This Old House

When I lived in Boston many years ago, there was a show on television called “This Old House.” Each season of the show, the host Bob Vila, handyman, architect, contractor and visionary would select an old house in the Boston vicinity. Many times, these homes were not merely in need of renovation—they were in need of resurrection. Week after week, episode after episode I would stare at the screen transfixed as new masonry replaced crumbling stone walls, and beautiful decorative moldings emerged from coats of old paint, much of it leaded. I marveled at the fact that one did not have to destroy an old house, raze it and tear it to the ground in order to have a new and better house emerge. It was all about preserving the “bones”, the integrity and the beauty while bringing new technology and materials to bear.

 

My husband and I owned two old houses when we lived in the Boston area more than twenty years ago. The second house was a Georgian style colonial, built in the 1920’s from red brick left over from building the “houses” at Harvard. When I first saw the house, it had been untouched since its birth during the Jazz Age. Strings of glass flapper beads hung in the opening between the dining room and the old closet that served as a kitchen. Gilded tin repousse valences topped windows that showed bubbles in the old glass. There was a foot of standing water in the basement. The well, as it turned out, had been dug on the neighbor’s property—folks just didn’t seem to pay all that much attention to property lines back then. I was instantly smitten. Two years, and my entire salary for those two years later, the old place was fine indeed, with a new kitchen, a new family room and a new master suite. Oh, and a new well. We made the final payment to the contractor and a week later, watched as our belongings were loaded onto a van for the move to San Diego. I cried.

 

Last Sunday I begged my daughter’s indulgence as we drove out Route 9 to Route 16 to the rural town of Sherborn, so we could cruise by—not the brilliantly renovated Georgian colonial–but the very first house we bought when we got married in 1980, an 1860’s post and beam Victorian, quite ridden with decay by the time we made our proud purchase. As we passed the old place at 10 Everett Street, I made her mortification complete as I spotted what appeared to be the latest owner in the driveway and hopped out of the car wielding my camera to introduce myself. When we lived there, the house was very small, barely 1500 square feet. Using Google Earth, I had convinced myself that the old homestead had been torn down and a brand new house built.

 

Staring wide eyed at the beautiful home in front of me, I realized that was not the case. The old aluminum siding had been taken down revealing the classic Victorian “fish scales” under the peaked eaves of the roof along with moldings mounted in a zig zag pattern, painted a dark burgundy against the pale khaki of the wood outer walls and the dark green window trim. The carriage house, which had been in a state of near collapse when we owned the place, had been shored up and connected to the main house with a new family room. The old garage apartment was now an art studio. Smiling, the owner invited me in. The front door still had its rippled stained glass, and the hardwood knotty pine floors underfoot still carried the coats of polyurethane my husband applied 33 years ago when he sanded the old paint off in a labor of sweat and love. She said, “We saved everything that was good about this place. We love it here. We will never leave.”

 
She led me through the house to the expansive back yard, the place where our first deerhounds ran to their hearts content and my daughter picked lilacs and forsythia and blueberries in the spring. She said, “I saved the best for last.” Suddenly, I spotted a new structure—a wooden barn painted to match the house. Two horses grazed in the field. Inside the barn was hung a painted sign which read, “It’s never too late to live happily ever after.” We romanticize our past when we should be planning our future. Happily ever after, indeed.

Nina

Sometimes you just get lucky. When I was pregnant with my first child, during my radiation oncology residency, we had a guy living in the apartment over our garage, which we liked to refer to as “the carriage house.” He was a dog trainer by trade, and in his spare time he played softball in a local adult league. When we told him he had to move out, because we wanted the apartment for a live in childcare provider, he had a different idea. He wanted us to hire a woman he knew—the mother of one of his softball teammates. He told us about this woman in detail—that she was the mother of six children and that she had also raised her nieces and nephews when their parents were killed in a car crash, and that she was currently doing foster care for the state but had grown tired of that and disillusioned with “the system. “ He pronounced, without a shadow of doubt, “She will be PERFECT for you.”

 

Nina came to interview on a hot summer day, and she never left. At least not until we left HER to move to San Diego almost nine years later. We never checked another reference and we never interviewed another person. There was just something about her that seemed so, well, “motherly. “ That was it. She was uneducated, grew up in a poor family in Newfoundland Canada, and we only learned later that she could barely spell when she began to write down phone messages while we were at work during the day, after my maternity leave was over. It mattered not a whit. My only hesitation in hiring her was that she was fifty-six years old at the time. Since I was only thirty, I thought that was old. I think differently now.

 

About a month into Nina’s tenure with our family, my father called to ask how things were going with our new babysitter. I told him, “She’s fine, but she has one annoying habit. She shows up at work early every day. It cuts into my bonding time with my baby.” Really, I said that. My father, having relied on my mother to raise HIS three children, retorted, “And this is a PROBLEM? Do you realize how LUCKY you are?” That may have been the smartest thing my father ever said to me.

 

A year after we left Boston, Nina suffered a massive heart attack while watching the Boston Marathon. She was rushed to Brigham and Women’s Hospital, and had emergency bypass surgery and survived. A few years after that, she was diagnosed with inoperable esophageal cancer, and underwent chemotherapy and radiation therapy and again, she survived. Last year, she lost Charlie, her beloved husband of more than sixty years, and still, she survived. And two months ago she fell, hit her head and had a subdural hematoma. At eighty-five years old, she is the definition of “survivor.”

 

On our way to Boston, my daughter said, “I think we should go see Nina on Sunday.” The last time she saw Nina was nearly ten years ago, when she was in college. So Sunday we drove out to Framingham, where her old babysitter lives in a senior housing project, attended to by her daughters who live close by. On the way there, we passed the Sunshine Dairy, where Nina used to take her for ice cream as a child. Alex said, “We have to get some for Nina. She loves their maple walnut. “ She was right. We were greeted at the door by Nina, a very diminished and frail Nina wearing a single strand of pearls I bought her for her sixtieth birthday. She smiled at us, and congratulated my daughter on her medical school graduation. I burst into tears. This woman more than anyone else, had made it all possible.

 

Young woman doctors—residents, fellows and medical students—sometimes ask me how to choose a “nanny”, as they are called now. I have no idea. Mine seemed to fall into my lap and stayed forever in my heart. I hope fervently for these young mothers that they get as lucky as I was.

The Red Baton

 

While I was in Boston last week, I got an email addressed to the School of Medicine faculty group from the president of the first year medical school class. It was an invitation to attend a ceremony which took place three days ago, on the courtyard lawn of the medical school. This ceremony was being held to honor those who had donated their bodies to science, more precisely to the anatomy lab where all first years learn to dissect out the intricacies of the human body. Families of the deceased donors were also invited to this event, an appreciation organized by the medical students. The class president urged as many medical students and faculty to attend as possible. I had never heard of such a ceremony but if I had not been out of town, I would have gone.

 
It was getting late last Wednesday night when we drove through Baton Rouge, Louisiana. When I saw the highway signs, I wondered about the significance of the name. As a little girl growing up in Texas, I had taken baton-twirling lessons, like every other little girl in Texas. Those lessons were short lived—I did not quite have the manual dexterity necessary to play that stick back and forth between my short chubby fingers. In high school I learned a new meaning for baton–that it was the stick passed from runner to runner during a relay race. I made a mental note to look up Baton Rouge when I got to the hotel since I thought perhaps I could use the meaning as a metaphor, having just “passed the baton” to my daughter, the newly minted doctor. Wikipedia disavowed me of that notion. Baton Rouge LA, or “red stick” was named quite literally after a cypress stick that the early French discoverer of the locale, Pierre Le Moyne, Sieur d’ Iberville, had found planted in a riverbed adorned with the bodies and blood of slaughtered animals to mark the boundary between the Bayou Goula and Houma tribal territories. By the early 1800′s the upper tribes of the Creek were known as the “Red Stick Warriors.”

 
It’s been a week or so now, but I’ve been thinking that perhaps that “red stick” analogy wasn’t so far off the mark after all. The bodies of those donors mark the end of the territory of innocence for a medical student. No matter how much black humor is displayed in the lab by nervous students wielding a scalpel for the first time, there is honor and dignity in there too. Along the way, the students see more bodies and more blood, both literally and figuratively as patients live and die by their hands, and new priorities and goals emerge, while old friendships and even marriages fall away. Parents send children away to college, and in these days of prolonged dependence and economic hardship, many times children return. At medical school graduation last Tuesday night, I saw no children wearing caps and gowns. A new generation emerged to wage war on sickness. The baton has indeed been passed.

Trot Trot to Boston

“Trot trot to Boston

Trot trot to Lynn

Watch out Baby

So you don’t FALL IN!”

Nursery Rhyme

My road trip expectations always exceed their reality.   Last Wednesday evening, after a frantic day of packing which included a trip to the tailor to pick up her favorite dress being repaired for a ripped hemline, my daughter and I set out in her aged Subaru for Boston, MA where she will begin her residency in Internal Medicine in a few weeks.   The last time I did this particular road trip was 1979, when I myself set out in my bright red Camaro—armed with a six foot five male friend and apartment neighbor whose airfare home was paid by my parents in return for his perceived protection.  My daughter had to settle for a Taser.   Last time we barreled through Montgomery AL, Atlanta GA and Washington DC where the unfortunate Camaro had its side bashed in by a group of inebriated sailors returning from a night on the town.  We drove all day and most of the night, my friend Ed’s CB radio alerting us to lurking highway patrol cars ahead.  I didn’t see much of the countryside but I did learn my fare share of trucker lingo, including a meaning for the word “beaver” that in my naivete, I had never even considered.

 

This time was going to be different.  I polled patients and friends alike regarding the best, most scenic route to take.  One of my patients, a former long distance trucker, voted for a drive through the eastern part of Tennessee and the western half of Virginia, declaring definitively that the truck stops there had both the best restrooms and the best souvenirs.  My dog showing friends, who regularly hit the road with Hyundais full of hounds concurred.  I imagined myself lazily browsing for antiques along the back roads of Knoxville, and scanning the craft shops of Gatlinburg for handmade brooms, the better to sweep up the ever present dog hair collecting behind the furniture at home.  I dispatched my daughter’s cat to the boarding kennel and bought her a cheap ticket to go retrieve him once she had settled in, since several days in a car with the perfume of kitty litter was not my idea of a vacation, no matter how well behaved or adorable the cat.

 

Despite a first evening arrival in New Orleans at nearly 1 am, and spending the night without either the food or beverages the city is known for, my back road dreams were still intact when we reached Knoxville late on day 2.  It was the morning of the third day, when two locals laughed across the aisle at the Cracker Barrel at my mispronunciation of Sevierville (it’s SEVERE-ville, not SEAVER-ville, for the uninitiated) before they revealed that Gatlinburg, and the entrance to the Great Smokey Mountain National Park were at least a 45 minute drive each way from the highway, when it finally dawned on me that one does not drive nearly 2,000 miles in 3 days and sightsee along the way.   No trips down the off ramps to sample the fare at local diners, no sweeping vistas to photograph at 80 miles an hour, no local yellow dogs rolling over to have their white bellies scratched.   It was Boston or bust, and we coasted into Beantown on Saturday night of the holiday weekend, having taken  nearly 5 hours to drive in pouring rain around the city of New York.

 

One of these years, I will climb in my old Suburban “Big Red”, 200,000 miles and counting, and really drive across this great country of ours and I will stop along the way, whenever I want for as long as I want.  I will buy Cajun hot sauce, brooms made of fresh straw and local honey along the way. But for now—mission accomplished—in good time, with good company!  Tomorrow, back to work with my back road daydreams.

Happy Mother’s Day

They lied to us, they did–Betty Friedan and Gloria Steinem and all the others who told us back in the 60’s and 70’s that we could have it all. Or maybe they weren’t exactly lying to the impressionable girls graduating from high school and like me, beginning their college and subsequent careers as professionals in schools and fields once exclusively reserved for men.  Maybe they truly didn’t know the physical and emotional tolls our lofty goals would exact on ourselves, our marriages and our children.  We have come of age now, and we are tired.

To the stay at home moms, who ran the carpools, acted as room mothers, cheered at every Little League game and had a healthy dinner on the table at six pm, I salute you.  I was secretly envious of the time you were able to spend with your children.  You didn’t miss a thing in their lives, and if you were secretly envious of me—my financial independence, my ability to walk out the door in the morning and leave the chaos behind to enter the adult world where you could actually reason with people most of the time—I never knew it.

To my fellow female doctors, lawyers, business women, veterinarians and leaders in industry, I salute you also.  No matter how tired you were at the end of the day, you made time for your children—you rushed out of work to get to the ballet recital, you helped with their homework, you got down on the floor and you played games when your back hurt and your eyelids were closing as you read “Goodnight Moon” one more time.  You were consumed by guilt most of the time—at work when you felt you could not give it your all after a sleepless night, at home when your child called you by your caregiver’s name.

This Mother’s Day is my first without a mother—she passed away in January, having lived her life as the wife of a busy plastic surgeon—the endless nights of caring for three children while he was on call, the arguments over promised wealth as a private practitioner versus the academic life he chose, the pampered later years when she could and did have anything she wanted.  But when I was a sophomore in college, majoring in English, she took me aside and said, “You have to DO something!  Don’t be like me. You must choose a career where you never have to depend on anyone but yourself.”  I listened and went to medical school.  Forty years later, it was the right choice for me.

When I was a junior medical resident at Beth Israel Hospital, Betty Friedan’s daughter Emily was one of my medical students.  In a week, my own daughter graduates from medical school.  As my children grew up, I had only one bit of advice for them that I remember repeating like a mantra:  Whatever you do, wherever you go, at the end of the day, every day, be able to look in the mirror and feel good about yourself.

And don’t think it’s going to be easy.  Motherhood never is.  Happy Mother’s Day everyone!

Such Stuff as Dreams Are Made On

Yesterday I had the unique experience of watching a production of William Shakespeare’s The Tempest, acted, with musical accompaniment, entirely by a group of fifth graders.  Friends of mine from Los Angeles, himself a teacher at the Hobart Boulevard public elementary school, had invited me to this year’s presentation by the Hobart Shakespeareans.  As many of you know, punctuality has never been one of my virtues, and the 105 mile drive, coupled with the infamous LA traffic, had me sweating before I even took my seat.  But once I had clamored over Kurt’s knees and nearly fallen into Heather’s lap, I settled in for nearly three hours of pure magic, and not just the magic of Propero, the magician of the Tempest.

 

Begun years ago by their remarkable teacher Rafe Esquith, the fifth grade Hobart Shakespeareans of Room 56 are a group of underserved, underfunded children of largely Korean and Mexican first generation parents.  Many do not speak English when they arrive at school, many are on federally funded school lunch programs.  But by the fifth grade, those children lucky enough to be in Room 56 have studied the works of Will to the extent that they produce, in full Elizabethan English tempered with the sounds of rock and roll, reggae and Beethoven, a Shakespearean masterpiece a year.  When the lights went down yesterday, at 11 am, I was transported, and overwhelmed–and instantly moved to tears.

 

As an English major in college, the teaching of the humanities, and English in particular, has always been near and dear to my heart.  I believe that by studying great works of literature, and Shakespeare in particular, one can experience the breadth and scope of human emotion—joy, sorrow, aspiration, suffering, love, longing, mystery and hope—in short, most of the qualities necessary to become a good doctor.  Sadly, college premedical requirements do not include more than a cursory English class or two, mainly to make sure that a student can string together a few words to write a sentence.  The world of science and medicine has become infinitely more complicated in the last several decades—there is so much to learn about biochemistry that taking on “extras” like an advanced literature class, or an art class or a philosophy class becomes a burden, instead of a pleasure.  While many medical schools encourage non-science majors to apply, the truth of the matter is that humanities majors are significantly disadvantaged when it comes to taking the MCATs and showing publications on their resumes.

 

The Hobart Shakespeareans come to school at 7 am, and stay until 5 pm.  They learn math, and science, and history and geography and government but lunchtime is reserved for rock and roll guitar lessons.   They wear T-shirts with the face of William Shakespeare and the caption, Will Power.  Judging from the college banners placed around the perimeter of room 56, and the names below them, ultimately they attend Yale, and Harvard, and UCLA and Stanford, as often if not more than their more privileged peers.  And many of them will become doctors. They live by the motto:  “Be Nice. Work Hard.”

 

We can all take a lesson from that.

 

For more about Rafe Esquith and the Hobart Shakespeareans, go to www.hobartshakespeareans.org

There Are No Shortcuts

“SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.”    The House of God

At roughly 3 o’clock yesterday I was putting together a hasty lunch in our tiny break room.  It was nothing special, just the usual—fresh mozzarella cheese and a sliced tomato sweetened with a very nice balsamic vinaigrette. More calories in than out, but what the heck—it tastes good.  As I put one forkful to mouth before scurrying back to my office to hide for five minutes, my office manager approached.  She said, “I am so sorry Dr. Fielding.  I forgot to tell you—you will have a third year medical student with you next week. She wants to go into radiation oncology.  She asked me for a list of patients that you will be seeing so that she can look up the records and get started on the history and physical notes ahead of time, to make it easier for you.”

I resisted the urge for intense sarcasm and searched for a meaningful reply.  I said, “Please tell her that she will have plenty of time with the new patients to elicit a history and to do a physical exam.  There is no need to prepare ahead of time.” My physicist was standing in the break room and looked at me questioningly.  I asked him, “Well, would YOU want your doctor to record your history and physical before even SEEING you?”  He replied, “No, but I see no reason to throw out all of the information available in the electronic medical record either.  I think it’s a way to improve efficiency.”  Spoken like a true physicist.  I am old fashioned.  I stood there slack jawed.

And then I replied, and here is what I said:  Patients forget important information.  Patients lie to physicians they have not yet learned to trust.  Patients are in denial.  Patients may detest one doctor—for the length of his hair, the sneakers on his feet, the color of his skin.  And they may open up to the next.  They may remember important details that they had forgotten, or their sister may have called from Buffalo to say that Grandma died of breast cancer, not of “bone cancer” when the cancer spread to her skeletal system.  They may admit, finally, that they are dependent on alcohol, or oxycontin, or vicodin and they may be seeking help, this time around.  And without questioning that patient, we may never know.

So here is what I really think.  The electronic medical record, or EMR as we like to call it, has unquestionably made my life easier. With templating, and Dragonspeak, the time and work it takes to dictate a history and physical and impression and recommendations has been dramatically reduced, and I am most appreciative.  But a patient is still a patient—real flesh and blood and emotions and memories that may or may not serve my purpose adequately.  We need to keep trying to get to the truth.  We need to stop propagating and repropagating the “untruths”. Without our truest and sincerest effort, all of our medicine may not provide a cure.

I told my office manager to tell the prospective student:  No need to cut and paste the history and physical ahead of time.  Dr. Fielding is “old school.”  She wants you to go in the room and see and examine the patients, and then write it up with your recommendations.  And by the way, bring your own lunch.

Really, truly, there are no short cuts.

Author’s Note: After receiving a number of comments on the original version of this post, I feel compelled to add an addendum.   What I was objecting to in this student’s approach (which I must say is “the standard” these days) was NOT her desire to read the history ahead of time.  It was her desire to actually construct most of the written history and physical in our electronic medical record before taking her own history and doing her own physical.  I do not expect a student to walk into a patient’s exam room “blind”, having never read the prior history, nor would I myself ever do so.  I hope this clears up my approach.  Miranda

Cancer and AIDS, AIDS and Cancer

For Dr. Abraham Verghese, who inspires me.

This evening on the way home from Boston I finished a book that I had started more than a month ago, on my way back from Albuquerque.  Well, that is not entirely truthful.  I stopped reading on page 408, because if I had kept going everyone on the plane would have seen me cry.  I finished it at home a few hours later.  The book is called “My Own Country—a Doctor’s Story” by Abraham Verghese.  I had read his novel, “Cutting for Stone” last year and wanted to read more.  This book, “My Own Country” is autobiographical, detailing the author’s early years after residency and a fellowship in infectious disease in Boston, as doctor caring for the first HIV positive and AIDS patients in rural Tennessee in the early 1980’s, when there was no treatment for the infection, and doctors watched helplessly as each and every patient they cared for died.

I am old enough to be all too familiar with this scenario—in 1982 I was a resident in radiation oncology married to an attending in pulmonology and infectious diseases and we were both seeing the ravages of this disease for which there was yet no blood test, only a constellation of symptoms and opportunistic infections that had heretofore been seen only in the most immunosuppressed cancer patients. It would be a few years before the medical profession figured out the exact mode of transmission, and discovered the retrovirus that caused the illness—and a few more years before the first treatment, the drug AZT was approved.  In the meantime, we watched the patients die, and it was not pretty.  In lighter moments, I would joke that we were the “fun” couple at the cocktail party—cancer and AIDS, AIDS and cancer.  In private, I realized that if I had to choose between one or the other, I would choose cancer.  At least most of my patients had a fighting chance.  My husband’s, at the time, did not.

Verghese left Tennessee, and a job he loved but which had clearly taken its toll on him personally, in 1989.  My husband left his post as the Chief of Pulmonary Medicine at the New England Deaconess Hospital in 1992.   If you ask him, he will say it was the lure of the biotech boom, and the promise of stock options and an early retirement.  But I think there was another side to it, the side that is difficult for doctors to talk about, that part of the job where each time a patient dies, a little part of the soul of the doctor dies with him.  In Boston, the pediatric oncologists at the Jimmy Fund were my heroes—to me, watching children die would be the hardest job of all.  The AIDS doctors, before the development of the drug combinations which have turned HIV infection into a chronic disease, had the second hardest job.

I’ve moved around quite a bit in my career—five years here, five years there, Houston, Boston, San Diego.  Every five years or so, I start to get a bit restless, and I look for something new, something different.  I like to say I need a new challenge.  Tonight, finishing Verghese’s book, I realized that he was able to put into words that nagging need for transformation, relocation, and change so I will quote him:  “It all happened so suddenly.  I left my own country, my beloved Tennessee.  Perhaps my perennial migrations, almost hereditary, are a way to avoid loss.  With deep roots come great comforts.  Yet deep attachments are the hardest to lose.  Maybe that is why drifters avoid them.”

For most of us doctors, leaving is easier said than done, for medicine is our own country.

A Culture of Tenacity

It occurred to me yesterday evening as I walked off my flight from San Diego into Terminal C at Boston’s Logan Airport that I have done this before—landed at an East Coast hub two weeks after a major terrorist attack.  On September 20, 2001, my daughter and I, not without some hesitation, boarded a flight to Boston to look at colleges.  That was a long time ago but the mood there at Logan was strangely similar.  I ducked into Hudson’s Books for a late night snack, since I was waiting for her flight from Houston, and a woman in line next to me said, “Do you have any of those Boston Strong buttons?”  I had been thinking the same thing, just as she said it.

 

Bostonians have a long history of resilience and tenacity.  When I was a horse loving kid I read a story about Paul Revere’s horse, told from the point of view of the horse (of course!)  Apparently Paul did not spare the spur in his midnight ride on Brown Beauty, a mare borrowed from Samuel Larkin—nothing would deter him from his mission, and the good people of Boston, their roots steeped in hardship and persecution and war and famine, have followed suit for centuries.   The blood shed on the cobblestones of Boylston Street two weeks ago was not the first, nor will it likely be the last.

 

What I loved about my training in Boston thirty years ago was that same unflinching and uncompromising commitment to patient care demonstrated by the forefathers in their commitment to freedom.  Yes, the hospitals where I trained had some of the best teachers and most dedicated researchers in the business.  They wore their old school bow ties like badges of honor, and they still do.  Doctors wore white coats, and medical students did not inquire if it was okay to wear shorts to clinic, as they sometimes will in Southern California.   There was a certain formality, which translated into respect—for their peers, for their students, and for their patients.  Especially for their patients.  We laughed about them, we cried about them, we read and lived “The House of God”, and in the end we gave our all for them. I have missed that these last twenty years.

 

It’s good to be back.