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Victor Hugo, Les Miserables

Gary Wills, Lincoln at Gettysburg

Stephen Greenblatt, Will of the World

Donna Tartt, The Goldfinch

James Martin, Jesus: A Pilgrimage

Disclaimer

The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Sunday
May242015

Joan Rivers

Joan Rivers: Not a person I ever thought I would write about. I was never a fan, finding her humor too biting and personal for my taste. Ad hominem, even. I also dislike celebrity culture, and in the last years of her life Rivers specialized in skewering celebrities and their private lives, developing a brand of inside Hollywood humor that seemed more and more distant from daily life. Relevantly and egotistically: More and more distant from me. While it may be true that her superficiality was an act and not her offstage personality, it was not a persona that appealed to me. I prefer substance in my humor.

And yet she possessed a rare drive that was hard to ignore. Her work ethic showed in her longevity, as she re-invented herself again and again, surviving as a comic from the sixties all the way to 2014. Such longevity almost never occurs in comedy, unless it is paired with superhuman effort.

Nevertheless, I wouldn't have given even this much thought, if not for a profile of Rivers on CBS Sunday Morning that aired a few months before she died. During the interview, she displayed a huge set of filing cabinets in her home that were full of 3 x 5 index cards. On the index cards were, she said, every joke she ever told, organized by subject and stamped with the date she first told them. There were hundreds of thousands of cards.

To collect every joke you ever wrote over a 50 year career and to catalog each one and file it away in a card catalog shows a remarkable dedication to craft. Although it was impossible to tell if she really had a card for every single joke in her long career, the catalog looked to be large enough that if all of them weren't there, it had to be close. I've seen substantial libraries with smaller card catalogs than Joan Rivers had in her home.

This was something I could relate to. It is the kind of thing that would impress any writer. Writing, after all, is nothing if not the process of collecting ideas and organizing them into a coherent body of work. To do this consciously and unfailingly over five decades is a remarkable dedication to craft, one many of the best writers never match. I would have loved to have spent a morning with that catalog, reading through 50 years of jokes, noting style changes and Rivers's own evolution over time. I bet there is a lot to learn.

Despite her superficiality, she was an artisan after all. You never know.

Sunday
Apr262015

Sentence(s) of the Week

 Leaflets
 At dusk they pour from the sky. They blow across the ramparts, turn cartwheels over rooftops, flutter into the ravines between houses. Entire streets swirl with them, flashing white against the cobbles. Urgent message to the inhabitants of this town they say. Depart immediately to open country.
   The tide climbs. The moon hangs small and yellow and gibbous. On the rooftops of beachfront hotels to the east, and in the gardens behind them, a half-dozen American artillery units drop incendiary rounds into the mouths of mortars.

-- Opening paragraphs of All the Light We Cannot See, by Anthony Doerr, which just won the Pulitzer Prize for fiction last week.

What impresses me about this passage is the almost complete absence of humans in it. Even though the section describes the dropping of leaflets from a plane warning a town to prepare for an Allied bombardment, there is no mention of people picking up the leaflets and reading them, of people panicking and streaming out of town, of anyone in these streets and under these rooftops doing anything at all. The town seems inert, weary, resigned.

The whole act of picking out a town for bombardment and warning is rendered completely impersonal and bloodless. This absence of human activity and response contributes to the drama when the first human action occurs, when "American military units" (also very impersonal) drop (here is the human action) shells into mortars. The mortars themselves, which have mouths, are more human than anything else in this passage.

Friday
Apr102015

Funny Things Patients Say (Part 1)

(Beginning of a series.)

"My body isn't like everyone else's."

You'd be surprised how often I've come across this one. What the patient is trying to express is that a standard medical treatment was used on him or her in the past and was ineffective. It is also an assertion that all patients are not the same, and doctors should not use a cookie-cutter approach.

While I have sympathy for this statement, and believe all medical care needs to be tailored to the needs of the patient, it can be misleading. If you are a human being, your genetic code is probably about 99.5% identical to the DNA of the person sitting next to you, even if you aren't related. Thus, the truth of the matter is that the majority of your medical care should be identical to the care everyone else gets.

This is an important issue, because most medical complications occur not because patients get a standard treatment that is not right for them, but because they fail to get a treatment that is standard of care for their medical problem. For example, most people who die in the hospital from a pulmonary embolism (a blood clot in the lung) do so because they did not receive the preventative treatment they are supposed to get (blood thinners). Sometimes this omission is intentional (the patient is actively bleeding from an ulcer, for example), but often it is simply because it was forgotten, or because of fear on the doctor's part that the patient might bleed. Thus, all too often the reason people have medical complications is because a standard treatment was forgotten, and not because the treatment that was given was inappropriate for that particular patient.

Put another way, there is usually more danger in not treating a patient like everyone else than there is in treating the patient as if he is the exception. Remember, exceptional cases are exceptions for a reason--because they are uncommon events. Uncommon events are usually not worth planning for. You plan for the common and stay on alert for the uncommon, not the other way around.

Consider car accidents. Every one of us has heard the statement "he survived the crash because he was thrown clear of the accident." This observation is sometimes cited as a reason not to wear seat belts. And there probably are cases of people who have survived accidents because they didn't have a seat belt and were thrown clear. Those are the exceptions, however. When you look at the data, the rate of auto accident deaths has decreased in the U.S. whenever seat belt use went up, such as the years in the 1990s when most states began ticketing drivers who didn't buckle up. While not wearing a seat belt may help the occasional person, for the majority, use is better than non-use.

Now, some may ask, what about allergies? Don't allergies dictate that patients be treated differently than the standard? Yes and no. Most allergies doctors have to contend with in patient care are to antibiotics (although there are other medically relevant allergies), and most recommendations for antibiotic treatment include an alternative treatment for the allergic. So, if you have pneumonia, you will be given ceftriaxone, but if you are allergic to that, the alternative is levofloxicin. Still a standardized treatment, just a treatment that takes allergies into account.

The point is that appropriate medical treatment usually means less personalization than most of us would like to believe. As patients, and as doctors, we need to be wary of plotting a course that is outside of the usual approach to a medical problem. As a patient, you should probably be saying to your doctor, "I'll have what she's having."

We are all more alike than we are different, and that should show in our medical care.

Friday
Feb132015

The English Major in Medicine, Or: I Wander Lonely As a Cloud

I once was an English major. From a BA in English and American Studies I went (after a brief sojourn in advertising copywriting) into the big house, the MD factory. And I never regretted my undergraduate choice; never for a moment thought my English degree was either a hinderance or a disadvantage in the world of science.

(At least not after the first six weeks, which was biochemistry. But even then, while my chemistry colleagues sat bored in what was for them a review, I was stimulated by the thought that for the first time in my scientific studies, I was learning something theoretical that I would use in practice.)

I could write a book (and maybe I should) about the value of a literary education in the life of a physician. But for today, here is the Cliffnotes version (and no, in college I NEVER resorted to Cliffnotes): 

  1. Literature teaches empathy. Empathy is a good thing in healthcare. And a scarce commodity.
  2. Years of reading about the lives of people in different times and with different values gives you a deeper insight into people from other walks of life. And if you are an ethical doctor, you must deal with every kind of person you can possibly imagine.
  3. It never hurts that your medical notes are clearly written and grammatically correct.
  4. Every patient has a story to tell. A doc who understands this listens well and pulls the elements of the story together into a coherent whole, something we fiction-heads call a theme but doctors mistakenly call a diagnosis.
  5. Shakespeare was the greatest psychiatrist in world history. If you can take apart Hamlet you can understand any patient. (A similar argument could be made for Captain Ahab. Or Isabel Archer. Oh, how I loved Isabel Archer.)
  6. You can make ethical mistakes in real life, or you can read novels about people who have ruined themselves instead and learn not to do what they did (recommendation: Appointment in Samarra by John O'Hara). Personally I find learning from others' stupidity the better of the two options. But I seem to stand in the minority here. (And for those who wonder if the study of history serves that purpose, too, I would say: Not entirely. History, honestly taught, is too muddy for clear ethical lessons. Literature, which has eyes to see inside individual minds, does that better.)
  7. Medical schools don't give a crap what you major in, so why not major in something that is fun? I swear it is true. No one ever, ever asked me about my major when I interviewed at medical schools. Nobody cared. I even think they were relieved to not have to interview biology major number 1369.
  8. When you finish a long, hard day up to your neck in human suffering, you can read Ulysses instead of the New England Journal of Medicine. This, my friends, is the greatest joy of all, the one for which I am daily thankful.

(One day, maybe I will write a book entitled, How James Joyce Made Me a Better Doctor. Anyone want to pre-order?)

Photo of Henry James from 1910 from Wikipedia.

 

 

Monday
Feb022015

What We Think Is New, Never Is

From The Son, by Phillip Meyers:

March 10, 1916 -- Yesterday Pancho Villa crossed the border into New Mexico, killing twenty. Today, hardly a white man to be seen without a pistol or slung rifle, even to buy groceries.

The Germans have promised to reinforce Mexican troops with German infantry should they choose to cross the border. Whole town in a frenzy; we are only ten miles from the river.

I do not point out there is little likelihood of the Kaiser sending troops to McCullough Springs when he is losing them ten thousand a day in France. I do not point out that the number of Americans killed in Columbus is the same as the number of Tejanos shot in bar ditches on any given night in South Texas. I do not point these things out because everyone seems happy with the news of this new threat; neighbors who didn't speak are suddenly friendly, wives have new reason to make love with their husbands, disobedient children do their schoolwork and come home early to dinner.

The Son is fiction, but Pancho Villa's raid is not -- I remember learning about it as a child -- and the reaction of the Americans in the town of McCullough is also well grounded in fact.

It is the folly of the immature to think that what they are experiencing has never been experienced by anyone before. If fact, America has been upset by the threat of terrorism before, as this passage attests. Moreover, people who have no ability to hurt us have used that threat to sucker us before, too. The Kaiser, no less, did what ISIS does now, almost a hundred years ago.

I could to write a PhD thesis about this, but it is possible through intuition to see to the bottom of this problem without spending quite so much time. Overreaction is a very ancient response to terrorism. Even the very oldest book in Western literature, Homer's Iliad, is about this problem. The Iliad tells the story of what the Greeks do when a group of Trojan marauders steal the wife of one of its kings. Destroy a good bit of the known world seems to be the answer.

It makes me wonder. If the Bush administration knew its Homer, would it have paused before going ahead in Iraq? After all, the Greeks defeated Troy, but at the loss of Achilles, Petroclus, Ajax, and thousands of Greek soldiers in the prime of life. Ultimately their action resulted in the total destruction of Troy, which probably didn't benefit the Greeks in the long run either. It was the very mixed results and the high price the Greeks paid for victory that gives Homer's Iliad the ring of truth.

A great work of art doesn't force an ending. It recognizes that events play out in unforeseen ways, and that humans pay for their choices, even when they make the right ones.

People who don't know their fiction make big mistakes. Because, as a critic once said, fiction is a huge time saver. Only by putting yourself in the minds of many people, living and dead, can you have the breath of experiences that allow you to contend with life. You couldn't possibly live long enough to learn all the moral and social dilemmas that are out there on your own. Fiction does that for you.

Good writers know predictable plots make bad fiction. Predictable plots cheat the reader of experiencing the moral complexities that allow for growth. That is what Phillips is showing in this passage in The Son: The townsfolk, acting like bad authors of a bad novel, write a conclusion to the Villa raid, one that is not grounded in reality, and end up looking stupid.

Every decent writer knows that a predictable plot leads to absurd outcomes, outcomes that defy life experience, outcomes that don't feel right because they are too controlled. What we have in The Son is a population that manufactures its own myth to seek comfort in (that taking a gun to the grocery store will protect America from Villa), a myth that leads them to be manipulated, and made a fool of, by the Kaiser of Germany.

Fiction says life is not predictable and the truth is not obvious. Like Texans 100 years ago who were fooled by the Kaiser, people today respond to terrorism and threats of violence by foolishly arming themselves to the teeth against an enemy unlikely to harm them, and as a result fall into a false sense of security. Like the citizens of McCullough, they think carrying a gun is the talisman that protects.

Predictable behavior leads to absurd outcomes, just as predictable plots lead to absurd endings. Finding the truth means looking beyond the obvious. Good fiction teaches us this.