StemCell Therapy

I grew up in Ohio and met my first real Westerner at age 27. Kate was from Durango, Colorado and lived next door to me for two months during a rural primary care rotation in medical school. They rolled up the sidewalks at night in Twin Falls, Idaho and so we had plenty of time to talk. Books always figured prominently in the conversation and she recommended her favorite book about the West

Reading that first iconic chapter, Time Spent, led to a 25-year Doig odyssey that eventually landed me in a Montana State University archive reading the final draft of that same chapter, marked up with Ivans own red pen.

It begins, That start of memorys gather: June 27, 1945. I have become 6 years old, my mothers life has drained out at 31 years. And in the first grey daylight, dully heading our horses around from that cabin of the past, my father and I rein away toward all that would come next.

The Doig archive at Montana State is a treasure trove for fans. Its extensively indexed and entirely on line and filled with pictures, original manuscripts and the collection of 3 x 5 and 5 x 8 cards on which Doig kept quotes and observations from his extensive research travels in Montana.

Ivan kept box after box of these cards, many of them with only a single type written sentence, sometimes annotated in longhand. He shuffled and reshuffled these bits of memory assembling them into temporary collections as material to flesh out a particular character or story line and then returned them to their boxes only to be reshuffled and reassembled for the next novel.

In summer 2019, Carol Doig met with a group of visitors and discussed her husband's journey in his last years. Joining them was her close friend, Betty Mayfield, who helped assemble Doig's edited manuscripts, diaries, correspondence and other documents that today are part of the MSU Doig collection. Those joining Carol in her living are, left to right, Betty Mayfield, Dr. Rob Patrick, Justin Shanks a post-doctoral fellow working on the Doig material to make it digitally accessible, and writer Todd Wilkinson of Mountain Journal. Photo by Kenning Arlitsch, dean of MSU Libraries

Sometimes this shuffling was frozen into a more permanent form when he collected them into 2-to-3 page novellas with titles like Scotchisms and Curses.Most assumptions arent conscious until they are shattered. Without realizing it, I had cast my favorite writer in his own movie that ran only in my head.

He woke up in the morning, hunted big game, slept with the world's most beautiful women, cavorted at the Algonquin round table, drank his weight in scotch and then, late at night, great work flowed forth from his pen in a tortured and inspired torrent. He threw himself down exhausted, only to arise and repeat the performance with the dawn. The truth that emerged from touching the physical remnants of his process was far different.

Ivan Doig was . . . a nerd . . .just like me. I clipped articles and collected them in folders, wrote down random thoughts and observations on cards, restacked, hoarded and recombined information. My stories were just about thrombocytopenia and clonal proliferation instead of resilient ranchers scraping out an existence under the Big Sky.

The champion of the lariat proletariat was a closet geek. How disappointing.But my biggest disappointment was yet to come.The archive contained an odd and alluring folder title medical journey that was irresistible to me as a physician. I hadnt realized that Ivan suffered from multiple myeloma for the last eight years of his life and had written four books after being diagnosed with a terminal disease.

Myeloma is a strange form of cancer as cancers go, it is both painstakingly slow to progress and inexorably fatal. Patients rack up complications from the treatment, not because treatment is so toxic, but because they live long enough to suffer from the cure as well as the disease.

The core of the pathology is something called a plasma cell which under normal circumstances produces the antibodies that help fight off invading viruses and bacteria. In myeloma, a single plasma cell mutates and grows uncontrollably crowding out everything else in a patients bone marrow and gumming up their organs with immunoglobulin. The mutant cells eventually cant be contained inside the bone marrow and invade the surrounding solid bone causing painful fractures in the spine and long bones of the skeleton.

As if that was not bad enough, the core of chemotherapy is high dose steroids, usually dexamethasone or prednisone. Steroids are the poster child for double edged swords in medicine. They are simultaneously incredibly useful for suppressing the immune system in autoimmune diseases, cancer and anything that involves inflammation, while at the same time having the most broad ranging side effect profile of almost any medication.

It was a love for wildlands in the West that led Rob Patrick, at right, down the trail of Ivan Doig's books and when he had an opportunity to dive deeper into Doig's final years he jumped at the chance. Another thing that brought him to Bozeman and Greater Yellowstone is his close friendship with Kenning Arlitsch, Dean of MSU Libraries. Here they are on an autumn trip into the Yellowstone backcountry.

Probably the most serious side effects for myeloma patients are immunosuppression leading to increased risk for infection, a softening of the bones accelerating the tendency of the disease to cause fractures and emotional lability. The last of these sounds trivial, but isnt.

My first patient who suffered from this particular side effect literally started a sentence laughing and ended it crying. The cognitive effects can be especially debilitating, because at its peak, the drug lulls one into a false sense of security. It can make patients feel super human and I had one multiple sclerosis patient tell me it was the most powerful antidepressant she had ever taken and she almost looked forward to her next flare so she could get it again. However, on the way up and the way down it can cause confusion and a loss of emotional control that is profoundly disturbing, especially to someone who depends on their brain to make a living. Truly a blessing and a curse of modern medicine.

One of my biggest losses of innocence after medical school was realizing that professors had pulled the wool over my eyes concerning one of the fundamental diagnostic tools in medicinethe patient history. During the pre-clinical years you seldom get to talk to an actual patient and instead hone your skills using case presentations which I later came to understand were carefully curated stories masquerading as actual patients in which the non-salient details were conveniently expunged and the salient ones amplified for teaching purposes.

My teachers smugly told me, If you dont know whats wrong by the time you finish taking the history, take the history again." This illusion is perpetuated during third year clerkships when cases are cherry picked for medical students so as not to dispel the myth. The gloves come off during internship when it is too late to turn back and you realize that most patients have a hard time telling you how they feel no matter how many creative ways you come up with to ask the same question. Its not their fault, they usually just have never felt like this before and dont have the words to describe it.

When you add intoxication, mental illness, dementia, etc. to the mix, taking a history often becomes an exercise in communication breakdown and frustration. So imagine my joy at finding a history written by a professional communicator whose livelihood depended on his ability to observe the world and record it. It was like winning the internal medicine lottery.

Doig observed of myeloma: The waiting room of hell, furnished with side effects.

Of those side effects, he observed, The dex makes me longitudinal - - concentrated on a single line of endeavor at a time, no latitude to speak of and I would go to blow my nose and find there was not a handkerchief within 50 of me. Pill bottle caps leapt for the floor. My ordinary thought process resembles a homesteader digging out a stump, when loaded with dex I plodded right past nuances of life in temporary fixations on getting to my desk and writing things down. Which, amazingly, produced pages of a novel faster than when I wasnt taking the stuff. Dex gave me a mental pop, off-the-chart energy upstairs while it played games with the rest of me. Writing proved to be therapy for therapy.

On the topic of mortality, he explained in a written passage, I am now in remission, that terra incognita but better than being off the map(oblivion). He would add, I have not come out of this as any cheerleader for Nietzche: thera are countless preferable ways to strengthen in life without having something trying to kill you.

Facing the reality, he noted, Invariably fatal. Damn. But then, so is life. Its probably not polite to laugh out loud at the writings of a dying man, but I couldnt help myself and I also couldnt help wondering what a pleasure it would have been to take care of him. There was plenty of correspondence in the archive between Ivan and his doctors, but the most striking examples would probably have been overlooked by the uninitiated. The age of electronic medical records and e-mail allow patients unprecedented access to providers.

Like most technology, this chart messaging is both a blessing and a curse. The blessing is that it doesnt take three phone calls to catch a patient at home and tell them about their lab results.

The curse is the dozens of chart messages to return at the end of a busy day. Consequently, as Doig chronicled, brevity is the rule: Everything normal on your labs today, see you in 6 months."

Doig, when in his prime, trying to instill the lessons of history into his work. Here he absorbs the vibe in an abandoned farm house where heart-felt dreams rose, fell part like a heartache and drifted away. Photo by Carol Doig, courtesy MSU Library Doig Archives

The messages from Ivans providers went on for paragraphs, like post cards from your grandmother, and often came close to open displays of affection. All patients are equal, but some are more equal than others.

My day in the Doig archive was followed by an evening at the annual trout lecture hosted by the MSU library and I happened to find the only other Doig nerd who had spent any time with the medical journey files. Todd Wilkinson, the editor of Mountain Journal, shared my fascination with this little known part of Ivan Doigs life and suggested we pursue an event centered around his medical journey.

I couldnt imagine who else would show up to hear about such a niche topic, but didnt want to spoil the glow of our mutual fandom and encouraged him to pursue it. Three months later I found myself sitting in Carol Doigs living room in Seattle.This would be a good time to disclose that I am not a casual Doig fan. Im not a religious person, but I have made two literary pilgrimages in my life. The first was to Arches National Park to find the location of Edward Abbeys trailer from Desert Solitaire and the second was to White Sulfur Springs, Montana to see the place that had figured so prominently in Doig'sThis House of Sky.

Something still haunted me about the archives. Aside from the few pithy quotes above, there wasnt much mention of how Ivan faced his own mortality. How does an author get up every day and write four more novels when he knows hes dying? More importantly, why does he do it?

My practice over the last 20 years was working as a hospitalist. All of my patients were sick enough to be in the hospital and these days you have to be pretty sick to make it through those doors. I had seen hundreds of patients die and typically had end of life conversations with patients and families several times a week. Indeed, I had been on a personal crusade in the last few years to get doctors to talk with their terminally ill patients about their goals for the end of life and had coached other providers about how to do it.

So here was my chance to salvage something of my shattered romantic ideal about writers. Ivan must have had some big epiphany, I thought, that just wasnt there in his writing and my task was to extract it from his widow. I was as if a literary anthropologist on a mission.

It led to having a wonderful day in Seattle, sunny and warm; the Doig living room had a commanding view of Puget Sound. The house was spare and elegant and warm and inviting all at the same time and I got to see Ivans personal desk with his typewriter and his book collection.

Carol was charming and intelligent and well educated and everything you would expect from the spouse of your literary hero. Todd Wilkinson was there and Kenning Arlitsch, Dean of Libraries at MSU, too, and the person responsible for securing the Doig archive. Our conversation flowed easily.

Todd had a flurry of journalistic questions for Carol about Ivan and his writing. I was the final interviewer and my experience told me that it was almost always the wife that was the keeper of the medical history. So I started with some easy logistical questions.

Doig's desk, where he completed five books in eight years, battling through pain, the effects of medicines and a bone marrow transplant. All this and yet critics say these final works contain passages that are among the most incisive and moving of his four-decade long career. Photo by Todd Wilkinson

No, she did not go to all of his medical appointments with him and she didnt even know about the folder where he had kept all of the materials about his illness until after his death. There goes my first assumption.

We walked through the chronology of his illness, his initial diagnosis, the stem cell transplant, chemotherapy, remission, relapse, second line chemotherapy. What was daily life like? How did they deal with telling friends and family since he was not obviously ill until the end? How long was he on hospice? What was it like at the end? I probed, I rephrased, I asked the same question a different way. But there was no profound epiphany.

What she described instead was a guy who got up every day, made breakfast, went to his study and pounded out his words for the day. If he finished a novel on Friday, he started the next on Monday. A literary proletarian if there ever was one.

I have watched plenty of people die in my career, some face it with grace and dignity and resolve and some fight it and raise their fist against the sky until the last breath. What separated those who faced their end well from those who didnt?

Regret. Regret for things they hadnt done or relationships that had soured, but it boiled down to not living life the way they wanted to. My epiphany was that there was no epiphany. Epiphanies are extraneous when you are already living your best life. Ivan Doig was a wonderful writer, husband, friend, and colleague. If it isnt broken, dont fix it.

Read more:
A Doctor Plumbs The Depths Of Ivan Doig's Illness And Asks: 'Did He Have An Epiphany?' - Mountain Journal

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