A Country Doctor Writes:

“Just as colleges introduce our young people to knowledge of the world important for the first half of life, there should be colleges for forty-, fifty-, and sixty-year-olds to prepare them for the challenges of the second half…”

Robert A. Johnson & Jerry Ruhl

During my vacation I went to the eye doctor to have a refraction done for a pair of reading glasses. Reading my iPad at night with my progressive lenses forces me, now that I am pushing sixty, to turn my head uncomfortably upward to read through the bottom of my thick eyeglasses. With a pair of dedicated reading glasses, I will finally be able to read up close in dim light with my eyes looking straight ahead.

One of the books I am reading is by Jungian therapists Robert A. Johnson and Jerry Ruhl, “Living Your Unlived Life: Coping with unrealized dreams and fulfilling your purpose in the second half of life”. Of course, that’s stretching it for me – last third is a more accurate description of my current location on life’s roadmap.

Back when I really was closer to the halfway mark, I read Johnson’s “He: Understanding Masculine Psychology” and “Transformation: Understanding the Three Levels of Masculine Consciousness”. The title of my current read, “Living Your Unlived Life”, really spoke to me when I first came across it a couple of years ago: I could have done so many different things, but I made decision after decision that eliminated those options and put me where I am right now. And sometimes, in moments of doubt, I wonder what my life would have been like if I had made a different choice at one of those virtual forks in the road. I knew from age four that I wanted to be a doctor, and ever since I first visited this country, I knew I wanted to be a country doctor here. I got exactly what I wanted, but I didn’t quite consider all the consequences of making a life for myself so far away from my family and everything I grew up with.

I was a Scout, very good with map and compass, and spent many a night by a warm fire under the stars in the vast Swedish forest, Kolmården. Some of us played guitar, all self-taught, and we shared chords and riffs as the evenings grew cold and the others went to sleep in their lean-tos deep inside their mummy sleeping bags. One of my friends, C., was a year older, taller, better looking, and more confident and outgoing, but we became close over the years. He was taking business classes in High School. I already knew I wanted to be a doctor. We lost touch after I started Medical School. The only time I see his face now is on the cover of The Wall Street Journal and when I occasionally watch TV during travel; he is the head of one of the world’s biggest multinational corporations. I sometimes wonder how come I couldn’t also have been a successful businessman, but then, I don’t even like to balance my checkbook, so why would I think I could have made it in the world of finance?

Closer to home, my High School classmate, J., also knew all along he wanted to be a doctor. He stayed on at the University Hospital where he went to Medical School, went into a subspecialty, got his Ph. D., and has been head of his department for many years. He has more influence in a vastly larger organization than I have, and his life seems more straightforward in the sense that he made his career right in his own back yard; he didn’t move halfway across the world and away from his family to find his life’s work. But sometimes when we talk, he speaks of my life as more exciting; considering the path not taken causes a twinge in each of us.

I just got an email again from my army buddy, L., who also started Medical School in Uppsala when I did. A few months into our first semester, his debut novel was published. A year and a half later, he dropped out of Medical School to write full time. He was just awarded one of the most prestigious literary prizes in Sweden. Before I even met L., I harbored secret dreams of writing a great novel. Forty years later, he is still putting them out, and my first one is still more of an idea than an actual draft. In his latest email, he expressed his admiration and approval of my Country Doctor lifestyle and confessed he was jealous about my having goats.

As I sit here near the end of my week off, I think of where I am in life right now. The minutes go so fast at work, and the evenings and weekends at home are so short; I don’t often have time to think as much as I have this week. While we were cooking this afternoon, Emma said, “This is the first time you’ve really just been home for a whole week in years.”

I know the psychological task for people my age is to make peace with who we are, and to gather up those dreams and desires we never seemed to have parted with willingly, as well as the wounds we never took time to heal; we must now give them their rightful, if only symbolic, attention in our lives in order to be whole persons.

The central idea in “Living Your Unlived Life” is that the “unlived” parts of our lives can be lived out in totally symbolic form – “Doing something by not doing it”. Symbols, unlike signs, have many interpretations and can even encompass seemingly opposite notions.

So, my only multinational business is being both a Swede and an American, practicing modern, yet old-fashioned primary care medicine in rural America among French-Canadian patients.

My only sphere of professional influence is my exam rooms and the community I serve. My life is here, and it is rich with nuances, contradictions and memories. I have few regrets, and even they make up part of the unique substance of my life.

My only literary calling, at least for now, is to keep adding to this five-year-old weblog about how it feels to do the work I do.

Countless times during the course of my day, some person, entity or task vies for my time and attention.

“If I could just have a minute of your time” begins a request to also see the spouse of a scheduled patient, a sales pitch from a pharmaceutical “rep” or home oxygen vendor, a phone call from a visiting nurse, a message from a far away relative of an elderly patient in tomorrow’s schedule or a plea to complete the form Mr. Henderson forgot to bring with him for yesterday’s appointment. Unspoken, the same request lies behind every email, fax, memo, journal and invitation that finds its way to my office. A minute of my time doesn’t seem like too much to ask.

In years past I would consider such requests with a constant awareness of how much my time was worth to my employer. “Seven dollars a minute”, I would say, only half joking, when non-patients asked for a minute of my time. That is the “opportunity cost” for a minute of a family practitioner’s time in today’s American health care industry.

Lately, and probably not a minute too soon, I have started to very seriously ponder what each minute of my time is really worth. And I now understand better that time isn’t measured in dollars. Sometimes it isn’t even measured in minutes.

To the patients that entrust me with their care, a minute of my time could make the difference between a good visit and a less than satisfying one. It could make the difference between making the right diagnosis in the first visit or much later. To the far away relative, a minute could mean the difference between needless worry, calm reassurance, or planning a last trip to see their loved one before it is too late.

The emails, memos and invitations obviously pale in comparison to the things I originally went into medicine for, but I have tended to become distracted by the interruptions. And the dollars-per-minute way of thinking is really a very large distraction, too: Again and again I have found that when I don’t watch the clock I am more effective as a physician and more powerful as a healer. I diminish the value of my professional skill, experience and wisdom by thinking of my work in flat rate terms. A minute at a bus stop isn’t the same as a minute at the Symphony, is it?

And, thinking of my employer’s “opportunity cost” – what about my own? My organization will probably be there long after my time is up, so how much is a minute worth to me, since I have fewer of them? I know what the real answer is, I have just had trouble claiming it for myself: My time is invaluable, priceless.

When our horse started to colic today and I left the office early, four patients with routine appointments had to be rescheduled. I made sure they were safe before I drove home to help my wife handle the situation. In years past I would have struggled with guilt, but today I didn’t.

I have come to realize that your days are numbered in the pressure cooker that medicine today can be if you aren’t well rounded in your life. You can’t help others if you aren’t taking reasonable care of yourself. This doesn’t mean that one should be selfish, but it also means one shouldn’t be forever self-sacrificing.

Every time I watched the “safety on board” presentation before takeoff, I have startled at the idea of putting your own oxygen mask on before helping others with theirs. But it is good advice.

My goal is to live long and work until the end in my profession. I want to be the kindest, wisest physician I can be. I also want to be the kindest, wisest human being I can be.

It was about time I let go of my dollars-per-minute yardstick for the value of my time at work. It is also high time for me to think of all of my remaining minutes, 13 million if I live as long as my parents, as absolutely priceless.

The horse is doing fine. The goats are chewing their cud. The barn is warm and cozy under the starlit late winter sky. It is well below freezing and the crusted snow crunches under the cleats of my winter boots as I walk back across the yard to our little red farmhouse.

My stay-at-home vacation has started. I intend to spend it wisely.

First published in 2012.

A mezuzah (Hebrew: מְזוּזָה‎ “doorpost”; plural: מְזוּזוֹת mezuzot) is a piece of parchment (often contained in a decorative case) inscribed with specified Hebrew verses from the Torah.

ט וּכְתַבְתָּם עַל-מְזֻזוֹת בֵּיתֶךָ, וּבִשְׁעָרֶיךָ. {ס} 9 And thou shalt write them upon the door-posts of thy house, and upon thy gates. {S}
                                        Deuteronomy 6:9

It’s almost 4:30 and I have three more patients to see before my Christmas mini-vacation can begin. Snow and sleet are beginning to fall outside. Our lab tech, who leaves between 3 and 3:30, just called from home to warn the rest of us that she had seen nine moose on Route 1, probably attracted by the road salt.

“Three encounters in thirty minutes”, I think to myself, “and neither of them completely straightforward”. I used to shudder when healthcare administrators called medical office visits “encounters” , but the more I have thought about it, the truer the word rings to me. Two people meet briefly and try their best to communicate in spite of sometimes very different viewpoints and agendas. I remember the phrase “Marriage Encounter” from my first visit to this country in the early 1970’s – an event where couples learn to see each other with new eyes and communicate more effectively.

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

4:35 – In Room 1 sits Bill Boland, the fellow who always sasses me for my habit of knocking on the exam room door before I enter. He had been in with pneumonia and his x-ray came back suspicious for a tumor. The purpose of today’s follow-up visit is to make sure he is feeling better and to tell Bill he will need more testing. I raise my hand in an automatic door knocking gesture, but catch myself and instead touch the doorframe briefly and take a slow breath before entering the exam room, ready to deliver the disturbing news.

4: 50 – In Room 2 sits Wally Parker, here to talk about his blood sugars. His wife is in the hospital with a lower GI bleed, and her colonoscopy showed an ulcerated tumor that is almost certainly malignant. “Why is he here tonight instead of at Mary’s bedside?” I ask myself as my hand reaches for the doorframe. At the same time I try to clear my mind of my own clutter and my guesses why he has chosen to keep this appointment under these circumstances.

5 o’clock – The child in Room 3 is an 11-month-old with a fever. He belongs to the pediatric group in town, but probably the slick roads and the late hour are the reasons he is here. A new patient, and a sick child at that, requires me to be unhurried and receptive. I must be aware of how well we connect, so neither this child’s young mother nor I miss something important in our encounter. In this case, the child has an ear infection and the mother is a registered nurse with an older child at home who has recurrent ear infections.

At 5:15 I wish Autumn and the new receptionist a Merry Christmas before I leave through the back door.

Route 1 is covered with snow and the large flakes coming right at me make it impossible to see with high beams. I drive slowly with only my low beams, and don’t see a single moose.

Our house is all lit up for Christmas. In one of the sunroom windows shines the metal star-shaped lamp that hung in my bedroom window when I was a child. I remember coming home from school in the dark, looking up at my star on the third floor of our Swedish apartment building, even closer to the Arctic Circle than where I live now.

I can see my wife in the kitchen window, but she can’t see me in the darkness outside. I quickly stomp the snow off my boots on the wooden steps outside the door. My hand touches the doorframe for balance, physical and spiritual, and as a brief gesture of love and blessing:

I am home. It is Christmas.