Susan held up her hand, stopping Skinner. Time for the quiz.
“Would you recommend hormone receptor studies of the tumor?” she asked Skinner.
“Yes—let’s see, they must have been…” He thumbed through the thick file and found the results. He was tired, as interns often are, and visibly pleased when his answer proved right. “Here. Negative receptor results.”
Susan did not let approval show. “Why give hormonal treatment, then?”
He shrugged. “It sometimes works anyway.”
She nodded but kept on. “Why might she be better off if her family had never come to the USA?”
“Uh, Japanese have a low incidence of breast cancer if they stay in the home islands.”
He had been doing his reading. She turned to another intern, a woman who seemed distracted. Susan thought it would do medicine good to have more women in it, but that didn’t mean she would coddle anyone. “Why the anemia?”
The woman blinked and supplied the right answer.
“Why might the patient’s blood cells be abnormally large?”
The intern gulped and stammered, then stopped completely, eyes wide. Skinner came in with the right answer. Fair enough. “What further diagnostic would you recommend, Mr. Skinner?”
“Look at the alkaline phosphatase level.”
“How about an ultrasound of the liver?”
“Uh, okay.”
He looked uncertain, but she could show no favoritism. “What would you do with the information?”
“Very little.”
“Why?”
“I don’t think there’s much to be done here.”
She had to nod. Adroitly, she turned the discussion to illustrate a point about cost containment, the constant problem. Then she led them into a discussion of pain “management” in cancer. After half an hour they were ready to see the patient.
Mrs. Yamada’s flowers crowded the little band of medical students into a tight crescent at the foot of her bed. The patient’s keen black eyes studied the circle of students with real interest. She was propped up with a book, her right arm encased in an orthopedic brace and sling. She had tugged her soft blue robe tight, as though to ward off a chill.
Skinner made the introductions, following protocol.
“I’ve been wanting to meet you, Dr. Hagerty,” Mrs. Yamada said in a surprisingly high, cool voice.
“We’ll try not to take too long.”
“I’d like to ask some questions. But I know your students want to put me under the microscope first, so—” She started to take off her robe.
One of the students drew the curtain while Susan helped her out of the left arm of the robe, trying to disturb the right arm as little as possible. As Mrs. Yamada leaned forward the back of the gown opened. They could all see dull red nodules pushing up in her pale skin. First Susan, then the others, ran a finger over the lesions, feeling the hard tumor mass beneath.
“Does that hurt?” one of the interns asked.
“No. They would if a man would come along and make me work hard while I was on my back, you bet,” Mrs. Yamada said impishly. The crescent dutifully chuckled.
Few seriously ill patients would talk to interns, especially flocks of them. With physicians, the local gods, they were more willing. Mrs. Yamada’s good-natured ribaldry was very unusual.
“What hurts is this.” She lifted her right arm a fraction. “And my ribs. A lot.”
Susan could tell that this wily woman knew perfectly well what the nodules were. Susan spent the next few minutes asking about reactions to the morphine, her digestion (always a fallback, to give the patient something to report positively), and minor symptoms. As she was helping the patient back into her robe, a voice said, “I see you’ve met our medical team.”
Susan turned to find Dr. Blevin peering around the curtain, apparently making a visit to his patient. He halted, glanced at the cluster of students, flashed someone a distracted smile. Usually other senior staff did not interrupt rounds. She felt a flush of embarrassment, remembering the curt remarks between her and Blevin a few days before. Susan saw now that events had piled up that day, fatigue and worry and sheer overwork weighing like cinder blocks on her, until Blevin had innocently chanced to tip them over. She had been unprofessional, self-righteous. Worse, she’d had no chance to take him aside and heal the breach. She caught his eye and flashed a quick smile, hoping she would see him at coffee break later.
“I wondered who had the chart,” Blevin said, moving alongside the bed.
Susan pulled back the curtain. “We’re just leaving—”
“Not yet,” Mrs. Yamada said alertly. “I don’t see anybody very often, and I wanted to ask someone—Dr. Blevin—if I have a pathologic fracture.”
Susan frowned and saw Skinner stiffen. Earlier Skinner had said that the patient did not know the X-ray results.
Blevin’s jaw jutted out irritably. “I see you have been talking with the house staff.” He looked significantly at Susan. “I was about to discuss the X-rays with you.”
Susan opened her mouth, but Mrs. Yamada cut her off. “I can read, you know.” She slipped a thick paperback out from concealment beneath her covers: Bantam Medical Dictionary.
Blevin said, “I’m sure, but—”
“I knew that bone scan was positive—you showed it to me last May, remember? I asked Mr. Skinner, studied this book. When cancer breaks down the bone, you can get a pathologic fracture, right?”
“Well, yes,” Blevin said. “We do think you have a tumor where the break is. We’ll fix that with a metal rod—the orthopedist just advised me on it. Who’s Mr. Skinner?”
“Uh, me. I’m a subintern.” Skinner spread his hands in nervous apology. “I may have mentioned pathologic fractures when I was in here yesterday, checking some details. I certainly—”
“Please do not blame Mr. Skinner,” Mrs. Yamada said precisely. “I am afraid that I badgered the information out of him. I needed it. He is a very polite young man.”
Skinner’s lips twitched apprehensively. Susan could not understand why; it was no crime to answer the questions of a bright, alert patient. House staff could pass on diagnoses, too. And Mrs. Yamada was plainly on top of things. Most patients regularly mistook students for interns or even staff; the only difference was a few years in age and a missing “M.D.” on the name badges. Patients asked all sorts of questions and usually remembered the answers in garbled form, if at all. Mrs. Yamada had retained the medical term and remembered as well that Skinner was a “Mr.”
The rest of the house staff rustled uncomfortably. Susan glanced at Blevin, who was still standing absolutely still in the doorway, head tilted up at a lofty angle. The lights reflected from his horn-rimmed glasses, making it hard to read his mood.
Susan asked Mrs. Yamada, “You needed information? I’m sure Dr. Blevin will describe the orthopedic—”
“My arm isn’t the problem. Not the main one, anyway.” Her eyes flicked to Skinner, jet-black marbles in a white setting moving so abruptly that Susan half-expected to hear them click. “It isn’t ever going to heal, is it?”
No, it isn’t, Susan thought. Often patients offered random comments, complaints—usually about the food. But to see clearly through the blur of detail was unusual. Mrs. Yamada was stern and controlled, giving away not a glimmer of self-pity.
“Well, we can’t tell,” Dr. Blevin said, getting a little more warmth into his voice. “We’ll touch it up with radiation, and we still have to finish your chemotherapy.”
“Chemo!” She gave them all a twisted smile, feeling her chest with her left hand. “It didn’t touch my skin cancer. Didn’t keep it from rotting my bones, either. What’s next—breaking a leg when I stand up? Or when I roll over in bed?”
Blevin sighed. “I can’t say what will happen. We’re doing the best we can. Remember how I told you that these therapies are only treatments, not cures? The precise course of the disease may vary—”
“That’s certainly
clear. So I asked Mr. Skinner here about that new idea, about freezing myself till they have a cure. He knew more about it than any other doctor I’ve ever found, believe me—and I’ve been to a lot of specialists in the last few years, plenty of them.”
Susan said hurriedly, “You should be aware that such measures are not part of the accepted protocol at any—”
“They all play dumb,” Mrs. Yamada said crisply. “More likely, they think I’m crazy. Won’t talk. But Mr. Skinner here—”
“Skinner,” Blevin interrupted, “is a subintern. Do not rely on him for advice in so personal a matter. This freezing thing is quackery designed to get your cash, nothing else. Save your money. There are always things to be done.”
“I asked you about it, remember?” Mrs. Yamada tossed her medical dictionary onto the bed. “You brushed me off.”
Blevin said stiffly, “I do not believe it is an appropriate alternative.”
Mrs. Yamada said quietly, “Should I not decide ‘alternatives,’ doctor?”
“I can see you’re upset. I’ll return later, and we’ll discuss this entire matter.” Blevin looked steadily at Skinner. “I’d like a word with you, if you don’t mind.” He strode quickly through the crescent of staff, sure that the waters would part before him.
Skinner started after Blevin, but Susan motioned for him to stay. She thanked Mrs. Yamada and promised to see her again soon. The small group, plainly rattled, followed her out of the room and down the hallway. Several looked around edgily for Blevin but he was not in sight.
“Well, a taste of real medicine.” This brought smiles of relief. “Disagreements are scientific, not personal. That’s crucial to our profession. Think that over, and I’ll see you Wednesday.”
They all left quickly, except Skinner. “Come on,” she said. “I’ll go with you. There’s nothing wrong with answering questions.”
They found Dr. Blevin standing at the main counter of the nurses’ station, writing in Mrs. Yamada’s chart with a gold Cross pen. He appeared not to notice them, then closed the chart and carefully returned the pen to his breast pocket before looking at Skinner with his head tilted back, horn-rimmed glasses again reflecting the overhead lights.
“Tell me, Mr. Skinner, is this your idea of medicine? Telling patients that they can always get frozen when they die?”
“No, I—well—she asked about what could be done, and I—she had already heard of the idea—even knew the term—and well, I—”
“The term?” Blevin’s bass rumble carried heavy sarcasm.
“Uh, cryonics.”
“Cryonics?” Blevin said with withering disdain. “And you recommended this ‘idea’ to my patient?”
Skinner opened his mouth, closed it, and in that instant seemed to regain his composure. “I told her about it. I did not recommend it.”
“And just how do you know anything about it?”
Skinner blinked. “I’ve read some literature.”
“Is that all?”
“Well—” He licked his lips. “I visited their facility.”
“Whose?”
“A company. They had an open house, and I just—”
“A visit. So you feel qualified to discuss this harebrained idea with my patient?”
“Well, sir, I—”
“Listen to me, Mr. Skinner. We let students into this hospital, we give them white coats, let them see our patients—because that’s the only way to learn. That doesn’t mean you’re free to do any damned thing you like. There are ethics, responsibilities. You must think like a doctor to be one. Is that clear?”
Skinner nodded, eyes on the floor.
Blevin cast Susan a cool, speculative glance. “I’m going to speak to the dean about this. Meanwhile, I believe that Mrs. Yamada had best be cared for by myself alone. House staff will no longer see her.”
Again Skinner nodded woodenly. Blevin returned the chart to its rack. Susan said to Skinner, “Later. We’ll talk later.” Still silent, Skinner left.
Blevin said casually, “You know, I don’t really have to admit any of my patients to the teaching service. It’s not as though it’s less work. In fact, it’s more. I have to check orders and sometimes deal with stupidities like this.”
Susan took a breath. “May we speak?”
He lifted an eyebrow. “I suppose. I’m headed for my office. You don’t condone this action of your student, do you?”
“It’s complicated.”
“In that case, we do indeed need to talk.”
Each medical specialty has its character, and Susan found them amusing.
Surgeons, for instance, were active by nature, ready to intervene. They thought that physicians procrastinated, fidgeting over diagnoses and splitting hairs while patients slipped away.
Internists, by contrast, saw surgeons as lightweights, untroubled by ambiguity. They, on the other hand, are the heirs of the noble Hippocrates—while surgeons descended historically from barbers.
And within internal medicine, the specialists who handled the most frail and sick of patients, nephrologists and oncologists, were hedgehogs. They contented themselves with tiny, incremental improvements. So they never saw the larger onrush of medicine, the spreading possibilities.
Susan reminded herself of this as she and Blevin marched in complete silence to Blevin’s office. He didn’t look at her, just kept walking so fast, she had trouble keeping up. He reached up and fidgeted with his yellow tie visible beneath his white lab coat, but otherwise kept a stony reserve.
At least that gave her time to think. Skinner had been a damned fool to bring cryonics into his remarks to a patient, but it was hard to ignore a direct question. Still, his infraction was minor. She would protect Skinner, partly because she liked the young man but mostly because she knew what a connection with cryonics could do to a budding career.
She hoped that some of Blevin’s hostility came from the incident several days before. She knew that she had let her foul mood ricochet crazily off Blevin’s sardonic diagnosis of Marie Lowenthal. A few sharp words, culminating in Susan asking him to leave her office. Yes, she could see a minor wound like that festering in Blevin. Well, it was her fault. But she saw also that to open with an apology for the earlier incident would be bad tactics.
Blevin had a good reputation and a curt, all-business style. Very well. She would be all business.
“I understand your concerns,” she began before Blevin had closed his door. “But I believe we have to keep our personal reactions quite apart from the students during our instruction of them.”
Blevin closed the door smartly, just short of slamming it. He came and stood close to her, not backing away to open any space, not offering a chair. This allowed him to peer down his hawkish nose at her. “I won’t have students spewing nonsense at my patients.”
Susan studied the determined set of Blevin’s chin. His stance was an effective tool, letting her know right away that he was rock-solid, adamant. But physical intimidation only worked if the target absorbed it subconsciously, and Susan could see right through him. She resolved to not let it bother her. Best to try a lateral approach, maybe. “She’s a lonely woman. She was probably just talking to him, and out came—”
“They’re hard enough to deal with, when they get more bad news every day, without them hearing drivel.”
Okay, back off, try another angle. “The chemo—I understand she was having no response?”
He nodded. “The tumor’s everywhere, all right. I’m going to try changing the protocol a bit.”
“She asked about cryonics before?” Let him talk it out, maybe. Behind the professional face men often just wanted to let off steam.
“Pestered me about it for days. Seems to think it’s some sort of miracle cure.”
Careful here. “Did you give her a name, a number to call?”
Blevin looked shocked. “What? Of course not!”
Susan stood firm, not backing away, not letting Blevin’s greater mass dominate the room.
“She’s a desperate woman. That Japanese manner doesn’t give much away, but look at her eyes. She probably just wants to talk to somebody about it.”
“Therapy, then.”
“No, I don’t mean the usual psychiatric counseling. She wants information, and that may help her to cope with what she’s facing.”
Blevin’s mouth compressed. “You’re not condoning this corpse freezing?”
“I’m not taking sides. I’m just suggesting—”
“Look, the issue here is that student. Not my patient, not my handling of her.”
“Of course. I was just trying to point out that the student probably just humored her a bit, let her talk it out—”
“That is not the task of a student. He’s out of his depth.”
Time to back-pedal. “Granted. I only mean that Skinner was probably moved by pity for her. She got the diagnosis right, she’s no dummy—but her emotions may not be so easily dealt with.”
Blevin drew himself up. “I will deal with my patients. And I am going to write this up as a formal complaint.”
“About his talking to her?”
“No, the nature of what he said. We cannot tolerate students who show signs of bad judgment”—his face reddened—“of outright quackery.”
“As I see it, he only—”
“No one should be allowed in this profession who displays such gullibility. To recommend freezing cadavers—”
“Don’t you think it might at least give them some hope?” Susan herself hoped that she could derail Blevin, whose face was becoming more congested and tight. He was plainly building himself up into a cold-eyed rage, and Skinner would be the target.
“What?” Blevin blinked.
“Mrs. Yamada. It might provide some solace to her.”
“And drain her bank account. We would have those cranks crowding in here, trying to sell her policies.”
“That’s not the way they work. All I’m saying is—”
“How do you know how they work? We’ve never allowed anything like that around here.”
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