My thoughts drift back to my early years of training, when for nearly 2 years I spent every third night on call in the hospital setting. One night still haunts me. more»
Interested readers can now access my latest Humane Medicine column — Hauntings: When the clinical mark is missed — recently published in the Journal of the American Academy of Physician Assistants.
Please note that all of my previously published Humane Medicine pieces can now be accessed here.
Several years ago, when I was laid up for 6 weeks with a fractured ankle and hand after a hiking accident, my wife decided to get a dog. She and my daughter drove to the pound to scout out prospective candidates. They came home with a scraggly terrier, rescued from certain annihilation. more»
Interested readers can now access my latest Humane Medicine column — Vestigial reflexes, gut reactions: When time is not enough to heal — recently published in the Journal of the American Academy of Physician Assistants.
If we should become wise, we come to understand that each of us has only the day before us to live. more»
Interested readers can now access my latest Humane Medicine column — Said and done: When the present is all we have left — recently published in the Journal of the American Academy of Physician Assistants.
There is an old adage in medical practice: when you hear hoof beats, think of horses, not zebras. In other words, any given clinical presentation will more than likely turn out to be a common disorder. In primary care medicine, esoteric diagnoses are relatively rare.
But sometimes when the sound of hoof beats returns in rapid succession, the clinician would do well to consider the possibility of a zebra in the forest. more»
Interested readers can now access my latest Humane Medicine column — Horse sense: Recognizing a rare diagnosis in primary care — recently published in the Journal of the American Academy of Physician Assistants.
Weatherbeaten by Winslow Homer
It’s always difficult to hand a new patient a disturbing diagnosis, or even to suggest that there might be something amiss. more»
Interested readers can now access my latest Humane Medicine column — Ebb and flow: Murmurings that are more than sweet nothings — recently published in the Journal of the American Academy of Physician Assistants.
In my youth I had visions of becoming an ophthalmologist. Nothing, I thought, could rival the anatomy and physiology of the human eye for sheer beauty and function. more»
Interested readers can now access my latest Humane Medicine column —Kitchen medicine: Focusing in on an obscure diagnosis— recently published in the Journal of the American Academy of Physician Assistants.
On her physical exam there is nothing amiss to report. Yet something is obviously bothering this child. Uncertain as to which direction to proceed, I take a stab in the dark. more»
Interested readers can now access my latest Humane Medicine column — The principle of uncertainty in medical practice — recently published in the Journal of the American Academy of Physician Assistants.
The more I looked, the more I began to see. The more I saw, the more the pieces of this complex pediatric puzzle began to fall into place. more»
Interested readers can now access my latest Humane Medicine column — Looking through a glass darkly, then seeing face to face — recently published in the Journal of the American Academy of Physician Assistants.
I first encountered Dr. Howard Spiro at a medical humanities conference in Williamstown, Massachusetts, some 20 years ago. As a guest speaker, Dr. Spiro shared the podium with Dr. Robert Coles. The two made quite a pair: both distinguished practitioners of the art of medicine; one from Harvard, the other from Yale. Dr. Spiro wore a brown bow tie that day. I recall that detail exactly, because it was the kind of bow tie you had to tie yourself; and I remember suppressing an impulsive urge to discreetly snug it up for him. Curiously, I didn’t actually make his personal acquaintance until nearly a decade later.
One evening in December of 2002 my friend and colleague Dr. David Elpern and I traveled to New Haven to attend an evening lecture at the Yale Humanities in Medicine program. During the drive down, Dr. Elpern told me that Dr. Spiro had founded the lecture series back in 1983. Later that evening over dinner at Mory’s, we learned from Dr. Spiro that he had gotten up a fledgling online journal of similar import, the Yale Journal for Humanities in Medicine.
By that time a few of my early pieces had been published in JAMA and BMJ. Dr. Spiro was eager to hear all about them. I don’t recall whether he asked me to consider submitting something to YJHM at that time or not. At some point I did send him a piece, which he graciously accepted for publication.
Sometime later, after he offered to review my book Patients Are a Virtue, Dr. Spiro asked if I would consider doing a monthly column for the journal. “What would we call it?” I asked him. “Call it what you like,” he said. Shortly after that my “Notes from a Healer” began to appear in the electronic pages of YJHM.
And so began a collegial relationship that lasted up until the time of his death. (Dr. Spiro approved the submission for my March “Notes from a Healer” column days before entering the hospital for a cardiovascular event that would ultimately end his life.)
Every month for the past five years I would send Dr. Spiro a piece for the column, which he would critique, usually in a few brief lines, before okaying it for publication. These critiques were not those of a typical editor. Many times he would comment about something in his own life or how the piece I submitted moved him personally.
“Engineers are among the most difficult patients, for they are convinced there’s a detectable reason/cause for anything/everything.”
“Wise, indeed. One learns with age.”
“You are sounding more like O Henry with time.”
“Your usual beautiful turns. I confess I would have seen the opportunity/really the genius of America in their story, but suum cuique!”
Occasionally, he would point out a grammatical error; and red-faced, I would shoot off a corrected copy with my thanks appended. At some point, he would finally bestow his signature stamp of approval: “Imprimatur.”
Dr. Spiro rubbed shoulders with some of the medical greats of his era. Many times I only learned of these relationships through casual comments he would make on pieces I sent him. For example, in response to one of my submissions he wrote:
“I knew Leon Eisenberg—admired him—look at his CV. I cannot believe that he would want to be considered a mere psychopharmacologist.”
After researching Dr. Eisenberg’s biography, I wrote back, “I took your advice. You were obviously correct in pointing out that the man was much more than just that.” I included an article from Harvard’s FOCUS Online which I thought Dr. Spiro might enjoy . Dr. Eisenberg’s story about the schlemiel was priceless.
Sometimes Dr. Spiro and I exchanged correspondence on matters of medical practice as well. Once, I discovered an article that referenced a paper of his. I sent him the link with a few observations:
“Reading through this review, I couldn’t help but think that you would enjoy it. As it turned out, you were mentioned toward the end of the article.”
‘Stress,’ the American gastroenterologist Howard Spiro writes, ‘increases vulnerability’ to other ulcer-causing agents ‘like H. pylori’. Medical fascination with bacterial causation has, he says, resulted in culpable neglect of the roles of the mind, the emotions and the dietary and behavioural patterns of everyday life. (A Modern History of the Stomach: Gastric Illness, Medicine and British Society, 1800-1950 by Ian Miller)
Dr. Spiro was obviously pleased: “Thanks, glad I am remembered! I worked on stress in the 1940′s, thanks to Selye’s idea of the ‘alarm reaction’ and published my first medical papers back then.”
In turn, I wrote back: “Perhaps my perspective is somewhat skewed, but it seems to me that precious few specialists seem to be able (or willing) to relate to such patients on a humane level these days, a demonstration of the lost art of medicine.”
Dr. Spiro’s assessment: “Boy, are you right! When I was young, we talked to patients. Lab data and images were scanty. Since 80% of patients get better with time and the right hand of fellowship, the clinician counted. But that will return after disenchantment spreads.” He had entitled this reply I-Thou.
On a professional level, Dr. Spiro was supportive of my clinical practice as a physician assistant. He strongly advocated for the advancement of “mid-level practitioners” as he called us, feeling that we were the answer to the primary care clinician shortage problem. “The expertise you demonstrate in the way you care for your patients is evident in your writing,” he wrote. “I argue with my colleagues, many of whom feel that medical practice should be regarded as the exclusive domain of the physician.”
“As you may know—or more likely may not—for the last 20 years I have been pushing the idea that physician assistants or nurse-practitioners should be doing pediatrics and general internal medicine. Very few in the internal medicine business agree.”
“Your enthusiasm, amity, empathy for your patients—and your prolific writing skills—continues to reassure me that physician extenders—if I can call you that—should constitute our general docs and pediatricians. It’s a canard that they will not recognize serious problems! I keep wondering why you do not talk about that—or maybe you do, indirectly, or in other places.”
This past fall Dr. Spiro wrote that he would be traveling to Arizona to give a medical humanities presentation at one of the medical schools there. “I would like to use you as an example of a clinician who not only practices humane medicine, but writes about it well. Send me a copy of your CV. I imagine you to be somewhere around 45, give or take.”
I sent him my résumé with the caveat that he was off on my age by more than a decade. “Hah! You write with the vigor of someone in his early thirties,” he quipped.
Toward the end it was evident that Dr. Spiro was becoming a bit forgetful. When the name of George Bascom resurfaced in one of our e-mail exchanges, he wrote: “Tell me again how you knew him.”
“It was you who knew him personally,” I wrote back. “I only knew him through his poetry. In any event, he was a fine mensch who continues to influence clinicians from beyond the grave.”
“If you didn’t know him personally, a word like mensch—which I take to be a personal assessment—might be out of place,” he replied. The response stung.
I took a deep breath and typed out a reply. “According to the dictionary, a mensch is someone to admire and emulate, someone of noble character. It’s meant as a compliment to highlight the rarity and value of that individual’s qualities.”
I suppose those words might just as well have been written to describe Dr. Spiro himself.
Howard M. Spiro, M.D. (Photo credit: Peter Casolino Photography, New Haven, CT)
Medical practice lay a-bed,
With fever to the core;
Sickness festered in her head,
While death passed by the door.
A string of suitors, all untrue,
Had left her bed of pain,
Parties of the third did woo—
Though not for love, but gain.
Big Pharma promised wonder drugs,
To ease the maiden’s plight,
True colors shown: this band of thugs,
Had raped her in the night.
So there she lay upon the cot,
Delirious, forsaken;
If she once had, she now had not—
Her very soul was shaken.
An ancient door eased open;
Humanity crept in
With tender thoughts unspoken
For dying medicine.
He slipped a hand in her hand,
Caressed the feverish brow;
He lingered by the night-stand,
Then turned the lantern low.
Humanity kept vigil
Close by throughout the night;
The heartbeat, once so feeble,
Had strengthened by first light.
When medicine awoke,
She stared into a face
That whispered words of comfort
And emanated grace.
So medicine was married,
Humanity, the groom;
Their grateful patients tarried
At tables in the room.
Now this is but a fable,
It never came to be—
Though fictions often lead to facts,
And blind men sometimes see.
2012 © Brian T. Maurer
