The Things His Father Taught Him

If you had asked me before today, I would have told you that I was beyond being inspired by cancer stories.  There are so many of them, and I have tried to share the ones that have been most meaningful to me with you. But today was different.  Today, Teddy Kennedy Jr. gave the keynote address at ASTRO. For those of you who don’t remember, Teddy Kennedy Jr was twelve years old in 1973, when he was diagnosed with osteosarcoma—bone cancer that was widely considered fatal at the time.  Teddy is now Edward, and he is an all grown up cancer survivor who has dedicated his life to health care law. He told  endearingly funny jokes and family vignettes as an introduction—he said that in turn of the last century Boston, his grandmother used to go to his great grandfather’s political speeches because back then Irish Catholics couldn’t become doctors or lawyers so they went into politics, and seeing how they were quite “prolific in their ability to multiply” (his words), they succeeded in getting elected.  His grandmother was quite adamant that the children and grandchildren not waste their hard earned political clout—they had to DO something with their lives.

Edward Kennedy Jr told us all what it was like to have his father tell him that the doctors were going to remove “part” of his leg.  When he asked what part, assuming that it would be the raised red lump on his calf, his father told him that it would be “all of it”—the lower leg beneath the knee.  And that when the surgery was over, he would be getting an experimental chemotherapy regimen of high dose methotrexate at the Jimmy Fund, the part of the Dana Farber Cancer Institute in Boston where they treat children.  As he put it, this was at an age where having a pimple was a disaster, and having a bald head was unthinkable.  He talked about how, as a Kennedy only a few years after the assassination of both his uncle John and his uncle Bobby, he was expected to keep up a façade of being brave.  He spoke of what it was like to have people tell him that they “felt sorry for him”.  And about how, after the operation, the doctors would come in with their entourages of medical students and residents, and look at his stump, but not at him.  And he talked about how his father, Edward Kennedy Sr told him that the biggest obstacles he would face would be the ones he created for himself.  His leg was amputated in November.  He was skiing again by March.  His father died in 2009 of a malignant brain tumor.  By then, he was called “the Lion” of the United States Senate.

The last part of Edward Juniors talk was about survivorship.  He reminded us that it is okay to be sad and to feel loss when diagnosed with cancer, and of the importance of aftercare for psychosocial and emotional issues.   He talked about the fact that when a person with cancer leaves my care, and the care of the surgeon and the medical oncologist, that person becomes a person with a pre-existing illness.   He spoke about Obamacare, and what this legislation has done for people with cancer.  He called it a godsend.  Insurance companies can NO LONGER deny a cancer patient coverage because of their pre-existing condition.  They cannot drop that person, or charge outrageous sums.  They cannot deny that person access to potentially life saving clinical trials.  He spoke of the birth of his daughter eighteen years ago, and how that event was the culmination of everything he thought would never happen to him and how grateful he feels, to this day, to the physicians who treated him.

One in four of us will get cancer.  And many of us will die from it.  Do we want to be cancer victims?  Or cancer survivors?  Do we want to help those less medically fortunate than ourselves, or not?  It is time to decide.

When I Was Young

I am in Boston, on the twenty sixth floor of the Copley Marriott Hotel, waiting out the storm. I have not been to ASTRO, my professional society meeting in three years.  I passed when the meeting was in San Diego two years ago, and Miami last year so that I could come to Boston, because I did my residency training here, started my career and my family here, and lived here for fifteen years.  And besides, New England is so lovely in the fall.  I chose my hotel carefully—not too far from the Convention Center, and very close to the restaurants and shopping in Back Bay.  I had it all planned.  All except for Hurricane Sandy.  I arrived here with my office manager on Saturday night, and managed to get in a half day at the meeting yesterday.  Today they “called it” at noon, and here I am back in my hotel room.  Tonight’s parties have all been cancelled but there seems to be a lively crew at the hotel bar.  I’m sure I will be joining them shortly.

We all say that we attend these meetings to learn what’s new in our field of radiation oncology, but the truth is that it’s very hard to learn anything when you run into an old teacher, or resident, or medical student between each lecture and it is ever so much more fun to sit and talk.  I bumped into one of my very first residents yesterday afternoon.  I mentioned that I had been writing down some of my old stories, and she piped in, “I have one for you—it’s about you!  I’ve never forgotten it.”  I said, “Oh, do tell me.”  I was a first year attending, and being responsible for a resident was a frightening prospect, although I tried very hard not to show it.

She said, “It was during my very first few weeks of residency.  I was called up to the ICU to consult on a 91 year old woman who was at the end of her life, on a ventilator.  The situation was dire, but they called us to ask about treating a large skin cancer on her face with radiation.   I knew that there was no way we could get her downstairs to treat her, but I didn’t know what to say on her chart.  So I came and asked you!”    I said, “What did I say?”   She said, “You told me to go up there and write on her chart: SURELY YOU JEST!”

Apparently my sarcastic sense of humor hasn’t changed much in the twenty seven years since that day. It’s how we oncology folk get through it all

Six Pounds of Hamburger

Six pounds of lean hamburger, two roasted chickens stripped to the bone, two pounds of green beans, a large steamed pot of brown rice, a couple of pounds of hard grated cheddar cheese and I am ready to go.  You might think that I am laying in provisions for a trip to the wilds of Alaska, but no, I am going to Boston for a meeting. They have restaurants there.  The food that I have carefully prepared is for my dogs and cat.   I will be gone for six days, and even though my husband assures me that he can take care of the four dogs, one cat and two horses still at home, it is important to me that it be done right. You may translate that to “it must be done MY way.”

I don’t know when it happened that I stopped feeding cheap store bought kibble and started to actually cook for the dogs. It may have been gradual—a sprinkling of cheese and a bit of hamburger here or there for a dog gone off its feed due to illness or injury.  I suspect that this little guilty pleasure surfaced at about the same time that my kids grew up and left the house and we all know that a mother needs to feed her children.  I measure out tablespoons of flax seed (keeps ‘em regular!) like I am doling out cod liver oil and vitamin E as my mother used to do when I was a competitive swimmer.  My husband gets into the act too—he tops off their dinners with Nilla vanilla wafers for dessert—a treat that the “laird” administers. Guests who are not dog people stare in wonder at the evening ritual, and no one more so than my houseguest from Kenya, a physician who absolutely REFUSED to believe that the creature I was carving up was a chicken—apparently they do not grow chickens that big in Africa.  Nor do they feed their dogs better than they feed their children.  I had the decency to be slightly ashamed, but not enough to go back to the cheap kibble.

Tomorrow I head out on JetBlue for ASTRO, the American Society of Therapeutic Radiology and Oncology annual meeting.  Apparently I am heading right into the “Perfect Storm”, although I thought they already made that movie.  Hurricane Sandy is due to make landfall soon, and I may be floating down Newbury Street and the Boston Common on my way to the convention center.  I don’t mind as long as I can get reservations at No.9 Park for dinner.  I will see old friends, do a little shopping, and maybe attend just a few of the educational sessions. If there is anything really new in the world of cancer treatment, I promise to write all about it.

In the meantime, my animals will be well fed, and my husband will survive—he always does.  But my writing may be a bit sparse for the next week.  Here is an open invitation to you all:  Please send your guest blogs to mfielding@crabdiaries.com   I know that my readers are nurses, doctors, front and back office staff,  psychologists,  veterinarians, dog people, horse people and of course my best friends and family.  Please write your own stories and share them with the rest of us.  I want to hear your voices, NOW!

Table for One

We’ve been very busy lately, and so it was 6:30 this evening before the last patient was escorted to the linear accelerator to be treated.  She had had a compression fracture of a lumbar vertebra last week due to metastatic breast cancer, and had been in excruciating pain despite a procedure called a vertebroplasty, where cement had been injected into the crumbling bone to shore it up.  When that gave her no relief, and her doctors were concerned about impending spinal cord compression, she was referred to me.  Despite the already packed schedule, what could we do except get her planned and treated as an add on at the end of the day?  The alternative of paralysis was not an option. I grumbled to myself all the way down to the vault—my feet were aching and I was tired.  As I walked into the shielded “maze”, I heard my radiation therapists cheerfully assisting the woman onto the treatment table as if she were the first patient of the day.

Once a week, on Mondays, I see all of my patients on treatment.  Each patient is escorted from the linac to an exam room by one of the therapists.  There is never a Monday where at least one of the patients, and many times all of them, comment about what a great “crew” I have treating down there at the machine.  I smile, nod, and say “That’s because I hired them!”  I am lying.  I did put that team together, but the truth is that radiation therapists everywhere have much in common. They stand on their feet all day, helping patients who are sometimes tearful, sometimes anxious, sometimes immobilized by pain or fear. Between each patient who is honestly grateful for their services, they deal with those demanding a schedule change daily, those who are chronically late, those who are chronically early, and those who will only be treated by a (woman) (man) (person with blue eyes) (whatever—you name it). They risk injury all the time, lifting and assisting patients who cannot do for themselves.  They smile, and they are pleasant and they care, leaving their own problems at home to be kind all day, every day, for their entire careers.  This is a profession, and believe me they are professionals, that selects for genuinely nice people.  It’s a hard job, both physically and emotionally and if you do not have the temperament for it, you do not last long.

There is one radiation therapist that I worked with longer than any other, for nearly nine years.  I changed jobs in 2004, but George is still there.  An exceptionally tall man at six foot five, his size alone inspired confidence in the patients.  Despite the fact that I always explained the treatment to them ahead of time, little old ladies would get two or three days into treatment, and say, “George, tell me again what the side effects of treatment are going to be.”   He would reply, without missing a beat, “You will have an irresistible urge to BAKE!”  And bake they did, cookies and brownies, and cakes and cinnamon rolls to make very sure that their special guy did not go hungry during a long treatment day. I remember the very first time I followed a patient into the treatment room at that place.  The linear accelerator, imposing in its immensity was ready; the treatment table, which we call the “couch” was covered with a clean white sheet. George stood by the set up smiling, one arm outstretched, gesturing like a maître d’ at a fine restaurant.  When he said, “Table for one?” the patient collapsed into giggles.

Nothing kills cancer like kindness and a good sense of humor.

For Lu

I am good at many things, but I have never been particularly good at training dogs.  Never saw much point in it really, since I love the laid back nature of hounds, deerhounds in particular.  Apart from occasionally eating all of the seatbelts and the bumpers off my Suburban, and removing saplings from the yard (we call this “landscraping”), they mostly lie around the house, preferably on the newly upholstered couch. No retrievers or terriers for me—they require intense supervision and effort.  Any dog that requires me to toss a stick or a ball endlessly is going to be very disappointed because I was always the last to be chosen for the softball team. I have no hand-eye coordination whatsoever.

Despite this, I believe strongly in the training of children, and so when in 1995 we acquired two new deerhound puppies, Timber and Valentine, I decided that it was time for my ten year old daughter Alex to learn to train a dog. I inquired at the veterinarian’s office and the local feed store as to who the best dog trainer was, and I was directed to Lu Meyer’s Obedience Academy.  Since there were two puppies and only one child old enough to handle a dog, I enrolled us both in our first obedience class.

To say that Lu was one “tough cookie” was to make a serious understatement.  She was extremely fit, had ramrod straight posture and a demeanor worth of a Marine Corps drill sergeant.  Fairly early in life she discovered two things– that she did not want to be married to a jerk, and that she was very good at training dogs.  She divorced her husband, raised her son by herself (and did a fine job of it), and started her obedience academy. By the time she got hold of me, my daughter and the deerhound pups, she had 30 years of experience and by golly she was going to show us how it was done.   And show us she did.

I don’t remember anymore which of us had Timber and which of us had Valentine.  I do remember that we worked hard in class, and we worked hard at home.  We did not want to fail in front of Lu, who would dismiss us with a characteristic “sniff” of her nose.  I later learned that this was related to a sinus condition, but at the time that haughty sniff was the penultimate sign of disapproval, sending us head down and home in shame. It seemed we could do nothing right, however by 1996, Valentine had earned her AKC conformation championship, handled in the ring by Lu, the “lowly” obedience trainer who managed to beat several professional handlers and several of the top dogs of the time.  Timber was another story.  Born with a short kinked tail, he was never going to win a conformation title. Deerhounds are not known for their affinity for obedience, but he wanted to please Lu, at least for a while.  She put two legs of an obedience title on him, but the third leg proved elusive.  Timber was smart and bored and tired of the game.  On the third or fourth attempt at that final leg of the Companion Dog title, he calmly turned to her in the ring and lifted his leg on her skirt.  She exited the ring, handed me the leash, and commanded “Neuter this dog IMMEDIATELY!”  And so I did.

Lu was diagnosed with Stage IV ovarian cancer in 2007.  It never occurred to her not to fight, and she fought hard.  When I was a medical student and resident, this diagnosis was a near immediate death sentence.  But the discovery of Taxol, a chemotherapy drug initially derived from the bark of the Pacific yew tree and later synthesized, changed all that.  Ovarian cancer became treatable, and Lu responded beautifully to treatment.  She would go to chemotherapy, and come home to hold back to back obedience and agility classes. Her upright posture and her characteristic sniff never changed—she was in command and dogs and humans alike knew it.  Even dog whisperer Cesar Milan would have yielded to her “calm assertive leadership.”  And so did her physicians, giving her second line chemotherapy when she failed Taxol, and third line therapy after that, and in the end, experimental drugs.  That is exactly what she wanted, and she got it.

Over the years, I became a decent hand with a dog in the show ring but decent does not equal grace or fluid movement.  By 2010, with Timber and Val long gone, I had my two Q’s, Queen and Quicksilver, and I did not want to embarrass myself or their breeder by stumbling around the ring.  I called Lu, who was still teaching despite being oxygen dependent.  She was eager to help me.  She had her oxygen in a backpack on her back.  Even though she was visibly short of breath, she was as strict and demanding as ever.  When I gaited a dog down and back, she got exasperated with my hackneyed knee action.  She grabbed the leash out of my hand and took off at a run down her lawn matching Queen stride for stride as she shouted, “THIS IS HOW IT IS DONE!!!”  The following weekend I did not win, but I did take reserve at the Western Regional specialty.  I know that Lu was smiling her approval from her hospital bed.

Today my daughter is a great hand with a dog, thanks to Lu.  As for Lu, she passed in August of 2010, a month after my last lesson, dedicated to the end to her son Victor, her clients and her dogs who were carefully placed with her closest friends. Her personal service dog Whisper, a beautiful Doberman, was by her side at the very end.  When Victor went to make arrangements at the funeral home, he took Whisper with him, since she had never been alone. It was warm that day, and the funeral directors, a young couple, asked Victor to bring the dog inside.  There was an immediate and surprising attraction between the bereft dog, and the couple whose job it was to comfort the bereft, and who were looking for a dog to help families through those most difficult times.  After careful consideration and time, Whisper became theirs.

Today Whisper continues her life as a service dog, doing what Lu trained her to do, but in a capacity that Lu never anticipated.  There could not have been a better outcome for this perfect dog if Lu had orchestrated it herself.  But then again, perhaps she did.

Perspective

When I was young and foolish, or very smart depending on your perspective, I married a man who is five and a half years older than me. When my husband was my age (and never trust a woman who will tell you her age, but between you and me I am 58), he started to say something quite often whenever he would get annoyed.  He would say, “I’m too old for this!”  This would irritate me no end because I thought that I would never be too old for ANYTHING, and if I was I would never admit it so freely.  I would reply, “If I ever start saying that, just take me out behind the barn and shoot me!”   Now that I am exactly the age that he was when he started to say it, I find myself saying it too.  Luckily for me, he hasn’t gunned me down yet!  Our tolerance for little annoyances seems to lessen as we age.  In other words, we become a lot more like our least favorite parent.

There is another curious phenomenon I have noticed. I had to put one of my all-time favorite dogs to sleep in July.  He was old, for a deerhound male and he had lived a wonderful life as the “patriarch”, the alpha dog and the undisputed best puppy raiser ever in our household.  As it turned out, we had to do the deed on our thirty second wedding anniversary, July 13.  This year, fittingly, that day was a Friday and I didn’t much feel like celebrating after that.  I am always sad when we have to put a dog or a horse down—it’s natural to feel that way.  But I am finding that the older I get, the harder I am taking each loss.  I’ve thought about it and I think the reason why is that I am staring my own mortality in the face when I watch another beloved pet die. When you’re a kid, you just don’t see how these things could be applicable to you.  When you’re older, you think you should get used to it, but the funny thing is, you just never do.

When I started in radiation oncology, most of my patients were older than me, in fact, a lot older.  Now each day I realize that many of them are younger than I am and that is a sobering thought.  In college, one of my favorite quotes was from Andrew Marvell’s “To His Coy Mistress” –“But at my back I always hear Time’s winged chariot hurrying near.”  I know what it means now.  It’s why I stay up late; it’s why I am writing.  The company No Fear updated Marvell’s sentiment on a T shirt that I wore until it wore out after too many washings.  On the front it said, “It’s not the pace of life that concerns me.  It’s the sudden stop at the end.”

Nothing like taking care of cancer patients to give you a little perspective.

You Can’t Tell a Book

 

Apparently I am not the only one who has learned a few things from my patients.  My husband surprised me and wrote this over the weekend, and I thought you might like to read it.

“ I was a pulmonary physician at a Boston hospital when I first met Martin, a patient with advanced emphysema that I was particularly fond of.  Martin lived in a poor neighborhood with his wife who worked as a sales clerk at Filene’s Basement, a discount department store.   He showed up for clinic visits wearing a white undershirt with wrinkled jeans, and carried a dusty backpack where he kept his breathing medicines.   His appearance stood out at this hospital, which typically served the more affluent people of Boston.  Perhaps because of his disheveled looks, other patients and staff seemed to steer clear.  Not surprisingly, I would usually find Martin sitting alone in the corner of the waiting room, often reading an old book.

Over the years I cared for him, I realized that we both shared a love of literature, since I had majored in English in college. Not only did Martin like to read literature, but he was also something of a poet.  He published short poems in a community newspaper and liked to show these to me in a kind of off-hand way saying, “thought you might be interested”.  I remember that I was often too busy in clinic to take the time to read these poems, but I did appreciate the effort that went into them.

One year Martin had several hospitalizations related to his lung disease.  Somehow he became convinced that my care was the only reason he survived these episodes.  Out of gratitude he started to present me with an old book on each clinic visit.    The dusty books piled up in a corner of my office, and I always thanked him but I never had the time to read them. Eventually they were put in a box, and I thought made their way home.

When Martin finally succumbed to his emphysema, I made a point of attending the funeral.  It was the only time in my career that I ever did this.  The funeral was in a large church with several hundred people in attendance. Some stood up and remarked on the positive contributions he had made to the community despite his breathing impairment. When they expressed the love they felt for him, it actually brought me to tears.

A few years later, Martin’s wife showed up in my office to say hello.  It was winter, and to my astonishment, she was dressed to the nines in a mink coat and had a large diamond pendant adorning her neck. “You look great!” I said and then added, “I see you must  have re-married”. She quickly corrected me, “No, I didn’t get another husband.  You see Martin was a good man in more ways than I knew.  After he died, I called up a local book dealer to cart out the stacks and stacks of old books Martin kept in our apartment.    Fortunately for me, this man was honest.  See these books Martin had collected over the years were really valuable.  Most were first editions, and some were signed by famous authors.   Funny thing, I took care of Martin all those years, and now he’s taking care of me after he’s gone.”

That night I rushed home. We had moved since Martin started giving me those books. My wife and I ransacked our house looking for the books but we never did find them. Like their owner, the tattered bindings and dusty covers yielded no clue as to what was inside.”

When I read this story the other night, my husband had an introductory line.  I’ve saved it for the end.  He said “Patients have a way of teaching us some of life’s great lessons, when we are able to see things for what they really are, rather than what they appear to be.”  I say it a little differently.  My patients teach me something every day, about themselves, and about me.  I only have to remember to take the time to look, and to listen.

A Room With a View

Space is always at a premium in any bustling medical office, and my department is no exception.  In the four years that we’ve been open, the patient volume has nearly doubled.  We’ve added a second physician, a second nurse and several additional radiation therapists.  My office manager does financial counseling in her tiny office that is more like a closet, and my physicist has doubled up with his own physics resident. Now we have a rad onc resident rotating with us and we’ve had medical students nearly continuously since July, both welcome additions to our daily routine but our “zen” is being stretched a bit thin. The question has come up—where do we put everyone?  As we walk the hallways looking for walls to knock down and more closets to turn into offices, all eyes turn to me, and it is clear that the vultures are circling.  Everyone wants my consultation room!

Long ago my mentors taught me two important concepts.  First, that it is the very first meeting with the patient and the family that gives them the lasting impression of the department and the doctor—first impressions do count.  Second, that talk about cancer and radiation therapy is threatening and scary and is best served up when the patient is fully clothed, in a comfortable chair, preferably in a room with a window.  Not that anyone wants to jump out of course, but somehow the sunlight pouring in makes patients feel like there is an escape hatch from that claustrophobic feeling they have when they suddenly realize that their lives have been forever altered.  As a consequence, all of the departments that I have built or directed have had a room, simply and comfortably furnished, where the patient and his family or friends are taken for the initial part of the consultation.   My consultation room has a couch, a coffee table and two large armchairs .  Landscape photos line the walls and the picture books on the coffee table are mine.  The large window faces south, and the sun streams in all day.

By the time we move to the actual exam room, there is an ease, and a familiarity, like we’ve all just met some old friends over coffee and the undressing and gowning for the physical exam goes smoothly and quickly. From our “customer satisfaction surveys” I would venture to say that most patients leave a lot happier than they enter.  So as we walk the halls looking for more space for our growing department, I tell my vultures to back off—that the large sunny consultation room is sacred and it is not going to go away because it is a neutral space between the fear of the waiting room and the vulnerability of the exam room. It is the space that makes my patients feel like they are human beings, not specimens, not tumors, and not cattle waiting to be prodded down the chute to an uncertain fate.

Now all that being said, there are two little issues I’d like to raise.  First of all, whoever took my coffee table book containing lovely photographs of our local community, could you PLEASE bring it back?  And second, when I sank into that armchair on that warm summer afternoon, I did not, I repeat DID NOT fall asleep as I was explaining radiation therapy for prostate cancer to you.  You only imagined that I fell asleep.  And it was only for a minute.  Really.

Let’s Get Physical

In his great book “Cutting For Stone”, Abraham Verghese describes one of his main characters, Dr. Marion Stone, as being obsessed with a certain aspect of the physical exam.  Dr. Stone, as the dictatorial chief of surgery at a major Boston teaching hospital, has drilled into his residents the necessity of performing a rectal exam on every patient.  One intern forgets to do this, and is so terrified of his mentor’s wrath that he proceeds to chase the newly discharged patient out on the street and into a bar to do the deed.  On that particular night in the place where everybody knows your name, “bottoms up!” takes on a whole new meaning. In real life, Dr. Verghese teaches at the Stanford University School of Medicine, and is as devoted to the art of the physical examination as Dr. Stone is in the book.  In a New York Times article published two years ago entitled “Physician Revives a Dying Art: The Physical”, science writer Denise Grady rounds with Verghese and a group of third year medical students who are clearly impressed watching a master clinician point out the stigmata of liver disease and diagnose cerebellar ataxia without a CAT scan.

All medical students are taught to do a careful physical exam. When I was a student, we practiced on real patients. Now there are “standardized patients.” Trained actors are paid to report certain symptoms, and to say ouch when the student hits the right spot. Quite amazingly, there are ladies and gents who get paid to teach the finer points of the gynecologic and rectal exams (as one of my colleagues joked, “Here’s your paycheck ma’am, and would you like a psychiatric consult with that?”) In the fourth year of medical school, a test is administered nationally where students go from room to room encountering 10 or so such standardized patients, and are given 15 minutes to take a focused history, perform a specific aspect of the physical, and write up their findings. They must pass this test to graduate.  So what happens to our students between the time they finish medical school and when they become your family physician who spends 5 minutes with you typing on his or her laptop, “takes a listen” through your shirt, signs a stamped prescription for a Z-pack and sends you on your way?  Time pressures, limitless technology at our disposal, fear of malpractice and fewer opportunities for bedside teaching have all contributed to the demise of the detailed patient exam.

My chosen specialty of radiation oncology has become perhaps the most technology driven in all of medicine.  All of our treatment planning is done from a CAT scan—nearly all radiation therapy departments have their own scanners.  We are fairly low down on the food chain of medicine when it comes to making discoveries on a physical exam—by the time the patient sees us, with the notable exception of head and neck cancer patients whose tumors are best cured by a combination of chemotherapy and radiation, those tumors have been scraped off, whacked out, frozen, melted or otherwise assaulted.  Oftentimes there is nothing really to examine—I have mentioned before my mentor who said “Radiation works best when there’s no disease!”   Knowing that my CAT scanner is just around the corner, I sometimes feel a little silly doing a thorough physical exam.  So you can imagine my complete shock a few months ago when asked to examine a patient who had some very nonspecific complaints of fever and malaise on her first day of treatment, and to hear a big WHOOSH WHOOSH WHOOSH as I listened to her heart. I looked back at my initial physical—there had been no heart murmur two weeks earlier.  I sent her directly to the hospital, and 24 hours later she was in the OR having both her aortic and her mitral valves replaced for acute bacterial endocarditis, an infection of the heart valves brought on by an infected chemotherapy catheter.  I can only imagine the eye rolling that took place in the emergency room when the radiation oncologist called in a case of endocarditis—I mean they all know we’re the guys in the basement playing with computers and pushing buttons!  It was not the first time, but it was probably the most important time that my three years of internal medicine training had a huge payoff for the patient.  It saved her life.

In the NYT interview, Dr. Verghese said something else about the physical exam that struck me as an uncommon truth.  He said that a proper exam earns trust, and is the ritual that transforms two strangers into a doctor and a patient.  My daughter is interviewing for an internal medicine residency at Stanford next month.  If she ends up with Dr. Verghese as a mentor and teacher, she will be very fortunate indeed.

The Purple Bathing Suit

“April is the cruelest month”  T.S. Eliot

Although I have spent my professional career battling cancer, cancer is not the cruelest disease.  Tonight I was looking through old photographs that my father had taken to a print shop to be scanned on to a disk.  He sent me a copy, but I had not had much time to look at the pictures.  When I finally did, last night, I was disappointed in the sloppy job that the print shop or camera shop had done—photos were scanned in upside down, backside forward, reversed, random and unlabeled.  There was no chronology or logic—it was just willy-nilly, get the job done.  And I am sure that they charged him a lot of money for that service.

Looking again tonight, there is joy and sadness in those old and out of order family photographs.  My sister smiles as she receives her diploma from Stanford.  My little brother, now long dead of a drug overdose, blue eyed and perfect as a three year old sitting next to my 5 year old pony-tailed self.  Me, in my favorite “car-coat” as my mother called it, felted and toggle tied and warm.  I remember that time it snowed in Houston—I was in first grade and I had pretended to be sick to stay home from school and then it snowed, beautiful white fluffy snow, and my Nana would not let me go outside to play because, of course, I was “sick”.  By the next day, the snow was gone.

Of all of those old pictures, there is one that jumps right off the screen at me.  It is a photograph of my mother, just graduated from college, in a purple skirted Jantzen bathing suit.  I know it is a Jantzen because I remember the logo from my childhood—a little diver with a swim cap covering her head, doing a swan dive into a pool, ubiquitously sewn onto every Jantzen suit of the 1950’s.  My mother is at the beach, sitting demurely on a beach towel that appears to be engulfed by a foamy wave which creeps just past her delicately crossed legs.  She is brunette, petite, beautiful and smiling.  She is 21, and her whole life is before her.  I like to think that my father, deeply in love, took that picture just before they married.

Sixty years later, my mother is a two time cancer survivor.  She was treated for breast cancer in 2001, and then for a disease of the blood, Waldenstrom’s macroglobulinemia, which involved her brain in 2005.  At that time she received chemotherapy directly into her central nervous system.  Five years later, in 2010, she began to lose her memory, and her will to walk, and to speak, and to eat.  Now, in 2012, she has advanced dementia.  She does not recognize me or my sister, and my father dutifully visits her at least every other day in her nursing home, where she receives excellent care, completely dependent on others for her survival.  Because her nurses are so attentive, she has not had a life threatening pneumonia or urinary infection or infected bed sore which would cause her demise.  And so, we wait.

I never got along very well with my mother, but despite that I wish fervently that she could be herself again, older and wiser, waiting out the tide in her purple Jantzen bathing suit. Cancer is not the cruelest disease—dementia is.   I am waiting to see which shoe will drop for me.