Boxing Day

When snow falls, the driveway beckons to be cleaned; and no matter what the weather, dogs must be walked, even on Boxing Day.

Boxing Day, the day after Christmas, is not celebrated in the states.  Traditionally, this was the day when gifts were given by the British upper classes to their servants and to the poor.  Servants were free to spend the day with their families, and cold cuts were the order of the day on the tables of the rich.

I awoke in the early morning darkness to the sound of a snowplow skirting the street, then drifted off again until the alarm sounded.  In the darkness I dressed, pulling my clothes from the bedside chair.  Outside, a wet white frosting lay on the driveway, not quite frozen.  I started the car and let it warm up while I scraped off the coating of snow.

Mid morning I set out with the dog under a still grey sky.  No one else had ventured out in the slushy snow.  Coming back, I passed the remnants of a snowman standing in someone’s front yard.  The head was no where to be found—only a torso and belly remained, draped with a long flowing multicolored scarf.  One black branch stuck out precariously from the side of the torso—an arm previously raised in greeting now bade farewell.

I imagined the mind of the maker when catching the first morning glimpse of this creation, and reflected on Richard Wilbur’s poem, Boy at the Window, in which a 5-year-old child finds himself in a similar situation.  In an ironic twist, the poet turns the tables in the second stanza:

Seeing the snowman standing all alone
In dusk and cold is more than he can bear.
The small boy weeps to hear the wind prepare
A night of gnashings and enormous moan.
His tearful sight can hardly reach to where
The pale-faced figure with bitumen eyes
Returns him such a god-forsaken stare
As outcast Adam gave to Paradise.

The man of snow is, nonetheless, content,
Having no wish to go inside and die.
Still, he is moved to see the youngster cry.
Though frozen water is his element,
He melts enough to drop from one soft eye
A trickle of the purest rain, a tear
For the child at the bright pane surrounded by
Such warmth, such light, such love, and so much fear.

And so I received my Boxing Day gift.  The dog seemed quite content as well.

A Winter Walk with Jackie

“Please take the dog out before you go to work,” my wife says.

I look up from the book I’m reading in bed.  “I thought you just took her out?”

“I did.  But if you take her out for a walk before you go into work at noon, I won’t have to take her out again when I get back.”

My eyes drift down to the book in my lap.

“Such a hard life you have—the life of Riley,” she says, pulling on her coat.

I hear my wife’s feet pad down the stairs.  Below, the dog barks in a frenzied fit when the back door closes.  Soon she appears at the side of the bed, leaps up onto the covers beside me and buries her nose under my book.

“Okay, okay,” I laugh, stroking her pink belly.  “Let me get dressed.”

Head cocked slightly to one side, she watches as I shed my pajamas and pull on my heavy pants, fleece and vest.  I hunt for a pair of woolen socks in the chest of drawers.  Judging from the movement of the branches in the tall pines behind our house, the wind is up.  The clear blue sky portends a biting cold.

The puppy precedes my step on the stairs; she bounds through the parlor to the kitchen door where, tail drumming, she waits.  “Okay, okay,” I say, pulling on my heavy gloves and reaching for the leash, “let’s go.”

We step outside into a cold so sharp that it burns the nostrils.  The wind has blown bits of recyclables from the back porch, scattering them about the yard.  I retrieve the items and hurriedly toss them back into the bin before heading out.

The snow has hardened in banks by the side of the street.  We push ahead, the dog straining at the leash into the wind which cuts at my throat.  Instinctively, I reach for the zipper at my neck and close the collar of my vest.  Soon we are off at a trot down the tarmac.  At the end of the street we turn the corner and don’t stop running until the end of the block.

Microscopic windswept pins prick the skin of my thighs through my corduroy trousers and sting my face.  Despite the gloves, my fingertips tingle.  We cross the intersection and head down the street.

At the bottom of the hill two crows rise up from a snow bank and pull their wings like black oars against the oncoming wind.  The puppy pauses to sniff the air.  Shortly, we are off again, running down the road.

We make our traditional loop in record time and ascend the hill, past the stand of grey maples sparsely clothed in remnants of bittersweet.  The dog stops abruptly at the row of pines behind the church, nose to the ground.  “Come on, Jackie,” I say, tugging at the leash.  “Let’s go.”  Thankfully, she responds, and we race back down the street to our driveway.

Inside I push the door to, hang up the leash, pull off my gloves and stocking cap and pour a cup of hot coffee from the carafe.  The heat from the cup permeates my hands; the coffee percolates down my throat.

Garrison Keillor once remarked that winter is the only season of the year that is actually trying to kill you.  Not that I have beaten Death—but only once more succeeded in postponing that final inevitable rendezvous.

Sufficient Depth

As a young man, Samuel Clemens spent two years learning the lay of the Mississippi River to become a licensed riverboat pilot.  No sooner had he completed his apprenticeship than he realized that the topography of the river had changed.  In order to maintain his proficiency as a pilot, he would have to continue to study the waterway, which remained in a constant state of flux.

Rivers are not the only things that change over the course of time.  Medical knowledge also morphs with each new piece of data that is discovered.  Just when we think we’ve got it figured out, voilà—a piece of information gleaned from the latest research hints that we’re probably off the mark; and so we set off, chasing a new lead.

Consider the influenza virus.  These small packets of RNA mutate every year, changing just enough to keep ahead of our immune responses.  We get exposed, we become ill; and, most of the time, we recover.  Yet history has shown that once in a great while a strain of virus surfaces which most of us have not encountered before.  At these times influenza pandemics have the potential to wipe out large segments of the human population.  Those of us who survive carry the immunity to prevent illness when next we are exposed to the same or a similar viral strain.  But just because we survive doesn’t mean that we can become complacent.  It’s only a matter of time until the next mutant arrives on the scene, courtesy of random genetic drift.

Thirty years ago conventional wisdom had it that peptic ulcers were produced by hyperacidity of the stomach, brought on by stress.  Patients were treated with medicines designed to neutralize or decrease the production of gastric acid and advised to seek productive ways to reduce stress in their lives.  Then, in 1979, Dr. Robin Warren, an Australian pathologist, discovered a type of bacteria prevalent in the lining of stomachs of patients who suffered from ulcer disease.  Eventually, Warren and his colleague Dr. Barry J. Marshall were able to prove that Helicobacter pylori was the causative agent of peptic ulcer disease.  Treatment plans were devised to eradicate the organism from the stomach, which led to a cure for this common malady.

So it is with medical science.  Many times what we think we know for certain turns out to be nebulous at best.  Still we beat on against the current of conventional wisdom, ever learning in fits and starts, never quite nailing down the truth.

Thirty years ago when I was a young student of medicine, our professors told us that fifty percent of what we were taught would ultimately turn out to be erroneous.  Their dilemma of course was that they couldn’t tell us which half was wrong.  We were forced to digest as much information as we could, hoping for the best.  The study of medicine, like the study of a river, is a life-long process.

As a riverboat pilot, Samuel Clemens would bark orders from the bridge to periodically sound the depth of the river to avoid running aground.  Soundings were taken by heaving a weighted line over the gunwale of the boat to measure the depth of the water in fathoms, indicated by knots in the line:  two fathoms marked sufficient depth for safe passage.

Like riverboat pilots, we must periodically sound our medical knowledge.  Sometimes we drift into shallow water and come up short; but so far the depth has been sufficient to avoid running aground.

A kind, big-hearted, gentle person

Daniel Mongiardo, a physician in Perry County, Kentucky, and also Lieutenant Governor of that state, recently described his colleague Dr. Dennis Sandlin as “a kind, big-hearted, gentle person.”  Dr. Sandlin had been in practice for over thirty years at the Leatherwood-Blackey Medical Clinic in southeastern Kentucky when a disgruntled patient showed up with a gun and shot him dead.  The dispute was reportedly over a prescription for narcotic drugs.

I was amazed at the vehement responses submitted as online comments to a recent editorial in the Journal of the American Academy of Physician Assistants which advocated that healthcare professionals counsel their patients on firearm safety.  Here are a few choice reader remarks:

Cars, swimming pools and tobacco can certainly be blamed for far more deaths than firearms. Quit being a nanny and do your job.

Since you seem to know nothing about firearms or their owners, I suggest you stick to practicing medicine.

You’re trotting out all the tired old anti-gun arguments in your text and you advocate disarmament.

Doctors should really advise us not to exhale, as the EPA has listed carbon dioxide as a dangerous pollutant. It certainly would cut down on all the hot bags of wind that try telling us in crappy little articles that they know better than I do when it comes to my safety.

The most amazing thing about every one of these emotionally charged comments is that their authors seem to have missed the entire point of the editorial, which advocated counseling patients on gun safety in the interests of keeping a safe environment in the home.  (Note:  All of these comments have been deleted by JAAPA editors because they did not adhere to comment guidelines and were deemed to be outside the scope of professional discourse expected on the journal’s website.  As of this writing, comment posting on this editorial has been closed to discourage members of the public from pursuing private agendas at this site.)

When I was a boy growing up in Pennsylvania, adolescents were required to complete a rigorous hunter safety course as a prerequisite to obtaining a hunting license.  The state was not advocating gun control or restricting the use of firearms—it merely wanted to insure that those who used firearms would do so in a safe and responsible manner.

Outside of the first year of life, the number one cause of mortality in the pediatric age group is accidents—deaths related to automobile accidents, drowning in backyard swimming pools, accidental poisoning by mouth, falls, choking hazards, burns from hot liquids and house fires (including smoke inhalation), and accidental deaths from firearms.  A good part of primary care pediatrics is centered on prevention of morbidity and mortality.  Included in this armamentarium of preventive medicine are the timely administration of childhood vaccines, monitoring the growth and development of young children, and counseling parents on how to keep their children safe.

Although I am not an advocate of carte blanche gun control, as a practicing pediatric clinician I do spend time counseling parents about how to keep their children safe.  Firearm safety is one piece in the accident prevention paradigm, and counseling patients on how to stay safe—regardless whether the issue is sexual practice, drinking and driving, substance abuse or proper handling of firearms—should remain an integral part of preventive medical practice in primary care.  The American Academy of Pediatrics has issued a policy statement on office based counseling for unintentional injury prevention which includes firearm safety.

Could gun control have prevented the death of Dr. Dennis Sandlin, a kind, big-hearted, gentle clinician, revered by his patients and the members of his community?  Perhaps; perhaps not.  But regardless of how an act of violence is eventually carried out, it is first formulated in the psyche of the perpetrator.

While we can all agree that when it comes to divisive issues, spirited debate is healthy and perhaps even desirable; those who resort to the use of threatening, abusive and demeaning language should be granted no voice in professional forums.

Humane Medicine — A Measure of Equanimity

In Sir William Osler’s farewell address to his medical colleagues in the United States and Canada, L’Envoi, he enumerates his personal goals: to do the day’s work well, to practice the Golden Rule, to cultivate a measure of equanimity that would enable him to bear success with humility.

Over the span of my 30-year career, I have seen several hundred children for suspected abuse. Yet I can’t help but wonder why every time I evaluate such a child, instead of Osler’s measure of equanimity, I’m left with only a hollow feeling deep inside.

Interested readers can now access my latest Humane Medicine column, Evaluating the patient with a measure of equanimity, recently published in the Journal of the American Academy of Physician Assistants.

Rain on the Roof

Rain on the roof: midnight serenade.  I awaken to the sound of pounding droplets, keystrokes on the roof, drumming out the cadence of thoughts—letters, words, sentences, paragraphs—stories composed overhead in the night.

Cormac McCarthy’s typewriter is to be sold at auction, the Olivetti through which flowed five million words over the course of his literary life.  I recall Hemingway’s Royal, on which he banged out his early journalistic copy and later short stories and novels; and Don Marquis’ archy the cockroach, hopping from key to key, leaving behind his trail of thought.  Helen Miller, big bosomed, sitting at her desk, hair pinned up, writing copy in the 1930s for the West Schuylkill Press:  did she touch type or, like Hemingway, hunt and peck?

Eleventh grade: Mr. Shirk’s academic typing class.  I sit at my desk, eyes glued to the top bound open book, fingertips on the home row, and begin to strike the keys: a, s, d, f; j, k, l, ;—next the reaches: t, r, e, w, q; y, u, i, o, p.  Later the words will come: The quick brown fox jumps over the lazy dog.

Mr. Shirk saunters up and down the aisle, periodically pausing at each student’s desk to observe.  “Check to make sure your fingertips return to the home row,” he says in a quiet voice.

I look up from the open book to the piece of paper pressed against the platen.  Through a slight shift of hand, a lateral displacement of the fingertips, I find that I have translated the quick brown fox into yjr wiovl ntpem gpc/.  Embarrassed, I reposition my hands and try again.

Early morning rain beats down on the roof: myriad millions of droplets, pounding out a story.  Tender is the night.  For forty days the rains descended during the great flood; the waters rose, covering every mountain top.  A rising tide lifts all boats—unless there’s a leak somewhere.

Dickens left his manuscripts, trails of thoughts composed in ink with quill pen; likewise Thoreau; later Hemingway and McCarthy on the platens of their Schreibmaschinen.  Modern writers leave no such trails behind.  Tracks are covered with spellcheckers and cut and paste, insert and delete.  How will future literary hunters track our train of thought to learn the art of our composition?  For we leave nothing behind but finished copy.

Raindrops on the roof, keystrokes, pound out the words:  nature’s story.  Seated at my desk in the darkness, fingertips poised on the home row, I take a moment to listen to this fine immemorial oral tradition.  Presently, the skies will clear; the pounding will cease, these words will slip away.

But the written word remains for all time.

“Notes from a Healer” — Coup d’flu

A recent article in the New York Times caught my eye: Swine Flu Wave May Have Peaked in U.S. Thank God, I thought, heaving a sigh of relief as I scanned the text. According to the Centers for Disease Control, influenza activity is declining across the country. New cases of the flu dropped significantly during the week ending November 13th.

Anyone working in primary care medicine can tell you that the past two months have been a nightmare. Offices and clinics have been bombarded with phone calls and patients scrambling to secure a dose of the H1N1 vaccine for themselves and their children. Initially, no one wanted the vaccine because it was so new. When it became apparent that supplies were severely limited, everyone clamored for a dose.

My latest installment of Notes from a Healer — Coup d’flu — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online clearinghouse for manuscripts dealing with the humanities and medicine. Interested readers can access a list of editorial board members and regular contributors here.

“Medicine in the time of the EMR” posted in YJHM

The EMR, we are told, will help cut healthcare costs.  When medical records are converted into digital format, data will be instantaneously available to all providers caring for the patient.  Clinicians will have carte blanche access to previous laboratory and radiological studies, thus insuring that such investigations are not performed repeatedly or needlessly.  Data will be collated and scrutinized to insure that standards of care are met and that medical errors are eliminated.  Electronic billing will become the norm.  One day patients might even be able to schedule their own appointments online.  Somehow all this will serve to lower costs and improve the efficiency and quality of healthcare delivery.

Indeed it might.  But in my mind healthcare delivery is something different than the practice of medicine….>>more

My latest essay, Medicine in the time of the EMR, is now posted at the Yale Journal for Humanities in Medicine blog, a companion blog for the Yale Journal for Humanities in Medicine.

The Grace of Gratitude

In her book The Gift of Thanks:  The Roots and Rituals of Gratitude, Margaret Visser examines what gratitude is and how it functions in our lives.  “Gratitude is always a matter of paying attention,” Ms. Visser observes, “deliberately beholding and appreciating the other.”

Humility is a prerequisite to being genuinely grateful.  If we are to become humble, we must learn to esteem others more highly than ourselves.

One afternoon this past week three patients appeared on my schedule for physical examinations.  The first was a 10-year-old boy.  His father suffers from paragangliomatosis, a genetic condition in which tumors arise from neuroendocrine tissue in the body.  The father has already had several tumors surgically resected and has undergone extensive treatment with chemotherapy.

This boy—Norman is his name—and his two brothers underwent screening for the defective gene; Norman tested positive.  This past summer markers suggesting a developing tumor appeared in his urine and blood.  A scan demonstrated a pheochromocytoma in one of his adrenal glands.  The tumor was resected successfully.  His oncologist continues to watch him closely with periodic tests every three months.

Norman is a happy boy.  He’s put on some weight this fall.  His mother tells me that she didn’t sign him up for soccer this year.  “We’ve had too much going on at home.  My husband had a relapse and had to go on more medicine.  I’ve been sick with a cough for four weeks—they just can’t seem to find out what the problem is.  I’ve been through three courses of antibiotics, prednisone, other medicines—nothing seems to work.”

“You’ve had a lot on your plate,” I say as I begin to examine Norman.

“Well, what can you do?” she says.  “We just take it as it comes.  No sense worrying about the future—that will take care of itself.”

In the adjacent room a 6-month-old girl greets me with a huge smile.  Her mother holds her up so the baby can bounce on the exam table.  “Somebody seems happy today,” I remark.  “How’s she been doing?”

“Terrific!” her mother says.  “She’s been eating like a champ and putting on weight since you recommended she start cereal.  My breast milk just wasn’t enough to satisfy her.  And she’s doing all sorts of things now:  rolling over, sitting up, holding toys, drooling from a new tooth—she’s a great baby.”

I proceed with the exam, point out the child’s robust percentiles on the growth chart, share some anticipatory guidance and administer the shots.  Afterwards, the girl quickly quiets in her mother’s arms, returning to her happy disposition.

“We should see her back in three months,” I tell the mother.  Then I remember to ask:  “How is your housing situation working out?”

“We finally got the trailer.  It’s a little cramped for me and the four kids, but we manage.  They say our house won’t be rebuilt until next June.”

“Another eight months,” I say.

She shrugs her shoulders.  “I’m not complaining.  We’ve got a roof over our heads and food to eat.  More important than that—we’ve got our lives.  Sometimes I can’t believe that we all escaped from that fire without a scratch.  Every day I’m thankful that my kids are okay.”

At 18 years of age, my next patient is technically an adult.  At least, he is classified as such according to the ICD-9 codes.  Although he’s been coming to our group practice for regular exams over the past four years, this is the first time I’ve seen him.  He’s here with his father.  Wes is a soft-spoken boy with a pleasant disposition; he’s got a light growth of downy hair on his chin.  When I introduce myself and offer my hand in greeting, Wes can barely lift his hand from the arm rest of the wheelchair in which he is confined.

The chart tells me that Wes was diagnosed with Duchenne muscular dystrophy at age 5.  He has gotten progressively worse over the past six years.  He has no strength to speak of in his proximal muscles; he is unable to straighten his legs due to contractures.  He has had spinal fusion surgery, and recently a pacemaker defibrillator was implanted in his chest.  His respiratory status is compromised:  due to extensive muscular atrophy, Wes is unable to use his accessory muscles to take a deep breath.

I ask Wes how he spends his days.  He tells me he likes to listen to music.  “What kind?” I ask him.

“Any kind,” he says, “classical, rock, country—heavy metal.”

His father rolls his eyes.

“What else do you do?”

“I play video games, read books, watch some TV, spend time with my family,” he tells me.

“Any plans for the future?” I ask him.

Wes looks at his father.  His father tells me that right now Wes is residing at home.  “My wife is a stay-at-home mom,” he says.  “Wes has talked about going to college, but right now he’s taking a break from his studies.  He just graduated high school last spring—cum laude.”

I examine Wes as best I can, given the constraints of the wheelchair.  Afterwards I comment that the physical exam is normal—normal apart from the obvious muscle wasting, contractures and inability to move his limbs.  “He’s due for two shots today,” I explain to his father.

“I’m good with that,” Wes says.

I administer the shots, and Wes thanks me for taking care of him.  I take a deep breath and say:  “You know, Wes, I think it is I who should be thanking you.  I’ve learned a lot from you during our time together today.”

Wes regards my face with silent eyes of innocence.

“Wes has taught us a lot—quite a lot—over the years,” his father says.

“I’ll bet he has,” I say.

Wes smiles.  “I’m no one special,” he says.  “I just try to do the best I can with what I’ve got—you know, take it one day at a time.”

That’s the grace of gratitude for you—lived out better than even the best author is capable of putting into words.

Streets of Philadelphia

I walked the avenue till my legs felt like stone
I heard the voices of friends vanished and gone
At night I could hear the blood in my veins
Black and whispering as the rain
On the streets of Philadelphia.

—Bruce Springsteen

This past weekend I did something I hadn’t done in thirty years:  I took the train to Philadelphia.

The occasion for my excursion was an editorial board meeting for a national medical journal.  Such meetings are held twice a year.  Six months ago I flew out to San Diego for the previous one.  This time round I took the train.

Friday morning I boarded a two-car commuter rail just north of Hartford, rode it to New Haven, and connected with the northeast regional to Philadelphia.  In thirty years I had forgotten that trains in the northeast corridor pass through rough stretches of country—past litter strewn ravines, boarded up brick buildings, scrap yards filled with piles of junked cars, graveyards populated by the dead.

Those of us on the train—the living—sit by the windows and watch graffiti covered walls stream by or read the morning paper, listen to an iPod shuffle or text message a friend.  Occasionally we rise to our feet and stagger down the central aisle to the john before picking up a coffee or a bottle of water in the café car and return to our seats.

I arrived at 30^th Street station in Philadelphia that afternoon and walked thirteen blocks to the Westin Hotel on 17^th Street and checked in.  The remainder of the afternoon I spent exploring the city on foot.  I sauntered down Chestnut Street to Independence Hall, glimpsed the Liberty Bell through the massive window, paused at the memorial in Washington Square and picked up Walnut Street on the return leg.  Near Jefferson Hospital I cut up to Chestnut again and stopped at a medical bookstore to browse the titles.

My first medical mentor had attended Jefferson Medical College in the 1960s.  Shortly after I got to know him in the late 1970s, he developed Hodgkin’s lymphoma.

I in turn took my medical studies at Hahnemann at Vine and Broad Streets, where I cemented a life-long friendship with another student who now practices family medicine in Arizona.  At the time we both roomed on north 15^th Street, although he and his wife later took another apartment ten blocks south near Spruce.  My wife and I sublet from them when they were out of town for a month that second summer.

I exited the bookstore with my hands thrust deep into the pockets of my trench coat.  It had started to rain; the wind was whipping up in cold wet gusts.  I passed by two musicians huddled in a stone archway playing a Michael Jackson tune on their saxophones.  I’ll be there, one horn soothed reassuringly, while shortly afterward its companion echoed the same soulful sentiment.  I tightened the collar of my trench coat against the wind and pulled the brim of my cap down tight.

That evening I met up with my fellow editorial board members for dinner at Upstares & Sotto Varalli on South Broad.  The remainder of the weekend flew by:  an all day meeting in the Director’s Room at the hotel on Saturday, dinner at the Raw sushi bar on Sansom Street, a late evening demitasse of melted chocolate at the Naked Chocolate Café on Walnut.

Back in my room on the 14^th floor of the hotel I stood at the window and looked down on the gleaming streets of the city.  I thought about the man I had seen slumped over a makeshift cardboard sign on which was scrawled one word:  “Hungry.”  A tangled mass of black hair emanated from the back of his stocking cap, his coat was marred with grease stains, his ankles showed white between the tattered cuffs of his trousers and the tops of his dirty sneakers.  When I dropped a few coins into the plastic bowl in his lap, he barely stirred.  In thirty years the streets of Philadelphia haven’t changed much.

The cabbie I hired Sunday morning chatted in Arabic on his cell phone all the way down JFK Boulevard to 30^th Street station.  I tipped him a dollar and stepped out onto the wet pavement in the early morning darkness.

As we gathered at Gate 3 to make our descent to the waiting train, I noticed a young couple standing off to the side, holding hands with their foreheads touching.  There are always young couples standing on station platforms, it seems; huddled together, oblivious to the rest of humanity.

Shortly after pulling out of the station we passed over the Schuylkill River.  I caught a glimpse of the macadam path that runs along the bank by the boat houses.  Another good friend and I attempted the Philadelphia marathon there when we were undergraduate students.  I logged 18 miles before I cramped up from dehydration and dropped out of the race.  Some things in life you never complete.

My mentor finally succumbed to his lymphoma this past year.  I still correspond regularly with my doctor friend in Arizona.  Once a year we get together for an afternoon saunter through another Pennsylvania town and catch up on our lives—far from the streets of Philadelphia.