I was normal… once. I went to parties. I ran. I carried on normal conversations, like a normal person. I laughed easily. Then my acceptance to medical school arrived with a 48-hour deadline to accept and 2 weeks to matriculate.
Waving in the darkness to my parents, I slowly rolled down the driveway, my momentum stolen by a U-Haul replete with the treasures of a 22-year-old: bedding, some posters, a reading lamp and a stereo with ginormous speakers. It was August 1986. By nightfall, I had driven 12 hours and shook hands on a room in an apartment with my new roommate, an absolute stranger, who felt kindness or perhaps pity toward this homeless student. We unpacked the U-Haul.
The first semester of medical school began post haste. Feeling unworthy, I spent most days and nights with my head in either an anatomy book or a cadaver. My circuit of apartment to class to lab to dinner to library was broken only on weekends, when it became apartment to library. Each book highlighted (blue was my color of choice), then outlined, then condensed, then committed to memory. Throughout the semester, the sky, my travel companion to the library, progressed from brilliant blue daylight to strawberry twilight to inky blackness. I returned the 12 hours to home only at semester’s end, with an honors grade in anatomy, to breathe and to escape the discomfort of daily chest tightness.
Waving in the darkness, my mother tried desperately to gain my attention as I loaded the car in the driveway for a family ski trip. Bags were packed in the trunk and skis on the roof rack when a faint voice pierced the morning stillness.
“Rick,” she hissed in a way that, to this day, still gives me shivers.
“I’m packing the car, Mom. I’ll be in in a minute.”
“Come in now… please. And keep your voice down. You’ll wake the neighbors.”
I approached the front door. “Did you forget anything?” Mom said.
“Don’t think so. It all went in pretty easy.”
“That’s not what I meant. Aren’t you cold?” she whispered, slowly pointing up and down at me.
Apparently, Mom was unimpressed that I would venture outside wearing nothing but long johns in full view of the neighbors. But unlike the classic elementary school nightmare of embarrassment at finding oneself outside dressed only in underwear, the medical school student just replies with a blasé, “Our bodies are just a bunch of pulleys and levers. The real me is hidden somewhere inside. Nobody cares. And if they do, they shouldn’t. It’s just a body.”
“Have you led these conversations before?” asked Nan. She’s the institution’s beloved social worker, with the wisdom of Solomon, the patience of a saint, and the wardrobe of a Broadway diva, harkening back to her primary career.
“Not really. But I’ve heard enough of them,” I responded naively.
“Maybe I’ll come along and we can do this together,” Nan offered.
Gynecologic oncology fellowship, or oncology school as I call it, built on the surgical and medical techniques I learned in residency. The curriculum focused on radical procedures and the intricacies of chemotherapy management. Although I was considered a trainee, this apprenticeship allowed more independent patient treatment. The educational, technical, and research components were highly regulated; the art of medicine, much less so. Helping folks understand and manage their impending death was such an art form.
I had never subscribed to the “It’s time to get your affairs in order” line. It said little and worried everyone. One of my mentors was known for his deliberate and methodical approach to getting this point across. It began as snowflakes, gentle and meek.
“Ya know, ma’am,” he’d confess in a broad Chicago accent. “Things aren’t lookin’ so good.”
The patient generally looked back quizzically.
“I mean there’s a lot of unusual stuff growing in your CAT scan.”
Quizzical look turns to concern.
“Ma’am. Don’t buy the big jars of mayonnaise.”
Look of concern turns to realization. “Oh. I understand.”
And just that quickly, snowflakes blew into a snowstorm. And if the “mayonnaise” line didn’t work, there were plenty of other avalanches to convey the gravity at hand. “You’re in a room with a hungry tiger. You have a shotgun and fired twice. And ma’am, you missed.” Or the endearing, ”You’re in a boat with a leak, so you put a finger in it. But then there’s another leak… and another. Pretty soon you got more leaks than fingers. And ma’am, you’re in a sinking ship.” One cringeworthy metaphor after the next, which surprisingly never offended any patients, who instead seemed relieved to know the truth. But, once again, not my style.
Nan and I stopped back after rounds to visit with Tonya*, a young mother dying of cervical cancer. Tonya, alone in her room, stared through the hospital window, which overlooked a brick exterior wall of an adjacent hospital wing, housing folks who looked back while also pondering life’s unjustness.
I began. “Tonya, did you understand what Dr. Black was saying on rounds today?”
“It was pretty clear,” she began, eyes welling. “I don’t have too much time left.”
“I’m afraid not.” I whispered, gazing downward.
“But what am I supposed to tell my kids? I won’t be there for their birthdays or graduations. Or anything! This is so unfair!”
Thoughts of my children, the same age as Tonya’s, instantaneously projected me into the same terrible situation. I opened my mouth to speak and merely squeaked. But even if I did have a voice, I had no words to utter.
Nan, speaking from wisdom and compassion, jumped in and took control of the conversation. She began to set up a plan to address all of Tonya’s concerns. “Let me get you some paper, right now. We’ll make a list of the important events that you’d like to share. Then we’ll write letters so you can let the kids know exactly what you’d like to say to them at those moments. And if you’re comfortable with the idea, we can make some videos for special days too. We’ll have your husband bring in the camera and I’ll give you a makeover. It’ll be hard, but we’ll help you. We’ll also plan a family meeting with the children and gently let them know how the next few months may go.”
I watched and learned as Nan thwarted mortality with paper and pencil. She was amazing. And walking back to the office after this experience, Nan took my hand and assured me that these conversations would get easier.
Eager to share her day, my wife launched into a breathtaking and breathless run-on sentence that would make Nathaniel Hawthorne proud. But it was 9:00 PM. I had been operating since 7:00 AM and I was spent.
“I’m sorry, my ears are tired and I’m exhausted. I’ve been operating for 14 hours.”
“Well, the taxes are done, if you could look over that and sign them. And the trash needs to go out, but I can do that,” she responded, miffed to be put off once again. “Dinner is in the fridge.”
“Thanks, but I’m not hungry, I ate lunch at 4:00.”
It was an exhausting day—but also a really interesting one. It began with an 8-hour case of tertiary debulking of recurrent ovarian cancer. I’ve treated Paula* for 7 years now. She functions well despite small-volume disease, now chemo and radiation resistant, which causes her bowel to intermittently obstruct. Surgery began robotically, but after 2 hours getting through adhesions, I opened her up. The next 6 hours saw three small bowel resections and a large bowel resection with a colostomy. All the while, my internal newsfeed read (in Paula’s voice), “I don’t want another stoma. I had one before and it was awful. I don’t want another stoma.” And though I did the right thing for the disease, I wondered if I had done right by my patient.
The next case, a quick robotic hysterectomy for a uterine precancer, lasted less than an hour. I had operated on several members of the patient’s family who had all done well. This case kept the streak going.
The final case of the day came billed as a robotic removal of a pelvic mass. In truth, we performed a hysterectomy on a dude. Born 70 years ago with ambiguous genitalia, Mike*, raised male, developed breasts as a teenager resulting in bilateral mastectomy and testosterone treatment. Now, an old hairy married guy with a pelvic mass on ultrasound, he either had a cancer or a uterus, both difficult to discuss. Fully expecting someone to say the wrong thing, I spent the day alerting the OR staff of Mike’s situation and the appropriate language to use. The case went well: no cancer, only a uterus, resected robotically and then carefully removed through Mike’s belly button. The buzz in the OR suite that day was about this case. Though it was late, I sent him home, as per his request, decreasing the likelihood of anyone making a verbal faux pas.
All in all, a pretty cool day, but HIPAA and exhaustion prevented any discussion of it. My wife went to bed. I fell asleep on the couch.
Most of us choose the medical profession for a rewarding career of getting folks through the most difficult days of their lives. A desire to be helpful. A hope to be needed. A need to feel important. However, the individual experiences of this noble endeavor change physicians deeply. Our normal deviates markedly from most. The study of medical sciences quickly dehumanizes, as we discover that life is a series of biochemical reactions and the body, a physical construct subject only to the laws of physics. Clinical medicine reinvigorates our humanism, but similar to other first responders, reinforces that lifetimes play out as a series of dramatic and spectacular events loosely interconnected with humdrum. We just happen to be involved in managing everybody’s furor, so our personal lulls are hijacked. The simple discussion of “How was your day?” falls by the wayside.
We live abnormally.
We are not the life of the party. In fact, if two medical folk meet at a party, they cling to one another like social life preservers. If three gather, then the entire conversation becomes medicine. If I am solo, I describe my work in gory detail to innocent bystanders often resulting in tears on the part of my listeners. I generally leave early, carefully rolling my wet blanket into the trunk for later use.
We leave our loved ones high and dry. “I’ll be home in a half-hour,” means “See you in the morning.” I cannot begin to tell you how many birthday parties—my own birthday parties—I’ve missed, returning late to a quiet house, a slice of cake, empty beer bottles, and some wrapped presents. Our kids remind us of the times we weren’t there for them.
Yet we endure. We know no other life. The career we chose came with a lifestyle, generally left out of the algorithm when we adopted it. Yet, in every career there are tradeoffs. Balances. Life is imperfect. And despite its abnormalcy, the career that chose me suits me quite well. In fact, I love it. I cannot see myself doing anything else. It’s important to me to be important to someone, and it’s a privilege to care for a fellow human being on her worst day. And as for the family, well, they accommodate. I don’t truly believe they fully comprehend my battles. My choices. My eccentricities. But at least they see my patterns, and love me anyway.
As for parties, if we haven’t seen each other since college, better just leave me off the guest list. I’ve changed.
This article was recently published on ASCO Connection.