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 rather 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.

Saturday, September 21, 2013

Weltur and the Eyes of Grandpa

     People who die young leave fewer memories behind. My grandfather left this world before I was born - his life, to me, is a puzzle with many missing pieces. Of all the belongings my grandfather once had, only one has remained in my possession. It is a German-made, folding Weltur camera that uses film and can capture black and white images.

     The Weltur is sturdy and heavy. It feels like a brick. It is protected in a thick, brown leather case. In its folded position, it is compact. Pressing on a button at its base, a door opens. First, the lens slowly appears, pushing forward like a turtle stretching its curious head out of its shell. Then, the bellow reveals itself, a black light-tight seal that opens like an accordion and through which light travels between the lens and the body of the camera where the film resides and an image is captured.

     I look at the Weltur and I am reminded of the lessons I once learned in a Biology class: “the human eye works like a camera.” The similarities were clear. Both the eye and the camera are enclosed, light-tight compartments with a lens mounted on one end and an image sensor at the other. Like the lens of a camera, the cornea (the outer, transparent part of the eye) and the lens of the eye bend rays of light so that an inverted and upside-down image is formed on a film, or on the retina of the eye. And both have mechanisms to control the amount of light that enters the compartment (the diaphragm of a camera, the pupil of the eye).

     But the similarities between a camera and the human eye end there. In a camera, for example, focusing on the object of interest is achieved by changing the distance between the lens and the film. In the eye, the distance between the lens and the retina is constant (less than an inch), and focusing is dependent upon the properties of the lens itself (made of rubbery, jelly-like material) and small muscles (called ciliary muscles) around the lens that can make it either more spherical or flatter.

     Technology is catching up, but it is just beginning its journey to become the marvel that the human eye is. Our eyes are not my grandfather's Weltur, nor are they the most advanced iPhone camera. They provide sharp, vivid, full of contrast, three dimensional images. They are mounted on a bipod (our legs) with many degrees of freedom of movement. They can move in their sockets, searching for relevant information. They have automatic focusing and light adjustment, and a mechanism for self-cleaning (eyelids and tears). They come fully installed. There is no need for online shopping. Shipping and handling fees are waived. They come for free.

     But the main difference between a camera and the human eye is that the eye is only a part, the frontier extension of a much larger system - our brain. The light that enters our eyes forms an image on the retina at the back of the eye. It is in the retina with its many layers of cells (called cones and rods) where light is translated into small electrical currents, into nerve signals. The signals are then delivered to the visual cortex of our brain, where information is not just recorded but also being analyzed: what is important is retained, what is redundant is ignored, and meaning is king.

     In the unlikely event that I will become a film director, the following is a scene in a movie I would like to make. The year is 2052. Thanks to the development of advanced time-machines, my grandfather and I can not only meet, but we can meet as persons of the same age, my age. Each of us, though, is holding a camera of his own generation: an iPhone for me and a Weltur for the grandpa I have never met before. We are talking and laughing. We are taking pictures, each of us using his own camera. We see each other and all that surrounds us, with the best of all cameras, the only camera that can see, our eyes.

The Art of Straightening a Banana, or Why Doctors Fear their Barbers

Part 1

     A doctor I know, a man of few words, shared with me one of his top secrets: “I am terrified of my barber,” he said. And as I wondered why this would be the case, he added, in his laconic way: “It’s a long story, about a feud that began more than a century ago, a French doctor, a company of barbers, and the art of straightening a banana.”

     Thinking about barbers, I first recalled my own barber, Adam, who commands respect but is by no means frightening, let alone terrifying. And other barbers came to my mind: the lovely Figaro from the opera 'The Barber of Seville' by Rossini; and, in sharp contrast, the completely fictional but still very convincing Sweeney Todd. Sweeney Todd's patrons die through a unique sequence of events: they sat in his barber chair; he pulled a lever; a trapdoor opened; they fell backward, sliding into the basement of his shop; on their way down, their neck broke; and then with a steady hand, a sadistic smile on his face, Sweeney Todd slit their throats using an instrument no barber can do without--a straight sharp razor; to dispose of his customers, he then collaborated with a Mrs. Lovett, who prepared meat-pies from their flesh. Visualizing this bloody scene, I quickly concluded: this is not the way to treat a customer.

     I then directed my attention to other words in the puzzle. I considered 'French' like in 'Paris at night', 'baguette', 'Eiffel tower', 'croissant' and 'French fries'. Then, I thought 'a French doctor', and 'the art of straightening a banana'. I asked myself: 'Why would anyone want to straighten a banana?' And BOOM, I realized that I was on to something.

     It was a French doctor, François Gigot de Peyronie, who in 1743, described a disease that affects 1 in 100 men between the ages of 40 and 70 years, resulting in penile curvature, or bent penis. It is believed that the condition is caused by an injury to the penis during intercourse. The body tries to heal the injury by forming a scar. Unfortunately, scars tend to contract (shrink) and therefore the injured area becomes shorter, resulting in a deformity or curve toward the injured area. Men affected by Peyronie's disease present with penile pain, penile curvature, a penile plaque (hard scar) that can be felt along the penis, and in some men erectile dysfunction.

     In some men the condition resolves spontaneously. Some will benefit from oral medications. But in others the curvature may persist creating not only a psychological burden but in the more severe cases also a functional one (difficulties with penetration). In these men, and only after the disease has been stable for 6 or more months, surgery may be indicated. The surgery is an exercise in 'straightening a banana.' Looking at a banana you will notice that it has a longer side and a shorter side. Straightening it would require either shortening of the longer side or elongation of the shorter side. And that is exactly what is done during the penile surgeries designed to correct penile curvature: the shorter side of the penis is elongated by removing the plaque and adding a larger graft (like a patch), or by shortening the longer side by several longitudinal incisions that are closed horizontally.

     I felt some relief knowing that the puzzle is almost complete. On my list I marked a check next to 'French doctor' and another check beside 'the art of straightening a banana'.

     But what about the 'company of barbers', and the 'feud' that led to my colleague's fear of barbers? I guess I will have to complete my story in my next column.

Part 2

     I previously wrote about a colleague of mine, a doctor, who told me that he was terrified of his barber. “It is a long story,' my colleague said laconically (he is a man of few words), “about a feud, a French doctor, a company of barbers, and the art of straightening a banana.” I felt that it was not simply the memory of Sweeney Todd's patrons–falling backward down a revolving trapdoor, their throat slit, and their flesh served as meat pies–that terrified my colleague. And as I was trying to solve the puzzle, I realized that the 'French doctor' was no other than François Gigot de Peyronie, a surgeon who described a disease affecting the penis, causing it to become curved; and that the 'art of straightening a banana' must refer to the surgery designed to correct the curvature, and amend the bend.

     To solve the puzzle and to explain my colleague's fear of barbers, I needed to address two more hints–'a company of barbers', and “the feud”.

     So I researched further. I looked at a picture of François Gigot de Peyronie–a serious man sitting in his library, dressed in the best garments Paris had to offer, and wearing a long, curly white wig. His expression was that of accomplishment, fame, and power. Indeed Peyronie was an accomplished physician: Chair of Anatomy and Surgery at the University of Montpellier, commander of the medical corps in the army of Louis XIV, and founder of the Royal Academy of Surgery. Famous: among his patients one can count the kings of Poland and Prussia; the mistress of the Prince, the Countess Vintimille; and perhaps more importantly, Louis XV, the king of France, whose confidence and affection he earned after he cured him from 'a delicate disorder' in 1738.

     And so, on a cold day on February 16, 1745, Peyronie must have realized that he possessed the kind of power and influence that allows people to change reality in their favor, for if he wouldn't, he would not have sat down to write a letter to the Lieutenant of Police regarding a group of people he was not happy with, the barber-surgeons.

     This must have been the 'company of barbers' my colleague talked about, I thought. Barber-surgeons were the medical practitioners in medieval Europe who served as barbers, surgeons, and dentists. Trained as apprentices without any academic degree, these barber-surgeons not only cut hair shaved chins, and trimmed beards, they engaged in almost any other medical intervention available at the time: leeching and bloodletting, enemas and fire cupping, neck manipulation, cleansing of the ears and scalp, draining of boils, and the extraction of teeth.

     Peyronie, the 'protector of surgery,' demanded that these barber-surgeons be forced to sign an agreement to quit. He sat down and wrote a letter, and soon thereafter, four of the barber-surgeons were arrested and locked up in jail, and later “enlisted in the regiments of Champagne (a military unit) and sent off to battle where they had a good chance to be shot, an action that, according to the Lieutenant of Police, “gave great satisfaction to La Peyronie.”

     A week ago, when I was sitting on the bench at the barber shop, waiting for my turn to have my hair cut, I suddenly remembered my colleague, the doctor, and his fear of barbers. In my mind the puzzle was solved. I looked at the barber pole, spinning with red and white stripes, a symbol to the two crafts once held by barbers, white for barbering and red for surgery, and in my mind the feud between doctors and barbers was long over. Still, just before I sat in the chair, I checked it carefully and found no trapdoor. And Adam, my barber, was cordial as ever.

Physician Shortage (Part 2)

     In my previous article, I presented a worrisome prediction, an impending challenge: physicians will be in short supply. A confluence of factors is expected to contribute to the storm of physician shortage: population growth, and aging population; changes in the delivery of health care mandated by the Affordable Care Act; and a relatively constant number of physicians. To add some numbers into the picture, I referred to the Association of American Medical Colleges prediction that “the United States faces a shortage of more than 90,000 physicians by 2020 – a number that will grow to more than 130,000 by 2025.”

     Today, I will suggest a few possible solutions to the shortage of physicians. I will also advise as to what organizations, communities, doctors and patients can do to minimize the impact of physician shortage.

     Automation: Yes, I know! Patients are not cars. But some aspects of Henry Ford's assembly line can be applied to patient care. Try to recall your last visit at the doctor's office and you, too, will admit that it could be described as a voyage on a conveyor belt: start at the receptionist station and go through registration, insurance verification, co-payment, questionnaire filling, paperwork signing; move on to the nurse’s station where your vital signs are checked and more questions are posed; then, an encounter (a word reserved to meetings with only two entities: aliens and doctors) with the physician where more questions are presented, lab results are reviewed, notes are taken, your case is finally discussed and a treatment plan is designed. Then, an office-note is generated (hand-written, dictated, or typed directly into the electronic medical records); and you are transferred back to the nurse where the visit is finalized: discharge instructions are given, lifestyle changes are recommended, your medications are ordered and surgery, or perhaps a follow up appointment is scheduled.

     This complex process is a puzzle in engineering or in practice management. At its core is the successful patient-physician encounter which can be achieved only if each of the components in this 'assembly-line' is well designed, streamlined, revised and perfected. An efficient 'assembly line' in the doctor's office would allow quality care to more patients in need.

     Delegation: While automation may streamline the work-flow, the question of who will perform each of the thousands of daily tasks in a modern practice remains open. These tasks include scheduling, gathering data on a patient's prior medical history, examining patients, choosing the appropriate diagnostic tests and treatments, patient education, coordination of care (with laboratory, radiology department, pharmacy, and practices of other physicians), and meticulous documentation of all that was done. These tasks could be completed by a single care provider (think of a family doctor working alone in a remote village). But a group of professionals receptionists, nurses, nurse practitioners, physician assistants, and doctors–working together as a choreographed team where each individual performs at their highest capacity, can complete these tasks in a more efficient way. Delegating as many of these tasks to other capable team members would allow doctors to focus on tasks where they are needed most.

     Retaining: In a market where the demand for physicians exceed supply, the competition between hospitals, networks and geographic locations over physicians will remain fierce. To win the competition, communities and hospitals will not only have to excel in recruiting of physicians, but also in retaining them.

     Recruiting physicians is an expensive artform: when a new opportunity is presented to a potential candidate, the natural beauty of the location, or its sophisticated cultural environment are painted with wide brush-strokes; any signs of remoteness, harsh weather, or financial instability are quietly erased; the candidate is then enticed with a combination of compensation and benefits. It then takes a doctor one or two years to adjust to the new place, build a reputation, and a successful practice.

     But then comes the real challenge – that of retaining the right physicians. Doctors are interested in a collegial and collaborative work environment, a workplace that offers the tools necessary for the best patient-care possible, a great deal of autonomy, open communication with hospital administrators, and a voice that would be heard where decisions are made regarding their work environment and the care of patients. Hospitals that address these interests will be best positioned to attract and retain physicians.

     In the upper peninsula of Michigan, we have seen many doctors come and go. Retaining the right doctors, would be a key to prevent physician shortage in our community. And here is what you can do, as a patient, to keep your own physicians in the area: on your next doctor visit, thank your physician for taking care of you, and for being a part of our community.

Physician Shortage (Part 1)

     Have you already asked yourself whether you are ready for a doctor shortage?

     The Association of American Medical Colleges suggests you should embrace yourself for a tough ride! According to their website, the demand for physicians will intensify in the coming years. The population is growing and aging, they explain, and the number of physicians is expected to remain relatively constant. They estimate that “the United States faces a shortage of more than 90,000 physicians by 2020 – a number that will grow to more than 130,000 by 2025.”

     What solutions are there to alleviate the 'I can't find a doctor' problem?

     At first glance, this seems to be a basic 'supply and demand' problem that one could solve even in the “half-asleep-and barely-alive state” so typical of students participating in an Economics 101 class: Increase the supply! Train more physicians! Increase the number of students in medical schools and in residency programs!

     But in reality, becoming a doctor is a long process (premed programs are 4 years long, medical school takes 4 years, residency is 4-6 years long, and should your doctor choose to further specialize, a fellowship program will take another 1-3 years). Building an infrastructure for training additional physicians is an expensive and prolonged endeavor. And even if we start this process now, we may still be way behind the rising demand for decades.

     Recruiting physicians from abroad may be another measure to increase the supply of physicians in the US. But this presents a moral challenge. After all, these foreign doctors (or International Medical Graduates, as they are frequently referred to) are a needed resource in their country of origin, at least as much as they are needed here, and importing them to the US would mean depriving their country of origin of their own doctors.

     Taming the demand for doctors may prove even more difficult. In an ideal competitive and free market, the imbalance of supply and demand would take care of itself through a change in the price of goods and services. In the real estate market, for example, a shortage of homes would result in an increase in their price. On the supply side, higher home prices may send a strong signal to builders, who would respond by starting to build more homes. On the demand side, a rise in home prices may sway potential buyers from purchasing a home. Buyers may wait for a better pricethey may rent a home, share an apartment, or choose the ultimate solution and move in with their mothers-in-law.

     But price rarely plays a part in the supply-and-demand equation of the American health care system. First, in medicine, the 'demand' is at most times inflexible. A patient with a broken leg or chest pain cannot wait for the cost of medical services to come down. Second, the true cost of medical care is not transparent. Unlike a restaurant where your decisions (pasta, chicken, or steak) may be influenced by the price tag, the cost of medical care is not known to the patient until after it is rendered (then the medical bill arrives, and with it shock and dismay). And last, most of the medical cost at the point of service are paid by someone other than the patient himself (for the insured patient, the 'deductible' part is paid by the patient, everything else is taken care of by the insurance companies). Taming demand through pricing would be a difficult proposition. It will require clear and transparent pricing, and a dramatic change in the way medicine is provided and paid for.

     Another way to decrease the demand for physicians is through rationing of medical care, including limiting access to physicians’ services. To some Americans, this solution seems inevitable, to others it is unacceptable. Whether rationing would become a force of change in the American health system remains to be seen. Even if it is fully implemented, it may not be enough to balance the supply and demand for doctors.

     So what is a patient to do? And what should we, as a community in the Upper Peninsula of Michigan, do to maintain the number of doctors practicing here, perhaps even to increase it? In my next article (see Physician Shortage, Part 2), I will bring a few ideas regarding the measures we could take, as patients, as doctors, and as a community, to face the expected doctor shortage, in the US, and in the Upper Peninsula. 

Breakfast at the Steins

     There is no breakfast like at the Steins' home. We were sitting at the table in the Steins' small kitchen: Professor Stein happened to be an orthopedic surgeon, Professor Stein's son happened to be my friend who had invited me to breakfast, and a version of myself, as I was back thena young and impressionable medical student. Engulfed by waves of steam and aroma that we could actually taste, Mrs. Stein worked in the kitchen in front of us, just a step away, cooking, and serving: milk and orange juice, coffee, an omelet made with golden onions and mushrooms, a variety of salads, bread, buns, and cake. Delicious.

     It is during meals like that breakfast, that ideas start to flow and conversation develops.
“Have you given a thought to what field of medicine you would like to specialize in?” Professor Stein asked, “Perhaps you want to become an orthopedic surgeon?”

     “Orthopedic surgeon?”

     Professor Stein stopped the silence with his deep and convincing voice. It was time for a confession, his: “They say about us, orthopedic surgeons, that we are as strong as an ox and almost twice as clever. They say that our job is dull, that we are the carpenters of medicine, cutting and sawing into dry bones. But there is nothing boring about bones, and we, orthopedic surgeons, can trick the body into healing itself in ways only few other doctors can.”

     And to prove his point, Professor Stein told me a story about another orthopedic surgeon, Gavril Abramovich Ilizarov, who became famous through a rather peculiar chain of events: Ilizarov lived and worked in Kurgan, a rural city along the western border of Siberia. Kurgan shared at least a few characteristics with Marquette, Michigan: it was remote, very remote; it was cold, extremely cold; and it was known to few, other than its own inhabitants. Ilizarov's innovative orthopedic abilities and his ingenious exploration into the nature of bones would have remained unknown to the western world if it wasn't for Carlo Mauri's broken leg. Carlo was an Italian explorer who entertained himself by climbing Mont Blanc, crossing the Atlantic Ocean in a vessel made of papyrus, and following in the steps of Marco Polo. It is no wonder then that when he broke his leg in an accident, it was a challenging fracture, a split that refused to heal, a defect that nobody could fix. That is, until Carlo met Ilizarov, and his tibial fracture was introduced to the Ilizarov apparatus.

     The Ilizarov's apparatus looked unimpressive: several parallel metal rings (similar to small bicycle wheels) connected by adjustable vertical rods, and forming a cylindrical frame. The process of treating a non-healing fracture, or lengthening a bone, required several steps: First, the apparatus was placed around the limb. Metal pins were then passed through the rings, into the skin and muscles, and finally into the bone (in the same way the spokes of a bicycle wheel pass through the rim and into the hub of the wheel). Once in place, the rings and the pins would align the bones above and below the injured area along the desired axis and in a stable, fixed position.

     And here comes the trick. Using a small screw, the two rings could slowly be pulled apart, allowing the two bones to move away from each other while remaining along the desired axis. This is when the natural healing process of the body kicks in. 'Seeing' the gap that was formed by moving the two bones apart, the body 'jumped in' to heal itself to form a bridge over the gap between the bones. This process, called distraction osteogenesis (osteo-, bone; genesis, coming into being), is slow. It takes a full day for the healing process to bridge over a gap of one millimeter (it would take about a month to lengthen a bone by an inch). But in the end a new bone tissue is formed, then mineralization takes place, and a new bone is born!

     Mauri’s leg was at last healed. Upon his return to Italy, his Italian doctors were impressed by Ilizarov's ingenuity and the results of Mauri's surgery. Ilizarov was invited to Italy–a first step in the long and successful introduction and adaption of his ideas beyond the iron curtain to the western world.

     As to Professor Stein, it has been many years since I saw him. I wonder what it would be like to meet him again. I am sure he would be disappointed to learn that I chose Urology rather than Orthopedics. On the other hand, I have learned a few other ways in which our body can be tricked into healing itself. Perhaps, one day, over breakfast, I will tell you...    

The Face

     Ask yourself: what's in a face?

     To answer, I suggest several exercises. Exercise #1: look at yourself in a mirror and carefully observe your face as you perform the following: try to erase any facial expression and look at your 'blank' face for a whole minute. Then, wear the following expressions, one at a time: raise your eyebrows; frown; take a deep breath as if you are smelling a flower and watch your nostrils widen; blink; try to move your ears (it is okay, only few people can); make an angry face; show fear, or disgust; remind yourself of a sad event and cry, or at least shed a tear; wait a bit, and then tell yourself a joke and laugh; then 'Smile though your heart is aching / smile, even though it's breaking'. Exercise #1 would make you realize that our face is a canvas on which our feelings are painted with wide strokes and intense colors. It is a form of expression, of communication.

     In exercise #2, imagine the faces of at least 10 people you have seen. Create your own gallery of faces and slowly flip through it. Here is the gallery of faces I have created: the 'Mona Lisa' smiling; Louis Armstrong blowing a trumpet; Bill Clinton looking at the TV camera; Albert Einstein sticking his tongue out; 'The scream' (a painting by Edvard Munch) screaming, Selvador Dali wearing a pointed mustache; a CEO at a hospital I work for; the faces of my mother, my father, my in-laws, my three sons, and that of my wife. Who is in your gallery of faces? How similar are their faces? And how different are they? Each face in my gallery is unique and distinct. Exercise #2 could end with only one conclusion: a face is an identity.

     For some unfortunate patients, 'losing face' is not just an expression, it is a devastating reality. Their stories read as if they are taken from a horror story. They were attacked by a bear, encountered a chimp, mauled by a dog, shot in the head, burnt in a fire, or electrocuted at work. The survivors are, at times, candidates for face transplantation – a heroic procedure at the meeting point between a desperate recipient, an unfortunate donor (living face-donors are hard to come by), and a heroic surgical team.

     Face transplantation is not for the faint of heart. It is new (the first full face transplantation took place in Spain in 2010) and is still considered experimental. It requires meticulous planning and exact execution. It calls for virtuosity and stamina, with a rotating team of specialists working for as long as 18 hours to complete the task.

     First, a match is made between the recipient and a brain-death, heart-beating donor: for race, sex, skin color, structure and shape, blood type and immunological characteristics. The face of the donor is then harvested: the skin is removed together, as a unit, with the underlying muscles, and blood vessels (both arteries and veins), and nerves (both motor and sensory), and, at times, the underlying bones. If the recipient is at a different hospital, the face is then transferred, soaked in organ-preservation solution and refrigerated, to its destination.

     Face transplantation is a delicate task of matching outlines, attaching surfaces, and meticulous 'wiring.’ Using an operating microscope, the blood vessels of the recipient are carefully connected to the donor's face (without proper blood supply, the new face will undergo necrosis, or in other words, die). Then, the nerves of the recipient and the donor-face are attached. Even with precise re-wiring of the facial nerves, it would take many months for the patient's nerves to regenerate, for the facial muscles to rehabilitate, and for the graft to reintegrate into the sensory and motor centers in the brain.

     The immune system of the recipient will always recognize the new face as foreign. To prevent rejection of the face, patients will require life-long medications to suppress their immune system.

     The results of face transplantation are mixed. Its success is judged based on both aesthetic and functional results. Will the patients be able to move their lips, to breath through their nose, to smell, to chew and swallow, to speak, to express their feelings, to smile? Will they be able to accept their new appearance, their new identity?

     To truly understand what's in a face I suggest one more exercise: suppose that you are living in the future where face transplantation has reached perfection. Imagine that face transplantation carries no risks, requires no donors (faces are manufactured on demand using a face-printer), and has perfect aesthetic and functional results. Would you want a different face? Whose face would you chose and why? How will your answers change if the surgery is reversible and you can return to the original you at any time?