The Art of Medicine — A good father

The couple sits side by side in twin chairs by the examination table. The mother cradles a bundle in her arms, a look of maternal contentment on her face. The father’s shoulders tower over her, shaved head giving way to a thick black beard reminiscent of Rasputin. His limbs are equally heavy and thick. He rises to his feet, a veritable giant, and in that moment I mentally muse how that shepherd boy must have felt with only five smooth pebbles in his pocket. more»

Interested readers can now access my latest Art of Medicine column — A good father — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

Twenty buckets of pine cones

He stands below the towering pines, shoulders slightly hunched, staring intently at the ground, working the mechanical arm with his right hand. Deftly he reaches, snares a pine cone, and transfers it to the white plastic bucket near his feet.

I pull back on the dog’s leash and stop to call his name.  “Picking up pine cones?” I ask.  He looks up, pausing from his work, and returns the greeting.

“I’m cleaning up the area for Sunday services,” he says.  “This is where the congregants gather.”

“You’ve got quite a collection of cones,” I muse.  “Where are you putting them?”

He turns his head and motions with his chin toward the dumpster in the parking lot.

“It takes eighty cones to fill the bucket,” he says, “and this is the twentieth bucket this morning.

I run the numbers in my head.  “Eighty cones a bucket times twenty buckets: that’s 1,600 pine cones!” I say.

“I guess so,” he smiles.  “I’ve still got all of this to do,” he motions with the mechanical arm.  “At least a couple hundred cones to go.”

“How old are you now?” I ask.

“Eighty-five,” he says.  “And counting.  How about you?”

“Sixty-seven,” I say.  “And counting.”

“They’re holding a memorial service for the rector day after tomorrow,” he informs me.

“Inside or outside?”

“Inside,” he says.  “Limited to thirty people.  I got an invitation with an RSVP.”

We both knew the man during his tenure as rector.  Born in 1927, he was ninety-three years old when he died.

The dog pulls at the leash.  “I guess she’s ready to move on,” I say.  “Don’t work too hard.”

“God be with you,” the old man says as he drops another pine cone into the white bucket.

The Art of Medicine — Doughnuts for breakfast

This 14-year-old boy has come to the office for his annual physical examination. I recall seeing him once or twice over the course of this past year, always with his mother. Today she sits in one of the two orange chairs by the window. The other chair is vacant. The boy has already assumed his perch on the examination table, head down between his shoulders. more»

Interested readers can now access my latest Art of Medicine column — Doughnuts for breakfast — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

Face to Face

For now we see through a glass, darkly; but then face to face: now I know in part; but then shall I know even as also I am known.”  —1 Corinthians 13:12

When the coronavirus pandemic struck, like most pediatric practices, we hunkered down, trimming staff to a bare-bones minimum, ratcheting back sick visits, focusing on well-baby checks below 2 years of age.  All personnel, clinical and non-clinical, were screened prior to entering the office with spot temperature checks; masks became mandatory.

As the pandemic peaked, medical students were instructed to shelter in place at home, confining their studies to online learning — a difficult task in the realm of clinical medicine.  When restrictions were lifted, students resumed their clinical training, cramming standard 6-week rotations into 15 days.  They too donned the mandatory mask prior to entering the clinical setting.

Angela was a 2nd-year PA student.  Petite in form and slender in build, she came to the office to complete her belated pediatric rotation, introducing herself in muffled tones through a black mask that covered the lower half of her face.

It wasn’t until halfway through the rotation that I learned that Angela’s parents haled from Kosovo. As a 1st-generation Albanian, she was the first person in her family to pursue a career in medicine.

In casual conversation I told her about Millie, another petite Albanian woman from Kosovo, who had immigrated to the U.S. back in the 1990s.  Millie worked as an au pair before taking a position as receptionist in a dental office.  After several years she was able to sponsor her parents and her brother and his family, sheltering their lives during the Bosnian conflict.  Eventually, Millie married an American and settled down into a new life: a modern Cinderella story.

Although our time together was limited, I was able to teach Angela the basics about growth and early childhood development.  We also covered several select topics, such as the vulnerable child syndrome, common dermatological conditions, obesity, and asthma.

One morning shortly before she left, I nudged her to read Cavafy’s “Ithaka,” a poem which lends itself well to the description of a lifelong journey in clinical medical practice.

We got swamped with patients the afternoon of Angela’s last day.  As I sat at my desk, struggling to complete my clinical notes, she turned to proffer a goodbye.  “Thanks for teaching me,” she said, giving me a hug, her eyes sparkling above the rim of the black mask that pressed into the contour of her high cheekbones.

It was only after the glass door clicked shut behind her disappearing form that I realized: over the course of the 3 weeks Angela had spent with us, never once had I glimpsed her face.

Till We Have Faces

“How can they meet us face to face till we have faces?” —C. S. Lewis

These days in clinical practice the mask has become the standard of care.

Our surgical colleagues have always worn masks in the operating room; likewise, anesthesiologists, nurse anesthetists, and medical personnel who work with patients confined to isolation rooms where the likelihood of transmission of infection is high.

But for those of us who practice in primary care, the ritual of donning the daily mask is something relatively new, something we are still getting used to.

Masks come in various colors, sizes, and shapes. There’s the N-95 mask, the industry standard; the fine-fiber surgical mask; the soft cotton cloth mask — each with its own degree of filtration efficacy. Some masks are homemade, some are purchased; many are disposable, others can be recycled. Some are comfortable, conforming to the contours of the face; others less so.

But to a large extent all masks hide the human face.

Masks muffle words; masks obliterate our ability to perceive another person’s emotional state. It is often said that the eyes are windows to the soul. Yet when cheeks, nose, mouth and chin are hidden, it becomes difficult to read patients through the eyes alone.

Masks offer some degree of protection from respiratory droplets spread by others. Wearing a mask also sends a message: “I care about your safety as well as my own.” Yet hiding the lower two-thirds of the face from view obliterates our ability to read the emotional state of another.

So much of our clinical acumen is dependent on global observations of the human face in real time. And how can we demonstrate empathy, kindness and friendliness when our faces are hidden from view?

These days the children are crying. Mothers bring their infants and toddlers to the office for well child care: toddlers turn away from our masked faces, infants fail to respond to our muffled intonations.

How can a 2-month-old exhibit a social smile, when the baby can’t see our own?

The Canadian physician Gabor Maté recites a story from his own childhood in the Jewish ghetto of Budapest during the Nazi occupation. As an infant, he had become inconsolable. Beside herself with worry, fearing that something was terribly wrong, his mother called the pediatrician. “Would you please come and see my son, because he’s crying all the time?” she asked. “Of course I’ll come,” the doctor said. “But I must tell you that all the Jewish babies are crying.”

These days the children are crying.

Infants are colicky, toddlers are cranky; preschoolers have become more testy, pushing parents to emotional exhaustion; children are irritable, adolescents act out. Understandably, parents are anxious, concerned that something is wrong.

There is something wrong, of course. In this pandemic all is changed, changed utterly.

But this time round all of the powders and potions in our medical armamentarium won’t fix things.

The science of medicine cannot provide parents and patients with inner peace.

The Art of Medicine — A mother in mourning

This mother looks as though she has gained weight since I saw her last at the infant’s 2-week well-child visit. I study her face. A trace of lipstick crosses the vermillion border of her upper lip, marring the subtle line between beauty and disarray. more»

Interested readers can now access my latest Art of Medicine column — A mother in mourning — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

The effect of digital media on children in their formative years

Over the past 2 decades, personal digital devices have evolved to become portable, attractive, readily accessible, interactive, and ubiquitous. Although digital and social media have evidence-based benefits, including early learning, exposure to new ideas and knowledge, and increased opportunities for social contact and support, unsupervised and unchecked use of personal digital devices can have negative consequences for the physical and mental health of children in their formative years.

The widespread use of portable digital devices has been accompanied by a concomitant rise in the prevalence of physical and mental health issues in children. Research suggests an association between these trends, which also may be considered from a public health perspective. Proposed interventions include the development and implementation of individual family media use plans for children of all ages. more»

Interested readers can access this special article authored by Lloyd “Chip” Taylor and myself, published online in the Journal of the American Academy of PAs.

The Art of Medicine — A lump in the neck

Establishing credibility is difficult in an initial encounter; the clinical waters have not yet been tested by time. more»

Interested readers can now access my latest Art of Medicine column — A lump in the neck — recently published in the Journal of the American Academy of Physician Assistants.

Please note that all of my previously published Art of Medicine pieces can now be accessed here.

The last of the human freedoms

“The last of the human freedoms is the ability to choose one’s attitude in a given set of circumstances.” —Viktor Frankl

Detailed reports have come out in the medical literature, describing signs and symptoms of SARS-Cov-2 viral infection in the human being, among them “COVID brain.” Here the cerebral vasculitis results in a distortion of perception (a loss of sense of taste and smell) as well as delirium. These effects can be temporary in survivors, albeit long lasting.

But there is another sort of COVID brain prevalent in the general population. This variety produces prolonged anxiety, panic attacks, agoraphobia, xenophobia, paranoia and depression, largely due to fixation on the likelihood of contracting the virus through social contact. At present a large segment of the population seems to be suffering from this syndrome.

Our daily lives have become inundated with the latest news and numbers of the novel coronavirus infections. Our brains bathe in statistics and outcomes. We cannot stay away from our smartphones, spending hours and hours “doomscrolling” to check the latest developments. COVID-19 has cast a long dark shadow across the landscape of our minds.

My wife and I sit on the front porch after the late afternoon rains. The eastern sky is filled with cloud formations illuminated by the setting sun: bright banks of cumulus clouds, backlit blue-grey puffs; inkblot watercolor washes along the baseline. Light and shapes change, morph minute by minute, as the dynamic of eventide rises in a crescendo of silence.

The spectacle is enough to bring me to my feet. I snap several photos from the front steps, recording the rise and fall of the intensity of light, shape, and color.

In his classic text “Man’s Search for Meaning” Viktor Frankl documents an evening sky from the viewpoint of his fellow prisoners at Auschwitz:

Standing outside we saw sinister clouds glowing in the west and the whole sky alive with clouds of ever-changing shapes and colors, from steel blue to blood red…. I sensed my spirit piercing through the enveloping gloom. I felt it transcend that hopeless, meaningless world, and from somewhere I heard a victorious “Yes” in answer to my question of the existence of an ultimate purpose.

Perhaps there is a cure for COVID brain after all, albeit terse in scope.

Et lux in tenebris lucet.

Surreal Reality: in our time

“Good pilgrim, you do wrong your hand too much,
Which mannerly devotion shows in this;
For saints have hands that pilgrims’ hands do touch,
And palm to palm is holy palmers’ kiss.” —Romeo and Juliet 1.5.102-05

“How are you doing in this time of surreal reality?” a colleague asks. In this time of the global coronaviral pandemic that two-word phrase nails it: surreal reality.

Hemingway lifted the title for his first collection of stories from the Book of Common Prayer: “Grant us peace in our time.” Instead of peace in our time, we’ve been granted surreal reality.

I just finished plowing my way through Atul Gawande’s latest New Yorker piece, “Amid the Coronavirus Crisis, A Regimen for Reentry.” He advocates using lessons learned in healthcare delivery as a template for reengaging on a societal level: hygiene measures, screening, distancing, and masks.

Those are precisely the measures we implemented at my workplace, a private pediatric practice in southern New England. Patients are screened with a series of questions over the phone and subsequent temperature measurements before being admitted to the office. Only one parent is permitted to accompany the child; both must wear masks. They are immediately escorted to a sanitized exam room for the well child visit. Providers practice good handwashing between patients before donning N-95 masks and gloves. For the first time since my house officer days, I habitually wear scrubs to work. Distancing is maintained within reason. (Even in a modified physical exam, it’s hard to keep a toddler at arm’s length.)

In primary pediatric care, this has become conventional surreal reality in our time.

It’s reminiscent of healthcare delivery, delivery room style.

Telehealth has also become standard care. We’ve had the technology to enable virtual visits for a long time. Lately, in our current surreal reality, telehealth has become an economic necessity for medical practice survival. Traditional screening tools have given way to the virtual screen: no touch, of course. Instead of a hands-on encounter, healthcare has become a conversation, albeit a virtual one.

Patients seem to be appreciative of our efforts. Most greet us with a smile; we make every effort to smile back. When asked, most say that they are holding up okay. Families are sheltering in place, parents are working from home, kids are engaged in online learning. Everyone is getting on everyone else’s nerves, but most everyone seems to be doing okay.

“We can’t complain,” a young mother tells me. “We’ve got a place to live, the kids can go outside, my husband can still work.”

“What does he do?” I ask.

“He delivers newspapers,” she says.

I ask if they’ve got enough money for food.

“We’re okay,” she says. “We can’t complain. Other folks got it a lot worse.”

The other week at the grocery store the woman standing in line behind my elderly parents told them she was paying their bill. “In honor of my grandson,” she said. “He passed away.”

Another man handed my mother a $20 gift card before he walked out the door of a local Subway shop. “For your sandwiches,” he said.

The last time my father went to the supermarket, there were only two loaves of bread left. He bought one and left the other on the shelf. “I figured somebody else might need it,” he told me.

Random acts of kindness have always been done; but lately, they seem to be more poignant.

After work I take my 3-year-old grandson out for a walk along the river. I point out the spring wildflowers, the warblers. We stop and talk to folks standing in the doorways of their houses along the street. The neighbor lady tells us to take some compost from the huge mound in her yard for our garden. Another neighbor invites us in to see the robin’s nest in the cherry tree in her back yard. She and her husband wear masks. My grandson and I practice physical distancing.

In our time of surreal reality, hugs and kisses are reserved for home.