I Had a Brother

Sometimes it’s the little things that trigger the memories.  A few weeks ago, when those young women who had been abducted in Cleveland were found, almost by accident, my father said to me, “I don’t believe this story.  It’s impossible that these women could be locked up for all those years and no one ever heard them, or saw them.”  I lashed out in anger, “Dad, there are BAD people in this world, whether you want to believe it or not!”  I went on, “Don’t you remember when Joel and I were little and you and Mom would be getting ready to go out on a Saturday night, and you sent us across the grocery store parking lot to the drugstore soda fountain to get dinner?”  My father was a plastic surgery resident then, and we lived, the five of us, in a two bedroom apartment in a complex next door to the A & P.  I was seven and Joel was five and I had a job–no, a DUTY to make sure that the server did not put mayonnaise on his hamburger.  He wanted it PLAIN and that was that.  I said, “Something TERRIBLE could have happened to us and you and Mom didn’t care.  You just wanted us out of the way so you could get ready.”  My father had no recollection of this whatsoever, and it occurred to me that perhaps he wasn’t even there.  Perhaps he was still at work, sewing up lacerations and dog bites and victims of car accidents.  There were no actual memories of him, only of my mother, sitting in front of her vanity, applying her make-up.  She was beautiful, my mother. While she put on her make-up, my little brother stole candy from the drugstore.

My brother spent his life between drug rehab facilities and prison, with brief moments of hopeful sobriety in between.  We stopped speaking for a very long time after he cashed in the ticket my parents sent him so that he could be best man at my wedding.  He spent the weekend in Las Vegas gambling.  He didn’t bother to call.  When our grandmother died a few years later, we met in Chicago at her tiny apartment just before her funeral.  When my father asked if there was anything of hers that we wanted, he replied, “I checked the silver.  It’s under the bed.  It’s plate.”  My brother survived car accidents, a bad marriage and the AIDS epidemic.  He was handsome, smart and charming.  You just wanted to believe him when he said that things were better, that he was getting along  fine.  His eyes were cornflower blue, and my favorite picture of him was taken when he was eighteen.  He was sitting on a ferry boat on the way to Anacortes, wearing a blue shirt.  In the picture, the sky is gray, and he looks young, and sad.

In 2003 my brother died of an accidental heroin overdose in a flop house hotel in Portland, Oregon.  Apparently, he had been shooting up with a friend, who was recently released from prison and was on probation.  The story I got was that the friend knew that my brother had overdosed, but fled rather than call 911 and risk going back to prison himself.  It was a few days before they found my brother’s body. I don’t remember much about the funeral, except that it was late fall, and turning bitter cold.  I still miss him.

The other day I was rifling through drawers in my office, trying to find an article I had saved about melanoma.  I had to pull out some old framed family pictures that were taken off my desk top during some construction in the office, and put in the drawer for safe keeping.  I showed the medical student the pictures of my kids and we had chatted about my sister and he asked, “Do you have other siblings?”  I replied, “I had a brother.”

Weights and Measures

The sudden illness of a colleague is always a shocking surprise.  As physicians, we are trained from an early age to ignore our own infirmities in the service of others.  Apart from my three C-sections, I have been extremely fortunate in terms of my own health—I can count the number of sick days I’ve taken in the last thirty years on one hand and I am thankful every day for that blessing.  In my day to day world of caring for cancer patients, I know that in an instant, by accident or by sickness, everything can change.  I think that my colleague must have felt the same—that calling, that mission to care for the stricken that leads one to suppress the rising signs of illness in order to keep that black curtain of infirmity a little further to the edge of the window frame of life.

On Monday I learned that the man I have grown to respect for his insight, his dedication to his profession and his kindness would likely not be coming back to work, ever. My entire department was devastated, especially his nurse who has worked so closely with him for the eighteen months he has been with us, and also his patients, each of them with cancer,  who asked me one by one when they saw me for their weekly on treatment visit, “I am so sorry to hear that he is ill.  When is he coming back?”  As the realization of the gravity of his illness slowly came to all of us, since he had not shared the knowledge of his disease with any of us, the weight began to descend.  Our patient load is at its highest, our working hours are extended, there are patients waiting to be seen, planned and treated.  Who will step in to consult on these patients, to plan their radiation treatments, to oversee their side effects and work the extended hours?  Right now, we do not know.

I have always said that unlike my father, I do not want to “die with my boots on.”  I want to retire while I am still healthy enough to do the things that I’ve put off for so many years—to write, to paint, to take photographs, to teach English, to travel, to play with my dogs, and perhaps, just perhaps, get another horse—an older horse, a calm horse (we grow so brittle as we age that we break more easily!) who will carry me down the trails so that I can smell the orange and lemon blossoms on the trees, up close, as they bloom in late December here.  I said this to my husband last night, at the end of a very long week.  He said, “No one ever knows what they will do when faced with a terminal illness.”

This was a very busy week in the clinic, and I had a medical student rotating with me. In the chaos that surrounded us, I had to keep reminding myself, first things first. Yesterday, together we saw a man with a life threatening cancer.  I was running very late, and he was the last new patient of the week.  My student took the reins—he interviewed the patient, examined the patient, explained the treatment and seamlessly introduced me to the patient and his wife, who were quite pleased with the care and attention he had already received. We completed the consultation together, and as I left the room I suddenly felt a deep sense of satisfaction.

When the weight of illness suddenly descends on an individual, my colleague, and consequently, his patients, his co-workers and me, his partner, we can still take comfort in the small measures of success–the satisfaction that we, as a team, are doing things right.  Sometimes it’s the little things, the small gestures and kindnesses that count.  We dust ourselves off, and we go on.

There Are No Shortcuts

“SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.”    The House of God

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

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

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

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

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

Really, truly, there are no short cuts.

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

You Play Hardball, Kid

Whenever I have a female medical student, as I did today, I always catch them looking at a framed cartoon on my desk and smiling.  The cartoon is an original hand lettered Doonesbury strip by Garry Trudeau, and it is indeed larger than life, each section about five by four inches.  If you look closely, you can see where Garry used white-out to make small corrections to give the strip that understated comic timing that Doonesbury  is so well known for.  When that particular strip came out in the Boston Globe in 1988, I knew I had to have it.  Since my husband was an old college buddy of Garry’s, he wrote to him and asked him if he would send it to me, and Garry obliged.  At the bottom of the strip, Garry wrote  “Courage and good luck!”  Twenty four years later, it is one of my most prized possessions.

The strip consists of four frames laid out horizontally in squares.  In the first frame, Joanie Caucus, mother and career woman, has picked up her daughter from daycare, and they are in the car together.  She says, “How did day care go today, honey?”  The kid answers, “Okay.”  In the second frame, they are still in the car, and the landscape has changed slightly.   The kid says, “I was crying because all the other children went home and you were late again, but Mrs. Wicker gave me oreos and let me watch cartoons and I called her “Mommy” by mistake.”  In the third frame, they are still in the car and you can see the long arm of a stoplight over head.  There is complete and utter silence in the car.  In the fourth frame, Joanie says, “You play hardball kid.”  The kid says, “Green light, Mommy.”

At the time, I had two children and was contemplating a third, who came along three years later.  I had a full time job taking care of cancer patients.  In college a zealous new wave of women’s studies professors had reassured and brainwashed the 250 women in my class (perhaps in defiance of the alumni who insisted that, yes women could attend this formerly all male bastion, as long as the college continued to graduate “1000 male leaders” per year).  They told us that we could “have it all”, and we believed them.  So off we went to medical school, and law school, and graduate school and business school to heal the sick, comfort the disenfranchised, teach another generation of women, and in some cases, make a fortune.  And many of us married, and had children.

People say to me now that my children are grown up, “How did you DO it?”  The answer is, I have no idea how I did it.  A lot of it is a blur. At this stage in life, I get exhausted even thinking about the fact that I was always rushing to work, rushing home, rushing to get dinner on the table, rushing to help with homework, and then on the weekend rushing to attend as many horse shows, soccer games, wrestling matches and do as many loads of laundry as I could cram into a 48 hour period.  My girlfriends, similarly over extended, and I would joke that “We need a WIFE!”   I had some serious “Bad Mommy” moments, which my grown up kids remember in excruciating detail, and will recount at holiday dinners, especially if they need money.  They STILL know how to play hardball, that’s for sure.

Sometimes a female medical student reads that old Doonesbury strip, gets to the end, clears her throat nervously and then asks me, “Would you do it all again?  Is it possible to have a full time career AND raise a family?”  The answer is always ” yes”, despite the homework that didn’t get checked, the house that didn’t get cleaned, the PTO meetings missed, the dog that peed on the carpet,  the late pick ups, the early drop offs, the hurried kisses goodbye, the need to see that one last patient having difficulties in the middle of a blinding snowstorm, the fatigue and always, the guilt.  And I will tell that young woman that when she is on her knees by the bathtub at the end of a very long day with a three year old splashing water in her face, and that toddler slips up and calls her by his nanny’s name, she need not worry about it quite so much.  Trust me, they do know who their mommy is.

In spite of me, or perhaps in some small part because of me—the kids are all right.