Dr. Dennis Maki

He called me up to play squash one Saturday afternoon, and I said, "I can't play, I've got to finish this chapter this weekend, and by the way, you never sent me back my blood work."  He said, "Everything was fine, but it looks like you had a viral infection."  I said, "Really?  Viral infection?  Why?  I'm feeling fine."  He said, "Your white count was a little low."  I said, "How low was it?"  He said, "2,700."  I said, "Really, Richard, that's awful low.  I don't have a viral infection.  What was the absolute granulocyte count?"  He said, "I don't remember."  I said, "Could you check it out for me?"

This is a Saturday, so he called the lab and got the results, and my absolute granulocyte count was 950.  I said, "Richard, I've got a myeloproliferative syndrome.  Probably a myelodysplasia."  The differential count was normal.  He said, "You're crazy, you're hysterical."  I said, "Let's look at it, Richard.  I'm on no drugs.  I don't have lupus, I don't have an autoimmune disease, I don't have HIV infection, and I don't have any kind of viral infection.  I don't have hepatitis B or hepatitis C.  Why would I have an absolute granulocyte count of 900?  I think I have a myeloproliferative syndrome."

"It Could Be All Over" 

That Saturday I suddenly faced my own mortality.  You know, you've been sailing along, you've been enjoying life, love what you're doing, have a wonderful family, and suddenly you realize it could be all over, way before you anticipated.  And I immediately got in the car and drove to the hospital to get it redrawn.  Maybe they made a mistake.  This is a month later, and now my absolute granulocyte count was 900 and my white count was around 2,500, my platelet count was 148,000, and my hematocrit was 39.  Everything was down a little bit, especially the absolute granulocyte count.  But the striking thing is my monocyte count was only 100.  That's a very low monocyte count.

I did a lot of reading that weekend, like all of us would do.  I was pretty sure this was probably myelodysplasia, which is a pretty gruesome disease, and there's a good likelihood you aren't going to be around in two or three years.  A bone marrow transplant just doesn't work all that great for myelodysplasia.

The next Monday I went in to see one of our best hematologists, who'd been a trainee.  I'd had him as a resident.  He'd been on the faculty 15 years, a very good hematologist.  I have to believe he's the best general hematologist I've ever seen, and I've seen some pretty good ones in my training years in Boston at Harvard.  I said, "Elliott, I'd like a bone marrow."

He examined me -- totally normal exam, no splenomegaly, no lymphadenopathy, nothing -- and he said, "I just don't think this is something we need to worry about.  Why don't we just watch it for a couple of weeks?"  I said, "That's fine, but if at the end of two weeks it's no better, I want you to do a bone marrow."

At the end of two weeks, everything was a little worse, so he did the bone marrow.  When he had trouble getting bone marrow -- looked like it might be a dry tap -- I knew there was something not good.  He finally got the core and got an aspirate, and I said, "Elliott, the smear will be out this afternoon, and I don't want you to tell me what it is.  I want to go down and look at it myself.  Just call me up and tell me when it's ready to look at."

So he called me midafternoon and I went down to hematology to look at the bone marrow slide, anticipating it was going to be a pre-leukemic syndrome, a pre-AML syndrome.  Bad disease.  It was one of the good days of my life.  I looked in and it was full of hairy cells.  I had hairy cell leukemia.  If you have to have a malignant disease, that's a very good one to have, because there's a very good therapy.

If we believe in the power of science as applied to human health, there's a good example.  The chemotherapy for that was a targeted therapy that was developed only about 10 years earlier.  Really only the trials had been done less than five years earlier.  My life was saved by that drug becoming available: 2CdA.

Preparing for Chemotherapy 

So I wrapped up all the things I had to get done, wanted to do my chemotherapy at home, and I washed out all the walls, got four Hepa filters into the house.  There was only one thing I worried about.  I wasn't worried about getting neutropenic sepsis.  I could deal with that.  But I really didn't want to get pulmonary aspergillus infection.  I knew I was going to be granulocytopenic down to close to zero for probably a week, not a real long period.

So I put the Hepa filters in, and I brought home Hepa masks, and every day I was home for my chemotherapy, I'd run in the neighborhood for about an hour with a Hepa mask, and that's not easy to do.  There's a lot of impedence in those masks.  But I felt that getting through the chemotherapy and everything, exercising at least an hour to an hour and a half a day, helped immensely, just immensely.  I slept better, I felt much better.  And it was a piece of cake.  It really wasn't bad at all.  I was back at work in a month.  I had no CD4 cells.  I had a CD4 count like an AIDS patient for about a year.  But there's very little risk, interestingly, with that disease, and I recovered completely.  I've been in remission for 14 years, so I could ask for nothing more.  So I was very, very fortunate.

The Second Blow 

In 2000, I was home reading The New York Times one night, late at night, actually Christmas Eve.  I was taking call both on the ID service and in the ICU, and I thought I could hear a murmur in my ears.  I put a stethoscope on my chest, and -- florid mitral regurgitation!  I'd never had a murmur before.  I knew I had mitral valve prolapse and had a click.  I figured I'd have to have a ruptured chordae.  I went in the next morning and got an echocardiogram, and indeed, I had a ruptured chordae.

There, I did what probably most of us would do.  I became an informed consumer.  I didn't want to have a mitral valve replacement.  I wanted a valvuloplasty.  People who have prosthetic mitral valves don't live as long as people who have native mitral valves.  The prosthetic mitral valve is still a work in progress.  It's not nearly as well defined as an aortic valve.

In any event, I needed to find a physician who could do this, a surgeon, and I shopped carefully and found three surgeons who did a lot of them and seemed to have very good results.  I chose one of them at the Mayo Clinic.  I chose the Mayo Clinic for two reasons.  I knew it well, having been there a number of times professionally, visiting the ID group or the critical care group up there.  But I also knew that they had medical intensivists in their post-cardiac surgery ICU.  Too many cardiac surgery ICUs -- this is sort of a scandal -- do not have very good critical care for post-op patients.  The surgical intern is in the house at night, and their backup is often a cardiac surgical fellow who's home, or often in the Operating Room.  That certainly is the experience in my hospital and the experience  in the Harvard hospitals I trained in, and the way it is in many large teaching hospitals.

I was dismayed when I would be called up to the cardiac surgery ICU to help a surgical intern with a complicated patient who had literally no backup, and I really didn't want that happening to me when I really couldn't do anything about it.  But Mayo had senior medical intensivists who staffed the cardiac surgery ICU, so for those reasons I chose Mayo.

The surgery was just a piece of cake.  There was nothing to it.  I mean, I was out of the hospital in two days.  My only complication was I had a post-cardiotomy syndrome, had a lot of pericarditis, a lot of pain, a lot of tachyarrhythmias for about a month, but it wasn't a big deal, and I was back at work in two weeks and did fine.

"I Dodged Two Bullets" 

So I consider myself a very, very lucky person.  I dodged two bullets.  I have a wonderful wife, I've been married for 46 years.  If I had to marry again tomorrow, I'd marry her again in a heartbeat.  It'd be a little faster than it was the first time.  And I have a wonderful family and I love what I do.  So I consider myself very fortunate.  I say that because when I talk about my experience as a patient, it obviously shades my feelings in this regard.

Now I take no scheduled medications at the present time, except for one aspirin a day.  I've never taken a scheduled medication except for Warfarin for about a month after cardiac surgery.  I also want to point out, I care for a lot of physicians.  I care for about 35 physicians, and I consider myself their doctor.  I cover them 24/7, without any resident coverage, and the cell phone makes it all possible.  Every patient I have, you get my card with my cell phone number on it.  I expect them to call me if they have a problem.  I don't want them running to an urgent care center because they've got a respiratory infection, or they've got something.  I'd rather they call me.  And nine times out of 10, if they need to be seen, I can see them.  If I'm not there or in town, I can see them when I get back.  If they need to be seen urgently, I can lay the way by calling the ER physician at my hospital, they can go in and see them, and it can basically allow for a more effective interaction.

Practice Overview 

I started doing general internal medicine, although I'm a quintessential specialist, I'm an ID specialist, I've been doing ID and have basically run an ID division for almost 35 years, and I'm the senior intensivist in my hospital.  But when I started in academic medicine, I didn't think I could call myself a true doctor unless I could take care of all areas of general internal medicine.  If you're going to be an internist, you have to be able to take care of depression and gastroesophageal reflux disease.  You've got to be able to take care of people who can't sleep at night, who have sleep apnea.  Things that aren't necessarily in the purview of specialists.  I wanted to do this.

So when the first person asked me if I'd be their general internist, I acceded enthusiastically.  I have a boutique practice of about 250 people.  They're mostly people that I've encountered as a specialist who have asked if I would take them on, and then, word of mouth, people have called and asked if I would take them on.  I've limited it somewhat, but I've tried to take new patients as much as I can reasonably handle.  I can handle 250 fairly easily.

Now I want to offer some insights, but I want to caution that these are personal insights.  This is not the absolute truth.  I was very uncomfortable talking about this, because I'm not a scholar in this area, such as Dr. Farber is.  I can only tell personal insights and at least what I've learned, both as a physician/patient and as a physician taking care of patients.

An Enriching Experience 

First of all, as a physician/patient, I believe strongly that serious illness from which one recovers can be an enriching experience.  I've had many AIDS patients tell me, "I really didn't start to live until I got AIDS, and I really understood the preciousness of life, and of family and of friends, and the enormous fulfillment of literature, of great music, and having a spiritual life."  Recovering from a serious illness lets you realize, jarringly, that life is very capricious, and there are no guarantees whatsoever.  Tomorrow we can be gone, or even worse, we could be severely, permanently incapacitated, which I think for many of us would be a fate worse than dying.

I believe that serious illness in a physician is an invaluable experience to our roles as health care providers.  It creates a lot more humility and empathy for our patients' fears, and the big fears of dependency and disability and dying.  If you experience them yourself, you have far greater empathy for your patients.

I used to joke with my critical care fellows before I had my surgery, "I'm sort of looking forward to this, I want to see what it's going to be like to be intubated, to be in an ICU."  I've intubated thousands of patients and done invasive procedures, and being intubated wasn't all that bad.  The urinary catheter was far less bad than I thought it was going to be.  I dreaded that, and that was nothing.  The one thing, getting suction through an endotracheal tube is very uncomfortable.  And number two, a nasogastric tube is not very comfortable at all.  It's miserable.  You literally count the hours till they can take it out.  So it's changed how I manage patients in a critical care unit.  It's made me much more sympathetic to the discomfort patients have when they have to be on a ventilator and totally dependent.  It gives us a greater appreciation, certainly, for the seams in our health care system, the gaping seams in what's supposed to be a seamless system.

Physicians Treating Physicians 

I found, as a physician caring for physicians, that physicians communicate and deal with physician/patients far differently than they deal with lay patients.  They assume way too much.  They defer too much in decision-making: "Well, what do you want to do?"  Well, you know, if I'm not a cardiologist -- I think I know a fair amount about heart disease, but I'm not a cardiologist, I'm not a cardiovascular surgeon -- I want your advice.  I've believed for a long time that the role of a physician in their interaction with a patient is to present them the reasonable best options and then make a recommendation, what we think is the best option and why.  They didn't go to medical school.  They haven't spent thousands of hours preparing.  But they should know the different options available.  They may choose one that you didn't recommend, but it's a reasonable option.  But you need to defend why you think that this is the best option.  If you can't defend it, then you haven't done their homework.

It drives me crazy to see this in the ICU all the time.  "Well, he's not doing very well, we could do this, we could do that.  What would you like us to do?"  And the families are bewildered, especially if you're talking about end-of-life issues.  I think in end-of-life issues, it's our responsibility to tell the family that we've done everything we can, there is no reasonable hope whatsoever that we're going to be able to get them better, all we can do is extend their dying a couple of weeks, maybe a month or two with life support.  But we're not going to save their life.  And we think that the kindest, most humane thing is to transition to comfort measures.  "We can assure you they'll be free of pain, or anxiety, or discomfort."  Not to try and let them feel they have had to make the final decision.  We should make the recommendation.  I believe this very strongly.

Physicians, in my experience, as patients paradoxically too often live in a state of really to me remarkable denial that they're vulnerable to the same diseases as are patients.  Why do I think that?  An awful lot of physicians I know receive no maintenance preventive health care, what we would consider as reasonable.  They don't have routine screening for hypertension, for diabetes, for cancer.  They don't have this done on any regular basis, or it's very fragmentary at best.  They commonly enter the health care system as patients only when confronted by illness, and even then, it's often in a very desultory manner.

Many of my patients I've picked up, they'll stop me in the hall and they'll say, "Let's go in the conference room, Dennis, I want to just show you something, I want to ask you something confidentially."  I realize they have something really significant, and I say, "Bill, I'm really happy to see you, but this is an insult to you and to me for us to try and transact any kind of medical care in this setting.  I'll be happy to see you in the clinic this afternoon.  Come down, let's make a chart, let's make a record, and it's confidential, you realize, and let me treat you like a regular patient.  You'll be much better served."  Almost invariably, they're willing to do it, and once you do that, you establish a relationship, and often you have a patient.  But I think you get much better care if a physician gets their care like we give our patients.

I find that many physicians practice far more self-therapy than they would like to admit.  Physicians as patients have a tremendous advantage.  They're being able to pick and choose their specialists, particularly for serious disease, probably much more wisely than lay patients can who may be looking for a specialist.  However, this isn't uniform.  I've often see physicians choose as a specialist for a big operation, or a very complicated illness, somebody that they know who's a friend, who I don't think is anywhere near as good a surgeon for this operation, even in our own institution.  So they don't always necessarily choose as wisely as they should when they're patients themselves.

The physicians I've come to know and respect most highly for their global excellence and their wisdom, interestingly, have most often chosen a capable internist that they see periodically.  They're willing to become patients themselves, to surrender some of that authority that they have as the health care provider, to become a patient in the system.  But remember, doing so never precludes being totally engaged in their care and being very informed medical consumers.

Communication Is Essential 

I'd like to close by just commenting, I think communication is absolutely essential to our being able to try to help our patients.  Most of us could do better, and some people could do an awful lot better.  I personally think, as a primary provider and even as a specialist, we should touch our patients every day we see them.  I shake hands with every patient I see in the clinic, and in the hospital, I often just will squeeze their hand after I've talked to them.  I just feel that personal contact brings a greater humanity to the relationship, which is what I think medicine should be.

Accompanying family or friends that you see in the clinic, or even in the hospital room, I think should be greeted, and if they're close family, they're going to be potentially caregivers, they have to be spoken with the same as you're talking with the patient.  They should hear the same message, and they should feel that they're being talked to the same as the patient.

Putting It In Writing 

I do one thing that I think has been very helpful.  Very early in my career, it became very clear to me that I could be sitting in the clinic with a primary care patient, or even a consult that I see, and I say, "I want you to do this and this and this, and we're going to do this with this medication, we're going to change this," and they sit there and they nod, they're intelligent people, they nod, they understand.  And then when they come back the second time, a lot of the things haven't happened, and they hadn't quite realized it.  And I suddenly realize how stupid I am.  I expect them to remember all these complex things, and that's not good enough.

So what I started doing almost 30 years ago is, every patient that I see in the clinic, I routinely cc my note to them.  That means I structure my note a little bit when I dictate it, but by and large, I say why we're changing their dose of their antihypertensive, why we're stopping this medication, why we're starting this new medication, what I'm concerned about, this symptom, what it might mean, what it might need in terms of further workup if it doesn't change or get better.  I let them see my thinking, and they take it home and they can read it, and I can't tell you how often patients have said how much they appreciate that.  They understand their disease.

Remember, a patient who's engaged in their health is going to do a much better job of taking care of their health.  And they become better engaged if they have a chance to really read and chew on what you think is going on and where you think the relationship stands medically.

With that said, I'd be happy to pause for just a few minutes if there are any questions.

Question-and-Answer  Session

Q:        How many professors do what you do?  I mean, what you do is very, very important.  I've been practicing general internal medicine in the office for 40 years and all the things you say are so important ... and communicating.  And I do infectious disease in the hospital, and there it's a little harder ... in isolation.  Touching isn't quite the same if you don't know them or establish that much of a relationship.  But my impression is that not a lot of professors of medicine in medical school do what you do, and we see more and more trained out, coming on the floors -- they want to do shift work.  They don't want their telephone number in the book ....

A:         Well, if we talk about shift work, it drives me crazy.  Critical care medicine is moving rapidly (and I just mourn this) towards ER medicine.  We always did one-month blocks in the ICU.  Did that for 20 years.  Then my colleagues wanted to go shorter, for three weeks.  Then it was two weeks.  And now most of my colleagues want to do one-week blocks.  I refuse to do one-week blocks.  I'll do two weeks, but they won't let me do longer.  It's really hard to have continuity of care in critical care, or in an in-hospital setting, with a one-week block.  That means half your patients are going to have to meet another physician, you're going to be the new physician for all the new people -- I think this fragmentation of care is deleterious to the relationship and to the effectiveness.  And we talk about smooth pass-offs, but I just don't think it's ideal.  But I don't think we can change the world, unfortunately.

Q:        A good example of that is the hospitalists.  Are there any hospitalists here?  Usually they don't come to any of our meetings.  They take care of the people in the hospital.  They do a wonderful job taking care of disease.  But I think they do an awful job taking care of people.  Because if you go in and say, "Who's your doctor?" -- I'm the infectious disease specialist, and I see them for five days.  Sometimes over the weekend, if I'm on call.  And then the next five days I'm back again and back again and back again.  Pretty soon the patients are looking at me as their doctor.  I'm just a consultant.  Their real doctor is the hospitalist, who changes every two or three days, they have a third one at night, somebody different in the day, and this shift work is just changing the whole dynamic.

A:         Well, it is.  And I'm very concerned about that.  I don't know what we can do about it, because I agree completely with everything you've said.

Q:        My take on the shift work issue really has to do with it's a responsibility that we gave up.  We did that when we wimped out with the challenge to our -- we did not communicate that part of our job to the public, to the government -- it is our fault that our profession is in the shape that it is right now, because if we had fought for a doctor-patient relationship along with the reimbursement issues, I don't think we would be in this.  We would be able to communicate it very effectively to young people, how to have a good lifestyle and practice medicine as a human being.  And I totally see that as a fault of our generation for focusing on reimbursement and not focusing on the importance of the patient-physician relationship.

A:         I think you're right.  Absolutely.

Q:        One of the things I was struck by is your talking about how your perceptions about life in general have changed after going through two serious illnesses.  I sort of went through it vicariously, but still have noticed how my professional life has changed, without me being a scholar and expert in this area.  I had an interest in patient-physician communication for many years, but in terms of dealing with physicians as patients and dealing with communication at the end of life, it's only been since my wife became ill, and it's changed much of what I do academically.  But more importantly, coming up to Alaska and looking around, it's gorgeous, and I'm sure I would have been struck even if I'd come up here 20 years ago, but not nearly as struck as I am.

A:         I think you're right.  The thing you find when you recover from a serious illness is, really, life is brighter.  It's more vivid.  I love classical music.  I mean, I just almost am brought to tears at times by great classical pieces, and I just enjoy it so much more.  I enjoy my family, my grandchildren -- the preciousness of your family and your close friends -- you realize that life is transient, and you life your life differently.  You live your life to the fullest and you appreciate it.  If I had to die tomorrow, I couldn't complain one iota.  I've been so fortunate in every respect in my life, and having gone through critical illness has made me appreciate that only so much better.  And as a physician/patient, I'm much more sensitive to patients' needs.  I've always thought that I was pretty good at it, but I'm much, much more sensitive.  I can read things in people's faces, I can see the anxiety, I can see the doubt, and I see that and I look for it much more than I did before, because I've been on the other side.  So I think that surviving a serious illness gives you a different perspective as a health care provider.

Q:        I'm very moved by that, and I've been a very strong believer in that for a long time.  I'm just wondering, do doctors ever talk to patients about the positiveness or the good things that may come from that?  When you're talking to them about a difficult cancer diagnosis or whatever?

A:         I try and tell patients who have fatal diseases, and I've had my share of them, and I encounter some of them in the ICU.  We may get them through the critical illness in the ICU, but they have a serious illness, they're not going to live more than another year or two.  And I will talk with them about dealing with life.  I'm willing to share with them that I have a fatal disease, and it's not time to give up.  There are advances being made every day and you don't create false hope, but it's very sad taking away hope from a patient.  There comes a stage when the inevitable is there.  The patient knows it before you do, that they're not going to make it, they're in their last phase of their life.  That's fine.  But long before then, they have cancer.  They have metastatic cancer.  They may have six months or nine months to live.  You don't want to take away all hope.  You don't want to keep focusing on "You're going to live another six months, maybe we can give you nine months."  I think giving some hope and focusing on the positive more than the negative is a very important thing in dealing with these kinds of diseases.

Q:        I was focusing more on you talk about how you enjoy your music more, family relations a lot of times improve, people will learn things about their inner selves.

A:         I've not done that to that degree with patients, but if they need something, that'd be worthwhile doing.

Q:        In studying people who are really sick ... I think it's very appropriate to talk about personal feelings.  You mentioned - everybody in this room has a story, and stories are told well, but many people have stories in a lot of different ways.  Every man on the street has a story.  What we're really describing here is our own maturing process as individuals.  We're getting older, we have a sense of mortality, we've achieved it in a variety of ways.  I mean, at age 19, you didn't do it this way.

A:         Oh, no.

Q:        We were all immortal.

A:         I think you used a very important term here, and that's maturation as an adult.  That is really part of the maturation evolutionary process.  That's absolutely right.

Q:        And it's okay to talk to people about personal issues, I think for the most part.  There are some people who will put up a barrier and say "Don't cross it," but most people I think really appreciate it when you open up a little bit.

A:         There's a great book that if you've not read it, I would recommend to everyone.  It changed my life very early in my life, called Adaptation to Life.  It was written by a Harvard psychiatrist.  It was the Grant study.  The Grant study was a very unique study.  If you're a psychiatrist, you've heard about it.  Grant was an industrialist who graduated from Harvard in like '06 and he left a lot of money to Harvard to do one thing.  He wanted them not to study disease, he wanted a study of what were the correlates of health and happiness and success in life.  And so he left this bolus of money that sat around for quite a while.  Finally they found somebody who'd be the principal investigator in this study and set up the study, called the Grant study.  Grant was the donor.  What they did was to study four Harvard classes, beginning about 1938, 39, 40 -- JFK's class was one of them.  The classes weren't that large.  What they did was to assume that all these people were going to do well, and they'd be happy and successful.  This was pre-control days.  But fortunately they had built-in controls.  Not everybody was happy.  Not everybody was successful.  People suicided, went to prison, and didn't have such a good life at all.  But they went on the assumption initially that everybody would do well, so they interviewed them all, they interviewed their families, they did detailed psychiatric histories, physical exams, and they saw them every five years for the rest of their life.  The study's been going on now for over 50 years.  The first book was published on about the first 35 years of the study in 1976.  It's an extraordinary book.  The person who wrote the book was the second principal investigator in the study, and really had modern outcomes and study techniques, and realized there were controls.  People didn't do so well, and people did well.  They defined pretty reasonably what was a good outcome, a successful life, a happy life, a fulfilling life, and what was not a fulfilling life, not a successful life.  And then they looked at what were the correlates.  Interestingly, they couldn't find any correlation with family background.  What they showed in this study -- what was so valuable to me -- was that everybody in the world has great psychic pain at varying times in their life.  Everybody's going to have times, the dark days of your soul, "God, what am I doing?  This isn't working very well, I'm not very happy, I'm not meeting what I wanted to do in life, I'm just not making it."  That was very valuable to me, because in my early 30s I became vulnerable to depression.  I was starting in academic medicine, I worked hard, I just didn't get as much done as I wanted to.  By any external measure I was doing fine, I got promoted early, but it wasn't enough.  I'd become anhedonic.  I'd become incapable of taking any pleasure from anything I accomplished.  I wanted more.  Reading this book, realizing that everybody has to face periods of time in their life when they get very depressed, very frustrated -- it's something we all deal with -- that was a tremendous revelation.  Because I was at the point, I was coming home from the hospital, sitting in the corner, looking in the corner for three or four hours at night, "What am I doing, where am I going?" thinking about, "Should I kill myself?"  I wasn't ready to go see a psychiatrist.  Should I take an antidepressant?  I'd read a lot about depression.  That book helped me.  And then I read about cognitive psychotherapy, and that helped me.  I basically did cognitive psychotherapy to myself.  My flaw was I should have gone to see a psychiatrist, I didn't, but I was lucky, it worked for me.  Fortunately it worked out.  These books gave me insight.  I've never been depressed again.  I've learned cognitive psychotherapy.  It's really very effective for many people.  Not everybody, but it works pretty well for many.  In any event, that book gave me a lot of insight.  I keep about a dozen copies in my office at all times.  I give them to all my fellows, give them to the residents I have contact with, I just want them to read it.  It gives people insight about life.  It's a very fascinating book.  It's really worthwhile reading.

Q:        What were the correlates for success?

A:         It probably was your defenses.  People who are successful have mature defenses, and the people who are not successful have very immature defenses.  Talk about mature defenses: intellectualization.  Being able to really examine the issue and intellectualize it and look at it and try and understand it better is often a very mature defense.  Humor is a very mature defense.  Sublimation is a mature defense.  They found that people who were successful had much more mature defenses.  They came up with a very high statistical difference between the two groups.

Q:        You said that you will automatically cc copies of your notes to your patients.  Do you give them a chance to opt out of that?  It occurs to me that many patients would find that unwelcome because of a fear of family members finding out.

A:         Actually I've never had a patient tell me, "I'd rather you not do it."  Never, not one.  About every 10 to 15 patients, they'll send a fax to me correcting it.  "This was not quite accurate, and I was taking this," and they want me to correct it in the records.  So I always tell them I'll be happy to do that.  But I've never had somebody say, "Please don't do it because it bothers me or I'm afraid somebody's going to see it."  It's interesting.  Most people welcome it.

Q:        I used to always give a copy of my notes to the patient ...

A:         I'm a firm believer in it.  I take care of a lot of very, very smart people.  I've had the good fortune of taking care of six of my former professors in med school.  They're pretty discerning people, and they will often discuss things, but they value it as much or more, often, than the patients, because it allows them to be just totally engaged in their health care.