By Meera Mohan, M.D., M.S.

On a beautiful Friday morning in the spring of 2020, Mr. B awaited his first dose of pembrolizumab in the chemotherapy infusion room. By this time he wrestled with cancer for about three years and underwent several lines of treatment, yet he was so resilient that that he continued weight training at home. He said, “It was still worth a try, if this could buy me some more time with my family.” After all, all bridges are built to be crossed. Like many cancer patients, his treatment was delayed as we tried to juggle our way through the current pandemic. It never ceases to amaze me how Mr. B always wore that big smile every single time I saw him. He says, “Smile makes me and people around me feel good; it is like an emotional contagion.” He was a true hero, navigating uncharted terrains, fighting this rare cancer for the past three years. He exemplified how an optimistic stance could negate even the most formidable conditions in life.

I met Mr. B for the first time three years ago as a very inquisitive first-year fellow. “We need help with a new patient in the walk-in clinic” announced the chief fellow, Dr. R. I volunteered myself. 

Mr. B had “aggressive anaplastic thyroid cancer,” a rare cancer that sounded even rarer to a first-year fellow. He was recovering from recent pneumonectomy two weeks ago but what was so “striking” was the glowing smile on his face. I scribbled down his age – 60s — as I assessed the “performance status.” He was in his best physical shape ever and ran six miles per day.  He had papillary thyroid cancer diagnosed at age 40 and now had recurrence in the lung with aggressive anaplastic thyroid cancer. He had smoked five cigarettes in his life, a noteworthy and precise remembrance. 

During the first visit, we went through the customary discussion of cancer diagnosis and work-up and set out a possible treatment plan. Just before he departed, he asked, “Doc, how does this cancer behave? How much time do I have?” These very questions were ones I tried to avoid with all the speculations overcrowding my mind. After a moment of silence, I looked into his eyes and said, “This is an unusual cancer which can outsmart us, but I can reassure you … I’ll do everything possible to help you.” He echoed how he appreciated the truth upfront and how the truth would help him prepare for rational expectations of his life ahead.

He started chemotherapy around Thanksgiving Day 2017, but by the end of the second cycle he suffered from cardiac toxicity and treatment was halted. He was taken off all treatment by January 2018 and we pursued active surveillance. I told him, “Perhaps we will need to see you often as there is no real consensus on optimal follow-up of anaplastic thyroid cancer”. Living in rural America, he navigated 190 miles to make it to those frequent appointments and scans, but he never missed a single appointment in 3 years. He was often accompanied by his wife, Mrs. B.  
 One day I noticed a look of disquietude in her face. I took a leap. “Mrs. B, is everything all right?” She answered promptly that she was being worked up for cancer. This was an incredibly challenging time in their lives, yet he was ever so optimistic as he expressed, “There is always hope in the days ahead.” Perhaps, this ingrained hope of the best possible outcome is the strong force that leads our lives as oncologists. During these visits, I learned about his family with three daughters and how proud he was of their accomplishments; how he and his siblings had been a caregiver to his father and later to his mother during their last months of life. At one time we discussed the benevolence and affection that enriched his life as he said, “Everyone is born with love in their heart.” The support of his close-knit family and religious congregation always uplifted him during these tough times. 

Eight months passed and on a Friday morning he came for a routine clinic visit. For the past two weeks he reported some heaviness in his tongue, his eating and articulation proving difficult. Being a young oncologist in training, I was still apprehensive in “breaking bad news” to my patients, but I gathered myself and told him that we might be dealing with a cancer relapse. Getting an MRI scan was tricky with Mr. B’s claustrophobia, but he insisted he would give it a fair try. As we feared, the tumor encroached upon his hypoglossal canals and caused compressive symptoms. By this time, he had lost twenty pounds and was unable to meet his nutritional needs. We discussed about percutaneous endoscopic gastrostomy (PEG) tube placement, but he disliked the idea. He received palliative local radiation and started on lenvatinib. Slowly, with the recovery of his neurological function, he started re-gaining weight. Life was again as normal as it could be except for the frequent Friday clinic visits. 

On one Friday clinic visit in July 2019, Mr. B came in for routine follow-up. I noticed his limping as he walked in. He had been hurting for the past three weeks and had issues keeping up with his usual 3-mile run. My heart sank. By this time I was maturing as I was learning to maintain an optimistic body language while still having doubts in my mind. Unfortunately, the scans reported a new left femoral lesion with cortical destruction and concerns for impending fracture. Again, we were faced with the dilemma of choosing a treatment for his rare challenging cancer. He went on to have orthopedic surgery followed by local radiation therapy. He completed physical therapy and was able to ambulate without any support. Fortunately, we started him on targeted therapy with larotrectinib that was approved for NTRK fusion mutation agnostic of tumor type. During this time, he turned down the options of referral to centers with clinical trials for this rare cancer. He stated he was a “homebody” and the logistics of travelling back and forth were too complicated. 

The ensuing eight months were mostly “uneventful” in our day-to-day lives and during this time he spent Christmas holidays with his family. Several weeks later in February 2020, we were confronted yet again with another glitch — disease progression in his lone lung threatening to cut off the bronchi. The ongoing battle had almost depleted our arsenal, but we searched deep for the slimmest ray of hope. Physical and psychological challenges during this journey got tougher — even brisk walking balancing out the risk of another fracture. By this time, he walked less than a mile a day. 

Mr. B was the last patient on the last day of my fellow’s continuity clinic in May 2020, at the throes of COVID-19. During the past 12 weeks, most clinical appointments were cancelled or rescheduled in keeping with best-practice guidance during this pandemic. With forbidden hugging and handshakes this time, he said, “I know your work is done here. Each of us have an intended role to play in a given time of our lives and then we have to get ready for the next chapter. All we can do is play our part well.” Indeed, our patients are part of our lives as much as we are theirs. Mr. B walked out with the same high-spirited smile that he wore the first time I had seen him. I realized the secret behind the smile is not to accept cancer as an ill fate and drown in sorrow, but to uplift each other and he did this with his “smile.” 

How a “seemingly simple smile” could leave behind an enduring impression in our lives.

Meera Mohan, M.D., M.S., was a fellow in the Division of Hematology/Oncology at UAMS.

By Sarah E. M. Hill, B.S.A.

World War III: a fight we never hoped to see, nor imagined would have come in form of a microscopic particle. To date, the novo-coronavirus has managed to cripple world leaders – not only from a health perspective but from a politico-socio-economic one as well. Globally, individuals are ill, isolated, scared, borderline-hysteric, and economically unstable. Meanwhile, media has curated a sensational military motif, waging war on our tiny, treacherous opponent. 

Headlines read “A view from the front lines of California’s COVID-19 battle”; “Countries test tactics in ‘war’ against COVID-19”; “Former CDC director: There’s a long war ahead and our COVID-19 response must adapt”; “Super-rich jet off to disaster bunkers amid coronavirus outbreak”; “To beat COVID-19…”; and “Fourth-year medical students graduate early to fight COVID-19”; and so forth…

This diction of “front lines,” “battle,” “war,” “bunkers,” “beat,” and “fight” is not uncommon to medicine. In fact, much literature has been published on the use of a military metaphor in medicine. Most commonly, the “battle” against cancer is described in military terms. One can draw obvious parallels between the experiences. A patient with cancer undergoes a mentally and physically grueling course of treatment, so unimaginable much like the struggles of a soldier in battle. Both are threatened by death at the end of the “war.” Both “soldiers” have commanding officers: colonels and generals or nurses and physicians. Likewise, both have support teams – one’s unit or social workers and, ideally, family, friends, and other care groups. And, both must transition back to their normal following “the fight,” as traumatic experience taxes one’s ability to adapt. Therefore, generally, the experience of cancer treatment and military action can be paralleled; as such, the military metaphor fits the medicine well. 

Moreover, in the last 120 years, there has been little time of global peace. While war may not be in every individual’s daily experience, the topic itself has been of quotidian discussion since the dawn of the 20th century, at least. As such, it is not surprising that the public has adopted relatable military language into common vernacular. 

But, what good do these metaphors do? While some may argue that metaphors allow for niche, esoteric topics to become common and understandable by the masses, the military metaphor changes the focus of the task at hand. In lieu of treating patients, in use of the military diction, we fight disease. The subject of focus shifts from the patient to illness. In “combating” a global pandemic, this may “rally the troops” to turn attention to the covert, yet terrible villain at hand, and encourage the public to participate proactively in conserving and promoting public health. Nonetheless, it can also be argued that a military motif would elicit fear of an under-educated public. All of a sudden, we have a common “enemy”: the novel coronavirus, COVID-19. But, enemies elicit fear, especially when one is not prepared to fight. 

When you had a nightmare as a child or felt scared of the monster under your bed or in your closet, you felt safe tucked in your bed, knowing that your parents were just down the hall. You felt safe in isolation. You were prepared to fight the enemy. Today, we are not prepared to fight the enemy. We do not feel safe in isolation. Self-quarantine has been compared to living in a “bunker.” There is much uncertainty in the world, and a war motif adds nothing to help qualm global citizens’ fears. 

Instead, regarding our current pandemic, military metaphors further stir mass hysteria. Political leaders and media outlets should use their privileged voices to inform in lieu of sensationalizing. Every word should be of the essence, especially in times of global crisis. We should not waste our breath, ink, or pixels on a metaphor with such a high cost-benefit ratio. We should not correlate experiences of illness and violence. We should not anthropomorphize viral particles as combatant enemies. Instead, we should use the media as a valuable tool to educate the public on preventative measures, like social distancing, without qualifiers reminiscent of war. We should inform the public of the actions being taken to mitigate the economic crisis triggered by this horrendous event. We should comfort and empathize with those personally affected by the virus. Overall, our diction should not be one of global war, but of international peace and universal efficacy. 

References

1. Cohen, J, Kupferschmidt, K. Countries test tactics in ‘war’ against COVID-19. Science. 2020 Mar 20; 367(6484): 1287-8.
2. Barry-Jester, AM. A view from the front lines of California COVID-19 battle. Kaiser Health News. March 18, 2020.https://khn.org/. Accessed March 21, 2020.  
3. Frieden, T. Former CDC director: There’s a long war ahead and our COVID-19 response must adapt. March 20, 2020. CNN. https://www.cnn.com/. Accessed March 21, 2020.
4. Neate, R. Super-rich jet off to disaster bunkers amid coronavirus outbreak. March 11, 2020. The Guardian. https://www.theguardian.com/. Accessed March 20, 2020. 
5. Collins, F. To beat COVID-19, social distancing is a must. March 19, 2020. National Institutes of Health. https://directorsblog.nih.gov/. Accessed March 20, 2020. 
6. Siddique, H. Final-year medical students graduate early to fight COVID-19. The Guardian. March 20, 2020.https://www.theguardian.com/. Accessed March 20, 2020. 
7. Strauss, A. Advice from a crisis expert on surviving a lockdown. New York Times. March 19, 2020.  https://www.nytimes.com/. Accessed March 20, 2020.  

Sarah E. M. Hill

by Frederick Guggenheim, M.D.

Do you remember your first patient in your chosen specialty, or what was to be your chosen specialty? My first such patient, new to a psychiatric diagnosis, was Eleanor. I was a Clinical Associate internist at National Institute of Mental Health at NIH, having finished three years of Internal Medicine residency. The year was 1965, and I was the On-Call physician for psychiatric emergencies every two weeks at the NIH Clinical Center, even though I had had no specific psychiatric training. I had, after all during my training years at Bellevue Hospital, pretty much seen “just about everything.”

Eleanor, referred to National Cancer Institute at NIH from a small town in California, was 22. When I first saw her, I noted that she was a blond, blue-eyed young woman with a round face, dressed in a hospital gown and lying on her back inside a formidable, clear plastic, oblong, plastic bubble — a so-called Life Island. I had never seen such an isolation device before: it was then on the cutting edge of American medicine, as was bone marrow suppression and transplantation. 

The Life Island covered the entirety of Eleanor’s hospital bed. Talking was easy enough. But because of the drug-induced immunosuppression used to treat her acute leukemia, the only way that staff could give her medication, or food, was through two side-by-side, plastic-encased portals that gloved hands or sterilized food samples could be quickly passed in. 

The psychiatric consultation for Eleanor was called in at just after the 8:00 p.m. close of visiting hours. Eleanor was upset, psychotically so. Her paranoia and shrieking were spreading histrionically. The precipitating event had been the visitation from a never-before-seen preacher from upstate Pennsylvania. He had traveled to the NIH Clinical Center specifically to see Eleanor. Somehow, he had heard that she was an identical twin being treated for acute leukemia who also happened to have congenital heart disease, while her healthy twin had neither condition. 

The preacher was described as a tall, bearded man dressed all in black and wearing a broad-brimmed black hat. He felt impelled to see her — to tell her that she must have acquired these disorders because, somehow, she had displeased God. This freaked Eleanor out. She began yelling and screaming. 

Enter, minutes later, me, in the unfamiliar role as the psychiatric consultant. It was very clear that I was having to work far above my pay grade.  It was nighttime, and all my psychiatric solons had long gone home. A small dose of oral Thorazine settled down the room, to my relief. After close to half an hour, Eleanor and I finally were able to talk, commiserate, unwind, and get past our introductions. 

Following this emergency meeting came months of daily semi-scheduled conversations. She did the talking, and I the listening. Eleanor’s twin, after the initial bone marrow donation, had since returned to California. Eleanor stated that she wanted to go back home, and preferably not in a plain wooden box. Fortunately, she didn’t want to bolt out of the Life Island, which she felt kept her safe, after a series of bone marrow suppressions. 

Eleanor was a help to me in my learning to be a psychotherapist. As my first case of supportive psychotherapy, she wanted to talk and she related warmly. We quickly developed a therapeutic alliance.  I helped her deal with her emotional distress by being a constant person during a time when her NCI Clinical Associates kept rotating in and out of her life. Mostly what I did was just listen attentively and sympathetically. Psychoactive medications did help. My role as her therapist was to focus on her issues, her voice, and her needs while not raising issues that she was not grappling with. Her mood improved and she became realistically hopeful about her potential for meaningful gains. 

Eleanor did talk about her twin, but not about how she was the unlucky one to have several disorders. She accepted what had been dealt her in a very mature way. We never heard anything more from that malevolent preacher. Eleanor did achieve a temporary remission at NIH. She was pleased to achieve her main goal — to fly back home in a temporary remission. 

Our work together was good for me, too. Having enjoyed the process with Eleanor, I decided to apply for yet another residency, this one in psychiatry. After all, what was wrong with adding a sixth, seventh and eighth year to my training if I felt it was meaningful!

Frederick Guggenheim, M.D., is Professor Emeritus in the Department of Psychiatry, College of Medicine. 

By Manish Joshi, M.D., FCCP and Thaddeus Bartter, M.D., FCCP

Before I (MJ) moved to the United States from India almost two decades ago, my usual way to greet people was namaste — a Sanskrit word referring to a gesture widely used throughout the Indian subcontinent as a respectful form of greeting, acknowledging, and welcoming a relative, a guest, or stranger. Handshaking was not part of my culture and only occasionally performed on special occasions — receiving a college degree on a podium, getting a sports trophy or a medal, or perhaps reconciling after a fight with a friend. Yet I distinctly remember shaking hands as a child with foreign tourists, mainly Europeans, in my visits to “the pink city,” Jaipur, where I grew up. In my 28 years of living in India, I don’t remember getting a hug other than from my own very close family members — and even that wasn’t in public. There was no culture of hugging in public except in rare instances such as to console a sad/crying person on the death of their loved one. 

Life changes. When I moved to the United States, the handshake became an integral facet of social interaction. I shook hands many times a day as I greeted colleagues and patients at social meetings. I also observed that hugging was a common form of greeting. The transition to handshaking felt reasonably natural for me, but it was not easy for me to assimilate into hugging; I always was (and am) uncomfortable and always feel that I am encroaching on somebody’s personal space and vice versa. Does this mean that I don’t hug my wonderful wife or two beautiful children? Absolutely not. But those are my immediate family members with whom I share personal space on an intimate and daily basis.

Life has changed again. With the COVID-19 pandemic, “social distancing” has become a household concept. As per the US Centers for Disease Control and Prevention, social distancing, also called “physical distancing,” means keeping space between yourself and other people outside of your home. (1)  Handshaking and hugging appear to have faded underneath the scourge of this pandemic. Dr. Anthony S. Fauci, who has led the United States through this pandemic, is now in the national forefront advising against handshakes during this COVID-19 pandemic and even during influenza season in order to prevent transmission of these respiratory viruses. (2) As I have listened to him, the normal customs of interaction in India and many other Asian and African countries have come to mind. Does namaste, a non-contact greeting, represent a greeting style which has evolved to decrease transmission of communicable diseases? Very likely. India has one of the highest population densities in the world; physical distancing can be difficult, and the community health implications of a disease that can spread by human-human contact are prodigious. Perhaps over millennia, the Indian subcontinent, one of the oldest civilizations in the world, adopted “physical distancing” without compromising “social interacting” as a means of protecting against communicable diseases that holds true in the 21^stCentury. 

Does the present scenario with social distancing mean that we should negate or eliminate the very humble gesture of acknowledging other human beings? I believe that genuine social greeting (with physical distancing) is more important now, as the entire world grapples with this apocalyptic crisis, than at any other point in modern history. I am a critical care physician, and have watched the teamwork demanded by this pandemic – between ICU nurses, respiratory therapists, physicians, housekeeping personnel, and many others working behind the scenes. I have watched commitment, a “can do” attitude, and collegiality prevail despite feelings of anxiety and frustration as this disease causes disruption of routine, changing guidelines almost daily, and risky shortages. Ironically, in this time of “social distancing” we depend on each other and need to work together more than ever. Namaste came back to me naturally with the loss of handshaking – it’s an art that greets, respects, and acknowledges that we are part of something larger than ourselves. I do feel a genuine expression of gratitude for all my colleagues when I say “Namaste” to them. And I get the same genuine feeling back from them. 

I (TB) was born and raised in the United States, although I could be called first generation. My mother was from a “distinguished” family with deep American roots, but my father had come to the U.S. alone as a teenager from the Philippines, where his British father was a missionary. My upbringing could best be described as Victorian. The handshake, accompanied by a look straight in the eyes, was the standard greeting. Caring was expressed sparingly, most often between a mother and her children. Expressions of intimacy between a man and his children were less common, and least common was any warm physical greeting between male friends. As I grew older and left my “cultural niche,” I watched the French hug and the Italians kiss friends (gender irrelevant) on the cheek. I preferred these expressions of warmth and companionship to the reserved constraint of my childhood. I felt that expressions of appreciation, caring, and even need for others represented a more open, honest, vulnerable, and rewarding approach to my relationships with those around me. I incorporated hugging for friendship (and occasionally consolation) into my lifestyle. 

As we enter the world according to Covid, things change. The need to protect ourselves with physical distance does not negate our needs for community, for collaboration, for recognition. And now my friend greets me with namaste, a word — and sometimes a gesture — with ancient roots embodying the elements of a handshake or a hug without physical contact, a word meaning acknowledgement, appreciation, and belonging. 

Physical distancing, a practice we all must follow, is vital to fight this pandemic which knows no cultural boundaries. As we transition to Covid, we also should transition not to “social isolation” but to human bonding and greetings such as namaste.

References

1. Social Distancing. Centers for Disease Control and Prevention.
https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html. (Accessed 5/8/2020)

2. Fauci: ‘In a perfect world’ Americans would stop shaking hands. ABC News. https://abcnews.go.com/Politics/fauci-perfect-world-americans-stop-shaking-hands/story?id=70062797  (Accessed 5/8/2020)

Manish Joshi, M.D., FCCP is a Professor of Medicine in the Pulmonary and Critical Care Division of the Department of Internal Medicine at UAMS and the Central Arkansas Veteran’s Healthcare System.

Thaddeus Bartter, M.D., FCCP, is a Professor of Medicine in the Pulmonary and Critical Care Division of the Department of Internal Medicine at UAMS and the Central Arkansas Veteran’s Healthcare System.

By Savanna Winsted

The Holy Spirit spoke to me as I sauntered past a hill of wildflowers along the pathway to my car. 

Look at the flowers. View the beauty in the chaos. All the different flowers, grasses, and entanglements of green. See, the world looks at this from the human perspective as weeds and messiness that instead should be plucked and manicured for straight lines and perfection. You destroy the very creation I call beautiful. God placed that wild arrangement there with purpose and destiny. I feed my grass; I grow my flowers; I lay them exactly where they were meant to be. See the beauty in how I care for my creation when it follows my will. 

Then He reminded me of the landscaped flowers and bushes I pass everyday on my way to work. He then tells me… 

Something greater planted these flowers and bushes. Man places the plants yet the rain and wind destroy them in an instant. It was never their purpose to be in that place. Though they are beautiful and appealing to human standards, they cannot thrive outside the spiritual realm. Human condition and human ideas fail and fall every day because they do not follow my will. You can only thrive where you were meant to be planted; you can only grow when you are led by the Spirit. The world sees my creation as wild weeds and a nuisance, but I find joy as they flourish, grow and spread as designed to do. As they obey my voice, they prosper to no end. This is what love does. This is the desire I have for my people — my creations. For too long you have done things beyond my will. You have searched for external beauty and perfection in appearances and placement. People have plans for their lives, but my purpose prevails. I have longed for my people to return to glory, to search their hearts, and understand the beauty that is already within. That beauty is concealed by expectations, false truths, and lies from the enemy. This is the time for my creation to return to its proper place, to understand its purpose, to know the truth. Hear my voice, and obey my commands. As you draw near to me, I will draw near to you. This is where love is found, in my arms and in my will. 

Savanna Winstead is a Patient Services Coordinator in the Care Management Department at UAMS.