13

It’s Not the Disease

I’M JUST A PATCHER-UPPER,” Phil says about his work as a neurologist.* “I mean, I’m like the shop mechanic. You come in and there’s something wrong with your car and you want me to fix it. I may tell you I don’t find anything very wrong with it, or I may tell you that it needs a minor overhaul, or I may tell you that there’s a serious problem, and we have to investigate further, and that I have to keep the car in the shop—or you in the hospital—longer. These are the things that I do.”

Although Phil is one of the smartest guys I’ve ever known—when we graduated from Erasmus, he received full scholarship offers from both Princeton and Cornell—and though the list of his honors, achievements, and publications is long and impressive (he was chief resident in Neurology at Bellevue, chief of Neurology at Denver General Hospital, chief of the Neuroscience Division at St. Anthony Hospital in Denver, et cetera), he remains so modest, blunt, and direct—so boyishly unsophisticated and unpretentious—that one can be fooled by his plain speech and unassuming manner into not recognizing just how brilliant and insightful he is.

What I did with Phil on my first visit in 1988—going on rounds with him at hospitals, and spending the rest of the day with him in his office—I have done the other half-dozen times I’ve spent with him in Denver. He introduces me to patients, family members, and staff, as a friend from high school who is a writer, and he always asks—Jerry does the same when I spend days with him—if it’s all right for me to be present during their talk and/or examination. We usually start the day on the intensive care unit at the Trauma Center, where most of the dozens of patients I have seen are unconscious, suffering from major head injuries, and, usually, from severe damage to various limbs and organs. The majority of the patients are young, often in their teens, and the majority of these young people are in the hospital because they have been in car accidents. Several times, after he has examined a patient and reviewed test results, when the patient asks what he or she thinks is the problem, or its cause (“If it’s not carpal tunnel, Doctor Yarnell, what could it be?” a woman has asked earlier on this day), I have been surprised at the easy way he simply shrugs, and, without missing a beat, says, “I don’t know.”

Or—this to another patient during afternoon office hours—“There are some abnormalities in your hand, thumb, and finger, but I can’t make a diagnosis.” He will, then, as with this woman, discuss what might be going on, and when, at the end of the visit, he records his notes into a tape recorder, he invites the patient’s collaboration. “Now listen to me, Shirley,” he says. “I’m going to talk about you and I want you to correct me. I’m going to talk about your illness.”

“I could confirm—yes—” he tells me afterward, “—but I was no help to the lady.”

“Because neurology, you see, is where cardiology was maybe forty years ago,” he explains. “When I was in medical school we didn’t have intensive care units. There was no treatment for a severely damaged heart other than digitalis. Bypass was just in its infancy. The heart-lung machine had a very high mortality rate, and there was no transplantation.

“So all these things are what we’re trying to find for the brain. But we’re in our infancy. In cardiology, if you have an abnormal rhythm, Rich may put in a pacemaker. If you have an abnormal brain rhythm, we give you some medicines to try to stabilize it, but we don’t have a pacemaker for the brain.

“No one really has a good way to make the brain heal—it’s the great mystery.* We don’t have the antibiotic that cured pneumonia. We don’t have an aid like portable oxygen—I mean, you see people carrying portable oxygen because their lungs don’t work. You don’t see people carrying around anything if they have Alzheimer’s—maybe a note pad, and they make notes. But you need a certain amount of cognition to do that.

“That’s why right now all our efforts are to prevent complications of the injury, to prevent too much pressure on the brain, to prevent inadequate oxygenation of the body. If someone bruises your arm, it may heal, but if you injure the brain in certain places, it can make you paralyzed, and nothing will change that. We don’t have a treatment for coma, no way of making that better, so all our efforts are to make the milieu the best for adequate healing.

“We don’t have a splint for the brain, or a nutrition for the brain.* You can’t say, ‘Take this diet and you won’t get brain problems.’ You could say, ‘Control your blood pressure and you’re less likely to get a hemorrhage, and you probably won’t get a stroke,’ but once you get a stroke all we can do is try to teach you to maximize your life with what you have left. If you’re a paraplegic, my job is to try to teach you how to live the best life you can in a wheelchair, and if anything gets better than that, it’s extra.”

It is late at night, and I am sitting in Phil’s office with him in his home in Greenwood Village, Colorado, just outside Denver. I often think of Phil’s office, a large room he and his wife Barbara added on to the house on the far side of the garage—fifteen feet wide and twenty-five feet long—as being the Brooklyn/Southwest annex of the Victoria and Albert Museum. It is filled to overflowing with an extraordinary assortment of things, including sculptures (bronze, wood, clay), paintings and prints (the American West), family photographs (some life-size), baseball and sports memorabilia (especially about the Brooklyn Dodgers), Judaica (menorahs, the Tablets of the Law), geometric forms (bright yellow plastic cubes, rhomboids, cones, pyramids), encyclopedias, medical books, magazines, skeletons, skulls, spinal cords, geodes, rocks, exercise machines, bicycles, skis, sculptures-in-progress, four-pound plastic jars of chocolate-covered raisins (Phil never eats lunch, but snacks on these all day), and lots of cartons filled with who-knows-what.

His desk abounds with a similar variety of items, along with medical papers, articles-in-progress, partly completed clay sculptures, several dozen model cars and trucks (Matchbox reproductions of racing cars, pickups, forklifts, et cetera), and lots of rocks. Phil has had a long, sustained interest in geology and archaeology (on my first visit with him in Denver, in 1988, he took me out of town to a highway cut on Interstate 70 in order to explain the geology of the region to me), and a passion for sculpture. He has made most of the several dozen bronze sculptures that are in his office and around his home, as well as those in his Denver medical office—abstract creations, along with sculptures of heads, skulls, torsos, hands, spinal columns, brains, children (Sibling Trio), baseball players and objects (Broken Bat), athletes (Women Volleyball Players), and scientific subjects (Showing the Moebius).

(After I reported on my visits with Dr. Haight and Dr. Melman, he sent me a one-and-a-half-inch-tall African sculpture of a man making love to a woman. “Note the straight organ—may it ever be so!” he wrote in an accompanying note; when I called to thank him, he told me he hoped to be able to send a life-size version of the sculpture soon.)

There are also, around the room, more than a dozen different sculptures Phil has made of Phineas P. Gage, foreman of a railroad construction crew in Vermont, who, in 1848, survived an explosion that propelled a three-and-a-half-foot-long crowbar through his head—it entered below the cheekbone and left eye, and exited through the top of his skull. Although, after the accident, a doctor could make his fingers meet if he put one finger through Gage’s cheek and another through the top of the skull, Gage lived for another twelve years without suffering any paralysis or physical disability (other than the loss of sight in one eye). Phil has written about Gage and the personality changes the trauma induced: in effect, Gage suffered the inadvertent effects of a frontal lobotomy, and his case became seminal in the history of neurology for it allowed doctors to begin filling in data on functional brain localization by revealing relationships between physical damage and personality and character change.*

Since my arrival a week before, Phil has done his best to avoid having me tape a conversation with him—he keeps saying that he’s not articulate or good at this kind of thing, that he won’t have much to say that’s interesting—and I recall that at the time of his daughter Elizabeth’s wedding the previous summer I was able to record a conversation with him only by turning on a tape player while the two of us were on our way to and from a local shopping center to pick up pizzas.*

Now, however, when I tell Phil about some of my talks with Arthur, he responds easily

“For a period of ten years, you know, Arthur and I didn’t speak to each other,” he tells me.

I say that I did not know this—they had been good friends in high school and during the years when Phil was at Bellevue and Arthur was getting his doctorate at Columbia, so I assumed they had remained close ever since.

“I was very hurt about what happened,” Phil says. “After he and Marcia got divorced and I was friendly with both of them, he married Paulette, and he heard me once say, or I think he thought I said, or I may have said, that I liked his first wife very much and that I didn’t really know Paulette.

“And also he felt that I didn’t understand his illness, which I didn’t at the time. I didn’t understand that he had had a major posttraumatic syndrome, and that this had led to the divorce.”

I say that Arthur has talked with me about how his experience in Vietnam and its aftermath, along with his analysis, led to profound changes in the way he looked at the world, and that for the first time he came to think of divorce—unthinkable before Vietnam—as an alternative he could seriously consider, even though he knew he was married to an absolutely lovely person.

“Yeah,” Phil says. “So after ten years I just called him up. It was on Yom Kippur, and he and Paulette were living in New York then, and I called to tell him that if in any way I did anything to offend him that I beg his forgiveness, because it was the Day of Atonement, and this is what you do.”

“You did?” I say.

Although, like Phil, I was taught that this was what one was supposed to do on the Day of Atonement—that God could forgive us for sins committed against God, but that only other people could forgive us for wrongs we had done to them—I cannot remember knowing anyone who had acted so literally on this rabbinic law.

“Yeah, I did,” Phil says. “So then he said, ‘Oh let’s get together!’ and when we got back together he told me about what had happened to him after he came home from Vietnam, that it was almost like a psychiatric break, and we became friends again, and it was like we never missed a beat.

“So I feel like I’m in the same relationship with Rich and Jerry now that I was in high school, and I think it’s because we have an underlying understanding of what we are—there’s a common cauldron and experience we share—and each of us has succeeded in some way, and none of us has regrets.

“None of us had fathers who said, ‘Look, you take over the garment business after me.’ We all knew we had to make it on our own. None of us were trust fund babies, and that was reassuring even though I resented it then. Because I look at us now, and I see how we made our way based on who we were then. Everyone did as best he could with what he had, and I don’t think any of us would have changed anything.”

“Nothing at all?” I ask.

“Well, I would have liked to have had less tumultuous marriages maybe—to have been smarter at that, at relationships—marital relationships.”

We talk about patients I’ve seen with Phil earlier in the day and, especially, about Beth Granger. I had last seen Beth in 1988, when she was lying in a bed at St. Anthony Hospital, in a coma. She was seventeen years old (a year younger than my daughter Miriam at the time), a junior in high school—an exceptionally pretty young woman, with long silky blond hair, large blue eyes (closed except when Phil opened them)—and while Phil examined her, tapped on her chest, talked to her and shouted at her, he told me he did not know whether or not she was ever going to wake up.

Phil referred to her as “Sleeping Beauty,” and in the weeks and months following this visit, he would call me, usually on his way to or from work—the way he still does, several times a week—to report on Beth’s condition. (“Remember that girl we saw at St. Anthony—the pretty blond girl in a coma—Sleeping Beauty? Well, this morning…”) What I found especially chilling at the time was the contrast between Beth’s outer condition—her exceptionally serene appearance (the accident had spared her face)—and her inner condition, potentially fatal, about which we knew so little.

More than 50 percent of all traumatic brain injuries in America result from car accidents, Phil tells me, and more than 50 percent of these cases are alcohol-related. In some instances, the patient is the only survivor; some teenagers who are in comas when I visit them do not recover—they either die or are condemned to marginal lives, mentally and/or physically, forever after.

“I could never own a liquor store,” Phil said to me the first time I went on rounds with him in 1998. I saw five or six of Phil’s patients that day—some of them grotesquely injured and disfigured: suffering from missing and maimed limbs and body parts, from horrendous damage to their skulls and faces, and with tubes and wires going in and out of all parts of them—before the floor began to rise, darkly, toward my face. I excused myself, walked into the hallway, found a chair, sat, and put my head between my legs.

“I forget that you’re not used to this,” Phil said to me a few minutes later, his arm around my shoulder. (On subsequent visits, I have done somewhat better, and have usually been able to make a complete set of ICU rounds before becoming faint.)

Going on rounds with Phil—after we visit the Trauma Center we go to Craig Rehabilitation Center, to visit with people who are in various stages of recovery from trauma—I never cease to be amazed by the fact that he does what he does virtually every day of his life, and that, as with my other friends, the disease and misfortune he has to deal with rarely seem to dim his spirits or his optimism.

On any given day, however, the sadness of what he sees can get to him. Thus, his call to me late one afternoon on his way home from work when, without preface—not even his usual “Hey Neugie—it’s Phil!”—he just started in talking.

“Oh, I had a very hard day today, Jay,” he said. “Very hard. Yesterday I was talking with this young woman—she’s twenty-two years old, and she came in with a brain injury—she fell while horseback riding—and today she’s dead.

“Yesterday she was confused and disoriented, somewhat agitated, but she was talking, and moving all her parts, and following commands. So we did a CAT-scan and saw that she had some bifrontal brain bruises. We observed her—restrained her for her safety: she was drowsy and tried to go to the bathroom on her own—and then she had a seizure-like activity, and her pupils were dilated. An hour later she had another seizure and we did another CT-scan, and there were no marked changes from the initial CT.

“I mean, she was stable all day yesterday, then today she went into sudden and irreversible brain swelling, which is a known but rare complication of brain bruises in young people.”

Phil was silent for a few seconds. Then: “I’m very experienced, you know, and for a young person to die like this, it’s just devastating. I didn’t expect it, and I wouldn’t have done anything different. We did what we could to reverse the brain swelling—medications—but nothing helped.”

That night, after Phil arrived home, we talked again, and we did so frequently during the next few weeks, and it was as if this young woman was the first patient he had ever lost. He was inconsolable.

“The problem we have is with anything that causes swelling of the brain,” he explained during one of our talks, “because when the brain swells, it pushes on the brain stem and that’s why all our treatments are to prevent an increase in swelling.

“The brain looks like a cauliflower, you see, and when we’re young it’s made up mostly of coral-like indentations—sulci—and small empty spaces. As we get older, the brain shrinks, and there are more empty, fluid spaces—less tissue—so you have more slack, and if there’s a bruise, say, the swelling has room to expand, and you’re usually okay. The skull’s a closed box, with three elements—the brain, spinal fluid, and blood—and with a young person, it’s very tight in there, and we watch out for anything that makes it tighter. When the swelling becomes too great, the pressure affects the brain stem, and when the brain pressure gets too high it impairs the ability of the heart to perfuse the brain—to get blood and oxygen into it—and we get no flow. When the pressure in the brain’s greater than the heart’s ability to get blood into the brain—greater than the blood pressure—you’re deprived of blood and oxygen, and this is why some young people die from just what starts out as moderate brain injuries.”

When Phil was explaining things to me, he sounded like the guy I usually talk with. But when he talked about the young woman who died—“This is terrible,” he said again. “It’s tragic. I mean, what do I say to her parents?”—he sounded like a very young person himself—distraught, helpless, bewildered.

Beth Granger, the young woman who, a dozen years before, had been in a coma, suspended between life and death for nearly three months, has come to Phil’s Denver office with her husband Tom and their daughter Samantha. Phil’s consulting office, though considerably smaller than his Greenwood Village study—about seven feet by nine feet—is as un-self-consciously disorganized as his home office. A large LeRoy Neiman print of Willie Mays, a black-and-white photo tucked into the corner of the frame, takes up most of one wall, surrounded by prints, diplomas, neurological charts, and assorted photos (some of Phil’s ranch and llamas). When patients sit across from Phil, I notice them stare at the clutter on his desk in a mixture of perplexity, amusement, and awe. How can this brilliant, busy doctor maintain such a diverse range of interests—sports, Judaica, the American West, archaeology, geology, lightning (Phil belongs to the Lightning Data Center, an organization, founded by a neurologist and two meteorologists, that meets on the second Friday of each month)—and, equally puzzling, how can he cram so much stuff into such a small space?

Phil had been at Beth’s high school graduation, and at her wedding—she is now pregnant with her second child—and I talk with Beth about having seen her when she was in a coma. I’m surprised, I say, that she doesn’t remember me.

Beth laughs and tells me she doesn’t remember the accident at all, but knows that the car she was in rolled over, that she was thrown from it, that her best friend, in the car with her, was killed, and that she was in a coma for nearly three months. Her short-term memory and her hearing have been permanently impaired, but, she says, gesturing to her husband and daughter, she feels very blessed to be here, and to have the life she has.

Me too, I say, and Phil tells her, briefly, about my surgery. Then he leaves, and Beth and I talk about surviving, and about feeling that we are the lucky ones—“Because I came so close to death,” Beth says, “I appreciate life that much more.”

After her recovery, Beth attended college and hoped to become a social worker. “But I learned that society is not set up for people with head injuries,” she says, “and the most difficult thing for me, during my recovery, was being isolated from people my own age.

“My parents were wonderful—they were there for me every day, and for everything I needed—and when I was well enough to leave home, they took me to live in this Transition Living Center.” She shivers, closes her eyes. “But when I saw it, I said I’ll kill myself or run away before I’ll ever live in a place like this.”

Tom tells the story of how they met—he had been in a car accident too, and one day while he was at home recovering from his injuries he saw Beth on television. “She was talking about her illness and her rehab, and I fell in love with her right then,” he says. “There she was, this beautiful woman and she had a head injury like I did, and I thought, ‘Hey—maybe we can get together.’ So I called the TV station, and—”

“—and then came the famous one-thing-led-to-another,” Beth says. She and Tom show me pictures from Beth’s high school graduation, and from their wedding, and they tell me about the house they are in the process of buying.

Tom works twenty hours a week in his family’s floral business, and Beth works for an organization that helps people who are in recovery from brain trauma. “What’s best,” she says, “is what Dr. Yarnell taught me—whatever is most normalizing. Isolation is as bad as—no, it’s worse—much worse than the deficits you may have from the trauma.”

When she says this, her daughter Samantha climbs onto her lap. “My life seems too good to be true sometimes—though I don’t feel this way every day,” Beth says. “That wouldn’t be real. But when I first came to, you know, after the accident, I couldn’t walk, or talk, or hear—I was completely deaf for a long while, and what I thought was happening was that I had already died and was watching it all—my family, the hospital room, me— from up above—from heaven.”

When I tell Phil about my conversation with Beth, he responds by saying the kind of thing he often says about his work: “You see, I’m merely a caretaker. I try to help patients make the most of what they have, but sometimes they say it’s too hard, and that they’re completely dependent on someone to turn them over in bed or prop them up, and they can’t answer the phone, or if there’s a fire, they can’t move unless someone moves them. Some patients get depressed and don’t want to be here, and just say it’s not worth it, the heck with it.

“And it’s frustrating to work very hard and get a result where the person’s totally disabled—or in a vegetative state—for the rest of their lives. Their eyes may blink, but they don’t seem to understand their environment, or they can type a little with one hand on a small computer to say, ‘I’m okay. Hello,’ and they need twenty-four-hour care, and you wonder. I mean, you wonder if they would have wanted to be saved if they knew what was coming—or if you knew, maybe you wouldn’t have worked so hard to save them.

“But no one knows, you see. So you give everyone the best shot you can, and hope for the best. And you saw the people today—some of them were grossly debilitated. And then there’s Beth and her husband—but if they didn’t have parents who had a business that Tom could go into, they wouldn’t be talking about buying a house with a yard.”

Phil repeats what he has said to me several times: that a family support system is the most important element in the rehabilitation of neurological illnesses—and that his biggest worry wasn’t about my heart, or the surgery, but about the fact that I didn’t have a wife or companion, so that if I came out of surgery with a major disability, who was going to be there to help me, and to manage my affairs?

“I mean, if you have to live with a debilitating illness and you’re not rich or don’t have the world’s best insurance, where’s your means of support? They don’t kill you, but they put you in a rundown nursing home where there’s barely enough help, and let’s hope your constitution is strong enough to make it. And the help there turns over quickly, and you might meet an aide you strike up a friendship with who’s good-natured and helps you. I mean, you remember that young woman who was living with the man who was a quadriplegic? As soon as she left him, he died. So that’s the real world.

“But I had two thrills today,” Phil says then, and his face brightens. “Two patients spoke to me who never had conversations with me during the entire month I’ve been taking care of them. I had three conversations with that boy you met who was paralyzed from the night he had a car wreck. And with that boy who was sitting and playing cards—the one who fell off a cliff while mountain climbing. I never had a conversation with either of them before today—and, as with Beth, that’s a thrill for me—the highlight of my week.

“And I sent one lady home! That’s the really good part of my life. I get to send them home. So I feel lucky, because I get to do a kind of work that’s meaningful every day, and there’s always new things happening and something to learn.”

I listen to Phil talk about his work, and why it remains ever fascinating to him, and I think of the fact that his attitude—his love of his vocation—is, alas, becoming less and less common. In a 1999 study of young California physicians (those under forty-five), for example, the authors report that in 1996 “only 61 percent of primary care physicians said that they would go to medical school again,” this figure “down from 79 percent in 1991.” Among specialists during these same five years the proportion fell from 68 percent to 63 percent.

Other surveys report similar findings—that young physicians’ “perceptions of a career in medicine may be both more critical than those of other professionals and worsening over time.”* High medical school tuition, huge educational debts, long hours, high malpractice premiums, growing corporate influence, and, especially, the loss of autonomy are the major reasons young physicians give for their dissatisfaction, and for saying that, given a choice, they would not choose to become doctors again.

And many of the autonomy issues relate directly to a doctor’s freedom to make decisions about, and to care for, patients. For example, the report on young California physicians notes, only 67 percent of these doctors believed they had the freedom to care for patients who could not pay, and only 64 percent indicated they had the freedom to care for patients who required heavy time and resource commitment—these levels down from 83 percent in 1991. “The psychic toll of declining satisfaction with practices and careers,” the authors comment, “may reduce even the most dedicated physicians’ ability to function at their best.”*

Like my other friends, Phil—his nickname is “Yago,” from Yagolnitzer, his family name until his father changed it when Phil was in the seventh grade (“I had mixed feelings—I felt like I lost part of my identity, but I also was happy not to have kids make fun of me on the first day of classes every year when the teacher called my name”)—did not start out intending to become a doctor. He entered Cornell, in the fall of 1955, as an engineering student.

“I always had an interest in learning how the human body works, and I didn’t like mysteries,” he says, “so I thought that if I would understand it, it wouldn’t be a mystery to me. But I didn’t like the idea of the pre-medical route, which seemed too conventional. Engineering seemed more scientific.

“So I was in the department of engineering physics at Cornell, but I saw that the profession was mainly either the business of running manufacturing outlets or you could be a pure scientist, only I didn’t think I was good enough to be an independent pure scientist. So medicine seemed a combination of technical knowledge, and also being able to make a contribution to helping people.”

I say that Arthur wonders sometimes if this desire we all have—to be of service to others, to make a contribution, to leave the world a better place than we found it—is as purely altruistic as people think, or whether, instead, it simply comes from our compulsive need to be productive—from our Brooklyn brand of Jewish Calvinism.

Phil shrugs. “I don’t know about that,” he says. “Maybe. But I know that by the third year of engineering school, I decided to look into going to medical school, and I took a few extra courses, and then I applied to medical school and got a scholarship, so instead of finishing the engineering degree—it was a five-year program—after four years, I went to medical school.”

“You never got a college degree?”

“No. I never got a college degree.” He laughs. “My mother was upset, because she said what would happen if I didn’t like medicine, and all I’d have was a high school diploma. I couldn’t even be a high school teacher, which she thought was a very noble profession.

“But mostly I just wanted to be educated—and I wanted to get out of Brooklyn. I think it’s like being a good ballplayer. If you’re a good ballplayer, you don’t care where you play, and you can play at any level. So that’s how I felt about learning and, later on, about becoming a doctor.

“My father pressed clothes in a dress factory—it was called ‘piecework’ because he was paid by the number of dresses he pressed—by the piece—and it was seasonal work, so he was unemployed a lot of the year, and he sat around and my mom yelled at him, and it was very disheartening because he was trapped, and he was a passive man who couldn’t figure out how to get out of the trap.

“We always ate separately. The kitchen was too small so my mother prepared three meals—one for her two sons, one for my father, and one for herself. My brother Allen and I ate on TV stands. We never ate together unless there was a special event, and then we ate in the living room.

“The bathroom was small too—it was so narrow that when you sat on the pot, the only way you could be comfortable was to keep your right leg over the side of the bathtub. Allen used to go upstairs to our aunt’s apartment to go to the bathroom. There was no air conditioning, one tiny bathroom for four people, waiting in line, no privacy.

“So I still have a recurring nightmare—like an anxiety attack in which I actually shvitz—where I sweat like crazy. I’m in my last year of medical school, and I miss an exam, or I fail it, and I have to go back and repeat the year again, and in order to do this I have to move back into my Brooklyn apartment. That’s the nightmare I still have all the time.

“Which is what I did—I was married for my last year of med school, but I lived at home for my second and third years, in the same room I used to share with Allen, and carrying my microscope on the BMT, hugging it like a baby.

“In high school, you see, I figured out that there were only two tickets out of Brooklyn. One was to be a great athlete, which was my dream until I got to high school and saw that there were guys ten times bigger and fifteen times faster than me.”

I remind Phil of the time, during our sophomore year at Erasmus, when we were on the junior varsity baseball team together and we got to play against the varsity. “Yeah,” Phil says. “And then, after my freshman year, when I gave up on being a pro ballplayer and saw I could get good grades by doing the things I did naturally, I said, ‘Well, if I do it a little more I’ll get very good grades.’ So I did a little more.

“And I knew that would give me power, and would be a way out. Everything I did was so I could get out of Brooklyn and escape my apartment. I mean, I felt it was all on me, even when I was away at college, because if my parents got sick I’d have to drop out and help them, and I resented that. Only, I was fortunate, and it never happened.”

I ask Phil about what has and has not changed since he started out in medical school.

“Well, the smartest doctors will still tell you that if you listen to the patient, the patient will tell you what’s wrong with him,” he says. “Because it’s not the disease, you see, but it’s how the particular disease affects the individual patient. I mean, a lot of us went into medicine because it’s first of all a science—you have to look at the illness, at the state of tissues, at organ systems, and try to understand what’s going on, and what you can do or have to do. Like, if a person has pneumonia, and you give antibiotics, you check the x-ray to see that the pneumonia’s gone. But you also have to look at the individual patient who has the disease, and see how the story of the illness takes place in this particular person—so that a doctor is somehow at the juncture of what’s both objective and subjective.

“Now, neurology started out by studying diseases of the brain, spinal cord, and nerves—how they express themselves—and we looked at the patient’s complaints, and examined the patient through the years, and then the patient would die, and we would examine the tissues at death. That’s how we started out. And we knew things grossly—like if there was a gunshot wound to the right side of the head, the left side of the body might be paralyzed, and if someone died and we saw a lesion on the right side of the brain it showed why the left side had been paralyzed.

“So neurologists took care of people who had something wrong with the ability of the nervous system to work, or it was hyperactive—like epilepsy, where there were seizures—or it was underactive, so a lesion was causing paralysis, weakness, loss of vision on one side, loss of speech, clumsiness. And once you localized it to where in the nervous system the problem was, you could make a presumptive diagnosis of disease and tell the patient he had something wrong with the right side of the brain, or the spinal cord at this or that level, or with the nerves coming out of the spinal cord. Then, if they decided it was amenable for surgery, you talked with the neurosurgeon, and maybe you’d have an operation.

“But that all changed when neurologists had a way of looking inside the black box of the nervous system. It started with x-rays, in the beginning of the century, which let you tell if there was an abnormal collection of calcium inside the brain, or if it was pushed to one side or the other, or if you had a broken head—if you fell down and got a fracture and there was air inside your head, or a bullet fragment, or a calcified tumor. After x-rays, then angiography came, or probably pneumoencephalography first, where you injected air inside the nervous system, and it filled the fluid structures and you could see if they were distorted in any way. Then the next thing was the injection of contrast material—metallic dyes into the arteries—and then you take an x-ray, and you can outline the arteries of the brain and see if they’re blocked, or if there’s an abnormal bulging of an artery, and so you could make inferences as to the disease that was causing the patient’s symptoms.

“At the same time, or about the same time, people also injected dye into the spinal canal, and studied the spinal cord, and all of those we called interventional techniques, and they all had risks associated with them. It involved the patients being punctured, and foreign materials being put into them.

“Then along came the CAT-scan, and that came after I finished my residency, in 1973, and you could put yourself inside a tube, and by mathematical analysis of x-ray absorption, you could get a look at the structure of the brain, which before that had only been visible at autopsy. And that revolutionized the field of neurology because you no longer had to make a guess based on the examination of the patient and the patient’s complaints. You now had a way of verifying things without risk to the patient.

“When it first came here, the governor of Colorado said Denver should have only one CAT-scan for the whole city. Now most hospitals have two, and we keep them running around the clock, and you can’t work without them.

“Then, in 1986, I think, came magnetic resonance imaging—MRIs, and PET-scans—and they gave you further anatomical clarity for the problems you were dealing with so you can fairly well localize a great deal of lesions. Some you can’t, and they still remain a diagnostic problem, but for those you can, the characteristics, on CAT-scanning and MRIs, may even tell you what the tissue type is.”

I remind Phil of how excited he was a dozen years before, to show me the first MRI machine at his hospital, a huge metallic cylinder that looked like a space capsule, and of how I watched with him while one of his patients was inside the machine. The patient was frightened, and Phil kept calling to him—“Just enjoy it, Sidney—make believe you’re in the love canal!”—and afterward Phil showed me how the dozens of images the machine produced were able to give him a three-dimensional picture of Sidney’s brain.

“The tubes are more comfortable, and some people have open MRIs now,” Phil says, “and we can tell the difference between a stroke and a tumor—we don’t have to guess—so our diagnosis rate is much better. The detail is just miraculous. In the old days, the very best neurologists—our teachers—maybe had a fifty percent accurate diagnosis rate, but now we’re up to eighty or ninety percent. We can localize much better, so the neurosurgeon knows exactly where he’s going to operate. He can cut down right on top of the tumor, or put a needle through the skull that will go right into the tumor instead of just searching around.”

Phil talks about the gains that have come about because of emergency response teams and evacuation teams that begin treatment at the site of the accident; about medications, antibiotics especially, that cure infections and prevent complications; about medications that are effective for high blood pressure; and about various ways we’re better equipped to deal with trauma and to enhance rehabilitation.

In the regular course of his work, he explains, people come to him with headaches, migraines, backaches, troubles with memory, dizzy spells, strokes, and the aftereffects of head and spinal injuries. He also deals with long-term management problems relating to degenerative diseases such as multiple sclerosis, Parkinson’s, amyotrophic lateral sclerosis (Lou Gehrig’s disease), and Alzheimer’s.

“So I see anybody who has these things,” he says. “My interest is in what happens when people get hurt. You know, what the doctor did when we were kids was he sort of held your hand and watched the natural course of the disease. A neurologist still does a lot of that.

“But he tries to see if he can alter it for the good, and manage it, and make sure nothing makes it worse. That’s why if you’re excluded from the patient’s pathway of care, or made ancillary—especially with chronic, long-term conditions—your expertise is not taken advantage of, and the patient suffers. A patient needs continuity of care and consistency. If you have a chronic illness and you switch doctors, it means the patient and doctor have to start all over again trying to understand things. The heart of medicine is the doctor-patient relationship, and if the patient does not feel he’s hired a specific doctor to work for him to maximize his health, then the patient loses trust in the system.

“With managed care, there’s a great emphasis on general practitioners, because with the insurance companies and the HMOs it’s much cheaper for them to have a generalist or a nurse practitioner do everything, and only ask advice from the specialist, rather than have the specialist manage the illness. This is backwards. You wouldn’t ask a high school physics teacher to work on the atom bomb or solar energy, although he might understand the concepts. You wouldn’t say, ‘Why don’t we just get the nuclear physicist to come and spend a day with you, tell you what’s wrong, and then you take over the experiment.’

“I mean, the patient may have only two visits with you when the illness is something that needs to be managed consistently. Or an MS patient may have several symptoms that a well-trained neurologist would understand in order to prevent further flareups. But if the patient is not encouraged to see the neurologist and just calls the doctor’s office and gets the nurse on the phone, she may or may not realize the significance of the symptoms. I mean, look at what happened when you first called and got the nurse! And if you hadn’t thought to call Rich after that, we wouldn’t be talking now.

“How you manage the illness, what advice you give to the patient, who you pick to do an operation, or what you advise about chemotherapy or radiation—that’s still the art of medicine. A test can’t give a diagnosis.

“Now, not long ago I advised two people against having radiation for malignant brain tumors—and for malignant brain tumors we’re still pretty much where we were forty years ago, unfortunately—and they both went ahead and had it, and they both sort of ruined their lives, whatever lives they had left.

“I recommended against radiation because I said it will debilitate the remainder of your life. But the radiation therapist recommended it, and the standard of care was that they should have it. So everyone wants to grasp onto something—that maybe this thing will stop it. Everyone would like to live to a biblical hundred-and-twenty with intact virility and no mental static, but I don’t think we’re going to find that in our time.

“And I spend a lot of time fighting with insurance companies too. So, for instance, I get this letter back after I write for one of my patients so he can pay for his treatment, and they send me a guideline they got out of a book, and the doctor who sent it—they have doctors doing this now—I talk with him and he says to me, ‘I understand your position but these are the guidelines we follow.’ So what can I say except that those are not the guidelines I follow?”

I tell Phil what Dr. Cabin said about me not being cured, that nobody is ever cured, but that I was as close as it gets, and that most of the work he does is like this—it’s a major reason he went into cardiology—and that he’s aware that it is not like this in other areas of medicine.

“So I look at what you do,” I say to Phil, “and I think, if this is what Dr. Cabin gets—what do you get?”

“Well, cardiology is way ahead of us,” Phil says again. “But my satisfaction comes from seeing the natural healing take place, and trying to prevent complications. I see myself as a caretaker of the brain, whereas he sees himself as someone who can actively intervene. He can put new blood in you, put a new blood supply through veins. I can’t do that yet.”

I talk about the theories concerning the infectious causes of heart disease and cancer, and Phil notes that MS, for instance, like other neurological diseases, may be infectious in origin. “Maybe brain tumors are an infectious disease. Maybe it’s a virus,” he says. “Okay. A lot of people get viruses, but what determines which one will go on to become a brain tumor, and which one will just live in symbiosis with the virus? We don’t know that. Maybe, as with Parkinson’s, we can inject cells into the brain to grow over it—but we don’t know if we can, and we’re just beginning. And there are hereditary defects where you don’t make enough of a protein, or you make too much, and maybe we can learn to regulate that. Friedreich’s ataxia, for instance, is a hereditary genetic disease—it’s a balance problem, where you get this unsteady jerking-type gait because of a recessive gene that doesn’t make a protein, or maybe an enzyme, that we need.

I ask about a former patient of Phil’s who, during the April 20, 1999, massacre at Columbine High School, in Littleton, Colorado (one town over from Greenwood Village), in which two students killed fourteen students and a teacher while wounding twenty-five others—was shot several times. Phil says he happened to see the student this past week—on the day I arrived, in fact, and that the student is going to school and doing well. “He’s lucky,” Phil says. “His injury was to the left side of his head, and he’s left-handed, so he didn’t lose use of his dominant hand. He may still have some deficits, though—in walking, and in his speech, I think. He answered all my questions in just monosyllables.” Phil smiles. “But I don’t know—I mean, how does that make him so different from my son Jared and his teenage friends?”