About Learning From Those We Hope To Serve Mother Theresa Servant to the Underserved
Richard is Gone by Robert C. Bowman, M.D. revised 11/29/05
Medical students in the United States continue to have the highest income and most educated origins. In AAMC studies, those of the most privileged origins are the least likely to have significant awareness of problems such as health access. Each year the US admits 500 – 700 (out of 16000) more medical students whose parents make more than $100,000 and fewer who have more humble origins. This group doubles in size each 5 years. Not only does this mean fewer who will choose primary care, family medicine, and office-based primary care in poverty locations, it means more and more medical students who have less and less comprehension of how the majority of Americans live, particularly the poorest segment. Despite this great and growing lack of understanding, those from elite origins and elite medical schools will continue to shape the health care of the nation or the lack of health care for so many. The most important decisions are not made by national leaders. The most important decisions are made every day by those that experience and learn and teach.
I just received a call from Tammy. Richard died. After years of health problems and abuses, he is finally at rest. He met death much as he lived life, alone in public housing in Jackson Towers. According to the police officer these places are 95% people just like Richard - poor, abused, chronically ill and little or no family. Those of us from the clinic saw only a fragment of Richard's life. We experienced the visits to the ER, the disruptions of the clinic, and the frustrations of those caring for him. Richard could be a handful at times, even scary. Upset hearing people have loud voices that are less intimidating than deaf people whose animated sign language and closer proximity is assaulting. Richard’s visits were a stark contrast with the convenient regularly scheduled work and job functions that we all prefer.
Most would see Richard's life as a waste. He had no money, few friends, no family, a history of severe mental problems, and chronic painful disabling medical conditions. One social worker years ago tracked down a relative and she was told in no uncertain terms never to call again. For fun, Richard visited people, bummed cigarettes, and collected things like cans, carts, baseball cards, and items that would not sell at the worst garage sale. He did have a place to live but little else. To be around Richard was to experience abuse. He was abused by all segments of society, criminals, doctors, and officials alike. Some of the worst abuse came from those who took advantage of deaf people like Richard. They would send the poorest and worst looking out to generate sympathy and donations, but at the end of the day they would give Richard little in return. Despite this Richard chose to live and live life as best as he could.
No, Richard did not die in vain.
First of all he had nothing, so he had to trust Jesus for everything.
Second, he was one of the best teachers.
Richard taught me about different levels of communication between doctors and patients. He taught me about the superficial level that we most often use. We moved on to the level where I understood how personal issues affected his medical care. Later I saw how Richard lived - what was important to him. There was more to learn and with Richard, I was the only limiting factor.
Richard taught me that there are also three levels of translators: Those that know the language, those that know the people, and those that know the person. We live our entire lives dealing with translators and interpreters, the news media, our parents, our teachers. Rarely do we go beyond simple language alone. Until we know the people and the persons, how can we ever make progress in any area?
Deaths make us reflective. In the final months, I was more distant from Richard. In a sense I gave up. I suspect that I felt that I could do little for Richard when he left assisted living against medical advice and returned to Jackson Towers. Perhaps my expectations are still too proud and too biased. In this area, Richard does far better than I. As I reflect on his life he did not let expectations cloud his judgment. In some ways this was most remarkable.
Despite years of abuse, he still trusted people. He let people in to his life and he would lose a TV, or monthly checks, and countless possessions to those who took advantage of him. Even near the end of life, when he knew things were too good to be true, he still went out on a limb to try out assisted living at our request. Perhaps he felt that we had given him little choice and he felt that we would not be as close to him if he did not do this. At least he tried it out.
Unfortunately Richard was right, the rules were not what they seemed, especially about smoking, and he returned to his home in public housing. Sadly I did not make as good an adjustment. My last day with him was at the clinic. I got him some food and medicine and I drug him around in my car to the county health department so that I could figure out what he already knew about what happened with his mental health appointments and the assisted living facility, then we went to the pharmacy and then I took him home. I waited too long to return to visit.
He did endure much at the hands of those around him. If Richard can endure such suffering and maintain faith in God and in people, certainly I should be able to do so.
That night at the funeral I had this big plan to read what I had pondered during the day. My plan had to be changed. I was in a different world. I knew when I got there and reread the letter that it was still too much about me. As a result I was even more humbled. As a final insult, Richard's main person in the world, Tammy, his interpreter and guardian, was called off to a family emergency with her father and could not sing for Richard, perhaps the one time he could ever hear her voice. She will need even more support from us now.
The night manager for the public housing building was the most devastated, and the most supportive. He knew about the abuse and how good and kind a man Richard was. When he (the night manager) had a heart attack and finally returned to work, Richard greeted him with one of his signature bear hugs plus a kiss on the jaw. Richard signed enough to communicate to him that they were now connected by both sharing a bad heart. Richard's love managed to overcome simpler human forms of communication.
On the right side of the church, another of Richard's interpreters signed for the one deaf person in attendance. Richard's friend had been with him many years ago in the orphanage and at the School for the Deaf. He began the sharing and noted how special Richard was and what a good heart he had. He noted how Richard had had mental problems for a time, but recovered from the alcohol, the schizophrenia, and the police trouble. The interpreter also shared a few words. Then it came time for Richard’s best friend to speak. Greg was pretty shaken. The night manager encouraged him, and Greg continued. Greg transported Richard everywhere and gave him time and food and more than anyone else. Despite this Greg felt guilty about not doing more and about the few times he said no. It is so typical for those with compassionate caring hearts to feel guilt where none should be. Next Richard's nurse got up to share. She risked home visits to one of the worst areas in Omaha for 4 years. Then it was my turn.
The letter that I had written was just not relevant at the funeral. The 12 people there either knew Richard well or wished they knew him. The people there all knew about abuse and suffering and how it changes lives. I did get the courage to talk, beginning with “My name is Robert Bowman, and I am a recovering physician.” I noted how special Richard was to be able to endure all that abuse and still trust others and Love the Lord. I confessed how distant I had become in a "recovering physician" kind of way.
I did talk over the things he taught me, about how easy it is for us not to care for people like Richard, about how hard it is to quit smoking, and about how even a few words or simple trinkets given as gifts can mean so much. The part about the smoking was main humor of the event. Richard was severely addicted, enough to get a bad burn when he smoked with his oxygen on. This ended his oxygen supply and almost sent him homeless again. Few ever saw Richard without a cigarette in his hand or a pack dripping out of his pocket.
As I was reflecting there in the church, I could see Richard as that Lazarus sitting next to the bosum of Abraham in heaven, while the rich man begged for relief from hell. At the front of the magnificent old church with the Christmas manger in place and angels all around it was not too difficult a vision. Richard loved angels.
I also had a vision of the end scene in the movie Places in the Heart with Sally Field and Danny Glover. In the movie, the abusers and abused alike all are restored to each other and to the community of the faithful. Living and dead, black and white, poor and rich, abused and abusers, they all share the final scene. It is a beautiful rendition of ultimate restoration, a real communion of the saints. In my mind I saw Richard there as part of this group. He had a hearing person next to him. This person signed to Richard, and Richard communicated back and they shared Jesus and understood one another perfectly.
When I wrote these words years ago, my family was in turmoil. My wife and I were unsure whether our daughter would live out the year. My son was also at risk of living a life of poverty, doing time in prison, or not living at all. Few realize how close we all are to poverty. As I packed my parents off to the airport today, it is a different scene. My mother noted how everyone seemed to be doing so well now. Graduations, stable relationships, jobs, etc. What we learned from God and others plus what we had in education and income from our family were able to get us through.
In my family, for this time, this is true, a time to be truly thankful. But given what I know about our nation and how we are all much more connected that we understand, it is not easy to rest. But how to connect and yet not get entangled.
Martin Luther King provides advice for those that are too liberal, or too conservative, or too loving, or too rigid:
You see, what happened is that some of our philosophers got off base. And one of the great problems of history is that the concepts of love and power have usually been contrasted as opposites, polar opposites, so that love is identified with a resignation of power, and power with a denial of love. What is needed is a realization that power without love is reckless and abusive, and that love without power is sentimental and anemic. Power at its best, power at its best is love implementing the demands of justice, and justice at its best is love correcting everything that stands against love. http://www.afsc.org/pwork/0412/041216.htm
What I had to learn and still have to learn has to do with the truth spoken in love and perhaps this is the lesson for all of us, both making the effort to learn the truth and then speaking it in love.
The challenges of growing up as a physician or professional were best described to me by an Episcopal priest who counseled me at a retreat back in 1979 when I was in medical school. He noted that medical and ministry and professional people often got lots of compliments and encouragement from those in their church or practices and those they worked with, but then when they got home, they were told to take out the garbage. They then tended to make choices that rejected the "unimportant" work at home, in favor of spending more time with "more important matters" at work. Once convicted, I was able to facilitate a reconciliation and able to instruct my son in how we reacted and what we needed to do and did. At times when I get too proud and arrogant, or suppose that I have justifiable anger, it makes me realize why God kept the thorn in Paul to keep him humble and serving. I also find myself years later doing most of the garbage and the laundry and not complaining about it.
Robert C. Bowman, M.D. rbowman@unmc.edu
Ending Scene Places in the Heart - A young black boy at the start of the movie accidentally shot Sally Field's husband, the sheriff. The boy suffers horrible abuse. Both he and the sheriff die. The black farmworker Danny Glover is beaten and has to leave town. A husband in the movie, Ed Harris, is unfaithful and his marriage is on the rocks, he and his wife have to leave town. There is much suffering in the movie and the events have all happened in real life, but the movie does not end in pain. One of my most moving recollections from movies is the scene at the end of the Places in the Heart as the unfaithful husband and his wife are back in town and share communion, as the exiled Danny Glover is back in town, and as blacks and whites are together in the same church. The scene then takes you beyond the troubled times to something very different. Why is the abused black boy next to the dead white sheriff that he killed? You realize that living and dead are both in the church, together, and reconciled. http://movies2.nytimes.com/gst/movies/movie.html?v_id=38274
Robert C. Bowman, M.D. Rbowman@unmc.edu