Two Hundred and Nine Short Essays Later

 

Here I am in Boston, on the eve of my very first writer’s conference, feeling a bit like an imposter.  After all, the extent of my writing so far has been this blog, apart from thousands of histories, physical exams and treatment plans over the last thirty-nine years since starting medical school.  It occurred to me that someone might actually want to know what it is that I write about.  And then it occurred to me that I had never actually thought about it.  So I did, and this is what I came up with.

 

WHAT I WRITE ABOUT:

Cancer                                                                                                                           Radiation Therapy                                                                                                                 Dogs                                                                                                                                   Cats                                                                                                                                     Horses                                                                                                                                   Being a mother                                                                                                                         My kids                                                                                                                                 Travel                                                                                                                                    My father                                                                                                                               My mother                                                                                                                             Being a doctor                                                                                                                         Life

WHAT I AM TRYING TO SAY ABOUT LIFE

Cancer patients inspire me and motivate me                                                                       I’d like to explain a few things about cancer                                                                         I’d like to explain a few things about radiation therapy                                                     Cancer is evil and is not selective and makes me sad                                                 Cancer patients can be funny and they also make me laugh                                   Sometimes people do really stupid things when it comes to cancer treatment         Sometimes simple people can be heroes                                                                         Dogs are good therapy for me, my cancer patients, and my kids                                     Ditto on cats                                                                                                                       Horses are beautiful, liberating, dangerous and always expensive                                     You can be a mother AND a doctor and it’s going to be very hard                                     Your kids will forgive your shortcomings                                                                            Your kids will make fun of you                                                                                           Your kids will be successful if you EXPECT them to be and don’t harass them              Travel is enlightening and sometimes difficult and sometimes funny                                    My surgeon father is both an inspiration and a source of extreme annoyance                       My mother had a hard life and a hard death, despite appearances                               There’s always someone worse off than you                                                                   There’s always something to hope for

 

WHAT I AM TRYING TO SAY ABOUT BEING A DOCTOR AND ABOUT MEDICINE

Examine your patients—it’s important                                                                               Think for yourself and follow your gut instinct                                                                Beware of templates.  They tempt us to cheat                                                                     The Rules of the House of God still apply                                                                      Doctors make mistakes.                                                                                                       Be very selective about who you hire and set a good example for them                             Be the captain of the ship                                                                                                     Try not to whine, even if you fail                                                                             Communicate with your referring doctors and with your patients                                     Take the time and make the time                                                                                         Learn to speak slowly and clearly in layman’s terms                                                           Try not to say no, and never say “never”                                                                             DO NOT DROP THE BALL when dealing with cancer patients                                           And finally, answer your goddamned phone calls

Did I leave anything out?

A Different Kind of Mask

“I want them to live again to the point where pain becomes art.”

Lawrence Durrell,  “Justine”

I have always loved masks.  Near sighted likely from birth, a fact which was discovered significantly later, I never minded stumbling around our neighborhood on Halloween, my already deficient depth perception further stunted by my Bugs Bunny mask.  To don a mask was a chance to become someone else,  and as I grew older my disguises became more exotic—a gypsy fortune teller with gold hoop earrings in high school, a Turkish harem girl in college.  My imagination, fueled by the old stories of the Venetian Carnivale dating back to 1162, knew no bounds, and I secretly dreamed of a masked ball where I would glide gracefully and soundlessly, recognizing and being recognized by a handsome prince, by touch and scent alone.

 

In 2002 I took the occasion of my daughter’s graduation from high school as an opportunity for us to visit Venice, and more specifically, the mask shop known as La Bottega dei Mascareri at the base of the famous Rialto Bridge where a lively market persists to this day.  Elizabeth Barrett Browning may have been speaking metaphorically when she said, “the soul’s Rialto hath its merchandise,” but I was subject to a more literal interpretation.  I wanted to buy a mask from the famous brothers Sergio and Massimo Boldrin, who fashion papier mache masks in the old Venetian tradition.  I picked out a good one, made by Massimo himself, and given the history it depicts—perfect for a doctor.

 

The mask is larger than my face and flat, hand painted with a crackle glaze to look very old, and it pictures a man in medieval clothing dancing around a bonfire,  wearing the peculiar bird beaked mask known to physicians of the plague years.  The beaks were stuffed with medicinal herbs thought to ward off the dread disease.  In just one scene, the mask depicts the horror of bubonic plague—the bird beaked man, the fire to burn the contaminated bodies and clothing, the “ring around the rosie” cheeks of the afflicted.  With some difficulty, I brought my prize home in a suitcase, only to find that it gave me nightmares.  Today it sits on a bookshelf in the study off our garage.   I can’t have it in the house.

 

My patients with head and neck cancer are all too familiar with the concept of the mask, but for them the mask has a different significance.  Fashioned of a material called Aquaplast, the mask starts as a thick sheet of perforated plastic.  Warmed in a hot water bath, the material becomes soft and pliable, and is stretched over the cancer patient’s head and shoulders where it shape shifts to appear like a woman’s fish net stocking, but without the softness.  The mask hardens to become a rigid immobilization device which is bolted to the treatment table.  In my field, precision is everything and the mask, custom made for each patient, allows the radiation oncologist to accurately target the cancer while sparing critical structures such as the spinal cord and the eyes.  Not for the claustrophobic, the mask is a temporary prison for seven weeks of daily treatment.  At the end of treatment, each patient is offered the opportunity to take his or her own mask home.  Most actually do.

 

Today at the biannual Multidisciplinary Head and Neck Cancer Symposium in Scottsdale, AZ, I saw something quite extraordinary.  In order to assist patients financially with these cancers, an organization out of Washington DC called 911 4 HNC mounted an exhibition called “Courage Unmasked”  (www.courageunmasked.org).  Cookie Kerxton, an artist who was treated for head and neck cancer herself enlisted other artists to transform radiation masks into works of art.  The results, several of which are on exhibit at the meeting, are objects of exceptional beauty, turning human suffering into inspiration and hope for others.

 

At the meeting, volunteers were handing out free posters depicting forty two of these beautiful masks.  When I get home, I will have my poster framed and I will hang it in the room where I examine my head and neck cancer patients.  I am hoping that the bright colors of the beautiful masks will lessen their fear, and transform their pain.  There is indeed great progress in the treatment of their cancers.

Primum Non Nocere

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

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

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

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

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

The Way I See It

When it comes to surgery for cancer, having a “positive margin” is a bad thing.  It means that when the surgeon said he “got it all,” even though he meant it with all of his heart, likely he didn’t.  For a woman undergoing a lumpectomy for breast cancer, that positive margin means a re-excision of the lumpectomy site or alternatively, a mastectomy.  For a woman who has just had a mastectomy, it means that she will likely be seeing me.

I saw a new breast cancer patient on Thursday, a very attractive woman in her early fifties.  She had undergone a mastectomy last March, and had a tissue expander placed at the time to facilitate a later reconstruction with a silicone implant.  The final pathology showed positive lymph nodes on her sentinel node biopsy, and a positive margin where the tumor was close to the chest wall.  She required chemotherapy because of her lymph node involvement, and radiation to her chest wall for the tumor cells that may have been left behind.  She finished her chemotherapy without any difficulty in June.  But instead of coming to me at that time, she elected to complete her reconstruction first.

The first time her expander was replaced with a permanent implant, in August, there were complications which resulted in a failed reconstruction. The plastic surgeon elected to take her back to surgery in November, and replace the implant, and transfer fat cells from her inner thighs to make the reconstructed breast rounder and more perfect.  When the patient saw me on Thursday, she was still not entirely happy with the result, and was looking forward to having additional fat transplanted in the upper inner quadrant.  She guided my hand to the area and said, “See?  The tissue is so THIN right there.”  I stared at her reconstruction in amazement.  It was one of the best I had ever seen.

But yes, there was a problem.  It was not a problem that she had concerned herself with.  The problem was that it was nine months after her mastectomy, and that no one had pointed out to her that a local recurrence of her breast cancer, for which she was certainly at high risk, is a harbinger of metastatic disease and death.  In other words, she had failed to grasp the fact that it was her cancer, and not her breast reconstruction, that she needed to pay attention to.  It took me the better part of an hour and a half to convince her that she should proceed with radiation BEFORE her plastic surgeon achieved the perfection that she sought, and BEFORE her cancer recurred, if it has not already.

I understand the importance of breast reconstruction, and of feeling whole, and feminine again.  But I also understand the evil nature of “the beast.”  I may be a curmudgeon, but I want my ladies to comprehend that it’s not about the boob and the plastic surgeon isn’t going to tell you that—that’s MY job.  First and foremost, pure and simple, it’s about getting rid of the cancer. That’s the only priority.  It’s just the way I see it.

The Techno-Freak in Me

At home, I have trouble working the audio-visual system.  A few years ago, my husband bought a television set for our family room with a huge screen, for better sports and movie viewing.  Gradually components were added on—a surround sound system, the keyboard to stream video from Netflix, the standard DVD player, and, a gift from a movie loving friend who knows how much I like foreign language films, a DVD player that plays movies released only in Europe.  The composite system required, at one point, five or six different remote controls to run and I was hopeless until Mick at the meat counter informed me that you could buy a single remote controller by Logitech that could run EVERYTHING.  I invested in one at Best Buy, but I confess–I still have no clue how to work it.

It is a mystery to me why I cannot figure out how to work the television or the coffee maker, but the inner workings of linear accelerators and cyclotrons, and the generation of high energy X-ray, electron, and proton beams pose no problem.  Thirty two years ago, when I started in radiation oncology, our tool box was very limited—treatment planning systems were rudimentary and “two dimensional”—in other words we could only visualize and calculate the trajectory of a beam from each direction separately, and sum the total, in one cross sectional plane of a patient’s body. Two developments in the last generation changed all of that: three dimensional treatment planning, where the body is reconstructed from a series of CAT scan images, along with intensity modulated radiation therapy, where the beams can enter the body from 360 degrees of rotation where tungsten rods not only shield the normal structures from every direction but also enter the path of the beam to block the “overshoot” of tissues beyond the tumor. “Star Wars” technology met radiation therapy at the turn of the millennium.

The last ten years have brought a new revolution in radiation oncology—the advent of the proton center.  In November I had the opportunity to spend a full day at an orientation for the new Scripps Proton Therapy Center here in San Diego. Six years ago, I traveled to the existing proton facilities at Loma Linda, University of Florida, Massachusetts General Hospital and MD Anderson as part of a task force to determine the feasibility of my own institution building such a center. I was surprised at that point in time to discover that the technology of proton beam radiation therapy had not advanced since my old days at the Harvard Cyclotron in the early 1980’s. The opening of the new Scripps Center will change all that—for the first time a scanning “pencil beam” of high energy protons will be able to “dose paint” the radiation directly onto the exact shape of the tumor, delivering the fastest, most accurate and potentially the least toxic radiation therapy ever.

So what does this mean for patients in an era of cost reduction and intensive scrutiny of new technology?  Of the utmost importance, it means that more and more children with cancer will be treated with a method which will not only save their lives, but will significantly reduce the risk of secondary complications from the radiation.  In 2010, 465 children with cancer were treated with protons.  In 2012 this number rose to 695.  For the children who receive cranio-spinal radiation for brain and spinal cord tumors, this means a 7 to 12 fold reduction in secondary malignancies and a significant reduction in loss of IQ compared to standard radiation therapy.  For patients previously thought to have incurable cancers such as hepatocellular carcinoma, local control rates of up to 80% are being achieved.  For patients with brain or spinal cord or bone tumors in critical areas which abut sensitive normal tissues, it may mean the difference between sight and blindness, or ambulation versus paralysis.

The critics of proton beam therapy cite the fact that the majority of patients currently being treated with protons are prostate cancer patients, where as yet no real benefit has been shown in terms of survival or complications over intensity modulated radiation therapy. This may change as we select younger patients with more aggressive cancers for the treatment. In the meantime, I remain as excited by this technology as I was when I first followed the physicist into the cluttered old cyclotron building on the Harvard campus in 1982.  Next month the techno-freak in me will be privileged to participate in the most advanced radiation therapy the world has ever seen.

Thank you to Dr. Carl Rossi for the statistics provided in this entry.

The Median Isn’t The Message

Since I am still recovering from Turkey Day laziness, I thought I would share one of my favorite essays with you instead of writing something myself.  Bear with me here because it’s long, but extremely instructive for cancer patients, their caregivers, their loved ones, and those well meaning friends who want to tell you everything bad that can happen.  It also explains why I’m still doing what I do after nearly 32 years of treating cancer patients.  The author, Stephen Jay Gould, was an evolutionary biologist at Harvard, who was diagnosed with an “incurable cancer” at age 40.  He lived another twenty years.  Here is what he had to say:

 

The Median Isn’t the Message by Stephen Jay Gould

My life has recently intersected, in a most personal way, two of Mark Twain’s famous quips. One I shall defer to the end of this essay. The other (sometimes attributed to Disraeli), identifies three species of mendacity, each worse than the one before – lies, damned lies, and statistics.

Consider the standard example of stretching the truth with numbers – a case quite relevant to my story. Statistics recognizes different measures of an “average,” or central tendency. The mean is our usual concept of an overall average – add up the items and divide them by the number of sharers (100 candy bars collected for five kids next Halloween will yield 20 for each in a just world). The median, a different measure of central tendency, is the half-way point. If I line up five kids by height, the median child is shorter than two and taller than the other two (who might have trouble getting their mean share of the candy). A politician in power might say with pride, “The mean income of our citizens is $15,000 per year.” The leader of the opposition might retort, “But half our citizens make less than $10,000 per year.” Both are right, but neither cites a statistic with impassive objectivity. The first invokes a mean, the second a median. (Means are higher than medians in such cases because one millionaire may outweigh hundreds of poor people in setting a mean; but he can balance only one mendicant in calculating a median).

The larger issue that creates a common distrust or contempt for statistics is more troubling. Many people make an unfortunate and invalid separation between heart and mind, or feeling and intellect. In some contemporary traditions, abetted by attitudes stereotypically centered on Southern California, feelings are exalted as more “real” and the only proper basis for action – if it feels good, do it – while intellect gets short shrift as a hang-up of outmoded elitism. Statistics, in this absurd dichotomy, often become the symbol of the enemy. As Hilaire Belloc wrote, “Statistics are the triumph of the quantitative method, and the quantitative method is the victory of sterility and death.”

This is a personal story of statistics, properly interpreted, as profoundly nurturant and life-giving. It declares holy war on the downgrading of intellect by telling a small story about the utility of dry, academic knowledge about science. Heart and head are focal points of one body, one personality.

In July 1982, I learned that I was suffering from abdominal mesothelioma, a rare and serious cancer usually associated with exposure to asbestos. When I revived after surgery, I asked my first question of my doctor and chemotherapist: “What is the best technical literature about mesothelioma?” She replied, with a touch of diplomacy (the only departure she has ever made from direct frankness), that the medical literature contained nothing really worth reading.

Of course, trying to keep an intellectual away from literature works about as well as recommending chastity to Homo sapiens, the sexiest primate of all. As soon as I could walk, I made a beeline for Harvard’s Countway medical library and punched mesothelioma into the computer’s bibliographic search program. An hour later, surrounded by the latest literature on abdominal mesothelioma, I realized with a gulp why my doctor had offered that humane advice. The literature couldn’t have been more brutally clear: mesothelioma is incurable, with a median mortality of only eight months after discovery. I sat stunned for about fifteen minutes, then smiled and said to myself: so that’s why they didn’t give me anything to read. Then my mind started to work again, thank goodness.

If a little learning could ever be a dangerous thing, I had encountered a classic example. Attitude clearly matters in fighting cancer. We don’t know why (from my old-style materialistic perspective, I suspect that mental states feed back upon the immune system). But match people with the same cancer for age, class, health, socioeconomic status, and, in general, those with positive attitudes, with a strong will and purpose for living, with commitment to struggle, with an active response to aiding their own treatment and not just a passive acceptance of anything doctors say, tend to live longer. A few months later I asked Sir Peter Medawar, my personal scientific guru and a Nobelist in immunology, what the best prescription for success against cancer might be. “A sanguine personality,” he replied. Fortunately (since one can’t reconstruct oneself at short notice and for a definite purpose), I am, if anything, even-tempered and confident in just this manner.

Hence the dilemma for humane doctors: since attitude matters so critically, should such a sombre conclusion be advertised, especially since few people have sufficient understanding of statistics to evaluate what the statements really mean? From years of experience with the small-scale evolution of Bahamian land snails treated quantitatively, I have developed this technical knowledge – and I am convinced that it played a major role in saving my life. Knowledge is indeed power, in Bacon’s proverb.

The problem may be briefly stated: What does “median mortality of eight months” signify in our vernacular? I suspect that most people, without training in statistics, would read such a statement as “I will probably be dead in eight months” – the very conclusion that must be avoided, since it isn’t so, and since attitude matters so much.

I was not, of course, overjoyed, but I didn’t read the statement in this vernacular way either. My technical training enjoined a different perspective on “eight months median mortality.” The point is a subtle one, but profound – for it embodies the distinctive way of thinking in my own field of evolutionary biology and natural history.

We still carry the historical baggage of a Platonic heritage that seeks sharp essences and definite boundaries. (Thus we hope to find an unambiguous “beginning of life” or “definition of death,” although nature often comes to us as irreducible continua.) This Platonic heritage, with its emphasis in clear distinctions and separated immutable entities, leads us to view statistical measures of central tendency wrongly, indeed opposite to the appropriate interpretation in our actual world of variation, shadings, and continua. In short, we view means and medians as the hard “realities,” and the variation that permits their calculation as a set of transient and imperfect measurements of this hidden essence. If the median is the reality and variation around the median just a device for its calculation, the “I will probably be dead in eight months” may pass as a reasonable interpretation.

But all evolutionary biologists know that variation itself is nature’s only irreducible essence. Variation is the hard reality, not a set of imperfect measures for a central tendency. Means and medians are the abstractions. Therefore, I looked at the mesothelioma statistics quite differently – and not only because I am an optimist who tends to see the doughnut instead of the hole, but primarily because I know that variation itself is the reality. I had to place myself amidst the variation.

When I learned about the eight-month median, my first intellectual reaction was: fine, half the people will live longer; now what are my chances of being in that half. I read for a furious and nervous hour and concluded, with relief: damned good. I possessed every one of the characteristics conferring a probability of longer life: I was young; my disease had been recognized in a relatively early stage; I would receive the nation’s best medical treatment; I had the world to live for; I knew how to read the data properly and not despair.

Another technical point then added even more solace. I immediately recognized that the distribution of variation about the eight-month median would almost surely be what statisticians call “right skewed.” (In a symmetrical distribution, the profile of variation to the left of the central tendency is a mirror image of variation to the right. In skewed distributions, variation to one side of the central tendency is more stretched out – left skewed if extended to the left, right skewed if stretched out to the right.) The distribution of variation had to be right skewed, I reasoned. After all, the left of the distribution contains an irrevocable lower boundary of zero (since mesothelioma can only be identified at death or before). Thus, there isn’t much room for the distribution’s lower (or left) half – it must be scrunched up between zero and eight months. But the upper (or right) half can extend out for years and years, even if nobody ultimately survives. The distribution must be right skewed, and I needed to know how long the extended tail ran – for I had already concluded that my favorable profile made me a good candidate for that part of the curve.

The distribution was indeed, strongly right skewed, with a long tail (however small) that extended for several years above the eight month median. I saw no reason why I shouldn’t be in that small tail, and I breathed a very long sigh of relief. My technical knowledge had helped. I had read the graph correctly. I had asked the right question and found the answers. I had obtained, in all probability, the most precious of all possible gifts in the circumstances – substantial time. I didn’t have to stop and immediately follow Isaiah’s injunction to Hezekiah – set thine house in order for thou shalt die, and not live. I would have time to think, to plan, and to fight.

One final point about statistical distributions. They apply only to a prescribed set of circumstances – in this case to survival with mesothelioma under conventional modes of treatment. If circumstances change, the distribution may alter. I was placed on an experimental protocol of treatment and, if fortune holds, will be in the first cohort of a new distribution with high median and a right tail extending to death by natural causes at advanced old age.

It has become, in my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity. Of course I agree with the preacher of Ecclesiastes that there is a time to love and a time to die – and when my skein runs out I hope to face the end calmly and in my own way. For most situations, however, I prefer the more martial view that death is the ultimate enemy – and I find nothing reproachable in those who rage mightily against the dying of the light.

The swords of battle are numerous, and none more effective than humor. My death was announced at a meeting of my colleagues in Scotland, and I almost experienced the delicious pleasure of reading my obituary penned by one of my best friends (the so-and-so got suspicious and checked; he too is a statistician, and didn’t expect to find me so far out on the right tail). Still, the incident provided my first good laugh after the diagnosis. Just think, I almost got to repeat Mark Twain’s most famous line of all: the reports of my death are greatly exaggerated.

The Dentist Will See You Now, or Why I am Not a Veterinarian

I’m usually pretty good at keeping track of all things medical—when my kids were vaccinated, when I need my mammograms and PAP smears, when the girl dogs come into season and when the horses need to see the dentist.  So when Norman the Lipizzaner arrived home from the boarding stable underweight, and two weeks later when he didn’t seem to be eating all of his hay, my thoughts turned to his teeth.  Unlike humans, domesticated horses’ teeth grow throughout their lives, and when people refer to an aged horse as being a bit “long in the tooth,” they aren’t kidding.  Lacking the need to forage 24/7, our stabled companions need the regular attention of a horsey dentist who will come in and do what is euphemistically called “floating the teeth.”  Think of the drill your dentist uses and multiply its surface area and sound by 100, and you’ll get the idea.  Reaching into twenty four year old Norman’s mouth, I felt sharp “points” on the molars, and realized why he wasn’t gaining weight.  I checked my records and realized that he and his buddy Dash were six months overdue.

 

If you’ve ever taken your three year old for his first dental appointment, you have an idea of how hard a tiny body can struggle.  Same with horses, only they are a lot bigger than we are.  None of them willingly open their mouths wide and allow insertion of a drill—the mere sound of it is terrifying.  So they must be anesthetized.  And just like with elderly humans, the trick with an old horse is to give them enough anesthesia that they tolerate having a vice put into their mouths and cranked open, yet not enough to kill them.  This, apparently is not an exact science.  The first shot directly into Norman’s jugular vein did exactly nothing.  Although he was restrained, the whites of both wide eyes were showing as he chomped down on the dental device.  The second shot seemed to have a light sedative effect.  But the THIRD shot—well, that was the one that did the trick.  Same thing with good old Dash.

 

Now here’s the thing—I was SUPPOSED to go to work after the dental appointment.  Our machine was down for maintenance, and I had a lot of paperwork to catch up on.   After the requisite 45 minutes, I released their halters, tied to the bars in their stalls. They both tried to fall down.  How do you leave when you’ve got two horses staggering around their stalls like drunken sailors?  You don’t.  With Norm, the younger of the two, the drug seemed to wear off quickly.  But with Dash, I spent the next two hours hanging on to his lead rope and elbowing him when the head got too low and the front knees threatened to buckle.  Finally he too came around, and I left them munching grass in the pasture, a full three hours later than I had planned to be at work.

 

Sometimes our head and neck cancer patients are really claustrophobic in their immobilization masks, much like my horses getting dental work.  I usually prescribe a light sedative, and then if that doesn’t work, I tell them to take another.  Sometimes, the family gets into the act with great enthusiasm and has the patient take a third, unbeknownst to me.  So far, I’ve been lucky.  I’ve heard a few snores, but no one has aspirated or fallen off the table from what we used to call “the neurosurgery height.” But watching those old horses yesterday, I realized once again that there’s a fine line between “not enough” and “too much.”  Come to think of it, that probably applies to radiation therapy and chemotherapy too, along with a whole lot of other things in life!

Cast A Cold Eye

“By his command these words are cut:

          Cast a Cold Eye, on Life, on Death.  Horseman pass by.”

“Under Ben Bulben”, by William Butler Yeats, inscribed on his tombstone.

Yeats has always been my favorite poet. From the full upper lip depicted in early photographs and paintings of him, to his unrequited love for Maud Gonne and his patriotism for Ireland—his very being and thus his poetry radiated passion.  I named my first deerhound Aengus in his honor, from “The Song of Wandering Aengus.”  Ten years ago at Del Mar I placed a two dollar bet on an imported Irish turf filly called “Golden Apples” from the same poem, never raced in the United States. She went off at 80 to 1, started dead last, and thundered home to win by three lengths.  I should have had more faith.

So I have never understood why a man of such extravagant emotion would insist that his gravestone be inscribed with a blunt command against emotion, against passion, against even stopping to consider the life lived so fully and buried in that ground.  Was it regret at the end of his life?  Was it a warning to those of us who feel too deeply, who care too much?  Was it meant to be ironical, or perhaps even romantic—if ashes are ashes and dust is dust and love is over, what is the point of stopping to weep over a grave?  I will never know.

What I do know is that my own life as a radiation oncologist is a daily struggle NOT to cast a cold eye. Thirty one years out from the beginning of my radiation oncology residency, I sometimes think I have seen it all, from the early stages of disease where I just KNOW that the patient will be fine, to the patient with late stage malignancy, where it would take a miracle to cure, or even help the patient, and miracles are in short supply.  Some days I have to remind myself that even though I have given that speech about a particular disease and treatment options thousands of times, each new patient is hearing it for the very first time, and it is terrifying.

In the Jewish religion, these last ten days have marked the beginning of a New Year, and a time for repentance.  I’ve never been a particularly observant person, but I do find the concepts of renewal and atonement useful both in my personal, and in my professional life.  For the times when I was too rushed with my explanations, too self-absorbed or self-conscious for a healing touch, too worn out for sympathy, I am sorry.  For the New Year, anno mundi 5774 on the Hebrew calendar, I pledge to try to never, ever cast a cold eye on life, or on death, and just pass on by.

Weights and Measures

The sudden illness of a colleague is always a shocking surprise.  As physicians, we are trained from an early age to ignore our own infirmities in the service of others.  Apart from my three C-sections, I have been extremely fortunate in terms of my own health—I can count the number of sick days I’ve taken in the last thirty years on one hand and I am thankful every day for that blessing.  In my day to day world of caring for cancer patients, I know that in an instant, by accident or by sickness, everything can change.  I think that my colleague must have felt the same—that calling, that mission to care for the stricken that leads one to suppress the rising signs of illness in order to keep that black curtain of infirmity a little further to the edge of the window frame of life.

On Monday I learned that the man I have grown to respect for his insight, his dedication to his profession and his kindness would likely not be coming back to work, ever. My entire department was devastated, especially his nurse who has worked so closely with him for the eighteen months he has been with us, and also his patients, each of them with cancer,  who asked me one by one when they saw me for their weekly on treatment visit, “I am so sorry to hear that he is ill.  When is he coming back?”  As the realization of the gravity of his illness slowly came to all of us, since he had not shared the knowledge of his disease with any of us, the weight began to descend.  Our patient load is at its highest, our working hours are extended, there are patients waiting to be seen, planned and treated.  Who will step in to consult on these patients, to plan their radiation treatments, to oversee their side effects and work the extended hours?  Right now, we do not know.

I have always said that unlike my father, I do not want to “die with my boots on.”  I want to retire while I am still healthy enough to do the things that I’ve put off for so many years—to write, to paint, to take photographs, to teach English, to travel, to play with my dogs, and perhaps, just perhaps, get another horse—an older horse, a calm horse (we grow so brittle as we age that we break more easily!) who will carry me down the trails so that I can smell the orange and lemon blossoms on the trees, up close, as they bloom in late December here.  I said this to my husband last night, at the end of a very long week.  He said, “No one ever knows what they will do when faced with a terminal illness.”

This was a very busy week in the clinic, and I had a medical student rotating with me. In the chaos that surrounded us, I had to keep reminding myself, first things first. Yesterday, together we saw a man with a life threatening cancer.  I was running very late, and he was the last new patient of the week.  My student took the reins—he interviewed the patient, examined the patient, explained the treatment and seamlessly introduced me to the patient and his wife, who were quite pleased with the care and attention he had already received. We completed the consultation together, and as I left the room I suddenly felt a deep sense of satisfaction.

When the weight of illness suddenly descends on an individual, my colleague, and consequently, his patients, his co-workers and me, his partner, we can still take comfort in the small measures of success–the satisfaction that we, as a team, are doing things right.  Sometimes it’s the little things, the small gestures and kindnesses that count.  We dust ourselves off, and we go on.

Cancer and AIDS, AIDS and Cancer

For Dr. Abraham Verghese, who inspires me.

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

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

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

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

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