Dr. Morris Maizels – Postcards from Appalachia
As written by Dr. Morris Maizels, MD
The founding president of the Southern Headache Society
Musings Upon a Career in Headache Medicine
I've often thought about it, fantasized about it, and anticipated it with a mixture of emotions. Dec 22 was my last day seeing patients. When it came, it was a day much like any other, although I was more in-tune with its significance, and more present for each interaction. It was a Botox day - maybe not all of the patients were special for me, but it turned out I was special for all of them. I made time for the story of one, a 40 y/o woman doing well, but whose father had recently died. Her parents had been divorced for 20 years, but the divorce settlement provided for my patient's mother receiving half of the estate. That apparently wasn't good enough for the mom, and her last words to her daughter were - "I'll see you in court." Listening to the story had little to do with my role as her headache physician, but for me exemplifies Headache Medicine. I learned my Botox technique from David Dodick - but was most impressed by how much time he spent with patients, even after they came in saying they were doing well.
My last "patient" was a medical assistant I've worked with a few times - she had a sudden onset of a severe migraine - she was sitting there in that position (has anyone given it a name?) hunched forward, massaging around her eye. I took her back and did the lidocaine. She said her pain went from a "12" to a 6 or so - helpful but not great. 30 minutes later she was practically singing and dancing - headache entirely gone.
Today is my last day as an employed physician, so a day of mixed emotions, strong feelings.
Headache Medicine is enjoying an unprecedented wave of revolutionary and effective therapies. So one might feel like a simple intermediary - passing along with little thought the tools we have been given in recent years. For me, its reward was always the access to the depths of the individual, the connection that is not readily offered in other practices of medicine, or outside of the practice of medicine itself.
One memory - a patient I did not previously think of as insightful or spiritual, made a comment about prayer. I asked her if prayer was important for her. She paused, looked up, and said: "Well every breath is a prayer."
For those with time, I've attached a file with a few anecdotes from my time in Asheville. If you have time to read only one, I would suggest "The bear and the frying pan."
I cant express what the Southern Headache Society has meant to me. It is not merely a source of collected wisdom that cant be found elsewhere. It is the source for many of us of community. Headache Medicine is often a lonely specialty, and each time someone posts on the Listserv, it is a reminder of our common aspirations. We have an incredible bright, energetic, and dare-I-say young Board, and the future is promising. I'd like to acknowledge here that Brian Loftus' role was as co-founder of the organization - he and I were yin-and-yang. I'm eyes-on- the-heavens, he is firmly feet-planted on the ground. Our secure footing as an organization is thanks to Brian.
And I have to thank Alan Finkel - friend, advisor, large-scale yoda and Liz Leroux for her spirit and inspiration.
There are so many others I would like to thank and acknowledge, but I fear if I single them out, I will be leaving out an equal number of others.
Here are 2 songs I'm working on - they're a bit beyond my skill level, but the words are everything I need to say in this moment.
I'm an old man now, I can't do nothing
Young folks don't pay me no mind
But in my day I sure was something
Before I felt the heavy hand of time
I'm an old man now, I'm bound for glory
Time to lay these burdens down
Had enough of this old world
Gonna trade my troubles for a crown
Well the road rolls out like a welcome mat
To a better place than the one we're at
And I ain't got no kinda plan
But I've had all of this town I can stand
There is so much more to be said, but that is enough for now. Look forward to seeing y'all again soon and in-person.
The Bear and the Frying Pan
Judd is a bear of a man and it comes as little surprise when I learn that he is a stoneman. Not stoneage, not a troglodyte, but he quarries stone. I doubt he has need of modern machinery for most of his labors. Measured in stone (the British unit of weight), he would be not quite 20 stone, or 280#. Measured in hands, as in a horse of 15 hands is 150cm (60” or 5 ft), Judd must be near 20 hands. Judd has headaches, and like most of my patients, he has them every day. Judd could be a poster child for the “Tough Guys also get Migraines” campaign. And Judd is accompanied by a young woman, Charlene, who is as petite as Judd is large. If Judd might be coarse, surely Charlene is fine. If Judd is a boulder, Charlene is an uncut gem. And the contrast is pleasing and makes me smile – not just within, but without. And because she is there, it is easy to see that there is a gentleness in Judd as well.
Charlene cares for Judd and she takes care of him. She takes notes. She asks questions – good ones. Ones that almost embarrass me, not that I don’t know the answers, but that I haven’t given the answer without her asking.
I don’t know that I’ve ever asked this question before during a medical visit, but I feel a kinship from the first few minutes, and soon enough I can’t help but ask, “Where did you find her?” as in, where did a guy like you find a wonderful woman like her? In fact, I probably asked three times. And Judd knows he is blessed. And he says, “Well maybe she’s my reward for my first wife.” Now there’s no going back. What was your first wife like Judd? “Well, she tried to kill me three times.” Now, on the West Coast, that would be metaphor. Sneaking egg yolks into an egg-white only omelette. Too much mint in the Mojito. But folks in the hollers and coves have little need of metaphor when it comes to violence. So I ask, innocently, What did she do? “Well, the first time, I was taking a bath, and she plugged a curling iron into the wall and stuck it into the water.” Fair enough I think, that’s one. What else? “Well, the second time she tried to poison me” Here I’m thinking some yuppie variation on fried squirrel succotash. She tried to poison you? I ask. “Yeah, I was already in the hospital, and she put some arsenic in my food. They had to pump my stomach.” OK, that’s two. What was the third time? He’s actually stumped and turns to Charlene. “Don’t you remember Judd, the frying pan?” “Oh yeah, the frying pan.”
A Testament to Character
A woman in her early 40s came in with daily headache and daily once/day hydrocodone use. She was diagnosed with a schizoaffective disorder, although it was not obvious in my interactions with her. She complied with all my treatment recommendations, including withdrawal from hydrocodone, but after several months was no better. I was willing to put her back on once/day hydrocodone but needed the agreement of her PCP. He never returned any of my calls. She no showed one follow-up, and when she returned, I asked her about it. She lived an hour or so away, in the mountains.
She began with – Well, I was on my way to see you, when I got called for the custody hearing.
“Custody hearing?” – I knew she had a teenage son. “What custody hearing?”
Here she paused – Well, we thought she was 16.
Uh oh - now I’m listening.
Turns out her teenage son had a relationship with a 15 y/o and she became pregnant. She lived with an abusive mother, who beat her, and told her she would be kicking her out of the home once she had the baby. So my 40-some y/o schizoaffective patient with a 16 y/o son and chronic daily headache went to court to obtain custody of the soon-to-be 16 y/o mother and her child, and raise them in a loving home.
I said – “Well that’s as much as I need to know about you to prescribe the hydrocodone for you.”
I had another patient – a woman in her mid-30’s with a 2 y/o daughter – who went to court to obtain custody of her mother’s 2 y/o daughter. The song “I’m My Own Grandpa” comes to mind.
I’m sitting in my office in Bat Cave (yes there is a Bat Cave NC – near Lake Lure, where Dirty Dancing was filmed) and I hear inconsolable crying next door. I walk in and see a drug-addict thin 30’s y/o man consoling his wife, who is crying hysterically. It turns out their teenage son had been arrested the night before for possession. The consoling spouse is as comforting as a man can be, but I noticed a teardrop tattoo at the corner of his eye. I wouldn’t have known what that was, but just the night before, had seen the film Winters Bone - probably Jennifer Lawrence’s first great role. This description does not do justice to the intensity of the film:
An unflinching Ozark Mountain girl hacks through dangerous social terrain as she hunts down her drug-dealing father while trying to keep her family intact.
If you’ve not seen it, it is one of the best films of its decade. The book is equally good, and not at all spoiled by seeing the film first.
The teardrop tattoo has many potential meanings, one of the more common being that one has killed while in prison, or alternately, been the subject of abuse.
So here is this young man with a teardrop tattoo consoling his inconsolable wife. He explains to me why she is so upset, and goes on to say, with vehemence – “This kid caint do anything I aint done when I was his age, and that’s why we’re so upset…”
And I think – I’m a character in Winters Bone.
He later mentioned that his kid had “3 hots and a cot” and so shouldn’t be wanting. I didn’t want to show my ignorance. The wife came back the following week and I asked her about the phrase – it means 3 hot meals and a place to sleep.
I do regret not having kept more notes on a Southern Lexicon, eg:
barn, verb. as in “Mah skin railly barns me”
A Southern Dilemma
Late this morning (already I must digress - there is a phrase here that folks are fond of, which is to say “Of a morning,” which for reasons unknown to me, drives crazy a beloved colleague, a pain psychologist, who despite being a born and bred Southerner, doesn’t know why folks speak that way. As he says, would anyone say, “of late this morning” or even “of this morning,” as it seems always to apply to a general day rather than a specific one).
Well, back to this morning. A 70’ish young gray-haired lady – let’s call her Loretta - was back for followup after her initial consultation. She had a headache type for which there is fortunately a designation, but not an explanation - because surely I don’t know what it is, For the sake of documentation and billing, it is called “Headache, not otherwise specified.” She had cancelled a couple of followup visits and on her intake sheet of this morning, she wrote she wasn’t doing well at all. But to my (mixed) pleasure, her headaches had actually responded superbly to a low dose of a standard preventive medication (venlafaxine). It was the rest of her life that wasn’t doing so well.
The dialogue started when she asked me what I thought was causing her headaches. It took me back a bit because I had just heard how she hadn’t had any headaches at all on her new regimen. Temporarily at a loss for words, I was relieved when she offered, “Could it be stress? Doctor, do you think stress can cause my headaches?” Rather than say “yes” or “no,” I offered my usual gambit: “Why, what’s going on?”
Her adult daughter had recently been in a major car accident, which was the reason Loretta had missed her follow-ups. Her adult son was a recovered alcoholic but had found religion. This is where the visit developed some juice. Because she knew her son would never have come to the Church had he not hit bottom as an alcoholic. (Which reminds me of another woman this morning, one or two generations younger than Loretta, who had come to a profound level of “acceptance” in her life, despite a stressful life and a history of abuse. When I asked her how she had come to acceptance as a way of life, she answered: “Oh I’ve had a lot of 12-steppers in my life.”)
Back to Loretta. So her son had taught her that suffering can beget salvation. She went on to describe the elation she feels when she walks through the doors of her Church, and breathes in the presence of God, but how this ecstasy can be destroyed in a moment when she worries that her husband is not only not a believer, he is positively antagonistic. We talked about god and we talked about faith and we talked about letting go of the need for our loved ones to believe as we did, and how suffering can lead to salvation. And the connection between us was so affirming, that I really wanted to share with her that I was Jewish, and wondered how that might affect the moment, our bond, her healing, and our future together.
Just as I was going to broach the subject (“I wonder would it matter to you to know that I’m Jewish?”) she “shifted gears” on me. Jeff Gordon had just won the Pocono 500. Now NASCAR in the South might as well be a religion, and Loretta was a devout follower. She was wearing a NASCAR shirt from a previous Jeff Gordon victory. He was her hero. He’d won the race sometime during last Sunday’s Church service, and I’m not sure if Loretta was following it on her iPhone or had some other celestial connection to the event, but when Loretta told the preacher, the announcement went out to the Church, and I can hear the chorus of Hallelujas as if I’d been there.
Now I’ve never cared about NASCAR and I’ve never heard of Jeff Gordon and around here, that’s like saying “Jesus who?” I’m really wanting to talk religion, but now I’m feeling like mentioning that I don’t know who Jeff Gordon is, and I’m wondering, what would be a bigger threat to the doctor-patient relationship in the South: being Jewish, or being a NASCAR non-believer.
I did what I’m sure was the right thing for the moment, which is I kept my mouth shut. Although I would dearly love to see Loretta often to keep my bead on religion and NASCAR, I told her that her primary care doc could renew her prescription so she wouldn’t have to come back to see me. But she said, no, this was where she wanted to come.
More on Opiates
Possibly my first patient was a young man who had been referred by a local neurologist. Got my juices flowing – just opened up, and already a referral from one of the local neuros. The records came as paper chart. Behind the face sheet was the most recent visit with his PCP, which stated: “Patient was assaulted in the parking lot by his pain physician, so needs a new prescriber.”
I thought – well, this is a pain patient at a new level. Either he really was assaulted by his pain physician, which would make him quite special, or he came up with a story that is worthy of an award, if he had the proper category of awards.
Speaking of awards, I humbly offer my own personal record for the most egregious request for pain medication. Middle-age man who had recently moved from Texas, requesting a refill of his Dilaudid for migraine. I asked how much did he take. He said well they were injections. Well how much do you use? Well they’re each 4 mg. Well how much do you use? The first answer is the one we all know and love – only when the pain is really severe. Well how often is that? Well every day. Well how many times/day? Four times/day. Every day? Every day.
Then there was the fellow who came in told me he was “volunteering” at the wildlife rescue center. Turned out volunteering meant doing community service as part of a prison sentence. He had lost the use of his left little and ring fingers from a stab injury damaging his ulnar nerve (my memory recalls it as a fragment of a pool cue embedded in the arm, but that might not be accurate. It turned out that playing guitar was what he loved the most. I’d only recently gotten into gypsy jazz, and knew that Django Reinhardt, the founder, had also lost use of those two fingers – in his case, in a fire in the caravan wagon that he and his wife slept in – he nearly died in the fire. So I shared this with my patient, encouraged him to resume his life’s passion, and left the interaction with that rare feeling that all the stars had aligned. I saw him back a few months later – asked him if he had gotten back into playing guitar. “Nah – my girlfriend stole all my guitars.”
As an aside, a good friend of mine in Asheville, and a very talented musician, had stringed instruments covering the walls of his living room and play room – one of which was a Spamjo. For those not familiar, it is a banjo-like instrument with a large (emptied) can of Spam as the sound board.
Tuesday 6/14/20 – my first evening working at the free clinic, run by ABCCM (Asheville-Bouncombe County Christian Ministry). Three highlights.
First - On my application, getting to answer the question: “What Church do you attend?” I had thought about this in the past, and always wanted to be asked the question. Because one of the great thrills for a Jew in the South is to go to Lowe’s on Sunday morning. I once went when there was only one other car in the parking lot. It was a spiritual if not religious experience. It was ecstasy. So I’ve wanted to say, “I attend the Church of Lowe’s.” But for the moment, for the sake of the application, I wrote: “Congregation Beth Israel.”
Second highlight – I saw a woman who had recently been in the ER with facial pain. We had access to the ER notes, and the plan says, and I’m writing this verbatim:
Reassurance. Norco Dosepak and additional Norco prescription for pain. . . .
Now I thought it must have been a typo, meaning to say Medrol Dosepak, but later in the plan was “a loading dose of prednisone and a 6-day course of additional prednisone.” So I’m trying to think of some way to call the ER to see if they’ve actually advanced the state of the art of medicine to the point of having a Norco Dosepak – possibly dispensed at a drive-through window?
Third highlight – my Hispanic translator was tall, thin, with a ruddy complexion and straw-colored hair. He seemed to know his Spanish. But I’ve never had a Spanish translator, at the end of a shift, say “G’night y’all.”