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As I'm beginning this on Wed Jan 18, I have to report that I've needed short-acting pain medication--one dose each day-- on Monday and Tuesday. The chest pain remains well controlled but I am having low back pain and weakness in my left leg to the point that I cannot lift my leg into the auto when I want to drive. So I'm scheduled for an MRI of the lumbar spine today to see if there is nerve compression.
Thu Jan 19. Yesterday was one of those mixed bags that makes it impossible to predict either short term or long-term future. I got the report from the Chest CT scan from last week and it showed shrinkage of the chest tumor and the lymph nodes in the chest. However, there was a significant increase in the amount of bone destruction in the spine. Yesterday afternoon, I had an MRI of Lumbar spine which demonstrated the increase in destruction and growth of the tumor into the psoas muscle, a large, powerful muscle that attaches inside the body cavity from the spine to the thighs. So, today, Dr. Stella, the radiation oncologist will go to work to develop a treatment plan for attacking the tumor around the spine and around the painful rib. He warned me to be sure that I took analgesics before coming to see him today. I'm very curious about this process and I'll do my best to relate it to you.
Fri Jan 20. I visited Dr. Stella yesterday. They use a very high voltage x-ray machine to deliver energy to the area of tumor. Because high energy beams are not particularly good for providing images, the high-voltage machine is attached in tandem to an imaging machine. I was positioned on the table and several pictures were taken with the imaging machine to obtain the exact area to deliver the radiation. In my case, there are two areas, one to my Lumbar spine where the tumor is destroying the vertebrae and pushing aside the muscle. The other area is to my left 5th rib which has been eaten away by tumor at the place where it hooks into the spine.
Dale is the technician at Dr. Stella's office that does the positioning and pulls the trigger for the high beam radiation. Once I had been positioned, another test picture was taken "just to be sure." Then I was zapped for about a minute in each of the windows. An India ink tattoo was placed on a few spots on my belly and chest so that I can be more easily repositioned on my next visit which will be Monday.
The reason that radiation works is because of the differences in growth rate between normal tissue and tumor. Tumor is reproducing much faster than normal tissue. In order to reproduce, the tumor cell has to go through "mitosis" where the chromosomes line up next to each other and copy themselves. While in mitosis, the cells are particularly vulnerable to radiation that causes mutations in the cells. One hopes that the mutation will prevent the cell from surviving.
In addition to a direct beam of radiation through my abdominal wall to hit the Lumbar Spine, the high beam machine can rotate through a full circle and attack the same area from the back. So the Lumbar treatment is split into front and back blasts of energy. The rib is only a centimeter or so away from the skin in my back. The treatment to the rib is from the back.
I was told that I might notice improvement in as little as 2 weeks. A normal course of treatment may be from 4-8 weeks. I was glad to get started yesterday. I'm hoping to be able to reduce the amount of pain medication. I think that will make me less tired.
Today, Jan 20, is my chemotherapy day at Stanford. A CT of the chest was done locally on January 13. The radiologist in San Luis Obispo thought that there was some overall improvement in things inside the chest with continued progression outside, in the spine and in the ribs. However, the radiologists at Stanford did not share that optimism and continue to call the disease "progressive." Dr. Neal, the oncologist, decided to stop the carboplatin and the Avastin and to continue the Alimta for two more cycles...today Jan 20 and again on Feb 10. I'll then get another CT to assess progress. He mentioned something about being offered another clinical trial of chemotherapy after Feb 20.
Mon Jan 23 The lost weekend. I had no symptoms from chemotherapy other than a change in sense of taste on Friday night. I awoke early on Saturday feeling well and started to work on taxes. Late in the morning I felt overwhelmingly tired. We had visitors coming at 2 P.M. and I wanted to get a nap, but I couldn't manage to get out of bed. I would awaken for a few minutes then doze off to sleep. Company came and went but I still couldn't get up. Over the next 12 hours or so, I was up and down with prostate symptoms as well and I ran a fever of around 100.6 with sweats.
Early Sunday morning I noticed that I was having low back pain that had escaped control of the Fentanyl patches and I began to take short-acting oxycodone and I've been using it off and on up until now. Since I am scheduled for a radiation treatment, I want to make sure that my pain medication is adequate to allow me to move around on the flat, hard surface of the x-ray table this morning. Yesterday afternoon I could not pay attention to the NFL games and I napped through most of them except the last half of the 4th quarter of the Giants game.
Believe it or not, the most annoying symptom is a strange smell that is faint and metallic. It makes me feel nauseous and like a crybaby. If I can sit outside in the sea breeze, the ocean smells block it out. I decided to see if pot were any help. Instead of using a vaporizer, I took a small pipe and took 1 hit. About 30 minutes later, I found myself eating. I was able to sit down with Jasmine for an hour or so afterwards and then I went and took another hit. It seems to let me tune out the smell.
This morning I am weak and shaky, but I am able to eat and the odd smell is much less prominent.
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Career Change at 50
In 1992 I had been working as a prison medical director for five years. It was probably the most challenging and interesting work that I had done in medical practice. It required hands-on medical practice, oversight of medical services, supervision of physician assistants and nurse practitioners, responding to complaints from a variety of sources, and resource management. It also gave me the opportunity to do a fun project by developing a computer-based inmate locator and reminder system for routine sick call and chronic disease clinics. I was also writing a small handbook for dealing with "Difficult Patients."
I had become very much interested in "relationships" in medical practice--particularly between doctors and patients. Of course the driving force for the relationship was "the patient's disease," a process that begins when the patient recognizes some change in his body. Most of the literature in this area came from psychiatry and I was increasingly drawn to fantasies about retraining in psychiatry. I was in a mood to return to an academic environment and to have an opportunity to learn new skills and to read extensively in the field.
With my two boys, there were two college education responsibilities heading in my direction, but Molly and I had agreed upon our separation that we would share these costs. I had made a decision many years before that it would be reasonable to bear the full costs for a state university and that any desire for something more expensive would be on the child who wanted to go that direction. My thinking at the time was that expensive undergraduate degrees were no better than state diplomas (I'm not as sure of that now) and that the child could find a way through academic achievement, work, and borrowing if something more was desired. I assumed that a choice of professional or graduate school was the most significant decision, far overshadowing the actual selection of 4 year university study.
Finally, the health care agreement between Maryland and our prison contractor, Correctional Medical Services (CMS), was in the final year. There were several companies that intended to bid for the new contract. All of this came to a head in 1992 and I began to look seriously at a career change. I have given my reasoning previously, but I'll repeat some of it here.
1993: I'm 50 and wondering if I can do this anymore
I have reached the age of 50 and realized that I had been a much
better family doctor at age 40, when I moved to Smith Island. At the age of 40,
I was still delivering a few babies each month, taking care of newborns and
children, doing routine GYN work, particularly pap smears, assisting in
surgeries, etc. I was still reading a lot of general medicine. By age 50 I had moved out of family
practice to prison work, all adult males and administrative duties. As the
medical director of a prison for 6 years, I had seen our wonderful
psychiatrist, 70 year-old Charlie Bagley, in action . He came to
work a few hours after I did and went home a few hours before I did and took no
call which I did for me and for him. He was making twice my hourly rate. It was
time to think about retraining for the home stretch of my career.
Psychiatry had great appeal. I had always been interested in it,
particularly so when working in a prison and discovering that most of sick call
was about something other than being physically sick. Not many physicians were
curious about this, but I was.
Consider the difference between medical and psychiatry emergencies
in sheer volume of the number different types of medical and surgical problems
that come racing through emergency room doors. Chest pain can be heart attacks,
pulmonary emboli, pneumonia, a cracked rib, shingles, peptic ulcer, dissecting
aortic aneurysm, etc. What about abdominal pain? Appendicitis, cholecystitis,
liver abscess, peptic ulcer, celiac or superior mesenteric thrombosis, Crohn's
disease, ruptured spleen, kidney stone, inguinal hernia, etc, etc. There are
severe time restrictions on making the diagnosis since survival with some of these
conditions is predicated upon very early recognition and intervention.
Compare these medical emergencies with the treatments that must be
provided the psychiatric patient? The primary tools that are useful in
psychiatry are threefold...
- talk to the patient, see if you can de-escalate
the situation
- if the patient is threatening self or others, you
may grab the patient and try to control the situation with overwhelming
physical force humanely supplied and applied
- medicate the patient with one of about 4 or 5
various cocktails of proven effectiveness
Voila! My goal at 50 was to practice medicine as long as possible.
Psychiatry was the most attractive. It is also a discipline where experience
gradually increases personal effectiveness. The wisdom of interaction with other
humans is collective. I could be a better psychiatrist at 70 or 80 than at 55.
I was sure that this was not possible for me in family practice.
Retraining meant that I would have to move. I had hoped to wait until Keith completed high school because he was active in basketball in a small school where he was guaranteed some playing time in his junior and senior years. He had a good group of friends--he was just a great kid with a wonderful temperament (it sure balanced out mine). He was very smart and funny.
In the last year of the health care contract at the prison, CMS decided that they could not afford to give raises to staff. Instead of raises, the company decided that they would do other things for employees, like sponsor picnics and group outings. The big bonus for the year was to take us Eastern Shore yokels to a Baltimore Oriole baseball game in Baltimore, 150 miles up the road to the gentrified part of Maryland.
Keith's Wisdom and Humor
Love Those Os
On a late spring day in 1992 there was a company-sponsored outing for our prison health workers. At about 8:00 we boarded a large bus in Princess Anne Maryland and made the trip to Baltimore Camden Yards, the home of the Orioles. It was a part of Baltimore that I knew well, a few blocks away from my medical school. We had made good time and we were told that we about 90 minutes to kill before entering the stadium. I took the boys for a quick trip to Burke's bar, an old hangout from time in Baltimore. It was a lot cheaper feeding and filling up two teen-age boys at a restaurant than trying to accomplish the same feat at a ball park.
We made it back to the bus in plenty of time and we were met by the CMS regional manager who was to escort us to our block of seats where the president of the company would greet us. As I recall we were parked near far left field while our seats were in far right field. So we started walking--a rather long walk through the crowds--down from left field, around the home plate area, and then another hundred plus yards down the right field line. When we reached the general area of our seats, we started to climb. And we climbed and we climbed to the top tier. Near the top of the stairs, we were greeted by the CMS president.
It was at this time that I could hear my son, Keith call out to me. He was a couple of rows down. He has a booming voice. "Hey, Dad. Your company spared no expense!"
I got a laugh out of watching the major leaguers do their pre-game calisthenics and stretches. I thought about Babe Ruth whose row house at birth was just a few blocks west. It had been turned into a bar and grill, named Ruth's, and was two blocks from University Hospital. It was a favorite watering hole with medical students, at least for my class. It had a pinball machine and good roast beef sandwiches. It was also a hang-out for people coming off call and frequently filled with resident physicians wearing various colored scrub suits and drinking draft beer at 8 A.M. Rather than being out there stretching before the game, the Babe would have been at a place like Ruth's bar, knocking back a couple of beers with hot dogs. Then he would look at his watch and say to his pals, "Let's go play some ball."
Finally, the game came. In the second inning I saw a line drive pass above the second baseman's outstretched glove at the same time that I heard the sound of the ball coming off the bat. The ball had traveled 127 feet before the sound had reached me. Keith was right.
On Being Fortunate
Selfish knave that I am, I had a significant self-interest in my boys making it to the age of 21 without being a participant in an unwanted pregnancy. I wanted no part of more child responsibility. So, I was the parent who would give the lectures about condoms on a yearly basis. To the disclaimer, "Dad, we know all that" my response was "If you know all that then show me right now how you will remove a condom."
The usual response to this query was "YUK."
The last time I asked Keith about his condom use was his first year of college. "Keith, are you practicing safe sex?" His response: "When I get lucky."
On Bereavement
A middle aged woman is sitting with her husband at my kitchen table. I'm serving cake and coffee. The lady is complaining about her 82 year old father who buried his wife of more than 50 years only 6 months prior and has just taken up with an old flame with plans of marriage. "I can't believe it is only 6 months," she said. Keith piped up in a consoling voice, "Maybe he mourns quickly."
Keith plays things close to the vest. He is wonderfully good natured and met the girl of his dreams midway through college. I've never seen them bicker. As far as I can determine, they are still in love after after more than 10 years. He works as an economist and he is able to balance his work with his family life. He loves to cook and has followed his wife's path into the veggie world. I admire this kind of ethical decision, but I suspect I will prefer warmed over bleeding beef until the day I day. I can't imagine the thought of life without a hamburger in my future. Should bovines go suddenly extinct, I'm likely to pull the plug.
BRIAN
Brian is very deep. As a child he was hard to soothe. In addition, his parents were engaged in their own struggles and he was in leg casts for much of his first year. He needed little sleep and didn't want to nap. His care could be very wearing. He also had recurrent, painful ear infections that added another dimension to the mix--really messy diapers from the antibiotics in addition to his pain.
He is mathematically gifted. I'm pretty good at doing mathematical estimates in my head. He is several times faster. While on Smith Island, he won the Math prize for the region that included several counties on the Eastern Shore. He received a similar award and scholarship in high school. He loved playing basketball and I think that he worked hard getting the most out of his physical attributes. (After all, we know that "White Men Can't Jump"--aren't you tired of all the bullshit that fails to recognize African-American superiority in many areas of Athletics? What is that denial all about? The Soviet Union was great at ignoring science that contradicted the various versions of Marxism that were fashionable in different eras. Don't we do the same thing with ignoring what we see in the NBA and NFL every day?)
In a much earlier post, I mentioned Racism and fessed up to some of mine. There is no way I can look into my childrens' heart of hearts and claim that there is no vestige of racism. However, I have good knowledge of how they spent their time and treated friends and acquaintances for the past 25 years. In 1987 they were very concerned about moving from a "lily white" insular culture and going to a larger school that was about 50% African American. However, they were basketball players and this was a sport that in Pocomoke was dominated by blacks with a sprinkling of whites. We had a color-blind basketball court in our back yard that was located close to the geometric center of town. I think that my boys are close to color-blind today but remain aware of what their black friends must still deal with in our society.
Brian married a Lorena, a woman from Guadalajara who is intelligent, has great people skills, and exerts a calming influence on this smart, restless guy. I didn't meet her until going to Guadalajara a few days before their wedding. I liked her from the start. She was very direct. "How do you explain having been married five times?" was perhaps the second question after "How was your trip?" That made me like her even more. I don't remember exactly what I said but I do know that it was equally direct. I may have pointed out that she owed me some gratitude for my first divorce and marriage to Molly thereafter.
Brian has been enveloped by his wife's large extended family. He is fluent enough to pass for a native speaker. A day after his wedding, there was a party with a mariachi band outside of the city. I remember looking at him sitting with his friends in light hearted conversation. He appeared to be so relaxed and to be in such a good place emotionally that I had one of those "Peak Moments," a place that is so good that it can't really be described very well in words. Seeing your children in a good place is hard to beat.
Their first child, Oliver, is "almost perfect" according to Brian. He is big, curious, bilingual, and stubborn. Two years ago, Brian and Lorena found out that she was carrying a "Down's Baby." This was confirmed by chromosomal analysis showing Trisomy 21 after birth. This was quite a blow to their sense of the future. Lorena is very close to her mother and I suspect that she had hopes for a similar intimacy with her daughter.
The baby, Ana Paola, was very sick. She had congestive failure to the point that she did not cry because of the additional exertion required by the heart. Surgical intervention was required but the heart was too small for several months. Surgery was finally done on October 2010. She was in the intensive care unit for a week. She required doubly synchronized electronic heart pacing--both atrium and ventricle. There were concerns that she may have had a stroke on the fifth or sixth day but the symptoms passed.
It has been eye-opening to see Lorena's and Brian's response to all of this--the blossoming of love for the child, the acceptance of the limitations. It was so gratifying to see my child demonstrate a level of love and concern that exceeds anything that I have been able to find within myself--and to see it done with such pleasure and grace is remarkable.
Privatized Medicine in Prisons
States have found that it is very difficult to use state employees to run a 24/7 medical operation--it becomes particularly expensive to staff nights and weekends because of overtime costs. With seniority considerations, the cost of labor increases yearly. The specter of rising pension entitlements is also as a negative.
California uses state employees to run prisons. The prison closest to my house in California is typical. There is a "chief of mental health" who supervises psychologist and psychiatrist supervisors, who then supervise psychologists and supervisors.
Above the "chief of mental health" is a "health care administrator at the prison," a set of regional administrators above that, a chief psychiatrist in Sacramento above that, and an assistant director of medical services above that.
So there are at least 4 layers of supervision above the chief of mental health. Of course no service work, i.e. face to face care, occurs except at the lowest levels--psychologists and psychiatrists, 2 levels below the chief of mental health. Lot's of layers on top of the folks who actually provide the services.
The Maryland system was much tighter. In Maryland, there was a headquarters staff that was headed by an Assistant Director of the Department of Corrections for the state. Below this there was a management team--experts in Medicine, Psychiatry, Nursing, Social Work, Pharmacy, Accounting, and Contract Monitoring. They were not there to supervise. They were there for planning, oversight, program direction, and quality evaluations. There were several nursing field workers who were capable of going to an institution and doing investigations of various complaints. So there was an essentially bare bones organization at the top. All of the supervision of medical line staff was pushed down onto the contractor who was given quite a bit of latitude provided that the medical care was considered acceptable.
The Maryland contract included staffing numbers of specific health care personnel during certain shifts for the various institutions. The contract was expected to staff at that level and to provide an adequate level of care. Accounting was done using reports from time cards with spot audits as well. Maryland imposed stiff penalties on the contractor for failing to provide any mandated coverage. I don't remember the exact rates. Nursing was the largest staff of employees. The penalty for failure to provide a contracted hour of nurse care might have been as much as twice the going rate from the standpoint of salary. This imposed a significant financial incentive on the part of the contractor to fill the positions or to fill shifts from contract or "registry" staff.
Musical Contractor Chairs.
In 1993 I saw how a changeover from one contractor to another comes about. It was not pretty. Nurses who had come when the prison opened had now worked five years for CMS. They had started at the entry level and had acquired raises along the way. In addition to increases in pay with seniority, there often comes some other benefits like more sick time or annual leave.
The new contractor was not bound by any arrangements made under the former contract. While the new company was anxious to keep good staff and to make sure that they would be able to deliver services from day 1, there was no obligation on their part to do it with the same personnel. This was a time of high anxiety for the healthcare staff as they were interviewed individually by the management team for the new contractor which in this case was Prison Health Services (PHS). The first concern was keeping their current job, the second being the reimbursement.
As it turned out, anyone hired by PHS was a "new employee" with benefits fixed to the company's policies. Everyone started over. It didn't matter that a number of employees were on the verge of celebrating a work anniversary with the prior company, Correctional Medical Services (CMS). All were back to square 1.
I came to believe that it might be beneficial to "lose" a contract from time to timed since it destroyed long-term seniority for any employee and prevented "benefits creep."
Looking at Residency Programs
My personal finances remained solid even with the new company. They tried to play hardball and would have if they could. I trusted my instinct that very few physicians would want the job. I negotiated a very good contract for myself but I immediately began searching actively for psychiatry residency programs. Normally, these are four year programs with the first year spent in general medicine with emphasis in neurology.
I was hoping to find an institution that would give me credit for my internship of 1969-1970. At the time Brian was beginning college at William and Mary in Virginia and Keith was entering 10th grade. Molly was a resident of Virginia which has an excellent state school system that included William and Mary (where Jefferson studied law), the University of Virginia, Virginia Tech, and others. Anyway, these state schools seemed to match up well with the more expensive private Universities.
My first choice of programs was Virginia Commonwealth University. It is located in Richmond within about an hour of William and Mary. I went for an interview. They would accept me if I chose to enter as a first year resident--meaning I would need to spend four years there to complete the program. There were no openings for me in the second year. It wasn't negotiable and this closed the door to the possibility of remaining within 90 minutes from the boys while I was retraining. Keith was not pleased at the idea of moving but he was stoic. I did want to know from him whether there was some geographic location that would be appealing to him for a couple of years, but he was non-committal. It was more likely that he would go to live with Molly.
At this point, everything seemed open. Without day to day parenting responsibilities, I could live anywhere and retrain anywhere. "Anywhere" was very attractive. After almost 10 years of East Coast weather, the thought of a dry Western U.S. environment was most appealing. I was particularly interested in New Mexico, Nevada, Texas, and Arizona. I looked at programs in Texas and Arizona as a visitor and I was encouraged to apply. However, I liked the atmosphere better in New Mexico and Nevada and I applied to those two institutions.
I liked both programs. Each had different strengths and weaknesses. The weakness in Reno was the small size of the department and the fact that the program was in its infancy--just a year old. There was an existing class of 1st year residents that I could join in the second year. This would be the first "graduating" class from the psychiatry residency program. Residency programs often supply "cheap" doctor manpower to the hospitals and clinics served by the program. If a typical psychiatrist was making $120K in 1993, a resident might be making $30K. It is cost efficient to use the resident whenever practical. New Mexico was excellent at squeezing residents in this way. The advantage of Reno was that the psychiatrists there were used to doing all the work themselves--I judged them to be less likely to be effective exploiters.
I was accepted by both programs. I chose New Mexico primarily because of the culture and history. It was a well-established department and the living conditions in Albuquerque and Santa Fe had attracted retired academic psychiatrists who enjoyed doing part-time teaching. If you check out the authors of various standard textbooks in psychiatry, it is surprising to see the number of contributors from the University of New Mexico.
I
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