How Change Happens

This week, I learned that one of the most frustrating aspects of medical practice that I addressed in print as well as in the clinic, has finally changed. I listened to a lecture online about the current treatment of obesity. The physician advocated “empathy and support”, asking patients about their “weight loss journey”, shared decision making and motivational interviewing. I cackled with delight.

When I was a young doctor, the “shame and blame” treatment of obesity was popular. We were instructed to weigh the patient at each visit, measure their waist circumference and then basically berate them for not losing weight. Surveys showed that doctors, just like the general public, thought that fat patients were lazy and unmotivated. Luckily, at Kaiser Oakland, I met a health educator, Pat Lyons, who called herself a “fat activist” and spearheaded a movement for “health at any size”. She pointed out that the evidence showed that physical activity helped fat people (she never shied away from the f word) decrease blood pressure, decrease risk for diabetes, decrease depression, improve self-esteem—-even if they didn’t lose a pound. And most people who dieted gained back the weight within a year. Those who did manage to keep the weight off were the people who exercised. So why not focus initially on physical activity ? She advocated treating patients with respect, taking a history and developing a program of lifestyle change with them rather than dismissing them with a one-size-fits-no one low calorie diet.

Following Pat’s advice saved my sanity as a primary care doctor, since about a half of my patients were obese. Rather than making them feel bad each visit by pointing out that the number on the scale hadn’t changed, I could be an activity coach, coaxing them off the couch, setting walking goals. And guess what? Exercise, unlike dieting, is self-reinforcing. When you feel better, you are motivated to eat healthier food, too. Blood pressure and blood glucose were easier to control and some people even lost weight. Pat and I used to do trainings together, advocating this approach to obesity. Doctors and dietitians were outraged. We were “coddling fat people”, “condoning obesity”. We doctors should “make” the patient lose weight, not ask them if they wanted to talk about their weight. When my colleagues sputtered indignantly, I asked them Dr. Phil’s question, “How’s that going for you?” Actually, these doctors often achieved what they really wanted —the patients never came back. Whereas my patients were anxious to come brag about how much they were walking. Everyone appreciates respect.

What’s fascinating is that mainstream medicine has now adopted the behavioral techniques that Pat taught me 25 years ago. No one ever admits they were wrong. But change happens anyway.

Pandemic Time

Another month, thousands more Covid-19 cases and deaths. This morning, in a movie review, Mick LaSalle said, “That is, we’re finding out firsthand that we can feel completely different—content and cozy or fearful and and frustrated—on days that are otherwise identical.” So true. I am depending on yoga, and practicing the piano, and Duolingo Italian to focus me when reading and walking and knitting and gardening are not strong enough to overcome the pervasive dread. Writing can be especially hard, because opening to feeling is tricky.

Last weekend was actually different. My daughter, the ER doc, came to visit for the first time in seven months. She’s fine, thank you, recently engaged, moving on with her life, like my other children. It was amazing to be in the same room with her and her fiancé, which probably violated the CDC guidelines, although they both tested negative. They are around many more people than I am, not always masked and six feet apart. I held her friend’s baby, born at the beginning of the epidemic. Simple pleasures.

I’ve been reading John Lawton mysteries, recently Friends and Traitors, where the friend and traitor is John Burgess. Lawton does a super job of weaving history into the Inspector Troy series, and music, always music. I am also racing through Marilyn Abildskov’s exquisite memoir of her time in Japan, The Men in My Country. She teaches writing at St. Mary’s College in Moraga and I met her in a Zoom workshop. It is somewhat painful, to read about travel, when we are stuck at home but I have to believe this won’t last forever. I started Wendy Lesser’s Scandinavian Noir, whose serious analysis has inspired me to try that genre again. ( I never finished Girl with the Dragon Tattoo, my first attempt.) Finally, I started Bleak House, a Dickens novel I missed along the way. OMG. It feels so comfortable, and funny.

I don’t feel any special need to read books by black authors this summer, given that I have a sixty year head start on my white peers. I did just finish The Street by Ann Petry, a novel written in 1946, which I wish I had discovered decades earlier. And I highly recommend Along this Way, James Weldon Johnson’s actual autobiography. Musician, author (The Autobiography of an Ex-Colored Man, which is a novel) activist, ambassador—what a guy.

Still sheltering with books

The best book I read this month was Women Talking by Miriam Toews. She is a Canadian writer with a Mennonite background, who was inspired by the story of women in a Mennonite colony in Bolivia who were drugged and raped at night by the some of the men in the colony. Amazingly, the story is philosophical and even funny, rather than depressing. The voices of the women in the novel, trying to decide what to do, whether to leave the colony and strike out on their own (although they are illiterate and poor), are distinct and thoughtful.

I thought of this book when I heard a review on the radio of the Netflix adaptation of Sally Rooney’s novel Normal People. The reviewer said that the television adaptation substituted sex scenes for the interior monologue of the novel. The fact that everyone says this works (I haven’t seen it yet) suggests that the narrator in the novel was not struggling with any deep concepts. The novel, which I have read, starts in high school, where an unpopular girl and a popular guy have a secret affair. Perhaps you recognize this story line? As someone who did not attend a large conventional public high school, I will never understand the fascination those years hold for most people. All I wanted was to leave my small school, to get on with my adult life, to find people I could talk to, which seemed way more difficult than finding a guy interested in sex.

Toew’s novel speaks to the condition of the majority of women, burdened with children, unable to earn a living, in thrall to men who are indifferent if not hostile. Even those of us who are well-educated and can earn that living typically contribute so much more than our partners do to home and hearth, as thousands of women are re-learning during this pandemic. We want so much for our children—just as the fictional women in the colony do.

A month of sheltering from Covid19

Yesterday, I joined the Zoom world for a piano lesson. It was weird at first but once we started talking about the music, the concepts distracted me from the technology. This month I was working on a short Mozart sonata in E flat major, K 282. He wrote it when he was 19 and composing for a pianoforte rather than a harpsichord. The pianoforte opened up a world of dynamics impossible to achieve on a harpsichord. So he wrote passages of LOUD/soft, LOUD/soft to show off. Full of 19 year old energy.

In other news, I have discovered the lyric essay. I read Bluets by Maggie Nelson and The Crying Book by Heather Christie. The first is a meditation on the color blue, the second on crying. The authors are both poets and each bit of prose ranges from a few lines to a couple of pages. They mix in science, lots of quotations, personal reflections. The selections finally add up to a brief narrative. Basically, the technique works, although it feels a little precious.

I also read Underworld by Robert MacFarlane, a nonfiction exploration of caves, catacombs, mines—the world underground. The contrast between his aggressively masculine work, where he’s putting himself at risk on glaciers and in cave labyrinths to report and the more feminine lyric essays is stark. In our time of confinement, I am jealous of McFarlane’s freedom to roam, although basically I don't understand the appeal of mountain climbing or spelunking. I do love travel and mountains, though, and I miss them.

In college, on a geology field trip to a mine in Maine, I learned that traditionally women were not allowed in mines because we brought bad luck. The manager of the mine had not realized that there would be a female student along but he let me go in, with some misgivings. I didn’t push for the privilege —I didn’t want to be responsible for a mine cave-in—but the professor argued for me.

The garden is my place of solace. I have irises blooming now, and the sweetheart rose on the back fence. The sweet peas should open any day now. The picture above shows the Cecile Brunner rose in 2015.

Flaubert's Parrot vs Covid19

Today marks a week of living under the shelter in place order for Alameda County. Last week was a flurry of cancellations, including a trip to Washington, D.C. today. I woke up at 4 am, as though I still needed to arrive at SFO early for my 7:10 flight. But no, we finally managed to cancel that flight yesterday after holding the phone for two hours to reach a person who worked for the Chase Credit card. Using points rather than cash to purchase a plane ticket turned out to be a huge disadvantage for cancellation, because we could not cancel directly with the airline. More than a week ago, I sent an online form to Chase, which they received, because they sent me an email saying they received it. However, we learned two days ago that they did not cancel our tickets, because the airline emailed that our flight was cancelled and they had booked us on another one later in the day. It turned out that that the email Chase had sent us was a meaningless place holder. Lesson learned.

So many lessons in this sad time. How vulnerable we all are. How hard it is to sit on the sidelines, retired from active medical practice, and watch colleagues cope with an unprecedented epidemic, so different from the unprecedented AIDS epidemic I faced as a young doctor. The anxiety remains the same, however. The fear about how the disease is transmitted. The constant “non-news” as the numbers of victims of the disease mount. Covid19 is easier to catch, because it’s a respiratory infection, rather than blood borne, but most people recover. With AIDS, everyone died.

I have more or less settled into a routine of practicing the piano and accordion, writing, knitting, walking, Duolingo Italian, for our long-awaited trip to Italy, now in rescheduling limbo, talking to the kids on the phone. The closure of the library hits hard. I can’t return my copy of Maggie Nelson’s Bluets (exquisite) so I lent it to my neighbor. I can’t take out any new books and our local bookstore is closed. So I shopped my own bookshelves and found Julian Barnes’ Flaubert’s Parrot, which I bought second hand last year. Completely delightful. Inspiring. How lovely to be reminded of wit, so lacking in the unfunny Covid19 jokes about hoarding toilet paper. Unfunny because people really are hoarding toilet paper.

My story translated into Italian!

My story, “Director’s Cut”, which appeared in the last year in the Spring edition of ZYZZYVA (see post May 3, 2019, Inspired by Japanese Films) is now online in Italian. An Italian literary journal Black Coffee has a arrangement with ZYZZYVA to translate and post one story from each issue. I am honored that they chose mine. https://www.edizioniblackcoffee.it/directors-cut/

So now an story in English that attempts to recreate the mood of a Japanese movie is available to readers of Italian. Truly multicultural.

Trip to Thailand

My husband and I traveled to Thailand in November, visiting temples and beaches. I always like to read a novel from the country I’m visiting. I saw a copy of Letters from Thailand by Botan in an airport bookstore and tried to find it in the Berkeley Public Library on my return. Our library didn’t have it but I was able to obtain it through the LINK system, that provides access to many other libraries. It turned out that the nearest copy was at the University of Nevada, Reno.

It’s an epistolary novel, 20 years of letters sent from a Chinese man who emigrated to Thailand in 1945 to his mother back in China. But you learn in the prologue that his mother never received the letters because life in Thailand appeared better than life in China, so they were censored. It was a fascinating window into Thai society, with emphasis on the relationship between the Chinese merchant class and the Thai people. The main character marries and has children, who are caught between the two cultures. Near the end of the novel, the father admits:

“I can love my children, argue with them and attempt to guide their steps, but I cannot protect them from the times in which they must live. Whatever I may think of it, this is their world and not mine, and who is to say that they will not make a better peace with it than their father made with the world of his own youth?”

I found that a hopeful parental thought in our own difficult times.

A Fortieth Anniversary

The Winter 2020 issue of The Threepenny Review is the fortieth anniversary issue. Forty years ago, I heard that Wendy Lesser had founded a literary journal and thought “Isn’t that gutsy!” Today, her continuing success at the helm of The Threepenny Review at a time when print publishing struggles to compete with Twitter and Instagram, is astonishing. I am honored that she included one of my short essays “Sitting Still” (see link below) in this issue, among many more distinguished authors. Wendy is a dream editor: she either likes a piece or she doesn’t, she tells you right away and if she likes it, she edits it carefully, without changing the meaning or the voice. I am sure I am not the only writer to feel relieved when she accepts a piece, partly because I know it won’t be mangled. Her own writing ranges far and wide, with books about music, architecture, reading. Whatever the subject, she brings a thoughtful and original critique in clear prose. I look forward to many more issues of The Threepenny Review.

https://www.threepennyreview.com/samples/martin_w20.html

Small victory

For those of you keeping track, I wrote an editorial about the use of race in calculating renal function which was published in The American Journal of Kidney Disease in 2011. Basically, I pointed out that most African-Americans have mixed African and European ancestry, and using one set of numbers for black patients and another for white patients was problematic every day: which set of numbers should we use for Obama? And would a doctor guess that he was half white?

Recently, I have learned that hospitals are starting to move away from this awkward formulation. I am pleased to be among those who recognized a need for a change: since race is a social construct, and there is no biological binary distinction black/white, it does not make sense to report kidney function in this manner. Below is a copy of a letter sent to the Family and Community Medicine department at San Francisco General Hospital.

Dear FCM SFGH community,

As you may have heard, recently a team of physicians undertook an advocacy effort to abolish race-based eGFR (estimated glomerular filtration rate) by meeting and discussing this issue with the leadership of the SFGH laboratory. We are pleased to report that we were ultimately successful in convincing them to change the laboratory reporting of eGFR to one that does not include a correction factor for race. We recognize that there has not yet been any kind of formal announcement explaining how and why this change occurred and the background context upon which it was grounded, but we understand that a laboratory memo will be forthcoming. In the interim, as the team who advocated for this change, we feel it is important that we share the information that we presented to the lab concerning the reasons necessitating this change. We believe this is a change of utmost importance; one that we hope will be the first of many steps towards eliminating the problematic and structurally oppressive use of race (a social construct with no biological basis) in clinical tools and guidelines. With this change, we hope to spark further discussions on how we can advance health equity for the patients we serve, by focusing not on faulty race-based rhetoric, but instead on examining the effects of structural racism in medicine and its consequences on health. Please see the summary of the information below and feel free to direct any further questions to us. Our team will also be speaking about this advocacy effort at an FCM-sponsored event today, Wednesday 11/13, dedicated to discussing the abolition of biological race in medicine, that we encourage our colleagues to attend.

Sincerely,

FCM Drs. Monica Hahn, Juliana Morris, Stephen Richmond (and Dr. Vanessa Grubbs, from the Division of Nephrology)

Serendipity

Both my parents are from Savannah and so was John Sengstacke, the owner ofThe Chicago Daily Defender when my father was the editor in the 1950s. Last week, we held a family reunion in the city, which was well attended. The Ralph Mark Gilbert Civll Rights Museum there is housed in the old Guaranty Life Insurance Building which my grandfather Scott built in 1914. He worked there until the week he died in 1961.

After the reunion, my husband and I spent a few days on St Simons Island, one of the Georgia Sea Islands. We had hoped to see some vestige of the Geechee-Gullah culture but there’s not much left. One day we took a bike ride out to Fort Fredrica, where the English, led by Oglethorpe, stopped the northern march of the Spanish in 1742. The fort is now a national monument on lovely grounds by the river. Wandering among the moss-covered oaks, we saw a stone obelisk labeled “Abbott” , and in the visitor’s center, we found a book in the” Images of America” series written by Myiti Sengstacke Rice, about The Defender. It turns out that Robert Abbott, the founder of The Defender, was born on the island and erected this monument to his parents in 1929, well before the government owned the property. In the book is one of the youngest pictures that I have ever seen of my father. Hardly what I expected to find in the visitor’s center for an 18th century English fort. See below.