July 28, 2023 

Dear Interested Readers,

 

The Beginning of My Journey 

 

Last week’s letter precipitated some interesting responses. Several people said they enjoyed reading about my personal experiences. One individual went so far as to say that he liked hearing about my experiences in life much more than hearing my opinions about healthcare policy and our healthcare system’s deficiencies. These comments seemed consistent with an opinion expressed by a very supportive friend and reader who advised me several years ago that I was a better memoirist than an essayist. I actually prefer writing about healthcare and not myself, but this week I am going to begin to describe the events and journey that carried me to where I am today. My experiences and the people that I met along the way were formative of the opinions and concerns that fill these notes each week. If you choose to follow the story, you may see how the story is connected to the opinions that I expressed last week and most weeks. I hope that writing about my own life will not sound narcissistic.

 

If you missed last week’s letter, it began with a discussion of life expectancy from my perspective of having recently enjoyed my 78th birthday which is as good as any point from which to look back over a life. I moved on to talk about the failures in my father’s medical care that prevented him from reaching his goal of becoming a centurion. If you are a regular reader of these notes you have probably picked up on the fact that he was a major influence in my life.

 

Over forty years ago in the late seventies and early eighties, I spent several years in “lie down on the couch and talk to the ceiling psychoanalysis” much of which was an exploration of my relationship with my parents. A good part of that exercise was about how to live my life as I wanted to live it and continue to have a loving and respectful relationship with my father who presented strongly expressed opinions that left me little room for personal expression without feeling that I was at odds with him or disappointing him.

 

I was fortunate to have been directed by the chief of psychiatry at The Brigham to whom I had gone for help to a wonderful clinician, Dr Charles Magraw who was the president of the Boston Psychoanalytic Society and Institute. Despite the fact that I saw Dr. Magraw for over five years, I did not know until I read his obituary in The Boston Globe many years later that along with Dr. Bernard Lown who was also one of my mentors at The Brigham, he had been a leader of the medical opposition to the war in Vietnam in Boson and active in the anti-nuclear movement. I did guess that he had wide interests and progressive political opinions because his waiting room magazines were The New Republic and The Bulletin of The Atomic Scientists.  In Dr. Mcgraw’s obit, Dr. Lown described his importance to the anti-nuclear war movement.

 

“We plotted how to stop the nuclear arms race and specifically the shelter program, where people went underground,” said Dr. Bernard Lown, a cardiologist who was a founder of Physicians for Social Responsibility. Lown shared the 1985 Nobel Peace Prize for helping found International Physicians for the Prevention of Nuclear War. It was helpful to have a psychoanalyst on hand to help the activists work well together, Lown said.

During one frustrating moment, Lown recalled, Dr. Magraw “put his arm around my shoulder and said ‘Bernie, have patience. You are succeeding remarkably well.’ And this little bit of psychotherapy calmed me down.”

 

Later in the obituary, we read:

 

Before the Vietnam War, the civil rights movement was the focal point of Dr. Magraw’s activism. In subsequent years, his family said, he advocated for greater understanding of gay, lesbian, and bisexual patients long before same-sex marriage joined the political landscape.

 

The only place that I ever saw Dr. Mcgraw, other than in the basement office of his Newton home which was literally and figuratively just off Commonwealth Avenue halfway up “Heartbreak Hill,” was at Fenway Park. Between 1977 and last year, I shared season tickets for some excellent seats for Red Sox games. I remember how surprised I was while returning to my seat between innings sometime after I terminated my analysis in 1982 to see him sitting about five rows behind me and a little bit more toward first base. He had obviously seen me before I saw him. Had he been watching me at games for years without my knowledge? We nodded at one another and never spoke, but for many years I would see him in those same seats once or twice a year when it happened that we both attended the same game.

 

I hope that you read the entire obituary because there is no question in my mind that Dr. Magraw could be a model for us all. Who I am is in part some blend of two very different but powerful male influences that were complemented in my life by my saintly mother who was always waiting to give me help and support without questions when I needed it.

 

Those thoughts in last week’s letter about life expectancy and the journey of my life had been precipitated by recently reading The Book of Charlie: Wisdom From The Remarkable American Life of a 109-year-old Man, written by the Washington Post journalist and author of several books of history, politics, and culture, David Von Drehle. Charlie White was a doctor whom the author met when he was a vigorous 102. He lived to the age of 109. Von Drehle speculated that a major factor in Charlie’s longevity was the seemingly contradictory philosophy of “Let Go and Hold On” which makes great sense when you explain it by saying that there is no benefit to continuing to worry over past mistakes and losses, but you can endure, or hold on, by using what you have learned from what has happened to shape your response to what will come. After discussing Charlie, I mused on uncertainty, the cosmos, black holes, and the futile search for some uniting principle in science, the so-called “Theory of Everything.” 

 

After some theological confessions, I moved on to a discussion of being “called” to a life’s work. I used a quotation from the recently departed author/theologian/minister, Frederick Buechner, whom I had discovered by reading his obituary in The New York Times and the salute that David Brooks had given him. The piece that I quoted from Buchner was entitled “Vocation.” It discussed the challenge that we all share to find what we are “meant to do.” A well-known Buechner quote is “The place God calls you to is the place where your deep gladness and the world’s deep hunger meet.”

 

I must admit that the letter up to that point was a long journey toward my ultimate destination which was a discussion of “moral injury” in healthcare. I am not sure if any of the people who said they liked my “stories” realized that the part of the letter they liked was a clumsy effort to introduce a difficult subject. 

 

As I said in the letter, I do not think that I have experienced a moral injury. Perhaps I should have, but I think I am more inclined toward Charlie’s philosophy of “Let Go and Hold On.” Although I did not know any more about Dr. Magraw than that he had been highly recommended to me by the Chief of Psychiatry at The Brigham, and that he was the President of the Boston Psychoanalytic Society and Institute and was a professor at Tufts, as I spent those many hours lying on his couch, something of his worldview must have rubbed off on me. In retrospect, he probably would agree with Let Go and Hang On which could be a summary of much of what I learned from talking to myself and him with him sitting in a big stuffed chair behind me and almost never saying a word while I talked to the ceiling. 

 

With those introductory remarks, I do think there is some benefit to telling you about my own sense of calling and my journey through healthcare and a few of the things that I think I have learned about myself and life from the experience. It will be a journey of several letters. You may remember some of the stories because over the years I have sprinkled many of the events and observations from my life into these musings, but I hope this serialized version will add something new and at least show how many events, mentors, and friends have been blended into my life, and “calling.” As the old hymn says, “God moves in a mysterious way, His wonders to perform.”

 

I do believe that we are informed and sustained by the sharing of “testimonies.” Moral injuries, uncertainties, challenges to ideals, confrontations with those we love, departures from the path of our heritage, and external realities and challenges that force us to change if we are to survive do occur in every life, and there is no better way to understand your own life than to closely examine your own experiences and ponder the experiences of other people. Good literature offers us that opportunity. Plato reported in The Apology of Socrates that at his trial Socrates said, “The unexamined life is not worth living.” With that background, I will begin my story. 

 

My father did have a sense of being “called” to the ministry, and like many devout Christians, my parents prayed to ask for God’s guidance at each moment of inflection in their lives. I have known for many years that my father kept a daily journal. He always said that he would burn his notebooks before he died. That did not happen, and everything went into storage when he died. This April, I made a trip to North Carolina to get the journals.

 

Over the last year, I have also digitized some of his sermons which were on tape cassettes. From the pulpit, he rarely dealt with doubt, and his words were declarative of the certainty to be found in the faith. From time to time we did have long philosophical conversations, and from things he said to me I suspected that he did have some doubts.  It has been difficult to read his journals. The exercise seems like a violation of his privacy, but I have discovered reading just a little of his journal from 2000, the year he was eighty, that his doubts were with him on a daily basis much like the doubts of Mother Teresa. Like many parents, he worried about his children, me included, and wondered why God was not more prominent in our lives. He could not understand why God did not use him more effectively, and why so many of his daily prayers were unanswered. These thoughts are balanced by a continuing celebration of how fortunate and blessed he felt he was, and how much he loved and trusted God despite his inability to understand how God was working in the world. In the few pages that I have read, he reflects on the mistakes that he had made in life and the satisfaction that he received from preaching and leading a church. Reading his journals has been a very slow process. I go days and days without returning to them because they stir up feelings that are painful. At the rate I am going, I may never finish reading them. They fill several boxes. As painful as it has been, knowing that he also struggled has been reassuring to me as I struggle with many of my own doubts, and I feel closer to him knowing that we share many concerns.

 

When I was a little boy I often “played church,” but after the age of six, I don’t think the idea ever crossed my mind that I should follow my father into the ministry. I don’t think I was “called” to medicine, but I do think I ended up where I belonged whether it was a preordained fact or just the outcome of following interests coupled with a genuine acceptance of another of my parents’ positions which was that one’s life should have a purpose that benefits others, and that I had the responsibility to figure out how to achieve that objective.

 

I was not a good student in the first few years of school. I think that I was a bit dyslexic, or perhaps I was interested in a lot of other things besides reading. I was a frequent visitor to the principal’s office for disruptive behavior in class until about the fourth grade.

 

Evidence of my disinterest in the processes of school other than recess or drawing was that as late as the third grade I was in the “slow reading group” and my mother purchased a copy of Dick and Jane which she tried to use to tutor me at home. At school and at home, I had other things on my mind. In school, I was daydreaming or drawing pictures. At home, I was a “feral child” living in a time when you could escape far beyond the control of adults into adventures from dawn to dusk on warm summer days. I don’t think that my parents were any more negligent than other parents in the early fifties because many of my peers joined me on these adventures. I do remember that about the time Senator Joe McCarthy,  was warning the nation of a communist infiltration of the government, my mother cautioned me not to eat any candy or chew any gum that I might find at the playground in the park near the center of town because those goodies might have been left as a trap by a communist. As an aside, I must say that Governor DeSantis seems to me at times to be a second coming of Joe McCarthy. I feel very lucky to have been a child in a different time having adventures that would not be possible today when parents keep their children close for fear of what might happen to them.

 

I have no idea how it happened, but by the fourth grade, I became a reader and was suddenly a very good student without much effort. I became very focused on completing and exceeding assignments.  I must have successfully entered Erikson’s fourth stage of development, industry versus inferiority. Perhaps, I was pushed in the direction of industry because my parents bought The World Book Encyclopedia for me which I used like the Internet. It gets easier and easier to succeed if teachers and other authority figures expect it from you. Years later, I can remember people musing about Wade Boggs’ batting titles by saying that he often got walked because the umpires thought that if he did not swing at a ball, the pitch must not have been in the strike zone. I think that I frequently got the “benefit of the doubt” because of the positive pre-existing expectations of my teachers who began to expect my success, and it is easier to give what is expected. Each accomplishment makes subsequent attempts easier. Success does build confidence and a positive outlook. 

 

I began to think about what I wanted to be in life pretty early on. It was clear that I could not be a professional athlete because they played games on Sunday which would have been a violation of the Sabbath. By the time I took tenth-grade Biology and began to study life forms and dissect frogs, I had decided that I wanted to be a doctor. In the twelfth grade, my high school offered an anatomy class as an elective which included dissecting a cat. By that time there was no doubt in my mind that my future was in medicine.

 

Some part of my interest in medicine was in response to the fact that in my senior year of high school, I was hospitalized for a workup of hypertension that was discovered when I developed a step throat. I was fascinated as well as terrified by what happened to me over about four days in the hospital. I was greatly impressed by the kindness of the cardiologist, Dr. Edwin Masters, whom my PCP, Dr. Hunter Rentz, had asked to evaluate me. (Click on Dr. Rentz, who is now well into his 90’s, to hear him interviewed about plant-based diets.) Dr. Masters explained every step of the workup to me. He never seemed rushed and always took my questions very seriously. I continued to see Dr, Masters after I was discharged, and through my four years in college. He eventually wrote letters of recommendation for me.

 

I wish that I could say that I studied hard. What would be more accurate would be that I studied regularly and efficiently while doing many other things. I liked to learn, and most things came rather easily. I am still a slow reader, I read every word, and most of the time I am deeply reflecting on what I am reading. I think that I must have some sort of low-grade photographic memory that enables me at times to literally “see” what I have read.  My ability to “regurgitate” what was in the textbook or what the teacher had said was a big benefit, as long as that was what was required to get an “A. What I discovered in medical school was that what got me an “A” in college was not enough to satisfy the best professors who asked questions that required you to synthesize what you had read or heard into something new that could be applied to a difficult question. It took me many more years to realize that the synthesis of information with the patient’s concern was at the center of good medical practice. Dealing with uncertainty is the challenge of non-procedural medical practice where uncertainty is your constant companion, and successful management often requires synthesizing medical and social facts while managing uncertainty and ambiguity.  I harbor the bias that many young doctors are drawn to procedural specialties that are more like trades because success only requires learning to do a procedure that can be applied time after time. Those procedurally related colleagues usually call for a medical consult when some complication introduces uncertainty which is the constant companion of those of us who deal with the symptoms and the emotions of patients as the core of our practice.

 

The further I progressed in my education through high school and college, the more it seemed that the idea of going to medical school seemed right for me. While applying to medical schools in the South like Emory and Vanderbilt (I was biased against Duke for reasons that I will not address). my father asked me why, given my grades and other activities, I had not considered applying to Harvard and Johns Hopkins, so I did. Somewhere in his challenge, he asked, “What do you have to lose?”

 

I was surprised when I was asked by Harvard to come for an interview. That trip to Boston is a long story on its own. I assumed that the Medical School was in Cambridge with the rest of the university and booked a room at the Holiday Inn on Mass. Ave. near the Arlington line. When I realized my mistake, I had a hard time finding the Longwood Medical Area. I followed the trolley down Mass. Ave. toward Harvard Yard. When the trolley went down the incline into the tunnel under Harvard Square I continued to follow it. I immediately realized my mistake, but there was nothing to do but to continue to follow the trolley. Worse yet was that I immediately became a source of great mirth for all the people getting on and off the trolley at the lower entrance of the Harvard Coop which was halfway through the tunnel. One fellow who was exiting the trolley pointed to the Georgia license on my father’s car which I was driving and then gave a gesture that suggested that I was crazy. As I followed the trolley out of the tunnel, one of Cambridge’s finest in blue stopped me and kindly gave me directions that took me across the Charles River and eventually to the Medical School Quadrangle in Boston.

 

My interviews occurred on a very dark and cold Saturday morning with snow flurries in early December. It was exactly one week after my last college football game which had been a loss to Clemson in front of a packed house at their very unfriendly stadium that is aptly called “Death Valley.” I did not play much in the game, in part because the coach knew I was not coming back, and in part because my talents belonged in a less competitive league. I was ready to move on to the next phase of my life although I had another year of athletic eligibility. Football had paid for my college education and I was thankful for that but anxious to get on with the next phase of my life.

 

Despite attending a “state school,” I had been able to pick some excellent professors, and before the last semester of my senior year, I had accumulated the academic credits required for graduation. I should mention that my favorite professor was Jack Russell. He was the son of “Honey” Russell who is in the Basketball Hall of Fame as a pioneer professional player and the first coach of the Boston Celtics. I was in Dr. Russell’s class when we heard that President Kennedy had been assassinated. His immediate expression of grief is a moment that I will never forget. Dr. Russell taught literature, but what he really taught was critical thinking. I am forever grateful for his contributions to my life. I think that I took every class he taught, and he was gracious enough to write a letter for my Harvard application which may have been the reason I got an interview.  

 

My first interview on that very cold December day was at the Peter Bent Brigham just across Shattuck Street, which always seemed like an alleyway to me, from the back door of Building “A” on the Medical School Quadrangle. The admissions office was on the first floor of Building “A.”. The interview at the Peter Bent Brigham was a pleasant conversation about my desire to be a doctor with a very gentle professor at the medical school. He was a grandfatherly gentleman with a famous last name in the history of the medical school and Boston’s history. He was a Warren. Dr. Joseph Warren was the hero of the Battle of Bunker Hill, and his brother, Dr.John Warren, was the founder of Harvard Medical School in 1782. 

 

After our low-key conversation, Dr. Warren directed me to my second interview which was down the street, around a corner, and down a gentle incline at the old Mass Mental Hospital. On a cold Saturday morning, the building looked abandoned. I followed the directions I had been given through dark and spooky empty halls and eventually found a door with the name Dr. Daniel Funkenstien painted on its frosted glass. 

 

I knocked and waited. Nothing happened and I knocked again. I could hear voices so I continued to knock. Eventually, a red-faced, angry-appearing older man, spewing spittle, opened the door and asked what was wrong with me. He pointed to a wooden bench where he told me to sit down until he was ready to see me. After a while the door opened again, and a very shaken and frightened-looking young man emerged and hurried away. He had the look of someone who had stuck his finger into an electric socket. After I had waited a little longer, I was curtly invited into the spare office, and our interview began with a scolding about my impatience. 

 

The first question was about why I had knocked so long and hard on the door. My answer was that I was not sure I was in the right place and that I was hoping that there was a secretary or some assistant who might either confirm that I was where I was supposed to be or would direct me to where I should go. My tormentor’s response was to ask me if we did not give secretaries Saturdays off in South Carolina. The conversation was downhill from there. Every question was a challenge to either my intelligence or my integrity. He noticed that my father was a minister and said that they had many sons of ministers apply. Did I want to be a doctor because I did not feel as righteous as my father? That was actually a much better question than the blunt “Since you are from South Carolina are you a racist?” If I had the interview today, I would probably acknowledge the shame of knowing that I must have some implicit biases, but that I war against those biases every day. What I did do was describe what I had learned working as the only Caucasian on a construction crew that was entirely composed of very skilled African American masons and their helpers.

 

With every one of his questions, I was challenged to overcome what appeared to be his stereotypical assumptions about me with some evidence from my life that would justify not accepting his opinion of me. I don’t remember anything positive about the interview. When it was over I consoled myself with the reality that I had already been accepted at Emory and Vanderbilt and had a very good chance of winning a full scholarship plus living expenses at Vanderbilt. It was snowing hard as I trudged up the incline toward where my car was parked on Mission Hill just up the street from the Medical School and the Brigham. What I did not know was that all the students from “elite” schools knew about Dr. Funkenstien and the lore about his “stress interviews.” They had been coached about how to deal with his aggressive interviewing techniques. Legend has it that once he nailed shut the window in his office and then asked the next person he interviewed to open the window. 

 

Dr. Funkenstein, it turns out, was also from the South and was a decorated trauma surgeon during World War II. After the war, he retrained as a psychiatrist.  His professional history as presented by Harvard is worth reading. Perhaps the most pertinent part is:

 

He was director of Clinical Psychiatry and Research, at MMH, he also became a senior psychiatrist at the Harvard University Health Service, and served on the medical school Admissions Committee… While conducting active research projects and clinical practice he authored five texts and over 300 articles.  As a Life Fellow of the American Psychiatric Association, he held office in practically all of the psychiatry and mental health societies, worldwide. He participated for Harvard Medical School in many committees of the Association of American Medical Colleges; and his mastery of “The Stress Interview” was an annual feature of the 2nd Year Medical School Student Show.

 

Years later, his son, Dr. Harris Frankenstein, was my colleague at Harvard Community Health Plan before his untimely death at age fifty while swimming in Florida where he had gone to a convention of neurologists. You can read his many accomplishments in his New York Times obituary on page D13 in the May 7, 1990 edition of the paper. 

 

The weekend after my adventures with Dr. Funkenstein, I was treated to a wonderful visit to Nashville as part of the selection process for the Justin Potter Medical Scholarships. I was flown first class to Nashville and put up in a very nice hotel. It was a weekend of pleasant interviews, interesting tours, and great dining. A few days later I learned that I had indeed been offered one of the four Potter scholarships which would pay my tuition and living expenses for my four years in medical school. A few days after that, on December 16, while celebrating my oldest son’s second birthday, I got a telegram from Harvard offering me a place in the class of 1971.

 

I was confused about what to do. I called Harvard and a very softspoken woman in the Dean’s office answered my call. Without knowing who she was or whether she had any authority, I explained my dilemma to her. Should I accept Vanderbilt’s scholarship or trust that I could get financial help at Harvard? There was a long pause and then she said, “I can’t remember Harvard ever allowing a student to withdraw for financial reasons.” I thanked her. I took her statement as a promise, and then I called Vanderbilt to thank them for their offer which I would not be accepting. 

 

I don’t know if I had a calling, but the point of the story so far is that I was very fortunate to have many doors opened for me. My path to medicine was a surprisingly easy journey because of all the help I was given along the way. I was always surrounded by supportive people who made many opportunities possible. Against the background of my experience, it would be hard not to feel as if there was a debt to be paid, or as they say, an obligation to “pay it forward.”

 

It pains me that for some reason today students interested in becoming a doctor face competitive and financial barriers that seem totally unnecessary if our objective is to address our healthcare workforce issues that are certain to become worse in the future. Something dysfunctional has happened since 1967. 

 

I will continue my story next week. In the interim, I would offer you an article that addresses the use of AI in medical education. It is interesting to consider how a Chatbot colleague might be a great source of support in our continual challenge to find the right diagnosis in a world where the doctors we have don’t have very much time to apply what they are learning. What a joy it could be with innovations like AI to have the opportunity to be a student again with the prospect of being part of the future of medicine for the next fifty years. 

 

A Pretty Nice Week

 

We have continued to have intermittent rain, but there have been some pretty nice days this week for us to enjoy between downpours. One thing about a lot of rain is that it stimulates some impressive plant growth. As you can see in the header, the ground between my deck and the lake is a combination of echinacea purpurea (coneflowers) and an overgrown hedge that needs to be trimmed. 

 

A few weeks ago this same area was overgrown with lupin. Since I took the picture on Tuesday, Rudbeckia hirta, commonly called black-eyed Susans, have made their appearance. On my walks and bicycle rides, there are dozens of different varieties of wildflowers to enjoy. At this time of year, I want everything to freeze in its place in time. The nice days of this really strange summer have just started, and summer will be over in less than six weeks! I feel empathy for those people in the South and Southwest who have been trapped under a “heat dome.” I fear that if there was more humidity the lethal “wet bulb temperature” might be exceeded for the most vulnerable among us.

 

I hope that your weekend will be cool and dry. The challenge is to stay comfortable while you enjoy the summer for as long as possible. One hope is that the weather that has compromised the front end of the summer will be balanced by some really fine days in the early fall which is just around the corner.

Be well,

Gene