Wednesday, October 22, 2014

Horowitz, 26.2 and Palliative Care

One evening when I was 5 years old, I was thumbing through my parent's records. After passing by Peter, Paul and Mary and the soundtrack to West Side Story (which I loved, I used to do reenactments of the entire musical for my probably bored-to-death mother in our living room), I came across this album with a a candelabra and a piano and Beethoven. It was Vladimir Horowitz, who, truth be told, is not the world's best Beethoven player by a long shot, but it stopped me from further seeking and I took that LP out of the cardboard cover and placed it on my parent's record player.

Now let me explain for a minute. A record is this thing that we used to use to listen to music. It is round, and has grooves in it and the needle of the record player contacts the grooves and magically produces music. Records look like this.

So anyway, it was a winter evening when I found this Horowitz album. It was dark outside. We had a very small house but the rest of my family was doing their own thing. My Dad was probably at a meeting. My Mom was watching TV after a very long day at work. My sister was probably at work or in our shared room listening to ELO or the Beach Boys. My brother was probably in his room plotting his next terrorist attack on me. I put this album on and laid on the couch which my parents had for approximately one thousand years, and I closed my eyes, and I listened to Vladimir Horowitz play the Moonlight Sonata by Ludwig Van Beethoven and I decided, then and there, that I was going to do that too.

This is a true story.

My husband wrote this song once with the lines: "when I was born I was gifted, now I'm just about average. So somewhere I drifted…"

Fast forward seven hundred years to the present time. Parents: dead. Sister and brother still tolerate me. Brother no longer with terrorist tendencies toward me. I am a music major gone astray, now a medical doctor and a mother of teenagers who don't know Horowitz from their very cute behinds.

I spend my days now largely caring for people either at the end of their lives or at the frail end of the aging spectrum. I ran this marathon last weekend, and at the awards, there were not one, but TWO guys in the 85-89 age group. They ran the half marathon. They are not frail, though they are aged.

What is frailty? Scientists really cannot come to an exact consensus on this. You can measure grip strength. You can do the "get up and go" test (how easy is it for you to get out of a chair and start walking). Usually it is more vague. Frequent falls. A lot of trips to the ER or hospital. Choking on food.  Episodes of forgetfulness. Your kids or loved ones start to wonder if you can manage anymore, and if you need to be "placed" somewhere to keep you safe.

Vladimir Horowitz did his last concert at age 86. This was in Moscow, and was the first time he went back to Russia since his exile 61 years prior. He reported continued stage fright even at 86, puking prior to performances. I find this oddly reassuring. He also owned over 600 bow ties.

My friend and colleague Dr. Michael Fratkin is doing some interesting work. People, it turns out, are more than their disease, more than their age, more than their cancer stage, more than their frailty index, more than their fall risk, more than their ability to run half marathons or do internationally televised performances at age 86. I think Michael's work is worth supporting. He is touching on something vital and true, and though I am a boot-straps-pulling midwesterner at heart, I can see that palliative medicine is what we all need: even if at the prime of our health. It is about health in the context of being a real, live human being, whether you are about to fall and break your hip, or on your way to radiation therapy for recurrent cancer. Cure may be sexy, but palliation is the very core of healing.  What does it mean to be mortal? And what is it you plan to do with your one precious life?

I ran my 6th marathon in 6 years this past Sunday. I am a Master (aka "older American"). I am not as fast as I used to be. I am not as sore as I was for the prior 6 marathons. In fact, after one day post 26.2 miles of dreading stairs, I am not sore at all. This makes no sense whatsoever. I can only think the following:
This run was palliation for what ails me.
I am meant to run, until I can no longer run, at which point I will call Dr Fratkin.

My next goal is to tap into my 5 year old self. The one that snuggled into the well worn couch of my Mom and Dad, and listened to a miraculous bow-tied gentleman play Beethoven, and knew this was my calling.

I do love Beethoven.

Sunday, October 12, 2014


"…so lift me up, increase my buoyancy. I'm still not floating, please, attach more nothing to me."
-Atthys Gage, "Surface"

I was reading through the medical records of a patient and came across this diagnosis in their chart:
Weightlessness. It turns out there is an ICD-9 code for this, specifically E928.0. This is not to be confused with E485, which is "an accident involving a spacecraft".  Neither of these is billable, incidentally. And in the case of this patient, I suspect it was the transcriptionist's mishearing of weight loss. Because if someone is weightless in a forest, do they really need a doctor?

For the last 19+ years, I have been either in training or in practice as a doctor. It starts, for most of us, as a naive wish to help, with no serious strings attached, nothing weighing us down. Most in this profession will give up something, or many things: time with family for sure, other passions and pursuits, often one's own health. Still, a good job: you get to be useful, and you will eventually usually get paid reasonably well.

As with most things in life, what was once carefree becomes slowly laden with the stuff that sticks to you, irritatingly increasing your friction and slowing down your cheerful ride. Like Katamari.
If a doctor was a Katamari ball, they would be covered in: MCATs, mean Attendings, grumpy senior residents, expensive licensing exams, soul-sucking debt, grief over all the sad stuff they see, PTSD from that noise that pagers make, one step away from madness from one-too-many middle of the night awakenings, and bewilderment at why, when they are generally just trying to help people, they are so often the target of people's anger and desire for more. Doctors are now on Craig's list alongside the guy who unplugs your toilet.

I have great respect for plumbers, let's get that straight.

Doctors can do some cool stuff that everyone admires, like my surgeon friend who fixed up the surfer who got munched on by a shark, or the times we pick up a diagnosis that was elusive, or when someone gets saved from the almost certain death of ebola. But a lot of times, what doctors do is create a space where someone can get hurt as little as possible while their own body does the work of healing. And truly, a lot of the real work is done by nurses. One of whom is now dealing with her own case of ebola after caring for the man in Texas.

Lately there have been some serious discussions though about what we cannot do. For instance, we cannot keep people from getting frail as they age. We cannot change the fact that the death rate for all humans remains at 100%.

As the parent of teenagers, one thinks a lot about what the point of life is. This is for two reasons:
1) You want to be some kind of advisor for these people who are about to step out of your nest.
2) You find yourself with less life ahead of you than behind you.

As the parent of teenagers, a hospice doctor and the medical director of a clinic for the frail elder, I think way too much about what the point of life is. I sometimes feel like I am trapped inside that Rodin sculpture, with my eyes darting back and forth while people admire me: wow, she's a thinker!

Advice to the offspring, to myself and for those that feel like they are a Katamari ball or trapped within a ripped, iron thinker guy:

Be kind and useful.

Ride your bike to work, take a run, do Zumba, do yoga, take a senior aerobics class, do chair exercises, wiggle your little toe: MOVE YOUR BODY. There is no better drug. Not even lipitor. I know: radical.

Let the angry people vent at you, smile and be kind, and useful.

Never let your work hurt you. Never let your passions wither.

Do not look only to doctors, pills or operations for salvation. They can help, sometimes. But ask yourself: what is it you seek? And did you eat well, exercise, and tend to your own spirit on this fine day?

Move your body, be kind, be useful. Let go, and float to the surface.