by Kate Ledger
“So, chocolate?” Julie turned to Rita.
“I did the whole regimen,” Rita said proudly. “Lots and lots of chocolate. Boxes of it. It was sublime for about a day, and then I couldn’t stand it. I had to keep eating, truffle after truffle, and I wasn’t allowed any other food. Nothing but chocolate. So I hit my limit. Even threw up chocolate. And now, I don’t eat it at all. Don’t want it. If I smell it, I want to get away from it.”
“But that’s sad,” Julie blurted. “Like bingeing and purging? That doesn’t sound healthy at all.”
“For some people, it’s a start!” Simon said, taken aback. “What’s not healthy is lying to yourself that that one diet or another’s going to work. Not everyone can maintain resolve on a weight-loss plan. Sometimes there has to be an internal mechanism—like negative motivation—to support a behavioral change.” He softened some, as he seemed to consider it again. “The Boardwalk Diet clearly isn’t for everyone. They do something similar for alcoholics, kind of a negative association thing to make people lose the urge for drinking, but I got to thinking—what about weight loss? What can we do here? That’s just my point. We have to be thinking constantly about what can help people.”
Rita smoothed both hands down the sides of her color-splashed dress. “I’m much thinner than I was,” she said. “It’s a good plan.”
“I never heard of that diet,” Julie said numbly.
“Of course, there were skeptics. They let me have it. There were letters in the paper. People were threatened. Some of them wanted my license suspended. You gotta expect that when you’re making changes, rethinking the way things are done.”
Rita sat down at the desk and snapped a headset over her head. “It worked for me,” she said.
“Julie’s very happy to be here,” Simon told everyone suddenly. He had a plan to offer. “We have to make sure we keep her happy.”
“Did he mention,” Rita said, “that he’s earlier than anyone in the morning, and after that he isn’t on time for one single thing for the rest of the day?”
“Don’t let anyone here try to convince you my lateness is a problem,” Simon said to Julie. “They’ll complain that we’re behind schedule, and they’ll complain that things aren’t in order, but I know what I’m doing. Couldn’t have been here for seventeen years if I didn’t know what I was doing.”
“There’s a method to the madness,” Julie said. He was relieved to see the return of the nod, so he did not address her comment. It was not madness to be driven, to be enthusiastic, to have ideas when real insights were in short supply.
“I was thinking,” Simon said to Rita, “Julie could follow me around for a few days until she gets the hang of things. Then we shove her out of the nest, and she’ll fly on her own.”
Julie nodded to this plan and her eyes looked to Simon. She said, “I won’t disappoint you, I promise.” He could smell it on her, the drive to perform. It was right there on the cardboardlike ketonic scent of her breath. He felt a rush of sympathy—and nurturing—for her all over again, as she appeared to picture a literal nudge from the nest, that first scramble through empty air.
He’d forgotten the gratification of having someone observe him while he worked, the pleasure of performing for an audience. Several years ago, he’d been on the list as a rotation site for medical students. A third-year—Winton Harbanger—had shadowed him for a month as Simon made diagnoses and ordered tests and described how to listen to patients. Winton had been curious, to the point of annoyance, about the economics of “hanging out a shingle,” as he put it. Question after question about reimbursement and insurance—Simon didn’t care about those details. He had no idea what had happened to Winton Harbanger in the end, if he had a shingle swinging over a doorstep somewhere, but the gratification of performing, explaining himself, being the authority had been real. Julie followed him into the exam rooms as he realized he should call the student affairs office to make sure his practice was still on the list. He knew there was ludicrousness to his energy, that some of his gestures constituted acting. He talked louder than usual, lingered with the patients, cracked jokes that showed how well he knew them and their families. He found himself striking poses as he listened to their complaints, pausing with his chin on his hand like a person sitting for a photograph, or placing his pen in various positions against his head. Emily, who’d once coached him in public speaking, would have been amused if she’d seen him. “No, no, no,” she’d said, sinking her face into her hands. “You look like you’re pointing out where the thinking’s taking place.” He couldn’t stop. Julie’s presence in the exam suites, just the fact of her watching, made him feel robust, completely refreshed.
They established a pattern: He entered the exam suites with her, introduced her personally to his patients, and then he left so that she could take their vitals on her own. He waited for her in the hallway outside his office, and they conferred before reentering the room together. He acted the instructor, the illuminator, the didact. “The next one’s Ed Penzy,” he said. “Just watch, he’ll come in for something small, a wart or something, and then just as I’m leaving the room, he’ll say, ‘Oh, by the way, I’ve been having these chest pains that make it really hard for me to breathe.’ ”
“What do you do?” Julie asked.
“I wind up sending him for a bunch of tests. But he’s proof positive that if you’re a good doctor, you don’t rush out of the room too fast.”
Or, whispering in the hallway: “The next one’s April Frock. Epileptic. Twenty at the time of her first seizure but never knew it. Thought she was having an allergic reaction to Chinese food, can you imagine? When she kept having these dizzy, fainting spells, a neurologist stuck her on medication and never even told her what the meds were for. I was the one who told her. Once she knew what she was up against, everything changed for her. Now she’s real positive about her condition, and she can drive and everything. We have to keep tinkering with her meds, though, to get the right levels in her system.”
Julie hugged the papers to her chest, listened and nodded. Yes, he was sure he’d done the right thing to hire her. It was an infusion of something to the practice, a jolt of something that had been missing. In late morning, Maxi Bailey was waiting in exam suite B, and he recognized instantly another opportunity to show off. “She’s a tough case,” he whispered to Julie in the hallway. “One of my toughest. She was in a car accident several years back. Haven’t seen her in a while. She’s one of those patients most doctors hate to treat because she wasn’t getting better. I’m not afraid, though. I don’t scare off easy.”
The truth was, he took pleasure in treating those patients, the chronic pain sufferers, who mystified and frustrated other physicians. They were patients whose pain continued for months—even years—on end, even though there was often no sign anywhere in their bodies of what was causing the trouble and no surefire method to stop it. You could break it down, to try to think about what was happening. The mechanics of acute pain—the pain of injured tissue—were fairly straightforward: First, a trauma. The awareness of pain alerted the body about the presence of a problem. The free, branching tips of pain cells, long silvery bundles of thin, highly specialized nociceptive fibers, took note of an assault on the skin or deep in the tissues of the body. Electrical charges shifted across the membrane of a neuron, the depolarized end firing a message through the length of the cell, like a flare shooting from a troubled ship. The alarm sped to nerve clusters, the dorsal root ganglia, lined up outside the junctures of the spine. There, operating like a gate, the pain message was processed with brute labels: “Significant!” “Worth noting!” “Get right on this one!” and was admitted to the main circuit, the spinal cord.
Onward to the brain! The pain message bounded up the lateral spinothalamic tract to the limbic system and the cortex. Long dendritic fingers at the end of one cell released chemical messengers that swam across synaptic oceans into the receptive docking points of adjacent cells. And at that point, Si
mon well knew, the route became complicated, infinitely convoluted and impossible to trace. The chemical response met and mingled with emotions and memory, conjuring past fears and instilling new worries, that could not only make sense of the injury but heighten the sensation. The very first message of pain could be answered by a motor reaction, descending from the brain, like one telling the arm to pull the finger away from the hot handle of a pot, but it also etched a path of experience, a way to make sense of the world.
But chronic pain, the kind that outlasted its function, was another story. Sometimes there was an injury that started the pain response, but sometimes there was no inciting event at all. In any case, something more happened. Injured cells released agents of inflammation, distress-signaling molecules—serotonin, bradykinin, prostaglandins, growth factors, and cytokines—that somehow altered the nociceptive nerve endings. The machinery itself became changed so that the life of the injury did not end. You couldn’t find a doctor the whole world over who could tell you what changed in the system, but even as the original damage appeared to heal, the effect in the nerves continued to thrive. Viciously, the pain cells continued shooting off messages of pain, an alarm continuing to sound. As they coopted messages from surrounding cells, the undamaged skin around the injured site suddenly became painful. The nerves became even more sensitive than before, responding as though they were confused about their function. The effects could be so terrible that people suffering from this hyperalgesia would cry even to have their bedsheets brush against their skin. For these patients, there was no clear pathology for any doctor to treat. By then, the pain message obscured the source. For these patients, there was only the mysteriously bushwhacked path—a sensation lost somewhere in the neurons, in the synapses, in the gateway to the spinal cord, in the brain—its course becoming more unclear. The pain became its own disease.
What Simon found amazing was that most physicians, accustomed to addressing a problem and fixing it, couldn’t stand the mystery. They hated not being able to pinpoint where the pain was or to measure its severity with any known tool. With only the patient’s description of sensations to guide them, there was only to take aim in the shadows for an unknown, unseen, untraceable foe. Simon welcomed the challenge. Chronic pain patients turned up often in Simon’s office. They sought him out, and he did not turn them away. The key to treating them, Simon had come to believe, was assuring them. They were scared most of all of being told that nothing could be done, that there were no easy answers, that the pain was all in their heads. Whatever they described to him, he treated. It was a game for him: find some form of relief for each person. He believed there was always another treatment to suggest, another dose of medication to alter, something new to try—just as long as he kept thinking, devising something new they hadn’t tried.
Once, after boasting a little too complacently about his ability to help, Gabi, the physician’s assistant, had accused him of being intoxicated by their gratitude. Gabi was long-limbed, from Jamaica, and bossy, with an oval forehead, a slender nose and a mouth capable—it seemed to Simon—of a hundred expressions of impatience and displeasure. She grumbled about Americans, their culture of entitlement, their self-importance, their get-it-done-yesterday attitude and their rudeness to one another, and she told him that he loved the pain as much as he loved the patient. He couldn’t deny she was right. He was aware of the way they looked at him when they were in its grip, the way they listened to his suggestions, the way they hung on his advice. Desperation made their attentiveness acute. They were hopeful, vulnerable, eager, angry at the world and at fate, and they came to him for answers. He did what he could to find solutions, and he didn’t begrudge anybody any kinds of drugs for any reason. He was not afraid of their needs. He prescribed for them the best that was available.
In suite B, Maxi Bailey sat on a chair next to the exam table and lifted a head of greasy blond hair with dark roots. She was only thirty-eight, with bone structure that suggested she’d once been a wholesome type of pretty, but her looks had taken on a decade’s worth of wear, as worry lines marred her cheeks and creased her brow. Her shoulders pressed forward, and her chin turned downward so that the prongs of her tinted bangs hung into her face. She regarded Simon as he entered, large brown eyes turned down at the outer corners, resulting in a grave and doubtful look, like a greyhound.
“Maxi, good to see you again,” Simon greeted her. “It’s been a while,” he added without pausing for a response. Maxi Bailey smiled weakly. Julie stood at his elbow as he asked Maxi about her son, who he remembered was a few years older than Jamie.
The greyhound eyes lifted, but the shoulders remained hunched. “Sam? He’s fine. Lifeguarding at a pool this summer. And my older one’s leaving for college.”
“Your husband—don’t tell me, let’s see if I can remember—still at Black and Decker?”
A small smile. “They promoted him this year,” she said, “so he’s been busy.”
“And how about you?” he inquired finally, with a tone he hoped sounded more intimate, more gentle. He sat on a stool, rolled close to where she sat and stretched his arm out so that it rested beside her. “What’s what?”
“I’ve run out of doctors to see,” she said slowly, her shoulders curled protectively. She held her body still and braced, as though she imagined mere blinks of her eyes could cause shockwaves through her body. “It’s still my back. I don’t know what else to do.”
“Still hurts.” He didn’t ask. He stated it, knowingly.
She glanced at him, then back at her hands, limp in her lap. “Worse, even. It feels like it’s down my arms.”
“When was the accident again? You were rear-ended, right?”
“Four years ago.”
“That’s a good while,” he said with sympathy. He saw his pain patients as victims of the nervous system’s infinite complexity, which was capable of horrific misinformation. Maxi’s car was butted at forty-five miles an hour, the chassis tweaked, the trunk crumpled like an accordion. As she jolted with the impact, her spine jarred against itself. All along her vertebrae, the adjacent muscles had been bruised, and the pain nerves sounded the distress signal. But what then? The bruises healed, the tissue returned to normal. But four years later, her nervous system continued to rail.
“It’s gotten so bad I can barely function,” she said. “I can’t sit for long before I have spasms. The worst you could ever imagine. Like a snake writhing through my spine. Like fire or something. Shocks go down from my shoulders. I never know how long it’s going to last. Some days it’s so bad I can’t get off the couch. When it hits, the pain’s so bad I can barely see. And then for hours after one of these—I don’t know what to call them—episodes, my arms are sometimes buzzing and sometimes numb like I can’t lift them. I can’t stand in line at the supermarket. I can’t even do the smallest house chores.”
He shook his head with understanding, but there was no way to understand, to know what someone else’s skin felt. Each patient’s pain was so individual, so intensely private. What was clearest was that there were never adequate words for the sensations. His patients groped among adjectives: searing, wrenching, pounding, jamming, twisting, aching, burning, prickling, buzzing, throbbing. Certain words, like a pain that buzzed, could tell him about the nature of the problem and sometimes direct him to a particular spot on the body. Often they came up with associations involving tools—a knife slicing or a vise tightening or a screwdriver jabbing—but they were only approximating to give a rough picture of what they endured. He would never say it to a patient, but he’d occasionally had the thought that the inability to describe the pain gave it a sacred quality, too. When you lacked words to make others understand your truths, you stood apart from the jabbering masses. You alone possessed proof of your unique and involuted humanness, and through that, contact with something divine.
But such notions didn’t help patients, whose own lives had become unrecognizable.
Noticing that her eyes were tea
ring, Simon placed his hand on her knee. Then he rolled back on the stool and looked at Julie. “Once it was a simple problem, but the body changes, trying to accommodate the damage,” Simon explained. He asked Maxi, “Do you have support at home?”
The greyhound eyes blinked. “My husband believes I hurt,” she said, “but he thinks I have a low tolerance.” Simon imagined the husband, whom he’d never met, a business-minded guy scared out of his wits about what was happening to his wife. Doctor after doctor and no answers. Simon had seen it happen before; it wasn’t just the suffering, it was the mystery that tormented. One person’s inexplicable and indescribable pain was like another companion. It moved in. It took a place at the table, demanded to be addressed. It was an intruder that could rip a marriage apart. “He thinks I should buck up. Or like it’s a bad case of PMS, and I’m choosing to stay inside and sit on the couch because I don’t feel like doing anything. But it’s nothing like that.” She smirked. “I gave birth to two kids—with no epidural or anything—and this is worse than any labor.”
When she’d last seen Simon, he’d given her the names of two doctors she could see, a spine surgeon he knew at Johns Hopkins and a rehabilitation specialist. He hardly was surprised to hear now that her journey had taken her to sixteen other doctors and treatment centers as well. The X-rays she’d had showed nothing, not even the mildest inflammation of arthritis. The CT scans were normal. The spine surgeon had told her that her back was in perfect alignment, all the vertebrae perfectly stacked up like checkers, adding that he wished his own back looked as good. There was no fracture along her spine, no tumor, no signs of infection. Simon peered in Maxi’s chart, reading the surgeon’s notes.