Chasing My Cure

by David Fajgenbaum

  And—yes—it was a competition. We were both dressed like the plebs we were: in the same short white coats, just barely reaching our waists. This set us apart (as it was intended to do). The attending physician and other resident both arrived resplendent in coats that nearly reached the floor. My legs never felt so naked. Especially because Oral Surgeon over there actually could have worn the longer coat if he’d really wanted to. He’d already earned it. He’d already made his way through the gauntlet. Becoming a physician requires first acing premed courses in undergraduate, and then grinding through four years of medical school. That’s step one. After that, you technically get your long coat, but you still need to complete residency and possibly fellowship training, which can last from three to more than twelve years—depending on specialty—before you can finally practice on your own as an attending. I still had a long way to go. But a first day was a first step.

  Our morning greetings and introductions (and my private ruminations) were interrupted by the beeps of a pager. Our first mission of the day. We rushed down the hall in order of rank—Oral Surgeon and I took up the rear.

  When we got to the patient’s room, a lump immediately rose in my throat. The room was dark. The patient was very sick. His cheeks were swollen from the corticosteroid treatments he’d been on, which reminded me of the way my mom had looked when being treated (also with corticosteroids) for her cancer. Her swollen cheeks had exaggerated her smile. The memory was bittersweet. I knew that I was going to struggle if I constantly thought of my mother. But I couldn’t shut those memories out. I didn’t want to—remembering her smile with those big cheeks made me smile.

  This patient wasn’t just sick; he was critically ill, and our goal was to evaluate whether or not he had the capacity to make medical decisions for himself. A woman sat beside the bed, holding the patient’s hand. His wife, we soon learned. Tears dripped down her face, untouched, and eventually made their way down between her hands, where she’d gathered some blanket. A small piece of comfort, now also damp with her sadness. The patient was confused, and he struggled to answer our questions on the mental status exam.

  “Where are we?”

  “I’m in New…”

  We were in Philadelphia.

  “What year is it?”

  “Nineteen seventy-seven.”

  It was 2010.

  We huddled outside the room, but the decision wasn’t difficult and the discussion was brief. The patient didn’t have capacity to make his own medical decisions; his wife should make them for him.

  Of course, medicine isn’t always so binary. It’s not just life or death, joy or despair. A middle ground exists where joy is possible in the face of death.

  My time as a member of the psychiatry consult service would be distinguished neither by duration nor by any particular talent. That is to say: When my two weeks on psychiatry consult were up, I happily transferred to working on the inpatient psychiatric ward, a locked unit in Pennsylvania Hospital. It was an intimidating place for a young doctor in training, a place for patients on the edge: struggling with depression, bipolar disorder, schizophrenia, and suicidality. Though this rotation was a necessary step toward becoming a doctor, I didn’t expect it to actually hone any future cancer-fighting skills.

  My first patient there was George. Aged fifty-two, divorced, tall with broad shoulders, George had been diagnosed with glioblastoma, an aggressive brain cancer—the worst kind, and the kind my mom had had. One side of his face drooped, and he walked with a limp. But that’s not why he was in the hospital. He was in the psychiatric ward for depression and his stated wish to commit suicide. Just that week he’d been told he had two months to live.

  My resident told me that George had not wanted to talk to anyone since he arrived and that he had stayed in his room almost all day, every day. She asked me to perform a mental status exam on him to round out his admission paperwork. Despite having a rapidly growing brain tumor, he scored a perfect 30 out of 30. Most of the patients that I evaluated who didn’t have tumors growing in their brains scored around 25.

  He was anything but dour when I showed him the results.

  “I aced it, Doc! Do I get anything special for it?”

  “I know. Way to go. Let me get back to you on your prize.” I grinned.

  He walked away with more confidence than when he’d come in. It was visible even in his stride, in his carriage. His limp looked more like a strut.

  But later that day, I saw him lying in his bed without the TV on. He was just staring at the wall. It seemed that the high I’d helped him get to with the test score was only temporary. Okay, even if it was only temporary, it could be repeated. There wasn’t any reason I couldn’t help him strut again. If that was the best we could hope for, it seemed eminently worth trying.

  I searched the Internet to find a new mental status exam that I could administer. This time he scored 28 out of 30, nearly as good as before, and well above the normal threshold of 25. Again, George smiled from ear to ear. The next morning, I didn’t see him lying in bed—I found him at the nurses’ station, bragging to all who would listen about how well he’d done on the two previous tests.

  I ended up giving George a mental status exam each afternoon he was in the hospital. They weren’t necessary for his care and none of them ever went in his chart, but that was hardly the point. George’s transformation from suicidal to upbeat had turned a routine piece of hospital paperwork into a joyful routine for both of us. In time, it led to something more.

  One part of the mental status exam instructs the patient to write any sentence he wants to on a piece of paper. Each time, George would write something about his daughter, Ashley. On Monday he wrote “I love Ashley.” On Tuesday: “It was Ashley’s birthday Saturday.” On Wednesday he wrote “I miss Ashley.” On Thursday: “I love Ashley!” The pattern was clear: Ashley was important to him. So I asked him about her. I learned that he hadn’t talked with her in a while but that he left voicemails with her every day. I am not naïve: I knew the situation was much more complicated than I could appreciate. I knew that estrangement has many causes, and many contributors. But at the same time, sitting in the psychiatric ward, watching a man spend his last days writing simple notes to his daughter that she would never see and leaving voicemails that she would not return—it wasn’t too complicated to untangle. I asked George if I could call Ashley simply to tell her how well he was doing, about his great tests and the notes, and about what it was like for me when my mom had brain cancer. He agreed. So I called and left her my own voicemail.

  The next day I saw George and asked him how he was doing.

  “I’m doing great! Ashley called last night!”

  When I rounded the corner, out of his sight, I gave a fist pump. This was the first time that I may have really helped one of my patients. And it wasn’t even some complicated procedure or coup of surgical dexterity. I hadn’t uncovered a medical mystery. I simply let my hope and desire for George to be happy during his final days direct my actions. George and I had gotten to a breakthrough by doing some paperwork. That’s all it was. The things that sustain us need not be anything more.

  While I had witnessed pure joy for the new parents and devastating despair for the incapacitated patient and his wife, I actually helped to bring about joy in the face of sadness for George.

  And it felt so good. I wanted more.

  Luckily for me, this phase of medical training is pretty much set up to give you more, and more, and more, and more. More than you can ever really handle.

  I SHOULD HAVE been too tired to do much of anything outside the hospital, but the endless hours and high pressure were actually energizing for me and pumped me up to take on more. In between grueling rotations and long hours on the wards, my best friends from medical school and I would steal time to hit the gym. Between exercises, we practiced what we called dynamic rest—we grumbled about
rotations, hospital staff, and, for me in the first weeks, Oral Surgeon.

  Since I’m a shell of my former self today, I don’t feel like it’s bragging for me to share that I could bench-press 375 pounds back then. My friends started calling me the Beast. Even as a Division I college football player, I had never been more Beastly.

  One night, a group of my friends were watching a Phillies game in my apartment while I studied in my room. I came out for a study break just as Ryan Howard was up to bat. At the time, he was one of the top power hitters in Major League Baseball. The commentator said that Howard could bench-press 350 pounds. My friend Aaron looked at me and said, “Howard’s using his three-hundred-fifty-pound bench press to hit homers. What are you using your bench press for? Holding back the skin during surgery?” Everyone laughed. Perhaps sensing that my laughter was a little forced, Aaron emailed me the next day with a link to a bench-pressing contest in Stanardsville, Virginia, with the words “Put that bench press to use.” I’m still not sure if he was entirely serious, but I took him up on the challenge: A few weeks later, nine of us packed into two cars to drive five hours from Philadelphia to Stanardsville, a town of about five hundred residents. I would be the only one competing, but my friends were willing to squander their precious downtime to show their support. Luckily for me, this particular league required participants to give a same-day urine sample, so I wouldn’t be competing against anyone using illegal performance enhancers. All I took were my requisite three Red Bulls—totally legal.

  I wasn’t hitting home runs for the Phillies, but I did win the bench-pressing contest that year for my weight class in Stanardsville. I missed the state record by five pounds. My friends cheered “Beast! Beast!” We celebrated hard that night.

  Maybe my bench-press adventures prove what some who know me would tell you: I’m a bit of a glutton for punishment. Which may be one reason that the constant demands of being a young doctor in training suited me perfectly. It felt like the more that was asked from me, the more I was able to put into everything I did, both in work and in play. Seeing what I could do to help people like George pushed me to focus on everything else I could do. It felt like I was finally discovering potential I had buried or put into cold storage during my first couple years of medical school.

  It was an old, good feeling. What had always truly helped me the most, back in school, back on the field, was that I could focus better and work harder than anyone. It’s the only way I ever got to excel in football; I played quarterback at Georgetown very much despite my God-given lack of foot speed.

  After struggling following my mom’s death, I was back up. I had the bull by the horns. I was healthy, I was thriving. I was the Virginia bench-pressing champion in my weight class, and I had a wonderful girlfriend, Caitlin, who had been a pillar of strength and support for me while I coped with my mother’s death and was now—even at a distance (she was living in Raleigh, North Carolina, finishing up her final year of college)—every bit as supportive of my drive to become a doctor. And here I was making strides toward one day defeating the disease that had killed my mother. I felt like I was conquering the world.

  But I was leaving worlds behind.

  One night, just a couple weeks after Stanardsville, I was studying for my neurology rotation—flash card after flash card after flash card—when my phone rang. It was Caitlin. We traveled between Philadelphia and Raleigh nearly every other weekend to see each other and had just spent a long holiday weekend together. It occurred to me that maybe she’d just come from a Fajgenbaum family dinner—she went to these even when I wasn’t in Raleigh to join them—and was calling to fill me in on family happenings. Or maybe she’d just come home from work and had something funny to share—when she wasn’t in class, she worked at my sister’s clothing store or babysat my three-year-old niece, Anne Marie. No matter the topic, these calls always seemed to help me feel good.

  Immediately, this one felt different.

  “Hey,” she said, “we need to talk.” Even though she’d said only five words, she sounded uncharacteristically sad and anxious. Now I wondered if she’d gotten bad news at work, had something go wrong in class, or if something had happened to her parents or brother, all of whom I cared deeply for. Then eight more words that felled me: “I think we need to take a break.”

  It was a stunning blow. In no iteration of my life plan was Caitlin not there. Didn’t she know that? Had I neglected to tell her? I needed her by my side. I thought, I assumed, she knew that and wanted me by her side too. I was at a loss for words.

  So, eventually and lamely, I just said, “Okay.” Then there was a long pause.

  It strikes me now that my reluctance to probe further and ask why was because I already knew but didn’t want to hear it. My torpedo-like focus, that thing that had helped me in so many ways and would help me so much in the future, was rarely directed at Caitlin.

  So, she filled the strange silence herself. “I think we need a break because you’re just not making me a priority.”

  I knew what she was saying, but I couldn’t help thinking: You knew all of this. You knew what I had to do, and what we were getting into. We have made it work for three years. We managed to keep this relationship alive—and have some of the happiest times of our lives together—despite time and geographic constraints: while I was at Georgetown and you were four hours away in Raleigh. I went away for a whole year to get a master’s in England and I worked my tail off to complete it in less than one year so I could return to the States to be closer to you. I’ve been seven hours away at medical school for two years already. I’ve had competing priorities all along, but you’ve always been near the top of my list. Don’t you know that? Why now? Why didn’t you bring this up when we were together last week? Why don’t you want to be together anymore?

  But I was too stunned to say any of that or even protest; I let the silence stretch out, which only seemed to galvanize her to end things. My utter surprise and speechlessness also represented our poor communication, which was likely a factor underlying this breakup in the first place. Somehow, we hung up the phone.

  Then, I broke my silence. “Is that it? Should I fight for us?” I said out loud. I allowed myself to indulge a kind of fairy-tale belief that everything would work out, that if this was “meant to be,” we’d find our way back to each other. Now clearly wasn’t the right time or at least that’s what I was telling myself to dampen the pain. Young, healthy, and largely blindsided, I thought that we had all the time in the world to work this out. I didn’t need to act. I could just wait and see.

  After the shock of it set in, I responded to our breakup the same way that had gotten me into this mess. I became even more focused. I studied harder. I worked longer hours in the hospital. I worked out and became even more Beastly. I did not want to stand still long enough to face what had happened. If I ran hard enough, I could outrun the pain.

  Two months later, Caitlin made it impossible to keep running from her. She was visiting her parents in Philadelphia and asked me to go out to dinner. Afterward, she told me she was ready for us to get back together if I was willing to make her a priority again. I was still hurt and living in a mindset that if it was meant to be, it would work out when the moment was right. My hyperfocusing over the last few months had prevented me from recognizing the feelings I still had for her. I turned her down. We had time, so I refocused on everything else.

  But there was only so much I could deny, rationalize, or compartmentalize. Life—and death—kept marching on, oblivious to my need to bury my head in the sand.

  * * *

  —

  A week later, a thin but healthy-looking woman in her sixties came into the emergency room with classic symptoms of a stroke. I was with the resident on the stroke service that morning when we got the page. We ran down the halls to the ER—and we really ran. The patient’s speech didn’t make any sense, and the right side of her body w
as paralyzed. We rushed her into the CT scanner.

  It was dire. The resident spoke to the woman and her husband: “There’s a medication that could possibly reverse some of the symptoms if given soon after onset. But there are serious potential side effects, risks you would be taking with its administration.” She explained what the risks were. But the message was clear: We had to move quickly if we were going to move at all. And there were huge implications to this decision.

  We stepped out of the room to give the husband and wife the privacy to decide what they wanted to do. When the husband emerged and told us they wanted to move forward with the treatment, we jumped into action to get the infusion started.

  I sat beside the patient’s bed, monitoring her for any signs of improvement. Actually—I wasn’t just monitoring; I was hoping and praying. That first minute of assessment felt like an eternity. And then she began to change. But not for the better. Instead, she got worse, rapidly. Her speech disintegrated more. She became unintelligible. She was experiencing a rare, but well understood, complication of the treatment: an intracranial hemorrhage or brain bleed. She began to struggle to breathe. We immediately stopped the treatment and did everything we could to keep her alive, including tilting the bed all the way upright, starting new medications, consulting with neurosurgery about performing an emergency craniotomy, and doing a lot of praying and hoping. Despite our best efforts, she died within three hours. This outcome was an uncommon but known risk, and we had informed her and her husband of it, but that didn’t make it any easier.

  I was twenty-five years old and had lost “my” first patient. I left the room in tears.

  That the statement “There was nothing we could do” is a cliché does not diminish its truth; it only makes the statement feel utterly outmatched by the reality it is supposed to convey. There was nothing more we could do to save her once she experienced the treatment’s rare complication. But if we hadn’t administered the drug to try to cure her in the first place, she may have survived, though with significant mental and physical disabilities. It was the most bitter possible lesson for someone like me, someone who had made doing the center of his life until it had expanded to push everything else out.