Thursday, February 26, 2015

I held my breath and you said something

Once upon a time, and it feels very much like a once upon a time situation in the sense of how far back (but not really, not really), I lived in a breathtakingly beautiful city. Inescapably beautiful. Punch-you-in-the-face, Tim-Riggins, Jordan-Catalano beautiful. My daily drive to and from work was an art school short film.

When you live in such a place, I think you tend to become lazy. You are used to the constant assault of picture perfection. Just before I left, I could walk down the street without being knocked off my feet. In the beginning, I remember talking with my brother at a rooftop party in San Francisco and blurting out, waving at the vistas all around me (and admittedly a little better with the help of spirits), "I think we've found the promised land!"

Which, in retrospect, is interesting, because it wasn't the promised land at all. It was a perfect moment. There is no promised land, I'm sorry to say. But there are perfect moments. Some of them are big. Like when you say goodbye to your best friend in an airport in Germany and know you'll never be close again. Or when you graduate from college and there are bubbles in your chest that are a mixture of nervous anxiety and optimistic excitement. When you hold your niece for the first time. When your cousin, after just doing something amazing, tells you that your support and encouragement inspired him towards that. When you make the decision to completely overturn your life to pursue a pipe dream and that moment that you realize the dream is going to come true. A first kiss. Then that first, intentional kiss. A perfect night out on a New York summer night. Sitting around a fire in the middle of nowhere in Maine. Standing over a roaring waterfall in Argentina.

There is a lot I don't have in my life. But sometimes we miss the trees for the forest. From the outside, perhaps it seems I don't have very much. And yet if you strung together all my perfect moments, it could be just as beautiful as the fog settling over the Golden Gate Bridge on a perfect San Francisco fall morning.

In San Francisco, the beauty was blatant and intentional. I loved it. I'm not sorry. But I realized that there are other kinds of beauty. Believe it or not, New Jersey was beautiful back when I lived there so many years ago (and probably even now). And where I live now is very much the same. It is easy to overlook. When I first moved here from San Francisco, I just viewed it as a means to an end. Good enough, but nothing special.

I don't feel that way anymore. It's not a beautiful place. That is true. But yesterday, I realized a cherry blossom tree has been growing in my front yard for the last three years and I never noticed it until then. In the fall, little yellow leaves gleam against the sun and sprinkle down onto the sidewalk on my way to work. In the heavy rains, everything turns a deep shade of green. Today, when I was walking home, another day of working late hours and not getting home before sundown, these very large dark trees waved out to me against the midnight blue sky. And it's not a beautiful place. But it will do.


Once upon a time, and this really was once upon a time, that far back, so far back that sometimes I can't believe I've been alive long enough for it to have been that far back, I used to get these letters (paper letters, no less) from the love of my life. Or what I call the love of my life, but I'm not dead, so who knows, that remains to be seen. We were all angst in those days, and back and forth's of what if's and maybe's and if only's. He was a very good writer, and I blame (or credit) that as to why I fell so hard for him. He had that Hemingway economy; he could explain better in five words what I couldn't quite put my finger on in five hundred. Once he wrote me a letter, and I don't honestly remember what it was he was turning over in his head or confessing to me. It was something that at the time twisted my heart in knots, but now it just seems likely to have been variations on a theme of wanting something to work out that was never destined to work out. He wrote some very anguished lines, the specifics of which I don't remember.

And then in the next paragraph, probably more to himself than to me, he wrote, "Pause. Take a sip of tea." And the entire tone of his letter changed after that.

Such a stupid, simple little phrase. Sometimes I don't actually fix myself a cup of tea. But I think of that saying all the time. I sometimes think he was put in my life just so that he could deliver that line. For lo and behold, I can be the queen of hyperbole and overanalysis and anxiety. I used to get crippling stomach aches when I was a child from just the thought of going to school. And every once in a while, I get into such spirals. A shame spiral, or a rage spiral, or a stress spiral, and I think the sky is going to fall on my head, and I hear this violent crescendo leading up to some fatal moment.

Then I take a slow, deep breath, let it out and calm myself. It's not always a cup of tea. Sometimes it's Dylan telling me, "all you can do is do what you must." Sometimes it is going to bed and forcing myself to believe that tomorrow is another day, another chance. Come to think of it, he and I read Candide together in college, and I don't know if all is for the best in this purportedly best of all possible worlds, but I do know that taking a breath, pausing, taking that sip of tea, it's a good way to cultivate your gardens.

Thursday, February 19, 2015

endless numbered days

I feel this every day, but some days I feel it more than others:
"For it is true we can seldom help those closest to us. Either we don't know what part of ourselves to give or, more often than not, the part we have to give is not wanted. And so it is those we live with and should know who elude us. But we can still love them - we can love completely without complete understanding." - Norman Maclean
Sometimes my heart feels so full and at the same time so useless.

Tuesday, February 10, 2015

destroy the middle, it's a waste of time

I'm having another one of those episodes.

I am not posting much these days. Work is exacting an impressive toll on me, more than I thought it would. The other day, I realized I don't have a lot of patience for drama in my social life because work is enough of an emotional rollercoaster. I almost cried in a patient's room (and for the record, in case it's not been made clear before, I usually have non-functioning lacrimal glands as a general rule. I remember one time I was upset about something personal, and tried to cry, thinking it would help to let it out, and nothing happened) because she said she felt badly about being nervous about undergoing a stem cell transplant. The woman is in her late 20s, has 5 children, had a full-time job, and developed acute myeloid leukemia, and after she managed to get a remission, she relapsed just as she was getting lined up for a stem cell transplant. It's fine to write it like that, and make it sound like it's all happening to her. After all, in the end, it is all happening to her. But she was 25 weeks pregnant when she first came into the hospital, and I was the one who got to tell her of her diagnosis. I got to explain the not-benign chemotherapy regimen and its side effects, which we administered to this woman while she was pregnant. I got to tell her that her the good news that her repeat bone marrow showed no evidence of leukemia. I waited it out with her from afar as she delivered her baby and then I'm the one who got to rip her away from that new baby to give her consolidation chemotherapy to keep her leukemia away. I'm the one who got to arrange transfusions for her when she finally got home. I'm the one who got to discover that she had an allergic reaction to transfusions and needed a special suspension of platelets to keep from having hives and rigors. And I'm the one who got to tell her that the leukemia was probably back. And now it is, and she is getting chemotherapy again, and she tells me she is nervous. I involuntarily laughed and then choked up all at once. It was highly unprofessional but she didn't mind. I  told her it was okay to be nervous- her doctors are nervous for her and we're not even the ones going through it. We had this uncomfortable moment of silence in which it was clear we just were no longer doctor and patient- it's an odd thing when you cross over like that. All of a sudden, we were in a different territory. Two people navigating a difficult journey together, different stakes, different roles, but both in it, all the way in it. And I knew, just at the same moment, that this was very dangerous. So yeah, I don't need a lot of drama with this sort of thing a natural byproduct of my career (which doesn't even feel like an appropriate way to describe my job, but it would be pompous to call it anything else).

And I find, yet, that I have capcity for so much rage still. About stupid things (like television shows, and I have since deleted that portion of this post, because after posting it, it suddenly seemed stupid and unimportant) and horrible things, like three innocent people getting shot in North Carolina, one Indian grandfather being injured in an arrest, and the disturbing fact that the man was stopped because he was mistaken for a black man (thinking about the reality of what that means enrages me on so many levels that I have to step away and take a deep breath). But all that rage gets quelled by the sad realities that I often see with this work- sudden deaths or long, drawn-out expected deaths. I treat cancer patients so they know what they're contending against, but it doesn't make it all that much easier. Life is short, and precarious. The world tends towards entropy. I wish we didn't have to contribute to that entropy but sometimes it's important to shift the focus to what you can't control. I am going to strive to do better.

Tuesday, December 30, 2014

better be home soon

I feel this big shift. It happens, not commonly, but it happens, in time. The plates move, and the tides turn. I hit a real low recently and thought I had made a lot of bad decisions in my life - maybe it was time to regret everything, and give into the very real temptation to wallow in misery.

Unhappiness is not the same for everyone, it really isn't. For me, it's not a sustainable condition. When I really feel unhappy, really (not ennui, not melancholy, not a moment of navel-gazing overanalyzing), I cannot be in that state for very long. It is not productive, it's almost paralytic. Yet it's also not, because it pushes me into reexamining the whole of my situation, because there is only one direction to go from there. Well, there are two directions to go, but only one that I can afford nowadays. At a certain point in life, you simply no longer have the luxury to go further down, darker, deeper. Not that you can always avoid it. But I know some years back, I could have looked at this point and seen it as a choice.

Now it is a matter of figuring out how to make that shift. That part used to be easier. Sometimes I yearn for the naivete I used to have. The business of getting yourself on the right track, it's more complicated than it used to be, when you're stripped of the notion that everything will work out. Not everything, in fact. So then, you have to figure out what needs to work out. If you can figure out what realistically needs to happen, it can in fact happen. That part does feel certain.

A family member recently wanted to get me something- this family member has a habit of making big purchases as a way to demonstrate affection. And it's not for me to judge, because I have my own odd ways of expressing (or not expressing, regrettably) my feelings. But I really thought about it, and the problem is, I don't want anything like that. I don't have an iPad mini or an iPhone 6 or an expensive pair of shoes, but it's not really because I can't afford it. Fellows get paid a measly sum but I don't really have much cause for spending, so I am not holding my breath to make ends meet. But what I don't have that I really crave, that I never appreciated until I became a physician, is time- which I know is awfully cliche to say. It is the end of the year, and when I fell down into the hole where I often find myself in December, I realized the real problem was that I just didn't have the time to scrutinize my life for long enough to determine what needs to change. But I guess that's the thing about time though. You have to make it - sometimes conjure it up even, if necessary.

Saturday, November 22, 2014

just for a moment, let's be still

Lately I have been thinking that I could just start a blog called "this week in heartbreak" based on my job. For example, this week's contenders would be:
  • The elderly man who has leukemia that just won't respond to any therapy, who is universally adored in our unit. I had to perform a bone marrow biopsy on him this past week and he thanked me and told me I did a good job. Also every time I go to see him, he always says he is glad to see me.
  • The couple who are in their 70s who sit side by side in the hospital room, like they are trying to reenact those scenes in When Harry Met Sally where elderly couples recount how they met. They met in Staten Island, childhood sweethearts.
  • The woman who was just diagnosed with breast cancer, who I met in my clinic for the first time yesterday, who ended our clinic encounter with "I am so glad you are my doctor." This was particularly heartfail material because about forty five minutes prior, I was seriously considering quitting due to not feeling good enough.

But I can't write about such things without it sounding awfully schmaltzy. I love, love, love my work, but at least once a week, more often multiple times a week, I question my competency. Everyone tells me it is the nature of the beast and all that, but it chips away at me, and usually by the end of the every week, I have a pit in my stomach and feel doomed.

Which is why, on my day off, I often find myself trying to do something in the kitchen. Because that's a place where I've spent a lot of time over the years. I don't follow recipes well, and I don't write down a lot of the details of how I make things, but most of the time, I can still produce something salvageable. And when I really want to feel accomplished, I make caramel. I have written about why it is therapeutic to make- it requires undivided attention and a feel for things. You can't daydream about chemotherapy regimens and lab results while you are making caramel, or that bastard will turn on you and take you down.

And now it is fall, and it is the season for caramel and all things apple. Last week I experimented on my day off and made a cake with grated apple and roasted sweet potatoes. It was okay (mostly because I covered it in brown sugar frosting), but it was not a keeper. Last year, I used smittenkitchen's recipe for apple cider caramels. I tinkered with it, but not much, because her recipes are fairly airtight. Those were tasty caramels but they were the kind of caramels you wrap in waxed paper and give your friends, and they love you forever. So, you know, kind of perfect. But I was not trying to make those types of caramels today. I wanted a caramel sauce. And I also did not feel like dealing with a candy thermometer.

Making this sauce was a process. First, I had to boil down 4 cups of fresh apple cider until it's about 1/3 to 1/2 cup. Then I deviated from the recipe, so all hell broke loose. But it's also different when I am in the kitchen, because the only downside of failure is a waste of perfectly good ingredients. So I just plugged away and sure enough, I managed to make a thick, apple-intense caramel.

On my next day off, maybe I will figure out what to do with it.


To switch gears a little, in my last post, I was writing about how the choices we make come with a price and we have to pay for our dreams, and the artist formerly known as piedpiper pointed out that this is more of a universal plight than I had perhaps suggested. He is right. And I was reminded of it this week, because someone very near and dear to me came out of the closet. It broke my heart a little that he felt he could not tell anyone sooner, and it was heartrending to hear that his family had put a lot of pressure on him not to tell anyone about it. He sounded so happy when he told me, and I realized how this must have weighed on him for such a long time. Already, he is having to pay a lot and in his case, it is not even a dream he is living, just his life.

Wednesday, November 12, 2014

good is better than perfect

Sometimes, this work gives one pause. Okay, not sometimes. All the time. But for different reasons, at different times. Sometimes, it's the work itself, sometimes it's the system in which we practice, and sometimes it's the repercussions of the work.

There are some matters which I find difficult to articulate for two distinct reasons- 1) it is so specifically personal that I am not sure I should be sharing it and 2) I have an irrational fear of being misunderstood- irrational because who cares and also hardly a handful of people read these words and most of them are fairly non-judgmental types.

For several years in this blog's history, actually, I wrote in an abstract away about this Goal I had, this big dream I was pursuing, and I knew, even as I was writing about it, that it would be a letdown when it was discovered that all I wanted to was become a physician. In some ways, the most unoriginal idea a brown nerd could dream up, really.

So I have no coolness factor. Oh well. That is no surprise, that has never been my area of expertise. What I did have was a deep certainty that I was doing the right thing for myself. And it is a good thing I did, because it was a long play. I mean, a longgggg play. Studying for the MCAT (while working full-time), going to medical school and 'carelessly' tossing away many of my savings in the process, three years of indentured servitude as a resident, all to get to this point.

All for the privilege of treating cancer patients. And it is a privilege. I can say that without a doubt, without reservation, and there are days when my rib cage feels like it is going to crack wide open from how full I feel from the satisfaction of this work. That is true.

But here is what is also true. This choice has cost me. It has cost me money, that is probably the most trivial of the losses. It has cost me friends. It has cost me family. It has cost me my own health. These are things we joke around about as physicians. But these are very real losses, and they exact a price that cannot be quantified and cannot be recovered.

Many, many years ago, I was still trying to figure all of this out, what I was supposed to be doing with my life. I knew I was not supposed to be working in a chemistry lab synthesizing molecules someone else told me to make. So I thought what I needed to do was get my PhD in chemistry. I started working on a research project in my spare time, after work and on the weekends. And I will never forget that my friend K casually remarked that she had stopped inviting me to things because she figured I would be too busy. It crushed me. I suddenly felt like I was really missing out, like the sacrifice of trying to pursue my PhD was too great to give up happy hours and weekends with my friends.

I trusted that feeling, I trust it still. When I decided to go to medical school, I kept giving things up, one by one, and it was frighteningly easy to do. Some of it is by design. Medical school is a wrecking ball, is a cult, is the Borg, is a hurricane. Medicine is a tidal wave that sweeps you out to sea, you drown and after a while, you learn to breathe under water, that is what I think.

This past weekend, after a particularly taxing week that made me question my stamina to complete fellowship and come out of it a competent oncologist, out of the blue, two friends of mine from the east coast texted me. They were drunk at a pub crawl. An annual pub crawl, a pub crawl I used to attend with them, many a year ago. They were planning an impromptu trip to New Orleans, and did I want to come?

Yes! I wanted to go. I missed them. I missed the outside world. My patients make me miss the outside world when I talk to them, and they tell me about their trips and their family and their dogs and their hobbies. They remind me of all the things I have set aside. So I wanted to go, and I cheerfully suggested February, when I had the sort of schedule that would allow me to take some time off.

My friends thought this was funny, and pointed out they were thinking more like next weekend. I had forgotten the meaning of impromptu, see. There is little in the way of spontaneity when you are a fellow. You have a schedule and you have responsibilities. They suggested December, and I thought about the patients who were scheduled to see me then. I am their doctor. I have obligations.

Everyone has obligations. Children. Pets. Mortgages. Everyone has them in some form. This time, I was not crushed when I told my friends I could not escape to the Big Easy on a moment's notice. I was sad. Because I miss my friends, and in an ideal world, I would love to be able to take off with that kind of spontaneity. But dreams have a price, and I knew, right from the start, that I would have to pay. So I have. And I will not apologize for that. As I have stated, there is nothing I want to do more. If I won the lottery today, I would do exactly this job. It is an obligation, this work, but it is a responsibility I have wanted, a purpose I have craved. I cannot pretend to regret that.

But what I will do is try. Not try 'to have it all' because I think that is a dream that we are fed to feel constantly like we are not succeeding, like we are something less. There is no having it all, there is no balance. Life is too messy for that, and chemistry has taught me that equilibrium is a dynamic state, that we are constantly being pushed in one or other direction away, but there is a pull, and it is not a pull away from the center. So I am just going to try not to let go of everything, not to be quite so weightless. I am going to try to find that steady state.

Saturday, September 27, 2014

caught between the scylla and charibdyes

A patient of mine- and now I really know what it means, for a patient to be mine, because he is mine, my responsibility more than anyone else's- came to my clinic yesterday, huddled in blankets and pale and miserable. He had been discharged from the hospital less than a week prior, and had a terrible hospital stay. He has a fairly rare tumor, and he was admitted to the hospital to undergo a cycle of chemotherapy, but ended up staying in the hospital for nearly a month because of a number of complications.

I was supposed to see him to assess whether he was ready to be admitted for another cycle of chemotherapy. I had seen him two weeks before, and he was not crazy about being stuck in the hospital, but he was smiling and joking around and frequently holding my hand. Yesterday he was irritable and weak and growling about not wanting to go back to the hospital.

In clinic, you're always on a schedule. There are always patients waiting to be seen. There is always a tightrope of trying to be present, mindful in the moment of seeing a patient, give them your undivided attention, but keep them focused enough to not fall far behind schedule. Then a patient sits in your office looking miserable, with low blood pressure, a fast heart rate, and you know that your afternoon is about to be derailed.

But that would be fine. With the help of one of the nurses, we cajoled the infusion center into giving this patient IV fluids, an attempt to stabilize him so that he could avoid being hospitalized for the day at least. An hour later, I checked on him between patients and he was feeling a little better. And then we had what I can only characterize as a futile conversation.

He was looking at me like I was plum crazy when I broached the topic, and I didn't really blame him. But his situation is so complicated that we are stuck trying to make impossible decisions- subject him to the brutal chemotherapy regimen that clearly causes him problems, or let a very aggressive tumor continue to impinge on some rather vital organs. This is the conversation we have with cancer patients all the time- it's the 'how do you want to die' conversation and it's the hardest of conversations, especially when you're in your first year of fellowship. It's a difficult conversation to have when someone is feeling well. When they're feeling this poorly, it's very nearly worthless.

A lot of people view medical oncologists as chemo-pushers, as physicians who will administer toxic medicines to their patients even if they look and feel terrible. I don't view myself that way. I have no aspirations to become that sort of physician. I don't believe in treating patients with medicine just so that you feel you are doing something. There's a saying one of my former attendings used to quote- when in doubt, do nothing. And I stand by that, usually.

But here in the grey zone, in the alleged cutting edge, it's not so much doubt as uncertainty. We're supposed to weigh the risks versus the benefits of providing a therapy. Many times, that is an easy decision to be made, or an easy choice to outline for a patient to make. But we sat there, my patient and I, and neither of us knew what to do. Neither of us could make a decision. He was looking for promises that I couldn't provide him. He was looking for me to push him in one direction or the other, but there is no good direction for him. I had told him from the beginning that any treatment we gave him would be to try to let him live longer, more comfortably, but it wouldn't be a cure, it wouldn't drive the cancer away altogether. But it wasn't hard to tell that he was struggling with his own uncertainty. He wasn't ready to die, he wasn't ready to consider the idea that he was already in the process of dying, so he focused on feeling miserable in the moment, in fixing that, and the matter of dying from cancer was just going to have to wait until next week. He won't be feeling much better next week, of that I'm sure. But maybe one of us will have more of an idea of what to do. That is my almost absurdly unrealistic hope. Maybe next week, I'll be a better oncologist.