The Leaky Roof

In this dry Southwestern part of the United States, there are only two seasons:  fire season and rainy season.  Fire season will end in another month, hopefully without further casualties or homes lost. The rainy season will start, such as it is.  Here we average 9 inches of rain a year, and we are perpetually unprepared.  The roads, slick with oil from a summer of busy vacationers’ rental cars, become virtual “Slip ‘N Slide” games for unsuspecting drivers who, not used to navigating in “weather”, hit their brakes hard and the famous freeway pile ups begin.

My small radiation therapy department was designed to give patients a sense of quietude and peace.  From the laminate flooring which absorbs sound, to the Japanese vases on the hall tables, to the landscape photographs which line the walls, each element was chosen to calm the anxious spirit of the newly diagnosed cancer patient.  Most of the department’s day to day functions take place on the second floor of the building, where offices and exam rooms and our consultation area are simple, functional and comfortable.   To get treatment however, the patients must descend down a floor to the “vault”, since the shielding of a linear accelerator cannot be retrofitted easily to an existing space.  Even the elevator down is “Zen”, wood paneled and carpeted, moving slowly and unjarringly to the lower level where the patient receives the radiation.  When the patients exit the elevator, they enter a sun filled anteroom, then walk down a ramp into a large well lit room with a state of the art linear accelerator.  The walls of the anteroom and the ramp are furnished with spectacular photographs of Bryce National Park, taken by a well known landscape photographer, who also happens to be a radiation oncologist, who is still working as such despite his beloved avocation of landscape photography because he is still paying the legal bills of his daughter, who famously refused to dry clean a certain blue dress, lest she be called a liar by those who sought to protect a President.

Our “vault” was an “add-on” to the building in 2008.  As such, there is a junction between the vault structure and the building itself.  Shortly after we opened in October of 2008, we realized that the roof was leaking precisely at that junction.  By November, mornings after a big rainstorm, we would exit the elevator into a large puddle.  By January, the puddle had become a river, flowing down the ramp towards $2.5 million worth of equipment.  This was not good.  We complained, and the builders of the “vault” did their best to seal the leak, to no avail.  The university got involved—after all, it was THEIR building.  A lawsuit ensued.  Meanwhile, we solved the problem by stationing a large gray rubber garbage can directly outside the elevator, lined with sheets of plastic which ascend to the ceiling and disappear behind the ceiling tiles.  Now, when it rains, the garbage can fills up.  It is the duty of the maintenance man to empty the garbage can every morning during our season of rain.

Somehow, our garbage can and plastic sheeting do not fit with the “esthetic” of our very Zen-like department.  But like anything else in a landscape viewed daily, they have become mundane, ordinary and invisible to our therapists, and even our patients once they’ve had those first few treatments, when the whole process is new and very frightening.  Four rainy seasons have come and gone, and at last report, the litigation has been “continued” until next spring.  Meanwhile, I fantasize that my department is an anchored antediluvian world where wickedness will soon be washed away by the great flood of floods.  I imagine myself as Noah, and reluctantly consider an ark (while replaying in my mind the great Bill Cosby routine where God asks a recalcitrant Noah, “NOAH….How long can YOU tread water?”).  If the waters breach the top of that garbage can, millions of dollars of equipment will be ruined, and our department will close until the damage is repaired and a new linac installed and commissioned.

How many University bureaucrats does it take to fix a leaky roof?  You tell me!

My Father’s Hands

I never gave my hands much thought until a few years ago.  They were never pretty, but they were functional serviceable hands that did what they were asked—I could examine a patient, type fast and accurately enough, and everyone always told me that my handwriting was outstanding.  That has always been a point of pride for I knew that I was never going to kill a patient because a pharmacist could not read my prescription.  I sign my name with the broad sweeping rounded cursive of a 10 year old child.

Perhaps because my hands are no longer young, I realized with a start a couple of years back that they look exactly like my father’s hands.  I was not thrilled to realize this, but it certainly explained the reaction I would always get when trying on rings at a jewelry counter—the salesperson would always say, with great surprise, “Your ring size is SO SMALL!”  Why wouldn’t my ring size be small?  I am a short person—just never grew much.  What I realized was that I have broad palms, and short fingers, and the proportions are all wrong for a person with a size 5 ring finger—yes, I dare say it—because of the proportions my fingers look fat.  This was a huge disappointment to me, since I have always desired the long delicate fingers of a nail polish model.  It does not matter if your ring size is a 5, if your hands are broad and your fingers are short.  Of all the things I could inherit from my father, the green eyes were welcome; the short fingers were not.

My father is eighty seven years old.  Never a tall man, he has lost several inches in height as he has aged, and now barely reaches five feet.  He is a plastic surgeon, once world renowned for his work in maxillo-facial surgery, where surgeons must truly be artists  to repair the faces of children with hideous birth defects, and victims of terrible accidents.  Although he has been “retired” for many years, he never stopped working.  He travels the world with various charitable groups who send surgeons to the far reaches of the globe to repair birth defects and accident and burn victims, allowing them to lead the normal lives that others take for granted.  Yesterday, he returned from Zambia where Surgicorps volunteer plastic surgeons and teams of scrub nurses, anesthesiologists, physical and occupational therapists performed miracles at the Beit Cure Hospital in Lukasa for 60 children in desperate need of surgery to repair their birth defects and burn scar contractures.  This time, for the first time, he took my daughter, the 4th year medical student with him.

My daughter, like me, has chronicled her life in photographs.  This trip was no exception.  She took pictures of the parents and of the children who patiently waited for hours on the hospital lawn, just to be seen, to be evaluated, to have a chance at a better life.  Despite the cleft lips, the cleft palates, the fused fingers and toes and the burn scars, there is happiness and joy in her photographs, and there is patience and forbearance and acceptance.  One photograph, in particular struck me with a force that brought tears to my eyes.  It is a photograph of my father, seated across from a tiny girl.  In this picture, the little girl’s hand, tiny and plump, has closed its fingers around my father’s right index finger.  They are gazing into each others eyes and they are smiling.

Today, I was proud to have my father’s hands.

My Doctor Shows

This week is a big week for me: my doctor shows finally return to primetime television!  I have been waiting a long time since the plane crash cliff hanger finale of last season’s “Grey’s Anatomy” for my tv counterparts to return.  Last night I was taken by surprise– just after the first elimination round of “Dancing With the Stars” I had walked outside to answer a friend’s phone call on my cell, when my husband appeared and whispered, “I’m going to bed, but I’m recording the season premier of “Private Practice” for you.”  Needless to say, the phone call ended very quickly, for I have been a doctor show junkie practically since birth, or at least since the handsome Dr.Kildare first picked up a scapel on primetime.

When “Grey’s Anatomy” appeared as a mid season replacement in 2005, I was barraged with phone calls from several of my friends, not physicians, who reported it as a “must see.” I was a bit slow to respond, having missed the first several shows.  When I finally turned it on, I was neither impressed nor amused.  George, one of the interns, was tasked with the unpleasant business of telling his own father that dear old Dad had, as George put it, “The Big C”.  I was indignant.  I called my best friend, who was by then the show’s biggest fan.  I told her emphatically, “THAT WOULD NOT HAPPEN!”  Medical students and interns do not tell their own family members that their worst fears have been realized.  That is a job for a senior resident!  And besides, I harrumphed, “NO ONE CALLS IT THE BIG C ANYMORE!”  I was astounded by the inaccuracy of the medical writing, not to even mention the mispronunciation of medical terms by the befuddled cast.

So how was it, that sometime later, between the third and the fifth season, that I found myself irrevocably sucked in by the story line, not only of “Grey’s Anatomy”, but also its spin-off show “Private Practice”?  I think it was when I finally suspended my own experiences and reality and started to believe in the characters.  Meredith and Derek, Izzy and Alex, and of course, the ever endearing Lexie, aka “Little Grey” were no longer just actors, stumbling over medical words they had never previously had reason to utter.  They were people, who laughed and loved and lived and cried, and died.  When George, the most inept of all the interns, was hit by a bus while shoving a stranger out of the way and maimed beyond recognition, he signaled his identity to his peers by signing 007 (“licensed to kill” as dubbed by his fellow interns) on Lexie’s hand.  I wept for hours.  Really, I did.

When Addison left for Santa Monica and “Private Practice,”  I followed.  “House” may have seen its last season, but that’s okay by me, because Addy and Jake are finally going to be happy.  Why do I love these shows so much?  I will tell you why.  When I see these beautiful young women and men, dressed to the nines in their form fitting clothes, sporting sparkling make up and very good hair, and better shoes, having even better sex, I can pretend, just for a moment, that that’s the way it really truly was. It is a very good fantasy indeed.

Atonement

At one of the boarding and training stables where I took riding lessons, there was a custom passed down through generations of instructors and eager children.  If a horse managed to unseat a young rider, the slightly bruised and dirty little victim was allowed to pull a few strands of said horse’s tail.  The instructor would braid the strands–black, or white, or grey or red—into a thin plait and secure the ends with rubber bands.  This small symbol of failure was sent home with the child with the pronouncement  “You cannot be a REAL rider until you’ve fallen off THREE times!”   Three braids of horse hair pinned to a bulletin board and a rider you shall be.

As a fourth year medical student, I eagerly embarked upon my “subinternship”, a make-or- break rotation for aspiring doctors where the student was expected to function as an intern on the admitting team, which consisted of two or three interns, a junior or senior resident, and an attending physician.  Each “Sub-I” took new patients admitted from the ER  in rotation with the real interns, and we were supposed to perform a history and physical, order appropriate tests, come up with a differential diagnosis and present the results to the attending physician on rounds the next morning.  My first “admit” was an elderly woman, massively obese, who had been found at home alone on the floor, in an altered state of consciousness.  After an EKG in the ER showed she had not had a heart attack, she was sent up to the floor to be evaluated. No one had been able to draw her blood in the emergency room—they could not find a vein and since she was stable, they sent her on up.  I was well trained in the art of blood letting, yet after two hours of poking and prodding various sites where veins were known to hide, I reported to my senior that I had not been able to coax out a single milliliter.  He said, “Well, go on home then, we’ll get the IV team to do it when they come around to start her IV.”  I arrived the next morning for rounds and terrible news.  At 2 am, my very first patient had had a cardiac arrest, and in fact she had died when the “code” team could not rescusitate her.  But, oh, they had gotten blood out of her then.  Her potassium level was 7.5, incompatible with life.  She had been in kidney failure and we had not known it.  The blood test which had not been done the evening before might have saved her life.

As a senior medical resident, in charge of such an admitting team, I rounded daily with the interns, dispensing sage advice on each patient on our floor.  Three days in a row we rounded on a lady with late stage breast cancer, in the hospital receiving chemotherapy, then given in the hospital due to significant side effects which in those days had few remedies.  Three days in a row, she had complained of leg weakness, which we attributed to the debilitating effects of her chemotherapy.  Of course she was weak, she had CANCER and was getting CHEMOTHERAPY.  On the fourth day, she was to be discharged home.  As we rounded, her complaint of leg weakness had changed.  She said, “I cannot move my legs.”  Indeed, she could not move her legs.  On our watch, she had suffered a spinal cord compression from metastatic breast cancer to her spine and was paralyzed.  Spinal cord compression is one of the most dreaded complications of cancer.  Unless detected in the early stages of weakness and numbness, it is nearly always irreversible.  Almost unbelievably, as an inpatient attended daily by a multitude of students, interns, residents and senior physicians, this woman walked into the hospital and left in a wheelchair, never to walk again.

In the emergency room, a macho mystique presides.  Again, to quote Samuel Shem in “The House of God”, the goal is to “buff and turf”:  Tune ‘em up and get ‘em out!   This somewhat testosterone fueled mentality results in an unstated reluctance to admit patients to the hospital—no senior medical resident in charge of an emergency room wants to be seen as a “wuss” by his or her peers presiding over the floors—the fewer the number of patients admitted, especially at night, the more sleep your fellow residents and interns can get, and the more they will thank you in the morning.  Each patient in the emergency room is triaged by the nurses first, and the senior residents last, nowadays with the blessing of the attending physician, but back then we were on our own in the wee hours.  One night during my senior internal medicine residency, a young healthy man in his early 30’s came into the ER, complaining of chest pain.  He was a budding young chef at an up and coming local restaurant.  He was slightly overweight, a condition which was exacerbated by his chosen profession.  To remedy this problem, he had decided to start jogging.  Earlier that day, he had gone for a three mile run.  During his run, he began to have chest pain, substernal chest pain radiating down his left arm.  The pain had subsided when he stopped, but he came to the ER to be checked out, you know, just in case.  His heart rate and rhythm were normal.  His EKG was normal.  The blood tests which we now do routinely to rule out cardiac muscle damage were in their infancy, and took 8 hours to run.  He had no family history of heart disease.  He had no heart murmur.  He was only 33, for goodness sake!  There was NO way this man could be having a heart attack. No way.  I sent him home.  But, just in case, I scheduled him for a stress test to be done a few days hence.  At 8 am, my 24 hour shift was up, and home I went.  Twenty four hours later, I returned.  In the conference room, the attending was rounding with the interns and residents.  He took report on the previous night’s admissions.  One of those admissions was a 33 year old chef who had returned to the ER less than a day after I had discharged him, clutching his chest in pain and fear, having a massive heart attack.  He was admitted to the ICU. He survived.

Perhaps it is the same with physicians as it is with children taking riding lessons—you cannot be a REAL doctor until you have made three mistakes that you will never forget.  Doctors hate making mistakes, and hate admitting them even more.  This is the reason for the conferences which take place at every teaching hospital in the country called “M and M’s”, which stands for Morbidity and Mortality.  It is where physicians, young and old,  stand up and say, “This is what happened and this is what I learned and that is why I will never let it happen again.”  Rarely do they say, “This is what happened and it was my fault and I am truly sorry.”  When I was in training, the conventional wisdom to avoid malpractice liability was to call Risk Management but to NEVER admit you were at fault.  That was for the insurers and the courts to decide.

That has changed now, for the better.  Now we are counseled that it is better to admit one’s mistakes, and to apologize.  I have my three braids of horsehair pinned to my brain, and to my heart.  And there are probably more.  I am sorry.  Truly sorry.

Cancer is a Word, Not a Sentence

I am the one who doesn’t like to fast forward during the commercials.  While others get up from the couch for a bathroom break, to grab a beer, take a phone call, or interrupt our programming to discuss the new season of whichever show we happen to be watching, I sit riveted to the screen. I wax nostalgic over the Hallmark ads, drool over the car and jewelry ads (especially those romantic proposals involving large diamond rings where every kiss begins with Kay’s), and weep copiously during the Kodak moments (Yes, I “turned around” and they were gone.).  I hear the Christmas harness bells of the Budweiser Clydesdales in my sleep. And I am faithful to my products, in my fashion.  To me, Chevy will always be “like a rock”, and CocaCola will always be “the real thing.” I love a good advertisement—always have and always will.

So it should come as no surprise that I am fascinated by the advertising slogans and campaigns which come and go in cancer—cancer awareness, cancer screening, cancer treatment, cancer support.  These ads and slogans  and symbols have become part of the national consciousness:  who can forget the television ad of the wasted old woman (or was it a veteran?) in a wheelchair, smoking a cigarette through a tracheostomy hole?  The “Anti-Marlboro” man creators may not have stopped kids from smoking, but you certainly can’t fault them on a shock value scale.  Pink ribbons and yellow wristbands have become part of our collective cancer symbolism.  See a pink ribbon, think breast cancer. See a yellow wristband, think Livestrong/Lance Armstrong.  Knee jerk, empathize, feel the pain, and above all, send the money.  It is desperately needed.

But to me, the best ads and slogans are the ones that involve a little humor, combined with a little humility and self deprecation.  I was watching the National Finals Rodeo on television last year and noticed that all the cowboys, including the bull riders ( the toughest of the tough though not necessarily the smartest of the smart) were wearing pink.  Each, to a man, had on a pink shirt, or a pink bandanna, even pink hats and gloves.  Kudos to Wrangler Jeans for their sponsorship, and their Tough Enough to Wear Pink campaign for breast cancer.  In a similar vein, some of the funniest T shirts I’ve ever seen during the Susan B. Komen Races for the Cure have been worn by men, including “Don’t Let Cancer Steal Second Base”, not to mention the one with an antlered stag on the front proclaiming  “Save the Racks!”.  And then there is my husband’s personal favorite:  “Save a Life, Grope your Wife!”

Four years ago I travelled to Kansas to pick up a Ford E150 van being sold by the son-in-law and daughter of a friend out there.  Said son-in-law and daughter were artists, who had spent several summers touring with Ozzy Osbourne and his Ozzfest tour, running the souvenir/concession stands.  Not being a huge Ozzy fan, yet tooling across country on Interstate 40 with an Ozzfest bumper sticker on my well used van, I decided it was time for some research.  I was surprised to discover that Sharon, his wife, had been diagnosed with colon cancer while still in her 40’s, and had undergone successful treatment.  I was even more surprised to see how much money she had donated to Cedars Sinai Hospital in Los Angeles, to develop a whole center for excellence in the treatment of colo-rectal cancer.  But what surprised and delighted me the most  was to see Sharon’s own take on advertising for cancer awareness—quite possibly the best slogan ever:

“GET SOME BALLS—CHECK YOUR ASS!”

Top that one if you can!

I’ll Take the Sexy Name

When it comes to radiation therapy products, the high tech companies really outdo themselves with names.  It seems to me that the higher the price tag on the item, the more thought goes into the label.  Varian, the largest manufacturer of linear accelerators, trumped its competition with the moniker on its latest linac, the “TrueBeam”.  What were all the other linacs–  “FalseBeams?”  Even the software gets a fancy name—I remember being in San Francisco a few years ago, sitting in a glass fronted restaurant when a city bus rolled by with the entire side painted with the Varian logo and the words “RapidArc” along with a letter from a child, in hand printed block letters, telling the mommy’s cancer to “be gone” now that she’s being treated with RapidArc.  RapidArc is just software that allows the linac to treat in a continuous 360 degree arc rather than making multiple stops along the way.  The technology speeds up the treatment, but in no way cures more mommies of cancer.

Nowhere does the name game get played out with more gusto than when it comes to anointing new stereotactic radiosurgery equipment.  This technical advance in radiation therapy originally allowed more precise targeting of very small tumors which were unfortunately located next to critical structures, particularly in the brain. Now it is used increasingly to treat lung cancers and metastases to liver and bone.  Roll down any big city freeway these days and you’re bound to see a billboard advertising Cyberknife (usually followed by exclamation points!!).  In a naming tour de force, the Cyberknife is made by a company called AccuRay—again, are the other companies “In-AccuRay?”  The name Cyberknife has made a big bang in the pantheon of medical terminology—with its connotations of cyborg and scalpel, both non radiation oncologists and patients alike imagine that the tumor explodes on impact, and disappears in a radioactive dust.  I am repeatedly amazed when I go to Tumor Boards and am asked, “Can’t you just Cyberknife it?”   Never in the history of radiation oncology has a new technology become a verb.  But when you think about it, if given a choice,would you rather be Cyberknifed, or would you rather go to BrainLab? Shades of Frankenstein!  Cyberknife wins hands down, despite the fact that BrainLab and Trilogy are competing, equally effective modalities for radiosurgery.

Radiation is radiation, my friends.  The technology is ONLY as good as the physician who decides to treat you in the first place, the dosimetrist who performs the calculations, the physicists who QA the plan, and the radiation therapists who aim that machine in the right direction.  So do yourselves a favor and don’t go chasing after the sexy names.  Ask about the credentials of your doctor and the physicist instead and you won’t go wrong.  But even so– my mind sometimes wanders back to my residency days when one of the Cobalt 60 units was called “The Eldorado.”   Now THAT was a name!

NURSE!!

For Donna,  Linda and Kelly

When I was an Internal Medicine intern, my very first rotation was in the Coronary Care Unit, aka “the CCU.”  Nothing could be more frightening to both the intern and the patient than an acute myocardial infarction the first week in July.  It is a well-known fact that hospital mortality blips upward in July of every year, as the new interns take over from their now seasoned peers.   I learned VERY quickly that there was only one person I could depend on without fail and her name was Donna.  She was an intensive care unit nurse who took me under her wing and quite literally, told me exactly what to do so I wouldn’t kill anyone.  She was my guardian angel, and she took her responsibility quite seriously.  I am quite sure that her expertise has been the dividing line between life and death for hundreds of patients (and hundreds of interns!) both before and after my time.

When I was a medical student rotating through the various hospitals, patients were still admitted to “wards”, something you never see today, at least not in this country.  Large open rooms, containing six or eight beds, presided over by a charge nurse, with various “team members”, meaning medical students, lab techs,  interns, residents and attendings all scurrying around like busy mice.  Invariably, as I would pass by a patient’s bed, he or she would call out emphatically, “NURSE!”.   On my good days, I would turn to the patient and say, “Sir, I am a medical student, NOT a nurse, but can I help you?”   On a bad day, I would just keep walking.  I was not a nurse.  I considered it an insult to my upcoming doctorhood.   I was young and stupid.

In the real world, it is not the doctors, but the nurses who truly take care of, and CARE for the patients.  Nowhere is it truer than in oncology nursing.  They are the ones who stand between the patient and the abyss of the “Big C”.  Their dedication, humor, inquisitiveness, persistence and above all, their compassion can mean the difference between a patient who is an anxious fearful “victim” versus a  “warrior” ready to face the challenges of treatment.  As the front line, the “advance man”  between me and the patient, my nurses establish trust, instill confidence, inform, educate and LISTEN.  In short, they make my life easier, and they make the patients’ lives, no matter how short or long, more comfortable. After all, in what other context would a patient knowingly lie down and offer their arm to a person who is ready to infuse a–to use the general public’s term for chemotherapy—”poison” into their veins.  I can think of none.

I have learned so much from my nurses over the years.   Now, when I walk by an exam room (and this doesn’t happen very often anymore), and a patient yells “NURSE!”,  I still correct them, saying, “Can I help you?  I am Dr. Fielding.”  But secretly, I know that I’ve been paid a compliment.

What Does Your Mommy Do For a Living?

The year was 1997, and my youngest was having his sixth birthday.  What he wanted for his party was for me to take him and his friends to the local amusement park.  They would have free access to the rides, swarm the arcade, play on the ersatz beach with its immense man made waves, and just generally be the hooligans that little boys are.  The reward at the end of the afternoon was a pizza party complete with cake and ice cream, provided by the park. All I had to do was drive seven of these fine young cannibals in my big Suburban and survive the trip.  So amidst jovial punches punctuated by squeals of pain and newly learned curses muttered under peanut butter breath, we set off.

As the boys settled in for the long drive, the physical combat waned while the verbal combat was just warming up.  The six year olds were actively engaged in a game of “mine is bigger than yours”.  Only they weren’t talking about their sexual prowess—that would be years in the future.  They were talking about everything else—who had the biggest bedroom, who had the biggest house, who had the biggest dog, and ultimately, whose Daddy had the best job and made the most money.  As the competition escalated, my son grew quiet and thoughtful.  As I glanced in the rear view mirror, I could almost see the cogs turning in his brain.  And then, the zinger!  He pulled himself forward in his seat, and announced, with great authority: “My Mommy makes her living putting her finger up men’s assholes!”.  Let’s just say that that was a show stopper.

Yes, I treat prostate cancer.  I have ALWAYS been interested in this disease, and several of my first research papers dealt with novel radiation sensitizing drugs for locally advanced prostate cancer.  Early on in my career, I worried and fretted about how to best “approach” (both literally and figuratively), these men who were more than twice my age and who were definitely NOT used to having a young female physician performing, shall we say, a rather delicate exam.  I discovered that the trick was putting them at ease with me as a person first, giving them time to tell me about themselves, making their wives comfortable in a consultation room, not an exam room.  And finally, joking with them that my fingers were “oh so very small, compared to those giant urologist hands!”  It was a cakewalk after that.

Years and years went by, and I had no problems whatsoever convincing these sometimes grumpy old men that it was just fine to have a female physician.  But late last year, despite all my efforts to build my reputation with patients and urologists alike, there was a problem.  My secretary told me that a prostate cancer patient had been referred, and his wife was insisting that he would ONLY see a male physician.  She said he was adamant—NO LADY DOCTORS!   Now this was a touchy situation—at the time, I was the ONLY physician at my facility, and his insurance dictated that there were no alternatives.  Once she understood that it was me, or no one, she accepted the appointment.

The day came for the consultation, and I escorted the patient and his wife into our consultation room, a lovely room outfitted with a couch, a coffee table and two chairs, a living room away from home.  We discussed his case at length, and after fully assessing his symptoms, we left his wife in the consult room and went into the exam room for his physical exam.   I knew that he would be nervous, despite the fact that he didn’t LOOK nervous.  In an effort to put him at ease, I said, “Mr. S, I know that you didn’t want to be examined and treated by a female physician, so I want to assure you that I will be very gentle with you and very discrete.”  His blue eyes crinkled and he looked at me sideways, and a low chuckle  emerged from a bright smile.  He said, “Who told you THAT?”  I said, “Well, your wife, sir.”  At that point he was laughing so loud his eyes welled up with tears.  He exclaimed, “That wasn’t ME who didn’t want to see a woman doctor, that was my JEALOUS WIFE!”   This man was 80 years old, and his wife not a day younger.

I don’t worry about these things anymore.  I know my patients love me for who I am.  And the word is out on golf courses all over town—I give the best “finger wave” in the business!

If Wishes Were Horses

For Missy

Is there any woman alive who can’t recite the old nursery rhyme “If wishes were horses,then beggars would ride”?  The line is etched into the memory of every little girl who ever wanted a pony, but its true lineage dates back to James Carmichael’s Proverbs of Scots circa 1628 when the original read  “and if wishes were horses, then pure (poor) men wald ride.”  In my post entitled “Nana”, I recounted my short though blissful riding career at age 10, ended prematurely by the illness of my grandmother.  During a brief college fling with a polo player (yes, he had a string of polo ponies and yes, his name was Julian, and yes, his family were Hungarian emigres of questionable political  heritage), I was treated to a ride at breakneck speed that started with an innocent giddyup and very nearly ended in my demise.  Ultimately I decided that I would prefer life and limbs intact and gave up on Julian and his horses that handled like Ferraris, but without brakes.

Twenty years went by– medical school, two residencies and three children later—I found myself as the Radiation Oncology director of a community cancer center equidistant between Cape Cod and Providence RI.  One day, I saw a young woman in her early thirties who had been diagnosed with breast cancer.  She had elected to have a  lumpectomy and radiation, and when I saw her for the first time she had just completed her adjuvant chemotherapy.  I noticed two things about her immediately—the first was that despite her hair loss and other effects of her chemotherapy, she was beautiful, athletic, confident and in control of her body, her life and her situation.  The second thing I noticed was her bracelet.  It was perfect—a golden circle made of beautifully worked horses heads, eyes alert, nostrils flared, ears forward, manes flying, the horses of my dreams .  There was no way that I was going to ignore that bracelet. But first things first—the cancer.  We spoke about radiation, the risks, the benefits, the course of treatment, the side effects.  She told me her biggest concern was her little girl who was only three years old—she wanted to make absolutely SURE that I knew that she was going to make it, because she could not bear the thought of her daughter growing up without her.  I told her I understood perfectly, and I did.

At the end of our session, I could restrain my curiosity no longer.  I asked her about the bracelet.  She told me she had always loved horses, and that she had grown up riding on the Cape. The bracelet was a gift from her husband, as was her horse, Percy.  She told me she rode that horse every day, rain or shine, stopping only briefly for her breast cancer surgery, and continuing on right through her chemotherapy.  She said, “He keeps me sane”.  She asked me if I rode horses.   I said, “No, but I always wanted to—I just never had the money when I was a teenager, and as I got older, with career and kids, I just never had the time.”  She looked me in the eye—and said to me, “Well the time is now.  You never know what is going to happen.  You could end up like me, with breast cancer or something worse, when you least expect it.  If you’re ever going to do it, you should start NOW.”

That was it—my wake up call from a patient who was smart enough to see what I had missed and game enough to point it out to her physician—that the only time and the best time one is ever guaranteed is right now, right here.  The following weekend, I got my 8 year old daughter out of bed, made a beeline to the girls boarding school riding stable near our suburban home, and signed us both up for riding lessons. My 5 year old son followed in breeches, knee straps and short stirrups, and my 2 year old– ever the cowboy—well, when he turned three and got his helmet, he loped Old Ellie around Far West Farm much to the shock and dismay of the other boarders, to see such a small boy piloting such a huge animal, completely on his own.

Twenty one years have passed since I saw and treated that patient.  I left the practice to move out west in 1993.  But every year, at Christmas, I get a card from her wishing me well, and thanking me.  Always included in the card are photographs of her, usually on her horse, though Percy is long gone, and also photographs of her daughter, now grown and a beautiful young woman in her own right.  And there is always a gift, a little something “horsey” chosen specially for me– a picture frame, a Christmas ornament, a beautiful box of stationery, a silk scarf—with ” clouds of white stallions with bright fiery eyes”. Every year, without fail, there is that renewal of our friendship, and a reminder of what is important in life.

As for the horses themselves– Rosie, Lucky, Veronica, Harmony, Sissy, Romeo, Truffles, Oscar, Shorty, Besty, Norman and good old Dash—they’ve served my family well over a period of twenty years, carrying us over miles of trails, and through both adolescent and midlife crises. They are the best therapists—they listen without comment or criticism, and they never mind when you cry into their thick strong necks. Winston Churchill said  “No hour of life is wasted that is spent in the saddle.”  But I still think that J.D.Salinger said it best in The Catcher in the Rye:

“I’d rather have a goddam horse.  A horse is at least HUMAN, for God’s sake.”

Who Wants to be First?

After much preparation, we opened our new radiation therapy department in September 2008.  Many many elements and “players” had to come together to produce a new state of the art community cancer center.  No detail was overlooked– the existing space had to be renovated  to create a more “zen-like” work flow and feel; the front office staff  had to be selected whose faces and voices would materialize as the “first impression” that our new patients would form as they entered a “brave new world”. My nurse had to be hired, who would play a critical role in the education and management of the patients.  Radiation therapists were recruited who would see the patients daily for up to eight weeks of treatment, directing the beams with the utmost precision while acting as “parents”, confidants, psychiatrists, social workers and otherwise infinite sources of knowledge, gossip and entertainment.  The physics staff– the dosimetrist who does the actual treatment planning and the medical physicist, ultimately responsible for the function of the machines and the safety of the patient—were chosen first, because in order to get a new radiation therapy department going, the linear accelerator must first be installed, and then “commissioned”.

A Linac is a very complex piece of equipment, housed in its own “vault”, a lead shielded room in the department.  Long ago, and far away, for precisely 24 hours before my written board exam, I could tell you EXACTLY how one works.  Now when a patient (and it is nearly ALWAYS an engineer!) asks me, “How does that thing produce radiation?”, I take his arm, and escort him to the office of my physicist who will gladly  explain everything (and I do mean EVERYTHING) to the patient.  Usually the patient emerges an hour later, with eyes slightly glazed over, and I am never asked another question.  And when it comes to explaining, and commissioning a linear accelerator, my physicist is simply the best.

The process of commissioning takes up to six weeks.  The company provides the “specs” of how the machine is supposed to perform, however we don’t just take the manufacturer’s word for it and plug it in and run with it.  After all, this is radiation, dangerous stuff if applied incorrectly.  The physicist uses his equipment to measure the output of the beam, at every different energy, at every different depth, for every different radiation field size.  Internal shields and beam adjustors and compensators are put through rigorous use to try to find faults. Computer connections are tested; video systems are monitored, and no stone is left unturned.  It is an arduous process, producing reams of data. At the end, when all is said and done, the machine must produce beams of sufficient strength, and fields of precise shape, or there will be no “acceptance”, and back it goes to the manufacturer.

So it was with great excitement and anticipation that we finally were ready to treat our first patient.  She was a lovely elderly woman with breast cancer, diminutive in size but full of personality!  She wore a royal blue boucle suit to her first treatment, replete with a silver flower brooch that she had made herself in her eldercare silversmithing class. She took tiny steps on her kitten heels down the ramp leading inside the vault.  Her hair and make up were perfect.  She was composed and polite to the staff.  She beamed at me.  As directed by the therapists, she changed into her gown.  They positioned her on the table, five feet off the ground.  They set the machine to its assigned position.  Everything was ready, so I pronounced, in my most important special occasion voice:  “Mrs. B, you are about to be the very first, number one patient EVER to be treated in this department on this machine.”

There was a moment of silence, and then Mrs. B EXPLODED into action, causing all of us, the therapists and me, to take a step backwards in surprise then forwards in alarm since she was at a height which could practically guarantee not only orthopedic but also neurosurgical injuries, should she fall.  She sat bolt upright and began to climb off the table, all the while exclaiming:  “The first?  THE FIRST??!!!  You never told me that I was the FIRST!   YOU GET ME DOWN FROM HERE AND EXPERIMENT ON SOMEONE ELSE FIRST!  I am not your guinea pig!  I’m going home RIGHT NOW!”

Okay…..would anyone else like to be first?