Who Owns This Business?

Today is International Women’s Day, but you probably noticed that because it’s all over social media.

I’m here for it.

Empowered women empower women. I wholeheartedly embrace this sentiment.

An anecdote:

Last week I was consulting with a patient and as we were wrapping things up, I asked her if she had any additional questions.

She did.

Who owns this business? Whom are you affiliated with? Which hospital do you work for? Who is your boss?

My answer: I do. I own this business. I am The Boss.

I filled her in: I own this practice with my two partners, one of whom is in the process of retiring. Women own 3/4 of the practice. We have 60 employees, over 90% women. We promote women to leadership positions. We hire and train women. In a former life, I was an employee and now I’m not. I love that. It’s a lot more challenging but at the end of the day, The Buck Stops With Me.

I am here to:

  • Care for Women
  • Educate Women
  • Support Women
  • Advocate for Women
  • Elevate Women

Her response: “Wow. That’s awesome.”

I agree.

Happy International Women’s Day. Together we rise.

A Powerful Tool

My Selfies Are Still Terrible

Last week I heard something so powerful on NPR that I had to pull over and write the words down.

From Journalist Maria Hinojosa:

One tool we have is our Humanity.

If you give Humanity, you will get it back.

Wow. This deeply resonated.

When I describe myself, one word that I frequently use is Authentic.

I strive to be Authentically Me in all situations, although the Authentic Me is often a Big Mess compared to the Carefully Curated Me that I could project.

Many people have commented that they are surprised about how open I have been with my cancer journey, but I can’t imagine being any other way.

I bring the same Authentic Me to my medical practice. Medical training teaches us some rudimentary interpersonal skills, but you really need to develop your own style, which loosely could be called your Bedside Manner.

My own Bedside Manner stems from a combination of personality, experience, time (20 years of being a physician – how did I get here?), and – now – my cancer experience.

But as I heard Maria Hinojosa’s words last week, a light bulb went off.

Humanity and Authenticity are nearly one and the same.

The times I feel I do best in life are when Humanity is seated at the table.

Even in difficult or tense situations – and trust me, I have plenty – showing your Authentic Human self almost always pays off. This can look many different ways, including being vulnerable, sharing a personal story, empathizing with the scenario at hand or acknowledging the elephant in the room.

Because at the end of the day, what I think we’re all striving for is to connect, be heard and hopefully understood.

Humanity is a powerful tool at our disposal to get there.

Grief Tsunami

It’s taken me a long time to write this post.

Like a long, long time.

It’s not that it hasn’t written itself in my head; it has. I just couldn’t muster the will to put it out in the world.

Me, today, January 22, 2021

Quick recap: January 3rd, 2021, marked my One Year Cancerversary from diagnosis.

I’ve been done with chemo since May 2020 and had my reconstruction surgery last August.

All along, I told everyone who would listen that “I’m doing great!”

And here’s the thing: at the time, I meant it.

Strength, wit and grit have gotten me pretty far in life and cancer was no different.

I jumped in head first to cancer treatment and at every turn, I took the harder path.

The dirty secret was that in the end, it didn’t *seem* too bad.

I took off less than 3 weeks for my bilateral mastectomy and 3 days for the reconstruction.

I barely scheduled any time off during chemo, minus the infusion day itself (and I even worked a half day leading up to my date with the IV drugs during one of them).

My energy was ok. I ate food. It didn’t taste great (Hello, metal mouth), but I managed to gain and not lose any weight (whomp, whomp). I exercised every day. I worked a lot. I was advised it was ok to go back into the clinic to see patients a month after finishing chemo so I went back one week BEFORE the final one (I’d worked virtually for two months at the height of lockdown in the spring).

And then, around October, it all caught up to me.

Cancer causes trauma. Period. Despite the strength I felt, and I genuinely do not think it was a front, a tsunami of grief flooded over me. I still can’t shake the PTSD.

My oncologist and other cancer survivors (yes, I am now tentatively calling myself a survivor) have told me that my experience is not unusual.

Diagnosis brings Go Mode, where it’s all adrenaline and fighting the beast. The treatment phase is Survival Mode, where you just need to do what it takes to get through it. But I am still figuring out the manual for Survivorship.

Post-cancer Me is different. I don’t want to go back to the old Me but I also don’t exactly want to stay like this.

On the plus side, I’ve got hair again and for the first time in my life, it’s CURLY. Like curly curly. I got it recently shaped on the back and sides (and was only charged for a men’s cut!) and the shape is approximating a pixie.

On the majorly negative side, I discovered that I am insulin resistant, aka pre-diabetic. My eyelashes are stubs and my brows – after a lifetime of Brooke Shields-esque unruliness – are ghosts of their former selves. The weight I managed to gain during chemo is stubbornly not coming off. I have an old person’s pillbox that is filled to capacity and every Sunday I painstakingly replenish the little AM and PM boxes for the upcoming week.

The Global Pandemic has kept me from doing something – anything – celebratory to mark the end of treatment (I had so many vacations planned!), which contributes to my feeling that the ending of the story remains unwritten.

I bought myself a pair of custom pink sapphire earrings with inverted, spikey stones and gold studs to commemorate (and never forget) the journey.

I immediately lost one, which is the most Me Thing that has probably ever happened.

This Is A Love Story

I know this picture is terrible. It’s hard to capture the back of your head.

This is a love story.

I am married to someone I’ve known since I was an awkward freshman in high school.

We bonded over sitting in the same row in Sister Geneva’s English class and our mutual affection for Chuck Taylor high tops.

I’m obliged to tell you at this point that we did not date until after college, although once in our senior collegiate year I asked if he’d ever thought about dating me.

He said no.

In retrospect, I don’t think that was true, but at some point he clearly changed his mind.

Love isn’t flashy all the time.

There are many ordinary moments I have forgotten over the past 22+ years. That makes me sad.

Our story includes moving five times for my work and many years of waiting to get to the next step, whether it was residency, fellowship, my first “real job” as an attending or some other nebulous goal that was just ever-so-slightly beyond the horizon.

Cancer was a new reckoning.

We’d been through so much already.

But love showed up – mightily- when I asked My Ever Patient Spouse to shave my head one step ahead of the chemo this past spring.

He did.

Months and months later, my hair started to grow back.

Regretfully, no one informed me that I was developing a mullet and it wasn’t until I looked at the back of my head for the first time that I realized I needed a barber NOW.

Once again, I enlisted him into action.

He gently buzzed my head again, but this time, not to scalp. It was just to neaten the edges. I think he did a pretty good job, even if the above photo doesn’t do it justice.

My friends, that is love.

Thoughts on #Pinktober

Well, well, with the turn of the calendar we’ve arrived at Breast Cancer Awareness month, complete with its cringe-y moniker #Pinktober.

Pinktober is highly controversial among breast cancer survivors.

Years of pinkwashing, exposes of “charitable” organizations that weren’t so charitable after all, and controversial political decisions by major players in the breast cancer sphere have soured many to the pink ribbon.

And let’s face it: seeing NFL players in pink jerseys may be a cute tribute, but I didn’t care about that when I was sitting in a chair with chemotherapy dripping into my veins.

More needs to be done.

For me, this is my first rodeo as a breast cancer survivor and I’m conflicted.

There’s the frustrated advocate in me who eschews the hype and demands action, and there is also the grateful human who has straddled the thin line between sickness and health – and she wants to celebrate.

So I’m leaning in to the pink. Hard. I choose gratitude and joy.

And I will proudly wear pink every day in October. I’m lucky that I get to.

Trigger Warning

I tell myself I’m getting better.

I *am* getting better.

Better better better.

I’m now 10 weeks past my final scheduled chemo.

Life is crawling back to some state of recognition.

I work full time.

I run.

I slather my eyebrows and eyelashes with an expensive growth serum and I think I am seeing progress.

I still overeat M&Ms on occasion.

Two things this week, though, sent me spiraling back to thoughts of dying – promptly – from cancer.

The first: Last weekend, I discovered a lump in my left armpit.

The left is my cancer side.

Trigger feelings of doom.

I am in a cancer group where the members regularly commiserate on post-cancer life, where every lump/bump/ache/pain immediately magnifies the tiny, constant worry that cancer has returned.

The lump is soft, mobile and slightly tender. All good signs for it being benign.

Rationally, I know it’s probably nothing. The most likely scenario is a slightly irritated lymph node from the friction sustained from my increased running.

But it nagged me all weekend.

Monday morning, I called my oncologist, just to be sure.

They took it very seriously and to my surprise, I found myself in her office less than two hours later.

I struggled to find the lump as she examined me (Good). It was not very impressive when I did (Good).

She decided to get imaging to be safe (Good plan), but the Worry Train had already left the station.

The second trigger: A song.

Specifically, “Our House,” by Madness.

This 80s tune brings back fond memories, although they’re from 2000, not 1983.

In the fall of 2000 I was a fourth year medical student, interviewing for OBGYN residency positions and traveling around the country for half of November and most of December.

In theory this is a stressful time, as getting into a good residency is a critical step for the future, the interviews can be intense with a lot of official and unofficial vetting going on, and most students (me) were traveling on borrowed student loan dollars and a shoestring budget.

I loved it.

Rushing to the airport, the red eye flights, the dodgy hotels, the pre-interview parties at resident’s homes, the early mornings, the tough questions – this is an environment in which I thrive.

I was so proud of my interview outfit. I had a charcoal gray skirt suit from Ann Taylor that I wore with a crystal blue silk turtleneck sweater and pearl stud earrings. I had the foresight to buy two sweaters so I could rotate them on trips with multiple interviews. I topped the look with a soft black trench from Talbot’s. At this point in my career I would dress for an interview with a lot more style, but at the time I felt like I’d found a respectable uniform.

I also had a soundtrack.

This was in the days of primitive file sharing, Napster and CDs. I had a mix CD – the late 1990s version of a mixed tape – that was filled with 80s and 90s hits, including “Our House.” I listened to that CD countless times in my travels and hearing the songs can send me right back to those moments.

Except yesterday, “Our House” sent me somewhere else.

The weather was perfect for a run yesterday afternoon, and my canine companion (Penny) and I were crossing the last bridge before home when this song came on.

The song reminisces about a happy childhood, yet these are the lyrics that got me:

“Father gets up late for work

Mother has to iron his shirt

Then she sends the kids to school

Sees them off with a small kiss

She’s the one they’re going to miss in lots of ways.”

She’s the one they’re going to miss in lots of ways.

I was flooded with thoughts about dying, loss and my children, and unfortunately, no amount of running seems to be able to tamp them down.

Survivorship is such a struggle, but I hope that I will continue to be a Survivor for a long, long time and eventually I will find peace with post-Cancer life.

Hopefully, the triggers will be fewer and farther between.

Regardless, I will continue to overeat M&Ms.

Finding Meaning

2020 has not been my year.

Last week Spouse and I were discussing the state of the world and its problems, and in our personal universe, Cancer now occupies the #3 spot on the Terrible/Awful List.

#3!

That’s how bad 2020 has been.

(If you’re curious, Racism and Global Pandemic “won” the top two).

I don’t think we’re unique in our opinion of 2020. Perhaps you feel the same.

The General Awfulness of 2020 has led me on a quest for meaning.

And I’m determined to figure it out. Here’s a place where I started:

This academic manuscript is old but remains relevant for 2020. Full text is available; the citation is above.

Ostensibly, it’s about cancer, but the messages can be applied to so much more.

Here’s an excerpt from the introduction:

According to theorists, human beings have a “will to meaning,” a fundamental need to seek meaning and fulfillment in life. Meaning has been equated with purpose in life, life satisfaction, and positively valued life goals. Others view meaning as a sense of purpose and coherence in one’s life, and awareness of the value, fragility, and preciousness of life, or the personal significance of a particular life circumstance … Reker has come closest to synthesizing these diverse conceptualizations by defining meaning as “the cognizance of order, coherence and purpose in one’s existence, the pursuit and attainment of worthwhile goals, and an accompanying sense of fulfillment.”

The authors also differentiate between Global and Situational Meaning, using a framework described by Park and Folkman.

Of the two, Global Meaning is the bigger concept. It refers to “people’s basic goals and fundamental assumptions, beliefs and expectations about the world.” Examples of Global Meaning include an individual’s personal beliefs encompassing religion, spirituality and the order of the Universe; these ideas provide a philosophical structure for interpreting the world, adverse events and life purpose.

Situational Meaning is more personal: it’s the interaction of one’s global beliefs and the immediate circumstances of their life, i.e. where the Venn diagram overlaps.

After studying cancer survivors, the authors of the above study developed a Meaning in Life Scale composed of four elements:

  • Harmony and peace: Positive emotions and thoughts connoting a sense of tranquility, serenity and comfort
  • Life perspective, purpose and goals: This is the individualized meaning assigned to oneself and one’s own life. Optimism about the future is a common thread.
  • Confusion and lessened meaning: This is the bad one on the list, and hopefully this is a temporary state. Per the authors, this is “a decreased sense of value to life and a belief that life is a negative experience.” They go on to say that many cancer patients (read: human beings) experience periods of meaningfulness and also periods of meaninglessness.
  • Benefits of spirituality

For me, 2020 has provided more than ample opportunity to search for Meaning.

Perhaps you relate.

And while I don’t have any answers yet, I’m here to learn.

Comfort with Discomfort

Today, exactly 16 days after finishing my last scheduled chemotherapy, I had my first cancer survivorship appointment.

Survivor.

I am so uncomfortable with that label.

It feels too bold. Unearned. Risky.

How dare I tempt the Fates?

The discomfort is gnawing and visceral.

But having comfort with discomfort is something I’ve practiced for a long time.

(Apologies in advance if you’ve ever been a student/resident/fellow who trained with me. You already know what I’m going to say).

Most people know that medical training involves a hierarchical model of learning. You start with easier procedures and gradually tackle those requiring more skill and responsibility.

By the time you finish residency and/or fellowship, you’ve spent anywhere from three to seven years climbing this pyramid, enough time to gain a level of confidence and expertise to know you can successfully complete the most complex tasks.

For OBGYNs, a classic example of this is a c-section. At minimum, two people are needed for a c-section, one to be the primary surgeon and one to assist. They stand on opposite sides of the patient and work simultaneously. For right handed surgeons, working from the patient’s right side gives you better access to the pelvis with your dominant hand, a mechanical advantage that comes in handy when you need to reach into the pelvis and safely deliver the baby’s head. Thus, when you’re learning to do a c-section, it’s much easier to be on the patient’s right side than the left. At the start of residency you’re always positioned on the right and at some point you become skilled enough to graduate to the other side of the table.

The thing about residency, however, is that even when you’re confidently leading from the left, there’s always – ALWAYS! – someone more responsible than you are. The attending physician (a.k.a. your professor) may not be physically in the operating room, but theirs is the ultimate responsibility for this surgical outcome, because at the end of the day you’re still a student.

The other thing you may know about medical training is that every June 30th, there is a magical turning of the calendar page and suddenly, everyone gets advanced one year. When it’s your turn to graduate, the buck now stops with you.

3 A.M., July 16th, 2005: The buck stopped with me. I was a newly minted fellow on overnight labor and delivery call, doing a c-section with a second year resident. I was confidently leading from the left and everything was going fine, but I recall a sharp moment of clarity when I realized that holy cow, I was the attending, the only attending, and no one was secretly standing by to swoop in and save me if I got into trouble.

The discomfort of that knowledge was gnawing and visceral.

Eventually, though, (and by “eventually” I mean years), I garnered enough experience, learning and growth to develop a level of comfort with discomfort.

What this is:

  • Confidence you can do the work
  • Confidence you can be successful
  • Confidence you can do hard things and then do more
  • Confidence that sometimes things will not go your way and you will need help, and that is ok
  • Confidence that you will be ok

June 4th, 2020: I find myself once again trying to find comfort with discomfort.

Cancer survivorship isn’t my only discomfort of 2020.

The social injustice and systemic racism unveiled after the murder of George Floyd in Minneapolis – where I live – presents a profound opportunity for reflection, action and personal development.

Eventually, though, (and by “eventually” this time I mean the rest of my life), I hope to garner enough experience, learning and growth to develop a level of comfort with the discomforts of 2020.

What It’s Like to Lose Your Hair

Spoiler: The anticipation is worse than the event itself.

Let’s start at the beginning: This picture was an above average hair day when I still had hair.

I’ve never been motivated nor skilled at styling my hair. Pictures of me dating back 25 years will show straight blond hair in various lengths from chin to shoulder.

I had a look.

Not saying it was a particularly good look, it was just the least-common-denominator style that got me through.

In retrospect, I should have mixed it up a lot more when I had the chance.

I had an elaborate plan after my first chemotherapy treatment. I would go to my long-time stylist and have her cut my hair into a chic short cut, then return a second time for an extremely close crop once the hair loss started in earnest. She was also going to help me find and style a wig.

Sidenote: Did you know a wig may be covered by insurance? Yes, you can obtain a prescription for a head prosthesis. Given that wigs range wildly in cost – ones with real hair can be over a thousand dollars – a prescription would come in handy.

While chemotherapy protocols vary, the side effects of mine (which I’d read, oh, at least a million times) indicated that hair loss would occur 12-14 days after the first dose.

And then, with one global pandemic, my careful plans fell apart.

Eight days after my first treatment, I started to notice some hair loss at my temples.

I decided to take step one and cut my hair myself.

I sectioned my hair into ponytails for easier cutting and put on lipstick for courage.

The end result was not perfect. This is likely my first and last foray into home barbering.

^^^ I measured, and this was also nearly three years of estimated growth.

This is what it mostly looked like during the week I had that cut.

This picture is also the last day I had hair.

Here’s the timeline:

  • Eight days after chemo: Self-Administered short cut
  • Twelve days after chemo: Hair loss started in earnest. Tugging at a small clump of hair was enough to pull some, but not all, out.
  • Also day twelve: I ordered a wig online. This was neither the planned nor recommended procedure, but the Coronavirus pandemic meant that my stylist’s advice and the local wig stores were not available. Furthermore, I did not get to use my head prosthesis prescription and had to pay out of pocket (~$300).
  • Days 13-17 after chemo: I joked that I was like a dandelion in the wind. The slightest brush or pull would result in a large clump of hair coming out. Zoom calls with patients, staff, friends and everyone else were starting in earnest and I was really concerned because my wig had not arrived, and I was quickly running out of options. I stopped brushing and washing my hair. To do so would have resulted in tremendous loss at once.
  • Evening, Day 17: I couldn’t go on like this any longer, wig or not. My dirty short hair was becoming matted and the loss just escalated. When the hair came out, the roots looked totally desiccated, like hair that had been burned. I didn’t torture myself with this activity, but I wager that I could have pulled out half or more of what was on my head with little effort. I asked my husband to use his old sideburn trimming clippers to shave my head.

When the time finally came to get my head shaved, it was more functional and less emotional than I thought it would be. I’d already pre-mourned my hair loss so much in the previous weeks and months that the act felt like a relief. Finally.

A few surprising pieces of information emerged: the first was that while my natural hair color – which I have not seen in a long, long time – was a boring dishwater blond, it was much less gray than I thought it would be. The second is that a bristly head is extremely itchy.

Fortuitously, my wig arrived the evening that I shaved my head. This felt like Divine intervention, the universe giving me a tiny bit back.

My daughter told me that my wig looked like American Girl Doll hair. She is 100% correct.

I don’t enjoy wearing my wig. Most of the time it rests in my closet on an improvised stand, a Nambe vase that I got as a wedding gift.

You can also see in the above picture that I have sorted out piles and piles of scarves to wear on my head. I have watched a lot of YouTube videos on how to style a head scarf.

As of this writing, I’ve been (mostly) bald for about two weeks. I also completed my second chemotherapy session (#2 of 4) during this interval, so in theory, I am halfway done with active treatment.

Internally, I generally feel the same. While I have had some side effects to the chemo, I am grateful that overall I have been doing very well.

Yet.

There are moments where I catch my reflection and gasp. Who is this?

My eyebrows and eyelashes are also getting into the Falling Out game, which just adds to the overall look.

I feel like a nude mouse:

Albeit one with lipstick.

Metal Mouth

When I was young, my grandparents lived on a farm whose water supply came from a well.

There was an old-fashioned pump like the one pictured above in their yard, and I delighted in pumping the handle to get the water to pour out.

The water had a specific taste: sharp and mineral. It was always icy cold.

Adding to its flavor profile was the glass that my grandmother kept – for years – turned upside down on the top the pump:

If you’re not old enough to recognize these, they are 1970s (? earlier?) aluminum tumblers.

I am sure they were manufactured with ALL badness and that there is not a small chance that cumulative environmental toxicity from things just like this contributed to my cancer diagnosis. However, the point here is that drinking from these tumblers produced a very specific mouthfeel, which was an unpleasant metallic taste and sensation that was coming at you from all directions. Adding these qualities to the minerality of the well water produced a drinking situation that was usually reserved for only the thirstiest scenarios.

Fast forward to now: this well water + aluminum tumbler combo is a reality I cannot escape.

Some cancer patients call this metal mouth.

An omnipresent metallic taste is an extremely common side effect from chemotherapy and up to this point, it’s the one I am experiencing the most.

And it won’t go away. Coffee is metal. Carrots are metal. Toothpaste is metal. Water is metal. Even air is metal as I breathe it in.

I consider myself lucky. Things could – and probably will – get worse.

Over the weekend I had a concerning episode that, once over, required me to replace a lot of fluids. I was worried that I wouldn’t be able to do it myself and would need to go to an ER or urgent care for IV fluids. Fingers crossed, I have been able to get by on my own.

And as time goes on, I am becoming increasingly scared of COVID-19 infection.

There will hopefully be more time to expand on this, but in summary, I have not left the house save for walking the dog for the past several days.