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Submitted December 2024
By Dr. Brian Sayers
Miracle Shall Follow Miracle
2024 started with our eighth grandchild, born too early, struggling in the Seton NICU. It was an extended stay causing all the anxiety and uncertainty you’d expect. Little Brooks struggled with each breath for many days, needing support until his own life force would emerge. We were so blessed with expert care and kindness by everyone in the NICU. And then, almost overnight, Brooks became Brooks…and he was ready to go home. So many more things could have gone wrong but didn’t. There was expert care to be sure, but still I couldn’t help appreciating both the mystery and the miracle that were right there in front of us.
Later in the year a long time patient of mine with a complex autoimmune disease struggled for a month in the same hospital, much of that time critically ill, her fate uncertain. She is no stranger to being this ill, but it seemed different this time. I’ve become very attached to her and prayed for her daily worried about her constantly. She made an amazing recovery, nothing short of miraculous, and there was great mystery involved as to just how she had survived. Why did she survive when others who receive similar levels of care don’t?
We are very good at what we do. We control chronic disease, keep people healthy, even save desperately ill patients with some regularity, but in doing so, sometimes I think we give ourselves too much credit, even give science too much credit. Rachel Remen notes that “we have traded mystery for mastery,” that we have largely lost the ability to recognize what lies beyond our grasp in treating our patients, that we have lost our ability to recognize the great mysteries of life and what goes on beneath the surface of medical care. In the great debate over the value of science in public and private decision making that raged these last few years, perhaps we have sometimes taken it too far, allowed ourselves to let science define the very essence of life, to let ourselves take too much credit ‒ or too much blame ‒ for outcomes in the care we deliver. Deep down we all know that science alone is far too narrow to truly define the mysteries and miracles of life.
Many of us feel closer to mystery and miracles this time of year, though it would do us all some good to recognize the presence of both in our daily work. The sense of awe and wonder and humility that such recognition brings can make us grateful and maybe give some perspective when things with our patients either go very wrong or very right. At the end of each precious day, perhaps a one line expression of thanks from Florence Shinn is in order: “Today is a day of completion; I give thanks for this perfect day, miracle shall follow miracle and wonders shall never cease.”
Photo taken in November
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers at briansayers24@gmail.com
Submitted December 2024
By Dr. Brian Sayers
Writing a Wrong
Twenty-five years ago, just a couple of years before tort reform became a reality in Texas, I faced the only malpractice suit of my career. It was in the days when few doctors were untouched by malpractice litigation. On the day that an armed constable arrived unannounced in my office with court documents, I was devastated, humiliated, and shocked. I was an innocent bystander in the suit and about a year into it the judge unceremoniously dropped me from the case, but not until I had gone through a year of worry, anguish, sleepless nights, and self-doubt. The patient, who died of an aggressive malignancy, was a kind, soft spoken man with severe arthritis. He was usually accompanied by his wife and daughter, and I grew close to them in the years that I cared for him, making being named in the suit even more painful. Forbidden to discuss the case with colleagues, I nonetheless did speak with a close friend and mentor who urged me to give voice to this hidden pain either with counseling or journaling. I was entirely unfamiliar with journaling, including expressive writing (reflective writing that explores thoughts and feelings surrounding traumatic or stressful experiences), but after some cursory research, I gave it a try. For me, expressive writing has been a life changing exercise that I continue to this day.
There are thousands of articles and scores of books that support a myriad of physical and mental health benefits of journaling. Dr. James Pennebaker, professor emeritus and psychology researcher at UT Austin, was an early pioneer in this research. He began his research decades ago when he tested out the benefits of expressive writing with college students. His early studies demonstrated a clear correlation between past traumatic experiences and current physical health measures, including frequency of infections and hospitalizations, persisting for years after the trauma. He subsequently developed studies in which he asked student participants to write about a traumatic experience in their life for just 15 minutes a day on four consecutive days. Those who participated in this early study subsequently visited the student health services only half as frequently as controls. This led to a flood of studies in subsequent years showing the benefits of expressive writing in all kinds of mental and physical health domains.
Over the decades that have followed, Dr. Pennebaker has offered concrete advice for people wishing to pursue this beneficial practice. He advises that the expressive writing should deal with our most traumatic or stressful experiences (current or past), as well as things that you might be thinking about or worrying about too much, issues adversely affecting your life or relationships. He recommends that over a few days you write about this experience, bringing to bare your deepest emotions and thoughts related to it. Fifteen minutes a day is plenty ‒ even as little as two minutes can be effective as there is residual processing after the pen in set down. He emphasizes that the writing should be for your eyes only to promote honesty and deep reflection. When you have completed writing about it you may want to save it, but it’s fine, even encouraged, to literally and symbolically destroy it. He recommends this as a PRN rather than daily practice to help you deal with experiences as they come up, experiences that you sense are being allowed to fester. It's free, not particularly time consuming and for most who practice it, can be liberating, even life changing.
It's on my mind this month as I came across the box of records, court notices, and personal notes about the case from all those years ago. It all finally went into our shred box, bound for HIPAA heaven, but strangely enough, even as I set it all aside for good, I couldn’t help feeling a certain fondness for this quiet, humble man who I came to know well in those years. In this big, beautiful life that we have been given, there are inevitably profoundly traumatic events, seemingly insurmountable challenges, mistakes, and regret. There are many effective ways of dealing with these challenges ‒ deep connection with others, counseling, meditation, prayer/faith, and journaling, to name a few. Within each of us there are deeply held experiences that we avoid confronting, that hold us back. That’s just part of the human condition. Among the many gifts that we have been given is the ability, if we are willing, to discern our own unique and sustainable path to wholeness through both the storms and blessings of life.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers at briansayers24@gmail.com
Submitted November 2024
By Dr. Brian Sayers
Wabi-Sabi, Clark Griswald, and Two Pieces of Swiss Cheese
Barely through with Halloween, stores fill with Christmas decorations and urgent holiday music. Examples of the perfect family, the perfect meal, and beautifully wrapped gifts fill the airwaves. Most telling of all, hapless Clark Griswald and National Lampoon’s Christmas Vacation is ubiquitous on cable and streaming services. We start planning and remember so many wonderful things about the holidays, things we look forward to. In a way, it really all comes down to celebrating relationships ‒ with people we care about, with ideas and faith and memories that we treasure. But for some, the holidays can bring sadness or loneliness, a sense of not being enough, a sense of disappointment that the perfect holiday season they had in mind becomes, well… imperfect.
Maybe holiday preparations should include reconsidering perfection. Rachel Remen wrote a piece that I always think about this time of year. She notes that while perfectionism is common in our culture, ancient, wiser, cultures attained a certain kind wholeness and peace by recognizing, even celebrating, imperfection. In Japan, Zen gardeners included a misplaced dandelion in the middle of their near-perfect meditation garden, and traditional Japanese culture embraced wabi-sabi, a world view centered on the acceptance of the transience and imperfections of life that stresses simplicity, modesty, humility, intimacy, and appreciation of the natural world. Native Americans wove a broken “spirit bead,” into their intricate beaded costumes, and Puritan quiltmakers purposely left a tiny stain of their own blood in their work. As Remen notes, “Nothing with a soul is perfect. When life weaves a spirit bead into your fabric, you may stumble upon a wholeness greater than you had dreamed possible before.”
One of the charms of Clark Griswald and Christmas Vacation ‒ why it endures ‒ is not just that it is funny, but within the slapstick there is great truth ‒ that while life, relationships, and holidays are exercises in imperfection, sharing it all in community with our imperfect friends and family creates intimacy and meaning. Sharing struggles, holding hands, realizing our blessings, finding common ground to nurture or reclaim kinship ‒ are all to be celebrated in special ways during the holidays. This requires that we let our guard down a bit, that we consciously open our hearts.
I recently finished Elizabeth Strout’s Pulitzer winning novel, Olive Kitteridge, a series of stories about an unusually cranky, cynical older woman who becomes a widow and gradually realizes her need for human connection. She reluctantly, but irresistibly develops a romantic relationship with a man who somehow sees the good in her. She finds herself in unfamiliar territory accepting, even loving, a human in whom she sees many flaws. In the book’s closing lines lies a lesson for us all, “And so, if this man next to her was not the man she would have chosen before this time, what did it matter? But here they were, and Olive pictured two slices of Swiss cheese pressed together, such holes they brought to this union ‒ the pieces life took out of you.” It’s an interesting image, two pieces of Swiss cheese being placed together, the holes and imperfections in each flawed piece covered when brought together. As Jerry Maguire might say, two friends or lovers completing each other when they are finally able to find it in themselves to allow such a thing to happen ‒ to literally embrace imperfection.
We stress over such trivial things, leaving so much that is good, so much love, unnoticed. But it’s always there, waiting for us to open our eyes. As Thomas Merton once wrote, “The more we persist in misunderstanding the phenomena of life… then the more we involve ourselves in sadness, absurdity, and despair. But it does not matter much, because no despair of ours can alter the reality of things or stain the joy of the cosmic dance which is always there.... the fact remains that we are invited to forget ourselves on purpose, cast out our awful solemnity to the winds and join the general dance.”
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers at briansayers24@gmail.com
Submitted November 2024
By Dr. Brian Sayers
A View from Section 5
It was pretty close to a perfect night with my son and daughter at the Texas – Georgia game. It was in the 70s with a little breeze blowing in at dusk, finally seeming a little like fall. The crowd was loud and excitement was reaching a fevered pitch when the national anthem started. Suddenly, 100,000 people had their hands or hats on their heart and sang together. It’s always been an emotional moment at UT games for me and often I tear up a little, but that night, it was much more—what some theologians might call a unitive experience. A tingle up my spine and a sense of being lifted up, momentarily inhabiting a thin space that separates the world from the soul and the unseen beyond, an intense sense of connection. With perfect timing, as we sang the last few lines, two B-1 bombers flew over the stadium, incredibly low, loud and powerful, blazing off to the south silhouetted by the fading blue sky and pink clouds of the sunset, their afterburners blasting fire with a furious roar punctuating the moment. I must admit that this time around I more than teared up. It was just such an incredible experience, all those people united in a common expression of patriotism. In that moment, as Americans, we were at our best.
The unitive, or mystical, experience is sometimes described as a sudden, spontaneous, intensely deep and emotional sense of unity or oneness going beyond our usual sensory and cognitive understanding. Well, I’m no mystic, but for me, I’d describe it as a fleeting moment being lifted up by intense connection, both with all that is around me and all that is beyond. I’ve felt it a handful of other times I can easily recall—when I held my first grandchild, when I saw my bride poised at the entrance of the sanctuary, framed with the afternoon sun pouring into the narthex all those years ago, and once when I stood on a cliff at Finisterre overlooking the endless sea at the end of a long pilgrimage through Spain. Those were equally powerful, but somehow more explainable. So why at a football game?
These are challenging times sometimes seemingly defined by suspicion, disrespect and meanness. But in the end, there is much more good than bad around us, and in that moment, shoulder to shoulder with all those strangers, those differences faded for a brief instant, and the divine spark, the essence of transcendent humanity present in us all, seemed possible again. It was a sense of what author Gregory Boyle calls our “unshakeable goodness,” the notion that within us all there is a diamond, “often covered with dust,” but it is there nonetheless. Our great calling and hope is to look for that in everyone and no matter how hard it seems at times, to not give up on each other. Standing there that night singing together, it somehow reminded me of going arm in arm with my colleagues all these years, through so many challenges, so many saves, so much joy.
As I write this, we are just a few days away from Election Day. One of the many things that I am so proud of our physician family about is how, though we are smart people with strong, varied opinions, for the most part we stay above the fray of political malevolence with each other. At lunch, at the hospital, politics only occasionally comes up, and when it does I've never experienced any tension in those discussions. Most of the time, there is an unspoken but palpable sense of respect and admiration for each other when we gather and share our thoughts and stories.
It's unlikely that any of us will sense a mystical experience when we are filling out our ballot in this election cycle, but one of the great practices of wellness is gratitude—to be aware of the things that we have been given, things that we have been blessed with, and to acknowledge that they are just that—gifts. Fleeting though many of those gifts are, some endure. Hopefully, something that endures is our love of country, regardless of who we vote for, and the opportunities and freedoms that we are blessed with here. At times it is as much a hope and an idea as it is a reality, but there is a reason why when we stand to sing our national anthem, we put our hand over our hearts, and for a moment we are all as one.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers at briansayers24@gmail.com
Submitted October 2024
By Dr. Jordan Weingarten
It could always be worse…
Most of us don’t think about bird migration very much. Yes, we are vaguely aware that birds migrate; you might look up and see a classic “V” of migratory geese or ducks, or notice that there seems to be more or fewer birds around than before. But unless you are a birder, you probably won’t notice that there are some new warblers in town, or that some of the winter sparrows have gone away. But in fact, about half of the bird species identified in Travis County are migratory. These birds either winter here (and breed up north), or breed here (and winter down south), or are here for only a short while in spring and fall as they pass through on the way to their final destinations.
What routes do these birds take on their journeys to and from southern Mexico or South America? Common sense would tell you that they fly over land, heading to south Texas, then through Mexico, and then the other direction back in the spring. And for some birds, such as the Golden Cheeked Warbler, you would be correct.
Golden Cheeked Warbler at Baker Sanctuary
For a surprising number of bird species though you would be quite wrong. Over 70 species (including many warblers, flycatchers, and vireos) that breed in our part of Texas or further north fly from here to the Yucatan Peninsula on a non-stop 500-mile journey across the Gulf of Mexico in the winter, and return the following spring over the same route.
Painted Bunting at Commons Ford Ranch Metropolitan Park
Dickcissel at Commons Ford Ranch Metropolitan Park
Grey Catbird at Mills Pond
Scissor-tailed Flycatcher at Commons Ford Ranch Metropolitan Park
Blackburnian Warbler at Mills Pond
Summer Tanager in my front yard, West Lake Hills
Ruby-throated Hummingbird, my back yard in West Lake Hills
But as remarkable as this is, to me, the most remarkable migration is that of the Ruby-throated Hummingbird. While the journey is the same distance, the bird weighs only 3-4 grams (a nickel weighs 5 grams, a large marshmallow weighs about 7 grams). And one day in the late summer or fall, a first-year Ruby-throated Hummingbird “knows” that it is time to head south. And one evening (if the wind is favorable) that bird heads out on a trip it has never made before, without the benefit of another experienced bird leading the way, guided only by instinct, stars and constellations, the sun, and perhaps magnetic fields. And if it is lucky, the next night after flying for roughly 20-22 hours it arrives in Mexico, ready to spend the winter before in the spring, heading back north to breed after another trans-Gulf crossing.
I’ve had lots of “bad days.” Left my stethoscope at home. Badge went missing and can’t get in the parking garage. Printer won’t print. Russian malware attack on the EMR. Pulmonary Fellow out sick with COVID, again. But I remember that at least I am not a four gram hummingbird taking off on a non-stop 500 mile journey over water on a route I have never travelled without the benefit of a weather forecast, GPS, or inflight entertainment. And suddenly, the day doesn’t seem so bad after all.
Jordan Weingarten, MD
Contact Dr. Weingarten at jweingarten@austin.rr.com
Editor’s note: Doctors have all kinds of practices for relaxation and well-being − photography and birding as Dr. Weingarten showed us today – but there are so many more. Please consider sharing your own strategy/passion with your colleagues. Send us a short essay or images to share!
Submitted October 2024
By Dr. Brian Sayers
Let It Be
Driving to our property near La Grange recently I listened to a podcast with Paul McCartney detailing the backstory behind the greatest hits of the Beatles and his own solo career. He was telling the story of "Let It Be," a song he wrote as it became clear the Beatles would break up, with all the anger and angst that would bring. He recalls that one night amid all that stress and conflict he had a dream. In it, his mother, Mary, who died when he was an adolescent, came to him and consoled him, guided him to acceptance and peace, in essence…to let it be. In a time of turmoil, the resulting song and its meaning became a great comfort to him, an anthem of sorts for the band, and a message of peace for the millions who would listen to it for the next half century and beyond.
Later in the interview, it came to him that perhaps another origin of the song may have come from studying Hamlet in high school. We all remember the “To be or not to be…” soliloquy, but almost no one remembers that later in the play, when his fate is sealed, acceptance emerges and Hamlet answers his own question twice, once nearing death when he tells Horatio, “Had I but time…oh, I could tell you…But let it be.” Well, clearly McCartney remembers Hamlet better than I do ─ apparently, I had my mind on other things in high school ─ but Shakespeare’s point is made along with countless songwriters and poets, saints and prophets: acceptance is a pathway to peace.
After a long day working and clearing my head around the property, in the early evening I sat down as a few swallows made their final flights. Sitting near my fledgling apple grove, the pond nearby with its large turtles still moving about, I was at peace. Nature is the great salve and sitting in the gloaming my mind wondered to where it will, but mostly I observed creation. The neighbor was cutting hay earlier, partly interrupted with a brief shower, and the fragrance of wet hay lingered. With the creeping darkness, the songbirds were silenced. The sounds of faraway tractors, of cattle trailers rattling down the narrow county road, of the occasional far away whine of a chain saw disappeared and there was quiet. Gradually it was replaced by the croaking of frogs, all manner of insect noises and more ─ all the sounds of the night that a city boy can neither identify nor be entirely comfortable with.
I have been blessed beyond measure in my life, but lately there have been worries ─ about a good friend, about work, about the health of some people I love, about a season of change. With some effort, it’s set aside ─ even if just for a few breaths at a time ─ and replaced with acceptance and gratitude and faith. Having worries is inevitable, living with patience, kindness, and joy in the face of it is one of the great challenges of human existence.
The world was coming to rest, even as nocturnal creatures began to prowl, unseen. But high above the cabin, above the pond and the fire, there was a crescent moon rising and countless stars with their timeless stories, and it was time to sleep. Soon enough, we will rise again and there will be challenge, sometimes even tragedy, but most certainly there will be joy and beauty. Like lamenters in the Psalms, I may shake my fist at times, but always, always I will be in love.
Let it be.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers at briansayers24@gmail.com
Submitted September 2024
By Dr. Brian Sayers
Three Bridges
Essays in this space by a variety of colleague-authors usually explore spirituality, whether inferred or overt within the writing. This is no surprise ─ physician well-being is inextricably linked to spiritual health. But what is spirituality and where does it come from? We all have some sense of what spirituality is, though it is hard to put into words. It certainly includes a deep sense of interconnectedness with those around us, those who preceded us, with nature, with the universe. There is a sense of something transcendent, something greater than us, moving around and within us, trying to speak to us and through us. Spirituality may be expressed and explored in many ways, only one of which is organized religion.
Most of us sense that things change in our lives when we connect with our embedded spirituality. Author Lisa Miller calls this state the “awakened brain.” I had a chance to hear her speak at a seminar in New Mexico recently. Doctor Miller's premise is that for years research scientists dismissed spirituality as a domain lacking scientific rigor. A wide separation developed between science and spirituality. Often confusing religious agendas with spirituality, public and private institutions have shied away from stressing the importance of spirituality out of a sense of political correctness or for a perceived lack of scientific evidence proving its critical importance. But as Dr. Miller asserts, “our individual health and flourishing depend on our choice to awaken. So do the health and flourishing of our schools, workplaces, governments ─ and the planet,” and she has data to back it up.
Doctor Miller has years of research utilizing several study modalities, including brain activation mapping, genotyping, twin studies, and other rigorous scientific techniques. She notes research increasingly seen for its significance shows that we are “innately spiritual beings,” spirituality being fully one-third innate and two thirds environmental. Her main point is that what happens to that innate spiritual yearning that we are born with, how it is nurtured (or ignored) by environment, primarily by our parents early in life, has profound and lasting effects on individual lives, and on society in general.
Her groundbreaking research demonstrates that those in whom spirituality takes firm hold are dramatically less likely to have serious depression or addiction issues, and as teenagers are less likely to commit suicide. Nothing else comes close to being as protective in those domains as spiritual awareness. Growing and nurturing that spiritual birthright, that basic yearning for connection and meaning, falls squarely on family. The consequences of missing the opportunity to equip our children with spiritual armor are seen by school counselors, college therapists, employers, even law enforcement. It is seen later in life with difficulty in life transitions, with burnout and mood disturbances.
Miller notes that there are “three bridges where we are hardwired to have an existential search.” The most important is the bridge in adolescence but also of great consequence are the bridges into middle and old age.
Societies through millennia have recognized the adolescent bridge into adulthood as an important time to recognize physical changes, but also the important spiritual transitions that must take place, that the soul longs for at that point in life, a spiritual awakening that is crucial for the rest of our life. Bat mitzvah, bar mitzvah, confirmation, vision quest, quinceanera, the Maasai coming of age ceremony, Khatam Al Koran are just a few examples. Miller believes that much of what ails emerging generations today is lack of nurturing this critical juncture within families, the consequences being the epidemic of teen depression and lack of moral compass so commonly seen. She contends that what is often diagnosed and treated as depression in teens is really an unmet spiritual yearning, a lost developmental opportunity that may haunt them into adulthood, something she contends is entirely avoidable if we see ourselves as torchbearers charged with the intergenerational transmission of spiritual values.
Sometime in midlife there is another surge of spiritual yearning, often called a midlife crisis, a sense of restlessness and questioning. We often conveniently blame a job that isn’t ideal or a marriage that seems unfulfilling, or a perceived lack of success, but Miller asserts that this is really a time that calls not so much for a job change or divorce (though sometimes it does), but more often for deeper examination of connectedness, meaning, and exploration of our relationship with something larger than ourselves before it’s too late.
That day in the high desert, Dr. Miller connected some dots for me regarding teen depression, our counseling program, and my own middle-aged angst. Perhaps for some of us, certain phases of midlife interpreted as depression or burnout are really arrival at that second bridge Dr. Miller describes, some of us arriving there without benefit of a fully formed crossing of the first bridge all those years ago. Well, it’s never too late. We are all a work in progress. As she notes, “We are all on a path of awakening, again and again facing new challenges, closing and opening doors, moving ever and always toward greater awakening.”
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers at briansayers24@gmail.com
By Dr. Tyler Jorgensen
Submitted September 2024
Out Here on the Asteroid Belt
In studying medicine, we learn that our bodies contain potential spaces—spaces between two adjacent structures that, like empty pockets, remain unfilled and flat most of the time—the pleura surrounding the lungs, the pericardium around the heart, the peritoneal cavity in the abdomen. The key, we learned, is to recognize when these transition from potential spaces, to fully-realized, filled, dynamic ones.
There’s a different sort of potential space I haven’t considered often enough in medicine, and I’ve come to think it’s the most important one of all—the space between us and our patients. If we fill this void, the possibilities are endless—we allow room for warmth and whimsy, for meaning and music, for laughter, for story, for connection. This is where the magic of medicine happens.
A physician ethicist and writer, Dr. Daniel Sulmasy, even goes so far as to write that “the transcendent, healing presence of the divine can be found in…the infinite space that subsists between our hands and the bodies of the patients we touch.”
I’d like to share a story of what should have been an ordinary patient encounter I had a few months back in the ER. It should have been ordinary, but it wasn’t. The story begins when I asked my patient a simple question…
*****
“What’s your happy place? The beach? The mountains? Where do you like to go on vacation?”
I often ask patients this question before I sedate them for a procedure. It seems to help them relax. Today’s sedative of choice was propofol. It is typically pleasant, dream-inducing, and only rarely hallucinogenic.
“My happy place is in a book—sci-fi and fantasy” answered my patient, a middle-aged brown-haired woman with a large sternotomy scar on her chest.
Well, I’d never gotten that answer before. But I felt a pull to explore further.
“OK…sci-fi and fantasy…are we talkin’ Middle Earth, or Outer Space?”
“Oh, definitely Outer Space. And preferably robots and computers and aliens with no humans involved.”
Well that’s specific, I thought. But boy did she seem ready for takeoff!
“Alright” I said. “Let’s go to outer space then.”
This procedure would be pretty quick. Ever since her valve replacement a few months ago, her heart had been bouncing in and out of atrial fibrillation. Today, I explained to her, we needed to use electricity to kick her heart back into a normal rhythm. “Like restarting a computer?” She asked.
“Sure. Like a reboot,” I replied.
“Alright then. Let’s reboot!” she exclaimed. I couldn’t help but love her enthusiasm.
I pushed the first dose of the milky white drug, and watched as a dreamy smile spread across her face.
“I’m on an asteroid belt, I’m a robot fixing computers…” her words began to slur. “I see colors. Yellowzzz and purplezzz and orange…and chartreuse…”
She was getting sleepier but still talking some. I gave her another half dose. Her words tailed off and stopped, leaving behind the irregular beeping of her heartrate monitor.
As I looked around the room, it then dawned on me that maybe, in this moment, she and I really had been transported into our very own scene from a science fiction book.
I mean, here’s this sedated patient lying totally still in a sterile-looking room, like a space explorer in hyper-sleep. She has no fewer than 16 wires attached all over her body. She has tubing pumping oxygen up her nose, an automated blood pressure cuff on her left arm, a pulse oximeter on her index finger, nine wires from an EKG machine stickered all over her chest, and two oversized sticky pads adhered to the center of her chest and her left flank wired to a powerful defibrillating machine.
I set the defibrillator to sync, pushed the charge button, heard the machine power up with its exciting and suspense-building crescendo, BOOOUUUPPPPP. I did one last check: “Clear? Clear!” and delivered the jolt, smashing down on the button with the lightning bolt icon until I heard the electric: Boom. 200 Joules of re-boot.
Her body jumped off the bed, she drew her arms up to her chest and yelled “eeyowch!” Then she squirmed on the bed briefly and was fully back asleep, her arms still up at her chest. And like that, her heart was back in rhythm, and a fresh 12-lead EKG was transmitted wirelessly to our motherboard. Mission Complete.
I can’t believe I had ever come to think that any of this is ordinary, just another day at the office. My patient’s fantastical imagination had reminded me see that what we do every day truly is out of this world. This is 2021: A Space Odyssey.
When she woke up she said she had had the greatest dream. She had seen colors—purple, orange, pink—but they were different. They were more than colors...they were alive. She had been a robot out on an asteroid belt fixing computers for the space station. And so had I.
*****
Lately I’ve been trying to explore this space between my patients and me. I don’t often get to travel to outer space with a patient, but sometimes we can simply connect as we discuss a common interest—a musician, an author, a show, a place. Sometimes patiently indulging in a super long story, or talking about their family or their faith, can help me gain a deeper understanding of what drives them. Sometimes we can listen to an old song on my phone that means a lot to them, and it reminds us both of happier times.
I am so thankful when I get to see in them that magical spark of humanity that’s inside of us all, because that’s what keeps me going in medicine. When I remember that this patient in front of me is nothing short of a cosmic miracle, not only am I practicing better medicine, but I’m finding it’s the reboot I need to stay in the right rhythm.
Tyler Jorgensen, MD
Contact Dr. Jorgensen at tylerscottjorgensen@gmail.com
Check out Tyler’s podcast “My Medical Mixtape” on Spotify.
(An earlier version of this essay was published in the Annals of Emergency Medicine)
Submitted by Dr. Louis Robinett
August 2024
The Year of the Mouse
My wife calls the winter of 2017 the “Year of the Mouse.” For whatever reason we had a horrible infestation of field mice in our old rowhouse in Baltimore. As the weather got colder, mice found their way into our home for warmth. We grew increasingly desperate as mice would peer over our kitchen cabinets, scurry across our living room floor, or gnaw loudly on something in the attic just above our heads at night. I bought one of every kind of mouse trap during a midnight trip to Walmart, and not long after caught a mouse in a sticky trap. To make it as humane as I could, I carried the immobilized mouse into my back yard, along with a large kitchen knife. I took a last look at what would otherwise be a cute and cunning creature, its beady, black eyes meeting mine, awaiting its fate. I did what I needed to do but did not expect the emotional and spiritual tidal wave that followed.
What happened to this mouse now? Is there a mousey heaven? Or is it simply annihilated? What about me? What happens when I die? What happens to my wife, children, and family? Is suffering ultimately meaningless? Is life itself meaningless?
An important context to that Winter is that it coincided with the completion of the toughest part of my medical training. Having powered through four years of medical school and three years of internal medicine residency, I had just started rheumatology fellowship. While the program kept me plenty busy, it was still a relative vacation compared with the intensity and relentless schedule of the training that preceded it. I suddenly found myself alone in the fellows’ office two blocks away from the hospital in quiet contemplation for hours at a time, fueled with a good night’s sleep. In this space of relative peace, my mind began to process the events of the last several years.
I told my wife and other friends from my church that I was starting to doubt the Christian faith that I had followed diligently up to that point in my life. The world that I lived and breathed was filled with seemingly irredeemable suffering – children and young adults dying of cancer, schizophrenic college students, people languishing in the hellscape of intensive care with no hope of meaningful recovery. And in that world, we toiled, doing our best to alleviate suffering and disease while knowing that the ultimate fate of all is the same. One patient’s daughter, whose father was dying and had received several calls from me, told me that she would never forget my voice. Mine was the voice that heralded death.
The journey through these questions lasted months and was filled with fright and worry. Everything was on the table, even my deepest beliefs, as I felt it would be disingenuous if certain thoughts were withheld from scrutiny. It was the first time in my life that I had asked these bold questions of faith, the deep Why and How questions that lay behind a door I had hitherto been too afraid to open but was now forced through by the weight of my experiences. Answering these questions largely consisted of reading books, listening to podcasts, talking to friends and family, and prayer. It brought me encouragement that there were plenty of other people who were asking the same questions – and even finding some answers. Perhaps what was even more important was being home every evening for dinner, getting eight hours of sleep every night, and spending substantial quality time with my wife and son – experiences that had been less frequent while I was in residency. Ultimately, the faith I knew found me again and brought about a deeper joy and balm for the arduous and often heartbreaking experiences of the past several years.
In retrospect, I find it important to remind myself that our training was truly an intense and nearly superhuman endeavor. We too often minimize these difficulties, perhaps because the generation before us had it even worse, or because others in our medical community are doing the same thing. But there are few other jobs, after limited on-the-job training, where people are suddenly thrust into making snap decisions that may save or cost a life, or situations where a small mistake or miscue could result in catastrophic consequences for the very people we are working to benefit. Being grounded in this understanding, and framing it with a theology of God and the world around us, was an important step forward for me.
My wife likes to call it the “Year of the Mouse,” but I prefer to call the winter of 2017 the “Year of Healing.”
Louis Robinett, MD
Send comments to Dr. Robinett at lrobinett@rheumtx.com.
Submitted August 2024
by Dr. Thomas Vetter
“Oh, The Stories He Could Tell”
(© 2024, Thomas R. Vetter)
An Old Man’s Friendship
Thomas “Tommy” Vetter
In the summer of 1977, after my freshman year in college, I land a well-paying job, going door-to-door, verifying in-person, the current data on county residential real estate tax records.
Each property has a corresponding, pale yellow, oversized index card, with its type-written pertinent building details on one side, and on the other side, a neatly hand-drawn diagram of exterior footprint of the main dwelling.
Plat maps and card stacks in hand, I quickly get the hang of it. I am supposed to venture inside each house. But to meet my daily quota, it becomes a game of trust and not verify—always from the safe spot just outside the front door. I poke around the plot or its surroundings, if something catches my eye, like a garden, bower, or vista.
It is mindless work, yet it takes me all around Summit County, Ohio, from banal tract ranch houses to stately Tudor Revival mansions, from classic, in-town Foursquares and bungalows to century-old, country farmhouses. The job gives me a chance to meet a variety of people: mostly good, some bad, a few ugly.
One interaction stands out in my mind—now nearly fifty years later.
One particularly hot and humid, late July morning, I come upon a modest, two-story house in the Summit Lake neighborhood in South Akron. Clad with snow white vinyl siding and sporting bright navy-blue shutters—both probably installed in the 1960s as a Sears home improvement special.
The original wood clapboard house dates from 1910s: the decade Akron was the fastest growing American city. But by 1970s, like much of Akron proper, the neighborhood is decaying, and namesake Summit Lake is heavily polluted with toxic industrial waste, dumped for decades by abutting mammoth tire and rubber factories.
As I climb the well-worn red brick steps onto its simple, tidy front porch, with shiny, freshly black-painted, wrought iron railings—the elderly, longtime owner greets me. I straightaway feel his grace, his goodwill. He invites me to sit in a sky blue, shell back, metal chair.
I am grateful to escape the beating rays of the Midwest midday summer sun.
His wife soon joins us on the porch, and with distinctly maternal air, she serves me a plate of homemade chocolate chip cookies and a tall, sweaty glass of ice-cold, sweet lemonade.
I spend the next hour, maybe longer, talking with those two good folks about our lives and our families. He and my father, factory workers, a generation apart, at Firestone Tire and Rubber Company.
He raises his gnarled hand, its calloused palm opened toward me. He shares, “When you get to be my age, Tom, you realize you can count on one hand, the number of true friends you’ve had in your life.”
Seeing my troubled face, he reassures me: “This truth doesn’t upset me. No, instead that handful of true friends, they’ve given my life its real meaning.” With a contented yet wistful smile, he nods to his wife. She beams back at him and softly kisses his withered forehead.
Back then, I am saddened by his fated observation—chalking it up to him being a fading, aged one.
As I grow older and my own twilight draws near, that gentle senior’s sage observation echoes, resonates stronger. I now know the wisdom in his observation: many acquaintances but only a handful of true friends.
I am a Unitarian. I believe in God. I believe God speaks to me through strangers—like that kindly, wise elder sitting on his front porch—if I just listen.
I sometimes dream I could assemble, in my current place in time, all the special souls coming in and going out, during my lifetime. But that’s not possible—and not meant to be—for I am no longer who I was then, and likely, neither are they. They are instead my host of friendly ghosts and abiding fond memories.
Thomas R. Vetter, MD, MPH, MFA
Send comments to Dr. Vetter at thomas.vetter@austin.utexas.edu
Submitted August 2024
by Dr. Brian Sayers
Homecomings… and Getting Flipped
Last week I attended the Coalition for Physician Well-Being annual meeting in New Mexico. We lived in Albuquerque for three years during my internal medicine residency in the 80s, so it was a homecoming of sorts. Those were great years. We had our first child there and enjoyed new friends. It was beautiful, wild country ready to be explored, and New Mexico in those days was a pretty good place to be poor. It was physically and emotionally grueling, but we did it in community, in and out of the hospital, as our lives in medicine were being formed. The house we lived in is barely recognizable to me now, and the two main hospitals where I worked bear little resemblance to my days in training, but here and there I found feelings of intense familiarity and connection, places that immediately evoked deep emotion and memories from those years that I look back on so fondly, days when I learned how to take care of diseases, and then how to care for people.
At the meeting, one of the talks touched briefly on the EMR as a primary driver of physician distress. The speaker mentioned, with little fanfare or emphasis, the importance of the “flipped SOAP note.” To most of you this is old news, but to me it explained much about the often frustrating form and lack of meaningful content in some of the notes I receive from colleagues. The flipped SOAP note, as I understand it, emphasizes the importance of spending most of our precious documentation time on the assessment and plan, with the subjective and objective components filled in with intentional brevity. Time, speed and efficiency are paramount, the goal above and beyond all else being to reduce documentation time. There's the “APSO” version that physically flips the order of the SOAP components, emphasizing what the reader is assumed to be primarily interested in as they hurriedly and incompletely skim your note. The implication is that the reader will seldom want to know how you reached your conclusions, only what your conclusions are, the details of the patient’s personal story secondary when time is primary.
This streamlining strategy is aimed at reducing documentation time, with the laudable goal of reclaiming time for more meaningful work, or rest. There's great irony in this, as the intentional act of de-emphasizing the hearing, absorbing, and then recording the story of a person’s illness ─ the patient's intimate, personal narrative ─ might actually be eliminating the key element that brings meaning to the physician-patient interaction: two humans bonding in the telling and hearing of a story, an act that moves us beyond mere data collection and into a holistic partnership. It's the process of hearing and being heard that the flipped soap note devalues in an era when we desperately need to find meaning in our work, where patients most of all want to be heard and their illness put into a personal context.
Clearly, not all interactions with patients need deep connection or well developed patient narratives, but many do, and we need it as much as our patients do. As we get more and more used to cutting documentation corners by telegraphing our patients’ personal stories of illness, and in the race to the RVU finish line, our tendency will no doubt be to explore those things less or leave the patient story behind entirely. As David Whyte notes, “The great tragedy of speed as an answer to the complexities and responsibilities of existence is that very soon we cannot recognize anything or anyone who is not traveling at the same velocity as we are.” Is this really the solution to the challenges of the EMR that we have brought upon ourselves?
The homecoming I experienced made me grateful for the countless gifts of those years, but also a little sad about what has been lost in the years since for our profession. I can now see that I am nostalgic for those days because the purity of being a doctor during training was undiluted by the practicalities of practicing medicine in the decades that would follow. Flying home across the vast West Texas desert, looking at the world and my life from 30,000 feet, I could only hope that the homecoming in my own office a few days later would carry with it some of that optimism and love and wide-eyed curiosity that defined that time in my life, perhaps a rediscovered gift brought home from the desert I loved in those years, now inhabited by ghosts and memories that hopefully can still inform my work today.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers to briansayers24@gmail.com
Submitted July 2024
by Dr. Lisa Savage
Count on Me
So much has been written about what we physicians have lost in modern medical practice…autonomy, respect, independence, control, income, time, fulfillment, purpose. Our collective losses stack up like so many charts waiting to be finished. The reasons we went into medicine can seem overshadowed by others’ priorities and metrics of success. We can blame corporate buyouts, insurance behemoths, government at every level, organized medicine, and ourselves for where we find ourselves and try to imagine how we can regain some of what we have lost, if that is even possible. That’s a worthy endeavor, but once in a while it’s nice to focus on what we still have and how we can make a difference.
One thing that can never be taken away is how we can help each other as members of the family of medicine. Ours is still a special and exclusive club, after all, and only those with an MD or DO after their name need apply. Who among your friends and colleagues can you call about your sister’s correctly self-diagnosed appendicitis when the sun is setting, and you want someone you know to do the honors? I’m guessing most of us have the cell phone number of a fellow physician who will turn around on his way home and come back to the hospital to help a sister out. Who among your friends and colleagues can you call from the back of an ambulance with what you know are multiple leg fractures and ask to alert the OR staff and get the ball rolling…so that when you are wheeled into the ER, it’s on a red carpet? For me and my husband, such personal connections were Dr. John Abikhaled and Dr. Mark Parella, respectively. Dave is not the only MD to have made such a call from an ambulance, either. This is the stuff of insiders’ privilege, to which we are entitled and by which we are empowered. While I don’t doubt that many an administrator would take advantage of a personal contact, it’s different when it’s from within, when it feels like an honor instead of an obligation.
I’m guessing we all have a number of such stories, when you or your spouse or child or other relative needed an opinion, a diagnosis or an operation, and you could reach out doctor to doctor instead of dealing with anyone’s nightmare of an automated phone triage system or patient portal. This collegiality is ours and isn’t subject to anyone with a clipboard telling us we can’t do it.
Another shining example of our generous solidarity is the Lady Docs of Austin Facebook group, expertly stewarded by Dr. Lauren Crawford. These women are a force for one another, from curbside consults, to getting a loved one in to be seen quickly, to where to shop for a Mother of the Bride dress, to how to find a lawyer or hire a nanny. The family of medicine comes together for mutual support and assistance. Here’s an example of a dialogue from the other day:
Query on a Friday: “my husband has been having some back and groin pain…he had a work physical this week that shows calcium oxalate crystals and protein. We are leaving the country on 7/7. Can anyone see him before then? Thanks!
Prompt reply: “My husband can see him Monday. Sent you a DM.”
How’s that for a supportive network and peace of mind? If you’ve ever called anyone’s office as an ordinary new patient, the contrast is pretty amazing.
While the days of being able to offer professional courtesy in terms of billing may be gone, professional courtesy in terms of access and VIP treatment is something to value and cultivate. Willingness to extend a helpful hand, to give and receive insider’s privilege among your colleagues brings the family of medicine closer as a community. It sure can be a bit more stressful to take care of a fellow physician or their family members, but consider it a high compliment, enlist help when needed, and be grateful we have each other to depend on.
Lisa Savage, MD
Contact Dr. Savage at lisasavagemd@gmail.com.
Submitted July 2024
by Dr. Brian Sayers
Kinship, Tenderness, and Being Rescued
Gregory Boyle is a Catholic priest who from scratch built what has become the largest gang rehabilitation and recovery program in the world, born in the toughest neighborhoods of Los Angeles in the turbulence of 90’s urban violence. He has written a series of three books starting with Tattoos on the Heart that tell the story of the program and teaches us much about how people come to be in gangs. More importantly, the books tell incredible, heart wrenching, uplifting stories of how change is possible, even when it seems impossible ─ but only within a certain kind of community. The magic of his program is that he takes hardened gang members and finds a way to access the tender places in their hearts, places that exist in all of us, even those we would least expect it in. With hearts open, a sense of kinship soon develops, even among young men from rival gangs who work side by side in the programs at Homeboy Industries.
Boyle describes kinship as “not serving the other, but rather being one with the other.” As physicians, we all learn about this when we or a loved one becomes seriously ill. We quickly learn what it’s like to be a patient or a family looking to our doctors for their skill, but also for hope and a sense of kinship. For most, these experiences forever after breed a kinship with our now fellow patients that changes not just the way we practice, but more importantly, how we see patients when they come to us in need of both curing and healing. Like the men and women at Homeboy Industries, when we as colleagues let our guard down and create a safe space to care for and about our colleagues, both kinship and tenderness emerge, something I have seen often in our work with physicians in distress. While it won’t make our EMR perform any better, or call any easier, that kinship ─ going arm in arm into our shared work and our lives in general, in good times and bad, can make all the difference.
For a decade after seminary, I was part of a small team that spent an evening a week with a group of men at Ministry of Challenge, a residential recovery center for unhoused men deep in East Austin, in the days when gentrification of this area was unimaginable. Overlapping with that I met weekly with the men of Matthew House, a place of transitional housing for men just released from the prison at Huntsville. Ostensibly, these were Bible studies, but what they really were was an evening a week to explore the hidden recesses of our lives, both them and me, and as different as we were in so many ways, the exploration in safe surroundings invariably revealed the kinship that Fr. Boyle describes. From this sense of kinship comes a certain kind of tenderness from people who to the world look hardened, or dangerous, or hopeless ─ people I would never have expected it from when I started. I’ve learned then and since, just as Boyle describes, that those places in the heart that allow kinship and tenderness, the ingredients of rescue, are potentially discoverable in everyone ─ even doctors, who in their own way can find themselves on the margins of life ─ if it can just be uncovered and if someone cares enough to make the effort.
Most of you have at least some experience with medical or religious mission work, so you know well that spiritual gifts pass to all involved, not just those that the mission targets. Pema Chodron, an ordained Buddhist nun, describes it well writing of love and compassion suggesting that “it's truest measure lies not in our service to those on the margin, but in our willingness to see ourselves in kinship with them.” At that certain point in my life, I needed those desperate men at least as much as they needed me. A few years behind me now, I still think of some of them, even looking for them at busy intersections and underpasses, hoping I will not see them. They were trying to reenter an often-unforgiving world, and while I told them every week just how proud of them I was, I’m not sure I ever explained to them that we were, in those hours and years, really rescuing each other.
Brian Sayers, MD
Send comments to Dr. Sayers at briansayers24@gmail.com
Submitted by Dr. Robina Poonawala
June 2024
"The Kill"
When we were picked up at the private safari sanctuary in Botswana, our guide, Professor Ice (Professor of the Bush- as they call the forest) asked us if we had any specific requests. My reply right away was, “I do NOT want to see a kill!” I had seen “a kill” about 20 years ago on a Tanzanian safari trip and was repulsed by it.
The next morning, we set out bright and early for our safari in a Toyota Land Cruiser. Professor Ice sniffed the air and looked at the pattern of footsteps on the path. He stopped by some footstep markings and told us that these looked like a wild buffalo had just crossed by and decided to follow the direction the hoofs were pointing. Lo and behold we did see a wild buffalo grazing nearby. Our guide decided to follow him— that led us to a large group of wild buffaloes on a remote patch of grassland. He told us to look through binoculars at a spot on a distant mound and we noticed two pair of triangular ears poking up. Lions like to sit on a mound to stake out their prey. Ahead of us was a small calf teetering behind the large herd of wild buffaloes. That was their prize! There was one large buffalo that would walk ahead but kept looking back on the calf following him every few feet.
Within a few minutes, we saw the two lionesses get up and walk toward the herd, eyeing the calf. Two more lionesses showed up to join the hunt from another direction. They started chasing and closing in on their target, the little calf. They would come close enough to pull the little calf down from behind and make it fall. The large buffalo noticed them and would quickly chase them away. This went on for quite some time. The one wild buffalo fending off the 4 lionesses!
A group of six or seven wild buffaloes from the large herd did come closer to the action but did not help. They just stood around and grazed and watched. One finally came closer and licked the face and nose of the calf, but walked away, as if giving it blessings or last rites. Suddenly, we noticed another group of six lions coming from the opposite side, two lionesses and 4 cubs. They all joined the chase. The large buffalo tried his best chasing them away but ultimately could not fight these six lionesses and four cubs coming from all sides. He finally decided this was a lost fight and walked away along with the rest of the large herd... leaving this calf to its fate.
By this time the calf was injured and could not get up. It sat bleating and looking for help. The first group of four lions came and started gnawing on the injured calf. Then came forward the other pride of two lions to steal the calf for their 4 cubs.
It was interesting then to see the fight between the two prides of lions. The first group of four had hunted the prey, but the maternal instinct of feeding the four cubs was stronger for the other pride of just two lions. They managed to chase the other pride away and settled down to keep watch in either direction while their cubs were busy eating the calf. The mothers did not touch the prey while the babies were eating. The calf’s bleating slowly stopped. We decided to leave the lions to their meal. We came back to this spot later and noticed that the almost eaten carcass had been dragged under a tree and the same pride of lions was still there. Sitting above on a branch now were four vultures awaiting their turn.
Just as we diagnose based on signs and symptoms, Prof. Ice would smell the air, look at the size, shape and direction of the footprints and determine which animal was going in which direction and how recently the footprint was laid. He would put his hand a little above the elephant dung to feel if it was still warm. In just two safari sessions of three hours each we saw all the “big 5!” Elephants, lions, one leopard, wild buffalo and white rhino. There were also other animals and interesting insects like the dung beetle, all living in perfect harmony and contributing to the ecosystem.
In our day to day lives, full of routine, work, and worry, it’s easy to lose sight of how narrow and sometimes stressed our line of sight is. Travel to faraway places, seeing the rawness and beauty of the natural world right in front of us opens new horizons in our imagination, feeds our creativity, and can help us set aside our tiresome burdens of day to day lives to breathe new life and wonder into our minds and our souls. I will enjoy these memories for years to come!
Robina Poonawala, MD
Send comments to Dr. Poonawala at robina.poonawala@gmail.com
Submitted May 2024
by Dr. Brian Sayers
Extroverts, Tortured Poets, and the Long Journey
Arthur Brooks is a Harvard researcher and author who has made it his mission to help us be happier. He recently collaborated with Oprah Winfrey on his latest book, Build the Life you Want: The Art and Science of Getting Happier. It is an interesting read but after several years of reading increasingly complex research on basic concepts like happiness, gratitude, generosity, forgiveness, self-compassion, and the like, I’m starting to feel that when data driven research is applied to these basic traits of the heart, they lose some of their spiritual gravitas.
Brooks and Winfrey start by relabeling our goal as the pursuit of “happierness” rather than “happiness.” Brooks breaks down the “macronutrients of happiness” into three components: enjoyment, satisfaction, and purpose. He distinguishes enjoyment from pleasure by arguing that seeking pleasure by itself is empty, often leading to addiction. Enjoyment takes the source of pleasure and adds two elements ̶ relationships and memories ̶ to make it an enduring ingredient of happiness. Satisfaction is the reward you get after you struggle for something. We need struggle, sacrifice, even suffering, to feel we have earned a reward. He makes a crucial point that the formula for satisfaction is: Satisfaction = all the things you have ÷ all the things you want, i.e., the path to happierness is not obtaining more, rather it is wanting less.
Purpose is more complex but is perhaps the most important macronutrient. His discussion is familiar, but he puts a different sort of spin on it by boiling it down to whether, and how, you can answer two basic questions: What are you on earth to do? What would you be willing to die for? Our road to answering these two questions − to the discovery of purpose and meaning − is not linear or easy. It is punctuated by times of insight and times when we are completely lost, by times of joy and sorrow, rich connections or aching loneliness. All are inevitable, sacred steppingstones on that path.
Brooks also looks at personality types and happiness as it pertains to extroverts and introverts. Using metrics to categorize people into extrovert vs. introvert and happy vs. not happy, four categories emerge: Happy extroverts, unhappy extroverts, happy introverts, and unhappy introverts (tortured poets). Extroverts outnumber introverts and according to Brooks are twice as likely to be happy by most metrics, but fortunately for us introverts there are caveats. He notes that extroverts tend to have more friends, but often most of these friendships are casual or transactional with a tendency to have few close friends − the most important people in whom you confide and connect deeply. Introverts, on the other hand, are often happy because even though they have fewer friends, the relationships they gravitate to and maintain are often deeply nourishing.
The book was a timely read for me, digesting it as I attended a 50th high school reunion. My family moved when I was in high school and this year there are two reunions for me. In my first high school with childhood friends, I was an introvert, a pensive, petulant kid who spent most of those first two years daydreaming and getting in trouble. In the remote, rural high school where I spent my junior and senior years, I accidently reinvented myself (or they reinvented me), quickly developed friends, elected class president twice. True to Brook’s description, the friends I am close with to this day are those from my introvert years and I have mostly lost contact with friends from my second high school where my friendships were a mile wide and an inch deep.
Now an expert about happiness, what conclusions would I reach about my old classmates and how life, gray hair, and waning hormones has changed them? I didn’t reach any conclusions about happiness as, like deciphering other people’s marriages, the casual assessment of someone else’s happiness can be deceiving. What stood out was that the lines of high school hierarchy, the cliques, had disappeared and there was relaxed, jovial conversation and openness that crossed all those lines as if they had never existed. At one of the events, I stood outside the bar where we gathered, finishing a phone call, when someone from the old days walked up, someone I rarely interacted with even as we saw each other daily. We visited for a minute when unexpectedly they teared up and told me they had lost a sibling just a few days earlier. We stood there and hugged for a long time, something that would have been unimaginable all those years ago and yet seemed so natural now, the winding road we had each traveled leading us to a common destination. It reminded me of a line from the movie, Almost Famous, when the main character laments about being marginalized in high school and his older mentor reassures him, “You'll meet them all again on their long journey to the middle.”
Brian Sayers, MD
Send comments to Dr. Sayers at briansayers24@gmail.com
Submitted May 2024
by Dr. Carsten Kampe
The Old Man and the Tree
An oak tree had been growing in our back yard since we moved into our house ten years ago. At the time it was small and unobtrusive. It never called attention to itself, and I never had occasion to consider its place in our world, either. Over the years, however, it grew—as oak trees do—to block our view of the beautiful verdant vista of the sprawling endangered golden-cheeked warbler nature preserve beyond our back fence and to rob our raised bed vegetable garden of precious sunshine. My wife and I decided it was finally time to remove our now thirty-foot tall oak tree. I had removed plenty of smaller Ashe Juniper trees effortlessly in my day. I would manage this in short order ... or so I thought.
As I began work—just me, a few hand tools, and the Tree—an interesting thing happened. I came to develop an unexpected relationship with, and respect for, the Tree in which I found myself trying to understand it better. We did not speak, for it was not to be, but I had time to ponder its size and stature, and to appreciate its greatness, its beauty, and its majesty as I worked with my hands, back, and simple tools to free it from its hold on the earth. Why did I wait so long to appreciate this wonder of Nature?
I reflected on our past together. I recalled days, as a younger man, when I stood underneath its branches benefiting from the shade it provided during the hot summer months, and observing how it provided a haven for birds, many of whom chose that tree to raise their young. It was selfless in its ways and generous in its gifts to earth’s inhabitants who shared its space.
I became interested in the significance of trees in our lives and learned that in many folk religions, the Tree represents physical and spiritual nourishment, transformation, and liberation, union, and fertility—Who was I, an arrogant human, to take the life of this majestic beast, a creation of God? But the work had begun; there was no turning back now.
I labored steadfastly, beginning by digging a trench around the base of the Tree, getting lost in an endless mass of tangled roots and severing them from their firm grip on the surrounding limestone as I progressed in stepwise fashion, taking frequent breaks to recharge my aging muscles. It was a long-drawn-out struggle. I could easily have hired a tree and stump removing crew but that didn’t feel right to me. In fact, I felt a sense of pride in not using electrical or gas-powered tools to achieve my goal. But was it still a fair fight?
The Tree proved a formidable foe. Neither it, nor the ground beneath it, yielded readily. I realized that this would be the last time I attempted such an arduous feat. I had taken on a struggle in which I would not likely prevail again. I am not young anymore. And yet, I felt I was destined to win this battle one last time. I persevered.
In the end, I was the “victor” ... or so I thought. But how proud was I really, having won? Was proving to myself that I had the willpower and stamina to complete the job meaningful? Was I, the garden (and the Tree) better off now? The golden-cheeked warblers would find other trees in which to nest, but where will I find shade when tending to my vegetable garden now? Who (or what) will be there to stand proud and provide physical and spiritual nourishment, transformation, and liberation? I collected my tools—and thoughts—together for the day and decided to put off sawing the trunk into smaller pieces to add to our firewood pile for another day." to show better respect for the beautiful tree.
I thanked the Tree for its sacrifice and what it taught me about life and our place in the world.
And then, while the sun was still hot in the sky, I planted a new tree.
… in whose shade I would never sit.
"The one who plants trees, knowing that he will never sit in their shade, has at least started to understand the meaning of life."
--Rabindranath Tagore
Carsten Kampe MD, PhD
carstenk@austin.rr.com
Submitted April 2024
by Dr. Brian Sayers
Tombstone
I was senior medicine resident in the ICU at the VA in Albuquerque one night many years ago. There was a terrible sleet storm outside, the roads were impassable, and we were going to have to cover the unit for a second night. Miles away in a remote area to the north, a blizzard was in progress. Somehow, Life Flight got out ahead of the storm and transported Ray, who landed on my service. He arrived in cardiogenic shock with the ominous tall, wide ST elevations ─ “tombstones” ─ of a massive anterior MI, signifying what in the 80’s would likely be fatal.
The usual frenzy of activity followed, using protocols that sound primitive now, all the while knowing his chances were slim. He rallied for a while and was conversant but seemed resigned to his fate. He reminded me of my grandfather, the same age and both had served in France in the First World War. He told me about his ranch, snow covered now, but soon, in the spring, lush green pastures would re-emerge in this deep valley, snow fed streams winding through it. It was paradise for him, sacred ground, where his wife was now stranded without phone service, and where tomorrow his son would have to try and drive the pickup into the pasture, his grandson pushing square bales out into the snow for the hungry cattle. The old man’s face was pale, deeply creased, sun damaged, at times with tears. Things were quiet for a while, and I sat with him, and he became unresponsive.
In a long career it's surprising how certain patients, even from the distant past, can stick in your mind. I remember those hours vividly, watching life slowly ebb from him as his heart failed, checking on him almost constantly, sitting by his bed, drawn to him, considering the heart. Not just the pump, but his spiritual heart and what might become of that when the physical one stopped.
Virtually every major religion and non-religious spiritual discipline attach special, sacred significance to the heart, references to this even found in ancient Egyptian art, in ancient mythology, represented in timeless Native American lore and art as a transformative symbol connecting humans, nature, and the spirit world. The heart is often seen as a place where the soul resides, the center of emotions and morals, compassion and courage, wisdom and peace, the source of love. It is a place where we might encounter inner peace, even sense the presence of the transcendent. We tend to go to great lengths on outward journeys throughout life looking for wisdom and peace and love in the world around us, but the real work takes place when we go inward, into the heart.
Occasionally, medicine calls on us to share our heart with a patient in need. Daniel Sulmasy notes that, “If we are committed to healing patients as whole persons, we must understand not only what disease and injury do to their bodies but what disease and injury do to them as embodied spiritual persons...Illness raises troubling questions of a transcendent nature ─ questions about meaning, value, and relationship. These are spiritual questions. How we answer these questions for ourselves will affect the ways we help our patients struggle with these questions.” Ultimately, our inner journey to wholeness is for those around us as much as it is for us. Ethicist Paul Ramsey describes us as “a covenant people on a common pilgrimage” and when we enter into relationship with our patients, such a covenant requires that we visibly express fidelity, love, compassion, and justice ─ acknowledgment of the sanctity of life ─ as we honor that relationship.
In those hours, I felt about as close to Ray as you can with a patient, but I did not have what I sensed he needed from me. I was able to listen, to touch his shoulder, to hear his stories, and that’s something, but I was young and had not experienced enough of life, enough of my own inner journey to be able to help him deeply in those last hours. It isn’t something taught in medical school… because it can’t be taught. It has to be discovered. Only its importance can be taught.
Ray never woke up, and he died just before rounds the next morning. There was someone in his little cubicle almost every minute since his arrival but sure enough, the minute he was alone he passed away. We were just a few feet away gathering for rounds, talking about the storm. I tried his home number again and this time his wife answered. I tried to convey how he described his love of his family and the land, but I don’t think she heard anything after the first sentence. By late afternoon the roads were passable, and I went home. And slept.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted April 2024
by Dr. Cindy Lynn
Reflections on Retiring, Tiaras, and Purple Hair
I am retiring next week, and many people have asked me what I’m going to do. I tell them I plan to dye my hair pink. You see, I have always felt that I must look professional, and after next week, that no longer holds. So why not go crazy with hair color? When I came to work at St. David’s Medical Center in Austin in 1992, fresh out of neonatology fellowship, there was an unofficial dress code. Ladies wore skirts or dresses; men wore ties. If I had a belt, I had a place for my pager. We didn’t carry cell phones yet. Those younger than 50 are likely gasping now. I had a cell phone about the size and weight of a brick with a foot-long detachable antennae. That beast stayed in the car. As the years went by, the dress code eased up. Now I mostly wear cargo pants with pockets big enough to carry a cornucopia of items, including my cell phone, ophthalmoscope to see a newborn’s red reflex, multi-page patient list, pens, lip balm, hand cream, and of course reading glasses.
During the pandemic I stopped covering my gray hair. I went totally gray/silver/white, which I like to refer to as “pandemic gray.” I have found that you really are invisible if you have gray hair. Young people working at store checkouts cut you a lot of slack when you don’t know how to use the store’s app. In fact, I find they are usually surprised that I have even downloaded it. Young children call me “Grandma,” even though I am not their grandma. I went to my hairdresser yesterday for a haircut, and told her I wanted pink hair, but not yet, I still have another week before I’m retired. She said I don’t want pink, I want purple, it’s classier. I gave her a “Seriously?” look which she ignored. She explained we don’t want obnoxious, and I replied, “Maybe borderline obnoxious?” After all, I’m pretty sure this will be a one-time deal. So, I have purple hair scheduled next week.
The NICU nurses have been questioning me about my favorite foods and favorite flavor of cake, so-subtle clues that they are planning a retirement party. Being oh-so-quick to catch on, I told them that I don’t want a party, I want a retirement tiara. When I said that, I felt like I was asking for a unicorn, something that clearly didn’t exist. As soon as it left my mouth, it occurred to me that you can get almost anything on Amazon. Sure enough, there are hundreds of retirement tiaras on Amazon. Again, seriously? I don’t know why I requested a tiara. I am definitely NOT the princess type. I don’t wear high heels; I have no designer purses. I always thought that if Cinderella wanted a sports car, she should put herself through med school and buy it herself, not wait for Prince Charming. But I am now the proud owner of a retirement tiara and decided to embrace it. I had planned to wear it on my last day but couldn’t wait. I wore it to perform a circumcision today. If not now, when?
While I feel extremely fortunate to love my job, it’s time to call it quits. Neonatology has a “best-by” date, and for me, it’s now. I will miss my colleagues. I hope to run into you out and about. You may not recognize me. I’ll be the one with a tiara on obnoxious purple hair.
Dr. Cindy Lynn
Send comments to clcindylynn@gmail.com
Submitted April 2024
by Dr. Brian Sayers
The Acorn
A year into the pandemic, stir crazy and probably not thinking straight, I bought a 15-acre olive grove near La Grange. Just before we bought it, it had 200 mature olive trees, a restored farmhouse, 160-year-old log cabin and, to me at least, the place seemed magical. Of course, there is a reason why Texas is not known for its olive industry and that terrible freeze in 2021 killed off the entire orchard. In the years that have followed I’ve planted all kinds of trees in the groves ─ apples, plums, and pears ─ and only a dozen or so apple trees have survived the droughts and heat.
As I sat on the front porch of the house one breezy, quiet Saturday early last spring, the misplaced, struggling fruit trees in the distance taunting me, I realized I was looking at what just might be the perfect tree. Tall, perfectly round, deep green, it stands at the center of the property, an example of nature’s perfection for which I can claim no credit. Somehow, I had not really noticed it before. It sounds silly, but that day a certain kind of wisdom about the land came to me: to watch and listen to the land, to learn its secrets, to honor and enjoy it rather than try to make it something it cannot be. It seems so obvious now. It’s not that it’s “not nice to fool mother nature” as the commercial from a few years ago said ─ it’s that trying to fool mother nature is… well, just fool’s errand.
Life is full of mystery. In my work in medicine, I often come up against a diagnostic dilemma and years ago I learned that what some of my patients suffer from defies understanding in its earliest presentations no matter how hard I try to figure it out. The process sometimes must unfold over months or years before we are sure about it, something I’ve come to terms with, but something understandably so hard for most patients to accept. A mentor early in my career told a story from a national meeting where the speaker, describing a particularly vexing case, famously said, “Having failed to make a diagnosis, we proceeded with treatment…” The story sounded ridiculous at the time, but now I think I understand what he was trying to say. Even as some conditions very slowly unfold, we must still be present and engaged with the patient, all the while trying to share with them an understanding that mystery is always part of life and frequently part of medical care. Honoring that, being honest and humble about it, all the while holding our patient’s hand is sometimes what is called for and is one of the most difficult things we do.
Accepting mystery, observing the world with curiosity and an open heart, and patiently letting life unfold is how we acquire wisdom. Accepting mystery is not easy. It requires patience and an open heart in a world that more often wants to harden our hearts. Physician wellness pioneer Rachel Remen writes of the “buddha seed” in all of us waiting to become a tree of wisdom if we will only allow it. “Life offers its wisdom generously. Everything teaches. Life asks us the same thing we have been asked in every class: ‘Stay awake.’ ‘Pay attention.’ Wisdom comes most easily to those who have the courage to embrace life without judgment and are willing to not know, sometimes for a long time... It involves a change in our basic nature, a deepening of our capacity for compassion, loving-kindness, forgiveness, harmlessness, and service. Life waters the buddha seed within us.”
Mystery is often a prelude to miracles. Within every acorn, there is a yearning and the mysterious possibility of becoming a beautiful oak tree. Clueless for so long about this land, and now at least a little wiser and more observant through painful failure, I’ve started planting live oak trees around our little “Grove House,” the house’s name now relegated to quotation marks. A couple of years in, they are growing nicely, but slowly ─ as oak trees do. By the end of this year, I will have planted one for each of our eight grandchildren, and like so many things we do in life, ultimately, the planting is not for me. Like my grandchildren, these trees will reach maturity in an unseen future many years from now. As I sit on the front porch on this magnificent spring morning, studying nature’s perfect tree and the much younger trees planted nearby, I smile to think that one day each of my grandchildren might sit in the shade of these very trees.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted March 2024
by Dr. Brian Sayers
Healing
In
a box in my office is a cherished collection of letters and cards from patients
and their families ‒ touching messages sent to me during these past 35 years.
There is also a list of patients who have passed away during those same years,
119 names on the list now, each written in my own hand with a single sentence describing them. Years ago, I thought that down the line I would need this prompt to remember them, but it turns out I don't. They are sacred memories from a lifetime spent in this office. Within this box lies the meaning I have found in my work, and I realize that the essence of this meaning comes from a certain kind of healing that was mutually exchanged with many of those patients. Many of my current patients have been with me for more than a quarter of a century and I realize now that no matter how much I have tried to give to patients, I have received at least as much in return.
Much has been written about physician wellness in recent years and more and more the search for meaning in our daily work has been recognized as a primary driver of physician well-being. As we dig deeper into what creates a sense of meaning in our lives as physicians, perhaps the key is healing. By this, we typically mean healing our patients, but if we're honest we often are most connected to our work when we receive healing ourselves.
What is healing? It's almost trite to talk about curing versus healing nowadays. Hopefully, we understand that when our patients are sick there are two processes present: there is disease ‒ a disruption of body function, and there is illness ‒ how patients experience disease, how it disrupts their lives. We increasingly recognize that curing or controlling disease is only part of our calling as physicians. It is incomplete if we ignore healing. Healing calls on us to give something of ourselves to others, a part of our heart, even if sometimes it’s just as simple as listening.
Authors have described healing as the “attainment of inner peace,” or, “a reclaiming of wholeness.” Saki Santorelli wrote that healing occurs when “we feel connected, whole, filled with a sense of belonging no matter what the condition of our body.” But I think it’s best described by Daniel Sulmasy who notes, “Ancient people readily understood illness as a disturbance in relationships… Illness disturbs more than relationships inside the human organism, it disrupts families and workplaces and shatters pre-existing patterns of coping.” He emphasizes that in ancient cultures, people were also keenly aware of the importance of the relationship between human beings and the cosmos. The task of the ancient shaman was to heal by helping the ill restore these disrupted relationships. Perhaps that is our task as well, both within, and beyond, our work as physicians.
In the long lineage of medicine, only recently has the application of science almost entirely displaced the practice of healing in our “encounters” with patients. Curing takes less effort, less time, less thought and patience than healing, but this emphasis was not always the norm. The roots of our proud history saw healing provided through shamans, curanderos, mystics, and ancient priests who with limited scientific tools knew that healing and curing are inextricably linked rather than two separate processes. Later, care by physicians, hospitals, and other organizations was often led by religious and charitable organizations that saw the need for healing of the heart as critical as the need for curing the body. This heritage of healing is becoming less and less recognizable in an era when the economics of healthcare hijacks the agenda, an agenda that too often sets aside the urgent call for healing. Anyone who really works with patients knows intuitively that we derive meaning from the healing process, both as givers and recipients, and when that is lost, so too is our sense of fulfillment and calling.
In that box in my office, on that list of patients who have passed away lies the name of patient #76. She was one of the first patients who trusted me when I opened my little practice all those years ago, and we were about the same age, just kids, back then. We grew older together along with her lupus in those next two decades before she unexpectedly died. She was a friend as well as a patient and I pray that in those years I offered her some help with healing. I know that like so many other patients, she gave me many gifts, one of which was a certain kind of healing that comes when we as physicians come to terms with our own humanity and mortality, with the limitations and imperfections that are part of our work. Healing is always possible. Even for us.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted March 2024
by Dr. Matthew Masters
Groundhog Day
In the 1993 film, Groundhog Day, Bill Murray plays “Phil,” a local weatherman who is obnoxious, self-centered, and entitled. It’s February 2nd and he must cover the Groundhog Day celebration in Punxsutawney, PA. “Punxsutawney Phil,” the groundhog, will predict how long winter will remain. Phil and his crew get stranded there by a winter storm and must spend the night. He wakes up the next morning and it's “Groundhog Day” all over again. In fact, every day from there on out is Groundhog Day. He meets the same people, the same things happen, and so begins a slow descent into desperation.
At first, it's kind of fun. He eats too much, he drinks too much, he seduces women, he takes all kinds of physical risks with no consequences. He wakes up the next morning and it’s Groundhog Day all over again. Over time he notices that there is no continuity in his interactions with others—he is not connected to them. Each day he must go through extraordinary efforts to re-establish his connection to them, but always with the goal of self-gratification. He sets his sights on seducing his producer, played by Andie McDowell, and fails repeatedly. He soon wearies of the endless boredom and desperate sameness of his life. He becomes suicidal and tries to take his life several times. No matter what he does he cannot kill himself. He awakens the next morning and it starts all over again.
One of his ploys in attempting to seduce his producer is to learn about everything she is interested in. This also fails, but it changes his course somewhat and he begins to study music and ice sculpture for his own edification. He experiments with service to others, and he is very moved by the death of a homeless man that he has tried to support and nourish that day. He recognizes the impermanence of life and the inevitability of death for everyone—except himself. He begins to use his talents to perform selfless acts of service and this eventually breaks the spell of Groundhog Day. He is returned to the status of mortal man and, of course, he gets the girl.
He has had a spiritual awakening which resulted in liberation. A series of experiences created a moment of clarity which put him on a path toward a different view of life. This is precisely the goal of 12 step recovery as it is contained in the 12th step: “Having had a spiritual awakening as a result of these steps, we tried to carry this message to others and to practice these principles in all of our affairs.” Addiction Medicine is one of the few areas in medicine where a “spiritual awakening” is an indicated form of treatment.
Alcoholism and addiction are real examples of “Groundhog Day.” The disease progresses through 3 phases: fun, fun with some problems, and just problems. Some patients begin to seek treatment in phase 2 if they are lucky, but most don’t come into treatment until they are solidly in phase 3. By then, their lives are a daily round of: chasing booze or dope, lying, cheating, stealing, manipulating, and committing criminal acts to get the money to do the dope. The first thing they lose is their dignity and self-respect. As the disease progresses, they have increasing problems in one or more of the following areas: romance, finance, health, family, work, or the legal system. They become increasingly isolated by: their use of the substance—they definitely don’t drink or drug like other people; their shame; and their increasing isolation from those who have been hurt by their conduct. They become desperate.
The antidote to their desperation is hope and hope is an acronym, it stands for: Hearing Other People’s Experiences. Their profound loneliness is transformed into connection with those in the 12 step program who have shared their experiences. Their sober peers now lead functional lives—free from the domination of alcohol and drugs. There is a cost, however, and that is hard work. They must work the 12 steps.
The 12 steps can be arbitrarily divided into 4 phases: the recognition that their “drug of no choice” is a malignant higher power, and they define a benign higher power that can displace it and restore them to sanity; confession; helping others by continuing to practice the tenets of the program. These steps are the action steps, and they require hard work. Steps 6 and 7, however, are the mystical steps of the program which only require the patient to become willing to have the higher power remove his defects of character.
For the most part, alcoholics and addicts don’t get a lot of good press, stories often ignoring the potential for recovery. Drinking and drugging can lead to wholesale destruction, but a lot of people don’t get to see what I get to witness with recovery: peace of mind, a functional life, restoration of family ties, and a release from “Groundhog Day,” all contingent on maintaining this spiritual awakening.
Special thanks to my mentor, Bob F., for suggesting that I watch “Groundhog Day” again as he feels it is the most spiritual movie he has ever seen.
Matthew Masters, MD
Dr. Masters is an Addiction Medicine specialist.
He serves on the TCMS Physician Health and Rehabilitation Committee.
Contact Dr. Masters here.
Submitted February 2024
by Dr. Brian Sayers
The Dump Truck
It doesn’t sound very compassionate, so don’t tell anyone, but I go a little bit crazy sitting with a loved one in the hospital. I get restless and irritable, even when everything is going well. It’s ironic because I spent so many years caring for patients in hospitals and only occasionally felt impatient then. Maybe it’s a complete loss of control in an environment where I used to be able to pretend I had at least a little bit of control as a physician. It’s hard to watch someone you love struggle, but also, if I’m honest, it’s... really boring. It’s sort of like the opposite of dog years ─ instead of time being accelerated, it comes to a crawl, at times seemingly to a complete stop, at least relative to the speed my anxious mind is racing. And so, I’ve been thinking about patience lately.
Patience is, “the capacity to accept or tolerate delay, trouble, or suffering without getting angry or upset.” Impatience is, to paraphrase psychologist Tara Brach, to be at war with yourself. It is to react to loss of control, lack of acceptance, to be unable to slow down. Patience has three domains: patience for life circumstances, patience for challenges in relationships, and patience for the countless trivial hassles of daily life. Studies teach us that patience has measurable benefits for our mental and physical health, yet it’s a virtue that too few of us successfully cultivate.
Our world does not encourage patience. Almost everything around us is designed for efficiency and speed. There aren’t enough hours in the day for all we think we need to do and being trapped in a line, or on hold, waiting for test results, or a patient to be ready in the OR, or a child to finish eating breakfast before school ─ anything that makes us wait ─ are reminders that we are not always in control. When busy days depend on the speed needed to keep up with our expectations, as one author notes, “…very soon we cannot recognize anything or anyone who is not traveling at the same velocity as we are.” Sailing past them, we leave these people and moments in our dust.
There are ways to cultivate patience. Even rudimentary mindfulness techniques can be helpful. Specifically, when you feel yourself getting impatient, simply stopping and realizing that you are being impatient ─ naming it ─ helps neutralizes it, but also reminds you to follow practices that help you through those moments. Breathing exercises are an essential ingredient to cultivating patience. Breathing exercises, as an independent practice or as an integral component of meditation and yoga and other practices, is a simple strategy used through the centuries. Cultivating practices like yoga, meditation, journaling, prayer, time in nature, that you can regularly practice, requires a certain discipline that most of us lack, but are pathways to cultivating patience and given a chance, also sets us on a pathway to slowing down and becoming more connected with the fullness of life ─ the people and the world around us.
When my 2-year-old grandson comes to visit, with just a look and a point that is familiar to both of us, we immediately embark on our routine. There are several stops ─ the castle, the cars, the cookies that we sneak in the pantry. Our next stop is the far corner of the den and the antique wooden toy box. He directs me to sit in a tiny toddler’s chair just inches away while one by one he pulls out dump trucks, cars, nerf balls, transformers, and Barbies one at a time, showing me each before he deposits them in a nearby brass trash can. After going through the many toys, he waits for me to tell him to move the things back to the box. He could do this forever and strangely, while I can’t sit in a hospital room for more than 30 minutes without going nuts, so could I. Suddenly anything more than 10 feet away from us disappears. I am entirely focused on him and the dump truck he holds in his hand, and, for the moment at least... I am patient and at peace.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted February 2024
by Dr. Brian Sayers
Simplicity
If you are a child of the 60s, chances are your mother or grandmother made some of your clothes from scratch. They would go to a fabric store, look through the hundreds of small packets of printed sewing patterns and select their next project. The patterns were sheets of thin tissue paper containing outlines of how the fabric should be cut, with instructions on how to piece them together. My mother dabbled in this when I was young and while she is an accomplished woman, sewing was definitely not her forte. I remember some of the shirts that she made ‒ buttons often not quite lining up, sleeves not quite the same length, too short in length, too loose across my small shoulders. But one piece she sewed is part of my origin story in medicine.
Around the time I was in first grade I watched the melodramatic medical show, Dr. Kildare, each week, watching the dashing young intern look deeply into the eyes of his patients, hold their hands and in less than an hour elicit miraculous cures. More importantly he was an inquisitive, sensitive, healing presence, and watching that show caused the six-year-old version of me to know that I would be a doctor.
My mother sensed this and found a pattern, Simplicity pattern number 4714, a themed set of pajamas, and made me an intern's smock, even stitching a crude caduceus over the left breast. I shamelessly wore this to school more times than I can remember during first grade. At that point in my life, it wasn't that I wanted to be like Dr. Kildare, I actually was Dr. Kildare. Looking back, it was pure, innocent, naive and, yes, it was figuratively and literally simplicity. Such was my pathway into medicine.
I’ve been thinking about this origin story lately. More than three decades into practice, a few missteps along the way, I still love my work, look forward to going to my small private practice each day to see my patients, our staff, and my office partner, but more and more lately I wonder why things have gotten so hard, so complicated. My career in rheumatology has seen almost indescribable advances for which I am grateful and in awe. So how is it possible that the same system that makes it possible to cure diseased bodies can create so many obstacles to our ability to bring healing to the souls who inhabit those bodies…and to keep the healers whole? You know exactly the obstacles I’m referring to, frustrations and hurdles that we endure ‒ and seemingly accept ‒ most every day in our work even as we try our best to care for our patients and maintain passion for our work.
As a profession, we are lost if we do not continually reexamine foundational things that make us and our profession what it is at its best, foundational things that we hold dear that called us to make the sacrifices it took to become physicians ‒ core beliefs and longings that enable us to treat patients with dignity and great care. Calling, values, the need for meaning ‒ the sort of things that we must discern and honor as individuals and as a profession, even as the importance of these is so seldom tangibly emphasized and modeled by powerful forces that increasingly control our workplace. What if we refused to work for organizations that don’t share, or let us honor, what we hold as precious, if we refused to be spread too thin to be able to properly care for our patients and ourselves, if we refused to work with that insurer that forces us to compromise care? The fact that we are often reluctant to make those hard choices threatens us as a profession and as individuals.
In his seminal work, Crossing the Unknown Sea: Work as a Pilgrimage of Identity, David Whyte writes, “We have our work now, a work that was formed in the growing imagination of the child we once were, but the work itself has changed and made us, formed us, into something different, something perhaps good but also disturbing at the same time… distant now from all other voices that crowded our childhood, try to imagine what that dreaming young self would think of the strange adult we have become.”
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted January 2024
by Dr. Richard DeBehnke
The Calculus of Giving
Over the las few weeks, due to an unexpected illness, I‘ve had to move to the other side of the exam table. Things are moving along, and I am doing well. But a lot of weird things start to happen when a doctor becomes a patient. The paradigm shifts as if a mirror is being held in front of you. All those patient-doctor relations we are so familiar with: developing trust, how to frame your message, body language, flip and the whole encounter starts to lend itself to some interesting introspection. I also realized I truly missed the interaction with my patients and tried to better understand why. What I decided I was missing was what I call the calculus of giving.
We find ourselves in the Christmas season but all through the year, and in all of our faiths, there is the tenet of “the giving hand is better than the receiving hand.” Generosity, charity, giving freely without the expectation of return is lauded.
In our profession we are called caregivers, and we are daily asked to give─give our time, give our expertise, share our compassion. Demands are high, hours are long and what we miss in the lives of those that surround us subtracts further. Burnout is common and efficiencies promised are years away from being actualized. But being forced to step away from the daily fray has helped me realize the wonderful gift we are presented with every day: the opportunity to help.
Think of yourself. How often do we avoid, decline, or ignore when help is offered, even if it is by someone near who perceives us as needy. That word implies fragility or weakness. Ask for help? How reluctant are we to “impose”? The reply is usually “I’ve got this!” “No thanks.” “I don’t want to be a bother.”
But they are, every day, our patients. Many in number, frustrating at times and perplexing in others, all lined up, an unlikely assortment of Magi waiting outside your exam room rather than outside a manger, waiting patiently to fill up your emotional needs of having purpose and making a difference. Voluntarily opening up with their secrets, exposing their fears, allowing invasion of their personal space, and for our surgeons, their very bodies. Trusting us and listening to us. When was the last time someone at home really listened to you, or were they just waiting to talk?
At the end of the day who, in this calculus of care, has benefited the most? What we do is important, we are good at it, but it is exhausting, and it can be overwhelming. But as givers ─ caregivers ─ we need to be thankful as well. Thankful that we are given a chance to help. Thankful that, for whatever reason, they have placed their trust in us.
By nature, humans are needy, and I now believe that our exchanges with our patients leave us much the richer as they fulfill our needs. I knew I needed to recognize these gifts and ask for the humility and grace to appreciate them. At the end of a visit, it is not unusual for our patient to stop at the door of the exam room and thank us. Maybe we should be thanking them.
Take it from me as someone who had to ask for a lot of help from a lot of people recently…. YOU’RE WELCOME. Welcome to my gratitude, welcome to my trust. As doctors we work hard to earn these gifts. Give yourself time to appreciate them.
Dr. Richard DeBehnke
Contact the author with comments here.
Submitted January 2024
by Dr. Brian Sayers
The Fourfold Path: Telling the Story
Each time one of our colleagues accesses our Safe Harbor Counseling program we ask them to fill out an anonymous evaluation form. We get a lot of feedback, but near the end of last year we got one remarkable testimonial that in part read, “My sessions are incredible. I started therapy because I felt lost and frustrated... now I find that the anxiety and fear that held me back are rooted in past experiences that I was never able to unpack.... Talking about these parts of my life reveals patterns in my behavior. I feel like a massive transformation is taking place...”
Among other things, what I believe our colleagues often describe involves both discovering and telling an untold, difficult story, naming the hurts that lay within that story and, in the end, writing an entirely new story. It was a great blessing to read this testimonial and coincidentally came at a time that I was reading the Archbishop Desmond Tutu’s “The Book of Forgiving.” In this book, which contains life changing lessons, Tutu describes the path to forgiveness using the “Fourfold Path.” In the often long, complicated, and liberating road to forgiveness of self or others, of recovering from trauma, the four components described are: telling the story, naming the hurt, granting forgiveness, and renewing or releasing the relationship.
Telling the story is a critical first step on the road to forgiveness or recovery from trauma. Not just telling yourself the story, but literally telling it out loud to others, to trusted friends, colleagues, family members, or a counselor. Importantly, it involves telling the story several times as retelling the story gradually reveals detail and perspective, clarifies facts, and makes feelings related to the event more tangible, easier to deal with. Tutu notes “Even if I intellectually know that it is through my story and its telling I will begin to heal from trauma, it is not always easy emotionally to take the first step… But when we lock our stories inside of us, the initial injury is often compounded.”
One of the most important things we can do for each other is to be approachable and available to hear these stories, even when they are difficult to tell and to hear. Since early in the PWP counseling program, I have been approached by colleagues facing challenges, sometimes even trauma, in their professional or personal lives. Many have carried the weight for months, even years, afraid or ashamed to share their very personal story. Whether they knew it or not, their soul cried out for a chance to tell their story, to name the hurt, and to begin the process towards healing, the process of releasing the past. Our job as a community that cares about each other is to make sure they have a safe, trusted outlet to tell their story, with us or a counselor. Tutu notes that we cannot avoid suffering and trauma in life but what we can choose is how we will respond, “…whether we will let this suffering embitter us or ennoble us. How do we allow our suffering to ennoble us? We make meaning out of it and make it matter.”
In each of our lives there are times of great joy, of love, family, friendships, and meaning. Just as surely, life inevitably brings challenges and times of suffering, times that require us to tell our story in order to reclaim wholeness. When I was too young to understand, my father and our family suffered with his alcoholism and his untimely death caused by it. Looking back, I can see how it negatively influenced my life until I finally realized while in medical school what had happened to him, and to us, and much later, through telling the story of my adolescence I was able to forgive him and those around him who I assumed had failed him. My college roommate, on the brink of a promising life, was lost to suicide, and it was not until well into middle age, having finally told the story during my years in seminary, that I was able to forgive myself and forgive him. As Tutu notes, “We are not responsible for what breaks us, but we can be responsible for what puts us back together again…how we begin to repair our broken parts.” So much wasted suffering in those years until I was able to release the past, finally able tell a new story, to turn it into something with meaning, to find a place for it in my heart. For those of you who are in need, I wish the same for you.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted December 2023
by Dr. Brian Sayers
A Train in the Distance
In preparation for a class I’m leading, I reread The Book of Joy: Lasting Happiness in a Changing World, a wonderful collaboration between the Dalai Lama and Archbishop Desmond Tutu. One section in the book focuses on the “eight pillars of joy.” The first four qualities are the pillars of the mind: perspective, humility, humor, and acceptance. The other four are the pillars of the heart: forgiveness, gratitude, compassion, and generosity. All eight pillars are important but as I thought about it, I realized that acceptance is the very gateway to forgiveness, as well as recovery from trauma, grief, and addiction.
Acceptance is surprisingly hard to fully define, harder still to describe how to achieve. The narrator notes that in describing acceptance, “the Dalai Lama had told us that stress and anxiety come from our expectations of how life should be. When we are able to accept that life is how it is, not as we think it should be, we are able to ease the ride…with all its suffering, stress, anxiety, and dissatisfaction…” Acceptance means fully acknowledging the facts of a current situation or circumstance and not fixating why it should not be that way. He goes on to note, “much of traditional Buddhist practice is directed towards the ability to see life accurately, beyond all the expectations, projections, and distortions that we typically bring to it.” Acceptance, as a practice, allows us to thoughtfully respond, rather than impulsively react.
Two critical concepts about acceptance should be noted. First, “the kind of acceptance that the Dalai Lama and the Archbishop were advocating is not passive. It is powerful. It does not deny the importance of taking life seriously and working hard to change what needs changing, to redeem what needs redemption.” At the same time, many things we accept cannot be changed. Twelve step recovery programs hold both acceptance and thoughtful response for change as core concepts. The very first of the twelve steps is acceptance of being powerless over alcohol. The Serenity Prayer, often evoked at AA meetings, includes: “…grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” Second, acceptance allows us to release the past, to set down disappointments, mistakes, or things beyond our control that led us to our current circumstances and turns our focus to the present, to response where needed, to looking forward.
Psychotherapist Amy Morin suggests a four-step approach to acceptance in tough situations: 1) Accept how you feel about a situation. Name the feelings. 2) Accept what is happening right now as a fixed reality. This does not preclude a thoughtful response. 3) Stick to the facts. Try to distinguish the situation from all the emotions that might swirl around it. 4)Acknowledge that you can still have a good life even knowing there will be challenges and suffering along the way. Therapists often use a variety of behavioral therapy techniques to help clients who struggle with acceptance.
Each morning at 4 o’clock, my wife and I are up. She’s had serious health challenges for a number of years, and we reposition and do some other sleepy tasks before dozing off again. We live a little less than a mile from Mo-Pac and there’s a train that goes by every morning right at 4 AM, the faint hum of the train and 3 long, mournful bellows from its whistle as it passes through town, disappearing into the night. It’s close enough to be heard in the quiet, but far enough away that it is deep in the background. I am comforted when I hear it. It always reminds me of a Paul Simon song, Train in the Distance, and a line near the end of the song: “Everybody loves the sound of a train in the distance. Everybody thinks it’s true….the thought that life could be better is woven indelibly into our hearts and our brains.” Simon once explained that he used trains as a metaphor for a hopeful future because they are always looking forward, moving on, leaving the past behind. Acceptance can be elusive. And so, I try to remind myself, each day (or night) that acceptance of current circumstance, the past set aside, is what keeps us grounded and grateful in the present, allowing us to look forward to the future… with hope.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
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Submitted December 2023
by Dr. Brian Sayers
The Imposter
My
first job in Austin, longer ago than I’d like to admit, was with a
multispecialty clinic where most of the best internal medicine specialists
practiced. It was an intimidating place for a rookie, and I was nervous and
self-conscious those first few months. Late one Friday afternoon, I got a call from one of our internists on their way out the door, asking me to see one of their patients before I signed out. It was a difficult problem, the referring doctor was unreachable, and in the end I had to find a surgeon to assess the patient in the ER, this being an era when a good doctor didn’t just send a patient to the ER without arranging care at the other end. The next week we were gathered at Seton for a quarterly staff meeting, and in front of a dozen of my new colleagues, the referring partner berated me for referring their patient to a surgeon they didn’t usually work with. I tried to explain, but they cut me off and repeated the warning, angry and dismissive. I had been scolded like a child and there was an awkward silence as I was revealed to be a fraud, an imposter, who didn’t know how things were supposed to be done. It sounds silly, even trivial now, but at the time it seemed devastating.
Imposter syndrome was originally described in the ’70s as an “internal experience of intellectual phoniness…It is usually witnessed in individuals who seem successful to others, but on the inside, they feel incompetent.” A 2022 study from Stanford surveyed 3000 physicians and found that 1 in 4 experienced frequent or intense impostor syndrome symptoms. The study author, Tait Shanafelt, notes that U.S. physicians are at an 80% increased risk for the syndrome relative to people with a doctoral or professional degree in another field. He notes that in its worst forms, impostor syndrome carries a greater risk of occupational burnout, profound work dissatisfaction, depression, even suicidal thoughts, resulting in loss of effectiveness, personal and professional distress, and loss of meaning in their work.
While it is prevalent across the demographic spectrum, imposter syndrome was originally described as a syndrome primarily affecting women, and though it can profoundly affect either sex, it may do so in different ways. Dr. Valerie Young, author of The Secret Lives of Successful Women, notes that gender differences that are present in this syndrome are often created by persistent differences in the way society judges men and women, and how they react to it. She notes that while society has often “forced fit” men into a certain definition of success generally measured in terms of money, power, and status, measuring success is often more complex in professional women, especially those with children where there are several success domains at play simultaneously. She describes that women often “have a more layered definition of success… that also includes meaning, balance and relationships.”
There are many strategies for managing imposter syndrome. Dr. Young notes that at the core of them is humility − making peace with imperfections and limitations while recognizing and reinforcing the intelligence, talent, and love that we work so hard to bring to work with us. “I think that’s one of the most important parts of recovering from this…saying ‘I don’t know’ and being OK with uncertainty, which is especially difficult in medicine.” One simple exercise is to put a Post-It note in a prominent spot at our desk that reminds us of the strength, sacrifice, accomplishments, and caring we bring to our patients, even with imperfections. Being honest about self-doubt with close colleagues can be helpful. For some, counseling can be a lifeline that provides much needed insight, perspective, and effective strategies.
I composed this sitting in a church waiting for a funeral to start, my third funeral this year, two earlier ones being close friends who lost long, difficult battles with cancer. For each, there were a couple of weeks at the end in hospice care − in transition − lucidity fading, briefly inhabiting what Celtic tradition calls a “thin place,” a liminal space where Heaven and Earth very nearly merge into one. Ironically, even as I considered death, I was also able to give a prayer of thanks, for in just a few weeks our eighth grandchild will be born. Birth and death − the very bookends of our lives in this world. At each of these extremes, life is distilled to its simplest, most essential elements, our souls laid bare − pure, loved, forgiven. How do all those years in between become so complicated, our expectations of ourselves so distorted, that feeling like an imposter is even possible?
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
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Submitted November 2023
by Dr. Brian Sayers
Herzensbildung*
Several years ago, I was leading a PWP small group when someone mentioned a study about friendship. As I recall, it said something about the average number of friends people claimed in a survey. We found this problematic for several reasons, in part because people have all kinds of friends. Commonly listed categories include acquaintances, casual friends, close friends, and intimate friends. That last category, the ones we know and who know us inside and out, are the ones that make all the difference. In his latest book, How to Know a Person: The Art of Seeing Others Deeply and Being Seen Deeply by Others, David Brooks examines what it takes to come to know and be known in this way.
Brooks shares scary statistics that lend urgency to learning these skills: 54% of adults say no one knows them well, and the percentage of people who have no close friends has quadrupled in recent decades. Brook’s thesis is that individually and as a society we have lost our ability to form “deep” relationships in which we know each other on a level that humans need to feel connected and heard. This type of relationship is not achieved without intentional and informed effort ̶ generous listening, curiosity, “accompaniment,” and other skills he outlines. There is equal and reciprocal benefit of knowing and being known deeply that can be life changing: “Seeing someone well is a powerfully creative act, no one can fully appreciate their own beauty and strengths unless those things are mirrored back to them in the mind of another.”
Brooks writes about two distinct types of people--diminishers and illuminators. Illuminators are capable, even equipped, to see through the superficial ̶ to listen, inquire and accompany people in a way that leads to deep understanding, encouragement, and illumination, that they in turn mirror back. Illuminators come to understand the depth of your pain and challenges, but also to see and celebrate your unique humanity and worth, your triumphs, and the gifts that you bring to the world around you that others, perhaps even you, may not recognize. As Brooks describes, “they are people who are just curious about you, and they make you feel lit up."
Of diminishers, he notes, "My theory is that in any group of people, there are some people [who] are diminishers. They make you feel invisible, unseen…. They’re not curious about you. They stereotype you. They label you.” He holds that recipients of this treatment who lack close connection with others often lash out against people around them in violent or otherwise viscous ways that are all too common in our society today.
Brooks notes that the skills evident from the first time you meet illuminators is eye contact that you can tell sees into you rather than through you. They listen, ̶ “lean-in listening” he calls it. Importantly, they are instantly curious about you and ask you questions. With nurturing, this leads to a relationship of accompaniment−in a sense just hanging out with an ongoing curiosity that may evolve into a sense of journey together, and a deep sense of understanding and connection.
It was not until well into adulthood, even middle age, that I discovered the power of this and the stark contrast that exists between one kind of friendship and another. Three seminal events in my life ̶ time in seminary, a chance leadership training program in a remote village in Ohio as we launched PWP, and a recent pilgrimage ̶ all showed me the power of seeing and being seen deeply, gifted me with new, unexpected, and life changing friendships, but also with new perspective or direction in other relationships. I’m a slow learner, but better late than never. This unique sense of connection and interconnection is among the most powerful things we can hope for in life, an antidote for much of what ails far too many people. It is, in essence, the way to find ourselves truly accompanied by fellow travelers on our uncertain and winding pilgrimage through life.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
* “The training of one’s heart to see the humanity in another.”
Submitted October 2023
by Dr. Brian Sayers
Finisterre
Frederic Hudson championed a theory of cyclic change that recurs throughout adult life. These are life transitions, and some are seismic, deeply desired, and visibly change our life trajectory. More often though, change is subtle, and we don’t always recognize when or where we might be residing on Hudson’s cycle of change at any given time, sometimes creating an uneasiness that we can’t quite put our finger on. Hudson describes four phases in the cycle of change: go for it, the doldrums, cocooning, and getting ready. In the “go for it” phase life seems to be working, there is a sense of purpose, of being on course. At some point though, a certain stagnation inevitably emerges in work, relationships, recreation, or particularly, in spiritual health. Such feelings are inevitable and are the gateway to the doldrums.
The doldrums is an ancient mariner’s term for what is now referred to as the “inter-tropical convergence zone,” a wandering area around the equator where the northern and southern trade winds collide, creating an area where there may be eerily calm seas and no wind for weeks at a time. It was the bane of ancient explorers, whalers, and merchant ships that could be stuck there indefinitely−bored, restless, irritable, anxious. Coleridge famously described it in The Rime of the Ancient Mariner:
Day after day, day after day,
We stuck, nor breath, nor motion:
As idle as a painted ship
Upon a painted ocean.
Sound familiar? In the cycle of change, the doldrums are downtime, a period of decline and malaise, but also as Patrick Williams notes, “The doldrums are meant to serve as a wake-up call, an invitation to restructure or reinvent life so it works again.” So, while the doldrums can be boring, it serves a purpose and is the gateway to the next phase, cocooning.
In cocooning, we enter a phase of transformation. Williams calls it an “emotional time-out to heal, reflect and discover new directions in life.” It may be a long period of sabbatical, or a series of short breaks where we explore what form the process of renewal will take for us and where it might lead. Like the butterfly in a cocoon, it may not look like much, but within the cocoon there is deep work occurring, and with time and patience something new will emerge.
In the days after my father died when I was 12, someone sent us a beautiful letter that I still remember the essence of, though not the exact wording: that with death we enter a cocoon that allows us, like the butterfly, to transform into something more beautiful, eternal, and free of the worries of this life. As a child, it was comforting enough that all these years later I still remember it, and I still think of it whenever I see a cocoon. As an adult, I think it sticks with me because I realize now that, with grieving, a transformation was occurring, as the adolescent version of me prepared for a life altered by that loss. Even then, there were cycles of change.
Significant change is seldom easy, even when urgently needed or forced upon us, let alone when it must be discerned and unfold with uncertainty. The process, even with defined stages, often involves a certain mystery, and gaining something new always requires giving up something old, something that no longer quite works. Indeed, our mental well-being and happiness depend on our perpetual capacity for change, on allowing the process to unfold with humility and patience, on living in the present while imagining a future…on letting the past be the past. The reward is Hudson’s “go for it” phase, where change is realized, acted on, becomes fully visible.
I recently spent a couple of weeks walking the last stages of the Camino de Santiago thru Galacia in northern Spain. It’s an ancient religious/spiritual pilgrimage that ends at the Cathedral in Santiago de Compestelo where relics of St. James rest near the altar. For many, the pilgrimage continues from there westward another 60 miles to Finisterre, where Spain meets the ocean, a place the ancients believed to be the “end of the world.” As you begin your Camino, you’re told to carry a stone, wherein you place your “ghosts,” the things or people you mourn, regrets, things lost along the way, trauma, whatever you need to set down on an inward journey to wholeness, and somewhere along the Camino you leave the stone behind. Discovering your ghosts is an integral part of the pilgrimage. All along the Camino at wayfinding markers you see stones that fellow peregrinos have set down, making room for something new. Finding discernment slow, I held mine all the way to Finisterre, where I went to the edge of the tall cliff below the lighthouse and threw my stone into the sea. What that will lead to remains to be seen…but I am hopeful.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted October 2023
by Dr. Tyler Jorgensen
Lifting Carts
We lived that summer in a tiny A frame house in the shadow of the Teton mountains. It had a front porch, a gravel yard, and an electric stove. I couldn’t have guessed the lilliputian square footage if I’d had to, but I can tell you I could hardly avoid hitting my head on the ceiling of the upstairs loft I shared with two strangers. Trey had the palatial downstairs bedroom to himself…he should’ve, he paid a greater percentage of the five-hundred-dollar-a-month rent. Not only that, Trey had been the catalyst for this whole operation.
A lot of us didn’t really have much direction in life right after college, but Trey had always had one very clear direction—west. To the mountains. That’s where we could find him, and where he was going to stay. By the first winter after college graduation, while Trey was thriving out west, thyroid problems had disrupted my east coast post-college plans. I found myself convalescing in my parent’s home in Houston and working part-time as a substitute teacher, and I was struggling again to find direction. What was I doing with my life? What do I do now? I dreamt often of mountains and gave Trey a call.
Trey must have lied about my wilderness bona fides to his employers at the outdoor school because he landed me a job working alongside him for the summer. What a dream! I had a job, in the mountains, living in a nasty old A Frame with one of my best pals.
There really is nothing quite like driving through the great American West in your twenties. I don’t know that I’ve ever felt more carefree, even though I really had no business working at that outdoor school. I knew far less than our students about surviving for a month in the woods. I didn’t know how to repair boots or backpacks. I could barely handle the stick shift F-350 truck with a trailer full of gear as I transported students across mountain passes in Montana and into the Owyhee Desert of Southwestern Idaho. This was not imposter syndrome—I was actually an imposter!
When we weren’t working, Trey and I would rock climb or hike up into the Tetons or fly fish. He was better at all of these than I was, but he coached me up as best he could. When good bands came through town we’d go see them. Most nights were pretty quiet, though. Actually, really quiet. I would try to get some conversation going, but it often didn’t work. Trey didn’t talk unnecessarily nor betray much emotion. He really was a Western man, cut straight from some tough Clint Eastwood cloth. Trey would sit in his chair after a day of outworking me, outclimbing me, read twenty pages or so of the unabridged Les Miserables, and fall asleep.
Over the summer months my physical and mental health steadily improved, I grew in confidence and outdoor savvy, and I figured out what I was doing at work. I think I even got decent at handling the F-350. As summer turned to fall and the aspen leaves began to yellow, I made a tough decision to move back to Texas to pursue some other opportunities. A number of us were leaving at the end of the summer, but Trey would stay behind. He had always known his direction, and that wasn’t changing now. We shook hands and parted. I couldn’t swear to it, but I think I saw a little moisture in his eyes as he said to me, “It’s been good, friend. Who knows? Maybe next time I’ll be the one under the cart.”
What a strange thing to say. I asked him to clarify.
“You know…in Les Miserables… Jean Valjean rescues the old man from getting crushed under the weight of the cart. He lifts it off of him. Maybe I’ll be under the cart next time.”
I drove off south and east, watching the A Frame and the Tetons fade in my rearview mirror, thinking about Trey’s surprisingly profound farewell. I hadn’t realized just how low I’d been a few months back, and how much my buddy had done to help me out from under that cart of illness and disappointment. I’ve been thinking about his words for two decades now. I am grateful for friends who’ve helped me over the years, especially physician friends who’ve been with me through tough times. I am thankful that in Travis County we have the Physician Wellness Program, a cart-lifting enterprise. If you find yourself under too much weight, please reach out to a friend, a colleague, a loved one, or the Physician Wellness Program. And keep your eyes peeled for opportunities to help lift a cart for someone else.
Tyler Jorgensen, MD
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Submitted September 2023
by Dr. Michelle Owens
Let go, with grace
the relationships that continue to take more than they give;
the failed ideals of where I should be right now;
imposter syndrome;
And the unrealistic expectations of motherhood in 2023.
Let go, with grace
the judgement from others;
the dreams of an organized Home Edit worthy playroom;
the idea of my kids willingly eating vegetables;
And the societal pressures of what my life should look like.
Let go, with grace
keeping up with the Jones’;
achieving FIRE (financial independence, retire early) in this decade;
being the perfect parent;
And all of the things I have no control over.
Let go, with grace
rocking my youngest to sleep;
the dream of sleeping in late;
the pressures of needing to be resilient;
And the harsh comments of my inner critic.
Let go, with grace
the hurt and trauma of the past;
the grief of what might have been;
the wrong words said;
And the words left unspoken.
Now, let us go gracefully into the future,
holding on to who and what matters most,
all that brings us joy;
And the knowledge that our time is finite so we should choose wisely how we spend it.
Michelle Owens, DO
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Submitted September 2023
by Dr. John Hellerstedt
Nobody Cares How Much You Know Until…
The recent piece, “Hippocrates Shrugged” brought to mind Theodore Roosevelt's memorable saying, "Nobody cares how much you know until they know how much you care." Now that I am a patient and no longer an active clinician, Roosevelt's observation has become especially cogent. With advancing age, my wife of 41 years and I are shouldering our share of America’s disease burden.
Some of the burden was predictable, some others – the worst parts – came as bolts from the blue. When the news is truly bad, the first thing you want to know is how much your physician cares. You believe they know their craft, or you would not have walked through the door. But now that you are in the exam room, baring whatever needs bared, you need to know if this person’s heart is in the right place.
As I have reached retirement, so have many of the physicians I had been seeing over the past decades. I knew I respected them, I knew I liked them, but I guess I didn’t realize I loved them, for only having to end a relationship with someone you love could explain the aching I feel when I now have to smile and try to make a good impression on a new, typically decades younger doc. I know, stereotyping is a two-way street. I do my best to not to come off as an old coot.
There are great, amazing, truly caring docs out there for sure and I have great optimism about getting to fully appreciate my new physicians. But what saddens and humbles me is that the difference between signaling indifference versus caring requires a mere modicum of clinical technique.
Rational patients—still the majority, one hopes—do not expect to gush forth their inmost souls, but rather, would be set at ease with some simple expressions of empathy, questions about their general life circumstances, and their reaction to those circumstances. We should be teaching the essence of caring made visible to every new generation of physicians, for without that skill, they will fail to reach their full potential as healers, and, I dare say, will not optimally flourish in their chosen career.
Only that personal connection truly satisfies—only that soul satisfaction can make up for all the sweat and anxiety that defines clinical practice.
I am humbled because when I think back to my early years in practice, I remember my faults more clearly than I remember my virtues. To the degree that I improved, many of those lessons were learned the hard way.
I used to be reluctant to engage the patient emotionally, if you will, believing incorrectly that to do so would turn every visit into a Jungian psychotherapy session. I now know nothing could be further than the truth.
There are (professional) shortcuts to empathy: eye contact, handshake, “how’s your day going,” “I’m here to help you through this.” Science tells us that the majority of our message is conveyed without words—primarily through body language. I am proud to say that I never wore a wristwatch in practice, and still don’t. While I was fully cognizant of the time, I didn’t want the patient to see me looking at my watch, which I know I would have done without thinking.
St. Thomas Aquinas said that love is an act of will, not an emotion: to love is to will and act to bring about the highest and best good of another. Honestly, I can’t think of a better definition of what our goal should be in treating patients.
In light of that definition, it is not only possible to love your patients, it is the very practical aim of each encounter. This definition gives me great solace in every dimension of my life, for I truly believe that we are called to love one another without exception. But how can I love someone I don’t even like?
The answer is that when you “will” and “act” to bring about the highest and best good in another person—perhaps especially one for whom you feel no emotional affection—you are obeying the commandment to love. If love were merely an emotion, fulfilling this ethical imperative would be humanly impossible.
Next time you care for a patient in this way, pause and be grateful that human connection is a shared gift in your work. Next time as a patient, when your caregiver expresses their love in this way, express your gratitude for their seeing the humanity in the patient before them. You will have helped each other heal.
John Hellerstedt, MD
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Submitted September 2023
By Dr. Tyler Jorgensen
Bad Weather
I can’t take it anymore—this heat. It’s making me crazy. My beloved creek is dry. My lawn is brown and crunchy. My grass smells like a harvest festival haybale. Every plant in my yard sags, withered and crispy. Even the cicadas seem desiccated and brittle—they sound like cornhusks in flight! Twice when it has rained recently, the rain has somehow smelled seared coming up off the grass or the pavement.
“There’s no such thing as bad weather, only unsuitable clothing.” Or so Aunt Judy taught me. Judy was always getting us outdoors — paddling down the Brazos River, camping in the great Piney Woods, or even just strolling through Houston’s Arboretum. Summer heat, winter rain, it didn’t matter. Just get outside. I’ve been telling my kids the same thing for about 16 years now, and I generally believe it’s true. Jog in the snow, run in the rain, stay acclimated to the summer heat, journey to extreme environments. Just get outside.
Alfred Wainwright, a British writer, first penned the line about “no such thing as bad weather.” (I don’t think he’d ever been to Central Texas.) Wainwright fell in love with hiking in England’s Lake District in the middle of the 20th century and wrote several books about the region and the pleasures of walking outside. He developed a 190-mile coast-to-coast trail across northern England and inspired other people to get outdoors and enjoy the beauty of the world around them.
One of the benefits of practicing medicine in central Texas has always been our incredible access to beautiful outdoor spaces. We may not have the grandeur of the Colorado mountains, or the perfect temperature of southern California, or the spectacle of the Northeast’s fall leaves. But we have easily accessible canyons and creeks, bountiful greenery and natural springs, varied terrain, rocks for climbing, rivers for paddling. And that’s all within the city! In addition, we are all just a short drive from beautiful state parks and natural areas that help us reset and clear our minds after hard days and nights of clinical work. Had a rough shift? A bad day at clinic? Get outside.
Well, Mr. Record-Setting-Texas-Summer, you have just about beaten Wainwright’s wisdom out of me. My son’s football practices are moved to 6:30 in the morning to avoid the superheated turf, my daughter’s getting heat illness during soccer games, and even the panacea of pool water feels warm and syrupy by late afternoon. We had a deal, Texas Summer. You keep it around 95 to 100, and we’ll stay active and not complain. You broke your promise.
Kudos to all of our colleagues who have stayed active and outdoors this summer. I haven’t. I recently realized that over the past couple of months I have been hiding in air-conditioned spaces whenever I can, and my aunt Judy wouldn't like that. This past week I decided to reclaim Wainwright's philosophy and get back out there. I’ve been on a couple casual hikes this week so far, and I realized two things: 1) There really is a such a thing as bad weather. 2) It may not be as wet and cool as I’d like, but it is still restorative to get outside. And it’s not sooo hot on a shaded trail in the morning.
This week I found another Wainwright quote worth sharing:
“Oh, how can I put into words the joys of a walk over country such as this; the scenes that delight the eyes, the blessed peace of mind, the sheer exuberance which fills your soul as you tread the firm turf? This is something to be lived, not read about. On these breezy heights, a transformation is wondrously wrought within you. Your thoughts are simple, in tune with your surroundings; the complicated problems you brought with you from the town are smoothed away. Up here, you are near to your Creator; you are conscious of the infinite; you gain new perspectives; thoughts run in new strange channels; there are stirrings in your soul which are quite beyond the power of my pen to describe…No man ever came down from the hills without feeling in some way refreshed, and the better for his experience.”
I recognize that he is referring to the green hills of northern England and not to Central Texas in the summer, but I think a lot of what he is saying still applies to us in Travis County. When you are ready, and with water and shade, get outside again. It can be restorative. Just make sure you have suitable clothing!
Tyler Jorgensen, MD
Send comments to the author here.
Submitted August 2023
By Dr. Brian Sayers
Hippocrates Shrugged
I came across an article not long ago about the Hippocratic Oath. Hippocrates was the true pioneer of ancient medicine, and original fragments of the oath attributed to him date back to the 3rd century. Both timeless and a product of his times, the earliest versions of the oath begin by swearing to a variety of Greek gods and goddesses that as a practitioner of the medical arts certain standards would be honored. There have been revisions through the centuries, and the modern version still used in graduation ceremonies dates to 1964. It is long, and if your memory is no better than mine, you probably mostly just remember that it says something about doing no harm.
I recently read the modern version of the Oath again after all these years. I was impressed by the fact that while the importance of scientific gains are emphasized at the very top, the Oath primarily lists the many ways that we hold our patients’ holistic wellness and dignity first and foremost, and how both our service to humanity as well as the meaning and joy we find in our work are derived from being healers. It is equally striking how the current medical environment that we work in, usually controlled by people who have never taken this Oath, makes the things that are of paramount importance in the Oath almost impossible to fulfill at times.
In a busy, overbooked clinic seasoned liberally with meaningless administrative tasks and onerous charting, just how easy is it to honor “…that there is art to medicine as well as science and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemists drug”? How often do the pressures of efficiency make it difficult to "...remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick”? Hippocrates was describing healing here, and it is embarrassing to try and explain to anyone outside of medicine, or to ourselves, how it is that honoring the Oath was allowed to become so difficult, how economics has been allowed to trump values, creating what we now call moral distress.
There was a popular book in the 1950s, Atlas Shrugged. The author, Ayn Rand, derived the book’s title from a reference to Atlas, a titan in Greek mythology who is remembered in myth and imagery as the giant who held the world on his shoulders. In the book, two characters have a conversation in which one asks the other what advice he would give to Atlas if the greater his effort, “the heavier the world bore down on his shoulders.” The other character replied that the advice he would give would be “To shrug.” Though the title is intriguing, I never read the book and It’s unclear whether to shrug means for him to express indifference or defeat to a hopeless situation, or if it means to not give up and to force his shoulders upward against the immovable force. This book title came to mind when I was considering the load that we physicians carry on our shoulders these days trying to honor the Hippocratic Oath that we all swore to in a more innocent time and how even Hippocrates himself might respond.
There is a story about a Zen master teaching someone about Zen over a cup of tea. As he was serving his guest tea, the Zen master holds the teapot over his guest’s cup and begins pouring. The cup fills, then overflows, but the Zen master continues to pour tea into the overflowing cup. Finally, he sets down the teapot and asks, “Now, can you put more tea into the cup?” The horrified guest replies, “No! It’s overflowing.” The Zen master replies by emptying the cup and placing it back in front of his guest. “Now the cup has been emptied and is ready for you to fill it with something new.”
Our lives in medicine are often overflowing, both with things critically important and with things that are utter nonsense. It’s the world we live in and the way we allow ourselves to live in it. Only when we realize this and can empty our cup just enough to make room for things that are essential and true and lasting, things that we swore an oath to, that our lives in medicine might change. As Hippocrates promised, if we act to preserve the finest traditions of our calling we may “long experience the joy of healing those who seek our help.”
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted August 2023
By Dr. Lisa Doggett
My transformation from doctor to patient
I woke up dizzy. It was November 2, 2009, two days before my daughter Clara's second birthday. I thought I was getting a cold, and I did my best to ignore it. I struggled to keep up with my usual schedule, seeing patients and teaching students at my small family medicine clinic near downtown Austin. I tried to take care of my kids, preparing snacks, reading bedtime stories, driving them to school. They were two and four years old – not exactly independent.
The dizziness – an unpleasant buzz combined with something akin to motion sickness – was relentless. I kept expecting it to turn into a respiratory infection or the flu, but then I started noticing diplopia and taste changes.
By the end of the week, I was convinced I had a brain tumor. Nothing else could explain my symptoms.
But my MRI didn’t indicate a tumor. Instead, it showed probable multiple sclerosis.
A chronic disease of the central nervous system and a leading cause of neurologic disability in young adults, MS hadn’t even been on my radar (I’m embarrassed to admit). Common symptoms include fatigue, impaired mobility and balance, visual and sensory changes, cognitive dysfunction, mood disturbances, and bowel and bladder problems.
Even though it wasn’t a brain tumor, MS was a shocking – and infuriating – diagnosis. I was 36 years old, and I couldn’t understand why I’d gotten sick. I had no family history, and I practiced all the healthy habits I preached to my patients: daily exercise, a healthy diet, no substance use.
I remembered my first encounter with MS. As a medical student in the mid-1990s, I met a man with progressive MS who was admitted with an intestinal obstruction. He was in excruciating pain and severely debilitated – barely able to move. He must have required round-the-clock nursing care even before he came to the hospital.
I realized that I could end up like that patient. And after I got a lumbar puncture, which confirmed my diagnosis, that's exactly what I thought was going to happen. Two days after the LP, when I should have been better, I got so sick I couldn't get out of bed. I still had dizziness, and I started vomiting. I was weak, exhausted, and so depressed. Unlike many of my patients, I had a supportive family and health insurance – the means to get good care. Yet I felt like my future had just been stolen.
An MS diagnosis can be devastating – physically, financially, emotionally. It often strikes people who are young and healthy. It doesn't discriminate, affecting nearly 1 million people in the US. Its course is unpredictable and random. Overcoming my symptoms and learning to live with the uncertainty that MS created have been among the biggest challenges of my life.
But nearly 14 years post-diagnosis, I’m doing well. My early pessimism was unwarranted. Thanks to advances in MS treatment – and a big dose of luck – I have bounced back after exacerbations. I’ve now been relapse-free for almost seven years. This spring, I finished my first half Ironman triathlon and biked the Texas MS150 for the fourth time.
My memoir, Up the Down Escalator: Medicine, Motherhood, and Multiple Sclerosis, will be published on August 15, by Health Communications, Inc. The book chronicles my transformation from doctor to patient while directing a clinic for people without private insurance. Writing it was fun and therapeutic – an outlet for my frustrations with MS and with the inequities of our dysfunctional health care system. But finding an agent and publisher was arduous – and took nearly eight years. After so much time, I am extra excited to be able to share this story with the world.
I still resent MS, but I’ve emerged wise, stronger, and more grateful because of my illness.
And I’ve realized that MS – or nearly any chronic condition – isn’t an excuse to stay home and cancel plans. Instead, MS is my launchpad to achieve big dreams: getting scuba-certified, hiking the Inca Trail in Peru, publishing my book. I’ve learned to focus on my abilities and strengths – and to push my limits, embracing a new mantra: Do more – more of what brings joy, adventure, magic, novelty, meaning, connection. And do it now.
Lisa Doggett, MD
Contact the author here.
Submitted July 2023
By Dr. Brian Sayers
Ubuntu
A story, or perhaps a legend, about Ubuntu: An anthropologist passing through a village proposed a game for children in an African tribe. He put a basket full of delicious fruit near a tree and told them that whoever got there first won the sweet fruit. When he told them to run, instead, they took each other’s hands and ran together, then sat and passed the basket around for all to share. When he asked them why they had refused to race ahead of each to claim the prize, they said: “Ubuntu. How can one of us be happy if others are sad?”
Ubuntu, a Zulu term, concept and philosophy with a long history, was championed by Archbishop Desmond Tutu and Nelson Mandela during and beyond the years of struggle in South Africa. Mandela once summarized the many interpretations of Ubuntu as, “the profound sense that we are human only through the humanity of others; that if we are to accomplish anything in this world, it will in equal measure be due to the work and achievements of others.” It is a concept worthy of each of us considering.
Medical societies from the national level, all the way down to the local level, have struggled in recent years to maintain membership, to convey their relevance to members in tangible ways that must evolve with our profession and the challenges we each face. In many ways, TCMS like other medical societies, claims relevance by what we do together, not just for our profession, but also for each other. This week, as we do each quarter, we celebrate what you have all done to help each other through the Physician Wellness Program and its Safe Harbor Counseling Program. Each of you reading this is part of this project, by financially supporting the program, contributing to our Sunday emails, by referring colleagues to the program, or checking in with them or supporting them in other ways. Your TCMS membership makes you a part of this.
Take a minute to study the second quarter donor list and the program statistics and feel proud of what we do for each other. As Ubuntu is sometimes translated, “I am, because we are.”
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted July 2023
By Dr. Brian Sayers
The Crawlspace, the Junk Drawer and Other Scary Things
It started as a simple repair job. A couple of wooden planks of siding showed signs of rot outside of our kitchen. I called a trusted contractor. Replace a couple of planks, match the paint and a couple hundred bucks later all should be fine.
Right? Well, it’s a 90-year-old house and it is never that simple. The three-month odyssey that ensued involved lifting that whole side of the house, replacing major support beams which in turn stressed our entire kitchen, cracked granite counters, affected plumbing, etc. etc. In the end, what started as a simple carpentry job ended with major renovations. I finally had to bar the contractor from exploring the crawlspace any further. There is just no logical end to what additional horrors he might find. Most of these painful repairs and improvements are entirely invisible unless one were to extensively army-crawl under the house to inspect the magnificent new beams that adorn the crawlspace.
Weeks later, most of the nightmare and clutter are behind us but for one very visible remnant. Purposely placed in a room we seldom inhabit, it sits on an ottoman in the living room, far enough away that I don’t have to deal with it but still catching my eye as I pass by, taunting me. Yes, it is the kitchen junk drawer, displaced during the renovation, its mother cabinet now resting in demo heaven. It is an orphan now, wanting attention, and it is no longer easy to ignore.
Every household has at least one “junk drawer,” and I’m betting you have more than one. This is where we toss the things that were once necessary, but now we don’t quite know what do to with them. I mean, they might be necessary, perhaps even essential someday, but in my heart, I know…probably not. But maybe. I’ve glanced several times, even discarded about half of it late one night, but it’s a bottomless pit. Batteries (used?), a dozen keys to locks that probably don’t still exist…but might. Hair clips we used to put in our daughters’ hair as they ate breakfast or as we hurried out the door almost late for school. Bread wrapper twisties, super glue in various states of decay, and on and on. A drawer full of things I don’t want to deal with.
Why am I still thinking, even writing, about this? My preoccupation with what still lurks in the crawlspace is well founded, I think. But also, I’m reminded of past readings about Carl Jung and our shadow−that archetypal figure that lives in the unconscious and possesses “everything about ourselves we find shameful or scary and not ready to face,” something writers often describe as lurking in our subconscious basement or under the bed. Perhaps, but in this case, I think it has more to do with 90-year-old wiring I don’t want to confront rather than my shadow, though both could probably use some attention.
The junk drawer? Just google the psychology of that. There are countless articles, blogs, images, videos, even entire books exploring this. As author Jeremy Berg notes of junk drawers, “We do something similar with our spiritual life. We are constantly accumulating feelings, experiences, wounds, doubts, conflicts, and questions, and we don’t quite know where to put them. Many of these don’t fit into our preferred life script, and so they begin piling up in some deep and hidden place in our soul.” For this, maybe some honest help from spouse or friend, or a week on a beach, a weekend in Vegas, or perhaps, time with a therapist to reclaim some insight, perspective, and peace.
Or maybe it really is just an old house and a junk drawer.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted June, 2023
By Dr. Brian Sayers
The Bear
In a recent episode of the TV show Lucky Hank, Hank and his wife are entertaining his not-so-beloved academic coworkers. Table talk is degenerating, and to change the tone of the conversation Hank's wife suggests a table game. She asks each person to give their two “happiness numbers,” the first one being their “percent happiness,” the second number asking how low that happiness number would have to get before they would make real change in their lives. The game was a terrible idea for a party, but it made me think: these last few years, the threshold for change for many of us has changed, often, but not always, for the better.
We have seen many versions of change around us, and you likely went through some version of the process yourself these last few years. Many of these transitions were admirable and involved careful discernment and often no small amount of sacrifice and courage. Reimagining work and changing an unhappy practice situation or career direction, taking a sabbatical from practice to catch your breath, cutting back days or hours to be more present with family, shedding a bad habit or bad relationship are frequent examples.
For many, there were other changes, often for the better but sometimes not as well thought out − pandemic pets, retiring early, or the greener pastures of a vacation home or moving far away. Many, if not most, share something in common − leaving something that makes us sad, or anxious, or unfulfilled in search of something better. Like some of you, over the years I have made my share of missteps in seeking change. But in the moment, in real time, how do we tell the difference between necessary change and just running away? We are, after all, hardwired to run away from things that threaten us.
In his cautionary essay, Wherever You Go, There You Are, Jon Kabat-Zinn explores the human tendency to run away. “The romantic notion is that if it's no good over here, you only have to go over there and things will be different... Change the location, change the circumstances, and everything will fall into place; you can start over and have a new beginning.” But he points out “you cannot escape yourself, try as you might...” He calls on us to consider that true change comes from the inside rather than from changing things on the outside, even when it is easier to run. Sometimes, that means standing our ground.
David Whyte describes it in another way: “Wanting to run is necessary, actual running can save our lives at crucial times but can also be extremely dangerous and unwise, especially in the presence of animals that are bigger, faster and more agile... In the wild, the best response to dangerous circumstances is often not to run but to assume a profoundly attentive identity, to pay attention... and not to assume the identity of victim.” Standing our ground, confronting perceived threats, resisting the urge to flee, is sometimes the hardest work we face as adults. But when it is time to run, the key, I think, is to make sure that we are running towards something and not just away from something.
Restless in that first year after the shutdown, I found myself in Colorado for a few days of hiking, hoping in vain to briefly forget the pandemic. One gorgeous fall afternoon, a few miles from the trailhead I came around a bend and found myself not more than 20 feet from a black bear. Both of us froze. I tried immediately to recall the recommended response to this situation, and based on that highly flawed recollection, I stood very still, made eye contact with the bear and… sang. Somehow, I thought there was supposed to be talking or quiet singing, though where I got that notion, I have no idea. There was a Bob Dylan song, Don’t Think Twice, It’s All Right, that I couldn't get out of my head that day, so I quietly sang to the bear… or maybe to myself. The bear stared at me for a solid minute, then turned and trotted off. Perhaps the defining moments in our lives are when we make a stand and when we run away. Admittedly, it was more paralysis than bravery, but in that moment, I was just fed up enough with bears and pandemics that I continued my hike, even with the sure knowledge that there are more bears in my future.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program
Send comments to Dr. Sayers here.
Submitted June, 2023
By Dr. Tyler Jorgensen
Jerry’s Place
During my fellowship in palliative medicine I have learned the value of home visits. I learn more about my patients’ lives in two minutes of seeing their homes than I could in a lifetime of clinic visits. During home visits, I get to pet dogs, touch quilts, study photos, and admire charming heirlooms that would fetch only a few dollars in a garage sale, but that in these homes are priceless mementos. Just as often, I bear witness to the mess, the filth, the foul smells, the poverty, and even the loneliness and despair. Regardless of whether I like what I find in a home, at least it’s honest, and it always helps me understand how to best care for a patient.
Driving out to Jerry’s place west of town for a home visit was an ordeal. We wove along roads that progressively narrowed—paved, then gravel, then dirt—dodging dogs and loose livestock all along the way. Jerry’s friend met us and walked us down a path to the old aluminum shell of a trailer where Jerry was staying as he battled lung cancer. I’ll be honest, I wasn’t too surprised to see an old confederate flag on the wall in this sad, stuffy space. Confederate flags are still fairly common in small town Texas. Mixed in with the flag I saw some more artful tapestries, but the faded colors of Dixie still popped.
As my eyes further adjusted to the dark inside of his hot trailer, I scanned the clutter and found jumbles of pill bottles, half-consumed bottles of Ensure, flies feasting on food that Jerry hadn’t touched. Then I saw Jerry himself, a specter lying in the dark, and his body revealed instant clues to the severity of his disease—labored breathing, gaunt features, the exaggerated convexity of his chest, each rib so distinct with no muscle or fat left to cover them. Sweat dripped off his pale body as he cried in pain.
We got him some of his pain medication and quickly made the decision to call 9-1-1. He clearly needed immediate attention and was not yet ready to embrace the finality of hospice at home. He was among the sickest patients I’ve ever seen outside of a hospital. I caught myself staring.
After some long spellbound moments I forced my gaze away. As my eyes drifted up from his ribcage, I saw something equally as sick as Jerry’s lungs—a full-size swastika flag on the wall right above his bed. I had missed it at first, but there it was. Crisp and clean. A freshly made, recently purchased SS swastika flag. This was no historical artifact—this was an endorsement. Now I started to feel sick.
In 2023 we still hear some who defend flying the Confederacy’s Stars and Bars, as hurtful as the flag is to so many, but there’s no debate that a swastika represents hate, antisemitism, evil, and white supremacy. The ceiling of this nasty old trailer had just gotten a whole lot lower; I felt as if the walls were closing in.
A question has echoed in my head ever since that day. How should I handle the tears of a Nazi? I had recently been reading some of the essays of the Trappist monk Thomas Merton who dealt regularly with questions like this. Merton wrote that, for him, empathy came from an understanding that his own faults and shortcomings were as great as anyone else’s. He believed that, deep down, he was capable of any of the monstrous depravities he saw in his society and in the world at large. To Merton, the fact that he had not traveled down certain dark paths was merely a reflection of God’s grace, not his own superiority. He must therefore extend love to all persons.
Beyond that, Merton felt a responsibility to engage with the societal problems of his times. He didn’t like that he had to deal with the realities of Auschwitz, Hiroshima, and Vietnam—all of which happened during his lifetime—but he felt he had no choice. These were the times into which he was born. He didn’t get a pass, and neither do I. I have to find my role in the midst of this messy society. On that particular day, in my capacity as this man’s physician, my role was easing the pain of a neo-Nazi.
EMS arrived, and we escaped from this rectangle of sadness back into the bright Central Texas sunlight. How should I handle the tears of a Nazi? As his physician, I should handle them the same way I handle the tears of anyone else. I should wipe them, and I should do my best to alleviate his suffering. Even when I’d rather keep my distance.
Tyler Jorgensen, MD
Send comments to the author here.
A previous version of this essay appeared in the author’s Substack newsletter, which you can find, along with other stories and essays, at Crash Cart Campfire.
Submitted May, 2023
By Dr. Thomas Vetter
Dead Horse Point: A Dandy Spot to Rest in Peace
The Grand Canyon of the Colorado is a magnificent place. Words struggle to do the aptly named chasm justice. If my experience is an indicator, the conjoint human eye and brain cannot fathom its magnitude. I recall upon first entering the rustic, timbered lobby of the Grand Canyon Lodge, perched atop Bright Angel Point on the North Rim, I mistook its south-facing, floor-to-ceiling windows to be a triptych of trompe l'oeil paintings. I had to walk outside, onto the lodge’s sun-drenched, Kaibab limestone terrace, to convince myself to the contrary. It is ten miles across—as lucky golden eagles get to soar—from rim to rim.
Like the Grand Canyon, Dead Horse Point State Park in Utah is one of the most sublime places on Earth. It sits on a windswept, polychromatic desert mesa, 2,000 feet above the Colorado River. From its dizzying verge, easily reached via Utah State Route 313, aka Dead Horse Point Mesa Scenic Byway, you look down on a huge bend—geological gooseneck, incised meander—carved out by the same erosive force of the Colorado River.
The vista from Dead Horse Point comprises an area the size of Massachusetts. The photographs I captured one splendid autumn midday confirmed that from its highest vantage point, you can see the curvature of the Earth. This sight and perspective might have prevented Christopher Columbus’ pre-performance anxiety, plus his oceanic navigational “yips” and “twisties”—but would not have spared the indigenous peoples of the Americas from genocide.
Traveling to Dead Horse Point feels like a journey to the ends of the Earth. Dead Horse Point is one spot where I am thinking of having my ashes dispersed after I die—my end of days. Other options for my final resting place include the medieval castle ruins in Najac, France, and clothing optional Anse du Gouverneur on Saint Barthélemy in the French West Indies.
I never really thought about it—until just now—how apropos it would be to have my ashes dispersed in the far reaches of a place called Dead Horse Point State Park. I envision my three beloved daughters driving a high ground clearance, 4x4 SUV from the adjacent Canyonlands National Park, by way of an old uranium road, into the lower level of the state park. Or perhaps instead, departing one fine October morning from the boat ramp located at the end of Potash Road on the outskirts of nearby Moab, and meandering under azure skies, along the Colorado River, lined with golden cottonwoods, until the three sisters reach the monumental gooseneck in the river.
Oh! One last father’s favor. My darlings, besides avoiding any forecasted rainy day, while you are at it, lay me to rest far above the river water’s edge. I do not want to end up, the following week, floating down river, through the Grand Canyon, and into the Gulf of California—or far worse, ending up as filtered sediment in a water treatment tank managed by the Las Vegas Valley Water District.
“Earth to Earth, Ashes to Ashes, Dust to Dust”
(Nikon F3HP, Nikkor 28-50mm f/3.5 AI-s, FUJICHROME Velvia 50, circa year 2000)
Essay and Image © Thomas R. Vetter, 2023
Thomas R. Vetter, MD, MPH, MFA
To contact Dr. Vetter
Submitted by Dr. Michelle Owens
May 2023
Mental Health Care is Self-Care
May is Mental Health Awareness Month, an important month to destigmatize taking care of our minds as an act of weakness, and rather as an act of self-care.
The last 3 years have only highlighted the need for mental health awareness and normalization of caring for our minds with as much intention as we care for our bodies. The most recent survey from Medscape this year again highlighted that 25% of U.S. physicians identify as feeling depressed. Approximately 10% of U.S. physicians continue to report suicidal ideation and we sadly lose 350-400 physicians each year to suicide. This data has remained consistent over the last 3 years, which further highlights the need to focus on our mental health. After all, mental health care is self-care.
Athletes, celebrities, and fan-favorite TV shows, like Ted Lasso, have emphasized the importance of focusing on mental health as non-negotiable for being human. In the medical community, the Dr. Lorna Breen Healthcare Provider Protection Act, has written into law that healthcare workers are protected from any retaliation for seeking mental health treatment. This is huge, as it has been such a barrier in the past to many physicians needing treatment.
The amount of grief many of us have carried these last 3 years alone may warrant help from a therapist for processing and moving forward. We have all experienced tremendous loss - whether that of a loved one, loss of a dream job, loss of a pet, loss of a co-worker due to attrition, loss of childcare, loss of innocence for the world we live in, loss of trust in our government, mistrust from patients, and the list goes on. These losses are often experienced as disenfranchised grief - a grief that is not honored in the same way a “traditional loss” would be. It is often not openly acknowledged as legitimate by society and has been noted as a contributing factor to physician burnout both pre- and post-pandemic. It’s important for us to recognize the need to process all we have been through and normalize the reality that we cannot do it alone. Trained mental health counselors are crucial in caring for our minds.
As a reminder to us all, me included, you are not weak for seeking mental health treatment. All human beings benefit from therapy. Connection is paramount to our well-being, especially connection that allows us to process our emotions. We are experts at caring for others yet often do not tend to our own emotional needs.
Giving ourselves self-compassion and grace as we start to navigate and process these last 3 years is important. This is our call to action - for ourselves.
Utilize the resources available to you including some that are anonymous and free, like our own TCMS Safe Harbor Counseling program. Take what you need from where you need it. Remember we are not superheroes, we are human beings, and we need to care for ourselves as such.
Take good care of your mental health - your life depends on it.
Michelle Owens, DO
Co-chair TCMS Physician Wellness Program
Mowensdo@gmail.com
Submitted by Dr. Tyler Jorgensen
April 2023
Looking Up
At age 18, my buddy, David, and I scaled the outside stucco of a hotel in Cancun, Mexico and soon found ourselves ten stories up, lying on our backs on the hotel roof, looking at the night sky. It was a terribly stupid idea—one of many we had back in those days. But once we were up there, David taught me the major stars and constellations of the summer sky. Cassiopeia, Draco, the Little Dipper, and of course, Polaris, the North Star.
Back in Houston after our trip, I was determined to remember what David had taught me. Every night after dark I would crawl out my window (sorry, Mom and Dad!), onto the roof of our house and look up. Despite the weird purple hue from the Houston skyline and the overwhelming light pollution, I found I could still make out most of the major stars of the summer constellations. I studied my hometown stars like a textbook, and I stared at them long enough that the pattern became forever etched in my mind.
When I went off to college in rural Virginia a few months later, I found the night sky looked quite a bit different—much less light pollution, way more stars. In fact, the brightness of all these stars now visible made it harder for me to pick out the constellations. I also noticed the constellations were a bit out of position relative to the horizon at this higher latitude. But as I took time to find the north star and re-orient myself, I was soon able to match this new night sky to the one I had looked at on my roof back home so many times. Far away from home, I found a great comfort in being able to look up at the night sky and see some old familiar “friends.”
For two and a half decades now, I’ve been a stargazer. When I find myself in new places, I look up. I look for the north star. Oddly, looking up always grounds me. I remember a night backpacking in the Redwoods when a chance glimpse of part of Corona Borealis through an otherwise cloudy sky revealed to me and my same buddy, David, just which way we had been traveling.
Looking at the stars in Argentina a few years ago really threw me. There were a few familiar celestial faces to the north, but up above me and down to the south were constellations I had never seen before (nor since!). Another time outside Rome, far away from home, I remember the great reassurance I felt looking up and seeing the same old Sagittarius I knew from home.
William Cullen Bryant wrote about it this way in 1832 in his Hymn to the North Star:
On thy unaltering blaze
The half-wrecked mariner, his compass lost,
Fixes his steady gaze,
And steers, undoubting, to the friendly coast;
The metaphors from all this star talk come easily. When we feel lost in life, when we feel far from home, when we seem to have lost some of our supports or to have wandered off course, it’s important to re-orient ourselves to our north star. What is it in life that has pointed you in the right direction? Is it friends? Maybe family? Is it your home? Maybe it’s a faith tradition? Maybe it’s your personal core values, or your sense of calling or mission?
The same can be true in medicine. Do you remember your north star in medicine? What inspired you to pursue this path back in the day? What did you write about in your medical school application? Sometimes it’s hard to even think back that far! In what ways can you get back to that old north star?
I have felt lost in life and in medicine many times. I imagine we all have. Look up from where you are, re-orient yourself to your north star and get grounded again. Then move forward in the direction that calls for you.
Tyler Jorgensen, MD
Comments can be directed to Tylerscottjorgensen@gmail.com
Other works by Dr. Jorgensen can be seen at Crash Cart Campfire
Submitted by Dr. Brian Sayers
April 2023
Gratitude
This week, Holy Week, grace has been on my mind. The upstairs of our house is now a vast wasteland of empty bedrooms long since abandoned by our adult children, but on a mirror in my youngest daughter's bathroom there is still a Post-it note that says “Grace: Undeserved favor.” It only takes a few dots to connect grace with gratitude. Like grace, gratitude is the recognition of things that we have been given ̶ given to us by people we love, by strangers, by luck, by a higher power, or from the vapors. From sincere gratitude, humility naturally flows. It's just unavoidable. To recognize things have been given to us ̶ to really appreciate them as gifts ̶ is humbling. And, as so many have written more eloquently than this, and as so much research has shown, as a practice, gratitude helps make us whole, appreciative of the world and the people around us.
Each quarter, we recognize the financial donors that have helped make your PWP Safe Harbor Counseling Program possible because we do not derive funds from TCMS dues, but rather every penny of the $300,000 it has taken to operate the program had to be raised, sometimes begged for. We are indeed very grateful to our financial donors. Now five years and 1700 counseling visits in, I realize that all too often I thank the people who give money but have neglected to thank the people who have supported this program in other ways.
Belinda Clare, our TCMS CEO came to me proposing this project back in 2017 and with her passion and hard work the program has thrived. But there are so many more to thank. Those dozens of colleagues who are writers, or photographers, or poets who have contributed to our Sunday morning emails. Speakers at our symposia, small group leaders, our TCMS board of directors, and those who encourage, suggest, and even those who criticize (and not always kindly) ̶ you have all made the program what it is. I’m grateful to our counselors, Charlotte and Blaine, Claire and Josh, who have dedicated themselves to getting used to the quirks of working with physicians and their loved ones, patiently and with great skill taking good care of us. For Maryann and Chantel, for Claire and Tyler, for Michelle, and for Jenny, and for all those I will kick myself for not naming, thanks to each of you for your unique gifts and support. My heart is full of love and gratitude for all of you who care enough about our colleagues and their families to have made this program possible. We are a family, and I am grateful.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program and
Physician Health and Rehabilitation Committee
Briansayers24@gmail.com
Submitted by Dr. Cindy Lynn
April 2023
My Almost Photo with the Bluebonnets
Yesterday I went for a bike ride with my husband at McKinney Falls State Park. If you haven’t been there, it is located only a short drive from Austin. It is a beautiful little state park, with hiking and biking trails, waterfalls, and camping. We exercise outdoors most days, for both cardiovascular and mental benefits. I agree with the studies that show that being out in the woods decreases blood pressure and improves mood. I have tried meditation, and find it is a great time to plan what’s for dinner, wonder when our next vacation is, wonder why it isn’t sooner, ponder world problems, etc. I concede I may not be doing it right. For me, being in a beautiful, peaceful outdoor setting is better than any antihypertensive medicine. And yesterday did not disappoint. The bluebonnets and other wildflowers were spectacular. I consider myself an amateur photographer and stopped frequently to snap yet another photo of
a different angle of a patch of wildflowers. To be clear, I’m very amateur, we are talking iPhone level. Thankfully, my husband is extremely patient, a great quality for a spouse of a physician.
By the time we were nearly done with the ride, I decided I wanted a picture of me amongst wildflowers. I had talked myself out of it earlier, because I thought it seemed rather silly for a 60+ year old. I think it’s great for small kids and even dogs, but old gray hair adults? So after deciding game on, I didn’t want to sit in a patch and damage any flowers. And my knees are also 60+ years old and not great at kneeling, so I got creative and decided to sit on a rock wall and have succulents and flowers in the foreground. I spotted the perfect site, handed off my phone to my husband with instructions on the shot I had in mind, and carefully tip-toed into position without damaging a single flower. I looked down, and there was a snake coiled on a rock about one foot from my foot. My first instinct was panic. But my son who has a degree in wildlife biology has told me multiple times not to freak out, most snakes are not poisonous. So I took a deep breath, and considered staying for the photo. The snake started to move, and I realized it could be a coral snake. I’m not saying it was; I’m saying I’m not knowledgeable enough to say it wasn’t. Then I realized how ridiculous I would sound explaining to the ER physician that this 60+ year old was trying to get a picture in the bluebonnet. So I hightailed it out of there faster than the Easter Bunny. I would like to say that I didn’t stomp on any wildflowers, but I can’t swear to that.
After my blood pressure came back down to pre outdoor levels, I realized how grateful we are to live in this beautiful area, and have such a spectacular wildflower display. I will continue to appreciate the flowers. I hope you get a chance to experience this splendor of nature. Just watch out for the snakes. And if I learn new skills, I might Photoshop me onto that rock wall
Submitted by Dr. Michelle Owens
March 2023
Grace & Flexibility
In reflecting back on the last few years, I am struck by an unusual theme that transcends both my personal and professional lives.
I met two new friends along this journey, although it wasn’t so clear at first.
Grace met me at a time that was dark, heavy, and dripping with overwhelm. Navigating caring for patients at the end of their lives in the midst of a pandemic involving a virus we were still learning about with two babies at home and bumbling through learning what the term “sandwich caregiver” meant as someone close to me slowly revealed that she needed more support than she’d like to admit.
Grace gently tapped me on my shoulder when I found myself drowning in the juggles and struggles of it all. She whispered, “Be kind to yourself, you’re doing your best in an unimaginable situation.” I didn’t listen at first. I had always been able to handle whatever came my way with a smile on my face ̶ many never knew of some of the struggles I had faced and overcome in my life. However, Grace persisted. She showed up daily at the most difficult of times. She felt like a warm embrace in the midst of a cold and cruel world. Why was all of this happening? A question that often echoed in my mind. She quietly shushed those thoughts and offered a safe space to reflect and validate that I was not alone in my experience.
Grace reminded me that I had been through tough times before and persevered. She reminded me of my strength, my resilience, and my ability to work through whatever came my way. She encouraged me to treat myself the way I treated my children. For I too am a child still learning life and all its complexities. I listened intently. I found myself longing for more and so deeply appreciative for what she had shown me. I asked her to stay, and she reminded me that she had always been with me.
Flexibility crept in when I least expected ̶ during the joys (and stresses) of parenthood. I never imagined how much uncertainty came with having a baby. As a physician couple, we figured we knew what we were getting ourselves into (enter Grace once again). Flexibility arrived with the energy of a toddler learning how to climb and jump on the couch for the first time. To be honest, I wasn’t a fan at first. I’ve always been a planner ̶ thinking of the 6th and 7th step ahead at times. Children have a way of keeping you in the present moment, a beautiful gift. So, when Flexibility showed up, I was not as welcoming. Why now? I pondered. My plans have worked so well up until this point, or so I thought.
Flexibility leaned in with curiosity and posited, “But imagine if you just allowed what is meant for you to be?” Without any control of my own? I replied. Nah, I’ll pass. I admit Flexibility remained flexible – shape shifting into various forms with the best of intentions. Bravery, vulnerability, and hope were a few of his disguises. I began to listen over time like a child who is now interested in learning how to read. Realizing that we have always been flexible and yet somehow flexibility seems to get locked away the older we become. I started searching for flexibility in the little things and normalizing its existence in my life. No longer a threat to my plan, but rather a welcomed friend on the journey. I began to imagine rewriting my narrative to be one that reads of both haphazard plans and amazing surprises with flexibility interwoven throughout.
These unexpected friends met me at a time when I needed them most, yet had no idea myself. Grace continues to lighten my days, warm my heart, and keep me from falling into the dark. Flexibility encourages my growth in accepting the uncertainty of life and propagates peace of mind that I’ll be okay no matter what comes ahead.
I am looking forward to more new friends in the years ahead. Grace and Flexibility have certainly been some of my favorites.
Michelle Owens, DO
Co-chair TCMS Physician Wellness Program
Mowensdo@gmail.com
Submitted by Dr. Brian Sayers
March 2023
Hospital Meatloaf, Yoda and Letting Go
Not too long ago I was struggling over a plate of meatloaf in the doctor's dining room. Fortunately, the table conversation was better than the food. Somehow it turned to how early career doctors tend to mirror the culture and clinical habits from their training program and how it often takes years to unlearn habits that don't serve us well in the long run, particularly habits related to work-life integration. Training programs are more sensitive to this now, but the economics of medicine are an inescapable reality we must navigate, and in our counseling program I hear of the struggles that some physicians experience to sustain meaning and joy in their work and healthy relationships and peace away from work. Students are now referred to as “learners,” and I pray that most of what they learn will serve them well after training, but it makes me wonder if we should all eventually progress from learner to “unlearner” and whether both states aren’t valuable in their own way.
There is much in popular psychology literature about unlearning. J.R. Rim famously noted, “Intelligence is what we learn, wisdom is what we unlearn.” Even the icon of pop culture wisdom, Yoda, of Star Wars fame, advised Luke that in his spiritual path forward, “You must unlearn what you have learned.” Ask any therapist – unlearning is foundational to new beginnings.
I revisited Richard Rohr’s, Falling Upward, recalling that a theme in much of his writing is about unlearning. As he puts it, “All mature spirituality in one sense or another is about letting go and unlearning.” Rohr holds that life really consists of two phases. The first phase is the egocentric phase, what he calls the “survival dance,” wherein the emphasis is on developing identity, success, security, and image cultivating. This is not to say this phase is bad – it is all necessary, and though there are many struggles, most often great good comes with it along with important learning, experience, love, and joy. Rohr holds that the ultimate task of this stage of life is building what he calls “a proper container” that will be needed in the second phase of life.
In the second phase of life, those learned survival and identity tasks fall into the background, habits that supported them are questioned – unlearned – and the container created earlier is emptied then filled with awareness and appreciation for deeper meaning. Things that the soul thirsts for, that were missing earlier, can now be fully discovered. It is a time of “letting go.” Rohr calls this the “soul dance,” Zen masters call it seeking the face you had before you were born. Some religious traditions call it being reborn. Some note parallels with the common literary structure of the hero’s journey. In any sense, it is a shedding of baggage accumulated earlier for something better. It can occur subtly or abruptly and depending on your early life experience it may show itself at any age, or in some, it may never become evident.
There's no good story, nor anything profound in all this, just an observation made over a half-eaten piece of meatloaf. The thing that we call our life journey may be a journey to the true self, to spiritual wholeness, or to God, but like any hero’s journey, it is always a journey home, the home your soul longs for. At some point, young or old, most will find themselves as lost as Dante: “Midway on our life’s journey I found myself in a dark wood, for the right way was lost.” It will be wise to remember at that point the importance of unlearning, of letting go. It is in the homeward part of that journey where rather than paddling furiously, we might just drift in the current and finally look up to enjoy the scenery that was there all along. And on the long journey home, as Mary Oliver urges, “If you suddenly and unexpectedly feel joy, don’t hesitate. Give in to it.”
Brian Sayers, MD
Chair, TCMS Physician Wellness Program and
Physician Health and Rehabilitation Committee
Briansayers24@gmail.com
Submitted by Dr. Brian Sayers
January 2023
Courage
Last week in this space Dr. Prentice wrote of the last few years with ALS in a courageous and inspiring essay. As it happens, in the weeks leading up to that I had been with two longtime friends who are both fighting health challenges against great odds, each in the two-front battle of resistance and acceptance. Their courage has made me reconsider courage in all the forms that we see it and what an admirable quality it is. As much as I admire their courage, it occurred to me that more often there is courage that is less grand and often hidden, but it is there nonetheless, and how in many ways it takes courage − daily courage − to practice medicine.
There are many forms of courage. There’s the kind we usually think about, that involves soldiers or first responders. Courage that involves protesting injustice or discrimination, or calling out those in power who misuse their office. Courage that goes into danger to help the poor, the hungry or those with no voice. Courage we have recently seen our colleagues exhibit on the front lines of a deadly pandemic. This is obvious courage. But far more commonly there is a silent, hidden kind of courage that each and every one of you reading this exhibit, most likely in ways that even you are not aware. There is great courage in caring for patients, in opening every exam room door, every operating room door. Courage in caring for people with complex diseases when the risks are high and the outcome far from certain. Courage even in the most casual, seemingly simple medical encounter where we all know things can unexpectedly go terribly wrong. It is a kind of courage that is just assumed we carry with us, and carry it we must, even when it often goes hand-in-hand with self-doubt, even fear, fear that even the courageous should admit to as they face it down. Brené Brown calls on us to redefine courage, arguing that, “vulnerability is our most accurate measure of courage… it is willingness to show up and be seen when you can't control the outcome or what other people think.”
We don’t leave courage at the door when we go home at night. Few things require more courage than parenting, where the stakes are high and where too often uncertainty exceeds even that which we experience at work. Uncertainty about how we parent and the things we do, things seemingly insignificant at the time that can intentionally or unintentionally change the trajectory of our childrens’ lives, for better or worse, in ways only seen and realized years later when we know them as fully formed adults. There is courage in long-term relationships, in being seen and loved then giving it back through the years, in seeing loved ones not just in joy but also through life’s inevitable struggles. As David White noted, “Courage is what love looks like when tested by the simple everyday necessities of being alive…From the inside, it can feel like confusion, only slowly do we learn what we really care about, and allow our outer life realigned in that gravitational pull…On the inside we come to know who and what and how we love and what we can do to deepen that love; only from the outside and only by looking back, does it look like courage.”
Yes, I have greatly admired the courage I have seen in my dear friends facing mortal challenges recently, and I’m inspired by it, but I am also inspired by less conspicuous acts of courage that I am coming to realize surround me as I go through my days at work and with my family. Courage is not the absence of fear, it is perseverance, even passion, in the face of it. Look around at the fearless way you and your colleagues go through your days, even when there is doubt, and all the good you bring into the world as you do it. Appreciate it for what it is. Courage is inspired by, fueled by, made fearless by, our love for the people and calling we hold in our hearts, for the love of life itself.
Brian Sayers, MD
Chair, TCMS Physician Wellness Program and
Physician Health and Rehabilitation Committee
Briansayers24@gmail.com
Submitted by Dr. James A. Prentice
January 2023
When a Delayed Diagnosis was a Blessing
In early 2014, I began to have muscle twitches, which by spring were severe enough to awaken me at night. These were mainly in my thighs, and I associated them at first as occurring after doing yard work at our one-acre property on Lake LBJ. In May 2014, I made an appointment with an old friend, a neurologist who had cared for my parents and my brother-in-law and my wife, and whom I had known for more than thirty years. After a neurological exam, it seemed most likely that at 77 what I was experiencing was not too uncommon for my age. A couple of years later, after 2016, another consultation took place when twitches, or “fasciculations” had become more common and were sometimes accompanied by muscle cramps. Again, I was carefully examined and it was felt that at age 79, I was likely experiencing symptoms of an aging neurological system. A couple of more years passed, and in September 2018 I again made an appointment with my friend as I was having trouble buttoning my clothes and doing other simple tasks with my hands. Another thorough neurological examination was performed. At this point it was not felt to be ALS, but the diagnosis was unclear, and we decided I should return for an EMG of my upper extremities, which I did in the following month. A diagnosis of bilateral ulnar neuropathy was made and I was referred to an orthopedist, who transposed my ulnar nerves at the elbow in November and December 2018. About the first of February 2019, the hand therapist who had been working with me told me that I was getting worse rather than better, and I should return to my neurologist.
A consult with a neuromuscular neurologist in February 2019 gave the diagnosis of ALS, a devastating diagnosis which has no cure and invariably ends in death. The prognosis is a lifespan of two to five years after diagnosis, and the course of the disease is constant loss of motor function and independence. Because of this, the patient usually begins to curtail activities in which he or she is involved. A trip in March to Mayo Clinic, where I had served on the staff in the 1970s, confirmed the diagnosis.
If I had known in 2014 that I had the early signs of ALS, I am sure I would have sold our lake house several years before I did, and I would have resigned from several boards on which I was still very active, including the Texas Medical Association Foundation, where I served as Treasurer, St. David’s Foundation, University of Texas Foundation, on which I served as President, Austin Symphony, where I served as Vice President for Individual Gifts, and the University of Texas College of Natural Sciences Advisory Council, on whose Executive Committee I served, all of this during the five years after I was symptomatic but undiagnosed. By being ignorant of my diagnosis I continued to enjoy those activities for several years that I otherwise would have been denied by early resignation.
Early on, ALS can be very difficult to diagnose, and like many complex diseases that develop gradually, only time and hindsight bring clarity. In my case the diagnosis of ALS was not made for at least five years after symptoms developed. Since there is no treatment available, timing of the diagnosis did not affect the course of the disease and the blessing was that I had five years of worry-free time. In those years, we took a cruise to Scandinavia and St. Petersburg, Russia, went on a Danube River cruise from Budapest to Germany, we visited England again, and traveled to Spain for the first time in forty years. The delay in arriving at this elusive diagnosis allowed me to continue to enjoy community activities, time with grandchildren at our lake house, and other activities I probably would have curtailed. I am grateful that my old friend the neurologist did not make the diagnosis early on. It allowed me those extra years of normal activity.
James A. Prentice, MD
gasman1937@yahoo.com
TCMS President, 1996
Transcribed by Alexandra Saenz, November 28, 2022
Submitted by Dr. Christopher Chenault
January 2023
Joy in Community
I am reminded, as this new year starts and 2022 has passed, how quickly it all seems to march right on by. As I see time passing, I am reminded of all the events that I have participated in and all of that which will not come again. I realize that most of what I remember are the people. Yes, I remember kindergarten and elementary school but mostly I remember my teachers and some of the students. I remember some things about high school including some sports and band but mostly I remember my fellow students, the ones I played with, and ran with, and dated. Some of those I am still in contact with through our organization of periodic reunions. There was college with little remembered glimmers of some of the classes but the friends who enlivened and enlightened my days are most important memories. Time has passed and so have some of them and I miss their stories of family and activities. Medical school, which I enjoyed more that most events of my life, left little time for more than a couple of friends from the class, yet enough to find my love that has tolerated me now for 58 years.
In Austin for 51 years, I found that I had grown some and entered into more relationship building. I had a great group with which to practice and exchange ideas and was involved with the community of physicians through many committees and governance appointments. The exchange of ideas, including moral musings, has enriched my path along the way. In retirement, I have come to understand the necessity of replacing relationships of office staff, hospital nurses, and administrative friends. I have actually purposefully engaged in lunch outings, church small groups, and choir activities to add to my community. In that way, I believe I have been enclosed in the community with new ideas, opinions, understanding, and feelings that stand as guideposts for a life enriched. They help me up when things seem down and keep me close with their warmth.
In this era of senior isolation and public loneliness it probably should not be surprising that there is physician angst as well. Being a relative top dog in the hierarchy of social positioning as they say, “It can be lonely at the top.” Not to mention other stresses of the profession. A lot of times there is disappointment, the distance between what we expect or hope for and what life really is. Where our dreams are crushed by reality. As purposeful as we have been to get into this profession, we should also work actively to create community that is not just social but supportive. I don’t believe that is a passive phenomenon. Certainly, in my case, it has been an active adventure. That is where I find joy.
If you look up the definition of joy it invariably includes happiness. But joy is not just happiness that you got a new puppy. Joy is entwined with purpose. The purpose to be involved in the world. The purpose to understand your position in making the world better and your patients healthy. And, knowing that your purpose is also rapped up in appreciating your community and knowing its value. That you know that you have the talent to meet the challenges and overcome them. And that you are involved in a life that is lived somewhere between unrealistic expectations and disappointment. That you will, absolutely, work to know your purpose in life and find valuable relationships and joy.
Dr. Christopher Chenault
cchenault@austin.rr.com