For Ellen

“to live in this world

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

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

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

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

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

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

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

I am Passionate About…

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

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

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

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

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

# WeddingFail

From Twitter today–jimmy fallon ‏@jimmyfallon

Hashtag game! Tweet out something funny, weird, or embarrassing that happened at a wedding and tag with #WeddingFail. Could be on the show!

 

My friend Jackie just got back from a family wedding on the East Coast.  She probably had no idea that Jimmy was auditioning #WeddingFail tweets for his show.  Jackie, we’re going to need to work on getting this down to 140 characters.  In the meantime, enjoy her full length version.

 

A WEDDING STORY

 

My husband and I just returned from his nephew’s wedding which took place back East.  We were able to connect with a lot of family and old friends and we ate and drank our way through the three days of celebrating.  We flew home today and I had a lot of time to reflect back on the weekend, parts of which made me smile and parts of which were downright horrific.

The Rehearsal Dinner was to be a most wonderful event hosted by the Groom’s widowed mother.  She had worked for months making preparations and selecting the menu; there was an open bar and an ocean view terrace for enjoying the beautiful scenery.  After cocktails and dinner and toasts and love all around the Mother of the Groom slipped and fell on her slippery 4″ heels and landed face first on the floor.  Black eye, swollen chin, black and blue elbow and knee.  The make-up lady had her work cut out for her the following morning.

The Matron of Honor was Big Sister to Bride.  Used to being the center of attention she became Queen Bitch of the day, arguing and tormenting her little sister up until the Wedding Party marched down the aisle.   Adding to the drama was the 2 year old “flower girl” daughter of afore-mentioned Matron of Honor.  She squealed and wailed in defiance of walking down any aisle not to her liking – and she didn’t like that aisle – so at the last minute Father of the Flower Girl swept her away so the ceremony could be heard.  Her behavior might have been attributed to the fact that she had a watery and snotty cold.   But Father of the Flower Girl in a selfish urge brought child back to the ceremony in order to hear final vows and just in time for her to let out another wail as she flung her juice box at the Bridesmaids.  Mother-Matron of Honor found this very funny and giggled.

Parents of the Bride divorced nastily over 20 years ago and yet despite two decades apart managed to save ugly remnants of their dissolution for the Wedding Weekend.  The exes had to be seated across the Reception Ballroom from one another and separated for fear of an explosion.  At the Rehearsal the night prior to the wedding a fight erupted between them over who got to answer WHO GIVES THIS WOMAN IN MARRIAGE TO THIS MAN.  Seriously?  When the Officiate asked that question during the ceremony no one breathed.  Thankfully he answered “Her Mother and I do”.  Exhale.

Meanwhile I enjoyed people watching (one of my favorite sports) at the blend of Wedding guests.  Groom is bi-racial; father African American and Mother Caucasian.  Bride is half Jewish.  We had Groom’s Aunt Thelma with full wig and weaves and Bride’s Aunt Anita who was covered in bling and commented to all who would listen that since she just had her eyes done she wasn’t up to outdoor photography and shouted out Mazel Tov whenever a toast was made.  The Groom’s mother has been married four times and has three children with three different fathers and both daughters were Bridesmaids.  The beautiful young people were fun to watch on the dance floor; the older and chubbier ladies – not so much.  One couple had just completed dance lessons – we could hear them counting …”and one-two-three…” for hours, but they seemed to improve as the night wore on.  But who really cared; the music was loud and the DJ played requests.

All in all it was a great weekend.   But I had to marvel at the drama and craziness and how unconventional most weddings have become these days with blended and re-blended families.  I think the best and the worst of family dynamics are on display at a wedding – and I know most couples, although excited to exchange vows, sometimes hold their breaths worrying that some dark secret or some inappropriate event will mar their joy.  I think the couple enjoyed their celebration; I know we enjoyed our trip.  But it was one wild ride.  Cheers, Mazel Tov and Halleluia!

Feet Don’t Fail Me Now

On Friday, once again, I cancelled my elective bilateral foot surgery, cheilectomies to ameliorate the effects of decades of running miles a day on hard pavement and wearing high heeled shoes to work. Like many other physicians faced with the dilemma of elective surgery, the “what-if’s” got the better of me—what if I get an infection, what if I have a poor result and am worse off than before, what if—god forbid—I end up with an amputation?  In the end, I opted out.  Six weeks after retiring from my job running a satellite radiation therapy facility for our local university practice, I am having far too much fun traveling, writing, gardening and culling the accumulated belongings of sixteen years in one house to undergo a forced “lay-up” for the summer.  The pain I know is preferable to that which my imagination can manufacture.  In short, I am a chicken.

Prior to becoming a chicken, I had always been an athlete.  At age seven, a swimming instructor announced to my mother, “She’s got talent!” and the next thing I knew I was trying out for the old Shamrock Hilton swim team in Houston, Texas.  To this day, the audition remains crystal clear in my mind—the coach asked me to swim the length of the fifty meter outdoor pool.  I had never seen a pool so enormous, but I resolved to try.  After all, what was the worst that could happen?  I jumped into the deep end reasoning that if I didn’t make the whole distance, at least by the time I tired, I would be able to stand up.  I reached the shallow end and touched the flagstone, gasping for air.  I stood up.  The coach said, “Okay, great, now SWIM BACK!”  I looked at my mother and began to cry.  She commanded, “DO IT!”  And so I did, despite the fact that the deep end loomed like a dark lagoon ahead.  I made the team.  Ultimately, my small stature and dogged nature suited me best for distance events—the 400 meter individual medley, the 1500 freestyle. The fact that I had once been daunted by swimming 100 meters seemed ludicrous a year later.

I graduated from high school one year before the passage of Title IX, the law that ultimately mandated athletic scholarships for women at every public university that offered the same for men.  With no incentive to continue a grueling five hour a day routine which produced green hair, bloodshot eyes and oversized shoulders, I turned to running for exercise.  And run, I did, for the next thirty five years—on the road, on the treadmill, in hot humid Houston and freezing snowy Boston—I ran away my fatigue, my stress, my disappointments and my sleep deprivation.  At age thirty one, after two residencies, I looked to be about eighteen years old, and so I wore heels, to make myself taller, more imposing, more apt to be taken seriously by patients and peers. Oddly enough, that strategy seemed to pay off, when my introduction of myself as “Doctor” no longer resulted in the question, “Really?”

The year before we left Boston in 1992, I watched the “Marathon Man” Johnny Kelley run his last full Boston Marathon at age 84.  Many years later, with these feet broken down from walking on tip toe when not running on asphalt, I am no Johnny Kelley. My running days are over for good, and even my walking days are fewer and farther between.  But as I contemplate the various ways in which our bodies fail us as we age—cancer, heart disease, stroke and dementia—I am thinking that arthritis and bone spurs aren’t all that bad.  I can always go back to the pool.  Or maybe get that little buckskin Quarter Horse I’ve always wanted.  There is no landscape, emotional or physical, that isn’t improved by the view from the back of a good horse.  I’ll get around to fixing those feet one of these days, sooner or later.  Probably later.

Heisenberg and Your Prostate

Uncertainty Principle:  A principle in quantum mechanics holding that increasing the accuracy of measurement of one observable quantity increases the uncertainty with which another conjugate quantity may be known.

Perhaps it is because I just got back from Albuquerque, a city which has become like a second home to me, that I have Heisenberg on my mind. For the one or two of you out there who are not “Breaking Bad” fans, “Heisenberg” is the name that mild mannered chemistry teacher Walter White assumes when he decides to manufacture pharmaceutical quality methamphetamine after being diagnosed with Stage III lung cancer. His motivation is to be able to leave his pregnant wife and son affected by cerebral palsy a little cash when he dies.  The evolution of Walter from upstanding high school teacher to ruthless drug lord unfolds over six seasons where moral ambiguity is the coin of the realm—in uncertainty principle terms, the more single mindedly he pursues his meth business, the fuzzier his personal ethics become.

Recently I have begun to think of the dilemma of PSA testing and the diagnosis and progression of prostate cancer in terms of the Heisenberg uncertainty principle.  Nowhere is this more apparent than in the case of men who have a rising PSA level post prostatectomy.  For many men faced with the choice of surgery versus radiation therapy, the selection revolves around the perception of certainty.  In medical school we are given the mantra, “To cut is to cure!”   Many patients choose surgery because of that perception—the ability of the surgeon after the procedure to say, “We got it all” and the satisfying thud of that post op PSA falling to zero.  Life is as it should be, the offending organ is gone, and the PSA is the definitive proof of cure.  In my own career I have pointed out countless times that if a man wants it black and white, cut and dried as it were, he may be more satisfied with the surgical option, since the slow fall in the PSA level post radiation therapy, with its attendant subtle blips and variations can be maddening to the patient, his family, and of course the attending physician.

But what of the patient whose PSA post prostatectomy does not fall to an undetectable level?  Or the patient whose PSA becomes unmeasurable, but months or years later starts to rise again?  On the one hand, our ability to measure serum PSA levels as a proxy for prostate cancer still lurking in the body has improved to the point of being able to measure values as small as hundredths of a nanogram per milliliter of blood.  We call this the supersensitive PSA assay and we accept this as proof that the cancer is there, somewhere, waiting to recur.  But what this supersensitive test cannot tell us is exactly WHERE those cancer cells are.  Neither bone scan, nor CAT scan, nor Prostascint imaging nor ultrasound is likely to give us the answer.  So what do we do?  As radiation oncologists we offer the patient the best we have, treatment to the “prostate bed”—the area where the prostate used to be—and sometimes the adjacent lymph nodes.  We know statistically that over a period of years, large groups of patients who were treated for their rising PSA with radiation do better than those who were not, but sadly this tells us nothing about the individual patient.  And the individual must decide for himself whether to take the leap of faith, and the side effects of one treatment compounded with another, that the cancer cells are still localized and that the radiation will kill them.

As a clinician treating patients with rising PSA’s post prostatectomy, I wait with bated breath for the first PSA after radiation to the prostate bed.  The patient is equally anxious—that stark simple but highly precise number is the measure by which we judge success or failure of the treatment.  But in focusing on the PSA, we often forget the obvious—that a number, even a highly precise number, is just that and nothing more.  What the patient will die from, and when, remains uncertain.  If I can help my patients remember that, and go and live their life with zest and satisfaction, then I have done them a real service.

Make Yourself At Home

I try not to sweat the small stuff.  Really I do.  But when I leave home, and leave my menagerie in the care of a house sitter, I am nothing if not explicit.  The directions for the care and feeding of my four dogs and two horses (the cat got a reprieve from his Boston eviction until May 9th) come to a total of four printed pages, small font, single spaced with nice paragraph indentations and bold headers like EMERGENCY!!   A walk through prior to the departure date is mandatory, to demonstrate the intricacies of the garage door and the cable TV.  The house sitter is equipped for every possible natural disaster. The keys to the van, already loaded with dog crates, are left on the kitchen counter and the van itself has enough water, canned goods, leashes and dog food to last a good month. Thermal blankets are located behind the driver’s seat, just in case hell freezes over here in sunny Southern California.  Flashlights are industrial quality, and batteries are included.  You could say that I am a “Be Prepared” kind of person.

Last week the rare occasion occurred where my husband and I had different trips planned at the same time.  He was going to Japan on business, and I had plans to meet a friend in Albuquerque for a three day getaway.  I tried to round up the usual suspects for housesitting, but all were previously booked. So rather than cancel my trip, I took the plunge and hired someone new.  She came over a week before the trip, loved the animals, memorized their names quickly, and took notes on top of my printed instructions.  She said she would leave her own dogs at home with her daughter and that she had no prior commitments during the time that I was to be gone.  I left home with a sense of relief that finally, I had found the right person for the job, and my parting words were, “Use the latches on the doors leading to the living room and please do NOT let those dogs pee on my brand new living room carpet!”

As I pulled through the gate onto my own driveway on Saturday night, the first thing I noticed was the horse trailer sitting inside.  A horse trailer?  My horses haven’t traveled in years.  I briefly considered peeking inside the trailer, but I could see my own horses down at the barn, and decided to go inside.  My dogs were lying down, relaxed, fed and happy–no worse for the wear.  So far so good.  My house sitter was seated at the kitchen table.  She beamed at me and said, “I enjoyed staying at your house SO much!  It was like having a vacation.  I should be paying YOU to stay here!”  She then elaborated, “I hope you don’t mind that I brought my horse over.  He didn’t get along with the white one so much, but he was fine with the chestnut!”  Seeing my look of surprise, she said, “I only wanted to take a little ride up the street to see the neighborhood.  I hope that was okay.”  I nodded numbly, wondering how far behind my horses were on their vaccinations.  She then went on cheerfully, “The dogs all got along great—my Great Pyrenees managed to go swimming in the muddy stream, so my daughter and I had to hose him down with the garden hose but we got him clean, and washed all the towels.”  I resisted the urge to run look at the certain hairballs in the washer and dryer.  She stood up and said, “I’ll come back ANYTIME!”  As she walked out she grabbed a large blue accordion that I had somehow missed on the way in.  She smiled and declared, “The dogs loved my music!”

As the horse trailer crunched out the driveway, I decided to have a look in the living room.  The stampede of pawprints were unmistakable, as were the large yellow spots on the white carpet that kept me occupied until around nine pm, when the sound of geysers through my open kitchen window led me outside. A trail of broken sprinkler heads crushed by the wheels of the swaying horse trailer created a fountain effect not entirely dissimilar to the fountains at Bellagio.  Unfortunately the water was not falling on the grass.

Multiple applications of pet odor and stain remover plus one brand new Bissell vacuum later, along with a hefty repair bill for the sprinkler system, parts and labor, all is well with the world.  My traveling companion said, “Did you call her?  Did you yell at her? What did you say??”  I shook my head.  As I said, I try not to sweat the small stuff.  After all, the “kids” are all right.  Anybody know a good house sitter?

Love in the Time of Cancer

I used to be able to paint my own toenails but that was before age and arthritis caught up with me and these days I can’t SEE my toes, much less paint them.  Here in the land of perpetual sunshine and flip flops one is not allowed to have ugly feet, so off I went today to see a lovely woman who takes care of such things.  Today she was very sad over the end of what had been a promising love affair. He had seemed to have all the “right ingredients”—handsome, slightly older than her but boyish still, owned his own business, long divorced with no pesky baggage such as alimony—for a while she thought he just might be “the one.”  I asked her what happened and she said simply, “Anger issues.”

A couple of months ago, writer and radiation oncologist Dr. Robin Schoenthaler shared with me an essay she wrote in 2009, which I had somehow missed when it went viral over the internet back then.  It is simply titled, “Will He Hold Your Purse?” and here is the link because it is a must-read for any woman seeking a man:  http://www.boston.com/bostonglobe/magazine/articles/2009/10/04/will_he_hold_your_purse/  I thought about that article today as my manicurist, age forty-five and gorgeous but still single described walking away from a relationship that she recognized could be harmful.  And I remembered some of my own stories from the cancer clinic, and I told her one of them.

I recall one couple distinctly, from 2003.  They were both in their eighties, and she had breast cancer. One reason they were so memorable as a long married couple was that he was African American, and she was Caucasian, and back in the 1940’s when they married, two schoolteachers in love, they must have faced nearly insurmountable prejudices and racism.  He was an attractive soft spoken gentleman, with a sweet smile and wiry close cropped gray hair.  She must have never been a great beauty, but time had thinned her hair, and added on pounds, and osteoporosis had twisted her spine. When I saw her after her surgery, she had had a wound infection, and her breast had become misshapen as a result.  He held her hand tightly though out the consultation, and when I left the room so that she could get dressed, he followed me out into the hall and grasped my own hand in both of his. With tears in his eyes, he asked, “Will she be alright?”  I replied, “Yes, she will.  Her cancer was caught at an early stage, and I think she will be fine.”  He sighed with relief, and still holding my hand, he said of his wife, “She is my princess and my queen and my better half and my best friend.  I could never go on without her.  Thank you, Doctor, thank you.”   We walked back into the exam room and he beamed at her.  She blushed as she met his gaze.

I don’t wish for any couple to have to undergo the litmus test of a cancer clinic.  But when my manicurist said to me today, “I don’t think I even believe in love anymore,” I sure wish we had a proxy for that partner who, in Dr. Schoenthaler’s words, “will sit in a cancer clinic waiting room and hold hard onto the purse in his lap.”  That’s the one we want.

It Helps to be Famous

Boston is a mighty fine place to visit, if you don’t mind the weather–my trip to the Harvard Writer’s Conference this week started out with four straight days of freezing rain punctuated only by gusts of wind.  But cold feet and wet shoes could not deter me and my daughter from our appointed rounds of Newbury Street and the Mall at Copley Place. Lugging my suitcase through Logan Airport last night reminded me that I bought more than books at the conference book fair.  In fact, I had already made a pit stop at Fed Ex to mail the books home—no room in the baggage.  I finally arrived back in San Diego at 11 pm, after seven hours on a JetBlue plane, where no matter how much they brag about the snacks being free, there’s only so long you can hold out on two bags of blue potato chips and a roll of Mentos.  The hastily bought tuna salad sandwich from Dunkin Donuts at the gate proved to be far too suspect to actually eat, and if you know me, you know that I am NOT a picky eater.

But back to the main subject at hand, the annual Harvard Writers conference (www.harvardwriters.com) was a welcome respite from the medical meetings I usually attend. The three days of talks by noted medical authors, publishers and literary agents were outstanding, but the best part of the conference was getting to meet other writers, some well published and some aspiring, to share ideas and stories.  I met specialists of every variety, including child neurologists (“How to Develop Your Baby’s SUPERPOWERS!”), sex therapists (“and let me tell you, I hear about a lot of BAD sex!”) and a surgeon who wrote a memoir of his internship called “The Year They Tried To Kill Me: Surviving a Surgical Internship Even if the Patients Don’t!”)  Who knew that the practice of medicine could be so exciting?  The fact that I have not ever actually WRITTEN a book did not deter me in the slightest—I signed up for every lecture, every work shop, every interactive demonstration to be had.  And I learned a tremendous amount.  Next year I’ll come prepared:  I will try to write a book.

Kudos to the course organizer, Dr. Julie Silver (www.juliesilvermd.com) , a breast cancer survivor, mother and Harvard physical medicine and rehabilitation specialist for putting together a stellar faculty.  She spoke about a subject familiar to many of the readers of this blog—she found that while she was able to survive her cancer, the aftermath of the treatments nearly killed her, which inspired her to write her book “After Cancer Treatment: Heal Faster, Better, Stronger,” a book which will help not only breast cancer patients but all cancer survivors recover from the side effects of therapy.  The prize for the most entertaining lectures had to be shared by Dr. Salvatore Iaquinta and Mr. Rusty Shelton. Dr. Iaquinta, the surgeon who self-published his memoir mentioned above created his book, soup to nuts, on Amazon’s vehicle “Create Space” (www.createspace.com) and highly recommended the process.  Definitely worth looking into.

Mr. Shelton, of Shelton Interactive (www.sheltoninteractive.com) gave two very enlightening lectures on the use of social media in publishing and marketing.  As it turns out, a lot of attention in the book publishing world is paid to something called “platform.”  In my hitherto world of swimming and diving, when someone said “platform,” they meant five meter or ten. But in the publishing world, the “platform” is the influence and following a would-be author has already built, not only through their professional associations and media appearances but also through the social media of a self-named website, a Facebook page, and especially a Twitter account.  The somewhat obvious conclusion here is that if you want to get a book published, it is exceedingly helpful to be famous already!

So grab your domain name now, and don’t forget Facebook and LinkedIn.  On your mark…get set…and START TWEETING!

Anxiety

Nearly two years ago, I sat with my younger sister at the airport in Houston, Texas waiting for our respective flights.  She was going back home to New Jersey, and I was headed back to California.  While waiting, she passed the time browsing SAT prep sites on her iPad.  Her oldest child, my nephew, was starting his junior year of high school that fall, and she wanted to make sure his summer was well spent, and that he had the opportunity to prepare for the exam which would determine his future college options.  As she talked about the merits of one approach over another—classroom instruction versus private tutoring– I felt my anxiety level rising like an uncomfortable expanding bubble in my chest, gradually cutting off my air supply.  The pressure was palpable.  After listening for a few minutes, I said to her, “Please stop talking about this—you’re making me very nervous and I’m not even TAKING the exam.”  She looked at me in surprise, and we moved to other topics.

 

On Sunday evening on our way out to dinner, I went with my daughter to take sign out from the intern who was leaving the ward service the next day, and turning the very sick patients over to my daughter’s care.  I tried to position myself unobtrusively, in the far corner of the residents dictating room, sinking as deep into the shelter of my wrinkled hooded raincoat as I could, but even from my self made cocoon I could hear them discussing in hushed tones the low platelet counts, the mucosal bleeding, the fevers unresponsive to antibiotics in these acute leukemic patients.   It was seven pm after a long weekend on call, and the interns and residents looked exhausted.  The white cubicles and the scuffed linoleum on the floor reflected the fluorescent ceiling lights overhead. The faint smell of stale fried food and sweat combined to form a vaguely nauseating aura.  Suddenly I was transported back thirty-five years to my own internship, and to my first night on the cancer service and in that instant, I felt every bit of anxiety that I felt so many years ago.  For anyone who has done an intensive medicine or surgery residency, these feelings form the impetus to learn and become competent—the overwhelming sense that a human being’s life is in your hands, and this night, and every night, you must be vigilant; you must perform and do your very best.  The end of shift can never come soon enough.

 

It’s been many years since I taught a class of high school students, or staffed an inpatient service run by interns and residents.  But if I ever do either again my recent “flashbacks” will serve me well.  It’s good to remember the fear and tension associated with being a learner in a stressful situation.  Teaching has always been a passion for me, and those are the memories and feelings which will make me a better teacher.

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?