Reflections of a Gynecologist

The Thrill Is Gone

What is more exciting than the playoffs, more riveting than a good mystery and more addictive than chocolate or sex? Delivering a baby! 

Many of my patients have asked me over the last year if I miss delivering babies. The answer is: yes and no. The high of delivery is hard to equal, especially when the baby is healthy and wanted. Unfortunately this high is extracted from a lot of hard work, long hours, irregular eating and all-out general exhaustion. These I definitely don’t miss. 

Why do obstetricians continue to work like dogs? It certainly isn’t for monetary remuneration, because reimbursements for deliveries are now similar to what they were in 1986 when HMOs started gaining ground. Here in Brooklyn this reimbursement is between $2800 and $3500. This includes 10–14 prenatal visits, innumerable phone calls both day and night, hours spent with the patient during labor (sometimes more than 12), several visits in-hospital after delivery and a post-partum visit. More often than not, it also includes filling out at least two disability forms - one for the employer before delivery and one for after. I would like to see a lawyer who would spend that many unbillable hours with, or working for, a client. Especially when many of these hours are spent between midnight and 7 am. To top it off, obstetricians are not reimbursed until 2–12 weeks after delivery. 

Let’s face it: you have to love it to do it. My son, a psychiatrist, did an OB rotation as a medical student and asked me, “Mom, how can you stand it? All that blood, those smells, and the gore of the OR.” I told this to another psychiatrist and he asked, “Don’t you just learn to tolerate it?” The answer is: no. You either have to love blood, guts and lochia (post-delivery discharge) or you can’t be an obstetrician. When I was a medical student I worked at a big-city hospital in Houston, and did about 55 deliveries myself. I remember that for two months I woke up feeling like I was drowning in blood.

Much like sex, delivery is immutable in its earthiness and messiness. The basics have not changed in thousands of years. We can dress it up and make it pain-free, but it is still a bloody mess often accompanied by mucus, urine, feces and vernix (cheesy substance surrounding newborns). And it ends with that primeval extra organ - the placenta. Also like sex, it is hard to explain the thrill of it to someone who doesn’t find it thrilling. I didn’t even bother explaining it to my son. You either feel it or you don’t. You know how you felt as a child when someone explained the mechanism of sex? It sounded gross! You see what I mean? If it were just about logic, it is gross. 

The other attraction of obstetrics is its humbling tendency to show that nature trumps mankind's best efforts. No matter how much we think we know and how much science we apply to the field, nothing on a labor-and-delivery floor happens according to plan. The patient who has had six previous children all in less than four hours takes 15 hours to deliver her seventh child, and the tiny patient who you worried would never make it through labor delivers in the admitting room before getting into labor-and-delivery. The patient with the short cervix who you admitted for premature labor four times during the pregnancy goes post-dates and has to be induced. As usual, nature makes a fool out of your knowledge of obstetrics. 

There are so many disincentives for doing obstetrics these days, I can’t see anybody practicing it in five years - at least not in a private-practice setting. In states like ours with no caps on suits, the yearly price for malpractice runs from $150,000 to $240,000. There are less suits than there were 10 years ago, but the average suit now pays out about $12,000,000. In New York City there are now only two insurance carriers who still cover private obstetricians (those who work in hospitals get coverage via the hospital). Most obstetricians now pay more than 50% of what they make on deliveries to the insurance company. And malpractice is not just expensive; it is corrosive. Make no mistake about it. If you are in practice long enough, you will be sued. Most OBs will be sued multiple times. Perhaps this is why the average age for a New York obstetrician to retire is in his/her forties. After four years of premed, four years of medical school and four years of residency, most people give up obstetrics after about 15 years, not much longer than they trained.

Delivery of a baby is an addictive, sensual experience. And it is an honor to share such an intimate life adventure with your patients. But can we expect that to outweigh poorly reimbursed, long hours (did I mention that most private obstetricians have to work the next day after missing sleep to pay the bills) and the expense and psychological distress of lawsuits? I missed so much of my children’s everyday lives when they were small and we celebrated birthdays and holidays all over the calendar but I wouldn’t change my life as an obstetrician. It was grand! But as B. B. King says, “The thrill is gone!” and I have now rejoined the human race and have begun to smell the roses. 

 

Good Fences

“Good fences make good neighbors” is an oft-quoted adage. This simple phrase can have many interpretations. On the site UsingEnglish.com, the definition is given as “it is better for people to mind their own business and to respect the privacy of others.” To me, it means well-demarcated boundaries improve relationships.

Boundaries can improve relationships both at home and at work. For instance, what grown child would appreciate their parents arriving unannounced at their abode or, even worse, letting themselves in to their child’s home, assuming they had a key? At a certain age, children realize that they do not want their lives to be an open book into which their parents can browse. Children, too, need to realize that once they leave home, they cannot come and go into their previous houses the same way they once did. Parents also appreciate being prepared before the arrival of their progeny and they don’t take kindly to their homes being treated like a crash pad with dirty towels left on the bathroom floor, just like in the good old days. It is easy to fall into teenagedom in your parents’ environment but one should resist the urge. 

Years ago I read several studies showing that people are happier working jobs where the individual responsibilities of that job are spelled out. If I have to negotiate daily what I should and shouldn’t be doing at work, it is certainly a waste of emotional energy. If I overachieve, I feel resentful that I did all the work and what-the-hell were you doing; and if I do less, I feel guilty and jealous that you will get all the credit. If I know the job description, that’s all I need to perform without having to second-guess how I'm doing.

Spouses also need boundaries. For this, communication is a must. I can’t guess what makes you angry. You will have to tell me and, of course, I should respect your feelings, not belittle them. The more you know someone, the easier it is to destroy him. You know the beams on which his fragile ego lies. (All egos are frail.) Thus, there are some places you should never go and some things that you can never take back. SO DON’T SAY THEM. When my son was a little boy and was mad at my husband, a composer by trade, he told him he hated his music. This made my husband and me roar, because it really was very savvy for a child who wished to be hurtful. If I told my husband I thought he was a hack composer or he told me he had never like my cooking or thought I was a miserable excuse for a physician, it might not be so funny. How about the people who say in anger, “And I never loved you.” Remember that word boundaries? 

If communication is not possible and there is not room for compromise, then we are left with the take-it-or-leave-it option. This may be acceptable if we have advanced warning, but we don’t want to hear our new office cleaner saying, “I don’t do floors or windows” six weeks after being hired. This should be discussed when considering the employment of said worker. Fences only work if the placement of those fences is agreed upon by those on either side. Obviously, this means all parties must be informed. Unfortunately, unwritten boundaries like “No wife of mine works out of the house” or “The man always drives”  may be discussed only after the marriage agreement has been signed and the take-it-or-leave-it option is a little less doable. This is when boundaries can become tyrannical.

Children’s behavior is another area where limits should be clearly set and not arcane or hard to figure out. These limits, unlike those between adults, are not something decided between consenting parties. When my kids were little I would often marvel at their friends’ parents who would be trying to negotiate with a screaming and irascible three year-old at our house. Please throw the kid over your shoulder and take the kid home. It is not okay to throw a temper tantrum at someone else’s house whenever you don’t get your own way.  Some types of behavior are just off-limit. Maybe if more physicians learned this as children, there would be less of them screaming in the O.R. or throwing hissy fits on the Labor-and-Delivery room floor.  

Boundaries can sometimes be detrimental, though,especially when they are used to keep children ignorant. Children learn the “Don’t ask, don’t tell” rule very fast. They sense, even when they are not told outright, what topics should not be discussed. It is incredible how efficiently unwritten laws get written into a child’s script. When it comes to behavior this can be good, but sometimes this is why children are in the dark when it comes to the one-act play in which they have a role. My husband’s family left Germany in 1938. He said he was told that this was because his grandparents ran a progressive boarding school. When I suggested to him years ago that maybe it was because they were Jewish (though non-practicing), he got angry at me. (He now is astonished at his previous ignorance.) More likely, the exodus from Germany was not up for discussion. Given no plausible explanation, my husband may have even substituted the “progressive school” explanation himself. Not-up-for-discussion can bury a lot of family history that needs to be aired.  

There are also some instances when delineation can interfere with adaptation. For instance, couples with less rigidly-defined sex roles seem to be able to roll with the punches over time more effectively than those where roles are set in stone. If one person is laid off, the other still brings in an income. If the primary caretaker is ill, the other partner still knows how to cook a meal or where the diaper pail is. Likewise, when parents or grown children are ill, they may have to reverse roles or get into each other’s intimate spaces to help out. As important as boundaries are, one must know when to drop them! 

So, what’s the take-home message? Good fences make good neighbors when both neighbors know where the fences are and agree upon the placement. Try, however, not to use those fences to protect yourself from intimacy with your children and friends. Let others know when they trespass and respect when they tell you that you are over the line. All this might take a lifetime. 
Good luck.

 

Data, Data Everywhere and Not a Drop................

We can learn a lot from evidence-based medicine. Scientific studies have the potential to improve patients’ outcomes but they can also push the clinician into an informational abyss. There are several possible pitfalls with studying scientific data: 1) the data can take preference over the patient’s clinical outcome; 2) the information can be valid but not pertinent to the patient’s situation 3) the data may become important for its own sake thus inspiring cheating or fudging of information; and 4) the information itself may be unreliable. Here are a few examples from my own professional career. 

Preference for clean data is more important than patient outcome

When I was a medical student we had a patient on the surgical unit who was dying of an advanced cancer. Due to cancer-related liver and renal failure he had anasarca, a condition in which patients can put on 20–50 pounds of water weight outside of their vascular system. It was apparent that the man was close to death. The residents following the case instructed C., a fellow medical student, to draw the patient’s bloods in order to monitor his electrolytes. My colleague went to the man’s bedside, saw that he was close to death, and realized that with his profound edema she would probably have to stick him multiple times. She asked herself, “Is this really helping the patient?” She then decided to draw the blood from a friend of hers and sent it to the lab in lieu of taking the patient’s blood. One hour later the patient expired. When the results came back from the lab, the residents were quite excited that they had managed to correct this man’s electrolyte status, even though they had lost the patient. Of course, you could argue the ethics of my colleague’s actions for a few millennia. But at least she was thinking of the patient as a person rather than a set of numbers. The idea of the patient as an entity, not just a set of labs is a good one and has now been embraced by end-of-life care communities. Thankfully, many patients at this juncture in their lives are nowadays in hospice care and not being managed by a team of over- eager residents or renegade medical students.

This same thought process is evident when patients complain to me: “I have reduced my calories and fat and I am exercising five times a week, but my weight hasn’t changed.” My aim as a doctor is not to impress your scale. My aim is to get you eating right and exercising. If you manage to incorporate healthy eating and exercise into your life, you have already won the battle. Many people’s scales show wonderful results when they go on fad diets and sit in a sauna for an hour without rehydrating themselves but neither of these are advisable nor particularly healthful. This is when data gets in the way of logical thinking.

Info is valid but not pertinent

Over the years, I have been to at least three grand rounds in which the presenters showed data proving that if we were to remove every middle-aged woman’s ovaries who comes in for any GYN surgery, then this would reduce death from ovarian cancer by tens of thousands. I do not doubt their findings.  Ovarian cancer is a serious disease that will afflict 1 out of 70 women. It is hard to detect at an early stage. This data, however, has no meaning unless you compare the lives of women who have had their ovaries removed with those who have not. As it turns out, when these studies were finally done, women who still had their ovaries lived longer, had less heart disease, less osteoporosis, and, in general, a better quality of life. In light of these newer studies (many of which are still in progress) we need to give women who are considering GYN surgery the whole story and let them decide which risks they are willing to take. 

Clinical performance based on data inspires cheating

As a medical student working in the emergency room, we worked in teams: blue, green and red. The red team was overseen by Dr. M, who was a famous surgeon and the chief of emergency medical services. Like many successful surgeons of that era he did not suffer fools gladly. Dr. M rounded on his patients every morning at 6:30 am. At 5:30 am the residents and medical students spent an hour putting the red labels on patients who seemed to be improving and assigning the less-well patients to the blue and green teams. In this way, Dr. M’s team always outperformed the rest. 

This same type of thinking creeps into all types of medical practices when performance is judged on limited data. Early in the 1980s, in-vitro fertilization specialists discovered that they had less success with women over the age of 40. Since their success was rated solely on full-term pregnancies, these physicians stopped women over the age of 39 from receiving their services. Once it was discovered that these women’s pregnancy rates improved from oocyte donations (the borrowing of a younger woman’s eggs), they were once again put into the statistical data. Previous to this, if you compared a reproductive specialist who treated women with an average age of 34 to one whose patients averaged age 39, the doctor with the younger set of patients always outperformed the one with the older patient base. In the same way, when looking at success rates for cardiac surgeons it is important to consider the surgeon’s patient base. If we do not look at the full picture, physicians being judged on just one  parameter of success will merely drop high-risk patients from their purview.  These patients, who may be older or have underlying medical conditions, such as diabetes or hypertension, will have to forego cardiac surgery because their outcomes are less reliable and thus their statistics worse. No one wants to have bad numbers!

Data is unreliable

During my residency, patients in active labor were placed on the Labor and Delivery Unit and those with complications of pregnancy or who were postpartum were placed in the Maternity Unit. One Sunday, I was called by a nurse to come up to the Maternity Unit and evaluate a patient. The patient was full-term and had been admitted to the hospital with high blood pressure. The patient thought she was in labor. The nurse stated that she had placed the patient on a monitor for an hour and the patient was not having contractions. On my way from the elevator to the patient’s room, I could hear somebody breathing in a way that only a laboring patient breathes. When I got to the patient’s room the baseline for her monitor was set at a hundred instead of zero. The monitor only registers readings from zero to a hundred. With a baseline of a hundred, nothing - even the most gigantic contraction - will not show up. On exam, the patient was ready to deliver. Two things are evident from this story. One is that your data is only as good as the collector of said data. The other is that you should never leave your common sense at home. A patient who says that she is in labor, breathes like she is in labor, and sounds like she is in labor should be taken seriously until proved otherwise by a competent clinician.

This reliance on hospital-collected data is how several radiology departments unwittingly over-radiated their patients. A recent New York Times exposé revealed that radiology technologists at many hospitals across the United Sates did not fully understand the data from their own scanning machines and the data was less than helpful because it did not contain an alarm or visual alert when the patients had received high doses of radiation. Once again, a clinician is only as good as the data that she collects. 

I don’t want to give anyone the impression that medical studies are useless and medical technology is a waste of time. On the contrary, clinicians have immeasurably improved the lives of patients by using evidence-based data and modern technological tools. However, when applying these, some caveats apply. We physicians should always be skeptical about the information we receive and should always ask the following questions. Are the studies we ask patients to get and the procedures we put them through going to change how we manage their cases and ultimately affect their outcomes? Can we trust the information we get from the laboratories and radiologists we use? When reading studies, does the information gleaned from these studies give us the whole picture or does it just look at survival, for instance, and not evaluate quality of life? When looking at success rates of physicians or surgical techniques, are we comparing apples to oranges? And when something looks too good to be true, we need to wonder if the numbers have been manipulated to the benefit of the author at the cost of accuracy.

       These days, many people receive medical information from the internet. This information may be about drugs, drug studies, physicians, or surgical procedures. We must all be vigilant that we understand how this data is collected, who is interpreting it and if it is even pertinent. It is easy to take a bad turn on the information highway.

Time is of the Essence

      Remember when you were a kid in grade school and summer vacation began? Remember how vast it appeared, almost infinite at the end of June? And then, seemingly out of nowhere, August would arrive. Suddenly you would realize only one more month of vacation was left. That date of return in September seemed to loom over and infect all of your activities thereafter. This is what it feels like to get to fifty and beyond. You look over the mountain and see the other side is in sight. There may be time and opportunity to accomplish your goals, but you realize you can’t fiddle-faddle about. That first day of school is looming and will arrive sooner than you think.
       When we are under fifty, most ot us take things for granted. What things? Seeing, hearing, balance, free movement of our joints, being attractive to the opposite sex, living without pain, the ability to enjoy sex (women, you know what I am referring to), the idea that we are invulnerable, the idea that opportunity abounds and that we can accomplish just about anything if we put our minds to it. As we age the list of fix-ables and do-ables gets smaller and the list of “I can learn to live with it” gets longer. As time passes, the givens of youth become more tenuous and elusive. There are myriad ways our bodies sabotage us as we age. My mom said she knew her hearing and sight would get worse as she got older, but she never dreamed she would be the weight she is now—ever. Add to these corporeal losses the death of some dear friends and family members and it becomes difficult to look at life as anything but a series of losses.
       It might seem curious then that an article in The New York Times recently stated that more middle-aged people report being happy than people in their twenties. This set me to thinking and I realized that those of us in our fifties and sixties have also had a few notches in the gains category:

     1. A feeling of mastery in our chosen paths. Whether a homemaker or executive, one knows the ropes, knows how to accomplish his or her ends in an efficient and timely manner and feels he or she is making a difference. This mastery bestows a sense of pride.
     2. Being part of a supportive social network, be it your own nuclear family, your close friends or those you work with. People in your circle know you and trust you and there is a feeling of mutual dependency. You no longer need to explain yourself.
     3. Self-confidence. Most of us become more confident with our ability to survive and thrive as we age. This usually translates into an ability to be assertive without having to be aggressive. And that grey hair many of us bemoan does bestow a bit of authority that people seem to respond to.
     4. Status. Feeling like what you do is important or that you are an important member of a community or family.
     5. Wisdom. There is no doubt that having a little experience and perspective helps in decision-making. By a certain age people know what they want and, sometimes more importantly, what they don’t want. This makes choices easier as we get older.
       So on the scale of living, there is the plus and the minus side. In his article “Useless But Valuable” [http://asithoughttobe.wordpress.com/2010/07/25/useless-but-valuable/] John Dunn describes three different approaches to the aging process. The first involves trying to look and act as young as you can; the second, the resignation that you are “going to die so what’s the point;” and the third being “useless, but valuable,” a phrase coined by Dunn’s wife. This last view was espoused by the author’s friend Alex, a priest in the Orthodox Church of America, who states he wants to spend less time on the front line and be more available for contemplative activities as he ages. He wants to be a guide, not a warrior.
       This goes along with the feeling many of us have as we enter our late fifties and sixties that we are tired of dancing to the same tunes that have ruled our lives up to now. Time pressures and work stress become less tolerable. At this age most people want at least some portion of their lives on their own terms. This is why people may choose new jobs with lower pay that are more stimulating, or have shorter hours and more compatible workmates. Money and status as defined by the business world have less meaning as we age.
       In January I left a practice with which I had been linked for 23 years. Although it was very stressful to start anew at age 58, it has been one of the most satisfying endeavors of my life. I now select my own employees, control my own hours and decide how my office is run. My work environment, once frenzied and fraught with tension and drama, is now pleasant and rewarding. I am making less money but I wouldn’t trade my new lifestyle for my old one for love or money or anything else I can think of. And like Alex the priest, I am enjoying having more time to write, to think and to communicate with my fellow human beings.
        Alex suggested to Dunn that he read the journals of his mentor, the priest Alexander Schmemann (1921–83). [See http://www.schmemann.org] Schmemann wrote about transforming the “knowledge of death” into the “knowledge of life.” As we age we experience not just the “dying of the heart” but the “rising of the spirit.” Knowing our days are numbered can be limiting, but it can also be emancipating. As my grandmother said on her 75th birthday, “You’ll see, one day you will just turn around and be seventy-five.” So I suggest instead of bemoaning your age, rejoice in it. Join those of us who are sharing our knowledge and whatever wisdom we have accumulated and who continue to add value and satisfaction to our own lives. Try to glean what is really important to you as you get older because, as my grandmother pointed out, time IS of the essence. August is almost over and school will be starting soon.

The Search for Natural

I think I might be described by many as a nature-lover. I have hundreds of plants in my home, I would rather walk in the woods than go to Disney Land and I think the smell of dirt is grand. But although Nature has brought us dogwoods, mountain vistas and rainbows, we should not forget about nature’s less beautiful gifts: rats, hurricanes, leprosy—just to name a few of the more-beloved gifts of Nature’s bounty. Nature demands respect. Four hours of heavy rain at the right time on a Friday, especially in the summer, can totally grid-lock New York City. Of course the beauty of Nature is she is out of our control, but it is also what makes Nature a fickle and untrustworthy mistress.

Despite the inability to control or predict nature, or maybe because of it, people often

think anything natural is superior to anything manmade. This is particularly striking as a physician when you are listening to your patients. Here are two twisted examples of what I have heard recently in reference to the mysterious word natural. A patient told me she no longer uses the birth control pill, because after her surgery she decided to go all natural. I enquired about the type of surgery she was referring to as there was no note on the chart. “Oh, “ she said, “after the tummy-tuck I had last summer.” And during the same week a patient with vitamin D deficiency who has had two skin cancers removed from her face told me she had stopped using sunblock because she preferred getting vitamin D from a natural source such as the sun rather than from a commercially available supplement. She was opting for the strong possibility of getting another skin cancer because she was afraid of vitamin D toxicity—a side effect which, if it exists at all, is exceedingly rare.

Of course, there are many doctors who employ the opposite logic: anything I give you is going to work better that anything you do for yourself. Rather than changing your diet or exercise, take my pill. This attitude is engendered in doctors because we see the unpleasant side of nature in graphic detail: fever, vomiting, pain, diarrhea, dementia and, of course, death. After a few encounters with some of these natural phenomena, you think modern medicine can’t do any worse and can only improve one’s lot in life. Seeing the sad lot of humanhood in medical school and as a resident makes the word “natural” lose some of its previous glamour.

We humans have problems with gray areas, but most of life seems to fall in that unfathomable space between white and black. I was asked at a party, “Do you believe in estrogen?” I had to point out it is neither a religion nor a political party. Like many drugs it has improved some women’s lives immeasurably and given other women an increased chance of getting a stroke. Most things we do in life have a risk/benefit ratio. We need to examine that ratio with all medications. What will I stand to gain and what am I at risk for? Unfortunately even drugs with a lot of gain can hurt you if you are the one-in-a-million to get a bad side effect. But not treating some maladies also has a risk/benefit ratio and that should also be examined before a decision on medication is made.

Nowadays, we have a third choice—“natural” products. Some may be superior to conventional Western treatments and some may be deleterious. Tobacco is a natural product but not one most people would use to promote their future health. Many, perhaps most, products sold as “natural” have had little testing and this is why most physicians are reticent to recommend them. Products that have been tested and found to have benefits and few risks such as red-rice algae or fish oil for elevated cholesterol should become part of a doctors’ armamentarium, perhaps before, or in addition to statin medications, but products like bio-identical hormones that are not made by recognized pharmaceutical companies and have no long-term prospective investigations should be looked at with skepticism until further studies are forthcoming. For example, we do not know that bio-identical progesterone creams are any less stimulatory to the breast than oral progestogens. They may turn out to have less risks or the opposite may be true.

Many people argue with some justification that FDA approval of a drug is no longer meaningful, either, especially in light of revelations about drugs like Vioxx or Avandia whose risks were obscured by the companies selling them. As a physician, I share those concerns. “At least do no harm” is probably the only part of the Hippocratic oath that most physicians can quote or even remember. I always prefer to wait a year or so after a drug comes out before prescribing it, just to see if any previously unreported side effects come to light.

Doctors and patients alike must have a healthy respect for medications. I totally understand when patients want to wait to explore all treatment options before deciding on a course of action. We as physicians should supply patients with as much information as we can and encourage them to research solutions on their own. We should all own our own health. But we should also abandon the idea that if it’s “natural” it must be better. 

In medicine we learn to individualize. The medication that sent you into the hospital with a frightening and potentially fatal side effect may have saved your neighbor’s life. When we prescribe a drug, no matter how much we know about you and the drug, an element of chance still enters. You could be the person with a serious allergic episode or this could be a drug which adds five years to your life expectancy or improves the quality of your life tremendously. Like Nature, medication can be fickle. In January, I had a life-threatening reaction to an anti-inflammatory medication. It would be easy to vilify these drugs as “bad”, but this class of drug has made my life livable. Although I have had a serious joint disease since I am twenty-nine, I am still walking, exercising and swimming and I don’t have any artificial joints. I have these drugs to thank. Back to that grey zone.

Medications or natural products should not be part of a philosophical or political agenda. I don’t want a pharmaceutical rep or a radical feminist deciding what is right for me. I want to have a physician I can discuss my health issues with, who can outline my particular risks and can help me decide how to live my life with quality and dignity, while incurring the least risk. When deciding on medications, whether traditional or not, I would recommend the same for you. And if you can’t discuss these issues with your current physician, may I suggest an MD trade-in. I hope nature treats you well this weekend. The current weather report has us in for 97 degrees tomorrow.

Oh, Brother

Many of my patients can never have their family members convene for a big family get-together. Why? Because relationships between their children are poisonous and it becomes impossible to have the siblings spend time together under the same roof. This is a very sad state of affairs and is very tragic for parents. Sometimes, the parents have wittingly or unwittingly contributed to the poison but, whether the parents have helped create the situation or not, it is a loss for everyone, especially the siblings’ children.

Perhaps it is not an accident that the first murder in the Bible is a fratricide. “I've interviewed people on marriage and religion and feminism, and I've never tapped such deep feeling as I did when I interviewed people about their siblings. Most people have not thought much about it before and when they do, it opens up the floodgates of emotion.” This is a quote from Frances Klagsbrun the author of Mixed Feelings: Love, Hate, Rivalry and Reconciliation Among Brothers and Sisters. Although a lot of ink has been spilled about the parent-child relationship, brothers and sisters comprise for the most part, uncharted and unwritten about terrain.

Research seems to indicate that sister–brother and sister–sister relationships do better than brother–brother relationships over the long haul. Siblings less than five years apart and siblings with close ties to their parents also tend to stay closer as they age. More blacks than whites have close relationships with their brothers or sisters in adulthood. By the time they are independent adults, about 80% of people say they are close with their siblings, 10% are apathetic and 10% say their relationships are hostile. Why does it matter?

For most people their brothers and sisters will be the people they have the longest relationships with. Unfortunately these relationships more often than not get stuck in childhood. The sibling who dominated as a 10 year-old still thinks he should run the family. If your sister/brother thought you were a loser when she/he was a teenager, she/he still thinks you are no matter what great things you have accomplished in adulthood. Parents, of course, can profoundly effect the sibling relationship. They can make things worse by reinforcing their own stereotypes of their brood: “He's the one who will get somewhere;” “She’s the most self-centered of the bunch;” “Some parent he's going to be!,” etc. 

Brothers and sisters are often in competition. And the competition is real. It starts out as a game for attention and love and then blossoms into a race for real goods: financial support, inherited items like jewelry and houses, etc. With competition comes jealousy. Going back to the Bible there is Jacob jockeying to inherit all the family goods by colluding with his mother and Joseph receiving the many-colored coat only to be deposited in the desert by his jealous brothers and then sold off as a slave. In neither case do we see any immediate remorse from the perfidious siblings. When I made my will I divided everything equally between my children. My lawyer said, "What if one is very wealthy and the other is a starving artist?" My reply was that I don't want one of my children to be wondering for the rest of their lives after I'm gone if I didn't really like the other one better. 

According to two New York Times articles, poor sibling relations are linked to relationship difficulties later in life. This makes sense to me: If you do not have the tools to resolve your earliest relationship, how will those skills improve over time?  Studies have shown that even parents who don't negatively impact the situation often don't help it either. Instead of giving the children the tools to work out conflicts and to openly discuss these conflicts, parents usually entertain the opinion that the kids will have to work out their problems themselves.

I lost my brother when he was 46 and I was 41. My brother was definitely one of my greatest boosters, a source of great joy and a well of fabulously-told dirty jokes. He was someone I spoke to a few times or more a week and whose opinion I valued. This was quite a trick, because my brother could be in Paris or Brazil. He was out for dinner with his numerous friends nearly every night of the week. He wrote music for shows, and had a typical performer's lifestyle, so while I was getting up at 6 am to go to work, he was just going to bed. Our awake hours just barely overlapped. He was an older brother, so of course he could be overbearing. He sent me a birthday card one year that said on the front “You are the greatest sister there is” and when you opened it, said “And I should know; I'm always right!” 

My brother was a very handsome, talented and gregarious guy. He had many admirers and was in our small-town newspaper frequently, often with an accompanying picture. I was very shy and often let my brother negotiate the outside world for me. Initially I was in awe of him and jealous of his talent, but as I got older, it became obvious to both of us that I made better decisions than he did and was a better judge of character. So after a certain age, my brother began to depend on my input and decision-making abilities. 

Siblings grow up in the same one-act play. They transverse the same landscape. My brother and I undoubtedly became close because my parents had a contentious relationship and we shared the secret of what a crazy place we came from. Our father had a raging temper and we helped each other navigate the treacherous surroundings. 

Dr Deborah Gold, who has researched siblings over 65 years old has found that positive relationships fall into three categories: “the loyal relationship” - we’re not friends, but I'll stick by you no matter what; “the congenial bond” - I like to socialize with you, but I don't depend on you for emotional support; and “the intimate relationship” - we are best friends and can ask each other to do things we would not ask others to do. My brother and I definitely had the intimate form. I moved through his final illness from AIDS with him and got a full perspective on what a 46 year-old person with a full life goes through on a day to day level when he knows he is dying. We died a little together.

Thus I find it heartbreaking to hear of people with healthy siblings who never want to see them again. There are definitely some siblings who lived under a reign of terror created by an older sibling and they don't want to be under this person's thumb again. Or the sibling who feels that whatever is yours is mine. Once established, patterns of sibling behavior are very difficult to alter. We are talking about altering a lifetime of repetitive, ritualized behavior. The chance that talking about it once as adults is going to change it, is small, perhaps futile. Very few people want to go into long-term therapy with their sibs! But all I can say is if you have brothers and sisters who are still living and breathing and you are not in contact with them, at least establishing a “congenial bond” might make the world a better place. It will make your parents feel whole again and might improve your own life as well. 

God's Garbage Heap- A little country tune to entertain

You said your love would last forever

And that our lives were intertwined.

All that’s left is with the leaf mold

Underneath the orange rind.

I threw your present in the compost.

Hope it breaks down with the rain,

Decomposes with the egg shells 

And takes away the pain.

The thing that really, really got me

Is that I know you must have thought

That I would give you all my lovin’

And you never would get caught.

I threw your present in the compost.

Hope it breaks down with the rain,

Decomposes with the egg shells

And takes away my pain.

You chased the first girl that would have you.

I’m sure you filled her head with lies.

Now the last gift you ever gave me

Is a big hit with the flies.

Threw your present in the compost.

Hope it breaks down with the rain,

Decomposes with the egg shells 

And takes away my pain.

Bon voyage and hasta luego.

Hope we never meet again.

You are fading from my mem’ry

Into God’s garbage heap of men.

I threw your present in the compost.

Hope it breaks down in the rain,

Decomposes with the eggshells 

And takes away my pain.

Now my only consolation

From this affair that I can glean

Is that my compost is improving 

And my life is ever green.

The Guiding Light

     "Ethics has no necessary connection with any particular religion, nor with religion in general."

-- Peter Singer (ed), Ethics, 1994    

         My mother is an atheist and a very ethical person. She says that since no one is looking over her, she feels she must answer to herself for what she does here on earth and that this keeps her honest. Of course, that's what a sense of morals should do: give us a guidepost which we internalize. Too often, humans seem to feel this guidepost exists only if someone else is watching. When I was about seven years old, I went to visit my second cousin. While in the grocery store with her, when her mom was not looking, she showed me how her brother and she would go around opening boxes of food and help themselves to what was available. I was appalled. In my family we called this stealing. I told my mother I didn't want to play with her again on a regular basis. I offered no explanation. Then my mom had to explain to her own overbearing first cousin (the mother of the help-yourself shoppers)  that Saturday play dates were a thing of the past for her daughter and me. This probably was a little embarrassing for my mother, but even though she didn't know the root of the issue, she was on my team.

         There is no doubt that what we think of as moral differs in different societies.  Long ago Herodotus, the first to chronicle and compare human behavior in different cultures noted that what is the right thing in one group is the wrong in another. He noted one group he visited cooked and ate their dead and another group embalmed them. When informed of the funeral rites of the other society, each group was horrified. Each culture had ritualized death in their own way and this was the moral way to honor the dead in their culture. The rituals may not have been the same, but honoring the dead with a ritual and the importance of not just dumping the carcass anywhere were inherent in the customs of both groups. Likewise there are many customs worldwide, but a sense of fairness and respect are arguably universal, even if the expression of these values may differ around the world.

          Why then do so many people feel the anonymity of the computer gives them permission to act like a bunch of louts? Much like many people who are aggressive and piggish in the car and do things they would never do while in line in a bank, people seem to think if you cannot identify them or retaliate, it is acceptable to be rude and boorish. If a picture of them and their phone number appeared with their postings, undoubtedly a number of these nasty commenters would disappear. My daughter-in-law recently  had her blog featured on Open Salon. This might be a moment of great pride for her, except that many people ridiculed her, making ad-hominum remarks and just taking potshots at her, mainly just because they could. The comments were just barely related to the content of the article, most not at all.

       Many societies feel they should follow a moral code within their society, but how a member of the group treats anyone out of that society is up for grabs and poor behavior to other groups is often tolerated and even encouraged. If we are anonymous to each other, everyone becomes an "outsider" and thus we can treat that outsider in whatever way we wish. When driving, if you put your blinker on with the intention of changing lanes in heavy traffic no one will respond. Put your hand out the window, and very soon someone will let you into his or her lane. Something about seeing that common body part works. This is similar to an article I read recently that explained how if there is a picture of a human face over a recycling bin, people are more likely to respond to requests to recycle. We should, however, do the right thing without having to be reminded that other humans are involved and perhaps are judging us.

   Several articles have been written lately about people's innate sense of morality and about research indicating that even babies have a sense of what is fair. There was even a recent article showing that dogs have a sense of fairness, as well. When two dogs are vying for biscuits and one dog consistently gets gypped, he will stop socializing, look depressed and stop trying for the denied biscuit. Even a dog can recognize when a playing field is not flat! 

       Over the years I have heard all sorts of reasons for bad behavior. I think humans can rationalize any misdeed. Fellow American medical students in Mexico told me when I lived there that it was okay to take food on a regular basis from a neighborhood restaurant, because if the owner was stupid enough to leave it in such an available place, he deserved what he got. Or it's okay to cheat on this or that test, because it didn’t matter anyway. 

   Milan Kundera, the author of "The Incredible Lightness of Being" said that all the great questions of life are asked in the first five years of life. I assumed he meant, for instance, "Why do people have to die?", "Where do we go when we die?", "How are babies made?" and the other innumerable questions that kids ask that we are hard put to answer.( Most parents should feel glad that at least they didn't have my inquisitive youngster who asked me at age seven, how gay people had sex. )

    Not only do kids ask many questions, but they have an intense sense of what is and is not fair, even though they may give sway to the same selfish desires that the rest of us have. They can recognize a bully and they know when they are being given questionable data. They value the truth. So my rule of thumb is if you can't explain your behavior to a normal five to seven year old without feeling ashamed, then your behavior needs to be changed. If you think having a mistress and wife is fine, because neither of them knows the existence of the other, try explaining to a kid how lying to the the two people who love you the most in the world is totally fine.  We need to learn to do the right thing EVEN IF NO ONE IS LOOKING.  Run some of your behavior by that virtual kid and see if it passes muster.

With an Ear to the Human Jungle

Why did "30 Rock" portray a woman's idea of pornography as a male who wants to listen? All people need to communicate, but very few have the luxury of having someone listen to them. There's a reason most languages differentiate between hearing and listening. A dog hears (some seem to listen) but only another human being can process what you are saying - listen, ponder, and perhaps empathize. Even if the listener says nothing a listener is an important figure. And for many woman such as the character played by Tina Fey on “30 Rock” a man who really listens is a sexy and unusual commodity. 

Papers compiled by a female physician, Clella Mosher, were found accidentally in 1973 by a professor doing work on another topic at the Stanford University Library. These papers comprise the first sex survey ever found. Dr. Mosher devised and conducted interviews with 45 women concerning their viewpoints on sex and sexuality. The interviews took place between 1892 and 1920, in other words with women of the Victorian and Edwardian eras. Questions concerned women's "sexual habits and appetites" and their "thinking about spousal relationships, children and contraception." 

The women interviewed were born between 1840 and 1890. Most were white, married women who were well-educated. I would love to read all the interviews. Ms. Platoni the author of an article on Dr. Mosher (see http://www.stanfordalumni.org/news/magazine/2010/marapr/feature/mosher.html) summarized that 35 out of the 45 women said they desired sex and 34 of them had experienced orgasm. Yet as Platoni points out, the prevailing view at the time was that "the majority of women (happily for them) are not very much troubled with sexual feelings of any kind." This is a quote from a Dr. William Acton from 1865. 

There are many wonderful quotes in this fascinating article. But what struck me is the conviction of the medical establishment without ever having consulted any women in a scientific manner. It took this way-ahead-of-her-time female physician to ask and to listen. Unfortunately Dr. Mosher never wrote up her findings, probably from fear that she would be reviled. From the start of her career Dr. Mosher had been cut out of the intellectual arena by her male colleagues and shut out of social circles by other women. Like many visionaries she hoed a lonely road. 

Being a good listener means taking an interest, asking open-ended questions and not inserting one's own agenda or opinions. In medical school we are taught to hone in on what is of importance (or what we think is important) in coming to a diagnosis. We are told not to let the patient dominate the dialogue. Never let the patient digress. This can lead to a faulty diagnosis. We stress what we think is important and shape the conversation until the patient points us where we have already decided we need to go. The more doctors who interview this patient the more readily this patient will tell us what we want to hear. Although digression into the grandchildren's soccer games may be tedious, a little more time with a little less physician input often gives the doctor a better feel for the patient and a better idea why the patient is there. 

All physicians in training learn about the "doorknob" comment. After a full visit with the doctor the patient has his or her hand on the doorknob and says, "I meant to ask you about the blood in my urine." And at this moment you realize this was the subtext and the real reason for the visit. There are several reasons why people do this: 1) The patient hopes that you will find something in the exam and you - not he or she - will be the one to broach the topic; 2) The patient is facing the door and finds it easier to bring up an embarrassing or concerning topic without making eye contact; 3) The patient, aware that you have a waiting room full of anxious patients, is hoping that you will blow off the question by saying "it doesn't sound too serious;" and 4) The doctor has not given the patient an open forum to discuss this problem earlier in the visit.

As Lisa Sanders, M.D., the author of Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis, tells us, every patient - all of us - has a story. Some are trite, some are unbelievable, some are contrived, and some just sad - but they all need to be heard. We as doctors, and all of us, should just listen to our friends, children, parents and co-workers without judgement, without much comment - just with the acknowledgement that we are all in the same human jungle and that life is indeed precarious.

Yours, But Only On Loan


There are many stereotypes of mothers using guilt to pressure, manipulate or dominate their children, but in the parental-child relationship, guilt is traveling on a two-way highway. This highway is wide and long--as long as the relationship, more often than not, the length of a lifetime. As soon as a child is born, a parent's "worry button" is depressed and it stays there for the lifetime of that child. Many years ago, one of my patients told me that now that her children were in their 30s, she had the most worries she had ever experienced as a parent. When you see what traps people fall into as they reach full adulthood, you might understand this statement.
I am thinking of this due to an article I read this week. A young man in his early 30s stole several hundred thousand dollars in cash from the employer of his parents and put it into a locker. His parents are Greek immigrants who both work two jobs in order to pay off a large mortgage. The son was in jail awaiting trial and knew that the police would eventually discover the money. He called his father from jail and told him he had won a lot of money in the lottery, and asked him take the money from the locker. The father didn't believe this story and refused. Then the son broke down, and begged him to retrieve the money, pleading that he did not want to go to jail for ten to twenty years. The father gave in, took the money out of the locker, and spent some of it to pay off his mortgage. He was caught by the police and arrested.
At the son's trial after sentencing, the son blew a kiss to his mom and said he loved his family. Meanwhile his dad is elsewhere awaiting trial. I kept wondering how many parents would refuse a kid they knew was a criminal if they thought their own criminal actions could protect this kid from years of jail time. And we think parents are masters of the guilt game!
Our job as parents is to protect our kids, but when should we retire? Sometimes the decision isn't ours. In my practice, I have many moms whose children have predeceased them -- from car accidents, cancers, asthma, and drug overdoses. My own mom is 86. My brother died in 1993 from AIDS at the age of 46. As the lifetime caretaker of our children, it is especially horrible to live on when they are gone. And, yes, it can be a cause of tremendous guilt, even when the parents know intellectually that they are not the cause of the child's demise.
As people age, they often fall into one of Dante's circles. They are driven by lust or greed, ambition, and so on. When reading "The Inferno" in high school it all sounded so silly, but now I think so many of these behaviors are genetically hardwired and nearly impossible to control. Add alcoholism, drug addiction, sexual adventurism and excessive gambling to the traditional list of vices. No wonder most world religions railed against these temptations and tried to keep people from ever coming into contact with them. These are behaviors parents have just about no impact on.
They say in Alanon (I paraphrase): as a family member, you didn't cause it it, you can't control it, and you won't cure it.
Ultimately we all own our own deeds. I am lucky to have two very self-motivated adult children. My daughter is a classical violist and my son is a resident in psychiatry. My daughter has spent her life practicing. When she was little, a neighbor called and said that her child was starting music lessons and she wanted to know how to get her to practice. I said I had no idea. I never really made my daughter practice. She had the passion and she put in the time. Likewise, I would have had no idea how to motivate my son. Once when I told him to do such and such homework, he told me it was his responsibility and all learning ultimately had to come from the learner. (He was a wise but sometimes snotty teenager.)
At any rate, when people tell me how proud I must be of my kids, I think pride does not really describe how I feel. I feel lucky, blessed and impressed at what they have accomplished. They, not I, put in the work. I have no more claim on their deeds than the mother of a criminal has on his misdeeds.
My idea of pride comes from having learned to read basic Hebrew at age 57--something my kids learned to do ages ago.