The Good Books

Where I come from, when most people refer to The Good Book, they are referring to the Bible.  This is not true for my father, because to him, the Good Books are something else entirely.  He describes a scene early in his career as a plastic surgeon, when he had taken his doting mother to see his new office. Coincidentally, a lovely thank you note had just arrived from one of his patients.  He read it appreciatively and passed it on to my grandmother, so that she could “kvell” over her son the doctor even more, as if that were possible. His secretary, having a penchant for scrapbooking and noticing the mutual positive reinforcement going on, decided that from that day on, when Dad received a thank you note or letter of appreciation, she would put it in a scrapbook, which he anointed as his “Good Book.”  By the time he retired from full time practice at age 75, he had accumulated a series of five very thick Good Books.  And he advised me to do the same.  He said that when he felt tired or depressed, he would read his Good Books and feel revived.

I’ve never been as organized as my father, who keeps meticulous files on everything that interests him, to this day.  Nor, as a young female physician just starting practice in the early 1980’s, did I ever have a secretary that I would DREAM of asking to “scrapbook” for me, much less bring me a cup of coffee.  But I had many appreciative notes from patients, and I read and treasured each one.  I put them in the top drawer of my desk, and would reread them when I came upon them while searching for a highlighter, or a directory of local doctors.  And when I left that particular job, or that particular city, or that particular office, I would read them one more time, remember the patients who wrote, and let them slip into the recycle bin.  There’s only so much you can take with you, apart from the memories.

Exactly two weeks ago, I received a letter at my office addressed to me personally.  The letter originated in Bradenton, FL where I know no one. I did not immediately recognize the name or the return address, but I opened it and read:

“Dear Dr. Fielding:

It has been 25 years since I completed treatment by you for Stage 4 Hodgkin’s Lymphoma.  I came to the Leonard Morse Hospital from Turkey with a tumor in my chest.  I was treated by Dr. Jao and referred to you for radiation therapy.  My treatment included radiation therapy and chemotherapy from November 1987 to October 1988.

I will always remember that when I would meet with you during my radiation therapy I usually felt “lousy.”  You would come into the exam room and tell me I looked great.  Your positive and caring manner always lifted my spirits and renewed my confidence that I would overcome Hodgkins.

I retired in 1995 and have enjoyed good health and my retirement in Florida.  Your caring and medical expertise saved my life and I am forever grateful.  I thank you and wish you a Happy New Year.    Sincerely,  RB.”

The letter was accompanied by a photograph of my patient and his wife, riding gilded carousel horses on a merry-go-round, hands held high to reach for the golden ring.  They appear to be very happy.

I have been thinking a lot lately about retirement myself.   There are places I want to go, people I want to see, and things that I want to do while I am still healthy enough to do them.  When I got home the evening I received that letter, I showed it to my husband who said, “I bet you won’t want to retire now!”  I thought about it for a minute and said, “No, you are very wrong about that. That letter made me cry, but not because I want to continue to do radiation therapy forever.  It made me cry because it made me feel that what I have done since I graduated from medical school in 1978 was worthwhile.  That it MEANT something. That I have not wasted my time.”

To my patients who have taken the time to write over the years—you have no idea how much that means to us doctors.  To my daughter, struggling through a tough internship year in Boston, and to my medical students—stick with it.  Thirty years from now you will be very happy you did, with or without some Good Books of your own.

Superstition, Karma and Faith

I have always been a mildly superstitious person.  With a casual air, I will walk around rather than under an open ladder and I never wear opals since they are not my birthstone.  I will happily pet a purring black cat then shiver when it runs across my path, and when I break a mirror my heart sinks.  I remember watching the Rachel Ray show one day and saw her toss a pinch of salt over her left shoulder after spilling some of it—and I thought, “I am not alone.” I tend to look at everyday occurrences as omens, good or bad.  And in my effort to impose some sense of justice in this crazy world, I believe in karma.  I try to stock up on the good stuff.

Today my 88 year old father had a left total hip replacement.  I had tried to talk him out of it for months, since he had only just had his aortic valve replaced in March.  He has been living independently again, and has actually been seeing a wonderful woman at the senior community where he lives.  With my mother’s dementia, he had not realized how much he had missed having someone to talk to, to confide in.  My sister and I were against him going in for elective surgery.  But as the months rolled on, he became more limited, and for the last month it has been obvious that he was in constant pain, and that surgery was inevitable.  My husband drove him to the hospital this morning, and stayed there while I worked today.  He called me at 3:30 to say that the surgery had gone very well, and had been done via an anterior approach under epidural anesthesia. Ninety minutes, start to finish, and Dad was awake, oriented and moving all four extremities.

I left work at 5:30 to go over to the hospital.  I stopped for gas before getting on the freeway, and as I stood at the pump, ready to disengage, I saw a tiny black dog dart across the busy street, collar and tags on with a six foot leash trailing behind him.  He ran quickly across the parking lot and I reflexively locked my car, glanced over my shoulder to see if there was an owner in pursuit, and seeing none, I took off after the dog, walking slowly, non-threatening, calling “Puppy, puppy, puppy” in my sweetest voice, the one I rarely use.  I was quickly joined by a man who had pulled into the station in an extended cab pick-up truck, his entire family in the car.  He jumped out of his car, said, “I saw the dog, I will help” and came with me.

The little dog, clearly terrified, ran to the far end of the lot where two teenaged girls saw what was going on and unfortunately, immediately gave chase down an alleyway between a garage and a guitar shop. A man covered in mechanic’s grease joined the rescue efforts, adding to the chaos of concern.  And then the tiny dog ran right into a side street, directly into the path of an oncoming car.  By the time we reached the lifeless body, the woman who had been driving the car was sitting in the middle of the road, sobbing uncontrollably, and putting herself in imminent danger. The man with me picked up the dog, a well-cared for black and tan Chihuahua, still sporting his collar and lead, and we checked him.  His eyes were open but he was gone. The small entourage carried him across the street to an open veterinary clinic, so that the owner could be notified, and would not have to search the empty streets tonight.  If you are a dog loving reader, and have never found yourself in that sad situation, you have been very fortunate.

I got to the hospital with a sense of impending doom, and was quite surprised to see Dad sitting up in bed, entertaining his nurse who was improbably named Evangeline.  She was catering to his every need; he was in fine spirits and his pain was well controlled.  I know he isn’t out of the woods yet, but I was relieved and grateful.  Instead of superstition, I should have had faith—faith in the doctors and nurses taking care of Dad, faith in the human beings who rushed to try to help that little black dog, and faith that there is a purpose and meaning in the events of the day. But somewhere a family is grieving tonight, and I am wondering why.

When Age is a Relative Thing

I remember when I was a medical student and an elderly patient would be admitted to the surgical service through the emergency room with a bowel obstruction, or a lung cancer, or blockage in the coronary arteries so severe that only a coronary bypass could save him.   The students and residents would gather around the attending, and debate the merits of operating on the patient, or “keeping him comfortable”, ensuring certain death.  One of the things I remember hearing, typically from the mouths of those advocating for aggressive management was always, “But he’s a GOOD ninety!”  Meaning, the patient may have been ninety years old, but he looked younger, and had no competing medical problems, and had been living independently and enjoying life.  As I grew in my radiation oncology career, and medical students and residents would debate the same with me, one of the things I always try to remind them is, “There’s nothing like radiation and chemotherapy to turn a GOOD ninety into a BAD ninety really fast.”  It’s the truth.

So when I returned from my mini-vacation at the dog show in Palm Springs at the beginning of last week, the first thing I did was check my schedule to see if any of the patients who were seen in my absence were on the simulation list for treatment planning so I could review their history and physical exams.  I found one unfamiliar name, so I picked up his chart.  It turns out, this man is an 86 year old retired figure skater, still active as an international figure skating judge, who had recently been diagnosed with an early stage intermediate risk prostate cancer, Gleason grade of 3+4=7, PSA of 9.  He had come in under duress to see one of my partners because, you see, he didn’t WANT radiation therapy.  He wanted a prostatectomy.  Now, in my world, and in the world of my referring urologists, 86 year old men do not get prostatectomies, robotic or otherwise.  There is too much risk of fluctuation of blood pressure and bleeding, and consequently heart attack and stroke. Dr. Donald Skinner, retired Chairman of Urology at the University of Southern California used to say, “I won’t even operate on a 70 year old man, unless he brings his 90 year old father to the consultation with him.”  This patient’s choices were watchful waiting, now known as “active surveillance”, hormonal therapy, or radiation.  After a long discussion with my partner, he chose radiation therapy.

When I walked in the exam room to get the patient to sign a consent before we started, I was fully prepared to try to convince him that at his age, it wasn’t likely to make a difference in his overall life span to be treated for this early stage prostate cancer.  What I wasn’t prepared for was a man who looked twenty years younger than his stated age, in great condition, holding hands with his equally attractive wife, also a retired skater.  My speech about the treatment being unnecessary “at your age” went unsaid.  Instead, I gawked and said, “Ice dancing or pairs?”  From then the discussion veered from the upcoming Winter Olympics, and then to the fact that he grew up in Seattle and came to San Diego on vacation, whereupon he discovered that there was a place where it didn’t rain every day and decided to stay. He was twenty when he met his fifteen year old bride to be at a skating rink in Orange County.  He was tall, with an elegant physique. She was petite and a beginner. He smiled at her as he told me the story of the “best pick up line EVER!”  He found himself next to her at the edge of the rink and said, “What are you doing there, standing in a HOLE?”

Perhaps it was not the best pick up line ever. But his vivacity, vitality and joie de vivre certainly bought him a definitive course of intensity modulated radiation therapy.  After all, he’s a GOOD eighty six.

Curmudgeonly Me

I didn’t like my flu shot very much this year.  Some years they hurt worse than others, and I haven’t yet figured out whether that depends on which nurse gives me the shot, or which strain I am being vaccinated against.  This year was a bad one—within 24 hours my arm was so sore that I couldn’t raise it above my head.  I received it on a Friday and with it, my little sticky badge to be placed on my hospital ID that proudly proclaims me duly vaccinated and safe to see patients. The next day I left on a Southwest flight to Albuquerque.  It is rare that I ever check luggage these days, after an unfortunate mishap in 2006 when my family ended up in New Haven, CT for my daughter’s college graduation, but our luggage went to Florida. As I hoisted my own suitcase into the overhead rack, I felt an acute twinge in my shoulder anteriorly in the region of the biceps tendon, same side as the flu shot.  By that evening, I couldn’t sleep because of the pain, and two months later, it still hurts. My husband says it was a coincidence.  I am not so sure, but I have no choice in the matter.  If I want to keep working, and seeing patients, an annual flu shot is mandatory.

This past Friday through Sunday I was in Palm Springs, CA for the Palm Springs Kennel Club dog show.  For those of us who show dogs, this is one of the biggest shows of the year, the “kick off” to the dog show season, and the prelude to the Westminster Kennel Club show in February.  If you win at Palm Springs, there is a very high likelihood that you will be winning at Madison Square Garden.  Or so they say, because I don’t travel in those rarified circles.  Still, many of my friends were slated to show their deerhounds, and even though I didn’t have any puppies to show, or adults who haven’t finished their championships, I had nothing else to do so I hopped in the car for the two hour drive on Thursday night, leaving my own dogs at home.  Dog shows are ever so much more fun when you don’t have to walk, feed, bathe or groom your own dogs.  I was there to have fun, and maybe do a little shopping at the big outlet mall at Cabazon.

My friend and oft traveling companion Rachel had delivered the last puppy from her recent litter to a woman in Texas who had just lost her own deerhound to osteosarcoma a few days before the Palm Springs show.  By Monday of the show week, Rachel complained of a sore throat and upper respiratory congestion.  She really should have skipped Palm Springs, but she’s a tough one, Rachel, so on Thursday early she loaded two dogs in her car and headed from Arizona to California.  By the time she arrived in Palm Springs, she had a severe cough, fevers, shaking chills, a headache and muscle aches so bad that she couldn’t stand for very long.  I arrived after she did and brought her four bottles of water, which she managed to keep down, but she couldn’t eat anything—the masseter muscles in her jaw hurt too bad.  I said, “Rachel, did you get a flu shot this year?”  I had just seen the television reports Thursday that H1N1 flu was at epidemic proportions in Texas.  She said “No, I never get flu shots.  They make me sick.” By Friday she was feeling faint, and barely managed to get around the ring with two dogs.  One of her puppy owners lives near the show site, and she insisted that I drive her to visit the nice man and his puppy.  Midway through the visit, she turned pale, broke into a sweat and I rushed her back to the motel to see if I could get her rehydrated and some food into her.  As she wiped her brow with her forearm, before making an emergency bathroom stop, she said, “I’ve never been this sick in my entire life.”

Bingo.  That’s the flu.  All these folks who go around with the sniffles saying, “I’ve got the flu” or when your co-worker says, “I spent the weekend goin’ and throwin’—I had the flu”—that’s not the flu.  That’s a cold, or a GI bug, or “I want to take a sick day.”  But when your friend who has served time in the Army and who has driven an 18 wheeler cross country professionally says to you, “I’ve never been this sick in my life”—now, THAT’s the flu, as in influenza.  Get your flu shots folks.  There’s still time if you’re not sick yet.  Don’t delay, because I won’t be around to nurse you through it.  I wear my “flu shot” badge proudly, and hope that my shoulder isn’t still hurting in the spring.

Primum Non Nocere

I don’t have much in the way of eyebrows.  They were victims of too much plucking back in the 1960’s and when you do that, sometimes they don’t grow back.  There’s a very nice woman in Solana Beach who shapes and darkens what I have left, infrequently, when I bother to think about it which isn’t very often.  I was in there about a year ago when she told me, “I won’t be at work for the next six weeks or so—I’m having some surgery.”  Never shy when it comes to these issues, I asked, “What kind of surgery?”  She said, a little too casually, “I’m having double mastectomies and latissimus flap reconstructions.”  I said, “Why are you doing that?”  She said, “Because I was diagnosed with ductal carcinoma in situ on the left, and I just want them both OFF.”  Ductal carcinoma in situ is what we call Stage Zero breast cancer—non life-threatening, but it does need to be treated because in some cases it can progress to invasive breast cancer.  Treatment options range from excision only, to excision plus radiation, to simple mastectomy for more extensive cases.  In NO case, unless the patient carries the breast cancer gene, BRCA 1 or 2, as Angelina Jolie did, is bilateral mastectomy the recommended treatment.

Again, I said to this nice forty year old woman with no family history of breast cancer, “Did you at least SEE a radiation oncologist for an opinion?  This is what I do for a living, you know.”  She said, “No, I did not.  My surgeon drew me pictures of the procedures, and he said I’d be back at work within a few weeks. This is what I want.  I have a six year old son.  I do not want to die of breast cancer.”  Her mind was made up.  In situations like this, I may offer an unsolicited opinion, but here my opinion was clearly not wanted.  This was the right choice for her.  It’s what she needed for “peace of mind,” and I was not going to stand in her way.  She had her bilateral mastectomies, and her reconstructions, and true to her surgeon’s word, she was back at work within six weeks.  She was very pleased with, and relieved by her outcome.

There are a couple of problems with this scenario.  First of all, my breast cancer treating colleagues and I have noted a somewhat alarming rise in the rate of double mastectomies for unilateral breast cancer in non BRCA positive patients.  The rationale for this is typically, “I want to do everything I can to reduce the chance of the breast cancer coming back”, but sometimes it’s “I want a matched set!”  What patients are often failing to realize, and are being failed by their physicians in terms of their education, is that the biggest risk they have of actually dying is from the breast cancer they already HAVE, not the breast cancer they might be diagnosed with in the future.  Once a woman has been diagnosed and treated for breast cancer, the risk of developing a contralateral breast cancer is about 1% per year, and the vigilance is stepped up accordingly—mammograms are no longer designated as “screening” but rather as “diagnostic”, and MRI’s are more frequently covered by insurance, not to mention the frequent blood work and body scans obtained in more advanced cases.

Second, prophylactic mastectomy and breast reconstruction is neither risk free nor does it often result in a “perfect breast”.  Infections can occur, implants can be extruded, flaps can fail, and even if none of these things happen, the resulting reconstructed breast is insensate—in other words, it doesn’t FEEL like a breast to the woman who is wearing it.  Even in a skin sparing, nipple sparing mastectomy, the nerve endings are cut.  If an abdominal flap is used, the abdominal musculature is compromised—important for women who are athletic and need these muscles.  The same goes for a latissimus flap.  Not to mention the fact that many woman who are diagnosed with breast cancer are still of childbearing age and many still plan to have children.  One can breast feed an infant with one breast, but not with bilateral mastectomies and reconstructions.

So if you have been diagnosed with breast cancer, please think long and hard about your treatment options and about what the goal is, which is to obtain local control of the cancer typically by either removing the breast, or by having lumpectomy and radiation therapy.  The “peace of mind” obtained by removing the opposite healthy breast in a BRCA negative patient is not only just a pleasant mythology, but is also potentially dangerous, putting a patient at risk for complications when she needs to be healing and considering the adjuvant therapy, whether that be hormonal therapy or chemotherapy or radiation to the chest wall or affected breast, which will truly reduce her risk of recurrence and extend her life.  And we physicians need to remember that principle of “Primum non nocere”—First, do no harm.  We don’t remove other paired organs just because one is diseased, and we shouldn’t be doing it with breasts either.  In my opinion, of course!

Ring Out The Old

Ring out, wild bells, to the wild sky,

The flying cloud, the frosty light:

The year is dying in the night;

Ring out, wild bells, and let him die.

Ring out the old, ring in the new,

Ring, happy bells, across the snow:

The year is going, let him go;

Ring out the false, ring in the true.

Ring out the grief that saps the mind

For those that here we see no more;

Ring out the feud of rich and poor,

Ring in redress to all mankind.

Ring out a slowly dying cause,

And ancient forms of party strife;

Ring in the nobler modes of life,

With sweeter manners, purer laws.

Ring out the want, the care, the sin,

The faithless coldness of the times;

Ring out, ring out my mournful rhymes

But ring the fuller minstrel in.

Ring out false pride in place and blood,

The civic slander and the spite;

Ring in the love of truth and right,

Ring in the common love of good.

Ring out old shapes of foul disease;

Ring out the narrowing lust of gold;

Ring out the thousand wars of old,

Ring in the thousand years of peace.

Ring in the valiant man and free,

The larger heart, the kindlier hand;

Ring out the darkness of the land,

Ring in the Christ that is to be.

Alfred Lord Tennyson, In Memoriam

 

 

As an aficionado off all things Scottish, it is ever so tempting to quote Robert Burns’ “Auld Lang Syne” tonight, especially when I remember that poignant scene from “Out of Africa” where Baroness Blixen, aka Isak Dinesen, realizes on a fateful New Year’s Eve that she is no longer in love with her husband, but with the handsome and unattainable Denys Finch Hatton.  But as always, I tend to wander from the main theme of tonight, which is a theme of thankfulness.

To all of my friends and family who kept me somewhat sane during this difficult past year, much of which I have shared with you on this blog, I say “Thank you.”  To all of the readers whom I’ve never met but who put up with my quirky musings on cancer, family, dogs, cats, horses and life in general, I am ever so grateful for your encouragement.  Next year I hope to continue to inform you, to make you laugh and cry and above all, to make you wish that you, like Baroness Blixen, had a Scottish Deerhound, or two, or perhaps even three.

As a radiation oncologist, it’s been a very long time since I took call on New Year’s Eve. I am at home tonight, with a nice glass of wine in hand, getting ready to cook dinner and watch the last few episodes of “Breaking Bad” on Netflix—a little sadly because I don’t think everything is going to turn out all right in the end, and I for one thrive on happy endings.  But before I sign off on 2013, I want to thank the good people who are out there “in the field” tonight, taking care of the rest of us across the country and abroad—the ER doctors and trauma surgeons, the nurses in the emergency rooms and in the ICUs, the firefighters and paramedics and police officers who are all vigilant and on high alert tonight, and of course, our armed forces at home and far away.  I wish you all a Happy, Healthy New Year.  Live long and prosper, and stay safe out there!  With gratitude, Miranda.