Dr. Michael Kleinman in the ER

Holocaust Memorial at
the York JCC

Childhood sweethearts Lili and Josef became separated while they were in the concentration camp, the work camp, during the Shoah, the Holocaust.  When the prisoners at Auschwitz were liberated by the Soviets in early 1945 Josef went to find his love again. He walked throughout Germany for six months anxiously asking anyone if they had seen her.  When some claimed that they heard she was dead Josef refused to believe them. He didn’t give up; he kept searching.  And he eventually ran into an old friend who told him that she was recuperating in a nearby hospital.  He found her and nursed her back to health. 

Ready to start a new life, they got married.  The longed-for State of Israel was created on May 14, 1948, and Josef and Lili moved there to help build the nascent country and to start their family.  

Dr. Kleinman

Lili and Josef are the "two dear parents" of Dr. Michael Kleinman, York Hospital ER physician. Dr. Kleinman said of his parents; “They rarely talked about the horror they saw and were not bitter.  Instead, my parents were protective of me and my sister.  (They were) nurturing, but not stifling.”  This awareness of their actions instilled in him a strong desire to be kind and fair to others.  He did not want to see “the other side of humanity” that his parents had witnessed and lived through.  

They often reminded him to “never forget” the Golden Rule.  The traditional Jewish version of this foundation for all ethical conduct is, “That which is hateful to you, do not do to your fellow.” He said that this deeply-felt belief steered him in the direction of providing service to his community. “And so the path of medicine became clear,” he offered.

“How did you decide to become an emergency room doctor?" I asked

He went to the Des Moines University College of Osteopathic Medicine and graduated in 1979, and after his internship, he went into a general medical practice with Dr. Kieren Knapp.  He enjoyed this, and after seeing patients in the office he spent some time “moonlighting”  in the Emergency Department at the York Hospital. 

How could Dr. Kleinman work in an ER without special training?  

Through the early years of the last century (did I really just say that?) and into the 1970’s the ERs were typically staffed by a general surgeon, a general internist, or a general practitioner

Busy Hectic ER Team

who called in specialists when they required help.  Over time, and seeing the need for improved care, and the benefit of specialization, the American College of Emergency Physicians was born on August 16, 1968, by eight maverick physicians in Lansing, Michigan.  The first dedicated ER Residency program was started in 1970 and the American Medical Association quickly recognized emergency medicine as a distinct specialty in 1972.  

Early in his career, Dr. Kleinman experienced this change in approach firsthand; emergency physicians became specialists.  Falling in love with the experience in the ER and the privilege of taking care of a wide variety of patients, Dr. Kleinman realized that if he was “going to do this” he had better get further training.

Dr. Kleinman did his emergency medicine residency training at Memorial Hospital in York, the first such program in the county.  He completed this in 1982 and received his certification in 1984. With a broad smile, he said, “My certificate is number 11.  I treasure this."  Following this, he and several other physicians including Drs. Ron Benenson, Merrill Cohen, Dave Eitel, and Lynn Jensen developed the program at the York Hospital in 1988.  What did he and the others need to know?

An excellent Wikipedia entry (1) notes: "The emergency physician requires a broad field of knowledge and advanced procedural skills...They must have the skills of many specialists--the ability to resuscitate a patient, manage a difficult airway, suture a complex laceration, reduce a fractured bone or dislocated joint, treat a heart attack, manage strokes, work up a pregnant patient with vaginal bleeding, stop a severe nosebleed, place a chest tube, and to interpret (imaging studies).  They also provide episodic primary care to patients during off hours and for those who do not have primary care providers" (whew, that was a mouthful!).

“After all of your years in practice was there, maybe, a single event that especially moved you?" I asked.

"As an intern, all the patients affected me equally,” he said.  Yes, they were all important to him.  But, he went on,“I clearly remember this one patient, a young woman in her early thirties with metastatic ovarian cancer.  She was married with two small children.  She was admitted to the hospital and never left.  She died quickly.  There was nothing we could do. This was in 1981 and there were no tools to help her back then, and I remember feeling so helpless." 

"That was me in 1981, but I lived, I left the hospital," I said, frozen in fear.

I asked Dr. Kleinman to repeat the story, and he did.  Though he was taken off guard by what I had just told him. Yet, I still couldn’t take in what he was saying. When I listened to the recording of the interview later I was jarred by my deafness.  Why did I not hear what he said? I don’t know. (I guess that’s why doctors learn to repeat themselves, repeat themselves, repeat themselves.)

Calvin and Hobbes

Yes, denial.  "Something horrible happens, and our mind plays tricks on us, tells us that it never happened, that it occurred differently than it really did, that it isn't quite what it seems.”  This often works for what has happened in the past. According to Dr. George E. Vaillant, “such trickery can reveal the mind at its most creative and mature, soothing and protecting us in the face of unbearable reality, managing the unmanageable, ordering disorder...putting out in the world what was not there before."  But in the ER the truth must be faced directly; denial is a poor option.

Dr. Kleinman knows this.  In his decades of work, how many thousands of times has he had to give unwelcome news to his patients?  How many times has he imparted unbearably sad information to loved ones?   How many times has he been forced to give up and admit failure?  That Josef will not find Lili.  But how many more thousands of times have things turned out well, much better than expected?   

Maybe, like the Swedish diplomat Raoul Wallenberg or Oskar Schindler, he is just trying to

One of many such plaques

save as many souls as possible.

References:

1.   "Emergency Medicine." https://en.wikipedia.org/wiki/Emergency_medicine

2.  George E. Vaillant. The Wisdom Of The Ego. Harvard University Press, Boston, 1993.

by Anita Cherry 2/17/18

Pediatrician Dr. Nussbaum Says: "Yes, Listen to Your Mother"

Allen Nussbaum, M.D.

"I love kids, and I love watching them grow," said Dr. Allen Nussbaum, recently-retired York pediatrician.  During his 35-plus years of practice he watched carefully as mother and baby formed their unique and critical attachment.  He also observed the mother's overwhelming anxiety about being able to protect her baby, the baby she loves with a new version of loving she had not previously experienced.  He responded by allaying mothers' fears by calm reassurance, frequently saying to them, "You're a good mother, a good mom."  That was nice for us to hear.  

He told me that as a new mother, "It seems that everyone has advice for you."  Because this can be disorienting he said, "So pick one person for advice.  Read one thing on the Internet.  And pick one book on child-rearing.  Because if you don't, you will get confused."

Only one book?  Only one Internet site?  When he said this I was taken aback at first, but as I thought about it later I realized why.  

As I awaited the arrival of our adopted baby I started reading "What to Expect When You Are Expecting" (though I wasn't technically "expecting") and quickly put it down.  My husband was absolutely sure that Burton White's book on the first three years was the best, and we read the first chapter together and gave up (too much).  We knew that Dr. Spock was popular once but sorely out of fashion now.  

Lioness and Cub by Billy Dodson

But later, as I held our daughter in my arms and looked down at her and she looked up at me I realized that if I followed my mammalian biologic evolutionary heritage, and was fully present, and in the moment, and went by instinct everything would go the way it was meant to be.  Dr. Nussbaum was right.  

What is involved in the specialty of pediatric medicine, a specialty that, according to Dr. Nussbaum, must be a true calling?  James Hughes (in his "Synopsis of Pediatrics," 1979, p.1) states that:

"Pediatrics is the knowledge of genetics, for this governs the seed.  It is the knowledge of the events of prenatal life, for this is the soil in which the seed grows.  It is the knowledge of the newborn, the infant and the young child, for this is the early growth period.  And it is the continued scientific supervision of the child until he [or she] achieves maturity."

Gesell and Ilg 1943

Gesell and Ilg write that "in a biological sense the span of human infancy extends from the zero-hour of birth to the middle twenties.  It takes time to grow."   And that, "physical growth is a modeling process which produces changes of form, and at the same time preserves a basic constancy of form.  That is the paradox of all growth--the baby remains himself despite the fact that he is constantly changing.  It might even be said that he is never so much like himself as when he is changing!" ("Infant and Child in the Culture of Today," 1943, p. 15).

So our pediatrician has a unique window on how we become who we are, and who we will be.  

I asked Dr. Nussbaum if he could tell me what led him to want to be a physician?  Without hesitation he said, matter-of-factly, "My mother decided I would become a doctor."   In his nerve-wracking medical school interview he was asked this same question (of course) and he replied the same way, and, as he told me with no irony, "And they took me!"  He then went to Temple and did his Pediatric training at Children's in Cincinnati.

I wondered if he could recall for me some especially high or low moments in his nearly four decades of practice.

"Getting an 18-month-old through an exam without tears was job satisfaction."  Though this sounds like a particularly low bar it is more likely the mark of a caring physician constantly honing his craft.  Dr. Nussbaum paid close attention to seemingly simple things.

Where other physicians might be satisfied by responding to parents' questions in the middle of hectic office hours by texting he needed to hear their voices to gauge their needs, and he always called them on the phone.  If there was a problem at ten o'clock in the evening he told parents to meet him at the office.

"One of the saddest memories was of a baby with acute meningitis.  This was due to Haemophilus influenzae type b (a bacterial illness, not the flu)," he said.  She was diagnosed and treated fairly quickly but the disease progressed rapidly and she died.  Her tragic death and the terrible pain it caused stayed with him.  

The vaccine against Hib was introduced in 1985 and it is 99% effective in preventing disease.  Before it was available there were about 20,000 cases of invasive Hib disease yearly in the U.S. and 1,000 deaths.  In 2006 there were 29 cases.  In 2008 there were seven cases in Pennsylvania.  One child had only a single dose of the vaccine (three or four are needed); the others were not vaccinated at all.  Three of these children died.

Hib cases in England before and after vaccine

In light of his experience Dr. Nussbaum said, "This (vaccine) has been a blessing and I always give that shot first."   The Hib is, of course, one of an ever-lengthening list of recommended childhood immunizations that have saved millions of lives worldwide over the past 50 years including two to three million deaths yearly due to diphtheria, whooping cough, tetanus, and measles, according to the World Health Organization.  Vaccination is one of the great success stories in medicine; prevention is way better than cure.  

But what about people now who fear or mistrust vaccines, saying that such treatments are dangerous and not necessary and refuse to allow vaccination of their children?  He said, "There has always been a group of people that is against vaccinations of any kind."  He and his group wrestled with this dilemma.  He said that while parents have an "absolute right to decide what to do for their child" his practice, as a group, also has the right to follow their conscience and to refuse to treat such patients.  They were, therefore, nicely referred elsewhere. 

Though no longer in practice he remains part of the York community and he is still surprised when parents greet him around town and happily remind him of the pearls of child-rearing wisdom he gave them.  He thought that he was just imparting, in his words, "common sense."  Maybe we all need more of that.  

by Nguyen Thanh Bin

After thirty years the mystery of the long journey of reciprocal love that is parenting has become clearer to me.  A woman is rarely fortunate enough to be at the right time and the right place emotionally, fully prepared, when her baby is placed in her arms.  Parents, like children, are incomplete works and are always becoming who they will be.  The stage may be set, a home, a special room for the baby, a crib, and a box or two of diapers.  But the woman is new to her task and learns on the job.  As children develop they teach their parents that while parenting itself is a fully-natural job it is still maddeningly confounding!

I wonder what would have happened if, when I was developing as a child, I had listened to my mother, like Dr. Nussbaum listened to his?  What if we all listened to our mothers?

References:

1. Hughes, James G. Synopsis of Pediatrics, Fourth Edition. C.V. Mosby, 1975 
2. Gesell, Arnold and Ilg, Frances Infant and Child in the Culture of Today. Harper and Brothers, 1943

Dr. John Manzella's Microbial World

Dr. John Manzella

So, say you are in the seventh grade and the assignment is to write a book report on a famous person. And say this is the late 1950s.  And maybe your favorite uncle was a doctor.  And maybe your uncle miraculously cured your mother’s “quinsy” (a painful abscess next to the tonsil)  a few years ago.  And maybe you were bowled over by that.  Well, you go to the school library and you look for a biography that engages your interest.  If you are John Manzella you read about Louis Pasteur and you think, “This guy is really cool!”  

A Children's Book

The French microbiologist (1822-1895) was the first to blame micro-organisms for spoiling of beer, wine, and milk.  He found that he could prevent this, and the economic losses it was causing, by heating the liquids.  Hence...pasteurization.  

In 1859 (the year of Darwin’s “On the Origin of Species”) he proved the “germ theory” by showing that a heat-sterilized liquid without further exposure to the air remains sterile (that is, life only comes from life).  He created vaccines for prevention of rabies and anthrax.  When he claimed that microbes spread diseases among humans the scientific community was skeptical.

Dr. Manzella didn’t tell me what grade he got on his book report (we will assume it was an A+) but it had a lasting impact.  In high school he liked biology and in medical school he, in his words, “became totally smitten with microbiology."  He attended Canisius College (like his uncle) and went to the SUNY University at Buffalo medical school.  He moved away from snow and went to  the University of North Carolina for residency training in internal medicine (and for basketball).  Two of his most impressive attendings were infectious disease specialists.  The emotional and intellectual connection could not be ignored and he took a fellowship in infectious diseases.  

He joined the York Hospital staff in 1979 and enjoyed his practice as he diagnosed and treated acute infections.  Infection control including rigorous hand-washing was stressed, and all was well.  But then something happened.  

Dr. Manzella faced a frightening situation as young men, men close in age to him, were struck with infections that were not supposed to occur in formerly-healthy individuals. The appearance of AIDS in 1981 forever changed his practice.  Several very intense years ensued as patient after patient suffered and died without explanation.  But in 1984 Dr. Gallo with the NIH and Professor Luc Montagnier from the Pasteur Institute in France (there’s Louis again!) shared in identifying the HIV virus causing AIDS, and there was hope.

However, there was no treatment for the underlying immune deficiency until 1987 when AZT was taken off the shelf and repurposed.  Dr. Manzella was hugely gratified that “something” could now be done.  As he cared for individuals with a chronic viral infection the long-term relationships changed him.  This was, he noted, the most singular experience he had in his life in medicine.  

After highly-active antiretroviral therapy became available in 1995 HIV truly became a “manageable” illness.   But where had this threat to society come from?  

Drop in Deaths after HAART

HIV/AIDS is a zoonosis, an infectious disease caused by an organism that changed and made the leap from a non-human animal host to a human victim.  The HIV virus evolved from a virus infecting chimpanzees in West-Central Africa.   

Zoonotic diseases can be due to viruses, bacteria, fungi, protists, parasites, worms, or misfolded proteins called prions.  They include scary things like rabies, Ebola, Zika, SARS,  MERS, Mad Cow, West Nile, plague, and bird flu, but also common food-borne salmonella and certain E. coli infections.  Zoonoses are fostered by our close connections with the natural world, with other living creatures (as exhaustively reported in David Quammen's "Spillover").

"Spillover" 

Lyme disease is another zoonosis endemic in our area and many of us know someone touched by it (or the fear of it).

One early summer day about fifteen years ago my husband had a circular red rash above his belt-line; he recalled no tick bite but it was itchy.  He had not been in the woods or around deer and he didn’t feel sick, but I said (with absolutely no experience to back it up), "You have Lyme disease!"  

He looked at a photo of the typical bull‘s-eye rash in one of his medical books and thought it dis not quite match.

Bull's eye rash of acute Lyme infection

But by the third day he was not feeling so great and I made an appointment for him to see Dr. Manzella.  He resisted (of course) but he listened and he was immediately put on doxycycline for three weeks.  No blood testing was done since he was seen early, before the diagnostic (IgM) antibodies would appear.   

Within 24 hours the spirochetes responsible for the sickness were being killed off and he developed fever, chills, shaking, and muscle pain of the so-called Jarisch-Herxheimer reaction, confirming Dr. Manzella’s clinical diagnosis.  We were relieved.  But my husband was still achy and tired for about two months.  Adequate treatment, we are told, almost always eradicates the disease, but it took time to feel better.  What if the rash is missed and treatment is delayed?  What then?  

I asked Dr. Manzella.  With early widespread infection, there may be nervous system involvement with headache, stiff neck, and facial paralysis.  There may be a heart arrhythmia, or acute arthritis (usually of the knee).  The neurologic and cardiac problems resolve with the standard treatment of two to four weeks of antibiotics.  But the joint symptoms may remain troublesome for a few years despite therapy, even though bacteria are no longer found in the joint.  Why do people then talk of chronic Lyme?     

Dr. Allen Steere (who was the first to identify Lyme disease in 1976) in a recent review notes that “In about 10% of patients with erythema migrans (the rash), and perhaps a higher percentage of patients with neurologic Lyme, fatigue, cognitive complaints, and musculoskeletal pain can persist for more than six months, or even years, after antibiotic therapy.”  He notes that placebo-controlled, randomized treatment trials of antibiotics (the gold standard) in patients with this syndrome have not demonstrated clinical benefit, and that evidence for the persistence of infection has not (to date) been found (Steere 2017).  

Dr. Manzella said that he is in agreement with these thoughts, conclusions also supported by the Infectious Disease Society of America.  He warns that prolonged antibiotic therapy has substantial risks including the development of resistant organisms, the nasty C. diff diarrheal syndrome, and indwelling catheter-related infections.  As Dr. Steere says, “Additional studies are needed to better understand the pathogenesis of persistent symptoms and to determine the best approaches for symptomatic relief.”  We don’t have all of the answers, and we need to be careful while we are looking for them.

(For example, a pending legal suit against the CDC argues that it suppressed a DNA test for Lyme that is many times more sensitive than the ELISA and Western Blot tests that are

currently used. The scientific community is still grappling with the limits of the technique and we need to be patient as we wait for the answer.)

So how did my husband get his Lyme?  In the garden.  We “knew” of "deer ticks" and the local deer problem, but it turns out that it was the black-legged tick carried by white-footed mice that transmitted the bug.  The busy housing construction in our neighborhood disturbed their natural habitats and they ended up invading our property.  Or did we invade theirs?  

Where will the next zoonosis come from? And will we be able to manage it? And who will be there to help us? 

Maybe somebody who is busily writing and stressing over a middle-school book report.  

By Anita Cherry 1/27/18

Addendum for those of us worried about ticks and acute Lyme disease (having weathered the expected zoonotic pandemic), the Infectious Disease Society of America, the American College of Rheumatology, and the American Academy of Neurology note:

We recommend that prophylactic antibiotic therapy be given only to adults and children within 72 hours of removal of an identified high-risk tick bite, but not for bites that are equivocal risk or low risk (strong recommendation, high-quality evidence). Comment: If a tick bite cannot be classified with a high level of certainty as a high-risk bite, a wait-and-watch approach is recommended. A tick bite is considered to be high-risk only if it meets the following three criteria: the tick bite was from (a) an identified Ixodes spp. vector species, (b) it occurred in a highly endemic area, and (c) the tick was attached for ≥36 hours. 

From: AAN/ACR/IDSA 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clinical Infectious Diseases, Volume 72, Issue 1, 1 January 2021, Pages e1-e48. (A reliable and complete reference,)

AC and SC 4/12/24

Polly Rost, PhD:On The Other Side Of The Couch

Since the older parts of our minds evolved long before the late appearance of consciousness their “automatic” work is not accessible to awareness.   The function of our “adaptive unconscious” (as Dr. Timothy Wilson in “Strangers to Ourselves” calls it) is completely hidden from view.  

"Strangers to Ourselves"

Through talk therapy our fears, phobias, and traumas that reside deep in the ancient parts of our brain can be brought to awareness so that they can be understood, and inhibited.  It falls to the skilled psychotherapist to help us understand how to rebalance the system and alleviate distress.  It is sad that we often have to feel our hurt intensely before we look carefully into what makes us who we are.

I had met Dr. Polly Rost many years ago, and I decided to ask her for an interview.  She enthusiastically said yes.  She is a York native, and she received her Ph.D. at Temple.  She started her practice of clinical

Dr. Polly Rost

psychology in 1986 from a small rented office on South George Street.  She said that she had “no grand plan or vision” and  that the growth of her practice was solely “due to the growing needs of the community."  The practice has thrived, and her 14 therapists help meet the needs of our town inside a stately Victorian home a bit further north on the same street in the city where she began.  

I opened the weathered front door and sat in the small sun room on the side of the house and waited for Dr. Rost.  I remembered coming here years ago in pain. Wouldn’t it be easier, I thought, to hook ourselves up to Dr. Wilson’s “Inner-Self Detector”?  After attaching electrodes to our scalp and adjusting a few dials we could ask it questions such as, “What am I really doing here today?”  And the machine would display the answer... just like that!

Anyway, Dr. Rost greeted me and I followed her into her therapy room.  Gordon, her lazy gray cat, was lying on his back displaying his belly.  Sinking into the well-worn cozy wing chairs we sat across from each other.  The stray cat and Dr. Rost had found each other years ago behind the house.  I thought, “What makes him different than the others in the house who come and go?”  Why, he lives here, he stays here, and is protected.

I asked Dr. Rost how she came to be a therapist.  She quickly said, "I love science and people.  I was delighted, even in high school, by being sought after by peers.  I was known as being a problem-solver.  And I learned in college that I was helpful to those around me too.

Before Insurance Coverage for Mental Health

 I realized, on some level, that just being available and helping people figure things out was good in and of itself."  And that is what she has done for the past three decades.  I was curious to know how her practice has changed.

Without hesitating for a second she got up from her chair and walked over to a bookshelf.  She handed me the second version of the “Diagnostic and Statistical Manual of Mental Disorders” (so-called DSM); it was about 40 pages.  She then produced the 2013  “DSM-5.”  It ran for  947 pages, more than 20 times as long!   I was struck by the difference; here was evidence of great work in understanding and treating mental illness.  

Tattered DSM II, 1968

I flipped through the tiny book and my mind wandered to what it was like in the early 1980’s when I faced cancer myself.  I was given exactly three short once-over visits with an oncologist-psychiatrist, visits to be used over two years.  No “tools” were provided to deal with the emotional trauma of a cancer diagnosis, and I was not exactly sure what these sessions were supposed to do for me.  Maybe there was no appropriate DSM code back then for young patients such as me.  No-one saw that my coat of armour was missing a few laces.

We now do better.  Just the other day (11/20/17) the BBC reported a Malaysian study in which 20% of cancer patients had full-blown post-traumatic stress disorder six months after their cancer diagnosis, and that nearly 6% still had debilitating PTSD four years later. The hopeful finding was that, compared with other cancer patients, women with breast cancer were three times less likely to have developed PTSD. The difference seemed to be due to the early counseling these patients received. Patients with serious life-threatening illness like cancer no longer have to carry the hidden burden alone. Caring and empathic doctors like Dr. Rost and her staff can help them navigate through, and come to understand, the early anxiety and fear of trauma to be able to prevent problems later.

"The Neuroscience of
Psychotherapy"

She is pleased that there is more ready access to therapy, and that our culture is more willing to include improved psychological along with physical functioning as a goal.  She feels that there is more  respect for the power of psychology now, especially seeing that as a culture we have come to value the quality of life; our personal lives, our relationships with others, the all-important parent-child bond.  She is glad that the medical community and the schools recognize that a multidisciplinary approach to psychological stress “can make all the difference.”  

Dr. Rost is an optimist, noting that our understanding of biochemistry and the brain's workings has enhanced our ability to relieve suffering, and she predicts that “one day there will be a blending of psychology and neurology.”  

Who are your most difficult patients?" I asked.  She paused, and said that after she sees patients at the hospital for "group" and she leaves the third floor Psychiatry Unit someone may see her stumble and ask, “Are you okay, Polly?"  Her quick response is to say that she’s fine.  She said that she never leaves these moving sessions without being deeply touched by the depth of the pain experienced by the hurting patients.   

She wishes that “others could somehow appreciate how dark it can be at times” for those who suffer.   And she works “very hard to bring sunshine to them.”   Her patients know that she will never give up on them, and that they will somehow work things through together.

Feeling her own emotion surface as she spoke, I asked if she is spiritual.

“Yes,” she replied, “I am one of the few people that can be sitting still and sweating at the same time that all of my being is (invested) in the patient in front of me.  There are times when I hear it, but I am not sure how to get things across to the patient.  I say a quiet little prayer,  ‘Please help me put this in a fashion that can be tolerated and is useful,’ and then something magically comes.” That is good, in and of itself.  

The Couch (Freud's, not Dr. Rost's!)

When Your Doctor is Your Friend ("Insights from Dr. Sanstead and 35 Years of Practice in York")

Jack Sanstead, M.D.

We have an absolute need to live with other people.  As Rabbi Jonathan Sacks has noted, “We reproduce as individuals, but we survive as members of a group.“  This is how we are still here.  Dr. John Sanstead recently retired from his practice of medicine  and he frequently reminded me that we are “big social animals.”

When the brain is finished with the task at hand it lapses into a default network.  That is, what it does when it has nothing pressing.  Matthew Lieberman (in “Social: Why Our Brains Are Wired to Connect”) has studied this and concludes that the "default network" is there to help us do our most important job as humans, to learn how to cooperate and share with others.  Thousands of hours of brain activity go into making sense of the people around us and of our role in the group.

There may be a limit to the size of such groups. According to the anthropologist Robin Dunbar this relates to brain size.  Our large brain allows us to have stable relationships with 150 people, casual friends.   These are “relationships in which an individual knows who each person is and how each person relates to every other person.”  Fifty is the number of our close friends.  Fifteen is the number of people we confide in and sympathize with, but are not true intimates.  Five is our closest support group, our best friends or family members.  On the other end of the scale, we may be able to put a name to a face for 1,500 people.  The composition of groups changes through time.

The number of our closest supports

When I was 23 a member of my close group, my family doctor and neighbor, died two weeks after he diagnosed his own pancreatic cancer.  At his funeral those that gave eulogies felt deeply that they were his friends.  So did the other shocked mourners in the audience.  We all felt the same connection.

More than 40 years later my general internist who cared for and counseled me though several difficult problems retired, and I again had a sense of loss.  Though he could no longer address my health he did agree to an interview.  I wanted to know what he had seen in more than 35 years of practice in York and what his concerns were for the future.  We sat in his cozy living room with the soothing “tick-tock” of a grandfather clock to keep us company.

I put my iphone on the coffee table between us and tried to turn on the recording app but the little “working” thing went round and round so I resorted to pen and paper. 

Why did he decide to become a doctor?  At Dartmouth he majored in Chemistry and minored in Religion.   He considered basic research, but he realized he preferred the socialness of listening to people, that this is where he would fit in.  In the late 1960’s youthful idealism and the reality of  a deeply unpopular war permeated college campuses and shaped his view of a world that was not black and white.

Vietnam War protest at Harvard in the 1960s

How would he contribute?  He turned to medicine.  He got his degree from Jefferson Medical College and did Residency training at Duke and the University of Pennsylvania.  He settled in York for his practice of medicine and geriatrics.   He had mastered science and learned textbook medicine in training but had brought the ability to feel what others feel with him.

Dr. Sanstead joined a practice and taught residents.  He greatly enjoyed being needed and found that he could know his patients through active listening.  After establishing a diagnosis guiding the patient  through (sometimes difficult) treatment or (imperfect) management  was rewarding.  But he always remained careful when recommending action. He took time to know the patient and their family dynamics; time to befriend them.  He accepted them just as they were, hoping this would allow them to accept themselves.  He always saw the good.  And as a friend, he needed to protect. 

Among the problems confronting those with illness, problems that may be physical, emotional, psychological, or  financial, one that particularly worried Dr. Sanstead was the overuse of prescription medicines.  While medicines for hypertension, for example, have been spectacularly effective in preventing heart failure, kidney failure, and strokes, others he saw as of dubious benefit and of unproven long-term safety.

For this he directed me to “An American Sickness” by Elisabeth Rosenthal who notes that in “1991 the FDA relaxed its rules for what constituted proof that a drug was effective…(as) drug makers no longer had to show that their product actually cured the (illness)...they could measure things like blood markers” (p.99-100).  He saw that this warped the pharmaceutical industry, as “pushing” of drugs for profit became the sole driving force, not the welfare of the patient . The cost  of medicines soared, and the benefits were inobvious.  This made him feel sad.  He protected his patients by refusing to be swayed by the lure of using the latest (and heavily advertised)  drugs without convincing data to support their use.  (Direct-to-consumer advertising is permitted only here,  in New Zealand, and in Hong Kong.)  He was also exceedingly cautious not to order  testing or recommend surgery when the benefit was questionable or marginal.

Dr. Sanstead loved seeing his patients out in the community, and feeling a part of it.  He  loved learning from patients and watching them grow, and said that he would have seen them for free (well, maybe not entirely for free).

Since leaving practice he has felt somewhat lost, he sorely misses the socialness of his life’s work.  His own Dunbar number used to be in the tens of thousands, now it is a whole lot lower.

Published in the York daily Record 11/12/17.