Mouse-Eared Princess Brides

Walt Disney World didn't seem an ideal venue for a professional symposium last month. Throughout every phase of managing my travel, the Disneyites referred to my trip as a "vacation," which hardly seemed appropriate as I hauled my jet-lagged backside to obscenely early meetings and lectures. Further complicating the jet-lag was the irksome practice of ending every day with a late night parade, complete with rousing renditions of patriotic music that certainly left one wanting to march to the beat . . . except when one wanted to clamp a pillow tighter over one's ears instead. Unless short-order fast food seemed appealing, breakfast was a boat-ride away. This entailed extracting one's bleary-eyed, post-nocturnal parade self from between the sheets at an ungodly hour, in order to hike to the dock and wait in the cold - and at that hour of the morning central Florida was cold in March! - for the boat, and then shiver in gratitude for the fly-back-to-Chicago clothes which, although not quite warm enough, surely were salvation from what felt like threatening frostbite as morning winds whipped over the open vessel making its way across the lake. I never had attended a professional meeting in jeans and fleece before, but, hey, Disney is good for nothing if not new experiences! Even if the mercury pushed its way into the seventies by mid-afternoon, there's no way my decorous skirts and blouses with coordinating light sweaters, were going to cut it on that boat!

Then there was the matter of timing: early to mid-March. Read: Spring break. Disney World no doubt is a magnet for children and families any time, but with many schools and colleges out of session for break, that week the place was a veritable wasp's nest of youthful revelers, everywhere, every hour, day and night. And Disney World is all about the children. A nap by the pool was punctuated by enthusiastic loud-speaker entreaties to join in a hula hoop contest. Every meal in every restaurant had a make-believe theme. Staff often were in costume, and those who weren't wore uniforms that looked like costumes. And wherever one turned, the landscape was ripe for acting out some fantasy. Indeed, each of the Disney World resorts has a theme, and expressions of that theme and opportunities for immersion in it and for absorbing play are everywhere. There are subtle and not-so-subtle suggestions and props at every turn, and everything a child would need to become the adventurer of his or her dreams.

And become adventurers and act out their fantasies they did. At about age three, "Pocohontas" stood next to me on Main Street of the Magic Kingdom, calmly taking in stride the sudden halt of a trolley-like vehicle, from which emerged colorful Victorian-era performers singing and dancing . . . even when one of them left the revue, danced up to little Pocohontas, greeted her by name, and engaged her in conversation. And although wide-eyed and a bit shy, Pocohontas not only did not back away from the attention, but instead gradually allowed herself to be drawn into it. Disney World is a safe place to be a child. And childhood is embraced, understood, and celebrated there.

A number of times I noticed a variation of the same ironic being: A little girl, with the trademark skull cap and mouse ears that characterize Disney, but also sporting a tiara in front of the cap, and a bridal veil behind it and down her back. Yes indeed: A mouse-eared princess bride. Princess costumes were everywhere, and mouse ears of course were ubiquitous. Interesting combinations of regalia from various Disney characters and individualized versions thereof popped up all around. But the mouse-eared princess brides were my favorite. And judging from the looks on the faces under this headgear, this look was the be-all and end-all for them, too. Such happy little girls!

In fact, the entire place was brimming with happy, happy children. I witnessed a rare, mild, fatigue-induced fuss now and then, but no tantrums, no whining, no aggression or violence, . . . only an extraordinary degree of patience, wonder, and sheer delight. Hundreds and hundreds of over-excited children in a strange place with their daily routines turned topsy-turvy, and little other than a large measure of happiness to show for it. And never once did I hear anyone tell a mouse-eared princess bride that she, in fact, could not be a mouse, or a princess, and certainly not all three, that she might not ever be, or actually want to be a bride, or that the other two options were out of the question entirely, thanks to immutable biology and heritage. No, if a little girl wanted to be a mouse-eared princess bride, then a mouse-eared princess bride she was, with the essential trappings provided and nothing but unassuming acceptance all around.

There's a lesson here. I have lived the better part of six decades, and have yet to encounter an adult who thought she was or wanted to be a mouse-eared princess bride. Maybe, just maybe, it isn't necessary, or desirable, to help children understand that their fantasies aren't real, to tell them that some dreams won't come true, or to admonish them to be realistic and grow up. And maybe the Disneyites have it right: If children are encouraged and supported in their creativity, they will tend to be happy, content children . . . and perhaps continue to create, begin to ask "what if?" and "why not?", and experiment and understand the world around them in ways that we in our paradigms, protocols, and evidence-based obsessions would never consider. Confident and brave, instead of doubtful and neurotic, perhaps these children can grow into adults who see ways out of the complicated mires previous generations have left them, and they might even be kind and generous enough to look kindly on their feeble and misguided elders, and protect us from ourselves.

Children don't need to be taught or told to grow up; it happens naturally (although we do have the wherewithal to make the process smooth or miserable). I suspect dreams and fantasies do the same: Supported, and then left to her own devices, the mouse-eared princess bride evolves into a new version of her dream, and then another, and another. Each one fits the circumstances of the child's life and level of maturity at the time, and if we try to mold, correct, or guide them, we produce only a damaged child and a lifeless dream with nowhere to grow and no empowering spirit.

Walt Disney World seemed a poor choice for a professional symposium, where experts from around the world would come together to understand and explore what is to be done to halt the epidemic of cardiovascular disease raging through our society and worsening alarmingly every year . . . while a giant, over-the-top, perpetual birthday party raged outside the meeting room doors. It seemed a poor choice, until I met the smiling, shining-eyed mouse-eared princess brides. And until I saw that if a little girl dreamed of being Mickey or Minnie Mouse, a princess living in Cinderella's castle, and a beautiful bride who would grow up to be just like Mommy, altogether, all at once, then she could do it, she could be it, with acceptance, support, and everyone around her eager to join in the game. Maybe, just maybe, we would solve the problems of cardiovascular disease, and poverty, and obesity, and cancer, and bad hair days, and all the rest, much more easily, much more creatively, much more effectively, and much less expensively, if we were allowed and encouraged to dream, to assume for awhile that the impossible is possible after all, and to ask "what if" and then act out the answers. Maybe our science would be better, and we would be a tad more effectively human, if we began our days with a boat ride to breakfast, lived our days in the spell of magical castles where anything is possible, expected people to pop out of vehicles on Main Street and break into song and dance, and never went to bed without a parade to celebrate all the good that the day had wrought.

I came home, in my fly-back-to-Chicago clothes, with a suitcase full of reports and samples, a bit of sunburn, and a wistfulness about the lack of a parade that night, and about there being no boat ride on the agenda for the next morning. Walt Disney World had not afforded me many quiet corners to have intense conversations about Important Matters with colleagues from across the country, and I was a bit sleep-deprived and overstimulated by days of being surrounded by throngs of excited children. I still haven't sorted through all those papers in my suitcase, and the volume of email generated from that conference is daunting. I'm worried about the toll to be exacted by the epidemic of "cardiodiabesity" that is upon us, and rue the lack of immediate answers. But I have a sneaking, smiling suspicion that even as we conference attendees go back to our laboratories, classrooms, and clinics and do our best to help those we serve and to advance the science that will help that process, the best ideas and most profound solutions may yet come a bit farther along in the future, from eager, insightful, creative, and confident clinicians and scientists who today are fortunate to be embraced and encouraged to be who they are and become who they will, beginning right now as

mouse-eared princess brides.

Gra'nanny Bed

Gra'nanny nurse come today.
And den Gra'nanny got a bed.
Gra'nanny ain't never had no bed befo'.
Gra'nanny sleep on the flo'.
Sometime I sleep dere with her,
when my bed full,
or I watch TV,
or it thunder.
But now Gra'nanny got a bed.
It go up an' down.
It set Gra'nanny right up, like in a chair,
only she still be in da bed.
It got bars she hold on.

How dat bed get here?
It be big. It be a whole bed.
Dem elevators broke.
Dey always broke.
Don't think dat bed fly upstairs
an' come in a winda'.
But it here.

Gra'nanny nurse come today.
The POlice brung her.
I was scared at first,
but he nice.
He show me his star,
and he play with me.
Gra'nanny nurse, she got needles
and stuff dat smell funny.
But Mr. POlice tell me stories.
He strong.
He pick me up when we play.
He help Momma.
He say the POlice got a summer camp
for kids like me.
I don't know about dat.
The POlice, dey got guns,
an' dey lock you up.
I know dat.

Gra'nanny nurse come today.
An' Gra'nanny got a bed now.
The POlice brung da nurse,
an' I might go to camp!
Some day I gonna be strong like da POlice
and carry beds upstairs,
so nobody Gra'nanny
never sleep on da flo' no mo'.

We'll Talk Later

Unlike just two or three years ago, no one in my personal circle seems to be feeling financially comfortable and confident right now. Payrolls have been "downsized," either by eliminating jobs entirely or cutting pay, companies are struggling, and I am newly aware of an undercurrent that must pervade much of otherwise happy family lives, as breadwinners wonder how much longer they will be able to pay the bills, or what threats may lurk around the next corner. An educator friend is giving me inside looks at the protests ongoing in Wisconsin, as the governor and allied lawmakers attempt to eliminate public employees' right to bargain collectively, a sobering and scary prospect. Many of my elderly clients, who worked and saved responsibly throughout their lives, barely can make ends meet now, and any unforeseen additional expense has the potential to pull them under. And I can't quite imagine how the bright but socioeconomically "at risk" student I tutor will pay for high school (yes, high school!) next year.

So far, my home is warm, my larder full, and my overindulged dogs content. But with clients who pay late and then only partially, or who are not-for-profit entities whose survival by no means is assured, or whose programs are faltering, there can be no assumption that next month's provisions are secure. And I am one of the lucky ones.

The temptation to succumb to fear is real, but the stronger that temptation grows, the more dangerous it grows as well.

Yesterday I lunched with representatives of a large company that would like to hire me . . . for approximately half the salary I made in my previous work. Not addressing the money for the moment, I explained that because I represent more than one client, it is essential that I remain an independent entity and that my role and relationship with each client is clear. There can be no appearance of using a relationship with one client to give a competitive advantage to another, and the ethics of representing an organization as an employee while simultaneously representing another client independently to the same market, are muddy at best. My luncheon companions understood.

I offered the option of their company procuring my services through my own company, Cima Services, in which case my independence and objectivity would be preserved, with my advocacy for and representation of all of my clients clearly defined, and no conflicts of interest apparent or extant.

The response? "We don't contract with nurses. We only contract with therapists." And my reply, "We'll talk another time."

There is little doubt that should that company want my services badly enough, they will enter into a business relationship with Cima Services without regard of its being owned by a nurse instead of a therapist; that reality may or may not ever come to pass. But the truth today is that the position of my luncheon companions' company can be taken liberally right now . . . because nurses permit it.

I walked away from that lunch with handshakes and smiles, and we will talk later . . . so that I can drive home my point with focus and clarity apart from the hubbub of the restaurant and the messiness of mutually feeling our way through a new relationship. But I walked away without a contract because too many other nurses do not walk away at all. Even as they complain about a "nursing shortage" and expect nurses to carry workloads dangerous to themselves and to their patients, employers in healthcare by and large continue to operate on the assumption that there always are more nurses to be found who will accept the abuse and its attendant risks. So it is not necessary to pay more, to redefine roles and responsibilities, or to enter into contractual relationships with independent nursing professionals. Nope, there's always another sucker out there who's worried about paying the rent, educating the children, and helping out the grandparents, and so who will drive 200 miles to make home visits to ten patients in one day, or work back-to-back double shifts day after day, or accept a low wage simply because it is offered, and it is a job.

Contrast this with another luncheon meeting last year, with the owners of another large company eager to hire me away from my previous employer. Never mind that the honchos didn't seem to have a job in mind that they wanted me to do, and seemed more eager to undercut my old boss by decimating his team than to build a quality operation of their own, but note their comment in passing that they simply were unable to recruit Physical Therapists. "They all have their own companies," lamented the honchos, "and when we have to contract with them we don't have the control that we would with our own employees. They tell us who they will see and who they won't, and they are considerably more expensive than our own personnel would be."

Hats off to our colleagues in Physical Therapy! They know their own worth, and have assumed control of their own practice. Many are personal friends, and I know they see patients on weekends, do paperwork at night, and drop what they're doing and head off to evaluate a new, high risk patient on a moment's notice . . . hard work, and less-then-ideal circumstances. But done on the therapists' terms, with the therapists having the power to accept or decline referrals, and to set their prices. Certainly if they are not competitive or not readily available their practices will suffer, but the decisions and control are theirs.

And then there is the nurse, often (albeit not always) with a broader scope of responsibility, more education, and more experience, who makes less money and is told, "You're on call because your employer determined you would be, you must accept this assignment, no matter if it's excessive, unsafe, you're tired, or if doing so would put you, us, and the patient at risk." The nurse grumbles, but acquiesces.

My word to my colleagues is, "You must stop." You are compromising your professionalism and integrity, you are placing yourself and those in your charge at risk, and you are enabling healthcare employers to continue to underpay and overwork nurses. You are enabling them to say, "We don't contract with nurses. We contract only with therapists." You are giving away your power. You are modeling passivity and a herd mentality for your children, despite the excellence of your professional skill.

Stop. When you tell that employer that you will drive fifty miles to see five patients, but not 200 to see ten, and stand your ground, that employer can choose between losing the revenue from all ten patients, if you walk away, or losing the revenue from only five, in which case there would be work left over for your nurse colleagues. Is this less lucrative for your employer? You bet! The CEO may have to give up one of his Mercedes or forego one of his luxury vacations . . . and it will be the fault of professional nurses who insisted on reasonable workloads and fair compensation. Reasonable workloads and fair compensation will not destroy the employer, no matter how much the employer wants everyone to believe otherwise. But insisting on these will constitute a much-needed step towards reducing that huge gulf between America's richest and poorest citizens.

Such a deal, my fellow nurses: More money, more power and control over your own practice, better patient care, a sane life, the opportunity to work independently if you wish, and doing your patriotic duty to boot, by taking some of the fat out of the executives and stockholders' wallets and seeing that it is reinvested in workers and in real work.

But it takes some courage: Courage to walk away with smiles and handshakes instead of employment contracts. Our colleagues in Wisconsin are talking, saying an unequivocal "No" to unilateral, top-down determination of their salaries, working conditions, and benefits, and insisting on having a respected place at the table, with a voice, a vote, and self-determination. Our colleagues in Physical Therapy have said "yes" to being their own bosses, and "no" to dictatorial employers. Historically it has been the workers who have prevailed to gain reasonable workweeks, benefits, safe condtions, fair compensation, and a measure of security. Nurses, no matter how scary the prospect and no matter how uncertain the times, whether we bargain collectively, or stand alone, it is time to do the same. It is time to explain what we offer and its price, to insist on a place at the table, rather than on the menu, and to leave with our values and dignity intact, knowing that regardless of the outcome,

We'll Talk Later.

Healing is a Two-Way Street

Alan had cooties, Julie was too bossy, Mike stuttered and was slow and clumsy, and Debbie was perpetually disheveled and wearing obviously homemade clothes. Required to bring cupcakes, Valentines, and other offerings for everyone in the class, the rest of us grade-schoolers dutifully handed out treasures to these classmates along with our "real" friends, but on the playground, in backyards, and during those all-important walks home from school, we were selective in our companions, sometime brutally so. Alan, Julie, Mike, and Debbie rarely were included, and never graciously.

One day, after discovering an uncle's old army shirt and a 48-star US flag in my grandmother's attic, I marched off to school with both in tow and quickly enlisted the entire fifth grade in The United States Children's Army . . . except Alan, of course, whose cooties afforded him the schoolyard equivalent of 4-F status. Proudly sporting the roster of new soldiers' names on a piece of cardboard hanging from my neck on a string, I shrieked and ran away as Alan chased after me, pen in hand, in hot pursuit of his opportunity to "enlist." I probably proclaimed his cooties for all the world to hear, and relished the embrace of my fellow cootie-phobes in our righteous little clique. I don't remember, but Julie, Mike, and Debbie may have been permitted to enlist. If so, they were relegated to KP or some other lowly and inconspicuous role, if that army game ever even reached the point of actually being played.

With his runny nose, curly hair, and rather odd demeanor, Alan remained a perpetual outsider. I lost track of Julie and Mike, but Debbie met with adult success and proved one of our most outgoing and inclusive classmates at reunions years later.

In the wake of the recent suicide of a talented music student whose homosexual exploits had been secretly streamed on the internet by his roommate, bullying, intolerance, and what to do about them have been the stuff of regular front-page stories. Experts and celebrities have come forward in a steady stream, broadcasting messages of inclusion, acceptance, and self esteem for those who are bullied, and offering guidance and support for standing up for oneself in the face of such harassment. Parents and teachers are being told what steps to take to protect children, and school systems, governing bodies of religious organizations, and secular government all are considering how to bring a halt to such torment. But only one perspective, and one set of needs, seems to be being considered: That of the victim of bullying behavior.

If, instead of suiciding, the music student had returned to his room, pulled out a gun, and shot his offending roommate, I suspect public sympathy suddenly would have been for the shooting victim, with undercurrents suggesting that gays are somewhat unstable, after all, and not really "normal." The bullying behavior would be forgotten, or excused, in light of the greater offense committed by its victim. Someone probably would point out that a virile straight male would be proud to have his sexual exploits streamed for all the world to see, although there would be sympathy on behalf of his girlfriend. And some would demand capital punishment for a cold-blooded assault.

Same video streamed in the same circumstances, two different possible responses, two very different public outcries. It seems that we are reacting to a response, rather than understanding the complexities of a two-person occurrence and considering the tools that we give young people as they learn to navigate sometimes perilous social waters.

Of course teachers cannot have students publicly bringing gifts and treats for some classmates while others look on left out. But the "Valentines for everyone" rule serves primarily to make the adults more comfortable, while giving a cursory nod to courtesy in the children's direction. It does not help children learn how to select friends and how to interact politely and with respect towards those not so chosen.

As adults we know full well that we do not choose to become personal friends with every one of our neighbors, every one of our coworkers, every other congregant in our houses of worship, or every other fellow member of our clubs, committees, continuing education classes, and organizations. Otherwise, obvious mismatches aside, our personal networks would be so large that we would be unable to be a genuine friend to anyone. As adults we know how to discourage unwanted overtures politely, how to issue invitations to those we choose for friends without offending those not chosen, and generally how to navigate social waters so that boundaries are maintained and relationships cultivated with an eye to genuine compatibility and mutual interest rather than broad-sweeping all-inclusiveness. And it's a good thing, too. I really don't care to join the young mothers' group, or the seniors' card game, or the holiday dinner with a co-worker's forty closest relatives, none of whom I know or am likely ever to see again. I am not offended when the mothers, the seniors, and the co-worker don't invite me, and if I were to stumble across them in passing and decline a perfunctory invitation issued on the spot, I feel sure they would be neither surprised nor distressed. This is a basic life skill. Most adults have it, but how do children learn it? "Valentines for everyone in the class" doesn't teach it, even if parity is preserved.

Add the insecurities and self-consciousness of adolescence, and the essential coming-of-age developmental task of learning who one is and differentiating one's identify from others, and the potential for hurtful choices mushrooms. One way of defining who one is is to distinguish oneself from who and what one is not. And in an effort, deliberate or otherwise, to surmount insecurity and self-doubt it can be all to easy to define what one is not as being lesser or inferior to who and what one is. So, if in the course of defining myself I choose particular music, TV shows, and characteristics, then those who share those tastes and characteristics are "like me" and therefore "good," whereas those who are different are inferior. Bullying may stem from trying to look bigger and more powerful by making the "different," "inferior" victim seem smaller and helpless.

Until children, and adults who never learned as children, learn rules and strategies for social intercourse that allow them to navigate difficult situations with ease and grace, and until they develop the confidence and self assurance to know who they are and that "different" not only is not inferior, but actually is a good thing because it creates contrast in the interpersonal landscape that highlights everyone's "specialness," and that one way of being special in no way diminishes another, until then, bullying and other forms of harassment will be with us.

And, if we demonize the bullies, the fragility and insecurity that underly their behavior will increase, creating an even greater inner tension and turmoil that in some way will be expressed. If bullying is thwarted in this way, other forms of violence are likely to replace it.

Relentless, cruel bullying that causes distress, sometimes to the point of suicide, is unacceptable. But those who choose this behavior are themselves distressed souls, or very ignorant ones at best. We are well advised to approach all parties, not just the victims, with uncompromising firmness . . . and compassion.

Alan, if you're reading this, please accept my apology for my cruelty towards you in my role of recruiter for the USCA. I knew how it felt to be excluded, and drawing and flaunting the line that kept you out automatically defined me as "in." I never considered how you felt, and no one ever taught me how to recruit for the Special Forces without demeaning those whose contributions would be made in other ways. I wish someone had; we'd all have been so much the better for it.

And Julie, Mike, and Debbie, the same to you, for myriad playground and backyard offenses over the years, their specifics long forgotten, at least by me, and I hope by you, too. While I may not have been a bully, I was not kind and considerate, and this diminished all of us. The gift of these antics may be that they were just mean enough to allow me to peer over to the other side and sense something of the distress that may prompt bullies to do what they do, and to remind everyone that

Healing is a two-way street.

"I'll Plaaaaay with You!"

As soldiers returned after World War II, housing for young families was in short supply, and my parents, like many, made do with what they could find. After starting out in a rented room in someone's home and then progressing to a three-room apartment, they were giddy with delight to become the proud owners of a five room ranch house in a new suburban neighborhood of "crackerbox" sized homes. Today I drive through the area from time to time and am amazed at the tiny houses, which held so much life 50+ years ago, set on large lots that would be the envy of many homeowners in modern developments today. When my parents bought their prize in 1957 there were cornfields at the end of the block, and few of the working class families in the new little houses had much beyond their homes, cars, and endless 1950s-variety optimism. Among the lacks were fences and fancy landscaping, needless extravagances both, and probably not even considered by many. For us children this was a boon, essentially turning block after block into an endless park, with the tiny houses little more than obstacles to be worked into the game of the moment, and the occasional tree or tool shed only loaded with potential for "Hide and Seek."

My mother used to tell of one Saturday morning shortly after we moved in. About four years old at the time and a friendless "new kid," I spied a group of children in a yard down the block and tore out the back door on a full gallop, screen door slamming behind me, and charged across the neighboring backyards calling, "I'll play with you! I'll plaaaaay with you!" Telling the story my mother would shake her head and smile at her younger self, describing how she stood in that doorway watching with the fierce intensity that only a mother has, thinking, "They better play with her!!"

I don't remember, but they probably did, as I don't seem to bear any psychic scars from youthful rejection, and do have many memories of charging across those lawns among an army of pint-sized fellow baby-boomers. But over the years, as I heard my mother recount that tale of our early days in the neighborhood, I came to wonder what happened to that little girl who never stopped to consider that perhaps those other children didn't want to play with her, perhaps she would be interrupting them, perhaps she wasn't good enough for them, maybe she didn't know the rules of their game, or if they might laugh at her or call her names, or if any one of countless other social disasters might occur. Instead, she saw children, wanted their friendship, and without a moment's hesitation took off with a big smile and bounding enthusiasm to offer nothing but her openness and companionship. I'd bet money it paid off . . . and more money that it still would, even now, whether the "children" in question be four years old, forty, or ninety-four.

Adolescent self-consciousness and self-doubt are unavoidable, I suppose, yet I know I was well past those years when I was still constrained by doubts that never entered the head of my four year-old self. And not the doubts born of the wisdom of age, either. Rather, baseless, exaggerated, self-centered, "what if" doubts, coupled with simple social carelessness, i.e., failure to realize that my presence is valuable and matters, that isolation is something one does to oneself, and that some of the niceties discarded in the rebellious 60s had merit beyond the obvious.

Until my early 40s I moved frequently, but only once did a neighbor welcome me with homemade cookies. And [gulp], only once have I done likewise. And I'm sure I would be embarrassed if I could remember how old I was before my mother's lessons sunk in; you know, the lessons about reciprocating invitations and gifts; about not rejecting others' overtures without a very good reason, and doing so graciously when necessary; about it being the duty of every guest at a party to be sure that every other guest has a good time; and about being sure to greet people on arriving and to seek them out to say good-bye on leaving any gathering. It's not about the gifts, invitations, or obligatory mingling; it's about having a framework for building social bridges and relationships in communities. The 1960s mantra "Do your own thing" shattered a lot of prejudices and stereotypes that needed to be gone, but it took with them some social conventions that are handy for making one's way in a community and for opening doors to potential friendships.

Or has friendship become passé? There are close family and more distant relatives, colleagues and co-workers, neighbors, employers and employees, clients and suppliers, fellow organization members, very full "schedules," . . . but, for many, an absence of companions and intimates chosen simply because they like one another, they enjoy each other's company, and their lives are mutually enriched by one another's presence. And those co-workers, neighbors, relatives, and others may occupy most of one's time . . . yet not be people one particularly likes or enjoys.

When I wasn't running across lawns around the little houses in my parents' 1950s and 1960s neighborhood, I tended to be at my grandmother's house, where on summer nights, over my whiny protests, she insisted that I carry the wicker chairs out to the front lawn. "But why do I have to take TWO for just YOU?" I complained, only to be admonished to do as I was told and be quick about it. Years later I got it: Grandma took her book out to one of those wicker chairs and sat reading, until a neighbor arrived to sit in the other chair and visit. Years later I wondered: "How did she know someone would come?" And years later I decided to replicate the experiment: In my 21st century neighborhood where no one sits in front of their houses, I set two chairs on the front lawn, parked my body and a book in one of them, and waited. And along came a neighbor to sit in the other. It's happened that way every time since.

Three months ago I left my position as a home health care executive and opened a small business that offers consulting and project management services in health care. The new hat I'm wearing gives me many opportunities to consider problems that affect health and what might be done about them. I can develop programs and write protocols, policies,and procedures; I can analyze and advise; I can evaluate and recommend; and I can - and particularly enjoy -roll up my sleeves and work alongside a client to achieve a goal or effect better outcomes. But as I look at more or less able-bodied seniors bored and lonely in their apartments; harried younger adults pressured by work, family, bills, and responsibilities; and children sequestered behind security fences and driven to play dates and other activities choreographed by adults, I wonder if one of the most health-promoting activities in which we all could engage might be running across a lawn, or taking a basket of muffins, or setting out an empty chair, all to say, "I'll play with you! I'm here, and I'd like to come to know you and be your friend. Won't you engage with me, and be authentic and open and your wonderful self? Won't you please?" Because if only you will,

I'll plaaaay with you!

The Club

,"One. In thirty years, just one."

The inpatient units of urban medical centers are busy places, and a week or so ago this one was no exception. Every chair in the central station area was occupied by a being focused on a task, but those beings frequently and quietly interchanged as one moved out into the corridors and patients' rooms and another came to the desk intent in consultation or gazing with furrowed brow into a computer screen. So much activity, an ambience of organized clutter, ample space to move about, but standing still risky business. Phones, faxes, pagers, someone's (forbidden in this area) cell phone, all those computers, occasional laughter, an ongoing white-noise-like drone of multiple simultaneous conversations.

I watched Ann as she spoke, and all the rest faded into background oblivion. Now in a senior inpatient position, she worked for years, thirty of them, as a nurse in the Emergency Room. And saw it all and did it all. The homeless and other down-and-outers tended to congregate there, and Ann took them in, treated their maladies of the moment, and let them hang out, where it was warm (or cool) and dry and safe. She had many, many "regulars" returning frequently with the same or still another problem, and for thirty years she dispensed emergency treatment, a human connection, access to a temporary safe haven, and a push in the right direction given in the eternal hope that the recipient would seize the momentum and continue on a constructive path. But the regulars kept returning, with another wound, another illness, another accident, the same old problem flaring up again, or just a desire for a safe place to be indoors for awhile. More treatment, the human connection again, the temporary haven, another "push," and out the door . . . only to return in a week or month or whenever.

And such characters they were! One was tattooed literally from the base of his skull to his feet, and a colorful fellow he was, too, in more ways than one. In and out of the ER for years, a "regular" dubbed "Tattoozie" by the staff. Here he is again, another problem, another story, patch him up, joke with him, give him the little lecture about the need to change his ways, and send him on his way until the next time. Eventually Tattoozie faded away as so many did, and the ER staff would wonder from time to time what had happened to them all, knowing that most probably whatever it was wasn't good, but not having time to wonder too much, because the next generation of regulars, and others, was streaming in the door.

Years passed, and one day while working in the back of the ER Ann was paged and asked if she had time to go up front, because someone was there to see her. She went, and approaching the front desk saw a tall, impeccably groomed man in a three-piece suit waiting for her and looking remotely, very remotely, familiar. She stared.

"You don't remember me, do you?" he asked.

As Ann studied his face for a moment, trying to clear the cobwebs from the deepest corners of her memory, he turned his head slightly, and just above the crisp white collar around his neck she saw the tip of a tattoo she once knew well.

"Tattoozie!" she exclaimed! "What happened to you?"

"I got Jesus," he responded, "and I've always wanted to come by and thank you for all the times you took me in and took care of me."

The sense of my eyes moistening slightly was a welcome relief after hours in the dry hospital air, and I blinked and told Ann, "I know. I was the nurse for Cabrini-Green."

Someone hit the "slow motion" button as Ann's and my eyes met then. She said quietly, "Then you do know." Turning away she fed a page into the copy machine before looking back to me. "Thirty years. In all those years only one came back. Just one."

"Yes, but you got one," I said quietly.

"I did. I got one." A small smile, our eyes met once more, and click. Confirmed mutual membership in The Club. And the pagers and phones and conversations and person trying not to be impatient in waiting for my seat came into focus once again.

There is a club-like camaraderie among those who have served in the trenches, be they in battlefields, on the front lines of wars on crime, or at the juncture where the ill and injured meet those who work to make them whole again. I am of the generation that served in Vietnam, and have heard countless times, "You weren't there, you don't understand." And I know that I don't and can't understand. I rode with Chicago police officers for years as they escorted me in and through Cabrini-Green. We swapped stories, I listened to their accounts of what had happened the night and day before, they learned to help me with bandages, counseling, and reconnaisance missions through the trash to locate incriminating evidence to explain why a blood sugar was elevated or a patient suddenly presented with an "altered" mental state. But when one of their own was killed in the line of duty and I would join the thousands of police officers from around the country paying their respects at the funeral I did not need to be told that I did not understand their loss. I understood mine, which was bad enough. But theirs would remain forever unfathomable to me.

And so it is among those of us who have shepherded the Tattoozies of the world through Emergency Rooms for thirty years, downed cold pizza and bad coffee in hospital corridors at 3 AM, banged on a chest and breathed our own breath into a "coding" body only to watch helplessly as it slipped into the next world, watched the sun rise through dingy hospital windows after a 12-hour shift that seemed at least three weeks long, caught new babies coming into this world and the tears of parents when other babies left it, saw the patient who wasn't supposed to make it walk out the hospital door on Christmas Day to go home to celebrate with family, and sat in stunned silence as the "routine" case went terribly, inexplicably wrong and the consequences were dire. "Gray's Anatomy" and "House" and "HawthoRNe" and all the rest don't begin to capture the bond that starts growing over undergraduate textbooks and the anatomy lab, through the development of sufficient knowledge and skill to work with confidence, to achieving a practiced eye and inexplicable intuition that "knows" in an instant what's afoot and what needs to be done. Often Club members speak in shorthand, or not at all, when they communicate; they know. And when seconds count that knowing is invaluable.

There's strong mutual trust and respect among Club members; there must be. For when the patient's life, the integrity of the team, and our individual livelihoods are at stake time and time again and every moment lost means heightened danger, we must know that our colleagues have our backs, and we theirs, so that together we can move a seamless operation forward with no looking over shoulders, our own or one anothers', to be sure all is right and proper. If that trust is violated, expulsion from the Club is prompt and permanent. This is not an act of anger, rather it is one of necessity and sadness, and we may speak for years of our hope that the expelled member availed him- or herself of assistance and was able to begin anew down a better path. I suspect the severity of this action is one reason doctors and nurses sometimes are tempted to protect a wayward colleague whose practice is not quite up to par or who has made errors in judgment. There is a sense of "there but for the grace of God go I," and a fervent hope that the troubled associate will see the light and make it right in time. We are human, we are capable of corruption and greed. Ignorance, fatigue, and short-sightedness exact their toll on us as they do on everyone. We have complementary strengths and different weaknesses, and no doubt the highest good is served by our truly collaborative efforts. But "outsiders" cannot know the nature and strength of the bond that ultimately unites us.

There are "associate" members of the Club, who are the therapists, counselors, dietitians, and so many others whose knowledge, skill, and contributions are in no way lesser, but whose services are more narrowly focused and temporally limited. There may not be a Registered Dietitian or Physical Therapist in the hospital at 2 AM on the Fourth of July, but you can bet there are doctors and nurses. For patients to heal and achieve the most complete rehabilitation possible nutrition and therapy are critical, and it is dietitians and therapists who will discern when a subtle change in a lab value indicates a need to tweak a tube feeding or when a slightly misplaced assistive device portends a fall. But those aren't the colleagues we expect to make decisions at the juncture between life and death, and few have had as much cold pizza and bad coffee watching the sunrise through dingy windows at 5 AM as have nurses and doctors.

And there are "emeritus" members of the Club, those who leave clinical practice to pursue careers in such fields as administration, bench science, medical sales, and teaching. These folks are respected as once having been "one of us," but with the awareness that they have lost their "edge," and have not experienced the real work of clinical practice in the circumstances of today. Health care changes rapidly these days, and those who harken back to their experience of even a few years ago already are "out of the loop" of contemporary practice and its context. This is not to denigrate administrators, basic scientists, business people, or educators; their roles, too, are important and respected. But they may not be the people you most want to call when decisions about your health need to be made.

There is even "cross-Club communication." Some years ago I treated Willie, a Cabrini-Green resident who, with diabetes, high blood pressure, and a myriad of other problems, had undergone bypass surgery on his legs in an attempt to improve his circulation and prevent amputation. The surgery failed, and Willie was left with gaping wounds on both legs, and little blood supply to help heal them. So I visited Willie for a very long time.

One day I walked in, looked at him, and said, "Willie, you're going for a ride." He nodded as I picked up the phone to call "911," and knowing Willie's strong dislike of hospitals, that nod was all I needed to see to have my decision validated. Now I don't remember what problem Willie had that day, but I set about completing my evaluation, gathering data for the paramedics, and preparing Willie for transport. The ambulance came, left with Willie on board, and "my" cop and I began the long walk down the highrise stairs.

"Suze, how'd you know he needed to go?" the cop asked me. He continued, "I mean, I'm not saying he didn't. And as you were doin' your stuff I saw what was happening and could tell that he really needed to go. But you just walked in the door and said, 'You're going for a ride.' You hadn't touched him, and he hadn't said anything. How'd you know that?"

How to explain. I looked at him, a tactical team member turned homicide detective, and countered, "How do you know who's the bad guy?"

A pause.

"Oh," he said, knowingly. Click. One Club meets another.

That conversation with Ann ten days ago was important, because I go to that medical center as an outside liaison, representing my home care company and helping to transition patients from the hospital to home. But although my name tag says "RN," there is no way for people to know if I am an active or emeritus member of the Club. In fact, I continue to maintain a clinical practice. And this is not, as I suspect my boss believes, just to "keep my hand in" practice or to satisfy a personal interest akin to a hobby. It is also because I know that to work effectively with the doctors and nurses who send their patients to my home care company I need to remain an active member of the Club. I must keep my "edge" razor sharp, speak their language, and be able to translate patients' at-home needs and circumstances into words their hospital- and community-based doctors and other providers can understand. I need to be fluent in the shorthand of the day, and to demonstrate that I still have my colleagues' backs, no matter our roles or professional affiliations. I hold a fancy title about "business development" now, but to be successful in my work, to grow and develop my company, to build relationships that matter, and to assure that clinical excellence happens, my most important credential is my intangible membership in the Club. It's not just about being able to answer a patient-care question that a non-clinical person could not; rather it's about speaking the language and having a common bond of experience with our collaborating providers. I made sure Ann knew that my Club "membership card" bears the date "2010."

Particularly with so many people unhappy in their work, or lack of same, these days, I am grateful for the opportunity every day to touch lives and make a difference, and that is the work of clinical practice, of Club membership. It took a year and a half, by the way, but Willie's legs healed and he recovered. The next time he got in trouble, he called me, and when I picked up the phone and made a plan with him, he said, "Thank you." (Hey, Ann, I got one.) And for all the frustrations and inefficiencies of the health care non-system these days, the next time you pick up the phone to call for help, thank your lucky stars whether or not the person responding has a fancy title or a corner office in an executive suite, as long as she or he is a member in good standing of

the Club.

And What Will They Say?

One gorgeous late summer afternoon last year my dog's delight at the dog beach prompted me to seek a similar treat myself. So I hopped on my bike and headed for my favorite local sandy shore. Settling on a spot, I pulled out the old sheet that serves as a beach blanket, and bent to spread it out as I had a million times before . . . and saw stars. Sudden, sharp, jolt-out-of-nowhere, take-my-breath- away-and-don't-give-it-back pain in my lower back. I hadn't twisted or turned, hadn't picked up anything, hadn't bent or moved strangely, but in a flash I could barely move at all. No positioning, no deep breathing, nothing seemed to help, so I gingerly reclaimed my bike and laboriously trudged slowly home, pushing the bike and trying not to breathe too much, because it hurt too badly.

When my first-ever deliberate mixing of drugs and alcohol (a cold beer to wash down an over-the-counter pain reliever) and hours of rest interspersed with various efforts to find a comfortable position failed to bring relief, my neighbors put my shoes on my feet and gingerly carted me off to the Emergency Room. There I was asked repeatedly to sit down, despite having explained that if I did so getting up again would be excruciatingly painful, and perhaps impossible; examined by a most deliberate medical student; and graced with the presence of the attending physician for approximately 90 seconds, after which came the pronouncement that my problem was muscle spasms, which would go away if I took a narcotic pain reliever and a sedative, and then got a good night's sleep, thereby relaxing the muscles involved. I then was to find and see an internist, and have a MRI somewhere along the way. An injection of a narcotic was administered to jump start the process.

So, after the obligatory pass through the drive-up pharmacy window, my neighbors carefully deposited me back home, where I downed the prescribed pills, and went to bed . . . only to wake up unable to move because every part of me seemed directly connected to my back, and anything more than twitching a finger sent that sharp, stabbing pain shooting through me once again. In desperation I figured a way to turn over while keeping my back straight, then push myself up with my arms, and finally shift my weight forward until I was standing on my feet. I then could shuffle to the bathroom, and swallow more pills. I felt groggy and mentally cloudy, but the physical pain remained as strong. The earliest available MRI appointment was a week away. The internist was out of the question.

A physician friend who had been monitoring my (lack of) progress via text message finally declared that if those drugs weren't helping me it was clear that I had slipped or torn a disc and would need surgery; he had a wonderful surgeon standing by, and was coming to get me. Back surgery? Me? Oh, no! I insisted on one more day.

The next day dawned with equal misery: Drugged stupor, and excruciating pain. There were two more doctors I wanted to see, who practiced together in what we loosely termed an "Arthritis Clinic" that we took on the road to various senior communities. More friends to the rescue, and my stuporous self was deposited among the oldsters in my very own clinic. "I won't even touch her until she has that MRI," shouted the MD. But the Doctor of Chiropractic sitting next to him, who also happens to hold the MD degree but chooses to practice chiropractic medicine, grinned slightly, watched me move, listened to my tale, and repeated, "I know what this is." He got me on the exam table (somehow!), did some kind of manipulation for just a moment, and asked how I felt. The answer was, "Fine" [shocked!]. He showed me three simple exercises and told me to do them twice a day, recommended that a Physical Therapist friend stop by and give me a few ultrasound treatments, and promised that I'd be good as new in a week.

He was right.

The Emergency Room and doctor there cost thousands of dollars and yielded an incorrect diagnosis and ineffective treatment. Had I agreed to see the surgeon and undergo surgery the cost would have been much greater, and the surgery would have proven unnecessary. Of course I would have lost time at work and created additional expense for my company, not to mention the unpleasantness of the post-operative recovery period I could have anticipated. The MRI would not have been cheap, and would not have yielded useful information, and of course my insurance company and I paid for the drugs that didn't work. I can only speculate about what the internist might have done, and that speculation includes additional costly tests and referrals to more (expensive) specialists. My problem was capsular entrapment; the chiropractic manipulation released it, and the drugs didn't touch it because the capsule doesn't have a blood supply. The MRI would not have visualized it, and blood tests and scans would have yielded normal results.

I have written previously about my concern about the availability of health care providers to meet the needs of those who need services. The "cousin" of that concern is the larger issue of how we are to evaluate and treat health needs, who best can serve patients with different problems, and how these providers shall be paid. My hunch is that if the full spectrum of reputable health care providers were covered by insurance and were not subjected to MD "gatekeepers," treatment would be more holistic and effective, and less costly.

Modern medicine is wonderful, and its doctors (MDs) knowledgeable, skilled, and concerned. But it is but one perspective, and one set of tools for maintaining and repairing the incredibly complex human organism. It is about the diagnosis and treatment of pathology, according to one model, and one set of standards. There are others.

One fifteen minute session with a perceptive and skilled chiropractor did what hours in the Emergency Room, drugs, expensive tests, and surgery could not. The doctors were not wrong; rather they were practicing without the tools they needed to do the job that I needed done. They did the best they could with the knowledge and tools they had. The chiropractor brought another set of knowledge and skills; this one happened to be the one needed. Some years before an accupuncturist brought me relief for a chronic tendonitis that medicine and therapy had not touched. As a nurse, trained in the science of people's experience of and reactions to changes in their health states, and in teaching and collaborating to move people towards their health goals, I have knowledge and skills that MDs do not. Certainly they have knowledge and skills that I lack. Are patients not best served when we work together?

As a patient, I want my providers to have a full "toolbox" from which to select the treatments that are best for me. Sometimes those will be prescribed and overseen by MDs, but other times a psychologist, chiropractor, accupuncturist, nurse, therapist, or other professional will better serve my needs. A prominent physician at a major medical center once remarked in a presentation at a scientific meeting that one of the things he had learned from his "colleagues in reflexology" was the value of the light touch in a physical exam. Reflexology? Snake oil for sure, I would have thought. But this highly credentialed, accomplished, and respected physician and professor had troubled to learn what "colleagues" in that field had to offer, and had come away with something of value. My guess is that more of us could benefit from such open-mindedness.

There is the legitimate argument that many "alternative" or "complementary" methods and treatments remain untested by rigorous scientific research; this is important. However, it also is true that this research often is blocked or given very low priority in the competition for funds and support, thanks to the overarching influence of western medicine and associated lobbies and interest groups. So support for research continues to go primarily to the sorts of problems and methods that have received priority for years, with fine results . . . but also at the cost of equally valuable findings in other fields of health care practice.

The House and Senate now have passed "health care reform" legislation, and are beginning the arduous process of hammering out their differences to reach a compromise package that can be passed by both chambers and signed by the President. I still get a headache thinking about this. But whatever the final bill that emerges, I wonder not only who will answer the phone call for an appointment, and the call light at the hospitalized patient's bedside, and the other pleas for health care help. But also I wonder when those responding providers meet the patients who summoned them,

What will they say?

Will they have only the perspective, tools, and training of western medicine, or will they be able to offer a full complement of health science and skilled, reputable practitioners to evaluate and meet those patients' needs in the most comprehensive, creative, and cost-effective ways possible? What tools do you want your providers to have in their toolboxes? Perhaps it's time to let your legislators know.