From a Place of Fire and Weeping, Lessons on Memory, Aging and Hope

By MARC E. AGRONIN, M.D.

24 dec 2008--The forest still stands, but the people are gone. Only a stone memorial guards their place, surrounded by tall grasses that hide bits of ash and bone deep beneath their roots.

On this spot on Feb. 4, 1942, more than 920 Jewish men, women and children from the town of Rakov in what is now Belarus were rounded up by the Nazis and herded into the synagogue. Several shrieking children were stabbed with bayonets and thrown over the heads of the weeping Jews just before the doors and windows were sealed and the building was doused with kerosene.

An unspeakable scene of wailing ensued as the once vibrant Jewish community was annihilated in the fire. My patient, now 98, still weeps when he describes witnessing this horror from a hidden perch in a tree. He gasps audibly when he recalls watching his father being pummeled by a Nazi soldier before he was thrust into the doomed crowd.

When this survivor first told me his story, I was speechless. He held tight to my arm, and I imagined myself as the branches of the tree that supported him during this trauma. I was now a witness.

As his psychiatrist I am obliged to ease his suffering, but no medicine of mine can touch such a memory. I have tried hard to understand how he and others managed to mentally survive such traumatic experiences. These aging Holocaust survivors, in particular, have taught me what I have come to call “lessons from fire.”

Lesson 1 is the most difficult for a doctor. Sometimes the perpetual sadness of many older survivors is not to be healed but shared. Over time, as memories fade and the voices of lost loved ones grow quieter, all that remains is a closely guarded sadness, persisting as a substitute for the losses. Any attempt to ease this emotion may be a threat to painful but beloved remnants of memory. What some survivors seek is not medicine or therapy: it is the attentive presence of a doctor and others to serve as the next generation of witnesses.

Lesson 2 brings a paradox. Surviving a grueling trauma does not inoculate one against the stresses of aging. A patient once told me that the small daily indignities she faced in the nursing home felt worse than her experiences in a Siberian labor camp. I realized that she could not bear feeling like a victim again, even in small measure.

Lesson 3 gives me hope. One patient, a survivor of Auschwitz, recently lost her husband of 60 years. She came to me severely depressed, with thoughts of suicide.

I asked her, “How did you have any hope in the camp, knowing that each day could be your last?” She smiled briefly and told me a story (I reconstruct her words from memory):

“My dear doctor, I believe in God, and he was with me in the camp. But I also had several young women from my town with me in the barracks.

“When we had to stand at attention for hours, we stood together, propping up one another when weak. When we dug ditches we did it together, one holding and moving the arms and shovel for another who didn’t have strength that day. We were desperate, but never alone.”

I referred her to a social club we created for older people with mild memory problems, and one day I crept into the room during a discussion group and hid behind a corner to listen.

One women spoke disparagingly of her memory. “I am losing my mind,” she said. “It is so painful.”

Then I heard my patient respond in a resolute voice: “You must have hope. We are all in the same boat here, together.”

As I listened I could feel tears welling in my eyes, but I kept myself hidden, afraid to let the group see their doctor weeping. From my hiding place I witnessed a beloved patient begin to heal herself.

These lessons from fire are not the only points of clinical knowledge that one needs to work with aging victims of trauma, but they’re a good start. When facing the last generation of Holocaust survivors, I offer my presence as a doctor and I feel strengthened by their words.

“Faith — I still have faith,” I hear a survivor say. “Doctor, hope for me!” another commands. These are the primal gifts of life that we share.

Marc E. Agronin is a geriatric psychiatrist in Miami.

Beware of ‘search satisfaction,’ a common cognitive error

18 may 2008--Daniel Ginsberg, FACP, related to us the case of a 60-year-old woman who presented to an urgent care clinic with lower abdominal pain and urinary frequency. Despite extensive evaluation, the cause of her symptoms was not recognized until four months later. We talked to Dr. Ginsberg about this case and the cognitive errors that likely led to the initially missed diagnosis.
Dr. Ginsberg saw the patient a few days after she visited the clinic. Test results from the clinic visit showed that a urine dip stick was negative for leukocytes and nitrites but positive for occult blood. She was treated empirically with ciprofloxacin but urine culture came back negative. Her past medical history was remarkable for esophageal reflux, bilateral oophorectomy and vaginal hysterectomy, as well as a laparoscopic cholecystectomy, but she was otherwise in good health.
The woman reported feeling better when she first saw Dr. Ginsberg but several days later, her symptoms recurred and a repeat urine analysis again demonstrated microscopic hematuria. A CT scan showed a small mass in the inferior pole of the right kidney, and it was noted that the appendix was enlarged at the takeoff from the cecum, without surrounding inflammatory changes. The radiologist felt the appendix was a normal anatomic variant. Urology was consulted.
About one month later, the patient underwent a laparoscopic right nephrectomy. Pathology showed a benign angiomyolipoma. When she returned to see Dr. Ginsberg three weeks later, she said that the surgery had not resolved her abdominal pain. On examination, she had some tenderness in the epigastrium, the right upper quadrant and the hypogastrium. Dr. Ginsberg attributed this to postsurgical pain.
A week and half later, the symptoms were no better and she had developed diarrhea. The woman was concerned about celiac disease, a condition her daughter suffered from, and was referred to a gastroenterologist. An endoscopy showed minimal chronic gastritis and two gastric polyps, but no evidence of celiac disease. She also underwent colonoscopy, which showed congested mucosa in the cecum; a biopsy of this area revealed non-specific inflammatory changes. She continued to experience intermittent abdominal pain which she described as “gas pains.”
Assuming that her discomfort was related to her prior surgery, the patient did not come back to Dr. Ginsberg’s office until about six weeks later, when she complained of two days of “sharp and gas-like” worsening abdominal pain located in the periumbilical area. On examination, she had mild hypogastric tenderness. A urine dipstick performed in the office showed 0-2 white blood cells and 10-20 red blood cells. A urine culture was sent and the patient was started on levofloxacin.
Two days later, she presented to the emergency room with increased abdominal pain, nausea, and vomiting. In the emergency room, she was afebrile. Tests revealed the following:
Her white blood cell count was normal with a left shift: WBC 9300 with 82% neutrophils
Serum transaminases were elevated, AST 88, ALT 188, and alkaline phosphatase was 265
A repeat CT scan, now four months after the initial CT scan, showed a 5.4 x 3 x 4 cm cecal mass
Malignancy was suspected and she underwent laparotomy and resection of the mass. Final pathology demonstrated an appendiceal abscess.
Dr. Ginsberg described the patient as a very pleasant person, and that he had cared for her and her entire family for some time. She was an accurate and reliable historian. During the course of her illness, he was convinced that something was wrong but was not sure what it was.
sIFR_callback_2_DoFSCommand(info, args);
Discussion: Seeing (all of) what’s there
We as clinicians are strongly guided by technology. Most of us, receiving the information that the radiologist gave Dr. Ginsberg, would have eliminated consideration of appendicitis in this case. But it is worth keeping in mind the cognitive challenges that radiologists face when reviewing images. Ehsan Samei, PhD, of the Advanced Imaging Laboratories at Duke University Medical Center, analyzed results from a variety of radiological procedures based on published data in the literature. “Currently, the average diagnostic error in interpreting medical images is in the 20% to 30% range. These errors, being either of the false-negative or false-positive type, have significant impact on patient care,” his study concluded (J Am Coll Radiol; Vol. 3, p. 400, 2006).
The workload for radiologists has increased significantly over the past decade. It is estimated that radiologists in private practice evaluated from 12,000 to 15,000 cases a year in 1997, but the workload now has nearly doubled. From 1998 to 2002, the number of CT scans in the U.S. increased by 95%, MRI by 51%, and ultrasound by 30% during traditional work hours, and each increased by 15% during on-call off hours (J Am Coll Radiol; Vol. 3, p. 433, 2006). Some cases, like chest X-rays, generate only a few images, but CT and MRI scans involve hundreds or thousands. Herbert Kressel, MD, a radiologist at our institution who is an expert in MRI, pointed out that how the CT or MRI scan is reviewed in a cine (akin to a movie) format can importantly influence the identification of subtle findings. That is, moving too quickly through the images can cause the radiologist to overlook an abnormality.
The difficulties in identifying abnormalities have been the subject of study by several researchers, including E. James Potchen, MD, at Michigan State University in East Lansing (J Am Coll Radiol: Vol. 3, p. 423, 2006), who has studied performance in reading chest X-rays. More than 100 certified radiologists participated in a research study where they evaluated a series of 60 chest X-rays that included duplicates of some of the films. When the radiologists were asked, “Is the film normal?” they disagreed among themselves an average of 20% of the time. This phenomenon is called “interobserver variability.” Remarkably, when a single radiologist re-read on a later day the same 60 films, he contradicted his earlier analysis up to 10% of the time, a tendency referred to as “intraobserver variability.”
One of the most striking findings in Dr. Potchen’s research came from the same study where one chest X-ray out of the 60 was of a patient who was missing his left clavicle. Here, 60% of the radiologists failed to identify the missing clavicle. When clinical data were added to the exercise, informing the radiologists that the 60 chest X-rays were obtained as part of an annual physical examination, 58% of the radiologists still missed it and scored the film as normal. However, when they were told that the chest X-rays were obtained from patients with cancer, then only 17% of the radiologists failed to identify the missing clavicle. The important conclusion is that specific clinical information from the referring physician can substantially improve the performance of the radiologist.
Harold Kundel, MD, of the University of Pennsylvania, has studied the physiology of image perception by tracking the eye movements of his fellow radiologists. The radiologist sits with an apparatus on his head that looks like a bicyclist’s helmet. In addition to a visor, the apparatus has a miniature camera. As the doctor examines a series of images, a beam of invisible infrared light is trained on his pupil, tracking his gaze. By this means, one can distinguish between abnormalities on an image that are not looked at and those that are not consciously processed despite the eye gazing at the site (J Am Coll Radiol, Vol. 3, p. 402, 2006).
These and other studies demonstrate a common error among radiologists called “satisfaction of search.” This means that once an abnormality is identified by the radiologist, his mind is “satisfied” and does not register a second abnormality. In Dr. Ginsberg’s case, the finding of a renal mass may have led the radiologist to dismiss the second finding of an enlarged appendix as merely a normal variant.
Dr. Ginsberg later discovered that the urologist had done a second CT scan. A different radiologist read this scan as follows: “1.7 cm right inferior pole renal tumor, possible renal cell carcinoma. Thickened appendix; this finding is non-specific but may have progressed since prior examination and could represent early appendicitis. Correlate clinically.” Unfortunately, the urologist made no mention of the appendix in his consultation note, focusing only on the renal mass, another example of search satisfaction.
Dr. Ginsberg told us that he viewed this case as “a horse masquerading as a zebra.” Why didn’t we see the horse? To help answer the question, Dr. Ginsberg sent us this picture of how the mind may not perceive a visual abnormality.

Medicine, Constantly Redefined and Redefining Lives

By ELISSA ELY, M.D.
About 15 years ago, I had a shy patient who ate nothing but white foods and who assaulted anyone who entered her air space on the hospital ward. She was mute but not uncommunicative, and with a little effort it was possible to learn her language.
Some of her problem was her psychosis. Most of it was her mother, who was her legal guardian, appointed by a court to monitor her medications. But the mother was also convinced that psychiatric medications were poison; the patient would go home on weekend passes and return with all her pills in bottles and without a shred of sanity.
This continued for months. Her mother brought a notebook listing side effects to each visit. She said the medication caused seizures, diabetes and heart disease, though the studies at the time showed none of these side effects associated with the drug we were giving. We thought she was sadistic, intent on standing between her daughter and independence. She thought we were evil experimentalists. The patient herself dreaded controversy and wished, wistfully, to please everyone.
Finally, we petitioned to remove the mother as guardian. It was controversial, against nature, to question a family member’s competency or guidance. When we met before a judge, both sides were filled with strong emotion. But we were also filled with strong data.
I remember looking at the mother across the courtroom while testifying about the hazardous nature of her beliefs and their effects on the patient’s mental state and future. Her size had changed. When she visited the hospital, something vibratory and angry about her made her seem to swell, so that neither her daughter nor I could look her in the eye. From the secure height of the witness box, though, she seemed to be shrinking — an ineffectual old woman, laboring under false beliefs, growing smaller as these beliefs were exposed one by one.
The judge listened without expression and took the case under consideration. We had no doubt about the power of our presentation. Within a week he had ruled in our favor. The new guardian did not oppose our antipsychotic drug, and the patient flourished. It was like time-lapse photography: in what seemed like only a day, she smiled, spoke, became lucid, joined a day program, began overnights in a residential house and was discharged.
We were full of public satisfaction, and private righteousness. Some aspects of psychiatry are clear-cut; they can be counted on. There might be no proof of the existence of Freud’s ego and id. But antipsychotic medications treat psychosis — this can be proven — and the patient’s life was going to be better for taking them.
It was, too. For a while, she sent happy, mostly intelligible letters from her residential house. The letters became holiday cards, and eventually, in the fullness of her world, they stopped. Someone else told me, years later, that she had developed diabetes and required insulin. The research by that time was clear: there was no doubt whatsoever of an association between her antipsychotic and diabetes and other metabolic problems. The studies had been confirmed again and again.
Kierkegaard wrote that we understand backward but live forward. Politicians say — using a tense so passive that it slinks out of the room before it can be noticed — “Mistakes were made.”
The facts we had then were incomplete, even if we didn’t know it at the time. We were right but we were wrong, innocent but at fault, acting in good faith with bad results. The ground beneath professional feet should grow firmer over time — one ought to feel more certain of what one knows. But the more I know, the more I am afraid.