The fat purple fig of public health

Here's some New Year's reading for you: 

I saw my life branching out before me like the green fig tree in the story. From the tip of every branch, like a fat purple fig, a wonderful future beckoned and winked. One fig was a husband and a happy home and children, and another fig was a famous poet and another fig was a brilliant professor, and another fig was Ee Gee, the amazing editor, and another fig was Europe and Africa and South America, and another fig was Constantin and Socrates and Attila and a pack of other lovers with queer names and offbeat professions, and another fig was an Olympic lady crew champion, and beyond and above these figs were many more figs I couldn't quite make out. I saw myself sitting in the crotch of this fig tree, starving to death, just because I couldn't make up my mind which of the figs I would choose. I wanted each and every one of them, but choosing one meant losing all the rest, and, as I sat there, unable to decide, the figs began to wrinkle and go black, and, one by one, they plopped to the ground at my feet. 

                                                                                                        - Sylvia Plath, The Bell Jar

Yes. I've always wanted each and every fig. In my twenties it felt like I could have them all, eventually. I turned forty and saw that the time remaining was finite. I sat there a while, having to choose, unable to decide. I considered Pete and his career, each of our kids, and our life in Vancouver. I cycled through all of the options, repeatedly. 

A year ago I wrote:  "And so 2015 felt to me like the year of endings, but not quite of beginnings. The beginning of beginnings, maybe. The Year of the Lull. An intermission. It was restful but I'm restless. I'm about ready to lay down the ten year plan. 2016 will be the year of decisions. It will be the year of beginnings. Fingers crossed, one of those beginnings is the foreword to my first book."

I did decide. I chose a Public Health and Preventive Medicine residency at UBC, and, as I learned on a 9 am phone call back in June, it chose me back. It's a five-year specialty training program, but I get full credit for my two years of family medicine residency. I started in September. Every night at dinner the family learns about rabies, or the Canada Health Act, or a kindergarten in Tokyo with a circular playground roof where the kids spontaneously run 4km of laps every day. All four of my kids can tell you about Typhoid Mary. 

I didn't write a word for four months. I'd been writing several hours a day for much of the year prior. My phone has a lot of pre-September photos that look like this, me and my muse, with reams of paper in the background. Then not one photo until Christmas vacation.

But over Christmas break, I did write the foreword to my book. It has a publisher! The manuscript has now gone to the editor. It looks like we have a title in our sights. Formal book announcement coming soon. 

Which figs will I let wrinkle and go black? A regular full-time family practice in Vancouver. A practice focused on care of the elderly. Unhurried days in a quiet house, at least for the next three years. The other areas that appeal to me - refugee health, medical education, mental health - will likely reappear as part of my public health career. 

*   *   *   *   *  

Deep Cove and I renewed our vows. Pete and I considered moving back into Vancouver, close to UBC, but the kids are thriving in their North Shore school. It's K-12, which means all four kids are at the same school. So we've stayed put, and I commute. It's 48 minutes each way, four days a week. It's not a problem. I have my best ideas in the car. 

We advertised for a nanny/housekeeper for three days a week back in September, but got no bites. We ended up with no hired help this fall. I bought a Dyson vacuum instead. I've decided that I'm a permissive doctor by choice, a permissive housekeeper by necessity, a strict parent, and a ruthless editor (of gardens, words, personal belongings). Quite balanced overall.

Things are peaceful on the home front. I study a lot, but I'm around. The amount of homework I do and the pleasure with which I do it is not lost on the kids. They're five to fifteen - a sweet spot, I think. They're increasingly independent, but have not yet made any decisions of which I disapprove.

*   *   *   *   *  

2016 was a good year for me. The restlessness is gone. I feel engaged and focused. Doing the work is a whole lot easier than deciding which work that's going to be. 

Land of Enchantment

I just returned from the Taos Writing Retreat for Health Professionals in New Mexico. I attended last year, too. 

New Mexico first piqued my interest when Natalie Goldberg referred to it so fondly in her book “Writing Down the Bones.” I try to piggyback medical conferences onto travel destinations, and alternate evidence-based review conferences with those exploring the art of medicine. I was due for some humanities, so when I learned of the Taos retreat last summer, I registered. A dozen medical professionals gathered for a week to write at the historic home of art patron Mabel Dodge Luhan, in a small town north of Santa Fe? This was my tribe. 

And they were. There was a urologist turned novelist from the Midwest, a San Francisco-based hematologist from the biotech industry, and a medical anthropologist nearing retirement. There was a soft-spoken neonatologist that I’d met at a writing course in Iowa the year before, and a witty radiologist from Michigan that I hoped to meet again (and who returned this year!). We were a diverse group, but our pleasure in gathering to read and discuss Donald Hall’s poem  "The Ship Pounding" was the same.

We spent mornings in the classroom, and had the option to meet individually with faculty in the afternoon to discuss writing, wellness and/or career. The rest of the time we were free to write and explore.

Most of us last year were at a career transition point. Several wanted to reduce their clinical load, some were planning retirement, and one was about to start a position in Alaska. I’d resigned from the refugee clinic months earlier. I was professionally disoriented, with plenty of ideas but no direction. I had written a book proposal but was second-guessing it. I left the retreat last August with a much clearer idea of professional and creative next steps.

I decided impulsively two weeks ago to attend the Taos retreat again. It seemed like a meaningful way to bookend the last twelve months. I flew out with my almost completed book manuscript in my carry-on, and five weeks remaining before the start of a residency in Public Health at UBC. I wanted one last vacation and some peace in which to finish the book.

I holed up in a hotel in Santa Fe for four days first, with chapters spread out over the tiled floor and visits to museums, galleries and historic sites when I needed to fill the well. I spent every meal with a novel. 

Then I headed to the Taos retreat for the week. The faculty, food and lodging were top-notch, again, and It was another great group. Of the fourteen attendees, three were men, thirteen were American but didn't want to talk politics, nine were physicians, one was a CEO and three knew what a Calvinette was. Want a group to cohese rapidly? Give them a safe place to write and share their work with each other.

I didn't get DH Lawrence's bathtub, but I did get Mabel Dodge Luhan's bed. I woke to sunshine every morning. There were afternoon thundershowers and pre-dinner drinks. I wasn't looking for career direction, but I got some. And on the morning of my last day, I emailed my agent my manuscript: 47,292 words. 

2015: Intermission

As we approach spring break, here's a post that's been sitting in my drafts folder since Christmas vacation.

I signed with a literary agent a few months ago. After resigning from the refugee clinic, I took April and May to write a book proposal. ("But how did you -- ?" Google.) I signed with Robert Mackwood of Seventh Avenue Literary Agency in August, dropping my contract into a mailbox in Quebec City while on vacation. I spent the fall at the kitchen table writing. It's been lovely. It's been lonely.

© Martina Scholtens. Charlevoix, Quebec.

© Martina Scholtens. Charlevoix, Quebec.

This summer, I took a one-week creative non-fiction course at UBC with Mandy Catron, and attended the Taos Writing and Wellness Retreat for Health Professionals in New Mexico. Both confirmed how much I love writing. Both made me wonder if taking time from patient care to write is indulgent. I'd spend two hours discussing memoir, then guiltily calculate how many patient visits I could have fit into that time. 

In November, with the Syrian refugee crisis, the niche area of medicine I'd worked in for years received unprecedented attention. The website I developed during my maternity leave with Ilia received a funding injection. I jumped on an opportunity to do consultant work, helping the province prepare for an influx of refugees over the next few months.

2015 was supposed to be the year I decided on my next long-term career commitment.  My consultancy work has an expiry date on it. Writing will always be ancillary to my career, not the focus of it. In December, still no closer to choosing from four or five very different career options (all medical, none related to refugees), I hired a career coach. Give me three more months. 

This was our tenth year in Deep Cove. I love the depths here, of the water, mountains and mood. It's quiet and beautiful. We ski Mt. Seymour, we hike the Baden Powell trail and we paddle in Indian Arm. And yet ten years strikes me as the perfect number on which to end. 

2015 marked my last year with a preschool-aged child. I've been home with Ilia three days of the week this fall. I love our slow days, the hum of the fridge in a quiet house while she paints at the kitchen table and I plan dinner. She turns five next month, and joins the other three at school full-time in the fall. That will end fifteen years of staying home with the kids part-time. 

And so 2015 felt to me like the year of endings, but not quite of beginnings. The beginning of beginnings, maybe. The Year of the Lull. An intermission. It was restful but I'm restless.

I'm about ready to lay down the ten year plan. 2016 will be the year of decisions. It will be the year of beginnings. Fingers crossed, one of those beginnings is the foreword to my first book.

Thoughts after two months away from the clinic

1. People are determined to name what I'm doing. Retirement seems to be the favoured term, but that's absolutely a misnomer. Not until 75, remember? Someone called it a home and garden leave - like a maternity leave, but you tend to your patio furniture instead of a newborn. I don't mind that. Call it a sabbatical, Pete tells me. That comes closest. I'm resting. Productively. 

2. I expected that within a month of leaving the clinic, six weeks at most, it would become clear to me what to do next. It hasn't. I have no shortage of ideas, but the frontrunner isn't ahead by enough for me to feel certain it's the winner.  

3. I feel much more guilt about not seeing patients than I ever have about being a working mother. Taking a break from clinical work makes me feel like a bit of a farce, professionally. I'm keenly aware of the current shortage of family physicians. Then there's the investment of years of medical training that feels like it shouldn't sit idle, not even for just a few months. 

4. It's remarkable how much easier life with four kids and a traveling husband is when I have no clinical commitments. There's no scrambling to sort out school pick up. I cook most nights: fish on Mondays, pasta Tuesdays, meatless Wednesdays. Not only is laundry caught up, the whites are hung to dry in the sun. Someone's coming by to install a new hot water tank? No problem, I'm around. 

5. I think a lot about boredom. Last week I read this in Saul Bellow's novel Humboldt's Gift: "Suppose then that you began with the proposition that boredom was a kind of pain caused by unused powers, the pain of wasted possibilities or talents, and was accompanied by expectations of the optimum utilization of capacities" (p 201).  Yes. This explains why I find stay-at-home motherhood difficult. Feeling bored at home doesn't mean I find my kids uninteresting or caring for them unimportant. 

6. It took six weeks, but I miss seeing patients. It's a relief to say that. It's a bit of an identity crisis to be a primary care physician who's not sure she ever wants to see patients again. Public health and pathology were looking very attractive. When I got an email recently asking me to cover a few shifts at the refugee clinic later in the month, it went in my calendar in all caps, with an exclamation point.

7. I hadn't realized how far I'd fallen behind on general life things. My first weeks off were booked with dentist appointments, haircuts all around, doctor visits and a mammogram. I still have boxes of maternity clothes in storage; Ilia is four. There's a stack of five years' worth of kids' report cards and school projects on my study floor. We'd been managing the daily basics, but there was no time for extras. Except those things shouldn't be extras. 

8. Never a big spender, I find myself curtailing my shopping even more now that I'm not bringing in income. It's not to do with affordability. I feel that by not earning money, I haven't earned the right to spend it, either. I like Pete and I to be co-earners and co-spenders. I don't like being the beneficiary. (Although I do enjoy texting Pete mid-day to remind him that he's the primary breadwinner, and to urge him to work harder.)

9. Leif mentioned a track and field meet a few weeks ago, and when I said - "When is it? I'll come watch!" he couldn't believe it. These are the kids that took a taxi home from their school end-of-year ceremony last year, awards in hand, and made themselves lunch. In the stands at Swangard stadium, I watched as my ten-year-old ran the last one hundred metres of his first race with his head constantly swiveling to the right, searching for his mom in the crowd. 

10. I love having time to reflect. I opened the fridge door the other day at lunch time, and mid-swing, had a sudden realization about the type of work I like to do. I stood there gazing at a shelf of leftovers while things sorted themselves out. I find it takes slowness, puttering, to make these kinds of connections. 

Reading this list over, I see a number of contradictions and competing ideas. Looks like I've captured my current state well, then. 

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

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:


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. 

IMG_3060 copy.jpg

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. 


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. 


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. 


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.


Every spring break we do a road trip, heading south on the I-5 in search of weather warm enough for bare legs. Last year we drove to Santa Barbara. On the way home, somewhere mid-Oregon, I was silently, guiltily wondering if I'd outgrown this kind of vacation, when Pete announced, "I think next time we should just fly somewhere." It's no longer money we need to be frugal about, but time. So this year: Oahu, Hawaii. 

Every vacation package out there is tailored to a family of four; I gave up on a resort or hotel. We found an oceanfront house on the North Shore on VRBO instead. View from the front yard beach looking back at the old plantation house, and toward the ocean:

We snorkeled. We ate pineapple every day. We ate at shrimp trucks and shave ice shops. The kids chased feral chickens and searched for lizards. We read voraciously and took surf lessons (and Pete has his fourth consult with orthopedics this week for a sea urchin spine embedded in his foot). 


There was a moment on the third day when I looked at my kids at the kitchen table - happy, but very noisy and very dirty - and I remembered that I don't usually go more than two days where I'm with them 24/7. I always get that break where I deal with death and disease for a few hours and return to the family refreshed. But this vacation was for them, not me, and a parenting marathon on a tropical island isn't exactly a sacrifice. 

Success! The kids unanimously voted it the best vacation ever. There was weeping the day we returned, the ultimate affirmation. And while in Hawaii, I registered for a vacation that would be all mine: a three day medical writing conference in Iowa.

Now, back to patients who invariably greet my return with, "You went away! Didn't you take a vacation last year?"


Wednesday, March 5, 2014

Queen Elizabeth Theatre

Every seat is taken. The theatre's lights are dimmed over a throng of excited Vancouverites, most dressed in black, some in pearls. After interminable introductions, Hillary Rodham Clinton strides in from stage right, in a navy pantsuit, stilettos and large glasses. She takes the podium and begins her speech on women's issues. She's funny, smart, engaging. 

I'm here for the curiosity, not the politics. I was offered a ticket that morning; I didn't even know she was in town. She doesn't disappoint. Her presentation is riveting. 

"One of the greatest blocks to the advancement of working women is their own self-doubt and perfectionism," she says.

Yes. That resonates.

She continues, "I've worked with many young people over the years, and almost invariably, when I offer more responsibility to a woman, the response is, 'Let me think about,' or 'Do you really think I could do it?' I have never once offered a promotion to a young man who did not feel more than entitled to it." 

I post that to Twitter. 

*        *        *        *        *       *       *

Friday, March 7, 2014

Residence, Deep Cove 

I'm going through pictures of my brother's wedding from the week before when I come across this:

Whoa. How'd that happen? I've got a girl who babysits, attends youth group and just submitted her course selection for high school. If she goes to McGill for university as she intends, I have just over five more years of seeing this face at the breakfast table every morning. 

Her childhood has always stretched ahead of me as far as I could see. The chances to do things with her, to become the mother I want to be - I live as if they will continue indefinitely. So how can it be that I can count on one hand the summer vacations remaining until she graduates high school? 

Wait! I think, and I suddenly feel scared, sad. I was going to read all of the childhood classics alongside her - A. A. Milne, Roald Dahl, L. M. Montgomery. I collected them from used bookstores, and she's read them, but I never got around to it. I still haven't made her bedroom an idyllic nest; the board is on PInterest but the brown carpet lives on. The plan at the back of my mind was to raise her somewhere with goats and an orchard; we live on a rocky cliff side without even a gerbil. 

I was going to become an excellent mom, or even just a really good one, the one she deserves. I could always see just how I'd be one day when I'd conquered all my personal faults. Calm and patient, attentive and selfless. I was going to start going along on field trips and watching her floor hockey tournaments. We would have long conversations lying on her bed in the evenings. I was not going to take her for granted, ever. 

I look at the face in the picture above, sweet and spotted, pretty and confident. A flight of conflicting responses pass through me. Pride, panic, affection, sorrow. What to do?

Do I say with satisfaction - Look at that. She knows she is loved, and knows how to love. She's an excellent student, a kind friend. Tucked into the past twelve years are moments I didn't, couldn't have planned. Dissecting a cow heart for her class, sharing anecdotes about her baby sister, playing Clue after dinner for nights on end. I'm irritable and impatient, yes, but I've always been up for adventure. I devote a large part of myself to patients, and she sees the joy that good work can bring. 

Or do I say, Hold up a minute! There's still time. Not a lot, and I'm going to have to be very deliberate about this, but there's still time. There are changes to be made, to home and work and heart, and we're turning this ship around, starting tomorrow.

*        *        *        *        *       *       *

Saturday night, March 8, 2014

Residence, Deep Cove

"Are you the father you wanted to be?" I ask Pete. I bring these things up in bed, lights out. 

"I've never thought about it," he says. I can't believe it. But I do, deeply envious.

"Scale of 1 to 10."

"Ummm. Seven." No trace of guilt or sorrow.

I can't help myself. "Seven's kind of low. Don't you feel bad about that?"

"When you imagine being a parent, you have no idea what it involves. Once you're doing it and you find out what it's really like, you cut yourself some slack. Lots and lots of slack." 

Owning 2014

For the first time, the idea of New Year's resolutions bores me. I've carried them out for thirty-something years, and if there are any self-improvement projects outstanding, I'm willing to accept that this is as good as I get. This cyclical reinventing is tiring me out. 

This year, I'm going to own what I already have.

I'm going to own having four kids; no more whispering Three was actually the perfect number! to onlookers. I'm going to own being a family physician at the refugee clinic. No teasing myself with ads for R3 residency positions this year, and no peeking at the eye-popping figures some of my medical school classmates bring in.

Also to be owned in 2014: this weathered house on stilts on the cliffs of Deep Cove, including wobbly walkway pavers and yellowing bathroom linoleum; a body that's borne four kids and carries me around without complaint, ever; a face with ever-darkening under eye smudges that still laughs every day with kids and patients. 

Let's include living in Vancouver, vibrant and gorgeous, despite property costs that make me sweat when I see what proportion of the mortgage payments went to interest. And friends, whom I don't keep up with enough - I'm going to own them, too. And family: my grandparents in their little New Westminster condo, my sisters who got the good hair in the family, in-laws and nieces - they're mine for life, and I'm going to own them.

All the unfortunate things I will do in 2014? They're mine. Any irritability, ridiculously late email replies, or impatience when you question immunization - I take responsibility. Any good ideas, generosity, incredible diagnoses? Also mine. 

So yeah. Even without resolutions, I think I've got a lot to work with. Funny how even better than dreaming is recognizing the parts of your life that you'd dream for if they weren't already yours. 

Happy 2014. Own it.

Once upon a beast 2014 Calendar by Hillary Kupish.

Once upon a beast 2014 Calendar by Hillary Kupish.

James Moes' portraits of our family in the woods.

A few years ago, I was reading an article when the accompanying photograph caught my eye. It was attributed to James Moes. There had been someone by that name in the very small ethnoreligious group in which I grew up, a younger sibling of my schoolmates. It didn't take much sleuthing to determine that yes, it was him, and he was now a Seattle-based photographer with an art degree and a breathtaking portfolio.

His work was different from the slightly overexposed, closely cropped photos I seemed to see everywhere else. He made great use of landscape in his portraits, and wide-angle lenses, and shadows. I followed his blog (now defunct, unfortunately), and joined his 1.2 million (yes, you read that right) Pinterest followers. I didn't enquire about hiring him because he lived in Seattle and didn't feature any family shoots in his portfolio. Also, he didn't post his fees on the website. The last time I enquired about something without a price tag was at a Granville Street art gallery, and they began by offering me financing. 

What follows is one of the reasons I'm still on Facebook - because for all the nothingness on there, there's the occasional prize. Pete's cousin posted a link to an auction that was to be held to help fund an adoption by James' cousin. I idly scrolled through the list of items, and, buried in there among gift baskets and wooden benches was a photography session with James Moes. This was it. I was certain that (a) few people in our shared community of origin would truly recognize the extent of James' talent, and (b) they wouldn't be willing to pay for it even if they did. Culturally-ingrained frugality runs deep in this group. 

I couldn't make it out to the auction, but there was the option of submitting a maximum bid online. One of the host's friends would act on the absentee bidder's behalf. Though I wanted to point out the conflict of interest in this setup, I went ahead and entered my bid and contact information. My phone rang minutes later. The caller apologetically told me that she had received my entry, but unfortunately it was garbled. She laughed and told me the ridiculously excessive bid amount she had received. "That IS my bid," I told her. The call ended awkwardly for both of us.

Next morning, I received the email announcing my win, at 2/3 of my bid limit. And it really was a win, even though I'd paid for it. 

A few months ago, James and our familly hiked up to Quarry Rock in Deep Cove. We've lived here for almost eight years, and the forest and water, trails and sword ferns, feel like our natural habitat. I love that they feature so prominently in the portraits. Here's a sampling:

You can find James at his website, on Twitter and on Pinterest.

In-flight medical emergency

The Italy vacation wasn't all cathedrals and olive groves. On the trip over, I encountered my first in-flight medical emergency. 

We're two hours into a nine-hour Vancouver-Frankfurt flight. To celebrate embarking on this trip I'm wearing my new hacking jacket, a grey wool blazer with leather patches on the elbows. The back of the Airbus is extremely warm, though, and I'm sweltering. I feel a little self-conscious about removing the coat and sitting in a public space in a camisole, but Pete assures me it's not a problem. 

I've just folded up my coat when a man four rows up stands and begins shouting in alarm and pointing at the fellow across the aisle, who's slumped over, unconscious. I rush to attend to him, only briefly considering and reluctantly rejecting the idea of taking the time to put my jacket back on. So there I am, kneeling beside this man, in skinny jeans, cowboy boots and a black camisole, announcing I'm a doctor. I don't think I cut a convincing figure. 

Meanwhile, they've made an overhead announcement calling for doctors on board, and an internist arrives from first class. She looks every bit a doctor: professionally dressed, mature yet attractive haircut, and self-assured. "It's awfully hot in here," she announces. "It's a lot cooler up front where I am."

As we tend to the patient together, who's short of breath and looks unwell, she tells me, "I know for a fact that there's a cardiologist on board. He's in first class with me, and I saw him going over his presentation slides." There's a reason that airline reservations offer a tick-box for Dr, and there's a reason physicians don't select it. 

Suddenly the patient's chest starts to heave. He looks around desperately and then tilts his head back and turns toward the aisle. Too late I recognize what's about to transpire. A fountain of vomit hits me, splattering me from my hair to my boots. His own face is covered in it. The flight crew rush up with towels, horrified for me, but I can't clean myself up before the patient is assessed and stable. I wave them away and call for barf bags as he retches again. Three helpful neighbours thrust one at me.

The internist and I move him to the galley. We go through the on-board medical equipment and find a stethoscope and blood pressure cuff. Soon he's feeling much better, his vitals are stable and we've dressed him in a grey button-down worker shirt donated by Lufthansa. 

The flight crew watch all of this with interest. One of them remarks, "Did you see that guy back there who jumped up to get a t-shirt form his own carry-on to give to this man?" Everyone murmurs at how remarkable that is. It pleases me no end to reply, "That was my husband." This is well-received. "He's not medical," I say, "but he does what he can."

They kindly offer me the same airline shirt they gave the patient, sealed in plastic, and I squeeze into the tiny washroom to wash up and change. It's next to impossible to rinse my hair. I do what I can to make the shirt work: unbutton a few top buttons, roll up the sleeves, half tuck it into my jeans. They don't have regulation pants, so I'm left to dab my jeans off with a damp paper towel. 

The internist and I make a plan for monitoring the patient, the flight attendant takes my contact information and assures me I'll be hearing from them, and I return to my seat. My beloved jacket is where I left it, folded and clean, and I realize how narrowly it missed an assault that no amount of dry-cleaning could undo.

Some kind of chemical absorbent has been spread over the surfaces which had contact with vomit: his seat, a little up and down the aisle, and a substantial pile exactly where I'd been positioned. The flight is fully booked, so when the patient returns to his seat a few hours later, he has no choice but to sit in the same now-soggy seat he started in. 

It takes me a while to wind down from doctor mode. I'm on high alert, ready for the next event. It takes hours for the indignity of the experience to sink in. It isn't until I notice a substance on my watch strap, missed in the wash-up, that I feel some revulsion.

When we disembark at Frankfurt, I see the man at the gate, chatting with the internist, fully recovered. It's good to see him well. 

Waiting for our next flight, looking around at the airport bustling with people, it strikes me what unusual beings humans are. When one of us goes down, even a stranger to the group, without fail another sounds the alarm, and others rush to help. I like that.