“Notes from a Healer” — A Singular Twist

“You’d better go to see this kid right away,” the medical assistant told me. “He’s acting kind of odd.”

I know this medical assistant well. She’s been working at our office almost as long as I have. I took her at her word and dashed into the room.

I found a 6-year-old boy sitting on the exam table, his mother standing by his side, her eyes wide open, filled with tears. I’ve known this mother since she was a little girl. She comes from a dysfunctional family, but she’s a survivor. She’s got a good head on her shoulders. Usually she’s pleasant, calm, in control. But here she was falling apart before my eyes.  more»

My latest installment of Notes from a Healer — A Singular Twist — 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.

The Inflammatory Response

“It’s truly amazing the progress we have made in our understanding of the disease process and how to treat it—all through basic cellular research. I have witnessed it all over the course of my career.”

I sat next to the Chinese woman and stared out of the salt-streaked window at the white-capped waves, conscious of the slight pitch and roll of the ferryboat. She was a Ph.D. biologist who headed a lab devoted to pharmacological research for treatment of dermatological disease.

“Thirty years ago,” she continued, “we treated the pain of rheumatoid arthritis with almost no thought to attacking the disease at the root of the problem—autoimmune inflammation. Now we have mapped the biochemical cascade of the inflammatory response—cytokines, prostaglandins, interleukins, components of complement—and we are in the process of designing drugs to block these agents to prevent tissue destruction. It is all so fascinating.”

We were returning to Hyannis from a weekend medical conference devoted to soft science on Nantucket Island. Ironically, here we sat discussing the benefits of basic medical research. There is always more than one perspective when it comes to the practice of medicine.

How much of what we experience as disease is in reality the result of the human body’s response to certain agents, such as viruses, bacteria, and other toxic agents?

A recent article in the New York Times spoke to this very idea.

A new insight in cold science: the symptoms are caused not by the virus but by its host — by the body’s inflammatory response. Chemical agents manufactured by our immune system inflame our cells and tissues, causing our nose to run and our throat to swell. The enemy is us.

The inflammatory response: a potent cocktail of the so-called inflammatory mediators that the body makes itself — among them, cytokines, kinins, prostaglandins and interleukins, powerful little chemical messengers that cause the blood vessels in the nose to dilate and leak, stimulate the secretion of mucus, activate sneeze and cough reflexes and set off pain in our nerve fibers.

Listening to my colleague speak, I thought back to a patient I had recently evaluated, someone diagnosed with bipolar disorder, a different kind of inflammatory response, where labile emotions flare in the limbic system of the human brain.

Perhaps one day basic medical research will enable us to delineate specific biochemical pathways that trigger such responses; and, in turn, help us to formulate pharmaceutical agents to block the cascade that results in the downward spiral of major depression.

With our current state of basic medical research we stand poised to micromanage these medical maladies.

What’s good for the cell is ultimately good for the soul.

“Notes from a Healer” — Mindless Medicine

Many times good doctoring entails more than just prescribing another pill.

My latest installment of Notes from a Healer — Mindless Medicine — 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.

Memes and the evolution of medical practice

A meme is “a postulated unit of cultural ideas, symbols or practices, which can be transmitted from one mind to another through writing, speech, gestures, rituals or other imitable phenomena.” The British evolutionary biologist Richard Dawkins postulated this concept in his 1976 book The Selfish Gene to explain the spread of ideas and cultural phenomena in evolutionary terms. Susan Blackmore, the British psycho-theorist, further developed Dawkins’ theory and believes that we are moving toward a new form of meme, the teme, which is spread by the technology we’ve created.

If we consider for the moment that memes do indeed exist (and their existence is far from certain), we could postulate that medical memes propagate through the medical community via medical journals, lectures and mentors. Published research eventually generates new approaches to the diagnosis and treatment of disease. Much contemporary medical research in the U.S.A. is underwritten by the pharmaceutical industry.

Nowadays, children routinely take medication for chronic conditions such as allergic disease, asthma, ADHD, depression, diabetes, gastroesophageal reflux and hypercholesterolemia. A spate of recent articles documents that 1 in 4 children covered by health insurance took some form of prescription medication in 2009. Annual spending for prescription drugs in children increased by 10.8 percent the same year, and the price of branded prescription drugs increased by 9.2 percent. Clearly, someone besides the patient is benefiting enormously from these trends in medical practice.

As a clinician who has worked on the front lines in ambulatory pediatrics for 30 years, I can vouch that these statistics seem to be supported by what I have observed over the past decade. The sheer number of children who take daily prescription medication for chronic conditions is astounding; and in my opinion these numbers will only escalate exponentially.

What drives these trends? Are clinicians becoming more astute at recognizing and diagnosing these conditions in children? Are the conditions themselves growing at an alarming rate secondary to cultural influences such as high fat diets, readily accessible food, over consumption of calories, unlimited access to TV and video games? Are parents themselves at fault, seemingly unable or unavailable to rear children with their best interests in mind?

Although any or all of these factors could potentially contribute to these disturbing trends, might medical memes—those ideas which seem to infiltrate medical practice and become acceptable norms—also play a role here? Are we clinicians too quick to reach for the prescription pad at the expense of taking time to offer wise counsel to our patients?

Some memes may replicate effectively even when they prove detrimental to the welfare of their hosts. According to Dawkins, “systems of self-replicating ideas can quickly accumulate their own agenda and behaviors,” which ultimately might prove to be good or ill for society, culture and the population at large.

Perhaps the medical profession needs to examine itself and take a closer look at what drives contemporary medical practice. In the meme, that might be a good thing.

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.

“Ruminating on GERD” published in YJHM

Something happened to change the approach to treatment of infant spittyness over the past decade:  H2 blockers and PPIs were introduced into the pharmacological armamentarium of pediatric primary care.

I was chagrined to learn recently that 5% of infants are prescribed medication for GERD—gastroesophageal reflux disease, the latest diagnosis du jour in primary care pediatrics. >>more

Readers can now access my latest essay, Ruminating on GERD, newly published in the Yale Journal for Humanities in Medicine.

A Socratic dialog on health care reform (IV)

The philosopher Socrates seeks advice from Apothos the sorcerer for a potion or pill to dampen the discomfort in the wound on his foot.

Socrates:  Hail, Apothos, purveyor of pharmaceuticals.  I trust that you might be of service to me this day.

Apothos:  Good Socrates, hail.  Tell me your needs, and I will prescribe a pill or potion guaranteed to restore you to homeostatic health.

Socrates:  Lately, I have lacerated the sole of my foot on a stone.  Aesculapius the physician cleaned and dressed the wound; yet even though I have been careful to guard it from further harm, I fear that it has suppurated.  (lifts his foot to show the wound)

Apothos:  Aye, you speak truly, as a philosopher is bound to do.  The purulence reeks of infection.  Let me peruse the bottles on my shelves.  Ah, here we go—just the medicinal substance to cure the vile suppuration.  One pill swallowed twice daily for three days will surely have you back on your feet in no time.

Socrates:  But tell me, Apothos:  what is this substance which you advise me to take?

Apo:  The substance, you say?  Why, nothing more than the most powerful antibiotic yet concocted by one of the most highly respected laboratories in the sorcerers’ guild.  It just appeared on the market last week.

Soc:  How new!  But tell me:  has it been tested properly before its release for public consumption?

Apo:  Of course, Socrates.  All of our medicinal substances undergo extensive field trials before they are released to the market.

Soc:  Then I take it that you vouch for the safety of the product?

Apo:  My dear Socrates, it is not I, a mere man, who vouch, but rather the sorcerers with their collective years of experience and expertise who stand behind the drug.

Soc:  And are there scientific studies published that substantiate its efficacy and safety?

Apo:  (chuckling) Of course, but of course, Socrates.  Here is one I just happen to have in my files vouchsafing the data on this particular drug.

Soc:  Although my eyes are dim with age, I perceive the fine print which states that this particular double-blind study was underwritten by the very laboratory firm that developed the drug and authored by sorcerers employed by the same company.

Apo:  A mere trifle, Socrates.  Science is science, not political opinion.

Soc:  Thank you for enlightening me on that point, Apothos.  Now then:  what would be the cost for this course of treatment?

Apo:  Of the cost you needn’t concern yourself, Socrates.  I will bill your health insurance directly.

Soc:  But I have no health insurance coverage, Apothos.  Alas, we philosophers have lately been forced to pay out of pocket.

Apo:  I sympathize with your plight, Socrates.  If you wish to purchase the medicine, it will cost 100 drachmae.

Soc:  One hundred drachmae!  For six tablets?  That’s 12-1/2 drachmae per pill!  Have you nothing equally efficacious and cheaper for those who must pay from their purse?

Apo:  If you wish, Socrates.  But this latest medication is by far the more modern drug.

Soc:  (shakes his head)  I can not afford to purchase it, Apothos.

Apo:  Then here—this will undoubtedly work as well.

Soc:  What’s this?

Apo:  An ancient generic drug of the penicillium mold.

Soc:  How much?

Apo:  (looks away)  Two drachmae.

Soc:  Two drachmae—compared to 100?  Such a decision is easily made.

Apo:  Suit yourself, Socrates.  You get what you pay for.

Soc:  (laying two coins on the counter)  Tell me, Apothos, what is your opinion of the debates in the Senate on reforming the Athenian health care system?

Apo:  Such proposals, I fear, would ruin the pharmaceutical industry.

Soc:  How so?  Please explain your reasoning to me.

Apo:  From what I understand there is talk of rescinding the ban that forbids the government to negotiate lower prices for drugs with the sorcerers’ guild.  If the ban is rescinded, prices of prescription drugs will drop, and market share will plummet as cheaper medicines are imported from Thrace and Macedonia.

Soc:  But would that not be a good thing for the citizens of Athens?

Apo:  Of course not.  If pharmacologic prices drop, profits will follow suit.  There will be less silver coin available to invest in research to develop newer and more expensive drugs.  Many of those in the sorcerers’ guild would lose their livelihoods.  The unemployment rate would continue to rise.  More and more of our citizens would lose their health insurance and with it, coverage for prescription drugs.  I would be forced to resort to peddling the ancient medicines like foxglove and acetylsalicylic acid, drugs to be had for next to nothing.  Why, I might even lose my apothecary shop!

Soc:  What might you do then?

Apo:  (ponders a moment)  I would consider opting for a career in politics and run for a seat in the Senate—or perhaps become a professional lobbyist for the sorcerers’ guild.

The biochemistry of love

Infuse the brain of a female prairie vole with the hormone oxytocin and she’ll quickly bond with the nearest male. In a similar manner, the hormone vasopressin creates urges for bonding and nesting when injected in the brains of male voles.

Neuroscientist Dr. Larry Young of Emery University opines that in human beings “sexuality has evolved to stimulate that same oxytocin system to create female-male bonds.”

It addition to working in concert with sexual desire and bonding, oxytocin seems to enhance feelings of trust and empathy. Somehow these emotions are wrapped up in the same stimulus package.

Analogs of hormones like oxytocin and vasopressin may turn out to be bona fide love potions, much more potent that those brewed by apothecaries in antiquity.

Biochemists might also be able to develop drugs that block these hormone receptor sites in the brain, producing individuals who seek the pleasure of sex without stimulating any need for long-term bonding. Some might argue that, in light of today’s sexual mores, such drugs would be unnecessary.

But would sex without emotional bonding be classified as love?

Unlike modern English, the ancient Greek language had four words for love. Storge denoted a mother’s love for her infant. Philia described brotherly love between friends. Eros, from which we get our modern term erotic, denoted sexual love. Agape was reserved to describe the unconditional divine love of God.

The ancient Greeks knew what they were talking about. Many times we in contemporary culture don’t, because we lack the vocabulary to crystallize these concepts.

While it may be triggered by surges of hormones, human love is more than mere biochemistry, because it entails more than just sex and bonding.

I recently read a profoundly descriptive passage on this subject in Betty Smith’s 1943 novel A Tree Grows in Brooklyn, in which the heroine, 16-year-old Francie Nolan, muses on her emotional needs:

“I need someone,” thought Francie desperately. “I need someone. I need to hold somebody close. And I need more than this holding. I need someone to understand how I feel at a time like now. And the understanding must be part of the holding.”

Despite the growing number of pharmacologic substances available to enhance the sexual act, I still feel, like Francie, that “the understanding must be part of the holding.”

In the end it’s the understanding that’s vastly more satisfying; it’s the understanding that makes us human.

“Notes from a Healer” — Waxing Nostalgic

In the icy grip of early morning winter cold and darkness, it’s pure joy to meet an old friend in a warm well-lighted place and chat over a hearty English breakfast of eggs, fried potatoes, biscuits and hot coffee. Even the very thought of such times makes me wax nostalgic.…

The latest installment of Notes from a Healer — Waxing Nostalgic — 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.

Office Psychotherapy

When he introduces himself, at first I don’t realize that he’s a doctor: he offers his first and last name only, without the title. Perhaps this is because, for the present, he regards me as next of kin—in the kinship of medicine—as evidenced by my bowtie and stethoscope draped around my neck. In any case, I offer him my hand and introduce myself in the same fashion—first name, last name; no title.

He has come to our office with his small entourage: two pharmaceutical representatives, both female, both strikingly glamorous. They are sponsoring the luncheon; he is the guest speaker. The doctor is chic himself—full head of thick wavy hair, parted in the middle, designer glasses, clean-shaven, wearing a pinstripe suit and dress shirt, open at the collar, no tie. The absence of the tie suggests a certain informality of youth and freedom. When he speaks, his accent betrays a southern origin.

He is, we learn, a psychiatrist. Currently he practices at a large mental health facility in Maryland. There are over seventy mental health providers in this agency: a fanfare of psychiatrists, psychologists, psychiatric social workers, family therapists, psychiatric nurses, as well as the usual gamut of support personnel needed to run a huge enterprise.

He tells us that he is also involved in psychopharmacologic research: he and his colleagues have published a number of studies in the medical literature, studies which lend credence to his professional standing.

We sit and listen to him talk, quietly munching our deli designer sandwiches and sipping bowls of hearty soup. The topic today is pharmacologic treatment of ADHD—specifically, the use of a newer non-stimulant medication. We learn that the doctor uses this medication routinely in all of his ADHD patients. In fact, it is the only FDA approved medication that achieves a steady state in the body to keep symptoms at bay twenty-four hours a day. What’s more, it’s safe: in his practice, he’s used much higher doses than recommended in the package insert with no toxic effects. Minor side effects such as drowsiness or abdominal discomfort can be lessened by dosing with dinner or in the evening hours. What’s the bottom line? Excellent drug: efficacious, easy to titrate, minimal adverse effects.

I ask about his clinical practice: what sort of patients does he see routinely? The gamut of child and adolescent psychiatric problems, he says: ADHD, oppositional defiant disorder, conduct disorder, bipolar disorder, panic disorder, anxiety and depression—in short everything except personality disorders: they don’t respond well to medication.

I inquire about his schedule: how many patients does he see a day? Forty to forty-five, he answers, matter-of-factly. I look surprised; my face has betrayed me. But, he’s quick to add, he’s got lots of support personnel available. If a patient needs counseling or talk therapy, there’s always a mental health provider on site to touch base with the family. He handles titrating the medications—after all, that’s his job; that’s what he was trained to do.

He encourages us to consider prescribing the drug: we won’t regret it, and our parents will thank us after we’ve helped their children get back on track. He winds up the session and slings his travel bag over his shoulder.

“Next stop, Springfield,” one of the glamorous pharmaceutical representatives says, glancing at her watch. “It’s just up the road. You’re scheduled for one o’clock.”

They disappear out the front door. We clean up the remnants of the lunch, and discover a box of designer cookies on the table: oatmeal raisin, white chocolate chip, chocolate chocolate chip, sugar cookies coated with vanilla icing.

I make my selection and savor the first bite, chewing thoughtfully. It leaves a slightly bitter taste on the back of my tongue as I swallow hard to force it down.