Becoming Well in the Real World

By George Link Spaeth

George Link Spaeth, a leading world expert in the treatment of glaucoma, reflects on a half-century of curing patients suffering from problems of vision and concludes that many of the most pressing problems affecting society today stem from our inability to see and react to daily life in realistic terms. As a result, many of us live in a perpetu

• Language: English
• Publisher: Paper Prize
• Release date: Jan 2, 2024
• ISBN: 9798868913723

Book preview

Becoming Well in the Real World

George Link Spaeth

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IMPRIMEO AD LIBITUM

Copyright © 2023 by George Spaeth

All rights reserved.

No portion of this book may be reproduced in any form without written permission from the publisher or author, except as permitted by U.S. copyright law.

This book is dedicated to Ann Ward Spaeth, who stayed with me, and by her way of living initiated in me good changes, still ongoing.

It is also dedicated to my parents, Lena Marie Link Spaeth and Edmund Benjamin Spaeth. My Mother believed I was being saved for something important. My Father’s energy, firmness, honesty, and courage still guide me.

Contents

Introduction

1.Two 30-year-old Patients: Some illustrative case studies

2.More Cases: Live like a wise Homo erectus, a relative of the Neanderthals

3.Do Not Lie or Deny - be honest with yourself and others

4. Learn - Be open to new ideas

5.Laud and be Grateful: They are both gracious and healing.

6.Laugh: See and express the delightful in and with yourself and others

7.Make a list

8.Love

9.Letting Go

10.Leap

11.Last

12.Leave a Legacy

13.Part 2: Becoming and Becoming Well

14....In the Real World

15.What is Truth?

16.Becoming

17.Nature and Nurture

18.Becoming Well

19.Symbols, Surrogates and Reality

20.Evidence, Information and Data

21.Confusions about Normal

22.Why People Find it Difficult to Take Care of Themselves

23.Profiling -The Use and Abuse of Labels, Diagnoses, and Categories

24.AWARENESS

25.A Bit about Me

Epilog

26.BIBLIOGRAPHY

Introduction

Evolution has brought us to a place of magnificence. Earth has changed from a barren battleground of volcanos to a living panorama of amazing beauty and diversity of life. Yet, it has also become a place of destruction. We, humans, have the ability to forge forward with our scientific, social, artistic, and commercial advancements. However, these advantages are two-edged swords. Our capacity to destroy has overwhelmed our ability to protect. Our capacity to hate has drowned our ability to love, and our capacity for domination has blinded us to other alternatives. The progress that led to the advantages we enjoy has also sown the seeds of destruction. End-of-the-world scenarios are no longer unlikely prophecies. Trends suggest a steadily deteriorating quality of life for people as well as for many species.

The Earth has been evolving for more than four billion years. The first living organisms may have been viruses and bacteria. These evolved into larger, more complex entities, such as jellyfish and people. As development happened, new abilities were added, including the ability to use symbols and to reason. Evolution is not necessarily onward and upward forever. It is simply constant change. Finally, many are aware by now that, due to human activity, the climate is changing. But it is not climate change that needs to be feared. No. What is to be feared is human nature.

We now have a world that includes Chartres Cathedral, many people living better lives after receiving organ transplants, billions of people flying from city to city each year, a World Court solving global crimes, and electronic communications connecting people. Despite these advancements, this planet is now home to over 8 billion people, more than Earth’s resources can sustain. Tragically, the only art seen by many is graffiti, many have never traveled at all, and wars are continuous; one out of ten people are starving, 85% of the world’s mammals have died, and much of the native wildlife that once inhabited the planet faces extinction. In 2021 storms and fires cost the United States more than 145 billion dollars, and climate change displaced 60 million people globally. (#100)

The intent of this book is to help us to become more aware of what is possible so that each of us can fashion our unique nature to become a better person, leading to a better world. There are people who take stock of themselves almost daily and constantly mold themselves into becoming better people. These people hold out a hopeful future for life on earth. They have proven that it is possible to become well in the real world. Though we cannot become everything that we want to become, and we may not be able to do everything that we want to do, we can influence our development in ways that presumably benefit both ourselves and others. At present, the focus is largely on cultural models directed at winning, achieving, excelling, and growing, often to the detriment of the defeated, the less accomplished, and the more ordinary. In themselves, these attributes, such as winning and excelling do not lead to the honest awareness essential to becoming well personally, which is essential to a flourishing ecosystem. Ideally, such an ecosystem is characterized by reciprocal respect.

Sixty years ago, I was already a practicing medical doctor, but it took me around thirty years to become reasonably aware. My awakening was not a conscious choice. It came from listening to people who shared with me stories of who they are. I also learned from those who criticized me, as well as from my wife and children. I was saddened by the large number of people who were taking care of themselves poorly. At the same time, I began to realize that poor care also explains why the Earth has become increasingly inhospitable to so many living things. I want to share the lessons I learned as an observer of the world, both locally and globally, primarily as a physician/ teacher/learner/investigator, but also as a person who has sought to learn about the damages Earth has suffered during the almost immeasurably brief time that I have been alive. Perhaps sharing thoughts about what it means to become well in the real world will have a beneficial impact. I believe these thoughts have benefitted some already; my hope is that they will help others.

This book is also the result of my grief at seeing a wondrous world deteriorate. The cause of many of the world’s woes is the people who are unaware of the damage they are doing. Some are comfortable, assured that soon everything will return to normal. They are unaware or even deny that the normal way we have been evolving and living has led us into the mess we are in today. We live in cocoons of denial, blind regarding ourselves and others. Why else do we fail to see that the world’s well-being requires the well-being of all or nearly all the world’s eight billion individuals, not just the few who are fortunate? Yet few hear the truth expressed by John Donne nearly four centuries ago, that Any man’s death diminishes me. If we were to see the world as it really is and if we were to acknowledge our impact on the planet, it is likely that our current journey toward disaster might be redirected.

What is the goal? It is loving and respecting the actual individual living thing. It is the act of fairness and the protection of the vulnerable. It is being aware of life on earth, and recognizing that our very existence is not for us alone, but for the whole planet; our ecosystem will not work if we only take and pillage. Though we do not know how we got to this place, the reality is that we did.

The world as we know it is both horrific and magnificent; it is possible that if enough of us become well in the real world, the awful may be less present than the wonderful.

After this introduction, I will describe specific cases. Each one concerns an individual person known to me. I selected these cases to illustrate characteristics and behavior that led to becoming well or not becoming well. Some identifying details have been modified to ensure confidentiality. These cases have been roughly categorized into various themes: awareness, living in a manner similar to a wise Neanderthal, learning, being grateful, laughing, prioritizing, loving, letting go, experimenting, persevering, and leaving a legacy.

Following the first part of the book, which deals with individual cases, the second part offers discussions of more universal characteristics: why we need to think of becoming rather than being, what it means to be well, and what constitutes the real world: Chapter 17 deals with the interaction of nature and nurture; Chapter 19 introduces thoughts regarding the necessity of focusing on the real thing itself, rather than on symbolic representations of that thing. Chapter 20 discusses how to evaluate and use evidence/data/information. This may seem dry, but it is central to understanding what this book is about. Confusion about the meaning of the word "normal’, and the consequences of this confusion are the subjects of Chapter 21; Chapter 22 examines why people do not care for themselves well, while Chapter 23 looks at the need for profiling and how to avoid the dangers associated with it. The final chapter, Chapter 24, is a poetic consideration of awareness.

All words have various shades of meaning. In hopes of increasing clarity, a glossary indicates the definitions of some words as they are used in this book. Further, an annotated bibliography is provided at the back of this book, alongside expanded discussions of critical issues. I have done my best to be relevant and accurate because irrelevancy and inaccuracy lead to erroneous decisions. If a reader considers something written here to be incorrect or irrelevant, please let me know at [e-mail].

The poet, Yeats, wrote, ...Things fall apart; the centre cannot hold; / Mere anarchy is loosed upon the world, / The blood-dimmed tide is loosed, and everywhere / The ceremony of innocence is drowned. My intent is to help people become more broadly well so that they have better lives. Further, if enough people do that successfully, I believe that evolution may actually be redirected, leading to a healthier, more joyful world, one more sustainable and harmonious, in which people are glad to be part of a symbiotic, flourishing ecosystem.

Chapter one

Two 30-year-old Patients: Some illustrative case studies

Two 30-year-old Patients: Some illustrative case studies

Let’s begin with the stories of two 30-year-olds and two teachers. One day two new patients came to see me. Both were thirty years old, and both were in excellent health.

Two 30-year-old patients

They had no known problems other than their eyes. The first was a woman referred to me by a corneal surgeon. She had come from a foreign country to be considered for a new, difficult type of corneal transplant. As an infant, she had had many surgical procedures for glaucoma; these had saved the health of the optic nerve that connects the eye to the brain, but the surgeries had damaged her corneas so that she could only see large, moving objects. She couldn’t read or recognize ordinary objects, even with available optical devices. The second patient had fallen and ruptured his right eye; a retinal surgeon had beautifully repaired this. With the eye that had been operated on, he could read the line next to the smallest line on a standard eye chart; with the other eye, he could read the smallest line.

Which of these two thirty-year-old patients was well, and which was disabled? Who was making the world better? Let’s learn more about these two.

The woman who had been unable to read or recognize anything since childhood was dressed colorfully. She was vivacious, upbeat, and enthusiastic. She had recently graduated first in her class from an internationally renowned law school and was now working as a lawyer helping immigrants. Though advised by her local ophthalmologists that no surgery could help her, she thought she could serve her clients better if she had better vision. The man had near-perfect vision after his eye was put back together. However, the drain that allows the fluid inside the eye to leave the eye had been damaged, so the pressure inside his eye was going to kill the nerve cells unless it was lowered. That would require more surgery, so I needed to know about his general health. When I asked about that, he replied that his health was excellent, but that he did not work because he was totally disabled: I can’t see.

This 30-year-old, almost blind woman was aware she fit into a category considered disabled. She had an accurate understanding of limitations and possibilities. The 30-year-old man, on the contrary, created a fictional disability, denying what was probably true. The woman who saw poorly was living in a difficult real world, made better than just tolerable due to honest, accurate, and relevant consideration of possibilities, so she could then act in ways to make her life and other people’s lives as good as possible. In contrast, the normal-seeing man disabled himself by an inaccurate assessment of his condition. His real world was real to him but was not the truth. He had become a parasite.

Two middle-aged teachers

The same day, I examined two middle-aged teachers. The first had been sent to me for glaucoma surgery. She had told her eye doctor six months earlier that she thought her reading glasses were too weak. He told her that the pressure in her eyes was too high, specifically 28 and 29-mm Hg and that she needed to start using eye drops to prevent glaucoma or she would lose her vision. When she came to see me, she was miserably unhappy. She had already lost much of her vision while being treated by the referring doctor. Her right eye could barely see the largest line on a vision chart. To make matters worse, she was experiencing extreme pain from damage to the surfaces of her eyes that the preservative in her eye drops had caused. She had been using four different types of eye drops but couldn’t name any of them. She was taking 12 different medications for her general health because doctors had told her to take them. When I examined her eyes, they were red and swollen. The corneas were cloudy, which I thought accounted for her poor vision. There was no sign that the pressure had caused glaucoma damage. I told her that in certain cases, it is possible to have pressure in the eye that is above average without causing damage. This information was relatively new. Many ophthalmologists, unaware of these recent developments, continued to treat these cases, trying to lower the pressure in the eye to a level that had previously been considered normal. Over the next two months, she was weaned off all her eye drops and most of the pills. Her corneas cleared, and her vision returned to normal. She felt stronger and more energetic. Her eye pressures were again higher than average. She was told that if she began to show signs of damage, other types of treatment might be necessary.

The second woman, also a teacher, had a similar history. She thought she needed reading glasses. Her eye doctor, he told her that she had glaucoma and advised her to use eye drops. She noticed that after several weeks her vision had worsened, and her eyes had become bright red. She mentioned this to the doctor. He told her to continue the eye drops because her pressure was too high. When she asked for a consultation, her doctor told her [responded] that she did not need a consultation. In this case, the patient decided to take charge of her own health. She came to see me. There were no signs of damage from glaucoma, and I advised her to stop using her eye drops. I suggested that she go to a drugstore and try on various reading glasses until she found a pair that let her read normally. I also cautioned her that she might need treatment in the future, so she should be sure to have periodic appointments. A month later, her distance and close-up vision were both satisfactory, and her eyes were comfortable. They were no longer red.

Both patients came to see me for the next 20 years. Both retained good sight, and neither needed additional treatment over that time span.

Which of these two teachers took good care of herself? One did what she was told and handed complete control to someone else. The other took ultimate responsibility for her health into her own hands.

Now for more cases, categorized:

Awareness

Case 1, Dr. G and color vision.

Awareness is at the core of wellness. Dr. G was a brilliant 91-year-old mathematician, one of the greats of the modern field. His glaucoma had been treated with well-performed surgical operations (trabeculectomies) on both eyes. One year later, the mathematician came to see me after his surgeon left the city. Although he had lost more than half of his vision before the surgery, his sight remained remarkably stable for 11 years after the operation. When he took a test to evaluate his remaining vision, the results were astoundingly similar to previous tests, an extremely rare phenomenon. During an examination, however, he told me that he saw colors less clearly in his left eye.

A repeat evaluation of his visual field showed a slight worsening. It was much less than the usual amount of noise that is always present. It was too little to be considered a sure sign of possible deterioration. However, he could tell that yellow was no longer yellow. For some people, deterioration of color vision may be a symptom of glaucoma. Even though his eye pressure seemed unchanged and still in a range often considered safe, 11 mm Hg, I told him that he needed to lower the pressure in his eye. He was eager to have something done because the change was apparent to him, and it was frightening. I was amazed that he had noted such a slight worsening. However, he was certain about the deterioration. I performed a laser procedure to lower his already low eye pressure even further. When he returned a month later, he was delighted; he thought his vision had returned completely to its prior quality, and colors were the same as before. The almost unmeasurable worsening of his previous visual field test had improved back to where it had been. His eye pressure measured 10 mmHg. He retained that vision until he died about five years later. The point of this case is that his extraordinary awareness led him to keep his vision.

About three years before his death, his wife invited my wife and me to a dinner party; the other couple she had invited was also elderly. It was an evening of laughter, graciousness, and honesty. He had adapted well to his lost sight. I wondered why he had lost so much vision before his previous surgeries. He may not have noticed it occurring, as the changes were gradual, and his sharp mind allowed him to compensate (he had played a fundamental role in developing early computers). Or, perhaps, he was so focused on his work that he had neglected himself. He may have mentioned his loss to his ophthalmologist, but because his eye pressure was low, the ophthalmologist did not believe him. At some point, however, he learned to value his awareness. Was the initial loss the stimulus for the later perceptiveness? Under my care, he volunteered what he observed happening to his vision. He wanted something done. He was living in reality. Why? The answer to this question is vastly more important than charting a course to Mars using the computer technology he developed, yet studies about why people are aware or deny are rare. Denial is often considered to be a necessary coping mechanism. It is not. It may make life appear to be all right, but when we are not aware of the changes taking place, we can no longer manage them.

Case 2, the self-blind divorcee

Mrs. B went to an ophthalmologist’s office to get new glasses. She probably chose this particular ophthalmologist because he was a next-door neighbor. He noted she had severe glaucoma, advised her to start eye drops to lower the pressure, and asked her to return in two weeks. She did not return. His staff called her. She did not return. He called her, getting a voicemail. She did not return. He wrote to her via registered mail indicating his concern. Five months later, she came back to see him. She was not using the recommended eye drops, and her eye pressure had caused even more damage. He referred her to me.

I discovered that Mrs. B had several issues]. It was readily apparent that she had marked open-angle glaucoma in both eyes. But, it was also apparent that she was brutally unhappy, angry, overweight, in the process of a divorce, and rude to the staff. When I discussed my findings with her, she told me how awful she thought I was because I had told her that she had a serious condition. I had discussed the extent of her loss of vision, but because I was aware of her anxiety and anger, I had emphasized the good news that her type of glaucoma usually responded well to treatment. I thought a laser treatment would probably be necessary. Still, I felt that she would have found that suggestion so threatening and anxiety-producing that she might have rejected it, so I did not mention it during that first visit. This was going to be a battle: I hoped I could help. I repeated her first doctor’s suggestion that she start eye drops designed to lower her eye pressure. She agreed to do that.

To my delight, she returned a week later so I could see how well the drops were working. They had caused only a slight lowering of the pressure, not nearly enough to stop further damage. She was possibly not using the drops but just told me she was. Whatever the reason, it was clear that she would soon be incapacitated if her visual loss was not stopped, so I told her about a laser trabeculoplasty. This is an outpatient procedure in which a highly focused laser treatment improves the drainage channels in the eye, resulting in lowering the pressure; it would not affect her vision and was almost completely without side effects.

Further, it worked in about three-quarters of the people on whom it was performed. Its major drawback was that the reduction in eye pressure often only lasted about five years, and because she was 57 years old, other treatments might be necessary in the future. She scolded me for frightening her. I do not doubt that my diagnosis was frightening. I had not managed to tell her what she needed to hear in a way that she could process it. At that point, I concluded that her major health problem was her emotional state. Her other troubles, including her inability to address her glaucoma, were the result of that emotional state, not the cause of it. However, I believed that any discussion of her mental state would backfire. Lest the reader concludes that I was unconcerned about her physical health and dismissed her problems as being all in her head, I quickly add that emotional and psychological conditions can be [are] just as physical as a blocked blood vessel that causes a heart attack.

The so-called mind-body distinction discussed at excessive length by Rene Descartes and others grew out of fanciful hubris; it is one of the many examples of the theorizing and philosophizing that have moved humanity into a world of unrealistic fiction. Descartes’ stress on the lack of connection between the mind and the body persists today, and it still causes harm. Further, the methodology Descartes used to prove that the mind and body are disconnected is still practiced today. That methodology relies on describing something you do not understand in symbolic terms and in an apparently reasoned way so that others will conclude that you know what you do not know. A different approach is to say: Hmm, I really don’t understand this. Perhaps it is not just me. Perhaps at this time and place, it cannot be understood. Hmm….

Obviously, an idea is different in some ways than a leg bone or a brain. On a scale designed for the study of a physical mass, ideas do not weigh anything. But ideas are just one of the many manifestations emanating from a living organism. An idea or a feeling has no independent existence. If it is not expressed and sensed in some physical form, such as writing, touching, or speaking, it does not exist. Emotional states are natural, not supernatural. Some may call what they feel on hearing Mozart’s Dove sono…‘ transcendent or miraculous. And indeed, it is transcendent and miraculous if by that is meant unable to be understood," but it lives in this real world of physics and biology. Back to Mrs. B……..

Mrs. B’s miseries originated in her cells and were as real as her cells. Someone might say they were all in her head. To some extent, that would be correct, as thoughts originate in the cells of the brain. However, I was concerned that if I commented on her emotional state, she would think that I was implying that her miseries were unreal and just the result of how she imagined the world to be. While that might be partially correct, since her imaginings were ideas that had no physical weight and occupied no space, they were, nevertheless, produced by the constellation of her body parts. The factors that eventually produced her condition were present in the fertilized egg, which ultimately became Mrs. B. That condition resulted from how biochemical nature was influenced by everything that happened to her as she evolved, including the imaginings that emanated from the interworking of all her body parts.

As I pondered how to change her perspective, I recalled my own past. When I was a student at Harvard Medical School, I developed tuberculosis. The physicians who examined me spoke to me as did Job’s comforters, smooth, distant, and impressed with their own panache. In contrast, the cardiac surgeon, Dwight Harken, was blunt, honest, and credible. I believed him when he told his resident that he did not think I had heart disease. After several days, when the conclusion was reached that I probably had tuberculosis and should be transferred to the Channing Room for Incurable Women - which had years before had been changed into a small tuberculosis sanitorium - a doctor, unknown to me, came to see me. I am abashed to say I have forgotten his name. After his examination, he told me that I almost certainly had very mild tuberculosis and that I would recover completely. He then added, in a non-condescending way, that if I learned from this experience and took care of myself well, I would outlive the vast majority of my classmates. He was prescient, and I continue to be grateful for his wisdom and humanity. I mentioned this story to Mrs. B, suggesting that she was diagnosed with glaucoma was like my being diagnosed with TB. Both glaucoma and tuberculosis can usually be controlled, and just as I did fine, she also would probably do fine. The apparent hardship of learning that she had glaucoma could be a wake-up call for her, in the same way that my contracting tuberculosis was a wake-up call for me. She could be alerted, as I had been, that my life was not going well. Glaucoma could be the start of a better life.

I am not a psychiatrist or counselor, but I have been successful in the past in helping people understand that their health issues involve many different aspects of how they are living, including habits and behavior. Unfortunately, I failed miserably with Mrs. B. I probably came across as preachy, critical, and unsympathetic. The volume [of her criticism increased in both the level of decibels and vituperation. The situation seemed beyond redemption. When it became apparent that there was nothing more that I could do, I suggested that I might not be the right person to help her. A doctor, who I knew was superb, lived in her area, and I advised Mrs. B to see her; I would get her an appointment in the next few days. However, I was bothered that I might have failed both the patient and the referring physician.

It turned out that the new ophthalmologist did do better. shS convinced Mrs. B that incisional surgery on her eyes was necessary and proceeded with this on the more damaged eye. The operating surgeon later informed me that the postoperative course was challenging. The patient continued to make constant criticisms and was unwilling to follow recommendations. I became involved in that postoperative care when the operating surgeon’s assistant called me on a Sunday because he could not contact the surgeon and wondered what to do. Mrs. B, at that point, about 2 two weeks after her operation, still had blurred vision and had come to the emergency ward. The assistant’s comments indicated that all was going well and the blurred vision would probably clear in several weeks or months. But, and here is where the assistant was stumped, Mrs. B insisted on knowing the exact date when her sharpness of vision would be the same as before the surgery; she would not leave the emergency room until the assistant gave her a date. The assistant asked me what to say. I advised him to tell Mrs. B….that he could not tell her precisely when her vision would return to its previous level and that nobody could do that because the healing rate varies from person to person. I reminded him that he had been taught not to guess. I added that if she was still unsatisfied, he should ensure she understood what she needed to do and then courteously say Good-bye. The long-term outcome is unknown to me because Mrs. B disappeared. She left that ophthalmologist to do… what? we do not know.

Patients are wise to be skeptical about doctors, as all people are wise to evaluate recommendations from others thoughtfully. I welcome skepticism in patients. Mrs. B, however, was not skeptical; rather, she was in that tragic state of being unaware that she was unaware. At one level, she probably recognized that her life was in a shambles, but that was too terrifying for her to acknowledge to herself consciously. Whatever the cause, she was sick and not living in the real world. Rather she was trying to flail out at the world and hide in a world she had created. To reach people who are unaware of their own lack of awareness is extraordinarily difficult. Her future was grim.

Case 3, The Observer of a Miracle

An important person in my development is PP. I use both her initials as a way of thanking her for making me aware of something important. The other Initials I use in this book are not those of the actual person. But, in this case, PP are her correct initials. I hope she may read this text and recognize that she is the one who is being described.

PP was on the teaching faculty of a well-known university in a major American city. When her eye doctor told her that she needed treatment for her juvenile-onset open-angle glaucoma she came to see me on her own. I told her that I agreed fully with her ophthalmologist’s diagnosis and recommendations. About two years later, she was worn out by the stress of slowly losing vision and the uncertainty of the future; she came to be examined by me and then asked if I would be willing to do the recommended surgery. I agreed that she needed surgery. Since she lived close enough to Wills Eye Hospital, postoperative care would not be a problem, and I said yes. I enjoyed doing glaucoma surgery, and I believed that I probably did it as well as anyone in the world.

Now, it is important that I provide some very rudimentary information about operative sedation, that is, drugs that are routinely used at the time of surgery to 1) prevent the person from becoming anxious. 2) make it so that the patient has no memory of what happened, and 3) prevent pain and movement. For most people, a surgical procedure on an eye is a frightening experience. Consequently, it is usual for them to be sedated. Various agents, such as Valium, are often used to prevent anxiety. These tend to make a person calm and sleepy. If the goal is to prevent the patient from having any memory of the operation, agents such as Versed are more effective in this regard. These drugs tend to cause effects that last a day or longer. Another frequently used drug is Propofol, which is injected into a vein and causes memory loss and unconsciousness, although usually for less than 10 minutes after a single injection. Propofol is also often used at the start of a surgical procedure to allow injections to be given without the individual being aware of pain, or in some cases; it is used to paralyze the patient to make procedures such as placing a tube in the airway easier. Different agents, such as Fentanyl and other narcotics, may be routinely used to make the person unaware of having pain. Local agents such as Novocaine may also be used to numb the nerves.

Since eye surgery is frightening, patients are usually given enough medication in various forms to keep them unaware of what is happening; this may be the total immobility and prevention of pain associated with general anesthesia or just enough anesthetic to induce twilight sleep. Such sedation and anesthesia have common side effects, such as drowsiness, confusion, and nausea, and rare side effects, such as liver or kidney damage or a long-lasting decrease in the ability to think clearly. Also, there are other risks, such as the patient awakening unexpectedly during the surgery or vomiting following the surgery, which may ruin the surgical result. For safety purposes, I insisted that the anesthetist sedate the patient minimally and administer just enough medication to take the edge off the patient’s anxiety. Several anesthesiologists considered this to be Prussian and uncaring, and many of them were often highly critical of me. Some even refused to work with me.

With that informational background, let us consider case #3, PP. PP was in the vanguard of those who wanted to be in control of their medical experiences. She did not want to be snowed. So she received no medication to relieve anxiety, make her forget, or make her unaware or even sleepy, and she received no systemic medicines to prevent the pain associated with local anesthetic injections. I told her, Now I am going to give you an injection on the side of your face so you can’t squeeze your lids shut. This will sting badly for about 10 seconds. I did that. Now I am going to give you an injection behind the eye. The needle placement will be uncomfortable, and the anesthetic agent will sting for about 10 seconds. I did that. She was then prepared by cleaning the lids and the face and covered with sterile drapes to prevent infection. As we got underway, I spoke with her in French and told her what was happening as the surgery proceeded. I mentioned that I was angry at her for not sending me the essay she had written on The Tempest, as promised. She asked questions, and I answered. She commented on the nature of the hands of the postdoctoral fellow assisting me. For most of the time, she was quiet. But it was clear she was attentive to what was happening. The procedure went well.

About six months later she sent me a copy of the Georgia Review, which included an essay, To Suffer a Sea Change, that captured what the operation had meant to her. She meticulously and poetically described her feelings at each stage of the surgical episode. She wrote that being fully aware of what was happening fundamentally changed her. For her to participate in an event that was miraculous to her and yet, simultaneously so work-a-day as to be almost casual, was a transformational gift. I read her essay with intense interest,

In the following years, as anesthetic and surgical techniques evolved, the ability to snow the patient became easier. Doc, I don’t want to hear or feel anything! was a standard patient expectation. A few patients were indeed so apprehensive that they required sedation, but for almost all, I would have preferred that they had the experience that PP had. I wanted the surgical episode to be a joint journey with heightened awareness, not decreased attentiveness. I wanted the people to be calm and comfortable but to grow. The opportunity for this to happen was provided by explaining fully to them what to expect during the operative procedure, touching them in the preoperative area and answering their questions, and remaining calm, aware, and attentive. I thought of the lesson I had learned from a senior surgeon during my training; Dr. Fry emphasized the essential nature of vocal and local anesthesia. My objectives in doing surgery were to have a good surgical result but also for the episode to lead to intellectual and emotional growth for the patient. PP’s essay in the Georgia Review did more than encourage me. Her awareness added a new dimension to her life and to mine. Her attention has benefited the lives of the many people on whom I subsequently did surgery in a way that engaged them in the process.

Case 4, The rower who ate cashew nuts

Mr. M was tall, very tall, lean, and tanned. He looked younger than his 45 years. He was a sport rower. He also needed to make a living, which he accomplished by working in the laboratory of Peter Medawar, a Nobel Prize winner who challenged the idea that immune responses are solely genetic. Medawar’s work is germane to the thoughts in this book because he showed that people’s ability or inability to protect themselves from something foreign could be acquired, that is, learned by the body in response to an environmental stimulus; that stimulus might be a virus or an organ denoted from somebody else. This will be discussed in detail in the Chapter entitled Nature and Nurture. There it is pointed out how nurture can change nature, that is, how our environment is constantly altering our basic genetic structure, including what we think and do. Mr. M found the intense competition and stress of the high level of research with Dr. Medawar troubling - secrecy and lack of collaboration between different laboratories were routine. Despite the excitement and opportunity of working with a Nobel Prize winner, the pressure was so intense that he emigrated to Philadelphia; the choice of Philadelphia was motivated by his major love in life - crew. He became a stockbroker and told me how much better he felt being part of a team in which all the members shared what they found worked or did not work. He also coached a rowing crew on the Schuylkill River. His coaching style favored slow, long workouts emphasizing skill and endurance.

Before coming to Philadelphia, he had surgery performed on both eyes. The surgery was done in London at Moorfields Eye Hospital, one of the finest eye centers in the world. He, like PP, had developed glaucoma in his 20s. When he came to me, he was no longer using any treatment because his surgery had worked well enough in both eyes, so his doctor advised him that eye drops were unnecessary. This concerned me because, as I reviewed his previous records and listened to him, I concluded his vision was probably gradually getting worse; the prolonged rate of change would not have been of concern, except for his excellent health and the high likelihood that he would live many more years. I concluded that the risks of further surgery outweighed the potential benefits, so he and I opted to resume using eye drops. His eye pressure appeared to be in a better range.

Several years later, at a routine visit, the pressure in both of his eyes was much higher than it had been previously, specifically, 20 in the right eye and 28 in the left, whereas it had been 16 in the right and 18 in the left. I could see no reason for this; his eyes looked unchanged from before, including the filtering blebs, where the fluid inside the eyeball seeped through the wall of the globe to the outside. That was a result of the surgical procedures done in London. The fact that the pressure in both eyes had risen suggested the problem was systemic, that is, it had not started in the eyes. At that point, he volunteered, I know this is crazy, but I have started eating cashews, I mean really eating. A tin a day! I said, Mr. M (I very rarely call patients by their first names, even though I put my hand on their arm and in other ways try to be emotionally and physically close to them), I am unaware of the effect of cashew nuts on intraocular pressure, but, who knows? I suggest you stop the cashews. What could explain the possible relationship? Perhaps the added salt that was in the cashews. He had been an empirical scientist, and he readily agreed to experimentally eliminate the cashews. Two weeks later his eye pressure had reduced to where it was close to prior measurements. He bridled at my next request, which was to resume eating the cashews the way he had before. His work had been in a basic research laboratory, where the inconveniences and concerns related to daily life were less apparent. He knew he had a blinding disease. Why risk the possibility that his pressure might again rise but not fall later? Nevertheless, he understood that causation cannot be established with adequate certainty just by noting an association. So, he agreed.

Two weeks later his eye pressures were 22 and 29. Again, not proof, but an indication that something related to eating those particular cashews in the amount he was consuming them probably caused his eye pressure to rise. But here he let me down, or, more accurately, I let evolution down. Why did the pressures rise? Was the relationship one of ’cause and effect’(eating salted cashew nuts causes the eye pressure to rise), a sign that his surgical procedures were starting to fail and worked sometimes and not at other times, or a reflection of an emotional state which led him to eat cashews when stressed? If there was a causal relationship, was it due to salt and unrelated to cashews, was it caused by cashews and unrelated to salt, or was something else responsible for the pressure rise? The observation needed explaining; a series of clinical and basic studies might lead to a better understanding of the effect of eating a relatively common food on human physiology. But he had acceded to one request, and that was enough. I believe the physician’s primary responsibility is to the patient; teaching and research have their place, but in my opinion, it is usually one that turns out to be inflated, what the Nobel Prize winner, Thomas Weller, called useless research in his presentation at the graduation of Harvard Medical Students in 1959. Two weeks later, Mr. M’s eye pressure was 15 and 19 mmHg. He was happy and volunteered that he would consume no more cashews. Although it was a happy ending, I may have let myself and others down because I did not study the observation further or at least report it in a refereed journal. I excuse myself by saying that the editor would probably say, Hmm, just one case. No other data. No. Not worth publishing. And I was already behind on what I wanted to do. But the world lost an opportunity to add useful knowledge. Awareness is but the start of making oneself and the world better; it is necessary but not enough.

I include this case because Mr. M knew how to care for himself. I would not have asked him whether he was eating cashews because I had no understanding that they could harm people with glaucoma. That information only surfaced because he had the good sense to mention it. He was aware and was taking good care of himself.

Case 5, The Burned-out Young Man

This case regarding awareness is dramatic. Before describing the man, however, it is necessary to understand some background information regarding the necessity of estimating life expectancy. I will start with that.

I have developed a conceptual framework to help guide thinking and acting about disease; it is called the Colored Disease Process Graph. I show it here because it is important.

Although this conceptual framework is still only used by relatively few physicians it is - I believe - a valid, relevant, and important contribution. The reason is that it directs both the caregiver’s attention and the attention of the person being cared for toward what matters. Specifically, it focuses on how the person feels. In Stage 1, the person feels fine. In Stage 2, the person still feels well but has something seriously wrong that can be noted by the doctor. In Stage 3, the person already feels sick. The graph can also be used to help establish whether the person in question will feel sick or well in the future. Initially, I used the graph as a black and white graphic, but after it became clear that most people make decisions on the basis of their viscera - how it feels in their gut and in their groin - the colors were added: Stage 1, green for good, OK, all’s-right-with-the-world, Stage 2, yellow for transition, caution, uncertainty, and Stage 3, red for danger, flag-in-front-of-the-bull, already sick. The change transformed the usefulness of the graph; suddenly those to whom it was shown immediately got the situation. Oh, I’m in the Green Zone? OK, that’s good isn’t it?. So I don’t really need any treatment even though I was told I did!. Great! Or, So you tell me I’m already in the Red Zone. Yeah, I know that. I feel crummy. What do I have to do?

When the graph is used to determine how a person who presently feels fine will feel in the future, additional data is essential; simply knowing whether the person is presently fine, in transition or sick is not enough to accurately predict the future. Other essential pieces of information include how rapidly the condition is worsening, how long the worsening will continue, and how much longer the person is likely to live. Caregivers have not been good at establishing this information, even though it is of cardinal importance to the people.

Monitoring feelings, that is, understanding how symptoms are changing, is both harder and easier than tracking findings such as blood pressure or the amount of cholesterol in the blood. It is harder because what a person actually feels, can’t be measured with a machine, at least not the way it is possible to measure blood pressure and serum cholesterol. Furthermore, there is a wide range of differences in the extent to which people are aware of themselves. At times, some people not to know about themselves. Often people are inarticulate, and frequently they are frightened or concerned about sharing sensitive feelings they fear will reflect on them poorly or make them vulnerable to exploitation.

It is relatively easy to ask how are you? But that question is rarely asked in a way that produces an accurate or relevant answer. Few people ask themselves how they really are. If someone else asks, they usually give a knee-jerk answer that responds to what they think the other person wants to hear. So if the eye doctor asks, How are you, they might say Great, I just saw my local doctor and he said everything is fine! But that does not answer the question in a way that was hoped for, which is specifically, How are you from your point of view? Caregivers are often pressed for time and they can be impatient at being told sloppy symptoms that are useless in helping arrive at a diagnosis and are almost always biased. Recording symptoms by talking with a patient should be easier than getting data with a machine or device, because all one needs to do is ask, and listen. Nevertheless, asking knowledgeably and empathetically, and listening proactively well is strangely difficult; Nevertheless, learning how to do this is largely