Passing The Torch: Out with the Old. In with the New

The Doctor Off the Coast of Vietnam 1970

 The Phantom flew down to North Carolina to attend the retirement party for his brother last night. His brother had been chairman of a department at a famous medical school for nearly 30 years and five years ago had been bumped upstairs to administration of the group of faculty doctors who provide services for the university hospital. 

His duties as the president of the faculty doctors crossed the divide of making sure the services rendered were of high quality from the medical point of view,  and making sure everyone got paid as much as circumstances and merit allowed, i.e., the financial end of things.
When he started his job, he found there was a financial man already in charge of the money end, negotiating with insurance companies for the best fees, being sure doctors got paid a fair wage for a fair day's work, and no more.
The financial guy, a MBA type, was not happy to have a doctor asking a lot of questions about how things were done. Doctors are not supposed to understand fiance. Render unto Caesar that which is Caesar's.  The MBA found many of the questions from the doctor, "embarrassing." 

The phantom's brother had the idea he could learn anything, and he would not accept the proposition that to be a team player was to ask no uncomfortable questions.

This conviction, had, in the past, turned out to be naive. The brother had been asked to serve on a board of directors of a company which made medical devices. It paid $50,000 a year, or something in that neighborhood, and all you had to do was read over a set of documents and attend board meetings. At his first board meeting, brother asked a few questions about the losses sustained by the company, which had over the previous five years,  lost about three million dollars. The chief financial officer brushed aside these questions,  and they all moved on to new business, which was to vote each of the board of directors a $50,000 bonus for that year, on top of their usual stipend. How, asked brother, could you vote an increase to the board when the company had not turned a profit, in fact had lost money? The directors smiled indulgently, and said, "You just don't understand how things are done in business."
Which, he took to mean, "We have the power to rape this company and the stockholders, and we will do it as we please."

Brother resigned soon thereafter.

"I guess I'm just not cut out for the business world," he said.

Now, Phantom's brother faced retirement in his faculty group job  because he had passed age 70. The faculty group organization had a rule requiring everyone to retire at this age. Nothing personal:  It was supposed to insure fresh blood, fresh ideas continued to infuse the organization.

The question is: Do organizations benefit so much more from young minds and "new" ideas they should automatically purge old minds?

At the beginning of the Civil War, the old war horse who commanded the Union armies, Winfield Scott,  was shoved aside as an old goat unable to guide the armed forces through the coming onslaught.  When Ulysess Grant consulted him, Scott said the fastest way to win the war was to secure control of the Mississippi, cut the South in half and then turn East and tighten the noose. The general was shoved aside, but his insight was sound, and it proved the winning formula, in the end. Before the North finally returned to this plan, a whole rogue's gallery of younger generals stumbled through terribly mismanaged battles, wasted untold lives and waved their hats to adoring ranks of enlisted and civilians, riding along, their un gray hair streaming in the wind.

Eisenhower, who as President,  looked old and tired as he fumbled through passionless speechless,  delivered in a high pitched monotone, had seen the wonders of the Autobahn, as he raced across Germany during the war. He built the interstate highway system. He warned against the emerging "military industrial complex"  which he could see coming and which did not bedazzle him. He could see when forts had become obsolete, when weapons systems were being built for no good military reason, but only to fatten the wallets in a particular Congressman's district.

These old, tired men knew some things, but were ignored, disregarded because they were old and what could they know which would be of value to the new, emerging world?

The Doctor as Older Brother circa 1954

In his departing valedictorian, the Phantom's brother noted that over the course of his tenure the greatest advance in the provision of services to patients was not the advent of the MRI or the CT scan, but something much simpler.   As was true at most university hospitals, doctors from the surgical service or the medical service could sign out X rays and cart them off to a doctor's office, or a ward, or an operating room, where they often moldered, got lost and became unavailable to any other doctor involved in that patient's care who needed to see the films. 

So the department of radiology decreed all films had to remain in the department of radiology. This met with considered objection, but eventually, the rule held and the teams of surgeons, internists, pediatricians built "radiology rounds" into their day, and they gathered around the view boxes in the radiology suites where they presented the cases to the radiologists who went over each film with the doctors caring for the patient, pointed out things the surgeons or the pediatricians could not see and very quickly radiology rounds became so central to the quality of care of patients nobody could understand how the hospital had managed to function before this practice had been initiated. 

This gathering of minds, where surgeons and internists and radiologists saw each other daily, face to face, enhanced the quality of care, not to mention the espirt des corps  of the hospital in ways nobody could ever measure. 

But it was abandoned when computer technology made X rays appear on computers on the wards, in the operating room suites and on tablets carried by doctors on rounds. 

Now, the radiologists sit alone in their offices, reading films, surgeons look at the films on the wards, intensivists never leave the ICU, and hospital doctors have returned to the old ways of isolation. 

Beyond that, doctors leave patients mid-crisis when shifts change, and doctors are no longer paid by the patients or by their patients' insurance companies, but by the companies which hire them.  An odd, if not perverse, set of incentives has emerged.

All this is unappreciated by new doctors and new MBA's who have never seen how a hospital could function when there was cross pollination of surgeons, internists, pediatricians, critical care doctors, all swirling through the same place--the radiology suite, like herds coming to feed at the same water hole. 

Oh, well.  The torch has been passed. The new crew, the young and the vigorous are taking up the flame and carrying it forward. 

They will make their own mistakes. 

Grease at the Ogunquit: The Ethical Time Warp

Last night, watching "Grease" at the astonishing Ogunquite theatre, the Phantom spun into confusion.  The musical began life as a non musical in Chicago but was quickly reworked for off Broadway, in 1971. 

This was a year in the building wave of revolution in sexual mores in America, and it is difficult to remember, sometimes, where we were then, psychologically.  But, now, in the age of relentless drumbeat about "date rape" and "No means no," the pivotal epiphany scene of "Grease" is an unabashed attack on saying "No."

In this scene, the heroine, Sandy, who has rejected having sex with her boyfriend in a car at the Drive In movie, is rebuked by Rizzo, the sexually liberated, and very sexually active femme fatale, for rejecting love.  Rizzo, at that moment, thinks she is pregnant. We are told she got pregnant when the condom broke, and her lover was not her boyfriend, such as she has a boyfriend--she maintains she can have sex with whomever and whenever she pleases.  Sandy expresses her regret that Rizzo has gotten into this sort of trouble, and Rizzo launches a full on frontal assault against Sandy and her sympathy.
      It's not me, who is really to be pitied, but you, Rizzo declares. "There are worse things" she says, than getting pregnant.  You can behave badly, teasing boys, flirting with them when you have no intention of having sex with them, leading them on and disappointing them and, worst of all, not experiencing real passion yourself.
     Sandy is enlightened by all this, and with Rizzo's help, she transforms herself into the greaser's dream girl, and she appears in sexy, black leather slacks in the grand finale, strutting around provocatively, and promising to deliver on the promise of sexual consummation. 
     So, Sandy's declaration of "No," which her suitor honors in the car, is portrayed as a nasty and dishonest rejection of life, joy and the American way.  She is brought to the threshold of sexual gratification and honest man/woman sexuality.
    Now, the Phantom is with Rizzo's basic argument in some ways:  The Phantom spent a good part of his teens searching for girls like Rizzo, and being confronted with preconditioned, striving girls who had been prepared for his amorous advances by all the might of parenthood, adult authority of church and state.  
    It is true, the Phantom admired and valued girls who were strong and daring enough to reject all that  indoctrination and launch into sexual adventures. But he also recognized most of these sexually liberated girls--the "early adapters" -- had no long term plans,  and when they got pregnant, these girls thought that ought to result in marriage, a baby and dropping out of school.
     Even then, the Phantom recognized the girls who withheld were typically focused on graduating from college and launching careers.
    What he was searching for was the girl who saw she could do both.
    But he did ultimately accept, when a girl was not ready to have sex at the drive in, even if she had been tacitly promising to "Go all the way," it was her choice to chicken out. 
    The message of "Grease" is that decision to stop things in their tracks is a moral affront, a personal and ethical failing, as surely as the paratrooper who freezes in the door of the airplane and refuses to jump, a failure of nerve and an act of cowardice to be despised, a "worse thing."
    The argument, from the 1970's sexual revolution, is an interesting one today, in the setting of the tidal wave of opinion which supports the college girls who get so drunk they cannot even recall having sex, but then file complaints of rape against the boys who had sex with them while they were in no condition to resist.
    What would Rizzo say about them?

Nurse Jenny Lee: I need to care. I cannot ration it, or turn it into an efficiency.

"I cannot turn it into an efficiency."

Once again, "Call the Midwife"  focuses on an essential truth,   missed by all the American doctor/ nurse/medical shows about the rapidly evolving world of medicine. It is a truth about the tension between efficiency and affection.

  Nurse Lee has returned to nursing, after a time out to recover from the death of her boyfriend. Rather than return to the East End midwifery service which provides home care and home deliveries, she opts for something of a new start at a busy London maternity hospital, where the National Health Service has designed large wards to deliver maximally efficient care to large numbers of women. 

To accomplish maximal efficiency, the tasks related to labor and delivery are divided, much as one would do on an assembly line, and Nurse Lee finds herself providing pre labor care on a busy ward, but once the mother to be  actually goes into labor, Lee has to hand off her patient to the delivery suite people; the mother is literally wheeled out of the ward, from one point on the line,  down to the next. Lee finds this loss of connection to the patient wrenching, as do some of the patients,  who came in frightened but are calmed by Nurse Lee, but once having established a connection, they are separated and hauled off to the next team for delivery. The laboring women are thus treated like partially assembled automobiles on the assembly line: one worker rivets in the door, the next puts on the tires. 

When Lee volunteers to stay after her shift has ended, to follow a patient who has become particularly attached to Lee,  the Sister (Head Nurse) rebukes her decisively and orders her off the ward.  What? You want to attach the tires, too? You'll wreck everything. 

Of course, the same thing is happening now in American hospitals, where, owing to Libby Zion laws, residents are sent home at the stroke of end of shift, no matter where they are in the care of their patients. 

It is not easy to dramatize what this shift work, division of labor does to patient care, but  "Call the Midwife" was able to do this artfully and persuasively and in the end, Nurse Lee gives the Sister (head nurse) her notice,  and says she is going back to the humble practice in the East End. She says, "I respect enormously what you do here, but I need to care. I cannot  ration it or turn it into an efficiency. That will never be my way."  She simply needs to connect with the mother and child and see them through to the conclusion.

Her statement, the most powerful indictment of bean counter care ever to be launched across the public airways, is delivered without bombast or even much drama. It is a simple, honest statement of faith in the old time religion. The choice of words is deliberate, precise and effective. She does not say, "that is just not my way." She says, "That will never be my way."   A subtle, but distinctive difference. She is not simply making an observation about herself, but a statement about the way things will and ought to be into the future, because that is the right way and always will be as far as she is concerned. Most of the viewing audience probably missed it, but  doctors and nurses leaped to their feet, in front of their televisions,  and cheered. 

There, she said it. Finally, someone has said it. 

So, Nurse Lee gives up her much prettier uniform, and her more plush and prestigious surroundings and goes back to the East End, where the midwives dress in simple, unadorned blue frocks and burgundy  cardigans and she is welcomed into the warmth of her adoring friends and patients, and we can feel the satisfaction of human connection triumphing over glossy material  attractions.

They need to care. 

This is what American doctors and nurses are confronted with now every day: The money drives everyone toward a division of labor, breaks down the complex tasks once done by a single practitioner,  into a series of billable tasks,  done by technicians, swiping bar codes from medication carts in front of portable readers on the wards. 

  Making a car lovingly by hand, one at a time cannot compete with the cars churned out by an assembly line. But delivering health care is a service, a process between people and efficiency demands detachment, and can be taken only so far before some crucial bonds are broken. So a patient seen by a doctor who used to do the history, then the physical exam, then the sonogram, then draw the blood, write the prescription and give the final instructions, that patient is now seen by a succession of technicians and her contact with the doctor is limited to 10 minutes. She develops a relationship with no one,  but  the tasks get  done, by robots, more or less. 

The Phantom is reading Stephen Ambrose's "D-Day" in which he explores the differences between the Brits and their American allies,  which came into bold relief once Americans flooded into Britain prior to the invasion of Fortress Europe. The Brits thought the war might be won after all, using "American brawn and British brains." They sensed what the Phantom had sensed--the Brits are simply brighter than we are, at least in some ways. Certainly, their television can be. 

Nurse Midwives at home in the East End

Memory : Daniela Schiller and the Spotless Mind

Clouds over Amesbury, Massachusetts

Reading "Dr. Faustus" in college at age 19, The Phantom was struck by a line from Mephistopheles,  "The greatest hell is remembering happier times."

Why, at age 19, having had fewer memories, and having so many new memories lying ahead, this struck the Phantom so powerfully is hard to say.  It may be that, even then, the Phantom appreciated the centrality of memory to what makes an individual, an individual. 

Now, in this week's New Yorker, a piece by Michael Specter about a memory neuroscientist, Daniela Schiller, addresses, once again the nature of memory.

That memory is fallible, mutable, not to be trusted is a clear message of the work of Elizabeth Loftus, who was vilified by lawyers who had a collective fit over the emerging truth from science that blew out the foundation of their clients' testimony about "recovered memory" in cases where adults sued priests, teachers, parents and other assorted adults, who the plaintiffs now recalled had raped or otherwise sexually abused them as children.

Hollywood has, of course, tried to market the essential elements of the discussion: "Eternal Sunshine of the Spotless Mind" proceeded from the fascinating premise of two people who had had a doomed love affair and decided to expunge that memory by use of a commercially available treatment in some future time. Of course, they meet again and are drawn to one another all over again, not knowing they've been down this path before.  "Total Recall" exploited the notion that once the adventure is over, all you have left is the memory, and so why bother with the risks and uncertainties of the adventure when you can have memories of the adventure in your brain? You've had a virtual experience.

Great Boar's Head, Hampton, NH--Obadiah Youngblood

As there is more road behind the Phantom, than that which lies ahead, memory has been more on the Phantom's mind.

When he was 30, the Phantom realized he has some important memories about the cancer wards at Memorial Sloan Kettering and he published a novel about them. That was a significant violation of the code of silence among physicians of that era, and the Phantom was rebuked for trying to exploit private experience, for violating the privacy of (even un named) patients, of selling out colleagues and his former teachers.  But the Phantom wanted to "remember" it all before he forgot it. And the experience had been traumatic, and writing about it was therapeutic.  Fine, his former friends said, write about it and then destroy it, or keep it but don't display bloody linen in public. Why publish?

Because, the Phantom said, the public perception of doctors, of what patients face in hospitals is all wrong and is perpetuated by what is publicly available. This was all before "ER" and "Hopkins 24/7" and a whole variety of "reality" TV shows based at Cornell and Columbia medical schools and courses at medical schools about "narrative medicine." What was then an anathema, a violation of trust, has now become a whole industry within medicine of presenting the "real" story of doctors and patients. After all, it is now argued, why should we allow people from the outside, Hollywood people to tell our story? They always get it wrong. Let's tell it right. Sunshine is the best disinfectant.

Now, it is perfectly okay that doctors give up their careers in medicine to go to Hollywood and write doctor TV and movies and reality shows.

One thing about revisiting memories which the Phantom wrote down half a life ago, after many years, is the shock of reliving experiences as they were recalled then. The memory of patients, the details of how they suffered, brings back the experience and scrubs off the patina from those memories.  We often remember painful stuff in a way which is easier to live with now, and we make marble statues which show no warts or blemishes,  but when you have a record written at the time, those details emerge to dissolve off the smooth surfaces down to the cracked and uglier  stuff beneath.

View from Plaice Cove, Hampton, NH--Obadiah Youngblood 

The last scenes of "Partial Recall" are so affecting because they are simple and the reason for Daniela's father's silence about his experience in the Holocaust becomes so obvious, one wonders what sort of Dr. Faustus dilemma is emerging for all of us as we learn more about memory. Dr. Faustus sold his soul for knowledge. He was willing to suffer eternally to see the truth, to gain knowledge.

Rte 1 A North Hampton--Obadiah Youngblood

 What Dr. Schiller is learning about memory is uncovering, reliving horror, may not be as cathartic as Freud once claimed. Suppressing or even changing terrible memories may detoxify them. 

People from Rwanda to South Africa to Israel to Germany have known this all along.

Hampton Snow Storm 

So Did the Fat Woman

Sarah Baker 

The importance, or lack of importance, of feminine pulchritude  is a topic the Phantom thinks he has already spent way too much time on--but since he has devoted some space to it and since Maud responded in  her customary rapier cut style, it is hard not to say something about the Louis CK episode, airing tonight,  about Louie's rejection of a fat woman, as he, a portly man himself, pursues movie star thin beauties. 

In the clip the Phantom heard on NPR the woman remarks, "You know I flirt with every guy who comes into this restaurant. And you know what?  The really drop dead gorgeous guys, the movie star good looks types, they flirt back. They are confident, loose and  easy. It's the fat guys who get uptight, who never flirt back, who would never be seen with me. Those are the guys who don't have the self confidence, who need to be seen with the super models."  

Or words to that effect.

And, not having seen the episode, but just having heard the clip, I suspect that observation has cut to the heart of the matter. 

Who Can Find A Virtuous Woman?

Van Gogh, Landscape at Twilight 1890

During the 1960's and 1970's Gloria Steinem and other women's liberation gliteratti  railed against men who desired women as "objects," by which they meant, they loathed men who lusted after women for their bodies, and who wanted those bodies to have no offensive or even strong odors, or blemishes or any real attributes of humanity.  The nude women of "Playboy" were air brushed clean of moles, stray hairs and wrinkles.  The "Stepford Wives" became the ultimate expression of what men were said to want--perfect robots of obedience and devices of pleasure.

It struck the Phantom then, and still strikes him as odd,  that women would demand men develop a different set of desires.  Who are these women to tell men what they should desire?

On the other hand, they had a point.  Men pursue in women not a human being, but an ideal and that is a doomed quest. Women, of course, do the same thing--they just have a different list of attributes they are looking for. 

On the other hand, what Steinem et al missed was what made women really attractive to men. Certainly not the sweet Geisha girl, who only smiled and bowed and aimed to please. Ugh. Of course, some men likely did dream about the living Barbie doll who had dimples but no odors, who were like adoring daughters, and who never criticized or belittled but only admired and praised their men.

For the Phantom, Myrna Loy (from the "Thin Man" series) had the right stuff--smart, unflappable, nervy and irreverent. She was not perfect. No human being is, but she was very attractive.  Beryl Markham, who wrote "West With The Night" had that right stuff, as did Brett Ashley, who had no intention of being restrained in her sexual pursuits, who had supreme self confidence. Sylvia Plath's "Bell Jar" spoke with a voice which set the Phantom fantasizing. Why did he not run into some Sylvia  Plath in all those East Side bars he haunted during medical school? 

"If you ever did meet a broad like that, "one of his friends told him. "She would have absolutely no interest in you."

At least such women provided a notion of virtues to be recognized.  The problem was, these women were largely obscure in those days and even now.  How can men know what they might be drawn to, if they never see such women? The Phantom scrolls through the heroines of today's fiction and current headlines and finds precious few models. Gail Collins has wit, but she is a byline, unseen.  Hillary Clinton? Please. 

Taken to a different level, there is now a movie about a man who falls utterly in love with a virtual woman, a voice on a computer, the creation of his own mind. But that is not even the most famous idea of a women who has no flesh and blood but only dialogue and image: Jessica Rabbit, the femme fatale, who seduces real flesh and blood men.  There was that "You've Got Mail" woman who Tom Hanks falls in love with and turns out to be Meg Ryan. He falls in love with a part of a woman, which is what happens now when couples exchange emails and even photos on line and have a "relationship" long before they physically connect.  Even in traditional courtship, both women and men with hold parts of themselves as they dance around each other, so how different is the with hold in on line courtship?  Plenty, I'd say. 

The husband of a woman I know asked for a divorce, sold his share in the house, dropped everything to move to Thailand to link up with the girl/woman of his computer dreams.  You don't need to be board certified in psychiatry to see the neurosis there. But how far is he from the legions who are computer dating now?  

This cultural  phenomenon does suggest, however, at least some men are not seeing women as objects as the women's liberation scions of yore deplored. In fact, these men are connecting mostly blind to the physical woman they are falling for. 

But what attributes have attracted these on line Lotharios?

If Marilyn Monroe was the most desirable woman of her day, with her child like whisper and her ingenue roles, if she was laying down the blueprint for what men want, then who is doing that for men today?

It is curious.  Where are the women who can launch a thousand ships today? You know they are out there. But why are they hiding their lights under bushels?