Live Long and Prosper

I was sitting at lunch with a friend today when she leaned over to check her phone messages and discovered the sad news that Mr. Spock, sometimes also known as Leonard Nimoy, had passed away due to complications of chronic obstructive pulmonary disease.  She looked up at me and said wistfully, “He was my first girlhood crush.”  To which I replied, “Mine too.”  In 1966, while my thirteen year old contemporaries swooned over the mop headed Beatles, I was madly in love with a guy with chiseled features, a low pitched but perfectly modulated voice, and above all, pointy ears.  I found him irresistible.

Some girls want a boy who will bring them candy hearts on Valentine’s Day and flowers for their birthday. Others prefer a tougher nut to crack.  To Spock’s adoring fan girls, he represented the latter, the “strong silent type” whose deep human emotions lurked well behind that cool Vulcan exterior. Secretly we all believed that we were the one, and of course the only one, who could penetrate Spock’s personal deflector shields to get to that emotional reactor core.  The challenges would be great, but so would be the rewards. Since Spock was significantly older, and entirely unavailable, we turned our attentions to the dark quiet boy in the back row of math class who sat scowling at his paper, pressing his pencil lead so hard into the paper that it snapped off.   He was no Spock, but he would have to do.

My girlfriends and I have hopefully long outgrown our attraction to emotionally unavailable men–candy hearts and flowers are most welcome these days.  Leonard Nimoy tried for a time to outgrow his identification as Mr. Spock, even titling his first autobiography “I Am Not Spock.”  He became a writer, a director, a poet, a photographer, and even at times a very bad singer, but despite his many accomplishments his admiring Trekkies continued to flock to Star Trek conventions to get a glimpse of the man with the pointed ears.  In later life, Nimoy embraced the character that made him famous—when you have become a cultural icon, resistance, as they say, is futile.

What is it now, nearly fifty years later,  that still draws us to the Vulcan mindset, where war, and rage, and yes, even passion were considered “highly illogical?”  Perhaps it is a longing for a simpler world and an earlier time, where each one hour television episode had a story with a beginning, an ending, and a moral and no one had any trouble figuring out who the good guys were.  Spock stood at Captain Kirk’s shoulder as a moral compass, a conscious reminder to put thought before action and to behave ethically towards all species.  We could all use a little Spock these days.  Leonard Nimoy, you will be deeply missed.

Medicine at the Crossroads

 

        “When you look for the bad in mankind expecting to find it, you surely will.”    Pollyanna

 

I try not to spend too much time on Facebook, but it’s always been a good way to keep up with “friends” in the Scottish Deerhound world.  The deerhound, being a rare breed, tends to link people across the country, and indeed the world, who have similar interests.  Lately though, the deerhound people haven’t been discussing dogs much.  Instead, they’ve been discussing their terrible experiences with the world of medicine.  One owner described being admitted through the emergency room of her local hospital for stroke-like symptoms.  By the evening of her second day of admission, she complained that she had not yet been seen by a physician.  Another complained that a family member had just been diagnosed with Type I diabetes, but was initially given an appointment with an endocrinologist in six weeks—completely unacceptable in this situation by any standard of care.  I am of course compelled by pride to speak up and defend my profession, but not without an increasing sense of embarrassment for what used to be considered a noble calling.

After I published my piece on the fatal shooting of Dr. Michael Davidson, I was contacted by Carey Goldberg, reporter and co/host of CommonHealth (http://commonhealth.wbur.org/) and asked what struck me the most about the nearly 200 comments left on the essay when it was picked up by KevinMD.com.  Here is what I replied, “There were several reasons that Dr. Davidson’s death hit me particularly hard, even though I never met him.  One reason was that I trained at the Harvard teaching hospitals, Beth Israel for Internal Medicine and MGH for Radiation Oncology, so this hit close to “home” especially with my daughter being there.  But more importantly, I come from a medical family–grandfather was a dentist, father (now 89 years old) is a world renowned plastic surgeon–and in my lifetime of 61 years, I have seen the sad decline of public affection and respect for physicians.  When I was a child, people would stop me on the street to tell me how wonderful my father was.  Now, when I sit in on conversations among people who do not know I am an MD, I hear nothing but derision if not outright hatred.  There are many, many more people, as evidenced by the response to my blog piece, who feel slighted not only by “the system” but also by their physicians.”

And why not?  Articles such as this, http://www.nytimes.com/2015/01/30/business/medicare-payments-surge-for-stents-to-unblock-blood-vessels-in-limbs.html on the front page of the New York Times continue to erode patients’ faith in their physicians to “do the right thing.”  Patients despair when they cannot get appointments to see their doctors in a timely fashion and when they are seen, that their doctors don’t spend enough time with them or explain things to them.  They despair over the cost of care in increasingly difficult economic times. But doctors are in despair also, at the ever increasing bureaucracy of medicine, the insurance conglomerate which makes documentation, authorization and billing a nightmare, the takeover of large segments of medicine by for profit corporations and the heightened expectations for positive outcomes fueled in part by misleading advertising by those same corporations.  Many have come to feel that the sacrifices, both personal and economic, that they made in order to go to medical school were just not worth it.

I do not pretend to have any answers to the multiple crises that contributed to the death of Dr. Davidson, or the current climate in which doctors and patients must function.  I wish I did. But I do have a request for both my patients and others, and my physician colleagues, as well as my Facebook friends and the media.  Let us try once again to see the good in one another again, and not just the bad.  We’re all human, and at some point we are all going to get sick.  For better or for worse, we depend on one another.

In Memoriam–Dr. Michael Davidson

In 1994, I was working at my first radiation oncology job in San Diego at Grossmont Hospital when I came into work to hear disturbing news.  One of my colleagues in medical oncology, a compassionate man known for his gentle nature, had stayed late at the Cancer Center the evening before to finish up paperwork.  With his back to his ever open door, he sat at his desk never once considering that he was in danger.  A disgruntled relative of a former patient surprised him from behind, and beat him viciously over the head and body causing broken bones and contusions, and leaving him for dead.  He managed to call for help, and he survived after spending two weeks in the hospital.  He returned to his practice of treating cancer patients after a long convalescence—after all, it was his calling in life.  He died many years later, suddenly at age 69.  I do not know if that beating years earlier contributed to his early death but the knowledge of it certainly changed my life.  I worked late, and was alone in many offices at night after that, but I remained cautious and vigilant about security, never again taking safety for granted.

Yesterday I got a hasty text message from my daughter, who is a second year internal medicine resident at Boston’s Beth Israel Deaconess Medical Center.  She told me that a doctor at Brigham and Women’s Hospital, a fellow Harvard teaching hospital, had been shot at work and that the hospital was on lock down.  She didn’t know how much was in the news yet, but wanted to let me know since I had trained and worked at these hospitals.  I was as shocked as she was, but I should not have been.  The doctor, Michael Davidson, was a highly respected young cardiovascular surgeon—a rising star in his career, and a husband with three children at home.  The gunman, having sought out Dr. Davidson, fired two shots at close range before retreating to an exam room and taking his own life.  Dr. Davidson was given immediate medical attention by his colleagues at his own hospital, one of the top trauma centers in Boston.  He died of his injuries late last night.  As it turns out, the shooter, Stephen Pasceri, had no history of violence and his gun was licensed.  But he did have a history of dissatisfaction with the “medical system” and sadly his mother had been a patient of Dr. Davidson’s, and had passed away two months ago.  Not much has been said in the news about her, but such is the nature of cardiovascular surgery—these doctors do not operate on healthy patients and not every outcome is successful.

When I visited the Hope Institute in Jamaica in 2013, I saw many patients dying of cancer, without the benefits of affordable chemotherapy, state of the art radiation therapy and even without a readily available supply of morphine.  But I did not see anger, in the patients or their relatives, who were cared for under the loving guidance of Dr. Dingle Spence.   Here in America, quite the opposite is true: we have come to believe that every disease is curable, that every outcome should be positive, and that death, in the words of Dylan Thomas, shall have no dominion.  Most of us, however do not take to the wards fully armed, looking for our doctors. Today I am in despair for his wife, for his children, for the surgical residents he would have taught, and for the thousands of patients that Dr. Davidson could have helped if his life had not been taken.

When we graduate from medical school, we take the Hippocratic Oath, which in the modern version not only exhorts us to heal the sick but to exhibit warmth, sympathy and understanding.  Let our patients and their families extend those same traits to us as we complete our daily rounds.  Let our clinics and hospitals be places of healing, and not of killing.  Please, please let us do our jobs.

Addendum January 22, 2015.  This was submitted by a colleague in the Comments section but I want to bring it forward to the actual page.  Please take the time to read and consider signing.

Dear colleagues,

The violent death in Boston of Dr. Michael J. Davidson, an inspiring cardiac surgeon who devoted his career to saving lives and improving the quality of life of every patient he cared for, is a senseless and horrible tragedy.

There was an incident in the past where a patient at a VA hospital made a threat to shoot a physician.

VA physicians are federal employees. Federal employees have enhanced legal protection against violence. The threat of violence toward a federal employee by itself is illegal. Police officers were able to conduct an investigation and speak with the patient. Once the patient understood that the threats could lead to prison, the volatile situation was defused.

Laws protecting federal employees against violence provide an additional tool to help direct an individual away from violence. Unfortunately, this protection does not extend universally to all healthcare providers.

The White House has a “crowd-sourcing” system where the executive office reviews proposals with at least 100,000 signatures obtained within a 30 day period.

http://wh.gov/i220E asks that the legal protections against violence currently provided to federal employees be extended to all healthcare providers.

While no law reduces risks to zero, our effort would be well worth the energy if it could prevent even one senseless death.

Please take a moment to sign this petition, and consider spreading the word. Everyone can sign this petition including your friends and family.

Thanks.

Love Letters

Another guest post tonight, from my friend Jackie Widen:

I miss letters.  Rather, I miss sending AND receiving letters in the mail, real letters on stationery.  Our cultural communication has been reduced to tweets, posts, texts, emails and Facebook messages. Another part of growing older is remembering and cherishing this simpler method of communication. I guess I am old.

I have always been a letter writer.  I remember as a child writing to both of my grandmothers who lived in California.  Both were widowed and led quiet lives, and at the time I just thought it normal to correspond regularly with them.  Now I realize how much they must have enjoyed receiving my crudely crafted letters.  The news to share was probably silly in hindsight; what grades I got on my spelling test (yes they actually tested for spelling back in the day) or what our pets were doing or how pretty was the dress my mother had recently sewn for me.   The postal rates were regular mail and air mail, and of course air mail was preferred. There were “air mail” stickers to plaster across the envelopes and to keep postage down we wrote on flimsy air mail stationery so that long letters were lightweight and could pass under a single unit of postage. Of course we used fountain pens.  Oh and don’t forget the sealing wax.  For my 8th birthday I received a set of stamps and sealing wax candles.  I can still smell the wax as it dripped onto the point of the envelope seal, and then I would select (quickly) the stamp of choice and stamp firmly, leaving a distinct initial or fleur de lis.

My father dutifully wrote each week to his mother, as did my mother to hers, but somehow I remember my father’s efforts more.  Phoning long distance to California was a luxury – forget unlimited talk or cell phone freedom – and so perhaps I observed his habit and incorporated it into my own routine.  When I left for college in 1970 my father wrote to me every week, and I loved opening my mail box in the Student Center and seeing his distinctive script scrawled across an envelope.  The letters were short, scratched out on tablet paper that I recognized from his work, and he always enclosed a few dollars for a treat. Usually our correspondence revolved around how the Dallas Cowboys had fared recently, or how his golf game was or just stuff about the family.  I saved every one of his letters and gathered them with ribbon.  Thank heavens in all the purging my parents did during retirement they didn’t throw out my special box of college mementos.  While cleaning out my mother’s house last spring I found all of MY letters that I had written to him.  He had saved them all too.

Preparing my 90 year old mothers’ house for sale was a tough project.  But there were treats along the way.  Packed carefully away in an old trunk were three sets of letters, bound up in aged ribbon and yellowed with time.  The first set were letters written to my grandmother from her then fiancée, the grandfather I never knew as he died when my mother was 12.  The paper was filmy onion skin, the script exquisite in its fluid loops and dips.  Why did we stop teaching penmanship in schools?  His cursive was amazingly beautiful, from a different era – I was dropped back in time into 1918.   I felt almost guilty reading about the anticipation about their upcoming nuptials.  The letters were sweet and innocent and filled with fervent passion about their future together.  The next set were the letters my grandfather had written to his daughter (my mother) while she was at camp – the summer she was 12.  A smaller stack, but the poignant part of that keepsake was the final letter written just before he was scheduled for surgery from which he did not survive.  The letter arrived after he passed away.  My mother put that final letter on top and bundled them up.  I am pretty sure she never revisited that correspondence.  She confided years ago that her childhood ended that day; that she felt old and heavy at the young age of 12 as she was an only child and felt enormous responsibility to care for her mother, a 42 year old widow who had never worked a day in her life or finished high school.  She was her mother’s caregiver until my grandmother passed away at age 98.

The final set were letters my father wrote to my mother during their courtship.  I recognized my father’s scrawl immediately.  It was more legible back then; hard to believe he had already served during World War II, gone to college on the GI bill and was just starting out at Shell Oil at the ripe old age of 30. He and my mother were engaged and he had been transferred out of town; so writing letters was the way they kept in touch.  Again I felt like a voyeur, but it was a wonderful piece of our family history that was indescribably beautiful.

As I ponder the New Year, I think about the ways I would like to make my life more meaningful.  I can lose a few pounds and exercise more, play more and worry less – but it occurred to me that I would like to write more and spend more time with pen to paper.  My calligraphy lessons have infused me with a new passion for the beauty of the printed word, but I know also the simple act of writing a letter to someone will give them more pleasure than it gives me.  So for my lovely mother-in-law and the elderly lady in California who we enjoy helping out – there is a fresh stack of note cards ready to be filled.  All I need is the sealing wax.  Amazon Prime is taking care of that.

The Library

“Books are a uniquely portable magic.”  Stephen King

If books are a uniquely portable magic, the same cannot be said for hundreds and hundreds if not thousands of books, but port them we did.  The first thing that my husband and I noticed about the house we ended up buying was the library—a room completely lined from top to bottom with built in bookcases.  I have lived in many places, and set up makeshift bookshelves from salvaged boards and cinder blocks, and later, the do it yourself–put them together to watch them fall apart IKEA models—but I have never had a library.  Say it with an affected British accent if you will—the “lye-brahr-ry”, or feign embarrassment and call it the “TV room”, this library has become the focal point of our home.

I consider myself fortunate—my family has always revered books.  I have two volumes from my mother’s childhood, Mary Poppins and Mary Poppins Comes Back, reprinted in August 1941.  You don’t remember Mary Poppins?  Let me jog your memory of a far more innocent time: “If you want to find Cherry-Tree Lane, all you have to do is ask the Policeman at the crossroads.”  At the end of the second chapter, the children Jane and Michael ask Mary where she’s been on her day off.  She replies, “In Fairyland.”  They are baffled when she tells them that she did not see Cinderella or Robinson Crusoe.  They proclaim that she could not have been in THEIR Fairyland.  Mary Poppins gives a superior sniff and replies, “Don’t you know, that everybody’s got a Fairyland of their own?”

My own Fairyland was created by Walter Farley, and Marguerite Henry and Albert Payson Terhune.  Farley wrote the famous Black Stallion and Island Stallion series of stories about Alec and The Black, an Arabian washed ashore with the young boy who tames him after a shipwreck, and Steve Duncan and Flame, the chestnut stallion he discovers on the mythical Caribbean island of Azul. Henry wrote Misty of Chincoteague, and Stormy, Misty’s Foal, inspiring little girls of my generation to long for their very own ponies.  Terhune wrote Lad, a Dog which I read when I was ten.  Twelve years later, while in medical school, the first puppy I ever bought on my own was a collie.  The dreams and myths inspired by a childhood of reading never really go away.

And so, when my children were young, I bought books upon books, and since I worked during the day, we read them together late into the night, before Harry Potter, which they were old enough to read on their own, and before video games, and computers and Facebook. The kids had their favorites—one was The Ox-Cart Man, describing the rhythmic seasons of life in colonial New England, by Donald Hall who later became poet laureate of the United States.  They also loved Wilfred Gordon McDonald Partridge, about a young boy who helps an elderly lady in a nursing home regain her memory by bringing her objects from the past, and of course The Giving Tree, by Shel Silverstein about selflessness and unconditional love.

When the kids grew up, and graduated to their own taste in reading material, I put away the children’s books—packed them lovingly into boxes and put them out in the shed by the barn.  And there they sat, quiet and safe, until the movers from Allied Van Lines retrieved them and brought them here, to the library.  As I unpacked all the boxes, the memories of childhood—my mother’s, my own, and my children’s came back full force as I indulged myself by opening and rereading nearly all of them, until I came to my own favorite, written and illustrated by Barbara Cooney in 1982, two years before my daughter was born.  It’s called Miss Rumphius, about a little girl named Alice who grows up and travels far and wide, but comes home to a city by the sea, where she plants lupines and becomes known as The Lupine Lady.  As a little old lady, she tells stories of her adventures to her great niece, also named Alice.  Little Alice says, “When I grow up, I too will go to faraway places and come home to live by the sea.”  The Lupine Lady says, “That is all very well little Alice, but there is a third thing you must do.”  “What is that?” asks little Alice.  Her great aunt replies, “You must do something to make the world more beautiful.”  “All right” says little Alice, who then reflects, “But I do not know yet what that can be.”

If books can inspire our children to make the world a more beautiful place, then they are indeed magic. I am so glad I kept all of ours.

A Not Quite Requiem for Big Red

Some of us think of the automobile as a means of transportation and nothing more.   Others, like me, see the car as something else entirely—an extension of ourselves, and an expression of identity.  Growing up I was influenced by my dear old Dad—our childhood was marked by a succession of American made muscle cars from the 1966 Ford Thunderbird convertible which met its sad end on the 610 freeway in the rain, to the Pontiac Firebird Formula 400 I drove out to Big Bend National Park, reaching its top speed of 160mph on a lonely stretch of interstate 10 before my new husband cried “Uncle!”  The first car I ever bought myself was a 1975 Chevy Camaro, V8 engine, bright red with white vinyl upholstery.  I was 21, and I was GOING PLACES.  I enjoyed that car for seven years until one too many spin-outs on Route 9 in the snow after I moved to Boston convinced me that it was time for something more practical.  The day I drove my brand new front wheel drive bronze Nissan Stanza out of the lot was the day I knew I had made a big mistake.  I was born for red cars with big engines.  I like people to see me coming.

Sometimes, however, we have to be practical.  By 1991 I had three children and a growing menagerie of pets.  I got my first Chevy Suburban, known then and probably now as the “National Car of Texas” on a company lease, and from then on I was hooked.  That car was indeed “like a rock.”  I drove it until the lease was up and then got another, this time the heavy duty three quarter ton with enough power to tow my house.  The menagerie had grown to include horses by then, and I wanted a car that I could both  live in and drive with three kids, 2 horses and an assortment of dogs.  There was nothing comparable to the trusty Suburban in the automotive world. A bemused trucker watched me struggle into a parking space at a truck stop and actually taught me how to park my behemoth.  By 2001 I realized that the horses were safer with professional drivers and big rigs, and I “traded down” to my current Suburban, affectionately known as “Big Red.”  That was in the spring of 2001, and I was in love—with a big red car.

I’ve had Big Red for nearly 14 years and 230,000 miles.  Shortly after the model year 2001, Chevrolet in its infinite wisdom decided to turn the historic first true sport utility vehicle into a soccer mom-grocery shopping car.  Gone was the bench middle seat, replaced by “captain’s chairs” for easier access to the third row.  Gone were the “barn doors” which opened from the middle out, one at a time, replaced by the hydraulically lifted single back window-door, which may have provided better grocery access, but was entirely impractical for those of us carrying three to four hundred pounds of dog, all wanting to exit the vehicle at the same time. Gone was the middle seat that folded entirely flat, allowing the entry of two 700 size dog crates, the only passenger vehicle to this day which had that much cargo space.  In my distress over the changes to my beloved Suburban, I spent an hour on the phone with a Chevy customer service representative from India, who duly noted my concerns, but had no idea what I was talking about.

Last week I covered a practice in El Centro, about 140 miles east of my home in Rancho Santa Fe.  I felt Big Red shudder and heave going over the Laguna Mountains.  For the first time ever, cars were passing me to the left as I struggled to maintain 55 mph. My good friends at Quality Chevrolet have been patching the air conditioning compressor together for years, but this was something entirely new.  Fearing the worst, I took the car back to the dealer today, with clear “Do Not Resuscitate” orders.  All day I waited, and finally around 4 pm I got a call from service.  Bill said, “Ma’am, I think your engine and transmission are okay.  We found a faulty oxygen sensor. We’ll replace it tomorrow.  You’ll be good to go.”

Good to go to New Mexico?  I sure hope so.  I don’t want a new car.  I love Big Red.  I am loyal and I persevere. The Chevy Suburban no longer comes in red.  My family thinks I’m nuts.

Lighting Out For The Territory

“But I reckon I better light out for the Territory ahead of the rest, because Aunt Sally she’s going to adopt me and sivilize me and I can’t stand it.  I been there before.”

Mark Twain, Huckleberry Finn

 

While I wasn’t looking, someone snuck up behind me and bought my house.  Well, not exactly “bought” yet, but all contingencies are removed and the closing date is set for October 3.  This wasn’t supposed to happen.  My realtor told me that our place is “special”, a euphemism for “old run down house with wonderful horse facilities.” She said it might take a year to sell, and that the right buyer would come along—someone who wasn’t too house proud, but who wanted to “live the dream,” as I did seventeen years ago.  Someone who had always wanted a horse of her own and had waited a very long time to get one—or two or three or maybe even four.  Someone, in short, just like me.  And let’s face it folks—how many people are out there who are just like me?  Apparently quite a few.  The house sold in ten weeks for close to the asking price. And there are back up buyers, who just didn’t get back to see it for a second showing in time.

For seventeen years, I put off having friends and family visit. I had no dinner parties because we were embarrassed.  The house was a mess.  The carpet was old, and pet worn and smelly, the roof leaked, the kitchen was hideous, the “powder room” was a disgrace with orange and brown tiles left over from the 1970’s. But my children, my dogs and my horses were blissfully happy with the place.  It was home. When my friend Catherine passed away in late 2012, she left me a little bit of money, which I used wisely for a new paint job, new carpet and curtains, a stunning garage renovation (after all, it belongs to my dogs!), a bathroom facelift and some nice hardware for the newly painted cabinets in the kitchen.  Friends began to visit.  They said, “We love your place.”  As I walked around the vacuumed soft carpet and outside among the newly trimmed hedges, pruned eucalyptus, reseeded pastures and freshly dragged arena, I said to myself, “They are right.  I love this place.”

But there was sadness here for me as well—the tack room with photos of children long grown and horses long passed lining the walls, the empty bedrooms, and the dogs dearly departing, one by one.  And the cost of maintenance in drought stricken energy gridlocked southern California was a daily reminder of the fact that in March of this year, I retired from my full time job so that I could experience a little more life, and a little less death.  It was a good decision, and one I don’t regret, but a reduction in cost of living was a necessary corollary.  So the house went on the market, and here we are.  I need to find a place to live and I don’t have much time.  My youngest son, and eighty nine year old father are still here in San Diego, but I yearn for the open spaces and big skies of the west.  New Mexico, with its spectacular sunsets and mix of cultures has indeed been the Land of Enchantment for me.

It’s not clear yet, but I may, like Huck, be soon lighting out for the territories.  I hope you will all come and visit.  Wish me good luck!

In Sickness and in Health: Seven Things to Know about Healthcare These Days

My 23 year old son says my blog posts are too long.  He says that his generation believes that if you can’t say what you mean in 350 words or less, you’re not worth reading. At the writer’s conference I attended last spring, I learned that books sell best if there are odd numbers in the titles (never mind the commercial success of “Ten Things I Hate About You”).   It has to be 5 or 7, because 6 and 8 just don’t cut it, and those of us old enough to remember know that Bo Derek is the only 10.  So here is my attempt at listing important things to know about how medicine works these days, in no particular order.

  1.  No news is NOT good news anymore.  The days of doctors calling you with your test results are, for the most part, over.  Do not assume that because you did not get a call, everything is fine.
  2. If we are treating you, please report your side effects so we can help you.  You don’t get brownie points for being a “good patient” by keeping quiet—you just get sicker.
  3. Please do not bring samples of bodily excretions in to the office on toilet paper in plastic bags.  You might make someone sick.  That someone might be the doctor. Brief quantitative and qualitative descriptions work well.
  4. If you need to get your doctor’s attention, one phone call may not be enough even though it should be. Go ahead, be a pain in the ass.  If the person up front gets tired enough of hearing from you, Facebook might be closed out and a message conveyed.
  5. Insurance companies are not your friends.  They will NOT call you back.  If you call and get a phone tree, press “zero” until a human being comes on, and then demand to speak to a supervisor. Your life and  bank account depend on it.
  6. Know the names of your medications and their doses, and if you can’t remember, write them down and put them in your wallet. Please don’t say, “A little yellow pill.”  UNDERSTAND what the pill does. Not knowing can kill you.
  7. Don’t say “I have the flu” when you have a cold or a little upset stomach.  Get your flu shot this fall or you will figure out what the real flu is when you really have it.

I could go on but I won’t.  As they say in obedience training, “Exercise finished!”

And Speaking of Plastic Surgery

I have a new favorite doctor show, “The Knick” on Cinemax, airing on Friday nights.   The show stars Clive Owen as the charismatic cocaine addicted Chief of Surgery Dr. John Thackery at a fictitious New York City hospital called The Kickerbocker at a time when surgery was one foot out of the barbershop.  The tagline is, as they say, priceless– “Modern medicine had to start somewhere.”  On the third episode, last Friday night, Dr. Thackery performs a pedicle skin graft from the upper arm to cover a gaping hole in a woman’s face where her nose used to be, before she got syphilis.   Back in those days, this was a marvelous feat.  Real progress in what we now know as reconstructive surgery didn’t come until the end of World War I, when Sir Harold Gillies, a New Zealand otolaryngologist later known as the “father of plastic surgery,” established the first hospital ward for the facially wounded in Queen Mary’s Hospital in Kent.

For over fifty years, I have been a bystander to the evolution of plastic surgery.  As a teenager I remember the heady early days of microvascular surgery—my father, Dr. Melvin Spira reattaching the scalp of a man whose hair got caught in machinery, then the tales of sewing back severed fingers and ultimately entire limbs with gradually improving functional results.  In the 1970’s the great French surgeon Dr. Paul Tessier, pioneer in techniques for cranio-facial surgery to correct birth defects came to the United States to teach, and I remember a Saturday morning clinic at my father’s office, where mothers whose children’s facial deformities were so severe that these kids had, literally, never seen the light of day waited in line to be seen by the great surgeon who could give them back a normal appearance, and thus a life.

Plastic surgery, like my own specialty of Radiation Oncology, has become one of the “lifestyle” specialties to which medical students aspire, particularly those with an artistic bent and good hands, and for good reason.  Cosmetic procedures are highly reimbursed, and are done during “regular” working hours. Walking around here in San Diego and Los Angeles, surely two of the plastic surgery capitals of the world, it’s easy to spot who has had “a little work” done.  Having one face lift might be a good thing (I wouldn’t know because, as I’ve covered in previous blog pieces, my imagination runs wild with the possibilities of complications and I am far too chicken for elective surgery), but have three and you become one of “Our Ladies of Perpetual Surprise”, eyebrows at the hairline.  Same goes for breasts—it is not normal for the “girls” to be rigidly immobile as their owner pounds away at the Stairmaster.

Last year I mentored a medical student who had started his medical education thinking that he wanted to become a plastic surgeon.  After a beloved aunt developed breast cancer and needed radiation, he started to think that perhaps he would rather become a radiation oncologist because he enjoyed dealing with cancer patients.  He was an outstanding student, and I was quite sure that he would be accepted, and do well in either specialty.  I assured him that with his gifts, and his compassion, he could combine his interest in helping cancer patients with his interest in reconstructive and restorative surgery. Residency interviewers for plastic surgery residencies have a difficult job these days: all of the applicants SAY they want to do reconstructive surgery, but most end up doing cosmetic work.  Apparently my student was convincing when he said he wanted to do plastic surgery to help cancer patients.  He started his plastic surgery residency at Stanford last month.  Dr. John Thackery of “The Knick” may be fictional, but I hope that my student leads the way in new innovations in reconstructive surgery.  My cancer patients may depend on it.

In Pursuit of Perfection

“Upon what instrument are we two spanned, and what musician holds us in his hands?”

Rainer Maria Rilke

This past week was a very busy yet very interesting time for me.  Early in the week, I had a visit from an old medical school classmate who is now one of our nation’s leading researchers in diabetes and other endocrine diseases.  Although most of his time is spent in the lab, he still prides himself on being an outstanding clinician, and I can attest to that.  I would choose him for my own personal physician any day, were he not based at Duke in Durham, NC.  He told me the following story:  a few months ago he was the attending physician on the endocrine consultation service.  The fellow on duty was called for a consult on a middle aged man who needed an amputation for vascular complications related to his diabetes, and the surgeon needed to make sure his blood sugars were under control before taking him for surgery.  The endocrinology fellow assessed the patient’s insulin requirements, and also mentioned that the man was complaining of some mild upper back pain, which seemed insignificant at the time. The case was presented to my friend, was assessed to be routine, and the patient went to surgery.  Shortly after the operation, the man suffered a cardiac arrest due to a myocardial infarction in the posterior circulation.  He did not survive.  My friend, whose job was NOT to assess the patient’s cardiac status, but rather his diabetic control, is still beating himself up about the patient’s death, many months later.  He insists that he should have asked the surgeon for a cardiac work up prior to the surgery.

On Thursday, I flew to Kalispell, MT to attend my nephew’s graduation from Montana Academy, a boarding school dedicated both to academic excellence, and the therapeutic mission of helping teenagers with problems learn to cope in positive ways. At the graduation ceremony, I was moved to tears several times, first by the headmaster’s recounting of the tale of Odysseus and the Cyclops as an analogy for the importance of finding and declaring one’s true identity, and later by the speeches of some of the parents whose children had benefited from this school, set in the green pastures and foothills of Montana. Finally, and even more importantly, some of the students themselves spoke, hesitating at first and stumbling over their words, but gaining strength from the support of the gathered crowd as well as their teachers, counselors and the founders of the school sitting behind them.  The students spoke of the failures which led them to the academy, each small but increasingly significant success they met there, and their hopes and dreams for the future.  These students were articulate and impressively intelligent. The last student who spoke was particularly moving, when she said, “Here I discovered that I am worthy of love, and that I DESERVE to love and be loved in return.”

We all strive for perfection, and yet for most of us it is our failures which teach us the meaning of life and of being human.  Some of us are lucky enough to learn this at eighteen, but many of us are still learning these lessons at sixty.  Last night, as I prepared for bed a row of necklaces I have hanging from pegs in the bathroom caught my eye—fossil mammoth ivory turned blue from arctic hoarfrost, and set with a fire opal, lapis prayer beads from Bhutan, ancient carnelian beads from the mountains of Nepal, and an old Chinese quartz crystal set in silver with enameled symbols of yin and yang.  I wondered, for myself, for my nephew and for my old friend, what talismans are these which can keep us safe, which can protect us from our own demons?  And what great musician holds us in his hands?  We can only continue to do the very best we can.