Is it the 4th COVID surge? I am losing count. I walked up the stairs in the medical school this week with a physician I didn't know. He complained about his exhaustion from COVID. "It's the unvaccinated we are caring for in the hospital. Such a waste of resources. Nurses are quitting." I empathized and agreed, "These are hard times."

I went to the barn where I lease a horse and the owner was complaining about the current state of affairs: the debt we are leaving his grandkids' generation, the forced vaccinations, the refugees at the border who are soaking up resources. I agreed with the hard times, but spoke to the value of vaccinations, that COVID is not a hoax, but a virus we are trying to figure out. It took science several decades to figure out AIDS.

The physician and I were on our way to teach the 1st and 2nd year medical students how to interview and examine patients. It's a little easier this year. We all wear masks, but not face shields because everyone is vaccinated. It is much easier to look in ears and eyes without a face shield in the way. This week the 2nd year students held an opthalmoscope for the first time. They enthusiastically examined the eyes of our patient actor (Standardized Patient) and each other. One was excited about shadowing in the Emergency Department where ambulances arrived with gunshot victims from rival gangs and staff worked with the police to keep the related parties separated from each other.

And the news keeps running pictures of the new refugee crisis, the Haitians on the Mexican-Texas border, refugees from yet another natural disaster and/or ineffective government. The border patrol on horseback pushing people back played again and again, as did the planes transporting the refugees back home. Back to what? I finally turned off the news.

A patient, a refugee from an African country, came to the clinic feeling stressed about an incident at work, a job she's held for six years. "I've been through a lot," she told me. "Prayer gets me through." She needed a week off to have some quiet at home while her children were at school, a week to pray, a week for the difficult supervisor to move on. I gave her the week off, arranged for behavioral health to talk with her, and a follow up with her primary clinician at the end of the week. I could only imagine what she'd been through as a refugee from Rwanda? Sudan? Ethiopia?

I gave a talk to a class of pre-medicine students who are in a yearlong masters program which includes some of the same courses as the first year of medical school along with health policy, social determinants of health and an introduction to primary care. They also spend time in primary care clinics, many are Federally Qualified Health Centers that serve the poor and uninsured. We examined the National Academies of Science Engineering and Medicine (NASEM) Report: Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care and its five goals for improvement: Payment, Access, Workforce, Digital Information,and Accountable (high quality primary care). The students were excited after working in their small groups. As they reported out their discussions and asked questions, I encouraged: "Be curious in your clinical sites." "Keep asking that question. There is a lot to fix in health care." The last report was 25 years ago, and the new report concludes that health care and primary care are now much worse off.

In a book discussion group at the Episcopalian Church I attend we are discussing Anne Lamott's book: HELP, THANKS, WOW The Three Essential Prayers. If you don't know her she is down to earth, irreverent, funny and deeply spiritual.

Perhaps her essential prayers are the way to close this post.

HELP-- these are incredibly difficult, dark and challenging times.

THANKS - for the enthusiasm and curiosity of the next generation of medical students and the gifts of those like my patient who remind me that tough times are surmountable and that sometimes the only thing you can do is pray.

WOW - Reminds me to keep looking for those surprises that show up, often unexpectedly -- the sunrise, the full moon, the calls of migrating flocks of geese. These gifts help me keep muddling on.