Existential Pain and History

mte5ndg0mdu0otg3mjq1mdcx“I am a dead man!” Alexander recognized immediately that his condition was mortal.

At first, the patient suffered such exquisite pain that Dr. Hosack did not strip off his bloody garments…When [the patient] complained of acute back discomfort, [the doctor] and other attendants took off his clothes, darkened the room, and began to administer [medicines] to dull the ache.

[The patient] was preoccupied with spiritual matters…No sooner was he brought to the Bayard house than he made it a matter of urgent concern to receive last rites from the…Church.

When [the pastor] entered the chamber, he took [the patient]’s hand, and the two men exchanged a ‘melancholy salutation’… He explained that…”It is a principle in our churches never to administer the Lord’s Supper privately to any person under any circumstances.” [The patient’s] friends thought it heartless to refuse a dying man’s last wish.

As befits a great orator, Alexander roused himself for one last burst of persuasion.

At that point, [the pastor] relented and gave holy communion to Alexander, who then lay back serenely and declared that he was happy.


One common felt pain for patients at the end of their lives is existential or spiritual pain. Though difficult to define, most of us practicing palliative medicine recognize it when we see it. The proper intervention for it is not additional opiates, but rather appropriate spiritual support.

It always impresses me, when reading history, just how often our common humanity binds us across time. The patient above is Alexander Hamilton, lying on his death bed following his infamous “Interview at Weehawken” with Vice-President Aaron Burr . This slightly edited account, taken from Ron Chernow’s masterful biography, Alexander Hamilton, is a dramatic rendering of a man in existential crisis at life’s end. Hamilton recognized instinctively, as he so often did, his need for spiritual input to his pain. Unfortunately, in today’s medical world, we too often fail to recognize this need, delivering the wrong intervention, in the form of another dose of dilaudid, to patients needing spiritual uplifting.

This is not the first time I’ve noticed this in reading through historical biography. U.S. Grant eloquently describes a palliative approach to end-of-life care, as he completes his famous Memoirs while dying from head-and-neck cancer. John Adams describes a receding of the fear of dying, to be replaced by a fear of dementia. Human life, and death, resonates across the ages.

As I prepare for another stint on our Supportive Care Unit, a typically draining two weeks full of existential pain, I find reflecting on our common humanity, and the special role physicians are privileged to play in it, helps sustain me through the experience.

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Filed under Books, End of Life Care, History, Palliative Care, Uncategorized

Everest: A Movie Micro-Review


To my wife’s chagrin, I love the book Into Thin Air by Jon Krakauer, the first-person account of the 1996 disaster on Mt. Everest. It’s gripping, terrifying, and heartbreaking, highlighting the difficulty of decision-making in lifeboats — even when those lifeboats of one’s own creation.

The movie is a faithful rendering of the tragedy, plucking away madly at the heartstrings as people freeze to death while talking to loved ones on the phone. It succeeds in telling the two most compelling stories, about Rob Hall and Beck Wethers. It modestly fails in showing the reasons for the tragedy — primarily people’s desire’s to achieve a goal overcoming their rational capacity to recognize when that goal is no longer achievable.

It is a near-great movie, better for those who have read the excellent book than for those seeing it without that benefit. Recommend for those who have read the book, wait for home rental or streaming on a nice screen for those who have not.

Side note: My 12-year old found it “boring”, except for the parts where people fell off the mountainside, which were not “dramatic enough” for him.

Side-side note: Krakauer, the author of Into Thin Air, didn’t like the movie, in which he’s a character. He has a small role in the movie, and some of the worse criticisms are reserved by the director his character.

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When Lincoln Kissed a Reporter: Tales from the Printer’s Row Lit Fest

I love the Printer’s Row Lit Fest — even though it will always be the “PR Book Fair” to me. A solid two-plus blocks of tents of book-sellers, including quite a few with a collection of “vintage” books, which I love.

This year, I found an original (1913) hard-backed copy, in very good condition, of a small book of 39 pages intriguingly entitled, “When Lincoln Kissed Me.” It’s an account from a young reporter, Henry E. Wing, a 25 year old reporter of the New York Tribune, the NYT of the day. Following the Battle of the Wilderness, the beginning no reports came from the front for 2 days — there was no account of the location of the 100,000 strong army US Grant was leading against Lee on the final push to Richmond. I had never heard the story before, and it is a gripping one, full of drama, intrigue, and insight. I read it on the train ride home.

After a harrowing journey through enemy territory over 70 miles over two days, much of it on foot, Wing makes it back to Washington. Not only does he have a report to deliver to his paper and to the President and his Cabinet, he has a personal message from General Grant for the President.

Lincoln dismisses the Cabinet members, locks the doors, and stares down at the reporter.  As Wing describes it:

“He took a short, quick step toward me, and, stooping to bring his eyes level with mine, whispered, in tones of intense, impatient interest, ‘What is it?’

“‘General Grant told me to tell you, from him, that, whatever happens, there is no turning back.’:

As the diminutive Wing tells it, while standing trembling in front of the towering President behind closed doors:

“Mr. Lincoln put his great, strong arms about me and, carried away in the exuberance of his gladness, imprinted a kiss upon my forehead.”

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Joshua Hemmerich, RIP

Joshua Hemmerich, PhD, was the first project manager I hired after I received my first grant as a new faculty member at the University of Chicago in 2004.  He was recommended to me by a member of the Society of Medical Decision Making, Julie Goldberg, PhD, with whom Josh had worked at the University of Illinois-Chicago.  As a cognitive psychologist with significant training in statistics, Josh was a perfect fit for my research agenda on the role of emotions in medical decision making for older cancer patients. Over the next decade, we became well-matched research colleagues as well as close friends.

Over that decade, as we co-authored 25 papers and successfully competed for several grants, we also shared innumerable conversations about life growing up in small towns in the Midwest, especially about playing sports under the demanding eye of tough-love fathers.  Over the years, we attended many SMDM conferences together, and we even managed to attract one of the Founding Fathers of the field, Arthur Elstein, PhD, to join us as a mentor and a collaborator.  We both marveled at our good-fortune to get to know such an important scholar who is also such a supportive mentor.  We each continued to build our respective careers, with Josh becoming the Research Manager for our Section of Geriatrics & Palliative Medicine, and then joining as our first PhD-only hire onto the faculty, an unusual ascension for a staff member.  When I became the Section Chief, we continued to expand our research, as Josh began building his own independent career, including as the Newsletter co-editor for SMDM.  Although we had increasing less time to share on non-work-related discussions, we were both looking forward to contributing more to the field of medical decision making.

With his untimely passing, coming as a shock to us all, I will deeply miss having Josh around, both personally and professionally.  In many ways, I am still struggling to figure out how to move our shared agenda ahead without him.  He was a uniquely gifted person, combining the insights of a psychologist with the acumen of an excellent statistician.  And for such a talented person, he we very down-to-earth and friendly, quick to tell a joke or to shoot the breeze about the latest in Cleveland versus Chicago sports.

One thing many may not know about Josh was his love of books.  I always admired, when I stopped by his office to chat, his eclectic collection of books on a wide range of topics from statistics, to cancer, to history, psychology, and (of course) decision making.  In honor of this collection, we have gathered the books he left behind and created the Joshua Hemmerich Memorial Library, which now lives in our Section Conference Room, for all to enjoy and to honor his memory.

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“I hope to have God on my side, but I must have Kentucky.”

Becoming a lay expert on a specific historical period, the American Civil War, two related methods for learning history have become crucial to me. First, having broad-based knowledge about this period deepens my understanding of specific local history. Second, travelling to a place to imbibe the local atmosphere where important history happened, brings the sights, smells, sounds and imagination to bear on that history. Both improve the richness of my full understanding of that time – and the human experience overall.

When travelling, I’ve taken to purchasing a book about local history, preferably about Civil War history, to bring these two learning tools together. My most recent experience in central Kentucky was especially delightful. The area we visited was Bowling Green, a place that switched hands several times throughout the war, as both sides tried to bring this crucial “neutral” boarder state into their fold. As newly-elected President Lincoln said about his birth state, “I hope to have God on my side, but I must have Kentucky.”

The book I found is Josie Underwood’s Civil War Diary, edited by Nancy Disher Baird. A passionate 20-year old woman from a prominent Kentucky family, whose father was a leader of the pro-Union elements in the state, writes movingly about the shattering impact of the war on the families in Kentucky. As the country descends from arguments about preserving the Union, the principles of the Constitution, and the status of slavery to outright war, the dissolution of families, friends, and communities into outright hostilities is heartrending. The articulate and beautiful young woman finds her life pulled apart as the miasma of a country in upheaval at a fulcrum point in history throws her life into disarray.
A favorite part of the book was her one-time meeting with Abraham Lincoln when in Washington with her father, who was being appointed by the President as Ambassador to Glasgow. Like many contemporary accounts of Lincoln, its cinematic quality is captivating:

“As we returned to the city, about sun down, there were no other people in sight on the road [from the Soldiers House] except a lone horseman we were meeting. He was on a long-tailed black pony (the horse looked so small) galloping along – a high silk hat on his head – black cloth suit on, the long coat tails flying – behind him. Pa called our attention to him—saying ‘some farmer – who has been in the hot city all day and is now eager to get home to supper and his family.’ So Miss Bell and I thought the man and he looked it. As we met, Pa had the carriage stop. The man did the same and Pa introduced us to Mr. Lincoln. He leaned over, shook hands with us, then slouched down on one side of the saddle—as any old farmer would do, as he talked for ten or 15 minutes with us.”

Can you imagine it? She captures so many historical facts in this one little story. Lincoln’s notorious lack of concern for personal safety, chillingly foreboding—His “everyman” demeanor of an uncouth Westerner—His benevolence toward humanity. It’s all there in this brief, personal account. She goes on…

“Pa and Mr. Etheridge thought is very imprudent and unwise risk for him in such a time of warfare and especial hatred of Mr. Lincoln himself for him to be riding unattended, unguarded out a lonely country road – and called his attention to the dangers—Mr. Lincoln’s smile—expressed kindliness to all men and fear of none—as he said—he ‘did not think anybody would hurt him that way’—shaking hands again with us—he galloped on, neither did we meet anybody else for quite a little way so it was very evident there were no guards—following him.”
Finally, she summarizes her impressions of the man she, and her contemporaries from the South, even those “Unionists” who supported the war effort.
“Lincoln in appearance certainly falls far short (though he is so long) of my idea of how a President should look. In fact a very common-looking man he is—but I must confess there was a kindliness in his face—that does not fit the tyrant—unfair man I have been thinking him…Thinking of his kind, troubled face I can’t believe it is.”

Absolutely spellbinding.

Much of this moving account, especially for a Civil War buff, is infused with details and examples of the local consequences of the war in the border states. I urge anyone with an interest in the times or who is visiting the area to read this mesmerizing account, especially during this 150-year anniversary of Lee’s surrender to Grant at Appomattox Court House. And to remember the 150-year anniversary of Lincoln’s untimely death at the hands of one of the people he so confidently believed wouldn’t “hurt him in that way.”

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Filed under Civil War, History, Lincoln, vacation

Vacation Kinetics: Purging the Matrix, Cleansing the Senses, Awakening the Spirit


Vacations are a way to get away – in every way.  Yet in today’s hyperconnected, hyperkinetic modern world, it is more difficult than ever to disconnect, decelerate and rejuvenate.  Our two-week family vacation was strategically planned by my lovely wife to allow rejuvenation of mental energies away from work concerns near the end of summer, including long stretches in the car; in remote rural areas; and being out the country – in part, to discourage on-line time.  The 24/7 maw of the social media world that is drawing us into a Borg-like meta-community has a gravitational pull into its growing sphere of influence.  Disentangling from it has become the primary challenge for a successful vacation.

Academic physicians seem evolutionarily conditioned to have our attention swallowed up by the immediacy of our daily work lives.  Our nervous systems seem finely-tuned to reflexively respond to our daily sensory input of general need.  At work, we are confronted with the “emergencies of the moment” that consume our carefully planned schedules.  For me, this includes urgent emails from my boss, cell phone texts from mentees needing deadline-driven feedback on a paper, voicemails from professional groups on sudden changes to upcoming conference calls, faculty members unexpectedly out for personal reasons needing coverage, or a page[1] from a nursing home on an immediate patient concern.  The amygdala-jarring, guilt-reflex that each of these inputs ignites, reinforced by years of professional acculturation demanding immediate responses to all needs, makes ignoring them genetically impossible. Adding the barrage of input from overseeing a section in a department of medicine at a large academic institution (read: middle management) only raises the cortisol levels further. It is no wonder why, among academic physicians, burnout and turnover are so high.

Sometimes the only way to break the cycle is to eliminate the sensory input.  Everyone I told that I was going on an extended vacation enthusiastically encouraged me to “avoid all work-related activities”. Easier said than done!


I was excited about our planned trip, even with the prospect of being locked in a car with my Eveready-bunny young boys for hours on end.  When I was a kid, we would jump in the old Datsun station wagon and drive to grandma’s house, twelve good hours of complete family immersion and outer-world isolation.  Playing “counting cows” and finding state license plates are over.  In our car, there are three smart phones, three tablet computers, and 2 regular computers, all internet-connection compatible. Perhaps the one advantage of my cell-phone service with Sprint is the relatively poor coverage it provides in non-urban areas and the ghastly charges they have for international service.[2]  Even worse, having identified “internet access” lying at the very base of Maslow’s hierarchy of needs, every place you stop along the way provides WiFi services.  It’s truly amazing watching people wander slowly about public places, slack-jawed staring at a phone, bumping into things.  In protest, I carry a book around with me everywhere, sitting and reading something in the open periods available.  Like other addicts, I spent hours each day in a cold sweat, trying not to connect my nervous system into the Matrix, slowly weaning myself off the electronic juice.  At the beginning of the trip, I wasn’t sure two weeks would be enough time.

Everything triggered a reflexive need to connect.  In reading a rest stop sign on the local history of Rome, NY – was it really the starting point for the building of the Erie Canal?  In seeing someone wearing a LeBron James jersey in Cleveland – how were the FIBA team practices going?  Had we heard back from anyone on our journal articles, especially the one to the Health Affairs Blog?  Slow, deep breaths…count to ten…ask someone a question…read your book…  This was work!  When did vacation become such hard work?!?


Recognizing the challenge ahead, my wife had brilliantly planned for us to spend many hours a healthy distance from the Matrix. First, living cozily in a small, rustic two-story motel on Old Orchard Beach — a lovely, genuinely historic locale inhabited primarily by thin, smoking French-speakers from Quebec. Meandering a mile barefooted down the silica, confronted by the sine-wave eternity of sandy saline, is a wonderful psychic purgatory.  We spent the first part of the trip at a local joint, catching an unexpected glimpse of a favorite celebrity, and hanging out with the bride and groom, moves the electronic buzz into the hazy periphery.  Being forced to stop at a local gas station, all gussied up, to get directions to the ceremony at “The Barn at Flanagan Farm” from a woman with a knowing smile, because the GPS won’t connect,  injects a healthy dose of humanity.  Spending the day-after brunch with across-the-country friends you’ve only interacted with on Facebook in over 20 years, and discussing foreign policy among the wild flowers with an intensity social media precludes, reconnects the vivid present to the unseen future through the past.  Hiking up a mountain, along sheer ravines with my adventurous sons, calves aflame, unable to send a reassuring text to my wife, calls forth a focus of intensity to block out the world. Staring through the cool, swirling mist of pulverized water on rock from the deck of a boat staring up at Niagra’s relentless falls, unable to snap pictures with your smart phone, forces you to simply enjoy the moment. Exciting the senses and calming the soul.


As the sensory apparatus was revived by salty ocean breezes, fresh seafood, bright wild flowers, prickly briars, and cool mist, the cognitive gears began turning again.  Freed from the character confines of Twitter chatter, narratives of new friends emerged.  Shared struggles up a steep, rocky mountain invited bonding discussions of oceanside views.  Meeting Ricki inside her beachside Place, quicky, discombobulated bookstore/motel/knick-knack/beach-equipment rental encouraged bibliophile bonding, and some more books for the collection. Open enjoyment of a new marriage in a field of clover led to wide-ranging discussions of the entrepreneurial spirit altering the landscape of international relations. Touring the Joshua Chamberlain museum, some more pieces of history clicked into place, as the WWII-vet docent filled in more details.  And another Civil War history book went into the collection. Stopping at the Fort Erie historical site, engagingly led by a young local woman in period clothing, and punctuated by the firing of a mortar shell ordered by my son, I could almost feel the neurons reignite.


As the vacation flowed along, as my senses revived, as my brain engaged, I found the need to write creatively emerging.  Using my long-dormant blog, I spent time each night piecing my thoughts together, gratified to find others who shared my thoughts.  Why was I so intrigued by professor-turned-soldier Joshua Chamberlain?  What did I enjoy so much about used book stores? Why was   I found myself feeling happier than I have for some time, enjoying the simple vitality of being alive, letting my inner self choose the topic, rather than responding to the “emergency of the day”.

I finally had some space and energy to contemplate – to, as Dr. Suess would say, “think about thinks”.  The true value of an extended vacation is less to get away from things like the matrix, but to get close to one’s inner self.  The “getting away” is really just the first part, to clear the playing field, to blow out the engine, to pull the plug on the tub full of dirty water.  Or like a beach after high tide, when all the sand sculptures have been melted down, and the canvas again lies pristine. Once that’s done, one can really get to work, focusing all of one’s energy on the creative task at hand.   I now feel like I imagine my kids do when they start on the new sandcastle or master a new skill, happily creating something anew from nothing, investing all of one’s ample energy in the project at hand.

I’m grateful to my wife for planning this vacation, finding a way to detach us from the persistent buzzing of our Web-ensnared devices, nudging us out into the wilderness of reality, allowing us to engage with the wider world.  I’m thrilled that she was rewarded in many ways: recognizing a favorite sit-com star who flashed across her field of vision, re-engaging with an old friend at the wedding (both wearing beautiful lavender dresses), playing on the beach with her boys, and enjoying another birthday dinner with me.  We’re now a little older, a bit wiser, and more thoughtful – and perhaps, a smidge happier.

[1] Yes, a pager. I suspect doctors are the only professional group that has failed to give up this antiquated, annoying form of communication.  Mostly symbolic, like stethoscopes and white coats, that allow physicians to maintain a professional identity, to the detriment of job function.

[2] As we discovered during our recent trip to the Black Hills of South Dakota, Sprint has absolutely no interest in providing any cell service whatsoever in that area.  They really ought to change this into a “feature” for vacationers like me, guaranteeing “absolutely no service, no matter the urgency of the matter”.


Filed under Aging, History, Philosophy, psychology, vacation

Robin Williams, Jimmy Wales, and Holes in the Universe

Many years ago, during my first stint living in the Windy City, Jimmy Wales of Wikipedia fame lived with us.  During that time, he told us a funny story.  He was in a park in a major city, I believe it was Central Park, but I can’t be certain.  He saw an aggressive mime bothering someone in the way mimes do, although this one seemed even more active and annoying than usual.  Suddenly, the man serving as the “audience” for the mime just slugged the mime, knocking him down.  I laughed – haven’t we all wanted to do this at some point in our lives?

This would have just been a cute story, except that Jimmy related seeing Williams on a talk show many years later – TELLING THE SAME STORY!  Only in that version, Williams was the mime being slugged.  I was laughing hysterically now, imaging my favorite comedian, being punched by some stranger who never knew his brush with fame.

All these many years later, I’m as stunned as everyone else at Mr. Williams’ death from suicide. Even as a physician who cares for many patients with depression, knowing the dangers it brings, I feel as sucker-punched as Williams-as-mime must have.

I vividly remember the first time I saw Williams on TV – in his role as Mork from Ork on my favorite childhood show, Happy Days.  His appearance on that family sit-com, in justice, should have been the “jump-the-shark” moment for the original “jump-the-shark” moment.  We would be calling such derailments of successful shows that have over-run their course the “alien-from-Ork” moments, I believe – except that Williams was just so damn funny.

I heard that, during the try-outs for the part of Mork, each applicant was asked to sit like an alien.  Williams spontaneously chose his now-famous head-down/ass-up posture, which nearly won him the role by itself.

There is nobody I can think of who filled my life with laughter as much as Robin Williams.  I watched Mork and Mindy religiously.  Even as a kid, I would stay up late, after begging my parents, to see him on the Tonight Show with Johnny Carson.  I watched every one of the charity specials that he co-hosted with Billy Crystal and Whoopie Goldberg.  I have seen virtually all of his movies, especially the comedies. I love to laugh, and nobody made me laugh more than he did.  The manic craziness, combined with the abstract flight-of-ideas, and the obvious delight in response of an audience – any audience – was infectious beyond belief.  There is just nothing like it.

I have read that one of the “reasons”, if such can be adduced after someone suffering from depression kills themselves, that he committed suicide was a recent diagnosis of Parkinson’s Disease. Since I treat many people with this disease, I wanted to comment that I hope that’s not true.  Many people with PD have a wonderful quality-of-life with the diagnosis, receiving treatments for it.  But I can’t help but wonder if, after playing the role of neurologist Oliver Sacks in the movie Awakenings, Robin was reminded of the unfortunate outcomes from that initial episode of using carbidopa/levodopa to treat a variant of PD.  But it is haunting to watch that film and not wonder a bit.

Now that Mr. Williams has written the final chapter of his life, he has left a hole in the universe, it seems.  His life, as much as anyone’s, was a singularity – and like the outer space version of such, it has left a black hole behind.  I wonder at this feeling of loss, this presence-of-an-absence, that some people leave behind.  It’s the converse of the bright flare of joy such people bring to our lives, and I’m going to try and le that shine on in my memory, as much as possible.  He really was the funniest person I’ve ever seen, and I see in my mind’s eye, him being punched for being TOO good a mime, with an astonished Jimmy Wales looking on, heading out to change the world in another way.  And you can read all about one due to the vision of the other.

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Filed under Comedy, Decision Making, End of Life Care, Philosophy