August 14th, 2014
Guests: Jack Ameil, Michael Begler, Dr. Stanley Burns ----------
DAVE DAVIES, BYLINE: I'm Dave Davies in for Terry Gross who's off this week. It's easy to take the miracles of modern medicine for granted. But a new TV series reminds us there was a day when somebody had to be the first person to get an appendectomy. And some doctor had to be the first to try and open a woman's abdomen and deliver a baby by cesarean section. The series called, "The Knick" is set in a turn-of-the-century New York hospital when surgeons were developing new techniques and inventions in a city teeming with immigrants and steeped in corrupt institutions. The operating scenes are graphic. And the relationships among the characters reflect the social and racial tensions of the period. The series is directed by Steven Soderbergh and stars Clive Owen. Our guests today are the series' creators and writers, Jack Amiel and Michael Begler. They've been a writing team since the '90s for television and film. Also joining us is Dr. Stanley Burns, a photographic and medical historian who's a technical advisor to the series, which airs Friday nights on Cinemax. In this scene, the brilliant surgeon John Thackery, played by Clive Owen, is about to begin a procedure in the operating theater of the hospital. He's addressing an audience of other doctors and students while the patient is awake and sitting on the operating table.
(SOUNDBITE OF TV SHOW, "THE KNICK")
CLIVE OWEN: (As John Thackery) Gentleman, before you is a patient who is infected with septicemia from his bowel. Normally, we would induce surgical sleep with ether, but due to a severe case of bronchitis he has developed post-operatively, we cannot. We must operate. But we cannot do it to a man who can feel pain. My solution - numb the nerves in the spine between the thoracic vertebrae six and seven so as to stop the brain from learning of the pain. I intend to inject a 2 percent cocaine solution directly into Mr. Gentile's spinal canal - low enough not to affect the heart and lungs, high enough to dull everything below.
UNIDENTIFIED ACTOR #1: (As character) My God. Won't that paralyze him?
UNIDENTIFIED ACTOR #2: (As character) Not if he makes with a hollow canal in the subarachnoid space.
OWEN: (As John Thackery) It's been tried once before on a Labrador retriever.
UNIDENTIFIED ACTOR #3: (As character) What happened?
OWEN: (As John Thackery) There isn't a day goes by where I don't miss that dog.
OWEN: (As John Thackery) If you could attempt to suppress your cough.
DAVIES: Well, Jack Amiel, Michael Begler, Dr. Stanley Burns, welcome to FRESH AIR. Congratulations on the series. It's gotten a lot of great reviews, although, a couple have mentioned you might not want to watch it right after a meal. One of the fascinating things about these operating scenes is that we have an operating room floor and then this big amphitheater where there is a huge crowd watching, and the doctor is describing what he is doing kind of like an entertainer introducing his act. Is that the way it went back in turn-of-the-century?
MICHAEL BEGLER: Yes, it was. The operating amphitheater was the way surgeons taught. And the most revered professors sat in the first row and the young interns in the top row. And this was a standard way. Often the doctors would turn around and lecture to the crowd. The doctors who lived 100 years ago, 200 years ago were just as smart, just as innovative, just as inventive as we are. But they labored under inferior technology and knowledge.
DAVIES: The other thing I notice about this scene, and others, is the way the doctor speak about the patients while they are right there listening. I mean (laughing), Dr. Thackery here is saying he's going to try this procedure which was attempted once a dog and he doesn't go a day without missing that dog. The patient is awake and hearing this. Anybody want to comment on that kind of bedside manner?
STANLEY BURNS: Well, I collect photography. And when they took photographs of patients, they didn't cover genitalia. They didn't cover their face. And the patients were to be - were of the mindset of appreciative of the care that they were getting. And that they were basically teaching cases so that every case they did was for a learning experience. And we see that in this particular example.
JACK AMIEL: I'd also add medicine hadn't advanced to a place where anybody assumed that they were going to live from it. So anything a doctor did was simply reversing fate. And so I think the doctors felt more free - at least our doctors that we created felt more free to speak in front of them because the reality was always there. There is no facade of you'll probably get better.
BURNS: I'd like to say something to that - that until the advent of surgery that's depicted in this era - the turn-of-the-century - most hospitals were looked at as a place to die. And it was because of the accomplishments of the surgeons at the turn-of-the-century that people realized they can go to a hospital, get operated on and live. And the surgeons were the ones who helped create the modern American hospital system as a result of this.
DAVIES: Dr. Burns, is it true that you have a collection of over a million vintage photographs mostly in your home?
BURNS: Yes, that's true. And the largest part of the collection is my medical photography collection and my memorial - postmortem photograph collection.
DAVIES: Those are photographs that people take when - of dead ones, of their lost loved ones or as they're about to die? What is that?
BURNS: It's both. And during the 19th century this was a very common practice. This is just a way of memorializing a loved one. We remove death from everyday life. And as - I think it was Jack who mentioned it before, this was a normal part of life. And it was only until after World War I that we had the major advances where people could expect to live to a ripe, old age. The advance of medicine drove us from a lifespan of 47 in 1900 to the 80's at the end of the century.
DAVIES: Jack or Michael, can you think of a photograph or a procedure that you saw at Dr. Burns' archive there that particularly impressed you or inspired a story or a scene?
BEGLER: Well, I can say that when we first went there, the first time, the very first photograph that Dr. Burns showed us was of an African-American surgeon in Paris. And he is the lead surgeon and he is surrounded by a white staff. And I think this is one of the only photographs that existed of this. And we had already written the pilot at this point but to see evidence of what we had created was astounding.
DAVIES: This is a black surgeon surrounded by a white staff in France?
BEGLER: A black surgeon surrounded by a white staff but in Paris because black doctors here in the United States couldn't work in a hospital. They would probably work in a - the best they could do is work in a Negro infirmary. But if they went over to Europe, they could study with the best doctors, the best researchers and work side-by-side. So that's what we - in our character of Algernon Edwards - that's what we depict. And so to see that photograph was just so affirming and incredible.
DAVIES: An important character in the drama here is Dr. Algernon Edwards, who is a brilliant black surgeon who was at the hospital but not at all treated well by John Thackery, the head of surgery, who is played by Clive Owen. He didn't want to hire this black surgeon but was forced to by a woman we're going to hear, Cornelia Robertson. She's played by Juliet Rylance. She's the daughter of the chair of the board. In this scene, Dr. Thackery is in his office and Cornelia comes to confront him about his terrible treatment of Dr. Edwards. Let's listen.
(SOUNDBITE OF TV SHOW, "THE KNICK")
OWEN: (As John Thackery) I expected you over an hour ago. What kept you?
JULIET RYLANCE: (As Cornelia Robertson) Your treatment of Dr. Edwards was indefensible.
OWEN: (As John Thackery) No, it was completely defensible. I'll tell you exactly what I told him. I'm not interested in leading the charge in mixing the races.
RYLANCE: (As Cornelia Robertson) Dr. Edwards is as capable as any doctor in this hospital, likely more so.
OWEN: (As John Thackery) Perhaps, but just as a shopkeeper would never stock an item on his shelves no customer would buy, I would not employ a surgeon no patient will agree to have operate on him.
RYLANCE: (As Cornelia Robertson) Then patients must be convinced of his ability.
OWEN: (As John Thackery) You can stand there and honestly tell me that the way out of our financial troubles is to hire a Negro surgeon?
RYLANCE: (As Cornelia Robertson) Once people learn that he is an excellent surgeon they'll change their minds.
OWEN: (As John Thackery) We're speaking about a patient's possible mortality. Is this really a fair time to begin a social crusader?
RYLANCE: (As Cornelia Robertson) Yes.
OWEN: (As John Thackery) We're an institution in dire condition. We're not an incubator for some progressive experiment for you and your father's money. Please, find yourself another hobby.
DAVIES: And that is Clive Owen and Juliet Rylance from the series, "The Knick." It airs Friday nights on Cinemax. You know, it's interesting that John Thackery, the lead physicianer, I mean, this - he is a man of science. You might expect he would have no tolerance for racial prejudice. Tell us about him.
AMIEL: Well, this was also an era when people were using science and medicine to bolster their racism as well. Thackery's not doing that. But what Thackeray is doing is simply part of the time. This was a society that, as a matter of course, was racist.
DAVIES: Were there African-American surgeons in this period? What were their lives like?
BURNS: There were. Well, there were African-American medical schools in the South, mainly. And they had their own hospitals and their own system of education that was within the parameters and within the norm of medical education at the time. But they couldn't go to major southern cities and be in their hospitals because of strict segregation. And up North it's as Jack portrayed it, there was a - as a matter of fact, I'll go the exact opposite way - there was actually a scientific thought, well worked out, rational basis for segregation. And this was a major aspect of 19th century - I hate to say it -medicine and science was finding ways to distinguish the races. And so African-Americans were not accepted. They did work in their own infirmaries. And they did have to be educated at the wrong medical schools. I know one of the liberal schools at the time in the 1880s was the University of Michigan. I think I have a photograph that has five African-Americans in that class. But that was highly unusual.
DAVIES: Jack Amiel and Michael Begler are the creators and writers of the series, "The Knick." Dr. Stanley Burns was a technical advisor to the series. It airs Friday nights on Cinemax. We'll talk more after a break. This is FRESH AIR.
DAVIES: This is FRESH AIR and we're talking about the new Cinemax series "The Knick" which is set in a turn-of-the-century New York City hospital. We're speaking with the series creators and writers Jack Amiel and Michael Begler and with Dr. Stanley Burns, a technical advisor to the series. "The Knick" stars Clive Owen as Dr. John Thackery. In this scene he's delivering a eulogy at the funeral of a colleague.
(SOUNDBITE OF TV SHOW, "THE KNICK")
OWEN: (As Dr. John Thackery) We now live in a time of endless possibility. More has been learned about the treatment of the human body in the last five years than was learned in the previous 500. Twenty years ago, 39 was the number of years a man could expect from his life, today it is more than 47. Eventually the train tunnels will crumble, the dams will be overrun, our patients' hearts will all stop their beating, but we humans can get in a few good licks in battle before we surrender.
DAVIES: The lead character here, the brilliant surgeon Dr. John Thackery, played by Clive Owen, is addicted to cocaine. Was that common at the time?
BURNS: Well, unfortunately it was. One of the principles of medicine at the time was that doctors practiced on themselves. There's doctors who - like Dr. Henry Head who cut his own nerves, you know, in his hand to see what innovation was like. And when cocaine came out it was a miracle drug. It was being experimented with for infiltrative, local anesthesia which freed the patient from the horrendous effects of general anesthesia where they used ether and chloroform. And doctors routinely took those medications and every other medication to see the effects. And unfortunately William Halsted, for which Thackery - Dr. Thackeray is modeled after to some extent, was a cocaine addict when he was in New York City here. And one of his close associates, another doctor, died from an overdose and they were using it to see the effects on the human body by injecting themselves not realizing how addictive it was.
DAVIES: I'm wondering kind of what dramatic possibilities it presents to have your lead actor - your lead character - on cocaine. I mean, and it struck me that, I don't know, that sort of edgy, sort of scary focus that you might get with cocaine would fit with being on the cutting edge of surgery. You know, experimenting at every high-stakes.
AMIEL: Well, I think what we wanted from this character is a guy who was always going forward. And the amount of bodies he has left behind is so great that I don't think he could function without something that's sort of put that at bay. You know, in the pilot it becomes too much for Dr. Christiansen and as people saw he committed suicide.
And in episode two - this is not giving anything away - but Thackery says to Christiansen's widow, that Christiansen stopped seeing the procedure and he started seeing the patient. And so for Thackeray the way to cope without - for not seeing the patient and just seeing the procedure was to use this cocaine to kind of keep his focus and his drive and his endurance to keep moving medicine forward.
BURNS: I'd like to add here that this of course was one of the great issues during the 20th century. The doctor became more emotionally removed from the patient and the humanism is being slowly brought back into medical schools with the creation of medical humanities departments with their emphasis on treating the patient as a human being before you worry about his disease. It's not a disease with the patient.
I remember going to school where, you know, I would say, hey, I'm making rounds where we didn't discuss this as Mr. Jones, we'd say this is the gallbladder and this is the stomach cancer and this is the. And today the emphasis is on the personal touch so that we do have to have that, to, empathy for what the patient is going through. And this is a great change in medicine. And with the amount of technology and the advances we have it's rightly so and just a little late in coming.
BEGLER: We also like to marry the idea of technology with medicine. And what I mean by that is in the opening episode we have the hospital being wired for electricity. And so Jack and I thought, well, how do we now use the electricity in the theater? And so we went about researching for different procedures that actually used electricity to the benefit of the patient. But sometimes this had really good results and sometimes it had really awful results.
DAVIES: One of the things that I noticed is a lot of the scenes are dimly lit and I suppose this is the way people saw things back then when they often relied on, you know, natural lighting and electric lights were just, you know, coming into use. Was that a way that you writers envisioned it?
AMIEL: The dim lighting was Steven Soderbergh's brilliant choice and it was real. This was not an era when you had high wattage light bulbs and everything was lit. It was an era when this was all new and not everything was wired for electricity and we wanted the reality of the darkness and the grit and what life really was like. Technology ironically helped with this because Steven uses the camera called the Red Dragon and it has such an incredibly sensitive light sensor that you can be in a room where two characters are only lit by one candle in the center of the table and you can shoot that scene. It can bring more light or less light. It is extraordinary.
And so Steven really took advantage of that and allowed us to see what the darkness really was back then. And I think it's wonderful. I think it's something you don't see in anything else. Steven also mentioned something that I thought was really interesting - which is that he kept trying to figure out why there was a different quality to the show than anything he'd done before. And when he was editing it he kept looking at it. And what he noticed was that the actor's eyes were different and it was because they weren't in bright light. So instead of dialing down their pupils, they were wide open. And it had a whole different effect and a sense of openness that I don't think many other productions have ever been able to capture.
DAVIES: It is interesting to consider how different the life of a surgeon is today, where there are so many specialties and so much equipment and you do so many of these things. From back then when they were kind of figuring it out. How does that help you kind of shape the characters?
BEGLER: I think we just looked at them, especially someone like Thackery, as an explorer. They were pioneers, you know, and what was the mindset of an Explorer? You know, how far would they go?
I think of someone like Percy Fawcett who spent his life searching for this lost city. In the same way I think of Thackery in that way. That he's searching for these things that are almost impossible to find sometimes but that he has this drive to keep going forward. And yes, today it is about specializing but back then they couldn't specialize because they didn't have enough knowledge to focus on just a certain part of the body or a certain system within the body. They had to first learn all about that and we now live in a time where you can do that thanks to the men of the early 20th century.
DAVIES: Well, Jack Amiel, Michael Begler, congratulations on the series and thanks so much for talking with us.
AMIEL: Thank you so much, Dave. It's been a pleasure.
BEGLER: It's been a real pleasure. Thank you, Dave.
DAVIES: Dr. Stanley Burns thanks for joining us also.
BURNS: Well, thank you. It's been a great privilege.
DAVIES: Jack Amiel and Michael Begler are the creators and writers of the new TV series "The Knick." Dr. Stanley Burns is a photographic and medical historian who's a technical advisor to the series. "The Knick" airs Friday nights on Cinemax. I'm Dave Davies. And this is FRESH AIR.
DAVE DAVIES, BYLINE: This is FRESH AIR. Jazz critic Kevin Whitehead reviews two new trio albums by tenor saxophonists who won the Thelonious Monk Jazz Competition. Last year's winner, 25-year-old Chilean-born New Yorker Melissa Aldana, and Joshua Redman who took the prize in 1991. Kevin says the two share a conspicuous influence - vintage Sonny Rollins.
(SOUNDBITE OF PABLO MENARES SONG, "TIRAPIE")
KEVIN WHITEHEAD, BYLINE: "Tirapie" by bassist Pablo Menares. One of her few catchy originals on the CD "Melissa Aldana And The Crash Trio." Her third album is "Leader." It's her first since she won the Monk competition last year. It marks her growing confidence. Aldana's prime inspiration as a teenage tenor saxophonist was Sonny Rollins. Her albums piano-less trio format, and a couple of long solo improvisations, speak to his lingering influence. Rather than hide how closely she studied him, Aldana has some fun with the idea. Her tune "M&M" and the solo she takes on it playfully riff on some classic Rollins licks.
(SOUNDBITE OF MELISSA ALDANA SONG, "M&M")
WHITEHEAD: It can be tricky paying tribute to a grandmaster. You don't want to invite a direct comparison. Melissa Aldana heads that off by not trying to sound too much like her hero. Her tone has body, but it's a bit lighter and smoother than vintage Sonny Rollins - more alto-like in the upper register. Aldana was mentored by saxophonist Greg Osby and George Coleman and you can also hear traces of Osby's floating sense of time and Coleman's smeary blues abstractions. That's one way to transcend your key influences - mix them together along with what you've figured out for yourself.
(SOUNDBITE OF UNIDENTIFIED SONG)
WHITEHEAD: Melissa Aldana with bassist Pablo Menares, who, like her, is from Chile, and Cuban-born drummer Francisco Mela who wrote that tune. Melissa Aldana's progress got me thinking about a young tenor player I heard 24 years ago on a gig with his saxophonist, Father Dewey Redman. The youngsters solos sounded like undigested John Coltrane and I didn't hear much promise there. That didn't stop Joshua Redman from winning the Monk Competition a year later. But Sonny Rollins had been his idol before Coltrane. And a few years ago his influence came back in force when Redman began leading his own piano-less trios. His new "Trios Live" pointedly starts with a tune Rollins put a stamp on - "Mack The Night."
(SOUNDBITE OF JOSHUA REDMAN SONG, "MACK THE NIGHT")
WHITEHEAD: Joshua Redman with Greg Hutchinson on drums and Matt Penman on bass, Redman catches some of the expansive spirit and expressive range of Sony Rollins, although he has his own pliable sound. When Redman slides into what sounds like Rollins' voice, it's not for long. There's some great saxophone playing on "Trios Live" though I could do without the cover of Led Zeppelin's "The Ocean." And on one fast piece, Redmond's phrasing gets maddeningly repetitious.
(SOUNDBITE OF UNIDENTIFIED SONG)
WHITEHEAD: Repetition aside, that passage shows how Redman has digested his John Coltrane, playing fast patterns his own way. Over all though, Joshua Redman's trio, like Melissa's Aldana's, suggests Sonny Rollins' increasing influence over younger saxophonists, partly because he's still here to inspire them. That be one more reason to be grateful for and to Sonny Rollins. Mr. Rollins, thanks again for everything.
DAVIES: Kevin Whitehead writes for Point of Departure and Wondering Sound and is the author of "Why Jazz." Coming up, taking chronic itch as seriously as chronic pain. This is FRESH AIR.
DAVE DAVIES, BYLINE: If you think itch is no big deal, it's probably because you've never had severe chronic itch. You might think, just scratch it and stop complaining. But our guest, Dr. Gil Yosipovitch, understands that itch can be as debilitating as pain. He's the chair of the Department of Dermatology at Temple University and is developing a center for itch there. He's also the founder of the International Forum for the Study of Itch. For years, he's been trying to get doctors in related fields such as neurology and oncology involved in researching new treatments for itch to change what he feels is a dismissive attitude among doctors that itch is the little brother of pain. Dr. Yosipovitch is also the co-author of the book, "Living With Itch: A Patient's Guide." He spoke recently with Terry Gross.
(SOUNDBITE OF ARCHIVED BROADCAST)
TERRY GROSS, HOST:
Dr. Yosipovitch, welcome to FRESH AIR. You've been trying to create itch as a separate area of specialization. Why do you want itch to stand on its own as a field?
GIL YOSIPOVITCH: I would say that I learned from my colleagues dealing with pain. A lot of the patients come with that complaint and we can't solve the underlying disease immediately, but they want us to treat their itch first and foremost. And I felt that, like our colleagues in pain that developed the concept that we first have to treat pain regardless of underlying disease, this has to be achieved also in itch. And in fact, we know that patients who have chronic itch, their quality of life is significantly affected by - very similar to patients who have chronic pain.
GROSS: I think a lot of people don't understand that because pain - I mean, pain is pain. And itch is supposed to be, oh, a little thing that you scratch, not a big deal. It doesn't hurt. So give us a sense of what kind of distress itch can cause.
YOSIPOVITCH: When a patient can't sleep at nighttime and wakes up scratching himself all night long, it affects, significantly, his capability of coping and working and enjoying life. So it starts from infancy, where you have kids who have atopic eczema. They can't sleep. Their parents can't sleep. And it also causes a vicious cycle that - often itch, scratch cycle. Patients some (inaudible) I would prefer even having pain rather than having itch. And think about someone who has it constantly, day and night.
GROSS: So, you know, there's the kind of basic itch you get - a mosquito bite, you get a rash, poison ivy. It itches for a while. It goes away. You can treat it and numb it when it's at its worst. But, you know, it's going to go away. But chronic itch doesn't go away. And it's very disturbing to the people who have it - interferes with sleep, interferes with other things as well. It's kind of itch gone berserk. So is the problem neurological? Like, is there something happening with the nervous system when you have that kind of chronic itch?
YOSIPOVITCH: That's an excellent question. And indeed, the neural system is significantly involved. It transmits the itch signals from the skin, where itch emanates, up into the spinal cord and up to the brain. The nerves are acting wacky. They fire when these patients have chronic itch, and we become very sensitive. So even small activities or very minimal activities that usually would not cause us itch like changing our clothes or changes in temperature and environment or exposure to soaps, could irritate this system and the patient feels more itch.
GROSS: So if we look at chronic pain and chronic itch, how are they similar? How are they different?
YOSIPOVITCH: Well, both of them are unpleasant sensations. There's some unique difference and one of the unique differences is that, in pain we retract from the area where we have a painful stimuli. While itch, we actually scratch it. We induce bit of pain to relieve it.
GROSS: Is that what we're doing when we're scratching - inducing pain to relieve the itch?
YOSIPOVITCH: It's interesting. I think there are two aspects to it. Yes, there is a bit component of pain but there is also - and that's unique, I think, to itch - is that there is a component of pleasure and scratching an itch. We find it relieving, but there is something in addition. Our studies and other groups' may suggest that there is a - also a brain mechanism involved in pleasure of scratching an itch and they are involving in this repetitive behavior, so it's bit addictive to start scratching.
And when a doctor tells a patient, stop scratching, it's easy to say that, but in fact, it's not easy to do because it really liberates - the scratching - some chemicals. Chemicals like opioids, like morphine-like. In fact, a lot of the patients say the only way to relieve her itch for a couple of hours is significant scratching.
GROSS: But, I thought if you keep scratching an itch - because of the itch-scratch syndrome, is that what it's called?
GROSS: Cycle, yeah. That you are going to make it worse if you have a bad inch. It's defeating to scratch it because you're not only going to scratch your skin and maybe even start bleeding, but also you're going to intensify the itch in the long run and you're just fooling yourself (laughter) if you think that scratching's going to help.
YOSIPOVITCH: You're perfectly correct but, on the other hand, the immediate relief of scratching is something that - that's the purpose most probably, of scratching, is that relief of itch. I think evolutionally this most probably was related to something, that animals were using scratching to relieve insects that were bothering them. My ideal treatment would be to induce an activity that would be similar to scratching but not damaging the skin. When we scratch, we damage the skin to cause inflammation and to activate more of these nerve fibers. But the idea is, if we were able to induce the same activation in the brain of scratching and inducing it without damaging the skin, we may end up with a good treatment for chronic itch.
GROSS: So let me see if I understand correctly - you're not only studying what happens in the brain when we have an itch, you're studying what happens in the brain when we scratch an itch and why that seems to produce a pleasure response. And you're trying to see if there's some kind of substitute we can use other than scratching, some kind of neurochemical thing, that we can do so it would relieve the itch by satisfying the brain?
YOSIPOVITCH: That's correct.
GROSS: That's so interesting. So are you thinking, like someday there's going to be a pill we can take that will basically do for the brain what scratching does?
YOSIPOVITCH: Yes. I do...
GROSS: (Laughter) That would be nice.
YOSIPOVITCH: ...Strongly believe in that. Always, with pills, you have to ask, so what are the side effects? So that's always something that we have to look into. But always, you have to outweigh the risk versus the benefits. And the benefit for a patient who cannot sleep at nighttime sometimes outweighs side effects. But we are on the verge of finding more drugs that are targeted approach for itch. And some of them work clearly on these mechanisms.
GROSS: So we were talking earlier about some of the connections between pain and itch, in terms of the neurological system. So what are some of the implications for medicines? Like, in pain now there's a lot of work being done with things like Gabapentin, to try to slow down the nerve response so that the nerves aren't communicating all this pain. I'm putting this in really bad layperson's terms so you can elaborate on that and explain, but are medications like Gabapentin, which are used to kind of quiet the pain response, also being used to quiet the itch response?
YOSIPOVITCH: I perfectly use them - agree with you - and perfectly use them as my treatments for patients with chronic itch. They don't work for all types, but those where there is neuropathic or damage to the nerve fibers, they work very well. Gabapentin or the Pregabalin; these are drugs that work for our patients. We sometimes use them in combination with other class of drugs from the anti-depression of those called Selective Norepinephrine Reuptake Inhibitor and it's not that our patients are depressed; they could be sometimes depressed due to horrible chronic itch, but because these drugs work in an additive effect, in reducing that sensitization what the nerve fibers as I mentioned, are acting wacky and firing. They reduce that firing of the nerve fibers, that's why it enables our patient to sleep better and to have less itch.
So a lot of times I'm asked by other colleagues, why do you give antidepressant? Why do you give anticonvulsants like Gabapentin, Pregabalin, and I say, I give them because it really reduces the itch intensity and the suffering. So there is a lot of similarities here with chronic pain.
GROSS: Since chronic pain and chronic itch are similar but different, are people who are prone to chronic pain also prone to chronic itch and vice versa?
YOSIPOVITCH: There's not really an epidemiology study to suggest that, but I would say, from my experience, there are a lot of overlaps of people who have some types of chronic pain and they're in the same spectrum of chronic itch, and they could have chronic itch. This is not well mentioned, but for patients who have, for example, fibromyalgia, if it causes chronic pain, a lot of times they complain also of chronic itch. So it won't surprise me, people who have irritable bowel syndrome, which is another form of - all these aspects of disease have something in common - they have a hypersensitization of the nerve fibers and it's very similar to what I described before, with a patient with chronic itch is that the nerves are acting wacky; they're just firing all over. And that's why it's so severe and why it's so difficult to treat these patients.
GROSS: You know, some people who have chronic pain syndromes say that their doctors are very dismissive. And you mentioned fibromyalgia; a lot of doctors don't even consider that a serious diagnosis. Does the same happen with chronic itch? Do you find that a lot of patients who come to you have been dismissed as having either imagined complaints, or neurotic complaints or exaggerated complaints?
YOSIPOVITCH: I agree with you and I think, we in our profession as dermatologists like to see a lot of times, skin signs, rashes. And when a patient tells you that he has itch, that he cannot sleep and - I use, a lot of times, a intensity scale, what we call a visual analog scale and ask him, rate your itch. And I think, for us as dermatologists, it's sometimes very difficult to, if we don't see the scratch marks but the patient tells you, I suffer from horrible itch, it sometimes causes us to think that maybe he's exaggerating. But from my experiences, it's not what you see, it's what the patient complains of. I therefore believe strongly that we need to address itch as a disease - chronic itch as a disease - on its own state and understand our patients' suffering.
GROSS: Now, you're a dermatologist, but a lot of itches you deal with aren't really about the skin - it's not a skin condition, it's not hives, it's not a bite, it's not a rash - it's something that's happening neurologically and you're trying to figure out, what is it that's happening neurologically?
But again, it's not a skin issue, per se.
YOSIPOVITCH: Well, I see it in the perspective of the skin. The skin is a sensory organ and has all the nerves. And the patients come because they think that the dermatologists have to solve it. And it's interesting - I don't want to be critical of my colleagues in neurology but - very few of neurologists are interested in some of those sensations. I would say that, I think one of the purposes of putting itch as a focus of my work is to raise awareness among other specialties, that they have to address this topic, including my colleagues in neurology, including other experts, even pain experts; that they have to understand that sometimes patients have both pain and itch, like, post Shingles.
And they sometimes would dismiss the patient - say, oh, well if you have itch, I'm not bothered with it; we just want to deal with pain.
But, I see that as part of the same spectrum.
GROSS: Dr. Yosipovitch, thank you so much for talking with us. I appreciate it.
YOSIPOVITCH: My pleasure.
DAVIES: Dr. Gil Yosipovitch chairs the Department of Dermatology at Temple University and is the co-author of "Living With Itch: A Patient's Guide."
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