The Things We Save, The Things We Give Away

Since I just spent the last several months sorting through my own lifetime accumulation of “stuff” in order to get my house ready for sale, it was only fitting that I volunteered to chair the auction and raffle at the Scottish Deerhound Club of America’s annual National Specialty show, held in Richland, Washington last week. After my fall, winter, spring and summer cleaning, I had plenty that I myself could donate, so why not go on vacation just to have the opportunity to sort through someone else’s stuff?  After all, I’ve gotten good at it.  My intrepid road trip companion and auction co-chair Rachel and I rented an SUV a week ago Monday in order to haul the deerhound related treasures 1300 miles, set them beautifully arranged on a table, label and describe them enticingly just so they could, in short order, become part of another deerhounder’s collection of stuff.  George Carlin famously said, “A house is just a place to keep your stuff while you go out and get more stuff.” This time I vowed that I was NOT getting more stuff.

But while we were there…well, the stuff just kept on coming.  Prior to the event, I had fretted because my email entreaties to bring donations for the auction and raffle went largely unanswered, but apparently not unheeded.  The knocks on our hotel room door started as we were unpacking our own suitcases, and the donors came indeed, bearing gifts of cardboard boxes filled to the brim.  By Wednesday evening we could have built a cardboard city, although a bonfire might have been more appropriate.  There were treasures there which were hard to resist—an 1883 edition of William Scrope’s Deerstalking in the Scottish Highlands—clearly a necessary reference book for my life in Southern California, and a handmade deerhound topped casserole dish, oven safe and dishwasher proof, for my imaginary culinary creations.  Some of the items were brand new—a brocade collar fit for the Royal Dog of Scotland, and some were a little more than gently used, with a fluffy patina of dog hair and dust.   We slowly worked our way to the bottom of each box, sorting as we went, until we got to the last one, where I found two old picture frames, face down, and picked them up.

The dog in the picture looks at me, head slightly cocked, ears askew.  His eyes are brown, and questioning. His coat is clean, and not matted, and his head is covered in the soft hair called for by our standard.  He is in a cheap frame, as is his companion, in a matching frame.  Why are they here, buried in the bottom of a cardboard box? I imagine they are dead, and that the photographs are now too painful to look at because they remind the owner of times past, happier times, and I burst into tears.  I hope that I am wrong, that the person who brought these to my room in a cardboard box was just tidying up—that he or she had scanned the photos into his computer as “wallpaper” and had no need for the actual photographs anymore.  But that is not what those pictures said to me.  I put them back in the box.

Bring me your old leashes, your dirty collars, your worn T shirts and sweatshirts.  We will recycle them for the next generation to carry on the “long grey line.” Bring me your antique bronzes lovingly crafted by the Animaliers of France and England in the 19th century, and your tales of stalking the red stag over the heather and the drink of Scotch from the quaich at the end of the hunt.  Bring me your handcrafted jewelry adorned with Celtic knots of silver and gold, and your art work and your crafts.  But please, don’t bring me pictures of your own dogs, buried and perhaps painfully remembered, perhaps forgotten.  Keep them, and the memories you have of them running through the fields, healthy and young again.

We turned in the SUV at the Portland airport, and flew home.  The auction was a huge success, and we came home to our families and dogs—the only things that really truly matter.

Love and Loyalty From the Souls of Dogs

“Such sadness and endearing and abiding love…”  Fran

I am by nature a “right brain” person—despite my training in science and medicine, I prefer paintings and photographs to words and mathematical constructs.  Over the past two years of writing this blog, I have resisted on many occasions the urge to add pictures to this website, despite the fact that I possess wonderful photographs of the things that I write about—my family, my dogs, my horses and my patients.  I am constantly taking pictures—I have chronicled my entire life in photographs from my first Kodak Brownie and I will continue to do so.  But I started writing again, thirty eight years after graduating from college with an English degree, to see if I could “describe” rather than “illustrate” the events in my life which have had an impact.  I want to write stories that leave a little bit to the imagination, to my readers’ right brains—stories that can be read out loud.

For the past few months I have been following the saga of Roo on Facebook.  Roo is an Ibizan hound owned by the artist Nan Kilgore Little. Affectionately known by their owners as “beezers”, this breed’s history dates back 5,000 years to the times of the Egyptian pharaohs.  The erect ears and tall lean bodies of these hounds are depicted in hieroglyphs in the tombs of Ptolemy, Nefermat, Mereku and Tutankhamen.  Think of the god Anubis, Protector of the Dead, and you will have a good visual image of the head of this hound.  Brought to the Balearic Islands off the coast of Spain by the Phoenicians in 800 B.C., these dogs have hunted to put food on the table of their masters for centuries.

Roo turned sixteen years old a few weeks ago, an extraordinary old age for a large sighthound. You can see it in the pictures—the eyes, once keen are now cloudy and the strongly muscled hindquarters have wasted.  The bone structure appears more prominent, and yet more delicate at the same time. The ears are nearly transparent, and beautifully veined.  Nan started to post pictures of him on his daily walks, interacting with the other dogs in the household, and resting on his favorite pillow—pictures which have inspired a legion of Facebook followers who clearly feel privileged to watch the “old man” in his waning days and to take that last journey with him and his loving family.

The last forty-eight hours have been tough. Old Roo, with his brightly colored bandanna and his watchful countenance has stopped eating and has taken to his bed, his head resting on his favorite pillow.  He is not in pain, but he is very tired.  No more walking in the Wild Yard and no more jumping over the Big Tree.  His best friend, an Australian cattle dog named Barkool, has taken up watch and rarely leaves his side.  Barkool is neither elegant, nor particularly beautiful and his squat body is a contrast to the lean and classical Ibizan.  He is Sancho Panza to Roo’s Don Quixote.  He is the friend we wish we all had.

My Facebook friends love dogs as do Nan’s and as a result, we frequently feel compelled to put up photographs of abused, starving and abandoned canines in need of rescue, or dogs beaten and bloodied in the service of man’s cruelest whims.  But rarely, in these hastily posted pictures, we see a glimpse of life as it can and should be.  Yesterday Nan posted a photograph of Roo and Barkool.  Roo is wearing his blue bandana and is wrapped the cocoon of his softest blanket, one covered by multicolored hearts.  Barkool’s head is tucked under Roo’s chin as a pillow and his stocky body is still as can be.  His eyes show apprehension, and resignation at the same time.  He is, above all, present for his buddy.

Sometimes friends and families of my patients are uncomfortable visiting their loved ones after a diagnosis of cancer, or even more so at the end of life.  They ask me, “What should I say?” or “What can I do?” The answer is revealed in Nan’s picture of Roo and Barkool:  without fanfare, without words, without tears, just be there.

Deconstructing the House

Photographer’s notes:

Please have the home prepared before the photographer arrives.
1. Turn on every conceivable light.
2. Open window coverings.
3. Remove pool hose, pool supplies and backyard toys.
4. Open patio umbrellas.
5. Remove BBQ cover.
6. Remove cars and trash cans from driveway.
7. Remove laundry, toys and cleaning supplies, brochure stands, etc.
8. Hide the dogs (and yucky evidence of dogs), if any.

My house is for sale and yesterday was the day for taking photographs.  I read the instructions carefully—I like to be prepared.  Numbers one through seven were easy, although removing two very conspicuous red cars, a Suburban and a Corvette, took a bit of doing.  And fortunately I have no brochure stands in my family room, or magazine stands in the bathroom (who has time?) But number eight—“Hide the dogs (and yucky evidence of dogs), if any”— say WHAT?  That was going to take some serious planning.  It doesn’t take much imagination to realize that not everyone loves large gray hairy dogs as much as I do.  It is interesting that horses add ambience because you can’t smell manure in the photographs, and even more interesting that there were no comments about hiding the yucky children.  The horses are pretty and the kids are grown and gone anyway.  But dogs, well, dogs are just yucky.

I tried my best.  I had the carpet, nearly new but already showing the telltale signs, cleaned professionally on Tuesday.  By 8:30 am, the dog beds were all dragged outside and piled on the patio outside the master bedroom, hidden from every conceivable camera angle.  The dog bowls were emptied and neatly stacked in the pantry.  The crates in the garage had new clean pads installed, and smoothed wrinkle free.  The grooming table was stashed behind the crates, out of sight.  The morning “deposits” were scooped and emptied into a heavy duty, heavily scented drawstring bag which was in turn, placed in the small shed where the garbage cans are duly hidden.  The footprints from the previous evening’s wandering through the freshly watered grass were wiped from the kitchen floor.  The three deerhounds themselves were fed early, and were napping in their kennel runs.  The only trace of dog impossible to erase was my vocal little rescued terrier/Chihuahua mix Yoda.  I resigned myself to the fact that the only way to keep HIM quiet was to carry him around with me.  Four hours and one aching left arm later, mission accomplished.  I sent the photos to my kids with the note: “Look ye upon these photographs and know ye, that ne’er before has this house looked so perfect, and ne’er again will it.”  I didn’t want them to miss that one brief moment where we could pretend that we had no muss, no fuss, no chaos, no life, and no love.

Last night I dragged the dog beds back in, and then for good measure–because one girl just finished her heat season, and as sisters often do, the other just started hers—I took throws accumulated from 20 per cent off discount coupons from Bed Bath and Beyond and completely covered the master bedroom floor in a patchwork of riotous color.  I refilled all the water bowls and made sure that the pillows on the couch were fluffed and arranged just the way Queen and Yoda like them.  I made sure that the house, so ordered and neat and perfect for the photographer, was once again, perfect for the dogs.  After all, they are the ones who live here now with me and my husband.  I took new photographs of life as it really is—messy, chaotic, sometimes downright dirty.  I wouldn’t have it any other way.

Rethinking The Hunger Games

When the movie The Hunger Games was released in the spring of 2012, it broke box office records during its opening weekend.  Not familiar with the books of the same name for young adults by author Suzanne Collins, I did not rush out to see it but I liked its young star Jennifer Lawrence, and was eager to learn more about the new film.  I asked my son, who had taken his girlfriend to see it in IMAX, what it was about.  He said, “You wouldn’t like it Mom.  It’s about children killing children.  It’s “Gladiator” for kids.”  Since “Gladiator” is the only movie I have ever paid, not once, but THREE times to see on the big screen, I beat a hasty path to “The Hunger Games” and I was not disappointed.  Yes, it is a movie about children killing children, but the shining presence of its young star Lawrence, as the fiercely determined and staunchly moral Katniss Everdeen–a name as evocative of lithe cat-like goodness, emerging sexuality, intelligence and of course nine lives as Humbert Humbert was of blunt force, dullness and downright evil… but I digress—diverts the viewer’s attention from the sad specter of death as mass media entertainment.

How strangely ironic it was then, today, to wake up to the news of the shootings at Isla Vista, the residential community that houses a large number of University of California at Santa Barbara students, and to find out that the perpetrator of this heinous crime—a child killing other children—was the son of the assistant director of the Hunger Games movies.  A nightmare come true—to see one’s son in videos detailing exactly what grievances would lead to this explosion of violence, and worse, to have called the police because of concerns over a son’s mental and physical health, and to have those concerns brushed aside when action could have possibly prevented the tragedy. The finger pointing and blame assignments have only just begun.  But the facts remain, whether we are speaking of Columbine, or Virginia Tech, or Sandy Hook or Aurora—alienated mentally ill teenagers and young adults with weapons destroying the hopes and dreams of many families’ futures.

Tonight I looked at the Facebook page of Elliot Rodger, the 22 year old assailant who died last night along with his victims in Santa Barbara.  Oddly enough, the page has not been taken down. There are pictures upon pictures—“selfies”—shot with a cell phone of the handsome young man and his black BMW and his Armani sunglasses and his expensive clothing.  It is telling that there are no other human beings in these pictures—just a young man and his fancy things—and yet there is a glimmer of talent there in the few photos taken from vantage points on solitary hikes in the Hollywood Hills—a moonrise, a view of the Los Angeles skyline in the evening.   But the rantings on video and even the captioning on his Facebook self-portraits speaks to a deeply disturbed, alienated and delusional youth, who is more than anything, alone and lonely.

The father of one of the victims has already cited that this tragedy is the fault of the NRA.  I do not believe that.  I believe that the problem lies in our society itself—a culture which creates a pressure cooker for high school students to succeed at any cost, a culture which glorifies violence while ignoring mental illness, a culture where movies about children killing children become major box office hits. It’s time to take pictures of our friends, and look at them and above all LISTEN to them instead of taking pictures of ourselves, our food, our sunglasses and our cars.  It is time, indeed, to rethink The Hunger Games.  My deepest sympathy goes out to all of those affected by this terrible event.

The Irony of It All, Part Two

The dogs are quiet today, sprawled out across their various rugs and beds in the family room.  After the panic and anxiety caused by the fires here in San Diego last week and the heat that generated them, it is pleasant to feel the cool breeze created by opposing windows in my kitchen.  I am waiting for delivery of a piece of furniture—an old Chinese grain storage bin which had been “repurposed” as a decorative cabinet long ago, and which is about to be “repurposed” anew to hold the television controller and cable box for my new flat screen wall mounted tv—the evolutionary equivalent of man’s preoccupation with necessity progressing towards his preoccupation with luxury.  I treasure the symbolism in my treasures, as it were.

The cabinet will put the finishing touches on the home improvement projects we started nearly a year ago.  My friends with giant dogs and horses will feel a pang of recognition when I say that by moving in here over sixteen years ago, we traded a beautiful home graced with a gourmet kitchen (with two dishwashers, no less!) for acreage with a tumble down ranch house that was a few years beyond “fixer upper” into true “tear down” geriatrics.  It all started with the cat, that self-same Bitty Kitty who visited a year ago while my daughter traveled for internship interviews.  He took a dust bath in the living room fireplace and carried the blackened ashes to the already worn couches and carpet stained by a myriad of prior pets.  When we replaced the couches and carpet, the owner of the furniture store oversaw delivery and remarked, “You’re too old to be living with three-day-blinds!  This is not an apartment!  Why don’t you get some real curtains?!” The new curtains gave the old paint job a dingy tint and the new paint job made the bathroom tiles look ever so dated, and well…you know how it goes.  Last week we actually epoxy’d the garage floor.  It is now perfect.

Severe drought in the West over the last few years and overly aggressive tree roots furtively seeking water had taken their toll on our landscaping, and the bulk of our meager water supply was emptying underground from broken pipes, so that too needed attention and correction and above all, money.  Six months after completing the irrigation work, our water bills are lower than they’ve ever been, and the rose bushes are blooming again.  San Diego may be a desert, but how green are my pastures!

So I am enjoying this brief period of “this old house” being “as good as it gets.” I am no Martha Stewart, nor was ever meant to be, and my husband is definitely not “handy”—he would rather hire someone than change a light bulb.  The kids are grown, the horses are ancient, and even the dogs have slowed down a bit.  The house is for sale, and rightly so.  But every so often, I sit in the kitchen and listen to the wind chimes and watch the mother bird nesting and chirping in the ceramic birdhouse outside the open window. And I wonder why it took me sixteen years to realize that my “tear down” is instead, a little piece of paradise.

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.