Open Heart (35 page)

“But no one knows, you see. So you give everyone the best shot you can, and hope for the best. And you saw the people today—some of them were grossly debilitated. And then there's Beth and her husband—but if they didn't have parents who had a business that Tom could go into, they wouldn't be talking about buying a house with a yard.”

Phil repeats what he has said to me several times: that a family support system is the most important element in the rehabilitation of neurological illnesses—and that his biggest worry wasn't about my heart, or the surgery, but about the fact that I didn't have a wife or companion, so that if I came out of surgery with a major disability, who was going to be there to help me, and to manage my affairs?

“I mean, if you have to live with a debilitating illness and you're not rich or don't have the world's best insurance, where's your means of support? They don't kill you, but they put you in a rundown nursing home where there's barely enough help, and let's hope your constitution is strong enough to make it. And the help there turns over quickly, and you might meet an aide you strike up a friendship with who's good-natured and helps you. I mean, you remember that young woman who was living with the man who was a
quadriplegic? As soon as she left him, he died. So that's the real world.

“But I had two thrills today,” Phil says then, and his face brightens. “Two patients spoke to me who never had conversations with me during the entire month I've been taking care of them. I had three conversations with that boy you met who was paralyzed from the night he had a car wreck. And with that boy who was sitting and playing cards—the one who fell off a cliff while mountain climbing. I never had a conversation with either of them before today—and, as with Beth, that's a thrill for me—the highlight of my week.

“And I sent one lady home! That's the really good part of my life. I get to send them home. So I feel lucky, because I get to do a kind of work that's meaningful every day, and there's always new things happening and something to learn.”

I listen to Phil talk about his work, and why it remains ever fascinating to him, and I think of the fact that his attitude—his love of his vocation—is, alas, becoming less and less common. In a 1999 study of young California physicians (those under forty-five), for example, the authors report that in 1996 “only 61 percent of primary care physicians said that they would go to medical school again,” this figure “down from 79 percent in 1991.” Among specialists during these same five years the proportion fell from 68 percent to 63 percent.

Other surveys report similar findings—that young physicians' “perceptions of a career in medicine may be both more critical than those of other professionals and worsening over time.”
^*
High medical school tuition, huge educational debts, long hours, high malpractice premiums, growing corporate influence, and, especially, the loss of autonomy are the major reasons young physicians give for their dissatisfaction, and for saying that, given a choice, they would
not
choose to become doctors again.

And many of the autonomy issues relate directly to a doctor's freedom to make decisions about, and to care for, patients. For example, the report on young California physicians notes, only 67 percent of these doctors believed they had the freedom to care for patients who could not pay, and only 64 percent indicated they had the freedom to care for patients who required heavy time and resource
commitment—these levels down from 83 percent in 1991. “The psychic toll of declining satisfaction with practices and careers,” the authors comment, “may reduce even the most dedicated physicians' ability to function at their best.”
^*

Like my other friends, Phil—his nickname is “Yago,” from Yagolnitzer, his family name until his father changed it when Phil was in the seventh grade (“I had mixed feelings—I felt like I lost part of my identity, but I also was happy not to have kids make fun of me on the first day of classes every year when the teacher called my name”)—did not start out intending to become a doctor. He entered Cornell, in the fall of 1955, as an engineering student.

“I always had an interest in learning how the human body works, and I didn't like mysteries,” he says, “so I thought that if I would understand it, it wouldn't be a mystery to me. But I didn't like the idea of the pre-medical route, which seemed too conventional. Engineering seemed more scientific.

“So I was in the department of engineering physics at Cornell, but I saw that the profession was mainly either the business of running manufacturing outlets or you could be a pure scientist, only I didn't think I was good enough to be an independent pure scientist. So medicine seemed a combination of technical knowledge, and also being able to make a contribution to helping people.”

I say that Arthur wonders sometimes if this desire we all have—to be of service to others, to make a contribution, to leave the world a better place than we found it—is as purely altruistic as people think, or whether, instead, it simply comes from our compulsive need to be productive—from our Brooklyn brand of Jewish Calvinism.

Phil shrugs. “I don't know about that,” he says. “Maybe. But I know that by the third year of engineering school, I decided to look into going to medical school, and I took a few extra courses, and then I applied to medical school and got a scholarship, so instead of finishing the engineering degree—it was a five-year program—after four years, I went to medical school.”

“You never got a college degree?”

“No. I never got a college degree.” He laughs. “My mother was upset, because she said what would happen if I didn't like medicine,
and all I'd have was a high school diploma. I couldn't even be a high school teacher, which she thought was a very noble profession.

“But mostly I just wanted to be educated—and I wanted to get out of Brooklyn. I think it's like being a good ballplayer. If you're a good ballplayer, you don't care where you play, and you can play at any level. So that's how I felt about learning and, later on, about becoming a doctor.

“My father pressed clothes in a dress factory—it was called ‘piecework' because he was paid by the number of dresses he pressed—by the piece—and it was seasonal work, so he was unemployed a lot of the year, and he sat around and my mom yelled at him, and it was very disheartening because he was trapped, and he was a passive man who couldn't figure out how to get out of the trap.

“We always ate separately. The kitchen was too small so my mother prepared three meals—one for her two sons, one for my father, and one for herself. My brother Allen and I ate on TV stands. We never ate together unless there was a special event, and then we ate in the living room.

“The bathroom was small too—it was so narrow that when you sat on the pot, the only way you could be comfortable was to keep your right leg over the side of the bathtub. Allen used to go upstairs to our aunt's apartment to go to the bathroom. There was no air conditioning, one tiny bathroom for four people, waiting in line, no privacy.

“So I still have a recurring nightmare—like an anxiety attack in which I actually
shvitz
—where I sweat like crazy. I'm in my last year of medical school, and I miss an exam, or I fail it, and I have to go back and repeat the year again, and in order to do this I have to move back into my Brooklyn apartment. That's the nightmare I still have all the time.

“Which is what I did—I was married for my last year of med school, but I lived at home for my second and third years, in the same room I used to share with Allen, and carrying my microscope on the BMT, hugging it like a baby.

“In high school, you see, I figured out that there were only two tickets out of Brooklyn. One was to be a great athlete, which was my
dream until I got to high school and saw that there were guys ten times bigger and fifteen times faster than me.”

I remind Phil of the time, during our sophomore year at Erasmus, when we were on the junior varsity baseball team together and we got to play against the varsity. “Yeah,” Phil says. “And then, after my freshman year, when I gave up on being a pro ballplayer and saw I could get good grades by doing the things I did naturally, I said, ‘Well, if I do it a little more I'll get
very
good grades.' So I did a little more.

“And I knew that would give me power, and would be a way out. Everything I did was so I could get out of Brooklyn and escape my apartment. I mean, I felt it was all on me, even when I was away at college, because if my parents got sick I'd have to drop out and help them, and I resented that. Only, I was fortunate, and it never happened.”

I ask Phil about what has and has not changed since he started out in medical school.

“Well, the smartest doctors will still tell you that if you listen to the patient, the patient will tell you what's wrong with him,” he says. “Because it's not the disease, you see, but it's how the particular disease affects the individual patient. I mean, a lot of us went into medicine because it's first of all a science—you have to look at the illness, at the state of tissues, at organ systems, and try to understand what's going on, and what you can do or have to do. Like, if a person has pneumonia, and you give antibiotics, you check the x-ray to see that the pneumonia's gone. But you also have to look at the individual patient who has the disease, and see how the
story
of the illness takes place in this particular person—so that a doctor is somehow at the juncture of what's both objective and subjective.

“Now, neurology started out by studying diseases of the brain, spinal cord, and nerves—how they express themselves—and we looked at the patient's complaints, and examined the patient through the years, and then the patient would die, and we would examine the tissues at death. That's how we started out. And we knew things grossly—like if there was a gunshot wound to the right side of the head, the left side of the body might be paralyzed, and if
someone died and we saw a lesion on the right side of the brain it showed why the left side had been paralyzed.

“So neurologists took care of people who had something wrong with the ability of the nervous system to work, or it was hyperactive—like epilepsy, where there were seizures—or it was underactive, so a lesion was causing paralysis, weakness, loss of vision on one side, loss of speech, clumsiness. And once you localized it to where in the nervous system the problem was, you could make a presumptive diagnosis of disease and tell the patient he had something wrong with the right side of the brain, or the spinal cord at this or that level, or with the nerves coming out of the spinal cord. Then, if they decided it was amenable for surgery, you talked with the neurosurgeon, and maybe you'd have an operation.

“But that all changed when neurologists had a way of looking inside the black box of the nervous system. It started with x-rays, in the beginning of the century, which let you tell if there was an abnormal collection of calcium inside the brain, or if it was pushed to one side or the other, or if you had a broken head—if you fell down and got a fracture and there was air inside your head, or a bullet fragment, or a calcified tumor. After x-rays, then angiography came, or probably pneumoencephalography first, where you injected air inside the nervous system, and it filled the fluid structures and you could see if they were distorted in any way. Then the next thing was the injection of contrast material—metallic dyes into the arteries—and then you take an x-ray, and you can outline the arteries of the brain and see if they're blocked, or if there's an abnormal bulging of an artery, and so you could make inferences as to the disease that was causing the patient's symptoms.

“At the same time, or about the same time, people also injected dye into the spinal canal, and studied the spinal cord, and all of those we called interventional techniques, and they all had risks associated with them. It involved the patients being punctured, and foreign materials being put into them.

“Then along came the CAT-scan, and that came after I finished my residency, in 1973, and you could put yourself inside a tube, and by mathematical analysis of x-ray absorption, you could get a look at the structure of the brain, which before that had only been visible
at autopsy. And that revolutionized the field of neurology because you no longer had to make a guess based on the examination of the patient and the patient's complaints. You now had a way of verifying things without risk to the patient.

“When it first came here, the governor of Colorado said Denver should have only one CAT-scan for the whole city. Now most
hospitals
have two, and we keep them running around the clock, and you can't work without them.

“Then, in 1986, I think, came magnetic resonance imaging—MRIs, and PET-scans—and they gave you further anatomical clarity for the problems you were dealing with so you can fairly well localize a great deal of lesions. Some you can't, and they still remain a diagnostic problem, but for those you can, the characteristics, on CAT-scanning and MRIs, may even tell you what the tissue type is.”

I remind Phil of how excited he was a dozen years before, to show me the first MRI machine at his hospital, a huge metallic cylinder that looked like a space capsule, and of how I watched with him while one of his patients was inside the machine. The patient was frightened, and Phil kept calling to him—“Just enjoy it, Sidney—make believe you're in the love canal!”—and afterward Phil showed me how the dozens of images the machine produced were able to give him a three-dimensional picture of Sidney's brain.

“The tubes are more comfortable, and some people have open MRIs now,” Phil says, “and we can tell the difference between a stroke and a tumor—we don't have to guess—so our diagnosis rate is much better. The detail is just miraculous. In the old days, the very best neurologists—our teachers—maybe had a fifty percent accurate diagnosis rate, but now we're up to eighty or ninety percent. We can localize much better, so the neurosurgeon knows exactly where he's going to operate. He can cut down right on top of the tumor, or put a needle through the skull that will go right into the tumor instead of just searching around.”