The journey to my current professional position has taken me down many exciting and challenging intellectual pathways. I had always wanted to be a physician but became unusually fascinated by human psychology while still in high school. My first exposure to the field was a summer project at Western Michigan University studying the precepts and experiments of B.F. Skinner—a behaviorist whose philosophy was diametrically opposed to the florid and mysterious inner world conjured up by Jung and Freud.
Then came four years of specialized studies at Yale covering, among other topics, abnormal psychology, physiological psychology, dream research, and orthomolecular psychiatry. I attended numerous national and international conferences, read scholarly articles prolifically, and even conducted research on nutritional treatments for hyperactive children. There were many psychological superstars at the time, brilliant pioneers whose take on human thought and behavior was insightful and dazzling—but one stood out above the rest: Albert Ellis.
Albert Ellis felt, as most psychologists do, that thought influences and shapes behavior. But to Ellis, there were no murky subterranean levels of human consciousness such as those proposed by Sigmund Freud: the ego, the id, and the superego—primitive controlling forces inaccessible to our conscious minds. For Ellis, explanation of our daily actions lays quite close to the surface, making introspection and therefore change much easier. What interested me most about him was the pragmatic approach that he advocated, one that involved isolating philosophical errors, repatterning behavior, and subsequently arriving at a different worldly attitude.
He called the philosophical errors “crooked thinking”, a concept best explained by the master himself in an outburst I witnessed at one of his free-wheeling seminars. The moment an audience member said “I feel sad when…” he rejoindered with “I make myself sad when…” This is quite a distinction: the latter allows for the possibility that we can gently reprogram our thinking patterns in more positive and productive ways.
The current term “personal mythology” owes much to these revolutionary ideas. It defines an individual’s unique system of values, some productive, others counterproductive, and yet others delusional. As a physician I have seen many patients whose health care hangs tenuously in the balance but “don’t need to get a check-up because I feel okay.” The rules they are following are self-made, and their rationalization is always self-validating: this is beautifully rendered in French as honi soit qui mal y pense. The road to ill-health and nutritional self-destruction is often paved with these philosophical errors, and it was Albert Ellis who showed me that “crooked thinking” can have both psychological and physical repercussions.
I add another layer of meaning to his philosophy, namely that how we look (our weight, our bodily physique, our hair, clothing, and skin) and how we behave (our self-confidence and our interpersonal skills) are also amenable to change—not just how we think. External characteristics, rather than merely being superficial window-dressing, can influence our emotions—and therefore we need to affect change in two directions: inside-out and outside-in. This is an expansion of the approach Dr. Ellis mastered, and I am honored to have been profoundly influenced by this unique genius.
Thursday, February 21, 2008
Fanfare for the Common Malady
After several decades of medical practice and an eclectic education in the science and art of healthcare, this physician/philosopher can truly say "I've seen it all." Of course, strictly speaking, that's not true, since Harrison's Textbook of Internal Medicine is several thousand pages long--there's enough pathology to last a lifetime, so to speak. Would you like to hear about some of the esoteric and exotic things I've seen? Of course, you would.
In 1965 I was a teenage volunteer at Maimonides Medical Center, working as a clerk in the dialysis unit. When the brilliant nephrologist in charge (Dr. Donald Snyder) learned that I wanted to be a physician, he took it upon himself to teach me how to take a blood pressure. In those days, we used a sphygmomanometer, an antiquated device with a column of mercury and an inflatable cuff. After listening to Dr. Snyder's careful instruction, I was told to take the blood pressure of the first patient to come into his clinic. "Pump it all the way up" he added. I did what I was told and recorded a blood pressure of 300 over 130. "You'll never see that again" Dr. Snyder remarked, and he certainly was correct. Fortunately, after dialysis, the patient's blood pressure normalized.
As long we're on the subject of astronomical elevation of vital signs, might I also mention the fastest respiratory rate I ever witnessed? 24 times per minute, due to an aspirin overdose. Or the most rapid heart rate? 240 beats per minute, part of a "thyroid storm," fortunately a rarity. Normal blood glucose is approximately 80-100; my all-time record was approximately 2700 (due to a hyperglycemic, hyperosmolar coma). The most spectacular and frightening cardiac arrhythmia I witnessed was torsade des pointes, an out-of-control spiraling of the EKG that looks like a DNA double-helix.
Lest you think that these startling experiences were merely passive observations, allow me to tell you about the first clinical skill I ever performed. Most medical students begin their hospital training by learning how to obtain a blood sample or start an intravenous infusion. This lucky student, during his first overnight shift, happened to walk by a room where attempted CPR was unsuccessful but the supervisory professor still wanted the interns to learn an extremely dramatic last resort--administering adrenalin through an eight-inch intracardiac needle. If you've seen John Travolta and Eric Stoltz perform this procedure on Uma Thurman in Pulp Fiction, you know what it looks like. If you haven't, I won't upset your stomach. The professor pointed to me, said "Let him do it", and I did what I was told--several days before I learned how to attach EKG electrodes.
Rare infectious diseases? How about tularemia, an extremely rare bacterial infection a Brooklynite caught from his pet rabbit? Or disseminated meningococcemia? "You'll never see this again" I was correctly told in 1977. Scarlet fever? I never saw it--I had it! Even on a vacation in Morocco, medical rarities fascinated me: I followed a leper around the Marrakech marketplace, stunned at his characteristic facial features and what I refer to as "the terrible power of illness". This was also evident on the single occasion I saw a patient with neurofibromatosis (incorrectly called the "Elephant Man's disease") and another individual with dextrocardia (not really an illness, since organs that develop as "mirror images" usually function normally.)
Why discuss these extraordinarily rare conditions? Perhaps to gain a sense of perspective on common maladies such as hypertension, diabetes, and heart disease. These chronic illnesses are most definitely debilitating and life-shortening, yet many people minimize their "terrible power" because they are so prevalent. Being overweight or obese invites over 20 serious illnesses into your body, and even one can change your life plans drastically. Medical rarities seem exotic and interesting, like tropical orchids or spectacular comets. Common illnesses, no matter how mundane they may seem to you, are the real problem, especially when you have the power to diminish or avoid them.
In 1965 I was a teenage volunteer at Maimonides Medical Center, working as a clerk in the dialysis unit. When the brilliant nephrologist in charge (Dr. Donald Snyder) learned that I wanted to be a physician, he took it upon himself to teach me how to take a blood pressure. In those days, we used a sphygmomanometer, an antiquated device with a column of mercury and an inflatable cuff. After listening to Dr. Snyder's careful instruction, I was told to take the blood pressure of the first patient to come into his clinic. "Pump it all the way up" he added. I did what I was told and recorded a blood pressure of 300 over 130. "You'll never see that again" Dr. Snyder remarked, and he certainly was correct. Fortunately, after dialysis, the patient's blood pressure normalized.
As long we're on the subject of astronomical elevation of vital signs, might I also mention the fastest respiratory rate I ever witnessed? 24 times per minute, due to an aspirin overdose. Or the most rapid heart rate? 240 beats per minute, part of a "thyroid storm," fortunately a rarity. Normal blood glucose is approximately 80-100; my all-time record was approximately 2700 (due to a hyperglycemic, hyperosmolar coma). The most spectacular and frightening cardiac arrhythmia I witnessed was torsade des pointes, an out-of-control spiraling of the EKG that looks like a DNA double-helix.
Lest you think that these startling experiences were merely passive observations, allow me to tell you about the first clinical skill I ever performed. Most medical students begin their hospital training by learning how to obtain a blood sample or start an intravenous infusion. This lucky student, during his first overnight shift, happened to walk by a room where attempted CPR was unsuccessful but the supervisory professor still wanted the interns to learn an extremely dramatic last resort--administering adrenalin through an eight-inch intracardiac needle. If you've seen John Travolta and Eric Stoltz perform this procedure on Uma Thurman in Pulp Fiction, you know what it looks like. If you haven't, I won't upset your stomach. The professor pointed to me, said "Let him do it", and I did what I was told--several days before I learned how to attach EKG electrodes.
Rare infectious diseases? How about tularemia, an extremely rare bacterial infection a Brooklynite caught from his pet rabbit? Or disseminated meningococcemia? "You'll never see this again" I was correctly told in 1977. Scarlet fever? I never saw it--I had it! Even on a vacation in Morocco, medical rarities fascinated me: I followed a leper around the Marrakech marketplace, stunned at his characteristic facial features and what I refer to as "the terrible power of illness". This was also evident on the single occasion I saw a patient with neurofibromatosis (incorrectly called the "Elephant Man's disease") and another individual with dextrocardia (not really an illness, since organs that develop as "mirror images" usually function normally.)
Why discuss these extraordinarily rare conditions? Perhaps to gain a sense of perspective on common maladies such as hypertension, diabetes, and heart disease. These chronic illnesses are most definitely debilitating and life-shortening, yet many people minimize their "terrible power" because they are so prevalent. Being overweight or obese invites over 20 serious illnesses into your body, and even one can change your life plans drastically. Medical rarities seem exotic and interesting, like tropical orchids or spectacular comets. Common illnesses, no matter how mundane they may seem to you, are the real problem, especially when you have the power to diminish or avoid them.
Sunday, February 17, 2008
Universal Health Care
What is universal health care? And why is it the subject of so much debate during a presidential election?
This purposely vague, somewhat-utopian concept takes the earthly form of access to medical consultations, testing, and treatments—regardless of an individual’s ability to pay and his or her current health status. Sounds like a plan, so be sure to vote for the candidate whose double-talk and blather most closely resemble your own views on the subject.
Can we deconstruct this term before proceeding further? Health, as defined by the World Health Organization in 1948, is “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.” Health care, according to UNICEF in 2001, embraces “preventive, curative and palliative interventions, whether directed to individuals or to populations.” Universal, as defined in the aforementioned political debates, refers solely to the United States, not, thankfully, to the entire solar system and distant galaxies.
Universal health care represents an effort to minimize the cost of office visits, medication, surgery, and hospitalization to the individual consumer. Because the threat of injury and illness seemingly affects all people equally, a one-size-fits-all system appears ideal. Of course, logic needs to be temporarily suspended for this idea to resonate: drivers, smokers, mountain climbers, and diabetics all have varying risks to different body parts.
Part, if not all, of the appeal of universal health care is that the term presupposes that health care is something that is done to us. We, seemingly, are passive entities upon whom physicians, nurses, their assistants, pharmacists, and psychologists bestow their wisdom and experience. Of course, they might recommend weight loss, exercise, smoking cessation, or serious introspection, but these are unnecessary when there is an endless amount of money to cover any subsequent medical expenses.
Even in the somewhat “universal” area of infectious diseases, disparity exists despite a human desire for homogeneity. Does the influenza virus affect all of its victims uniformly? Contrast the able-bodied businessperson with a nursing-home resident who might easily develop a secondary bacterial pneumonia. Who will decide which patient to vaccinate, or is universal access to vaccines also “guaranteed”?
Health care, in contradistinction to its current misdefinition, is something that is done primarily by us. A country where 66% of the adult population is overweight or obese is an unlikely place for grand, utopian medical initiatives to flourish. Perhaps 2009 will see the transformation of the United States into Shangri-La—the mythical kingdom where no one ages. If it doesn’t happen that way, be sure you redefine health care as a personal issue, delineated by the boundaries of your own body—and unaffected by mountebanks of any political party.
This purposely vague, somewhat-utopian concept takes the earthly form of access to medical consultations, testing, and treatments—regardless of an individual’s ability to pay and his or her current health status. Sounds like a plan, so be sure to vote for the candidate whose double-talk and blather most closely resemble your own views on the subject.
Can we deconstruct this term before proceeding further? Health, as defined by the World Health Organization in 1948, is “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.” Health care, according to UNICEF in 2001, embraces “preventive, curative and palliative interventions, whether directed to individuals or to populations.” Universal, as defined in the aforementioned political debates, refers solely to the United States, not, thankfully, to the entire solar system and distant galaxies.
Universal health care represents an effort to minimize the cost of office visits, medication, surgery, and hospitalization to the individual consumer. Because the threat of injury and illness seemingly affects all people equally, a one-size-fits-all system appears ideal. Of course, logic needs to be temporarily suspended for this idea to resonate: drivers, smokers, mountain climbers, and diabetics all have varying risks to different body parts.
Part, if not all, of the appeal of universal health care is that the term presupposes that health care is something that is done to us. We, seemingly, are passive entities upon whom physicians, nurses, their assistants, pharmacists, and psychologists bestow their wisdom and experience. Of course, they might recommend weight loss, exercise, smoking cessation, or serious introspection, but these are unnecessary when there is an endless amount of money to cover any subsequent medical expenses.
Even in the somewhat “universal” area of infectious diseases, disparity exists despite a human desire for homogeneity. Does the influenza virus affect all of its victims uniformly? Contrast the able-bodied businessperson with a nursing-home resident who might easily develop a secondary bacterial pneumonia. Who will decide which patient to vaccinate, or is universal access to vaccines also “guaranteed”?
Health care, in contradistinction to its current misdefinition, is something that is done primarily by us. A country where 66% of the adult population is overweight or obese is an unlikely place for grand, utopian medical initiatives to flourish. Perhaps 2009 will see the transformation of the United States into Shangri-La—the mythical kingdom where no one ages. If it doesn’t happen that way, be sure you redefine health care as a personal issue, delineated by the boundaries of your own body—and unaffected by mountebanks of any political party.
Saturday, February 9, 2008
Extra Caramel
Midtown Manhattan is not spared the presence of several famous fast-food franchises, one of which happens to be across the street from my home. On a recent cold morning, I decided to try their coffee, avoiding the synthetic admixtures that resemble bagels, donuts, and croissants.
Imagine my surprise when my neighbor on line, a young overweight adolescent, ordered her breakfast: “a caramel mocha latte, with extra caramel.” Thoughts raced through my head: “To this we’ve come.”-- “What hath God wrought?”—“Yick.” Recent houseguests, two German naturopaths, had prepared for me a breakfast of curried vegetables and millet. From the sublime to the ridiculous, you say?
Allow me to transport you back a few years, when I was asked to give nutritional advice on Breast Cancer Awareness Day for a major network news show. What foods would be the best choices to lessen the risk for this dreaded disease? This is as foolish a question as exists, since the answer, for most Americans, is less food.
As repeated studies have demonstrated, visceral fat, an “organ” deep inside the abdomen, is responsible for abnormal production of estrogenic hormones. Weight correlates with breast cancer risk, a fact well known to the American Cancer Society. Therefore, unless I missed something when studying logic at Yale University, the best way to minimize this risk is to lose weight.
This was too sensitive an issue for the television producers, and my appearance was cancelled. Certainly you’ve seen more controversial material on the air, whether mind-numbing violence, hysterical political blather, or inappropriate sexual content. Is it a badge of honor to be censored because of a statement in the textbook of internal medicine?
Or is it better to allow free reign to individuals who want an extra boost of caramel in the morning to start their day? Vitamins? Minerals? Amino acids? Who needs them when you’ve got corn syrup, thickening agents, and emulsifying additives?
A recent bill proposed in Mississippi recommended that obese people should be denied service at state-licensed restaurants: http://www.thesmokinggun.com/archive/years/2008/0201081fat1.html
Yea or nay? How much micromanagement would you be willing to allow? “Sorry, sir, we cannot allow you to have salt or catsup with your burger.” “Ma’am, it’s a salad or nothing.” “Put down that slice of pizza and step away from the counter.”
Is it an inalienable right to make unwise food choices? Would communities be more responsible if they policed their residents’ health-related affairs? Should I have said something to the young woman who asked for extra caramel? If the latter case, you know the answer: she might not have enjoyed her morning drink but instead poured it over my head.
Imagine my surprise when my neighbor on line, a young overweight adolescent, ordered her breakfast: “a caramel mocha latte, with extra caramel.” Thoughts raced through my head: “To this we’ve come.”-- “What hath God wrought?”—“Yick.” Recent houseguests, two German naturopaths, had prepared for me a breakfast of curried vegetables and millet. From the sublime to the ridiculous, you say?
Allow me to transport you back a few years, when I was asked to give nutritional advice on Breast Cancer Awareness Day for a major network news show. What foods would be the best choices to lessen the risk for this dreaded disease? This is as foolish a question as exists, since the answer, for most Americans, is less food.
As repeated studies have demonstrated, visceral fat, an “organ” deep inside the abdomen, is responsible for abnormal production of estrogenic hormones. Weight correlates with breast cancer risk, a fact well known to the American Cancer Society. Therefore, unless I missed something when studying logic at Yale University, the best way to minimize this risk is to lose weight.
This was too sensitive an issue for the television producers, and my appearance was cancelled. Certainly you’ve seen more controversial material on the air, whether mind-numbing violence, hysterical political blather, or inappropriate sexual content. Is it a badge of honor to be censored because of a statement in the textbook of internal medicine?
Or is it better to allow free reign to individuals who want an extra boost of caramel in the morning to start their day? Vitamins? Minerals? Amino acids? Who needs them when you’ve got corn syrup, thickening agents, and emulsifying additives?
A recent bill proposed in Mississippi recommended that obese people should be denied service at state-licensed restaurants: http://www.thesmokinggun.com/archive/years/2008/0201081fat1.html
Yea or nay? How much micromanagement would you be willing to allow? “Sorry, sir, we cannot allow you to have salt or catsup with your burger.” “Ma’am, it’s a salad or nothing.” “Put down that slice of pizza and step away from the counter.”
Is it an inalienable right to make unwise food choices? Would communities be more responsible if they policed their residents’ health-related affairs? Should I have said something to the young woman who asked for extra caramel? If the latter case, you know the answer: she might not have enjoyed her morning drink but instead poured it over my head.
Friday, February 1, 2008
The Truth Will Set You Free !
"You can't handle the truth" shouted the angry officer memorably portrayed by Jack Nicholson in A Few Good Men. I've sometimes had the same thought in my quest to deliver objective, life-saving information to patients, friends, and media audiences. Let's stipulate that in matters of art, music, and food, there are usually no right or wrong choices: de gustibus non disputandum est, as they said in ancient Rome.
In the world of academic medicine, however, proper logic, statistical analysis, and reasoned extrapolation are indispensable components of scholarly opinions. This was my environment from 1975 to 1983, the years I spent as a medical student, extern, intern, and resident at Maimonides Medical Center in Brooklyn, New York. My professors included pioneering cardiologists like Sterling Jonas, David Dresdale, and Adrian Kantrowitz. Dazzlingly brilliant clinicians such as Norman Brunner and Nathaniel Plotkin seemingly knew every word in the textbooks of internal medicine.
It was not enough for students to have the answer to every question asked on morning rounds or the noon conference; often, a direct citation of a particular study, medical article, or editorial was necessary--chapter, verse, and word, as it were, not unlike the duties of a biblical scholar.
May we contrast this education with the sensory bombardment you endure every day, listening to "advice" from "health reporters" whose hospital experience may be limited to watching bedpans emptied on a popular medical/soap-opera television show? How about the unsolicited "pop-ups" on your Internet browser that give you the latest "nutritional" information? Stop by your local bookstore and count the number of "health books" written by television personalities, whose unique qualifications make such trifles as a college diploma, medical degree, and hospital experience totally unnecessary.
Sad to say, scientific reality is very much a part of human illness--and therefore a set of basic truths, whether we are willing to face these or not. "Where ignorance is bliss, 'tis folly to be wise"--except if you are an overweight diabetic, in which case retinal hemorrhages, dialysis, and impotence might become part of your daily routine. The "truth" that "you can eat whatever you want" with no consequences will eventually become a distant memory.
How do you know that a particular "diet" works well? From promotional advertising? From the testimonials of a few well-paid "patients"? From the mere fact that the products are sold in your local box-store or pharmacy? Do you also believe the claims of every car manufacturer? Do you see every movie released because there are a few good reviews cited in the ads? On Election Day, do you break the handle in your voting booth as you cast your ballot for every candidate? How could you disbelieve any of them?
When I discuss the "success rate" of various famous "diet" programs in a radio interview--as reported by the Journal of the American Medical Association, the British Medical Journal, the Annals of Internal Medicine (none are available at your supermarket check-out counter)--I watch the host's facial expression change into that of a child who has just discovered the truth about the Easter Bunny. The disconnect between the perceived "reality" and the actual truth is a chasm wider than Grand Canyon, even though the data is easily found on the Internet or in any medical library.
If knowledge is power, Americans have a steep learning curve as far as health matters are concerned, especially regarding weight loss. There is enough misinformation to fill several [incorrect] textbooks. Perhaps we should resurrect an expression from the 1960's: "Everything you know is wrong." Yet the more we look for the truth, particularly where our lives are at stake, the better and longer are lives can be. Critical thinking will pay off more when it is applied to critical issues--and there is nothing more important than your own health, safety, longevity, and happiness--all of which are bound inextricably to each other...and to the truth.
In the world of academic medicine, however, proper logic, statistical analysis, and reasoned extrapolation are indispensable components of scholarly opinions. This was my environment from 1975 to 1983, the years I spent as a medical student, extern, intern, and resident at Maimonides Medical Center in Brooklyn, New York. My professors included pioneering cardiologists like Sterling Jonas, David Dresdale, and Adrian Kantrowitz. Dazzlingly brilliant clinicians such as Norman Brunner and Nathaniel Plotkin seemingly knew every word in the textbooks of internal medicine.
It was not enough for students to have the answer to every question asked on morning rounds or the noon conference; often, a direct citation of a particular study, medical article, or editorial was necessary--chapter, verse, and word, as it were, not unlike the duties of a biblical scholar.
May we contrast this education with the sensory bombardment you endure every day, listening to "advice" from "health reporters" whose hospital experience may be limited to watching bedpans emptied on a popular medical/soap-opera television show? How about the unsolicited "pop-ups" on your Internet browser that give you the latest "nutritional" information? Stop by your local bookstore and count the number of "health books" written by television personalities, whose unique qualifications make such trifles as a college diploma, medical degree, and hospital experience totally unnecessary.
Sad to say, scientific reality is very much a part of human illness--and therefore a set of basic truths, whether we are willing to face these or not. "Where ignorance is bliss, 'tis folly to be wise"--except if you are an overweight diabetic, in which case retinal hemorrhages, dialysis, and impotence might become part of your daily routine. The "truth" that "you can eat whatever you want" with no consequences will eventually become a distant memory.
How do you know that a particular "diet" works well? From promotional advertising? From the testimonials of a few well-paid "patients"? From the mere fact that the products are sold in your local box-store or pharmacy? Do you also believe the claims of every car manufacturer? Do you see every movie released because there are a few good reviews cited in the ads? On Election Day, do you break the handle in your voting booth as you cast your ballot for every candidate? How could you disbelieve any of them?
When I discuss the "success rate" of various famous "diet" programs in a radio interview--as reported by the Journal of the American Medical Association, the British Medical Journal, the Annals of Internal Medicine (none are available at your supermarket check-out counter)--I watch the host's facial expression change into that of a child who has just discovered the truth about the Easter Bunny. The disconnect between the perceived "reality" and the actual truth is a chasm wider than Grand Canyon, even though the data is easily found on the Internet or in any medical library.
If knowledge is power, Americans have a steep learning curve as far as health matters are concerned, especially regarding weight loss. There is enough misinformation to fill several [incorrect] textbooks. Perhaps we should resurrect an expression from the 1960's: "Everything you know is wrong." Yet the more we look for the truth, particularly where our lives are at stake, the better and longer are lives can be. Critical thinking will pay off more when it is applied to critical issues--and there is nothing more important than your own health, safety, longevity, and happiness--all of which are bound inextricably to each other...and to the truth.
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