The Journey from Hack to Hackers.

Show: FRESH AIR
Date: MARCH 27, 2000
Time: 12:00
Tran: 032701np.217
Type: FEATURE
Head: Dr. Jerome Groopman Discusses `Second Opinions'
Sect: Medical
Time: 12:06

This is a rush transcript. This copy may not
be in its final form and may be updated.

TERRY GROSS, HOST: From WHYY in Philadelphia, I'm Terry Gross with FRESH AIR.

On today's FRESH AIR, when second opinions aren't enough. We talk with Dr. Jerome Groopman about what he's learned as a doctor and as a patient about getting the right medical treatment. Dr. Groopman is a Harvard Medical School professor, an AIDS and cancer researcher, and author of "Second Opinions: Stories of Intuition and Choice in a Changing World of Medicine."

Also, rock critic Ken Tucker reviews the new Steely Dan CD, and linguist Geoff Nunberg considers the words "hack" and "hacker."

That's all coming up on FRESH AIR.

First, the news.

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GROSS: This is FRESH AIR. I'm Terry Gross.

When you're facing a major medical crisis, it's good to get a second opinion. But if that opinion contradicts what your first doctor said, then what do you do?

My guest, Dr. Jerome Groopman, has written a new book called "Second Opinions." He writes about the difficult decisions he's had to make as a doctor, analyzing conflicting data in an era of new and still experimental approaches. He also writes as a patient and a parent about tough medical decisions he's made in the face of conflicting information.

Dr. Groopman is a professor of medicine at Harvard Medical School, chief of experimental medicine at Beth Israel Deaconess Medical Center, and a researcher in cancer and AIDS. He writes about medicine for "The New Yorker" magazine.

Let's start with a story about second opinions that comes from Dr. Groopman's experiences as a parent when his first child was about 10 months old.

DR. JEROME GROOPMAN, "SECOND OPINIONS": We were in Connecticut, visiting my wife's family. He woke up, he was feverish, very cranky, flexing his legs to his belly, and he had diarrhea with a very pungent sulfurous smell.

And my wife and I both thought that he was seriously ill.

GROSS: You thought that there was a lot of blood in his stool.

GROOPMAN: We -- it was very dark and tarry. We didn't see bright red blood, but it looked like blood that had been digested in his intestines.

GROSS: So what was your first approach? What -- did you want to go the emergency room, to a doctor?

GROOPMAN: It was the July 4 weekend, and we spoke to neighbors of my in-laws, and the prevailed upon the local pediatrician to see us at his office. We took Stephen (ph) there. He was about 10 months old. And we met this pediatrician in his early 60s, very neatly dressed, well appointed. He listened to the history, examined Stephen, and turned to us and said, "You have a perfectly healthy baby. This is just a GI bug."

GROSS: Now, you're both doctors, you and your wife, so you have a lot of medical knowledge you could call into play here. What did your medical knowledge tell you?

GROOPMAN: Our medical knowledge was confused. We were frightened, and we also had vowed that neither of us would make medical decisions about our children or about our own family, because we worried that our emotions would color our judgment. So we thought this was blood in the stool, but I was particularly cowed by this pediatrician telling us that nothing was wrong. And when my wife began to object, he dismissed her, and he said, "You know, I was once a neurotic, overanxious doctor-parent also."

GROSS: You decided to take your baby to Children's Hospital in Boston. What were your fears about going to an emergency room on a holiday weekend in July?

GROOPMAN: Well, there's a painful joke among doctors, which is, Don't get sick in July. That's of course because the new interns and residents begin on July 1. So we came in around midnight to the emergency room, and as usual it was a wild scene, and we were taken care of by a resident who was a green doctor. Looked at the baby, looked at Steve, made the correct diagnosis, which was that he had an intestinal blockage.

But then said to us, "In my experience, there's no need for urgent surgery. This can wait at least until the morning, and I'm going to try to get some sleep."

GROSS: Your reaction?

GROOPMAN: We were paralyzed, initially completely paralyzed. It was clear to us that Stephen was very sick. It was also clear to us that this resident was distracted and that he was more interested in getting a few hours of shuteye than really taking care of our baby. And we didn't know what to do for a very long moment.

GROSS: What did you do?

GROOPMAN: Well, we went around him, and we -- I made a call to a physician that I didn't know that well, but the only one I knew at Children's Hospital. It was amazing that his private number, his home number, was listed in the Cambridge directory. And he called a surgeon, a senior surgeon, who came in in the middle of the night, who rushed Stephen to the O.R.

GROSS: Well, you were really lucky that you as a doctor knew a doctor that you could call.

GROOPMAN: We were incredibly lucky. And one of the reasons for writing this story is to give people the courage to press their intuition and to demand a second opinion and to get a senior physician to pay attention if they feel that they're not being cared for properly, because not everyone, obviously, is a doctor and has that opportunity and access.

GROSS: I guess, you know, just to update the story a little bit, I mean, your -- so your baby was operated on without waiting till the next morning, and the surgeon said that if it hadn't -- if you had waited, the baby might have died, because the blockage was so severe.

GROOPMAN: Absolutely. We could have lost our son because of two medical misjudgments, one by a senior local pediatrician who didn't pay attention to my wife's intuition about her baby, and the second by a glib resident who just really didn't act.

GROSS: Yes, well, this is one of the things I find so frightening about the story. Your book is called "Second Opinions," but it wasn't until, like, the third and fourth doctor that you spoke to that you actually got on the right course.

GROOPMAN: It's very difficult for all of us, you know, to evaluate medical advice and to make choices about treatment. But I believe that you need to continue to press. If you have a deep, intuitive feeling that something's wrong, and it doesn't make sense to you what you're being told by your doctors, then you have to keep seeking and keep pressing.

GROSS: There's always this fear that you're going to be punished for it, you know, that, for instance, the resident is going to be offended that you distrust his or her opinion, and they're going to end up waiting till morning to do the surgery anyways, and they're just going to have lost respect and interest in you, and you'll pay the consequences.

GROOPMAN: We felt that, and I was very ginger about confronting this resident, because I was vulnerable, we were vulnerable. At that moment, we were terrified parents and were not in a position of power or control.

I end the story talking about a woman, Ellen O'Connor, who's not a doctor. She's an accountant, and her husband's a salesman. And she had a similar situation, and she just would not take no for an answer. She kept pressing regardless of what feathers she might ruffle, and ended up saving her baby an unnecessary surgery.

GROSS: Now, how do you feel when you have a patient whose intuition contradicts your medical judgment? Do you always go with their intuition? Where do you -- how do you navigate that when you're the doctor in control?

GROOPMAN: Well, I pay close attention to it, and it causes me to reexamine my initial assumptions, because I think a person's intuition is very important, it's very smart. Even if it's wrong, it needs to be addressed and explored. Sometimes also it causes me to think that I didn't communicate or explain clearly to my patient what my thoughts were in terms of an alternative path.

GROSS: Your firstborn son, when he was an infant, his life was saved because a doctor that was called on your behalf in the middle of the night came and performed surgery, after the resident of the hospital thought that the surgery was unnecessary. The resident was wrong. So the surgeon who came in the middle of the night saved your child's life.

How often are you called on in the middle of the night to do something medical, and what's your reaction when your sleep is interrupted? Are you always willing to go out and do it?

GROOPMAN: I'm called on occasion in the middle of the night, and I think back to Stephen, and as hard as it is at 2:30 in the morning to be roused from bed, I try to grab coffee, or I look for coffee, I get myself awake and focused, and either, you know, try to handle it by the telephone, or sometimes go in. You know, and we're talking about people's lives. And it's absolutely essential to do whatever needs to be done.

GROSS: Now, I think it's when you were training residents and interns that the residents and interns had a closed-door session where they confessed their errors, or at least the ones they recognized, and -- was that when you were working with residents and interns?

GROOPMAN: I was actually a resident at the time. And this was mostly done on the surgery service, and they had what were called EJs and ETs. EJs were errors in judgment, ETs errors in technique.

GROSS: And what were -- what was the point of this closed-door session which residents and interns would confess their errors to each other?

GROOPMAN: Well, the point was certainly for people to learn from each other's mistakes, but I think this has been a difficult issue for the entire medical establishment, and the recent report from the Institute of Medicine about medical mistakes, estimating that some 40,000 people in the United States may die because of medical errors, is really the first time that this has come out of closed doors, and I think that's very healthy for the medical profession.

GROSS: So do you think that this closed-door confession technique is one step toward dealing with medical errors, to get people to realize that they're -- to get young doctors to realize that, A, they're imperfect, they make mistakes, and B, that they should learn from their mistakes instead of covering them up?

GROOPMAN: Well, it's not only young doctors. Old doctors, myself -- I write about medical mistakes that I've made, errors in judgment and errors in technique, which are incredibly painful but very important. And I think it's critical that we learn from our mistakes and we be open about them to the public.

The more human we are, the more we admit our fallibility, the more it encourages our patients to express to us their thinking and their intuition and form a real partnership in caring for people.

GROSS: Problem is if you admit to a mistake, you can be sued, and that could have disastrous effects for a doctor and his or her career.

GROOPMAN: It's a real risk, but I think that if you're honest and caring, and you tell a family that an error was made, and you express genuine contrition, that usually you're not sued. It's usually when you try to cover it up, or you make believe it didn't happen, that people get really angry. And that's what triggers malpractice suits.

GROSS: My guest is Dr. Jerome Groopman, a professor at Harvard Medical School and author of the new book "Second Opinions." We'll talk more after a break.

This is FRESH AIR.

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GROSS: My guest is Dr. Jerome Groopman. He's a professor at Harvard Medical School, chief of experimental medicine at Beth Israel Deaconess Medical Center, and also he writes for "The New Yorker," and he has a new book now called "Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine."

Let's talk about a medical problem you had, and this is in another story that you tell in your book, "Second Opinions." In 1979, you had hip pain while you were training for a run in the Boston Marathon. You went to the doctor. What was the first diagnosis?

GROOPMAN: First diagnosis was that I had a bursitis of the hip, and he gave me some anti-inflammatory medicine, told me to stop running, and told me to start crewing, just to keep up my endurance for the race.

GROSS: And that's what you did.

GROOPMAN: That's what I did, and it was a misdiagnosis. It turned out I had a pinched nerve in my back. The pain in my hip was so-called referred pain from the pinched nerve. And I had actually blown a disk in -- a lumbar disk.

GROSS: And you made your condition worse by continuing to exercise.

GROOPMAN: Yes, the crewing was the absolute worst thing you could do for a ruptured disk in your back.

GROSS: You got a second opinion. What was the second opinion?

GROOPMAN: Well, unfortunately, I was younger and impetuous, and in a lot of pain, and I was desperate to run this race, and a surgeon told me that I should go right to the O.R. and have surgery to remove the disk.

GROSS: And you did. What was the outcome?

GROOPMAN: The outcome wasn't very good. I still had persistent back pain and hip pain. About six months later, without much provocation, I developed severe back pain, and this time I was even more impulsive, and I saw an orthopedic surgeon who said, "I'll fix you, we'll fuse your back, you'll be running, everything will be fine."

GROSS: And what happened?

GROOPMAN: I woke up and I couldn't move my legs. I had hemorrhaged during the surgery around my spinal nerves. I was incredibly despondent. I was sleeping on ice for four months, taking painkillers, including narcotics, and becoming really close to depressed.

GROSS: How much have you recovered from that?

GROOPMAN: I recovered a fair amount, but I'm still limited. Sitting on a back support as we speak now. I still can't run, I'll never be able to run. I substitute, I swim and so on, which is a good sport for me. I can bike. But I've been limited for my adult life because of that error.

GROSS: Again, this was the -- what, three different doctors who you saw, each leading you in the wrong direction. And so the idea of a second opinion, it's just, like, not enough, two opinions, sometimes.

GROOPMAN: It isn't, but I made -- the mistakes here were twofold. One was that I relinquished my control. I just wanted to put myself in the hands of a doctor who was telling me what I wanted to hear. And the second is that family and friends who were around me who had a more sober perspective, I didn't really pay much attention to that.

It's very hard when you're a patient. You're in pain, you're confused, you're fearful, and you can make major mistakes. And I did.

GROSS: So you think when you're shopping for a second opinion, you shouldn't just shop for the opinion you want to hear.

GROOPMAN: You shouldn't shop for the opinion you want to hear. You shouldn't shop alone. It's very important to have family or a friend or an advocate or someone with you who can listen carefully and help interpret what's being said.

GROSS: How do you think this episode in your medical history affected your approach as a doctor?

GROOPMAN: Well, it transformed me as a physician. It's very, very different being on the other side of the examining table, and I understand what it is to be a patient, to be frightened and to be confused and to be in pain, to hang on every gesture that a doctor makes and every word.

GROSS: Has it affected your feeling when one of your patients wants to get a second opinion from a different doctor?

GROOPMAN: It's absolutely changed that, and it's something that I encourage and that I want. I'm not perfect, I may miss something in diagnosis by thinking about a treatment may -- is not necessary right all the time. So I encourage people to get second opinions, particularly the kinds of people that I care for.

GROSS: My guest is Dr. Jerome Groopman, and he's a professor at Harvard Medical School. He writes for "The New Yorker" magazine about medicine and has a new book called "Second Opinions."

You have had a lot of patients with life-threatening illness, and I know a question you always have to face is how much do you tell a patient, how much detail do you go into, how much do you tell them about what might possibly go wrong in the future? I want to quote something you say in the book.

You say, "When a patient asks if the treatment -- what's going to happen if the treatment doesn't work, you'll often say, `Well, we'll cross that bridge if we need to.' It can be daunting for a patient in the midst of severe illness to know all the possible negative outcomes. These, rather than the positive outcomes, can become the dominant scenes that patients play in their minds."

Would you expand on that for us, why you sometimes if a patient says, Well, what if this doesn't work, then what do we do? why you won't go there?

GROOPMAN: Well, I think we know what the negative outcome is implicitly. If someone with cancer or with AIDS, the treatment is not working, that certainly means that we come closer to death. I think it's important to focus initially on the battle, on the battle to live, and to succeed in terms of the therapy.

I would never sugar-coat or dilute the difficulty that's faced, but to go into a theoretical scenario about a failed treatment right at the outset of engaging a battle against disease, in general unnerves people to such a degree that it's hard for them to hold on.

On the other hand, I don't want people to say to me, I just put myself in your hands, you do whatever needs to be done, don't tell me any of the details.

GROSS: Why not? Why, why, why don't you like that approach?

GROOPMAN: Well, because I need them to tell me what's going on in their bodies and what they're feeling. That -- I'm at a disadvantage if my patient is not expressing to me his intuition. I'd rather someone cry wolf 10 times than to miss something important.

GROSS: Do you find that there's much of, you know, the negative placebo effect? You know, the positive placebo effect is you're given a medicine that might just be a sugar pill, but it helps you improve anyways, because you have some faith in it. The negative placebo is you're worried about something damaging you or about a bad outcome, and you help bring about that at -- bad outcome through the imagining of it, you know, through pure psychology. Do you find that a lot, that if a patient knows a lot about the worst possible outcomes, that they find a more direct route toward getting there?

GROOPMAN: Well, there are psychological mechanisms of what's called, for example, anticipatory nausea. Everyone knows that you can become nauseated with chemotherapy. Happily, there are better drugs now for chemotherapy to block nausea. But if you focus excessively on that, people will tend to become more nauseated. It doesn't mean you don't state that nausea can happen, but there has to be this fine balance between encouragement and frank discussion about potential side effects.

GROSS: Do you encourage your patients to read about their disease after you've diagnosed something serious?

GROOPMAN: Absolutely. I want people to understand what their illness is about, and I want them to question me and to have me explain as clearly as I can the nature of the diagnosis and the options for therapy.

GROSS: But if they read about it, they're going to find out about all these, you know, worst possible scenario type of outcomes.

GROOPMAN: They are, but that's -- they know that. There are no pretenses that go on in terms of cancer or AIDS or blood diseases. We know what the negative is, we talk about the negative, and then we sort of put a plan together to try to achieve the positive.

GROSS: Dr. Jerome Groopman is the author of "Second Opinions" and a professor at Harvard Medical School. He'll be back in the second half of the show.

I'm Terry Gross, and this is FRESH AIR.

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GROSS: Coming up, Ken Tucker reviews the new Steely Dan CD, "Two Against Nature." We're listening to it now. Linguist Geoff Nunberg considers the words "hack" and "hacker." And Dr. Jerome Groopman discusses new developments in treating breast cancer and leukemia.

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GROSS: This is FRESH AIR.

I'm Terry Gross, back with Dr. Jerome Groopman, author of the new book "Second Opinions: Stories of Intuition and Choice in the Changing World of Medicine." Dr. Groopman is a professor at Harvard Medical School and a cancer and AIDS researcher. He writes about medicine for "The New Yorker" magazine.

Now, among the things that you do is that you're chief of experimental medicine at Beth Israel Deaconess Medical Center. And one of the things you've studied is the biology of bone marrow growth. And I know as a doctor you've had patients who have had bone marrow transplants.

The recent studies on bone marrow transplants and breast cancer have shown that they're -- that the transplants aren't really effective in preventing death. Correct me if I have this wrong.

GROOPMAN: No, you're completely correct. There are two important studies now which show that there's no benefit in survival for bone marrow transplant...

GROSS: Well...

GROOPMAN: ... in women with metastatic breast cancer.

GROSS: For our listeners who aren't aware of what a bone marrow transplant is, give us the kind of short version of it.

GROOPMAN: OK. Basically, what you do is, you take out cells from the bone marrow, blood cells, so-called stem cells, which are able to reproduce and re-form your entire blood and immune system. You put those in a bank, so to speak, you freeze them away, and then you treat someone with doses of chemotherapy or radiation which essentially wipes out their entire marrow, and at the same time, you hope that it wipes out their entire cancer.

And then you rescue them by giving you -- giving back these banked stem cells, which reproduce and re-form the blood.

GROSS: And, and, and you nearly kill, you come, like, you know, a hair away from killing the patient before bringing them back to life again.

GROOPMAN: You do that, and in diseases like leukemia and lymphoma, it's lifesaving. In the context of breast cancer, it was hoped that it would be like leukemia and lymphoma, but it's not.

GROSS: Now, when you read these studies, were you surprised? What, what, what, what was your actual experience as a doctor of patients who had had metastasized breast cancer and had the bone marrow transplant therapy?

GROOPMAN: It was mixed. there were some women who had done very well and seemed to have benefited, and there were other women who had relapses. But as in every other situation, it needed to be compared head on with women who had had standard chemotherapy. And it turns out, looking at two sets of studies now, that there is no significant difference in terms of survival between women who were transplanted versus women who were treated with intensive chemotherapy but short of a transplant.

GROSS: What are you working on now in your lab?

GROOPMAN: Well, we've discovered a new gene which appears very important in breast cancer. We've just made a crystal structure of this, and we're using computer simulation to try to develop completely new drugs, very specific targeted drugs, that get at the genetic roots of breast cancer.

GROSS: Are you recommending that the women who are your patients get the test to see if they have the gene?

GROOPMAN: It's a very complicated individual decision, but I think it is important for women to know if they are genetically predisposed to breast cancer, because there seems to be more that can be done to try to prevent it. Women can have a 50 to 90 percent risk of developing breast cancer if they have this inherited genetic mutation.

GROSS: And what can they do to prevent breast cancer if they know that they have the mutation?

GROOPMAN: Well, there's a very difficult and harsh therapy, which is to have their breasts removed and their ovaries removed. There's work from the Mayo Clinic and other centers which show that you actually reduce your risk by 90 percent if you do that.

Then there are also experimental trials giving women estrogen blockers like tamoxifen, to see whether, short of surgery, this will reduce this extremely high risk of breast cancer.

GROSS: What are some of the new drugs or procedures in the works now that you think have a lot of promise?

GROOPMAN: I think the great promise is that we're beginning to understand the fundamental abnormalities, the genetic abnormalities in all forms of cancer, and computers are allowing us to visualize in three dimension the kinds of targets that exist within these cancer cells, so that we can make so-called smart bombs, targeted therapies that hit the abnormality, rather than just carpet bombing, and the very primitive and toxic therapies of radiation and chemotherapy.

GROSS: How much of this is already available?

GROOPMAN: Well, recently a disease called chronic myelogenous leukemia, which is a very severe leukemia that affects people in middle and later age, a smart bomb, so to speak, was developed against this. Thirty-one out of 31 people who had failed standard chemotherapy have complete remission of their leukemia with this new drug. It was just presented in December. It was developed at the University of Oregon.

That's the kind of therapy we need, intelligent, rational, based on the abnormality in the cancer.

GROSS: Have you as a patient tried experimental drugs, or do you prefer to wait till they're tested?

GROOPMAN: If I had a life-threatening disease for which there is no good standard therapy and no curative therapy, I would seriously consider an experimental treatment. But I'd also get a second opinion before making that decision myself.

GROSS: What would you want to know about the side effects before deciding?

GROOPMAN: I'd want to know what the quality of life would be if the drug worked and if it didn't work, and I'd also want to make sure that the physician I was seeing, the researcher I was seeing, was not promoting this particular experimental therapy because it was his pet project.

GROSS: Is that something you have to be careful of?

GROOPMAN: Very careful of, very careful of. And, you know, the tragic case at the University of Pennsylvania of this young boy, Jesse Gessinger, you know, I read in the newspaper the statements of his father. And what he said, more than anything else, was he wished that he had spoken to other researchers, expert in the field, who could have given him an independent perspective. And that would have allowed him to make a better decision, perhaps.

GROSS: I want to get back to breast cancer for a moment. You have treated a lot of women with breast cancer. You are doing research into the gene, you know, into a gene that causes breast cancer. I'm wondering what advice you're giving your women patients now who are going through menopause about estrogen.

GROOPMAN: This is a very complicated question, and again, it's an individual assessment. On the one hand, estrogen in moderate doses, after menopause, protects bones, so there's protection against osteoporosis, and it's also important in heart disease. Heart disease was largely overlooked in women, and estrogen protects against heart disease in women.

On the other hand, it predisposes and potentiates the development of cancer. So in a woman with a very strong family history of breast cancer, or in a woman who's had precancerous lesions, abnormalities, in her breast, I'm very leery about the use of estrogens.

On the other hand, if a woman performs self-exam, has mammograms done regularly, estrogens can be used, because actually more women die of heart disease than of breast cancer. And you will protect them from that and give a better quality of life.

GROSS: My guest is Dr. Jerome Groopman, a professor at Harvard Medical School and author of the new book "Second Opinions." We'll talk more after a break.

This is FRESH AIR.

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GROSS: My guest is Dr. Jerome Groopman. He's a professor at Harvard Medical School, chief of experimental medicine at Beth Israel Deaconess Medical Center. He writes for "The New Yorker" magazine and is the author of the new book "Second Opinions."

You deal with medicine all the time and with experimental medicine. Do you use at all alternative medicine, acupuncture, meditation, relaxation techniques, I don't know, homeopathy, diet? Are you using any of that in conjunction with the old and new medicines that you prescribe?

GROOPMAN: Yes, actually I had acupuncture for my back, which helped me a great deal in terms of managing the pain. We had set up an acupuncture program here for people with AIDS, with advanced AIDS. I think meditation is very, very helpful, and there's a lot of work in terms of preparing people for chemotherapy using these so-called alternative techniques.

In terms of herbal treatments, I think those have to be looked at on a case-by-case basis. You know, there are important drugs that come from plants, digitalis comes from foxglove, and vinchristine, which is important in childhood leukemia and lymphoma comes from periwinkle.

On the other hand, if a patient believes, like when I was training, that laetrile, which comes from apricot pits, is going to cure their pancreatic cancer, I can't endorse that unless there's data.

GROSS: What made you decide to try acupuncture for your back?

GROOPMAN: I was desperate. I hated the drugs that were being given to me as painkillers, the narcotics. They made me woozy and stupid and depressed and constipated. And I think that 3,000 years of Chinese empiricism is not foolishness. And there is, I believe, a physiological basis for stimulating certain nerves in the body which feed back into the brain and will allow for better management of pain. I don't think we understand it yet on a molecular or deep scientific basis, but my sense is it was worth trying. And the alternatives being offered by traditional medicine weren't very attractive.

GROSS: What did you learn as a doctor by trying this technique that's completely different to your approach as a Western doctor?

GROOPMAN: Well, I think you need to be open-minded. You need to be open to everything. If your aim is to help your patients and do the best for them, then you welcome opinions and techniques which are not those that you necessarily grew up with.

GROSS: You've been writing about medicine for "The New Yorker" for several years now. And I'm wondering if writing about case studies, if writing about your experiences, both as a doctor and as a patient, has affected your sense of practicing medicine, because in a way, you're not only the doctor but then after reflecting upon the case, you become a character in the story that you tell.

GROOPMAN: It has. It's actually made me a better doctor. It's had me examine places, moments, when I was misguided or thick-headed, when I didn't communicate well with my patients. It also, since many of my patients read what I write, gives them a platform to begin a discussion with me about their particular case.

So it actually has become, you know, part of the fabric of my role and -- as a doctor, and my relationship with the people I care for.

GROSS: Has it made you more self-conscious knowing that whatever you do, there's a chance that you'll be reflecting on it through a story that you'll tell in print?

GROOPMAN: To some degree. I'm very careful, though, that I would never write about anyone, any patient, who doesn't want to be written about. But it does make my sense of observation more acute.

GROSS: Do most of your patients want to or not want to -- what kind of range of reaction do you get to the idea of being written about?

GROOPMAN: Well, some patients say to me, you know, I don't want to be a chapter in your next book, and I assure them that they won't be. Other patients are deeply flattered. And probably the most moving instances were where I wrote about people who ultimately died, and their families saw the chapters as a memorial and as a gift to perpetuate who this person was.

GROSS: Did you always want to write, or was this something that came much later?

GROOPMAN: It came later. It was sort of my midlife crisis in my early 40s. I'm still desperately in love with my wife, and I didn't want a red Corvette, but I was restless, and I wanted to do something different.

(LAUGHTER)

GROOPMAN: So I started to write, and frankly, the first stories that I wrote were awful, they were a mess. And my wife, Pam, read them, and she honestly told me they were a mess. And it was a very hard process to learn how to write.

GROSS: How'd you learn?

GROOPMAN: I learned by repetition, sort of obsessive repetition. I actually read Oliver Sacks, and I read Richard Seltzer, and I read Sherwin Nuland, and I saw how fluid and clear their prose was, and I realized that the key was to try to express yourself in simple, declarative, straightforward sentences and to write from the heart.

GROSS: Well, Dr. Groopman, I thank you so much for talking with us.

GROOPMAN: Thank you, it's been a pleasure.

GROSS: Dr. Jerome Groopman is the author of "Second Opinions," and he's a professor at Harvard Medical School.

Advances in medicine and technology have added many new words to our lexicon. Our linguist, Geoff Nunberg, has been thinking about a word that comes from the computer world, "hacker."

GEOFF NUNBERG, LINGUIST: There's a law of meanings that's like Gresham's law of money, the bad ones drive out the good ones. "Senile" used to mean just old, but that meaning disappeared when the word acquired a sense of mental defectiveness. A "junket" was originally just a party before it got the sense of a trip taken at public expense.

Or take the word "hack," as in "hack writer." That was originally a shortening of "hackney," which referred to a horse that was easy to ride. Then it came to refer to a horse kept for hire -- that's where we got the use of "hack" to mean cab driver -- and then to anybody who hires himself out to do mean or servile jobs. In Shakespeare's time, in fact, the words "hack" and "hackney" were synonyms for prostitute. Then it was applied to any incompetent work, as in "hack job." Then finally, "hackneyed" came to mean a tired phrase that's in promiscuous use.

These uses of "hack" had only an indirect influence on the way computer programmers started using "hack" and "hacker" back in the 1960s. Probably the new sense is owed as much to the use of "hack" to mean chop, but like the older senses of "hack," the programmer's hack started out as a positive term, part of the cult language that grew up among programmers at places like MIT and Carnegie Mellon.

When you hear a programmer say, She can really hack, it's in the same appreciative tone that a jazz musician uses when he says, He can really blow.

In recent years, though, "hacker" has gone down the same steep road that "hack" and "hackney" did a couple of hundred years ago. The process started early on. Already in the 1960s, engineering students were using "hack" to refer to an ingenious prank, which might involve a computer system breaking.

Sometimes these were just irrepressible student hijinks. Sometimes they were more malicious acts by hacker wannabes. And when break-ins by those self-styled hackers began to make headlines in the 1980s, the press naturally took the term to describe the perpetrators, to the point where that's the only sense of the word that most people know.

A lot of programmers still get indignant about this use of the word. They want people to reserve "hacker" as a term of praise, and suggest the word "crackers" as a name for people who do malicious break-ins.

I appreciate their point, but there's no possibility the process will be reversed, no more than "hackney" is going to go back to meaning a horse that's easy to ride. For one thing, the figure of the hacker has clearly caught the public's fancy as the perfect villain for the information age.

And the media contributes to that hacker's sinister allure. You think of John Markov's (ph) best-seller, "Takedown," a nonfiction thriller about the escapades and eventual capture of the arch-hacker Kevin Mitnick. Or there was the 1995 film "Hackers" with Angelina Jolie as one of the ringleaders of a bunch of adolescent misfits who break into corporate servers and uncover fiendish criminal schemes.

Of course, most programmers don't bear much of a resemblance to the hacker stereotype of the precocious sociopath. For that matter, they don't bear a lot of resemblance to Angelina Jolie either. But I can understand why people would be tempted to take the hacker as the representative of the entire breed. If you're unable to log in to your stockbroker while your portfolio tanks, you're not usually in a mood to care whether the problem is due to the deliberate mischief of some hacker or the purely inadvertent mischief that ordinary programmers can do.

It's a little scary to realize that the smooth operation of our economy is at the mercy of a tribe of 20-somethings in pony tails and Converse sneakers who regard the rest of us with undisguised condescension. Every time I have to call into the help desk of some software company or online service, I have the sense of being cast in a recurring episode from the old "Sky King" TV series, the one where the pilot of a small plane has passed out, and somebody in the control tower's trying to talk his 8-year-old passenger in for a landing.

Now, Billy, I want you to pull back slowly on that stick in front of you. That's good, Billy.

You can see why the public hasn't been interested in according the word "hacker" the respect that programmers think we owe it. In fact, I'm starting to hear programmers themselves using the word the way everybody else does. Partly, this is just their realization that it's a losing battle trying to keep the positive sense of "hacker" alive, but it also reflects a kind of demystification of their trade as programming becomes a more commodified skill, and all that stuff about the hacker code comes to seem a little precious.

In the end, that's always what happens to the cults that emerge among the early practitioners of new technologies, from the steamboat to the telegraph to the airplane. But programmers can at least have the consolation of knowing that the same process always tempers the villainous specters that also grow up around these technologies, the Frankensteins, the Dr. Strangeloves, or the demoniacal hackers of the recent headlines.

Not that hacking's about to disappear any time soon, but after a while, it'll be just another one of the hackneyed criminalities of modern life.

GROSS: Geoff Nunberg is a linguist at Stanford University and the Xerox Palo Alto Research Center.

Coming up, Ken Tucker reviews Steely Dan's new CD.

This is FRESH AIR.

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TO PURCHASE AN AUDIOTAPE OF THIS PIECE, PLEASE CALL 877-21FRESH
Dateline: Terry Gross, Philadelphia
Guest: Jerome Groopman
High: Jerome Groopman's new book is "Second Opinions: Stories of Intuition and Choice in a Changing World of Medicine." The Harvard Medical School doctor and researcher says patient and doctor should be working together, using intuition, cutting-edge science and personal values to make critical medical decisions. The book's case histories include Goodman's infant son, who was misdiagnosed in a hospital emergency room and almost died.
Spec: Health and Medicine; Death; Science; Technology

Please note, this is not the final feed of record
Copy: Content and programming copyright 2000 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 2000 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: Dr. Jerome Groopman Discusses `Second Opinions'

Show: FRESH AIR
Date: MARCH 27, 2000
Time: 12:00
Tran: 032702NP.217
Type: FEATURE
Head: Ken Tucker Reviews Steely Dan's New Album
Sect: Entertainment
Time: 12:52

This is a rush transcript. This copy may not
be in its final form and may be updated.

TERRY GROSS, PHILADELPHIA: Steely Dan has a new CD called "Two Against Nature." Their previous recording, "Gaucho," came out 20 years ago back in the days when albums were still on vinyl. Rock critic Ken Tucker says that Steely Dan's two masterminds, Donald Fagin and Walter Becker, have picked right up where they left off with unusual grace and wit.

(AUDIO CLIP, SONG EXCERPT, STEELY DAN)

KEN TUCKER, ROCK CRITIC: Steely Dan has always been Donald Fagin and Walter Becker plus whatever studio musicians they hire to execute their intricately arranged, jazz-inflected pop songs. Becker provides many of the group's snaky guitar lines, while Fagin plays keyboards and sings in that somehow compelling chalky whine. And who knows degree of collaboration goes into the composition of their assiduously wry, mordantly funny whenever not frustratingly opaque lyrics?

But one of their best new songs is all too ruefully clear. Ponder this portrait of a 40-something slacker working in New York City's Strand Bookstore when he runs into a highly successful old flame.

(AUDIO CLIP, SONG EXCERPT, STEELY DAN)

TUCKER: When Fagin murmurs a line later on in that song about "our old school," fans will flash back to a classic decades-old Steely Dan tune called "My Old School," which, for Fagin and Becker, was Bard College. There, in the '60s, the pair briefly employed future comedian Chevy Chase as their drummer and were even then perfecting a version of rock and roll cool filtered through the jazz music they actually preferred.

When Becker was asked recently what was his favorite among all his albums, he replied drily, "Kind of Blue."

On "Two Against Nature," the pair stretches out most jazzily on the eight-minutes-plus "West of Hollywood," a bit of tight meandering featuring oblique non sequiturs that might have been lifted from a John Ashbery poem.

(AUDIO CLIP, EXCERPT, "WEST OF HOLLYWOOD," STEELY DAN)

TUCKER: The concessions that Steely Dan makes to the new millennium on "Two Against Nature" might seem limited to tossed-off references to CDs and the fancy coffee shops of Dean and DeLuca, but running through this collection like a strain of seductive poison is a theme they addressed as long ago as 1980 on their last hit single, "Hey Nineteen," that is, two dirty old men so decadent they don't think it's cool to disguise their lust for young girls.

This perfect self-loathing, the sexual equivalent for the self-contempt that Fagin and Becker feel for being rock and not jazz musicians, finds its most potent expression here on "Cousin Dupree."

(AUDIO CLIP, EXCERPT, "COUSIN DUPREE," STEELY DAN)

TUCKER: With specials airing on PBS and VH1 and the fact that their album debuted on the charts at a surprisingly strong number six, there would seem to be still an audience for Steely Dan's essential paradox, what might be called passionate archness. The fact that they haven't become mired or mannered is as exhilarating news as any being delivered by any pop musicians 30 years younger. Backstreet Boys, watch your backs, Steel Dan has returned to seduce your core constituency.

GROSS: Ken Tucker is critic at large for "Entertainment Weekly." He reviewed Steely Dan's new CD, "Two Against Nature."

FRESH AIR's executive producer is Danny Miller.

I'm Terry Gross.

We'll close today with a recording by trombonist Al Gray who died Friday at the age of 74 from complications relating to diabetes. Gray played with the Basie band for the better part of 20 years. He also led his own bands.

Here's his 1990 recording of "April in Paris."

(AUDIO CLIP, EXCERPT, "APRIL IN PARIS," AL GRAY AND THE COUNT BASIE BAND)

TO PURCHASE AN AUDIOTAPE OF THIS PIECE, PLEASE CALL 877-21FRESH
Dateline: Terry Gross, Philadelphia, Ken Tucker
Guest:
High: Rock critic Ken Tucker reviews "Two Against Nature," the new release by Steely Dan.
Spec: Entertainment; Music Industry; Art

Please note, this is not the final feed of record
Copy: Content and programming copyright 2000 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 2000 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: Ken Tucker Reviews Steely Dan's New Album
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.