General Interest

Goodbye, My Old Friend

Dr Bob

Lucy
 
Today is a day filled with many tears and much heartache: a loved one has passed on.

The call came late in the day. Lucy, our 13 year old chow, had been showing her age, but still seemed in good health, generally happy and active. Over the past few weeks, however, she had had some days of pronounced lethargy, and had been eating very little and losing weight. Nevertheless, she seemed herself most days — until today. She refused to eat, was unable to stand, and was taken to the vet. The news was grim: she had widely metastatic cancer, and was in her last days. The choice was difficult, but we knew it was the best for her, and after saying our goodbyes, she was gently put to sleep in my wife’s arms.

I stayed late at work, doing nothing either urgent or important, but simply passing time, not wanting to go home. My family was together at my wife’s mother’s house, and I knew our home would be empty. I drove up to the house, dreading my destination. No raucus barking proclaiming my arrival. No smiling face at the back door, no gently wagging spitz-curl tail, no pinned back ears joyful at this reunion, no vocal squeals nor licks on legs.

There was only, silence.

I walked around the house, knowing she was gone, but still in some irrational hope thinking I might see her. Her spot by the window, where she spent endless hours watching the neighborhood, stood empty. Her food dish, barely touched, sat where final attempts to give her nourishment had failed. The fire in my heart burned hot, its acrid smoke tightening my throat, and tears flowed freely.

Lucy as puppy
 

She had been a fine dog, noble, reserved, deeply affectionate with her family, loyal to a fault. She was strong of will, and needed a firm hand at times, but always came around. You could always get her to lie down — even against her will — but you’d better expect some sassy backtalk when she hit the ground. She had her idiosyncrasies, as most pets do: a passionate love for Kleenex, cookie dough, marshmellows–and toilet paper. If you left the bathroom door open, you could always find Lucy: just follow the paper trail, carefully unraveled–and there she’d be at the end, happy as a clam, munching on her paper snack. Her sweet spot sat beneath her curled tail — an area which you simply could not scratch enough. We used to joke that you could go for days without seeing Lucy’s face: she would butt her hind end right up to you like a trucker at a loading dock, demanding that you scratch her back. “No” was not an acceptable answer, as she snapped her head around and sassed you until you complied. Give her a new bone, and she would trot in circles around the house, proudly parading the spoils of her most recent kill, until finally, in sheer exhaustion, she lay down to savor her repast. She was inconsolable when any one of her pack left the house: whimpering, crying, pacing from door to window, desperately hoping to see you. It mattered not one whit that everyone else in the family was still inside with her: she only wanted to be with the one who had just left.

There are some who will not own a pet, because they cannot bear the thought of losing it. The pain of loss can be so great as to overshadow the joy of their companionship. But the years of friendship, humor, affection, — and yes, maddening frustration — cannot be replaced at any price — even at the price of so great a loss. Our animals bring out the best, and sometimes the worst in us, drawing forth our love and affection in almost boundless measure, even while testing our sanity and patience — and always crushing our hearts and breaking our spirits when they leave us.

Lucy
 

The death of an animal is the death of its spirit: so say the philosophers and pundits. But they are wrong. Our animals are redeemed by the passion of love which we pour out upon them — a passion which enlivens their spirit throughout eternity, as they live in our hearts, and in our memories, and in the richness they have brought to our lives. I have no doubt that this fine animal is now at peace, and that our spirits will never be separated from her throughout eternity.

UPDATE: Thank each of you from the bottom of my heart for your thoughts and expressions of sympathy. Frank Porretto, of the always-excellent Eternity Road, has also written about his loss earlier this year of Bruno, his Newfie, in prose far more moving and powerful than my simple words. If you have ever lost a beloved pet, read this, for you will understand–and weep.

The Path – I:
Genesis

Dr Bob

The Path Part 1: Genesis

A journal of one fool’s journey, and the faith which found him.
Genesis It was, at the outset, about direction. Direction demands trust.

At the outset, I had neither.

Faith came easily when young, with a naturalness almost peculiar in retrospect. Ours was a religious home, Roman Catholic, not by any means an oppressive one or coercive as are some, but one in which faith was real, taken seriously, practiced more than preached, rather a quiet but ever-present fact of life. I took to it easily, a shy, timid kid, more at home with books and fantasy than with games and friends. The inner life was lord–for the outer life was, if not utterly chaotic, not entirely healthy or sane either.

My mother ruled the roost: daughter of an alcoholic father who abandoned his family when she was young, and an immigrant mother from Poland whose rage at her own abandonment (sent by ship alone to America at age 14, married at 16, abandoned by her drunken spouse after 3 daughters a few years later) was never resolved in any meaningful way. Grandma’s bitterness was never far from the surface, poisoning my parents’ lives in a host of ways–and she passed this dark inheritance to her daughter. Grandmother had moved in with them shortly after their marriage, and lived with us throughout their married life, outliving my father–to my mom’s deep and oft-expressed resentment. My dad was quiet, gentle, rather a passive man, a physician adored by his patients and loved by his staff, but rarely seen by his family–in part due to devotion to his profession, in part, I suspect, to spend as little time with his mother-in-law as possible. My mom, left to husband a mother she at once loved and detested, concocted thereby a semi-toxic brew of smothering love and unpredictable rage which made engagement with her either emasculating, or terrifying–or both. To hide was the safest path–and hide I did. I learned to live alone while living among others.

Our home was but a few blocks from our parish church–a magical walk, with aged oaks hung low, cool and verdant in the moist heat of summer, stark and graceful in winter snows. I found the church a place of refuge–not during Mass, when far too crowded–but in those quiet times when pews were empty, lights were low, soft echoes of footsteps on marble, shadows of votive lights darting on darkened walls and sainted statues. The flickering candles whispered of a quiet presence: a comfort, a peace I rarely if ever found elsewhere. I loved it there: God was close. It was the only place where I knew no fear.

But children grow, and become teenagers. The Jesuit prep school I attended–men only, a tedious commuter train trek from home (my love of the rails its only saving grace)–fed me robust education and rotten theology. It introduced to me an angry God, constantly seeking to catch you in your faults, punishing you for every misdemeanor, trivial and trite. For a timid, wounded kid, it was hell: a lonely, graceless, fearful place with few friends and no happiness. It was a glorious day when I left those dark halls, their lockers like cell blocks in juvenescent jail. Abandoned in tatters was a simple faith of earlier years, replaced with cynical disgust for the hypocrisy of self-righteous religion.

College was liberation–a liberation, like most, more enslaving than ennobling. Whiskey, weed, and women were the new watchwords–success forthcoming in but two of three, as my social ineptitude and painful interpersonal impotency made relations with the opposite sex futile at best, moot most often. But booze and bogies trumped babes in spades–tequila demands no small talk, rejection revels in rotgut wine. These chemical friends restored a measure of serenity, divine ecstasy in empty bottles, cannabis incense, and solemn hymns of Hendrix and the Dead. There were, by grace, sufficient periods of sanity and enough non-toxic neurons to survive with good academic achievements. Miracles do happen, indeed.

There is in life always a guiding theology–though you be atheist or agnostic, religious or indifferent–as was I. Mine in this period was remarkably feeble: a passing acknowledgment of some vast Being able to create a billion unique snowflakes, yet caring not one wit about some solo slob stumbling through life. So, I figured, I was on my own–and on my own wasn’t going well: my chosen major, chemistry, a crushing bore, and a career therein unimaginably awful; an aching loneliness for relationships never fulfilled; the dreaded demand to settle on a lifelong career with no inkling whatsoever of a course which might bring happiness or satisfaction. My draft lottery number–31–assured a rapidly evaporating school deferment would soon sweep me to new and untold adventures in the steamy jungles of ‘Nam. Panic is not too strong a term to describe my state of mind.

The decision was easy–if profoundly superficial: with my father a physician, and a brother headed as well down this path, medicine was the default choice–and offered an extended student deferment, and the faint hope of the approval of a remote father–a hope never to be realized.

Was there ever a more noble calling to the healing profession?

But the simple fact was that I had not one clue: no way of knowing if the choice was the right one; no means to judge my own suitability for such an undertaking; no tools, skills, or craft for assessing such a weighty decision; no sense of calling or direction. I was a blind pig praying acorns weren’t afflictions, stumbling forward with blind faith in pure dumb luck.

And thus, as if guided by some mighty unseen hand, I chose a course of life which would by turns transform that very life, in ways I could neither anticipate, nor plan, nor hope for, nor even dream possible. That journey, and the faith thus engendered, I hope to share in some yet unwritten and undiscovered entries in this path’s journal.

Christmas Break

Dr Bob

Christmas TreeBeen a bit remiss about posting, but there’s been a lot going on. In addition to the usual Christmas rush of shopping and social events, my mother-in-law has been in the hospital this week, so there’s been precious little time to write.

We did get our Christmas tree up last week. The Pacific Northwest, while lacking the snow which adorns much of the country this season, is rich in evergreens, thanks to our warm, wet winter climate. We cut–as our annual tradition–a fresh Noble fir, about 8 feet tall. The Noble is a magnificent tree–firm branches and sturdy needles which are very resistant to dropping (last year we left the tree up for nearly 8 weeks, and had but a dustpan or two of needles on the floor). The branches are typically open, allowing lots of space for decorations, and the needles not too sharp. The smell of a fresh tree is extraordinary.

My wife finds ways to put more ornaments on the tree than is humanly possible–many of them Christopher Radko blown glass which she has been collecting for years. My role is to be the lumberjack, cart the beast into the house, string the lights, and place a few ornaments high on the tree where my height is useful–then rapidly move out of the way while the artist takes over. The lumberjack then reclines to observe the masterpiece take shape while drinking egg nog–not a bad gig, actually.

Anyway, I hope to get a post or two up the next few weeks, as time permits.

My best to all my readers, enjoy your Christmas and holiday time, and God bless.

Doin’ da’ Bird

Dr Bob

turkeyOK, just when you thought it was safe to forget about the overindulgence and caloric excesses of Thanksgiving day, here comes another blog post on Thanksgiving recipes. This one sticks to the basics: roasting the turkey itself and making gravy. It is my traditional holiday task to make the dim-witted bird into a delectable feast (and yes, I know wild turkeys are very smart), so this recipe has matured with age–unlike me. So grab your blunderbuss, put on your Pilgrims hat, and let’s get to it.

First a few basic points.:

  • The Bird–I have a preference for fresh-killed turkeys over frozen–their water and fat content is lower (avoid pre-basted turkeys at all costs: the all-too-common Butterball is an abomination, if you must know, literally dripping with hydrogenated vegetable oil, the worst kind of fat). I have had a so-called “free range” turkey one year: excellent taste, but they are pricey, a bit dry, and relatively hard to get in my neck of the woods. We tend to have a lot of folks for dinner on holidays, so we usually get big birds–25 pounds this year.
  • The Pan–a large, heavy roasting pan is a necessity; the disposable foil ones are not only flimsy, but they seem to prevent browning to considerable degree, and definitely prevent the caramelization of the pan drippings and ingredients essential to making a good gravy.
  • The Rack–a good sturdy adjustable roasting rack is also a must. Letting the turkey sit on the bottom of the pan causes it to stew, prevents proper cooking and reduction of the pan drippings, and generally leads to a sodden mess unfit for eating.
  • The Oven–I have the good fortune to have a convection oven in my home, which is superb for roasting, as it cooks more quickly and at lower temperatures. The gas-or-electric dispute approaches a religious war in some circles; electric is easier to regulate temperature-wise in my mind–and besides, that’s what I have. Oh, and no foil tents–tin foil is ideal for conspiratorial hats and the like, but terrible for roasting, stewing the meat instead of roasting it.
  • The Temperature–I like keeping the temperature relatively low–the bird cooks more slowly, and browns more evenly. I use 325 degrees throughout; without convection, I’d move up to 350. Rack low in the oven.
  • The Saucepans–you’ll need two heavy sauce pans, one 4 quart (for the stock), one at least 2 quart (for the gravy). Of the two, the gravy pan is the most important, as even heat distribution with no hot spots is important when making the roux.
  • The Ingredients–if you’re looking for exact quantities here, you’re outta luck: this is definitely an eyeball project. Use fresh ingredients and spices–I am partial to Penzey’s spices, which are outrageously fresh and aromatic, compared to the decades-old spice bottles on the shelf at your local supermarket.

The project begins with the roasting pan–you must be thinking of the end when at the beginning. The key to a superb turkey gravy (or any meat gravy, for that matter) is in the pan drippings. The sugars caramelize to a dark brown, providing exquisite flavor and rich color critical for good-tasting gravy.

pan

I place the roasting rack in the pan, and surround it with sweet onions (Walla Wallas, Vadellias, or Mexican) coarsely chopped, chopped celery, a hefty handful of whole peppercorns (Penzeys has a 4-pepper blend which is both colorful and relatively mild), and yes–your eyes aren’t lying–apple slices. I use a crisp, moderately sweet apple (Fujis here in the Northwest). During roasting, the apples disintegrate, adding both sugars for caramelization and lots of liquid for the gravy stock.

stock

Next comes the turkey stock, which will be used in addition to the pan drippings for the gravy. In the 4 quart stock pan, I place the giblets, the gizzard, and the neck, followed by celery and celery leaves (the leaves have much more flavor than the stalks), a large chopped onion, several cloves of garlic, some celery seed, a pinch of salt, and more peppercorns. Fill the pan about 4/5 with water, and simmer slowly on a back burner while preparing and cooking the bird.

turkey

Now on to the bird: I pat the skin dry (moisture prevents browning), place the bird breast-side down on the rack, and place lots of butter and a hefty sprinkling of pepper and tarragon. (If you’re on a low-fat diet, this is not the meal for you; for the rest of us, that’s why God created Lipitor). The breast-down approach keeps the breast moist as it cooks. As you may notice, this turkey is ridiculously large for the pan–kinda like an elephant wearing a miniskirt. It works–but just barely (a larger roaster is on Santa’s list for this year, so I’m being nice not naughty). The bird then goes in the oven.

basting

I baste it periodically with a butter-tarragon mixture, kept over the oven vent to keep just melted without burning.

Cooking time? Anyone’s guess–it depends on the oven, the size of the bird, convection vs. non-convection. I generally give a bird this size about 1-1 1/2 hours breast down, basting every half hour and watching for the golden brown color of the skin.

stock

Now it’s time to flip the bird (I practice in the off-season while driving on the freeway). One heavy carving fork goes in the neck cavity, another in the tail, and a helping hand holds the rack down during the process.

turkey

As you can see, the breast is very moist, and has not browned at all. It is basted with the butter-tarragon mixture, and popped back in the oven. Notice the red dot: this is a cooking indicator. When the meat reaches temperature, a restraining wax melts, allowing a red thingy to pop up. Problem is, it’s hardly foolproof: I’ve had them stick, resulting in a desiccated bird–if you like pterodactyl, it’s just the thing. Your eyes, nose, and fingers are better judges of when it’s done. This bird took about 3 hours 20 minutes.

Turkey, like most fowl, is a bit tricky to roast, as the dark meat on the bones cooks at a different rate from the breast meat. I lean toward white meat that’s still pretty moist (but not pink), which generally leaves the thighs done about right. The indicators I use are the skin color; juices which run clear from the thigh; and a firm breast meat texture to compression. Wish I could be more specific, it’s an experience thing: if you’re uncertain, use a meat thermometer. I rarely do any longer.

turkey

Once it’s done, I turn my attention to the gravy. The turkey is removed from the rack, and the rack scraped to get all its precious drippings into the roasting pan. I then add some of the clear turkey stock we made above to the pan, and heat it on the stovetop while gathering all the caramelized drippings into solution.

drippings

Notice how the apples and the onions have largely disappeared.

juices

The drippings are then poured out of the pan into a large measuring cup, using a sieve or a press to squeeze the juice out of the solids. The fat (butter plus turkey fat) rises to the top–some of this will be used for the roux, to thicken the gravy, the rest discarded. Notice that the quantity of fat is relatively low–with a Butterball, you will have 4-5 times this amount, and it’s nasty and high in salt.

gravy fat

Some of the fat is then skimmed and added to your gravy pan–the amount depends on how much gravy you want, though I tend to be generous. Heat the fat over medium-low heat, until the water-based drippings just start to simmer.

The key to smooth, unlumpy gravy is the roux and the liquid addition. A roux is a flour-fat mixture– most commonly butter and flour–which is cooked together before adding liquid. The cooking creates a paste which eliminates the raw flour taste, and which will absorb a lot of liquid.

gravy

I add enough flour to make a paste about the consistency of cookie dough, and cook it slowly, avoiding burning or browning, for about 5-10 minutes. I then gather the roux on one side of the pan, leaving the heat about the same.

gravy

The dark liquid from the drippings (sans fat) is then added using a ladle, a little at a time, allowing it to heat up to a simmer in the bare pan before stirring. To avoid lumps, the roux must be well-cooked and blended, and the liquid hot, and added in small amounts initially. As you begin to blend the drippings into the roux, it will actually thicken at first, becoming quite stiff.

gravy

Repeating the routine–pushing aside the roux, adding liquid until hot, then thoroughly blending before adding more liquid–you will get to a stage where the paste is smooth and the consistency of thick pudding. At this stage, you may begin to add a little more liquid at a time.

gravy

The liquid from the pan drippings gives the gravy a rich, brown color–almost too dark. At this stage, I strain the clear turkey stock created earlier, and begin adding it to lighten the color and add more flavor. I tend to end up with a relatively thin gravy, which will thicken as it stands and cools.

The final touch is seasoning: salt and pepper. Taste it first–I use a lot of peppercorns, so more pepper is rarely needed, but salt sometimes is necessary.

gravy

So there you have it–all ready for feasting and piling on a few more pounds to take off after New Years.

The Engine of Shame – Pt I

Dr Bob

The Engine of Shame - Part 1

Steam locomotiveA wise friend–a man who helped me emerge from a period of considerable difficulty in my life–once taught me a simple lesson. In less than a minute, he handed me a gift which I have spent years only beginning to understand, integrating it into my life with agonizing slowness. It is a lesson which intellect cannot grasp or resolve, which faith only begins to illuminate–a simple principle which I believe lies close to the root of the human condition.

My friend taught me a simple distinction: the difference between guilt and shame.

While you no doubt think I am devolving into the linguistic morass of terminal psychobabble, I ask you to stick with me for a few moments. What you may discover is a key to understanding religion, terrorism, social ills such as crime and violence–and why the jerk in the next cubicle pushes your buttons so often. On the other hand, if you’re among those who believe guilt and shame are simply the tools of religion and society to restrict your freedom–that as a perfectly liberated postmodern person you are beyond all that–well, you are probably wasting your time reading this. But most of us recognize the influence of guilt and shame in our lives–even while trying not to focus on them, as they are uncomfortable emotional topics, best avoided if possible.

There is a tendency to conflate guilt and shame, merging them into a single human response to bad behavior or personal shortcomings. Yet they are quite different. Guilt is about behavior, shame about being. Allow me to expand on this a bit.

Guilt is an emotional–or some would say spiritual– human response to behavior or actions which violate a respected set of rules. The rules violated may be internal or external, and may be based either in reality and truth or distortion and error. The rules which may engender guilt must be respected: that is, they must originate from a valid source of authority–parents, elders, religion, law–or have been internalized into one’s personal mores or conscience from one or more such sources. Rules which are not respected pose no difficulty: I feel no guilt at not becoming a suicide martyr for Allah, since I do not respect (i.e. recognize as valid) the rules which promote such behavior. The response to violating respected rules is at its heart based on fear: fear of punishment by God or man, fear of rejection, or fear of ostracization from friends, family, or society.

Since guilt is an uncomfortable emotional state, we generally make efforts to avoid or mitigate it if possible. There are a number of means by which this can be accomplished, with greater or lesser efficacy. We may of course, practice avoidance of the behavior which induces the guilt. If the rules are legitimate and based on worthwhile principles, this is obviously a beneficial approach: if you don’t steal things, you won’t go to jail for burglary. But avoidance may prove destructive if the rules are based on error. For example, if your parents or religion have taught you that all sexual activity is wrong or evil, this can prove a huge impediment to physical intimacy and relationships in marriage.

Guilt may also be mitigated–especially when it is chronic and recurring–by changing the rules. You may leave a religion which is highly legalistic for another less so–or for none at all; you may change your situation or environment to one where the rules can be ignored and not enforced; you may seek counseling to correct perceptions about sexuality or other destructive interpersonal biases or beliefs. Or you may simple practice denial–justifying your behavior through the creation of new internal or social rules, while avoiding or rationalizing the inevitable consequences of your still-errant behavior.

So guilt may be addressed by modifying behavior or changing belief systems, through choice or denial. What then about shame?

Shame–the very word makes us uneasy, striking deeply into the core of our being. For shame is not about what we do, but about who we are. It speaks to a deep sense of unworthiness, rejection, inadequacy, and isolation. It says we are not OK, that what we truly are must be hidden. And this we do with all the energy at our disposal, throwing up an impenetrable wall to keep others out at all costs. For the essence of shame is relational–it says that if you really knew what I was like, you would be repulsed and thus reject me. The resulting isolation–real or perceived–is a devastating threat, engendering a pain so profound it approaches unbearable.

The origins of shame are varied, and not fully understood. We seem to be programmed to interpret certain words and behavior by others–especially parents and siblings in childhood–as not simply critical of our behavior, but a statement of our worth. This is an especially powerful force coming from parents, under whose authority and supervision we are molded into social beings. While this may be especially pronounced in dysfunctional or abusive homes–alcoholism, sexual abuse, and mental illness come to mind–it occurs even in well-functioning family units, and with speech and actions which are not intended as critical or demeaning, but which are interpreted as such. The soil of the soul seems fertile ground to bring forth a tainted crop of shame, even from the seemingly benign bruises of normal human interactions and relationships.

From the Judeo-Christian perspective, this propensity toward shame is understood as rooted in the spiritually-inherited rupture of our relationship with God, manifesting itself in an extreme self-centeredness and self-focus, which acts as a toxic filter letting in the destructive while keeping out the good. Having been born into a state of remoteness from God–perceived at a spiritual level as rejection by Him, though in fact just the opposite–we are acutely sensitized to rejection by others: it fits the mold perfectly. Thus every real or perceived hurt, criticism, or rejection simply confirms that we are rejected, worthless, and of no value. Our self-centered mindset insures that even events not focused on our self-value are interpreted in ways that affirm our sense of shame–hence the child that blames herself for her father’s drinking and abusiveness.

While shame lives deep below the surface–a monstrous child kept hidden from public view–its manifestations are legion, and its ability to percolate to the surface and alter our lives and behavior is formidable. The pain of shame requires response, no less than a hand on a hot stove, and it may be triggered by many means: by concerns about physical size, strength, skill, or ability; by issues of dependency or independence; by competition with others; by worries about personal attractiveness and sexuality; or when dealing with matters of personal closeness and intimacy. Thus triggered, an outward manifestation is inevitable, and will generally fall into one of these areas:

  • Withdrawal — perhaps the most natural response to pain, we retreat from its source to avoid the risk of exposing our vulnerability. Hence we steer clear of people or circumstances which may trigger shame, withdrawing into a nominally safer–but profoundly lonely–world. This response may range in manifestation from shyness up to deep, pathologic depression or psychosis.
  • Attack the Self — The loneliness of withdrawal and isolation is itself a deeply uncomfortable state, and often raises the profound terror of abandonment. To avoid such painful estrangement, many will resort to demeaning and depreciating themselves, thereby becoming subservient to others more powerful, resulting in a condition of dependency. While this may lessen the pain of isolation and abandonment, it further exacerbates the underlying shame by reinforcing one’s worthlessness and inferiority. The relationships so formed are not those of equals, and therefore satisfy the need for true intimacy poorly. Such responses range from obsequiousness and self-demeaning deference to others, to depression, and all the way to masochism, self-mutilation, and suicide.
  • Avoidance — If the shame cannot be eliminated, the feelings most surely can: shame is soluble in alcohol, can be freebased, and its pain assuaged as well by a host of other self-destructive behaviors. One’s choice of drug–chemical or behavioral–is influenced by genetics, neurochemistry, and environment, but all have the common goal of emotional oblivion. Eating disorders, obsessive-compulsive behavior, behavioral addictions to work, computers, gambling, or sex can divert the mind and stimulate sufficient endorphins to make the pain go away–at least for the moment. But the drugs and behaviors only worsen the underlying sense of failure and inadequacy, and lead to fractured and destroyed relationships, loneliness, and sometimes physical illness and death.
  • Attack Others — Rage and anger are common responses to shame, as we seek to defend our threatened worth by destroying the antagonist–or at least diminishing their worth, through sarcasm, criticism, gossip, physical, verbal or sexual abuse, or violence. But as with other coping mechanisms for shame, the outcome is invariably destroyed relationships, and adverse consequences, both legal and personal.
Thus the engine of shame drives a host of behaviors which are both personally destructive and socially disruptive. If you scratch the surface of nearly any dysfunctional personal or social problem–alcoholism and drug abuse, obesity, international terrorism–you will find at its dark heart the issue of shame. It is, at the very least, a common thread among such societal and personal liabilities, if not a central driving force.

So it behooves us to get a handle on this matter of shame, uncomfortable though it may be. Our responses to its provocations are major causes of personal agony and social crisis. But like a schoolyard bully, once confronted face-to-face, the tyranny of shame can be broken through courage and openness, and the strength of numbers. On these thoughts I will be reflecting in a subsequent essay.

The Call

Dr Bob

The Call

cancer Damn!, I hate these calls… Lying on my desk, clipped to a yellow manila binder, is a single sheet of paper. Its pleasant color format and sampled photomicrograph belie the gravity of its content:

Adenocarcinoma, Gleason grade 9, involving 60% of the specimen.

How do you deliver a death sentence?

Your first impression of Charlie is his sheer mass: 50 years young, healthy as a horse, built like a tank, a former football player turned popular coach at a local high school. He arrived at my office after seeing his family physician for an acute illness, with fever, chills, and problems urinating. His doctor had diagnosed a urinary tract infection, placed him on an antibiotic, and drew a PSA–a screening test for prostate cancer. It was markedly elevated: over 100, with normal being less than 4. I grumbled to myself as I reviewed his chart: Those damned primary care docs shouldn’t draw PSAs when patients have prostate infections–it just muddies the waters.

PSA (prostate specific antigen) is a test which measures a protein in the blood stream released by prostate tissue. It has greatly improved early detection of prostate cancer in the 20 years it has been in widespread use–but it is not, strictly speaking, a cancer test. It is noisy–often abnormal in other conditions, including benign prostate enlargement (BPH), inflammation, and prostate infection. It is virtually always elevated in the presence of an acute prostate infection–often markedly so–and can take months to return to normal. The high PSA alarms the patient, however, who is told he may have cancer. But most do not–and Charlie looked like a classic case of infection.

His history was typical, and his response to antibiotics appropriate, so this seemed at first glance like so many other similar cases I had seen. His prostate exam was alarming, however: rock-hard and irregular, unlike the typical soft, boggy texture of an infected gland. Experience and training kicked in, and I knew exactly what we were dealing with: a relatively uncommon form of prostate infection called granulomatous prostatitis. I had seen dozens of cases–always alarming on first exam, with very high PSA values–and always responding to long-term antibiotics. Charlie was started on a one-month course of high-powered, high-priced bug exterminator, and came back for follow-up after its completion.

He was feeling better, and his PSA had dropped markedly, to 45. His prostate exam also seemed improved, but still quite abnormal. I remained quite confident in my diagnosis–after all, cancer doesn’t get better on antibiotics–but was unwilling to wait much longer to know for sure. I scheduled a prostate biopsy, reassuring him after its completion of my optimisim that the results would show only infection.

The report was a blow to the gut. I sat silently, staring at it, in stunned disbelief.

In the age of PSA screening, most prostate cancers are detected at an early, curable stage–although their slow-growing nature makes treatment less important in very elderly patients. The chances for cure at diagnosis are determined by an estimate of the size and aggressiveness of the tumor. Size is determined by exam, ultrasound findings, and total PSA values; aggressiveness by the Gleason score–a value indicator (between 2 and 10) of the aggressive appearance of the cancer cells under the microscope. Higher is not better: Gleason scores of 9 and 10 indicate rapidly growing cancers which tend to spread early and are difficult–if not impossible–to cure. Charlie had drawn a pair of deuces in a high-stakes poker game: large volume, high-Gleason score cancer. The statistics were dismal: he would likely be dead of cancer in 5 years, regardless of treatment. And as cancer deaths go, this one’s not pretty: pain is a huge management problem in many, as the cancer infests and erodes the spine and long bones, breaking even the strongest of men. One learns to hate this disease before very many such cases have been seen.

And now I had to call him with his biopsy results.

The actual call will be brief: I will inform him that, unfortunately, the biopsy has shown cancer, that additional tests will be needed to determine its extent and the best way to manage it, and arrange for a follow-up visit in the office. The real bad news will be transmitted then, face-to-face, with more than enough information for its gravity to sink in. To do this–without robbing hope–will require more inner strength than is readily at hand.

But for now, I simply need to tell him he has cancer.

The word cancer encapsulates the deepest fears and anxieties of man, embodying in one small word pain, suffering, loss of control, hopelessness, dependency, death, the fragility of our dreams and hopes, and our uncertainty about the hereafter. To inform a patient that he has cancer is to shatter the illusion, the daily denial that death may yet be outmaneuvered, forestalled, kept on hold for some future date of our own determining. It is an illusion which dies hard–surprisingly so, as we alone among all creation are cognizant of its inevitability and certainty.

Perhaps the cruelest wish a man might be granted–were there some bottled genie passing out such favors–is knowledge of his own future. Yet, in some small measure, that power has been granted to me, and others of my profession. Not in any specific manner, of course–not of days or years, details or circumstances–but in knowledge deep enough to see the broad strokes: shadowy figures through rippled glass, of pain, and loss, and shattered dreams, of desperate grasping at the frail straws of fading hope, as the drumbeat of mortality pounds ever louder toward its dark crescendo.

Patients receive the call in different ways. Most accept it with seeming stoicism, and little expressed emotion–yet it is not hard to imagine–and sometimes to sense–the tight grasp of fear that grabs the throat and grips the heart. When wives are listening, the fear is more immediate, more palpable, as voices tremble with panic despite every effort to control it. A million questions will arise–but almost never on the initial call. On rare occasion, there is a casual indifference to the news–prompting reflection on what strength of spirit–or dense denial –such men possess.

I often wonder how I would receive the call. As a Christian, I am confident of a life hereafter, eternal, spent in the presence of Him who loves me. Some call that arrogance, or self-righteous; it is not. God alone knows better than I the darkness of my heart, the depravity that makes me uniquely unsuited to be in the presence of the Holy One but for one moment, much less eternity. But I have been adopted–an unwanted child by an unspeakably loving and merciful Father, who only asks submission to His tender guidance and direction, and transforms a lost fool into something useful, something cherished, someone with purposes aligned–though poorly so–with His own.

But the call of death–so confidently faced from the comfortable vantage of good health and cheap grace–will strike fear into my heart when it arrives, for far smaller challenges have brought dread in larger measure. There will be the fear of the ordeal, the journey of suffering, the loss of things now treasured but instantly made worthless. There will be the pain of watching the loss of those close to me, struggling to make sense of a relationship, undervalued while unthreatened, yet now more precious while counting down inexorably to its end. I know–by the tutor of past and bitter experience–that faith will sustain me and mine through it all. But one cannot know what that day will be like–nor should we wish to ever know.

But for Charlie, the battle will now be enjoined–the weapons and werewithall of modern medicine in all-out war against its implacable foe. Perhaps by some miracle or unexpected grace he will be given a reprieve, a window to revalue and reassess life’s course, its priorities, its purpose. For even when we are cured, we are healed to face death again: Lazarus, once risen, will revisit the stony crypt. Yet the Voice which called him forth calls us also, beckoning toward a painful light from the cold terrors of death.

How difficult to be the herald of another’s mortality–it is a burden no man should have to bear. Some will deliver it through the steely detachment hammered hard by years of training; some avoid it altogether where possible, through choice of profession or abdication of responsibility. But for those who must speak this hard truth, may there be grace and wisdom, empathy and compassion. May it be also for me.

Voice Recognition Redux

Dr Bob

trollSeveral months ago, I upgraded my voice recognition software to Dragon NaturallySpeaking version 8. I have been using voice recognition software for over five years now, and have been very satisfied with it, although older versions could be maddening at times–and hilarious at others. This version is amazingly accurate–my only complaint since upgrading is that I am not having nearly as much fun proofreading my notes as I have the past.

Voice recognition software is rather remarkable technology, and to watch the medical version crank out complex terms with aplomb is almost magical. The software does not make spelling errors, but contextual errors are relatively common, and need to be carefully screened before sending your documents out the door.

A few of the contextual swaps I have encountered are as follows:

What I said: The patient said Viagra wasn’t working, and wanted to try Cialis.

What it typed: The patient said Viagra wasn’t working, and wanted to try and see Alice.

What I said: The patient was thoroughly reevaluated by her previous physician.

What it typed: The patient was thoroughly violated by her previous physician.

What I said: The patient will be started on depot testosterone.

What it typed: The patient will be started on devil testosterone.

What I said: The patient has prepubertal pubic hair changes.

What it typed: The patient had puréed pubic hair oranges.

The accuracy of this latest version has made such–ahem!–interesting errors quite a bit less common — to the point where I was becoming a bit complacent about careful proofreading. That is, until today:

What I said: The patient was seen several years ago for problems of urge incontinence, and has been on Detrol with good symptom relief.

What it typed: The patient was seen several years ago for problems of urge incontinence, and has been on a troll with good symptom relief.

And you thought they spent their entire lives living under bridges…

Deep Waters

Dr Bob

Deep Waters

Lake ClarkThey say that hell is hot. Sometimes, though, it is very, very cold.

Jim loved Alaska–it had been his home since birth. God’s country: wild, unpredictable, spectacular in beauty–there was no place like it on earth. Cities were a necessary evil, with their services and surliness, but out in the wild was where life could be found. Out among the glaciers, the ragged mountains framing the endless blue sky like jagged, broken glass, out where grizzlies snatched salmon from raging rapids, shortening their march to death as they fought wild currents to reach their spawning grounds. Out where eagles graced the sky, soaring above green fir spires and spotless snow fields. Out where God lived, where a man could see His hand, and hear His voice.

Jim lived a simple life of simple faith. He loved his wife as he loved the land, and together they were blessed with six children–three older girls, the twin boys, and a baby son their most recent gift. Each was a treasure greater than the next. Their lives were story book: The lodge they owned nestled near the shores of Lake Clark, a large inland glacial sea, mirroring the snow-peaked mountains surrounding it. Summers were busy–hunting and fishing tours, visitors from afar seeking trophies and photographs, decked in newly-purchased gear from REI in the lower 48. Jim loved to fly–the float planes lifted gracefully from the lake, carrying their awestruck passengers over endless miles of breathtaking beauty to some far-away stream where tied flies touched water and fish broke airborne for their last meal.

Out in the bush, relationships were few in number but rich and deep. Church was more than a Sunday obligation–it was a place where life was shared, joys celebrated, suffering consoled–a place where faith begot works, where love put on snowshoes and helped stack the winter’s wood. Family life was alive, ripe with blueberries picked, hikes to the falls, and quiet nights beside campfires. Summers passed quickly at Bible camp, concentric ripples of cannonballs and giggles of joy rolling across the lake from the old dock. Dates with dad and high tea with mom found no competition from mindless cartoons, and bedtime prayers thanked Jesus for His goodness and God for His gifts.

Winter was time for quiet reflection, as the short days and deep snows kept sportsmen far away, and school and indoor chores made the time pass slowly but with purpose. The plane was their lifeline: what few roads there were became impassible in deep snow, and flights to Anchorage a necessity for supplies and health care. The girls came along often, although the younger boys stayed with friends and relatives for lack of space.

Jim had tens of thousands of hours of flying experience, a skill which paid rich dividends in the harsh, capricious winters of south Alaska–there was little in the way of flying conditions he had not challenged and mastered. So this flight to Anchorage in February was a pleasant surprise: the low gray skies broke open to display the rare winter glory of sunshine on pristine snowfields, the glorious tinted rim of Alaska Range peaks and deep seas of Cook Inlet. The supplies garnered and the girls’ dental care completed, they took off for the return flight to home and hearth.

The storm struck without warning, a white she-devil blown in from the Gulf, the Cessna buffeted by sharp, hard winds as visibility and ceiling dropped precipitously. The instruments held true, and countless hours of difficult flying forged Jim’s nerves steely and his focus intent. Mom held the girls’ hands, distracting them from natural fears with songs and stories and heads held to breast, her own pounding heart betraying her calm demeanor. “Will we be OK, mommy?” “Jesus will bring us home, honey.”

The GPS told Jim they were indeed near home–the lighthouse in space beaconing safety and rest. By reckoning they should be near the lake, just a few miles out from the landing strip. But Nature had not finished yet, her rage reserved for one final blow.

A whiteout in a small plane is dreadful beyond imagining. Suspended between earth and sky, with no point of reference, no sense of up or down, sensory deprivation in a aluminum rocket. Your training trusts your instruments, but instinct and eyes scream for visual confirmation. There! On the right! Through a brief window in the suffocating white blindfold, a dark line: the outline of the lake shore. Jim banked the plane toward this beacon of hope. “Are we home yet, daddy?” “Almost there, honey.”

But wild Nature held one last vengeance: an atypical winter thaw had opened a long dark crack in the ice, normally frozen solid in February. The line Jim saw was not the airstrip. The plane hit water at airspeed.

The prop and windshield exploded. The cabin filled instantly with icy water, as Jim craned his neck to reach the fast-retreating air, still restrained by his harness. Years of wilderness training sprung to life, as without a thought he grabbed his Bowie and cut free the webbing. He struggled with the girls’ restraints, hopelessly locked between seats crumpled by the impact. His wife was nowhere to be seen. Time was up–the air was gone. He broke from the cabin, gasping for air at the surface, hoping to dive and try again to free his treasures. It was not to be: the plane sank like a millstone, 600 feet to the bottom of the frozen fjord, entombing the family he worshiped.

In shock, he looked around. His wife, by some miracle, thrown from the plane at impact, had struggled to the surface and clung to a floating berg. Spared from a frigid tomb, they stood on a fragile shelf of thin and breaking ice. Over two miles from the shore, clothing soaked through in sub-zero temperatures, their survival was still a loser’s bet. Slowly they worked their way shoreward, breaking through the ice at times, body temperatures dropping despite their exhausting physical efforts. Guided by some hand unseen, they finally fell exhausted on shore, finding shelter in an empty lodge. Blinded by cold and head trauma sustained in the crash, Jim was led into the cabin by his wife, who cut off his frozen clothes and started a fire.

Friends awaiting their arrival grew anxious, and the Air National Guard was called. A rescue helicopter–braving the same merciless weather–located the crash site, and ultimately reached them at the cabin. Even then, they could not be evacuated, as conditions grounded the helicopter until morning. A friend flew a Piper cub–braving the same horrendous weather–to bring arctic sleeping bags and warm food. Bravery, love, and duty had spared their lives.

Months passed. Physical healing came quickly, but the rawness of heart wept like an open sore, gently salved by friends and faith, prayers and potlucks, tears and thankfulness. The boys were precious as never before, but the emptiness of heart left by a lost child cannot be filled. The rage at God passes–slowly–as strength flows from trust born of countless old decisions to set aside self and act in faith. But the memories remain–the laughter lost, the peace of a sleeping child, the love of a flower picked, the hug unexpected. There is no answer to “why?“–only time, and trust, and talk, and the tender whispering of a gentle Spirit. Yet one haunting regret refused to die: the vasectomy Jim had undergone after their last son–expeditious at the time, financially prudent–was now a self-imposed prison in a home filled with family, yet achingly empty.

And so they sat in my office, seeking my skills to restore what no man should be asked to provide–hope and happiness. And they told their story, my heart aching with each small detail disclosed. Jim was a man of enormous character and strength, his wife still bearing the unspeakable pain on her face–yet there was no shame in the tears that welled up in their eyes. As I gently probed deeper with almost unseemly curiosity, I was drawn in by the most remarkable revelation: these two would stand. Theirs was a strength not merely of hardiness, or training, or steely denial hiding a dying heart, but of power beyond the means of any mortal. They had faced the hell that men fear even to consider, and conquered it. There was glory in their weeping, victory in their agony. They would never be alone, and never be defeated. I, the proud expert, felt strangely insignificant in their presence.

The surgery went well, and early recovery smoothly. As I spoke with Jim before he left for home, he talked about the girls who had loved their daddy and whom he still loved so deeply. “You know, if I could fly to heaven and bring them back, they would not want to come. Their happiness is complete, ours still unfulfilled. Jesus has indeed brought them home.”