“Anatomy is destiny.”
-Sigmund Freud  

The intricacies of Head and Neck anatomy fascinate me. As my schedule has permitted, I have spent a few afternoons every fall helping the first-year medical students explore this remarkable anatomy.  

A recent article in the October 2007 issue of the Bulletin of the American College of Surgeons describes the participation of volunteer surgeons in the first-year anatomy course at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md. Having surgeons in the dissection lab helps students see how the anatomy relates to diseases. The Medical College of Wisconsin anatomy course also includes clinicians whenever possible.  

Working with medical students in the anatomy lab is a humbling experience for me for several reasons:  

First, the anatomy is wonderfully complex yet remarkably unwavering. Each time I enter the anatomy laboratory, I marvel again how each nerve, muscle, vessel, and structure courses above, below, behind, or around the others in dissection after dissection. Anomalies do occur, but they are rare and noteworthy.  

Second, I learn each year how little I know. Despite spending my career performing surgery in the region, there are structures tucked away in corners that the surgeon never approaches or recognizes. My teaching time has improved my surgical insight, but I still carry my trusty 30-year-old atlas from table to table as I tackle the students’ questions.  

Third, each year, I am reminded that human dissection is one of the watershed events of a medical career. Life can be broken down to “pre-cadaver” and “post-cadaver” years. Looking back, the privilege of probing, examining, learning from, and marveling at another person’s anatomic secrets remains almost incomprehensible. The students, to varying degrees, sense this already.  

As the head and neck portion of the course draws to a close, the students review their lists, preparing for a rigorous exam and searching out tiny anatomic structures. I tie the anatomy we are exploring to real patients' problems about which the students will soon be learning. I am already looking forward to next fall.

“Doc, when I started smoking, EVERYONE was smoking. It was the thing to do. This,” – he says, pointing to the permanent hole in his neck – “proves it wasn’t the thing to do.”  

My patient with the laryngectomy exaggerates a bit. In 1964, just over 50 percent of adult white males in the United States smoked cigarettes. That is down to a shade over 20 percent now. There is a lot of societal and legislative pressure to push that number further down.  

Why did so many people smoke and what made it so acceptable? One clue is the advertising that was prevalent as smoking rates were climbing in the first half of the 20th century. Smoking was glamorous! It made you thin! Celebrities, movies stars, cute kids, teenagers, and athletes all appeared in the advertisements. “More doctors smoke Camels!” declared a series of ads. “Science proves they are milder!” It was a different time.  

Want a glimpse into that era? The Lane Library at Stanford University has a remarkable collection of vintage advertisements collected by Dr. Robert Jackler.  (People with Flash 9 installed on their machines, including staff inside of Froedtert, might not be able to view the link.)

It makes me wonder, what advertisements from today will be collected and ridiculed in 50 more years? Fast food? Gas-guzzling cars? Coffee shops? Who knows?

“There is much to support the view that it is clothes that wear us, and not we, them …”  – Virginia Woolf  

Although I do not pay much attention to how they are dressed, I realize that some patients have spent time struggling to decide what to wear to each clinic visit.     

Some patients arrive wearing jeweled cufflinks and handsomely tailored Italian silk suits. Some wear handcuffs with their orange County Jail one-piece jumpsuits. I have seen everything in between.  

Clothing choices often reflect the individual’s vocation, activities or passions. I have seen paint-splattered pants, work shirts with name badges, embroidered sweatshirts emblazoned with “World’s Greatest Grandma,” Harley-Davidson coordinated leathers, exercise outfits, steel-toed work boots, motor oil-impregnated shirt sleeves, carpenter’s suspenders, and lanyards with corporate ID badges.  

Among my cancer patients, some women wear “guardian angel” pins. Survivors, both men and women, wear “Livestrong” bracelets. Some cancer survivors wear ribbons. These people are truly set apart.  

Several years ago, a young woman came to my office for the first time with an untreated tongue cancer. We discussed the evaluation and management, settling on a surgery date. She was wearing a brand new T-shirt, the fabric still creased and the printing fresh; I realized later that it might have been the only clean thing she owned. There, sitting in front of me, was a young woman preparing for cancer treatment, wearing a shirt that read in large, glaring orange letters: “Newport. Alive with pleasure!”  

What was my patient thinking when she chose to wear that shirt? Whenever I happen to spend a minute or two selecting my clothes, I suspect I want others to surmise that I am a little cleaner, a tad better pressed, and a bit more organized than I actually am. Maybe she went through that thought process, as well.

Initially, I didn't think she noticed the irony of appearing in a cancer surgeon’s office dressed in a shirt she obtained by sending in coupons from cigarette packs; however, she never wore it again. 
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A previous version of this essay appeared in the MCW Cancer Center News.

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The following is feedback received for this blog:

From your blog and the current essay in JAMA, I'd say you have the basis of a great book there. - Mike McLellan http://drmikem.blogspot.com/

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His life revolved around his family, his traditions and his wheelchair. As a young man in Russia, he lost one leg during the Siege of Leningrad. As an older man, he lost the other to severe blood-vessel disease.  Now, as an immigrant who spoke no English, he was dependent on his daughter to push him from place to place and to explain all of the inscrutable American customs along the way. I think he found us all to be very amusing.  

Like many other Russians of his generation, he loved his vodka, his cigarettes and his traditional foods. In the months before I met him, his voice had changed from a joyous baritone to a coarse whisper. The growing cancer had taken away his voice and was affecting his swallowing. His eyes betrayed the universal sense that the things he loved deeply might soon be taken from him.  

His treatment was difficult; he was not well and the recommended surgery and radiation therapy initially made things worse. For the first several weeks, he could neither talk nor eat. His dependence on his family grew, and he became very discouraged.  

Gradually, though, he recovered. He brightened visibly as his voice returned – not to the rich tones of his youth, but to the point where he could sing the old folk songs to his grandchildren. His swallowing and sense of taste improved. He was able to eat many of the foods he remembered from his mother’s kitchen. Some of the touch points of his world had, at least in part, returned to him.  

“You are doing very well,” I would tell him at his follow-up visits. “I see nothing that worries me at all. The cancer is completely controlled.” He eyes would move anxiously from my face to his daughter’s, waiting for her to translate my words into his mother tongue.  

“The doctor says everything is fine,” she would say in Russian.  

Sometimes, at this point in the encounter, he would smile broadly and reach into the bag he had kept poorly hidden by his side since rolling into the examining room. From within, he would pull a gift and press it into my hands with surprising force. “Spasiba!” he would exclaim. Thank you!  

The first time this happened, I was very surprised. I looked at the gift, a small box of specialty chocolates and a bottle of liquor. “I can’t accept this!” I protested. “Please! This is not necessary!”  

The daughter intervened. “Doctor, this is my father’s tradition! Good news is always celebrated with chocolate and alcohol. You have given us the best news possible today! My father wants to share his celebration with you. Please accept! He truly will not understand if you do not.”  

I sputtered briefly as I reflected on the situation. Celebrate good news with European chocolates and a pint of Goldschläger? What a concept! It didn’t take long for things to come into focus. “Hmmm,” I thought to myself. “This seems like a remarkably fine tradition!”  

I opened the box of chocolates and offered them to the others in the room. “Spasiba!” I repeated back to him.    

He did not bring gifts every visit, but often enough, to be sure. The colleagues with whom I shared the gifts jokingly wondered whether or not we might ask him to return more frequently for check-ups.    

Several years have passed since he died of heart disease, but I clearly recall his delight and how he used gift-giving to keep one of his traditions alive in a land far from home. The gesture deeply ingrained both his image and his graciousness on me. I have had several thousand patients pass through my practice over the years and, I admit, I remember some much better than others — some I do not remember at all. However, one of the most memorable was the wheelchair-bound Russian-speaking survivor of both war and cancer who celebrated good news with chocolate and a toast.    

"Spasiba," I think again, and, sadly, "Dasvedanya."

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The following is feedback received for this blog:

Great story. So much gratitude from someone with so many difficulties to overcome is inspiring. Makes me wonder what I can do to help my doctors remember me. - Russ What a great idea. I think celebrating good news is the best possible reaction. - Chuck McKay www.advancemypractice.com another lesson in courteous behavior. Our culture will sometimes forget that to accept a gift graciously is to bless both the giver and the one who recieves it. - Holly Thanks so much for the response to the essay. I like your take on the interaction. -Bruce Bruce H. Campbell, MD you're very welcome. I thought, as I read the eloquent way you phrased all that, how difficult it would be to be a "stranger in a strange land" and how I might feel if it were me. Feeling out of place in a different culture, trying to find a way to say thank you to someone who gave me such a great gift (of life). As I have told my kids over and over, good manners (please and thank you) are never out of place, and this was a gracious way of saying both thank you and you're welcome. - Holly

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Now that I have been writing this blog for six months, I wanted to take a moment and talk about the process.  

The blog came into being because the Froedtert Hospital Marketing Department asked if I would take this on. I have a pathologic need to be liked so, of course, I agreed. I had already written monthly columns for the MCW Cancer Center News based on exploring what I felt were the attributes of a “good” physician. I intended to post an entry every four to five days; so far, so good.  

Basically, I write because I see things that make me go, “Huh?” Writing allows me to process what I see, both the exhilarating and the devastating. I have kept a journal off-and-on since college (pretty much continuously for the past 10 years), accumulating stories and experiences; the blog allows me to re-think some of those moments.  

I was a bit surprised to find out how much time would be involved. The shortest essays sometimes require the most effort; they are the most rewarding when finished. Annie Dillard once quoted Thorton Wilder describing the process of writing: one line drops from the ceiling, “and you tap in the others around it with a jeweler’s hammer.” That really rings true for me and keeps me coming back for more.  

By the way, I appreciate readers’ reactions. The stuff I write about is not controversial, but I really enjoy hearing your insights about the topics. Feel free to hit the “Feedback” link below. Most people, however, choose to call, e-mail, or talk in the hall. I don’t need an audience, but, truth be told, it’s nice to know you are out there.  

So, to recognize the six-month anniversary, we are re-christening this blog as “Reflections in a Head Mirror.” The head mirror, an almost archaic medical device, is the symbol of the doctor in cartoons everywhere. As an otolaryngologist, it is still one of my most cherished instruments. 

Thanks for reading! Thanks especially to Christopher Sadler and Tamara Kroll who have made this all possible. If you have topics you think I should explore, please let me know.

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The following is feedback received for this blog:

Thanks for writing. I really enjoy your essays. - rlbates http://rlbatesmd.blogspot.com/ you have answered one of my most enduring puzzlements. for the last thirty years, i have been asking my colleagues, what's that round mirror thing you guys wear (or used to wear). it's such a ubiquitous symbol that we used it on the cd cover for my band, dr. linda and the ultrasounds. even the great and wise dr. linda didn't know what it was! now i do, and i will lord it over everyone i know!!! -dick

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Every week, a medical blogger (yes, there is a whole community of such people) hosts "Grand Rounds," collecting interesting posts that are written by patients, students, residents, nurses, pharmacists, physicians, and anyone else interested in healthcare.

This week's Grand Rounds is particularly clever. It includes links to 40 posts on various topics and was created by Dr. Rob Lamberts, the host of "Musings of a Distractable Mind," one of my favorite sites. If you have a moment, check it out! One of my old posts is included ... see if you can find it. (Hint: it's part of the Frivolous Fun Finale Fling.)