UGET1GO

Since California is the center of the universe when it comes to vanity, there are a whole lot of folks with so called “vanity plates” on their cars.  Here you are allowed a combination of seven letters or numbers and apart from obscenities, pretty much anything goes.  Back in Massachusetts, I had a vanity plate on my old Audi—the plate said simply CURE CA.  Most doctors know that CA is an abbreviation for cancer, but when I moved to California with my Massachusetts plates in 1993, I notice that a lot of drivers were less than pleased with my “statement” that something in California needed curing.  It didn’t take me long to figure out that the upturned middle finger from the driver in the next car had less to do with my driving than my license plate.  Or so I would like to believe.  I exchanged the MA plate for a CA plate with discrete letters and numbers, hoping to dispel the sound and fury by signifying nothing.  It helped that the new plates went on a half-ton Chevy Suburban driven by a very determined mother with three screaming kids and three hundred pounds of Scottish deerhound in the car.  People no longer gave me the finger—they just stayed out of my way.

I didn’t give the whole vanity plate thing another thought until ten years later, when I bought the red Corvette.  Corvette and I were born the same year—1953—and it seemed only fitting that I should have that red car that I had coveted my entire life for the fiftieth anniversary of our mutual birthday.  Armed with a lead foot and a 36 month no interest loan that Chevy offered for my convenience and temptation, I bought myself a fiftieth anniversary Z06, after making sure that that particular model came only with a six speed manual transmission which my two eldest and newly minted drivers would not have a clue how to drive.  And then I set about trying to figure out the perfect vanity plate for the object of my affection.  I wanted something that would scream, in seven characters or less, that sometimes it’s not just okay, but IMPORTANT to live with abandon, to have some real fun, to put the pedal to the metal.  Here in California you can check out your choice of vanity lettering on line—if your first choice is taken, you simply move on to your second, or third.  I spent one sleepless evening submitting every abbreviated derivation of that sentiment I could find, to no avail.  RUHVNFN, ULIV1C, 1XAROND, ULIV1X–they were all taken.  Eventually I found one that wasn’t taken, but by then it was late and I couldn’t decide between the palm tree and Yosemite, so I went to bed.  As I have said before, I have a fairly short attention span so I forgot about the vanity plate.

Ten years, three speeding tickets and one rolling through a stop sign later, I am a veteran of the “Corvette wave,” of traffic school, and of the exhilaration of rapid acceleration.  I was thinking about this tonight, after seeing cancer patients all day and on the eve of my father’s open heart surgery—about how Prince was right.  Sometimes you just have to say, “Move over Baby, and gimme the keys.”   After all, as we say in Texas—you only get one go.

Dear Catherine

When I saw the peonies just poking their new shoots above the ground next to your house, it was almost too much to bear. I love peonies. In 1991 we bought the house on Strawberry Hill back in Dover Massachusetts. The perennial gardens were seventy years old then, and I had no idea what was planted there. That spring was a miracle—tulips and irises and daffodils and crocuses shot up in green tendrils through the last few mounds of old snow and blossomed into a riot of color. But the peonies were a surprise—crawling with ants they lifted their heavy heads and bloomed into unparalleled delicacy. I was in awe, and the peonies and the lilacs are two of the things I will always miss from my years in Boston. I wish I had taken more photographs. When I saw your peonies, I cried for both of us.

I have been to New Mexico many many times, and I agree with all of the tourist literature and hype: New Mexico is indeed the Land of Enchantment. Everyone knows and loves Georgia O’Keefe, but in my opinion Wilson Hurley did it best. He captured the big skies and sunsets that the Navajo saw before the white folks came and that keep people like me coming back. The sunsets, and the friends I have made there hold a special grip on me. Of all of my friends, you were unique. An Army “brat”, you had lived everywhere—Florida, Europe, Japan, New York City. You were educated, you spoke several languages, you rode horses and had collies and you loved the ballet. But in the end, you came back to Albuquerque, to a home you loved. We met because of the deerhounds—in a world of instant gratification, fast food and big screen violence and romance, we were anachronisms together.

I too came back to Albuquerque–on Wednesday to help Joan settle your estate. Your parents died in 2008 and 2009—you had no brothers or sisters or children. In the end, crippled by an old accident which had shattered your legs at nineteen and dampened your spirit, you succumbed to diabetes, heart disease, infection and time. I could have done, and should have done more for you. When I visited, I always stayed at the hotel you recommended. You said, “Stay with me NEXT time, after I get the house fixed up.” I did not want to inconvenience you, and besides, having so many dogs and cats and demands at home, staying in a quiet hotel, with the soothing sounds of an air conditioner and no midnight potty calls seemed like a luxury to me.

In August, when you got sick, Joan finally had the key and let us into your house. I was appalled at the conditions you were living in. I had no idea—Natalee was supposed to be taking care of you. She failed miserably at her duties, and she took advantage of you, and I was determined that you could not, and would not go home until we had remedied the situation. We spoke in the hospital of your expansive back yard, and of the charm that the little adobe home must have had in the past. You agreed that it was time, finally, to reclaim that charm, the sun filled living room, the warmth of those thick adobe walls, the cozy bedrooms, and the photographs of the greatest dancers the world has known. You knew that it was time, and you let Joan hire a contractor. All you ever wanted was to be home by Christmas.

The house is beautiful, Catherine. The living room walls are a pale turquoise, just as you picked out. Your bedroom is the same color and the guest rooms are a lovely yellow, the color of the New Mexico sunshine. There is an amazing tub in the bathroom, perfect for a person in a wheelchair such as yourself—you just grab the handrails and do the transfer and sit on the bench while the door seals itself shut and you soak in warm water up to your neck. I am so sad that you never got to enjoy it. Joan did a wonderful job.

I miss you Catherine—your wit, your humor, your love of pretty colored gemstones, and of course the calendars you sent me each year of the handsomest men in the world. I know you always favored Viggo, but you humored me with photos of Gerard Butler and Sean Bean and Orlando Bloom and Javier Bardem and Olivier Martinez. I will keep those calendars forever, to remind me that we, you and I, can always dream of handsome men and beautiful jewels. I hope that your deerhounds met you at the “bridge”, and that you are there as in your youth, dancing in your finest pearls.

For the rest of us, tell the people you love, that you love them every day. You never know when you won’t get a chance to anymore.

Denial Is Not a River in Egypt

If you desire healing,
let yourself fall ill
let yourself fall ill.”
Rumi

Yesterday I saw a patient—an 80 year old woman with metastatic cancer involving her bones.  She had near complete replacement of her twelfth thoracic vertebra by tumor, and also significant destruction of her fourth and fifth lumbar vertebrae, demonstrated by PET-CT scan and bone scan.  She had so much pain in her legs that it was difficult to walk.  In attempting to discertain whether her pain was coming from her thoracic or her lumbar spine, I asked her a series of questions.  The only answers I got were that she had slipped while getting into the bathtub a few weeks ago and that her pain was in her left ankle and her right thigh, both of which had been X-rayed and were normal.  Questioning her about her bowel and bladder function was also unrevealing—sure, she had problems with both, but that was because of the radiation she received in 2009.  It would seem as though her cancer was causing her no pain at all, yet that was why her medical oncologist had asked for a stat referral.  After 30 minutes of discussing her bathtub mishap, her daughter had had enough.  She nudged her mother and said, “Mom, you KNOW that is not why we are here.”

My eighty seven year old father has been similarly reluctant to attribute his recent symptoms to his failing aortic valve.  Despite being told last summer that he had aortic stenosis, he asserted to his cardiologist that he had no chest pain, only a little shortness of breath with exertion.  He was able to walk downhill the eight tenths of a mile to his tennis club, but walking back up had become more difficult.  In December, he was still playing doubles tennis despite the fact that he had squeezing chest pressure which occurred with exercise, and was relieved by rest.  His cardiologist believed him—that his symptoms were pulmonary rather than cardiac.  The pulmonary doctor from Denver was summoned, and the lung consultation was exhaustive.  The conclusion was that my father had nothing wrong with his lungs.  My father, who by the way is a physician himself, could not admit that his symptoms were classic angina pectoris, and were worsening to the point where he was having them with minimal exertion. For the last two months he has insisted to every doctor who has interviewed him, “I have no chest PAIN, only a little squeezing pressure when I exercise.”  The result has been undiagnosed congestive heart failure which would have killed him, if he had not contracted an upper respiratory infection which landed him in the hospital and led to the real diagnosis.

I admire the stoics, the non-complainers.  I am not one of them.  When I have an ache or a pain, the entire world knows about it.  But there should be a limit to stoicism and that limit should be where the patient who is in denial is doing himself harm.  On Monday, my patient will undergo a CT simulation for radiation treatment of her thoracic and lumbar vertebrae before she suffers from a spinal cord compression and paralysis from her cancer.  On Tuesday my father will have his aortic valve replaced.  May they both emerge from their ordeals physically and mentally intact.  And may their doctors, including myself, learn to diagnose and treat these patients before they do themselves irreversible damage.

Closing up Shop

They say that as we age, time accelerates.  Those endless waits for summer vacations, Christmas and our birthdays that we experienced at age six, become a mere blink of an eye at age sixty.  And if you’re approaching sixty, you will remember, like I do, those old Kodak commercials:  “Turn around, turn around, turn around and they’re gone.”  Indeed they are.

 

A few weeks ago I visited a good friend in Arizona.  We were talking about her horse, a beautiful and rare Fell pony that she bought as a two year old stud colt, mahogany bay and full of promise.  She has had very little time to train or ride him, and now gelded, he lives on her small ranch, solitary and unworked.  I asked her, “What are you going to do with Scooby?  He’s six and a half now, and he’s being wasted.  Surely there are people who would love to have him as a riding or driving pony!”  She protested, “There is NO way he could be six years old already!”  I replied, “Oh yes, he most certainly is—I remember driving with my daughter from California to Texas four years ago when she started medical school.  We stopped in to see your new horse. You had just gotten him—he was two and a half. You know she is graduating in two months.”  She was completely taken aback.  How is it possible that four years have gone by this quickly?

 

Four years ago we came to Texas and looked at condominiums to buy.  Texas is very supportive of its young doctors in training—if you become a homeowner, after one year you qualify to become a state resident, and the cost of attending medical school drops by two thirds.  Texas of course, has that Texan way of thinking—if you live here for a few years, and grow to know and love the state, you won’t ever want to leave.  In many cases, it’s true, and those of us who eventually do leave feel pangs of regret and forever when asked, we say, “I’m from Texas.”  Four years ago, we looked at my parents condominium—empty and unused after they retired and left for the mountains of Aspen, Colorado.  The maintenance costs were too high, and we settled on a nice one bedroom within walking distance from the Texas Medical Center, the Museum District and the live oak shaded avenues around Rice University.  My daughter has loved living here, in this light filled place with her cat perched on the eighth floor windowsill.

 

My parents’ place is now “under agreement” and I spent the day Thursday sorting through their possessions that remain there.  Today my daughter and I will do the same for her place, and this afternoon we meet with a realtor.  Four years—still a near eternity for her, with the rigors of medical school being what they are.  For me, a mere blink of an eye.

Back to the Future

I am in Houston, Texas today—the place where I grew up.  From the moment I got off the plane on Wednesday, I had a strong sense of déjà vu—the small town feel of Hobby Airport, the banners welcoming me to the Houston Fat Stock Show and Rodeo, the drive to the Texas Medical Center where I visited my Dad at his office as a child.  But there is no possible sense of déjà vu more powerful than I felt today, in the sunny courtyard of my former medical school, waiting for the results of “The Match” to be unveiled.  For those of my readers who are not doctors, and who do not come from medical families, the Ides of March is the day that every fourth year medical student in the country finds out where they are going to do their residency.  Earlier in the year, aspiring internists, pediatricians, surgeons and obstetricians applied for internships and residencies, interviewed and finally made a list, in order of preference, of programs they wished fervently to attend.  Residency programs did the same, for students they fervently wished to attract.  And then a computer program called the National Residency Matching Program did its thing.  Today at precisely 12 pm EST, the results were announced in a white envelope.  The tension, as they say, was palpable.

 

Exactly 34 years ago today, I stood in the same place as my daughter stood today and felt my life change.  I would be leaving my hometown, my boyfriend, and last but not least my dog, to move to a city where I knew absolutely no one, because I had been given the gift of an opportunity to do my internal medicine residency at Boston’s Beth Israel Hospital, now known as Beth Israel-Deaconess Medical Center, one of the three Harvard training programs in internal medicine.  While I was there, I learned to practice medicine from some of the finest teachers and clinicians I have ever met, people who remain friends and mentors to this day.  I met my best friends, I married my husband, I got my first Scottish deerhound and I had my three children there in that order.  I hated the cold weather, but I loved the values which were instilled in me there, and which I hold to this day—in medicine, the patient always comes first;  family and tradition are paramount, and the Red Sox must ALWAYS beat the Yankees.

 

At 11:02 today Central Standard Time, the waiting and the culmination of four hard years ended.  My daughter opened her envelope and learned that she too would be headed for Boston, to the same place her father and I met so many years ago.  I think she was very pleased.  As for me—well, I did what any proud parent would do.  I beamed, took a picture, and burst into tears.   Well done, Alex, and I hope I didn’t embarrass you too much!

Long Ago and Far Away

I got a call a few days ago from Sandy Arledge.  Sandy is semi-retired now, but when my kids were growing up she was the owner of a magical place called Far West Farms.  Just a few miles from the ocean, between the strip malls of Del Mar Highlands and the housing developments that crowd the coastal cities of Southern California, Sandy managed to live out her girlhood dream.  In her thirties she gave up her lucrative law practice, bought one of the last remaining tracts of ranch land in Del Mar, and set out to establish the premier Quarter Horse breeding and training operation in California.  In doing so she turned an entire generation of children, including my own, into cowboys and cowgirls.

The reason that Sandy contacted me, long after my last kid hung up his spurs, was that she had received a call from a horse rescue group up in Los Angeles.  An older horse had been abandoned in Baldwin Park, starved nearly to death.  A rescue group took him in, and after feeding him and getting cleaned up, they noticed a brand on his left shoulder, a simple five pointed star known internationally as the brand of Sandy Arledge Quarter Horses.  Thinking he might live, they christened him Winston.  They photographed his markings and notified Sandy to ask if she recognized him.  She thought she did—that he might be Romeo, a handsome dark bay colt I bought sixteen years ago today, the day he came out of his mother Jinny Jiggs who was the closest thing to a saint on four legs that ever lived, when it came to teaching the young’uns how to ride.  Romeo’s registered name was Justa Believer, which fit right in with my line of optimism.  When Romeo was three years old, I mistakenly decided I had too many horses (can one EVER have TOO many horses?) and I sold him.  I’ve made a lot of less than smart decisions when it comes to horses, but considering what I kept, that one was one of the dumbest.

When Sandy described the horse’s markings to me, I realized with a great deal of relief and a twinge of sadness that it was not Romeo, and I confirmed that when I got home from work that evening since I had kept a copy of his papers.  Relief because I would be mortified to think that a horse that I sold in good faith could end up like that, abandoned and unloved, and a twinge of sadness because had he been my long ago colt, I would have brought him home.  As I searched for my copy of his registration papers through old files containing pictures of horses long past, the memories of Far West came flooding back—my oldest son getting his first horse Harmony for his eighth birthday, my daughter trying to convert old Rosie from a pony hunter back into a Western trail horse, my youngest son, chubby and five years old proudly perched on an equally chubby mare holding up his ribbons at the Del Mar National Horse Show.

Sandy sold Far West Farms in 2006 to play a major role in the American Quarter Horse Association, and to travel and consult.  But like the true horsewoman and the responsible breeder that she is, she never stopped caring about the horses she bred.  She will find out who Winston really is, and she will make sure he never suffers again.  As for me and my grown up children, we’ll never forget the lessons and the trail rides and the horses we loved there near the ocean, the sea breezes blowing us the smells of salt, sweat and love.  Thanks again, Sandy, for Far West Farms.

The Irony of It All

My son wants a government job. After obtaining a Masters degree in Public Policy, with an emphasis on economics, he was the envy of his classmates when he actually got a job.  He has been working for the last seven months for a giant consulting corporation.  Early every Monday morning, at the bidding of his superiors, he takes an early flight from Los Angeles to Denver.  Once he gets there, he rents a car and drives it to the company where he is consulting to remedy an old story—the company grew too big, too fast, and the folks who had the great idea, and who started their little company at the ground floor are baffled and bewildered by the demands of a grown up interstate business.   My son works from early in the morning until early in the morning—sixteen to seventeen hour days being the norm.  At the end of the week, he flies back to Los Angeles, where he actually lives.  By the end of this month, he will hear whether he won the Presidential Management Fellowship he applied for.  If he did, he will go to Washington, DC and join one of the bureaus or the State department where he will learn the intricacies of our government while making low wages and in all likelihood, being expected to work nine to five.

I don’t get it, as much as I admire public service.  Perhaps it is because I actually HAVE a government job, but only in the sense that I am paid through the University of California. My benefits and retirement plan are top notch.  My mentality however, if not my salary, is still back in the private practice customer service mode.  In my little satellite department, we start early and we work late and we get the job of treating cancer patients done, no matter how long it takes.  When I took this job five and a half years ago, I was at the “mother ship” cancer center for a year, while the satellite was being built.  This gave me the opportunity, for the first time in my career, to observe folks who actually treat the business—no, the “calling”—of caring for cancer patients as a government job.  Each role, whether it be receptionist, billing specialist, or medical assistant is fragmented down to its smallest components, and each person is judged by whether they can manage their own limited but particular task.  Never have the words “not in my job description” been adhered to so strictly.

When I hired my staff for the new satellite in 2008, my prime objective was to get people who shared my vision of service to patients, and who I knew would go above and beyond their job descriptions if necessary.  People who could cross cover other department members, and who were eager to learn new skills were at the top of my list.  I did not want to hire anyone who used an answering machine to screen calls.  I wanted one thing—plain and simple—commitment to the best care for our mutual patients.  No matter what the job description or who pays the salary and the rent, caring for cancer patients cannot be just another “government job.”

I know my son well enough to know that wherever he lands, he will be a leader, and he will strive for excellence and demand that others do so as well.  Give him a little time, and the government may never be the same!

When Only a Dog Will Do

My husband used to be afraid to leave town.  He travelled a lot on business, and he never knew what he might come home to.  That is because when I get stressed, as is often the case, and if chocolate and a good glass of red wine fail to comfort me, I tend to look for something warm and fuzzy.  Most of the time, a new dog is just the thing.  Sometimes a horse, sometimes a cat, occasionally a guinea pig or two, and I daresay there were some fish—but mostly it was a new dog.  At some point, the husband put his foot down.   He decreed, “No animal shall set foot in this home unless another animal leaves!”  He knew that there was only ONE way an animal ever leaves my care—and that is if they die.  Have I mentioned that there are two horses in my backyard who are going to be twenty eight and twenty five respectively this May?  May they live forever—good old Norman and Dash!  Still, I am a good girl.  I try to play by the rules.  But it was time.

I have written my obituaries for my dogs on this blog.  If you are new here, read “Empty Chairs at Empty Tables” and “A Dog Story.”   I am sentimental.  My dogs, when they go, are irreplaceable.  But that does not mean one should not try.  When we put Jack down in December, I could not actually believe how much I missed my eleven pound Brussels Griffon—the one who made me a caricature of myself—a slightly pudgy middle aged woman with a toy dog who was never adequately housebroken and who yapped constantly to the point where I think he knew his name was “Shut the F-ck Up Jack!”.  I know, it’s horrible, but it was true.  When he went blind and deaf he finally stopped barking, and everyone who came to my house was saddened by the silence.

So I admit that I was vulnerable, when a veterinarian friend up in the Oakland area posted a photo on Facebook, of a little white dog with dark stains under his big brown eyes and oversized ears.  He had been found running in the middle of Fremont Avenue, starving, flea infested and loaded with tapeworm.  Someone had likely tossed him out of a car, and a client of my friend had halted traffic to pick him up.  He weighed five and a half pounds, and you could feel every rib.  My friend and her vet techs named him Yoda, and the name stuck.  I was in the Galapagos on vacation when I happened to sign onto Facebook and see his little face, with a sign hanging around his neck saying, “My name is Yoda.  I need a new home.”

Yoda lives here now.  He is a tiny mixed breed being, likely a terrier-Chihuahua mix. He is loving and kind and does not bark, except when we go out at night and he senses the coyotes lingering just beyond the fence line.  We are working on the housebreaking, and he’s smart enough to get it.  He’s put on a bit of weight, to the point where I’ll have to watch it. Like any creature starved for food and affection, he can’t get enough of either.  The deerhounds are tolerant—I think they missed their little dog too.  The cat is not amused.  Despite the stress of my job, and my concern over my father who will shortly be undergoing aortic valve replacement, this little dog makes me smile.  If you too are worried and stressed, here’s a bit of advice for you:  Get a dog.

Thanks For Your Support

My husband likes to say, “No good deed goes unpunished.”  I don’t always agree, but sometimes you just can’t argue that concept.  One of my favorite patients, a forty nine year old woman who I treated for head and neck cancer a year ago is a good case in point. Head and neck cancer is on the rise, and is linked, like cervical cancer, to infection with human papilloma virus which is sexually transmitted.  Patients who are treated for this type of cancer have a very rough time.  Typically, curative treatment these days involves combining chemotherapy and radiation, reserving surgery for salvage in the case of an incomplete response or recurrence.  Patients have severe mucositis, inflammation of the oral cavity and the throat, and oftentimes require a feeding tube for nutrition. They lose their sense of taste, they are hoarse, their mouths are intolerably dry, and they are fatigued and miserable.  The good news, however, is that the majority of these patients are cured, even with advanced stage disease.  Many go on to be advocates for others just starting on their journeys.

It was with this in mind that my patient’s ear nose and throat doctor asked if she would mind speaking to a man of similar age and circumstance who had been recently diagnosed.  Of course she agreed.  She had been through the war, won the battle and wanted to help if she could.  She called him and they spoke at length about treatment side effects.  But something seemed a little “off.” Soon he was calling and texting her daily.  He wanted to meet her.  She politely declined, but she invited him to attend an event at our cancer center celebrating survivorship, and the role of complementary therapies.  He wanted more.  Soon his urgent text messages dominated her cell phone, culminating in the question, “So how did you get your HPV infection?  You must really like oral sex!”   She got a restraining order.

I saw another patient a week ago with breast cancer for an initial consultation.  She was very nervous, unduly so considering that her cancer was detected very early and she had completed her lumpectomy and sentinel node dissection.  The tumor was tiny, the nodes were negative and she was not going to need chemotherapy.  When I could not dispel her anxiety, she finally confessed that another breast cancer patient of mine had sent her a picture on her cell phone of her breast at the end of treatment, at the peak of her skin reaction.  This other patient had undergone chemotherapy first, which sensitizes the skin to radiation; she was large breasted which also increases the skin reaction; and she had refused to follow advice regarding her skin reaction.  She had an area of moist desquamation—peeling skin—in the inframammary fold.  She is now completely healed, with no permanent skin changes, but in the interim she deemed it important to frighten a new patient nearly to the point of refusing therapy.

Many years ago another head and neck cancer patient said to me, “When I found out I had cancer, I joined a club that I never wanted to be a member of.”  Support groups can be wonderful—many of my patients tell me they have met their best friends at group support meetings.  But always beware of people with hidden agendas.  When it comes to cancer support, there are far too many of these.