Saturday, October 27, 2012

Life, Interrupted: Changed by Cancer -

On Monday evening I stood on a stage in front of a thousand people and talked about what I've learned since my diagnosis with cancer two years ago at the age of 22.

I was speaking at the Angel Ball, the yearly red-carpet event for the Gabrielle's Angel Foundation, which in this past week alone raised nearly $4 million for blood cancer research. I had never spoken in front of so many people before. It was one of the proudest moments in a tough journey over the past two years. And I was able to meet world-class doctors and researchers, other cancer survivors and even some celebrities.

On the drive over, though, my nerves were shot. All I could think about was whether I had spent enough time memorizing my speech, and whether I'd chosen the right dress. Lurking in the back of my mind was a laundry list of "to do's" and checklists thrown like scraps on a mounting pile of anxiety.

But there was something different about this stress. It took me a minute to put my finger on it, but there it was: For the first time since my diagnosis I was stressed about something that didn't have to do with cancer.

I bristle when the word "gift" is used in the same sentence as "cancer." There is no upside to having a life-threatening illness. It can ruin lives, friendships, families and dreams, and trying to focus too much on finding a silver lining can trivialize real suffering. I would never have voluntarily chosen to go down this path. But like any other struggle, cancer has changed me. I wish I could learn about overcoming struggle by training for a marathon or applying for a new job, like many of my peers are doing in their early 20s. But life is unpredictable, and we don't always get to choose our battles.

Cancer robs you of your ability to look at the big picture — or at least obscures it. The news that I had cancer ripped away the expectations I had of myself to be a certain type of person with a certain type of life. I used to think that looking at the "big picture" meant figuring out 1-year, 5-year and 10-year plans. Back in 2010, I had just graduated from Princeton with highest honors, and I felt pressure to get on the fast track to success — whatever that meant. Like a lot of my peers, I was in the thick of the culture of anxiety surrounding achievement. I signed a two-year contract at a fancy corporate job even though I knew I much preferred Birkenstocks to high heels, creative writing to spreadsheets. This path wasn't right for me, but even though I felt miserable I continued going to work each morning because I was focused on the idea that having a practical, long-term plan was part of seeing the big picture.

I like to think that I eventually would have found my way to a career that both inspired me and paid the bills. But before I was able to figure out what that was, the cancer showed up. My life was interrupted. My doctors told me I would need intensive chemotherapy and a bone marrow transplant. From the looks on their faces, I could see that there wasn't going to be any quick fix for my disease.

I had spent a lifetime focusing on the big picture, but cancer forced me to look at the small picture. I had no choice. I quickly learned that trying to predict the results of a bone marrow biopsy or a round of chemotherapy was a torturous and futile exercise. So, for the first time in my life, I began to focus on the present.

In the midst of doctor's appointments and long hospitalizations I tried to organize my days around small acts of happiness by asking myself: What will make me feel better right now? How do I handle the worry I'm feeling right in this moment? Gone were the vague worries about a future career. Sometimes the answer to those questions was writing in my journal, visiting with friends and family, or eating peanut butter cups and watching bad romantic comedies. On other days, it meant having a good cry under my comforter. Little did I know, I was building muscles along the way — not lats and biceps, but invisible muscles that now kick in to carry me through stressful situations.

And so there I was, sitting in the limousine, a few minutes before I was to give my speech. I was nervous — that wasn't going away. But I also felt a sense of calm. After two years of nonstop chemotherapy and a bone marrow transplant, I realized that as a cancer patient, I had experienced my share of real stress and pressure, and I had learned how to confront it and cope with it.

I still can't see the big picture — the long view remains obscured. I can't change that. But I'm noticing that I am changed. And I learned on Monday night that giving a speech in front of a big crowd — something that would have been difficult to imagine before my cancer diagnosis — was now well within reach.

Friday, October 26, 2012

Current Health News | HealthDay

The HealthDay news service, a division of ScoutNews, LLC, provides daily health news for both consumers and medical professionals.

My Multiday Massage-a-Thon -

About a month ago, editors from this magazine, which employs me, and from which I am therefore loath to turn down assignments even when they are horrifying, assigned me to get a series of massages and other body treatments here in the coastal town where I live, Wilmington, southeastern N.C., Port City of Progress and Pleasure. There was a semi-legitimate journalistic impulse behind it, but it was also billed as an act of mercy. I'd been traveling and writing a lot for them, spending a lot of time in middle seats on international flights, and my body had reached new levels of vileness. The yellowish gray-green circles under my eyes had a micropebbled texture, and my skin gave off a sebaceousy sheen of coffee-packet coffee. My calves had developed a vague thrombotic throb. It was the kind of premature aging where you think, I'll come back from this but not all the way.

When you feel like that, you don't leap to be naked in rooms with an assortment of strangers while they rub their hands all over your bare flesh — there's probably a fetish group for becoming as physically disgusting as you can and then procuring massages, but that's not my damage. Also, there's something about massage in general that makes me less, not more, relaxed. The boredom of it, the entrapment. Like you, probably, I know a couple of people who go around parties rubbing other people's backs, and I cringe at their approaching hands. One of these shoulder-pirates laughed at me for it once, after I flinched, telling me I needed to "learn to receive love," and I thought, That's probably true, I'd bet I do. Faux-wise passive-aggressive hippie maxims always seem true and wounding in the moment.

Still, everyone, including my mother, who was visiting, said: "Your job! To get paid to get massages!" So I tried to embrace that. It seemed churlish not to. Even my body deserved to be touched, to be kneaded and ministered to. I drove around town checking out different places — only a couple looked sketchy; I think Wilmy has a pretty light scene when it comes to massage of the highway-billboard variety. I made a few appointments and then canceled them. Massage and I were just teasing each other.

Then one morning, inevitably, I woke up with a headache. Not a migraine, but a kind of necky, achy number. I rang up Miller-Motte College, a technical school on Market Street with a locally recognized department in Massage Therapy.

The next morning, a brown-haired young woman who looked to be in her very early 20s — and turned out to be 19 — introduced herself as Victoria and said that she would be my therapist. The room she led me to was spare, with a kind of maroon-gray-olive palette, hotel-conference-room colors. Victoria opened the blinds on the door window — it was one of the things the therapists had to do, so that their teachers could look in.

The erotic element of nonerotic massage is somehow comical. Even to mention it seems louche, but to glide past it is bizarre. My spouse, for instance, would say it's creepy that I noticed it, but if I were blind to it, that would mean I was a sexually dead person, and she wouldn't love me, and would be seen to be keeping me around purely in a "Weekend at Bernie's" kind of way. When you think about it, there's no other situation in life in which a man or woman touches you the way a massage artist touches you except in bed, or on the way there. It doesn't matter if your person is attractive to you or not, and it can be the opposite sex from the one you're attracted to if you're attracted to only one. It's just the simple act of someone rubbing her hands all over you, and not with the precise, deliberate motions of a medical procedure, but with, you hope, a certain tenderness and warmth. Even the traditional phrases — "I'm going to step out; you undress to your comfort level" — imply a problem, that a wrong move could make things uncomfortable. Nothing wrong with all this, of course — it probably adds to the health benefits — I merely mark the static.

I can't say that the first massage penetrated very far. I had thousands of hours of Quasimodo-like keyboard-hunching stored in my torso, so it would have taken a genius to break through in an hour. Thankfully, Wilmington is full of massage places — there's one in every strip mall practically — and I'd soon booked some tables. My take had shifted. The first massage was nice, and now I remembered that I could get unlimited free massages anywhere, which suddenly seemed exciting and like something I'd been cryptically but deeply deserving for a long time. I shaved, I took a shower, I took a couple of walks, I didn't want to be quite as gross for the next one — motivation was creeping in. It's like what they say: If you leave the house, you'll want to go out more.

I got facials, something I never thought I'd do. It was like impersonating someone. For the people doing the facials, it must have been like having a grime-encrusted hillbilly come out of the forest and ask for a Brazilian. I did a couples thing with my wife at Paradise Body Works and Day Spa, where a woman named Rose worked on me. Rosita Messier is her full name. One lotion she put on me had a certain evocative smell I couldn't place ("Pumpkin," Rose said — they'd gotten in new scents for the holidays). Later, at the slightly more upscale Sambuca Modern Apothecary, I got a blissful two-hour biodynamic facial/massage from Tracy Meyer, learning about Dr. Hauschka's skin-care products, said to be pure in ways that others aren't. That procedure left me almost unable to rise from the table. I wanted to lie there like a glowworm in the feeling of cellular wellness. Tracy had good stories about her years traveling the world doing massages on cruise ships and a European ferry. More than a few of the people in the bodywork world, I noticed, had done significant international travel before choosing the profession. Massage can be one of those jobs you fall into when other things don't work out. But that's true for so many of us — we fall into our lines of work like coins dropping into slots, bouncing down off various failures and false-starts. And just as many of the women seemed sincerely passionate about their art. I was moved by them, and by the strip-mall salons and parlors where they do their healing work.

My face looked markedly better when I got home. Blood was getting to more of the cells. I had extrication performed on a few bad pores. I had that gleaming countenance you see on people who've just come back from the spa. This is why they do it, I thought. No wonder there are more and more metrosexual men. Why wouldn't you want to look slightly less ghastly? I bless their rage against the dark, saluting them as they pass by into a future of prolonged sexual plausibility, while I remain hobbled by my father's midcentury notion of manhood, that any male who spent more than five seconds considering his physical appearance might as well be living in Liberace's guesthouse.

That night, I went with my mother to the Asian Relaxation Center, better known among locals as the Asian Foot Soak Sanctuary, in the same strip mall as Fuzzy Peach fro-yo shop. You walk through a vestibule into a dark room, with black leather chairs, like beauty-shop chairs but as comfortable as those coin-massagers in airports. My petite mother sat in the chair next to mine. We got our feet soaked and I hope desanitized in tubs of fragrant red fluid, she by a powerfully built man in his 40s, and I by a woman, equally strong-looking. They started on our heads, which I loved, but which my mother could have left off the ticket, because it messed up her hair. But when they moved to our feet . . . there's something about the feet and the ears, I noticed across the various sessions. This woman was practicing Chinese reflexology on me. She got her fingers up into the bones of my feet and started playing Rubik's Cube. I yelped when she popped my toes. It's easy to hurt the feet — which seems strange, when you consider all the abuse and weight-bearing they're heir to. I've read a theory that possibly they evolved so many nerves because they're prone to infection as well, and the more you can feel them, the less liable you are to slash them open and die of some disease. My mother at one point announced into the silence, "This foot massage is incredible!" It was. But the remarkable thing happened later that night, in the shower, when I bent down to wash my feet and found that I could feel them in a way I hadn't done in 10 years. They felt almost strange, as if they belonged to another body, the way a limb feels when it has fallen asleep, only not numb in this case but newly sensitive, and softer. The woman was a magician. But quiet. I hadn't even been able to extract her name. She'd been in the country only three months. She spoke very little English and mainly just smiled and nodded to questions, so I gave it up as awkward.

One woman I visited was unlike the others, a multimodality healer from New Mexico named Susan Chavez. She had silver bangs and was seemingly in her early 50s, though she professed to be many billions of years old. When she answered the phone the first time, she told me that she was outside gathering kale, and I pictured her in a field or forest, but as it turned out, when I showed up to her charmingly cluttered one-story house in a tucked-away neighborhood, she was growing kale in pots out front. She put me on a table in her side treatment room and used different psychometric devices on me, tuning forks and Tibetan singing bowls, also a vibrating eye mask. She told me I had a giant glass ball around my head, which needed cracking, and after she cracked it, she performed a Lakota Sioux raindrop treatment on my back.

Susan's was the most complex of the treatments I received. She was full-on spiritual, whereas I, like Esqueleto in "Nacho Libre," believe in science. So I was torn between my uncontrollable skepticism toward her techniques and the fact that some of them seemed to work — the singing bowls really did seem to be vibrating certain zones of my body in an obscurely powerful way. I don't know. I'm still working through stuff I got into with Susan. I felt newly open to massage after meeting with her, but also vulnerable to it. After all, even if there's something inherently funny about massage, down to the very word, massage, there's also something unavoidably intense about paying that much attention to your body, not as an abstract concept but as the physical dying fact of it, lying in all its animality like a study by Lucian Freud. At certain moments I missed my old mode, which was to proceed as if I had no body at all.

But the treatment that left the deepest impression on me was one that in the moment left almost no impression at all, the craniosacral with Mindy Totten, at the Oasis Center. You may know what craniosacral is already — I'd never heard of it. In fact I thought that "sacral" referred to sacred, and that it was more mystical than it is, but really it refers to sacrum, the triangular bone at the bottom of the spine. That said, it's still somewhat mystical. There's little hard science yet to show that people who practice this treatment are actually helping to regulate and balance the flow of craniosacral fluid through your body, or to indicate what such a balancing would achieve. But people subscribe to the method like you wouldn't believe.

Mindy said, "We generally work in silence." For an hour I lay in a room while she barely touched me. At times I actually didn't know if she was touching me. Her hand would hover above my leg, or lie under it, in perfect stillness.

Some profoundly emotional memories rose to the surface, the kind that can follow a troubling dream. I was thinking of people who died with whom I was not sure I had perfect transparency while they lived. It felt at the time as if the natural magnetism of Mindy's palms was conjuring these thoughts. Whether something was being effected through the laying on of hands, perhaps through some unknown mechanism of the physical world, I can't say. It seemed to matter less and less. Maybe that's what massage is to a lot of people, those who don't have chronic pain or migraines — it's enforced meditation for those of us too distracted to meditate. You're paying someone to meditate you. It's not anything they're doing, necessarily. It's that they open a little window. They give you an excuse to lie there in silence and pay a deeper attention to the fact that you exist. The true value of shamanism may be a concealed one, that it holds us in place and says this.

Also, in the end I did look better. My mother before she left to go home commented on my skin, which had gone from looking like two cigarette holes in a white blanket to something more alive-seeming. I can't say my immersion in the world of massage gave me calm — my anxiety proved impenetrable to all modalities, none of them touched the core, none of them breached the sarcophagus. But I am alive, and ready for fresh insults. I can feel my feet, albeit less and less each day.

Thursday, October 25, 2012

Study: We overestimate how much medicine can do - Washington Post

Between 2003 and 2005, a team of researchers at Harvard asked over 1,000 cancer patients about their expectations for chemotherapy.
All patients surveyed had received a diagnosis of metastatic lung cancer or colorectal cancer four months earlier. These are some of the most difficult-to-treat conditions. Medical research says that, in these extremely challenging cases, chemotherapy can extend life by weeks or months but it is very unlikely to provide a cure.
That's what the science tells us — but that's not what most late-stage cancer patients believed. The majority who elected to have chemotherapy believed there was a chance it would do something it wouldn't: Namely, provide a cure.
Sixty-nine percent of lung cancer patients and 81 percent of colorectal cancer patients gave responses "that were not consistent with understanding that chemotherapy was very unlikely to cure their cancer," the researchers report in this week's New England Journal of Medicine.
"I was really surprised," says lead study author Jane Weeks, a professor at Harvard Medical School. "Prior studies have suggested maybe a third of patients don't understand. Those studies are done in the optimal setting though, and this was the first to look at a big population. I thought the numbers were disturbingly high." 
The most surprising finding in this study, though, might come from when the researchers looked at what the patients' thought of their doctors. The survey asked about how good their oncologists were at communicating about treatment.
Patients who rated their doctors as the very best communicators, the most open and honest, were the most likely to have the unrealistic, inaccurate expectations.
"This suggests that patients perceive physicians as better communicators when they convey a more optimistic view of chemotherapy," the authors conclude. "Similarly, the finding that patients, especially those with colorectal cancer, who were treated in integrated networks were somewhat more likely to understand that chemotherapy is not curative suggests that providers may be able to improve patients' understanding if they feel it is part of their professional role."
In a weird way, the health-care law may encourage doctors to make a rosier prognosis than the medical evidence warrants. Beginning this month, the health-care law tethers some hospital payments to patients' rankings of their hospital experience. The whole idea is to improve the patient's hospital stay. If patients are happier, the thinking goes, they're probably getting higher quality care. 
"This is a cautionary tale," Weeks says. "I think everybody agrees that satisfaction alone is an incomplete measure of quality. It doesn't give you the whole story. I think this is an example of that."

The Nurse as Family Doctor -

The Family Health Clinic of Carroll County, in Delphi, Ind., and its smaller sibling about 40 minutes away in Monon provide full-service health care for about 10,000 people a year, most of them farmers or employees of the local pork production plant. About half the patients are Hispanic but there are also many German Baptist Brethren. Most of the patients are uninsured, and pay according to their income — the vast majority paying the $20 minimum charge for an appointment. About 30 percent are on Medicaid. The clinics, which are part of Purdue University's School of Nursing, offer family care, pediatrics, mental health and pregnancy care. Many patients come in for chronic problems: obesity, diabetes, hypertension, depression, alcoholism.

What these clinics don't offer are doctors. They are two of around 250 health clinics across America run completely by nurse practitioners: nurses with a master's degree that includes two or three years of advanced training in diagnosing and treating disease. By 2015, nurse practitioners will be required to have a doctorate of nursing practice, which means two or three more years of study. Nurse practitioners do everything primary care doctors do, including prescribing, although some states require that a physician provide review. Like doctors, of course, nurse practitioners refer patients to specialists or a hospital when needed.

America has a serious shortage of primary care physicians, and the deficit is growing. The population is aging — and getting sicker, with chronic disease ever more prevalent. Obamacare will bring 32 million uninsured people into the health system — and these newbies will need a lot of medical care. According to the American Association of Medical Colleges, the United States will be short some 45,000 primary care physicians by 2020.

The primary care physicians who do exist are badly distributed — 90 percent of internal medicine physicians, for example, work in urban areas. Some doctors go to work in rural areas or the poor parts of major cities, treating people who have Medicaid or no insurance. But they are few.

In part it's the money. Primary care doctors make less than specialists anywhere, but they take an even larger financial hit to treat the poor. Particularly in the countryside — even with programs that offer partial loan forgiveness, it's very hard to pay off medical school debt treating Medicaid patients, much less those with no insurance at all.

And the job of a primary care doctor today is largely managing chronic disease — coordinating the patient's care with specialists, convincing him to exercise or eat better. Poor patients can be a frustrating struggle. Compared with wealthier patients, they tend to have more serious diseases and fewer resources for getting better. They are less educated, take worse care of themselves and have lower levels of compliance with doctors' orders. Very few people start medical school hoping to do this kind of work. Those who do it may burn out quickly.

It might seem that offering the rural poor a clinic staffed only by nurses is to give them second-class primary care. It is not. The alternative for residents of Carroll County was not first-class primary care, but none. Before the clinic opened in 1996, the area had some family physicians, but very few accepted Medicaid or uninsured patients. When people got sick, they went to the emergency room. Or they waited it out — and then often landed in the emergency room anyway, now much sicker.

Just as important, while nurses take a different approach to patient care than doctors, it has proven just as effective. It might be particularly useful for treating chronic diseases, where so much depends on the patients' behavioral choices.

Doctors are trained to focus on a disease — what is it? How do we make it go away?

Nurses are trained to think more holistically. The medical profession is trying to get doctors to ask about their patients' lives, listen more, coach more and lecture less — being "patient-centered" is the term — in order to better understand what ails them.

"I've been out of nursing school since 1972 and I still remember that when faculty members finished talking about the scientific parts of the disease they would talk about the psycho-social part," said Donna Torrisi, the executive director of the Family Practice and Counseling Network, which has three clinics in Philadelphia. "It's not about the disease, it's about the person who has the disease. While in the hospital you'll often hear doctors refer to a patient as 'the cardiac down the hall.'"

Younger doctors are no doubt better at this than their older peers. But the system conspires against them. The 15-minute appointment standard in fee-for-service medicine — which pays doctors according to how many patients they see and treatments they provide — makes it unlikely that doctors will spend time discussing a patient's life in any detail. Physician reimbursement places a zero value on talking to the patient. But nurse practitioners are salaried, giving them the luxury of time. At the Family Health clinics, appointments last half an hour — an hour for a new diabetic or pregnant patient.

Jennifer Coddington, a pediatric nurse practitioner who is a co-clinical director of Family Health Clinics, said that she spends a lot of time teaching patients and their families about their diseases and how to manage it. "We want to know socially and economically what's going on in their life — their educational level, how are they making it financially," she said. "You can't teach patients if you're not at their educational level. And if a patient can't afford something, what's the point of trying to prescribe it? He's going to be non-compliant."

A physician might suggest that a patient lose weight and hand him a diet plan — or refer him to a nutritionist. At the Family Health clinics, nutrition counselors — graduate students at Purdue — will sit down with patients to talk about the specific consequence of their diet, and suggest good foods and how to cook them, Coddington said. "When you don't have enough money to buy fruits and vegetables, so you go to the dollar menu at McDonald's — we help those people put planners together for the week."

Data has shown that nurse practitioners provide good health care. A reviewof 118 published studies over 18 years comparing health outcomes and patient satisfaction at doctor-led and nurse practioner-led clinics found the two groups to be equivalent on most outcomes. The nurses did better at controlling blood glucose and lipid levels, and on many aspects of birthing. There were no measures on which the nurses did worse.

Nurse-led clinics can save money — but not always in the obvious way. Many are cheaper than comparable physician-led clinics. Suzan Overholser, the business manager of the Family Health clinics, said that their cost per patient was $453 per year — lower than the Indiana average for similarly federally qualified clinics (all the others physician-led) of $549. But nurse-led clinics aren't always cheaper. Coddington examinedpublished studies of clinic costs and found that in some cases, nurse-managed clinics had slightly higher per-patient costs than traditional clinics.

Although nurses are paid less than doctors (Medicare reimburses them at 85 percent of what it pays doctors,) nurse-led clinics are often very small, and so don't have the variety of practitioners necessary to keep a clinic running at full capacity. They also serve the most difficult and expensive patients.

The biggest financial benefit, however, likely comes from offering patients an alternative to the emergency room. Coddington's review cites studies showing large savings in paramedic, police, emergency room and hospital use. A traditional clinic in an underserved area would do that, too, of course — it's just that nurses tend to go where doctors won't.

There are about 150,000 nurse practitioners in America today. The vast majority practice in traditional settings — only about a thousand are in nurse-managed clinics. One reason these clinics are rare is that they may equal traditional clinics in health care, but not in business success.

Nurse-managed clinics have to overcome regulatory and financial obstacles that traditional clinics don't face. Powerful physicians' groups such as the American Academy of Family Physicians opposeallowing nurses to practice independently. "Granting independent practice to nurse practitioners would be creating two classes of care: one run by a physician-led team and one run by less-qualified health professionals,"says a paper from the A.A.F.P., citing the fact that doctors get more years of education and training. "Americans should not be forced into this two-tier scenario. Everyone deserves to be under the care of a doctor."

Only 16 states and Washington, D.C., allow nurses complete independence. In other states, some of the restrictions are bizarre — in Indiana, for example, nurse practitioners may do everything doctors do, with two exceptions: they can't prescribe physical therapy or do physicals for high school sports.

Jim Layman, the executive director of the Family Health clinics, said he thought that nurse practitioners cared for the majority of Medicaid patients in Indiana. But if you look through Medicaid records, you'll find only doctors — nurses are not allowed to be the primary caregiver of record. So the Family Health clinics, like others, employ a physician off-site from 4 to 6 hours a week who uses electronic health records to examine a sample of cases and consult when necessary. Medicaid is billed in his name.

It is not easy for nurse-run clinics to win status as a Federally Qualified Community Health clinic, which would allow them to get federal grants. This is largely because most come out of universities, and most universities don't want to cede control to the community — a requirement for this status. Purdue decided it would, and the Family Health clinics qualified in 2009. Before that, they received some money from the state, and raised the rest from local March of Dimes, United Way and Chamber of Commerce donations, plus fund-raising dinners and auctions. This was enough to support just one full-time provider at each clinic. Getting F.Q.C.H. status allowed them to hire more staff and move the Carroll County clinic into a modern new building — and probably saved them from collapse. "It would have been very difficult for us had we not gotten F.Q.C.H. status," said Coddington. The Affordable Care Act — Obamacare — did authorize $50 million for five years for nurse-managed clinics. So far 10 clinics have gotten a total of $15 million.

In some ways, the nurse practitioner-managed clinic is a throwback to the small-town family practice, when your doctor asked about the schoolyard bully and your dad's unemployment. Among the many changes needed in how America values and reimburses health care, it's important to encourage and support these clinics. They may be old-fashioned, but that doesn't mean they should be financed with bake sales.

Wednesday, October 24, 2012

A Town’s Passion, a Retired Doctor’s Concern -

DOVER, N.H. — The agenda for the Oct. 1 school board meeting did not call for anything particularly exciting. But during a segment called "Matters of Interest," Paul Butler, a retired doctor and relative newcomer to the board, floated an idea: end the football program at Dover High School.

Speaking in his soothing, deliberative tone, Butler said, "I'm beginning to believe, from what I've read of the literature, that as governors of the school district, we have a moral imperative to at least begin the process of ending this game in Dover."

Butler is a retired surgeon, with no specialty in neurology. But he had followed the growing evidence of the peril football poses to the brains of the people who play it. Butler had no beef with football, for he had played it in high school and in college.

He was, he said, just trying to frame the question of the future of football in the most practical of terms, drawing upon the implications of the class-action lawsuit filed in June against the N.F.L. on behalf of more than 2,000 former players alleging that the league did not adequately warn them of the evidence about the dangers of repeated head trauma and concussions.

Butler warned his fellow board members that if city officials did not end football at Dover High, "the lawyers will do it for us" someday.

The next morning, Butler said, he attended a weekly 7:30 a.m. medical conference at Wentworth-Douglas Hospital, where he was a general surgeon until retiring in June 2011. By the time he and his wife had made the drive down to Arlington, Mass., to baby-sit grandchildren, he was being sought for television interviews. His comments to the board, it turned out, had been reported in the local newspaper, Foster's Daily Democrat.

By day's end, Dover's school board chairman was forced to issue a statement denying the city had any plans to end football at Dover High. Even so, Peter Wotton, the school's athletic director, had a news truck parked outside his house.

"Our brain is really who we are," Butler said in an interview last week. "In this society, in this time, if your brain has been altered, you have been fundamentally altered."

Small Town, Big Interest

Without exactly meaning to, Butler had inserted Dover — about 70 miles north of Boston, a community of roughly 30,000, and a place with a history dating practically to the Mayflower —into the middle of a 21st century culture war.

Foster's Daily Democrat came out firmly opposed to the notion of ending football. "Here in New Hampshire — as in 38 other states — a law has been passed to mandate precautions be taken any time there is an indication of a head injury in any sport," an editorial in the newspaper read.

The football program at Dover — the team is known as the Green Wave — is big in the community. But so too are soccer, lacrosse and ice hockey — all sports in which players are vulnerable to concussions and other head injuries. Wotton said that 8 of the 68 students who played varsity, junior varsity or freshman football last season sustained concussions. But there were also five concussions in girls' basketball, nine in boys' lacrosse and four in cheerleading, he said.

"I appreciate his concern," Wotton, sitting in his office last week, said of Butler. "This might end up being a good thing in the end. It's just a semipainful way to get there."

Butler is not the first school board member in the country to risk proposing what for many seems heretical. Last June, a member of the Council Rock School Board near Philadelphia said that it was "no longer appropriate for public institutions to fund gladiators." Rush Limbaugh used the comments as further proof that, as he had said on an earlier broadcast, football's future was under attack from liberal "pantywaists who want to try to take the risk out of everything in life."

Butler's celebrity, if a bit baffling to him, has not seemed to wound him. He has heard from a producer at HBO's "Real Sports" and a woman who identified herself as part of the N.F.L.'s Health and Safety Improvement program. A caller from Brian Williams's office at NBC seemed mostly to want to know if Butler had grandchildren. And a company sent him a product called the Guardian Cap, a piece of padding fastened by Velcro over a helmet to mitigate the force of head-on collisions.

More locally, any heat Butler has taken seems to stem more than anything from the notion that he had somehow spoken out of turn about a cherished culture in a tight-knit town. Local officials praise his standing in the community while making it clear they stop far short of siding with him about the need to end football.

Familiarity With Football

Butler does not fit a stereotype. At his home on the Piscataway River last week, he was wearing a pair of Crocs with the logo of the New England Patriots. He is 6 feet tall, reed thin and broad-shouldered. When he spreads his long fingers, one can see why he was an effective tight end. He gave up rowing the Piscataway, but at 68 is the oldest guy on the ice in a weekly 6 a.m. hockey game.

He is at once not of the youth football world in Dover but knowledgeable about the sport, having played it at his high school in Wakefield, Mass., and at Amherst College, where he also played hockey. He speaks wistfully of the character-shaping experience and recalls begging his father to let him play. He thinks football probably gave him a leg up when he applied to Amherst.

"The thought of hurting my brain did not occur to me at all," he said.

Now he figures he sustained numerous subclinical concussions.

"I don't remember ever getting knocked out," he said, "but I do remember getting up slowly because I was dizzy or couldn't quite see correctly."

Over several long chats, Butler emerged as a thoughtful man with an idiosyncratic streak who, restless in retirement, volunteered for a two-year term on the school board as a gesture aimed at giving back.

"I'd just retired and I was trying to get my bearings," he said. Now he jokes that no one will be sorry to see his two-year term end.

"She can see I'm one of these old Yankee cheap guys," Butler said of the schools superintendent, Jean Briggs Badger.

As much as he sees ending prep football as a moral issue, Butler was also chagrined, he said, that money was spent on reconditioning Dover High's football helmets when the district was haggling over the current budget, in which 10 teaching positions were eliminated. (Briggs Badger said any money spent on helmets could not have carried over into the current fiscal budget, anyway).

New Hampshire has no sales or income tax, and Dover has a tax cap that puts a ceiling on how much property tax revenue the city can raise. Butler supported ending school bus service to cut expenses.

"Walk, ride a bicycle, run, jog," he said when asked how children would get to school. "I stood up in front of a crowd of very angry parents and said, 'I think kids should walk to school.' "

Sensitivity to Lawsuits

It was around that time that Butler first quietly broached the subject of abandoning football. He e-mailed Wotton and Briggs Badger. More recently, he wrote to the city attorney to ask about the school district's vulnerability to future lawsuits related to brain injuries on the football field. By then, he had been reading up on the science of brain trauma, and the brain-cell-killing protein called tau found in the autopsied brains of retired players in which chronic traumatic encephalopathy, or C.T.E., was diagnosed.

Butler is perhaps more sensitive than most to a nightmarish hypothetical of a day when a former high school player or his parent sues the district. One of the reasons Butler said he moved his family to Dover in 1977 was because, as a young surgeon opening his first private practice, he could afford the medical malpractice insurance premiums, which in New Hampshire, he said, were considerably lower than in Vermont, where he had done his medical residency.

In Butler's book group, they're reading Kafka's "The Trial." In a different sort of book group, Butler would have every school official read "Play Hard, Die Young: Football Dementia, Depression and Death," by Dr. Bennet Omalu, a neuropathologist known for diagnosing C.T.E. after studying the brains of Mike Webster, the Hall of Fame center of the 1970s who died of a heart attack at 50, and Andre Waters, a star defensive back who suffered from depression and committed suicide.

Having brought the issue into the spotlight, Butler now concedes he does not have the votes on the school board to win a recommendation to end football at Dover High. But he said he might put the matter to a vote in December anyway.

Told that Wotton, the athletic director, said that contact in practice was limited to 10 to 15 minutes twice a week, Butler said, "To me, limiting contact in practice is equivalent to what the cigarette industry did when they said, 'Well, we put filters on our cigarettes, and so they're safe.' I think it's an improvement, but I don't see how you can take away the danger that I'm concerned about without radically altering the game."

A Mother's Perspective

Christine O'Hara's son Eric, a junior at Dover High, is listed at 5-9 and 220 pounds. He plays middle linebacker and running back.

"I think that his concern is very valid," O'Hara, a nurse for Liberty Mutual Insurance, said of Butler. And yet she says she would not want to see football taken away from her son. Eric, she noted, was taught proper tackling technique by his father at an early age and besides, there are far worse things a teenager can get himself into.

O'Hara said Eric had had two concussions playing high school football. After the first one, she noticed that he was behaving differently on the sideline, but not in a way that would have been obvious to someone who was not his mother. "He always paces," she said, but this time, she noticed that Eric kept putting on and taking off his helmet. That was enough for her to tell the coach to pull him from the game.

"In reality, most of the symptom-watching comes from the parent," she said.

Butler's children attended prep schools in the area, and he has never attended a Dover High football game. At the same time, it is not difficult to find people in the stands who are related or have gone to him for a cancer operation, appendectomy or hernia operation.

On a windblown Friday night in October, when the temperature dipped into the 30s and there was a run on hot chocolate at the concession stands, the 1-5 Green Wave took on 5-1 Bedford, a bigger, deeper team.

The game was close throughout. Sandy Patria sat bundled against the cold. She was at the game to support her grandson, who performs in the marching band. Butler did her mastectomy operation 20 years ago, she said. As she spoke about him, her eyes watered, although the cold weather might have contributed.

"He's just trying to make it safer," she said of Dover football.

Then she let out a groan. Tailback Kyle Seawards had just caught a pass and turned upfield, his shoulders and helmet lowered as a defender from Bedford came in to hit him. It was the sort of battering-ram hit Butler talks about, but it was also just a football play. On the sideline, Dover's trainer gave Seawards what looked like a Breathalyzer test. He did not return to the game. At halftime, children from youth league teams were introduced, each running the length of the field as their name was announced.

Several days later, Wotton, citing nationally established privacy rules that prevent him from speaking publicly about player injuries, would not comment on whether Seawards had a concussion. But Royce Stegman, whose son Derek is the Green Wave's starting quarterback, figured Seawards would be held out of the next game.

Stegman is a burly man of 48. In Stegman's days of high school ball, the game was "three and a half yards and a cloud of dust." Nowadays, Derek accesses game film on his iPhone using an app called Hudl, studying strategies and formations. Dover runs a spread offense, with more receivers involved, and the game is faster. Rather than go with the Riddell helmet issued by the team, Stegman paid $400 to get Derek the Xenith, whose Web site boasts of its "adaptive air-cell shock absorbers." O'Hara, too, has bought helmets for her son Eric.

The focus of some recent research has been on the question of whether children, teenagers or younger, are more vulnerable to injury because their brains are not fully developed.

"Big heads on little necks," Butler called it.

Researchers now use helmets equipped with sensors to measure the force of the trauma absorbed by the brain on otherwise ordinary plays. A study by the Pediatric Brain Trauma Lab at Massachusetts General Hospital, published in the October issue of the Journal of Neurosurgery, found that 486,000 combined head impacts had been recorded over a five-year period among players from the football teams at Brown, Dartmouth and Virginia Tech, as well as two men's and two women's hockey teams.

A Focus on Awareness

Dover is one of six high schools in the area that take their cue on sports-related concussions from the Seacoast Center for Athletes in Somersworth, led by Dr. Fred Brennan, the team doctor at the University of New Hampshire and a sports medicine specialist. Brennan's focus is awareness and making sure athletes have cleared various ascending levels of physical activity before being allowed to rejoin a team.

"We stay on the tip of the spear of what's happening in concussions," he said. He was sitting in the athletic trainer's office at Oyster River High in neighboring Durham, where he had addressed a teachers staff meeting. When Brennan asked the teachers how many had a student who had sustained a concussion, most hands went up. Brennan stressed the need for concussed student athletes to receive "cognitive rest," including a reduction in homework until they no longer had symptoms.

Oyster River does not have football; its enrollment will not support it. At Dover High, they have been playing football for more than 100 years. Now realignment is coming; the Green Wave next season are moving into a division with Philips Exeter Academy, one of the local football powerhouses.

Before the game against Bedford, Wotton, checking his BlackBerry for the score of his daughter's volleyball game, ticked off all the other reasons the Green Wave were 1-5. Some youngsters had taken part-time jobs; others did not want to give up several weeks in August to practice. The team's prospective 6-foot-6 starting quarterback transferred to Hampton Prep to play basketball.

Wotton still looks like the tree of a defenseman he was on the U.N.H. hockey team. During home games he stands under the scoreboard behind his team's end zone.

"I think the thing that bothers me is, we didn't talk," he said, referring to what he regarded as Butler's ad hoc attack on his football program.

Late in the game, with the score tied, the Green Wave drove down the field, only to fumble on a play in which it was unclear if the ball had crossed the goal line before Bedford's defense recovered it in the end zone. The referees ruled in favor of the visitors, and Bedford then marched down the field for the winning touchdown.

The losing had continued at Dover — at least for the moment. But football looked safe from extinction — at least for the moment.