Reason to Believe

“Still I look to find a reason to believe.”  Tim Hardin

The events of the last few days—no, the last few months—have been horrendous.  From the attacks in Paris and Brussels to the slaughter in Orlando and the bombing of Baghdad, it seems that every time we turn on the TV, or open up a newspaper, we are assaulted with more violence, more bloodshed, more hatred and more death.  At a time when we as scientists are on the brink of a new era in technology—a visit to Mars, cars without drivers, a “moonshot” to cure cancer—we as the human race seem to be backsliding into a new and darker Dark Age.  For me, the dregs of misery came when I read the transcript of Diamond Reynold’s video of the shooting death of her fiancé Philando Castile in front of her four year old daughter, on the front page of the New York Times right alongside of the story of five Dallas policeman being shot and killed in cold blood.   I could not watch the videos of either event.

Today at work one of my physicists gave me a gift.  He is Romanian and recently returned to the land of his birth.  He brought me back a photograph of the monastery at Voronet, in the form of a refrigerator magnet.  He said that in Romania, there has been a rebirth of spiritualism and faith.  The photograph is beautiful, and I later learned that this monastery is also called the Sistine Chapel of the East.  From Wikipedia, legend tells us that the monastery was built by Stephen the Great, who in a moment of crisis in his battle against the Ottoman Turks, came to Daniel the Hermit in his skete and asked for advice.  Daniel told him not to surrender the battle, but that if he won, he must build a monastery dedicated to St. George.  Stephen the Great won the battle and in 1488, dedicated the monastery with these words:

I, Voivode Stephen, by the Grace of God Ruler of Moldavia, son of Bogdan, have started to have the monastery of Voroneț built to the glory of the holy and well-known St George, the great and victorious martyr, in 6996 in May on 26, on one day of Monday, after the Pentecost and I had it finished the same year, in September, 1488.

In these best of times, these worst of times, we all need to find a reason to believe.  I believe that ALL lives matter—black lives, white lives, police lives, Syrian lives, children’s lives—all of us need to relinquish the fear and hatred that has taken over our lives and our human decency.  Like St. George, we need to reaffirm our faith, whether it be in God, or in love, or in kindness, or in our fellow human beings.   We need to do it now.   We have met our nemesis and he is us. Time is short and we have a dragon to slay.

An Extraordinary Life

“Death, be not proud, though some have called thee

Mighty and dreadful, for thou art not so”—John Donne

On a Sunday in January, 2014, I opened the New York Times Opinion section and stumbled upon one of the most unusual essays I had ever read.  It was written by Dr. Paul Kalanithi, who at the time was a 36 year old neurosurgery resident at Stanford who had been battling metastatic lung cancer for eight months.  Here is a link to the essay, entitled “How Long Have I Got Left?”– http://www.nytimes.com/2014/01/25/opinion/sunday/how-long-have-i-got-left.html?_r=0    The author’s point was one well understood by cancer patients everywhere—if the doctors could not tell him whether he had a month, or a year, or ten years, how could he possibly determine what his priorities should be and how best to live his life?  Should he finish his residency?  Should he write a book?  Should he have a child?  In his worst moments he wrote that he fell back on his first love—literature.  In the last sentence of Samuel Beckett’s The Unnamable, Kalanithi found a mantra to live by: “I can’t go on.  I’ll go on.”

As it turned out, he did not have long.  Despite the optimistic and sometimes humorous tone of the essay, Dr. Paul Kalanithi died of his lung cancer 14 months later.  But not without first doing ALL of the things he mentioned in the essay.  He finished his neurosurgery residency as chief resident. He repaired a fractured marriage.  He had a child.  And to our great benefit, he wrote a book called “When Breath Becomes Air” published posthumously in January of this year—a book which despite my oft stated incredible reluctance to read anything I know will make me cry, I grabbed off the shelf the minute I spotted it in a local bookstore.   I was not disappointed, and yes, I cried.

The courage of cancer patients, and of all patients facing life threatening disease astounds and inspires me.  Many go through grueling and exhausting treatments and manage to put one foot in front of the other—they “can’t go on…they go on.”   Paul Kalanithi not only went on…he wrote about his experience in a book that will stand not only as a cancer memoir, but as a profound piece of writing.  When faced with dying, he chose life by completing his training, by having a child, by believing every day that he still had much to offer.  In an essay for Stanford Medicine he wrote words for his infant daughter which were included in his book: “When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.”

I hope you get a chance to read his book.  Even if it makes you cry.

In Praise of Angelina

I have always been one of Angelina Jolie’s biggest fans.  The Academy of Motion Picture Arts and Sciences saw fit to reward her 1999 performance in “Girl Interrupted” with an Oscar, but I wasn’t well and truly smitten until the second Lara Croft Tombraider movie was released in 2003.  In that film, Jolie, who performs her own stunts, is seen galloping on a dark horse while spinning a heavy shotgun from side to side to shoot alternating targets.  And she is riding SIDESADDLE.  If you don’t believe this, have a look here:  https://www.youtube.com/watch?v=tz1lCcs9tac  In the Lara Croft movies, she is the epitome of a strong, athletic, intelligent and self assured woman.  It may not seem like much, but I granted Miss Jolie a high honor indeed—in 2004 I named a dark, agile and fast deerhound puppy after her, the soon to be champion Caerwicce’s Lady Croft, aka “Angelina”.

 

In the years that followed the Lara Croft movies, Angelina Jolie went on to surprise her public in more ways than one.  The girl who initially achieved notoriety for wearing a vial of her second husband Billy Bob Thornton’s blood gained a different type of fame when she adopted a Cambodian child, and subsequently became a respected ambassador for the United Nations.  She has become well known for her humanitarian efforts, devoting as much time to improving the lives of refugee children as she does to her own career.  Recently, she has added the titles of author, director, and Mrs. Brad Pitt to an already impressive resume.

 

But perhaps the biggest surprise of all came two years ago, when she went public in the New York Times with the revelation that she is positive for the breast cancer gene BRCA1. In a moving statement, she wrote of her difficult decision, at age 37, to undergo bilateral prophylactic mastectomies and reconstructive surgeries in the hope of staving off the cancers that took her mother, her grandmother and her aunt.  She was clear and concise, reasonable and dispassionate in her account.   Not only did she raise awareness of the heritable form of breast cancer, she gave courage to all women facing the challenge of a mastectomy.  If one of the worlds most beautiful and sexy women could undergo such surgery in the glare of the celebrity spotlight and come out looking stronger and even more beautiful, so could some of the rest of us.

 

Today she has done it again.  In a New York Times article entitled “Diary of a Surgery” (http://www.nytimes.com/2015/03/24/opinion/angelina-jolie-pitt-diary-of-a-surgery.html?ref=opinion&_r=0 ), she reveals that she has recently undergone removal of her ovaries and fallopian tubes to prevent ovarian cancer, the disease that killed her mother.  She describes precisely the terror she felt when informed that some recent blood tests were equivocal, the dreadful anticipation of the results of a PET/CT scan and the realization that now, at age 39, she has entered menopause.  But she also describes the relief she felt once she had made a decision to go ahead with the preventive surgery: “I know my children will never have to say, ‘Mom died of ovarian cancer’.”

There’s bravery and then there’s true courage and grit.  It’s one thing to perform gymnastics while swinging from the rafters of the Croft estate, or to shoot a rifle off the back of a galloping horse.  It’s quite another to write clearly and objectively the story of being diagnosed with a genetic mutation, and of the careful informed decisions she made to minimize her risks, while at the same time admitting that her decisions were not necessarily the right ones for everyone.  As Angelina says, “Knowledge is power.”  We owe her thanks for sharing hers with us.

 

Medicine at the Crossroads

 

        “When you look for the bad in mankind expecting to find it, you surely will.”    Pollyanna

 

I try not to spend too much time on Facebook, but it’s always been a good way to keep up with “friends” in the Scottish Deerhound world.  The deerhound, being a rare breed, tends to link people across the country, and indeed the world, who have similar interests.  Lately though, the deerhound people haven’t been discussing dogs much.  Instead, they’ve been discussing their terrible experiences with the world of medicine.  One owner described being admitted through the emergency room of her local hospital for stroke-like symptoms.  By the evening of her second day of admission, she complained that she had not yet been seen by a physician.  Another complained that a family member had just been diagnosed with Type I diabetes, but was initially given an appointment with an endocrinologist in six weeks—completely unacceptable in this situation by any standard of care.  I am of course compelled by pride to speak up and defend my profession, but not without an increasing sense of embarrassment for what used to be considered a noble calling.

After I published my piece on the fatal shooting of Dr. Michael Davidson, I was contacted by Carey Goldberg, reporter and co/host of CommonHealth (http://commonhealth.wbur.org/) and asked what struck me the most about the nearly 200 comments left on the essay when it was picked up by KevinMD.com.  Here is what I replied, “There were several reasons that Dr. Davidson’s death hit me particularly hard, even though I never met him.  One reason was that I trained at the Harvard teaching hospitals, Beth Israel for Internal Medicine and MGH for Radiation Oncology, so this hit close to “home” especially with my daughter being there.  But more importantly, I come from a medical family–grandfather was a dentist, father (now 89 years old) is a world renowned plastic surgeon–and in my lifetime of 61 years, I have seen the sad decline of public affection and respect for physicians.  When I was a child, people would stop me on the street to tell me how wonderful my father was.  Now, when I sit in on conversations among people who do not know I am an MD, I hear nothing but derision if not outright hatred.  There are many, many more people, as evidenced by the response to my blog piece, who feel slighted not only by “the system” but also by their physicians.”

And why not?  Articles such as this, http://www.nytimes.com/2015/01/30/business/medicare-payments-surge-for-stents-to-unblock-blood-vessels-in-limbs.html on the front page of the New York Times continue to erode patients’ faith in their physicians to “do the right thing.”  Patients despair when they cannot get appointments to see their doctors in a timely fashion and when they are seen, that their doctors don’t spend enough time with them or explain things to them.  They despair over the cost of care in increasingly difficult economic times. But doctors are in despair also, at the ever increasing bureaucracy of medicine, the insurance conglomerate which makes documentation, authorization and billing a nightmare, the takeover of large segments of medicine by for profit corporations and the heightened expectations for positive outcomes fueled in part by misleading advertising by those same corporations.  Many have come to feel that the sacrifices, both personal and economic, that they made in order to go to medical school were just not worth it.

I do not pretend to have any answers to the multiple crises that contributed to the death of Dr. Davidson, or the current climate in which doctors and patients must function.  I wish I did. But I do have a request for both my patients and others, and my physician colleagues, as well as my Facebook friends and the media.  Let us try once again to see the good in one another again, and not just the bad.  We’re all human, and at some point we are all going to get sick.  For better or for worse, we depend on one another.

Why Doctors Should Be English Majors

In early May, I was lucky enough to receive an invitation to see a production of “The Tempest”, by the Hobart Shakespeareans, a fifth grade class led by renowned elementary school teacher Rafe Esquith.  The production was scored, lit, set and acted by inner city ten year olds who, lacking funds for elaborate Elizabethan garb, all wore the same T-shirt emblazoned by an image of William Shakespeare, with the simple slogan “Will Power.”  I wrote about my experience in the blog piece “Such Stuff as Dreams Are Made On.”  Two weeks ago, an op-ed piece by Verlyn Klinkenborg in the New York Times decried “The Decline and Fall of the English Major: http://www.nytimes.com/2013/06/23/opinion/sunday/the-decline-and-fall-of-the-english-major.html?ref=opinionHYPERLINK   As I read it, I reflected on my own experience in medical school and beyond, and I think that Mr. Klinkenborg’s message is one that medical school admissions committees should be hearing loud and clear.

Despite the fact that doctors are faced with increasing mounds of paperwork and decreasing autonomy, medical school admissions are as competitive as ever. All handwringing about the state of the profession aside, young people still desperately want to be doctors.  Students who would vie for a coveted slot in medical school must start their resume building early in their college careers, and must complete with flying colors a standard premedical curriculum which with rare exception has not changed one iota since I applied to medical school in the fall of 1974. Students who major in the basic sciences—biology, chemistry and physics—have an advantage in the race for med school admission because they typically outperform other majors in their MCAT scores and because their majors allow them to get a leg up in scientific research.  In many cases, college students who are science majors apply for medical school with first author publications listed on their curriculum vitae.  And at the end of medical school, students who have taken the time to obtain a dual MD-PhD degree are the ones who are most competitive for those coveted specialties of dermatology, plastic surgery, orthopedic surgery and radiation oncology where the prize at the end of the road is a controllable “lifestyle” combined with high reimbursement.

But even in the rarified world of first author scientific publications in peer reviewed journals, there is that moment of truth, when push comes to shove, and a group of editors must decide whether to publish the paper of one author, or someone else’s.  No matter how brilliant the tables and graphs, in the end that decision will be made on how well the author EXPLAINED the data, how compelling was the argument, and how explicitly the new data informs both the reader and the greater body of work on the subject.  In the end, this is where those former English, and history, and philosophy majors shine, and surpass their basic science background colleagues.  Just ask Dr. Harold Varmus, the current director of the National Cancer Institute, Nobel Laureate, and possessor of both undergraduate and graduate degrees in English from Harvard.

This week I worked with an excellent medical student.  He was bright, personable, and thorough and the patients truly enjoyed speaking with him.  We saw six or seven new patients together, and here is an example of the narrative on the physical exam on one: “ABD: SFT, sMS, NTDR, NABS, NHSM.” Say what?  For the non-MD readers out there, that means that the abdomen was soft and non-tender with no masses, abnormal bowel sounds and no enlargement of the liver or spleen. In this fast paced world of texting messaging and abbreviation, this old English major would like to see her own life history and physical exam written in English, please!   Why does this matter?  Colum McCann said it well in Let the Great World Spin:  “Literature can remind us that not all life is already written down: there are still so many stories to be told.”  Very few doctors will ever win a Nobel Prize.  But all of us should be able to tell a patient’s story, tell it well, and make sure it’s worth listening to.  After all, it could mean the difference between life and death.