Despite our divided family and households, and our older sister’s departure, Victoria and I, both now teenagers, fell in love with our new independence. London was full of protests and hippies, pop art and music. For two teenagers with time to kill, everything seemed possible. We listened to music and wandered around Kensington High Street and Notting Hill Gate, mostly on our own. We adopted cool new wardrobes of velour tops, clogs, and brushed-denim trousers. In an effort to fit in with the other kids, we began to smoke cigarettes and professed a willingness to try beer and alcohol, which led to a lot of repressed nausea and the development of acting skills, as we enthusiastically pretended that we liked the bitter taste.
Victoria’s companionship gave me the courage to explore. Some of my fondest memories of our time in London are of Saturday mornings on Portobello Road. A discerning antique-buyer’s paradise, it was also a candy store of possibilities for kids with no discernment whatsoever. There was adventure in picking through piles of junk to find treasures. The dealers rented out stalls in cramped, narrow passageways behind the storefronts. They kept their goods in boxes piled on rickety wooden tables, and if you engaged them in a chat, you got a history lesson in family crests or sword fighting or how to properly set a formal table. After the World Wars, many of the grand estates in England became unaffordable for the titled class, so the titled had unloaded family possessions for the rest of the world to harvest: boxes of tarnished silver overflowing with delicate teaspoons and grape scissors, enormous soup spoons, and knives with flat ivory handles; colored glass goblets; umbrella stands made from the legs of elephants; gold pocket watches; and stately grandfather clocks with intricate brass hands. Strange, slightly menacing, porcelain figures piled on rickety tables dared you to pick them up. I generally didn’t; Victoria often did.
I admired rows of miniature lead soldiers from various regiments: splendidly dressed Prussians; Russian Cossacks on horseback; British World War I infantrymen, their uniforms exact replicas down to each beret and lapel ribbon. Meanwhile, Victoria paraded around the stalls with a wide grin on her face, trying on fox fur stoles like the ones our grandmother Liboo wore back in Chicago. Victoria commanded attention, but also forbearance, as her performances generally amused, rather than annoyed, the onlookers. Everyone was in on Victoria’s jokes; they were never at anyone else’s expense. Surrounded by lead armies, I watched from a safe distance—mortified by her theatricality, yet envious of her confidence. In my memory, Victoria is always there with me on those rainy winter mornings, trying on hats adorned with exotic feathers and sorting through trays of rings set with gaudy gemstones, each one bigger than the next.
During the school holidays, we traveled together by train. Our parents arranged for us to stay on a farm in Brittany so we could learn French, presumably through immersion. This learning experience turned out to involve hauling rocks from the host farmer’s fields and watching in complete horror as he castrated a bull. We attended an outdoors camp in Wales where we learned to pitch a tent and rock climb. Most of our holidays occurred in the spitting rain, and while I took to the outdoors and continued to seek adventures in the mountains and trails, I think my sister learned to appreciate a nice hotel with hot running water and “creature comforts.” I am pretty sure she never went camping again.
As one extra year became two, reflecting the uncertainty of our situation, Victoria grew interested in theater and began performing in school productions. I took to science and crew at my all-boys’ school.
Caroline commuted back and forth from the States each summer and for the longer school holidays. My sisters missed each other and made an effort to keep in touch, eleven-year-old Victoria’s letters already suggesting her grown-up self:
Dear Caroline,
I’m sorry that you feel that way about me. I really don’t want you to dislike me, which I feel you do.
I miss you so much, and I really wish you were not angry with me this summer.
I don’t have as many boyfriends as everyone makes out, just I’m always falling in love with people, but they don’t always feel the same way about me.
Well, I hope your view of me will change, but I cannot do anything to change it for you.
I was so upset about the day I saw you, because it wasn’t long enough, I barely saw you.
Well …
Jody has started judo and I’m very scared about being practiced on. Mommy is working very hard, and I think it is leading to success. Dad and J are fine. I am just about to go out to dinner with him …
XXXX
Our father bought a canary yellow E-Type Jaguar, and on Sunday afternoons Victoria and I went out on the roads with him. My father drove with the convertible top down, seemingly oblivious to the risks, both his children standing up in the back and holding onto the front seats, wind ripping through our hair as we sped along the M40 at over one hundred miles an hour. I don’t believe we ever considered the use of seat belts. I felt safe with my sister, and none of my childhood would have been as thrilling without her wholehearted embrace of adventures large and small.
When Paul McCartney was trying to obtain a visa to return to the United States in the hopes of a Beatles reunion, our father served briefly as his lawyer. Marijuana charges stood in his way; despite Dad’s efforts, McCartney’s entry was forbidden. One of my fondest memories was being invited to the Hammersmith Odeon to attend a Wings concert. This was the heyday of theatrical 1970s rock, and we had landed right in the thick of the action. Victoria and I found the deafening noise and flashing lights electrifying. Our balcony seats were with VIPs, and we spent the evening running around collecting autographs from the famous audience. The list included Roger Daltrey, Eric Clapton, Gary Glitter, Suzi Quatro, David Frost, and Ringo Starr and his wife Barbara Bach. Some of them were completely drunk, and all of them were happy to sign our concert posters. We were giddy with excitement and, once again, entirely unsupervised.
Afterward, we met Paul, Linda, and the other members of Wings and got them to sign our posters as well. I would never have had the courage to ask them for their autographs—Victoria didn’t hesitate. Not the least bit intimidated, she walked right up to her intended targets, thrust out her poster, and requested their signatures. My poster was signed as well, but only after Victoria had staked her claim.
When Victoria was thirteen and I was fifteen, we returned to DC and the quiet, nurturing campus at Sidwell Friends School. She jumped back into life with all of her old friends; it was as if she had never left.
Both our mother and our father eventually remarried other people. I graduated from Sidwell and went to the University of Michigan-Ann Arbor, where I studied liberal arts and majored in history. When I later decided to attend medical school, I stayed at Michigan for medical training and then for neurosurgical residency.
Victoria graduated two years behind me and went on to Smith College. She starred in many school productions, only some of which I saw, and performed in summer stock at the Weston Playhouse in Vermont, later moving to New York to begin her stage career in earnest. In the city, she shared a cramped Upper West Side apartment with her friend Monique from Smith. Clothes, costumes, and leather boots cluttered the floor and filled their one (red velvet) couch. To me, visiting from the disciplined world of surgical residency training, it seemed like an impossible way to live. Even using their bathroom was often the cause of great embarrassment for a brother, festooned as it was with lingerie draped over wire hangers. Tubes of makeup occupied every spare surface.
My sister had a greater tolerance for risk and rejection than I ever did. She would audition for parts over and over, only to be passed up, yet she would return the next day and try again. I would have found that degree of exposure intolerable. I was drawn to the more clearly defined life of a surgical resident. It didn’t require the same leap of faith, despite the long hours and demands. If you successfully completed the training program, you would be qualified to practice as a neurosurgeon. The direction, the expectations, were cl
ear. In many ways, mine was the easier path.
Acting, by contrast, is risky and unpredictable. Victoria’s optimism and confidence helped her weather countless rejections without losing her self-esteem or passion for acting. She was innovative, and often daring. Always determined, she took the initiative: when she couldn’t get a part, she went about making her own movies. She supported her fellow actors, cheering their successes and consoling them when they failed.
Victoria loved being in New York, loved the energy of the city. She worked as a waitress most evenings, auditioning and attending theatrical workshops during the day. It was during these years that she was introduced to the man she would eventually marry.
Pat was starting his own venture capital firm and Victoria was trying to establish herself as an actress. At some point, they decided that her acting prospects would be better in Los Angeles and Pat’s business ventures could be just as successful there as they were in New York. Flying by the seat of their pants, they packed up their belongings and moved across the country to begin a new life.
Once Victoria became ill, I realized, looking back, how easy it was for us to take each other for granted. How easy it was for me to take her for granted. My time and attention were consumed by work and by family, by all the scheduled activities of soccer tournaments, ballet, tennis matches, and bar mitzvah preparations. My sister and I lived parallel lives on opposite coasts with children at different developmental stages, immersed in different activities. We spoke infrequently. I felt I had been neglectful. I felt guilty that we had become so removed from each other’s lives. Part of my fear when she received her diagnosis was that too much time had passed and too great a distance had grown. Would we be able to reconnect? As it turned out, over the course of her illness one of my great pleasures was the discovery that those connections were still very strong and very much alive for both of us—and that, with my medical training, I could be truly helpful to Victoria in her time of crisis. Later, I learned from her journal that these feelings were mutual.
I am so glad Jody is here. Not only is he here to give me his wise advice and council [sic] but also I am really enjoying my time with him. He has been our go-to consultant throughout. Pat and I have called him repeatedly to help us decipher various medical pronouncements. And, when he is not here, he texts me daily to ask how my numbers are. He has been very much part of our team. And now that he is here again, I’m able to enjoy spending time with him. With him living in North Carolina, raising three kids, and leading the busy life of a neurosurgeon, we haven’t seen each other nearly enough. I feel like we are making up for lost time, having wonderful talks about so many things. He is also just sitting with me, as Pat has done, keeping me company, hour after hour. The mask and gloves don’t bother him much since he is used to wearing them for work. He has played a lot of games with me, too. It has been a real treat to have him here with me, keeping me on this side of sane.
—APRIL 20, 2015
CHAPTER TWO
learning to tie knots/ the arc of a career
The arc of a neurosurgical career is like a surgery to remove a brain tumor or an AVM [arteriovenous malformation]. In the beginning, you are very aggressive and bold. Early on, the tumor is not near any critical structures. But, as the case progresses, you become more and more timid, until at the end, you become fearful.
The trickiest part of the surgery is at the end, when you remove the last part of the tumor, which is wrapped around the carotid artery or the optic nerve.
And that is when you know you can hurt a patient.
—KYLE CABBELL, FELLOW TRAINEE AND CURRENT PARTNER
Stocky, with thinning sandy hair and head perpetually tipped in a quizzical way, Dr. Julian “Buz” Hoff was a remarkable teacher, researcher, surgeon, and leader. He was the chairman of the Section, now the Department of Neurosurgery, at the University of Michigan. He was also the reason I became a neurosurgeon. Equipped with a seemingly limitless supply of aphorisms, which he delivered with impeccable timing, he made us laugh. He also cut the tension. “I’ll have you farting in silk pajamas,” he would announce at a particularly arduous moment in a surgery. Or he’d lean over with a conspiratorial wink and declare, “You haven’t had this much fun since the day the pigs ate your baby brother.”
Dr. Hoff inspired devotion and hard work by example, bringing kindness, compassion, and humility, as well as superb skill, to the practice and teaching of neurosurgery. He was a true mensch and treated his patients and staff with dignity and respect. He was devoted to his patients and they to him—so much so that they would often confide they were doing well rather than complain, because they didn’t want to disappoint him.
He understood the importance of keeping one’s cool and not getting caught up in the moment. I remember running down the hall of the hospital during my second year of residency to inform him about a patient who was deteriorating from a hemorrhage he had had in his brain.
“Doctor Hoff!” I blurted out. “We have a problem.”
He stopped me and looked me in the eye, suddenly serious. “No, the patient has a problem. You and I are just fine.” Buz was restoring calm and order, defusing a tense situation, maintaining perspective—all essential skills of an effective physician. He was pointing out the importance of being concerned and invested, but at the same time maintaining awareness of the distinction between the patient and the doctor and not becoming overwhelmed by the drama of the moment.
It is an awesome thing we are entrusted to do to people. We cut their skulls open, reroute blood vessels, remove tumors from deep within their brains, rebuild their spines with rods and screws, and replace disintegrated bone with artificial discs. There is an awful lot to master on the way to becoming a fully competent independent neurosurgeon. It takes seven or eight years of post-medical school training to acquire the skills needed to practice general neurosurgery.
There were only two residents in each training year, and we were all encouraged to work as a team. Cooperation and mutual support were crucial. I completed my training before work restrictions came into effect after the Libby Zion case, when 100-hour-plus workweeks were the norm, rather than the exception. Yet despite the long hours, the spirit of collegiality permeated our training. There were nine professors in addition to Dr. Hoff in the Department of Neurosurgery. They all shared a dedication to teaching, reinforcing the humanity of the program. Each resident worked closely with an attending surgeon, one-on-one, in the operating rooms, where the attending directly inculcated skills and techniques to the neurosurgeon in training.
Neurosurgery training programs are notoriously grueling. They begin with a yearlong general surgery internship, followed by six more years of neurosurgery residency in a teaching hospital. The load of responsibility and complexity of the surgeries increase with each training year, until you are performing the most difficult cases largely on your own by the end of the seventh, otherwise known as the Chief Year. We began our apprenticeship with fairly routine lower back surgeries and gradually made our way up the spine to the neck, the skull base, and finally the brain.
There was also much to learn about the operating rooms themselves. At the University of Michigan there would often be as many as ten or twelve people in each operating room, including the attending surgeon, resident trainees, medical students, scrub technicians, nurses, and the anesthesiologists and their trainees. Technicians would shoot X-rays, operate specialized equipment such as lasers, nerve monitors, and ultrasound imaging, or manage extensive trays of implantable hardware if we were performing spinal reconstructive surgery. Not infrequently, the neurosurgeons would work with teams from other medical disciplines, such as otologists (for acoustic or skull-base tumors) or general or vascular surgeons to perform unusual surgical exposures, such as temporarily moving large blood vessels to allow us access to the front of the spine for our surgeries.
The training is demanding and thorough. On completion of residency, you have developed a unique set of skills and judgment
s, as well as the flexibility to incorporate new skills and techniques going forward.
Even twenty-five years ago, we neurosurgery residents were taught how to integrate new technology into our operating rooms and to function as a cohesive group. A good neurosurgeon (or any good doctor, for that matter) is a lifelong learner. Many of the surgeries we now perform regularly had not even been conceived of during the years of my formal residency training. Often, we improve the way we operate while in practice, continually adjusting our surgical techniques as new approaches become available. For example, all of the minimally invasive spinal surgeries have come about in recent years, replacing older operations that had wider exposures. We now perform extreme lateral decompressions of nerves that have become pinched by bones, ligaments, or ruptured discs and fusions in the lumbar spine through tubular retractors, which we pass through the patient’s side to dock onto the disc space, navigating with X-rays and electrical monitoring. We place screws in the spine over wires placed through stab incisions based on X-rays. None of these techniques existed during my formal training.
I recently performed an operation on the base of a patient’s skull and upper cervical spine using intraoperative CT scanning and a navigation system that superimposes the surgical instrument on the CT images, making for a safer, more accurate surgery. These navigation systems didn’t exist during my training. Now, when I place a screw into the first cervical vertebra, I watch the computer monitor as well as the patient, seeing a virtual projection of the screw to confirm that it will be well positioned in the bone and not penetrate the vertebral artery, which courses millimeters away. The slightest injury to this artery could mean disaster for the patient.
Grief Connects Us Page 3