“Notes from a Healer” — Best Laid Plans

A good bit of life is learning how to deal with contingencies; the same could be said for medical practice.

My latest installment of Notes from a HealerThe Best Laid Plans — 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.

First Light

Only that day dawns to which we are awake.  —Thoreau

I awake in darkness and grope for the small chain dangling from the lamp on the bedside table.  A small tug and the room instantly floods with light.

Padding to my office adjacent to the bedroom, I reach for the wall switch. Because this sliding switch incorporates a rheostat, a different sort of illumination ensues.  As the lights come up on stage at the beginning of a performance, so these overhead lights gradually illuminate and define the objects in the room.

I descend the stairs in darkness to the kitchen.  While the coffee brews I peer through the back window.  The first light of morning has sketched out the structures of the ancient garage, the scalloped fence and the trees beyond.  Now merely shades of charcoal grey, these objects will soon take on their true colors in the increasing intensity of the light of the sun.

Back upstairs, cup in hand, I sit at my desk and watch the morning unfold outside:  shadows gradually give way to sharp definition as light makes all things new.

Tacitly, I reach for the slider switch on the wall and dim the artificial illumination within the confines of the office as sunlight streams through the double-hung windows, filling the room.

The season of shadows that has eclipsed our outlook for so long is gradually giving way to the promise of spring.

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.

Living on the edge of being

In an article that appeared in the New York Times Magazine on Aug. 26, 1990—Doctor, Talk to Me—Anatole Broyard envisioned the ideal physician who would treat a patient’s body—and his soul:

”In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and much to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror and exaltation of being on the edge of being, between the natural and the supernatural.”

Each one of us lives every moment of our lives on this edge of being, even though most of the time we pass our days totally unaware of it.  In part we are too busy, too caught up in the mundane affairs of everyday living, to glimpse it.  And I suspect that most of us would find living in a constant state of such awareness too intense to bear.  Wonder, terror and exaltation can fill our lives with awe—or burn us out.

As clinicians we are called to minister to our patients in many ways.  Sometimes we are called to talk, sometimes to listen.  In Broyard’s words, we have much to gain by letting our sick patients into our hearts.  The wise clinician learns that compassion helps to heal in ways that medication cannot—and that such healing can be reciprocal as well.

Anthony Martinez, a retired Navy eye surgeon, spends his days doing house calls on the homeless in Washington, D.C.  Each morning he slings a bag of medical supplies over his shoulder and tramps off on foot to visit those who live under bridges or in the street.  Martinez says that his work has given him a newfound purpose in life.  “It helps me deal with my own demons,” he observes.

In her poem “What I Learned from My Mother,” Julia Kasdorf writes:

Like a doctor, I learned to create
From another’s suffering my own usefulness, and once
You know how to do this, you can never refuse.
To every house you enter, you must offer
Healing: a chocolate cake you baked yourself,
The blessing of your voice, your chaste touch.

The power of poetry

Many times a poem begins with observation—a sudden awareness of a situation that unfolds before the poet’s eye and grows in his mind.  Slowly, he steeps it in a large cerebral cauldron, adds some spice to the mix and boils it down. Gradually, (if he is lucky) his concoction will take on a rich distinctive flavor of its own. A dash of insight might be required to bring out the final taste.

Powers of Ten

We magnify the universe
And scrutinize the atom,
Record for better—or for worse—
The knowledge that we fathom.

We peer through interstellar space
With polished Hubble’s eye
To calculate our humble place—
But fail to question why.

Through microscopic lens the light
Reveals the tiny thread
Of tissues, cells or cancerous blight:
What message have we read?

As tunes to every atom spun,
As music to the spheres,
As harmony blends parts in one,
Would we incline our ears?

Though I might ponder galaxies,
Or muons, quarks and flavour;
Of maximums and minimums—
It’s poetry I savor.

2010©Brian T. Maurer

“Notes from a Healer” — Flashback

She brings her 12-year-old son to the office for his sixth grade physical examination.  I have not seen the boy in three years.  She blames it on the health insurance—“they only cover a physical every other year now”—even though I suspect otherwise.  No matter: here he sits before me, quietly waiting. >>more

My latest Notes from a Healer column — Flashback — 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.

“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.