Siskel and Ebert

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

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

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

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

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

A Different Kind of Mask

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

Lawrence Durrell,  “Justine”

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

 

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

 

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

 

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

 

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

 

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

The Glass Is Half Full

A couple of weeks ago my nurse came to me with a request for a consultation.  Since our schedule has been packed full lately, she’s been asking me where I can squeeze patients in.  She said, “I’m not sure about this one—he says you treated him twenty years ago and he wants to see you.  But there is no new pathology so I don’t know how urgent it is.”  I looked at the consult request and did not remember the patient but there were several handwritten jottings on the cover sheet from the referring physician that listed phone numbers and beside them, “no answer at this number X 3,” and “Dr. Fielding hasn’t worked here since 2004.”  Apparently some effort was made to track me down, since I have changed jobs a few times in the last twenty years. I said, “Well get the latest information on the patient and put him in the open emergency slot a week from Friday.”

So Friday came yesterday and this patient was scheduled at one o’clock.  I like to review the charts before I see new patients, so I picked up the chart during a hurried lunch and read through it with a growing sense of recognition, and no small amount of dread. The man had been treated for advanced head and neck cancer back in 1994.  He had presented with cancer on the lateral aspect of his tongue, which was excised by his surgeon.  Six months later, he recurred both on the tongue, on the soft palate, and in his neck, with a large tumor wrapped around his jugular vein.  His surgeon tried, even sacrificing the large vein, but he could not resect all of the cancer and the patient was referred to me for post-operative radiation therapy.  Given that the man was only fifty one years old, his medical oncologist made the decision to give him chemotherapy along with the radiation, a decision which was considered quite radical at the time.  Treatments for head and neck cancer back then were crude by today’s standards, and fraught with complications, and this man had had all of them.

By 2000, he could no longer swallow, and his esophagus had to be dilated.  This happened again in 2008, and another procedure provided relief.  His saliva never fully returned after treatment, and so in 2012, plagued with tooth decay, he began a series of extractions, augmented by hyperbaric oxygen therapy to prevent osteoradionecrosis of his mandible.  Unfortunately this did not work, and he ended up having a portion of his jawbone removed.  A year ago, he began to have a new issue—when he tried to swallow the food was going down “the wrong way” and causing him to choke, resulting in several episodes of aspiration pneumonia.  It was becoming hard for him to go out socially, and enjoy a meal with friends and family. His carotid and vertebral arteries were narrowed, putting him at risk for stroke. Multiple recent studies showed no evidence of recurrence of his cancer, but there was scar tissue in the back of the throat which prevented the epiglottis from closing over the trachea when he swallowed.  These were the things I read in his chart before I saw him, and I anticipated that our session together would be an angry one.

Tall, older and thinner than I had last seen him, the patient greeted me with a huge hug.  His wife smiled warmly.  As we sat and talked in our sunny consultation room, he described his current difficulties and told me that his surgeon had referred him back to me for electrical stimulation therapy of the throat muscles, which might help his aspiration.  Our institution has an entire department for the rehabilitation of head and neck cancer patients.  I groped for the right words to say to this man who had suffered through complications which are rare by today’s standards of care.  I apologized profusely, and explained that now we have better ways of shielding normal tissues to spare patients the terrible late effects of treatment.  I told him I would be happy to put in a referral to our swallowing and speech rehabilitation specialists.  He looked at me in surprise, and said, “Doc, I didn’t come here for that.  Dr. M (the surgeon) already put in the referral. When I found out you work here, I came to say thank you.  I was fifty one when I was told that my chances of survival were 10 per cent.  Now I’m seventy one years old.”  He squeezed his wife’s hand and said, “We’ve traveled the world together.  We’ve seen our grandkids graduate high school.  We’re going on a cruise to San Francisco next week.  Yeah, I’ve had my problems but we’re still having fun!”

Some folks are just “the glass is half full” kind of people.  Having always thought of myself as one of them, I’m surprised it took me a whole consultation to recognize that in my patient. Taking care of cancer patients has always been a good way to remind myself that my own life is not so bad.  Lesson learned, again.

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

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

 

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

 

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

 

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

The Gift of the Magi

When I was young, one of my favorite stories was O. Henry’s “The Gift of the Magi.”  Originally published in 1905, the short story became standard fare in public school reading classes and I doubt that there are any of you out there who have not read it.  But just in case– the story is about a young couple, poor and deeply in love.  At Christmas, they have no money to buy each other gifts.  She cuts off her long golden hair, her prized possession, to buy him a watch chain for his own treasure, the pocket watch his grandfather left him.  He sells the watch to buy ornamental combs for her beautiful tresses.  In a classic example of cosmic irony, the two are bereft of everything except their enduring love for one another.

Yesterday, an eighty five year old man was crying in my office.  A month ago, he completed a grueling seven weeks of treatment for head and neck cancer. Otherwise healthy, he endured the side effects of treatment with great equanimity—the loss of taste, the sore throat, the dry mouth, the hoarseness, the skin reaction, the fatigue and the weight loss associated with treatment.  His reward is great—he is free of disease and very likely to remain so.  He drove himself to every treatment, clearly motivated to complete his therapy despite his advanced age.  I never had to cajole him into continuing and finishing the treatment—he was clear that he was doing this for his wife of sixty three years, and for his family.  He wanted more time, and more healthy time with them.

When I saw him in follow up, I asked him how his post treatment time had been.  Many times for radiation therapy patients, the week or weeks following treatment are even more difficult than the treatments themselves—the side effects may worsen before they improve.  So I was not surprised when he said, “It’s been TERRIBLE.”  I patted his arm and said, “Tell me about it.”  He replied, “Right after I finished, my wife was hospitalized and now she is in kidney failure.  She started dialysis on Wednesday.”  Somewhat surprised that an eighty five year old woman would choose to go on dialysis, I asked him, “Do they expect her kidney function to improve?”  He said, “No, the doctors said there is no chance of improvement.  The hospital doctor said that under no circumstances would he recommend dialysis for her.  But the kidney doctor said it was her choice—to have dialysis and live, or to be made comfortable and die.  She chose to live, for me.”  And then he wept.

We can all be cynics or pragmatists if we choose.  We can talk about the escalating cost of healthcare, and the wisdom or folly of treating eighty five year olds with intensity modulated radiation therapy and daily image guidance and their wives with hemodialysis.  But what I saw yesterday was an affirmation of enduring love, in two elderly people, who gave one another a gift not unlike “The Gift of the Magi”—the gift of sacrificing self to continue to live.  It’s hard to be cynical about that.

Thanks For Your Support

My husband likes to say, “No good deed goes unpunished.”  I don’t always agree, but sometimes you just can’t argue that concept.  One of my favorite patients, a forty nine year old woman who I treated for head and neck cancer a year ago is a good case in point. Head and neck cancer is on the rise, and is linked, like cervical cancer, to infection with human papilloma virus which is sexually transmitted.  Patients who are treated for this type of cancer have a very rough time.  Typically, curative treatment these days involves combining chemotherapy and radiation, reserving surgery for salvage in the case of an incomplete response or recurrence.  Patients have severe mucositis, inflammation of the oral cavity and the throat, and oftentimes require a feeding tube for nutrition. They lose their sense of taste, they are hoarse, their mouths are intolerably dry, and they are fatigued and miserable.  The good news, however, is that the majority of these patients are cured, even with advanced stage disease.  Many go on to be advocates for others just starting on their journeys.

It was with this in mind that my patient’s ear nose and throat doctor asked if she would mind speaking to a man of similar age and circumstance who had been recently diagnosed.  Of course she agreed.  She had been through the war, won the battle and wanted to help if she could.  She called him and they spoke at length about treatment side effects.  But something seemed a little “off.” Soon he was calling and texting her daily.  He wanted to meet her.  She politely declined, but she invited him to attend an event at our cancer center celebrating survivorship, and the role of complementary therapies.  He wanted more.  Soon his urgent text messages dominated her cell phone, culminating in the question, “So how did you get your HPV infection?  You must really like oral sex!”   She got a restraining order.

I saw another patient a week ago with breast cancer for an initial consultation.  She was very nervous, unduly so considering that her cancer was detected very early and she had completed her lumpectomy and sentinel node dissection.  The tumor was tiny, the nodes were negative and she was not going to need chemotherapy.  When I could not dispel her anxiety, she finally confessed that another breast cancer patient of mine had sent her a picture on her cell phone of her breast at the end of treatment, at the peak of her skin reaction.  This other patient had undergone chemotherapy first, which sensitizes the skin to radiation; she was large breasted which also increases the skin reaction; and she had refused to follow advice regarding her skin reaction.  She had an area of moist desquamation—peeling skin—in the inframammary fold.  She is now completely healed, with no permanent skin changes, but in the interim she deemed it important to frighten a new patient nearly to the point of refusing therapy.

Many years ago another head and neck cancer patient said to me, “When I found out I had cancer, I joined a club that I never wanted to be a member of.”  Support groups can be wonderful—many of my patients tell me they have met their best friends at group support meetings.  But always beware of people with hidden agendas.  When it comes to cancer support, there are far too many of these.

What Comes Next?

Multi-tasking has never been my forte and so I like to keep my schedule organized.  Mondays, I see all of my on-treatment patients.  Tuesdays and Thursdays I see new patients in consultation.  Wednesdays are reserved for treatment planning and research projects.  But Fridays—well, Fridays are usually the best day of the week.  Not only is the weekend approaching, with time to spend on my menagerie and the ever present home improvement projects, but on Fridays I see my follow up patients.  Nothing is more gratifying than seeing a patient who was near death from a locally advanced head and neck cancer a year ago leading a normal life now, back at work, and grateful not only to be free of disease, but also for the excuse to leave work early on a Friday afternoon for a follow up visit.  Together we’ve shared many a TGIF moment!

Sometimes, however, the first follow up visit that a patient makes is not such a cheerful encounter. Yesterday was such a moment.  A young breast cancer patient came in for her first follow up a month after completing all treatment for her early stage, but high risk breast cancer—she had her lumpectomy and sentinel lymph node dissection, followed by four rounds of dose intensive chemotherapy, and finally, her radiation therapy to the breast. She is a beautiful young woman, and despite her hair loss from the chemotherapy, her presence and broad smile lit up the radiation therapy department every day when she came in for treatment.  But when she arrived yesterday, something had changed.   Despite her artfully sculpted short fringe of hair, her colorful bangle earrings and her pretty red lipstick, she answered my nurse’s questions with terse replies, fighting back tears.  When I entered the exam room, the floodgates opened.  I was horrified, took her in my arms and said, “What has happened?  What is the matter?”  Through her tears she managed to blurt out, “I just don’t know what comes next!”

There have been many scientific papers written on the phenomenon of depression post cancer treatment, mostly relating the depression to physical symptoms such as fatigue and other side effects of treatment. I know that there is a different reason because I see it at least once every Friday.  Cancer, especially those like breast cancer and head and neck cancer which require multimodal treatments, is a disease that keeps you busy.  Once the diagnosis has been made, and the treatment plan is laid out, the patient has a new career.  Just as with any other job, there is new terminology to be learned, new orders to follow, and new sensations, both emotional and physical to experience and cope with.  People are surprisingly resilient—after the initial anger and “woe is me” moments, most patients get their game on.  They take care of their incisions, they appear for their blood work, they shore up their reading material and their support systems for their chemotherapy, and they organize their schedules around their daily radiation treatments.  In short, they put one foot in front of the other, one day at a time, and they count the days until their treatment will end (and trust me, never argue with a patient who tells you they have only 12 more radiation treatments when you think they have thirteen—the patient is ALWAYS right!)

The hard part is when the treatment ends.  Fears that have been shoved deep under while the patient is so busy just getting through each day of treatment surface with a vengeance.  The demons of what might have been, and what might yet be creep through the doorjambs and windowsills of dreams.  For patients who overcame the shock of their diagnosis, and who battled through the side effects of their treatment—this is their time for pause, contemplation, realization and reaction.  And when it happens, I tell patients that there is only one thing to do and that is to seek professional help. Cancer is a life changing event. Denial only carries us so far.  Caring for the emotional needs of a cancer patient is not easy, and cannot always be managed by a spouse, a parent, a child or a well-meaning best friend.  When this happens to my patients—when they fall into this post treatment abyss– I tell them to get the help they need, even if it requires antidepressant medication.  This, even more than the treatment that I have offered, can be life-saving.  There is no shame in it.  From what I have seen, lux ex tenebris.  Whatever comes next, come what may.

Hunger Strike

The Q’s will not eat.  My two female deerhound sisters, Queen and Quicksilver, aka Quibbets and Little Grey, are coming four years old in January.  They are both AKC Grand Champions and as such, I have not spayed them yet, thinking that perhaps I will breed a litter, my first since my only prior litter in 1997.  At that time, I discovered that it is much easier to BUY a nice deerhound than it is to raise a passle of poopy giant puppies. In some respects, I am a quick learner.  Anyway, when the Q’s come in season and go out without being bred, a month later they stop eating.  The veterinarians call this a false pregnancy.  I call it a hunger strike. Today I have cooked fresh ground beef, chicken, brown rice, green beans, and have shared some expensive Sargento shredded cheddar cheese. The fruits of my efforts have gone untouched.  Queen is now ensconced on the family room couch.  She is glaring at me.  Later, I will cook bacon and pretend it is for her.

I don’t know why I seem to spend an inordinate amount of time trying to get others to eat.  Although my children were never picky eaters, my youngest went through a period where he would ONLY eat jelly sandwiches for lunch.  Forget the peanut butter, forget protein, forget the healthy apple and the mozzarella string cheese.  It was gooey jelly sandwiches, or NOTHING.  Years later, he said to me, “Do you KNOW how unhealthy that was, what you fed me for lunch?”  I said, in my best Jewish mother voice, “Really?  I was supposed to let you starve?  Over my dead body would you go hungry at school!”  As a girl, I cleaned my plate, always, because of the starving children in Africa.  Still do.  I have a theory that if every time I reached for a bowl of ice cream, a touch screen in my freezer would give me a choice—eat the ice cream myself OR see the calories get deposited DIRECTLY into the mouth of an emaciated child—I and millions of Americans just like me would hit the “kid” button, walk away from the ice cream and make the world a better place.

Now the intended objects of my need to feed are my patients.  I plead with them, I entreat their spouses, I offer prescriptions for Ensure, Boost and Jevity.  In some cases, I recommend feeding tubes.   I tell them that they MUST not lose weight, because unintentional weight loss in many types of cancer can be a very poor prognostic sign.  I tell them to forget their cholesterol and focus on their cancer—eat protein, eat fat, eat sugar (yes, even sugar!), but please just eat.  I tell them that my job is to cure their cancer.  And then I tell them in no uncertain terms, that THEIR job is to EAT.  Even if it doesn’t taste good.  Even if they aren’t hungry.  Even if they used to be fat.  If my lung cancer and bowel cancer and head and neck cancer patients will just eat, their bodies and their spirits will get ahead of that thing that is eating THEM alive. And since most of my patients want to be good, to be cooperative and above all to live, they try.

As for me, age, arthritis and a very busy clinical schedule have not been conducive to keeping off the excess pounds.  My kids will know that indeed I am dying, if I ever miss a meal.  Especially if that meal is paired with a nice glass of wine and has a dessert course which includes chocolate.  But right now, I have to go.  There’s bacon to be cooked!

FIFTY/FIFTY

When I was 30 years old, I learned the true meaning of optimism.  During my residency, I was fortunate enough to have as a mentor one of the world’s greatest radiation oncologists for head and neck cancer.  This man was  born in China to two Chinese Christian missionary parents.  He and his twin brother were brought to the United States as teenagers, and both managed to graduate from the most prestigious medical school in the country.  Years later, both brothers had established themselves as pre-eminent leaders in their respective fields of surgery and radiation oncology.

My mentor celebrated his sixtieth birthday while I was on his service, yet he was as energetic as men half his age.  Day after day, I would stand behind him looking over his shoulder as he examined some of the most desperate patients in the world, patients who came from every state in this country and from every country in the world, having failed standard treatments for their cancers in top medical centers near their homes. They would wait anxiously as he reviewed their cases, and would lean forward to have their throats and necks examined by the great expert.

And then they would ask the question, the inevitable question—”Doc, what are my chances?”  And the good doctor always had one answer:  “Fifty/fifty”.  Every single time the question was asked, the answer was “fifty/fifty”.  Now I was a good student and a good resident.  I knew that these patients, having such advanced disease and having failed so many other treatments, did not have anywhere close to a fifty-fifty chance of survival.  I knew that at best, their chance of making it five years was 3%.   Or maybe 5% if they were lucky and all went well.  So one day, I couldn’t stand it anymore.  I felt that the patients were being misled, if not actively lied to.

You must understand that it took some courage, not to mention a good dose of moral outrage, for me to confront the great man one day, outside of the exam room.  I said to him, “Dr. W, why do you tell these patients that their chances of survival are 50-50.  You KNOW that is not true!   Why do you say that to them?”  He sighed wearily as if I were the slowest resident in the world,  looked me in the eye, and said something I’ve never forgotten.  It helps to imagine his Chinese accent, still strong more than 40 years after arriving in this country.  He said to me, “Statistics, statistics, STATISTICS!  All you residents ever want to do is quote statistics!  For every patient, either he gonna LIVE, or he gonna DIE!  FIFTY-FIFTY!”

That my friends, is the definition of optimism.  Take it to the bank!

(This man also said many other rather unforgettable things.  When a resident managed to get an answer right during morning conference, he would positively CROW:  “In the land of the blind, the one eyed dog is KING!”  But that’s another story…)