Emotional Intelligence in a Complex World

By Andrew Lenhardt MD

Richard Duncan is a medical doctor who solves mystery illness cases. He sees patients with complex health issues and tries to sort the underlying causes that can then be reversed. A company named Diagnostix has a plan to gradually introduce intelligent systems into healthcare in such a way that the need for most physicians is ultimately phased out. Richard enlists the help of a hacker John to delve into the deeper programming of the Diagnostix system so they can determine its true purpose. They are ultimately faced with the task of bringing down a system that is supported by powerful forces behind the scenes.

• Language: English
• Publisher: BookBaby
• Release date: Mar 20, 2019
• ISBN: 9781543965490

Book preview

(Diagnostix)

Introduction

One of the primary goals of the book is to introduce the reader to the concept of functional medicine. Functional medicine is essentially a mainstream version of a holistic, integrated approach to wellness. It seeks to individualize care as much as possible and delve into the root causes of each and every health problem. Most functional practitioners are traditional medical doctors who hope to bring research and evidence into the field as much as possible.

The first part of this book involves a fictional story with an idealized main character Richard Duncan. His practice is dedicated to solving mystery illness cases and he utilizes functional medicine principles throughout. The way he assesses his patients is a divergence from the way doctors, nurse practitioners, nurses and other medical professionals are trained in the Western world. The principles of functional medicine will be reviewed in more detail in the second section of the book.

The second section of the book reviews each of the patient cases that Richard Duncan sees in his office. If the reader has a particular interest in one of the cases, he or she can go to the second section and read more about the potential root causes and underlying elements of those health issues. It is probable that many readers will connect with one or more of the patient cases especially in regards to a particular friend or family members who might have challenging chronic health issues. The goal is to keep the majority of the technical information within the second section of the book, so it doesn’t bog down the main story. There are parts of the novel that include jargon and more in-depth medical information. One of the challenges was to find a balance in this regard where the reader would (hopefully) have just enough information to understand the patients that Dr. Duncan sees in his office, but not enough to become tedious.

The fictional book is set at some time in the relatively near future. The reader can decide for him or herself how far in the future these issues may be. The majority of ideas in the book will likely come about in our lifetimes. The trajectory of our modern society is a slow shift such that machines will do the work rather than people. Machines are already performing many tasks more effectively and at dramatically lower costs. The economics of this trend are unavoidable.

There is a dystopian angle to this book, but it remains to be seen what the impact will be for medical practitioners and others who work in the healthcare arena as artificial intelligence gradually insinuates itself into medicine. With each new technological development since the industrial revolution, there have been fears that the demise of civilization is at hand. Each time, however, society has adjusted. New skills are required as the need for others fades away.

Is it conceivable that the majority of current occupations will be replaced by intelligent systems? Yes. Will the world transition to one that primarily requires technicians, engineers and programmers to maintain the automated processes? It is hard to imagine that anything will slow down this progression. As is foretold in the Terminator series, the Matrix trilogy and other sources, might the AI systems ultimately achieve a status where they can do the building, repairs, programming and other necessary maintenance functions themselves such that human beings have almost no role in society? Could this progress to a utopian existence where human beings are left to pursue some of the deeper existential questions of self-actualization? Or will this create a world like the animated movie Wall-E, where morbidly obese people have no purpose and ride around on scooters drinking soda? We will probably find out the answer to these questions and many others we haven’t anticipated over the next five, ten or twenty years.

In this book, a company Diagnostix has a plan to gradually introduce intelligent systems into healthcare in such a way that the need for most physicians is ultimately phased out. It is using an algorithm-based system to make diagnoses for patients and come up with treatment plans. Currently, we have intelligent systems like IBM’s Watson that are already doing analysis on patient cases and making recommendations. One key question related to this development is whether these automated systems will mirror mainstream medicine’s approach or whether they will ultimately pursue the type of inquiries that are similar to what functional medicine has to offer. Functional medicine practitioners assess a long list of factors relevant to the Why? of it all. Why does one person develop an autoimmune condition like multiple sclerosis? What genetic variation, environmental contributors and lifestyle factors played a role? This is a fundamentally different approach in the assessment of a person’s health problems. Why do some obese people with terrible lifestyles have perfect blood pressure, normal blood sugar and excellent cholesterol numbers while people with optimal lifestyles are on blood pressure medications with metabolic derangement that leads to type 2 diabetes?

Doctors are generally trained to go through a process so they can come up with a working diagnosis. With that working diagnosis, there is sometimes an effort to correct the problem, but often the goal is to manage the condition on a long-term basis with one or more pharmaceuticals. There may or may not be much of an effort to figure out why that particular patient developed that specific diagnosis. How can we hope to reverse, cure or prevent health conditions without a clear understanding of the underlying root causes?

These concepts and many others are explored in the book. I have blogs, protocols and links also through my website drlenhardt.com if you’re interested in other aspects of functional and integrative medicine. Fortunately, there are many other healthcare practitioners also working on these areas.

Acknowledgements

I will start on a more personal level and work outward. My wife Mary Lenhardt has probably had more influence on my personal life and my clinical approach than any other person. She has been a holistic practitioner in one way or another for more than twenty-five years with an incredible background involving many disciplines in health.

I’m grateful to work with my primary editor Ellen Szabo. I followed almost all of her advice, large and small, and the finished product is vastly better than it would have been without her input.

I would also like to thank Janice Fullman who did a thorough job of editing to clean up the book. Even with smart systems available, we often need a conscientious human mind to do things properly.

Jody Shirley is a brilliant person who has spent a significant amount of time reading through drafts of my manuscript to give me advice. Her input was always appreciated and helped me in many ways.

Joseph Scholnick was convinced that I could write a fictional story involving characters within the fields of medicine. He encouraged me relentlessly until I finally agreed to at least write thirty pages that would be the start of the project. It remains to be seen how successful this project will be.

This is an incredible time to be in medicine. The movement towards functional and holistic approaches continues to gain momentum. I am grateful there are so many practitioners in the world moving things forward including Jeffrey Bland, Mark Hyman, David Perlmutter, Dave Asprey, Kara Fitzgerald, Neil Nathan, Robert Thompson, Sara Gottfried, Daniel Amen and many, many others. I went to a functional medicine conference several years ago in Austin, Texas and there were almost 2,000 participants. Everyone in the room had the same goal: to provide a more in-depth level of individualized care focused on the underlying root causes of illness.

Shifting medicine is a great undertaking and will be slow, but more and more people are interested in a deeper understanding of health. It is only by understanding the root causes of each and every health problem that we can hope to reverse, cure or prevent chronic illness. There are so many dedicated doctors, nurse practitioners, physician assistants, nurses, physical therapists, nutritionists and other providers working. We need the efforts of as many as possible in these pursuits.

Chapter 1

After seeing his morning patients, Dr. Richard Duncan sat in his office reviewing an online article. Brandon, the medical student working with him, peered over Richard’s shoulder to figure out what he was reading. Dr. Duncan was an internist, but a medical specialist in his own right. Over his twenty-plus years in practice, he had carved out a niche. He helped patients lost in the healthcare system. The more complicated the patients, the more his interest grew. The more systems involved, the more his skills came into play. He had diligently honed and refined his approaches, individualizing patient care to a fine degree. He resisted the herd mentality of public health.

Time for lunch, Richard said abruptly.

Brandon backed away as Richard got up and then followed him down the hallway to the lunchroom. Richard had a small office with only three employees and they were all sitting at the lunch table talking animatedly in between bites of sandwiches. Richard had tried several times to get them to change their food choices away from gluten, but with no success. He reviewed the slew of research supporting a gluten-free, wheat-free diet, but they just wouldn’t change.

Oh, there you are, Ellie, the woman who worked at the front desk, looked up at Richard as he walked into the lunchroom. She was particular about her dress and manner, so would have been upset to know she had tomato sauce on her cheek from her chicken Parmesan sub. "Have you heard that Diagnostix is moving to Phase Two in a few months? She smiled. That hunky Diagnostix rep Brad was in and he told us the company was moving forward. She paused. He still wants you to be involved and for us to be a pilot site."

As a matter of fact, Richard stated, the medical student and I are driving over there after lunch to observe a demonstration.

Oh? his medical assistant Barbara looked up from her salad. I didn’t know you were out of the office. Barbara was a broad shouldered African-American woman who helped manage Dr. Duncan’s affairs.

Um, Richard scrambled not wanting to upset Barbara, can you clear my schedule please.

Barbara gave a huff of agreement.

So Doctor Duncan, his nurse June asked, what do you think of these artificial intelligence systems? She wasn’t one to ask a lot of questions, but was curious about the topic. June was married with four daughters and two granddaughters even though she was just over fifty years old. She lived near the office and typically rode her bike in. She, like Barbara, brought warmth and empathy to the office. This offset Richard’s quirky personality tendencies.

Barbara looked at Richard, I thought you were a believer that human beings could be reduced to an equation.

I am, he responded. Although not everyone wants to hear that.

Many professions had already been replaced by computers and robots including automobile assembly, tollbooth takers, travel agents, financial analysts and some lawyers. Translators were being replaced by sophisticated ear bud systems that allowed two people from different countries to each speak in their native languages. This provided automatic translation into the other person’s ear. The system could translate any language on earth, so it wouldn’t be long before foreign language teachers were unnecessary. Robots vacuumed floors and the bottoms of pools. They could now paint the inside and outside of houses efficiently. Computers could win at the television game show Jeopardy. They could beat the human world champions in chess. More people than not were now commuting to work in self-driving cars with an impeccable safety record.

The marketplace had already decided that the Diagnostix systems had a place in medicine. The stock price continued to soar even with no immediate profits on the horizon. Richard, a staunch capitalist, believed that the American model led to innovation and progress. He understood, however, that it was not a tidy process and there could be collateral effects. He was uncertain if any physicians would survive the conversion to AI. Applications to medical school were down by over ten percent since Diagnostix entered the public sphere. Would physicians eventually fade away, replaced by an advanced computer system with therapists for the human touch? Would surgeons give way to sophisticated robots? Would scanning programs replace dermatologists?

‘What do you think Brandon?" Ellie asked, turning to the medical student who was sitting off to the side listening.

Well, he said, it’s always been my dream to go into Radiology. I remember one of my classmates’ fathers in first grade was a radiologist. He came into my elementary school and showed us radiograph images of inside the body. I was transfixed as he pointed out the various bones and then the lungs and finally the heart on a chest x-ray.

I wouldn’t go into Radiology, Richard commented without looking up from his plate of chicken salad. Visual recognition systems, Richard explained, are very close to implementation. There is no way these systems won’t take over the field of Radiology. Why would you pay a radiologist five hundred thousand dollars a year with benefits when you have a system that can more quickly interpret images with a lower error rate and no threat of a lawsuit?

Brandon’s shoulders sagged, but Richard kept going. The computer system will work twenty-four hours a day, seven days a week, correctly interpreting images within a minute or less. It doesn’t come in at nine-thirty and disappear in a back room drinking coffee. Oh, and forget Dermatology and Pathology for the same reasons. Law school may have been a better choice now that I think of it. Richard was lost in thought for a moment, not fully aware that other people were there with him in the lunchroom. Doing something that requires creativity and empathy would be good for someone young I guess. He then realized the medical student was sitting there listening. Oh, he said trying to be helpful, Maybe you could paint or play a French horn?

Brandon was six foot six inches tall. His whole life people had asked him what position he played in football, but he had no interest in sports. He had always loved science. He was frustrated by the negativity about his hard earned future and said, What about you then Dr. Duncan? Won’t you be replaced by artificial intelligence systems as well?

I have wondered about that myself, Richard answered with no signs of defensiveness, but my guess is that the systems will mirror the current medical model and thus, will not even try to replace some of the work that I do. I am someone unwittingly on the fringe of medicine.

Richard looked down at his watch and grunted before standing up. He ignored Brandon, and abruptly left the lunchroom. Brandon chased him down the hallway that led to the back exit.

Dr. Duncan, Brandon panted, where are we going? And what’s the rush?

Without slowing down or looking over his shoulder he replied, "You and I are going on a field trip. We are going to a demonstration across town of the new Diagnostix artificial intelligence system. They say it will irrevocably change the path of medicine. I have been invited, he said, and this should be interesting for you as well Brad."

Brandon, the medical student said, my name is Brandon.

Richard appeared not to hear Brandon as he burst out the side door of his medical office into the parking lot. Brandon tumbled out behind him, almost getting smacked in the face by the door as it closed. Richard got into his black 5-series BMW, turned the ignition and started to put the car in drive when the medical student whipped the door open and jumped in. Richard had both hands tightly clutching the steering wheel.

Richard sped down the highway, working his way around cars inhibiting his path. Brandon gripped the side of the door with each lane change. Brandon had been working a few days a week in Richard’s office as part of his third year primary care rotation in medical school. From the beginning, there had been tension between them as they often disagreed about how to approach certain medical issues. Richard considered Brandon as more of a passive observer, but Brandon wanted more involvement in patient care.

Clarice, Richard said to his electronic personal assistant, what is my ETA?

Brandon, engrossed in his cell phone, was surprised to hear the female voice coming from the car’s internal systems. Hearing her speak was enough of a distraction for him to look up.

At your current rate of speed and impatience Doctor Duncan, a silky English voice came on from overhead, "you should arrive at the Diagnostix facility in seventeen minutes at two oh five pee em in the afternoon."

Any shortcuts that would get us there before two? Richard asked.

There is an alternative route, Clarice responded, that takes you through a congested area with an elementary school. That would shave six minutes off your time if you drove at roughly double the speed limit of twenty miles per hour.

Direct me that way, Richard said.

I would remind you Doctor, Clarice commented, that you should be careful about any children in the area.

What time do the kids get out of school today?

There was a three second pause while Clarice searched the Internet and found the answer. At Brightview Elementary School, the children are let out at two fifteen. It will take them approximately four minutes…

Can I get by the school safely without endangering anyone? Richard asked.

Yes, with over ninety-nine percent certainty, Clarice replied. Get off at exit twenty-one coming up in zero point six miles and then you will take a right at the bottom.

Clarice directed Richard off the highway and down backroads through the countryside. He buzzed by the school before the children came out. Two lefts and then a right and he turned into the back entrance of the Diagnostix facility in Waltham, Massachusetts. The building was an impressive cube of dark blue tinted glass sections with a parking lot full of cars.

After parking the car, Richard rushed into the building with Brandon close behind.

A young blond behind the desk stared down at her phone.

Richard stopped and Brandon ran into him with a thud sending Richard forward. Excuse me, he asked in the direction of the young woman. When he didn’t get a response, he walked over to the desk. He stood over the woman who was rooted to her spot in the chair texting madly with both thumbs. Demonstration, he said, but got no response. Demonstration, he said a second time more loudly. Still nothing, so Richard reached down and grabbed the cell phone from her grip. It took a bit of force to extricate the phone.

Hey! the young woman exclaimed. What the hell?

Her reaction caused Brandon to take a step to the side and turn away as if he didn’t know Richard.

With controlled calm, Richard said, Can you please tell me where the demonstration is at two o’clock. He held the phone in front of her.

But sir, she said snatching it out of his hand, I was in the middle of something… She sighed. Oh, ok then, the demonstration is down at the end. She pointed down one of many hallways that ran diagonally away from them.

Richard stalked off and Brandon kept up. They passed one closed door after another and finally reached the end of the hallway. Richard opened the door and found twenty people sitting facing a rectangular table at the front. All heads turned to watch Richard and his medical student enter the room and sit down. A placard on a stand near the front said, Welcome to Diagnostix.

Richard was well aware of the company Diagnostix and the impact they were already having on the world of healthcare. They had developed an algorithm to help providers come up with the most likely diagnosis for a patient who had a certain presenting complaint. Using powerful computers, they accessed most of the standard medical textbooks in the world picking up associations of words within sentences. The real breakthrough was when they weighted the algorithm to primary care textbooks rather than specialty textbooks.

One of the most well known expressions in medicine is: When you hear hoof beats, expect horses, not zebras. Horses represent common causes for a medical issue and zebras represent the relatively rare causes. The textbooks that focused on a primary care practitioners view of the medical world, roped in the most common diagnoses and the system became more applicable.

The user would enter their chief complaint in the Diagnostix system and then answer a series of questions. With each question answered, the probability would change among the most likely diagnoses. In Phase I, the system centered on relatively simplistic diagnoses like conjunctivitis, urinary tract infections and upper respiratory infections. It was already reported as a success in correctly identifying the most appropriate diagnosis. In limited use to augment providers at participating clinics, it had cut back on the use of unnecessary antibiotics.

If a computer says that there is a 98.2% likelihood that your symptoms are caused by a virus and thus, antibiotics would be of no value, there is not much room for discussion. There is no human to cajole. It is a more definitive answer.

Ah, Dr. Duncan, a balding man with a thin moustache was standing at the front. Thank you for coming. You are just in time for our demonstration. He smoothed down the front of his suit jacket and tie with both hands. On the table is our computer interface, he pointed to a small black box on the table, and I will be conducting the patient simulation…with me in the role as the patient.

Interface, he said to the small black box, I am here with a chief complaint.

A monotone male voice that sounded close to human answered. I’m glad to be able to assist you. Please give me your name and date of birth.

Fred Bingham, the man said, August eight, nineteen fifty-four.

Very well Mister Bingham, the voice stated. Please tell me your chief complaint.

Well, Bingham said, I have been having some burning when I pee.

You are having pain when you urinate. Please tell me how many days you have had this symptom.

Three.

Are you urinating more frequently?

Yes.

With more urgency than usual.

Yes.

As Richard listened, the questioning came across as somewhat scripted to him. He leaned over to his medical student and whispered, I think even you could do a better job than that computer.

Brandon winced.

Are you having any fever? the system continued.

No, I don’t think so.

Are you having any nausea or vomiting?

No.

Are you having any pain to your flank?

No.

Richard leaned over and whispered to Brandon. The system is inquiring about pyelonephritis, a urinary infection that has extended up into one of the kidneys.

Yes, Brandon mumbled, I’m aware.

Have you noticed any blood in your urine? the computer asked.

No.

Have you had this problem before? the interface continued.

Yes, I remember having a similar problem about five years ago. Bingham answered as he looked over his shoulder to make sure his audience was paying attention.

How would you rate your pain on a scale of zero to ten with zero being no pain and ten as the worst pain you could imagine.

I would rate the pain as a five out of ten.

Kidney stone questions, Richard commented and Brandon rolled his eyes.

Have you noticed any abnormal discharge from the penis?

No. Bingham answered.

Now it’s asking questions relative to STIs, Brandon preempted Richard, sexually transmitted infections.

Back in my day, they were called STDs, Richard commented more to himself than the student. What’s wrong with using the term disease? Is there more stigma associated with a disease than an infection? Richard’s voice was rising and a few audience members in front of him turned around. One put her finger to her lips for him to shush.

How many sexual partners have you had in the past year? the computer asked with the same bland intonation.

One, Bingham replied, my lovely wife of thirty-six years.

Congratulations on your marriage Mister Bingham, the system commented, I only have a few more questions. Have you been on antibiotics in the past three months and, if so, which ones? Do you have any antibiotic allergies? Will you be able to give us a urine sample today?

The answers are, No, No and Yes, Bingham answered with a smile.

Thank you for your cooperation, the computer interface closed.

Bingham turned to address his small audience. There you have a brief demonstration of the basic system as it has been designed. This is Phase One of our program and this version of the system was actually completed almost a year ago. Our programmers and computer engineers have been working diligently to expand the breadth and scope of the system. This demonstration is really only an introduction for you, a group of prominent healthcare practitioners, so you get a sense of what we’re working on. Robin is coming around now with a brief questionnaire and we ask each of you to complete it before you leave. Thank you very much for your time and interest.

Most of the participants waited in their seats while a young woman came around with paper and pencil attached to small clipboards. Richard got up and made his way out the back with Brandon trailing along behind. Dr. Duncan had a few more patients to see that afternoon so he wanted to get back to the office as quickly as possible.

So what do you think? Brandon asked as they were walking back down the hallway toward the building entrance.

About what? Richard replied.

About the system.

Oh, well, it seemed a bit predictable to me and rudimentary.

It worries me what might happen in the near future, Brandon said. I sure hope I can still work in medicine. All of the work I’ve put in for so many years…

This seemed like a change of subject to Richard and he wasn’t sure what Brandon meant. It is hard to know where this will all go, he said looking straight ahead as they walked out the front door and down the steps toward the parking lot. But I don’t think anything is going to stop this trend toward a reliance on computers to do the work that people have done in the past. They reached Richard’s BMW and both got in. As Richard was sliding into the driver’s seat, he continued, One of the most important questions in human history might be answered relatively soon. Richard pushed a button on the dashboard and the engine came to life.

Which question is that? Brandon asked as he buckled his seatbelt.

Richard turned to look over his shoulder as he backed the car out of its parking slot. Can an artificial intelligence system truly reproduce all levels and nuance of the human brain such that one cannot distinguish between the two?

There was silence between them as the car left the facility parking lot.

We have been studying the brain in our neuroscience class, Brandon said. One hundred billion neurons with more than one trillion connections is staggering. Hard for me to imagine that can be easily duplicated.

Clarice, Richard said into the air, direct me back to my office by a more traditional route.

Yes, Richard, she replied immediately. "You will take a right at the next intersection and then continue for two miles watching for signs to get on route one twenty-eight southbound.

The brain is a physical object and thus is finite in nature, Richard said as he accelerated the car, and so is reproducible, but I agree it must be a challenge for the programmers to reproduce all of the synaptic output of so many cells and connections. My impression though is that the automated systems use different methods to try and generate the same outputs.

What about emotions? Brandon asked. That would seem beyond the capacity of an artificial system.

The only way an artificial intelligence system couldn’t reproduce the brain, Richard thought, was to invoke metaphysical elements that were outside of and beyond the closed system of the physical brain. Love and other emotions are not fundamentally different from other processes in the brain, Richard blurted after an extended silence between them. They just require more sophisticated programming.

Brandon turned to Richard with a look of disbelief, What?

People tend to romanticize certain topics, Richard said, and it can cloud their ultimate judgment on the matter.

Brandon shrugged and turned to stare out the passenger window.

Back at Richard’s office, they reviewed some of the cases that were coming in that afternoon. Brandon was particularly interested in seeing a young male who had been diagnosed with Multiple Sclerosis a few months prior. One patient had been rescheduled so they could attend the Diagnostix demonstration.

I got you a thank you card as an appreciation for letting me come and work with you for a couple of months. Brandon pulled a card out of his white lab coat pocket and offered it to Richard. I know I just started working with you, but I wanted to thank you in advance.

Richard looked at the card as if he were uncertain what to do with it. He finally took the card and mumbled a thank you, but wasn’t sure if it was appropriate to thank a person for a thank you card. It seemed redundant.

It’s an Amazon gift card. I know you like to do research.

By the way the student was staring at the envelope, Richard realized that the gift card was probably inside. He opened it and read the note. There was indeed an Amazon gift card inside which Richard extracted and put in his pants pocket. He dropped the note into the trash.

The medical student looked distressed, but Richard didn’t understand why. Was I supposed to keep the card? Did that make sense? Would it have been better to keep the card for a day or two and then throw it in the trash? Was that the proper thank you note etiquette?

Chapter 2

That night, Richard was in his kitchen, doing some prep work for dinner. Audrey Swift, the neighbor in the house to his left, was a vegetarian, but would eat fish. John Dinbingniham, the neighbor to his right, would eat anything. Really, anything. If it weren’t for Audrey, Richard would be tempted to serve the most outlandishly exotic food just to see if the human trash compactor would balk. Durian fruit compote over slices of headcheese with a side of gefilte fish maybe?

The three neighbors had a routine where each would cook on Thursday nights in a rotation. It had been Richard’s suggestion initially because he knew it was important for him to have more social interactions with people. When Richard asked John and Audrey to dinner the first time, it was done in an awkward, abrupt manner and he was surprised they had accepted. Richard had been practicing his conversations with Clarice, his AI personal assistant, but thought it was better to participate with real human beings as often as possible. From early on, Richard found it more beneficial for him to interact with Audrey. She was a better listener. It was hard for Richard to easily explain, but there was a distinct difference between his interactions with Clarice and Audrey beyond just the difference in their physical forms. There were subtle differences in cadence, diction and rhythm, but it was more than that as well. Richard couldn’t exactly describe why it was more satisfying to talk with Audrey, but made efforts in between the dinners to see her and talk with her as much as possible.

Audrey and John gave Richard grief for following recipes to the letter. Richard argued that the recipes he used were the culmination of the work of experts who had already, through trial and error, come up with the proper ingredients in the ideal proportions. It would almost be disrespectful to diverge from the recipe.

Richard tailored his meals more to Audrey’s palate. He was serving seared halibut, spinach sautéed in garlic and olive oil with an accompaniment of lentils in the Andalusian style. At one point, they had agreed that one guest would bring dessert and the other some new cocktail or bottle of wine.

Audrey showed up right on time in a black cocktail dress. She had made a lemon meringue pie from scratch. Richard greeted her at the door. She touched his arm gently when he didn’t lean forward. Good to see you Richard, she said. How is everything at work?

Oh, it’s good, I guess. He half turned away and then turned back rather than leave her on the threshold by herself. Why don’t you come in, he stammered, I’m just getting the food pulled together.

What are we having tonight? Audrey asked.

Richard described the menu.

Why those are just about my favorite foods, Richard, Audrey beamed. You spoil me.

Well, Richard shifted and said in a low, suppressed voice, I thought you liked halibut, but wasn’t sure about the others.

Audrey followed him into the kitchen. I’ll help, she said, just let me know what you want me to do. She yanked an apron off a hook and tied it around her waist. Richard didn’t say anything, so she started tidying up some of the dirty pans and dishes on the counter.

So work is going well? she asked. Still trying to ‘crack the code’? Richard was working on a book on medical complexity. His working title had been: Medical Case Studies Using an Integrative Framework within Systems Theory. At one point, Audrey had recommending something with more general appeal. She had gone through some successful book titles to try and show Richard what people would respond to and buy. Richard protested for a while, confused. Didn’t it make more sense, he countered, for people to get a sense from the title of what they were buying. Why would you use some obtuse title for a book that didn’t represent its contents?

After many conversations after dinner with John passed out on the couch, Richard finally relented. Audrey worked with him and he finally agreed to change the working title to Cracking the Code. At first, Richard asked her if they could call it Cracking the Code, but add a subtitle like Functional Representations of Complex Patients. Audrey smiled at that, but thought the simple title alone would be more intriguing to people and they would want to figure out what code was being cracked. The picture on the cover would be important and people would be more drawn to open it up based on that anyway.

Work is good I guess, Richard replied with his back to her, mincing onions. But sometimes I’m not sure.

How so? Audrey moved around to his side to at least be in his peripheral vision.

I saw a woman this week who came in a while back because of chronic fatigue, bloating, difficulty losing weight and some other issues. Her urine for organic acid test showed she doesn’t metabolize fat very well and… Richard stopped. Well, anyway, some of her tests were concerning to me so I ordered follow-up tests that are almost certainly consistent with a malignancy. Cancer.

Oh, Audrey leaned in toward him, that’s tough. Did you talk with her about it?

Yes, Richard’s tone dropped, and I don’t know how it went. Maybe I should have someone call her on the phone to check in. I’m not sure. It’s really not my strong suit.

What happened?

Well, she was in the room, sitting comfortably. I asked how she was doing and she said fine. She asked me about her tests…and I think I said something like, Your tests are somewhat concerning overall and there is a good chance you have cancer.’"

Oh, Audrey replied. So how did she respond to that? She was probably expecting you to talk about her fatigue or her metabolism or something more general.

I never thought about that, Richard said. She was quiet after that for a while but, to my surprise, didn’t get upset. She just sat there. I tried to give her a few minutes to collect herself. Richard brought back the clear memory of sitting in the room with the woman. She didn’t cry. She didn’t get angry. She asked some details about the test results, but seemed kind of glazed over.

Maybe in the future, Audrey suggested, you could have someone else in the room? For her and for you actually. Audrey tried to get Richard to look at her, but he was still ghost-mincing the onion. For someone to hear news like that, it would help if they had someone there for support, but also to ask questions and get information. That woman was probably in somewhat of a state of shock over the idea of cancer out of the blue.

Richard nodded. The medical student Brent was in the room with me, but he wasn’t saying much.

Was Barbara in the room with you? Audrey asked.

Richard shook his head No.

That would probably be a good idea in the future. She could help.

You’re probably right about that, but I’m the doctor. Barbara is the medical assistant, so I can’t really have her talk to patients about these kind of things.

As long as the patient gets the best care, isn’t that all that matters? Your patients all know Barbara and like her. If she can help, it’s all the same whether she’s a medical assistant or a nurse or the head of Oncology at Mass General, Audrey continued. And how are you doing with all of it?

I’m fine, I guess, Richard answered. At this point, I’m trying to figure out how to guide her. For most of my career, I was a proponent of the standard surgery, chemotherapy and radiation scheme. But, much of the research I’ve done the past few years says that those aggressive, toxic approaches are probably not best. Or at least they aren’t best by themselves. There are many ways we could potentially reverse and cure her cancer…but it’s a hard sell because I wouldn’t want to put a person’s life at stake.

Richard, Audrey said softly, I meant how are you doing with the difficulties of telling someone they have cancer.

For Richard, working in medicine was a challenge from the beginning relative to his lack of genuine empathy. He eventually found Barbara, his medical assistant, and over time they established a system. Richard didn’t know to ask for help, but he didn’t need to because Barbara intuitively understood the support he needed. She guided him every day and now, after working together for so many years, the coaching was automatic between the two of them. When Richard was unwilling or unable to provide the support a patient needed, she would usually assert herself at the visit and fill the void herself.

Richard was grateful and understood on an intellectual level how important it was for his patients to be heard. He had read the studies. When it came to interpersonal relationships, however, Richard still felt lost. He couldn’t really hire Barbara to be with him all of the time. She had a life after all, he had considered many times, and a family. They needed her as well. Right?

I also saw a patient today with multiple chemical sensitivities, Richard said as he pulled another large onion from a bowl in front of him. Those are some of the most challenging people that I see in the office.

Richard, Audrey said, whoa, I think you can slow down with the onions.

What? Richard looked down at an enormous pile of chopped onions on the cutting board in front of him that had spilled onto the counter all around the board. Oh, I didn’t realize…

Audrey laughed. No problem, she said. I think we’re good for onions for a while. She went back to cleaning the stovetop. What were you saying about the patient with sensitivities?

Many complex people I see have difficulty tolerating certain environments because they are sensitive to various stimuli. Richard went on to describe some of the details of the woman he saw that day in the office as he remembered a breakthrough that came out of nowhere years prior.

One of the most important developments in Richard’s practice had to do with the concept of limbic