The Big Tree (I)

Early in the morning the men came. You could feel the house shake as the big trucks rumbled down the street. The dog growled from the upstairs window and barked back and forth frantically, pacing through the parlor.

“The men are here to take down the tree,” my wife said. “You’d better move your car.”

I slipped on my shoes, grabbed the car keys and hurried out into the street. The tree surgeon stood at the side of the cherry picker, pulling on his safety harness. I hopped behind the wheel of my station wagon and moved it further down the street, well away from the massive ash tree in the neighbor’s yard. Today was the day they would take the ancient tree down.

Soon the street was crowded with vehicles: two dump trucks, a bucket loader, an industrial wood chipper, the foreman’s pickup truck. “You might want to move your other vehicles now if you’ll be needing them later,” the foreman told me. “Unfortunately, we’ll be blocking your driveway for most of the morning.”

I backed the other vehicles out of the driveway and parked them behind the station wagon before retreating to our front porch to watch the men work.

Soon the tree surgeon was high in the air, riding the bouncing grey bucket to the upper most branches of the massive tree. Shortly, his chain saw whined through the cool morning air as smaller limbs began to plummet down through a veil of cascading sawdust. They made sharp snapping sounds when they hit the street. The men on the ground collected the limbs and fed them into the wood chipper, which chewed and spat the fresh wooden flakes into the bed of one of the trucks. The air filled with the sweet scent of fleshy wood.

At one point the tree surgeon dropped the bucket down to retrieve a coil of heavy orange line and a block and tackle. Once again he propelled himself skyward in the cherry picker. He fastened the block and tackle to one of the sturdier limbs overhead, passed the line through the pulley and cinched it fast to a nearby limb. On the ground below a man stood by on belay at the other end of the rope, holding it taut. The tree surgeon’s chain saw barked to life and bit into the base of the tethered branch. In a moment it fell, dangling from the line. The man on the ground payed out the rope behind his back, lowering the branch gently to the ground, well away from the electrical wires that ran from the utility poles to the house.

Gradually, one by one the heavy limbs were amputated and dropped into the street, thudding against the ground like giant coffin nails. The bucket loader gorged itself on the pile of newly minted logs and regurgitated them into the bed of the other dump truck. As the tree surgeon worked, the clouds overhead began to break up. Blue patches grew larger and larger as the limbs of the old tree dropped to the ground with rhythmic thuds against the macadam pavement.

I was the one who had planted the seed for the tree’s demise. It was I who first voiced a suggestion to have the tree taken down. Many of the old limbs were dead and decayed; more than a few had splintered in the street during windy winter storms. I feared for the telephone and electric lines—or any unsuspecting passer-by. I spoke to my neighbors about it. They shrugged their shoulders, stared off into the distance an eternal moment, then nodded in agreement. Yes, the tree wasn’t safe; it should come down, they agreed. There was nothing else for it.

Through the morning hours I watched the men work: the tree surgeon deftly making his precision cuts high in the open air theater overhead; the ground crew feeding the severed branches and debris into the mouth of the wood chipper; the bucket loader scooping the heavier limbs and depositing them into the beds of the big trucks; the big-bellied foreman observing his men work.

Mid morning the sun came out, and the men continued to labor in the hot sun. Several of them pulled off their sweatshirts and paused to wipe their brows and readjust their yellow hard hats. Some of the men smoked, some of them drank from thermoses while they watched the tree surgeon contemplate his next approach as he swung the bucket back and forth high overhead.

As I watched, the scene took on that peculiar drama of a public execution. We were all in attendance to witness the demise of the big tree. Secretly, I had made myself a bet as to its age: 150 years. Later, I would count the rings at the base of the severed trunk.

But sitting on the front porch just then, I felt a sudden chill, as though I had betrayed an old and dear friend.

Fathers’ Day

Although we e-mail one another several times a week, my friend and I see each other but once a year. Once a year he travels from the southwest to visit his boyhood home and reconnect with his eastern roots. Once a year during his week-long stay we plan an afternoon rendezvous in a small town nestled in the mountains of eastern Pennsylvania.

Time, as always, is at a premium. Only a few hours are allotted for lunch on the wide veranda of the antiquated red-brick inn on the square and a subsequent stroll about town, but the conversation is continuous as we jointly mine each rich vein that runs through the bedrock of our lives.

Each of us has pursued a career in primary care medicine, he in family practice and I in pediatrics. Each of us is married with a family of our own; each of us a father in turn, although his little girl is much younger than my own children. And providentially, this year we meet on Fathers’ Day.

Several years ago, on the eve of another Fathers’ Day, my friend told me that his mother informed him that his father had recently died. My friend was taken aback: his mother had never spoken of his father before; they had separated when my friend was an infant. My friend had been raised in a fatherless household; and he was shocked to learn that the man who was his father had lived his entire life in the same small town, several blocks from where he grew up.

Recently my friend wrote that he was going to spend an afternoon with a nephew—the son of his wife’s sister—to discuss the boy’s decision to enlist in a ROTC program. “I asked him to help me clean up the yard,” my friend said. “It will give us some time together to talk.” The words of a seasoned father.

Mothers bring children into the world; some fathers help to raise them. Fathers are not infallible. Like all men, in our blindness we see through a glass darkly. We beget as we were begotten; we nurture as we have been nurtured. Sometimes it all comes together; sometimes we miss the mark.

But still, in spite of our shortcomings, we strive to love as we are loved.

Medicine and the Art of Motorcycle Maintenance

In his recent New York Times Sunday magazine article, The Case for Working With Your Hands, author-mechanic Matthew B. Crawford argues for the pursuit of work that is straightforwardly useful—like plumbing, electrical work, or car repair.  After earning a PhD and bolstering his résumé writing abstracts of scientific articles he admits he seldom understood, Crawford opened up a motorcycle repair shop.  Based on his recently released book, Shop Class as Soulcraft: Manual Competence and the Struggle for Agency in Modern Life, Crawford’s essay seeks to honor the manual trades as work worth pursuing.  Ironically, this piece could just as easily have been titled “Medicine and the Art of Motorcycle Maintenance.”

“[Useful] work is sometimes frustrating, but it is never irrational,” Crawford writes.  “And it frequently requires complex thinking.”  Do those words ring true for those of us involved in the practice of clinical medicine?

Medicine combines the disciplines of science and art.  Clinicians strive to formulate diagnoses by melding historical information gleaned from patient interviews with clues from the physical examination, laboratory tests and imaging studies.  There is an art to synthesizing these data, just as there is an art to delivering the diagnosis and treating the patient.

“Without the opportunity to learn through the hands,” Crawford maintains, “the world remains abstract and distant, and the passions for learning will not be engaged.”

Clinicians learn physical diagnosis by laying hands on patients.  They learn human anatomy by cadaver dissection.  Procedures are practiced under the adage: “See one, do one, teach one.”  In developing these skills, early successes spur the student on toward greater self-confidence.  Most practicing clinicians have experienced the satisfaction that comes from suturing a simple laceration, applying a plaster splint or draining an incised abscess.

As for the art of medicine, “The attractiveness of any hypothesis is determined in part by physical circumstances that have no logical connection to the diagnostic problem at hand.”  In spite of those myriad clinical algorithmic flow sheets designed to walk the clinician down the path toward formulating a proper diagnosis, Crawford surmises that “proper response to the situation cannot be anticipated by a set of rules or algorithms.”

In motorcycle repair “[s]ome diagnostic situations contain a lot of variables.  Any given symptom may have several possible causes, and further, these causes may interact with one another and therefore be difficult to isolate.  In deciding how to proceed, there often comes a point where you have to step back and get a larger gestalt….What you need now is the kind of judgment that arises only from experience; hunches rather than rules.”  Is this not what we do in clinical practice every day?

Here are several more of Crawford’s aphorisms that lend themselves well to the practice of medicine:

• “Good diagnosis requires attentiveness to the machine, almost a conversation with it, rather than assertiveness…” (The art of taking a medical history.)
• “As is the case with many independent mechanics, my business is based entirely on word of mouth.”  (“Know of any good doctors?”)
• “The mechanic deals with a large element of chance.” (Also the clinician’s constant companion.)
• When Crawford succeeds in recovering an accidentally dropped feeler gauge from the crankcase of a Kawasaki Ninja, he feels as if he has cheated death.  “I don’t remember ever feeling so alive as in the hours that followed.”  (Remember how we felt when a timely intervention worked to save a patient?)
• “Often as not, however, such crises do not end in redemption….a keen awareness of catastrophe [is] an always-present possibility.”  (Think malpractice suits.)
• “The core experience is one of individual responsibility, supported by face-to-face interaction between tradesman and customer.”  (A good definition of the provider-patient relationship.)
• “A good job requires a field of action where you can put your best capacities to work and see an effect in the world.” (Public health.)

In his subsequent review of Crawford’s book, Francis Fukuyama writes:  “All these activities, if done well, require knowledge both about the world as it is and about yourself, and your own limitations. They can’t be learned simply by following rules, as a computer does; they require intuitive knowledge that comes from long experience and repeated encounters with difficulty and failure.”  There you have it: the art of motorcycle maintenance; the art of medical practice.

Matthew Crawford praises people who do useful work:  “We idealize them as the salt of the earth and emphasize the sacrifice for others their work may entail.”

Even Osler would say “Amen” to that.

Humane Medicine — Face to Face

We all wear masks of some sort; some look better than others. Most of us never take them off in public; some of us don’t even take them off when we look in the mirror.

Sometimes it takes a child’s love to see through the mask to the true person whose soul bears little resemblance to the outward appearance.

Interested readers can now access my latest Humane Medicine column, Face to face: glimpsing the man behind the mask, recently published in the Journal of the American Academy of Physician Assistants.

Clear shining after rain

“As the light of the morning, when the sun riseth, even a morning without clouds, as the tender grass springing out of the earth by clear shining after rain.”  II Samuel 23: 4

The cabbie was a small bald man with a thin grey moustache.  I asked him if the weather was always like this in San Diego:  clear, pleasant, dry.  Yes, he said, always.  I asked him if it ever rained.  Very seldom, he said.  I had read in the Union-Tribune that there was a water shortage in the Sacramento valley.  “All over the state,” the cabbie told me.  “This year there is a terrible drought.  We are constantly told to conserve water wherever possible.”

Riding in the back of the cab to the airport, I recalled the lyric, “It never rains in southern California.”  Evidently, this year that was true.

By mid morning we had flown over the sparsely treed white dry mountains of southern California.  You could tell that we were flying east from the shadows cast by the mountain peaks in the morning sun.  I looked out the small port window at the landscape below:  reddish brown and wrinkled bare burnt mountains.  Soon we crossed the dessert, flat and forsaken; but ahead I noticed a wide swath of patchwork greens bifurcated by a blue ribbon.  Water, I thought, amazed at what that one life-giving substance can do in this dry arid zone christened Arizona.

From the air Phoenix took on the appearance of a massive computer chip, its inlaid silver streets and structures gleaming in the morning sun.  Underneath us a sea of clouds speckled the skies, and their black shadows fell across the land.  Off in the distance below the faultless blue dome there arose a string of white buttes, their tops flattened by the icy jet stream.  Occasionally the black gnat of another aircraft appeared against this backdrop, buzzing off in another direction to some unknown destination.

Somewhere over eastern New Mexico the yellow browns of the earth gave way to uniform rectangular patches of various shades of green, purple and grey.  In the Texas panhandle each rectangle contained a circle.  Some of the circles were green and some were brown; some had pie-shaped wedges cut out of them.  In Oklahoma the motif was the same, but the rectangular fields were smaller, sewn together like a handcrafted quilt.

A thick white glacier of clouds blanketed the land as we crossed into Arkansas.  I glimpsed the wide chocolate syrupy Mississippi as it meandered down to the coast.

We touched down for a layover in Atlanta, then headed northeast, over the tiny irregular green and brown patches of farmland east of the Appalachians that looked like a Cezanne canvas.  The clouds became more and more dense.  I caught sight of the Chesapeake Bay just before a white blanket occluded all earth-bound landmarks.

Overhead the skies were blue; nothing but grey below.  The western sun streamed in through the windows and fell on the pages of the open book in my lap.  As we made our descent, the intense light gave way to a nebulous ghostly grey.  Like an elevator we dropped through the clouds.  My ears closed off and all sound ceased.  For an eternity we fell through timeless space, then suddenly there were the familiar landmarks of human existence:  the interstate highway, the river, the grid of houses, one or two ball fields.  The ground rushed up to meet us; the landing gear skidded against the ridged concrete runway; and we were home.

Outside the terminal, unlike the west coast city I had left early that morning, the pavement was wet from recent rain.  It continued to rain for the remainder of the evening and through the night.  Morning brought cool air under a powdery blue sky.

Everywhere I looked all was dewy green, clear shining after rain.

“Notes from a Healer” — Ma’salama

When I saw Halim last week with his infant daughter, he told me that he and his family — along with his two brothers and their families — would be returning to Syria.  For these three brothers it was the end of a dream.  I had taken care of their children from the time they were born. Saying goodbye to a dream of a promise of hope was not easy — in any language….

My latest installment of Notes from a Healer — Ma’salama — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online clearinghouse for manuscripts dealing with the humanities and medicine.