To the stay at home moms, who ran the carpools, acted as room mothers, cheered at every Little League game and had a healthy dinner on the table at six pm, I salute you.  I was secretly envious of the time you were able to spend with your children.  You didn’t miss a thing in their lives, and if you were secretly envious of me—my financial independence, my ability to walk out the door in the morning and leave the chaos behind to enter the adult world where you could actually reason with people most of the time—I never knew it.

To my fellow female doctors, lawyers, business women, veterinarians and leaders in industry, I salute you also.  No matter how tired you were at the end of the day, you made time for your children—you rushed out of work to get to the ballet recital, you helped with their homework, you got down on the floor and you played games when your back hurt and your eyelids were closing as you read “Goodnight Moon” one more time.  You were consumed by guilt most of the time—at work when you felt you could not give it your all after a sleepless night, at home when your child called you by your caregiver’s name.

This Mother’s Day is my first without a mother—she passed away in January, having lived her life as the wife of a busy plastic surgeon—the endless nights of caring for three children while he was on call, the arguments over promised wealth as a private practitioner versus the academic life he chose, the pampered later years when she could and did have anything she wanted.  But when I was a sophomore in college, majoring in English, she took me aside and said, “You have to DO something!  Don’t be like me. You must choose a career where you never have to depend on anyone but yourself.”  I listened and went to medical school.  Forty years later, it was the right choice for me.

When I was a junior medical resident at Beth Israel Hospital, Betty Friedan’s daughter Emily was one of my medical students.  In a week, my own daughter graduates from medical school.  As my children grew up, I had only one bit of advice for them that I remember repeating like a mantra:  Whatever you do, wherever you go, at the end of the day, every day, be able to look in the mirror and feel good about yourself.

And don’t think it’s going to be easy.  Motherhood never is.  Happy Mother’s Day everyone!

Yesterday I had the unique experience of watching a production of William Shakespeare’s The Tempest, acted, with musical accompaniment, entirely by a group of fifth graders.  Friends of mine from Los Angeles, himself a teacher at the Hobart Boulevard public elementary school, had invited me to this year’s presentation by the Hobart Shakespeareans.  As many of you know, punctuality has never been one of my virtues, and the 105 mile drive, coupled with the infamous LA traffic, had me sweating before I even took my seat.  But once I had clamored over Kurt’s knees and nearly fallen into Heather’s lap, I settled in for nearly three hours of pure magic, and not just the magic of Propero, the magician of the Tempest.

Begun years ago by their remarkable teacher Rafe Esquith, the fifth grade Hobart Shakespeareans of Room 56 are a group of underserved, underfunded children of largely Korean and Mexican first generation parents.  Many do not speak English when they arrive at school, many are on federally funded school lunch programs.  But by the fifth grade, those children lucky enough to be in Room 56 have studied the works of Will to the extent that they produce, in full Elizabethan English tempered with the sounds of rock and roll, reggae and Beethoven, a Shakespearean masterpiece a year.  When the lights went down yesterday, at 11 am, I was transported, and overwhelmed–and instantly moved to tears.

As an English major in college, the teaching of the humanities, and English in particular, has always been near and dear to my heart.  I believe that by studying great works of literature, and Shakespeare in particular, one can experience the breadth and scope of human emotion—joy, sorrow, aspiration, suffering, love, longing, mystery and hope—in short, most of the qualities necessary to become a good doctor.  Sadly, college premedical requirements do not include more than a cursory English class or two, mainly to make sure that a student can string together a few words to write a sentence.  The world of science and medicine has become infinitely more complicated in the last several decades—there is so much to learn about biochemistry that taking on “extras” like an advanced literature class, or an art class or a philosophy class becomes a burden, instead of a pleasure.  While many medical schools encourage non-science majors to apply, the truth of the matter is that humanities majors are significantly disadvantaged when it comes to taking the MCATs and showing publications on their resumes.

The Hobart Shakespeareans come to school at 7 am, and stay until 5 pm.  They learn math, and science, and history and geography and government but lunchtime is reserved for rock and roll guitar lessons.   They wear T-shirts with the face of William Shakespeare and the caption, Will Power.  Judging from the college banners placed around the perimeter of room 56, and the names below them, ultimately they attend Yale, and Harvard, and UCLA and Stanford, as often if not more than their more privileged peers.  And many of them will become doctors. They live by the motto:  “Be Nice. Work Hard.”

We can all take a lesson from that.

For more about Rafe Esquith and the Hobart Shakespeareans, go to www.hobartshakespeareans.org

At roughly 3 o’clock yesterday I was putting together a hasty lunch in our tiny break room.  It was nothing special, just the usual—fresh mozzarella cheese and a sliced tomato sweetened with a very nice balsamic vinaigrette. More calories in than out, but what the heck—it tastes good.  As I put one forkful to mouth before scurrying back to my office to hide for five minutes, my office manager approached.  She said, “I am so sorry Dr. Fielding.  I forgot to tell you—you will have a third year medical student with you next week. She wants to go into radiation oncology.  She asked me for a list of patients that you will be seeing so that she can look up the records and get started on the history and physical notes ahead of time, to make it easier for you.”

I resisted the urge for intense sarcasm and searched for a meaningful reply.  I said, “Please tell her that she will have plenty of time with the new patients to elicit a history and to do a physical exam.  There is no need to prepare ahead of time.” My physicist was standing in the break room and looked at me questioningly.  I asked him, “Well, would YOU want your doctor to record your history and physical before even SEEING you?”  He replied, “No, but I see no reason to throw out all of the information available in the electronic medical record either.  I think it’s a way to improve efficiency.”  Spoken like a true physicist.  I am old fashioned.  I stood there slack jawed.

And then I replied, and here is what I said:  Patients forget important information.  Patients lie to physicians they have not yet learned to trust.  Patients are in denial.  Patients may detest one doctor—for the length of his hair, the sneakers on his feet, the color of his skin.  And they may open up to the next.  They may remember important details that they had forgotten, or their sister may have called from Buffalo to say that Grandma died of breast cancer, not of “bone cancer” when the cancer spread to her skeletal system.  They may admit, finally, that they are dependent on alcohol, or oxycontin, or vicodin and they may be seeking help, this time around.  And without questioning that patient, we may never know.

So here is what I really think.  The electronic medical record, or EMR as we like to call it, has unquestionably made my life easier. With templating, and Dragonspeak, the time and work it takes to dictate a history and physical and impression and recommendations has been dramatically reduced, and I am most appreciative.  But a patient is still a patient—real flesh and blood and emotions and memories that may or may not serve my purpose adequately.  We need to keep trying to get to the truth.  We need to stop propagating and repropagating the “untruths”. Without our truest and sincerest effort, all of our medicine may not provide a cure.

I told my office manager to tell the prospective student:  No need to cut and paste the history and physical ahead of time.  Dr. Fielding is “old school.”  She wants you to go in the room and see and examine the patients, and then write it up with your recommendations.  And by the way, bring your own lunch.

Really, truly, there are no short cuts.

Author’s Note: After receiving a number of comments on the original version of this post, I feel compelled to add an addendum.   What I was objecting to in this student’s approach (which I must say is “the standard” these days) was NOT her desire to read the history ahead of time.  It was her desire to actually construct most of the written history and physical in our electronic medical record before taking her own history and doing her own physical.  I do not expect a student to walk into a patient’s exam room “blind”, having never read the prior history, nor would I myself ever do so.  I hope this clears up my approach.  Miranda

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.

Bostonians have a long history of resilience and tenacity.  When I was a horse loving kid I read a story about Paul Revere’s horse, told from the point of view of the horse (of course!)  Apparently Paul did not spare the spur in his midnight ride on Brown Beauty, a mare borrowed from Samuel Larkin—nothing would deter him from his mission, and the good people of Boston, their roots steeped in hardship and persecution and war and famine, have followed suit for centuries.   The blood shed on the cobblestones of Boylston Street two weeks ago was not the first, nor will it likely be the last.

What I loved about my training in Boston thirty years ago was that same unflinching and uncompromising commitment to patient care demonstrated by the forefathers in their commitment to freedom.  Yes, the hospitals where I trained had some of the best teachers and most dedicated researchers in the business.  They wore their old school bow ties like badges of honor, and they still do.  Doctors wore white coats, and medical students did not inquire if it was okay to wear shorts to clinic, as they sometimes will in Southern California.   There was a certain formality, which translated into respect—for their peers, for their students, and for their patients.  Especially for their patients.  We laughed about them, we cried about them, we read and lived “The House of God”, and in the end we gave our all for them. I have missed that these last twenty years.

It’s good to be back.

When I was a radiation oncology resident in Boston in the early 80’s, a few brilliant minds in physics and medicine came up with the notion that it would be a good idea to treat certain cancers with a beam of protons.  Protons are the positively charged particles which are created with a hydrogen atom is split into its component parts, a proton and an electron.  When accelerated towards a human being by means of a cyclotron, the proton has a unique characteristic compared to the regular X-ray beams we radiation oncologists use—it rolls into the body creating very little disturbance at the surface, comes to a stop at the tumor to do its damage, and unlike an X-ray, or photon as we say in the business, it does not exit the body leaving injured cells in its wake.  It just stops.   This makes proton radiation therapy ideal to treat children, where the entrance and exit doses of radiation can cause growth defects and trigger secondary malignancies years and years down the line.  But the first patients treated back at the old Harvard Cyclotron were not children—they were old men with advanced prostate cancer, where conventional therapy with the doses needed to control the disease had a high likelihood of rectal damage.  My job, as the resident, was to insert a balloon into the rectum of said patients, to separate the posterior rectal wall from the prostate gland.  Each day I would hitch a ride with our physicist over to the huge brick building which housed the cyclotron, insert and inflate the balloon, and wait while the patient was treated.  I didn’t mind a bit—the technology was new and exciting, and the physicist was very handsome.

Tonight, thirty years later, I toured the new proton facility in San Diego, where my university, along with other institutions will soon be allowed to treat patients.  The building itself is massive, over 100,000 square feet.  There are five gantries and treatment rooms, and once the facility is up to peak capacity, the cyclotron will run sixteen hours a day, treating over 2,000 new patients a year.  At 8 pm this evening, a team of six engineers was still hard at work in the control room, honing the precision of a beam which will be responsible for curing cancer, for saving lives.  Patients with every kind of cancer will be treated here, but in the end, the population which has lived the longest and has the economic wherewithal to seek out the best and the latest treatments—our prostate cancer patients—will be the bread and butter volume income supporting the treatment of the youngest and most vulnerable of our patients, the pediatric cancer patients.  As one of my old colleagues who treats the kids at Massachusetts General Hospital said to me a few years back, “Finally we have protons in the clinic, and I can sleep again at night, not worrying about the horrible late effects of radiation on my pediatric patients.”

Many things have changed about the way protons are produced and utilized in radiation therapy over the thirty years since I was a resident, but some things remain the same—as we were touring, one of the physicians mentioned that rectal balloons are still used to stabilize the prostate away from the rectum during prostate cancer treatment.  I smiled inwardly and thought to myself, “Yes, but this time it won’t be ME putting the balloons in.”   San Diego is about to join a small cadre of cities that boast the best, most advanced and safest radiation technology available to cancer patients. And I say, “Long live the Brotherhood of the Balloon!”

“Today the road all runners come,

Shoulder high we bring you home

And set you at your threshold down

Townsman of a stiller town.”

A.E Housman

As this afternoon’s events unfolded, I sat glued to my computer screen between patients.  My life has really been a tale of three cities—Houston, Boston and San Diego.  Boston was where I did my residency training, met my husband, had my three children and my first “real” jobs.  I wrote to my best friend, a physician and lifelong resident of Brockton and Boston—I was worried, since her two kids, now in their late 20’s are active, athletic and in a waking nightmare, I pictured them at the scene.  I received this reply from her: “Fortunately, we are all safe.  Boston is quite crazy right now.  The hospitals are in lock down, and there are amputations going on in every OR.  Thank goodness we have so many fine institutions in the area.  Everyone is stunned.  So very, very sad.”

Every year since we met, in 1982, until the time I left Boston in 1993, she and I would watch the Boston Marathon together.  But we didn’t go downtown—we always went exactly to the halfway mark, thirteen miles in, where the route goes directly in front of Wellesley College.  My friend had gone to Wellesley, and in fact had married one of her professors and they lived close by on the appropriately named Lovewell Road, a block from the marathon course.  I have happy photos from the time—I did not have children yet, but she had a beautiful little girl, blonde and blue eyed, who would sit perched on her Daddy’s shoulders to get a good vantage point.  Tuppence, their stubby little rescued pound pup was in attendance also, and all together we would cheer as the runners went by, and the Wellesley girls, dressed like Greek goddesses in their togas would flash their beautiful smiles, and occasionally their beautiful breasts at the runners.  The guys always picked up their pace a little when they made their way through Wellesley.  Thoughts of terrorism had never entered our minds.

That all changed on September 11, 2001, when our nation and people collectively lost their last thread of insular optimism and belief in the goodness of mankind.  But what happened in the world of medicine—specifically in the world of hospital based emergency medicine—in the wake of 9-11 has doubtless saved many lives in Boston today.  The ER and surgery residents and attendings of Massachusetts General Hospital, The Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Boston Children’s Hospital, Boston University Hospital and Tufts New England Medical Center earned their keep today and are still earning it as I write tonight.  They are treating shock, and abrasions, and contusions, and head trauma, and learning to triage under real disaster conditions.  And sadly, many of them are learning to perform amputations for the first time.  On video footage I watched physicians wearing yellow coats who thought they were there for the fun of it– to administer fluids to dehydrated runners and wrap them in thermal blankets and congratulate them—jump the barriers with EMTs and National Guardsmen to staunch bleeding and administer CPR.  I know that the survivors are in the best of all possible hands tonight.

Boston, like New York City, will overcome this tragedy.  But I don’t think anyone will watch the Marathon with the same innocent enthusiasm that we had so many years ago ever again.

When she was being examined in the emergency room, the resident noticed a very large breast lump on her left side.  He asked her, “How long has THIS been here?”  She was vague in her response–it may have been “a few months” or it may have been “a few years”. It wasn’t hurting her, and she had other things to worry about–namely her 70 pound weight gain.   Mammograms and ultrasound while she was an inpatient led to a biopsy which showed malignancy.  Cardiac echo showed both coronary disease and cardiomyopathy.  She was treated with multiple cardiac medications and began to diurese, and her heart function improved dramatically, especially after a stent was placed in her left anterior descending coronary artery.   Finally she was able to go to surgery to remove the breast mass, and today she showed up for her consultation looking very chipper indeed–a slender 134 pounds down from 206, breathing normally, with no ankle edema.  The breast cancer turned out to be stage I, and she will receive radiation therapy in the next few weeks.

When I walked into the consultation room, I introduced myself and asked her to say her name, which was somewhat difficult to pronounce.  She laughed and said, “Just call me Cleopatra, because I am the Queen of Denial!”  Fortunately, I think she is going to be just fine.

 
I may be dating myself but I vividly remember hearing Chick Corea’s Return to Forever band play a set in Boston in the early 1970’s. I was in medical school at the time, but that didn’t stop me from scraping together the ticket money to hear the group do some of my all-time favorites like Spain and Crystal Silence. In the 1980’s Return to Forever was re-configured as a jazz rock group with Chick playing synthesizers instead of the acoustic piano. I was particularly fond of the Romantic Warrior album which I listened to on my way to the hospital as a young physician. In 2011 the band was resurrected for a world tour. Although I didn’t get to see the live concert, I enjoyed the YouTube videos. Listening to this music again was magical, and brought me back to the earlier days of my medical career. Like déjà vu all over again, so to speak.

This past week I’ve had another “Return to Forever”experience. It happened when I entered a skilled nursing facility where my father-in-law was staying to recuperate after cardiac surgery. Here’s what I noticed: the name of the facility is the Goldberg Center and the first patient room I came to was occupied by Gussie and Sadie Schwartz, one of whom was screaming “I’ve got a sore somewhere! Get me out of here!” Instantly, I was transported back in time to the decade or so I spent as a young doctor at Boston’s Beth Israel Hospital. Some of you may know this as the “House of God”, the title of an (in)famous book about the mostly funny and sometimes outrageous fictitious exploits of the young doctors in training there. Our present day Gussie and Sadie would have felt right at home there in the House of God.

While I was an intern at the House of God I had my own outrageous exploits which (thank God!) did not make it into the book. My favorite involved an elderly man who was brought by his wife to the ER late one night with chest pain. When I told him that the diagnosis was a heart attack, his wife shrieked and clutched her chest. She, too, was having a heart attack, and like her husband was admitted to the Coronary Care Unit, where they ended up sharing the same room. The following morning as I entered the Unit I found the staff standing in front of their room not reviewing their cardiac status as expected, but laughing uncontrollably and pointing at the name plate on the door. It read “Ike and Tina Weiner” (I swear).

The House of God had a serious role in my life, too. It’s where I met my wife, and where my children were born. Recently, our daughter learned that she will be a resident in medicine there. My wife and I are thrilled by this. We hope her experience there is as meaningful for her, as it was for us. Now, let’s see if she can top the “Ike and Tina” story.

My sister was here recently to help me out while my father was in the hospital.  She is much kinder and more patient than I am, so I was very grateful for her help. She is leaving to go home to New Jersey tomorrow.   Tonight before dinner we took the deerhounds for a walk.  In my better days, I could walk four at a time.  Last weekend, I tried three on three leashes and it did not work out too well.  They spotted a man they did not know walking up our street.  Perhaps they found him threatening.   With three hundred pounds of dog lunging and barking, it took all my strength to maintain control.  It turned out to be a very short walk.  Today, my little sister took Magic, who outweighs her by at least 20 pounds, while I took the two Q’s, Queen and Quicksilver.  We had a pleasant time.

As we ended our walk this evening by coming through the back gate, near the barn, Norman the Lipizzaner stuck his head out the stall door and nickered softly.  I said to my sister, “Let’s go visit the horses before we cook dinner.”  Into the barn we went, where the two old geldings called to us with some degree of impatience.  We loaded their mangers with Purina Equine Senior and horse treats and prepared to close up.  As we walked by the closed door of the tack room, I stopped.  I said to my sister, “Do you want to see the saddest thing?”  She looked at me, her eyes questioning, then said yes.

I pulled open the door to the tack room.  In that room there were five closed tack trunks, each stamped with the initials of a family member.  Saddles were cleaned and covered and neatly perched on their racks, ranging in size from a small child’s Western saddle with full Quarter Horse bars, to my husband’s beautiful dressage saddle.  Blankets were washed and wrapped in plastic.  Shipping wraps were bleached white and stacked in place.  Bridles were oiled and ready and bits were gleaming and polished.  But there was no one home—just old framed photographs on the walls.  I said to my sister, “Enjoy your children while you may.  This room is the ghost of childhood past.”

I hope that my children appreciate and look back with fond memories on the years when we would saddle up and ride out together.  It was a special time to me.  Lucky and Harmony and Veronica are gone now, but Dash and Norman and the memories remain.  To me, it was time and love and money well spent, and I hope that my kids, now grown, feel the same.