My Father

“It is, I believe, the greatest generation any society has ever produced.”                          (Tom Brokaw, 1940 --) 

My father was born in Kansas City on May 4^th, 1919.  He was the middle of three sons born to immigrant parents.  His mother died when he was 5 years old.  He subsequently moved from town to town as his father went from job to job.  When his father couldn’t afford otherwise, he and his brothers were sent back to K.C. to live with aunts and uncles. 

During the Great Depression, when my father was 16 years-old, he moved to Houston, finding work as a shoe salesman. He discovered he was good at it.  He then briefly attended the University of Texas but had to leave school abruptly in order to avoid trouble from a gambling scheme gone bad. 

He subsequently enlisted in the Army.  He was stationed in San Francisco when Pearl Harbor was attacked.  He applied and was accepted into Officer Candidate School.  He joined the Army Air Corp and completed training as a B-17 bombardier.  It was during his training at Lowry AFB in Denver where he met my mother. 

In the months preceding D-Day, my father flew 25 missions over France and Germany.  Among his honors, he earned the Air Medal, the Distinguished Flying Cross, and the Purple Heart.  He served in a unit that had over 40% casualties.  When on leave, his plane and crew were shot down. 

My father and mother married in Oct. 1944.  Shortly thereafter, my father was honorably discharged from the service.  Back in Denver, he opened Boxer’s Steak House.  He and his older brother ran the restaurant for twenty years. Initially the restaurant did well but began to fail in its final ten years. 

When I was approximately 12 years old, my father sold the restaurant.  A few years later he opened The Antique Trader, finding success in the antique and used furniture business. He was never happier than when he was in one of his stores or at an auction.  The stores were open seven days-a-week.  Unless forced to do so, he never took a day off.  He didn’t want to.  He continued working every day well into his 80’s. 

My parent’s marriage lasted over 60 years, but it was not a happy marriage, at least not while I was growing up. My father was the classic workaholic, though for him his work was his play.

As a young child I remember my father teaching me how to catch a ball and how to ride a bike.  I remember him asking me my spelling words and checking my homework.  As I got older, we interacted less and less.  There were never any arguments or harsh words spoken between my father and me.  But neither were there any meaningful heart-to-heart conversations.  Once, when my father nearly died from an ulcer, he wrote down his feelings about me and my sister, expressing his love.  Ordinarily, he never shared his feelings.  My sister and I were at a loss to know what to do with his new-found demonstrativeness. However, once recovered he quickly reverted to his old self. 

When in High School, or home from college, I would occasionally work at the store driving the delivery truck.  My father would get very short and impatient with me.  The message was clear. I was not going to continue in the family business.  My sister and her husband would fill that role.  I was expected to continue my education. 

I tried at times, in his last years, to engage my father in dialogue.  My effort was hindered by his refusal to wear a hearing aid.  I would start the conversation. “What did you say?”, was his usual response.  I had some evidence to suggest that his poor hearing was, in part, selective and that he could hear better than he let on.

My father was largely about three traumas; the death of his mother, the depression, and the war.  He learned to build a protective wall, always in control and never allowing himself to get too close. He could be very generous, but he could never accept the generosity of others. He was afraid to love and was uncomfortable being loved. He was self-contained, finding fulfilment in his work, but not in his family.

My father’s wall could not be breached, not by me.  He died October 15^th, 2012.

ADHD and Medication

I wear glasses.  As far as I know, my eyes are healthy. They are not sick or diseased.  However, I am significantly myopic and must wear my glasses in order to function effectively.  My glasses are a tool that makes my life much more manageable.  However, my glasses don’t do my work for me.  I must still do that.

Many times I’ve talked about my eyesight and my glasses to children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and who are about to begin medication. I point out the parallels, comparing my near-sightedness to their poor focus, comparing my glasses to the medication they will soon begin taking. I explain to them that, as far as I can tell, they are healthy.  They are not sick or diseased.  However, they cannot focus very well and like my glasses there are medicines to help them to function more effectively.  Medications are a tool given to make life, especially school life, much more manageable.  But, as with my glasses, I remind kids that they still have to put forth the effort. Medication may help to improve attention, but little else.  Making good choices, having a good attitude and working hard is up to them.  Medication may help to make it easier to complete the task, if they so desire, but it never does the work.

As a father and grandfather, the decision to prescribe medication was never made lightly.  I knew of many children whose lives were transformed for the better with the proper use of medication.  However, I knew just as many children who did not need medication or who did poorly when medication was tried. I saw that the use of medication required more than adherence to “evidence-based” algorithms. Rather than get trapped into the polarized and politicized view that medication was either wonderful or awful I knew that each child had to be carefully, meticulously evaluated. When all the information was gathered and considered, I then would ask myself, “If this were my child?”

I remember diagnosing a 5^th grader with ADHD and starting him on medication.  A few weeks later he came to my office excited to tell me how school was going.

“Dr. Boxer, it’s been great!  I’m getting my work done.  The teacher’s not yelling at me any more.”

I smiled and said, “That’s great.”

He then looked at me, pointed his finger and said with a serious expression, “But Dr. Boxer, I want you to know something.”

“What’s that?”

“Dr. Boxer, it was one-tenth the medicine and nine-tenths me.”

I asked him to explain.

“Well, Dr. Boxer, the medicine helped me to sit still and pay attention, but I still had to do all the work.”

I nodded and told him, “You’re right.”

Often there are misconceptions or magical thinking associated with medication.  Some parents and children come hoping that medication will make the problems go away. Some come expecting a fix or a cure.  However, at least for ADHD, if improvement is to occur, it is both the medication and the patient effort.  One-tenth to nine-tenths is about the right ratio.

Very Interesting

“My experience is what I agree to attend to.  Only those items which I notice shape my mind – without selective interest experience is an utter chaos.”  (William James, 1842—1910)

Once-a-year I taught an interesting class, a class about ‘interesting’.  It started when I became aware how often I heard that word come out of the mouths of medical students and trainees.  “Dr. Boxer, I have an interesting case to discuss.”  I became interested in ‘interesting’.  I heard the word so often that I figured that it must mean something very important, it being used so frequently by so many.

Tell me you have an ‘interesting case’, and you’re telling me to pay attention.  I am about to hear something good, something worthy of my time and reflection. You’re also reassuring me of your consideration.  You would never take up my time with something mundane or boring. Tell me that something is ‘interesting’, I will likely invest my time and mental energy.  Actually, if you tell me that something is 'interesting', you are hoping I will find it to be so.  You may or may not.

‘Interesting’ has a positive valence but is not final judgment.  If it is ‘interesting’ it is worthy of attention, observation and scrutiny, but it does not predetermine good or bad, right or wrong.

Calling something ‘interesting’ creates a dichotomy.  If there are interesting cases, there must also be uninteresting cases. Maybe there is not a dichotomy but a spectrum from most- interesting to least-interesting.  Of course, that opens the possibility of an inverse spectrum, least-boring to most-boring.

Is ‘interesting’ an inherent feature of the observed or a subjective impression of the observer?  Answer, yes.  What makes something interesting?  Answer, multiple factors:

·         Biology, including instinct, intelligence, talent and temperament, factors into what is selectively interesting to us as humans.

·         Psychology, factors into what is selectively interesting.  Called ‘confirmation bias’ we select that which supports our beliefs and exclude that which refutes or challenges us to think otherwise.

·         Development plays a role.  What is interesting to an infant is different from what is interesting to a toddler.  What is interesting to an adolescent is different from what is interesting to an adult.

·         Experience, the cumulative narrative of our past, our family, our education, and our social environment, factors into what, for us, is interesting.

‘Interesting’ has a physiologic component, a state of arousal and an orientation towards something. ‘Interesting’ has emerged evolutionarily.   It might be said that the sun is interesting to a plant. I know from personal experience, that a mayfly is interesting to a trout.  Certainly, a ball of yarn is interesting to a cat. Advertisers are experts at identifying and exploiting that which is interesting to the human species.

Humans, especially, seem vulnerable to disorders of interest – too much, too little, inconsistent, misdirected, inappropriate, or pathological.

The world is far too vast, far too busy, and far too complex to be experienced fully.  Our lives our governed through the lenses of selective interest.  We ask, we listen, we see, and we understand according to our interest.  To avoid “utter chaos” we, by necessity, select and then filter out the rest.  Think about it.  It’s really kind of interesting. 

Nostalgia

Nostalgia is an interesting word.  It comes from the Greek roots, nostos meaning a return home, and algos meaning pain, suffering.  Originally, it was used to describe severe homesickness.  Over time, it has evolved to mean a bittersweet yearning, usually associated with fond and idealized memories of the past.

It’s almost June, almost the beginning of summer vacation.  It’s a time when I recall memories of summers past, years spent at summer camp, and I am filled with nostalgia. From age thirteen through age twenty-three, my summers were spent at the J Bar CC Ranch Camp, just outside of Elbert, Colorado.  I began as a camper.  My final year was as the camp’s assistant director.  In between are most of my memories of adolescence.

Ironically, the first week of my first year at camp I suffered from nostalgia, in the original sense of the word.  At night, I buried my head under my pillow homesick, ashamed and afraid of being teased.  That phase of nostalgia quickly passed.  For most of the nine years that followed, I looked forward to being at camp from the beginning of June through the end of August. It was a safe place to be and to grow.  Now, my nostalgia is that bittersweet yearning, the lovely memories of a time long past, the experiences that were my transition from child to young adult.

I think of camp and I am flooded by a collage of words and phrases, words triggering my memories and emotions, each calling to mind a story. Horseback riding, swimming, archery. Hikes up Pike's Peak. Camp outs. Campfires, music sung, guitars played.  Star-filled skies. My first ‘girlfriend’. My first dance.  The mess hall, the rec hall, the corral. Capture-the-Flag.  Hailstorms, often followed by rainbows.  Meadows filled with wildflowers.  The sound of pine trees in the wind.  The smell of pine trees in the rain.  The final campfire of summer. Old friends.

Not loving my first year of medical school, I did my second year of medical school over two years, while working half-time as assistant director of the camp.  I was trying to decide whether-or-not to continue my medical training or to make camping my career.  As assistant director, I became involved with boards and budgets, hirings and firings.  Camp was no longer camp.  It was a job.  I returned unambivalently and fulltime to medical school, never regretting my choice. No doubt, though, my years of camp counseling influenced my eventual decision to become a child psychiatrist.

I have a strong yearning to return to camp, just once more, to walk the land that I remember so well.  To this day I can clearly visualize the terrain, every hill and every valley.  Once, many years ago, I visited camp with my wife.  Prior to that visit, I told her what a beautiful place it was.  My wife saw it and was not nearly as impressed.  Yet, she found my comment reassuring.  I told her, “That which is beautiful is not necessarily loved, but that which is loved is necessarily beautiful.”

The Name of the Rose

“Perhaps the mission of those who love mankind is to make people laugh at the truth, to make truth laugh, because the only truth lies in learning to free ourselves from insane passion for the truth.”  So says the protagonist Brother William to his young pupil Adso as they survey the monastery and its great library burned and in ruins.

I recently reread The Name of the Rose by Umberto Eco.  Published in 1980 this historical novel and murder mystery is a difficult read, but worth the effort.  The story takes place in the early 14^th century within the walls of an Italian Benedictine monastery.  It was a turbulent time in the history of Christianity.  There was contested leadership within the church and a direct challenge to established church authority with the rise of monastic orders.

The protagonist, Brother William, is a Franciscan monk called upon to investigate a series of murders that occur within the walls of the monastery.  William, once an inquisitor, no longer relies upon the inquisition’s harsh methods. Instead, his tools of investigation are logic and philosophic inquiry.  William is mentor to a young Benedictine novice, Adso, in whose voice the story is narrated.

Woven into the story's multiple mysterious murders are a series of theological debates, told as they would have taken place in the 14^th century.  Religious ‘truths’ were passionately argued. One man’s truth was another’s heresy.  To be on the wrong side of an issue could mean death.  To be on the right side, especially if martyred, could mean sainthood.

One debated ‘truth’ concerned monastic vows of poverty.  For those taking such a vow, this was their measure of faith and piety.  Not so according to established church leadership, believing that ascetic vows posed a threat to church wealth, power and authority.

Within the monastery was a great library.  There was debate about the purpose and usefulness of the library. Some saw the library as a great repository of knowledge.  Others argued that God’s words, as revealed in the Bible, stood alone.  Books were extraneous, the product of man’s arrogance, man’s sinful pride in cleverness and knowledge.

Laughter itself was cause for dispute, one side seeing laughter as a joyous acknowledgement of God’s goodness, the other side arguing that laughter was derisive and frivolous, making light of man’s sinful state, working in service of the devil.

In the novel, religious ‘truths’ were argued with fatal results  The murders and motives solved, William warns his young pupil, “Fear prophets, Adso, and those prepared to die for the truth, for as a rule they make many others die with them, often before them, at times instead of them.”

Umberto Eco, writing with imagination, scholarship and eloquence crafted a story that reminds us of the dangers and cruelty of dogma, that "insane passion for the truth.”  And he reminds us of the necessary corrective power of laughter and humor.

In another time and another place philosopher Isaiah Berlin warned, “It is a terrible and dangerous arrogance to believe that you alone are right . . .”   I couldn’t have said it better.  Umberto Eco did.

Medicine and Philosophy

“It is a lame creature who calleth himself a physician and he be void of philosophy and know her not.”  (Paracelsus, 1493—1541) 

My formal background in Philosophy consisted of one undergraduate Intro to Philosophy course, which was the most numbingly boring class I ever took.  I was assigned two papers for that class, one on Hobbes and one on Kant. The only all-nighters I ever pulled in college, were writing those awful papers.  I agonized over those papers, knowing as I wrote them that they made no sense. I recently reread them. They still make no sense.  Yet, I got an A in the class which only confirmed for me, at the time, that Philosophy was a lot of bull.  Philosophy was off my radar for many years thereafter.

It was during my psychiatry residency, I realized there was a gap in my education, a gap that my background in science and in psychology could not fill.  I wanted to better understand my patients.  I wanted to know the degree to which my patients had no choice but to do as they did. Was their behavior determined?  Where there is no choice, there can be no blame. Or, did they have choice, free will?  Where there is choice, there is accountability.  And I wanted to be consistent.

I wanted to know more about the mind and the brain.  How does thinking arise from matter?  I wanted to know more about human nature.  Are we inherently good or evil or neither?  I wanted to understand how we know what we know.  What can we know for certain?  What makes for a good and meaningful life?  An ethical life?  After all, as Socrates admonished, “the unexamined life is not worth living.”  My interest in philosophy was rekindled.

This winter I will be back in the classroom, teaching a new course, Medicine and Philosophy, to a group of senior medical students.  For most of them, it will be their introduction to philosophy. I will look back on the experience of my introductory course and try not make the same mistakes. My task ahead is to make philosophy as meaningful, interesting and exciting to a group of skeptical medical students, as it is now for me.

The introductory class I’m planning will not be a historical survey of philosophy nor will it be taught didactically.   My class will be constructed on two premises. First, everyone is a philosopher.  Second, philosophy is not passive, it is an activity.  In class, we will do philosophy.

Everyone is a philosopher.  Some just need help putting their beliefs, their values and their opinions into words. The first task in class will be for each student to begin to articulate their philosophies. Once that has begun, we will proceed with the work of philosophy.  I will provide some basic tools, tools that date back 2500 years to the time of Socrates and Plato, and they will be asked to critically examine, refine and sharpen their thoughts.

The over-arching goal of this course Medicine and Philosophy is for students to develop and expand their critical and creative reasoning, and along the way, learn to apply the critical and creative thinking of philosophy to sound medical practice.  I want no student physician in my class to ever be accused of being a lame creature, void of philosophy.

Philosophy comes from the Greek roots phylos meaning to love and Sophia meaning wisdom. I will teach a class about wisdom and hope they love it as much as I.

That’s lesson plan one.  Only fifteen more to go.

An Educational Challenge

Several years ago, I taught a course on parent guidance to a group of child psychiatry Fellows.  This was a bright group of students, all of whom were in their 4^th or 5^th year of post-doctoral training. 

I assigned them a task.  I asked them to pretend to write an advice column for a parent magazine, a 400- to 500-word column, sharing their views and opinions in response to parent inquiry.  For their first column, I asked them to respond to a parent seeking advice about spanking. 

A week later, I collected their columns.  I read them and, for the most part, thought they were dull and mediocre.  My wife read them and thought there was something not quite right about them.  After doing some investigation, she discovered that 7 out of 8 papers were written almost word-for-word from articles found on-line. 

Initially I was angry and disappointed.  I let the students know that if they had been on faculty, they would have been fired for plagiarism.  If they had been in a graded course, they would have failed. 

The students thought I was being unfair.  After all, if I had asked them to write a column about the side-effects of Paxil, wouldn’t they have Googled side-effects of Paxil in order to get the information?  I tried to explain that they were comparing apples and oranges. I didn’t ask for a recitation of facts about spanking. I asked them to articulate an opinion, their opinion. 

As I talked more with the students, I began to understand why they struggled with my task.  I was reminded that they worked in a high-pressured academic environment in which time was short and demands excessive.  Some admitted to going on-line as a short-cut, a time saver. I was reminded that much of their science and medical education, preceding my class, was done on computer while trying to learn massive amounts of information. It was their reflexive response to seek out the right answers on-line.  I was reminded that these students functioned in an environment where they were under constant supervisory scrutiny. They were afraid to be wrong. To be creative and original was to risk being wrong. 

As a teacher, that class was an awakening.  I became aware of a potentially serious educational pitfall. For many years, my student’s education had not encouraged the formulation and expression of opinion.  They had neither the experience nor the confidence to put their own thoughts into words and think that it could be okay. 

I have shared my cautionary story with teachers of all grades and levels, reminding them that, in this age of information, we must conscientiously teach critical and creative thinking.  Every student deserves time to think, to play with ideas, to develop opinions.  No right or wrong.  Computers off.  No Googling allowed.