Gifts of the Magi

In my mind’s eye, I see them coming—a long processional stretching back years, each with a different cloak of disease, each with a small receptacle.  They come bearing gifts  for me, their doctor—a small box,  a carefully folded tissue, a child’s sippy cup (the top tightly closed), and occasionally, yes, toilet paper.

What are these gifts my patients bring me?  No frankincense or myrrh, nor precious jewels, nor Godiva chocolates. The Magi explain:  “I coughed THIS up this morning and thought you might want to see it!”. “When I moved my bowels this morning, THIS came out.”  “I went to blow my nose, and LOOK AT THIS!” “I gagged taking my pills this morning and THIS came right out of my throat!”  From every orifice of the body, they bring these gifts to me, and to my nurse, sometimes stopping on their pilgrimage to show my secretary, and other interested parties in the waiting room.

Pathologists and internists LOVE these gifts.  They have special foodie names for things that they like to look at under the microscope or see in the emergency room, like “caseous necrosis” which means “dead cheese” found in the lungs of tubercular patients, and “red currant jelly”, the color and consistency of blood and mucous mixed in the stool, and “coffee ground emesis”, which is what a bleeding ulcer produces when mixed with stomach acid.  The descriptors go on and on.

Here’s the thing.   When you come to me, you already HAVE a diagnosis of cancer made by a very competent pathologist.  You are likely already under treatment.  So whatever comes up, or down, and out of you, I don’t need to see it.  Really I don’t!  Write down when and where it happened, what you were doing at the time and perhaps a small description of the “item”.  But please, leave the wadded up toilet paper at home!  Thank you very much.

On the other hand, a box of chocolates would be very nice!

The Golden Rules of Cancer

Rule # 1:   I didn’t give you your cancer so be nice to me.

And the corollary:

Rule # 2:   You didn’t give you your cancer so be nice to yourself.

I believe that in dealing with cancer, it helps to play by the rules.  The first rule means that as angry as you are about being diagnosed with cancer (or in fact, any other life threatening or life changing disease), try not to exhibit that anger towards your doctor.  It’s counterproductive for the patient (you don’t really want the entire staff calling you names behind your back and doing quick about faces when they see you in the hall, do you?  And don’t imagine for a minute that we don’t!)   And it’s disheartening for the physician who has dedicated his or her life to taking care of people just like you.  There will always be the occasions where the doctor and the patient just don’t “connect”.  If that is the case, and there is no rapport, please try to find another doctor who better fits your needs and personality.  It is absolutely your right to demand your doctor’s time and attention.  It is not your right to verbally abuse the doctor.  Early in my career, I had a lung cancer patient who was absolutely vicious—he answered every honest question with a snarl.  One day, I had had enough  (another one of those epiphanies!).  I said, “Mr. M, I know you are angry that you have cancer, but I didn’t give it to you and I am only trying to help you so please be nice to me.”  We got along famously after that and  I have had more than one occasion to say those words since.

As for Rule # 2, I cannot say how many patients come in blaming themselves for their cancer.  Trust me, I have heard it all.  They say, “if only I had had a better diet….”.  Or  “if only I had exercised more….”.  Or, “I didn’t handle stress well and it gave me cancer….”.  And their friends and neighbors can be ever so unhelpful—”If only you had eaten the Andrew Weil  way….”.  Or, “if only you had done Tai Chi which is more spiritual than that yoga YOU do….”.  Or “if only you had never lived 100 miles from a nuclear power plant…..”.  (Interestingly enough, no one EVER blames it on the cigarettes or the alcohol,  but that’s another whole story.)    Let’s face it folks—cancer, like many other life threatening diseases, is in most cases multifactorial and not at all related to one’s personality or one’s diet if one is not obese, or one’s spirituality, or whether one even does one’s laundry and which detergent one does it in. And (sadly for most of us!)  you can’t choose your parents and grandparents for the good genes. Whether it’s a virus, a bacteria, a bad gene, an environmental toxin, an evil substance you voluntarily smoke or ingest, genetic or whatever—in many to most cases we’ll never know.  It’s just shitty rotten luck, most of the time.  So stop blaming yourself and get with the program, which means quit smoking (smokers have a higher relapse rate for nearly all types of cancer than nonsmokers), start exercising (the Harvard Nurses Study showed that embarking on an exercise program after the diagnosis of breast cancer reduces the risk of relapse and it’s likely true for other cancers as well), and get to your ideal body weight because fat people get more cancer (and yes, trust me, I DO know how hard that is!).  Got that?

And finally, Rule # 3:  Unashamedly stolen from that great book of my youth, The House of God, by Samuel Shem:

The Patient is the one with the Disease!

Which means, I have to hold up my end of the bargain. Come what may, I need to walk into that consultation with a warm smile and a handshake.  I can’t come to work with all the baggage I bring from home—what aggravations and grievances my dogs,cats, horses, kids and husband have caused.  I can’t whine about my own problems  to my patients. (I do maintain the right to whine to my friends and family, however.)   And finally, I can’t blame my patients when they lash out in anger, or take it personally when they refuse treatment or don’t follow my advice.  It’s their right:  the patient is INDEED the one with the disease.

I think the cancer business would be a little bit more pleasant, a little bit more tolerable, if we all played by the rules.  Don’t you?

THE FREEDOM TO BE NEEDED

Doctors lie all the time.  Call it hubris “I can do THIS for you!”, call it denial  “I KNOW you are going to get better!”, call it what you want.  But nowhere do they lie more than when you ask them if they want their children to go to medical school.  Most of them come right out and say, “Never!  If he goes, he’ll be $200,000  in debt when he finishes.  And besides, you know the practice of medicine is not like it used to be—it’s all about paperwork, and insurance authorizations, and seeing your quota of “X” patients per hour.  Get ‘em in, get ‘em out, don’t look back.  I DON’T want my kid to study so hard for 4 years, and then another 3-6 years of residency where he’s paid a subsistence wage, to finally finish and deal with the sorry state of affairs we have now.”

My husband and I were pushed HARD by our parents when we were kids.  As the eldest children in our respective families, many expectations were placed.  It wasn’t enough to do well in school  (“What’s the matter here—you have all A+’s except in math—you got only an A?  What happened???) or in athletics (“Go swim next to Marilyn, and BEAT HER!”)   It was pervasive and it was truly unpleasant.  Both of us left home when we were 17 years old, and never moved back in again.  And we vowed, repeatedly, that we would NEVER do that to our own children.

So when our eldest went to college, and showed a strong interest in film and photography, we did not bat an eyelash when she decided to major in film studies.  And when she graduated and could not find any paying job in the industry (“no, honey, I will NOT support you while you spend the next year as an unpaid Go-fer for a screenwriter, no matter how famous she is!”), we said “yes” when she decided to go to cooking school in London, spending the last bit of cash I had set aside for her to go to graduate school.  And we were supportive and enthusiastic when she returned from cooking school and got a job as a line chef at a fancy downtown restaurant, despite the fact that she made minimum wages and had no benefits whatsoever—health or retirement.

Sometimes epiphanies are hard to come by.  Mine came after my sophomore year of college where I was an honors English major.  I was backpacking and youth hosteling through Europe with my roommate and we were on a train from Brindisi to Rome.  By the time we ran for the train as it was pulling out of the station, there were no available seats.  So we stood up in the aisle the entire trip, which was overnight.  Unlike my horses, I do not know how to sleep on my feet.  An overnight trip surrounded by sweaty co-travelers reeking of garlic would not SEEM to be conducive to self- exploration, but oddly it was.  I thought about what I wanted to be when I grew up.   I loved English literature, particularly poetry.  And then I thought about what teaching jobs were likely to be available to me—perhaps a job teaching remedial English at a local junior college?  Or a low level editor at a publishing house (back when there WERE publishing houses)?   I knew already that there were people in my class who were destined to teach at the Ivy Leagues—they had won poetry awards, they had developed a new way of looking at Chaucer, they could read and speak five languages—in short, they were brilliant.  That was not me.  On that hot July night, on that train, standing up swaying and lurching, it came to me that when I was in high school my most rewarding experience had been working as a candy striper at a spinal cord rehabilitation center.  I was APPRECIATED.  I was NEEDED.  And that was the night I decided definitively to go to medical school.  And besides, I knew that Daddy would be so proud.

I think that my daughter had a similar epiphany.  Cleaning splattered grease off the ceiling from a ladder in that hot kitchen at the restaurant at 2 am, to take home a wage that would never allow her to move out of our home, she assessed her skills, and her history, which was that she was always the care giver—to her animals, to her brothers, and sometimes even to her parents.  She knew that she was very good with knives and with her hands.  And without much ado, and very much like her mother before her, she decided to go to medical school.  Which I am not ashamed to admit, pleased me greatly.

My daughter will finish medical school in less than a year.  Right now, she is in Zambia, at the CURE hospital there, working with my father, a retired plastic surgeon, on correcting birth defects, and lessening contractures in children who have suffered horrible burns from the main resource for cooking in that country—charcoal.  She is the third generation in my family to go into medicine, fourth if you count my grandfather who was a dentist, and my husband’s grandfather, who was a veterinarian.  This trip will be life changing for her—of that I am certain.

When I was a medical student, a very smart man who was doing his Pulmonary fellowship at Stanford said to me,  “Medicine is the freedom to be needed”.  That is a statement I have never forgotten.   And if you ask another doctor whether they would want their kid to become a doctor and they say “No”, trust me, they are lying to you.

Fire and Ice

“Some say the world will end in fire, some say in ice…..”     Robert Frost

Sometimes there is a very fine line between doing too much, and not doing enough.   I have been thinking about this lately as I watch patients go through radiation therapy.  It’s not  just the acute side effects that worry me with radiation, it’s the late effects also.  One only needs to have known a few patients who were treated for Hodgkin’s Disease in the 1970’s, with now archaic radiation therapy techniques, to realize the havoc that can be wreaked  later, in the form of breast cancer, coronary artery disease and other secondary malignancies.  And yet I always counsel patients who need the treatment to take it, because as hard as it is to say this, the cancer that the patient already has is far more likely to kill him than the theoretical risk of something bad happening 25 years down the line.  For some reason, patients have a hard time understanding this concept.

When it comes to an individual patient, the radiation dose is sometimes the issue.  Most cancers have a clear dose-response curve, where the higher the dose, the more likely the tumor will be obliterated– up to a point, and that point varies from individual to individual and from tumor to tumor. At the highest doses, the complication rate starts to rise, and some complications can be quite severe indeed.  So one of my duties is knowing when to stop, when enough is enough.

When I was a young doctor, just out of residency, the first year of practice was the hardest. One of my very first patients was a 50 year old Polaroid executive with a very advanced form of nasopharyngeal cancer.  I had the sudden and startling knowledge that I alone was responsible for curing this man—in those days chemotherapy and surgery played no role in treating this type of cancer.  It was terrifying to have that responsibility, even though I had been well trained.    I asked one of my mentor/ teachers about the total dose that he would use.  He gave me a rather conservative number, stating grandly that “A tumor recurrence is an Act of God, but a complication is YOUR fault”. I went with the conservative approach; the patient was cured, and seven years later I named my third child after him.

Many years later, I was chatting with a colleague and we were talking about philosophies of treatment.  I drew myself up, and in my most senior, most pompous and most commanding voice I said:  “A tumor recurrence is an Act of God, but a complication is YOUR fault!”  He laughed.  I had ten years experience on him and he actually laughed at me.  And he replied, “Well, my own mentor always said to me, the WORST complication is a tumor recurrence!”

Are you, my readers, fire or ice people?  I’ve discovered through the years, that “cooling it down a bit” has served me well.  But then again, I’ve never been a risk taker.  Not with my life, and not with others.

You Took Your Dog’s Medicine, REALLY?

I was lecturing to a group of medical students on Tuesday –it was their first introduction to breast cancer and I was determined to make those two hours as exciting as possible.   They had just started their second year, and after the first, spent entirely learning about the “science” of medicine, they were eager to hear something of the “art”.  So when I woke up that day and my elbow was a little sore, I attributed it to a scrape I’d gotten a couple of days before.

By the time the lecture was over, and I went to the car to drive back to my main practice site, that elbow was really bothering me, so I rolled up my sleeve and had a look. “YIKES” and “OMG” do not adequately describe my reaction. What I saw did NOT make me happy.  There was a large red welt where my elbow used to be, and redness extending down towards my forearm.  So what did I do?  I stopped by the house.  Why?  Because I keep a large supply of antibiotics on hand for my dogs–a veritable pharmacy, in fact.  Metronidazole for diarrhea, Keflex for skin infections, Cipro for urinary tract infections, you name it.  I even call in prescriptions for them, as Bartley K9 Fielding, or Dusty K9 Fielding.  Or at least I did, until my pharmacy changed hands and the new pharmacist had moral objections to my practicing veterinary medicine without a license. But that’s another story.

So yes, I went home and took the dogs’ medicine.  I needed to get back to work, in a hurry. I had patients waiting.  I started with Cipro, good for most skin organisms, and off to work I went.  By the time I got home that evening, it was worse, and I sought consultation with my husband, who is also not a veterinarian, but who used to practice medicine.  He pronounced his verdict:  “Add some Keflex starting tonight!”  I was quite certain that I would be better by Wednesday morning.  I wasn’t.

Upon my arrival in the emergency room on Wednesday afternoon with my fever of 102 and my forearm the size of Popeye The Sailorman’s, the nice ER doc sat down to take my history.  He was very earnest.  He diagnosed “cellulitis”, probably staph or strep.  I told him I was a health care worker, a doctor in fact, so that he would understand what I meant when I said that because I did not want to disrupt my schedule or inconvenience my patients, I took the dogs’ medicine.  He was incredulous.  A crowd gathered to see and examine the doctor who took her dogs’ antibiotics, quite unsuccessfully but very determinedly nonetheless, because she didn’t want to take time out to actually go SEE a doctor!

Nearly three days later, I am home from the hospital.  It is always sobering to actually BE a sick person, instead of just taking care of them.  Trying to negotiate my way to the bathroom while sporting an IV pole instead of a Hermes bag as an accessory is a humbling experience.  And Jack Nicholson’s got nothing on me as far as the unintentional “rear exposure” when it comes to those delightful hospital gowns.  I hid deep under the covers and fervently hoped that none of my colleagues would feel like making a visit.  They were smart.  They did what I would have done under the same circumstances—they sent flowers!

The infectious disease consultants, the hospitalist, and the nurses (not to mention the medical students) all had a roaring good laugh retelling the story about the doctor who TOOK HER DOGS MEDICINES!  But I remain unrepentant.  For I know, that in my heart, if I had gone to my primary care doctor on Tuesday, her first response also would have been to give me Keflex or some other oral medication, and not to hook me up to an IV bag full of Vancomycin.  She just wouldn’t have called it dog medicine!

Somehow, I don’t think that this is what was meant in Luke:  4:23 which reads:  “Physician, heal thyself”.  But I probably won’t try it again.

Fallout

September 11, 2001 was supposed to be a very good day.  It was my mother’s seventieth birthday, and she and my father were scheduled to fly from their home in Colorado to New York City to celebrate with my sister, who lived on West 72nd Street, a few blocks from the famous Museum of Natural History, where dioramas of early man invite young and old visitors to step into prehistoric times.  As my parents opened the trunk of their sedan to start to load their suitcases, their next door neighbor came running outside, to tell them, “You’re not going ANYWHERE!  The World Trade Towers have been struck by airplanes!.”  In utter disbelief, they went back inside and turned on the television, to discover that America’s worst nightmare, a terrorist attack on our own soil had come to pass.

Because my mother did not get to go to New York to celebrate her birthday with champagne and a Broadway musical, she stayed home and scheduled her overdue mammogram.  Shockingly, because she had not palpated a lump, the mammogram showed a small tumor in the upper outer quadrant of her left breast. The biopsy was positive for invasive ductal cancer, and she had a lumpectomy and axillary node dissection, followed by radiation therapy.  The cancer was Stage I.  Eleven years later, she is cured.  Perhaps it is just a coincidence that she “remembered” to schedule her mammogram the day after 9/11 but I don’t think so.  I think that sitting at home, watching human beings falling from buildings and wives crying over lost husbands, and firefighters standing helplessly as the buildings themselves collapsed, their brethren inside, gave my mother a tiny premonition, a chilly little reminder that we are all mortal, and that we should never forget it and always take care.

On the day before the eleventh anniversary of 9/11,  there was finally fall out from that day that was eagerly welcomed by many:  The James Zadroga 9/11 Health and Compensation Act was expanded to include compensation for 58 different types of cancers potentially caused by exposure to toxic fumes and chemicals, exposures which were particularly intense for first responders and survivors at the scene, but which also affected the search and rescue volunteers and the clean up crews.  The Zadroga Act, passed by Congress in December 2010, and signed by President Barack Obama in January 2011, was named after a New York City Police Officer who died at age 34 of lung disease attributed to working around toxins at Ground Zero. New York Mayor Michael Bloomberg lauded the additional coverage, stating “Tomorrow we will remember those we lost to the 9/11 terrorist attacks and also those who bravely responded during and after the tragedy.”

I have not been to Ground Zero since the attack.  But I have dreamed of that place many times since that day.  In my dream, there is a stairway that rises naked from the ashes, and reaches the clouds where it disappears.  At the bottom of the stairway, there is a policemen, standing feet apart, one hand to his mouth where he blows a whistle whose noise pierces the dust and smoke, the other hand pointing the way OUT for the survivors.  Coming down the stairs, there are two men descending very slowly, because they are between them carrying a tiny elderly woman in her wheelchair. And just above them, on their way up, their faces lined with determination, are two firemen in full gear, hurrying skyward with no hesitation whatsoever.

Nana

When I was ten years old, there were only two things in life that I loved beyond question:  horses and my Nana.  Nana, whose real name was Jenny Silver, was my maternal grandmother.  She and my grandfather, known of course as Papa, lived in Augusta, Georgia on a tree shaded street in the true heart of the deep South.  I was sent to visit them in the summers, and to me their house was paradise, with beautiful wallpaper depicting knights on horses in the dining room, and carpet the color of teal on the floor.  Their backyard seemed vast, especially since we had no yard then—my parents and two siblings shared a 2 bedroom apartment in Texas.  Running the length of that yard gave me a true sense of freedom, and privacy behind the low brick walls that lined the yard, cool with the scent of magnolias.

That summer of 1963, when I was turning ten, was to be a special summer for me.  After years of being begged, my parents finally succumbed to my pleas to let me take riding lessons, and I found myself at Pin Oak Stables, home of tall , genteel and beautifully gaited Saddlebreds.  I was assigned to a nondescript brown gelding—an old school horse named Toga.  I was taught to put the bridle on and to lift the saddle to his slightly swayed back and to fasten the girth.  As I climbed on from the mounting block ( I was far too small to get on from the ground), my proudest moment was when I confidently pronounced the words, “Walk on, Toga!”  It would be many years before I heard the Arab proverb, “The air of heaven is that which blows between a horse’s ears”, but from my vantage point on Toga’s back, I knew the meaning of happiness.

That happiness was to prove to be very short lived.  One hot afternoon, as I arrived home from my weekly riding lesson, my mother greeted me at the door.  She said, “Your Nana is very sick.  She has cancer.  We are bringing her to Houston to be treated at a special hospital for cancer patients called MD Anderson Hospital.”  It turns out that Nana, who was 59 years old,  had been having abdominal pain all summer.  She was treated for various ailments including ulcers and a “nervous stomach”.  There were no CAT scans and no fiberoptic endoscopies back then.  She was losing weight. She had fevers and night sweats.  Finally, in desperation, the doctors took her for an “exploratory”.  It was, as they say, an “open and shut” case.  Her abdomen was loaded with tumor, which was biopsied and found to be lymphoma.  They closed her up.  There was nothing they could do.

But they didn’t know my Nana.  She was determined that at 59, she was NOT ready to die.  She had my Papa to take care of, and she had, by that time five grandchildren.  She was going to go to the ends of the earth to fight this thing, and that is what she did.  At MD Anderson, a new chemotherapy drug, Cytoxan, had been developed, and was in early clinical trials to determine the appropriate dose and schedule.  Nana was assigned to a high dose arm, and her lymphoma began to melt away.  She had tremendous side effects, bleeding from her bladder being the most difficult for her, but she persisted.  Needless to say, my parents were far too preoccupied by her illness and her appointments and her medical expenses to take me to my riding lessons, and I knew better than to complain. By the end of that summer, her cancer was gone. By late fall she was able to return home to Augusta, where she lived another 22 action packed years.  She was a feisty old lady as she aged—at 75 she insisted on having breast reduction surgery.  She said to me, “I didn’t survive cancer to drag these old bags around for the rest of my life!” Until she died, she proudly invited her granddaughters to take a peek at her perky uplifted remodeled breasts.

It was Nana who taught me about grace under pressure, about stoicism and about courage.  She taught me other, quite practical things like how to knit (I’ve long since forgotten), how to appreciate good jewelry and to be sure to meet the parents of any man I dated. (“The apple doesn’t fall far from the tree, dear!”)  She also told me “It’s just as easy to marry a rich man as a poor man.”  (Obviously, I didn’t listen to everything she said!)  Her proudest moments were dancing at my wedding, and meeting my daughter, her first great grandchild.  When she finally passed away, in her early eighties, her entire community mourned, and my grandfather, who lived to be 93, was never quite the same.

In medical school, I had the opportunity to do electives in many different specialties, and there were many that I loved, especially those that required enhanced visual skills and spatial orientation—I liked “looking”, and “seeing” to make a diagnosis.  Dermatology fascinated me, radiology was fun and easy, and plastic surgery was beginning to merge the boundaries between art and science, with the advent of microvascular techniques in reconstruction of birth defects and trauma victims and the reattachment of severed limbs.  But in the end, it was the memory of my grandmother’s fight, and her victory that drew me closest and keeps me where I remain, taking care of cancer patients.

Nearly 30 years passed after that fateful summer before I got back on a horse.  In the words of the late Vicki Hearne, in one of my favorite essays of hers, “Oyez a Beaumont”……that was the soonest I could get to it, what with one thing and another.

TANSTAAFL, or There Ain’t No Such Thing as a Free Lunch!

Robert Heinlein got it right.  In “The Moon is A Harsh Mistress”, sometime in the future, we colonize the moon.   But we don’t send our best and brightest, we send our criminals, our misfits, our dregs of society.  They eke out a hard living in this future penal colony:  their language becomes muted, shortened;  their luxuries are in short supply.  They learn lessons about survival early and often and they become a tough, spare people whose motto is “There ain’t no such thing as a free lunch!”

It is a great misfortune that this axiom is true in cancer treatment as well.  Sometimes patients come to me too late.  They have been seeking the path to a cure elsewhere, and in this part of the country elsewhere is many times across the border, where all manner of crooks and quacks (and as my Yiddish speaking grandmother would say, “SHEISTERS!”) have set up shop to convince patients with dread diseases that THEY alone have the cure. The first wave of so called “alternative” cancer treatments came in the 80’s with laetrile, distilled from the pits of apricots and peaches.  This was followed by a whole load of so-called “cleansers”, some of which involved putting some pretty disgusting substances into orifices that should have been on the giving and not the receiving end of the body (coffee ground enemas, anybody? Anybody?)  From the macrobiotic diet, to the wheat grass cures, to the more expensive and extremely dangerous Insulin Potentiation Therapy which killed Coretta Scott King, patients come in droves to line up for any “cure” but standard of care curative treatment. Scott King, Martin Luther King’s widow,  died a miserable death at the Clinico Santo Tomas, which was not legally licensed to perform surgery, take X-rays, run a laboratory, or dispense drugs from a pharmacy, all of which it was doing until an investigation after her death shut them down.  Patients will go to great expense and travel extraordinary distances from their homes to line the pockets of snake oil salesman.

Why do they do this?  They do this because they are so frightened of conventional surgery, chemotherapy and radiation, that they will do ANYTHING to avoid the purported side effects of such treatment.  I say “purported” because the reality of standard cancer treatments is often times far less toxic than what lies in the imagination.  Friends and relatives are often less than helpful, even though they are usually well meaning.  Trust me, there is no vitamin you can take, or juice you can drink, or special berry that you can put where the sun doesn’t shine that will cure you. Conventional treatments have side effects, but they also CURE cancer.

We’ve made great progress in the 30 years that I’ve been a radiation oncologist by reducing normal tissue doses, increasing shielding ability, shaping more precise radiation beams, and my medical oncology colleagues have done the same, with targeted disease specific drugs rather than the old “shot gun” approach.  But if you think that it is possible to cure cancer without risk, side effects and yes, even potential harm, think again.

In cancer, in life:  There Ain’t No Such Thing as a Free Lunch!

Expect the Best (but prepare for the worst!)

It occurs to me that I say this quite a bit.  It applies to a lot of things in my world—living in an area where natural disasters are a way of life, my van stands gassed up and ready to roll with dog crates, blankets, extra water, cleaning supplies, a change of clothes and even a camp stove and some canned goods.   I took a disaster preparedness class at a Wilderness Medicine Conference a few years ago and the Air Force Survival instructor scared me half to death.  He said, in ominous tones, “You just NEVER know when you might become lost in the wilderness!”  Immediately after the lecture, I went out to the exhibit hall and was overwhelmed by the sheer volume (not to mention the genius) of modern survival gear.  Faced with such choices,  I bought a large orange plastic whistle, which I still have tucked behind the driver’s seat of my Suburban.  Just in case. I do know how to whistle!

I say this to my patients a lot:  Expect the best but prepare for the worst!   I’m a firm believer in dotting the “I’s” and crossing the “T’s”.   I’m superstitious (and believe me, I hate to admit it!).  I think that the best way to prevent something terrible from happening is to plan for it.  And the best way to make it happen is to ignore the possibility.  I am a worrier.  I like to have plans.  Cancer can be a huge wake up call, just like a major heart attack or a bad car accident.  Carpe diem all you want, but PLEASE make sure the emergency number on your registration form is filled in, your will is completed, and your lawyer knows beyond a shadow of a doubt that your husband’s new wife is NOT going to get your jewelry!

Sometimes I think I might go a bit too far.  Tonight, I listened to my daughter the medical student relate a story of a fourth year resident in Urology (why women choose to become penis doctors, I’ll never know but I’ll continue) whose fellow residents and attendings turned on her after she became pregnant and had a child during her residency training, making her so miserable that she dropped out of the program.  My daughter (have I mentioned she is a medical student?) was very concerned that by the time she finishes her residency training, the proverbial biologic clock may have tick tocked its way down. In my most commanding voice, I said, “Expect the best, but prepare for the worst!”  She said, “What do you mean?”  I said, “You know, maybe by the time you’re done with your residency, you could take a month off, and, well, harvest your EGGS!”

You could have heard a pin drop.   Could someone please hand me a shovel so I can dig myself a hole?

Why I Am Not a Psychiatrist #2

After that last uplifting little story, I figure I better write Part Two of “Why I Am Not A Psychiatrist”.  It’s always important to have a good laugh after a good cry!   So back to my Adventures in Psychiatry.

As I mentioned before, my psychiatry rotation was at the VA Hospital.  My attending physician was a very experienced senior psychiatrist who truly believed in the axiom  “Know Thyself!”  And therefore he had a way of helping us students toward that end.  Back in those days, it was common during a psychiatric evaluation to administer a test called the MMPI, which stands for the Minnesota Multiphasic Personality Inventory.  As I recall, the test took several hours to take and was quite maddening—the questions were repeated over and over, as if to “catch” the test taker in a lie.  It was not a fun test to take, say, like an IQ test where you arrange difficult little triangles into a square box, or a “what should you be when you grow up” test (I was strongly encouraged by that one to do musical theater, or to become an opera singer, which is quite hilarious if you’ve ever heard me sing!).  No, this was a long BORING test which had no apparent purpose. And yet, my psychiatry attending decided that ALL of his medical students were going to take the MMPI, after which we would sit around and discuss the results of our newly discovered personalities.

The day came, and there we were—six medical students, a couple of interns, a resident, and the attending.  We were handed sheets of paper with our names, on which there were scores for several different categories, which were then pictorially demonstrated by a connect- the -dots graph.  Each test taker was given scores for basic personality traits, such as empathy, obsessive compulsivity, narcicism, obstinacy, and, of all things, paranoia.  So I am looking at my scores and I am bobbing along quite nicely at the fiftieth percentile for each of the 8 or 9 different traits, thinking “nice, I am NORMAL!”.  But wait….at the very end of the list there is the category paranoia and my graph takes off like a helicopter, I mean STRAIGHT UP UP AND OVER the 100 percent line.   What was this?  WHAT WAS THIS???  I had a moment of panic, and then I settled…turned to my attending and said, “Look at THIS!  Paranoid?  I’m NOT paranoid!  You must have graded mine wrong!”

All eyes turned to me, and the little sniggles of laughter welled up into great big guffaws.  I would venture to say a few folks in the room actually wet their pants, judging by the tears of laughter in their eyes.

Okay, so I’m paranoid.  But let me tell you, I also won the Award for Student Excellence in Psychiatry.  And I never took another personality test, ever!