A long but absolutely wonderful entry copied from the blog of Scott Adams, the creator of Dilbert. This is why medicine and humanism go hand in hand – how else can we make sense of experiences like this, much less understand the impact that this illness had on a creative and well-known person’s life and the hopefulness and similar creativity with which he seems to have solved the problem? And of course I have a soft spot for neurological bizarrities. [Thanks Alex!] P.S. I attended this year’s first meeting of the HMS Writer’s Group, a workshop-style meeting to which everyone from second-years to senior physicians came and contributed poetry and prose, medical and non-medical. I’ll submit something one of these days… I’m just so glad to have found a group of like-minded people who are approaching medicine in some of the same ways I am.

Good News Day

As regular readers of my blog know, I lost my voice about 18 months ago. Permanently. It’s something exotic called Spasmodic Dysphonia. Essentially a part of the brain that controls speech just shuts down in some people, usually after you strain your voice during a bout with allergies (in my case) or some other sort of normal laryngitis. It happens to people in my age bracket.

I asked my doctor – a specialist for this condition – how many people have ever gotten better. Answer: zero. While there’s no cure, painful Botox injections through the front of the neck and into the vocal cords can stop the spasms for a few months. That weakens the muscles that otherwise spasm, but your voice is breathy and weak.

The weirdest part of this phenomenon is that speech is processed in different parts of the brain depending on the context. So people with this problem can often sing but they can’t talk. In my case I could do my normal professional speaking to large crowds but I could barely whisper and grunt off stage. And most people with this condition report they have the most trouble talking on the telephone or when there is background noise. I can speak normally alone, but not around others. That makes it sound like a social anxiety problem, but it’s really just a different context, because I could easily sing to those same people.

I stopped getting the Botox shots because although they allowed me to talk for a few weeks, my voice was too weak for public speaking. So at least until the fall speaking season ended, I chose to maximize my onstage voice at the expense of being able to speak in person.

My family and friends have been great. They read my lips as best they can. They lean in to hear the whispers. They guess. They put up with my six tries to say one word. And my personality is completely altered. My normal wittiness becomes slow and deliberate. And often, when it takes effort to speak a word intelligibly, the wrong word comes out because too much of my focus is on the effort of talking instead of the thinking of what to say. So a lot of the things that came out of my mouth frankly made no sense.

To state the obvious, much of life’s pleasure is diminished when you can’t speak. It has been tough.

But have I mentioned I’m an optimist?

Just because no one has ever gotten better from Spasmodic Dysphonia before doesn’t mean I can’t be the first. So every day for months and months I tried new tricks to regain my voice. I visualized speaking correctly and repeatedly told myself I could (affirmations). I used self hypnosis. I used voice therapy exercises. I spoke in higher pitches, or changing pitches. I observed when my voice worked best and when it was worst and looked for patterns. I tried speaking in foreign accents. I tried “singing” some words that were especially hard.

My theory was that the part of my brain responsible for normal speech was still intact, but for some reason had become disconnected from the neural pathways to my vocal cords. (That’s consistent with any expert’s best guess of what’s happening with Spasmodic Dysphonia. It’s somewhat mysterious.) And so I reasoned that there was some way to remap that connection. All I needed to do was find the type of speaking or context most similar – but still different enough – from normal speech that still worked. Once I could speak in that slightly different context, I would continue to close the gap between the different-context speech and normal speech until my neural pathways remapped. Well, that was my theory. But I’m no brain surgeon.

The day before yesterday, while helping on a homework assignment, I noticed I could speak perfectly in rhyme. Rhyme was a context I hadn’t considered. A poem isn’t singing and it isn’t regular talking. But for some reason the context is just different enough from normal speech that my brain handled it fine.

Jack be nimble, Jack be quick.
Jack jumped over the candlestick.

I repeated it dozens of times, partly because I could. It was effortless, even though it was similar to regular speech. I enjoyed repeating it, hearing the sound of my own voice working almost flawlessly. I longed for that sound, and the memory of normal speech. Perhaps the rhyme took me back to my own childhood too. Or maybe it’s just plain catchy. I enjoyed repeating it more than I should have. Then something happened.

My brain remapped.

My speech returned.

Not 100%, but close, like a car starting up on a cold winter night. And so I talked that night. A lot. And all the next day. A few times I felt my voice slipping away, so I repeated the nursery rhyme and tuned it back in. By the following night my voice was almost completely normal.

When I say my brain remapped, that’s the best description I have. During the worst of my voice problems, I would know in advance that I couldn’t get a word out. It was if I could feel the lack of connection between my brain and my vocal cords. But suddenly, yesterday, I felt the connection again. It wasn’t just being able to speak, it was KNOWING how. The knowing returned.

I still don’t know if this is permanent. But I do know that for one day I got to speak normally. And this is one of the happiest days of my life.

Dissection Lab started with a mess before we got anywhere near the cadavers: the entire first year class running up and down the stairs between our first floor clothing lockers and the fourth floor anatomy labs, everyone losing locker combinations and dropping keys and realizing that they didn’t have the right clothes. There was a communal moment of uncertainty about where to change–the bathrooms were small and we were already running late–and then people just started pulling off shirts. It wasn’t quite a naked free-for-all yet, but it certainly had the feel of middle school locker rooms when everyone is pulling one shirt out from under another and half-hiding behind the locker doors, except this time there were boys. I think it somehow made sense in the context of the experience we were all about to share, or made no less sense than that one: when you’re getting ready to go and do unimaginable things to a human body, who really cares about being seen in their underwear? I slipped into a pair of surgical scrubs “acquired” under partially-true pretenses from the MGH laundry room after PD on Monday (which I promise I’ll post about!) so I was walking around with MGH emblazoned across my chest. I had some of the same feeling seeing my classmates (and myself) in scrubs as seeing us in white coats for the first time – part pride in our future profession and professionalism, part awkward newness. At least scrubs are comfy. Then up to the labs (I’m so grateful they are not in a basement) and into a scramble for more locker combinations, lab coats of which everyone got the wrong size, who was in which room, etcetera etcetera etcetera and then we were in the lab with the plastic-bagged shapes on the tables listening to a brief introduction to the skeletal features of the thorax and distribution of the dissection manuals and then it was time to start. I am trying to give a sense of the swirling chaos with no-time-for-thought that ushered us into this experience; it wasn’t a bad thing by any means, but I just found it interesting and such a contrast to how I and others had chosen to begin this day, and I’m trying to convey how it felt that I had been dropped through space into a sudden moment of stillness before the hum of activity resumed as we opened the bag.

And it was okay. In fact, the whole lab session was wonderful. The first moment of seeing skin surprised me not for its strangeness but for its familiarity, and although it seems paradoxical I like it better that way because I don’t want this ever to become abstract or to try to ignore the meaning of what we are doing. The body, a man, looked much more like it had in life than I had thought it would; the skin was skin-colored and skin-textured. It was dappled with age spots, and much of the hair was white, which in the back of my mind reassured me greatly to know that he had probably lived out a full life before coming to us. The rib cage stuck out from the skinny body at something that immediately in my mind was “a proud angle”; I haven’t fully made sense of that yet anatomically, but the phrase came to me and seems to fit my experience of this body so I’ll share it. The head was covered separately and we did not choose to look at it yet; I noticed that, without explicitly avoiding it, no one touched it during the entire course of the lab. My two group members and I looked at the teaching skeleton in the lab to identify the bones then returned to identify the bony landmarks that would guide our first incision. Somehow it seemed right to me, before starting to palpate the chest and or trace the lines of the deltoids, to touch the cadaver the same way, at the same “entry point”, that I would instinctively touch a patient. So, for just a moment, I held his hand. It was cool, but not cold, and the skin was smooth and dry. And then we began.

Our cadaver is, from a dissection perspective, perfect. As I mentioned, it is a skinny man, so there is much less adipose tissue (fat) under the skin that would obscure the external landmarks and make getting down to the internal structures more difficult. All of the cutting went beautifully. And we could see… everything. We just did the chest and part of the shoulder, and already I love the way muscles are layered upon each other. The intercostal muscles between the ribs are described as like plywood: they are thin, but strong, because the layers align in different directions. The external intercostals are oriented down towards the middle, the direction of putting your hands in a sweatshirt pocket. Below that, the internal intercostals are up and towards the middle, and below that are transverse muscles that wrap around horizontally from the sides. I can see how even the best textbook or atlas (Netter’s Atlas of Human Anatomy is a work of art) or even the new fancy 3D computer modeling can’t clarify relationships and structures the way actually seeing them can. Our cadaver also had had chest surgery, so his sternum had been wired back together, and he also had a pacemaker that we got to take out. Ellen Rothman reflected on her own HMS dissection experience that a classmate had to “struggle to make the transition from the physical body to the uniqueness of the individual. ‘Every time we would look at a new structure,’ she said, ‘I would think, this is the one that’s going to be different. This is the one that’s going to make him special. Yet every time, it was the same. All our bodies looked the same.’” I was relieved that this was not the case for us, and I have a feeling that it will prove not to be the case in general. The table next to ours had a cadaver with a double mastectomy; another had a pacemaker. And more than these alterations, I think I will find that there are enough traces of the individual’s life experience–the age spots for instance–to come to terms with difference, just as there is a powerful lesson in anatomy lab about our shared human similarities.

I’m losing steam and there’s so much more to write about. But with these auspicious beginnings, I know that anatomy is something I will be thinking about with reflection and with joy for the next seven weeks, and of course beyond…

Yesterday was such a long and full day that I’ve barely begun to make sense of it, but I’ll do my best!

The morning reflection session went better than I had even envisioned it. About eighteen people showed up (many more before or after expressed a wish that they had been able to come), and we sat in a circle on the floor of one of the small lecture rooms in the MEC with two things in the middle. The first was a candle,  a practically universal symbol of spirituality and reflection. The second was a letter written by one of the donors to the students who would work on her body, which was included in our course introduction; that way, at least one of the donors was symbolically present there with us as a real person. I thanked everyone for coming and read these opening words:

We are not our bodies.
But without our bodies, we are not ourselves.
Our bodies are the pages of our books,
upon which we write children borne,
childhood scrapes,
and the traces of every smile.
Our bodies are our houses,
holding us from the beginning to the end of our time as living beings.
If the house we live in is a healthy one,
warm and well kept,
structurally sound and reliable even in a storm,
then we can be and do anything.
We can push the limits of endurance running a marathon;
we can turn our breath into song;
we can see the faces and hold the hands of the people we love.
If the house we live in is broken or diseased,
then every day can be a struggle
between the house and the human spirit it houses.
We can lose the trust we had in our house to keep us safe.
We can be frustrated by our limitations,
by the things—large and small—that our bodies will not allow us to do.
By losing parts of our lives, we can lose parts of ourselves.
Through healing, we can be whole again.

The donors of these cadavers gave us great gifts: not only these physical bodies, but the power to learn to heal bodies, and with that, to heal people. As we become doctors, may we always respect and honor both the bodies we touch and the spirits housed inside.

Several people then shared thoughts or readings they had brought, and as I had hoped and anticipated, it was the sharing of many voices that at least for me made the experience truly powerful. I can still hear the sound of a Jewish student reading a prayer in English and then chanting it very softly in Hebrew; another student read from the Psalms. One classmate spoke of a very intimate and deeply personal experience with the death of a family member and related it to Islamic religious and cultural traditions about preparing the bodies of the dead and carrying their life-force onwards. Another classmate introduced and read a story from the Lakota tribe with which her family has close ties, about a man who knows he is dying and gives everything away until at the end of his life he has nothing left but is remembered forever for his generosity. I read a piece sent to me by someone who couldn’t attend about how medical students in Thailand refer to their cadavers not as sop (cadaver), but as ajarn yai, great teacher. It was so wonderful to see the diversity of our class made evident so spontaneously (I didn’t know in advance what would be read) and so meaningfully. And then we sat quietly for a while, and I had the now-familiar awareness of what often happens during silent prayer at First Parish (when the babies in the side boxes aren’t choosing to fill the silence) of the absolutely wonderful strangeness of being silent in the company of a large group of people… It happens so rarely in any other aspect of busy, crowded life, and just because of that it is moving, not to mention the power of awareness of first one’s own thoughts and then of the thoughts that others are having. I never realized it until now, but even though it does not actually involve sharing aloud, the practice creates a mindfulness of other people’s emotional, psychological, and spiritual lives just by defamiliarizing the experience of being in the company of others. It was especially powerful to get to know my classmates in such a different context than how I normally get to interact with them.

I closed with these words, we all took a breath together, I blew out the candle, and we slowly and quietly left to start the day:

The life spirit that once flowed through these bodies is gone, but it lives on beyond death in the generosity of these donors. It flows too through our future patients, supporting them as they strive for health and wellbeing. And it flows through us, in the compassion and commitment that have led us to become healers. Let us always remain mindful of the great responsibility and the great gift bestowed upon us by every person who puts his or her body into our hands. Respectful of this gift, we open ourselves up to learning from our cadavers, and we will strive to use this education for the good of our patients.

Overdue, backdated…

I had a great first interview for Patient-Doctor I with J., a woman who was 38 weeks pregnant and glowing. I really appreciate our faculty leaders’ decision to have us interview pregnant women first, as a way of seeing medicine as being about health as well as about illness and to let us practice our skills on people who hopefully didn’t have too much “wrong” with them but who still had a medical issue to talk about with many emotional, psychological, and social facets as well as of course many biological ones. More from the reflection portion of my write-up:

“J. was a great interviewee: she was warm, light-hearted, patient, and answered questions well. I was not as nervous as I thought I would be, and felt that the time passed easily and quickly; I was shocked when I found out afterwards that the interview was more than fifteen minutes long. It was sometimes hard to know what to ask her only because she seemed to be doing so well in every respect, and also because I didn’t know much about the biology or psychosocial experience of pregnancy. I keep thinking of more questions I could or should have asked her—not the least of which are her age, more about her first delivery, when her miscarriage occurred, and rapport-establishing things like what she intends to name the baby. I also was not sufficiently specific about her past medical history, only asking if she had any concerns about it rather than specific questions like hospitalizations, surgeries/procedures, and medications. If I were her clinician (and was asking to improve her care rather than just for my own learning, as we discussed afterwards) I would have probed more into the emotional experience of losing her second pregnancy, and how having her first child had affected her life and career.”

We had our last exam yesterday for MCMD (Molecular and Cellular Basis of Medicine and Development), so our first “real” medical school course (I’d get in big trouble for saying Intro to the Profession wasn’t a real course, but you know what I mean…) is done. I haven’t written much in this journal lately and I think it’s because of something I explained to Mom and Dad last night (welcome to Boston for the weekend!). Dad asked what one thing had really stood out to me in my experience in medical school so far, and I couldn’t really think of one thing to point to, any particular experience that was in and of itself surpassingly important or meaningful. I think the reason is that it is in the synthesis of often disparate experiences that I have found intellectual or emotional joy, as evidenced in one of my previous entries. I enjoy the kind of knowledge and wisdom that do not come in a flash of revelation, but by accumulation, or at least for which the accumulation of different parts and underpinnings enables the addition of one more piece to make the solution to the whole puzzle snap into focus. And so far that seems to be at the very root of my medical education, inherent to the subject matter and artfully supported by the structure of our curriculum: that information from different disciplines and different levels (molecular, cellular, organ, organ system, organism, family, society, world…) is intrinsically inter-related, and ultimately informs the provision of care. So there was nothing specifically striking in last week’s collection of lectures on development, tutorials on breast cancer, histology etc. but the pleasure came in putting it all together by hearing a great lecture on teratogens (things that cause birth defects) and how to approach them in clinical practice after having researched the teratogenicity of tamoxifen for tutorial and studying everything we’ve learned about development for the exam.

We start anatomy on Monday, and first see our cadavers on Tuesday. I’ve been thinking for a while about finding some way to approach the overwhelming meaningfulness of this experience before it starts. I think what I’ve settled on is a small group session on the morning before our first lab. I sent the email excerpted below to the class, and I already (on a Friday afternoon/evening) have gotten a lot of positive responses.

One thing I have been thinking about is wanting some way to approach our cadavers philosophically or spiritually before we approach them scientifically. I think HMS usually has a memorial service at some time in November, but I’m writing to see if anyone wants to join me in putting together an informal session before our first gross anatomy lab on Tuesday. [...] I was thinking just something along the lines of a few readings/prayers/meditations and a few minutes of quiet time, a chance to share thoughts with each other, maybe light some candles, and (if I’m really on top of things) homemade breakfast munchies. Coffee can definitely be arranged too! As for content, you can really bring whatever you want – your own words or someone else’s, sacred or secular… just some expressions of mindfulness and appreciation for the gifts that our donors have given us. As long as it’s on the short side (tutorial starts at 8:30) and is inclusive of people of any (or no) religious affiliation.

The enthusiasm surprised me and made me happy; while I am sure that most or all of my classmates are mindful and reflective people, I feel that we haven’t gotten that many chances to share that side of ourselves with each other. A notable exception would be the introductions we gave in the Castle Society White Coat Ceremony, which I found extremely powerful. And I’m excited at this first chance for me to take a more active role in creating a sacred space and time with others.   I was moved yesterday to write a few things to read on Tuesday and I’m hoping other participants will bring things to contribute. I’ll post mine when they’re in their final form. Feel free to leave a comment or email me if you have suggestions.

In other related news, I’ve been writing again! Just a little bit actually down on paper (digital paper…) at this point, but I’ve been trying to make more methodical observations about the Longwood area that I will turn into something that is at the moment tritely titled “My Longwood.” Say “tritely titled” ten times fast. I’ll post bits and pieces here if it makes sense to do so. Anyway, the point is to be more mindful about life in general and to make some sense and meaning out of the fascinating environment that I’m in. AND there’s an HMS Writer’s Group! “The group is composed of members of the Harvard community who meet monthly to share and workshop their prose and poetry. The subject matter ranges from scientific to personal topics, and people of all levels of writing experience are welcome to come.”

Finally, in a Google search for something, I found out that HMS can also stand for Heart, Mind, and Spirit. I knew this was a good school