by Matt Richtel
“I pulled up a chair next to the minister. People need to feel you are the same level that they are on. Never forget the power of your white coat to unnerve; there’s almost nothing you can do to diminish it. So find the humblest place you can. The less arrogance you communicate, the more likely that most patients will share a real history with you. In the case of the minister, the second that I sat down, he dismissed everyone in the room with a wave of his hand. The bodyguard didn’t move and then the minister swatted him out as well.” Lyle then explained that he had asked the minister basic questions to establish a baseline of communication and gauge cognition. How old was he (seventy-one); where was he born (outside Medina); what was he a minster of (domestic police); did he have a family (yes, wife, two sons, and a daughter); did he have much interaction with animals (no); what was his diet like?
“Are you a doctor?” the minister asked Lyle.
“Yes.”
“Then get on with the doctoring,” the man said. He had a white beard and he had been heavy once. Sleeplessness tore at his eyes and left cracked skin at each corner of his mouth. Fear and inner ugliness trickled out in his voice, the sound of a powerful person unaccustomed to feeling helpless.
“The minister’s comment that I should get on with the doctoring was an important moment,” Lyle explained to the students. “It told me that this might be one of those people who actually preferred me to be in a position of authority, rather than one of mere expertise. I don’t want to make more of bedside style than necessary, but I also want to tell you how essential the role of listening, really listening, is. In this case, he was telling me I didn’t need to be so humble after all.” He paused. “So I could just go ahead and be the arrogant jerk my wife tells me that I am.”
There was a smattering of laughter but not so much. Lyle continued with the story. Next to the minister’s bed, Lyle cleared his throat.
“May I examine you?”
The man struggled to pull himself up on his bed.
“Just turn over,” Lyle told him. “Please, pull off your shirt.”
The minister removed the body-length nightshirt, his back exposed. Lyle ran his hand along wrinkled skin over depleted back muscles. He spent some time moving the skin around on the man’s neck.
“Right-handed, played a sport. You have slightly more developed muscles and scar tissue on the right.”
“Hound hunting.”
“You’ve had some hearing loss.”
“Yes.”
“Did the hunting cause your hearing loss?”
“No. How can you tell about my hearing?”
“Small mark on the skin around your ear. Sometimes, that area can get itchy if the nerves get irritated from a hearing aid. Behaves like dry skin.”
“My hearing loss is a state secret. I have to pretend I’m listening to the king.”
“Of course. Doctor/client privilege. How long have you been married?”
“Sixty-one years.” The minister was starting to relax. That was the goal. Yes, Lyle was looking for any unusual external markings, bites or lesions, signs of infection. Mostly, he was getting the man to relax. This was a veritable backrub.
“You are monogamous—with your wife?”
“The only woman for sixty-one years.”
An hour later, Lyle had been over the man head to toe. He’d looked at the chart, read the CT scan. He’d looked in the man’s eyes, causing the minister to recoil, confirming the light sensitivity. He cocked his head back and forth, like a metronome, lost in rhythmic thought.
Back in the auditorium at UCSF, the audience hung on his story, much like Lyle had the minister caught up in the examination. It had been an act of trust building.
“I explained to the minister that I thought we needed one more test,” Lyle told his audience of med students. “Would anyone like to guess what that test was?”
Lots of looks down by students at their laps. Even in an audience this big, many students felt like they’d not like to let down Dr. Martin with a flier, a wrong guess. From the back, a hand rose.
“Yes,” Lyle said. “No hands needed here. Just let ’er rip.”
“An MRI of his brain,” said a woman’s voice. “With contrast, I’d guess.”
“Very good.” Lyle nodded approvingly. “Just what I told the minister. Almost my exact words.”
The minister said, “Sure, yes. If you say so. What will that tell us, Dr. Martin?”
“The MRI is going to show us your brain. I suspect, strongly, it will show us a fungal infection. Crypto meningitis.”
“So that’s what I have? Meningitis?” The minister pushed himself up on his bed, his gown back on, his face strained with pain he struggled to hide.
“Yes and no.”
“Which is it: Yes or no?”
“The fungus is a by-product.”
“Of what? Of the MERS?”
Lyle felt it had gone on long enough. “I’d like to talk about your sexual history.”
“I told you already. I’m married.”
“And you’ve never been with another woman.”
“You are testing me?”
“You’ve been with a man.”
“Excuse me?”
“I believe you’ve got HIV, on top of MERS. It would be simple enough to give you an HIV test to prove it. But I bet your doctor wouldn’t even allow himself to think about such a test. It would insult you and even be dangerous. I hear they flog people here for that sort of behavior.”
“What sort of behavior.”
“Homosexual.”
“I flog people for that sort of behavior.”
“Well, Minister, I think you’re going to want to change your policy or your own practices.”
“You’re a quack!” His words exploded in a hacking cough. He doubled over.
“Minister, let me add it up for you. You haven’t responded fully to MERS treatment. You’ve got cognition issues and light sensitivity. Pronounced stomach issues, a lung nodule. All of that says to me that your immune system is compromised. On top of that, you sent your people out of the room when it was time to talk to me—”
“So.”
“Maybe nothing. Maybe that you wanted privacy. And I can see why, given the marks.”
“What marks?”
“You’ve got several areas of light purple skin on the back of your neck.”
“I’m getting older. It’s my skin.”
“You know the term quack, Minister, so I’m guessing you are also familiar with the term ‘hickey’?”
The minister glared at him. “This is a joke. Are you the best that the United States has to offer me?”
“I’m definitely not the best. But I have had my share of hickeys, and I’ve given a few too. I know what they look like. And I have seen my share of men die terrible deaths from HIV. Most of them contracted it through sex with other men.”
The minister clenched his jaw, now seemingly to calculate.
Back in the auditorium, Lyle leaned on the lectern. “Nothing special about the diagnosis. In fact, I suspect his personal doctor knew what it was and was looking for someone from the outside to take the fall. In the end, they left the official diagnosis as meningitis and gave the minister an antiviral cocktail that just happened to be the same thing they give for HIV.
“The minister died nine months ago. His condition wound up being widely speculated about. He also spent the last few years of his life intensifying his attacks on homosexual behavior. His rage at his own condition, his hypocrisy, amplified. I mention this, and the story, to impart a particular idea about pathologies, diseases. They are, in their own way, straightforward. They aim to kill an otherwise healthy body. They have a deadly agenda but they don’t hide it. Pathology is not duplicitous. It does not discriminate. It doesn’t choose. It is precisely what it represents itself to be. The same cannot always be said of people.”
At the edge of the stage, Emily, Lyle’s intern, tensed. Dr. Martin was out on that Dr. Martin ledg
e again, heading to parts unknown. In the back of the room, Dean Thomas had a similar but less generous version of the thought: The asshole is going to get rave reviews again, and for what, storytelling?
“Hickam’s dictum,” Lyle continued. “Patients can have as many diseases as they damn well please. Implicit in the phrasing is that people choose illness. This, of course, is utterly false on its face. They don’t choose. But they can reveal. Even inadvertently, often, in fact, inadvertently. I urge you, when you sit at the bedside, to think about the person, the individual. Consider his or her history, habits, as well as the larger context of culture, constituency, demographic. Think about what makes a person tick. What separates a good doctor from a great doctor, in my opinion, happens outside the pages of the book.”
In the back of the room, the man in the too-tight suit smiled. He thought, Dr. Martin is brilliant, just as advertised.
“Dr. Martin,” Emily called quietly. He turned to the side. She pointed to her watch. He nodded and turned back to the stage.
“Having said all that about going beyond the book, I’d like if everyone could read the next three chapters of infectious disease principles and practices. If there are any questions, I think we’ve got some office hours set up in the lounge.” A smattering of applause accompanied the sound of students standing, packing up, hustling on. Lyle could feel his heart working double time with the pulse of dehydration and still metabolizing sleep drugs, and from stress toxins left over from his fight with Melanie. He let his eyes wander to the dean and her guest. Whatever they wanted to talk to him about, he’d seen enough to know. Someone was dying.
Nine
Dean Thomas marched up the aisle, looking ever the headmistress. She made a beeline for Lyle. Trailing her, a foot behind, more measured, walked Michael Swateli, a Tanzanian attaché to the CDC. Lyle ignored the both of them and followed Emily to an adjoining conference room they sometimes used for office hours. It was antiseptic, just a rectangular table made of cheap wood and, on the wall, a whiteboard. A yellow sheet of paper tacked inside the door indicated the place was not to be used for study.
Nearly two dozen students showed up. Lyle sat on the edge of the table and the students mostly stood, a few taking the nearest chairs. The dean stood near the door, resigned that Lyle appeared to be going through with his office hours. She was in a bit of a tough spot in that she had just a few weeks earlier urged him to show up for all his obligations (by which she mostly meant his faculty obligations) and couldn’t now easily yank him from his scheduled office hours. Even though a foreign governmental official stood nearby with an urgent request.
“Mr. Swateli,” she said in a low voice, “I do think Dr. Sanchez could be a great alternative for you.”
“We had this conversation, Dean Thomas.”
“She’s respected without peer for her broad-based understanding of—”
“I’m happy to wait,” Michael said, putting it to bed.
In pushing Dr. Sanchez, the dean was genuinely suggesting a terrific clinician. But she had a low-level ulterior motive: the dean knew such a consultation might well irk Dr. Martin. Dr. Sanchez was by the book, the sort of scholar who privately blanched at some of Lyle’s more “creative” methods, and he, the dean guessed, was just as unimpressed by her. It would be nice to see something get under Dr. Martin’s skin.
On the other hand, as the dean stood there, she managed a feeling of genuine pride as the students asked Lyle their questions. This group, like all the graduate students at the UCSF medical school, were not just among the best and the brightest but were arguably the best, a pick of the litter that matched Harvard, Stanford, and the rest. One student, seated at the table, pulled from his backpack a white mask. He described it to Lyle as a new version of an N-95 respirator, which, generically, was one of a handful of field air-purifying respirators. But the student said his version, which he’d made in his spare time, did a better job at resisting degradation from industrial oils. Would Dr. Martin take a look?
“Not exactly my expertise—product design. But I’m happy to glance,” Dr. Martin said, turning the mask over in his hands. “Check with me next week. If I’m still alive, it worked.” Laughs. “Okay, anything else? I can see that if I keep Dean Thomas waiting any longer, I may be killed anyway.”
He looked around the room. It seemed the meeting was over when his eye fell on a student whose arm was half raised, as if she couldn’t decide whether to ask a question.
“What’s on your mind,” he encouraged.
“What about doctor-patient privilege?” Her voice sounded familiar.
“Sorry, I’m not sure I know what you’re asking,” Lyle said.
“You shared the story of the minister—in Saudi Arabia. What about privacy?”
Now Lyle placed the voice’s familiarity; it was the woman seated in the back of his lecture who had correctly shouted out “CT scan with contrast” in answer to a question Lyle had asked the audience: What procedure did the minister need?
Lyle studied the face belonging to the voice. Dark blue eyes and short hair, glasses with edgy frames.
“The minister is dead,” Lyle said.
“Does that matter?” Her tone seemed equally curious as pointed.
Lyle took it in. “It can. Societal concerns factor in. When weighing what to describe publicly about any medical issue, I ask myself: Does the disclosure serve a larger health-related purpose? Anything else, gang? As you can see the dean awaits.”
“That’s what the AMA says.” It was the woman’s voice again.
“Pardon?”
One of the other students said, “Sheesh.”
But the young lady, seeming to have found the full of her voice, continued undaunted. “The American Medical Association says doctors can disclose patient information following death if there is a societal benefit.”
“Right. Okay, so we’re on the same page . . .”
“Isn’t there another wrinkle?”
“I’m not following, Ms. . . .”
“Obviously your work is so much about the societal good, the big picture, and it requires you in some cases to divulge personal information. Y’know, to make a larger point. To, say, prevent an outbreak. I’m just wondering if that is truly necessary or if it can be done without . . .” She paused.
“Go on.”
She cleared her throat. “Bringing notoriety to yourself.”
“Oh, come on,” another student said.
“No, hold on. You know what?” Lyle smiled. He could feel a touch on his arm. Emily, his intern. Instinctively, she was trying to hold him back from saying something untoward. But he had no such thing in mind. “That’s a damn good question, you’re asking, Ms.-I-didn’t-catch-your-name, and a fair one. My answer is that the patient comes first and, then, would-be patients and, in the case of the story I told you, then the doctors who would serve them. I felt it was valuable to impart the story as a way to inform the doctors of the future. I sincerely hope I’ve made the right call in this case but I am never beyond reproach.” He had been looking around the group but, near the end of his explanation, let his eyes meet the woman’s glasses-obscured gaze. She blinked, losing her nerve.
“I . . . I think you did,” she stammered. “Thank you.”
“Keep asking good questions,” Lyle said. “You all could learn something from her.”
The students quickly departed. Dean Thomas, watching them walk out, could only shake her head at how Lyle had managed to turn yet another situation in his favor. Now the students would imbue Lyle with the characteristic of humility, of all things. In her view, he was humble like frozen yogurt was nonfattening—it’s what everyone let themselves believe but she knew better.
“Okay, Dean Thomas, you can see that I’m warmed up for your skewering,” Lyle said, turning to her. “Emily, thank you for everything today. Let’s chat over the next few days.” In this way, he dismissed his intern.
The dean made sure everyone had left the room.
&nb
sp; “Lyle, this is—”
“Michael Swateli.” The man extended a beefy mitt. Lyle took it and shook. “Impressive lecture. Your reputation as a clinician proceeds you, but I had no idea about your capacities as a presenter.”
Lyle studied the man’s eyes, the faintly lighter skin where his sunglasses had been, a residue of brown dirt beneath his thumbnail. “You were just there. How many days ago, or was it mere hours?”
“I beg your pardon?”
“Wherever you want me to go. You were in the midst of it. You had to borrow someone’s suit. A family member or someone formerly in your unit?”
Michael laughed. “Wrong about that one, Dr. Sherlock Holmes. It is mine or, rather, it was. I wore it for my own college graduation and I have since had much more food. But you are correct that I was there not very long ago. It is bad. Very bad. I only had time to race home to get this old suit and get on an airplane.”
“Tanzania?”
“You’ve been, I think.”
“Years ago with the CDC. Has high rates of albinism, twelve times greater, I think, than does virtually any other population.”
“Yes, yes. My green eyes. It is in here somewhere, as you can see,” Michael said. He looked down and Lyle understood why: time was wasting.
“Look, Mr. Swateli, I want to hear what’s going on. I also want to let you know that it’s a very busy time. Class and grant reports due and, chiefly, my wife and I have just gotten settled and—”
“Please, Dr. Martin,” Michael cut him off. He reached for the inside breast pocket of his too-tight suit and pulled out several pieces of paper. “Just look.” He unfolded the papers on the table. The pictures printed on them were grainy but clear enough. Bodies ravaged by disease. One showed a woman who looked like life had literally oozed out of her.
The dean cringed.
Lyle looked down and gritted his teeth. “I’m not sure that I can—”
“Dr. Martin,” the dean cut him off. “How can you look at this and not say yes. What’s going on with you?”
Lyle studied her. He tried to hold back his thoughts but he couldn’t. “Don’t pretend you give a damn, Jane. You’re only here because, what, there’s foreign grant money on the line, or who knows what.”