'tis the Season

There was a time in my life when I looked forward to Christmas and Easter.  But now I am at the point when I look forward to Advent and Lent.  I find there to be just something so powerful in the seasons of watchful waiting or self deprivation that makes those “holidays” seems all the more real.   The seasons put the holidays in context for me, and help me realize more fully what it is we’re celebrating. 

The other day we had a lunar eclipse, the last one we are to experience for sometime.  And I found myself riveted.  It was a slow, nearly majestic execution of the moon, taking nearly two hours from its start to totality.  And then there was nothing, for nearly an hour.  Darkness screamed at me from the void once filled by the full moon.  And as I strained to look at the darkness, I realized that, before my eyes, it became light again.  Relief.  The radiance pierced the night sky – first a sliver, then more, and then finally the total magnitude of the full moon.  Order had been restored.

And so now, in the midst of lent, I find myself doing a research rotation at a cancer center.  Cancer really is a bit like a season.  While we have a tendency to look at the end-point, we realize that the cancer has been there for sometime, growing steadily and deliberately, bringing its message not in a day nor in a treatment but rather over the course of many days and many treatments.  And while the climax is all too often not the way we hope for, its end is sometimes accompanied by the restoration of order, or at least by a certain sense of relief.

I hate cancer.  But if I am to be surrounded by it, let it be in this season of lent – a season whose promise is one that beats cancer every time.   

High-fives in Heaven

In Charles Dickens’s “Great Expectations” the human hand is a recurring icon.  It is used throughout the text as a way of getting to the essence of someone – a manifestation of the past and present, as well as a predictor for the future of one’s life.  As the narrative moves along, so are we introduced to more hands, and learn more details about them.  A quick survey of the hands I’ve encountered and it’s easy to see how Dickens came to this concept – the rugged hands of the laborer, the chaliced hands of a musician, the soft hands of a child, the weathered hands of the homeless. 

It all makes the hand-shake or the high-five pretty special, doesn’t it?  A temporary joining of lives.

I recently learned that I have been accepted into a general surgery training program, which is to say that my hands are going to be of great importance to me for the foreseeable future.  Actually, it means that my hands will be of most importance to my patients who will literally put their lives into the care of my hands.  Atul Gawande writes in his book “Complications, a Surgeon’s Notes on an Imperfect Science” that the director of his surgery training program once remarked how rarely doctors came into the program with “good hands” but that, after the five years of training, they all left with the necessary set of skills needed to operate.  That hands can change, to a budding surgeon, is encouraging. 

And so when I called home the other day to tell my parents the news of my being accepted to the surgery program, I was struck by something my father said.  He quietly lamented that none of my grandparents could share this moment, but quickly added, “I’m sure they’re exchanging high-fives in Heaven.”  And just like that we had a temporary joining of lives – me, my father, and my grandparents. 

And it was overwhelming.  

Structural Numbers

December 6, 2007

There are two types of questions to ask, Paul Farmer once said. Those that are meant to end a conversation, and those that are meant to start one.

I am currently reading a book called "The Golden Ratio" which tracks the ratio phi through various architectural, artistic, and naturalistic happenings in nature. I admit that I am not reading the book very quickly, but nonetheless it has gotten me thinking about numbers and ways in which we can use them in our lives.  

This vague thinking of numbers has very quickly gotten my mind to C.S. Lewis, one of my favorite authors. Lewis writes that true repentance to God means returning to the point in our lives before sin. In other words, we must get to that moment before the sin, otherwise we are simply going on in our lives without addressing that fatal moment. He uses the analogy that if we are writing out a mathematical problem and somewhere along the way have made an error, the only way to get the final correct answer is to re-check our work and correct that problem. Simply going on - even if we make no more mistakes - will only ever lead us to the wrong answer in the end.  

This all, to me, sounds a lot like osteopathic medicine. Treating the whole patient, as osteopaths do, necessitates not only addressing the illness at hand, but also asking ourselves why that illness is there in the first place. Simply carrying on - even if we treat the patient perfectly - may only be masking something much deeper.  

I am currently working in an urban health center in west Philadelphia. And with every patient I treat I ask myself "what is really going on here?" Is there something much deeper that is bringing these patients to me? I know the answer must be yes, but I can't yet put a label on it. Paul Farmer might refer to this as "structural violence" -- an otherwise preventable violence (in this case TB, an STD, malnutrition, diabetes) that is the direct result of the structure of a conscious society. Now the question is not so much "what is going on that these people present so to me"" but rather "what are we doing as a society that makes these people present so to me?" and "Is there a way to stop it?"  

I admit I don't know the answer. But I know it's an important question to ask. Let the conversation begin!

Chatter

September 2, 2007

One of the many perks of growing up in Washington, D.C., was getting to read Thomas Boswell's editorials in the Sports section of the Washington Post. Boswell wrote on a variety of topics, but his true love was baseball, and all aspects of it. Of particular interest to him was what, exactly, made baseball America's pastime despite it's poor translation to television. Boswell points out that simply going to the ballpark makes for a completely different experience than viewing the game on TV, in large part because it allows one to hear all the chatter that can only be appreciated in person. There is the chatter in the stands, of course, about what is going on on the field, but there is also the chatter in the dugouts, in the bullpens, and chatter among players on the field, and chatter with the umpires. And all of it, amazingly, is about the game. Baseball allows, or even cultivates, a chatty environment that uniquely defines and even enhances the game itself.  

Many people may not realize that the operating room is full of chatter as well. In a stadium of sorts, while the patient is nervously falling asleep, the anesthesiologist is chatting to the nurse anesthetist about the necessary drugs; the scrub tech is talking with the nurse manager to make sure the supplies are all correct; the attending surgeon is speaking with the residents and students about what will all take place. And all of it, even though it may seem chaotic, is all ultimately about the patient. The operating room needs this kind of atmosphere to make sure patient care is supreme.  

And so it's funny that both baseball and surgery have this talkative environment in common. So even now, as the Phillies push for the playoffs and I apply to surgery residencies, I wonder: why is it that I'm attracted to chatty environments? There is just something amazing about a periphery of noise that is ultimately about improving the task at hand -- if it's made a pastime for baseball, surely it can make a future for me.

Motion

August 29, 2007

When is a piece of matter said to be alive? When it goes on 'doing something,' moving, exchanging material with its environment" -- Erwin Schrodinger

Of the four tenets of osteopathic medicine, perhaps the most well-known is the inter-relationship between the structure and function of the human body. The structure of something -- whether the vertebrae of the spine, the dome of the diaphragm, or even the contour of the fibro-cellular matrix -- reveals the ideal function, and likewise the function determines the structure. When one has been infected with pathology, so too must the other follow. And so to treat the one will undoubtedly improve the other.  

I once had an English teacher in high school who, perhaps because of her exceptionally high expectations of us, remains in my mind one of the best educators I have ever had the privilege to study under. She used to make the point that the form an author chose to write in revealed something about the content he was writing about. The fact that something was a poem in meter may be as important as the poem's content itself.  

Of infinitely more importance (while at the same time using identical logic), I once knew a priest who drew this conclusion: that what Jesus said pales in comparison to the fact that he was saying it at all in the first place.  

And so this last month has been very difficult for me, as I have been working in a dedicated trauma intensive care unit (TICU). Because there we take care of people who have lost all ability to move, to function within their environment, and to do anything whatsoever that we might call living.  

When you take care of people like this, it is easy (although I believe dangerous) to de-humanize them. One individual sticks out in my mind. He had gotten into a fight with his girlfriend, had a drink or two, and then crashed his motorcycle into a tree. He suffered serious brain injury, a collapsed lung, and numerous facial fractures. He acquired an infection, and was fighting the consequences of septic shock. He was dying. And to us, for just a moment, he became a lot of work. His ventilator settings were complicated, and his oxygenation status simply wasn't cooperating. He was so bloated with fluids that trying to insert lines or chest tubes in him was horribly difficult. And we hadn't even gotten to his brain injuries.  

And then his mother came in. She cried the sort of hysterical crying that makes you pray your own mother will never do. She collapsed on the floor, stood up, and collapsed again, this time on top of her comatose son. When we told her there was nothing we could do, the sad pain in her eyes brought tears to my own.  

The relationship that she had with her son in that TICU, even though it was short, brought meaning to both their lives. It was obvious to all of us how much this young man meant to his mother: the love that she has for him brought meaning to him. There was a kind of motion there -- not a typical, mechanical kind, but rather a kind built upon emotions. The structure and function of the situation was somehow apparent. There was something indeed exchanging between the two of them, and they were both, at that moment, very much alive.

Tapping, Part I

August 24, 2007

When I was younger, I sang in the Washington National Cathedral Choir of Men and Boys. As choirs go, this was the real deal -- we sang 5 services a week, practiced multiple times a day, for a total of about 18 hours per week. And that's a lot for a boy of 12. While the commitment surely came with a whole host of sacrifices, it was surely one of the best times in my life: a chance to work hard at something I truly loved that could have an influence on many.  

Our practices during the weekday morning consisted of just the boys (around 16 of us) and one conductor. The conductor would sit at a piano in the middle of us, alternately conducting with his hand or head and playing along as much as possible.  

I recall one rehearsal, one morning, a long time ago. We were struggling with a difficult passage, and in frustration our conductor stopped playing altogether and clapped his hands loudly to halt the music. He reached for his pencil (never a good sign) and simply began tapping it loudly and deliberately on the ledge of the piano. He was counting the rhythm for us -- something that, to a group of individuals who supposedly knew what they were doing, was somewhat condescending. He had done this so often that the piano had a divot in it from the repetitive striking of wood on wood. We spoke through the measure first, than sang it slowly, then faster, and then without the tapping, and then finally with the accompaniment. The process was painstaking, but effective.  

And so even now, when I hear a tapping sound, I stand up a little straighter, tune in my ears extra close, and focus intently. I know that what will happen next may be painful, but ultimately will get us to our goal.

Now what?

June 13, 2007

The other evening I was walking to my car after a long day's studying. I opened the door from the stairwell and entered the parking garage, but after only two steps or so something on the ground caught my eye. It was small, and white, and after only a moment of inspection it was clear that it was a broken bird's egg. I looked up to the ceiling and there, sure enough, behind a concrete rafter, was stashed an empty bird's nest. It was tragic, really, for I imagined the denizens of that nest so excited about their egg, only to have their dreams dashed in a moment of bad luck. They were so distraught, I concluded, that they abandoned home.  

The ICU of any hospital contains the sickest of patients, and it is there that fortune can change in a moment's notice. Just yesterday a man of about 50 came in with some nausea and vomiting after a company cookout -- most likely food poisoning of some sort, right? He stayed the night, but the next day stumbled out of his bed and feel. A CT was ordered, and it turned out that the gentlemen had a massive bleed in his head that most likely caused his nausea in the first place. Within and hour or so the man was brain-dead -- there was nothing to be done except transport him to a hospital where he could donate his organs to someone in need. It was so fast. I'll never forget the look of the man's father as he followed the gurney off the floor. He was distraught. Helpless. It was a combination of sadness and loneliness, with a bit of confusion over who was abandoning whom.  

I guess things can happen quickly here, no matter what we may do to protect ourselves. And all we can do is react appropriately. One option, for sure, is to abandon home. The other, apparently, is to pick up the pieces as best we can, and perhaps help someone else in the process. The uncertainty of life may be tragic; what we do with it may turn out to be a blessing.

Thunder and Rain

May 27, 2007

Last night we had the first good thunderstorm of the year. And as much as I like to see the bright flashes and feel the rumblings in my chest, I have to admit that I've always been a good bit afraid of lightning. It doesn't matter how many times I'm told that that odds of my being struck are somewhat lower that my being abducted by aliens -- I just don't like the idea. So I choose to focus on the rain  

I think I instinctively like the rain more because it's easier to understand. Electricity is hard to grasp. But rain...I mean, it's water, right? It's in the shower, I drink it, I use it to cook...H2O, I get it. At least, I thought I did. Turns out water is pretty complex after all. Irvin Korr, a monumental figure in the history of osteopathic medicine, had this to say about it: "Nothing we know about either oxygen or hydrogen accounts for the three states of water (liquid, solid, and gas), their respective properties, the boiling and freezing points, viscosity, and so forth. Water incorporates yet transcends oxygen and hydrogen."

Today in church we had a Baptism. I have always found that particular service especially moving, and today's was no exception. And more so than ever, for me, the awesome mystery of water was on display. Through prayer in the service, the historical importance of water is recounted -- "Over it the Holy Spirit moved in the beginning...Through it you led the children out of Israel...In it your Son Jesus received the baptism of John." Moreover, it's importance in the life of Christians today is made plain: "In it [water] we are buried with Christ...By it we share in his Resurrection. Through it we are reborn by the Holy Spirit." 

Is it any wonder, then, that something so important in the life of church as water should be, as Irvin Korr observed, capable of transcending its simple components? And is it any wonder that it continues to hold our fascination today even in the midst of an awesome thunderstorm?  

Amazingly enough, I hear the beginning of another storm right now. Maybe it's water's way of saying goodnight.

Rationale

May 18, 2007

Early on in his work "The Idea of the Holy," Rudolf Otto writes about the process of rationalization and how it provides a way in which to understand that which would otherwise be too great to grasp. For example, he writes that a song is a way of rationalizing music -- a way of taking the infinitely immense variations of cords and intervals and melodies and transforming them into something that is capable of evoking a unique response that can only be called "musical." Likewise, he continues, religion is a way of rationalizing God -- a manageable method of understanding the divine within a human framework.

As I am nearing the end of my third year of medical school, I cannot help but think that medicine, for me, is a way of rationalizing the human body. The human body itself is of such profundity that it warrants attempts at rationalization - what with its unique shape, peculiar requirements, and endless potential - and surely others have sought to do so. The simple vastness of sculpture, writings, paintings, and performances that help define the ages are a testimony to this quest of understanding who we are and what we are all about.  

But surely medicine, you say, stands alone, for while medicine addresses specifically the human body, the other arts are more concerned with the human condition.  

But the human body and the human condition are intimately related. The manner in which humans complete the most basic of actions...the way in which we eat and sleep, the way we jump for joy or recoil in fear, the way we reach out to someone, the way we love...in short, everything that makes us human starts and ends with the body. And therefore to study the body from a medical perspective is to attempt to gain insight into our humanity by way of rationalizing the body.

Enough -- off to study!

Gentleman Jack

May 15, 2007

I found out last week that the Headmaster of my old school, St. Albans, passed away from acute leukemia. Jack McCune was a special person in my life, and though his influence on me has been great, I confess that I have not yet adopted as much of his personality as I would like.  

In the most simplest sense he was a gentleman. Kind, compassionate, sincere...he was all of those. This is not to say he was soft - he could be stern when he wanted - but he always went about things in the right way.  

I don't mean to reduce him to simply "Happy Jack" as he affectionately known to us, for he was much more than a nice fellow. The thing is...his demeanor towards us was the embodiment of his love towards us. His behavior was not an act nor the mere product of his upbringing -- it was a sincere manifestation of his endless caring and admiration he had for his students and all those around him.  

If only I could do the same...to believe in something so strongly that it affects the way I act towards all, and all the time, with no holidays for rest or slips of absent-mindedness. To be so grounded as to not falter in one's belief.  

These words are from a commencement speech he delivered in 1981: "Never, never underestimate ... the power of graciousness and simple politeness. ... Be ever gentle and caring and you cannot help but quit yourselves like men. Be ever gentle and caring and you cannot help but be strong. Above all remember this."

I will indeed never underestimate such a thing. If it impacted me, then surely it can impact others.