Monday, May 27, 2019

Research Subject

Image result for research subjectWhen I was on staff at a large medical center, the CEO established four core values for the institution which he arranged in a diamond pattern, safety at the apex, think of yourself as a patient at the bottom corner.  While it seems hard to assess how seriously this mission statement was taken, or if anyone really remembered which value went in which corner, the institution expanded and he got to retire shortly after my departure to a different institution.  Thinking of yourself as a patient usually includes not wanting to be one.  Fortunately, medical care is not all rescue from misfortune.  Research abounds.  If American health care underperforms markers of access and outcome of other countries, our laboratories sparkle like no other.  We have assigned once dreaded diseases to the medical history books, made pneumoencephalography obsolete, and have transformed our biochemistry courses from understanding metabolic pathways to understanding the molecular basis of diseases.

Having watched patients on Medicare assign their too frequent doctors' visits to their prime social outings, I resolved on retirement that I would find other reasons to venture out of my house.  The Osher Lifelong Learning Institute became a valued destination.  While the ties to the state university are generally loose and subordinate, they are not absent.  As our health varies from unimpeded to not entirely independent, we make for a good pool of research subjects to enroll in several ongoing projects at the university's expanding health institute, which does not yet have a medical school but promotes allied health professions training in a big way.  Seeing a project on mental acuity, my son's neurology fellowship pursuit, I opted to sign onto one of the research protocols.  Since I can drive my car safely in all but highly flooded weather and never have to hit the alarm option on the key to find it in the parking lot, they designated me a Control.

While I've done mental status assessments as part of history taking for my entire career, I was not prepared for the sophistication of the battery that came my way.  Lists of words, unrelated, floundering at first but able to put the unrelated single words into a few categories.  My memory is mediocre, attention span so-so, ability to learn verbally very good.  They showed me shapes and had me place them back in order.  I named each shape, then put each back on the screen.  Right sided spacial reasoning did not go as well.  I had to find an object but could not relate fixed landmarks that would enable me to find it when hidden.  I was also not allowed to move the joystick backwards.  What I did instead with limited success is the fishing technique of fanning.  Having no idea where the fish are in the pre-electronic age, we would cast repeatedly in a semicircular pattern from our starting point.  It got me to the target about a third of the time.  I'm just not right-brained but my spacial orientation is adequate to drive safely, though I still struggle to parallel park.

Finally the uncontrasted MRI.  An hour's relaxation with a supine posture, slightly itchy nose that had to wait, noises that reminded me of a confined contraption at an amusement park and an occasional instruction from the technician as there were some dynamic elements.  At the end, I read my scan.  An empty sella, I think, More cerebral atrophy than I might have predicted from my still pretty decent intellect, and no masses or asymmetry.

In another month we get to part 2, an exercise test for which I am self-training on my treadmill with decent compliance and another battery of psychometrics.

Medicare folks whose office visit is their periodic home escape often make a day of it.  I thought about doing that too, especially since I still had 40 more minutes before the next parking surcharge.  Looked for lunch on campus.  Too expensive.  Went into their 5&10, a dying breed, dominated by University logo items.  More than I wanted to spend.  Paid the parking fee and went home.

Friday, May 17, 2019

Medical School Scholarships

Image result for scholarship applicationsHaving retired and wanting to stay busier than a Maytag repairman but not as busy as and endocrinologist, I volunteered to review college scholarship application that a local charitable foundation manages for a variety of donors.  It was one of my more fulfilling tasks, 61 submissions, every one of them worthy of consideration.  There really are some terrific young folks floating around.

While the scoring of the applications was done on my computer on my kitchen table, a meeting was held to decide who gets the monetary awards.  At the conclusion of the session, I received eight more applications to review, these from current or entering medical and dental students seeking assistance from two available sources.  Each awards $2-4000 a year, which probably would allow the student to choose between a microscope and auto insurance but still leave each with a lot of loan debt.

While the high schoolers entering college had transcripts and SAT's, medical students with one year under their belt have a series of Passes.  High school transcripts have honors and AP courses.  Medical students all take the same curriculum and the description of the curriculum has lost much of its delineation to anatomy, physiology and histology, instead being lumped as either an organ system or the more amorphous introduction to being a doctor with no discernable curriculum.  As a result, I was left to evaluate personal statements.  Everyone wants to become a doctor for similar reasons.  Where the applications separated was by intended specialty and the background that generated that decision.  Again, some very good kids.  I was asked to rank them 1-8, which I did.  Probably 6 of the 8 would be competitive for the awards.  Choosing which is somebody else's task. 

Monday, May 13, 2019

Batting 1.000

Somebody did a study, or maybe did a meta-analysis of multiple studies, on how physicians view their work.  We get enthused about 25% of the time, despise 25% and the broad middle takes up the rest.  What goes at each end varies a lot.  I did not like returning phone calls or reporting lab results over the phone.  I basically dreaded the phone.  I did find the residents energizing, even when exasperating.  On occasion one doing an elective with me would request a letter of recommendation for fellowship.  I never turned anyone down.  Most but not all were for Endocrinology fellowships, but if somebody was knowledgeable and diligent, the specialty did not matter if they were pursuing their 25%.

From the first in 1993 all the people I sponsored matched to a fellowship, often their top choice.  Only one ever called me a few years later to let me know of successful specialty board results, but I have seen a few at the Philadelphia Endocrine Society meetings, some as invited presenters of their fellowship research, to know that the good things I predicted for them were true.

My last letter, however, was left in limbo.  A fine second-year resident spent a few weeks sharing the office and hospital.  At the end she requested a letter which went off with the assistance of the residency office that had to guide me through the current electronic submission system.  I retired, heard nothing, and really did not think about it until last week.  Did my letters still score 100%?  I sent a note off to our program director who got back to me with the good news.  A match at one of the universities in Philadelphia.  Not endocrinology but something else of interest to her, a specialty not represented at my hospital.  Bodes well for the future.

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Friday, March 29, 2019

Staying Sensitive

In retirement, I have latched onto an arm of our state university directed to the 50+ crowd, though the number lacking a Medicare Card seems few.  Among my course selections was an advanced writing course.  To my surprise, of the fifteen or so registered participants, I am the only one who does regular public submissions and the only one who does medical writing as an offshoot of journalism.  Most do memoirs, some exceedingly well written, with an audience of family or vault.  A few attempt short stories or anecdotes.  Each of us is asked to submit for class scrutiny 2-3 submissions of under 3000 words over the course of the semester.  My turn arose and I submitted the tribute to my teacher The Zipe.

This bridges medical writing and perhaps eulogies.  The Zipe takes credit for showing me the intricacies of a formal mental status exam, described in the essay.  I submitted it for distribution two classes ago for discussion at our next class.

Unfortunately our class has an elderly gentleman whose mental acuity has obviously declined since the beginning of our semester.  At the last class it was his turn to present.  We read an interesting essay written in 2010 describing his devotion to fitness limited by an arrhythmia.  His dementia had progressed to where he could not follow his own submission.  With that background, I thought it insensitive to proceed with my essay on the evaluation of very early dementia before it becomes obvious.

Finding an alternative paper to submit was easy.  Submitting it has not been so easy as there are errors on the class email list.  We have a week off so I will continue to work on it. 

Derech eretz kadmah l'Torah

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Wednesday, March 13, 2019

Meeting Old Friends

Image result for retired doctorDoctors by our nature do not handle idleness well.  We value our vacations, of course.  I never sought out a study to see if doctors vacationed differently than others.  Some probably hang out someplace warm, others seek out the best eats of the place they are visiting, some cannot wait for the cruise ship to dock so they can disembark for a tour of a new place.  Vacations, though, are an interlude between doctoring activities which inevitably return.  Retirement is different.  Travel is possible, durations more flexible yet it is permanent.  There is no doctoring looming ahead.  Professional activities consumed a lot of waking time.  Lack of professional activities leaves that same amount of time unstructured.

Most of us probably had mixed emotions about our careers.  Most retired voluntarily, anticipated over a number of years, financial stability arranged in advance, but time utilization and talent utilization not nearly as meticulously planned.  Our appointment schedules disappear, our minds and our interests do not.  With some combination of luck and clean living, vitality gets preserved.

Being a doctor has its predictable imprints.  While we may not hit all twelve elements in the Scout Law, many of us becoming irreverent in a jaded way and less loyal or kind than we once were, trustworthiness and a default toward helpfulness usually remain. The activities of our Golden Years would not be entirely fulfilling were that not true.  Not only are our phones smart, but so are we.

In my area, the state university sponsors a program for seniors as part of a national Osher Institute of Lifelong Learning.  It is a place where we can avoid isolation, in the smaller classes exchange ideas or recapture familiarity with the musical instrument we used to play or take a literal and figurative stab at woodcarving or some other activity we thought we always wanted to try but didn't.

For some seniors, the week's highlight might be the doctor's visit.  For me it has become OLLI, even though I have only been enrolled for a month.  My classes keep me there most of Tuesday and on Wednesday mornings.  One class is a large lecture, not very interactive, one a writing seminar with scheduled critiques, one a current topics discussion group where everyone is really an amateur about the weekly topic but verbal anyway, and one wood carving session where everyone else has been there before and has sharp implements that cost a lot more than my beginners gouges from Goodwill.

While the classroom is the focus, minimizing social isolation so damaging in the post-workplace years counts among what Mr. Osher had in mind as he funded these programs.  Classes, including mine, are not always in consecutive time slots, leaving a lot of time for people to be mingling in the common rooms.  The library is small but with soft chairs, a table and charging stations.  The dining area seems too large to ever fill but last time I peered inside there were no totally unoccupied round tables.  Musical performances take place in the lobby.  For those up to a power walk in good weather, the grounds seem spacious, attractive and generally safe.

With that background, physicians once separated have reappeared.  I left the mainstream community eight years prior to retirement.  The others all stayed in our community, dominated by a single central mega center.  It is these people who reappear in the halls, either in transit to the next class, hanging up their coats on arrival, or just in line at the popcorn machine.  We all wear name tags, but I didn't need that except once to identify each retired physician.  All were senior to me.  Some I expected to just plod onward professionally until their significant other gave an ultimatum that Florida would be better or they appeared in the local newspaper's obits.  But they really did retire.  As I greet each one, I am starting to establish a routine of reacquainting.  My questions include the duration of their retirement but never the circumstances.  Most have been attending OLLI from the onset of their retirements.  A few engage in medical education as Grand Rounds.  And I like to know what courses they chose.  As I get more experienced and need to choose a new list, I will eventually ask for their recommendations on what they have taken previously, but so far I haven't asked that.  We don't ask about health, though one fellow volunteered a recent knee replacement to explain his cane.  No beards that weren't there before.  No ties either.  No talk of prostate trouble.  We have an intercession approaching so what old colleagues, most more highly paid than me, are planning to do with their upcoming week off will add to my insight of what docs do when the patients are no more.

I do not know if there are any formal studies of doctors in retirement, what we do, how we fare, correlations between health and those who use their time to travel, visit grandchildren, or keep their intellects afloat.  OLLI has shown us that we have minds, and as the commercial for another fund-raising purpose reminds us, "a mind is a terrible thing to waste."  The docs at OLLI seem to keep our minds challenged voluntarily.

Monday, February 11, 2019

Lasted 15 Minutes

While not really wanting to burn the SERMO bridge, I do not want to become like Elazar ben Arach either.  For those unfamiliar with the tale, he was the rabbincal prodigy determined by the President of the Rabbinical Academy to be of the highest potential, at least what he said in private, though he promoted somebody else in public.  Those who study Talmud today, which is a lot people, rarely study Elazar ben Arach's insight.  This talented youth became a mediocre intellect in his prime years.  At the insistence of his wife, who was left behind in the rabbinical social whirl, he accepted a position as sage in a resort area away from the center of learning.  On arriving there he had a vision of elevating their residents and exposing them to state of the art Torah analysis.  Instead of them becoming more like him, he became more like them, hanging out in the warm springs that made the area attractive to the neglect of advancing himself professionally.  Eventually he attempted a second act at the central academy but it was clear to himself and others that he was no longer their intellectual peer.

Rather than hoist my Libtard banner against persistent sloganeering inciting reaction for the trivial, I opted to just ration my time.  Three days a month, the day ending in zero, which makes only two in February, I set my timer for 25 minutes, scroll through the comments that have appeared in previous ten days and respond to up to three, medical or not.  At 25 minutes I sign out, returning briefly the next day to see if anyone responded beyond my remarks to those threads.  To my chagrin, my interest lasted only 14 minutes and a single comment.  No risk of becoming like Elazar ben Arach.

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Tuesday, January 15, 2019

The Zipe

One who learns from his fellow…a single law…must treat him with respect. For so we find with David, king of Israel, who did not learn anything from Achitofel except for two things alone, yet he called him his "master," his "guide" and his "intimate"… (Ethics of Our Fathers, ch.6:3)

Image result for irving zieper mdFor some unknown prompting, maybe in response to current events, my mind gravitated one recent day to my esteemed neurology teacher, known to us as The Zipe, an abbreviation of his real name.  He passed away in early 2018, after a very distinguished career with a substantial obituary in the Boston Globe imported to  I would have remained unaware of this had is impact on me not transferred from the storage neurons to the more frontal ones.  At the time of my residency, The Zipe was in his prime professional years, approximately age 50.  He had been a veteran, a few years junior to my father.  The obit was not clear if the military preceded or followed his medical school years.  Capable neurologists were readily available but capable and colorful seemed in shorter supply.  In a Catholic environment, he was recognizably Jewish, a member of my synagogue not far from the hospital.  

Two stories stand out.  On a neurology rotation at Boston's main VA Center, The Zipe had been assigned ward attending.  We had a big group, headed by our senior resident, a somewhat compulsively thorough Radcliffe College/ Hopkins Med alumna with a childhood origin from a different stratum than the Zipe or me.  I was one of the junior residents and I think we had interns and I know we had at least one student.  Teaching rounds were conducted in a conference room rather than at the bedside, which the senior resident could handle very capably herself.  At one session, The Zipe wanted to demonstrate deep tendon reflexes to the group.  At the time, and maybe even now, neurologists were the last specialty to carry the classic black leather bag.  I had one too, a bulk purchase by my second year medical class.  They needed various equipment, from a reflex hammer, to visual cards, prescription blanks, a variety of tuning forks to test hearing and vibratory sensation, something to test olfaction, typically a vial of coffee, maybe a hat pin to test sharpness with the point and peripheral vision with the mother-of-pearl head.  The reflex hammer was usually not the rubber tomahawk that residents kept in their pockets but a more sophisticated torus with a weighted rubber edge held by a long plastic handle that had a pencil type point at the end to test sensation.  Too big for a pocket.  

Since The Zipe needed this reflex hammer, in the fashion of the 1970's he barked to the medical student:  "Hey Student, gimme my reflex hammer from my bag."  On lifting it off the table to get it, the student noted that The Zipe's black bag was a lot heavier than his.  He opened it, reached inside, and blanched with an "Oh My God."  Instead of pulling out the tool The Zipe asked for, he extracted a rather heavy pistol.  There's always one resident wag who asked whether this unexpected equipment was intended to test hearing or pain sensation.  The Zipe asked the student what was next to the gun in the black bag.  He pulled out a prescription pad.  The pistol was to protect those papers which even unsigned had street value and whose presence made the carrier, in this case the doctors, vulnerable.  The reflex hammer was also in the bag and retrieved next.  Our lesson proceeded. I have never felt any inclination to carry a weapon to protect my person or possessions in my professional capacity, but over the years, whenever an attack on a physician made the news, I wondered if The Zipe would have prevailed if he were the intended target.

His more enduring impact on me, one that likely made me think of him again, occurred at bedside rounds.  A consult had come in to assess a man who had been prematurely losing his mental acuity.  As students we are taught the elements of an orderly mental status exam and carry one out at least informally on all the patients we see in the hospital from then on.  People are usually obviously able to provide a history and converse normally or are obviously demented so the checklist of 

  1. Judgment
  2. Orientation
  3. Memory
  4. Affect
  5. Knowledge
  6. Attention span
  7. Insight
tabulates quickly and informally.  When not obvious, there is a process for sorting this out.  The Zipe took us to the bedside to see if this veteran was prematurely demented.  He could carry on a fluent conversation, had little understanding of why he was being evaluated and knew he was in the hospital.  As was common among VA patients, and Boston citizens in general, he consumed a fair amount of alcohol.  Patients are asked the day of the week, who the President is, what the weather was like yesterday, where they served in the army which would reflect remote memory, and to start from 100 and count backward by 7's.  This fellow was a little iffy on some of the responses.  When asked the name of the President, though, he responded that he avoided politics, which were a lot less toxic then than they are now.

The Zipe completed his assessment, already done by one of the residents the day before, then back to the conference room for discussion.  Since this affable patient could get by until his deficit was exposed, the discussion involved what is and is not a true deficit.  People are just expected to know who occupies the White House as an unavoidable part of being immersed in a seeing and hearing environment in America.  People are expected to be able to subtract 7 from 100 irrespective of their education.  Even somebody who makes their living as a bank robber understands thou shalt not steal, but consciously selects to violate this.  Insight and acquisition of knowledge along with its retention are what make us a durable species.

In our contemporary environment, two generations of neurologists beyond The Zipe, people are a little uneasy with the various public presentations and rationalizations for the very reasons The Zipe tried to teach.  There is something fundamentally wrong about caging people along the border and separating children from adults.  Rationalize it any which way, it violates the CNS evolution of knowledge and insight.  Denying ethnic targeting when any observer can recognize it, something very common through American and World History, falls below the mental expectation that The Zipe, or me as his medical descendant, would have for normal CNS function.  These realities either did not exist or were dormant when The Zipe presided in his conference room.  Realities change, core principles of how a brain should be able to reason do not.

Very few teachers shaped my reasoning skills more than The Zipe, which is probably why my mind automatically migrated back to that indelible imprint just as valid today as when I sat in his conference room or a few rows from him at synagogue.