The Good Doctor (10 page)

In addition to his misgivings about allowing the surgery to proceed while he was away, my father also regretted never having “had the opportunity to repay [Meyer] for the fortunate way our lives turned out.” Years later, after seeing a play,
The Loman Family Picnic
, about a struggling working-class family, my father pondered how the uncomplaining Meyer surely must have chafed at spending his whole life as a salaried employee of others.

After the funeral, my dad penned a simple obituary: “Meyer. Born in Poland. Lived and worked in America. Prospered but not in the material sense. We always had food and shelter and essentials. Raised a family, had grandchildren and love from all.” But his real tribute to his father was this: every day for a year after Meyer died, either my father or his brother, Allan, two very nonobservant Jews, went to temple to say the Mourner’s Kaddish. I went occasionally. Although my father perhaps did this out of a sense of guilt, and although he again found the prayers and rituals “fruitless” and “misleading,” he nevertheless persevered because
his
father believed that Judaism was so important. It also kept Meyer “more alive” in his mind, as did looking at his father’s driver’s license, which my dad had placed in his own wallet, and rubbing his watch, which he kept in a drawer in his office. Going to temple also provided him with serenity and relaxation. The year of Kaddishes began the day after the funeral, and my father, sitting at home, put a yarmulke on his head and tried to learn the whole mourner’s prayer so he wouldn’t be “faking all but the few well-known first lines.” He also mused during the year about resurrecting the huge family seder, inviting all his Cleveland cousins, but this never occurred.

My father’s diaries post-1977 contain several entries about Meyer, often in the form of dreams he had about him. For example, on Easter Sunday in April 1987, even though my father had not consciously realized that it was the tenth anniversary of his father’s death, he dreamed that Meyer emerged from a swinging door, which caused my dad to awaken with a start. In the dream, Meyer was much younger than he had been when he died, probably in his fifties. Later that day, when my mother pointed out the anniversary and said that she was going to light a Jewish memorial (
yahrzeit
) candle for him, my father actually cried.

In January 1995, my dad woke up from a dream screaming. This time, Meyer had “sauntered around a corner” and frightened him because Meyer was “supposed to be dead.” Later that week, my father made the connection. The day before his dream, my son, Ben, almost two years old, had uneventfully undergone correction of two hernias, the same type of operation that had “killed” Meyer. Nonetheless, my father was happy for the visit. “The subconscious is a wondrous thing,” he concluded.

It is said that physicians—even those who know the latest statistics from large clinical studies—make many medical decisions based on previous vivid experiences. Such cases tend to be either great saves or bad screwups. I don’t know if my father became fixated on preventing blood clots as a result of what happened to Meyer. He was an infectious diseases consultant, so it was not really his bailiwick. Yet even though I was almost a decade away from becoming a doctor when Meyer died, I remained—and still remain—almost obsessive about preventing blood clots. Thus, when I attend on the wards, I regularly scour the list of doctors’ orders to make sure that the resident physicians have given patients anticoagulants, compression stockings, or some other appropriate intervention. Have I prevented any blood clots, and perhaps deaths, through my surveillance? Once again, it is impossible to know. But I always felt that my surveillance was a sort of gift that the kind Meyer was giving to his grandson’s patients.

We were slowly recovering from Meyer’s death when, two months later, my mother found a lump in her left breast. She was only forty-two years old. For the first years in Cleveland, my mom had been a housewife, but once my sister and I were old enough to take care of ourselves, she became bored. Rather than simply returning to the classroom as a teacher, she got interested in educational theory, particularly the idea of tailoring education to fit the student. Eventually, she took courses at a local college, studying learning disabilities. By the mid-1970s, she was teaching children with learning problems in various classroom settings.

I know that my father was proud of what my mother was doing. But his job—and personality—continued to take precedence in the house. My mother was a quiet but strong person, something I would soon come to appreciate even more. But much of her energies went toward placating my father and trying to make him happy while bearing most of the burden of raising my sister and me. Yet when she became sick, it went without saying that my father would assume complete charge of her care.

My memories of my mother being diagnosed with breast cancer are, again, incomplete. I remember my father reassuring all of us that the biopsy of her lump was likely to be negative. I’m not sure if the breast surgeon told him that, or if he thought that himself, or if he was just being his usual paternalistic self, but years later, as a doctor trained in bioethics, I would struggle with this same issue with my own patients. Was it better to be as frank as possible with bad news or to sugarcoat things and always maintain some optimism?

Anyway, I had believed my father enough that when the biopsy came back positive, I was surprised. He told me in the backyard. My mother was inside. I remember hugging him for a long time and then going inside and hugging my mom. Not surprisingly, my mother was much more concerned about the impact of her illness on her family than she was about herself. She reassured me that everything was going to be all right, and I desperately wanted to believe her. Truth be told, the whole experience was a little surreal. I had grown all too familiar with death in the previous few years, but not deaths among members of my parents’ generation. I probably could not even conceptualize the possibility of my mother dying.

One great thing about being part of a physician’s family is that you have access to very good doctors and are often treated like a VIP. This was especially true in the 1970s, when insurance coverage was less complicated and there was still professional courtesy. My mother’s doctor was Charles A. Hubay, a well-respected surgeon at University Hospital, the main teaching hospital of Case Western Reserve. She received the standard operation for the era, a modified radical mastectomy. Because it was 1977, my mother benefited from the activism of women like Rose Kushner. The biopsy and mastectomy were done separately. The modified radical procedure meant that her chest-wall muscles remained intact, which was a much less disfiguring operation than the old Halsted version. Still, my father termed the operation “mutilating” when documenting my mother’s ordeal.

The results of my mother’s mastectomy showed that the cancer had already spread to two of the underarm lymph nodes located adjacent to the left breast. Moreover, there were also what my father called “emboli” of cancer located higher in the underarm area. Thankfully, there was no evidence of spread to other areas of her body, such as the lungs, liver, brain, and bones. My mother’s case was classified as stage II breast cancer because there was disease in the breast and underarm. Once she completed surgery, she received radiation to her chest wall, followed by chemotherapy—powerful intravenous drugs designed to kill any microscopic cancer cells that remained in her body. For the chemotherapy, Hubay entered my mother in a clinical trial that compared various treatments.

It is difficult to conceive of a woman who gets breast cancer in her forties as lucky. But my mother was. First, had she developed cancer only a few years before, she would not have been offered chemotherapy and would likely have died when the invisible areas of cancer grew into metastases. Prophylactic chemotherapy for microscopic disease, which is now routine, had only recently been introduced. Second, she was randomized to the most active arm of Hubay’s trial, receiving not only three chemotherapeutic agents but tamoxifen, an anti-estrogen compound, and the Bacillus Calmette-Guérin (BCG) vaccination, designed to boost the patient’s immune system. Although BCG turned out to have no salutary effects, tamoxifen decreased recurrences in women who had estrogen-receptor-positive cancers.

Even though Shirley Temple Black, Betty Ford, and Happy Rockefeller had courageously come out about their breast cancers in the five years preceding my mother’s diagnosis, secrecy still surrounded the disease. My memories of this time are that things around the house were very hush-hush. My parents surely told our close relatives and friends, but my sister and I were probably instructed to tell people who asked only that my mother was sick.

I don’t remember my mother mentioning Betty Ford, but she did read a book written by the journalist Betty Rollin about her experiences with breast cancer. Entitled
First, You Cry
, Rollin’s book explicitly avoided what she termed a Pollyanna approach to the disease. Crying, she told her readers, was okay. So, moreover, was laughing. Rollin’s book was filled with self-deprecating asides and amusing anecdotes, such as her attempts to find a prosthetic breast at a “tit shop.”

But Rollin, who I interviewed for
The Breast Cancer Wars
, was the exception to the rule. As was the case with most women, my mother did not find breast cancer a laughing matter at all. It did not help that the wife of one of my father’s boyhood friends was dying of breast cancer at this very same time. On the day the woman died, the husband had frantically called our house, hoping to ask my dad a question about whether he could give morphine to his wife. The man, of course, had no idea about my mom’s recent diagnosis, but it is hard to imagine a more jarring event for someone battling the same disease.

I recall my mother spending a huge amount of time by herself in her bedroom. She had never been a person who tolerated medications well, and what my father called her “god-damn chemo” consisted of considerably higher doses of the three agents in question—Cytoxan, methotrexate, and 5-fluorouracil—than are given today. In the early era of chemotherapy for an often fatal disease, it was assumed that more was better. In addition, the medications available for the side effects of chemotherapy, notably nausea, were not especially effective. I remember hearing a lot of retching and vomiting coming from behind her closed door. The treatment induced early menopause, leading to hot flashes. Regrettably, my frugal and self-abnegating parents did not install air-conditioning to help relieve her symptoms during another humid Cleveland summer. My father speculated that the experimental BCG immunotherapy my mother received probably added to her discomfort by causing rheumatoid arthritis–like pain in her joints.

I recall being mildly irritated with her, wishing at times that she might try a little harder. I suspect that, as a teenager, I wanted my mother to be as normal as possible. In retrospect, I see that her response to the disease was an example of my mother’s strength. She had been diagnosed with a potentially fatal disease in an era in which a diagnosis of breast cancer came with shame and stigma. Plus, she had suffered greatly from her treatment. Her extensive time by herself was a primary part of a stiff-upper-lip mentality that enabled her to deal with the vicissitudes of her illness.

Along these lines, I do not remember there being many visitors at our house during my mother’s treatment. To the best of my recollection, we mostly managed on our own, relying on my grandmothers to help out with meals and with getting my sister and me off to school. Indeed, during the first couple of years of my mother’s illness, several people who were friends with her or with both of my parents dropped off the radar screen. Overtly, at least, my mother was not resentful, speculating that her diagnosis of potentially fatal breast cancer at age forty-two had probably just overwhelmed them. Still, it had to hurt. In later years, when my father had advanced Parkinson’s disease, and the number of visitors to the house again seemed smaller than it should have been, I revisited what had happened decades earlier. My parents are extremely private by nature and it is quite possible that in some instances, my mother, inadvertently or not, had gently pushed people away. As late as December 1978, they canceled a New Year’s Eve party at our house because my mom was simply not up to it.

My father, of course, was a rock. He was caregiver, reassurer, and all-controlling presence for his patients, and these tendencies became magnified when the patient was his wife. “Thank God, I can be strong here,” he wrote nine days after the mastectomy. “I must steel myself, strengthen myself and protect her as best I can,” he added. “And protect the others as well.” His paternalist inclinations were present in full force. Concealing the cancer diagnosis from my mother, which he might have tried to do ten or twenty years earlier, was certainly no longer an option. But doling out selected bits and pieces of information to various family members, including my mom herself, most surely was. For example, the only person my dad informed about the cancer emboli was his brother, since Allan was also a doctor. “I can’t tell her about the emboli,” he wrote, “because I don’t know their significance.” (Years later, when I had joined the fraternity of doctors, he told me about them. I was interested to learn the details but I responded, predictably, by questioning all the secrecy, something that doctors were no longer supposed to do. I asked him if he had ever told my mother about the emboli, and he said no.) While my father remained publicly optimistic about the chemotherapy, in private he was not so sure. “Does the chemo cure or just delay?” he asked himself. “When can we breathe easily? Three years maybe, but I don’t know.” When reading my dad’s journals, I found an even more perplexing example of how he had micromanaged things: at one point, he ordered a blood test on her to check for residual cancer and speculated that he would not tell anyone if it was positive.

Did my mother suspect that her doctor-husband was protecting her from bad news? I’m not sure, but it probably did not occur to her to ask. My father could be imperious, and, occasionally, my mom challenged his authority. But when it came to his role as physician, she ceded almost all control. It is hard to imagine a doctor’s wife doing otherwise in the 1970s.