Sadly the great memoirist Frank McCourt has died from complications of metastatic melanoma. 

His first book Angela’s Ashes is one of my favorites.  If you haven’t read it yet, pick up a copy and bring to life his words, especially if you have some poor Irish blood in you.  One of the most memorable book openings I can think of begins:

When I look back on my childhood, I wonder how I survived at all. It was, of course, a miserable childhood: The happy childhood is hardly worth your while. Worse than the ordinary miserable childhood is the miserable Irish childhood, and worse yet is the miserable Irish Catholic childhood.

People everywhere brag and whimper about the woes of their early years, but nothing can compare with the Irish version: the poverty; the shiftless loquacious alcoholic father; the pious defeated mother moaning by the fire; pompous priests; bullying schoolmasters; the English and all the terrible things they did to us for 800 long years.

After a childhood full of adversity and poverty, McCourt immigrated to New York and eventually became a teacher. Among other things he taught his creative writing students that their own lives were their best material. Taking that advice to heart, he finally wrote his first book after retiring in his 60’s.

Melanoma, as you may know, is an ugly and tenacious adversary.  It is estimated that 1 in 65 people in the US will be diagnosed with melanoma in their lifetime.  You can learn more about the disease here at Medline, with particular attention paid to recognizing risk factors and maximizing prevention.  News of McCourt’s diagnosis was released just 2 months ago, and he was undergoing chemotherapy as recently as May, 2009.

Speaking to students at Bay Shore High School on Long Island in 1997, he said, “I learned the significance of my own insignificant life.” 

I think that sentiment is what I liked best about Angela’s Ashes.  The insignificant tale of an unknown boy growing up in the slums of Limerick was not really unique – most people live uncelebrated lives of hardships overcome and adversities faced.  But in the telling of his story Frank McCourt added a poignant thread to the grand human tapestry, and touched upon our common humanity.

My wife and I have a pact that if we make it to our 90’s we are going to eat chocolate ice cream three times a day. Such reckless consumption of saturated fats would be quite tasty, even if it hastened our ultimate deaths.  It’s a way of trivializing and coping with the stress of a more grave concern – that one day we might have so much pain, disability, incontinence, and dementia that admonitions like eating healthy seem petty and absurd. Plan B, for when the ice cream comes up in a bilious storm of vomit and nausea, is too upsetting to contemplate – yet people are forced to heroically consider it somewhere in the world, each day.

Yesterday the controversy surrounding euthanasia for the terminally ill was thrust into the spotlight after reports that a famous orchestra conductor and his wife ended their lives together.

Sir Edward Downs, past conductor of the BBC Philharmonic Orchestra and of the Royal Opera House in London, and his wife Joan, a choreographer and ballerina suffering from terminal cancer, both ingested a lethal dose of sedative medications and died peacefully alongside one another after 54 years of marriage.

From the New York Times:

The couple’s children said… that last week they accompanied their father, 85, and their mother, Joan, 74, on the flight to Zurich, where the Swiss group Dignitas helped arrange the suicides. On Friday, the children said, they watched, weeping, as their parents drank “a small quantity of clear liquid” before lying down on adjacent beds, holding hands.

“Within a couple of minutes they were asleep, and died within 10 minutes,” Caractacus Downes, the couple’s 41-year-old son, said in the interview after his return to Britain. “They wanted to be next to each other when they died.” He added, “It is a very civilized way to end your life, and I don’t understand why the legal position in this country doesn’t allow it.”

There are several layers of controversy in this matter. The most obvious is the notion of assisted suicide for the terminally ill. Should a person suffering from an incurable illness be allowed to end their life?  Washington State voters approved a “Death with Dignity” referendum in November, 2008 by a 58 to 41% margin, becoming only the second state in addition to Oregon to allow physician-assisted suicide for the terminally ill.   A majority of American’s responded “Yes” in a 2005 Gallup poll, although the specific wording of the question impacted opinions.
Continue reading →

I applaud President Obama’s choice for Surgeon General.
Dr. Regina Benjamin looks like an excellent choice from what I’ve read and heard so far. Here’s what NPR had to say about her:

As a small-town doctor, Benjamin moonlighted in emergency rooms and nursing homes until she could convert her office into a rural health clinic, according to her Web site. She founded the Bayou La Batre Rural Health Clinic in 1990, serving a community of 2,500, including a large number of immigrants from Vietnam, Cambodia, and Laos.

The clinic provides physical exams, routine medical care, preventive care, lab work and minor surgeries regardless of whether patients have medical insurance or the money to pay for their care.

When the clinic was wiped out by Hurricane Georges in 1998 and Hurricane Katrina in 2005, Benjamin treated her patients in their homes and mortgaged her house to rebuild, the president said.

The clinic was destroyed a third time by a fire, leaving Benjamin and the community to dedicate themselves to rebuilding again with donations. “Through floods and fires and severe wont, Regina Benjamin has refused to give up,” Obama said.

Charged with promoting disease prevention, acting as chief health educator, and coordinating the 6,000 member U.S. Public Health Service Commissioned Corps, she is uniquely qualified as a family physician. Half of our days involve educating patients about their illnesses and trying to prevent complications from chronic diseases, while coordinating the fragmented care patients receive from various institutions and specialists.  Dr. Benjamin has also shown an amazing willingness to serve her patients and to work for the betterment of her community at the expense of her own wallet. While I’m not advocating that doctors work for less money, I do think the contributions of family doctors have long been undervalued and trivialized, and that a redesign towards a health care system that rewards preventive care, evidence-based good performance, and a team approach to chronic illness is inevitable, and mostly desirable.

Can you name any Surgeon Generals since Koop? Most people can’t I’m sure. And Sanjay Gupta from CNN would have come off insincere like a franchise, having branded his name and small empire so extensively. From the limited info I have, it seems like this pick is a diamond in the rough.

I also find Obama’s choice a natural one for him. He is an avid reader and an accomplished writer, and a student of human story. The narrative of Dr. Regina Benjamin’s life, like Sotomayor’s, is one of adversity overcome, promise redeemed, and hope not lost within the still great American meritocracy. Regardless of your politics, you have to respect her story.

Good luck, Dr. Benjamin.  Make us proud.

One of the most helpful parts of a person’s medical history is the catalogue of illnesses that affected their family members. It provides a context for present complaints and worries. It helps the clinician estimate risks. Knowing what troubles befell genetically related individuals provides a lantern in the darkness of diagnostic uncertainty. The family history is also the most cost-effective “genetic testing” we have, still dwarfing the promise of the Human Genome Project that mapped some 25,000 genes.

But the taking of the family history, if you were to let it, can bring you to tears that spill like a salty blot upon an otherwise austere medical chart.

“So… Your mother died at 53 of breast cancer, and your father died at 72 of colon cancer. I’m sorry. That must have been really hard for you. But with this information we should pay particular attention to breast and colon cancer screening, and talk about preventative strategies.”

That’s what the suspension of full empathy while taking a family history allows. A level-headed, composed and somewhat thoughtful response that is mostly appreciated by the patient, who is also suspending joyful and painful memories of the past.

My copy of Bate’s Guide to Physical Examination and History Taking states:

The family history helps you to assess the patient’s risks of developing certain diseases and may also suggest family experiences relevant to the patient’s concerns… Note the age and health, or age and cause of death, of each immediate family member (i.e., parents, siblings, spouse, and children). Data on grandparents or grandchildren may also be useful…

But what if we were to let slip the velvet curtain for moment? What if we let loose the true spirits of the silent actors who once graced the stage?

The suffering of your poor mother, unthinkable, the woman who dreamed you up, whose very womb cherished you into being, whose selfless love and surrender of freedom achieved your present stature as she set you free like a paper boat upon a great stream; her thoughts, prayers, and counsel guiding and protecting you like an unseen wind. That she suffered the indignity, the absurd pain and torture of a slow death from withering cancer… It’s almost too much to bear. That your proud father, a man who, like your mother, had imperfections, but who loved you with fervent hope for your happiness, who tried his best to be a hero for his family, who fought wars and sleeplessness to console your infant cries, and who thought of you every night of your life as he lay his head down upon a pillow to rest, even as a rotting colostomy, obstructed bowels, and incessant pain rendered him ridiculous.

It’s enough to make you cry, every day. There’s an epic poem within each trivial office visit.

To let just the right amount of empathy through in conversation is an art form all of us practice in daily life, sloppily at times, with too much paint, clashing colors, and mistaken strokes that cannot be taken back.

Too much empathy is not good. To lapse into maudlin imaginations of another’s experience can be presumptive, invasive, and uncomfortable. The exposing of vulnerability might be constructive or destructive to health, relationships, and wellbeing. To step too far into another’s shoes can sap the very resourcefulness needed by both parties. Perhaps empathy is best displayed when it acknowledges suffering, with merely one foot in the shoe of another.

But sometimes, even if it’s just a single breath, I allow myself a silent, meditative, and empathetic pause. Great literature, tragedy, and the very bones of our pitifully glorious existence are forever one question, and one perilously considered answer, away.

Driving home for a visit, looking through old photos, sitting with family and old friends who are now ill… I suspect you know how to take a family history, too.

It’s time to start writing again.

After a two year hiatus, I’m reopening the examining room. It’s dusty in here, I apologize. Some of you might remember me, others not.

Originally I wrote about what I was experiencing during my first days as a family doctor. This helped me connect with the humanism that is so important, yet so easily lost, in the doctor-patient relationship.

I found that in writing about medicine, I was a better doctor for it. The poetry of people’s lives, their loves, ills, and struggles was more easily perceived and appreciated. In writing about the ever-improving body of medical knowledge, I stayed better informed. In writing about my life in medicine, I sustained my energies in a healing art that has existed for as long as people have felt pain and tried to help one another with it. The reflective moment, embodied in the art, analysis, and literature we create, brings light to our present endeavors.

And so begins the second iteration of The Examining Room of Dr. Charles. I’ll be focusing on the current conversations in medicine, as sparked by medical news, recent discoveries, and other voices on the web and in the media. I reserve the right to embarrass myself by posting a poem at times, or to indulge in the occasional sentimentalism that first got me noticed in the medical blogosphere.

I may not have the time to write as often, or as thoroughly as I might like, but I hope that you and I will both get something good from this blog every once in a while. And if nothing else, at least you’ll get to see the tasty tomatoes from my garden later this summer.

I almost never buy bottled water to drink. Instead I prefer to drink filtered water from the tap. But on a recent trip to New York City I have to confess that I coughed up a ridiculous $3 a bottle for “Fiji Natural Artesian Water.” I don’t know if it was the indulgence of being on vacation, or the less-deliciously presented bathroom sink of my hotel room, but I fell into the trap of paying for water three nights in a row. Fiji Water, according to their website, is “Far from pollution. Far from acid rain. Far from industrial waste.  There’s no question about it: Fiji is far away. But when it comes to drinking water, ‘remote’ happens to be very, very good.”

Is it? Who knows.

The Fiji website has a lot of good stories about their water production, but I can’t find anything even approaching an unspun scientific accounting of chemical contaminants.

According to two studies presented today to members of Congress, the tap sounds better and better.

One of the reports, published by the Environmental Group, a non-profit, found the following:

Unlike tap water, where consumers are provided with test results every year, the bottled water industry is not required to disclose the results of any contaminant testing that it conducts. Instead, the industry hides behind the claim that bottled water is held to the same safety standards as tap water. But with promotional campaigns saturated with images of mountain springs, and prices 1,900 times the price of tap water, consumers are clearly led to believe that they are buying a product that has been purified to a level beyond the water that comes out of the garden hose.

Among those chemicals isolated from various bottled waters were trihalomethanes, bromodichloromethane, chlorine disinfection byproducts, and urban wastewater pollutants (caffeine, pharmaceuticals, heavy metals, arsenic, fertilizer residue, solvents, plasticizers, propellants).  Mmm.  Sounds like a Twinkie.  Often the water tested was indistinguishable from, or inferior to, regular unfiltered municipal water. The study didn’t even get specifically into phthalates – esters added to plastic bottles to increase their flexibility, which have been linked to some ill health effects, and are increasingly banned in other products such as children’s toys in the U.S. and E.U.

But then there’s this: Continue reading →

Oliver Sacks, a noted neurologist and writer, appeared on The Daily Show with Jon Stewart last week to promote his new book Musicophilia.

Besides the entertainment value of the interview, which is significant, several interesting topics emerged, including the following claims by Dr. Sacks:

– a unique pattern of brain enlargement occurs in musicians, making their brains grossly distinguishable from “typical” brains, like yours, mine, and Albert Einstein’s.

– music is a broad construct in the brain, the representation thereof built within multiple areas, and is therefore quite resistant to being wiped out completely with a stroke. He states that music is quite rudimentary and fundamental, and that rhythm is so elemental and deep in the brain that it is rarely lost.

-he also says that when a child dances to music it is a uniquely human ability, and further states: “A chimpanzee can’t dance. People often try to teach their dogs to dance, it doesn’t work.”

Animals do, however, respond to music. An interesting article in Discovery (which unfortunately does not list its sources) claims that one study showed a better growth rate in fish. Babies and monkeys both prefer lullabies to techno music. Other studies have shown the propensity of woodpeckers, kangaroo rats, and chimpanzees to “drum” objects in their environments for the purposes of communication, territorial displays, and attraction of females. Other research has found similarities between whale songs and human communication. In the scheme of evolution it only makes sense that music, rhythm, and language would not be completely novel. Here’s the number one hit for “dancing dog” on Youtube:

This dog, while certainly talented, intelligent, possessing an impressive memory for a repertoire of commands, and worthy of 5 million views… is getting its cues from the trainer and not the music directly.

Anyway, an interesting interview with Oliver Sacks, and a topic worth further exploration, with your dog or cat perhaps. That’s just the sort of thing You Tube needs more of, don’t you think?

{7/9/09 addendum} an excellent commenter pointed me to this undeniable evidence of a cockatoo grooving to “another one bites the dust.” Oliver Sacks, you need to start blogging! Cockatoos have a language ability, which supports the nexus between language, rhythm, and dance. Where was this cockatoo when I needed someone to start the dancing at my wedding?