Greg stops abruptly. I slam into him. He almost slams into the person in front of him, and a line of doctor dominoes almost goes down. “Sorry,” I say, but he doesn’t answer because we’re in silence.
Mick tells us to start walking again. This time I’m more careful. I do notice my breathing. I wonder whether the person behind me is staring at my ass. I hope not. To hell with them if they are. I hear my grandmother’s voice, warning me every time she saw me enjoying a cookie when I was a kid that if I ate too much, I’d get an ass like my auntie’s. I wasn’t even old enough to understand what she meant. Was it a comes-in-the-mail kind of thing, or more like that time she woke up with shingles?
Bring the mind back.
Make the mind great again.
Mick tells us to stop in front of our cushions. I try not to look at Jodie again lest she think I’m a weirdo. We’re sitting back down, and I tuck my legs in, balancing on the half-moon pillow in the middle of the big cushion.
We sit for a few minutes longer. Then Mick surprises me by reading a poem.
Start close in,
don’t take the second step
or the third,
start with the first
thing
close in,
the step
you don’t want to take.
Did Mick write that himself?* It’s pretty good. He reads it twice, in case anyone was too dumb to catch it the first time.
Do I have a first step I don’t want to take?
I can’t answer that question. I notice how the long, thin windows above Mick and Ron are filling with light, changing colour, yellow, then pink, like urine test strips.
That’s gross, Horton.
What would it be, this step I don’t want to take?
Finding a way back into my life? I don’t even know what that means. Or if that’s possible.
Is it possible?
I sort through the thoughts as they come to me in the silence. Some are only half formed.
Something about Wendy, shadowy. Something about medicine, a kind of black-hole feeling tugging me along with it. Writing. Something about writing. All that old cesspool with food.
Forgiveness. Something about forgiveness. That’s the spot. Like finding the tender point on the abdomen, when a patient suddenly winces, pulls back, everything tightening involuntarily. That spot is where the money is. I’m doing that, inside, as I land on that word.
Who do I need to forgive?
It can’t just be the students. They’re only the last mile on a long journey.
Mick, I’m going to fail this test. But I know you’re onto something, because I’m super uncomfortable, and it isn’t just because my quads are getting necrotic from sitting like a pretzel for thirty minutes.
That’s when Ron rings the bell, which means we’re done, for now. The metallic note lingers in the air. Like one more unanswerable question.
8
The Nausea
Let me get something out of the way.
It’s Toronto, and the year is 2000. It’s one of the hottest summers on record. Garbage is piled everywhere on curbs, and the city stinks like an inhospitable planet. I’ve just moved here from a medical school run by brilliant, optimistic hippies, and now I’m at an institution whose culture, rumour has it, eats hippies for breakfast.
I matched to a program in internal medicine. I chose internal because I liked its complexity. I had come within a hair of choosing pediatric neurology, but fortunately at the last minute I seemed to recognize there was a pathology in that choice, a way in which it was too close to something I couldn’t name or bear to constantly relive for the next forty years.
I don’t know many people here. I spend the first few weeks couch-surfing, because my living arrangements have fallen through catastrophically. I make one resident friend in the first few weeks, Todd, who is from the West Coast and critiques everything I wear. He has come up with a motivational mantra he chants into my voicemail every time I don’t pick up the phone: Our lives suck.
Residency is really tough—terrifying, actually. I’m rotating through a lineup of massive downtown teaching hospitals, each one bigger than the next. At Mac, people were pretty calm. My new colleagues seem like they’re on amphetamines.
We start our days with an exercise in humiliation and dominance: morning report. At my first new hospital, this standard-practice spectacle is led by an old Dutch physician lauded by the local internal medicine residents as an institution. He sits at the head of a huge oblong table. The chief resident begins by telling the Dutchman about a challenging or interesting case on the internal medicine service. Then the Dutchman, beginning with the student on either his left or right, asks questions about the case. So, if you sit next to him on his right, you have a 50 percent chance of getting his first question, which will usually be fairly basic—in which case, you’ll probably be spared looking like an imbecile. But if he starts on the opposite side, you have a 50 percent chance of getting one of the questions that comes after he has worked his way around the table—and those questions are likely to be incredibly specific. If you’re unlucky enough be on the wrong side of that table, and the Dutchman asks you a question that you not only can’t answer but might never be able to answer because it is so esoteric and abstract, a long, ominous pause will ensue. That silence speaks for itself. It tells everybody in the room what you really are: an imposter.
Is it any wonder that one day, sitting in those rounds, I have a stomachache? And then again the day after that? The free muffins and coffee and fruit, all laid out like a recurring last meal: none of them tempt me. Day by day, I get more nauseated. I’m doing a thirty-hour in-hospital call shift one-in-four—every fourth night—and when I’m not on call, I’m so wired from residual adrenalin I can barely sleep. Patients here are really, really sick. The other night somebody bled to death in front of me, a column of red spurting out of their mouth like Old Faithful. The ward is my personal version of Vietnam, and I don’t know who to talk to about it. I can’t worry my family. I don’t have friends here yet besides Todd. And I’m not about to risk making any of the faculty think I can’t handle the pressure.
So one day, in the hall, because I don’t even have a family doctor and I think maybe I have an ulcer, I timidly ask the Dutchman if he could see me. He tells me to come by his office the next day. His nurse ushers me in. I put on a paper gown for the exam. The Dutchman asks me some questions. He pokes at my abdomen. He says kindly that everything looks good, and I’m probably just buckling under stress. He tells me if I lost ten pounds, my weight would be perfect for my height. Then he says something about family medicine residency being very stressful, and when I correct him and say I am an internal medicine resident, I’m fairly sure his face registers surprise.
Why would he be surprised? The answer comes to me as I’m shedding the stupid paper gown and slipping back into my clothes. He is surprised because internal medicine residents usually know more in internal medicine rounds than family medicine residents, and he’s remembering my silence around the table. I’m sure of it. He’s seen right through me; he knows the truth about me. I don’t belong here, the home of the discovery of insulin, walking in the shadows of Banting and Best. I’m not one of the best. I’m the idiot who can’t even remember how to write an order for an insulin infusion or peritoneal dialysis, the same one who panicked last week and blurted out something about a fire ant when the Dutchman was going around the table, asking us for increasingly obscure differential diagnoses of a kind of skin lesion I couldn’t even pronounce. One summer I learned half of Bach’s Goldberg Variations by memory in less than seven days, the next half the following week. Every note, thousands of them, by memory. There’s no way any of the people at the rounds table could do that. There’s no way the Dutchman could do that. But now, I’m the girl who can’t even remember where the nurses keep the tongue depressors, no matter how many times they show me. And all I can see is the look on the Dutchman’s face, my memory of hi
s expression more incredulous and further from reality each time I recall it.
Thereafter, in morning report, I developed a kind of neurotic feedback loop. No matter where I was seated at the table, I would think to myself, I’m not going to know the answer. It became impossible to muffle that screaming, accusatory voice, even though on the wards I actually seemed to be taking pretty decent care of patients and had kind of figured out what to do when someone was having chest pain or seizing or just needed a few kind words in moments of pain or existential crisis. At McMaster, I was relaxed, invigorated and valedictorian; the residents had called me “super-clerk.” Even when I was tired and post-call, I still radiated an inner joy and confidence, a feeling of being among my people and doing something I wanted and needed to do.
But something had snuffed out that light. The tree the Dutchman had unwittingly planted was a barbed, poisonous invader. I lost confidence. I perseverated. I couldn’t shut off an alarm that was sounding constantly, telling me London was burning. The Dutchman said there was nothing the matter with me, but I had a problem that was about to take a much more serious turn.
Camus knew when he wrote The Nausea that it wasn’t just a physical symptom but rather a state of mind—a deep affliction, both emotional and physical. I began to suffer nausea from the time I woke up in the morning to the time I lay down for bed. I tried manipulating my diet. I cut out dairy, then gluten, even before gluten was declared an enemy of the people. I boiled ginger root and drank it as an elixir. I tried acupuncture on myself with a small-gauge IV needle, so my arm looked like I really had been bitten by a fire ant. I took Gravol, rendering me barely able to stay awake during even the regular twelve-hour days, let alone the ones that spilled over to thirty. I tried eating less. Then less still. And then, by accident, I discovered that I am one of those people who feels excellent when I eat very little, and that I feel even more excellent when I eat almost nothing—all the inconvenience, light-headedness, obsessiveness and unnatural weirdness associated with eating next to nothing outweighed by the total relief of low-grade starvation-induced chemical euphoria. Somewhere, in the back of my mind, I must have remembered that the Dutchman had given me a hint. There was at least one way I could be perfect.
That was my emergency switch. I had only been a doctor for six months when I discovered it. Soon I was hitting that switch literally all the time. On call? Don’t eat anything. Home alone and worried about tomorrow’s exam? Bed without dinner will take care of that. The need for relief got bigger, I got smaller, and soon the whole thing had evolved into a situation I couldn’t really recognize, because I was walking around in a state of semi-starvation, looking more like a coked-out Ralph Lauren model than a person who should be running cardiac arrests at one of the biggest hospitals in Canada.
I read about this all the time, and you probably do too. Women and the odd gay or straight man, often artists, sometimes academics, interviewed about their most difficult years, saying something coy, like “I was taking terrible care of myself. I’d drink coffee and eat a stick of Juicy Fruit, then go to the gym for three hours.” Sweethearts, that’s not just taking terrible care of yourself; that’s an eating disorder. Somewhere in the next paragraph, a nod to the current state, which involves being a suspiciously angular yoga instructor/keto-vegan/Iron Man or Woman. This is gaslighting. It’s scattered throughout all age groups and professions, a tweetable insta-scam.
Occasionally, during my years as associate dean, a student would come into my office, rail thin, mood a little too elevated, with a too-bright smile, yet bringing a shadow into the room. I’d know that shadow anywhere. I’d feel a tightness in my chest as I watched her contort her body in the chair across from me, could almost inhabit her rising panic about jeans too tight, hip bones not palpable enough beneath what she was convinced was a thick layer of subcutaneous fat. She had painted herself into the corner of the attic, and now had to choose. Stay put, or ruin the masterpiece.
Looking back through the prism of the curse of knowledge, I was such an excellent candidate for an eating disorder. The only remarkable thing is that it emerged so late. The tendency to play the piano until I couldn’t feel my fingers. The desire to always do my part, to never give anybody anything to worry about. The inability to label situations correctly, or my own feelings correctly, because my own feelings had to be carefully managed, contained, needed their own handler. I could look almost anybody in the eye and say I was perfectly fine in a withering voice that made them feel stupid for even asking. My residency was drilling into me that the needs of every single person in the hospital were more important than mine. I would do anything for anyone; the worse their circumstances, the more I rose to the occasion. But the one person I seemed totally unwilling to help was myself.
Why was that so difficult for me? The literature tells us that siblings of children with disabilities often experience lasting challenges of their own. There’s a storybook version of that life, one I used to tell every time someone handed me a microphone. My sister’s my hero. My parents are my heroes. I’m so lucky my siblings are disabled, because it made me who I am. There’s a current of truth in that version, an alternate, more meaningful life of service I get to live as a result of those things, different than the life I might have had without it, a way in which we are christened in flames. But good/bad or blessing/curse is hardly the whole story. I was a classic dichotomous thinker, another thing that made me a top-tier candidate for a top-tier eating disorder.
What might my residency, my life, have been like without the full-time job of hiding a secret vice? Why, instead of walking past the eating disorders clinic, cowering behind the ID badge that said I was a doctor, didn’t I walk right in? Part of the illness is you don’t believe it’s an illness at all. No matter how many warning lights are blinking, you don’t see a problem. You don’t open your mail for months. Then one day, your heat goes off, but you never make a connection between these things. That’s what it was like for me. I couldn’t see why I needed to cross into that waiting room, couldn’t think of a reason why this problem was even a problem, or why it would be worthy of anyone’s attention.
How did I get over it? There were fits and starts, flares and times when it faded into silence because other things drowned it out, and eventually, down the road, a psychiatrist who listened for long enough to ask the right questions, the ones I’d been avoiding for most of my life, and helped me find the right answers. It still flares sometimes, very occasionally, the way a bum knee acts up when you push it too far. I’ve retreated to it during times of total emotional overload, just the way you might go back to a bad relationship in a moment of extreme vulnerability. But I’m mostly done with it, and vice versa. I like euphemisms; I like saying I struggled. But what I was really struggling with was a void in my life, a pre-existing hole that the soul-crushing aspects of being a doctor continued to probe and excavate for years. All these things were related. One devil hand-feeding another.
Early on, there was one epiphany. In the years that followed I would come back to it, examining it from different angles the way you inspect something you’ve had for a long time when you’re trying to decide whether it is worth keeping. It came like a vision, a few years into the whole mess. I was post-call, walking home through a park. I stopped suddenly in the middle of a rundown playground, sat on the edge of a rusty slide. I saw it so clearly in that moment. All the starving and exercising, obsessing and organizing my life around food: none of that was going to change anything. It was all just palliation, self-medicating, like numbing pain with booze or drugs. None of it would restore my sister to her former glory; none of it would put the piece back into my family’s life that was obliterated before I was even born, and none of it would change one bloody thing. I glimpsed the truth in that moment, but I wasn’t ready to let that truth into my life. And I wish things hadn’t gone on for so long, or gotten quite so out of control, because I don’t get to go back and do another take of those prime years of my life when I
was renting out a lot of my best cognitive real estate to a tenant I didn’t know how to evict.
My dad used to say, you can’t turn back the clock, not even one second. When I was growing up, it had always seemed like a platitude. But I would come to see it as a sacred truth, a simple truth that can take us our whole life to apprehend: we are never, ever going back.
* * *
RIGHT AT THE start of this madness, in the first several weeks of my residency when I felt I was just barely keeping my head above water, my staff physician stopped me on the ward and asked if we could meet later that afternoon. He wanted to give me some feedback about my performance on the rotation thus far. I went through the next few hours in a daze, staring at blank pages in charts I was supposed to be filling with notes. He’s figured out I don’t know anything, I thought miserably. He knows I’m an imposter. I tried to think of what I’d say, how I’d justify my performance, whether it was still possible for me to salvage my career. How would I tell my parents? I had loans to pay. I’d never get another full scholarship to Oxford. I had come so far, all of it for nothing.
I was practically trembling when I went to his office, knocked timidly on the door, sat down, my gaze settled on the floor. My eyes were seconds away from filling with tears as I awaited the inevitable blow. He knew the truth about me; I would confess to it all. I opened my mouth to apologize. Mea culpa.
Before I could say anything, he clapped me enthusiastically on the shoulder. “First month is almost over, and things are going great!”
There was a long pause.
“They are?” I said quietly.
“You’re a star, Jillian. You’re chief resident material.”
We Are All Perfectly Fine Page 5