Tuesday, August 19, 2014

Conversation


“If you don’t mind my saying,” my Friend said to me, “I have noticed something about these little visits you make. You know you have been coming to visit for quite a while, and I always enjoy our time together immensely, more than you can possibly imagine. But I must say, I notice a strange thing about how you converse. Do you mind if I share it?”

“Not at all,” I said, surprised and pleased. “Please do.”

“Well, I notice that you come to visit and you always have such things to talk about, really very deep things, although most of them you do not understand in the slightest. You seem utterly determined to keep the conversation on those topics. Why is that?”

“I am afraid I don’t understand,” I admitted, slightly puzzled and, truth be told, just the tiniest bit offended, though I reminded myself that my Friend’s bluntness was just exactly what I needed most. “What exactly do you mean?”

“Well, you will be going along, chattering away about metaphysical hogwash and yadah yadah, and you will start to go off on a tangent. Maybe you will start to talk about the leaky faucet and how you have been meaning to get to that, or that bill that is going to be overdue in a week; but then, right as you are about to get going, you stop, you apologize, and you go back to your high-falutin’ talk.”

“I suppose I do,” I said, somewhat stiffly.

“Why? Why do you always cut the tangents short? And why the apology?”

“Well,” I answered, “For more or less the same reason I don’t answer my cell phone here. I don’t want to be distracted from the conversation. It is out of courtesy to you.”

My Friend laughed. “Oh, but Bless your Soul, did you really think this was a conversation? Goodness, a conversation implies two-way communication, and thus far you have done most of the talking. But let me explain it this way. Suppose you were in the middle of one of your ‘conversations’ with me and one of the children came in and asked for a drink of water? Or your wife asked you to grill some hamburgers. What would you do? Would you say, ‘Oh, sorry, go away, don’t bother Daddy now, he is talking to his Friend? Sorry, babe, I am in the middle of a VERY IMPORTANT CONVERSATION!’ Or would you get up and do as they asked?”

I shifted uncomfortably in my seat. “I hope I would get up and do what they asked.”

“You would,” he agreed kindly. “Rest assured you would do it, and I know you would. Why?”

“Because you would always want me to fulfill the duties of my state in life before any other consideration.”

“Very correct,” my Friend said with a hint of irony. “Do you think that I am not within the children? Within your wife? Within each and every person, down to the very least of these who has a claim upon your service? Do you think you could serve them without serving me?”

“No,” I answered. “I know that in serving them I serve you.”

“And do you not know that when I come to you disguised as a child it is no less me than when I come to you disguised as bread and wine?”

“I know this.”

“Then apply that same logic to your tangential thoughts,” He said. “Do you think any thought arises in your mind that I have not allowed? Do you think any thought, even the least stray imagining of yours, is uninteresting to me? Who gave you this list of approved topics of conversation that you follow so scrupulously?”

I knew not what to say, so I said nothing.

“Perhaps instead of biting off those tangents and shoving them back into a corner somewhere (where they will either go bad or go to seed, but never go away), maybe you should take up one or two of them? I already know what is worrying you, far better than you do. Let me see it (by which I mean, ‘let me show it to you’) and share it with you, and we can deal with it together. Who knows, perhaps this conversation thing might become an actual conversation after all.”

Thursday, August 14, 2014

Patient Interactions

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My favorite part of medicine is interacting with patients. My second favorite part is fitting the puzzle together, piecing all of the various bits of data from history, exam, labs and the literature to form a coherent image. For some providers, I suppose, that is the most exciting part. Dr. House comes to mind as an example of that disease oriented provider. Others are all about the procedures. They just enjoy getting hands on the patients, physically manipulating the diseased part, and providing healing that way. I suppose that category would include most surgeons. I find, however, that most patient encounters do not require much puzzling. Most are actually quite straightforward. Hardly of my patient encounters require procedures, although they are fun when they happen. However, every patient encounter includes an encounter with another human being. Sometimes these encounters are memorable, sometimes not. Sometimes they are fun, and sometimes they are not. Sometimes there is good rapport, and sometimes it seems that you are speaking totally different languages. Regardless, the encounter is always an encounter with the ineffable other of a human being who is not myself.
Tacoma is known for having a very high percentage of Asian populations. In fact, South Tacoma Way, one of my favorite strips for Asian cuisine, is informally called “South Korea Way.” Street signs are even labeled in Korean. Being a Special Forces soldier, my training includes a foreign language, which, in my case, is Korean. I would not say that I am fluent. I can order food, exchange pleasantries, and maybe chat a little bit about C. S. Lewis’ book “The Four Loves,” (I memorized a good deal of vocabulary for that book when I was preparing for my Korean speaking and listening test). It is not, however, to allow me to hold a conversation with ease with a native Korean speaker.
Several of my patients over the last two weeks were older Korean ladies, wives of Korean war veterans. I usually enjoy chatting with them a little, enough to say “Hello, how are you doing, where does it hurt?” One patient, in particular, was a very sad looking Korean lady who complained of fatigue, tiredness, pain, and heartburn. We talked with her for quite some time trying to come up with a list of her complaints and prioritize them, but she was a very listless and haphazard historian and she complained of confusion. Finally I asked, in Korean, “Sunsengnim (term of respect), do you get confused talking in Korean?” Her eyes widened and she repeated my question back to me in more correct vocabulary. I asked about her Korean friends, and she shook her head sadly.
“I not trusting Hanguk (Korean) peoples, they not sharing feeling. They nod yes, yes, when talk but later they like this behind you back,” she made a blabbing gesture with her hand. I asked if she had any American friends and she said, “I no likey Miguk (Americans) either. They just talking talking saying whatever come in they head. I not like that.”
While the doctor typed his note we chatted about this and that, and she slowly became more and more at ease. It was more “konglish” than either Korean or English. I learned that she was very lonely, and almost always sad. Her house had been broken into (she lived alone) and she just felt nervous and unsafe. She gave me an impromptu lesson in Korean language, history and folklore, and explained why the Korean number 4 “sa” is considered unlucky. I very much doubt we were able to provide any lasting relief for her symptoms, as I strongly suspect most of them had a behavioral or social health basis. She was a sad, lonely old lady, and she needed a friend and a hug more than she needed pain medications, but her fears and isolation kept her from those, so pain medication was all she could understand. However, she seemed to be put at ease by my broken attempts to speak and listen to her in her own language, and there was even something like a half ghost of a smile on her face when we shook hands goodbye.
Was that a good interaction? A positive one? I would not classify it as such, objectively. We learned very little to point our way to a treatment plan, and I do not have much hope that her symptoms will ever be resolved strictly by medicine. However, the attempt to reach out to her was just a little less negative than it otherwise would have been, and I think therefore it was more than worth it.
Another Korean lady the same day came in for coughing and post nasal drip, but she refused to believe that she had allergies. She was very upset at not being able to see her regular doctor (who was on maternity leave) and she denied ever having taken allergy medicine that her doctor had prescribed her. “I throw that medicine away, because I not like takey the pills!” It was hard not to laugh. She was about four feet tall and about two inches in diameter and bound and determined that something was wrong with her, because she could not stop coughing or sneezing, but it was NOT allergies! Bless her heart!
No amount of cajoling in English or Korean could convince her that, yes, in fact she very likely did have allergies, and it was perfectly normal and treatable. We tried to get her to promise at least to try the allergy medicine. When she would not we tried to sneak it into her medicine list without telling her what it was for! We said, “Oh, that’s to make you sniffles stop,” which was true, but she would have none of it. “I not takey the pills.”
Finally when the visit was over she stood up and said, “Thisa better working. You not makey me better I go to Korean doctor!” I felt like saying, “Fine! Go to a Korean doctor! What sense does it make to come to a western doctor and then refuse to take western medicines?” She never got angry, she just laughed at us like we were too ridiculous for believing that she was so weak that things like allergies and pills could apply to her. She did, however, tell us most emphatically that kimchi was going to keep us young and healthy and that I was going to live longer than the doctor because I loved kimchi and he “only likey the pizza!” He had never said that he didn’t like kimchi, he simply had never tried it, but in her mind that lumped him in with all the other pizza eating Miguks!
I cannot get angry at patients like that. I love their eccentricity, and I respect their autonomy. God bless them, if they want to grow old and cantankerous and get their kicks out of making fun of western medicine, more power to them. I hope I have enough spark left in me when I am old to be grumpy and funny like that.
The patients I feel sorry for are like the 60 year old man who came in for a regular checkup. In the course of the interview he mentioned having a new feeling of shortness of breath whenever he walked up hill. This prompted a deeper interview, a physical exam, an EKG, and the end result was that he was going home with a bottle of nitro, a bottle of baby aspirin, and a follow up appointment for an exercise stress test. As the appointment progressed and the diagnosis took shape, I could see the growing possibility reflected in his face and posture. His shoulders sank, more and more, his face became more and more bewildered, distant, afraid. It was a relief when the doctor finally said the word: “Heart disease.”
“We need to make sure you don’t have heart disease.” Amazing how we all knew that was what we were talking about, but we were reluctant to say it.
“Are you doing okay?” I asked.
He looked up at me. “I guess. It’s just I have a lot going on at home. I have family troubles, and my dad is not doing too well, and now this.”
“A hell of a thing,” I said.
“A hell of a thing” He agreed. His dad’s brothers had died in their early sixties of heart attacks. His face fell even further when he found that he could not work out until after the stress test, because of the risk of having another incident. “I can’t go to the gym?” His build spoke for itself. Despite his slight beer gut, his shoulders and arms were thick and powerful. He had been lifting his entire life. Now he would have to give it up, perhaps for a very long time, perhaps forever. Not only that, but because Viagra reacts synergistically with nitroglycerin, and can cause a catastrophic drop in blood pressure, he could not take Viagra until after the stress test, when we would have a better plan.
He looked at the doctor. He looked at me. “No weight lifting? And now you tell me no sex? Doc, what’s the point?”
At times like this you feel guilty about the clock, ticking away, reminding us that his appointment was only supposed to last twenty minutes, and that is long since up. How do you kick him out the door so the next patient can come in and tell us all about his acne and how it is affecting his social life?
I might be getting old, or maybe my parents were just poor and backwards (poor they certainly were) but it never would have occurred to them to take us to the doctor for acne, especially not acne so mild as to be invisible under long, thick black hair. There were a dozen or so cystic comadones around the hairline on his forehead, and another dozen along his hairline in the back. This rates a trip to the doctor?
And yet, it is a big deal to him. It never was to me, (I could have cared less for popularity at that age) and that may make it difficult to relate. One hopes that he grows to be a little less concerned about such things as he gets older and gains perspective, but he is not older. He is a teenager. This is where he is, this is important, and in its own way it is as devastating to him as a tumor would be to me. Why should I allow my age and experience to deprive me of empathy for his lack of age and experience? Would not that be shallow mindedness without even the excuse of youth and ignorance? And how difficult is it to prescribe some erythromycin face wash and an exfoliant? We sympathize with many, many older patients who are just as silly, and with less excuse. Certainly in my life many, many older and wiser people have put up with my ignorance and silliness. Shall I refuse to do the same for him?
So I resisted the urge to write him a script for “soap and water” or “a nice cup of man the heck up!” and provided one for face wash instead. I wish him well at his next high school social function. He was a nice kid, after all.
In reviewing these patient encounters I find it very difficult to classify them as “positive” or “negative.” That is more or less to be expected. Any encounter with another human being is essentially an encounter with the unknown. We do not hear the other perfectly, we do not communicate perfectly. The best I think we may expect of ourselves is the continual effort to be present; beyond all filters, preconceptions, contexts and languages, present for the other to be the other. Is it possible? Probably not. It is a worthy effort, I think, for only thus is any real meeting possible between humans. So, in any encounter, there is always more that could have been achieved, or less that could have been said badly, or some aspect that could have been improved. It is never perfect. The mistake, I think, is to try to reduce it to a technique. Technique is a tool, body language, active listening, participatory conversation techniques, or what have you. The essence, however, is goodwill towards the other. It is goodwill that will overcome all barriers, and hopefully shine through our clumsy, inept attempts at using our various languages, to communicate with something essential in the other person. On that level, perhaps we may even hope that some kind of real healing might occur.

Sunday, August 10, 2014

Prophetic Work


In a dream the angel said to me: “Lift up
O Man, prophetic voice to ask the world
‘Are you happy?’ Noting with compassion
The desperate dullness, unspoken in their eyes
Behind vehement affirmation.”
                                                            Why so shrill,
The gray voices of the elderly choir ladies,
Cracked, wavering, unmatched?
                                                        “You hear matter
Only, which has been only partially ruled
Since its Lord and Lady long ago
Abdicated their authority in rebellion
Surrendering to a spirit the world of things.
Atoms have not obeyed so well since then,
Atoms and the movements in between
In ear and air and throat.”
                                                Alas, I said,
Unruly matter! Such a clumsy tool
For so sublime a task.
                                       “Unruly matter?
Matter is innocent, docile to its law,
Perfect as ever it was. It is the spirit,
Unruly and therefore most unfit to rule,
Which bears the blame for this. The blame for all
Disharmony which plagues the life of man:
Unworship of molecular machines in cancerous cells, and
Of worms inside intestines, drinking blood, and
The preying of man upon his fellow man, and
The withering fear of being preyed upon, which
Shrinks the soul, bitters the tongue, pinches pennies.
The ownership of the poor by the middle class, who
Flatter themselves that they are not the rich, so
Not to blame.”
                        Complicit up to my eyeballs
I stood ashamed.
                              “Prophesy, O man,
And ask the world, ‘Are you happy?’ For all these crimes
Those curly heads and balding heads and gray
Trembling hands, enforce imperfect obedience
From dry larynx, arthritic knees, kyphotic spines,
Offering the very best of all their so,
So imperfect work. This we call “the Liturgy.”

Wednesday, August 6, 2014

Mercy


Lord, I worship you, crucified
In the bodies of your children, and
Crucified still more terribly
In the souls of your children
Who crucify them,
And in the souls of your busy children
Who do not intervene.
In all these, still you abide,
In perfect love.

Tuesday, August 5, 2014

Unfair

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You trammel me, O Lord, you hem me in.
Your grace surrounds, confounds, prevents everywhere
Inescapable. Ever present utter care
Abounds all the more around my sin,
Even which rebounds, resounds within,
Redounds unto your glory. As well the air
As grace I might escape; as your unfair
Ubiquitous immanence in all that is. You win.
For you have seiged me round with bread and beer
And tumbled upon my head (with only my shelf
To blame). You tripped and caused to slip from under
Me my plant-foot foolish, mulish heels; my fear
And bristling, brawny, barreled back; my self.
Let fly your locust cloud creation. I surrender.

Sunday, August 3, 2014

Eleanor


Bright fish, praise the Lord!
With leapings, ignore my hook.
I still laugh with you.

Saturday, August 2, 2014

Hail Mary: The Catholic Gateway Drug

Once upon a time I was a teenage Catholic who wanted to go to heaven when I died, someday. I figured I would get the going to heaven thing taken care of and then get down to the business of living life, knowing that I had the afterlife under control. I suppose there was a sort of wisdom in that. That is, I recognized a fundamental principle that "what does it matter if one gains the whole world, if you pay for it by losing your soul." I realized that it would be a bit embarrassing if I made it through life acheiving all sorts of great things, and found that I had missed the grade by a few Masses or a good confession. So I set out to find for myself what I had to do to get to heaven.

 I knew, of course, from my years in catechism class, that if you died after making a good confession you would eventually end up in heaven, by way of purgatory. Bonus points could be acquired by receiving communion and last rites at the hour of death, and, if all else failed there was always an "act of perfect contrition." At the moment of death I would simply make an "act of perfect contrition" and be forgiven and end up in heaven a few minutes later. (My naivete in that regard is subject for a whole other blog!)

All of this was well and good, but I had a sort of idea that I wasn't doing enough. I didn't want to put the whole Catholic thing on autopilot until I was sure it was on the right course with a little wiggle room to left and right, just in case. Given that life could last for a while and unforeseen circumstances might arise, it seemed wise to me to have a fallback plan, a little something that would put me over the top.

In the course of my extensive reading of somewhat childish hagiography I had somewhere come across the idea that if you said three Hail Mary's a day, every day, you were guaranteed to save your soul. There were other options out there, such as wearing the brown scapular or the medal of the Immaculate Conception, but three Hail Mary's seemed the least bother and most reliable. After all, a medal or a scapular can break and fall off, but I am not likely to lose my ability to say the Hail Mary. So I said, "Three short prayers a day, about two minutes of praying if I really stretch it out, in exchange for guaranteed eternal life? Deal!!!"

Little did I know! You think you're just going to say three a day, no big deal, not super crazy or anything. You can rattle through them no problem, and it needn't interfere with your busy schedule at all. It's a sweet deal, but you need to read the fine print.

That is really the reason I am writing this, to warn other innocent teens out there to be careful about saying Hail Mary's. It like the marijuana of the spiritual life. (All sorts of jokes about "Mary-uana" are being consigned to oblivion in my brain right now.) You start out with three a day, and you go along just swimmingly for a bit, but sooner or later a little voice in your head is going to start saying, "Well, three are nice, but wouldn't five be nicer? What about ten? That's only about five minutes of prayer time a day, and then they become a decade of the rosary, which is super extra bonus points!"

But you cannot say just a decade, you have to say the "Apostles Creed," "Our Father" and "Glory Be" as well. And then you have to have something to think about while you are making your way through those five tedious minutes, so you start looking up the mysteries in the Gospel to read about them. Then you start feeling like maybe you should at least try to pay a little bit of attention at Mass, you know, not like getting into it or anything, but maybe, you know, like actually thinking about the Mass and stuff instead of video games.

Who knows where you go from there. You see, it starts out with a little Mary-uana, and then you decide to try out some Eucharist, maybe some spiritual reading, even a holy hour now and again. It is a slippery slope, and, all jokes aside, it is utterly terrifying.

I remember two such instances, both from when I was 19 in Korea. That was when I committed to saying a decade of the Rosary every day, and when I committed to reading for chapters in the Bible every day. Both choices scared the Hell out of me (in the most literal possible sense). In the case of the Bible reading I was afraid of failing, and getting bored with it. I argued myself into it on the grounds that it was not a valid argument against. After all, how is trying and failing in any way inferior to not trying at all? And why would I fail? What was there to prevent me from following through other than my own laziness?

In the case of the Rosary I was frightened because I had a feeling I would like it, and then it wouldn't be enough. I would then be called to a whole rosary, five decades, every day. I was okay with offering God 7 minutes a day, but not 20, and I knew if I gave Him the 7 it would not be long before He would demand the 20. It is the same with giving money or time to ministry or the Church. It is not enough, and we know it is not enough when we give it, and we know that as soon as we are accustomed to this level of "generosity" a higher level will be required. Best not even to mess with it.

This is how it has always been. I have come a long way since my three Hail Mary days, and I know that I have not gone far enough. I have become a hardcore user, I am into Mass, Eucharistic Adoration (the ecstasy of the spiritual life), and spiritual reading. This is where it becomes a slippery slope. You lose the "what is He going to ask from me next" and you turn a corner and you just want to give it all to Him. Not give away, necessarily, because in reality He takes very little from you. Instead you want to give it to Him in the sense that you want everything you have and are to be available to Him for His use, every second of every day, 24/7/365 until the end. You lose all fear of being drawn deeper, and instead fear not being drawn deep enough. Instead of asking "How much do I have to give to make the grade," you ask, "How can I squeeze out just a little bit more to give?" You look back on all the times you have held back and they break your heart. I look back and see how even as recently as this morning I held back, I did not give everything, and I wish I could go back and change it. You see how far short you fall, how enough is never enough because we are utter emptiness waiting to be filled with utter fullness, and anything that at present seems to fill us is nothing but an appetizer. The insane abandon and reckless radicality of St. Francis, St. Theresa of Avila, St. Teresa of Calcutta, St. John of the Cross, and St. Therese of Lisieux, begin to make sense, and to accuse you. When St. Paul's hardcore zealotry begin to make sense, you know you've hit a new low.

Then even the weaknesses in your prayer become the subject of your prayer: "Lord, I pray so poorly. Make up what is lacking in my prayer. My lips are moving but I do not know you in my heart. Reveal yourself to me. I think great thoughts but do not live them in the office, at home, in the world. Live your life in me."

And the descent continues.