“My fiftieth year had come and gone,
I sat, a solitary man,
In a crowded London shop,
An open book and empty cup
On the marble table-top.
While on the shop and street I gazed
My body of a sudden blazed;
And twenty minutes more or less
It seemed, so great my happiness,
That I was blessed and could bless.”

—W. B. Yeats, Vacillation, Part IV

We cared for each other once — I thought, as I surveyed my former classmates seated at rows of tables — way back when we were young, so long ago that perhaps it might have been only yesterday.

Why do we come, I wondered; why do we periodically gather together in our later years? To boast of our accomplishments? To brag about our children? Some might; but personally, I experienced little of that.

Mostly, I think we gather to touch a common base that once we were a part of, a community of sorts, a home. Our gatherings become periodic homecomings, where we eat and drink, sit and reminisce, tell our stories, and listen.

The stories themselves can become quite intimate. Suddenly, in the moment, we are prone to share beyond what we might have felt we comfortably could. “I didn’t graduate with our class,” one woman told me. “I got pregnant, dropped out, had my baby, then went back to complete my GED. I got a good job with the state, and then after 40 years, I retired. Life is good.”

“In high school I was painfully shy,” a man at the top of his profession told me. I had always considered him to be quietly reserved.

“You will always hold a piece of my heart,” another woman whispered, as she hugged me at the end of the evening before we left.

In each interaction I felt blessed, blessed that some folks I hadn’t seen in perhaps 45 years felt comfortable enough to share such intimate details of their lives with me. I trust that I may have blessed some of them just by listening attentively to their stories.

When we said our final farewells and walked out the door, overhead a full moon blazed in the clear night sky. As I looked up at that ancient glowing orb, I considered that those who came had chosen to make themselves vulnerable once again, to offer up the remnants of their broken lives to one another, perhaps in the hope of finding forgiveness and a certain undefined redemption.

In our gathering together, I felt overwhelmingly certain that some of us had indeed.

The GMENAC report and the PA profession

The GMENAC was convened in 1976 to forecast the supply and demand for physicians nationwide in 1990 and 2000. Despite the use of sophisticated analytic models, predicted trends ultimately missed the mark in breadth and scope. more»

Read more about the GMENAC report and its influence on the Physician Assistant profession in my latest entry on the Musings blog of the JAAPA editorial board here.

JAAPA is the official publication of the American Academy of Physician Assistants.

A bird’s eye view

I arise early this crisp autumn morning, determined to make a day of it.

Out the door before sunrise, I stride down Winthrop Street, cross Main and cut through the empty lot behind the pub. Sauntering over the bridge, I face an endless string of southbound traffic; but the din melts away the moment I step into the woods.

I discover a shortcut to the old blue-blazed path and follow it deeper and deeper into the wood. It crosses what had been a narrow brook, now dried up in the long summer drought. I begin the diagonal climb up the ridge below spruce and hemlock, gingerly picking my way along over stretches of broken basalt rock. It isn’t long before I reach the top.

At the summit I step off the trail onto the rocky ledge high above the gorge. At my feet runs the river; directly opposite, nestled among the maples and oaks, lies the hamlet, now partially illuminated in the morning sun.


Off to the west a blanket of grey mist floods the far valley. Directly across from where I stand, the Barndoor Hills rise up from the valley floor. Roof-lines of houses and the spires of two churches wax sharp in the morning light as the sun cuts through the stands of trees behind me.

I bring my binoculars up to pan the landscape, then let them fall gently against my chest. I drop my gaze to the river below to study the current. It meanders by the old mill, then slowly picks up speed, forming ribs of white water as it cascades down past the old bridge abutments into the gorge.

Suddenly, a shadow flashes across my eyes. I glimpse an airborne form floating over the river below. A big black bird pumps its broad wings, then soars through the air, its white head and alabaster tail blazing in the sunlight.

Momentarily mesmerized, I scramble to reach the binoculars at my chest. I ease the eagle into focus and follow the final few wing beats before it disappears around the distant bend.


The Art of Medicine: A distant close encounter

I glance at the encounter form and step into the examination room. A young boy sits on the examination table. A man, presumably his father, stands off to the side by the back window, chatting on his smartphone. more»

Interested readers can now access my latest Art of Medicine column — A distant close encounter — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.


She was rough-cut, a girl of the streets, small but wiry; she’d mouth off to anyone or anything that got in her way. No object was too big for her to tackle; she took no guff from any other living thing.

And yet, she had a tender side, too; albeit one that took a great while to surface. Man or animal, when you have suffered years of untold abuse, it takes a long time and a lot of unconditional love to surmount the hurt. She knew almost immediately when she had transgressed a trust and readily rolled over in submission. Subsequently, she loved to lie on the settee to be idly stroked by whomever sat in contemplative solitude.

Like all of us, she had her bad habits, moments when reason gave way to outright rage; and many a morning solicitor regretted ringing the doorbell or rapping on the front door. Shamelessly, she begged tidbits from the table, dutifully making her rounds until she found the softest heart willing to sneak her a morsel below the cloth.

She loved to be out exploring on an early morning walk; an afternoon saunter by the river was equally pleasant. Her floppy ears, one brown, one white, would bounce in unison as she padded down the street. Intelligent, she would readily sit and offer a forepaw when asked, then wait patiently for a tasty reward.

She played aggressively with stuffed toys, snapping them back and forth in her mouth as if to break their spineless backs; but there was hell to pay for the individual who might attempt to extricate the toy from her teeth.

She adopted any number of stuffed animals as though they were her own offspring, gently cuddling them in her paws, resting her chin on their heads. No human mother was ever more possessive of her children. Jealously, she guarded the bed of any family member she slept with, growling at the approach of another — until it was time for her morning walk and feed.

We did not know what demons possessed her until the very end, when one afternoon without warning she began to pace the kitchen floor in smaller and ever smaller circles, oblivious to her surroundings. She whined and whimpered, pressed her head against the side of her bed, refused to acknowledge our attempts to soothe her discomfort.

A Friday evening wild drive to emergency care resulted in the final diagnosis: some sort of “central neurological event,” most likely a brain tumor.

The palliative care was brief: she didn’t respond to a cocktail of steroids and sedatives; and eighteen hours later we once again returned to the house of healing for her final exit. She died in her mistress’s arms, the young doctor kneeling at her feet, her master looking silently on in untold horror and grief, understanding everything and yet comprehending nothing in the same moment of briefly elapsed time.


Death of a dog

“How long has she been acting like this?” I say, dropping my valise by the corner hutch.

“All afternoon.” My wife pauses momentarily with her knitting. “I don’t think she hears.”

I step over the gate into the kitchen. The little dog continues to pace in circles clockwise, in and out from under the table, always to the right.

I call her name, softly at first, then louder. I clap my hands above her head as she circles; there is no response.

“Did you call the vet?”

“No. I wasn’t sure what to do.”

“Did she go out for a walk today?”

“Just down the street, but she wanted to come home right away. She ate a little bit this morning, but she won’t drink.” The knitting stops. “What should we do?”

I step back over the gate into the dining room and rummage through the stack of papers under the stand for the local telephone directory. I punch in the numbers and wait. Surprisingly, someone picks up on the other end after only two rings. I explain the situation and ask if the vet might be able see the dog.

“We’re all booked up today, tomorrow morning and Monday. The earliest I could get you in would be next Tuesday. I wouldn’t want the dog to wait that long. You could take her to the Veterinary Emergency Center this evening.”

I jot down the number and address. “Thanks for your help,” I say.

Back in the kitchen the dog continues to pace. The circles have gotten tighter and tighter. She approaches her dish in the corner, holds her muzzle above the fresh water, but won’t drink.

I dial the number for the Emergency Center and verify that they are open.

“I suppose we should take her down.”

Immediately, my wife drops her knitting, rises from the chair and reaches for the dog’s leash.

She climbs into the back seat of the SUV, holding the dog swaddled in a towel in her lap. The dog whines and pants. She has never been a good traveler in the car.

It’s a 25-minute ride as I race over winding back-country roads. “Can’t you slow down?” my wife says. “You’re scaring her!”

At last I pull into the small parking area in front of the white clapboard building. Formerly a house, it has been converted into a medical clinic. The front door is partially ajar. A sign on the wall outside says: “Please ring for attendant.” My wife pushes the door open with her foot and steps inside, cradling the swaddled dog in her arms. Across the room an attendant looks up from her desk and greets us with a smile.

“My husband called,” my wife starts to say. Almost immediately another attendant appears from the far door marked “Employees Only” and accepts the dog from my wife. “The doctor will assess the dog in the back,” she says. “We’ll come and get you.”

My wife takes a seat. I stand at the desk and complete the intake form and hand it to the attendant. Soon we are beckoned from the doorway of an exam room opposite. Inside, the dog paces the linoleum tile floor in circles, dragging her twisted leash behind.

The attendant asks us a series of questions: “When did the behavior start? Has the dog been eating? When did she poop last? Was she able to squat? Any recent illnesses? Who is your regular vet? Is the dog up to date on her immunizations?” She records our answers in the computer by the exam table. “The doctor will be in shortly,” she says and steps through the doorway, pulling the door closed behind her.

I sit and watch the dog continue to pace in circles. No amount of coaxing will break her out of it. I think back to our daily walks this past summer. Sometimes she would vomit without warning. Once or twice she collapsed on the ground during these episodes, momentarily losing consciousness. Periodically, her hindquarters would tremble for no apparent reason. Sometimes, as I sat on the front porch, the dog would suddenly start to lick my legs without pause for 20 minutes or more. My wife said she thought the dog craved the salt on my sweaty skin.

The door opens and a young woman appears. She introduces herself as the veterinarian and immediately observes the dog pacing about the room. Shortly, she steps over to the computer and studies the screen with a frown. “When did all of this start?” she asks. Once again, we rehearse our lines. Slowly, she nods her head and taps a few more keys on the keyboard.

The same attendant appears to assist with the examination. The dog resists having her ears looked into. The vet listens with her stethoscope and studies the dog’s eyes. Afterwards, the attendant lifts the dog down from the stainless steel table to the floor. The dog immediately resumes pacing in circles.

“Sometimes we see this behavior with ear infections,” the vet begins, “but there doesn’t seem to be much evidence of that on exam.” She clears her throat. “I’m worried that this behavior is being driven by some sort of neurological problem, probably in the brain.” She pauses a moment, then continues. “I doubt she’s had a stroke — there’s no unusual eye movements, and she’s able to keep her balance — but she could have a tumor in her head. We wouldn’t know that for sure without doing an imaging study. A complete work up would cost somewhere around $1500, and then you’d be looking at treatment options. Frankly, the outlook is not optimal.”

“As far as you can tell, could this be due to some sort of contagious disease. Would we be at risk by keeping her at home?”

“No, this isn’t a contagion. If you don’t feel comfortable taking her home, we could board her here overnight.”

I look over at my wife, who continues to watch the dog pace around the room. “Can you give her anything to calm her down?” she asks.

“We can give her a sedative and some steroids,” the vet says. “That would help get her through the night. You could call us tomorrow with an update. I’ll be here all weekend.”

I nod my head. “Let’s do that.”

Two attendants return with a set of syringes. One attendant lifts the dog back up onto the exam table and restrains her while the other injects the medicines into the dog’s hindquarters. They hand the dog to my wife and usher us out to the front, where I pay the bill.

Back home the dog once again resumes her endless pacing. My wife opens a box of chicken broth and pours some into the dog’s dish. She holds it up to the dog’s nose. Surprisingly, the dog begins to lap the fluid. She drains the bowl, turns her head to the right and immediately resumes her pacing.

Later, I awake in the dark and enter the kitchen to find the dog lying in her small bed, her tiny muzzle resting on the edge. Gently, I place my hand over her head. She opens her eyes, stares straight ahead, then closes them once again. Suddenly, she rises to her feet, steps out of the bed, circles the floor several times, stumbles back into her bed and buries her head in the fluffy lining.

The next morning I call the Emergency Veterinary Center to report the dog’s condition. “I think we need to bring her back in,” I tell the receptionist.

“I’ll let the doctor know you are coming.”

It’s a chore to get the dog into the car. My wife wraps her up in an old towel and climbs into the back seat. I can hear the dog whimpering the entire way down.

There is only one car in the small parking lot when we pull in. Inside, the attendant is waiting. She escorts the two of us into a back office. “The doctor will be in to talk with you shortly,” she says. She looks down at the dog pacing the floor in circles. “Poor thing,” she says, closing the door behind her.

We sit in padded leather chairs, watching the dog pace and pant. I search for the right words. “I don’t think she’s going to get any better,” I say.

“Neither do I,” my wife says. “I don’t want her to be in any more pain.”

Minutes elapse. The dog’s circles become smaller and smaller. Soon the leash is tangled in knots on the floor. Finally, the door opens and the doctor steps into the room. “How did it go last night?” she asks, hunkering down on her haunches to watch the dog.

“Not well. She was up all night, circling on the kitchen floor,” I say. “This morning I saw her pushing her head against the edge of her bed. She seems to be oblivious to both of us.”

“I don’t want her to suffer any more than she has already,” my wife says.

“Yes, I agree,” the doctor says. “These things usually don’t have a good outcome. I’ll have the attendant come to take her in the other room. We’ll give her a sedative to calm her down and put in an IV port. Then we’ll bring her back to you. Would you like to hold her in your lap while we give her the final injection?”

My wife nods. The doctor offers her a tissue from a box on the desk. “She’ll be back shortly,” she says and walks out.

The attendant returns. There are papers to sign, a check to be written. She takes the dog out on the leash. Minutes later she returns with the dog wrapped in a blanket and shifts the bundle to my wife’s arms. The dog’s forepaws are trembling. One foreleg is wrapped with a green elastic dressing. An IV site protrudes from the lower edge.

“I’ll give you a few minutes before the doctor comes in,” the attendant says.

My wife cuddles the dog as though it were a newborn baby. She strokes the fur on her muzzle and whispers into her ear. I stand by the desk, motionless, watching, waiting for the realization of what is happening to sink in.

The door opens and the doctor enters, kneeling down at the foot of my wife’s chair. “She’s heavily sedated,” she says, “not feeling any pain any longer. I’m going to flush the IV port, then administer the medicine.” She reaches into a sleeve on the side of her khaki trousers and withdraws a syringe. The clear fluid flows easily through the IV site. She caps the needle, then withdraws another syringe from an adjacent sleeve. I watch her push the opaque pink fluid into the port. Afterwards, she reaches for the stethoscope around her neck and slips the diaphragm under the dog’s foreleg.

Finally, she says: “She’s gone.”

“I’ll take her to the back and we’ll meet you at your car. Would you like us to remove the collar? You can exit here through the back door privately and walk around.”

Outside, my wife pauses at a flower garden by the walkway while I continue on to the car. The attendant exits the front center door carrying a small cardboard box in her arms. The dog’s collar dangles from her right hand.

I open the rear car door and rest the box on the seat. My wife appears and speaks briefly to the young attendant. I slide in to the driver’s seat while my wife climbs in behind me.

I back the car around and pull out onto the road. “Do you want to go directly home?” I ask, glancing into the rear view mirror.

“Where else would we go?” my wife says.

I shrug my shoulders and drive the rest of the way home in silence.