A new year

The phone rang; my wife picked it up. I could hear her voice from the other room.

She appeared in the doorway, holding the receiver against her shoulder. “They want to know if we want to joint them for dinner at the pub. Are you up for it?”

I had been sitting on the sofa in the dark, mesmerized by our Christmas tree all lit up in the corner.

“If you want to go, we’ll go,” I said.

“We’ll swing by the apartment on our way down,” my wife said into the phone. Slowly, I rose from the sofa and reached for my coat and cap.

A thick fog blanketed the wet streets as we walked beneath the streetlights. I pulled up the collar of my coat and jammed my fingers into my gloves. The cold dampness cut through my trousers as we walked down the street beneath the yellow cones of light in silence.

We knocked at the door of the first floor flat. My son-in-law let us in. He and his father had been working in the new old house most of the day, tearing plasterboard off the walls in the upstairs bathroom. His mother had finished sanding the walls in the master bedroom, getting them ready for the first coat of primer. Both of his parents had worked all day without eating. They looked spent.

They pulled on their coats and we stepped back outside into the fog. It was a short walk to the pub at the end of the street.

The dining room was vacant; a few regular patrons lounged at the bar; a sentinel Christmas tree stood silently in the corner.

We shed our coats and slid into a booth. A waitress appeared to take our order. “Where are all your customers?” I asked. “It’s New Year’s Eve.”

She shrugged her shoulders and smiled. “Somewhere else, I guess. We’re thinking of closing early.”

“Is the kitchen still open?”

“Of course.”

We ordered a round of drinks and studied the menus.

Later, my daughter and son-in-law arrived with my son and his girlfriend. They sat down at the table next to our booth.

“This place is dead,” my son said.

“It’s quiet and warm and clean,” I said. “What more do you want?”

“A party,” he said. “You going to watch the ball drop on TV?”

“I’m going to drop long before that — into bed,” I said.

“Ian posted a letter he wrote me when he was away at college.” He handed me his smartphone. I scrolled down to read the text written 15 years before. Work on your grades, his older brother had written. You don’t have to get A’s to get into college, but you have to graduate from high school. Otherwise you’ll be pumping gas at the Getty station or bagging groceries when you’re 30.

I laughed. He was 31 now with an undergraduate degree, working for the government, going back to school in the spring.

“When we tore out the wallboard, there was knob-and-tube wiring underneath,” my son-in-law’s father said. “You’ve got to be careful when you do demolition in these old houses. No telling what you might run into. I cracked my head on a beam in the basement.” He dropped his chin to show us the red crease on his scalp.

I thought about the work I had done on our home shortly after we purchased it 26 years ago: stripping paper, priming walls and ceilings, replacing the subflooring in the bathroom, repairing a leak in the roof.

“I told them to concentrate on one room at a time. That way they can see some accomplishment. It gives you a little incentive to move ahead. Somehow, it doesn’t seem so overwhelming.”

We finished up and stopped by the table to say good-bye to the kids, who were now starting out on their own, just like we did three decades ago.

Outside the fog lay in the street. But overhead the stars were out. A clear crescent moon hung in the sky.

The next morning dawned faultless blue above the village. Outside the back window, high up in one of the maples, a woodpecker pummeled the bark of a broken limb, a remnant of last October’s storm.

Humane Medicine — The year of the great-grandmother

“It’s been a tough year,” she says. “I’ve got my mother living with me now. I didn’t think it would be quite like it turned out. She’s 85, and with frontal lobe dementia, she requires constant care. But what can I do? She’s my mother. And then there’s Meg—I’ve still got Meg at home. You remember Meg—”  more»

Interested readers can now access my latest Humane Medicine columnGenerational Medicine: The year of the great-grandmother — recently published in the Journal of the American Academy of Physician Assistants.

Humane Medicine — Faith in a Seed

Every seed germinates in its own time. Some of the seeds that we plant might lie dormant for months, perhaps even years. Sometimes we might even forget that we planted them. But then one fine day suddenly we see the first tiny shoots unfolding in the light. more»

Interested readers can now access my latest Humane Medicine column — The art of medicine: Having faith in the seeds we plant — recently published in the Journal of the American Academy of Physician Assistants.

Touching Portraits

In 2005 the artist James Esber produced a line drawing of the turbaned bearded face of Osama Bin Laden. He subsequently sent a photocopy of his sketch to nearly one hundred friends, inviting each one of them to reproduce it on tracing paper and enhance the work to their liking with shades of black and red ink. The compiled results form the heart of his exhibition “You, Me & Everyone Else” currently on display at the Pierogi gallery in Brooklyn.

Some of Mr. Esber’s friends were members of his own family. Some were professional artists in their own right; others had no previous artistic training. Yet they all succeeded in expressing themselves in a unique way. In Mr. Esber’s words, “personal touch becomes paramount.” Each person possesses a unique touch, which under the proper circumstances can be drawn out.

When I step into an exam room to see a patient, I enter another world. I offer a greeting—an invitation of sorts—create an ambiance, ask a question or two. If the chemistry is right, the patient begins to talk, expressing concerns, fears, pain; sometimes hope, even joy. I provide the framework, the blank canvas, on which the patient might choose to render a drawing, a portrait—a blend of some segment of existence.

I recognize that any narrative might be slightly different depending upon the nature of the interaction. The technique works best with gentle guidance. As with any work of art, it fails miserably with inadequate time and attention to detail.

Thoreau writes: “It is something to be able to paint a particular picture, or to carve a statue, and so to make a few objects beautiful; but it is far more glorious to carve and paint the very atmosphere and medium through which we look, which morally we can do. To affect the quality of the day, that is the highest of the arts.”

Perhaps, like Mr. Esber, that is what we who work in the helping arts are tasked to do: to draw out the unique touch of those whose lives we touch every day.

A Pupil of Picasso

“I’m worried that my son might have a lazy eye.”

Seated in the chair by the exam table, this mother wears a concerned look as she produces a photograph from her purse.  “There—you see what I’m talking about?”

She points to the left eye in her son’s recent school picture.  By a narrow margin, it appears to be slightly smaller than the right one.  I study the color portrait and note that the light from the camera’s flash reflects off each cornea at the exact same spot.

The medical assistant has already checked the boy’s visual acuity on the Snellen chart:  20/20 vision in each eye.

“Anyone with lazy eye in the family?” I ask, reaching for a penlight to peer at the boy’s pupils.  “No?  Anyone in the family ever have eye muscle surgery?”

I ask the boy to follow the light: over, up, across, down, back to center.  I check for lid lag; I perform a cover test.  Finally, I use the ophthalmoscope to peer through the boy’s pupils to study his retinas.

The entire exam is normal.  I expected as much when I first glimpsed the photograph.

I find such encounters gratifying, because I’m able to reassure families that everything is fine purely on the basis of a thorough clinical exam.

“Then why does his one eye look smaller than the other?” his mother asks.

“It has to do with the distribution of the fatty tissue below the surface of the skin around the eyes,” I tell her.  “Have you ever studied Picasso’s works?  If so, you know that Picasso almost never rendered his subjects’ eyes as mirror images of one another.  They are usually of different size, location and proportion in his drawings and paintings.”

The mother seems pleased with my explanations.  She’s also happy that there is nothing wrong with her son’s vision.  All in all, it has turned out to be a good visit—for everyone.

In the Adventure of the Copper Beeches, Sherlock Holmes remarks: “To the man who loves art for its own sake, it is frequently in its least important and lowliest manifestations that the keenest pleasure is to be derived.”

Over the years I have taken keen pleasure in the art of medicine—and in the art of Picasso as well.

Help me to not be afraid

Like all 4-year-olds, Skipper had his likes and dislikes, his favorite activities and things he would rather not do. Like most 4-year-olds, Skipper’s world consisted of family, friends, pre-school and home. And like few 4-year-olds, Skipper’s world came to a grinding halt when his doctor diagnosed him with a brain tumor.

Because of its location, the tumor was operable. The neurosurgical team labored over him for eight hours and succeeded in resecting the growth. Because the pathologist was unable to differentiate the cellular type, the slides were sent out to a world-renowned regional cancer center for review by the experts.  The results came back equivocal.

The parents were given the option of a short course of local radiation, an extended course of chemotherapy, or observation. Because of the side effect profiles, they elected to watch and wait. Unfortunately, the growth recurred.

This time round Skipper was enrolled in a chemotherapeutic protocol. Periodically, he would receive four days of toxic medications. These rounds were scheduled at monthly intervals. The initial treatment regimen knocked him down, but soon he was up and active again. The second round was worse. The morning before the trip to the hospital, Skipper’s grandmother was helping him to put on his socks when he made his small request: “Please, Grandma, help me to not be afraid.”

What do you say to a 4-year-old? What sort of reassurance do you offer? How far out on the limb do you go?

At that age, reassurance takes on the mantel of love. Words help, touch helps, doing an activity together helps. We work with whatever tools we have.

Sometime later after I heard this story, I drove to a local bookstore to browse the shelves in the children’s section. It proved difficult to locate a specific book, because they are categorized under different genres according to the perceptions of the adults who work in these areas. For the young child, a book is a story—nothing more, nothing less. Its category means nothing—it is only the story that holds meaning.

I made my selection and paid at the register. I laid the parcel on the seat beside me as I climbed into my car. I hand carried the book to the house that I had last visited years ago. Tucked in among the towering pines, it was still there, just as I had remembered it: neat and trim, well cared for.

With a short stammer of inadequate words I placed the gift into the hands of the grandmother I had come to know over the past decade. She invited me to come in, and we sat among the plants in the conservatory and talked a long while about children and grandchildren, parenting and grandparenting, love and tough love.

She gifted me a poem by one of her favorite writers, Wendell Berry.

When despair for the world grows in me
And I wake in the night at the least sound
In fear of what my life and my children’s lives may be,
I go and lie down where the wood drake
Rests in his beauty on the water, and the great heron feeds.
I come into the peace of wild things
Who do not tax their lives with forethought of grief.
I come into the presence of still water.
And I feel above me the day-blind stars
Waiting with their light.
For a time I rest in the grace of the world, and am free.

At my age, reassurance takes on the form of caring. We learn to care for one another as best as we can, with whatever tools we can muster.

“Notes from a Healer” — The Lives We Touch

Today I placed a tuberculosis test on the forearm of a young lady who is enrolled in nursing school. I’ve known her since she was an infant. She’s all grown up now, striking out on her own. I last saw her several years ago when she came in complaining of panic attacks shortly after her father died from metastatic bone cancer. Back then she was vulnerable; now she’s confident. She’s decided to devote her life to caring for others.  more»

My latest installment of Notes from a HealerThe Lives We Touch — 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. Interested readers can access a list of editorial board members and regular contributors here.

El Tío Nayo

The small Citroën takes the narrow curves in stride as matchstick eucalyptus trees zip by.  Every so often a break in the foliage reveals a channel of the estuary where it cuts into the green stone-hedged fields.

We pass an oxcart filled with fresh hay, the old man staring straight ahead from his wooden seat.  “How much horsepower does an oxcart have?” I ask my sister-in-law in Spanish.  She laughs:  “Ningún—none—only ox power.”

Up ahead we pass through the tiny village of O Pedra, “The Rock.”  My sister-in-law tells me the local joke about the necessity of the novia to pass through O Pedra before reaching Cariño—tenderness—our final destination.

We enter the narrow winding cobblestone streets of the port of Cariño and weave our way up the inclines past the fountain in the small plaza.  Up above, at the cemetery, the vista opens up.  From here you can look down on the red-tiled roofs of the town past the ancient stone wharf across the bay to the Isle of San Vincente and the large expanse of white beach beyond.  Off to the left, away to the northeast, the jagged coastline stretches all the way to the punta of Estaca de Bares, the northern most point of Spain.

It is a clear day, and the blue sky is filled with puffy white clouds driven by the wind across the Cabo Ortegal.  At our back, the Serra da Capelada rise steeply from the sea.  On the other side of the bay, behind the long stretch of white sand beach, lies the Serra da Faladoira range.  All of the mountains are draped in green except for the outcroppings of bleached grey rock at the peaks.

We stop at the cemetery to place a bouquet of flowers from the nuptial mass at the grave of my father-in-law.  The vase is top heavy and keeps falling forward off the narrow lip of white-washed concrete.  The graveyard mason offers a small piece of brick to balance the base.

We return to the car and continue up the unpaved road to the oddly shaped three-story yellow house whose footprint resembles a trapezoid.

An old mastiff barks and strains at his chain near the back entrance.  Next to him two emaciated cats mew a lament.  Chickens cluck inside a wire pen, scratching the ground.  My sister-in-law calls out, but no one answers.

We push open the heavy mahogany door and step into the coolness of the marble corridor.  A few steps down the hallway lead us to the open door of the bedroom.  My sister-in-law raps on the lintel:  Se puede?”

Inside an old man sits upright in a chair by the window next to the bed.  He smiles when we enter.  His hair is combed straight back, revealing ruddy cheeks and bright eyes that sparkle like sea glass on the beach in the morning sun.

Hola, tío!” my sister-in-law greets him.  “A ver, si conoces a este hombre?”  She says this in reference to me.  Four summers have come and gone since last he saw me.

He stares at my face and smiles.  His eyes continue to sparkle, but there is no recognition.

“Soy el marido de tu sobrina,” I tell him.  “I am the husband of your niece.”

Suddenly the scales fall from his eyes.  Si, si; le conozco.  Ahora le reconozco.”

Que tal?” I ask him. “How are things with you?”

Regular,” he says.  Then he adds:  “Con los 90 años que tengo.”

“Uncle, you aren’t 90 years old.  You are only 86.”

“Am I?  I must have made a mistake.”

“He likes to watch the football on TV,” my sister-in-law says.  “He was watching when Spain won the World Cup this month.”

El tío Nayo nods his head.  Jugaban bien,” he says.  “They played well.”

I notice the catheter than exits from his trousers to the bag at the side of his chair.  Y esto?”

“La próstata,” he says.  “El riñón.”

“He has a marcapasos as well,” my sister-in-law says.  “The last time I took him to the residencia for a checkup, they found that his pacemaker hadn’t been working for four months!”

“Amazing,” I say.  “Some hearts are smarter than machines.”

“They said that he had a heart attack at some point in the past.  But when we asked him, he couldn’t recall any episode of chest pain.”

El tío Nayo nods his head.  “E verdad,” he says.

“Do you get outside these days?” I ask him.

“No, hombre.  Me quedo aquí en mi habitación.”  He turns his head to look out of the window.  We look out over the red-tiled roofs and the fishing boats in the port across the bay to the mountains beyond.

“Aquí se puede vivir como un rey,” I tell him.  “Here you can live like a king.”

El tío Nayo turns his gaze to the window and looks out at the vista below with misty glistening eyes.

Humane Medicine — House calls, Homebodies

In my student days, I trained at an urban health clinic. Although we saw the gamut of general medical ailments, my most invaluable lessons came when the doctor and I ventured out into the local community to make house calls.

Interested readers can now access my latest Humane Medicine column, House calls, homebodies: Remembering that you came, recently published in the Journal of the American Academy of Physician Assistants.

The light within

People are like stained-glass windows. They sparkle and shine when the sun is out, but when the darkness sets in, their true beauty is revealed only if there is a light from within.

                                                     — Elisabeth Kubler-Ross

 “Would you mind if I brought a friend along to our Saturday breakfast?” my friend Al asked.  “I’ll be chauffeuring him up to Vermont afterwards that morning.”

“Fine with me,” I said.  I recognized the name—someone I had met previously but didn’t know well.

Our guest ambled into the restaurant with a cane.  A big man, he sported a neatly trimmed white beard and moustache.  We had selected one of the large booths to accommodate everyone.  Our guest inched down along the padded bench until he settled directly opposite me.

He had bright blue eyes and a strong voice.  He stowed his cane on the seat and shook hands all round.

The waitress poured the coffee and took our orders.  We made small talk until the plates of food arrived.

Our guest told us he was born on Long Island three months before the 1938 hurricane.  “They never forgave me for it,” he chuckled.

“Who?” I asked him.

“The city of New York.  They figured the storm was all my fault.  We moved south shortly after that.  Then on to Michigan’s upper peninsula.  At that time the houses were built with a front porch on each story.  With an average annual snowfall of 25 feet, local residents would sit out on the lower porch in summer and the upper one in winter.”

“A story for each season,” I mused.

“Yes,” he laughed.  “Eventually, we ended up on the west coast.  I call San Francisco my home.  That’s where I fell in love with sailing.”

“I used to do some sailing myself,” I told him.  “Up in Boston, when I was stationed on a Coast Guard cutter.”

“A Coastie, yes?  I served in the auxiliary for years myself.”

“What did you do for a living?” I asked.

“Worked as a newspaper reporter on the San Francisco Call-Bulletin for a number of years before I matriculated in theology school.  Went to British Honduras for a spell; later got into prison ministry at the federal penitentiary in Tallahassee, Florida.”

He knew the folk music groups from the 60s:  Peter, Paul and Mary; the Kingston Trio; the New Christy Minstrels.  “That’s where John Denver got his start, you know,” he said.  “Of course, his name wasn’t ‘Denver’ back then—some long Polish name, never could pronounce it.”

Somehow the subject of Kubler-Ross’ stages of death and dying came up.  I told him that I had just returned from Atlanta, where I gave a presentation on caring for terminally ill children.

“I worked with Kubler-Ross when she was doing some studies on terminally ill children at Dallas Children’s Hospital,” he said.  “Some of her research was quite insightful:  doll play and creative art.  One kid drew a bird with a broken wing.  Another drew a bright yellow butterfly—I remember that one vividly.  Big, bright yellow.  He died shortly after that.”

We sat in silence for a moment.  An entire era flashed through my mind: the hurricane of 1938, the snows in upper Michigan, sailing on San Francisco bay, the civil rights movement, the Vietnam war and Woodstock, a boat in Belize, the Tallahassee penitentiary, death and dying in Dallas—somehow all coming together over a Saturday morning breakfast of bacon, eggs and homefries.

He was a big man with a white beard and moustache.  If you looked carefully at his bright blue eyes, you could sense the light shining from within.