Deconstructing the House

Photographer’s notes:

Please have the home prepared before the photographer arrives.
1. Turn on every conceivable light.
2. Open window coverings.
3. Remove pool hose, pool supplies and backyard toys.
4. Open patio umbrellas.
5. Remove BBQ cover.
6. Remove cars and trash cans from driveway.
7. Remove laundry, toys and cleaning supplies, brochure stands, etc.
8. Hide the dogs (and yucky evidence of dogs), if any.

My house is for sale and yesterday was the day for taking photographs.  I read the instructions carefully—I like to be prepared.  Numbers one through seven were easy, although removing two very conspicuous red cars, a Suburban and a Corvette, took a bit of doing.  And fortunately I have no brochure stands in my family room, or magazine stands in the bathroom (who has time?) But number eight—“Hide the dogs (and yucky evidence of dogs), if any”— say WHAT?  That was going to take some serious planning.  It doesn’t take much imagination to realize that not everyone loves large gray hairy dogs as much as I do.  It is interesting that horses add ambience because you can’t smell manure in the photographs, and even more interesting that there were no comments about hiding the yucky children.  The horses are pretty and the kids are grown and gone anyway.  But dogs, well, dogs are just yucky.

I tried my best.  I had the carpet, nearly new but already showing the telltale signs, cleaned professionally on Tuesday.  By 8:30 am, the dog beds were all dragged outside and piled on the patio outside the master bedroom, hidden from every conceivable camera angle.  The dog bowls were emptied and neatly stacked in the pantry.  The crates in the garage had new clean pads installed, and smoothed wrinkle free.  The grooming table was stashed behind the crates, out of sight.  The morning “deposits” were scooped and emptied into a heavy duty, heavily scented drawstring bag which was in turn, placed in the small shed where the garbage cans are duly hidden.  The footprints from the previous evening’s wandering through the freshly watered grass were wiped from the kitchen floor.  The three deerhounds themselves were fed early, and were napping in their kennel runs.  The only trace of dog impossible to erase was my vocal little rescued terrier/Chihuahua mix Yoda.  I resigned myself to the fact that the only way to keep HIM quiet was to carry him around with me.  Four hours and one aching left arm later, mission accomplished.  I sent the photos to my kids with the note: “Look ye upon these photographs and know ye, that ne’er before has this house looked so perfect, and ne’er again will it.”  I didn’t want them to miss that one brief moment where we could pretend that we had no muss, no fuss, no chaos, no life, and no love.

Last night I dragged the dog beds back in, and then for good measure–because one girl just finished her heat season, and as sisters often do, the other just started hers—I took throws accumulated from 20 per cent off discount coupons from Bed Bath and Beyond and completely covered the master bedroom floor in a patchwork of riotous color.  I refilled all the water bowls and made sure that the pillows on the couch were fluffed and arranged just the way Queen and Yoda like them.  I made sure that the house, so ordered and neat and perfect for the photographer, was once again, perfect for the dogs.  After all, they are the ones who live here now with me and my husband.  I took new photographs of life as it really is—messy, chaotic, sometimes downright dirty.  I wouldn’t have it any other way.

Rethinking The Hunger Games

When the movie The Hunger Games was released in the spring of 2012, it broke box office records during its opening weekend.  Not familiar with the books of the same name for young adults by author Suzanne Collins, I did not rush out to see it but I liked its young star Jennifer Lawrence, and was eager to learn more about the new film.  I asked my son, who had taken his girlfriend to see it in IMAX, what it was about.  He said, “You wouldn’t like it Mom.  It’s about children killing children.  It’s “Gladiator” for kids.”  Since “Gladiator” is the only movie I have ever paid, not once, but THREE times to see on the big screen, I beat a hasty path to “The Hunger Games” and I was not disappointed.  Yes, it is a movie about children killing children, but the shining presence of its young star Lawrence, as the fiercely determined and staunchly moral Katniss Everdeen–a name as evocative of lithe cat-like goodness, emerging sexuality, intelligence and of course nine lives as Humbert Humbert was of blunt force, dullness and downright evil… but I digress—diverts the viewer’s attention from the sad specter of death as mass media entertainment.

How strangely ironic it was then, today, to wake up to the news of the shootings at Isla Vista, the residential community that houses a large number of University of California at Santa Barbara students, and to find out that the perpetrator of this heinous crime—a child killing other children—was the son of the assistant director of the Hunger Games movies.  A nightmare come true—to see one’s son in videos detailing exactly what grievances would lead to this explosion of violence, and worse, to have called the police because of concerns over a son’s mental and physical health, and to have those concerns brushed aside when action could have possibly prevented the tragedy. The finger pointing and blame assignments have only just begun.  But the facts remain, whether we are speaking of Columbine, or Virginia Tech, or Sandy Hook or Aurora—alienated mentally ill teenagers and young adults with weapons destroying the hopes and dreams of many families’ futures.

Tonight I looked at the Facebook page of Elliot Rodger, the 22 year old assailant who died last night along with his victims in Santa Barbara.  Oddly enough, the page has not been taken down. There are pictures upon pictures—“selfies”—shot with a cell phone of the handsome young man and his black BMW and his Armani sunglasses and his expensive clothing.  It is telling that there are no other human beings in these pictures—just a young man and his fancy things—and yet there is a glimmer of talent there in the few photos taken from vantage points on solitary hikes in the Hollywood Hills—a moonrise, a view of the Los Angeles skyline in the evening.   But the rantings on video and even the captioning on his Facebook self-portraits speaks to a deeply disturbed, alienated and delusional youth, who is more than anything, alone and lonely.

The father of one of the victims has already cited that this tragedy is the fault of the NRA.  I do not believe that.  I believe that the problem lies in our society itself—a culture which creates a pressure cooker for high school students to succeed at any cost, a culture which glorifies violence while ignoring mental illness, a culture where movies about children killing children become major box office hits. It’s time to take pictures of our friends, and look at them and above all LISTEN to them instead of taking pictures of ourselves, our food, our sunglasses and our cars.  It is time, indeed, to rethink The Hunger Games.  My deepest sympathy goes out to all of those affected by this terrible event.

The Irony of It All, Part Two

The dogs are quiet today, sprawled out across their various rugs and beds in the family room.  After the panic and anxiety caused by the fires here in San Diego last week and the heat that generated them, it is pleasant to feel the cool breeze created by opposing windows in my kitchen.  I am waiting for delivery of a piece of furniture—an old Chinese grain storage bin which had been “repurposed” as a decorative cabinet long ago, and which is about to be “repurposed” anew to hold the television controller and cable box for my new flat screen wall mounted tv—the evolutionary equivalent of man’s preoccupation with necessity progressing towards his preoccupation with luxury.  I treasure the symbolism in my treasures, as it were.

The cabinet will put the finishing touches on the home improvement projects we started nearly a year ago.  My friends with giant dogs and horses will feel a pang of recognition when I say that by moving in here over sixteen years ago, we traded a beautiful home graced with a gourmet kitchen (with two dishwashers, no less!) for acreage with a tumble down ranch house that was a few years beyond “fixer upper” into true “tear down” geriatrics.  It all started with the cat, that self-same Bitty Kitty who visited a year ago while my daughter traveled for internship interviews.  He took a dust bath in the living room fireplace and carried the blackened ashes to the already worn couches and carpet stained by a myriad of prior pets.  When we replaced the couches and carpet, the owner of the furniture store oversaw delivery and remarked, “You’re too old to be living with three-day-blinds!  This is not an apartment!  Why don’t you get some real curtains?!” The new curtains gave the old paint job a dingy tint and the new paint job made the bathroom tiles look ever so dated, and well…you know how it goes.  Last week we actually epoxy’d the garage floor.  It is now perfect.

Severe drought in the West over the last few years and overly aggressive tree roots furtively seeking water had taken their toll on our landscaping, and the bulk of our meager water supply was emptying underground from broken pipes, so that too needed attention and correction and above all, money.  Six months after completing the irrigation work, our water bills are lower than they’ve ever been, and the rose bushes are blooming again.  San Diego may be a desert, but how green are my pastures!

So I am enjoying this brief period of “this old house” being “as good as it gets.” I am no Martha Stewart, nor was ever meant to be, and my husband is definitely not “handy”—he would rather hire someone than change a light bulb.  The kids are grown, the horses are ancient, and even the dogs have slowed down a bit.  The house is for sale, and rightly so.  But every so often, I sit in the kitchen and listen to the wind chimes and watch the mother bird nesting and chirping in the ceramic birdhouse outside the open window. And I wonder why it took me sixteen years to realize that my “tear down” is instead, a little piece of paradise.

For Ellen

“to live in this world

you must be able
to do three things
to love what is mortal;
to hold it

against your bones knowing
your own life depends on it;
and, when the time comes to let it go,
to let it go”
Mary Oliver, New and Selected Poems, Vol. 1

As a parent, you are not supposed to have a favorite child, and since some of us physicians feel a strange but kindred protectiveness for our patients, likewise we feel guilty about having favorites.  But we always do. My favorite patient died last night.  On my last day of work, I gave her my email address and my cell phone number, so we could keep in touch.  She gave me a bright red stuffed teddy bear, so that I would always remember my “wild red headed woman from Texas.”  Except that she had no hair–she had grown and lost it so many times over the six years I treated her that even I lost count.  When I retired, I made sure that she had a follow up with one of my colleagues, who I trusted would give her his best opinion and effort in managing her care.  When he saw her in March, he told her there was nothing more he could do.  She signed on to hospice the following week.

She was diagnosed with a rare form of cancer of the uterus nine and a half years ago.  By the time I met her, in 2008, she had already developed lung metastases and had undergone several courses of chemotherapy, none of which had kept the metastases in check for very long.  After a trial of radiofrequency ablation which resulted in a pneumothorax and chest tube, she was referred to me for consideration of stereotactic radiosurgery.  We treated her lung lesions one by one, and one by one they faded into scar tissue.  She was happy and relatively without symptoms until eighteen months ago, when she began to recur in the lung, and brain, and soft tissues of her muscles.  She remained upbeat, larger than life, encouraging the radiation therapists to treat each new lesion as it occurred.  My entire staff looked forward to treating her every time she returned to the department.  We joked about awarding her “frequent flyer miles” and she laughed and her blue eyes sparkled. Her chocolate chip cookies were legendary, and she gave us the recipe, but they never turned out the way they did when she baked them.  We accused her of leaving out a secret ingredient and she protested vigorously.  She said she would never do that.

She traveled a lot in the last year of her life—to visit her children, to see a new grandchild being born.  Her last trip was to New Orleans with her husband, where she looked forward to eating beignets and listening to Dixieland jazz, even though her trip was interrupted by an emergency room visit for shortness of breath. When we parted at the end of February, we promised to keep in touch and get together for lunch or dinner but she had complications from her last course of therapy, or from the cancer itself, and when I heard from her by text and by email, the news was not good.  In her last email, she told me she had joined a gym, determined to try to regain some of her strength. She promised to call when she was feeling better.

She did call me, last weekend, to see if I could have lunch with her and her husband on Thursday.  I missed her call, but I knew I was busy that day, so I called her back to reschedule but she did not pick up the cell phone.  And so I was not surprised when I received the news today that she had passed away last night.  Not surprised, and yet astounded, that such a vital life force had left us.  My entire staff is bereft.

In his email to me and I am sure, countless others who knew and cared about her, her husband included two photographs of her.  In the first one, they are cutting their wedding cake—she in her beautiful white dress with her long flowing red hair and he, handsome in his tuxedo and moustache.  Over thirty years must have passed between the first photo and the second, where she stands alone, healthy, beaming, and holding a yellow rose.  After all, she was from Texas. As I looked at the pictures again this evening, it occurred to me that I knew that the ingredient she poured into those chocolate chip cookies but forgot to write down for the rest of us was love.  Simply and purely, love.

I am Passionate About…

A few days ago I decided that since I have been officially retired for two months, it was time to change my profile on the LinkedIn social network.  After all, the purpose of that network is to link business and professional people to potential opportunities and ideas.  I needed to let contacts know that I am no longer with the University where I practiced for the last seven years, while at the same time, just labeling myself “retired” seemed far too final.  LinkedIn, as it turns out, has a “prompt” on each member’s profile page which encourages us to say succinctly what we’re all about.  The prompt is “I am passionate about…”  It took a few moments for my brain to dispel romantic visions of the great love stories of all time–Catherine and Heathcliff?  Zhivago and Lara? Scarlett and Rhett?  The realization dawned on me that what LinkedIn was alluding to was professional and not physical.

What I am passionate about, and remain so despite the significant burn out that led to early retirement, is community based cancer care.  Contrary to what I believed during my residency, when I referred to patients being admitted by LMD’s (local medical doctors) from St. Elsewhere, over the course of a long career I have come to believe that most cancer patients are served best by being treated in their own communities.  Certainly there will always be patients whose presentations, diseases and complications merit immediate referral to a tertiary care center, however most patients with typical presentations of common cancers are also people who have jobs, who have children and/or elderly parents to care for, who have concerns about the financial burdens of treatment, and for many elderly patients concerns about transportation to and from treatment.  Our job, as community based cancer specialists, is to make sure that the treatment being provided measures up to the standards of care and safety that we have learned from our colleagues in major academic practices.  In communities with limited resources, this can be challenging.

For physicians and community leaders interested in creating a community cancer center the key ingredients are simple. First, you need a mission.  Decide what the goals of your center will be and write them down.  Create a statement.  An example could be:  “Our mission is to deliver medically and technologically advanced cancer care to residents of this community in a supportive environment close to home.”  These goals will be your guiding light as you proceed.  Second, you need a building.  Although many of the functions of a tertiary cancer center can be spread out into the community, we are not yet at a point where we can deliver “virtual cancer treatment.” Many pre-existing buildings can be modified to accommodate chemotherapy and even radiation therapy, at a fraction of the cost of new construction. Third, you need equipment.  Specifically, in order to deliver radiation therapy you need a multipurpose linear accelerator, capable of delivering highly focused stereotactic radiation as well as standard of care intensity modulated radiation therapy and superficial electron therapy for skin cancers.  Although it makes a good PR campaign to have the latest “sexy” name in equipment, much of this highly specialized equipment is not designed for a general practice. You will need infusion equipment and likely some laboratory equipment.    Fourth, you need highly trained and certified personnel to administer chemotherapy and radiation therapy, and particularly in the case of radiation, to insure quality. Fifth, it is my opinion that community cancer centers benefit greatly from affiliation with university practices in terms of access to clinical trials, to tumor boards, to advanced pathological diagnosis and to the expertise of specialists in each disease site.  Finally, and perhaps most importantly, you need the support of the community. To paraphrase Hillary Rodham Clinton who said, “It takes a village to raise a child”, I would say that it takes the dedication of a community to create a successful cancer center.

The future of cancer treatment, indeed of medicine in general, is unclear however we must not lose sight of the fact that patients are more than their cancer diagnosis, their chemotherapy recipe or their radiation dose prescription.  We need to keep them in their jobs, with their families, functioning as normally as possible under difficult circumstances, throughout their treatment and afterwards.  My own experience has shown that this is achievable in a personalized setting in the patient’s community.  That is what I am passionate about.

This piece is condensed from a longer talk I gave in Jamaica in October 2013.  For the full transcript feel free to email me and I will send it on.