Sunday, January 18, 2015

Choosing Wisely

     Two weeks ago I was under the weather. A heavy precipitation event took place in my body (my nose was dripping), I was shivering like a lonely leaf on an autumn night, I felt hot and my muscles ached. A day later, I developed deep, course coughing. Shortness of breath then ensued. In brief, it was a whole catastrophe.

     Armed with over-the-counter multi-symptom medications, cough drops, and unfounded optimism, I arrived at work. Around lunchtime, Linda, my nurse, informed me that she talked with my doctor, Dr. Grossman, and that he will be seeing me today, whether I think I need him, or not. And with Linda I do not argue.

     I wondered what Dr. Grossman will do to help me. What tests will he order? What medications will he prescribe? I know Dr. Grossman for years. I know him to be a wise doctor. But after reading about the 'Choosing Wisely' initiative I was truly wondering: will my doctor, Dr. Grossman, be choosing wisely?

     'Choosing Wisely' is an initiative of the ABIM (American Board of Internal Medicine) Foundation. Its aim is to “encourage physician and patient conversations about overuse and misuse of tests and procedures to help make smart care choices.” On its website, '', you may find multiple lists of 'Five Things Physicians and Patients Should Question'. These lists were developed by societies of medical specialists in the USA. I counted 51 different lists by organizations such as the 'American Academy of Family Physicians', 'American College of Cardiology', and the 'American Headache Society'.

     Each list is composed of at least 5 tests or procedures that physicians and patients should question as being unnecessary, and at times even harmful. The American Academy of Family Physicians, for example, advises against an annual electrocardiogram (EKG) for patients without symptoms who are at low risk to develop coronary artery disease (blockage of the arteries delivering blood to the heart itself). They also recommend avoiding antibiotics for children aged 2-12 years with otitis media (ear infection) if they present “with non-severe symptoms where the observation option is reasonable.”

     The 'Choosing Wisely' initiative was developed by doctors and their societies, and not by health insurance companies or any governmental body. It therefore does not seem to solely aim at cutting costs, ration medical care, or undermine the patient-doctor relationship. Its declared goal, “to improve patient care through better treatment choices, reduced risks and, and where possible reduced cost,” seems plausible, even noble.

     But no initiative, not even the noblest, can pass without criticism. In an article published in the New England Journal of Medicine (February 2014), Dr. Nancy E. Morden and collaborators write that “on the surface,...” it seems that “physicians are willing to make recommendation to improve health care value even against their own financial interests,” but in reality, she notes, most medical societies participating in the 'Choosing Wisely' initiative were more likely to name other specialties' services, rather than their own services, as being low-value. The list of the 'Otolaryngology – Head and Neck Surgery', for example, includes three imaging tests (which are read by radiologists), but not even one statement on procedures such as tonsillectomy and tympanostomy ('ear-tube placement') “despite decades of literature on wide variation and overuse” of these procedures.

     To me, the 'Choosing Wisely' initiative is a welcome step in the right direction. So much of what doctors do may be unnecessary, wasteful, even harmful. The temptation to 'do more' is strong: patients want their doctors to 'do something', they want to be evaluated, they want to be treated; and administrators want doctors to 'do more' in order to generate the income their hospitals and health systems need to survive. So when I read the second item on the 'Choosing Wisely' list of the 'Society of General Internal Medicine' that states “Don't perform routine general health checks for asymptomatic adults,” I feel relieved, for doctors are moving in the right direction, in control, holding themselves back, avoiding unnecessary care that may do more harm than good.

     Dr. Grossman listened carefully to my story. He thoroughly inquired about my symptoms. He examined my throat and carefully listened to my lungs and heart. He did not order a chest X-ray, nor did he prescribe antibiotics. He told me to rest a little more and to come back if my symptoms do not improve. He is my doctor—a doctor who is choosing wisely, for I am feeling much better now.

Sunday, January 4, 2015

Princess of Onions

What can you learn from the story Knight of Onions and Knight of Garlic 
about the role of intention in choosing a professional career

     There will be a time in your life when you will be called upon to give advice to a younger person regarding the professional direction he or she should take in life.

     Any good advice, I have learned, should start with a good story. And the story most relevant to the what-should-I-choose-as-my-profession question is this:

     Once upon a time, there was a prince who traveled the world until he arrived in a remote, unknown and mysterious island. The king of the island invited the prince to a delightful feast. Nothing seemed to be missing until... until the prince realized that something was missing, something that nobody on the island had ever seen, no one had ever smelled, and nobody had ever tasted before – “the common, simple, garden onion!”

     Being the kind soul that he was, the prince gave the king the onions he just happened to carry in one of his golden baskets. A new feast was ordered, but this time it was cooked with onions, to perfection, its match was never met. The king was so grateful that he decided to return the favor. And so, after asking the advice of his seventy councillors, he rewarded the prince with a basket filled with golden coins.

     Upon return to his home, the prince threw a feast to which he invited the other princes in the neighborhood. (Oh! The life of a prince – from one feast to another.) He told the tale of the remote, unknown and mysterious island he visited, and its king, and the missing onions, and the gift of golden coins. Among the listeners was the king's son (a different price, I will call him the king’s son) who thought: “Why should not I achieve the like?”

     And so, the king's son embarked on a long journey to the island. Like the prince before him, the king's son was invited by the king to a feast. The feast was perfect, or to be more precise, almost perfect, for there was something lacking, a missing ingredient. Expecting to be rewarded with golden coins, the king's son provided the king of the island with the missing ingredients - garlic, and a lot of it. A new feast was ordered, but this time it was cooked with garlic (and onions), to perfection, its match was never met. The king was so grateful that he decided to return the favor. And so, after asking the advice of his councilors, he rewarded the king's son with something he regarded as being even more valuable than golden coins. He rewarded the king's son with an onion.

     The story of the prince and the king's son, called 'Knight of Onions and Knight of Garlic', was written by Hayyim Nahman Bialik and translated to English by Herbert Danby. It is told with great humor, in acrobatic rhymes and a dancing rhythm. But besides its linguistic beauty, the story has a moral: intentions matter. Those who act out of their love to fellow human beings will be rewarded. And those motivated by greed alone will fail.

     There are those who claim that the road to hell is paved with good intentions. But it is not the good intentions that pave the road to hell or to failure. Rather, it is poor planning and poor execution (and at times, I must admit, a stroke of bad luck).

     So what will you answer the young person seeking advice regarding their professional future? Start by checking their intentions: does the future schoolteacher aspire to help students materialize their full potential? Is the future architect passionate about designing homes that will be both functional and beautiful? Is the writer interested in sharing his ideas or in merely becoming a famous author? Ask the future cook if he truly wants to create an outstanding culinary experience.

     A few weeks ago, a daughter of a close friend of mine asked me if she should become a doctor. Trying to decipher her true intentions, I asked: “Do you want to help sick people?” She thought for a moment and responded with a simple 'yes'. I looked at her and I saw the most beautiful, good-intentioned, Princess of Onions.

Sunday, September 28, 2014

A Warning Against Joy

     There are warnings everywhere. A label on my toaster declares that I should beware of hot surfaces. My peanut package warns of the possible presence of peanuts inside. And in London, while using the tube (the underground train), the overhead system constantly reminded me to mind the gap (between the platform and the train, that is). Therefore, I was not completely taken by surprise when I read that the universe of warnings has recently expanded to include two human activities that are usually associated with joy.
     R. E. Ferner, an honorary professor of clinical pharmacology from the UK, embarked on a mission to explore the benefits and harmful effects of laughter. The results were recently published in the Christmas edition of the distinguished British Medical Journal. Ferner searched the medical literature using the search term 'laugh' and found not less than 4961 scientific articles. Then, articles by researchers by the names 'Laughing', 'Laughter' and 'Laughton' were removed from the analysis and so were other irrelevant articles including research on the Caribbean sponge Prosuberites laughlini. After reviewing the remaining articles, Ferner concluded that the potential benefits associated with hearty laughter include a decrease in the levels of anxiety, depression and anger, and a reduced risk of myocardial infarction (a heart attack). Turning to examine the potential harms of laughter, the distinguished professor declared that the results were no laughing matter, or to put it in Ferner's words: “laughter is no joke.” The potential complications caused by laughter on the heart, for example, include the development of a syncope, cardiac arrhythmias, cardiac rupture, asystolic arrest, and even death. There are also potential negative effects on the respiratory system (triggering an asthma attack, for example), on the central nervous system (cataplexy or sudden loss of muscle tone, and even a cerebral infarct), the gastrointestinal tract and the urinary tract. It seems that no system in our body is immune to the devastating effects of laughter. The good news, though, is that these severe adverse events have been rare, have usually occurred in patients with medical conditions that made them susceptible to such complications, and have taken place only after an episode of intense and sustained laughter.

     Professor Ferner's article itself is entertaining. Reading it, I found myself smiling at first, then giggling, and then bursting into short, syncopal episodes of rumbling laughter. In short, I almost fell victim to some of the more serious harmful effects so well described in the article.

     It seems that laughter is not the only pleasurable human activity that carries rare, yet significant risks; for another article, from the University Department of Emergency Medicine in Bern, Switzerland, suggests that sexual activity may lead to side effects so serious that you may end up in a hospital bed. Altogether 445 patients with sexual activity-related emergency department admissions were studied. More men than women were injured during sexual activity and most were young - the oldest individuals in the study were a 71 year old man, and a 70 year old woman. Some patients presented with the usual, expected side effects that are occasionally associated with sexual intercourse - bladder infection, urethritis and sexually transmitted disease. Others presented with serious complications such as cardiovascular emergencies or trauma. More peculiar injuries associated with sexual activity included injuries sustained in patients who seemed to have used their head for other than its intended purpose: 27 patients presented with a simple headache, but 12 had subarachnoid hemorrhage, and 11 suffered from transient global amnesia (perhaps some experiences are better left forgotten). “Sexual activity,” the authors claimed, “is mechanically dangerous, potentially infectious, and stressful for the cardiovascular system.”

     In the sea of warnings around us, one should design a strategy to stay afloat. I ask myself what risks should be ignored, and which should be considered an unavoidable cost of participation in the business called life. What action should we take in order to avoid the risks presented in these articles? Should we wear a frown rather than an occasional burst of hearty laughter? Should we be wearing a helmet in the bedroom? In order to stay afloat in the perpetually expanding sea of warnings, I always mind the gap – the gap between the risks we have come to know, and those which are worthwhile avoiding.

Thursday, September 18, 2014

Don't Just Talk the Talk, Walk the Wok!

     For me, visiting JJ's Wok-N-Grill is not just a routine, not even a ritual, it is a fortnightly rite. I visit JJ's on my way back from the Copper Country after two days of seeing patients. I arrive tired and hungry, with very high expectations. The restaurant is located in the unassuming Pearl Street Mall in Houghton. It is a one man, one wok show. The atmosphere is unpretentious, but JJ's food does not just taste authentic - fresh, sweet and salty, and pleasantly savory - it feels authentic.

     JJ is a confident man who cooks with exuberance. His place is the kind of restaurant where you are, at times, told what you would eat today, because JJ knows what is good, and more specifically, what is good for you. And so, after becoming a 'regular' and establishing a rapport with JJ, I was promoted to the desirable and enviable status of no-longer-allowed-to-chose-his-own-dish. Instead, JJ would say, for example: “today, chicken and mushroom, very good.” And I would oblige, showing no hesitation, feeling no reservation.

     As expected by the name of the establishment, JJ has a wok (I am not aware of a grill though). Each meal is prepared from scratch, in front of you, over intense inferno-like flames. “Heavy wok; short, very hot cooking gives taste,” JJ says. 

     My attempts to retrieve any more information from the man have not been very successful. When I asked him to share even one recipe, he asked if I would, in return, take him to the operating room and teach him how to perform surgery. 

     “I will write a story about you in the Mining Journal, good for business” I said, trying to perhaps bribe the man. But JJ remained steadfast. 

    “You can write,” he said, “today, chicken and peppers, good combination. Yes?” 


     The following is a recipe I have been working on. It is inspired by one of JJ's dishes. As promised in my last article, on the health benefits of nuts, the recipe includes a serving of peanuts (you may use other nuts). Although not as authentic as JJ's recipes, the result, I believe, is both healthy and delicious.

Stir-fried chicken with mini-peppers, mushrooms and peanuts (will feed 3-4 people)

10 yellow, red and orange mini-peppers
6 medium-size mushrooms
½ Jalapeno pepper
1 clove garlic, peeled
½” fresh ginger root. peeled
3-4 skinless boneless chicken thighs
4 tbs canola or vegetable oil
3 tbs Hoisin sauce
6 tbs soy sauce
1 cup roasted unsalted peanuts or cashews
3 cups cooked rice or one package Chinese-style noodles (such as Chow Mein Stir-fry Noodles)

For the marinade (optional):
1 tsp cornstarch
1 tsp beaten egg
1 tbs soy sauce
1 tbs of rice wine (Mirin) or dry sherry
  1. Cut each chicken thigh into 9 small cubes (about ¾ of an inch). If you choose to marinade the chicken (for softer, smoother consistency), mix all of the ingredients of the marinade until it becomes smooth, pour the marinade on the chicken, mix, and let sit in the refrigerator for at least 30 minutes.

  2. Cook the rice or the noodles according to the package instructions.

  3. Heat the wok to medium heat, add ½ tablespoon of oil and toast the peanuts until they brown (watch closely and remove the peanuts before they burn).

  4. Heat a wok to as high a temperature as allowed by the manufacturer. (I prefer a cast-iron wok that allows for extremely high temperatures rather than non-stick woks).

  5. Cut the mini-pepper lengthwise and then cut each half into two-three pieces. Slice the mushrooms, Jalapeno pepper and garlic. Cut the ginger into slivers.

  6. Once the wok is extremely hot, add 1 1/2 tablespoons of cooking oil to the wok. Add the garlic and ginger and immediately add the mini-peppers, Jalapeno peppers and mushrooms. Cook briefly while stirring the ingredients gently trying to use as much of the cooking surface as you can (2-3 minutes will suffice for the end result should be slightly cooked, somewhat crunchy vegetables). Then, remove the stir-fried ingredients to a separate plate.

  7. Add 2 tablespoons of oil to the wok. Add the chicken cubes and spread them so each cube touches the surface of the wok. After about a minute, add the Hoisin sauce and stir, then add the soy sauce and stir for 2-3 minutes until the chicken is done (it will become dark brown). Add the peanuts and then the stir-fried vegetables that you kept on a separate plate and stir together.

  8. Serve the final stir-fried combination over the freshly cooked rice or noodles. And Enjoy.

Monday, September 8, 2014

Bilingualism, a Blessing or a Burden?

     My mother-tongue died almost two thousand years before I was born. It died like languages do – gradually. It died as a result of a miscalculated revolt, a war that could not be won, bloodshed and exile. Almost two thousand years later, it was miraculously revived. And so, by the age of 7, and completely unaware of these dramatic turns in the history of my mother-tongue, I was quite fluent in Hebrew.

     For the Ministry of Education in Israel, Hebrew was not enough. Therefore, from the tender age of 7, I spent 4 hours a week in the classroom studying compulsory English. Many more hours were spent doing homework in English. Exams had to be taken, and in return, grades were given.

     The differences between Hebrew and English became evident: Hebrew is written from right to left and books are opened in what seems to the English speaker as the last page. Hebrew has only 22 letters (some are written differently when they appear at the end of a word). Its vocabulary is limited compared to that of the English language, nouns are not gender-blind (a chair is masculine, but a tomato is feminine), and the order of words in a sentence is less rigid ('I love you' and 'you I love' have the same meaning).

     Confronting two different sets of vocabularies and grammatical rules must have had some effect on my brain. For example, when looking for words to express myself, I am often encountered with the unpleasant realization that the words that appear in my mind are in the 'wrong language'. Words in Hebrew keep presenting themselves when I communicate in English and vice versa. This and other burdens of bilingualism are not unique to me. In an interview with NPR, Gustavo Perez Firmat, a Cuban-American who writes poetry, novels and academic works in both Spanish and English said: “I don't have one true language,” and “I have the feeling that I am not fluent in either one, words fail me in both languages.” He has the Bilingual Blues (a name he gave to one of his poems).

     But the news is not all bad for bilinguals. In their review 'Understanding the Consequences of Bilingualism for Language Processing and Cognition' published in the Journal of Cognitive Psychology, Judith F. Kroll and Ellen Bialystok confirm that “bilinguals activate information about both languages when using one language alone.” They also report that “studies of executive function have demonstrated a bilingual advantage with bilinguals outperforming their monolinguals counterparts on tasks that require ignoring irrelevant information, task switching, and resolving conflict.” Oh! What a relief it is.

     As if bilinguals did not have enough good news, a recent study published in the journal 'Neurology' found that bilingualism delays the age at onset of dementia. The study had a unique perspective. Prior studies looked at the effects of bilingualism on dementia in a population of immigrants, making it difficult to separate the effects of bilingualism from other related factors such as diet, lifestyle or ethnicity. The participants in this study live in Hyderabad, India where several different languages are spoken. And they have been living there for generations, making it easier to appreciate the true effect bilingualism has on the age at onset of dementia.

     The researchers looked at a group of 648 patients with dementia, 391 of them were bilingual. They found that bilingual patients developed symptoms of dementia 4.5 years later than the monolingual patients. The difference remained significant when the researchers considered different types of dementia (Alzheimer disease is just one type of dementia. Other types of dementia, such as vascular dementia, also exist). This difference in the age at onset of dementia was also observed in illiterate patients and was independent of other factors such as level of education, gender, occupation or place of dwelling (rural vs. urban).

     Is bilingualism a blessing or a burden? The answer may be encouraging for the bilinguals among us, and for those who wish to learn a new language. We intuitively knew the many benefits of mastering a second language (communicate, work, create and learn with people of other geographic locations and of different cultures). Then, the newer, more scientific evidence became available (bilinguals outperform in several important tasks, and the onset of dementia is delayed). But the most important benefit is often forgotten. Learning a new language is about finding joy and beauty – raw and untranslated – an adventure taken through a different set of words, sentences and ideas.


Sunday, August 31, 2014

The Stethoscope

Dr. Madjar's essay, The Stethoscope: “The sounds of the heart,” I said, “it’s beautiful.”
Don't just hear, listen! 


     It was during a rotation in the Department of Internal Medicine that I realized that our bodies are a confused orchestra, a cacophony of sounds. Early in the mornings, we would make rounds with our professor, Dr. Armon, shadowing her like ducklings following their mother. With each patient we followed the same routine: she would sit on the bed beside a patient, and then gently lean over him, aiming her stethoscope at his heart. “Shhhhhh,” she said, putting her finger to her lips, “Quiet! Let's listen.”

     Taking turns, we carefully sat next to the patient. Hesitantly, we aimed our new, shining stethoscopes at his chest. Anxiously, we listened. Asked to describe what we had just heard, one student said he heard a systolic murmur. Another said, “It was diastolic, certainly not systolic.” Yet another student noticed galloping heart sounds, “Like a horse, running in the meadow.” And when my turn came, I listened for what seemed to be a long time. I heard the heart beating, with rhythm and vigor, and perhaps a gentle swooshing sound as well. I tried to peruse, in my mind, through the chapter I read the previous night in DeGowin's Diagnostic Examination, and go over the recordings of heart sounds and murmurs I had listened to, but listening to our patient's chest, I could not decipher the matters of his heart. “The sounds of the heart,” I said, “it’s beautiful.” Dr. Armon looked at me kindly, totally ignoring the jeering smiles of my peers. “It is beautiful,” she said, “isn't it?”

     Listening to the sounds of the heart, lungs and other organs is an ancient art (called auscultation) that has miraculously withstood the test of time. At first, doctors listened by applying their ear directly (or over a silk handkerchief) to the patient's chest, or lungs. But then, in 1816, a French physician by the name of René-Théophile-Hyacinthe Laennec encountered a difficult situation: examining a young woman with symptoms of heart disease, René felt that direct auscultation was “inadmissible due to the age and sex of the patient.” And since necessity is the mother of invention, he immediately had an idea which he later described: “I rolled a quire of paper into a kind of cylinder and applied one end of it to the region of the heart and the other to my ear, and was not a little surprised and pleased to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of my ear.”

     Today's stethoscope is a binaural (allowing listening with both ears), flexible, light-weight fine-tuned acoustic instrument. It is mass-produced and reasonably priced. To listen in style I recommend you pamper yourself with a stethoscope such as the Littmann Classic II SE ($76 on Once you have got your hands on this beauty, lie down in bed and turn all electronic devices off. And then: listen to your heart beating; listen to your lungs while you are breathing deeply, in-and-out; place your stethoscope over your abdomen, press gently and wait long enough to hear the sounds of your bowels moving (peristalsis); then move your stethoscope over to your carotid arteries and note your blood rushing, gushing in your arteries. You are alive! And making lots of noise doing so.

     While the origin of the word stethoscope is from Greek (stēthos, chest; and -skopeion, to look at), a slight change in spelling, 'status-scope' may shed light on another role of this fine instrument. Stethoscopes are carried conspicuously, with pride, allowing everyone to associate the person who carries a stethoscope with the status of being a doctor, or other health care professional.

     Although I am not a cardiologist, I examine each new patient using a stethoscope. I become a student again, searching for rales, rhonchi and wheezing, for heart sounds, rhythm and murmurs, for bowel sounds and bruits. I then put my stethoscope aside, reminding myself that for me, a stethoscope is not a status symbol nor is it a mere instrument of listening. Rather, it is a note-to-self that says: don't just hear, listen!

Sunday, August 24, 2014

Adventures in Self Diagnosis


     There is something I need to tell you: I am a recovered do-it-yourselfer. Now that I said it, let me clarify: by 'recovered' I do not mean completely recovered. There are days, for example, where I find myself in a Do-It-Yourself megastore, at Menards or just across US41, at Lowe's. There, I wander seemingly aimless through the different departments, and along the aisles. I take stock of tools that may become handy, replacement parts, missing screws and lonely nails, appliances and raw materials. I smell the scent of cut wood at the lumber department, and that of fresh flowers in the garden section. I observe the droves of patrons and I try to see who is still a devoted do-it-yourselfer and who is a fellow almost-recovered do-it-yourselfer, just like me.

     This self-reflection did not appear out of the grey skies of Marquette on a cloudy autumn day. It is a result of my encounters with a few patients of mine who themselves are do-it-yourselfers. I call them the doc-it-yourselfers, for they decided to cut the middle man (the doctor) and to confront their maladies, at least partially, on their own.

     Technology is almost all-ready for the do-it-yourself medical revolution. Medical information has never been so approachable, so transparent, so searchable. And doc-it-yourselfers take advantage. They Google their symptoms. They self-diagnose. They search for solutions, for treatments. They come to their appointments ready, armed with a list of questions and answers they downloaded from the internet. They are active participants in their medical care. Is there anything wrong with that?  

     In an attempt to address that question, I visited the symptom-checker tool of the Mayo Clinic ( It is a paradise for doc-it-yourselfers. To test it, I clicked on 'headache', then I checked 'moderate to severe', 'around face or forehead', 'is sudden', 'less than a few minutes', 'gradually becomes more frequent', 'worsened by chewing', 'relieved by lying down in the dark', and 'accompanied by change in personality, behavior, or mental status'. And when I pressed on 'Find Causes', I found out that should I have had such a headache, I would most likely be suffering from a brain tumor, or migraine, trigeminal neuralgia, encephalitis, giant cell arteritis, cluster headaches, tension headaches, or TMJ disorder. I immediately realized that if I had used this website for its intended purpose - to self diagnose as a layperson, I would most likely develop another set of symptoms - chest pain, palpitations, and fear of death. (Would that be consistent with a heart attack? I was afraid to check.)

     Self diagnosis is not limited to the realm of the internet though. Given the opportunity to self-diagnose, patients will gladly skip the middle-man. A study by J. C. Donofrio from the Department of Emergency Medicine in Rhode Island looked at 50 women with symptoms suggestive of a urinary tract infection. 82% of the women thought they had a urinary tract infection. 60% preferred, if given a choice, to buy over-the-counter antibiotics instead of seeing a doctor. 30% were able to identify a specific antibiotic they would take. But only 61% of the women who were self-diagnosed as having a urinary tract infection, actually had one. The authors concluded that “women should be encouraged to seek medical attention to confirm the diagnosis.”

     Meanwhile in New Zealand, a 48 year old man searched his symptoms online. He decided that he had a renal stone and treated himself with pain medications.  After 10 days, and after his symptoms did not improve, he consulted his family doctor and convinced him that his diagnosis is that of a kidney stone. Two weeks later, once his symptoms got even worse, he paid a visit to the Emergency Department where he was diagnosed (this time correctly) with missed appendicitis complicated by severe perforation (which could be life-threatening). “When formulating a differential diagnosis,” the authors who described the case wrote, “extreme care must be taken not to be unduly influenced by a patient's self-diagnostic conclusion.” 

     The other day, I diagnosed a leaky faucet in my kitchen. My initial instinct was to cut the middle man, search the internet for solutions, pull out my toolbox, make several trips to the do-it-yourself megastore, and learn, on the fly, the secrets of plumbing. Instead, I reflected on what I have learned about doc-it-yourselfers, self-diagnosis, and self-help. I picked up the phone and called a professional plumber.






























Saturday, June 21, 2014

How to Become Exceptional

     You would expect doctors, for the sake of their patients, to do their job well. You would expect doctors that have dedicated their lives to the study of medicine - through medical school and a long residency program - to almost uniformly reach the highest degree of expertise.

     A new study by Dr. Birkmeyer and colleagues, published in the New England Journal of Medicine, dares to ask interesting questions: are there significant differences in the abilities of fully-trained doctors? And if so, do these differences make a difference in terms of their patients' outcomes?

     This is how the study was conducted: twenty bariatric surgeons (surgeons specializing in the treatment of obesity) submitted a single videotape of themselves performing laparoscopic gastric bypass. To prevent any bias, the identity of the performing surgeon was concealed. These videotapes were then viewed by their peers, also bariatric surgeons, and rated. The raters judged the gentleness of the performing surgeons, the quality of the their surgical exposure of tissues, the way they handled surgical instruments, the smoothness of their motions, and the flow of the operation. The general surgical skill of each of the operating surgeons was then summarized by giving each performing surgeon a score.

     Reassuringly, none of the surgeons flunked the test (the lowest score, 2.6 on a scale of 1 to 5, was higher than the skill level expected from a surgeon toward the end of his training). On the other hand, only a few surgeons reached a score close enough to that representing the skill level of a master-surgeon.

     Am I surprised by the observed difference in surgeons' skills? Not at all. First, because it just follows the laws of logic: people differ from each other; doctors are people; and therefore doctors differ from each other. And second, because I have observed and collaborated with quite a few surgeons in my life, and I can attest that some surgeons are exceptional (I call them 'naturals', short for 'natural talents'): they press the scalpel onto the patient and the skin submits; they attack human maladies with strategy and might; they navigate using anatomy as their map; they cut gently, handle with care, and sew precisely; and as they leave, they bring tissues together, perfectly mended. And then there are other surgeons...

     Does the observed difference in surgeons' skill (the art, the beauty of surgery) translate into actual difference in patients' outcomes? Once the performing surgeons in Birkmeyer's study were divided into 3 groups of expertise, it became clear that surgeons' skill had a major impact on patients' outcomes. Compared with patients treated by the highest-score group of surgeons, patients treated by the lowest-score group were according to the study “at least twice as likely to die, have complications, undergo re-operations and be readmitted after hospital discharge.”

     If surgical skills are so important, one wonders what factors are associated with higher surgical skills. According to the study, it is not the number of years a doctor spent in practice, or whether he had fellowship training (advanced training following a residency program), nor is it related to her affiliation with a teaching hospital. What is it, then?

     Before I reveal the answer, I will tell you about Malcolm Gladwell and his book 'Outliers, The Story of Success'. In it, Gladwell examines the factors that contribute to the extreme success (therefore the name 'Outliers') of individuals such as elite hockey players, Bill Gates, and The Beatles. Gladwell's conclusion: the key to success is practicing a specific task for a total of at least 10,000 hours.

     Birkmeyer's study does support Gladwell's conclusion. It seems that in order to become a great success as a surgeon, one should accumulate a greater number of hours performing surgery: “Surgical skill was,” Birkmeyer states, “strongly related to procedure volume.” The highest-score surgeons performed 241 bariatric procedures a year compared with 106 procedures a year in the lowest-score group.

     Could you become exceptional at what you do for a living, or in what you do for fun? Would 10,000 hours suffice? Here is my recipe: first, take advantage of the variability in human talent and choose a field in which your natural talent shines (look at me, for example, and it would become immediately evident that no matter how long I practice, my chances to become a prima ballerina are slim). Then, work hard to develop your abilities. And with a little luck (the right place, the right time, etc.), you too may become exceptional. Sounds complex? Difficult? It is because becoming exceptional is, well, the exception.

In the Battlefield of Ideas (about stress incontinence, Kegel exercise, and the sling procedure)

     Medicine is a vast battlefield in which competing ideas are constantly tested. Some ideas gain initial popularity, then some momentum and eventual acceptance. Other ideas are short-lived, quickly losing ground to the rise of newer, more appealing ideas.

     The following is a story about ideas. It starts like a joke (an Englishman, an Irishman and a Scotsman enter a bar...) but it is actually about an American, a Swede and several Dutchmen who entered the battlefield of ideas seeking to solve the problem of urinary incontinence in women (male readers should keep reading for there is important information here for you too).

     The American, Arnold Kegel, was a gynecologist and an inventor. He invented the Kegel perineometer, an instrument designed to assess the strength the pelvic floor muscles by measuring air-pressure inside the vagina. The Kegel perineometer became obsolete (although you can still buy one on, the Chinese competitor to Amazon). On the other hand, Kegel's idea - that the muscles of the pelvic floor can be trained and strengthen (Kegel exercise) and that doing so may be beneficial to one’s health – withstood the test of time, for several decades. Kegel’s claim that “the pubococcygeus (a muscle in the pelvic floor) is the most versatile muscle in the entire human body” might sound exaggerated, but his and other studies suggest that strengthening the pelvic floor muscles play an important role in the treatment of urinary incontinence, pelvic prolapse (prolapsed bladder, for example) and even sexual function. Kegel claimed that women performing Kegel exercise could achieve orgasms “more easily, more frequently and more intensely.” And years later, Kegel exercise was shown to improve erectile dysfunction and premature ejaculation in men.

     The Swede in my story is no other than Dr. Ulf Ulmsten, who in 1996 described a new procedure for the treatment of stress urinary incontinence (urinary leakage at the time of straining such as with coughing, or laughing). Traveling the world, he gave talks in English colored with a thick accent that would not put to shame the Swedish Chef in the Muppet Show. His idea, to treat stress incontinence by supporting the urethra with a hammock-like, long and narrow strip of synthetic mesh, gained wide acceptance. And soon thereafter, the mid-urethral sling, a minimally-invasive procedure that takes less than 30 minutes to complete, and results in excellent outcomes and minimal morbidity replaced the more involved procedures that took main stage before it.

     Which treatment for stress urinary incontinence is better? Is it Kegel exercise or the midurethral sling procedure? Several Dutch doctors decided to resolve the conflict and bring resolution. They did so in a study, 'Surgery versus Physiotherapy for Stress Urinary Incontinence' that was published this week in the New England Journal of Medicine. 460 women with moderate to severe stress urinary incontinence were randomly assigned to either physiotherapy or a midurethal sling procedure. One year later, the rate of subjective cure (as reported by patients) was significantly higher in the group of women who had surgery (90.8% vs 64.4%). Similarly, the objective cure rate (no incontinence observed during a cough stress test) was also higher in the women treated with surgery (76.5% vs 58.8%). The number of adverse events in the surgery group was, according to the authors, 'infrequent.' However, these adverse events were not inconsequential and while most adverse events could be successfully addressed during surgery, 6 of the 215 women who had initial surgery needed re-operation.

     Reading this article, I wonder which idea really won? Was it Kegel exercise? Or was it the Ulmsten's sling? And what is the value of the additional information provided by the Dutch study? For me, things stayed the same and there is no clear winner: the Dutch study proved (again) that Kegel exercise has a good chance of cure with no risk of adverse events, and that surgery works even better but carries small but not inconsequential risks. I therefore encourage woman who are willing and able to perform the Kegel exercise to do so. And if symptoms remain bothersome, I perform surgery as a measure of last resort.

     In the battlefields of medicine, the war between competing ideas is constant and fierce; only few ideas survive the test of time, and only seldom does a winner take all.

Sunday, September 22, 2013

The Evolution of Monogamy

     The other day, I thought, for a brief moment, that I discovered a new species - the Homo matrimonous. Its members are the long-time married couples.

     And this is how it happened: I met with them in my office. The man, Bernard, was in his eighties, and his wife, Sarah, looked several years younger. They sought advice for the husband's medical problem but it was Sarah who answered most of my doctorly questions. She did the talking and Bernard did the nodding. “So what did you do for a living?” I addressed him directly. “He was a university professor,” she said. “And how long have you been married?” I tried to extract at least a few words from his mouth. “We have been married for so long, that;” he said. “That we complete each other's sentences,” she said, “we were high-school sweethearts, I could not have picked a better husband, could I?”

     That night, I stumbled upon the new issue of 'Science' magazine. In it (was it divine intervention? I wondered) were two articles that could shed light on the subject of long-term relationships. 'Why Male Mammals are Monogamous?' opened with a statement and then a question: male mammals have a greater potential for producing offsprings than female mammals (a man, for example can have multiple children from many different woman). Why, then, would a male sacrifice his potential reproduction and confine his reproductive activities to a single female?

     In an attempt to answer this fascinating question, D. Lukas from the Department of Zoology in Cambridge, United Kingdom, analyzed no less than 2545 non-human mammalians species. He found that monogamy is not common among mammalian species: in 68% of mammalian species, females were solitary (live independently and encounter males only during their mating); in 23% of mammalian species, females were living in social groups (several females share a common range, or forage); and only in 9% of these species, females were socially monogamous (a single male and a single female sharing a territory).

     After analyzing the data and considering the evidence, D. Lukas arrived at an interesting conclusion: social monogamy, he claimed, evolved in mammals where competition for feeding between females was intense. This caused females to be intolerant of each other and live far apart. Under these conditions, the best breeding strategy for a single male was to guard a single female, and to live with her on one territory, hers.

     As to man, the question 'Why Monogamy?' lingers. Evolutionary biologists believe that our ancestors were polygynous. And Lukas writes “the evolution of human monogamy could have been the consequence of the need for extended parental investment.” Or, ”the result of a change in dietary pattern that reduced female density and limited the potential for males to guard more than one female.”

     When Sarah and Bernard came for a repeat visit, I noticed that when I presented them with his diagnosis, she looked concerned, and then she reached for his hand. In my imagination, I saw Sarah and Bernard, the high school sweethearts: Sarah was young and pretty, Bernard was tall and full of life. I imagined them on their wedding day, and a year later holding their first child. I saw him sitting in his La-Z-Boy and reading the newspaper while she was working in the kitchen. I saw them bickering with each other and then making peace. I saw them sending their kids to college. I saw them sitting around the Thanksgiving table with their children and grandchildren. And when my mind shifted back, they were sitting in my office again, waiting. I forgot species and territories, I ignored mammalian evolution, dietary patterns, and competition for feeding. I dismissed breeding strategies and solitary females. I even forgave the miserable attempt to explain man's behavior by reducing it to a mere strategy of gene propagation. I saw Sarah and Bernard: two people sharing their histories and hopes, a man and a woman carrying a basket full of each other's memories.

     And when Sarah asked me to keep Bernard alive for a few more years because she does not know how she could live without him, I promised her to do my best.

Light at the End of the Tunnel

     And at the end of life, yet another transition awaits: from life to death, from being to being no more. What happens at the twilight zone, just before life ends, is an interesting question. And attempts to better understand this 'near-death experience' have always drawn the attention of curious minds.

     Before I dwell on the recent attempts made by the scientific community to address the phenomenon of near-death experience, I wanted to tell you about a Russian writer by the name of Lev Tolstoy. Yes, he wrote 'Anna Karenina', and 'War and Peace', but much more relevant to our discussion is his novella 'The Death of Ivan Ilyich'. Tolstoy's characters suffer from palpable pain, heart-wrenching grief, and tremendous misery. And such is the story of Ivan Ilyich, who at the age of 45 developed incurable and painful disease. His pain was excruciating, his suffering unimaginable. Desperate, he sought medical advice, but “it was all as he expected, it was all as it was always done. The waiting and the assumed doctorly importance...” Diagnoses such as a floating kidney and appendicitis were triumphantly made. Later, “Ivan Ilyich drew the conclusion that things were bad,” and in the end, there was no relief, no cure. He realized that he was not merely ill, he was dying.

     'The Death of Ivan Ilyich' ends, how surprising, with Ivan Ilyich's death. The book is short, but Ivan's painful death is studied in details as if it was a scientific journey into the soul of a dying man. And what exactly was the near-death experience Ivan Ilyich had? Tolstoy writes: Ivan Ilyich “sought his own habitual fear of death and could not find it. Where was it? What death? There was no more fear because there was no more death. Instead of death there was light... He drew in air, stopped at mid-breath, stretched out, and died.”

     The attempts to solve the mystery of the last moments of life did not end with Tolstoy, nor did it end with the demise of his fictional character, Ivan Ilyich. More than 100 years after the publication of 'The Death of Ivan Ilyich', a group of Dutch scientists set to investigate the experiences of 344 patients that were successfully resuscitated after their hearts had stopped beating (cardiac arrest). Out of this group, 62 patients (18%) reported 'near-death experience' with at least some recollection of the time of their death. Most patients reported that they remember having positive emotions, half of the patients reported being aware of themselves being dead, and several patients reported out of body experience, moving through a tunnel, observation of colors or of celestial landscape, and meeting with deceased persons. But more interestingly, fourteen patients (23%) had experiences similar to the one described by Tolstoy, whereby they had “communication with light.”

     More recently, a group of scientists from the University of Michigan went even further in their quest to understand near-death-experiences. In their experiment, they studied adult rats. They served the rats food and water and let them acclimate to their new home at the laboratory. Then they put the rats under anesthesia and implanted electrodes in their hearts, and into the cortex of their brains. They fixed the electrodes to the rats' skulls using dental glue. Then they injected potassium chloride solution into the rats' hearts, inducing their death. What followed was a surprise: at their last moments of life, the rats' brains was not quieting down or shutting off. On the contrary, their brain activity was surging, producing oscillations that were “global and highly coherent.”

     The scientists from Michigan then took a far-reaching leap to humans and their near-death experience: “We now provide,” they wrote “a scientific framework to begin to explain the highly lucid and realer-than-real mental experiences reported by near-death survivors.” And the poetic and compassionate description of near-death experience by Tolstoy became a simple current of minute electrical impulses.

     If life is a series of consequential transitions, then at the end of life, yet another transition awaits. When my time comes, I would prefer my last vision of life be described by a writer, not a scientist.

How to Wait

     Lately, I have noticed that my general state of anticipation is often interrupted by unrelenting periods of waiting. I wait in a line at the grocery store, I stand in a line at the bank, I remain on the line for the next available representative (only because my business is important to them), I wait at the gate for an airplane, and at times, I am jammed in traffic, idly sitting in a car.

     Giving the subject a deeper thought, I realized that I, too, add to the unbearable burden of global waiting. But I do so in style! While others arrange their patrons in a long line, separate them into several smaller lines, or form a 'zig-zag', serpentine sort of a line, it is members of my professional group, doctors, that have been using, for generations, a distinct architectural structure with an unapologetic name that hides nothing – the 'waiting room'.

     Solutions for 'The Problem of Waiting' are as ancient as the line itself. As with almost any other problem, one solution is to do nothing, for the waiting line carries valuable information: that the service or the product provided at its end is worth waiting for. Still, at times, a line, especially a long line, sends another message – that of inefficiency, even chaos. And patrons react - by leaving.

     In the eyes of mathematicians, 'The Problem of Waiting' is solvable by using mathematical models and formulas. I am not going to elaborate on these models for fear of creating lines of readers, heading for the exit, as they are trying to escape the boredom of mathematics. Instead, I am going to briefly mention that the length of a line, according to the queueing theory (the mathematical study of waiting lines) is determined by the number of servers, the rate at which customers seeking a service arrive, and the time required to complete the tasks at hand.

     The wonders of these models and formulas may work like this: as you are sitting in the dreaded waiting room, waiting for your doctor, you are starting to wonder why it is taking so long. You immediately remind yourself of the queueing theory. And you forgive your doctor because you realize that in the case of medicine, the number of servers is limited (doctors are not easy to come by), the rate at which patients arrive to seek treatment is highly unpredictable (picture an emergency room minutes after a motor vehicle accidents with multiple injuries), and the time required to complete a task is highly variable (addressing a sore throat may take 7 minutes, but Mr. Smith comes in with chest pain, diabetes, hypertension, an in-growing toe nail and a long list of questions he compiled after searching the internet).

     Most of us, though, are not so cerebral, and while we try to analyze our queueing condition rationally, we fall victim to our 'standing in line' emotions and feelings. 'The Problem of Waiting' quickly translates into smaller, yet critically bothersome psychological problems: waiting in line, we get bored; expecting the line to move faster, we get frustrated; and seeing someone else cutting the line in front of us, makes us angry.

     The other day, my patients were perfectly scheduled with enough time allocated to each, and an occasional gap in the schedule to allow for an additional patient in need. But an emergency surgery put me “well behind schedule,” and Mrs. J. was waiting for me for almost an hour. Yet, when I entered the room, sincerely apologizing for my delay, she greeted be with a smile. “I was sitting here reading my book,” she said solving the 'problem of boredom'. “Your nurse told me that you had to perform an emergency surgery,” she added, solving the problem of 'I-am-angry-because-others-cut-the-line-in-front-of-me' problem. And “I know that it may take some waiting at the doctor's.”

     The next and last patient that day was less understanding, a frown crossed his face. I finished the day exhausted, and thirsty. I decided to stop at the fast-food joint and to quench my thirst with a tall glass of soda. Driving into the drive-through I reviewed the advantages of the fast-food industry over medicine – seemingly unlimited supply of servers, short and fixed preparation time, and relatively predictable rush hours. And yet, as I approached, I realized that I would have to wait, for there was a line of three cars standing in front of me.

A Memorable Read

Sharon falls in love with her books, but not faithfully. She commits to live-happily-ever-after with one book, but later she abandons it and dates another in secret, only to return to the arms of the first book, findings comfort and solace in its pages. She is a general, commanding an army of books that occupy our home. Some are obedient, standing tall next to each other on shelves like good soldiers, but others have defected from the line of duty. They lie on top of each other at different angles and threatening to fall. At times her books are an angry crowd hungry for attention. They demonstrate on chairs and sofas and on tables and desks. Yet others are shy, quietly waiting for their turn, hiding in the bedroom upstairs, in the kitchen cabinets, and on the countertop, just around the fruit plate. Whether they are non-fiction or fiction; biographies or memoirs, suspense or murder mysteries; simple stories or convoluted plots, Sharon reads them all.

Like Sharon, I read too. But I choose my books carefully. I judge books by their cover, and by their weight, and the size of their fonts. I like short stories in soft covers, and moderately complex essays with bright, concise ideas. To prevent confusion, I prefer tales with less than five characters whose names and looks are different from each other. I prefer plots in which nobody hops on an airplane, and all characters stay put. I like my readings to be completed in one sitting: articles on current and past events, art and leisure, money and business, science and medicine. When I read, I fashionably wear a pencil tucked behind my ear, and at times when I feel the urge, I draw it like a sword, and I mark interesting ideas, words that I did not know existed, and just anything I find beautiful.
The other night, I asked Sharon: “In the end, what will happen to our memories?” She stopped reading her thick book, 'War and Peace', I believe it was, and said, “write a memoir and your memories will last forever. I may read it too, if I find some time.”

I thought the discussion on memories was over, but on the next day Sharon urgently correspond, via email, informing me that she just read an article I would be interested in,. “It is about memory, memories, and their preservation,” she wrote. The study 'Life-span cognitive activity, neuropathologic burden, and cognitive aging' was conducted by Robert Wilson and his colleagues from Rush University Medical Center in Chicago. It was published in 'Neurology'. Participants in the study were first asked about their life-long participation in cognitively-stimulating activities such as writing letters, visiting a library and reading books. Their cognitive function (including their memory) was then measured, yearly, using 19 different tests. Several years later, once the study participants eventually died (of natural cause I must clarify; the authors should be congratulated for their patience), their brains were removed, and their brain tissue preserved, sectioned (I will spare you the details), examined under the microscope and evaluated for changes typical of Alzheimer's disease (amyloid burden, presence of Lewy bodies). The results were clear: “more frequent cognitive activity across the life span has an association with slower late-life cognitive decline.” In other words: the more people read, the better they remember.

I tried to remind myself that statistical associations do not necessarily mean cause-and-effect relationships. But still in my mind I could see the droves of avid readers, discussing the findings of this research in book stores and in libraries, in book clubs and in literary forums over the internet.

As for myself, and just to be on the safe side, I immediately asked Sharon for some book recommendations – longer books, with multiple characters who tirelessly wander around the world in search of meaning.

What is Cancer? An Answer in Three Short Stories

     I am often asked what cancer is, how cancer can be won, and why a battle with cancer is sometimes lost. I could, of course, resort to a game of definitions such as 'cancer is a disease where abnormal cells grow out of control'. But people usually learn from stories better than they do from cold, dry facts, so I decided to tell you a story about three people I know, and about their cancer.

The First Story: Lance's Journey Back to Life

     I have never met the first person I am going to tell you about. Yet, I feel that I know him, because he is a celebrity, and as such, a person other people feel they know well. I read a book he wrote, 'It's Not About the Bike, My Journey Back to Life.' And then I watched a video clip of him riding a bike: he was working the pedals hard, his bicycles swaying under him. He was riding up a steep hill. I could almost hear his heart pounding, his lungs puffing. And when he crossed the finish line, raising his arms into the air, his hands turned into fists, I could see that his face, his whole being, was screaming victory.

     Before he won the 'Tour De France' seven times, Lance Armstrong won over cancer, testicular cancer. His cancer, like every cancer, started with one of his own cells, a single abnormal cell, a cell that broke loose from its program, a cell that went rogue.

     Normal cells contain information within their DNA, the genetic code that dictates their shape, function and behavior. This code also dictates the cell's life cycle. It tells the cell when to divide and multiply, it instructs the cell when it is time for it to die (it is natural for our cells to die and be replaced by newly formed cells). But the cell that started Lance's cancer was different; it was defective. It carried the wrong information. It escaped the normal program every cell has. Instead of obeying the normal code of behavior, it started to multiply rapidly and uncontrollably. As a result, many abnormal cells were formed. These cells possessed bad characteristics: they could invade tissues around them, they could travel into lymph vessels and lymph nodes, and into the blood vessels, carrying themselves to remote destinations. They could evade the natural process of cell death and escape the immune system.

     Before long, Lance had a very serious condition: an advanced stage, metastatic, testicular cancer, with metastatic spread to his lungs and brain.

     The news that Lance had cancer hit him hard. And Lance fought back. He consulted his doctor and then he got a second, and a third opinion. He studied the medical literature. He considered his treatment options and the side effects and complications involved with each of them. He examined which treatment option will give him the best chance to return to competitive bicycling. Considering his survival, he repeatedly asked himself: “What are my chances?”

     The road to Lance's cure was long and tremendously painful. His cancerous testicle was removed by a urologist; his brain metastases were taken out by a neurosurgeon; his lung metastases were addressed by an oncologist using aggressive chemotherapy. And, beating almost all odds, Lance Armstrong won. In the winter of 1997 he was declared cancer-free.

     In his book 'It's Not About the Bike, My Journey Back to Life,' Lance writes: “When you think about it, what other choice is there but to hope? We have two options, medically and emotionally: give up or fight like hell.” And “pain is temporary... If I quit, however, it lasts forever.”

     For Lance, the battle against cancer is a competition, a war, a race that should be won.

     But then he adds: “The question that lingers is, how much was I a factor in my own survival, and how much was science, and how much miracle?”

     But I have a lingering question of my own: if facing cancer is a war and those who survive are winners, what should we call those unfortunate souls who succumb to the disease?

     In the next couple of stories I will tell you about two more cancer patients I know, but before you continue to read, I would like to remove any doubt from your heart: 'losers' is not the correct answer to the question above.

The Second Story: Shlomi's Story

     My brother and I are separated by 6890 miles, at least 24 hours of travel, 7 hours of time difference, and a long flight that spans over three continents, two Great Lakes, an ocean and a sea. I live in the Midwest (bad weather, good neighbors) and he resides in the Middle East (good weather, unpredictable neighborhood). Lately, we have been separated by another divide: I am a doctor, and he is a cancer patient.

     He tells me that having a doctor in the family can become handy. That is because people who live on both side of the divide between cancer patients and their doctors do not speak the same language. He, for example, speaks both Hebrew and English, while I am also well versed in Medicalese, a language spoken by doctors.

     When thinking in Medicalese I use words like: carcinoma, stage, grade, invasive, metastasis, and 5-year survival rate. And he wants to know: Is it cancer? Am I going to survive? How long do I have to live?

     The difference between doctors and patients is not merely in the vocabulary they master. For I, as all doctors, have seen the different faces cancer has. And I know how cancer kills: It is not personal! Cancer cells have no face, or emotion, or a grand scheme. They are devoid of motivation or personal drive. They just do what they are programmed to do - multiply. And at times they invade tissues around them, replacing normal cells and preventing them from performing their tasks – lung cells can no longer participate in respiration and liver cells can no longer remove toxins from the blood stream. Cancer cells can also push and block one of the many conduits or tubes in the body – blood vessels that supply blood, or an air duct that deliver oxygen. Or, cancer cells may just sit there and multiply, quickly, using up nutrients, thereby starving normal cells, until they can survive no longer, live no more.

     Shlomi and I were sitting at Ichilov's Oncology outpatient Clinic in Tel Aviv. We were waiting for the results of his blood tests which would determine if he could receive another course of chemotherapy. He showed me the results of his CAT scan and asked me to translate from Medicalese to 'normal people's language.' At that moment, I did not want to be a doctor. I wanted to forget what I knew about cancer, and the ways it can kill. For once, I wanted to be just a 'normal person’.

     I looked at the report and I knew that the tumor was advanced and that it could not be surgically removed. But there was good news too: the changes from the last CT scan were small, and the spread of cancer was limited. Then the nurse came over, a wide smile on her face, saying that the blood cell count was stable and that Shlomi could proceed with another course of chemotherapy. And Shlomi, he jumped out of his chair, his face alight with happiness. Good news, he said, good news. Minutes later, his chemotherapy, part cure, part poison, was silently, slowly dripping into his body.

     At that moment, my Medicalese was totally forgotten. I asked myself: Is he going to survive? How long does he have to live? And then I realize that the hard, cold facts that I knew as a doctor were no longer important, and that no matter how this story was going to end, it was Shlomi's spirit, facing cancer daily, with temporary defeats but eternal hope that was winning.

The Third Story: Dolores, the Invictus

The diagnosis

     This scene takes place in a doctor's office. The walls are painted in a comforting beige. Dolores, a patient in her late sixties, is sitting on the left. The doctor, wearing a white coat, a stethoscope hanging around his neck, is sitting on the right. The doctor and his patient, Dolores, are leaning toward each other, engaged in conversation. He is doing most of the talking. She listens. And she asks a few questions. Imagine the expression on Dolores’ face: her forehead is tense, and her eyes are focused on the doctor as she is carefully listening to what the doctor is saying. He is talking in a soft voice, but he brings upon her terrible news. It is a new diagnosis – she has bladder cancer.

The treatment

     Bladder cancer tends to recur. The doctor may remove a tumor but then, several months later, the tumor can come back, at the same place, or in a different location along the urinary system. For each treatment, Dolores is put to sleep, the doctor looks through a cystoscope into her bladder and removes the new tumors. And Dolores is pronounced free of cancer, until a new tumor arises, and so on, and so on.

A portrait of Dolores

     Her hair is dyed and is carefully combed, she wears her makeup tastefully, her dress is red and bright. A smile lingers at the corners of her eyes, a smile of confidence that indicates that she had lived a life that could fill the pages of a novel. From the way she compliments the doctor on the dimples in his face (“dimple-face”, she calls him at times, making him slightly uncomfortable), he deduces that she had won the hearts of many. But looking at her face, the doctor can also see sorrow, and worry, and pain. And determination, and hope, to keep living.

The decision 

     After years of treatment, a new tumor was found in Dolores' bladder. It was unlike any of the cancers that were previously removed. The new cancer was small but its cells were more aggressive, it invaded deeper into the wall of the bladder. It could not be removed without taking the whole bladder out. This type of surgery is extensive, with significant risks of complications. Moreover, without a bladder, Dolores' urine would have to be diverted to an opening in her abdomen (called a stoma) where it would be collected in a plastic bag. After receiving the news, Dolores decided to avoid surgery. She was fully aware that without surgery the cancer cells would multiply, invade deeper and farther, and send metastases to her lymph nodes and bones. She knew that her life would soon end.

The final scene 

     Dolores is lying down in a bed in a large hospital room. Dolores' son is with her. Dolores' boyfriend is in the room too. They sit on both sides of her bed, holding her hands. The doctor comes in. They talk about the winter that will never end. He asks about her pain. She says that she is lucky to have her son and her boyfriend next to her, and “now you, my doctor, dimple-face, you are also here,” she says. And then, as if she could read her doctor's thoughts, she says “do not worry, you did what you could do, dimple-face, we all did what we could do, this is life.”

Invictus (Latin for ‘unconquered’)

     Dolores died several days later. She lived a full life. She confronted her cancer with dignity and bravery. Her decisions throughout treatment, even the decision to have no more treatments, were brave. She died without pain, or fear, surrounded by the people she loved most. Her obituary may read “she lost the battle with cancer.” But her doctor will forever remember her as if she, herself had written the last paragraph in the poem “Invictus” by William Ernest Henley: “I am the master of my fate: I am the captain of my soul.” Her doctor will remember her as Dolores, the Invictus.