The Handshake

Sometimes I want to believe that I possess supernatural powers. When I meet a new patient, I sense the atmosphere in the examining room. Then, identities are exchanged - I introduce myself; they do the same; I study their expressions; I ask questions about their place of residence and occupation, and whether they enjoy what they do for a living. And here comes my supernatural talent, for from this encounter I can, at times, formulate a story about my patient's life. Oh, wait! I almost forgot. To complete the story about my patient, I need one more component - a handshake.

​The other day, I saw Ms Smith. Her face was lit up with a wide smile, her white hair perfectly combed, her eyes kind. She lived not too far from my office. She used to be an English teacher at the high school. She loved it. Her handshake was pleasant, not too firm, nor too gentle, but her fingers felt awkward, different. And this reminded me of a man who was never a patient of mine, a man I have never met, a pianist by the name of Byron Janis.

​When Byron Janis played the piano, his hands were two giant tarantula spiders running along the keyboard in a rite of lust, the notes turned into butterflies, freed through the spread wing of the piano, into the air, dancing, flickering with millions of colors.

​Byron played the piano for years. He became known for his virtuosity and appeared on the most prestigious stages. All that time, his immune system worked as it was designed to, as a disciplined army, orchestrating its action in a clockwork manner, against invasion of infectious agents, toxins and cancer cells. Byron's immune system was the dream army every general would be proud to have: immune cells with exotic names like phagocytes (cells that swallow) and natural killer cells, helper T cells, B cells, and  killer T cells, served as soldiers; some of these cells patrolled Byron's body, traveling through the blood stream; other cells were strategically stationed along sensitive ports of entry such as his nose, lungs, and intestine; Byron's army could recruit soldiers quickly and dispatch them to the desired location where conflict was inevitable; these cells communicated via top-secret codes (protein molecules called cytokines); they had a strong military intelligence (we know you are the enemy), superb memory (we remember – you are the enemy), and Y-shaped sticky darts (antibodies) with which they could paint-ball the enemy; they had killing capabilities second to none: phagocytes in Byron's immune system were capable of recognizing an unwelcome invader, engulfing it, and killing it, quickly, quietly, without hesitation.      


​But then Byron's immune system turned against him. He was afflicted with rheumatoid arthritis, an autoimmune disease in which the immune system identifies normal tissues within the body as being foreign and attacks them. Rheumatoid arthritis afflicts 1% of the population. The disease may affect the lungs, the envelope around the heart (pericardium), and the skin, but it more often affects the lining inside the joints (called the synovial membrane). The joints (typically small joints in the hands and feet) become inflamed, swollen, warm, and painful.  The inflammation may eventually result in destruction and fusion of the joints and eventual deformities with romantic names such as 'Z-thumb deformity', and 'swan neck deformity'. Romantic as they may sound, these deformities are crippling.  

​Byron has suffered from a severe form of rheumatoid arthritis for years. He might have been treated with medications.He even had surgery on his hands, but eventually his fingers failed him, and he could play no more. Losing what he loved doing most, he sank into deep depression. Then, he found strength and started composing and playing the piano again. He trained his hands, the two giant tarantula spiders, to work together, supporting each other in their dance, and notes turned into butterflies again.

​I look at Ms Smith's hands, at her bent, disfigured fingers, and I can recognize the signs of rheumatoid arthritis, the crippling effect of a treacherous immune system. All it takes is a handshake and I can tell a story about her disease, and about her life. But will my story be anything close to Ms Smith’s life?

Just a Little Stone (about idney stones, part 2 of 2)

     In my last column, I discussed what happened to Emma, a young woman who came to the Emergency Room with acute, severe pain, worse than she had experienced when she delivered a baby a few years ago. An imaging study, a computerized tomography, or CT scan, showed a urinary stone in her ureter. Emma received pain medications and her pain disappeared. She was sent home hoping that her stone will pass spontaneously without a need for surgical intervention. Four weeks later she was seen again, this time in my office. She had a few more episodes of pain, but these responded well to the pain medications she had. We were looking together at an X-ray image she took that morning. "Here is your stone," I said, pointing at a white spot on the computer screen, "Unfortunately, your stone is still in the same place; it did not move much."

     "So what are my options?” she asked.

    

     Once a stone fails to pass on its own, there are several treatment options:

     SWL, or Shockwave Lithotripsy (litho means ‘stone’ in Greek and tripsy means ‘to break’), is a treatment option for urinary stones in which shockwaves are applied and transmitted through the skin without a need for incision. The urologist is identifying and aiming at the stone using X-rays. In the best-case scenario, the stone breaks into multiple small fragments that can then pass spontaneously. Some stones are more difficult to break than others, and depending on the location and composition of the stone, the success rate may vary widely. On average, the stone will break and its fragments pass in about 7 out of 10 patients. The procedure is performed under anesthesia. Patients leave the hospital on the same day and can return to their daily activities shortly thereafter.

     Ureteroscopy is a different treatment option in which a small-caliber instrument, slightly larger than the tip of a pen, is advanced through the urinary tract into the area where the stone is located. Advanced technology such as a miniature digital camera at the tip of the ureteroscope and high-definition TV monitors allow superb visualization of the stone, just like watching a football game on a large screen TV. Using a minute laser fiber, the stone can be broken into tiny pieces. Stone fragments are then collected and removed with a miniature basket. The procedure is considered a minimally-invasive procedure. It is performed under anesthesia, with the patient being discharged home either on the same or the next day. Complications are rare and include bleeding, infection, and injury to the urinary tract. Success rate is higher than with shockwave lithotripsy. About 9 out of 10 patients will be stone-free following a ureteroscopy.

     PCNL, or Percutaneous nephrolithotomy, is usually reserved for larger stones in the kidneys. This is a more involved operation in which a tract, about a finger-wide, is created through the skin into the collecting system within the kidney. Using a long and narrow optical instrument, the stone is then identified and a source of energy is applied to break the stone. Because the tract is larger, bigger stone fragments can then be grasped and removed through the tract. The procedure is performed under anesthesia and usually requires hospitalization. Complications occur more frequently than with a ureteroscopy.

     Emma chose to have a ureteroscopy. Her stone was removed without complications. Like other patients with urinary stones, she will still need to undergo an evaluation including blood and urine tests to assess her risks to develop another stone. She will need to drink plenty of fluids, possibly make some modifications in her diet, and perhaps take a medication to prevent another urinary stone. "I will do anything," she said, "I just don’t want to have a pain like this again."    

Just a Little Stone (about kidney stones, part 1 of 2)

     Emma is waiting for me in the Emergency Room. She is holding her left flank, tears in her eyes. “It hurts so much,” she says, “more painful than when I was in labor.”

     Emma has a kidney stone.

     One in 10 Americans will develop a kidney stone in their lifetime. If you have a family history of kidney stones your risk for developing a stone is higher. Once you had a kidney stone, your chances to develop another one is much higher, about 50%.

     Urinary stones are usually formed in the kidney. They grow pretty much like a snowball. A tiny sand-like gravel that is slowly and gradually increasing in size. The most common stones are made of calcium and oxalate. Left untreated, a stone can either grow in size in its original location, or start moving down the ureter (a narrow long tube connecting the kidney to the urinary bladder, delivering urine). Once a stone is moving, it may cause obstruction to the urine flow and dilation of the urinary system. It is this dilation that generates pain. The pain is typically severe, unrelenting, and is not helped by changing positions. It may be accompanied by nausea and vomiting, and if infection is developing as well, also with fever and chills. In other instances, a stone may reside within the urinary system without any symptoms, diagnosed later in life during an imaging study taken for an unrelated condition.     

     Emma was already evaluated in the Emergency Room. A urine test showed she had blood in her urine. While the stone was passing through her ureter, it was scratching it from the inside, causing bleeding. She also had a CT scan (Computerized Tomography, see picture below), taken while she was lying down on her back in a long tube-like X-Ray machine scanning her body. CT scan uses X-Rays and a highly powered computer to generate a three-dimensional image out of multiple two-dimensional pictures. To better understand how a CT scanner works, imagine how you could study the internal architecture of a bread loaf once you sliced it into slices and observed each of the slices separately.

CT scanner (computerized tomography)

     The treatment of kidney stones has been revolutionized in the last several decades. And like in many other areas of medicine, multiple options exist. One option is to provide pain medications and possibly an alpha-blocker, such as Tamsulosin (Generic name for Flomax), a medication that allows relaxation of the ureter and possibly easier passage of the stone. Ninety percent of stones smaller than 5 millimeters will be able to pass on their own. Only half of the 5-10 mm stones will pass spontaneously. It might take days to weeks though, and for some people, waiting would be too much to go through.

     So are there other options for stones that cannot pass on their own, for patients who cannot or do not wish to tolerate the pain until their stone has passed?

     Historically, an open procedure was required for patients that did not pass their stone. A long incision was made on the skin of the belly or the side, and dissection was carried until the kidney or the ureter were identified. The stone was then extracted and the wound was closed. This required hospitalization for several days with considerable amount of pain, discomfort, and complications. Those patients who developed recurrent stones had to have this done again, and again. An open procedure is rarely used today.

     The procedures most commonly used today are SWL (Shockwave Lithotripsy), ureteroscopy, and percutaneous nephrolithotomy (PCNL).

     Now Emma’s diagnosis was confirmed. A small, 6 millimeter stone was found in the ureter closer to the kidney. “Just a little stone and see how much trouble it causes,” she said. It was decision time. Emma wanted to know more about her options.

     To read more about urinary stones, treatment options, and what happened to Emma, read my next column (Just a Little Stone, part 2 of 2).

M.D. Writer (part 2 of 2)

     My last column, probing into the 'Doctors are the Best Writers' hypothesis drew quite a visceral reaction from my readers. Professor Ray Ventre, the Department Head of English at Northern Michigan University wrote: “Fun article last night... I loved it but... While you have proven that some doctors can write well and some characteristics of doctors prove useful in writing, that doesn't mean all doctors write well (look at prescriptions for example!!!). Nor does it mean that only doctors write well, nor that doctors occupy all or any of the top ten places in the literary panoply. I can't wait to see what your conclusion will be... “

     So, in an attempt to further my research into the phenomenon of doctors who write, I read 'Errand', a story written by a non-doctor, Raymond Carver, describing the fate of Anton Chekhov, a writer who happened to be a doctor. The story begins one evening in 1897. Chekhov was enjoying a meal in the best restaurant in the city, when suddenly blood began gushing from his mouth.

     As a doctor, Chekhov must have known this was an ominous sign of tuberculosis; a disease caused by a mycobacterium (a type of bacteria). Mycobacteria invaded Chekhov's body inconspicuously: it was transmitted from a person already infected with tuberculosis and released by coughing, sudden sneezing, perhaps singing; it was carried by a droplet –a minute cloud-like drop; it gained entry and then settled in his lung, invading the same cells that were supposed to serve as guardians against infectious agents, as soldiers of the immune system (alveolar macrophages); within Chekhov's lungs, mycobacteria lived and multiplied; it did so slowly, but relentlessly.

     Here is what might have happened; mycobacteria spread to adjacent lymph nodes, and through the blood stream to almost any other organ in Chekhov’s body. His immune system tried to contain the infection by recruiting inflammatory cells and building scar around the invading bacteria. Some mycobacteria within the walled areas died, leaving behind a cheese-like material. Others remained viable. Chekhov's immune system fell short. He developed severe coughing, fever and chills, and night sweat; his appetite diminished and he became thin and frail. Chekhov, a doctor and an ingenious writer succumbed to tuberculosis.

     Carver describes Chekhov's reaction to the disease with the voice of a documentary producer. He tells us that Chekhov “spoke with seeming conviction of the possibility of improvement.” But being a doctor, he must have known that his end was near: prior to being diagnosed with tuberculosis (also called consumption) Chekhov wrote: “When a peasant has consumption, he says, 'There is nothing I can do. I'll go off in the spring with the melting of the snow.' “

     Carver tells us that Chekhov moved to a spa in the Black Forest with his wife, Olga Knipper and that when his condition deteriorated, his doctor, Dr Schwöhrer, who quickly realized the gravity of Chekhov's situation, took an action that was “so entirely appropriate it seems inevitable,” – he ordered a bottle of the hotel's best champagne. Chekhov drank from his champagne. “A minute later, his breathing stopped.” And then, “There was only beauty, peace, and the grandeur of death.”

     Carver proceeds not as a documentarian but as a careful observer of the human mind. In the last segment of 'Errand', Olga gives detailed instructions to a waiter who works at the spa, as she is sending him on an errand to fetch a mortician. Though her instructions are detailed and calculated and her voice is reserved, her pain is palpable and her deep love for her husband bursts out as a mute cry of loss.

     All that is required to disprove a theory such as 'Doctors are the Best Writers,' is finding a single case in which a non-doctor would demonstrate writing ability equal or greater to that of any doctor who writes. I read 'Errand' and I was astonished at Carver's ability to dissect Chekhov's last days. He writes with a sharp lancet, cutting into his characters’ soul with a precision of a meticulous surgeon. And yet, Carver is a writer, not a doctor.

     This revelation, although painful, comes with a sense of relief, for now I can write without the pressure of proving I am the best of writers - just a doctor who writes.

   

   

M.D. Writer (part 1 of 2)

            Lately I have become concerned about the future of medicine. Everywhere I turn, another doctor is emerging as an outstanding writer. What if, I think, all doctors will abandon medicine, desert their patients, and become writers instead of being doctors. I immediately decide to take action and search for the truth about doctors and their writings. To make it more interesting, I formulate a hypothesis (somewhat unrelated to my initial concern but still intriguing): doctors are the best writers.

            In an attempt to prove my hypothesis, I first consider Sir Arthur Conan Doyle, a Scottish physician and a writer, and his most famous protagonist – the fantastic, and always eccentric detective – Sherlock Holmes. Mr Holmes is in a constant mode of fast-paced and action-packed adventure. He carries a pistol and uses a sword; when in need he transforms into a formidable bare-knuckle fighter; and in The Final Problem, during a mortal combat with the criminal mastermind, Professor Moriarty, he manages to avoid falling into the steep Reichenbach Falls using his skills in a Japanese system of wrestling he calls Baritsu. It is not his physical attributes, though, that make Holmes the most famous detective of all times. It is his inquisitive mind, his use of science in the crime scene, and above all his power of 'deduction,' or intellectual reasoning. 

            Where did Sir Arthur Conan Doyle draw his inspiration from when he conceived the character of detective Holmes? In a rare black-and-white film interview taken in the summer of 1927, you can watch Sir Arthur Conan Doyle, dressed in a three piece suit and accompanied by his dog, explaining in a thick Scottish accent, how the stories of Sherlock Holmes came about: “I used to, as a student, have an old professor, his name was Bell, who was extraordinarily quick at deductive work. He would look at a patient, he would hardly allow the patient to open his mouth, but he would make his diagnosis of the disease... entirely by his power of observation... so if a scientific man like Bell came into the detective business, he wouldn't do these things by chance, he would get things by building it up, scientifically. So, having once conceived this line of thought... I had a new idea of a detective... and I began to write stories...” 

            I quickly determined that Sir Arthur Conan Doyle could not have been the best detective story-teller in the history of mankind if he had not been a doctor first.

            Swiftly I switched to another writer who happened to be a doctor: Anton Chekhov. In his short story 'Misery', Chekhov tells us about Iona Potapov, a sledge-driver, and his little mare. One night they find themselves lost in thought and covered in snow, traveling through dark streets covered with sleet, carrying passengers to their destination. Iona holds a secret. Horrible news he wants to share with somebody, anybody. Throughout the night, Iona tries to open his heart, first to his passengers: an officer; a hunchback and his two friends; and then with a cab-man on a street corner. “My son... er... my son died this week, sir,” he reveals. But nobody wants to listen to Iona's story, instead he hears abuse addressed at him, and all he sees is indifference. Desperate, Iona opens his heart to the only one who would listen, his mare: “Kuzma Ionitch is gone... He went and died for no reason... Now, suppose you had a little colt... And all at once that same little colt went and died... You would be sorry, wouldn't you?” And the little mare listens and “Iona is carried away and tells her all about it.”

            When you read Chekhov's stories, the earth stands still. Chekhov's pen is a sword that splices your heart with an unmatched insight into the human soul that is unbearably controlled by love, longing and sorrow. And I ask myself, who else but a doctor – a person at the junction of life and death, despair and hope – is in a better position to understand the mysteries of the human soul?

            Sharon, my wife, entered my study just as I was ready to finalize my research and reach an inevitable conclusion regarding doctors who write. She stuck a book of short stories by Raymond Carver into my hand. She asked; “Didn't you tell me you are reading Chekov? You must read his story, 'Errand'. It is about how Doctor Chekhov, the writer, died,” she said.

            For those of you wondering whether 'Errand' changed my 'doctors are the best writers' hypothesis, I promise to return in my next column with a conclusion that may satisfy many but surprise only a few.

Sesame Twist

    

     Sometimes it is the seemingly simple concepts that are hard to understand, even harder to explain. 'What is a cell?' is such a question.

     I could always revert to simple definitions such as 'a cell is the basic unit of a living organism,' or 'cells are the building block of life,' (is a cell just like a Lego piece?). But as I sat at the Marquette Baking Company the other day, enjoying my favorite, elongated loaf of bread, twisted upon itself and sprinkled with sesame seeds – a sesame twist, I wanted a different explanation to what cells are. I wanted to really comprehend the concept of cells.

     My Sesame Twist was still warm as it was just taken out of the oven, its crust perfectly golden, the inside soft and light, its aroma overwhelmingly addictive, and its taste delicious. Behind a long counter loaded with bakery goods, I could see a bakery buzzing in action: the dough is cut, kneaded, and folded, left to rise, and shaped into loaves and baguettes, buns and rolls, cookies and croissants. And then I realized that sometimes an answer to a seemingly simple question such as 'What is a cell?” may come from an unexpected source – a baker.

     Ask Peter Claybaker, the owner and head baker at Marquette Baking Company, what cells are and you will hear a detailed answer woven with interesting stories. “A loaf of dough is a living thing,” he says. Peter got his first cell culture from a friend of his more than 20 years ago. He keeps these cells in a soup-like broth at room temperature, feeding them water and flour. This culture of cells contains millions of yeast cells (fungus cells called Saccharomyces cerevisiae). Given the right environment, these cells multiply and thrive, reproducing in a process called budding, where a new cell develops from an outgrowth of another cell. Peter uses some of these cells for baking, but the population quickly replenishes itself “as in a city, Paris for example, where its citizens constantly change but the culture, the city itself, continues to live.”

     Yeast cells convert sugars into carbon dioxide (gas) and ethanol. They do so in a process called fermentation in order to gain energy, which they need to sustain their life. Yeast cells incorporated into dough release carbon dioxide which is trapped as tiny bubbles in the dough leading to the typical rising. Once placed in the oven, the yeast cells in the dough continue to release gas, but eventually, once the temperature becomes unbearable, these cells die. Peter says ‘they die a horrible death.”

     How can cells – structures that are not bigger than a few micrometers (1000 cells in a row will be 5 mm long) – participate in complex biochemical interactions, multiply, and survive? I look at Peter and I see his eyes shine with enthusiasm. He talks about yeast cells as if they were little animals, not just building blocks of a larger organism. And I share his enthusiasm and his awe, for each cell is a large busy factory in a miniature structure. At its core, a sophisticated information department – long DNA molecules that contain all the genetic information needed for the factory to survive. Within its boundaries, a variety of tiny machines – molecules that create energy, and allow cells to multiply, survive and thrive.

     I am a ten-trillion-cell organism who is now sitting at Marquette Baking Company. My cells are different from the yeast cells in Peter's culture. They have combined into one organism. Each of my cells is a specialist: the cells in my eyes dance to light, the cells in my ears sway to the sounds of music, my brain cells are humming like a swarm of bees, my heart cells are relentlessly beating. As I take the last bite of my beautifully crafted, aromatic, tastiest than ever Sesame Twist, I start to comprehend what a cell is - a miracle of life!  

The Lighthouse

     A small group of nurses, doctors, and other health professional meet yearly at the beautiful lighthouse in Big Bay. They call these meetings the 'Janus Project'. They sit around a long oval dining table and the story about the beautiful lighthouse is told again: once upon a time there were two keepers-of-light that lived in this lighthouse, which was split down the middle, by a large wall, separating it into two almost identical living quarters. The two keepers of light shared a common mission - keeping the lens at the lantern room intact, and the oil flowing, and the stream of light at the top of the tower shining.
  
     Then, Dr Michael Grossman, a family doctor at Bell hospital and the founder of the group, and Jon Magnuson, its spiritual leader, reminded the participants as to the mission of this year's meeting: We will discuss only one body system, emphasizing the interplay between mind and body, and looking at the fundamental role our mind plays in health and disease states. We will do so as a group, participating in intense discussion; providing honest feedback to each other; engaging in strenuous physical activities including hiking, snowshoeing or cross-country skiing; and practicing Tai Chi.

     These meetings are always thought provoking and challenging. But for me, the highlight of the 'Janus Project' has always been an hour in which we invite one of our patients to participate in the discussions. This year it was a patient of mine that was invited (here, I will call him Robin). He was nervous speaking in front of us, hesitating at first, his voice breaking, but then his story flowed: one day as he was riding his bike, he found himself airborne. He hit the ground hard, injuring his head, his collar bone, and his spine. 

     In the weeks that followed, Robin was hospitalized and underwent an intense rehabilitation program. He learned to walk, and to cope. His wife was always besides him, supporting him both physically and emotionally. He overcame many physical challenges. But to him, it seems that the road ahead is still challenging, demanding, and at times impassable. There are voices in his head that discourage him from continuing in his long way to recovery. And there is always the doubt that he will never be able to be the man he used to be. He said all this and his voice trembled with anger, and with despair. And still, he finds the strength to continue, re-inventing himself, renewing his relationship with his wife, redefining what he is, as a new and stronger person.

     It was our turn, as a group, to provide Robin with feedback. One doctor thanked him for his courage to come and speak in front of us all. Another remarked on the strong bond he has with his wife and how instrumental she is to his success. The feedback came from around the room and my turn came. 

     I was the only person in that room that had known Robin before. I knew him as a patient of mine. I saw him on several occasions in my office and in the procedure room. I examined him and evaluated his medical condition. I formed an opinion and designed a treatment plan. I did listen to him, carefully, I thought.  And yet, I have never truly met Robin, not at the same intensity and depths as I got to know him on that night at the 'Janus Project.'

     I wanted to tell him that he is so much more than the sum of his medical conditions--he is the experience that has changed his life, his courage, his strength, his ability to cope, his new relationship with his wife, the man he has become, not a bit less than the man he used to be.

     Robin and his wife left. I thought: the walls that divided the lighthouse into two separate living quarters, keeping the keepers-of-light apart are no longer there. But what about the walls between doctors and their patients? Do they serve a purpose? Or are these walls just an obstacle to better healing?   It was dark outside.

     Someone suggested that we should step out and look for the northern lights. And there, for the first time in my life, I saw the northern lights, vibrating waves of colors - shining streams of light.

The Three Monkies (on bladder control in women)

     ​Whenever I am asked to give a talk about bladder control in women, I open it with a slide showing the 'Three Wise Monkeys'. In this picture, three monkeys are sitting next to each other: one is covering its eyes, the second conceals its ears, and the third hides its mouth: “See no evil, hear no evil, speak no evil.” What does this have to do with bladder control? In my opinion, we relate to bladder control problems the same way these monkeys behave: patients and doctors alike prefer to avoid discussion of bladder control problem, turning a blind eye to a condition that affects one in three women.   ​

     Women with bladder control problems may have overactive bladder symptoms such as urinary frequency, urgency, and urge urinary incontinence (urinary leakage that develops after a sudden urge to urinate). Other women may have stress urinary incontinence, or leakage that appears with strenuous activities such laughing, coughing, and lifting heavy objects. Some women have mixed urinary incontinence with both stress and urge urinary incontinence.     ​

     The evaluation of women with bladder control problems include: history taking including extensive review of urological symptoms; physical examination including pelvic examination; a voiding diary, in which patients write down the type and quantity of fluids they are drinking, and their daily urinary output; a bladder ultrasound to measure if they empty their bladder; and urinalysis to exclude urinary tract infections and other abnormalities.    

     ​In some women, a more extensive evaluation is recommended. This includes a cystoscopy (in which a urologist looks into the bladder using a small camera), and urodynamic studies in which the function of the bladder (how it works) can be determined.  Urodynamic studies are performed by introducing a small-caliber catheter into the bladder and filling it up with fluids. The behavior of the bladder is observed: does the patient leak with straining (cough, for example)? Was the bladder stable or was it overactive?    

     ​Once the true nature of the problem is determined, the most appropriate treatment can be tailored to patient's needs. In some women a behavioral modification is all that is needed. A story of a patient of mine comes to mind: She had severe urinary frequency and urgency on certain days. A voiding diary revealed that on those days, she and her husband spent several hours on a boat, fishing, and continuously drinking coffee. The elegant solution: decrease caffeine consumption. A few weeks later, she came back smiling and said: “we caught fewer fish, but my bladder problems are gone.”  

     ​Other women may benefit from Kegel exercises, or exercise of the pelvic floor (the muscles used when trying to stop the urinary stream). Performing Kegel exercises correctly and on a routine basis can strengthen the pelvic floor and improve bladder control problems in many women with mild to moderate urinary incontinence.     ​

     Patients with overactive bladder who do not respond to behavioral modification may benefit from anticholinergic medications such as Ditropan (Oxybutynin), Detrol, Toviaz, Vesicare and Enablex. These agents inhibit transmission of nerve impulses by blocking the receptors on smooth muscle fibers in the bladder, and therefore relax the bladder. They can cause a variety of side effects, the most common being dry mouth and constipation.     ​

     Women with stress urinary incontinence, who do not respond to conservative measures, may require a surgical intervention. The most commonly used procedure is a sling procedure, in which a strip of synthetic mesh is placed, like a hammock, underneath the urethra. Upon coughing and straining, the urethra – the tube through which urine flows – is kinked or supported by the sling so that leakage is prevented. The sling procedure carries risks including bleeding, infection, and injury to the bladder and surrounding anatomical structures. However, it is considered a relatively safe procedure with satisfactory results.  

     ​The era of 'see no evil, hear no evil, speak no evil', that of avoiding the subject of bladder control problems, should have been long gone. Women with overactive bladder and urinary incontinence should raise questions regarding their condition.  And doctors should openly discuss the subject, for modern medicine has excellent solutions for patients with bladder control problems. Are you controlling your bladder? Or does your bladder control your life?         ​

My Time Capsule

     You cannot overlook the city of Munising, for the beauty of its Grand Island Harbor is astounding, and its wintry breeze, drawing cold from Lake Superior, is piercing. It is in Munising, at the charming ‘Falling Rock Café and Bookstore’, that I found a book that made me think about medicine, our pursuit to heal and be cured, and about memories and time capsules.

     What is a time capsule? It is an attempt to communicate with future generations. Here is a recipe for the creation of a time capsule: First, take a box (preferably a sturdy structure that will hold against the typical wear and tear of nature). Then, fill it with items you believe may serve, in the future, as historical evidence of your life today. And last, bury it in the ground, or hide it in a place that will protect it from catastrophic events, and still allow future generations to find it.

     The ‘Crypt of Civilization’ located at Oglethorpe University (in Atlanta, Georgia), for example, is an airtight chamber containing artifacts such as a can opener, more than 800 classic works of literature recorded on microfilm, a bottle of Budweiser beer, the original copy of the movie ‘Gone with the Wind’, and a pacifier.  This time capsule is intended to be opened in 8113 AD.

     In Munising, at ‘Falling Rock Café and Bookstore’, I found a treasure – an old book called ‘Surgical Diseases and Injuries of the Genito-Urinary Organs.’ It was written about a century ago, in 1914, by J. W. Thomson Walker, a professor of Surgery and Pathology and a member of the Royal College of Surgeons of England.

     Some of the chapters in Walker’s book deal with conditions that modern doctors in the western world rarely see (scrotal elephantiasis, for example), and most chapters are outdated:  Figure 9 shows the Beckmann’s apparatus used for estimating the freezing point of the urine (obsolete); prostate cancer was typically diagnosed only at later stages, after it had caused symptoms; and impotence was treated with strychnine (a deadly poison, don’t try it at home).

     As to the treatment of bladder stones: Professor Walker would introduce a long curved rod, equipped with two blades, into the bladder. He would then try to blindly identify the stone by tactile sensation, and attempt to break it by closing the blades, crushing the stone into fragments. 

     Today, the procedure is safer. It is performed using a delicate laser fiber, and a small-caliber camera (cystoscope) which allows the surgeon to observe the procedure, as it is being performed, on a large, high definition screen.

     Reading through the yellowing pages of Walker’s book, I could hear his authoritative voice, his curiosity, his honest attempts to understand disease, and his genuine desire to cure, all in the face of limited knowledge and rudimentary technology.  Reflecting on his work, my heart is filled with admiration, but I can also see how much we, in the medical profession, have progressed - our tools sharper, our knowledge vast.

     How will physicians of our generation be seen a century from now? I want future generations to know about medicine at Professor Walker’s times, and the progress that we have made to date. I want them to realize that no matter how advanced their medicine seems to be, there is always more that can be learned. To that effect, I decided to create a time capsule. In a large sturdy box, I gently placed Professor Walker’s book,  the textbook I am using now (many more pages, more profound knowledge), and a copy of this article to serve as a code.

     ‘A time capsule like this,’ I thought, ‘is the best way to communicate with future generations.’ But then, in my mind, I saw my descendants gather around ‘The Box’, trying to decipher what it all means. One of them will throw ‘The Box’ in the back of his truck (or rocket ship), and on his way home, he would stop in Munising, and sell it, at the ‘Falling Rock Café and Bookstore’ – for less than a buck.

Just One More Thing

     A dead body is found and Lieutenant Columbo is called to the scene. He wears a rumpled beige raincoat, and smokes 'Toscano' cigars. His right eye is made of glass. He stands slightly hunched. For sake of simplicity, he calls his dog 'Dog.' He is polite, his demeanor is pleasant. He seems somewhat confused, unassuming, and at times naïve. But he can still solve some of the most complex murder cases. He does so by using a unique style of investigation: after a seemingly complete interrogation, Columbo exits the scene, and then, once his suspects let down their guard, he returns asking 'just one more thing...' It is the answer to this additional question that provides the key to the mystery.

     The 200 Anniversary issue of The New England Journal of Medicine details the happenings of detectives of a different kind – the medical detectives called to investigate a serial killer, coronary artery disease (the narrowing of the blood vessels supplying blood to the heart) which is the leading cause of death in the United States in both men and women.

  

     This investigation spanned over more than two centuries and took place in different countries. It was conducted by professionals of various disciplines who were working in parallel universes. Their findings, an immense body of knowledge, eventually converged to what we know today.

     First came the clinicians. Dr William Heberden, an English physician, described the classic symptoms of Angina Pectoris or chest pain, a results of coronary artery disease, in 1768: “They who are afflicted with it,” he noticed, “are seized while they are walking, (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life... The pain is… often more inclined to the left than to the right side (of the chest. SM). It likewise very frequently extends from the breast to the middle of the left arm.”

     More than a century later, Ludvig Hektoen, an American pathologist, concluded that myocardial infarction (heart attack) is caused by thrombosis (blood clot) in sclerotic (hardened) coronary arteries.

     In 1948, cardiologists, bio-statisticians and epidemiologists started to collaborate in the Framingham Heart Study (Framingham, Massachusetts). After years of investigation they identified the risk factors contributing to heart disease: elevated blood pressure, high cholesterol, smoking and obesity increase the risk for heart disease; exercise reduces it. The Framingham study is still underway, now involving the third generation of participants. It gave rise to the Framingham Risk Score, which allows individual patients to estimate their risk of heart disease (visit www.framinghamheartstudy.org to check your risk), and to the idea that coronary artery disease can be prevented by behavioral changes (diet, exercise, smoking cessation), and by medication (for high blood pressure and elevated cholesterol levels).

     And then, in 1977, in Zurich, Switzerland, a German cardiologist, Andreas Gruentzig, was the first to perform a successful balloon angioplasty on a human. Through the femoral artery (in the leg), he introduced a small balloon into the occluded coronary artery. He then inflated the balloon, thereby stretching the narrowed artery. The initial technique described by Gruentzig is augmented today by the use of a metal stent (a wire mesh tube) which is introduced together with the balloon and is left behind to keep the stretched artery open.

     So, first a pattern was noticed: a man with a chest pain, a woman with a heart attack, many others who succumb to a heart disease. A culprit was then identified: an occluded artery. Then risk factors were investigated, prevention strategies were studied, treatments were developed and their efficacy was tested. Thus, the work of numerous medical detectives allowed for all of this progress to take place, resulting in a dramatic decline of the death rate from heart disease

     But the mission of medical detectives investigating heart disease is not over. DNA sequencing may help identify individuals most susceptible to heart disease. Highly effective medications, based on the genetic composition specific to different subgroups of patients, may prove more effective. Damaged hearts could be better mended. There is always 'just one more thing' a medical detective can investigate, so that the centuries-old mystery of heart disease can be solved.  

Writing Under the Influence (of Driving)

     “I write while I drive my car.” I told George, a patient of mine who was interested in how, being the busy doctor I am, I find time to write. I promised him that I will explain more...

     At one point in my life, I aspired to be an academic urologist – I wanted to see patients and teach in an academic institution, conduct research and publish my work in scientific journals.

     What is it like to write a scientific article? First, start with an idea – a question. Then design an experiment to answer that question, follow by collecting data and analyzing your results, and finally reach a conclusion. Luckily, the structure of a scientific article is just that – structured: In the 'Introduction' you present the question you want to answer; in the 'Materials and Methods', you describe what measures were taken to investigate the problem; in the 'Results' section you describe what you found out; and in the 'Conclusions' you tell your readers what you have learned; you append with a 'References' section where you cite the resources you have used.

     The style of writing a scientific paper is somewhat awkward. Patients are described as cases, never as individuals. Their identity is concealed. They have no personalities, nor traits, no distinctive features, wishes, or character. They are faceless carriers of disease to be investigated and nothing else. They are described in passive voice by researchers who, for the sake of objectivity, distance themselves from their patients.

     Adapting to a different style of writing is not the only challenge. Writing a research paper has always been a formidable task. After hours of work on a scientific manuscript, I would garnish it with a long list of references for which I had to travel to the Medical Library and rummage through multiple volumes of The Index Medicus, a compilation of all prior medical publications listed according to subject and author's name. I can still remember (although vaguely), how I submitted the hand-written papers to our departmental secretary, Mrs. Smith, who seemed to always be frowning, her hair meticulously combed up tightly in a bun. She took her time typing my manuscript, but also the liberty, as she said, “to improve on your work, I hope you do not mind.” The manuscript would then be sent to the editor of a medical journal, in 3 copies, in a large manila envelope. Several weeks would pass and a return envelope would arrive. With trembling hands and my heart pounding, I would open the envelope and search for the verdict. The paper may be accepted as is (a rare event), accepted upon suggested modifications (three reviewers have read it, each has suggestion of his own, often contradictory), and at times rejected (implying a need to resubmit to a different journal, with revisions and additional encounter with the dreaded Mrs Smith).

     During the next several years, writing for scientific papers had become easier. Index Medicus was replaced by the much easier to use medical search engines such as PubMed. Reference lists could be generated by reference management software, and the place of the frowning Mrs Smith was taken by the doctor himself using word processing software. Writing a scientific paper remains a difficult task but I can now admit that nothing compares with seeing your paper, with your name on it, eventually published in a respectable scientific journal.

     Nowadays, I no longer want to be an academician. Instead, I enjoy being “just” a clinician. I fill my urge to share my thoughts by writing for the Mining Journal. Compared with scientific writing, the process here is much simpler. An idea comes to mind and then, as I have alluded before, I write it while I am driving.

     If a picture of me pulling out an old typewriter and pressing on black round keys comes to mind, I would like to clarify: While I drive to work, and only when the weather and the traffic conditions allow, I let my mind wander thinking about my next column. I compose it in my head: an 'introduction' --the sole intention of which is to entice the reader into a particular subject in medicine and the 'body of the article' in which I describe what I have learned about this particular subject. All that is left is to sit down and actually type the article, and then garnish it with an ending that, I hope, will leave a taste for more.

Shark Teasing, Snow Shoveling and the Art of Risk Assessment

     A patient of mine told me that he enjoys going on adventures. On his next vacation he is planning to stand on a steep cliff overlooking a body of water; fresh blood will be thrown into the water below him where sharks abound; attracted by the smell of blood, the sharks will gather. With only straps around his ankles, and subjected to the undeniable force of gravity, he is going to be hurled from a great height and dive into the water; his first fall will only tease the sharks; but then, the elastic rope will pull him up, just in time to avoid the horror of clenching jaws; it is the second descent that he fears the most, for it is then that the sharks will be at their utmost awareness, hungrier than a child whose ice-cream is taken away, and ready as never before.

     On another occasion, Mrs. Thompson asked me if her husband, who had a recent operation, should shovel the snow off their driveway? “Is it too risky,” she asked worryingly.

     'What is risk?' I wonder. How does one perceive and measure risk? How does the perception of risk change our choices?

     Risk can be measured, calculated and compared with other risks: your chance of being killed by an asteroid falling from the sky, for example, is one death in 7,000 years. You may find your risk of dying of almost any cause you could imagine: attack by a shark (without the bungee diving part): one in 300,000,000; hit by a falling coconut: 1:250,000,000; plane crash: 1:11,000,000. More probable eventualities include being killed in a road accident: 1:8,000; dying from cancer: 1 in 5; and succumb to a heart attack or stroke: 1 in 2.5.

     But risk comparison is not pure arithmetic. According to Adam Finkel, an expert in the field of risk assessment, comparing risks is more like comparing apples to oranges (and like choosing between many other dissimilar states such as marrying or staying single, deciding between Mary and Barbara as a life partner, choosing medical or law school, or living in Boston or in Marquette). First we look at the different attributes each option has. In the case of apples and oranges, we may want to compare their taste, calories and vitamin content, and price. This is followed by forming a judgment on each attribute and finally reconstructing each option by combining the pros and cons contributed by each judgment.

     Comparing risks would involve consideration of attributes such as the magnitude of that risk (number of fatalities from an airplane crash, for example); the degree of fear a certain risk provokes (terrorist attacks are designed to cause fear); the degree of ability to control a specific risk; the benefits of the risky behavior (“it is so much fun”), and the cost and feasibility of reducing that risk.

     So what should I tell Mrs. Thompson about her husband and whether he should shovel their driveway? The American Journal of Emergency Medicine estimates that during a period of 17 years, 195,100 individuals were treated in emergency rooms in the USA for injuries related to snow shoveling (the yearly risk of injury was 4.15 per 100,000 people). According to the study, you may slip and fall, be struck by a snow shovel, exhaust yourself, experience a cardiac event, and even die (1,647 deaths were recorded).

     I had read the article and immediately concluded that snow shoveling carries risks of significant magnitude. Then I reminded myself that risk assessment is not just about numbers. It is the fine art of considering attributes and comparing options. Does Mr. Thompson dread the risks involved with snow shoveling? Absolutely not. Can he control the situation? He is planning to pace himself and take breaks. Does he have any alternatives? He can ask his neighbor for help but he prefers to take care of his own property. He may hire a snow shoveling company, but has “better things to do with his money.” It seemed there is nothing harder than to give advice about risk.

     Suddenly I felt an urge to call the patient who was planning the bungee-jumping-shark-teasing event and to strongly advise him to avoid such a dangerous activity. But then I realized he has never asked for my opinion.

Our Collective Wisdom

     Suppose you are a doctor. Someone like 'Doctor House' on the popular television show. Your patients may believe that you know it all. Your colleagues consider you an expert. You are not particularly humble but you are honest enough to admit, at least to yourself, that you know just almost everything, for there will always be a case you cannot solve, a disease you cannot cure, a patient that will leave you puzzled.

     Now suppose that earlier today, you admitted a patient to your service. She is 13 year old and has a disease called Systemic Lupus Erythematosus (SLE). It is an autoimmune disease – a condition in which the immune system mistakenly identifies a part of the body as being foreign, and attacks its cells. SLE can affect almost any part of the body: the kidneys, liver, lungs, joints and the nervous system. It behaves in unpredictable ways, with periods of exacerbations and remission, attacking different organs at different times, mimicking other conditions, and confusing the best of doctors. In some patients, the immune system attacks the skin, creating a typical reddish rash on the cheeks, resembling a butterfly, or the pattern of fur on a wolf's face, hence the name Systemic Lupus Erythematosus (Lupus is Latin for wolf, erythro is Greek for red).

     Let's choose a name for your patient, say 'Elizabeth'. You could create a picture of the healthy Elizabeth: with a soft brush, paint her hair red on your mental canvas; add a wide smile with white teeth; with a sharp pencil, draw several happy freckles on her cheeks. But today, upon her admission to the hospital, she is pale, and frightened, her smile erased. Her blood work is ominous. You find out that her immune system has chosen a new target: her pancreas. She is seriously ill. If you listen carefully, beyond the usual hum of a busy hospital, you may hear her asking her mother a question to which you are not sure what the answer would be: “Mommy, am I going to die?”

     A case of a 13 year old patient with SLE was recently published in the New England Journal of Medicine. The patient was in critical condition. Her doctors were concerned that her condition may become complicated by thrombosis (formation of blood clots inside blood vessels). They considered the use of anticoagulation to prevent the formation of thrombosis. But they were facing a dilemma: should they hold anticoagulation their patient may develop thrombosis. However, if they provide anticoagulation, she may bleed profusely. Under usual circumstances these doctors would consult a textbook, journal articles, or their colleagues. Unfortunately, there was very little knowledge of anticoagulation treatment in critically ill children with SLE. There was no reliable data or clear evidence to guide a decision.

     Having to decide swiftly, they turned to an innovative approach. Using a sophisticated search engine, they skimmed through a group of pediatric patients with SLE whose data was stored on the institutional electronic medical records. Using relevant keywords, the doctors were able to quickly identify 10 patients with a condition similar to their 13 year old patient, review the treatment provided to them, analyze the outcomes and draw a conclusion regarding the treatment their patient should have. They chose to treat with anticoagulation. Their patient did not develop thrombosis or any complication related to her treatment.

     Can we learn from each individual patient encounter? Is the sum of the collective experience of doctors larger than its individual parts?

     Suppose we could all record our own life experience. Each day you would fill an anonymous online diary recording your decisions, your thoughts, your moods, and your degree of satisfaction and happiness. A complex algorithm would analyze the outcomes of decisions made by individuals with traits and motivations similar to yours. Now, imagine that you are facing a fork in the road with a major decision in your life: a decision regarding your career, your health, or your love life. Faced with two or more options, you may consult the decision making software and see what happened to people similar to you who chose a certain path. Would you rather rely on your own decision making or would you follow a collective wisdom?

The Narrative of Life

           

            Gloria gripped the steering wheel. Adam was leaning back in the passenger seat. The car engine was running. It was a cold night in November. Flakes of snow were clumping together on the wet slushy ground - a reminder of a long winter to come. They were waiting for the car to defrost, the thin film of ice on the windshield to melt, the mist of their breath inside to dissolve. The picture in front of them became clear: a large building made of glass and cement, white against the dark night, red neon signs 'Emergency Room' and 'Entrance,' and scattered, square, gently lit windows, frames to pictures of patients and doctors, and their stories of struggles, and hopes.

            Tears were running down Gloria's cheeks, along her nose, slowly finding their way down her cheek. She noticed she was crying only when she tasted the salty drops of despair covering her lips. She looked at Adam. To her, he looked the same: the young man she fell in love with, the father of their children, an inventor with an ingenious mind, a gentle man, a gentlemen, love of her life. To her, it looked as if time has stopped, or perhaps, to be more precise, she admitted to herself, she wanted time to rewind. Gloria wanted to become oblivious to the years that have passed, to the diagnoses that were made, one after another, as Adam became sicker: his uncontrolled diabetes, his curved back, his blindness, his failing legs, the wounds that refused to heal, the countless operations, the hope, and despair, and hopes again. And then the final words, calm but informative, scientifically carved with a cold sharp scalpel, whispered as a declaration of defeat, along an empty, overly bright hospital corridor, coming from a doctor who was trying, at all cost, to avoid eye contact: "we tried everything," he said, "I am sorry, but there is nothing else we can do, there is no cure."

            What alternatives do patients and their families have when their options for cure dwindle? When their illness is advanced, or terminal?

            One solution for terminally ill patients is a hospice. A hospice is not any particular place; it is a concept, a philosophy of care. Hospice care focuses on relief from pain and other symptoms, and on quality of life, rather than on extending life.

            This does not mean that patients choosing hospice care will necessarily have a life span shorter than those who choose more aggressive medical care aimed at extending their life. For example, a recent article in the New England Journal of Medicine (published in August 2010) concluded that patients with metastatic lung cancer who received palliative care had significant improvement in their quality of life, and mood, and they lived longer than similar patients who had standard care. 

            Hospice care typically offers 24 hour access to professional care that includes physicians, nurses, social workers, spiritual counselors and volunteers. Hospice care addresses not only the medical needs of patients but also their financial, psychological, social and spiritual needs, helping patients and their relatives to cope with illness, death, and bereavement.

            Hospice care is typically offered to patients with cancer, severe heart disease, debilitating dementia or other terminal conditions with life expectancy of less than 6 month.

            In the USA, hospice care is mostly delivered at home, but it can also be provided in a hospital, inpatient hospice, nursing or assisted living facility. Hospice services are covered by Medicare, Medicaid, and most private insurance plans - 1.56 million individuals in the USA received hospice care in 2009.

            Gloria and Adam chose hospice care. Adam was attended to by a doctor, nurses, and social workers. He was alert, his symptoms were well controlled. He actively participated in the decisions regarding his care. He understood that these are his final days and so did his wife and children. He died several days later in his home, surrounded by his loving family. 

            Most of us have no control over how long we live. Having some control over the environment in which a patient dies, and the care he receives in his last days will, in many cases, determine the narrative of his life, how he will be remembered, and how his family will cope with his death.

The 10-point prostate cancer screening consultation

     Some debates refuse to die. Such is the debate on whether or not to screen for prostate cancer. The US Preventive Services Task Force has recently recommended against PSA screening. Their recommendation is in sharp contrast with recommendations of other medical organizations.

     Confused? You are not alone! The information available on prostate cancer screening is vast and the time available for discussion of the subject in a typical 15-minute doctor visit is limited.

     Here is my personal view – the '10-point prostate cancer screening consultation':


     Prostate cancer is common: one in six American men will be diagnosed as having prostate cancer. 


     Prostate cancer can kill you: In the United States, prostate cancer is the second leading cause of death by cancer among men. One in 35 men (about 3%) will die of prostate cancer.


     Most men diagnosed with prostate cancer will die with their disease rather than from it. This is because prostate cancer is, in many cases, a slow disease that is diagnosed later in life.


     Prostate cancer screening is simple: it consists of digital rectal examination and a simple blood test called PSA (Prostate Specific Antigen). PSA is not an ideal test (a rise in PSA may indicate prostate cancer, but it may also be due to benign conditions such as enlargement or inflammation of the prostate), but it is the best prostate cancer screening tool we have! If the rectal examination is suspicious for cancer (hard prostate or a prostate nodule), or the PSA is elevated, a prostate biopsy is taken to confirm the presence of prostate cancer and to evaluate its aggressiveness.


     Prostate cancer screening is not devoid of risks: The main risk is diagnosing a patient with cancer that may be clinically insignificant (with no effect on patient's longevity), thereby exposing him to unnecessary anxiety, uncomfortable tests, and potentially harmful interventions.


     Prostate cancer screening can save lives: this point is still in debate, but let me explain: Two recent studies on prostate cancer screening were recently published in the New England Journal of Medicine. The first study, performed in America, showed no statistical difference in prostate cancer death between a group of men that were screened for prostate cancer and a control group, but it raised significant criticism: some of the men that entered the 'no screening' arm of the study were actually screened prior to initiation of the study, thereby 'contaminating' the results of the study. The second study, performed in Europe revealed that PSA screening reduced the risk of dying from prostate cancer by 20%. According to the European study, the chance of dying from prostate cancer was reduced from 3 to 2.4 percent. It is estimated that with a longer follow-up and by looking at specific patient subgroups, the reduction in the number of deaths caused by prostate cancer will be even more significant.


     Saving lives comes at a price: According to the European study, 1,410 men will have to be screened, and 48 men will have to be treated, in order to save one man from dying of prostate cancer. Treatment options for prostate cancer such as radical prostatectomy (surgery to remove the prostate), radiation treatment, or cryotherapy (freezing), may lead to serious side effects such as urinary incontinence and erectile dysfunction.


     The key is individualized screening: Elderly men (a cutoff of 75 year old was suggested) and men with serious medical conditions and limited life expectancy (less than 10 years) are unlikely to benefit from prostate cancer screening. The rationale: even if they have prostate cancer, they are more likely to die of other causes. Younger men (starting at 50 year old, or at 40 if they are African-American or have a first-degree relative with prostate cancer) with life expectancy of 10 years or more, should be offered PSA screening after discussion of the risks and benefits.


     Once prostate cancer is diagnosed and its severity is determined, treatment can be tailored according to factors including patient age, other medical conditions, and results from the prostate biopsies. Some men will do well with observation alone, others may benefit from active treatment.


     By individualizing screening decisions and tailoring treatment to patients' needs, men can benefit from early detection of prostate cancer and lives can be saved, while minimizing anxiety, and reducing side effects of unnecessary tests and treatments.  


     Questions? Opinions? Please comment on my column.

Two Curious Men

​     ​This story is about two curious men.

     ​They were born in the same year and lived in a town only slightly larger than Marquette. They might have passed each other on their daily walk. It is believed that these men knew each other quite well. When they died (one of them died young, the other lived to be 90 year old), they were buried in the same church.   ​

     Yet, their lives were different.   ​Johannes Vermeer was an artist. Antonie Phillips van Leeuwenhoek was a businessman who will be remembered first and foremost for one outstanding scientific discovery – the microscope.   ​

     Vermeer and Leeuwenhoek were born in 1633 and lived in Delft, a city in the Netherlands (same as the name of the movie theater in downtown Marquette). Despite significant differences in their personalities and their life stories, they shared--at least--one character trait: curiosity.  

     ​I can imagine Vermeer painting: a woman in a room with a high ceiling and tiled marble floors. She is alone, or has company; she may be lacemaker, or a milkmaid; she is asleep, holding a glass of wine, or reading a letter by an open window; she is laughing while she is talking with a soldier; she wears a pearl earring, or a pearl necklace; she is playing a guitar and holds a love letter; she ignores everyone, immersed in her thoughts, or looks you in the eye. But she always holds a secret.

     ​It is the light that gives life to the women in Vermeer's paintings. The light, pouring through the long windows, accentuating colors, building drama in reds, yellows, and blues. It is the light that brings suspense, creates an atmosphere, draws us in.  It is the light that breaks the silence: we can hear the milk pouring, the guitar playing, the girl's laughter, a secret whispered.

     ​And at a different location in the same city, I can picture Leeuwenhoek processing glass, transforming glass spheres into lenses, constructing a microscope. And then using his newly designed instrument, I can see him curiously peering into a world never seen before: single cell organisms (he called them animalcules), bacteria, and spermatozoa.   ​

     What is the driving force behind creative minds such as Vermeer's and Leeuwenhoek's? Is it fame? Riches? Leeuwenhoek was financially successful, but it was not his scientific discoveries that made him rich, but his business acumen. As to Vermeer, his death was attributed to financial stress. He was unknown outside of Delft.

     ​In arts and science, as in any other human endeavor, asking the right question is the first step toward new discoveries. The curious artist asks: how should a character be depicted? What colors will brings it to life? How would light create an atmosphere? The scientist inquires: what hypotheses can be generated? How can they be tested? What models can be constructed? Leeuwenhoek inquired: is there life beyond what I can see with my naked eye?     ​

     Doctors are engaged in three main activities: They treat patients, conduct research, and teach ('doctor' stems from the latin verb docere – to teach).  Without curiosity, doctors could not adequately perform any of these tasks. In a recent article in 'Medical Education,' Dyche and Epstein state that curiosity is fundamental to understanding each patient's unique experience of illness, building respectful relationships with patients... supporting clinical reasoning... and encouraging lifelong learning.”  They claim that “medical educators (and, I believe, all educators, S.M.) should balance the teaching of facts... with approaches that help students cultivate and sustain curiosity and wonder.”  

     ​Add 'be curious' to your daily 'to do' list. Ask a question, look the answer up in a book, search for it on the web, consult with a friend, a family member or an expert. Curiosity is an integral part of our intellectual life. It is the spice of our thoughts. It is the passion of our minds.     ​

     This column is my humble answer to a question: “what is curiosity?” I was just curious.