“Notes from a Healer” — Grave Error

Sometimes anxiety drives a parent to seek medical care for a child for reasons other than the symptoms at hand. If the clinician stands ready to listen, the hidden agenda may rise to the surface … with a lesson of its own.

The latest installment of Notes from a HealerGrave Error — 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.

Impressive Perspectives

My wife and I took our niece to see the retrospective Impressionists by the Sea at the Wadsworth Atheneum yesterday afternoon. My niece, who has been stateside on an extended visit, is due to return to her native Spain shortly. We thought that she might enjoy this special exhibit after her visit to the Boston Museum of Fine Arts earlier this month.

Impressionists by the Sea provides picturesque vistas of the Normandy coast as seen through the eyes of 19th century French artists Monet, Boudin, Courbet, Daubigny, Isabey and Manet. Like summer tourists at the beach, we ambled through the galleries, pausing to view scenes of sea-spray and sea-wrack, waves breaking against the rocks, fishing boats beached at low tide, adults promenading in their summer finery beside children digging in the sand. Transported briefly into another time and place, we caught the scent of salt in the summer air and felt the intense warmth of the summer sun on our faces as it reflected off the water.

My wife and my niece grew up in a small fishing village on the northwest coast of Spain—a different country with a similar coastline. In these paintings they recognized scenes from their own region: unmarked paths through sandy dunes, wide grey beaches at low tide, brightly colored fishing boats resting at their estuary moorings, rocky outcrops towering above the pounding waves of the blue-green sea below.

“Perhaps we never appreciated the views that awaited us every day when we were growing up,” my wife mused as she stood before Monet’s Etretat Cliff at Sunset.

As we returned to the car, legs heavy after four hours of wandering through the museum halls, I realized that the exhibit had left its impression, coaxing us to consider former vistas from a fresh perspective.

Two hemispheres make a world

In 1996, at 37 years of age, neuroanatomist Jill Bolte Taylor experienced something both devastating and insightful at the same time—she had a stroke.

When her brother was diagnosed with schizophrenia, Taylor decided to devote her professional life to brain research. She worked in a lab at Harvard, mapping activity in various parts of the human brain. One day she woke up with a searing pain behind her left eye. During her morning workout, when she started having distorted views of her own body, Taylor realized she was having a stroke.

“I thought: wow; what a great opportunity for a neuroanatomist—to be able to study the effects of a stroke as it’s happening in your own body!”

Taylor struggled to remember the course of events as they unfolded. Initially, she experienced a sense of euphoria. “I was at total peace with the universe,” Taylor explains in a recent video clip. She realized that her right brain—the creative hemisphere that functions in the here and now—had taken over. “I was unbelievably happy without a care in the world,” she says. Then suddenly her left brain—the calculating rational hemisphere—kicked in and reported: “Hey, you’re having a stroke here—you’ve got to get some help!”

By the time she got to the phone, she could no longer use her right arm. When she looked at the cards in her address book, she couldn’t read the numbers—the only things she saw were pixels. After forty-five minutes she located the contact she was searching for, but she couldn’t remember the digits as she struggled to dial the number. Finally, she threw her right hand across her torso and used the index finger to cover each digit as she dialed the number with her left hand.

“Someone picks up on the other end of the line, and I tell them it’s me; I’m having a stroke and I need help,” Taylor says. “But the words come out sounding like a golden retriever barking.” At that point she realized that the stroke had knocked out the speech center in her left brain—she could no longer communicate with the outside world.

They traced the call, got an ambulance to the scene and took her to the hospital. En route Taylor said goodbye to the world. “I was totally helpless at that point. I knew I couldn’t save myself. It was up to the doctors to salvage what they could.” When she woke up several hours later in the ICU, she was astonished to find that she was still alive.

Although it took eight years, Jill Bolte Taylor has fully recovered from the residual effects of her stroke. Now she spends her time speaking about her experience. “At one point during my euphoria, I felt one with the universe, one with all of my fellow human beings. It was absolute joy and peace. If you experienced a vision like that, wouldn’t you want to share it with others?”

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.

The Road More Frequently Traveled

At one time many medical school graduates pursued careers as generalists, opting for residencies in internal medicine or family practice. Historically, careers in these areas guaranteed long work weeks—daily office hours coupled with frequent overnight calls and emergencies—in exchange for median level salaries, with little time left for family life and leisure.

Nowadays, more and more graduates are opting to travel a different road, pursuing careers in Radiology, Ophthalmology, Anesthesiology, or Dermatology—the ROAD to reasonable hours, few emergencies and financial success.

Today’s New York Times carries an article about two recent graduates from Harvard Medical School, a husband and wife with two small children, both of whom have elected to pursue careers in dermatology. Both of these individuals have been stellar students throughout their academic careers; both are backed by degrees from prestigious universities. And together they are heavily in debt—over $330,000—not including the $20,000 they borrowed to finance their recent cross country treks to interview for those few select spots in dermatology residencies.

If their selections match, they will be set for life in jobs that will guarantee relative autonomy, reasonable working hours, and excellent salaries ($200,000 – $500,000/year).

Those of us slugging it out in the trenches of primary care medicine work long hours, servicing many more patients every day than we are comfortable seeing, for considerably less income. Most times our remuneration is determined exclusively by third-party payers. Perhaps we need to have our heads examined. But be forewarned—chances are you’ll have to wait at least three months to get an appointment with a psychiatrist: most of them work eight hour days and have their weekends free.

Down-shifting a career of service

Last Friday evening I attended the retirement dinner of a colleague, who also happens to be my mentor and friend. After 35 years in medical practice, he decided the time had come to down-shift his career in pediatrics.

Although we’ve kept in touch over the years, I hadn’t realized the full extent of my colleague’s professional activities until a host of speakers announced his accolades. Domestically, he had moved from the practice of primary care pediatrics into what was back then the ground-breaking specialty of evaluating physically and sexually abused children. Internationally, he was instrumental in opening a dialogue with a number of pediatric specialists in Siberia. Through these efforts he developed a global network of professional relationships which continue to this day. Over the span of his career, he has also been active in social justice, advocating universal healthcare coverage and global nuclear disarmament.

Those who spoke on his behalf painted the portrait of a humble man, both caring and competent in his field, who was always willing to listen to others in an effort to build consensus to solve the problem at hand. Several social workers commented that initially they thought this board-certified physician was one of their ranks, so unpretentious was he in his demeanor.

In addition to members of the local medical community, several international players attended the celebration. One woman, whose two handicapped children had been among my colleague’s first patients when he practiced in primary care, had flown in from Iowa for the occasion. All told, there must have been well over 120 persons in attendance.

True to form, when my friend rose to speak, he congratulated everyone in the audience on their efforts to better the lives of children everywhere. “One of the things I’m looking forward to not doing in the future is completing any more 136 forms,” he said, referring to the standard form for reporting child abuse in the state of Connecticut. “And I look forward to that day,” he said, “when none of us will ever have to fill out any such form again.”

Many of us derive meaning in life from our work. If we have been lucky enough to be of service to others during the course of our lives, we can, like my colleague, count ourselves among the truly fortunate.

And me? Let’s just say that I count myself truly fortunate to have crossed paths with an excellent mentor, a good man and a true friend.

Ag Borradh

Ag borradh, a Gaelic phrase, refers to quivering life about to break forth. This is no where more readily apparent than in springtime, when the earth begins to thaw, the trees begin to bud, and animal life begins to stir.

It has been a long winter here in New England, made longer still by belated March snows. Somehow the winter cold, coupled with the soaring price of home heating oil, seemed colder still this year.

But today I was up early, out with the puppy. Pink clouds filled both the eastern and western sky at first light. We passed more than a few male cardinals on our walk, each one piping a short phrase to announce his personal claim to a particular treetop territory. Overhead, strings of Canada geese cried honks of encouragement to their comrades in flight. The puppy looked up in momentary wonder; then circled the tufts of brown grass at my feet, her nose against the ground, searching for scents of spring.

Quickening—when life first stirs in the womb, announcing its soul presence. Ag borradh—as in the womb, so in and on the earth in spring.