Bleeding Hearts

I see the torn slip of paper lying by the mail on the dining room table when I come home from work. I recognize my wife’s handwriting; the words are few. “Nancy’s funeral, Friday, Valley Baptist Church, 7:00 PM.”

Yesterday my wife and I had an argument at dinner. I left in a huff, went out for a walk to cool down, made my way through the town, across the bridge and out to the end of Old Hartford Avenue, where I stood by the guardrail, watching a red-tail hawk perch in the branches of an old oak. On the way home I paused by a flower garden on a knoll to admire the freshly blooming spring flowers—bleeding hearts.

Back at the house I discovered that my wife’s car was gone. I sat on the porch and read the Times Sunday magazine, now a week old. I watched the goldfinches flitting about the bird feeder in the front yard. I went into the house and poured myself a glass of red wine, then finished up the last of the cashews. Later I stood by the kitchen window as my wife’s car pulled into the driveway.

“Where were you?” I asked.

“Visiting Nancy,” my wife said. “It won’t be long now. I never saw her look this bad.”

Nancy was diagnosed several years ago with stomach cancer. She and her two teenagers lived with her sister. Nancy and her husband had divorced years before she was diagnosed. My wife looked in on her from time to time.

“I went out, down to the mall,” she continued. “I passed by a flower shop and bought a potted plant for her—so pretty. Her sister thought it was lovely, too. She said the flowers were Nancy’s favorite.”

Today I leaf through the mail on the dining room table when my wife steps through the kitchen doorway. “You saw the note?” she asks me.

“Yes. When did she die?”

“Last night, around nine-thirty. Her sister called me this morning. Somehow I just knew when I saw her yesterday.…” her voice trails off.

“At least you had a chance to say good-bye,” I say.

“Yes, we had a good chat. I did most of the talking, I guess. She liked the flowers—they were her favorite.”

“What did you get her?”

My wife looks up at me; our eyes meet. “Bleeding hearts,” she says.

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Family Feuds

While driving to early services this morning, I hear news of the latest escalation of sectarian violence in the Middle East—bombings and sniper fire in Gaza; rocket attacks on Israel. Two Palestinian factions—Hamas and Fatah—are at each other’s throats. If the rockets attacks continue, the Israeli government is threatening to take more decisive action.

This brings to mind Mark Twain’s description of a family feud in Huckleberry Finn. In the passage, Buck explains it to Huck like this: “A feud is this way: A man has a quarrel with another man, and kills him; then that other man’s brother kills him; then the other brothers, on both sides, goes for one another; then the cousins chip in—and by and by everbody’s killed off, and there ain’t no more feud. But it’s kind of slow, and takes a long time.”

Indeed—sometimes millennia.

Last week’s New York Times Sunday magazine (May 13, 2007) carried a story about the millions of Iraqis that have fled the conflict in their country, only to incur continued violence as refugees—in many cases from infighting among themselves—Sunni and Shiite sects. Those who dare to extend a hand to help a fallen foe end up in the morgue, their bodies mutilated. In some cases, it’s a luxury for family members to locate the body of a missing loved one.

The following Sunday, Huck accompanies Buck’s family to church. Members of the other family attend the service as well. Huck reports that “the men took their guns along.” The preaching was “pretty ornery—all about brotherly love, and such-like tiresomeness; but everybody said it was a good sermon, and they all talked it over going home, and had such a powerful lot to say about faith and good works and free grace and preforeordestination, and I don’t know what all, that it did seem to me to be one of the roughest Sundays I had run across yet.”

Later, after Buck and his father and brothers are killed in a shoot out, Huck flees the scene and is reunited with Jim. The two escape by raft on the river. “I was powerful glad to get away from the feuds,” Huck admits. “You feel mighty free and easy and comfortable on a raft.”

I wish it were that easy to escape the daily reports of violence today. I can only take solace in the words of Dylan Thomas: “After the first death, there is no other.”

A Word to the Wise

Socrates was said to be the wisest man in ancient Athens, because he knew that he didn’t know. In other words, he was well aware of the limitations of his knowledge. Yet he attempted to learn wisdom by questioning others, leading them to logical conclusions of their own.

What is wisdom? Any attempt to define it leads to a certain fuzziness.

Wisdom is right thinking. Wisdom is the art of weighing the odds in a given situation in order to make a good decision. Wisdom is negotiating your way through a difficult maze of options to arrive at the best possible alternative.

Perhaps, like the Supreme Court justice’s definition of pornography, wisdom is difficult to define, yet we know it when we see it—or in this case, when we witness it in others or experience it ourselves.

A recent New York Times Sunday magazine article attempted to flesh out wisdom by reviewing the psychological research to date.

According to Monika Ardelt, a German-born sociologist at the University of Florida in Gainesville, wisdom integrates three separate but interlinked ways of dealing with the world. The cognitive aspect allows a person to examine a situation clearly, and, relying on the ability to understand human nature, to make good decisions despite ambiguity and uncertainty. In the reflective sphere, a person demonstrates the ability to step outside himself and understand another’s point of view. The emotional aspect allows a person to feel compassion toward others and remain positive in the face of adversity, with graceful calm.

“Wisdom in action … might manifest itself as good judgment, shrewd advice, psychological insight, emotional regulation and empathetic understanding; it could be found in familial interactions, in formal writing and in the relationship between a student and mentor or a doctor and patient (my italics).”

How do you acquire wisdom? This remains an important question, as it has become a fairly widespread conclusion that “there’s not a lot of wisdom around.” Or in the common vernacular, “common sense isn’t so common.”

The wisdom literature in the Hebrew Bible exhorts the reader to “get wisdom.” Perusing the book of Proverbs reveals that the idea of wisdom is closely linked with both knowledge and understanding. It also implies striving to lead a moral life: love justice, be kind and generous to others, practice humility. And the New Testament echoes this instruction, exhorting readers to be “wise as serpents and innocent as doves.”

You may think that wisdom is cultivated over a lifetime, yet a good deal of evidence suggests that the seeds of wisdom are planted early in life, and may be associated with early exposure to adversity or failure.

Although we can learn wisdom from negative experiences, there is no guarantee that we will do so.

In his novel A Farewell to Arms, Hemingway describes a scene where the young protagonist, Frederick Henry, is playing billiards with his ninety-four-year-old acquaintance, Count Greffi. In idle conversation, the Count remarks: “It is the body that is old…and the spirit is no older and not much wiser.”

“You are wise,” Henry comments.

“”No, that is the great fallacy; the wisdom of old men. The do not grow wise. They grow careful.”

Perhaps that in itself is a wise statement.

Announcing the publication of “Village Voices”

Brian T. Maurer is pleased to announce the publication of his latest book, Village Voices. In this new collection of tales, Maurer captures life in a New England village, where everybody has a story to tell.

“Old Bill, who made a living trapping muskrat and beaver along the river, and Miss Pritchard, who worked her way up to a management position at the Connecticut Mutual Life Insurance Company, are gone now, along with a host of other folks from that era—but their stories remain. I’ve added some of them to the pot, stirring them in with my own, and let them simmer over the years before serving them up for my readers to savor.”

“Some of us are on the move; some of us stay put. Some are just starting out, trying their wings, while others are on their last legs, coming home to say good-bye. The birds still sing every spring down along the forest path that runs by the river, where it meanders through the hairpin curve on its way down through the gorge, eventually becoming one with the sound and the sea beyond.”

Interested readers can view a brief description of the work, peruse a preview of the text, and order a copy online here.

“Notes from a Healer”—Teacher and Student

How relevant is the teaching of clinical medicine in today’s high-tech world? And what can an older clinician teach a young student already versed in the latest medical techology?

Interested readers can peruse my recent Notes from a Healer column “Teacher and Student” in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine acts as a clearinghouse for manuscripts dealing with the humanities and medicine.

The Long and the Short of It

Recently I saw an adolescent boy for a routine physical exam. As he was disrobing in the exam room, our medical assistant handed me a sealed envelope along with his chart. The envelope contained a one-page letter from his mother, asking that I address several concerns: his frequent visits to the nurse at school, recurring headaches, a question of substance abuse, self body piercing, and the discovery of a cache of gay pornographic magazines in his bedroom. I had been allotted 15 minutes in my busy afternoon schedule for this visit.

It’s a small wonder that a decade after adolescent medicine became a board certified subspecialty, it is largely shunned by doctors seeking to advance their careers—only 466 certificates in adolescent medicine were issued by the American Board of Medical Specialties from 1996 to 2005. In the same period, 2,839 were issued in geriatric medicine.

Yet despite these numbers, geriatric medicine is in no better shape, as Dr. Atul Gawande attests in his recent New Yorker article, “The Way We Age Now.” “Despite a rapidly growing elderly population,” Gawande writes, “the number of certified geriatricians fell by a third between 1998 and 2004. Applications to training programs in adult primary-care medicine are plummeting, while fields like plastic surgery and radiology receive applications in record numbers.”

Why these trends? According to Dr. Gawande, “Partly, this has to do with money—incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, most doctors don’t like taking care of the elderly.”

I would argue that the same logic follows for adolescent medicine as well. Regardless of whether you consider adolescents as pediatric, family or internal medicine patients, they all require extended office time to address their issues and concerns. This is a luxury that most high-volume private primary-care practices can not afford. And then again, as is the case with the elderly, most doctors don’t like taking care of adolescents.

What can be done to remedy the situation?

“Nothing,” according to Chad Boult, a geriatrics professor at Johns Hopkins. “It’s too late.” Gawande reports that “creating geriatricians takes years, and we already have far too few. This year, just three hundred doctors will complete geriatrics training, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade.”

“Boult believes that we still have time for another strategy: he would direct geriatricians toward training all primary-care doctors in caring for the very old, instead of providing the care themselves. Even this is a tall order—ninety-seven per cent of medical students take no course in geriatrics, and the strategy requires that the nation pay geriatricians to teach rather than to provide patient care.”

In my estimation, the same strategy may hold up for adolescents, most of whom are cared for by pediatricians. But the pediatric clinician must be willing to devote the time to care for the adolescent patient.

So, what did I do with my adolescent patient? As it turned out, he knew nothing about his mother’s note. I addressed her concerns with him, point by point. After I examined him, I discussed the results. We talked about his issues. With his permission, I spent some time conferring with his mother afterwards. She was grateful, and so was he. “I never had a physical exam like this before,” he remarked as he left.

I felt immensely satisfied for a moment, until I stepped in to see my next patients—a pair of seven-year-old twin boys with severe behavioral problems and ADHD. As I glanced at my watch before entering the exam room, I noted that I was already half an hour behind.