Teachers and lessons

Not every teacher is human, not ever question answerable.

Some lessons are learned after the teacher has left.

Ok, so summer came late this year.....at least it came (sort of)

Let me begin by apologizing to everyone I know who reads this in Texas, I know it has been hot (think 1980 hot) if not more, so you may well want to skip this post while I talk about the weather from this summer (think cool and wet).  Why am I talking about the weather?  Well, because it is a time honored tradition on the Island and it has been as unusual as ever based on the reports of my Octogenarian patients.  

Let’s begin with tradition.  If you visit our Fair Island, then one thing you must be aware of is that each conversation must contain some discussion of the currently prevailing meteorologic conditions.  Typically this is phrased in the form of a rhetorical question....

‘Getting enough snow at your place?’

‘Not to dry for you is it?’

The former question being the one you got over the winter, and the later being the question for this sumer.  You see, our winter this year was a little warmer than the previous winters which translated into massive amounts of snow.  The weather has to be warm enough for it to snow, and this year it was.  Additionally, the storms came through in a pattern that was unusual and it made for lots more snow sticking around.

The typical pattern for weather here is to have a storm, a couple of clear days then another storm.  It really does not depend on the season, it is the pattern that seems to prevail year round.  The main difference is that the season will determine the quality of the moisture delivered, not the pattern of the cycle.  In winter, this is snow, in the remainder of the year in rain.

This winter the pattern was windy day, storm day, windy day x 2 storm day, windy day x 2, storm day, windy day x 2 etc from January through mid March.  There were none of the typical clearing days after the storm, just the wind from the departing storm and then from the approaching storm.  As spring approached everyone was hoping for a change, and on schedule it occurred.  The snow turned into rain, but the pattern did not alter.

This made for a very cool, very wet spring.  The spring lobster fishermen had lower than average catches because of the stormy cold waters, and all the farmers were gritting their teeth waiting on the chance to work their fields and plant.  We got a few breaks in late May early June so that the farmers planted (as did gardeners) and then the cycle kicked back into gear and things stayed wet (and cool).  We were wearing sweaters into July as the cool temperatures persisted.  

In conversations with my patients, the weather played an important role.  Everyone was/is worried about the gardens as this is a key staple for storage for winter, and lots of folks had to plant their gardens a second time because of the weather.  Usually by mid July summer has really arrived and the temperatures are getting into the high 80’s (mid 20’s C) and low 90’s (Low 30’s C) throughout the day, but still in the 60-70 degree range at night(15-22 C).  July this year has seen our daytime temps from mid 60’s to low 80s for the daytime highs and the evening temps in the 50’s and 60’s.  This combined with regular rain and cloud cover have made summer seem down right spring like.  

So, what does all this mean in practical terms?  Well, it is after all the weather, and there is not really much that can be done.  It does mean that the growing season is a little funky, and that farmers who are making hay have had a hard time finding the perfect window to cut the hay so it can dry and be baled prior to the next rainy day (our hay farmer usually puts 10,000 bales back yearly and had only done 3,000 by mid July).  Some crops are doing well (if you land is well drained), but the warm weather garden crops (think peppers and tomatoes) are struggling.  For my part, I have a bumper crop of carrots, broccoli, radishes, lettuce, celery, onions, squash, pumpkins, and beans.  My tomato plants are large, but the tomatoes are green, and the peppers may not produce at all (time will tell).

It is as odd as the extreme heat in Texas, and the older patients are all apologizing to me about the lousy weather.  If is funny, but it is a part of life here, and always part of the conversation.  Hoping the weather is favorable where-ever you reside.

Sometime you just want to be able to dig out…….

So, this winter on PEI has been a bit or a ‘slam’, and we are having trouble digging our way out.  As most of you (in the US) know, the Northeastern United States has gotten pounded with record snowfalls.  Well, it is not like those storms run out into the ocean once they cruise past northern Maine, they run into Nova Scotia and New Brunswick, and then PEI.  So, we have gotten a pretty good dump of snow on a regular basis.  This definitely has an effect on the delivery of healthcare in our little section of the world, that is, it increases the number of snow-days that we all suffer.  In fact, over the last 14 days, the schools have been closed for 5 consecutive days (today included). 

But aren’t you guys ready for snow?  Well, yes.  However, being ready does not mean managing.  The snow has been coming so quickly that the snowplow operators are having trouble clearing the roadways between the storms.  You see, when the snow along the edges of the roads gets built up enough, then they develop into walls, and it is hard to push the snow off the road when there are 4-8 foot walls.  Needless to say, this has caused many of the roads to become one lane roads (if you want a closer look watch the video).

The other issue from the storms is the regular re-arrangement of the snow after it has fallen by the strong winds that come with the storms.  The snow drifts quickly backfill the cleared areas of the roadway and so the plow drivers have to constantly circle round re-clearing the drifts.  This has combined to close the schools for the last five days and I have had more storm days in February than I have had in the preceding two years.  Thankfully, the forecast appears to indicate enough warmth that we should have some melting in the very near future.

Buried in paperwork….Nancy has been working to get our paperwork ready for the Taxman.  The joy of the New Year means that in addition to digging through the snow, it also means digging through the tax prep for the coming year.  Nancy is preparing documentation and intermittently suffering from Traction Alopecia[1] from the numerous separate supporting documents to ensure that our savings accounts do not represent an attempt to cheat the government our of our tax.  That is the US government, not the Canadian government, and they want to make sure we do not hide anything from their eyes.  It requires that we document the balances throughout the year for each account, documenting the highest balance and lowest balance, providing samples of hair saliva for testing (well, maybe that is a little exaggeration).  It is crazy, and as Nancy has mentioned, the BS to Fun ration is getting a bit unbalanced right about now. Thankfully, she continues to dig for all she is worth and hopefully we will see the top of the pile sometime soon.

Well,  at least it is starting to rain today, so maybe we will have a little drop in the snow, and can only hope Nancy will get some similar relief  for her pile soon.

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[1] That is pulling her hair out

Who has inspired you?

I am a physician in no small part due to the influence of one individual. My Grandmother, LaNere Gilligan, always told me that I would be a great physician, and as we all know, it is very difficult to doubt the truth of our grandmothers. From as early as I can remember, she told me that I would become a physician, and that I would be a good physician. I never doubted what she said, and really never wavered from this idea, this goal.

She came from a much more practical time in the world. She was born in 1916 , Woodrow Wilson had been nominated during the Democratic National Convention, and WWI was raging in Europe, the United States was not to enter until one year later. She was the youngest of five, a child of the depression, for whom her parents died when she was young. She grew up in Austin Texas being raised by her eldest sister. She met my grandfather in Junior High and dated him through college. They were married in 1939. She studied nursing a Seaton School of Nursing in Austin Texas, and practiced as a nurse for many years. Many things influenced her life, and subsequently mine, but her time during the depression and her life as nurse were the things I remember the most.

From the Depression, she gained a sense of frugality. She always planned for the worst, expecting that things could decline as they had done when she was young. This frugality was something that my Grandfather had never known, he was the son of a drag-line operator, and his father always had work in the coal region of Indiana. LaNere, knew hunger, and knew early that she was an extra mouth to feed, one that was not yet able to pay her own way. This drove her toward self-sufficiency, and in that time this meant secretarial work or nursing.

Nursing was very different in the 1930’s, as was medicine. It was a time when great discoveries still lay ahead, penicillin had only come to light in 1928, and the use of certain advance surgical techniques (electrocautery) were just beginning in surgery. It was a time a paternalistic medicine. She learned her craft during this time and it influenced her interactions with physicians from that point forward. She was of an age that did not question the physician, right or wrong that was the time. She learned many skills from this environment, one of which was to encourage behavior she wanted indirectly, and this she used to great effect on me, in my youth, as she molded me into a physician.

This influence came in many forms, from the first anatomy book at an early age (pop-up), to a Gray’s Anatomy for Christmas. She encouraged exploration and investigation in all things, there was never a wrong answer, just a conclusion that needed more work. As well, there was the need to ensure the well rounded nature of her young pupil, indeed of the young physician. Lessons hard learned from an earlier time had to be passed on, and an appreciation for the lives of others must be instilled. These she did without my even knowing or seeing. Understanding of our shared past, from whence we came (the family history as it were) should be learned so that you would be grounded for the future.

As with all things, the time comes when those who influence our lives pass on from our view. Their care and concerns, the lessons learned are instilled deeply in our lives, so much so that they live on within our hearts and minds. The influences they have laid upon us are so subtle and so deep that we can hardly see where they end and we ourselves begin, they simply are part of who we have become. These influences carry us forward and help make us who we are. So, on this day, as I reflect on the life on LaNere Gilligan, one of the most influential people in my life, I send my thanks to her for all that she taught me, for the unending support and for the steadfast belief in what I could become even when I doubted myself. May I always act in a manner befitting this legacy, as may we all.

LaNere Gilligan (Thornberry) June 5, 1916-November 27, 2010

Who has inspired you?

I am a physician in no small part due to the influence of one individual. My Grandmother, LaNere Gilligan, always told me that I would be a great physician, and as we all know, it is very difficult to doubt the truth of our grandmothers. From as early as I can remember, she told me that I would become a physician, and that I would be a good physician. I never doubted what she said, and really never wavered from this idea, this goal.

She came from a much more practical time in the world. She was born in 1916 , Woodrow Wilson had been nominated during the Democratic National Convention, and WWI was raging in Europe, the United States was not to enter until one year later. She was the youngest of five, a child of the depression, for whom her parents died when she was young. She grew up in Austin Texas being raised by her eldest sister. She met my grandfather in Junior High and dated him through college. They were married in 1939. She studied nursing a Seaton School of Nursing in Austin Texas, and practiced as a nurse for many years. Many things influenced her life, and subsequently mine, but her time during the depression and her life as nurse were the things I remember the most.

From the Depression, she gained a sense of frugality. She always planned for the worst, expecting that things could decline as they had done when she was young. This frugality was something that my Grandfather had never known, he was the son of a drag-line operator, and his father always had work in the coal region of Indiana. LaNere, knew hunger, and knew early that she was an extra mouth to feed, one that was not yet able to pay her own way. This drove her toward self-sufficiency, and in that time this meant secretarial work or nursing.

Nursing was very different in the 1930’s, as was medicine. It was a time when great discoveries still lay ahead, penicillin had only come to light in 1928, and the use of certain advance surgical techniques (electrocautery) were just beginning in surgery. It was a time a paternalistic medicine. She learned her craft during this time and it influenced her interactions with physicians from that point forward. She was of an age that did not question the physician, right or wrong that was the time. She learned many skills from this environment, one of which was to encourage behavior she wanted indirectly, and this she used to great effect on me, in my youth, as she molded me into a physician.

This influence came in many forms, from the first anatomy book at an early age (pop-up), to a Gray’s Anatomy for Christmas. She encouraged exploration and investigation in all things, there was never a wrong answer, just a conclusion that needed more work. As well, there was the need to ensure the well rounded nature of her young pupil, indeed of the young physician. Lessons hard learned from an earlier time had to be passed on, and an appreciation for the lives of others must be instilled. These she did without my even knowing or seeing. Understanding of our shared past, from whence we came (the family history as it were) should be learned so that you would be grounded for the future.

As with all things, the time comes when those who influence our lives pass on from our view. Their care and concerns, the lessons learned are instilled deeply in our lives, so much so that they live on within our hearts and minds. The influences they have laid upon us are so subtle and so deep that we can hardly see where they end and we ourselves begin, they simply are part of who we have become. These influences carry us forward and help make us who we are. So, on this day, as I reflect on the life on LaNere Gilligan, one of the most influential people in my life, I send my thanks to her for all that she taught me, for the unending support and for the steadfast belief in what I could become even when I doubted myself. May I always act in a manner befitting this legacy, as may we all.

LaNere Gilligan (Thornberry) June 5, 1916-November 27, 2010

In Remembrance....

On January 1989 I arrived at Marine Corps Recruit Depot in San Diego California. The bus arrived on post under the cover of darkness and the minute we came to a stop, it was very clear that we were no longer in the civilian world. That first night was a blur as we ran from place to place picking up and labeling all our gear, getting our first haircuts, and beginning the transformation all Marines undergo during their training. As I woke the next morning, looking into the mirror at a bald face that was unrecognizable, I wondered quietly if I had made some kind of mistake. This quiet reflection was to be the first of many over the course of my time in San Diego. These moments seemed to occur regularly as we ran along the edge of the San Diego Airport, watching planes take off for unknown ports while we seemed to be stuck in time, stuck in training. The reflection occurred during the hours of endless drill on the parade deck, at the rifle range, as we stood guard in the mud and rain.

The time in ‘Boot Camp’ was over before I really knew it and once again I found myself standing in front of a mirror, getting my dress uniform arranged, and I did not recognize my own reflection. The time had stripped away the weight, but it had also changed something much more fundamental, the face in the mirror was one of resolve, of determination, of pride.

Change is a fundamental aspect of life in the military. The motto of the US Marine Corps is Sempre fidelis- always faithful. However, the unofficial motto wasSempre gumby- always flexible. Military service trains you to be adaptable, to change your course mid-stride, to roll with the variations that life offers. You are in one place, on a post, then orders come and you move, you deploy, or head to the field. Things are always in motion, and the only certainty that you ever entertain is that whatever you expect to be doing, it will change. The constancy of this change makes you a quick study of those around you. As you arrive on post, you meet the neighbors, get to know your unit, and quickly immerse yourself in the culture of your new duty station. It is the friendship borne of change that creates such a lasting bond. Your families suffer the same difficulties of deployment and training, learning to lean on each other while their loved ones are being warriors. They depend on each other for the arrival of babies, broken arms, lost puppies, and uncertainty. The depth of friendship forged in the military lasts well beyond the end of service, and is unlike any other.

In my life I have had the honor of serving in two branches of the US Military, the Marine Corps and the Army. I have had the privilege of serving with the best people I have ever met, ordinary, humble, steadfast, and honorable. As a physician, I have the honor of caring for those who came before, the veterans who have served. These men and women are part of my extended family. These veterans were the reason that I chose to serve, and the motivation to serve well. We all take a moment on Remembrance Day to pause and reflect on the vets who have provided our freedoms. For my part, I thank them daily for helping me to become the person I am today, without their service, their tradition, I would be left wanting. Sempre fidelis

Social Networking and the Doctor Patient Relationship.

So, I was listening to a CBC radio program White Coat, Black Art which is a weekly program about medicine from the viewpoint of doctors. This week’s program reviewed the role of social networking on the doctor patient relationship.

This prompted me to think a bit more about the role Social Networking should or should not play in the relationship of a patient and physician. When I look at my use of handheld computing, I am finding that I use my smartphone in almost every patient encounter. I use the phone to look up answers to my patient related questions, and I use it to send consults all the time to many local physicians and ancillary medical folks (i.e. PT, OT, etc). I also use e-mail to communicate with patients, if they wish, to keep up with patients when they are away from the local area (as many folks are who work in the Alberta Oil Fields). Is it really that big a step to move forward to communicating via FaceBook direct message?

Many of my patients enjoy the fact that I have a website (www.docgrimes.com) where they can access information that I find valuable. Some of them have commented that they appreciate it that I have a place where they can go and get answers that they feel that I have pre-screened for value. A few have commented on the fact that I post Tweets to the site of things I find fascinating or useful, it provides some insight into the way in which I look at some of the non-patient aspects of medicine. All of them like the ability to look at my schedule of when I am going to be in clinic seeing folks, and when I am in the walk-in clinic. All of this seems pretty straight forward.

I do have a FaceBook page for my clinic Doc Grimes Clinic, but I limit some of the things that can occur on the site. It really reflects (quiet literally) the content of the website albeit a little late. There is no real way to contact me through FaceBook, but via my page you can send me feedback. I know that some folks, especially teens and young adults, use FaceBook to communicate. What do you think? Should your physician be available via FaceBook? Should they be available through Twitter or E-mail? How about via SMS or Text?

I admit that I am a little fuzzy about what is to much or not enough availability, after all, I live in a small town, people stop by my house when I am out working. Everyone already knows what I am doing (building a barn, tilling the new garden, buying a horse etc) so it is not like I am losing any more privacy, just changing my accessibility. Let me know what you think.

How do you remember?

In the last several months I have begun a new job, a Medical Director position, and with that, a certain amount of paperwork has come my way. Inevitably, people will stop by, mention things that require attention, which quickly slip you mind if you do not tackle it right away. In the past I have made liberal use of stick notes. You can probably imagine the picture, a desk with lots of notes in various stages of organizational clutter. Without fail, the important note filters to the bottom, is forgotten and your are in a crunch trying to get things done that have literally slipped you mind. If we add a bit of complexity to this, say an office at work, home, and the hospital, and then you can see how the layers of confusion and forgetfulness will multiply.

So, I have been working to find a way to make all of this electronic so that I can have one way to round up the notes and ideas into a central location that would be easily accessible from any place, via any device. I wanted to get away from the stick notes, and I am not really keen on typing everything into my calendar every time something comes up, especially when some of it comes up in the middle of meetings, or passing in the hallway. My research led me to a few solutions that I want to share.

Google: In running my calendar off of Google, I am able to synchronize the office, BlackBerry, and home laptop without too much difficulty. If also allows folks who share my calendar to look and see where I am and what I am doing at a given time (excellent for sharing schedules at home). The use of Google Documents has allowed me to post up the common documents for our medical group, and grant everyone access to those documents. I am posting my PowerPoint there and the use of Google Bookmarks means that I have my bookmarks on any computer I run across. In sharing these Bookmarks with others, we can build a common library of on-line resources that the group finds useful.

Evernote: This is my permanent repository for documents. Even with Google, I find that I use Evernote for backup of documents, and it allows me to tag the documents so that they are searchable. I can also upload audio files, photos, scanned documents and tag them as well. The documents are searchable within the text (if they are PDF or word processor documents). The photos are searchable, and the program allows me to clip web pages for later use. It is accessible form any of my platforms (phone, laptops, office computer) and it was free. I upgraded to premium in order to be able to search through PDF documents as well. I do not think I have even begun to crack the coolness of Evernote, but I am working on it hard.

reQall: This is the last tool that I am using to stay a bit more organized. I like this because it is my quick generating To Do list. I can speak into my BlackBerry and it turns into a quick To-do item, or if I give it a time, then it becomes an appointment. It synchronizes with my Google calendar, and so it synchronizes with everything. I can remember something I need someone else to do, put in a quick note, and off it goes to their e-mail so they have been reminded. It works with Evernote, pulling in related items to the topic of the note. So, if I have documents related to a meeting sitting in Evernote, and the meeting topic as a reminder in reQall, then they automatically relate them to each other. It is pretty cool

So, why am I writing about all of this? It is from the viewpoint of an epiphany I had the other day with a patient. This patient has had a head injury, has significant memory problem, and these problems have created a lot of trouble for them. For those of you who are involved with the military, I know that you are seeing a lot of post IED exposed soldiers, and memory problems are HUGE in that group. So, this head injury patient is having trouble remembering to do things. The pocket spiral notebook is being used, and it has helped, but the notebook does not remind anyone when an appointment is due. So, since Evernote, Google, and reQall are all free, we downloaded them in the office to give a try at a different way or staying organized. So far, so good. Fewer missed appointments, bills, groceries etc. I know that the use of these applications has freed up some space in my brain, and it appears useful for others.

My question to you…..what are you doing to remember, and how do you accomplish it?

The Generous Fisherman

One of the unseen and often under-estimated joys of living in on a small island is the local fisherman. When you think of the taste of fresh food, often thoughts turn to the farmer’s market. Who can deny those lovely tomatoes of summer, so sweet and juicy they hardly make it home before they are consumed. How about the lettuce that is crisp, cool and sweet. The carrots that may not be the straightest, but taste like a carrot should. The benefits and joys of a farmer’s market are well known to all, and if they are not, then you should definitely rise early and explore some of the best food you will ever see outside of your own garden. When you think of local, of sustainable eating, often we do not think of our local fisherman.

The local fisherman is every bit as sustainable as the market gardener or local farmer. They are as local as the free range beef, pork or chicken that comes from friends around the corner. They harvest and manage their ‘crop’ just as much as all the others, and they often know when things are at their best, advice which is well heeded. Sometimes you are lucky and you know just such a fisherman. Sometimes you are extraordinarily blessed and this fisherman is your neighbor.

David is our neighbor, and you have read about him around this time last year when I had the chance to go lobster fishing with him last spring. He is a fisherman, and he fishes in the spring and through the early summer. He also farms mussels and oysters, but his first love is lobster. In order to fish lobster, you have to have bait for the traps. Often this bait is cut fish that has been caught elsewhere. Many of the lobstermen will purchase mackerel or flounder for bait for their traps, but some fish their bait to ensure freshness and a steady supply at a reasonable cost. David fishes his own mackerel.

Tonight, David brought over three lobsters for a cooking lesson that Nancy will be having in our house in two days. As usual, we called to ask him if we could purchase a few lobster form him, and as usual, he refused to take our money. Normally he will cook the lobster for us as he steams in to shore, in the sea water. The quick steaming of lobster in sea water and rapid cooling in the same imparts a flavor to the lobster I have never had in any other setting. Tonight, he chose not to steam them as he thought that part of the lesson would involve the cooking of the lobster. You can imagine Nancy’s surprise when she reached into the bucket for the lobster and they were still kicking. Having never cooked lobster before, the lesson commenced, and David taught us the best way to steam lobster (if you are not doing it in seawater). Whenever we have cooked and eaten something that had recently been kicking around, and their demise was at our hands, we take a moment to give thanks for the life that is given for us.

David was full of surprises, in addition to the lobster, he had brought two 8 ounce mackerel that he had caught earlier in the day. He was kind enough to clean and scale them for us, and he provided us with a couple of recipes that he often used when cooking mackerel. Neither of us has ever had mackerel that we can recall, and it is not a common item on the menu at the local restaurants. However, David assured us that it was a really good fish, and aside from just burning it all to heck, it would taste lovely. So, despite the chili that was in the slow cooker, the lobster that was to be saved for the cooking lesson on Friday, we turned our attention to the mackerel.

Mackerel is an oily ocean fish that is high in omega-3 fatty acids, and is best eaten fresh. There are many different types of mackerel and the Spanish is supposed to be of the lightest flavor, the Atlantic the most savory. Well, ours was Atlantic, and savory was the order of the night. A quick call to Judy (the chef who will be giving us lessons) and we had a quick and dirty recipe for the mackerel. We elected the grill, to help render some of the oil, and allow the flavor to intensify a little bit. Since our herb garden is in full swing, a little fresh Greek oregano, English Thyme, and rosemary made a lovely bouquet. A quick Google search yielded a basic recipe (minus the olives) to compliment the one from Judy and it provided a nice lemon pepper sauce for the fish.

To say that this was the best fish I have ever had may seem a bit over the top, but consider that it is 22:45 at night, after a long day, and I am writing about this fish because it was so wonderful and that should give you a bit more perspective. The flesh was firm yet tender, and the taste was savory but not overwhelming. It did not taste strongly ‘fish’, and with the herbs and lemon-pepper sauce, it was quiet simply the best meal we have had in a long time. The season for mackerel is roughly four week in our area, so we can enjoy this fish from the end of May through June and then it is gone. It is a fish stock that is strong and has not been stressed by production fishing. Given the health benefits of this fish, the lovely flavor, and the ease with which it was prepared on the grill, it is beyond my understanding why it is not more popular.

So, as our night comes to a close, we give thanks to the local fisherman. He has once again brought us a joyful meal, local, sustainable, and yummy. May you all be so blessed this week.

What are you doing to slow down?

It is an unusual question. Have you been asked this before? Have you considered it in your daily life? Most folks do not actively think about slowing down, and to do so is contrary to everything that has value. No one wants a slower car, and the microwave tells us all we need to know about our desire to slow down in the kitchen. How about those handy time saving devices- food processor, ice maker, ice crusher, blender, dishwasher, etc. The presence of these devices in our lives informs the casual observer of our “need for speed”. The unbridled desire to get things done faster is all in the name of giving us free time to spend as we choose, to loosen the reins on our lives so that we can carve out a niche (after work, prior to bedtime, following dinner, pre-TV part of our world) to spend some quality time with those around us and the world in general. Is that what we do? Is that what we enjoy? Is this speed bringing you closer to your dream life, to the happiness and joy in your living? If not, why?

In the last two years, Nancy and I have taken the slow lane in life. We are the folks who are headed up the big hill with our blinkers on, windows down, looking at the world as we cruise by slowly. We have changed our concept of time, and in so doing, of the quality of the time that we spend. In preparing to move, we looked at things we could live without, and discovered (as the microwave that was 15 years old died) that you can get by without a fully stocked modern kitchen full of appliances. To be sure, we still have some, but we have asked ourselves if they are truly necessary, or simply convenient. It is the same question we apply to any new (or new to us) purchase. Is it needed or wanted. In doing so, we have found that many things really are wants, and that the promised time savings that is provided is really fictional. Sure you save time grating the cheese in the food processor, but the time spent cleaning it up afterward consumes the time saved. What have you saved? What have you lost?

In the kitchen, part of the joy of our time together is talking as the meal is being prepared, discussing the ingredients cleaning up after each other and generally making it a communal event. The time is not saved by the microwave; it is savored over the stove. It allows us to immerse ourselves in the moments. To smell the meal as it comes together, to enjoy watching someone cook, and reveling in their presence. It allows us to show our love for another. We take joy in our meal, the preparation, consumption, and clean-up; the entire process, together, as a family.

Our lives slow down when we take time to look at the world around us, take time to see the world as it is, right now, in its full beauty. We could do things more expediently on our farm with a tractor, but there are times when the use of a pitchfork and wheelbarrow is more satisfying. The way the mist lays over the trees like a blanket, the manner in which it alters the smell of the earth, the sound of the seagulls, is difficult to perceive from the seat of a tractor. The rich smell of the loam as the manure pile is turned and moved, the sight of the worms, fungi, and beetles rummaging through the compost is missed as the front end loader dives for the next scoop. That time to connect with the senses, to connect with the world cannot be appreciated at Mach-1.

So, what are you doing to slow down?

And everyone shows up at once…..

Time (n) the concept that keeps everything from happening at once.

Funny, it did not seem to be in play this week. We have been on The Island now for close to two years. We have not had many visitors, in fact we have been visited by our Niece, Abbey, and last summer and otherwise, the house has been ours.

Well this week we had a few guests. Arden (a dear friend, and our current tenet on the Texas farm) had been planning a visit. He was headed back from a WHO conference on dementia in Germany and decided that if he was flying through Newark, it would not be that tough to come a little further north for a visit. This visit has been in the works for a few months. We have looked forward to this visit and had made a few plans for some of the things that we wanted to do, but mostly it would involve hanging out and being cool.

Ten days prior to his arrival, I got a call from my paternal Aunt. I had not spoken with her in some time, e-mailed infrequently, and kept up primarily through her yearly missive outlining her travel adventures from the previous year. She had come across some American Airlines super saver mileage fares and it would allow her a trip to Halifax on the cheap. Apparently she had been in touch with Dad, and soon things were squared away for a visit to Canada. Once she had settled that, she got in touch with me to see if it would be possible for a visit to the Gentle Island. Having not seen her or Dad in some time, it sounded like fun.

“When do you all plan on arriving?”
“We will land on Tuesday and try to come see you on Wednesday.”
“Next week?”
“Yeah next week.”

So suddenly we had Arden here, and then after a few days, Charlie, Nita, and Ronnie would be spending a few days in our neck of the woods. The schedule was changed, but what the heck. So, after a little bit of work, we had recommended some lodging in the area and things settled down.

Thankfully the weather held for most of the week so that everyone got to see the island at a pretty moment in time. It was not as warm as we would have liked, but you can’t get everything. We have more visitors for the summer yet to come. We are expecting another visit from Abbey in June and a visit from Katy and Johnny in July. All in all it will be a busy summer.

Well the Strawberry plants need some attention and I still have to give the garden a quick weeding. Hope your days are as fun filled and that time will keep you from having to do it all at once.

Reflections on practice

It has been a while since I attended an international conference. In fact, I have not really been to any formal national or international conferences since I moved from Texas to PEI. I am spending today and the next several days in Vancouver, British Columbia at the Society of Teachers of Family Medicine, STFM. Today the preconference workshop on Palliative Care promoted a reflective sense, and allowed the opportunity to look back at how much has changed during the last two years.

The pre-conference workshop was geared toward developing a curriculum for the education of residents and students in palliative care. It may have been the group, the topic, or the electromagnetic forces at play, but the room was full of many people who love what they do, strive to be the best at their profession, and are keenly aware of their short comings in their endeavor. It was interesting to sit in a room full of people who are mindful. The listening and discussion had a different tone in this room, it reflected the struggle. Into this room, at the close of the day, we turned our attention to ‘self care’.

In the realm of palliative care it is a fact that burnout shadows the work, and in the crucible of academic medicine, the shadows may overtake you before you are aware. In an effort to assess our needs as a group, a small exercise was in order, a pictogram representing where our time and efforts are spent. After drawing a box and labeling the corners (work, family, friends, self-care) the time was divided to reflect the amount of time and energy we spent in each corner. The comparison of my time slices today look very different from the slices two years ago.
Then
Work 70 hours (71%) Family 14 hours (14%)
Friends 7 hours (7%) Self care 7 hours (7%)

Now
Work 50 hours (58%) Family 21 hours (36%)
Friends 7 hours (8%) Self care 7 hours (8%)

The feeling surrounding life has changed far more than the 13% reduction in my work hours reflect. The chaos that comprised a fair bit of life is no longer present. The sense of having to run to keep up is virtually absent, and the smoldering resentment surrounding work has vanished. This change has allowed for a more important evolution in patient care, it has allowed for the return of empathy.

Mindful patient care is something that is difficult to achieve if you have sliced your time so thin as to become transparent. If there is no substance to you, no opportunity to focus your attention on the patient at hand, then you are unable to be mindful and present in the room with the patient. It is this presence that is transformative. Being present, attentive, and without distraction allows you to see the patient as they are, at that moment, in the moment. In seeing the patient, the moment for change occurs. The ability to look past the superficial mask which we all wear allows you the chance to speak to that divine spark within each of us, that little bit of God we all hold, the portion of each patient that can effect change. It is seeing this person, hearing this person, and speaking to this person that we act in ways that allow them to see the change, to become the change.

It is in the quiet times that we can look and see the things that need to be done, and move the things that need moving. On the Island, in my practice, with my patients, I am privileged to observe the comings and goings of these quiet times in the patients and families for whom I care.

Namaste

Signs of Spring.....

The calendar tells me that today is the first day of spring, the vernal equinox, the day the sun crosses the equator. In watching the sunrise at 7:20 am and set at 7:27 pm I confirm the calendar, but the arrival of spring seems so much more than the length of the day or the date on the calendar. Spring does not greet you with a harsh slap on the face like winter, and it does not induce nostalgia in tones of sepia as autumn. Spring is quiet, gentle, easing your senses out of their slumber after a winter’s nap. It is a comfortable season, you are surprised when you look around and find that it has arrived while you were attending to other business.

On the island, spring gives you subtle clues that it is coming. We did not appreciate those clues last year as we were being pummeled by a snow that continued to fall well into April. The island weather has been gentle this year and we have kept our senses open for the changes that indicate the subtle arrival of the gentle season. The undeniable urge to start going through the garage and discard anything that you have not used in over a year is surely one of the first signs we encountered. The fact that we built a barn this year and had a significant amount of construction debris likely played a small part in the early arrival of this impulse. It was on one of our ‘dump runs’ that we noticed several other signs of the season.

As we finished loading the back of the Suburban with the construction debris, we paused for a moment to listen to a sound that had not been heard since November. The sound of several hundred nesting seagulls that inhabit a small sand bar in the middle of the bay our house overlooks. Their raucous caws and cries were a welcome sound, complimented later in the day by several over flights of geese returning to the island from the winter feeding grounds.

Along the roadway we noticed Islanders going about their business, clearing away the road sand that had gathered in their drives over the winter. Like the seagulls, the Islanders began to pop out of the homes, cleaning their cars, washing the front porch, and hanging laundry on the line to capture some of the sun’s warmth that had begun to arrive. In the flower beds, the first of the paper-whites have begun to erupt from the snow cleared ground, and in the pasture, the horses are all enjoying long rolls in the soft earth as they work to shed out the winter coat.

In a short time, the days will warm and lengthen; summer will surely arrive with the obligations of the garden, the yard, and the flower beds. But for now, with an afternoon of sun, the chores completed, we take a moment to sit, breath in the changing of the season, and rejoice in the arrival of spring.

Merry Christmas Message

In our little corner of the world, Christmas morning has arrived with a little snow on the ground and a definite nip in the air. We have had a wonderful year on Prince Edward Island, and with the arrival of our second Christmas, we have come to appreciate and enjoy the warmth of our small town even more. The island has allowed us to slow the speed of our lives, given us the chance to look around, and reminded us of the joys of daily living. It has given us the chance to learn who makes our food and buy from them directly. It has given the opportunity to see the needs of others and help. It has reminded us of the spirit of community and encouraged our inclusion. It has released us from the bonds of time by asking us to sit for an hour when we drop by for a visit. In short, our little corner of the world has helped us return to the values and ideals that we believe in our core. It is our sincere hope for each of you, that this opportunity to return, refresh and re-energize comes you way, and in so doing renews the joys of your life and living.
Merry Christmas to you all….…..Gil and Nancy

Do the right thing.......

There has been a profound change in my practice since I left Texas, hospice and palliative care have become a very significant portion of my practice. This change has left me with deep questions regarding the practice of medicine, and has left me considering the obligation to ‘Do the right thing’.

When the focus of your practice is to diagnose and treat with an eye toward recovery, the right thing is a bit more obvious. Your charge is to figure out what is ailing the patient and make it right as quickly as you can with the least amount of harm to the patient. It is a balancing act between beneficence and harm. Harm comes in many forms, cost (for unnecessary tests), radiation (CT scans), pain (invasive tests), misdiagnosis (finding the wrong thing, or finding something incidentally that leads you on a goose chase), and side effects (every treatment has a risk). You are always balancing this against the good you are working to accomplish, asking yourself if these things are really needed in order to help the patient heal.

How does this change when your role is to help someone have a ‘good death’? The purpose is no longer recovery, but to comfort, and that changes the equation. Comfort care seems very straight forward when presented as such. You provide care to the patient that brings them comfort, relieves their suffering, and makes them at ease. At first glance this does not appear to be that difficult, and in many cases it is not. The symptoms that the patients have are such that they can be managed without any direct risk to their well being and care is provided with a minimum of risk.

When pain is a significant symptom, then the situation changes, the risks increase and the chance of harm is ever present. Most patients fear the suffering associated with pain. Pain is a great teacher; it is there to keep us alive. Pain is there to make us release the hot object, struggle against the trap, fight against the darkness. Pain is an intrinsic element of humanity, it is the great equalizer. The treatment of pain is a first order priority in the care of the hospice patient. In the minds of many, the control of pain is essential to a ‘good death’. The unfortunate risk involved in the treatment of pain is the hastening of death. The medications that are used to treat pain, narcotics primarily, all have side effects that include depression of the respiratory system, that is, they slow your breathing, sometimes fatally. The inclusion of anti-anxiety medications often makes the respiratory problem worse, and unfortunately many people have a great deal of anxiety as they approach death.

How do you balance this equation, providing for the comfort and care, but avoiding the ultimate harm? It is easier when the patient looks you in the eye and tells you what to do “I do not want to suffer, and I do not care if the medicine makes me die sooner”. But what of the patient who asks you to “Do what you think is best”. What is best? How can you know? What is best for this patient? Do you work to relieve the suffering knowing you are shortening their life? If that time is but a few hours you might not worry, but what if it is a few days, a few weeks? What if the treatment you provide gives complications that increase the suffering of the family? How do you balance these equations?

Currently the province of Quebec is having a vigorous debate on euthanasia ( CBC, Forum, Government). This debate is also happening in Europe on a larger scale (BBC , Research Article) and in the United States as well (Grid on Legal Efforts by state, Annals of Internal Medicine ). I suspect this debate will continue throughout my lifetime as it has throughout the lives of others. However, my question for now remeains, when does the provision of care and relief of suffering cross that line, and how will I know if I am doing the right thing?

On not knowing everything………

We make decisions every day, most of them without any consequence at all. What are you having for lunch? Going for vacation? Getting your friend for Christmas? These decisions may take a lot of our time, but the outcomes do not usually make a large difference in our lives. What happens when the decision has greater implications? What happens when your decisions may impact the health and welfare of others? How comfortable are you with the unknown? When you clearly do not know something does it make you uncomfortable? Does it make a difference if this is public or private ignorance?

In medicine we often have a chance to review these thoughts as we go in to the ‘office’. As a family physician, often you are seeing the undifferentiated, the patient who has not been seen before for the problem at hand. These patients could have anything, and often do. This is the heart and soul of family medicine, and more than anything else, it is this aspect of the profession that I often find the most difficult in the long hours of the night.

When students ask me what they should do for a living, I often ask them how much tolerance they have for the ‘gray zone’ of family medicine. By the time that they have spent six weeks with me in the hospital and clinic, I usually have a good feeling for their tolerance of the uncertainty that caresses every action of your day. Those with minimal tolerance are encouraged to pursue specialties where, to quote one of my local dermatologists, you can ‘know more and more about less and less’. This whittling of the number of problems that you are responsible for allows you to focus in on a subset of problems and become expert in these diseases. You learn to recognize the intricate variability of a presentation of each of those diseases, learning the common and uncommon presentation of ‘your special illnesses’. When a patient arrives in your office with a consultation, your role it to determine if this patient represents one of these diseases or not, provide advice on the management of the disease if it is in your realm, and if the patient does not have anything in your specialty identify what they do not have and return them to the referring physician. As a family physician, these patients are often back into you office with a long list of what they do not have and you are back to square 1.2 where you restart your diagnostic processes again, the gray zone of uncertainty has returned.

Students who truly relish the gray zone, exhibit significant comfort in the zone, and are willing to work hard to develop tools to improve their work in this zone become the rural physicians of old. These folks work on ‘gut’ instincts at times taking a chance on a hunch when the data is not always there, but the feeling that you have is undeniable. This is a skill that some are born with, but most develop over time as a side effect of lessons learned. These lessons come through every patient that passes through our clinic, every specialist report that lands on the desk, every specialized test that you have ordered. What is important is how you supplement this instinct, and that is something that has changed over the last years.

In 1996 I worked in a small rural clinic at Dugway Proving Ground in the west desert of Utah. I had received the minimum training needed to not be outright dangerous to people, but I had hardly received what would be called sufficient training. In this location I performed the duties of a rural family physician, taking care of any and all that came through my doors. In my examination room I kept a copy of the Merck Manual so that I had the best compact source of information to assist me with the diagnosis and treatment of my patients. It served to help me fill in the large gaps in my knowledge base as I saw my patients, and I often took it off the shelf while the patient was sitting on the table. I knew what my limitations were, and had no difficulties letting the patients know that my fund of knowledge had definite limitations. This was one of the driving forces behind my desire to expand my knowledge base, complete my training, and my enthusiasm for on-line evidence based medicine.

In order to work well in a rural clinic and do so without waiting years to develop the fund of knowledge that comes from practice, you must have a series of tools at your disposal to help you shrink this zone of uncertainty. For my part, DynaMed, PubMed, and ePocrates serve as my peripheral brain. They help fill in the gaps in my knowledge base, remind me of things I once knew, and help me to become a better physician. Despite these tools, there are still times when you find yourself faced with patients for whom you simply run out of good ideas. These patients are the ones who haunt you as you sleep.

As a family physician, even the presence of these tools may leave you with a patient for whom you still do not have an answer. These are the patients that drive you to study more, to deepen you fund of knowledge. These are the patients that leave you with a feeling of inadequacy as you pull on your hair at night trying to figure out what may ultimately be unknowable. In a rural setting, this absence of knowing can eat at you as you see the patient routinely and feel you inadequacy tugging at your sense of self. What is left is often something very different than you might want something somber and reflective as you look back on the day a thoughtful player in this world.

The beautiful flame fractal on this page came from the following website

http://lojjic.net/gallery/1000words/20031208-flame-fractal.jpg

Fresh Pressed Cider and other Glories Fall

Dew has been coating every outdoor surface for the last few weeks, the folks in town have experienced a couple of light frosts, trees have exploded with vibrant color, and my usual attire has been modified to include my waxed cotton fedora and rain jacket. Fall has arrived on the island my friends, and with it comes the annual apple harvest, a true treasure of the season. Fortunately for us, there is a local orchard that is just down the road, and on my route to and from work.




Apples are something that I was not expecting to find all that different. After all, an apple is an apple right? Well, I must admit, that was prior to tasting apples fresh from the tree. The apple season starts around the end of September with the earliest apples being the Jona’s Red. These apples are exceptionally juicy. When they are fresh picked, they are crunchy and sweet. They soften over 3 days by which time the juice can be seen running down chins as people enjoy them. Just about the time you are really getting used to having them fresh daily, their season is over and the Cortlands and Honeycrisps have arrived followed quickly by the Spartans and MacIntosh. It is apple heaven, and the arrival of the MacIntosh heralds the arrival of fresh pressed cider.




Let’s talk about cider for a moment. If your image of cider is from a large glass jug in the store, then you are as mistaken as I was regarding the joys of fresh cider. The cider from our neighborhood orchard is pressed and slightly filtered but not pasteurized. It is a blend of the late season apples and has a crisp sweet-tart flavor that is extremely refreshing. Like the apples, it is here for a short while and then gone again. It is like the harvest season, it arrives with a bang and is out the door almost as quickly.




The fall also marks the harvest season for the crops you have nurtured along all summer. Our little garden has treated us well, and with a little luck I can extend the season through until the snow flies. We have had plenty of broccoli, bell peppers, lettuce, and jalapenos from the garden for the last 2 months. I planted things in succession so the crops have arrived in a staggered fashion preventing us from being overwhelmed by any single crop (jalapenos excepted). The tomatoes have had a bit of a rough time, primarily due to my late planting and a cool wet summer. We have gotten some from the vines, but for the most part they have remained green and firm, teasing us with their unrealized potential. The carrots have gotten long and firm, growing deep into the loose soil, and I was genuinely surprised by the number of potatoes that I was able to harvest from four small plants. The corn looked great, but we let it sit out one night to many and the raccoons came through and helped themselves to every stalk, lesson learned. Thankfully, the local vegetable stand (Webb’s vegetables) had plenty of corn for us and they did not get raided by varmints. Their stand has gone from offering lettuce and corn to late season tomatoes and pumpkins. It is a popular spot on the main highway and they are always busy with customers dropping by for weekly produce for as long as Webb’s can keep it coming.

Of course another glory of the fall is the exuberant display of color the trees put on when the days begin to shorten. My favorite color has to be the vibrant red and fluorescent orange of the sugar maples. These line the roadway on my drive to work so I find that I must focus exceptionally hard on my driving so as not to be distracted by the show. It we are lucky and the winds do not blow too hard too soon, the color will stay around for a month. Like everything else, it will pass quickly so you have to enjoy the moment while it is here. That is the lesson of the island for us for the last year, and we are making the most of the moment while it is here.

A lot happens in a year……

Despite the truth the calendar flaunts, the fact that a year has elapsed since our arrival in Canada is surreal. In fact, it was only when I was answering a question about how long I have been on the island that the realization of times passage hit home.

“One year, as of today”

Granted, a few days has passed since that statement brought me to a stop in my tracks, but the time has allowed for reflection of the year passed and with that reflection comes today’s post.

Nancy asked me what I had learned in the last year. The easy answer was the use of standardized units for lab values (different from the US system), as well as the odd names for all those drugs that I spent time learning, plus a whole bevy of new ones that are not approved in the United States. However, that answer would not really get to the truth of the last year and while placating some, would not be satisfying.


Universal health care is good for people. I have come to more firmly believe in this over the past year. It is not perfect by any stretch, and I am sure there are other places that do this better than Canada, but the Canadian model of care, providing some baseline level of care for everyone is better than the system I came from. The Canadians value the community, and therefore they value coverage for everyone, even if it means that you pay more to cover someone else. They accept this fact and feel that the end result is worth the price. The end result is that people can be seen and treated before things get very bad. Now, the downside is that not everyone has a Family Physician or NP looking after them because there are doctor and nurse shortages here as there are everywhere else. However, you can be seen without worrying that it will break the bank, and you know that if you get sick, the cost of your recovery will not leave you in poverty before you are ever well. Things do not move at the speed of light, but that also means that the doctor or NP has to think twice about ordering some expensive test with a waiting list. Not everyone who has a migraine headache gets an MRI to rule out a cancer.

Practicing medicine is fun. With the removal of the bountiful paperwork that seemed to reproduce on my desktop in Texas, I have re-discovered that I enjoy practicing medicine and taking care of patients and their families. It is the same joyous feeling I had when I practiced in Dugway Utah, that feeling of connecting with and helping out patients every day I went to work. I do not feel like an overpriced administrator, and I certainly do not feel that I am being given paperwork as a way to discourage ordering a test/study. I get to sit down and talk with my patients, listen to their stories, and take care of their needs. The fact that my panel is stable means that I am seeing the same people over time, therefore, once I get them caught up on their prevention, I have additional free time to chat about other important things like their kids and grandkids, the state of their farm, the lobster catch, and of course commodity prices. This provides a great deal of insight into the inner working of the island world, and with that comes a deeper understanding of the inherent worries of the lives of the islanders. This knowledge allows me to understand them in ways I was never able in my previous practice. It has brought the joy back to my practice and that is invaluable beyond measure.

Life outside of medicine is important. The change in pace over the last year has been the most surprising thing on this journey. When we arrived last year we did not understand how people could spend all their time ‘Up West’ and rarely venture to Summerside or Charlottetown. The idea that you had everything that you needed ‘Up West’ seemed ludicrous when we arrived, after all, how anyplace could ever have ‘everything you needed’. The interesting thing about needs and wants is that once you have taken away the drumbeat of advertising, slowed down enough that you notice the change of the seasons, the number of things that require travel to obtain reduces on its own like a neglected garden. It is the deceleration of time which allows you to look beyond the demands of tomorrow to see the glories of today. As time slows, you can see the world, listen to the wind, and connect with the earth in a way that cannot be rushed. This modifies you sense of need, and provides a deep sense of fulfillment in your routine life that no longer has room for the unnecessary. You begin to live each day with joy and purpose, that is, you begin to look at your day differently. You ask yourself if the things you are doing are really worth spending one of your precious days upon the task, or if the time would not be better spent on something more important. These changes percolate into the way you work so that you begin to ask the same questions of the tedium that intrudes upon you day. Your realization of what is and is not important allows you to put medicine into a place in your life, no longer the shadow over your life.

The year has taught us many things, has slowed us down enough to look beyond the ordinary to see it for what it truly is, wondrous beyond the imagination. So much in such a short time, makes you wonder what we will discover next!

County Fair

Summer would be incomplete without a county fair, and so far we had not had a chance to take in one of the local fairs. It seems that every time we wanted to go to a far something else got in the way. Well today we made up for lost opportunity and took in a day at the Prince County Exposition. This exposition has been an annual event since 1926, and it is exactly what you would expect from a county fair. Yesterday was the judging of all the home economic contests. The baking, sewing, knitting, cooking, gardening, farming competitions had all taken place, so we had the chance to wander through the various halls looking at all the goods. Now I know that some of you are probably chuckling a bit at the idea of strolling through the exhibition of crops, but I tell you, if you have horses, finding out who won the hay contest is very important. It is also nice that you have the chance of taking a close look at the hay, and it was definitely a cut above. Since the contestants name and address were on the entry slip identifying the hay, we wrote it all down and will be calling soon to place an order.

Today, the focus of the fair was on the livestock competition, so we got to take in the farm animal judging as well as the horse show. It was cute to see all the 4-H kids competing. The afternoon held the delight of another horse pull, always a very good time, and then the evening had the best of all, a live concert by a local group, ‘The Grass Mountain Hobos’.

The Grass Mountain Hobos are all local lads who have been playing together for over 10 years, and their work has paid off in the form of an East Coast Music Association Bluegrass Album of the Year. They play bluegrass music in a way that makes even those with an allergy to such music have a good time. In watching them play I am reminded of my favorite bands Brave Combo, in that these guys are exceptional musicians, and enjoy their craft as much as the audience does. I recommend them unapologetically as a must listen album. So take a moment and head over the their website and listen to a little joy from Prince Edward Island .