Revisiting Oahu

You wouldn't think of going to the mountains without coming home with a fern lei. That's it, I remember, that's what going to the mountains meant. Go up and fashion yourself a lei, and wear it, and feel it, and smell it, you know, be imbued with it. That's the feeling I got when going up the Pali. You know that feeling, being part of it, because isn't that what love is, really touching it. Then it means something.

- Rachel Kinney Johnson, 1964 (via the Bishop Museum)

We loved the north shore of Oahu, Hawaii so much last year that there was no discussion about where we'd go for Spring break this year. 

The trip started poorly, with our evening flight delayed by five hours. When we landed in Honolulu well past midnight, the rental car company was closed. We ended up taking a taxi across the island to our vacation rental and eventually pulled onto a dirt drive at 3 AM, following the homeowner's directions to "the house with the green roof and giant lizard in the yard." Feral chickens squawked in the bush, the kids dozed in the back of the van, and Pete and the taxi driver roamed the night with their iPhone flashlights in search of the lizard landmark. Eventually they found a house whose lockbox opened to the code we were given. (Days later, Saskia discovered overgrown stone slabs set into the lawn, in the shape of a massive reptile.)

By this point I was bitterly second-guessing traveling four thousand kilometres with four kids, but the next morning I pulled back the shutters to this:

Hawaii is just so life-giving. Everything feels ripe. That warm water keeps rolling in. There are thick glossy leaves on the shrubbery, and flowers on the roadside hedges. We saw sea turtles and humpback whales without looking for them. Nothing is subtle or muted. I hadn't realized how faded I'd been feeling. Everything around me was undeniably good. 

For the next fifteen days, we cycled through our usual activities of daily living, but with the luxury of doing them unhurriedly, and with bare legs: we ate, we slept, we read. In between, we enjoyed the local attractions. We ate at dodgy shrimp trucks, snorkelled almost daily, and visited Pearl Harbour. 

Some photos below. I restricted myself to a dozen. 

Top | Hiking Makapu'u Point Lighthouse trail. Leif and I made an extra climb to check out the WWII bunkers.
Second | Foraging for coconuts in the yard of our vacation rental. Photo angle a result of me lazing on the lawn post-margarita. 
Third | Pulled over near Waimea Bay one evening to watch whales. 
Bottom | Tidal pools near Hau'ula. Ilia's holding a little treasure in virtually every picture I took this vacation. 

Snorkelling reminds me so strongly of medicine: the mysteries just under the surface, the privilege of listening in, and the distant noise of the outside world. It's like auscultating a chest.  As I snorkelled with Saskia and Leif at Hanauma Bay, I suspected that the experience would make my life's top five.  It's such a pleasure to share activities with my kids where the enjoyment is mutual, after years of either resigning myself to experiences that were heavily geared to their amusement, or trying to pacify them while they endured those meant for mine. 

Top | Hanauma Bay, a snorkelling destination formed by a volcanic crater with one side long since slumped in and flooded by the Pacific. 
Second | Saskia, waiting for the shrimp truck to serve up lunch. Thirteen and an elusive portrait subject. 
Third | Exploring Ko'olina with Ariana. Eight and a very accommodating portrait subject. 
Bottom | Evening walk along the beach near Laie.

Top | Watching humpback whales along the Makapu'u trail. She'd just learned about them in preschool, and there they were, dozens of them, so in her mind now they're as common as squirrels. 
Second | A rogue wave promptly washed over the turrets once Ilia climbed in, and she found herself in a bath tub.
Third | Leif and Ariana, lithe lightweights, attracted an audience of envious kids whenever they scaled a tree or rope swing.
Bottom | Tidal pools near Hau'ula. 

Bonus parent selfie | Pete grew a beard, because by the time we realized that the taxi driver who called insisting that we'd left a small bag in the taxi at YVR was right, and that it was Pete's toiletry bag, we were in Hawaii. Pete saw fit to buy a new toothbrush but not a razor. 

When we got back, a colleague asked earnestly if I'd been able to do some soul-searching. I did not. With four kids, much of the time I felt like a chaperone on a class field trip, I told him cheerfully. For fifteen days, my most pressing concern was sunscreen application. It was quite glorious. 

Ending things


For years, I've been working out of a clinic just a few blocks from BC's biggest hospital, in the heart of Vancouver. The specialists I refer to are stacked a dozen layers high in the medical office buildings just down Broadway. At lunch, you can strike out in any direction and find a satisfying $8.95 lunch in minutes: congee, bagels, sushi, ramen. The neighbourhoods hold heritage homes with porches and wildflower gardens. There's traffic and sirens. It's a vibrant hub.

In December, the health authority moved the refugee clinic across town, further east, to the city outskirts. It's far more accessible to patients, most of whom don't live in Vancouver. It's made my morning commute ridiculously complex. Everything's shrunk a little - the team, the exam rooms, parking options. There's Tim Hortons or Fresh Slice for lunch. 

*   *   *   *   *

The patient is a young Iraqi mother, and I ask her how she's doing. She speaks so quickly that the Arabic interpreter can't keep up. Suddenly the patient stops talking and digs in her purse for her phone. She stabs at the screen. She's going to show me a photo, I'm sure of it.

This often happens in the clinic, and I never know what I'm going to be presented with. More than once it's been an album of toilet bowl contents. Sometimes it's a rash. Once it was a picture of the patient in his previous life, standing in front of a grand home with an orange grove out front. And sometimes patients show me something terrible: third degree burns sustained during torture, or a crucifixion. 

She passes me her phone, and I'm looking at a scene of dead bodies strewn across a living room. I look at the picture like it's my job, because it is. It's part of caring for this patient. Something doesn't make sense, and I automatically do a finger spread, zooming in, only to realize that the bodies are mutilated. I hand the phone back to her, and she looks grimly satisfied. The visit ends soon after. She doesn't need anything else today. 

When I see her later in the waiting room, she blows kisses at me with both hands. 

*   *   *   *   *   

Last year I came across a GTD (getting things done) principle that I found particularly interesting. The idea is that we lose productivity because we spend too long on one task before moving on to the next. That is, the problem isn't necessarily that we don't have the discipline to start a project, it's that we find it extremely difficult to stop whatever we're currently doing.

The context was of discrete, minutes- to hours-long activities: I don't go to bed on time because once I dive into work emails I can't stop. I don't get around to the laundry because the quick kitchen tidy evolved into a pantry reorganization. 

But I wonder if this applies on a much larger scale. Perhaps too often we continue with our work, say, because it's the comfortable default, and we've built up a momentum that would take too much effort to interrupt. 

Maybe we need to be better at ending things in general. 

*   *   *   *   *

I've worked at the refugee clinic for over ten years. Tuesday was my last day. 

Fewer patients, more friends

On the face of it, a day at the clinic seems very social. I see patients, one after the other, from nine until four, with a break for lunch. Most of my patients I've known for a while now. I get caught up on their their lives - school, family, work. "How are your spirits these days?" I ask almost every time, patting my right hand over my heart, using the most effective cross-cultural mood elicitor I know.  It doesn't get much more personal than this. It's just me and the patient, our knees almost touching, in a small exam room with the door closed and an interpreter behind my left shoulder. 

I leave work after a day of this, drive the five minutes to pick up my three-year-old from preschool, and begin the commute home to Deep Cove. Suddenly I'm ravenous. I ask Ilia what's left in her lunch box and she hands me some carrot sticks and cubes of cheddar from the back seat. Ten minutes later, around Grandview and Nanaimo, I bottom out, utterly exhausted. The idea of having to shepherd four kids through meal time and bedtime chores after this feels impossible. 

If Pete's not away on business, I come home to sous-vide salmon and curried cauliflower, and we divide up the after-dinner work. If he's traveling, we eat the lasagna my thirteen-year-old put in the oven when the big kids came home from school. Then I oversee homework and lunch making, brushing teeth and laying out tomorrow's school uniforms.

I cut corners. I pick the bedtime book with one sentence per page. I move up the bedtimes of the kids too young to notice. I want the noise to stop, even the singing. They're getting shortchanged, I think, but  I'll make it up to them later in the week.

For years, I've seen patients Monday, Tuesday and Friday. Mid-week I'm home with my youngest, grateful that Deep Cove is off the beaten path. We can't see our neighbours from our place. Looking up from the laptop now, I see a stand of waving cedars, the gunmetal grey winter waters of Indian Arm, and the dark bulk of Belcarra rising from the opposite shore. The solitude is perfect. No play dates, thanks. No community centres or meeting up for lunch, either. I might be up for something on the weekend, but it'll take until Saturday evening to recover from Friday's walk-in clinic.  I need a respite from human contact, and I prefer as much solitary time outside the clinic as four kids will give me. 

Where I live. And why I live here. © Martina Scholtens. Deep Cove, BC. 

Where I live. And why I live here. © Martina Scholtens. Deep Cove, BC. 

I forget, though, that seeing patients isn't at all a substitute for catching up with friends over drinks.  At the clinic, the topics of conversation, the confidences, the complaints - they're all one-sided. It often strikes me that family physicians are professional friends: non-judgmental, accessible, reliable, skilled listeners and excellent secret-keepers. There's pleasure in seeing patients, but really, it's business. 

If you had told me that I'd have four kids and eight hundred patients, and feel lonely, I'd never have believed you. But my work drains me to the point that all of my spare time is spent trying to recuperate. Pete would love to have people over more, and vacation with other families. I always imagined a noisy, boisterous home with friends and family coming and going, but with my work commitments, I don't have the psychological reserves to make it happen.

Then I had an epiphany. Clinical work exhausts me with the people lineup, and my social life is extremely thin because I need stretches of alone time to recharge from work. I ought to reverse this. I need to implement more solitary time at work, and more people-time in after hours. 

I've started on this.  In October I gave up my Friday clinic. I've worked Fridays since I finished residency in 2003. Now I finish the week with administrative work and other projects instead, alone in my organization's secret library. Just me, a row of computers with access to our clinic's EMR, shelves of journals on paediatric nutrition, and a yellowing poster on Boolean operators. I can do this very happily for much of the day, and still have the energy to go out with Pete at night. It's been life changing. 

I knew from residency that I couldn't see forty patients a day, five days a week. I find it hard to do half that. Maybe it's that my patient demographic, refugees with trauma histories and multiple barriers to care, are particularly challenging. Or maybe it's the demands of four kids. Maybe our clinic needs to use a different model of care. Maybe an office with some natural light and a view of the North Shore Mountains would help. There are probably other changes I could make to bolster my psychological fortitude and soldier on, even thrive, in this setting. But for now, I've reduced my work hours devoted to direct patient care.

Three months in, and no regrets. Before, I felt like I spent everything at the office. Now I've got this feeling of having a bit of pocket money. There's the promising jingle of spare change.

crossposted at www.mothersinmedicine.com

Current plan: work until 75, then die.

My doctor is so old that it crosses my mind, often, that he might collapse right there in front of me and I’d have to resuscitate him in his own exam room. He's in his eighties. Sometimes when I'm talking he drops his chin to his chest and closes his eyes. I can't tell if he's resting or thinking, but just when it's getting unnerving he'll straighten up and offer a relevant reply. He takes a lot of vacation time, but when he's in the office, golden with an Arizona golf tan, it's clear that he's enjoying himself. "I'm going to practice as long as they'll let me," he told me once.

Turns out he's part of a substantial cohort. Pamela Fayerman's article "How old is too old when it comes to physicians?" in the Vancouver Sun notes that "there are 1,724 doctors over the age of 65 practising in BC, including 174 between the ages of 75 and 79, and 90 aged 80 and over." According to the article, Dr. Ailve McNestry, deputy registrar of the College of Physicians and Surgeons of BC, cites these as the reasons doctors work past typical retirement age: "[T]hey derive much satisfaction from it, their identities are wrapped up in their professional lives, and they need or want the income." 

I've always planned to work well into my senior years, too, as does Pete. The idea of retiring at 60 or 65 doesn't appeal to me in the least. Medicine's interesting and collegial, and I never doubt on the drive home that I've done worthwhile work. When our financial advisor asks when we plan to retire (and I found it very disheartening that we began to discuss this at our very first visit, when I was barely in practice), and we tell her that we plan to just gradually wind down as we need to, it's clear that's not the answer that she's looking for. She pauses politely and says, "For the sake of argument, let's assume you retire at 65. With your current RRSP contributions . . . "

But then I read the best thing I've come across in a while, and it changed my mind about working into my eighties, because I came around to the author's conclusion that I only want to live until my mid-seventies.  I read "Why I hope to die at 75" by Ezekiel Emanuel, an oncologist and bioethicist, in The Atlantic.  

His line of thinking, roughly, is this: Americans are obsessed with cheating death and extending life, and overlook the costs of age-related disability. We (because I don't think Canadians are all that different in this respect) pull out all the stops to maximize the quantity of life, while ignoring its quality. He's not advocating for suicide or euthanasia - in fact, he's actively opposed to both - but proposes that at a certain age we refuse efforts to extend life, be it by screening for prostate cancer or treating pneumonia. 

He makes the point that "over the past 50 years, health care hasn't slowed the aging process so much as it has slowed the dying process . . . [T]he contemporary dying process has been elongated. Death usually results from the complications of chronic illness - heart disease, cancer, emphysema, stroke, Alzheimer's, diabetes." 

He settles on the age of 75 as the ideal life expectancy because typically at that age one has made their contributions to society, raised their children and met their grandchildren, but mental and physical decline has not yet picked up enough momentum to become debilitating. 

Both of my grandparents died earlier this year, in their nineties. For the past decade, whenever people asked about them I'd answer, "They live in a little condo in New West," and I'd silently correct myself: "They're dying in a little condo in New West." It was awful to witness their deterioration.

And yet, no one questioned that Oma's kidney infection should be treated. Except the doctor in me, very quietly, feeling like a heartless pragmatist. "She's going to die of something - why not this?" I thought (and said, but only once, and not to Oma). My grandparents gave up their classic Dutch plates of cheese and sausage, which they'd enjoyed their entire lives, in their eighties, because their doctor warned them that their cholesterol was high. When Opa had a suspicious chest x-ray at 93, no one thought twice about organizing a bronchoscopy. And even with a granddaughter urging them to organize a DNR, Opa's final hours involved an all-out resuscitation attempt on the living room floor of that little New West condo. I wish their doctor had had a conversation with them ten or twenty years ago, ensuring that they understood that they had the choice to decline medical intervention. Maybe they wouldn't have chosen anything different. 

Besides Emmanuel's practical suggestions regarding curtailing investigations and treatments at a certain point in one's senior years,  I appreciate his ideas around stepping back and considering one's life and its purpose:

"Many of us have suppressed, actively or passively, thinking about God, heaven and hell . . . We also avoid constantly thinking about the purpose of our lives and the mark we will leave. Is making money, chasing the dream, all worth it? Indeed, most of us have found a way to live our lives comfortably without acknowledging, much less answering, these big questions on a regular basis.

But 75 defines a clear point in time: for me, 2032. It removes the fuzziness of trying to live as long as possible. Its specificity forces us to think about the end of our lives and engage with the deepest existential questions and ponder what we want to leave our children and grandchildren, our community, our fellow Americans, the world." 

I've never been one to think much beyond the next five or ten years, partly because it's difficult to plan for a future that could extend to age 75, or 85, or, given my family's outstanding longevity, more than 100. If I'm gunning for 75, things become more concrete and planning becomes a whole lot easier. For the first time, I feel excited at the prospect of mapping out my remaining (35, God willing) years.  

But then I watched "Elaine Stritch: Shoot me."

It's a 2014 documentary on the Broadway legend, in her late eighties and still working, on 30 Rock and doing live shows. She was mesmerizing - smart, funny, and poignant, especially with respect to aging.

She was fortunate - and unusual - in that she lived a very rich life until the very end, and then died in her sleep. Still, the idea that she might have resolved to die by 75 seemed ridiculous, even morally repugnant. I have to remind myself: her story is anecdotal evidence, and she's an outlier.

And so my current plan is this: to practice medicine into my seventies, part-time, and then to reject any efforts to extend my life past 75.  

The count-down is on: after my annual flu shot this week, thirty-four to go.

Wild blueberries on Mt. Seymour


Forget the PSL. The true harbinger of fall is the wild blueberry crop on Mt. Seymour. 

We go every year, several times, in late August and September. See previous posts here and here.  Pete thinks I shouldn't advertise this activity quite so freely - why jeopardize the solitude and loaded bushes? - but our last visit there was no one there but us, save a security guard watching over bundles of film cables snaking off into the bush. 

The berries are small and tart. They're fantastic in pancakes with maple syrup, and that's where they all end up, if they're not consumed by the fistful on the mountaintop. 

It wasn't all dappled light and organic snacks. There were indignant screams by the three-year-old when her older sister had the gall to head down the path first. It's not an unfamiliar scene these days, so let's mark that for posterity, too:

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No bugs, no bears, but the crop was about done. That's it, until next year. 

Real beaches have conifers

We didn’t make any elaborate summer vacation plans this year. We live in a seaside village. Why leave the Deep Cove beaches and popsicle shop during a glorious Vancouver summer? Let’s wait for that grey wet stretch between October and March, and then consider skipping town.

Pete’s parents came out for two weeks at the end of August, and we did jump over to Parksville (on the east side of Vancouver Island) for five days. I love Pacific Northwest beaches. I’ll take pinecones and grey moody waters over hot white sand and palm trees three days out of five.

Deep Cove has mountains hulking over it and short rocky beaches. There’s nothing subtle about it. Parksville has sandy beaches that stretch on forever, and discrete coastal mountains on the horizon. It’s very demure.

We rented side-by-side cabins for us and the in-laws. The kids rode bikes and collected sand dollars. My father-in-law mastered Instagram and I read Emily Carr. We ate at our favourite Indian restaurant, watched the salmon run, visited Cathedral Grove in the rain and hopscotched over to Hornby Island for an afternoon. 

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It was Emily Carr's The Book of Small that I had with me, in which she writes about her childhood experiences in Victoria in the late 1800s. It’s a delightful read, remote enough to be fascinating and current enough to be recognizable. 

“The waters of the Straits were icy. Occasionally we were allowed to put on white cotton nightgowns and go bathing in the sea. Your body went down, the nightgown stayed up, icy cold bit through your skin. At the first plunge you had no breath left; when it came back it was in screeches that out-screamed the seagulls.”
- p 104

“I was a very small girl when the business men of Victoria chartered a steamer and . . . made a tour of Vancouver Island. It took the boat, the Princess Louise, ten days to go all round the Island . . . Father was overwhelmed by the terrific density of growth on the Island. Once when they were tied up for three hours he and another man took axes and tried to see how far they could penetrate into the woods in a given time. When the ship’s whistle blew they were exhausted and dripping with sweat but their attack on the dense undergrowth scarcely showed. Father told of the magnificent trees, of their closeness to each other, of the strangling undergrowth, the great silence, the quantity of bald-headed eagles. . . . Great white owls flew silently among the trees like ghosts, and, too, they had seen bears and whales.”
- p 109

Reading about her own pleasure in these very woods and waters underscored my own. 

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Above left | Cathedral Grove.
Others above | Salmon run at Stamp Falls Provincial Park. See the little guy that didn't make it, on the ledge? There's a parable in there somewhere. 
Below | Tribune Bay, Hornby Island.

We've been back a few weeks, and it's that crossover time of year when the burgeoning front hall closet has boots and flip-flops, sunglasses and toques. The kids are back in school (Grades 8, 5, 3 and preschool), we're into our annual fall surge of refugees at the clinic, and Pete's putting in a tonne of fourth quarter traveling.

But if we're returning to routines, so is everyone else - which means that with summer's end, Deep Cove beaches are handed back over to the locals. 

Toby

This family has never had a pet. We have had some unsatisfactory substitutes.  A few years ago I ordered one of those self-sustaining enclosed ecosystems developed by NASA, where shrimp and algae and bacteria live in perfect harmony, forever, in a sealed glass globe. As I was describing it to the kids on the way home from school, Saskia (then 9) interrupted me with, "Mom! What you're telling us, is that you got us a pet!" The depth of emotion in that exclamation made me feel quite terrible. When the shrimp arrived, I wondered why they were pink; turns out they overheated in transit, and the colour transformation from greyish brown was the same phenomenon one sees when they're sauteed in butter and garlic.

A couple years later we got a Roomba, one of those robotic vacuum cleaners. The kids watched the demonstration video with me.  As a fleet of three Roombas hummed down a hallway in formation, Leif said reverently, "This is better than Planet Earth." 

We agreed we'd get a dog once Ilia was out of diapers. But then Pete and I, who've never had any difficulty making decisions together, could not settle on a breed. I like my dogs big and dignified. Pete likes a dog that can fit on your lap and makes the tiniest poos imaginable. A few times we tried to compromise on something mid-sized like a miniature Australian Shepherd, but we were both too resentful.

So we got a kitten. 

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I thought I'd find a free kitten in the classifieds. It doesn't work that way anymore. Kittens aren't free, at least not west of Chilliwack. They're not exactly sold, either; you'll get flagged if you post a pet in the "for sale" section of Craigslist. They're under "community," and they're available to be "rehomed" or "adopted" - but for a fee. They're $50, $100, more, and they go like hotcakes. Finally I found a litter for $45 a piece, in Abbotsford, that had one kitten remaining when I called an hour after the ad was posted. We'd wanted the experience of picking a kitten from the litter, not taking the leftover. I put it to the kids. We set off for the Valley.

The kitten was a tiny five-week old tabby that had been orphaned and bottle-fed. The kids were instantly smitten. No question - this little guy was moving to Deep Cove. 

His name is Toby, and he's got the undiluted affections of four kids directed at him, which he doesn't seem to mind. Ilia slings him over her arm like a purse, and he hangs there resignedly, front and back halves stretching down almost to the floor. He's figured out that Leif's bedroom door is the one that won't quite click shut, and in the night he'll body slam it open and curl up on Leif's wool blanket. He waits at the top of the entry hall stairs when the kids come home from school, eager, like a dog. 

Pete and I were out to dinner a few weeks ago and our conversation turned to meta living. I was saying that a life preoccupied with how one ought to live - while one of my very favourite topics - sometimes strikes me as ridiculous and exhausting. That’s why I love running - the animal, very present sensation of heart thudding and limbs cycling. It’s a relief to pull back from the big picture of life - or is it a pulling back? Maybe it's actually an embracing? There. I’m doing it again. “That’s why the cat is awesome,” said Pete. “He doesn’t think about it - he  just does. Eat. Drink. Play.” Looks like Toby will be my muse. 

He's not without his challenges. He was out exploring the cliffside behind our house when the neighbour's dog cleared their deck railing it a fit of overexcitement. Toby scaled a cedar tree in terror and remained there for the entire day until the neighbours brought out their ladder and rescued him. He tried a similar trick a few weeks later, necessitating Pete climbing onto our roof and setting up a kind of 2x4 balance beam to the treetop for the kitty to mince down. 

He chews plants, he flies at my legs from under the bed during the evening witching hour, and he is not absolutely odourless, as I prefer pets to be. When Pete and I are lounging on the couch on the deck in the evening, though, and Toby spots us from the yard and comes up and across the deck straight for us, shoulders bobbing up and down purposefully in this funny happy gait he has, I forgive him. He's a sweet little beast, and part of the gang. 

Bocconcini salad

Two girls walk into a bar.  A bistro, actually, a block from the Park Theatre on Cambie Street, where The Grand Budapest Hotel is playing. And we're not exactly girls anymore, with seven kids and two thousand patients between us. The bistro has a bar, though, and my visiting girlfriend Erin and I have a half hour till showtime.

She has a beer and I have a whiskey sour. The place is packed, Saturday night noisy. I’m poking at the ice in my glass with a straw, and Erin’s telling me about a patient from her practice in Comox. The server approaches with a tomato and bocconcini salad, a glorious trifecta of tomatoes, basil and cheese with the balsamic drizzled artfully across the plate. I expect her to pass by, but she stops and reaches over to set it down between us. 

“That’s not ours,” I say, regretfully. 

She looks confused.

“It’s not ours,” I say again. “Not unless someone ordered it for us.”

She takes it back, apologetic. “Your face just lit up when you saw it,“ she says.

"It does look delicious," I admit. We laugh, she brings it to the couple a few feet up the bar, and Erin and I are back to our drinks and conversation.

Ten minutes later, the waitress approaches with another tomato and bocconcini salad. She sets it down in front of me. It’s déjà vu,, except this time the bartenders and another server pause to watch, smiling.

“Someone ordered this for you,” she says. We stare at the plate. 

“The guy that was sitting at that table over there, " she says, gesturing behind us. "He ordered this for you." I turn, and he’s gone, just a crumpled napkin and the bill folder on the table. 

Our show is about to start, but I enjoy every slice of Roma tomato, every pale oval of cheese, every basil leaf, and with each bite I think happily: A stranger bought me a bocconcini salad, anonymously, simply to delight. 

Photo by Steve Brown, from Australian Good Taste. 

Photo by Steve Brown, from Australian Good Taste. 

* * * * * *

A few years ago I came across a description by Phyllis Theroux, American essayist, of an ecstatic experience where she watched the morning sun light the cockleburrs next to a sleeping porch. This was an experience from which she drew strength later: 

Could it be, and this is the question of a speculative,  unmarveling adult, that every human being is given a few sights like this to tide us over when we are grown? Do we all have a bit or piece of something that we instinctively cast back on when the heart wants to break upon itself and causes us to say, "Oh yes, but there was this," or "Oh yes, but there was that," and so we go on?

- (California and other States of Grace, p 55) 

She’s referring to childhood experiences in nature, but the idea of clinging to the recollection of an extraordinary experience of goodness in moments of despair resonated with me.  

A few weeks ago I saw pictures of captured Iraqis before and after execution by militants. I saw their faces and hands. I struggled to grasp that humans treat each other this way, and I couldn’t make sense of it.

Then I read this article in the Guardian about men being raped in war, and it fit exactly with my experiences at the refugee clinic. A person, deliberately, severely damaged by another person. Multiplied by a thousand people, over a thousand wars. 

These days, when my heart wants to break upon itself and I’m desperate for a small reassurance to hold on to, I remember this story:  the one about the guy who bought the girl at the bar a bocconcini salad.

Oh yes, but there was that. Humans do that to each other, too.

Two points for knowing what you don't know

I’m driving the kids home from school, winding along Dollarton with afternoon sun glinting off Burrard Inlet, and Saskia’s telling me about the Gauss Mathematics Contest she wrote that morning.

“I left one question blank,” she begins. It’s a confession: a perfect score is off the table. She doesn’t add up test scores, she works back from 100. She goes on, “But I did that because of how the scoring system worked. You got six points for a right answer, two points if you left it blank, and zero points for a wrong answer. I wasn’t sure about the last question, so I just left it.”

I make her repeat that, making sure I have it right, because I know I’ll be chewing on this for days.

They were rewarded for leaving alone what they didn’t know.

Making a wild stab at an answer was worth less than no response at all.

For once, it wasn’t about doing one’s best, but about acknowledging one’s limitations.

*        *        *        *        *       *       *

I was assigned to a family practice when I began residency in 2000, for several 4-week blocks over the two year program, and callback every Thursday afternoon. It was an established practice on Broadway and Granville, and a good group of doctors, but I dreaded seeing the patients, mostly well-heeled reproductive aged women.

Making a diagnosis and treatment plan on my surgery rotation, or in the emergency room, wasn't a problem, but these women kept presenting with issues that weren’t in any textbook. One couldn’t interpret her baby’s cries; another needed advice on dealing with strangers’ remarks on her child’s birthmark; the next had discovered her teenage son’s porn collection. Working at this family practice was by far my least favourite rotation, and I was doing a family medicine residency. That worried me.

My preceptor and her partners took the entire clinic out for Christmas lunch that first year, between morning and afternoon clinics packed with patients wanting to be seen before the holidays. I remember Sarah pausing during the meal and saying to me congenially, “You know when we knew you were okay?”

I had no idea, but I was relieved they’d arrived at that conclusion.

“Remember that rash?” she asked. “The four-year-old with the vesicles on his legs who’d just come back from camping?”

I remembered. Yet another patient that had had me stumped.

“When I asked what you thought it was, you said ‘I don’t know,’” she went on. “That’s when we knew we had a good resident.”

The other physicians agreed. “We don’t care what you know,” said Joan. “We care that you know what you know.”

*        *        *        *        *       *       *

I teach residents myself, now, and it’s true - I don’t pay particular attention to how comprehensive their knowledge bank is, but to whether they recognize what’s missing. Nothing raises a red flag like a learner who already has all the answers.

And then there are the patient encounters where you can’t turn to UptoDate for backup. Sometimes there really isn’t an answer, in that brisk bullet point way that physicians love. Sometimes the P of SOAP feels terribly inadequate; writing ‘counseled’ or ‘conservative’ or ‘follow’ feels like a fail.  Physicians get the God-complex jokes all the time, but from where I sit, we're keenly aware of our limitations. Medicine teaches you how very much is unknown.

That's using the Gauss scoring lens to look at one field in one profession. Imagine if we approached everything from a place of humility.

I read comments on news articles on refugee matters, vociferous ones, that are ignorant of the basic facts of the system. I’ve heard someone predict the eternal destiny of another person’s soul with the same degree of certainty that they state their summer vacation plans. I’ve seen someone with no more than Biology 11 comment with the authority of an immunologist on vaccines.  

I can't say that those lessons I've learned in medicine have overflowed into every other part of my life, either. 

So how about each of us, the next time we’re in a conversation - with a client, in a staff meeting, on social media or out to dinner - consider whether we truly know the answer to the question at hand.

And if not, take two points for keeping our mouths shut.

cross-posted at Mothers in Medicine

Crab hunting

Collecting crabs is a favourite pastime of all my kids. We're a short walk from several Deep Cove beaches, and when the tide is out, the kids search out the promising rock 5-10 lb rocks, roll them, and catch as many crabs as possible as they scuttle for the nearest shelter. They've done this since they were babies; none of them have outgrown it yet. 

I love the joy and camaraderie in these pictures. It always strikes me how thoroughly engaged my kids are at the beach, or in the woods, even when they've come barehanded.  The things that exasperate me in the house fit in naturally here: messes, climbing and jumping, excited raised voices, brandished sticks. We need to spend more time outside.

I won't pretend I'm not pleased to have daughters that can handle a crustacean without screaming. Look at that: Sunday dress, black rubber boots, dandelions in one hand and a crab in the other. These pictures make me feel like a good mother.