Assumptions and Expectations

The setting: My old apartment building on Valentine's Day, over twenty-five years ago.

As I stepped into the foyer, my eyes immediately went to an absolutely beautiful, large floral arrangement wrapped in cellophane and waiting beside the inner, locked door. "Oh!" I thought, "Cindy is going to love that!"

"Cindy" was the neighbor who lived across the hall from me, and other than the usual tidbits that city apartment dwellers pick up from sheer proximity to one another I didn't know her well. She was pretty and smart, with an engaging smile, warm eyes, and an easy conversational style that drew people to her. Cindy worked in sales and seemed born for the job; I imagine she was very successful. Although there was a time or two when I saw her with the puffy eyes and red nose that go with a respiratory infection and one instance where she clearly was distraught after a row with a beau, Cindy characteristically was smiling and perfectly decked out for whatever an occasion required, with her long, dark hair falling in easy waves down her back, sometimes corralled with a scarf or pushed aside with sunglasses atop her head. We shared a housekeeper and a hairdresser, and I found my new favorite radio station after noticing the music coming through her apartment door, but although our lives intercepted in the hallway from time to time they didn't otherwise overlap and we weren't close friends.

Nonetheless, I noticed that Cindy usually had a boyfriend, and she and her man always seemed rather like Barbie and Ken. I'd see them heading off to play tennis or go skiing, or notice him ascending the stairs behind her, arms laden with groceries and other miscellany from their shopping excursions, smiling and obviously happy to be of help. The floral arrangement I saw on that Valentine's Day seemed the perfect gesture for Cindy's boyfriend to have made, and I knew she'd be delighted.

I, on the other hand, was dating "William." William always was "William," never "Bill" or "Will," and certainly not "Billy" or "Willy." Named after his father, he hadn't picked up a nickname to help distinguish one from the other, such as Chip or Bud; no, it always was just "William." William was handsome and smart, educated at the best schools and successful in his profession. He was a gym jock as well as a studious dancer who knew all the steps and moves, even if he sometimes seemed to be marching through them more than dancing. My girlfriends envied me: William was a catch: An attractive, accomplished man, trustworthy and reliable, and one who not only would and could dance but also was a strong lead. What more could a lady want?

William was somewhat socially awkward, though, and a bit shy. It could be hard to draw him out, and no one ever would accuse him of being romantic. In fact, after awhile I chuckled knowing that every holiday and special occasion would be met the same way: I would receive a perfectly nondescript card that equally well could have been sent to his mother, boss, or child's teacher, with a generic message of good wishes for the day and William's inscription, "Happy [occasion] from William." "Happy birthday from William." "Happy holidays from William." He might take me out for a lovely evening and would spare no expense, but tangible mementos weren't William's style and the say-nothing cards "from William" made me smile but didn't touch my heart. That just was William and how he rolled.

So on that long ago Valentine's Day I peeked through the slots of the mailboxes on my way by, noted that the mail had not yet arrived, and made my way to my apartment intending to return later to look for mail again, anticipating the obligatory Valentine greeting "from William." Once home I set about putting things away, changing clothes, and perhaps making a snack or lunch before settling down to make phone calls and do paperwork, and thought idly of the lovely surprise downstairs that awaited Cindy. I couldn't help but think that it would be wonderful to have a beau who would send me something like that, but reliable, dependable, rock-solid, hardworking William just didn't do things that way. A woman could do a lot worse than William, I knew, and I needed to appreciate him as he was.

Still, the thoughts lingered and niggled: "I wish . . . I wonder if any amount of hinting or begging would make any difference . . . If only . . . Hmmm. It wouldn't hurt to look. It's a long shot, terribly long, but I could look, and promise myself not to be disappointed to see Cindy's name on the card." After all, the simple elegance of that floral arrangement simply screamed "Cindy," and sending it was exactly what I would have expected her boyfriend to do.

So, having steeled myself against likely disappointment, I retraced my steps and went back downstairs. The flowers were even prettier than I remembered . . . and there on the card was . . . my name! I picked them up and floated upstairs, and even had the pleasure of encountering the man who lived above me and observing that he was duly impressed. Once back in my apartment I removed the cellophane and discovered that in addition to the flowers the arrangement included two mugs adorned with red hearts and assorted small packages of coffees and chocolates. William knew me better than I'd realized, and perhaps better than I knew him. As though to ensure that I kept at least one foot firmly on the ground, however, the card bore the characteristic message, "Happy Valentine's Day from William." I had to laugh!

Last week, the very day after I wrote about "Uncle" in this space, the next mug up in my rotation was the one remaining heart-covered one from that long ago gift from William:

As I looked at it, sitting there in my kitchen with the morning's joe ready to help jumpstart my day, I thought of all the goodness that people overlook simply because they don't expect to find or receive it. Had I not happened to go back downstairs that day, albeit fully expecting to be disappointed, I would have missed William's gift. It's a sad state of being when one walks right by a much longed-for blessing without so much as bothering to glance at the card, and receives it only when the universe clunks one over the head. I've needed many a clunk of that sort over the years!

But beyond being head-shaking sad, expectations and assumptions can be actual health hazards. The assumption that physical and mental frailty are normal aspects of aging, for example, and therefore nothing that should be evaluated and treated, or the expectation that crushing chest pain will subside spontaneously if one just doesn't give into it, robs countless people of both quality and length of life. And some expectations and assumptions can drain the vitality and joy from literally decades of living.

Consider "Viola," a ninety year-old patient whom I first met while she was in the hospital. Her friend "Warren" was at her bedside, and we talked together about her going home and the home healthcare she would receive once there. Viola has a quick wit and sharp tongue, and I liked her at once. Thinking it unfair to use my position to take all the "good" patients before they even left the hospital, I sent her referral to the home care office with no recommendations about staffing but hoping she might come to me. Unfortunately, once home she was seen only once by a weekend nurse before she landed back in the hospital with cardiac complications. I saw her frequently during her second stay, finding Warren with her every time and thinking more and more that I'd like to have her as my patient when she finally returned home.

It happened. The home care scheduler sent a list of patients who needed Case Managers, and Viola's name was on it. So I jumped on it, and as soon as she went back home Viola was mine.

My impressions from those hospital visits weren't wrong. Viola is quick and witty. She reads voraciously, loves crossword puzzles and classical music, and has a condo full of treasured collectibles. We disagree about politics and so stay away from that topic, but she regales me with stories and we "solve the world's problems" together while I unpack and later repack my gear. However, I have seen Viola either in the hospital or at home for two months now, and don't believe there has been a single encounter when she has not mentioned being an orphan.

Ninety years ago, almost a century, Viola was dropped off at an orphanage when she was days old and stayed there until she ran away as an older child, not happy with the nuns' insistence that she eventually enter the convent herself. "I've been on my own ever since," she says.

Ninety years later, every time I see her she speaks of being an orphan. From time to time she remarks, "Nobody loves me" and "Nobody wants me," half joking, but clearly not entirely so. "I'm all alone," she'll say matter-of-factly. "I have no one." Yet Warren, with whom she worked for decades before they both retired, drives over an hour one way to visit her and to take her back to his home to visit, later driving her home again and then driving still more to go back home himself. Warren calls every day "to be sure I'm ok." One of Viola's old doctors, now long since retired, takes her to lunch, and she's busy looking for a book for him now. Until recent health issues slowed her down she was active in the community, and recently intervened with the alderman, who heard and respected her enough to resolve successfully a dispute within the condo association.

One day last month I went to see Viola for a scheduled appointment, but the front desk attendant could not reach her to announce me. I waited in case Viola was in the bathroom or down the hall throwing trash in the chute, but repeated calls yielded no response. We were worried. A building engineer joined us and looked concerned when he learned what was happening; he went to procure a master key from the building office. As other residents passed through the lobby the desk attendant asked if anyone had seen Viola lately. Everyone seemed to know her, but none had seen her in the previous two or three days and each one paused to express concern, with clearly apparent and genuine positive regard. The engineer returned and escorted me to Viola's unit, where there was no response to the door and where it turned out the master key did not fit one lock that Viola evidently had changed. We returned to the lobby, and the desk attendant agreed to ask Viola to call me if she appeared, while I would search the hospital records later for Warren's phone number. I considered calling the fire department to break down Viola's door, a decision that for me often is based on a "gut feeling," but opted against it, which turned out to be a good choice.

Viola is fine. Thinking she could go and return quickly, she had ducked out to pick up medicine from a pharmacy around the corner, expecting to be back in time for my visit. I missed her by minutes.

But I now know that there is a big high-rise condo building full of people who like and care about Viola, as well as loyal Warren, the doctor who takes her to lunch and for whom she seeks books, and who knows who all else, as well as this nurse who singled out Viola early on as someone who would be a special patient. But Viola's self-talk is "I'm all alone," "No one care about me," and "I'm an orphan." After ninety years of such talk, I don't suppose that is likely to change. Yet just as I once assumed that a lovely floral arrangement was for Cindy and walked right by it without even checking the card, so Viola has convinced herself that she is alone and abandoned to the point that she doesn't "see" even Warren, calling every day and driving hours to visit her, much less her neighbors and others whose lives she has touched. Viola literally lives in the middle of a caring community, but because of her assumptions and expectations she doesn't recognize it.

In the "new age," self-help world there's a adage that says, "If you can believe it you can achieve it." I don't know that simple belief always is an assurance of a desired outcome; surely the action taken to effect the achievement is critical. I do know, though, that it's almost impossible to receive and achieve that which one cannot even imagine.

We caution children to be careful, to look out for danger, and to take safety precautions. "Stop, look, and listen," we tell them, "You can't count on drivers to see you and stop." "Don't talk to strangers." "Lock the doors." "Know how to use a fire extinguisher and to call 911." "Don't go out alone at night, and don't go into 'bad neighborhoods' at all." "Don't run on the pool deck or with scissors in your hand." "Be careful; you could be hurt."

What would happen if we invested the same level of energy in teaching them to pay attention to the goodness around them? When he was a boy Fred Rogers' mother used to tell him to "Look for the helpers" when news stories frightened him. The helpers always would be there, she said. Suppose we also encouraged children to look for the people who are happy and smiling, to spend time with those who leave them feeling good, and to expect generosity and happy surprises and to delight in extending those as well. Imagine explaining that sirens in the distance are good signs, because they mean someone who needs help is receiving it and that others have the opportunity to be helpers. What if we taught them to see the value in every type of work that any person does and to appreciate it? Suppose we instilled a sense of wonder and endless possibility, instead of just "stranger danger" and defensiveness. Certainly children need to be careful and safe, however, one-sided teaching that focuses on darkness risks leaving young people oblivious to the light.

This is a season of imagining and story-telling, whether around the Christmas tree, menorah, ceremonial solstice fire, days of Kwaanza, or something else. Thinking of Viola, and of my own failure once upon a time even to consider that a gift might be for me, I wish for all of us times of thoughtful storytelling and conscious listening, both in the immediate weeks ahead and in the new year that follows. May we pause mind and body alike, to listen to the stories around us, others' and our own, and dare to correct errors heretofore unnoticed, so that as we move into the new year we carry with us light and wonder and a sense of the possible, free at last from the binding of unrecognized but powerful

Assumptions and Expectations.

Uncle

I collect mugs. I never intended or planed to collect mugs; it just sorta happened. When my kitchen was redone a number of years ago the designer popped a small section of floor-to-ceiling shelving in what otherwise would have been unused space, and a display area for mugs was born. I still didn't get it, and only after randomly unpacking, trying to put the new kitchen in order, did I realize that the mugs I'd absently set on those shelves belonged there. Looking at them later I realized that most of them have a story. This is one:

Many years ago I visited a quadriplegic patient. Injured in an accident the details of which I long since have forgotten, he was a talking head. He couldn't move his arms or legs at all, and I'm not sure now that he even could turn his head. Japanese, he lived with family who respectfully called him "Uncle," and they couldn't have been more courteous or deferent if he'd been able to rear up and threaten them with every sort of violence imaginable or to dole out wads of cash. As are many Japanese homes, the apartment was minimally appointed and spanking clean, always. That it was a third floor walk-up didn't stop the men from carrying Uncle down the stairs and strapping him first into the car and then into a wheelchair so they could take him fishing. Uncle loved to fish, and a little thing like quadriplegia wasn't about to stop him from going!

All I did was visit once a month to change his urinary catheter. Never did I find a mark on his skin, a drop of water in his lungs, a hint of infection, or any other complication of such profound immobility. Uncle always smiled and always asked after me, while at least one family member hovered in the background ready to assist and eager to hear any suggestion I might have to make Uncle's life the least bit better. I don't recall ever having even one; this family had it down perfectly. Nonetheless, Uncle and family alike never failed to extend heartfelt thanks at the end of each of my visits.

One Christmas they gave me this mug. It probably was part of a Starbucks gift package; I don't remember. Of course any coffee or hot chocolate that might have come with it was devoured with relish long ago.

I use my mugs on a rotating basis so I can enjoy each one and none become too dusty on a shelf. Every time this one comes up in the rotation I remember Uncle, his smile, his appreciation, his spirit in the face of circumstances that would have broken most people, and also his dedicated family. It now has been some fifteen years since he died.

Funny the impact that the smallest gesture can have. A simple, mass-produced coffee mug keeps Uncle and all that he and his family stood for alive in my heart every single time I see it.

For many this is a season of giving, and also for many there comes a certain angst about what to buy, what to do, what another wants or needs. I suspect the perfect gift is simply seeing and honoring that other, as Uncle's family saw and honored him, and that any item chosen to represent this will be just right as long as it is selected with love and good will. Indeed, one need only pop by the likes of a Starbucks and pick a package off a shelf as long as that package contains within it the joy of giving along with a mug and anything else. I can attest that when this happens both gift and giver will remain with the recipient always, much as in my heart I carry to this day the memory and spirit of

Uncle.

A Pork Chop, a Potato, and a Nice Green Salad

Costco began slipping red and green ribbon onto the shelves in July, and I still was riding my bike in shorts and a tank top when I first noticed decorative "snowflakes" adorning city lampposts. Now several catalogs arrive in the mail every day, and in the hospital lobby this morning workers were busy hanging garland and ornaments. A Facebook friend tells me that between November first and January fifteenth there are 29 holidays observed among seven major world religions. It's "that time of the year." Yet among all the symbols and traditions abounding I never would have supposed that for me one of the most powerful images of the season would be a pork chop, a potato, and a nice green salad.

"Marge" was one of my all-time favorite patients. We first met when, at 83, she had both knees replaced at the same time and I was her visiting nurse. Over the years she developed a vitamin deficiency requiring monthly injections, a spell of high blood pressure that was challenging to control, a diagnosis of diabetes, various wounds, and occasional mobility issues resulting in falls and misbehaving body parts. I saw Marge for about a decade, with those monthly vitamin injections keeping her on my "active" list even when everything was going well. She lived in a subsidized senior housing building where I saw many other patients, so between our routine visits I often encountered Marge retrieving her mail, stopping to chat with workers in the building office, or popping in to see a friend.

Marge's apartment had big, sunny windows that faced east, and in the mornings the sunshine streamed in as Marge settled in her recliner, which was tucked in a corner of the living room with everything she might need arranged within arm's reach around her. Marge had been the personal secretary to a senior executive of a large company, and she was nothing if not organized and efficient. A stack of books, the phone, coffee and snacks, a pad and pen, and any projects in which she was involved all were placed carefully around her chair, convenient, but neat and not cluttered. The television was across the room facing the recliner, but in the mornings Marge had jazz softly playing. With the bright sunshine, soft music, aroma of coffee and breakfast, and Marge's smiling face looking up at me from her recliner "command post," I used to tell her that she was my role model for how to do retirement. "It's nice, isn't it?" she'd respond with a satisfied smile.

Marge was as efficient in selecting friends as she was with everything else. Her friendships were carefully nourished, and although she had cordial relationships with almost everyone, "Maude," "Alma," and "Dorothy" were her closest cronies. If one needed something the others stepped up to provide it. They sat together at activities in the building, and checked on one another by phone every morning and every night. "We don't talk," Marge once emphasized, "We've agreed. Five minutes, and then we all have things to do." Maude, Alma, and Dorothy all were my patients at various times, too, and I remember more than one frustrating evening when I tried to call two or more of them to schedule appointments for the next day only to find all of their phone lines busy. Of course I had hit upon the hour that they were checking in with one another, confirming that all were home safely and no one needed anything. In the mornings it would be the same thing: A tizzy of phone calls among the four of them to be sure all were awake and ok, and to pass on such messages as that Maude was taking the "shopping bus" and could pick up small items for the others, Alma had been baking and would stop by with cookies later, and Marge just had finished a book that Dorothy would love, so Dorothy should pick it up when she went out.

Visiting Marge at least monthly, I saw the seasons change through her big windows, and her observances with them. A few items adorned with red hearts appeared around Valentine's day, a green tablecloth with a spunky leprechaun atop it adorned her table in March, and a wreath of artificial pastel flowers hung on her door in springtime. And so it was throughout the year. Often I'd comment: The autumn scarecrow on a shelf was adorable, the red, white, and blue coffee mug was perfect for the fourth of July, etc. So when the Halloween-themed items were replaced with a cornucopia on the table and the kitchen towel sported caricatures of turkeys, I asked Marge about her Thanksgiving plans.

"I'll be right here," she said, smiling.

"You're not having dinner with your cousin or doing something with Maude?" I asked, surprised.

"No, I'll have my own dinner here. I like it that way."

Over the years I often thought about many of my patients who were home alone on holidays. Some were lonely and seemed to have contracted energy that turned inward and left them in dark places of self-pity, regret, and longing. Rarely did anyone ask anything extraordinary of me; nonetheless those living in their own dark clouds were hard to be around.

Marge and her friends were different. Maude's and Dorothy's families lived far away, and while Alma's family visited regularly she wasn't up to many long drives to their homes for hectic days of celebration. Many times as Thanksgivings, Christmases, and other holidays passed and Marge remarked that she would be home alone I considered taking a break from my own holiday to deliver a nice dinner from my own table. Other times I wondered about arranging a small gathering in the building's community room where residents could celebrate together. My colleagues and I could donate some food, and residents could bring dishes to pass as well. And once in awhile I thought about just taking something that Marge could share with whichever of her three friends were home on the day in question.

By the grace of God, something stopped me each time. I might have been called to work or had a last minute change of plans. Once or twice I may have been ill, and I know there were times when I had houseguests who kept me more than busy. Perhaps the car was in the shop or I just hadn't organized my time well enough. But I never assaulted Marge or her friends with my turkey, pumpkin pie, or good intentions. It took years and years of Marge saying quietly that she would be home alone and liked it that way before I truly heard her. This was the story that finally got through to me:

The day before that Thanksgiving Maude was taking the "shopping bus" to the grocery store, and Marge mustered the energy to take her walker and go, too. Once there she spied a thick, fresh pork chop in the butcher's case, with just the right amount of fat. She bought it to enjoy the next day. Then, in the produce department she carefully selected one small potato, just right for one person, and also saw containers of pre-washed mixed green salads. She bought those, too.

Marge always loved the Macy's Thanksgiving Day parade, and as November unfolded she looked forward to settling into her recliner with her coffee and delighting in the entire spectacle, with no obligation to help in the kitchen, no one moving in front of her and blocking her view of the TV, no distracting music or radio in the background, and no not-so-subtle hints to change the channel to the pregame shows before kickoff. When the parade ended Marge breaded and seasoned her pork chop and put it in the oven along with the potato. As they baked and with holiday music in the background she wrote her annual Christmas letter, and after dinner put away the turkey decorations and cornucopia and set about decorating her apartment for Christmas. A small ceramic tree went on the table, a red and green wreath on the door, Santa Claus towels hung in the kitchen, a stuffed reindeer wearing a red hat appeared on the sofa, and assorted figurines and mementos found spots around the home.

No homemaker or medical people came, nor did bills and junk mail appear. Maude and Dorothy called as usual; Alma was away with family. Marge's cousin called, as did her nephew in Phoenix. But the building engineer didn't need to inspect or repair anything in her home, and there were no responsibilities to other people that needed to be met.

Instead, Marge watched the entire Macy's Thanksgiving Day parade uninterrupted and relished every minute of it. Her own home smelled of good things cooking, a rarity for one who as a rule subsisted on frozen dinners, and her music brought joy to her soul. She loved the look of her apartment newly turned Christmasy, and felt a sense of accomplishment when the holiday letter was done. That night she watched an old movie on TV, and then went to bed truly thankful for a peaceful, happy day.

Had I appeared with a plate of turkey-with-all-the-trimmings, or pressured her into a celebration with friends or neighbors that I had orchestrated I'm sure she would have appreciated my efforts . . . and at the end of the day been tired, perhaps a bit out of sorts, and without her holiday season started in the efficient way she liked, apartment decorated and letter written. And the poor pork chop would have needed to wait another day, and then be hurriedly prepared when the homemaker wasn't in the kitchen, with Marge retrieving the mail and filing a work order in the office instead of listening to music and enjoying the aroma of good home cooking coming from her own kitchen.

I didn't appreciate it at the time, but now never will forget the smile on Marge's face and the light in her eyes as she told me, "It was a wonderful holiday. I had a pork chop, a potato, and a nice green salad."

Over time I came to recognize flaws in the common assumptions about holidays and how people do or don't observe them, and I learned to believe what my patients told me:

Widowed after more than 60 years of marriage, "Edna" had made more holiday dinners than she could count, and she was ready to be done with them. Just the thought of all the hubbub of a big gathering was tiring, and she preferred smaller, more personal visits or calls. If she was alone for a day she considered it a blessing.

"Elizabeth" had a tremor in her hands. Her doctors had been unable to come up with a diagnosis or cure, so whenever she reached for something her hands shook. As a result, Elizabeth was a messy eater. She spilled on the table, on the floor, and on herself. She didn't need or want to be fed ("Like a baby!" she said), but mealtime never was neat and clean. Embarrassed, Elizabeth did not want to eat around other people, and with the kitchen being the only other room in the family's small house she could access, Elizabeth chose to stay in her bedroom. She was not lonely or isolated; often I found three generations of family around her bed. For health reasons I wanted her up and walking; it was years before I realized that Elizabeth never would act on my encouragement to walk to the kitchen and sit with her family. There always was food being prepared and served in that kitchen, and Elizabeth was not about to put herself in a situation where she would be expected to eat in the company of others. Uh uh; not happening.

"Thomas" has diabetes and chronic cardiopulmonary and kidney disease. He must avoid sugar, minimize sodium intake, be careful of proteins, and watch how much fluid he drinks. He observes all of those restrictions perfectly, with his strategy being not to have inappropriate foods in his home, because, as he tells me, "If it's in front of me I'm going to have a taste. And then I have another one and another one, and before I know it I'm in trouble." Thomas now chooses not to attend most parties and family gatherings because he knows his own shortcomings and wants to avoid another stay in the ICU. Instead, he asks people to visit him at home, and he controls the refreshments.

Many people, particularly elders, don't hear well in crowds or can't filter out background noise. Some don't see well or can't manipulate tableware well with arthritic hands. Others worry about having ready access to bathrooms, or don't like taking portable oxygen or medications with them when they go out. Many have told me over the years that most of the family they knew have died or moved away, to the point that near-strangers surround the holiday tables as more distant kin bring in-laws and friends to celebrations. "It's more like making small talk with strangers than being home with family," one person told me, and for him that wasn't worth the effort. Some people are shy, some are socially awkward, and some find groups of people tiring rather than enjoyable.

To be sure, there are people who are achingly lonely, perhaps newly widowed, far from home, painfully isolated, people who would relish an invitation, a visit, or being remembered with a plate of leftovers. But in an unthinking hurry to have someone like Marge have the kind of holiday experience that someone like me assumes she would want and should have, there's a risk of doing violence to that person's way of life and creating more stress than joy.

With many wise elders to teach me, quickly before I began loading my car with holiday meals or planning parties few cared to attend, I (finally!) have learned a few things that may be helpful to others who wish to be generous as another season of holidays unfolds. These are some of my lessons:

(1) Instead of asking, "What are you doing for [holiday]?" ask, "Do you observe any holidays this time of year?" Let others tell about their beliefs and practices, and consider what might be offered that would fit in and be appreciated.

(2) Ask before making a gesture: "May I bring you a plate?"

(3) Respect the limitations that others establish. If they say that something is too much, too tiring, too far, too whatever, then it is so.

(4) Offer options: "We really want to see you at [holiday]. Will you come for dinner, or may we stop by over the weekend?"

(5) No one wants to be a "charity case" or afterthought. A call at the last minute to say, "If you don't have anywhere else to go you can come here" is a slap in the face rather than an invitation, as it appears that the caller waited as long as possible in hopes that the person being "invited" would have other plans, and further supposes rudely that she or he has less than a full social calendar.

(6) "I just don't want you to be alone for [holiday]" is offensive to someone who lives alone, as it implies that his or her normal way of life is inferior, ok, perhaps, for some days, but certainly not for [holiday]. Invitations should be issued and gestures made without judgment or comment about the recipient's lifestyle.

(7) Guests honor us with their presence; we do not rescue them by taking them in. Last minute or spur of the moment invitations work when they're phrased well. "George! We just came home and saw your television on. If you're home and have any time on [holiday] we'd love if you would join us for something. Dinner is at [time], or if that doesn't work if you could stop by for dessert or drinks or even just a cup of coffee in the morning or to watch the game we'd love it. We're sure you have plans, but if you could work us in it would make the day all the more special." George may decline altogether, or he may appear before the sun rises and stay until the last dish is washed and put away that night, or something else. But he will know he is a wanted and welcome guest rather than an afterthought or the subject of his hosts' pity or self-conscious guilt.


Soon the media and various social service and religious organizations will be admonishing us to remember those who are alone during the holidays. Thanks to the patient teachings of Marge in particular, and many others as well, I've learned there's, if not an art to this, at least a need to ride herd on assumptions and stereotypes and to muster up a load of respect and courtesy lest charitable intent breed less than comfort and joy. In the weeks ahead I will visit many patients who live by themselves while observing one or more of those 29 holidays celebrated this season. And for me the right gesture to make for days that are merry and bright entails visions not of Santas, angels, trees, creches, stars, candlelight, "winter wonderlands," or anything else, except mindfulness of once upon a time when on the day of a holiday there was in one home just

A Pork Chop, A Potato, and a Nice Green Salad

Listen.

Any who have stayed with this page from the outset may remember that its grammatically incorrect name, "Tell It Good," came from an encounter with a patient and her daughter many years ago. Longtime residents of Chicago's Cabrini-Green public housing development, they had watched its rise and (eventual literal) fall, and ultimately had been relocated to a newly constructed apartment adjacent to the site of the old "projects." Albeit clean, bright, and critter-free, with an absence of drunks in the hallways and drug dealers outside the front door, the new place came with its own set of problems, ranging from tenant-paid heat that they couldn't afford to rules against congregating in common areas, which left them isolated and without both their former community and their usual ways of meeting people and making friends. Reminiscing, they told me that for all the problems in the Cabrini of old, were it possible they'd give up the new apartment and go back in a heartbeat. Listening to their poignant, witty accounts I told them they should write a book, that their story should not be lost, and when I pressed they told me, first one speaking and then the other, "You write it." "You tell it." "Yeah, because you tell it real good." Ever since then I have striven to tell the stories that have played out in my work as a nurse, because stories teach as nothing else can. Stories touch hearts and build bridges, and remind us of our common ground. And sometimes telling a story itself births good; from a new understanding or realization of shared humanity goodness grows such that "telling good" is less bad grammar than an actual movement of energy from words to being in the world. But we must not be so busy telling our own stories, often over and over to those whose stories are similar, that we fail to heed the stories of others, to listen.

"Roshell" was a single mom caring for her young children and for her own disabled mother, "Myrtle," who had suffered a stroke some time before I met them and had several other health concerns as well. They lived on a high floor of a Cabrini-Green high-rise; did I climb six flights of stairs to see them, or was it nine? I don't remember, but it was a considerable vertical trek with a heavy backpack, casebook, assorted supplies, flashlight, and police escort. There were drug dealers outside and often more "working" in the stairwells; we'd ask which stairs we should use so as not to disrupt their "business." It was dark and smelly; often there was human waste or vomitus on the stairs, and always there was trash to be skirted. Occasionally we'd come upon rodents that had met their demise; more frequently live ones scurried out of our way.

Things weren't much better in Roshell's apartment. Cockroaches prowled about in broad daylight, and our shoes stuck to the floor as we walked from room to room. The first time I saw Myrtle she was lying on a sagging double bed in urine-soaked linens and clothing, unable to turn without help, much less stand or walk. "She's wet, Roshell. If you'll bring some clean clothes and linens I'll help you clean her up," I said.

Roshell sighed. "I just did that yesterday. Maybe I can do it again tomorrow or the next day, but I'll help you push her over where it's not so wet."

"How often do you bathe and change your mother?" I asked.

"A couple times a week usually," came the response.

A licensed professional nurse, I am a mandated reporter of any abuse of children or vulnerable elders I encounter. It's the law. And here was an old woman, unable to move about or care for herself, living in filth and left lying in her own waste for days on end. It would be time for me to pick up the phone. Once I made that call an investigator from the state Department of Aging would follow up, and finding what I found no doubt would pursue legal recourse to remove Myrtle from the home and send her to a nursing home where she would be cleaned and changed promptly and also assured the food, medications, and other basic care she needed. Of course what that would do to her spirit and to her family is another matter. So I asked Roshell to tell me about taking care of her mother.

Most of us pee several times a day, and Myrtle was no exception. But Roshell had a limited supply of linens and clothing, and doing laundry entailed taking two buses to the nearest laundromat, after carrying the soiled items down the same dark, dirty, gang-infested stairs up which I just had come. This could happen only when someone turned up to be with Myrtle and any of Roshell's children who were home at the time. Frequent trips to the laundromat were expensive, between bus fare and the cost of the washers and dryers, so laundry days had to be limited for financial reasons as well. And because the old mattress was wet and never had time to dry before being wet yet again, clean linens became wet and dirty as soon as they were placed on the bed. The best Roshell could do was try to push her mother from one side or corner of the bed to another so she lay on the cleanest, driest possible spot.

On hearing this my judgment shifted from Roshell-as-abusive-daughter to Roshell-who-made-heroic-efforts-to-do-the-best-she-could-with-what-she-had, and who was as loving and devoted as she could be given the resources available.

Within a day I had a hospital bed, disposable underpads, adult diapers, and Physical Therapy in that home. Next came a bedside commode, and before long the therapist had taught Roshell to transfer Myrtle from the bed to the commode. Later Myrtle learned to do this by herself. Wet linens became largely a thing of the past, and trips to the laundromat decreased to once weekly, with less expense because there were fewer items to be washed. Somewhere along the way the sticky floor was cleaned, perhaps because Roshell had more time for that part of housekeeping, and gradually as we addressed Myrtle's other health issues the home overall became brighter, cleaner, and calmer. A year or two later Roshell and her family were moved from Cabrini-Green to a nearby new apartment and their old building was demolished. Myrtle died a year or two after that, in her clean home surrounded by her family.

Had I knee-jerked and done my legally mandated duty when I first found Myrtle unable to move, lying in urine-soaked clothing and linens, and in the care of a daughter who didn't seem to think this was a problem and who appeared to clean her mother and do laundry only when the stars aligned to allow it, the outcome would have been very different. I wish I could say that I just was savvy and wise and so knew to elicit and respond to Roshell's story, but the blunt truth is that my early days in "the projects" had brought me up short so many times, so often leaving me feeling helpless and at a loss for how to proceed, that all I knew to do was go back, show up, and see what happened, see what avenues for some, any, kind of progress might begin to open. And so, having shown up and encountered what was there, I had asked Roshell to tell me her story.

No matter how overwhelming the situation, every. single. time. I simply showed up, often without a clue what I'd do once there, an opportunity presented itself. It may or may not have had anything to do with a patient's "diagnosis" or why I might have supposed I was going there in the first place, but a way to begin to make an inroad appeared. I learned to show up, to be as authentically present as I could be, and to listen.


Today approximately half of our country is reeling from the outcome of yesterday's presidential election. The other half is celebrating and hoping that urgently needed change is on the way. In about an hour from now there will be a massive protest downtown in my city, with similar ones taking place across the country. Had the election gone the other way we're told the other side would be plotting a revolt. I have heard many wonder if women, people of color, non-Christians, and those born in other countries would be safe in the new administration. All over social media I see people on both sides declaring that they'll have nothing to do with supporters of the other candidate. Physical, psychological, and financial violence all have been threatened.

But the scariest thing of all is that no one is saying that it's time, indeed, way past time, to show up, be as authentically present as possible, . . . and to listen to the other side.

Writing about problems with healthcare financing some weeks ago I told of a mid-career physician colleague struggling to make a living in private practice and resisting joining the ranks of corporate medicine, to the point that he now works for the government in remote outposts of the western USA, two weeks on, two weeks off, leaving his home, wife, and children behind when he goes. We spoke last week. In the heart of a rural "red state" he just had finished a grueling night shift. There had been a serious accident on a nearby highway, with one fatality and others badly hurt. He had been up all night and was ready to collapse into bed, except that the post-crisis adrenaline rush persisted and he was wired. Exhausted, but still running in overdrive, he wanted to talk. "It's crazy here, Sue, crazy. These are Trump people. There are Trump signs everywhere. It's scary. I have two daughters . . . But the farmers are having a terrible time. It's really bad. The farmers come to the hospital here and talk; I'm telling you, the farmers are screwed. And the government's done it to them."

Between home visits of my own, standing at the side of a busy road next to my bicycle and knowing my next patient was waiting, I tried to cut the conversation short. "When will you be back home?" I asked.

"Tomorrow morning," he replied.

"Good. Let's talk then."

"Done. I'll call you. But these farmers are screwed. I don't know what they can do, and they're mad. And all for Trump. They think he's going to save them. Crazy, man!" Eventually I managed to nudge him off the phone and towards some much-needed sleep. But I wondered. The farmers are screwed? What has happened to our farmers? They're that angry? When was the last time I talked with a farmer? . . . When was the last time I talked with a supporter of the now President-elect . . . and really listened?

Once over the course of ten years I lived in two small towns. But that was almost 35 years ago, and I've been an urban dweller ever since. The farmers are screwed? Now, I'm not totally ignorant of the plight of agricultural 21st century America, but the farmers are that "screwed" and that invested in a Trump presidency?

As election returns came in last night political analysts I respect were stunned, and as I flipped between channels I heard many say, "We were wrong. Our polls were all wrong. We missed this entirely. How did this happen? We need to rethink completely how we poll and report." One who long has struck me as being never at a loss for words, a skillful and determined but courteous and thorough interviewer, sat mutely staring into the camera.

I suspect he and his colleagues haven't been talking with the farmers either. Or with the non-urban natives of the deep South.

Our new President-elect ran on the theme, "Make America great again." If one is a "screwed" farmer, which I imagine means one can't make a decent living off the land any more, to the point that one's entire way of being is threatened with no feasible alternative in sight, the prospect of making America great again might sound awfully appealing. And hearing the other candidate affirm, "America is already great!" might sound like a promise of more of the same policies that have destroyed the lifeways of farming. If one has watched factories close and move to Mexico or overseas, shrinking the population and tax base of one's community and leaving economic rubble in their wake, the appeal of making America great again is understandable. If a candidate says, "I understand, because my father was a small businessman," but that father's business thrived and his daughter received an Ivy League education, the struggling shopkeeper in a dying town might find that candidate lacking in empathy.

It's a normal human response to difficult circumstances to become nostalgic for an earlier, happier, more prosperous and secure time. Who among us hasn't daydreamed about previous homes, friends, old loves, past jobs, and good times and thought, "Those were the days!" So if "Make American great again" seemed to portend bringing back industry and shoring up farmers instead of freeloaders, that might sound pretty good. If it seemed to straight, white, Christian men that they had done everything right but all the perks went to people of other colors and/or from other places or to uppity women, the prospect of a return to 1950s America might have strong appeal. If one side is talking about free college, then those who didn't finish high school but went to work, paid their bills, and made lives for themselves might wonder where they fit in the picture, as their expenses rise and incomes fall. College is fine for some people, they might think, but keeping their auto repair shops or hair salons open would be the greater priority. And how they're going to do that and pay a minimum wage of $15/hour eludes them, while refugees from across the globe are lining up for free healthcare while hardworking citizens can't afford insurance, much less copays. When every time there's footage of war on the news or a terrorist attack executed or thwarted at home and the perpetrators seem to be Muslims, it becomes easier to see how the struggling shopkeeper, "screwed" farmer, or laid off factory worker might think it best just to keep "those people" out, and maybe to build that wall on the Mexican border, too.

It appears that half the country is hurting, and those folks haven't been, or felt, heard . . . until last night. Bring back industry, keep out the "foreigners" who are draining our resources, take care of the farmers and other "real" Americans, put God back in the schools, make Christianity the national religion, have women live the life of June Cleaver, and don't mess with our guns or other rights, and life, and America, indeed will be great again.

It won't, of course. As Abraham Lincoln said, revolutions do not go backwards. We are, always have been, and always will be a nation of immigrants. Separate but equal wasn't, and even now the white offender has his hands slapped while the black or brown one goes to prison for the same offense. The cost to the country, much less to their own sanity, of sending women out of board rooms and universities and back to hearth and home for full-time homemaker careers is unfathomable. We are immeasurably enriched by the diversity of cultures, religions, and talent around us; a "white bread" society couldn't begin to compete. The problem of terror is the problem of terror, not of another's religion or heritage. Etc.

But we have failed to listen to one another. If the squeaky wheel gets the grease, then the "screwed" farmers, unemployed workers, and lost non-urban, straight, white men who don't know quite who they're supposed to be anymore and who never seem to catch a break even though they're told they enjoy "white privilege" and see others receiving "handouts," evidently haven't been squeaking loudly enough. Or, they're far enough away geographically and culturally that it's easy to disregard them. Until they rise up, and elect President Trump.

I am so glad I didn't act on my first impression of what Myrtle needed those many years ago, and regret that it was only in the face of defeat ("What on earth could I possibly do here?!") that I learned to show up, shut up, and listen. As our nation transitions to a Trump administration we might do best to protest in the streets and plot resistance a bit less, and to listen more. And as we're urged to volunteer for causes we fear now may be jeopardized, we would do well to heed yet another lesson from the "great" days of old: Keeping "church ladies" in the kitchen, Sunday School, and choir effectively kept them out of the pulpit, off the governing board, and away from the finance committee. Community service is a good thing, but volunteer efforts can be exploited and can deplete energy needed for strategy, coalition building, and leadership.

Remembering Myrtle and Roshell today I am reminded of the power and efficiency that come with understanding, and that understanding never is one-sided. I also am reminded that stories "told good" and heard well build bridges.

Let's make American great in new ways, building both on the historic greatness to which President-elect Trump alluded in his campaign and on the greatness extant in our country today, stirringly cited by Secretary Clinton. And most of all may we show up, be authentically present and open to those around us, and

Listen.

The Lightening Bug

To paraphrase Mark Twain, the difference between the right word and the almost-right word is the difference between lightening and the lightening bug. I fear we nurses are confusing our publics with unfortunately imprecise language that may surprise even us. Here are some examples of our misleading chatter:

1. "Bedside nursing."

We may say "bedside nursing," but what we mean is "clinical practice." Most of us don't work in hospitals, and most of our patients, even those who are in hospitals, aren't in bed. In fact, generally except for periods of needed sleep bed is a bad place to be. Bed is where people are most likely to develop everything from pressure injuries ("bedsores") to pneumonia to sleep disorders, to arms, legs, and other body parts so stiff that they won't move any more. That's why even intensive care nurses wrestle with IV lines, breathing tubes, assorted monitors, catheters, and perhaps reluctant patients to move people from beds to chairs whenever possible, and from chairs to walking after that.

Beyond this, nurses work in clinics, schools, industry, shelters, public health departments, private homes, retail stores, their own offices, and many other places, providing skilled assessments and diagnoses, hands-on care, education, and advocacy for people who absolutely are not in bed. As a home health nurse, last week I saw exactly one patient who was in bed, and he was there because I arrived on short notice before he had the necessary time to prod his chronically pain-riddled body to a vertical position and then to wash and dress it before settling into a chair. Yet last week I administered infusions, tube feedings, wound care, and much more. While I definitely was engaged in clinical practice I was nowhere near a bed the vast majority of the time.

We perpetuate a narrow understanding of nursing practice when we slip carelessly into language born in a time when nurses graduated from their basic education and went to work either in hospitals or as "private duty" nurses in patients' homes. In those days the thinking was that people who are ill should rest in bed, so it was at bedsides that nurses worked. Today we know better. So now most practicing nurses are not at a bedside much of the time, but they absolutely are delivering healthcare.

It is important that those we serve, and those we bill for our services, understand this and recognize the depth and breadth of clinical acumen they are receiving. We're not "bedside nurses." We are nurses in clinical practice.

2. "Nursing school."

In the early days of what would become modern nursing, hospitals "trained" nurses in their own schools as a means of having free (i.e., student nurse) and cheap (i.e., graduate nurse) labor. While it is a stretch to call some of these endeavors "schools," many hospital programs produced generations of outstanding clinical nurses. By the middle of the twentieth century, though, nursing education was moving increasingly into the collegiate setting, initially alongside the remaining hospital schools (causing no end of confusion for the public, as people wondered how one truly becomes credentialed as a "real nurse"), and with the latter gradually closing their doors. I have worked with many of those hospital-based "diploma graduates" and know them to be outstanding. Indeed, a nurse newly graduated from a hospital diploma program was likely to be a stronger clinician than a new bachelor's-prepared nurse from from a university, because hospital programs were highly focused and included more hours of practice in patient care.

But as professional nursing moved beyond the bedside (see #1 above) and the importance of nurses' contributions to research, policy, business, healthcare leadership, and a complex, multi-cultural global society grew, it became increasingly clear that, for its many strengths, the narrowly focused "training" provided by hospital schools for hospitals' own purposes was less than optimal preparation for full participation in the broader world of healthcare and that nursing education belonged in the university. Bottom line: Today those who aspire to careers in nursing go to college. They study alongside those who aspire to careers in medicine, law, business, education, the arts, engineering, and other professional fields. Nurses earn undergraduate and graduate degrees, including both clinical and research doctorates. While some nurses patiently teach newly diagnosed diabetic patients how to prepare and administer insulin injections, other nurses run hospitals or are elected to public office. But precious few graduates of actual, old-time "nursing schools" are in practice today, and all practicing nurses have gone to college. (As nursing education evolved hospital schools began affiliating with universities, where the nursing students earned many of their academic credits. So even hospital-trained "diploma nurses" earned significant college credit.)

So that it's clear that our publics, both patients and others, aren't receiving services from graduates of an outdated "trade school" model we need to replace, "When I was in nursing school . . . " with "When I was in college/an undergraduate/finishing my bachelor's degree/a pre-professional student at [Name] University . . . " Those we serve deserve no less.

3. "Use"

People aren't commodities and expertise isn't a tool like a hammer or kitchen tongs.

People don't "use" a home health agency or therapy clinic; they choose one. And we'd do well to remember that, in a respectful and collaborative way. One doesn't "use" a medical or counseling practice; rather one is referred. Patients don't "use" a hospital or clinic; they do their research, seek recommendations, and make informed decisions. If decisions are made for them in emergency situations, patients may make different choices as soon as they are able, or their agents may act sooner. And when that happens business literally may go out the door.

We're going to work together much better and be more sensitive to and respectful of our patients as persons if we "lose the 'use,' and 'choose' instead." Instead of "use," we work with, collaborate with, refer to, partner with, and, definitely, choose for ourselves and also empower our patients to choose as well.

4. "Seniors."

Efforts to safeguard vulnerable adults have become ageist, overtly or covertly prejudicial. That is offensive to elders who find themselves stereotyped and it puts at risk others who are overlooked because they don't fit the image of a "senior" or are outside the targeted group.

When there is a blizzard or a blackout or a persistent and oppressive heat wave, when a hurricane or bitterly cold snap is forecast, or when other emergencies loom, the public and healthcare providers alike often are counseled to check on seniors. I suppose I qualify for that moniker myself now: The silver in my hair is complimented often, and I'm never asked for an ID when I request my "senior discount." But I also go to work every day, own and maintain a home, manage three large dogs, ride my bicycle everywhere, and this past weekend completed a 5K. My age alone probably does not put me at greater risk from natural and other disasters than anyone else. And I see patients who are considerably younger than I and who are far more vulnerable: One is paralyzed, several have significant chronic illness, and one is an abused woman living in temporary housing.

If we stereotype people by age we risk dehumanizing them, turning individuals into mere specimens of the group to which we have assigned them. And our assumptions about such groups are broad, general, and wrong. This is true with respect not only to age, but to race, gender, sexual orientation, religion, occupation, educational level, address, cars people drive (or don't), and fashion sense (or lack of same). A healthy 80 year-old is at less risk than a debilitated, chronically ill 50 year-old, and a 30 year-old bedeviled by drugs or alcohol who has given up may be worse off than both of the others.

While there are instances where grouping by chronological age is legitimate and useful (e.g., when referring to child development or to hormonal changes at points in adult life), most of the time this is but sloppy and prejudicial thinking, an erroneous convenience. This is harmful to the individuals in question and to those around them who don't receive and appreciate what they do not see. And those who need attention or services may be overlooked because the label attached doesn't fit them.

So when the ice storm hits, yes it's important to look out for frail or ill elders, and also to look out for single parents with small children and little support, disabled but functional adults whose personal assistants may not be able to reach them, the strapping young jock who lives alone and happens to be down with a bad case of the flu, the family on a tight budget that can't afford home repairs or even to turn on the heat; in short, for vulnerable individuals. Seniors may have solid support networks of family, friends, churches, community services, and neighborhood ties, while the 20-something who moved from out of state to go to graduate school or start a new job may be alone in cheap housing with little money and less knowledge of available resources and help.

We need to say "elders" or "seniors" when there's legitimate reason to refer to an age group, and "vulnerable" or "affected" adults the rest of the time.

5. "Still."

"Still" is used for emphasis and to point out a deviation from the norm or expected, as in, "Are you still awake?" or "Are you still there?" But when we attach it to normal, healthy, productive living we imply that normal, healthy, productive living somehow deviates from the norm, and that the norm is frailty, debility, and withdrawal from activities and social engagement.

So, instead of remarking, "Clarence is 80 years old and still going to the office every day," we might do better just to say, "At 80 years old Clarence goes to the office every day," and then we'd better add why this happens to be noteworthy, such as, "and he knows criminal case law better than anyone else in the firm. The junior partners and young associates pick his brain all the time."

"Dr. Becker had two heart attacks but he's still practicing medicine" becomes, "Dr. Becker recovered well from two heart attacks and is practicing at University Hospital. It takes awhile to get an appointment, but I understand she is accepting new patients."

Or "Mabel has her own consulting business but she still works as a nurse" is better said, "Mabel owns a consulting business and also practices as a nurse. Having that current 'real world' perspective makes her invaluable to her consulting clients."

What say that instead of assuming that elders should be frail, cognitively dull, and engaged only in playing Bingo and watching Jeopardy on television, we assume that it's normal to serve, give, and pursue a variety of interests throughout the lifespan? What if younger workers aspired eventually to retire not to lie on the couch but to explore and develop new paths? What if recovery after being knocked down by illness or adversity was expected instead of met with marveling and awe? What if experts, of course!, were expected to practice actively in their fields instead of sitting behind desks telling today's clients what worked twenty years ago?

Let's lose the indiscriminant "stills" and actively foster expectations that health, strength, creativity, and lifelong contributions are normal.

6. "Like"

Educators, physicians, engineers, attorneys, and many others specialize in particular areas of their fields. So do nurses. Expecting a cardiologist to replace an arthritic knee or a dermatologist to do brain surgery would be silly, as would be asking a high school science teacher to take over a kindergarten class. An attorney who specializes in international business law might not be the best person to call when one lands in jail on drug charges.

Nurses may specialize along medical or other lines. Some are cardiac nurses or cancer nurses or neuroscience nurses. Some are drawn to HIV or diabetes. Others are certified in wound care, pain management, or anticoagulation therapy. And while some nurse is better than no nurse, just as some doctor or lawyer is better than none when one has a medical or legal need, when the expertise of the provider matches the need of the patient, exceptionally great things can happen. And when there's a significant mismatch major errors can occur. Unfortunately, many employers don't recognize that, or they afford it no more than a passing nod while citing immediate institutional and budgetary needs (Read: "Send the pediatric nurse to the cardiac floor; there aren't many children here today but five new heart patients just arrived.")

While few would maintain that an ophthalmologist and a vascular surgeon are interchangeable, nurses' professional interests and areas of expertise often are reduced to "likes," as in, "Tom likes brain injury patients" or "Jennifer likes geriatrics."

It's a fair bet that Tom does not "like" seeing patients arrive after major strokes, accidents with head trauma, or brain tumors that are suspected or newly diagnosed. But if he has a strong professional interest in this area it is highly probable that his neurologic assessment sells are finely honed, to the point that he will discern a small increase in pressure inside a patient's head well before anyone else would notice, and before the patient is adversely affected. It's likely that he knows more ways to help patients adapt, communicate, and function as they recover. It's likely that he teaches brain-injured patients exceptionally well, understanding what and how they are able to learn at each point in time as their brains heal.

And Jennifer probably is not eager to take field trips to museums with the local seniors group, just so she can hang out with oldsters. Instead she understands the assortment of challenges and abilities that often come with advanced age. She knows how to assess individuals thoroughly and accurately, without lapsing into stereotypes or assumptions (see #5 above) but while realizing that there are differences between a 90 year-old body and a 20 year-old one. She knows how to compensate for deficits and build on strengths, and she understands the ways problems can present differently in this population than they do in younger folks. She's a whiz with "polypharmacy" and can explain comorbidities and interactions in her sleep, but is not surprised to meet an 85 year-old who takes no drugs and never has been in the hospital.

It's not about "likes," and unwittingly or intentionally assuming otherwise is counterproductive at best and dangerous at worst. A cardiologist doesn't "like" a failing heart, a neurosurgeon doesn't "like" a bleeding brain, and a nurse who is a wound care specialist doesn't "like" a gaping, infected wound. They "like" being able to make a difference, and they "like" understanding the fine points, subtle differences, and individual cues that each patient presents. They likely are fascinated by the underlying science and dynamics, and they have a unique wealth of experience from which to draw.

If patients dismiss the expertise of seasoned clinicians and specialists ("He likes coming to see me," or "I like for her to check on me") they're less likely to derive full benefit from their healthcare. And it's more probable that they won't notice if they're in the charge of a lesser qualified provider, such as an aide who also is "nice" and who "likes" the work, or that pediatric nurse reassigned to the cardiac unit with the mysterious monitors that he can't read. Where everyone is equally "likable" and seems to "like" what they're doing is where mistakes happen and are noticed too late.

Of course employers need to realize the multifold risks of sending that pediatric nurse to the cardiac unit. But they also would do well to step back and see the difference in outcomes when the nurse with a passion for diabetes or cancer works with those patients. Carefully seeing that such matches happen isn't about coddling employees or making them "happy" doing what they "like." Rather it's recognizing that professional interests and expertise translate into extraordinarily effective and efficient service . . . and into plummeting staff turnover rates.

It's not about "like." It's about the caliber of service offered to patients and the win-win-win (i.e., patient-nurse-employer) payoff that comes with acknowledging, respecting, and supporting professional interests and expertise.


So where "seniors" who once graduated from "nursing school" "still" work in "bedside nursing" because they "like" it, one might be best advised to "use" another hospital or provider. But where graduates of collegiate nursing programs bring to their clinical practice the finely honed skills of assessment and judgment born of many years' experience, because their expertise makes a difference in human lives and health and that matters, one would be wise to choose such providers . . . remembering that differences in the words we choose reflect differences in thought and action, and in the practices, systems, and outcomes that emerge from them, indeed the very difference between lightening and

The Lightening Bug.

"What Should I Write?"

The number of the Intensive Care Unit flashed on my caller ID as I picked up the phone. "Sue, it's 'Nancy,'" the social worker said, "I have a patient for you. Her name is 'Marilyn,' and she's in ICU bed six. She came to the ED in acute respiratory failure, and they found an infection, and pneumonia, and she's been in ICU ever since. She has a tracheostomy and is on a ventilator, and she'll be going home today. She's pretty obese, too. The doctor is right here with me. He can explain more, and you can tell him what you need."

Nancy handed the phone to the intensive care physician managing Marilyn's case while my curiosity mounted. Few patients are discharged from the ICU directly to home, so as home healthcare liaison I don't see critical care folks very often and am an anomaly when I appear in the unit. "We're getting ready to send her out," the doctor said, "She will need a nurse to see her at home. But what would a nurse do for a patient like this? I'm writing the discharge orders now, but, about the nurse, what should I write?"

It's a good and fair question, although I smiled at the realization that the doctor knew the patient needed a nurse, but he couldn't say why or what that nurse would do. It was perhaps the most honest and refreshing question I've been asked in a long time, but the fact is that none of us really know exactly what our colleagues in other professions know and do, at least not well enough to write orders or treatment plans for them.

From time to time I send patients to the doctor, or to the Emergency Department, or to a Physical Therapist or another provider. But I don't tell the doctor, ED, PT, or anyone else what to do once the patient arrives. I call ahead and explain why I'm sending the person, describe what I have observed and done, note how the patient responded, and sum up with a status report of how the patient is at the moment and any circumstances or special considerations I think the receiving provider should know.

But having done that I don't say, "And Doctor, I expect you to do a complete examination, order these blood tests, that scan, an EKG, and x-rays. Then when you have narrowed the differential diagnosis down to 'x' vs. 'y' vs. 'z' you should . . . " No. I provide my input as the treating nurse, and trust the doctor to practice medicine.

I will tell a Physical Therapist that I'm referring a patient because she or he was very weak when I visited, having difficulty rising from a chair, holding onto furniture for balance while walking, and complaining about back pain that made standing upright difficult. I don't say that I expect the therapist to do a comprehensive evaluation of the patient, assessing strength of all muscle groups, balance, endurance, gait, transfers, and the patient's ability to fling an empty beer bottle at the television when the referee makes a bad call. No. After I have described my observations and detailed my concerns, I trust the Physical Therapist to do his or her job.

I may call a counselor, a dietician, a speech pathologist, a pharmacist, a respiratory therapist, a member of the clergy, a chiropractor, a social worker, and/or any of a plethora of others, but I don't tell them what their jobs are or how to do them.

And that's a darned good thing, because no matter how capable a nurse I am, I'm not qualified to practice any profession other than my own. And neither is anyone else, including physicians.

The work of medicine is diagnosing and treating pathology. That's what doctors do. Along the way most have learned something about preventing some diseases, and so they counsel against smoking and in favor of "flu shots." But their focus is disease, and symptoms are the clues that tell doctors if they're proceeding well, that is, if patients are improving or deteriorating. Treat the disease, manage the symptoms and side effects of treatment along the way, and keep tweaking the plan until the patient is well, or as close to well as possible. Yes, that's what doctors do.

When healthcare is assumed to be synonymous with disease management, symptoms are a secondary focus, markers along the road that are an indication of the extent to which the pathology at hand is being well managed. This may be why doctors sometimes downplay symptoms that are important to patients: The doctors can see that the disease is improving and so the symptoms matter less, because in time, if all continues to go well, the pathology will be banished and the symptoms with it. In this line of thinking, some dizziness, discomfort, constipation, insomnia, nausea, whatever, are but relatively insignificant bumps on the road to health, and while a few pills can be tossed into the mix to lessen these, "really" the patient is "fine" and there's little cause for concern.

However, for patients the experiences that doctors call "signs and symptoms" are primary most of the time. While of course patients want their broken bones to heal, their hearts to recover from "attacks," their cancer to go away and never return, and their other diseases to be cured; in short, while in this way they and their doctors share a common goal, in the day after day dailiness of their lives what most affects patients is not that their ejection fraction is 30% but that just making a sandwich and washing the dishes wears them out. It's not that the x-ray looks "beautiful," but that the fracture site throbs at night and it's next to impossible to get dressed because the cast is in the way, nothing fits over it, and keeping one's balance while attempting the feat has become a gymnastic event. And while there's no better news than that the scan shows the tumors are smaller, what is in the forefront of patients' minds most of the time is the relentless fatigue that has taken over their lives since chemotherapy started, along with the sores in their mouths and and the backsides that have become almost unbearably tender from so many trips to the bathroom.

When as a teen I announced my interest in a career in nursing teachers and many others often encouraged me to reconsider and choose medicine instead. I was too smart, too quick, too capable for mere nursing, they said, and really should be a brain surgeon or neurophysiologist instead. Or something else. But certainly not "just a nurse." And somewhere past the halfway point of my first undergraduate year the full crisis hit, and I sat sobbing in my dorm questioning whether I should change my major to pre-med after all and transfer to the "better" university that also had accepted me, in order to be as well positioned as possible for a slot in a top medical school three years later.

I stayed where I was, in one of the best undergraduate nursing programs in the country, but it was years before I could articulate why.

If one is fascinated by the human body as a biological organism and by pathophysiology and all that can be done, down to the sub-cellular level, to confound it, and if one feels a yen to serve by curing diseases and eliminating the suffering they cause, then a career in medicine is the way to go.

But if one is fascinated less by the disease, less by the biological science, less by the body as an organism, and more by persons, the choices they make, and life in all its richness and messiness that unfolds in so many different ways for different people, then the world of medicine is far too confining. Similarly, when patients want to be vibrant and healthy; comfortable, strong, and free; and able to envision the lives they want and to go about making those lives happen, regardless of age or of the specifics of their dreams or heartsongs, then "healthcare" that reduces to "sick care" simply isn't enough.

Nursing is the profession that is about helping people position themselves to live their best lives, whatever that means for them, whatever is possible for any given human being. We start where the patient is and move forward. We don't and can't do it all by any means, but we may be the best at knowing who can help, which referrals are in order, what other expertise to tap, and how to coordinate all the pieces.

Although I couldn't explain it at the time or for years to come, at fifteen, with a year as a "Candystriper" (hospital volunteer) under my belt, I knew better than my teachers and mentors where I belonged. And today I shake my head and try not to roll my eyes every time someone mentions "doctor's orders," because apart from the rather small slice of the healthcare pie that is medicine doctors really don't "order" anything at all, or know what to order in the first place.

"Well," I said to the intensive care doctor on the phone, "I'm hearing about Marilyn for the first time right now. I haven't met her or reviewed her chart. But based on what Nancy just told me I'd say that this patient is at high risk for pulmonary complications, so a nurse visiting her at home will assess and evaluate her respiratory status carefully, looking for any indication of infection, decreased pulmonary function, or other problems. I imagine you have tweaked Marilyn's medication regimen while she's been in the hospital; the nurse seeing her at home will evaluate the use and effectiveness of those drugs. The nurse also will assess the learning needs that Marilyn and her husband have and provide needed education based on those findings. Infection prevention and control are likely to be important, and the nurse will address those and also will address nutrition, both to promote strength and healing and to support the goal of weight reduction. I don't imagine Marilyn is moving around very much, so the nurse will be looking for complications of poor mobility and teaching ways to prevent these. And I'd suggest a Physical Therapy referral for a safety evaluation and to get this patient moving in whatever ways are possible."

"That's awesome!" the doctor exclaimed, with a tone that sounded truly awed, as opposed to the commonly overused, hackneyed invocation of the word to refer to anything positive or good, "That's perfect; thank you . . . " And I heard him muttering as he typed, " . . . evaluate respiratory status . . . nutrition . . . refer to Physical Therapy . . . "

"Really, just give me a jumping off point," I said, "'Evaluate and treat' or 'Home health to consult' almost always is sufficient. From there we'll evaluate the patient, flesh out the treatment plan, and send it to the patient's doctor. I'll be down shortly to start that process for Marilyn, once I meet her and read her chart."

All of us in healthcare professions bring something different to the table. In my state and many others a physician cannot even testify in court about the practice of a nurse or other non-physician; they are different professions, all highly educated, individually licensed, and uniquely experienced. It is a disservice to patients to implicitly or explicitly limit their healthcare to things falling under the umbrella of "doctor's orders," and everyone is best served when complementary disciplines work together. There was a time when physicians circled the wagons and fought to maintain control of healthcare, arguing that this was in patients' best interests, although that it served the financial and political self-interest of doctors was glaringly apparent. In the practice setting that is easing somewhat now, with day-to-day posturing of this sort mostly focused on squabbles about the actual diagnosis and treatment of pathology that has been doctors' forte all along (to what extent should Nurse Practitioners be able to make medical diagnoses and prescribe drugs, for example).

Be this as it may, and while yes, we yet have a ways to go, it is mightily encouraging when, instead of strapping on the traditional blinders of medicine and assuming that a correct diagnosis of pathology and a proper medical treatment plan is the sum total of 21st century healthcare, a doctor treating a patient, even a patient in a critical care setting, calls a nurse about the work of nursing to ask,

"What Should I Write?"

Chasing Two Rabbits

It's said that when one attempts to chase two rabbits at the same time the only sure outcome is that both will escape. And for all our talk about busy-ness, multi-tasking, and juggling, to the point that these come to seem normal if not praiseworthy, the fact remains, with an increasing body of supporting data, that one cannot do two things at one time and do them justly and well. Even Jesus of Nazareth said no one can serve two masters, yet in healthcare we're expected to do it every day.

"Lucille" is 93 years old and in August went to the Emergency Department with back pain that turned out to be due to a compression fracture of one of her vertebrae. This means that one of the bones in her back had collapsed, a problem that occurs fairly often in advanced elderly patients who have thinning bones. She was admitted to the hospital to undergo a procedure that restores the height of the collapsed bone and then cements it in place so it doesn't collapse again.

The next day the manager of the orthopedics department called me. Lucille wants to go home, he said, but she lives alone in a second floor walk-up apartment and has homemaker services only fifteen hours per week. While her granddaughter and grandson-in-law live downstairs, they both work outside the home and so aren't available to help except in the evenings and on weekends. Lucille was doing well after her procedure the previous day, but the manager was concerned. "Will you go talk with her and see what you think?" he asked.

On a personal note, August was a bear for me. Property taxes for half the year were due, a painful bite in excess of five thousand dollars. At the same time, the car developed a two thousand dollar problem, and two of the dogs ran up a nearly thousand dollar tab for the vet. The mortgage, utilities (including summer air conditioning expense), and routine expenses ranging from groceries to gas all had to be paid as well. Some months just are like that, but darn! they're tough when they happen.

One of the professional hats I wear is that of home healthcare liaison to an area hospital, where I help to transition patients from hospital to home, being sure that they have the supplies, equipment, and services they will need once discharged. I meet with patients and their families or other helpers before they leave to answer their questions, assess their needs, and evaluate whether there may be safety or caregiving issues at home while the patients recover or as they cope with chronic illness. I review the medical record and discuss each case with the hospital providers, and then send pertinent information to the home health agency so services can be initiated. Roles of this nature have been around for a long time, but too often these days their focus has shifted.

Originally liaisons were service providers whose job was as described above. However, with the rise of for-profit healthcare there has been increasing pressure to turn liaisons into sales people whose job is to secure new business (read: "patients") for the home health company. When I took this part-time gig I said very clearly that I would be there to serve and not to sell, except to the extent that good service and outcomes themselves generate business. Nonetheless, there is a provision for bonuses attached to my employment agreement, whereby I receive a four-figure bonus any month in which I generate a specified number of referrals, a designated percentage of which have Medicare as the primary payer. (Medicare is the best payer for home healthcare.)

So there was Lucille, 93 years old, home alone most of the time, stairs to her apartment and probably dated fixtures and accommodations within it, with a broken back and a wish to go home. And Sue, with eight thousand dollars in new and due bills superimposed on the usual monthly expenses, and happening to be within striking distance of earning a bonus for the month of August.

Rabbit #1: Lucille's health and safety
Rabbit #2: Sue's sorry finances that month
Rabbit #3: A for-profit hospital and for-profit home health agency with stockholders who expect a good return on their invested dollars

No clinician ever should be in a position where his or her personal financial interests come up against the health interests of his or her patients, while a corporate entity looms over them all with an eye to maximizing investors' returns.

But it happens every day, many, many times a day, in ways great and small.

Lucille turned out to be a very alert, spunky senior with a sparkle in her eyes, a smile that would melt a stone, and determination that would move the rock of Gibraltar. She had walked to the bathroom by herself that morning, she told me, and then dressed herself. And she was eager to go home, having told the ortho manager very clearly that she wanted no part of any inpatient rehabilitation setting. I explained what home healthcare is and what we do, assured her that whenever she went home we would be there to provide those services, and said that she and her doctors would be the ones to determine when that happened and if any intermediate steps were needed. And I told the manager that I had done just that.

Lucille went to inpatient rehab, I never saw her again, and I earned no bonus that month. In fact, I'm proud to say that in the two years I've been doing this job I never have earned that bonus. To do so would require meeting an absurdly high quota, which in turn would require aggressive selling, promising services I know wouldn't be delivered, and pushing patients like Lucille towards home and home healthcare despite it being clear that they would be best served in another setting.

When I walk into a patient's room, in my white coat with my name tag bearing not only my credentials but also a large, easy-to-see attachment that says "NURSE," that patient must be able to know that I am there to advocate for his or her best interests. The day that doesn't happen is the day I've sold my soul to the devil.

Today, every day, in innumerable ways, every provider faces these situations. Some are blatant and glaring, others so subtle that they could be overlooked.

There are managers who receive bonuses for keeping costs down. By far, the biggest line item in a hospital budget is nursing services, so by cutting nurse staffing to a bare bones minimum significant dollars can be saved, and bonuses paid to managers and dividends to stockholders. Someone recently wrote that the appearance of nurses marching on the Capitol in Washington is the canary in the coal mine for healthcare. In May of this year nurses indeed marched, for safe staffing standards, and I'll tell you that the canary indeed is on its back and kicking very feebly. Nurses aren't agitating for better staffing because they want cushy jobs; most of us are terrible at sitting around and truly want to work and to serve. But a nurse cannot rightly attend to one critically ill patient while another who is just as ill waits, others whose needs are less urgent don't see a nurse for hours, and none receive instructions they can understand or the support they need to be able to care for themselves safely when they go home.

Last week a newly diagnosed diabetic patient with little command of English went home with insulin but no needles to inject it and no meter to measure his blood glucose. The doctor had written a prescription for insulin but not for needles, and the nurse was too busy to check to confirm that the orders written were complete. In two days the patient was back in the Emergency Department with a sky-high sugar level. Had he delayed any longer, he would have died.

Another day, at 3 PM doctors determined that a patient with a serious bone infection in his leg could go home with intravenous antibiotics. The infection was particularly difficult to treat, requiring two different and very strong drugs, and if treatment failed the patient would lose his leg and possibly die. Processing an order for home infusion takes some time, as a special infusion pharmacy must be contacted and someone must gather and send supporting clinical data for the pharmacist there to review and in turn complete and submit a request for insurance payment for the infusions. Once insurance coverage is confirmed any copayments that are required must be discussed with the patient and arrangements made to collect those. Then the drug must be prepared, all the supplies for maintaining the intravenous line gathered and packed, everything loaded onto a truck, and the order dispatched to the patient's home, which usually is many miles away and where someone must be available to receive it. Knowing this, I stood in front of the nurse and said, "Don't let this patient go until I tell you that arrangements for his home infusions are in place. He will need his last antibiotic dose for today here at the hospital before he leaves, as this late in the day there is no way to make a delivery to his home tonight." But the patient was discharged before he received the drug and without the blood test needed to assure that the dosage was correct, which meant the infusion pharmacy could not proceed with the home order at all because the dosage to be dispensed was unknown. There had been a discharge order, someone had arranged transportation earlier in the day, and when the van arrived the patient left, while the nurse was busy with another patient and didn't see him go. Mercifully, he was contacted and agreed to return to the hospital the next morning.

Physician colleagues regularly tell me that for-profit corporations are decimating their practice, adding layers and layers of paperwork and authorization requirements while cutting payment and denying services. Recently a paralyzed patient with bedsores was discharged from the hospital; since being home she has been unable to see a doctor because none will accept her "Medicare Advantage" insurance plan. The reason? That plan isn't paying even its own contracted physicians. Another of my patients is able to eat only small amounts of fruit and occasionally oatmeal because he is so sick from cancer spreading through his body and from the chemotherapy being used to treat it. He is skin-and-bones, and no longer able to climb the stairs to the only bathroom in his home. His "Medicare Advantage" plan refused to approve a request for a bedside commode. Excuse my language, but the insurance company that has taken his Medicare dollars for years will not give this man a pot to piss in. Literally.

A few years ago a senior physician with whom I worked for years at one of the university medical centers here shared his concern about young doctors graduating "with a mortgage but no house." Suffocating in debt for their medical education they cannot afford to practice in primary care and many other specialties, and often cannot afford to do the work they love, that which initially drew them to medicine. Instead they are casting about for any opportunity that promises to help pay the bills and keep their heads above water. Just this week another mid-career physician spoke of the reduction in payment and billing issues that soon will make it impossible for doctors in private practice to make a living at all, effectively forcing them into corporate or very "nontraditional" positions.

So the rooster is going to have to go to work for the fox guarding the hen house.

If car repair bills, veterinary expense, and property taxes could set someone like me in opposition to the best interests of patients like Lucille, what are these far more dire and ongoing circumstances likely to do to the lives and judgment of our doctors?

There are those among us who "tsk-tsk" and "cluck-cluck" about all of this, but think themselves somehow exempt. However, under their Armani suits or ragged jeans they are as vulnerable as anyone else when they land in an Emergency Department and find themselves looking up at name tags that say "NURSE" or "PHYSICIAN." And if the HMO didn't pay the doctor that month or the nurse had to come up with tuition dollars for a child and there is a dollar bonus attached to swaying patients' care one way or another, a burnout and fatigue factor operating from chronic understaffing, a pharmaceutical company ready to "take care of" a doctor who orders its drugs, and/or a ruthless insurance company out to serve its own interests, even the tsk-tsker and cluck-clucker are likely to experience first hand the consequences of pitting the best interests of patients and the best practices of clinical science against the greed of insurers, big pharma, and other corporate interests. And ultimately all will experience the fallout of simultaneously

Chasing Two Rabbits