One week prior to her hospitalization, she experienced diplopia, or double vision. When she looked straight ahead, objects appeared normal, but if she looked to the right they underwent binary fission. At first she thought nothing of it, but it persisted. Her vision was her livelihood. Her work depended on absorbing sketches, drawings, and visual plans. So she came to the hospital.

On my exam I noticed only one abnormality: Her right eye would not abduct. When our eyes look in one direction or another they ought to move together. Because of this intricate biological design, when we look in any direction, images align as if we are seeing everything with one eye. In this patient’s case, a lesion damaged the nerve (abducens nerve) for the muscle moving the right eye laterally. We ordered an MRI of her brain to look for a cause.

In her brainstem sat a brain tumor called a glioma. The prognosis was poor, maybe a couple of years. But it wasn’t just the limit on her life that was the issue. As these tumors grow they wreak absolute havoc on their victims. Patients develop weakness, vision loss, and headaches. They require wheelchairs to get around. And all this occurs in a step-wise fashion, often with preserved cognition such that the patient is ensured the maximal amount of suffering with the maximum amount of awareness.

She knew none of this when we finally sat her down to tell her. But she needed to know. And so we broke the news. The whole scene is a bit of a haze. I can’t remember the exact details of what was said but I do remember her tears and the question she asked us through them: “Will I ever see thirty?”

In 2014, Dr. Atul Gawande, a Harvard physician and writer, penned Being Mortal, a book about the last stages of life and the financial, sociological, and ethical implications of how we, as physicians and as patients, deal with these final moments. In one particularly striking part of the book, Gawande discusses what makes life worth living when we are old, frail, and disabled. From the perspective of the young and healthy, we fear that life and its pleasures will end when we can’t run or multitask or drive or engage as visibly with the world around us. We fear being unhappy when time inevitably snatches our youth away.

Laura Carstensen, a professor of psychology at Stanford, studied this question: Do people grow unhappier as they age? Between 1993 and 2005, Castensen and others involved with the study tracked 180 Americans between the ages of 18 and 94.  Every five years, the subjects were given pagers and were randomly paged for a one-week period. They immediately responded to questions regarding their happiness, satisfaction and comfort. Carstensen found that, in fact, people grow happier as they age. As she stated,

As people get older, they’re more aware of mortality. So when they see or experience moments of wonderful things, that often comes with the realization that life is fragile and will come to an end. But that’s a good thing. It’s a signal of strong emotional health and balance.

Other studies since then have reinforced these findings. But does this really have to do solely with age or is there something more at play here? “Suppose,” Gawande writes, “it merely has to do with perspective — your personal sense of how finite your time in this world is.”

He continues,

When horizons are measured in decades, which might as well be infinity to human beings, you most desire all that stuff at the top of Maslow’s pyramid — achievement, creativity, and other attributes of ‘self-actualization.’ But as your horizons contract — when you see the future ahead of you as finite and uncertain — your focus shifts to the here and now, to everyday pleasures and the people closest to you.

Carstensen developed multiple experiments in different populations to test this theory. She studied patients with terminal AIDS who were young, and conducted the same studies with people from Hong Kong. When the end is near, regardless of age or cultural background, people value time with their loved ones more. However, when the end is far off, people tend to value time with their loved ones less. Our situation, not our age, gives us a sense of perspective, a sense of either finality or infinitude and consequently changes our priorities and the way we live.

Working in medicine provides this kind of perspective. The hospital collects people facing stygian tragedies and places them directly in our laps. Our minds don’t stray too far before we are once again reminded of the fragility of human life. Becoming a physician and being a physician forces this realization upon us. As such I feel unfortunate and fortunate. I am lucky because I am always reminded of how lucky I actually am, of how sheltered and shielded I have been (thus far) from true tragedy in my own physical life. And I am unlucky because not a day goes by when I do not realize that, despite my age, true tragedy for myself or a loved one may not be far off — that is a sobering thought with a perennial lesson.

In this blog I attempted to share a bit of that perspective, and more. But perspective is due to one’s ability to see the beginning and the end, to look from above and to understand that nothing goes on indefinitely. And so this will be my last post. As my career advances, I recognize that the blog has served its purpose and reached its closing act, though my writing will continue elsewhere.

For what exists here at The New Atlantis there are many people to thank. But there are a few in particular who deserve mention. It was under Adam Keiper, former editor of The New Atlantis and former Books & Arts editor of The Weekly Standard, that this project began. He was receptive to it and encouraging from the very beginning. My writing and thinking benefited greatly from his steady hand. And this blog’s conclusion comes under the similarly steady hand of Ari Schulman, who has been encouraging and receptive to its continuation. He is a true friend and intellectual guide. I have benefited greatly from his edits as well as those of Samuel Matlack and Brendan Foht. A writer and his or her work leans more heavily on great editors than any reader will ever know; this blog has had great editors.

And to you dear reader, I hope the writings herein contributed something to your understanding of medicine, of the life of a physician, of the education of a physician, of medicine’s theoretical, practical, and ethical complexities — and thus also of life itself. I bid you adieu.

The post How Finitude Makes Us Happy — My Final Post appeared first on The New Atlantis.

His decision perplexes us further when we realize that Chekhov experienced misery and anguish his entire life. His father flogged him and his siblings regularly. In 1875 he came down with a severe infection of his abdomen. His brothers left home against their father’s wishes to work in Moscow, leaving Anton to absorb his father’s beatings. Meanwhile the family shop went bankrupt and Anton’s father fled, leaving his mother to face his debts. Anton’s brother, Nikolai, would die at a young age of tuberculosis. And as Anton became a physician and eventually attained success as a writer, he developed pulmonary tuberculosis, too. And yet, Chekhov departed for Sakhalin Island.

In the eponymous book on his trip, Sakhalin Island, Chekhov fastidiously describes what he sees: the people he meets, the geography of the landscape, the weather, and the suffering of the exiles. Yet he ignores our most burning question: Why give up precious time — especially given his deadly illness — for months in the bowels of humanity? What drives one to do this?

Though he does not directly address this in his book, his March, 1890 letter quoted above hints at an answer: “Even assuming that the journey will yield me precisely nothing — nonetheless, however, might there not occur, during the entire journey, two or three of the kind of days which I’ll recall my whole life with delight or bitterness?” Such an excursion might provide moments of invaluable self-reflection. And they might bring with them a sense of gratitude, a reminder of great deeds and what matters in life. He clarifies,

No longer than 25 or 30 years ago our very own Russians, while exploring Sakhalin, achieved astonishing feats, for which a human being might be idolized, but we don’t need all this, we don’t even know who these people were, but only sit gazing at four walls and complaining that God has created mankind so imperfectly.

A trip to Sakhalin would also shake Chekhov from the morass of daily life in which he found himself.

Chekhov also sought to expose the impeachable offenses committed at Sakhalin:

From the books which I have read and am reading now, it’s clear that we have allowed millions of people to rot in prisons, to rot for no purpose, without any consideration and in a barbarous manner; we have driven people tens of thousands of versts through the cold in shackles, infected them with syphilis, perverted them, multiplied the number of criminals, and put all the blame on to red-nosed prison overseers.

Here is Chekhov’s chance to reveal such barbarism, to see and understand what life is like beyond the confines of European Russia, to reflect on his own life, to appreciate what was done to build such an outpost and to shame those who turned it into the festering residence of the Demogorgon. And so, at the age of 30, sick with tuberculosis and the knowledge that he might soon die, Chekhov undertook his brutal journey.

After years of training, lassitude overtakes young resident doctors for a surfeit of reasons:  exhaustion with long hours, one’s own feeling of ignorance, meager pay, and the steady push and pull from patients, colleagues, hospital administration, nursing, and life beyond the inpatient wards. Everyone wants something from you, an order in the computer for Tylenol, another note on top of the hundreds of others you’ve written during residency, another training module for HIPAA compliance laws or electronic health record training. These meager requests accumulate quickly and trap us in a morass of bureaucracy and mindless tasks.

American medicine piles on such red tape for some good reasons. In serious academic medical centers the department chairs rightfully build in layers of support for trainees. Before making a decision about a patient, a junior resident speaks with a senior resident and then the senior resident consults with a fellow and then the fellow talks to the attending physician. In other words, strata exist to ensure that we make the right decisions. Second, nurses add another layer of protection — a good, experienced nurse will double check a physician’s decision or order; the same thing goes with a pharmacist who releases the medication to the nurse. Moreover, some of our patients are well-educated and curious and ask us to explain our decisions. All this leads to better care. In one study from 2018, patients with all levels of complex medical illnesses had better outcomes at academic medical centers.

On the other hand, because of this layering, trainees often feel dispensable. Whether true or not, a stratified system makes the decision and reasoning of one person seem less relevant. I am not arguing that residents don’t matter. In fact, they matter quite a lot, as do their decisions. But it can seem, in the thick of it, that they don’t.

Furthermore, in a system like ours, the immediate availability of lab tests and imaging creates a sense of security and reliance on powers beyond one’s own intellect. If we’re uncertain about the exam and history we simply order an advanced radiologic study. Such blessed resources, alas, distort our reasoning. Consequently, we practice medicine in a defensive way, in order “not to miss something.”  This, too, makes medical work feel less relevant, less significant.

With all this in mind I resolved to leave my training hospital for sub-Saharan Africa to teach and practice medicine. I traveled with one of my professors to a resource-poor setting. Here was my chance to do something good and fulfilling, to teach and to care for patients without access to a limitless medical system. I, too, would benefit from this trip, and not just educationally. I anticipated an antidote to the aimlessness one feels during training, the purposeless rut in which we often get stuck. I would see and understand what life is like beyond the confines of American medicine, reflect on my own profession, and appreciate the Western medical miracles while trying to bring some sliver of them to others.

I thought of Chekhov’s journey to Sakhalin Island, a foreign land inhabited by those far less fortunate than his Euro-Russian comrades. I, too, hoped to escape “gazing at four walls and complaining that God has created mankind so imperfectly.” And so, at the age of 31, I boarded a plane for sub-Saharan Africa.

One evening we saw a patient admitted with a diagnosis of “altered mental status.” The nurses brought her up to the ward and placed her on a cot in a corner of the room as flies hovered around her, alternately landing on her arms, legs, and face, and floating toward the window before about-facing and landing back on the patient. At the age of thirty, she suddenly lost the power of speech and movement on her right side. Intermittently, she held her head with her left hand and cried out in pain, the obvious signs of a terrible headache. The nurses tied down the left side of her body so she wouldn’t pull at her IV.

We asked the residents to transfer the patient to a coveted and expensive intensive care bed in case she got worse. Most patients, no matter how sick, do not qualify for a high-acuity bed. But a young patient with a potentially salvageable life and a child at home needed intensive care and she needed it promptly. When we came back the next morning, though, the patient was still in the same corner of the room. She no longer had an IV and thus could not get any IV medications. And she was much more somnolent than she had been the day before. She barely opened her eyes during the exam. How did this happen? How was she left to lie in a corner of the room without any medical care overnight? When we asked the staff, we received shoulder shrugs.

As foreigners, we had little control over patient placement in the hospital. We asked one of the physicians if we could bring her down to the ICU ourselves.

“You are white doctors,” she replied earnestly. “You can do anything.”

We pushed the patient down to the ICU on a rickety stretcher with malfunctioning wheels. Unfortunately, however, basic ICU care there did not function as well as it does in the United States. While we examined other patients, the young woman developed a “blown pupil.” The pupil failed to constrict when exposed to light; it fixed in a dilated state indicating deadly brain herniation. Due to high pressure in the skull, the temporal lobe of the brain (the uncus) pushes downward and compresses the oculomotor nerve, causing pupillary damage. After one of the residents notified us, we rushed back and explained to the ICU team that this was a medical emergency — the patient needed an IV medication called mannitol to decrease the swelling to save her life. After one dose of the medication, her pupil returned to normal size and she woke up.

We left the hospital soon after this tumultuous experience, hoping that she would survive the night. But she passed. The next morning no one knew what had happened. As we exited the ICU after receiving the news, I turned to one of the autochthonous physicians and exclaimed: “That is so upsetting!”

“Welcome to Africa,” she replied.

Yes, there was tragedy, but there was also hope. As we tore through floors and floors of patients in the sultry African heat, soaked in our own perspiration, we altered prior diagnoses, treatments, and medication doses, asked for labs tests, performed procedures. For some patients, we made little difference to the outcome, merely offering a diagnosis where a previously erroneous diagnosis plagued the paper chart (no electronic health records existed). But for others we made enormous improvements in their health care simply by changing a seizure medication. By doing so, we often contradicted some of the more senior physicians in the hospital. Of course, we did not in any way malign the hospital’s physicians. We came to help and to teach and we sought the accurate treatment and diagnosis; mendacity for diplomacy’s sake was not an option.

We could do this only because we luckily trained in a system with abundant resources, worldwide experts, and subscriptions to all levels of scientific journals. This evoked a sense of guilt. But even more discomfiting, we were told we could do anything because of our skin color.

In 1922, George Orwell joined the imperial police in Burma after poor grades and a tenuous chance at a university scholarship limited his academic options. It was nearly 100 years into British rule in Burma (it had begun in 1824). During their reign, the British destroyed and burned villages, abolished the Burmese monarchy and exiled families form their homes if they were disloyal. Indeed, one can imagine the kind of tension this created between the imperialist British and those under the yolk of their rule.

In his essay, “Shooting an Elephant,” Orwell describes the kind of moral dilemma and its accompanying moral disgust he felt as an imperial policeman. He absorbed the hatred the Burmese felt for him and the English staying there. They insulted him, tripped him during football games — small acts of rebellion to make his life and the life of his comrades more difficult. Orwell despised the job, he “hated it more bitterly than I can perhaps make clear.”

He continues,

In a job like that you see the dirty work of Empire at close quarters. The wretched prisoners huddling in the stinking cages of the lock-ups, the grey, cowed faces of the long-term convicts, the scarred buttocks of the men who had been flogged with bamboos — all these oppressed me with an intolerable sense of guilt.

Imperialism, Orwell suggests, turns one into an inhuman, brutal monster and destroys one’s conscience. Consequently, one loses all sense of agency. As Orwell readies himself to shoot a wild and destructive elephant in front of a crowd of Burmese, he explains,

Here was I, the white man with his gun, standing in front of the unarmed native crowd — seemingly the leading actor of the piece; but in reality I was only an absurd puppet pushed to and fro by the will of those yellow faces behind. I perceived in this moment that when the white man turns tyrant it is his own freedom that he destroys…. For it is the condition of his rule that he shall spend his life in trying to impress the “natives,” and so in every crisis he has got to do what the “natives” expect of him. He wears a mask, and his face grows to fit it.

The imperialists do what is expected of them from the population they rule. They keep up appearances. This, according to Orwell, defines a relationship where one group rules over another. And in the attempt to carry the White Man’s Burden, the British became entangled and confused in their own power, perceived moral high ground, and colonial duty.

A medical mission is by no means the same as nineteenth-century imperialism, but there is undoubtedly a residue of it. Being told that we can do anything because we’re white physicians is part of that. The other part is fear of us and what we might do because we’re white. I remember performing a lumbar puncture on a patient to obtain cerebrospinal fluid for diagnostic and treatment purposes. I stuck the needle in the patient’s back and she began screaming at me, using the slang in her language for “white doctor.”

We strike a tenuous balance between helping and imposing our ways on the patients and physicians of this African hospital. If we are seen as doing the latter then all we have done is for naught. As my professor said to me, “we are not here to change their system.” It is not our place to point out the failings of an overburdened third-world hospital. On the other hand, we cannot, for the sake of truth and patient survival, allow them to make incorrect diagnoses and treatment decisions. And even if one threads the needle perfectly, even if we are deferential and humble and polite, our abilities and technology still clearly surpass those of most of the continent’s. It produces the same sense of guilt Orwell felt, though to a lesser degree. But it also creates an absurdly high expectation of us, to know all, to fix all, to make everything better — our own version of shooting an elephant. There were multiple instances where young residents would pull me aside and ask me about patients we weren’t going to see. “Can you tell me if this is right?” they pleaded. We did our best, but I couldn’t shake the feeling that we were wearing a mask and having our faces grow to fit it.

She lay on a stretcher in the back corner of the room — the infectious disease corner. In the hospital I worked in there are no individual rooms for most patients; the badly functioning stretchers line up next to each other in a large, square room packed with people. No negative pressure rooms exist to sequester infectious patients. The powers-that-be stick patients in the back of the room and hope the disease stays put, too.

The patient’s face was gaunt and thinned with concave cheeks. And she was cross-eyed. Despite the obvious pathological changes, she looked to be a young woman. Her face, devoid of wrinkles, devoid of the dark recesses of the brow that oftentimes characterize the old, glistened in the sunlight.

We heard her story: a twenty-four year old female newly diagnosed with AIDS and cryptococcal meningitis, leading to increased pressure in her brain and on the nerves that supplied her eye muscles. Her CD4 count was 23 cells per microliter of blood (a normal CD4 count is at least 500 cells per microliter of blood). But we knew that she had not been infected from birth — the CD4 count declines, on average, by  50 cells per microliter a year. Indeed, she almost certainly had not been born with it given the following statistics: between 25 percent and 30 percent of children who have HIV at birth die before they turn one. More than half die by the time they are two. Most of the babies born with HIV become symptomatic with infectious diseases or fevers, enlarged lymph nodes or other symptoms. The average age of death for these children is between 6 and 7 years.

If she had not been infected at birth from her mother — referred to as vertical transmission — how did she contract the virus? Her mother insisted she was a virgin. After all, she was unmarried and came from a religious Muslim family. Indeed, every day her mother and sister traveled from the backcountry, a place with far fewer resources, to take care of her and feed her. With such a dedicated family, how did she get AIDS?

The residents brought in a 16-year-old girl from their clinic for us to see. She had experienced a few weeks of double vision when she looked straight ahead and when she looked to the left. She developed a chronic headache, too, and unsteadiness on her feet. Petite and quiet, she answered our questions in one or two words as we asked about her symptoms. A CT scan of her brain done at a new hospital one week prior to our arrival was reportedly normal. When she got up to walk she seemed to do okay, but when we asked her to walk on a straight line, the way a police officer might do with a suspected drunk driver, she stumbled and nearly fell.

We pulled up her CT scan. Her brain showed signs of hydrocephalus, a buildup of fluid and pressure within the cavities (or ventricles) of the brain. We brought her into the hospital and diagnosed her with tuberculosis meningitis; tuberculosis infected her brain, causing swelling, increased pressure, and damage to the nerves innervating the muscles of her eyes. Then we tested her for HIV. One doesn’t have to have HIV to get tuberculosis, but it is more likely to occur in patients with HIV. She was HIV positive, at 16 years old. Here, too, her religious family was shocked and again the father insisted she was a virgin.

We spoke with some of the infectious disease physicians at the hospital. Despite the evidence against it, they assured us she contracted it from her mother. They even told the family this. There was no social worker to help establish a sense of support at home. There was no police involvement. The powers that be brushed her diagnosis and its etiology under the rug. The patient would be put on the proper medications and sent home. Part of this dismissal has to do with the scant resources in the region. But there is, perhaps, something else at play. This is neither an inevitable tragedy nor an isolated incident. The statistics of HIV in young women are startling: In some parts of Africa, nine in ten new cases among adolescents occurred in girls. The reasons for this in poorer African nations vary, but there are clear and deeply problematic etiologies, including sexual abuse and transactional sex. Sexual abuse is not uncommon in sub-Saharan Africa. Data is not widely available, but some researchers have estimated that approximately 0.6-1.8 percent of all children in countries with high HIV-incidence in the region experience penetrative sexual abuse by an HIV-infected perpetrator before the age of 18. As for transactional sex, multiple studies have demonstrated that school girls use money obtained from sex to pay for school, clothing, pencils, and even packets of peanuts. In other words, the insidious problem of HIV in young women is well-documented and pervasive. Why ignore this tragedy? I honestly don’t know. It has little to do with moral sensibilities, especially in deeply religious African countries. Does it have to do with a sense of defeatism on a continent that is awash in poverty? Or perhaps it is so common that these cases disappear in a large ocean of numbers? Do we ignore what we don’t want to admit exists? How do we break out of this cycle of infection that plagues many young women of sub-Saharan Africa?

On our last day, one patient in particular concerned us. Only twenty-two years old, she presented after developing difficulty swallowing, as well as vomiting and weakness in her legs. Unable to breathe on her own, she required a ventilator. She clearly had significant weakness in her legs, but her arms seemed perfectly strong and she understood everything we told her, but could not speak due to the breathing tube.

We diagnosed her with neuromyelitis optica (NMO), an autoimmune disease in which the body attacks certain channels on cells, leading to inflammation in the central nervous system. We gave her three days of intravenous steroids. Though she still could not breathe on her own, she already recovered some of her strength. We spoke with her mother who thanked us profusely for our help.

We ended the trip on a high note. Our decisions about the hundreds of patients we saw made differences. Moreover, we taught dozens of medical students and residents. As they furiously took notes on rounds, we showed them physical exam maneuvers, demonstrated physiologic and pharmacologic concepts, and explained the classic symptoms and treatments of disease. And they expressed their deep appreciation for us, too. We exchanged phone numbers and email addresses with the residents, who have since gotten in touch to ask questions. I have never experienced such profound gratitude. We made a difference in a way that did not seem possible in the United States.

Back at our guest house, the water pump was not working, so I showered and shaved using buckets of water from a faucet outside and took a cab to the airport. We zoomed past motorcycles, mopeds, huts, street shops, and women in traditional garb carrying large containers as dust and dirt from the road swirled in the air. Nearly a day later I landed back in America.

The chasm between our world and theirs seems unbridgeable. My unfettered access to internet, drinkable tap water, air conditioning, subways, restaurants, supermarkets, clean streets, a soft mattress, my own kitchen, relatively cheap MRI scans, CT scans, lab results, blood pressure machines, IV poles, computers, drugs for common illnesses, specialist physicians, family, and friends contrasted starkly with what I saw in Africa. Even the ability to walk across the street to the CVS and pick up a cold Gatorade seemed delightfully novel to me. I was home, in a society flush with resources and technology, thankful for this remarkable country.

That evening, however, I found out that the NMO patient had died the night I left. It is unclear why, but we suspect it was a pulmonary embolism — given that she was bedbound, she may have developed a clot in her leg that migrated up her veins and into her lungs, cutting off blood flow into her lungs from the right side of her heart. And as my appreciation for the accessibility of professional and personal resources in the United States waned over the next few days (how quickly one gets back into the rhythm of life!), I thought perhaps that our success was an illusion, an attempt to help gone awry. I could only hear the words in my head of the African physician, and now my friend, over and over again after the death of another patient earlier that month: “Welcome to Africa.” And my response to the voice echoed just as loudly, “I have to come back.”

The post A White Doctor Goes to Africa appeared first on The New Atlantis.

It is unclear what the patient understood about her malady, as is so often the case when all communication occurs through an interpreter. Based on the notes in the chart, the oncologist offered chemotherapy merely as a palliative measure. No hope for cure remained, but the chemo might add weeks to the patient’s life by keeping the tumor at bay. Now, however, given the patient’s failing liver, any further treatment would kill the patient faster; it would hurt rather than heal.

But the patient expected chemotherapy. I told her this was unlikely but that we were going to admit her and see what we could do. Perhaps she had a treatable infection around the gallbladder, causing worsening inflammation and obstruction. Alternatively, was the cancer itself obstructing the liver’s ducts? If so, the gastroenterologists or interventional radiologists could place a stent to keep the duct open.

Ultimately, though, there was nothing to fix beyond the patient’s spreading cancer. No stent or antibiotics would help. Death approached, and chemotherapy would only hasten it.

Our medical team sat down with the patient and her family, using a phone interpreter, and explained the situation. But the patient, deaf to our explanations, repeatedly asked why she couldn’t get chemotherapy. Each of us in the room explained the same answer in a different way — the chemotherapy would make things worse, it would kill her. In short, the oncologist was not offering chemotherapy.

The patient broke down sobbing: “give me chemotherapy!” she cried in Bengali, “I want chemotherapy. ” “Please give it to me.” In between the tears we were silent. She was begging for something that didn’t exist — a cure. She was begging for a medication that would surely end her life.

In medical school I never learned the art of prognostication, the art of prophesying how much time was left in a patient’s life. Instead we learned how to “break bad news.” We role-played patient and physician and told each other about a cancer diagnosis. But we never addressed the reason any of these diagnoses were bad news. We care about the diagnosis because of the prognosis.

To be sure, it is difficult to teach the art of prognostication to medical students, who have limited knowledge and experience. How do you ask someone to prognosticate about a disease they’ve never seen? Moreover, different diseases follow different paths. I, for instance, am wholly unfamiliar with the typical course and treatment of lung cancer. I could not prognosticate about such a diagnosis. On the other hand, I am quite comfortable discussing the prognosis of various types of strokes. In other words, medical students have neither the knowledge nor the experience to engage in accurate prognostication. And yet, it is necessary to learn about it as early as possible, as so much of what our patients ask of us revolves around it.

In his book Death Foretold, Dr. Nicholas Christakis describes the importance of prognostication in medicine. He writes,

Predicting death is a way to counterbalance the sense of failure that arises when, despite the deployment of powerful technology in the care of the seriously ill, death cannot be prevented…. Patients and physicians alike believe that patients should have some general — albeit carefully circumscribed — awareness of death and its impending occurrence.

 If a patient knows death approaches, he or she makes financial, spiritual, and filial arrangements. Such knowledge is indeed power, power to make one’s last days as meaningful as possible. Moreover, a prognosis allows patients to come to terms with a diagnosis. We need time to accept our own mortality. It is not akin to getting on and off a train.

Unfortunately, as Christakis points out, “physicians regard prognosis with anxiety and disdain, and they avoid it if possible.” We worry about prognosticating correctly. Many veteran physicians I admire make mistakes about a patient’s course. Such uncertainty checks my own confidence; I worry about hubris, about overextending the power of my profession. Christakis writes, “The great majority of physicians, 92 percent, are ‘reluctant to make predictions about a patient’s illness when the clinical situation is uncertain.’” And this reluctance grounds itself in reality. In a study conducted by Dr. Christakis and Dr. Elizabeth Lamont, only 20 percent of 468 doctor’s predictions were accurate. Most of these (63 percent) were overoptimistic. Fearing such inaccuracies, we avoid prognosticating altogether or hedge in our conversations with families.

According to Christakis, given its moral import, we oughtn’t avoid prognosticating. But using what we know we can recalibrate how we assess a patient’s timeline. We can be less optimistic and more realistic. We can ask our impartial colleagues to weigh in. And we can continue to study and publish on the prognosis of various diseases, allowing physicians to draw not just on their personal experience and training but on accumulated scientific knowledge. No study will perfectly characterize each individual patient’s situation, and no prognosis will be 100 percent accurate, but at least physicians can use scientific literature as a guide when prognosticating. And we must emphasize this to medical students.

I don’t know if my Bangladeshi patient truly understood the viciousness of her disease or the low likelihood of her survival. But those who understand what the outcome will be in advance have an easier time when the outcome arrives. They are no less sad about the ending. But they are, perhaps, more accepting. By prognosticating we help them come to terms with their mortality, allowing them to seek meaning at the end of their days. At the very least, they place hope in something not of this world rather than in a poison that will only hasten their end.

The post The Art of Prognostication appeared first on The New Atlantis.

In war, those with their lives yet to be lived are also those most urgently needed to fight. It is one of the tragic ironies of conflict. In the U.S. Civil War, the average soldier was 26 and approximately 620,000 soldiers died. In World War I, over 2 million German soldiers died, and 40 percent of German combatants were between 21 and 25 years old. In the Vietnam War, 58,193 American servicemen died — approximately 24 percent of those killed were 20, and roughly  17 percent of those killed were 21. We comprehend the risk in sending young soldiers off to battle: the abrupt cessation of so much potential and promise. It is no less tragic than the death of sons and daughters in any other context, but at least we understand the possible outcome.

But what of the young who do not fight, who expect to live full lives off the battlefield? Alas, forces beyond their control operate surreptitiously; a few dangerous mutations cause a cell to run awry, errant motorists drive recklessly, malfunctioning plane hardware fails mid-air—– all of these cut life short in unexpected ways.

In my brief career, I have already seen patients from infancy to young adulthood fall victim to the cruelty of nature. As physicians we don’t feel the shock of such events in the same way as the patients’ friends and family. We see the patients, we take care of them, we escort them to their end, and then we move on to take care of the next casualty or convalescent.

Dr. Jon Marc Finamore, a 30-year-old colleague and close friend, upended that sense of detachment for me. Jon and I were in the same class in residency and that created a sense of camaraderie. We shared night and weekend calls along with the traditional weekday rotations. We signed out to each other, always commiserating over one frustrating experience or another. During our time off we mulled over a couple of beers with our other friends, running through stories and talking about our future aspirations in medicine.

It was easy to be friends with Jon; sure, he was kind, but his unwavering jovial manner persisted throughout the most difficult moments of our training, always making a dry, hilarious, and self-effacing joke.

When on-call with him, I can think of multiple instances where he would pitch in to help even if it was not his primary responsibility. On one Thanksgiving a couple of years ago, I was covering consult calls in the hospital and was quickly overwhelmed, all while trying to escape home for festivities that evening. When it was clear I would be stuck, Jon, without asking, started seeing some of my patients. He simply took on some of the burden for me. I got out on time.

These sorts of gestures were evident elsewhere, too. In a social setting, he would turn to our quieter comrades and ask if they were okay with a particular bar or movie and if they had any preferences, such that no one steamrolled anyone else. He looked after everyone but himself, attentive to the smallest amounts of discomfort or dissatisfaction. Even at his bachelor party, while trying to negotiate the wants and needs of his residency friends and everyone else, he asked a few of us if we were fine going to a particular pub everyone else had suggested.

If this was true of Jon with his friends, it was doubly true of Jon with his patients, who were as dedicated to him as he was to them. We sometimes substituted for each other in clinic, if one of us worked nights that week. I saw many of Jon’s patients, some of whom were Spanish-speaking (Jon spoke Spanish), and many of them seemed disappointed when I walked into the exam room. Where was Jon? When would he be back? Could I make sure they see him next time?

And despite his easy-going way, Jon also took his studies seriously. He carried around a notebook with him wherever he went, documenting what he learned and saw. When I took over at the VA hospital after his rotation there, I entered the workroom and saw his diagrams of nervous system motor, sensory, and visual pathways drawn on printer paper sitting on the desk. He never let a moment go to waste; he endlessly fed his curiosity.

Amidst this scintillating and effervescent life, something happened to Jon during our third year of residency. His wife, Erica Finamore, Features Editor at Food Network Magazine and The Pioneer Woman Magazine and Jon’s eventual champion, writes in a beautiful and moving essay for Cosmopolitan about this sudden change. Jon was unable to speak Spanish. He could not find the words. Moreover, he slept almost 19 hours a day, had trouble with recall of facts and figures. He and Erica went to the emergency room, where the doctors there ordered an MRI of Jon’s brain.

The news was not good. Imaging revealed a large brain tumor, known as a glioblastoma multiforme. The malignancy wreaks havoc on the mind and the body. Life expectancy, depending on the genetic mutations of the tumor, ranges from 1 to 3 years. The mutations within Jon’s tumor were all bad; it was as aggressive as it could possibly be. He hadn’t done anything to cause this. It was probably a sporadic mutation. Nature rolled the die for him and this was the outcome.

I cannot possibly imagine what he felt that evening when he looked at the MRI of his brain and knew his diagnosis. As a neurologist, Jon was au fait with his fate from time zero. He had seen his own patients wilt under the weight of this disease as it took away speech, strength, cognition, and eventually all the pneuma of life, with seizures, hospitalizations, chemotherapy, radiation, and surgery as pit stops along the way.

Jon began that journey with rounds of various treatments, only to find that the tumor grew. The price to extend life even just a little bit was steep for Jon and Erica, but the time itself was precious. And throughout this, Jon remained the same selfless person he had always been. Though he took medical leave, we saw him regularly. We went to movies, played video games, went out to dive bars or restaurants. If Jon hadn’t seen someone in a while he would ask how they were. He offered to pay for our meals and drinks and movie tickets. When we discussed his illness, he was surprisingly sanguine. There seemed always to be another option for treatment, and as long as a backup to a backup to a backup existed, he found reason for hope. About a year and a half into his illness he told me: “Everything is great now, everyone is great, I love it all.”

Weeks, however, turned into months, and months turned into years; and options dwindled and disappeared, as they have for so many others with this tumor. I saw Jon and another friend from residency; we had lunch and watched television. As a show started, he turned to me and asked “Are you okay with this show or do you want to watch something else?”

In the third century b.c.e., the Greek school of stoicism took root in Athens. We still study its intellectual champions and progenitors: Epictetus, Marcus Aurelius, and Seneca among others. The name stoicism, which was derived from the Greek word for the colonnaded walkway where they would gather to discuss their ideas, has come to be synonymous with the exercise of control over one’s emotions or reactions as a way of dealing with the world. At the risk of oversimplification, we might describe their approach to life as a refusal to let the external world affect internal emotions. Seneca, a Roman stoic philosopher from the early first century c.e., paid particularly close attention to death and how stoicism might help us deal with mortality.

As a Roman senator and eventual tutor to the Emperor Nero, Seneca saw death often. In his life he witnessed young Emperor Caligula’s murderous and paranoid rampages, was sentenced to death in a politically-motivated show trial, though that sentence was commuted to exile, and then, in 65 c.e., Nero, another paranoid and psychotic ruler of Rome, forced Seneca to commit suicide. In the midst of this chaos, Seneca obsessed over how we ought to face mortality. In particular, he addresses the concept of unexpected death over and over again. He explains in a letter to his friend Lucilius:

I’ve seen many who kept a calm mind when facing human beings, but none who did so facing gods. Instead, we berate Fate every day: “Why was that man taken off in the middle of his journey? Why is that other not taken off? Why does he prolong his old age, making it troublesome to himself and others?”

Which do you think more fair, I ask you: that you obey Nature, or that Nature obey you? What difference does it make how fast you depart a place that must, without doubt, be departed? We ought to take care that we live not a long time, but enough; for we need Fate to help us live long, but our own minds, to live enough. Life is long if it is full, and it gets filled when the mind returns its own good to itself and passes over into control of itself…. Just as a man of smaller stature can be complete, so a life can be complete in a smaller stretch of time.

There is no such thing as premature death in his mind, as nature does not owe long life to any of us. It is beyond our control; in order to face death, we can only change how we approach it. We must accept that it might happen at any moment. In his book Of Consolation to Polybius, Seneca expresses frustration at our reactions to death in the young:

You may complain, “But he was snatched away when I didn’t expect it.” Thus all are deceived by their own trust and a willed forgetfulness of mortality in the case of things they cherish. Nature promised no one that it would make an exception to necessity. Every day there pass before our eyes the funerals of the famous and the obscure, yet we are busy with other things, and we find a sudden surprise in the thing that, our whole life long, we were told was coming. It’s not the unfairness of the fates, but the warped inability of the human mind to get enough of all things, that makes us complain of leaving that place to which we were admitted as a special favor.

Seneca’s annoyance at the universal human tropes of “why me?” and “gone too early” seem like a backhanded slap popping out from the page. “Why not you?” He replies in a rebuking manner. And I admit begrudgingly that he is indeed onto something. The world owes us very little. For most of human existence our fate was much hardship and early death. It is only of late, thanks to the miracle of modern science and technology, that our lives reach far beyond that once-common and hasty end.

But one bristles at Seneca’s conclusion, too. To be sure, many lives that end feel like they end too early. In one of the Jewish rabbinical commentaries on Ecclesiastes, the rabbinic sages wrote “No one leaves this world with even half his desires fulfilled.” The rabbis wisely pointed out that no amount of life is enough, we all fall short of what we want in some sense. Nevertheless, we can point to lives that seemed well-lived and fuller than other lives even if those other lives were just as well-lived. To take an extreme example, the death of a ten-year-old, no matter how well-lived differs tremendously in its fullness from the death of a ninety-year-old.

The arc of a long and well-lived life also prepares us for death. Early on we ignore or dismiss impermanence. We aspire toward professional goals, seek mates, go on trips, take risks. But as we age, we accumulate bruises and bumps, some of which never go away. We get arthritis, our vision slowly deteriorates, our balance becomes less certain, we have surgeries, we get high blood pressure and high cholesterol, and we have strokes. And our children begin to take our place. Growing old is not pleasant and it can even be enervating, but it provides a contour to our lives. It slowly escorts us to the ultimate end, allows us time to come to terms with our own mortality.

If only Jon could have had these experiences! He should have had a long marriage. He should have experienced the undulations of life, the ups and downs, successes and disappointments that come with it and the eventual rapprochement with his own transience. After all, he didn’t volunteer to risk his life in war. Instead he was pushed off the ledge by the capriciousness of our own existence. Evidently, even if we don’t risk our lives for our country, we are nevertheless born into a struggle. It is a struggle with the same inevitable outcome for all of us no matter what we do. And that denouement came far too soon for Jon. But Jon was a stoic. He embodied the best of stoicism in the way he dealt with his imminent end. And he embodied the best of medicine in a way that all of us wish we could.

In ruminating on Jon’s death, and death in the young, I think of this passage from Shakespeare’s Macbeth. Toward the conclusion of the play, Macbeth slays Young Siward, a courageous soldier. Ross reluctantly tells Young Siward’s father about the tragedy:

Your son, my lord, has paid a soldier’s debt.

He only lived but till he was a man,

The which no sooner had his prowess confirmed

In the unshrinking station where he fought,

But like a man he died.

The post Death in the Young appeared first on The New Atlantis.

Writing in The Atlantic last summer, Zeynep Tufekci described the tragic situation these policies created:

Of all the wrongdoings of this pandemic, the one that haunts me most is how people are left to die alone. Health-care workers have been heroic throughout all this, but they do not replace the loved ones whom the dying need to be with, and speak with, even if only one last time.

As we faced the second-wave of the coronavirus over the fall and winter, with overburdened physicians and nurses, overcrowded wards, and a dramatic increase in Covid-19 cases, hospitals once again cut down on family visitation. This time, thankfully, many institutions have been relaxing their policies. The University of Pennsylvania, Temple Health, MedStar, and Geisinger are some healthcare systems making rare exceptions to their no-visitation injunctions. They now allow visitation for patients the ends of their lives. This is an important start. But with cases declining rapidly, we need to be even more liberal about visitation policies now.

A few years ago I accompanied a family member to a doctor’s appointment. After a traumatic scrape she had gotten a superficial skin infection and required a brief course of antibiotics to treat the infection. It would be a quick and easy visit. A culture had been taken from the traumatized skin prior to the visit to determine if there was a particular bacteria that could be treated. This helps the physician prescribe the right antibiotic, one that will actually kill the bacteria or stop its growth. The doctor showed us the results of the culture and told us what she was going to prescribe. As I looked over the culture report, I noticed the bacteria was, in fact, not sensitive to the antibiotic she prescribed and pointed this out. Admitting her error, the doctor switched the prescription.

Interactions like this happen in doctor’s offices and hospitals throughout the country because physicians are humans and make mistakes. Family members at the patient’s bedside or in the clinic with the patient help catch those mistakes to improve patient care. Furthermore, if a patient isn’t feeling well or doesn’t look well, physicians who don’t know the patient might miss subtle changes in the patient’s appearance but family will point them out.

Research bears at least some of these positive effects out. In one study published in 2013, the burn intensive-care unit incorporated families in dressing changes (burn patients require frequent changes of the dressings over their burns). They found that patient satisfaction scores increased and infection rates did not increase. In another study from 2017, a meta-analysis, integrating caregivers into discharge planning at the conclusion of hospitalization actually reduced the risk of hospital readmission. Another study found that among those stroke patients admitted to the hospital, family members and their accompanying positive attitudes improved cognitive outcomes in post-stroke rehabilitation. While there can certainly be downsides to having families intimately involved in medicine, such as stubborn requests for certain dangerous medications or interventions, families are a boon to their loved ones.

Why, then, are we so aggressive about limiting visitors? There is a reasonable concern that visitors could bring Covid-19 into the hospital if they’re asymptomatic. They can get their admitted relatives sick. They can get healthcare workers sick. Perhaps it could cause a super-spreader event in the hospital. While these concerns are certainly valid, patients lose the benefit of having their loved ones at bedside. Some of my friends have had to watch from afar as an immediate family member disappears into the bowels of the intensive care unit for weeks, sedated, paralyzed, and intubated, their only line of communication through overworked and exhausted nurses and resident physicians.

While we ought to be cautious, we don’t need to be as strict as we currently are. The risk of Covid-19 transmission in hospitals is incredibly low, as this JAMA article indicates: Of 697 hospitalized patients with Covid-19 only one was infected after exposure to the virus in the hospital. Though, admittedly, this case was from a pre-symptomatic spouse who was visiting daily, it occurred at a time before visitor restrictions and masking were implemented. In another hospital, of 44 healthcare workers exposed to a patient before contact and droplet precautions were implemented, 2 of the 44 (5%) developed Covid-19 “potentially attributable to the exposure.” So while the risk of infection with Covid-19 certainly exists in hospitals, aggressive masking and handwashing can mitigate that risk. Moreover, certain units are more protected than others. This British Medical Journal editorial points out that “Working in intensive care units is not associated with an increased risk of infection, possibly owing to the protection afforded by high level PPE or to the decrease in infectivity that occurs in the later stages of the illness, even among critically ill patients.” They continue: “The greatest risk to healthcare workers may be their own colleagues or patients in the early stages of unsuspected infections when viral loads are high.”

Given the benefits of family visits, and the relatively low risks of infection in hospitals, one needn’t advocate for opening the floodgates to all visitors, but more exceptions should be permitted. For instance, we can allow a limited number of family members (one or two) into units where they are needed most and at the lowest risk of transmitting infections, like the ICU. This would be helpful for the patients. An aggressive rapid testing policy for family members of patients coming to visit would further mitigate any risks. These would need to be done on a limited basis for the families of sicker patients. Visiting hours can be limited. And, of course, a universal masking policy and frequent handwashing policy should absolutely be in place. Hospitals can be strategic, cautious, and generous in a targeted fashion, ensuring that more patients safely have advocates and loved ones at their bedsides during the pandemic. It will make this devastating pandemic a bit less devastating.

The post Let Them Visit appeared first on The New Atlantis.

The effervescent rays of sunshine spread their warmth across my back as I walk along Omaha Beach in Normandy. French children kick around a soccer ball, shouting and giggling across a fifty-yard stretch of sand. A tranquil ocean extends into the horizon, effortlessly mingling with the sky making it impossible to tell where one starts and the other ends. Looking out across the serene water, I imagine June 6, 1944 and the chaos that once enveloped these beaches. The young American soldiers landing here faced an onslaught of bullets from Nazi pillboxes — concrete bunkers with holes to fire through — hidden safely in the hills.

That day alone, Americans suffered two thousand and four hundred casualties. As the bodies of young men washed ashore, the fortunate survivors endured gunshot wounds while crawling up the beach amidst the blood-soaked waves. One member of the 116th Infantry Regiment said: “They’re leaving us here to die like rats.” D-Day provides a chilling and indelible reminder of the terror of that war and its tragic necessity; of the noble and valorous sacrifice our young heroes made to rid the world of Nazi Germany.

I think of my trip to Omaha Beach as the 76^th anniversary of D-Day approaches and I enter the hospital each morning during the Covid-19 pandemic. “Welcome healthcare heroes!” one sign reads outside an academic hospital. “Heroes enter here!” reads another. I walk in with a mask and use a squirt of Purell on my hands, as a nurse in a gown, face shield, and mask takes my temperature. If I’m afebrile I enter the hospital. A nurse standing at the entrance shouts “Thank you, heroes!” at approaching physicians and nurses. This is not restricted to hospital entrances. Toymaker Mattel created a #ThankYouHeroes toy line of nurses, physicians, EMTs, and delivery workers. Signs hanging outside of house windows read: “Thank you essential workers for your heroism!” The quarantined populace clangs pots and pans at 7 pm throughout the city streets in honor of essential workers. From cooks to janitors to doctors: all are now heroes in the public eye. This wellspring of gratitude is well-intended and appreciated. But are those of us who work in these jobs truly heroes?

In the mid-19^th century, Thomas Carlyle, a British historian and writer, published a series of lectures in a book entitled On Heroes, Hero-worship and the Heroic in History. Though Carlyle offered some unusual theories about the role of heroes, we ought to consider the elements of his definition of a hero:

They were the leaders of men, these great ones; the modellers, patterns, and in a wide sense creators, of whatsoever the general mass of men contrived to do or to attain; all things that we see standing accomplished in the world are properly the outer material result, the practical realization and embodiment, of Thoughts that dwelt in the Great Men sent into the   world: the soul of the whole world’s history, it may justly be considered, were the history of these.

A hero doesn’t just make a difference. A hero alters the trajectory of mankind, changes the soul of humanity, and, I think, takes a significant risk or makes a weighty sacrifice in the process. A hero is not a god but may seem god-like.

What about those who make a difference even if they’re not shaping the arc of history? True, there are many who, through their professions and their actions, perform moral and selfless deeds. But, as Carlyle explains, “We see men of all kinds of professed creeds attain to almost all degrees of worth or worthlessness under each or any of them.” A hero reaches even beyond such worth despite his or her imperfections. 

Fortunately, there are plenty of examples throughout history of this, like the soldiers who stormed Normandy. Through their ultimate sacrifice they brought an end to Nazi genocide and sowed the seeds of freedom for millions of others. They suffered the cruel conditions at Omaha Beach and on other battlefronts to shape the world order for the better. 

While physicians risk their lives during this pandemic, it is not quite the same. We come to work each day knowing that the day will end as we climb into bed, however far away from our families we are. For those of us with access to supplies, we don masks, gowns, and gloves to take care of patients with the virus and wash our hands before and after every encounter. As Dr. Greg Katz, a cardiologist in New York (and, full disclosure, my chief resident when I was an intern), writes,

After the first few weeks of the pandemic when I had a legitimate fear for my safety due to the PPE shortage, we’ve largely been able to protect ourselves working in the hospital….

When we suspect a patient may have COVID, they get a designation as a PUI, or person under investigation, and are kept in an isolated room. We only enter wearing full protective equipment – N95, gowns, gloves, head covering.

When we are in a COVID unit, the equipment is even more protective, where each physician has a PAPR along with supervised donning and doffing procedures.

Don’t get me wrong, it’s not a risk free endeavor, but health care workers who take adequate protections have a pretty low risk of getting sick.

While we make a dramatic difference in the lives of our Covid-19 patients, we are doing what we do every day, whether there is a contagion or not: helping patients as we swore to do when we entered the profession. This is not to say that there are not heroes among us. For instance, the late Dr. Lin Wenliang, a Chinese ophthalmologist who faced censorship from the Chinese government while risking his life and reputation to warn the world of the pandemic, is a hero. And yet, even while some physicians and nurses selflessly volunteer on Covid-19 units or in overwhelmed hospitals, a good number of us sometimes shirk our duties. In a piece for Quillette, Amy Eileen Hamm, a nurse, writes about how some doctors and nurses would rather not have to work. 

To be sure, this is an exceptionally difficult time, even as tragic hospital work goes. Read the terrifying diaries of those working during this frightening contagion:

The evening before I’m due to return to the hospital, a colleague messages our group to say that a 49-year-old Covid patient of hers, who was waiting in the E.R. for an inpatient bed, was found blue and dead in a chair. Nobody even knows if he gasped before he died.

These stories echo throughout the daily news reports. Moreover, this virus takes a horrible, irreversible, and deadly toll on some of the doctors and nurses themselves, many of whom die or suffer from Covid-19. At least several thousand health care workers have been infected by the virus, and some dozens have died. Indeed, one mustn’t forget or dismiss the awful consequences and sacrifices of working in a hospital during this contagion, whether we call these workers heroes or not. 

But it is confusing to call them heroes while hospitals and government bungle a response to the pandemic. For example, some physicians and nurses do lack the appropriate PPE to shield themselves from infections. This is not true at every institution, but it was prevalent enough at one time to endanger doctors and nursing staff. And if they protested against such shortages, as Dr. Ming Lin of PeaceHealth St. Joseph Medical Center found out in March, hospitals threatened or dismissed them. Other physicians, in the face of plummeting hospital revenue, face pay cuts of up to 40% as well as staffing shortages. In a survey one-fifth of physicians experienced pay cuts or were furloughed due to the economic tragedies of the pandemic. True, many institutions experience financial hardships. However, hailing physicians and nurses as heroes while making these cuts and threats does not change that reality as much as it reinforces it. 

Ultimately, using the “hero” misnomer reveals an appreciation for those treating Covid-19 patients. But let us not confuse gratitude with near-deification. Doctors and nurses are humans, filled with cowardice and courage, both of which manifest in different ways. Physicians do not storm Omaha Beach in the face of gunfire. Nor is the soul of the whole world’s history the history of them. By obfuscating this, we needlessly amplify doctor’s and nurse’s deeds and diminish our own failures to aid society’s healers.

We should not call our physicians and nurses heroes, even if many of them act courageously. Nor should we call them by the anodyne and mundane name, “health care providers.” They are, perhaps, something in between.

The post Are Doctors Heroes? appeared first on The New Atlantis.

Her symptoms were consistent with an ischemic stroke – a blood clot lodged itself in a blood vessel cutting off circulation to the right motor cortex in the brain. (In our brains, the right side controls the left body and vice versa.) The emergency medicine physician ordered an MRI of the patient’s brain and intracerebral vessels. The MRI confirmed the diagnosis, showing a stroke with a clot in one of the large arteries known as the middle cerebral artery. Was there anything, the doctor wondered, we could do for this patient?

In the treatment of stroke, we often say “time is brain.” And the scientific literature bears this out. Approximately 1.9 million neurons die every minute the brain is deprived of blood flow. Ergo, strokes require immediate intervention for the best possible outcome. For those who present within four and a half hours of symptom onset, we give them tissue plasminogen activator (tPA). This drug breaks down clots in the body and though it poses a risk for bleeding, multiple trials demonstrate significant efficacy. Beyond four and a half hours, brittle vessels and brain tissue lead to an even higher risk of hemorrhage, outweighing the benefit of the drug. In patients with a clot in a large vessel in the brain (like the patient I was called about) we can use a catheter to pull out the clot from the blood vessel. Remarkably good evidence supports using this procedure up to twenty-four hours after symptom onset. Patients with large clots come in without the ability to walk, see, or speak. Ten to fifteen years ago they would have died in a nursing home. Today, with timely treatment, they can walk out of the hospital 2 days later. But if patients present after 24 hours from symptom-onset we can offer little beyond rehabilitation and secondary stroke prevention.

Though the patient was out of the time window for any acute therapy, I asked the physician to transfer her to our hospital to ensure she didn’t worsen further. After arriving by ambulance, I met the patient in the emergency room. On my exam, she barely lifted her left arm and leg, hopelessly struggling against the necrotic brain tissue. I discussed her condition, what had happened, and how we might help. We would have her doas much rehabilitation as possible to take advantage of neuroplasticity and get her stronger.

“Will I ever be able to live by myself again? Or walk again?” She asked.

Unfortunately, given the size of her stroke, she would likely require help to cook, walk, and drive. At least in the near future, her whole life would be dependent on the help of others. What would come one year down the line was uncertain. I told her not to lose all hope. Rehabilitation after stroke takes months and patients can make significant strides.

“Also,” I asked, forgetting myself, “any reason for waiting to come to the hospital?”

“Yes,” she said. “I was scared about the coronavirus and I wanted to avoid getting sick.”

Before Covid-19 hit the United States, I saw many patients who, alas, presented too late for treatment. Occasionally they couldn’t even use their dominant arm, but they waited hours or days to seek help. Some said they thought their deficits would improve, others worried about the hospital bill, or were skeptical of physicians. The data over the past few decades corroborates this experience. In a 1997 study in the Annals of Internal Medicine, physicians examined patients with myocardial infarction, or heart attack, and the delay between the onset of symptoms and hospital presentation. Forty percent delayed theirpresentation for over six hours. In a 2001 study, one-third of patients with symptoms like abdominal pain, chest pain, and shortness of breath – all potentially serious – delayed seeking care. And over two-thirds of these patients waited because they thought the problem would go away. In a 2019 study, Greek physicians found that of patients presenting to the hospital with acute stroke symptoms nearly one third arrived over four and a half hours after their symptoms started, putting them outside the window for tPA eligibility. In other words, even prior to the pandemic, many patients either chose not to come or physically could not come to the hospital despite life-threatening symptoms.

Covid-19 directly causes physical devastation and in so doing exacerbates the kinds of delays described above. The exact death rate from coronavirus alone is unclear given our lack of widespread testing and our ignorance about how many people actually have it. At one point, the case-fatality rate in China was 2.3%, in Italy at another point 7.2%, while some estimate 1-2% and lower. Whatever it ends up being, it is highly significant and crippling. As of this writing, notwithstanding drastic quarantine measures, the virus has claimed over two hundred thousand lives worldwide, and that number continues to increase. Most of us understand the risk and we seclude ourselves to mitigate the disease’s damage.

However, there are unintended effects of the current mitigation campaigns. There will likely be an increase in morbidity and mortality from other diseases. For instance, other hospitals and our own emergency room call us less frequently. My colleagues are seeing this as well; far fewer stroke patients come to the hospital now. Another colleague recently admitted a patient with a massive heart attack who stayed at home for fear of Covid-19. It’s not that the incidences of stroke or heart attacks are acutely falling – a highly unlikely scenario. Unfortunately, among other possibilities, I suspect patients, afraid of the virus and for their lives, avoid the hospital. They stay home with incapacitating symptoms, as the patient I treated did. Our public health response to the virus, though appropriate, compounds patient hesitancy to seek help.

The most up-to-date data bears out these anecdotes. In a small and imperfect observational study from Hong Kong during late January and early February, patients with bad heart attacks took nearly four times as long to present to the emergency room as othersin prior years. Another study in the Journal of the American College of Cardiology collected data indicating a 38% drop in calls for certain types of heart attack emergencies across major hospitals in the country. And it’s not just in vascular disease where these kinds of delays and deficiencies occur. Reportedly, vaccine prescriptions have plummeted during the pandemic, too. Public health experts in England have warned that cancer deaths as an indirect effect from the virus will be higher than those directly caused by the virus. A New England Journal of Medicine article tells multiple stories of patients who were misdiagnosed or experienced a delay in care due to bias in favor of or fears of Covid-19. A full accounting of this kind of delay in or lack of treatment has yet to be done. But these are the other casualties from the Covid-19 pandemic: patients with treatable conditions who do not get treated in time.

How do we communicate urgency to our patients during this bizarre and frightening time? An ideal public health policy advocates staying home but encourages patients to seek treatment if something goes wrong. Unfortunately, in the chaos of a pandemic, myopia reigns and we focus on one disease to the exclusion of others. A deadly disease is deadly and requires treatment regardless of the contagion around us. If we and our leaders cannot modulate our message we may face an even worse, and preventable, tragedy.

The post The Other Victims of Covid-19 appeared first on The New Atlantis.

From 1665 to 1666, the Great Plague spread through London. Caused by a bacteria transmitted by the bite of a rat flea, it killed nearly a quarter of London’s population in the span of 18 months. Such a deadly conflagration must have seemed strange and terrifying to its victims; there was no germ theory to explain its spread, and the bacteria wasn’t even discovered until the late 19^th century. Lack of understanding must have greatly amplified the terror caused by the symptoms: fevers, chills, headache, swollen lymph nodes, gangrenous limbs, and a tortuous journey to the other side. Attempts to ward off the disease included bonfires to cleanse the air, smoking, killing dogs and cats, sniffing sponges soaked in vinegar given to the sick, and bleeding patients with leeches.

In 1722, Daniel Defoe, of Robinson Crusoe fame, published A Journal of the Plague Year. Though he was only around five years old when the plague cast a pall over London, Defoe wrote the book through the eyes of an in-person narrator, based on his collecting of facts, statistics, and journals. What emerges is an imaginative yet historically detailed account of the horror engulfing London. In an introduction to the book, UVA English professor Cynthia Wall writes: “Defoe was fascinated by this history of darkness, pain, and fear…. [H]e was always interested in how human beings behaved under conditions of great stress.”

That question is a perennial one. Plagues always come and go, from smallpox, bubonic plague, and influenza to the coronavirus. Nature often pits species against each other, and during pandemics the simplest organism pits itself against the most complex. In the new coronavirus, many of us bear witness for the first time to a widespread and frightening infectious disease. But the way we behave in the throes of this threat is neither strange nor unprecedented. Despite the advancements in germ theory, our fears, reactions, and actions remain altogether familiar. Some of this is due to the nature of avoiding the disease (isolation and quarantine), but some of this is due to human nature. In reading Defoe’s Journal, one senses his descriptions of the plague could be used for our encounter with today’s Covid-19. Below, I juxtapose my own voice (in regular font) to Defoe’s (in italics) to demonstrate just that.

Only weeks ago I walked home from work and the streets were packed with students, tourists, physicians, professors, campus security, nurses, and others heading out of their offices. I waited on the street corner in a throng of people, and as the traffic light turned green for us, we bolted, as a herd, to the other side. Even when I came to the hospital at night, the music and shouting from undergraduate parties percolated through the crisp wintry air. Now, with a quarantine in place to stop the spread of Covid-19, I walk home alone. It is rush hour and the empty streets offer only the echo of my clogs hitting the ground.

It was a most surprising thing, to see those Streets, which were usually so thronged, now grown desolate, and so few People to be seen in them, that if I had been a Stranger, and at a Loss for my Way, I might sometimes have gone the Length of a whole Street, I mean of the by-Streets, and see no Body to direct me….

Restaurants and bars and construction sites, once bustling and clamorous, have morphed into inhospitable vacancies. 

All the Plays and Interludes, which after the Manner of the French Court, had been set up, and began to encrease among us, were forbid to Act; the gaming Tables, publick dancing Rooms, and Music Houses which multiply’d, and began to debauch the Manners of the People, were shut up and suppress’d; and the Jack-puddings, Merry-andrews, Puppet-shows, Rope-dancers, and such like doings, which had bewitch’d the poor common People, shut up their Shops, finding indeed no Trade.

Alas, such closures, even if they are necessary to stem the tide of the virus, come with significant consequences for the economy and human lives. In the United States the number of jobless claims hit a record high, the markets experienced a free fall, the Federal Reserve’s index of financial stress is the highest it has been since the financial crisis over a decade ago. Airlines, hotels, opera houses and others lay off and furlough thousands of workers due to a fall in revenue. Many small businesses and gig-economy workers are now left without a source of income.

Tradesmen and Mechanicks, were…out of Employ, and this occasion’d the putting off, and dismissing an innumerable Number of Journey-men, and Work-men of all Sorts, seeing nothing was done relating to such Trades, but what might be said to be absolutely necessary. This caused the Multitude of single People in London to be unprovided for; as also of Families, whose living depended upon the Labour of the Heads of those Families; I say, this reduced them to extream Misery.

Only the supermarkets bustle with perpetual activity. Even there, however, something unsettles. As I walk in, a hush overtakes the entire floor. The volume of music is lower than usual, few conversations take place, no one speaks on a cellphone. The occasional cacophony of clanging shopping carts drowns out other ambient noises. Some shoppers wear masks and gloves, others don’t. They all rush to complete their shopping, heads down, stealing furtive and suspicious glances at others. Some, outwardly hostile, cut off comrades to get to the avocados or the bananas first. Handmade signs hang throughout the store limiting two milk cartons or two packages of butter per customer, as people scramble to store provisions. Shelves of canned goods lie empty, with the exception of canned beets (even during a pandemic, people haven’t lost their taste). 
I must here take farther Notice that Nothing was more fatal to the Inhabitants of this City, than the Supine Negligence of the People themselves, who during the long Notice, or Warning they had of the Visitation, yet made no Provision for it, by laying in Store of Provisions, or of other Necessaries; by which they might have liv’d retir’d, and within their own Houses, as I have observed, others did, and who were in a great Measure preserv’d by that Caution.

As I walk home from the grocery store, those few people left on the street keep their distance from each other and from me. At the hospital, the same sense of anxiety and precaution exists. A nurse coughs in the hallway and everyone walking in his direction about-faces. A patient comes into the emergency room who spent an hour in a New York City airport two weeks prior and, though he is without symptoms, half a dozen phone calls are made to get the patient isolated and tested for Covid-19. We hold conferences by phone or by Zoom, we speak to each other while six feet apart, we all wear masks. We do all this with good reason. How can one know who’s infected and who’s not?  Who is the one person who will infect hundreds or perhaps thousands of others? Everyone potentially carries the enemy and we must treat them with caution.

It was a very ill Time to be sick in, for if any one complain’d, it was immediately said he had the Plague. (…)

And when People began to be convinc’d that the Infection was receiv’d in this surprising manner from Persons apparently well, they began to be exceeding shie and jealous of every one that came near them.

Then I say they began to be jealous of every Body, and a vast Number of People lock’d themselves up, so as not to come abroad into any Company at all, nor suffer any, that had been abroad in promiscuous Company, to come into their Houses, or near them; at least not so near them, as to be within the Reach of their Breath, or of any Smell from them; and when they were oblig’d to converse at a Distance with Strangers, they would always have Preservatives in their Mouths, and about their Cloths to repell and keep off the Infection.

Some disagree with strict measures and act as such: spring breakers in Florida, some religious communities who have insisted on gathering in person. Ergo, the virus hit these groups particularly hard. 

And tho’ it is true, that a great many Clergymen did shut up their Churches, and fled as other People did, for the safety of their Lives; yet, all did not do so, some ventur’d to officiate, and to keep up the Assemblies of the People by constant Prayers. (…)

And indeed when Men are once come to a Condition to abandon themselves, and be unconcern’d for the Safety, or at the Danger of themselves, it cannot be so much wondered that they should be careless of the Safety of other People. (…)

By the Well, I mean such as had received the Contagion, and had it really upon them, and in their Blood, yet did not shew the Consequences of it in their Countenances, nay even were not sensible of it themselves, as many were not for several Days: These breathed Death in every Place, and upon every Body who came near them; nay their very Cloaths retained the Infection, their Hands would infect the Things they touch’d….

The consequences of ignoring the stay-at-home orders are not just devastating for those we encounter at work or on the street, they are deleterious to our families and friends. In New Jersey, one woman and three of her children died from the virus while other infected family members required ICU care — all likely contracted the disease at a family gathering held on March 10th. One family in rural Georgia faced a similar tragedy after a funeral on Feb. 29^th became a “super-spreading event,” causing relatives to fall ill. 

They told us a Story of a House in a Place call’d Swan-Alley, passing from Goswell-street near the End of Oldstreet into St. John-street, that a Family was infected there, in so terrible a Manner that every one of the House died; the last Person lay dead on the Floor, and as it is supposed, had laid her self all along to die just before the Fire.

In order to prevent such contagion, family members cannot be with their loved ones in death. Though understandable, this is heartbreaking. I, unfortunately, have seen this with some of our patients. And many have died without family at their side or at their burial, and family members saying goodbye over FaceTime.

I could give several Relations of good, pious, and religious People, who, when they have had the Distemper, have been so far from being forward to infect others, that they have forbid their own Family to come near them, in Hopes of their being preserved; and have even died without seeing their nearest Relations, lest they should be instrumental to give them the Distemper, and infect or endanger them.

Coronavirus has also caused material shortages. Doctors make their own masks, ventilators are in short supply, morgues are overflowing, trenches are dug to bury the dead.

It was a great Mistake, that such a great City as this had but one Pest-House…. I say, had there instead of that one been several Pest-houses…I am perswaded, and was all the While of that Opinion, that not so many, by several Thousands, had died. (…)

I say they had dug several Pits in another Ground, when the Distemper began to spread in our Parish, and especially when the Dead-Carts began to go about, which, was not in our Parish, till the beginning of August. Into these Pits they had put perhaps 50 or 60 Bodies each, then they made larger Holes, wherein they buried all that the Cart brought in a Week, which by the middle, to the End of August, came to, from 200 to 400 a Week…. But now at the Beginning of September, the Plague raging in a dreadful Manner, and the Number of Burials in our Parish increasing to more than was ever buried in any Parish about London, of no larger Extent, they ordered this dreadful Gulph to be dug.

In the midst of the chaos, fear, and tragedy, some have advertised unproven remedies, sometimes for personal profit. In March, Dr. Vladimir Zelenko used a combination of the antimalarial drug hydroxychloroquine, the antibiotic azithromycin, and zinc sulfate to help patients, saying that one-hundred percent of his patients survived the virus without any hospitalizations. At the time, little was known about the potential effectiveness of hydroxychloroquine for Covid-19 to put much confidence in this; an NIH trial is now underway. Other claims have been more outrageous. The FBI recently arrested Keith Lawrence Middlebrook, an actor who has been charged with soliciting investments in a company claiming to have a cure and prophylactic drug for the disease. And in March, the state of Missouri sued televangelist Jim Bakker for selling a spurious antidote on his show.

On the other Hand, it is incredible, and scarce to be imagin’d, how the Posts of Houses, and Corners of Streets were plaster’d over with Doctors Bills, and Papers of ignorant Fellows; quacking and tampering in Physick, and inviting the People to come to them for Remedies; which was generally set off, with such flourishes as these, (viz.) INFALLIBLE preventive Pills against the Plague. NEVER-FAILING Preservatives against the Infection…. INCOMPARABLE Drink against the Plague, never found out before.

Some resort to thieving. In Australia, some have stolen personal protective equipment and hand sanitizer from hospitals. Others use the pandemic to defraud unsuspecting consumers: the FBI sees a rise in phishing emails from fake charity organizations, the CDC, and airline carrier refund accounts to steal people’s money. 

That there were a great many Robberies and wicked Practises committed even in this dreadful Time I do not deny; the Power of Avarice was so strong in some, that they would run any Hazard to steal and to plunder.

Some hospital leaders have been accused in the press of fleeing the chaos, instead of leading from the front.

It is very certain, that a great many of the Clergy, who were in Circumstances to do it, withdrew, and fled for the Safety of their Lives.

In the United States, most of this could have been prevented, and the failure of our leadership to respond swiftly when it had the chance, instead of playing down the threat, will go down in history as a colossal, deadly mistake.

But it seems that the Government had a true Account of [the Plague], and several Counsels were held about Ways to prevent its coming over; but all was kept very private. Hence it was, that this Rumour died off again, and People began to forget it, as a thing we were very little concern’d in, and that we hoped was not true.

Even in the midst of failure and greed, there is hope. While some of our officials were slow to respond, many are demonstrating remarkable leadership and resolve. Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, is one of them. He regularly speaks with all kinds of public figures including basketball stars, talk show hosts, and Silicon Valley executives, to update the public on the virus and the plans of the Covid-19 response team, all while dodging partisan politics. Always well-informed and steadfast, he understands how serious this is and what needs to be done to mitigate it; and he communicates frankly and clearly to his audience. As thanks for this, he received numerous threats and the Department of Health and Human Services beefed up personal security for him. Captain Brett Crozier of the Navy’s USS Theodore Roosevelt disseminated a memo warning Navy leadership about a Covid outbreak amongst his crew on the ship, bringing attention to a deadly scenario. For this act of leadership, unfortunately, the Navy removed him from his post. 

But ‘tis true also, that a great many of [the Clergy] staid, and many of them fell in the Calamity, and in the Discharge of their Duty.

Other charitable actions give us hope, too. The government, notwithstanding some dithering, passed a massive financial package to help those affected economically by the virus. While some will undoubtedly need more, this is a good start. And private donors stepped up as well. Whatever one may think of his politics, Sheldon Adelson, a Las Vegas hotel mogul, pledged to pay all his workers for two months despite the brutal economic downturn hitting the hospitality industry. The New England Patriots owner Robert Kraft sent the team plane to China to pick up over 1 million N95 masks and bring them back for healthcare workers. And here is a list of 30 companies donating their proceeds to relief charities. These are just a few of many examples. 

The Concern also of the Magistrates for the supplying such poor Families as were infected; I say, supplying them with Necessaries, as well as Physick as Food, was very great, and in which they did not content themselves with giving the necessary Orders to the Officers appointed, but the Aldermen in Person, and on Horseback frequently rid to such Houses, and caus’d the People to be ask’d at their Windows, whether they were duly attended, or not? (…)

Nor was this Charity so extraordinary eminent only in a few; but, (for I cannot lightly quit this Point) the Charity of the rich as well in the City and Suburbs as from the Country, was so great, that in a Word, a prodigious Number of People, who must otherwise inevitably have perished for want as well as Sickness, were supported and subsisted by it.
Difficult times lie ahead. It remains to be seen how successfully we get through the worst and how quickly we will settle back into a relatively normal life. One hopes that it is soon enough to help those in dire economic straights, but not too soon as to cause unnecessary death. I imagine we will one day witness what Defoe described: 

It is impossible to express the Change that appear’d in the very Countenances of the People…. It might have been perceived in their Countenances, that a secret Surprize and Smile of Joy sat on every Bodies Face; they shook one another by the Hands in the Streets, who would hardly go on the same Side of the way with one another before; where the Streets were not too broad, they would open their Windows and call from one House to another, and ask’d how they did, and if they had heard the good News, that the Plague was abated.

The post A Journal of the Plague Months appeared first on The New Atlantis.

Over the next two days, we ordered other labs, and their results concerned us. Not only were the patient’s platelets low and getting lower, but other blood markers were abnormal, too. Her fibrinogen, a protein that circulates in the blood and helps the blood clot, was also dangerously low. Her INR (international normalized ratio), which measures the time it takes for the body to create clots, was high. These aberrations indicated disseminated intravascular coagulation (DIC). In this disorder, the bloodstream rapidly forms clots, thus exhausting the body’s platelets and clotting factors. With fewer available platelets and clotting factors, patients also experience bleeding. DIC induces aterrifying, circular, and deadly process of clotting and bleeding. As one study showed, if the underlying cause of this brutal pathology is not controlled, mortality is over 20%.

A plethora of disorders, including bloodstream infections and malignancies, cause DIC. But the patient did not have a bloodstream infection — all of her blood cultures were negative and she had no symptoms of an infection. On day two of her hospitalization, we obtained a CT scan of her abdomen and chest, looking for a malignancy. Tragically, metastatic gastric cancer lesions riddled her liver while a recusant growth consumed her stomach leaving little normal tissue in its wake. Unfazed, she calmly stated she understood and asked what her next options were. Though her husband seemed more shaken by the diagnosis, he, too, wanted only to know what came next. This was a diagnosis she had faced and survived before. She believed strongly she could survive it again. We told the patient and her husband that we would contact her oncologist, the same one who had treated her gastric cancer originally. She would, we explained, help us figure out what treatment options existed. It was as if there was a transient release of pressure in the room; they trusted the oncologist and were glad that we were getting her involved. Since it was late in the evening, we promised to reach out first thing in the morning.

On the third day, I called the patient’s physician. Because she was busy seeing patients in clinic and unavailable to take my call, I left a message with the secretary asking that she call me back as soon as possible. The secretary also took down the patient’s information so the oncologist could at least look at the scans and laboratory results to get an understanding of what was going on. When we rounded that morning, I let the patient and her husband know of this development; all of us expected the oncologist would reach out to our team later in the day. But by the end of day three there was no word. I spoke with my attending physician about our dilemma. Since we were not oncologists, we could not prescribe chemotherapy and we didn’t know what the appropriate treatment should be for the patient. All we could do was treat the DIC by transfusing platelets and control the patient’s pain and nausea. Suspended in a kind of medical purgatory with our patient and her husband, we waited for some direction. Our attending physician reached out to the oncologist that evening via email. Perhaps a fellow faculty member’s missive would indicate the urgency of the matter.

But day four brought more of the same. None of us had heard anything from the oncologist after three calls that day. The patient and her husband became understandably more frustrated and their future seemed much more opaque. The patient’s husband pulled us aside and sternly rebuked us. How could we let her sit here like this with no treatment? What was our plan to help her? How were we going to deal with this resurgent cancer diagnosis? With no good explanation we deferred and equivocated, stating that we were doing our best to get in touch with the oncologist who would hopefully give us some guidance soon.

On day five the patient’s mental status deteriorated. She drifted in and out of sleep. Three meal trays came and went untouched. We called another oncologist and asked him to see if he could get in touch with the patient’s primary oncologist or at least recommend some kind of treatment — later in the day he told us that perhaps there were some options but it was not his area of expertise. Not to worry, he assured us, he had spoken with the primary oncologist and she would be in touch with us soon. But she never called. The patient’s husband expressed more and more frustration and anger. Why did the oncologist, someone they had known personally for years, not even come to the bedside to see them? Why did her office not return even the husband’s calls, let alone our own? It was not just a personal affront to them but a professional affront to us. We felt helpless.

Finally, on day six, our attending got in touch with the patient’s oncologist and during a phone conversation asked about possible chemotherapy options. She replied, “What chemotherapy? There is no chemotherapy option! There’s no treatment option whatsoever.” By this time our patient was more somnolent, more often unconscious than conscious. She labored to breathe as her pale and gaunt face withered away. She was dying. I spoke with the husband and told him that we had finally heard from the oncologist: no chemotherapy options existed. We could only make her comfortable as she passed from this world. It was as if he knew this was coming, throwing his hands up in the face of this tragedy and walking out of the room in tears.

At the end of the week, the patient died.

We were indignant. Clearly, the oncologist abandoned her patient. Despite the close relationship they once had, she had not come to see the patient nor reached out to her or her husband to explain the situation. Anger permeated our team’s discussion that evening as the two residents on my team and I packed our bags and headed out of the hospital. We swore we would never do that to our patients.

One cannot know for certain what was going through the oncologist’s mind as her patient’s illness evolved. And it is difficult to malign such behavior without knowing all that was happening at the other end. Did she feel overwhelmed by the grief of her day-to-day job? Because of her closeness to the patient and the patient’s husband, did she want to avoid telling them the prognosis and outcome? Whatever the case may be, it was wrong of her to vanish when the most trying time came. Yet it is worth exploring what may have occurred.

In his book Thinking, Fast and Slow, Nobel laureate Daniel Kahneman, an economist and psychologist, explains that psychological literature supports the concept of familiarity breeding comfort. Repetition, he states, “induces cognitive ease and a comforting feeling of familiarity.” He describes how, in an experiment run at the University of Michigan and at Michigan State, psychologist Robert Zajonc and his team placed Turkish words in ad-like boxes in the student newspapers. Different Turkish words were shown at different frequencies, some once, some up to twenty times. The investigators then sent questionnaires to the students asking about their impression of the words. Kahneman writes, “The results were spectacular: the words that were presented more frequently were rated much more favorably than the words that had been shown only once or twice.”

Medical training is nothing if not a long series of repetitions, of exposures to similar diseases and situations. An oncologist sees cancer and its morbid consequences every day. This may not breed the kind of positive reactions that Kahneman describes, but it likely elicits an increasingly tepid and nonplussed response from the physician. Poor outcomes or test results shock less than they would most others. Perhaps our patient was one of ten with similar diagnoses witnessed by the oncologist in the last month, and one of a hundred in the last year. And maybe that led to a dismissal of this fatal and unconquerable diagnosis. Why invest time in another situation like this when failure is guaranteed?

Danielle Ofri, a clinical professor at the NYU School ofMedicine, thinks about this slightly differently. In her book What Doctors Feel, she references a 2012 study on the nature of grief and patient loss in the lives of oncologists. The oncologists in the study attempted to compartmentalize their sadness and grief in order to keep them separate from their work and their personal lives. But they failed terribly. Dr. Ofri writes,

The pervasiveness of death often led to a relentless sense of grief among the oncologists, not just for the patients who had died but for the patients who they knew would be dying soon…. Grief ate at these doctors, distracting them from both their families and their patients. Many reported withdrawing from emotional involvement with their patients and that their patients had noticed they weren’t fully present.

The problem, in Dr. Ofri’s eyes, is an overwhelming amount of grief thrown at the physician on a day-to-day basis. It is certainly possible, in the particular circumstance I described, that the oncologist felt too sad and too upset to come see the patient.

Interestingly, both of these theories are rooted in the same etiology: overexposure. It is a conundrum of our nature as human beings. Repetition either exhausts us or anesthetizes us. Do we need to limit physician hours or days worked? Do we need to limit physician obligations during the day to allow for these kinds of important conversations? I don’t know the answer. Until we figure out a solution, reason and empathy must keep watch over our conditioned responses, lest we abandon those most in need of our help.

The post The Absent Oncologist appeared first on The New Atlantis.

I remember my first encounter with great literature. Before bedtime, my father would read Great Expectations to me, using different voices for different characters. I remember Pip and Miss Havisham, though I don’t think I fully understood Miss Havisham’s peremptory and eery commandment to Pip to love Stella. I remember the stygian scene with the convict in the graveyard. I also remember reading Sherlock Holmes under my covers, enamored with his brilliance and the game that was afoot. I remember tearing through the Lord of the Rings books and the first few books of Robert Jordan’s The Wheel of Time series. Great stories left a large impression on my childhood. The thrill of diving deeply into an engrossing world still makes me a bit giddy. Even when I read books far more socially complex now, books I would never grasp as a young reader, like Thomas Hardy’s novels, I am reminded of the initial excitement I once felt discovering new stories.

As a child, these stories didn’t remind me of my own life or people in my life, they were just thrilling. I fantasized about writing my own stories one day. I created comic books with different monsters, though my drawing was appalling. I once sat down to hand-write my own epic fantasy story – I don’t think I got very far. I suspect, then, that my desire to write and tell stories was present at a young age. But I lacked the sedulousness to work on my drafts. I would write an essay for school or a story at home and immediately hand it in or toss it aside, assuming that was the end.

Since then, of course, I have written more and learned more. The process certainly has not gotten any easier, especially as time spent writing crowds out time for other things in life like music, friendships, reading, TV shows, and family. Indeed, the time invested has not been trivial. Just as an example, I was covering the intensive care unit one night during my first year of residency and during the few brief quiet moments of the night I was reading a book about the psychology of the Nazi war criminals for an essay for the Jewish Review of Books.

Why do I attempt this seemingly crazy task? It is a question prompted by a recent fellowship interview, when an interviewer asked me: Why do you write? And what drives a physician (and there are many physician-writers) to write?

In 1946, George Orwell explored the reasons for his own writing in an essay entitled “Why I Write.” Orwell explains that there are four great motives for writing: egoism, aesthetic enthusiasm, historical impulse, and political purpose. Writers, he argues, “desire to seem clever, to be talked about, to be remembered after death…. It is humbug to pretend that this is not a motive, and a strong one.” Because of this, serious writers are “vain” and “self-centered.” Of course, there is an element of solipsism in writing. No writer, physician or otherwise, writes without anticipating some kind of audience. It does help give our writing purpose, to know that it affects or influences others. But such an aspiration is not unique to writers, as Orwell concedes. All professionals – scientists, artists, politicians, etc. – desire, to some extent, to be remembered through their research, art, or deeds. No ambitious citizen can deny that this plays some role, large or small, in what he or she does. But the entire writing motive is not necessarily self-aggrandizing: Writers appreciate beauty, “pleasure in the impact of one sound on another, in the firmness of good prose or the rhythm of a good story.” An author, no matter what his or her topic, attends to “aesthetic considerations.” And the content matters, too. Essayists, novelists, political journalists all “desire to see things as they are, to find out true facts and store them up for the use of posterity.” In other words, they aim to portray the world as it is, to draw away the curtains. And there is also a “political purpose” to this. Though writers do want to see things as they are, they also want to imagine the world as it might be or “to alter other people’s idea of the kind of society that they should strive after.” Orwell does not argue that one of these is more important than the other: “These various impulses must war against one another,…fluctuate from person to person and from time to time.”

Most of what Orwell says pertains to physician-writers. For some of them, for instance, politics drives much of their work. Atul Gawande, a surgeon and public health researcher, is a good example. Gawande’s books, like Being Mortal or The Checklist Manifesto, both agitate in some way for reform of our medical system. In Being Mortal, he urges us as a society to rethink the way we take care of the elderly and those closest to death such that we provide them with more independence and choice and less invasive care. In The Checklist Manifesto, he discusses the importance of checklists for the safety of patients in a hospital, in particular during surgeries.

For most physician-writers, however, I suspect that the primary purpose is to reveal to the reader what the world of medicine is like – a world that contains the kinds of riveting stories that fiction offers.

Physician-writers face unpleasant facts; or, rather, unpleasant aspects of life. Most of the stories I relate on this blog are tragic in some way – some of this comes out of a frustrating sense of injustice, but a lot of it comes out of a sense of the inevitability of tragedy and the beauty and rare success coupled to that struggle. Thomas Hardy reportedly said, “The business of the poet and the novelist is to show the sorriness underlying the grandest things, and the grandeur underlying the sorriest things.” The physician-writer shows the sorriness and grandeur underlying our physical life. In that sense, I write with a historical impulse, “to see things as they are.” What is medicine really like? What does it mean to be sick and helpless? What does it mean to be sick and poor? How do physicians react to all of this?

Perhaps the thrill and romance from childhood stories has faded somewhat, but the hunger for nonfiction as a grounding tool has taken their place. This blog provides, among other things, a way to impart the great complexities of medicine and diseases, which are often only understood by other physicians and the victims of those diseases.

I wish I could write a novel with the same flair for storytelling and the same talent for diction and the same eloquence as Dickens or Hardy. That I cannot is unfortunate. But stories about medicine are powerful and the most I can offer. And I am “driven on by some demon” to write about them; a purposeful struggle to put to the page these stories that are filled with meaning, and that might otherwise disappear.

I will never retire this task, whether it’s through this blog or elsewhere. But as my career advances I ought to give myself space to breathe. I start my fellowship in neurovascular disease this summer and have an important specialty board exam this year, both of which require, I think, all of my intellectual energy. So things will be quiet on this blog for now, but look for more in the coming year.

The post Why I, a Physician, Write appeared first on The New Atlantis.