Braille Monitor                                                 November 2010

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A Practicing Blind Physician

by Dr. Tim Cordes

Tim Cordes, MDFrom the Editor: One of the things that makes the Dr. Jacob Bolotin story intriguing and worthy of the recognition we give it through our awards is the thought that a blind man could, almost a century ago, overcome the attitudinal and physical obstacles that stood between him and being trained and licensed as a doctor. Some people are amazed by what he did with very little technology, while others see the lack of medical technology in his time as a distinct advantage. In Dr. Bolotin's day making a diagnosis depended primarily on talking with the patient, conducting an examination by touch, using the doctor’s sense of smell, and listening to the patient's heart and lungs. Implied in the observation that it might have been easier then than now is the concern that today a diagnosis is made based on quantifiable results delivered by machines. Are the pictures, graphs, and numbers presented in a form a blind person can use? Stated differently, we love to hear about pioneering blind people like Dr. Bolotin, but what about today? Can a blind person still become a medical doctor?

To answer this question, President Maurer invited Dr. Tim Cordes, a practicing physician completing his last year of residency, to appear on the agenda immediately preceding the presentation of the Dr. Jacob Bolotin awards. Dr. Cordes was a recipient of a National Federation of the Blind scholarship in 1995, and in the presentation that follows he speaks not only to the pioneering spirit of Dr. Bolotin, but to our current generation of blind pioneers who explore the new frontier in the twenty-first century. This is what he said:

I want to thank you for the opportunity to be here today and maybe set the stage a bit for the Jacob Bolotin awards, coming next. Now Jacob Bolotin was the first blind physician here in the States, and they asked me to come to talk as someone who has benefitted from his trailblazing ways. So they asked me to talk about how I do what I do and perhaps a little about how I came to do what I do.
So I’m a psychiatrist, meaning I specialize in the brain: disorders of thinking and feeling in the organ that is connected to everything else in the body. In order to do that, I went through medical school like all the other physicians. I can still recall that first day at medical school. We had done a little gross anatomy, where we dissect cadavers. I had the smell of preservative on my hands, although I had washed as best I could. I sat down in the corner of the lounge to eat my sandwich, and a senior student came up to me and said, “Why are you here?”

I mumbled something like, “Well this is where I thought you were supposed to eat lunch.” That wasn’t quite what he meant. It was a reminder to me that, when you are doing such things, resistance is real. The way I like to think about resistance is that, if everybody likes what you’re doing, you’re probably not doing anything worthwhile.

Winston Churchill put this best perhaps when he said, “A kite flies highest against the wind.” The unchallenged life is boring. It leads to stagnation, and it leads to complacency. Just as we build our muscles through careful resistance training, we build ourselves in the same way. Although the resistance may say more about the other person than it does about us, the way we rise to it says more about us. And I am grateful for those who have systematically chipped away at resistance before me.

Why are you here? The question still remains, though. What is your purpose? There was a psychiatrist, Victor Frankel, who survived the Nazi concentration camps, who came up with a type of therapy which boils down to, if you can come up with a “why,” you can survive nearly any “what.” So when we seek to push limits, we have to have our why in hand for ourselves, and it is very hard to convince others if we don’t have that why straight. So my purpose and my why kept me going on those 4-a.m. mornings rounding on surgery.

But a purpose alone is not enough. It requires tools, so I use the fundamentals. I used Braille for mathematics for biochemistry and one of my anatomy texts; solid mobility skills so that, when they plop you down in a new hospital, you know how to get from A to B (it actually reached the point where the new interns asked me the shortest distance between two points when I was a medical student); and, these days, computer skills. When the tools weren’t there, I made them. I’ve written software that describes proteins through sound. So the tools provide a basis. They provide a point for confidence. The way I like to think about it is: “Confidence without competence is of little consequence.” So confidence is an attitude. What are other attitudes that have helped me in this journey? One, I think, is a sense of humor. I was interviewing at a residency in the northeast, and the chair of the department wanted to meet with me. After some pleasantries he said, “You know, I just don’t get it. How are you going to know what’s going on with a patient?”

I paused, and then I said, “Well I know you’re reading your email right now as you are talking to me.” That opened a door, surprisingly enough, because I was able to use some humor to challenge the preconceptions that all people bring to bear.

So along with humor the other tool I’ve found helpful is a sense of certainty. Now this goes beyond confidence and is in a way about humility. It’s the commitment to a goal that you right now may not know how you will reach, but you know you will reach it. Once you decide something will be done, it then just becomes a matter of how.

So let’s talk about the how. I did anatomy by touch, feeling the nerves and muscles, doing some of the dissections. I was the guy who reached into the chest cavity up to my elbow to pull out our cadaver’s lungs. When it came time for testing, I had the same test as everyone else and felt and identified the muscles and nerves that way. We used raised-line drawings to describe cellular concepts, things that are done with microscopy, also to explain physiological relationships: curves and charts. Much is made of the visual nature of medicine, and, although we would love 100 percent accessibility, the vast majority of information is easily accessible with speech software, electronic documents, CDs, and the Internet. They don’t tell you that, but it’s true. And, when it came time to do things like a physical exam, I learned that some things were quite easy. Listening to hearts and lungs: I was used to using my ears. When it came time to adapt certain things, I found I could study how someone’s joints moved by putting my hands in certain places and asking them to move. I picked up ideas here and there. For example, there is a blind rehab doc on the West Coast who studied how people walked by walking behind them with his hands on their hips. I’ve also learned that you can detect certain eye movement problems by placing your fingers over closed eyes. So my radar is always on for ways to add, to adapt, and to expand.

With these tools in mind, I did the med school rotations. I was in the operating room. I scrubbed in, holding that retractor for hours on end. I reached into live people’s bellies and identified organs and blood vessels. I caught babies. In pediatrics I examined kids. One of the children’s parents was a guy I knew. He said, after they finished the exam and walked out, his son said, “That was fine, Dad, but who was the dog for?”

One thing you might think is challenging is that on our anesthesia rotations we’re asked to put breathing tubes down people’s throats so that they can be on a ventilator for surgery. It’s a two-week rotation, and I arrived, and one of the physicians enthusiastically said to me, “You know, Tim, I know how you’re going to intubate.” This was great news to me because I didn’t have a clue. This was one of those why-not moments--those moments when your decision to say why not take a risk, taking a chance can make all the difference.

Our society tends to isolate us from risk--air bags in cars, wearing helmets for everything. But that chance to reach for the next handhold can open a lot of doors. So this physician had a tool. It’s called the Fast Track, which is sort of two right angles as a scaffold for a breathing tube. You can insert a tube through it, so I used that. Our anesthesia monitors can play musical tones to indicate the carbon dioxide level in the tube. So I got the patient ready. I had the mask over the face, breathing 100 percent oxygen. I put the Fast Track in place, snaked the tube through while the musical tones confirmed I was in the right place, and then I think I took my first breath. The experience was only slightly marred by the surgeon’s saying, “Can you shut that thing off?”

So I paid my dues. I was an intern and a resident; I am still a resident doing thirty- and twenty-four-hour shifts, caring for sick people with pneumonia, heart problems, and pancreatitis. I used an Opticon. Some of you may have heard of this tool. I had originally come across it to use for line spectra in organic chemistry, but it became invaluable for electrocardiograms. So I’ve done that, and now I have one year to go in my residency. I see psychiatric patients. I am already licensed by our state as a physician. I have about a hundred or a hundred-twenty people that I follow in my outpatient clinic. I’ve cared for the uninsured, people with schizophrenia, people with psychiatric problems from age seven to seventy, in the legal system, where handcuffs and x-ray machines are the norm.

Let me just tell you about how one of these experiences might go. On our consult service, we see people with acute psychiatric problems either in the hospital or the emergency room. So I would be in our consult room, my pager would go off, I would hit a button, and it would read the text message. I’d pick up the phone. I’d dial the ER, and it might be one of my buddies. If it were two in the morning, he would apologize. He’d say, “I have a patient I need you to see, Tim.” And he would tell me a bit of the story, and I would think about it, suggest some laboratory studies he might need to order. Then I would log on to the computer, where our medical records are now electronic, and read through the chart on my own. If a medical student was on the rotation with us, I would introduce a teaching point and get him or her thinking about the case too. I’d grab my knfbReader, my cane, or my dog, and I would lead the team down to the emergency room.

So it’s nice that after that much experience my presence there is commonplace. I might get a warm greeting, a comment on how I haven’t gotten a haircut yet, and then I’d probably walk into the security guard who is outside the room. He would say, “Dr. Tim, what’s the story?” And he always does better and watches your back if he knows what you’re thinking about and what’s going on, so I would fill him in because this might be a case where his help is needed. So, as I step through that door, I think about what could be going on. It could be a person so depressed that she can hardly move or talk. It might be someone bouncing off the walls with ideas of conspiracies or his super powers. He might be high on something. She might be confused because she’s really medically sick, and it’s my job to tell the emergency room doctor that this is not schizophrenia, and they need to figure out why this person is so ill.

Regardless, I step through the door. Now the patient may be surprised to see a blind physician, but with all that’s going on in her head, she may not notice. So I begin, and I take the time to listen. You know, maybe your mother told you to put on a happy face. They don’t tell you to put on a happy voice. So I listen to the voice. I listen to where it projects. I listen to how the body moves, to the sound of clothing, to jewelry. I notice perfumes or odors, and I build a picture. With that picture I transform from the physician with the cane or dog to the physician who can help. We make that profoundly human connection that enables us to help people get what they need.

Now as a resident I still have a supervisor who needs to pop in from time to time. In one such case that I recall, the supervisor and I walk in, my patient says to the supervisor, “Get out of here. He’s my doctor.” Not wanting to agitate the patient further, my supervisor turned on his heel and said, “Dr. Cordes, do what you think best.” So, if the patient needs to be examined further, a physical exam for admission, I’d do that. I put the orders in the computer and add my note by typing it or by using the telephone as other people do. There are places where I work with a sighted assistant in our old-school paperwork: tracking, billing, and the like, and paper charts. But, as one of my supervisors says, “The day goes on, patients are seen, and the job gets done.”

So with the people we have heard from today and we will hear about with the Jacob Bolotin awards, they are no strangers to getting the job done. I am honored to be a part in some small way in this process of their recognition. [Applause]

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