OCR Text |
Show THE SECOND JACOBSON LECTURE Reflections and Advice From an Aging Academic Robert B. Daroff, MD ( J Neuro- Ophthalmol 2009; 29: 338- 341) I appreciate the honor of being the Second Jacobson Lecturer and want to acknowledge my indebtedness to my two neuro- ophthalmologic mentors, Lawton Smith and Bill Hoyt. Bill is in the audience today and many of us were either trained by him or trained by someone who trained under him and certainly benefitted from his wisdom at these North American Neuro- Ophthalmology Society ( NANOS) meetings. When I was President of the American Neurological Association, I introduced Hoyt at the formal banquet by quoting President John F. Kennedy's remarks to a group of Nobel laureates he had invited to the White House for lunch. Kennedy said, ‘‘ Never in the history of the White House has there been such an accumulation of brain power, except perhaps when Thomas Jefferson dined alone.'' Upon reaching the podium, Hoyt, with his typical modesty, quipped, ‘‘ I'm nauseated.'' I've been asked why I chose this title for the lecture. As I have been out of full- time clinical practice for the past 15 years, there is nothing new I can tell you about clinical neuro- ophthalmology. Instead, I will dwell on some nonclinical issues. TEACHING AND PASSIONS Almost all neuro- ophthalmologists teach. Why? For openers, I can't disagree with Osler's statement, ‘‘ Your students and discipleswill constitute your greatest honor'' and Henry Adams' comment, ‘‘ Teachers affect eternity- one can never tell where their influence stops.'' ButWilliam Parsons was justifiably undecided as to whether ‘‘ we teach for altru-istic reasons or to fortify our own narcissistic self- images.'' My vote goes to William Chambers, who taught neuro- anatomy when I was a medical student at Penn. It was before the use of slides, and he illustrated his lectures with blackboard drawings. His first lecture was on the anatomy of the thalamus, the second on the thalamo- cortical connec-tions, and the third on thalamo- spinal connections. At the start of his fourth lecture, he told us it would be on thalamo-thalamo connections and turned to the blackboard. Just about everyone in the class softly groaned, but 125 groans got Chambers' attention as he began to draw the thalamus. He turned around and said something like, ‘‘ I guess you wonder why I'm telling you all this, which will have no benefit for you as practicing physicians. I am giving these lectures for the same reason I spend my life studying the thalamus. It PLEASES ME.'' He then turned around and began to draw. The thalamus was his passion, and his justification had an impact on my career decision- making over the years. The legendary gambler Nicholas Dandolos ( Nick the Greek) said that his greatest passion was ‘‘ gambling and winning.'' His second greatest passion was ‘‘ gambling and losing.'' Warriors seem to share passions. Beowulf wanted ‘‘ to die with a sword in hand, and to be transported to spend the whole of eternity eating, drinking beer, and fighting.'' For Kipling, it was ‘‘ women, horses, power, and war.'' Of Churchill's Boer War experience, he wrote, ‘‘ Nothing was more exhilarating then being shot at and missed.'' French Colonel Christian de Castries preferred ‘‘ a horse to ride, an enemy to fight, and a woman to bed.'' When the notorious bank robber Willie Sutton was asked why he robbed banks, he allegedly replied, ‘‘ That's where the money is.'' But in his autobiography he wrote that he robbed banks because he enjoyed it. He felt more alive when hewas robbing a bank than at any other time in his life. Rather curious passions were those of Oxford scholar Benjamin Jowett, who wished ‘‘ to arrange my life in the best possible way, that I may be able to arrange other people's,'' and Anton Chekhov, who longed to ‘‘ be idle and to love a fat girl.'' My passions are in accord with those of William Butler Yeats' ‘‘ continuous drinking of knowledge,'' and H. G. Wells' ‘‘ editing someone else's manuscript.'' I would add family ( awife, 3 sons, and 6 grandchildren) and teaching. RECEPTIVITY TO LEARNING AND PERFORMANCE To be optimally receptive to learning, trainees should be relaxed. I never asked students or house officers serious questions in a group setting. I wanted them relaxed and unconcerned about being put on the spot. When alone with one of them, I have not hesitated to ask such questions because the wrong answer won't be embarrassing. Department of Neurology, Case Western Reserve University, Cleveland, Ohio. Address correspondence to Robert B. Daroff, MD, University Hospital of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106- 5015; E- mail: Robert. daroff@ case. edu 338 J Neuro- Ophthalmol, Vol. 29, No. 4, 2009 That anxiety degrades performance became quite evident to me in an incident involving the late Peritz Scheinberg, the first chair of Neurology at the University of Miami and my first boss. Tired of having to teach the neurologic examination to every new group of rotating students, Scheinberg decided to make a teaching film of the examination. He selected the brightest fourth year medical student as the subject, and when he got to the mental status exam, he asked this young woman, who was about to take her internship and residency at Harvard, to subtract 7 from 100 serially. She was so nervous during the filming that she made numerous mistakes with a simple task that she would have performed easily in a relaxed state. EFFECT OF MORALE ON PERFORMANCE In 1965, after finishing my neurology residency, I entered the US Army and was soon sent to Vietnam as the first and only neurologist serving the allied forces. I was attached to a psychiatric unit and, given our unique expertise, we expected to be stationed in a Saigon hospital and housed in a nice villa. Instead we were sent to a remote hospital carved out of a jungle and rubber plantation. Psychiatric casualties appear to do better if hospitalized in a facility that simulates field conditions. If you take a young soldier who cracks up in the field, and put him in a nice clean, safe hospital with nurses dressed in white, and serve him good food, he won't want to return to the field. But if you put him in our hospital with giant rats, spiders, snakes, and incoming mortars, he would regard the battlefield as being safer. The living conditions for the Medical Corps at our Evacuation Hospital in Vietnam were terrible. Indeed, the non- physicians had better accommodations. Dr. David McK. Rioch, the head of neuropsychiatry at the Walter Reed Army Institute of Research, visited our unit to discuss our patients. He casually asked about our living and working conditions. We didn't hesitate to ventilate about our lack of hot water for showers, lack of drinking water, and terrible food compared with what the enlisted personnel and nurses had. The more we complained, the more Rioch seemed pleased. He finally said gleefully, ‘‘ They've read my study.'' During the Korean War, he had studied the effects of morale on performance in all military units and found a direct correlation between high morale and optimal performance in all units except the Medical Corps. He concluded that physicians were so well trained, that no matter how bad their morale, they performed well. Thus, in a limited resource environment, the military didn't regard Medical Corps morale as being an important con-sideration. Reluctantly, we agreed with the logic. We were working hard and efficiently despite our global dysphoria. Years later, as an attending in a teaching hospital, I realized that Rioch was wrong. The performance measures he probably used for the Medical Corps were the number of patients seen and the mortality rate. But no matter how poorly a physician may feel, he or she will see all the patients that need to be seen and keep them alive if possible. What may be missing is compassion and empathy. It is difficult to be compassionate and engaged when feeling poorly or depressed. I noticed that when our residents were unhappy, they performed their basic functions but without compassion and personal interest. I thus became, to use a military term, a ‘‘ morale officer.'' When I would see obviously unhappy residents, I'd take them aside and attempt to determine the cause. I would then counsel them or send them to a professional. PRESCRIPTIVIST OR DESCRIPTIVIST I mentioned that I don't ask serious questions to trainees in a group setting, but I do ask nonthreatening questions to illustrate a point. If a resident describes a patient's ‘‘ legs'' as weak, I might say, ‘‘ Define the leg.'' The correct answer would be ‘‘ the distal portion of the lower extremity beginning at the knee.'' I was being a ‘‘ prescrip-tivist'' rather than a ‘‘ descriptivist.'' When I was a medical student at Penn and a neurology resident at Yale, if I said ‘‘ leg'' when I meant ‘‘ lower limb,'' I was publicly corrected. I might ask trainees to define ‘‘ foot'' and then point out that the Ohio Revised Code ( the applicable law in the state) defines foot as ‘‘ the terminal appendage of the lower extremity that includes the ankle joint, distal tibia, and fibula.'' ( It seems that the podiatry lobby prevailed with our state legislature). A follow- up question might be, ‘‘ Do subhuman primates, carnivores, and other creatures have feet?'' Abraham Rabiner, the most prominent academic neurol-ogist in Brooklyn, a man who had retired to Miami in his mid 80s, said ‘‘ no.'' He had written an article in Brain in the 1920s contending that ‘‘ the foot defines the extremity in which the big toe forms the fulcrum in walking.'' If so, only humans have feet. A further question might be, ‘‘ Why does the foot only plantar flex or dorsiflex, but never extend?'' This question often provokes an interesting discussion. PROFESSIONALISM Professionalism may clash with reality concerns and personal safety. InVietnam, we not only treated our wounded soldiers but also cared for our enemies, the Viet Cong ( VC). Wounded VC captured by American soldiers were often taken to our hospital, and we gave them our best care. I recall an American soldier who was unconscious with a bloody head wound. An x- ray revealed a hand grenade in his head that hadn't exploded because the firing lever was tamponaded by the brain and the hematoma. The frontal lobes seemed totally destroyed. We knew that 339 Second Jacobson Lecture J Neuro- Ophthalmol, Vol. 29, No. 4, 2009 ultimately the grenade would explode. Should we eva-cuate the hospital and try to remove it? We had only three neurosurgeons in the whole country. Was it prudent to put one at risk and risk the lives of operating room personnel to save the life of someone who, at best, would be in a vegetative state? A pragmatic decision was made. Professionalism may also clash with personal animosity. At the end of World War II, the distinguished Norwegian neurologist Sigvald Refsum ( of Refsum syndrome) was asked to examine Vidkun Quisling, the former Norwegian head of state who had been imprisoned for collaborating with the Nazis during their occupation of Norway. Professor Monrad- Krohn, the senior neurologist in Norway, suspected some type of brain disease must have led to such treacherous behavior. Taken in prison garb to Refsum's office for a neurologic examination, Quisling greeted Refsum and extended his hand. Refsum refused to shake it. The examination was normal, and Quisling was ultimately shot by firing squad. According to Refsum's obituary, for the remainder of his life he felt remorse for letting his personal revulsion interfere with a basic element of professional behavior- the shaking of a patient's hand. Professionalism is better modeled than taught. We saw the model in our faculty at Penn. During rounds, I. S. Ravdin, the chair of surgery, always sat at the patient's bedside, showing empathy and concern. On rounds, Francis Wood, chair of medicine, once led us into a patient's room and immediately placed his thumb on the patient's radial pulse. Then he had us leave the room and asked, ‘‘ What did I do wrong?'' We all replied, ‘‘ You don't take a pulse with your thumb,'' to which Wood responded, ‘‘ You mean that I can't tell the difference between my pulse and the patient's pulse? What I did wrong was not introducing myself and you to the patient and not telling him what we were going to be doing.'' When I finish examining a patient on resident rounds, I make it a point to replace the patient's socks and to put the bed, side rails, and IV pole back to their original positions. The resident and students get the message. PUBLISHING I want to help you get your articles published. Follow the 1881 rules of John Shaw Billings: 1) have something to say; 2) say it; 3) stop. Another suggestion is to avoid using the passive voice. Do not write ‘‘ It was felt that the patient was weak,'' but rather ‘‘ The patient was weak.'' The passive voice should only be used in the Methods section, where ‘‘ The cats were then sacrificed'' is preferable to ‘‘ We then killed the cats.'' You can find many additional suggestions in Neurology 1996; 46: 298- 300. If you describe a new syndrome, it would please your parents and grandchildren to see your name eponymized. When Milton Shy, as chief of the Neurologic Institute at the National Institutes of Health, described a newly recognized muscle disease as ‘‘ central core disease,'' that apt designa-tion stuck, prompting Shy to say that if you wanted an eponym, be sure to give diseases names that have long Latin descriptors such as ‘‘ polioencephalitis hemorrhagica supe-rioris'' ( which became Wernicke encephalopathy), ‘‘ angio-keratoma corporis diffusa universale'' ( which became Fabry disease), or ‘‘ heredopathia atactica polyneuritifor-mis'' ( which became Refsum syndrome). CAUSALITY Samuel Johnson remarked, ‘‘ Physicians seem to confuse subsequent for consequent.'' The Latin expression post hoc ergo propter hoc describes this logical fallacy, which trainees should be taught to recognize and avoid. I usually provide some examples. The swine influenza vaccine of the late 1970s was said to produce Guillain- Barre ´ syndrome, and billions of dollars in lawsuits followed. Arthur Asbury finally conducted an epidemiologic study showing that Guillain- Barre ´ syndrome incidence after the vaccine was merely at its baseline rate. To dispel the notion of ‘‘ post- vaccination crib death,'' I tell the story of the woman who, when taking her infant for vaccination and finding a long line in the physician's office, decided to go shopping and come back later. While in the store she took her eyes off the baby for a few minutes and then discovered that the baby was dead in the stroller. Had the baby been vaccinated as planned, there would have been little doubt in many minds that the vaccine had caused the death. THE GOOD OLD DAYS We are living in bad economic times, but did we think we were living in good times 5, 10, 20, or more years ago? When were ‘‘ the good old days?'' In 400 BC, Socrates noted that children had bad manners, did not rise when an adult entered the room, contradicted their parents, and intimidated their teachers. In 55 BC, Cicero recommended that ‘‘ The budget should be balanced, public debt should be reduced lest we become bankrupt, and people must again learn to work instead of living on public assistance.'' The first century Roman poet Ovid described mankind's decline from the Golden Age, when man had uncorrupted reason and pursued good, to the then extant Iron Age, when fraud, avarice, and force had replaced truth, modesty, and shame. The 13th century Castilian monarch Alfonso the Learned immodestly remarked, ‘‘ If God in his wisdom had only consulted me before embarking on His creation of the world, I would have suggested something simpler.'' The aging Jefferson, decrying the deterioration of American society, wrote to John Adams, ‘‘ They'll never 340 q 2009 North American Neuro- Ophthalmology Society J Neuro- Ophthalmol, Vol. 29, No. 4, 2009 Daroff know what we had.'' Somewhat later, the newspaper columnist Franklin Pierce Adams ( 1881- 1960) mused, ‘‘ Nothing is more responsible for the good old days' than a bad memory.'' Artie Shaw ( 1910- 2004), the oft- married clarinetist and band leader, astutely stated, ‘‘ These are the good old days the next generation will hear so much about.'' Medicine is particularly criticized because of its departure from the good old days. Awise contemporary has noted, ‘‘ The old time doctor who waited by the patient's bedside while he died was held in higher esteem than the physician of today who provides a prescription, and then absents himself while his patient recovers.'' In a 1907 issue of the Journal of the American Medical Association, a writer stated, ‘‘ It's perhaps fair to say that the average physicians of today have too exalted an idea of the science of medicine and too pessimistic a view of the art of medicine. Too many physicians sit back in their easy chairs, waiting for a laboratory to solve a problem whose solutions can often be just as accurately reached by the use of their own eyes, ears, and fingers.'' Dr. Francis Peabody ( 1881- 1927) at Harvard was particularly critical of his contemporaries, stating that ‘‘ The laymen of the older generation feel that something is lacking, like warmth, sympathy, and understanding, and want to return to the good old days of the general practitioner.'' He went on to say, ‘‘ To put it more bluntly, current medical school graduates are too scientific,' and do not know how to take care of patients.'' Joining the self- criticism in 1938, the physician- scientist Isadore Snapper wrote, ‘‘ House staff have the tendency to consider taking the history and performing the physical examination as an old fashioned method, which should be declared obsolete. These souls believe that they will stumble upon the diagnosis if only the expensive machinery of the clinical laboratory would send them sufficient report slips.'' To put this matter into perspective, one of my heroes, UCSF Nobel Laureate J. Michael Bishop, noted, ‘‘ It seems we have always been in troubled times, no matter what era of recorded history it might suit your fancy to sample.'' This assessment puzzles me because I do believe things are getting worse, but perhaps since at least 400 BC. How could there always have been ‘‘ the good old days,'' even in ‘‘ the good old days?'' Perhaps Logan Pearsall Smith ( 1865- 1946), the essayist and critic, was correct when he said, ‘‘ The denunciation of the young is a necessary part of the hygiene of older people, and greatly assists the circulation of the blood.'' SURVIVAL SKILLS Given that things are bad and are destined to worsen, I'll provide you with some nuggets of advice. A simple experience affected my reactions to many irritations. While at the University of Miami on an oppressively hot August day in the 1970s, I entered a crowded hospital elevator in which a posted sign read, ‘‘ It is illegal in this elevator to ask is it hot enough out there for you?''' We were all deprived of ‘‘ basic elevator talk,'' and I realized how our moods were influenced by the weather, and how the accepted custom of complaining about it may actually enhance dysphoria. I then decided that the weather, be it a blistering summer Miami heat or a Cleveland blizzard, should be ignored, as long as the car starts and the roads are driveable. There is a slight downside to this philosophy. You can never say, ‘‘ It's a nice day,'' because that implies that some days are not nice. I never comment about good weather, and when someone does ( rarely in Cleveland), I may say something like ‘‘ I wouldn't know, I've been inside all day.'' Or, I might relate the elevator anecdote. G. Gordon Liddy, of Watergate infamy, felt wronged by our judicial system. In his biography, he noted being often asked whether he was ‘‘ bitter'' and he replied, ‘‘ Bitterness can only be experienced if one simultaneously indulges in self- pity, and self- pity is the most useless expenditure of psychic energy I can imagine.'' When I find myself aggrieved about something for more than a few days, I return to that Liddy remark, and try to get over it. Rabbi Kushner, author of When Bad Things Happen To Good People, said, ‘‘ Expecting the world to treat you fairly because you are a nice person is like expecting the bull not to attack you because you are a vegetarian.'' To paraphrase Osler's 1903 address to the University of Toronto medical graduates, ‘‘ I propose to tell you the secret of life as I have seen the game played, and as I have tried to play it myself. I propose to give you the Master Word. Though a little one, the Master Word looms large in meaning. It is the open sesame to every portal, and the great equalizer in the world. The average person among you will be made bright, the bright person brilliant, and the brilliant student unsurpassable. With the MasterWord in your heart, all things are possible. It is directly responsible for all advances in medicine during the past twenty- five centuries. The Master Word is WORK!'' I try to follow the advice of former mentor Lewis Mumford ( 1895- 1990): ‘‘ Nothing is sacred but the integrity of your own mind. Your main need is to have a firm inner center based on your own identity and your own work, an affirmative self- respect that no institution, no outward circumstance, can violate: your own yes and no.'' We are dealt a hand and we should play it to the best of our ability, without wasting the time or the energy to complain about the cards, the dealer, or the rules of the game. Just play out the hand. 341 Second Jacobson Lecture J Neuro- Ophthalmol, Vol. 29, No. 4, 2009 |