Michael Gordon's blog

Offering patients more choices about end-of-life care

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Originally published in December 2012 on the Baycrest.org

Dr.Michael Gordon A National Post story (Nov. 8) reported that New Brunswick was the latest province to move in the direction of offering patients more choices about end-of life-care, beyond the standard “do or do not resuscitate” policies.

Fast on the heels of this article was a story in The New York Times (NYT) on Nov. 24 about end-of-life care. The NYT reported that when advance care planning is done well “there is good evidence that…it can greatly increase the likelihood that patients will get the care they really want. And, as a secondary benefit, their choices may help reduce the cost of health care as well.”

What I found surprising about the National Post article was that one would think after reading it that offering dying patients more choices in their end-of-life care was a novel idea. As the NYT article pointed out, the history of so-called advance care planning dates back several decades. Canada has played a strong role historically in the development of the idea of the “living will” – a document used for the process of stating one`s wishes and values for end-of-life care, which can be expressed verbally or in writing. In Ontario it is supported legislatively through the province`s Health Care Consent Act.

The NYT story states, “Many people sign living wills that specify the care they want as death nears and powers of attorney that authorize relatives or trusted surrogates to make decisions if they become incapacitated”. As part of a nation-wide American project, Physician Orders for Life Sustaining Treatment have been created to ensure that a patient’s wishes are followed and not misplaced or too vague for family members to be sure what a comatose patient would want. According to the NYT article: “With these physician orders, the doctor, or in some states a nurse practitioner or physician assistant, leads conversations with patients, family members and surrogates to determine whether a patient with advanced illness wants aggressive life-sustaining treatment, a limited intervention or simply palliative or hospice care.”

With the shift toward giving patients more choices about their end-of-life care beyond do or do not resuscitate, we need to be careful of the real risk of developing a quick and cheap fix – that is, relying on a simple form in which people select from a menu of categories of choices for their final phase of care. This process has been shown by many in the field of ethics and end-of-life care to be too minimalist to capture the nuances and emotional complexities of expressing end-of-life wishes. Many would say the important part of the process is not a “form” that is filled out, but a robust conversation with those that you depend on to respect your values and wishes and interpret the potential treatments offered when the time comes to agree to or reject a treatment.

Pre-planning one’s future is never easy and can lead to unexpected and unwanted consequences if not done with careful thought and planning. The importance of the National Post and NYT stories is that they support the importance of having the conversation with close family members or those you might expect or appoint formally to carry out your wishes when you are no longer able to do so. This personal responsibility must be supported by public policy initiatives that promote education and training of those who ultimately will be responsible for assisting individuals and their families in tackling this challenge.

Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Late-Stage Dementia: Promoting Comfort, Compassion, and Care and previous two books being Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com

Plants are Good for the Soul Including for those Living with Dementia

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As I was leaving for a bike ride I passed my wife, out for her morning walk; "I think it was a successful resuscitation!" She asked who I was talking about and I answered, "The three foxgloves", beautiful purple flowered plants I had planted days earlier that were wilting in the terrible summer heat. I "diagnosed" severe dehydration and therefore I provided large doses of water so that overnight the leaves filled out and the tall stem holding the gorgeous flowers were almost upright. It seemed to be a miraculous feat of plant care for someone who having been brought up in Brooklyn knew close to nothing about flowers or plants. Betty Smith's famous 1943 novel, A Tree Grows in Brooklyn, had little impact on my botanical knowledge or skill.

My wife had a good laugh and I biked away recalling my fond association with the foxglove that was important to me because of my medical studies in Scotland in the 1960s. During medical school what is now digoxin, a medication used for various forms of heart disease was provided as a biological preparation known as digitalis leaf, which meant its purity could not be as exactly determined compared to the more contemporary purified digoxin product. I was on an outing with classmates to the west of Scotland which culminated in a difficult uphill hike on the foothills of Ben Nevis part of the western Scottish mountains. As I stopped to catch my breath, Andrew Johnson, one of my more playful classmates, kneeled over me with a flowering plant in his hand and said laughingly in his Yorkshire accent, "here Michael, take a nibble of this, it will strengthen your heart," while waving a foxglove in front of me. I had never seen the plant but from then on, its appearance and medical importance was imprinted in my brain.

Digitalis was introduced into medical practice by William Withering (1741-1799) a great English medical botanist. Born in Wellington, Shropshire, England, he attended Edinburgh Medical School from 1762 to 1766. In 1776, he published, The botanical arrangement of all the vegetables naturally growing in Great Britain, an early and influential compendium of British Flora. The foxglove plant, digitalis purpurea, had been known for centuries as a folk remedy for the treatment of dropsy, or congestive heart failure, and other conditions. Withering in 1785 published his classic work, An account of the foxglove, and some of its medical uses: with practical remarks on dropsy, and other diseases. His observations changed the course of medicine and although digitalis is presently used less in current medical practice, I had frequently used it previously and observed its often dramatically life-saving effects.

My personal foray into gardening has occurred late in life but I have witnessed professionally the important therapeutic impact that raising plants can have on elderly individuals including those with cognitive impairment and cancer. There is a growing body of knowledge, studies and observations about the beneficial effect that plant care and gardening can have on those living with dementia. On a March 7, 2008 the website Caring Today (http://www.caringtoday.com/reduce-stress/garden-therapy) provided some interesting insights as to the therapeutic benefits of gardening and the care of plants by individuals living with dementia. "Gardening requires certain steps or sequences," says David B. Carr, MD, a geriatrician at Washington University in St. Louis. "Lots of patients, especially those with Alzheimer's or dementia, need guidance or mentoring because they can't go through all the steps alone, but they can do some of them."

Carr describes one of his male patients whose wife was the brains of their gardening operation. "She told him how deep to dig the hole, what to put in it and how to water it. This way of attacking the activity worked for them," he notes, "and they got to spend quality time together. "It has been my experience that those patients (with Alzheimer's or dementia), doing activities (gardening being one example) do better in the long haul and have a slower rate of decline than those who don't do anything," says Carr. "Gardening is one of the non-prescription interventions that have the ability to slow the rate of cognitive decline."

As reported on a BBC News website in September 20, 2011 by Huw Williams a BBC Scotland reporter an article appeared entitled, Garden therapy could bear fruit for dementia care (http://www.bbc.co.uk/news/uk-scotland-tayside-central-14979146). In the article it is noted that "Dementia patients across the country may be spending 24 hours a day locked in hospital wards—an unacceptable regime even for convicted prisoners. But now growing numbers of experts say access to the outdoors, and physical activity such as gardening, could transform life for patients with conditions such as Alzheimer's disease or other forms of dementia.

Annie Pollock, landscape designer from the Dementia Services Development Centre at Stirling University, says it, "should not be surprising that core skills from one's lifetime of gardening remain, even as the disease takes away other aspects of one's personality."
And she says," there is plenty of evidence of the benefits outdoor activity such as gardening can have for people….(with dementia)."

Also in the article a note of caution from Fiona Thackeray, from Trellis, a charity promoting therapeutic gardening which is organising a course on designing gardens for people with dementia. She cautions that unlocking the garden gate does not necessarily mean you can keep the drugs cabinet closed. She says: "We wouldn't argue that gardening is going to cure you, or take away all need for any other interventions. "But it can be a really powerful addition, or complementary therapy, to any drug regime." "It's a great physical activity so it's a good way to keep fit, or get fitter. Most people find it calms them down, it's a great stress reliever." Ms. Thackeray adds: "More and more we're seeing the importance of vitamin D. Although we don't have much sunlight in Scotland, if you're outdoors in the garden you're going to be boosting your vitamin D levels." And, she says, "the sense of smell is a really strong trigger for memory, so what better place than a garden, with all the scented flowers and herbs, for people with dementia? It can help them think back to their past, and bring back positive memories."

On a You Tube video the beneficial aspects of gardening is the focus of the story: Therapeutic gardening helps residents with dementia: Residents with dementia at the Norwood Crossing assisted living center participate in therapeutic gardening that helps them build confidence and a sense of community. The center raised enough money to open a new garden outside, which residents will be able to tend to daily. (http://www.youtube.com/watch?v=T_hvKZv4ViE)

The short-story writer O'Henry captured poignantly the life-affirming impact of what was believed to be a lingering vine leaf on a pneumonia-stricken woman in The Last Leaf. The patient's ultimate recovery is at the expense of the old painter who as his last heroic artistic effort painted the leaf on the wall facing the window to give the illusion of the still-living leaf, only to contract fatal pneumonia as the price paid.

On the palliative care unit where I work at Baycrest, there is an active plant group that with a recreation therapist and dedicated volunteers helps patients nurture their plants. One elderly gentleman with advanced malignancy had always raised his own vegetables. His plant project was to raise some beans while he was on the unit and the joy that he experienced watching his carefully tended blooms yield their produce was a testimony to the life-affirming power of plants living and thriving through our human efforts.

Gardening and the tending of plants is part of the spectrum of life-affirming activities that we can use in the care of the elderly especially those with dementia or those with end-stage illnesses such as malignant and non-malignant disease. To tend to a plant, watch it grow and produce its leaves, flowers or vegetables affirms for many that there is a meaning to life, even as one may realize that one's end is on the horizon or when may not realize exactly what life has in store because of cognitive impairment but anything that gives life meaning is a worthwhile endeavor.

This article first appeared in part in the August 7th, 2012 issue of the Canadian Jewish News.

The Art of Listening Again and Again

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It was a replay of a common interaction. I was telling my daughter some story from my past to make one point or another and she responded with, “I know, I know, you have told me that before.” At that moment I realized what a common occurrence this sort of interaction was and explained to my daughter, “Even if you have heard the story before remember that it is important to listen again because first of all I may not remember that I told you the story before and more importantly the telling of the story may have as much meaning and significance for me as it might have for you.”

As I thought about the issue I realized how often in my geriatric medicine practice one of the salient complaints by families is how often their loved one tells them the same thing over and over again, and they use that symptom as do we in practice as geriatric health care providers, as possible evidence of cognitive decline and the inability to recall what was said previously. I am beginning to believe that this symptom, although very common, and often indicative of a decline of cognitive function is also a manifestation of a very common human propensity to focus on the narrative of one’s life and to recall and recount that narrative as part of one’s process of self-identity and validation. The question is; what is the separation between the normal and very common attribute of story-telling and the narrative of one’s life, and the pathology of cognitive impairment that interferes almost completely with the awareness that a story or occurrence has been recently recounted to a loved one?^1,2

What most of us understand at some level is that the telling of stories is a very important part of our existence. Some do it more than others, but in normal relationships and conversations we spend much of our efforts recounting events of our life and experience to others. And the propensity to be repetitive is quite universal as anyone in a long-standing relationship will admit. In fact, if one were to track the topics of conversation between spouses and family members over a period of time I predict that one would find the same topics in one form or another repeated. This includes the common topics related to work, especially when there are conflicts or important decisions to be made or about important family members that includes children or parents depending on one’s age. I would suspect that if there were a prohibition on the repetition of topics to be discussed between partners and other family members there would be very little to be discussed.

A very common point of evidence to this phenomenon is the discussion of newsworthy items and political views. Any member of a couple usually knows pretty well the political views of the other partner. When in a social setting the topic comes up they often patiently listen to their partner express their views to presumably a new audience (although this to the chagrin of some friends or family members is not always the case) without interrupting the narrative with statements such as “we have heard your views before—if you do not have a new one just stop talking”. That would be considered extremely rude and likely the basis of the disruption of a social or personal relationship.

The question and challenge for those facing the extremes of repetition in a loved one who is developing or already has evidence of dementia is what to do? Those in such situations usually learn very quickly to avoid conflict that interrupting the recounting of an event already recounted with a “you told me already or I know” usually results in some element of conflict with a denial that the conversation in fact has taken place. Also, in the context of normal aging, family members may find that the propensity to retell and recall one’s life narrative occurs more and more frequently. This is partially because it is one of the ways all of us validate our lives which is important as the past becomes increasingly important compared to the likely options for the future. It is because of this human need to tell our narratives that there is such an interest by many in writing autobiographies and memoirs and an interest in readers in learning about other people’s lives, some because they are “famous” and others because they are deemed to be interesting or unusual and at other times because the reader finds the particular narrative congruent with their own life experience. The recognition that another’s life story in some way intersected, overlapped or was in parallel to one’s own is a very powerful way of validating one’s own life and confirming its relevance and importance.

A special dimension to repeating stories and recalling the narrative is when those stories are associated with great suffering and pain. Those of us that deal with Holocaust survivors, or those who have lived through other atrocities as have occurred in many parts of the world in the last century may be plagued by the content of those stories and the retelling may be associated with great emotional reactions. This can be very disconcerting to a family member especially as each retelling of the story becomes in essence a re-living of that particular horrific episode in that person’s life.³

The best recommendation that I can make about this inevitable process of repetition of a loved one’s “stories” is to find ways to be patient with them and accept that even though you have heard the story before, actually acknowledging it and expressing an interest in it is helpful and even therapeutic to both of you.

Bursack, CB. What to Do When a Parent Repeats the Same Things Over and Over? Aging Care.com, http://www.agingcare.com/Articles/elders-repeating-the-same-story-146023.htm
Mild Cognitive Impairment (MCI); What do we do now?, Prepared by the Center for Gerontology, Blacksburg, VA October, 2006; http://www.gerontology.vt.edu/docs/Gerontology_MCI_final.pdf
Gordon M. Dementia and the Holocaust: What to do with those memories? January 29, 2012, HealthPlexus.Net: /blog/dementia-and-holocaust-what-do-those-memories

Special Mentors in My Life: the Path to Geriatrics and Dementia Care

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I am reading the biography of a well-known author. Like other biographies, one of the wonderful aspects of such writing is appreciating those people who have had a profound influence on the life of the person whose biography is being read. We all know about the usual influences from family members, teachers, friends, colleagues and sometimes people whose influence was one of those haphazard accidents of circumstance and nature. Sometimes it might be a book or lecture, movie, poem or piece of music that has had such an impact on a person’s life that they attribute who they are, in least in part of that particular person or event.

I can identify a small number of people, events or books that had such a profound influence on my life and I sometimes wonder what would have happened had those influences not occurred. Of course I had a number of teachers in primary and secondary school that were inspirational and supportive of my inquisitive nature as well as some who were quite suppressive of my interests that were somehow outside the formal structure of the school system. One example of a suppressive spirit was an English teacher I had in junior high school who after reviewing the books proposed for in-depth book reports as a special project literally “forbad” me from reading Thomas Wolfe’s classic Look Homeward Angel which I had in fact already read, but because of her dictum was not able to use it for the book report—her motivation was her self-internalized Catholic beliefs and the negative view of such a book by the Catholic Church—such a prohibition would not be acceptable currently, but at that time had a profound influence on me as she told me the book was “evil” when I had found it inspiring—both components of the event influenced my views of the Church which had not been particularly positive as a young Jewish boy knowledgeable of the history of the Church in Jewish history, the events of the Inquisition, and most recently the Holocaust. Wolfe remained one of my favourite authors throughout the rest of my developmental years. The official Catholic prohibition against the reading of certain books was reversed by an official Papal decree published on the 15 June 1966.

The negative influence of certain teachers, books and events which often had the opposite effect of the intended or expected was more than balanced by those individuals, books and events that helped nurture those aspects of my personality and value systems that ultimately were instrumental in my ultimate choice of profession and my deeply ingrained value systems which were incorporated into my personality inclinations.

It was in my first year at Brooklyn College, that I entered in 1958 after graduating from the exceptional Brooklyn Technical High School which set the stage for my life-long interest in science, engineering and the desire and ability to “fix things” a character trait supported by my father’s engineering profession and his personal capabilities as a perpetual “fixer” of all things that had a mechanical source of function. The two first year college teachers were quite different, but their influence was similarly profound. I had entered college as a pre-medical student which was a decisive change in my original post-high school goal that was to apply for a degree in engineering, in the footsteps of my father. This decision was changed by a book I read during my last year of high school which profoundly changed my educational directive and in essence the course of my adult life.

I do not recall the reason I chose to read The Citadel by A.J. Cronin. I was an avid reader, but why this particular book caught my attention is no longer part of my recollective capacity. It may very well have been one of those events that “just happened”, the book was there and it looked interesting. The result was dramatic. I suddenly thought about studying medicine rather than engineering which had been my direction. Soon after I read the book I visited a dear friend, a girl about whom I had romantic fantasies, but who looked to me as a close friend which in the absence of the alternative coming to pass I cherished. I mentioned to her my musings about medicine and she said with great certainty and passion, “You would make a much better doctor that engineer—do it”. I left her house and within about 10 minutes I pondered her statement as I arrived home where I informed my parents about my decision (which during that 10 minute walk had been finally determined). I could see that my father was pleased, but he was not a very verbally expressive person. My mother said, “Oh it is such a long time of study”, but I got the sense that she was pleased as well. At this point there were no doctors in my extended family although other than my mother all of my immediate elders despite coming from immigrant uneducated parents had finished at least undergraduate university degrees. So this would be a new venture for my extended family that ultimately produced a number of physicians—including a very close first cousin and a number of second cousins.

The decision on my part to study in Scotland was the result of spending six months traveling around Europe during my junior year at Brooklyn College, an undertaking stimulated by one of my first professors in social sciences in my first year required course. Edgar Z. Friedenberg, who beyond mesmerizing me in his classes and stimulating me to want to travel, engaged me on my return from my sojourn through Europe that eventually completely changed the direction of my life and studies, as a research assistant for one of his seminal books, the Vanishing Adolescent published a year after I left for medical school. He had such a profound influence on my thinking and the range of my intellectual interests that I felt honoured that he kept in touch with me, even arranging a couple of trips with him to overseas destinations while I was studying medicine in Dundee Scotland. He left the United States and immigrated to Canada to teach at Dalhousie University. His move to Canada mirrored a similar move I made in 1968 also for the same reason—in opposition to the Vietnam War, not as a pacifist, but because I felt the war was a terrible mistake of United States policy.

In medical school in Dundee had a number of mentors that influenced my views of medicine and my approach to the concepts of the “story” of medicine and during my post-graduate years my views of the relationship between the humanities and medicine. The renowned Sir Ian Hill, our professor of medicine taught the art of the lecture that enchants, elevates and deeply engrosses an audience into the mysteries, meanderings and miracles of medicine. His description of the famous Zermatt typhoid fever outbreak of 1963, the year after I started medical school, will never be forgotten and still acts as a model for me for the wonders of the sleuthing required of public health challenges. It was Professor William Walker, our head of Midwifery (Obstetrics and Gynecology in North American parlance) who during my final oral examination asked me why I had a Scottish family name that allowed me to weave my family’s genealogy tale to the point of using up all of my time short of one quick obstetrical question and that resulted in the 500 pound prize. That windfall ultimately financed my trip to Israel that resulted in my connecting to the country in a way that had an impact on my life as almost nothing else has in my adult years.

It was another William Walker who went from the Department of Medicine in Dundee to Aberdeen who I followed there for my first house job (internship) who had the profound influence on my appreciation that one could combine a love for the humanities and medicine. While in Dundee he gave a series of after-hours lectures on “Humanism” which had a profound effect on my world view, already having been primed by my previous exposure during undergraduate education and range of reading. I was so impressed with him that in the culture and practice of post-graduate training in Scotland in those days I deliberately requested on a personal basis that he take me on in the department he was to head in Aberdeen, which he did, and that turned out to be one of the best clinical experiences of my career.

It was the five months following my Aberdeen house job that had the most profound effect on the trajectory of my life. With the 500 pound prize that followed my midwifery examination, I received permission to use it to fund a second “house job” in midwifery in Haifa Israel, a place I had visited as a medical student two years previously. It was during that student visit that I had an epiphany in terms of my identity. Although I was raised in a Jewish family, mostly of secular Jewish persuasion other than my paternal grandparents, I had not a particular interest in that identity other than from the strong historical and cultural ties that I felt. I had a strong sense of the importance of the Holocaust on the history of my people, but Israel itself held no particular powerful attraction to me as it did for many other people with my background. However, in response to many questions from family members why I did not visit Israel while already being on the “other side” of the Atlantic I decided to combine one of my summer medical training experiences to include Greece for a month with a follow-up month in Israel which was “just across the Mediterranean.”

I had arranged to work at the Rambam Hospital in Haifa, named after the great ancient Jewish medical scholar and sage also known by his more complete name (Moses ben-Maimon, or more commonly Maimonides).

The profound experience I had occured on the second day after settling into my small prefabricated hut that acted as housing for interns, residents and visiting students like me. I went to the beach that was adjacent to the hospital which sat on the Mediterranean shore and as I looked around at the throngs of people, many with small children, somewhat reminiscent of my exposure to Brighton Beach where I was raised, I had a sudden wave of recognition. I thought to myself, even though these people were strangers, “these are my people”, every single one of them. When I went on the local service bus the next day I had the same revelation. I kept looking at the different faces, clearly from different parts of the world, light skinned like myself, Slavic looking women with high cheek bones, but fair eyes, dark skinned men with almost black eyes, all speaking what I knew must be Hebrew despite my limited exposure to that language during my upbringing other than what I learned mostly by rote for my Bar Mitzvah. I kept thinking, “I share a history with all of these people”.

I started working the next day and met the head of the department among other members of the staff. Professor Aharon Peretz welcomed me warmly, asked about my heritage and established that he and my grandparents came from Lithuania which I could see meant a lot to him. He asked me what I wanted to learn and when I said “anything and everything” he said I could shadow him in all his clinics as well as other members of staff and if I wanted to assist him in the operating room that too would be fine. I could not believe my good fortune as being in the operating room at that point in my studies was still an exciting option which I did not have that much access to at medical school. I did not realize that the interns on the service would be more than happy to have someone else stand during surgeries and hold retractors which for me was still very exciting as the professor explained everything that he was doing and pointed out all the anatomic landmarks that I had seen only on my anatomy cadaver.

I learned a lot during that month and was given a great deal of latitude in what I could do. I observed Professor Peretz interview patients with various gynecological problems who had been holocaust survivors and were applying for reparations. I noted that whatever the condition which he was very good at explaining to the patient in Hebrew or Yiddish or Russian or it seemed whatever language was necessary, he then explained to me and then signed the necessary reparations form which I learned went to an adjudication committee in Germany which decided on the merits of the claim. When I naively asked if all the conditions were Holocaust related, he paused for a moment, looked at me deeply, drew in a breath and said in perfect English, “As far as I am concerned, every gynecologic problem that afflicts these women either directly came from the holocaust experience or was exacerbated or complicated by that experience. I could see from the look on his face that he felt this was a mission of his to make some sort of amends for what these women had experienced during their years as prisoners, refugees, people in hiding or just experiencing the cold, hunger and monumental trauma and grief related to those dark years of their lives. I only found out later that he was one of the key witnesses during the Eichmann trial in Israel in 1961-62. During a recent visit to a special exhibit at Yad Vashem (the Holocaust Museum) in Jerusalem I saw a picture of him bearing witness at the Eichmann trial, and seeing him there brought back a flood of memories of my time with him in Haifa.

When I left to return to Scotland, I recall the great sense of a new chapter of my life opening up that I did not realize was there. On my return to Dundee I had not formulated a definite plan of return, but knew that in one way or another I would be back to the country I had discovered resonated in my inner-most consciousness. After I received the prize in midwifery and confirmed with my professor that I could use the 500 pounds for a repeat visit to Israel to do in essence part of my internship in obstetrics and gynecology, my plan began to solidify. I would do my first 6 months of post-graduate training as a house-officer under the supervision of Dr. Walker the internist-humanist who had moved to Aberdeen where he agreed to take me on, and then I would return to Israel, a visit I looked to with great anticipation.

Dr. Walker in Aberdeen had a profound effect on my approach to medicine, but also to all the people with whom he came into contact. It was from his modeling and style that I realized the importance of acknowledging and asking the opinion of nurses with whom we were doing rounds, a practice that I integrated into my style of practice after witnessing its positive impact on the staff during that six month period. He deferred at times to the opinion of the head nurse and always sought the input and opinions of the house officers with whom he did rounds, sometimes writing in the chart that a certain idea or suggestion came from one of us—something I had never witnessed before from a staff physician. He could be critical in a very instructive way, but when he praised me for something I did he gave me such a lift and that too became part of my practice-style when I entered into the role of a medical teacher and mentor.

As I came closer to my career choice I had the various influences of rotations, specialties and probably most important the mentors in my life. As it turned out when I ended up settling in Toronto, rather than pursuing a career in nuclear medicine which I had come for, but soon found that the lack of patient contact made it not particularly attractive for me. It was then the influence of two wonderful physicians in Toronto that pointed me in the direction of geriatrics: the first was Dr. Abe Rapoport, an internist and kidney specialist that I had met and gave a lift to in Jerusalem just prior to my move to Toronto, ostensibly to learn nuclear medicine and bring it back to Israel where it had not yet been developed in any substantive way. While driving him back from Hadassah Hospital where he had given a seminar that I attended to the centre of Jerusalem I mentioned that I was going to spend a couple of years in Toronto. He said, “If I can help you when you are there, please feel free to contact me.”

After a number of months doing nuclear medicine it became clear to me that it was not a specialty suited to my medical interests and personality, I did seek out the advice of Dr. Rapoport. After I told him about myself he suggested I look into Geriatrics and contact the people at Baycrest while at the same time pursuing a chief residency position that I became aware or at Mt. Sinai Hospital. When he mentioned geriatrics as something that might satisfy my desire to continue in a broad based specialty in internal medicine and not focus on just one organ system or realm of diseases (such a specialty in infectious disease might provide) I conjured up recollections of the wonderful geriatric unit in Dundee where among other things the staff physicians were among the best in the medical school and the patients were delightful—often referred to with endearment as auld wifies.

I followed up with a visit to Baycrest and when I was offered the position of chief resident at Mt. Sinai Hospital with which Baycrest was affiliated I requested of my second wonderful mentor, Dr. Barney Berris, the head of the department with whom I would be working if I could do the Baycrest consultations who were at Mt. Sinai while I was working for him. He agreed and besides being a mentor in terms of gentleness, clinical brilliance, and warmth he helped me formulate my career in geriatrics which when I passed my Royal College examinations that fall, resulted in him and another mentor, Dr. Henry Himel, the chief of medicine at Baycrest offering me a conjoint position which I accepted—thus determining my career path.

For many years my roles and path of academic development moved in a very satisfying direction with areas of great satisfaction in many domains especially in teaching and writing. I had always had an interest in writing, but with my academic roles the opportunities grew and I was able to undertake initially academic articles and then in 1981 my first book was published, Old Enough to Feel Better: A Medical Guide for Seniors. With it a new aspect of my career was launched that of author and over the years since that time a number of other books in addition to articles for the professional and lay press where the objects of my writing interests, all of which reflected my experiences in medicine and the care of the elderly.

As the various challenges of geriatric medicine began to coalesce in my practice I became increasing interested in the ethical aspects of eldercare which resulted in my completing a masters in ethics which was soon followed by an interest and the incorporation into my clinical and administrative practice palliative and end-life care—with all these threads of these special interests intersecting in a very meaningful way.

This eventually resulted in the focus of my clinical care, ethical deliberations, writings and teaching to become increasingly focused on dementia, especially the later stages where special aspects of care and caring come into play and where ethical conundrums become very common. The culmination of these influences has been my most recent book, Late Stage Dementia: Combining Compassion, Comfort and Care. The result has been a dramatic shift in my approach to my clinical ambulatory practice and focus on my teaching of trainees who accompany me in the clinic and my role helping those in our palliative care unit understand the special challenges of caring for those with non-malignant disease especially those with dementia, an increasing challenge in the long-term care system.

I have been very fortunate along the path of my career to have had many teachers and mentors who have inspired, guided and influenced me on the path that finally became my own and now gives me the opportunity to do the same for my students and medical trainees. It goes back to one of the tenets of the teaching of medicine, that one has the duty to learn and then the duty to teach so that the continuity of the wonderful art and science of medicine is assured for the future.

Being Rich, Famous or Smart: No Immunity from Dementia

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I can usually anticipate where the conversation is going when a family member accompanying a loved one living with dementia to my clinic starts the conversations with the words, “Surely, in this world of modern medicine, there is something more we can do to halt the decline in my (fill in whichever family member is effected). Sometimes this phrase is said with a degree of anger, sometimes with anguish and sometimes with a degree of aggressiveness as if somehow I, a geriatrician, and not a neurologist or psychiatrist might be inept in my knowledge or “holding back” on some new discovery that I do not know about. Sometimes the question is accompanied by a package of internet-based articles on “new or novel” treatments for dementia ranging from megavitamins of the already known and touted category (and generally proven ineffective in the evidence-based medical literature) or a concoction with a mysterious ingredient that “doctors won’t talk about” as they work in cahoots with the pharmaceutical industry.

Usually, even though often quite time consuming, a careful explanation of the state of the knowledge of treatment of dementia of the various kinds (the most commonly defined being Alzheimer’s disease), the person can be brought back to the reality of the current state of affairs. Most times they can be brought to focus on the real challenges that will be faced as the course of their loved one’s condition declines and they must face the very difficult decisions that will ultimately occur including planning for challenging behaviours well beyond the cognitive decline and the inevitable need to plan for end of life care that almost always occurs at some point in those who reach the later stages of dementia.

I recently saw the movie, The Iron Lady that looks at the developmental and political life of former Prime Mister of the United Kingdom, Margaret Thatcher, from the vantage point of her experiencing the earlier and then later stages of dementia. It vividly portrays the impact the disease has not only on her behaviour, memory that includes a very poignant and vivid melange of past recollections and current experiences. This is something all of us working the field recognize in our patients and which we must often explain to their family members. One often hears the lament, “She can remember in great detail her sea voyage as she escaped the ravages of the war in Europe or her childhood run-in with her brother in the village in the Ukraine, but cannot remember what she had for breakfast today”.

Sometimes the intrusion of experiences from the past can cause great agitation and behavioural outbursts and sometimes can lead to warm and sometimes tearful recollections about loved ones that they think are still alive and are distraught to find that they have died. This is something illustrated in The Iron Lady when Thatcher’s daughter has to remind her mother of her late husband’s death as she struggles with emptying his clothes from the closet and donating his previous belongings that she can associate with in her memories of him that enter and leave her consciousness as she struggles to recall the events of the present.

The movie with the stunning role of Thatcher played by the incomparable Meryl Streep stirred a sense I have had previously as I observed some of the greatest or best known minds or public figures in the world afflicted by the usually devastating effects of one form of dementia or another, most often of the apparently Alzheimer type. This has helped me explain to the family members of my own patients that “surely me” with their scepticism that either medical science can be so limited or I can be possibly “out of date” in my knowledge of contemporary advances in the disease. It becomes evident to them that some of the most famous and wealthiest people in the world when afflicted with this condition, suffered in the same way as their loved one, despite presumably having access to the greatest medical experts available in the field.

In my own lifetime I remember the gradual decline of the late President Ronald Reagan who those of us in the field suspected he was beginning to develop symptoms of the disease as in his public appearances he seemed to rely more and more on the side whispers of his wife Nancy, the first lady, in a way reminiscent of what occurs in our office visits of many of our patients who when asked a relatively straight-forward question quizzically turn to their loved one, often unconsciously for the answer or to support the answer that they bring forth. We often use that common manoeuvre by our patient as a pretty sound clinical indicator of problems with cognition even though it can be quite subtle and the spouse (most often or sometimes it can be a child) may not even be aware of their response to support the ability of their loved one to function cognitively, although when asked directly they usually acknowledge that occurrence as part of their communication interaction.

Of interest is the family conflict over when the late President demonstrated some impairment of his previously sharp mind and wit and facility with words. The difference of opinion expressed and documented by his two sons has led to differences of opinion among them and has become an historical talking point- the question being– when did the 40th president begin to become mentally impaired by the disease? He was formally diagnosed with Alzheimer's in 1994, five years after he left office. Reagan died 10 years later at 93. His two sons differ in their opinions on when the symptoms first began but the controversy is not unlike that which all of us that practice geriatric medicine and deal with dementia see in our own practices as family members differ as to when a loved one first manifested some evidence of loss of cognitive function. With the variability in the course of the disease which for some starts with what is often called mild cognitive impairment which in many but not all gradually evolves into obvious dementia which itself can have a variable course depending on its own trajectory or one modified by the use of so-called cognitive enhancing medications, it is not surprising that in retrospect it might be hard to define definitely when the symptoms of Alzheimer’s dementia were clear in someone with such a public profile as the late President.

The film The Iron Lady reminded me a bit of a previous film in which the main character was a famous author, Iris Murdoch. In the film, Iris, the progressive decline of this gifted writer into the depths of deepening dementia is witnessed by her husband, played as it were by the same actor that played Margaret Thatcher’s husband, Jim Broadbent—a gifted and talented man who may have learned a great deal about the condition now that he has played a role in essence similar stories, both replete with movement from the present to the past. Both films capture important aspects of dementia and the powerful impact of such a disease on the person of such intellect and talent.

In my own personal associations with dementia two of the great mentors of my medical career developed dementia in the latter years of their life—despite lives and careers of great accomplishment and intellectual challenge and productivity. One physician was instrumental in my choosing geriatrics as a career, almost inadvertently and the other in arranging for my early association with Baycrest Centre which became the focus of my clinical and academic career.

Lastly, my own father who had a profound influence on every aspect of my personality, emotional, and intellectual development and character traits suffered from dementia in the last part of his life providing me with the opportunity to experience as a loving son and sibling of my most devoted sister who was the “it” in his care as he lived out his last years in a Chicago vicinity retirement home under her watchful eye aided by a most devoted personal care worker. It is through his life’s last experience that I get much of my fervor about the importance of “having the conversation” about the wishes and life’s values with those we love who are living with dementia so that when the time comes for difficult decisions at the end of life to be made, we, the loving family members who are the substitute-decision makers will have the strength and courage and devotion to their expressed wishes or value systems to act to promote compassion, comfort and caring at the end of the struggle with dementia.

For those of us who must respond to those family members who interject the “surely, there must be more that can be done for my (father, mother, aunt etc.) in this world of modern medicine, we who carry the responsibility of providing the best of available medical care, can draw on our collective personal and professional experience to provide an acceptable response to the questioner. To be able to recount the lives of the rich and famous and talented to confirm the limits of modern medicine allows us to demonstrate that even they have had to live with dementia in the same way in essence as the loved one in question. We doctors, along with their family member will care for to the best of our abilities and within the confines of contemporary medical practice, those that are living with dementia throughout the course of the disease as they enter the last stages of their life.

Dementia and the Holocaust: What to do with those memories?

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Dementia poses many difficult challenges and choices to those living with the condition, and to those who are close to the person who has the disease. No one is spared the collective experience that dementia often causes when individuals and their families and friends and those in the role of professional caregivers are faced with as a result of the many cognitive and behavioural challenges that are often poignant and terrifying. During a recent media interview on the subject of behavioural symptoms associated with dementia and the array of potential interventions including medication therapy, I described to the media interviewer the special challenge that I have encountered when trying to address the complex and often terrifying events that affected holocaust survivors as their distant horrific experiences come to the forefront of their consciousness. This is usually much to the dismay of those caring or living with them who often seek some respite from health care professionals to help their loved one find relief from the horrors of their memories.

The interviewer, presumably as a way of categorizing the anecdote I was describing to her of a recent patient I saw in the clinic said, “Oh, I guess it is a post-traumatic stress disorder experience” which I agreed to without really having the chance to dissect and realize that the analogy was at best superficial. I realized that the comment an analogy did not fully capture the profound impact that the holocaust experience had for many of the older patients I care for and the effect that those life events of the holocaust itself added to what was for many a previous life as an outsider in a world in which they were never really welcome and for which the holocaust was a final devastating chapter on top of a life of fear and insecurity. I concluded to myself after the discussion that there was a different element to surviving the holocaust, especially in those from Eastern Europe that multiplied the concept of post-traumatic stress disorder as a way of understanding their experience of the holocaust and how it effects their life as they develop symptoms with dementia with its cognitive disruption and ultimately behavioural manifestations.

Most people who suffer the various iterations of post-traumatic stress disorder (PTSD) had prior to the event that was traumatic a reasonably “normal” life experience. That does not mean that everyone had a quiet, safe and sedate life but most did not have an experience of a comparable magnitude that was deemed to be the type of stress that can be categorized and sufficient to cause PTSD. Among the common events to which this syndrome has been ascribed is war and how it impacts soldiers who have survived,, people who have lived through natural disasters that resulted especially with the loss of life, either of close family and friends or of entire neighbourhoods or communities. For some it may have been a violent and close encounter as may occur in a capital crime such as a witnessed murder or the tragic loss of a loved one in other tragic events such as a motor vehicle accident. Whatever the cause, usually the preceding life experience was nowhere near the magnitude of the tragic occurrence as the event itself.

The difference that I have seen with many of the holocaust survivors that I have treated for dementia and related conditions is that prior to the holocaust they had witnessed or been subjected to a vast array of life-threatening, life-demeaning or harrowing experiences related to virulent anti-Semitism that was often rife in the communities that eventually succumbed to the holocaust period. However, there were some stark contrasts between different European communities and how the holocaust manifested itself. Those Jews that lived for example in most of Eastern Europe experienced severe and often individually murderous and harmful anti-Semitism long before the holocaust period as part of ambient culture and strong negative bias towards the Jews. For others such as the Jewish population of Germany that had endeavoured to be absorbed and accepted into the general community, the “shock” of rabid anti-Semitism and harmful actions was for many difficult to fathom or accept.

For many of the holocaust survivors that I have seen in my clinical practice, the memories of the past are often something that plagues them as the present and the ability to recall new items is lost and all they have to dwell on is the past. I remember one patient, a Polish holocaust survivor whose family was endeavouring to find a live-in support person to look after their mother as part of their commitment to try to keep her at home rather than have her admitted to a long-term care facility for which she qualified. They were looking for someone who could speak to her in her early spoken languages as with the dementia taking its toll, her English which in any event had not been well developed gradually slipped away and she reverted to her mother tongue which was Yiddish with Polish being remembered, but not used often.

According to the daughter in the distant past they had a Polish speaking housekeeper for her mother with whom she got along with quite well and there were never any problems between the two. The daughter found a Polish speaking person to be a support worker/caregiver to live in the home with her mother as a Yiddish speaking caregiver could not be found and those from other backgrounds that they spoke to were not able to communicate adequately with the mother for a relationship to develop. The daughter was very pleased to interview someone who had the qualifications she was looking for as a care provider who also spoke Polish. To the shock and horror of the daughter within a few hours of the person beginning her first day on the job she called the daughter and said she was being screamed at and cursed by the mother and wanted to leave which she did as soon as the daughter arrived.

The mother was in tears and shaking as she explained to her daughter that she was exposed to an anti-Semite and was fearful whenever the caregiver opened her mouth and spoke to her in Polish. She kept reiterating the threat she felt from being in the presence of someone speaking Polish and was sure the person had the intent of hurting her. No amount of explanation by the daughter was sufficient to calm her mother and get her to understand that they were no longer in Poland and that this woman was not a threat—needless to say the Polish caregiver did not return and an English-speaking Filipino woman with lots of experience and a gentle disposition was found with whom the mother managed to communicate adequately for her needs to be met.

To summarise my point, in order to provide an appropriate and sensitive level of care, when dealing with those patients who suffer from dementia and who are holocaust survivors, treating physicians and caregivers must understand that although there are some similarities between Holocaust survivors and those suffering from PTSD, there are many differences that need to be recognized as well. A more robust understanding of and attention paid to the pre-holocaust experience must be included in the evaluation of behaviour so that appropriate steps can be taken to minimize negative and frightening associations with past experiences.

How Can You Remember What You did not Hear?

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A lot of effort goes into alerting people to the symptoms of Alzheimer’s disease and other causes of dementia. Organizations such as the Alzheimer Society have done a commendable job in helping the lay public as well as health care professionals as to what the symptoms and signs are in people showing evidence of possible cognitive impairment and urging them to see seek assistance, assessment and advice. Among the cardinal symptoms that most people now recognize as potentially pointing to such a clinical problem is memory impairment. In fact for many lay people their concept of dementia focuses almost exclusively in memory rather than the various behavioural symptoms that may also be indicators of underlying cognitive impairment such as depression, agitation, easy irritation and a wide range of other apparently “mental health symptoms”.

It is well recognized that hearing impairment is a common phenomenon in the older population. Many individuals have at some time in the their later years recognized a degree of hearing impairment and many do seek advice and may eventually undergo hearing enhancement and routine follow-up by qualified health care professionals in the field of hearing such as audiologists and Ear Nose and Throat physicians who may provide regular monitoring in addition to what may be done by a family physician. There are however a great many elders who deny that they have a problem or who, for one reason or another, choose not to wear hearing aids and they and their family members may just accept the need to raise one’s voice and repeat things in order to communicate. It is this group that may present with a concern about cognitive impairment that health care providers as well as family members must be alert to in order to provide proper interventions and to avoid erroneous assumptions about their cognitive status.

It was a bit of an unusual clinical situation, two patients in a row that I was evaluating because of concerns about dementia based on observations by family members of apparent problems with memory demonstrated significant problems with their hearing. In one situation the hearing issue was evident as soon as I started doing my interview but in the second circumstance it took a while and some probing to ascertain that hearing impairment was an ongoing issue but did not on the surface to cause much in the way of problems, at least according to the patient and family.

In both situations after my interviews which included seeing the difference between speaking to the patient face on so my lips could be read and speaking to them “sideways” which of course occurs commonly during various types of conversations it became apparent that they were “filling in” the gaps from their hearing using other clues such as body language and lip reading.

It reminded me of the long process of getting my late father to acknowledge that he had a hearing problem and finally accede to some sort of amplification system. For the years that he was still living alone in Brooklyn when I would phone on a weekly basis to “catch-up” on his progress and function it was clear that he was having problems hearing the phone conversation even after we had the phone modified with an amplification device. On one of his visits to Toronto I arranged a formal audiology examination and the result confirmed the hearing impairment. I had explained to the audiologist that my father was an engineer and very knowledgeable about how things “worked” and claimed that his hearing was fine so that convincing him of a problem would not be easy. A the end of the examination the audiologist demonstrating her respect for his knowledge and understanding said to him, “Mr. Gordon, you are correct that your hearing is adequate, but your discrimination is very poor, that is your ability to distinguish between the different sounds creating a problem in your ability to actually interpret what you are hearing.” He accepted the explanation but remained resistant to any amplification system such as a hearing aid.

In both of the patients that I saw on that morning, they had in the past been tried with hearing aids but rejected them because they were either “uncomfortable” to use or had a lot of “noise” that made them difficult to tolerate. The children acknowledged some attempts in the past but just accepted that the rejection of the devices was the end of the story and did not associate what was clear to me to be significant hearing impairment to their current complaints of memory deficiency. Each of the families were especially concerned that when they had conversations in person or on the phone, sometime after the parent acted as if there had not been a conversation and could not remember “what was said or agreed to when for example a meeting was being arranged.”

The formal mental status examination in both cases revealed some deficiencies but not of a degree that might necessarily warrant medication intervention or a firm diagnosis of dementia. I then put on each patient a Pocketalker which is a simple amplification device that through earphones and a small amplifier the size of a pack of cards allows conversations to be amplified. The device I use in my office is in fact the one that eventually I obtained for my father and for more than a year it improved his hearing and quality of life substantially.

In each case, with the device in place and the volume turned up modestly there was a look of surprise on the face of the patients and an acknowledgement that they could hear better and they could answer questions without the previously noted hesitation prior to wearing the amplifier.

Each family promised to rent for a trial or purchase the device and see how things were over the following few months after which I would do another assessment. Whether the amplifier will resolve the apparent memory problem completely remains to be seen, but as I have often said to families and patients, “If you did not hear it, you cannot remember it.” Even if there were a component of cognitive impairment along with the hearing deficiency, improving the ability to hear would only enhance whatever other interventions would occur to improve cognition and function.

Egypt Memories

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The closest I came to Egypt was the Sinai Peninsula which was under Israeli control following the Six-Day War before it reverted back in 1979 to Egypt’s jurisdiction under the Sadat-Begin accord stewarded by then President Carter. From 1970-71, during my service in the Israel Air Force as a physician, I would rotate for duty at Rephidim Air Base which was the Hebrew re-name of Bir Gifgafa, which was the Egyptian name for the isolated air strip 90 km east of the Suez Canal. It would be my home for three days every month to make sure our advance station pilots had round the clock medical access. They literally sat in their Mirage interceptors for hours on end. I and the other doctors were there to care for them and the crews that serviced their planes. The mosquitoes at night were terrible and I recall looking at the blood speckled wall, where I had successfully swatted my nemesis. No matter how often the screens were repaired they always managed to enter my Spartan room, my nose and ears and every part of my skin even though I slept, despite the heat, covered from head to toe by blankets.

From Rephidim we performed helicopter evacuations all along the Bar Lev line. This was the first line of defense on the Suez Canal. We also covered the armor and infantry bases spread around the Sinai as part of the defense against Egypt with whom during the period of my service, the War of Attrition: in essence an air, artillery and missile war took place. Sometimes a mission required the helicopter evacuation crew to move closer to the Canal Zone if we were in a situation in which forces might cross the Canal and might need to be evacuated from enemy territory.

Serving as an Israeli Air Force base doctor

I recall one such mission where our base for over-night readiness was a Hawk anti-aircraft missile encampment. I watched mesmerized: the battery of Hawk missiles rotated rapidly and whiningly every time an Egyptian plane took off from beyond the Canal and headed towards Israel even for only a few moments before it veered in a different direction. I had a vivid nightmare of having crossed the Canal to extricate a soldier and being pursued by Egyptian soldiers to whom I was trying to explain that I was a doctor from Brooklyn and would not be much of a prisoner pleading my case while brandishing my Beretta side arm which I had learned to use months earlier during my officer’s training course. When I awoke in the morning, having slept fully clothed in my khaki multi-zippered flight suit, the sun was rising, the Hawks were quiet and the helicopter captain was giving orders to my medics and paratrooper crew to pack our things as we were “going home” (“ha beita”) -- a phrase I mastered early in my quest to learn Hebrew, literally “on the job” during my air force service.

During my last six weeks of military service, by then as a reservist, after having completed my regular military duties and just prior to my leaving Israel for post-graduate training in Montreal, our helicopter got a call to evacuate a Bedouin boy with measles and severe dehydration from the Sinai Peninsula in the region of Santa Katarina. This was the site of an ancient monastery at the foot of Mount Sinai where according to the Old Testament; Moses received the Ten Commandments from God. With the setting sun swathing the desert with pink and purple hues, the monastery loomed ahead, barely visible in the darkening horizon. As we landed near the spot, illuminated by a few flares lit by a district field nurse, we could see a small make-shift stretcher holding a boy who, when I got close, I could see was covered in a measles rash and was severely dehydrated and delirious with fever. His father looked at me as the nurse explained who we were and I said my “salam aleykim” greeting as the boy was prepared for the flight to Eilat, where we had arranged for his treatment. I managed to get an intravenous into him before loading him into the Bell helicopter knowing how difficult it would be to successfully undertake such a maneuver with the jolting, undulating and bouncing movements, once the helicopter was in flight.

Santa Katarina Monastery with the Sinai range in the background, Egypt

The father followed in after the boy, his eyes wide in wonderment. The flight did not take that long and I felt the comfort of the dripping of the intravenous into the boy’s arm and anticipated that he would be fine once he received enough fluids. This was confirmed the next day when the hospital was contacted for follow-up so I could complete my medical evacuation report.

It would have been nice if my associations with Egypt, which had just recently made the front pages of newspapers, computers and television world wide, as the population successfully revolted against its dictator Hosni Mubarak, could have been more positive. While trying to empathize with those demonstrating in the streets I could not suppress my negative experiences as the air base medical officer who had to bear witness to the Egyptian military treatment of two of the pilots from my air base whom they had captured. As the television news continually showed the mounting political crises, I happened to be reading David Grossman’s latest book To the End of the Land in which one of the main characters recalls his torture and suffering at the hands of his Egyptian captors and another character describes the terror experienced by the soldiers left in the bunkers on the Suez Canal’s Bar Lev Line, having learned that massacres had occurred to their colleagues in bunkers that had been overrun by Egyptian soldiers who had crossed the waterway at other junctures at the beginning of the 1973 Yom Kippur war.

My first actual associations with Egypt related to Israel, occurred during the early summer of 1967 after I had finished a 5 month internship in obstetrics and gynecology at Rambam Hospital in Haifa. This followed a 6 month internship in Aberdeen Scotland which took place after my graduation from my medical school in Dundee Scotland in June 1966. I left Israel in late May 1967 to visit my sister who was a Peace Corps worker in Tunisia. As I left Israel during those late days in May and arrived in Tunisia in early June, the atmosphere in Israel was foreboding as Egypt’s president; Abdul Gamel Nasser amassed his army in the Sinai Peninsula and closed the Straits of Tiran, choking Israeli’s water access to the Red Sea. Within two days of arriving in Hammam Sousse, a small Tunisian village where my sister was developing a pre-school program, the Six-Day War broke out on June 5th. For three days the only radio contact I could get, using a battery powered old short-wave radio, was local Arabic broadcasts which my sister could translate, and an English transmission from Egypt which chronicled the gradual and graphic destruction of Israel. The broadcasts were accompanied by martial music and the most vicious language to describe the country I had just left and the people with whom I felt a very strong bond, whose utter destruction was predicted. Fortunately all that was being broadcast were Egyptian lies and the truth came out to the world a few days into the war with Egypt eventually surrendering a few days later – but the words of the English broadcaster have remained vivid in my memory and those images although erroneous of Tel-Aviv burning from Egyptian victories cannot be erased.

The graphic and emotionally compelling account of the character in Grossman’s book brought back memories of my pilot neighbor on the air base at which I served. He was a Phantom F4 pilot and his co-pilot and navigator/weapons control person was, like all of the airman on the base, one of my patients who in keeping with their love of flying would do anything humanly possible to avoid my grounding them because of, for example, an upper respiratory condition which for them could be very dangerous with the sudden changes in air pressure but which they nevertheless tended to minimize. He was a very handsome and likeable young man with deep blue eyes and fair hair, the kind of person about whom, those who do not understand the Israeli/Jewish mosaic of appearance might say, “He does not look Jewish with his blond hair and blue eyes.”

IAF F4 Phantom

One day on the radio I heard that a Phantom had been shot down and the two crew members had been observed ejecting from the plane and parachuting to land. I was driving at the time and like anyone in my position I felt a pang even without knowing if the crew was from my base but knew that it could be the case as we were one of the bases with Phantom squadrons. When I returned to the base I discovered that not only were they from my base but indeed they were my neighbor and his co-pilot. I was devastated but immediately took on my professional role as the base doctor and visited the pilot’s wife who lived next door. She, like the wives of most pilots, had her way of dealing with this potentially impending tragedy and was receiving, as best she could all the base staff, pilots and their wives who visited to give her moral support – “after all he had parachuted out and there were international rules of war and prisoners”, even though many knew that the practice by Egyptians towards military prisoners was not always what it was supposed to be.

A few days later the news came that the two crew members were both alive but that one was “very severely injured” and the other had a fractured leg. Then weeks of quiet until I received a call at the base medical office that the co-pilot had “died” from his wounds and was being returned to Israel in exchange for some Egyptian prisoners. I heard quietly a few days later that there was evidence that his death had been due to or aggravated by electric shocks to his body. There was no new word about my neighbor.

One early evening while driving back to the base from one of my stints of working on the local kibbutzim or moshavim (communal farms) as a locum, while their doctor was often doing their reserve duty, I heard that my neighbor had been returned to Israel, very ill and was at Tel Hashomer Hospital. I wheeled around and drove to the hospital in Tel Aviv and found that he had gangrene of his broken leg and was in renal failure. As I arrived I heard that he had just been taken to the operating room for an amputation and would be going on to renal dialysis. His prognosis appeared awful and I could hear murmurs from the doctors in the hall about what terrible shape he was in and how awful had been his medical treatment in Egypt. Despite low expectations because of his terrible condition, he survived and eventually after rehabilitation and a refresher course was accepted to medical school-- something he would often talk to me about, during some of our nighttime neighborly chats, calling it a suppressed wish of his.

The last time I saw him was in the parking lot of the Tel Aviv University Medical School where unless you knew him very well you would not know he was walking with a leg prosthesis -- he greeted me warmly and told me how much he was enjoying his medical studies.

A few years ago, while visiting a family member of my wife’s brother who had immigrated to Israel, as we sat on her roof-top patio in Tel-Aviv she started talking about how strange the world could be in terms of where experiences and occurrences take you. She mentioned someone she knew “who had been a pilot, was shot down, almost died and then went to medical school….”- as she continued I sat up in my chair and asked her if she was talking about my neighbor and she looked at me and said, “you know him?” to which I said, “I was his neighbor on the base, of course.” She then told me he in fact had become a very senior physician in the air force and was just finishing his career and was focusing on archeology as a new career path. And the last piece of information was that he lived across the street. He was not home that afternoon when I ventured to his apartment but I told a young lady who said she was his daughter who I was and I wrote a little note. I was leaving the country that night so it was not until a year later that I connected with him.

After a very warm greeting he filled me in on his life and I marveled at how he managed to turn his near tragedy into a great success and was now redirecting his energies away from medicine altogether into another career. We talked about mutual friends from the base and he showed me the picture of the chief of the air force to be who was another neighbor and a star pilot who took me on a most exhilarating flight in an F4 phantom as his gift to me for having completed the first Israeli fight surgeon’s course which they allowed me to take even though my tour of regular duty was coming to an end.

Israeli Air Force days

My recollection of my neighbor who survived his captivity and torture and his co-pilot who did not, kept intruding on my thoughts as I observed in repeated episodes of televised world news, reports of what was happening in Egypt. Would these people, now free from the shackles of a military dictatorship currently at least at “cold peace” with Israel, find a way to resurrect their hostility to the country and join those whose agenda was an existential threat to the country that I love so much. As I presently follow the press reports from Egypt I feel frightened that some of the potential future leaders of the new government are those who have even during the period of the peace treaty, expressed enormous hostility towards Israel.

The confluence of thoughts and personal experiences related to the Egypt of the past made it difficult for me to share in what seemed to be a general optimism in the West about its future. I have become obsessed with the news out of that country hoping for signs that the situation will not regress and become part of a regional threat that appears to gain traction around the world that threatens Israel’s ability to defend itself and its wonderful, inclusive, creative way of life. How Egypt goes in the next little while may presage what Israel will be facing in the years to come. I hope that my personal recollections and associations will be able to be filed away as the “then” as will the literary depictions in Grossman’s book.

As someone who witnessed the sorrows of the war, if there is a return to the past hostility, with the pre-eminence of Egypt in the Middle East, my deep distrust and associations will be justified. Whatever one can hope for as a future should include Egyptian and Israeli populations that have learned from the past and will focus on peace and a desire to build a Middle East in which both Egypt and Israel can have a “warm peace” to replace the cold one that has existed for so many years.

Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com

Geriatrics: An Unintended Journey

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I looked at the certificate that came as registered mail in early December 1981. I already knew that I had passed the first Geriatric Medicine Royal College examination, with the oral taking place in Winnipeg, which when compared to Toronto was bitterly cold. I recall thinking as the examiner asked me questions that he was asking me more of an internal medicine examination than a geriatric medicine oral, but I wasn’t going to quibble with him as the encounter seemed to be going well. By the end of the day I knew I had been successful but the contents of the envelope held a surprise. In the right-hand corner of the certificate was the number one. I had received the first Canadian certificate of specialization in Geriatric Medicine which I knew was not because I was the first successful candidate but because my name must have been the first in the series of those who passed. But that number one has held a symbolic place in my life and career from the day I received that elongated piece of paper with the Royal College coat of arms in its middle.

Certificate #1 of the Royal College of Physicians and Surgeons of Canada

The journey started about 38 years earlier when I as a young boy moved from Dearborn Michigan to Brighton Beach in Brooklyn to live with my maternal grandmother. She was divorced and living alone a few blocks from the actual finely sanded Brighton Beach on the Atlantic Ocean. The apartment had only one large bedroom which I shared with her and my younger sister. My parents slept in the living room which was divided by a low-set bookcase into the sleeping area and guest area. In the guest area besides a sofa and a few large chairs was a Sohmer baby grand piano, which had been purchased by my grandmother for my mother during the depression years, being paid for by a weekly payment plan on which they never defaulted. Therefore this gorgeous piano was mine to learn on a few years later and now sits in the home of my eldest daughter who carries on the tradition of ownership.

“Tell me again about why you came to America and what was it like when you came.” That was a recurrent question I asked my grandmother, affectionately called by the Yiddish “bubby”, especially when the lights were out in the room before we went to sleep. She would recount the stories from Eishyshok , the small shtetl in Lithuania where which was her home prior to her immigration to the United States. I heard about her village and her family and then the pogrom which left many people injured and killed which precipitated the decision by her family to go to America where they already had some distant relatives.

Eishyshok in its glory

I heard about the terrible ship voyage and how so many people died because of the awful primitive conditions. She told me about living in the immigrant Jewish neighborhood on the lower East Side of Manhattan and how she got into the garment industry as a seamstress, work that was very common amongst young female immigrants. I heard from her the tragedy of the Triangle Factory fire of 1911 in which 146 of the 500 employees, mostly recent Italian and European Jewish immigrants had died, many brutal deaths from the flames and smoke or from leaping from the upper floors of the factory.

The event propelled my grandmother like others of her background and experience to become members of the Ladies' Garment Workers' Union (ILGWU), which I heard about from her and their meetings as I grew up. I did not realize until many years after her death, while cleaning up my parents’ house after my mother’s death, that my bubby had in fact completed high school in New York, at night, a feat that was quite remarkable in those days for a woman with her background.

My bubby had a beautiful voice and sang in a Yiddish Choir and often attended performances of the Yiddish theatre to which she took me when I was old enough to accompany her and appreciate what were often massive productions of song and dance. One of my tasks as my mastery of the piano became sufficient was to accompany her on the piano when she practiced for recitals. With my mother often out of the house working, my bubby was very critical to my childhood development and I loved being with her, whether it was watching her prepare gefilte fish for Friday night, chopping the fish with a hand chopper in a large oval wooden bowl or bringing her the forvitz (the Yiddish paper Forward) which she read from front to back. I recall once asking her how it was that she spoke what seemed to me so many languages and she said with a short laugh, “Where I grew up, you didn’t know from day to day who was in charge, so in order to survive you spoke all the languages you might need to get by.”

My bubby died when I was 12 years old after an illness the first evidence of which I witnessed on the way back from a Yiddish Theatre production to which she took me. It was a glorious event. On the subway platform of Brighton Beach she suddenly said she did not feel well, staggered a bit and then threw up. After a few minutes of this, she said she felt better and we got home by bus. That was the beginning of the evidence of what apparently were brain metastases from what I think was breast cancer, only because I once saw her coming out of the bathtub and even with my imperfect understanding of female anatomy I recognized that one of her breasts was missing and there was a scar in its place. Her death left a serious lonely void in my life which of course passed with time, but she was always present in my consciousness.

I loved to take things apart, put them back together and figure out how they worked. My father was an engineer and he was a whiz at fixing things. I cannot recall ever having a tradesperson in the house to repair a sink, a roof or an electric appliance. I loved the sciences and math in school and decided I would be an engineer like my father. I even went to one of New York’s special schools within the public system that catered to students with special interests and talents, Brooklyn Technical High School, geared for those interested in careers in engineering. I loved the school, especially the various “shops” which were done after the regular curriculum – woodworking, foundry, sheet metal and best of all machine shop- where one learned to use very complex and sophisticated lathes and punches and drills. Throughout my life I have used the skills learned at “Tech” as we called it, to build and fix the same things my father did during my childhood.

Brooklyn Technical High School

I was so focused on engineering that when it came time to apply to university; the schools I looked at all had special reputations in engineering or were of the high quality technical universities such as the so-called Polytechnic Institutes. Although I excelled in the sciences and mathematics in high school I enjoyed other studies and activities, especially English literature, photography and music. I had developed the habit of reading as a child when one of the weekly activities my father exposed me and my sister to was a trip on Saturday morning to the public library where as we left he always said, “The library is the greatest institution in the world” to which when we knowingly asked, “why daddy?” he would answer with, “because it contains all the knowledge of the world.”

In my last year of high school, while in the process of preparing for and applying to university, I picked up the book that changed my life, The Citadel by the physician-author, Archibald Joseph Cronin(his nom de plum being A.J. Cronin). The book so enthralled stimulated and consumed me that by the time I finished it I decided that I might change my studies from engineering to medicine. I recall visiting the home of a very dear friend-girl to differentiate her from someone with whom I had a romantic relationship, although I actually had hoped to develop one at some point. I mentioned to her that I was thinking of medicine instead of engineering, to which she replied with words that became in many ways the essential step in my decision-making process, “You’d be a much better doctor than engineer. I think you should do it.” That statement was the sum total of my career counseling.

When I broke the news to my parents, my mother’s initial reply was, “It will take so many years,” but I could see from the look on her and my father’s face that they were pleased with my decision. I therefore changed all my university applications to read “pre- medicine” in the field of interest and career goals. For reasons of finance I ended up going to our Brooklyn College, one of New York’s five schools of higher education that later on would coalesce into the City University of New York. I was a chemistry major within the “pre-med” program but managed to focus heavily on arts subjects whenever I had the option and in those days it was required to do a whole range of the so-called 101 courses in English, Philosophy, History, Classics, Social Studies and languages- to which I added a few extra English literature and Philosophy courses which looking back were among the most important educational exposures in my life and which formed the basis in many ways of my future academic and creative interests.

Brooklyn College

One of the profound influences on my education and life was Professor Edgar Z. Friedenberg whose seminal workComing of Age in America, had a profound impact on education in America. He was my Professor in my first 101 Social Studies course and indirectly stimulated me to want to travel in Europe, which at that time (the late 1950’s) was not yet in vogue and certainly not something readily accomplished by people in my socio-economic situation. My parents, being the very unusual and progressive people that they were agreed to my taking six months off from Brooklyn College as long as part of the plan was for “educational” purposes which was accomplished by attending a summer language program in Lausanne Switzerland.

That six month journey changed my life and attitudes towards education and adventure. The last part of the journey which was spent in Copenhagen, much of it in the company of a group of primarily female medical students helped formulate my determination to study medicine on the other side of the Atlantic rather than in the United States which would have been part of the “normal” chain of events. The experience overseas also exposed me to a whole new world of “other” than what were the traditional values and cultural mores and practices of America. I broke the news of my idea of studying overseas to my parents and couched the reasoning into financial terms which was one of the factors that allowed them to agree to consider the proposition. As a reflection of their progressive view of the world, the agreement stipulated a tentative agreement to include having my then 16 year old sister visit me during my fist summer to travel in Europe with me.

My original plan to study in Denmark or other Scandinavian country fell through but I was very fortunate in being accepted to the University of St. Andrews, Scotland’s first university and the third oldest in the English speaking world, founded in 1413 with the medical school being founded in 1450 somewhat after Oxford and before Cambridge in England. I was very fortunate to have been accepted a year earlier than initially anticipated and into second year because of my pre-medical education at Brooklyn College because as I only found out after my first year when my class-mates felt comfortable telling me, one of their classmates died in first year, leaving an empty place in second year. That vacant place went to me so from the tragedy of one young medical school student’s premature death, my future opened up- a bitter-sweet tale when told to me by a few of my closest class-mates.

Medical School in Dundee, Geddes Quadrangle

Medical school in Dundee where the medical was actually situated was wonderful. Once I accommodated to the dreary gray weather, the strong at times unintelligible Dundee accent, the paucity of any food worth eating other than fish and chips and the damp cold of the housing, I had a fabulous experience. The main point of my studying abroad was to travel and indeed with almost five months off a year and a system where medical students could choose places to go and get foreign experience based on place, area of study and time I managed over the years to travel and work in Scandinavia, various Eastern and Western European countries, different places in the United Kingdom, and what became another seminal experience in my life, Israel.

I was exposed to geriatric medicine as a medical student where the Geriatric rotation and ward proved to be one of my favorites because of the instructors and wonderful experience with the “old wifies” as the elderly Scottish ladies were called. One of the geriatric wards in Maryfield Hospital was made of a large room with a potbelly stove at its centre and in the evening all those women patients who could sat around in their easy chairs, drinking tea, chatting and knitting- it was a glorious warm vision and experience as they just loved us young medical students.

Following a student placement in obstetrics and gynecology in Haifa Israel I unexpectedly won the prize in Obstetrics and Gynecology in my final year based on my final examination. The 500 pound sterling prize allowed me to return to Haifa for a 5 month internship on the same ob/gyn service which ended just prior to the 1967 six-day war. I had already fallen in love with the country as a student, but this prolonged period confirmed my initial impression.

Serving as an Israeli Air Force base doctor

I returned to the United States for my U.S. internship at the height of the Vietnam War and chose to move north to Canada following which I immigrated to Israel with my then Israel wife who I had met just prior to the six-day war. I did a six month pathology training rotation when I first came to Israel because of lack of language skills and then unexpectedly was invited and accepted a commission as a physician in the Israel Air Force where I served as an Air Force based doctor which included a monthly rotation as a helicopter evacuation crew member which was among the most exciting experiences I ever had.

On my release from the Air Force I took a position as a senior and then chief medical resident at the Shaare Zedek (Gates of Righteousness). It was during this two year residency that I became involved for the first time since medical school with geriatrics- Shaare Zedek had one of the first dedicated geriatric units in Israel. It was a remarkable experience and I witnessed outcomes that I had not seen on our general medical wards and the idea of a true multidisciplinary approach was taking shape. I also found much humour and good feeling among the staff and patients on the unit as we endeavored to improve the function and quality of life of older patients who had in many ways been dismissed as “not likely to improve” from other medical and surgical sources- this of course changed as our reputation in the hospital and in the city grew.

Israeli Air Force helicopters

I returned to Canada in 1973 with the goal initially of studying nuclear medicine with the plan to return to Israel and help develop that specialty at Shaare Zedek Hospital. Two things happened to change that plan the first being that I realized after a very short time that nuclear medicine did not satisfy my clinical and human interests- although I could master the technical aspects of the profession I missed the deep interactions with patients as people. I therefore decided to transfer back into Internal Medicine. The next major issue was the recognition that my marriage was beginning to unravel and going back to Israel was not going to happen in the near future or at all.

While trying to figure out what aspect of internal medicine or one of its specialties I would pursue I remembered my meeting in Jerusalem with Dr. Abe Rapoport from the Toronto Western Hospital who when being driven back to his hotel by me after presenting as a visiting professor at Hadassah Hospital offered to meet with me if I ever needed his help or advice. I went to him and after explaining what I wanted to do and how much I loved general internal medicine he asked me, “Have you thought of geriatrics?” to which I responded, “I did not know it was a recognized specialty in Canada.” He replied, “No it isn’t but there is a great institution called Baycrest and if you take the position offered to you by Dr. Berris at Mount Sinai as chief medical resident, I am sure he would let you do some work with or for Baycrest which is closely allied with Mt. Sinai.”

Baycrest Hospital for Seniors

I followed his advice and met the staff at Baycrest. I was impressed. I took the position at Mt. Sinai and started doing consultation for Baycrest for applicants and for those seniors transferred to Mt. Sinai for treatment. Within two weeks I knew that I had found my place in Medicine. The rest is history: working to get Royal College Certification which came in 1981, helping to build the capacity and reputation of Baycrest, returning to study Ethics and receiving my Master’s degree in 2001 and having a most satisfying career in academic geriatrics and ethics at Baycrest, Mt. Sinai and the University of Toronto- an unintended but most wonderful journey.

Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com

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