Staring at Death

While learning “The Sailor’s Tango” from Happy End, a Weimar-era play with songs by Bertold Brecht and Kurt Weill for performances this winter, I recently discovered a major obstacle that had inhibited my full realization of this musical mini-drama. Within the span of a few lines, I would have to evoke and enact the most frightening experience possible: confrontation with the most fearsome, shattering, and terrifying thing in all of life—death.

“Der Matrosen-Tango” tells the story of humble sailors, the lowest ranking men aboard the German ships of the 1920’s. They return from shore leave, bragging about the booze, cigars, and girls left behind. Laughing at God and religion, they depart for Burma, only to meet their fate amidst the whirlwinds of a tropical typhoon. Their last-minute prayers are unanswered as they witness their ship destroyed, drifting down to a watery grave. A “sea of blue” will be their home for all eternity.

Naturally, it’s a rare privilege to learn a Brecht/Weill song, even for someone who directed The Threepenny Opera as a 19 year-old Yale undergraduate. Their music collaboration produced masterpieces whose hypnotic harmonics and intense drama are uniquely haunting. I too have been haunted by “The Sailor’s Tango” and not just by its subtle dance rhythms and literally hair-raising words. A very dear Yale friend, Glenn Mure, a brilliant actor and singer, included this number in a 1986 cabaret program for his closest friends immediately after he was diagnosed as HIV-positive. The horrifying pleadings of the sailor took on an extraliterary significance that still give me chills.

During my years as a medical student, extern, intern, resident, and emergency room attending physician I saw by my estimation approximately 3000 people die in front of me. Almost all doctors have crossed that same battlefield. Some of those people had lived long, happy lives. Others were cut down in their youth. Some were victims of accidents or unforeseen health crises. Others were infants, children, or adolescents who never experienced the beauties of health, friendship, and joy. How did these experiences steel me in a resolve to fight disease and help people in need? I don’t think I will ever know.

Now I find myself reliving the deaths of close friends, family members, and even some strangers as I channel the primal terror that a doomed fictional sailor experiences—compacted into 20 seconds of the Brecht/Weill song. A lifetime of death, as it were, passes through my mind. As does my reaction to this incessant fear caused by the inexorable forces of nature and illness. When I first started to witness multiple cardiac arrests during a typical day in a large Brooklyn hospital—despite heroic measures and amazing dedication by humanitarian physicians, nurses, and assistants—I realized that I needed to live each day fully, caring for others and enjoying my favorite things, namely friends, theater, and music.

When I perform “The Sailor’s Tango” I will be once again staring at death, and it won’t be the last time.

What is the Worst Illness in the World?

What is the worst illness in the world?

I was reminded of that rhetorical question this week when I examined a patient rapidly losing her vision from retinal hemorrhages and a central retinal vein thrombosis. She had struggled with poor vision in one eye and now has lost almost total vision in both eyes, only being able to perceive shapes and light. Amazingly, although 86 she has no other chronic illnesses and has never taken any prescription medicine.

Naturally this patient is overwhelmed by the sudden development of this affliction. Now she must become reliant on neighbors and friends for her daily activities, and her security and independence have been permanently changed. She humorously pretends to consider suicide but wouldn’t be able to ascend the Brooklyn Bridge on her own.

As a physician, I am repeatedly faced with the difficult task of giving consolation and courage to people such as this wonderful woman. What can you tell them? Throughout 30 years as a doctor and a healer, I have had the singularly unpleasant responsibility to tell family members that a grandparent, relative, friend, lover, spouse, or child is dead. My training for this terrible task came from years of exposure to humanistic psychology, not from medical textbooks. One needs to be especially empathetic because we will all eventually be on the receiving end of such news.

When I lay recuperating from ulcer surgery in 1991 at St. Claire’s Hospital, tubes everywhere, I began to feel sorry for myself. That lasted about ten minutes when I realized that I was in a hospice unit and my neighbors were terminal patients. I imagined going to their bedsides and asking if someone would want to trade places with me. You know the answer: anyone dying of cancer or another frightening illness would welcome the opportunity to erase their disease and substitute a totally healed gastric ulcer. I stopped this foolish and selfish thinking immediately.

Illness brings out our worst fears and challenges our inner strength and stability. Personal myths such as “I never get sick” can be shattered in seconds. Yet, I have seen patients with pancreatic cancer accept their fate. In contrast, I have seen a young patient newly diagnosed with mild asthma commit suicide in his hospital room.

Physicians are not merely diagnosticians, clinicians, tradesmen, or surgical technicians. We deal not only with human bodies but diverse reactions to bodily trauma and incapacitation. Interestingly, a given individual may have multiple different responses to illness at different times. Elisabeth Kübler-Ross discusses this eloquently in On Death and Dying. Even seemingly mundane illnesses such as diabetes or hypertension can elicit diverse reactions ranging from denial and depression to total loss of self-control.

What did I tell the lovely 86 year-old who was now confronting a future of darkness? I recycled my own experience at St. Claire’s and told her to visit a nursing home or hospice and ask patients if they would trade places with her. After a moment of reflection, the patient smiled and decided instead to visit the Lighthouse and the Jewish Home for the Blind. They would be able to provide the necessary support system for her daily activities and routines. She will supply her own courage.

I often ask patients and myself: “What is the worst illness in the world?” The answer is the same every time: “It’s the one that you have.”

A Pig in a Poke

Which illnesses frighten you the most? Leprosy, with its disfiguring skin and facial changes? Tuberculosis, depicted in the theater by frail, pale young women coughing up blood onto their bed linens? Perhaps high blood pressure, which has the following signs and symptoms…[none]?

Let’s face it: infectious diseases are inherently the most terrifying. The thought of viruses, bacteria, protozoa, or parasites invading our body parts and invisibly spreading toxins remains a child-like fear throughout our lives. The Bubonic Plague (poetically rendered as “The Black Death”) is perhaps the prototype, although centuries have passed since rats swarmed through London. Of late you’ve no doubt heard of the influenza epidemic of 1918, the most infamous public health catastrophe of the 20th century.

Even in recent years, infectious diseases, unlike many more common illnesses, seem to grab the headlines, producing a somewhat distorted view of American health emergencies. Television viewers are apparently numb to the endless litany of articles on obesity and overweight, extremely unhealthy conditions that affect 67% of the adult population. A personal myth seems to be: “If there are commercials about diabetic medications and blood testers, diabetes really can’t be much more dangerous than athlete’s foot.”

On the other hand, mention a new or revived infectious disease on the air and you’re guaranteed an attentive audience. SARS, an extremely rare type of bird-flu, resulted in mass-media hysteria in 2003. Every station covered the story as if a new plague had arrived—the humble author of Dr. Fischer’s Little Book of Big Medical Emergencies did almost 50 separate interviews on the topic! [but he’s not complaining]. Remember West Nile Encephalitis? That caused more panic several summers ago than Elizabeth Taylor’s performance as Cleopatra. And how about “Mad Cow Disease”? I assume that McDonalds hasn’t changed its menu.

Diabetes, hypertension, high cholesterol (and 40 other conditions in 9 organ systems directly related to obesity) don’t grab headlines because of “over-exposure”, although these are the most prevalent threats to anyone’s health at present. Contrast this with wall-to-wall coverage of swine flu: although 25% of the pediatric population is obese, “concerned” parents are rushing their children to local emergency rooms for evaluation and treatment of a transitory infectious disease. Swine flu lasts approximately two weeks. Diabetes and obesity can reduce life expectancy by four or more years. Which seems more serious to you?

In 1976 swine flu became front page news after an outbreak at Fort Dix. A mass inoculation program was rapidly put into effect as thousands of people swarmed to medical offices and hospitals to protect themselves against certain death. Unfortunately, the opposite occurred, as can be illustrated by the story of Stuart Fischer, medical student at Maimonides Hospital. As a dedicated health care worker, I was lucky enough to receive swine flu vaccination thanks to the generosity of the hospital administration. Upon returning home right after the injection, I put on the television news and saw that the entire inoculation program had been abruptly terminated that day.

As it turned out, the vaccination provoked an illness called Guillien-Barre Syndrome. At its worst, this resulted in respiratory arrest and sudden death. Such was the fate of 25 otherwise healthy individuals. In fact more people died from the vaccination than from swine flu itself. Needless to say, I have been extremely suspicious of government health programs since then and have not taken or recommended any flu vaccinations, unless the individual has severe pre-existing cardiovascular conditions.

Influenza epidemics are a fact of life, a necessary evil in a world filled with microbes of every type. Periodically our immune systems need a workout just like our muscles do. If we need a vaccination for every known infectious disease, how will we be ready to fight off other health challenges? Cancer, for example, may be partially due to viral infections.

Now that Americans have been made aware of an impending crisis in healthcare (due to obesity) and health insurance (due to overrun costs) we may need to consider cost-effectiveness on a national level. Simply put, and not unlike your budgeting household expenses, should we be spending millions of tax dollars on a recurrent, seasonal mild infectious disease or utilizing the money for hospital clinics, nursing homes, low cost medication, prenatal care, and ambulances?

By all means, protect yourself and your family as best as possible from viral respiratory illnesses every year. Practically this means hand washing, sanitizing surfaces, avoiding ill people, and covering your mouth when sneezing or coughing. But keep a sense of perspective. Swine flu and its mischievous friends will outlast us all. On the other hand, obesity will shorten your life. Don’t buy a pig in a poke.

Personal Myths

Have you ever wondered why you act the way you act? Have you ever wondered why you think the way you think? Are your decisions based on past experiences, parental teaching, religious beliefs, or self-generated errors in thinking? Or a combination of some of these? Is your pattern of behavior a thoughtful process or a set of automatic responses?

Psychologists, philosophers, and even some poets (Blake), have viewed human consciousness as a reflection of deeply embedded personal and social beliefs, some productive, some destructive. Behavior patterns and thought processes may be instilled during childhood or may be developed through life experiences. Of course, a great deal of our mental and interpersonal activity depends on mysterious forces, as yet unknown properties of the human brain, of hormones, or of neurotransmitters.

Taking time to examine your own belief systems (your “personal myths”) can be an interesting, beneficial, and life-extending process. This takes the form of self-guided introspection, an activity that can be as healthful as eating correctly or exercising. In fact deconstructing your personal myths—namely, figuring out why you think the way you think and then correcting the errors—can in itself lead to better eating and exercising habits.

Albert Ellis, one of America’s most esteemed psychologists, often discussed “crooked thinking”. Unlike the psychoanalysts of Vienna and their disciples, he taught that personal beliefs and thoughts lead to resultant behaviors and emotions. He recommended that we learn to think in rational, healthy, and goal-enhancing ways. The ego, id, and superego were, to Ellis, nonexistent forces: we are who we are largely through learned behavior (albeit with some influence from our genes) and therefore bad or destructive behavior can be unlearned.

In recent times, Dr. Stanley Krippner has devoted enormous creative energies to helping people discover, rethink, and redefine personal myths. His workshops and writings help teach individuals this process of self-discovery. For him personal myths reflect deep feelings by which people make choices everyday in their acquaintances, jobs, and self-care. Our self-concept is the totality of everything we think about ourselves, and this is certainly dependent on experiences in childhood, our environment, and our most intimate relationships.

Moreover, our image, namely our appearance and behavior, is the projection of our self-concept into the social world. Simply put, this means that what we think about ourselves is viewed by others objectively as our weight, bodily physique, clothing choices, hairstyle, and other components of image. You needn’t be reminded that people suffering from depression, inertia or loneliness have “self-neglect” written all over them. Conversely many individuals with distorted personal myths lead apparently normal lives yet still show signs of carelessness—obesity, unstable medical conditions, unrealistic plans, or limited interpersonal relationships.

Self-actualization and personal improvement must be continuous goals throughout our lives. And examining our own personal myths at any stage of life can be a liberating and thrilling experience as we unburden ourselves of incorrect thinking and destructive habits. The Park Avenue Diet is the first application of this technique to weight loss. Who among us has not thought: "I had a hard day at work, so I deserve to eat and drink whatever I want." For some reclusive individuals, this might be an attempt at rationalizing unhealthy behavior: "No one cares what I look like, so why should I?" Even healthcare professionals are not immune to disordered thinking: "Because I take vitamins I can eat whatever I want to."

All of the above statements are dangerously wrong, although superficially they sound like reasoned thinking. Considering them objectively, however, these personal myths carry with them considerable risks for chronic diseases, shorter lifespan, and unhappiness. Why would anyone want to live that way? Unearthing personal myths, examining them in broad daylight, and realigning priorities can provide benefit on physical, mental, and social levels.

The inner journey to discovering one’s own correct and incorrect belief systems may stimulate spiritual renewal that lasts a lifetime. Simplistic “quick fixes” (such as willpower, a non-existent entity) make weight loss a temporary phenomenon, since irrational and unproductive thought patterns have not been identified and corrected.

Self-understanding must be a constant goal for all individuals, even during times of apparent success. “Know thyself” [γνῶθι σεαυτόν] is received wisdom from the Ancient Greeks, and examination of personal myths is the perfect way to begin this process.

The Physician sings "The Physician"

I've been a medical student, extern, intern, resident, emergency room attending, diet-doctor, private practice physician, media health-expert, scientific author--and now, just in time for a special birthday, a singer !

"The Art of Medicine", my exploration of poetry and prose on the topics of health, doctors, and related philosophical issues, now turns a new page by opening the Cole Porter songbook. In 1930 the distinguished and witty composer wrote a mock-romantic song for a forgotten musical called "The New Yorkers." He recycled it for "Star Dust" in 1931, but when it appeared in "Nymph Errant" (1933) the song made theater history. You can hear the legendary Gertrude Lawrence sing "The Physician" on a YouTube audio-only recording. Julie Andrews' version in the movie "Star" is beautifully sung, tastelessly staged.

Now it's my turn. After all, as a Yale graduate and a guy, I've got a few things in common with Cole Porter. And who better to grasp the ironies, double-entendres, and musings on the "doctor-patient" relationship represented in "The Physician" than....? I think you see my point.

I first heard the song in 1969 in a revue of forgotten Cole Porter songs, presented by Yale undergradutes and directed by Robert Kimball--the brilliant music-theater historian who is credited with rediscovering one of America's greatest artists. Like the rest of the audience, I was shocked at some of the racy imagery and naughty language--how could these have eluded censorship?

40 years later, I've prepared my own deconstructed version, which I mischievously feel honors Cole Porter's unexpressed intentions (the song is never performed by men, let alone Yale graduates or actual physicians). "The Physician" purportedly describes the plight of a shy patient infatuated by a healthcare practitioner--or does it?

It's showtime !

A Letter from Uncle Abe

Still reflecting on my recent 30th anniversary of entering the medical profession, I came across a rare piece of memorabilia: a letter written to me in 1979 as I started my clinical studies at Maimonides Hospital from my Uncle Abe--the only other physician in our family, then age 80.

I'm presenting it to you to show the depth of dedication that he and so many of his colleagues demonstrated almost every hour of their lives. His philosophical ruminations haunt me after three decades of direct patient care; I am still humbled by the responsibility and the healing powers that a physician develops. Here is my Uncle Abe teaching me once again, his letter to me in its entirety:


July 21, 1979


Dear Stuart,

Congratulations on your start into the medical profession! Good luck, good health and happiness, and constant efforts on your part will make you successful in your choice of the Healing Art.

I’d like to quote Nietzsche (in spite of his anti-Semitic feelings). “A good physician must possess the persuasiveness that adjusts you to every individual you see as a patient; the suave negotiation and adroitness of an efficient detective in understanding the secrets of a soul without betraying it” (He must have said this about psychotherapists). It applies to all M.D.s.

The world is populated by people who are scared, anxiety propelled, and ill both physically and emotionally. Each person is human and imperfect. No one escapes the trials and tribulations of the human experience. Living is a continuous strife.

Remember in your dealings with mankind that humans are at best frail, phobic, ill, tired, and imperfect--regardless of their social status, their financial accomplishments, religious trends, color of skin, or ethnic origins. Try to be helpful, understanding and apply all you’ve acquired, and will acquire, of knowledge to accomplish some therapeutic gain. The Talmud says, “If one saves one human life, it is equal to having saved all the world.”

You will be rewarded with unusual feelings of expressed gratitude and deep personal satisfaction and happiness.

But never forget that you are a human being too and that no one escapes the frailty, uncertainty, and anxiety that confront all mankind. Be humble in your tasks but avoid self hurt, humiliation and “keep your chin up” while respectfully applying the art of our profession.

Good Luck!

Your Uncle Abe

A House Call by Doctor Astroff

This week, 30 years ago, I graduated from medical school. My mother, my aunt, and my nanny attended the ceremony; all are gone. You probably know that medical school merely provides the infrastructure and the lexicon of the profession and that the most important learning comes from direct patient care. Only a few weeks after my graduation, I started a four-year stint at Maimonides Medical Center, as extern, intern, and resident in internal medicine.

If asked why I became a physician, my answer has always been the same: to be a healer, to help my community, and to lessen people's suffering. And I'm lucky to have chosen my calling at age 9, thus narrowing my professional aspirations considerably. My idealistic side never evaporated, having been formed and solidified in the late 1960's. And it's a source of happiness and contentment that I've saved thousands of lives by heroic intervention, uplifting motivation, and maybe a book or two.

But the life of a physician is a difficult one, filled with unpleasant tasks, conversations, and decisions. We expect physicians to be humanitarians, not simply scientists, and that is quite a weighty responsibility. Everyone probably has a story of the aid and comfort given to him or her by a doctor, perhaps even an anonymous emergency room physician. The words might stick in our minds forever. I have somewhat more down-to-earth epigrams carved into my memory, such as this one from my internist Benjamin Rosenberg during my teenage years, when I asked him if he liked all his patients: "Stu, I have put my finger into the rectum of people I wouldn't shake hands with."

Perhaps Dr, Rosenberg was being flowery, as we Brooklynites have been known to be. Interestingly, I found out what he meant, metaphorically speaking of course, when I worked as an attending physician at Cabrini Medical Center's emergency room: many of the patients were criminals, Runyoneque-types, or worse, yet my duty was to diagnose broken bones, suture lacerations, and restore vital signs--this was not the location for social change, personal opinions, or dramatic confrontations. I was simply their physician at that moment in time.

My great-uncle Abe Fischer, the only other doctor in my family, had dazzlingly colorful stories that would make me even more excited to be going into his exalted profession. As a general practitioner in 1920's to 1930's Brooklyn, he had suffered through an ordeal in his Maimonides training (being on-call every night for three years), accepted a chicken as payment for a house call during the Great Depression, and treated the high (young Maria Callas) and the mighty (Al Capone and Dutch Schultz). Being a physician, he always sat at the head of the table wherever he went and was the sole speaker, with beautiful silvery hair, orotund tones, and a Freudian beard. He had gravitas, authority, and a wealth of experience, the sort that can only come after witnessing the ravages of disease and the pain of earthly sorrow.

In reflecting on my journey through the medical profession, I recently recalled another early influence, this time a fictional character: Doctor Astroff in Uncle Vanya. I had seen a stellar Mike Nichols production of the classic Russian play on Broadway, with George C. Scott as Astroff and Julie Christie as the woman he loved and lost. The more I watched Astroff's world-weariness, combined with his refusal to stop being a caretaker and healer, the more I knew I was on the right path, challenging though it might be.

Dr. Astroff might be a fictional character, but all students of theater know that he's a stand-in for the playwright himself, Anton Chekhov, also a physician. How much of Astroff is Chekhov? And how much of Chekhov is Sonya, the melancholy and lonely woman who experiences life as a vale of tears and longs for peace in the grave? How could someone have written her final speech without experiencing at least some of the emotions? I'm as ebullient and fun-loving as anyone else yet over the course of 30 years, I've seen, by my own estimate, 3000 people die in front of me.

These conflicting, seemingly irreconcilable aspects of a life in medicine haunted me when I began to record excerpts from Uncle Vanya for my project "The Art of Medicine." A house call by Doctor Astroff proved very dramatic, stirring up memories and feelings that are as much a part of my medical education as pathology and anatomy. How do we become who we are? Sometimes the insights come not from science and textbooks--but from art and life.

The Art of Medicine

Who said "Ars longa, vita brevis" [Life is short but art is long] ? It was a Greek physician, namely Hippocrates, and although he was referring to the "art" of practicing medicine, we generally use this famous phrase as an appreciation of the durability and complexity of self-expression through drama, painting, movies, and music.

The Roman philosopher Seneca translated this famous statement into Latin, and its common usage is also a truism: our earthly activities have a finite duration but creative work can transcend the boundaries of time, geography, and ethnicity. An easy example: theater pieces dating back 2000 years often surprise modern audiences with their topicality and psychological insights (for example Lysistrata, The Trojan Women, and The Bacchae).

As a physician since 1980, I have always had special interest in artistic works that address medical and health topics. Often the author/composer/poet discusses the topic directly--a favorite might be the role of Dr. Astrov in Uncle Vanya, a stand-in of sorts for playwright Anton Chekov (himself a general practitioner). Other times the focus might be on illness as a metaphor for the tragic arc of a pitiable character; successful performances of Puccini's La Bohème should have the audience in tears when Mimi succumbs to tuberculosis.

I will be sharing some of my lifelong favorites with you on my website--and in upcoming personal appearances--and I'm thrilled to have accumulated a wealth of entertaining, insightful, and quite contrasting selections drawn from diverse sources. The title for this performance anthology seemed to suggest itself: The Art of Medicine.

Up first: ten contrasting literary works that address the topic of health in completely different ways. I’ll leave it up to you to discover how, letting the authors speak for themselves. The settings are quite different (a Civil War hospital, bucolic Tennessee, cholera-infested Venice) and so are the characters (drunken medical students, Medieval true believers on pilgrimage, an artist doomed by tertiary syphilis). To come: two songs from 1929 about health issues, one naughty, one frightening. But the focus is similar: our fragile bodies, the human spirit, and the gift of life.

The Art of Medicine: where science ends--and poetry begins.

Enjoy!

Resilience

What is resilience? Faced with a serious crisis, some people have the ability to cope with stress in a positive and productive manner rather than crumbling under pressure and falling to pieces. Other people don't, and their world can be shattered as lifelong plans unravel and health deteriorates.

And who has this most evanescent of traits? Where does it come from, innate survival powers or learned behavior?

These questions had always puzzled me before reading a brilliant book by the esteemed psychiatrist Dr. Frederic Flach, Resilience, that focuses on this very lofty and necessary behavioral skill. Yet true to the complexity of life, resilience is also a phenomenon in ecology (whereby an ecosystem tolerates natural disturbances and thereafter returns to a stable state) and physics (the ability of a substance to absorb energy when deformed and then elastically restore itself--something cartilage does as a "shock absorber" in our hips and knees).

I have witnessed careers ruined due to relatively minor personal problems, individuals turned into recluses when intimate relationships ended, psyches scarred by failure preventing further attempts at success. Various philosophers have had their say, as in this passage from Twilight of the Idols by Friedrich Nietzsche:

Was mich nicht umbringt, macht mich stärker.
(What does not destroy me, makes me stronger.)

or in this memorable truism from the Broadway musical Gypsy, via lyricist Stephen Sondheim:

"Some people have it and make it pay. Some people can't even give it away!"

Your ability to be resilient is directly linked to your self-concept (the sum total of all your ideas about yourself) and therefore your image (the projection of your self-concept into the social world, a visible representation of your belief systems). The stronger your self-confidence and the stronger and more realistic your bonds to the outside world, the more impervious you will be to negative thinking, feelings of hopelessness, and abandonment of plans. Resilience isn't courage, egocentricism, or focus, although these may be some of its components--nor is it a conscious effort to ignore pain, loss, or potential tragedy.

Resilience, on the other hand, implies a practical approach to problem solving, one where sadness and despair are redirected into new goals, new situations, and a new set of rules. I have often thought of life as a narrative that Charles Dickens might have written, full of twists and turns of the plot. His most memorable characters, Oliver Twist, Nicholas Nickelby, and David Copperfield, for example, endure poverty, loneliness, and estrangement, only to find themselves unlikely heroes by the end of their ordeals. The outcome of the story could never have been predicted at the onset.

It is this view of life, as a rather prolonged roller-coaster ride, that makes resilience an easier process to accept, a survival technique that must be learned by transcending life's challenges. Various social institutions have proved helpful for many troubled people seeking a pathway back to a happier life: religion, artistic self-expression, therapy. All are potentially helpful, yet the outcome must still be the same: moving on to a new chapter of one's life, turning the page as it were in one's own non-fictional narrative. Like self-confidence, resilience is a learned skill; hopefully, as we mature, it will help to keep us steadfast and comforted.

Resilience, like physical strength, requires effort, repetitive steps, and balance. Practical tips and remarkable insights are provided in Dr. Flach's masterful book, one that belongs in your library. Simply put, whether discussing resilience or Resilience, you can't live without it.

The Other Side of the River

An inevitable part of life is transition, whether from one height to another, as we grow, from one location to another, as we relocate, or from one image to another, as we change. And may I remind you that "the only thing constant is change" ?

Part of this change--specifically learning how to change--serves as a protective mechanism. This is not unlike an evolutionary modification described by Charles Darwin, when he studied how physical changes in a species (such as larger wingspan or the ability to camouflage) reset the species' genetic makeup and help insure survival.

Humans don't adapt by changing body parts. This takes millennia, not a few decades. Instead, we change by adapting our image to the surrounding world in a way that maximizes our comfort, safety, and success--maybe by developing better interpersonal skills, so we can make new friends in a new setting (a new job, a new school, a new city) or perhaps by changing our "look" (dressing differently when we move to a new area of town, for example from swank Sutton Place to the cooler-than-cool West Village in New York City).

Is transition an enjoyable and painless process? Not really, because truth be told, emotional and social inertia is somewhat reassuring. All of us can get used to unpleasantness, stagnancy, or "a routine" and we may not want to summon up the energy, self-awareness, and courage to change. How many times have you been in a situation that was quite negative but you didn't want to look for an alternative (job, friend, home) because you'd "gotten used to" a modicum of unhappiness and dissatisfaction--or loneliness? Did you convince yourself that being unfulfilled was easier than trying for something better? Such is the "personal myth" of people trapped in go-nowhere jobs, dead-end relationships, social isolation, or, as far as this diet-doctor is concerned, obesity.

People who have forged a successful path though life avoiding its many physical, psychological, and social obstacles have made the ability to change, to transition, a useful and oft-called-upon skill. They upgrade their appearance frequently, watching the latest fashions and choosing the best, most au courant look. Their hairstyle reflects the latest trends; their conversations include the most interesting current subjects; they make new friends gracefully, slowly, and sincerely.

No one is incapable of making such a transition. Conversely put, we all must learn this essential skill and learn not to fear change. Beyond your current surroundings, whether geographical or emotional, are new opportunities for personal enhancement, upward mobility, and fun. By working on improving your weak points (whether in appearance or behavior--or just weight) a better version of you will emerge, one which will be more capable of success and more attractive to the outside world. Surely you don't think you're a "finished product." On the other hand, it's best to believe that you are "a work in progress" and strive daily to add embellishments of every type.

And when the time of transition comes, and you might not recognize it, the hallmark will not be something you see but something that the outside world sees in you: a new friendship might suddenly blossom, for example, someone very special that might have forever remained a stranger or a missed opportunity for intimacy. But once that transition occurs and your life becomes happier and the sun shines brighter, you will never want to reverse the process, go back into your shell, and return to a life of comfortable stagnancy.

I've likened such a transition to crossing a river on a raft. Once you've summoned up the courage to make that journey and made the necessary changes in appearance and behavior to become a better version of yourself, you will arrive on the other side of the river and step into a new world. You might be tempted to look back and see where you came from, but if all the right variables align, you will never want to go back again. Now on the other side of the river, you can take your first steps inland and explore the new territory. Of course you will be a little afraid. All people take their first steps cautiously when their physical or emotional landscape is new.

Learning how to make transitions, how to cross the river, gets easier with each new challenge. Some day it might be much less problematic, but as you learn to improve your life--and you may have to, whether you want to or not--the process will become more comfortable. Get off the raft, put your feet on the dry land of a new chapter of your life, stand tall, walk forward, and never look back.