After work

It was not a particularly stressful Saturday morning to work in the office. Only three prescheduled physical examinations and a handful of sick children came in by morning’s end.

One child, a 1-month-old, my first patient of the morning, had colic. His mother reported that he wanted to feed constantly; whenever she didn’t give him a bottle he fretted, sucking on his fingers and hands. I had evaluated him one week ago for similar complaints. Since then the child gained 1-1/4 pounds, nearly three times the expected weekly weight gain. Obviously, she was overfeeding him. I suspected that part of the reason might have been because her first child was born prematurely and had a difficult time gaining weight.

Mothers nurture through feeding; a thriving baby exemplifies good maternal care, but sometimes too much of a good thing is not best.

As the morning wound down I ruminated behind my desk and reviewed the remainder of outstanding laboratory reports, signed off on a stack of physical examination forms and phoned in prescription renewals. The medical assistants finished with the filing and departed, locking the front door behind them.

I snugged the bow tie at the base of my throat, picked up my blue blazer and stepped out the side door. It was a short drive to the funeral home. By the time I arrived the lot was nearly filled with vehicles.

Inside people milled about, speaking in low tones, touching one another briefly on the arm or shoulder, exchanging whispered words. Some paused before the large displays of photographs mounted on easels in the hallway.

I stepped into the parlor, signed the guest book and found the end of the receiving line. There were stands of flowers everywhere, roses mostly — pink and red and white — done up in intricate arrangements identified by cards signed by family, friends and well-wishers.

A small silver urn stood in the center of the table; a golden crucifix rested against it. On either side lay two stacks of books — three on the left, two on the right. I noted the author of the two on the right — medical titles reflecting her area of expertise.

Most physicians don’t leave any written creative works behind; she had left two — these two texts, in addition to her two teenaged sons, who stood in the receiving line on either side of their father. Each of the three wore a pink tie. Pink, the color of the ribbon supporting breast cancer research; pink, the color of the delicate rose in full bloom; pink, the color of fading rose petals at the close of day.

My words were inadequate — “I’m sorry for your loss” — followed by handshakes and brief smiles.

“How are things at the office?” the father asked.

“Busy,” I said. “Back to school physical exams, you know. It’s the same every fall.”

He nodded. “Thanks for stopping by.”

I left by the side door and stepped out into the heat of the early afternoon sun.

As practicing clinicians we are granted the high privilege of glimpsing the struggles of families entrusted to our care. For brief periods were share in their triumphs, their joys and ultimately, their grief.

But many times it’s the grief that seems to linger the longest.

2012 © Brian T. Maurer

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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)

Final Night

For Howard Spiro M.D., on the eve of his passing

In the darkness of the night,
Blindly, I arise and stumble,
Half asleep, with shoes I fumble,
Pause before the soft blue light
To parse the message in the night.

In the darkness of the night
Groping for my coat, I swag,
Search the corner for my bag,
Pull the door behind me tight,
Step outside into the night.

In the darkness of this night
A waning gibbous moon appears,
As it has through finite years;
It hangs upon the cheek of night,
The Bard’s rich jewel, this silver light.

In the darkness of this night
It questions me with faceless stare
To ask if I might tarry there
To speak a word into the night,
Into the dark, before first light.

In the darkness of the night
The orb embraced by silver shroud
Now slips behind a veil of cloud
Serenely, as it fades from sight
In the silence of the night.

3/12/2012 © Brian T. Maurer