Taking Care

 “Taking care” is such an important term and concept.  No matter how determined we are to be independent, especially if we have been frustrated by not being well cared for in the past, we want to be cared for.  I'm 82, and I remember when I was a little boy, and my Mommy and my Daddy took care of me.  They cared for me assiduously.  I never doubted for a moment that they would take care of me.  They were so reliable and assiduous in their care that, frankly, it never occurred to me to think about it.  They were there, they would always be there, that's the way it was.

I still miss that.  Not the infantilization, who wants that?  But someone to care for me.  My wife has died and I took care of her until the moment that she died and she knew I took care of her and she thanked me for it and she told me she loved me.  She had not been well cared for as a child.  When it came time to go to college, my parents bundled themselves, me, my three younger siblings into the station wagon with my bags, and we all decamped for Cambridge together.  It was a little embarrassing, and I didn't mind it when they left, but I did dream about my mother as I made this first big dig into independence that I hadn't particularly looking forward to, tell you the truth.  My senior year in high school was great, my friends were great, and I wasn't straining at the bit.

When my wife Ann left San Marino for Cal, her father took her to the airport and she took off for San Francisco with her suitcase and didn't know where she was going, exactly, and didn't know how she would get there, but she was very eager to go and to get there and looked forward to the independence and being away where she had not been well cared for.  She always wondered and worried that she would end up not being cared for, maybe even being a street lady, and I was the happy news that that wouldn't happen to Ann.  I took care of her, her caregivers took care of her, her doctors were attentive, and her kids were concerned and attentive and all three were there for her last days.

Everyone needs to be cared for.  If someone is not personally cared about by whoever is manning the medical care system, then that is a failure of the system and the people in it.  Everyone deserves to be cared about and cared for, everyone.  It's a human right.  If you are sick and worried, you deserve to be cared for.  Now that I am a widower, the one person who cared about me more than about anyone else in the world (except maybe her kids) is gone.  My kids, all five of them, care about me.  I treasure that they do.  I try to be a good person and a good parent, but no one bats a thousand, and I have done well enough that no one has written me off.  If I get toward the end and no one is there to care for me, that will be a shame, but I'll get by.  Meanwhile I have a good doctor who cares for me, who is good, and I'm safe with him until he retires. Then I'll probably be in the soup, but we'll just have to see.  I’m not going to worry about it.

So, on Labor Day I was out in Walnut Creek turning in my laptop at the Apple Store for a new keyboard (I have Apple Care, so it'll be $99, and the experienced tech who helped me was so nice, kind, and patient – you can imagine who he runs into in his job), when I dropped into Lululemon for some slacks – Peter keeps telling me I need some new clothes and he's right.  Lululemon is not aimed at my generation, of course, so even if I don't look my age, there was no one near my age in the store – try Nordstrom's for that, or maybe Saks in the city, where Ann and I used to go and see Thomas up on the third floor, where we were treated like king and queen with the assurance that we would be dropping a few thou.  I was met at the Lululemon door by a saleslady standing there, just waiting for the next customer to come in even though they were fairly busy – they're well organized – who greeted me warmly and personally, got my first name, and helped me find some slacks to try on.  She led me back to the fitting room suite with the two pairs of pants to try on – Pete tells me, go for slim – and turned me over personally and by name to a guy who was to take care of me.  I went to try on my pants and never saw him again.  I didn't have anyone to ascertain that I had chosen the right pair, but I figured I'd just do what I had to do.  I headed out of the suite rather confused, I guess, wondering who I had been handed over to, and a young lady saw my confusion, said my name and asked what she could do.  She warmly directed me to check out, but didn't offer anything else.  I wasn’t going to ask.  They were well organized and upbeat at checkout, fast-moving line, and I was out in a jiffy.  Judgement – they were organized to care, they were coached to care, they showed some caring – but you know they really didn't care, and their system broke down somewhere.  Their system is customer-centric, and the personnel give the simulacrum of caring.  They’re acting.

Then, yesterday, I went to my long time dentist for a problem of tooth #13.  I have gone to him regularly, he is set up industrially — beautifully organized — with maybe 15 or more assistants, runs over 10 bays simultaneously, charges high, makes a fortune.  I had complained about this tooth and the same one on the other side.  He had put a crown on the other tooth, had said that we should probably do the same on this tooth, but then I wondered if he changed his mind because we just let it lie.  But it had begun to bleed when I used the water pik on it and I came in and he said that he was sending me to the periodontist because l had lost bone and needed either a bone graft or extraction and an implant.  Which was very discouraging.  Actually, he didn't say that.  He omitted saying that.  He just said, we have to send you to Doctor Horn, and it was up to me to ask why, as he tried to leave the bay, and then he told me.  Then he was hurrying out of the room again and I said, if we had done something about this tooth earlier, could we have prevented this and he said yes.  His assistant had said in reviewing the chart that Dr. Kami had recommended a crown on tooth #13, but then why hadn't he done it?  She implied it was my fault.  I've always done exactly what he said.  He didn't say anything more when I told him that he had decided to wait on the tooth, just hurried out of the room.  Didn't want to deal with the bad news, for one thing, and the implication of inadequate care, for another.

Did he care?  I guess not.  He always calls at night after a crown or a procedure, he has the form of caring and the procedures of caring, I am always short with him when he calls because I know he has many calls to make.  But when he rushed off without telling me what he was sending me to Doctor Horn for, and he just hurried off, just got out of there, didn't deliver the bad news, just told me where to go, I guess that tells the tale pretty well.

Then I had an appointment with our old family therapist just two hours later.  I've been seeing him every other week, he says we're family and I find it helpful.  He is a warm and caring man whom I like a lot, and who certainly knows our history.  I went and worked out at my gym then walked over to his office.  I had been away for August and this was my first week back.  I hadn't checked with him about the appointment, but I kind of knew that I should have, because even when we check the appointments verbally, he often manages to screw it up.  He still keeps his appointments on paper.  But I trusted this time and just showed up, two minutes late. I turned on the switch that signals his office that the next patient is there, and he came out and told me that he wasn't sure when I was coming back and so had booked my time.

Did he care?  More than the others.  It's his system that betrayed him, and my not emailing him, and his inherent disability to schedule.  I was unhappy.  Cognitively I know what happened, but on the other hand, my father would never had made that mistake.  With my father I was always number 1.  But I'm a big boy, I tell myself, and I'll feel better about it in a few days, but for the moment I just got out of there.  Is wanting the same care your father would give you unreasonable?  I guess.  but it shouldn’t be.

Hell, people have strict limits on their caring.

It bothers me that at the description of the Harvard Medical School curriculum section of developing to be a doctor, they say they will teach the students to show empathy – “show empathy” rather than “feel empathy.”  Actually, I think there is an important difference.  Lululemon tries to show caring, but who would mistake that for real caring?  And if HMS wants to teach empathy, they need to do much more in getting students to know and to care about real patients, to get close to them, not just to tell patients that they imagine that the situation is hard on them, that being sick must be hard, to acknowledge their feelings.  That’s necessary but not sufficient.  They are preemptively surrendering to a system set up not to have continuity of the carer, not to have sufficient time and contact.  Caring and time spent knowing is a waste to the measures the leadership used to chart productivity.  Caring isn’t productive to them, it’s an outdated frill.  They assume that as a doctor learning to interact with a patient, that you are new to the patient, not someone who has known the patient for a long time.  There's a difference, guys, there's a difference, and you teach one one way and the other another way, showing empathy versus knowing and caring about the patient and feeling that empathy deeply.  

My dentist does a good job generally, is affable, knows who I am and notably that I have a house in Maui – that fascinated my former ophthalmologist, too, before he missed the diagnosis of my macroadenoma of my pituitary and delayed therapy for six months and could have cost me some of my eyesight because of the pressure prior to surgical extraction, but luckily didn't.  My ophthalmologist always asked about Maui, that was his first question posed, probably jealously.  But when I complained of poor vision he didn't think to do a very easy test of my peripheral vision.  Just stand nose to nose and put your arms out wide and see how wide you can see, or more carefully, just use the machine they have.  It’s not hard — but of course, it’s also not billable.  Did he care?  He never apologized – seemed to act as though it was my fault, or there was no fault because it was finally caught when I insisted that I be checked, and he should be congratulated and I should be grateful.  They just get scared or defensive.  My father would be accusing himself into the night, which wouldn't be helpful, but no one cared more than he did.  And my mother, too, whom I took for granted.  Little did I know.

And these medical offices who sometimes think it shows caring and emotional closeness when they teach their medical assistants to call us by our first names.  A recently graduated medical assistant will be calling a retired professor of medicine in to see the doctor but standing at the doorway and calling to the room at large, “James?”  Then she will set him up in the exam room and say “Dr. Goldberg will be coming in soon.”  The professor who taught Goldberg is “James,” and the former student is “Dr. Goldberg.”  That's not warm caring, people, that's lack of respect.  That’s stupid and careless.  Faking intimacy inappropriately.

Everyone deserves people to care about them.  The financial industry has officially tired of ripping customers off by consenting that their account representatives should act as fiduciaries for their clients, putting their clients' interests above their own and their company's.  Tell that to the company that used to manage Ann's money, who, when Ann wanted to establish a college fund for her granddaughter, put her into a fund with a 5% load, which meant that the company collected a fee, when they could have just as easily chosen a no-load fund, which would have been a better deal for their client, but not for them.  They're just doing their job, ripping off the unknowing and then seeking to defend it when the knowledgeable husband calls them on it.  I’m still pissed, I notice.

But in medicine, where the stakes are high and the connection is intimate, caring, really caring, should be high on the list.  I remember when my pediatrician friend Bob Shimuzu retired, he said he found that now he could relax.  I asked him what had made him not relax when he was in practice.  Worrying about the kids, he said.  I admired that.  Old school.

Think any of those I discussed here worry about me?  Not really, but I guess there’s nothing really to worry about.  Not that I want them to.  But Lululemon didn't win me as a friend, I'm now real disappointed in my dentist who I have always liked and relied on, and I'll relent on my family therapist – he just can't keep a damn schedule, I guess, and it was my fault for relying on him for that.  Nobody bats a thousand.  My ophthalmologist?  Failure, man, failure.

We all need to have people that care about us, but I really don't want to be a burden on anyone.  If they care for me enough to want to do things and it makes them happy when they do – that's the way I felt about Ann – then fine.  But that's all I want, something that works for them.  And not too much.  And, I don't want someone who knows how to show empathy – I want a real friend.  Take that fake stuff and send it out to some clothing store in Walnut Creek.  Act as though you’re empathetic, gin it up.  Not for me, I think.

But what caregivers, like Ann had?  These wonderful professionals that we relied on and whom we made friends with – some of them.  I can accept their caring, they're being paid for it, take it for what it is.  But sometimes, of course, it becomes real.  I'm going to go out to lunch with Ann's chief caregiver, Lai, pretty soon, and it's been over 2 ½ years since Ann died.  My admiration for her is immense.  She was there a lot, and I guess we all got to like each other, and to admire.

It's not an easy subject, but I guess appropriateness and honesty are the hallmarks.  I guess.  I guess there are others, too.

Budd Shenkin