Skin In The Game



Basal Cell Carcinoma: Abnormal, uncontrolled growths or lesions that arise in the skin’s basal cells, which line the deepest layer of the epidermis. BCCs almost never spread (metastasize) beyond the original site. Only in exceedingly rare cases can it spread to other parts of the body and become life-threatening. More than 4 million cases of BCC are diagnosed annually in the United States. It is the most frequently occurring form of cancer.


And I was one of the 4 million for 2016. Driven entirely by vanity I made an appointment with a dermatologist to get the 411 on Botox, fillers, etc for the 11 lines in my forehead which I have been cleverly covering with my bangs until they get too long and swept to the side. After the litany of suggested injections, paralysis of forehead muscles, silicone and $1,000 plus for each of the 4 to 5 visits a year, I decided to stick with the bangs and get them trimmed more often. But as long as I was there almost naked on an exam table I asked her to give me a check up on a few darks spots scattered here and there. She looked at my various heres and theres (and inbetweens) and declared me to be fine until she saw a little bump under my left eye and said, “We have to take a look at this,” and she directed a beam of light onto my upper cheek. As I was thinking “oh that little bump…it’s been there for about 8 years and no one has said anything about it, just a little annoying when I put on my make-up so of course it’s nothing….” I felt the sting of a hypodermic needle in my face. I thought wtf…but said nicely (after all she had a needle in my face) “umm I thought you were just looking. “   Alas looking to her meant numbing, slicing and putting a piece of my flesh under a microscope. About a week later I got the call. “That’s a basal cell carcinoma. Better call Moe.” Huh?


Moe is not Moe, but MOHS. MOHS, also known as chemosurgery, developed in 1938 by a general surgeon, Frederic E. Mohs, is microscopically controlled surgery used to treat common types of skin cancer. During the surgery, after each removal of tissue, and while the patient waits, the tissue is examined for cancer cells. That informs the decision for any needed additional tissue removal. So I did not call Moe but I did call Dr. Yehuda Eliezri in Pomona, New York, and scheduled an appointment. I was advised that the procedure would only take a few minutes but then I would have to wait two hours for the results. If all was good, i.e., they had been able to remove the cancer cells plus 1 millimeter all around, I could be stitched up and go home. If however, the cancer cells went beyond the millimeter, there would be more tissue removal, more cutting. Dr. Eliezri, a very charming man, reviewed this with me, was very gentle with the anesthetic needle and truly only took about 2 minutes to cut and patch me up with a gauze pad. Then I waited in a waiting room filled with people with gauze pads taped to their cheeks, noses, chins, necks, arms, a couple of legs, 1 foot. We looked like inhabitants of the land of the boo boo people. During my 2 hours, there were people who were called back into the clinic rooms and would emerge stitched up, with heavily packed bandages and they would head out to their cars with a wife or husband. Others however, came back to the waiting room with gauze and another 2 hours to wait. Disconcertingly, one woman came out quietly sobbing. Then I was called. As soon as I got into the hallway with the nurse she said, “You’re good to go…just some stitches;” on the exam room door I entered was my paperwork with Neg written in yellow highlighter. I had passed some rooms with the word Pos in red. I have always loved yellow highlighters.


So I am home for a few days, changing my bandages which have morphed from big pieces of gauze to little strips of Telfa to now Disney Princess Band aids. I clean the incision with peroxide, dab with Vaseline and apply an ice pack every couple of hours. I also gaze in the mirror at the crescent line hash tagged with little black stitches that Dr. Eliezri so carefully placed as he kept saying, “I am bringing the edges together perfectly, no puckering, no folding,” “perfect,” “perfect.” The bruising has faded to drupelets of pale raspberries clustered on my cheek and in fact the scar does look quite perfect as a nice line under my left eye where there used to be a pearly bump. In 2 days the stitches will come out.


So I have added one more landmark to my scardom which I use to track a certain personal history. The one on my right lower cheek that I have brought from babyhood as an 18 month old cut on the metal edge of a toy doll stroller. The line on my left inner knee from a swimming fin buckle that jabbed me in the fortunately sharkless waters of Long Island Sound. And my favorite, until now, my ankle scar covering the titanium screws and plate that reunited the shattered pieces of my fibula.


My skin. It may seem ironic but this new scar reminds me of how lucky I have been (and now how careful I have to be) to have skin that has been broken, sliced, banged, burned, wrinkled and crinkled. And this, this one perfect scar is the only remnant of real damage. When we were kids no one used sunscreen, I don’t even remember there being such a thing as sunscreen. I grew up on Long Island where my childhood summers were daily beach outings to the rocky West Meadow Beach in Old Field to swim in the Sound and at least once a week a big packed lunch and sojourn with my friends Carol and Jim (and eventually Richard) Winkler and our mothers to the sandy south shore ocean beaches. We burned and peeled and tanned, and it was all just part of the wonderfulness of summer at the beach. As a teenager, along with my girlfriends, I slathered myself with baby oil, sometimes with the daring additive of a few drops of iodine; now I am slathering with sunscreen.


And so yes, I have been lucky and I think genetically blessed. I have always given my paternal Czech grandmother Emilie Zapotocka credit for my creamy usually tanned skin and blue eyes. I remember her face as light brown, like suede, not wrinkled but with soft folds, around her blue eyes and smile, under a big braid of silver hair. My favorite picture of her is her standing in her garden in Queens, New York, surrounded by roses. But my other memories are of her making dumplings in the kitchen (a talent inherited by her daughter-in law, my mother,) cursing in Czech when she got a bad hand at cards, and her head thrown back with laughter at the Woodbox, a luncheonette in Stony Brook where she, my parents and I were eating after showing her the property they were buying to build our new house. In response to my query about a plastic tomato on the table she held it up, and gave it a squeeze which covered my 5 year old face with ketchup. My parents who had stepped away from the table looked at my red drenched face horrified until they realized that I had only been the victim of a condiment and my grandmother’s humor. She always claimed she had no idea that the tomato would spew forth upon my face. She was an interesting woman who lived with my Aunt Millie and Uncle Larry in Queens, but clearly she was the owner of the house. My grandfather had died when I was a baby, but she had a “man friend” named Mr. Hruska. One of my earliest childhood memories is being in her garden wrapped up in an old canvas hammock like a cocoon with little twinkles of light coming though the woof and warp of threads on my face, and my grandmother and Mr. Hruska singing and swinging me gently.   I am sure it was quite scandalous, but we children didn’t know anything, except that she moved to Florida and Mr. Hruska moved there too. It was on one her trips back up north Christmas of 1959, that the car my uncle was driving with my aunt Millie and grandmother in the back seat, was struck by a drunk driver running a red light and the car spun on the ice so the back doors opened. Both my aunt and grandmother died, in the world before seatbelts that would have held them against the centrifugal force and saved their lives.


I was 11 when my grandmother of the soft brown skin and blue eyes died, the Czech curse words and her dumpling making lost with her, and almost lost was much of her history. When we were children not only did we not know about the Hruska affair, but we didn’t really know about my grandmother’s emigration from what was then Czechoslovakia. We assumed that she and my grandfather came here together, settling in Westfield, Massachusetts , right near where my youngest daughter Alex went to school at U. Mass, on a farm where my father, the youngest child and only boy, and his 3 older sisters were born. But several years ago, my sister Barbara, the historian, began piecing together some other information. In 2005, 4 years after my father died, when I joined Barbara in Prague while she was there on a sabbatical, we met with my father’s cousin, Jarmilla, who filled in some of the family history, including my grandmother’s departure from Svaty Jakub, a little village east of Kutna Hora, which is the beautiful Czech city with the Cathedral of Saint Barbara, for whom my sister is named. The story is like a puzzle with lots of missing pieces but a strong central portrait of a very courageous, maybe impetuous, daring, risk-taking young women. My grandmother, by some accounts, 14 years old and by some 19 in 1904, left her home having, unbeknownst to her family sold her dowry collection of quilts and other household items, risking all of her possessions and money, and traveled to Bremen, Germany. From there she took a boat to New York. That seems to be the basic story. The rest is assorted puzzle pieces some which easily fit together and others that don’t, but the one fact that seems clear is that my grandmother was a teenage runaway, leaving her family, her home, her village, and her church to travel to New York, possibly alone, possibly with a girl friend, possibly with my grandfather, possibly pregnant, definitely leaving behind her a reputation for being the family bad girl. There was some information that indicated that she had been betrothed to a much older wealthy farmer whose wife had died. She may have met my grandfather and left with him, but she may have not met him until she arrived in Bremen; nothing really connects them in Svaty Jakub, since he was from much further east, although he was a traveling veterinarian. Or she and a girl friend may have just decided to try their luck in the new world. But, for independence, for love, for luck, for some mysterious reason of the heart, run away she did in pre World War I Czechoslovakia somehow traveling about 500 miles from her village to Bremen to New York where she, carrying a baby, was met, according to the Ellis Island records, by my grandfather, Ptyr Ripl.   I try to imagine what it must have been like for her to step out of her house into the night and set out on such a daring journey, what plans she may have had, what hopes, what fears, what courage. She was so brave, following her heart.


There is something else we do know about my grandmother Emilie. Whatever her motivation for leaving, she and my grandfather were successful on their farm, and able to go back to Czechoslovakia by boat to visit her family in 1920 when my father was 5. According to Jarmilla, this was my grandmother’s way of saying, “See I was right to run away.” And, she was right. While the Czech family endured World War I, the depression and World War II, the genocide and devastation of Nazism, and then the repression of Communism, Emilie and Peter’s family was in New York, where they moved and opened a grocery store on the upper eastside; none of us were ever hungry, threatened, deported, arrested, sent to concentration camps. We lived in the land of the free, home of the brave. My grandmother had a beautiful rose garden, she cursed in Czech, she made dumplings, she gave me my creamy skin and blue eyes, and I think she would like to know that I traveled to Prague, Kutna Hora and Svaty Jakub; I went to Nepal alone; I got off a plane in Entebbe, Uganda in the middle of the night by myself; I slogged through the monsoon in Mumbai; I lived for a week at a clinic in Burundi and swam in Lake Tanganyika.   In addition to her skin, now bearing this lucky scar, I believe she slipped me a little trinket of DNA that said, “Be brave and follow your heart.” It is a genetic message from Emilie that I have passed on to my children, to be continued by my children’s children and my children’s children’s children.

Thank you to gentle Dr. Eliezri and his kind and attentive staff.

Please Wear Sunscreen

Photo above:  Emilie Ripel with her husband, Peter Ripel and their nephew Willie Ripel in Piermont, New York, where Willie was the original owner of the Piermont Community Market.



The Write Stuff

The patient presented with multiple diagnoses:  Morbidly alcoholic with fits of anger, depression, anxiety, and insomnia.  His appearance was one of self-neglect with a disassociated affect.  But the doctor did not prescribe antidepressants, counseling or electroconvulsive shock therapy.  He placed a blank journal in front of the patient and positioned the pen on the page toward him.  “Write it down,” he said.  “A memory, a thought, a place.”  The patient was Nick Carraway.

Write something.  I do not mean for this to be an intimidating suggestion.  It makes no difference whether you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group.  Just write.  What you write need not achieve perfection.  It need only add some small observation to your world.  Atul Gawande, MD. in his book Better: A Surgeon’s Notes on Performance  is writing about changing the world.  The doctor at the Perkins Sanitarium, in Baz Luhrmann’s The Great Gatsby, is telling Nick Carraway to write to change himself.  He tells Nick that it doesn’t matter if anyone else reads what he writes or if he burns it.  Just write.

Far be it from me to suggest that anyone who has a mental illness not receive necessary treatment, but there is something about the prescription of writing that is healing, that is life enhancing, that is empowering, that is both personally and publicly changing.

We all know the power of writing from the glyphs on the walls of the caves of Lascaux, to the Guttenberg printing press, to the emails and texts we now zap off and retrieve in nano seconds. John Snow’s essay On the Mode of Communication of Cholera in i849; Ignatz Semmelweis’s Etiology, Concept and Prophylaxis of Childbed Fever both had powerful, although delayed, effects on public health.  But what does writing do that changes the writer whether it is a blog, a poem, an essay, a professional paper, or The Great Gatsby?

First, there is the actual physical act of writing.  Nick starts out writing in the journal in cursive which Luhrmann conjures up as the words scrawling and draping across the screen.  In 3D, the curlicued letters actually float out to embrace the audience.

….scientists are discovering that learning cursive is an important tool for cognitive development, particularly in training the brain to learn “functional specialization,”[  that is capacity for optimal efficiency. In the case of learning cursive writing, the brain develops functional specialization that integrates both sensation, movement control, and thinking. Brain imaging studies reveal that multiple areas of brain become co-activated during learning of cursive writing of pseudo-letters, as opposed to typing or just visual practice. Other research highlights the hand’s unique relationship with the brain when it comes to composing thoughts and ideas. Virginia Berninger, a professor at the University of Washington, reported her study of children in grades two, four and six that revealed they wrote more words, faster, and expressed more ideas when writing essays by hand versus with a keyboard.

There is a whole field of research known as “haptics,” which includes the interactions of touch, hand movements, and brain function.  Cursive writing helps train the brain to integrate visual, and tactile information, and fine motor dexterity.   MEMORY MEDIC by William Klemm, D.V.M., Ph.D.       What Learning Cursive Does for Your Brain | Psychology Today.html

Then there is the whole right brain/left brain relationship in writing that connects the creative emotional side of ourselves with the sequential verbal side.  So here is what is going on in each side of our sophisticated bicameral brains that developed around 1,000 BC when a purely reactive brain was not capable of figuring out complicated stuff, and a meta consciousness was required:  thinking about thinking, desiring about desire, worrying about worries, wondering about wonder.  Julian Jaynes thought about these thoughts documented in his 1976 book The Origin of Consciousness in the Breakdown of the Bicameral Mind.

Here’s what each side of the brain does.


uses logic
detail oriented
facts rule
words and language
present and past
math and science
can comprehend
order/pattern perception
knows object name
reality based
forms strategies

“big picture” oriented
imagination rules
symbols and images
present and future
philosophy & religion
can “get it” (i.e. meaning)
spatial perception
knows object function
fantasy based
presents possibilities
risk taking

Writing gets the major highway system between the two sides of the brain, the corpus callosum, activated in fact, bringing a wholeness to our thoughts, our expression, our selves.  Fantasies, dreams, ideas, fears, beliefs, travel into verbal language, knowing, acknowledgement, comprehension.

So this is what happens when we write, and I can tell you it is happening to me right now.  There is a total engagement, there is a sense of being “together,”  there is what Mihaly Csikszentmihalyi calls FLOW in the book by that name, subtitled Steps Toward Enhancing the Quality of Life.  Enhancing the quality of life; isn’t that what we strive for in our personal health and public health?  (Don’t right brain panic over how to pronounce Mihaly Csikszentmihalyi .  It is actually quite simple if you don’t let all of those consonants throw you and your left brain just goes with the sequence.  First name: Me High.  Last name: Cheek Sent Me High.)  Flow is what happens when your left brain and right brain are working in complete participation with each other, when we are “lost” in experience, in creation, in process. Experiencing flow is a positive experience; in fact, some people refer to it as “optimal experience.” Flow doesn’t just happen for writers—athletes call it being “in the zone.” Artists, surgeons, dancers, and others also experience flow when they’re completely passionately focused on something they love.

So this is the fun part of being healthy, enhancing the quality of our lives, of choosing to go with the flow, of optimal experience.  There isn’t one single prescription.  It isn’t one size fits all.  There is no standard operating procedure.  Natalie Goldberg in her book on writing, Writing Down the Bones notes that journals should be big enough to write big, but William Carlos Williams, the poet who was also a pediatrician, often wrote his poems on his prescription pad.  How perfect, the prescription of a poem.

It’s all about you and doing what engages your self fully, right brain, left brain, body, soul, spirit.  Garden, bird watch, play music write music listen to music, paint, dance (actually no matter what else you do always dance,) practice yoga, solve mathematical equations, build something (I can actually get a little too engaged walking around Lowes,) heal someone, heal yourself.  And do write.  You can do it anyplace on anything at any time.  I have actually written various stories, essays, articles on the back of grocery store receipts and pay stubs.  If you feel the least bit inhibited about writing something, I recommend a book called Wreck This Journal.  If you write in this book you will never feel inhibited about writing again, in fact you might never feel inhibited about much of anything again.

“Write something,” prescribes Dr. Gawande, ”it need not achieve perfection.”

So back to Nick Carraway, (fresh faced and glowing after a nap on the couch and the accumulation of his typed pages,) and the final line of The Great Gatsby with my own edits, (and no apologies whatsoever to Mr. Fitzgerald, who would probably have loved to have been able to approve,) on this fine morning, May 27, 2013:

but that’s no matter–tomorrow we will run faster, stretch out our arms farther…and one fine morning–so we write on, boats against the current, born ceaselessly into the moment.”

 boats against the current


Some of you know that in addition to writing this blog, I write essays, professional articles, and short stories.  I wrote the following for my granddaughter and so it is titled For Sonoma at Bedtime, but it is also known as

The Mermaid and the Cowboy

Once upon a time, under the great blue green curls of the waves in the deepest most beautiful ocean, lived a mermaid with golden curls and eyes the color of the blue green waves.  With her beautiful blue iridescent tail she swam with the whales and played with the dolphins and raced with the seahorses.  She and her mermaid friends dreamed of love and adventures and flirted with the sailors on the passing ships.

Over time all of her friends fell in love with sailors and traded their beautiful iridescent tails for feet.   Ah the better to walk with on the piers and dance and love their sailors.  But the mermaid with the blue green eyes was determined to find love and keep her iridescent beauty and the power of her swimming.  So as her friends left one by one she was lonelier and lonelier but also bolder and bolder as she explored the ocean from the crests of the waves to the deepest darkest crannies of caves and she became acquainted with every living creature in the sea.

And so it happened that one night as she swam over the castle spires of a reef, a great storm blew in from some dark and violent place and the mermaid, caught in the winds of change and the rains of despair, was carried far from her home in the sea, to craggy coastlines, up muddy rivers to a sandy creek’s edge.  Covered with mud, scraped and bruised she lay on the sandy bank sleeping off the nightmare of the storm.

A cowboy, dusty and weary, walked his pony along the creek looking for an easy place to settle in for a quiet rest and to let the pony drink.   As they wandered down the bank, the cowboy was dazzled by a glimpse of iridescent blue at the edge of the water.  When he scooped into the sand he found beneath a layer of mud, golden curls and glistening scales and peachy, though scraped and bruised, arms and hands and shoulders and a face that slowly revealed, as her eyelids flickered open, the blue green of a sea he had only imagined.  And the mermaid, her vision a little blurred from the night of tears and fears, looked at the cowboy and was dazzled by the gold dust glistening in the sun that shone upon his face.

Though he was awkward, at the water’s edge the cowboy washed the mud off of the mermaid, and then bandaged her cuts and scrapes.  He made a pot of coffee on a little fire he built at the edge of the creek and took some biscuits and wild strawberry jam out of his saddlebag. The mermaid sipped the coffee and ate the biscuits with him and was warm and cozy, feelings she had never experienced in the deepness of the ocean.

For a month the mermaid and the cowboy lived on the sandy bank of the creek while her bruises and scrapes healed and his exhaustion faded.  She told him about the ocean and the creatures of the sea, the waves and the deep dark places in the underwater caves.  And he told her of the prairies and the forests, of snow and butterflies and falling leaves.  He took his guitar from his saddle and sang to her of moonlit nights and lost loves and little lambs found.  And the mermaid sang to him in the lulling voices of whales and the cadences of the dolphins and the soothing tones of the tides.  Some days the cowboy would ride off for a while on his pony and the mermaid would dip and swim and splash her tail in the creek as she grew stronger.  And once, just once, the cowboy joined her in the water and clumsily tried to swim by her side.  But he floundered, frightened by what seemed to him dark and scary beneath the surface of the water.  He sank and had to spit out the water that poured into his mouth.  And once, just once, the mermaid tried to sit on his pony and go for a ride, but her tail slipped and she fell into the grass.   She tried to maintain her dignity, but she was embarrassed and tearful.

So the days and nights passed and one morning after a night with a full moon, the cowboy and the mermaid simply said, “good-bye,” and she swam away down the creek, along the stream and into the river and out to the sea without once looking back.  And the cowboy climbed up onto his pony and rode away from the creek, across a field, through a forest and over some mountains and out onto the prairie, and he tried not to look back.

There were no calendars in the sea or on the prairie and so no one could guess how many days or months or years passed, but after many many full moons and snowfalls and campfires, the cowboy realized that he had left his heart on the sandy bank of that creek and it had been carried deep into the sea.  And after many many tides and migrations of whales and births of seahorses too many to count, the mermaid also realized that she had left her heart at the edge of that creek and it was far away somewhere on a dusty prairie.

And so the cowboy and his pony boarded a ferry, and then a boat and then a ship and they sailed around and around the world looking into the sea for a glimpse of iridescence and the blue green eyes of the mermaid he loved.  And the mermaid swam up rivers and into streams and creeks, and painfully wriggled into ponds and the shallowest of puddles on the prairie looking for a cowboy who was dusty and dazzling and who she loved more than anything.

It was a kind storm of graceful rains and fortunate strong winds that tipped the ship and beached the cowboy and his pony and that washed the mermaid out of the puddles and down the creeks and into the rivers, back to the sea where the whales and the dolphins and the seahorses conspired to carry her to a brilliant beach where she awoke in the cowboy’s arms.  In the moonlit nights of days that were on no calendar, on that beach at the edge of all oceans they sang together and danced.  And each fine morning a cowboy, holding the hand of his mermaid, swam in the blue green curls of the waves and each evening, a mermaid safe in the arms of her cowboy, sat proudly on the back of his pony as together they rode off into the sunset.