To Examine or Not to Examine That Is the Question

B''H

I just read an article in JAMA[1] questioning the need for routine physical examination on a healthy patient as there is no "evidence" to support this. The author then presents an anecdote regarding his own father who on a routine physical examination was thought to have enlarged aorta by palpation: leading to an ultrasound showing a normal aorta but question of a pancreatic mass; leading to a CT scan showing a , of course, normal pancreas but a possible liver lesion; leading to a biopsy (of a hemangioma); leading to a hemorrhage; and , finally, the denouement, leading  to a stay in an ICU. Cost: $50,000. Admittedly, the author is trying to pick a bone with routine yearly physical examinations but the article gives impression that examination of a "healthy" organ is worse than useless and calls into question the usefulness of any physical examination.

Since we are in the realm of anecdote let me present a few. In my career, I have picked up on routine examination six or seven abdominal aortic aneurysms of significant size. All of these patients were smokers and had a bruit. My yield on this physical finding is about 80%. I suspect the author's father's internist had never palpated an actual aneurysm. When I taught in a medical school, I told my students and residents that the key to physical examination is not to be Dr. Joseph Bell[2] but just to do it. In other words, the key is to look for the obvious not the subtle.[3] Unfortunately fear of lawsuits has made all of us order tests for insignificant findings.

Beethoven and Yiddish

B''H

Many people have asked me to tell the story of how a Beethoven sonata is related to how people speak Yiddish today. Okay, I will take a crack at it. But a warning, it is very politically incorrect.

First, some background. My wife, spoke five languages fluently, English, German, Yiddish, French, and Hebrew, where German was her best because she has studied it most intensely and spoke multiple dialects, including archaic ones; played flute, alto flute, piccolo, recorders, historical flutes, piano, harpsichord, and harp; had received performance certificates from two music conservatories, one in France and one in Chicago; had studied music with Helen Kotas Hirsch, the first woman to be a first chair with a major symphony in the United States, the Chicago Symphony; and had received a Masters degree in musicology from the University of Chicago where her major interest was 18th-century German music theory (meaning she was unemployable).

Where is Joe Welch?

B''H

(slightly cropped)

While decluttering my house after the death of my dear wife, I found this photograph (yes, that is me), taken circa 1980. Whenever I show this photo, the immediate response is laughter. If I attempted to do this today, assuming I could get this close, the end result would probably be a bullet through my head. Back then, nobody cared. I am sure if I had jumped the fence, something would have happened. We, as a country, have gone overboard.

Consider what happened to the lady who either had a mental breakdown or simply panicked when she approached or tried to run her car into the grounds of the White House. She was shot down like a dog. It is not that she was simply shot but that she was shot so many times "they had difficulty identifying her because of the extent of her injuries"[1]. If you take the time to view some of the videos taken after the incident, you will see the officers involved carrying M-4s: the same weapon our troops use in Afghanistan. Lethal military-style force with overkill was used against an unarmed civilian who probably had a psychological disorder with a baby in a car. And nobody, at least in power, seems to care.

Our country has a long history of periods of overreaction against foreign threats: the Alien and Sedition Acts over fears of the French Revolution coming to the United States; the Know-Nothings in the 1850s after the revolution of 1848 in Europe associated with the influx of immigrants from Germany and Ireland; the Red Scare after 1919,  the Russian Revolution; the McCarthy era in the 1950s; and, I believe today, after 9/11.

On continuing the process described above, I discovered correspondence between my wife's grandfather and his relatives in Europe prior to and during World War II. The letters are written in Polish, Yiddish, and German. When I showed them to my 92-year-old father-in-law to find out who was who, he expressed interest and surprise, asking "where did I get them?", having never seen them. They had sat in his basement for 30-plus years in a box after the death of his mother. I have inherited them. In 1939 the return address on a series of them changed from Lodz, Poland to Warschau (German for Warsaw) with a Nazi stamp on them. Until 1941 the postmarks in Chicago are dated fairly contemporaneously, but after that date the letters were not received until 1946. This entire family perished.

A Technician Not a Doctor

B''H

William Osler examining a patient.

I recently read an article in JAMA[1] wherein a transplant surgeon describes his consultation with a patient.
From my reading, the surgeon almost accidentally finds out the man had been shot seven times and tortured. Much to my surprise, the surgeon does not want to ask any personal questions for fear that he would be "pry(ing) too much". As far as I can tell the patient was never examined by this highly specialized surgeon at an elite Medical Center. Instead, our protagonist discovers that the patient, a Visiting Professor of Theater, has written plays about his experiences in his native land in Africa by "Googling" him rather than taking the simple human expedient of asking questions. He then orders the patient's play from Amazon.com, reads it, and is justly disturbed. His mother notices this (during Mother's Day) but he ducks her questions for fear of "violat(ing) my patient's privacy". Remember this patient has published all of this. I found this entire story quite disturbing: this physician seems to deny both his and his patient's humanity. He seems to miss the whole fun of medicine: meeting people from all walks of life and helping them. When I discussed this incident with several of my colleagues, one of them very astutely said, "Perhaps we should call him a transplant technician rather than a surgeon".

The Perfect Student

B''H

Hannah Rose told me many times that she was the "perfect student": doing everything the teachers asked in an overly thorough way. She felt thinking independently only came to her after a professor in graduate school rightfully, in her view, called her a "silly little girl" (lucky he he did this 30 years ago). This occurred when she was doing a presentation on Bach and the professor pointed out how she had stumbled on a very important question. My perfect student then continued with her pedantic report at which point the professor stopped presentation with the above exclamation and told her not to go on. This was a life-changing episode. I ask you, would this happen today? Are we too afraid to correct?

I recently read an article published in the New England Journal of Medicine roughly three years ago[1] recounting in first person singular an event that happened on an airplane to the author. A passenger coded. The author, a neurologist, and his wife, a hospitalist, began resuscitation assisted by an AED, and an Ambu bag, and other equipment. Three other physicians, passengers, an oncologist, a surgeon,  and an anesthesiologist, rapidly volunteered to help. A dang good code team.

After 25 minutes, despite the efforts of, and in the opinion of, these highly qualified physicians, the man was dead. They turned to his wife and informed her that further efforts would be useless. They called the code. At this point in time, the stewardess informed the physicians present that airline policy insisted that CPR be continued until the plane landed and that she and the other flight attendants would take over from five board-certified physicians.

Yehudit bat Aharon

B''H

Hanna Rose's actual name was Joanne Galler Rubin (Yehudit bat Aharon v'Esther V'dorah-Judith daughter of Aaron and Esther-And-Her-Generations).  She died on 24 April 2013 peacefully surrounded by friends and family.  Below are the notes Rabbi Jonathon Bienenfeld used to deliver her eulogy.

Joanne Rubin – Yehudit bat Aharon

·       We pay tribute today to Joanne Rubin, to Yehudit bat Aharon v’Esther Vedora—wife of Steve Rubin, mother of Isaac and Rachel, daughter of Mr. Aaron and Mrs. Esther Galler.

·       Joanne’s was a life that was cut far too short, finally succumbing to a protracted battle with cancer. Yet it is a life that one cannot do justice to—for she accomplished more and touched more souls in her shortened life than most people possibly could in ten lifetimes.

·       And it is difficult to speak of Joanne for another reason—because of her complexity. If you knew one facet of Joanne’s personality, you’d make certain assumptions, only to be thrown completely off guard by another facet. If you knew her from angle A, you’d soon be blown away by angle B.

·       Joanne was brilliant. Growing up in Chicago, she attended Northwestern University, then receiving a masters in musicology from University of Chicago. She was fluent in numerous languages. I was recently having a conversation about studying Talmud with Isaac, and she mentioned that she had a wonderful textbook we could use—the subject matter was ancient Aramaic, the instruction in modern German. She was a deep thinker and an avid reader—studying both secular and religious subjects passionately. If you knew Joanne’s brilliance, you would expect the cynicism that often goes along with it—a philosophy that all can be studied and all can be explained. And you would be completely taken aback by the simple, pure faith in G-d that such an intellectually sophisticated person could possess. Her brilliance made her shrewd and thoughtful, not cynical, never disbelieving. Her faith was awesome and awe inspiring. True faith is not the belief that something will happen, but that anything can happen. True faith realizes the G-d can do anything, that G-d can make miracles, but that the miracles don’t always unfold the way we might like them to.. Joanne’s take on miracles is best expressed in her own words, words she shared as “Hannah Rose,” her blogging pseudonym:

"Oxygen is smooth and comforting.  It is the breath of G-d, the elixir of life when the lungs are filled with fluid.  Oxygen keeps the body at peace while the siphon drains liters of fluid from the pleura.  Then the pleasure of coughing begins.  It is important to puff up the lungs so they may work again.  There is nothing boring about breathing.

There is nothing boring about any aspect of life.  Miracles are multi-dimensional and have nothing to do with that little purple and pink wand with the star and the ribbons and the glitter that sings a song when you tap or whack someone. Miracles assign many responsibilities.  It is difficult business to rise to the occasion of this gift." 

A Last Entry*

B''H

"Courage, courage, courage, courage, courage.... This mystery is not so great."

This is what Rachel said as she cradled my head and whispered into my ear. She stroked my head and kissed me on the kepe.