A MAN FOR ALL SEASONS

Today, we lost Senator Edward M. Kennedy, aka Ted Kennedy. He was a giant among men, and he earned the nickname "The Lion of the Senate" after 46 years of service. My first exposure to politics and Democratic politics (capital D) was through my father. He revered the Kennedys and often spoke of the time during college when he shook President Kennedy's hand. To him, the Kennedys represented everything that was great about America- a family of Irish Catholics who worked hard, made the highest sacrifice with their public service and their own blood, and who never ceased to look out for the little guy despite their station in life.

While Teddy was considered to have the dimmest prospects of all the Kennedy boys for success, his contributions to Americans and people the world over may have been the most profound of any of his family. The list of his legislative accomplishments is far too long to review here tonight, but they include: S-Chip, the Voting Rights Act, OSHA, Americans with Disabilities Act, and No Child Left Behind. He was also able to work across the aisle, and I was struck by the tone and words of comfort expressed by Republicans today after news of his passing. Despite that, he was a liberal through and through, and he was one of the few Democrats to vote against authorizing the Iraq War in 2002- how prescient.

He knew how to give a great speech, and he will go down as one of the greatest orators of our time. Who could forget the eulogy after RFK's shooting, the concession speech at the 1980 Democratic National Convention, and the addresses at the nominating conventions for both John Kerry in 2004 and Barack Obama in 2008? He was America's senator and the face of the liberal wing of the Democratic party. Teddy is, to a great extent, why I am proud to call myself a liberal, and why I always viewed it as a compliment whenever a conservative critic attempted to malign Barack Obama or another candidate by saying his legislative record was to the left of Kennedy.

While his dedication to public service is unmatched in the modern era, he also had his own personal failing including an episode of cheating while at Harvard, a role in the death of a young woman at Chappaquiddick, struggles with his weight and alcohol abuse, and rumors of womanizing. It was those failings that were brought to light in real time, which made Ted Kennedy the most scrutinized Kennedy of his generation. It was also what made him seem the most real of any of that dynasty and what endeared him to many of his constituents and Americans whose lives were affected by similar problems.

The political scientist Norman Ornstein put it best today when he said about Teddy, “He was a quintessential Kennedy, in the sense that he had all the warts as well as all the charisma and a lot of the strengths. If his father, Joe, had surveyed, from an early age up to the time of his death, all of his children, his sons in particular, and asked to rank them on talents, effectiveness, likelihood to have an impact on the world, Ted would have been a very poor fourth. Joe, John, Bobby ... Ted. He was the survivor. He was not a shining star that burned brightly and faded away. He had a long, steady glow. When you survey the impact of the Kennedys on American life and politics and policy, he will end up by far being the most significant.”

You will be missed Teddy...

THE MUSIC MAN

This is a video of Nicholas participating in a "Toy Symphony" with the Portland Symphony Orchestra from Laurelhurst Park in Portland on 8-15-09. It speaks for itself.

AIN'T NO MOUNTAIN HIGH ENOUGH

This past weekend I read, from start to finish, the book "Mountains Beyond Mountains" by Tracy Kidder about the physician Dr. Paul Farmer. The book chronicles the story of Dr. Farmer from his childhood, to his work as a volunteer and student of anthropology in Haiti, to his days as a medical student, resident, and fellow in Infectious Disease in Boston, and to his numerous pursuits to rid the world of suffering, particularly in the poor. I had first heard about Farmer from an article in the New Yorker many years ago. It was one of those classic articles in the magazine that goes on forever, but which is entirely compelling. I had the good fortune to meet Dr. Farmer and to go on rounds with him at the Brigham and Women's Hospital in Boston when I was a visiting Chief Resident there in 2002. Unfortunately, I joined the team near the end of rounds, but I found Dr. Farmer to be both incredibly personable and captivating. His belief in the primacy and divine right of health care is enunciated best in this piece from NPR's "This I Believe" series.

Farmer's work with the poor in Haiti is the focal point of this book, and much of the focus is on the hospital Dr. Farmer helped build in Haiti called Zanmi Lasante, Creole for Partners in Health, which is the name of Farmer's global health non-profit organization. In the book, Farmer quotes from Virchow to summarize what motivates him, "Physicians are the natural attorneys of the poor…and social problems should largely be solved by them." This book and this quote reminded me of the patients I served during the course of my early medical training, which took place in county hospitals in Houston and Dallas. In both cases, these hospitals were the only place the poor in these communities could get quality medical care. Particularly in Dallas, however, I still feel as though the level of emergent or inpatient care these patients received was among the best in the world due to the drive and passion of the physician residents and attendings who worked in Parkland Hospital. What we lacked, however, was easy access to outpatient care and services and a system of community outreach to help patients improve their lots in life (educational services, social services, job training). Without the latter, can a patient or a population truly thrive? The answer, in my experience, as I saw the same patients present with the same problems over and over (congestive heart failure exacerbation due to the fact that salty canned foods were more affordable than fresh vegetables, asthma exacerbation because steroid inhalers were too costly or because of the poor air quality of the inner city, etc, etc) was clearly no.

I read a review of "Mountains Beyond Mountains" by Abraham Verghese after I finished the book, and in it he describes Kidder's book the following way:

''Mountains Beyond Mountains'' is inspiring, disturbing, daring and completely absorbing. It will rattle our complacency; it will prick our conscience. One senses that Farmer's life and work has affected Kidder, and it is a measure of Kidder's honesty that he is willing to reveal this to the reader. In 1987, a book called ''And the Band Played On'' changed the direction of my career and that of many physicians of my era who decided to devote themselves to the care of persons with AIDS; I had the same feeling after reading ''Mountains Beyond Mountains'': that after I'd read the book something had changed in me and it was impossible not to become involved."

I had the same sense after I turned the last page of Kidder's book, and I find it quite impossible to sit on the sidelines and to not work, in some small way, to ease the vast suffering which plagues our world. The mountains out there may be high and the troubles that the world faces may be vast, but is there a more worthy endeavor than helping those who are less fortunate? I leave you with a quote from my hero Albert Camus, which summarizes Paul Farmer's life and his life's work:

"I leave Sisyphus at the foot of the mountain! One always finds one's burden again. But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well. This universe henceforth without a master seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man's heart. One must imagine Sisyphus happy."

WORDS BY WHICH TO LIVE

If you ever want a good dose of fear, become a doctor or a parent. I have certainly had some very scary moments during my medical career and most of them involved young patients (unlike my current practice of prostate cancer patients) who had very serious but potentially reversible illnesses (e.g. a 20 year-old asthmatic to whom I gave medicines to paralyze him, in order to facilitate placement of an endotracheal tube and mechanical ventilation, whose vocal cords I could not quite visualize for 60 seemingly interminable seconds in the middle of the night during residency, a 27 year-old whose fruity breath from across the room, due to the accumulation of ketones, and whose slow, deep Kussmaul's respirations betrayed a diagnosis of new onset diabetes and life-threatening ketoacidosis, and my own son whose audible wheezing and shortness of breath at the age of 5 months taught me to respect the virulence of Respiratory Syncytial Virus. I cite these examples not for dramatic effect but rather to highlight the incompatibility of life with inadequate oxygen content, abnormal pH, or inadequate perfusion of one's tissues.

Last night, I had a scare of a very personal nature. Little Cate had been having loose stools for about 4 days. She had been drinking okay, but her appetite for food was poor. Yesterday, however, she began to refuse even bottles while her diarrhea continued. A babysitter watched her during the day, and when I returned home, the sitter said she had not had any wet diapers, although she had had plenty of loose stools. To anyone in the medical field, there are a few simple nitrogenous credos, "no urine, no life," "urine is golden," etc, etc. I feared that she was severely dehydrated and that she would not be able to make up for her GI losses by taking food or drink by mouth. Thus, I threw her in the car and headed to the ER.

I was met by Kathleen and Nicholas there, and we were quickly taken back to a room. The nurses attempted to stick the little one for blood work and placement of an IV. First try, no success. At that point, I decided to take Nicholas out of the room in order to not make his rejection of the medical profession 100% certain (currently at around 99%). We came back in 30 minutes, and 3 additional tries later there was still no IV access. Cate took a few sips of water, and the senior nurse suggested we simply encourage her to drink more and re-assess in 1 hour. Mind you, I am a pretty diplomatic guy and physician, but I flat out told her that that was stupid. The patient was clearly volume-depleted and had not been taking enough in by mouth for several days. No amount of oral consumption was going to ameliorate the situation... fast enough. I told her that we needed to try again. A different nurse was called in (it is funny but the best nurses for procedures always seem to have some goofy article of clothing, and this nurse was no exception in his Sponge Bob tie over his scrub top). He was able to secure an IV and obtain labs after his second attempt, and the re-hydration commenced.

I took Nicholas home after that and Kathleen stayed with the baby, who was admitted to the Peds unit. Little Reese (Cate's middle name) was kept overnight, and about 7 hours after IV fluids were started, she finally made urine and wet her diaper. I was not aware of this until this morning... after a night of little sleep and much worry. I have never been so happy to hear that she needed a diaper change; again, urine is golden! Cate was discharged today and is taking food and fluids better. Although her illness, a case of Enterovirus gastroenteritis, has not completely resolved yet, we expect it to run its course in the next few days.

I suppose I never realized the parallels between medicine and parenthood, both of which should be about helping people by identifying problems and their gravity early and then instituting the appropriate courses of action to solve/prevent said serious problems. This may be encapsulated in a simple phrase from the Hippocratic Oath- "First, do no harm!" Harm can occur as easily through acts of omission (not placing the IV for a clearly dehydrated child or not teaching one's children about safe sexual practices) as it can by acts of commission (performing an unnecessary procedure, which leads to a poor outcome, or spoiling one's children). The answer in this situation was not to take an inferior course of action, a seemingly easier course of action, and to hope for the best; we all knew the baby needed an IV, but it's placement was not easy given her dehydrated state and poor veins. The answer was to do the right thing, the hard thing, which was the only tenable solution to the problem. That is how I have tried to practice medicine, and that is how I try to raise my kids. "First, do no harm!" Words by which to live.

A WORK OF ART

"A guilty conscience needs to confess. A work of art is a confession."
-Albert Camus



One of the most important things in life, if you ask me, is art. Whether it be music, painting, literature, or even dance, art has the ability to transform the way one feels and thinks. The foundation of much of civilization has rested upon cultivation and appreciation of art, and I can identify with that. I am not sure exactly when an interest in art developed in me, but I love most modes of art.

My favorite art form is music, mainly rock but also classical, bluegrass, world music, etc. My friends have been instrumental, no pun intended, in turning me on to various bands- the Smiths, Soundgarden, Martin Sexton, Jeff Buckley, etc. However, I discovered one of my current favorite bands, Bon Iver, all on my own. The lead singer is Justin Vernon, and their album "For Emma, Forever Ago" was hailed by many as the best record of 2008. I could not agree more. A clip of an impromptu a cappella performance of their song, "For Emma" in a hallway in Paris may be found here.

This song never ceases to amaze me or move me, and I think it is because there is a confessional quality in Justin's words and notes. I do not know exactly who "Emma" is, but I feel like I know her. Perhaps that is the true measure of great art- reaching the audience and bringing them into the artist's world while they also bring the artist into theirs.

A "JANUARY PICK"

One of the people about whom I have not written extensively in this blog is my wife Kathleen. We met a little over 10 years ago in January, 1999 when I was an intern and she was a 3rd year resident in Dallas. She was very good friends with my senior resident, and she stopped by our team room to talk to her friend one day. (Of note, when I interviewed in Dallas as a 4th year medical student, about one year before that, I went on rounds with her team, although she and I did not really converse at that time. I do remember thinking she was cute, though). That day, in the rounding room, when we met for real, I realized we had several common interests: running, movies, and a love of literature. I had started a book club as an intern for the express purpose of meeting women, so of course I asked Kathleen to join us. We were reading "The God of Small Things" by Arundhati Roy. Shortly thereafter, we started going out, and on our first date Kathleen was at my place and asked me if she could use my phone for a long distance phone call. I said yes, and she called her future boss, Craig Nichols in Portland, to accept a Heme-Onc fellowship position for 1 year from then. Neither of us expected that our relationship would progress to anything substantial in that time frame... or so we told ourselves.

However, as we continued to date and the time came for Kathleen to move to Portland, it was clear that we had strong feelings for each other. We decided that Kathleen should still go, but we decided to make a go at a long distance relationship. The first 2 years were spent between Portland and Dallas, but in the final year of our separation, I was in Baltimore for my own Heme-Onc fellowship. I guess 1/2 a continent apart was not enough of a challenge for us! We somehow survived those 3 years apart with a mixture of nightly phone calls and Q4-6 week visits. Nonetheless, I would not wish a long distance relationship on my worst enemy. Anyway, Kathleen relocated to Baltimore, and we were married shortly before her arrival. We eloped and got married in City Hall in Manhattan. Why NYC? You could say too many Woody Allen movies, but, in our minds, if one is going to elope and get married in a city hall, shouldn't it be in NYC?

We lived together and worked very hard during our first 2 years together in Baltimore; I was in the lab, and Kathleen was in private practice in Annapolis, MD. We spent weekends in D.C., Philly, NYC, or at home. We went running together, biking together (including a hellacious bike trip through the ghet-to, but that I will leave for another time), and enjoyed the company of friends. I knew she was an amazing friend and wife, but I do not think I truly came to appreciate her until the day our son was born, and I almost lost her.

One day past her due date in July, 2005, she went into labor on the way home from a full day on her feet in the hospital. Despite the fact that the July intern on call tried to convince her that maybe she had just an episode of incontinence rather than her water breaking ("um, there were chunks," thank you), we went into the hospital for a prolonged bout of labor on pitocin, which is used to stimulate uterine contractions. Sixteen hours later and after a failed epidural for much of the night (it was finally replaced by an Anesthesia attending before shift change at 7AM- remember folks this is July with new housestaff in the hospital), the decision was made to deliver our child with forceps. He came out, and we were both in tears. Shortly thereafter, Kathleen felt faint; her blood pressure had dropped, and she was having profuse uterine bleeding. The cavalry came in, and she was resuscitated.

I have never been so scared in my life. A lot went through my head in those interminable minutes. How could a moment of utter joy turn into such a nightmare so quickly? How can they not get IV access? Where is the central line kit- I will have a line in in 2 minutes! How can I possibly lose the woman whom I love more than any whom I have known who has just given me a beautiful son? Fortunately, the bleeding stopped, and Kathleen stabilized, but not before she had lost 1/4 of her blood volume. We took our little boy home together just 2 days later, which is a tribute to her resilience- she elected to take oral iron and refused a blood transfusion; I told you she is tough.We have since had another child, little Cate.

I must say that as much as I had appreciated Kathleen before we had children, parenthood has helped me realize how lucky I am to have found her and married her. As much as I love the kids, this is dwarfed by her devotion and selflessness to them. Perhaps this comes from having carried each of them for 9+ months, but I think it is deeper than that. She senses that this is the next phase of our lives together, and (like everything she has done in her life which she has valued: family, science, medicine) she is giving her all to it. The loss of her own mom when she was a teenager probably left her with an understanding that we are here "until further notice" and that everyday is a gift. No one need remind her of that on a daily basis.


This was best exemplified when we were in Vancouver 2 weeks ago. A friend had recommended a great Indian place called Vij's, which is called "the best Indian restaurant in North America." Kathleen dropped me off at the front around opening time for supper while she parked the car with the kids. Miraculously, there was an opening, and I was seated. I quickly discovered by looking around at the decor and clientele that this was not a highchair and kids' menu kind of place, and I wanted to make a run for it. A few minutes later Kathleen arrived with the kids in tow. She sensed my unease, but she just smiled and said that no one was asking us to leave and that it would be okay. She helped entertain little Cate and filled her with Cheerios until she was calm/sated. It was the best Indian meal I have had in my life (sorry mom!): BC spot prawns and halibut with black chickpeas in coconut-lemon curry and beef short ribs in cinnamon and red wine curry with warm greens. Kathleen was right; we all survived the meal intact... thanks to her.

To summarize how I feel about my wife, I turn to a political analogy I heard for the first time last summer when the respective nominees were considering running mates. There was talk of the advantage of various candidates and what they would bring to the ticket. There were "September picks", ones who would provide a huge bounce out of the convention but not necessarily win over voters on election day (see Palin, Sarah and think one-night stand). There were "November picks," ones who would win over a crucial state or demographic group (see Clinton, Hillary and Palin, Sarah in Senator "Hail Mary" McCain's wildest, most drug-addled dreams and think fling), and there were "January picks," ones who might not move a single voter into one's camp but who would allow the President to govern most effectively throughout his/her term (see Biden, Joseph and think partnership). What I have discovered (and which I try not to forget) is that my wife is a "January pick" through and through. While I loved our care-free dating days and newlywed days, her true character, strength, and resolve have been most apparent since we left the B.C. (before children) phase of our lives. Nicholas and Cate could not have wished for a better mom and I a better wife and best friend.

CUTTING FOR STONE

I recently finished the new, debut novel by Dr. Abraham Verghese entitled "Cutting for Stone." In ancient times, "cutting for stone" was the act of surgically attempting to extract mental illness/madness. The Hippocratic Oath, which I, myself, took 11 years ago (has it already been that long?) states that one will not do this. Those Greeks were wise!

I first became acquainted with Abraham Verghese in 1994 when I was a medical student in Houston. He gave a lecture, or rather a reading, from his first non-fiction book, "My Own Country." It is the story of an Ethiopian-born physician of Indian descent who came here on the "cowpath to America" to do residency training in a small, rural hospital in Tennessee populated by foreign grads; he had no other opportunity. He went on to do his Infectious Disease training at Boston University, a pre-eminent center in its time. Subsequently, he returned to rural Tennessee, and "My Own Country" chronicles his life and practice there as someone, like the young, gay men with AIDS whom he treats, who has never had a place of acceptance, a home, a country to call his own. For me, it was not until medical school that I found a community to which I truly felt I belonged (see Amit, Asim, Donohue, Swurz, Chap, etc).

His second book, "The Tennis Partner," details his friendship, played out on the tennis court and beyond, with a medical student who is a recovering drug addict. I had the good fortune to hear Abraham read from this at the Dallas Museum of Art during my residency and to meet him afterwards. He was every bit the gentleman and inspiring figure I imagined he would be. In many ways, this blog, my way of sharing and recording my thoughts on life, family, and medicine, springs from his example. .

"Cutting for Stone" is described as fiction, but the influences from Verghese's own life are obvious. The novel is set in Ethiopia and revolves around a set of twins born to a nun, Sister Mary Joseph Praise, who dies in childbirth in the opening section of the book. The man, who is presumably the twins' father, Dr. Thomas Stone, a legendary surgeon, hastily leaves the mission hospital, at which he and Sister Mary had worked closely together for years, in despair soon after her death. From here the novel recounts the story of the twin boys named Shiva and Marion Stone and their growing up in 20th century Ethiopia. It is a story about love: filial (the love of a son for his adopted mother and father and for the specter of the biological father whom he never knew), brotherly, and also romantic (the love of a young man for a young woman whose flame cannot be easily extinguished...despite her best efforts). It speaks to the power of this emotion despite class, race, and distance, and the strength of this emotion even within a young, awkward, persistent teenage boy who felt he had found someone special (Been there, done that).

I will not "spoil" the story, but when I closed the book after reading the final page on a transcontinental flight back home to Portland, I had tears in my eyes. I cried not only because of the beauty of Abraham's words but also because someone had written something so personal and yet which I found to be so resonant of my own life, my own thoughts, and my own story. While I respect the critics in the New York Times Book Review, there is an intangibility, a transcendence in Abraham's writing that may be lost on experts of literary criticism but which is not lost on those who have felt like they were on the outside looking in for much of their lives. It is my belief that it was for us that "Cutting for Stone" was intended.