Keywords:  Adrienne Rich, dermatology, ICD-10, solo practice, death, middle age, Maya, provision of medical care, Obamacare, doctor patient relationship

Adrienne Cecile Rich (May 16, 1929 – March 27, 2012), an American poet, essayist and feminist, was one of the most widely read and influential poets of the second half of the 20th century. She was put on the map by her early poems written while she was an undergraduate at Radcliffe College. In 1951, her last year at college, Rich’s first collection of poetry, “A Change of World,” was selected by W. H. Auden for the Yale Series of Younger Poets Award. He went on to write the introduction to the published volume. I find Rich’s brooding poem, “A Walk by the Charles,” set in the autumn in Cambridge Massachusetts. to be compelling and precocious for its insights into life and the changeable and illusionary nature of the work. A Walk By the Charles, A.C. Rich

Medicine’s metamorphosis in technology, taxonomy, and remuneration leads me to re-walk the path that led me to a career in dermatology, and to saunter down new paths. I think, sometimes, of my days at Harvard Law School before I had any profession and the words of Adrienne Rich’s poem A Walk By the Charles^r come to my lips.   I ruminate over the changes to come in our profession and recast them against the words of this poem.

Rich starts “Finality broods upon the things that pass.”  I ponder if the solo practice of medicine, as a mode of economic existence, is in its final days.  There were once a million livery divers in New York City and now their are a 150.  Will I, like a livery driver or luddite, have to find a new occupation?  I brood over the changes each year will bring. (Table 1).

“Persuaded by this air,” I deliberate the last decade since I started practice in 2003 of the evolution of dermatology’s armamentarium of medical tools — better (and more expensive) combination acne creams, biologics, excimer lasers, fraxel lasers and vasoconstrictive creams.  Rich’s words echo, “The trump of doom might hang unsounded.”  Perhaps I will still make my way providing these marvels in solo practice still. After all I made it through Columbia College, Graduate School in American History, Harvard Law School, Yale Medical School and fellowship training in dermatology and pediatric dermatology.  But I am different now at 50 with 2 children.

Rich rejoins, “While the autumn gloom darkens the air and smokes the river’s glass…” Perhaps ICD-10 and big data will cast a shadow over how I provide care and smoke me out of my solo practice niche.  Rich continues “for nothing so susceptible as death but on this forenoon seems to hold its breath.” I think of my patients who have passed over from melanoma, or age. Some day, I too will depart like Lerner, Ackerman and Shalita, but for now I still breathe and serve my patients.

While Rich continues her train of thought, “The silent single oarsmen on the stream/ Are always young, are rowers in a dream,” and I think there will always be new patients to replace the ones who have passed, there are also bright-eyed new residents and physicians who will care for those who need healing hands even if I fall and am no more.  I ponder how medicine will be affected by the recent increase in the number of medical schools to 141, twice what it was in 1960.  However, I know that change in the way I practice is inevitable.

Change is inevitable.  You can never step in the same river twice. Rich continues “The lovers underneath the chestnut tree,/ Though love is over, stand bemused to see/ The season falling where no fall could be.”  The Buddha said that masses, myself among them, are immersed in illusion but the world is constant.  I wonder whether we will see diseases differently when we use the taxonomy of ICD-10 and abandon ICD-9 come October 1, 2015 – when I un-remember 706.1.  At the age of 50 I think of the beginning of Dante’s Interno.

Midway upon the journey of our life
I found myself within a forest dark,
For the straightforward pathway had been lost.

Rich continues “You oarsmen (she could just as easily could have said “you dermatologists, farm-laborers or consultants” but the poem would have lost its meter!), “when you row beyond the bend/” (or when we behold the final new system of medical care beyond the current purview of Obamacare or how we were taught to practice in our decade of medical school, residency, and fellowship), “Will see the river winding to its end.” I muse upon the transformation of my practice, my specialty, those I love, myself, the end of seeing dermatology as visual reaction patterns as opposed to reaction patterns of cytokines, I recollect that I started my life as an academic dermatologist; will I need to be one again?.

The poet rises on “Lovers that hold the chestnut bur in hand/ Will speak at last of death, will understand,/ Foot-deep amid the ruinage of the year,/ What smell it is that stings the gathering air.  Death hangs over all that we do, and over us.  The cycle of change itself is part of the way of the world.  I think of the myth of eternal return that everything that happened before will happen again.  In dermatology, that is immunology made flesh, the constant real time changes and alteration of the immune system is our meat and our salt.  Ruination leads to rebirth but the process, for all but a bodhisattva, is traumatic so closely are we intertwined with Maya (the illusion) of life.

And as we re-juggle our solo practices merging into larger entities and consider doing more cosmetics, Rich reminds us “From our evasions we are brought at last,/ From all our hopes of constancy, to cast/ One look of recognition at the sky.”  I think of ICD-10 and how there is still no code for keratosis pilaris, I think of halving of payment for processing dermatology specimens, and injecting paralyzing toxins for sweaty underarms.  Rich continues to ponder the autumnal scene:” The unimportant leaves” (are there any leaves that are truly without significance? does not every detail matter in patient care?) “that flutter by./ Why else upon this bank are we so still?”  I think that we are still because we do not know what will happen yet with electronic medical records, Medicare fee schedules and continuing maintenance of certification. Rich rejoins “What lends us anchor but the mutable?”  I suppose this why we must be recertified every ten years because medical knowledge is always changing.

What brought us to this point is our love of medicine and Rich recasts this more broadly, “O lovers! Let the bridge of your two hands/ Be broken like the mirrored bridge that bends/ And shivers on the surface of the stream.”  Our love for medicine evolves and changes the connections to patients and to practice are constantly askew and evolving. And in Rich’s call to use to that former self that we will always have dermatology residents “Young oarsmen, who in timeless gesture seem/ Continuous, united with the tide,” she takes us back to the time when we believed all diseases were in the textbooks and that our certainty of our knowledge, our teachers and our specialty was one of perfect confidence.  And then Rich reminds us that our belief in the perfect diagnosis, the perfect patient encounter, was only a dream and gently advises “Leave off your bending to the oar (perhaps put down your copy of The Blue Journal), and glide/ Past innocence, beyond these aging bricks, (our medical schools, our residency clinics and our private offices) To where the Charles flows in to join the Styx.”  We must migrate to that state where our knowledge fails us and we are immersed in the patients whose diagnosis is never really known, to the medico-legal world where the regulations come at us so fast and furious that no consultant, or newsletter, or conference is an aegis, to the state where all our reading, our learning, fails, to that place where all the dermatological diseases stay that do not read the textbooks.

I might just as easily have heard Billy Joel’s tuneful “River of Dreams” fill my consciousness and my ear and move my lips as to ponder Rich.²  We dermatologists are in for so many changes in law and dermatology that sometimes it is only the art of poem or song that captures the tectonic changes best.  I have scanned the 1500 pages of ICD-10 and , in short, am left afraid of how big data and big taxonomy will change our medical world.  For the moment I will brood over the constancy of change in all things possible: personal, and professional, as I contemplate Rich’s autumnal rhymes, and like Eliot’s Prufrock “will go then through half-deserted streets” to my office every morning to practice dermatology.

References:
1. A Walk by the Charles by Adriene Rich published 1950 included in her first poetry
collection entitled “A Change in the World” Yale University Press, New Haven CT 1951

2. River of Dreams is the twelfth and final studio album by American singer-songwriter
Billy Joel, released on August 10, 1993. The Song River of Dream was the cover Song of
the album

3. The Love Song of Alfred J Purfrock by Thomas Stearns Eliot published 1915 http://books.google.com/books?

Author Note:  Noah Scheinfeld, a Yale Medical School graduate & Columbia University faculty member dermatologist, is an American Board of Dermatology certified dermatologist and pediatric dermatologist.
Noah Scheinfeld M.D, J.D.
Assistant Clinical Professor of Dermatology, Weil Cornell Medical College
150 West 55th Street,  New York, NY 10019
ScheinfeldATearthlink.net