My official First Day Back was January 25, 2016. It was actually a half day, but that does not have the same ring to it. Ever since I was taken out of clinic 10/29/15 by ambulance, I struggled to figure out when (and if) to return. Apparently, this is something for your doctor to evaluate and advise, but I was an active participant in this decision with my PCP.

On 10/29/15 during my brief 3 hour hospitalization, the hospitalist told me I could not drive for 6 months. The Spectrum Cardiology office on Bradford Ave is not a very convenient stop on Staci’s morning drop off routine en route to Breton Elementary.  However, my neurosurgeon and neurooncologist felt a faster return to the road would be safe given no history syncope, and no recurrence of seizures after surgery as well as stopping my anti-seizure med Keppra.  Dreams of adding fat tire bike to my growing collection in the basement faded, and the fat tires on my GMC Acadia would have to do. There went one barrier to work.

I first started thinking seriously about work when my neurooncologist stated some GBM patients could even get back during radiation.

“Have you thought about starting back at work?” But I have brain cancer.

After creatively wiping my schedule clear for November and December (read: colleagues took my patient responsibilities, call and weekends), nobody was in a hurry to reopen my schedule prior to the New Year. Still, the seed was planted. I could get back to work.

Getting back to work involved much more paperwork than leaving. “We need a note from your PCP about your restrictions like hours allowed to work, any weight restrictions, special circumstances.” How about no nights, weekends, and every Friday off? GBM is just the worst at those key times.  As a non-invasive cardiologist, I don’t lift much beyond my own weight. I cannot see myself greeting any patients with a big bear hug and twirl. I think I can still lift a pen, stethoscope, and push a mouse around while I type. I have given myself extra time per patient for these first few weeks. It has been nice since I often need to provide a bit of personal history as well.

After several hellos, I’m fine, yes it is good to be backs, I knocked on the first door in Pod C at the Bradford office. This was usually so commonplace, I barely thought about it. However, after about a 3 month hiatus, it felt significant again. Usually, I would just burst through the door, automatically thank the patient for his or her patience, and get going.

“How are you doing, doctor?” Fine, I guess. Was that merely for conversation, or are you asking more? So far, about 1/3 of the patients have no clue, 1/3 were aware of my medical leave, and another 1/3 knew my diagnosis, maybe even reading this blog.  Hi!

“My primary doctor said you were not coming back.” Well, here I am.

My job was a combination of hospital based rounding (just like you see on TV without as much drama or sex, or at least for me—was I missing out?), testing, and a once weekly pilgrimage to Reed City clinic. There was enough variety to keep my on my toes, but still remain an expert. Even with a specialization, I get the most satisfaction out of either looking up new things, or texting colleagues a clinical scenario and asking opinions. It is amazing what still falls in the gray areas despite multiple clinical guidelines by the ACC / AHA.

I thought something would be different, but that puts a lot of pressure on each patient encounter. Knocking on the first patient room door was a bit weird, but then quickly started to feel like routine. I doubt I am a ‘better doctor,’ whatever that means. That puts too much pressure on me. But I do find myself more interested in the social history, how the symptoms or disease are affecting everything at home and vice versa. I am not sure I even have anything to add specifically, just genuine curiosity.

I saw an 82 year old on the first day with a history of stable coronary disease. She gave the impression she was married, but she was with an adult daughter.  Where was the husband?

“Are you divorced, or widowed?’

“My husband died 6 years ago.”

“Oh, how did you meet?”

“We just hung around same crowd near Cannonsburg.”

“Did you chase him, or did he chase you?”

“Oh, it was probably mutual.”

“I bet he would say he chased you.”

She smiled. “I do not feel like he is dead since he feels very alive in my heart.” If that ends up being my only afterlife, I won’t complain.

At this point, she was on stable, standard meds with well controlled risk factors. It was very unlikely I would ever make a decision that would impact her life. But I enjoyed her story.

I had another patient that is turning 92 this July. He had a mitral valve repair for mitral valve prolapse (the real mitral valve prolapse) about 8 years ago, and had a very uncomplicated course since that time. He wanted to live longer than anybody else in his family. “I want to live another 10 years.” me too.

And other difficult to answer questions:

“Did they get it all?” Um, yes. Or no. Complicated question with GBM.

And, “Oh my, what happened to your head?” I don’t remember. Where am I?

And then I recently saw the police officer that was my last appointment 10/29/16. Last time we saw each other, I started having a seizure. He was the one who actually called dispatch for an ambulance. It was in the same room, Pod C, room 1. So after I reviewed the last few months since he saw me leave on a stretcher, we talked about his health habits, including diet and exercise which can have a big impact on AFib reduction.

“I can bench and squat over 400 lb” Holy crap.  I can run 6 minute miles for 1.5 hours, but I want the police officer coming over when I’m in trouble that can bench and squat that amount. If someone needs to be chased on foot for over an hour through Grand Rapids, I’m your man. Otherwise, call this guy.

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Prior to starting work, I also needed to refresh myself in the medical literature. I once heard that 50% of what we learn in medical school is false, unfortunately, we do not know which half. A lot can happen in 3 months. I started skimming titles in the New England Journal of Medicine, reading those related to cardiology or just interesting, and restarted listening to audio updates. Oh, and those regular e-mails from ACC News Digest. Most of that information is only partially digested and sometimes contradictory. Mainly, those e-mails are confidence boosters that I did not miss much.  Here are a few screenshots of e-mails I’ve taken over the years.

 

Figure: Conclusion, eat chocolate for breakfast to reduce stroke.  Maybe.

 

Figure: Apparently, you need your PCP to write that you cannot sit at work, but physically demanding work isn’t for you, either.  Lounging and casually walking.

 

 

some patients ignore

Figure: Not a surprise.

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In the first 1 – 2 weeks, I started thinking of all the things I’ve heard from patients, and just did not have time to believe anymore.

1. I have a high pain tolerance. Show, don’t tell.
2. This is not all in my head. Did I say that it was? I need a better poker face.
3. Nobody can figure out these symptoms. Need that poker face.
4. I am pretty active. define that please.
5. I barely eat anything.
6. I don’t smoke that much.

And the things that worry me:
1. It is probably nothing.
2. My parents and siblings all died at my age, and they didn’t smoke, either.
3. I was so worried about the symptoms, I stopped smoking. Whoa. You were worried.
4. It only occurs when I walk up a slight incline.

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With GBM, size (and location) matters. For some, presenting symptoms are a gradual decline in cognitive function or memory (now, don’t all call your PCP for that MRI, GBM is very unlikely). For others, headaches or seizures. For many, returning to work just doesn’t make sense due to cognitive or physical limitations from cancer and treatment. I heard of one patient that has undergone two surgeries, is doing and looking great 6 years out, but has difficulty following the steps to make a cup of coffee. That would make return to work impossible. At this point, I am doing well, I’ve trained to do cardiology forever, and I have limited other skills. Seriously. I just put together a cabinet from Target and realized I the doors wouldn’t fit because I made a mirror image of the design. Frustrating, and it wasn’t the cancer. I always felt these were designed for the skill set of a single mother. My father in law Gary has multiple skills around the house, but I am the equivalent of a med student in surgery holding retractors. I just did not acquire those skills growing up. I have learned to remove wallpaper, paint ceilings, and cleanly apply window dressings. But I still need to do everything wrong once. Regardless, I better keep my day job.

Figure: Left, date with Queen Elizabeth at Daddy – Daughter dance at Russ’.  Right, needing more shaving cream nowadays.  Since I’m doing the head and face, might as well be thorough and do the shoulders.