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.

When Life Gives You Lemons

When I was about ten years old, swimming on a Texas swim team, I remember hearing that the child of one of the local coaches had been diagnosed with leukemia.  The idea of a kid dying of an untreatable disease was so foreign to me that I am sure that I have blocked out most of the details.  I do know that the child died, and it didn’t take very long.  In the fifty years since, the landscape of childhood cancer has changed dramatically for the better.  Today, most children diagnosed with acute lymphocytic leukemia—the most common type—survive.  But in the past, we oncologists significantly underestimated the cost of that survival.

For the last six months, I have been taking care of one of the earliest survivors of childhood leukemia.  In her late forties now, she was treated with life-saving combination chemotherapy when she was six years old.  A couple of years later, she relapsed with leukemic cells in her brain and spinal cord, and received cranio-spinal irradiation—radiation therapy to her entire brain and spinal cord, a toxic treatment associated with short stature due to reduced growth of the spine, lowered IQ, and a depressed immune system.  Again she survived, and grew up to be a teacher of disabled children—the ultimate in “giving back.”

In 2005, she was diagnosed with breast cancer, likely a consequence of the radiation exposure she had as a child.  She underwent a mastectomy, and then did well until last fall when she noted a lump in the medial aspect of her breast reconstruction.  A staging work up revealed a benign appearing brain tumor which, again, was likely a late effect of her brain irradiation.  Since she had no symptoms from her brain tumor, her medical oncologist forged ahead with chemotherapy for the breast cancer, followed by removal of her reconstructed breast and its residual cancer, followed by radiation to her chest wall and lymph nodes given by me.  All of this she bore without question, without complaint.

I saw her in follow up on Friday and she was doing well, but she knew she needed to undergo more testing for an enlarged and nodular thyroid—possibly a thyroid cancer, also radiation induced.  She also needed to have a follow up MRI for her brain tumor, to be sure that it is not growing rapidly.  She was matter of fact about the inconvenience, not to mention the anxiety, of having multiple additional tests and procedures over the next few weeks and months.

I am continuously amazed by her grace and equanimity.  I said to her, “You are my hero.  How do you just keep going, day after day, month after month, year after year, dealing with cancer, one cancer after another?”  She said, “When I was a child, dying was NOT an option.  My parents never even mentioned the possibility, so I was never afraid.  I just did what I had to do.  Now it’s the same thing—I know that this is the price I have paid for the wonderful life I have led.  I just keep putting one foot in front of the other, one day at a time.  I know that I will be okay.”

Here’s the thing about oncology folks:  It puts everything else into perspective.  If this brave woman can take the lemons life has given her and make lemonade, so can you and I.   This is the crux of the matter; this is what has kept me going in this field for over thirty years.  If this woman considers herself lucky, so should we all.