Finding Your Way Home, Again

But all great voyagers return 

Home like the hunter, like the hare

To its burrow; below, earth’s axle turns

To speed their coming, the following fair

Winds bless their voyage, blow their safe return.

 Barbara Howes

Today I saw an 80 year old patient with skin cancer—not a melanoma—the dangerous one, but a routine garden variety basal cell cancer sitting right on the edge of his nose, where the nose meets the skin of the cheek. His surgeon told him that he could cut it out, but that there might have to be a flap rotation or a skin graft to fill the gap, and the patient declined surgery.  As a result he was referred to me.  After hearing about radiation, this nice man decided to go ahead with treatment, but he had one question—could he wait until after the holidays?  The reason was that all thirteen of his grandchildren were coming to visit him, and bringing his first great grandchild.  I reassured him and told him that of course he could wait—the treatment of skin cancer is never an emergency, and while he might sing “Rudolph the Red Nosed Reindeer” to his grandkids, we didn’t want him to look like that famous deer!

My daughter arrived back in Texas yesterday after travelling since Thanksgiving on the residency interview circuit.  She has covered both coasts and eight different cities since showing up on in San Diego just before the holiday. She said it was good to be home, even though she misses her cat, who remains here with me during her travels.  I sense a grown up transition in the transference of “home” from being here with her parents, to “home” being her own condominium in Houston.  Although I miss having her around, I am happy that she has found her own ground, and her own friends, and made a life for herself there. Her biggest job in the next few months will be to figure out just where her next home will be, for the next three to six years. The best advice I can give her is to choose her next move based on her comfort with the people she has met along the way.  Not only will they be her peers and her mentors, but they will most likely resemble her “family” in the coming years—she will spend more time with them in the hospital where she lands than she will with any of her real family members.  For newly minted doctors, the hospital where they do their training becomes home.

I am glad that Christmas Eve and Christmas Day fall on a Monday and Tuesday this year.  My department will be closed both days, which will give my patients a four day weekend.  For some, this means they will get to take a trip home, wherever that may be.  For others, the four day rest will give them some relief from the side effects of treatment.  For those of us not undergoing treatment, may the fair winds blow your friends and families to you, or you to them, and safely bring you home.

No I Could Not Write a Book

Since I’ve been writing this blog, quite a few people have said to me, “You should write a book!”  Let me be clear in my self-assessment—first of all, I don’t have the attention span these days to write a book.  A novel has a plot, well developed characters, a beginning, a middle and an ending.  I’m not sure but I have a feeling that most good fiction writers have a clear idea of the story they want to tell before they start writing.  “But wait”, you say. “You should write a nonfictional account of your work—a true cancer doctor story.” This territory has been covered, most famously by Jerome Groopman who wrote The Measure of our Days, which became the inspiration for the television show Gideon’s Crossing.  How about a history of cancer itself?  Again, already taken in the most definitive way imaginable—I give you The Emperor of All Maladies by Siddhartha Mukherjee.  Of course, the books that scare me the most are the ones by cancer doctors who actually GET cancer and there are several of those out there too—consider I Signed as a Doctor by Laura Liberman whose title refers to the fact that when she had to sign consent for her own cancer treatment, she signed on the wrong line—the doctor’s space.  Call me superstitious but I don’t want to tempt fate.

Why do so many physicians feel compelled to write?  Ethan Canin (Carry Me Across the Water, America America) graduated from Harvard Medical School and actually practiced medicine for several years until the publication of his third novel allowed him to write full time.  He now teaches on the faculty of the Iowa Writer’s Workshop, and has been quoted as saying that “everyone has an expressive urge, but it’s particularly pronounced among those who practice medicine.”  He goes on to say, “It’s like being a soldier—you’ve seen great and terrible things.”  I don’t think being a doctor is like being a soldier because our lives are not typically in danger (although ER doctors in inner city hospitals might argue that point!)  I think of it more as a compulsion to “bear witness,” Ancient Mariner-style.  We spend much of our days writing down histories, and many of those histories give a small glimpse into the essence of what makes us human, and what gives us courage and hope.  There is nothing like a serious illness to separate the wheat from the chaff of life.

I was an English major in college, and though I will never be a John Keats or a William Carlos Williams-two of my physician-poet idols, I will never regret the time I spent reading their works, or the great works of Shakespeare and Milton and Hemingway and all the others. I may have been a bit behind in the basic sciences but that path of study gave me the tools to actually listen to my patients, to interpret what they are saying, and in turn, to be able to write down their stories.  I don’t have a major new novel swirling around in the back of my head, so for now I’ll just continue with these little vignettes.  And I would really appreciate it if my friends and readers would send me some of their own stories.  Who knows—there might be a blockbuster movie in there somewhere.  If not, there’s always law school!

On Friendship, by Jackie Widen

My adult daughter and I were having a discussion recently about friendships.  She is at that awkward age – mid 20′s and graduated from a college that is now 2,000 miles away, early married and living in a city different from where she grew up.

 

Her circle of friends has changed over these past couple of years and it distresses her.  During a great chat about the nature of friends, their evolution and how some friendships change with age, life events and geography, we were able to identify two basic types of friends.  The first type is those you meet up with in common activities–your school class, the gymnastic or cheerleader squad you’re on,  student council, your various carpools, the church youth group. Growing up, there are limitless opportunities to encounter situations where everyone has a commonality with you.   College brings on another fertile breeding ground for friends– the dorm, campus life, parties.  As the years pass and majors are fine-tuned, you find yourself with a familiar group of friends who are taking those final courses for that specialized degree.  Pacts are made to always remain close, no matter what, and for a while, those promises are easy to keep.  But then life and choices sometimes alters those bonds.

 

As the years pass these “passage friends” fall away.  Phone chats are forced or inconvenient and interests change.  People marry and begin lives that suddenly involve a new circle of acquaintances.  But then there is the second type — those special friends who stay in your heart no matter the time spent away, the miles apart, the changed interests,  the new job.

 

Kind of like me and Miranda.

 

I like to call this type of friends “forever friends” because no matter how your life changes you always have a touchstone with these special people.  I find it more so with women than men who don’t communicate as well in general.  They don’t call up their bestie to cry when their Dad suddenly dies, or when they find out they are having twins with already a 2 and 4 year old.

 

Miranda and I are polar opposites.  We met when we were 10 years old and swimming for opposing teams.  We swam different strokes and seldom competed against one another, but we were both the best at our respective events.  Circumstances brought us to join a third team during our teen years and that’s when we really became good friends.  We lived close to one another and our mothers teamed up for carpooling to and from our 2 -a day workouts  in Houston.  Back in the 1960′s we could whip across the Houston freeways from the southern areas to Memorial in 20 minutes.  Now it would take more than 20 minutes just to gain access to the freeway.  By the time I turned 14 -legal driving age back then – I was given the keys to the family vehicle and I drove us to and from our practices.  I remember when we stopped at the convenience store after morning workouts to get giant Slushees and candy bars.  We used to compare the new eye shadow colors we liked.  We even shared a boyfriend.  No!  It wasn’t anything naughty – it was just an innocent crush on a guy who turned out to be a Blue Ribbon Jerk.  But he drove a red Corvette!

 

Miranda was Jewish and I was Methodist.  That didn’t seem to matter.  In our spare time during the spring and summer we put on our little bikinis and lay out by her pool to get some color on our pale bodies.  Practicing in an indoor pool didn’t allow much tanning.  When we were bored we would look at her father’s slides; all those plastic surgery cases.  Sometimes we would wish we could trade hair.  Mine was stick straight and I had to force it to curl.  Hers was curly and frizzy and she would slather on the gel to make it behave.

 

We chose different adult life paths.  After college I married and spent my time on the Mommy Track raising 4 small children spaced way too close together.  She went off to be brilliant in medical school and excel at her challenging Internship and Residencies.   I would ask her “Isn’t it difficult to do all those long rotations?” and she would smile and answer “Not as hard as our swimming workouts.”  And when she learned I had juggled all those kids with an alcoholic husband for over 25 years – she asked “Wasn’t that horribly awful?” and I would answer “Not as hard as our swimming workouts!”  Though our commonality was rooted in our swimming days, little did we know we would be bonded for life because of discipline and hard work.

 

We’ve made the effort to try and stay in touch during the past five decades.  Gee whiz – Did I say decades?  She lives in California and I live in Texas.  When we do have dinner or occasionally chat on the phone it is like the years dissolve and we are still teenagers.  As I approach a very significant birthday, I am profoundly grateful for my “forever friend”, Miranda.  We have birthdays only 2 days apart, and so I always think of her when I celebrate my special day.  This year, my 60th (yes I am the senior, she is a baby at nearly 59) I would like to say Thank you Miranda, for being a Forever Friend.  It is a rare and special thing to call you a friend for 50 years.  As I toast myself this coming weekend, I will raise a glass for you too.  Life is so very short and we need to remember the things that matter in our lives:  Faith, Family and Friends.   Especially Forever Friends, like me and Miranda.  Happy Birthday to us!

 

Thank YOU Jackie!  I couldn’t agree more.  Miranda

From the Margins

One of the things that obsessive compulsive people do is to check things.  And recheck them.  And check them again.  The Dashboard feature on WordPress makes this habit hard to resist.  Every time I hit the Dashboard button, I can see how many people have been reading the blog, and how many times the page has been “hit.”  And if I hit the little word “Counterize” on the Dashboard, I can even see what days of the week the site gets “hit” the most, and even which hour is most popular for reading. What is even more bizarre is that I can see what people were actually searching for when they end up on my blog.  I probably shouldn’t tell you all this.   That’s another habit of obsessive compulsive people—we talk too much. But tonight, as I got home after a Christmas shopping foray to the local mall, I hit “counterize” and there, in the right hand margin, someone had googled “Is it possible to be depressed when you own a Corvette?”  Although I have not yet addressed this in the blog, I can answer that question with an unqualified and emphatic YES!  I have owned a red Corvette since my fiftieth birthday, and it is certainly possible to be depressed when you own a Corvette.  Though I will admit that getting behind the wheel and driving one really fast helps with that, at least until you get pulled over.  I have been to traffic school more times than I can count.

The other thing that is fascinating when you begin to write a blog is the sheer volume of spam that you get in the Comments section.  It took me awhile to figure out that there are programs that filter out the spam from the readers who genuinely want to comment on the writings posted.  And here I will admit that we bloggers live for your responses—otherwise what would be the point?  But some of the spam is so entertaining that I have saved it.  My son the computer genius says that these comments are generated by drone computer programs installed by people that seek out ways to link to your site or server to get traffic for their own.  Below, for your enjoyment, are a few of my best samples:

“What i do not realize is in truth how you are not really much more neatly-favored than you might be now.”   I am happy to be neatly flavored!

“I do think with the best excellent on the market today, best of all the fashionth. Your tip toes will almost always be warm each time sending these items.”  My husband can tell you my tip toes are NEVER warm.

“We accommodate all kinds of dear propertys that sink in fare in a variety of styles, colors and sizes at wholesale price. All Mother of the Bride Dresswedding dressesprom dresses”  What a shame that I need not a prom dress nor a Mother of the Bride dress. And if I did I would not want to sink in it.

And finally, best of all—“Saw a son of the building Lord, I sank into the serious thinking. I think, if not the son of the building Lord top up, is a betrayal of the truth, is the great compromise on fallacy. Therefore, I decided no top!”

I don’t know who the building Lord is, but one thing is for sure—I’m keeping my shirt on!

I Do Not Need A Concierge

My veterinarian answers my phone calls.  The other day I called her office to ask for a renewal of the pain medication for my little dog Jack.  He has been blind and deaf for over a year, but now his rear end is going and he is falling a lot and having a hard time getting up. When I asked for the medication, I did so with a certain queasiness that perhaps refilling the prescription was my way of putting off the inevitable.  Suddenly I wanted to talk to the vet.  I told the receptionist that it was not an emergency, but could she please call me back by the end of the day.  She called me back within the hour.

Today I sat with a patient who has recently been through a battery of tests to determine whether his cancer has spread.  He told me how frustrating it has been for him to call his doctors’ offices for the test results, and not receive any calls in return.  This man belongs to an HMO where he can go on line and look at his results himself.  I asked him why he did not do that and he said, “Because I am scared to read the results when I don’t know if I will understand them and there will be no one to talk to.”

Six months ago I received a letter in the mail, from the University that employs me.  The letter said that because I am faculty, I am eligible to have a “concierge doctor” at a sharply discounted price.  For a mere $5,000 a year more than the exorbitant rate I already pay for my Blue Cross PPO, I (and my spouse) will be entitled to a doctor who will see me within 48 hours if I get sick, who will help me “navigate” the system if I get cancer, who will return my phone calls within 24 hours, and who will make sure that if he is on vacation, a covering physician will see me.  My Jewish grandmother rolled over in her grave, sat up and said, “This, I should pay EXTRA for?”

Growing up in a medical family is both a blessing and a curse.  My husband and I are third generation practitioners, if you count my grandfather who was a dentist, and his grandfather who was a veterinarian.  As a consequence, we remember the days when physicians were expected to return patients’ phone calls themselves in a timely manner, guide their patients through difficult decisions and life crises, and see their patients urgently when necessary.  Merriam-Webster defines “concierge” as a person in an apartment building, usually in France, who serves as doorkeeper, landlord’s representative and janitor.  Is this what I want from my doctor?  Is this what I want to be?

My husband and I had the same reaction when we read our proffered “concierge letter.”  We want a doctor who will see us if we are sick, advise us when we have a crisis, and return our phone calls without being paid extra, because IT IS THE RIGHT THING TO DO.  This is what we expect.  This is what I provide for my own patients.  This is what all patients deserve.  If my veterinarians can behave like doctors, so can we.

You Can’t Go Home Again

“Look homeward Angel, now and melt with ruth,

And O, ye Dolphins’ waft the hapless youth”

 

In the fall of 1971, I entered Yale University as one of 250 freshman women, the third class of women to be admitted to a college still dedicated to the concept of graduating “1000 male leaders” a year.  I was seventeen and thrilled to be away from Texas and my parents. I wasted no time actually going to most of my classes, especially the 8 am conversational French class and the entirely uninteresting inorganic chemistry class which required a one mile trek up Science Hill.  When the weather turned cold, so did my dedication to chemistry and so ended my first premedical career.  By the end of the first semester, I had partied my way to earning barely passing grades in the classes I did go to, and a big “F” in the detested inorganic chemistry, which I ameliorated by groveling before the teaching assistant and swearing never to take another science class.  He passed me.  My parents’ response to my less than stellar performance was a typical Southern “You better straighten up and fly right or we will bring you right back home to the University of Houston!” And so I did.

When I graduated four years later I finally did go back to Texas for medical school, but the allure of those “bright college years” had not quite worn off—the brilliant if unappreciated professors, the gothic architecture, the endless “intellectual” conversations over cigarettes and alcohol which went late into the night and early into the morning, the snowball fights, the chess games played out on a human scale between the North and South Courts of Berkeley College, the dogwood and cherry trees blooming in the spring.  During my fourth year of medical school, I had the opportunity to do “away” rotations, the medical student’s way of testing the waters to see if a particular program might be a good place for an internship and residency.  In November of 1978, I chose to go back to Yale for my medicine “subinternship.”  During the days I roamed the wards of Yale New Haven Hospital, dutifully following my resident’s every command.  At night I huddled under an electric blanket in a spare room in the poorly heated medical student dormitory, a far cry from the hissing radiators of the undergraduate colleges.  I figured out very quickly that being an undergraduate at Yale was very different from being an intern in an inner city hospital where there was no film society or cabaret club to entertain you in the evening.  By the time applications were due, I opted out.

My own daughter graduated from Yale in 2006, and like her mother before her, entered medical school after a period of intense resistance to her life’s calling.  And like I did, so long ago, she is applying for residencies in Internal Medicine.  I told her, “Don’t bother applying to Yale, it’s not the same as being in college.”  My husband, Yale ’70, told her the same thing.  Kids don’t listen to their parents, and besides, she still has friends there.  She flew from Houston to Hartford yesterday and made her way to New Haven for interviews today.  I spoke with her tonight, and despite dinner at Mory’s, a quick stop into Atticus Bookstore Café and a mild gray cloudy day, she told me that our instincts had been confirmed.

You can sing “Boola Boola” all you want, and call yourself an “Old Blue”, but you can only be seventeen and full of dreams once.  Thomas Wolfe was right—you can’t go home again.

Dear Diary

I was talking to a friend the other day about the fact that what we now call “blogs”, we used to call diaries.  Then I said to her, “I should pull out the diaries that I kept in college and in medical school and see what my old self had to say.”  And so I did.  The first entry was October 28, 1974.  The last one was June 10, 1977.  After that, I just got too busy to write anything down—that is, until now.

One thing is for sure—I didn’t want to embarrass my future self.  I was so much more discrete back then.  I hardly ever mentioned anyone by his or her full name, which is a shame now since I cannot remember who the heck B.C and E.S  were, which somehow dilutes the profundity of my observations about them.  And I left out the really juicy parts which is even more of a shame—I mean, isn’t that what diaries are for?  Certainly not to quote Cat Stevens, which I did rather liberally, and with great feeling.

Still, upon review, there were a few things that I read tonight where I recognize the self that I have become.  In February of 1977, on my core Internal Medicine rotation, I watched a 34 year old man die of complications of lupus, a disease which was significantly less treatable then than now.  He had developed pneumonia, with fluid on both lungs which required chest tube drainage.  I wrote, “He’s been asleep since we let the fluid out.  Sometimes these days I have to turn my head and walk away from a patient’s bed so that they won’t see that I’m crying.”

In March of 1977, I had started my general surgery rotation.  I wrote, “Today I wheeled a patient out of the operating room into recovery, a nineteen year old girl who woke up from the anesthesia screaming, “Don’t let my Daddy rape me again!  Please don’t let my Daddy rape me again!”  I wonder what the hell I am doing here.”   That day I wrote a letter to a friend, saying, “I am so happy that you’re still here watching and listening and caring.  I mean somebody better be, because no matter what they say about life being too short and all, it seems like this is going to be a long haul.”

And the last entry, June 10, 1977—“What seemed so menial, so mundane becomes the only way.  Medicine is the only way.  I think I see now; medicine is not for those who hate and fear death, but for those who hate and fear loneliness.”

Sometimes it’s nice to look back and see that somehow, it all worked out.

The Care At The End Of The Road

Seven months ago, in Carbondale, Colorado, staff at the skilled nursing facility where my mother had resided for over a year recommended that she be placed on hospice.  My mother has severe advanced dementia and can no longer walk, speak, feed herself or recognize her family members. As much as I know about hospice care for cancer patients here in San Diego, I knew nothing about hospice care in Carbondale for severely demented patients.  Although we had declared my mother DNR (“Do Not Resuscitate”) when she entered the nursing facility in January of 2011, my concern was that this meant that once she was transferred to the care of hospice workers, albeit in the same bed in the same facility, she would be left alone in soiled diapers to die.  She could not ask for anything, did not need any medications for pain or otherwise, and did not respond to questions.  I envisioned that hospice had more pressing problems to deal with—for example, cancer patients in severe pain or with debilitating shortness of breath or inconsolable family members. My father was convinced, but I was not.  I could not have been more wrong.

On November 12, the news broke in the San Diego Union Tribune that the San Diego Hospice, a not for profit highly respected hospice in our area, was being audited by Medicare.  The hospice had stopped accepting patients November 10, and there was a threatened layoff of 200 of the 870 employees.  Two programs—one for HIV/AIDS and one for the parents of newborns with life threatening illnesses who were not expected to survive, were halted immediately.  And what crime did the San Diego Hospice commit?  The audit focused on whether the hospice had been “too liberal” in its admissions.  You see, in order to qualify for Medicare hospice benefits, you have to be expected to die within six months.  If you are terminal by this definition, Medicare pays $172 per day for your care.  The thing of it is that all of the patients admitted by the San Diego Hospice did not die on schedule.  The hospice spokeswoman was quoted as saying, “We put the concept of patients and what we were able to do for them above what the guidelines are.”  A day later, both the physician CEO and the CFO resigned.  Ironically, the reason that the hospice is being penalized is perhaps that the care was just too good—that by taking away fear, and providing excellent pain management and emotional support—the patients lived longer than the expected six months.  And there is no comparison “other side of the coin”—what would these patients have cost society if they had continued on active chemotherapy or radiation, or had expensive acute care hospitalizations for infection or pain management?

Medicare has been offering a hospice benefit since 1982.  In 2000, 513,000 patients took advantage of the benefit.  In 2010, 1,100,000 patients went on hospice.  The cost to Medicare was 3 billion in 2000, and 13 billion in 2010.  Do the governing bodies of Medicare truly think that this is because hospices all over America are plotting to defraud the government?  Personally, I think not.  While there is Medicare fraud in all segments of the medical and hospital businesses, I prefer to think that the increase is due to the aging of our population, the acceptance into hospice of more Alzheimer’s and other chronic disease patients, and the growing level of comfort among physicians to consider hospice when there is no chance of a reasonable recovery for their patients. Undeniably, there has been a sharp increase in the number of for profit hospices nationwide, from 34% in 2001 to 55% in 2011, causing alarms to go off and triggering Medicare audits across the country.

A week ago my father called me to say that the nursing facility in Carbondale had no other choice but to take my mother off of hospice.  The volunteers who came in to read to her, despite her lack of response, the massage therapists, the bright smiles and the occasional little gifts of lotion and a flower—are all gone. My mother, because of the excellent care she has received at the nursing home and from the local hospice, had simply failed to die on time of a bedsore, a urinary tract infection, or aspiration pneumonia.  My father is lucky—if he chooses to he can continue some of the services that hospice was providing by paying for them out of pocket.  San Diego Hospice closed the doors of its 24 bed inpatient facility yesterday.  I wonder if the patients who were being cared for by the wonderful doctors and nurses and staff there will be so lucky.

Get A Cat

I have to admit it—I never liked cats.  Actually, to be more accurate, they never liked me.  Where dogs would always drool and fawn, the cats I knew as a child were reserved and aloof, and heaven forbid you should touch them in the wrong place.  The reward could be bite marks and a row of painful scratches down the back of your hand.  When I was thirteen, I found an abandoned kitten.  She was tiny and jet black and I smuggled her into our house inside my coat, thinking that I had found the answer to the mystery of cats—one of my own, who could teach me how to be a proper cat owner.  She snuggled against me as we fell asleep that night.  Sometime later, I was awakened in the dark by a tiny monster gnawing at my earlobe. My screams of terror woke my parents, and likely the dead too, and by morning my little secret had been deposited at the local animal shelter.

When I was pregnant with my daughter, our old dog passed away, and we were amazingly without pets for three years. While I realized that with a toddler and a full time job, a large breed puppy would likely be the proverbial “straw” to break my back, I was still longing for a dog.  My best friend in Boston said, “Why don’t you get a kitten? They are SO much easier than dogs.”  I said, “I don’t like cats.”  She said, “That’s because you’ve never owned one.”  Couldn’t argue with that!  The next weekend we were at the Animal Rescue League, picking out a six month old plain gray tabby who approached us through the bars of his cage.  That boy must have known he needed to behave like a dog to win my heart, and so he did.  He came when he was called, enjoyed having his belly scratched, begged for food, and greeted me at the door every night.  His name was Max, and he taught me to love cats.  He also taught me that a cat that goes outdoors when you live next to a hundred acre nature preserve is a short lived cat.

Fast forward to 1995.  I met a woman who was a breeder of Bengal cats.  She had a litter of three kittens and she invited me over to see them.  The dam of the litter was stunning, a golden yellow with beautiful rosettes decorating her entire body.  She had three kittens, all yellow and striped.  I said, “Where are their spots?” She said, “Oh, they get them when they get older.”  Four hundred dollars later, I took home my Bengal kitten and christened him Timmy Tom.  When I took him to the vet for his shots, the receptionist took my information, the cat’s name and birthday, and wrote down “Domestic Shorthair” under breed.  I said, “Excuse me, he is a Bengal.”  Twenty minutes later, the vet pronounced my kitten healthy.  I said, “Do you know when the spots come out?”  He looked at me, smiled, and said, “How much did you pay for your yellow tabby?”  When I told him, I am sure that his guffaw could be heard at the front desk.  The receptionist giggled as I left.

Timmy Tom is a huge cat, now seventeen years old.  In his prime he was a hefty twenty one pounds, an apt illustration of hybrid vigor.  His coat has lost a bit of its shine, and he may have dropped a pound or two, but he has his eyesight, his hearing and all of his teeth.  He is the undisputed king of the household, and the giant hounds shrink back if he bares his teeth and hisses at them.  He screams at me if I am slow to slice the chicken breast he eats for breakfast every morning, and he likes his shrimp without cocktail sauce.  He never learned to cover his business in the litter box, and he does not care one iota if my bathroom smells because of it.  I exist to please him and not vice versa.  After all, he is a cat.  I am still waiting for his spots to come out.

A year ago my daughter the medical student cried and said she was lonely and missed her dogs.  I nodded sagely and gave her my best advice:  “Get a cat.  They’re easier than dogs.”  And so she did.