Octogenarian pearls

SDecial Editorial

OCTOGENARIAN

PEARLS

Eben Alexander, Jr., M.D.

Department of Neurosurgery (Emeritus), Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina

When one reaches the age of 80 years-as I haveand is made aware of the old injury to the right leg from playing squash and of other body parts or systems that are not quite up to par, one naturally is humbled by the experience, but not to the extent that one cannot pontificate. Pontification is a difficult tendency to suppress at my age, and maybe it is worth my discussing the direction that the lives and careers of younger people should take, as long as I do not try to tell those people to change their lives. Maybe it would be well to relate a few things that I have learned, so that younger people can consider paths that they otherwise might not have noticed: paths that, if taken, might lead away from mistakes made by some of us who have preceded them. Not many people feel they are at the top of their careers; no matter what recognition they have received from their peers, and no matter what their successes have been, they feel there is always something more to learn and something else that needs doing. The same inquisitive, compulsive, perfectionist drive that propels those people toward the top does not automatically cut off when they reach a certain age or a certain level of success. The drive that propels them in their professions may comprise the same factors that lead them to develop certain character traits that will help them enjoy life at all levels and at all ages. My father was a surgeon who trained around the turn of the century; he worked hard, and success did not come easily, but his advice for achieving success consisted of three rules: Know your business. Tend to your business. Behave yourself!

He hard ceed terms

had seen a number of his colleagues working and knowing their business, but failing to sucbecause they didn’t behave themselves, in of their relationships with the other sex, their

0 1996 by Elsevier Science 655 Avenue of the Americas.

Inc. New York,

NY 10010

relationships with their colleagues, or their tionships with their patients. Alton Ochsner in New Orleans was another believed that there were at least three things essary for success for a surgeon. His choices

relawho necwere:

Ability Availability Affability

There avoided,

are also three and these are:

“A’s”

that

should

be

Avarice Antagonisms Arrogance

Paul Shay, in a commemorative lecture, said that of the seven deadly sins of the Middle Ages-pride, avarice, gluttony, envy, sloth, lust, and angersloth was the only one that had been discarded by the competitive, ambitious, acquisitive, materialistic Renaissance man. The Renaissance man made the other sins into virtues, but they are not. Avarice is on the “A” list already, while envy and anger compound to make antagonisms; certainly, pride is basic to third “A’‘-arrogance. Avarice is an easy sin to commit, even in its minor forms, and we in our profession may be particularly susceptible. Our years of training are long, indebtedness may be very great, and some of us may be almost middle-aged before we make enough money to break even. It is important, however, to remember that the end result is a mighty comfortable living, as far as financial security is concerned, and we should strive to ward off the sin of avarice by using the attribute of generosity. Whether guided by religious convictions or not, one should support the forces of good in community, state, and nation. The Jewish injunction to tithe each year dates back to a period when farmers were told to leave the edges of their field uncut and the corners 00903019/96/$15.00 SSDI 0090-3019(95)00476-9

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unkept, so that those less prosperous could glean these areas and thus be fed. Surely those of us who are most richly blessed should share. That sharing could be through the United Fund of the community, could be through various national health agencies, could be specific for a needy child or a needy young college student, could be in the form of a week or two operating in one of the poverty-ridden third-world countries, or could be in the form of donations to one’s church or synagogue or alma mater. The sin of avarice destroys character and isolates a person from his fellow man. The act of giving strengthens character and keeps one more in touch with the world. As Elizabeth Barrett Browning wrote: A poor man served by thee Shall make thee rich A sick man helped by thee Shall make thee strong Thou shall thyself be served by Every sense Of service which thou renderest. Antagonisms are common in professional life, but they are unattractive in every form. They are frequently built on envy and fed by anger, and they are frequently based on false premises that one’s colleagues have some evil design on one’s position or security. This is very commonly seen in an urban area with an academic medical center. For the medical center, there must be a closed staff in order to support a faculty dedicated to the teaching of students and research, as well as to patient care. Since those in private practice may not be privy to the inner meetings and decisions of those in the medical centers, the former frequently assume that the latter are trying to take all their patients. If such antagonisms are to be removed, this problem must be placed in perspective: the need to train young men and women for medical practice, and the need for physicians who will investigate medical problems and take the time to publish the results, are significant needs, and they must be met, but also explained. Arrogance is unattractive in any profession, but it seems particularly inappropriate in medicine. The late Francis Ingelfinger, past editor of the New England Journal of Medicine, indicated that a certain amount of arrogance was necessary in the physician who was caring for him, since he wanted that physician to be authoritative and tell him what he must do during a critical, eventually fatal, illness. It should be countered that arrogance and authority are not synonymous. Arrogance may well

Alexander

lead to antagonisms; authority, in itself, need not. What Doctor Ingelfinger thought really necessary was an expression of interest in the patient, a devotion to the need to help that patient, and confidence in one’s ability to help that patient. Unfortunately, it is that very confidence that so often comes across as arrogance. In 1966,73% of persons polled in a Louis Harris survey had confidence and respect for those in the medical profession. By 1982, that percentage had dropped by 36 points. That means that 63% of persons polled in 1982 held physicians in low esteem, and when asked what they disliked about physicians, the answer was most often arrogance. Such arrogance is particularly galling to intelligent persons in other professions who wish to discuss their illnesses and medical problems with their physicians on a comparable plane of intelligence. Normal Cousins, past editor of the Christian Science Monitor, and the author of recent books on the subject of illness, make this point distressingly clear; it has been expressed by physicians who have found that once they become patients the physician who is treating them no longer views them as intelligent equals. I pity those physicians who resent the inquisitive patient. Let me give you an example of what appears to be physician arrogance. About 1915 when a young, attractive girl with an abdominal mass came to consult my father, he examined her carefully and told her she was pregnant. The girl rejoined that she wasn’t pregnant, and he answered that she certainly was and that she had no reason to contest his opinion. Then he said, “Tell me, honey, have you laid yourself liable?” When she allowed that she had laid herself liable, he insisted that she give him the name of the man responsible for her condition and, without the slightest hesitation, he contacted the young man and made the two marry. As it turned out, 9 months later, the tumor had grown little or none, and obviously she had not been pregnant. My father then operated on her and removed a large fibroid tumor. There was certainly arrogance in my father’s opinion about his diagnosis and his subsequent high-handed behavior. But that arrogance was tempered by-and the physician-patient relationship was salvaged by-the saving grace of empathy, of which my father had an abundance. A year after that operation, my father delivered the couple’s first child, a normal baby. The couple seemed to have had a good marriage, and they continued to consult my father, so it turned out for the best. Empathy, after ability, is the greatest attribute a

Special Editorial

Surg Neurol 1996;45:587-9

physician can have. Empathy is identifying with one’s patients, genuinely feeling their concerns and their sorrows, and expressing to them one’s own concerns and feelings. Not every physician has empathy and, unfortunately, not every physician wants it. Some prefer to maintain a strict separation of their emotions and those of the patients they care for. My feeling is that involvement with one’s patients is essential if one is to enjoy the practice of medicine. Even the sorrows-which may be greatare, when properly shared, often responsible for the greatest satisfaction in medical practice. In a sense, the neurosurgeon has assumed the role of the old family physician of 75 years ago, who sat beside the bed of a child dying pneumonia, feeling the child’s pulse through the night and sup porting the parents with his presence, even though he knew he could not save the child. That child now receives an injection of antibiotic and the physician tells the family to call in 4 days if the child is not well. It is easier for the parents of today to feel that the physician is not very concerned about the patient, and that the physician has no compassion. But the modern physician can do so much more for the family now than could ever have been done by the old family physician. The modern physician may seem to lack compassion, but his or her skill and knowledge help the patient. The neurosurgeon sits beside the bed of a teenager who was well one minute and then devastated by a head injury or an injury to his spine the next minute. The neurosurgeon takes what is left of a crumpled skull, brain, or spinal cord and does the best that can be done. In the process, the neurosurgeon becomes as close to the family as the old family physician did. The patient and the family are not good judges of whether we are good physicians; that can only be done by our peers-not by our students and not by our residents. However, the patient and the family ore better able than anyone else to judge whether we really care, or whether as someone put it, we “don’t give a damn.” What we say to them doesn’t really matter-and some physicians use words bet-

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OUNSEL WOVEN IS WIDSOM.

WALTER

BENJAMIN

(1892-l

INTO 9401,

589

ter than others-but the members of the family look directly into our souls and they know whether we care or not. If one makes a survey of why patients pick certain neurosurgeons in various communities, one would find that, just as often as not, they do not send one of their relatives or friends with a serious illness to the neurosurgeons who cured them of a ruptured disc or benign brain tumor, but to the one who took care of a patient with a malignant brain tumor, who died nine months later, or to the one who operated on a patient with a myelomeningocele, who never walked again, because these patients were well cared for and cared about by the neurosurgeon. Through conscientious and caring attendance to the head-injured patient who never recovers consciousness, the neurosurgeon becomes a very personal friend of the family and is more likely to have patients referred because of his handling of those poor results than when there has been great success, but no empathy or compassion. Our failures often lead to successes. To summarize, the three “A’s” to be avoidedAvarice, Antagonisms, and Arrogance-should be replaced by Generosity, Communication, and Caring. Neurosurgery is ripe for greening. As Harvey Cushing said in his article “From Tallow Tip to Television,” it should be possible for an individual and a profession “to ripen its own time.” Neurosurgery should do that. It is important to pull together in a country undergoing marked economic and sociologic changes and in a profession that is at a crossroads. Neurosurgery can become a cohesive, organized profession with balance in the areas of clinical practice, research, and teaching, or it can become an unbalanced, disputatious profession, whose members destroy it. The present generation will direct neurosurgery through the crossroads. And again, let me quote Elizabeth Barrett Browning: “We live in deeds not years, in thoughts not breaths. In feelings not in figures on a dial. We should count time by heartthrobs. He most lives who thinks most, feels the noblest, acts the best, and he whose heart quickest, lives the longest.”

THE

FABRIC

GERMAN

OF

CRITIC, “THE

REAL

LIFE

PHILOSOPHER STORYTELLER”