What Do You Mean?

A two-page story “Caring for Strangers” raises a whole range of issues worth the conversation we won’t be able to have in our less-than-an-hour Monday seminar—patients’ fears, how doctors miss cues, how medical training can dehumanize, what love has to do with it.  Hearing it aloud adds a dimension to its drama.  It’s not only worth reading, but worth reading together, especially with doctors in training.  That part is a privilege.
But I find myself distracted by stylistic quirks in the story that bother me.  Imprecisions bother me (what the hell is “a chance of a missed occasion”?  What are “drooling dispositions”?)  Overstatement and poor verb choices bother me.  So am I just being a nit-picking English teacher?  The kind that kills “Ode to a Nightengale” at close range?
I don’t think so.  I love close reading.  I can be very forgiving if I see something of value in what people have bothered, bless their word-loving hearts, to write down.  Still, in the midst of the widening conversation about the value of writing in medical environments—poems by physicians, patients’ stories, cancer chronicles—I find myself wanting to say something about the value of writing well.
One student asked this morning about how to avoid falling into clichés.  I want to pat him on his lovely head for caring about the question.  The challenge of writing anything worth devoting a sentence to is finding a way to invite a reader back to a place she thinks she’s been for a second look.  “Words strain, crack break, Eliot wrote, strain with imprecision, will not … will not stay still, …leaving one always with the intolerable wrestle with words and meanings.”  I don’t believe as fully as I used to in the sheer value of writing things down, though sometimes it is, in itself a heroic act.  I think the value comes in the wrestling with words and meanings that makes the writing itself part of the arduous, demanding, surprising work of healing.
I’ve gone to websites where patients post their poetry, and am generally disappointed in the quality, though I applaud the impulse.  I wish someone could help them take it a step further, as my friend Vicki used to when I brought her a thought or a rough draft.  “What’s behind that?”  she’d say.  Where did this image come from?  Why did you start with this phrase?  Did you notice what you’re not saying?  Why did you pick that verb?
This kind of long look at unpolished sentences isn’t just the professional purview of English teachers—it’s human work.  “What do you mean?” is a searching, valuable question.  It’s a second draft question.  It deserves to be asked and answered.

Postponed Pleasures

Years ago, when I asked a clerk in one of Oakland’s independent bookstores for a book about migraine (since I’d been having them more often, and medication didn’t work, I thought, like a good academic, I’d at least read about them).  She rose from where she’d been sitting behind the counter—an older woman, a little bent, with the kind of rich voice that made me think she probably sang in the gospel choir at her church.  “You get migraines, Honey?” she asked, as though she really wanted to know.  I nodded.

“I used to get those,” she said.  “But then I just decided too many people think they need somethin’ from me.  So I got rid of some of those people.  Now I got fewer people.  And I don’t get headaches.”

I think I walked out without a book, but I went home with a piece of advice I revisit regularly.  Some days I wake up with tremendous gratitude for all my friends, for good colleagues, for children who like introducing me to their friends, for college roommates who stop by on their way through town.  Other days I remember that woman and wonder how to decide when the dance card is full and, what’s harder, how to tell the people who didn’t make the cut.

More and more, I neglect my friends.  I learned this morning that Heidi, who often tell us when she needs a ride to UCSF med center for another excruciating procedure, has been in pain for the past two weeks.  She evidently got a ride to her last desperate procedure—burning the sciatic nerves to disable the pain communications while trying to leave her motor nerves intact.  I’ll call her tonight.  I meant to call her.  She’s near the top of the priorities list, but not quite in the half dozen slots that occupy the hours of any given day.
I want to have been there for her.  I will be, now.  But it’s late, and I’m guilty, and again I wonder how many people it’s possible to extend lovingkindness, compassion, and attention to.  I don’t write Suzanne because it takes me ten minutes to write an actual card in human handwriting, and I know she loves those.  I don’t call Vicki, one of the wisest, funniest friends I have, because she loves to talk, and it’s hard to make a conversation with her shorter than 45 minutes.

My mother visited the sick.  She was a compassionate listener and people called her.  She sat by our beds when we were little, and by my grandmother’s when she was very old.  She worked full-time.  She made time.

She also didn’t live with the ratcheted up expectations most of us have of ourselves now—an ethic of staying in touch multiplied to impossibility by the technologies that extend our touch worldwide.  An ethic of loving one’s neighbor that stretches “neighbor” to a far-flung “network” of newly accessible people.

When I agonize about all the people I neglect, my husband smiles calmly and says, “You can’t do all the good things you want to do.  If you’re reading Dostoevsky you’re not playing the cello.  (He read that somewhere.  I don’t play the cello.  And I’d rather read Tolstoy.  But then, if I’m reading War and Peace, I’m not reading Moby-Dick.  And I’m not visiting Heidi with homemade soup.

What’s Mine?

“Spare change leads to spiritual change”

My mother worked at a school for orphans in India for thirteen years.  Those years profoundly shaped the rest of her life stories and much of mine.  In a simple way that was never offensively moralistic, she reminded us, even—or perhaps I should say especially—at the end of a month when grocery money reached a serious limit—to be thankful.  Gratitude was a way of life for her, and giving.
I’ve traveled a winding road since those lean years, and my mother is gone, but I think of her when I walk the streets of Berkeley and give money–or don’t.  I feel blessed to have her example so deeply branded in my memory—though the sense of not being able to live up to it remains uncomfortably with me as well.
I’m blessed not only by her example, but, more presently, by my husband’s.  As I wrestle with my own anxieties about money, ownership, the painfully visible inequities we all live with here in this polarized city, and at this time of rightful and vigorous protest, it helps me to watch him talk with the homeless people who stop us as though he was just hoping they’d stop him to ask for money.  “What’s your name?” he asks, as he fishes through his pockets.  “Where you from?”  “Tom.  Good name.  My grandpa was named Tom.”
My brother engages any and everyone with similar genuine interest.  At our father’s funeral, though he and dad had had some hard times over the years, he gave a touching eulogy about how Dad would welcome conversation with anyone from the school custodian to a CEO with a natural egalitarianism that seemed to come from what was sometimes an utter and awkward lack of class consciousness.  “Who are you?” he wanted to know.  “What can I learn from you?”
The money exchanged on these occasions is not, of course, incidental.  It isn’t enough to look people in the eye and speak with them.  My brother carries a roll of quarters for the purpose.  Dad sometimes brought people home for something to eat.  But what I have learned from these whom I have loved, and from many others in my fortunate life is that gratitude is a dimension of giving—gratitude of the kind that says I’m so glad you asked me for money!  I’m so glad I found you just on this street corner while the light was red.  I’m so glad you picked my freeway exit and I saw your sign, even in the rain.  I’m so glad I happen to have some money right here in my pocket.
Some days I rush past the people who need what I have.  Busyness and hurry erode generosity.  Some days I occupy myself with my first-world problems.  I’m grateful for the days I don’t.  I’m grateful for the people who have taught and continue to remind me that what isn’t shared is wasted.

In Praise of Specificity

Specificity is a form of compassion.  The most compassionate people I know deal in details.  Their eyes take in the sticky residue on the floor where a toddler will plant the hand that goes into her mouth.  Their concern about housing leads to questions about cockroaches and rats.  They see the faint pesticide cloud breaching the edges of the field that borders on migrant laborers’ homes.

In his remarkable book The Working Poor, David Shipler models this kind of compassion in his close attention to the daily decisions and weekly crises of people whose every choice involves a tradeoff.  He invites readers to sustain their attention to specifics long enough to feel what they “see.”

I can’t help, in this pre-election month, contrasting his humble, careful portrait of the poor with the abstract rhetoric about poverty that wins points for candidates—or worse, stereotypes the poor.

One of the most convicting phrases I heard in graduate school was when a friend worked herself to a place of quite justifiable outrage about “affordable middle-class morality.”  By that she meant holding people to standards that could only be met by people with choices:  cleanliness, preparedness, “good” parenting, social grace.  These standards are hard, sometimes impossible to meet without money, or in a state of grinding fatigue, or when chronic anxiety and depression deplete one’s inner resources.

Imagining Compassion

“Systematizing compassion risks introducing a parade of disingenuous gestures that will be read as artificial and patronizing.”
(David Watts, “Cure for the Common Cold,” NEJM 9/272012, 1185)

Good cooks know the limits of the recipe.  Good cooking is about patient practice of observation with all the senses engaged:  as the sauce is stirred the good cook notices texture, color, the layers of fragrance—rosemary mingling with oregano—even how the simmer sounds, and, at the appointed moment, taste.  Good cooks trust their trained intuitions—a phrase that may seem oxymoronic, but, in fact, points to the well established fact that intuition can be trained, and in the culinary arts, as in any other art, must be trained.
The analogies to medicine may seem a stretch.  But after years of hanging around medical professionals, medical students, and aspiring premeds, I believe nothing is more important in training competent, compassionate clinicians than helping them develop intuition, imagination, and empathy—all prerequisites to real compassion.  What one beloved colleague has wryly called the “social sciencing” of higher education troubles me—meaning no particular insult to those who labor in the social sciences.  They have their place.  But when the methods of social science—data gathering, measurement, graphs, charts, and—well—systems–dominate academic discourse those of us who inhabit alternative discursive universes—in the humanities, for instance—are increasingly encouraged to forsake our “soft” language and methods for what seems to be more reliable.
This morning a student in our “Narratives in Medicine” seminar brought in a bar graph with a bell curve on it illustrating the “vicious cycle of avoidance.”  One axis is labeled “anxiety.”  The other is labeled “time.  The right end of the bell curve is labeled “mastery of anxiety.”  It looks definitive there in black and white, neatly symmetrical.  But those of us who experience anxiety in fits and starts, or who have learned to laugh at ourselves in the midst of it, or who know it can coexist with deeper levels of calm and trust, and that “mastery” doesn’t really even serve as a meaningful objective, have to wonder at the way such diagrams too readily invalidate experiences that are better accommodated by other, messier narrative structures.  Wendell Berry’s description of a dying man’s relatives who, unlike the efficient folk in the hospital bureaucracy, offer a kind of care that belongs to “the larger looser, darker order of merely human love” comes to mind as a vision that challenges what medical and educational institutions institutionalize.
Watts claims that “the product we should seek is not proficiency in literature, but brain balance.”  Yes to the latter, but I’m not sure the latter can be fully achieved without the former.  Proficiency in literature, after all, offers the skills necessary to defend oneself against the domination of bell curves and bar graphs and numerical analyses of data.  There may be, as one critic opined, only 36 plots, but the ways to tell a story are nearly endless, and endlessly generative.  To recognize a patient’s narrative strategies, to wonder why she might have begun her story with an allusion to her mother’s fear of abandonment, to consider the logic of her metaphors and the parabolic quality of her stories from the workplace, to notice how she situates herself relative to the incidents she reports, or how the inflection of her sentences disempowers her and invites her listener to doubt…these noticings can be sharpened and enhanced by literary awareness.  Anyone who has noticed that Romeo and Juliet’s first conversation is a double sonnet is not likely to skim through any other dialogue without looking at its architecture.  Anyone who has laughed over Holden Caulfield’s recurrent opener, “If you want to know the truth…” is less likely to overlook the little flags and tags that offer clues to a good listener.
Can compassion be trained?  To a point, absolutely.  To what point?  I can’t, or won’t put a number on it:  85%, 50%?  It doesn’t matter.  Compassion can be encouraged, modeled, reinforced, spotted in stories, witnessed on Grand Rounds, recognized in the moments when one’s own heart opens.  We develop it in community, in koinonia—the ancient Greek term that means both community and participation.  We step into a magnetic field created by others’ compassion and find ourselves reoriented. It is difficult to get a bell curve from poems, yet doctors deepen their practice every day by means of what is found there.

What Medicine Can’t Cure

Borges:  “Medicine cannot cure what happiness cannot.”

Recently I heard Russ Baker give a lively talk about the copious book he’s published after over a decade of intense investigative reporting on some of the worst government corruptions, scams, assassinations, and consequential lies in US history.  The analysis went back to the Kennedy assassination and beyond.  The general tenor of the talk was that any reason we think we have to trust the major media or the government probably needs to be reexamined.  And that things are worse than we thought.  One of the most remarkable moments in the Q&A that followed, though was when, asked how he managed not to become overwhelmingly cynical and depressed, Baker said, convincingly, “I’m a cheerful guy.  And I love doing this stuff.  Truth is exhilarating.”
It was a good reminder that happiness isn’t dependent on good news, or positive thinking, or the sort of ignorance often mistaken for bliss.  Some of the happiest people I know have complicated lives, precarious finances, or chronic pain.  Barbara Ehrenreich’s recent book, Brightsided, offers a characteristically edgy critique of the culture (or cult) of positive thinking that encourages members of the public to avoid “being negative,” to enjoy life, to make a project out of happiness.  The result of such efforts to “be positive,” she points out, is dangerous neglect of critical questions that need to be asked, critical thinking about public issues or consumer decisions, and even a kind of atrophy of the emotional musculature it takes to sustain a deeper sense of well being than the superficial cheerleading that often passes for happiness.
My mother had that.  My dad—a large-hearted but difficult, eccentric, high-maintenance spouse—asked her on occasion, “So—do you love me in spite of it all, or because of it all?”  As I recall, she evaded the question deftly, and they both moved on, with a little ritual laughter.  From this distance, it seems to me the obvious answer was “Both.”  It’s probably the true answer for most relationships.  And it’s probably true that the deepest happiness any of us achieves comes both in spite of and because of circumstances.  “Be joyful,” Wendell Berry admonishes, “though you have considered all the facts.”  In order to do that, we have to learn something about joy that isn’t obvious, and isn’t circumstantial, and certainly isn’t marketable.  Happiness like that has something to do with discipline, maturity, simplicity, contentment, hope and, I think, what Frankl would have called a search for meaning.

The Thing with Feathers

Emily’s “thing with feathers” sings a tune “without the words.  She makes a point of that, setting the phrase off with one of her famous dashes–so often a sign that she’s dropping into a slightly deeper, more ambiguous place of momentary reconsideration.  No words would seem either a condition of abject limitation for a poet whose words are her wellspring, or, ironically, a condition of freedom from what Eliot called “the intolerable wrestle with words and meanings.”  Hope, in either case, appears to be a state that defies, or doesn’t need, explanation, rationalization, or even description.  We don’t need, she suggests, to philosophize or theologize about it.  As a recent movie title puts it (and let us try to suspend the sexy images of Sandra Bullock that come to mind) “hope floats.”  It is a lightness of being.  And perhaps it is pure gift.  Perhaps, like poems to a poet, it just “comes,” not because of, but despite, our desperate summonings, like the angel who shows up to help, always to offer an invitation to something new, always having to begin the invitation with “Be not afraid.”

Bless the Vets

It’s Veteran’s Day.  Like Memorial Day and the Fourth of July, the matter of honoring veterans evokes complicated feelings.  I grew up on my dad’s war stories–most of them funny, almost none of them allowing us a sense of the darker side of the war experience.  We heard about how he used his coveted leave time to visit antique bookshops in the English villages near the air base.  We heard about how be bought and lugged around an iron frying pan in order to prepare his own food on occasion, and how his commander singled him out in the course of a farewell address to the troops:  as the story goes, he paused at the end of his remarks to the men, looked around, and asked, “Where’s Chandler?”  When Dad waved his hand, the commander looked him in the eye and gave him the parting order, “Chandler, get rid of your junk!” then turned and boarded the plane.  It was an endearing story.  It didn’t occur to me until later to wonder why all his war stories were crafted for amusement value.

When Dad died at 83, two uniformed veterans came to fold the huge flag they had draped on his coffin and ceremoniously hand it to my mother.  By that time, the war that so shaped his coming of age had been superceded by a shameful series of armed conflicts, none of them duly declared, all of them in gross violation of the standards of “just war.”  Villages had been strafed and napalmed, civilians tortured and small farms turned into minefields.

Today is set aside to honor the people who participated in those armed conflicts.  How do you honor the participants without honoring the enterprise?  I am ashamed of the rapacious imperial abuses of power our nation has perpetrated on others, of the unwarranted attacks on civilians, the waste, the brutalizing of the young men and women who are trained to kill.  Still, I recognize the courage required to put your body on the line, and to submit to the strenuous physical and mental disciplines the armed services require.  Good people died at Gallipoli and at Dunkirk and in the Mekong Delta.  And if I think they died in a dubious cause, and that the sacrifices soldiers are making even now in the mountains of Afghanistan are tragically misdirected, and that war will never make us safer or more civilized, I still want to honor the ambiguities that keep me from passing judgment on people who have put themselves through things I would be loath to take on, and who bear, perhaps with as much innocence as any of us capitalist consumers at home, the burden of decisions made in our name but more and more often without our votes.

It’s a good day to remember my first visit to the Viet Nam memorial in Washington, D.C.   Walking down along the lengthening list of names, I thought of Macbeth’s bleak line, “and all our yesterdays have lighted fools the way to dusty death.”  There are better things to say for human endeavor, all of which seems indelibly and perhaps inevitably marked by greed and pride and ambition.  For today, I imagine the best way to mark the occasion is to deepen and renew the resolve to pray for and participate in the long project of making the peace we can barely imagine.

Remembering Kevin

Could’a gone fishing
But then I got thinkin’
The road to the river’s
A mighty long way…

Commemmorating Kevin Mack

I keep saying I knew him less than the other folks in the program—that all I have to remember are isolated moments.  Then I remember that’s always what we have—the moments, few or many, that left an imprint, bent the branch a little, inscribed something on the imagination around which other experiences arrange themselves.

I remember his hands—how he held them widely parallel, as though making a large space for the idea he wanted to convey.  At the last faculty meeting I attended, he gave a report on the PBL program he was helping to launch in Florida.  The combination of excitement and humility—those shining eyes, those open hands—moved me.  People speak of his passion for medical education—so often these days the phrase is in danger of melting into cliché.  But to witness it was to see how love fuels the intelligence that fuels action—one act after another until something is begun that others continue.

I remember his serving food at a curriculum committee, how he came early and set up full plates of aram sandwiches and chips and salad—hard to eat gracefully at a meeting.  After the meeting two of us helped him gather up what remained to take to the break room for students.  He seemed as eager and pleased to be the bearer of leftovers as he was to bring the freshly piled plates an hour earlier.  Both were gifts.  Nothing was wasted.  It seems a little cheesy to compare people to Jesus, but it did at the time and does now make me think of Jesus at the feeding of the 5000 when he aid, gather what is left.  And there were 12 baskets.