May 19, 2022

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Is It Time to Play Chess With Death?

For 3 years, from mid-2017 to mid-2020, I wrote an essay on a weekly basis about my views about medicine and about life. MedPage Today kindly published my work in a column named Revolution and Revelation.

My goal was to tell true stories that conveyed a surprising lesson or unpredictable conclusion, stories that would evoke constructive communal emotions that are the essence of humanity. True stories that would make people think and smile or be angry, sad, or joyous. I sought to portray the ironies of life from the viewpoint of a philosophically oriented narrator who (for some inexplicable reason) had spent most of his life as a physician. But most of my stories were not really about medicine or physicians or healthcare.

I wrote with the intent of bringing forth memories and shared experiences. I wrote with the purpose of describing both the silliness of life and the nobility of the human condition. I wrote with the hope of expressing what others were feeling, but did not have the time, opportunity, or willingness to write. My essays touched many souls and many nerves. Readers reached out to agree and disagree — often vehemently so.

That was the whole point of writing essays.

At its peak, the blog was viewed by >100,000 readers throughout the world. During its tenure, the blog received the prestigious Jesse H. Neal Award for Best Commentary, the Pulitzer Prize for specialized journalism. In 2018, I was only the second physician to win the Award in its 64-year history.

And then, suddenly, I stopped writing essays. After more than 100 essays posted on a near-weekly basis, my blog went silent. The stories disappeared. The postings ceased without a hint of an impending farewell or a single good-bye.

Why?

Was my health failing? I have certainly been in better health in my younger years. But I did not stop writing because I was sick.

Did my institution apply political pressure? Not at all. Baylor University Medical Center celebrated my blog and encouraged my postings, even those that were highly critical of healthcare and medical institutions.

Did I suffer from writer’s block? Not in the slightest. Over the past 18 months, I have authored more than 80 scientific papers, most often as the lead or senior author. There was a great deal to write about. As the chair of the Executive Committee for the EMPEROR trials, I was privileged to be able to report on the findings of two very important large-scale trials for the treatment of heart failure.

But writing scientific papers exercises a part of your brain that is disconnected from your soul. Ideally, reporting evidence should be a dispassionate human endeavor. Publishing and interpreting data is about showing your work in the least opinionated manner possible. If the reporting of data evokes feelings of self-congratulations for the authors, the best path is to suppress them. An investigator who becomes prideful and overly enthusiastic commits a serious blunder, which taints her/his reputation and raises worrisome suspicions. Researchers should maintain a high degree of skepticism of their own work. If the data generate a celebration, it is better for others to lead the way. If the red carpet is laid out, it is best to be watching from the sidelines.

So, for the past 18 months, it was possible for me to write scientific papers, but not personal essays. I could report clinical trial evidence without difficulty, but I could not bring myself to write with constructive passion. I tried for weeks and weeks, but nothing worked. Early drafts of blog posts were discarded; potential subjects rapidly reached dead ends; promising pieces collapsed in fragments; and the blog went dark and silent.

Was this related to the pandemic? No. Was my inability to write essays brought on by the stark polarization of our society? No.

The reason? In the middle of 2020, my wife died after a heroic battle with breast cancer. And the driving force of my life died with her.

My wife was an incredibly accomplished physician-scientist. I and others celebrated her life and her life achievements after her death. Those celebrations were critically important to all who knew her and had cherished memories of her, including her family. But my grief remained unabated. And for a long time, my grief was inexorably intertwined with despair.

Why despair?

People lose loved ones all the time. As a physician, I have been the direct messenger of death to countless grief-stricken families. I believe that many physicians — including myself — choose medicine as a career path, because it represents an activist approach to battling death. Or at least, delaying death. Every successfully treated patient counts as a temporary reprieve in a war whose eventual outcome is already known.

I know that many people think that medicine should be devoted to promoting wellness, and that is probably the right approach. But to me and to the generation of physicians trained 40 to 50 years ago, the whole point of medicine was to understand how the body worked for one purpose, and one purpose only. To cheat death.

I prided myself on cheating death. In my mind’s eye, I had succeeded in cheating death hundreds — perhaps thousands — of times. My experiences as a physician reinforced the explicit assumption that there was always something that medicine could do to make things whole again.

Until it couldn’t.

I could not tolerate the idea that — in my lifelong battle with death — death had won, much earlier than expected and under circumstances when the outcome of the battle determined the fate of the most important person in my life. I had this overwhelming sense that the dire outcome might have been averted if I had only been smarter or more vigilant or persistent. Faced not only with loss of my driving life force but also with a sense of personal failure, my response was — despair.

As Viktor Frankl wrote in Man’s Search for Meaning, humans experience despair when they suffer without a sense of purpose. Frankl, a highly influential Austrian neurologist and psychiatrist who survived Auschwitz, argued that “meaning” was the central motivational force in human beings. (In contrast, Sigmund Freud and Alfred Adler — two other foundational Austrian psychiatrists — postulated that humans were driven by pleasure and by power, respectively.) According to Frankl, despair is suffering without meaning.

When despair dominates your life, it is a good idea not to post essays in your blog. No one wants to or deserves to listen to despair.

So now, after 18 months, why start writing essays again?

Those who are fans of Ingmar Bergman’s “The Seventh Seal” will remember that, in his iconic film, the director depicts a disillusioned crusader who returns home in the midst of a pandemic and faces a crisis of spirituality.

To some, those circumstances may closely resemble those of 2020-2022, but in truth, the scenes of the film take place 700 years ago, in the 14th century. Consumed by doubts about the meaning of life, the protagonist (Antonius Block) challenges Death to a game of chess, with the intent of distracting Death long enough to carry out one memorable act of justice before he dies. Tricked and faced with inevitable defeat, Block breaks the rules, knocking over the chess pieces to divert Death’s attention long enough to save the lives of a few people (at least temporarily). By doing so, in the face of his despair, he gains purpose, because for one brief moment, he elects to give himself a voice.

My scientific work gave voice to the parts of my brain dedicated to innovation, but my essays gave voice to the parts of my brain that housed my innermost sense of meaning and purpose. My medical papers allowed me to influence medical practice, but my blog gave me the opportunity to impact practitioners and patients. That duality of mission has allowed for a broader and more meaningful footprint.

For most of my life, my wife was my guiding light. Whether writing scientific papers or philosophical essays, she was always my muse. And the past 18 months has not changed that role in the slightest. Her memory reminds me that there is much work to be done. And as in the case of Block, if there is an opportunity for memorable acts before we lose our games of chess with Death, it is not an occasion that should be squandered. It is time to start writing essays again.

Milton Packer, MD, is currently distinguished scholar in cardiovascular science at Baylor University Medical Center at Dallas and visiting professor at Imperial College in London. Packer is an internationally recognized clinical investigator who has made many seminal contributions to the field of heart failure, both in understanding its mechanisms and defining its rational management. His work has spanned more than 40 years and has established the cornerstone of the current modern treatments for heart failure, including ACE inhibitors, beta-blockers, angiotensin neprilysin inhibitors, and SGLT2 inhibitors. He has authored nearly 600 peer-reviewed publications and has been the overall principal investigator for 20 large-scale international trials of novel interventions in heart failure.

Disclosures

During the past 3 years, Packer has consulted for Abbvie, Actavis, Amarin, Amgen, AstraZeneca, Boehringer Ingelheim, Caladrius, Casana, CSL Behring, Cytokinetics, Imara, Lilly, Moderna, Novartis, Reata, Relypsa, Salamandra. These activities are related to the design and execution of clinical trials for the development of new drugs. He has no current or planned financial relationships related to the development or use of SGLT2 inhibitors or neprilysin inhibition. He does not give presentations to physicians that are sponsored by industry.

https://www.medpagetoday.com/opinion/revolutionandrevelation/96513