Newly married zeal prompted me to share with Mark my fantastic dream: Now we can go to India! After all, we were free—no kids or real jobs yet. I was only twenty-four. He was twenty-six. A chunk of time off between medical school and residency seemed a perfect opportunity to take the epic journey to India I'd always imagined. Think of it—the birthplace of Gandhi!
“We'll go together!” I exclaimed, after presenting my vision of India to my beloved in our freeway-hugging apartment, frugally adorned with unfinished pine Adirondack chairs. Mark looked at me, bewildered, and said: “What? I have no interest in going to India. Why would you want to go there?”
We'd just returned from our honeymoon, which preceded our clinical rotations as medical students in Minneapolis. I was simultaneously excited about the life we were building together and apprehensive about what lay ahead. I thought India would give me something to look forward to. India was the farthest place I could imagine from where I stood as a freshly minted wife and soon-to-be MD I longed to explore places that were foreign in every way before settling down to a “normal” life. Maybe it was just a longing to be free again—unfettered, even if just for a little while—after the rigors of medical school.
I wasn't yet aware that India was calling to me from a more subtle place—beyond the predictable chicken josh, colorful saris, and winking mirrors. Watching the film Gandhi with a few close friends in high school had struck a deep chord in us. We had dubbed ourselves the “Gandhettes” as a sort of loose show of affiliation with this amazing man and his mission. A part of me wanted never to forget this great leader, his warm smile, and the equanimity that fairly beamed out of him despite all the violence and suffering he saw and endured.
Because of this, I was blindsided and baffled by Mark's response. Who wouldn't want to go to India? Surely this wasn't the adventurous guy I'd married a few weeks before, the man with whom I was to live out my decades in harmony. Mark was still talking, but I had tuned him out, until he said: “It seems odd that you'd actually enjoy a place like India,” implying that extreme poverty, crowds, and general disorder didn't seem compatible with who I was. I was crushed. Didn't he know by now that I loved mayhem of all sorts?
In the months that followed, I began to wonder if we had made a huge mistake. Maybe we had rushed into marriage too quickly. In fact, that first year of marriage proved a most difficult year for us.
“This red pepper looks awesome for dinner tonight,” I said, tossing it into the cart.
“Did you see the price? I don't think so,” Mark said, lifting it out and putting it back on the pile. “We can just do a green pepper—they're half the price.”
I wasn't used to conferring over vegetable purchases. In retrospect, I realized that, during our courtship, I had often footed the bill for things Mark didn't deem necessary—new CDs, red peppers, and take-out pizza. After a year of marriage, however, we seemed to pass some significant milestone, and it got a bit easier.
CHAPTER 3
Realization and Refusal
For the hero who refuses the call to adventure, all he can do is create new problems for himself and await the gradual approach of his disintegration.
Joseph Campbell, The Hero with a Thousand Faces
A few months after our honeymoon, I found myself on the hospital ward with Dean, a second-year resident in internal medicine. I was a third-year medical student, and this particular hospital rotation was pushing me to my limits intellectually, physically, and spiritually.
In order to finish rounds on my patients before Dean arrived, I left our apartment at 4:30 in the morning, arriving in the Intensive Care Unit around 5:00. I did a physical exam on our first patient and then sat at the desk poring over the chart, which was three inches thick, trying to decipher the cryptic notes left by specialists, following up on labs and culture results, noting all recorded vital signs, and making sure that I hadn't missed anything before I wrote up my assessment and plan, which would be reviewed by my resident and the attending physician.
But these routine aspects of medicine weren't what was most difficult for me. What stopped me in my tracks was something for which I'd received no formal training.
One morning, I was faced with a patient—a recently divorced twenty-nine-year-old mother of three—who was on an experimental bone-marrow transplant protocol for Stage IV breast cancer. We'd flooded her body with incredibly toxic chemotherapy to obliterate her tumor, but the destruction was nonselective. For the treatment to succeed, her native bone-marrow elements had to regenerate in order for her to survive. But her platelets (the tiny cell fragments that help blood to clot) had dropped to almost nil and were refusing to recover.
Dean and I stood by her bed and stared at her frail frame covered in heavy blankets. We were fairly close as we spoke with her, maybe three feet away, but I felt as if we might just as well have been talking to her from behind a thick glass wall. “Your platelets remain low,” Dean said. “But we're hoping to get a bigger bump with today's transfusion.” I had no words, so I just smiled weakly. I felt so separate, as if I couldn't really touch the problems she was facing. Or was it that she was feeling the distance that separated us? Had she already given up?
Despite the thousands of memorized medical facts and concepts that swam through my brain, the skills of my admirable resident, and the collective wisdom of modern medicine, it seemed to me that we were missing the point. She could very well be dying. How could we help her with that?
This patient haunted me all the way home that night, and I began to question everything, including what I was doing and what modern medicine dictated we do. I found myself wondering what it would be like if it were my job to talk with this patient about death. What would I say to her?
I was reassured by the way Dean had spoken to her in a soft, measured voice. I loved him for that. He had a quiet stillness. His bustling-physician self seemed to recede, and he was able to line up with the patient perfectly, the way a lake merges with its shore. Though we didn't talk about it, I could feel that he sensed a need to treat her with all the tenderness he could muster. I wanted to ask him what he was feeling about her, but we were so busy that the time never came.
Days later, while Dean and I were sprinting toward a new consultation through an echo-filled stairwell that reeked of linoleum and fresh paint, we received a voice page from the ward. Our frail patient had bled to death early that morning. Though her recovery had been very uncertain, it still caught us off guard. We paused for a moment, sitting down on the rubbery stairs, and allowed our tears to come. For this, I was grateful. I later learned that this was rare. Most rotations I would do, and most residents, didn't allow you to stop for a moment of humanity like this.
Months later, at the University of Minnesota, a six-week hematology/oncology rotation left me emotionally shattered. During my exit interview, the attending physician, whom I'd barely met, asked me for feedback. As he waited for my response, his eyes looked searchingly at me and then down at the form he needed to fill out. I couldn't get the words to come out. I unexpectedly took in a sharp breath, and the dam inside me broke. I began to sob, seized by a sorrow so deep and painful that I was overcome by it.
Remembered scenes flashed through my mind: the liver-transplant patient who seemed more dead than alive, the families wiped out by grief, the way patients were callously treated by the angry and dismissive resident with whom I had been paired. Each room we walked into had felt so heavy. The suffering had felt unbearable to me. It had taken everything I had just to stand there and look these patients in the eye. Our visits seemed to provide no apparent relief.
After a few minutes of uncontrolled weeping and shuddering, the baffled attending physician handed me a box of tissues. Though I was trying desperately to control my emotions so I could tell him what I'd experienced, I just couldn't stop. I gestured helplessly toward the door, grabbed my bag, and escaped to keen in the privacy of a bathroom stall down the hall. I waited until it was quiet in the hallway, and, my tears
subsided, I slipped out of the building.
Our internships took a new and deeper toll on Mark and placed an intense pressure to perform on me. One Saturday at home, we got into an argument, and I became furious with him. The only thing I could think of to exact revenge was to take his beloved houseplant and drop it unceremoniously into the sink with a crash. Plant violence was, apparently, the best I could come up with. He was understandably angry. But I was extremely surprised when he charged toward me. Instinctively, I began to run, but he tackled me as I tried to escape up the carpeted stairs. I was shocked and scared. Mark was one of the kindest and calmest people I knew. What was happening to us? Later, I told him that, if he ever grabbed me like that or tackled me again, I would have to leave.
After that, Mark became even more distant and unavailable, and seemed to undergo a complete change in personality. I knew that working a hundred hours a week could do that to a person, but I became truly worried. I talked Mark into seeing a couples’ therapist on one of our rare days off. After thirty minutes of listening to us, the therapist said: “I see a lot of couples, and I can tell that you two love each other very much. You're going to be just fine.” I drove away feeling slightly better, but wondered how she could be so sure.
After the death of my bone-marrow-transplant patient and my own disturbing discovery that I was ill-prepared to serve patients at the level I sensed they needed, I decided to sidestep the whole troublesome aspect of caring for patients personally and chose pathology as a specialty.
By choosing pathology, I committed to mastering something tangible and dodged the most painful and confusing aspect of medicine—addressing the patient's emotional and spiritual needs. As a pathologist, I only had to look at slivers and bits under a microscope and occasionally do a few autopsies.
But I discovered that I enjoyed pathology immensely. The doctors were brilliant and collaborative. It was also, at times, very exciting. During one typical intraoperative neurosurgery consultation, I heard:
“Mary, get the down here to the multiheaded scope! We've got a doozy of a brain biopsy, and I need you now!”
Mary skidded into the room moments later, threw down her glasses, and slid into a chair. She put her eyes up to the scope and demanded clarification: “What the fuck are we looking at here?”
“Twenty-seven-year-old frontal lobe mass with necrosis,” the other pathologist replied.
Mary immediately began directing the examination like a boot-camp drill sargeant: “Okay, okay, move to the right … no, left … okay, there … go down on that cell … I need to see it closer, Bob!” It fascinated me to watch these brilliant people wrestle with significant diagnostic problems and collaborate to provide the very best answer for the patient.
Another instructor from medical school was very influential in my decision to become a pathologist. Most medical school professors I had met were introverted types who enjoyed the symphony, a good Sudoku, and quiet nights at home. But this physically imposing guy with a huge bald head frequently said outrageous and shocking things. In fact, sometimes I wonder whether he was, in fact, the only reason I was initially drawn into pathology. I remember one after-class party at which he invited unsuspecting students to look at photographs he had taken under his microscope, challenging them to determine how the patient had contracted the infection. Baffled, the students peered with great intellectual interest at the clumped patterns of bacteria, each wanting to come up with the correct answer. It took a while for most to realize that he had used patterns of a bacteria known to be transmitted sexually to spell out “fucking.”
Pathologists are “the doctors’ doctors.” They consult with all other physicians, providing diagnostic clarity where possible and diagnostic possibilities where it is not. As I watched pathologists interact with surgeons and oncologists, I saw how important their role was and thought that, perhaps if I worked hard, I could be helpful as well.
At its most essential, pathology is good pattern-recognition. During my student rotation, I got feedback that I was showing promise as a diagnostician, and it encouraged me. As a pathologist, I thought, I could avoid the discomfort of witnessing human suffering, be a mother who gets to see her children (at twenty-six, these children were still notional, but pathologists were purported to have fairly regular hours), and I could be myself and swear like a sailor whenever I needed to.
For that first year, I lived, breathed, ate, and slept the study of disease and how to make a solid diagnosis. It was like learning a whole new language in which I needed to become fluent—fast. I loved staring for hours at each week's ten “unknown” cases, trying to make the most accurate diagnosis. It was a little like trying to remember the name of a specific wallpaper pattern (like Farrow and Ball's Toile Trellis). Each time, the details are similar, but not identical, to patterns you've seen before.
CHAPTER 4
Lightening the Load
Until one is committed, there is hesitancy, the chance to draw back, always ineffectiveness … the moment one definitely commits oneself, then Providence moves too.
W. H. Murray, The Scottish Himalayan Expedition
After five years of residency and a few years practicing in Wisconsin, we were thrilled to find jobs in Duluth and return “home.” We had begun our family by adopting a son, George, during our final years of residency. By the time we had settled into our practice, George was four and a half, and we were ready to adopt our daughter, Katherine. I loved being a mom but often felt lonely and stressed. Mark left around 7:00 in the morning and didn't come home until between 9:00 and 11:00 most nights. On-call weekends were worse. I felt like a single parent who had her own intensely demanding job.
One night while we were lying in bed together after a particularly draining week, I tried to open a conversation.
“Isn't there any way you could see fewer patients or lighten your load somehow?” I pleaded. “I can't go on like this.” I reminded him of how, in residency, we had said that we wanted to work part time, share parenting, and have a life.
“It's not easy,” Mark said defensively. “We have to see all the patients and consults. It all takes time.”
When I begged, he promised that he'd lighten his schedule, and he did—for a few months. Then, slowly, his workload ratcheted up again. When I spoke to the other spouses in his practice, they seemed frustrated as well, but also resigned to the fourteen-hour days. I frequently ended the day in tears—exhausted, confused, and lonely.
My days often began in the dark. Mark had usually already left to complete his early hospital rounds before his clinic started. Katherine, by then a toddler, got a diaper change and some kisses before I parked her sleepy self on my hip. Then I rousted George, and we headed down to the kitchen. Both kids were already dressed—they slept in their street clothes, a trick I'd devised in residency to avoid the morning dressing fiasco.
After assessing the condition of Katherine's hair to determine whether I could avoid a hair-combing battle, I was usually confronted with demands from George to be picked up early, complaining that he was always one of the last kids to be retrieved from childcare. Thinking about my packed schedule, I promised to be there as early as I could, with a knot beginning to form in my stomach as I admitted to myself that I'd probably be one of the last parents there again. Then we went through the wrestling match required to get sunscreen applied—something we all hated with the white-hot passion of a thousand suns.
After a quick breakfast, we leaped into the van and sped off to “before-school care” for George. Then I drove across town to bring Katherine to her childcare, which was located in a church near the hospital. I often left saying a silent thanks for the loving care she received there and feeling ashamed that I was too busy to give her that care. At times, I wished I were a daycare provider and not stuck at the hospital, thinking what a delight it would be—however challenging—to hang out all day with my daughter. Then I got back in my car and headed to the hospital. Sometimes tears sprang up—tears I quickly swal
lowed. I had to keep moving. Some days, I even had to admit that it was a relief to drop off my kids, because I felt so unqualified to meet their needs in my harried state.
At night, I repeated this whole process in reverse. Occasionally, Mark escaped work to join us for dinner or we met him at the hospital cafeteria. But, more often, he and I only saw each other briefly at night when he finally got home.
At one pain-filled point, after a particularly difficult week of solo parenting, I confronted Mark in desperation. “If I'm going to do this all on my own,” I complained, “I might as well drop any expectation that you're going to be part of our lives.”
“I don't really appreciate being threatened like that,” Mark replied. “I know things need to change, and I'm working on it.”
Frankly, I was grateful that Mark didn't get angry with me in the moment; I also felt guilty for pulling out the big guns. I was beginning to realize that looking to him to solve this problem was a mistake. I wanted a partner to help me carry the load, but I still wasn't sure how to proceed.
During that extremely lonely period, I envied people who seemed to believe in God, despite the challenging circumstances of their lives. They seemed calm and sure. But I had no such refuge, because, frankly, I couldn't fathom that kind of belief. I cynically suspected that religion was just a misguided way to help people cope with the vast unknowns in life. I tried to discuss this openly with my closest friend, Suzi, a grounded yet effervescent Norwegian farmer's daughter. When I did, she smiled at me and said: “Sarah, I think what you're having is a faith crisis.” Although she didn't intend it, her comment made me feel even more isolated.
When younger, I had pleaded with our reserved and tight-mouthed confirmation instructor at church to help me understand concepts like the holy spirit and the holy ghost. She got extremely flustered and angry. I'd been going to church for my entire life and still felt as if I just didn't get it. Nor were my parents ever able to explain their own faith to me in a way that I could understand. I once tried sharing my confusion and lack of faith in God with Mark's mom, but learned through her quick and surprised response that she would never question her faith—as if somehow even questioning it portended bad things. Though she meant no harm, I felt ashamed all over again for even mentioning it.
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