Howard Markel, MD, PhD


December 15, 2004

My wife and I are expecting a child. This has led me to think a great deal about my father, Sam, who died 3 years ago. The child of Russian Jewish immigrants, my father was born during the Great Depression. Sam's life was molded by the fears of his Yiddish-speaking parents and an aversion to risk -- a worldview that was often at the root of our filial disputes.

Ironically, he earned his living as a stockbroker, a job he described as one where "every day you begin at zero." He was a natural-born salesman who could warmly converse with anyone he met.

From the age of 28, when my father was first diagnosed with insulin-dependent diabetes, he battled against a relentless and insidious foe. Obsessive about his health and diet, Sam was convinced that modern medicine would protect him. Years later, when I became a physician, my clinical experience with other diabetic patients informed me that my father was a walking medical time bomb. But I never told him exactly what I knew about his condition, nor did I ever allow myself to dwell on these harsh realities.

Consequently, 15 years ago, I was stunned to learn that that my father had suffered a massive heart attack, one of many devastating complications that diabetes encourages. The evening I found out, I was on-call in the hospital where I worked, 600 miles from my hometown. As if the medical data weren't dire enough, Sam's cardiologist added, "Pack a dark suit."

Somehow, my father's team of cardiologists and thoracic surgeons managed to pull him out of an early grave. In a single day, at age 58, he was forced into early retirement and benched during the stock market boom of the 1990s. For a man whose only significant interests were his family and his work, far more than half his myocardial muscle mass died -- part of his soul died, too. He was transformed from a genial, funny, take-charge type of fellow into someone barely recognizable to me. He was now decidedly old, introverted, and fearful.

All father-and-son relationships contain some element of competition. A boy's father is often the measuring stick of what he should become, accomplish, or avoid. As the son grows older, he learns how to outmaneuver the father in a manner that is not always polite or pleasant. Yet most sons also demand applause from the same men they seek to vanquish.

Just as my father was reeling from the edict that his career was cut short by circumstances completely out of his control, mine began to thrive. Through the haze of depression, quiet anger, and resentment that were every bit as much a part of his illness as his abnormal electrocardiograms, it was difficult for my father to be unconditionally complimentary or outwardly happy about my victories in life. That is, at least, in his dealings with me. His friends tell me he bragged about me all of the time. In return, I failed to comprehend the sorrow he was experiencing and often responded with anger when he was less than supportive.

For almost 12 years, I convinced myself that Sam's illness had reached a steady state and he had outwitted the inevitable. In retrospect, of course, there were clear signs of continued cardiac decline. Three years ago, his battered heart abruptly gave out and I received another urgent long-distance call from a physician to fly in immediately. It was clear that this time there would be no reprieve.

I helped my mother take care of my father in his final days, and for much of that brief period, Sam and I held hands. He had long, slender fingers and a gentle touch.

This simple act reminded me of events that transpired more than 40 years ago. When I was a little boy, my dad drove a big, green Chevrolet. While driving, he often stretched his arm over the driver's seat into the passengers' section to reach for his children's hands. My sister and I fought over who would get to hold our father's hand and typically settled on a draw. I got the pinky and ring finger, and she, being the oldest, had reign of the thumb, index, and middle fingers.

Every child, no matter how old, seeks that physical connection with his parent. As I held his hand at the very end of his life, he told me, once again, in his own form of expression, how much he loved me and reminded me that he had always expressed those feelings -- even during the last years of illness. It was just that his son had to learn how to listen carefully to what he was saying.

Our last conversation went something like this:

"Howard, you're the greatest."
"So are you, Dad"
"I'm sorry if I was sometimes hard on you, son."
"That's okay, Dad, I usually gave as good as I got."

My father ended this conversation by stating, "I never thought this would happen to me." The part of me that was used to upstaging my father with my medical expertise almost erupted, "You had diabetes and astoundingly high cholesterol levels for 40 years, 2 heart attacks, and a decade of congestive heart failure! What did you expect?"

Thankfully, another part intervened. I sat there holding his hand and tearfully replied, "Me neither." He was right, of course. As a physician, I knew precisely what my father's prognosis was. But as his son, it was an entirely different matter watching him die.


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