Gone With The Wind

I have forgot much, Cynara! gone with the wind,
Flung roses, roses riotously with the throng,
Dancing, to put thy pale, lost lilies out of mind,
But I was desolate and sick of an old passion,
Yea, all the time, because the dance was long:
I have been faithful to thee, Cynara! in my fashion.

Ernest Dowson

Having no artistic talent whatsoever myself, nonetheless I am fascinated by art, and especially by artists themselves.  My father has been both an artist and an avid collector since the ship he served on as a Navy dentist docked in Sicily, and the local artists were allowed to come aboard to sell their wares.  He still has paintings he bought in 1945 hanging on his walls.  As a teenager in Depression era Chicago, he took classes on Saturdays at the Chicago Art Institute and wanted to become a portrait artist when he grew up.   His father, my grandfather, told him to get real and learn a trade.  He chose dentistry, and only later, after going to medical school, discovered that as a plastic surgeon, he could both be a portrait artist and earn a living.

Many of my artist friends do not take commissions.  When asked why, they say that it is often very difficult, if not impossible, to reconcile their own interpretation of a subject with that of the person commissioning the work.  Fortunately for me however, some do, and I have been the appreciative beneficiary of portrait work by artists such as Stephanie Snell, Paul Doyle and Marilyn Terry.  What do these artists paint?  They paint my dogs of course.  My children and I would never be able to focus and sit still for our own portraits to be painted and besides, despite this age of “selfies”, we are far too self conscious.

A few years ago, a young man’s wife developed breast cancer at age 25.  He is a well-known video artist known as Daarken and he and his wife needed money to meet their medical expenses.  An on-line fund raising auction was conceived, with the theme stated as “Beautiful Grim.”  Beautiful, because despite his young wife’s diagnosis and treatment, she was and always will be beautiful– yet for some young women with breast cancer, the prognosis can be grim indeed.  His friends and fellow artists rallied to the cause, and many contributed original works to the auction.  I am a friend of Daarken’s sister, and I followed the auction with interest.  In particular there was one painting that I kept coming back to, that no one was bidding on.  It was a portrait of an African American woman, beautiful and naked, except for her long stockings which were peppermint striped, red and white. Her hair was a tangled wild mass of curls against her beautiful skin. When no one else bid, the portrait was mine.

Over the years I have become very friendly with the artist and his wife, who shall be unnamed because of the personal nature of this anecdote.   They visited our home this past summer, and we commissioned a work of art.  The assignment was intentionally vague—“just paint something you see in New Mexico that inspires you.”  A few weeks ago the painting arrived, a full 4’ X 4’ landscape entitled “Sombrillo Vista.”  It is as beautiful as I had hoped, and emblematic of the New Mexico I have come to love.

When I called to offer my sincere gratitude, the artist’s wife said, “You know, just after he finished your painting he received another commission—a most unusual one!  A man called and said he wanted a portrait painted of his ex-wife. He is still in love with her and wants an oil painting to remember her by.”  Apparently he had sent a few snapshots of his ex along with his request.  Always a romantic at heart, this struck me as both somewhat insane, but also a true romantic gesture.   I said, “Send me a phone pic of the work in progress.  I want to see the woman who inspired this act of unrequited love.”  She did.  The woman was indeed beautiful, and playful, and mysterious all at the same time.  I said, “Well if the ex-husband doesn’t like the portrait, let me know because I will buy it.”

Shortly after our conversation, a photo of the unfinished work was sent to the hopeful ex-husband.  He liked it a lot, but he felt that it was not quite there yet.  He had some advice for the artist– he said, “Just think—complex and Mona Lisa eyes with a dash of mischief and you’ll nail it!”  I laughed and said, “Now that should be simple.  You know, just be Leonardo da Vinci.” The finished portrait was unveiled to the good patron last week who promptly proclaimed, “It gave me goosebumps!”   The man likely needs a good therapist instead of a portrait of his ex.   But let us be clear:  he has been faithful to her, in his fashion.  And my artist friend, well—clearly, he NAILED it!

You Know You’re at a Plastic Surgery Meeting When…

My friend Dawn and I recently attended an evening meeting of the Houston Society of Plastic Surgeons.  Since we were invited guests, and not plastic surgeons, we didn’t stop on the way into the lovely formal dining room to pick up our name badges because the organizers had not made them for us.  On the way out, however, we both noticed clear plastic perfectly formed oval objects sitting on the table, looking for all the world like crystal paper weights.  I picked one up and it slithered out of my hand, slippery as a water balloon.  It was then that I realized that the beautiful paper weight was indeed, a silicone breast implant made by the company that sponsored the dinner.  After all, what do you expect when you attend a gathering of the plastic surgery clan?

I have learned in medicine to expect the unexpected.  The reason that I got in my car and drove 970 miles from Santa Fe to Houston was that my father, now nearly 91 years old and an emeritus Professor of Plastic Surgery at Baylor College of Medicine, had been asked to give several lectures as a visiting Professor for the residents and fellows in training.  Several is a bit of an understatement.  He was actually asked to give five separate talks, including three on consecutive days at 6:30 am, because as we know, surgeons start their days early.  After assuring Dad that I would not be getting up to attend ANY 6:30 am lectures, I set out for Houston in the midst of some of the worst rainstorms and flooding seen in that town in over thirty years.  Dad has had to curtail his practice over the last few years due to significant health issues, and when he came down with a bad cold days before the trip, I tried to no avail to convince him to stay home.  He of course wouldn’t hear of it.

His assignment for the evening lecture last Thursday night was to talk about his surgical missions overseas to repair cleft lips and palates, other birth defects, and contractures due to severe burns and other injuries. Especially since he retired from active practice, he has participated in several trips a year with Surgicorps International, traveling to Guatamala, India, Bhutan, Viet Nam, Zambia and other countries to attempt to give a normal appearance, and thus a normal life, to those unfortunate enough to require his services.  Devoted parents travel great distances to wait all day for their children to be evaluated, and once the schedule is set, surgeries proceed for the next 7 to 10 days, twelve hours a day, until the work is done.  Dad methodically showed the construction of each trip, from soliciting donations, to transporting equipment, to evaluating prospective patients, to post-operative care. At the end of his talk, he showed a blurry photograph of a 43 year old man who had lived his entire life with a severe facial deformity.  He told us that when the patient woke up in the recovery room, the first thing he asked for was a mirror.  When he saw his own face, swollen from surgery, but yet distinguishable as a normal human face, this patient burst into tears.  As my father told the story, everyone in the room did the same.

Plastic surgeons often get a bad rap.  In our youth driven, appearance conscious world, it is all too easy to make jokes about their bread and butter cosmetic work—the breast implants, the face-lifts, the nose jobs, and the botox.  At dinner last Thursday night, my friend and I, and the residents in the room, were privileged to catch a glimpse of what these talented surgeons can do to change the life of a child, and that child’s family and future.  The residents in the room are lucky—in a few years they too will have the skills to give the gift of a normal appearance and normal function.  As for me, well, I think it’s time to get back to work treating cancer patients.

And Speaking of Plastic Surgery

I have a new favorite doctor show, “The Knick” on Cinemax, airing on Friday nights.   The show stars Clive Owen as the charismatic cocaine addicted Chief of Surgery Dr. John Thackery at a fictitious New York City hospital called The Kickerbocker at a time when surgery was one foot out of the barbershop.  The tagline is, as they say, priceless– “Modern medicine had to start somewhere.”  On the third episode, last Friday night, Dr. Thackery performs a pedicle skin graft from the upper arm to cover a gaping hole in a woman’s face where her nose used to be, before she got syphilis.   Back in those days, this was a marvelous feat.  Real progress in what we now know as reconstructive surgery didn’t come until the end of World War I, when Sir Harold Gillies, a New Zealand otolaryngologist later known as the “father of plastic surgery,” established the first hospital ward for the facially wounded in Queen Mary’s Hospital in Kent.

For over fifty years, I have been a bystander to the evolution of plastic surgery.  As a teenager I remember the heady early days of microvascular surgery—my father, Dr. Melvin Spira reattaching the scalp of a man whose hair got caught in machinery, then the tales of sewing back severed fingers and ultimately entire limbs with gradually improving functional results.  In the 1970’s the great French surgeon Dr. Paul Tessier, pioneer in techniques for cranio-facial surgery to correct birth defects came to the United States to teach, and I remember a Saturday morning clinic at my father’s office, where mothers whose children’s facial deformities were so severe that these kids had, literally, never seen the light of day waited in line to be seen by the great surgeon who could give them back a normal appearance, and thus a life.

Plastic surgery, like my own specialty of Radiation Oncology, has become one of the “lifestyle” specialties to which medical students aspire, particularly those with an artistic bent and good hands, and for good reason.  Cosmetic procedures are highly reimbursed, and are done during “regular” working hours. Walking around here in San Diego and Los Angeles, surely two of the plastic surgery capitals of the world, it’s easy to spot who has had “a little work” done.  Having one face lift might be a good thing (I wouldn’t know because, as I’ve covered in previous blog pieces, my imagination runs wild with the possibilities of complications and I am far too chicken for elective surgery), but have three and you become one of “Our Ladies of Perpetual Surprise”, eyebrows at the hairline.  Same goes for breasts—it is not normal for the “girls” to be rigidly immobile as their owner pounds away at the Stairmaster.

Last year I mentored a medical student who had started his medical education thinking that he wanted to become a plastic surgeon.  After a beloved aunt developed breast cancer and needed radiation, he started to think that perhaps he would rather become a radiation oncologist because he enjoyed dealing with cancer patients.  He was an outstanding student, and I was quite sure that he would be accepted, and do well in either specialty.  I assured him that with his gifts, and his compassion, he could combine his interest in helping cancer patients with his interest in reconstructive and restorative surgery. Residency interviewers for plastic surgery residencies have a difficult job these days: all of the applicants SAY they want to do reconstructive surgery, but most end up doing cosmetic work.  Apparently my student was convincing when he said he wanted to do plastic surgery to help cancer patients.  He started his plastic surgery residency at Stanford last month.  Dr. John Thackery of “The Knick” may be fictional, but I hope that my student leads the way in new innovations in reconstructive surgery.  My cancer patients may depend on it.

You Can’t Keep A Good Man Down

It’s been awhile since I got my readers up to speed on the adventures of Dad.  For those of you who are new to this blog, my father is a plastic surgeon who retired from full time practice about 15 years ago after a very successful academic career.  He turned 89 years old in July and the last couple of years have not been kind to him:  my mother passed away in January of 2013, and shortly after that Dad had an aortic valve replacement followed eight months later by a hip replacement.  These surgeries were in addition to coronary bypass surgery ten years ago, a splenectomy a few years later necessitated by his penchant for running red lights, and a badly fractured collarbone after taking an expert ski run a little too fast at age 85.  Despite all of this, I was not surprised when he told me a few months ago that he planned to go to Guatemala last week with Surgicorps International, a group that performs plastic and reconstructive surgery in developing countries.  What DID surprise me however was his announcement that he was taking his 84 year old girlfriend Evelyne with him.  He was positively gleeful—he proclaimed over dinner that he was going to teach her to clean instruments and prepare the OR between cases. I did not think this was a good idea, and my opinion was backed up by my sister who has never been a big fan of medicine in general, blood and guts in particular.

A week after the big “reveal”, I took Dad aside and told him that while I had no objections to Evelyne accompanying him on the trip, I thought it was a TERRIBLE idea for him to consider taking her into the operating room.  I said, “Dad, Evelyne was a piano teacher, not a nurse!  And don’t you remember what happened the first time you took ME into your operating room?”  He remembered.  I was seventeen years old, a high school student mildly interested in medicine, at least to the degree that I was volunteering at a local hospital as a candy striper (do they even have those anymore?). He invited me to watch a face lift, being performed under local anesthesia.  I was fine for the first 30 minutes or so—the slice of the scalpel, the smell of the Bovie, the careful undermining of tissue between the skin and the soft tissues of the face.  But when he then peeled back the loose skin to reveal those sinewy muscles below—well, the last thing I remember hearing was—“QUICK!!  Somebody catch her!”  I fainted dead away.  I could only imagine poor Evelyne doing the same, and cracking her head on the instrument cart.  Dad smiled and nodded.  A week later he announced that they had driven to San Marcos so that she could pick out scrubs.

Dad and Evelyne returned home from Guatemala on Saturday night.  On Sunday afternoon, I went over to their senior community to return their cat, whom I had been keeping during their trip.  Well, actually it’s my daughter’s cat, but that’s another story.  I loaded kitty into his carrier, and the litter box, the unused kitty litter, the big bag of food, the two stainless steel bowls, and numerous cat toys into the back of my car.  I called and gave Dad the 15 minute warning:  “Meet me downstairs because there is too much for me to carry.”  He dutifully met me in the parking lot, but there was still too much paraphernalia.  I said, “I’ll just run the cat up to Evelyne’s place.”  So I did.  I knocked on the door, cat in hand.  No answer.  I rang the doorbell.  No answer.  I knocked again, louder.  Still, no answer.  I dropped the cat carrier and ran back downstairs.  I said, fearing the worst, “Dad, when was the last time you SAW Evelyne??”  He said, “Last night—why?”  I said, “She’s not answering the door.”  He said, “Well, I think she’s been on the phone for a long time.  I keep calling her but the line is busy.”  At this point, I am completely unhinged.  I said, “DAD—SOMETHING COULD HAVE HAPPENED TO HER!!!!  WHAT IF SHE IS UNCONCIOUS AND DROPPED THE PHONE??”   At this point, even he is looking a little scared.

I ran back upstairs.  The cat is meowing in his carrier.  I knock, no, I BANG on the door shouting, “Evelyne, it’s me, come to the door!”  I ring the bell again and again.  And finally, I hear stirring and a small voice inside the apartment.  Evelyne appears at the door, a little bewildered that I have made such a fuss.  She says, “I’m sorry.  I didn’t hear the door.  I’ve been on the phone all day, telling EVERYONE about my adventure!”  As I sighed with relief, I said, “Oh, you enjoyed yourself?”  She said, “It was the greatest experience of my whole life.  I even got to see a gall bladder being removed.  And when they cut open the gall bladder, I got to see REAL gallstones!  I had to call everyone I know and tell them ALL about it.”  She looked exhausted, and utterly triumphant.

Needless to say, they are already planning to go with Surgicorps to Viet Nam in October.  At age 89, he has found a soul mate.  And at 84, she has found a new calling in life.  There’s hope for the rest of us, for sure.  We’re planning one heckuva ninetieth birthday party for him in July.  That is, if his schedule permits.

The Good Books

Where I come from, when most people refer to The Good Book, they are referring to the Bible.  This is not true for my father, because to him, the Good Books are something else entirely.  He describes a scene early in his career as a plastic surgeon, when he had taken his doting mother to see his new office. Coincidentally, a lovely thank you note had just arrived from one of his patients.  He read it appreciatively and passed it on to my grandmother, so that she could “kvell” over her son the doctor even more, as if that were possible. His secretary, having a penchant for scrapbooking and noticing the mutual positive reinforcement going on, decided that from that day on, when Dad received a thank you note or letter of appreciation, she would put it in a scrapbook, which he anointed as his “Good Book.”  By the time he retired from full time practice at age 75, he had accumulated a series of five very thick Good Books.  And he advised me to do the same.  He said that when he felt tired or depressed, he would read his Good Books and feel revived.

I’ve never been as organized as my father, who keeps meticulous files on everything that interests him, to this day.  Nor, as a young female physician just starting practice in the early 1980’s, did I ever have a secretary that I would DREAM of asking to “scrapbook” for me, much less bring me a cup of coffee.  But I had many appreciative notes from patients, and I read and treasured each one.  I put them in the top drawer of my desk, and would reread them when I came upon them while searching for a highlighter, or a directory of local doctors.  And when I left that particular job, or that particular city, or that particular office, I would read them one more time, remember the patients who wrote, and let them slip into the recycle bin.  There’s only so much you can take with you, apart from the memories.

Exactly two weeks ago, I received a letter at my office addressed to me personally.  The letter originated in Bradenton, FL where I know no one. I did not immediately recognize the name or the return address, but I opened it and read:

“Dear Dr. Fielding:

It has been 25 years since I completed treatment by you for Stage 4 Hodgkin’s Lymphoma.  I came to the Leonard Morse Hospital from Turkey with a tumor in my chest.  I was treated by Dr. Jao and referred to you for radiation therapy.  My treatment included radiation therapy and chemotherapy from November 1987 to October 1988.

I will always remember that when I would meet with you during my radiation therapy I usually felt “lousy.”  You would come into the exam room and tell me I looked great.  Your positive and caring manner always lifted my spirits and renewed my confidence that I would overcome Hodgkins.

I retired in 1995 and have enjoyed good health and my retirement in Florida.  Your caring and medical expertise saved my life and I am forever grateful.  I thank you and wish you a Happy New Year.    Sincerely,  RB.”

The letter was accompanied by a photograph of my patient and his wife, riding gilded carousel horses on a merry-go-round, hands held high to reach for the golden ring.  They appear to be very happy.

I have been thinking a lot lately about retirement myself.   There are places I want to go, people I want to see, and things that I want to do while I am still healthy enough to do them.  When I got home the evening I received that letter, I showed it to my husband who said, “I bet you won’t want to retire now!”  I thought about it for a minute and said, “No, you are very wrong about that. That letter made me cry, but not because I want to continue to do radiation therapy forever.  It made me cry because it made me feel that what I have done since I graduated from medical school in 1978 was worthwhile.  That it MEANT something. That I have not wasted my time.”

To my patients who have taken the time to write over the years—you have no idea how much that means to us doctors.  To my daughter, struggling through a tough internship year in Boston, and to my medical students—stick with it.  Thirty years from now you will be very happy you did, with or without some Good Books of your own.

Back In The Saddle

An email from a reader early this morning reminded me that I have not given my Crab Diaries an update on the adventures of my eighty-eight year old Dad.  The story left off on our trip back from Aspen, Colorado where we held a memorial service for my mother on September 29.  The thin mountain air had proven too much for him, necessitating a mad dash to Denver to get him down from the altitude.  He was mighty tired after that journey, and cancelled a trip which was to have taken place the following weekend for a reunion of his old “travel club”, a group of plastic surgeons, most of whom are quite elderly now, who have been getting together once a year for at least the last forty years to teach one another while having fun in remote locations. The destinations have grown decidedly less remote in the twilight years, and while I was sad for him, I agreed that a trip to Chapel Hill, NC was not in the cards.

So you can all imagine my surprise when he announced, a week after the cancelled travel club excursion, that he was “still going to Viet Nam.”  Say what?  I knew that Surgicorps– the volunteer group of plastic surgeons, nurses, physical and occupational therapists and lay support team that he has travelled with for years– had a return visit planned to Ho Chi Minh City from November 1 through 12, but I was unaware that he had bought tickets.  His seven hour open heart surgery to replace a stenotic aortic valve was only this past March.  He swore that his cardiologists had given him the “ok” and I realized in short order that there was nothing that my sister or I could do or say to keep the man at home. I committed to an early morning wakeup last Friday to drive him to the airport.  As he walked with his suitcase to the car, I noticed that he seemed short of breath, and I said, “Dad, you really don’t have to do this—you have nothing to prove anymore.”  He insisted that he was “fine” and that “this is a test—to see if I can still do this.” For Dad, life is just a series of unending “tests” and he hasn’t failed one yet, unless you count hypoxemia at altitude!

A week later, I got this brief email:   “Hi…….everything is good. We have four long operating days…many cases…incredible variety.  I’m enjoying myself immensely but my hip is a big problem.  Definitely plan to have surgery when I return.  Cannot sightsee because of the need to walk long distances. That’s OK as I’ve already seen most everything.  Food is incredible…hospital puts out a feast for lunch!!! Hope all are happy and well. I am upgrading my return air ticket. Off to happy hour!!! Love….Dad”

According to the Surgicorps Facebook page, the team has now completed fifty eight surgeries in five days.  On Monday they will do their all day follow up clinic and then the plan is to depart for home.  In the meantime, Typhoon Haiyan has decimated the Phillipines, and is headed straight for Viet Nam.  There will be widespread flooding in the low lying areas of Southeast Asia.  I hope that the team will be safe, and that the populace has ample time to prepare.  Knowing my father, ever the optimist, I can only imagine that he is congratulating himself for his recent swimming workouts and thinking, “At least I don’t have to worry about altitude sickness!”   I guess hip replacement surgery is next on the agenda.  You can’t keep a good man down.

The Adventures of Dad, Continued

If you’ve been following this blog for a while, you’ve probably figured out that my father is one tough old bird.  He was my grandmother’s first born son, and was yanked forcibly from his mother’s womb a month prematurely via a forceps delivery after her water broke.  As a result, his left brachial plexus was damaged, leaving his left arm paralyzed.  By good luck and sheer determination, the paralysis was not permanent and he went on to graduate from high school at 16, attend college and dental school, join the Navy, decide he didn’t like being a dentist, go to medical school, and ultimately become a world renowned plastic surgeon. It’s been a tough act to follow, that’s for sure.  There are two things I remember vividly from my childhood—the first is that wherever we went he was always on the lookout for imperfection in the faces of strangers, and never hesitated to let us kids know how he would fix such imperfections.  The second is that he was an artist, in real life and not just in the operating room.  In this age of computer modeling, it is hard to remember that there was a time when my father would see a new patient in an exam room, study her profile, sketch it on the white exam table paper, and proclaim, “This is how you look now.”  He would then draw an idealized portrait next to the first sketch and state triumphantly, “And THIS is how I will make you look!”  If you think there was a single patient who could resist that kind of sales pitch, think again.

If ever I was going to doubt my father’s resilience, it was this year.  When my mother passed away in January after a long struggle with dementia, he promptly went into congestive heart failure from a stenotic aortic valve.  Ten years after his coronary bypass surgery, he had a second open heart surgery to replace the valve.  When we all realized that he could no longer tolerate the altitude of his retirement home in Snowmass, Colorado, he decided to move to San Diego, living with me while we sorted out his health issues.  After the heart surgery, he began to chafe for his independence, but was also not confident of his ability to meet new people, make new friends and start over at the age of 88.  We urged him to at least try, and so, two weeks ago he moved into the lovely retirement community of La Costa Glen in nearby Carlsbad, California.  The first week was a bit rocky—at one point the community lost electricity, and I had forgotten to supply him with simple safety gear—a flashlight, some candles.  He worried that he could not remember the name of every new person he met, until I reminded him that the reason La Costa asks its residents to wear their name tags is that no one ELSE could remember HIS name, either.  Sometimes I can’t even remember my own, these days.

Yesterday however I knew he had turned the corner.  He spoke excitedly about a dinner party he attended on Friday night, and about the bridge games he was playing, and about the Great Ideas sessions that the community holds where residents who are retired from all walks of life can discuss the nation’s problems, and potential solutions.  But the truth was revealed when he whispered conspiratorially over the phone, “And a lady has already asked me to partner up!”  I said, “Partner up?  What does that mean?”  He said, “You know—each person has their own living space, but you do EVERYTHING together, meals, activities, and ….you know!”  I said, “Dad, you’ve only been there two weeks.  You are going to have to beat those ladies off with a stick!  You need to play the field for a little while before you partner up!”   He laughed.  It’s good to know that life begins at eighty eight!

There Comes a Time

Written while returning from my Galapagos trip, posting now.

It’s happening—the moment that we all dread as we age, that point in time where we realize that we are becoming our parents.  When I was a child, my father was a busy man, completing his residency in plastic surgery, establishing a practice, climbing the academic ladder.  He didn’t have much spare time for us kids, but occasionally he would make an effort to take us on an outing—the circus perhaps, or the zoo.  On those outings, I remember one thing above all.  As we walked along beside and behind him, he would methodically point out every physical imperfection he could see on passersby—a bulbous nose here, a weak chin there, a jagged scar perched on an otherwise perfect cheek or a poorly repaired cleft lip.  The world of the unbeautiful was his oyster and he knew what to do to fix it.

On our recent trip to the Galapagos Islands, I found myself scanning faces and bodies in a similar fashion, but I am no Pygmalion out to transform the luckless Galatea’s of the world.  What my roving eyes were seeing under that equatorial sun were skin lesions aplenty—a benign nevus here, a senile keratosis there, but then, more importantly, an obvious basal cell carcinoma above the upper lip of one of my fellow explorers.  And then came my dilemma:  do I say something to the hapless traveler?  Can I convey in a casual sentence or two, “By the way Joe, you have a skin cancer on your face.  You should have that looked at when you get home, but don’t worry about it!  It isn’t a melanoma, the life threatening kind of skin cancer.”  What to me is a simple helpful hint might be to my companion a bomb dropped in the middle of that peaceful archipelago.  I took the easy way out.  I exercised my right to remain silent rather than risk ruining his vacation.

There was one incident, however, on a bumpy Zodiac ride from the good ship Endeavor to our first sandy beach landing for snorkeling.  Our naturalist guide Xavier had applied a coating of zinc oxide over his nose and cheeks so thick it looked like Comanche war paint.  Yet still, that greasepaint could not disguise an obvious bump arising from his right malar prominence.  He admitted to me that his doctor in Guayaquil wanted to “cut it off.”  Quickly I motioned for my father and together we performed the first National Geographic skin examination of the tour.  As the zinc oxide was wiped away, simultaneously we crowed, “It’s benign!!!”

A day later, Xavier admitted to me that he was so relieved he called his wife and children on the mainland to tell them the good news.  Have I mentioned that dermatology was a field I strongly considered while in medical school?   Reporting from afield…. Miranda.

Cancer is Not a Lifestyle

I’m not sure when I stopped being merely opinionated, and became a true curmudgeon. But I think it was about the same time that medical students started telling me that radiation oncology is one of the “lifestyle” specialties in medicine. According to the National Resident Matching Program, this year radiation oncology ranked 5th on the list of the most highly competitive residency programs, right after (and in order) dermatology, orthopedic surgery, otolaryngology, and plastic surgery. How, when and why did this arcane little specialty become so popular?

When I left internal medicine for a second residency in radiation oncology thirty years ago, we were thought of as the weird guys in the concrete shielded basement who spent all day pushing buttons to “zap” patients with evil rays which were just as likely to kill them as to cure them. When did this all change? When I was a resident in medicine, I knew that I wanted to take care of cancer patients. I had applied for, and been accepted at an excellent fellowship in hematology/oncology. During my senior medical residency, I realized that as a cancer doctor, I should know something about radiation therapy since it was one of the three modalities used to cure cancer, along with surgery and chemotherapy. There was no elective time in my upcoming fellowship, so I asked my Chief of Medicine if I could spend a month in the basement with the weird guys who pressed buttons. In medical school then, as now, no time had been relegated to teaching medical students about the therapeutic use of radiation. He said “yes”, and the rest, as they say, is history. Back in those days we had no good antinausea drugs, and we had no medications to boost a patient’s white count after a strong dose of chemotherapy. After receiving curative doses of chemotherapy for leukemias and lymphomas, patients would spend days if not weeks in laminar flow rooms, “hot and low”, meaning febrile and neutropenic, hoping that their bone marrow would recover before infections took their lives. We were curing cancer, but often at a terrible price. In that hospital basement, the early days of breast conservation therapy for early stage breast cancer were playing out before my eyes. Happy women who had been offered the choice of lumpectomy and radiation over mastectomy cheerfully bared their breasts in follow up clinic, exclaiming “Look at THESE!” I made the leap, and never looked back. Lifestyle had nothing to do with it.

So what do dermatology, orthopedic surgery, plastic surgery, ENT and radiation oncology have in common? In the first four, physicians who choose these specialties can virtually, if they choose, limit their practices to regular hours and high paying procedures where oftentimes they are paid cash for their services. Even though it would seem that orthopedic surgeons and plastic surgeons are amongst the first responders for the so-called “train wrecks” that are brought to the ER, in reality they can choose to do only the “elective” aspects of their fields, such as sports medicine and cosmetic surgery. And we all know what Botox and “fillers” have done for dermatology—they’ve practically put the plastic surgeons out of business! Radiation oncology has the advantage of regular hours (our patients are nearly always outpatients) and high reimbursement (our medical reimbursement system is based on how many procedures one performs, and the planning and delivery of radiation are considered procedures). And if you love computer games and movie special effects, effectively hitting your “target”, the cancer, while dodging the normal tissues, that radiation beam can become your personal “Avatar” in the war against an extremely formidable enemy.

But here’s the thing, kids. In dermatology and those other highly desired specialties, you get to “hit and run”. You don’t need to follow your patients long term, unless you want to. You help them, make them beautiful, cure their acne, fix their broken bones and tendons, give them new breasts, or eyelids, or noses, or even rear ends! You give them better hearing, or better breathing, or better speech. You make them young again; you make them run again. But if you want to cure cancer, it’s a whole different ballgame. Your patients may have side effects, difficult side effects, which you must manage on a daily basis for six to eight weeks. Your patients may have late effects, years after the radiation, just when they think that life is good again and they are home free. Your patients may actually die, either from their cancer, or from your treatment.

Think about that when you think about “lifestyle” specialties. If you can live with that, and maintain a cheerful countenance with a generous helping of compassion for the next thirty to forty years, then by all means, join me.