The pursuit of happiness Paul W. Brand, MD, Seattle,



y first lecture to this great Society was about 40 years ago as a guest of then president Dan Riordan. That invitation resulted from a trip that Dr. Riordan, Dr. Guy Pulvertaft, and others had made to India at the request of the World Health Organization to see and evaluate the early attempts by an unknown young hand surgeon, Dr. Paul Brand, who was claiming that it was possible to operate successfully on the deformed hands of leprosy patients. Now this is the second time, Mr. President, and I want to tell you how much I appreciate this honor. Quite frankly, I appreciate the honor more than I appreciate the subject you suggested-ethics in hand surgery today. You told me you would do it yourself except that you thought the subject would be more appropriately raised by an older member, who might bring a longer perspective to bear. It is interesting that my first guest lecture was because I was young and full of new ideas, while my second is because I’m older and supposedly better able to evaluate change! I told you that I really did not feel comfortable talking to all my old friends about ethics, but I would like to tell them. from my own experience, how to enjoy life

Presented at the Fellows and Members Luncheon, forty-sixth annual meeting of the American Society for Surgery of the Hand. Orlando, Fla., October 1991. Reprint requests: Paul W. Brand, Seattle. WA 98116. 3/1135017

MD, 1026 California

Ln., S.W.,

as a hand surgeon. I said that to me this was the other side of the same coin and that it would be easier to talk about. You agreed, and that’s why I am here today. I remember that first lecture in Miami in the 50s. It was about the hand in leprosy, and I spoke about the stability of the thumb meeting the fingers in pinch and grasp. Having enjoyed sailing before I went to India, I likened the thumb to the mast of a sailing ship and pointed out that a mast does not stand by the strength of its fixation at the base but has to have stays acting as guy lines in every direction from which the wind might come. The thumb has the support of its multiple intrinsic muscles to support and stabilize it against the thrust of each type of pinch or grasp it has to meet. Today I do not plan to talk about the hand in leprosy, but I do want to begin by talking about sailboats and tell you a true story of a sailing adventure I had when I was a medical student in London, England. I was part of the crew of a two-masted schooner taking part in ocean races between Britain and Europe. We had entered the annual race from Ryde, England, to Dinard on the coast of Brittany. Part of the course took us around the Channel Islands in a great sweep where two tides meet, creating some of fastest ocean currents in the world, rather like the tides in the Bay of Fundy in Nova Scotia. We started well, but the wind was light and we had a heavy boat. It was a handicap race, so we started ahead, but we watched the fleet of sailing boats overtake US one by one. Then our skipper called me to him and







quietly told me to get hold of our light kedge anchor, which was secured by a rope rather than a chain, crawl unobtrusively to the prow, and lower the anchor gently by hand into the water. “The bottom will be sandy” he said, “and I’m sure it will hold.” Mystified, I did as 1 was told, and soon felt the anchor hit the sand and the rope tighten as it took hold. To my astonishment, the rope angled forward, not backward. To my still greater amazement, we suddenly found ourselves gaining on all the other boats. All those who had overtaken us were now slipping behind, while we forged ahead. Finally one or two of the smarter skippers recognized what we had done. The rope ahead of us told them how we were winning. They saw that they would have been smarter if, instead of watching each other to see who was getting ahead, they had thought about their progress in relation to the unchanging contours of the earth beneath us. They would have realized that we had all been going backward because the tide was pushing us faster backward than the wind was pulling us forward. So, one by one, all the boats dropped anchor and stopped losing ground until the tide slackened and the wind freshened and we could make real progress again. I have never forgotten that lesson in sailing and have had occasion to apply it to many aspects of life and work. It is a good basis for a pause to ask ourselves the questions: “What do we mean by progress?” “How do we measure success?’ “What kind of progress is compatible with happiness?” I love this Society. I really believe it to be the best in the world. I like the way we run our meetings. I like our JOURNAL and its editorial policy. I love the correspondence newsletters. I often wish the Society had not grown so large. It used to be that we all knew each other, but today there are too many of us for that intimacy. Yet I see no alternative to growth. We have something good, and we cannot complain if others want to share it. As I look at the changes that have taken place in hand surgery since I first knew this Society, I can observe that we are much better at accurately evaluating disability so we can tell whether our new methods really work; we have seen a revolution in treatment of flexor tendon injuries; microsurgery has become an accepted and valuable technique; we have formed a close and valuable alliance with hand therapists; we have seen the advent of joint replacements based on sound biomechanical principles; endoscopes show promise of major benefits with only minor wounds. All of these things have come about with free discussion and exchange of ideas. However, we should never forget that,

The Journal of HAND SURGERY

with this huge technocracy, there is a lot of money at stake. We must make sure that patients are the beneficiaries of these technologic changes and are not exploited. Another trend in technology is the use of computers. I was intimately involved with these in the Hand Research Laboratory at Carville. After a great deal of work, which involved not only study on our part but the acquisition of powerful computers with three-dimensional graphics and a staff of programmers and engineers to make them work, we were able to transfer much of our biomechanical data into digital storage. We were then able to set up the computer programs to simulate various types of paralysis and further to show how different tendon transfers would work in a given pathologic condition. It was fascinating to watch the effect on the programmers and engineers as they were introduced to the wonders of the hand. They had never worked with a machine that was as adaptable as the human hand. They marveled as they learned that when surgeons make mistakes in tendon transfers by setting too much or too little tension, the forgiving fibrils can add or subtract sarcomeres to correct the resting tension. They allow the surgeon to look good when really the credit belongs to the amazing servomechanisms of the hand. A computer programmer who had designed a robot for spot welding in an automobile factory knew how complex that simple action was to design, and he was particularly impressed at the scope of the functioning hand, which can go from picking up rocks to playing the piano to being an instrument of mutual joy and ecstasy through acts of stroking and caressing another. Patients and hand surgeons rarely come together to marvel at this wondrous instrument, the human hand. The one comes for correction of some malfunction, and the other focuses on fixing that problem. It is a mistake not to spend some time standing in awe of the hand and the processes for repair that stand, ready for action, after injury or disease. As I have been trying to identify the unique opportunities for happiness that have made my life in hand surgery so enjoyable, I have come down to two. One is my enjoyment of the wonders of the normal human hand, and the other is the opportunity to enter into the minds and hearts of those who come to me as patients and to share with them the challenge of a return to normal life. Today, more than ever, I find pleasure in a childlike sense of wonder. Almost every time I examine a hand that has a problem, I pause and direct the patient’s attention away from the problem itself and comment

Vol. 17A, No. 4 July 1992

on something positive. If it is a joint problem, we talk about the muscles, and if it is a fracture, we talk about the function of osteoblasts and how they know the blueprint of their bone. Whenever an operation is planned, I tend to downplay what I can do and emphasize that there is healing in the hand itself. It is the patient’s platelets that will clot the blood, it is the patient’s own fibroblasts that will make strong unions to replace my flimsy stitches; above all, it is the patient’s will and courage that will find a way to move the tendons through their new pathways and integrate the wounded hand back into the harmony of sensation and purposeful movement that will allow the patient to forget the hand and think only of what he or she wants to do or to feel. I find that patients heal better and rehabilitate faster when they have a pride in their hands, and it sometimes takes a person with authority to convince a patient that the hands are great. I do this sometimes for myself and my own hands. They are a bit ugly now; the dorsal skin is wrinkled, spotted, and almost transparent, but the function of my hands has not changed much, and they still don’t tremble when I work. I love to recognize that in these hands, and in the segment of my mind of which they are a part, lies the experience gained from fifty thousand hands and feet that I have examined through the years. When a patient puts his or her hand in mine today, before I start to measure range of motion or read a meter quantifying strength, I know a dozen facts that my young hands would not have known. The temperature and moisture of the skin, the subtle swelling near a joint, the texture of the calluses-all these things and many more connect to banks of memory and translate to facts uncovered in the past. My hands are programmed and have learned their wisdom by constantly updating lessons only partly learned and by the humbling experience of being wrong. Most days I never think about my hands, but every now and then I like to bring them out and recognize their worth. I need to tell myself that nothing man has ever made compares in scientific excellence or in beauty of design and craftsmanship with these two hands of mine. They themselves have skill to make and to repair. And they are fun to use. Now computers are fun too. It is exciting to manipulate data, create graphics, and recall information with miraculous speed. They are very useful in my life, but they are a means to an end and not an end unto themselves. They should never be allowed to replace the brain-hand interface of the surgeon; nor should they be used to shorten the time the surgeon needs to spend with the patient. This is the highest priority, but I have learned that not everyone in our Society shares that

The pursuit of happiness


priority. Because time is money, some will take the path of minimizing the time to maximize the money. Contrary to what some may think, making money is not basic to the pursuit of happiness. When it assumes a high priority, it may prove to be incompatible with the real joys of being a physician. A special source of happiness in hand surgery is the interaction between me as a person and the person of my patient. The hand, more than any other organ except the brain itself, is symbolic of the mind and soul of a person. It represents his life, his work, his strength, and his love. One touch of a hand may mean more than a thousand words. The quality of the touch of my hand may mean more to a patient than the assurance of my voice or even the content of what I say. Touch is mutual. It is a seal of the oneness of the sick person and the healer. It is a statement that my thought and understanding, my sympathy, and my faith have gone into the diagnosis and will now carry us forward together through the treatment. As a person, I stand behind my judgment, and with my hands I demonstrate that I am there to serve the person whose life now is somehow linked with mine. I used to wonder why it was that elders of the church laid hands upon the sick. There is a mixture here of symbolism and of power. I remember a man with leprosy who came to me as a beggar. We used a new type of operation on both his hands, with variations on the two sides. We taught him how to care for fingers that had lost the sense of pain. Years later, now a successful farmer, he came back in response to our request for a follow-up examination. We asked him what he thought had made the biggest difference to his life. He thought a while and then replied that he had once despised his hands and thought them dead because they could not feel. Then he saw me hold his hands in both of mine and handle them with care. He said he saw affection in my touch and thought they must be worth respect. He worked to justify my faith in them, even before he believed in them himself. When we have shared not only our knowledge and skill but part of ourselves with our patients, when we see something of our hope and faith awaken in them, then something comes back to us. It is in the mutuality of medical care that we experience real joy. I started this lecture with an account of sailing in an ocean race. I commented that, as a young sailor, I had learned from an old sea captain that it is easy to be deceived about real progress if you look only at competitors. Now I am here to tell this Society that I sense a tide running in a direction that is against the happiness and sense of fulfillment of the members of our profes-



sion. It is a tide that is separating doctors from patients, and thus it hurts our patients as well. Individually, we are becoming more efficient, and our collective knowledge increases year by year. But we are drifting away from our patients and from our public as well. There is a gradual change in the perception of doctors in general and of surgeons in particular-less as caring and serving professionals and more as businessmen and -women out to make a buck and succeeding pretty well. I have described this as a tide because a tide is something outside the ship, which imposes itself on the desire of the sailors. There are many influences that, together, have been responsible for this current. Some may point to the boom in malpractice suits and the mental attitude that has induced in patients. Others may say it is due to governmental regulations and interference. All of these may be true. Yet we need to ask ourselves: “Who is really in charge of all that I do? Who runs my office? Is it an MD or is it an MBA?’ Some of us have rejected the concept of service, which has always been the foundation of our profession, and have accepted instead the concept of the marketplace and trade. It may be only a few who have taken up new and ingenious ways to “unbundle” or otherwise amplify accepted schedules of fees, but all of us have to share the ignominy of new restrictions designed to close the loopholes that our colleagues have discovered. And all of us are affected by some erosion of trust and its gradual replacement by watchfulness as patients try to size us up. “Is this doctor really here for me. or does he see me as being here for him?” There is something comfortable about a tide. When everything and everybody is drifting in the same direction, it is easy not to notice it. We look at each other, and our relative position has not changed much. In our competitive positions we are all moving forward in a relative kind of way. The AMA is running a big advertising campaign to tell the public that doctors are doing a lot of good and generous things, and of course this is true. The fact remains that we are part of a system in which we are doing pretty well, while more and more of the working poor in America are not getting medical help. They cannot afford to get their carpal tunnels released or to have their arthritic knuckles stabilized or replaced. The other side of that coin is that many doctors are missing out on opportunities for happiness. Small actions can make a big difference to both the giver and the receiver. I am happy to note the increase of volunteer associations within our ranks. Some are going to short-time projects overseas, and some are

The Journal of HAND SURGERY

giving part-time help to clinics for the poor. It helps us to adjust our scale of values when we become involved and to give some time to meet a need without thought of gain. Early in my own professional life, my wife and I went to India on a l-year contract to work and teach at the Christian Medical College. Our work was among the poorest of the poor. Our salary was little more than a subsistence allowance. Most of those we served had leprosy and had no means of repaying us for anything we did. Our l-year contract stretched out to 19 years. We finally left only because our older children needed to go to college. Since then, working for the U.S. Public Health Service, our dollar reward has been many times greater than before, but nothing has ever exceeded the happiness of the years when we struggled with the challenge of real human need in situations where, if we had not been there, lives would have been overwhelmed by deformity and disability. Even today, when I go back to India I feel that lift, that aftermath of joy, and share it with the men and women we have helped, who in return have made our happiness complete. In that ocean sailing race in 1937, our skipper did not seek to change the tide. He recognized its presence and its power. He simply chose to let the tide go by. He chose to link his boat to the structures of the earth that would not change or move. The tide moved on, but he chose not to drift. His example had effect, and soon the fleet of ships lost no more ground. Dr. John Najarian, president of the American College of Surgeons, spoke for many thoughtful and concerned physicians when he said that the components of skill and science mean little if the moral fiber is not there. “The surgeon must have a soul,” he said, “an inner, unwavering commitment to the highest standards of responsibility and compassion. This can be accomplished,” he noted, “by applying the Golden Rule to patients, along with the simple but absolutely essential act of touching themthe ‘laying on of hands.’ Today’s world, with public immorality in politics, in the federal government, in colleges, professional societies and athletics, makes one wonder if the tablets from Mount Sinai are considered by some to be ten suggestions rather than ten commandments.” While I am somewhat hesitant about mentioning religion on a secular platform such as this, I will say that if you should happen to be in church when I am on that platform, you would probably hear me say that the same Higher Power that wrote the Ten Commandments knew that in the keeping of them lay not only peace in the

Vol. 17A, No. 4 July 1992

community but happiness for the individual as well. Ladies and gentlemen, in these times of drift, I suggest that we each consider dropping anchor and hold to principles that do not change. Let us accept with pride the role of servants. Let us be healers, not only of hands but of the persons who bring their hands to us. Let our doors and hearts be open to those excluded from the system. I was delighted last month in perusing the latest batch of correspondence newsletters from the Society to see one from my old friend and our past president, Jim

The pursuit of happiness

Dobyns. He describes his partial retirement and comments on the pleasure that he now has because he is able to spend time with each of his reduced number of patients. He gives them a thorough examination and a thoughtful evaluation in the way he always wanted to but did not have time for. He says it gives him happiness amounting to ecstasy. Let’s not wait for retirement. We can retire just from the rat race and experience happiness through practicing hand surgery the way we all know we should. Jim Dobyns , I like your choice of words. The result is more than happiness; it really is ecstasy.

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The pursuit of happiness.

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