My fundamental beliefs and attitudes about doctoring grew out of my experiences as a student in the 1960's, long before there was such a thing as "holistic medicine." Practical dilemmas first encountered on the wards of a large city hospital led me to study philosophy before going into practice, and have continued to shape my career ever since, throughout internship and more than forty years of clinical work.
In my school days I felt no particular calling to heal the sick, and there has never been another physician in my family as far as I know. Studious and scholarly by nature, I would undoubtedly have felt more at home in an academic discipline like history or philosophy than a worldly career such as medicine. Nor have I ever wholly overcome an instinctive distaste for the actual stigmata of illness, by which I mean not only physical and emotional suffering, but perhaps even more the tyranny they impose on loved ones and caregivers alike.
Why I chose a profession for which I had so little natural inclination, ambition, or special aptitude, and why I persevered in it despite repeated failures and disappointments, thus defines a mystery, and suggests powerful unconscious forces at work. Framing the question in this way takes me back to my grandfather's death from renal failure around my sixth birthday, when intimations of mortality turned my life upside down. One night as I lay in bed, unable to sleep, my thoughts and fantasies coalesced into a vision of absolute clarity that I too was destined to die, a fate from which no earthly power could save me. At my wits' end and desperate for solace, I burst into my parents' room, quite sure that I wasn't dreaming, and indeed awake as never before from the knowledge that death wascertain, a standard of truth utterly new to my experience. From their bland dismissals and obvious reluctance to discuss it, I gathered that death was a mystery I would have to plumb by myself.
Born with a crossed eye that resisted correction with glasses and orthoptic exercises, at thirteen I underwent corrective surgery that left me with a divergent squint both obvious and permanent. Equally powerless to achieve binocular vision or to stop trying to achieve it, I have never wholly adjusted to the resulting headaches, eyestrain, and distrust of "experts," specialists, and high-tech solutions that have nevertheless become almost second nature to me.
During the summer after my junior year at Harvard, while employed as a research trainee in biochemistry, I received a wake-up call that could and perhaps should have ended my medical career before it started. Justly famed for its pioneering work in animal genetics, the Laboratory where I worked derived the bulk of its income from breeding and exporting pure strains of mice, rats, dogs, cats, monkeys, rabbits, and other species for biomedical experimentation all over the world. Extrapolating from the modest number of animals sacrificed in my own work, as well as that of my mentors and colleagues, I conjured up a rough estimate of the vastly larger total that we supplied to others for similar purposes, and thus came to appreciate the enormity of this terrible enterprise and my own undeniable complicity in it. Ever since then, no argument however subtle or forceful has persuaded me that human progress requires the systematic torture and killing of helpless creatures on such a scale and for such a purpose, or that valid standards of science or ethics could ever be built on such foundations.
In spite of these misgivings, I entered New York University Medical School in the fall of 1959, right on schedule. Most of our clinical work was performed at Bellevue Hospital on the East side of Manhattan, a venerable but antiquated institution that provided the most advanced diagnostic and treatment facilities gratis to anyone who needed them, along with substantial quotas of neglect and abuse from overworked interns and residents, and attentions both welcome and unwelcome from the students as we rotated through each service.
In those days, medical students were initiated into the mysteries of patient care by "drawing the bloods" for the day, a ritual happily long since dispensed with in most places. In charity hospitals maintained at public expense, indigent patients were routinely taken advantage of by us and the house staff in exchange for their care, and were expected to surrender unlimited quantities of blood for any tests that we were even remotely curious about. Even today, more than thirty years later, I can still almost hear the low, mournful wail that greeted us every morning, as the patients saw us coming with our implements down the hall. After days or weeks of experimentation on veins often weak and traumatized to begin with, our last resort was the dreaded femoral puncture, which took only a few seconds to execute, but left both victim and perpetrator holding our breath until the huge syringes were filled at last.
Accustomed to thinking of illness as a particular episode or life experience that we come down with, work through, and eventually recover or perhaps die from, I was wholly unprepared for a reality in which disease was the underlying condition, and a vast nexus of goods and services had been created to manipulate and exploit it. On those rare occasions when the beds were empty and the wards deserted, I could still almost smell the ineradicable miasma that lingered in the air, like the accumulated residue of all diseases past and present. One of my favorite assignments was night call on the maternity service, where the miracle of birth occasionally burst forth before anybody had a chance to step in and interfere with it. Listening to the chorus of women in labor from my cot in the next room, I often reflected on the word "obstetrics," derived from the Latin preposition ob, meaning "against" or "in the way of," and the root stet-, meaning "stand" or "standing:" an obstetrician, I came to realize, was a physician named and indeed celebrated for standing in the way of the birth process, for manipulating and controlling it for doubtless worthy purposes of our own.
On the medical wards, we were responsible for admitting all lobar pneumonia patients, usually alcoholics from the Bowery, for whom a high fever, productive cough, pleuritic pain, or some equally serious ailment was their only ticket to a warm bed and regular food on cold winter nights. In most cases, the sputum was loaded with Streptococcus pneumoniæ, an organism easily detected by microscopic examination and in those days wholly curable with minute doses of penicillin. Before initiating treatment, however, we were required to inoculate the specimen into the peritoneal cavities of two mice, which yielded an almost pure culture of the pneumococci when we sacrificed them two days later. Since the test was largely academic, I only pretended to do it, not daring to raise the issue of animal testing, but unwilling to witness the atrocity myself.
Routinely enlisting us to perform their dirty work, the house staff merely pointed out that we could lord it over our own crop of students when their turn came. In this fraternal spirit an intern once hit on me to pass a Rehfuss tube into the duodenum of a tiny Puerto Rican woman whom he was working up for possible pancreatic disease. Basically a stomach tube tipped with a weighted metal ball to carry it through the pylorus into the small intestine, this little devil was practically impossible for an unanesthetized person to swallow without gagging. After three failed attempts, I found myself wishing that doctors be given a taste of their own medicine before being allowed to administer it to others. When the intern finally took over, he fared no better, but proceeded to blame the victim, unleashing a torrent of abuse that included racist slurs like "stupid" and "animal" that required no translation. Pulling herself up in bed to face him, this little lady suddenly assumed a proud and majestic stature, rebuked his insolence, and vowed retribution if he ever molested her again. Not long after that, I spotted two burly, mustachioed young Latinos lurking about the ward, and made myself scarce, but in my heart I wished them well.
In like manner, the hospital also dramatized the need for patient empowerment in the gnarled and twisted shapes it often assumed there, like the middle-aged black man with a chip on his shoulder who lived on the street, but knew more about chronic lung disease than most of the doctors treating him for it, and could usually be found in the library boning up for our discussion of him on rounds the next morning. It took me a bit longer to understand that the inequality in rank and power that allowed us to do whatever we wanted, and compelled our patients to obey and even thank us for it, culminates in the actual propagation of disease, both indirectly, by spreading fear and doubt, and directly, through excessive use of diagnostic and treatment procedures with obvious power to harm.
One such example arose from the belief of a senior Professor of Surgery that the cause of chronic pancreatitis was spasm of the sphincter of Oddi, by producing reflux of bile into the pancreas, and hence chemical inflammation of the gland. After successfully creating a facsimile of the disease in animals by applying electrical stimulation to the sphincter and clamping off the common bile duct behind it, he developed a protocol for human subjects that blithely crossed the frontier of ethical restraint into a gray zone where the only law was whatever the traffic would bear, and whatever a tenured Professor could get away with.
Under his tutelage, Residents at the Surgery Clinic would select a quota of indigent patients with digestive symptoms for "pancreatic studies," provided they were not yet diagnosed or claimed for other projects, like the Puerto Rican lady described above. Those who survived the ordeal of the Rehfuss tube might then become eligible for surgical insertion of a T-shaped catheter into the common bile duct, through which samples of bile and pancreatic juice could be taken for analysis, and radio-opaque dyes introduced for X-ray close-ups of the biliary and pancreatic duct systems, leading in some cases to cutting open the sphincter if it actually proved to be spastic. While I like many others was slow to put it all together, it should not have been a surprise to anyone that traumatizing these highly delicate structures would often irritate and inflame them, thus provoking spasm of the sphincter, and eventually chronic pancreatitis as well. In this stepwise and almost imperceptible fashion, his careful methodology not only confirmed the theory that had inspired it, but also provided a continuous supply of experimental material, since once scarring had occurred, it usually proved irreversible.
During those same years, another equally memorable example was the work of a well-known pediatrician, already celebrated for his work with the virus of infectious hepatitis, now known as Hepatitis A, who conclusively proved for the first time what many had long suspected, that the disease is transmitted by mouth, through ingestion of contaminated feces, just like polio and other intestinal viruses. He too succeeded by his willingness to conduct dangerous experiments on individuals without their consent, in this case retarded children at Willowbrook State School, who could not speak for themselves, and often lacked parents or guardians who were willing or able to speak for them.
Feeding stool samples from those with known infection to other inmates not yet sick, this doubtless sincere and even dedicated physician soon had irrefutable data regarding the portal of entry, incubation period, clinical course, liver enzymes, and every other known parameter of this major infectious disease. Some years later, when a citizens' group tried to blow the whistle on his research, which was conducted largely at public expense, he correctly pointed out that the disease was rampant at the school in any case, because of overcrowding and poor sanitation, and was allowed to continue his work without interruption or even a reprimand.
Neither man was intentionally cruel or malicious, in the manner of serial killers who defy social norms, or torturers and war criminals who carry out atrocities or give in to coercion or social pressure under extreme circumstances. What they did was evil and indeed monstrous for precisely the opposite reason, that they were successful and even illustrious in a system which prizes their work so highly and rewards its achievements so richly that the distinction between valid science and criminal or immoral behavior is far less clear, and the legal and moral standards regulating it are correspondingly ambiguous.
By my fourth year, as "matching day" for internships drew near, I realized that I could not bring myself to practice medicine in the way I'd been trained, and accepted a graduate fellowship in philosophy at the University of Colorado, in large part to try to find clarity and meaning in what I had just lived through. Long before I found words to articulate or concepts to explain it, I "knew" at some deeper level that reducing illness to "diseases" and abnormalities, and thus using drugs and surgery to separate or literally remove them from the patient's body, are always fraught with ethical and practical risks that I could not accept on a routine basis, or simply because that was how things were done.
In 1966, three years later, I served a one-year internship at St. Anthony's Hospital in Denver, including rotations of three months each in Medicine and Surgery, and two months in Pediatrics, Women's Health, and Emergency Medicine. With well over 500 beds and no Residents or permanent clinical Faculty, it was not designed or run as a teaching institution. Our instructors were simply the Attending Physicians using the hospital to admit and care for their private patients, on whose behalf we might be asked to complete an admission workup, insert an IV or venous cutdown, assist in surgery, or carry out any other menial tasks the Attending or Nursing Staff might require. In addition, indigent patients referred in from the ER or Outpatient Clinics, which we staffed and ran, were assigned to our personal care, under the nominal supervision of our Preceptor for each service.
In short, we operated for the most part under the old apprenticeship system, which grounded me thoroughly in how medicine was actually practiced, allowed me to learn at my own pace, and left ample room for close personal relationships with supervisors, attendings, nurses, and patients alike. But while generally knowledgeable and helpful if we could find them, our preceptors were far too busy with their own patients to be available consistently when we most needed them. With only eight of us to cover the whole place, we were usually on our own, often in the dark, and wont to proclaim as a virtue the "see-one, do-one, teach-one" philosophy we were obliged to live by. While our patients undoubtedly appreciated and benefited from our personal attention, they paid for it many times over by having to run the gauntlet of inferior care that followed from our having to learn everything more or less by the seat of our pants.
In a typical vignette from this period, my first D & C was ordered by my OB/GYN Supervisor, for "diagnostic purposes," in a Welfare patient with a history of excessive vaginal bleeding. Since the Hospital was owned by the Catholic Archdiocese and closely supervised by nuns, I was surprised when he told me not to bother with a pregnancy test, but I didn't argue. In the Operating Room, he took plenty of time to show me how to administer para-cervical anesthesia, dilate the cervix, and curette out the endometrial lining, but then grew oddly impatient during the procedure itself. "Moskowitz, get finished, already!" he kept barking at me, seemingly heedless of the fact that I was still removing handfuls of tissue, with no trace of the harsh, grating sound he had just taught me to wait for as the endpoint of the procedure. Once again I obeyed, but the Pathology report confirmed a pregnancy, and the next day we had to take her back and finish the job. Although he continued to deny any prior knowledge or suspicion of it, both the illegality of abortion in those days and the woman's profound gratitude for what had happened pointed to our flawed collaboration as the only way for her to get the help she needed. Far more than any technical information, these were the lessons that stuck.
Another memorable experience grew out of my friendship with a patient, a Hispanic guy in his mid-forties who had developed chronic thrombophlebitis of the deep veins of the calf as a result of the surgical ligation and stripping of his unsightly varicosities that he had been so eager for not long before. I have yet to hear a convincing rationale for this purely cosmetic procedure, which by removing the superficial veins effectively doubles the load on the deep system, itself already compromised in many cases, and thus often brings about the same kind of venous insufficiency that had more or less crippled this man with little hope of relief.
In time, we became friends, and one day he invited me to his home in the projects to meet his wife, sample her famous enchiladas, and stay the night. In the wee hours of the morning, he woke me with an urgent plea to examine his aged father, who lived across the courtyard and was complaining of severe chest pain. As I entered his room, the old man was sitting up in bed, leaning forward with his hands clasped over his heart and a look of mortal terror in his eyes, a textbook picture of acute coronary occlusion.
Though equipped with nothing but my little black bag, and understandably reluctant to treat him at home, I feared even more to subject him to the quasi-military atmosphere of the ambulance and Emergency Room, where his inability to speak or understand English made the risk of a serious or fatal complication loom even greater. So I gave him a shot of morphine, and within minutes he fell into a deep and peaceful sleep. By the time I left for work, he was resting comfortably in bed, obviously feeling much better, at which point his wife told me that he had recovered from at least three such episodes in the past, without any medical attention whatsoever. That made me wonder whether a lot of patients might not heal better at home, not only from heart attacks, but from many other serious ailments as well.
As in most hospitals, the bulk of our instruction actually came from the nurses, who basically ran the place, but knew how to make it look as if they were followingour orders, rather than the other way around. Thus on a typical night in the ER, if a patient came in, say, wheezing from an allergic reaction, some version of the following dialogue would most likely ensue:
Nurse: Shall I get the Benadryl, Doctor?
Doctor: Yes, thank you . . .
Nurse: How much, Doctor, maybe 50 mg. IM?
Doctor: Yes, that sounds about right . . .
Along with much practical information of this type, we also learned from the nurses how to "play doctor," to enact the part of a physician in society, including roughly equal parts of bedside manner, educating the patient, and simply "breaking the news." Once I tried in vain to revive a 49-year-old man who had suffered a massive coronary in a Hospital corridor, while awaiting elective surgery for some minor problem. With no idea of what had happened, his wife walked in just as he was being carted off to the morgue. Asking what the ice was for, she was told matter-of-factly, "We always pack 'em like that when they expire," and her hysterical screaming and sobbing left me to grope for what few words of comfort I could come up with. From then on, the nurses often called me at such times, because I would take the time to speak with the relatives, and make sure that they too were cared for.
Much as I enjoyed the thrill of performing surgery, and admired the technical skill and ingenuity that made it possible, at 6 in the morning it was always a challenge to get down enough breakfast to avoid feeling faint or nauseous at some point during the gastric resection or hysterectomy I was about to scrub in for. Although certainly in favor of chemical intervention and reconstructive or emergency surgery in acute or life-threatening situations, I already distrusted long-term drug treatment in most instances, and avoided elective surgery wherever possible, regarding them as a last resort, rather than the model for what we were supposed to be doing. But they were still all I knew. Had anyone brought up acupuncture, homeopathy, or anything equally outlandish at the time, I'm sure I wouldn't have been in the least interested in or hospitable to it.
After completing my internship and licensure, I took my first job covering for a busy GP who was taking a long-overdue vacation, having left strict instructions to his patients not to come in unless their problems wouldn't wait until he returned. Even so, I worked harder during those four weeks than at any comparable period before or since, beginning with Hospital rounds at 7 a.m., then office visits practically non-stop until 9 or 10 at night, averaging at least 50 patients a day, 6 days a week, a schedule by no means unusual for a GP then or now. On top of that, I officiated at eight births, and covered the Emergency Room one night a week, when I could expect to be up into the wee hours admitting, working up, and following new patients without established physicians of their own.
On one such night, the ambulance brought in a heavy-set, 45-year-old Polish lady, who spoke not a word of English, and limped in bent over, holding her back, and groaning in pain. Suspecting a kidney stone, I palpated her abdomen and was surprised to find her far along in a pregnancy of which she herself was unaware. From her husband's very rough translations, I learned that she had never been pregnant before, had had no period for 9 or 10 months, and had simply let it go at that, not feeling or suspecting anything out of the ordinary, assuming she was menopausal, refusing to believe her husband when he told her the news, and flying off the handle at us both for making a joke at her expense. When a vaginal exam revealed that she was also in advanced labor, I rushed her to the delivery room, just in time to hand her a nine-pound baby girl, who seemed perfectly normal in every way. Back in the nursery, however, she regurgitated whatever she drank, and a Barium Swallow and Upper GI revealed a tracheoesophageal fistula that had to be repaired without delay. Both mother and child went home in fine shape in less than a week, but the greater part of this saga occupied just a few hours in the eventful life of my absent employer, whose seven-league boots I was struggling mightily to fill.
When he returned, I became House Physician at the Beth Israel, a smaller hospital nearby, where my duties were much the same as during my internship, doing chores and little favors for the nurses, the Attending Staff, and their patients, as well as assisting in surgery, being on call for any emergencies or special needs, and supervising the Old Folks' Home out back. Always a favorite part of my practice, working with the elderly demands mainly personal care and attention, with little expectation of radical cure, yet earns profound gratitude for any relief of pain, suffering, or the accumulated burdens of survivorship.
At the same time, I moved back to Boulder, and began seeing patients in my little ground-floor apartment, as an experiment to make my practice more open, informal, and as consensual as possible. My procedure was to examine them as noninvasively as the situation allowed, using only the simplest tools, with as much give-and-take and direct participation as they seemed to want, or could handle, making the diagnosis, to be sure, but then putting it "on the shelf," so to speak, and waiting for their own individual need or history to suggest a regimen and plan of treatment most uniquely suited to them. While often difficult, and by no means uniformly effective, this down-to-earth approach was clean, honest, unlikely to cause harm, and kept me closely attentive to the doctor-patient relationship at every moment. Ever since then, these same priorities have continued to guide me in my search for a method and style of practice that could pass the test of time.
As the War in Southeast Asia continued to spread and intensify without letup, I began to realize how thoroughly both my medical training and the culture of illness and disease that we all grow up with are steeped in the imagery of warfare and combat. With drug ads and hospital and charity fund drives all promoting the conventional wisdom that viruses and bacteria are simply invaders to be expelled, and diseases enemies to be fought, most people were and still remain ready, willing, and eager to use chemical weapons, such as antibiotics, antihypertensives, antimetabolites, and other "magic bullets," against any complaint or abnormality that threatens or merely bothers them. But when an American General openly boasted of destroying a village in order to save it, his words borrowed almostverbatim from the cancer specialist, the gruesome footage of such exploits transformed what had formerly seemed like a mere figure of speech into a systematic philosophy of militarism for its own sake, with a bottom-line ferocity that began to shock even its own proponents. It dawned on me that I had been trained as a soldier, to fight in the front lines of an endless war against disease, armed with the latest weapons to shoot down and kill symptoms and abnormalities whenever and wherever they showed themselves. Once again, as in medical school, I prayed for the courage and the opportunity to desert my post and fight no more.
By then I was practicing what I would call "minimalist" medicine, that is, giving out liberal helpings of education and advice, while doing as little as possible of a drastic nature, seeing my rôle as mainly to guide people through the medical system and protect them from being hurt too badly. These are still important priorities for me; but back then, with fewer and fewer procedures available that did no harm and made sense to me in other than acute or extreme circumstances, I had little to offer my patients when their illnesses got worse, while my growing estrangement from the profession as a whole made it increasingly difficult and unpleasant for me to practice at all.
Applying to a Boulder hospital for admitting privileges, I quickly discovered that my antiwar views and unorthodox style of practice had alienated many of the doctors in town. On the advice of a friendly internist, I introduced myself to as many of them as were willing, and was narrowly approved for membership by one vote, but the Board of Trustees simply overruled them the next day, evidently alarmed by the fact that what they feared or imagined I stood for had split the Medical Staff right down the middle.
Then in April of 1969, with my confidence and self-esteem close to rock-bottom, an unusual request changed my life in a big way. Due to give birth in a month, a woman I knew very slightly telephoned to ask if I would come to her house to help with the labor, which none of the other doctors she tried would agree to do. I'd never heard of anyone who had done such a thing, or even imagined that anyone would want to, and was well aware of my own feelings of insecurity, with no nurses to hand me instruments, and no hospital to back me up. But in my sorry state, I understood right away that here at last was something I could do as a physician, without doing harm to people or telling them how to live their lives.
When her time came, I arrived expecting to perform a vaginal examination right away to assess how the labor was progressing. Whether because of the candlelight, or the Bach playing softly, or the rapt expression on all their faces, somehow I understood that the exam was a routine procedure I had been trained to do, rather than anything that Dorothy herself really needed or was asking for. After considerable soul-searching in this vein, I decided that if anything went wrong, I could trust myself to figure out what needed to be done at the time, and that the best thing to do at the moment was to sit down, be quiet, and pay attention like everyone else. Without saying more than a few words, she taught me pretty much the whole course that day, and I still don't know how or where or from whom shehad learned it, since her first child had been born under general anesthesia nine years before.
Adam was born at dawn, and both mother and child were bathed in a soft halo of light that extended for a short distance all around them, like a Madonna of Raphael or Filippo Lippi, and we all saw it and gazed at it and her and the baby, and each other, as human beings have doubtless always done since the beginning of time. In no way uncanny, strange, or outside the realm of natural law, the birth was a miracle in precisely the opposite sense, of something happening in full awareness, which only our customary inattention would need to single out, and only our remembering what all other animals have never forgotten bespoke a real deliverance.
Her daughter Erica announced that she was taking the placenta to school, but when her friends came by and tried to veto the idea, she wrapped it in a plastic bag and stuffed it under her coat, like a reluctant conspirator carrying an oversized bomb. Less than an hour later, the school nurse telephoned in a panic, so I stopped off to fetch it on my way home. After ssurding me that "I'm not really against this sort of thing," she explained with some embarrassment that they didn't have refrigeration for it, to begin with; that she'd have had to ask the principal, who happened to be out of town; and in fact that she could lose her job if she acted on her own. I wish I'd asked her what she thought of a state of affairs in which she could lose her job for talking to a bunch of schoolchildren about giving birth to a baby, or indeed what her job was if not that. But I didn't. The holy relic lay in state on my coffee table for a week without the slightest odor or trace of putrefaction, like the dead bodies of certain saints or ascended masters.
Adam's birth showed me a path that I could follow as a physician that still works for and makes sense to me. Even the most enlightened hospital has to make rules for people, to act as if it knew what's best for them, better than they do themselves, while as a guest in Phil and Dorothy's home it was no longer appropriate for me to tell them what to do or how to live. Indeed my rôle was no longer to do anything in particular, but rather simply to be there for them in whatever way seemed useful at the time, which included helping them to make whatever decisions they needed to make and to complete the natural process that was already under way.
For a long time I guarded the memory of that experience, like a precious jewel in a secret box: it never occurred to me that anybody else would try to duplicate such a crazy idea. Moving back to New York in search of new directions, I took a full-time position on the Medical Staff of a Neighborhood Health Clinic in Brooklyn that was created as a subunit of President Johnson's "War on Poverty." With a clientele that was mainly poor and black, and lived in the slums of Red Hook, our spanking-new facility was incongruously located in upscale Brooklyn Heights and included a fleet of reconditioned taxicabs to ferry our patients from the bottom of the socio-economic ladder to the top, and back again.
Gratified that our budget at least provided for home visits, one day I was sent to the projects to see an old man in his nineties who was too ill to travel. As I entered the bedroom, he spotted my silvery moustache and rose smartly to attention, saluting me as if I were General Pershing, his commanding officer, and he still a doughboy in the First World War. Before I could play along, he doubled over in pain, and while easing him back into bed I could feel the vast bulk of his liver, studded with hard, metastatic nodules in an obviously terminal state. Confiding to his wife that he had cancer and would undoubtedly die soon, I offered to find her a housekeeper to make them both more comfortable in the time remaining; but she was over eighty herself, with major health problems of her own, would not hear of him dying in that wretched little apartment, and insisted that we admit him to the hospital, and care for him there as best we could.
As a satellite of the vast Kings County Medical Center, our Clinic was required to admit all inpatients to Long Island College Hospital, its local affiliate, and to surrender all authority over their care to the interns and residents in training there. Determined at least to meet and talk with them first, I argued that since both the diagnosis and the outcome were already certain, the most humane and sensible alternative was to give him plenty of morphine, make him as comfortable as possible, and let him die in peace. But the House Staff greeted this suggestion with such contempt and disbelief as they reserved for throwbacks to a benighted and discredited past. Just as I had feared, they were determined to perform a liver biopsy and begin chemotherapy purely as a training exercise, well aware that the drugs were highly toxic, debilitating, and of no lasting benefit, and that the procedure itself would very likely result in pneumonia and a miserable death, as in fact it did.
By the summer of 1970, I'd had enough, and once again sought refuge out West, renting a cabin high in the Colorado mountains. But almost as soon as I arrived, women began calling me to help with their home births, and before long I was as busy as I could be, attending maybe 40 births by spring, and 150 in the three years I lived there, long enough to watch Dorothy's wacky idea catch on and spread like a prairie fire through the subculture. Without an office, nurse, appointments, or even a telephone at first, I was totally available to my patients if they could find me, an arrangement that, while clearly unsuitable for some, fit in quite well with the flourishing grapevine and frontier ethos of that time and place. The way it worked was that patients made it their business to know or find out where I was at all times, while I taught them the basics of emergency childbirth in case I didn't make it, and dropped in on anyone close to term whenever I came to town, a journey of twenty miles over rough mountain roads that in winter became an arduous and sometimes thrilling adventure. The best part was what happened when I got there, like finding the labor already in progress, or being treated like an honorary member of the family for a while, or at least being rewarded with a hot meal, good company, and a warm bed for the night.
In any case, I never missed a birth, lost a baby, or needed to take anyone to the hospital in those days, a record that I can't explain and never equaled or even came close to in later years, when I opened an office, hired nurses and receptionists, hospitalized people when I had to, and witnessed my full share of complications like everyone else. Only in retrospect can I fully appreciate how fortunate and indeed in a state of grace I must have been, as if blessed by the vision that Dorothy had bestowed on me, and determined to do everything in my power to be worthy of it. Whatever the reason, it cannot have been any particular skill or affinity on my part, since I had only a rudimentary knowledge of pregnancy and childbirth, felt even more keenly than my patients my unworthiness to supervise this most womanly activity, and could only justify it as an anomaly of medical history, which the home birth movement itself would and did eventually rectify.
One memorable birth still evokes the wide-open, experimental atmosphere and flair for self-discovery that seemed so characteristic of those years. Bored with successful careers in the New York theater and art scene, a newly-married couple set out on their honeymoon in an old school bus that they had transformed into a romantic bower of velvet hangings, silk brocades, and other offerings of beauty and magic to the new life they dreamed of. Aiming for California like so many others, they never made it past the mountains, where they ran out of cash, discovered they were pregnant, and fell under the sway of Chögyam Trungpa Rimpoche, the charismatic Tibetan master who lived and taught nearby.
Taking advantage of electric and water hookups at a friend's house in town, they continued to live and hold court in the bus, where we met to prepare for the birth. As the labor began one raw November morning, dozens of friends and well-wishers gathered in the house, and began carousing and drinking heavily to celebrate the event as if it had already taken place. By nightfall, Maggie was tired and panting rapidly, but her cervix was still only minimally dilated, and all the patience and encouragement I could muster failed to help her over this seemingly huge and insurmountable obstacle. With her labor at a standstill, I went back into the house, and solemnly announced that she needed the collective energy and moral support of everyone there, but without any clear idea of what I actually had in mind. As if on cue, they filed out into what had become an icy drizzle, lined up alongside the bus, and began chanting the sacred syllable in a loud, insistent drone that sounded as if it would continue until something pretty impressive happened.
Thus summoned to what would become perhaps the greatest performance of her career, the former actress quickly revived in the presence of her audience, inviting everyone inside the bus, passing out candles, and leaving no room for doubt that she knew exactly what to do next. Opening the I Ching at random, I read aloud from the first hexagram I turned to, and although I remember nothing of the actual passage, it was followed by a chorus of nods and murmurs as if it were cosmically appropriate to the occasion. Taking hold of two ropes that her husband had hung from the ceiling for just this purpose, Maggie pulled herself up to a squatting position on the bed and began bellowing like a heifer with each contraction, though she was still by no means fully dilated, felt no definite urge to push, and taught herself as if by sheer force of will how to recognize and direct an instinct that still lay hidden deep inside her. When her daughter finally emerged, weighing almost eleven pounds, her prodigious size made the physical and moral difficulties of her birth seem almost legendary in Maggie's heroic mastery of them.
These early experiences also taught me to respect my patients' life choices even when I disagreed with them, questioning and at times arguing when I felt strongly, but in the end giving them the say about the kind of health care they wanted. With no past experience to guide me, I worried a lot about the nutritional state of a macrobiotic couple who held forth as if they exemplified the highest moral virtue through their superior understanding of dietary matters, but I also enjoyed the dinner they set before me well enough to persuade me to work with them. As it happened, the labor and the birth went off perfectly, and although the baby was smaller than average, as I've since come to expect, she grew to be as strong and healthy as anyone could wish.
Over the next twelve years, I attended somewhat more than six hundred home births, and the model of doctor-patient relationships that emerged from them is as relevant today in my office practice as it was then in the field. I feel as proud as of anything else I have ever done to have helped these families come together and bear their children in a manner and setting of their own choosing, and in spite of the generally lackluster support and at times active opposition of the medical community.
Through its gentle, family-centered atmosphere, home birth also promoted and left ample room for self-healing in other ways, and thus encouraged me to explore subtler and less aggressive modes of treatment in my medical practice as well. With background and interest in biochemistry, I naturally gravitated to the study of plant and folk remedies, and soon began combing through old herbals, learning to identify various local species, making infusions, poultices, ointments, and suppositories, and trying them on myself and my patients. In these investigations my principal mentor was Hanna Kroger, an old German woman who had emigrated to the States after the War, owned a health food store in town, and had a large, devoted following that included young and old alike. Bothered by a broad range of ailments, the customers she knew and trusted would follow her into a small back room, where she often dowsed with a pendulum for a variety of energy disturbances, and prescribed treatments that were specifically tailored to fit them, and consisted of vitamins, herbs, supplements, and even homeopathic remedies, which I first heard of in her shop. At times she would also send saliva and/or hair samples to an even more aged colleague in Albuquerque, who claimed that she could detect trace amounts of toxic wastes, parasites, and other pathological residues by using some kind of radionic or magnetic device known only to herself.
Although most of what Hanna did seemed like hocus-pocus to me at the time, she also introduced me to the whole realm of esoteric phenomena that intuitively I knew must exist but had never directly witnessed or experienced myself. Whenever I tagged along with her, she would show me things that I couldn't believe or understand, yet stimulated me to imagine what the world would have to be like if they were true. About two months after giving birth, one of my patients called late at night because of severe abdominal pain that had developed that afternoon, after a trip to her in-laws to show off the baby. On pelvic examination, I felt a taut, bulging mass the size of a tennis ball in the area of her right ovary, which clearly needed to be removed surgically without delay, but before agreeing to go to the hospital she begged me to call Hanna, who only agreed to come after some coaxing on my part.
On entering the room, she went straight to the bedside, knelt by the left side of my patient, and began to pray, placing the palm of her left hand gently on the abdomen over the cyst, and allowing her right arm to dangle by her side. After a few minutes, Hanna's body began to shake convulsively, and I fancied I could sense a current of energy passing up her left arm, across her chest, down her right arm, and out her free hand. Proceeding methodically to the other side of the bed, she then placed her right index and middle fingers on the right pubic ramus, a pressure point for the right ovary, she told us, and pressed down firmly on it, eliciting a scream of pain from my patient that almost catapulted her out of bed, but then gave way to quiet moaning and whimpering for perhaps fifteen seconds, after which she fell silent. Similar pressure on various other points elicited no more than a brief wince or two, after which Hanna rose and left, prescribing nothing more complicated than a molasses douche and a day in bed.
Re-examining her immediately afterward, I was amazed to discover that the pain and the cyst had both completely disappeared, and I can vouch for the fact that they never came back in the two years I kept track of this woman and her baby before leaving the area. Neither before nor since have I ever personally witnessed another spontaneous cure of an impending surgical emergency to rival this one, which left me with the conviction that healing is always possible, even when we least expect it, have no idea what form it will take, and can never adequately explain it by any doctrine, concept, or method, however scientific its foundation.
In 1973, I moved to New Mexico to study acupuncture with Masahilo Nakazono, a Japanese master who also taught aikido and his own version of Shinto, the ancient religion of Japan, based on chanting what he called "the sacred sounds," whereby our earliest proto-human ancestors were said to have expressed and communicated their feelings directly, without the mediation of symbolic language, either spoken or written. While beginning to train a few Western students, he had been chosen to preside over the newly-created State Board of Acupuncture after curing a number of legislators of serious ailments. Much as I revered him as a teacher and healer, his religious practice and authoritarian style always remained somewhat foreign to me, as did his practice of seeing patients one, two, or even three times a week for months at a time, notwithstanding its undoubted usefulness for certain patients who are seriously or gravely ill.
What I most deeply respect and admire about Oriental medicine is its systematic philosophy of the organism as a unitary life principle, operating prior to any subdivision of it into thoughts and emotions, on the one hand, and organs, cells, and molecules on the other. By learning to palpate subtle variations in the radial pulses, using nine positions on each side, a skilled practitioner is said to be capable of assessing the energy state of the internal organs, based on the condition of the "meridians" or longitudinal energy currents on the body surface that are thought to correspond to them. Thereby entirely avoiding the "mind-body problem," acupuncture diagnoses and treats illness uniquely and globally in each patient as a unified bioenergetic system, elegantly solves a number of ancient but still intractable philosophical riddles in the Western tradition, and is capable of curing or relieving illness, and restoring and promoting health on a deeper level and with subtler methods than Western medicine, with all of its heavy artillery, seems capable of or even very interested in. As my introduction to energy medicine, acupuncture continues to open up new paths in my thought and practice, and I will always be grateful to the Sensei and honor his memory for sharing his truth so generously with me.
Not long afterward, I stumbled into homeopathy. After poring over an old text I found in a used bookstore, I got no further than wanting to try Apis mellifica, the honeybee, for a patient who was highly sensitive to bee stings, and telephoned an aged homeopath I'd heard of back East to ask if that would be an appropriate prescription. "Well, sonny boy," he replied in his economical Vermontese, "I think you'd better come to our summer school!" I decided to give it a try, but neither the backwoods state college where the course was held nor the advanced age and semi-retired status of the doctors who taught it augured well for the future of the method. Few of them were still earning a living from practicing what they were telling us, as if the whole generation of active, full-time practitioners that should have preceded us had never materialized. The course itself lasted only two weeks, after which they simply turned us loose to practice what we had learned. With no full-time schools, clinics, or teaching hospitals to its name, and very few retail pharmacies to send patients to, it was a stretch to imagine that homeopathy in America would survive much longer.
Yet from the moment I entered that class, I knew that it was exactly the approach I had been looking for, and that I could happily devote the rest of my professional life to studying and practicing it. Long before I'd taken remedies myself, or seen them work in a patient, it made sense to me as both a philosophy, a coherent body of thought with basic assumptions that rang true, and the detailed, systematic methodology that followed from them. Most of all, it showed me a better way of doing what I was already trying to do, first making the diagnosis, but then putting it aside, and allowing the unique features of patients' symptomatic responses to suggest the most appropriate treatment for them. Reinterpreting illness as the attempt of the organism to overcome whatever is keeping it out of balance, homeopaths look for the most characteristic and distinctive features of the total symptom-picture in each individual patient, and administer ultramolecular doses of the one medicine that most closely matches that ensemble to focus and enhance the self-healing process that is already under way.
Far from repudiating conventional medicine because of it, I chose homeopathy because it charted a clearer path through the hidden risks and self-imposed obstacles that had kept me from practicing medicine at all for such a long time. As to whether such an eccentric approach really works, I can do no better than offer up the whole of my career since then as evidence that it does, having used it more or less exclusively for the past twenty-three years with never a cause to regret it. My first patient was myself, waking from a concussion after a head-on collision with a drunk driver, bleeding from a scalp laceration, and in considerable pain from several rib fractures. Sitting erect in the ambulance, I felt dazed but otherwise tolerably OK until the tech deposited me at the ER on a Gurney, flat on my back, helpless, and immobile, the slightest change in position sending stabs of pain through my chest that sapped my strength and will to recover. When my nurse arrived to take me home, I asked her to give me a dose of Arnica 200, a few tiny sugar pellets impregnated with an alcoholic solution of leopard's bane that had been diluted 1:100 200 times, which immediately dissolved on my tongue. Within a few seconds, I managed to lift my bloody shirt over my head and take it off without assistance, an incredible feat under the circumstances, felt no more pain for days, and recovered without further incident.
That first winter, I saw mostly acute illnesses, i. e., colds, flu, Strep throats, bronchitis, and other incidental complaints of pregnant women and their families, who formed the backbone of my practice at that time. Whenever a patient needed medicine, I rummaged around in my books until I found one that seemed suitable, and both of us were often very pleasantly surprised at how quickly and effectively it worked, not only to relieve pain and suffering, but also to impart a feeling of strength and well-being that helped cut short the natural course of the illness. Soon I began trying remedies at births, too, with similar results: at times none, often good, sometimes extraordinary.
One such was the experience of a twenty-year-old woman, pregnant for the first time, who gave birth to a girl after a prolonged second stage. Although well-formed and weighing over eight pounds, the baby was covered with thick meconium, took one gasp, and then breathed no more. After brisk suctioning of the nose and mouth produced only more of the same, I tried and failed to intubate or even visualize the trachea, as the child lay pale, limp, and motionless, with a heartbeat of only 40 per minute, responding feebly to mouth-to-mouth resuscitation, but still unable to breathe on her own. I put a tiny powder ofArsenicum album 200 on her tongue, and almost instantaneously she awoke with a jolt, crying and flailing, her heart beating vigorously at 140 per minute, and her skin glowing pink with the flame of new life. Experiences like these are inscribed for life in every practitioner's mind.
Since 1974, I have practiced homeopathy more or less exclusively, and according to the classical method, which prescribes only one medicine at a time for the whole patient. Those whom I fail to help I refer to another homeopath, if possible, or for conventional treatment when indicated. If practiced conscientiously, the method poses minimal risk of harm, and allows me to develop my skills through experience and to learn and grow at my own pace. Since I can see only as many people as I can see, and learn only as fast as I can learn, most of my patients understand and forgive the fact that expertise is acquired little by little, and at the cost of numerous mistakes and failures. On the other hand, I have also been able to help people heal themselves in many ways and situations that would have been inconceivable to me before.
I am thinking of a 34-year-old woman who came to see me in Boston, long after I had stopped attending births, with a history of severe and at times painful endometriosis since her teens. Already a veteran of four surgeries to remove large, blood-filled cysts from her bladder and pelvic organs, and several courses of male hormones to try to counteract the imbalance, she hoped mainly to restore her menstrual cycle, having long since abandoned any hope of childbearing. While intensely painful at first, her periods had become scanty, "dead," and dark-brown as a result of so many operations and years of hormones and oral contraceptives in the past. In the course of her treatment, they became fuller and richer, and within six months she was pregnant. By the time I next saw her for a different ailment, eight years later, she had produced two healthy children after uncomplicated pregnancies and normal, vaginal births and had remained in good health ever since. While no one can ascribe such an outcome to a remedy or any other agency in precise, linear fashion, my patient has never stopped thanking me for it, which is reason enough to be grateful for a process by its very nature persuasive and catalytic rather than forcible or compulsory.
I can readily understand the skepticism and incredulity in the eyes of my patients when after a long interview I put a tiny bit of "fairy dust" on their tongue and ask them to come back six weeks later. What we call the "Law of Similars" has never attained general acceptance in medicine or among the public at large, and even those of us who use it every day regard it as a mystery, and by no means solved or proven. Still less has anybody ever satisfactorily explained how a medicinal substance diluted beyond the molecular limit of Avogadro's number could possibly have any effect on a patient, let alone a curative one. But the standard argument that homeopathic remedies are merely placebos also cuts both ways. For quite apart from how they do it, the extent to which people are able to heal themselves without drugs or surgery, whether through acupuncture, homeopathy, placebos, faith healing, or the laying-on of hands, correspondingly reduces the need for costlier and more drastic methods and deflates the extravagant promotional claims made for them.
I have never believed or taught that homeopathy is the only way to heal people or even necessarily the best way for everyone. By no means a panacea for all ills, it has substantial limitations of its own, some of them inherent, and others that will need to be reassessed in the light of a new bioenergetic science that is still in its infancy. I practice it mainly because it is the philosophy and the method best suited to my own particular history and personal style. Even when it is better understood, I seriously doubt that it will ever become the dominant mode of scientific treatment for this or any other society, and indeed, if it did, I suspect I might begin to lose interest in it. What I mean is that nobody has all the answers, and everybody has some of them, so it makes the most sense for us all to work together, by discovering our several truths wherever we can find them, and by celebrating beauty for its own sake.