This entry may get a little graphic…though I will try to temper it with the poetic. I already have one foot over the line towards familiarity–desensitization?–with this view of the body, so read on with that in mind.

For the last dissection of the continuing anatomy elective today, most likely the last time I will be in the anatomy lab with the full cadavers (neuroanatomy is not until next year and the brains have already been separated), it seems fitting that we dissected the orbit and that my group then dissected the eye. We took a “brain’s eye view” for the approach to the orbit, going in not from the front but from above, where a thin shell of bone separates the orbit from the cranial cavity. It seems fitting, given how overwhelmingly visual our experience of life usually is, that the eyes should be nestled right up under the brain. We tend to think of the brain as being so sheltered and isolated from the rest of the body, both functionally and physically, with the skull all around and the “blood-brain barrier” (actually about as impermeable a border as the US-Mexican one…). Actually, there is all kinds of communication between the brain and the outside world, not only through the senses but also through all the vessels and nerves and cavities that perforate the intricate bony lattice inside the skull. Anyway, it was interesting enough to descend through the layers of muscles that encircle the eye to enable it to move in all directions. But the best part was definitely revealing the white sphere of the eye itself, with the massive optic nerve emerging from the back like an enormous anchoring root. I have always been fascinated by eyes, as evidenced by a certain habit when I was very young of poking the eyes of whole fish from the market to see how squishy they were, and by how clearly I still remember the look and feel of the cow eye we dissected in 5th grade (after we had finished with our fetal pig, whose name was Lawrence… the things we remember!). And I certainly got fired up by the visual system every time I learned about it in my neuroscience classes in college. Maybe for the same reason I liked the Mind/Brain/Behavior program in the first place: it’s a point of interface between the brain and human experience, in which all those little electrochemical events are organized and reorganized through successive layers of processing until somehow… meaning is created. You recognize the face of your child, because the relay race carried a signal from the eyes in the front through the crossover in the middle (the optic chiasm) to the mysterious architecture of the occipital cortex all the way in the back and then moving forwards again through more and more specialized regions until that signal bloomed into consciousness.

They say the eyes are the windows of the soul. How intriguing then that they should be the very last thing we dissect. It’s hard to think about, but the cadavers by now are in pieces, and many parts of them are beyond recognition. Successive dissections necessitated separating top from bottom, then lower right from lower left, then top of head from bottom of head, then the left and right halves of the face. We thoroughly examined parts of the body that are taboo even to talk about in virtually every society or social context. We sliced open hearts that had been painstakingly repaired by hours and hours of surgery. So much of medicine is geared towards protecting the spinal cord at all costs, and so much suffering occurs when the spinal cord is damaged… and during the first continuing anatomy lab we pried it out of its spine-formed cage and snipped it in half to see the butterfly-shaped outline of the gray and white fibers. We severed the troublesome ACL to open up the knee, and explored the bits and pieces of the over-crowded shoulder joint. Like a graphically real pop-up book, we made holes to peek into atherosclerotic arteries, the ridged wall of the stomach, and all those convoluted nasal sinuses. By today, there was virtually no hidden place left that we had not revealed and entered. And not that we were looking, but I can’t say that we found a soul in any of those hidden places, or that we found anything that was other than what it was: a miracle of engineering, a masterpiece of evolution, matter. The eyeball remained intact as both a cavity and an entity, a functional presence defined in part by the absence inside it that lets the light rays swim around in their pool of fluid. By the time we had revealed the eye from above through all those layers of muscles, curiosity and wonder had gotten the better of any squeamishness or reluctance, so I tugged on the optic nerve and released the muscle attachments until… I was holding a human eye. It was part Halloween, part horror movie, part little girl poking fish, part doctor, and all amazing. The lens wasn’t as lens-like as I remembered from 5th grade, and preservation had deprived the retina of that unbelievable rainbow-colors shimmer. But we could see the optic disk with all the little blood vessels running into it–a sight I will see from the front, via my ophthalmoscope, countless times in my career ahead–and we could see that her eyes were brown.

And that was it. We had probed every last bit. If the soul had been hiding anywhere in there, it had managed to fly away without our seeing it go. And yet reducing a human body down and down and down to its component parts never once challenged the wonder of a human being (quite to the contrary). At the reflection session at the end of Body Block, I shared the experience that I have had since day one of feeling a deep impulse to hold the cadaver’s hand. Still, as I sit writing this, I almost typed “patient.” And all throughout, especially when something particularly troubling was about to happen–to open the skull and bisect the face, we had to use saws–somehow it felt okay as long as I was touching the cadaver’s hand. It came to me very instinctively, as if I were comforting a patient while he went through a difficult procedure. And the thing was, it was never about “mistaking” the cadaver for a patient, despite my almost-typo above. I think that would have been going too far, would have been too resistant of the maybe-necessary desensitization that I talked about in my last entry. It was more that I had a profound sense that there was something there, even as his body got reduced and reduced until its integrity was completely gone. Today, as we cleaned up and prepared to zip up the bag for the last time, I said thanks to the cadaver (not the same one as before; I had already said my goodbyes to him), but the idea of the hand came to me as an afterthought, and I didn’t act on it. So maybe the eyes really were the windows to the soul, or maybe I just finally had a sense of completion and closure. I had initially thought about dropping continuing anatomy because of time and energy constraints, but I decided to stick with it at least in part because I felt I owed it to the person who donated their body to learn everything I could from it. I think today that task felt complete, since–after the dissection of the eye–there was really nothing left to dissect. The deep part of me that responds as a human to a human, the part that had been telling me all along to take the cadaver’s hand, today finally told me that it was time to let go.

The best part about our Genetics block is the clinics we have three times a week. An actual patient will come in, usually with their doctor and sometimes with family members, to talk to the entire class about their life experiences and put a face on the genetics we are learning about. In just two weeks we have met patients with Huntington’s, ALS, sickle cell anemia, androgen insensitivity syndrome, Down’s syndrome, and MELAS, and each patient in his or her own way has been inspiring and insightful, and they have made the genetic principles relevant and interesting in a way no textbook ever could.

Today’s clinic was even more meaningful. The patient was a man in his mid-20s – our age – with MELAS (an acronym for mitochondrial encephalopathy, lactic acidosis, and strokelike episodes), a mitochondrial disorder with a spectrum of disparate symptoms that can range from seizures to stroke symptoms to hearing loss. He had had a series of bizarre experiences that constituted the initial presentation including seeing kaleidoscopic flashing lights after physical exertion. I should say that these were bizarre to him and his initial physicians; they were part of a “perfect history” if you knew he had MELAS. The mitochondria are the “power generators” of cells since they make the ATP that the cell uses for all of its energy-requiring processes, but his were defective such that he would quite literally run out of ATP, especially after an intense basketball game. When that happened, for some reason in his case one of the first things to be affected (a big energy user other than the muscles) was his brain and specifically the occipital cortex, the visual area. Basically, his occipital cortex was starving for energy, so he had the strange visual symptoms. Skipping over some details that I don’t fully understand, he was basically having either a migraine “aura” or seizures – not the kind that everyone pictures with flailing limbs (those are generalized seizures), but sensory seizures in which the wiring in his occipital cortex was just going nuts with electrical activity. After this had happened a few times, one unfortunately turned into status epilepticus, a dangerous and very damaging event in which he had four seizures in a row. That was the beginning of a long story of different hospitals, medications, medication allergies, and now ultimately relative normalcy and management… most of the time.

The patient seemed somewhat distracted or “out of it” during much of the interview, and told parts of his story out of order or with some confusion about what had happened. He was starting to answer a question when he suddenly stopped, put his hand to his head, and I could swear he mumbled – or maybe just embodied – the words “I don’t feel so good.” This was in front of a lecture hall of 200 people, on video, with a microphone clipped to his shirt and all that. We all froze, but the neurologist who was facilitating the interview – who I am proud to say is my tutorial leader – leaped into action. She pulled off his microphone and started asking him a barrage of questions, holding his hands to reassure him but also to check his muscle strength, testing his vision, and getting him to move his eyes certain ways. In a matter of seconds that definitely seemed like forever to us, she had taken charge of the class and the patient’s family, figured out what was happening, summoned the two neurology residents conveniently sitting in the back of the lecture hall as escorts, and was sending them all to the emergency room. She smoothly picked up the pieces of the situation as soon as he was gone and explained to the class that he had suddenly lost the ability to see in the left side of his visual field for a few minutes, that she had probably ruled out that he was having another stroke, that she believed that it was another sensory seizure, and that she was concerned that it would generalize so she sent him to the emergency room where tests could be done and he could be looked after.

The entire class seemed somewhat in awe as we left the lecture hall, and I think it was that every single one of us had been reached by what happened. Even people who didn’t “get it” previously, who hadn’t yet been truly struck by the realities of the impact of medical genetics on the lives of real people just by hearing those real people talk about it, had seen the impact with their own eyes.

For me, two things happened that made this particular clinic unforgettable. First, the second the patient put his hand to his head and started making helpless gestures as he tried to make sense of what was clearly an explosion of sensory information and misinformation in his brain, I felt physically ill, like the blood had suddenly rushed out of me. Not in a bad way… I think I was at a deeply visceral level empathizing with his obvious suffering. There was nothing in me at all in that moment other than a deep concern for his wellbeing. The second thing that happened was my reaction to seeing the neurologist, whom I already greatly respected, jump up and radiate confidence and concern and knowledge as she examined him. She knew exactly what to do to take care of that patient. He even hugged her as he left the room, to say thanks, and he isn’t even her patient. What was running through my mind as I watched her work? “That’s it. That’s what I want to be.”

I feel that my commitment to medicine so far has had a wealth of affirmations that far outweighs the challenges.

It’s just awful that it has been this long since I last posted… not for any lack of things to post about recently (quite to the contrary) but just because anatomy wound up taking all my time and energy. It’s no excuse – a life in medicine will always be busy and draining, and I know that writing and reflection are not only critical to my professional satisfaction but also personally restorative. However, two things have made today a day to post.

First, after our final exam this past Friday, I am done with the main part of anatomy. I will post about that later; I also at least for now intend to take the Continuing Anatomy elective. But life from now at least through the end of January should be significantly less busy, and perhaps all the way through the end of the year – I think Anatomy is one of those defining courses of medical school and we covered an amazing amount in only seven weeks, so it was pretty intense.

Second, today I attended the first day of a continuing medical education course on Spirituality and Healing in Medicine run by Herbert Benson and Christina Puchalski [the link is to the pdf of the pamphlet]. Technically I was volunteering rather than attending, which basically entailed me handing out syllabi for an hour in exchange for free attendance!   Just a few highlights that hopefully I will be able to go into in greater detail in the future:

* Dr. Benson began with a lecture very similar to the one he delivered for my Mind-Body Medicine elective, which is how I knew about and became interested in the conference in the first place. Since that course also ended yesterday, today’s events made for a great recap and extension of the ideas to which we had been introduced. He reviewed the basics of the Relaxation Response, his condensation of key features of meditative practices. It’s an extremely interesting concept for a number of reasons. First, in and of itself it is secular (consisting only of focusing on the breath, repeating a word or phrase such as the number “one,” and passively letting go of all other thoughts) but it is derived from a set of practices common to religious and spiritual traditions from throughout history and around the world; conversely, some people have found that evoking the relaxation response itself without it being in the context of prayer or religious meditation can produce spiritual experiences. Second, it has shown to be effective in alleviating a huge number and variety of medical conditions (including depression/anxiety, chronic pain, infertility, insomnia, side effects of chemotherapy, and hypertension, to name only a few), all of which point to a major role of stress and the body’s stress response (the sympathetic autonomic or “fight or flight” response, the opposite of the relaxation response) in very widespread and fundamental diseases. More basically, just ten or twenty minutes of evoking the relaxation response leads to statistically significant changes in metabolism as measured by oxygen consumption and respiration rate, and as seen on fMRI (functional magnetic resonance imaging, a real-time look at regional brain activity) very significantly decreases the brain activity of “everyday thought” across virtually the entire brain (with the exception of a few interesting areas that I’ll go into some other time). Overall, it’s a basic paradigm for increasing health on all axes (physical, psychological, spiritual, emotional…).

* Dr. Puchalski is a GREAT speaker and obviously an incredibly insightful and gifted researcher and clinician, bridging mind and body very effectively. Her talk emphasized the central role of spirituality in healthcare, specifically eliciting from patients their spiritual beliefs, honoring these beliefs regardless of the clinician’s own, and understanding how spirituality relates to the patient’s illness experience and even illness outcome. Basically, she pointed out how religion/spirituality have come to be seen by much of the medical world as at best tangential and at worst problematic, when really it is situations like illness and stress that can lead to hugely important questions of meaning and purpose with the possibility for reflection, growth, improving patient-provider relationships, and healing (whether in the sense of a cure or just of improving the patient’s psychic experience even in the face of incurable illness). I really appreciated that she, unlike some of the other presenters today, embraced a very broad definition of spirituality as “an individual’s search for ultimate meaning through participating in religion and/or belief in God, family, naturalism, rationalism, humanism, and the arts.” As a unitarian in the sense of believing in the core unity both of disparate “spiritual” or religious practices and of other practices like art, music-making, relationships, and [good] scientific investigation, it was extremely meaningful for me to hear the word “spirituality” defined in this way and to have Dr. Puchalski encourage an understanding of all of these things as potential components of spiritual health. Her talk was great and no summary does it justice, but a main parting point was encouraging healthcare providers to be comfortable with mystery in the the clinical setting, because there is a genuine patient need for spiritual considerations to be addressed and indeed many patients will have spiritual thoughts or experiences related to their illness, and because it opens up patients to their physicians and physicians to a deeper, more meaningful, more professionally fulfilling, and more therapeutic patient-centered relationship.

I’m running out of energy already and I’ve only made it through the first two sessions…and there is another full day tomorrow! There are so many things from this conference that I think I will be processing for a long time, but it could not have come at a better time in my personal, medical, and spiritual education. It was just so refreshing to be in a room full of nearly 500 people with a shared vision of a new path for medicine – by no means one that excludes the highly successful paths down which biomedicine and science have travelled, but just an additional path along which there is surely a great deal of room to grow.