Our fellows share their thoughts and experiences!!!!

Eli Spencer - 12/2008

On my first day in Capetown, I was taken to synagogue by a man named Wynchank, Synclaire. Radiologist, amateur ethnobotanist-extraordinaire, a British born physicist turned physician, forty years in South Africa and tour guide for yours truly. This was a few years ago. I was fresh off the boat from 'da Bronx. Sinclair picked me up at my hotel at six-thirty on a clear Capetown morning. Six hours after arriving in Southern Africa. He's a friend of the Seftel's, a small clan of South African Jews my family hangs out with on occasion. Sinclair's wife was away in the Eastern Cape for the weekend and he had volunteered to show "the Yank" around. He pulled up to the entrance in a red Fiat convertible from the sixties. Wispy, tall, gray and grinning, kerchief around his neck, he shook my hand firmly. Recognizing me from emailed photos I suspect. "Hello Eelayaa, " he smiled, "' 'am Sinclair, please. I'll be your tour guide it appears. I hope you like the sound of my voice, for I surely do." We were quick friends.

Our first stop he decided should be the Orthodox "Shul" his wife's family attended. A famous Hebrew scholar and Rabbi was speaking there and he wondered if that wouldn't be an interesting African introduction for me (yes I was hoping for a safari). So to temple we went. Driving casually past couples, torn from pictures of Fiddler On The Roof, old men with their grandchildren, familie's on foot, walking to worship on a sabbath in fall, thousands of miles of Africa separating them from their homeland.

The temple was old-fashioned, with a screen running down the center to divide women and children from somber older men.–dovvening, praying, aloof and alone. We walked in on the finale of Bar Mitvah prayers just before the Rabbi was to speak. We sat with a half dozen octogenarians "sitting shivha", mourning. They were sad and old and seemed to me to sum up everything about this small synagogue less then ten miles from Kailicha, a tent city of over a million "Blacks" living in a few square miles-- with two hundred gunshot victims each sabbath.

My thoughts did not long settle on this irony though. The Rabbi was speaking–an Israeli-Zionist from an illegal West Bank settlement- giving an impassioned plea for charity from those who have to all and any who need! He spoke of the epistemology of the word 'charity' in many of the world's languages, deriving from concepts such as justice, fairness, obligation and compassion in various cultures and tongues. He ventured into charity as Man's moral obligation, once self-awareness is attained. He spoke of the Judeo-Christain, Socratic and Eastern traditions as road maps that take one from ignorance to awareness through teaching and observation, but-- having become "enlightened"--, confers on them the onus of returning to the place of their ignorance to live among those on their way to 'understanding'.........

I remember it was late into his sermon that I returned from the complete fixation with which I had followed this graying old man. When I came to, I remember this sudden shock of sadness-imagining the impossibility of what he was describing. Bringing people to the heaven of enlightenment, then discarding them back to a world full of deep suffering.....momentarily, I realized these feelings were no accident. They'd be deliberately engendered by the Rabbi with his magical tale.

I had been set up.

For just as I was asking "how we can possibly solve even the least of human suffering", he had the answer. The Tzaddikim. Originally thirty-six righteous men from esoteric Judaism. The rabbi dissembled on the concept of the "co-incidental" appearance of "great-men" (and women) throughout human history. As he introduced this concept, it struck me as quite similar to reincarnation, the emergence of Buddhas, or the periodic appearance of Messiahs, Messiachs, Prophets, etc... But this rabbi was making a more pragmatic argument. Rather than falling to God for the periodic emergence of "luminaries", he was simply noting that, statistically speaking, every so often a truly amazing human being is born. That the essence of greatness is emergent from the sum of a human's genes and circumstances rather than a divine hand belonging only to one sect of human religion....Needless to say, I was already feeling like a monkey drowning in bananas, along I presume with a substantial portion of the now somewhat disquieted audience, but he went on. He claimed that the world goes through times of rapid and great change. Punctuated societal equilibrium perhaps. That this time is presaged by fear, violence and societies adrift. At these times in human history, notable characters seem to "emerge" and form the center of movements that will ultimately prove revolutionary. In the Rabbi's view, we are already familiar with the concept of Tzaddikim. They would be embodied by Ghandi, Mother Teresa, Nelson Mendela, Martin Luther King, but also Plato and Socrates, Marx and Freud, Leibnetz and Newton (apparently this is heretical as the Tzaddikim are supposed to be anonymous).

He ended with this idea. 'We are in such a time now- of chaos and phase-change, a vast, connected system of individuals capable of ethical choice. We are in a time of rapid change, and this time will be heralded by the appearance of the Tzaddikim..

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Admittedly, the world appears a bit more absurd than usual. Anyone else think something's up? Maybe we are at the hot, bubbling interface of a big pot of molten reality about to seriously shift. I'm not sure who the Tzaddikim of today are. But I can't help but think about the Rabbi's story when I see President-elect Barack Hussein Obama talking about hope in a country that would not have allowed his grandfather to vote. It makes me think about the Dalai Lama writing books to assuage the suffering of western life while he LIVES in exile so far from his own home. I giggle a little at the Yoda-like Eckert Tolle talking about curing man's suffering through self awareness and mediation....on Oprah Winfrey!!. Perhaps Gates, Google and Soros, the Zeitgeist movement, synthetic-biomics, statistical-group-think-
analysis, Linus and his Linux and the open everything we are moving into-- are all a part. No matter, I say the world is going bonkers, and at sufficiently biblical proportions that I expect a few messiahs to roll on in and save us.

If a rebel Rabbi can stand at the door to Africa and ask for world peace and the ending of human suffering through individual acts of goodness inspired by great leaders.... maybe anything can happen.

Happy Hannukwanzachristitet........
and a Happy New Year!

Eli Spencer - 8/20/08

Seuss rhymes with Voice.

"I like nonsense, it wakes up the brain cells. Fantasy is a necessary ingredient in living, It's a way of looking at life through the wrong end of a telescope. Which is what I do, And that enables you to laugh at life's realities" Dr. Seuss.

Please indulge me for a moment:

I would posit that one cannot practice medicine in San Diego without a thorough appreciation for the life of Dr. Seuss. Did you know he was born Theodor Seuss Geisel in Springfield Massachusett, in 1904? Ironically his parents were German, so, contrary to popular belief his name actually rhymes with Voice. I apologize, I know this may be traumatic to some (For me it will always rhyme with Deuce). Dr. Seuss went to Darmouth where he eventually wrote under his nomme de guerre. He took a D. Phil (became a real "Dr.") in Literature at oxford, and after the war would eventually settle with his wife in La Jolla California.
Dr. Seuss was the son of Brewers and was ardently opposed to prohibition. He was the unfortunate object of significant anti-semitism (despite being German Catholic) and was a vocal antagonist of racism in mid-century America as well as the world abroad. His children's books subtly remarked on capitalisms wasteful tendencies, on our overblown fear of communism and our misplaced trust in Naziism. He was early to recognize and publicize the Holocaust, to point out the hypocrisies of American foreign policy. He told us long ago that the environment should be nurtured rather than stripped....It seems he told us a lot.And, he was really, really funny. Even when he attacked the deepest biases of his time, the most rooted taboos, the darkest secrets of modern life-his stories remained ludicrously whimsical. Suess got to the core of things. He taught us and made us smile.

If you asked me the one difference between residency and fellowship, I would tell you it is the time and need to complete thoughts. To sit down, nurture an idea, mull it over, stretch it a little. Discard it or move on. You realize very quickly that stigmas and political borders may at once be irrelevant to infectious disease, or serve as the nidus for unneeded suffering. As you learn to think more mechanistically, the world of pathogens and hosts, antibiotics and vaccines, begins to settle into a rational framework. You sense that there may be a logical approach to the apparent chaos.

That said, at current count I have had two complete thoughts in the last 25 or so months. My first, brief attempt was cut prematurely short By the "google doctor". To briefly recount, Joe Vinetz and I met a pleasant young gentleman in clinic a few weeks ago with the curse of recurring fevers, stomatitis, pharyngitis and swollen glands. Four years of being flummoxed, frustrated and sick. He came to us after he'd seen every doctor in San Diego. What should have been weeks of arduous searching through arcane case reports to diagnose this patients rare and occult disorder, ended abruptly five minutes after the appointment. A cursory "Google-consult" immediately spit out the "Syndrome of Periodic fever, apthous stomatitis, pharyngitis and adenitis, PFAPA". Well I'll be damned, years of training and I'm beat by Dr. Google..and anyone could have come up with that name. (Aside: 3 days later the patient emailed Dr. Vinetz, having made the same diagnosis on his own.) Suffice it to say five weeks of ID fellowship induces humility and frustration in equal measure. It makes you think and little harder then you might have before.

So I find it strange that my second shot at linearity leads to this blog, to this slightly absurd juxtaposition of comedic and medical doctors. Nonetheless, when I really think about- it I wonder...What would Dr. Suess say?

What if Dr. Seuss were the fifth ID fellow at UCSD. How would he diagnose Tijuananito's with TB or Bajan's with Cocci? Universal HIV testing?- No, too many patients with HIV-An unfinanced mandate.... What would he say to this? Would he run from the MRSA spider, use Vanc like water? Would the riddle of BMT antibiotic algorithms inspire him to new, ridiculous heights?

This is what I wonder, five weeks in.....So,

When the ER calls, Dr. Seuss comes running.
His demeanor a mess but his consult skills stunning
The treats on his tie give him away
Yes, he's the fellow on call to the divisions dismay.

"Ancef for all! This isn't a Bank!
If there's MRSA afoot we'll use Ceftaz and Vanc!

Don't come in on Levo, it's not carried here.
Its Moxi or Zithro if you have any fear.

Try Doxi for now, since you're doing ok?
We'll add Imi and Lini if you spike later today.

But someone should tell you your nose is quite red!
Its Rudolf's Disease I say, not all in your head.

When Christmas arrives, and the rash goes away,
You'll be tiptop no doubt-save the scars from this stay.

Alas before you leave, we must check you for bugs.
We don't think you have AIDs, but you have taken drugs.
Don't sue the UC, its not really their fault!
The state has a mandate, sanity stays in the Vault!

Thanks for the consult its been perilously fun
I'm being paged by the SICU so I'll run run run run....."

Maile Young - An oldie, but a goody!

My dream/my hope…

There once was a young doctor of spunky disposition. Her life was filled with HIV/infectious diseases visionaries, that is, people whose business was to monitor the state of HIV/disease in the world and pursue studies and solutions to help regulate health.

The visionary recognizes global health problems and more or less attempts to contain them by evaluating the issues surrounding these problems and aiding in the creation of solutions. All this is done of course to avoid all possible danger of an excess of disease flowing into surrounding countries. If of course the burden of disease overflowed it could soon inundate the whole world. Even the little HIV/infectious disease fellows know that constant watchfulness is required to keep the flood of disease from overwhelming a country and eventually the world, and that a moments neglect of the visionary’s duty may bring ruin and death to all.

One lovely spring afternoon, when the doctor was about (ahem) thirty years old, she obtained consent to travel to South Africa to carry some N95 masks, gloves and powerpoint presentations to the local physicians who lived in this country. The little doctor started on her errand with a light heart, and having spent some time with these local physicians, she bade them farewell and started on her homeward route.

Trudging stoutly along (in heels), she noticed how years of poor access to care, neglect, and misunderstanding had swollen the burden of HIV/TB. Even while humming her careless, childish song, she thought of the visionary’s brave accomplishments and felt glad of their strength, for thought she, “If they gave way, where would the world be? These pretty fields would all be covered with the angry ugliness of suffering and death.” And with these thoughts just flitting across her brain, the little fellow stooped to pick the pretty flowers that grew along her way.

Suddenly the doctor looked around her in dismay. She had not noticed that the sun was setting. Now she saw that her short shadow on the grass had vanished. It was growing dark and she was still quite some distance from home and in a lonely place, where even the blue flowers had turned to gray. She quickened her footsteps and just as she was bracing herself for a run, she was startled by the sound of soft moans and cries. Whence did it come? She looked up and saw a small child, a young woman, an old man…suffering from disease. Any HIV/infectious disease fellow would shudder at the thought of a leak in the system! The doctor understood the danger at a glance. That small amount of suffering, if allowed to continue and trickle through, would soon be a large one, and a terrible inundation would be the result.

Quick as a flash, she saw her duty. Throwing away her flowers, the doctor clambered up the heights until she reached the suffering. Her tiny eyes and hands examined the suffering, her brain processed the cause, and her voice recommended a solution. Almost before she knew it, the suffering had quieted (well not really, but for metaphors sake)! Ah! She thought with a chuckle of naive delight, the angry, ugly suffering must stay back now! The country shall not be drowned while I am here!

This was all very well at first, but the night was falling rapidly. Chill vapors filled the air. The little doctor began to tremble with cold and dread. She shouted loudly, she screamed, “Come here! Come here!” but no one came. The cold grew more intense, a numbness, commenced in the tired little hands/brain/voice. She shouted again, “Will no one come?” She tried to whistle. Perhaps some straggling doctor might heed the signal, but her teeth chattered so, it was impossible. Then she called on God for help. And the answer came, through a holy resolution: “I will stay here till morning.”

The midnight moon looked down upon that small, solitary form, sitting upon a stone, halfway up the hill. Her head was bent, but she was not asleep, for every now and then a new voice would cry out in pain. Her mind and heart struggled. If she drew away, the angry flow of suffering, growing angrier still, would rush forth, and never stop until they had swept over the town, the country. No she would stay till daylight. What did this strange ache mean? Knives that seemed pricking and piercing through heart and to the soul. She was not certain now that she could draw away, even if she wished to.

At daybreak a physician in the US thought he/she heard groans as he/she read this blog. Investigating further he saw, an infectious disease fellow, across the world, sharing her experiences.

“In the name of wonder, girl!” he/she exclaimed, “What are you doing there?”
“I am keeping the suffering from running out,” was the simple answer of the little doctor. “Tell them to come quick.”

It is needless to add that they did come quickly.

This is adapted (several parts word for word) from: The Hero of Haarlem by Mary Elizabeth Mapes Dodge…better known as “that story about the Dutch boy who put his finger in a hole in a dam.”
Come…quick

Maile

Winston Tilghman, 3/27/2008

While Alexis is traveling around Mozambique, I get to write a blog! I, too, am new at this kind of thing, but I’ll try. This month has been a good one. I have been working at the Owen Clinic, which is the HIV clinic here at UCSD for those of you who do not know. I have been doing a lot of work in the clinic, which is appropriate since HIV has, in a lot of cases in the developed world, become a chronic problem like diabetes or hypertension that is often managed on an outpatient basis. However, one definitely does not have to go to South Africa to see advanced cases of AIDS with opportunistic infections (although I am looking VERY forward to going there in July). One only has to walk one block to the main hospital to see some quite interesting cases, actually. Throughout the month, we have had patients on the inpatient service with Pneumocystis jiroveci pneumonia, Cryptococcal meningitis, pulmonary and disseminated tuberculosis, and intestinal perforation due to Mycobacterium bovis infection. Cases of amoebic liver abscess and Castleman’s disease in patients with newly-diagnosed HIV have also made for an interesting mix of pathology. I am also constantly reminded of the challenges with which we are faced in terms of fighting the epidemic (substance abuse and poverty, in particular) despite the huge advances that we have made in terms of development of new medications to control HIV infection.

Although the global statistics regarding the HIV epidemic are daunting, I am always inspired whenever I work at the Owen clinic, because everyday I see so many people from different backgrounds and with different types of training working hard to improve the lives of people living with HIV. There is such corroboration among doctors, pharmacists, substance abuse counselors, social workers, and dieticians, whose common goal is to help people with this infection take control of their lives, that the clinic really should be a model for HIV care worldwide. This extends beyond San Diego and the USA in the San Ysidro clinic, where I have had the pleasure of working with advocates for the Latino community around the US-Mexico border. We have also had visitors from Peru and Kenya who have shared with us their efforts to deal with the global problems of HIV and TB in their communities through patient care and research. There is also a great emphasis on education at all levels in the clinic, from basic interactions with attendings to lectures and grand rounds covering a wide array of topics. I hope to apply all of these things to my own practice both as a clinical mentor in South Africa this summer and after fellowship as I figure out my own way to make a difference, however small, in the world.

Sanjay Mehta - 3/11/08

I guess this is what happens when we get a new secretary... She gets ideas, wants to change things… and I end up writing a blog. I ve never written one… and Im not sure if I should offer advice… or just muse on the state of the world. I guess it probably doesn’t matter… as long as I don’t write anything in Arabic, or talk about any bioterror agents… probably no one will even read this.

Well I think Ill just muse… I think many medical students start out with the philosophy that they want to do something, have a career, doing something useful. Traversing the medical path, I think everyone cant escape developing a little cynicism. Are we truly improving our patient’s quality of life.. are we truly making people better, or are we just titrating snake oils to improve some vague laboratory numbers. Of course, people do get better, but in the field of medicine…sometimes it can be hard to see.

I sometimes have those same sorts of sentiments when I think about “international health”. Of course, improving sanitation, finding sources of water, and treating disease improves quality of life. Thousands of individuals will have many more fruitful years now that we are able to provide highly active antiretroviral therapy to individuals with AIDS across the third world. And slowly we are working on issues of sanitation, water, and nutrition. However, I wonder about what we don’t or cant provide. Nothing improves my quality of life like a good joke, conversation, an interesting idea. The internet to me is magic… it provides humor, news, and the information that lets the crossfertilization of ideas occur instantaneously. It is the library of Congress in a machine the size of a single book. So perhaps, in an addition to making an effort to improving the tangibles in peoples lives, health, nutrition and water… we should make an effort to improve the intangibles as well… and perhaps getting people connected to the internet is the answer.

That’s the end of my musings for today….

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