Reflections of a Gynecologist

Long Time Coming

When Al and Skipper Gore decided to separate, many newspapers ran columns discussing the rupture of long-term relationships and probing the reasons why they occur. As a gynecologist, I am privy to many stories. If there are eight million stories in this naked city, I must have heard at least that many over the last 25 years. Here are some of the most common scenarios I have encountered involving the break-up of the greater-than-twenty-year union.

1. The couple suffers a major loss, especially the death of a child. When someone dies, especially after a protracted illness, many people intimately involved feel the need to affirm their aliveness and want to reconnect to the world of the living— perhaps “too soon” for those peripherally involved. Being a caretaker, parent, spouse or child of someone in death’s throes is a bit different from being the friend who visits twice during the person’s descent into death. As my mother once candidly put it, “Death can make you horny.” People grieve differently as well, and reach acceptance at different times. It also seems to me that men and women grieve differently. Women seem to get depressed and draw inward and men try and bury how they feel and look for a reason to live. Like all generalizations about gender, this one is only partly true. There are plenty of women who go out and party after losing a loved one and men who lock themselves in a room. For the partner who is left behind when his/her spouse goes out to re-find life and rediscover a reason to be alive, it is quite painful. First they lose their child and then they lose their best friend. 

2. One partner discovers the other is, or has been, having an affair (or multiple affairs) with a partner of the same sex. This is a more common scenario than one might think, perhaps because coming out of the closet was not a practical or safe option 40 years ago or because some people do not realize until late in their lives that they have a feeling of never having felt fulfilled. Unfortunately, adultery with the same or opposite sex usually involves deceit and subterfuge. It is the breach in trust and the feeling that one has been living a lie which often is the final blow to the marriage.

3. One partner who is already disaffected from the relationship rekindles an affair with someone they loved in their youth. This has been occurring more and more often due to the wonders of the internet and Facebook in particular. Anyone can find that guy they had a brief fling with but who stupidly married someone else and is now free, or the guy who moved to L. A. for his PhD when you were doing yours in Boston, or the one your parents dissuaded you from marrying. He is now divorced or a widower and has been waiting for you to rediscover him after all these years. For some reason, we seem to be most drawn to those we knew as an adolescent or young adult. The love fostered during our youth never dies and its embers keep burning for years—sometimes a lifetime.

4. One member of the union is diagnosed with a terminal illness or has a slow, debilitating disease and the other one decides to get out while the going is good. A patient of mine who was married for 40 years was diagnosed with terminal breast cancer. Her husband immediately left upon hearing the bad news and now has a girlfriend twenty-years younger who he brought to my office for a gyn exam. The office staff felt disloyal to his wife for being nice to her replacement and the man’s daughter has stopped speaking with him. He, however, looks quite satisfied. I know of three women diagnosed with MS between 20 and 40 years-old whose husbands left and never returned. The fathers no longer see their children, who now have no healthy parent to help them.

5. The relationship is terminated by mutual consent.This is the most commonly cited reason for the demise of a long term relationship. "It's happening more and more. Forty years goes by like nothing. People still have a lot of life to live and if the partnership isn't good for either of you, you owe it to yourself to do what's best for your life. People change and you shouldn't remain stagnant.”  This is a quote from a woman who divorced her husband of forty-plus years. (Kristen Houghton, “Divorce, Women and Age: Tipper Gore is Not Alone in Her Decision.” http://www.huffingtonpost.com/kristen-houghton/tipper-gore-divorce-women_b_597536.html) After being married for years and rearing several children, two people look across the breakfast table and think, “What are we doing here together? We have totally separate lives and interests and our kids are our only mutual point of connection. Sharing grown kids barely qualifies as a reason to sustain our marriage. We are both young enough by today’s standards to find new love interests, so why are we both here staring at each other across the table?” This last scenario reminds me of the joke Billy Crystal told in the documentary film The World of Jewish Humor. (it might be one he took from Milton Berle—I don’t remember.)

 An old Jewish couple who divorces after more than fifty years of marriage dies and goes to Heaven. When they get there God asks them why they decided to separate after so many years. Their reply: “We were waiting for the children to die.” 

For some reason when my husband and I first heard this joke, we were convulsed in laughter. I still have to chuckle. It is such an upside/down perversion of common wisdom and makes about as much sense as some of the other reasons people offer as to why they stayed together or separated.

6. One of the partners in the relationship is abusive and the abused partner finally gets the financial, emotional or family resources to allow them to do what they have desired to do for many years.

 Stay or leave, there is no magic answer nor is there any right decision for everyone. My own parents divorced after being married for over twenty years. After rehashing the same resentments ad nauseam, they realized love is not always enough to hold a relationship together. Not only were they both much happier after they separated, we children were, too. Instead of harboring the suspicion that nothing ever changes or gets better in the screwed-up world of adults, we were pleasantly surprised.

For a relationship to be successful, both partners have to feel fulfilled. You can’t force your heavy heart to be happy when it is not aflutter. But I do feel that appreciation for what you have at home and a sense of loyalty should enter into any decision one makes  when weighing whether to stay or leave. Many break-ups of long-standing relationships are precipitated by feelings of one’s own mortality that creep into one’s head more and more as one ages. “Is this all there is?” as our friend Carl Banner pointed out, often is the impetus for a search for “What else is out there?” Well, marriage, like anything else, is what you make it. It can be a boring cruel sham or one of the greatest sources of joy and comfort one has. When Paul Newman was asked why his relationship with Joanne Woodward had lasted so long, he said, "Why go out for hamburgers when you have steak at home?”  Unfortunately, he did try a little hamburger from time to time. I’ll just stick with steak.

 

Hanging In There

    We used to have two cats and a dog living with us. One cat, Sasha, was female, about eight years old and had been declawed before we adopted her. The other cat, Fluffy, (no, we didn’t name her) we had inherited from a relative. Like Sasha, Fluffy was female, declawed and around eight years old. And then, of course, there was that other pet, Banjo, the terrier who loved chasing cats. Sasha let Banjo know early on how she felt about terriers. She gave him a gratuitous slap of the paw whenever she happened to pass him. She often sat in the middle of the stairs and dared him to come up. Fluffy had a different approach. She ran and hid in a closet whenever she heard him coming. After about six weeks, the cats had Banjo trained. He never went near Sasha. He would turn around if he saw her on the stairs or in the doorway. He had a great time chasing Fluffy around and terrorizing her. This was a great lesson to me on how personality affects destiny.

    One of Shakespeare’s characters says the gods treat us like little boys pulling the wings off of flies, arbitrarily and cruelly. And although life is certainly arbitrary, we do have some tiny control over whether we are selected for wing-pulling. When we are younger, we tend to put more emphasis on being smarter or more talented and we think that raw ability will lead to success. But as an article in The New York Times Magazine pointed out a few weeks ago, students with grit, zest, curiosity and a few other key personality traits had more sustained school achievement than students who had the best academic test scores. In my experience, talent and brains are great, but passion and stick-to-itiveness are what bring in the goods. As Woody Allen once said “Eighty per-cent of success is just showing up.”

    My husband and mother are both fantastic examples of people with grit and passion. For most of her life, my mother was an artist without a medium. She painted, she redesigned our house, knocking out a wall here, inserting an alcove there. She designed and put together a four-panel mosaic that went around the fireplace. Then in her fifties, she discovered sculpting. At first she sculpted in stone. For the last twenty years or more she has been designing sculptures that a fabricator later builds out of steel. The sculptures are 10–16 feet tall and are made for the garden or outside space. A friend of hers convinced her to create a website, so at 87 years old, she had a friend take pictures of her work and hired someone to design her a website. This month she sold one of her works to someone who had found her on the Web. She also had a sculpture park approach her and offer her a show on their grounds, although it turned out they did not have sufficient funds to transport her large sculptures. At 87, my mother finally got some validation as an artist.

    My husband has been composing music every day now for the last forty years and only now identifies himself to others as a composer. He thought if he hadn’t written a movie score or had a piece played by The New York Phil, maybe it didn’t count—even though this is what he spends 80% of his time doing! This is a person whose fingers are tapping out a tune before his eyes are opened while he is lying in bed in the morning or who used to bring crumpled wads of paper with notes on them home from work so he wouldn’t forget what he had composed in the subway. Undoubtedly, even if no one ever played his music he would still be writing it. He doesn’t know how not to be a composer. Composing is a tricky business. When my husband started out he was too jazz-oriented to enter a conservatory (conservatories used to frown on jazz and none of them had jazz programs) and his music was too written-out for some jazz players. He is not the product of a school of like-minds. He is just a guy with a lot of talent and skill and a passion to write music. This week he did glean some recognition for his efforts. He got a rave review for one of his pieces in an on-line newspaper, was praised by a heavy who curates the jazz program at The Smithsonian Museum. A program of his music will be played at The Kennedy Center in Washington, DC in the coming week. Once again personality plays a role. My husband is a serious non-showbiz type and is not particularly good at networking or glad-handing. His talent and passion have carried him along, but it has taken him a long time to get out there.

    Obviously, success can be measured in many ways. Popular success is elusive at best, and should never be used as the barometer of personal success. It is especially fickle and arbitrary, being appreciated and recognized for what you do and sharing your work with others is achievable by most, however if they hang in there long enough. It helps to live past 40, for instance. Bizet died in his mid-thirties thinking that Carmen had been a huge flop when only years later it became the most performed and recognized opera of all time. Schubert, who died at 31 years-old, never heard any of his nine symphonies played by an orchestra.

    It is very appealing to think if we just sing better, act better or are smarter, we will be successful, but that is rarely the case.The best SAT score does not feed the soul. Even those with such overwhelming ability that they quickly rise to the top rarely stay there if they do not have depth of purpose, the consuming passion to do what they do and the curiosity to be constantly pushing the envelope. Personality isn’t set in stone. We need to imbue youngsters with the personal depth of character to achieve long-terms goals. These are not acquired by hiring experts to help them with their college essays or buying their way into Ivy League schools. The lesson that money talks is not lost on kids and it is true to some extent, but its words ring hollow in the long run.

 

Back to the Sixties

     Excuse the lag in blogs. My husband, Charley Gerard, and I have been working on some new songs together. Material from the Gerard/Weinstock songbook will be performed by vocalist Christine Adams, saxophonist Charley Gerard, violist Eva Gerard,  plus guitar, bass and drums in Manhattan on Friday, September 2nd at 7:00 pm at Miles Cafe. I hope you will put the date down now on your calendar and come out and have some fun. 

     Like everyone else, I have been thinking a lot about insurance coverage lately. How could I not? I have been sharing a great deal of my earnings with insurance companies.

1. As a physician, I pay malpractice insurance. I also carry disability coverage in case I have a medical problem that prevents me from working.
2. As a small business owner, I pay health insurance for my employees. I pay for theft and liability to protect my place of work. And I am mandated to pay into the state’s worker’s compensation fund monthly.
3. At home, I pay for theft, liability and weather damage to protect my house. My husband’s and daughter’s instruments are covered in a separate policy. Of course I carry car insurance on my vehicles. I also pay for comprehensive life insurance to make sure my family will be financially secure if anything happens to me. And until last month, I paid for my family’s health insurance.

    I am not a mathematician, but it seems fairly obvious that a huge percent of my income goes to insurance companies. I probably should also carry long-term illness insurance, but there’s not a lot of money left to pick up an additional policy.

   We Americans are paying a huge price for the right to sue for liability, for protection against illness and loss and to make sure some natural or unnatural disaster does not leave us bereft. We are all paying for the lacks in our social system, a system that does not provide a safety net for those down on their luck. If someone slips in your office or someone walks off with the car you use to get to work, insurance can be the difference between disaster and a piece of bad luck. It is no wonder we get sued anytime a baby is born with a problem. The finances of raising an impaired child can ruin a family. There is no bad-baby insurance policy currently being offered to parents. Families with babies needing expensive medical interventions can only collect through their doctor's malpractice coverage.

     Health care has become so expensive in our country that even having insurance is no guarantee against weathering all storms. According to NPR radio, the second most common reason cited for bankruptcy in the USA is having a medical condition not covered by your insurance company. If you have insurance, it is not possible to get Medicaid to cover your emergency, even if your insurance will not pay for it and the price tag is exorbitant. That type of emergency Medicaid is available only to someone with a medical disaster who has no insurance. As the majority of Americans are covered by insurance policies picked by their employer (who is most likely just looking at the bottom line) many of us carry sub-standard policies with many loopholes. One only discovers these loopholes, unfortunately, when ill. 

      Paying for insurance and the fear of losing coverage is changing the fabric of peoples lives. Here are a few examples of people I know:

1. A friend of mine, an Ob/Gyn living in California is almost sixty. She would like to slow  down a little or retire, but these are out of the question. Ironically she comes from a well-off family, so what is the issue? Her husband has Type I diabetes and is going to need dialysis soon. If she leaves her job, he will not be able to get insurance thereafter. One of my friend’s medical partners has just developed breast cancer and has taken a six month leave of absence, so my friend is on call more now than she was previously. So, despite being well-off, my friend is forced to work long hours in order to keep her husband covered. Their lives would probably improve if they divorced, her husband picked up Medicaid, and she could work a part-time clinic job and take care of him the rest of the time. Sad, but true.
2. A colleague who recovered from cancer a few years earlier would like to get a  separation from her husband. Despite the fact that they lead separate parallel lives, she is just biding her time for now. She is afraid that if she loses her job, she will be unable to get new insurance coverage. She is basically married to her partner for insurance reasons and I don’t blame her. Life is precarious.
3. A patient of mine,in her twenties, is on medication for ADD. She hates her job, but cannot leave. Although she lives at home with her parents and has low expenses, she needs the job in order to have insurance that will pay for her medication.

    Every year our dollar stretches less and less and our standard of living erodes. Insurance costs are eating into our personal incomes and into those of our businesses. As time goes by, less and less of us will be able to maintain our middle class status, unless we wish to stop having children, buying cars, owning homes or starting our own businesses. We can all go back to being single, poor bohemians living day to day with no one to depend on and no one to depend on us. Welcome to the Sixties! Haight-Ashbury anyone?

 

 

 

Valentine's Day Fluff-Up

I have been pondering the resignation of Dr. Lazar Greenfield, the president-elect of The American College of Surgeons. His offense?  As editor-in-chief of Surgery News he wrote a Valentine’s Day editorial that quoted several recent studies touting the mood-elevating abilities of human semen and concluded with, “So there’s a deeper bond between men and women than St. Valentine would have suspected, and now we know there’s a better gift for that day than chocolates.”  After many years of supporting women in surgery, the word sexism will forever be associated with his name. I think there is little doubt that the culture of most surgery departments has been very difficult for women to navigate. Most surgical services have a macho bent and are military in their hierarchical nature. Many were old-boys clubs and maybe some still are. But does Dr Greenfield’s article reflect this or are charges against him an over-reaction?

Just like modern women, men have been searching for their role in the twenty-first century. Not one but three recent movies had as their theme, artificial insemination. My daughter-in-law Caroline Hagood wrote a thought-provoking article last summer, “Artificial Insemination and the Mother of Moral Panics” for the London Guardian in which she looks at Hollywood’s take on man’s role when his semen is more valued than his good looks or sense of humor. The movies in question were “The Back Up Plan,” “The Switch,” and “The Kids Are All Right.” As Caroline points out, “these films illustrate the conflicted state of feminism, masculinism, and the couple in the 21st century.”  Why should Dr. Greenfield be any less confused than the rest of us? If a guy can be reduced to just his semen, it must be pretty good news for him to know it can do more than just spark a new life. It might have other qualities valued by the recipient.

There have been a few findings recently which might not be that welcome in feminist circles. In 1993 Pierre-Yves Robillard of The University Hospital of Pointe a Pitre, Guadeloupe reported that if women who did not use condoms got pregnant within four months of starting sexual relations with their partners, they had a 12-times chance of getting preeclampsia over those who had been with their partners for longer. With a new partner as father, their chances were five times higher. A study from The Journal of Reproductive Immunology from November, 2006 found that if a woman swallows her partner’s semen, her chances of having preeclamsia are reduced significantly. Good thing Dr. Greenfield didn’t try to tackle this topic in his editorial.

I  have tried to analyze exactly why Dr. Greenfield’s article incensed so many women. First, it implies women need men to feel good. This is probably objectionable to many straight and gay women, who feel that life without heterosexual sex can be just as fulfilling as life with it. This might be true for many women, but the majority of heterosexual women would attest that a healthy sex life does elevate their mood. Two, Dr. Greenfield is basically advocating throwing away those condoms. This message is not a particularly valuable one for women. How long will that mood last when you discover you have contracted HIV? Third, there is a certain smugness to the idea that men have power over women’s psychological well-being. It harks back to some of the worst quotes that stick in the back of women’s psyches like, “She’s asking for it” or “She’s gotta have it.” These little quotes which hide in the inner recesses of our brains are perhaps what made this a red button issue. 

I have discovered a lot about human semen since I began to research this article. For instance, sperm comprise only 3% of semen. The rest is a mixture of water, glucose, immunosuppressants, FSH/LH (which help  induce ovulation in the recipient), endorphins, prolactin and TSH as well as numerous minerals. There is even a site on the computer called Semen Therapy which advocates swallowing semen three times a week to prevent just about any ill of man you can think of. Poor Dr. Greenfield. All he was suggesting was that perhaps sex (without a condom) is a better high than chocolate. Many readers might agree with him.

 

 

 

 

 

 

 

 

 

 

That Alternate Universe–Old Age

Thursday was a sobering day at my office.  A lot of my Medicare patients love to make appointments during my Thursday morning hours. If you ever bought into the Golden Years idea, our Thursday mornings would cure you of any delusions. Many doctors have little patience for seniors. Older folks take time to undress and dress, they like to chatter–sometimes I am their sole social engagement for the week–and they are often opinionated and don’t want to follow anything you have to recommend. In the practice I left last year, we had many patients who had been with us for fifty or more years. For this reason when I decided I could not afford to take private insurance at my new practice, I also decided I would accept Medicare. I just could not abandon these patients. And there was another reason. I really love my elderly patients. They have a lot to teach us if we would open our ears and our hearts.

The morning began with R., an 88 year-old patient who comes in every three months. She has a long history of anxiety and depression. She asks you the same question many times and she has told me for at least eight years that she has nothing to live for, although she has a very loving and attentive daughter who should probably be selected for sainthood. Despite all this, she is a very charming woman who is extremely warm and has a very funny black sense of humor. Since last seeing her, she has lost her short-term memory and on Thursday she seemed frightened and hobbled compared to her previous self. She has started that downhill slide where older people get further and further from the world they inhabit. Despite telling me she wanted to die for many years, she is obviously scared to death of the process she has been sent into. Even for those who like to fly, being whisked off by storm-force winds is frightening. Lucky for me, her GYN problems are a little less daunting than those her psychiatric team has to deal with.

My next patient was D., also in her 80’s. She has macular degeneration and a hearing deficit. She can only read on her Kindle, because it is backlit and she can choose very large lettering. She said her 90 year-old brother was completely deaf and almost completely blind–as is her 92 year-old sister. Her 102 year-old aunt lived her last ten years in profound silence and darkness. She said she could see where things were going and it made her very depressed. She said when she got depressed in her youth she would get a part-time job on top of her full-time job and family duties, just to get her going , but at 85 this was hardly an option. She had mentioned to her primary-care physician that she felt very depressed. His response? “No you don’t!” I sent her to a gerontologist to find some resources for those with macular degeneration and to be evaluated for anti-depressant therapy. I also spent a long time chatting with her.

Anyone who has reached 80 should wear a badge signifying that they are survivors and that they deserve our respect. Many people this age, especially women, have lost at least one spouse and many have lost a child. They have learned to live with a lot of aches and pains and disabilities they never asked to have. And many have taken care of another aging person–either a mate, sibling, parent or child. They have undoubtedly weathered a lot of storms in eighty years. In general, the world ignores or lampoons them. They are not sexy and they are definitely not new or exciting.

But guess what? They are us. We have met the slow, chattery, orthopedically-challenged and they are indeed us. We just haven’t gotten there yet. People are always giving me family medical histories, but amending them so that it appears to them that nothing that happened to their mothers or grandparents will happen to them. “She had colon cancer, but her diet was terrible." "My mother had severe high blood pressure, but she never took care of herself.” Although environment is very important, the implication that none of the ills of humanity will befall us if we exercise and eat right is a bit naïve–especially when other members of our family carry genes for these ailments that will probably eventually afflict us.

Encoded in a lot of “useless” chatter are life lessons. You have to have the patience to listen to the extraneous noise in order to hear them. It’s similar to baseball signals. Most of the signs you see are extraneous. In baseball there is a designated signal that marks the beginning of the true encoded message. Conversation can be much the same. Especially with women, the code can be very arcane. When my 99 year-old great-aunt tells me how much she loves my mom and how good her other niece is to visit her and how thoughtful she is, the interpretation is “I love your mom. My other niece goes through the motions, so I can’t badmouth her, but I don’t love her in the same way.” She knows I can interpret easily as we’ve known each other for 58 years and I trained with my grandmother who was the queen of doublespeak. If she haad given me the right look, the interpretation might have been: “My other niece tries to do the right thing. I don’t really like her, but I am dependent on her visits.”

Now that medicine has become a business and efficiency is valued more than quality, these older patients are not being heard. They do not move fast enough to keep a bustling practice turning over at the pace it needs to keep financially solvent. They are not direct about their needs and often a good practitioner must learn to read between the lines. You might need to hear a lot of lines before you can piece the whole story together. It’s easy to dismiss their problems as just part and parcel of the aging process. I had an 85 year-old patient who used to come to her appointment in a jogging suit. I diagnosed her with uterine cancer and I wanted to do a hysterectomy. Her family initially dismissed the whole idea. After all, she is eighty-five! She had the surgery and is now 102. At the age of 99, she started slowing down and now lives in an assisted living facility.

No matter what age, we all have the same needs and desires. We want to be loved and appreciated. We want to be able to have the ability to smell the roses and see the beauty of the natural world. We want to live pain free. For the elderly, these can be elusive. We should all practice taking a little more time speaking directly with those from generations that precede us. It would be enlightening for us and stimulating for them. Don’t pretend they are in an alternate universe you are never going to inhabit. If you’re lucky, you might live there one day, too.

Don't Ask Tolstoy for Advice

I don’t condone it. It’s not good for your mental or physical health, but I certainly understand why some people have indiscriminate sex and eschew all human relationships. Let’s face it, human relationships are thorny and after trying a few, some people go for the warm body experience minus the baggage. You know that baggage we all harbor -- old hurts, need for approval, deep-seated anger, pride and the whole panoply of needs, wants and resentments we all carry?

In the first chapter of Anna Karenina Tolstoy wrote, “Happy families are all alike; every unhappy family is unhappy in its own way.”  I think, however, that his thinking is upside down. His marriage and family life, however you might want to characterize them, were certainly unconventional. His wife Sofya (Sophie Andreevna Bers)  was sixteen years his junior. On the eve of their wedding, he urged her to read his diaries which detailed his sexual adventures, including an affair he had had with a serf who had begotten him a son and was still living on the family’s property. Despite the exhortations of Sofya, Tolstoy refused birth control and his wife gave birth thirteen times. Eight of their children survived to adulthood. After thirty-seven years of marriage, he wrote The Kreutzer Sonata, a book disparaging the “animal excesses” and “swinish connection” of the sexes and basically proposing celibacy as a way of life. The protagonist eventually kills his wife in a jealous rage and is acquitted of any wrongdoing. The final major chasm in their marriage opened up after the author, also later in his life, decided that he needed to disencumber himself of all worldly goods and give away all that he owned including the rights to royalties on all his works. He certainly had some creative ways of antagonizing his wife. 

In most marriages, however, the same culprits contribute to making a relationship untenable: alcohol, drugs, extramarital sex, inability to express feelings, ignoring your spouse’s needs, uncontrollable rage, depression, differences in expectations due to different upbringings or cultural values. Some of these predate the marriage and some begin afterwards. Thus, unlike Tolstoy, I feel most unhappy families are not unhappy in individual ways but repeat the same mistakes over and over. We humans have very little control of the baggage we carry and unhanding it can take a lifetime. Just realizing it’s there can take longer than your spouse might want to wait. Tolstoy had a very unusual marriage, but I still think his relationship exhibited some of the typical pitfalls including not listening to your spouse’s feelings and coming from very different backgrounds with different expectations.

I just finished reading A Happy Marriage by Rafael Iglesias. It is purportedly a novel, but appears to be autobiographical. It would be more aptly titled “A Mutually Satisfying Long-Term Relationship.” This excellent novel chronicles a twenty-seven year relationship that ends in a long battle with bladder cancer fought by the protagonist’s wife. Although the couple is not always happy together and there are long stretches where the relationship is not satisfying for one or both partners, it is a wonderful study of two people’s abiding love for each other and how they manage to forge a long-term relationship despite having very different personalities and coming from families who measure success very differently. When life is most difficult and he and his wife have to deal with making some harrowing decisions about her cancer care, the couple become most close. This is probably because the neediest half of the couple, the writer, becomes the most needed. This same turnaround is also seen in Elinor Fuchs’ book Making an Exit. This book covers the author’s relationship with her mother. During most of the author’s life, she is emotionally estranged from her diva mom. Their relationship blooms during “The Emergency,” the many years during which the mother becomes more and more incapacitated by Alzheimer’s disease. It is only as the mother becomes more dependent that their relationship grows after stagnating for many years.

Am I the only one who has asked herself, “Why are dogs so much easier to love than humans?” A few reasons have occurred to me. Most dogs are not big on baggage. They barely remember what happened yesterday unless they are severely scarred by a previous owner. They have few needs and they have no problem communicating them. When Dante gives us that big brown-eyed dog look, he either wants a biscuit or to be taken outside. I don’t have to wonder if I hurt his feelings earlier in the day when I said, “Sit down” a little harshly or when I said “Leave” when he was bothering a visitor to the house. He doesn’t harbor grudges. He doesn’t do drugs or drink alcohol. He came with very few expectations -- a bowl of food, a lot of love and exercise. He rarely misunderstands or misconstrues what I say. (My body language is more important to him.) I don’t think I remind him of his mother (but I can’t be sure on this one) and I know he depends on me and needs me. I am IMPORTANT to him in a big way and he lets me know it. He is rarely depressed for more than 10 minutes (He didn’t like the party hat we put on him for New Year’s.) And, you guessed it, like most dogs he is a paragon of faithfulness.

 Happy families, Mr. Tolstoy, come in all shapes and sizes and no two of them are alike. As long as both partners are happy and fulfilled, the particulars don’t really matter. Most unhappy families tend to carry similar baggage. I would suggest, Readers, consulting Dante, not Tolstoy, for advice on success with your marriage or with any family relationship. He’s a natural. When it comes to love, he’s got what it takes. Who else could have a chin covered with toilet water and look so downright adorable?

 

 

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Follow-up on my cousin's murder: A 21 year old has been charged with the murder. He was picked up in the murder of another person and confessed to the murder of my cousin, as well. He said he had to kill both men because he could tell they were thinking gay thoughts. Both men were husbands and fathers. Many lives destroyed by a paranoid schizophrenic. It is quite sad and mind-numbing.

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On the Darker Side

Happy New Year, and I hope for all of you it will be just that. On this day, however, I am harboring some darker thoughts. 

My brother-in-law Philip Gerard has written a blog piece on man’s “intrinsic” warlike nature (http://radixliber.net/author/phils-posts/). In his piece, Phil argues that by changing people’s attitudes through persuasion and legislation, our bellicose natures can be changed for the better. He looks at war as a  “collective pathology” that we can somehow ameliorate just as we have ended slavery and improved the lives of women in most of the world. Phil points out that families suffer for generations with the after-effects of war. 

 History has been a series of displacements and migrations for the human species. There is no doubt that nature’s arbitrariness in causing drought, hurricanes, avalanches, etc. has also contributed to these migrations, but just in the last hundred years, we have had two world wars causing huge amounts of death and displacement, and genocide affecting entire populations such as the Armenians, the Jews and the Tutsis of central Africa. Since 1960 we have seen wars in Vietnam, Korea, Iraq, the Balkans, Iran and countless other parts. We have seen governments murdering, persecuting and evicting their own citizens. In the wake of this destruction is an incredible amount of human suffering handed down from generation to generation.

 On December 16th, 2010, my first cousin Paul B. was shot to death at around 7:15 in the morning at the garage he co-owned in the Kendall section of Miami, Florida. He was shot between the eyes with a dummy bullet, the kind that explodes in your head and makes sure you don’t go home. In other words, he was intentionally murdered - not by some strung-out junkie looking for drugs, but by someone who wanted to make sure he was never going to see his family again. Paul was 46 years old. As I celebrated holidays home here with my own family I could not help thinking that whoever killed Paul was also probably celebrating and having a good time with his own family.

 Paul was a larger-than-life person who was adored by many people. As his brother Danny pointed out in an article in The Miami Herald, Paul’s answer to any quest for his assistance was, “No problem.” Danny and Paul were born in Sao Paulo, Brazil, where my uncle (my mother’s brother) lived with his second wife. They had a beautiful house and lived quite well. This came to an abrupt end when my uncle developed multiple sclerosis and almost died. My aunt had to move the family by herself while my uncle was in the hospital here in New York. She and my cousins went from living in a large house with live-in help to living in a small apartment. My aunt had to find a job in a new country and adapt to life in the United States. Luckily, she had lived here briefly before marrying my uncle and her English was excellent. My two cousins who were still in grade school only spoke Portuguese. They had not been to the United States before and they had never had a working mother. They had never lived in an apartment. 

 As Paul grew up, he became everybody’s security blanket. The family moved to Miami. It just so happened that my mom also moved to Florida after marrying her second husband, a Floridian. She was the person Paul could confide in when times were hard. To his family, however, he was the rock. He started bringing in money when he was in high school. He started working at a garage as a teenager and eventually owned one. He married a woman with two children from a previous marriage who he brought up. He was a father to them emotionally and financially. He and his wife also had a child of their own who is now a teenager. 

 I’m sure somebody knows who killed Paul and why, but we in the family are totally in the dark. There are seven police investigators on the case, but so far no news. As I contemplate this deed and try to digest it, I can’t help but marvel at what ends men will go for power, land, money, status or revenge. Paul’s death is just a little star in the sky of human misery. Perhaps it was just a random killing, but it seems more likely that someone killed him for some of the same reasons that wars are declared and unfair laws are written. 

 Everyday I am amazed at the courage, kindness and altruism of my patients. People will go through tremendous obstacles for those they love and will sacrifice almost anything for those with whom they identify; but unfortunately, that same kindness and dogged bravery is not shown to people who are them not us. We humans are tribal. We protect our own or those who look or sound like us, but are savage to those not included in our circle. Sometimes even those in our circle, but who look different or who practice a different religion, may be singled out, as happened in Rwanda and Bosnia.

 Right now on the first day of this new year I am ruminating on the amount of damage humans inflict on one another, the long-term effects of that damage and how, in the long run, it hurts us all. The human heart can motivate the most inert, but within us all is a savage black space out of which we seem incapable of emerging.

   

 

The Thrill Is Gone

What is more exciting than the playoffs, more riveting than a good mystery and more addictive than chocolate or sex? Delivering a baby! 

Many of my patients have asked me over the last year if I miss delivering babies. The answer is: yes and no. The high of delivery is hard to equal, especially when the baby is healthy and wanted. Unfortunately this high is extracted from a lot of hard work, long hours, irregular eating and all-out general exhaustion. These I definitely don’t miss. 

Why do obstetricians continue to work like dogs? It certainly isn’t for monetary remuneration, because reimbursements for deliveries are now similar to what they were in 1986 when HMOs started gaining ground. Here in Brooklyn this reimbursement is between $2800 and $3500. This includes 10–14 prenatal visits, innumerable phone calls both day and night, hours spent with the patient during labor (sometimes more than 12), several visits in-hospital after delivery and a post-partum visit. More often than not, it also includes filling out at least two disability forms - one for the employer before delivery and one for after. I would like to see a lawyer who would spend that many unbillable hours with, or working for, a client. Especially when many of these hours are spent between midnight and 7 am. To top it off, obstetricians are not reimbursed until 2–12 weeks after delivery. 

Let’s face it: you have to love it to do it. My son, a psychiatrist, did an OB rotation as a medical student and asked me, “Mom, how can you stand it? All that blood, those smells, and the gore of the OR.” I told this to another psychiatrist and he asked, “Don’t you just learn to tolerate it?” The answer is: no. You either have to love blood, guts and lochia (post-delivery discharge) or you can’t be an obstetrician. When I was a medical student I worked at a big-city hospital in Houston, and did about 55 deliveries myself. I remember that for two months I woke up feeling like I was drowning in blood.

Much like sex, delivery is immutable in its earthiness and messiness. The basics have not changed in thousands of years. We can dress it up and make it pain-free, but it is still a bloody mess often accompanied by mucus, urine, feces and vernix (cheesy substance surrounding newborns). And it ends with that primeval extra organ - the placenta. Also like sex, it is hard to explain the thrill of it to someone who doesn’t find it thrilling. I didn’t even bother explaining it to my son. You either feel it or you don’t. You know how you felt as a child when someone explained the mechanism of sex? It sounded gross! You see what I mean? If it were just about logic, it is gross. 

The other attraction of obstetrics is its humbling tendency to show that nature trumps mankind's best efforts. No matter how much we think we know and how much science we apply to the field, nothing on a labor-and-delivery floor happens according to plan. The patient who has had six previous children all in less than four hours takes 15 hours to deliver her seventh child, and the tiny patient who you worried would never make it through labor delivers in the admitting room before getting into labor-and-delivery. The patient with the short cervix who you admitted for premature labor four times during the pregnancy goes post-dates and has to be induced. As usual, nature makes a fool out of your knowledge of obstetrics. 

There are so many disincentives for doing obstetrics these days, I can’t see anybody practicing it in five years - at least not in a private-practice setting. In states like ours with no caps on suits, the yearly price for malpractice runs from $150,000 to $240,000. There are less suits than there were 10 years ago, but the average suit now pays out about $12,000,000. In New York City there are now only two insurance carriers who still cover private obstetricians (those who work in hospitals get coverage via the hospital). Most obstetricians now pay more than 50% of what they make on deliveries to the insurance company. And malpractice is not just expensive; it is corrosive. Make no mistake about it. If you are in practice long enough, you will be sued. Most OBs will be sued multiple times. Perhaps this is why the average age for a New York obstetrician to retire is in his/her forties. After four years of premed, four years of medical school and four years of residency, most people give up obstetrics after about 15 years, not much longer than they trained.

Delivery of a baby is an addictive, sensual experience. And it is an honor to share such an intimate life adventure with your patients. But can we expect that to outweigh poorly reimbursed, long hours (did I mention that most private obstetricians have to work the next day after missing sleep to pay the bills) and the expense and psychological distress of lawsuits? I missed so much of my children’s everyday lives when they were small and we celebrated birthdays and holidays all over the calendar but I wouldn’t change my life as an obstetrician. It was grand! But as B. B. King says, “The thrill is gone!” and I have now rejoined the human race and have begun to smell the roses. 

 

Good Fences

“Good fences make good neighbors” is an oft-quoted adage. This simple phrase can have many interpretations. On the site UsingEnglish.com, the definition is given as “it is better for people to mind their own business and to respect the privacy of others.” To me, it means well-demarcated boundaries improve relationships.

Boundaries can improve relationships both at home and at work. For instance, what grown child would appreciate their parents arriving unannounced at their abode or, even worse, letting themselves in to their child’s home, assuming they had a key? At a certain age, children realize that they do not want their lives to be an open book into which their parents can browse. Children, too, need to realize that once they leave home, they cannot come and go into their previous houses the same way they once did. Parents also appreciate being prepared before the arrival of their progeny and they don’t take kindly to their homes being treated like a crash pad with dirty towels left on the bathroom floor, just like in the good old days. It is easy to fall into teenagedom in your parents’ environment but one should resist the urge. 

Years ago I read several studies showing that people are happier working jobs where the individual responsibilities of that job are spelled out. If I have to negotiate daily what I should and shouldn’t be doing at work, it is certainly a waste of emotional energy. If I overachieve, I feel resentful that I did all the work and what-the-hell were you doing; and if I do less, I feel guilty and jealous that you will get all the credit. If I know the job description, that’s all I need to perform without having to second-guess how I'm doing.

Spouses also need boundaries. For this, communication is a must. I can’t guess what makes you angry. You will have to tell me and, of course, I should respect your feelings, not belittle them. The more you know someone, the easier it is to destroy him. You know the beams on which his fragile ego lies. (All egos are frail.) Thus, there are some places you should never go and some things that you can never take back. SO DON’T SAY THEM. When my son was a little boy and was mad at my husband, a composer by trade, he told him he hated his music. This made my husband and me roar, because it really was very savvy for a child who wished to be hurtful. If I told my husband I thought he was a hack composer or he told me he had never like my cooking or thought I was a miserable excuse for a physician, it might not be so funny. How about the people who say in anger, “And I never loved you.” Remember that word boundaries? 

If communication is not possible and there is not room for compromise, then we are left with the take-it-or-leave-it option. This may be acceptable if we have advanced warning, but we don’t want to hear our new office cleaner saying, “I don’t do floors or windows” six weeks after being hired. This should be discussed when considering the employment of said worker. Fences only work if the placement of those fences is agreed upon by those on either side. Obviously, this means all parties must be informed. Unfortunately, unwritten boundaries like “No wife of mine works out of the house” or “The man always drives”  may be discussed only after the marriage agreement has been signed and the take-it-or-leave-it option is a little less doable. This is when boundaries can become tyrannical.

Children’s behavior is another area where limits should be clearly set and not arcane or hard to figure out. These limits, unlike those between adults, are not something decided between consenting parties. When my kids were little I would often marvel at their friends’ parents who would be trying to negotiate with a screaming and irascible three year-old at our house. Please throw the kid over your shoulder and take the kid home. It is not okay to throw a temper tantrum at someone else’s house whenever you don’t get your own way.  Some types of behavior are just off-limit. Maybe if more physicians learned this as children, there would be less of them screaming in the O.R. or throwing hissy fits on the Labor-and-Delivery room floor.  

Boundaries can sometimes be detrimental, though,especially when they are used to keep children ignorant. Children learn the “Don’t ask, don’t tell” rule very fast. They sense, even when they are not told outright, what topics should not be discussed. It is incredible how efficiently unwritten laws get written into a child’s script. When it comes to behavior this can be good, but sometimes this is why children are in the dark when it comes to the one-act play in which they have a role. My husband’s family left Germany in 1938. He said he was told that this was because his grandparents ran a progressive boarding school. When I suggested to him years ago that maybe it was because they were Jewish (though non-practicing), he got angry at me. (He now is astonished at his previous ignorance.) More likely, the exodus from Germany was not up for discussion. Given no plausible explanation, my husband may have even substituted the “progressive school” explanation himself. Not-up-for-discussion can bury a lot of family history that needs to be aired.  

There are also some instances when delineation can interfere with adaptation. For instance, couples with less rigidly-defined sex roles seem to be able to roll with the punches over time more effectively than those where roles are set in stone. If one person is laid off, the other still brings in an income. If the primary caretaker is ill, the other partner still knows how to cook a meal or where the diaper pail is. Likewise, when parents or grown children are ill, they may have to reverse roles or get into each other’s intimate spaces to help out. As important as boundaries are, one must know when to drop them! 

So, what’s the take-home message? Good fences make good neighbors when both neighbors know where the fences are and agree upon the placement. Try, however, not to use those fences to protect yourself from intimacy with your children and friends. Let others know when they trespass and respect when they tell you that you are over the line. All this might take a lifetime. 
Good luck.