A Disease With Perks

… but you have to look for them.

by Alan Sanderson, MD

I have been thinking about cancer lately, for two reasons. The first was the story I wrote about my aunt Steffanie. The second reason is a blog I recently came across which is written by one of my neighbors, Christie Perkins. She has stage IV breast cancer, and has been really fearless in writing about her experience. Her blog is called “How Perky Works,” and it is a case study in unsinkable optimism. Spend an afternoon with her blog; I promise you won’t regret it!

Cancer lends itself to all kinds of lessons, and the pages of Christie’s blog are full of them. She teaches about how to accept and acknowledge the sadness of a serious illness and still choose happiness. Again and again and again she describes a setback in her illness, and how it tears at her emotions, but she works through it and comes out ahead, with a smile from ear to ear. And you can’t help but smile with her.

So what are the perks of having cancer? Read her blog to find out! I will point you to one example, which is a list of the Top 10 Perks of Wearing a Baby Blue Mask. (She had to wear a surgical mask for a few weeks because her immune system was really suppressed from the chemotherapy.)

Christie is a teacher and a mentor, showing us by example how to rely on God’s grace. Sometimes extreme examples clarify the boundaries of a problem, and cancer has a way of taking us to extremes. As I have said before, disease can be one of God’s most powerful refining tools. Continue reading

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Forced Family Fun (In a Jar!)

A few thoughts about the importance of families

by Alan B. Sanderson, MD

Last week my wife said that she was getting tired of the same old family activities and wanted to change things up a bit. She compiled a list of a few hundred activity suggestions, printed them on paper, and then cut them into individual strips of paper which we folded up and put in a big ceramic urn. Then on Monday night during our Family Home Evening (more on that later), we opened the jar and pulled out one strip of paper. The rule was that we had to do the activity written on the paper that night, if at all possible. We call this game “Forced Family Fun (In a Jar!)” because that sounds better than “Forced Family Fun (In an Urn!)” The first strip of paper we pulled out said, “Visit the place where Dad works and get a tour.”

IMG_20170904_193637270I said, “Alright, everyone. Let’s go!” and we packed into the van and drove to the clinic. By the time we arrived the baby was asleep, so ironically my wife sat in the van while the older kids came with me for our Forced Family Fun (In a Jar!) activity. It was after hours, so no one was in the clinic but us. After a quick tour I had one of my kids sit up on the exam table and I demonstrated a neurologic examination. This went over well, so we went into the other room and I performed a quick nerve conduction study on another kid, who laughed every time his hand twitched, and a neuromuscular ultrasound examination of another kid’s median nerve. I considered doing electromyography on one of them, but I thought better of it and instead did the needle examination on my own hand muscle. The kids were duly impressed with my specialized geek skills, and went home with a better appreciation of what I do every day at work. Even the ones who were initially grumpy about the activity had to admit that they enjoyed it. Continue reading

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Where Is the Pavilion?

A story of family faith and tragedy.

by Alan B. Sanderson, MD

My grandfather wrote in his autobiography: “Sometimes a storm seems to blow up out of nowhere, a tiny cloud on the horizon which brings rain, hail, and winds so fierce that everything is devastated in its wake. So it was with Steffanie’s illness.”

Steffanie and Ivan L

Steffanie with her father, 1947.

My aunt Steffanie was the third of six children in her family. They lived in Orem, Utah, in the shadows of the Wasatch Mountains. She was a kind and helpful youth, a natural teacher, and was famous for making delicious brownies. Her temperament was described by her mother as “happy, gentle, fun-loving,” and “the joy of our home. I often marveled to think, ‘This child is pure 100% joy!'”

Steffanie and Doll

Steffanie, about age 2.

Steffanie’s father, my grandfather, had served overseas in World War II and had missed important parts of the early childhood of his two older boys. Consequently he developed a special bond with his third child, Steffanie, whom he saw grow up from her infancy. “How he doted on her!” wrote Grandma. “If ever I saw two kindred souls.”

When Steffanie was eleven years old her mother had a serious and prolonged illness. During this time Steffanie baked a large batch of bread every other day and picked up the slack in doing all of the household chores. A few years later her mother said to her, “I know your young arms became weary with that heavy kneading and all the work of a large family, but never have I heard you complain or refuse to do what was asked. Instead, you took pleasure in doing it all as well as you could, in making good meals to surprise your family.” Continue reading

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Is Life Fair?

“The Lord gave, and the Lord hath taken away; blessed be the name of the Lord” (Job 1:21).

by Alan B. Sanderson, MD

Diagnosing brain death is never an easy experience, even when the medical facts are relatively straightforward. The old fashioned way to die is to stop breathing, have your heart stop beating, and to cease neurologic function, usually all at about the same time. A primary insult to one of these three functions quickly leads to completion of the other two if no intervention is made.

But modern medical technology has made it possible to temporarily separate these mechanisms from one another. Ventilators can preserve respiratory function to a remarkable degree, and there are also many ways to support and maintain circulation. A body with a severely damaged brain may be artificially supported by intensive medical care; it is possible to temporarily maintain respiratory and circulatory function when there is no evidence of brain survival. What to do in this situation has presented medical practice with an ethical dilemma which is unique to our age of the world. Over the past few decades the concept of brain death, or “death by neurologic criteria,” has emerged to help doctors and families determine when further supportive care is medically futile (which is another concept fraught with ethical difficulty). The main problem is that demonstrating that there is no brain function is not as simple as determining that the heart is not beating, and the criteria are much harder to explain to families. Understanding the concept of brain death and how it is diagnosed requires a fair amount of knowledge about neuroanatomy and neurophysiology, which most people don’t have.

Some years ago I had a patient who was a middle aged-man with a wife and teenage children. When I first walked into the hospital room with my team of residents and medical students his wife was sitting at his bedside reading him a novel out loud. He had more tubes and IV bags and medical devices than I think I have ever seen on one person at a time. This man had suffered a cardiac arrest, and heroic efforts had been made to support his heart, lungs, and kidneys. Unfortunately his brain did not tolerate the cardiac arrest and subsequent medical instability, and I was called to help determine just how damaged his brain had been. Continue reading

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Firsthand Knowledge

Some things are best learned through experience.

by Alan B. Sanderson, MD

I’m a firm believer in subjecting myself to the same things I put my patients through – within reason, of course. (Admittedly this would be a harder ideal to aspire to if I were a surgeon.) A few months ago I was touring the new MRI machine at the hospital where I work. While I was there the MRI technologist asked, “Hey, Dr. Sanderson, you want to get scanned?”

And I said, “Yeah!” I was on my lunch break, so I had time to do the whole brain MRI protocol. That was my first time in an MRI machine, and it was a fascinating experience. The machine was much louder than I expected, and that hole in the machine starts to feel pretty tight after about 30 minutes. Now I understand why so many patients have a hard time holding still inside the MRI scanner, and why some of them won’t even get inside it to begin with.

The MRI was one of my more recent experiences, but I have been doing things like that since medical school when my classmates and I practiced doing blood draws and ultrasound scans on one another. In residency and fellowship we would practice doing nerve conductions and electomyography, and I have long felt that a trainee should not be allowed to do needle EMG studies on patients until they have had it done on themselves.

Perhaps my most memorable experience with volunteering to have medical procedures was when I donated cerebrospinal fluid for a research study, and ended up with a post-LP headache for 10 days. At that point in my residency I had already performed dozens of lumbar punctures, and had seen several complicating headaches, but I didn’t expect it to happen to me. I didn’t complain, though, because I figured the experience would bring me good karma and would help me to understand and empathize with my patients. It also got me out of two overnight call assignments and a day of resident’s clinic. The headache wasn’t that bad, because the pain would go away completely if I laid flat for long enough. My wife and kids loved having me at home lying on the couch for 10 days, and my kids joined me for mealtimes on the floor. I read the book of Hosea a few times, and I also read most of Diagnosis of Stupor and Coma by Plum and Posner.


Mealtime on the floor with kids when I had a post-LP headache.

Continue reading

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Unspoken Wishes

“In the quiet heart is hidden sorrow that the eye can’t see.” – Susan Evans McCloud (from “Lord, I Would Follow Thee“)

by Alan B. Sanderson, MD

I learned an old piece of wisdom when I was in medical school: “When all else fails, talk to the patient.” The first day I heard this saying I laughed, appreciating its cynical and sardonic humor, but I did not foresee how much this simple maxim would one day help me.

About halfway through my medical internship I had to spend a month working on the nephrology service, taking care of patients with severe kidney diseases. Most of them were in the hospital due to some complication related to hemodialysis. At the start of the month I looked over the list of patients on the service, and one of these was an elderly woman who had a serious infection in her dialysis catheter. This infection was recurrent despite powerful antibiotics and multiple attempts to replace her catheter. This poor woman had a very long and complicated medical history, including a major stroke, and we were informed that she had severe dementia so that she could not meaningfully interact with people. It was pitiful to see her, lying in bed looking ill and unable to talk. Sometimes she would look at me as if she wanted to say something, but no words would come out of her mouth. Once she even grabbed my hand, but I couldn’t tell what she wanted and I didn’t have time to find out, so I had to just walk away.

My senior resident and I worked diligently to treat her infections, and after may days all of her blood cultures were clear. She was ready to receive a more permanent dialysis catheter, which was a procedure done in the Interventional Radiology department, and as soon as this was done she would be ready to leave the hospital. But that afternoon I received a phone call from Interventional Radiology informing me that she had refused the procedure. Continue reading

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Christmas on Call

Be grateful for every Christmas you can spend with your family.

by Alan Sanderson, MD

This month I made a recording of “Away in a Manger” with my wife and kids. This is one of my favorite Christmas carols because the lyrics contain such a heartfelt prayer for the Lord’s love and presence to be felt in our lives.

You can download the recording here.

I have lately been remembering my first Christmas as a resident physician, when I had the assignment to do an overnight call on Christmas Day. This was in the middle of my medicine internship, and I was working in the cancer hospital that month. The other residents on my team felt bad for me because I had to be on call, and let me come in a bit later in the morning so that I could open presents with my family before coming to the hospital. This was a Christmas like no other one I had ever experienced.

Earlier that month I had heard a story about Dr. Michael DeBakey, one of the pioneers of heart surgery. He was rounding on Christmas Day with one of his residents, and complained that none of the medical students were there rounding with them. “Don’t they want to learn from the great Dr. DeBakey?” he asked. His resident replied, “Well, Dr. DeBakey, they are all at home celebrating the birth of another Great Man.”

You would imagine that most hospitalized patients would rather be home on Christmas Day than in the hospital. We actually had discharged a lot of people home on Christmas Eve that normally would be considered too sick to go home. Those left in the hospital were some of the sickest people in the city, and these were the ones that I took care of that night. Continue reading

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Liberty and Tolerance

You cannot claim freedom of conscience for yourself without also allowing it to others.

by Alan B. Sanderson, MD

I can remember a time during my medical training when I was singled out in a negative way because of my religion. It was in the operating room of a smaller community hospital where I was rotating, and I decided to work that day with a surgeon I had not met before.

“Where are you from?” he asked me.

“Utah,” I said.

“Oh, you must be a Mormon then.”

“Yes, sir, I am.”

“Then how many wives do you have?”

I was taken aback, but tried to keep smiling. “Just one,” I answered.

“Just one, huh?”

“The Church has not practiced polygamy for over 100 years,” I explained. But I suspected that he probably already knew that.

He proceeded to quiz me on the details of the procedure we were performing, and on any other tangential topic that came to his mind. If I answered a question correctly he would ask progressively harder questions until I could no longer answer. This is an old ritual in medical education known as “pimping,” which has brought countless medical students to tears and has been the subject of many treatises (my favorite is here). At the time I was a third year medical student with very little experience, and the majority of what I knew about surgery I had learned from an exceptionally boring book that I couldn’t manage to stay awake while reading. Of course I didn’t know the answers to most of his questions, and the more questions I missed the faster he asked them. It was clear that his purpose was not to educate me but to belittle me, and he took obvious pleasure in his task. After a number of uncomfortable minutes, and as the procedure was drawing to a close, he finally acknowledged in bare terms his actual purpose by telling a joke: “What is the difference between a medical student and dog [poop]?” I stared at him in disbelief for a moment before he gave his answer. “No one goes out of their way to step on dog [poop].” Continue reading

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Burning Out and Back Again

Learning to endure for 30 Hours, 30 Days, 30 Years, and Forever

by Alan B. Sanderson, MD

During my medical training I learned that I can do anything for 30 hours, or 30 days. No matter how insanely busy my call night was, I knew that it was only a few hours from being over and that I would be able to sleep like the dead once I got home. And no matter how intolerable my work assignment was that month, I knew that I was just a few weeks or a few days from moving on to a new assignment the next month. I lived my life from call night to call night, and from monthly rotation to monthly rotation, trying to see or at least imagine the light at the end of the tunnel when things got really dark. But along the way I learned that the tunnel never ends. What I thought was the light at the end was really just a window, and the tunnel seemed to keep going on forever and ever and ever. How long was it? When I graduated from fellowship and started my first real job I tried not to think about that question. I knew I could endure for 30 hours or 30 days, but could I do this for 30 years?

Last year I wrote about my wrenching decision to move away from my first job (see Best Efforts and Highest Priority). My wife and I wanted to strike a better balance between my work demands and my time available for family, and I’m happy to report that this move has turned out to be a good one for us. At the time I moved through my job search intuitively, not really knowing what I was doing but trusting that the Lord would guide me to make the right decisions. I trusted him to help me because I know that he loves me and that he wants to help me. Our decision was guided by the hand of Providence, and I feel like he has led us to our Promised Land. The thought of staying here and working at this job for the rest of my career makes me happy, and I have none of the burned-out or deflated feelings I used to have when contemplating the future of my career.

Occupational burnout is a form of psychological stress in which the sufferer feels distress, exhaustion, and decreased motivation. Workers who experience burnout tend to develop ineffective coping mechanisms such as cynical attitudes, compassion fatigue leading to empathic failure, or substance abuse. Health care workers have very high rates of burnout when measured using standardized scales. A 2014 survey of physicians found that over 50% exhibited at least one sign of burnout, which is higher than the burnout rate in the general US population, and higher than a physician survey from 2011  (see the American Medical Association info page). I was not surprised to find that my own specialty was above the average, with nearly 60% of neurologists experiencing burnout. Burnout is a subject that all doctors are intimately familiar with, but few seem to really understand it. We all have colleagues who are hopelessly burned out, and we all know what it feels like to keep working despite having no energy reserves, but we don’t really talk about how we feel because that would be a sign of weakness. Continue reading

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“[We] came to believe that a Power greater than ourselves could restore us to sanity.” –(The Twelve Steps of Alcoholics Anonymous, step 2)

by Alan Sanderson, MD

This week I received a letter from Dr. Vivek Murthy, MD, MBA, who is currently the United States Surgeon General. In fact, every doctor in America was sent the same letter, and this is the first time in history that a Surgeon General has reached out individually to every physician in the United States. What public health crisis was so important as to warrant this historic action? Was it the Zika virus? Was it heart disease or cancer, the top two causes of death in the US? It was none of these. His subject was the opioid epidemic, a problem caused largely by our profession’s chronic mismanagement of pain. His letter states:

“It is important to recognize that we arrived at this place on a path paved with good intentions. Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely. This coincided with heavy marketing of opioids to doctors. Many of us were even taught – incorrectly – that opioids are not addictive when prescribed for legitimate pain.

“The results have been devastating. Since 1999, opioid overdose deaths have quadrupled and opioid prescriptions have increased markedly – almost enough for every adult in America to have a bottle of pills. Yet the amount of pain reported by Americans has not changed.”

(The full text of the letter can be found here: TurnTheTideRx.org.)

Early in medical school I was taught in a memorable lecture that it is shameful for a doctor to let a patient suffer pain. We were instructed to open the flood gates and bathe our patients in the sweet balm of narcotic goodness they needed. (The lecture was a bit more nuanced, but that was the very clear take-home message.) A year or so later during my clinical rotations I began to see firsthand a much darker side of the picture: drug-seeking addicts with insatiable appetites for controlled substances, manipulating every relationship with the goal of getting more drugs. I have seen how addiction can poison doctor-patient relationships in every specialty I rotated through in medical school and residency, in hospitals, clinics, and emergency rooms, and countless times during my career in neurology. Continue reading

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