Reflections on a wedding, five years later

(Picture:  Mom and I on my wedding day)

We got married five years ago today, on the lawn of a recreation center in Sun City, Arizona.  It was Easter Sunday 2009, and it was utterly without pomp or circumstance.  I wasn’t in white and he wasn’t in a suit.  There were no bridesmaids or groomsmen or flower girls.  Nary a band or deejay was in sight, my dress was from Kohl's,  I think my flowers might have come from Costco, and there was no first dance or bouquet toss or any of the trappings that usually come with a wedding.  It was simply the two of us, with immediate family (minus a couple of people on his side) and a few members of my grandparents’ church.  I think we went out to dinner afterwards, probably to the Olive Garden, though I am somewhat ashamed to say that I don’t remember.  There was no honeymoon – we drove the four hours back to Loma Linda that same evening because my 4^th year neurology clerkship was starting the next day.  My new mother-in-law sat in the front seat of the car, and when we got pulled over for speeding, did her best to get us out of the ticket by impressing upon the officer that we had gotten married hours earlier.  He wasn’t impressed at all, and when the day ended, we were back in CA, newly married, towing both a mother-in-law and a speeding ticket.  Auspicious beginnings, indeed.

Believe me when I say that this was not what my wedding day had looked like in my daydreams. 

We’d had much different plans in the beginning.  We’d put down a relatively hefty, non-refundable deposit on a gorgeous facility outside of Baltimore {Cloisters Castle, if anyone is interested} for a late June wedding.  We’d had bridesmaids and groomsmen lined up.  We’d plunked down some money for a pretty cake and I’d gone taste testing for the reception dinner.  I’d even purchased a dress, which was in the alterations stage.  And then it all unraveled...quite quickly.

The wedding date overlapped with the required intern orientation for my upcoming residency.  A couple of my bridesmaids had to back out (one was starting medical school overseas, another had an educational obligation that they couldn’t get out of).  I was trying to coordinate a Maryland wedding from California by myself whilst also finishing medical school and preparing for a cross-country move. Money was tight and time was even tighter.  My only grandfather was failing in both health and mind, unable to travel long distance, and it was important to me that he be a part of my wedding.  For a million reasons, the timing was just not right.  I was at the end of my rope.  When my grandmother suggested that we hold a very small ceremony in Phoenix, we mulled it over and agreed.  We called up our respective parents to let them in on the plans and let my grandmother and her wonderful church family take over from there.  They got busy and ensured that the key elements of a wedding – joy and love – were present in abundance.  They even threw in a bouquet, a pastor, a rehearsal dinner, and a lovely gentleman to take photographs of the event. 

I will not lie – even after five years, there are some times that I look back at my wedding day and feel a bit sad.  It is not that I undervalue the efforts of my grandmother and her friends who worked to put together a wedding in a two week timeframe.  I don’t undervalue that at all.  What they did for us was Christian love in its finest moment.  But really – what girl doesn’t want the “big deal,” even just a bit? I wanted the cake and the flowers and the dancing and the filet mignon and the honeymoon in Tahiti and all eyes on me as I walked down the aisle; I wanted every bit of that and sometimes I feel momentarily sad that I got none of it.  Then, I remember that our wedding day was quiet and sweet and we were surrounded by most of our family.  Everything in that moment was distilled down into just him and me.  In the end, I think that’s what truly matters.  Him and me.

 Sometimes it’s hard to remember that marriage is not about who designed your dress (or the size of said dress).  It’s not about whether you carried imported Brazilian orchids or Costco carnations down the aisle.  It’s not even about the size of the engagement ring, the pricey string quartet that serenaded your walk, the professional photographs to hang on the wall or the plane tickets to Tahiti that bankrupted your savings account.  In the end, absolutely none of that stuff matters.  The white dress will get packed away in a storage unit, the flowers will dry up and turn to dust, and airbrushed photographs on a wall do not guarantee everlasting happiness or a successful marriage.

I have come to realize over the course of five years that it’s not the trappings of a wedding that make a marriage.  Marriage is more than just one perfectly orchestrated day.  It’s about the love and commitment shared freely between the two people standing at the altar – and it doesn’t matter where the altar is, as long as you and he are there.  It’s about the promises that you speak to one another.   It’s about choosing to love one person every single day for the rest of your life - and you can do that dressed in a burlap sack holding a bouquet of dandelions.  Marriage is for better and for worse, in sickness and in health, for richer and for poorer, forever.

Five years ago, I made those promises to my very best friend.  It was the smartest thing I’ve ever done, and probably the best thing I will ever do in my lifetime.  And I’d like to think that our marriage is built on things more solid than satin and seed pearls.  I married someone who loves me much more than I really deserve and who always treats me with kindness and respect.  He has never underestimated me, and in fact grossly overestimates what I am capable of.  He is my rock when everything around me is quicksand, and he is my gentle place to land when I am falling.  He has carried me through some awful times that would test even the longest of marriages and he has done it with grace and patience and with a heart that is so much bigger than mine.  He's seen me in my best moments and he's seen me in the moments when I have utterly failed as a human being and somehow, he manages to love me in both of those conditions.  He’s generous and thoughtful and intelligent and handsome and just about all of the good adjectives one can imagine.  Best of all, he’s mine.

Happy anniversary, handsome man.  Thanks for making me the luckiest woman in the world, every single day.

In which I write a long post to answer dumb questions about my medical subspecialty

Questions I get asked about being a pathologist (in no particular order):

“Are you even a real doctor?  You don’t see patients.”

Yes, I am a “real” doctor.  I understand how it might be confusing for a patient, because unlike primary or specialist providers, patients don’t actively choose the pathologist involved in their case.  But please rest assured, I completed the same four years of medical school that your surgeon, internist, pediatrician, or OB-GYN completed.  My title includes the letters M.D.  I also completed four years of general anatomic and clinical pathology residency to learn how to do everything that a pathologist does.  And then I added a year of subspecialty training, too.  Yes, I am a 'real' doctor.  

"So you're like a lab tech then?"

No. No, no, no…just no.  A pathologist is not a glorified lab tech.  Calling me a lab tech is sort of on the same level as assuming all women who work in healthcare must be a nurse - it just makes you look stupid.  Please note that I'm not at all dismissing what lab techs do - which is a lot of really important stuff - but their role in healthcare is different than mine.  In the same way that I am not qualified to do what a lab tech does, they cannot do what I do - we are not interchangeable entities.  {Also, on a distantly related note, when you assume I'm a lab tech and you treat me like dirt *ahem, surgeons*, it makes me angry - not because you are treating me like dirt -  but because it means you are likely treating my lab staff even worse.  I can bust you for your unprofessional behavior on the spot, MD to MD, but my staff doesn't have that luxury.  So please, for the love of all that's good, quit letting your inner jerk out to play}.

“So pathology, huh?  That’s like CSI stuff, isn’t it?”

Wrong.  Stupid wrong, on so very many levels.  I have not once analyzed a soil sample or found a killer using only a strand of blond hair.  I work in a hospital, not in a Hollywood studio.  The killers I look for are tumors of unknown origin.  And what I do to find them is wicked cooler than CSI.

“So what is it, exactly, that you do?”

I look at stuff.  Lots of stuff.  If it comes out of your body, the odds are good that a pathologist has been involved somehow.  This includes the breast (or appendix, gallbladder, uterus, lymph node, prostate, colon, etc) that your surgeon removes.  It includes the skin lesion that your family practitioner biopsies.  It includes the sputum that you cough up, the pus that grosses you out, and the urine that you pee into a cup.  It even includes poo…and semen.  It includes the fluid that your endocrinologist aspirates from the nodule in your thyroid, the lung mass that your interventional radiologist samples, and the pancreatic cyst that your endoscopist biopsies.  It includes the pterygium (or the encleated globe) from your ophthalmologist and the tooth cyst from your dentist or oral surgeon.  It includes blood from your lab draws and bone marrow from the aspirate that your oncologist performs.  It includes the placenta from your newborn baby and the small, 18-week gestation fetus that you miscarried.  It includes the bodies of both the 20-year-old woman who was texting while driving and the 56-year-old man who was found unresponsive on the floor in his home.  It even includes the tick that you picked off of your child’s small leg and the fluid from your lumbar puncture.

“Um…ok.  So you look at stuff, like, all day.  What does that even mean?”

It means that I give you (and your clinician) answers. It means that I can tell you whether or not the lump in your breast or the mass in the head of your pancreas is cancer.  I can tell you what type of cancer it is and if that small hypodense region in your liver indicates metastatic disease.  The immunohistochemistry that I perform on your tumor helps determine both your prognosis and your treatment options.  When your surgeon sends down a sample for frozen section during your surgery, I help them determine how much more of your tongue they need to remove to rid you of your oral cancer.  I diagnose familial cancer syndromes using a combination of histology and advanced molecular techniques.  It’s not just cancer that I diagnose – I diagnose everything from benign skin to colon polyps to neuroblastoma to Crohn’s disease.  Really –I do mean everything.  When I autopsy a fetus, it means that I do my best to help its parents find a cause for why they have miscarried the baby they waited so long to conceive.  And when I find the complete blockage in the left anterior descending coronary artery accompanied by areas of old myocardial scarring, my report tells a family, with reasonable certainty, why it is that their loved one is no longer with them.

It means that I can tell you what kind of bacteria is causing your pneumonia – and the kind of antibiotics to which it will (or won’t) respond.  {Ditto for any organism – fungal, viral, mycobacterial, or parasitic – that you throw my way.  I’ll even tell you what kind of tick your kid picked up during their camping trip and whether or not you should worry about something like Lyme}.  Looking at your peripheral blood, I can tell that not only are you anemic but also the probable cause of your anemia.  I diagnose leukemias and lymphomas by integrating cytogenetic analysis, flow cytometry, and histology.  I determine that the cause of your joint pain is crystalloid and not infectious in nature (this helps save you a trip to the OR, by the way) and I interpret the serologic tests that determine whether you have HIV, syphilis, hepatitis or a host of other conditions.  I oversee the clinical tests that determine how likely your fetus is to have Down syndrome, and if you should (heaven forbid) require amniocentesis or other invasive testing, I also interpret the subsequent testing that gives you a more definitive diagnosis.

It means that when you need a blood transfusion, I am there to help your clinicians select the safest unit for you; and when you need specialized and hard-to-find units, I am there to search the country for those products.  It means that I will beg, plead, and cajole a blood center 2,000 miles away so that you get the best product at the time when you need it most.  When you have a reaction to transfusion, I am there to diagnose what went wrong and help prevent it from happening again.  I provide product support for your ECMO, LVAD, or liver transplantation – and when you crash your car into a streetlight while texting, I’m there to monitor the massive transfusion protocol which will likely help to save your life.  I manage and interpret the coagulation testing for complex, bleeding patients and I help diagnose exactly why a 16-year-old patient with no apparent risk factors unexpectedly threw a pulmonary embolism.  Because tissue typing falls within my jurisdiction, I help patients proceed to organ transplantation.  With therapeutic apheresis, I help you keep your transplanted kidney when your body starts to reject the organ.  I reduce the risk of mortality in patients with acute TTP and help treat leukostasis in leukemic patients with hyperleukocytosis.  I restore quality of life to patients with complex neurological disorders, reduce cholesterol levels in patients intolerant of medications, and collect stem cells that will be transplanted into a leukemic patient.  I even scrub in order to harvest bone marrow from you (or your loved on) in the operating room that will be used for transplantation. 

Believe it or not, this is not even close to being an exhaustive list of all that I do for patients.  When I said that I do everything, I meant it.  You’ll likely never see me face to face, but the odds are good that I have played a role in your care, whether you are undergoing outpatient screening or inpatient intervention.

“So why did you choose pathology?“

That’s easy – I chose pathology because at the end of the day, it’s what I love.  It doesn’t get simpler than that. I didn’t choose pathology because I’m socially stunted or because I hate patients.  None of that is true.  I picked my career like I picked my spouse – for love.  I love pathology because what I do every single day makes me a part of the care team for every single patient, even though most of them will never know that I exist.  I truly believe that what I do has a profound impact on patients.  I love my job because it’s fascinating – the human body, in health and disease, fascinates me.  I love pathology because it’s incredibly beautiful – looking under the microscope at stained tissue, with all its architectural variations, is art in motion.  I love pathology because it astounds and challenges me and teaches me something new every single day.  That’s not to say that I don’t become frustrated – every job has its problems.  Being a medical provider is hard work; it can eat you alive if you let it {a blog for a different day, perhaps}.  I have moments where I forget about the awesomeness and importance of the work that I do – and I’m entitled to those moments when they happen.  But thankfully, they pass, and I am usually left with the feeling that what I do is quite possibly the coolest job on earth.

“You love your job; great.  But what do you hate about pathology?”

I hate how under-valued pathologists are.  I hate how easily we are overlooked. I hate that Hollywood cheapens what I do and turns it into a farce.  I can’t fault patients when they don’t recognize all the services that we provide for them; after all, chances are good that none of them have actually met a pathologist, let alone the pathologist that signed their biopsy report.  I do, however, fault fellow physicians when they overlook pathologists, because they ought to know better.  I can’t tell you how many times I have heard comments like, “Pathology?  Really?  But you’re so smart…,” or “people pick pathology because they can’t hack it in real medicine,” or “…just some dumb pathologist that doesn’t know the first thing about medicine.”  Yes, I am smart.  It’s why I picked a discipline that requires me to use my brain every single day – it’s why I’m considered the “doctor’s doctor.”  I’m not just some dumb pathologist; I’m a physician that knows quite a lot about medicine.  And the medicine that I practice is real medicine – it’s medicine and science in the most pure form, disease distilled down onto a glass slide.  Sure, I can put my stethoscope on a patient’s chest and pick up their soft, holosystolic murmur  (I do this in apheresis clinic, btw) - but can you take one look at a slide and know that you’re dealing with a myxopapillary ependymoma?  Or a parosteal osteosarcoma?  Can you differentiate reactive atypia from neoplasia?  My point is that one good, motivated pathologist is worth 10 mediocre internists.  So please don't make the mistake of underestimating (or under-valuing) my specialty.

Why I wrote this internet novel:

Because I'm passionate about what I do, and I want to share it with others.  And also because nobody seems to have any clue what it is that I spend my days doing - and I think that's really sad, because what I do touches on essentially every aspect of a patient's medical care.  So please, patients - get acquainted with your pathologist.  Get to know what it is we can do for you and for your loved ones. Give us a call.  Better yet, drop by to have us show you your biopsy (or your appendix, etc).  We can't give you therapeutic advice (it wouldn't be ethical), but we can absolutely introduce you to the lab and sit you down to show you exactly what your gallbladder looks like under the microscope and why we made the diagnosis that we did.  We love our job - and we'd love to share our job with you.

Lift up your head, princess; if not, the crown falls

There are many things in life that I will be, many places that I will go and many things that I will do…but unfortunately, joining the faculty in Vermont will not be one of them.  After waiting on tenterhooks for my application to be reviewed, the final(ish) verdict came this evening: my application is, unfortunately, not a member of the “first round” candidate applications. 

I got the call shortly after leaving work.  Ironically, my iTunes app was playing Ryan Shupe’s “Dream Big” song.  I made small talk with the attending on the other end of the line, the one who is chairing the search committee, for a minute before he launched into discussing the status of Vermont’s faulty position.  I got the standard, “lots of outstanding applicants,” and “your application is under consideration,” and all the rest of the platitudes, that I’m sure everyone hears, and then the other end of the line got quiet.  There was some throat clearing and a few pregnant pauses on the line, and those told me everything that I needed to know before the words hit the airwaves:  I was not going to be invited to interview- at least not yet.  The applicants had been sorted into groups according to the strength of their candidacy, and unfortunately, my application had not landed into the top-picks column in the ledger.  I think the moment was awkward for both of us.

I was told that “of course, your application is absolutely still under consideration.”  I was also told that the institution would be following up with me again, likely in three to four weeks, after the ‘first round’ candidates had been through. The utility of the follow-up is questionable.  I strongly suspect that the second round candidates (and third, or fourth, or wherever my application happened to land) won’t be traveling to Vermont.  I am sure that the newest member of their faculty resides somewhere in that first group of candidates.  Sadly, the newest member of the faculty will not be me. 

He kindly asked if I had any questions about the application review process, etc.  In fact, he asked this question three separate times, not out of any sort of meanness, but because I think he genuinely wanted to give me an explanation.   He is the sort of person that treats others gently, and for that I am grateful.

Perhaps someone with more objectivity than I possessed in that instant would have asked dozens of detailed questions about the review process in an effort to figure out how and why it all went wrong.  But in that moment, standing in -10 degree weather on the outdoor commons of the University Hospital, it was all I could do to end the conversation politely whilst not crying like a three year old.  After all, in weather this cold, the tears would freeze on my cheeks, an icy testament to my disappointment.  I’m not prideful, but I have pride enough to want to avoid that sort of public display.

I asked no questions, partly because my mind had gone temporarily blank, but also largely because I’m not sure that the answers (if I’d even really been able to listen to them) would have helped me much.  If there was something fundamentally flawed in my application, there isn’t much I can do to correct that, as the rest of my applications have already been distributed.  If it’s a relative lack of blood-bank related research/publications, I can’t put up much of an argument.  If it’s an experience issue, well, I can’t correct that, either.   It’ll correct itself in about five years…I hope.   And if it’s a lack of significant interest in coagulation…well, that may never correct itself.  Asking questions, learning WHY it is that I’m not a “first round” candidate, wouldn’t change anything at this point.  It would only make me feel more unwanted and inadequate.  And so, standing alone in the frigid, grey Michigan evening, I began to let go of Vermont.

Even the saddest moments in life bring lessons.  The lesson that I was reminded of is something that I have always known and generally tried to ignore – that rejection hurts.  Years from now, I suspect that I will look back on this moment and while it will not be as acutely painful, it will probably always sting just a wee bit.  That’s what happens when a dream tumbles down around your feet.  And though the pain of rejection is fresh in this moment, I am also prompted to consider that sometimes the destruction of one cherished hope scatters around building blocks that can be used to build something magnificent.   Knowing this doesn’t lessen the blow, of course; right now, I’m wounded enough that I am struggling to keep things in healthy perspective and I am by no means able to be completely objective tonight.  But I suspect that one day, a couple of weeks from now, when my objectivity has returned to me, I’ll start to sort out those building blocks.  I’ll decide which to keep and which to toss, and I’ll build a better castle in which to store my dreams.  After all, there are far worse things that life can throw at one than the opportunity to rebuild and rediscover. 

So play on, Ryan Shupe, and let your words be true.