“Reir hasta el llanto” — Laugh until you cry

It’s been a bit of a rough stretch these past few days after the announcement of Robin Williams’ death by suicide. Like many of my colleagues and friends, I’ve been struggling to maintain myself in the wake of overwhelming sadness.

How could someone so upbeat, so sharp, so funny, have taken his own life?

Robin Williams was the comedian for my generation. His extemporaneous rapid-fire deliveries cracked us up. (I still recall that incomparable line his character uttered when caught behind enemy lines in “Good Morning, Vietnam” — “This isn’t going to look good on a résumé!”) During his hilarious free associations Williams pulled us out of ourselves and made us temporarily forget our troubles. Yet he himself died as a result of overwhelming depression.

A good many comedians harbor hidden sadness; many struggle to maintain themselves in the face of personal despair. I think of Red Skelton and Carroll O’Connor: both suffered the death of a son during their professional careers.

Freud reportedly observed that wherever he went, a poet had been there first.

All of this brought to mind a poem by Juan de Dios Peza, Reir Llorando.

The opening lines allude to Garrick, an English comedian —

el más gracioso de la tierra y el más feliz

— who acknowledged public applause with a hearty laugh of his own. Even the most distraught noblemen would double over, cackling and guffawing during Garrick’s performances.

The poem then goes on to relate the tale of a man suffering from chronic melancholia who consults a famous doctor known for his clinical expertise, hoping for a cure for his depression. The doctor takes a careful medical history, ascertains that his patient is indeed overwhelmingly depressed, and begins to offer suggestions for treatment. But everything he advises his patient to do, the man has already tried, to no avail. Finally, the doctor prescribes an evening out to a performance of Garrick, the world-famous comedian, who will undoubtedly lift his spirits.

“It won’t work,” the man explains. “You see, I am Garrick.”

The proverbial funny man is impotent to lift his own spirits.

Nada me causa encanto ni atractivo;
no me importan mi nombre ni mi suerte;
en un eterno spleen muriendo vivo,
y es mi única pasión la de la muerte.

“Nothing enchants or attracts me;
Neither name nor luck are important;
In an eternal melancholia I live dying,
My only passion is the thought of death.”

The poet goes on to lament those who are downcast in this life:

¡Cúantos hay que, cansados de la vida,
enfermos de pesar, muertos de tedio,
hacen reir como el autor suicida
sin encontrar para su mal remedio!

“How many are there, tired of this life,
Sick of its weight, dying of tedium,
Who goad themselves to laugh like the suicide
Finding no relief for their despair.”

Here are Dios Peza’s last three stanzas with my translation:

¡Ay ! ¡ Cuántas veces al reír se llora!..
¡Nadie en lo alegre de la risa fíe,
porque en los seres que el dolor devora
el alma llora cuando el rostro rie!

“Ay! How often one cries in laughter!…
No one trusts in the happy smile,
Because in those whom pain devours
The soul cries out when the face laughs!”

Si se muere la fe, si huye la calma,
si sólo abrojos nuestras plantas pisa
lanza a la faz la tempestad del alma
un relámpago triste: la sonrisa.

“If faith should die and calmness should flee,
If the soles of our feet tread only on thistles,
Then cast on your face the tempest of the soul
a sad lightning bolt: the smile.”

El carnaval del mundo engaña tanto;
que las vidas son breves mascaradas;
aquí aprendemos a reír con llanto
y también a llorar con carcajadas.

“The carnival of this world well tricks us;
Our lives are masked in brief;
Here we learn to laugh with weeping
and in our laughter hide our grief.”

Freud was right: Dios Peza’s quatrains describe Robin Williams’ soulful life to a tee.

How poignantly they speak to me in this time of collective grief!

My last day

On this, my last day,
After 20 years in this practice
I saw 31 patients,
Administered 19 immunizations,
Counseled 4 distraught parents,
Reassured 17 mothers,
Praised 3 new fathers,
Called in 8 prescriptions,
Reviewed 14 laboratory studies,
Signed 9 daycare forms
And 6 school exam forms,
Completed 5 authorizations for medication,
Ran 4 rapid group A strep tests
(3 of which were positive),
Explained 25 times why I was leaving,
Ate a piece of homemade carrot cake,
Emptied out the contents of my desk,
Watered the dying peace plant,
Hauled my files, books, notepads,
Cards and gifts (2 bow ties)
Out to my car,
Slammed the tailgate shut,
Climbed into the driver’s seat,
Adjusted the belt and harness,
Inserted the key,
Hit the ignition switch,
Slipped the car in gear
And rolled across the parking lot,
Forgiving a betrayal
Without looking back.

15 November 2013

2013©Brian T. Maurer

After work

It was not a particularly stressful Saturday morning to work in the office. Only three prescheduled physical examinations and a handful of sick children came in by morning’s end.

One child, a 1-month-old, my first patient of the morning, had colic. His mother reported that he wanted to feed constantly; whenever she didn’t give him a bottle he fretted, sucking on his fingers and hands. I had evaluated him one week ago for similar complaints. Since then the child gained 1-1/4 pounds, nearly three times the expected weekly weight gain. Obviously, she was overfeeding him. I suspected that part of the reason might have been because her first child was born prematurely and had a difficult time gaining weight.

Mothers nurture through feeding; a thriving baby exemplifies good maternal care, but sometimes too much of a good thing is not best.

As the morning wound down I ruminated behind my desk and reviewed the remainder of outstanding laboratory reports, signed off on a stack of physical examination forms and phoned in prescription renewals. The medical assistants finished with the filing and departed, locking the front door behind them.

I snugged the bow tie at the base of my throat, picked up my blue blazer and stepped out the side door. It was a short drive to the funeral home. By the time I arrived the lot was nearly filled with vehicles.

Inside people milled about, speaking in low tones, touching one another briefly on the arm or shoulder, exchanging whispered words. Some paused before the large displays of photographs mounted on easels in the hallway.

I stepped into the parlor, signed the guest book and found the end of the receiving line. There were stands of flowers everywhere, roses mostly — pink and red and white — done up in intricate arrangements identified by cards signed by family, friends and well-wishers.

A small silver urn stood in the center of the table; a golden crucifix rested against it. On either side lay two stacks of books — three on the left, two on the right. I noted the author of the two on the right — medical titles reflecting her area of expertise.

Most physicians don’t leave any written creative works behind; she had left two — these two texts, in addition to her two teenaged sons, who stood in the receiving line on either side of their father. Each of the three wore a pink tie. Pink, the color of the ribbon supporting breast cancer research; pink, the color of the delicate rose in full bloom; pink, the color of fading rose petals at the close of day.

My words were inadequate — “I’m sorry for your loss” — followed by handshakes and brief smiles.

“How are things at the office?” the father asked.

“Busy,” I said. “Back to school physical exams, you know. It’s the same every fall.”

He nodded. “Thanks for stopping by.”

I left by the side door and stepped out into the heat of the early afternoon sun.

As practicing clinicians we are granted the high privilege of glimpsing the struggles of families entrusted to our care. For brief periods were share in their triumphs, their joys and ultimately, their grief.

But many times it’s the grief that seems to linger the longest.

2012 © Brian T. Maurer

Ten years after

When we left the house as the party broke up last evening, I looked up at the night sky.  “Look!” I said to two of my companions, pointing up at the yellow cracks in the dark grey clouds backlit by the light of the moon.

“Apocalypse now,” one of my friends murmured.

I laughed, shrugged off his words and said good night as I slid into the seat behind the wheel of my car.

Halfway home, the full moon appeared, shining brightly in the midst of the panoramic inkblot of clouds silhouetted against a cream-colored sky.

Early this morning I awoke to peruse the NYT home page and found the words of the headline burning into the retinas at the back of my eyes:  Witness to Apocalypse: A Collective Diary — accounts of “the fall of the trade center told moment by moment and person by person drawn from the more than 600 interviews collected in the September 11, 2001 Oral History Project” — somber reading at best.

We humans mark anniversaries of birth, marriage, and death.  The first two are celebrations of joy, the latter a remembrance of loss punctuated by grief.  As anyone who has ever lost a loved one will tell you, those feelings of grief and loss tend to resurface acutely on the anniversary of the death.

Every generation has memorialized those tragic events that have served to define it in history.  The sunken ships of Pearl Harbor, the eternal flame at JFK’s grave, the black wall bearing the names of our dead in the Vietnam War; and today, ten years after 9/11, the dedication of  the World Trade Center memorial.

Certainly, the string of events on that clear blue morning of September 11, 2001, defined the first decade of the new millennium for Americans.  At the outset it ushered in a brief era of compassionate service.  It changed the way many of us would come to view the world.  It created a national paranoia, which still resides in our collective western psyche.  To a certain degree it eroded our civil liberties, spurred two unwinnable wars, and drained hundreds of billions of dollars from the U.S. treasury.

I do not wish to minimize the mourning of those who lost loved ones in the tragic events that unfolded ten years ago today.  An anniversary is a suitable time to pause and reflect on irreplaceable loss.

But perhaps with the dedication of this memorial at Ground Zero, we as a nation can choose to let the tragedy of 9/11 take its place in the queue of similar tragic historical events, and begin to move on.

Expressing the Inexpressible

In his review of The Autobiography of Mark Twain, American humorist Garrison Keillor charges that Samuel Clemens’s belated musings are “a powerful argument for writers’ burning their papers.”

While Keillor is somewhat less than kind to Sam Clemens for baiting the public for a century with the promise of his last hurrah, he recognizes some gems in this massive volume (the first of three).

“What a wee little part of a person’s life are his acts and his words!” Twain writes.  “His real life is led in his head, and is known to none but himself…. The mass of him is hidden — it and its volcanic fires that toss and boil, and never rest, night nor day. These are his life, and they are not written, and cannot be written. . . . Biographies are but the clothes and buttons of the man — the biography of the man himself cannot be written.”

Keillor concludes his review with these words: “The death of the beloved daughter far beyond her father’s love and care is a disaster from which there is no recovery. Boyishness cannot prevail, nor irreverence. The story can’t be written. The man buttons up his clothes and resigns himself to the inexpressible.”

I distinctly recall my high school physics teacher brooding over how to define a problem.  “If you can’t express it in a mathematical statement,” he said, “it simply can’t be understood.”

Some things border on the inexpressible.  While it is difficult to come to grips with grief, making the attempt sometimes pays off.  Our muddled emotions stir about inside our heads.  We define them by turning them into words, fleshing them out, even if in their final form they fall short.

A friend from the other side of the globe writes that she is wrestling with two recent tragedies, one national, one personal.  “Why do these things happen?” she asks.  “I cry deep in my heart.”

Six words that express the inexpressible.

Humane Medicine — A Grief Observed

Turning back the clock is something most of us have wished to do at one time or another. We experience the loss of a loved one, or the parent of a patient under our care takes a turn for the worse. If only we could turn back the clock, we think, everything would be just fine.

Interested readers can now access my latest Humane Medicine column, A Grief Observed, recently published in the Journal of the American Academy of Physician Assistants.

Grief and Mourning

Grief hits us hardest when we least expect it.

I recently returned from the AAPA national conference in San Antonio, Texas, where I helped facilitate a small group discussion in the “Breaking Bad News” workshop. This ground-breaking seminar was the first of its kind sanctioned by the AAPA conference committee. Traditionally, continuing medical education national planners have considered such topics to be soft science, not worthy of recognition for ongoing educational credit.

The workshop was well-attended; over forty people showed up, and most stayed for the entire two and a half hour session.

We used Joan Didion’s book The Year of Magical Thinking as a literary text to facilitate discussion. In the pages of her journal, Didion records thoughts and feelings over the span of a year after her husband’s unexpected demise at the dinner table. Although outwardly she appears to have accepted the fact of his death, inwardly she continues to wait for his return during her year of magical thinking.

Immediately after the event takes place, the death of a loved one changes us forever in ways that we do not understand.

In small groups, participants had the opportunity to consider an instance when they were required to deliver bad news to a patient or receive bad news themselves. Without exception, the folks at our table found that they could readily recall such events with heightened clarity, although in most cases these events had taken place years ago.

Mourning, the process of working through grief, takes time. Sometimes, like a recurrent abscess, it requires periodic incision and drainage to heal.

I felt good about the discussions we had. I was amazed at how little time it takes for individuals to open up to complete strangers when given permission to do so in a safe place.

I returned home exhausted from my three-day trek. I never sleep well on the road. My son met me at the airport. We had a nice dinner together. It was only later after I checked my e-mail that I learned that a close friend’s family member had been brutally murdered by a street gang in another country while I was away.

Grief hits us hardest when we least expect it; mourning takes time.