Reflections of a Gynecologist

Eulogy for Long Island College Hospital

I am sitting here with tears running down my face because LICH, a member of my family, has just bled to death. Remember when Princess Di married Prince Charles and foolishly believed that that was going to be the beginning of a beautiful relationship only to find out it was a cynical ploy to create a few heirs for the crown? Well, we got into one of those relationships with SUNY—a merger in name only. This “merger” was obviously a ploy to help Downstate (a pension and salary-heavy institution where six people do what one computer could) reach solvency. No money was put into our facility for infrastructure; a modern billing system was never contemplated; no residents were rotated through us; and the new head of our department made less than five visits in three years to check out what was going on at our campus. No effort was ever made to engage us in any interactive activity or to include us in decision-making for our future. Quite a marriage!

I first set foot in Long Island College Hospital in December, 1981 when I was looking for a residency position. I was finishing up at Baylor College of Medicine in Houston and I wanted to return to Brooklyn, because I had many friends here and family was close by. I could live across from resident housing and my infant son and husband could come visit when I was on call. Labor-and-Delivery used to be situated right across from my apartment and my son and I would wave to each other across Amity Street when I was working. I was also attracted to the small scale of the hospital and its friendliness. I loved the old amphitheater where we used to have Friday conferences. It looked like a picture from a nineteenth-century medical text. And the mix of upscale Brooklyn Heights types and poor immigrants from all over the world also appealed to me.

On my first visit to the hospital, a guy who introduced himself as Sandy Lederman showed me around and chatted with me in the L&D doctors’ lounge. He was very optimistic about the future of LICH and our department. This lounge was filled with sundry people’s wherewithal (shoes, backpacks, lunches, coats) and was used by attendings, residents and nurses. There was a small room off the lounge where residents and attendings passed out when they were too tired to converse. Men, women, old and young all piled into the same tiny room. It was very collegial. The night shift consisted of two nurses—Grace and Jeannie. There was no central monitoring. The monitors were all kept at full volume as decelerations in babies’ heartbeats were heard and not seen. Dr. Lederman extolled the virtues of the hospital and why I should join them there and he was very excited that a Dr. Comrie had recently come back from graduate school to join the staff. I had been to a few other interviews and met many residents. This day I met one of the first year residents, Andre Persaud. He was much warmer and more open than most of the residents I had met at other hospitals. I ranked LICH number one on my match form and I started my residency there in 1982.

Many of the nurses I started with are still working at LICH. Many were delivered or cared for by our practice. The guy who does the night shift cleaning (Billy?) always gives me a hug and kiss when our paths cross. He started at LICH when I was a resident and can recognize a fellow veteran. I love seeing that guy. I haven’t worn an ID tag when entering LICH for many years. When I was a resident, my son and husband were there so often that all the security men knew them, too. The day my daughter was born, my mom left to pick my son up from camp. When she arrived with him at a side door, the security guard took one look at my son and said to my mom, “Oh, you must be with Dr. Weinstock. Go right up.” My daughter was born at LICH and was delivered by that same guy, Sandy Lederman, in room two. When my son arrived with my mother from camp, Dr. Lederman cut him out a yellow gown just the right size for a five year old so he could see the new baby.

The next day the lady who managed the kitchen at LICH at night sent a 16” cake to my room. I wasn’t aware until that moment that anyone in the kitchen there could cook anything that anyone might want to ingest. The cake was delicious. I called all the floors I usually worked on and let out the word to come on over and help me eat my cake and celebrate. This felt especially good, as my father had died three weeks before and celebrating my daughter’s new existence was a wonderful change from the three weeks previous to her arrival.

A lot happened to me and to New York City during my stint at LICH. One day in September, 2001, I pulled into the parking lot which looks over the water towards Manhattan and saw a nurse I had known for many years watching the tip of the island. I had heard on the radio on the way over that a plane had hit a building at The World Trade Center. As we looked toward the Center, another plane came out of nowhere and flew into the second building. The nurse burst into tears and this was the first time it occurred to me that there were people in those buildings. I went in to do my rounds and when I came out from seeing my last patient, the unit receptionist said to me, “Oh my God, the building came down.” I was unable to compute. “What do you mean the building came down?” By the time I got out to my car, billows of grey and black smoke filled the air and I could hardly breathe. I had to hold a newspaper over my mouth to get to my car.

Long Island College is a lot like New York City. I love New York, but often wonder why am I living here? Why am I paying a fortune for rent? Why am I living in such a dirty place? Why am I living in a place where I have to pay to park my car or search for hours for a parking spot?. Why do I like a place where one often has to stand on line for a movie or a meal? At LICH, I often wondered why I was so attached to such a dirty, dysfunctional place. I can’t answer this question any better than I can the ones about New York City. Suffice it to say that once you get it in your blood, you’re hooked—kind of like falling in love. RIP, LICH.

Death of a Centenarian

     My grandmother’s last sister (there were five Miller sisters in all including my grandmother) just died with the advent of the Jewish New Year. She was 100 years old. She was my mom’s pal and they were close for eighty-eight years. She was twelve years older than my mother and used to babysit for her when my mother was a little girl and my aunt was a teenager. 

    My aunt was always very trim and, more often than not, wore a gold chain belt around her waist. She was perpetually atop spike heels. She developed foreshortened Achilles tendons secondary to her lifelong perch on those heels. Eventually she had to wear even bedroom slippers with high heels. Her hair was very important to her as well, and, make no mistake about it, you were not welcome if your visit coincided with her appointment at the hairdresser. Even in her nineties, a hair salon appointment took precedence over just about everything. She preferred silk shorty nightgowns, even if she said she was cold at night. Imagine this slender, perfectly coifed eighty- or ninety-year old in her silk nighty on her heeled slippers and you will start to envision my aunt, the way she looked until she was just too tired and frail to care.

    Aunt Gladys was married to Uncle Julie, who died thirty years ago. He said he fell in love with her ass while she was in white shorts playing ping pong. I have no idea if this was the case, but he certainly was very in love with her during their long marriage. In my family they often referred to him as the sixth Miller sister as he thought nothing of sitting at the kitchen table with the lethally chatty and judgmental sorority while they gossiped about each other and their acquaintances. The rest of the husbands convened elsewhere. Gladys and Julie were very social, threw wonderful parties and had many friends, but their life together was ultimately one of shared sadness.

    They had two sons, Allen and Steven. When I was a kid the four of them went on a car trip through the Western states and had a very serious spinout on the road, during which everyone suffered serious injuries and their youngest son, Steven, was killed. Gladys and Allen were rushed to a hospital and Uncle Julie was left waiting for help with his dead macerated son in his lap on the roadside. As fate would have it, Steven had been a very smiley, charming child who seemed adored by all the world. Their eldest son, Allen, was quiet, introverted and, even before the accident, always seemed sullen. Now he had to compete with his dead brother for attention. It couldn’t have been easy.

    Eventually Allen married. Soon after that, he stopped speaking with his parents. Many people in the family tried to intervene, but Allen had made up his mind. He gave differing  reasons for his decision to different people. He wrote a letter to Gladys in which he stated that her unending criticism of his wife was the factor that led him to his choice. He made an appearance at his father’s funeral, but for the rest of his life he saw his parents less than 5 times except across the aisle at temple. He died of a heart attack about 5 years ago. When Gladys called to be included in the funeral, one of her grandsons told her she was not part of their family. None of the grandsons had ever spent a moment with their grandmother.

     Gladys was not an easy woman. They didn’t make easy women in the Miller family, but in many ways she was a wonderful person. She could be controlling and critical, but she was also generous and warm. She would ply you with food with a relentless tirade until you had properly overeaten and could badger you to death when she wanted something. She was vain and she was proud, but she was a fantastic aunt. When I stayed at her house as a kid, she couldn’t do enough to entertain me. She fed me, she took me places, she was funny and I always went home with lots of goodies. She was my great aunt and she was a great aunt.

      She was also always a prankster and a little naughty. When my mom was a child riding in the car one Sunday on her family’s weekly jaunt, she saw a girl rollerskating up their street who had a dress very similar to one she owned. Then she realized it was her aunt wearing her dress which she must have lifted from my mother’s dresser. When my mother was fifteen, my aunt took her to a burlesque show with the admonition, “Don’t tell your mother or my mother or I will be dead.” The show stopper was a nude woman who came out in a circulating green-tinted bottle.

      She was also a great booster. If she was on your team, you had a fantastic parntner and a good chance of succeeding. She raised a tremendous amount of money for children with respiratory illnesses and for other causes sponsored by her temple. You couldn’t say no to her.

      In her seventies, she got breast cancer and had a long hard road with chemotherapy. She told me that if she had a recurrence she just wanted to die, because she couldn’t go through chemotherapy twice. Uncle Julie took very good care of her and didn’t push her to do anything she wasn’t up to doing. She lived thirty years after being treated, but unfortunately Uncle Julie died of a heart attack soon after her recovery. 

      Later, Gladys had a beau named Hy. He used to call her name and it sounded like he was calling a dog, but they had a long warm relationship that terminated when he died. He left her enough money to live very comfortably and to be taken care of in her own home. During her last twenty years she suffered a hip fracture, a broken leg and a few other orthopedic problems, but she just seemed to bounce right back. She had spunk. She had spirit.  She was frail but still had tremendous personal strength. She almost drove her aides to drink. We all loved her very much and she always said my mother Mimi had her heart. It was mutual.

Identity Crisis

What if Kermit, after years of singing,”It’s Not Easy Being Green” found out that he was really beige? My guess is it would send him into a bit of a tailspin and not just for a moment, either. Green is not just a color he associates with himself, but also with his mother, father, grandparents and ancestors. He probably feels a shared history with other green creatures and eats the same kinds of food as they do, as well. He has an affinity for things green and this kinship would be in question if he were, for instance to discover he was red or purple.

 Well, it is Spring and an old woman’s fancy turns to Passover at about the same time her husband reads a book showing that The Exodus probably never occurred as related in her Passover Haggadah. The Passover story is relived every year to remind Jews of their shared sorrows and triumphs. We eat bitter herbs and unleavened bread to try to share in the experience of our ancestors and to share in their pain and, by the end of the long evening, we can, thus, share in their successful journey. But what if they never took that journey?

 Identity is so many things. We have a personal identity. We have a professional identity. We have an identity through the history of our family members and we have a historical identity gleaned from our own people’s saga. Of course, there is a lot of overlap and these facts and fictions get intertwined over the years. We carry around a lot of baggage. This baggage can be supportive and be a foundation to build on or it can weigh us down and render us immobile. 

 Identity is fluid. There is no real “who you are” only how you see yourself. I know four individuals whose fathers are Jewish and mothers are not. One of them was bar-mitvah’d and considers himself Jewish, one of them knows nothing about Judaism and announced almost in horror, “I’m not Jewish,” one considers herself a Catholic with a Jewish father and one says “I’m not really anything.” The Jewish identity question is especially difficult, because Judaism is both a religion and an ethnicity. For Black Americans, it often doesn’t matter how they identify themselves. If they are black at all, the rest of America considers them Black, whether one of their parents is Jewish, Sicilian or Egyptian. After a while, they might as well identify as Black, because the culture at large has already pigeon-holed them. 

Many adults have discovered they are not who they thought they were. Jack Nicholson discovered rather late in life that his sister was really his mother and his mother, who had raised him, was his grandmother. Madeleine Albright discovered her Catholic parents were really Jewish refugees from war-torn Europe. And countless individuals have discovered that their fathers are not really genetically related to them. One of my patients and her brother uncovered a family secret after their parents’ deaths. Their mother’s physician was their biological father. Their mother had been inseminated, using the treating doctor’s semen (one-stop shopping) due to their “father’s” infertility problems. The documents were in their parents packet of vital documents. 

 My husband’s announcement concerning Passover was not heralded in our family. First my daughter and I protested. We felt angry, as if he had stolen our holiday. My husband got a lot of grief. After doing my own research, however, it appears there is good archeological evidence to support that no large movement of Israelites out of Egypt occurred in the thirteenth century B.C.E. “The conclusion that the Exodus did not happen at the time and in the manner described in the Bible seems irrefutable when we examine the evidence at specific sites where the children of Israel were said to have camped for extended periods during the wandering in the desert.” After reading the book from which this came, The Bible Unearthed by Israel Finkelstein and Neil Asher Silberman, it brought to mind a show I saw on TV about tracing man’s journey out of Africa by examining the genes of people all over the world. One fascinating exodus was from Africa to India, along India’s western border and later through Southern Asia into Australia — that of the Aboriginal people of Australia. When this evidence was presented to this population, however, they became angry. They have their own myth of their origins and it did not mesh with those of the geneticists. They reacted pretty much like I had to my husband. No thanks. Our rabbi’s reaction to our initial response? “:-) no worries. Just throw in a Dayeinu and it will be fine. By the way, evidence shmevidence. What other people would keep a record of a 12 day hike taking 40 years!”

I believe our rabbi’s point of view is that, although we might feel like Passover is a part of our shared history that we do not want to be extricated from, its importance is metaphorical, not historical, or archeological. It informs our world view; it imbues us with a system of values. We are not lost in the dark now that we rethink the factuality of our holiday. Whether it occurred where it is said to have happened or when it was said to have happened, our ancestors bound together as a people, shared a national set of moral values (the Ten Commandments) and have survived many regimes anxious to annihilate us. Finkelstein and Silberman conclude: “Passover proves to be not a single event but a continuing experience of national resistance against the powers that be.” In that frame of mind I will do my spring cleaning and prepare for our family seder and forgive my husband. 

 

 

POSTCARD FROM THE FIFTIES

I grew up in the time of TV knobs, typewriters and one telephone service for all.

We rode bikes, little red scooters and roller-skates.

Cars had fins.

I wondered why my family didn’t act like The Cleavers and why my dad was always so angry.

I asked my mom why the good heroine always was beautiful and had blonde hair and why the bad sisters and evil temptresses were always dark, like me.

I asked my mom why the women who came to clean our house once a week were always black and she said, "Shhh, we’ll talk about it later."

We swam in the river that ran through town during the summer. Only women and kids were there. A literal no-man’s land.

I played all summer with the boy next door. We had a secret hiding place and a club with rules.

My dog, Mac, came with me and waited patiently all day, ready to escort me home through the woods.

I never wore shoes. My grandmother said I would step on something and die.

My parents showed us how to identify copperheads, but we never saw any.

We got sick eating Concord grapes we found in the woods. Don’t ask how many we ate.

We had hula hoops. We had yo-yo’s.

When school started my next-door neighbor and I pretended we didn’t know each other until the next summer began.

My great aunt, now 99 years old, told me to get a teaching degree when I grew up.That way if something happened to my husband, I could always get a job.

Don’t look astounded when I say men committed suicide for getting outed at work.

The Communist Party was the only national organization whose agenda included racial equality.

It was against the law to be a communist.

We hid under our desks to be prepared in the event of a nuclear attack while we were at school.

We thought about Russia a lot.

We saw pictures on the nightly news of Khrushchev banging his shoe on the table at the U.N.

“We will bury you,” he said.

One summer I fantasized my mother and brother were going to abandon me somewhere. Maybe someplace ordinary I wouldn’t suspect. Like in the Grand Union parking lot.

The air smelled different then.

It was the fifties.

 

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?