DON'T LIKE CHANGE?

You've probably seen that clever saying taped to the tip jar in your local espresso shop: "Don't like change? -- Leave it here!" It seems like a lot of people don't like change, but that has never been my philosophy. I've always believed that the only constant in life is change and, for the most part, I welcomed it - even forced it on myself at times just to get out of my comfort zone and grow a little bit.

These days, for some reason, I'm seeing "change" more as "impermanence." Yes, they can have similar meanings, but one seems a bit deeper, a bit more philosophical than the other, and I've been trying to get more of a sense of what impermanence means. As with many concepts (left, right; dark, light; hot, cold) I decided that to understand impermanence, I also had to grasp the meaning of permanence.

About the most permanent thing I could think of is the Earth. Historically, mankind has used analogies involving the earth to express solidity, firmness, durability (i.e. "solid as a rock," "grounded in one's conviction"), so on my meditation walk today I concentrated on the Earth, and what I could learn from it.

As I walked, I concentrated initially on how my heel touched the ground, then how my weight rolled toward the front of my foot and how my toes pushed off as my other foot started its step. Trying to be mindful without overly thinking things, I tried to sense the interface, to feel my feet and how they interacted with the solidness of the ground. It's easy to walk without thinking, to let one's mind wander and experience what really is a pretty fascinating coordination of human tissue. One starts to be aware of the gentle balancing swing of the arms, the subtle shifting of the skeleton to counter uneven terrain, the balance of the head on top of this pile of muscle and bones and the constant movement of one's center, smoothly transported forward.

In Aikido, one constant in movement is to keep one's weight "underside." What ever part of your body is facing the ground, the bottom of one's feet, the underside of one's arms, legs or hands, is weighted heavier than the opposite, upper side. So as I walked, my center moving forward, my weight underside, my feet pushing off the earth, I felt grounded. I felt like there was something solid I could rely upon and even draw energy from. I felt like I was beginning to understand permanence.

It was quite comforting. The next step, however, will be to try and grasp the concept of impermanence. Somehow, I don't think that will be quite as comforting.

PATIENCE, GRASSHOPPER!

I don't know how David Carradine's character got the nickname "Grasshopper" on the TV series Kung Fu, but I can imagine an energetic youngster jumping around with the impulsiveness of youth and needing the steadying hand of his sensei to calm him down. Now, I don't have the energy or impulsiveness of youth, but, I have to admit, I am not the most patient person in this world. My wife always has thought I was impulsive but I always just considered myself a "quick study" who was able to get rid of the chaff and quickly find the kernel of the issue. No sense getting paralyzed by too much analyses or over-thinking. If your going to do it anyway, do it now --why waste the time?

I woke up at 4:30 this morning anticipating my 9:30 infusion appointment - the first in a series to receive the drugs which would kick off my internal war against cancer, rev up my immune system to attack the tumors and start down the path that will, hopefully, extend the time I have with family and friends here on earth.

Then I got the news that instead of starting today, my therapy will have to be delayed a couple of weeks. Apparently there were some logistical issues with how some of the pre-study tissue analysis was handled, so it has to be repeated -- a time-consuming process requiring more tumor tissue. The word "Bummer" was not the first expletive I thought of.

Perhaps this is a lesson -- "Patience, Grasshopper!"

Like all the challenges faced by Odysseus trying to get back to Ithaca, a two week delay to start therapy is the challenge thrown up in front of me as an opportunity to demonstrate my strength, learn patience and practice calmness. Even in the midst of frustration.

On my walk today the oft-used, but appropriate invocation came to me:

Grant me the strength to accept the things I cannot change,
The strength to change the things I can
And the wisdom to know the difference

FAILING MEDITATION 101

I failed Meditation 101 today. It seems like I couldn't do most anything "by the book," even though it was a beautiful morning to be on my walking meditation path. It's Saturday, so the path was full of others taking advantage of a sunny, warm December solstice. Lots of dog-walkers, joggers, bicyclists, but my mindfulness kept getting distracted.

One's meditation should be an attempt to become mindful of one's place in the universe, allowing the inevitable distractions to pass through your mind and concentrating on "I am." Perhaps even getting to the point where the "I" becomes irrelevant and one is mindful of existence as part of the universe with no beginning and no end.

Well, I didn't get there today -- not even close. I became more and more mindful of the distractions, partly because they were making me feel more and more a part of the universe:

The two older immigrant men who were walking arm in arm, comfortable in their old-world clothes, comfortable in their native language and comfortable in how they expressed their friendship.

The two cyclists talking and laughing as they cruised by with synchronized pedaling. Were they laughing about having to bunny-hop over a rattlesnake sunning on the pavement? About a sore butt after their early morning fifty-miler? Whatever it was, they were obviously in the moment -- and joyfully so.

The family parade with the two young kids on their training-wheeled bicycles leading the way while their parents sagged them with strollers full of jackets, blankets, lunch and snacks. The parents themselves being the link between the kids and the grandparents walking behind, juggling their lattes as they hurried to keep up. They seemed quite happy to accept a level of chaos in exchange for being with their grandkids for the day.

The elderly couple sitting in the warm sun on a bench flanked by a cane and a walker. It had taken quite an effort to get to that point (in more ways than one), but there they were, smiling and holding hands. As I walked in front of them I felt the warmth -- was it the sun?  Or the warmth of the love between the two of them?

MY BRAIN IS WHAT?

As I was growing up, I never considered school as very challenging -- or very academic. My parents never put emphasis on my academic performance and would routinely pull me out of school for church events and anything else when school attendance got in the way. We moved so often, and I went to so many different schools (four different high schools) that it was difficult to established relationships with teachers, or even other students. Consequently, education was just kind of there. I never studied. I never took any homework home. I had no goals other than finishing high school and getting a job. Well, that happened -- but so did Viet Nam and the most reasonable way of staying out of Viet Nam was staying in school. So I worked and attended a community college for a few years.

Somewhere along the way it all started coming together. I gradually grew enthusiastic about learning and found that I did it well. I finished a Bachelor of Science degree and applied to graduate school. I finished a PhD/MD program, completed my Residency, then started practicing. Even while practicing full-time I completed a MPA degree in Health Services Administration.

I had gained confidence in my intellect and realized that my limits had been self-imposed.

Although I never sought out any quantitative measure of my intellectual capabilities, it was occasionally required for various things and I was pleasantly surprised that the assessments were always above average. That is, until recently.

As part of the melanoma work-up and monitoring, I have had several Brain MRIs and have always felt mildly irritated when the evaluation has always turned out "unremarkable." I realize this is a good thing -- anything "remarkable" would probably be bad news about metastases -- but there's still just a little sting having my brain being described as "unremarkable."

KEEPING HEALTHY

The whole idea of having Stage 4 melanoma could be very intimidating and/or scary. By definition, I have metastatic tumor beyond the area of the original lesion and lymph nodes to other organs and body areas. That makes it sound like I'm full of cancer and infers that I'm quite sick. Actually, other than a slight non-productive cough, I'm feeling pretty well.

I've looked at all the imaging studies (MRI, CT Scan, PET Scan) and, in reality, there's very little tumor in my body. One about the size of a walnut in my lower leg, one about the size of a peanut and 2 or 3 the size of a small pea in my lung. That leaves an awful lot of healthy tissue left in my body, but if I sit around thinking I'm sick, pretty soon I will be.

I have to keep working to keep the healthy tissue healthy since that's mostly what's in my body. Yes, these parasitic tumors could grow, but with the therapy I start next week they could also shrink, maybe even disappear, depending on how my immune system responds. There appears to be anecdotal evidence that better-conditioned patients have more of a response to these new therapies, so I need to be a better-conditioned patient.

My walking meditation takes me on a daily route of about 3 miles and the past few days I've added half an hour on an exercise bike and some light weights. Since there's good evidence that exercise strengthens ones immune system, why not do whatever I can to put the odds of fighting this cancer in my favor?

So I started running again today. Maybe I should start swimming again soon.

A LIGHT-HEARTED WALK

Yes, I have Stage 4 melanoma, but no, I am not a desperate man looking for some quack cure. I have what I think is a reasonable plan to explore treatment and I have enrolled in a clinical trial of an investigational drug which shows promise. That is the preface for the following story:

My daily walking meditation keeps evolving, and I'm finding variations are happening most every day. Overall, I think this has been a very positive activity and, if nothing else, is at least de-stressing. Although I have minimal expectations as to how this will affect my clinical outcome, I usually feel better after meditating. After all, I am a physician with a strong science background and, in general, expect treatment to be related to evidence-based outcomes. (Not to say that there is no evidence on the positive effects of meditation.)

So I came across part of my usual walking route today that was remarkably deserted. It's a particularly pleasurable part of my route with a wide, flat, straight path stretching about a mile and directly aligned with the summit of Mt. Tamalpais which stood out against the bright blue sky and streaks of white clouds. With no one else in sight and with calming music streaming though my ear buds, I kept my eyes barely open, concentrating on my breathing and trying to empty my mind while walking this path. A strange imagery started to build in my mind of a bright white light coming from the summit of the mountain and aimed directly at my heart. Every time I inhaled, some of this light would enter my body and as I exhaled a grey fog would leave my mouth. Now I am not on any mind-altering drugs, have no history of hallucinations nor brain metastases and I felt still completely in contact with reality, so in my scientific mode, I decided to just observe this phenomenon for a bit. The more I walked toward the mountain, the more it felt as if my body was becoming filled with light until at the end of that path I felt like the little luminescent plastic Jesus that used to be glued to the dashboard of my uncle's car and would glow at night.

I had no idea of the meaning of this illusion, but there was no doubt it was a positive experience. However, even I can take only so much of this Marin County guru stuff, so when I got to the end of that path I switched over to a lively jazz playlist and high-stepped it the rest of the way home, finding I had a big smile on my face.

NO SIDE EFFECTS?

Radiation therapy was a piece of cake -- at least the first few weeks. I was pretty well prepared by the support team that gave me skin care advice, nutritional counseling, dental hygiene pointers, etc. I had almost fully recovered from neck surgery before starting radiation so, physically, I felt well. I had started running again and was up to at least 3 miles daily as well as going to the gym for some strength workouts.

I scheduled my treatments early in the morning (hoping to minimize schedule delays) and got into the routine of checking in, getting positioned on the table, listening to the photon accelerometer spin around my head a couple of times, then heading out for my second cup of coffee for the day. The whole routine often took less than ten minutes.

Like I said - a piece of cake. Then things started to change around the third week of daily treatments. My salivary glands quit working normally and I had an incredibly dry mouth. It was very difficult to swallow, although that was OK because every time I did swallow it felt like I was swallowing a handful of razor blades. My taste buds were destroyed and that completely eliminated any appetite. My skin in the radiated area became burnt, crusty and very sensitive, despite following all the preventive measures and I was always tired, even with routine naps every afternoon.

At the end of four weeks I was glad to see the last treatment, although the side effects continued to get worse for a couple of weeks before things turned around and I started to heal.

We moved into a new house the day after radiation ended. As bad as I felt, we did the social thing and went out to meet the neighbors. One neighbor's comment when he first saw me was "I recognize that neck!" He was ten years out from surgery and radiation for a neck tumor, so could empathize with what I was going through.

As word of my diagnosis and treatment got out to friends, I got a lot of support and well wishes. In their own way, whether through prayer, meditation or just good thoughts headed my direction, they provided a pleasant, and much needed, infusion of positive energy. As my best friend from medical school wrote - "We're sending all the positive energy we can toward you -- think of it as radiation but without the burns!"

ORGANIZED RELIGION?

I grew up immersed in organized religion. Both parents were ordained ministers in a relatively conservative church. My parents may have been a bit more conservative than the church, however, so I had a pretty tight leash. I was taught (and was expected to demonstrate) their beliefs, their values, their ideology. They made sure that my grade school education was at private, Christian schools, even though we had little money. Any potential rebellion simmered while attending public middle school, then erupted late in high school. I got in with the wrong crowd -- no, not the pot-smoking free-love hippies there in San francisco during the mid '60s, it was the philosophical intellectuals, some of whom were in our own church! We questioned everything, stripping it to the bone looking for flaws in logic, looking for reasonable explanations, wondering why so many religions based on the same teachings expressed differing doctrines yet there were similar doctrines between religions based on differing teachings. A few years of this and I got pretty frustrated with organized religions, in general.

About the same time, I took up the martial arts of Karate and Aikido. Although not religions, there is a strong Buddhist philosophy supporting them and this led me to explore eastern religions a bit more. After all the intellectual gymnastics I had gone through, I found eastern philosophies very refreshing and surprisingly well-aligned with what had turned out to be my personal spiritual values. I didn't "adopt" Buddhism, but in my non-religious life it was comforting to know that it was sort of within arms reach, in case I needed to look somewhere for guidance.

I still had pieces of the belief system I grew up with, and I had borrowed theories here and there from the diverse religions I had explored during my questioning period, but nothing had been codified in any sort of doctrine or even "value statement." Although I had found great value in meditation, that happened sporadically, often only while I was on the massage table and just before falling asleep.

So now I find myself back into that questioning mode at a time when a belief system associated with an organized religion might be a nice thing to hang onto. Do I want to retreat into a snug, comforting, "has-all-the-answers" organized religion? Hmm… no thanks, I think I'm pretty comfortable with my unorganized religion.

MEL AND I

Let me start by saying I don't like Mel, never did like Mel, never will like Mel. First acquaintance was in the late '80s or early '90s and although fairly innocuous, Mel still had to be forcibly removed from me. Since then, however, our relationship has has gotten downright ugly. Mel showed up again in 2006, acting very threatening. With a little help, I was able to call the bluff and Mel, I thought, was gone for good. Unfortunately, this year, Mel is back with a vengeance.

Mel's full name is Malignant Melanoma, but since we are on such familiar terms, it's just "Mel."

Its initial visits were small pigmented lesions in sun-exposed areas, which were easily removed in the Dermatologist's office. The next visit was a little more involved as I had an occasionally crusty lesion removed from my scalp. It was with Mohs surgery, so the margins were microscopically clear and it was very shallow in the skin. I was counseled to have regular derm check-ups and, of course, use sun block.

Fast forward six years (during which I saw dermatologists at least every 6 months, had little sun exposure and always used sun block) when a lump on my neck was identified as a melanoma tumor in my parotid (salivary) gland. << A little medical semantics lesson here - since it was in the lymphatic drainage area of the scalp lesion which had been excised, and was not in a major organ, it was considered an "extension," and not a metastasis.>>

A full-body work-up showed no other lesions or tumors, so I had the tumor, the parotid gland and 32 lymph nodes (one of which had a few melanoma cells) in my neck surgically removed. Recommendations were to have post-op radiation to my neck, so I ended up with 20 fractions (sessions) over a month which totaled up to 4,800 rads. No other therapy was recommended since the risk of a recurrence was about the same with or without standard Stage III therapy and the treatment had significant negative side effects.

Other than the challenge of recovering from radiation (much more difficult than I thought it would be), things were looking okay. I was feeling well, back to my usual activities and life was good.

After a routine derm visit 4 months post radiation, a biopsy of a small lump in the neck incision scar revealed recurrence of Mel. Further work-up over the next month uncovered recurrent lesions in my neck, a metastatic lesion in my leg and more metastases in my lungs. So that's where I'm at right now - Stage IV Malignant Melanoma.

Now, when I was in medical school in the '70s, this would have been a death sentence. The more cynical docs in the lounges would have talked about telling the patient not to fill up their gas tank all the way, and even consider not buying green bananas. Luckily, things have changed. Although there are no outcome guarantees, therapies now exist that have had some remarkable longevity statistics. I have enrolled in a Phase III clinical trial of an investigational drug and will start treatment in a week or so.

Any wonder I don't like Mel?

IN THE GROOVE (or is it a rut?)

Long ago, and far away (as many stories start) I used to meditate regularly. I was a graduate student in an accelerated MD/PhD program and was, without a doubt, under a lot of stress. My stomach hurt. It would hurt during the day, especially if I didn't have time to eat. It would really hurt at night when I tought the acid would burn a hole right through me. At the time, the only treatment was a roll of Tums or Rolaids carried in my pocket during the day, and a swig of that incredibly foul, chalky Maalox before going to bed. I found that on nights that I went to Aikido, which included some quiet breathing exercises, the pain wasn't quite so bad. I started doing my "breathing exercises" each night at home and this gradually evolved into a ritual where I would sit in a comfortable zazen position for an hour or so each evening and meditate. I soon had no need for antacids.

As life moved forward, that hour was harder and harder to find until, all of a sudden, it had been decades since I had meditated. I had developed other coping mechanisms for stress - most involving movement, like running, bicycling, kayaking, skiing, surfing, etc. Now, after thousands of miles and hours of these activities, and a few knee surgeries, but a renewed need to meditate, theres no way I could get back into that zazen position for a minute, let alone an hour. That's one reason I have taken up "walking meditation." I try to be mindful, when I walk, of my body movement, of my breathing, of my surroundings and of the random thoughts going in and out of my head. If I can let those thoughts go, things occassionally quiet down enough that I can put my walking on "body-mind autopilot" and become aware of my mind drifting off to a comfortable, quiet place. My mind is detached, but totally engaged with the universe. I experience a sensation of peace and serenity. This doesn't happen all the time - there are days where I can't let go of the thoughts - but when it does happen it really feels like I am "in the groove."

So, that's where I was today on my walk when I was pulled back to the real world by water running down my cheeks. I was calm, peaceful, relaxed - so why was my body crying? I tried to become more aware of what was happening. Thoughts started sliding through my mind - is this an unrecognized/unresolved emotional issue? Is this some sort of release of repressed emotion? It's hard not to think of crying as having an emotional basis, but I wasn't feeling emotional. Yes, there has been a little heaviness and fullness in my chest of late… OK, I'm satisfied at calling that feeling in my chest emotion - that's better than calling it tumor.

CARPE DIEM -- WITHOUT THE CARPING

I've gotten into a pattern of "meditative walking" for about an hour or so each day. I live in such a beautiful area of Marin County, CA that I can step out my back door and onto a wooded path and walk as far as I'd like. With relaxing music in my ear buds I let my mind wander. Lately, it has been wandering repeatedly to this place that says I should be writing - writing partly to tell stories, but primarily to focus my own thoughts and concentrate on how to face a significant challenge in my life.

I try to keep out any negative thoughts and welcome the positive ones, as well as opening myself to all the positive energy heading my way from family and friends. What I don't want to do is get stuck in that whirlpool of negativity surrounded by blame, whining and self-pity.

I've always had, in general, an optimistic view of life. When beaten back, I've tried to work harder to overcome. When I've made mistakes, I've tried to learn from them, and when I have complained, I have tried to follow the complaint either with alternatives to the problem or at least some means of coming up with a viable improvement. That was the "cheese" to go along with the whine.

I've always been building and/or renovating. Old cars, old houses, both old and new boats, bicycles, furniture, gardens…  It seems like I've had a focus on how things can be better, on an improved future that grows splendidly from, but respecting, the past. One of my biggest challenges now is to pull that focus much closer -- to see how good things are today. I can still build, I can still renovate, but I need to do so seeing that what I am doing today is what counts and accepting the greater impermanence of all things, including myself.

So, in the course of my writing, I will be attempting to catch, distill and understand the thoughts that float up in my mind during my daily walks. There won't be any complaining, no whining, so no need for the cheese.