Category Archives: Medicine and Humanism

My Writing Process

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One frequently asked question  readers have since publishing Carrying The Black Bag is about my writing process and any efforts utilized to foster creativity. I’ve decided to add some thoughts here on my blog to answer my readers more fully:

Yes, some authors do goofy things to stimulate their creativity. i’ve known some and read about others. The superstitious may choose to sit only in a specific chair or drink only one brand of tea. Others play up-tempo music or stirring classical works. Admittedly, I’ve been known to don a cap (my Greek fisherman’s cap’s my favorite) to prime the creative juices. But the goal for each author, no matter what the idiosyncrasy, is to achieve a creative fervor whereby the characters take command of the story and  fingers simply race to keep pace with surging thoughts.

For me I appreciate sitting before my word processor with a clear mind, a comfortable chair, and an exciting idea. I usually outline the story before beginning it. This isn’t an absolute but generally I find outlining helpful. I try and determine what the chapter requires for plot or subplot and then with trepidation shove off into the unknown.

Nothing inspires fear more in writers than a blank page or screen. Once immersed in the story, my pace inevitably picks up. Usually after the first draft I simply hate it. I often think what I have written is not fit for bathroom walls. It is not until  many more drafts later that I begin to like it even a little bit.  I then put it “in the can” for awhile. Usually after a week or so, I am able to spot additional flaws and weaknesses. I then adjust the story, much like adjusting a recipe to taste, substituting stronger verbs, adding apt similes/metaphors, and creating further descriptions.

The next stop for me on this literary journey is my writing group. Our group of five writers has met for many years and by now has developed a sense of trust. While we possess vastly different styles and genres, the feedback never fails to benefit my story. Soon thereafter I make the additional changes. After a final read through with minor edits I may write THE END. If the writing project is particularly important I may ask a beta reader for his/her thoughts. These are extremely valuable folks who must like your writing and be anxious to share their precious skills.

The question among writers that repeatedly comes up is whether the spouse should act as an informal editor or serve as an alpha reader. The usual response and one to which I hardily agree is NO, absolutely NOT! Having said that, almost every author I know or have read about uses (abuses) their spouse in this way, so long as he/she is halfway literate. I fully recognize this marital extortion is totally unfair to my spouse. In general the writer’s wife or husband feels torn between being supportive and being honest. To this I say, “tough.” No one ever said marriage would be easy!

So yes, Trudy regularly reads my stories. I ask her to do this when I am simply written out or else in need of a fresh eye. She also is good at word choice and grammar. Sorry Trudy. Such editorial services I’m sure must have been hidden in the fine print of the marriage contract.

My inspiration often springs from my surroundings and experiences. I love to tell stories. I love to watch people and animals and try to figure out what makes them do what they do. I love seeing people in extraordinary circumstances do extraordinary acts (this is the watermark underneath my patient stories  in Carrying The Black Bag). These stories show real people demonstrating courage and perseverance that, in some instances, they never knew they possessed. They tell us something good about the nature of our humanity.

Animal behavior also strikes me as overlooked for the substantial insights it provides for human behavior. I love animals. Maybe that is why in college I majored in Zoology. It wasn’t simply because it was a good Pre-Med major, and Chemistry, the other option, held for me no allure.

Much has been written on the creative process. I’m convinced creativity steals into the picture and cannot be forced. When it hits me, it does so unexpectedly much like a pigeon dropping. A rested mind, a beautiful scene, and a tickling of intellectual stimulation all enhance my potential for creativity.

Since the writing process per se is language-based, it is is strongly left brain. However, sudden insights like solving a problem or flashes of intuition come from the right brain. This  ability to perceive a solution requiring synthesis is right hemispheric and cannot be arrived at verbally. To write well, both sides of the brain need to work together. To paraphrase and alter the old Greek saying, we need a strong left hemisphere and a strong right hemisphere. That is, the brain must process verbal material, but also be able to discern some broader interpretation in order to tell a good story.

I believe this to be true, and try to put this into practice. And now so much for superstition or goofy acts. Now where was it I laid my Greek fisherman’s hat.

Thoughts On Love

Lately I’ve been thinking a lot about love. And when I say this, I mean with its many facets. Strangely this began when our daughter Katie and her dog Olive visited last weekend. Olive does not appear as your typical dog. Olive looks like a dog put together by a committee. As best we can determine, she has German shepherd and either Corgi or Basset hound in her background. Olive is a very sweet and a good natured dog but one that elicits gasps and startled comments, such as “Oh my gosh, what is it?”

Olive has the face and head of a German shepherd but possesses a low slung body with front paws that angle outward at nearly 45 degrees. Now how exactly a German shepherd and a short-statured hound got together, I don’t know. My guess is the German shepherd mother got drunk one Saturday night and fell into a ditch- then along came Daddy.

Katie and Olive

Katie and Olive

Another reason for my recent fixation on love is that I have been reviewing chapters from my unpublished nonfiction book (tentatively entitled The Man Who Played Pinochle With Dogs). One chapter describes an elderly lady with a massive stroke who EMS brought to our emergency room. Initially we didn’t even know her name but determined from the CT-scan that the brain hemorrhage  gave her a very low chance of survival. The  woman physically was in very poor shape and not much to look at. Her hair was stringy and yellowish, finger nails grimy, skin fissured and aged, and she looked malnourished. I must admit at that point, we looked at her more as an old lady with failing physiology and decrepit body than as an individual with particular wants and loves. In our defense we had nothing else to go on.

The next day Ned, her octogenarian husband, with mincing steps walked into our medical intensive care unit and filled us in on her background. Ned not only gave us factual information about her health, but also absolutely changed the way we thought about this woman. We learned that both husband and wife had spent their lives as migrant workers. The had met as children at the end of a long cotton row and later started a common law marriage. Neither could have been described as anything but common in appearance. They had little in the way of worldly possessions and possessed little education. They had no children that might have cemented their relationship. Despite this  rocky foundation on which to build a relationship, their love had thrived.

It soon became clear to us just how much in love they had been. They never had been apart in all their years together. They worked hard, looked out for one another, and moved about together following the crops. The husband was absolutely devoted to his wife, a woman in the story whom I refer to as Maggie.

Whether it was Olive’s speculated upon parents or this pair of octogenarians, love always seems to play a central role for all of us in our lives. Whether it was simple lust as I suspect with Olive’s parents or a deeper, longer, and more meaningful love as with my memorable couple that love provides tremendous importance for our lives.

As I review my medical stories, how often I find an underlying theme about some aspect of love. It enters in the form of caregiver sacrifice, spousal love, love of a parent for a child, or love among unlikely and inherently unlovable people. Love often becomes the engine of transformation in my creative nonfiction stories. The stories also underscore the affection doctors and nurses develop for the people they care for.

Medicine is a calling like no other. I am fortunate to have experienced not only an education in medicine but having medicine provide for me a greater understanding of human nature, human strivings, and human fallibilities. Thank you Maggie, thank you Ned for helping me to understand a bit more about love.

Today Sent My Baby Into The Cruel World

As many of you know, I have written two books and have a book proposal placed with a literary agent in New York City. He is at present sending the book proposal to various publishers. The process seems endless.

Almost by happenstance I have had an interaction with a major university press. After reading the book proposal, the Director of the Press asked for the whole manuscript. Today I sent it off.

I have strange and mixed emotions: on the one hand I am pleased and flattered since this press also co-distributes with two other large university presses. This would be a comfortable place to publish although not as prestigious as a national publishing house. On the other hand, I am strangely uneasy sending the manuscript off. Is it ready? Will it be seen as marketable? Are medical stories able to have a wide enough appeal?

As a result I am feeling apprehensive yet hopeful. Time will tell. Will let you know how all this turns out. Hold a kind thought.

The Man Who Played Pinochle With Dogs

Many may know of my interest in writing down patients stories that inspire or entertain. This led to my writing a book of stories gleaned from my medical career. All of these impressed on me the strength of the human spirit. I now have an agent at Trident Media Group in New York City who is shopping my book.

A shortened version of one of the chapters, entitled The Man Who Played Pinochle With Dogs, was submitted to an annual contest by the American Academy of Neurology. To my surprise it won the prize, one thousand dollars, and invitation to an awards ceremony October 2012,

I thought some readers might like to read this shortened version. It will provide a taste of what hopefully the published volume will offer. The story follows below:

THE MAN WHO PLAYED PINOCHLE WITH DOGS

I strode toward a full chart rack.  The intake note read:  “75-year-old Muleshoe farmer, eight-year history of PD, med check.”

Wasn’t Muleshoe that cotton town northwest of Lubbock near the infamous Bloated Goat Saloon?  I had heard about this boot-scooting, brawl-provoking West Texas watering hole.

I scanned prior chart notes, planned my examination, and considered treatment options.  Like battle plans in war, my considerations would soon become obsolete.  As I entered, an elderly man sitting on the exam table glared.  He was short and had a face as fissured as a prune.

“What’s keeping you doc, playing golf?”

“Sorry to keep you Mr. Woodley.  I’m Doctor Hutton.  What can I do for you today?”

The man peered at me like a hawk sizing up its prey.  He wore a sweatshirt that screamed, “If things get better with age, then I’m approaching MAGNIFICENCE.”  I sat on the exam stool and acted nonchalant, as if I had ample time to wait out his petulance.

“It’s nice to finally see you,” he intoned, not yet abandoning his piqueWhile his words were barbed, his West Texas drawl and soft Parkinson’s speech reduced their sting.

“Mr. Woodley, I see Doctor Reynolds treated you.”  Doctor Reynolds, the founder of the Parkinson’s Clinic, had since decamped for a position at Johns Hopkins.

The corners of Sam Woodley’s mouth turned up slightly.  He nodded his head

and ran a gnarled hand along the exam table, smoothing the paper.

“Yep, for years Doc Reynolds my doctor.  Without him suspect I’d move slower’n a constipated slug.  Liked that funny talking Yankee.”  I continued my get-acquainted conversation, sensing a thaw in my frigid reception.

“Do you have family?”

“Wife up and died three years ago.  Kid took off for godless California. Not much to do since leasing out the farm.”

After a few sympathetic clucks, I asked, “Live by yourself?”

“Yep, but ya see a young heifer wantin’ to play house with an old fart like me, ya let me know!”  A mischievous grin came over his weather-beaten face.

I began to admire the pluck of this old farmer.  “I’ll keep it in mind, Mr. Woodley. How do you spend your time?”

“Frankly, not much. Just call me Sam.”

”Okay Sam, what do you do with your time?”

”Take care of the homestead.  Played cards with my Gladys, before cancer took her.”  Before he turned his head away, I noticed his eyes begin to glisten.  His defiance by then had dissipated, replaced by vulnerability and loneliness.

I steered the conversation toward his health.  “How’s your Parkinson’s disease been treating you Sam?”

Sam began describing difficulty cutting his food and tying his shoelaces.  His tremor and shuffling feet embarrassed him.  Surprisingly he said he also found it harder to shuffle cards.  Why, I wondered, did he need to shuffle cards?

Sam conceded his memory had slipped.  I listened, nodded, sympathized, and discussed making lists.  I inquired about side effects of his medicine with a series of nonproductive questions.  Then I asked, “Have you seen animals or people that were not really there?”

Sam hesitated.  I noticed his jaw muscles tighten.  His face took on a look of puzzlement that could not have been greater if I had stood on my head and begun to spit marbles.  Sam measured me, his bushy eyebrows knitting up like two angry caterpillars about to do battle.

“Maybe, maybe not.”

“Please tell me more.”

He ran the back of his hand across his square chin.  I observed his lips quiver.  After taking an unusual interest in the ceiling tiles, Sam Woodley finally blurted,  “Well doc, I see dawgs.”

I quickly followed up in my best nonjudgmental tone.  “Dogs, huh, well big or little?

Sam tugged at a dangling ear lobe.  With a weary sigh, his resistance gave way.  He shared his mystery by relating a bizarre story.  Trust must be earned, as it resides at the core of the doctor/patient relationship.  Sam provided his guarded experiences that allowed me to gain insight but also created for me a challenging dilemma.

“Well, ‘bout every afternoon three dawgs drop by.”  He fell silent awaiting my response to this snippet.

“Go on,” I gently urged.

In his monotone he described a large yellow Labrador, a black and white Border Collie, and a smaller white and brown Cocker Spaniel.

“Are they scary?” I asked.

“Nah, gentle as can be. Besides we play together.”

Puzzled where the conversation was leading, I asked if the dogs had names.  He nodded.  “Yellow Dawg the Lab, Skipper the collie, and Coco the spaniel.”

“Well what do they do?”

“Mostly like to play cards.”

I wondered if my ears were tricking me.  “Oh, I see,” I said, trying to sound, as if I was often told about three dogs playing cards. “Well, what card games do y’all play?”

“Usually pinochle, their favorite.”

“So, play pinochle, do they?”

“Oh yeah, especially Skipper and Coco.”

“I see, make noise while they play?”

“Never a sound, but I know what they want.”

“Please tell me how you and the dogs go about playing pinochle.”

Sam described how he would place the card table and arrange the chairs.  He would then invite the dogs onto their chairs and begin the game. “Coco likes to beat the boys. Upsets her if she loses. Been known to leave in a huff.”

He described shuffling and dealing but admitted he had been having difficulty managing the cards.  Sam said his canine friends had even greater difficulty than he did, forcing Sam to deal.

“You see doc, my hands aren’t as good as before this here Mr. Parkinson’s disease.  Be obliged if you’d just, well, give it back to him!”  With his quip, an endearing smile crossed his weathered, old face.

“Well, maybe I can help,” I encouraged.  Intrigued by his narrative, I gestured for him to continue.

“Well Skipper, the Border, wears green eye shades, you know like bookkeeper types and uh, Coco, the Cocker Spaniel sits on a pink handkerchief, thinks it makes her lucky.  Oh, and Coco sits with the floorboards, not across them- feels strong bout this, just like my Gladys.  Suspect Yellow Dawg comes for the sandwiches.  He’s not good at pinochle.

My mind was reeling, visualizing this elaborate scene.  I concentrated, trying not to project incredulity.  Sam was relating an unreal event with the nonchalance of describing weather changes or the cotton crop.  Was his elaborate hallucination prompted by Cassius Marcellus Coolidge’s series of pictures, Dogs Playing Poker?  My knowledge of pinochle was not extensive, but I knew it was a game for two to four people, not a pastime for dogs.

Mentally I had already determined that Sam required a medicine change to get rid of his hallucinations.

With twinkling brown eyes, Sam warmed to his narrative.  I observed his hand tremor increase, as he affectionately described his daily visitation.

“I make sandwiches before they come.  Yellow Dawg likes ham and cheese and lots of ‘em..  The spaniel and collie prefer turkey.”

He told of putting out dog biscuits.  “They prefer beef flavored ones.”  I sensed Sam’s pride as host.  “Put down a bowl of water in case they’re thirsty.”

“Mr. Woodley, can you touch the dogs?”

“Nah, if I try, hand passes right through ‘em.  Makes ‘em disappear.  Learned not to.”

“What about smelling the dogs?”

“Hadn’t thought ‘bout it, but can’t smell ‘em, feel ‘em, or hear ‘em neither.”  I considered for a few moments what I had heard.  Sam’s hallucinations fit with medication related side effects of Parkinson’s disease but they sounded more complex than I had previously encountered.

“When we finish the game, dawgs head for the door.  Disappear without me even opening it.”

“Do you and the dogs play anything besides cards?”  I wished to learn the extent of his interaction with the dogs and whether an emotional dependence on them existed.

Sam thought and then replied, “Watch the Cowboys on TV.  Don’t know about being America’s team, but sure as hell the dawgs’ favorite.”  Sam laughed heartily.  His hand tremor again increased, acting like his emotional barometer.

“How do you know that?”

“Well, Cowboys make ‘em a touchdown, Skipper jumps off the couch and tears around the room, jumping over furniture—his own little end zone celebration.  If the other team scores, dawgs lay their chins on their paws and look real sad.  Easy to read my dawgs.”

I was by then more certain his hallucinations needed squelching.

“Mr. Woodley, a healthy person’s ability to move about is like a wagon pulled by a team of eight horses.  With Parkinson’s only two healthy horses remain to haul the wagon. To keep it moving, we drive these two harder with medicines- like swinging a whip over the horses’ heads.

Sam sat quietly, listening to my analogy, one to which I hoped he could relate.

“Unfortunately urging them too hard can cause horses to get balky, like side effects, such as seeing things not really there.”  Sam listened without comment.  I explained how Parkinson’s had diminished his store of dopamine and that levodopa/carbidopa supplemented his brain’s inadequate supply.

“You see Mr. Woodley, too much treatment causes hallucinations.  We must reduce your medicine.”

Sam sat motionless.  Then his mouth began chewing movements, as if chewing his thoughts into declarative sentences. He then crossed his arms across his chest.  I quickly assured him that we could banish his hallucinatory hounds.

He at last replied, “Don’t know ‘bout that doc.”

I was taken aback. “Well, you agree we need to get rid of your hallucinations?”

“Dawgs ain’t bothering me none.”

I considered what further arguments to make.  “Are you worried about your movements slowing?”

“Nah, I got plenty of time to do my work.” Sam chewed more before asking.  “But how would I spend my afternoons, if I didn’t play pinochle with my friends?”

I searched for a rejoinder, but before finding one, Sam Woodley added, “Besides whatever would I do with all the extra sandwiches?”

Such rarified moments provide insight.  I gained a better understanding of the unmet emotional needs of Sam Woodley.  The experience also reminded me to view the situation through the other person’s eyes, a valuable lesson in medicine and in life.

My earlier training had taught me that hallucinations required adjustment of medicine.  I knew hallucinations could be well tolerated, and rarely welcomed.  But I also understood hallucinations could increase and become frightening.

Sam showed no signs of hostility or incipient paranoia and claimed reduced boredom.  But still these hallucinations were florid.  And what would my new colleagues think if they learned that I had failed to address them?

Hours later after completing my charting and shrinking a stack of paperwork, I directed fatigued footsteps toward the doctors’ parking lot.

My thoughts returned to Sam Woodley.  I hoped he had arrived home safely.  Remembering, his pugnacious approach to life made me smile.

Had his truculence arisen from a lifetime of farming cotton in borderline soil, violent weather, and semiarid conditions?  Sam’s sad lack of human connectedness struck me as bleak as the flat, treeless Llano Estacado; his loneliness, disease, and his medicine, having given rise to his illusory dogs.  Multiple factors contributed to his elaborate phantasm. One thing seemed certain; his dogs had provided unusual companionship.  I felt satisfaction, knowing I had gained sufficient trust for him to share his dogs with me.  Thirty years later, I appreciate his trust no less.

I visualized Sam arriving at his remote farmhouse.  I imagined him placing the table parallel to the floorboards and moving the dogs’ favorite chairs.  Perhaps he fixed enough ham and turkey sandwiches to satisfy the hungry Labrador.  I felt a smile cross my face.  I felt confident about my decision, considering this individualistic man and his lifestyle.

For now Sam Woodley would continue to enjoy his extraordinary pinochle parties with his dawgs.

What Old Fashioned Neurology Offers 21st Century Medicine

Like other areas of medicine, Neurology has experienced phenomenal technological achievements during the last thirty-five years.  Our current stellar imaging and modern therapeutic modalities couldn’t have been imagined at the time of my training in the 1970s.  Back then we focused on EEG, pneumoencephalography (I shudder even recalling that archaic and painful test), skull X-rays, the “black box” of Dr. A.B. Baker, and the importance that psychological influences had for neurological symptoms.

With improved recall of information via computer searches, current knowledge is more accessible than before.  The practice of medicine has become more sophisticated, and we must never denigrate such great progress. However these wonderful technical successes also place our profession at risk of becoming overly insular.  A tendency exists for current physicians to interact less with colleagues and to spend more time with machines.

During my internship and residency on-call nights, the midnight meal  provided social lubrication that benefited the collective care of patients by physicians of different specialties.  Over the day’s leftovers, the house staff met to discuss cases, tell stories, gossip, and let down their professional guards. We would lay down our stethoscopes and put up our feet.

I don’t know if this quaint custom even still exists.  If it does not, then other means are needed to provide a human interface among physicians, so that our most personal and caring of professions never veers into a numbers crunching, overly compartmentalized group of disciplines.

The evolution of modern medicine will rely heavily on doctors, hospital administrators, and other staff working together to solve common problems. An active exchange of thoughts among all members of the health care team will be required to bring about a truly integrated health care system that reduces costs, cuts medical errors, and advances quality and safety. The neurological approach, despite appearing anachronistic, offers an example that might provide advantage.

Neurology with its reliance on medical history and careful neurological examination remains an anachronism in modern medicine.  Who else but neurologists still tote around little black bags?  Who else but a neurologist spends more time taking medical histories and performing examinations than reviewing laboratory tests?  Neurologists must not avoid the newer technological achievements.   But perhaps by the anachronistic nature of our discipline, Neurology has become a model for a bridge from the present to the more humanistic, interconnected physicians of the past. Such improved socialization of medicine represents my fondest wish for medicine.  Moreover I hope our discipline that parenthetically McDonald Critchley endearingly referred to as “The Divine Banquet of the Brain” and by which I was seduced so many years ago, leads the way toward an improved interconnected clinical effort from which patients will benefit.

Meaning of Medicine Spirit

Bluebonnets & Paints

by Tom Hutton

 

My interests lay in humanistic medicine and life in the Texas Hill Country. Our ranch is named Medicine Spirit Ranch for the following reasons:

The beauty of the Texas Hill Country has always created strong bonds between the land and its people. Over the centuries, Native Americans, Europeans, and Americans have fought to occupy and harvest its bounties.

Native Americans believed this land possessed “strong medicine” that supported the body and enriched the spirit. The gentle breezes, fields of wild flowers, inspiring terrain, and plentiful wildlife  continue to heal the hurts of

A buck on a misty morning

mind and body.

The current stewards of this land, in recognition of these strong healing properties, respectfully name this ranch, Medicine
Spirit.