Words for a friend

Last week my mentor and friend Dr. Joe Meek passed away. Today I had the real honor of delivering some words at his funeral. This is what I said:

Over the last few weeks, near the end as Joe was declining I called Bette a few times to warn her I was coming around. A couple of those times I got her answering machine. I’m in the bad habit of hanging up on most people’s answering machines or voicemails. I just prefer to try again later. But I didn’t hang up on hers. I listened. Because the message on the Meek family answering machine was recorded by Joe. Some people have the ability to bring the pulse in the room down a few beats, to calm us down just by the way they sound, or the way they interact with others. It turns out that Joe Meek’s ability to do this extends beyond death. I found comfort in hearing his strong voice telling me to leave a message.

Most of us set out to accomplish something in our short lives, even if it’s just the simple pursuit of happiness. But I don’t need to tell you that Joe accomplished more than most. He married Bette young and had kids, Tom, Nancy, and Kathy. Then he spent the rest of his life talking about them. Or at least the years from 2001 through 2019. I can’t speak for the time before then. But I have my suspicions. He was a Lt. Commander in the United States Navy. As an endocrine fellow at Scripps he discovered that Graves disease, the most common cause of an overactive thyroid gland, was the result of a confused immune system. It was the beginning of a life-long love affair with the thyroid gland. Bette was his wife, but that little butterfly shaped gland in at the base of your neck? That was his mistress. He studied dizziness in astronauts in the Mercury space program and once appeared in Life magazine examining astronaut Scott Carpenter. He was department chair of Internal Medicine, then Vice Chancellor to Academic Affairs, then medical school dean. He was a delegate to the American Medical Society and the Director of Rural Health Care and Outreach. He not only earned the University of Kansas Distinguished Service Medallion; he had at least one award named after him, which may be the most apt description of all, since he never seemed to meet a leadership position he didn’t like: Alpha Omega Alpha, Kansas Medical Society, Medical Society of Sedgwick County, Wichita Grand Opera, Sedgwick County Zoo, and others. Depending on your tastes or your line of work some of these acronyms and organizations may not mean anything to you. Don’t worry about it. It doesn’t matter. What matters is how his position in those organizations reflected his life’s philosophy. He considered himself so privileged. Not in the high income, private school, trust fund sense. Privileged in the sense that he had these opportunities. Joe once told me that there are people in the world that wanted to be somebody, but who didn’t want to do anything. “Justin, don’t be one of those people,” he said. In retrospect, I have to wonder what it was that I said or did that made him say that!

He did it all without ever taking himself too seriously. If you don’t mind, let’s all geek out about hormones for a minute. Remember: he discovered thyroid stimulating immunoglobulin, the antibody that confused immune systems make that overactivates the thyroid gland. But his paper describing TSI only beat a competing paper into the literature by a few weeks. Once, while humoring my questions on his discovery, he confided in me that he thought the main reason his paper was published in the Proceedings of the National Academy of Sciences a few weeks before Joseph Kriss’s competing paper in the Journal of Clinical Endocrinology and Metabolism was that his own mentor had a contact within the National Academy that expedited editorial review and the penning of the accompanying editorial. He thought this was hilarious. But it says something about his character that from then on, he happily shared credit for the discovery with Dr. Kriss. And that picture in Life magazine? The one of he and astronaut Scott Carpenter? He loved to tell the story of how hard they’d worked to get a good camera angle for the photographer once the initial data collection was complete. And it is a dashing picture. There’s just something about those Navy whites.

I loved his sense of humor, but I admired his enthusiasm. He struck you as the happiest person alive. He was immune to questions of fashion. He flashed his crooked-toothed smile at everyone--and I do mean everyone--he met. He was not a creature of irony. He was sincere to a fault. The act of engaging in our cultural default setting for David Letterman-esque cool, ironic snark would have been like a trip to Mars. Because in my experience with him he almost always took people at face value. I say almost. Once as a student, I reported to him that a patient’s chief complaint was “an impending sense of doom.” He looked at me as he put his hand on the door to go into her room and said, stone-faced, “Justin, she’s not the only one.” But seriously: he operated in good faith, and he expected the same from others. I can’t imagine that anyone else’s opinion of his vocal love for opera or medical history or brown loafers or obscure thyroid diseases ever crossed his mind. I have no doubt that people--maybe even some in this room--had periodic dustups with Joe Meek. That’s the cost of doing business in leadership. But if you managed to make yourself a lasting enemy of Joe Meek’s, I’m not saying you’re a bad person, but I’d encourage a sincere evaluation of your life philosophy. There. I said it.

That makes him sound boring. He wasn’t. He and Bette shared the trait of being great storytellers. Fifty years of medical students, residents and fellows--not to mention patients--know how much he loved to tell the story of Dr. Hashimoto, the so-called “thyroid hero of Japan.” And of Robert Graves, whose grave--ironically--he’d visited in Dublin. I actually stole that joke from Dr. Meek, and I’ve used it over and over. It goes like this: Graves disease doesn’t mean you’re going to the grave. It’s just a guy’s name. Okay. So maybe he wasn’t a comedian. But he was funny. He used words that I’d never heard anyone use before. You may know somebody who routinely uses the phrase “to wit.” It means something like “that is to say.” But I dare you to find another person who uses the word “folderol.” That’s f-o-l-d-e-r-o-l. It means “a trivial or nonsensical fuss.” He pronounced “helicopter” “heel-i-copter.” He sprinkled these kinds of words into conversation the way most of us reflexively use “like.” The effect was thrilling. Even through the ravages of a degenerative neurologic disease and sometimes through swollen lips and bandages from accidents and falls, he routinely told me stories that made me giddy.

He once told me a story about a brittle diabetic he’d taken care of named Dora. Even though I’m not sharing it with you today, he still knew her last name, decades later. He wasn’t sure that was a good sign. Dora was in the hospital a lot because of complications of her diabetes, and one day she asked Dr. Meek: “We raise a lot of our own vegetables. Can I bring you in some vegetables?” He wasn’t sure if it was a peace offering or a way to try to get special treatment. But he said yes, stressing to her that it was not a requirement, and she said, “I’ll discuss it with mother, and I’ll bring you in something.” And so Dora showed up to her next appointment with a sack of Brussels sprouts. Not long after, Dora’s mother began calling Bette and Joe’s home phone. One time she called in the middle of the day and Bette answered and said, “Ma’am, he’s at the medical center, and I do not welcome you calling his home like this.” Mother said, “Mrs. Meek, you remember them Brussel sprouts?” Bette’s abject lack of gratitude for the Brussels sprouts was a joke between Bette and Joe after that. Joe admitted in confidence that the Brussels sprouts were really, really good.

He was my portal into a different era. Like a time machine. I don’t mean just to say that he was old. But he had once taken care of a patient who had been cared for at age eight by Dr. Arthur Hertzler, the famed Horse and Buggy Doctor from Halstead. Dr. Hertzler had told the patient’s mother that the daughter needed a goiter operation, and the mother said, “Well, should we make arrangements at your hospital for surgery?” And Dr. Hertzler said, “Madam, I said your daughter had a goiter and it needs to come out!” So mom served as the anesthesiologist, presumably with ether, and Hertzler did the thyroidectomy on the kitchen table. When Dr. Meek took over her care sixty years later she was in good health, with no complications of her procedure. He remembered her name, too.

It was all a reflection of his sense of wonder. He once told me regarding his discovery of TSI, and this is a direct quote: “Leaps forward in medicine were sitting there, just below the surface, waiting to be unearthed.” In clinic he would stand behind patients with his fingers delicately around their necks, feeling the thyroid gland. When a patient swallowed and he felt a thyroid nodule move under his fingers, Dr. Meek would sometimes say “There it is!” And then he’d almost always reassure the patient that it was only a matter of getting a needle biopsy to diagnose the problem, and that it wasn’t a big deal, and that most people with thyroid cancer--if that’s what it was--did just fine.

One time we saw a patient together that had acromegaly, a pituitary condition of excess growth hormone. All that extra growth hormone causes the hands and feet to enlarge, and causes the patient’s skin to take on a particular texture. He and I were examining the patient, and he put my hand over the patient’s and said, “Feel this, Justin. It’s like she’s made out of warm dough.” The patient asked “Is that okay?” And he said, “It’s great.” And then he reassured her that we would get to the bottom of her pituitary issue, and that she would do okay. And she did.

That confidence came with experience. Like any doctor, he often saw patients for whom there was no simple answer. They had problems that were hard to fix. Bad eyes from pituitary tumors or Graves disease. Metastatic thyroid cancer. He would evaluate them and simply lay it out there: We don’t have a perfect answer for you. We have a lot of bad options and one decent option, and the decent option is the one we’re going with. Modern-day practitioners trained in shared decision making--that’s the generally sound principle that patients should have more of a say in their own care--would have raised an eyebrow at this. But I think there was comfort in that approach for a lot of patients. Because this wasn’t some stranger telling them the bad news. He’d never met a stranger. Most of these patients had already been on the business end of one of his so-called “hundred-dollar hugs,” as the nurses called them. So by the time the hard decision making really kicked in I think people thought, “That’s okay. I know Dr. Meek. I know he’s got my best interest at heart. I know that my friend wants the best for me.” Or my group, or my organization. In preparing for this I spoke to a couple docs in town who’d worked with Dr. Meek. He’d had the same effect on them. They would go to him with a tough decision about a patient or their career, and he would have an answer, often quickly, based completely off his own instincts and extensive experience. And more times than not his instincts were right.

In saying my own goodbyes to Joe over the last year or so, I was struck by his dignity in the face of an illness that spared him nothing, dignity least of all. The disease even took his voice, then his laugh, then his crooked-toothed smile. But to the end he insisted on brown loafers, slacks, and a tucked-in shirt. Maybe he was a fashion icon after all.

“I don’t fear death,” he told me once, though he did say how much he would miss seeing friends, his kids and grandkids, and Bette. But I’m comforted by the thought that old endocrinologists never really die. If cowboys ride off into the sunset, endocrinologists just shuffle off into a bright hospital-fluorescent light. And if there is justice in the universe, someday we’ll meet again. He’ll be under that fluorescent light in a perfectly pressed white coat and brown loafers, telling the staff about Dr. Hashimoto, the thyroid hero of Japan, and patiently waiting for the arrival of the next data set.

Old endocrinologists don't die. They walk off into the fluorescent light of the big lab in the sky.

Last night one of my mentors passed away. Dr. Joseph Meek was a lot of things to a lot of people. To me, he was the Dean of the School of Medicine at the University of Kansas in Wichita when I started school there, then an attending endocrinologist who wrote me a letter of recommendation for fellowship, and later in life a friend.

After he left the medical school to ride out the last few years of his career in private practice we lost touch for a year or two. But then in 2015 I became interested in his role in discovering the autoimmune cause of Graves’ disease.

I started visiting him every week, and every week I seemed to get a better story. So I asked if I could start recording them, and he consented. Dr. Meek told the stories with remarkable enthusiasm. He was a gifted storyteller, even the times he was speaking through a forehead bandage and a crusted upper lip from a recent fall. (note: I’ve not fact-checked these. I’m not a journalist. If anyone finds an error, please let me know so I can note and correct it.):

He had a lot to say about the discovery of thyroid-stimulating immunoglobulin:

Meek: ...at that time, the cause of Graves disease was entirely unknown. And since such luminaries as--I haven’t thought of his name--Sydney Warner felt it was due to a pituitary factor, and the TSH was involved.

Moore: So they thought some over-secretion of TSH was involved?

Meek: Yeah. And about that time a guy by the name of Brown-Dobbins discovered what he regarded as the exophthalmic factor. And so the hyperthyroidism was explained by an oversecretion of TSH and the exophthalmos of Graves disease was explained by the exopthalmic factor, “ES.”

Moore: Okay

Meek: And so that was where it stood to 1964. Well, McKenzie had developed a TSH assay, bioassay, that involved the preparation of mice.  You injected radioactivity into the mice and it was recorded as an uptake. And then the mice were bled and two hours after the injection of TSH or Graves disease patients [ed: I assume he means the plasma/serum of Graves patients] they were bled--the mice were bled--and there was observed a rise in the radioactivity level of the mice.

Moore: That’s interesting.  Okay.

Meek: Yeah. And the mice had to be prepared in a special way, and ruled out that it was a stimulation versus an infectious agent that caused the destruction of the TSH. The mice were initially prepared that stimulation was proven and the mice did stimulate and discharge radioactivity.

Moore: And the source of the stimulation was either the TSH or some other stimulation factor in the serum that had been injected?

Meek: Yes

Moore: Yeah.  Yeah.

Meek: And in Graves disease patients there was evidence of a long-acting stimulator, LATS.

Moore: Yeah, yeah.  Uh-huh.

Meek: Yeah. And the mice would stimulate sort of at 2 hours, and there was increased activity in the blood 7-24 hours afterwards. And Van der Laan [ed: 4th author on the paper above] came up with the idea (that’s my mentor)...

Moore: Was that in San Diego?

Meek: Yes.  At the Scripps Clinic and Research Foundation in La Jolla. ...that it would be explained by an antibody.  That was a unique observation, although it was copied by a Maxwell McKenzie and, oh gosh...well, this was a race.

Moore: Yeah.  I bet.

Meek: Yeah. And the work that I did was to prove that it was an antibody, that it was a 7-S-gamma globulin that was present in the serum of mice and the serum really came from patients with Graves disease. And the stimulator was an antibody. Well, the man’s name was--from San Francisco, and he’s dead now--he came out with a publication about the same time that I did, and he is given credit for this work that he did, and it was published in the Journal of Clinical Endocrinology and Metabolism [ed: I think it was this paper]. But I beat him by a month through the National Academy of Sciences.

PNAS 1964 Aug; 52(2): 342–349.  PMID: 14206601

PNAS 1964 Aug; 52(2): 342–349. PMID: 14206601

Moore: That was the journal that you published in?

Meek: Yes.

Moore: A better journal! You got it into a better journal. (laughs)

Meek: And it was not peer-reviewed to the extent that it was in the Journal of Clinical Endocrinology.

Moore: It wasn’t? That’s interesting.

Meek: And it was introduced by Dr. Astwood, who was a member of the National Academy of Sciences, and so there was a race on, which fell in my favor due to circumstances beyond my control by senior men Van der Laan and Astwood. And they had known each other through their collaboration prior. The competitor just won’t come to me… And it culminated in review in Atlantic City. And that was when Atlantic City was meaningful as the senior moment of the Central Society for Clinical Research. They would hold their annual meeting in Atlantic City, NJ, and I was invited back in May of 1964 to give a paper. And so I did. And I remember an anecdote that before I left Scripps I was rehearsed by Dr. Van der Laan and Igray Diamond, who knew me from, because of, medical school days.  And he was back in Kansas at that time as chairman of the Department of Internal Medicine.

Moore: And you had gone to medical school at KU, correct?

Meek: Yeah. And he was the speaker at Alpha Omega Alpha (AOA) when I was President of the AOA. And I introduced him as saying that--it was a brash statement on my part--as the erstwhile, but seldom seen, member of the faculty because he was gone so much of the time. (laughs). And he got up and said after that introduction that he had secured a spot for his residency in my favor and he was considerate of my position and he gave me the position as resident in Internal Medicine right on the spot. And so he knew me and said that my slides had not been acceptable because they were all on blue. At that time I couldn’t do anything about it.

Moore: (laughs)

Meek: Yeah. He went on and on in remorse, it caused remorse in me, because he said that was not acceptable.  They should be in black and white. Yeah. And I came to give the talk in Atlantic City and found out that blue was more or less the outstanding color.

Moore: The industry standard.

Meek: Yeah.

Moore: Good.  It was really hard to change slides back then I’m sure. You had to go back to the photography place.

Meek: The plates were in evidence and I couldn’t--I had to board the airplane to Atlantic City the next day and there was no way I could get the slides done. Well, that’s an anecdote. The work of mine was justified in my way of thinking because I had done some biochemistry and proved that it was a 7-S-gamma globulin.

Moore: That the stimulator was a gamma globulin?

Meek: Yes. That LATS, as defined by the mouse response, was due to an antibody in patients with Graves disease. And so from that point on the, and subsequent work, and I did a a little of this, was to see if you could convert TSH to a long-acting thyroid stimulator, and conversely, you could modify the 7-S-Gamma globulin by fragmentation and show that it was an antibody on that basis and convert short-acting thyroid stimulator by modifying the gamma globulin.

Moore: Uh-huh.

Meek: Well, then I went back to Kansas and did some clinical work and that was my highlight. And I am proud of the fact that I contributed something to the medical world.

Moore: A pretty big thing, I think.

Meek: Yeah.

Moore: Did they--I assume it was pretty well established by this point that antibodies were responsible for other autoimmune diseases, like Rheumatoid arthritis and whatnot?

Meek: Yes. Rheumatoid arthritis. Although they never--RF factor, which is an antibody in rheumatoid arthritis, was never injected into a patient and produced the joint destruction. And I, for long time, believed that the uniqueness of Graves disease was due to two factors: one, it was proven to be an antibody, and two, that it was a 7-S-gamma globulin antibody that was unique to, based on the fact that it stimulated the thyroid gland.

Moore: So you could actually reproduce the disease by introducing the antibody?

Meek: Yeah. And that sort of is where it was in 1964.

Moore: You know, the fact that it was a race, as a lot of these things are, interests me. Nowadays when you submit a paper to a pretty high-end journal like the Proceedings of the National Academy of Sciences, you have a response back in hours to days, at least an initial response.

Meek: Yes.

Moore: So you can go from a completed paper to having something submitted for publication in the course of a few weeks. If you’re lucky.  I assume that back then there was a huge element of faith involved. You had to send off a manuscript that got distributed out and it might take months to get edits back.  Is that how it was?

Meek: Yes. The editorial that the edited version of the paper came out in the Proceedings of the National Academy of Sciences pretty much on--I think it was accepted for publication in May of 1964, and published in July issue. Whereas Kriss! Joseph Kriss! That was the author that did the companion.  He did the work about the same time that I did, but he went through the channels of the JCEM, and got his published in September (laughs) [ed: it was October]

Moore: Somebody held up the editing process, somebody didn’t get their edits back in time.  That’s the way it always goes.

Meek: Yes. Well, Chris is subsequently referred to--what’s the word? Referred to as the contributor to that just as frequently as I am. And to this day it’s still holding up. It’s an antibody, and the locus is sort of where TSH is, and it stimulates the patient to develop hyperthyroidism, and it, based on the TSI (thyroid stimulating immunoglobulin), it’s pathognomonic for Graves disease.  So it’s still valuable information.

Moore: Yeah. I agree.  Someone at the time must have thought that it was important to have solicited an editorial to accompany the paper.  That doesn’t happen every day.

Meek: No. And subsequently the EPS, the Brown Dobyns work, has faded from the scene.  I know that his assay was an Atlantic minnow, and the Atlantic minnow developed exophthalmos (laughter). The lateral displacement of the minnow’s eyes was measured with a micrometer.

Moore: That’s amazing.

Meek: Yeah.

Moore: Would they just put the stimulator in the water?

Meek: They injected it into the animal. The Atlantic minnow.

Moore: Very interesting.

Meek: Yeah.  I never did that assay. But I remember hearing about it.

Here’s one about the Mercury Program:

Meek: Yes, and I was found to be acceptable, and so Diamond wrote down to Captain Greybill, that was a Navy Captain, and he was in space medicine at Pensacola. And accepted me to avoid the draft and I went into the Navy and was assigned to Pensacola dispensary or flight aviation for two years. Well, Greybill was into flight disorientation.

Moore: OK

Meek: Now, it was kind of ironic that my trouble--current trouble [ed: at this point, Dr. Meek was suffering from frequent falls and dizziness]--preceded that. And his claim to fame was disorientation about space sickness, which was brought about by circular rotation of the spaceship to create artificial gravity so the astronauts would have an up-down location/knowledge base.

Moore: So they were thinking of designing spacecraft that rotated to generate centrifugal force so that an astronaut would have some artificial gravity as it were?

Meek: Yes.

Moore: OK.  I’m following.

Meek: So the work really was brought to a head for NASA’s standpoint by the space race which we were engaged in in 1962. We participated in that because we in the Army and Navy were the only ones doing disorientation. So I was appointed as a research assistant, a typical post-doctoral fellowship.

Moore: You were out of residency at this point?

Meek: Uh-huh.  Although just out of residency. And it was before I had seen Van der Laan [ed: 4th author on the above paper] and before I arranged for my endocrine fellowship at Scripps Clinic and Research Institute. Well, I thought that was a pretty good deal to be established in the Navy stateside for the following reason: captain Greybill had an understanding with the United States Navy that he would never be transferred from Pensacola.

Moore: That seems remarkable.

Meek: Yeah. And they were willing to do that because he was a student of Paul Dudley White, and White was Mr. Harvard Medicine at that time. And they wanted somebody to head up their space program, so many of the astronauts were navy recruits or marine recruits, including Scott Carpenter and John Glenn. So we did some preliminary data on the original seven Mercury astronauts, and, so, NASA was in a race with the Russian cosmonauts, and the cosmonaut fell into space at that time, certainly in the capsule…

Moore: Gagarin?

Meek: Yeah, Yuri Gagarin. That name is familiar to me only because the space race was going on in full intensity at that time, and NASA had not considered it until Gagarin became violently ill in space because of the tumbling.

Moore: Did the Soviets admit that he’d been ill, or was it just intelligence? Somebody on the inside who’d passed along the information?

Meek: Yes.

Moore: Wow.

Meek: That’s how it all happened. So NASA said, “Where is our counterpart to this space station to be?” And the answer was Ashton Greybill.

Moore: He was the guy to solve this problem?

Meek: Yes.

Moore: got it.

Meek: And so I was assigned to the recovery of Scott Carpenter on the space flight. I went for seven days on special assignment to sea. And I was assigned to the recovery ship the Intrepid.

Moore: Very famous ship.

Meek: Yes. The Gray Lady. Had a colorful history of being sunk but not being sunk, and being towed into Australia and refitted, and went out to sea. She is parked in the--because of her history--she is parked in NYC, and I went aboard her some years after I got out of the Navy. Well, there is a little anecdote around that which I will refer to at a later date. So the recovery mission of Scott Carpenter ended up 40 miles off range. 40 miles.

Moore: 40 miles away from the intended spot of impact, or whatever?

Meek: Yes. Drop. And so we were on the flight deck of the Intrepid and craning our sights to the skies and seeing if we could see the ship come down. Only to learn later that she had--that Scott Carpenter had landed 40 miles downrange, 40 miles off the target area. And the plans were diverted on the spot to a destroyer picking up Scott Carpenter. Well, the Navy, in contrast to the marine corps, had Jet-assisted helicopters [ed: he pronounced “helicopter “heel-i-copter,” which is officially the most Kansan thing ever], and that was in the early days of jet-assisted helicopters, and Huey current breed of helicopter which followed that. And that had the range of 40 miles. But the Marines didn’t have that, so the Navy left the Intrepid the original plans were adhered to. Well, there was a big folderol and I was in my moment of glory, and I gave Scott Carpenter the original assessment to see if there were any remains of space sickness occurred. Including a ice water bath to induce nystagmus.

Moore: You mean irrigation into his ear canal?

Meek: yes. I only mention that because my hands were steady during the entire procedure and the intrepid was under full steam to make it to the islands, Grand Turk Islands, and the ship just yawed and strained and it was awfully difficult to hold a steady hand.

Moore: Well that’s a very difficult environment to evaluate someone’s balance, I’m sure.

Meek: Yeah! And Scott Carpenter was a wonderful guy, and he’s still alive--or just died [ed: he died October 10, 2013]--and he played it to the hilt. Now there was this about it: Scott Carpenter had been out on the Caribbean sea for a long time waiting for his recovery. So if he did show any deterioration in his baseline figures, including the threshold caloric test, it would have been seasickness rather than space sickness.

Moore: Because he’d been bobbing in the water forever waiting for someone to come pick him up?

Meek: Yeah. But we played it to the hilt and I received some notoriety about that. Because you can’t imagine how the people stateside were enamored with the space program.

Moore: Those guys were the rock stars of their day.

Meek: They were, and they handled their fame beautifully, as would be expected, as they had so much training to do prior to the selection for the space program, and even today the space station is not accommodated to generate artificial gravity. And that remains to be seen, whether NASA intends the space station to be constructed to generate artificial gravity or not. It doesn’t take much: 3-6 rotations per minute in weightlessness corrects artificial gravity to a point that, up and down, is reproduced artificially.

Moore: Was that at a specific radius?

Meek: Well, we did some preliminary space sickness, and we felt that everybody was subject to space sickness, although you adapted to it over the long haul.

Moore: How long did it take?

Meek: 72 hours, +/- their sensitivity, as determined by the threshold caloric test. And whether you had been a seasoned aviator or not, that helped.

Moore: Meaning experienced pilots got over it a little more quickly?

Meek: Yes.  They were subject to less of it, although the seasoned aviators, including the astronauts, could always manifest space sickness by sweating.  They couldn’t control that. But the nausea and vomiting that accompanied that--car sickness would be the closest we could come, land-locked selection, and not everybody was subject to car sickness, but everybody would, if they had normal semicircular function, was subject to nausea and vomiting.

Moore: Did you guys consider using anti-cholinergic medications?

Meek: Yes. Scopolamine. And that masked it, but it brought out some undesirable side effects from the scopolamine. And the patients were subjects in the slow rotation room environment, and then re-adapted to space sickness symptoms upon entering weightlessness. And there was a little readaptation.  And I think it’s been proven enough of a problem that they don’t create an artificial environment because of that single effect. And they always give the astronauts time to re-adapt to weightlessness and following their return to earth. You aren’t aware of that, but they sit out on the space recovery mission after that, and they’re a little wobbly.

Moore: You mean after they launch they get some time to adapt before they’re assigned any tasks, and after they re-enter they get a little while to re-adapt before anyone asks them to do anything else? I see.

Meek: Yes.

Moore: That seems cheaper than building a rotating spacecraft.

Meek: The human is--particularly the seasoned aviators--used to that through their flying

Moore: Was the idea with this slow rotation room, was that something they tried to do pre-launch to get them accustomed to it?

Meek: Yes.

Moore: From what you’re telling me I assume it didn’t work very well.

Meek: No. Well, the history of the intrepid was such that its glory days were extended through the second World War, the Korean War, and other war duty.

Moore: All the way into Vietnam, right?

Meek: Yes. They put a pictorial essay, pictures, up when we, just prior to when we went aboard the time it was tethered in NYC. And you could go aboard and see the Intrepid. The pictorial essay of space was pictorially depicted about the Intrepid’s life at sea. And the time aboard we took time aboard, they had just done the pictures--taken them down--and so we thought that it was all over, although we had no idea that they’d depicted the shot that showed me administering the Heath Rail balance problem to the astronaut, to Scott Carpenter.

Moore: So there was a photo in the exhibit showing you doing this with Scott Carpenter? How about that.

That’s Dr. Meek on the right with the clipboard. From  https://bit.ly/2Bespfg

That’s Dr. Meek on the right with the clipboard. From https://bit.ly/2Bespfg

Meek: Yes. And it had been in Life magazine.

Moore: Wow!

Meek: And the Life photographer, who was a neat guy, captured that when Scott Carpenter was interviewed after the tests were administered. And so sick bay was converted into the ability to do the threshold caloric test and the Heath Rail. So Scott Carpenter came in to pictures being taken, flashbulbs going off.

Moore: (laughs) More things to add to the validity of the testing.

Meek: Yes. And because the Navy wanted maximum publicity on this, the results were negative plus or minus three, the threshold caloric and the Heath Rail test was administered by me, and you had to stand up on the rails, which looked like a railroad yard, for so many seconds, and there’s Scott Carpenter with his arms folded and looking intently down on the Heath Rail and balancing. Now, that wasn’t the purpose of the picture, to get my picture in with Scott Carpenter, but it added to my luster. (laughs)

Moore: I would have put that in my application to fellowship, for sure.

Meek: Well, that was it.  That was my claim to fame. Six days aboard the Intrepid, and subsequently the falderal and attention that I got as…

Moore: Were you allowed to publish any of the data you got out of this experience? It wasn’t classified then?

Meek: No. Although my publications were on the experience I had in the slow rotation room in Pensacola. That’s in Aerospace Medicine. [ed: paper regarding monkeys and slow rotation here: http://www.ncbi.nlm.nih.gov/pubmed/14472044] And that was one of the publications I got out of it in my quest to enter academic medicine.

Moore: How much time did you have in the Navy after this experience was over? Was this near the end, or was this...

Meek: This was right during the end.  I got out in July of that year, ‘62, and went to my fellowship and discovered the antibody formation of LATS [ed: long-acting thyroid stimulator] that we have discussed prior to that. But even though the ENT work was instrumental in that period, it was never exposed beyond the publicity on that, although when we went to Pensacola some years thereafter, after I got out of the Navy, the slow rotation room was still in operation.

Moore: Is that right? Were they using it for just routine flight medicine stuff then, or was it still affiliated with NASA?

Meek: No, the building was semicircular, a full circle, and that was constructed because of the human centrifuge that had gone on prior to that. But Captain Greybill slowed the centrifuge down and found out that we could reproduce the symptoms at a very slow rotation. So he had done all that work prior to my entering the Navy. And I developed the threshold caloric test and Heath Rails that were part of the experience--part of the “package”--that astronauts were put through as well as the Navy recruits that came in.

Moore: I’m sure they cursed your name if they knew.

Meek: Yeah. (laughs) They did. They forced me to ride aboard the spacecraft, slow rotation room, and experience first hand the adaptation that occurred. And we had dials that you had to set up here and over here to bring out the case of space sickness.  Because if you kept your head in the plane of rotation you could avoid the adaptation.

Moore: You had to move around?

Meek: Yeah.

Moore: That is so fascinating.

Meek: The experiments at that time were pretty crude, and they consisted of a water bath and temperature adjustments which were displayed on a human--I forget what we did to keep the water bath temperature and they syringing adjusted to threshold as determined by nystagmus.

It was so fantastically great hearing those stories and others. It was good even after he lost the ability to talk and we just watched baseball together for 30 minutes a week.

I’ll miss him. I’ll miss his excitement at nailing down a straightforward diagnosis of Graves disease. I’ll miss the enthusiasm with which he told the story of the time he discovered and successfully treated a case of thyroid lymphoma. I’ll miss the way he tried to hug everybody, including me, even though I hate hugging.

But I won’t forget him, and that’s all most of us can wish for.

My own, personal e-bike: How to riide

After my excitement about dockless e-bike share in Washington, D.C. last spring, I started shopping around for an e-bike for Double Arrow Metabolism to use for short business trips.

I wanted a bike that was adjustable so that more than one person could use it without much trouble. I tried to find refurbished Jump bikes, but I struck out. I think they’re just too new. Many of the purpose-built bikes on the market are really expensive and/or look like Kawasaki motocross bikes (you really get how some people are complaining about e-bikes being e-motorcycles in disguise).

So it took some looking. I really like the retro fabulous looks of Faraday bikes. I love the looks and techie features of Stromer bikes, but the price is way too steep (especially for Stromers), at least until I really know what I want. And for the money, the looks of the mainstream bikes like Specialized and Trek just aren't what I’m looking for.

I considered building my own e-bike by adding an aftermarket hub motor and a battery to a bike I already have. Then I looked around and found a page for refurbished Riide bikes. The price on these was what really attracted me. They don't cost the three or four grand that some of the other bikes mentioned above cost. In fact, they're within a few hundred bucks of the Money Mustache conversion that piqued my attention toward e-bikes in the last couple years. Riide has an interesting subscription-based business model for its new bikes, but more important to me, they’ll sell their old ones: 

Screen Shot 2018-05-13 at 6.16.12 PM.png

They'll allegedly fit a rider between 5'2" and 6'2". That easily fits my wife’s and my height, and it gets close to my daughter's. So I hit the Add to Cart button and waited. Unfortunately, when I ran out giggling to greet the FedEx guy, I found an open box and no front wheel. Somebody decided they needed it more than I did:

IMG_1661.JPG
The front wheel is apparently in the same place as Jimmy Hoffa.

The front wheel is apparently in the same place as Jimmy Hoffa.

But not to worry. I got to spend some time talking with Riide founder and owner Amber Wason via email (and even with a personal call to my cell phone [!]), and we got it straightened out. We got the missing wheel replaced, and we had a new e-bike in no time. 

If you doubt the size difference in riders the Riide can accomodate, that's a 4'7", 60 lb human riding the same bike that'll haul my 6'1", 180 lb corpus around.

If you doubt the size difference in riders the Riide can accomodate, that's a 4'7", 60 lb human riding the same bike that'll haul my 6'1", 180 lb corpus around.

The ride of the bike is different than the Jump tanks I rode in D.C. First, the bike is a fair amount lighter, since it doesn't have the built-in racks and electronics of the Jump. Also, Riide isn't controlled by pedal assist. Instead, you twist the throttle like you're riding a Yamaha.

This doesn't really affect the sensation of riding the bike. When you twist the throttle you still get a satisfying little kick from the motor. It does affect the appearance of the bike, though, since you can easily cruise along without even turning the pedals. I’m not in love with the twist throttle, though. My thumb and forefinger get crampy from holding it in place. I think I would like a thumb throttle better.

One feature I really like is that the brakes kill the motor. My son learned the value of this the hard way on about day two, when he accidentally twisted the throttle as he was dismounting and skinned a knee. Use the brakes. 

I eventually rode it to work:

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After taking these pics, I immediately deleted the rides from Strava. Strava is the de facto place to log rides, but it doesn't feel right to post e-bike rides on it. Strava's for human power only. But I can't help but obsess over data, so I put Map My Ride on my iPhone for ebike use only. Then after a few hundred miles I deleted it and just let the abject lack of data wash over me. Digital minimalism forever.

The advertised speed of the bike is ~20 mph, but I think that estimate assumes a new bike and battery, and I think it assumes a smaller rider than me. I can only get ~17-18 mph out of the Riide on flat ground. That’s still pretty good. It gets me to where I'm going faster than I could get there on the fat bike I often commute on: 

Sure, a different route. But a significant increase in speed, with a significant decrease in sweatiness.

Sure, a different route. But a significant increase in speed, with a significant decrease in sweatiness.

At the end of the day, I think the Riide may be what I want, not the bike I ride while I'm deciding. It looks good in a way that doesn't draw a lot of attention, it is inexpensive and comes with a warranty that I've already tested and that works, and it gets me around in a satisfyingly blue-collar way.

IMG_1849.jpg

Now I’ve ridden it a thousand miles, maybe, and I feel pretty good about it. The bike didn't come with any rack or panniers, so I had to add one. No problemo. Because buying bike stuff is. The. Best. The front rack from Velo Orange. It looks great and can hold a ton (or at least a case of beer). I’ve found it easier to strap my soft-side briefcase to the front rack than to stuff it in a pannier bag or strap it to a skinny rear rack like I do on my fatty.

A few Riide-specific tips, if you care:

Don’t air the tires up to the maximum pressure. It’s tempting to do this to try to maximize battery efficiency, but the bike rides like a lumber wagon that way. And remember that higher pressures aren’t always better. It’s way, way more comfortable to pump the tires up to a nice, soft-ish pressure to allow a little give over the bumps.

The battery is really glitchy about over-charging. I’ve found that if I accidentally leave it plugged in overnight it’s out of commission for the day. I don’t know why, and I’m no stranger to plug-in electric vehicles:

IMG_2544.jpeg

The phenomenon is reproducible. In my mind it’s a complication of over-charging. But that could be my imagination running wild. Anyway, either set up the charger on a timer that shuts it off after ~3 hours or set a manual timer to remind yourself to unplug your Riide.

Finally, if you have multiple people using the bike you’ll need to put the brake levers in a medium position. Since I’m a foot-and-a-half taller than the other people riding it but I use it 90+% of the time for work, I keep the levers pointed down a little. But not as far down as I would if I were the only rider. I tip them up just a little to make them reachable by everybody else.

Riide on!

The pleasure of going deep

I took the ABIM endocrine maintenance exam a couple months ago.

I love the ABIM logo. It reminds me of the logo for the  Southeastern Conference .

I love the ABIM logo. It reminds me of the logo for the Southeastern Conference.

Spoiler alert: I passed. But this isn’t about my ability to pass a standardized test designed to fail only the small number of docs who can’t achieve a minimum level of competence. This post is about how good it feels to set aside the distractions of the world for a fraction of the day and really concentrate on learning something.

Ironically, the format of the exam was new. The test now includes sections in which UpToDate is available for reference. These were tricky because the availability of a reference was so seductive, much like the availability of the internet in your pocket at all times is so seductive. Lucky for me, my preparation had somewhat steeled me against this. I forced myself to use the physical version of the Endocrine Self-Assessment Program (ESAP), and I forced myself not to look up answers on the computer or my phone willy-nilly. I read through the questions, answered, read the responses, and took old-fashioned analog notes that I reviewed later. I studied around 30 minutes a day, five days/week for September and October. I kept a “30 min board review” item on my daily to-do list. I attended the Cleveland Clinic review course, which was helpful. I was amazed at the new diagnoses that have come about since I last did full-time endocrine practice. Pigmented macronodular hyperplasia? Okay then.

Analog study materials.

Analog study materials.

Ironically, I’ve somehow activated notifications on my computer so that Apple News headlines keep popping up in the corner of my screen as I’m typing this, which only serves to show how much attention residue I avoided by doing it the old-fashioned way. But even still, the first section that allowed access to UpToDate almost tripped me up. I found myself second-guessing even simple answers and clicking on the UpToDate icon to double-check myself. Even though I’m a pretty fast test-taker, and even though every UpToDate check took only a minute or so, they really added up, and I had to really hustle toward the end of that section to get done on time. For the next two sections I forced myself to finish the questions to the best of my ability and then go through any that I’d marked as potentially wrong to check them. This method left me much, much more time.

When I finished the test, mostly sure that I’d passed, I felt a sense of satisfaction that only intensified when I got my test results back. I had prepared for the test, performed well enough to pass, and legitimately increased my knowledge of endocrine diseases and their treatments. As big a pain as the board certification process is, it ultimately made me a better doctor and reinforced some of my technological minimalist views of the world.

Many of us do the same job tasks day after day. I’ve warned med students and residents about the “Groundhog Day” phenomenon. If you go into general surgery, you better like gallbladder disease, because you’re going to see it all day, every day, forever. If you become an endocrinologist you better like hyperthyroidism, because again, it’s gonna take up a lot of your day. (I would have said diabetes there, but it’s so rapidly automating that I’m not sure it will be part of the day-to-day of endocrine practice for much longer.) I’m sure the same thing is true of banking, law, manufacturing, farming, or a thousand other professions. But by going deep, you can find new sources of pleasure and satisfaction even in work that has a tendency to become rote.

Links for Wednesday, October 17, 2018: TV's first drug ad, does mold really make us sick? and big-ass Canadian pumpkins

Behold: the first television drug ad in the US

It was taken down after 48 hours. And now the US is one of only two countries worldwide to allow direct-to-consumer advertising of drugs.

Science has yet to prove that mold makes us sick

I grew up in a farmhouse that was originally an in-ground house and, well, you know how this ends. The basement, which was originally just called “the house,” leaked like a sieve. This led to chronic, unrelenting nighttime exposure to mold in the nooks and crannies of the place. I never felt like it made me sick, but relatives tell me it makes them feel bad. It’s a bummer that medicine can’t tell them whether they’re wrong or right.

Wikipedia

Wikipedia

Canadians (Canadians!) are racing to grow their first one-ton pumpkin

In my day, we were happy with an orange decorative guord that you could hold in your hands and gently disembowel for purposes of internal illumination. We didn’t want anything to do with these monsters that gain 50 pounds a day to deform under their own weight and need a forklift for transportation. But I do admire they’re trying to do it a different way:

“…weights in the United States and Europe have long passed 2,000 pounds. In Canada, where regulations prohibit some of the chemicals used elsewhere, they have yet to hit this mark. Getting there has become a point of national pride.”

FYI: Pumpkinnook.com tells me the current world record is owned by German Mathia Willemijn at 2,624.6 lbs in October, 2016:

Pumpkinnook.com

Pumpkinnook.com


Links for Monday, October 15, 2018: Uber quantifies the curb, non-yelling coaches, criminal malpractice, and handlebar shapes

Uber—not a bus company—has proposed a formula for optimization of curb space that makes buses look pretty good:

(quoting directly from the article)

Activity/(Time x Space)

“Activity” is the number of passengers using the curb space by a specific mode, “time” is the duration of their usage, and “space” is the total amount of curb footage dedicated to that use.

Here’s the example that the consultants use in their report, where a 20-foot length of curb is used for four hours as a parking spot by a single car carrying two people:

2 passengers/(4 hours x 20 feet) = .025 passengers/hour-feet, or 0.5 passengers per hour per 20 feet of curb

But if that space is instead used as part of an 80-foot bus stop serving 100 people in that four-hour block, the equation looks like this:

100 passengers/(4 hours x 80 feet) = .3125 passengers/hour-feet, or 6.25 passengers served per hour per 20 feet of curb

Clearly, the bus stop is a better use of public space. And naturally, those Uber cars that don’t take up curb parking look good, too. No surprise there, considering the source.

John Gagliardi is dead, which means that the Nick Saban school of coaching just got a little stronger. That’s a tragedy

My antipathy toward football is cresting (just search for “football” in this site and you’ll see why). But who can argue with a philosophy like this one?

“Gagliardi essentially preached a philosophy of anti-coaching, one that prized self-reliance and self-motivation and abhorred cruelty and authoritarianism. These were not bullshit, repackaged, supposedly out-of-the-box ideas like you find coming out of Silicon Valley. Gagliardi’s philosophy was deeply HUMAN, and deeply trusting. It also happened to be highly effective, so much so that similar techniques are now widely used in parenting books, academic teaching, and other fields.”

One thing the best coaches I’ve had did well—in sports, medicine, music, or other—was to make me feel good about what I was doing. They made me feel good about the process of improvement, no matter my starting point in terms of skill. They essentially told me, “I know you’re a person who tries hard. Let me help you direct that effort in the way that will get the most out of your foundational ability.”

A Texas neurosurgeon was so bad at his job that he got life in prison

When I was a resident, a local doc prescribed so many narcotics to so many patients at such outrageous doses that admitting one of his patients was a near certainty on any overnight call shift. But what did the guy in wasn’t that he was committing malpractice on a daily basis; it was that he improperly supervised his wife as a mid-level provider, leading to money laundering and conspiracy convictions.

We in medicine do a bad job of policing our own. The surgeon who body-checked Dr. Death away from the operating table in Texas deserves major credit.

On a lighter note, What Bars? lets you compare the shape, drop/rise, and weight of a few dozen different handlebars

Links for Tuesday, October 9, 2018: Overtreatment of subclinical hypothyroidism, altruism and specialty choice, and Roman wiping technology

Treating your TSH level of 10 mIU/L with thyroid hormone probably won’t make you feel better

But your doctor will probably try to talk you into it, anyway (paywall):

“Although current guidelines are at first sight cautious with treatment recommendations, more than 90% of persons with subclinical hypothyroidism and a thyrotropin level of less than 10 mIU/L would actually qualify for treatment. However, results of this meta-analysis are not consistent with these guideline recommendations.”

Are altruistic students more likely to choose lower-paying specialties in medicine?

This paper is complex and paywalled, and I won’t pretend to understand it. But yes, it does seem that altruism is related to choosing lower-paying specialties and more underserved areas:

<$300,000 per year is defined as a lower-paying specialty, which calls my career choices into doubt.

<$300,000 per year is defined as a lower-paying specialty, which calls my career choices into doubt.

How did ancient Romans wipe without toilet paper?

Let’s all share a collective shiver at the thought of a communal, stall-less bathroom with sponges on sticks, shall we?

Links for Wednesday, September 5, 2018: docs are nervous about weight loss meds, risky low-carb diets, why I'm not a pediatrician, and continuity of care is good

Why don't more docs prescribe weight loss medications?

Speculation: 1) cost (and by extension, prior authorization requests); 2) residual fear from fen-phen, as one of the docs interviewed alluded to. We can surely put this to bed, since the current crop of meds has been on the market much longer than fen-phen had been when its harm was revealed; 3) nihilism. Five percent weight loss is meaningful from a medical perspective, but unless the doc is consciously, prospectively measuring outcomes like blood pressure, lipids, and fasting sugars, it won't knock her socks off. Patients won't be thanking her for getting them ready for bikini season; and 4) the old Risk Evaluation and Mitigation Strategy (REMS) for Qsymia was such a PIA that it scarred some docs to prescribing these meds.

Can we stick a fork in low-carbohydrate diets? (Ba Dum Tss)

What's a 32% increase in mortality among friends? Investigators (in a study that, to my knowledge, has not yet been published, so caveat emptor) found an association between the lowest quartiles of carbohydrate intake and death:

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers.&nbsp;

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

Remember: we can't draw causality from this. There is some chance that people who are sick and more likely to die from heart disease, cancer, or stroke are more likely to adopt low-carbohydrate diets. But it doesn't seem likely. The people at highest risk in this study were those over age 55 and "non-obese."

Reason # 1,001 I'm not a pediatrician:

Can. Not. Do. It.

Special shout-out to the 100 cell phone text alerts during the video. 

If lack of continuity is a mark against telemedicine, then it's a mark against the hospitalist model in general

Links for Tuesday, August 21, 2018: patients love good news. And weed. Patients love weed.

Patients liked a blood pressure app better because it was inaccurate

If I were to pick a single study that wraps all my angst about medicine up into a tidy bow, it would be this one:

"...user enjoyment and likelihood of future BP monitoring were negatively associated with higher-than-expected reported systolic BP. These data suggest reassuring app results from an inaccurate BP-measuring app may have improved user experience, which may have led to more positive user reviews and greater sales."

A better writer could hold forth on how doctors (and devices?) are so bad at giving negative but meaningful information to patients that patients simply avoid the process altogether, leading patients to seek a relationship with their doctors that more resembles that between a shaman and a subject than that of a modern, informed, dynamic doctor-patient exchange of information.

*head explodes*

Dr. Robert Badgett, on seeing this study, reminded me of a quote by Voltaire:

"The art of medicine consists in amusing the patient while nature cures the disease."

I certainly feel like I'm in the entertainment business some days.

With wider availability of cannabis comes wider use and wider abuse

"Public-health experts worry about the increasingly potent options available, and the striking number of constant users. 'Cannabis is potentially a real public-health problem,' said Mark A. R. Kleiman, a professor of public policy at New York University. 'It wasn’t obvious to me 25 years ago, when 9 percent of self-reported cannabis users over the last month reported daily or near-daily use. I always was prepared to say, ‘No, it’s not a very abusable drug. Nine percent of anybody will do something stupid.’ But that number is now [something like] 40 percent."

I knew guys in college who were stereotypical "potheads," and I think my bias at the time was that all but a few of them would be reined in by the relative difficulty of getting the drug (not that it was difficult). Now that the reins are off, we're stuck addressing possible solutions to the problem. This is not an argument for going back to hard-core criminalization. As Annie Lowrey points out, the US still arrests more people for marijuana offenses than it does for all violent crimes combined. That seems, shall we say, excessive.