Why I, a Physician, Write

“One would never undertake such a thing if one were not driven on by some
demon whom one can neither resist nor understand.”

 – George Orwell, “Why I Write”

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.

What Makes a Great Physician?

At this blog’s inception nearly five years ago, I asked myself the following question: “When you watch impressive doctors at work,
what is it that most impresses you?” In other words, what makes a great
physician? I was a third-year medical student at the time and I couldn’t
answer the question. At the beginning of training one can hardly keep up
with the incoming information, let alone consider the characteristics that
make a great physician. I liked and disliked certain doctors depending on
the way they treated residents, medical students, or patients. But beyond
kindness, their traits varied widely. During residency I have been
fortunate to work with many admirable doctors, and consequently my sample
size has grown. Seeing what I’ve seen thus far, I think
curiosity and humility are the two most impressive characteristics of a
great physician.

Wikimedia

Galen of Pergamum (AD 129–ca. 216), the Greco-Roman doctor, wrote extensively about how to
make physicians great again in his treatise That the Best Physician Is Also a Philosopher. He bemoans the lost art of medicine and the
corruption of the profession. He advocates for a temperate lifestyle,
arguing that if a physician puts virtue above wealth, he or she will be
“extremely hardworking” and will therefore have to avoid “continually eating or drinking or indulging in sex.”

A doctor must also be “a
companion of truth.” “Furthermore, he must study logical method to know how
many diseases there are, by species and by genus, and how, in each case, one
is to find out what kind of treatment is indicated.”

He continues,

So as to test from his own experience what he has
learnt from reading, he will at all costs have to make a personal
inspection of different cities: those that lie in southerly or northerly
areas, or in the land of the rising or of the setting sun. He must visit
cities that are located in valleys as well as those on heights, and cities
that use water brought in from outside as well as those that use spring
water or rainwater, or water from standing lakes or rivers.

Notice that Galen does not endorse brilliance as a required characteristic of a
physician. No, he advocates for the intelligent use of one’s faculties.
Indeed, he seems to favor curiosity about the surrounding world as a
necessary quality for a doctor.

Curiosity, a desire to discover and a desire to know, is inseparable from a
great physician. In residency we are often told by our attending physicians
that we must be “lifelong learners.” Curiosity naturally creates lifelong
learners. Medicine, after all, is not confined to what one learns in
medical school or residency. If it were, our doctors would not be very
good. One does not see every disease process in residency, one often
forgets certain things, and

the evidence

and guidelines are forever changing and improving. Thus, we must always be
looking up the latest evidence on the diseases we see.

Moreover, there isn’t always a clear diagnosis or treatment, and
physicians must scour scientific literature for the answer. When, as so
often happens, there is a diagnostic mystery, curiosity works against our
inclination towards laziness and forces us to stay on our toes, question
what we believe and why we believe it.

Curiosity also aids the clinician-researcher. Physicians since Galen’s time
have participated in various forms of research, attempting to answer
questions that have not yet been answered. For many of our predecessors
the questions were quite basic, given the general ignorance about the world
of biology. Yet there are still vast areas of medicine for which answers
are needed. The most obvious examples in the specialty of neurology concern
brain tumors or diseases like

Parkinson’s
. The lifespan for patients with certain brain tumors is a year and a half
– how does one improve treatments for these virulent neoplasms? For
Parkinson’s disease, we can only treat symptoms but cannot slow the disease
down – what treatments might reverse this pathology or at least stop it in
its tracks? Curiosity drives physician-researchers to make discoveries and
to seek answers to these questions.

But there is another characteristic, too, necessary in order to be a great
physician. The sheer volume of material one must know and understand about
medicine as well as the natural world is enormous and infinite. Because of the infinite knowledge they cannot possibly possess,
doctors must also confront this world with humility, humility about how
much one must truly know and understand in order to be great.

What was true in Galen’s life is doubly true today: There is a vast world of knowledge
in the realm of medicine. Humility, like curiosity, provides doctors with a
sense of the struggle to accumulate a vast amount of knowledge.
It helps them confront the possibility of being wrong. And
as I’ve written on this blog,

doctors are often wrong
. Humility makes us more likely to double-check ourselves, to re-examine
the patient when we’re unsure, to look things up when we feel insecure in
our diagnosis. It makes us more thorough. It urges us to listen to the
opinions of other doctors, of nurses, or even of patients.

What, then, when I watch doctors at work, most impresses me? What, then,
makes a great physician? Curiosity and humility are necessary
characteristics. There is not a single physician I look up to who does not
have both of these qualities. These alone may not be sufficient but I have
also noticed that other remarkable characteristics tend to accompany
curiosity and humility: kindness, self-discipline, intellectual rigor,
equanimity.

William Osler
Wikimedia

In his valedictory address to the University of Pennsylvania School of Medicine in 1889
(also known as the essay Aequanimitas) Dr. William Osler, one of the original four physicians at Johns Hopkins Hospital and a
legendary professor of medicine at the Hopkins medical school and later at
Oxford, discusses the quality that he thinks is most integral to being a
physician – imperturbability or equanimity. He writes:

A distressing feature in the life which you are about to enter, a feature
which will press hardly upon the finer spirits among you and ruffle their
equanimity, is the uncertainty which pertains not alone to our science and
arts but to the very hopes and fears which make us men. In seeking absolute
truth we aim at the unattainable, and must be content with finding broken
portions.

What lies behind Osler’s idea of equanimity is an acknowledgement of
uncertainty in medicine. And such an acceptance arises first from a humble
and inquisitive outlook. Curiosity and humility acknowledge this
uncertainty and the need to prepare for it, with equanimity.

Medicine as a Vocation

“Hey, doc, come over here!” the patient shouts at me and gestures with a
quick wave of his hand as I walk by his room. “I need to show you
something. Take a look at this.”

Without waiting for me to ask him what is wrong, he takes out his member
and testicles and points at them.

“One of my testicles is swollen. Look! And it’s painful, doc. There’s this
shooting pain going up into my stomach. I feel nauseous. Can you get me
something for the pain?”

I look at his testicles and feel both of them with my gloved hand. One is
certainly larger than the other and the patient winces in pain when I touch
them. Though it is close to the end of the day, perhaps ten minutes or so
before I sign out to the nighttime physician, I run through the possible
diagnoses:

testicular torsion

(the testicle twists on itself, reducing blood supply and causing intense
pain and eventual infarction of the testicle),

epididymitis

(an inflammation of a certain part of the testicle usually caused by a
sexually transmitted disease), a varicocele (the
veins of the testicles enlarge due to malfunction of valves within the
veins, causing increased pressure and pain), and other, less common
pathologies.

At this point, the best next step is to get an ultrasound of the
scrotum. This imaging study, which is fairly quick and cheap, gives the
physician a sense of the pathological process. Of course, this has to be
ordered rapidly because if the patient does have testicular torsion, he
needs to be seen immediately by a urologist.

After examining the patient, ordering the test, and calling down to the
ultrasound technician to make sure the patient had the imaging study done,
it is time for sign-out. But I am in a bit of a bind. It is my
responsibility to make sure the patient gets the treatment he needs, but I
also have plans with a couple of friends all the way across town. If I
leave now, I can make it but will surely be late. If I wait for the study,
I will never make it.

I stop by the night physician’s room and let her know that it will be a
little bit of time before I sign out because I’m going to follow up on this
study. She, understanding my conundrum, tells me to leave and kindly
volunteers to take over. Frequently, residents cover for each other in
these situations, for we know, given our hectic schedules, how hard it can be
to find time to keep up with friends, date, and attend weddings, religious
ceremonies or graduations. I jet out of the hospital and just make the
crosstown bus in order to show up twenty minutes late.

At the bar my friends and I discuss our respective days at work. And then
comes the dreaded question, directed at me: “How was your day?”

I pause as I do when people ask me this question, not because I don’t know
what to say, but because there is so much to say I really don’t know where
to begin or what is appropriate. Do I tell them how only an hour ago I was
examining another man’s penis? Do I tell them about the patient I admitted
to the hospital and watched die over the course of five days because his
metastatic cancer was so bad that there were no treatment options? How
about the time a patient walked into the hallway, pulled his pants down,
and pooped on the floor by the nurse’s station?

If I’m honest about the events of my day, I now know the look I’ll receive
in return: the eyes widen, the eyebrows go up, the mouth twists in slight
disgust and the jaw drops ever so slightly. “Why,” their shocked facial
expressions seem to say, “are you telling me this?” The problem is that
these stories and experiences not only are a part of work; they become a
regular occurrence and a part of life. Resident hours are so long and so
intense that, frequently, there isn’t much else to talk about. Anything
outside of the hospital feels unnatural to residents; we no longer fit in.
Our singular experiences mark us in a sometimes Hester Prynne-like way among our
friends and significant others outside of medicine.

Sometimes, too, we mark ourselves not outwardly but inwardly. When I am
with friends at a bar or at an apartment sipping on a beer, it will
suddenly occur to me that three hours prior, a patient was vomiting on me or
dying

as I pumped on his chest
. The juxtaposition between these two very close moments in time is
bizarre.

But even beyond these occasional strange realizations and awkward
interactions is something much more expected. When I describe to acquaintances what
neurologists do, a typical response goes something like
this: “My grandfather is losing his short-term memory — could this be
Alzheimer’s?” Or, “my grandmother has Alzheimer’s, are there new
discoveries being made on how to cure it?” Some of this is about making
conversation related to my job. However, what becomes clear is that you cannot
escape the profession. For better and for worse, it

follows the doctor everywhere
.

~

In February 2017, Dr. Farr Curlin, the Josiah C. Trent Professor of
Medical Humanities at Duke University,

wrote a wonderful essay in Big Questions Online
 about medicine, titled “What Does It Mean to Have a Calling to Medicine?”
In it, he explains his hopes that young physicians see medicine as a
vocation: “To practice medicine as a vocation is very different [from other
professions]; it means putting oneself forward not merely as a physician
but in order to become a physician.” And becoming a physician takes “a lifetime of effort.” He compares it to the theological
concept of vocation, in which one is summoned or called by God to a certain
task. His purpose, I think, is not to portray doctors as gods or medicine
as the holiest of professions, but to make clear how absolutely consuming
medicine is if taken seriously.

To practice medicine as if it were just another 9-to-5, Dr. Curlin
observes, “is akin to play-acting.” One attempts to keep the role at a
distance. This is a fool’s errand, as no serious physician can manage it. Any serious approach to the profession necessarily leads to a consuming embrace. I think even of physicians I know who
have reached the highest levels of their field, but who still respond to
patients’ emails at night after they’ve come home from work; they must be
available by phone day and night when they’re on call; they still have to
keep up with new research, which they read on their own time; and many even
do medical research outside of work hours. This is not to mention the incredible and unsettling statistic that physicians have one of the highest suicide rates of any profession, a rate more than twice that of the general population.

Anton Chekhov via Wikimedia

Dr. Siddhartha Mukherjee, a physician-writer, has considered this dilemma,
too. In a stunning essay for The New Yorker,

he writes about Anton Chekhov
, the great Russian playwright. Chekhov gave up his medical practice to
travel to Sakhalin Island, a Russian island in the North Pacific Ocean. At
the time it was a penal colony, packed with the destitute and hardened
criminals of the Russian Empire. Why would Chekhov travel here? What
purpose did this trip serve? Mukherjee argues that Chekhov used Sakhalin
“as an antidote.” Chekhov, he claims, had become desensitized to his life
as a physician, numb to human suffering as well as to the greater corrupt
political struggle in Russia. And it is here, among the detritus of society, where Chekhov discovered sensitivity. This story poses the question faced by all physicians, Mukherjee writes: “What will move me
beyond this state of anesthesia? How will I counteract the lassitude that
creeps over my soul?”

In one sense, Mukherjee’s essay serves the purpose of encouraging the discouraged,
angry, numb physicians. But in another sense it illustrates the point that
medicine is a vocation. When patients’ suffering becomes just another task to
deal with, physicians falter not just as physicians but as people. Medicine
reaches beyond its worker bees and into the hive. It claims
physicians as human beings. It claims a part of their souls.

This is not all bad or all good. But it is nearly impossible to
dissociate the personal life from the professional life as a physician.
Medicine practiced well must be a vocation.

Bigotry, Medicine, and Pittsburgh

“You’re one of them wealthy people, from that wealthy family — what are
they called? The Rothbergs?”

“You mean the Rothschilds?” I asked.

“Yeah they’re the ones. You’re related to them?”

“No, sir. My last name is Rothstein — different family but same religion.”

Most of the time I don’t hear about race or religion in medicine but often
enough I do have interactions with patients about my religion that make me
wince. In another instance I saw a patient after a large surgery. I
introduced myself and asked him how he was doing. “I’m okay,” he responded.
Then, after a pregnant pause, he looked at my ID badge, then my face, and asked, “You’re Jewish, right?”

“Yes, I am,” I responded.

“I have great respect for the Jewish people. You know Jesus was Jewish, right?”

“Yes, I did know that.”

“But you don’t believe Jesus was the Messiah, right? You know, Jesus is our
Lord and Savior and he performed incredible miracles while he was alive.
Did you know that?”

“Yes, I’ve read some of the New Testament and I’ve spoken with Christians
about their beliefs.”

“Well, then, why not believe in Jesus? He built on Judaism. His thinking
revolutionized religion. It is the latest prophecy, the latest and truest
Word of God. Would you be interested in seeking out Jesus?”

“I appreciate the offer but I’m comfortable with my own religion.”

“Well, you should convert. It’s the only way to seek the real Truth. Jesus
is the Messiah and if you don’t convert you won’t be going to heaven.”

“Thanks, but I’m okay. Now, how’s your surgical site doing? Are you still in
any pain?”

Sometimes it even goes beyond this. There was a patient I saw regularly in
the hospital who would intermittently get aggressive, annoyed, or
anxious. The nurses called me to talk him down. One evening he was
particularly upset about being in the hospital. I entered his room as the
nurse was leaving. “Tell that n***er to leave me alone!” he shouted.

“Excuse me, that is inappropriate. We do not use that kind of language.”

He looked at my name badge and shouted, “Well guess what? I’m Hitler, so I
think you should leave.”

This is not to mention a co-resident who was told by a patient,
“You’re such a Jew.” Or another patient who told a Jewish co-resident,
“All you want from me is a pound of flesh” — a reference to The Merchant of Venice, where Shylock, a Jew, lends money to a Christian and demands a pound of his flesh as security.

These experiences and others I’ve had run the range from threats of
violence to humorous to uncomfortable, but there is a theme behind them.
Unfortunately, my experiences are not unique. All physicians take care of
racist or bigoted patients. In January 2018, the Wall Street Journal
published a piece

on racist patients, quoting doctors discussing their experiences. In a 2017 blog post by the
American Academy of Family Physicians, multiple physicians retold their stories of interacting with bigoted
patients. Dr. Lachelle Dawn Weeks, a resident at Brigham and Women’s
Hospital in Boston, wrote a

short 2017 essay for STAT News
 chronicling her experience with racism. She concludes that

in an ideal
world, hospitals would categorically disavow cultural and religious
discrimination. Hospital administrators would publicly refuse to cater
to culturally biased demands and express a lack of tolerance for derogatory
comments towards physicians and staff as a part of patient non-discrimination policies.

Dr. Dorothy Novick, a pediatrician,

wrote in a 2017 Washington Post op-ed
 that “When I treat racist patients but fail to adequately address the effect of
their words and actions on my colleagues, I not only avoid teachable
moments; I condone hate.” Dr. Farah Khan

wrote in 2015 in The Daily Beast
, denouncing bigotry she’s faced in the hospital. She asserts, “We should be
taking strides within the medical community to break down unfair judgments
and racist ideals.” Moreover, “Of all the things that I had imagined brown
could do for me, I never really expected it to make me feel out of place
both inside and outside of the hospital.”

These interactions do make a physician’s job difficult. Patients refuse
treatment from a particular physician or verbally abuse him or her on the basis of race or religion. A physician cannot offer
an argument against this to assuage the patient. And it is
difficult to hear or experience these insults and epithets after
years of training to help others.

What, then, ought to be done? Many of the physicians I cited above offer
condemnation and resolve not to tolerate racist behavior. But in
practicality these are non-specific, anodyne proposals. Of course hospitals, and we, should condemn such behaviors. But what does that mean in terms of our conduct in the hospital?

In an earlier post, I’ve written about the more general difficulties physicians regularly experience because of frustrated patients, who may swear at, insult, or even slap us, and since writing those words I’ve been punched or swung at by
patients multiple times. I’ve been accused of not caring about my patients,
of being a bad physician. This is part of the difficulty of the profession.
Physicians and nurses bear the brunt of patients’ frustrations or hatred. And while we
can tell patients that their language is inappropriate, part of being a
physician is offering our services when they are ill, despite
how we might feel about them or they might feel about
us.

This is nowhere more true than during war. As I’ve previously written about the role of the Hippocratic Oath in wartime, “The physician … is responsible only for the good
of the patient no matter what uniform that patient may wear. The Oath makes
no exception for wartime or for the treatment of an enemy.”

Tree of Life synagogue in Pittsburgh / CTO HENRY (Creative Commons)

One of the most recent and heartening examples of such principled medical
practice was after the attack in Pittsburgh this past week, where an anti-Semitic gunman killed 11 Jews in a synagogue, screaming

“All Jews must die.” After being injured in a gunfight with police
officers, the gunman arrived at a hospital

where Jewish doctors and nurses took care of him
.

Yes, there are bigots and racists who not only insult those who are
different but murder them. However, in the face of such hatred we must
continue to offer the patient treatment. To treat patients in their time of
acute need despite what they’ve done or said is part of our professional
responsibility.

This may strike some as a deeply unsatisfying conclusion. Where is
justice? Where is the punishment for these people? Why shouldn’t they face
consequences for their hatred? But we see these
patients for a brief moment in their lives. Distributing punishment is not
our purpose, nor will a refusal to treat them change the way they feel or
act. In fact, a physician is far more likely to change such behavior and to
make an impact by treating the patient. After that, we trust our legal
system to distribute punishment, and hope the prejudiced patients figure the
rest out themselves.

Is More Medical Testing Better?

“I think this patient needs a CT scan of her chest,” the consulting
physician said to me over the phone. “Her lungs sound bad, and given her
history, we need to make sure she isn’t developing pneumonia.”

The patient, though only thirty-five, had been through a lot during her
hospitalization. She came in a week prior with some shortness of breath, an
abnormally high heart rate (tachycardia) and chest pain. But her heart
checked out just fine. An EKG was normal and her troponin, a protein
that spills into the blood with damage to heart, was undetectable. Because
of her tachycardia and chest pain we tested her for a

pulmonary embolus
, or clot in the lungs, with a CT scan. It was positive. The potentially
deadly clot blocks off blood flow coming from the right side of the heart
into the lungs causing heart strain and disrupting oxygenation of blood and
the functioning of the heart.

We admitted the patient to the

intensive care unit

where she received IV medication to thin her blood. She recovered but
continued to experience residual chest pain that would clear in the months
ahead. As we prepared to discharge the patient, the consulting physician, a
cardiologist, told us he wanted her to get another CT scan of her chest.
She had not had a scan since the initial stages of her workup. What if she
developed pneumonia in the interim? Her white blood cell count, often a
crude marker of infection, was not elevated. She did not have fevers. When
asked, she felt well enough to go home and wanted to leave. Then again,
being in the hospital made her susceptible to infection. Moreover, on her
physical exam, we heard crackles in her lungs –
this sometimes indicates an intrapulmonary pathology. The cardiologist’s
concern gave us pause and we ordered the imaging study.

~

Doctors often feel uncomfortable with areas outside of our expertise. Consequently, we call other specialists to see the patient and give us advice. Moreover,
patients sometimes ask to see a specialist in the hospital: “Can you call
the neurologist to come see me?” or “We’d like you to call a cardiologist
to see our father while he’s here.” Because consultants share a different
knowledge base than the team primarily caring for the patient they may ask
for more tests to rule out other serious pathologies that the primary team
neglected to consider.

The patient’s repeat CT scan merely demonstrated small collapsed alveoli.
These terminal branches of the lungs often collapse when we draw shallow
breaths or lie flat for a long time, a typical finding in many hospitalized
patients. Given the benign nature of this finding, we discharged the
patient. Yet she had received an extraneous dose of radiation and her
hospital bill would be hundreds of dollars more. Did she absolutely need
this? This common story raises other questions, too. Do patients do better
with more specialists seeing them? Do patients do better with more testing?

In a 2012 post for the New York Times Well blog, Tara Parker-Pope

pointed out

that “overtreatment – too many scans, too many blood tests, too many
procedures – is costing the nation’s healthcare system at least $210
billion a year, according to the Institute of Medicine.” And the stories
she tells about astronomical hospital bills due to overtesting are
disturbing.

In
a 2015 article in the Journal of the American Medical Association, a group of researchers found mortality for high-risk
heart failure and cardiac arrest among patients was lower in teaching hospitals
during national cardiology meetings compared to the rest of the year – meaning that the absence of a large number of cardiologists, who were attending meetings, was correlated with lower mortality for these heart conditions in the hospital. In an editorial in the same issue, Dr.
Rita Redberg makes a disquieting suggestion: “How should we interpret these findings? One possibility is that more interventions in high-risk patients with heart failure and cardiac arrest leads to higher mortality.” Is there too much being done, especially by experienced
physicians?

Dr. Ezekiel Emanuel, an oncologist and bioethicist, elaborated on these questions in a New York Times op-ed in 2015:

We – both physicians and patients – usually think more treatment means
better treatment. We often forget that every test and treatment can go
wrong, produce side effects or lead to additional interventions that
themselves can go wrong. We have learned this lesson with treatments like
antibiotics for simple medical problems from sore throats to ear
infections. Despite often repeating the mantra “First, do no harm,” doctors
have difficulty with doing less – even nothing. We find it hard to refrain
from trying another drug, blood test, imaging study or surgery.

When specialists like neurologists or cardiologists see a patient, they
approach the bedside from a unique perspective. The pathologies they know
and think about are very different from what family medicine or internal medicine doctors thinks of when they see a patient. Specialists, who often act as consultants, consider the diseases they are most worried about within their field. They’ve been asked to see the patient to
recommend workup for a disease potentially related to
their area of expertise. Their view, in other words, is necessarily myopic – if you give a carpenter a hammer, surely the carpenter will find a nail.
This does not always happen, but by nature there is a bias when a consultant
approaches a patient – and that bias is toward ordering another test,
toward doing something. Part of the art of medicine, especially as a specialist or consultant, is figuring out when the patient needs
something and when the best approach is to do nothing at all. Our patient
at the beginning of the story did not really need a repeat CT scan. To be
sure, the cardiologist didn’t recommend it simply to radiate the patient or
increase the hospital bill. But none of us wanted to miss something.

A conservative method of practice can come with experience, but as evident
from the JAMA study referenced above, that’s not necessarily the
whole story. Some of this, I think, requires thinking regularly about how well the
patient in front of the doctor is doing and how a test will change the
course of the patient’s treatment. “Will this change our management?” is a
question our attending physicians always ask us before we order a test. And it is a
question all doctors must ask themselves.

John Ruskin: Fit the Third and Last

Years ago I had an argument with a biblically-minded friend who claimed that there could have been no tools of any kind, no technology whatsoever, in the Garden of Eden. So did Adam and Eve do all their “tending of the garden” (Gen. 2:15) with their hands? Pruning branches by breaking them off, sowing seeds only by kneeling and pawing the ground? No, he replied, there would have been none of that — there could be no labor in Eden, so the garden would have taken care of itself and all the man and woman had to do was eat what it produced. I pointed out that what distinguishes a garden from a wilderness is that labor is put into the shaping of it and the caring for it, and that the Hebrew words used to describe what Adam did there clearly denote work, but he was immovable. Labor and technology are post-lapsarian phenomena, period. End of story.
Well, my friend was wrong, and the question we theologically-minded critics of technology need to ask goes something like this: Given that the use of tools is co-extensive with humanity itself, how might we distinguish between technology that is consistent with obedience to God and technology that manifestly isn’t? Something like this question is common to almost every serious thinker about technology, even when God isn’t involved. Perhaps the guiding concepts involve purely human flourishing. 
Take Heidegger, for instance. Here’s a summary from George Steiner’s excellent overview of Heidegger’s thought:

Once, says Heidegger, nature was phusis, the archaic designation of natural reality which he reads as containing within itself the Greek sense for “coming into radiant being” (as it is still faintly discernible in our word “phenomenon”). Phusis proclaimed the same process of creation that generates a work of art. It was, in the best sense, poiesis – a making, a bringing forth. The blossom breaking from the bud and unfolding into its proper being (en eautō) is, at once, the realization of phusis and of poiesis, of organic drive – Dylan Thomas’s “green fuse” – and of the formal creative-conservative dynamism which we experience in art. Originally, technē had its pivotal place in this complex of meanings and perceptions. It also sprang from an understanding of the primacy of natural forms and from the cardinal Greek insight that all “shaping,” all construction of artifacts, is a focused knowing. A “technique” is a mode of knowledge which generates this or that object, it is a re-cognition towards truthful ends. (Something of the Heideggerian reticulation can be made out in the cognate range, in English, of “craft” and of “cunning,” with their respective derivation from Germanic roots for “knowing” and “forming.”) No less than art, technē signified a bringing into true being, a making palpable and luminous, of that which is already inherent in phusis. Heidegger’s word for authentic technology is entbergen.

Steiner goes on to point out that zu entbergen can mean either “to reveal” or “to guard in hiddenness.” So healthy technology both reveals something true and guards something valuable.
Consider all this a prequel to a post I wrote last year, which quotes Ruskin on this point. Ruskin’s distinction between the rough but richly human imperfections of Gothic stonework and the rigid regularity of modern industrial stonework is immensely relevant here. Ruskin is articulating in very specific and practical terms what Heidegger is articulating theoretically.
Note that in that post I also cite Ivan Illich’s notion of “tools for conviviality,” which is another way of pursuing the same general ideas. I could also cite Ursula Franklin’s distinction between holistic and prescriptive technologies. Franklin on the former category: 

Holistic technologies are normally associated with the notion of craft. Artisans, be they potters, weavers, metal-smiths, or cooks, control the process of their own work from beginning to end. Their hands and minds make situational decisions as the work proceeds, be it on the thickness of the pot, or the shape of the knife edge, or the doneness of the roast. These are decisions that only they can make while they are working. And they draw on their own experience, each time applying it to a unique situation….Using holistic technologies does not mean that people do not work together, but the way in which they work together leaves the individual worker in control of a particular process of creating or doing something.

And the latter: 

Today’s real world of technology is characterized by the dominance of prescriptive technologies. Prescriptive technologies are not restricted to materials production. They are used in administrative and economic activities and in many aspects of governance, and on them rests the real world of technology in which we live. While we should not forget that these prescriptive technologies are often exceedingly effective and efficient, they come with an enormous social mortgage. The mortgage means that we live in a culture of compliance, that we are ever more conditioned to accept orthodoxy as normal, and to accept that there is only one way of doing it.

So we see the same essential point being made over and over again, since the middle of the nineteenth century at least. Ruskin, Illich, and and Franklin all see that there are technologies that liberate human creativity, that enable human power, and, by contrast, technologies that enslave us, that force our very being into conformity with their codes and structures. 
Some version or another of this essential distinction has been central to this blog over the decade or so that I’ve been writing it, and I have come to believe that I have unpacked the relevant questions as thoroughly as I know how. At this point I am merely repeating myself, or playing tiny scraps of variations on the Great Theme. I still want to think about the matters that this blog has been concerned with — and to think more about John Ruskin! — but I need to find new ways to do it. So this will be the last Text Patterns post. Look for me later on in the pages of The New Atlantis, and at my own site, but I’m wrapping this blog up. 
Gentle readers: Thanks for coming along for the ride. It’s been real. 

updates on various tools

Micro.blog: A couple of days ago I posted this: “I really do think this is a great service, and I’d like to be here regularly, but I wonder how much longer I’ll do this if no one I know (or almost no one I know) is here. I’m keeping fingers crossed that friends will show up!” And immediately I started getting a flood — well, honestly, it was just a trickle, but given how small the place is overall it felt like a flood — of dudes advising me how find new people, how to get more followers, and I thought: Ah. Here we go again. I’m a pretty intense introvert: I don’t want to meet new people, in an ideal world I would have no followers I don’t already know and like, and nothing will ever convince me that giving unsolicited advice to strangers isn’t extremely rude. (Acknowledgment: I know those guys were “just trying to help.” I get that. Nevertheless.) It’s the old problem of intimacy gradients all over again, but on a platform that actually has fewer controls on what you’re open to than Twitter does.
In theory I’m totally supportive of the simplicity of micro.blog, but … what all this demonstrates to me is that with social media I have two choices: far more unsolicited human interaction than I’m comfortable with, or no social media at all. So I just need to make my call and live with the consequences. 
AirPods: I went back and forth about these for several months I wrote about them last year. I’m pretty sure I would be using them regularly if they worked regularly for me — but they don’t. Apple promises that if you flip open the AirPod case a sheet will slide up showing the charge percentage of the AirPods and the case; this happens for me maybe on-third of the time. When you put the AirPods in your ears they’re supposed to pair automatically with your iPhone; this happens for me maybe half the time. And one time in five the phone tells me the AirPods are connected, but sound is coming through the phone’s speaker instead. By contrast, my wired buds always work precisely as expected, so I rely on those. (Everyone else I know who uses the AirPods simply raves about them, so either they don’t have these problems — which wouldn’t surprise me, because I’m digitally cursed: no computing device ever does for me what it’s advertised to do — or they overlook them because of the convenience of going wireless.) 
Notebooks: For several years now I’ve been using the Leuchtturm1917 A5 notebooks, which are just marvelous. But they are fairly narrowly ruled, and I find that writing a little smaller than comes naturally to me tends to make my hand cramp. So when I finished my last Leuchtturm I decided to try the slight-more-widely-ruled Conceptum in the same size, and it’s great. The thicker paper is also very nice to write on. For around the same price it has fewer pages, and of course I’ll write fewer words per page, so I’ll go through this more quickly than I would a Leuchtturm, but that’s a relatively small price to pay for more comfort. Plus, it’s sort of fun coming to the end of a notebook and putting it on the shelf with its predecessors. 
Pens: I have a few fountain pens (nothing fancy, mostly Pilots) that I like, but it seems that when I write my grip slides down the barrel of the pen in such a way that I always end up with ink on my fingers. I don’t mind being metaphorically an ink-stained wretch, but I’d rather not make that literal. I tried a Tombow rollerball but I find it a scratchy experience. I don’t like using throwaway pens but I have found that the smoothest, most enjoyable writing experience I can get for a reasonable price and no inky fingers is the Pentel Energel. Highly recommended. 

living in the past

In later posts I’ll strive for a substantive engagement with Ruskin, but I want to make a general preliminary comment here. Ruskin was one of those figures who lived through a massive social transition and who never forgot what the world was like before its change. “It has been my fate,” he wrote in a late work, “to live and work in direct antagonism to the instincts, and yet more to the interests, of the age; since I wrote that chapter [in the first volume of Modern Painters] on the pure traceries of the vault of morning, the fury of useless traffic has shut the sight, whether of morning or evening, from more than the third part of England; and the foulness of sensual fantasy has infected the bright beneficence of the life-giving sky with the dull horrors of disease, and the feeble falsehoods of insanity.”
That sounds like the ranting of an angry old man, and yet … Ruskin not only watched the sky and noted the weather every day but also kept a detailed record of what he saw — for decades. And in a pair of lectures called “The Storm-Cloud of the Nineteenth Century” he described in great detail the alterations in the sky and the weather, not just of England but of Europe as a whole, that he had observed. It turns out that everything he said in this seemingly most crazily extreme of his writings was precisely correct: the emissions of factories, and other side-effects of the Industrial Revolution, really were changing European weather. As Wolfgang Kemp records in his excellent biography of Ruskin,

The 1870s and 1880s form a unique period in the history of environmental and weather study. The skies darkened, the air became thicker and unhealthier, the climate damper and colder. One result was a progressive increase in the numbers of people dying from respiratory ailments. Trees and animals died too, not only in foggy England but also on the Continent. For example, starting in the 1880s, there were widespread reports of damage to forests in Germany. Rosenberg tells us that “From 1869 through 1889 the temperature in London was below average for eighteen of the twenty-one years … reliable figures for sunshine are available only after 1879, but sixteen of the twenty autumns and winters from 1880 through 1889 were below average, and the total sunshine was below average for more than sixty per cent of the decade.”

So old men may complain about the condition of their times simply because they’re old men and (therefore?) grumpy; but they may also complain because things really have changed and they’ve seen it. And the people who live on both sides of a cultural or political (or even meteorological) divide may be very useful observers of their scene.
Jacques Ellul is another such figure, who lived through a massive transformation in French society; and I might also cite Lesslie Newbigin, who left England as a young man to serve as a pastor in South India and returned forty years later to find a very different culture, which he sought to address theologically and pastorally in a brilliant book called The Gospel in a Pluralist Society. People who have experienced massive social changes and do not merely react against them, but rather strive to comprehend them analytically, tend to be very valuable thinkers indeed. And their habits of critique can be enormously helpful to those of us who are living through our own period of change. That is why when I try to understand our current technopolic moment I find that the thinkers who help me the most are not the ones fully immersed in our own time, but those who remember an earlier time, or those from the past who underwent similar social transformations. It is very hard from within this technologically oversaturated moment of ours to discern its outlines clearly. I’m therefore drawn to thinkers whose vocabularies are tilted or skewed in relation what I see and hear every day. This is one of the many uses of reading old books.
More details about Ruskin soonish.

John Ruskin: Fit the Second

So what interests me about Ruskin’s Fors Clavigera? Several things:

  • a lively interchange of ideas about political economy with ideas about art and aesthetics;
  • a conviction that our tools, our technologies, interact ceaselessly and complexly with art, politics, and economics;
  • an understanding of writing as one way to contribute to the knitting up of a frayed social fabric;
  • a willingness to take up certain traits of one’s age (in Ruskin’s case, the manic energy of a society determined to transform and rule most of the known world) in order to critique them;
  • a persistence in seeking constructive means to engage in conversation when so many of the usual channels are anything but constructive;
  • an embrace of open-endedness, with a resulting willingness to tolerate intellectual and professional risk.

All of those elements are exciting and worthy of emulation, and I can’t help thinking that it would be really exciting if I could, here on this little blog, follow in Ruskin’s footsteps. But there is something missing from Fors Clavigera that I’d like to add to my reflections here.

Ruskin was raised as an evangelical Christian, and his early writings on art and architecture are saturated in biblical language and characterized by deep theological reflection. Indeed, I think that in those early works, especially The Seven Lamps of Architecture, there are profound resources for a theological aesthetics that to this day have not been fully tapped.

But in 1858, when visiting Turin, and having been depressed by a boring and stupid sermon, Ruskin saw Veronese’s painting of King Solomon and the Queen of Sheba and was overwhelmed by the sensual immediacy of the work — which seemed to him far more obviously true than the spectral doctrines of Christianity. He experienced what he called his “deconversion,” and this lasted for nearly twenty years. He returned to some kind of faith only in 1876, when in the midst of writing Fors, but this was accompanied by a deterioration in his mental condition which eventually led to bouts of complete insanity, so his thinking of the time, while deeply embedded in biblical texts and images, is not fruitful for anyone else’s reflection. It wasn’t fruitful for his, either.

(All of these aesthetic and religious experiences were for Ruskin fantastically intertwined with his tormented and disastrous erotic life, first his unconsummated marriage to Effie Gray and later his unconsummated passion for Rose la Touche. But we’ll ignore all that mess.)

What intrigues me is the question of what Fors would have looked like if Ruskin’s reflections on social, political, economic, and aesthetic issues had been informed by religious commitment and theological reflection. To be sure, the letters of Fors are studded throughout biblical imagery and reference: Ruskin had known the Bible intimately from early childhood, and had a terrifyingly powerful memory. (I say “terrifyingly” in part because one of his psychological problems, as he himself sometimes commented, was that he remembered everything he had ever read or seen and therefore found it all too easy to draw correspondences between texts and images and ideas that really had nothing to do with one another. His prodigious memory made his mind too fertile.) But the absence of a theological dimension to Ruskin’s thought in this period makes the social analysis of Fors more agitated, more purely angry and often despairing, than it needed to be.

So — in case it’s not obvious — what I am trying to imagine is a Ruskinian approach to our own moment that uses digital technology against technopoly, that sees art and economics and politics as mutually animating (for good or for ill), and that can situate all these reflections within a serious theological framework. In the days and weeks to come I’m going to try to work through these possibilities, and that will involve reading, in a thoroughly non-systematic way, many of Ruskin’s works. So stay tuned for that, if you’d like. And if you make provocative comments I will try to engage with them in future posts!

In the meantime, check out the posts about Ruskin on my personal blog — there are many wonderful images there. Ruskin drew beautifully.