Contemplating Empathy, Early This Morning After the Earthquake

Last night I began reading a long essay, Regarding the Pain of Others, by Susan Sontag. The work dates to 1993, and centers on the power of photographs of war. She considers Virginia Woolf’s earlier reflections on horrific images from the Spanish Civil War, in Three Guineas.

Sontag writes: “Not to be pained by these pictures, not to recoil from them, not to strive to abolish what causes this havoc…for Woolf, would be the reactions of a moral monster… Our failure is one of imagination, of empathy: we have failed to hold this reality in mind.”

This morning I awoke early and saw video of an earthquake rattling portions of Japan and a tsunami destroying broad swaths of land in a country where I’ve never been. I’m distracted by those images and while I’m trying to work on another subject, my mind flips back to what’s going on there, along the Pacific.

Japanese Tsunami Victims

(from Flickr: Japanese Tsunami Victims, by Logan)

So it seems like the right day to review some basics on empathy. I hope my readers won’t mind if this part is too simple. It’s just that the word is thrown around so often lately, in places like Twitter and Time Magazine, on doctors and compassionate health care; I should remind myself if no one else exactly what empathy is supposed to be.

First, a distinction: Sympathy usually refers to feelings elicited upon a mutual or shared experience; empathy involves understanding another’s experience.

A post on KevinMD by Barbara Ficarra, a few months back, led me to a 2003 academic review on empathy in clinical medicine, by Jodi Halpern, MD, PhD, who writes:

…Outside the field of medicine, empathy is an essentially affective mode of understanding. Empathy involves being moved by another’s experiences. In contrast, a leading group from the Society for General Internal Medicine defines empathy as “the act of correctly acknowledging the emotional state of another without experiencing that state oneself.”3

Halpern explains the difference between empathy and sympathy, with a distinction I was taught in a rudimentary ethics class in medical school:

This recent definition is consistent with the medical literature of the twentieth century, which defines a special professional empathy as purely cognitive, contrasting it with sympathy. Sympathetic physicians risk over-identifying with patients…

Th open-text article in the Journal of General Internal Medicine (18: 670–674, 2003) is well-worth the full read.

Meanwhile I’ve discovered measurable criteria for physicians’ empathy, the so-called Jefferson Scale of Empathy. From the Science Daily (via the Tweet, above) on a report in the journal Academic Medicine:

Researchers used the Jefferson Scale of Empathy (JSE) — developed in 2001 as an instrument to measure empathy in the context of medical education and patient care. This validated instrument relies on the definition of empathy in the context of patient care as a predominately cognitive attribute that involves an understanding and an intention to help. The scale includes 20 items answered on a seven-point Likert-type scale (strongly agree = 7, strongly disagree = 1)…

This sort of empathy rating system seems strange to me, even alienating; it’s plainly too numerical.

I’d rather stick with my feelings, and stare at today’s photographs and videos, and finish reading Sontag’s notes on The Pain of Others, this evening.

Monster Quake Hits Japan (the Australian.com, March 11, 2011)

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Portrait of a Peculiar Relationship at the End of Life

Last weekend I went to see a strange, slightly unnerving play, The Milk Train Doesn’t Stop Here Anymore by Tennessee Williams. It’s a sad take on the end of life, and desperation in some lonely characters.

Olympia Dukakis plays an aging, vain, older woman who’s dying of an unnamed condition. She takes morphine injections help her “neuralgia,” and uses liquor to entertain guests and, without success, to blunt her emotional pain. A handsome young man, presenting himself as a poet and sculptor of mobiles, climbs up the hill on which rests her Italian villa.

She’s no fool and quickly learns of his moniker, “the angel of death.” It’s said he has a particular fondness for terminal, moneyed women. Still he is impoverished; he shows up essentially starving and with nearly nothing in his sack; he has not exactly benefited from his exploits.

Darren Pettie and Olympia Dukakis

Dying alone is scary, unbearable. So she lets him in; her fear outweighs the final compromise of being used, and touched, by a stranger seeking something in exchange.

A straight read of the play might make you think it’s the story of a man who flatters older women in exchange for shelter and food. Another take might consider the man’s need or desire to comfort, to reduce another’s pain, which might be genuine while pathologic, and the pleasure he might feel in doing so.

Hard to know what was Williams’ intention in this 1963 work. I found it intriguing.

A medical lesson?

Yes, I’d say it is, especially now as doctors may become as robots. I can’t help but think of a patient who somehow and for whatever reasons alone in the hospital at the end of life, who cannot be helped by a machine. One role of the oncologist or other familiar physician, some might say, is to be there – even if paid, “on duty” if you insist – to hold the patient’s hand when the end comes.

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A Video About a Robot and a Patient

Since Watson won on Jeopardy, there’s been lots of talk of robots assuming doctors’ roles. Ten years into our future, machines with programmed empathy and nuanced diagnostic skills will solve diagnostic dilemmas, deduce optimal treatment and make us well.

Yesterday I found a new Xtranormal video, this one crafted by Dr. Charles of his excellent Examining Room blog, on Dr. Watson and the 7 Qualities of an Ideal Physician.

from the Examining Room of Dr. Charles

Dr. Charles cites a 2006 Mayo Clinic Proceedings review on what patients say are essential characteristics of a good physician: The ideal doctor is confident, empathetic, humane, personal, forthright, respectful, and thorough. In this clever, short movie crafted by Dr. Charles, the robot-doctor tries to demonstrate his capability in each of these dimensions in his interaction with a cartoon patient.

I hope the folks over at IBM, who are collaborating with real medical centers now about designing artificial doctors’ intelligence, might take a close look at this video.

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May I Call You ‘Doctor’?

Last week I considered the relationship between the Prince Albert and his speech therapist in The King’s Speech. One aspect I wanted to explore further is why the future king initially insisted on calling the practitioner “doctor.”

In real life, now, patient-doctor relationships can be topsy-turvy. This change comes partly a function of a greater emphasis on patient autonomy, empowerment and, basically, the newfangled idea that the people work “together, with” their physicians to make informed decisions about their health. It’s also a function of modern culture; we’re less formal than we were a century ago.

Patients enter the office with their own set of information and ideas about what they need. The recent Too-Informed Patient video highlighted this issue, effectively.

Doctors are human, we are painfully aware in 2011. They make mistakes and they sometimes need to have dinner with their families. They may even let us down.

When I was a young physician, my patients almost universally called me

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The King’s Speech is Not Just About Stuttering

Over the weekend I went to see the King’s Speech. So far the film, featuring Colin Firth as a soon-to-be-King-of-England with a speech impediment, and Geoffrey Rush as his ill-credentialed but trusted speech therapist, has earned top critics’ awards and 12 Oscar nominations. This is a movie that’s hard not to like for one reason or another, at least most of the way through. It uplifts; it draws on history; it depends on solid acting.

What I liked best, though, is the work’s rare depiction of a complex relationship between two imperfect, brave and dedicated men. At some level, this is a movie about guys who communicate without fixating on cars, football (either kind) or women’s physical features. Great! and, dear Hollywood moguls, can we have some more like this, please?

The film’s medical aspects are four, at least: the stuttering, the attitude of physicians toward smoking, a closeted sibling who had epilepsy and died at an early age – just mentioned in passing, and, finally, the king’s trusted practitioner’s lack of credentials.

King George VI (Wikimedia Commons)

At the start, Prince Albert (young King George VI) has a severe speech impediment. It’s said that he stutters, and on film Firth does so in an embarrassingly, seemingly extreme and compromising degree. He’s the second of George V‘s sons, and might or might not succeed to the throne depending on events in history, his older brother’s behavior, and his capacity to serve the Empire at the brink of war. Being effective as King of England in 1936, and especially at the start of war in 1939, entails speaking confidently.

Prince Albert’s been through the mill with doctors who’ve tried to help him talk. Some recommend he smoke cigarettes; these, they advise, would help him to relax and, they say, is good for the nerves. One asks him to speak with a mouthful of marbles, on which this doctor watching the film worried he might choke. Eventually Albert’s wife, Elizabeth (Queen Mother to be), finds a speech therapist in London, Lionel Logue, who uses unorthodox approaches with, by rumor, exceptional results. Eventually Prince Albert – or “Bertie” as the therapist insists on calling him – trusts and accepts help from this peculiar Australian who, it turns out, developed his methods of assisting stutterers through his work with shell-shocked soldiers in WWI.

According to MedlinePlus, stuttering affects as many as 1 in 20 children, with typical onset before the age of 5. The problem can persist for weeks or years, of manifold causes. Some families are disproportionately affected, but there’s no known genetic cause. Stuttering can arise upon emotional trauma. It’s more common in boys than in girls.

As for doctors recommending cigarettes, the concept is familiar from some old literature regarding schizophrenia. In a recent post, I included a curious TV ad featuring doctors smoking Camels. I don’t have a good sense of just how comfortable most physicians were with smoking prior to 1950, and would like to know more. Did they have their suspicions?

Finally, on the relationship between the king-to-be and Mr. Logue, it’s fascinating: Prince Albert prefers to call his therapist “doctor,” but Logue is adamant that they refer each to the other on a first-name basis. Well into the film, we learn that Logue hasn’t ever attended speech therapy school, or medical school, or whatever it is that someone who treats another person in London circa 1930 should have completed before providing quasi-medical, essentially psychological care as he did to his royal highness. Nonetheless, the king trusts Logue more than any suitably-credentialed therapist recruited by his staff. This topic – of the therapeutic relationship, trust and expectations – warrants separate attention.

Meanwhile, I hope you have the chance to see this movie, if you haven’t already. The Oscars are scheduled for February 27, just two weeks away.

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Doctors Enjoy Smoking Camels, in an Old Cigarette Ad

A new Twitter follow led me to LongartsZwolle, a blog by a pulmonologist in the Netherlands. A February 1 post needs no translation:

More Doctors Smoke Camels Than Any Other Cigarette

The clip is said, on YouTube, to be a 1949 commercial for Camel cigarettes. I tried to find more on this, first by clicking on the Camel website, sponsored by the R.J. Reynolds Tobacco Company, but the virtual age filter checkpoints asked me for too much information, so I gave up.

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Note: Using Google translator, I initially found that longarts means “lung” in Dutch. Zwolle is a city north and east of Amsterdam. But @longartszwolle clarified via Twitter: longarts means pulmonologist. – updated by ES, 2/4/11, 9AM.

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Discovering Google’s Art Project

Today’s Wednesday web sighting ranks high in awesomeness. I discovered Google’s Art Project through molecular biologist Jessica Palmer’s always-gorgeous Biophemera blog.

The find is Google Art:

The Battle of the Nile, by Philip James De Loutherbourg, Tate Collection

I couldn’t make up my mind which image to capture for this post.

So take a break and explore some of the world’s finest art collections, right at your computer. Call it a mental health exercise if you like, or just go ahead and take a look. It’s fabulous!

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The Broccoli Connection

(considering the Future of Health Care in America, and Life on TV in the Office)

This week’s NEJM is filled with good stuff.

There’s a super-extra-really important article on a new breast cancer drug, a PARP inhibitor called iniparib, for patients with triple negative breast cancer, and an accompanying editorial that matters. (Some ML readers might want to take a look at an article I wrote for Cure Magazine on new drugs, including PARP inhibitors, for treatment of metastatic breast cancer.)

There’s a perspective I still need to read on the scope of what nurses might do. Another on future nurses, and another on how to assess an ACO, which by the end of this health news-rich week every citizen should know stands for an Accountable Care Organization.

And there are some stomach-churning letters about the mammography screening debate.

But for this Friday morning, I’ll just mention the perspective piece called Can Congress Make You Buy Broccoli? And Why That’s a Hard Question. Really I think the better question is whether or not the government can force people to eat broccoli.

Michael waves a broccoli stalk in front of Kevin on the Office

And how could those NEJM authors have anticipated last night’s episode of the Office, that Michael would break HR rules by forcing Kevin to eat a stalk of raw broccoli, because he’d made a new year’s resolution to eat more vegetables? Kevin spat it out, forcefully and problematically for some viewers.

My tentative conclusion is that someone needs to teach Kevin and his colleagues how to cook.

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Regional Dialects on Twitter, and Other Things You Gotta Know

I was listening to All Things Considered yesterday while preparing dinner. A short, interesting story came on: You Have An Accent Even On Twitter. The NPR host, Robert Siegel, interviewed Jacob Eisenstein, a post-doc at Carnegie Mellon who has been examining regional variances in Twitter usage.

Some highlighted examples of Twitter dialecticisms:

In New York, people tend to do “suttin” (i.e. something, and usually having nothing to do with Sutton Place)

The use of “hella” to mean “very” as in “I’m hella tired” is more commonly iterated by people who’ve lived in Northern California.

(LOL is universally understood.)

I was sufficiently intrigued to track down Dr. Eisenstein’s paper, A Latent Variable Model for Geographical Lexical Variation, presented on January 8 at the annual meeting of the Linguistics Society of America in Pittsburgh. It’s a technical article befitting an MIT graduate, with un-trendy headings like “Cascading Topic Models,” “Inference” and heavy math. Still, I enjoyed the perusal.

Eisenstein and his colleagues started with a Gardenhose Twitter sample stream, which they say contained ~15% of public messages, from the first week of March, 2010. They whittled those down by selecting for tweets geo-tagged to the continental U.S. by authors who sent at least 20 messages during that period, and without URLs. Ultimately, they examined at some 380,000 Twitter messages (tweets) from 9,500 users.

The findings are really cool. (To be clear – that would be “coo” in Southern CA, or “koo” in Northern CA.)

Good to know that “af” signifies “as f-ck” (as in “very”), and is more commonly typed in Los Angeles than in some other parts. “Ima” for “I’m going to” is a New York kinda thing. “Gna” for “going to” is popular in Boston, but sounds familiar to this mother of a teenager in NYC.

From the Carnegie Mellon press release:

Studies of regional dialects traditionally have been based primarily on oral interviews, Eisenstein said, noting that written communication often is less reflective of regional influences because writing, even in blogs, tends to be formal and thus homogenized. But Twitter offers a new way of studying regional lexicon, he explained, because tweets are informal and conversational. Furthermore, people who tweet using mobile phones have the option of geotagging their messages with GPS coordinates.

…Automated analysis of Twitter message streams offers linguists an opportunity to watch regional dialects evolve in real time. “It will be interesting to see what happens. Will ‘suttin’ remain a word we see primarily in New York City, or will it spread?” Eisenstein asked.

I guess we’ll see how this progresses. I’m reminded of sometime around 8 years ago, when I tried cracking the IM code: “POS” meant “parent over shoulder.” That was easy. “Code 9” meant suttin similar, if I recall.

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On a Velázquez Portrait, and the Value of Expertise

This is an unusual entry into a discussion on the limits of patient empowerment.

In late December the Times ran a story, beginning on its front page, about a portrait in the Metropolitan Museum of Art by Diego Velázquez, the 17th Century Spanish painter. The news was that the tall representation of the teenage Prince Philip IV would be back on display in the European paintings galleries after a 16-month cleaning, restoration and re-evaluation of the work. And, in case you weren’t up on your art history news – the painting really is a Velázquez.

label (ikonic's Flickr)

I learned this morning that the museum received the painting in 1913. It was a gift of Benjamin Altman (that would be B. Altman, as in the department store of my childhood…). The 7-foot portrait was considered a true masterpiece for hundreds of years, its authenticity supported by a receipt signed by Velázquez and dated Dec. 4, 1624. According to the Times now, in 1973 experts at the museum formally revised their opinion of the painting; they down-rated it, saying it’s a product of Velázquez’s studio, rather than of the artist himself.

Velazquez' Portrait of Philip IV, at the Metropolitan Museum

Evidently Michael Gallagher, the chief paintings conservator at the Met, recently became concerned about the painting’s “workshop” label based on his experience upon cleaning another, later Velázquez portrait at the Frick. “Its true condition was obfuscated by the decades of varnish and the liberal repainting,” he said of the Met portrait. According to the Times, Philip’s left eye was missing, possibly from flaking or vandalism. Ultimately, x-ray analyses and careful examination of the cleaned portrait convinced Gallagher and his colleagues of the portrait’s legitimacy.

I was in the neighborhood, so I thought I’d check out the work for myself, in light of this new information. I spent a while staring at it, studying the prince’s hand and other features about which I’d recently updated my knowledge. Still, I realized, there was no way in the world I could tell, on my own and even if my life depended on it, if it were a Velázquez, or not a Velázquez.

Sometimes you have to rely on experts. I don’t have a Ph.D. in art history. Or anything approaching sufficient knowledge of Velázquez and his workshop, Prince Philip IV of Spain, x-ray analyses of oil paintings, varnish and resins, 17th Century receipts and signatures, or similar “cases” – like the related portrait that turns out to be in the Prado, and other works by the same painter – to know the difference.

That’s the thing – in medicine, if you have an unusual health condition, like a rare form of T cell lymphoma or an obscure infection, you may find that you depend on a doctor’s expertise. Recommending the right treatment (which might be no treatment) requires knowing and understanding the correct diagnosis. Figuring out what’s the correct diagnosis requires a lot of knowledge, and experience.

detail of hand, in Velazquez' painting

As for patient empowerment, I think what patients with rare or puzzling conditions can do is to make sure they’re comfortable with their physicians, that their doctors know what about what they’re treating and will admit when they’re unsure of a diagnosis or need more expert, specialist advice. The problem, then, is for doctors to admit what they don’t know, which in the end requires that they be well-educated and able to discern unusual cases and outliers, and take the time to notice – and not dismiss – details about their patients’ stories that warrant further examination and thought.

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The U-Shaped Curve of Happiness

This evening, when I finished cleaning up the kitchen after our family dinner, I glanced at the current issue of the Economist. The cover features this headline: the Joy of Growing Old (or why life begins at 46). It’s a light read, as this so-influential magazine goes, but nice to contemplate if you’re, say, 50 years old and wondering about the future.

The article’s thesis is this: Although as people move towards old age they lose things they treasure—vitality, mental sharpness and looks – they also gain what people spend their lives pursuing: happiness.

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Does Cathy Make the Right Cancer Treatment Decision in the Big C?

scene from season finale, The Big C

“I don’t want to get sicker trying to get better and then just end up dying anyway” – Cathy, the 42 year old protagonist with advanced melanoma, on the Big C.

ML’s incoming search data suggest that some people out there are very determined to know exactly what happens to Cathy in Showtime’s new series about a young-seeming, middle-aged woman with advanced, presumably stage IV, melanoma. In last week’s review I elected not to give it away. Now I’ve reconsidered. So here’s a spoiler alert: Don’t read this post if you don’t want to know what happens to Cathy at the end of the Big C‘s first season.

After months of unusual and comfort zone-breaking behavior, Cathy reconsiders her initial decision to forgo treatment. She, possibly influenced and clearly supported by her husband’s enthusiasm for her middle-aged life and continued existence, indicates that she’s willing and ready to try treatment with Interleukin-2. Cathy seems to know something about the FDA-approved drug, which is generally toxic and ineffective in most melanoma cases. At one point, she lists its putative side effects, according to the show: “burning scabs all over my body, constantly throwing up, fluid on the lungs, my veins could shut down, I could die on the table…”

Nonetheless she decides to accept treatment:

“I’m gonna hang on as long as I can. And I’m going out ugly,” says Cathy, played by the actress, Laura Linney.

“It will never be hard for me to look at you,” responds her supportive husband Paul, portrayed by the actor Oliver Platt.

At this point Cathy’s hoping the Interleukin-2 (“interlaken,” as her husband keeps calling it, perhaps metaphorically, subconsciously, or else just simply) will keep her alive for six months, when she might or might not be eligible for an experimental anti-melanoma drug in a clinical trial.

So she goes for it: in the final scene she’s in the hospital, her mind cloudy, and dreaming. You may wonder what I think of her decision.

As an oncologist I’m half-relieved. The patient will, undoubtedly, die too soon – within months or a year or, if she’s lucky, maybe two years or even longer – because you never really know for sure about these things, if she doesn’t take any treatment. Deaths from metastatic cancer can be unpleasant and painful. On the other hand, conventional therapy for stage IV melanoma rarely leads to complete remissions and, essentially, never cures the disease.

I admired that the patient, until this last episode, maintained such a no-nonsense approach to her condition. Her perspective seemed more mature than her oncologist’s. Despite her weird and nearly unraveling behavior, she’s clearer in her priorities than many patients I’ve known; she seems to understand that a treatment might give her a few additional months but is very unlikely to help her get well and, likely, would make her sick for the duration of her life.

Sometimes oncologists get carried away with hope. What I liked best about the story is that she, the patient, was realistic in this. She didn’t want to take toxic medications in desperation, without reason.

As a patient, my feelings are mixed, too. I respected Cathy lack of passivity in her decision. Accepting treatment initially would have been the easier, “normal” thing in our culture. In effect, so far, Cathy’s taken control of what happens to her body. At the same time, I couldn’t help wonder – what if she tried it? Maybe there is a cure in the pipeline, and she’d be eligible for an experimental agent in a few months, and that drug would help her, and she’d live beyond middle age, or at least until she’s 45 or 46.

Today is Monday, but there’s no new Big C episode because the season’s over. We won’t know how Cathy fares with the Interleukin-2 for a while. Even though she is just a cable TV character, she’s in a position to teach us about oncology and living with cancer.

Hopefully the show’s producers will provide insights into immune treatments, targeted agents, clinical trials, informed consent and palliative care. (I will consider Interleukin 2 and melanoma in a separate post, to follow.) But given the TV scenario, do you think Cathy’s made a sound decision?

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First Season Ending of the Big C

Last night I stayed up late to see the season finale of the Big C. For the first time in watching this series about a 42 year old woman with advanced melanoma, in a near-final scene involving the protagonist Cathy’s teenage son, I cried.

The storyline is moving, finally, in a real and not necessarily happy direction. I must admit I was disappointed overall with the program overall until lately. That’s not because Cathy behaved recklessly and irresponsibly upon receiving her Stage IV cancer diagnosis – her decisions are her personal business and a plus for my engagement. At least the program’s not too preachy.

My gripes are with the show’s other confused characters: her homeless brother, in a TV relationship with Cynthia Nixon’s spent, post-Sex in the City character, is so extreme in his strangeness, choosing not to shower for instance, he distracts from the narrative; her obese student, played by Gabourey Sidibe, seems like she’s stuck in the wrong program; her “oncologist” is so free with his time, and apparently has so little else to do (how about studying for his boards, if he still hasn’t any other patients besides Cathy?),  he comes across as a joke instead of as a credible and sensitive physician who’s completed his training.

The good news of course is Cathy, played fantastically well by Laura Linney. She’s amazing, perhaps more than ever, a good example of how women don’t have to be knock-out gorgeous to shine. Phyllis Somerville, as Cathy’s crotchety old neighbor Marlene, offers a revealing image of loneliness and dementia, with a bit of paranoia thrown in her mix. The two men in Cathy’s life – her husband and recent lover – provide a strange balance that somehow works around her: the lover is nice, supportive and easy-going; her husband is intense and devoted; his uber-love is persuasive. As for Cathy’s son, well, he’s grown on me over the past few months.

My favorite scene, easily, is Cathy dancing with a way-alternative cancer treatment provider, the Canadian “bee man” portrayed by actor Liam Neeson. How sad he must have felt, on the set, holding close a middle-aged woman in the role of someone facing death in slow-motion.

I don’t want to give the plot away, so I’ll just say that I will definitely keep watching the Big C. I can’t wait to see what happens with Cathy, if she’ll make it to the clinical trial that opens in six months and if she’ll be eligible for experimental therapy. This is no ordinary TV show.

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A Play About the Life and Work of Dr. Rosalind Franklin

Last weekend I snagged a last-minute ticket to see Photograph 51, a new play about the work and life of Rosalind Franklin. Her data, possibly stolen, enabled Francis Crick and James Watson to decipher and model the double-helix structure of DNA.

The intimate production, enacted by the small Ensemble Studio Theatre on the second floor of a nondescript building on West 52nd Street, affords a fresh look, albeit partly fictionalized, into important moments in the history of science. Most of the scenes take place in a research lab in post-War London, at King’s College, where Franklin took on a faculty appointment.

Franklin’s story starts like this: She was born in 1920 to a Jewish family in London. She excelled in math and science. She studied physical chemistry at Cambridge, where she received her undergraduate degree in 1941. After performing research in photochemistry in the following year on scholarship, she joined the British Coal Utilisation Research Association (BCURA) and carried out basic investigations on the micro-structure of coal and carbon compounds, and so earned a Ph.D. from Cambridge University. She was a polyglot, and next found herself in Paris at the Laboratoire Central des Services Chimique de l’Etat, where she picked up some fine skills in x-ray crystallography.

You get the picture: she was smart, well-educated and totally immersed in physical chemistry before, during and after WWII. Single-minded and focused, you might say –

Franklin in Photograph 51 wears a simple brown dress with large black buttons straight down the middle of her lithe frame. Her lipstick and haircut seem right, but her three inch heels, even after a few years of experiencing the joie de vivre in Paris, or just being holed up in a research institute there, seem a tad too high for such a pragmatic soul. The lab set is perfect with its double-distilling glassware, wooden pegs on racks, tall metal stools with small, flat circular seats, light microscopes, heavy metal desks with file drawers and a contentious cast of characters.

As this narrative goes, Franklin spurns socializing with most of her colleagues. They find her difficult. She spends nearly all of her time and late hours using x-rays to generate crystallographic images of DNA and making detailed notes and related calculations. Eventually a lab assistant gives her key data, Photograph 51, to her colleague, Maurice Wilkins, who is inexpert in crystallography and cannot independently interpret the structure. While Franklin continues working at a measured pace, refusing to rush into publishing a model until she’s sure of her findings and the implications, Wilkins shares the image with Watson and Crick. They move quickly, publish first in Nature and, later, win the Nobel Prize for the discovery. Meanwhile Franklin leaves Wilkins’ lab and starts a new project on the structure of tobacco mosaic virus. She dies at the age of 37 of ovarian cancer, likely caused or effectuated by the radiation to which she exposed herself at work.

It’s a sad story, but instructive, engaging and very well-done, so much that it’s haunted me for days. Hard to know what’s real –

According to a program note from Anna Ziegler, the playwright: “this play is a work of fiction, though it is based on the story of the race to the double helix in England in the years between 1951 and 1953.” Ziegler refers to several books from which she drew material: The Dark Lady of DNA (by Brenda Maddox), The Double Helix (by James Watson) and The Third Man of the Double Helix (by Maurice Wilkins).

My favorite part is Franklin’s statement at the beginning: “We made the visible, visible.”


For a (depressing) counterpoint to this play’s version of events, you can take a look at Nobel Laureate James Watson’s 2007 TED lecture on YouTube. “She was a crystallographer,” he says of Franklin, and other things, before delving into his late-life happiness and current ventures in cancer genetics and autism studies.

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Doctors Singing On YouTube

A few weeks ago I found some doctors singing on YouTube. They made me laugh and perhaps, even, feel better.

Doctors in Cyberspace

I contacted the singing doctors to check, among other things, that they’re still in business. It turns out that Drs. Barry Levy and Greg LaGana both graduated from Cornell University Medical College just a few years back, in 1971. They’ve been performing together for years and still do.

“Why rant and rave when a laugh will do?” said the New York Times about the pair, in 2004.

Now, they have a YouTube channel. Of the five videos available, my preference is Doctors in Cyberspace (above) but that’s probably because I’m partial to the “I Feel Pretty” melody from West Side Story. Health Care Business, to the tune of “There’s No Business Like Show Business” comes in at a close second and, based on the number of YouTube viewings so far, seems to be the public’s favorite.

Their website is called Damaged Care. You can buy a CD for a holiday gift. Or hire the doctors to entertain at a real-life party or other event: they’ve performed for state medical societies, hospital associations, the AMA, pharmaceutical industry associations, the Federal Reserve Bank of Boston and the General Assembly of the Presbyterian Church among other agencies, and at Off-Off-Broadway venues in New York City.

The Damaged Care Doctors

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A Story About A Doctor and His Neighbors

In recent years, some physician authors have wrestled with why doctors might want to think twice before “friending” their patients on Facebook. The usual reasons are to protect the physician’s professional image – that the public might see their weirder, or not-so-polished-as-while-working side and, also, to maintain a certain “distance” – lest doctors become so concerned about their patients’ well-being that they can’t render objective opinions or advice.

Others suggest it’s a good idea for doctors to be socially out there, so to speak. Besides, through most of history, or at least the civilized part in which there have been designated healers, many individuals knew their doctors, who often resided in the same village or region as their patients. People trusted their physicians or didn’t, based on what they knew about their reputations as practitioners and as local denizens.

In the October issue of Harper’s Magazine, T.C. Boyle provides a disturbing portrait of a portly, unkempt doctor who lands a job in small town, presumably in Maine. His unmannerly behavior disturbs some residents. The piece addresses, at least peripherally, some ultra-modern and ancient concerns about relationships between patients and doctors within a community. I don’t wish to give more of this short story away, so I won’t.

I do recommend What Separates Us From the Animals, part of a forthcoming novel, When the Killing’s Done, to my readers. With his frank, absorbing language, Boyle offers insight into human beings as sometimes social creatures who take far-from-perfect care of themselves. Doctor included.

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No Quick Fix

On History and Health Riffs in the musical, Bloody Bloody Andrew Jackson:

“If it’s chafed, put some lotion on it.”

– some practical advice, offered by the character portraying Andrew Jackson, speaking toward the audience in the last scene of Bloody Bloody Andrew Jackson, a play written and directed by Alex Timbers

Yesterday I had occasion to see the outrageous politicoemo-rock musical, Bloody Bloody Andrew Jackson, which recently moved to Broadway’s Bernard B. Jacobs Theatre. The production focuses on the life and times of the 7th President of the United States.

Now, Old Hickory comes on like a rock star. The story is narrated, in part, by an excitable, graying Jackson groupie who bumps around the stage in a motorized wheelchair. A wild and rattling cast sets the thing’s tone in a startling first number, “Populism, Yea, Yea!” An early review of this musical, toward the end of its early 2008 LA run, cites these lyrics:

Sometimes you have to take the initiative.
Sometimes your whole family dies of cholera.
Sometimes you have to make your own story.
Sometimes you have to shoot the storyteller in the neck.
Sometimes you have to take back the country…

(These words antedate the Tea Party, to which the play vigorously alludes in its current form.)

You get the idea: it’s lively, a bit disjointed and politically relevant. And fun. It messes with the facts, and is tangentially rife with medical topics:

In the play, Jackson’s father, upon witnessing the whoosh and arrow-in-her-back slaying of Jackson’s mother in a backwoods cabin somewhere in South Carolina or Tennessee, immediately and without hesitation attributes her death to cholera. A moment later, he and a cheery cobbler are felled by similar instruments. The future President Andrew Junior, who’s playing with toy cowboys and Indians while both of his parents are shot dead in this life-motivating scene of pseudo-history, refers later to his parents’ deaths from cholera.

Most historical sources and Jackson’s Tennessee home’s current website, attribute the mother’s death to cholera. According to a scholarly review of cholera epidemics in the 19th Century, the disease didn’t appear in North America until after 1831 or so. A fascinating, original New York Times story details the ravaging effects of this illness in Tennessee in 1873, but that would be long after Jackson’s death in 1837.

An unexpected medical writer’s gem of a song, “Illness As Metaphor,” cuts to the heart with a message about blood, symbolism, love and Susan Sontag’s classic essays on the meaning of tuberculosis and cancer in literature and in life. The lyrics of the song from Bloody, Bloody Andrew Jackson are hard-to-find on-line, but you can get it through iTunes, by which I found these words:

A wise woman once wrote that illness is not metaphor.
So why do I feel sick when I look at you?
There is this illness in me and I need to get it out, so when I bleed
It’s not blood, it’s a metaphor for love.
These aren’t veins just the beating of my heart.
This fever isn’t real it represents how I feel…

You can see a Spanish-sung, sickly romantic version on a YouTube video:

I’m not sure how Susan Sontag would feel about emo-rock in general and about this song in particular, but I should save that subject for some intense, future writing project –

A few other medical digs include mention of Jackson’s hepatitis – acquired on “the battlefield,” as he explains to his admirers, syphilis – a killer of Indians and, consistent with the play’s hemi-modern approach, Valtrex – which some of the prostitute-turned government advisees run to get when it’s given for free.

All in all, it’s a terrific play about Americans, Manifest Destiny, populism, anti-elitism, economic frustration, anger toward foreigners, fear of terrorism, emotions and the founding of the Democratic Party.

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Tomorrow is Election Day. Remember to vote!

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The Music of H.I.V.

Yesterday I came upon something I’d never heard before: Alexandra Pajak, a graduate student at the University of Georgia, merges art and science in a novel way. She composed a new work, the Sounds of HIV, based on the virus’s genetic sequence.

A CD, produced by Azica records, will be available later this month. A ScienceRoll post, by Bertalan Meskó, clued me into this fascinating project. He shared the artist’s explanation of her work:

Sounds of HIV is a musical translation of the genetic code of HIV, the Human Immunodeficiency Virus.  Every segment of the virus is assigned music pitches that correspond to the segment’s scientific properties.  In this way, the sounds reflect the true nature of the virus.  When listening from beginning to end, the listener hears the entire genome of HIV.

In English, the nucleotides Adenine, Cytosine, Uracil/Thymine, and Guanine are abbreviated with the letters A, C, T, and G.  Since A, C, and G are also musical pitches in the Western melodic scale, these pitches were assigned to the matching nucleotides.  To form two perfect fifths (C-G and D-A), “D” was arbitrarily assigned to musically represent Uracil.  I assigned the pitches of the A minor scale to the amino acids based on their level of attraction to water…

According to a May, 2010 post in the Daily Scan, the artist has assigned pitches to each viral segment’s properties:

…The composition’s Prelude and Postlude correspond to the first and last 100 nucleotides, and the sections named after the proteins (Proteins 1-9) represent translations of the amino acid sequences…

Upon searching further, I tracked down some partial HIV music clips, available now, at ClassicsOnline. The start of the prelude sounds calm and lovely to my rock-trained ears; other portions are distinct and lively.

I look forward to more listening!

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First Take On the Big C

Laura Linney as Cathy in The Big C

Last night I stayed up to watch the first episode of Laura Linney portraying a middle-aged woman in a new series called The Big C. The story is that she’s got a teenage son and a recently estranged, overweight husband who loves her. She lives in a suburban house that could use some work.  She teaches in a high school. She has a brother who’s deliberately homeless.

Her name’s Cathy – how ordinary can you get? Well, Cathy recently found out she has a terminal case of melanoma. In a change of pace, she expresses herself freely and does pretty much whatever she feels like doing.

For me, this TV situation has some big draws:

Laura Linney‘s a fine, not uninteresting actress. A few years ago she played a charming Abigail Adams in a history-minded miniseries. But I couldn’t bear to watch her miscast counterpart, Paul Giamatti, pretending to be President John Adams, so I didn’t. As in the storyline of the Big C, here’s an opportunity for Linney to shine.

Gabourey Sidibe, a young obese woman who stars in the movie Precious, may or may not be a fantastic figure on film or TV. She’s yet to be established beyond her debut and after watching last night’s episode I’m concerned already that she’s being “used” as an object for the protagonist’s preterminal beneficence. Still, she’s a definite plus.

The Big C‘s plot includes at least two “atypical” and potentially complex features. First, Cathy chooses not to take chemotherapy or other treatment. This intrigues me, and may be the show’s most essential component – that she doesn’t just follow her doctor’s advice. Second, she doesn’t go ahead and inform her husband, brother or son about the condition, at least not so far.

We’ve seen this non-communication before in movies (Susan Sarandon in Stepmom, for instance) and in real life, for most of human history. It’s too-easy for a blogger-patient-oncologist to forget that not long before our Facebook era, most people didn’t talk much about having cancer and even today, many patients prefer not to do so. Norms change.

If the point of the Big C is to broaden the dialog on cancer and talking about cancer, that’s worth a lot, still.

What’s wrong with the program? I think the doctor has some brushing-up to do about his image. He’s 31 and Cathy’s his first “case” – all of which is credible, but with the exception of an x-ray briefly revealed on the wall-mounted light-box, it’s not clear if he’s an oncologist or a dermatologist somehow offering her chemotherapy and pamphlets. His white coat is too short, in the style of a medical student’s. He uses few polysyllabic words. He looks well-rested and neat. In one strange scene, the patient and doctor meet for lunch at a pleasant outdoor restaurant. That’s not how oncology’s practiced, at least as I know it.

But I’m learning, too. And I’m wondering about the informational content of the doctor’s slick handouts, about which the protagonist, Cathy, has a vision.

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Shutting Off Nurse Jackie

A few months ago I wrote that I’d take another look at Nurse Jackie, a ShowTime series about a drug-addicted ER nurse and mother. The posters, featuring Edie Falco as the program’s heroine, caught my eye; she’d charmed me in her previous role, as Carmela Soprano. Besides, this story’s set in NYC. The hospital is vaguely-modeled upon St. Vincent’s Medical Center, a recently-shuttered Catholic Hospital in Greenwich Village.

Out of some sense of compulsion, wanting to provide careful follow-up to my readers, I forced myself to watch each episode before completing this review. Unfortunately I found the series so unpleasant, besides uninteresting, that it took me months to plod through my assignment.

Jackie is supposed to be a crackerjack nurse who has some serious problems including drug addiction. That premise might be fair enough, in a House-like way, if her life-saving skills had unique value. But they don’t: the underlying problem with this show is that Jackie has no exceptional or redeeming qualities as a nurse. Sure, she cares about some of her patients, but that’s nothing extraordinary. Rather, she stands out by lying, making up results and, not infrequently, cutting out when and where she’s needed.

The emergency department where Jackie works is supervised by a not-quite indifferent administrator portrayed disappointingly by Anna Deavere Smith, whose real talents reach far beyond the realm of the petty disputes and not-unusual life issues that plague this TV hospital’s staff.

As a physician-blogger who’s trying to understand the potential value of Twitter in health care, I thought perhaps I might learn from the show’s ER doc Cooper’s social media skills: he tweets while working, nominally as a physician. But he’s presented as such a vain, stupid twit that he’s just not credible as a doctor of any kind. Even his Tourette’s tics are adolescent – he grabs women’s breasts when stressed, a curious behavior that seems, if anything, to suit the show’s shallow drama more than any real patient’s disease.

Plenty of TV shows have offered insights on health care delivery by quirky, self-absorbed and sometimes-deluded workers with interpersonal issues and stress (think M*A*S*H, for starters). But this series doesn’t make that grade. There’s no adult humor, no attempt at medical mystery-solving or even a good, old-fashioned medical ethics quandary. Unlike the Sopranos‘ story, here most of the characters bear little depth. Jackie’s multiple psychopathologies are a vile, exaggerated example of a woman juggling too many things, badly.

So I was surprised to find out that Jackie’s contract was renewed. Even more, I wish that the real St. Vincent’s Hospital, which once provided care to me and, over the years, helped countless other real New Yorkers, were still open.

I won’t revisit this show. But I’m looking forward to The Big C, which starts on Monday. Hopefully that will deliver better entertainment, or at least some fresh ideas.

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