PE R S PE C T IV E
Waxman recently noted. Menthol winding, and uncertain. Oppo-
remained legal, pending review
by the newly created TPSAC.
In referring the issue to the
FDA, Congress set the stage for a
decade of litigation. In 2011, the
TPSAC determined that evidence
suggested that “removal of men-
thol from the marketplace would
benefit public health in the Unit-
ed States” but made no recom-
mendations about banning prod-
ucts.5 Tobacco companies quickly
challenged the committee’s legiti-
macy, charging that some of its
members harbored conflicts of
interest. In 2014, a U.S. District
Court agreed, but in 2016, a fed-
eral appeals court overturned this
ruling. For the next 2 years, how-
ever, the FDA was reluctant to act
on menthol.
Now, nearing the 10th anni-
versary of the 2009 legislation,
Gottlieb seems poised to act,
though the agency has yet to take
the next crucial step by propos-
ing the new rule. To date, no
hearings on banning combustible
menthol tobacco products have
been scheduled. The industry has
responded to the proposal with a
familiar tactic: claiming that sci-
ence does not support such a ban
and threatening litigation.
If the past is prologue, any
path to removing menthol ciga-
rettes from shelves will be long,
When Sparks Fly
When Sparks Fly — Or How Birding Beat My Burnout
Joshua Schor, M.D.​​
A  little more than a year ago, I
took up birding as a hobby.
As a child and into my 20s, I
built model airplanes, shot rifles
(don’t ask), and chased the planets.
Since that time, I have not had a
bona fide hobby. I have read about
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The New England Journal of Medicine
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Copyright © 2019 Massachusetts Medical Society. All rights reserved.
FDA’s Proposed Ban on Menthol Cigarettes
and e-cigarettes, will also hinge
nents worry that a ban would
create a black market for men-
thol cigarettes and profound dif-
ficulties in enforcement; propo-
nents insist that the science and
the law are on their side and that
the public health benefits are
overwhelming. Bans or restric-
tions have been instituted in
Canada and in several U.S. cities,
including Somerville, Massachu-
setts, and San Francisco. New
York’s City Council recently be-
gan hearings on a ban. With bil-
lions of dollars at stake, it may
take years of litigation for Gott-
lieb’s promise of better health to
be realized.
The questions surrounding
menthol are intertwined with
the agency’s decisions regarding
e-cigarettes. Although the indus-
try argues that there’s no scien-
tific evidence that menthol is haz-
ardous or addictive, the health
effects of menthol smoking are
worrisome; similar concerns sur-
round e-cigarettes. As the case is
made against menthols, the scien-
tific issues will be extensively de-
bated: the likelihood of increased
addiction, the question of added
difficulty in quitting smoking,
and the health consequences of
deep inhalation. But the regula-
tory debates and legal challenges
to come, regarding both menthol
the tragic disappearance of hob-
bies from young people’s lives,
though given that I’m approach-
ing 60, my adoption of a new hob-
by won’t really move the needle
for the young. Nevertheless, I
thought maybe it would preserve
on the history of marketing —
how companies have used these
products to encourage blacks,
women, and young people to take
up a behavior with serious pub-
lic health consequences.
Disclosure forms provided by the author
are available at NEJM.org.
From the Woodrow Wilson School of Public
and International Affairs, Princeton Univer-
sity, Princeton, NJ.
This article was published on February 20,
2019, at NEJM.org.
1. Gottlieb S. Statement from FDA Com-
missioner Scott Gottlieb, M.D., on proposed
new steps to protect youth by preventing ac-
cess to flavored tobacco products and ban-
ning menthol in cigarettes. Silver Spring,
MD:​Food and Drug Administration, Novem-
ber 15, 2018 (https://www​.fda​.gov/​NewsEvents/​
Newsroom/​PressAnnouncements/​UCM625884​
.htm).
2. Family Smoking Prevention and Tobacco
Control Act, Pub. L. No. 111-31, 123 Stat.
1804(e)(1) (111th Cong.) (https://www​.govinfo​
.gov/​content/​pkg/​PLAW​-­111publ31/​html/​PLAW​
-­111publ31​.htm).
3. Brown & Williamson Tobacco Corpora-
tion. Stipulation as to the Facts and Agreement
to Cease and Desist, file no. 1-14737. 1942
May 22. Brown & Williamson Records;​
Minnesota Documents (https://www​.industry
documentslibrary​.ucsf​.edu/​t obacco/​docs/​
mrdc0136).
4. Quinn M. Don’t aim that pack at us. Time.
January 29, 1990 (http://content​.time​.com/​
time/​magazine/​article/​0,9171,969261,00​.html).
5. Food and Drug Administration. Prelimi-
nary scientific evaluation of the possible
public health effects of menthol versus
nonmenthol cigarettes (https://www​.fda​.gov/​
downloads/​ucm361598​.pdf).
DOI: 10.1056/NEJMp1900204
Copyright © 2019 Massachusetts Medical Society.
FDA’s Proposed Ban on Menthol Cigarettes
my cognition and stave off other
erosions by a few more years.
What I’ve discovered is that a tiny
part of me that long reveled in
making a “great diagnosis” was
burning out, and birding has
helped me have some fun again.
997
PERS PE C T IV E
American Oystercatcher.
Many birders can recall a par-
ticularly beautiful “spark bird”
that materialized out of the sky
and inspired them to take up the
binoculars. My spark bird ap-
peared across a shimmering blue
bay one fine Sunday morning last
July. I was biking in Sandy Hook,
New Jersey, eager to get in my
requisite miles, when I passed a
turn-off that I’d passed many
times before. I noticed a wood
platform projecting into Sperma-
ceti Cove near parking lot E. An
older man with a spotting scope
was gazing out toward a sandbar.
He offered me a peek, following
Rule 4a of the American Birding
Society Code of Ethics: “Freely
share your knowledge and expe-
rience. . . . Be especially helpful
to beginning birders.” If you’ve
never seen an American oyster-
catcher (Haematopus palliates), I can
tell you that its graceful red beak
and fiery orange-yellow eyes throw
its black and brown feathers into
eye-catching relief (see photo). In
the 1800s, the species had been
hunted to near-extinction for its
plumage and for sport, but now
there are nearly 50,000 along the
U.S. Eastern Seaboard alone.
Intriguingly, I’ve found that
998
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Copyright © 2019 Massachusetts Medical Society. All rights reserved.
identifying a rare bird presents
challenges not unlike those of
deriving a diagnosis from a puz-
zling set of medical findings.
Birds have “field marks” such as
wing bars, eye rings, and plum-
age changes, as well as distinct
habitats such as the salt marshes
favored by oystercatchers or the
tip-tops of trees chosen by glitter-
ing American goldfinches. These
features, along with behaviors
such as pumping their tail up and
down (palm warblers and phoebes)
or dashing off a tree limb to
snag a tasty fly (great crested
flycatchers and eastern wood-
pewees), are akin to signs and
symptoms such as pallor, dyspnea,
rusty sputum, and fatigue. Throw
in the countless songs of the
songbirds — the rales and mur-
murs of the avian world — and
you have yourself a set of clues
worthy of a tricky CPC case.
The birder, author, and artist
David Sibley has said that the
trick to identifying a baffling bird
is not finding the traits it has in
common with another similar
bird, but discerning with a sensi-
tive eye and ear the differences
between them. The least sand-
piper and the semipalmated sand-
n engl j med 380;11 nejm.org March 14, 2019
The New England Journal of Medicine
When Sparks Fly
piper are almost identical “peeps,”
but for the slightly richer, choco-
latey brown back on the former
and the darker legs on the latter.
Similarly, distinguishing two close-
ly related vasculitides, such as
Behçet’s and Buerger’s diseases,
depends on the caliber of the
blood vessel that’s inflamed. Mak-
ing such fine distinctions is what
birders and diagnosticians have in
common. More telling may be the
ways in which the two diverge.
In 1984, during a neurosurgi-
cal rotation in my fourth year of
medical school, a few classmates
and I met a young woman with a
headache who had the subtlest in-
dications of frontal release. That
she ended up in this particular
clinic meant that someone had
suspected a neurologic condition,
but the attending physician had
us speak with and examine her
before committing to a diagnosis;
we settled on a frontal lobe tumor.
When the CT scan confirmed
that there was a meningioma in
the anterior of her brain, my fel-
low students and I had to stifle
our reflexive grins. Though we
genuinely felt compassion for the
woman (who did well after resec-
tion of the tumor), the awkward-
ness of that moment helped crys-
tallize for me that what may have
been a great day for me in terms
of my budding ability was possi-
bly the worst day for the patient.
With all our years of training
to “get it right,” is it a failing to
celebrate making a correct rare
diagnosis? Imagine the oncologist
Keith Ramos, U.S. Fish and Wildlife Service.
for the first time piecing the clues
together to diagnose a newly re-
ported rare cancer. Does the phy-
sician’s repeated repression of so
many feel-good moments contrib-
ute in even a tiny way to burnout
in medicine? Has it resulted in too
much gallows humor, too many
dehumanizing moments of “us
 PE R S PE C T IV E When Sparks Fly

versus them”? The real challenge,
of course, is to align your won-
der as a medical scientist with
your compassion as a fellow hu-
man and so ally with your pa-
tient in fighting the disease. Per-
haps birding has enabled me to
enjoy the diagnostic thrills of
medicine that I once so appreci-
ated but that I often quashed in
an effort to be “professional” and
compassionate.
A colleague tells me that to
diagnose occult depression, he
sometimes asks a patient “When
was the last time you had fun?”
Ask yourself the same about your
medical life. We know that ours
is a solemn occupation, and we
have committed under oath to be
serious and sober practitioners.
But there is a zero-sum feature to
the way I sometimes seem to prac-
tice medicine, as if my pleasure
in my craft subtracts from the
emotions of the patient in front
of me. I’m now good at hiding
that pleasure, but too much con-
cealment can hurt. Osler called
pneumonia the “captain of the
men of death,” and as someone
who cares for the frail elderly, I
know exactly what he meant —
but would I dare toss off such a
characterization to a patient or
her family?
So maybe birding has saved me
from zero-sum and landed me in
win–win. When I nail a tricky
identification by distinguishing
between the common tern and
the Forster’s tern using only my
eyes and ears, I feel the joy of a
differential diagnosis well played.
I immerse myself in the majestic
migrations of fall and spring, the
trace of a bird on the wing bring-
ing the loveliness of a common
yellowthroat and its soft song. As
the new joy of diagnosing bird
species suffuses my life, perhaps
my binoculars substitute for the
microscopes whose H&E-stained
images and Gram stains I once
gazed at with awe. Birding even
includes in its code of ethics a
directive to be kind to the nov-
ice, much like medical training’s
well-intentioned “see one, do one,
teach one.”
I have prided myself on avoid-
ing frank, diagnosable burnout,
but maybe there was a subclini-
cal form that needed treatment.
Others with more talent can stave
off burnout with sculpting or
music or marathoning. Though I
strive to be a sober and sensitive
physician, some days I miss the
joy of making a tough diagnosis
and singing it from the treetops.
Birding helps me beat the burnout.
Disclosure forms provided by the author
are available at NEJM.org.
From Daughters of Israel, West Orange, NJ,
and OptumHealth, Eden Prairie, MN.
DOI: 10.1056/NEJMp1812109
Copyright © 2019 Massachusetts Medical Society.
When Sparks Fly

Interactive Perspective: Major Events in

the Life Course of New Drugs, 2000–2016
An interactive
This interactive graphic allows viewers to explore data — gathered by Reed F.
perspective is Beall, Thomas J. Hwang, and Aaron S. Kesselheim — on the time required for
available at investigational drugs to reach important U.S. milestones, such as new drug
NEJM.org applications, FDA approval, expiration of market exclusivity, and market entry of
a generic version. Data may be viewed by individual drug, therapeutic class,
approval pathway, and approval year, as well as in aggregate.

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