Grand Rounds

The Best Bromance Ever

Steven Schlozman, MD — Mon, 21 Dec 2009 22:52:22 +0000

My best friend and I meet every morning to go for a walk in the woods.

It’s cold in Boston these days, well below freezing, but if you dress right, the crunching sound of frozen dirt and the smell of crispy maple leaves bring their own satisfaction.

My buddy almost always notices things I miss; the stream, he points out, keeps gurgling near the middle of the riverbed, but the periphery is iced over and solid. The snow melts more quickly at the base of deciduous trees than it does around conifers, and there are a surprising amount of animals up and about in the frozen morning.

We don’t say much because its cold, and its fun to watch our breath, visible in the morning sunlight, linger towards the sky in the frigid breeze.

I’m not all that tall, but I’m still a bit taller than my friend, so I get the rare experience of feeling paternal and fraternal all at once. It’s an odd experience, feeling so platonically responsible.

After about 15 minutes my pal stops and seems to want to say something. Then he squats and poops, at some very special place that only he knows is special, and I lovingly pick up his excrement in a plastic bag.

This is the best bromance ever.

His name is Corduroy, now 6 months old and a good 60 pounds, and he is the long awaited response to the endless questions and promises from the younger members of my family. My daughters swore to walk him, to feed and to bathe him, and my older child found him online through petfinder.com, a website that is simultaneously addicting and heart-wrenching.

And now, despite the promises of my progeny to walk and feed him, it is I who rouses at 6 AM, wearing the goofiest outfit I can tolerate that will still keep me warm, but Corduroy never, ever rolls his eyes at my plaid scarf and the corny hat with the ear flaps. He doesn’t do sarcasm. It’s not in his repertoire.

He is the most uncomplicated thing in my life.

I have never once received a text message from him. He doesn’t seem to care about twitter, and he is utterly disinterested in my CV or my academic promotion.

My dour Eastern European family has noted that it will be sad when he dies, but I am philosophical. It will be horribly sad, but still wonderfully uncomplicated. There won’t be all those discussions I wish we’d had. There will not be a plethora of unfinished business. It’ll be sad – pure and simple sadness. Uncomplicated. Pristine.

Once, Corduroy and I almost had a disagreement. I was non-chalantly throwing him chicken skin from the table, and he seemed ecstatic. Imagine, being happy over chicken skin! How great is this for a neurotic guy who aims only to please?

So, I give him one greasy piece, then another, and pretty soon I realize that it has to stop somewhere. I don’t know why I realize this…. Corduroy doesn’t think it should stop. I don’t really want it to stop. Still, I figure that he IS a dog and he DOES have his own food, and, plus, my dog-owning friends have advised against feeding him from the table. This doesn’t quite make sense to me, though. If I pick up his poop, then surely he’s worthy of the same chicken I eat. And, I’m only giving him the skin. But still, I am conflicted, and I therefore tell him that I’m done, trying for one of those dog-owner lies, because he sees me eating and knows I’m not done eating, just that I’m done feeding him.

He tilts his head, does that furrowed-brow thing, and then, as I hold the line for no good reason, he calmly walks to the other side of the dinner table and proceeds to become, ahem, calmly and rhythmically amorous with my wife’s leg. He’s looking right at me as he does this, but as my wife is facing me, Corduroy has to turn his head to an almost unnatural angle in order that our eyes might meet.

“Is this OK?” my wife asks. She has never had a dog, and until now her main pets have been our cats and a chicken that her scientist mother brought home from the lab in downtown Buffalo where she (and, I guess the chicken) grew up. Never once did the chicken hump anyone’s leg. She is baffled.

“Nope,” I say, instinctively knowing that it is expected behavior from my buddy, a compliment to my wife and an innocently articulated middle finger to boot. I swallow my green beans and explain. “Its uncouth. We’d like our dog to be couth.”

Corduroy is still looking at me, or my chicken, or both, and I tell him to stop having his way with my wife. He relinquishes her knee and wags his tail before retreating to his food bowl.

Good boy, I think, and I am satisfied and happy.

I really love my dog.

The Passing of Brother Blue

Steven Schlozman, MD — Mon, 09 Nov 2009 15:47:50 +0000

Brother Blue passed away last week. He was 88 years old, and he died in his home in Cambridge, Massachusetts.

A gentle, almost magical man, he told stories. That was his job, and he was a pro. In fact, he had (and I am not kidding) a PhD in story telling. He earned this distinction in 1973 from Union College, a collaborative educational endeavor between Harvard University and the Episcopal Divinity School in Cambridge.

A PhD in storytelling is about the coolest form of doctoring I can imagine.

Plus he could play a mean harmonica, his eyes twinkling like stardust, like an inside joke, like the foreknowledge that things were gonna get rocky but that if we could just clown it up a bit we'd all be OK.

So, here's what stinks for me. I NEVER KNEW ABOUT HIM until last week. In a lovely confluence of events that, I think, would have tickled the good doctor, a friend of mine suggested that I might very much enjoy watching George Romero's movie Knightriders. It turns out that Dr. Hugh Morgan Hill, the other name by which Brother Blue was known, plays a pivotal role in the story. Thus, I met him once and only once, on my laptop, on a plane, and I forgot for a while because of him and others in the flick that I was sitting packed like a sardine into a 30-ton behemoth at 34,000 feet.

If you don't know Knightriders, check it out. I gather it is sort of a cult film, wonderfully and whimsically shot, in which a band of motorcycle dudes led by Ed Harris as the putative King Arthur roam the country as part of a Medieval faire, doing their best to respect, potentially to a fault, the governance and chivalry of Camelot. People think of George Romero for his zombies, and I happen to love those zombies, but unfortunately when the undead start mucking about folks forget about the other stuff that Romero has done. Knightriders is about as much fun as you can have on DVD right now, and no small part of that is due to Brother Blue.

You see, Brother Blue plays Merlin, and anyone who has read Malory knows that Merlin is a tricky fellow. Merlin knows how to heal but also knows that healing too soon might miss wisdom downstream. Hell, Merlin raised Arthur, knowing full well how it would all turn out, and yet it was worth it to Merlin. It was worth the story.

Go rent the film, especially if you, like me, never got to hear Brother Blue in person. At least there you can watch him weave stories as freely as most of us respire. He lets Ed Harris's character screw up, damn near lets him die, but does so because there is truth to be realized and truth sometimes hurts as much as it tickles, and it is possible to feel both. Harris's character laughs as he suffers, learning and becoming a better man, and if that isn't the point of stories, then we have to give serious thought as to why we still listen with rapture to tellings and retellings of Beowulf, of why friends tell jokes, of why I read to my kids at night.

As a physician and perhaps especially as a psychiatrist, I find stories as necessary as oxygen. I am an obligate listener, not only because it is my job (though I am lucky enough that it is) but because stories make me feel.

And Dr. Hugh Morgan Hill could make you feel just by looking at him. I know there are others out there who know a lot more about the man than I do, and I'd love to hear more stories about his life. I read in the article in the Boston Globe that his last story, on his deathbed, was a love story. This is a man I wish I had met.

For now, I will remember him puffing on the harmonica in Knightriders, butterflies painted on his face and forehead, a little bit sad but always smiling, as he watches humans go through the motions of trying to understand. I know this is maudlin, but I will miss him despite having seen him only once, in one movie, and it bugs me that I work in the same town where he passed on. Perhaps going forward I can look around more carefully. I don't want to miss another one.

Wayne's World, Wigs, Wecovery and Wesilience

Steven Schlozman, MD — Mon, 03 Aug 2009 20:32:35 +0000

I look exactly and uncomfortably like Garth Algar from Wayne's World when I wear my wife's wig.

This may sound sort of clichéd and confessional (i.e. "Hi, my name is Steve, and I like to wear my wife's wig") but that's not what this is about.

The fact is, a few weekends back, my whole family took turns wearing my wife's hairpiece. My 9 year old looked sort of retro, like a new member of the B-52's without the mini-skirt. My 3 and ½ year old looked, oddly, crazy and old, a mixture of Benjamin Button and perhaps an exotic terrier.

And I looked exactly like Garth.

It helped that I was bouncing around the room, jumping on the bed, flinging my "hair" back and forth, relishing the feeling as the strands alternately danced along my bare back and then flopped forward to cover my eyes. Maybe a bit of AC/DC would have helped, but it was good enough just to dance.

This was the experience of an entire family breathing as one, acknowledging and then mocking the ugly visitor that showed up rudely and uninvited last Thanksgiving. On that day, I managed, like an idiot, to check my wife's medical record before the doctor got back to her and discovered that rather than being able to reassuringly tell her that the lump she had discovered was benign, in fact she was now, officially, a cancer patient. She had breast cancer, and there was no in-between.

Life degenerates quickly into stale axioms during these times, and we wore all those sayings down to nothing but threadbare coverings of terror. We'll cope. We'll see the best doctors. It could be worse. (I hate that one - of course it could be worse, but that doesn't mean it still doesn't personally suck.)

We are now, thankfully, through the initial surgeries, through the chemotherapy, through the surreal walks through the healing garden and the oddly peaceful setting of the infusion suite where you sit, reading books, and receive toxins that make no attempt in their nomenclature to hide their steadfast intentions. In my business, brand names for medications confer sought-after qualities - Abilify (confers ability), Celexa (will settle you), and Seroquel (makes you serene.)

What went into my wife's arm? Cytoxin. Cell poison. There's no ambiguity in that name.

And yet, these unambiguous names for chemotherapeutic agents were about the most concretely reliable thing about the entire experience. There were all sorts of unpredictable events, even though we had a relatively uneventful course. And I know I keep saying "we", and that only my wife in fact had (or has) cancer, but I can tell you, it was definitely "we." No other pronoun works. At least not for me.

We received excellent care. Our friends and family were incredibly supportive and generous. My wife is strong and beautiful and did very, very well. We are, in fact, and thank goodness, very, very fortunate.
But it still sucks. I had a medical school professor who famously told us that at times you have to say to the patient: "Gee whiz, cancer sucks." And he's right. It does.

But now my wife's hair is growing back. It is downy, a soft landscape taking root on her scalp, soft as lamb's ear. We all like to lounge around up there, rubbing our fingers through the silky texture. It's like frolicking on a cloud.

But when it first disappeared...well, I couldn't stop thinking of a famous poem. You see, her hair just sort of plopped out. No explosion or renting of garments. It was terrifying precisely because of its banality. Remember Eliot's "The Hollow Men?":

This is the way the world ends
This is the way the world ends
This is the way the world ends
Not with a bang but a whimper.

I thought my world was ending. A bald wife I can handle - but the meaning o f her baldness, of that wig, scared me nearly to death. I could barely whimper.

But the world, my world, didn't end. After 8 months of that damn wig sitting like an otter on its four pronged stand, I decided to pull it over my naturally bald head. I jumped up and down on the bed and my wife laughed so hard she was crying. It damn near killed her to laugh so hard. My daughters ran around the house, the wig streaming behind their relieved backs, the breast cancer maybe there, maybe gone, but we were done with it for now.

It was Wayne's World. Party Time. Excellent.

Silly Love Songs

Steven Schlozman, MD — Tue, 02 Jun 2009 00:34:08 +0000

On Sunday evenings, I sit on the toilet and play my guitar.

I have the lid down. It's not that pathetic.

It's just that I really love playing my guitar, and I happen also to be not all that good. I can play the usual chords, the stuff of easy harmonies and illicit beach bonfires. In fact, I may be the only guy who has ever strummed Uncle John's Band and still never, ever, been stoned. Note that I mention this fact neither as a badge of honor nor as a confession. It is more a kind of contextual aid.

So, I get my kids into the bathtub, cover them thoroughly with soap, and then I rush to the bedroom to grab my six-string. They are trapped, a truly captive audience. My older daughter is now sufficiently jaded to mount a decent protest, to roll her eyes at my crooning, but she will still occasionally request that I play something by Taylor Swift. My younger one, though, stares at the guitar with wide eyes, her blond curly hair laced with fruity smelling bubbles, and I am grateful for the fact that she'll still with limited objections listen to me play just about anything. Van Morrison, Cat Stevens, and the Itsy Bitsy Spider are welcome sets. (A performer must balance his repertoire with a mixture of personal passion and the wishes of the audience.)

It was in this setting, just last night, that I stumbled like a lost hiker into an old and previously misplaced memory. The chords ringing out, a G here, a C there, and before I could stop myself, I was playing a song that I myself had written for a high school sweetheart more than 20 years ago, rehearsed over and over for her anticipated visit to my bedroom at the end of her freshman year of college.

Now I know why rediscovered structures are sometimes called ruins. Yesterday evening felt like nostalgic polyester, my ears actually blushing purple as I plundered through the lyrics of that old heart-wrecked song. I seemed to be channeling an unholy alliance of Air Supply with James Taylor through the unfortunate lens of suburban, balding sensibility, and I bravely suffered through this memory of my ex-girlfriend sitting on the floor in her tie-die skirt, her wry smile hiding whatever expletives were thought but not uttered. Mercifully, I was lucky enough to recall that she tried her best to stifle an embarrassed giggle or two.

She had met a sculptor in college (I clearly didn't stand a chance) and my song, with lyrics like "you take that missing brick, and it all comes tumbling down" really couldn't compete with a guy who welded scrap metal collected on hikes in the mountains into vaguely sexual representations. Still, like a plane caught in bad turbulence, at that wonderfully hopeful age of 19, I pushed forward through my wooing, even then beginning the transfer of the moment into deeply and increasingly buried ignominious memory.

So, why last night? What made last night different from all other nights? I've sat on the toilet and played my guitar thousands of times. I must have worked hard to suppress this memory, and still out it came, like a gas, like a wide necktie at a fashionable gathering. I suppose we cannot really choose our memories and when they visit, and before interpreting this moment I thought last night that it was most prudent to just go for the ride. There must be other things I've truly, really forgotten, so it follows that there is a reason that this scene made its way to conscious excavation. Could it be my elevated cholesterol (newly discovered), or something more guardedly optimistic? After all, my 3 year old stared and bobbed her head. I think at least she was smitten.

The Goalie Has to Hurl: Musings of a Soccer Dad

Steven Schlozman, MD — Sun, 03 May 2009 12:01:45 +0000

Sacred places are never a function of cubic feet, and they have little to do with monetary value. They are sacred because they are declared sacred via rules and rituals that go unquestioned and obeyed. Some old Shaman, probably as a joke, decided to tell everyone who would listen that this scrappy rock or that barren mountain mattered, and then, because people listened, it started to matter. O, how the gods must laugh.

Today I watched my daughter in just such a place. She turned her back on the rough and sacred land, the small rectangle of magic that was hers to keep safe and uncontaminated, and instead she focused through battle-hard eyes on those around her, all of them friends less than an hour before, but who now made their wonton intentions clear. They planned, without a single regret, to rob her of her holiness.

My God, no wonder she feels like puking when it is her turn to play goalie.

I know very little about soccer and a whole lot about anxiety, so I have had all sorts of time to study the fear of playing goalie carefully. Unlike a well-versed soccer Mom, I am in fact a soccer moron, so, naturally, I am the assistant coach. Over three years of coaching, I have been like an anthropologist, trying my best to characterize the anxiety of being goalie across both gender and development. I recognize as well that I have a scientific obligation to name this syndrome and thus confer it with well-earned validity.

Though I considered briefly "Schlozman's Disease," it seemed on reflection too non-specific, summing up instead the myriad worries that characterize my temperament and the potential temperaments therefore of my unfortunate progeny. After careful consideration, I have decided to go with "Severe Goalie Anxiety Syndrome," S-GAS for short, thus calling attention to the gastrointestinal changes that accompany the anticipatory hyper-adrenergic state occurring just before the Goalie Uniform is donned. (This is invariably made worse by the round of generously brought cupcakes grabbed quickly from a super-market "bakery," distributed with great fanfare to the warriors before the start of battle. Lest you should see cupcakes as confounders challenging the validity of the syndrome, rest assured that I am trained as a scientist. There is flatulence without cupcakes. Just less flatulence.)

So, the response of my daughter and her friends to the role of guarding the goal allows the thoughtful observer many opportunities to ponder. Is the pressure greater or less because you can use your hands in the goal? Do the special gloves confer the comfort of being different, or the anxieties of unique privilege? All high priests have their outfits, their robes and hats and incense, and they must feel different and a little bit awe struck when they face the common folk in the audience, the holy space now at their backs.

The Goalie dresses differently, acts differently, is blamed too much for the loss and celebrated too much for the win. All this talk about it being a "team effort." HA! I betcha professional goalies have a lot more superstitions than their non-goalie team mates. A goalie on a hot streak will never, ever, change his socks.

But how, on a neurobiological level, do we understand the almost nearly universal tendency for players who are not themselves determined goalkeepers to feel the need to expectorate as their turn in the goal grows near? Vomiting, it turns out, is a relatively complex physiologic event, something much more adaptively sublime than words like "hurl" or "puke" might evoke. It is first and foremost a primitive mechanism. The Area Postrema is present in all sorts of brains, from shrews up to humans (and perhaps aliens as well, though this would require a significant tangent to this particular post). It is adaptive, as it is good to throw up that which can kill you or at least ruin your day. The smell of rotting flesh is nauseating, the evolutionary biologists tell us, because we would prefer our brains to reject the potential nourishment of rancid food given the risk of disease and great discomfort. Thus, the Area Postrema "listens" to the Olfactory Bulb, sends a text message to the Solitary Nucleus in the brainstem, and the eject button is viscerally and profoundly triggered.

However, we cannot entirely implicate the Area Postrema. My daughter does not eat the goal, and though the cupcakes she feeds herself prior to competition are enough to make me lose my cookies, I have seen with my own eyes her capacity to down these sweets with intestinal impunity in the absence of an impending game.

It is the IDEA of the goal that is threatening, just as the Areas Postrema receives the news from our higher cortical regions that the IDEA of rancid meat is intrinsically bad. And here is where we declare ourselves as wonderfully social creatures. The biology of mirror neurons suggests that if one player sees another fare less than wonderfully while guarding the goal, the observing player will recruit regions of her brain associated with the assumed emotional response of the actual faltering goalie. Assumption is a key element here, because it may in fact mean not nearly as much to the kid in the goal that she has let a few wayward balls cross the line.

For my daughter, however, a goal scored by the opposing team suggests a fundamental breech in the order of things. The goal is sacred, profound, not to be trampled and besmirched by opposing heretics. The IDEA of disrupting the natural order of things is sickening, disorienting, even fragmenting. Today, the Hawks (my daughter's team) were invaded by the Tigers (hardly a fair fight, as the Hawks were precluded from flying), and the sacred Hawk goal was transgressed more than once. We Hawks suffered a contagion, S-Gas spreading among the usually steadfast raptors like a rare swine flu. (!)

We recovered with ice cream and a play date, but that does not mean that there wasn't suffering in between. Those who hate crossing bridges will tell you that in retrospect the fear during crossing seemed silly and mundane. They realize, though, with feigned nonchalance, that there are always more bridges. And then even cupcakes don't help.

Oh My! Have you had any unusual sexual contacts lately?

Steven Schlozman, MD — Mon, 02 Mar 2009 20:58:05 +0000

So, I found myself in the Emergency Room. The orthopedic resident, a tall blond woman who rowed crew at the University of Wisconsin, smiled and confirmed the diagnosis. "It's really pretty common," she reassured me, and she recited a litany of professional athletes who had suffered similar ruptures of their Achilles tendons. Gabe Kapler for the Red Sox, Vinny Testaverde for the Dolphins, and so forth. All had to endure the downstream effect of evolutionary pressures so strong to be upright that we saw fit as we developed as a species to have a single tendon in between us and our capacity to walk. At least I was in good company. Gabe Kapler, Jewish and a hell of power hitter, was nick-named the "Hebrew Hammer". I could be the "Circumcised Suburbanite." At least it was alliterative.

I had the surgery, and to prevent any infection in the easily friable skin along the wound site, I was given a zillion gallons of antibiotics interoperatively.

Two days later I awoke with razor blades in my mouth, a nasty case of Oral Candida (a yeast infection) having found refuge and sustenance in my now bacteria-free oral cavity. I called my primary care doctor and explained, and he dutifully arranged an appointment.

Before I saw him, however, I was greeted by an enthusiastic medical student, her white coat shining smooth as a hard-boiled egg, her stethoscope worn proudly, her eagerness palpable, her energy enviable.

My doctor explained to me that the student was on her primary care rotation and wondered if she might see me first. I teach medical students, and I, personally, feel that our students give some of the best, most thorough care in medicine. I was delighted.

Then the exam started.

Medicine is all about the history. Get the story, I tell my students. Confirm the story with your physical exam, answer unanswered questions by looking for signs. Don't lay hands on your patient before you talk. Talk first.

Nope. She started with my feet. All she had to do was ask "What brings you in today?" and my answer would have lead her to my mouth, to the white fibrous colonies hanging from my palate like oozing stalactites (or stalagmites - I can never keep that straight). She would see one of the best cases she had ever seen of thrush. Instead, she was carefully examining my toe-nails.

The clock ticked. "Take a deep breath," she said, her stethoscope in place, and I complied. She was getting closer now, moving north along my body, feeling for nodes along my neck and jaw.

"Can I take a look in your mouth?" she asked. (Finally!) She could have been asking whether I wanted to see the dessert menu, so enthusiastic was she at the nearing completion of her examination. However, there was still no attempt to take a history. Not a question. Only politely given instructions.

"Open wide," she politely instructed, and then her eyes grew wide at what she had discovered.

"Oh my," she exclaimed. "That looks like Oral Candida. Have you had any unusual sexual activities lately?"

Just like that. No hesitation, no explanation. She could have been informing me that today's dessert special was mango sorbet.

I couldn't help myself. I laughed. It hurt, the guffaw lifting my palate and stretching the inflamed skin that was angry at the invading yeast buds. Still, it was pretty funny.

She looked troubled. "Why are you laughing?" she asked. She knew I was a professor at the medical school, and I knew then I probably shouldn't have laughed.

"Well," I whispered, my throat raspy and raw, "My life really isn't that interesting."

"Huh?" she startled, standing still, her stethoscope clipped around her neck, oscillating like a pendulum with the audibly ticking clock on the wall.

"Typically we lead into these questions." I explained.

"What do you mean?" she asked.

And I felt bad. I am a medical educator, and here I had an indication of where things have gone very strangely in the education of today's doctors. So much primacy on the technology of diagnosis! So much emphasis on the collection of measurable data, on the discovery of fascinating symptoms, on genetic analyses and imaging that puts Star Trek to shame. And yet, the core, the centrality of why we practice medicine, is getting increasingly forgotten maybe because we have taken it for granted for so long that it is no longer granted as taken.

We should talk to our patients. My goodness, the fun is in the story, the finesse is in the listening, and the skill is in the application of the information within the context of the patient's world. It is a service profession. We are not surveyors. Any medical student ought to put Oral Candida together with immunosuppression, and it is appropriate to ask about sexually transmitted disease once that connection is made. How, when, and why you ask it - that is the art of being a doctor. Otherwise I might as well talk to a drop-down menu on a computer.

Oh wait. That's exactly what we increasingly do.

We medical educators have our work cut out for us...

Mad as Hell and Worried I'm Going to Have to Take It

Steven Schlozman, MD — Mon, 23 Feb 2009 22:39:32 +0000

Let me go over a few maddeningly unchanging facts, with a few opinions thrown in for good color commentary. Much of this many of you will already know, but, as with all political issues, sometimes it is helpful to restate the obvious in order to accentuate the corresponding lack of progress.

1. We are the only developed country to carve out psychiatric care to for-profit insurers. Thus, although much of our health insurance payers are non-profit (Blue Cross, for example) we see fit as a culture to allow for-profit, private companies to "manage" a significant portion of our health.

2. These for-profit companies have a major obligation to their board to deliver the most "cost efficient" - read, "cheapest" - care possible. By definition (i.e., "for-profit") these companies must make the most money possible in the least amount of time. I don' think this is necessarily immoral. If you are "for-profit," then your job is to profit. I need to make more than I spend to take care of my family; that's how you make a living. I just find the juxtaposition of these payers with my work at best tacky, impersonal, and inconsistent, and at worse, down-right horrific.

3. Folks are tied to their insurers through their work. As work changes, so changes their insurance for health care. With every change in insurance, there are corresponding changes in mental health insurance as well.

4. Since folks are changing jobs a lot these days, they are also changing insurance. This means that in order to turn a profit, the for-profit mental health payers can make the most money by, to put it bluntly, stalling. Every little barrier to care saves money, and believe me, the barriers have increased dramatically over the last few months. People move onto to other insurers, and if the companies can create enough barriers, people whose very suffering makes them more prone to give up will go on suffering and cost a given mental health carve-out less money than if services were more readily available.

Thankfully, some of these ongoing circumstances lead to the long-awaited passage of Federal Mental Health Parity in this country. This development was loudly applauded at a recent meeting I attended in England discussing international approaches to reducing stigma in public and professional perceptions of mental health.

Part of the reason a bunch of international academics who study stigma were interested involves current research that psychiatric insurance carve-outs have a significant attitudinal consequence among medical students and other current and future health care providers. Many have gotten the impression that because our culture has deemed it legitimate to carve out psychiatric care and thus make it more difficult to receive needed services, then there must be some validity to the prejudice and short shrift that psychiatric suffering itself receives in our country. This has been studied and documented.

All of this is akin to shopping at Whole Foods for all of your medical care and then bopping into 7-11 for some beef jerky and a soda when feeding your psychiatric needs.

And, boy, am I worried that things are going to get worse. Things will certainly look economically bleaker before they get better, and these very stressors that lead to increased psychiatric illness are likely also to lead our enlightened policy makers, once again, to cut costs in the psychiatric arena in an effort to save a few bucks.

If you're lucky, you haven't had to directly confront these issues. However, given the amount of psychiatric and psychological suffering, the odds are that if you haven't been down this Byzantine path, someone you care about has. They just haven't told you, potentially because the very barriers to care that they've encountered make them feel ashamed of needing the care in the first place. This reaction has also been documented.

I have watched, over the last two months alone, the amount of regulatory oversight into my work mushroom to new heights. Although I prefer my posts to be more light-hearted, I find it hard to scrape levity from the increasingly nasty practice of telling people I don't know all about patients for whom I care deeply and then having the people I don't know read off a series of questions, like Stepford reviewers, and then at first deny care.

It is a game. They know they'll approve care. I know they'll approve care. There's a script we follow, like actors in a failing Kabuki theater heading down an inevitable path while the audience chuckles sadly at our seeming inability to just arrive at the last scene without all the drama in between.

"I'll have to have you talk to our doctor on call," they say eventually. "Thanks," I say back. (My script allows for little more here, though the language of my unspoken affect is more colorful if not fit for all audiences...). The doctor-on-call comes on the phone, sitting someplace, I imagine, or perhaps working out on the stair-master. Maybe he or she is wearing a bathrobe. I don't have any idea who I am talking to, how they can assess my patient whom they've never met, and how they determine proper care from their kingdom of pre-approval. Usually things go OK and treatment is approved, except it can take as long as a few days, and by the end of all that, I feel pretty beat up and genuinely saddened. What a message to convey to our culture, that all of this is necessary to validate a certain kind of suffering.

I am all for cost oversight. I just think we can do it better and more humanely.

At the end of the day, this is stigma, formally defined as an explicitly visible sign, a stigmata, that confirms shame on those who show it. We have sanctioned this stigma for way too long, and the stage is now set, as we rebuild our increasingly dysfunctional health care system, to get this right. It is our ethical as well as our economical imperative, and I would put the priorities in exactly that order.

A Vampire Flick with Emotional Teeth

Steven Schlozman, MD — Thu, 19 Feb 2009 23:26:21 +0000

I am a fan of vampires. I have been for a very long time; ever since I was 11 years old, enjoying one of the first evenings when my parents saw fit to trust me at home alone. "I can watch whatever I want on television," I thought, grabbing some Pringles and Dr. Pepper and settling in on the family couch in our wood paneled living room. I switched on the newly arrived Showtime Cable Entertainment Network, and scared the hell out of myself watching the movie version of Stephen King's "Salem's Lot."

It's actually a pretty bad movie, but that didn't matter. I remember with alarming accuracy the teen-aged vampire hovering outside the protagonist's second story window, his teeth long and curved, more like a beast than a demon, his long finger-nails grating like needles on a chalkboard along his poor victim's window. He looked simultaneously desperate and vulnerable. A hungry predator, himself being hunted, he needed blood like a teen needs attention, like my 3 year old daughter craves cuddling when she has a fever. There was something profound going on in this lousy movie, which didn't mean I wasn't frightened all night, but did mean that I have never shaken the potentially complex construct of the vampire myth from my imagination.

I have written about vampires in academic literature and in the lay press. As my wife will lament, a vampire flick has to be pretty bad for me to not have a good time.

So, imagine my delight, my curiosity, my thirst, when reviews like this from the New York Times started chasing around an obscure Swedish movie this summer called "Let the Right One In":

"[Director Tomas Alfredson's] movie smoothly and seemingly without effort works through a canny amalgamation of cool and hot, diffidence and passion..."

The movie received all sorts of critical acclaim. Alfredson won the coveted Tribeca Film Festival's "Founders Award for Best Narrative Feature." The folks in Tribeca described the movie as a "mesmerizing exploration of loneliness and alienation through masterful reexamination of the vampire myth."

Hmmm. I could see Twilight (girl has forlorn love with boy who happens to be a vampire, he is cold to the touch, has no reflection in mirror, and ultimately can't decide whether he wants her for her blood or her passion...yawn. Been there. Bring your grandmother.)

Or, I could, I did, and I urge you all as well to go see "Let the Right one In." Roughly, the story involves a latency-aged friendship between a picked-on skinny kid, friendless in the endless night of Northern Sweden during winter, and his almost-romantic interest with a half wild vampire girl who protects him and loves him with equal vigor. Given her need to feed, there is enough gore to satisfy whatever cravings vampire fans bring to the theater, but the chills come with simple lines, spoken amidst constant snow, white powder interrupted by just a drop of blood quickly buried by the ceaseless blizzards.

"How old are you?" the boy asks his new friend, the reality of what she is dawning on him like a dream.

"I'm 12," she notes, "But I've been 12 for a very long time."

I was hooked as the movie started, but that line pulled me in. Go see it or rent it. It'll make you thirsty.

Rose of Sharon

Steven Schlozman, MD — Fri, 13 Feb 2009 12:38:20 +0000

The fig tree putteth forth her green figs, and the vines with the tender grape give a good smell. Arise, my love, my fair one, and come away...
Take us the foxes, the little foxes, that spoil the vines: for our vines have tender grapes.
My beloved is mine, and I am his: he feedeth among the lilies.

How'd you like to feed among them Lilies?

The Songs of Songs is about the sexiest thing I read in Hebrew School. Granted, there wasn't much competition...sure, there's all kinds of steamy stuff in the Old Testament, but my recollection is that things often went badly for those who succumbed to a celebration of unbridled physical love. I mean, David did get all interested in Bathsheba, sending her husband off to war so he could get a minute of her time. This kind of love could only really be admired by the perversity that mixes immediate satisfaction with the immature garnering of desires typical of the Sopranos.

But the Songs of Songs is something different. "the fig tree putteth forth her green figs." Wow. Ever look at a fig? It's a damn sexy piece of fruit, subtle as spring wind, just sweet enough and full of purple juice. It puts a banana to shame.

In the 1930's, a lovely man named Rabbi Haddas arrived as an eager and pioneering spiritual leader in Kansas City, Missouri, and managed to perform the marriage ceremony for about every adult I grew up with. The kinds of feelings he still evokes are remarkable. He was the essence of a good man.

When he arrived in Kansas City, the Great Depression weighed heavily on the nation. The Jewish community of Kansas City, like all communities, was frightened and isolative. There was little work and little hope. How could a spiritual leader steer his flock to love in such dire times?

With his gift for optimism and inspiration, he formed the YPL - the Young People's League - and invited the youth of his congregation to gather in the evening to study together. I imagine newly immigrated parents, thick with Yiddish accents, ushering their young adult children out the door and into the economically starved night to attend these study groups, lest the Rabbi should thing badly of his congregants and their desire for contemplation.

Staring at his bedraggled participants, carefully, I'd guess, mixing the men and the women throughout the room, he sang to them from the Song of Songs. Eye's lit up and imaginations wandered. Sadie couldn't help but to admire Mordechai's smile. Rebecca blushed at Sammy. The room was growing warm.

And this is how two of my very favorite relatives met. My great Uncle Morrie was a towering 5'3". He was smitten by my not-yet Great Aunt Mary, a brilliant woman who, remarkably, had graduated from college during those difficult times with a degree in comparative literature. A wealthier aunt had paid for her to leave Kansas City and to attend the University of Wisconsin, and she returned home the apple of every Jewish boy's eye. She was smart, after all, and smart was sexy. At least it was to Uncle Morrie.

Mary could recite the Song of Songs in French and Spanish, and her Hebrew was smooth as butter. She could sing the verses without looking at the text. (Later, I would enjoy quoting Shakespeare with Aunt Mary, the only one in my family content to read the Bard with me after Shabbas dinner, smiling without interpreting.) Uncle Morrie was not nearly as schooled as Mary, but he remains the most charming man I have ever known. He made up for his relative dearth of formal education with a keen sense of humor, an unbridled charisma, and a powerful conviction that living righteously was not incompatible with a love of laughter and chocolate.

Mary was working as the librarian at the Jewish Community Center, so Morrie went to visit her shortly after that first YPL meeting. He approached the desk confidently and asked her to find a book about a "red ship." She looked puzzled, eager to help her potential suitor, but unclear as to his request and perhaps troubled by her lack of recognition of something literary. Until then, there had been no work of literature with which Mary was not completely intimate.

"It's a poem," Morrie repeated, his eyes twinkling. "A love poem...about a red boat...or maybe a ship. I think you'd like it."

Mary blushed and turned away, thumbing through the old card catalogue for "ship" or "boat" and references to the color "red."

Here is where the family legend goes fuzzy. To this day we don't know with certainty whether Morrie was joking or truly got the words wrong.

"The Rubaiyat!" Mary exclaimed, the answer coming to her suddenly, an inspired and flirtatious realization.

"That's it!" agreed Morrie.

And Rabbi Haddas married them, and they had five children, and they were together for more than 50 years.

"Rise up my love, my fair one, and come away."

That Song of Songs is powerful stuff.

The Intimate Cues of Primitive Urges

Steven Schlozman, MD — Tue, 10 Feb 2009 20:26:48 +0000

postamble();

The male black widow has to endure many injustices. A fellow can't be called a widow, for example, even before his has met his mate. This must tug even at the primitive sensibilities of an arachnid's pride. Worse, he is teeny, especially when compared to his female counterpart. The sexual dimorphism of nature is particularly pronounced in this species, so that while the women-folk widows are dreaded for their shiny red hour-glass warnings of significant neurotoxicity, we humans will scarcely even notice the male unless we are accustomed to looking twice at what first appears to be dust in the dark corners of our basements.

Not that it would matter. His bite, unlike hers, is as harmless as the nibblings of a lady bug. Worst of all however, he must endure a good deal of mythology and lore with regard to his sexual habits. Sexual cannibalism, the process by which females devour the male after mating, is widely and erroneously thought to occur among this species. The male still must approach carefully, but when he manages to mate he almost always escapes to see another day.

You see, it is all about reading cues.

There are varied reports in ethological literature, but in general the male black widow, whose abdomen is less than ½ the size of the female's, but whose legs are long and gangly like those of an awkward adolescent, must approach his beloved with a paradoxical mixture of caution and anticipation. Slowly, twittering at the thought that he might finally complete his designs of transferring his genes, he approaches the sloppily made web of his woman with what looks a bit like a dance. The trick is for him to get close enough to carefully extend one of his 8 legs and to tickle the underbelly of the female as if affectionately calling attention to the metaphor of passing time that her red hour-glass design suggests. If her mood is right, her belly full, her sensing of the sound genetic stock of her suitor sufficient, she will let him approach without eating him, and he will most likely live to see the sunrise with the knowledge that his progeny will be furthered . A wrong move, though, and he is converted to a tidy and probably unsatisfying lunch. There is little wiggle room in the tense sexual life of the black widow spider.

And yet, some might argue, we have more in common with the lowly black widow than we'd at first like to admit. Human sexual rituals are many and complex, but at the end of the day our burgeoning relationships can often seem dangerously tenuous. We have really big brains, but this can at times only muddle our perceptions, and in fact one might argue that the only plausible reason we celebrate romantic love on a day named after a presumed chaste and abstinent priest is that we are ourselves ambivalent and conflicted about how to read the tea leaves of sexual permission. Remember, though, that the urge to be close is powerful and complex, and understanding sexual and pre-sexual human behavior requires equal parts cortex and something more sub-tentorially located. An incorrect interpretation can lead us to believe that we are marching along a very different narrative than reality suggests. This is not always our fault, but the consequence of misinterpretation can be painful, or funny, or painfully funny. Such is the nature of the human condition. Consider the following story:

When I was in my first year of residency training, I escaped on a camping trip to the San Juan Islands near Seattle after suffering a particularly nasty break-up with my girl friend. (She dumped me for a surgeon...) I brought my guitar and rented a cabin which was called, ironically and presciently, "Lower Karma." The island had natural hot springs which were proclaimed "clothing optional," and when I wandered down there the first evening under the growing Northwest mist, the steamy pool was filled with young, frolicking naked people.

I shrugged, removed my bathing trunks, and stepped into the rocky enclosure. Almost immediately a woman approached me and began giving me a back-rub. I smiled at my luck, even congratulated myself on the rapidity of my rebound. However, just as I was getting relaxed, I realized from the conversation among the people in the water that they all knew each other in some way. I perked up and gleaned that they were there for a wedding. Some were friends of the bride, some of the groom, and they had rented a few of the cabins on the island. What to do?

I waited, aware that I really had no choice now but to let the sad story play out its own tragic, unique course.

"So, how do you know Sally?" asked the young woman who had worked her way to my mid-back, kneading my stiffening muscles with increasingly uncomfortable intimacy.

"I don't know Sally." I responded.

"Oh, so you know Jim!" she exclaimed.

"Nope, don't know Jim either," I guiltily admitted.

She pulled her hands away quickly, as if I had leprosy or some kind of oozing lesion.

"I, uh, guess I'll go back to my cabin now," I mumbled, the whole crowd staring at me with that look that we reserve for deviants and miscreants.

"That would be good," said one of the men, taking on his role of alpha male with particular gusto.

I hunched over and used my hands as fig leaves, reaching for my towel and covering myself with it, my still dry swimming suit left behind on a nearby boulder. Back at my cabin, I lit a candle and strummed a bit on my guitar. "How does it feeel," I crooned, imagining Dylan's wrinkled and sympathetic face. "To be on your own...."