Time, part 2

The first two years of medical school are spent in the classroom and the lab, which was good for me because my dad had died 10 months prior and I was having trouble taking care of houseplants let alone a patient.

When you start medical school, you realize you’re doing something totally new when first-year anatomy begins. It’s one of the milestones that makes it into movies about medical school (a pretty uncomfortable one called Gross Anatomy is the example that comes to mind). On top of the learning part, it’s when you start to learn to contend with the heavy existential concepts like illness and death. When there’s a deceased person on a table in front of you, there’s nowhere to hide.

The all-nighters and pots of coffee and two-foot-high stacks of textbooks that you see in movies are a bit of an exaggeration (I pulled a total of three all-nighters in medical school), but the cadaver dissection holds every bit of adventure that you’d predict. My medical school treated it like church: before we even walked into the anatomy lab, it was very clear that this was to be approached with utmost reverence, that this piece of our education was available because of a deceased person’s generosity.

It pains me a little to calculate that it was almost 14 years ago, but I clearly remember the first day we were let into the lab – ten stainless steel tables in a fluorescent-lit basement room, each with a shrouded body on it. Modest. Each head wrapped because 1. we wouldn’t study the face and head until later in the course and 2. adjusting to touching a deceased person for three hours three times a week is harder when the face is visible.

You can predict the tension between my own blocked coping process and the need to learn hundreds of anatomic structures by exploring a recently dead person’s body. My newly-made friends/anatomy lab-partners were invaluable and in many ways I hold them responsible for bringing me through. Four of us were assigned to each body and my friend Julie (whom I’d known for a total of about two weeks) promptly named our woman ‘Effie’. That simple gesture kept Effie a human to us, rather than just another medical school subject to learn. Over the weeks to follow we learned our way through the thorax, then the abdomen, the pelvis, the head and neck, the limbs. We leaned over the table with our Netter anatomy atlas open (initial attempts to keep this free from debris were abandoned within a week as we eventually became mostly comfortable transitioning from dissecting to page-turning and back without wasting time or gloves. That copy never made the return trip home).

In my naïveté leading up to the time of my dad’s death, a part of me was hoping there would a some silver lining of growth that came from it – some deepening of my person that could only be the fruit of such adversity. Unfortunately, It didn’t feel that way at all. It just felt awful. I was numb and stressed all the while fearing some emotional release/crash was impending but knowing that to entertain such a luxury would cut into studying time, so I walled it up high.

I may not have felt it at the time, but now that I have a little more breathing room I can appreciate how formative an era that first year was for me. Even though I stabbed my partner Peter in the finger many times with my scalpel (to be fair, I asked him to stop pointing at the thing I was trying to cut…) and our fourth member Christine got to the point where she’d spoil surprises by having eidetically memorized every structure in the order she knew they’d appear during the dissection process, these were also the moments during which we revised our preconceptions about life and death. The fear and mystique of touching a dead person evanesced and the fragility and complexity of life became sharper – the presence of a fully intact body without an occupant, yielding all of its fine detail without complaint, demanding our commitment but meeting us halfway every time with new information.

Next to this knowledge, the most valuable things I took from that class were my friendships with Peter, Julie, and Christine. We remained an academic unit throughout the two classroom years, varying combinations of partners for histology, pathology, microbiology, and reconvening as a foursome for our autopsy during second year. When second year ended, they went on to clinical rotations and I went to the lab, and we continued to have lunch and perpetuate inside jokes and remain astounded at how old we would be by the time we had real jobs (mostly they were astounded at how old I would be when this happened).

While I was in the lab for four years, they finished their clerkships and applied for residencies and got them. I directly benefited from this: by the time I went back for my clinical rotations, they were a source of inside information on which rotation to do when and how to study for the next step of the boards and which books to buy for the 3rd year surgery rotation. When it was time for me to apply for residency, they were already well into their training. Julie and Christine matched at residencies (internal medicine and pediatrics, respectively) in the same city and during my 4th year of medical school, Julie was a chief resident in her program. I rotated through for a month and ended up staying for my residency and am still here for fellowship. Christine finished her pediatrics residency and practices primary care now. Peter learned how to treat kidney disease and practices close to his hometown.

At the end of her fellowship, Julie and her husband got pregnant and when their baby was born, Julie was diagnosed with (her words) ‘an extremely rare and aggressive cancer’. The tumor was removed with the hope of curing her, but a year later she went to the emergency room for back pain and the cancer was in her bones and liver. (She described all of this in an article for the Journal of the American Medical Association; I’m not revealing any of her secrets). She had chemotherapy and radiation and palliative surgeries to try to slow down the disease but ultimately the cancer’s aggressiveness overtook her body and she passed away last year.

I saw her twice after her cancer came back, and the degree to which her loss has affected me speaks to how much more those closest to her have reason to mourn. She had a rapier wit, but she kept her humor always positive (she chronicled her journey through cancer here). The first time I saw her after her treatment started was during my own chief residency year, in the office she had occupied four years prior. Treatment had changed her appearance a bit, which she defied by adjusting her clothing style from mostly understated and conservative while we were in medical school to a new thing with scarves and bright colors and head wraps that projected taste and was her outward challenge to cancer. When I saw her, she was not interested in talking about her cancer, but much more interested about my career plans and my kids and laughing about how ludicrous our fear from a decade before of not being able to memorize the cranial nerves seemed now. We had soup in the cafeteria and she hugged me and left (and jokingly reminded me to apply for disability insurance had I not already) and as she went I feared I wouldn’t see her again and I didn’t.

When her cancer recurred, Julie knew the historical data showed that her chances of surviving 5 years were zero percent. She had no illusions about the reality that her life would be shorter than she had planned. She cast denial about her disease aside and in spite of the fact that each passing day was likely the best day she had left, she continued to feed the people around her with her sense of humor and joy.

Mourning her loss is paralleled by the selfish acknowledgement that we were the same age, and I haven’t managed to shake this fear yet. It’s the emotion that rises to the surface every time I meet a new thirty-something patient with a horrible new cancer diagnosis, and I wish I could say that it has forged an appreciation of every new day and that I now embrace each moment as it happens, but to be honest those sentiments seem a little cheap in this light. Of course these are circumstances we process for the rest of our lives, but I can say right now that reflecting on the heroic way Julie navigated her cancer course illustrates how important it is to release what may have happened in our past and be realistic about what may happen in our future, but more importantly to sit in the current moment and try to accept it for what it is, because usually there’s no option to do otherwise and with resentment and bitterness we most of all hurt ourselves.

The four of us used to sit at the lunch table and project forward to the days when we would be done with schooling and training and our lives would begin. It was a romantic thought, but I know it cost me some of the experience of the time because the misunderstanding buried in those conversations is that what we were doing in those days was somehow inferior to what we would someday be and have. Sometimes we believed that completing our training was better than being in training because we’d be able to buy homes and not be evaluated from six directions at every moment and feel like our peers who had jobs right out of college. That idea takes a lot for granted.

I used to sit at home and wait for my Dad’s death to make sense, and convince myself that when this piece fell into place, then everything else would straighten out and the coherence of life would be restored. That the narrative of my life was dependent on a comprehension of this loss and that it would somehow provide leverage into a better place.

Now I’m starting to see that the risk we run when we stall in the moment because we’re waiting for the future to happen is that we end up with a very distracted and dissatisfying past. It may serve us more to dispense with what we think the present and the future should be, and live with what is now. Then what may come, be it illness or loss or catastrophe, has no ability to rob us of the things we postponed our happiness waiting for.

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Cure

WhyNoCure

Sometimes I tell people I’m learning how to treat cancer, and their first question is ‘why haven’t we cured cancer yet?’

We will.  It’s coming.

In medicine we’re much better at treating infections than cancer, but it wasn’t always that way:

  • We didn’t know washing your hands before delivering a baby was safer for women until 1847.
  • The concept of a germ was proposed in 1870.
  • The first vaccine was made in 1879.
  • Penicillin didn’t show up until 1928.
  • The last fatal case of smallpox was reported in 1978, and smallpox was declared eradicated in 1979.
  • The AIDS epidemic began in 1981 when five previously healthy patients were diagnosed with Pneumocystis carinii pneumonia.
  • Now, HIV has changed from a deadly incurable disease to a chronic treatable infection thanks to anti-retroviral therapy.

When my grandparents’ grandparents were alive, we didn’t know that ‘germs’ existed.  Today we can prevent HIV from becoming AIDS.

The cure for cancer won’t be one discovery.  It won’t be one bold headline or a news broadcast.  Right now we’re in the phase of research that is like walking into a pitch-black room and feeling around until you find a light switch.  Practicing oncology is like standing at a wall of light switches and flipping the right ones (thankfully the scientists label them for us). Discoveries are made one light switch at a time, someday we’ll find the whole room is lit.

We’ll keep pushing things forward and one day we’ll notice that the word ‘cancer’ no longer strikes fear in us the way it does today. Cancer may become a chronic, suppressible disease like HIV has.  Maybe we’ll find better ways to find it early before it’s too advanced.  The days of toxic chemotherapy will be gone, and things like cancer vaccines , cancer-selective antibodies, drugs that target cancer-specific gene mutations, and drugs that cut off cancer’s blood supply will take its place.

But that’s only part of it.

Look at how people phrase this question, ‘when will we cure cancer?’ The we who will cure cancer are not doctors or scientists or drug companies or governments.  The people who will cure cancer are the patients.

Thank you if you have ever participated in a clinical trial.  Your contribution to cancer research is more valuable than any discovery that has ever made by a lab scientist or physician.

Thank you if you have ever accepted the care of a medical student, resident, fellow, or nursing student in an academic hospital.  You are the most important teachers we have.

Thank you if you are currently trusting us to treat your cancer, or if you trusted us to treat someone you loved.  This is not an honor we take lightly.

Thank you for your help.

Because of you, someday we will look back with incredulity and say ‘can you believe there was a time when young people died of cancer?’ and the fear we now feel when we say its name will be gone.

Breathe

We’re born into our bodies, and we take that for granted.

Our first job is to take a breath, something we’ll hopefully do many millions of times and never think about.  That first breath changes everything:  our blood starts to flow through our heart and lungs in a different way and for the first time we taste a new world.

Before we’re born, all our needs are met via an artery and a vein.  It’s how we get our oxygen, our nutrients, our means of fighting infection.  When that connection is lost,  we start to depend our own body to notify us when we need something.  If we’re fortunate, there’s someone nearby to respond, to feed us, to clean us.

Sometimes that need is simply to be held, a combination of touch and movement and hearing a larger heart beating, and we learn to assemble those things into love.  Messages from our body, delivered to our brain and becoming the most important emotion we’ll ever experience.  A reassurance that what we need will continue to arrive, that we will be able to grow and thrive and remain.

Anyone who attempts to distill these things down to science, to a cascade of synaptic firing and neurotransmitter release can never have held their own child during the moments of those that first breath, that first cry, after making it through all that pain and fear and blood and  felt the flood of relief carried on that mighty shriek. The first of hundreds of millions of breaths to come.  Much more than physiology and catalytic enzymes.

Our bodies – astoundingly complex assemblies whose chemistry we’ve only begun to understand, physical substance that is driven and maintained by emotions that become so intertwined as our bodies and minds develop, that we cease to understand them as distinct things.  We discourse about the physical self and the emotional self as if they’re separate, but they’re not.  Each is made of the other.  They are undissectable.

When we’re young, our bodies are our deliverance.  Uncontainable energy, flexible and cartilaginous and healable.  Limited only by the height of the countertop and too many syllables.  Sometimes our bodies report pain, but it’s usually the byproduct of growth spurt or exertion.  Sometimes it’s a bone knitting back together or a scar forming.

As we age, we calcify.  Our thoughts and legs less prone to frenzy and sometimes harder to compel.  We creak and pop and sometimes forget.

Sometimes we discover a new character of pain.

I had a patient who was diagnosed with stage IV lung cancer, found when she came to the hospital for weakness in her legs.  It was in her lungs, her bones, her spine, her brain.

The body she had come to trust, to recognize as herself, the place she depended on, now an enemy. Now she was confined in a small space with a fast, destructive thing whose motives were unknowable.  Her cancer all but ignored our medicines, and her back pain and headaches became the landscape on which all other things were placed.  Nothing was just one thing anymore.  Hunger and eating both meant pain.  Eventually her ribs hurt so much that the previously effortless act of taking a breath was restricted as if tied by wire:  the memory of deep lungs unable to be satisfied by her short, stabbing attempts.  Her physical home, invaded and traitorous.  Her mind, however, remained without self-pity or resentment.

My colleagues in Palliative Care were able to give her the only thing she needed then:  a reprieve from the relentless transformation of her physiology into the source of her greatest pain.  She passed away comfortably in her home attended by hospice nurses.

She and others have taught me that there’s a part of us that’s unafflictable.

There’s a thing in us that cannot suffer disease, or degenerate, or know pain.  Objectively, I don’t know what a spirit or a soul truly are, but I can say with some hope that I don’t think our bodies are our limit.  When our physical self transforms into something malevolent, we remain something else: a thing that is capable of dignity and strength even when our ability to raise our head is taken away.   This thing opens our eyes when we first join the world, and squeezes our lungs to project that first high-pitched roar in the delivery room.

It’s the thing that drives our first breath.
It remains after our last.