On a Friend’s Retirement

 

A dear friend, with whom I worked closely for three decades, is celebrating his retirement at a lakeside party this weekend.  His practice of medicine was what I would consider ideal; my friend so embodied the mythical Good Doctor that I wanted to raise a glass of Champagne (that most festive of beverages) and share my admiration on this blog.  For privacy’s sake, names have been omitted or subtly altered (for example, I call my friend Chappy, because I actually once met someone with that memorable name).

I remember:  It was a Monday morning, July 6th, 1987.  Just out of Rheumatology fellowship, I entered my new office at Station One and met Chappy for the first time.  It was clear right then—and has become even clearer as I look back from beyond the Great Divide– that I was a very lucky man.

We either shared an office or worked next door for many years.   Almost never, at work or anywhere else, can you hope to meet someone so open, sincere and forthright as Chappy, so utterly devoid of pretension.  In a work environment that was always competitive (for better or worse), he never jockeyed for position, despite his obvious talent; he was so ambitiously dedicated to his patients and loved by them, so respected by the doctors and staff– and yet never felt tempted to turn this to his own advantage.  For young doctors coming up in our profession, whose eyes are often more focused on the administrative ladder than on patient care, Chappy’s total indifference to self-promotion is a great role model for the practice of medicine:  patients always come first.  As Station Leader, he was like the coxswain on a crew team:  gently keeping the beat and ensuring that the rowers pulled at the oars all together.   His constancy was truly impressive.  He didn’t zig and zag as personal opportunities arose, but steered a true and steady course every single day, for the three decades that we worked together.

(By the way, I will remind everyone at the celebration that, at the conclusion of any successful crew race, it’s traditional for the team to throw their coxswain into the lake!)

Going back to that first day in 1987, Chappy suggested we go out to lunch, so we grabbed a couple sandwiches and walked down to St. Leo’s School, where we sat on the grass and talked.  On my final day of work, in 2015, we again brought sandwiches to St. Leo’s.  Although the topics and the sandwiches were different, the heart of our conversation was the same—honest, optimistic, pragmatic and philosophical.   These conversations were like two bookends to my career.  In between the bookends, Chappy’s openness to sharing and his positive nature informed  the many discussions we had.  And when we talk now, it’s just remarkable:  except for a few gray hairs, he is essentially the same today as when I first met him.

My great fortune in working with Chappy, who was born in Okinawa, has inspired a few modest poems, which I have written in the Japanese 5-7-5 syllable Haiku style:

Six Haiku For Chappy

 

An anxious Monday

Hi, I’m Charles—call me Chappy

Not bad after all

 

Anderson sits down

Lester comes in just to chat

It’s the coffee pot

 

Beef and broccoli

Scrambled eggs and shrimp on rice

Just don’t talk ‘bout work

 

Staying true to self

Uncontaminated by

The lure of power

 

Build trust, not status

Lead quietly among peers

Family comes first

 

You could read my mind

I could read your handwriting

We’ll miss you, old friend

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The Faceless Base

In the wake of the astonishing Helsinki summit between Presidents Donald Trump and Vladimir Putin, a meeting at which Vlad impaled Donald in front of the entire world, the range of responses here in the United States has been only slightly less mind-boggling.  To a few, this was outright treason, or at least a debasement of America by our president, calling for immediate impeachment; to many Republicans in Congress, it was merely a “missed opportunity,” or an embarrassing mistake; to others, it was proof that Putin holds some compromising secret over Trump, whether of a financial or personal nature (also look closely for Putin’s bite marks on his throat).  And to many of those lumped together by political analysts and the media as Trump’s Base, the summit was actually a success.  They consider it only the visible tip of a giant, submerged iceberg of grand strategy and geopolitical philosophy.  The Base agrees that Russia is guilty of something, but Trump, like a canny chess player, must be striking a mega-deal somewhere.  He must have a hidden plan, a trump card, up his sleeve.  Not only will the Base never abandon our Chaos President, it seems they will cling ever harder to his agenda.  Aren’t these mad loyalists suffering from cognitive dissonance, we ask?  Aren’t they what Hillary Clinton mistakenly dismissed as the “deplorables?”  In my opinion, for Democrats to continue viewing Trump’s Base in this light would create a self-fulfilling prophecy.

Trump’s agenda may be racist, misogynist, unethical, hypocritical, dangerous to worldwide stability, pro-dictator, anti-immigrant, pro-wealthy, anti-alliance, pro-global warming, anti-science and environment, and so on.  But individuals within the Base are unlikely to hold these values and beliefs, all at the same time.  A racist may not be a misogynist, and a coal producer may believe in free trade.  However, if continually encouraged to see itself as a homogeneous, faceless mass, the Base will stretch in that direction; individuals will adopt attitudes initially foreign to them.  The tolerant will become more racist, the devout will shrug at sin, the scientist will deny evidence.  It’s almost as though such behavior is expected of them, and so they comply.

Those who took Psych 101 in college will probably remember the Prisoner/Guard experiment:  subjects were randomly divided into two groups, to play the roles of prisoners or prison guards.  When their names and individuality were removed– when they were assigned numbers instead, and made to wear uniforms– and then placed on either side of prison barriers, the “guards” became increasingly harsh, sadistic and tolerant of brutality over time, whereas the “prisoners” became submissive and frightened, willing to turn on one another.  In anonymity, individuals lost their bearing, giving up their innate compassion, empathy, ethics, principles and willingness to stand up for what they had previously believed.

By thinking of Trump’s Base as some sort of anonymous mob, are we assigning them numbers and uniforms?  Many of them are probably spouting opinions about tax reform, immigrants, gays, minorities and victims of sexual harassment that they don’t truly believe (or so I would hope).  Cases in point:  those embracing economic policies which ultimately hurt them financially, or want to destroy the Affordable Care Act, when the ACA provides their only access to healthcare.  Women for Trump.  Mexican- and African-Americans for Trump!  The poor in rural areas, cheering tax cuts which benefit the top 1%, while waving baseball caps saying Make America Great Again!

In a dystopian fantasy, the faceless Base– repeatedly labeled as such, their resentment cynically fueled by a President who values his own “winning” over the good of the nation, and pushed into a corner by an equally intolerant political left– takes up arms:  the perfect setting for Trump to declare martial law and unfurl his true agenda.

In my dystopian novel Child of the Fourth World, nearing completion (and with it, the Fourth World trilogy), the rebel leader Sun Wu Kong contemplates the effect he has had on his followers in the China District.  Here’s an excerpt:

His staff had designed the shiny outfit to reinforce his role as an avatar of the Monkey King of legend.  Of course, Sun knew perfectly well that the entire concept was nothing more than mystical hogwash, but the rank-and-file had embraced and— judging by their incredible surge of energy— been swept into a frenzy by it.  Based on his previous work in the Ministry of Cultural Genetics, Sun suspected that the Han Chinese genome— in particular, the so-called Faith Gene, which 97% of his followers possessed— was in play, predisposing them to believe in the power of religious figures.  The Monkey King had revived the troops’ flagging courage, and they had fought like crazed zealots in his name, resulting in a series of near-impossible victories against the PWE.  His strategists and field commanders were baffled by their own success: the troops battled as fiercely as wild animals finding themselves trapped in a corner, one officer had suggested.  Sheer desperation leading to mass hysteria? That seemed a plausible motivator, others agreed— but perhaps augmented by wishful fantasy.

As a former PWE bureaucrat, Sun understood that post-war modernization of the China District and the alignment of literature and the arts with political thought under the PWE had not altered certain indelible traits lying at the heart of the 22nd-century Chinese mindset.  One such trait was the perception that China had always, in one form or another, been under attack by foreign forces:  not just the ancient Middle Kingdom or any subsequent form of government, but the people themselves were the target— and these ordinary people were China, even though the country itself no longer existed.  The attack on the traditional concept of China, the oppression of its people, came in various forms:  military might, economic exploitation, moral and cultural corruption. Against that assault, according to the popular fantasy, there would always come a hero, an underdog who would rise up from defeat and lead the masses to glorious victory.

Why not a divine Monkey King?

 

Gimme A Vowel II

This morning, for the second time, I woke up thinking of sentences missing the first vowel, which rhymes with Eh.  The first time I did this (see my 5/19/17 post on this blog), you remember, President Trump left on his worldwide religious tour, meeting with the Pope in Rome, etc.  This time he returns surrounded by rumors of the Nobel Prize.

It must be Trump’s trips (or trip-ups) which inspire me to deconstruct my writing, in the futile hope of selectively removing noxious elements.  From his journeys, he brings us more worries over money, old friends, old enemies, his/her/their sincerity vs hostility, thus worsening doubts re our security, or even our very lives.  He proudly crows and struts while synthesizing his own version of the truth, selling it like True News.

So there’s no more risk of some olive-green missile hitting New York City or DC, exploding with the power of hundreds of hydrogen bombs?  Did he truly utter, “Sleep well tonight?”  To die, to sleep no more… there’s the rub, eh, shuffling off this life-ending coil of ours?  Trump thinks he won over this new friend, this little rocket person:  to our not-so-innocent president, the vicious and cruel Kim Jong-Un is “funny,” loves his country (though not ours), supports the downtrodden, is beloved by his underfed people (he does resemble someone’s juicy dumpling).  But don’t forget, mister President, you might choose to lie, but your new friend Kim is sly.  Me, I prefer Seoul to the soulless.

Rude insults tweeted to our wonderful neighbors to the north?  Stubbornly refusing to sign the G7 document?  Simmering resentment from the otherwise serene Ms. Merkel, or her British friend Therese (nom de mon plume)?  In commerce, we lower punitive levies on steel/’luminum imports (supposedly to better the region’s security?), followed by the other sides’ vengeful counter-levies, before we pile on even more ruinous obstructions to sensible, profit-yielding business.  Of course the ensuing bitterness, the multi-directed finger pointing, is toxic to old friendships.

On our own shores:  school gun violence without some response from Congress?  The IG’s report on the FBI/ H. Clinton, now spun into obvious lies by the GOP, just to enfeeble Robert Mueller?  The grinning Betsy DeVos, just for being who she is?  Steve Pruitt’s endless petty grifting?  Bill Clinton’s defensive #MeToo moment?  Denying medicines to the uninsured with pre-existing conditions?  Young children torn, sobbing, from their mothers just within our pristine borders?  Jeff Sessions tells us the Bible instructs on this issue:  the very book supposedly forbidding dessert for two grooms-to-be!  Come on, hurry up, mid-term elections (don’t forget to vote)!

Pretty close to the words of the funniest of four Brothers, Groucho:

Gentlemen, your policy is quite impossible to me; whichever it is, I oppose it!  I’ve been yelling since you first proposed it; I oppose it!

The DOnald, schOOls,  rOcket men, bOmbs, COngress, #MeTOO, cOnflicts with friends, Oh-Oh!

Next time I might just expunge every word which shelters the evil letter O.

A Pirate in the Kitchen

The news of Anthony Bourdain’s suicide in France came as a shock this morning.  And yet, somehow, it wasn’t beyond belief– he lived so intensely, so close to the edge, that it seemed almost a matter of time before some event in his life, even a minor one, would tip the scales.  Honestly, I’m glad not to be like that, but his intensity and edginess did serve as an inspiration to me in what I chose to write.

In the late 1990s, I was a mid-career physician with my eye on writing science fiction in retirement.  The books I was reading then were by authors such as Georges Perec, John Irving, William Gass, Jim Harrison and Jonathan Safran Foer.  One day, because of my love of cooking, I picked up Kitchen Confidential out of curiosity, and was immediately struck by Bourdain’s lurid stories of drug abuse, dropping out of college, alcohol addiction, brutal relationships, and the corrupt realities of the restaurant business (all the more vivid now, in the broad wake of Mario Batali, Ken Friedman, Charlie Hallowell and the #MeToo movement).  I learned about the mob’s ties to NYC fish delivery; cringed at the image of a huge pirate-like sous-chef who calmly lifted searing-hot pans out of the broiler with his bare hands; and I learned the horrible truth about what goes into those Sunday brunch buffets.  Kitchen Confidential, much more than the cookbook I was hoping for, changed everything– for me in my world view, patronage of Sunday brunches, and ultimately my fiction writing; and for Bourdain, when its success launched him into the public eye.  CNN signed him to the popular television series Parts Unknown, now cut short in its 12th season.

When interviewed by the Associated Press about Parts Unknown, he said:  “If you think about who the audience is and what their expectations might be, I think that’s the road to badness and mediocrity.  You go out there and show the best story you can as best you can.  If it’s interesting to you, hopefully it’s interesting to others.  If you don’t make television like that, it’s pandering.”

That is exactly the argument that ran through my mind almost a decade later, when writing Fourth World, the first novel in my science fiction trilogy.  Reading it over, I noted the density of medical technology (for example, genetic engineering with multi-species recombinant DNA) and discussions of related ethical questions (debated in 2018, but settled by law in 2196).  In that book, I even invented a space engine– necessitating a new, fictitious subatomic particle– in order to allow Benn and Lora to fly from Mars to Earth in only four weeks!  Was I going too far, risking the alienation of my readers?  To me, that would be better than waving a hand and simply issuing the order, “Warp nine– engage!”  Wasn’t it preferable to stay true to my own vision of the novels– to be a pirate in my own kitchen?

But who was the audience?  Who were my readers, and what might their expectations be?  If I edited the novel to suit some hypothetical, “average” reader, Anthony Bourdain would call it pandering and a road to mediocrity.  And indeed it would be.  With the conviction that this was my one, best shot at writing, I decided that if the content was interesting to me, then hopefully it would be interesting to others as well.

A few weeks ago, I spoke to two sixth-grade classes about the Fourth World series and writing (see my blog post Kids These Days!).  I advised the potential writers among them to read as much as they could, in order to absorb some of the vocabulary and craft of writing.  Also, they should write about what they know– in my case, medicine, science, colonialism, geopolitics, food and wine.  What I omitted was the importance of being true to themselves, to write what came from within, and not for the sake of external acceptance and positive reviews.

(I know, I know:  marketing!  For all those professional writers in the blogosphere who are now groaning at my remarks, I apologize and readily acknowledge that it’s easier to ignore ratings when you’ve already had a career in medicine).

Should I, or shouldn’t I, have taken an axe to potentially challenging material?  You be the judge.  Here’s the passage from Fourth World with which I wrestled long and hard, before deciding to leave it in, completely intact:

After hanging around the engine room aimlessly for a couple of days, Benn finally asked a sympathetic engineer for a tour.

“All right, Benn, I’ll give you a simplified version.  To start with, let’s consider these subatomic particles as such, although we analyze them as waves.  Flowsorb takes a variety of hyped-up particles, by-products harvested from the fusion reactor (efficient, right?) and fires these particles from the central initiator, where they first enter the cyclic counter-current mechanism. Meanwhile, at the terminal emitter, each compatible, or what we call candidate, particle degrades to a capacitron:  you remember that’s a cousin of the anti-proton, capable of absorbing energy like a sponge, storing that energy until a specific threshold is exceeded, then discharging it. Following me so far?”

Benn nodded uncertainly.

“See, the Flowsorb mechanism exploits the power of the Almighty Exponential,” said the engineer, bowing his head only half in jest.  “Changes in particle direction are forced by plasma nano-platforms, which are folded by powerful magnetic fields. These folds are embedded in thousands of larger platforms which fold into larger convolutions, and they, in turn, fold upon themselves– and so it goes, over and over.

“The repeated folding forces streams of energized particles to pass streams of capacitrons traveling in the opposite direction, millions of times over, each time transferring a portion of energy back toward the center.  Finally, a new cycle begins– but with their energy multiplied in each cycle, these exponentially-accelerated particles asymptotically approach the speed of light. You see?”

The engineer, now multiplying his own energy level, waved his hands in the air.  “Particle velocities literally explode by orders of magnitude! Then we eject these particles into space, and the rest relies on Newton’s Third Law:  you know, action and equal-slash-opposite reaction. Major thrust is what I’m talking about!  And that enables us to reach Earth in only four weeks, a journey that used to take more than seven months!”

 

Opioid of the People

Karl Marx called religion the opium of the people, its drug-like influence blinding them to the realities of the world, and therefore advocated atheism.  Also fearing an opiate effect on his audience, Bertolt Brecht used entfremdungseffekt, or alienation, in his theatrical productions in order to avoid sweeping the audience into a make-believe world.  It might be argued whether religion or theater was closer to an addictive drug historically, but in recent times, the opioid of the people turns out to be much more literally so.  It is the drug OxyContin, manufactured by Purdue Pharma.

Starting in medical school (I graduated in 1981), it was drummed into students that opioids are addictive, dangerous, life-changing, not to be prescribed lightly, a last resort only.  We grew up disciplined, ready to tackle the tough decisions, morally rigid and a bit self-righteous.  We were automatically skeptical whenever patients demanded stronger pain meds, and in steadily escalating quantities.  Of course we knew real pain existed, and we were sympathetic– but at the same time, there were sure to be malingerers, addicts, and those who would resell prescribed narcotics for a huge profit.  The fear of treating pain insufficiently was often eclipsed by the fear of being taken advantage of, as health care providers.  As we gained experience, some became better judges of character, but no one ever knew for sure; I remember a couple of seemingly reliable patients forging my signature for Demerol injections in the Urgent Care Clinic.

Then came a blizzard of editorials in medical journals and the lay press– sometime in the ’90s, as I recall– excoriating doctors for their callous under-treatment of chronic pain and pressing for a liberalized approach to the prescription of opioids.  It felt like a public shaming of our profession for its paranoia and lack of compassion, and was taken by many as welcome permission to loosen up our self-imposed standards.  But despite a universal sense of relief, a rational approach to opioids remained elusive.  It made sense that terminal cancer patients should never be denied a narcotic for their excruciating pain, but elsewhere on the spectrum of pain, the same uncertainties prevailed.

Now with the opioid crisis making daily headlines, the pendulum has swung all the way back.  The public is outraged about the ubiquity of opiates and resulting societal problems; over-prescribing doctors and the pharmaceutical companies share the blame. And it seems that Purdue Pharma had knowledge of the dangers and abuse of their product long before admitting it to drug regulators.  Huge profits and corporate greed attached to OxyContin, not surprisingly, outweighed public health concerns.

In my Fourth World novels, the drugs in question are psychopeptides, the proteins made by translating recombined multispecies DNA– including DNA discovered in Martian fossils.  The giant pharmaceutical company Eunigen discovered those fossils and secretly manufactures these products.  Here’s an excerpt from Fourth World:

“Thor Ibsen, my name is Dr. Walther Beame.”  He was speaking more rapidly now. “I am about to give you a higher dosage of a drug very similar to Deep Coma.  Is that all right with you? I should tell you that there may be a substantial risk of serious side-effects at this high a dosage, including rash, headache, fever, abdominal pain, death, incontinence, loss of taste, and loosening of the nails.  All right then?” Beame smiled thinly at Trip and nodded encouragingly as he spoke.

“Yes.  Q.”

“Note that informed consent was obtained,” Beame murmured to 0749, who duly marked a box on his datadisc.  Without further ado (except for an audible gasp from 0749), Beame then applied the Dermamist injector and emptied the entire contents of the white vial into the subject’s carotid artery.

It took only a few seconds for the effects to begin.  Trip’s eyes slammed shut, his jaw clenched, his lips pulled tightly back in a grimace reaching almost ear-to-ear and revealing gold-capped molars on either side.  Nice, thought 0749: designed to match his gold chin cup and nostril ring. Trip’s tremulous hands grabbed onto the seat, knuckles white; his back arched against the plastic restraints pinning down both shoulders; his feet kicked violently against securely tightened leg straps.

…..

That wasn’t quite a seizure, thought 0749, but it was close.  He searched his datadisc. Seizures were not listed among the side-effects.

“Dr. Beame, just what are we observing here?  I mean, what are we expecting to happen to the subject?  Do you think the higher dose of drug will result in a more prolonged extra-corporeal experience?  And will the withdrawal therefore be more painful than the previous?” 0749 tried to suppress the rising anger so familiar by this point in his short career at the Repro Division.  He really should get around to filling out a transfer application, and soon.

Beame continued to stare at Trip’s contorted face, as he considered the question.  0749 was struck by the resemblance between Beame’s face and that of the subject: the tightness of its expression, the mouth drawn back, the look of one greedily searching for something in the obscure distance.    Finally, the director explained matter-of-factly to his conscience-plagued lab technician, “Don’t worry yourself, 0749; he will not experience any painful withdrawal this time. Extrapolating from results so far in our titration protocol, you can rest assured that this time the subject will successfully expire.”

 

Kids These Days!

I just got back from a reading and discussion of the Fourth World trilogy (final installment pending) in two separate sixth-grade classes today.  Frankly, I hadn’t expected very much engagement; to me, Fourth World seemed much too dense with 22nd-century medicine, genetic engineering, stem cell technology and even the mechanics of space engines, to appeal to students in sixth grade.  But the intro and Q&A sessions covered the art and science of both sci-fi and medicine, which seemed to draw rapt attention– something for everyone.  About two-thirds of the class said they preferred the arts, while one-third classified themselves as science-heads.  Anyone want to write as a hobby or professionally?  Quite a few hands shot up.  How about doctors?  Almost an equal number– amazing, at this age.

For those who denied any interest in writing, I advised keeping an open mind:  years from now, they may find that writing has become one of their greatest passions.  My advice to the nascent writers in the class:  first and foremost, read a lot!  In junior high school, some books I read for fun were Moby Dick, A Tale of Two Cities, The Foundation Trilogy, some Kurt Vonnegut, Dune and Lord of the Rings.  But To Kill a Mockingbird has had the greatest influence to this day.  Love of reading does not lead to good writing any more than love of music leads to composing skills or mastery of a musical instrument– but in the absence of high-quality reading, good writing is impossible.

Second, write what you know:  that is as old as the hills and twice as dusty– but still valid.  Of course I wrote Fourth World drawing from my experiences in medicine, bench research, patients’ stories and so on.  Although too young to have accumulated much experience of that sort, most sixth-graders have gone through the gamut of family struggles, (cyber)bullying, good and bad relationships, lack of confidence, and personal loss.

Third, know what your theme is before you write.  When students were asked what they would write a book about– or would like to see in a book written for teens– recurrent themes included character growth through the school years and entering professions such as medicine.  Those were expected, as well as themes oriented around gaining control of one’s life, as well as the fear of death.  More surprising, one student who had lost her father recently said that she hated doctors for failing to save him– but wanted to become a doctor herself.  Another student– thanked by the teacher for sharing– wished for a book about a girl who was constantly abused by her mother, then discovered superpowers in herself.  Yet another planned to solve, and write, murder mysteries.  In the end, there was universal enthusiasm for an ethnic cookbook– food conquers all!

Then came my reading from both novels.  When given a choice of passages, the overwhelming majority of kids chose Benn’s discovering a scene of horror in a locked medical ward (from Fourth World Nation).  I thought they would!  A baseball game played on Mars came in second, and no one wanted to hear about a band of young children fleeing an invading army (now that I had not expected).

These students, maybe ten to twelve years old, were very bright, definitely engaged, and not shy about speaking up.  They understood various references, albeit not in detail, that I made to artificial intelligence, genetics, space and medicine.  In contrast, when I was ten and entered sixth grade, as far as I can recall, I had no knowledge of anything.  It must be the energy and generous spirit of their teacher, supplemented by the Internet Age; the whole time I thought my readings would fall on deaf ears, I needn’t have worried at all.

Three paragraphs above, I mentioned a book about a mother’s abuse of her daughter, who subsequently gains superpowers.  Here’s a mercifully brief excerpt from Fourth World, in which Benn mulls over his strict upbringing:

“Honestly, his father’s long absences were a relief to Benn, as Owen’s oppressive approach to child-rearing (traditional among the Chinese, Benn had learned from a library book on psychosocial development) included caning his son when he broke the rules, or slapping him for asking impertinent questions.  Benn rubbed the back of his head, imagining a dent where Father had once applied his shoe. The effect, however, was the diametric opposite of what Owen intended: as a child, Benn reacted to physical punishment by further rejecting the rules, his impertinence growing with every blow.”

To the girl who requested that book:  Benn does develop extraordinary abilities later in Fourth World, and to a degree, justice is served.  Keep on reading!

 

Testing One-Two-Three

The patient’s spiking fevers had lasted over two weeks, and all efforts to diagnose an infection (the most common cause of fever) had yielded nothing.  She was admitted to the hospital for further workup, and late one evening, I was asked to see her, as the rheumatologist on call.  The electronic health record showed a normal admission physical exam (except for her temperature) and dozens of normal blood tests.  The only abnormality was a markedly elevated erythrocyte sedimentation rate, which is a nonspecific indicator of inflammation– it can be high in infections, malignancies, autoimmune diseases etc. and did not narrow down the diagnosis by much.  The inpatient ward team’s primary question for me was:  Out of all the numerous lab tests associated with rheumatologic diseases, which should they order?  ANA?  SSA/B?  RF?  ANCA?  aCCP?  What’s the best rheum test to diagnose an autoimmune disease? they earnestly inquired on the consult request.

After taking a detailed history of her illness, I looked at her skin, her mouth, nose, ears, felt for lymph nodes, listened to her heart and lungs, pressed on her abdomen– most are routine features of the physical exam– without finding anything abnormal.  It seemed the admission exam was accurate, and it was going to be a long evening.  Then I threw back the bed covers, to take a look at the legs.  The abnormal finding was immediately obvious:  her right foot was pointing at the ceiling, while the left foot was pointing at the door.  Hard as she tried (with me cheering her on), she could not point it upwards.  How long had that been going on?  Oh, about two weeks, she said– was it important?

She had what is called a foot-drop!  I went back to the electronic record, which made no mention of it (“Neuro, nonfocal,” it said).  And yet her conspicuous foot-drop, a result of a condition known as mononeuritis multiplex, led to the correct diagnosis of vasculitis (after a biopsy):  PAN, polyarteritis nodosa.  Long before the biopsy result came back, the patient’s fever had already resolved on treatment begun later that night.  Further blood tests did not contribute to her care; the “best rheum test,” it turned out, was throwing back the bed covers.

What brought this episode to mind was an article by Dr. Abraham Verghese in today’s NY Times, How Tech Can Turn Doctors Into Clerical Workers, in which he warns of the downside of electronic health records and artificial intelligence, in terms of mistakes made, the temptation to cut corners by simply making a keyboard click, the decline in the interpersonal aspect of patient care, and physician burnout.  It is human nature, I suppose, to seek the fastest path to a solution; to order more and more tests rather than look at the patient’s feet; and to write the daily progress note electronically by replicating the previous day’s note (with minor additions), assuming that the admission note had not missed anything.  In 2018, we seem to rely less on ourselves, our senses, our analytical skills, and more on all our ingenious inventions– our computer algorithms, antibody screens, DNA sequences, cell counters, all our technology– and in this way, we become subservient to them.

In the dystopian society of the Fourth World trilogy, machines use A.I. to make the diagnoses and prescribe the treatments.  Here’s an excerpt from the first novel, Fourth World:

“The patient, W.P., is a 64-year-old transportation executive who complains of severe, sharp pains and tightness in all of his muscles, of eight months duration.”  Kai began his presentation, reading from his open da-disc to the small group of interns, who were supervised that Friday by Dr. Hol Chan. W.P. was sitting hunched over on the hard examining table, wrapped in a short white cellulose gown, hands spread on his exposed knees.  He had been through this ritual ordeal so many times before. Less than a meter away, his wife sat stiffly upright on a short metal step stool. Standing just to her left, Benn observed her jaw muscles, clenching and unclenching. A state of agitation. Her middle and distal knuckles showed the bony enlargement of mild osteoarthritis.  There was a tiny growth on her forehead, which he diagnosed as a seborrheic keratosis; the Probot would have concurred. Because the room had been designed to accommodate only the patient and one physician, Dr. Chan and her interns were forced to crowd around.

“He is previously healthy, except for a very brief period of PsySoc rehab in his twenties, and his social and family histories are non-contributory.”  Kai glanced nervously at Dr. Chan, who, having heard Kai’s presentations before, watched him with an expression of deep concern as she activated the wall projection.  Kai continued, “I have put W.P. through the Probot twice, and both times the results were identical: signals of tissue injury or regeneration, inflammation, pre-mutagenesis and metabolic derangement are completely absent.  Epigenetic expression, including at the micro-RNA level, is normal. Risk loci mapping and haplotype structure are unremarkable. You can see on the next screen that the central and peripheral chi are not in any way obstructed.  I entered the patient’s history, systems review, family history, physical exam and lab data into the analyzer and found no matching diagnosis. And so, without a suitable coding of his diagnosis, there is no way to initiate the billing process.”

Dr. Chan, studying the wall screen, nodded in agreement.

Kai looked up from his da-disc and shrugged.  “In fact, W.P. is perfectly healthy, even though obviously he is persisting in his illness behavior.”