THIS IS FORTY?

I could write about a lot of things tonight, especially since I have now officially spent forty years on this planet. I could write about each of these items shown on this hog's body from my futsal team's shirt, but I will spare you!

Indeed, when I thought about this post in recent weeks, I had very different ideas about what to write than I do tonight.

First, we will get the accounting out of the way.

I have been a parent for over twenty percent of my life - 8 years.

I have been a cancer researcher for over twenty-five percent of my life - 10 years.

I have been married to the same woman for over twenty-five percent of my life - 10 years.

I have been with said woman for over one-third of my life - 14 years.

I have been in medicine for nearly half of my life - 19 years.

Historically, I have thought of life as a continuous, mind and soul-numbing struggle for more years than I can count. Pico Iyer recently reminded us that there may be value in suffering, but try telling that to one who is suffering.

My adult world view can ultimately be distilled to a simple proposition - we have limited control over the outside world, but that does not mean we are powerless. Indeed, in a world devoid of God, we are responsible for everything we do. We are accountable to ourselves, to the ones we love, and the ones with whom we share this life. With this world view, a higher power becomes superfluous.

I came to see life this way through a variety of experiences - how others treated me (see high school and college years - you know who you are), through mistakes I, myself, made, and through the works of others - Camus, Kieslowski, Kundera, among others.

Thinking about this adult world view, reminds me of the perspective that my parents tried to instill in me as a child. I was trained to be thankful for what I had. I cannot count the number of times my mom said, "Look down and not up! Think of all the people who are less fortunate than you rather than those who are better off!" 

With all due respect to mom and dad, the past twenty years have been about constantly looking up. In college, I was motivated to get the best grades possible because that was necessary to get into a good medical school. 

In medical school, it was impossible not to stress out over grades, class-ranking, and standardized test scores because a great residency was at stake. 

In residency, I came to realize that I was quite good at doctoring. I went the extra mile not only because the patients deserved this and because that is the way I was raised. The opinion of my peers and my teachers was also at stake as was the spot of Chief Resident - an honor bestowed on the two top doctors out of each residency class at my institution. When I was named Chief Resident, additional opportunity and pressure followed. What top fellowship program would I apply to? 

During fellowship at arguably the nation's best hospital, I was surrounded by the best and brightest. It was hard not to look up at my peers who were more successful and more fluent in the language of research, especially since I was a beginner at science in such a competitive environment. 

Next came a faculty position and the pursuit of career development and advancement at my current institution. I recently completed my packet for promotion. For promotion, I wrote a three page letter describing why I thought I should become an Associate Professor. As I read the finished product, I found myself asking, "What was the opportunity cost of doing all the things I had done in the past six years to advance my career?" "What research opportunities had I missed out on due to administrative obligations?" "What family events  had I missed out on?" Two summer vacations my family took without me because of grant deadlines and countless seven day work weeks in the lab come immediately to mind. 

All of this is to say, that the past twenty years have been spent looking up - higher and higher and higher - almost to the point of vertigo.

Today, as I thought about writing this post later tonight, I considered how my experiences these past forty years have colored my vision and made me who I am. What struck me more than anything was how events in recent weeks have conspired or inspired me to write an altogether different account of my forty years than I would have written even one month ago. Indeed, these past few weeks seem more influential than nearly all the other weeks of my life combined. I think this ultimately comes down to a change in my perspective.

Recently, I have learned volumes from others' writings (e.g. George Saunders), others' songs (e.g. Neko Case), others' life stories (e.g. Emir Kamenica), and my own writing and my own experiences. I have learned that life is not not something to be suffered through. Life is a gift. Kindness is a lost treasure that can be shared and found. Beauty still exists on this earth. 

I am reminded by new and old friends alike (you know who you are!) and my family, especially my mom and dad and brother and sister, that I am fortunate to have people in my life who care about me and love me unconditionally. 

Despite the challenges of my marriage, I am fortunate to have a wonderful family and two loving, adorable children whose imagination and talents are equally matched by their potential to be forces of positive change in this world.

All of this brings me to to a revelation I had tonight on my way home. In the past two months, I have been riding my bike to work each day, which is a gift in itself. It is a peaceful ride that allows me to clear my head, get some exercise, and reflect on many things. Tonight, as I crossed the Willamette River I happened to look back - westward - at downtown. I saw the sunlight reflecting off the water and the buildings. I realized I was strong enough and well enough to ride 5.5 miles each way without difficulty due to my good health. I realized that I live in a place where it is safe to ride one's bike without fear of stray bullets or cars due to a caring populace and good urban planning. On this short commute, I saw my own life's journey of forty years in perspective. 

In short I took the time to look around, rather than looking up or down. What a novel concept! Indeed, appreciating what I have without regard to who has less or who has more, to quote Frost, has made all the difference.

I will leave you with the final number from Neko Case's show last night. 

I love Neko and this song, but I do not wish to be anything other than what I am tonight. 

May the next forty years be as sweet as the last forty year have actually been!

SHE'S BACK

This week, Neko Case released her new album, "The Worse Things Get, the Harder I Fight, the Harder I Fight, the More I Love You." While it has been four years since her last album "Middle Cyclone," this album was well worth the wait.

Her album is all the more refreshing because of the foolishness that currently monopolizes radio airtime [think Miley Cyrus, Robin Thicke, et al]. In stark contrast, Neko sings about the juxtaposition of despair and beauty that is ever-present in our world. She has the ability to capture moments in life that demonstrate the frailty but vibrancy of life like few artists, and that is what I love most about her songs.

No doubt her songs are colored by her own upbringing (or lack thereof) and recent battle with depression. Emotive is the word I would use to describe her songs more than any other, and the new album is no exception.

One song in particular completely blows me away. That song is called "Nearly Midnight, Honolulu," which Neko sings a cappella. I cannot do the song justice with my words, and I suggest you listen to it. Better yet, I suggest you buy the song and the album.

I am not sure yet whether "The Worse Things Get, the Harder I Fight, the Harder I Fight, the More I Love You" belongs in the class of "Middle Cyclone," one of the finest album of the past decade. However, Neko's new songs are quickly growing on me. Stay tuned!

It just so happens that Neko will be performing in Portland on Sunday, and I just snagged some tickets. Pics and musical memories to follow!

Good night and thank you Neko for reminding me of the beauty that is ever present in our world despite all our travails...

WHY I FIGHT

Today was Tuesday, which means I was in clinic. It was a hectic day because I had an overbook at noon, several patients were running late, and I was scheduled to speak to our Prostate Cancer Support Group at 5:30.

Nonetheless, I was reminded today why it is a privilege to be a doctor and an oncologist.

My first patient was an engineer in his early fifties. He had surgery but had concerning features suggesting that radiation could be useful. We talked not only about side effects but also about how he wanted to be around for a long time for his 11 year-old daughter. I told him that that was my hope, too, and that we had a good chance to control his cancer long-term. This visit reminded me that patients worry not so much about dying but about leaving love ones behind or leaving unfinished business. Life is until further notice.

The next patient was an emergency room physician whom I had seen as a second opinion on several occasions. His cancer was now back with a vengeance, and he was too weak for any more treatment. I was honest with him and said that I believed that more treatment would not help and that focusing on shrinking his symptoms with hospice rather than trying to shrink his cancer made more sense. I shared the Kleenex box with his wife on several occasions, and I explained that stopping treatment did not mean that his doctors would stop caring for him. If anything, hospice would allow his family members to go back to being family members rather than medical providers. With hospice, we would have our eyes, ears, and hands in his home. We hugged as they left my office for the last time. Baseball games in front of the TV with their grown son, with whom he had recently traveled to several stadiums, awaited as did quality time with his loving wife. I shared that if I were to become sick, Nicholas and I would surely try to see the great football teams of Europe in their stadiums. Cherish every moment.

Another long-time patient in his nineties came in. He had advanced prostate cancer that is responding to targeted therapy. He joked about wanting to make it to 100, and as usual asked for my cell phone in case of emergencies. Sorry. As usual, he asked about the kids and said he would bring them See's candy again next time. Life is like a box of chocolates sometimes.

One other patient was also particularly touching. He and his wife are lawyers and among my dearest patients and favorite people. He is in his sixties with a son in college, and I have treated him with several therapies, most recently chemotherapy. His clinical picture was a little confusing today, but all in all his disease looked stable. We talked about next steps and whether to take a break from chemo. He talked about closing his law practice and said he wanted to head to the East Coast for several weeks to see family. I endorsed this idea and said we could work treatment around his schedule. There was a pause, and then he and his wife asked the inevitable question, "How much time do I have left?"

I told them that I did not have a crystal ball and that if I did I would be playing the tables in Vegas. Knowing me for the past few years, they both replied, "You would not be caught dead in Vegas!" I chuckled and agreed with them. I said, "Worst case scenario is 6-9 months, and best case scenario is 12-15 months."

Like water rolling off a rock, these two brave souls took this news in stride, and we moved on to other matters. We exchanged hugs at the end of the visit, and I told them I would see them next time. I hate being wrong, but oh what I would give to be proven wrong about his prognosis.

Four brief visits. Four exceptional individuals. Four stirring vignettes. All true. Too true. So true that it hurts.

People often ask me why I went into Oncology. The short answer is that I wanted to do something epic, and there are few jobs more full of the big stuff - life, death, love, and longing. However, I have come to realize that I am not interested in these themes in the abstract or in characters from a novel or a play. I am interested in real people in the flesh and blood, and I am interested in helping them live as long as possible and as well as possible.

You might think that when I look at my patients, who are all older than me, I see my dad. Sometimes that is true. However, more often I see myself. I think about all the things I hope to achieve, all the places I hope to go, the grown-ups I would like to see my children become, and the life that I would be grateful to live to an old age.

Moreover, I do what I do because someday I know I will be on the other side of the exam room with a serious illness like cancer. When I think about that, I try to care for my patients as I hope someone might care for me. I know I am far from perfect, but my patients make me a better doctor and a better man.

I will leave you with a quote from the author Colum McCann from his wonderful novel and ode to New York City Let the Great World Spin that sums up why I fight. "The world spins. We stumble on. It is enough."

Tuesdays remind me that stumbling on is indeed more than enough...

QUOTABLE QUOTES

Catherine Reese is always one to entertain, but recently she has had quite a few verbal quips.

Here are but a few:

On hearing a loud argument- "What's all the hullabaloo?"

Contemplating wealth- "If I had money, I would spend it all on pizza and ice cream!"

What a cutie!

INJUSTICE

Yesterday, the jury announced that George Zimmerman was not guilty of killing Trayvon Martin. Martin was an unarmed, defenseless, Florida teenager whose only crime was being born black. 

The proceedings of the trial were closely followed, and many had hoped for a different outcome. No one made a stronger case for what was at stake in this trial than the New York Times columnist Charles Blow, who is a father of two young African-American sons. That is why, I first turned to Mr. Blow's twitter feed after the verdict was announced and why I looked for his column today. That column may be found here and includes a video essay by Mr. Blow.

I was so moved by this piece that I sent him an email tonight. That email is excerpted below.

Dear Mr. Blow,

I am writing to express my profound sadness about the verdict in the Zimmerman case. I am dumbfounded by the ruling, and I cannot understand the conclusions that these jurors reached.

As a brown man living in this country with a biracial son, I worry. I worry that this young man, who is pure innocence, will not be viewed that way by strangers because of his skin color. I worry that they will call him nigger like they called me when I was only a kindergartner. I worry that we have not come far enough in this country, and that a post-racial society will never come.

However, I also have hope. I hope because there are people like you who are a voice of reason and conscience. I hope because I have seen an outpouring of outrage, sadness, and compassion from all corners of the globe. I hope because the alternative - despair - is a pill that I am not ready to swallow.

Words - your words - always touch me, but never more than in defense of Trayvon and boys like him in every community. Thank you for all your efforts, for your words, and for giving voice to the concerns of so many who cannot be heard or will not be heard.

Best,

Joshi Alumkal
Portland, OR

What more is there to say?

TAKING STOCK

Life is busy, and it is easy to lose track of our own or other's growth or change. However, children are a great guidepost by which to measure progress because they go through such interesting and often fleeting stages.

This week, I took stock of two very special children - Cate and Nicholas.

Cate is now four and a half - make that four and three-quarters- years old and has had tremendous growth in the past year on all fronts. Cate can read books and is constantly sounding out words she sees written in magazines, prints on our walls, or even food packages. Cate can write her name and simple words by using phonics.

Cate continues to astound me and others in the coordination department. She was recently invited to join a "Premier" group of children in a soccer development program, and I have no doubt that she will become a great, multi-sport athlete.

Before I had Cate, I always said, "If I have a daughter, I hope she is a confident, poised woman like Mia Hamm" (who happens to be the world's best female soccer player of all time). Cate is on her way.

Most importantly, Cate's personality continues to take form, and I am constantly astounded by how much she and I have in common. Cate is a fierce critic of herself and is a perfectionist in everything she does. For example, the other day Cate knocked a magnet of the Barca stadium off the fridge by mistake. She knew that this was a special magnet that I bought in Spain, and she quickly ran upstairs to her room after she realized what she had done.

I followed her upstairs to comfort her. When I found her, she was visibly upset and kept repeating, "I am so clumsy." I quickly corrected her and told her that she was anything but clumsy and that accidents happen. After some distraction, I was able to help her move on.

While I appreciate the desire to do one's best, I have also witnessed firsthand the toll that perfectionism can take on one's self. I hope to help her become more comfortable with failing because life is littered with failures.

Nicholas is a creative and emotive young man, who also continues to astound me.  He is the most passionate child - make that person - whom I have ever met. His interests continue to evolve, and he looks within rather that to peers or the mainstream for his interests.

Currently, he is a scholar of all things soccer-related. This year, he did his Arbor independent project on the history of soccer, and it was, in my humble opinion, the best of the bunch of some very good projects.

Nicholas continues to love drawing and art.  Below is an amazing self-portrait that he drew at school.

Nicholas is also fascinated by the world at large and different countries and cultures. He may still have trouble pronouncing his "Rs," but he can pronounce multi-syllable, vowel-deficient Polish or other Eastern European names without difficulty.

One day, Nicholas found out that his babysitter had a great grandparent who was from Poland. He asked her if they could go on the internet to print out Polish words. That afternoon, he spent several hours writing out common Polish words and their English definitions. There are no Polish schools in Portland, but we hope to channel his energies into Spanish classes.

Nicholas' current goal is to become "a soccer player who eventually goes to play in Spain or somewhere else in Europe." Afterwards, he hopes to become an architect who builds soccer stadiums because, as he put it, "I love soccer, drawing, and building things. An architect seems like the best job."

Nicholas also continues to make strides in music. He began playing ukulele 3 years ago, and he is now playing mandolin.  He has surpassed me and Kathleen in competency, and he loves to perform. Recently, he and his teacher put on quite the show at Arbor for the whole school. I could not be prouder of the young man he has become.

I am always astounded when I step back and take the time to appreciate the growth of these kids. They are growing up so fast, and it makes me sad to think that they will leave one day or that I will no longer be here to see them keep growing and changing. Times like tonight remind me how lucky I am to be their dad.

After Manchester City won its first Premier League title in over 40 years last year in the last minute of the season, the great soccer commentator Martin Tyler exclaimed succinctly "I swear you'll never see anything like that again... Drink it in!" If I were drinking to celebrate Cate and Nicholas tonight, I would be a very proud and drunk dad...

BEFORE MIDNIGHT

Tonight, I went to see the new Richard Linklater movie “Before Midnight.” This is the third movie in a trilogy that began with “Before Sunrise” and then “Before Sunset.”  Each movie features the same characters – Jesse, an American man, and Celine, a French woman.

These characters meet for the first time in their 20s in “Before Sunrise” while each is on holiday. In that movie, Jesse somehow works up the nerve to strike up a conversation with Celine on a train. He convinces her to get off with him in Vienna and explore the city. A romantic night of talking and connecting follows. However, in the end, these characters go their separate ways.

Jesse eventually becomes a writer and writes a book about that night. In “Before Sunset,” Jesse is in Paris on a tour promoting that book. As you might have guessed, Celine shows up to the reading. At this time, the characters are in their 30s, and Jesse is unhappily married with a young son living in the U.S.  Jesse and Celine reconnect and enjoy another memorable day together. At the movie’s conclusion, we, the audience, are left wondering what will happen next for these two.

In “Before Midnight,” Jesse and Celine are in their 40s. They are now a couple that lives in Paris with their twin daughters, and they have settled into a domestic routine.  The movie takes place during their holiday in Greece, and much of the movie features the two of them conversing about their lives. A lot of deep-seated feelings and resentments bubble up to the surface, and their calm, whimsical discussions quickly become resentful. 

It is amidst the fighting, that we truly come to appreciate the humanity of these two characters. They are not two beautiful people with perfect lives and carefree existences. On the contrary, they are people who have deep misgivings about some of their choices, their partners’ behaviors, and their futures. 

In this sense, these characters embody so many people who are or have been in long-term relationships.  It is not easy to sustain a marriage… especially when one is busy with work, kids, and life and continually stressed-out. On top of that, we all change as we grow older. What was once desirable, acceptable, or tolerable no longer feels the same way. It is in these moments, when one begins to wonder, was it all worth out? The answer is complicated and most definitely very personal.

For most of our post-pubescent lives, we long for one thing – to be accepted and to be with someone else. Who can ever forget the worry of finding a date to the prom, having a girlfriend, or getting married? Our society constantly presents marriage and relationships as the norm, the ideal. Evolutionary theory also tells us that it is in our interest to pair up and reproduce so that we may leave a genetic legacy.

However, what if marriage and coupledom is not the panacea for which we had been hoping? What if living in a prolonged state with the same individual leaves one feeling diminished rather than aggrandized?  This is the theme Jesse and Celine tackle on the night in which “Before Midnight” takes place. Just like in real life, there are no simple answers or endings to their tale. The audience, or at least this audience member, is left wondering what will become of these two and also what should become of us?

Life does not always turn out the way it is supposed to. In many instances, that is no one’s fault. If anything is to be blamed, it is time. Time passes quickly, but change is continuous though often imperceptible. That is, until one steps back and realizes what has become of one’s life, one’s family, or one’s marriage.

Some - perhaps the ones that we often call wise - are able to appreciate the good with the bad. Others only see the darkness without the light. However, before midnight it is difficult to know which of these perspectives is wrong and which is right...