Daniel Menaker | A Good Talk

(On a bench in Central Park on a beautiful May day.)

OLD FRIEND:  You look tired.
ME: You know, I’ve always thought that that is one of the worst things you can say to someone.
FRIEND: I meant to be sympathetic.
ME: All it does is make a vain person like me feel bad.
FRIEND: You’ve always been too sensitive.
ME: I have not!
FRIEND: See what I mean?
ME: Where do I look tired?
FRIEND: Under your eyes, and you also look pale.
ME: Great.
FRIEND: It’s because I care.
ME: Sure.
FRIEND: How was your lunch with ____________?
ME: Extremely interesting. We talked a lot about his father [a famous man, deceased].
FRIEND: And?
ME: And what?
FRIEND: Don’t fuck with me. And what did he say?
ME: He said his father, and I quote, “dug himself into a hole with his mistress and couldn’t get out.”
FRIEND: By all accounts she was a harridan.
ME: Yes. But I said to ________, “He could have gotten out, you know.” And ________ said, “What do you mean?” And I said, “Well, he could have gotten out—that’s all. If you aren’t an actual slave or tied up or something, you can get out.”
FRIEND: Aha!
ME: Aha what?
FRIEND: Aha, you have just shown me that despite all your fancy positions against free will, you actually believe in it.
ME: I showed you no such-a thing.
FRIEND: Yes you did. You said he could have gotten out.
ME: What I meant was–
FRIEND: Oh no you don’t! You said he could have gotten out, which means you think he could have made a decision to get out but chose not to.
ME: Look, I talk like everyone does on this social–
FRIEND: You believe in free will–it’s clear to me and you can’t wriggle away from it this time.
ME: Let me finish. I talk like everyone else on this social level–she could have not dyed her hair purple, he could have married Susie instead of Sally, my boss could have chosen to let me offer more for Atul Gawande’s first book.
FRIEND: Yeah–what happened there, anyway?
ME: I’ll tell you later. My point is that like everyone else, in ordinary conversation I talk the way people talk, as if people have real choices about what they do, agency independent of their physical brain’s neurological functioning. But I don’t actually believe it. We just use it as a model. I don’t actually believe that _________’s father could have gotten out of that hole. He stayed in it because that’s just the way he was. It was his brain that kept making his consciousness so-called “choose” to stay in the hole. In fact, I think that’s exactly what _______ and I were talking about: his father’s not being able to choose to get out of the hole.
FRIEND:  Oh, wriggle wriggle.
ME: OK, then–I choose to return to the subject of my looking tired.
FRIEND: What about it?
ME: Well, if you must know, I had a terrible night last night.
FRIEND: I’m sorry–what happened?
ME: I had this weird chest pain.
FRIND: And did you call the doctor this morning? You should have.
ME: No. I did freak out a little, I admit. When you have cancer you sort of automatically become a hypochondriac and also a rationalizer at the same time.
FRIEND: You have no choice.
ME: Get off it, OK?  I didn’t call the doctor, because it just didn’t feel like anything cardiac.
FRIEND:  Call the doctor.
ME: No, I really don’t think I have to. I think I figured it out.
FRIEND: _______
ME: So at first I was sure it was angina–my father had it.
FRIEND: What did it feel like?
ME: Just to the left of my sternum, this little bud of warm pain would blossom every four or five minutes and then sort of evaporate. It wasn’t severe but it kept me awake.
FRIEND: Call the doctor.
ME: So I got up and Googled angina and learned all about stable angina and unstable angina and so on. With stable angina, it says the patient can predict when it will occur. So at first I thought, Oh, well, I can predict this because it seemed to be coming and going regularly.
FRIEND: What time was this?
ME: It started at 2:30.
FRIEND: You got up and looked at your computer at 2:30? By the way, stable angina sounds like an equine disease, like dogs with kennel cough.
ME: Very funny. This is serious, So just to make sure, I went back and lay down and timed the pain buds–sure enough, every four to five minutes. So then I went back to the computer and looked more and found put that by “predictable” they meant that patients could predict like, well, after a stressful event or too much exercise, they knew they would have an angina attack.  They didn’t mean that it would occur at regular time intervals.
FRIEND: Well, of course not. Moron.
ME: What did you say?
FRIEND: Oh, nothing.
ME: You said “moron.”
FRIEND: No, I didn’t.
ME: Yes, you did. Anyway, so now I was really getting scared that I would have a heart attack. Now, you know I have gotten through all my cancer treatments without much in the way of hypochondria. Just simple, justifiable dread.
FRIEND:  You’ve handled this whole thing very well.
ME: Thanks.  But at this point, anyway, cancer actually came to my rescue.
FRIEND: Tell me.
ME: I realized that what I was experiencing was chest-wall pain. Which is a famous side effect of the the fancy radiation therapy I finished in the winter.
FRIEND: But that was months ago.
ME: That’s the fiendish thing about some radiation side effects–they can happen six months, a year later. And chest-wall pain and rib fracture can be among the most delayed. So I decided that’s what this was, took an Advil, and finally went back to sleep. But I was up from about 2:30 to 5 in the morning.
FRIEND: This is all to explain why you look tired?
ME: Exactly!
FRIEND: Very convincing.
ME: I’m sure that’s what it was.
FRIEND: Call the doctor.
ME: With Gawande’s first book, by the way–it was a collection of his pieces from The New Yorker, and my boss just had this reflexive reaction that collections of already-published pieces were a bad publishing bet. So I couldn’t match another publisher’s offer.

Tags:Health Care, Humor, Memorable Conversations
Filed under: Talky Talk by Daniel Menaker
Friday, May 18th, 2012 at 10:29 am
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(Since I started these Onconversations, about a year ago–with the recurrence of malignant nodules in what remained of my left lung after a lobectomy in 2008 for a 2.5 cm. adenocarcinoma–this site has gotten as many as a hundred and as few as zero clicks a day, according to Google Analytics.  Even a hundred is nanochicken-feed, I realize, so those of you who do stop by here for a few minutes every now and then, thank you, and please share the destination with others who might find it interesting or amusing and maybe even worthwhile. It’s by no means just a matter of raising Google-search numbers and seeing if there’s enough traction here to consider a book project for myself. Though it is partly those things, I confess.  It’s also a matter of being in touch with and creating a community of cancer patients, physicians, and those close to them who have some philosophy about and perspective on the illness–something beyond the usual [though useful and helpful] medical sites, professional and patient-generated. I’ve found that every instance of others’ intelligence, insight, humor, and candor about cancer has proved to be tonic in itself–and, paradoxically and most important, has proven antidotal to obsessing about it.

Small as the site’s visitor numbers may be, you-all have landed here from just about everywhere–Japan, Ukraine, Bangladesh, Finland, Brazil, Singapore, Croatia, India, Argentina, Canada, Germany, Malaysia, Norway, Pakistan, Mexico, Belgium, Brazil, Georgia, England, Papua-New Guinea, France, Colombia, Greece. Not Italy yet, as I recall. What’s up with that?  This is thrilling to me, not just out of self-regard but because it gives evidence of what kind of potential good–or at least pleasure and interest–a global globe can provide, even about cancer.

Anyway, I meet a friend and fellow-patient on the street very near my apartment. He has on a black jacket and his left arm is close to his side, his left hand in his pocket.)

ME: So, I take it you’ve had the surgery. (It was, as I recall, surgery for a recurrent tumor that would paralyze his arm.)
FRIEND: Yes. (He nods toward the arm). It’s now just decorative, I’m afraid.
ME:  You can’t use it at all?
FRIEND: Nope. Useless.
ME: Well, I’m sorry. But on the other hand–
FRIEND: Watch it!–
ME: It wasn’t deliberate, I swear. On the other hand, you’re well now.
FRIEND: From your lips to God’s evidently pretty deaf ear.
ME: You look well, anyway.
FRIEND: Thanks, but that’s about one-twentieth the battle, don’t you think?
ME: It depends on how vain you are, I guess.
FRIEND: And you?
ME: Finished radiation treatments–very fancy and futuristic–three months ago, and the last CT scan was encouraging.
FRIEND: Oh, yes–encouraging.
ME:  No, really! But I have another scan in July which will be more telling.
FRIEND: Good luck with that.
ME: What are you doing around here, anyway?
FRIEND: I’m taking part in a wall-to-wall Gertrude Stein thing at Symphony Space.
ME: A fellow-cancer patient.
FRIEND: Yes. Not so encouraging.
ME: You know, you are just too quick. You do two-upsmanship better than anyone else I know.
FRIEND: Well, you can find anything you want in Gertrude Stein to bolster whatever you are trying to bolster. In our situation, my favorite would be “Considering how dangerous everything is, nothing is really very frightening.”
ME: Excellent. I’ll keep it in mind as July approaches.
FRIEND: Are you going out to the Southampton conference this summer?
ME: Yes, but I’m not sure what I’ll be doing.
FRIEND: In our situation, getting there will be almost all the fun.

Tags:Health Care, Humor, Memorable Conversations
Filed under: Talky Talk by Daniel Menaker
Wednesday, May 9th, 2012 at 2:51 pm
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(I talk to my main oncologist on the phone, after my radiation treatments are over and after he and I have exchanged emails about the follow-up CT scan three months later. [See ONCONVERSATIONS XXX])

ME: So I potentially have this job offer coming my way. Can you imagine–at seventy, cancerous, mildly diabetic, with no thyroid function. But I don’t know what to do about this, because of my lung situation. I’d like to renovate the big barn behind our house in the country, or at least shore it up. So the money would be nice.
DR: Just do what you want to do.  The last time we wrote, you were saying something about an investment decision. Is this the same thing?
ME: No–this is something different. One had to do with maybe selling a stock that had done well and this one has to do with a possible job offer. But they both raise the question of How Long.
DR:  We can’t know, but in my opinion, long, unless something else gets you first.
ME: Well, you still haven’t answered my earlier question about similar cases: recurrent small malignant lung nodules, same lung, isolated, indolent, no evidence of mets.
DR: “Mets,” eh? You’re learning the slang.
ME:  All these abbreviations–you have to have them because so many of the words and phrases are so long.  Chemo, IV, SBRT, QOL, dexy–
DR: “Dexy”? That’s dexadrine. You didn’t have dexadrine.
ME: Well, I thought I had made that one up. It was supposed to be for “dexamethasone”–that steroid I took when I was on chemo. I mean chemotherapy.  But back to the outcomes in cases like mine, please–people in more or less my situation who have chosen stereotactic body radiation therapy over surgery.
DR: I can think of a few comparable cases. One guy, a CEO, is walking around happily seven years after being treated.  Another person, a woman, is four years out.
ME: Are you repressing less favorable results?
DR: Probably.
ME: Oh, great. You don’t know? Or are you suppressing
DR:  In the last year alone, we’ve found new ways of treating your condition, if it gets worse.
ME:  Good! What?
DR: Some of my patients tell me, “All you have to do is keep me alive for a few more years and you’ll find something new to work with.” And sometimes they’re right.
ME: Great! But, you were saying “in the last year alone”?
DR:  Yes–remember we found that you have this mutation–EGFR–but it didn’t seem susceptible to Tarceva, the targeted therapy for some lung cancers. It didn’t have the right structure?
ME: How could I forget? That was the low point, I think. Although it’s the abbreviation that gave me my most impressive medical terminology–epithelial growth factor receptor.
DR:  Excellent! Well, there are further findings that suggest strongly that Tarceva is applicable in your case. Which would be a very good thing if and when we have to do more.
ME: Well, that’s extremely encouraging.
DR: Yes. I really am encouraged, as I said in my emails.
ME: Why didn’t you tell me about this Tarceva news earlier?
DR: There was no point–you were having SBRT.
ME: So you kept it on the QT.
DR: Very funny.  So I say, take the job, if it’s offered, and hold on to the stock, whatever it is.

Tags:Health Care, Memorable Conversations
Filed under: Talky Talk by Daniel Menaker
Monday, April 23rd, 2012 at 8:27 am
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(The following is a slightly redacted email exchange between me and my thoracic oncologist.)

ME: As I wait for the results of the follow-up CT scan I just had (which Dr. _______ [the oncology radiologist] says will likely show not much change, but I’m not counting on that in any direction–same, better, or worse), I wonder if I could make an appointment with you, or have a phone call, about a couple of questions I have which are sort of vague and maybe even loopy, and probably repetitive. One (not so loopy), for example, is:  If and when there is further need for treatment, whether without knowing more about these lesions–the more that you might have known if I’d had surgery–there are targeted therapies that you might consider using more blindly on the basis of what you do know, from the biopsies. Or would that be dumb? Also, have you treated patients like me, with recurrent small, relatively indolent multiple same-lung nodules who are in pretty good shape, around my age, who have had SBRT, and if so, what have been the outcomes? Yes, I am thinking again about Time Left, especially in view of some recent financial good fortune. Not Scrooge McDuck scale but nice enough.

I hope that you yourself are well, and I’m sure that one way or another, at one point or another, we’ll be talking again.

DR: Happy to discuss these questions.  Could talk on the phone Monday or Tuesday next week or see you in clinic next week on Wednesday.  If Scrooge McDuck has an “investment” decision that needs to be made sooner, I’m happy to try to find time sooner.

DR: [Later that day] I just looked at your CT scan.  It looks good.  From the report:  “Nodules in the left lower lobe are stable to minimally decreased.”  There are some changes which we can attribute to the radiation: “New adjacent focal subpleural ground glass opacity in the left lower lobe” and a “small loculated pleural effusion.” Altogether, it shows nothing of concern to me and some encouraging findings. Enjoy the weekend.

ME: Thanks very much for getting this information to me. I take it that the loculated pleural effusion is what remains of the earlier one–it showed up during the SBRT treatment but (clearly) wasn’t  serious enough to preclude the treatment, after the major portion of it was aspirated by Dr. _______. Also, Dr. _________ said that this partic. CT scan would probably not show much change but the next one might–one hopes in the direction of shrinkage or even obliteration. The next one is six months from now–is that correct.
These nodules seem really obdurate. Are they made of Kryptonite, or what?

DR: This exactly what we would expect to see if everything had gone perfectly.  There is no right answer on when the next scan is.  I’d say confirm with ________ when you see him–4 or 6 months would be reasonable.

(Despite the tricky grammar of that first sentence, I am of course very pleased to hear this news. Also pleased to learn this elegant new word–”loculated.”)

Tags:Health Care, Memorable Conversations
Filed under: Talky Talk by Daniel Menaker
Wednesday, April 18th, 2012 at 8:18 am
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(A spectacular spring day in a Riverside Park dog run, a cindery expanse where dogs are allowed off the leash and often stand around or sit around or lie around rather than run. Their owners stand around or sit around on benches and talk on their cell phones or talk to each other, almost always about dogs–a conversation both as limited and infinitely variable as the sonnet form. Example:

OWNER 1: What is she–some kind of hound, I think. Right?
OWNER 2: She’s some kind of mix–probably beagle and chow, with a touch of spaniel.
OWNER 1: Very pretty!
OWNER 2: Thanks. Don’t you think it’s funny when owners say thank you for a compliment  to their dogs?
OWNER 1: Well, they can’t.
OWNER 2: Who can’t?
OWNER 1: The dogs can’t say thank you. Somebody has to say it, I guess.
OWNER 2: Right- -Daisy, no chewing!
OWNER 1: They like that loose skin, like jowls, for instance.  I can’t let Maxwell play with any dog that has jowls or any kind of folds.
OWNER 2: Which one is Maxwell?
OWNER 1: He’s over there. That Jack Russell is trying to hump him.
(The Jack Russell’s owner, heard in the distance, shouts, “Angus, now you know better than that. He’s not interested.”)
OWNER 2: Hilarious!
OWNER 1:  So Daisy is a rescue?
OWNER 2: Yes.  From Arkansas. They bring them up in a van.
OWNER 1: There are a lot of rescues from Arkansas and the Carolinas and so on. I wonder why.
OWNER 2: I don’t know. Maybe more dogs are abandoned in the South, or something.  Maxwell is–what? A wheaten?
OWNER 1:  A Tibetan. A Tibetan terrier.
OWNER 2: He’s beautiful.
OWNER 1: Well, um–thanks! Ha ha. (Just a little defensively): You know we had a rescue before–Pepper.  When our kids were little.
OWNER 2: Hey–far be it from me to judge.
OWNER 1: You know, Tibetan terriers aren’t terriers.
OWNER 2: Really?
OWNER 1: No, it seems like when the British were pillaging Tibet or whatever they were doing there, they saw this temple dog and one of them probably said something like, “Nigel, look here: this dog looks rather like a terrier, don’t you think? I say, let’s call him a Tibetan terrier!” And Nigel said, “Jolly good, Freddy!” But they’re not genetically terriers. More related to Lhasas and Shih-tzus.
OWNER 2: Temple dog?
OWNER 1: Yes, they lead the monks to prayer, supposedly. But you know, you can’t sell or buy these dogs in Tibet. You have to give them or receive them as a present. They’re sacred dogs. He’s sacred to me because he doesn’t shed.
OWNER 2: Daisy sheds like crazy. She like leaves a wake in the early summer.

Etc.  So I’m in the dog run and run into a friend there whose wife has had a liver transplant because of liver cancer, or so I recall):

FRIEND:  Didn’t you have a CT scan recently?
ME: Today, in fact. Just this morning.
FRIEND: How did it go?
ME: Fine. The technician was very cheerful. Of course he didn’t tell me anything.
FRIEND: They never do.
ME: They’re like cheerful Sphinxes. They probably know more than some of the doctors do. I just can’t figure out why the radiologist won’t call me later today or maybe tomorrow. I have to wait until Monday to have my appointment with him.
FRIEND:  Well, you know ______ [the wife] has gone through this. Georgie, why don’t you play with Maxwell? They do everything by committee. I think it may have something to do with liability.
ME: Maxie–go ahead and play with George. What liability?
FRIEND: Well, they probably want to consult with their colleagues and make sure that they do everything as carefully as possible. With ______ so many people contributed to her current well-being–they all want to be super careful. Also, you know, if the scan is ambiguous or something….
ME: Well, he said there would probably be not much change. It has been three months since the last radiation treatment. Uh-oh, here comes this black dog with four white feet. He’s a puppy. Maxwell loves to play with him. I want to go back to “not much change.” I think there must be no more forests left standing in the world.
FRIEND: What?
ME: I have been knocking so violently on so much wood, and it would be a good thing if there was not much change, nothing new, so I have to knock wood again right now.
FRIEND: (Laughs) Why not much change?
ME (leaning over to push Maxwell into contact with the black white-footed puppy): Evidently–that’s it, Maxie! Play with that dog. Wear yourself out–it takes a while for the vacuum cleaner to come through and clean up after the radiation mess, or something like that. Like months. The CT scan next October will be more significant. Unless, of course, some monstrous thing like from “Alien” has suddenly started growing in there during the last three months. (Puppy, on her back, squeals.) Maxwell, do not chew on that dog’s neck. Like he really understands.
FRIEND: Well, let me know.
ME: I will. How is _______ doing?
FRIEND:  She started interferon-triple-cocktail. She has to take it once a week. And she has to go over to 70th and York every day
ME: Every day?
FRIEND: For a blood test. Yes, there is this one-hour window three times a day during which she has to take this new drug which is experimental in post-transplant patients. And with it, she has to eat something with twenty ounces of fat. Three times a day!
ME: Mmmmm! That’s not so bad. What’s she using?
FRIEND: Haagen-Dazs.
ME: Yum.
FRIEND: She doesn’t have to go over there for the interferon. She gives herself her own injection.
ME: Hey, Maxie–don’t be so rough. He’s being rough. Maxwell, come here. I said come here. Do you want a treat? (Maxwell comes over.) I’m putting you on the leash. Why didn’t you play with George here? (I push him once again toward George, who growls ominously.) Never mind. I guess it’s time to go.  So remind me when ______’s cancer was diagnosed?
FRIEND: Oh, it wasn’t liver cancer. Come on, George–I guess we’ll go too.
ME: Really?
FRIEND: Nope–Hep C! I guess she did have cancer by the end, but I don’t like to say she had it, because I’d rather she didn’t. But she’ll say she had cancer.
ME: Eh?
FRIEND: Well, she actually did. When you’re in the end stage of Hep C, your liver has got much wrong with it that it has everything, and cancer was a part of that. It also moved her up the transplant list.
ME: But she’s feeling all right now?
FRIEND: Yes.  But the side effects of interferon are cumulative, and she has to take it for a year!
ME: That’s tough. I can’t imagine.

Tags:Health Care, Memorable Conversations
Filed under: Talky Talk by Daniel Menaker
Monday, April 9th, 2012 at 6:00 pm
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