Remembering Dr. Howard Spiro

I first encountered Dr. Howard Spiro at a medical humanities conference in Williamstown, Massachusetts, some 20 years ago. As a guest speaker, Dr. Spiro shared the podium with Dr. Robert Coles. The two made quite a pair: both distinguished practitioners of the art of medicine; one from Harvard, the other from Yale. Dr. Spiro wore a brown bow tie that day. I recall that detail exactly, because it was the kind of bow tie you had to tie yourself; and I remember suppressing an impulsive urge to discreetly snug it up for him. Curiously, I didn’t actually make his personal acquaintance until nearly a decade later.

One evening in December of 2002 my friend and colleague Dr. David Elpern and I traveled to New Haven to attend an evening lecture at the Yale Humanities in Medicine program. During the drive down, Dr. Elpern told me that Dr. Spiro had founded the lecture series back in 1983. Later that evening over dinner at Mory’s, we learned from Dr. Spiro that he had gotten up a fledgling online journal of similar import, the Yale Journal for Humanities in Medicine.

By that time a few of my early pieces had been published in JAMA and BMJ. Dr. Spiro was eager to hear all about them. I don’t recall whether he asked me to consider submitting something to YJHM at that time or not. At some point I did send him a piece, which he graciously accepted for publication.

Sometime later, after he offered to review my book Patients Are a Virtue, Dr. Spiro asked if I would consider doing a monthly column for the journal. “What would we call it?” I asked him. “Call it what you like,” he said. Shortly after that my “Notes from a Healer” began to appear in the electronic pages of YJHM.

And so began a collegial relationship that lasted up until the time of his death. (Dr. Spiro approved the submission for my March “Notes from a Healer” column days before entering the hospital for a cardiovascular event that would ultimately end his life.)

Every month for the past five years I would send Dr. Spiro a piece for the column, which he would critique, usually in a few brief lines, before okaying it for publication. These critiques were not those of a typical editor. Many times he would comment about something in his own life or how the piece I submitted moved him personally.

“Engineers are among the most difficult patients, for they are convinced there’s a detectable reason/cause for anything/everything.”

“Wise, indeed. One learns with age.”

“You are sounding more like O Henry with time.”

“Your usual beautiful turns. I confess I would have seen the opportunity/really the genius of America in their story, but suum cuique!”

Occasionally, he would point out a grammatical error; and red-faced, I would shoot off a corrected copy with my thanks appended. At some point, he would finally bestow his signature stamp of approval: “Imprimatur.”

Dr. Spiro rubbed shoulders with some of the medical greats of his era. Many times I only learned of these relationships through casual comments he would make on pieces I sent him. For example, in response to one of my submissions he wrote:

“I knew Leon Eisenberg—admired him—look at his CV. I cannot believe that he would want to be considered a mere psychopharmacologist.”

After researching Dr. Eisenberg’s biography, I wrote back, “I took your advice. You were obviously correct in pointing out that the man was much more than just that.” I included an article from Harvard’s FOCUS Online which I thought Dr. Spiro might enjoy . Dr. Eisenberg’s story about the schlemiel was priceless.

Sometimes Dr. Spiro and I exchanged correspondence on matters of medical practice as well. Once, I discovered an article that referenced a paper of his. I sent him the link with a few observations:

“Reading through this review, I couldn’t help but think that you would enjoy it. As it turned out, you were mentioned toward the end of the article.”

‘Stress,’ the American gastroenterologist Howard Spiro writes, ‘increases vulnerability’ to other ulcer-causing agents ‘like H. pylori’. Medical fascination with bacterial causation has, he says, resulted in culpable neglect of the roles of the mind, the emotions and the dietary and behavioural patterns of everyday life. (A Modern History of the Stomach: Gastric Illness, Medicine and British Society, 1800-1950 by Ian Miller)

Dr. Spiro was obviously pleased: “Thanks, glad I am remembered! I worked on stress in the 1940’s, thanks to Selye’s idea of the ‘alarm reaction’ and published my first medical papers back then.”

In turn, I wrote back: “Perhaps my perspective is somewhat skewed, but it seems to me that precious few specialists seem to be able (or willing) to relate to such patients on a humane level these days, a demonstration of the lost art of medicine.”

Dr. Spiro’s assessment: “Boy, are you right! When I was young, we talked to patients. Lab data and images were scanty. Since 80% of patients get better with time and the right hand of fellowship, the clinician counted. But that will return after disenchantment spreads.” He had entitled this reply I-Thou.

On a professional level, Dr. Spiro was supportive of my clinical practice as a physician assistant. He strongly advocated for the advancement of “mid-level practitioners” as he called us, feeling that we were the answer to the primary care clinician shortage problem. “The expertise you demonstrate in the way you care for your patients is evident in your writing,” he wrote. “I argue with my colleagues, many of whom feel that medical practice should be regarded as the exclusive domain of the physician.”

“As you may know—or more likely may not—for the last 20 years I have been pushing the idea that physician assistants or nurse-practitioners should be doing pediatrics and general internal medicine. Very few in the internal medicine business agree.”

“Your enthusiasm, amity, empathy for your patients—and your prolific writing skills—continues to reassure me that physician extenders—if I can call you that—should constitute our general docs and pediatricians. It’s a canard that they will not recognize serious problems! I keep wondering why you do not talk about that—or maybe you do, indirectly, or in other places.”

This past fall Dr. Spiro wrote that he would be traveling to Arizona to give a medical humanities presentation at one of the medical schools there. “I would like to use you as an example of a clinician who not only practices humane medicine, but writes about it well. Send me a copy of your CV. I imagine you to be somewhere around 45, give or take.”

I sent him my résumé with the caveat that he was off on my age by more than a decade. “Hah! You write with the vigor of someone in his early thirties,” he quipped.

Toward the end it was evident that Dr. Spiro was becoming a bit forgetful. When the name of George Bascom resurfaced in one of our e-mail exchanges, he wrote: “Tell me again how you knew him.”

“It was you who knew him personally,” I wrote back. “I only knew him through his poetry. In any event, he was a fine mensch who continues to influence clinicians from beyond the grave.”

“If you didn’t know him personally, a word like mensch—which I take to be a personal assessment—might be out of place,” he replied. The response stung.

I took a deep breath and typed out a reply. “According to the dictionary, a mensch is someone to admire and emulate, someone of noble character. It’s meant as a compliment to highlight the rarity and value of that individual’s qualities.”

I suppose those words might just as well have been written to describe Dr. Spiro himself.

Howard M. Spiro, M.D. (Photo credit: Peter Casolino Photography, New Haven, CT)

Winter advisory

"Winter Window" 2012 © Brian T. Maurer

Since acquiring an iPad, I’ve gotten used to checking the Weather Channel app every night before retiring. Most times the predictions are humdrum, but every once in a while I’m brought up short by an unanticipated forecast.

Last night the app carried a winter weather advisory. A major storm would strike our area shortly before noon today. The advisory called for 3 – 5 inches of snow over the course of the afternoon and night, ending in sleet and freezing rain.

I got up early this morning to run several errands before the storm. I topped off the tank in my car and brought back additional gasoline in a 2-gallon container for the snow blower, should the need arise. I pulled the snow shovels out of the garage and cleared extraneous debris from the driveway. Last night my wife had made a big pot of chicken soup for dinner. I turned on the burner and let it simmer. After working outside in the cold, there’s nothing like coming in to a bowl of steaming soup .

I gave myself a pat on the back, pleased that I had been able to prepare for the weather in advance. But even the best laid plans can’t anticipate everything.

Mid-morning I stared at a reply that popped up shortly after I e-mailed the editor at one of the medical journals I write for. Entitled “Away,” the automated message informed me that the editor would be indisposed for an undetermined period of time. Several personal contacts were listed, among them his spouse and granddaughter—not the sort of contacts that you would typically find in an automated e-mail.

Immediately, I shot off a couple of messages to some friends, asking whether they’d heard anything recently about the state of this editor’s health. I’m probably jumping to conclusions, I muttered under my breath as I pounded the keyboard; but I couldn’t help it—my clinical nose was twitching. I feared something was up.

The snow started to fall shortly before noon. Within an hour the yard was blanketed white. Snow lay on the bare branches of the maples in back of the house and accumulated on the cars parked in the street. Outside the window of my office it continued to come down steadily. This was certainly no ordinary snow, I mused, recalling the advisory. Such a rate of descent portended more than a mere dusting.

Another message popped into my Inbox. This one was from the editorial assistant. She confirmed my fears: the editor was indeed in the hospital. She didn’t know the particulars. She imagined that he wanted to keep things quiet—no fanfare, no fuss. She admitted that she was worried too. She would let me know as soon as she heard anything more. Meanwhile, outside the snow continued to fall.

Soup—piping hot, chocked full of fine noodles with bits of celery, carrots and corn. I lifted a spoonful from the edge of the shallow bowl to my lips and blew softly to cool it off. The dog perched at my side, eyeing the spoon and begging for cracker crumbs.

Years ago a friend and I had visited the editor at his townhouse. For lunch he had warmed up some homemade soup on the stove.

How different the hospital must have looked through his eyes from the bed. This esteemed professor emeritus who had attended so many patients over the course of his lengthy career was now at the mercy of his own attending physicians, a patient himself.

A thick layer of heavy wet snow accumulated on the driveway. I downed a cup of fresh brewed coffee, pulled on my cap and coat and stepped outside into the winter whiteness. I grabbed the shovel on the back porch and started pushing the snow off the driveway, herring-boning my way down the long expanse of macadam to the street. As I worked the snow continued to descend. The wet snow stuck to my woolen cap and my coat; soon I was blanketed with the wet whiteness.

“Do you tip your barber?” the editor had written after reading the manuscript of my piece Haircut. “I still do, though people tell me it’s no longer done.”

“When I read your latest, I was reminded of the stout cigars I used to love when I was stationed overseas.”

“Crafted with your characteristic twist, served up with a touch of grace—imprimatur!

Imprimatur!—that was his stamp of approval: Let it be printed! I learned a bit of Latin phraseology through our casual correspondence. He was a wonderful mentor, even when he wasn’t aware that he was teaching.

By the time I reached the street the upper driveway was once again covered in snow. I shouldered my shovel and trudged back to the top. For the second time that morning I threw myself into my work.

Afterwards, I pulled the car into the driveway off the street. My wife let our little white terrier out and handed me the leash. We took a short walk around the block. Several times the dog stopped to shake the snow from her rough coat. She bounded through the snow like a miniature sheep, tugging at her leash.

Back home I brushed the snow from my cap and coat in the mud room. I dried the dog with an old towel, kicked off my boots and stepped into the warm kitchen. The soup still simmered on the back burner of the stove.

I hurried upstairs to check my e-mail. A new message from the editorial assistant informed me that the editor had suffered a stroke during cardiac catheterization. No one knew anything more at that point. I dashed off a quick reply, thanking her for the timely update.

Outside the snow continues to descend. The bare maple branches bend precariously under the weight of the wet snow. It will only be a matter of time until one of the weaker ones snaps.

Unemployment Assistance

My pulse kicked into overdrive when I read the subject line of a recent e-mail from a friend: “Bad News.”

I took a deep breath as I opened the message and read the lines of text. My friend had lost his job. The previous day, with no prior warning, he had been let go from a position he had occupied for the past seven years. The company was undergoing reorganization. His boss had decided to wipe the slate clean and start fresh—new younger workers with less experience could be hired for considerably less money. Needless to say, my friend was left in the lurch. He’s married, the father of a 2-year-old toddler and has a mortgage on his home.

What’s so odd about that scenario, you might ask. In these difficult economic times many folks are in the same predicament. Ordinarily, I would have to agree with you. Except in this instance, my friend is a family physician. He’s bilingual and has spent most of his career working with the poor and the indigent. He’s competent, conscientious and cares deeply about the patients he serves. So why was he let go? Although he’s asked, his questions have fallen on deaf administrative ears. Perhaps he wasn’t productive enough to pump out yet another patient with a myriad of medical problems every 12 minutes, who knows?

My friend subsequently drew up a list of the medical needs of his most complicated patients and forwarded it to the administrator of the clinic where he worked—the same administrator who had in fact let him go. My friend wanted his replacement to have the background information to be able to deliver good care to his former patients.

In the interim period, as luck would have it, my friend happened to reestablish contact with an acquaintance from years ago—a wandering sort of sage, who was practically homeless at the time. Out of the blue this fellow called up my friend to chat. When he learned that my friend had recently lost his job, this fellow offered to send him a bit of money to tide him over.

My friend was astounded at the offer. It wasn’t as if he needed the money; he has always been prudent with his finances and will do just fine in the long run. No, it was the fact that this homeless fellow had made a sincere gesture to help, even though he had little to spare for himself.

My friend wrote that he felt like the Jimmy Stewart character in “It’s A Wonderful Life”—George Bailey returns home after his Walpurgisnacht wanderings through the streets of Pottersville to be greeted by family and friends, who dig deep into their pockets to raise the funds to support him in his time of need.

I am confident that my friend will soon have another job. People with his skills, talent and experience don’t stay unemployed for long. But even the unemployed man who has the poorest of true friends is rich beyond measure.

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.

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.

Our daily work

If there is a certain humility in serving, there are also untold rewards in our daily work.

The Kabul rehabilitation center, constructed on an old hospital graveyard, has never been attacked by any political faction in Afghanistan, even though it is staffed primarily by foreigners. One of the workers serving in a managerial capacity there also provides direct patient care as a physiotherapist. Alberto Cairo traded a career in law for the opportunity to serve the poor, the maimed, and the hopeless under the auspices of the Red Cross in this war-torn country. According to him, there is nothing else he would rather be doing with his life. Mr. Alberto has become the most revered Western relief worker in Afghanistan, at least among the Afghanis.

“What I’m doing here is so rewarding,” he said. “For me, it’s perfect. I feel I have been very, very lucky.”

“To watch the first faltering steps of men, women and children, some standing for the first time in years, is a transformative experience.”

In his essay The Master-Word in Medicine, Sir William Osler reveals the secret of the professional life in medical practice: “Though a little one, the master-word looms large in meaning. It is the open sesame to every portal, the great equalizer in the world, the true philosopher’s stone, which transmutes all the base metal of humanity into gold….Not only has it been the touchstone of progress, but it is the measure of success in every-day life….And the master-word is Work…”

Indeed, although he penned his essay a century ago, Sir William’s words seem to foreshadow Mr. Alberto’s attitude in action: “You enter a noble heritage, made so by no efforts of your own, but by the generations of men who have unselfishly sought to do the best they could for suffering mankind….Yours is a higher and more sacred duty. Think not to light a light to shine before men that they may see your good works; contrariwise, you belong to the great army of quiet workers, physicians and priests, sisters and nurses, all over the world, the members of which strive not, neither do they cry, nor are their voices heard in the streets, but to them is given the ministry of consolation in sorrow, need, and sickness.”

In Alberto Cairo’s words: “If you can improve the life of a person it gives you so much joy….If I had to compare what I give to what I get, I get much more than I give.”

Pupil and Teacher

The new student, obviously nervous, arrived at the clinic that Monday morning. He had had some previous medical experience during his years of military service. As a hospital corpsman, he had shouldered several independent duty assignments. Although he knew something about medicine, he was acutely aware of how much he didn’t know.

The doctor at the inner city clinic had only recently taken the position. He was relatively young himself, having completed his own medical training within the previous five years. After fulfilling his two-year military obligation, this doctor joined a fledgling private practice, only to find the night call overwhelming. Clinic patients were serviced through the local emergency room after hours. This arrangement suited the young doctor much better.

It didn’t take long for the doctor to determine the student’s level of competency. He gave the student free range to evaluate patients in the clinic. They discussed each patient afterwards; the doctor co-signed every chart.

Under the doctor’s tutelage, the student learned office gynecology, pediatrics, psychiatry and adult medicine. Beneath the doctor’s watchful eye, the student performed minor surgical procedures. Every Tuesday morning the two clinicians—doctor and student—would drive to the local hospital for the weekly grand rounds presentation and have lunch together afterwards in the cafeteria.

During one of these weekly sojourns, the doctor, whose hobby was photography, pointed out two wayward youths lounging against a large granite headstone in the local cemetery. “If I had my camera,” he said, “I’d capture that photo — and call it Waiting.” They both laughed at this remark as they drove to the hospital.

One day the student developed an abscess on his arm. The doctor lanced it, drained the infection, and gave the student a short course of antibiotics gleaned from samples provided by a pharmaceutical representative. Some time later the doctor asked the student to remove a small skin growth from his side; the surgical procedure went well.

The student was there the day that the doctor discovered a mass in his own neck. At the doctor’s request, the student felt the lump and gave his opinion. The student was also there when the biopsy results came back showing Reed-Sternberg cells, the sine qua non of Hodgkin’s lymphoma.

Over the following months the student shouldered more responsibility for care of the clinic patients while the doctor underwent radiation treatments for the cancer. Other doctors were contracted to cover his hours and to supervise the student.

Eventually, the cancer went into remission and the doctor was able to return to work. When the student graduated from his program, the doctor took a voluntary reduction in salary to enable the clinic to hire the student as an employee. The former student continued to work with the doctor for the next two years before moving on to pursue further training in a postgraduate program in another state.

The two colleagues managed to keep in touch over the years. They published a series of pieces in an online journal devoted to the medical humanities. The former student provided the text; the doctor contributed complementary photographs. Together they made a good match.

Then one day the doctor’s lymphoma recurred.

Not long ago the same student, now a seasoned clinician, opened a plain white business envelope to find an obituary clipping that bore a black and white photograph of the doctor who had mentored him into medicine three decades before.

Quietly, the former student read through the text. Afterwards, as he stared out through the window in his office to the stately pines silhouetted against the late-afternoon sky, he recalled the words of the great Canadian physician and humanitarian teacher Sir William Osler:

“The pupil and the teacher working together on the same lines, one a little ahead of the other.”