Friday, February 17, 2023

Dr. Lynn Jensen: ER physician who aimed to hit the right notes

 

Dr. Lynn Jensen
Nearly two years after I asked him for his story, Dr. Lynn Jensen decided that it was time. But his wife, Dr. Leslie Robinson, who relayed the information to me, said that I had to wait until after archery season.  Archery season? I imagined him aiming at a big plump yellow, red, and blue target set up on a tripod as I recall from summer camp (where the flicked bowstring really hurt my forearm). But that was not the archery Lynn had in mind. 

You see, he was going to traipse into the woods, climb up a tree into something called a stand, and use a bow and arrow (yes, an actual bow and arrow!) to hunt for deer. If successful, he would drag the poor dead animal out of the forest and butcher it himself, to be safely stored away for the winter. Have you ever heard such mishegas, such craziness?

Anyway, the hunt being finished, Dr. Jensen finally came by to talk. He started off by telling me that he went to medical school at the University of Michigan and that this is where he and Lesie got together. (Though they were quietly attracted to each other when Lynn was funding his education by working as a painter and was doing Leslie’s parents’ house). 

Sprawling University of Michigan Medical Campus
(From The University of Michigan)
He left Ann Arbor in June of 1975 and promptly began his one-year so-called rotating internship at the York Hospital in July. His initial assignment was the emergency room. And on day one, as the seasoned staff physicians left for home at eleven, Dr. Jensen was the only doctor in the ER until the morning. Fortunately, he noted, he was supported through the night by experienced and compassionate nurses. And he was wise enough and humble enough to listen as they gently guided him. 

Before his time, he said, the nurses would see patients at night without waking, without bothering, the doctor, if they felt they could handle things on their own. They would then have the attending physician sign the stack of charts first thing in the morning.

Lynn admitted that “it was trial by fire.”  An intern in the ER by himself in the late 1970s had to be able to pick up things quickly, to be able to learn on the job, and act confidently without the help of the wide variety of rapid blood test results and advanced imaging studies now available. He said that you had to “use your brain” to make sound clinical judgments. For example, when someone came in with chest pain or belly pain you had to think systematically to generate a list of the most likely diagnoses while making sure not to miss something really serious, maybe life-threatening, even though much less probable. 

Cartoon noting the many causes of chest pain
(From artibiotics by Ciléin Kearns)
Young Lynn found it somewhat surprising that he quite liked the experience. That this type of acute medicine suited him. That it fit his learning style and personality. He said that “when you know you're going to be there (in the ER) by yourself you have a tendency to prepare that you would not have if you were being babysat.” 

In fact, there was no recognized specialty of emergency medicine itself until 1979. Any physician could work in the ER, even residents who needed extra cash.  So, after only a year of formal postgraduate training, Lynn decided to do emergency work full-time. He enjoyed the challenge and he could make enough money to allow Leslie to attend medical school herself (at Hershey, just 40 miles away) without incurring debt.  

He found the sometimes hectic ER work stimulating and rewarding, and he “sat for” and (of course) passed the oral and written Emergency Medicine Board exams. And he was active in the residency teaching program championed and developed by Dr. David Eitel, said Lynn. So, practicing acute medicine in the ER “just kind of stuck for a thirty-five-year career.” 

Dr. Jensen especially liked the demand of trying to meet each person’s specific needs even though he would likely see them only once and not have an ongoing relationship. He appreciated the importance of  “critical thinking” and informed decision-making when dealing with urgent (or even not-so-urgent) clinical problems; often with incomplete or misleading information, and the ever-constant pressure of limited time. 

According to ER physician and writer Dr. Jay Baruch, “to be an emergency room doctor is to be a professional listener to stories. Each patient presents a story; finding the heart of that story is the doctor’s most critical task. More technology, more tests, and more data won’t work if doctors get the story wrong.”

Doctor Who: "Listen" (From the BBC)
(The episode was "a creepy study of fear and loneliness")
So Lynn dutifully practiced his craft and tried to get the stories right as he took care of his patients, quickly establishing a working diagnosis while calming their anxieties and allaying their fears whenever possible. 

He told me that the first twenty years at the York Hospital were good and that he was happy. But things began to slowly change. He lamented, most especially, that the practice of medicine gradually became more and more influenced by corporate bureaucratic interests. And, importantly for the day-to-day practice of physicians like Dr. Jensen, the electronic health record (the EHR) was born.

Sure, paper charts, when they could be located in a timely manner and retrieved from the records room or one of the floors and brought to the emergency department (no longer just a “room”) had their problems. The handwritten progress notes were occasionally nearly illegible, and sometimes several thick volumes with page after page had to be combed through to find what you needed. But dealing with paper was simply the way it was, and it was okay. 

The now-obsolete but familiar paper charts
(From shorelinerecordsmanagement.com)
The first EHRs arrived with the promise of better efficiency and improved accuracy. But they were awkward and seemed to be designed by individuals not familiar with actual patient care. Oddly, the ED, where time may be critical, was chosen as the guinea pig for the new system at the hospital. Dr. Jensen found the chosen version to be needlessly cumbersome and intrusive, and frustratingly time-consuming. Over time, he began to feel that he was practicing medicine while wearing handcuffs. The electronic record was clearly built, he said, for something other than taking care of sick people.

And he gradually realized that the important diagnostic and interpersonal skills he had acquired by talking with and meticulously examining thousands of worried patients were becoming less valued than the results of increasingly sophisticated, but often superfluous, imaging and other tests. Seeing disembodied images became believing; the cold objective numbers from the lab told the tale. No need to listen to, or touch, the patient. This was very disheartening for Dr. Jensen to witness.

And as the ED became more and more crowded, more overloaded, Lynn eventually became tired of coming into work in the mornings and apologizing to patients who were being kept overnight in make-shift beds in the hallways.  Having to apologize for something that was not his doing.

The Maimonides ER after Hurricane Sandy 
(From The New York Times)
Regarding this very common scenario, Dr. Jay Baruch notes that:

Crowding and prolonged waits in the ER are more than an inconvenience; they’re linked to grave medical consequences, including higher inpatient mortality, longer length of stay in the hospital, increased medical errors, more harmful cardiac outcomes, and delayed treatment for pain. (p. 108)

So, at some point, Lynn decided that he had enough. And Dr.  Baruch has this to say about "burnout," or moral injury and disengagement: 

Many influences contribute to burnout in medicine. They include lack of control over the work environment, a disparity between personal values and those of the system, more time spent with electronic health records then with patients, and a sense of not making a difference. (p. 102)

We can readily see some of these factors playing a role in Lynn’s story and his decision to retire early. So he left clinical medicine at 62. Since then, he has had dreams of being back at the hospital. In some of these dreams, he’s frustrated as he deals with the cumbersome EHR. In others, everything ”goes to hell” and he has to reassure his beleaguered coworkers and nursing staff that they are just in his dream and that things will be okay. 

And in these lucid or sentient dreams, as he is aware that he is dreaming, he has sometimes wondered why he even agreed to take the shift in the first place, knowing that he no longer had privileges at the hospital and was not allowed to see patients at all! Lynn said that, ironically, he did not recall dreaming about the ED when he was actually working there.

The pattern of 40 Hz brain activity in lucid dreaming 
(From "New Scientist)"
Dr. Jensen told me that he would have probably continued to practice to age 70 if he felt he was still able to deliver what he considered to be high-level care. And he said that as he got older he cared more. Anyway, he did a few years of didactic teaching after retiring from hands-on work but decided to give that up as well when he sensed that he no longer had “credibility,” when nobody knew him anymore. 

Reflecting on his experience, he said that while manning the ED with talented colleagues suited him well overall he would not make the same career choice now. What would he have done instead? He thought a moment and offered that he might have gone into ophthalmology.

This brings up the question of how Lynn decided to go into the medical field in the first place. Nobody in his family was in medicine. His father was a Presbyterian minister in Valley Forge and his mother had a degree in home economics. Both of his parents were strong advocates for social justice and international peace. So Lynn was raised in a culture in which getting an education was important, and providing service to people, providing something of real value to others, was expected. And Lynn thought that he should also be a good provider for his family.  

Valley Forge Presbyterian Church, King of Prussia in 1956
(From the Presbyterian Historical Society)
He was certainly smart enough, as he was the first student from his high school, Upper Merion, to attend Harvard, and a career in medicine as a way to help people was an obvious good choice in the idealistic late 1960s. Becoming a professional poker player, to take a trivial example of another option, would not be an acceptable career choice (though he admitted that enjoys the game) since it gives nothing to others, he said, apart from a bit of light entertainment. 

(Lynn comes from a family of four and his older brother chose the same path and is a primary care doctor.)

So Lynn and his wife, OB/GYN-turned-urogynecologist Leslie Robinson (her story can be found here), were able to successfully navigate two active medical careers while raising their two children (Annie is a pediatric ophthalmologist and Dane is a clinical psychologist). And they brought two complementary styles to the task, noted Lynn. How so? For example, take the simple task of packing a dishwasher as an insight into people. Dr. Jensen said that he will carefully read the directions and make sure that everything is fitted into its proper place to avoid “shadowing.”  Leslie, on the other hand, will just cram in everything she can, filling every possible crevice until there’s no room for anything else. (What does your dishwasher style say about you?)

"First and foremost, load the dishes with the dirty side down and
at an angle toward the center of the dishwasher; don't overload it."
(From WikiHow)
And in retirement, Leslie (in line with the above) fits more into a day than anyone Lynn knows; he can’t keep up with her, he said, though he is busy, too.  He hunts for deer (when in season), plays pickleball (having given up the more strenuous racket sports), does close sleight-of-hand card magic (no self-working tricks for him), reads critically (non-fiction), and keeps up a daily routine of practicing the piano (especially enjoying the classical works of Schubert and the modern difficult 12-tone compositions by Samuel Barber). Yes, Dr. Jensen still seems to like doing stuff that requires lots of patience and focused hard work.

Well, after the pleasant ninety-minute interview came to a close my husband walked Lynn back to his car, at which point Dr. Jensen admitted that maybe he was getting a bit too old to be deep in the Pennsylvania woods by himself strapped high in a tree in chilly November waiting for a suitable target for his sharpened arrows. But maybe not.

Archer Dr. Lynn Jensen perched securely and scanning for prey.
(How did he get up there? And how will he get down?
And who took this photo?)



Readings and references:


1. Baruch, Jay. Tornado of Life: A Doctor's Journey Through Constraints and Creativity in the ER. MIT Press. Cambridge, Massachusetts, 2022. (A very candid series of short takes on ER work.) 

2. Ceresi, David. "Aim for safety in your tree stand." Mayo Clinic Health System Oct 7, 2022 (3,000-4,000 hunters are injured each year in the US falling from tree stands; Dr. Cresi explains how to prevent this.)

3. Talbot, Simon G. and Dean, Wendy. "Physicians aren't 'burning out.' They're suffering from moral injury." STAT+. July 26, 2018. (Moral injury involves knowing what care patients need but being unable to provide it due to constraints beyond one's control.) 


One of my paintings from the 90s


By Anita Cherry 2/17/23

Friday, December 16, 2022

Dr. Kenneth Brein: Seeing More Clearly


Kenneth Brein, M.D.
Ken’s mother helped support the family with a thrift shop in Germantown. Her youngest son had an ear for music, so when she acquired a slightly-cracked Gibson guitar for twenty-five dollars one day, she lovingly handed it to him. He was ten years old. He practiced. And practiced. And by the time he was in the seventh grade his band, “Celestial Fire,” was performing somewhere every weekend. It was the early ‘70s and they played “everything you heard at Woodstock,” said Ken. It was his life. That is, his life apart from his early interest in science, math, and physics. Yes, Dr. Kenneth Brein confided to me that he was “the nerd” in the family. But he was a nerd with a guitar.

He did well at Harriton High in Lower Merion just outside of Philadelphia, and he thought he’d be a scientist. His father (who, said Ken, joined the Army after graduating from Overbrook High but then struggled in a variety of businesses) recognized his third son’s potential. His often-whispered advice to Ken? “Be a doctor, be a doctor...”

But when Ken finished high school in 1974 near the top of his class of 250 his plan was to study science and engineering, not medicine. He applied to four elite schools and when he visited Princeton’s 500-acre bucolic campus it was “a gorgeous day in April.” When he toured Penn in West Philadelphia, it was a gloomy rainy day. So, Princeton it would be. 

Princeton University in the spring (from the Fulbright Commission)
PRINCETON AND PENN

While in central New Jersey, Ken refined his interests and decided to study biomedical engineering. But the course offerings were limited. He took whatever he could, and for his senior thesis he wrote the complex math for a theoretical model of blood flow  (a fluid, but with cells floating in it) through the small tubes of an artificial lung. Ken was (once again) advised to go to medical school. 

So he applied to a number of medical programs, received acceptances, and chose Penn (despite his weak first impression of the area). He enjoyed learning biology and doing medicine but seemed to lose interest in research. And as he progressed through the various rotations, he didn’t develop a feeling for a particular specialty. But one day, he was given a nudge. This happened when he was visiting his mother and her second husband George at their apartment on leafy Rittenhouse Square in downtown Philadelphia.

WHY OPHTHALMOLOGY

Dr. Zubrow
His mother’s personal physician and good friend, the highly-esteemed cardiologist Dr. Sidney Zubrow (who lived in her building) called her. He said that he wanted to see Ken. Dr. Zubrow, said Dr. Brein, was “the old-fashioned internist” who knew everything about his patients. The wise older clinician gently asked the young student how things were going in medical school. He asked him what he was considering doing in his career.

Ken thought for a bit. Maybe he’d go into Hematology-Oncology, he said, having recently done an intense rotation in that.

“Try something else,” said Dr. Zubrow flatly.

“Maybe Cardiology?” (Surely, Dr. Zubrow would be happy with that answer, thought Ken.)

“Try something else,” was the cryptic response.

“Maybe Infectious Disease?”

“Try something else,” came the reply once more.

By that point, the perceptive medical student began to catch on.

“Oh. Well…ophthalmology looks pretty good,” offered Ken.

“That’s a good one,” said Dr. Zubrow.

“Maybe Dermatology?“ Ken guessed as he was guided along.

“That’s a good one.”

The attentive pupil was “getting the message, loud and clear.” And when the time came to decide on the next phase of his training, a residency, Ken chose to study the many diseases of the eye. He would have loved to have gone to the Will's Eye in Philly but was content to be accepted into the ophthalmology program at the University of Pittsburgh. So, after medical school, and a year of internship at Pennsylvania Hospital (where a portrait of Dr. Zubrow is prominently displayed) he and Jessica took the turnpike (called “America’s First Superhighway” when it opened in 1940) 300 miles west. Wait a minute! Did I forget something? Who’s this Jessica? 

UPMC Presbyterian Complex in Pittsburgh (from UPMC)
HOW KEN MET HIS FUTURE MATE

Well, during the Christmas break the first year of medical school Ken took the train to Manhattan to visit one of his college roommates. When it was time to head back to Philadelphia he boarded at the busy Penn Station. He realized that he forgot to bring a book or a newspaper to keep him occupied for the hour-plus trip. What was he going to do? As he made his way down the aisle of the crowded car he spotted an empty seat next to a pretty girl. Somehow, he had the intuition that she was from Long Island and returning to Penn (no, she was not wearing the U of P red and blue). He thought they might hit it off.

So he sat down next to her, but she made an expression like ”you're invading my space.” He would have to play his cards right. So Ken, trying to be optimistic and trying to impress, reeled off his credentials (you see, he didn’t have a guitar with him). After chatting for a while, he asked her to dinner. But Amy (that was her name) was on her way to Penn to see her (quick stab in the heart) boyfriend. However, “I have a sister you might like,” she said. So she gave Ken Jessica’s phone number. What did he have to lose? He decided to give her a cautious call and soon wined and dined her, taking her to the fancy “La Terrasse” French bistro on the Penn campus. I guess it worked out, as they married and have three adult children and six grandchildren. 

Watercolor of the well-known Locust Walk at Penn (by elliemoniz.com)

AFTER RESIDENCY, WHERE TO PRACTICE?

Though Jessica would have been happy to stay in Pittsburgh after Ken finished his three-year residency, and he was offered an opportunity there, he wanted to be closer to the Jersey shore, to tiny Ventnor City, a two-square-mile vacation spot of many soothing childhood memories. So as Ken searched for a place to practice through print ads in the journals, he learned that Dr. Charles Letocha (also a product of Princeton and Penn) in York was looking for a partner. After a series of letters (yes, actual handwritten letters) back and forth, careful Chuck finally decided to meet Ken (and Jessica). They clicked right away, and Ken moved to York and joined the private practice in 1986. 

As a clinical ophthalmologist, Dr. Brein focused his energies on perfecting his skill in cataract surgery, addressing the clouding of the lens in the eye that is the cause of half of the world’s blindness. But a type of blindness that can almost always be cured.  

CATARACTS

Let’s talk about the cataract. The clear crystalline lens focuses incoming light to the fovea at the back of the eye, the area of the retina with the highest density of light-sensitive cones serving color vision. With age, (and UV light exposure) the proteins in the lens change and coalesce and the lens becomes progressively opacified, letting less and less light pass through. Though attempts to stick a sharp needle into the eye (ouch!) to push the clouded lens out of way go back as far as the fifth century BCE in India, the first “modern” cataract surgery was performed by a French surgeon in 1747. Serious complications were not unusual, and vision after the procedure was poor; thick heavy “Coke bottle” glasses were needed to see clearly in the absence of a lens. 

So physicians used to wait until there was a nearly complete loss of vision before removing the severely opaque lens. But advances in surgical techniques eventually made the procedure much safer. And Dr. Brein said that cataract surgery was revolutionized by Dr. Charles Kelman in 1967.  He devised a procedure termed phacoemulsification. With this, a thin ultrasound-driven needle inserted through a tiny incision breaks up then and then sucks it out. This is a very safe technique. It is the standard now, though it took a while to catch on (like most bold innovations in medicine). 

The development of the plastic artificial lens in 1974 by Dr. Harold Ridley in London to replace the worn-out body part provided a much more satisfying vision outcome for patients. And when the foldable plastic lens was invented in 1980, the incision required to insert it became even smaller and less traumatic.

Phacoemulsification and intraocular lens implant (artwork by Christine Cote)

For experienced surgeons, like Dr. Brein and his partners, cataract surgery became extremely controlled and consistent. And it is claimed that nearly 98% of patients can expect a successful outcome, a truly remarkable statistic for any surgical procedure. Complex lenses can now correct a variety of refractive errors, like astigmatism, etc. Over his satisfying 31 years in practice, Dr. Brein was able to deliver better sight to many thousands of individuals in York. 

HE HAD TO STOP DOING SURGERY

But Dr. Brein had to stop performing the extremely delicate surgery after he developed nerve injuries affecting the strength and coordination of his right hand. He underwent surgery for median and ulnar entrapment, but recovery of dexterity was slow and he did not want to expose his patients to the risk of a slip-up (fear of such things during his practice would sometimes keep him up at night) so he put away his scalpel. He still saw patients for refractions and for the diagnosis of the many ailments that can affect the eye, but he could no longer offer them his surgical expertise. He was okay with that, but then something else happened.       

ANOTHER BLOW

This next part of Ken’s story is particularly difficult to take in. And it was painful for me to hear. It happened five years ago. 

It was a routine day at his office. For a few weeks, Ken had been experiencing what he thought was right-sided tooth pain spreading into his cheek. He did what many doctors do (and shouldn’t): he diagnosed himself. He assumed that he had developed maxillary sinusitis. But when Ken spoke with his wife from the office he sounded confused. It was clear to her that something serious was wrong. Jessica told him in no uncertain terms to stay put. That she was calling for emergency medical services. She then spoke with one of his partners, Dr. Matt Bilder, and said, “Make sure he gets into the ambulance.”

A head CT scan in the York Hospital ER showed that Ken had a right frontal lobe mass, an angry-looking mass compressing and distorting the brain. There was swelling and an ominous “midline shift.” He had to be admitted to the ICU to be monitored and watched closely. Later that night, he was wheeled away for an MRI.

Well, it turns out that Dr. Brein had created his Wellspan Health account a week before. With this part of the electronic health record, a patient can use their laptop or their phone to view their test results, any time of the day or night, wherever they are, even when they are in the hospital. So, lying in the ICU, with several IVs dripping and devices beeping and flashing and keeping time, alone in the darkness, he picked up his iPhone and cautiously opened his portal. There was a message: “You have a new test result.” The report of the MRI was already posted!  Ken paused briefly, then opened the document. The radiologist felt that the mass was a tumor, “most likely a glioblastoma.” Ken, was very aware of the terribly grim statistics for survival after the diagnosis of a GBM and thought, “I’m dead.”

Images of a frontal GBM with a midline shift (from David C. Preston)

“How were you able to deal with this?” I asked.

Ken waited for a moment, and then replied: “I have not said this before, but I think I went into denial.” 

You see, when he was an intern in Center City Philadelphia he had taken care of a woman dying of this rapidly progressive untreatable tumor. So while he knew “intellectually” that he had received a death sentence he quickly determined that this harsh decree would not cripple him emotionally. 

“Do you think you should have been allowed to view that MRI report, to be faced with such a grim diagnosis when you were alone?” I asked (but already knew the answer).

“No. I don’t think I should have been put in the position to see the test results at that point,” he answered. Sure, one of Ken’s doctors did come in the following morning to talk about his MRI and to explain things, but the psychic punch of facing imminent mortality had already landed; he said his “whole world was turned upside down” in that instant. 

He recalled that early in the AIDS pandemic when there was no cure (there still isn't), and no effective treatment, the results of the testing for the HIV virus were to be given to the patient only with the help of a counselor. “That would have been helpful for me,” he said.

So, as a student of science and mathematics, Ken looked carefully at the dismal survival curves. While almost all patients died within two years (many in the first year), there was a tail of the curve to the right, an exceedingly small tail, but a tail nonetheless. In fact, it has been reported that about 5% of adults with a GBM survive five years and nearly 2% make it to ten years. He could, statistically, find himself in those tiny groups (higher physics and mathematics informed him that even exceedingly unlikely things do eventually happen).  

GBM survival curves with different dosing of Temodar
(from Bin Huang 2021)

FOLLOWING THE DIAGNOSIS OF THE BRAIN TUMOR

After standard treatment with radiation and chemotherapy with Temodar, Ken’s oncologist in York found an ongoing trial of immunotherapy at Duke that appeared promising. Fortunately, Ken met the very strict criteria for the study. In that, they produced a personalized vaccine by harvesting some of his own white blood cells and exposing them to a specific antigen found in GBM tumors but not in normal brain tissue. They then injected these reactive cells into Ken’s thigh so they could find their way to the lymph nodes in his groin. Once there, they could generate T-cells to attack and destroy tumor cells carrying the targeted antigen. It seemed like a long shot, but it made sense to Ken to try; he had nothing to lose and everything to gain.  (Two reported studies from Duke were very small, but 4 of 11 patients in one group and 2 of 6 in the other were alive at five years compared to 0 of 23 historical controls.)

Five years on, and after regular trips to Durham, and a bunch of noisy MRIs Dr. Brein, remarkably, has no evidence of recurrent disease. There is no talk of cure or even remission, he said, just no visible disease at this time. The “sword of Damocles” is still dangling precariously over his head, he noted. 

Dr. Ken Brein chanting Torah on Yom Kippur 2022
 By Jewish tradition, it is on this holiest of days that God decides
 each person's fate for the coming year, who will live and who will die.
(Rabbi Marshall Klaven, Jessica, and daughter Courtney are looking on.)

WISDOM GLEANED

“Have you changed over the past five years?” I asked (again, knowing the answer).

“ How can you not?” he replied.

Early on in his journey, he was given the simple advice to “make every day count.” At the end of each day, he and Jessica ask each other these few questions: Did we do something good today? Did we have fun today? So Ken tries to do what he enjoys. And he believes that his positive, attitude allows those around him to feel better, as well. For example, Ken has had the opportunity to meet with others coping with brain tumors like his. He discovered, somewhat to his surprise, that he could connect easily with them and that he could be compassionate in light of their shared experience. And he often imparts the wise counsel he received after his diagnosis. This has been rewarding. (Ken’s father, having lost a leg in an auto accident, helped console Veterans who had similar traumas.)

THE MUSIC

As Ken tries to follow his own guidance, (forced) retirement has had a “silver lining,” he said. It has allowed him to pursue his life-long interest in music in more depth. When Ken began playing the guitar he followed the popular rock and roll track. This served him well for many years. But when he, by chance, listened to a jazz album one day not too long ago he was struck by the colorful sound. There were different chords and chord progressions and complex harmonies. And there was an emotional element that intrigued him.

So he studied music theory; that there are specific patterns of sound frequency and rhythm that are especially pleasing to us, and moving. He studied the mathematics and the physics that result in, literally, “music to our ears.” 

(My husband reminded me that there is no music or sound "out there," and no color. These are the private experiences the brain produces as it processes different wavelengths of energy detected by various sense organs. The tree that falls in the forest does not make a sound if is not perceived, it just disturbs the air.  And he reminded me of Duke Ellington’s famous comment about music; "If it sounds good, it is good.") 

Ken became serious about this and studied jazz guitar technique and theory (mostly online) with master guitarist and teacher Martin Taylor.

Music theory: The complicated (mathematical) circle of Fifths

Jazz music originated in the African-American communities of New Orleans in the late 19th and early 20th centuries. It evolved from Blues and Ragtime.  Jazz (according to masterclass.com)  “rarely uses three-note triads that define pop, country, and folk music. Nearly all jazz chords feature the seventh chord tone, and many include tensions like ninths, elevenths, and thirteenths.” And (importantly) improvisation (promoting creativity and flexibility) is an...element that “unites nearly all forms of jazz.”  

Ken is grateful to have been part of York’s “Unforgettable Big Band” for the past five years as they perform swing and classic big band music for appreciative audiences. He said that he has learned a lot from these talented and  “professional musicians.”  But he has been toying with the idea of playing solo jazz guitar in coffee house-type venues. And he might even try his hand at the intricate fingerwork of classical guitar.

AND MORE

Not content with sixteenth notes and syncopated rhythms and the physics of scales and harmonics, another one of Dr. Brein’s current interests is (wait for this…) cosmology, the study of the origin and development (and eventual running down) of the entire universe. Modern cosmology builds on insights about the curved fabric of space-time and elusive gravitational waves envisioned by Albert Einstein (a resident of Princeton in his later years). Remarkable insights that revolutionized our concepts about the nature of reality. (This, alone, should be enough to keep Ken plenty busy.)

And when he’s not with Jessica, or the rest of his family, or with his bands, or playing golf (where, he noted, you “keep your own score”), or fooling with one of his many guitars (including his first one), or reading stuff by Brian Greene or other cosmologists, you might find Dr. Kenneth Brein carefully covered up on the beach in Ventnor enjoying the peacefulness of the rolling ocean waves and the gently setting sun, the celestial fire sustaining life on Earth.

The quiet, soft, Ventnor City beach (from Shawn R. Smith)

References and Suggested Readings:

1.   MasterClass. "What is Jazz: A Guide to the History and Sound of Jazz." accessed at https://www.masterclass.com/articles/what-is-jazz (A succinct overview; but a start.)

 2.  Batich, Kristen, et. al. “Once, Twice, Three Times a Finding: Reproducibility of Dendritic Cell Vaccine Trials Targeting Cytomegalovirus in Glioblastoma." Clinical Cancer Research 2020 Oct 15;26(20):5297-530. (A report of the encouraging, though limited, experience at Duke, one of a number of centers looking for a way to shift the survival curve in GBM to the right.)

3.  Greene, Brian. Until the End of Time: Mind, Matter, and Our Search for Meaning in an Evolving Universe. Alfred A. Knopf. New York, 2020. (Not just physics and math, but a far-ranging erudite exploration of what it means to be human and concluding that "in our quest to fathom the human condition, the only direction to look is inward." p. 326)

4.  Davis, Geetha. "The Evolution of Cataract Surgery." Missouri Medicine 113(1): 58-62 2016.




By Anita Cherry 12/16/22

Saturday, September 10, 2022

Dr. Paula Jacobus: A geriatrician who thinks for herself

Dr. Jacobus 
She was the oldest of five children and she had crooked teeth. Her siblings also had crooked teeth. And after visits to the orthodontist, twenty-five miles each way, her teeth were much better, though still not perfectly straight. But the before-and-after plaster dental castings were on display for all to see. The young girl, Paula Jacobus, was affected by her experience. And she enjoyed the treat of her father taking everyone out for lunch afterward. So she thought of becoming an orthodontist; she believed that she “would be good at it.” But this was the 1960s in a small town in rural western Pennsylvania; not so fast…

When she informed her high school guidance counselor that she “wanted to be a dentist” she was quickly advised that she could, as a girl, be a dental hygienist instead. She did not want to settle for that. But Paula lived in Kane, Pennsylvania, with a population of five thousand and there were no advanced placement, or AP, classes; she had to “fight” to take physics, humanities, and higher math to get into a good college.

Paula is now Dr. Paula A. Jacobus, a fellowship-trained geriatrics specialist.

Her college-educated mother (1930-2013) taught high-school English, and her father (1927-2000) was “a good car salesman” and businessman whose own college studies were cut short when he was drafted during World War II. They were both concerned when Paula, their firstborn, was two and still not talking. They were afraid that she was slow. Afraid that she would be below average. 

They realized that the Catholic school classes were much too large for a single nun to provide individualized teaching, so Paula (and her siblings) went to the public school a block from home. It turns out that Paula was not slow, of course, just careful. And of the 160 students who graduated high school with her, Paula was one of only ten who went on to further education.

Postcard rendition of the Kane business section
at some time between 1930 and 1945
(from Wikimedia Commons)

 (Paula wasn't the only one in the family drawn to a career in medicine. Her sister Susan is an oncology nurse in Ventnor, N.J. and her sister Judith practiced medicine for 20 years before deciding to become a Catholic nun; she lives in, get this, St. Malo, France. Judith is her "Sister sister.")

Before we get to her unusual college experience, let’s see how the future geriatrics expert was drawn to the elderly. As a child, she spent a lot of time with her Italian grandmother. “Nonna was a wonderful cook,” said Paula, but she could not read (any language). So when she lovingly “read” a picture book to the kids she made up a story. And she left out the violent parts; the cat, for example, did not catch and eat the mouse.  

And Paula’s first job as a teenager, at 15, was to stay with an elderly woman who simply needed someone to help her get up at night. At 16, she served as the chauffeur for her 96-year-old neighbor, two doors away, who had purchased her cars from Paula’s father’s auto business. She had her own room in the woman’s home, a definite luxury for a girl with four younger siblings. Paula said, simply, that she “always liked older people.”

Okay, back to her formal education.

College

When it was time to apply for college, small-town Paula didn’t actually have a lofty or special place in mind.  And, as we have seen, the unhelpful school counselor didn’t provide meaningful guidance. 

So, how did she get to the very highly-regarded St. John’s College in Annapolis? “Purely by chance,” she said. She was in a humanities class and doing a report on education. Her father had a business trip to the area, and as she looked into the school’s curriculum she thought that it sounded “pretty weird.”  So she went on the trip with him. 

The "Old Library" at St. John's (from Wikimedia Commons)

She was intrigued by their educational approach. “It was the most amazing thing,” said Paula, because (unlike in her high school)  “everybody was there to learn.” And (this is surely unique) each student took exactly the same courses! As the daughter of an English teacher, she couldn’t resist.

You “start with Homer,” she said, “and over the four years, you read the classics,” the primary sources, in literature, philosophy, history, and the sciences. And discussed them, and picked them apart in small seminar settings. You also took two years of Greek and two years of French and some math. While at St. John’s you were forced to develop the skill and the habit of critical thinking, of thinking for yourself, she said.  

According to their website: “St. John’s students learn to speak articulately, read attentively, reason effectively, and think creatively.”  They "practice radical inquiry" and are urged to "establish habits of civic responsibility."

The noted humanist physician-turned-ethicist and teacher Dr. Leon Kass was one of Paula's important tutors. He was a “really really good seminar leader” and he took her (as a freshman) to the Kennedy Institute of Bioethics to “hang out.” Paula said, reflecting, that this “might have been a pretty significant influence” on why she ended up in medicine. She has read “most of his books.” She enjoyed the intense experience at St. John’s and graduated in 1978.

The 1978 graduating class at St. John's, Annapolis (from their website)
(If you can't immediately spot Paula, she's seated in the second row on the right.)

Transition to Medicine

After this broad liberal education, Paula knew that she still wanted a career in one of the medical fields. The only two doctor role models in Kane were husband and wife, Charles and Elizabeth Cleland. Elizabeth (affectionately known to the Jacobus family as “Dr. Betty”) had to give up her pediatrics residency when she got married (not pregnant, mind you, just married). Nevertheless, she was the one who took care of the kids in the small town as her husband tended to “the sicker adults.” Though Paula couldn’t (she was told) be a dentist, she could (it was clear to her) become a doctor. 

So she went to Bryn Mawr College for a year to take the required premed science courses she couldn’t get at St. John's. And in 1980, after a year off, she began her studies at the University of Pennsylvania Medical School (the country's first medical school). 

Things were pretty difficult at first, she said, as they crammed all of the basic science stuff into the first ten months and Paula had arrived with only “the bare minimum” preparation. However, in her clinical years, she quickly caught up with her more single-minded classmates. 

Penn's medical campus 1829-1871 at 9th and Market in Philadelphia
(from archives.upenn.edu)

While she was In medical school planning her future, she thought about doing something familiar, family medicine. But that new “specialty” was frowned upon at Penn. So she dropped that and considered going into either internal medicine or pediatrics. During her three-month Peds rotation at the York Hospital (affiliated with Penn, then), “three or four kids died.” She was shaken by that and concluded that pediatrics was “not the way to go.” 

Following Medical School

After medical school, Dr. Jacobus chose to come back to York for a three-year residency in internal medicine. She followed this with a fourth postgraduate year of her own design where she was especially influenced by (the also well-read) Dr. J. Wolfe Blotzer, the program director. Her make-shift “office” was adjacent to his, and they often sat and talked about what was on their minds. 

She had learned a lot during a three-month rheumatology rotation with Wolfe and even considered going into that specialty for a while before choosing to focus on the care of older individuals. (She lamented the fact that the intimate mentor-mentee relationship she was privileged to enjoy as a resident is no longer the way things are done.)

While at Penn, she was taught by Dr. Laurence Beck, a nephrologist who went on to do and teach geriatrics, so, when the time came, she wanted to go back to Philadelphia to train with him. She did that, but when she soon heard that “Larry was leaving” she applied to the highly-regarded UCLA fellowship for the following year. But it turned out that they had an unexpected opening and she was accepted for that current year. 

Dr. Reuben
Paula moved to California and was not disappointed, as UCLA “was a great program.” She rotated through “a lot of different places” including a rehabilitation center and "The Jewish Homes for the Ageing" where she witnessed “good quality nursing care.” She had “top-notch teachers” including Dr. David Reuben and Lisa Rubenstein.  She told me that it was "purely by chance" that she "got a way better education" at UCLA than she would have (in the much smaller program) in Philadelphia.

 Return to York

Dr. Jacobus returned to York with the idea of joining another physician in a new geriatrics program, but by then he had already changed his mind and gone into administration. So the staff waited anxiously for Paula for six months. Upon arrival, she had to go it alone and it was difficult. There were vexing personnel issues and she went through six different administrators in five years. 

Marta Smith, MPH, (with whom she is still close) was the sixth; they got along and “moved things forward,” but “not to where they should have been.” Dr. Jcobus realizes now that she “didn’t have the skill set to run a geriatrics assessment program” and that “it wasn’t meant to be.” 

So, as she was “pretty burned out” after six or seven trying years, she decided to stop doing just geriatrics. She had nothing specific in mind when she decided to talk to nephrologist-turned-general internist Cyrus Beekey for his advice. Cy, it turns out, was looking for a partner. Paula stepped in and worked with him in private practice “for quite a few years.” 

But, after a while, it became clear that “private practice (of internal medicine) was dying” (was being slowly choked off). Dr. Beeky saw this and joined the expanding WellSpan Health system.  Paula resisted and stayed independent as she continued to do general internal medicine along with some geriatric work in nursing homes. She was happy.    

But she had “health problems” along the way, including breast cancer at 43 and the development of diabetes requiring insulin. She didn’t let these setbacks slow her down and she only missed a single scheduled on-call stint. But years into her busy practice she began to worry about how her patients would fare if “something happened” to her and she wasn’t able to continue to take care of them. So Dr. Jacobus thoughtfully arranged for another well-trained physician, Dr. Heui Yoo, to take over her practice as she planned her “semiretirement.”

Retirement on Hold

In fact, she might have retired altogether (“Life is short; do what you want to do,” noted Paula.) were it not for (another) unexpected turn. Within days of setting things up to allow herself to wind down, Dr. Jacobus got a “cold call” from the large Lehigh Valley Health Network in Allentown about 90 miles from York. They were looking for another geriatrics specialist.

It turns out that she had interviewed with them in 1996 when they were searching for someone to head their geriatrics program. At that time, she would have taken over for a blind doctor “who was a wonderful physician,” she said. But another administrative job was not for her. (The sightless doctor was Dr. Francis Salerno, the same doctor who “saw,” as they trained together in Reading in the 1970s, that my husband would become a neurologist.) 

This new offer from Lehigh was appealing and suited to her skills and she applied. It took a while “to get on board,” but she eventually started there in March 2015. “It’s been a great place to work,” she said. She initially did half-days at the small Luther Crest Nursing Facility and half-days at the comprehensive Fleming Memory Center for individuals with (or concerned about) dementia. 

Lehigh Valley Hospital (from LVHN)
She has dropped back to part-time for the past three years, spending three days a week at the clinic. The work is “very easy” compared to what she used to do, and she has time for other pursuits (mentioned below).

As a Patient

She is not pleased, however, as she has seen the breakdown of the primary care model of coordination of medical services she experienced during her formative training years. She receives her own care through her employer’s system, and she said that she’s already had three different primary care internists in less than seven years. 

Her endocrinologist, for her well-controlled diabetes, has been stable and reliable, sure.  But when she needed a dermatologist for terribly itchy (undiagnosed) psoriasis she “couldn’t get past the front desk.” And even as a physician within the system itself, she was stymied when she needed to see a specialist or even when trying to see her regular internist for a week of gnawing belly pain that was due to a ruptured appendix.

And exactly a year ago, on her sixty-fifth birthday, 21 years after her initial shocking diagnosis of breast cancer, she woke up, rolled over in bed, and felt a hard lump in her breast. She knew that she had to have a diagnostic mammogram, but setting this up was needlessly difficult and she was “scared to death” for nearly three weeks until she got a study and it was determined that the lump was just scar tissue. 

These frustrating experiences were quite unlike what transpired when she was diagnosed with breast cancer more than twenty years ago. She had called Dr. Eamonn Boyle’s oncology office to make an appointment “for a new patient.” When they asked who the patient was and Paula told them it was she, herself, they said, “Five o’clock.” (As Dr. Jacobus recalled this story about her cancer, and that doctors used to take care of each other, her voice cracked and she cried softly.) 

Alzheimer’s Disease

Seeing that obtaining timely health care has become a problem even for physicians, I wondered whether improved treatment of Alzheimer’s dementia, the disorder she mostly sees now, makes up for that lack. Unfortunately, it doesn’t. Dr. Jacobus said that donepezil (Aricept) and the two other similar medicines for Alzheimer’s “might (at best) slow the progression by six months for 10-20% of the patients.”  She will prescribe them if requested, but she doesn’t “push” them, since she doesn’t see any “appreciable degree” of improvement. The same can be said for another medication for Alzheimer’s, memantine (Namenda). 

When Biogen’s anti-beta amyloid monoclonal antibody Aduhelm, designed to remove clumped deposits of the amyloid protein that are one of the hallmarks of the disorder (tau "tangles" being the other), was given approval earlier this year over the objections of the independent reviewers the phones at the memory center were “ringing off the hook.” 

But the enthusiasm for this treatment to slow or stop the dreaded disease process itself, not just treat the symptoms, faded quickly. As a result of the weak and inconclusive clinical data despite the evidence that amyloid was removed, and the seriously suspect accelerated approval process, this very costly medication with potentially serious side effects is currently available only in the setting of a controlled study. 

Enrolling patients has been painfully slow and might end altogether as the industry funding dries up and other promising treatments are pursued instead. And, importantly, not all researchers believe that trying to remove the amyloid plaques is the right approach, as the phosphorylated tau tangles disrupting nutrient transport within cells may be more critical.

PET scans showed that deposits of amyloid (in red)
were removed (from www.sciencenews.org)

PET Scans and the Diagnosis of Alzheimer’s 

What about making a diagnosis, one of the important tasks of the geriatric specialists at her center? Until relatively recently, Alzheimer’s was a so-called purely clinical diagnosis, made after other causes of dementia have been excluded. There was no definitive imaging or blood or spinal fluid test for the condition, and it was only diagnosable with absolute certainty at autopsy. 

Being able to see the accumulating amyloid beta deposits during life with special PET scans has aided research studies (as those for Aduhelm, noted above). But using any type of PET scan (there are several, each showing different things, but all are very expensive) for individual patients with dementia (or a suspected dementing process) isn’t precise, and may be misleading. Positive scans make the diagnosis of Alzheimer’s more likely and negative scans while reassuring, don't rule it (or other causes of dementia) out. Misdiagnosis is still not uncommon.

So Dr. Jacobus is currently “starting a quality improvement project about PET scans” at her facility. She said that of the five practitioners in the office, two don’t order them for patients: she and Heidi Singer, CRNP, (who was trained by Dr. Salerno). The other three do.  Patients and practitioners, she noted, both need to be aware of the limitations of imaging. 

But (and here’s an important point) “even if we can prove today that (our patients)  have Alzheimer’s, we’re not going to do anything to majorly impact that,” Paula said.  (As a resident at the York Hospital many years ago, in another lifetime, she was taught that “you don’t order a test if you are not going to do something about the results.”)

For an accurate diagnosis, it may be preferable, she noted, to carefully examine patients over time to see if their memory deficits or other cognitive or behavioral problems worsen, consistent with dementia, either Alzheimer’s or something else.

But sometimes patients and families want certainty, they want to know for sure what they are up against, and push for (what they hope will be) a definitive test. They feel the need to be their own advocates within the large complex regional health systems, a role that Dr. Jacobus, as a patient herself, understands.

In any case, in the absence of an effective treatment for the very slowly developing brain disorder (it likely starts decades before symptoms are detected), a major focus at the busy but understaffed center in Allentown is on education (as was repeatedly emphasized during her training years under Dr. Blotzer). And this group effort is carefully tailored to the specific needs of each particular family (As, in Tolstoy's Anna Karenina, “every unhappy family is unhappy in its own way”).  

More Technical Neurology Stuff  (with the neurologist's long-winded input, of course)

Scientists have not determined exactly what leads to the gradual accumulation of the toxic misfolded amyloid-beta and hyperphosphorylated tau proteins that damage the delicate synaptic connections between neurons and result in the death of the neurons themselves. They do know that the spread from the initial sites in the brain areas for forming memories (the hippocampi) proceeds along the connecting neural pathways.

Mathematical model of the spread of misfolded tau
through the so-called connectome
(from royalsociatypublishing.org)

Early-onset disease, seen in much less than 5% of patients, is caused by mutations in amyloid precursor protein and presenilin genes; the much more common late-onset disease is related to a multitude of interrelated factors, both genetic and environmental (as for most chronic disorders).

Research has shown that lipid metabolism plays a very important role in Alzheimer’s. Apolipoprotein E (apoE), through interactions with cell membranes, regulates the clearance of damaging extruded amyloid beta fibrils before they clump up. Carriers of one of the three forms of this protein, apoE4, have the early accumulation of amyloid beta deposits, substantially increasing the risk of developing Alzheimer's down the road. Carriers of apoE2 have a lower risk while the apoE3 is neutral.

The gene variant coding for apoE4 is found in about half of those with Alzheimer's; people with two copies have about a 60% likelihood of developing Alzheimer’s by age 85 compared to 10-15% of those without the gene variant.  And so, there are other important factors in play. 

Prevalence of Alzheimer's by age (in 2005)
(from ResearchGate)

It turns out that age itself, living a long life, poses the greatest risk of late-onset Alzheimer’s (as it does, for example, for hypertension, cardiovascular diseases, cancer, osteoarthritis, Parkinson's, type 2 diabetes, and cataracts). Up to 50% of those older than 85 may be affected by Alzheimer's dementia. The next most significant risk is having a parent with the disorder, especially a mother (who supplies us with our mitochondrial DNA). But the genetics is way more complicated since more than 800 genes may modify the metabolism of the amyloid precursor protein. 

The misfolded tau protein story is only beginning to be understood.

We are stuck with our genes (so far) but genes are turned on and off (through epigenetics) and there are modifiable risk factors for the feared condition. There is a significantly heightened likelihood of Alzheimer’s dementia in people with vascular disease, hypertension, and (especially) insulin resistance and overt diabetes. Mid-life central obesity, repeated head injuries, heavy alcohol use, cigarette smoking, lower educational level, social isolation, untreated depression, inactivity, poor diet, and hearing loss all increase the chance of developing dementia.   

In fact, it is felt that anything that influences the health of an individual through life and the rate of aging is a potential factor.

Buffers against developing substantial late-life cognitive impairment include adequate treatment of hypertension and dyslipidemia, a habit of regular exercise (the link is surprisingly strong), lifelong cognitive pursuits (learning something new; doing something new), getting enough sleep (allowing removal of toxic debris), mindfulness meditation (shown to lengthen the protective telomeres at the tips of our chromosomes ), and regular social engagement (our brains are shaped by other brains). 

And if you have more interconnections and more synapses to begin with you can lose a good bit and still function well. And, contrary to formerly accepted dogma, we have stem cells in the brain (and especially in the hippocampus) that can generate new neurons and supporting cells when stimulated to do so. 

Image of brain interconnections
(from the Human Connectome Project)

We can improve the chance of our brain aging well if we make the right choices early enough in life.

The Future?   

I asked about her thoughts on the future of medicine. Paula is particularly worried about the quality of care in rural areas. For example, her nephew in Kane was (accidentally?) shot recently by his girlfriend. He is now a T4 paraplegic and when he had “horrible” diarrhea the other week the diagnosis of C. diff (that was obvious to Dr. Jacobus when she heard the story) was missed in the ER as he was initially told he had prostatitis. And years ago, when her mother had a brain tumor, a benign meningioma, she had to make three trips to the local ER before her symptoms were taken seriously enough to result in a brain scan. 

What about telemedicine (for these remote underserved areas)?” I asked. “I don’t think that’s the way to go (for most things),” said Paula.

Looking at the other side of the medical encounter, another one of her nephews has just started an emergency medicine residency in Cincinnati. She is uneasy as she sees the shortened rotations and the lack of hands-on learning at her current institution. And she is uneasy as newer trainees seem to rely less on their clinical skills while they rush from patient to patient and “do a lot more tests.” This (over-) testing greatly increases the societal cost of healthcare, likely to the point soon, Paula believes, where it will simply be no longer affordable. 

As it is, we spend a lot more on healthcare per person than any other wealthy country. And the future burden to society to care for the rising number of people with Alzheimer's as our population ages is expected to be enormous.

She feels that doctors need to be mindful of this and aware that spending more time with patients can result in less need for costly studies and more efficient medicine.  (I found online that Dr. Jacobus has a master’s degree in public health, an MPH, from Loma Linda University in California; she failed to mention that credential during our interview.)

Paula feels fortunate that she can still take as much time as she needs in the office since many of her elderly patients are confused and lots of things have to be sorted out. For example, their long medication lists (one of her patients brought in 67 bottles, she said) need to be simplified. In fact, Dr. Jacobus tries to limit her patients to five essential medicines. And when they come back for a follow-up, having stopped potentially harmful unnecessary pills, ”they are (often) better.” This “deprescribing” is an important new tool for geriatricians. 

And as for general advice, she strongly encourages her patients, of course, to remain mentally and socially active and to exercise whenever possible. 

Outside Interests

What does Paula like to do when she not doing medicine? She enjoys quilting and belongs to several guilds devoted to that craft. She just finished a classic “attic windows signature quilt” to present to her boss (who is retiring). She made 32 “bright and colorful” quilts for Jessica and Friends, a local faith-based program for adults with autism and other intellectual disabilities. And she has made quilts for Camp Erin for bereaved children. (Her first purchase with her “own money” was, in fact, a sewing machine!)

She loves to travel and the experience of being in a different culture. She has been on every continent except Antarctica, sometimes with a group from Penn State York, and sometimes with her friend Marta. Paula has been to the 400-year-old Oberammergau Passion Play in Germany four times (it is performed once every ten years according to a promise made in 1633 when the town was spared the ravages of the Plague). She doesn’t know where she wants to go next. 

Paula and her new Berber friend in the sand dunes
of Erg Chebbi, Morocco, on 3/10/20
 (the day before the pandemic was officially called)
She has thought about doing international medical missions where she might help out for six months “or even a year” as long as she was in good health. Especially if she could go someplace where she could use her Spanish. But Paula also noted that there are underserved areas “even in the U.S.” where she would be needed. And, who knows? Something unexpected might come along to catch her interest. But for now, she still sees patients in Allentown Monday to Wednesday and is content with that. 

So...

When you are a young child with crowded misaligned teeth you need to find a competent orthodontist to straighten things. When you are a somewhat forgetful older adult with missing teeth or no teeth at all you need to find a well-read compassionate geriatrician to help guide the way. Preferably one who’s been a patient herself.


Suggested Readings:

1. "Alzheimer's Disease." from Wikipedia. (accessed 9/2/22) (A very good and complete resource with lots of science.)   

2. Cohen, Gene D, M.D., Ph.D. The Mature Mind: The Positive Power of the Aging Brain. Basic Books. New York, 2005. (A reassuring and easy read by the first chief of the Center on Aging at the National Institute of Mental Health, a psychiatrist.)

3. Pachana, Nancy A. Ageing: A Very Short Introduction. Oxford University Press, Oxford, United Kindom, 2016. (A nice overview by a psychologist.)


A braided Challah 



By Anita Cherry 09/10/22