Gratitude

For the

sound the ocean makes, and the way the sky and the dog is reflected in the wet sand after the waves break, making a downward dog doppelgänger who also enjoys chasing large flocks of shore birds.

imperfectly good health that grants me a daily run, if I make the time.

fact that even when life is too much, the chickens still require release from their shelter not long after sun-up.

three teenagers who are flying from my nest, one by one.

piano that once was the Leithold's. They owned the music store in my home town. It was middle aged when I was a teenager, and now I am middle aged and my piano is old and wise enough to play Brahms.

22 years plus with my best friend, who knows the words to every important song, and knows word-crafting like Ollivander knows wands.

memory of my parents.

one certain redwood on trail 10 that is my touchstone.

friends, silver and gold. Which totally makes sense if you ever spent a summer at Camp Ehawee.

fact that I do not have to spend every day worrying about Ebola, malaria, my next glass of clean water and what the heck that huge insect is crawling up the wall by my bed.

work I do, which is interesting, pretty useful, and gives back to me more spiritual mojo than you can shake a stick at.

endorphins. If everyone on earth just ran a lot, we would not have any drug addicts. We might, however, run out of deodorant and spandex.

smell of my dog's feet. Seriously, it is like cinnamon and nutmeg and pine needles. I know this because he often shoves them directly into my face when I am trying to sleep.

ability to live on the coast. Despite my midwestern beginnings, I seem to need the ocean really close by.

fact that it is now seasonally correct to listen to The Messiah. Over and over. Till your family starts making jokes about how much we like sheep (see below).

smell of the top of my children's heads.

quotes of William Osler.

books, music, movies, art, food, drink, travel I will experience, with no end in sight. Unless my plane crashes. In which case, I told you so! You know who you are, all those who quote me facts about the safety of air travel every second of the day.

metro card.

terrifying and beautiful and awful and inane nature of being human.

exhilarating feeling of knowing you are going to totally kick ass in this race (Go Tigers!).

heck of it.

If Music

"If music be the food of love, play on."-Twelfth Night, Shakespeare

I am a musician. More a musician than a runner. More a musician than a doctor. More a musician than a person soon to get a root canal.

I left music professionally to be a doctor and I wish I could be a professional runner, but the sub 5 minute mile eludes me, so, here I am. But music, it never stops feeding my soul. I play it, I listen to it. And I listen to it while I run.

I am thinking about bringing my headphones and music to listen to during my root canal. There is some vague science to support this. What is an optimal root canal play list? Please, let me know your thoughts on this.

Running playlists, they are very personal, I think. I recall the days of carrying a walkman while running. Now why they did not name this the "runman" I do not know. And why it has to be a man, not a person or a woman or an ambulator not otherwise specified, well, this is mysterious to me. What I can say is they were cumbersome and often skipped if you ran over a bump. The fact that I can turn on my playlist on my iPhone and just run for miles and miles without a glitch is a gosh darn miracle!

My running playlists vary. Some days I truly do not want any music at all. Or books, because the other thing I enjoy is audible.com which is the iPhone version of books on tape. This is nice for a 3 hour long run. Advertisements show Ryan Hall listening to the Odyssey on his long runs, but let's face it: Ryan Hall is so fast that the Odyssey would still be in the introduction and he would already be showering and eating his pancakes.

I do not listen to music when running with my dog, Miles. I like to be in tune to what he is needing and to talk to him along the way. Like, "Hey buddy! Almost home!" or "Boy, you sure showed those seagulls", or "C'Mon Miles, this hill is nothing. We OWN this hill. You are king of the hill, my friend."

Usually, he just looks at me quizzically. He is not disturbed by hills. And he does enjoy torturing the beach birds. Sometimes he does fall behind, usually at the end of a long run. But if a cute labrador retriever comes running by, he suddenly is Mr. Speed and Strength. I know when he is F.O.S. but I never call him on it. I love him so.

Before track meets as a high school kid, I liked this song. When I hear this song, I still automatically recall the smell of Icy-Hot. And that feeling of anticipation before a 1600 meter run on a track, where there was nowhere to hide.

I have running playlists dating back a few years now, to when such a thing was first possible for me, device-wise. I have been strongly influenced by my friend Martha and my daughter Vera. And her friends, on the road during the Portland to Coast high school challenge. Each of them would request a song to hear blasting as we drove by them, maybe at 2am, maybe in the middle of a hot, sunny day. I have been influenced by a musical education, alas a degree in music as it turns out. I have been influenced by my brother and my husband and my checking out what the great runners of today listen to. I turns out I am often shocked by the language in the songs the great runners of today listen to, but they are usually in their 20's and I am…..not.

Sometimes the music takes away the pain. It is an interesting thing, as a scientist of the physiological being, to consider that there is power in something so benign as music. Maybe the greatest marathoners could've broken 2 hours by now if they could've run with music.

Run. Play music. Listen to music. This is my ideal job description. Is anyone hiring? Hellllooooo out there?????

Here's a great one. A helluva great one.

Day of the Dead, Day of the Alive

"The reports of my death have been greatly exaggerated".
-Mark Twain


The whale on the beach where I ran last night was most certainly dead. In fact, its skull stared me in the face, but parts of its flesh still clinged to its body. A flipper and some vertebrae were present. Down a bit further, some more of said whale. Certainly more existed elsewhere, perhaps washed up on some other beach for some other runner to stumble upon. Miles, a poodle through and through, was skeptical and a little disgusted. I, a nerd and a philosopher through and through, was intrigued.

Whale, Nov 1, 2014

I have observed death several times. Mostly in patients: I have been present for many deaths and pronounced many others. I am a good doctor, really. But people die, and I want to be there for them in that moment too, so, there it is. I have seen the gruesome, the serene, and the personal. Watched my Dad die, and he seriously cracked a joke as his final words. My Mom? I sat vigil for days, but she waited till everyone went down to the stupid hospital cafeteria. She, apparently, was not interested in spectators. Death is mystical, physical, inevitable, sad and not all that pretty. It is almost impossible, in my experience, to make peoples eyes close after they die. Death on television is much cleaner.

I used to read this book to my kids about Day of the Dead. We have often celebrated it, in the blunted American sense. Our departed are not found in local graves, and my sense of mysticism has not been adopted by my children. But somewhere in their brains is planted this idea about death as a part of the journey, and the departed as part of us all.

The Mission District, San Francisco, November

Until we die though, I think we should live. I have 3 teenagers, and they are very set in their ways. If they would believe a thing I said, I would want them to believe this:

Life is full of beauty. Notice it. 

I ran in the woods this evening, with my dog. We set the clocks back last night, and the sunset came hard and fast at 5:30pm. So Miles and I, we ran in the dusk. I breathed the crisp air of fall, and reveled in the soft redwood carpet below me. Miles hung close to me, and we were solidly planted in the moment. Once my phone rang: the hospital, about a patient. I breathed, and responded. Miles cocked his head at me, wondering when we would resume running. But even he was not bothered. 

How can one be bothered, under the canopy of a redwood forest, on a fall evening, with the crisp air caressing skin and the clean air of the north coast filling the lungs? 

Please, please, when I die: visit my grave with marigolds and sweet pan de muertos. 

Until then, notice the beating of your heart and how it bids you to be alive. Yeats says it best:

      WHEN you are old and gray and full of sleep,
    And nodding by the fire, take down this book,
    And slowly read, and dream of the soft look
    Your eyes had once, and of their shadows deep;
    How many loved your moments of glad grace,
    And loved your beauty with love false or true,
    But one man loved the pilgrim soul in you,
    And loved the sorrows of your changing face;
    And bending down beside the glowing bars,
    Murmur, a little sadly, how Love fled
    And paced upon the mountains overhead
    And hid his face among a crowd of stars.

 

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.

Weightlessness

"…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.

It Hurts

Around age 6 or 7, I was solemnly walked into the CCU to say goodbye to my father, after his massive heart attack at age 40-something. He went on to live into his 60's (albeit gaining a literal new heart along the way), against the odds. When I was 10, I came home one day from school and could not get into the locked and dark house. I was furious, and when my folks came home, finally, I let them know in no uncertain terms. Turns out Mom had been diagnosed with breast cancer that day, and I still feel guilty for being such a brat.

Both my folks made it into their 60's, against the odds. I feel sorry that they died so young, but happy I had them as long as I did. Sorry they had to be sick, but happy our family grew closer in the process. Sorry I have such anticipatory grief, like Jiminy Cricket on my shoulder every second of the day, telling me to beware of the inevitable loss of all I love. But happy that I know just how important it is to notice life. In fact, my largest irritation with people over the years is how they take the beauty and impermanence for granted, and find so much negative to focus upon. Teenagers are fairly expert at this,  which is highly annoying, but I too was a teenager once. It hurts.

Anyone who knows me knows I do two things when I hurt. I write, and I run. Ironically, when I run, I sometimes hurt more than I did before I was running, but it is a different kind of hurt. When I had my angst-ridden moments as a child and preteen, I often burst out the front door and went running down the street. It was dramatically therapeutic, histrionically healing.

Today, when the call came that Matt had died, I felt trapped. I had 14 minutes to get my shit together to lead a family conference at work. I was trying to field questions about medications and I was just about to renew my ACP membership. I mean, I was pulling out my credit card to renew my ACP membership when I got this call that my friend and colleague and partner and sometimes irritator of 12 years was dead! I shoved my glasses on my head and cried like a stupid baby, then could not find my glasses. I called my husband. I called my friend who knows about death. My medical assistant asked what she could do. I wiped my snotty nose and went to run a family conference.

Several weeks ago, I spoke to Matt and explicitly told him I was concerned about his health, given the stress of his job. He was too, but this guy had elected to take on a monstrous task: the well being of a medical staff in a very broken world, the well being of patients with unfathomable needs, the well being of a budget that is geared toward some alternate universe.

I was thinking today: is it written on our DNA somewhere when we die? I mean, does it matter what we do or is it all just fate? As a physician, I must believe it matters, at least somewhat. But I watched my grandmother eat red meat and butter and live a life on the plump side, and she fell into her final sleep on the couch at nearly 100 years of age. I watched my mother live a life of healthy food and exercise, and she gets her ass kicked at age 42 with the big C.

What matters?
Kindness. Compassion. Love.

Jiminy Cricket would say: do not take it for granted.

Garmins, Coaches, Young People, Poodles, and Half Marathons.

My Garmin died. You may think this is not a true tragedy. I would have to agree. Yet consider this:
1) Garmins are made of plastic and probably will NEVER leave the landfills.
2) I have only had it for about 3 years.
3) If I continue running with Garmins till I die, which could be tomorrow but let's just say it is 40 years, that is approximately 13 more Garmins I will go through.
4) The Earth is doomed.

I ran yesterday with Map My Run. OK, this is actually a pretty cool app. It lets you choose your music from your list (I chose shuffle from all of my music, which led to a pretty crazy mix of Bach, Beyonce and John Coltrane). Then you hit start workout, and you just run and every mile this flight-attendant voice comes on, politely pausing the bebop or English Suite or whatever and tells you your mileage, overall pace and split for the last mile. Bitchin'.

It does not (yet) talk to Strava though. I really like Strava! All my friends use Strava! It is not real if I do not post it to Strava!

Yesterday, I went out to run, to see where my body was at. I am signed up for the local fall marathon. I have not, however, put in enough miles to give it its due respect. Yesterday was a test run, and my body said "Yeah, so, not going to happen." I mean I can run 26 miles. But not with gusto, and I want to run with gusto. So, as the song goes, If you haven't got a marathon, a half marathon will do. If you haven't got a half marathon, God bless you.

There is an amazing athlete who gives me some coaching. She is like a God(dess). She was kind enough, when I informed her of my decision to go half instead of full, to say I was wise to listen to my body or something like that. Also, I think she said something about kicking some ass at the half. Gulp.

Coaches are key, if they are the right ones. Mean words, discouragement and abuse do not a good coach make. But someone who can see a flicker of fire within you, and blow on it and add just the right amount of kindling to turn it into a full on roar? That is priceless.

Several weeks ago, on a run with my eldest child, I spoke out loud my uncertainty. I said I am not actually sure I am a runner anymore. My body just does not seem to respond like it used to. In a couple of short weeks I turn 45, and maybe I am just done as a competitive runner. My child, who really is no longer a child, turned to me with these words. "Don't stop." And something along the lines of wanting to be as fit as I am when she is my age. I think the word inspiration might have come up in this particular conversation. I held back my tears.

And then there is my dog. He is not super fast (except when the pit bull was chasing him a couple of weeks ago: man, was he fast then). But he LOVES running. When we go for a walk, he looks at me quizzically, as if to say "What is this? Why do you move so slowly? Are you somehow damaged or lame?" The best is the beach. Off leash, he stretches his limbs and we run. For the first 2 miles, he is ahead or by my side. After that, he falls behind, but his tracks are neatly aligned with mine, evidenced in the sand which tells you where you were and what your gait is and what size shoe you wear. Do not commit a crime, then walk through sand.

He falls behind, but he is so content, running at his own pace for 6 or 8 miles, on the beach, with the spy-hopping seals and the flocks of chase-worthy birds and the smell of sea salt and fish and rotting seaweed.

As much as I love the Earth, I will get another Garmin.
As much as I doubt the fire within, I will listen to my Coach.
As much as I mourn my lost youth, I do appreciate the word of a kind young woman.
As much as I hate the way my dog smells after a beach run, I will continue to take him along and revel in his joy.

Thirteen point one: kiss my (almost) 45 year patooty.