2012

The last couple years were pretty difficult. Personal problems, professional problems, existential problems.

But, rather than view 2012 as some kind of "new" year, I'm starting to accept that all pain is simply the flip side of happiness.

As I see countless cancer patients struggle with their lives and deaths, I start to see it all as the grand cosmic cycle of life and death, birth and creation.

Ecclesiastes. The Tao. Samsara.

We are all just cycling through, brief ripples on the cosmic ocean of life.

I have tried so hard over the years to insulate myself from pain. Exercising, studying, saving money, trimming negativity from my life, cultivating spirituality and on and on.

Yet, no matter how much free range, grassfed, fair trade, organic, local food I eat... no matter how caloric restricted my diet is or Zen-like my demeanor is, the truth is that I will get age, get sick and die some day soon.

Just like everyone else.

I was reading something about this concept of big self, little self.

Often, when faced with something good or bad, we operate in the little self.

Why me? I am feeling well. I feel anxiety. My sadness is unique. What am I going to do about this?

But, we can just change our thinking to say things like: I am touching the feeling of wellness. I feel the emotion of anxiety or sadness. What do others do in this same situation? Why not me?

If we do this small step, we can tap into the larger mind, the larger more common existence and emotion and feeling of others and the universe.

We are not alone, even in our death. We are not the first to die. Not the first to have joy or sorrow.

Indeed, if you believe the Gita and perhaps modern physics, we were never born and will never die in the first place.

Our energy, our matter, is constantly recycling over and over again, just manifesting in different life forms and cosmic energy and star stuff.

My molecules are the same as those that existed in the Big Bang. I share some with the Buddha, or Jesus, or Hitler... or Mount Vesuvius or Halley's comet.

I hope this year, 2012, is an insightful and spiritual one. I hope I become closer to God and to my loved ones. To truly feeling a connection with the universe and my own place in the cosmos.

I know that's a little far out, but I finished 2011 with a whole spate of self-help/spiritual books... :)

Cancer Love

L.D. was one of those patients that I sometimes get a crush on. Not in a teenage, pimply, excited kinda crush, but a chemotherapy, bald-person, gaunt, I-wonder-why-that-person-has-such-equanimity kinda crush.

Like, how is a 49 year old single female chiropractor with metastatic colon cancer and liver and omental metastases so cheerful coming into the clinic? So appropriate and mentally balanced despite being totally shafted by nature, biology, God and country?

Why does she smile and laugh after vomiting? Or pull clumps of hair cheerfully out of her scalp? Or gently respond patiently that she drove here alone for the umpteenth time? Or that she might check out acupuncture or Reike or craniofacial therapy or any host of things that are really cool, except if you have a fucking bowel obstruction.

Nasogastric tube placement. Now that's a good first date.

That's the kind of patient I go for.

Just so pretty on the inside. A supermodel of personality. The sexiness of humility and kindness.

I find myself wandering the infusion center just to chat with her. Maybe get a glimpse of what Victorian novel she's reading or just preening for a jaundiced smile or laugh at one of my canned cancer jokes. Hell, she sometimes looks at my Eeyore face and asked ME if I'm okay... sheesh. You had me at hello.

Her bloated stomach needing a paracentesis is something horrifyingly beautiful to me. Maybe it's the way she bears it, accepting in a yogic way that this is just the natural end of her life. What was it supposed to be? Why NOT me who gets cancer, she asks?

Children used to die in droves young, mothers in childbirth, men by some wayward industrial accident. It's not so abnormal for a young healthy vegetarian athlete to get huge goombas in her liver, is it?

Do you believe in God? No.

Do you have much other family? No.

Are you depressed? I don't think so.

Denial? Definitely not.

Bitter? No, I've had a wonderful life.

Are you an angel? (No answer)

Can you teach me how to accept my own life? (Just a smile and a squeeze of my hand)

L.D. died a few months ago. She elected not to get any more chemotherapy. She wanted to spend her remaining months with friends and traveling a bit.

She didn't travel much. Maybe a couple miles up and down I-95.

But, she traveled deeply into my mind and that strange, sensitive, underdeveloped place in the center of my chest, between my lungs, under my ribcage... that thing that seems so deadened sometimes by hospice talks and vomit and shit and bleeding and crying and mourning and loss.

The Tin Man would have had it bad for her.

Hair gray from stress and meds, gaunt, ascitic, bloated... but, still smiling. Still laughing. Never questioning why. Never blaming or lashing out.

I'm not the first person who ever was born, lived and died... it's just my time.

I still find myself sometimes looking for her in her favorite chair, my heartbeat quickening, my hands reaching to straighten my tie, trying to think of something funny and wise to say.

Quite a lady, that one. I'll miss you, L.D.

The Buddha didn't have goddamn a thing on you.

Phoenix Rising

There is something about insomnia that makes one want to express thoughts for anyone on Earth to read. Banal, predictable, but personal and sometimes pithy thoughts.

I've passed nearly the 6 (or is it 7) year mark in practice. G-d, it's hard to believe.

What are some of the highlights?

Engagement broken
Lawsuit
Cynicism and Depression (they need capital letters)
Failed romance
Nearly quitting my practice out of burnout/ethical disgust/boredom/emotional impairment
Hating my job
Selling the practice and becoming financially secure
Buying a lot of crap
Giving said crap away
Buying more crap
Taking a lot of trips
Feeling the escapism of said trips
Therapy
More therapy
Kung Fu
Yoga
Meditation
Friendships
Parents divorce saga
Parents individual healing
Lots of vacations with same parents (individually)
Broken relationships
Celibacy (hopefully not permanent)
Kindness of strangers
Letting go of perfectionism
Learning from so many patients and their struggles
Crying
More crying
Vulnerability
Actually feeling some emotions
Helping so, so many people die
Maybe curing a couple of folks
Being amazed at people's fortitude and love and perseverance
Coming to love my job
Being loved
Feeling human
Grace
God (or Brahman, take your pick)
Feeling honored again to be not just a doc, but a human being

It's funny. When you start medical school, there are these "soft" classes amidst the daily grind of anatomy, histology, pathophysiology and the like.

Classes like "Doctoring" and "Compassion" and "The Impaired Physician"

You meet older docs talking about their travails, their burnout, their personal relationships, their addictions, their frailties.

As a twenty something year old, it all just seems so foreign, so narcissistically weak and alien.

But, six (or seven) years into full bore clinical oncology practice, I see it. Not just in us, but in the other docs, in other specialties.

In me.

Physician, heal thyself.

It ain't that easy.

The perfectionism that works so abundantly well in calculating chemo doses or clipping through 25 patients a day really doesn't work so hot in your personal life.

Who are we when no one is looking?

Am I moral? Ingmar Bergman, you ain't got nothing.

I remember PBS having a long term documentary chronicling Harvard medical students as they go from their first days, through training and later decades of being attending physicians. The divorces and emotions, the idealism and despair, the physical and mental toll. The glimmer of youthful passion and idealism still there, peeking out shyly amidst the money and status and time demands and stress and oncoming aging of the once bushy-tailed participants.

Francis Weld Peabody once wrote that "the secret of the care of the patient is IN CARING FOR the patient."

And how can we care for someone if we cannot care for ourselves?

I see now the beauty of medicine, the holiness of it. I once talked of A.J. Cronin's "The Citadel" and how medicine was something to be cherished. How easy it is, as in the book, to slowly slip into something that you don't want to do or be. To lose that gentle naiveté, that openness to ideals and love of fellow man. That purpose that makes healing and palliating so wonderful.

It's so easy to crumble your dreams in the face of lawyers and accountants and diagnosis codes and RVUs and bonuses and mortgages and alimony.

It is easy to get caught up in narcissism and self-pity, self-gratification and banal materialism.

I know. I have been there in such a short time, despite my protestations.

But, there is a way, a more human way forward, I believe. Not the youthful blush of innocence, nor the jaded, self-absorbed path of pride.

But, in realizing that we are human. We caregivers are every bit as broken and in need of healing as our patients. My MD and my white coat are no shield against my own demons and diseases, real or imagined.

The care we give is the care someday we hope to receive.

If I can just serve another dying cancer patient in the dignified and humble way that I hope to someday be cared for myself, then perhaps I can rise again to the Citadel.

Accept myself and pick myself up and I will try not to forget to hold my patient's hand and cry for them as I will someday cry for my parents, my lovers, my children, myself.

The phoenix rises, older and different, less perfect. Less, but more.

That is the beauty of oncology. I am blessed to even touch this for my brief time on earth.

Thank you for waking me up, cancer.

Clean my body and soul my Guru, you bring light to the darkness.

It's Time To Hang It Up

This is my last entry. This blog has served its useful purpose in my life. It's allowed me to explore many emotions and thoughts during this transition point in my life, from student to physician and maybe to the beginning of healer.

But, it's a vanity in a way. A service to ego and it's time to face life without a crutch.

Time to turn inwards as we still fight to grip with all that is outwards.

I am grateful for the responses over the years. The many insights. The love. And, sometimes lack of love.

Time to unplug and whip out the old pen and paper...

Grief

Lunchtime. I don't each lunch, really. Maybe tea time. Or downtime. Or depressed time.

This morning was a bear. The sounds of crying. Not ostentatious crying. Just sobbing.

I'm sorry. There is nothing more I can do...

I must say that to people ten times a week.

Most of the time it's just a stunned silence, then a polite thank you.

Every now and then, it's anger.

Sometimes, histrionics.

But, then there is just the solitude of grief.

It doesn't matter how many family or friends are in the room. When the realization dawns on the patient that life is over, there is this retraction of space, this contraction of feeling.

Alone, facing your death.

This morning was one of those.

I feel washed out. I have to gather myself for the afternoon panel of patients.

Two Steps Forward...

The "no consumption" thing is terrifically difficult.

Coffee and other beverages are being phased out.

My canvas bag travels with me to the fruit and vegetable aisle.

Takeout, carryout, order out, etc. has been crushed.

Books from Amazon have slowed to a trickle and will soon dry up.

And yet, there is still a small amount of recycling that I had to put out this morning...

I liken this attempt to my yoga practice. Or my meditation practice. Or my practice of medicine for that matter.

You keep trying. Despite some injuries here, or boredom. A setback. A steak dinner. A piece of styrofoam.

But, hopefully, with practice, you become the person you want to be.

I was listening to an audiobook about Confucius and his philosophy. Like all religious teachers before and after, like the Buddha or Jesus, Confucius emphasized behavior and attitude. Part of the emphasis on propriety and politeness is a recognition that as we perform the outer trappings of humility and compassion, eventually, they become part of our personality.

Our minds, like our bodies, are modifiable.

Habit. Samskara. Patterns of behavior. Patterns of thought.

Just like when we meditate and our mind is racing. We come back to our breath and begin anew. Eventually, it becomes natural and easier. But, there is always awareness that, without constant vigilance, the thoughts arise forcefully.

So, I begin again. And again.

Trash one day.

The odyssey of life another.

The Fatman

I don't know why I always think of this patient as the "Fatman".

Well, other than the obvious fact that he is quite overweight, tipping over 300 lbs on a 5-10 frame.

Maybe it's his lack of self-consciousness about it. His laughter and cheer and egolessness, if that is even a word.

Which spellchecker tells me it isn't.

A wonderful guy, a healer. A therapist. Not just any therapist, but an uber-therapist. Well regarded nationally, urbane, published, graceful, the Fatman is a mensch in every way, except in regards to himself.

I first met him more than 3 years ago. He came to me ostensibly for thrombocytopenia, or a low platelet count. After ruling out the various bad actors, I got an ultrasound of his liver.

Lo and behold, he had cirrhosis, probably from "fatty" liver, a growing problem in our society.

I explained the dietary things he needed to do, the lifestyle changes, the exercise, the low fat, the diabetic control, etc., etc.

He proceeded to gain 60 more pounds, develop congestive heart failure, eat like a pig and get horribly depressed.

All the while, he continued to counsel patients and even other therapists, serve on national committees, hob nob with rich and famous people and generally just carry on.

Every time I saw him, I would berate him. He would look at me patiently, full of remorse, with sad Eeyore, droopy eyes and promise to do better.

I admitted him to the hospital. Had him see multiple cardiologists. Got him a liver specialist at Johns Hopkins. Transfused him when he bled from an ulcer and then bled again from esophageal varices.

Just trying to die.

I couldn't understand it.

His IQ exceeds mine easily.

His EQ in theory is off the charts as well.

He lacks for not. His wife and family are sophisticated and supportive.

Why?

Today I finally understand why, after nearly 4 years.

I guess, in retrospect, predictably so... he, like most of us, is in a whole lot of pain.

A lifetime of helping others is only a mask for being unable to help himself. Of being masochistic.

Today we talked of his broken family.

His schizophrenic mother who tried to kill him more than once.

Of being beaten and starved.

Of viewing food as a safe place and a refuge emotionally.

Of abuse.

Of self-loathing despite brilliance academically.

Of his own depression and low self-worth.

Of a family genetic tendency towards mood disorder.

Manifesting in his only son as schizoaffective disorder.

Of him offhandedly turning down an offer to accompany his son to Montreal for a conference and then being called 24 hours later that his son had killed himself, blaming the father for leaving him.

Of 20 years of guilt and self-abnegation. Self-loathing.

Of wanting to die.

All the while, collecting accolades and wealth and the trappings of success.

I haven't cried in front of a patient in an exam room in a while.

And he doesn't even have cancer like most of my patients.

What a waste...

In all these years, he himself has NEVER seen a therapist.

It never ceases to amaze me how troubled we all are underneath the veneer of a placid home life. How the banal collides with the absurd and existential in all of us.

All the Fatman needed was someone to just listen to him and let him sit with the pain of his past life and just be okay with it.

No pushing. No pulling. Just letting it wash over him and recede. Again and again, until he learned to just sit with it.

Instead, he's going to die of liver failure. Yellow. A miserable death, slow, tortuous and painful.

I know he thinks he probably deserves it for failing his son and doing something to make his mother hate him so much.

But, I don't think so.

Why do some war veterans survive near death experiences, none the worse for wear?

And others are crippled mentally forever, victims of post traumatic stress disorder?

The more I do this job, the more I realize that we are all carrying some hidden shame inside of us.

That we all fear how our loved ones or society would reject us if our true selves emerged?

We are not free, for the most part. Not free to be truthful. Not free from fear.

It's not just the cancer that kills. It's the guilt or shame or anger or ignorance.

Physician, heal thyself, Hippocrates once admonished.

Heal thyself.

Heal.

Fatman, I pray you find some peace before you die. You've helped a lot of people in your life. Given a lot of love.

I hope you pour yourself some one of these days.

Heal yourself.

If you can, maybe I can too.

This Is a Lot Harder Than I Thought

My list of violations so far:

1. forgetting my steel mug when i sometimes get coffee or tea (even though i'm trying to get rid of the habit altogether anyway)
2. forgetting to bring my reusable plastic bags to the health food store and then needing another bag
3. driving when i could easily walk or bike to my local coffee house/drug store/grocery
4. getting tired of composting, especially since i don't grow anything
5. forgetting to use my drying rack (better today, though)
6. having a constant urge to buy another lawnmower (my old-school push bladecutter just does a terrible job; i feel like i'm lowering my neighbor's property values with my inability to make the lawn look even semi-presentable)

this is challenging.

granted, i'm a lot more aware of consumption. it's like a constant reminder to stop getting things.

it's mind boggling when you think of the zero-sum nature of our planet. commodities get used up, like oil, gems, precious metals... they get turned into non-degradable and rarely recycled things like plastic-everything, rings and other jewelry, cans, toiletries, etc.

it's not even conspicuous consumption that's the problem.

it's consumption in general.

at our medical conferences, i've become very aware of the catered-food, and all the plastic cups and plastic utensils. the cans of soda. the plastic containers for the food... all of which is NOT recycled, just trashed.

all the paper that we use.

like, i said, it's mind-boggling.

i just saw this documentary, the "Age of Stupid".

A British tongue-in-cheek imaginary scenario set in the year 2055 or thereabouts.

the planet is in ruins. twelve feet or rising seas have engulfed the planet. warming is real. countries are destabilized. nations destroyed. famine, ruin.

an archivist or the sum total of world knowledge looks back to the beginning of the 21st century with real stories of people struggling with the reality of climate change.

an aging mountaineer near Mont Blanc. A British wind farm activist. an ironic retiring oil geologist for Shell/ecologist whose home is destroyed by Katrina. An aspiring medical student in Africa.

All real stories. Their struggles to survive, all the while confronting the day-to-day choices, the mundane, banal choices that we all face... that seem so insignificant, yet have huge, lasting impacts on our environment and ultimately, our very existence.

It is like that famous butterfly in chaos theory that gives rise to the hurricane.

It is so hard for each of us to be mindful of our daily impact, when we are just trying to make a living, find some love and happiness, have good time.

Yet, if we are not mindful, the consequences eventually will imperil us all.

I wish I weren't so damn addicted to Starbucks feta wraps...