Gone With The Wind

I have forgot much, Cynara! gone with the wind,
Flung roses, roses riotously with the throng,
Dancing, to put thy pale, lost lilies out of mind,
But I was desolate and sick of an old passion,
Yea, all the time, because the dance was long:
I have been faithful to thee, Cynara! in my fashion.

Ernest Dowson

Having no artistic talent whatsoever myself, nonetheless I am fascinated by art, and especially by artists themselves.  My father has been both an artist and an avid collector since the ship he served on as a Navy dentist docked in Sicily, and the local artists were allowed to come aboard to sell their wares.  He still has paintings he bought in 1945 hanging on his walls.  As a teenager in Depression era Chicago, he took classes on Saturdays at the Chicago Art Institute and wanted to become a portrait artist when he grew up.   His father, my grandfather, told him to get real and learn a trade.  He chose dentistry, and only later, after going to medical school, discovered that as a plastic surgeon, he could both be a portrait artist and earn a living.

Many of my artist friends do not take commissions.  When asked why, they say that it is often very difficult, if not impossible, to reconcile their own interpretation of a subject with that of the person commissioning the work.  Fortunately for me however, some do, and I have been the appreciative beneficiary of portrait work by artists such as Stephanie Snell, Paul Doyle and Marilyn Terry.  What do these artists paint?  They paint my dogs of course.  My children and I would never be able to focus and sit still for our own portraits to be painted and besides, despite this age of “selfies”, we are far too self conscious.

A few years ago, a young man’s wife developed breast cancer at age 25.  He is a well-known video artist known as Daarken and he and his wife needed money to meet their medical expenses.  An on-line fund raising auction was conceived, with the theme stated as “Beautiful Grim.”  Beautiful, because despite his young wife’s diagnosis and treatment, she was and always will be beautiful– yet for some young women with breast cancer, the prognosis can be grim indeed.  His friends and fellow artists rallied to the cause, and many contributed original works to the auction.  I am a friend of Daarken’s sister, and I followed the auction with interest.  In particular there was one painting that I kept coming back to, that no one was bidding on.  It was a portrait of an African American woman, beautiful and naked, except for her long stockings which were peppermint striped, red and white. Her hair was a tangled wild mass of curls against her beautiful skin. When no one else bid, the portrait was mine.

Over the years I have become very friendly with the artist and his wife, who shall be unnamed because of the personal nature of this anecdote.   They visited our home this past summer, and we commissioned a work of art.  The assignment was intentionally vague—“just paint something you see in New Mexico that inspires you.”  A few weeks ago the painting arrived, a full 4’ X 4’ landscape entitled “Sombrillo Vista.”  It is as beautiful as I had hoped, and emblematic of the New Mexico I have come to love.

When I called to offer my sincere gratitude, the artist’s wife said, “You know, just after he finished your painting he received another commission—a most unusual one!  A man called and said he wanted a portrait painted of his ex-wife. He is still in love with her and wants an oil painting to remember her by.”  Apparently he had sent a few snapshots of his ex along with his request.  Always a romantic at heart, this struck me as both somewhat insane, but also a true romantic gesture.   I said, “Send me a phone pic of the work in progress.  I want to see the woman who inspired this act of unrequited love.”  She did.  The woman was indeed beautiful, and playful, and mysterious all at the same time.  I said, “Well if the ex-husband doesn’t like the portrait, let me know because I will buy it.”

Shortly after our conversation, a photo of the unfinished work was sent to the hopeful ex-husband.  He liked it a lot, but he felt that it was not quite there yet.  He had some advice for the artist– he said, “Just think—complex and Mona Lisa eyes with a dash of mischief and you’ll nail it!”  I laughed and said, “Now that should be simple.  You know, just be Leonardo da Vinci.” The finished portrait was unveiled to the good patron last week who promptly proclaimed, “It gave me goosebumps!”   The man likely needs a good therapist instead of a portrait of his ex.   But let us be clear:  he has been faithful to her, in his fashion.  And my artist friend, well—clearly, he NAILED it!

An Extraordinary Life

“Death, be not proud, though some have called thee

Mighty and dreadful, for thou art not so”—John Donne

On a Sunday in January, 2014, I opened the New York Times Opinion section and stumbled upon one of the most unusual essays I had ever read.  It was written by Dr. Paul Kalanithi, who at the time was a 36 year old neurosurgery resident at Stanford who had been battling metastatic lung cancer for eight months.  Here is a link to the essay, entitled “How Long Have I Got Left?”– http://www.nytimes.com/2014/01/25/opinion/sunday/how-long-have-i-got-left.html?_r=0    The author’s point was one well understood by cancer patients everywhere—if the doctors could not tell him whether he had a month, or a year, or ten years, how could he possibly determine what his priorities should be and how best to live his life?  Should he finish his residency?  Should he write a book?  Should he have a child?  In his worst moments he wrote that he fell back on his first love—literature.  In the last sentence of Samuel Beckett’s The Unnamable, Kalanithi found a mantra to live by: “I can’t go on.  I’ll go on.”

As it turned out, he did not have long.  Despite the optimistic and sometimes humorous tone of the essay, Dr. Paul Kalanithi died of his lung cancer 14 months later.  But not without first doing ALL of the things he mentioned in the essay.  He finished his neurosurgery residency as chief resident. He repaired a fractured marriage.  He had a child.  And to our great benefit, he wrote a book called “When Breath Becomes Air” published posthumously in January of this year—a book which despite my oft stated incredible reluctance to read anything I know will make me cry, I grabbed off the shelf the minute I spotted it in a local bookstore.   I was not disappointed, and yes, I cried.

The courage of cancer patients, and of all patients facing life threatening disease astounds and inspires me.  Many go through grueling and exhausting treatments and manage to put one foot in front of the other—they “can’t go on…they go on.”   Paul Kalanithi not only went on…he wrote about his experience in a book that will stand not only as a cancer memoir, but as a profound piece of writing.  When faced with dying, he chose life by completing his training, by having a child, by believing every day that he still had much to offer.  In an essay for Stanford Medicine he wrote words for his infant daughter which were included in his book: “When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.”

I hope you get a chance to read his book.  Even if it makes you cry.

You Know You’re at a Plastic Surgery Meeting When…

My friend Dawn and I recently attended an evening meeting of the Houston Society of Plastic Surgeons.  Since we were invited guests, and not plastic surgeons, we didn’t stop on the way into the lovely formal dining room to pick up our name badges because the organizers had not made them for us.  On the way out, however, we both noticed clear plastic perfectly formed oval objects sitting on the table, looking for all the world like crystal paper weights.  I picked one up and it slithered out of my hand, slippery as a water balloon.  It was then that I realized that the beautiful paper weight was indeed, a silicone breast implant made by the company that sponsored the dinner.  After all, what do you expect when you attend a gathering of the plastic surgery clan?

I have learned in medicine to expect the unexpected.  The reason that I got in my car and drove 970 miles from Santa Fe to Houston was that my father, now nearly 91 years old and an emeritus Professor of Plastic Surgery at Baylor College of Medicine, had been asked to give several lectures as a visiting Professor for the residents and fellows in training.  Several is a bit of an understatement.  He was actually asked to give five separate talks, including three on consecutive days at 6:30 am, because as we know, surgeons start their days early.  After assuring Dad that I would not be getting up to attend ANY 6:30 am lectures, I set out for Houston in the midst of some of the worst rainstorms and flooding seen in that town in over thirty years.  Dad has had to curtail his practice over the last few years due to significant health issues, and when he came down with a bad cold days before the trip, I tried to no avail to convince him to stay home.  He of course wouldn’t hear of it.

His assignment for the evening lecture last Thursday night was to talk about his surgical missions overseas to repair cleft lips and palates, other birth defects, and contractures due to severe burns and other injuries. Especially since he retired from active practice, he has participated in several trips a year with Surgicorps International, traveling to Guatamala, India, Bhutan, Viet Nam, Zambia and other countries to attempt to give a normal appearance, and thus a normal life, to those unfortunate enough to require his services.  Devoted parents travel great distances to wait all day for their children to be evaluated, and once the schedule is set, surgeries proceed for the next 7 to 10 days, twelve hours a day, until the work is done.  Dad methodically showed the construction of each trip, from soliciting donations, to transporting equipment, to evaluating prospective patients, to post-operative care. At the end of his talk, he showed a blurry photograph of a 43 year old man who had lived his entire life with a severe facial deformity.  He told us that when the patient woke up in the recovery room, the first thing he asked for was a mirror.  When he saw his own face, swollen from surgery, but yet distinguishable as a normal human face, this patient burst into tears.  As my father told the story, everyone in the room did the same.

Plastic surgeons often get a bad rap.  In our youth driven, appearance conscious world, it is all too easy to make jokes about their bread and butter cosmetic work—the breast implants, the face-lifts, the nose jobs, and the botox.  At dinner last Thursday night, my friend and I, and the residents in the room, were privileged to catch a glimpse of what these talented surgeons can do to change the life of a child, and that child’s family and future.  The residents in the room are lucky—in a few years they too will have the skills to give the gift of a normal appearance and normal function.  As for me, well, I think it’s time to get back to work treating cancer patients.

In Praise of Angelina

I have always been one of Angelina Jolie’s biggest fans.  The Academy of Motion Picture Arts and Sciences saw fit to reward her 1999 performance in “Girl Interrupted” with an Oscar, but I wasn’t well and truly smitten until the second Lara Croft Tombraider movie was released in 2003.  In that film, Jolie, who performs her own stunts, is seen galloping on a dark horse while spinning a heavy shotgun from side to side to shoot alternating targets.  And she is riding SIDESADDLE.  If you don’t believe this, have a look here:  https://www.youtube.com/watch?v=tz1lCcs9tac  In the Lara Croft movies, she is the epitome of a strong, athletic, intelligent and self assured woman.  It may not seem like much, but I granted Miss Jolie a high honor indeed—in 2004 I named a dark, agile and fast deerhound puppy after her, the soon to be champion Caerwicce’s Lady Croft, aka “Angelina”.

 

In the years that followed the Lara Croft movies, Angelina Jolie went on to surprise her public in more ways than one.  The girl who initially achieved notoriety for wearing a vial of her second husband Billy Bob Thornton’s blood gained a different type of fame when she adopted a Cambodian child, and subsequently became a respected ambassador for the United Nations.  She has become well known for her humanitarian efforts, devoting as much time to improving the lives of refugee children as she does to her own career.  Recently, she has added the titles of author, director, and Mrs. Brad Pitt to an already impressive resume.

 

But perhaps the biggest surprise of all came two years ago, when she went public in the New York Times with the revelation that she is positive for the breast cancer gene BRCA1. In a moving statement, she wrote of her difficult decision, at age 37, to undergo bilateral prophylactic mastectomies and reconstructive surgeries in the hope of staving off the cancers that took her mother, her grandmother and her aunt.  She was clear and concise, reasonable and dispassionate in her account.   Not only did she raise awareness of the heritable form of breast cancer, she gave courage to all women facing the challenge of a mastectomy.  If one of the worlds most beautiful and sexy women could undergo such surgery in the glare of the celebrity spotlight and come out looking stronger and even more beautiful, so could some of the rest of us.

 

Today she has done it again.  In a New York Times article entitled “Diary of a Surgery” (http://www.nytimes.com/2015/03/24/opinion/angelina-jolie-pitt-diary-of-a-surgery.html?ref=opinion&_r=0 ), she reveals that she has recently undergone removal of her ovaries and fallopian tubes to prevent ovarian cancer, the disease that killed her mother.  She describes precisely the terror she felt when informed that some recent blood tests were equivocal, the dreadful anticipation of the results of a PET/CT scan and the realization that now, at age 39, she has entered menopause.  But she also describes the relief she felt once she had made a decision to go ahead with the preventive surgery: “I know my children will never have to say, ‘Mom died of ovarian cancer’.”

There’s bravery and then there’s true courage and grit.  It’s one thing to perform gymnastics while swinging from the rafters of the Croft estate, or to shoot a rifle off the back of a galloping horse.  It’s quite another to write clearly and objectively the story of being diagnosed with a genetic mutation, and of the careful informed decisions she made to minimize her risks, while at the same time admitting that her decisions were not necessarily the right ones for everyone.  As Angelina says, “Knowledge is power.”  We owe her thanks for sharing hers with us.

 

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.

The Curbside Consultation

Recently a friend of my husband’s in San Diego had a mammogram which showed some suspicious microcalcifications in her right breast.  She underwent a stereotactic biopsy which revealed ductal carcinoma in situ, the earliest form of breast cancer also known as Stage 0 breast cancer.  This type of cancer is non-invasive and does not metastasize, however, if untreated it can progress or recur as a more serious type of breast cancer, so at the very least excision of the abnormal area is indicated, and in some cases radiation and/or mastectomy are necessary.  My husband asked if I would speak to her regarding her breast cancer, and somewhat reluctantly I said yes.

 

Why reluctantly, you might ask.  Isn’t that the nice thing to do?  I said to my husband, “I think it’s a mistake to do consultations over the phone.  I have no access to the mammograms or pathology report, and I cannot examine her.  These things are important to have and do to give someone an informed opinion about her case.”  He said, “But can’t you just talk to her a little bit and recommend a surgeon, and maybe give her a bit of information about radiation therapy?”  I agreed to do it.  A few days later we connected by phone.

 

Having practiced in San Diego for twenty one years, and having a major interest in breast cancer, I know every surgeon in San Diego and Riverside counties who specializes in breast cancer.  Likewise, every radiation oncologist and medical oncologist.  I am a virtual referral encyclopedia—tell me where you live and I will tell you where to go.   In this case I recommended the surgeon whom I would choose to operate on ME, if I had breast cancer.  Same thing for radiation oncology.  I did this for my husband’s friend, and we discussed her case at length.  Because of her relatively young age, excision alone was a bad choice, so we discussed the pros and cons of excision plus radiation versus simple mastectomy with or without reconstruction.  At the end of the conversation she thanked me, and then mentioned that there were actually TWO areas in the breast that were biopsied and were positive, and they were not particularly close together.

 

That little fact, which I would have known if I had had her pathology report and her mammograms in front of me, changes everything.  If a woman has multifocal disease, there is a good probability that she may be better off removing the breast.   I backtracked and covered that point, but I worried that I had made an anxiety provoking situation much worse by confusing a new breast cancer patient.  In the end, she sought the care of an excellent breast cancer surgeon, and I know she will be fine.  But I have the lingering feeling that in trying to do the nice thing, I did the wrong thing.

 

Think of this when you stop your doctor friend on the street to ask about a friend or relative who has recently been diagnosed with cancer.  Curbside consultations do no one any favors.  If you or a friend or relative need an opinion, get an INFORMED opinion—present to the consulting physician with your history, your radiology, your lab work, your pathology and your body to be examined.  Then, and only then, you will be assured that the recommendations that you receive are the ones you should truly follow.  It could save your life.

When Cancer Comes To Call

A patient story tonight, from Jackie:

 

It was one of those days.  I had been to the gynecologist the week prior because I somehow knew the sporadic bleeding which I had experienced was NOT a simple Urinary Tract Infection for which I had been treated three times.  My doctor did the scrapings and biopsies and had me run down the hall for an ultrasound.  I’d had lots of ultrasounds during my pregnancies – especially with my twins -  but this one wasn’t fun.  There was no cute baby to smile at.  This time it was a transvaginal ultrasound which involved the insertion of a rather large tube into “that place” to look at the uterus.  “My what a big wand you have” I joked with the sonographer.  She didn’t smile.  That’s when I got a bit nervous.

Of course my doctor put a positive spin on everything – prior to the biopsy results.  He said it was probably just an over thickening of the uterus, Hyperplasia.  So I decided to wait until there was something solid to review and went on about my life.  I had a dental appointment a few days later.  My dentist announced I needed a root canal immediately and sent me to a nearby Oral Surgeon.  As I was pulling up to the Oral Surgeon’s office my cell phone rang.  It was my gynecologist.  “Well, there is a malignancy….”.  The words hung in the air.  We had a brief conversation – darn, I thought – I had researched  Hyperplasia thoroughly and knew all the right questions to ask.  I felt like I had studied for a test and then the test changed.   He said I needed to contact a special Gynecological Oncology surgeon and that his office would tell me what’s next.  So I called and left a message with that doctor but said I couldn’t talk for a couple of hours because I was just about to go in to have a root canal.  One thing I will say about those specialists’ offices; they run like a well oiled machine.  As I walked back to my car 2 hours later there was a message on my cell phone.  It was Jay, the Office Manager for the Gynecological surgeon I needed to see.  He was calling to schedule my appointment.  He paused and said “Good luck with the root canal. Sounds like you are having a great day”.   And so it went.

My life was forever changed.  May brought the diagnosis.   June brought the scheduling of the hysterectomy.  July 1 was the surgery.  July 10 came the pathology report.  Not what we had hoped for– the “once and done” hysterectomy revealed some naughty cells lurking within the uterus that have a tendency to “jump” into other areas.  Chemo or Radiation? My case was submitted to the Austin Gynecological Oncology Tumor Board for review as recommended by my Surgeon.  I was overwhelmed.  I didn’t know what I didn’t know.  As is often the case when you do get the “C” diagnosis; you are thrown into a blender of emotions but when the dust settles the appetite for knowledge takes over.  And so it was decided that radiation was the protocol. After I healed from surgery, radiation began.

So here’s the thing:  it wasn’t that horrible.  For anyone who has been through tough times, worked hard and experienced inconvenience or sadness – you are mentally strong and prepared for this challenge.  It is definitely a Mind Game.  I decided to fight and endure and not to whine and whimper.  For 6 weeks my life revolved around daily visits to the Oncology Center.  The treatment wasn’t bad.  The hardest part was drinking 40 ounces of water prior to treatment.  The side effects clicked in about 3 weeks in; lower GI issues.  But oh well, diarrhea is not the end of the world.  My pubic hair fell out which I found fascinating. I met wonderful friends in the waiting room.  The therapists and nurses and doctors were wonderful.  My neighbors and family rallied and emotions ran high.  Food and flowers poured in.   My sweet neighbor who had just finished two years of breast cancer diagnosis, surgery, chemo, radiation, reconstruction – I was at her door daily for her battle.  Now, she was at mine.  Life sifts down to the basics of priorities: Faith and Family and Friends.

I finished my radiation on September 15 and got to Ring the Bell which is special to all cancer patients because it means YOU ARE DONE.   My sweet family and a few friends showed up.  Tears flowed.  My husband pushed through the group to shake the hand of my Radiation Oncologist and choked “Thank you for helping my wife”.  I was ready to start my new healthy life.

Check-ups will continue for a few years and I will see both my Surgeon and Radiation Oncologist often. That’s okay.  My Surgeon is cute (I think he is almost the same age as my oldest son) and my Radiation Oncologist is an incredible mother of four who never seems hurried or distracted and makes me feel like I am THE most important patient in her practice.  I feel so blessed to have been in such capable hands.

I feel wonderful.   Celebrating my December birthday was more special this year.  Welcoming the New Year signaled almost a palpable relief to make a fresh start.  I take nothing for granted and try hard to live in the moment.  Ever the planner, this has been my most challenging goal.

For Christmas this year my daughter gave me a beautiful silver charm.  On the front it says “Faith”.  She told me to turn it over.  On the back was engraved 9-15-2014.  My final day of radiation.  It has been the most horrible of years, but it has been the most wonderful of years.  When Cancer comes to call you rise up and fight the good fight.  And then, you go on.

Siskel and Ebert

I have always loved the movies.  Like every grade school kid watching reruns, I cried when Bambi’s mother died, and when starry eyed Judy Garland clicked her heels and said, “There’s no place like home!”  But when the big budget films hit the screen in my early pre-teen years—Ben Hur, Camelot and Lawrence of Arabia, I was irretrievably hooked.  Sitting in a dark theater, I could escape from actual or imagined troubles.  Some people prefer live theater, but for me it was always the big screen, where I could pretend to be Guinevere as Lancelot leaned in for a kiss, or Holly Golightly, or Cleopatra, up close, more real than in real life.  By high school I was reading the film critic’s reviews in our local paper, and by college I had my favorites.  Pauline Kael was far too esoteric for me—my “go to guys” were Gene Siskel and Roger Ebert with their trademark “thumbs up” or “thumbs down.”

I was channel surfing last night and I just happened upon CNN which was airing a documentary film about Roger Ebert, his career and his struggle with cancer called “Life Itself” from his memoir of the same title.  I had been aware that Ebert had been battling head and neck cancer for years before his death but I was not well versed in the details of his illness.  Roger Ebert was diagnosed with papillary carcinoma of the thyroid in 2002, typically a rather low grade cancer treated primarily with surgery. Unfortunately he was unlucky and the cancer recurred, ultimately necessitating removal of his lower jaw with subsequent loss of his larynx, and his ability to speak and swallow.  What was unique about Mr. Ebert was that unlike many public figures, especially those in the visual media whose jobs sometimes depend on facial appearances, he chose not only to go public with his illness, but to ENGAGE his many fans and followers in his day to day struggles via his website, his blog, and his Twitter account.  He allowed Steve James, the documentary filmmaker, to film him not only on his best days, but also on his worst.  He smiled and joked for the camera nearly immediately after his radical mandibulectomy and neck dissections, even as he was being suctioned for the secretions which if left untended would choke him.  His wife Chaz, his stepchildren and grandchildren were equally generous, at a time when the family was undergoing much pain and hardship.  He clearly had his demons and his days where he wanted to quit, but ultimately he was buoyed by the support he received from not only his fans, but from directors and actors he had at times panned.  To see Martin Scorcese pause to wipe a tear on camera when discussing his friend was a window into what this person meant to his friends and peers.

What I had forgotten, and was reminded of while watching the documentary, was that Ebert was not the only member of the Siskel and Ebert team who suffered from cancer.   Gene Siskel was operated on for glioblastoma, a malignant brain tumor, in the spring of 1998.  Only his wife knew of the diagnosis—he chose not to even tell his children.  He was back at work nearly immediately, and only when he became symptomatic again in early 2009, did he request a leave of absence from his show.  He died of complications of a second surgery to deal with recurrence in February 1999.  His friend and colleague Roger Ebert only learned the truth about the disease on a Friday, just days before he died, and had planned to see him on Monday.  Siskel died that weekend.  Ebert and his wife were devastated that they had not known, and had not been able to convey the love that was in their hearts.  I can only imagine how his other friends and family felt.

In my career, I have seen it both ways.   I have had patients who have their entire families with them for each treatment, who have written books about their illness, who have blogged about it, who have made public appearances and who have been pillars of support groups.   I have also had patients who were absolutely adamant that no one, sometimes not even spouses or children, should know about their cancer and treatment.  The reasons have been many—fear of unemployment, fear of upsetting loved ones, fear of being seen as weak or ill, and in one case, a minister who feared that his congregation would see his illness as punishment for prior sins.  But the common denominator was always one thing:  fear.

My patients generally have made up their own minds about what to reveal and to whom.  I respect their decisions and support them in whatever way that I can.  But when they do ask me, I always tell them that it is better not to take this particular journey alone.  Not every movie has a well-executed plot or a happy ending.  But as Siskel and Ebert would always say, there is joy in the characters you meet and love along the way.

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.

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.