I can happily report that the church lady recovered uneventfully from her operation. Her EHE never recurred or metastasized to another site, despite having malignant features like vascular invasion. I never again heard her emit a word that would earn an R rating at a movie theater. Nonetheless, her husband and daughters were relentless and ruthless every time I saw her in the clinic. At each visit, when I first entered the examination room, one of them would exclaim, “The real Muhthuh is here to see you!” The poor lady would simply blush and apologize at least half a dozen times. I couldn’t convince any of them to let it go, it had become family lore. Parenthetically, the three daughters with slow, east Texas drawls all developed good imitations of a Brooklyn accent.
Later that year, in December, my patient had a scheduled appointment with me in the clinic. She presented me with a wrapped box and sheepishly stated, “This is to make up for the nasty things I said to you.”
I smiled and reassured her a gift was not necessary. I promised her I was not offended. I’m a surgeon, after all. She insisted I open the box. My patients frequently have talents I know nothing about unless I follow them over time and learn about their skills, hobbies, and aptitudes. Inside the box was a beautiful wooden Santa Claus. It was a single, solid piece of wood and on the surface my patient had painted a face, features, arms, and a sack full of gifts. It seemed as though the wood had been shaped perfectly for the exceptional object of art. She asked me if I recognized the wood. I confessed I did not. Sitting beside her, her husband proudly informed me it was a cypress knee. Cypress knees arise from the underwater or underground roots of cypress trees that grow in swamps or boggy soil. My patient would venture out to the wild cypress groves near her home a few times every year to select and harvest a collection of cypress knees. She would study the shape of the wood to discern the character hidden within, polish the wood, and then paint intricate faces and features onto each piece. She had no formal art training. Remarkable. Every figure was unique. A spectacular specimen of homemade art destined to become a prized family heirloom. I thanked her for the exquisite gift.
She smiled, and apologized again.
The next December, she presented me with a second box. Inside was another cypress-knee Santa Claus. It was amazing and very different from the previous year’s Kris Kringle, but equally beautiful. Recognizing a developing trend, I thanked her repeatedly, but I asked her to not give me any more of these heartfelt gifts. I appreciated her efforts, gratitude, and talent, and I told her I would prefer that she gave these to other people. She informed me that she gave her cypress-knee figures to friends and family members, and sometimes sold them at craft fairs and donated the money to a local shelter for the homeless. A good-hearted woman, I was touched by her thoughtfulness.
The deacon’s wife lived for more than a decade after I removed the unusual liver cancer. Toward the end of her life, she developed Alzheimer’s disease and stopped coming for annual visits. But while I was still seeing her routinely, she could not escape the good-natured teasing from her husband and daughters. They refused to forget “the time Momma cussed out us and Dr. Curley.” When she passed away, her daughters sent a note thanking me for my care and for the additional years they, and their children, had gotten to spend with this extraordinary woman.
I still have the cypress-knee Santa Claus figures. They are carefully wrapped and stored each year to be displayed on my mantel during the Christmas season. Every time I unpack them, I smile remembering the story of “the real Muhthuh.”
Why the @%&# wouldn’t I?
18
The Photographer
“People are like stained glass windows. They sparkle and shine when the sun is out, but when the darkness sets in, their true beauty is revealed only if there is a light from within.”
Elisabeth Kübler-Ross
Beauty: A combination of qualities, such as shape, color, or form, that pleases the aesthetic senses, especially the sight
Anyone who has a cellular telephone is a photographer. People take pictures of their meals at restaurants (really?), vacations, and family, or “selfies” with pets, friends, and the occasional random minor or major celebrity they chance to encounter. I remember the days when we carried photos of our children or pets in our wallets or billfolds. Space constraints made it impossible to carry more than just a few. Now, we are not so fortunate. The seemingly endless number of pictures stored on cell phones is a dilemma.
I wish to share an opinion and an important bit of information. The coefficient of cuteness of your children, grandchildren, dog, cat, boa constrictor… whatever, drops at a logarithmic rate with the increasing number of images you feel compelled to share on your phone. The screen is small, increasing and decreasing the size of the image with your fingers is distracting, and the whole scrolling thing almost induces seizure activity. My personal limit is about three pictures. Up to that number, I am engaged and interested. I will verbally provide appropriate congratulations, sound effects (“Ooh,” “Ahh,” or “Nice!”), and confirm your good fortune at having a beautiful subject in the image displayed on your phone. However, after three pictures, I am finished. My excitement wanes, my eyes rapidly flick left and right seeking an escape route, and yawning is induced. This is a public-service announcement; I am not alone in these feelings about cell phone–photo overload.
In the hands and viewfinder of someone who appreciates and understands light and conditions, photography is a wonderful art form. New Mexico, where I grew up, is known for its natural effects and vivid colors in the outdoor world and man-made environments. It is not possible to visit a museum or gallery without seeing photographic scenes from around the state in color or black and white. I had two high school friends who had their own dark rooms. I was impressed by their composition, angles, and framing of photographs of different events and places. Frankly, they were not much fun when they were together, going on tediously about f-stops, light meters, and backlighting. Enough already! Hurry up and snap the picture, will you? I am smiling. This is a smile.
Obviously, I never developed an abiding interest in learning or practicing photography as an art form. Like most humans I use it indiscriminately to record family gatherings, events, or a striking sunset. I don’t worry about light angles, shadows, or if the top of somebody’s head is outside the frame. But I do enjoy stunning photographic images and those who capture them. One of my favorite photographers is a former patient of mine. Former, because a couple of years ago he succumbed to the cancer we battled jointly for almost a decade.
The photographer was one of those people who illuminate a room. Joy and physical presence emanated like a force field around him. When I met him in the clinic for our initial consultation, he bypassed the customary handshake and gave me a hug and a kiss on the cheek, then pulled back and said, “Great to meet you, brother!” His wife remained sitting in a chair in the examination room, and smiling she said, “What can I say? He’s a happy man.”
Nothing wrong with that.
Physicians are taught in medical school and in postgraduate training that cancer tends to be a disease of elderly populations. Historically, many types of malignant disease are most common in individuals in their sixties or seventies. All of us know, however, cancer can strike at any age. The photographer was an active, healthy gentleman in his mid-forties when he developed progressively worsening constipation and intermittent abdominal pain. Upon further questioning, the photographer admitted he had been feeling more fatigued than usual, but as many of us tend to do, he attributed this to a busy work schedule and getting a little older. I can’t begin to count the number of times I have heard patients dismiss concerning symptoms for months or more until they are finally convinced to see a physician, only to be diagnosed with cancer. Before we met, a CT scan revealed a mass in my patient’s colon, which a biopsy confirmed to be a colonic adenocarcinoma. The scan also revealed probable liver metastases in both lobes of the liver.
The photographer was symptomatic from sig
nificant narrowing of the colonic lumen by the tumor, so a surgeon in his city performed a routine oncological colon resection and biopsied a liver lesion, which confirmed the presence of metastatic colon cancer. The photographer recovered uneventfully and met with a medical oncologist who informed him and his wife that the finding of bilobar, multiple liver metastases was a poor prognostic indicator—and even with chemotherapy he could expect to live eighteen months or less. That news didn’t sit well with this couple so they referred themselves to me.
I abhor nihilistic thinking. It is correct to inform patients that the presence of stage IV malignant disease indicates it is unlikely they will be cured by the multidisciplinary treatments we have available these days. Stage IV colorectal cancer in particular is not an automatic and irrevocable death sentence. There are new treatments and developments for many types of cancer coming out at a remarkable pace. Furthermore, we don’t “cure” patients even of some benign diseases. Once someone is diagnosed with diabetes, he or she will always have diabetes. The same can be said for high blood pressure, autoimmune disorders, and neuromuscular derangements. But patients with these so-called benign conditions can live long and productive lives with proper care and treatment. There are additional variables we have no ability to measure, predict, or control. In oncology care we occasionally witness remarkable responses to therapy, and some patients are able to live with their malignant disease for many years.
The photographer was not satisfied with an inevitable death pronouncement in eighteen months. When he and his wife visited with me and with one of my colleagues in medical oncology, we formulated a treatment plan that included three months of chemotherapy, followed by repeat imaging with CT scans of the chest, abdomen, and pelvis. He was a vibrant and otherwise healthy man. He had no problems or major side effects from the chemotherapy, and continued working at his craft throughout the cytotoxic drug infusions.
After three months the photographer and his wife met with me again in the clinic to discuss options and next steps. CT scans revealed significant reduction in the size of his liver tumors, and he had no evidence of tumors at any other site in his body. I pointed out that the majority of his liver metastases were located in the right hepatic lobe. There were two small, now partially calcified (from response to the chemotherapy) tumors in his left hepatic lobe. During our first meeting, we had already discussed a goal of surgically removing or destroying his liver tumors, so before I could state that I believed we were ready to proceed with an operation he told me, “I’m ready to rock, Doc!”
That’s all I needed to hear. We discussed the requisite technical details, risks, alternatives, and expectations about hospitalization and recovery time. A few weeks later I performed a right hepatectomy, completely removing the right lobe of his liver, and radiofrequency ablation of the scarred tumors remaining in the left lobe of his liver. He was a thin, active gentleman so the entire operation took less than three hours to finish. He was up walking the following morning.
I knew from our conversations he was a professional photographer, but he had not previously shared any of his images with me. Now that I had him as a captive audience in the hospital recovering from an operation, I asked him to show me examples of his work.
My patient responded by pulling out a laptop computer and placing it on the ever-present wheeled table. (You know, the surface used for food trays, plastic water pitchers, urinals, tissues, and incentive spirometers to encourage postoperative deep breathing. I’ve seen thoughtful and thoughtless combinations of items on these bed tables. I apologize—a digression on tables has nothing to do with photography.) He tapped the keys of the computer for a few seconds, and a long list of files appeared. He smiled slyly, and asked, “How much time do you have, Brother?” I surveyed the file names and chose one that struck my fancy, “Music.” He selected the folder icon and dozens of tiny photographic thumbnail images filled the screen. He clicked on the first one in the upper left corner and it enlarged to full size. The photographer proceeded to scroll through image after image for almost thirty minutes.
I was awestruck. More than 90 percent of the photographs were black-and-white. He confessed he preferred black-and-white because of the contrast in light, shadows, and shading he could attain using this format. The images varied from shots of bands playing on stage, close-ups of entertainers, some of whom were famous and some of whom were local artists I didn’t recognize, backstage support-crew members, and the crowds and individuals enjoying the performances.
I would visit every day while he was in the hospital, and we would open another file. His work documented everything from architecture to street scenes to ordinary or important events to well-known or common people. I particularly enjoyed one series entitled simply “Shoe Shine.” These images showed boys or men on the streets or in buildings around the city posing for him, or caught in the act of performing their work. The angles, the lighting, the composition, and the artistry were obvious even to me. The images drew me into a place, a moment, and a mundane but gloriously rendered and recorded service that came to life.
After recovering from his liver surgery, the photographer received another three months of chemotherapy. We then began the nerve-racking process of routine follow-up evaluations with CT scans and blood tests, watching for any evidence of recurrence. He made it almost three years before a CT scan revealed three new liver tumors and some enlarged lymph nodes in his retroperitoneum. He resumed chemotherapy with a new regimen. After six months the lymph nodes had returned to normal size and the three liver tumors were smaller. I performed a second operation and removed two of the tumors and did radiofrequency ablation on the third. I also biopsied several of the previously enlarged lymph nodes, and was pleased to find that no malignant cells were identified by our pathologist. While the photographer was hospitalized again I used the opportunity to view more of his stunningly beautiful work.
I recognized that all of the photographs in my patient’s portfolio came from the city where he and his wife lived. When I inquired about this observation, he informed me he was the official photographer for his city. I was surprised; I didn’t realize cities had official photographers. It made sense and I understood why he had captured everything from buildings, street signs, street scenes, events, and people from his city.
When we reached the five-year mark after his initial cancer diagnosis, he noted sardonically that he had bypassed the eighteen-month prediction by a significant amount of time. We laughed about the grossly inaccurate forecast, and he reported he had no feelings of ill will toward the mistaken physician.
But then he suddenly developed a solemn expression. He hesitantly mentioned he had more photographs to show me, but warned they were emotionally challenging to view. His city had been severely impacted by Hurricane Katrina a few years previously. He opened a file on his laptop entitled “Hurricane” and started to scroll silently through the images. Images can speak soundlessly and evoke powerful reactions. I have no words to describe what I saw. The destruction, death, and devastation were overwhelming. He had shot photographs not only in the immediate aftermath of the storm but also for more than a year thereafter. It was gut-wrenching to view. I could only imagine how difficult it had been for the photographer to witness and record the images. His photos caught the personal expressions of pain, helplessness, and hopelessness following this catastrophic event. It was impossible not to experience a visceral reaction and at one point, I looked up as a tear was rolling down his cheek. “I can’t look at these too often. It’s just too much to remember.”
Great photography has the ability to evoke a full range of feelings. My patient was an accomplished practitioner of his craft. He was blessed with a gift to look at common people and places and find extraordinary grace and beauty. Conversely, he was also willing to see and record pain and ugliness. He captured all aspects of life.
Almost six years after his original diagnosis, my patient’s cancer recurred for the second time. He had malignant masses in th
e liver, lungs, and lymph nodes. Because another surgery was not an option, my colleagues concocted more chemotherapy treatments and used radiation to treat a painful area of lymph node recurrence behind his liver. Impressively, throughout all of the side effects and pain caused by his cancer and therapies, he never failed to smile when I entered his room. The invariable greeting was a hug, a kiss on the cheek, and “Hello, Brother.”
The photographer continued to practice his art right up to the time he died. His images are an eternal legacy to a time, a place, and a city. He was genuine, gracious, and thankful for the common, everyday gifts he received. I learn important lessons from every patient I meet, and from every person I encounter. The lessons I learned from the photographer about noticing, observing, and enjoying fleeting, mundane events in ordinary life are indelibly etched on my soul.
Thank you to the photographer for reminding me daily to appreciate simple gifts.
19
The Rancher
“You know, you don’t have to look like everybody else to be acceptable and to feel acceptable.”
Fred Rogers
Acceptance: Agreement with or belief in an idea or explanation; willingness to tolerate a difficult situation
Sitting in my office I scanned the day’s list of patients I was scheduled to see before walking over to the clinic. I noticed one new patient had been diagnosed with rectal cancer. Other than the gentleman’s name and age, I had no additional information. I was in my first month as an assistant professor of surgery after completing nine years of postgraduate training. After graduating from medical school, the next almost-decade was divided into five years of general-surgery residency, two years of basic science-laboratory cancer research, and two years of surgical oncology fellowship. I finally had what my parents called a real job. I realized the new rectal cancer patient was scheduled to see me in ten minutes. I ambled over to clinic.
In My Hands: Compelling Stories From a Surgeon and His Patients Fighting Cancer Page 13