David Grob, M.D.

Last week I received the news that my greatest teacher, Dr. David Grob, had passed away. We first met in the mid-1970's when I was a medical student at Maimonides Hospital and he was the Director of Medical Education, as well as the chairman of the Department of Internal Medicine.

Dr. Grob was an internationally renowned expert in myasthenia gravis as well as a professor with impeccable academic credentials. To me, however, he was simply the most inspiring healer and teacher of a lifetime. Dr. Grob charted my entire academic pathway after medical school, giving me priceless opportunities to learn clinical medicine on the wards of Maimonides Hospital. From 1978 onwards for five years, I was immersed in patient care as an extern, intern, and resident, spending approximately 108 hours per week mastering the diagnostic and technical skills needed to help critically ill patients.

What made learning from Dr. Grob so very memorable was not merely his orderly and encyclopedic knowledge of the basic health sciences--in addition, he seemed to present medicine as a holy art, marveling at the intricacies of the human body and showing enormous empathy for the suffering individual. At times, while he was examining patients with the manual dexterity of a piano virtuoso, he would close his eyes, as if communing with Hippocrates or healing spirits.

One session of morning rounds in the intensive care unit featured five patients with myasthenia gravis, each one with a different set of signs, symptoms, and response to therapy. He instilled in us that day a great respect for the infinite mysteries of the human body, wherein even an extremely rare disease can unfold in multiple, different ways.

A brilliant practitioner of physical diagnosis, a lost art in itself, Dr. Grob would map out the outline of a patient's liver by percussing the surface of the abdomen, then draw an outline on the bemused person himself (patients enjoyed this as much as the students, by the way). On other occasions, he would lie a pencil down on the left ribcage directly over the "point of maximum impression" [where the heartbeat is most easily felt] and we would watch the pencil bobbing up and down with every heartbeat.

In another impressive display of physical diagnosis, Dr. Grob showed me how to "feel" atrial fibrillation, a sensation resembling a "bag of worms" writhing under my hands. Who else would have taught us how to estimate a blood pressure by touching the wrist artery? I still use this skill almost every day, and several times in Cabrini Emergency Room it was actually of crucial importance.

I hope that you too will have your life enriched and ennobled by brilliant teachers and mentors. Dr. Grob represents to me a Golden Age of healthcare--the technology and information were not as extensive as they are today, but the empathy, sense of wonder, and ability to inspire will last me a lifetime. Thank you, Dr. David Grob. Hail and farewell!

Honi Soit Qui Mal Y Pense

Human beings have a wide range of belief systems, techniques of reasoning, and methods of problem solving. Some of them are logical. The issue at hand is not how one confronts complex geopolitical or sociological challenges that affect the planet. On the contrary, to paraphrase Mark Twain: “Man is the only animal that lies about its health or needs to.”

In numerous, unintentionally funny studies, experimenters derived statistics about weight loss from telephone conversations with the involved participants. The researcher would discuss height, weight, eating patterns, and exercise regimens with a disembodied voice on the other end of the telephone line. Was proof offered? Was there visible, objective evidence of these statements, perhaps provided by a digital optical device linked to an e-mail address? Or did the researchers rely on scientific noblesse oblige, a blind faith in the honesty and integrity of those being studied?

You already know the answer: many people lied. Interestingly, men lied about their height, hoping that their weight would seem better to the researcher if distributed among extra imaginary inches. Women who were less than contrite would give their weight in high school. Another study, even more mirthful than this one, added another step: the arrival at the experimental subject’s home of a small van with a scale in the back. Oops! The scale’s readings often didn’t match the reported poundage. But the deception these people attempted was minor compared to their self-deception, namely that the vital statistics involved were inconsequential—to the medical study, to the researchers, and to themselves.

Self-deception takes many forms, but the most potentially lethal ones concern health. “I don’t need to get a checkup because I feel okay.” “I read numerous health-related websites daily, which means that I have great insight into my own body.” “I take numerous vitamin supplements—so I don’t need to worry about cancer or heart disease.” “There are many studies that show no correlation between weight and human illness—please pass the chocolate syrup.”

Self-validation is a method used by self-deceptive individuals to rationalize their questionable behavior patterns. Albert Ellis called it “crooked thinking.” Dr. Stanley Krippner has written extensively on “personal mythology.” But I think it sounds better in French: honi soit qui mal y pense. Which I translate somewhat loosely as: “Whatever you say.”

May I offer some medical examples? A diabetic might tell me: “I can eat whatever I want—I just have to take extra insulin.” A hypertensive might offer: “I don’t need to follow a low salt diet. I’m taking a water pill.” An overweight person might step to the counter and order a low-fat muffin with a large orange juice. It’s right because I say it’s right!

The original French expression originally appeared in an entirely different context. It was a reproach to people who think that something relatively innocent is shameful and scandalous (namely, the accidental slipping of a leg garter while a woman was dancing in front of British royalty). I’ve brought the expression into modern times with its converse meaning—it isn’t scandalous because I say it isn’t scandalous.

“I’ve had a hard day at work, so I deserve to eat anything I want, especially at dessert time.” “My children aren’t overweight. That’s baby fat, and they will outgrow it eventually.” “March is the perfect time of year to go on a diet. I needed all that extra padding during the winter to protect me against the flu.” Do any of these sound familiar? Is there anything remotely logical in these statements? Have you heard (or thought) anything similar recently?

If so, go to the mirror, look at yourself, smirk, and repeat after me: honi soit qui mal y pense. And then, stop trying to fool yourself.

The Observer Effect

Principles of science can be useful tools, especially when you watch or read promotional material from the weight-loss industry. For the past 40 years, The Dark Ages of Dieting, Americans have been offered a wide range of ineffective therapies, all purportedly having innate logic and objective validity. Pharmaceutical corporations-- although themselves the subject of much controversy and scrutiny-- are exemplary models of ethical rigor when compared with supposedly trustworthy “nutritional” sources.

Let’s not discuss, for the moment, whether or not grapefruit, cabbage, red peppers, unlimited protein, the glycemic index, macadamia nut oil, or salmon is the unique cure for obesity—or why these epiphanies were reached by individuals, as opposed to physicians at the Mayo Clinic or the Pasteur Institute. Several years ago, I had the unique pleasure of congratulating a voluptuous television star on her new weight-loss vitamin line--I was being polite, and you would have too. Did she design the formulations from her own research into biochemistry and physiology? Could she spell?

Scientific research, a discipline totally unknown to a majority of Americans, includes certain “checks and balances” that ensure the integrity of the findings and their interpretation. One safeguard is protecting against the observer effect, a phenomenon somewhat tangentially related to the Heisenberg uncertainty principle. Here’s an easy example: students will behave differently if their exams are proctored by several teachers—observation of their behavior (by watchful monitors) will affect their actions (avoiding cheating). Do you drive more carefully when police cars, hidden cameras, or speed traps might be present? Observation of your behavior, whether visible or possible, makes you much more likely to follow the rules of the road.

How about a television spokesperson for a weight-loss program? Is he or she totally motivated by health concerns, idealistic beliefs, or the need to lower cholesterol? On the contrary, the mere fact that this individual is being observed (and, of course, paid) affects his or her own food choices, exercise schedule, and wardrobe contents. This doesn’t happen if the spokesperson is trying to sell you home insurance, power drills, or lawn furniture. Are you impressed when that spokesperson “sticks to the program” and is photographed in smaller-sized clothing?

A fascinating weight-loss study reported in the British Medical Journal several years ago described two groups of experimental subjects. The first group was given precise caloric guidelines by medical personnel and nutritionists. The second group, the “controls”, were simply told that they were in a weight-loss study but given no instructions of any kind. Not surprisingly, both groups lost weight, although the first group did slightly better. The observer effect was responsible for this unusual outcome. When people become aware that their weight is being watched by others—no matter what the reason—behavioral changes can occur, even if not specified or supervised.

How does the observer effect play a part in your daily life? That’s at the epicenter of The Park Avenue Diet, since one’s image—which is a projection into society of a lifestyle pattern—is by definition the only thing other people can observe. Upgrading appearance and behavior can enhance this phenomenon, leading to better relationships, job opportunities, and health. How the outside world perceives us is extraordinarily important—so let the observer effect become your strategic partner, not a mechanism of distortion and misinformation.

Albert Ellis

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.

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.

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.

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.