How Old is Too Old?

Yesterday I saw a 90 year old woman in consultation.  She presented to the emergency room in September with abdominal pain, and in the process of working her up, a chest X-ray was taken which showed an infiltrate in her lingula, part of the left lower lobe of her lung.  As it turned out, there was nothing wrong with her belly, but a follow up CT scan of her chest showed this strange fluffy area in the left lung—not quite a tumor, but not quite a pneumonia either.  She had smoked for years but quit in 1980 and she had no symptoms of cough or shortness of breath.  The decision was made jointly between the patient and her primary care physician to just “watch it”.  A repeat scan was done two months later, in November, which showed that the area had “slightly” enlarged.  She was seen by a pulmonary specialist who recommended that she have a biopsy and she was referred to interventional radiologists who were asked to put a needle in it and withdraw cells for analysis.  They declined, unfortunately, citing that the risk of causing a lung collapse or bleeding was too great in this elderly woman.  The pulmonologist could have tried to reach it with a bronchoscope, but he doubted that he could—it was a little too far in.  So two months later, she was referred to me for consideration of radiation therapy, still entirely well, with no lung symptoms whatsoever–and no diagnosis of cancer.

Yesterday she and her equally intact and otherwise healthy 90 year old husband sat in my exam room as I explained to them that, while there is a high likelihood that this abnormality in her chest is indeed a cancer, to operate to remove it could be fraught with complications, even fatality, and to give her radiation without a diagnosis was equally unconscionable, given the fact that the area was very near her heart and that radiation itself can cause serious inflammation in the lung.  She looked at me without a trace of irony and said, “Doctor, all I want is another ten years.”

And there we have it.  Next week she will have a PET-CT scan to see if the abnormality is positive on PET (a clearer indication of cancer than a plain CT scan), and to rule out cancer elsewhere in her body.  If it is larger now, and PET avid, she will be referred to a tertiary care center for a specialized bronchoscopy which can reach the lesion for biopsy.  If the biopsy is positive for cancer, she will be treated with whatever modality is deemed most appropriate for her type of tumor, be it surgery, radiation therapy, or chemotherapy.  It is what she wants, and what her husband wants for her and they clearly understand the risks.  She is ninety.

People say to me all the time, “What would YOU do if this was your parent?”  The answer, honestly, is I do not know.

For Once, Then, Something

As I was leaving for Boston, I asked if anyone would care to contribute to this blog.  I am still processing the wonderful things that friends and family have sent me.  This one is from my husband.

One drop fell from a fern, and lo, a ripple
Shook whatever it was lay there at bottom,
Blurred it, blotted it out. What was that whiteness?
Truth? A pebble of quartz? For once, then, something.    Robert Frost

Our daughter is in the last year of medical school and is having a hard time deciding what career path to take. She has applied for a residency program in internal medicine, but a recent experience with her grandfather in Africa where she was able to assist in the surgical repair of a variety of physical deformities has made her wonder if a career in surgery might be a better fit.

Choosing a career is a really big deal. Since most of us have to live with the choice – good or bad – for much of our adult lives, it’s a decision not to be taken lightly. This is particularly true in medicine, where the training is long and arduous, and by its very nature is not something you want to repeat again should your first career choice not work out. Yet, there aren’t many “how to” books written on the subject, and few of us feel comfortable directing someone else along a career path that might not work out for them. So, what advice – if any – might I give my daughter?

Based mostly on personal experience and some library research I performed as an undergraduate, I suspect that many of us choose a career based on a “gut” feel. Sometimes a career just feels right. Perhaps it’s the intangibles or maybe just good fortune. I know in my case it was a little of both.

My daughter recently asked me how it was that I ended up being a pulmonary physician. The question brought to mind how many different career paths I actually explored along the way. Once, I wanted to be a psychiatrist. This was at the beginning of medical school when I was fresh from spending endless hours listening to the sometimes neurotic musing of my college friends. Hey, this was interesting and could be fun, particularly if you’re getting paid for it. So, I picked psychiatry for my first elective rotation in med school, and saw what real mental illness is like. One of my patients was a teenage girl, who seemed outwardly normal, but confided in me that she had had an immaculate conception and was going to deliver the Lord’s baby. When I asked the attending psychiatrist if there was a pill for this, he looked at me like I was the crazy one. Psychiatry was definitely not my cup of tea.

Then, I looked into neurosurgery. As an undergraduate, I did an essay on a famous neurosurgeon named Harvey Cushing. An amazingly gifted physician whose written descriptions of his patients – complete with very accurate sketches – can be found to this day on display at Mass General Hospital. It would be great to have a career like Cushing, so I signed up for a neurosurgery rotation. But, this didn’t appeal to me either. The patients didn’t improve very often, and perhaps equally as important, I just couldn’t identify with the attending neurosurgeons who didn’t appear to be as interesting as I imagined Harvey Cushing to be.

So, like my daughter I applied for an internship in internal medicine. From an intellectual point of view, this seemed like a good fit, and I did identify with the attending physicians who seemed smart and articulate. But, there are so many specialties of internal medicine; I really wasn’t sure which to choose. Then, something happened. I was reading up on a patient with an unusual lung infection when I came across an article called “In Defense of the Lung” by a physician named Gareth Green. It described the complex interplay of factors that protect the lungs from infection, and how someday it might be possible to modify lung defenses to help susceptible people actually resist pneumonia. Something about this notion resonated with me, and for the next two decades the interface of infectious disease and pulmonary medicine was my career focus.

Some people find themselves in the career they always imagined for themselves, but I wonder if this is a good thing or not. Did they get a chance to explore how other career paths might have worked out? Were they willing to experiment and take a few chances along the way? As I say, I don’t know if this is a good thing or not. It may be much easier to pick something and stick to it, like my wife has. And in her case, it has been a remarkably rewarding approach. But, I can’t help wishing that my daughter would keep an open mind about opportunities that might come along in medicine or in surgery or in some other branch of medicine. Once this happens, then it could well be that something unexpected and great will be in store for her. I hope so.

Go Ahead Kids!

Okay, I confess.  I have smoked a few cigarettes in my time.  In fact, more than a few.  While my teenaged brother was hiding his favorite smoking material  in the Encyclopedia Britannica under the letter “M” (much to the horror of my mother, who decided she needed to read up on this new scourge called  marijuana), I was trying to be the cool kid, the girl who knew how to—what did we call it?—French inhale.  The girl who watched films by Bunuel and Truffaut and made fun of the pretty cheerleaders in their short skirts.  In high school it was Marlboro Lights (I’m from Texas, surely you can understand!).  By college it was Dunhills, Warhol and Stan Brakhage, but only a half pack a day, and ONLY that much during the final exam period which required the pulling of “all-nighters” to make up for a semester of less than perfect attendance.  I have never been much good at getting up in the morning.

By the time I got to medical school, smoking was still considered marginally acceptable.  I spent six weeks on Dr. Michael DeBakey’s cardiothoracic surgery service, trying stay out of the way and not block the cardiac monitor while earnest cardiac fellows learned to transform saphenous veins into new coronary arteries. Senior surgeons would peek in the rooms periodically, pulling their scrub gowns up as shields to hide the cigarette dangling from their mouths, the ash dripping on the floor as they exclaimed, “Lord, please help this poor patient because OBVIOUSLY no one in this operating room can!” The OR lounges, where scrub nurses and residents took their breaks, were smokier than Las Vegas casinos on a Saturday night.

That all ended when I started my internal medicine residency, and fell in love with a pulmonary doctor.  One simply cannot be a smoker while dating someone whose idea of sexy is clean pink lungs without a trace of carcinogen. I quit completely in 1979.  I gave up those cigarettes and never looked back.  No, that’s not entirely true–I’m lying a little bit, we all do.  There is not a former smoker on the face of the planet who can say honestly, truthfully that they never EVER crave a cigarette.  But craving a cigarette is unbecoming of a radiation oncologist.  By the time I finished my second residency, in radiation oncology, I had seen enough lung and head and neck cancer to be permanently and forever in the nonsmoking lane of life.

Now, occasionally I have to stop at the gas station, or the pharmacy or the grocery store on my way home from work.  I see teenagers, barely “of age”, at the counter buying cigarettes and paying a lot more for them than I ever did.   I see them hanging around outside, enjoying a smoke, texting their friends.  Sometimes, in fact most of the time, I want to stop them—talk to them—invite them to spend a day with me at the cancer center up the road, where they can watch the lung cancer patients coughing up blood, or gasping for air, or wasting away from cancer related anorexia and weakness.  But I never do.  Even I know that you can’t talk to teenagers like that—besides, after all these years, I’m still a little bit shy.

At home, I still have an ashtray.  It’s a big one, blue and flat bottomed, and we use it as a candle holder because I love scented candles (have I mentioned I have four dogs and a cat?)  It was given to my husband by his college friend Garry Trudeau, creator of the Doonesbury comic strip.  On it is a picture of Mr. Butts, Garry’s fictional advice giving cigarette caricature, spouting his words of wisdom to the youth.  Mr. Butts says, “Go ahead kids.  You’re immortal!”  Would that it were true.