH group (although of course he's also sympathetic to spirituality too, or he wouldn't be there) took it upon himself to play Devil's Advocate. The best way to sell spirituality, he told us, would be to find rigorous, double-blind scientific studies demonstrating its impact on health. No one was quite sure if that sort of evidence exists. There has been some research on the helpful role of spirituality in depression, for instance, but no one knew how extensive or scientifically bullet-proof such studies have been.

I asked if, in the absence of double-blind studies, anecdotal evidence would be acceptable. Our EBM doc allowed that it was a distant second, but would have to do if nothing better were available. One of the residents, who'd just finished a rural rotation with a family-practice doc, told us a story about how that physician offered a brief nondenominational prayer at the end of each office visit, but only for patients he already knew would welcome it. The resident was intrigued by this, and observed that the prayer process seemed to smooth any preexisting tensions and end the visit on a positive note.

With all this in mind, I'm hereby conducting an extremely informal and unscientific survey of blog readers, consisting of four questions, some with subsections. It's probably worth mentioning here that I define spirituality as "how we define the larger meaning of our lives." I'm not sure exactly how GWISH defines it, but the FICA questions should give you a good idea of what they're looking for.

1. Do you know of any research categorically demonstrating the impact of spirituality on health, or its value in medical care?

2. If you are or have been a medical student:
a) How important do you consider spirituality in medicine?
b) Have you been taught about spiritual issues in medical school?
c) If you have been taught about them, what was most valuable to you in the information you were given?
d) If you haven't been taught about them, do you wish you had been? If so, what form would you want that to take?

3. If you're a practicing physician:
a) Have you had patients for whom spirituality was a vital element of medical care? If so, can you venture a guess as to the percentage of your patients in this category?
b) Are you comfortable discussing spiritual issues with patients?
c) Do you incorporate spiritual questions or content into interactions with patients? If so, under what conditions, and in what form?
d) How do you think healthcare professionals can become more comfortable with and better informed about spiritual issues?

4. If you're a patient (and that includes all of us, right?):
a) How important is your spirituality to your health?
b) Are you comfortable discussing spiritual issues with your healthcare providers?
c) Have any of your healthcare providers raised spiritual issues? If so, in what context? Were you comfortable with their doing so?
d) Do you think healthcare professionals need to be more "spiritually literate"? If so, how?

Note: I know that nurses deal with spiritual issues also, as much as (if not more than) doctors do, but since I'm trying to get information for our medical school, I'm phrasing the questions mainly in terms of physicians. But if you're a nurse and want to give me your two cents, I'd be delighted!

You can either leave your responses in the comments section, or e-mail me privately at SusanPal at aol dot com.

Thanks so much!

Wednesday, August 08, 2007

The Gamut


This afternoon, I visited some friends whose first child, a little girl, died in utero, eight months along. She'd been doing splendidly, and then she just -- stopped moving.

Perhaps I shouldn't say that this child was their first; they lost another baby to miscarriage, much earlier along.

The hospital folks induced labor (they claim it's better psychologically to go through the entire process, although it seems to me that laboring to deliver a dead baby has to be the worst experience in the world), but it didn't work, so after twenty-four hours of induced labor, they did a c-section.

My friends got to see and hold their little girl, who looks perfect. No one has any idea why she died. They're doing tests to find out.

I saw photographs of her, along with a plaster plaque with her handprints and footprints, a small pink newborn cap, and a poem by a mother whose child was stillborn. All of this was in a box the Labor and Delivery team gave the parents. That's a lovely set of mementos, although heart-wrenchingly sad.

They're going to have a memorial service in a week or two.

On my way home from the hospital, I stopped to buy wrapping paper and a gift bag for a baby shower I'll be attending tonight, for some friends expecting their second child (also by c-section) on August 15. I expect that gathering to be as joyous as the one this afternoon was somber.

One of the gift bags had tiny baby footprints on it. At any other time, I might have bought that bag, but today, I couldn't bear to look at it.

Carnival of Hope: Announcement and Reminder


Please remember that the Carnival of Hope deadline is tomorrow at 5 PM PDT. If you're a regular reader of this blog and have a post that might fit, please send it to to me! (SusanPal at aol dot com)

This will be the last edition. I've been putting together this carnival for a year now, and the effort hasn't been worth the return. I've met some interesting people and read nice posts, but every month I get swamped with cheesy inspirational "personal-development" posts -- the kind where the predominant pronoun is "you," rather than "I" -- and I haven't figured out how to carve out my own niche so I won't have to deal with that stuff. (Carnival of Personal Narrative? Carnival of First-Person Anecdote?) And CoH consistently gets fewer hits than my other posts do. And there are other places I'd rather be putting my energy.

So: it's been fun, but it's time to move on. I'm looking forward to the last edition, though!

Tuesday, August 07, 2007

Grand Rounds, and Trees


This week's Grand Rounds is up! I was not, alas, organized enough to submit a post this week -- although I had one in mind I'll submit next week -- but I'm looking forward to reading the others.

In the meantime, here are photos of that tree in Berkeley I mentioned. These pictures really don't capture the tree's beauty, or the unusual shape of its branches, but they're the best of the ones I took. Enjoy!

And now I'm off to take the car in for an oil change, swim, and continue class prep!