Reeling in the years

A surgeon reflects on the loss of identity that comes with retirement and on how aging can bring renewal.

By Cathy Shufro

Doctors who retire must accept the painful fact that they will “no longer be seen as anybody’s healer,” said Sherwin B. Nuland, M.D. ’55, HS ’61, clinical professor of surgery. “Doctors have a great tendency to identify themselves by their calling, their profession, rather than by their humanity. Medicine is their identity.”

Fifteen years after he gave up surgery to write books, Nuland, 76, still feels the loss of his identity as a physician: “I’ve relinquished my technical identity. I’ve relinquished the leadership of a team. I’ve relinquished my role as someone to whom a single individual can look for a healing touch.” Although his writing career has not disappointed—he won the 1994 National Book Award for nonfiction for How We Die: Reflections on Life’s Final Chapter, which has sold nearly a half million copies in the United States and been published in 24 languages—Nuland calls caring for sick people “the most important thing I did in my life.”

In his 10th book, The Art of Aging: A Doctor’s Prescription for Well-Being, Nuland interweaves advice, case studies and descriptions of the physical impact of time’s passage. Growing old, he writes, is “simply entering another developmental phase of life.” While his book provides a scientific survey of the diminishments of age—loss of agility, libido and immunity to disease—Nuland argues that aging can offer its own riches.

“There comes a point, probably in your late 50s, that you ought to start rediscovering yourself, the person you were before you went to medical school or journalism school or business school,” he said. “You’re rediscovering your humanity and beginning to separate yourself from a complete reliance on identification with that profession.”

His own efforts at remaking himself have turned Nuland into “a gym rat.” His workouts paid off when he joined a group of physicians on a trip to Sri Lanka in December 2004 to provide emergency medical care after the tsunami. Nuland said he easily kept up with much younger colleagues. (As a scholar, he may be motivated to exercise in part by one fact that he notes in the book: exercise causes secretion of a brain-derived hormone that adds to the functioning of the cerebral cortex.)

As part of the renewal process, Nuland advocates writing. “You find out about your interests, about how you’ve synthesized life, things that you’d never discover if you didn’t write. Most people have a lot more going on in their heads than they ever dreamed they had.”

One pleasure of aging for Nuland is his love for his three grandchildren (with the fourth expected this fall). “It’s not a question of my DNA continuing,” he said. “It’s a question of what my children have brought to their own lives, which is a great source of pleasure and wonder to me.”

In contrast, the death of friends and mentors causes pain. “My advice is not to think that once that star has fallen out of your firmament that anyone can possibly replace it. … Let yourself grieve for as long as you need to.”

Still, Nuland does not wish that humans were immortal. “Because life is finite, we recognize its value. If life were infinite, we wouldn’t understand anything about this treasure we have been given.”

Bookshelf focuses on books and authors at the School of Medicine. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.

A podcast of Sherwin Nuland speaking on this subject can be found on the Yale page on iTunes U. Visit itunes.yale.edu or launch iTunes, then select Yale from the offerings under iTunes U. The podcast is included under “Yale Books & Authors.”

Book notes

What’s Your Poo Telling You?
by Josh Richman and Anish Sheth, M.D., FW ’08 (Chronicle Books) This adult version of the children’s book Everybody Poops will help you understand what’s going on with your body through what’s in the toilet bowl. The book offers sidebars, trivia, unusual case histories and medical explanations of “poo” through witty illustrated descriptions.

Appetite for Profit: How the Food Industry Undermines Our Health and How to Fight Back
by Michele Simon, M.P.H. ’90 (Nation Books) This book provides a guide to the public relations techniques, front groups and lobbying tactics that food companies employ to market junk foods, especially to children. It also includes an entertaining glossary that explains corporate rhetoric, including phrases like “better-for-you foods.”

Status Epilepticus: A Clinical Perspective
edited by Frank W. Drislane, M.D. ’80 (Humana Press) This text reviews the many forms of status epilepticus (SE), their causes, manifestations, methods of diagnosis and appropriate treatments. The book focuses on the disease as encountered by the clinician in the field and the importance of correct recognition and diagnosis. Additional highlights include EEG reproductions that provide classic examples of patients with SE, a discussion of SE in very young children and neonates and an analysis of the cellular physiology and processes occurring in SE.

Complementary and Alternative Medicine and Multiple Sclerosis, 2nd ed.
by Allen C. Bowling, M.D. ’88, Ph.D. (Demos) The second edition of this book reflects advances in the field since the book’s initial publication. Therapies are organized alphabetically so that readers can pinpoint a specific treatment and learn about its origins, merits and possible uses in treating multiple sclerosis. Also discussed is the use of supplements, herbs, vitamins, acupuncture, biofeedback and other alternative treatments. This guide offers new options for relief when conventional therapies are limited, exploring which therapies are effective, low-risk and inexpensive and which are ineffective, dangerous and costly.

Your Heart: An Owner’s Guide
by John A. Elefteriades, M.D. ’76, HS ’81, FW ’83, chief of cardiothoracic surgery and the William W.L. Glenn Professor of Cardiothoracic Surgery, and Lawrence S. Cohen, HS ’65, the Ebenezer K. Hunt Professor of Medicine (Prometheus Books) Heart disease remains the leading cause of death in the United States. The authors provide clear up-to-date medical information about such well-known problems as hypertension, high cholesterol and angina, and such lesser-known conditions as valvular heart disease, rheumatic fever and arrhythmia. They also discuss tests and diagnoses; lifestyle changes; medications and therapies; and such surgical procedures as valve replacement and heart transplants. A special section is devoted to women and their hearts.

Body Language: Poems of the Medical Training Experience
edited by Neeta Jain, M.D., Dagan Coppock, M.D. ’04, and Stephanie Brown Clark, M.D., Ph.D. (BOA Editions) This anthology of 91 poems by medical students, interns, residents and attending physicians chronicles their challenging experiences. Physicians who are also poets address a diverse range of medical situations in this book, which offers insights into the inner world of people who regularly deal with life-and-death decisions.

Sports Dermatology
by Brian B. Adams, M.D. ’95 (Springer) This book gathers the most clinically relevant information in the emerging area of sports dermatology. Each sports-related skin condition—both the commonplace and the unusual—is discussed with attention to the following: epidemiology, clinical presentation, diagnosis, treatment and prevention.

Acute Aortic Disease
by John A. Elefteriades, M.D. ’76, HS ’81, FW ’83, chief of cardiothoracic surgery and the William W.L. Glenn Professor of Cardiothoracic Surgery (Informa Healthcare) This source helps physicians examine and evaluate affected individuals in clinical or emergency care settings. Offering an array of illustrations, X-rays and operative photographs to emphasize key anatomic observations, this guide surveys the latest biologic, radiological, clinical and surgical developments in the field.

DNA Vaccines: Methods in Molecular Medicine
edited by W. Mark Saltzman, Ph.D., the Goizueta Foundation Professor of Chemical and Biomedical Engineering and professor of cellular and molecular physiology, Hong Shen, and Janet L. Brandsma, Ph.D. ’81, associate professor of comparative medicine and pathology (Humana Press) Divided into five sections, this volume contains state-of-the-art procedures for the latest DNA vaccine technology. Part I contains DNA vaccine design protocols, Part II presents methods for DNA delivery, Part III discusses current methods for enhancing the potency of DNA vaccines and Part IV describes several key areas of application in the field. The book concludes with a review of protocols for vaccine production and purification as well as applicable methods of quality control.

Play=Learning: How Play Motivates and Enhances Children’s Cognitive and Social-Emotional Growth
edited by Dorothy G. Singer, Ph.D., senior research scientist in the Child Study Center, Roberta Michnick Golinkoff, Ph.D., and Kathy Hirsh-Pasek, Ph.D. (Oxford University Press) This book describes varieties of play—make-believe, storytelling and story-acting, and mathematical—and provides insights gleaned from more than 40 years of research linking play to increased attention span, creativity, constructive peer interaction and mental health. The book also discusses the value of play for children with autism and those who have suffered traumatic injury or loss.

Immunology of Pregnancy: Medical Intelligence Unit
by Gil Mor, M.D., associate professor of obstetrics, gynecology and reproductive sciences (Springer) This book gives a complete review of current knowledge of the role of the immune system during pregnancy and the interactions between the placenta and the maternal immune system. It also covers in detail a range of hypotheses and studies related to the immunology of implantation and provides a practical approach to the application of basic reproductive immunology research to such complications of pregnancy as pre-eclampsia, preterm labor and intrauterine growth restriction.

Autism and Pervasive Developmental Disorders, 2nd ed.
edited by Fred R. Volkmar, M.D., the Irving B. Harris Professor in the Child Study Center and professor of psychiatry, pediatrics and psychology (Cambridge University Press) This updated edition reflects the most recent progress in the understanding of autism and related conditions. Chapter topics include current approaches to definition and diagnosis; prevalence and planning for service delivery; cognitive, genetic and neurobiological features; and pathophysiological mechanisms. A new chapter covers communication issues, while the final chapter addresses the nature of the fundamental social disturbances that characterize autism.

Hardworking Puppies
by Lynn Reiser, M.D. ’70, clinical professor of psychiatry (Harcourt Books) This is a story for children between the ages of 3 and 7 about working dogs and their jobs. Like the song “Ten Little Indians,” the book helps children learn to count backward from 10 to zero, as each puppy pairs up with a hardworking human—a firefighter, a clown, a lifeguard and a hospital volunteer, among others.

Retinal Degenerations: Biology, Diagnostics and Therapeutics
by Joyce Tombran-Tink, Ph.D., visiting associate professor of ophthalmology and visual science, and Colin J. Barnstable, Ph.D., adjunct professor of neurobiology and ophthalmology and visual science (Humana Press) This book focuses on what is currently known about the environment, genetic factors and mechanisms that lead to retinal degenerations. It discusses new diagnostic techniques and innovative therapeutic modalities to preserve vision.

The descriptions are based on information from the publishers.

Send notices of new books by alumni and faculty to Cheryl Violante, Yale Medicine, 300 George Street, Suite 773, New Haven, CT 06511, or via e-mail to cheryl.violante@yale.edu.

In circulation

A librarian in the OR

When medical librarian Denise Hersey, M.L.S., overheard Paul G. Barash, M.D., HS ’74, professor of anesthesiology, joke that he wished he had a librarian in the operating room, she took him seriously. While Hersey does not enter the OR itself, she comes pretty close: every week she spends several hours answering questions in the anesthesiology lounge in Yale-New Haven Hospital’s south pavilion.

Anesthesiologists face the universal problem of figuring out how to access information on the Internet. As Barash puts it, “You have a paradox: you have an overload of information and an inability to get it.”

Hersey’s regular visits to the OR suite solved that problem. As a librarian for liaison activities, she could use the visits to forge a connection between the library and the department. Anesthesiology faculty members and residents began asking for her advice on Internet search strategies.

Soon Hersey began brainstorming with the department’s chair of education council, Viji J. Kurup, M.D., assistant professor of anesthesiology and assistant director of medical studies, to find new ways of searching the Web. They held a PDA-loading party at which they showed faculty and residents how to load electronic medical resources into their personal digital assistants.

Kurup and Hersey also enlisted residents to record definitions of anesthesiology keywords so that their fellow residents can listen to them on MP3 players in preparation for board exams. When Hersey noticed that the doctors kept hanging journal club articles on a bulletin board, she posted them on an electronic bulletin board.

“It’s been fun,” said Hersey, who now serves on the department’s residency education committee.

Kurup knew that Hersey was making contributions but, like any good scientist, she wanted proof. A study Kurup conducted found that faculty and residents significantly increased their electronic searches for articles in key anesthesiology journals. Kurup presented her findings at the summer meeting of the Society for Education in Anesthesia.

Barash is enthusiastic, too. “It opens up all of Cushing Library to those whose hours don’t let us go to the library.” The medical librarians, he said, have “reinvented themselves.”

—Cathy Shufro

In Circulation focuses on activities at the Cushing/Whitney Medical Library. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.



Lamb		Koutsky



Koepsell		Berga

On campus

Can children tell the truth? Evaluating claims of abuse

How, asked Michael E. Lamb, Ph.D. ’76, should police, psychologists and social workers evaluate children’s claims of sexual abuse? Speaking at pediatric grand rounds in April, Lamb, a professor at Cambridge University in England, said that a child’s testimony may be the only evidence. “Most incidents of sexual abuse take place in private,” he said. “In most cases, the primary source of information is the child.”

But children’s claims have received numerous courtroom challenges. Some forensic psychologists maintain that children can’t remember, that they indulge in fantasy and that they can’t distinguish between truth and inventions. These assertions, said Lamb, fail to withstand scrutiny. Children are just as reliable and truthful as adults, said Lamb, who wrote the protocol on interviewing children for the National Institute of Child Health and Human Development at the National Institutes of Health.

But proper interviewing methods are essential. Numerous studies have found that open-ended questions elicit far more accurate information than leading questions. “As much as possible, keep the focus on specific incidents,” Lamb said. “The role of the interviewer is to let the child give you information. The less you say, the better the interview.”

—John Curtis

Advocating protection against cervical cancer

“This is my favorite topic,” said Laura Koutsky, Ph.D., professor of epidemiology at the University of Washington School of Public Health.

Koutsky was referring to two human papillomavirus (HPV) vaccines, both of which protect women against cervical cancer, a disease that claims 250,000 lives a year worldwide. Merck’s Gardasil was approved by the Food and Drug Administration in June 2006, while GlaxoSmith-Kline filed for approval for its vaccine, Cervarix, in March 2007. Koutsky’s research on the HPV vaccine is supported by funds from Merck.

Koutsky gave an overview of the safety, efficacy and immunogenicity profile of the prophylactic HPV vaccines during a talk at the School of Medicine in April. Noting that HPV is highly contagious and widespread (in one study 28 percent of test subjects who had only one sexual partner became infected with genital HPV within 12 months), Koutsky recommended that the vaccines, which have been found to be successful in preventing infections, be “widely used and widely available.”

Ideally, girls should be inoculated before they become sexually active. To parents uncomfortable with this recommendation, Koutsky said, “Teach your values,” but also advised, “Children need age-appropriate protection from the consequences of sexually transmitted infections, and despite evidence to the contrary, most want their parents’ help.”

—Jennifer Kaylin

Granting patents on genes hinders biotech research

Companies shouldn’t hold patents on genes any more than they should own the air we breathe, said David R. Koepsell, J.D., Ph.D., a Donaghue Initiative Visiting Scholar in Research Ethics at Yale University’s Interdisciplinary Center for Bioethics, speaking at a lecture in June.

“I think the current situation, where about 20 percent of the genome is patented, is a disincentive for innovation and chills research,” said Koepsell, a philosophy professor at the State University of New York at Buffalo. “It’s not based in either good policy or logic.”

Koepsell argued that genes found in nature do not fit into the current definition of intellectual property. They are neither inventions nor the expression of a new idea. Patents, he said, should reward novel uses of genes for tests and therapies, rather than simply the sequence of DNA itself. Patents are currently granted for both genes and their uses.

Some scientists say putting a stop to gene sequence patents could harm the biotechnology industry, but Koepsell disagrees. “In fact,” he said, “I think it will create new opportunities for small players who want to come in who can’t afford the licensing fees. I think it would actually be a boon for technology.”

—Sarah C.P. Williams

Bringing values, relationships back into medicine

Sarah L. Berga, M.D., administered a dose of idealism to residents in the Department of Obstetrics, Gynecology and Reproductive Sciences during Residents’ Research Day in June, calling on the young doctors to “make health the priority, not making money.”

Berga, the James Robert McCord Professor and chair of the Department of Gynecology and Obstetrics at Emory University School of Medicine, delivered the 4th Annual Nathan Kase Lecture: “The Social Contract of Medicine.” As healing has been transformed into a business and health has become a commodity, she said, the medical profession risks breaking its moral contract with society. “Many people feel we’re not doing as well as we should,” she said.“Leadership in medicine today is seriously failing.” Part of the problem, Berga said, is that some doctors are “overly competitive.” Others are so focused on the “technical aspects” of their profession that they give “short shrift to the big picture.”

Berga’s advice? “Integrate the concept of professionalism—the morals, values and relationships that underpin the trust the public has in doctors—into the business of medicine.” She also recommends getting involved in the next presidential election.

—J.K.


			Originally published in Yale Medicine, Autumn 2007. Copyright © 2007 Yale University School of Medicine. All rights reserved.