A tapestry of song

My life has been a tapestry of rich and royal hue
An everlasting vision of the ever-changing view
A wondrous woven magic in bits of blue and gold
A tapestry to feel and see, impossible to hold.

—Carole King, Tapestry

When we arrived home from the Tapestry Singers annual Valentine’s Day cabaret concert, I counted up the musical numbers listed in the program. There were exactly twenty — a full musical score.

The songs ranged from Broadway hits to country ballads, patriotic medleys to spiritual worship songs. For two hours we were treated to poignant arrangements of pieces like Leonard Cohen’s “Hallelujah” and Enya’s “Only Time,” Jerry Herman’s “Ribbons Down My Back” and Irving Berlin’s “Anything You Can Do, I Can Do Better,” Mark Hayes’ “Consecration” and Marie Barnett’s “Breathe.” For the grand finale there was a special rendition of “Over the Rainbow.”

This annual event was the brainchild of Jana Pivácek-Cole, a talented vocalist and voice teacher, who succumbed to cancer at the close of last year. Since 1998, Jana’s Tapestry Singers, composed of former voice students of all ages,  has offered public performances to raise financial support for the Kateri Medical Clinic in the Kaduna province of northern Nigeria.

Without the benefit of Kateri Medical Clinic, thousands of Nigerians who reside in the region would have no access to medical care. Last year over 14,000 people received care at Kateri for the amazingly low cost of $5 per encounter.

As I sat through this moving musical repertoire, I reflected on our medical mission to Nigeria last summer. We saw nearly 6,000 patients in a 2-week stretch. Many more were unable to access care during our stay; although the needs were great, the workers were relatively few.

When my eyes began to water, I wasn’t entirely certain why. It might have been the poignant pieces of music I heard — or perhaps the memories of those Nigerian patients I had seen. Both sets of voices were certainly present, and together they sounded sweet and low in my ear.

In a Paris Review interview literary critic George Steiner opined:

The next Copernicus may have something to tell us about what music does inside us and how it is created. Above all, music illustrates for me that order of meaning that you can’t translate, can’t paraphrase, can’t put in any other terms, and yet which is intensely meaningful.

Some say that music can heal the heart; I know it can heal the soul. Perhaps it is even capable of moving beyond the borders of space and time to touch the lives of others in need, continents away.

Show me the way to go home

Like ghosts, late-morning mists hovered momentarily over the mountain, winding their way upward to lose themselves in the low-lying clouds. Up on the ridge the old tower stood stately firm, a shell of its former glory. We wound our way along the river road, the pavement still glazed from morning rains.

Down the interstate we flew, making the Pennsylvania border in record time, then coasted into Milford, where we turned southwest to begin the descent through the long green valley. Off to our left through the trees we caught glimpses of the grey Delaware. A wild turkey strutted through the brush; an oriole darted across the road into the trees. A short detour twisted through a stand of dense forest.

We turned off at Smithfield, picking up the shortcut that my uncle had told us about decades ago. Shortly, we glided over the crest of the hill and dropped down into the old town. We pulled into a parking space, crossed the street and slipped inside the church just in time to catch my cousin’s eulogy, the prayers, the creed, and a few familiar hymns from long ago.

The graveside interment was brief. The hillside lay dotted with flags freshly planted for the Memorial Day remembrance. We returned to our cars and headed out to the banquet facility on the hill.

I met my cousin at the entrance. “It was a good talk,” I told him.

“I almost didn’t get through it,” he said.

“You did fine. I liked your description of what it was like when your dad would get home at the end of the day, pulling into the driveway, jingling the change in his pocket, humming some old tune.”

“It was the best part of the day for him—and for us.”

We filed inside and found our seats at one of the long tables. It had been years—fourteen, in fact—since I had sat down to break bread with my extended family, the remnant of aunts, uncles and cousins I had grown up with. I shook hands and exchanged hugs, recalling snatches of their personal histories, knowing that they knew mine. Collectively, a family grows, breaks, gathers together to bind up its wounds and moves on.

We ate and reminisced, stood and shook hands, introducing ourselves to the younger set we hadn’t seen in years. Finally, before dessert, we sat to sing my uncle’s favorite, “Show me the way to go home.”

It was a shorter drive back up the valley to the interstate. Despite patches of heavy fog and steady rain along the extensive stretch of darkened highway, we navigated our way through the night back home.

Recommended reading

In preparation for a routine medical checkup, a good friend of mine drafted a list of concerns to discuss with his physician.

Even though my friend’s life now spans seven decades, he remains in reasonably good health.  Like most of us, he’s got some minor issues related to the wear and tear of his body over time, but nothing insurmountable.

He sat and thought and jotted a few items down on paper.  First he listed his current medications.  Then he wrote a short note to remind himself to mention the problem of his ongoing knee pain.  After that he recorded his concern about his recent inability to remember where he puts things.  Lastly, he added a particularly worrisome problem—inability to rest at night because of recurring bad dreams.

My friend enjoys talking with his doctor, because, as he puts it, his doctor always takes the time to listen.

Whenever my friend checks in with the receptionist for his scheduled appointment, he always inquires just how far behind the doctor is running.  The usual answer falls somewhere between one to two hours.  Undaunted, my friend takes a seat and opens whatever reading material he has brought along to pass the time until the nurse calls his name.

One recent morning over breakfast my friend shared the notes he had taken down during this latest doctor visit.  One by one we reviewed the issues.  When it came to the sleep problem, I asked him what his doctor had advised.

“Oh, he said I should read Thoreau’s Walden,” he told me.  “He feels that it’s a good book to cleanse the mind.”

On hearing this advice, I smiled.  I re-read Walden every spring.  Perhaps that’s why I haven’t been plagued with disturbing dreams for years.

Walden is melting apace. There is a canal two rods wide along the northerly and westerly sides, and wider still at the east end. A great field of ice has cracked off from the main body. I hear a song sparrow singing from the bushes on the shore,—olit, olit, olit,—chip, chip, chip, che char,—che wiss, wiss, wiss. He too is helping to crack it. How handsome the great sweeping curves in the edge of the ice, answering somewhat to those of the shore, but more regular! It is unusually hard, owing to the recent severe but transient cold, and all watered or waved like a palace floor. But the wind slides eastward over its opaque surface in vain, till it reaches the living surface beyond. It is glorious to behold this ribbon of water sparkling in the sun, the bare face of the pond full of glee and youth, as if it spoke the joy of the fishes within it, and the sands on its shore,—a silvery sheen as from the scales of a leuciscus, as it were all one active fish. Such is the contrast between winter and spring. Walden was dead and is alive again. (“Spring” in Walden)

Precious Stone

“We are all fixing what is broken.  It is the task of a lifetime.”     —Verghese

By chance, when I was a boy searching for rocks to add to my growing collection, I found my first piece of pyrite — “fool’s gold.”  This particular nugget was big, certainly much bigger than any crystalline mineral I had previously encountered.  As I turned it over in my hand, it reflected a tarnished brassy light.

This treasure turned out to be nothing next to the tiny flakes of real gold that later, as an adolescent, I panned from the mountain streams of New Mexico.  That brilliant yellow sparkle was unmistakable.  Once you encounter the real thing, you never forget; it burns itself into your memory and you guard its image forever.

For me, now a seasoned clinician, Abraham Verghese’s 2009 novel Cutting for Stone is the real thing.

Against the backdrop of Ethiopia, a country so beautifully depicted that his descriptions can hurt, Verghese crafts the timeless narrative of two brothers, twins joined at the head by a mysterious cord identified at birth.  In an emergency caesarean section the obstetrician who will become their surrogate mother clamps and divides this tube, uncertain if it contains meninges, gray matter or aberrant blood vessels.  Thus separated at birth, the twins retain a mysterious bond between them throughout the rest of their lives.

Thomas Stone, their surgeon father, normally level-headed and dexterous in the operating theater, flounders on how to proceed with the delivery.  Because of his lack of timely intervention, the mother exsanguinates on the table.  Unable to cope with his perceived incompetence, Stone flees the hospital, the country, and, as we later learn, the continent.  He appears again in the final section of the book where he will be called upon in his brokenness to perform a surgical miracle.

Meantime, the boys are adopted and reared by Hema, the obstetrician gynecologist, and Ghosh, the internist, at Missing (a mispronunciation of “Mission”) Hospital in Addis.  Both boys are introduced to the practice of medicine at an early age.  Each pursues it in his own fashion.  Marion, the first-born, blossoms under the tutelage of Ghosh, the competent and kind clinician; while Shiva, his mother’s favorite, blazes his own unique path, pioneering and perfecting the techniques of fistula surgery that will save thousands of ill-fated young women.

Estranged from Shiva over a fiery young woman, Marion is forced to flee Ethiopia for political asylum.  The paths of the brothers will converge seven years later in America, where, in a manner of speaking, they become reunited again.

In Cutting for Stone, Verghese gives us his best, exploring how the sins of fathers are visited upon subsequent generations, the intricate relationships between broken people, the history of modern medicine from clinical practice to the art of transplantation, the interrelatedness of human existence on this planet.  The narrative is chocked full of medical aphorisms and old saws, a well-stocked larder for the practicing clinician.

Cutting for Stone was placed in my hands by a good friend who thought I might enjoy it.  He and his wife had read it over the course of their recent two-month trek through Australia and New Zealand.  I discovered a bookmark sandwiched between two pages — a dog-eared boarding pass from one of their intercontinental flights.

The read itself turned out to be a fascinating journey, one enriched by precious stone.

Help me to not be afraid

Like all 4-year-olds, Skipper had his likes and dislikes, his favorite activities and things he would rather not do. Like most 4-year-olds, Skipper’s world consisted of family, friends, pre-school and home. And like few 4-year-olds, Skipper’s world came to a grinding halt when his doctor diagnosed him with a brain tumor.

Because of its location, the tumor was operable. The neurosurgical team labored over him for eight hours and succeeded in resecting the growth. Because the pathologist was unable to differentiate the cellular type, the slides were sent out to a world-renowned regional cancer center for review by the experts.  The results came back equivocal.

The parents were given the option of a short course of local radiation, an extended course of chemotherapy, or observation. Because of the side effect profiles, they elected to watch and wait. Unfortunately, the growth recurred.

This time round Skipper was enrolled in a chemotherapeutic protocol. Periodically, he would receive four days of toxic medications. These rounds were scheduled at monthly intervals. The initial treatment regimen knocked him down, but soon he was up and active again. The second round was worse. The morning before the trip to the hospital, Skipper’s grandmother was helping him to put on his socks when he made his small request: “Please, Grandma, help me to not be afraid.”

What do you say to a 4-year-old? What sort of reassurance do you offer? How far out on the limb do you go?

At that age, reassurance takes on the mantel of love. Words help, touch helps, doing an activity together helps. We work with whatever tools we have.

Sometime later after I heard this story, I drove to a local bookstore to browse the shelves in the children’s section. It proved difficult to locate a specific book, because they are categorized under different genres according to the perceptions of the adults who work in these areas. For the young child, a book is a story—nothing more, nothing less. Its category means nothing—it is only the story that holds meaning.

I made my selection and paid at the register. I laid the parcel on the seat beside me as I climbed into my car. I hand carried the book to the house that I had last visited years ago. Tucked in among the towering pines, it was still there, just as I had remembered it: neat and trim, well cared for.

With a short stammer of inadequate words I placed the gift into the hands of the grandmother I had come to know over the past decade. She invited me to come in, and we sat among the plants in the conservatory and talked a long while about children and grandchildren, parenting and grandparenting, love and tough love.

She gifted me a poem by one of her favorite writers, Wendell Berry.

When despair for the world grows in me
And I wake in the night at the least sound
In fear of what my life and my children’s lives may be,
I go and lie down where the wood drake
Rests in his beauty on the water, and the great heron feeds.
I come into the peace of wild things
Who do not tax their lives with forethought of grief.
I come into the presence of still water.
And I feel above me the day-blind stars
Waiting with their light.
For a time I rest in the grace of the world, and am free.

At my age, reassurance takes on the form of caring. We learn to care for one another as best as we can, with whatever tools we can muster.

Anger, Hate and Reconciliation

As I scanned the overnight fax reports clipped to the pile of medical charts on my desk this morning, I learned that one of our teenaged patients had been discharged from a residential psychiatric facility.  The girl was admitted for observation after voicing suicidal ideation, thoughts that surfaced after she was informed that she would have to testify against the perpetrator who raped her a year ago.  In spite of the fact that the perpetrator admitted his guilt, the legal system dictated that the girl would still have to face him once again—this time in the public setting of a courtroom.

Modern psychological theory has it that a victim who has suffered intense trauma needs to tell her story in order to heal.  Healing is a process that takes place over time.  Some of us heal faster than others, and some of us need to tell our story more than once to work through it.

There are those theorists who maintain that reliving a traumatic incident ad infinitum might serve to sear the trauma into the victim’s memory to such an extent that it will never be erased.  In short, the more we relive a traumatic event, the more likely we are never to forget it.

Communal groups, whether small or large, might also find that collectively revisiting traumatic events serves to heal.  As human beings, we do have the need to commemorate those fellow creatures victimized by some tragic event—a war, an attempted genocide, a terrorist attack.  In some ways it does us good to ponder and reflect.  It helps us work through our collective grief—something we need to do in order to heal as a community, as a society, as a nation.

Yet there is a danger that lies in revisiting such events ad infinitum.  That danger has to do with rekindling our anger and hatred for those who perpetrated the horrendous act.  When our collective anger flares, we relive not only the trauma of the historical event itself—it also serves to harden our hatred and prevent us from allowing ourselves to heal as a community, as a society, as a nation.

On this 9^th anniversary of 9/11 I arose early to read through several opinion columns in the press.  Largely, columnists fall into one of two camps: those who prod us to maintain our vigilance “lest we forget what happened on that day,” and those who advocate a sincere attempt to separate the perpetrators—the militant fanatics—from the major religion with which they have come to be identified.  Some advocate the use of “free speech” to decry the enemy, while others strive to emphasize the need for peace and reconciliation.

As a nation, how do we commemorate the victims of 9/11 without fanning once again the flames of hatred?

Such thoughts ran through my head as I began my day seeing patients in the office.

I spoke at length with a father about his obese son, giving him some practical tools to help the boy move toward a healthier lifestyle.

I counseled a young man suffering from depression, attention-deficit disorder and drug use.

My last patient of the morning was the youngest daughter of a Muslim family that I have known for more than a decade.  Her mother brought her to see me because the child was complaining of a sore throat and belly ache.  During the course of the visit the mother pointed out the nits in her daughter’s hair.  Suddenly, she began to cry.

“I don’t know how she get this,” the mother told me through her tears.  “None of my other children ever have such a thing.  She bathe every day.  I make sure she have clean clothes to wear to school.  We are a clean family.”  And then, exasperated, she sobbed, “I am so ashamed.”

Here the daughter began to cry as well.  “She don’t want to tell her teacher because she afraid that the other children will make fun of her,” the mother said.

I reassured the mother that head lice was a common malady in young school-aged children, that it had nothing to do with personal hygiene, and that it was fairly easy to treat.  I wrote out a prescription and explained to the mother how to apply the preparation.  “You’ll have to comb the nits out afterwards,” I told her, “but she will get over it.”

As I handed her the prescription I noticed an intricate henna tattoo on the mother’s left hand.  “Today is holiday in my religion,” she explained.  “Eid-ul-Fitr, the day after Ramadan ends—a day of forgiveness, a time of giving and sharing.  That is why I do this, to remember.”

All of us set aside special days to remember—some to commemorate, some to ponder and reflect, some for feasting and celebration.

Perhaps the time will come when one day we will agree to set aside a special day to reflect on one more thing:  forgiveness.

The Poetry of the Commonplace

In her recent New York Times column, Compelling Stories, If Not Literature, Dr. Abigail Zuger bemoans the recent outpouring of health-related memoirs. “Few of these efforts rise to the level of great literature,” she writes. “None of these books comes close to succeeding according to the usual standards. The language is clumsy and full of clichés; the dialogue is stiff and unreal; the pacing is way off.”

Dr. Zuger also has something to say about doctors who have taken to writing their own stories: “the great majority are sentimental and predictable, and a few manage to be as pedantic, self-important and annoying as, one ventures, their authors must be in person.” Her conclusion? “Most of these books aren’t great literature either.”

Still, Dr. Zuger confides, she has a soft spot in her heart for such books. In the face of all of her prior criticism, you have to ask yourself why. Is Dr. Zuger merely being sentimental? Or does she identify with the sentiments of her patients and colleagues?

In my opinion, what Dr. Zuger fails to recognize is that the patient’s story, no matter how ineptly told, becomes an integral part of the healing process itself.

Medicine’s great 19th century humanitarian physician William Osler remarked that, dealing as he does with poor suffering humanity, a good doctor has to keep his heart soft and tender, lest he develop too great a contempt for his fellow creatures. Osler reflects on what he terms “the poetry of the commonplace”—the ordinary man, the plain, toil-worn woman, their love and their joys, their sorrow and their griefs.

According to Osler, such tales serve to sustain the weary-worn clinician in his daily work. They also serve to sharpen his compassion for his fellow creatures.

My collection of clinical tales in the art of medicine, Patients Are a Virtue, might not be great literature. Few practicing clinicians and fewer patients will ever read it. Most likely it will eventually be relegated to the dustbin of narrative medical writing. And yet I take heart when I receive that occasional communication from cyberspace, such as a brief e-mail from a doctor in rural western Pennsylvania, who wrote that, after reading my book, he felt energized and renewed in his commitment to his patients. He felt so strongly about it that he purchased additional copies for his colleagues and encouraged them read it as well.

Is every patient and practitioner a poet? Dr. Zuger asks. In his consideration of the poetry of the commonplace, I believe that Dr. Osler would answer her rhetorical question in the affirmative.

Office Visit

Office Visit

Now you are ten, and
With ten pastel-painted toenails
When daffodils bloom
You come to me complaining of
A sore throat.

Your mother smiles, tells me
She’s taking you to Disney World
Next week; wants to make sure
It’s nothing serious,
Your sore throat.

The faint pink test line
Signifies streptococci, but
No matter—
Nothing that a course of
Bubblegum medicine won’t fix,

Unlike your older brother’s
Neuroblastoma, which
Took him this month
Eight years ago,
When you were only two.

18 April 2010

Humane Medicine — Telling It Slant

Emily Dickinson advised us to tell all the truth but tell it slant.  In difficult clinical situations, telling it slant might be the best way to approach the healing truth that sets the sufferer free.

Interested readers can now access my latest Humane Medicine column, Telling it slant: Using poetry as a venue for healing, recently published in the Journal of the American Academy of Physician Assistants.

Addiction: Biochemical bondage or voluntary behavior?

“Addiction is a chronic and relapsing brain disease.”  Few would dispute this statement purported by the National Institute on Drug Addiction (NIDA).  Those of us who work in the disciplines of clinical medicine and research pharmacology have been inculcated with its corollary:  “once an addict, always an addict.”

Such claims conjure up the notion that those addicted to substances remain powerless over their pharmaceutical spells.  Substances like alcohol, nicotine, cocaine, opiates and their derivatives create a physical dependence in those addicted to them.  Denying the body access to such drugs triggers symptoms of physical withdrawal.  Those who succeed in extricating themselves from the regular use of such drugs remain constantly at risk for relapse.  Such facts are borne out by modern research and methods of treatment.

Or are they?

Now comes a work—Addiction: A Disorder of Choice—in which research psychologist Gene Heyman challenges the view that substance abuse is an irresistible act wholly beyond the control of the user.  Although Heyman does not deny that addiction is independent of the brain, he does argue that it is in part voluntary behavior.  He further maintains that “it is not possible to understand addiction without understanding how we make choices.”

Repeated use of drugs ultimately changes brain structure and function by altering biochemical pathways, reinforcing those that mediate the experience and memory of pleasure.  Such neuronal pathways persist, producing cravings even after the addict has stopped using.  If addiction itself is not a brain state, but rather a behavior, the question then arises:  do neurochemical changes in the brain prevent the user from exercising voluntary control over choice and actions?

Heyman argues that “drug-induced brain change is not sufficient evidence that addiction is an involuntary disease state.”  He points to a number of studies where, through the judicious use of contingencies, addicts demonstrated the ability to voluntarily change their behavior and stop using.

The more we learn about brain functioning from biochemical research, the more apt we are to regard behavior as something regulated by the action and balance of neurotransmitters in brain.  Ultimately, we might decide that all behavior is involuntary, that each one of us is an automaton, dependent upon the synaptic activity of the moment.  And yet—as any parent knows—behavior can be shaped by meting out consequences and contingencies.  Eventually, children learn to modify their own behavior through voluntary choice.

Heyman extends his argument to include other addictive behaviors such as compulsive gambling, shopping, and sex.  Each involves a craving, an intense impulse and—for Heyman—a voluntary choice.

These arguments bring to mind a passage from John Steinbeck’s epic novel East of Eden, in which he discusses sixteen verses from the book of Genesis about humankind’s ability to wrestle with the temptation of sin.  For Steinbeck, “these sixteen verses are a history of humankind in any age or culture or race.”  The crux of the premise centers around timshel, a Hebrew verb translated as “thou mayest.”

But the Hebrew word, the word timshel—‘Thou mayest’—that gives a choice. It might be the most important word in the world. That says the way is open. That throws it right back on a man. For if ‘Thou mayest’—it is also true that ‘Thou mayest not.’

Steinbeck goes on to develop this idea through character dialogue in the book:

‘Thou mayest’! Why, that makes a man great, that gives him stature with the gods, for in his weakness and his filth and his murder of his brother he has still the great choice. He can choose his course and fight it through and win.

Steinbeck concludes the passage with these words:

I feel that a man is a very important thing—maybe more important than a star. This is not theology. I have no bent toward gods. But I have a new love for that glittering instrument, the human soul. It is a lovely and unique thing in the universe. It is always attacked and never destroyed— because ‘Thou mayest.’

If Steinbeck and Heyman are correct, in the face of seemingly insurmountable odds, struggling addicts might be able to triumph over their addictions by an exercise of the will—one day at a time.

If they are wrong, ultimately we may be forced to confront our own pyschopharmacological demons in the form of serotonin, dopamine, norepinephrine and GABA.