WATCH AND WAIT | Orly Farber

 

When I was a kid a friend once asked if my father, the coach of our softball team, was a different race than me. Several shades tanner than my apple-core complexion, my dad’s skin looks like the old walnut glove he brought to softball practices. It even has the same texture, broken in, but cracking along the folds.

“So, is he, like, black?” my friend asked.

“Uh no!” I both laughed and fumed, “He lived in Israel, that’s why he’s so tan,” I half-lied, inexplicably recalling my dad’s study-abroad experience twenty years before I was born. 

On weekends, my father donned a cap, and gave the kinds of pep talks only a child psychologist could offer a group of freshly insecure pre-teen girls. We ran bases, practiced bunting, and slid around the dusty field sweeping up rolling, neon-yellow balls. We also played a more cerebral game: The psychologist taught us to anticipate every possible scenario, so we’d know exactly what to do if the ball landed in left field or if a runner stole third-base. When up to bat, he taught us to wait. Unless the first pitch was the perfect one, we were to hold our bats still and watch the ball zoom by, gauging the pitcher’s speed and style.

“Watch and wait for your pitch!” he’d holler, as though my pitch would cross home plate with my name on it.   

On game days, we sang silly cheers and gossiped on the sidelines. Wearing blue jerseys and knee-high socks, we sweated under the visors that trapped our ponytails, beneath the sun I’d later blame for adding insult to injury. 

My father also used the weekends to soak up artificial light at the tanning salon. Tanning alleviated his psoriasis, a chronic skin condition that studded his legs and arms with itchy, silver scales. He kept purple goggles with nearly-opaque green lenses in the glove compartment of his car, next to a handful of quarters and a tire gauge. He’d drop by the salon on Sundays before picking up half a dozen bagels for lunch. When he wasn’t looking, I’d steal the goggles and pucker my eyebrows, sealing them to my face. Walking around in a tunneled, forest-green world, I’d imagine encounters with fairies and goblins played by my reluctant dog. When my brow relaxed and the goggles fell, they left a crease on each cheek. 

My dad tanned under the guidance of his doctors. But back when he started, physicians didn’t understand the long-term costs of UV radiation or of the new medication he used. Treating the psoriasis with light not only browned his skin, but damaged it beyond repair. Over the years, my family has watched his skin like geologists, identifying raisin-colored eruptions, small surface skin cancers, that his doctors would shave back down to a healthy foundation. Doing so prevented the cancerous cells from diving beneath layers of tissue and spreading throughout his body.

I see my dad’s skin in the strangest places. I saw it at Joshua Tree as we slowly hiked across the craggy desert expanse, scrambling up and down the jagged rock formations bursting out of dry sand. I imagine his red undertones in the pasta sauce my mom insists is better made from scratch. I see the puffiness of his fingers, swollen around my grandfather’s ring every time I get on a plane. He always reaches for my hand during takeoff.

A few months into my first year of medical school, my dad felt a mass in his armpit. 

“You have to promise you won’t get sick while I’m gone,” I joked, just weeks before I boarded a plane to California where I would start school 3,000 miles from home. 

“I won’t get sick until you’re a doctor,” the realist hedged.  

But becoming a doctor takes time, and his cancer cells outpaced my ability to learn about them.

It was winter when I caught up, but seasons bleed together here. I was just beginning to acclimate to the cool mornings that require a heavy jacket, and the afternoon ritual-shedding of sweaters and scarves. My brother was in town for the weekend, and I was excited to show him this funny new place. As we ate the sushi bowls that he picked up while I was shadowing in the hospital earlier that day, we chatted about hiking plans and television shows. I was still wearing my scrubs while we ate, and he laughed, “You almost look like a doctor, kiddo!”

“It feels like a costume,” I shrugged.

Seaweed bits and sesame seeds dotted my teeth when our parents called.

“Are you both together?” they asked.

“Yep!” I said before launching into a description of the surgery I had watched earlier that day – the kind of monologue youngest children are most guilty of, and the kind of story medical students relish telling. They listened patiently, asked questions, and earnestly said “How cool!” When I finished sharing every last detail, my dad changed the tone: “We have something to tell you two.”

As his steady voice – tuned over years of coaching sports teams and calming anxious patients – echoed over the speakerphone, I saw his skin. Brown flecks on my arms, tomato-red hints under my brother’s chin. I stopped hearing my dad after the word “invasive,” and instead, pictured a surgeon cutting out a cancer as pink as the raw salmon clustering like grapes in the corner of my bowl. After we hung up, I threw away my food in disgust and sobbed as I explained chemotherapy to my older brother.

Later, when I was certain that my brother was asleep on the air mattress, his feet dangling off the already-deflating edge, I pulled out a textbook, jumping to pages I had not yet marked up. Examining the magnified photographs of bright, fleshy cells and the dense, intermittently bolded text, I did what any medical student would do: I studied the unfamiliar disease. I prepared myself for every possible next step.

My mother’s over-the-phone updates, read from the notes she scribbled during my dad’s appointments, guided me through textbook chapters. First, I learned about cancer types. I thought of the pathologist, hunched over a microscope, zooming in to focus on glass slides compressing slices of my father’s tissue. I wondered if they saw a lymphoma’s landscape of blueberry dots or the Pepto-Bismol pink swirls of a carcinoma. I studied both, until I learned that the answer was swirls, documented in the pathologist’s report as “squamous keratin pearls,” a name too graceful for something malignant. This meant that the cancer started in the skin – a fact we anticipated – but no one could pinpoint where the balloon of cells had begun to auto-inflate and roll. Invasive, they said, of unknown origin.

As we waited for contrast-enhanced images to reveal how deep and far the cancer had migrated, I memorized the size cutoffs and cell shapes that determine stage and grade. I did this for other cancer-types too, whenever I needed a relevant distraction.

The updates came with answers, until it came time for treatment. Therapy was more of a question than a fact. No two doctors agreed on the best course of care.

As the weeks dragged on and my dad juggled opinions, my attention was pulled in two directions until it split. My legs carried me to school while my mind wandered to a different hospital. I sat in class, but my laptop was open to articles discussing new immune therapies. I tuned out lectures on the relay center of the brain and common cold-causing viruses. With my homework set aside, I read the few academic papers written about my dad’s specific cancer type, carefully eyeing the survival curves – sets of descending staircases corresponding to deaths over time. I stared at the curves until they blurred into a puddle of black and white uncertainty. I was bleary-eyed, but couldn’t sleep through the night. I awoke in tears, gauging how long I’d already been crying by the size of the salt stain on my pillowcase.

“Can you look up this medication?” my mom texted. I did. “Do you know what that means?” my dad asked. I didn’t. I sent cold emails to faculty at my school asking for their advice. I gave answers when I could, and tried to be honest when I couldn’t. I kept a running list of drugs, doctors’ names, and clinical trials in the margins of my notes.

For me, the start of treatment came with a dose of relief and a prescribed set of concerns. What if his magnesium level dropped? What if he lost his hearing? What if he could no longer take the subway to the hospital? I practiced, anticipating every possible scenario and its corresponding play. They’d give him a magnesium infusion. He’d wear hearing aids. I’d fly home and help. 

My dad tells me that he golfed his way through treatment. He walked through dozens of courses in his head while lying perfectly still during radiation or awaiting the end of a chemo drip. He imagined swinging the club, and watching the egg-sized ball fly over sand traps and lakes. It kept him calm, he said, helped him cope. He doesn’t know that I played my own mental game too.

A few months later, I touched down on the East Coast on a definitively summer day. The heat from the tarmac seeped into the jet bridge and I cut through it, running to meet my dad. Like every time he’s picked me up from the airport, I found him patiently reading a New Yorker at baggage claim amid the buzzers and moving belts.

From a distance I could see a gauze pad over the areas where radiation had burned him and a thick compression sleeve guarding one arm. The sleeve looked like a large bandage, and it pushed fluids that, after surgery, had lost their natural path to drain. But even with it on, his arm was swollen from his shoulder to his fingertips. Up close, I noticed his face was thinner, with dark rings beneath his eyes. But for the most part, he looked the same. 

“Love the bionic arm,” I immediately joked, giving him a careful side-hug.

“Welcome home,” he said, his voice hoarsened by the radiation that grazed the edge of his voice box. “You survived your first-year of med school.”

“You survived treatment!” I replied, a little too cavalierly. 

To my relief, he laughed.

Early the next morning I packed up the car, lifting our overnight bags into the trunk. We drove four hours to the hospital where my father had received care for his first follow-up appointments. The nurses greeted him by name, and wanted to know if I was the medical student daughter he was always bragging about. His doctors asked about my curriculum before asking him about his symptoms. One physician showed me how to palpate the lymph nodes in his neck to feel for thick scar tissue or possible cancerous spread. I felt much more at ease being spoken to as a student than as a patient’s child so I put on my best smile and threw out a handful of questions. I asked one doctor how she chose her specialty and if she’d choose it over again.

She stared at me for a moment and took in a sharp breath. “Uh, no, I’m not sure I would,” she almost whispered, and when she turned to wash her hands, my dad smiled at me from the table as I stifled a wide-eyed laugh. Her career kept him alive, but it seemed to be wearing her down.

As she wrapped up the visit, my dad turned to her and asked, “So. What now?”

“Now?” she said, rolling away from the computer, planting her feet firmly on the ground. “Well, now, we watch and wait.” She made eye contact with me and smiled in a practiced, but gentle way. 

I looked at my dad’s hands clasped together, his one thumb rubbing the other right where it poked out of the compression sleeve’s glove. I reached for his swollen hand. It would no longer fit in a baseball mitt, but I pictured him gripping a bat, the whites of his knuckles only visible on his good side. He steadied his breath, slowly nodded his head, and together, we wait.


Orly Farber is a medical student at Stanford University School of Medicine. She is passionate about bioethics, medical humanities, and journalism. Farber has written stories on medical education, health research, illness experiences, and more as a reporting intern for STAT News. Several of her articles have been reprinted in The Boston Globe. She is also a regular contributor to the Stanford Medicine blog, Scope, where she reflects on her time as a student. Before starting at Stanford, Farber studied allergic disease at the National Institutes of Health; she now focuses on more qualitative research projects. Farber is excited to pursue a career that will allow her to care for patients, continue research, and explore Narrative Medicine.

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