Rest From Work

I'm taking a break from early morning starts.

I'm taking a break from difficult airways and back-to-back epidural placements.

I'm taking a break from preop evaluations that make me grimace, or mentally roll my eyes, or make we want to go back home, curl up under one of Ramona's quilts, and take a nap.

I'm taking a break from surgeons who repeatedly have multiple add-ons to their schedules.

I'm taking a break from nurses who think room air is adequate oxygen for desaturating patients, who announce in loud voices that if they were "anesthesia" they'd throw their bodies across the door rather than allow a particular complicated patient to be brought to the operating room, who question my not giving a certain drug without thinking that I might be trying to protect the patient from that drug's potentially deleterious effects, and who in general either aren't comfortable with acute crises or who think they know more than the rest of us do about how to handle them.

I'm taking a break from A-lines and those who might forego using them to monitor the induction of anesthesia in really, really sick patients.

I'm taking a break from the 2 a.m. pages that I get because someone else didn't put in the right orders for a patient.

All those moments are in the past and across the ocean now. Now I am in a time and space of healing and rest. I'll eat food from the garden and listen to music from my son's violin, the chorus of frogs at the pond, the birds and sheep in the meadows. Now I'll inhale the scent of honeysuckle, lavender, and roses all around me, and just be.

V.I.P.'s

People often seem to think that members of the medical world are excessively preoccupied with, defined according to, and ruled by a status-oriented system. That may have been an accurate perception a generation ago, but I've seen enough surgeons sweeping O.R. floors, attending physicians socializing with interns, and doctors having deep conversations with custodians to believe that "medical people" have matured a little past the old caste systems that governed the hallowed halls of medicine. Not a lot, perhaps - but a little.

I've been busy over the last couple of weeks - overwhelmingly busy, in fact - immersing myself in another world which is full of joy and fulfillment for me but which also surprised me by what it had in common with medicine.

• People highly trained and skilled in a discipline that demands total commitment, superb knowledge, hard work, talent, and long hours.
• Shop talk, engaged-in with relish and even pride, that can often leave outsiders feeling out-of-the-loop or even condescended-to.
• Excessive preoccupation with who's "important" - the seasoned, perhaps famous professional, the experienced teacher, the uber-talented whiz kid - and where everyone fits into a silently understood hierarchy.

You'd think I was talking about doctors, but I'm actually referring to musicians.

I'm producing a concert that means more to me than pretty much any other creative project I've undertaken, and I've just held some auditions for both the principal and ensemble roles. In the process I've been gently chided for being over-friendly with "V.I.P.'s" (for example, faculty members at music colleges) and surprised by things like a singer's discomfort over the possibility of running into one of his students at our audition. I guess I just don't understand why there's so much lack of humility in these circumstances. So what if your student goes to the same audition you go to? How wonderful that you prepared him well enough to be ready for that!

As for the "V.I.P." thing, well - I have a number of reasons for disliking the whole notion. The first is my background: a grew up in a society in which the line between haves and have-nots was and is as stark as can be. I was born into the side that held the power, material comfort, educational advantages, and prestige, and I saw people lord it over those who didn't, and I hated that and hate it still.

Another reason is my profession: I don't believe in V.I.P.'s on my operating table because I'm going to take care of the disheveled, impoverished vagabond with the same standard and attention as I would take care of the queen of England, the president of the United States, or any Hollywood celebrity. Illness and death remind us all that no one human being is, in the end, intrinsically more powerful than any other; we just allow or prevent the exertion of power by various means. I also use trousers as a reminder: we all put them on one leg at a time; no one's that special.

A third reason is my faith, meaning my view of the world and the human person. The teacher I've chosen to learn my life lessons from taught that I should love each person. Period. That even the so-called least in society are worth the world. End of story. And because that picture of human worth includes me, then I need not look askance at others - either for their faults or disadvantages or for their talents and successes. It just so happens that the concert I'm producing is concerned, at its core, with this very idea, so I was doubly surprised that people would show interest in it but still feel preoccupied with who should be in a place of honor and who lower or higher.

I don't pretend to be immune to insecurities about being good enough, fitting in, or doing well. On the contrary, I've often struggled with such insecurities both in medicine and in my other endeavors. Learning humility has been a journey not about acquiring some kind of false modesty, the kind that leads people to deny their gifts or abilities, but rather about learning to see and affirm intrinsic goodness and good work in others and myself.

Several evenings ago my daughter and I attended a master class given by two amazingly talented, intelligent, artistically generous New York songwriters. We learned so much, not only because the feedback they gave singers and composers was so insightful, incisive, and well-articulated, but also because they offered their wisdom with such genuine humility - with kindness, humor, respect, a clear intention to affirm others' good work and effort, and self-effacing wonder in the achievements of others. I am convinced now that the most effective teachers are those who have the inner security in themselves that comes from genuine humility: the openness to recognizing the goodness of others, and to letting their light shine while sharing one's own light generously with them.

The Michelangelo Code

Ian Suk and Rafael Tamargo see a pons and medulla / brainstem in God's throat in Michelangelo's Sistine Chapel fresco The Separation of Light from Darkness. I see it now too. [Hat tip to Dr. Douglas Field's article in Huffington Post for highlighting Suk's and Tamargo's Neurosurgery paper on the subject.]

In 1990 Dr. Frank Meshberger also observed in a paper published in JAMA that the stuff around God in Michelangelos' God Creating Adam looks like a brain in cross-section.

I guess all those hours secretly dissecting cadavers - an activity strictly forbidden by the Catholic Church at the time - really did have an impact on Michelangelo's art. I wonder if hours spent reveling in great art has an impact on our practice of medicine? I think it does, at least in subtle ways.

***

Addendum: This was my son's comment as he looked over my shoulder at the above fresco. "Is that supposed to be God?"

"That's how Michelangelo painted God on the ceiling of the Sistine Chapel," I replied.

He paused for a moment, thinking, then said, "I think God should be painted as a circle. No beginning, no end."

That's probably the best idea I've heard yet to express any concept I might have of God / a divine presence or energy in the universe. That, and the name given by God to Moses in the Hebrew Bible: I AM. No Patriarch-in-the-Sky for me.

Le Roi Est Mort, Vive Le Roi; or, is God dead? Or alive? And What Does That Mean, Anyway?

A week ago Craig Venter announced the creation of the first synthetic cell: an organism with a fully synthetic genome. That is, he and his team took more than 1000 preassembled units of DNA, constructed from them the full genetic code of the organism Mycoplasma mycoides, and transplanted this prefab genome into the emptied-out cell of the organism Mycoides capricolum. The latter's protein-building molecular machinery recognized the DNA and "booted up" the cell. In short, it came alive.

Some have gleefully touted this the beginning of the end of religion. One commenter at OnPointRadio wrote,

"Science has accomplished what was inevitable and finally robbed religion of the argument that life is more than mere chemical processes...that it is some mystical, magical thing for which only 'god' can account...Hopefully this puts religion one step closer to obsolescence...humanity will never be rid of this human scourge that is responsible for so much intolerance, division, war and strife, but little by little, science is removing religious dogma regarding the monopoly 'god' has on life...At long last, religion's final tenuous argument about the mystical nature of life dissolves..."

Art Caplan, who directs the Center for Bioethics at UPenn, said on the On Point radio episode about Venter's achievement,

"To make non-living parts come to life I think is a major achievement. Not only does it open the door toward, as you've been discussing, some of the design of the microbial world to serve our purposes but it also philosophically pushes the notion that some sort of vital force or special force is necessary to understand life itself. I think this achievement kind of refutes that and basically says it is possible to understand what makes life tick in a more reductionist, mechanistic way...

...When you start to be able to figure out your million base pairs and order them up the right way, and then transfer them into a dead husk of another microbe's cell, and have the thing fire up and do everything that a bacteria's supposed to do, you have in a sense brought to an end maybe 3000 years of debate among philosophers and biologists about what is life. You're basically saying it's something that's under the control of a set of coded instructions. If you have the right chemistry around it, you can make things come to life. That's a pretty amazing demonstration and a pretty important moment in the history of science. So in that sense, understanding life, understanding how it works, seeing that you can even create it and manipulate it - I don't want to push that into the background. That's major...[It] puts you on the road that says we will be able to pull apart the ingredients of life, artificially synthesize the whole thing someday, and that there's no mysterious force out there, no ineffability."

I agree with science writer John Horgan, however: the mystery of life's origins is not solved by this laudable experiment. I also don't think that simply being able to figure something out, down to its molecular mechanisms, or even recreate it, proves the non-existence of the divine or the mystical. Everyone has beliefs about what Reality is and little "proofs" to defend those beliefs, but most of the "proofs" I've heard from both rationalists and believers strike me as dissatisfying or incomplete. I have no well-formed concept of God, nor do I deny the possibility of us all being merely biological machines whose consciousness passes into oblivion when the machines stop working. But I have experienced the ineffable and the inexplicable. Thoughts and ideas themselves, attractions and aversions, enjoyment and creativity, to me would remain somewhat inexplicable, greater than the sum of their parts, even if one could parse out every molecular mechanism behind them.

The more important question, I think, is not whether Venter's achievement and synthetic genomics prove or disprove matters of faith (which are inherently un-provable anyway) but whether we have to worry about the Frankenstein phenomenon: lab experiments spinning monstrously out of control. Time and time again we get ahead of ourselves ethically and morally: we start doing and making things without having responsible conversations to prepare for the issues that inevitably arise with technological advancement. According to Venter his latest achievement breaks that mold, and bioethical discussions occurred before the experiment was carried out. I hope thoughtful reflection - so easily and arrogantly dismissed as unnecessary or unfashionable - becomes the norm rather than the exception in an era in which science is galloping ever-faster as politicians, lawyers, and religious leaders try to keep up.

A Spouse's Silent Sorrows

I have given anesthesia for a lot of breast surgery. I don't think I'll ever get used to the fog of pain and sorrow surrounding a double mastectomy.

All surgery is invasive in some way. Amputations, in particular, have a horror all their own; the idea that destroying someone - cutting off a body part, violating a coherent whole - should be necessary in order to save a life is almost too horrible to bear. When that kind of mutilation reaches the most private and intimate parts of people's bodies and lives, the very air around patients and their loved ones can be heavy with unspoken suffering.

As a woman I cannot imagine the grief of such a dramatic physical loss. I remember having bouts of depression when I was recovering from an elbow fracture years ago. Anxiety, too - I was afraid I would lose the ability to use my arm and hand effectively. Certainly that kind of functional loss would have been devastating. But there's something about mastectomy that makes the loss seem so utterly cruel, the devastation completely personal. Maybe I'm wrong, but I imagine the tears I would shed at having to face a mastectomy would be much more agonized and primal than those I shed worrying about my arm.

I wonder if anyone ever talks about the grief of husbands and partners. I think about that every time I see a patient supported by a spouse or partner who clearly loves her deeply and truly. I still remember the husband of a beautiful young woman who replied, after she said, "I love you" right before we wheeled her into the operating room for her mastectomy, "I am in love with you." More recently there was another kind, compassionate husband who kissed his wife and said affectionately, "Bye, Babe. Love you," then looked forlornly at us as we wheeled the bed away from him to take her to the O.R. He looked as if he didn't know what to do, as if he were about to cry.

In that one moment a thousand thoughts seemed to be emanating from his lost look: There goes the woman I love. I'm so sad for her. I have so many memories of her. The nights we held each other, the children she nursed, the decades of flirting with each other in the kitchen. How can I not feel her pain when it's my pain too? Is it wrong that I feel it's my loss too? I love her so much. How could this be happening? I miss her already. I miss what we had. I'm scared of what's coming. My heart hurts. I just wanna scream and cry. It's not fair.

I'm guessing, of course. But that's what his face seemed to say. Some men or women might feel people would criticize them for grieving the loss of their beloved partner's breasts. I think when there is real love between two people - sexual love, physical love, spiritual love, and committed love that inspires them to work on a lasting relationship every single day - then such grief is completely understandable and natural and inevitable and right. When you love someone body and soul, then Body and Soul are inextricably intertwined in the forging and deepening of the relationship. A loving partner would be saddened not because he or she thinks breasts are the end-all and be-all of female sexuality, or that a woman's worth is related to her body parts, but rather because such surgery strikes so visibly and painfully at the heart of a lot of shared stories, intimate moments, mutual devotion, and cherished physicality. Such raw, heavy grief hurts all the more because it is often unspeakable.

One time I was discussing a painful experience with someone, with my husband listening, and while I was describing the regret I felt I started crying a little. I looked up and saw my husband's face full of love and support for me, his eyes a little wet as he felt in part the pain I was feeling. So often the beauty of compassion between partners is overlooked or forgotten, but when it exists the connection between the two can be felt by everyone in the room. This is what I see when I meet supportive husbands, boyfriends, and lovers of women who must have mastectomies. I wish I could tell them their profound grief hasn't gone unnoticed, unwelcome; that the love to which it bears witness matters tremendously and has touched those of us who are taking care of the women they love.

Oboe Feast Day

The music director at my church says the sound of the oboe is supposed to represent the Holy Spirit - perhaps one reason he invited a wonderful oboist to play for Pentecost liturgy today.

My favorite piece for oboe, Ralph Vaughan Williams' Concerto for Oboe and Strings, contains several moments that sound Spirit-filled to me (the opening of the third movement, for example), so I'm posting it today, played by the incomparable Celia Nicklin.

As I listen I'm trying to reflect today on the symbols of the Spirit - wind and fire - and think of the things that "set me on fire" or "catch my breath":

• the people I love
• music
• dance
• the written word
• learning languages
• teaching
• learning
• working with others to create something special
• the desire to combat injustice

The concerto:

You can also listen right on Youtube through these links: first movement, 2nd movement, 3rd movement.

Language Matters

Happy Eliza Doolittle Day!

This NPR article says it all for me.