emotion trumps reason

     I had this list of topics that I found fascinating during lectures but somewhere along the way, I just never got around to exploring them.  Time to rectify that.  The first one is about the amygdala.  A bit of basic background before watching the movie below.  When we learn information, there are two components to how that information is processed.  The one most people would guess first is just the simple "What" pathway.  It is concerned with determining factual memories.  The apple is green.  Like the classic Dragnet, just the facts ma'am. 

     The other is the associative pathway.  That is the primal part of our brain that takes facts and associates them with feelings and emotions.  It's really our "gut feeling" that kept our ancestors alive.  You see, when Grog the caveman happened upon a lion, his brain doesn't really have time to go through the cognition of my eyes see a lion.  Lions are dangerous.  I should probably hide.  That takes too long.  So the brain short circuits the higher thinking and develops emotive visceral responses that cause us to act instantly.  It's the part of the brain that can also take logical facts and turn them on their head.  For example, when I was a kid, I loved canned pears.  One day, I ate a whole can and then jumped on my parent's bed a little too exuberantly.  Those pears along with every bit of my stomach contents decided to seek residence in a bucket, in the toilet, on the bed, everywhere.  To this day due to simple Pavlovian conditioning, I cannot possibly eat or even smell canned pears.  Logic has nothing to do with it.  Visceral emotion trumps reason.

As I said, emotion trumps reason nearly every time.  For better or worse.  When we get married, most people don't make a logical assessment of their potential partner.  We react emotionally and the amygdala is part of that process.  As I see my brother become viscerally ill at even the thought of MDACC and chemo, I can see how strong that association really is.  And I wonder, how does a physician help that then?  Yes, there are anti-emetics and there are cognitive therapies but those are pretty ineffective when it comes to these associations.  There is a pretty strong evolutionary drive to make that neurological wiring work well.  Without it, our ancestor wouldn't survive too many encounters with dangerous plants and animals.

summer

     I've been asked the question quite frequently, "what are you going to do with your summer?"  My first gut reaction was, "not a damned thing."  Typically, med students do one of three things.  They either do research, a preceptorship or they travel.  Research?  Been there, done that and see no reason to do any measly experiments only lasting a month or two.  Hell, we used to have projects that'd go for years and more than half the time the experiments didn't work properly.  Preceptorship?  It's more clinical exposure and that interested me.  Unfortunately, my class seems to be rich in gunners and overachievers because by the time our advisers had gone over the program, they were already full.  Scratch that.  Travel?  Going to Guatemala and working in a clinic, while interesting, isn't exactly practical in my situation.  Besides, I scratched that itch to some extent in college.

     And as I pondered it some more, I don't really want to accomplish anything this summer.  The question is more properly framed as what do I want to experience?  When I ask it that way, it became a bit easier to answer and it breaks down into two parts.  There are purely selfish desires and I mean that in the best possible way.  And then there are ones that focus on relationships, two specifically.

     For myself, I want and need to recharge my batteries.  And that means paying attention to the more creative side of me.  It'll involve some hiking and kayaking trips, some by myself but some especially with my son.  His Leydig cells are really starting to pump out the ol' testosterone so he's keen on hitting the wilds in a very masculine and primal way. 

     I'm also going to read.  Before med school, I started reading the Modern Library's Top 100 fiction in english during the 20th century.  Some like Lolita or Heart of Darkness, I found abysmal.  I would recommend those only as punishment.  Others, like The Heart is a Lonely Hunter (obviously given the title of my blog) or Of Human Bondage I found moving and beautiful.  In no small way, those books will impact my abilities as a doctor more than many of my classes.  Great writers know the human condition in ways that medical school simply cannot teach.  So I'm going to plow through some more after just finishing The Catcher in the Rye.  It had some interesting aspects that I can relate to being a doctor so that'll be a separate post.

     But as I get older, relationships become more important.  Since I'm not gainfully employed doing research or a preceptorship and I can't use the excuse of "I'm studying", I needed some way to bring in a bit of change.  My dad asked me, half jokingly, if I wanted to mow yards like old times.  Now, you must understand that I hated mowing yards and have absolutely no desire to go back to doing it.  But, when I did do it, I got to know my dad in a way that I never had before.  In between lawns, we'd sit and talk about philosophy, religion and the meaning of life.  I can remember commenting on how surreal it would be if someone were to happen upon one of our conversations.  Here were two blue collar, no, that'd be more a brown collar from the dirt if there even was a collar, who for all intents purposes look akin to those workers smuggled across our Texan border to mow yards, but we were debating Calvinistic theology.  That exchange would be fun to revisit now that we're both at different stages of our lives.

     Since my brother's diagnosis of carcinoma, I've tried to be his staunchest advocate in the foreign language that is medicine and that meant setting aside my emotions many of the times because that's what was required.  Since he's just a little halfway through chemo and doing great, I feel like I'd like to take the white coat off a bit and just be his brother from time to time.  Over the past couple of weeks, he's really opened up and I'd like to get to know that side of him more intimately.

     So, yeah, I guess I do have some things I want to do this summer.

health wednesday

The older I get, the more curious I get about eastern modalities with respect to health.  I've especially become interested in their relation to cancer for obvious reasons.  But I'm also a western empiricist so any therapy that works should well,....work.  Any therapy, east or west, conventional or alternative, etc should stand up to the rigours of empirical testing.  I separate them into what works and what doesn't.  I don't care as much about the explanation as the pragmatic effect.  Whether it's energy or molecular switches doesn't matter.  Yoga is one of those modalities that has held up pretty well to what little western scrutiny that has been applied and it's been something I've been trying to get my brother to try.

This study to be presented at the American Society of Clinical Oncology looked at the effect of yoga on sleep quality.  I hate to link to a glorified press release and not the actual study, but the study is intriguing in its approach.  They took breast cancer survivors and had them perform a specific yoga routine twice a week for a little more than an hour during each session.  Researchers claimed that the yoga group had improved sleep quality, reduced fatigue, and they reduced the amount of sleep medications required. 

I have only one big question.  Is there something specific about yoga and any benefits it may confer?  In other words, how would the quality of sleep compare to different types of exercise performed twice a week such as walking, swimming, weight training, etc.  Is it exercise in general or is there something unique about the rhythmic breathing involved?  My hunch is that while just about any exercise in general is good, rhythmic deep breathing may have effects on its own based on some other data.  MDACC apparently has received a grant to begin to investigate the meditative breathing and the effects on stress.  We'll have to see if maybe my brother could tap into that study.  WebMD also has an article covering the study.

back

     Long time no blog.  I had my finals, my brother's CT results and then we had a family reunion down at the beach at Galveston.  So everything was a bit of blur there for a couple of weeks.  As my son told me last night after partying with his cousins for the past 5 days, "I need a vacation from that vacation."  Indeed.  Probably the hardest thing was I got my first Pass grade (they have been Honors or High Pass up until this point).  Missed High Pass by a measly 7 tenths of a point in Neurology.  I'm just average.  I'm also just kidding.  Sort of.  I hardly studied at all for that class so it was actually quite reassuring that even a half-assed attempt can be sufficient in the classes that I don't care for.

     So now I can refocus and blog on some topics that have been ruminating for awhile now.  I can sit back and digest my journey towards becoming a physician and be able to pursue cancer topics with a bit clearer head knowing the tumorous bastards are half the size they were before.

quiet

A stillness falls.  It's 10:30 at night and I'm on the second floor looking out over MDACC watching the shift change as individuals in blue scrubs file out.  Gone is the hustle and bustle of the activity during the day.  Not us.  Three more hours of chemo to go.

The last 8 weeks, well really the last 8 months, has been a blur.  It'll probably take me that long again to sort out all how I feel.  Med school was....well, school.  All of the challenges were mental - not in the sense of intellectually difficult (though yes, it is difficult) but in the sense of metaphysical.  It all boiled down to the question, "can I do this?"  Before deciding to make the plunge into med school, I did about a year of intense psychoanalysis with a psychologist who could not have been a better fit for me (I picked him because his website had a quote from Hermann Hesse but that's a story for another time).  And in the final visit, he told me a simple story that I will carry with me the rest of my life.  He spoke of patients in nursing homes wrestling with the pain, the sorrow, the anguish of disease at the end of life.  In the end, we all face these same questions and fears.  The question is as old as time itself.  So why not face it now?

So, here I am.  The question, "can I do this?" is still here.  But in a way I never imagined.  Now, it refers to my brother.  To life.  Can this be done?  The primary tumor shrank ~50%.  Only about one in five of patients respond in such a fashion.  A collectible sigh went through the room and tears began to flow, this time from relief and joy.  But in looking down the road, the doc said that we're still not clever enough to figure out how to get the tumors to disappear completely.  The best he's hoping for is to shrink and stabilize them.  But, can more be done?  It's a great thing when you learn that you're still able to surprise yourself.  You begin to question what else is possible.

I now realize that if I'm honest with myself, I'll never reach a point in life where I'm so self assured that I still won't have fears that tremble me to the soul.  Life never yields us enough experience to become so sagacious.  But oddly it does not leave me with a sense of hopelessness or futility.  Instead, it stirs me to passion.  While gazing out the windows peering out on the med center, I'm reminded of Frost's poem.

shrinkage

Fifty percent reduction in primary tumor size with improvements in the bone mets.

mephistopholes, part II

At the beginning of my medical training, I was a razor's edge from walking away.  My wife was the one who held fast.  Rough times, those.  Heated exchanges took place.  She believed there was a purpose to it.  Call it a hunch.  And in the end, it was fear that held me back.  Fear of the weakness within me.....which is so rich in irony.  To most people I come across as confident.  And I've learned confidence for me is not absence of fear.  It's recognizing your demons and continuing on anyways.  That ain't easy.  For me, my demon seems to be an inherent glitch in who I am.  My upbringing was great and I never suffered any tragedies so nothing to blaim there.  I only half jokingly tell my wife that I'm a genetic roll of the dice that comes up craps.  Yes, I'm smart and yes I've been blessed with an ability to unravel complex problems.  But in return I'm also afflicted with dark moods....and I mean dark existenstial angst.  (More irony as my name means "laughter".)  I've experimented with different approaches - psychotherapy, medication, denial, wishful thinking - and though some get me further than others, each runs out of gas at some point.  When I finally decided to stick it out with my training, I now realize that I made my own deal with Mephistopholes.  I will not run from them.  Well, not so much that I won't, but I can't run fast or far enough anyways.  I am forced to suffer and embrace those dark moods and in return, it seems I will know the dark nights of the soul that accompany a patient who is suffering.  It's not sympathy as I seem incapable of feeling that emotion.  It is a scar. 

And so in response to my brother who says 

But I have not thought of myself as brave in this situation. I am simply doing what I need to do to give myself the best chance of living. Who wouldn't do that? It seems like a natural response.

I tell you that not every patient has that strength to go on.  I know what that feeling is to give up.  If not for my wife, I would've given up with med school.  No, that's not a life and death decision but to my soul, it was.  I will forever be endebted to her.  If I had given up, it would've meant giving up on all that is me.  And if you listen closely, you will see others around you that have walked that razor's edge wondering if one more breath is truly worth it.  Only by the endurance of those around them did they survive it.  And sadly, some do not.

mephistopholes, part I

After the past two rounds of chemo, it's taken my brother ~7 days to return to a pre-chemo state. He's then granted a reprieve of 14 days of lucidity before the next visit to hell to make a faustian deal with chemotherapy. That will occur a total of 6 times over the course of about four and a half months.  And I wonder, where would each of us draw the line?  One week in exchange for two?  What if it's two weeks for one?  For my brother, it is worth it.  At least it seems that way to me.  After just two rounds, he's forsaken all pain killers - vicodin, morphine, hydrocodone, celebrex, naproxen, even ibuprofen - all of them.  To me, it means the tumors are no longer impinging on other structures to create pain.  But there are four more deals to make with Mephistopholes and his retribution will be greater each time.  If one takes other patients with his disease, most are getting milder chemo and/or only four cycles of it.  I suspect the limiting factor is the ability to endure the chemo.  He's having the equivalent of the Somme thrown at his body with 4 more waves to come. And I wonder, how many of us would be brave enough to make that exchange.....

interpreter

One of the roles I play is interpreter.  It's still a bit of surprise to me how much of a disconnect there is between the doctor and the patient but they really are speaking different languages.  Not all of that is the physician's fault.  I do think there needs to be a manual entitled, "How to be a good patient".  But right now, I'm the go between.  One of my brother's questions was whether he should take a multi-vitamin.  The oncologist suggested it might be a good idea and I disagreed.  Neither one of us seemed to have a terribly strong opinion either way so I thought I'd go back and review the literature regarding vitamin use.

So is there a role for multi-vitamins in general?  In certain instances, there appears to be.  Pregnancy comes to mind.  Since the implementation of prenatal vitamins, neural tube defects have decreased.  Interestingly, a meta analysis concluded that there was a trend towards a decrease in pediatric cancers in those situations where the mom took a prenatal while pregnant.  Certainly in cases where malnutrition exists multivitamins can help.  But when I look at the data from large populations where food is plentiful, there doesn't seem to be much evidence that the ingestion of a multivitamin helps to prevent cancer.  Some studies find an actual increase such as this study that showed a very mild increase in breast cancer in Swedish women.  Or, the often referenced ATBC study where heavy smokers randomized to beta-carotene had a 20% higher chance of developing lung cancer.  Likewise, the CARET study found that in smokers or asbestos exposed workers, those taking beta-carotene and vitamin A had increased lung cancer rates.  The Physicians Health Study took ~11,000 physicians and gave them beta-carotene while another ~11,000 of them received a placebo.  Approximately 10% were current smokers and ~40% were former smokers.  No effect on either cancer rates or cardiovascular disease were seen.  The Woman's Health Initiative looked at ~90,000 women in an observational study and nearly 70,000 women in interventional studies.  It did not find any effect of vitamin intake on cancer, heart disease or mortality.  Most of the data showing benefit are in smaller populations or in malnourished people.  All in all, the data seem sketchy at best with respect to cancer prevention.  There doesn't seem to be a clear benefit and in some cases liker smokers or asbestos exposed people, they may make it worse.

All of those trials were prevention.  But what about as an adjunct to therapy?  One argument for it is that chemo is incredibly rough on the body for a hole host of reasons.  On top of that, the patient is often not eating so it's not a stretch to conceive that the patient is becoming malnourished.  But there just aren't any good data to say that supplements are the way to go for someone who is able to eat.  The American Cancer Society recommends  that patients get their nutrition from food but a multivitamin "is a good choice for anyone who, for whatever reasons, cannot eat a healthful diet."  They also outline where in certain cases, supplements are warranted based on blood levels of vitamin D, B12, etc.  No argument there.  If there is diagnosed and a quantifiable deficiency, then it is reasonable to supplement it back.  The National Cancer Institute concludes "there is no scientific evidence that dietary supplements or herbal remedies can cure cancer or stop it from coming back.  The NCI strongly urges you to depend on traditional, healthy foods for vitamins, minerals, and other nutrients."  The oncologist referred to one interventional study but I haven't yet been able to find it.  I think it was in the context of B12 deficiency.  I'll have to get the specific trial next time we're in the office to give the matter a thorough consideration.

end of the line

I'm just a few days from the end of the first year and I find myself feeling nothing what I expected.  Elation, relief, satisfaction.  None of that, really.  And I'm not really sure why.  I could very easily say it's been overshadowed by my brother's diagnosis with cancer but I have difficulty with admitting that.  In a strange way, it's almost a cop out to feel the way I do.  But realistically, it's been daunting. 

As I write this, I'm struck by a realization (which is why I write).  I have felt this way once before.  It was after my wife finished her master's degree.  Never much for planning, we did our life a bit backwards.  We had our child rather young.  My first job out of college paid a whopping $20k for a family of three.  My wife was going back to school at the time to finish her bachelor's degree.  I worked not just hard, but smart starting at the bottom of the bottom.  I achieved some goals in the workforce that made me feel good.  But beneath it all, the primary motivation was supporting my wife and child.  When my wife finished her master's, it suddenly all felt different.  While I was still the main bread winner, we could breathe a big sigh of relief being on sounder footing.  And I realized two things.  One, I no longer wanted to do what I was doing.  It was immensely rewarding and I wouldn't hesitate a moment to do it again but it was no longer enough.  Two, I felt tired.  I felt an exhaustion that went emotionally to my bones. 

So I was left with two opposing forces.  One wanted to wander out on a new path.  The other felt dog tired.  And I guess that's what I feel now.  Through the diagnosis, the doctor's appointments, the screw ups, everything....I can now say my brother is completely off his pain meds after just two rounds of chemo.  Part of me wants to follow the logical path of where that leads, ie smaller tumors.  The emotional part finds it a bit harder to follow down that road.  I guess I'm not so cold after all.  I'm still afraid to get my hopes up, even though the rational part is telling me the first step of the journey is almost done.  We'll know next week after his CT scans.

So as before, I'm left feeling emotionally depleted and so not quite emotionally ready to wander off down the next step of my medical training.  I think my wife was right when she said I need to disappear off into the woods for a few days.  But back to studying until then.

different perspective

The 2nd round of chemo was graced by the presence of my wife sitting quietly in the corner knitting.  (I garden and she knits.  We've GOT to get some hobbies that aren't associated with nursing home age people.)  Afterwards, I asked her what she thought of the doctor.  Keep in mind that my wife and I are night and day, sun and moon, wet and dry.  We couldn't see the world more differently so whenever I want an honest perspective that I know wouldn't have occurred to me, I asked her.  Never knowing quite what to expect, she still suprised me by her one word answer.  Arrogant.  That's it?  Yup.  Huh.  I never saw him as that.  I was completely oblivious to it.  If I had to describe him in one word it would be 'competent'.  It ain't braggin' if you can back it up, after all.  Yes, he's cold and his bedside manner is not exactly effusing with warmth.  But hell, the man's got my brother on the most aggressive therapy, listens sincerely to any concerns we have, and even entertains my utterly naive oncology 101 questions.  I'll take that over warm fuzzies anyday.

And then it hit me, "you do realize that I'll be the same type of doctor?"  Yup.  Wouldn't be the first time I'd been accused of being aloof, cold, distant....arrogant.