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.

Life On Hold

How are you feeling?


No, really, how are you feeling?


Fully vulnerable here: I’m scared. Worried. Agonized. Overwhelmed. Angry. Fearful.

The list goes on.

And I imagine you feel the same, too.

How do we keep going in a time of unprecedented uncertainty?

As you know, my own situation is layered with the fact that I was recently diagnosed with breast cancer and am undergoing chemotherapy. As the side effects of cancer treatment take hold, I add to them the very real worries of Coronoavirus infection to my immunocompromised body. I do not wish this burden to anyone.

But I worry less about myself than others: patients, our dear employees, my loved ones – many people fall into more than one of these groups – and we are all living with heavy burdens.

My heart hurts.

My brain hurts.

My body hurts.

Fertility treatment is literally on hold. We have been directed by the American Society of Reproductive Medicine and the Minnesota governor through a direct order that we must stop treatment. I will get into it later on whether fertility treatment is elective (it is not in my opinion), but our hands are tied. We can’t even do procedures that involve gloves. This effectively rules out almost everything we can do to help our patients build their families.

Super vulnerable: This morning I was feeling particularly hopeless. This is very unlike me; I am generally an optimistic person. I made a list of things I could not control. It was bleak.

I cannot control that there is a global pandemic. I cannot control that I have cancer. I cannot control that my life’s work and purpose have been – temporarily – taken away with an uncertain timeline to resume. I cannot control that patients whose own fertility timeline is limited are being forced to put their lives on hold. I cannot make this virus go away and get our lives back to normal.

And then I made a list of what I can control.

I can write in my gratitude journal every day; today’s entry was that I was safe for one more day. I can be present. I can show love to my family and pet. I can be kind. I can maintain relationships. I can eat nutritious foods when I am able due to my cancer side effects. I can hydrate as I am able. I can walk outside – alone – when energy allows. I can think and reflect. I can follow isolation guidelines to minimize my risk of infection. I can not give up hope.

And I can plan. Normally I do not have the luxury of time to think; I just do. Now I can plan. How to do better and be better. How to be a better physician, colleague, partner, parent, friend and human. As myself how I can help patients NOW. We may not be doing embryo transfers this week, but we will be back. And I can plan and be ready. We are finding ways to stay on top of the changing landscape and be able to nimbly slide back into our mission and work, only better.

Sending love and strength to all.

Chemo #1 Is in The Books

^^^ Wore some mantra bands – all gifts – for luck and courage. Seemed to work!

If you’re curious, here’s how my first chemotherapy session went on Tuesday. 

My check-in time was 12:45. I squeezed quite a bit into the first half of the day before chemo started.

I had a baseline bone density test (DXA scan) scheduled in the early morning. This will periodically be used to monitor me for osteoporosis, which I am now at greater risk for developing from the cancer treatment and its side effects. This was quick (10 mins) and painless. The technician performing the scan was making small talk and asked what I was planning to do the rest of the day. Me (brightly): “Getting chemo!” Her: Silence.

And once again, cancer becomes the ultimate conversational mic drop.

She mentioned one interesting thing to me, namely that I was the last patient on their schedule. Because of Coronavirus, they were stopping all bone density testing and routine mammograms. This got my attention. As I’ve mentioned, my cancer was detected when a routine, on time, mammogram in December 2019 showed a change from exactly one year earlier. 

Have you ever delayed a screening test because you forgot or didn’t have time? I have

This led me to think: what if I’d not scheduled that mammogram on time? Maybe I’d remember in January or February and would have been one of those patients getting deferred for now. By the time the restrictions are lifted and the backlog of patients is accommodated, I could easily envision a scenario where my “routine,” no rush mammogram was pushed to May. That would have permitted my cancer to linger, fester, grow and potentially spread for nearly SIX Months. I shudder to think of this.

After the bone scan, I went to work. We are navigating the Coronavirus and wow! It’s dizzying to keep up with recommendations for patient and staff safety. This is far from over.

I left work a little later than I’d planned but with almost zero traffic, I crossed the metro with ease.

After checking in, I had labs drawn. The immediate concern is to see if my immune system is strong enough to get chemo. It was, although that’s not surprising since this is my first treatment and haven’t had the drugs yet.

I had a brief but pleasant appointment with one of the providers on my team and she signed off on the orders to go through with the chemo.

I was led to the infusion room, which was sunny and warm. I picked a chair by the window. I would describe the chairs as being like functional airport seats, definitely not as nice as a massage chair at a fancy nail salon, but not terrible. I mention this because that chair was my home all afternoon. They offered me a blanket or pillow but I declined.

Because of the Coronavirus risk, they staff was also clear that there were absolutely no visitors allowed in the infusion room. I was secretly so happy about this! I envisioned large extended families in matching t-shirts all crowding around Great Grandma to keep her company and support her during chemo. Looking around today, there were definitely some candidates for this scenario but the room was blissfully quiet. Spouse and I had a debate on whether he should accompany me. I said no; it didn’t seem purposeful to have him ruin his afternoon waiting around. Turns out, I was right. It was kind of boring.

^^^ My eyes look a little red, which is weird because this is one of the few days I did not cry.

After getting an IV placed and re-applying lipstick, the infusions started.

First up: two pre-medications to prevent/abate side effects (they both combat nausea) from the other “real” drugs. These each took about 20 minutes and were given one at a time.

Next up: Docetaxel. This is chemo drug #1. It took a little over an hour to slowly drip in. I was given warning signs about potential allergic type reactions that could happen but I was fine.

Finally: Cyclophosphamide. This is chemo drug #2. This can be given in as little as 30 minutes but the kind infusion nurse helping me today said that some patients have sinus pain (? weird?) and giving it over 40 minutes reduced that symptom, so she liked to follow the slower route.

While I was getting the infusions, I read the newspaper, listened to two podcasts, transitioned to music and read a magazine. Their internet was spotty so I couldn’t download the new book I had pre-ordered that became available today. Mental note for next time: download in advance.

When the medicines were completed, I had one more thing to do: I got an automated medication delivery device – it looks like a case for AirPods – attached to the skin of my abdomen. This device is filled with a medication designed to boost my immune system and is set to automatically inject me tomorrow night. One it deploys, I can peel it off.

Total time for this adventure was just over four hours. I felt fine afterwards and was able to drive myself home, and then go for a social distancing approved walk outside with Spouse, Trixie and our dog.

While this was a straightforward experience, I also know it is early. This was cycle #1 of 4, and effects are cumulative. Side effects also don’t kick in immediately, for example, my appetite is low but real nausea doesn’t kick in for 6-10 hours. Immunosuppression starts about a week out and peaks (actually, nadirs) at two weeks, then (hopefully) recovers by the third week – at which time the cycle starts again.

Could the Timing Be Worse?

^^^Rhetorical question.

I write posts when I’ve got something to say and a (little) time to do it.

Some I schedule to post in advance, usually within a few days.

Looking through some of the most recently posted – but not necessarily written – it’s striking how much everything changed so quickly in our world due to the unprecedented global pandemic we are experiencing.

There’s never a good time to do chemotherapy, but starting today feels particularly scary.

After some deliberation, this is what I chose to wear.

The irony of the message on the t-shirt isn’t lost on me, and I am not wearing this to be snarky.

There is so little I can control now.

I can’t control cancer.

I can’t control Coronavirus.

I can’t control my immune system.

I can’t control the calendar, fast forwarding several months to a time that is better, more convenient or less risky.

I can control my attitude.

So I will choose to believe that this day is the start of the next phase, one that will hopefully get me closer to being whole again.

I Canceled Getting My Highlights Done

My roots look terrible but I canceled an appointment to get my highlights done last week.

Really, what’s the point?

My hair’s going to fall out soon anyway.

$300 saved.

My current plan is to get my head shaved approximately one week after my first chemo treatment.

Here are some terrible but accurate comments about chemotherapy-related hair loss:

Hair usually begins falling out two to four weeks after you start treatment.

It could fall out very quickly in clumps or gradually. You’ll likely notice accumulations of loose hair on your pillow, in your hairbrush or comb, or in your sink or shower drain. Your scalp may feel tender.

Your hair loss will continue throughout your treatment and up to a few weeks afterward. Whether your hair thins or you become completely bald will depend on your treatment.

People with cancer report hair loss as a distressing side effect of treatment. Each time you catch a glimpse of yourself in a mirror, your changed appearance is a reminder of your illness and everything you’ve experienced since your diagnosis.

My take on the loss is that it is inevitable. I have followed some other patients’ journeys via Instagram and it seems that even those who try to fight the good fight eventually succumb to a full head shave, and the in-between stages are not exactly awesome.

Plus, I am lazy. I do not like to clean at baseline, much less sweep up masses of hair from every surface of my home and unclog disgusting shower drains. It seems more efficient to have this done in one fell swoop in a salon setting that does not require me to maintain cleanliness.

Here is what I am really upset about, though:

New hair may grow in just like old hair, or it may be thicker, curlier, straighter, or a different color than it was before treatment. Some women who regularly color-treated their hair are surprised when new hair growth is completely gray.

Oh, my god.

Now would be the time for me to hit the panic button. Repeatedly.

I have always joked that I will die blonde, dyed blonde.

This led me to google the following:

Fortunately, it seems that extremely short hair is still dye-able.

Whew.

Now here’s hoping to get to that next phase.

Here We Go

Well, I still didn’t get around to buying a wig yet, but it’s time: I start chemotherapy next week.

With our planned spring break trip quashed by the Coronavirus, it opened up an opportunity to start chemotherapy sooner rather than later.

It took a lot of finagling (props to my amazing assistant, C, for getting this done), but I am squeezing in chemo session #1 after an early morning bone density scan (I’m the patient here; this is a baseline pre-chemo requirement), then doing procedures in clinic #1, driving across town, finishing a half-day in clinic #2, driving across town in a different direction, (hopefully) getting the chemo, and finally circling back home.

The rest of the week is already fully scheduled, so fingers crossed that I follow the predicted path where my worst post-chemo days will fall over the subsequent weekend.

No rest for the working #doctormom.

I mentioned above that my assistant worked extremely hard to make this happen, and that is a gross understatement. When the earlier chemo appointment was offered to me, I knew I had to make it work, but it felt insurmountable given the patients who were already scheduled. I hate to cancel or move patients. In my entire four year residency, I did not take a single sick day. I missed one week my intern year when my father died, but I was on an off-service rotation and it did not impact anyone else. I was so conscious of this.

In the past 15 years, I can count the times on one hand that I have called in sick (One was memorably on Election Day in 2008, when our entire family had a horrible GI bug and I was 23 weeks pregnant with Trixie, but I was DETERMINED to vote for Barack Obama and went to the polling site with my own trash bag in case I needed to throw up. I digress).

Much like when I was trying to schedule my mastectomy, I feel terrible that I am inconveniencing others, making patients change long-planned appointments or incite anger or frustration that causes them to fire me and go elsewhere.

Or eviscerate me on review sites.

While some of the grit I have shown throughout my career is what makes me a good doctor (and I can appropriately say that at this point), I also wonder when enough is enough.

If I was giving advice to someone else, I would tell her she’s nuts to prioritize a half day of work over GETTING CANCER TREATMENT. We are talking about chemotherapy here, not highlights at the salon.

And there is also the nagging voice in my head that also wonders (fears?) that some of the unrelenting stress I have brought upon myself has contributed to my diagnosis in the first place.

For now, I am going to play cycle #1 by ear. I don’t know how I’ll respond. I don’t know how I’ll feel. I don’t know which side effects will affect me. I don’t know if I’ll need time off or if I can (mostly) work full-ish time.

And I will need to make peace with that.

“Cancel Everything”

This article in The Atlantic is getting a lot of (well-deserved) attention.

The link is above and it’s well worth your time to read it.

As someone who is currently undergoing cancer treatment – a.k.a. a high-risk, immunocompromised individual – I feel strongly about taking pro-active measures to keep society – and myself – safe.

Our long-anticipated spring break cruise?

Canceled.

While it was not a hard decision for our family to make, I am still part of a social media group of fellow cruisers who are still planning to embark as scheduled.

It’s disappointing to see so many comments along the lines of “Whoo-hoo! Less people at the buffet!” or “Free upgrades for everyone!”

The most dangerous fallacy, I believe, is this: “But I’m healthy.”

Up until recently, so was I.

I practice a very niche area of medicine and for the most part, I don’t have a high patient volume nor are most of my patients extremely ill.

But think about other medical specialties like geriatricians, ER physicians, oncologists, critical care physicians, etc. There are many specialties where patient acuity and volume are both high. Some fellow OBGYNs I know routinely see up to 40 patients a day.

So, even if you are a healthy individual, an infected-but-asymptomatic (or incubating) health care provider could easily be a point of contact for dozens of really sick people every day.

Patients who are seeking care for one illness may be put at risk for acquiring another.

This could get bad very quickly, and likely will.

I agree with many of my colleagues that health care providers, and especially physicians, should lead the way as role models as we wade through the Coronavirus pandemic.

Hopefully some of the residual cruisers will also get the memo, although as we’ve seen recently, even if they don’t, their vacation may get an unwanted 14 day extension in quarantine.