The Greatest Blessing of Life

At designated times of the year like Easter, Passover and other holidays, we are often asked to count our blessings. Maybe you’ve been reminded of this somewhat hypothetical activity when confronted with someone else’s problems. “There but for the Grace of God go I” seemed an archaic rumination until I had emergency ulcer surgery in 1991—feeling sorry for myself until I realized that my room at St. Claire’s Hospital was on a ward of people with terminal illnesses. All my intravenous lines, electrodes, and tubes seemingly vanished when I pondered the depth of those patients’ despair and suffering. It was an epiphany of sorts, but one arrived at through transformation of selfishness into empathy for others less fortunate.

Are you conscious of how seamlessly the human body works? Think about the organs over which you have no control: your spleen, ureters, ciliary muscles, alveoli, pons, and portal triad (among dozens of other body parts) are actively engaged in highly specific tasks beyond the scope of human understanding, let alone noticeable feelings. Put another way, the parts of your body that you actually notice—your brain (via self-talk and voluntary actions)…your muscles (via your conscious movements)…your digestive tract (via hunger and subsequent satiation)—are a tiny component of the entire machine. The part of you that’s unique (your thoughts, your memories, your knowledge base, your appearance) is really very small when compared with the dazzling molecular structure, biochemical interrelationships, and mechanical intricacies of the musculoskeletal infrastructure. Shakespeare called the human body “the beauty of the Earth, the paragon of animals.”

Yet there is something even more beautiful than the human body, and that is the mysterious set of emotions that draws people together. While we share these unknowable forces with every member of the animal kingdom, we humans seem to do it more poetically. From earliest childhood when we are taught social behavior, we can develop a need to share, a special pleasure in the attention and affection of others, and perhaps even an inner calm and contentment when we find ourselves in intimate relationships.

Like optimal health, personal contentment is an evanescent pleasure, one subject to the whims of fortune, the inexorable forces of nature, and the ultimate fragility of the human body. The people we are closest to will eventually vanish from our lives, even under the best circumstances. The loss will be magnified exponentially the closer and more intense the relationship was. That cannot dissuade us from trying to reach out to others, hoping by some strange twist of fate, or perhaps just good luck, or even the kind intervention of a friend, to find someone who can give a meaning to life that eludes all of medical science.

The greatest blessing of life is the one that transcends the ravages of time, aging, disease, despair, loneliness, and fear. It is the force that ennobles us, makes us capable of being more than ourselves, more than complex biochemical machines, more than a collection of organ systems. Like the human body, it is magical, powerful, uncontrollable, and all-enveloping. It is ample reason for life itself. It is love.

Time's Winged Chariot

You don’t need to be a physician or sing depressing Brecht/Weill songs to know that mortality is an evanescent state. From cradle to grave, certain biological values decline: heart rate (from a fetal heart rate of approximately 120-150 to zero), the number of brain/heart/kidney cells, all measurements of cognitive function. Other values may increase: blood pressure commonly rises as aging arteries stiffen, sodium is retained, and renal filtration worsens.

Those wishing to know the actual probability that they will die can easily consult an actuarial table. The benevolent souls calculating your health-insurance premiums do this with the same empathy they experience while urinating. Perhaps your need-to-know has lured you into the over-decorated salon of a psychic. Otherwise, how could you possibly know how long your “life-line” is? This crucial information was left out of all my medical school textbooks.

Allow me to simplify this. Life tables reveal such information as the chance that you will survive any given year of your life, your remaining life expectancy, and what percentage of people born the same day are still alive. Here is a straightforward way to determine this important information as you begin a new year and a new decade:

If you were unable to calculate your answer readily, you might have to adopt a different philosophy, namely that each day requires ongoing life-sustaining efforts and life-affirming projects. In fact, you might have to reconstruct the aforementioned approach as a double-negative. Allow me to explain.

Diabetes, hypertension, obesity, overweight, insulin resistance, hypercoagulability of blood, arterial wall inflammation, and elevated cholesterol can and will shorten your life. Perhaps a few hours, perhaps a few months, perhaps a decade. I often ask patients who are unable to control these conditions “How much less do you plan on living?” It has recently become clear that elevation of blood sugar is the last step in the development of diabetes, not the first. Most of the damage done to the circulation occurs in the “quiet” stages when the patient feels well. Where ignorance is bliss, breakfast is an overdose of calories.

In a political environment where the term “healthcare” means some odious type of government program, the true definition seems totally antithetical. Nevertheless, healthcare is what you do for yourself, not what is done to do. Preventative medicine requires self-control, foresight, and delayed gratification. You might be fooling yourself through disordered personal myths, but your bodily organs experience the brunt of unhealthy eating and thinking.

“I can eat diabetic cookies because I take medication”—“I know fat people who never get sick”—“My good deeds will cancel out my bad habits”—there are delusions that can be custom-fitted to any unhealthy lifestyle. “I eat whatever I want to because some day I’ll drop dead” a corpulent patient once boasted. I asked him “How do you know that you won’t have a paralyzing stroke and be in a nursing home for years?” The silence thereafter spoke volumes.

Conversely, living life to its fullest, enjoying the moment, developing new and surprising relationships, and reinventing yourself periodically are techniques of survival and templates for happiness.

The ancient Greeks thought that the sun moved across the sky drawn by Apollo’s chariot and horses. In high school I became fascinated with a poem by Andrew Marvell, “To His Coy Mistress” wherein the “horny” narrator puts the moves on his reluctant girlfriend. The description of mortality is particularly haunting:

“But at my back I always hear Time’s winged chariot hurrying near...
"Though we cannot make our sun stand still, yet we will make him run."

Staying a few steps ahead of our fate, instead of unwittingly hastening it, is distilled wisdom from poets, psychics, and actuaries. So what are you waiting for?

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 !