Memory and Acuity

My brother Ken, four years younger than me, has a more accurate long term memory of the events of our youth than I do. Whereas I recall the effect of the events on me in fairly vivid detail he had the more acuity for the event itself. I knew enough to know never to argue with him because he was almost always right. I had remembered, I thought, of an event I heard of in 1946. My uncle Edgie had been a prisoner of war in Stalag 8B for 3 and a half years after Dieppe. I was telling Ken's son that in prison Edgie had wagered a fellow prisoner that he could swallow a dead mouse for a dollar. I was telling Ken about this and he said, "No, you are wrong, the bet was that he could bite the mouse in half for a dollar." He did! Now neither Ken nor I have talked about this probably for 60 years but his acuity in the matter does not in any way take account of the horror I felt learning of that event and whether it was biting or swallowing is completely beside the point in my memory of my interior revulsion at the time. So far this little story has nothing elevating or useful to teach, but I have been reading Roger Lundin's book, Emily Dickinson and the Art of Belief. He says," for her, (Emily) memory meant the recollection of intense experiences or encounters rather than the rituals of general commemoration. It usually involved the revival of a sensory impress." In addition, he says, "She was intrigued only by the memory of what went on within the dwelling of her conscious life." I think that may be the difference between Ken and me. He saw and remembered the details of what went on in life vividly but accurately. My recollection of the same facts that I would have heard so long ago, is completely colored by the recall of the feelings. The acuity is swept up by the memory of the feelings which are the more powerful in me. In a world of law, testimony, false memory syndrome, accusation, redemption, recall, feelings, emotion, acuity,  and recompense---Justice demands, stick with the reporter rather than the poet.

Walking

Somehow, I have probably driven the six blocks to town a thousand times, while passing the features along the way. They are as familiar to me as the details of the interior of my house, but a blur. I could walk the distance in my sleep without foundering.  Or, so I thought! I have been grounded for a while, so have been unable to drive. I have been unwell and am beginning to rehabilitate by walking. Ambling is closer to the description of my ambulant adventure. It is closer to the adventurous walking that a child in no hurry would do. What struck me with such intensity is the myriad things that I missed in driving one thousand times past them. My trail was a zigzag beside the roadway and into the grassy byways. The trail was punctuated by stop and go, periods and dashes. I saw disuse and decay, new hope and splendor. I saw trial and error, failure and success. I encountered friends and strangers, talked to some and nodded to others. It's hard not to acknowledge passers by in a small town. A fish store closed out of season, a stone sculptors studio empty from his death, a towering new apartment climbing a rock face, a rotting house buried on a waterfront slope at the end of the harbor, a band shell ready to make music, unused wharfage and rotting steps to the harbour, blocked off, and all the wild shrubs and trees and byways between them. A marina with a few winter boats and signs forbidding parking other than guests and staff, and a church inviting all to come and park. That of course is the macro, but each feature in fact, was a picture that invited one to stand there and see the micro in it all. I think I saw what a painter might see. I finally came to the town and all is familiar there because after a drive, I have always, perforce, walked around in the town.

Random Harvest

The top banana of the Greek Gods, Zeus, swallowed his wife Metis at the time that she was pregnant. Eventually,  Metis gave birth,  and Athena, who because she was part of the meal, had to emerge through the top of Zeus' head. This isn't a book of stories about food or obstetrics or neurosurgery or even a cranky husband though it may include some or all of these topics. It's about control, or rather the lack of it. Zeus had to deal with Athena's arrival on her time table rather one of his choosing. She ended up being useful to him, rather than stronger than him as he had originally feared! If I am a fermentation vat, from time to time a bubble arises from below, breaks my surface with a "boing", and produces a spreading ring that lasts a while. The vat doesn't know when the bubble is going to break out and can't stifle it. Like Athena, the bubble rises up in its own time, ruffles the surface, and thereby is part of the fermentation. The random harvest of thoughts, that arise de novo; grasped at and scribbled about, without questioning the birth process, and without stifling yourself, is therapy of a sort; like taking a stroll through your head. It's clear that there is a lot to see there, but it only shows itself to you when it will. Like Zeus, I must have eaten a lot of stuff in my life that is still sitting around waiting to be born, or wanting to be born, but perhaps I am too thick-skulled yet to let it all out. Possibly I am still stuffed with stuff and long to empty myself, but I must wait for Athena, Goddess of Wisdom amongst other jobs and useful to me as well. It's at least intriguing to me what the muse will say next, and when the bubble will arise. Constipated or not, I am content to sit on the stoop and wait for it.

Mountain Climber

Today is the feast of the Transfiguration. Those who climb the mountain to the top will be changed if not transformed. To reach the top is not to stay there. The hardest part is to go back into whatever valley your have to deal with where you wanted to be cool,  not giving up and giving in to the new view. The priest today said that some of us may have been at the mountain top and were transformed. I was, I was, my hand is up! I didn't ever really diserve to get there, but I was placed there by a Holy Helicopter. I felt like a bird with wings for three months and moved with the wind but was probably considered mildly mad by my colleagues and friends. I may have been dreadfully eager to reach all those I saw in need who treated me with compassion, but it all gradually faded since living on a mountain top too long addles the brain. Transformed, no, transfigured, no, but changed and slowly adapted, yes. The valley is where we are to be, not the mountain, not Olympus, not Mount of Olives, not the Acropolis not even the mount of the Transfiguration. I actually prayed a prayer that the feeling of religous euphoria would leave me because it was interfering with my ability to do my work. Not to worry, some of it all sticks. You may be lucky enough to have your string jerked as well, but gradualism is the thoughtful and longitudinal way to go. That's just the work part that is demanded of those of us in the valley. Partly blind, partly poor, partly weak, control recused, hardly cool, that's us.

Testing the Waters

You never know what you are capable of until you are tested in the waters. Once one has come through a testing we can say, "I know that I can cope with that and get through it, so I can push through that much storm thus far, which opens my possibilities." When the family of the pianist and I managed a wooden cabin cruiser for over twenty years it was scary at first running the inland Salish Sea. I had at first made tentative forays on calm days till I mustered up courage and took three of my friends for a weekend of fishing several kilometers out in the briny deep. I had taken the Power Squadron course and read a book on seamanship as well. I guessed that I was ready. The weather was calm for two days and we had a great time putting into moorages along the way and celebrating our feats of seamanship on land and sea . On the way back to the homeport the weather changed and the boat, already an older boat at that time, with a wooden dingy that would accomodate one, blew off the transom and broke up. We secured our life jackets and stayed whitefaced at the large following high seas, that swung our backside from side to side like a dog in heat until we entered the first safe harbour along the way, still far from home. We anchored out and called to the waterfront houses till some one rowed out and rescued us. The pianist picked us up and drove us home. She said to all of us, "You guys stink." That of course compounded the chagrin. Sailors indeed. Stinky nonsailors indeed. That foolhardy experience, notwithstanding however ill prepared I was, taught me what our boat could cope with; tested by the waters. Yet, whatever foolhardy lack of preparation was present, I learned in spades. It's hard to learn everything from a course, when passion will teach you from experience.  As one prepares for, and expands what you thought were your limitations, as in the limitations of your craft, one pushes the boundary further and further incrementally, always aware of the endpoint of pushing the boundaries to foolhardiness. There has never been a shortage of life without risk in the young, but calculated risk unfortunately only comes with experience. Mistakes if you survive can frequently teach more than success.

Casuistry

Casuistry may seem an obscure word, but it is a noun more employed in the world at the moment than any other I can think of, from all advertising, political rhetoric, advocacy groups and legal selectivity. It is not hyperbole, it is worse. It is more subtle, more damaging and employs both anabole and hyperbole as well as deceptive reasonableness. Anabole at what it wishes to ignore and hyperbole about what it wishes that you not ignore. It can be seen in newsprint and internet and in the clever constructions from the comment sections. It is convincing to those who hear or read things, the spectators of life, than those who do things. Unfortunately, there is such a limited breadth of things we can do, and such a wide breadth of things we can watch! The only object of the casuist is to convince. We must always ask what is the interest of the convincer? The reaction of the audience may be cynical and believe nothing, or gullible and believe everything, or somewhere in between. You may in fact have already become aware that this paragraph I have written is an example of casuistry. It may not rank as a clever construction but it smacks of too much generalization to be on the high road. Still, it probably contains a tuppance worth of truth that those who already share the premise will find it wholely satisfying. If the file folder in your cerebral cortex is only available for A and not for B, then A will be accepted and B rejected. We have been programmed as spectators. As always, evidence is in the eye of the beholder. How do we get to a folder AB? I wish I knew!

Vaillaume cello

I have no background knowledge of music or musical instruments since I am a surgical mug and tone deaf, but I am married to the pianist so I glean her occasional droppings. I go to the occasional soiree and nod at expressions of ecstasy expressed by friends so as to join in, but I know where I belong and it's in the other kind of  theatre, the operating theatre. I have tried! The pianist's mother was a concert cellist, and she played until she was eighty five, and practiced in our home rather than her apartment since she was driving her adjacent apartment dwellers crazy with her unending scales! I was working one day years ago in the operating room with a colleague doing a long case and he was going on at the time endlessly it seemed, about a side occupation that he did in addition to his general practice. He was a classical music lover and scholar and had an interest in brokering string instruments! He was enthusiastic about a Stadivarius that he had aquired the rights to, and had traveled to Olympic City, "Where the money is, "he said, to show it to a client. I idly listened to him as he rattled on gaily about his forays into the precious instrument trade, while keeping track at the same time to the surgical matter at hand. Then he said, "I have a bead on  a Vaillaume  cello as well and they are very rare but there is a client of mine who is in the market if I can find one. There is a beautiful one in Olympic city I can't access." "Oh yah," I said, half listening, "We have one of those in our closet at home." There was silence. He knew I  was a barbarian and couldn't tell the difference between a cello and a kettledrum. At least that's what he thought. "No,"he said. "Yes,"I said, "I think it's in a closet somewhere."  Well, there was no way that he wasn't going to see it that night. He said nothing more and assiduously paid attention to what we were doing to his patient for the balance of the case. He bounded up the stairs at our home at 10 pm and said in an air of profound disbelief to the pianist, "You don't have a Vaillaume cello in your closet, do you?" "Yes", she said,"my mother bought it in Paris in 1920." My friend examined it carefully and then looked at me as if I were a newly hatched giant of the music industry. I felt like a poseur, but after all that talk, I wasn't going to let him know that I was just a surgical mug who knew what was in the closet.

Busy Hands

In the olden days when my children were teenagers, from time to time, when lassitude struck and indolence lurked around the corner, I would observe the axiom that, "Busy hands are Happy hands!" It was and is a tenet of faith I carry, but of course they would respond immediately by gagging motions into a fake barf bag. I expected such a response of course, but we had communicated and they  knew it, though it became sort of a joke, (CBS) Corny but Satisfactory. I was astounded to get a communication from the Royal College of Physicians and Surgeons of Canada the other day with information that we had unemployed Orthopedic surgeons, Neurosurgeons and Cardiac surgeons, newly graduated, that couldn't find places  to work in Canada now. The cream of the crop that we can't seem to fit in after all that training and skill; not being utilized to the fullest. One of the most satisfying aspects of my career in Lotus City was part of the recruitment and utilization of young Orthopedic surgeons added to our roster every three to four years throughout most  of the past thirty years. They added greatly to the health of our Service with the contribution of current knowledge and new skills. Rather than competition, the addition of these surgeons added to the energy of all and confirmed the adage that busy hands are indeed happy hands. Rationing of health care in this country by governments may save money, but in the face of inordinate waiting lists, inadequate expansion of high tech facilities, and unwillingness to address the antiquated Canada Health Act for fear of political suicide, the slow erosion will continue. Where is a latter day Edmund Burke when we need him? He may have been turfed by the electors of Bristol after a term, but he lives on in our minds and literature, while the ever compliant politicians of his day were never heard of again. My long association with surgeons has taught me this: these brothers and sisters under the skin would work for nothing if the tool shop is excellent and the team is topnotch. Money is not the big issue; it is the side issue, even though the money is good. I too am cognizant of the over all major costs these surgeons secondarily generate for the health care budget. Let's face it!  Health care Delayed is Health care Denied! A stitch in time saves nine. The work is fascinating and truly, "Busy Hands are Happy hands!"

Fishing Story

Some years ago, when we as a family fished often and successfully as well, the pianist's aunt and uncle and married children, a farm family, came from South Dakota for the Christmas season to Lotus City. On a beautiful winter's day several of the party, including the pianist's uncle, went fishing with me to Fiddle Reef. Now Fiddle Reef is aptly named because the reef is the shape of a violin and is marked by a navigational bouy at the wide end where though traffic is heavy, and at the stem end by a bouy as well! The rock is low enough in the water, that at maximum low tide it doesn't dry. We all planned to have supper at the marina after the fishing excursion, so the others gathered at the appropriate time in the evening. I was absolutely intent on my guests all catching a fish and trolled for the entire afternoon around the margins of Fiddle Reef, delicately avoiding grounding our lures on the reef! They all took turns with the lines but despite my best effort; nothing! The pianist's uncle was one of these special gentle human beings and it was his turn on the lines. The rest of the family had gathered at the marina restaurant and they could see us at Fiddle Reef, still fishing in the gloom, lights on now, and it was cold, so we trailed clouds of steam as we went back and forth in terminal desperation to catch a fish. The season was such that these were almost entirely winter spring salmon of 5 to 15 pounds, developing size at that time of the year. Suddenly, as we were about to give up, a line screeched into action and a fair sized fish started breaking water at a tremendous speed, shaking and writhing with each jump. Fortunately it was a Penn reel rather than a knuckle duster so our uncle could play the fish more easily. The violent action at the end of the line did not abate for some time.  I ventured to everyone on the boat that it was a large cohoe because a spring salmon, as I said, rarely if ever leaves the water in its struggle to free itself. Was I ever wrong! One thing the spring salmon does to a bait fish ball is to enter the school with its tail lashing, crippling some of the small bait fish, and then turning and eating the crippled fish at leisure. Sure enough, the 10 pound salmon we hooked, was hooked in the tail. It behaved like a cohoe only because of that. I had never seen a tail hooked fish before or since, but that seems strange in retrospect because of the manner by which the salmon generally, within a bait fish school, cripples them before it returns to eat. That's why almost all salmon lures are created to simulate crippled bait fish. Salmon, like all of us, like getting things the easy way and having a leisurely meal. We got back to the marina to join the crowd who forgave us for the wait.Our uncle had lots of fun fishing, but when he went home to South Dakota he said he had quite a tale to tell. Pardon me!

Death of the Autopsy

In the decades of the 50s, 60s and 70s the autopsy rate gradually diminished until the present time when the indication for post mortem examination is now largely confined to forensic reasons leading often to inquests, or sudden unexplained death within 24 hours of hospital admission: almost always ordered by the coroner or court. Why this particularly useful examination has been discarded as a frequent assessment in the past of the utility of treatment ; an overview of disease and disorders commonly missed in diagnosis and treatment; and as a teaching tool in clinical-pathological conferences to enlarge the diagnostic acuity of the clinicians and students; can be surmised in the light of the litigation sensitive time we live. As a result we have trouble claiming a unbroken willingness to pursue all avenues of evidence based science in the interest of developing continuing patient care. I am sure that my practicing colleagues would say, "It's OK for you to espouse this now because you are no longer in practice!" Fair enough! Still, there are a lot of other reasons routine autopsies are not more frequently done. The deceased's family is unwilling to have their loved one's body subjected to autopsy for reasons of pure science. The hospitals on tight budgets are unwilling to add further expense that would compromise immediate needs. There is an acute shortage of pathologists and a complete autopsy is very time consuming. The provincal governments are unwilling to increase the allocation for non-treatment expenses. Physicians erroneously believe the sophisticated imaging of today is a satisfactory replacement for a comprehensive autopsy, or at least good enough as a routine. Physician insurance and hospital insurance companies would be reluctant parties to expanded autopsies that might increase the number of litigants based on hitherto uncovered live data. Let sleeping dogs lie is in order. Maybe that is so. Good medical care still exists in this country where informed consented risk taking by physicians is practiced, rather than cherrypicking only easy cases and offloading the more  risky. All these factors come into play and evidence based science is the loser as a result. And so, in fact is the patient in the end when the doctors are often having to look over their shoulder. Whoever might win are the lawyers and the chronically disgruntled! Oh well, easy for me to say. I still remember with fondness the cut and thrust of the clinical path conference with the clinician pitted against the pathologist: the clinician attempting a rational assessment of a patient, unknown to him, but with all the clinical records available, in the bright glare of his colleagues and students, thereby exposing his diagnostic acumen or lack thereof, before the autopsy findings were finally revealed. What a way to learn to think systematically and still remain humble!

Shake Your Head!

The last permissible opportunity for us to be publicly uncouth was the Freshman Parade in downtown Winnipeg in September 1953. My friend Larry, Mel and I were appointed by the class as the parade committee for the Medicine Float in the  Freshie Parade of that year. The theme of each float was to reflect, in some way, the ethos of each faculty to which we were ostensibly to become devoted. Let the gestating Engineers hang Volkswagons from bridges, the Aggies sit on their straw bales and milk a plastic cow, ours was the Sex Machine in full production. To allocate the portrayal of the dignity and image of Medicine to a callow group of youths, not yet baptized in the rigor of the course, must have shaken the heads of the faculty. Having interviewed, in the last few years, applicants for Medicine at UBC, I saw the quality of goodness and mercy, at least presented to us by them, bore no resemblance to the unihibited attitude we unfortunately displayed. It seems scary to me now. Christine Jorgensen, once George Jorgensen, was the first person known to have a sex change operation. The procedure, an amputation and vaginoplasty, was done in February 1953, and she was an instant celebrity from then on. Taking advantage of a topical, and somewhat, then permissibly mentionable topic, was an idea we thought was timely, edgey, and colourful enough to win the first prize for the best float in the parade. Our advantage was that two members of our class were identical twins. One would enter the Sex Machine dressed as a man and the other twin would immediately walk through the exit on the other side, dressed as a woman. The committee had a great time building the sex machine out of plywood on a flat bed truck and embellished it with levers and wheels with all sorts of dirty labels describing the surgical activity within the box, augmented by fireworks and smoke issuing forth from the machine thoughout the duration of the parade. Rather than winning the prize for the float, we were castigated by the Winnipeg Free Press for unbecoming behavior  and  immorality. Curiously, we were never sanctioned by the Medical Faculty, though we did receive a significant series of lectures on ethics, dignity and grace necessary to the practice of Medicine. Thank goodness for me, in 1953 the entrance criterion was entirely based  on marks. There was no interview process for putative medical students at that time. I suppose the possibility of taking raw material; intelligent, but still in the stage of a lump of clay; demonstrably human and unrestrained;  callow but honest; posed a interesting challenge for faculty. Better the students that would have been too dumb to lie, than those who are often facile during the interview. Still, I do have to shake my head.

Battling over Symbols

The Wand of Hermes, called the Caduceus, is a stand alone symbol that once represented the medical profession in the United States. The wand  consists of a staff with two serpents rampant.  The Wand is quite pretty. Hermes, or his Latin equivalent, Mercury, was the god of commerce. Like all Greek gods he had a variety of other jobs like protecting travelers, including bandits and  card players and any on the road.  Generally meeting the needs of  hustle-bustle. Hermes was as fast as Mercury. That's how the planet and the metal got their name. The Rod of Asklepios is in fact the historically correct symbol of the medical profession and employed world wide. It however, had to be radically redesigned in order to be pretty  Asklepious was the Greek god of Medicine, but his Rod is ugly and does not have a stand alone tradition. In all the statuary and  vase painted images I have seen, the Rod is held in the hand of Asklepios. As a symbol one is stuck with images of Asklepios holding the Rod and the single serpant  not so rampant, if verity is to be prized.  Do not believe symbols are powerless.As a stand alone symbol, the Rod of Asklepios in the original would look  like a fat club with a snake wrapped around it. From the temple reliefs and statuary it looks like something that would be carried by Alley Oop.  It's a saw-off then. Did the US go for pretty, but hopefully inaccurate as a representative of physicians; Fast Eddy, commerce, itinerant travelers, card sharks, banditry, and sharp practice. Or do we take UBS (Ugly But Satisfactory) and tart it up. If symbolism is a visible manifestation of an invisible ideal we don't have much of a choice.

Mummies Blankets

At the risk of being considered a sissy by those of  hard-nosed countenance, I have a paean to the pianist's and my mummy as we  use, on our beds today, the blankets they knit 60 years ago: both used by us as praise, remembrance and as a talasmanic connection to the past. The pianist's mother's blanket, a soft blue and brown and white in a zigzag pattern:  a strictly uniform, closer knitted, crisp and perfectly preserved. My mother's: a looser block knitted, tan, brown and orange with touch of white and tasseled. Both are beautifly finished as could be expected from these women in their 40's, knitters as they were then. My blanket is smaller than the pianist's since my mother was more impatient, so quit earlier to do other things. The blanket for the bed and chair gives warmth, comfort, and an embrace that reflects what they, as women, gave to us, along with the continuity they still provide. If they could look down today they would smile at the blankets they prized and are still prized and used today. When my mother provided me with my satin smooth blanket in infancy until I was three, it was my talisman of her when I slept and it gave comfort. The pianist and I can still celebrate the presence of our mothers today with the resumption of our  now knitted blankets. Why did I not realize in the years of my life from age 3 to 78 that the blanket would have kept me safe in that long  interval of time? Just a DOF! Dotty Old Fool!

Crumbs

Write your own moral stand
and designate it as the high road
Scandalize those who don't walk it
Enjoy the heady view
Your standpoint allows it and your ramparts seem secure

You are worthy to gather the crumbs
You are worthy to eat the whole loaf

But

Your concrete doesn't bind
The stones loosen and roll
It's a long way to fall
All is vanity

The Wonders of Wax

In the early 70's the pianist and I, on impulse to fulfill our role as guides to the young minds of our children, embarked on family viewing of a programme called The University of the Air. At that time the television set was in what we called the TV room, a tiny room in which we had inserted sound proofing to the walls so as to avoid noise pollution disturbing the cultural sanctity of the rest of the house.  The programme was developed by CTV and began at 6 AM for a half hour with a variety of topics, presented largely as lectures. We had been given an electrical warming platter by a grateful patient so the pianist used it to keep our porridge warm as we all assembled at 6AM in little chairs to watch and listen as the lecturer discussed the Wonders of Wax for the half hour, or other equally dreary topics. This meant of course that we woke at the ungodly hour of 5:30AM to make breakfast before the programme. In retrospect, to have imposed this unconscionable event on three little children from 10 to 15 years of age, not withstanding the pianist and me, and our busy day, was education gone mad, breakfast interruptess, and well meaning insanity. Thank goodness the grumbling from the pediatric set soon brought an end to this misattempt at togetherness and we all went our own way without further necessity to ruminate on the wonders of wax. I do think however , given a topic like the wonder of wax, the real wonder is that CTV was able to continue this programme from 1966 to 1983. They probably got a Canada culture grant. Our mistake!

Dementia Defended

One of the early signs of dementia includes having to hunt for your own Easter eggs which you laid the day before. Then, yesterday, I performed the possible sin of repeating the same blog I  previously had written; different words, but the same context, and then failed to recognize it until too late, once published. I did that very thing last night with "The Surgical Scrub" and an earlier post called " Dirty Fingernails". One might think that it's easy to avoid duplication but the ageing brain often has a short term memory deficit and also, a less brisk collection of Betz cells with fewer stories, stored, to analogize about. I remember talking to my mother in the nursing home one day when she was ninety and it became apparent that she wasn't sure who I was. Then I said to her, "Mum, do you know who I am?"  She chuckled and said, "Your face looks familiar." Then she said, "If you want to know who you are, you can go ask the nurse!" I don't need to ask the nurse or anyone else who I am. Self knowledge is the greatest thing we can achieve in life. Mum provided me with the love that allowed me to love myself and enter the region of forgetfulness without fear of failure or the risk of exposure. If I write about the same thing again, I don't give a damn. That's just me! I have listened to the same old jokes and stories from the same people I admire, told many times to the same other people for years. It's like fine old wine, or a story, gilded, not tarnished, with the patina of long life. Why should oral always trump written, even though oral gets away with it because there is no record of repetition? For some inexplicable reason a subject might bear repeating simply for the thrill of inadvertently revisiting one's creation and savouring it again, tasting your old Easter eggs anew.

All Joking Aside

Out of interest, I travelled once to a alternative therapies conference on back pain. It was an interesting experience to listen to the diverse opinions and the seriousness with which the proponents of the treatments described their results. At a break in the conference for lunch I was seated next to a young women practitioner of a discipline with which I was not familiar. We engaged in a short conversation as she seemed very pleasant and was surprised when I told her I was a medical doctor. She said, " Pardon me for saying this, but why is it that medical doctor's handwriting is so illegible?" "Well", I said," it's because we are taught to write bad. In second year medicine, the Course, 'How to Write Bad 201' is taught." "How can that be?" she said credulously. I waited for a glint of humour in those eyes but it didn't appear. "Well," I said, piling it on, "we then can't be held responsible for what we wrote, since no one can read it but us!"  "Good heavens ," she said, " I didn't know that!" I looked for any sign of amusement but the was none to be found in that serious mien. Up the ante was my way to deal with the matter. Surely in that stretch she would see I was joking!  "Yes," I said, " and in the Course in third year medicine, 'How to Mumble, 301' we complete the skill set 'How to communicate without doing so'. That way we avoid any trouble such as 'You said this or that'." "Well", she said as she rose from the table, "I'm glad you told me that!" I could see that I was in deep trouble. She didn't get it. My humour fell flat. To disavow it now would be disingenuous and reaffirm what she wished to believe, probably in the first place. I had just trashed myself and medicine in the face of an attempt at ill advised humour in the wrong arena. I could imagine the furtive looks of disgust from the assembly in the coffee hour later. I slunk away and listened to the rest of the meeting in the shadows.  As so many of my loved ones have said before, "Why can't you ever be serious for once?"

The Surgical Scrub

In the usual course of events the referring family doctor would from time to time to attend the surgical procedure for their patient and assist with the surgery out of interest for the patient's care and the informed knowledge that was to be gained for the patient's after care, by doing. Certainly a desirable and attentive act to provide counsel to the family and longitudinal care for the patient. On the other hand, some family practitioners worked on a part time basis as professional surgical assistants when the patient's doctor was not available. Many of these doctors became very skilled and knowledgeable with respect to surgical techniques and their experience was enhanced since they assisted a wide variety of surgeons and absorbed the diverse skill sets that they observed. Every two weeks or so, a physician who was a long standing surgical assistant, helped me during one of my surgical days. We got on well and since we had a rather intense common interest in gardening it was often a topic we talked about. We were standing at the scrub sink for the first case of the day one morning and he was particularly effusive in respect to his enjoyment of surgery and particularly singled me out as a source of this delight. I must say that I was touched by his enthusiasm and my role in it. As we stood at the sink, and resumed talk of gardening, scrubbing our hands vigorously, cleaning our nails scrupulously, lathering hands and arms and wrists with the antiseptic soap, rinsing with copious amounts of water, we talked and time stood still. Basking in the glow of his approbation of what I thought was my surgical skill, he said, "Yes, I particularly like working with you because we scrub so completely and talk so long at the scrub sink that my gardening hands stay clean for my patients for days on end. That's why I enjoy coming with you every two weeks." He smiled at me with simple joy!

Cross Fertilization

In the training period of specialization in any field, the focus toward acquisition of a skill requires commitment to all the elements that comprise the specialty. This is not only true but is self evident. It is abundantly clear that the more the time, effort and applied intelligence is availed, will result in greater knowledge of the elements needed for superior performance. Narrowing the field of specialization will enable the individual to seek and find higher and higher planes of information leading to superspecialized knowledge on a narrower base, and more and more unique capabilities, but often bound to the tree rather than the forest. In the practice of orthopedic surgery for instance, the knowledge base of generalized medicine and surgery precedes the specialization in order to give a sound foundation to the surgical decision making. Embarking then on progressively exclusive specialization diminishes the time available to renew the broader knowledge base, up to which half of it changes every ten years. The fragmentation of medical specialties and subspecialties has sacrificed general knowledge for specific knowledge. The concept of the ideal orthopedic surgeon of yesteryear is best exemplified by my written examination for  Fellow of the Royal College of Surgeons of Canada, (Orthopedics), of 1963. I say this not to recommend it but to show the degree of emphasis at that time. The exam was on four topics, given equal importance. 1. The causes of Essential Hypertension 2. Fractures of the Tibia  3. The mechanism of Renal Tubular Absorption 4. The Embryology of the Spinal Cord. To be granted a Fellow, was to have a broader knowledge. The excellence achieved by repetition and focus on the other hand, in surgical procedures, as in "practise makes perfect"  leads to technical success at the cost of openness to the challenge of change and broader learning . In the forty years of orthopedic surgery that I participated in, the progressive narrowing of the individual's scope of his field of work was necessary in order to to maintain the skill-set in a era of rapid progression of knowledge. The value of intraspecialty team practice as provided by closely knit groups, working intimately together, allows for greater discovery and shared insights. The value of new insights provided by interspecialty surgical relationships is often not taken advantage of with the pressure of time but is a potent source of discovery. I have often thought that the ideal surgical model for excellence is threefold, granted equal skill and knowledge brought at the begining of one's surgical career.
1. Close knit group practice in the chosen specialty (ongoing learning from the intraspecialty activity due to cross fertilization)
2. Progressive narrowing of the scope of practice with ageing.
3. Closer connections with the wide range of medical specialties (ongoing learning from contact to interspecialties leading to hitherto unrealized cross fertilization) calculated to counter fragmentation, and avail oneself of the deep well of current medical knowledge and what one can steal to apply to one's own specialty.

comforting sounds

The pianist lies in bed at night trying to sleep with the sound of soft snoring, interposed with episodes of stertorous sounds of air intake from her companion, the gentle dream cries, the rocking noise of the bed from body tossing that are signs of life and provide ambivalent comfort as one senses the continuation of the life force in place, at least for tonight. The pfsst of flatus from time to time and the thrash of an arm give a sense of life in the dim room,  that another day of "ourness" will survive. The coughing and sniffing sounds rising up with his flatfooted beat on the stairs, announces reconnection,without which all is void. The sharp echoes of argument and passion re- awake the entrance to the brain-bridge that defies all  the unconnectedness of indifference! Every day is reality therapy! There is no soundlessness here which always leads to gulf and distance. Passion and stridence give a form of musical harmony, both "cordant" and discordant, but essential wholeness . Sitting on the medical ward in the still of the night; making the hourly rounds; listening carefully to the comforting sounds through the dim light by the bedside, blesses the tiptoe listener with the music of the hospice that sooths. Comforting sounds from the crib with the nightly vigil of the night visitor who leans and rearranges the blanket tossed, and gathers in the sounds as soothing recognition of life, listened to and heard. A still small cry from the depth of rubble, or the airless shaft, announces life to the frantic rescuers  and comforts someone,somewhere, that a blessing is possible and what cannot be seen, nor can be touched, is music that sings to each of us. Harmony Divine!