Grand Rounds, Volume 4, #49: The Seven Ages of Man

Some of you may know I am an amateur Shakespeare scholar. I pursue the study of the Bard during my spare time, which means I don't pursue it very deeply. Medicine and blogging seem to be the great consumers of time lately, but this week's Grand Rounds gives me the chance to marry the three subjects together. I present to you a Shakespearean Grand Rounds, and I begin with a literary digression.

The Seven Ages of Man speech is delivered by Jacques in As You Like It, a pastoral comedy featuring the adventures of lovers and fugitives in the Forest of Arden. Jacques is a melancholy officer in the service of a banished duke, and he has some of the greatest lines Shakespeare ever wrote:

All the world's a stage,
And all the men and women merely players;
They have their exits and their entrances,
And one man in his time plays many parts,
His acts being seven ages.

The speech addresses the cycle of a person's life, from birth to extreme old age, and touches upon some of the roles and achievements we try to accomplish at each stage. For this week's Grand Rounds submissions, I have categorized each within the stage I think most suited for the post's topic.

A few more administrative notes:

• All images are in the public domain. Click on them to be taken to their Flickr page for more info.
• For those of you who are unfamiliar with Elizabethan vocabulary and usage, click the links in the above paragraph for more info, or you could consult a discussion at Where's My Cape on how to help the lyrically-challenged.
• I have not attempted to change or apologize for Shakespeare's use of the universal masculine pronoun. Some feminists may take offense. However, I believe Shakespeare's universal appeal--proven by the enduring interest in and reinterpretation of his works, including many by women artists who have revealed the complexity of the feminine in his work--speaks for his universal humanity. There is nothing to correct in his words, only in our attitudes.

Now, on to the first age:

...At first, the infant
Mewling and puking in the nurse's arms.

Mr. Shakespeare didn't have much to say about infancy, did he? This is to be expected, given the high neonatal and infant mortality during the Elizabethan era. Birth and survival are the major tasks of this age. A few bloggers touched upon these issues:

• Doc Gurley commented upon a recent UK study which concluded that oral contraceptives act against women's natural instincts to find unrelated mates. She finds these conclusions B.O.G.U.S. Mr. Shakespeare might have called them A tale told by an idiot/Full of sound and fury/Signifying nothing.
• In the modern era, there are so many ways to be born. ...and a doula, too has written an excellent post asking us, what is natural childbirth? She describes many possibilities for a birth experience unknown in Shakespeare's time.

Infancy is a good time to learn all about bodily excretions, and our bloggers are ready to teach!

• Allergy Notes gives us a great review of snot-producing conditions.
• Scholarly blogger and all-time most popular guest on the Doctor Anonymous Show, Ramona Bates from Suture for a Living, captivates us yet again with an in-depth review of paronychia, a common (and pus-y) condition most doctors will encounter more than once during their careers. I believe Shakespeare would have appreciated the ooze and putrefaction of our profession.

On to the second age:

Then the whining schoolboy, with his satchel
And shining morning face, creeping like snail
Unwillingly to school.

Around the country, school is starting for kids and adults. Shakespeare didn't seem to like school, but when he was a kid he had to memorize Latin texts for 10-12 hours a day, so you can't blame him. A couple of bloggers had a lot to say about starting school:

• Peggikaye at Pearls and Dreams writes of her first week of college, having returned to school in the middle of the adventure of her life. She reflects on her dream career path, and how her extensive experience as a patient has let her to the trailhead.
• Everyone returning to school, shining morning face-d or not, should read about back to school boot camp at Teen Health 411.

And what are our scholars think about the learning process?

• An Australian medical student at Med School Unplugged writes about failing academic standards in medical school.
• Captain Atopic reveals the potential benefits of international rotations.
• A number of scholars have theorized about William Shakespeare's teachers and mentors. He must have known some remarkable people to have invented his universe of characters who have endured for four centuries. Beth at Life. Not terribly ordinary has had the good fortune to find a mentor. Imagine what she will accomplish now.

Our young scholar now moves on to the third age:

...And then the lover,
Sighing like furnace, with a woeful ballad
Made to his mistress' eyebrow.

Oh love! The capacity to love and express our love in art makes us human, and no one expressed the depth and breadth of love like our friend, Will S. What would he have thought about these bloggers and their comments upon the state of love today?

• There's a lot of love out there for Olympian Michael Phelps. Clinical Cases and Images Blog examines our concerns that he may have Marfan's Syndrome.
• Summer Olympics and the U.S. presidential elections always happen during the same calendar year, I wonder why? Is it to sate our appetite for popularity contests? The Health Care Law Blawg examines how Senator Barack Obama is wooing the American public with the promise of single-payor health care.
• Do we love our dogs more than we do our fellow humans? Maybe. Robin at Survive the Journey shares her theory that dogs might be diagnosed with Cushing's Disease sooner than their humans do.
• Monash Medical Student warns men to be careful where you bathe if they want to be ardent lovers.

If Shakespeare's lovers do not self-immolate from their passion, they move on to the fourth age:

...Then a soldier,
Full of strange oaths and bearded like the pard,
Jealous in honour, sudden and quick in quarrel,
Seeking the bubble reputation
Even in the canon's mouth.

The end of youth signaled entry into a productive line of work for the average Elizabethan. For those not lucky enough to have the means to enter the Church or the law, the army provided a chance to earn a small stake in life. War was a profitable event in the 1500s. Some things never change. Our friend the Bard wrote about many funny and ugly events occurring during war and personal conflict, and so have our bloggers:

• The one and only Bongi tells us about being a war doctor during a time of so-called peace.
• You don't need to go to war to get injured, as Vitum Medicinus and Gown Open To the Back demonstrate in their harrowing accident stories.
• As doctors, we're often in a position to prohibit young people from hurting themselves going after the bubble reputation. Country Doctor gives an example of being the bad guy by preventing a kid from entering contact sports.
• Laurie at a Chronic Dose urges us not to forget: illness is not a competition.
• Not all battles, not all injuries are physical. Kerri at Six Until Me writes about fighting for insurance benefits to cover her glucose testing supplies. Finding health care coverage for everyone may be the biggest and deadliest battle we will ever have to face.
• Christine at Corn Allergic describes her battle to avoid corn-based binders in commonly-prescribed medicines. Another reason to battle against corn-based industrial agriculture.
• I'm not kidding when I describe health care as a battle. Kim at Emergiblog shows some of the emotional scars of being a nurse within the current system. What's great about Kim is how she rallies back from the downside of being a nurse to raise awareness for a good cause.

Once our soldier has returned from the wars, he enters the fifth age:

...And then the justice,
In fair round belly with good capon lined,
With eyes severe and beard of formal cut,
Full of wise saws and modern instances;
And so he plays his part.

Flush with the spoils of war, our Shakespearean case study becomes a person of standing in his home town: a justice, who weighs evidence and metes out sentences for crimes large and small. This is an age of responsibility and discovery, with wisdom the ultimate achievement. Some of our bloggers are exploring how wisdom is obtained--or undermined.

• On her new blog, The Scalpel's Edge, Cris Cuthbertson explains why she does research. She is a wise and learned woman, like Mr. Shakespeare's Portia, or Rosalind.
• The Buckeye Surgeon considers the costs of reputation and expertise, including the burden of reproducing excellence with each procedure or encounter. (He cites Cicero, I prefer Shakespeare. We are both closet literists.
• One of the challenges of the fifth age is responding to those who question our wisdom. Dr. Rob discusses why doctors cannot be compared to barbers. Strangely enough, barbers used to perform surgeries in early European history, resulting in fine operas such as the Barber of Seville.
• The fifth age brings about its physical toll as well. The justice might develop symptomatic disc disease, carrying around his fair round belly. Dean Moyer at the Back Pain Blog shares the first step in repairing herniated discs.
• Even if the body is beginning to feel the wear and tear of the fifth age, our Shakespearean justice has nothing to fear. Doctor Anonymous shares news of innovative health care interventions currently in trials in South Africa.

Wisdom progresses unto the sixth age:

...The sixth age shifts
Into the lean and slippered pantaloon
With spectacles on nose and pouch on side;
His youthful hose, well saved, a world too wide
For his shrunk shank, and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound.

In Shakespeare's time, if you lived to be 45 you were a village elder. I suppose I would be a lean stout and slippered pantaloon at my current age of 40. Food for thought. In any case, most of what he has to say about this sixth age is about physical decline and looking back upon fading youth. Our bloggers weigh in on these subjects:

• The lean and slippered pantaloon should watch out for slubs in the carpet, because as he ages he's at more risk of slipping and breaking a bone, and the resulting MRSA osteomyelitis might just kill him. Read the Cockroach Catcher's take on the scenario. On a more therapeutic note, Dr. Penna discusses the Lautenbach procedure for delivering intraosseous antibiotic therapy.
• Which raises another point: the irrepressible Dr.Val, who is one of the new organizers of Grand Rounds, writes about why she doesn't think infections should be considered "never" events. I agree; remember, hospitals are where sick people are. Infections acquired during a hospitalization are not necessarily the fault of the hospital; the underlying disease may predispose/contribute to a patient becoming infected.
• Oh, and during that hospitalization, make sure you ask for a good bowel regimen. Scanman is now promoting his blog via an eponymous laxatives for the older set. Shakespeare would have loved this. He had high regard for bathroom humor, and eponyms. If you wish to avoid pharmaceutical bowel regimens, try Purplesque's tasty-looking wheat krispie treats instead.
• Thinking about it, the best thing would be to avoid falling at all. The Fitness Fixer has a post about balance and ankle stability with advice to prevent falls.
• If our pantaloon isn't insured yet, he'd better look for a policy right away. Read about some of the basics of Health Insurance 101 at the Colorado Health Insurance Insider. He'd also better check out her local hospitals: the expert staff at InsureBlog write about transparency in reporting hospital M&M rates.
• Leslie at Getting Closer to Myself is a young person, but she raises a question most of us face as we age and need to see more than one physician for specialty care: how can we get doctors to talk to each other about a mutual patient's care? This might be something EMR will help improve, but Shakespeare could write a comedy of errors about the kinds of miscommunications that can happen between two doctors, no matter how communication is achieved.
• A much more optimistic outlook arrives from Dr. van den Broek, aka ShockMD, who discusses research suggesting longevity does not automatically mean disability. Phew.
• The sixth age is a time to reflect upon your achievements. Uber-tech doc Symtym shares his tips to store, process and remember your lifetime's achievements. An ultimate archivist, Symtym has retained a lifetime of PDAs.

Now we approach the last of the seven stages, and the end of life:

...Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.

Here, Will Shakespeare describes a phenomenon most of us who have cared for people at the end of life will recognize: the physical, sometimes intellectual, regression to the needs and habits of childhood. Instead of Huggies, we need Depends. Instead of using a knife and fork, a nurse's aid feeds us. Have a stroke, you might develop dysphagia and a speech therapist will insist you eat a pureed died that looks suspiciously like Gerber baby food.

• Dr. Happy gives an example of second childishness heard in Happy's halls.
• Fat Doctor shares her own example of discovering a demented patient's sweet snot. (You see, we are back to snot again. Ah, the circle of life.)
• Meanwhile, Dr. Toni Brayer at EverythingHealth finds herself scolding Ed McMahon for filing frivolous medical lawsuits.

For those who love and care for us, there are other concerns at hand:

• An Episcopal Chaplain at the Beside discussed an excellent case involving mixed messages in end-of-life decisions. This is the dark side to having doubled our life expectancy since Shakespeare's time: your life no longer ends, it dwindles away, and no one can bear to talk about it.
• Thank goodness, therefore, for PalMD at Denialism, who takes the time to examine the fine line between empathy and pathologic identification with end-of-life patients. I think Will S. would have understood this fine line. I think he would have written a magnificent scene about it.
• Meanwhile, PalliMed reviews another barrier to discussing end-of-life issues with patients and their families: biased media reporting, in this case about Terry Schiavo.
• The Anesthesioboist, another closet literist, writes about visiting a Shaker village and being reminded of this great piece of wisdom: "Do all your work as if you had a thousand years to live and as if you were to die tomorrow." (Mother Ann Lee). Strangely enough, this sentiment summarizes Shakespeare's life quite well. The chronological duration was brief--he died at 52 years old--but his legacy is timeless. I think he made a liar out of his own character, Jaques, in defying that great melancholic's assertion that we end our strange eventful history "sans everything."
• Leisure may not extend our lives, but make them seem richer and more memorable. Amy Tenderich at Diabetes Mine reports on her recent vacation.
• Perhaps we will not end sans everything, but we risk spoiling nature with our consumer-driven habits. Paul Auerbach at Medicine for the Outdoors reminds us what may happen if we end sans wilderness.

Thus ends the Seven Stages of Man, and this edition of Grand Rounds. My last word to all bloggers, doctors and writers: insert a little bit of Shakespeare into your sensibility. Create for eternity. Let every word pierce the heart.

Comments

[Doctor Anonymous]

I like it! Great job! Thanks for including my post this week.

[Dr Am Ang Zhang]

In my book ”The Cockroach Catcher”, in a Chapter called Sadness I quoted from As You Like It:
And your experience makes you sad:
I had rather have a fool to make me merry
than experience to make me sad…..

As You Like It - Act II, Scene 7

Know your Shakespeare, well done and thanks for including my 82 year old professor.

The Cockroach Catcher