When the doctor is the patient

Robert Klitzman’s resistance to his own depression led him to explore what happens when doctors get sick.

By Cathy Shufro

Robert L. Klitzman, M.D. ’85, expected the grief that followed the death of his sister Karen, who died at the age of 38 in the World Trade Center on September 11, 2001. But he did not expect that he would be unable to sleep and would suffer from persistent flu. Or that he would stop listening to music and take no pleasure in reading.

When friends told Klitzman that he was depressed, he rejected the idea. As a psychiatrist, of course, he knew that emotional depression often manifests itself in the body. “I’d read it in textbooks,” he acknowledged. Eventually Klitzman did recognize that it was depression, not flu, that was making him feel that his body had “given way” beneath him. “Going through it myself made me realize how much I didn’t know about what it was to be a patient,” he said. That realization, he said, was “a defining moment.”

Klitzman, a research scientist and associate professor of clinical psychiatry at the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, had already written five books. In fact, he’d gotten his start as a writer by reviewing books while a medical student at Yale—a starting point he recommends to students today. His role models included Richard A. Selzer, M.D., HS ’61; Sherwin B. Nuland, M.D. ’55, HS ’61; and Howard M. Spiro, M.D.—Yale physicians who are also prominent authors. Klitzman had already contemplated writing a book about doctors as patients. Now, however, “It was no longer an academic question.”

When Doctors Become Patients is the product of interviews with 70 physicians of all ages who were facing cancer, heart disease, Huntington disease, bipolar disorder, HIV and other illnesses. Klitzman analyzes such common themes as denial of illness, doctors choosing doctors, “self-doctoring,” going public about one’s disease, overworking, coping and the role of spiritual beliefs.

Klitzman found that the doctors viewed themselves either as patients or as doctors, “as if individuals had a zero-sum identity.” In reality, Klitzman said, “They’re not entirely doctors and they’re not entirely patients.” Klitzman called this “odd hybrid form” the “doctor-patient”—one doctor-patient with a foot infection brought his own bag of opiates to the hospital. And as patients, Klitzman’s interviewees were often upset by the carelessness with which their doctors addressed their fears. A surgeon told one doctor-patient that a procedure carried a 5 percent chance of dying. The patient would rather have heard that he had a 95 percent chance of living.

Just as Klitzman resisted the notion of his own depression, his colleagues also denied that they were sick. They told him, “I feel like I have a magic white coat. Illness happens out there—not to me.” Klitzman noted that magical thinking is part of our everyday lives: “When we blow out the birthday candles, we all make a wish.” But doctors deny their irrationality, contending, “We do not engage in magical thinking. We’re trained scientists.”

Perhaps because doctors see themselves as scientists, they are reluctant to discuss religion or spirituality with their patients, as Klitzman’s research suggests. Yet “when patients are lying in bed, that’s what they’re thinking about,” he said. He advocates adding at least a lecture on the topic during medical school.

A reviewer wrote in the New England Journal of Medicine that Klitzman’s book “goes to the very heart of the question of what a physician is.” In addition, When Doctors Become Patients serves as a lasting memorial to Karen Klitzman.

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

Book notes

Polarities of Experiences: Relatedness and Self-Definition in Personality Development, Psychopathology and the Therapeutic Process
by Sidney J. Blatt, Ph.D., professor of psychiatry and psychology (American Psychological Association) The author proposes that psychological development is a lifelong personal negotiation between two dimensions: relatedness, which he terms the anaclitic dimension; and self-definition, or the introjective dimension. He contends that emphasis on one developmental line at the expense of the other, however, can lead to a variety of mental disorders. Within this framework, Blatt sees mental disorders as compensatory exaggerations of the normal polarities of relatedness and self-definition rather than clusters of present or absent symptoms. Blatt discusses research indicating that anaclitic and introjective persons respond differently to psychotherapy. He then argues that this conceptualization of personality development has clear implications for refining approaches to therapy.

The Kazdin Method for Parenting the Defiant Child: With No Pills, No Therapy, No Contest of Wills
by Alan E. Kazdin, Ph.D., the John M. Musser Professor of Psychology, and director of the Yale Parenting Center and Child Conduct Clinic (Houghton Mifflin) In this book and DVD, Kazdin lays out his science-based program for using praise and rewards to alter children’s behavior. Kazdin provides a step-by-step method that relies on positive reinforcement and a reward system for dealing with behavior problems. The book describes approaches for children of different ages; discusses ways to involve siblings; and provides scenarios for coping with such commonplace difficulties as tantrums, dawdling, resisting homework and delaying bedtime.

Saving Sickly Children: The Tuberculosis Preventorium in American Life, 1909-1970
by Cynthia A. Connolly, R.N., Ph.D., assistant professor of nursing and the history of medicine (Rutgers University Press) The author provides an analysis of public health and family welfare viewed through the institution of the tuberculosis preventorium of the early 20th century. This facility was intended to prevent TB in indigent children at risk for developing the disease or who came from families labeled as irresponsible. Connolly further explains how the child-saving themes embedded in the preventorium movement continue to shape contemporary pediatric health care delivery and family policy in the United States.

Attachment and Sexuality
edited by Sidney J. Blatt, Ph.D., professor of psychiatry and psychology; Diana Diamond, Ph.D., and Joseph D. Lichtenberg, M.D. (The Analytic Press) Each paper featured in this text forms a separate narrative strand that clarifies different configurations of the relationship between attachment and sexuality. The unifying thread is the notion that the attachment system, and particularly the degree of felt security—or lack thereof—in relation to early attachment figures, provides a paradigm for relationships that forms a scaffold for the developmental unfolding of sexuality in all its manifestations. These manifestations include infantile and adult, masturbatory and mutual, and normative and perverse sexuality.

Apoptosis and Cancer: Methods and Protocols
edited by Gil Mor, M.D., Ph.D., associate professor of obstetrics, gynecology and reproductive sciences, and Ayesha B. Alvero, M.D., associate research scientist in obstetrics, gynecology and reproductive sciences (Humana Press) This book, a collaboration between academics and industry-based scientists, describes the performance of contemporary techniques for studying the biology of apoptosis and its role in cancer. The protocols described within will aid both academic laboratory workers interested in further characterizing the mechanism of apoptosis and industry-based researchers concerned with identifying new target molecules or screening for new compounds with potential clinical use. The text covers the newest methods as well as basic conventional techniques.

The Future of Medicine: Megatrends in Health Care That Will Improve Your Quality of Life
by Stephen C. Schimpff, M.D. ’67, HS ’69 (Thomas Nelson Publisher) This book describes and evaluates health care innovations in areas including genomics, imaging, pharmaceuticals, the operating room, and alternative and complementary medicine. The author combines scientific fact with personal stories and experiences to describe the tools, techniques and treatments that are making a difference in health care. These innovations include vaccines that prevent cancer and chronic disease; surgery simulation and robots in the operating room; and smaller, more powerful medical devices that help a patient’s heart beat, relieve depression and replace failing organs.

Hip and Knee Surgery: A Patient’s Guide to Hip Replacement, Hip Resurfacing, Knee Replacement and Knee Arthroscopy
by Robert E. Kennon, M.D., HS ’04 (Lulu Publisher) This book contains information for patients considering treatment for hip or knee arthritis and related conditions. The author explains what to expect before, during and after hospitalization; describes postoperative exercises; and offers recommendations for rehabilitation. Illustrated sections discuss hip and knee surgeries; nonoperative treatment options; surgical approaches, the latest minimally invasive surgery techniques; implant materials and designs; and potential complications of joint surgery.

Neuroinformatics (Methods in Molecular Biology)
edited by Chiquito J. Crasto, Ph.D., M.S., associate research scientist in neurobiology (Humana Press) This book describes advances in data sharing and the use of computational models in neuroscience. It provides expert summaries of specific computational models and simulations as well as approaches to data mining. The authors also discuss informatics representation and approaches to the structural complexity of the brain using a variety of both traditional and noninvasive imaging methods. The book’s final section considers the value of using neuroinformatics to understand such complex mental disorders as dementia, schizophrenia and Alzheimer disease.

Comfortably Numb: How Psychiatry Is Medicating a Nation
by Charles M. Barber, M.F.A., lecturer in psychiatry (Pantheon) The author argues that without an industry to promote them, nonpharmaceutical approaches to reducing emotional distress are overlooked by a nation that sees drugs as instant cure-alls. He argues that Americans are under increasing pressure to self-medicate. In analyzing these influences, Barber cites direct-to-consumer advertising; the promise of the quick fix; and the blurring of the distinction between mental illness—for which medication might be appropriate—and everyday emotional problems. Barber then offers therapeutic alternatives to prescription antidepressants.

Seldin and Giebisch’s The Kidney: Physiology and Pathophysiology, 4th ed.
edited by Robert J. Alpern, M.D., dean of the School of Medicine and Ensign Professor of Medicine (nephrology), and the late Steven C. Hebert, M.D., former C.N.H. Long Professor of Cellular and Molecular Physiology and professor of medicine (nephrology) (Academic Press) This edition has more than 40 new chapters and 1,000 illustrations, providing comprehensive coverage of renal physiology and pathophysiology. The topics move from the molecular biology of the kidney and its cell physiology to clinical issues surrounding renal function and dysfunction.

Before You Take That Pill: Why the Drug Industry May Be Bad for Your Health
by J. Douglas Bremner, M.D., former associate professor of diagnostic radiology and psychiatry (Avery of PenguinGroup) The author offers an inside look at the pharmaceutical industry as well as a scientifically backed assessment of the risks of more than 300 prescribed medications, vitamins and supplements. This book distinguishes between the pharmaceuticals that are essential to the health of consumers and those whose benefits may not outweigh their potential side effects.
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 Yale librarian upgrades Internet access for physicians in Uganda

When librarian Mark Gentry, M.A., M.L.S., set out to expand Internet access at a hospital in Uganda, he experienced déjà vu. “The speed of the Internet took me back 15 years to the beginning of the Web, when we had dial-up modems,” said Gentry, the clinical support librarian at the Cushing/Whitney Medical Library.

Gentry learned about the idiosyncrasies of satellite-based Internet service in Uganda when he joined the Yale-Makerere collaboration, a partnership that includes the School of Medicine, Makerere University and Mulago Hospital in Kampala. Since 2006 Yale attendings and residents have traveled to Kampala for rotations at Mulago Hospital, and Ugandan residents are now coming to Yale for clinical training.

While visiting Mulago Hospital in the spring of 2008, Gentry streamlined Internet use for physicians by setting up a home page that links directly to such often-used functions as e-mail and online journals. “Click: you go right to it. Because every time you get an intermediate page, you have to wait from 10 to 30 seconds,” said Gentry. Meanwhile a Yale resident compiled CDs that allow Ugandan colleagues to bypass the Internet—the disks contain copyright-free information on diseases such as HIV, tuberculosis and malaria.

Gentry next began building up the library for the Department of Medicine at Mulago Hospital, where the medical textbooks were 20 years old. Gentry collected 50 essential texts that were hand-delivered to Kampala. Up-to-date books are a godsend, said Ugandan resident Fred Okuku, M.D. During a five-month rotation at Yale last spring, Okuku discovered journal articles about research done in Uganda that he’d been unable to access at home.

While in Uganda, Gentry promoted a free Internet service called HINARI; sponsored by the World Health Organization for health care workers in developing countries, it provides links to nearly 4,000 journals.

Gentry said the Makerere collaboration has been a natural extension of his work on Cedar Street. “Part of my job as a clinical support librarian is to do what I can to support our people wherever they are.”

—Cathy Shufro

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



Offit		Bertino



Zeanah		Janicki

On campus

Lawsuits could bankrupt vaccine program

A program that encourages childhood vaccinations could collapse under unproven allegations that the shots cause disease, an expert warned at grand rounds for the Department of Pediatrics in May.

Paul Offit, M.D., chief of infectious diseases at Children’s Hospital of Philadelphia, said that the fallout from a 2008 court decision would discourage vaccine makers from continuing production. Since 1955, when a bad batch of polio vaccine killed 10 people, testing and regulation of vaccines have improved. But subsequent court rulings that vaccine makers could be held liable without being negligent led to “a flood of lawsuits” in the 1970s.

In 1986 Congress created the National Vaccine Injury Compensation Program to protect vaccine makers while compensating those harmed by faulty vaccines. But Offit said that the program took “a sad turn” in 2008 when a special “vaccine court” composed of epidemiologists and clinicians ruled that claims can be granted even if it’s only possible—with no epidemiological evidence—that vaccines are responsible.

About 5,000 children who claim to be harmed as a result of vaccination await a decision that could bankrupt the vaccine program. If the decision allows for monetary compensation, “it could eliminate the program,” Offit said.

—John Dillon

A gene to protect bone marrow from chemotherapy

In a new approach to cancer treatment, researchers are studying a form of gene therapy that may make bone marrow more resistant to chemotherapy, allowing for higher doses and better outcomes.

“We are turning the tables,” said Joseph R. Bertino, M.D., interim director and chief scientific officer of the Cancer Institute of New Jersey, at Yale Cancer Center grand rounds in May. “This therapy will allow for safer use of drugs and an increase in dosage. If we do this we can protect patients from a wide variety of chemotherapy drugs.”

Bertino, who was director of the Yale Comprehensive Cancer Center from 1973 to 1975, said this approach calls for introducing a drug-resistant gene into hematopoietic progenitor cells. That could limit the drugs’ toxicity and preserve the marrow’s ability to produce infection-fighting white blood cells. Oncologists would then be able to prescribe higher doses of chemotherapy, potentially leading to improved outcomes.

Bertino said two clinical trials—one for lymphoma and another for pancreatic and breast cancer—are in the planning stages.

—John Curtis

Children, foster care and orphanages

When Nicolae Ceauşescu took power in Romania in 1965, he believed that his country needed a larger work force. He decreed, said Charles H. Zeanah Jr., M.D., Sellars-Polchow Professor of Psychiatry at Tulane University, that all women must bear five children.

The economy didn’t improve, Zeanah told an audience at pediatric grand rounds in May, but more children entered the country’s orphanages. “Children with a history of institutional rearing have a high risk of psychological and social problems,” Zeanah said. In 2000, Zeanah and Charles Nelson, Ph.D., of Harvard and Nathan Fox, Ph.D., of the University of Maryland began a four-year study of 136 children who ranged in age from 7 to 33 months, and found that their development lagged in most areas. Half of the 136 children were then placed in foster care, previously unavailable in Bucharest, and half remained in institutions.

Foster care enhanced development in most areas, but complete recovery was rare. For cognitive development and attachment, recovery seemed to have more to do with the timing of interventions than their duration. Children who entered foster care before their second birthday, Zeanah said, were more likely to recover from the severe deprivations of Romanian orphanages.

—J.C.

Bolero, dementia and the creative process

In 1930, when Maurice Ravel composed Bolero, his best-known work, he may have been in the throes of frontotemporal dementia (FTD), a neurodegenerative disease that usually affects people in their late 50s. Ravel’s meticulous handwriting had become irregular, he had lost his bags and tickets on a concert tour and, while conducting one of his works, he had uncharacteristically skipped from the opening movement to the coda.

In a talk at neuroscience grand rounds in May, Sarah C. Janicki, M.D., M.P.H., HS ’08, said Ravel’s case is not unusual—FTD has been linked to strong bouts of creativity. “Over time a series of patients were coming to light, patients with FTD developing creative skills,” she said.

Although the reasons for this connection are not clear, the brain’s left temporal lobe appears to be involved. And the disorder appears to release artistic inhibitions—artists move from representational to more abstract forms of expression. But as the disease progresses, that process reverses itself. “As [the patients’] language skills declined, their art became fairly representational instead of a creative manipulation to generate new thought,” Janicki said.

—J.C.


			Originally published in Yale Medicine, Autumn 2008. Copyright © 2008 Yale University School of Medicine. All rights reserved.