Who Was That Masked Man?

Shortly after beginning the practice of medicine I took evening shifts at a local hospital's emergency room to make some extra money.  One shift was to be indelibly memorable.

There was pandemonium that night in the ER and, with all hands on deck, we struggled to help all the patients.

One patient somehow got lost in the shuffle and a nurse, suddenly aware that the patient had been waiting for a long time, asked me to see him pronto.

Pulling the curtain back I saw a man who was decidedly dead.  The nurse said she would gather the family together so I  could deliver the bad news.

This was a very large family.  They took the news with disbelief, followed shortly by anger, then fury.

Though they did not know what role I might have played in the death (I never laid a glove on him), I was the messenger, and despite the conventional wisdom not to kill the messenger, they circled me, looking as though they were going to rethink the messenger advice.  Indeed, one family member accused me outright of killing his relative.

Just then a short man in suit and tie appeared.  He seemed in no hurry as he went into a desultory gait.  Finally, he parted the circle and took up his position in the center.

What happened next was magical.  He bent down, lifted his right foot and began dusting off his shoe with rhythmical swipes.

All eyes were on him. In just seconds murderous feelings gave way to deep grief.  No one noticed that I was still there.  The shoe dusting somehow broke the tension and incredibly became the focal point.

I never got to speak with the shoe swiper (he just disappeared) but i did learn that he was a psychiatry resident.  If he didn't save my life, he, at least, saved me a long stay on the orthopedic ward.

I had occasion to use his technique over the years.

If you find yourself shoeless a tie suffices.

 

To Sue Or Not to Sue

A young woman sustains a major complication after receiving, from the nurse, ten times the ordered dose of an anticoagulant.  Family and friends clamored for a lawsuit but the patient steadfastly declined to launch one.

Why?  Perhaps it was because we came clean with her about the error.  No jargon.  No flinching.  No rationalizations.  “Honesty is the best policy” is indeed a cliche but it is nonetheless true.  This contrasts sharply with those who think doctors bury their mistakes.

Though I did not encourage her to sue (we never discussed legal matters) I thought her family was correct about getting compensation.  After all, the error was transparently clear and the complications great. Perhaps she was concerned lawyers would leave the nurse and hospital for road kill.  She was that kind of person. 

Over the years,  when I inevitably made a significant error, I explained to patients, remembering that young woman who seemed to need nothing more than honesty, how I had been errant, and what I planned to do to set things right. To my amazement and gratitude they were almost always forgiving.  

They didn't need me to be perfect; they needed me to be honest.

Gluten Free

Tour your local supermarket and you will be peppered by an exhaustive range of products labeled gluten free.

Gluten is a protein found largely in flours such as wheat, barley and rye.  It gives bread much of its elasticity.

Individuals with coeliac disease (a form of inflammatory bowel disease) are worsened by even small amounts of dietary gluten and total abstinence from the substance is critical. 

While this association is important it doesn't explain the near hysteria regarding gluten among foodies.  After all, the number of individuals with coeliac disease and gluten hypersensitivity  is less than one percent of the population. This hardly indicates the need to send gluten to a nutritional gulag.

Yet this is just what is happening, with more and more foods and services designated gluten free.  Consumers look for this branding and those items designated as gluten free fly off the shelf.

While some of the products have gluten removed, most (say peaches) are gluten free to begin with.  Shoppers oftentimes embrace these items for the first time believing  they are especially safe and healthy choices.

There are numerous gluten free sightings during the course of a usual day.  

For example, many restaurants proclaim that a number of their dishes are gluten free.  Ice cream parlors are gluten free.  A dentist advertises gluten free teeth cleanings.  Perhaps we'll even have gluten free condoms one day.







                                                                                                                                                                                                                                                                                                                   

No Thank You

A local clinic recently announced on the radio that they had begun to offer same day, early morning, late evening and weekend appointments.

Is this good news?  Probably not.

While patients will doubtless appreciate increased options, there are downsides to the strategy. 

Making it too convenient to be seen will likely result in many patients checking in for symptoms that would remit safely on their own in a few days.

While most patients will get good care off hours a good number will fall prey to false positive tests and run the risk of becoming medicalized (over diagnosed). These individuals would be better off staying home or at work.

Moreover, it is unlikely that patients would see their own doctor, making the visit tantamount to a walk in clinic visit, more expensive and less accurate.

From this perch, the marketing of extended hours, is more an homage to the bottom line, than a concern for patient care.

It's basically a case of clinic administrators, dressed in the robes of public service, looking for patients. 

To Tell The Truth

I learned a great deal about truth-telling from a young woman who had multiple admissions to the hospital for critically low potassium levels in her blood stream, making her vulnerable to serious and even fatal heart irregularities.

It was significant that her potassium levels remained normal after replacement in the hospital but regularly dropped to critical levels after discharge, bouncing her back into the hospital.

The evaluation of low potassium (hypokalemia) includes a number of sophisticated and esoteric tests which in her case were all normal.

A common cause, however, is the surreptitious abuse of laxatives, especially in patients with a background of anorexia nervosa.  In these individuals the key to confirming the laxative abuse is to firstly consider it after ruling out other causes with laboratory investigations.

My patient fervently denied the use of laxatives and she resented my probings into the matter.  She accused me of not trusting her which often left me, despite my growing belief that I had good reason not to trust her, with pangs of guilt, especially when she often appeared misunderstood or hurt.

Hospital visits became increasingly strained as feelings of guilt (she hit the guilt target flawlessly) and suspicion (I was virtually certain that she was not being honest) competed for my attention.

We were at an impasse.

I spoke to a colleague in psychiatry about the case, especially  as people with laxative abuse often have serious emotional distress.  

He asked me if I told her I did not believe her.  I had not, probably because it would have left me open to feelings of insensitivity.  But that was what he thought was needed and I determined to tell her I did not believe her, despite my anxieties about confrontation, on the next visit.

So the next day I visited her in her hospital room and told her  that I did not believe her and felt she had been secretly taking large doses of laxatives.

What followed was a thorough bombing, with everything within reach - lamps, glasses, books - flying at me as I fled the room.

It was not immediately apparent that truthfulness had served me well, but the next day I encountered a different person.  She was tearful, apologetic and confessed that she had been abusing laxatives.

She had a serious condition and I was relieved that we could finally begin treating her.  She was too.

This case reminds me of how amazing the truth can be, especially when it is painful.

On Touching

Touching has always been a way to express our love and humanity.  Its ability to heal has been recognized since physicians made house calls in caves.  

Royalty has used it to great advantage too, knighting with touches of the hand and sword.  Moreover, the "royal touch" of British and French monarchs, which was believed to cure a glandular form of tuberculosis, enhanced their position as purveyors of divine power for many centuries.

There is still plenty of touching in the 21st century but the practice is somewhat on hard times.  I am reminded of one of my patients, a grade school teacher, who was terminated after hugging a child who had fallen and scrapped her knee on the playground.  My patient was ultimately pushed out of the school district by parents and administrators who couldn't see the difference between compassion (which it was) and perversion.

The workplace is now largely free (you can thank Anita Hill) of unwanted gropings and touchings.

But at a price.

Fear of  sexual harassment is so widespread at work  that  tearful and overwhelmed individuals must oftentimes soldier on without the immense benefit of a pat on the shoulder or a discreet hug from a colleague.

In medicine, touch remains  one of physicians most powerful tools.  

I remember a woman on a rehabilitation unit who had unmanageable pain.  She was in great distress and the staff and I were at wits end.  Finally  I recalled an article suggesting that severe pain could be relieved by hair brushing.  After getting myself and the nursing staff to buy into the idea that this kind of touching could relieve severe pain, I ordered hair brushing for ten minutes every six hours, scheduling the brushing just like a pain pill.  The results were astonishingly good.

Doctors have many different ways of comforting patients utilizing touch.  In my case,  I placed my free hand on their right shoulder while examining various organ systems.  My belief is that this practice created a connection between us that was strong, resilient and therapeutic.

The smart physician can sometimes diagnose and treat patients effectively without ever touching or examining them.

The wise physician knows that the addition of a perfunctory physical exam (say aah) in such cases can result in speedier and more durable cures.

Placebos remain one of doctors most powerful tools and touch is arguably its quintessence.

Asking For Help

Primary care physicians often refer their patients to specialists, say a cardiologist,  for what is simply known as a consultation.  If the doctor or patient is unsatisfied with the consultation, a second consultant might be  brought in for what is called a second opinion.  On rare occasions,  an internist might refer a patient to another internist for advice and consultation.

While the primary doctor usually orchestrates the referral, patients sometimes do it themselves.

A second opinion might be invoked when someone has been advised to have a major operation.  Or, it might be invoked in an unusually complicated case where the primary physician and his/her consultants are out of ideas.

The selection of the doctor to give a second opinion can be fraught with biases.

Consider the following.  If the patient makes the choice, it is often influenced by family and friends who can be easily moved by the celebrity of a consultant, or their personal experience with him/her,  rather than objective performance measurements such as post operative complication rates.  

When the primary doctor picks the consultant, it is often someone in their own group.  This introduces a financial bias where keeping the fees in house might trump inviting a consultant from another organization, who might be more qualified to weigh in on the case.   

If the ordering doctor picks a colleague from their own group, there are at least two more important concerns. The doctor giving the second opinion might be reluctant to disagree with care rendered by someone who is in their personal, clinical and financial orbits.  Additionally,  there is the matter of herd mentality (common in groups and hospitals) where physicians, with social and clinical ties, tend to manage certain problems uniformly, making it less likely that alternative approaches will be considered.

Surprisingly, internists almost never ask internal medicine colleagues for formal consultation.  This is unfortunate since another internist, with a panoramic view of medicine, might be of much greater service in mysterious or complicated cases than a squadron of sub-specialists who tend to look at cases through a single lens. 

My years in medicine have shown me that a consultation or second opinion, centered in knowledge and a wide ranging experience, is often, in tough cases, more valuable than endless testing, which tends to get more and more  incoherent as time goes on. 

Sound judgement is vastly superior to rampant testing, which once unleashed,  tends to generate more smoke than light.

In good hands the second opinion (a third opinion is almost never a good idea) is often clarifying and reassuring for both patients and doctors.  Bias should be kept to a minimum and doctors and patients should work together in picking a consultant.

On Cleavage

It is almost inevitable that a physician will experience, over a long career, sexual arousal while seeing a patient.

In the vast majority of cases the feelings are rare, brief, without any violation of decency standards.

Many of us learned in our training that we might experience occasional erotic sensations  in the course of our clinical work.  We were assured that it was not abnormal to do so, though we were told we must never  act out any of those feelings.   To Wit, fleeting feelings were normal, prolonged feelings were a call for going on red alert.

Episodes of arousal are  usually biological, without emotional baggage, but they could indicate, presenting as a flirtation or seduction, a significant personality or psychological disorder.  

When the experience is anything more than ephemeral it becomes crucial to determine whether it is the doctor or patient launching Cupid's arrow.   In either case problems may go way beyond the exam room, permeating important relationships.  Psychiatric consultation can be of great benefit in sorting things out.

About twenty years into my practice I felt confident that sexual arousal in the exam room was not one of my problems.

But that changed one day when a new patient with a cough was brought into my office.  

Not only was she curvaceous but she had a full bosom with an an arresting cleavage.  Inchoate feelings of arousal started almost immediately and I found myself in a battle to not look at her chest, hoping my eyes would lock instead on to her eyes,  suggesting sincerity and caring rather than the embarrassing and over heated feelings I was struggling against.

Alas, my defenses crumbled when I examined her.

It was my habit to tell  patients what I was doing as I examined them: now I'm going to look at your throat, now I'm going to listen to your lungs.  Disaster struck when I came to listen to this patient's heart when I heard myself say, quite clearly and audibly - and now I'm going to listen to your breasts.

She gave no signal that she heard me though I felt certain she had.  Since she said nothing I decided not to open a can of worms and,  feeling exposed  and mortified, said nothing.

For the next twenty-two years, when coming to a  heart exam 
I would faithfully say, "and now I'm going to listen to your (pause, pause, pause, get it right) heart.

What did I learn?

I learned that  I was human and not always as in command of my feelings as I had imagined.  Moreover, I learned that patients can be generous in forgiving our frailties.  

Whatever feelings of attraction  I had for the patient were extinguished by the experience and our doctor patient relationship took an ordinary trajectory.

Retry

Dear Reader -

I sent out my last post, Televised Snake Oil, on 6/13/13.  I've since learned that some of you never received the post or had to go through some tricky gymnastics to view it.

It's not clear to me why this happened.

I will resend hoping the problem somehow auto corrects.

Blogspeak

Televised Snake Oil

I was looking up the meaning of a word on my desktop the other day when a small box containing an advertisement drifted, uninvited, onto the screen.

The advertisement was for an inhaled steroid used to treat asthma and chronic obstructive pulmonary disease.  The drug is often effective, but it is in no way a first line treatment as there are multiple strategies, with significantly lower cost and fewer side effects,  which may work as well or better.

It is only in recent years that drug firms have taken their products directly to the public on television and the internet.  Previously, the main sales strategy was to have drug representatives meet directly with physicians to trumpet their products.

Doctors were flattered, cajoled and bought to gain their endorsements.  For example, lavish lunches were provided for the doctors and their staffs in exchange for ten minutes of the doctor's time.  Clinicians and staff came to regard these lunches as an enshrined benefit.  

While  wolfing down sandwiches (stuffed with arugula), golf balls,  pens, refrigerator magnets, pads and all manner of tchotchkes were put out for the taking. While any self-respecting  robber would never steal a tchotchke, doctors couldn't get enough of them.

Physicians, who additionally agreed to give talks favoring use of a company's new drug, were oftentimes regaled with all expense trips for two to exotic places.  Generous stipends such as a financial aid package for millionaires were not uncommon.

Altogether, the relationship between many drug companies and a sizable  minority of doctors was whoreish.  The pharmaceutical industry has lots of money to buy favors and many doctors are on the take.  Even physicians who never put themselves up for sale were too willing to accept drug companies as the first and last word on treatment issues.   In doing so, doctors left the fox (the pharmaceutical industry) guarding the hen house.

Happily, many medical organizations have now set limits on gifts which doctors can take from a drug company.  The free lunch is disappearing and many clinics do not allow drug reps on their premises.  Moreover,  free drug samples, a major hook for commanding physician time, is now regarded as off limits.

Despite these reforms, the relatively new phenomenon of marketing medications directly to the public via TV or the internet is even more sinister and egregious than the previous system of marketing centered around drug reps and a culture of payoffs to doctors. 

Television has proven to be a remarkably effective tool in influencing and seducing buyers.  This is not much of a concern for, say, tooth paste commercials,  but it becomes a big concern when viewers are left to interpret medication commercials which at bottom are high on promises and low on scientific rigor. 

The physician is conspicuously left out of the equation until calls start pouring in from patients who want to go on an advertised medication.  Many of these patients (consumers) were doing just fine until they came face to face with the idea that they could have, say, low testosterone.  No wonder they felt tired and could no longer press 300 pounds.  Both men and women were alert to the suggestion that correcting low T with an under arm application of a testosterone gel might well promote a feeling of sexual vibrancy. 

While some  people might benefit from T.V. promoted drugs, the vast majority either do not need them or are already doing well on standard treatments.  Moreover, since someone has to pay for air time,  publicly advertised drugs are usually much more costly.

The point remains that the devil you know is better than the one you don't know.

It's the doctors job to evaluate new treatments, including benefits and side effects.  Their  opinions should result from scholarly sources such as the best medical and pharmacological journals. 

Responsible journalism, promoting rational discourse, also has an important role to play in engaging and informing the public on medical issues.

Direct advertising is biased and misleading, it raises prescription costs, and is without a net benefit to society.

Canada, the UK and Australia ban direct advertising and we should do the same.  In doing so we would go far to insure  that when treatments are ordered, it is the doctor, not the drug company, that is guarding the hen house.

On Doctors And Data Entry

Managers are typically keen to know how hard the bees are working in the beehive.

When the bee is, say, a factory worker it's fairly easy to measure work output and quality: count the number of glass objects placed on a conveyor belt in an eight hour period and note the amount of breakage, if any.  Workers can be easily compared using this metric.

When the bee is a family practice physician or internist measuring work output and quality of work becomes problematic because the work elements that count defy straightforward analysis.

Undaunted by the complexity of this task managers sometimes plow ahead with a simple measurement, believing, it seems, that if something can be measured, it should be measured, regardless of how limited the return.

For example, I recently learned about a very good clinic that came up with the very bad idea of reviewing physician performance based on their skill and versatility at data entry.  

In this case, a computer review of physician records evaluated how often doctors documented that they, among other things, recommended colonoscopies and mammograms to their patients.  The information had to be entered in a specific place in the electronic record or it was assumed that the doctor did not make the recommendation, even if the information was entered elsewhere.

Getting to the designated documentation spot involved navigating the electronic record with a variable number of clicks depending on where the doctor was in the patient record.   The time necessary to click and enter the information likely ranged from a few to thirty seconds.

When the study period was over the computer analyzed all the data and the physicians were assigned grades (a report card).  Those who scored low were encouraged to shape up.

Using the computer, with its pixilated wisdom, to answer the above questions is actually a good idea.  The documentation of screening tests is important.  And placing the information in a standard place makes lots of sense.

But considering that the average fifteen minute appointment is chock a block with patient concerns, doctors have precious little time for data entry.

It's of great interest that two of the very best clinicians in this study got the lowest grades.

Why?

It appears that given the choice of talking with their patients or entering data, they chose the former. What really counts - empathy, availability, ethics, intelligence, thoughtfulness - cannot be measured in the usual sense and certainly not by a doctor's talent for data entry.

In the end, the measure of a doctor is not subject to formulas but by reputation, the child of character.

The Annual Exam

Patients often emerge from an annual exam wishing that they had stayed home, especially after the doctor freights them with enough new findings and diagnoses to shatter the most bullet proof sense of good health.

A typical list of problems and recommendations might look something like this:

You have freckles galore, almost always innocent, but you never know, so on to the dermatologist you go.

You mentioned heart burn, probably due to simple esophageal reflux, but you never know, so off you go to the cardiologist, it could be angina. 

You have a deviated nasal septum. 

You have bilateral heel spurs.

You have a creaking of the neck (arthritis?).

No wonder many fear the annual exam more than root canal. 

Still, the idea of finding problems before they hatch, seems both important and logical.  If this were indeed true, then  maintaining good health would doubtless trump the negatives of going through the exam.

However, the Cochrane Group, the epicenter of evidence based medicine, has studied the annual exam issue extensively and concluded, in an October 2012 study, that large groups who have them regularly fare no better than those who do not.

There have of course been individuals who have benefited greatly from a screening exam.  Finding a melanoma on the back in its earliest stages or unequivocal elevation of blood pressure in an asymptomatic individual come to mind.   

It's just that if you compare large groups of individuals who take annual exams with those who do not, their health outcomes are very much the same. This applies also to illness related to cancer and cardiovascular disease, leading causes of morbidity and mortality. 

But if some people benefit from the screening exam, then, why not have one?

Traditionally, lots of information is collected during the exam (do you have gas, do you have trouble swallowing?) that takes up lots of time to gather with surprisingly little benefit. 

Since most of these patients will do no better than the unexamined, it is likely that many of the diagnoses made will actually be a form of over-diagnosis.

Over-diagnosis oftentimes leads to unnecessary tests and, even worse, unnecessary treatments.  Side effects in this scenario are especially intolerable as we ask the patient to buy risk with little prospect of benefit.

Finally, there is the matter of squandering health care dollars at a time when savings are badly needed.

So what can physicians implement to replace the current annual exam?

Let's replace the annual exam, with its painting by the numbers motif, by one that allows the patient to engage the doctor, in an unhurried way, about their concerns (it is common that the concerns of doctor and patient differ widely during exams).

So while the physician is hell bent on asking questions about every organ and body system (rarely decisive or illuminating), the patient is keen on discussing their longstanding backache or worries about memory loss.  Perhaps our exams could begin like this: "Hi Joe, what would you like to discuss today?"

In whatever form this new style exam takes it is necessary that there be ample time to discuss prevention strategies and immunizations.  

Given the research of the Cochrane group fewer people will get routine screening exams. When, how often and if to take these exams will be guided by further research on health outcomes.  For now decisions should be made on an individual basis.

What appears clear, however, is that we are putting too many patients through routine exams with little to show for it.  This is counterintuitive but supported by good research.

Whether one gets routine exams or not the following are major factors in achieving and sustaining good health:

Always notify a doctor when experiencing new signs or symptoms.  It's especially necessary when the changes are outside ones experience or when they represent an acceleration of a known problem.

Make and keep friends.

Search for intimacy.

Choose your parents and blood line wisely.

And most importantly, do all things in moderation.

OK most things.

Doctors and Guns

When I saw patients for routine exams, I would ask them, among other prevention issues, if they wore seat belts, had functioning smoke alarms  and whether or not they owned firearms.

The great majority wore seat belts and seemed to accept research showing a marked reduction in injuries and fatalities in those who buckled up.  When it became illegal to not wear them, most of the remaining stragglers appeared to sign on.

Patients were oftentimes puzzled at why I asked about smoke alarms.  They caught on when I suggested that it would be a shame to have corralled  their cholesterol and blood pressure with diet, medicines and exercise, only to go up in flames.  On returning one year later, many informed me, with great gusto, that they had installed fire alarms and regularly checked the batteries.

Asking about guns was another matter.  Most patients openly wondered at what gun ownership had to do with medicine.  While not comprehending the reason for the question, most listened politely to my concerns.  At least two individuals, however, became quite hostile about being asked  and told me it was none of my business.  I wondered if they possibly thought me an undercover agent for the Alcohol, Tobacco and Firearms Bureau (ATF).

With as much diplomacy as I could muster, I explained to all my patients that my concern was not over whether they owned guns but whether or not they were safely maintained.

That meant that the guns should be locked up so that children and intruders would not have access to them.  The ammunition should be stored separately from the guns and also locked up.

Why?  It is not unusual to read of children who kill themselves or their friends when playing with loaded guns which they have come across in explorations around their homes.  It's thought that about 2,800 children and teenagers die a year from gun related deaths.  This includes an appalling number of teen suicides.  Moreover, it is very common for intruders to disarm gun users and then turn the weapons against the owners.

Additionally, I recommended that those who kept guns loaded by the bedside (not at all unusual among patients living in high crime areas)  separate the gun from the ammunition, explaining that loaded weapons in the home resulted in more deaths of family members than criminal intruders (read: husband's night flight is cancelled and he comes home, unannounced at 1:00 AM, to a hail of bullets, set off by a terrified wife.) 

Over the years, it seemed that at least half of my patients had firearms, mostly rifles.  It was not at all unusual for a patient to say he had a rifle but hadn't seen it for twenty years and couldn't say exactly where it is.  This is where the kids and bad guys come in.  They have a nose for missing weapons.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Finally,  if I thought a patient suicidal, and learned that they owned a gun, I did what I could to get them and/or their families to disarm the individual.  This was especially urgent as guns are both a gateway and final destination for the majority of people determined to kill themselves.  

My efforts were not in vain as many patients would tell me they had locked up their guns and kept them unloaded as a result of our discussions.  

While I sometimes felt like  the nanny (nag?)-in-chief, I firmly believe that a discussion of gun safety issues belongs in the routine medical exam. Management of violence and mayhem is unarguably a health issue.

Guns And Can Openers

The events in Newtown have many of us thinking about the horrors of gun violence.

That’s when the NRA springs into action, trotting out its ballistic mantra, one of the most egregious dodges of our time: it’s not guns that kill people, it’s people who kill people.  

Hmm.  So it must be equally true that it’s not can openers that open cans, it’s people who open cans.

Go try opening a can without a can opener.

And go try killing someone without  a gun, the weapon of choice for murderers, who like to keep their hands clean and value the savage efficiency of rapid fire guns and exploding bullets. 

Indeed, guns are, at the very least, guilty by association.  If we do not contain them, it will not be going over the budgetary cliff that will ruin us so much as a firearms induced state of poisonous incivilty.

Let’s talk to each other and our political representatives as much as possible about new gun laws, including reliable background checks, a ban on assault rifles and large bullet clips as well as more attention and resources for mental health issues.

If not now, then when?

Holding On

Leaves finally give way to gravity, painting the ground with a riot of color, dancing all the way to their deaths.

Still a few stalwarts, going dry, pale and cracked, refuse to let go, suggesting that we just might be able to hold on too till the next wave of leaves, popping out audaciously, full of themselves, ride in on the next season and its green destiny.

Word Pouncing

We pounce on words and somehow red turns blue

We pounce on words and they pile up into books, literature, not literature, mortgages, advertisements, curfews, claims of love, claims of hate, report cards, the price of bananas, instructions for an electric toothbrush, speed limits, a history of Atwater Beach

Which of these words deserves coronation and which the guillotine?

Words, rolling around in the stream of understandings and mis-understandings, which they forge, makes it hard to know 

But isn’t that the game?

Survivors

We are holocaust  survivors

The sun lays a late afternoon table of luminous shapes

Our children read the script and always graduated with honors

Desultory  and panicked walks in the forest became the stuff of legend

School children push and shove to breathe in the ether of bravery which perfumes us  

And yet we are still holocaust survivors, nothing more or less, leaving us in mourning, wondering who we are, and who we might  have been, hoping to find at least a trace of our remains.   

Sex Talk

With the arrival of drugs like Viagra and Cialis, designed to treat erectile dysfunction (read erectile collapse), men stampeded to their doctor's offices.

These medications are oftentimes effective, generally well tolerated and a far cry better than previous ones which tended to be  gothic

(anyone for a round of intra-penile injections?) in nature.  

But not everyone was a candidate for medicines.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        I remember an illustrative case, a mid thirties man, who typically had six orgasms in a night of love making with his partner.  Recently, he fell off to four orgasms and feared he was in decline,perhaps on the cusp of old age.  All the same, his erections were steadfast and they never took a powder.

This man was not a candidate for medications because he did not have, by any stretch of the imagination, erectile dysfunction.  What he really needed was a cold shower and reassurance.

Another grouping of men (thirties and up) seemed to redefine their idea of good sexual health based on the extravagant promises of drug company advertisements.  In this pharmaceutical world there is little tolerance for normal (perhaps the man is sleep deprived or loaded with alcohol) lapses in erections, and climaxing seems to be all but guaranteed. The sense of inadequacy that the ads create in men, who functioned normally most of the time, ise powerful.

Some of these men were then keen to begin medications immediately, hoping I could be persuaded to skip the performance anxiety lecture, along with a recommendation that they purchase a copy of the Kama Sutra as soon as possible.

These individuals seemed to see their sexuality through a narrower lens, where sex was strictly defined as penetration with orgasm.  In their view the major goal was getting the ball, as it were, into the end zone, running up the score whenever possible. After reassurance, many men abandoned their search for medications.

The remaining men were similarly anxious about their sexuality.  They tended to engage more, however, in hugging, kissing, massaging, touching and oral sex, giving them a much broader view of love-making. 

They were told that these expressions were normal and healthy and they were encouraged to collaborate with their partners in creating, with or without penetration, creative forms of climaxing of their own invention.  For a number of these individuals the playfulness and openness of this approach trumped medicines which became a second line of defense.

So while ED drugs are valuable for many men, many others are actually sexually intact and should not be bullied by the drug companies into thinking otherwise.

Medicines have their place; so does a loving embrace.