“Notes from a Healer” — Telephone Triage

It had been an exhausting week at the office: an unrelenting barrage of patients every day.  I could barely think straight by the time I packed it in every evening and headed home.  I had dinner, checked my e-mail, lay down on the sofa to read and fell asleep instead.  The next thing I knew, my wife was handing me the phone….

 

My latest installment of Notes from a HealerTelephone Triage — 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.

Attention Deficit Disorder: a cultural phenomenon?

It got so bad that we finally posted signs throughout the office:  Please turn off cell phones during your visit with the doctor.  Still they persisted.  Parents and adolescents alike would reach for their phone when the jingle sounded, mumbling an apology as they flipped open the device:  “Sorry, I forgot.”

 

For me the students were the last straw.  A number of them had telephoned the office, asking if they might arrange a time to shadow me and observe my interactions with patients.  They were required to log so many hours of observation prior to launching into their clinical rotations.

 

The students came on separate days.  Each laid her coat on the extra chair in my office.  Each extracted her cell phone from the pocket, placed it on the chair and proceeded to check it periodically.  If the phone buzzed or beeped, the student would snatch it up and quickly peer at the incoming number.  Sometimes they text-messaged an immediate reply; sometimes they actually took the call.  “Sorry,” they’d say, “I’ve got to answer this one.  It’s important.”

 

What they were really saying, of course, was that their call was more important than the educational discussion at hand.  Even though I had granted their request and carved out time in my already busy schedule for them, their time was more important than my time.  For the sake of their convenience, I had unwittingly agreed to inconvenience myself.

 

Maggie Jackson sheds light on this cultural phenomenon in her recently published book, Distracted: the erosion of attention and the coming dark age.  In Jackson’s view, an inability to focus our attention on the task at hand has become a widespread social problem.  We constantly face distractions throughout our day. Jackson believes that we need to relearn how to think deeply and filter out these distractions in our day to day existence.

 

Contemporary culture has devolved into narcissism.  Each of us has chosen to go his own way.  You might say that, as a society, we have developed widespread attention deficit disorder.  Collectively, we have lost the ability to wrestle with issues on a deeper level.  We skim the headlines, check the stats, glimpse the twitter, then cut and run.  Although the lake of available information has grown exponentially, for many of us this body of knowledge remains shallow indeed.

 

Our English word attention derives from the Latin, attendere:  to stretch toward something or someone.  It takes a certain amount of effort to attend to another person.  Paying attention to the patient is one of the basic tenets of empathetic medical care.  When we focus on what another person is telling us, we send a covert message through our posture and eye contact that we value that person as a human being.  Contrariwise, when we brush them off we give the subliminal signal that we really don’t care.  In the common vernacular, we exhibit rude behavior.

 

Attention skills can be cultivated by practicing the art of observation.  Exposure to the natural world works as well as a dose of medication to improve concentration.  Harvard researchers demonstrated that physically fit children did better academically on standardized achievement tests.  The New York Times reports that a recent study published in the journal Pediatrics found that the attention span of school-aged children improved after physical activity on the playground.

 

Thirty-eight years ago as an undergraduate student I wrote a paper on the value of athletic activity in the liberal arts curriculum.  My premise was that regular organized physical activity enhanced the student’s academic performance and sharpness of thought.  At that time there was little original research to support my thesis.  Reading through the Times article, I now feel somewhat vindicated.

 

And as for the students, those presently knocking on my door seeking opportunities to fulfill their prerequisites, I am sorry to report that their pleas have lately fallen on deaf ears.  I’ve decided that I need some quality time to sit down and think about it.

 

One should not enter into such contractual relationships without giving it a good deal of thought—preferably with no distractions.

 

Humane Medicine: Troubled Waters

Passing over the bridge on my way to work under grey morning skies, I glanced out over the turbulent water. Swollen from overnight rains, raging waves the color of coffee milk danced down the wide expanse below the bridge. Only time would tame the river’s fury. But the bridge stood solid on abutments firmly rooted below the boiling waters….

Interested readers can now access my latest Humane Medicine column, Like a bridge over troubled water, recently published in the Journal of the American Academy of Physician Assistants.

Improvisation

Saxophonist Benny Golson has composed some of the most memorable numbers in jazz, such as “I Remember Clifford,” “Whisper Not,” “Along Came Betty” and “Killer Joe.”

 

In a recent NPR interview with Scott Simon, Golson tells the story of playing a gig in a club one evening.  Before the performance, one of the owners asked him what he planned to do for a solo number.  The owner was astounded when Golson told him that he wasn’t sure of his selection.  Golson explained his reasoning in this way:  “Jazz is improvisation.  You go to the same forest night after night, but each time it’s to a different tree.”  In other words, you go with the flow; and when the time comes, you perform as the spirit moves you.

 

An interesting aside here is that, as a young man, Golson aspired to become a concert pianist.  His favorite composer was Chopin.  It’s well worth listening to his rendition of Chopin’s L’Adieu (Farewell Waltz) with Eddie Henderson on trumpet accompanied by piano.  (By the way, Eddie went to medical school and trained as a psychiatrist before cashing it all in for a career as a jazz musician.)

 

Thirty years ago, when I was a student in training, I worked at a neighborhood health center in the seventh ward of Lancaster, Pennsylvania, with a family physician who hailed from Bayonne, New Jersey.  One morning a mother brought her baby girl to the clinic to have the infant’s ears pierced.

 

At that time we didn’t have prepackaged 14-carat gold sterile studs available to push directly through the earlobe.  Instead, we instructed mothers to bring a set of earrings along, which we would then insert through holes in the earlobe made with a large-bore 18-gauge hypodermic needle.  The only problem with this method was that many times it was difficult to feed the post of the earring through the opening in the flesh that would immediately collapse after the needle was withdrawn.

 

This particular morning the physician decided to let me have a go at piercing the baby’s ears.  We mummy-wrapped the infant, then the mother and our nurse held the child steady while I cleaned off one of her earlobes with an alcohol pad.  I opened the 18-gauge needle, withdrew it from its plastic sheath and regarded the ear before me.

 

I lifted the lobe and punctured it from the back, pushing the needle out through the front of the fleshy appendage.  Then I had a thought.  Instead of withdrawing the needle immediately, I inserted the post of one of the earrings directly into the bore of the hollow needle, then pushed the entire assembly back through the earlobe.  When I pulled the needle out, there stood the post protruding from the back of the lobe, waiting for me to attach the backing.

 

“Wow!” the physician exclaimed.  Everyone stood still for a moment, reflecting on the improvised procedure they had just witnessed.  I couldn’t help but grin at my humble success.

 

“You know what that was like?” the physician said.  “That was like, like…that was like the bull’s head that Picasso made from a bicycle seat and handlebars.”

 

I knew the piece of contemporary sculpture he was referring to.  I could see it in my mind’s eye.  Improvisation it was.  Just like an impromptu jazz sax solo blown in the far reaches of the night.

 

Two years later, when it came time for me to leave the clinic to pursue further training, this same physician, who was also an artistic photographer, gifted me a black and white print of a bull charging a matador, who waits with a pair of banderillas held high in his uplifted arms.  The images are drawn with a few strokes of an inked brush; the date in the upper left-hand corner reads “3.4.59.”

 

The artist is Picasso, of course.

 

The drawing hangs on the wall in my office above my desk, a reminder of a long ago friendship born in part from an improvisation, blue like jazz.

 

I like to think that Benny Golson would approve.

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.

A Diverse Life

In his e-mail my father had typed “A Diverse Life” in the subject line. The opening paragraph announced the death of our former family doctor. He was 86 years of age.

My father had written earlier that this doctor had been confined to a hospital bed in the dining room of his red brick home, the same home which housed his office through forty-two years of general practice. It was a comfort to know that in the end he had been clever enough to circumvent the hospital and die at home.

This man had treated my father and my mother, my sister and me, and eventually, for a brief time, my wife and our first child over the course of his medical career. He was always reticent to prescribe medication—especially antibiotics—unless he could see a clear benefit for the patient. Initially, he treated my father’s high blood pressure by telling him to eat less salt in his diet. Later, when I read his obituary, I learned that the governor of Pennsylvania had appointed this man as chairman to oversee the establishment of all cardiac care units in the state.

I remember walking to the doctor’s office for the occasional physical exam, turning in at the narrow concrete walk that led up the steps to the front entrance in the big brick house on Maple Street.

The waiting room was paneled in dark wainscoting. Two rows of spindle-backed colonial chairs faced each other from opposite walls, and on those walls hung various framed prints depicting historic moments in medicine: Harvey’s discovery of the circulation of the blood; Drs. Samuel Gross and D. Hayes Agnew in the surgical theatre; Galen; Hippocrates; Maimonides. There were copies of National Geographic and Reader’s Digest on the table in the corner. At the far end stood the door with a small polished stainless steel sign that displayed the words: “The Doctor Is In.” The only time that door ever opened was when the doctor’s nurse, a massive woman with a huge round face, appeared to call in the next patient.

There were two small exam rooms behind that door, each off the short narrow hallway where the nurse had her desk. All pertinent data—height, weight, blood pressure, pulse—were recorded on a 5 by 7 lined note card with a ballpoint pen. You sat in a wooden chair by the table that housed, among other things, a stainless-steel tray filled with surgical instruments and glass hypodermic syringes. A stethoscope hung from a brass hook on the back of the white peg-board paneled door. The exam table was covered in dark brown leather. Above this table, the doctor’s framed diploma hung on the wall.

Eventually, with a quick rap on the door, the doctor appeared, always dressed in his white coat, always with a stethoscope suspended from his neck, always with the hint of a smile on his face. His hair was grey and thin, even back then when I was a boy.

Our family doctor practiced in the days of big doctoring, when general practitioners routinely performed procedures in the office that most family physicians refer to specialists nowadays. Many times he was paid for house calls in huckleberries, dandelion wine, ham and chow-chow, a Pennsylvania Dutch pickled dish.

Once, when I was an adolescent, applying myself at school and working hard at distance running, I hit a rough stretch, where nothing seemed to be going right. My mother made me an appointment to see the doctor.

He quietly listened to my tale of adolescent woe, and then replied: “That’s how you shape iron, son. You thrust a piece of it into the fire and heat it red hot, pound it on an anvil with a smithy’s hammer and shove it into a barrel of cold water. Back and forth, back and forth—one extreme to the other—that’s what makes it strong.”

I never forgot that lesson.

“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 HealerWaxing 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.