When young Ira was a history student at Cornell University pondering what to do with his life, six words came to mind that he scribbled on a piece of paper: “Medicine is the most noble profession.”
He took his own words to heart and made them his life’s work. Today, at age 72 and retired after four decades of practice as a general surgeon, Ira Levine, M.D., can look back on that daydreaming student and say: You had it right, kid.
Of all the conditions he operated on, and that included much of the rogue’s gallery of diseases, breast cancer evolved into a strong interest. He would see two to four new cases a week.
He likes to keep in contact with former patients, who often call him for advice. “I’m very comfortable giving it, especially to breast cancer patients. I visit them in their homes. I have become very close to them and their families and their husbands.
“I always told them that (recovery) would be a six- to eight-month process. It’s going to be very difficult, but when it’s all over and you’ve survived, you are going to be different person. You are going to look at yourself and just say, ‘Boy, I did it!’ ”
And he remembers many of the rest …
The surgeon, like any other professional, functions mainly by routine, except for the patients. They’re never routine.
“I had one 32-year-old patient, a striking woman from Ethiopia, a positive person with happy eyes and beautiful dark skin. She badly wanted children but had suffered three miscarriages. She is a medical technician who came in with two breast cancers. After pre-operative chemotherapy, I removed the breast partially and also the lymph nodes. We discharged her with no evidence of cancer.”
However, bad news returned eight months later when the radiation oncologist discovered a tumor in her armpit. She also had tests that indicated it was the most aggressive of tumors.
“A month later, we did a complete mastectomy with reconstruction and removal of more armpit lymph nodes. At that point, her survival prognosis was approximately 80 percent over five years.”
(Levine is not comfortable putting people’s lives in percentiles, but in medicine, it is what it is.)
“I talked to her the other day, seven years later, and she is still a buoyant person, cancer-free and pregnant with her second child. Many times, cancer treatment gives us renewed hope for happy lives, just like hers. It’s quite amazing.”
But not always, and in ways sometimes crushing to the spirit.
A patient was referred to Levine for possible surgery about six years ago. She was a college professor in her 30s with advanced breast cancer. Because of the size of the tumor, Levine recommended chemo before surgery.
“Astonishingly, she refused. She said she had suffered enough from other medical issues and didn’t want any more. Her boyfriend had left her, and her spirits were obviously down. But she said something else that was shocking — she said her family had told her she deserved to have cancer.
“I don’t know why she said that, or why her family said that, and I didn’t pry. You learn soon enough that you can’t help people who don’t want to be helped.
“She never came back to see me. I lost track of her until I read her obituary.”
The word “surgeon” is heavy footsteps in our ear because some stranger who holds that job will likely someday put us on a table and stick a knife into us; it’ll be for our own good, but still, it’s a knife. Surgeons are like cops — we’re intrigued to meet them, but prefer it under social circumstances.
Levine is asked about post-surgery malaise, where the patient’s energy level does not rebound until long after the bandages are removed. Is it reality or myth?
“It exists, absolutely. I think physicians need to be honest with their patients as to what’s going to happen after surgery. There is no question it takes much longer to get over it than we might tell them. And as one ages, it takes even longer.”
Is the malaise physiological or psychological?
Both. It’s primarily physiologic, but if you can’t do what you want to do, then it gets between your ears. The only treatment is patience, family encouragement and just do small tasks.”
Over the years, you’ve obviously lost people.
“Very rarely. Lay people think medicine is a life-and-death business, but it’s seldom that way, even for a general surgeon.”
He says that of his approximately 10,000 operations, far less than 1 percent died as a result of complications, and many of those were expected, given their condition. Most times it happened in intensive care, not on the operating table.
What are your thoughts when you lose a patient?
“It’s the worst feeling in the world. It’s a terrible, depressing feeling, especially when you know the surgery went well. You question the decisions you made, you question your ability. You think, am I really up to this? But the self-doubt passes, and you go back to work.”
And then, after that sad event, the family awaits ...
“You’ve got to go out and talk to them.”
Do they sometimes get angry at you?
“Yes, but you just do the best you can.”
As do most physicians, Levine had a sense that mortality was all around him. He even had a personal yardstick for patient survivability that he tied to failings of body systems; for example, renal failure, pulmonary failure or poor cardiac function. “I developed a rule that if you are over 90, you can’t have more than one complication. If you are over 80, more than two; over 70, more than three; or over 60, more than four. And if you did, your chance of surviving was greatly lessened.”
He remembers a 93-year-old female patient in intensive care who had a failing heart and was on dialysis with renal failure and respiratory failure.
“One day I walked into the ICU, and she was being visited by one of her relatives. I said, ‘It really isn’t nice to keep this woman going on dialysis, on these cardiac medicines or the ventilator. If we stopped any one of them, she would die.’ And I said, ‘In fact, we treat our dogs better than we are treating this woman, because we put them down when they are not well, and we know when to do that.’”
Were you urging the person to say end it?
“I was indirectly urging that.
“So I went home and was immediately called. I was told that her granddaughter was very upset. She was put on the phone, and said, ‘What do you mean, I’m treating my grandmother like a dog?’ And I said, ‘I didn’t say that. I said you are treating your grandmother worse than a dog, because we know how to kindly put our pets down when they are not doing well. And if we were to stop this medicine right now, your grandmother would die. If we were to turn the ventilator off, your grandmother would die. If we were to stop the kidney machine, she would die. So there is nothing that we are doing that’s keeping her alive except artificially. And I think she wouldn’t want that. It’s cruel and inhumane punishment.’
“(Consequently,) the granddaughter told the nurses to stop the treatment. The woman was dead in four hours.”
And then, I bet you said to yourself: I’ve got to find a new metaphor.
The worst-kept secret in medicine is that most doctors, at one time or another, assist in easing a patient into death.
“A longtime patient of mine had far advanced colon cancer and came in with metastasis, both in the liver and lungs. He was dying. He looked at me, and said, ‘Please, just make me comfortable.’ He made it clear he wanted to die. I explained what I proposed doing, and he agreed.
“So I wrote orders to give him increasing doses of morphine, enough morphine to make him go to sleep and die. It’s really euthanasia, but it’s disguised as making them comfortable. And after I wrote the orders, I went to his nurse and said, ‘You know what we’re doing here?’ She said, ‘Yes, I do.’ I said, ‘Are you comfortable doing it?’ She said, ‘Yes, I am.’ The man died within 12 hours.”
Levine is unafraid to question his own judgment. He recalls an operation that went well, but had an eventual bad ending. He did an emergency operation on a woman in her 80s with a hole in her large intestine. Feces was escaping into the abdominal cavity, and she was in shock. The operation was successful, and she was given a colostomy bag.
Later, she asked for the bag to be reversed and removed. Levine had his doubts, but performed the operation. The woman had a post-surgery stroke and died. In retrospect, he believes he should have refused to do the second surgery.
Levine learned an important and humane lesson when a friend was lying comatose with a severe stroke. Though the man couldn’t respond, Levine would often go to his bedside and chat about the Padres, the weather or whatever came to mind.
The man made an unexpected recovery, and Levine asked if he had heard what had been said to him.
“He looked at me, and said, ‘Ira, I heard every word.’ That gave me the shivers. From that moment on, I would tell families when patients were comatose, ‘Talk to them, because my friend heard me.’ ”
Tomorrow: The art of listening to patients.
Fred Dickey’s home page is freddickey.net
His email is firstname.lastname@example.org