by Samuel Shem
6
At the end of three weeks, the Fat Man was TURFED out of the House of God to do a rotation at one of the neighboring community hospitals, what he had called one of "The Mt. St. Elsewheres." Although he would still be the resident on call with me every third night, in his fat wake came the new ward resident, the woman named Jo, whose pop had just leaped to his death off a bridge. Like so many of us in medicine, Jo was a victim of success. Growing up short and wiry, plain and tough, in adolescence Jo had ignored her mother's invitations to come out as a deb and had concentrated instead on biology, dissecting rather than attending balls. She first became a victim of success when she successfully annihilated her twin brother by getting into Radcliffe while he went off to some beerswilling football factory in the Midwest, a trombonist in the marching band. Her academic performance continued to accelerate through college, rocketing her into BMS at a barely pubescent age, her meteoric rise halted only slightly by her mother's all?American involutional psychotic break, which had had the effect of reducing her pop to a quivering jellylike mass. The disintegration of her family had intensified her medical achievement, as if by learning how to do a stellar rectal exam she could detect her family's psychological cancer. And so Jo had come to the House of God, and had become its most ruthless and competitive resident.
From the first day that Jo stood before us, feet apart and hands on hips like the captain of a ship and said, "Welcome aboard," it was clear that she was so different from the Fat Man that she would be a threat to all he'd taught us. A short, trim woman with clipped black hair, a jutting jaw, and dark circles under her eyes, she wore a white skirt and a white jacket, and in a special holster fastened to her belt was a two?inch-thick black ring notebook filled with her own transcription of the three?thousand?page Principles of Internal Medicine. If it wasn't in her head, it was on her hip. She spoke strangely, in a monotone devoid of feeling. If it wasn't fact, she didn't handle it. She recognized no humor. "Sorry I couldn't be here when I was scheduled to," she said to Chuck and Potts and me and the BMSs that first day, "but I had personal reasons for being away."
"Yes, we heard," said Potts. "How are things now?"
"They're fine. These things do happen. I took it in stride. I'm glad to be back at work to get my mind off it. I know you had the Fat Man for the first three weeks, and I want you to know that I do things differently. Do things my way and we'll get along swell. There's nothing sloppy about the way I run a ward. No loose ends. OK, gang, let's go make rounds. Get the chart rack, eh?"
Delighted, Levy the Lost leaped up to get the chart rack.
"With Fats," I said, "we sat here for rounds. It was relaxing and efficient?"
"And sloppy. I see every patient every day. There's a no excuse for not seeing every patient every day. You'll soon find out that the more you do in medicine, the better care you give. I do as much as possible. It takes, a little longer, but it's worth it. Oh, by the way, that means that rounds will start earlier?mix?thirty. Got it? Swell. I run a tight ship. No slop. My career interest is cardiology. I've got an NIH Fellowship next year..: We'll be listening to a lot of hearts. But listen: if there are any complaints, I want to hear 'em. Out in the open, got it? OK, gang, let's cast off."
There was no way that Chuck or I would show up for rounds an hour earlier than we had been showing up for rounds. We followed Jo as she marched out of the room with that fanaticism known only to an overachiever, one who lives with the eternal fear that soma lurking underachiever will, in a flash of brilliance, achieve more. As we wheeled the chart rack into and out of the room of every one of the forty?five patients on the ward, with Jo examining each one and then shooting off a lecture from the transcription holstered on her hip, telling each of the terns what he had forgotten to do, I felt a growing apprehension. How could we survive her? She went against everything Fats had taught. She would work us into the ground.
We came to the room containing Anna O. Looking through the chart, Jo went in and examined Anna, despite the Wing of Zock jackhammers, focusing on Anna's heart. As Jo listened and poked and prodded, Anna grew more and more resentful and cried out:
ROODLE ROODLE ROOOOO?DLE!
After she'd finished, Jo asked me what the most important part of Anna's care was.
Thinking of the Fat Man's LAWS, I said, "Placement."
"What?"
"PLACEMENT COMES FIRST."
"Who taught you that?"
"The Fat Man."
"That is baloney," said Jo. "This woman is suffering from a severe senile dementia. She's oriented neither to place, time, nor person, all she says is ROODLE, she's incontinent, and confused. There are several treatable causes for dementia, one of which is operable brain tumor. We've got to work it up completely. Let me tell you about it."
Jo shot off a lecture on the treatable causes of dementia, filled with obscure neuro-anatomical references that brought back to me a story I'd heard about her and an anatomy exam at the BMS. The exam had been impossible, the average score forty?two, and Jo had made ninety?nine. The one question she'd missed was to "identify the Circle of Polgi," which turned out to be a trick question, the said Circle being the traffic island situated just outside the front door of the BMS dorm. Jo's lecture on Anna was crisp, complete, coherent, and cohesive. She finished, looking as if she'd just had a satisfying bowel movement.
"Start ordering the tests," said Jo to me, "we're really going to work this up. Completely. No, one's going to be able to say that we do sloppy work."
"But the Fat Man said that Anna O. is always like this, and that in a ninety?five?year?old, dementia is normal."
"Dementia's never normal," said Jo, "never."
"Maybe not," I said, "but the Fat Man said that the way to treat her is to do nothing except try like hell to find a new bed at the nursing home."
"I never do nothing. I'm a doctor, I deliver medical care."
"The Fat Man said that for gomers, doing nothing is the delivery of medical care. If you do something, he said, you make everything worse. Like Potts hydrating Ina Goober?she's never recovered from that."
"And you believed him?" asked Jo.
"Well, it seems to be working with Anna," I said.
"You listen to me, smartass," said Jo, amazed and threatened. "One?the Fat Man is nuts; two?if you don't believe me, ask anyone else in the House; three?that's why they wouldn't let him start with the new terns; four?I'm the captain of this ship, and I deliver medical care, which, for your information, means not doing nothing, but doing something. In fact, doing everything you can, see?"
"Sort of. But Fats said that was the worst—"
"Stop! I don't want to hear it. Do the work?up for treatable causes of dementia: LP, brain scan, bloodwork, skull films. Do it all, and then if it's negative, then talk to me about placement. Ridiculous. All right, gang, let's shove off and move on. Next?"
We sailed through Rokitansky, Sophie, Ina with her football helmet that Jo removed, the sick Dr. Sanders, and all the rest, almost all of whom wound up with some hitherto undetected cardiac disease, Jo's specialty. We finished just outside the door of the Yellow Man, at the border of the domain of 6?North. Even though he was not our patient, Jo had to have a look at him. Coming out, she turned to Potts and said, "I heard about this case. Fulminant necrotic hepatitis. Fatal unless you catch it early and use steroids. Let me tell you about it."
She blasted off with her lecture on the disease, oblivious to the pain on Potts's face. She finished, said she would photocopy references for us, and left to tell the Fish and the Leggo, on their rounds, about our rounds. Somehow she'd managed to deflate each of us. She'd left something in the air, something tight and heavy and gray, a stomach churning in the leap down toward the water from the bridge.
"Well, she sure is something else than Fats," said Chuck.
"I miss him already," I said.
"Seems like everybody knows about the Yellow Man," said Potts.
"Do you think I should do the dementia work?up on Anna O.?"
"Don't look like you got much choice, man."
"The Fat Man was never wrong, not once," I said.
"I don't think there's anybody in the whole worl' who knows more about the gomers than Fats," said Chuck. "He was a cool dude about these gomers. Be cool, Roy, be cool."
Prodded by my fear of missing something and being haunted by it as Potts was haunted by the Yellow Man, in the first weeks with Jo I did what she suggested. I ordered every test I could think of on every patient I had, and I wrote down everything in the charts. With Jo's help, I even wrote down references, in footnotes. The charts soon looked terrific, BUFFED to a fine shine. The House Slurpers like the Fish and the Leggo took a look at the shiny BUFFED charts and their faces lit up with fine and shiny smiles. BUFF the chart, you automatically BUFF the Slurpers. Not only that, but I soon found out that the more tests I ordered, the more complications there were, the longer the House kept the patients, and the more money the Privates collected. BUFF the chart, you automatically BUFF the Privates. Jo was right: the.more you did, the more you BUFFED the doctors.
The hooker was the patients, especially the gomers. About the gomers Jo was dead wrong. The more I did, the worse they got. Anna O. had started out on Jo's service in perfect electrolyte balance, with each organ system working as perfectly as an 1878 model could. This, to my mind, included the brain, for wasn't dementia a fail?safe and soothing oblivion of the machine to its own decay? From being on the verge of a TURF back to the Hebrew House for the Incurables, as Anna knocked around the House of God in the steaming weeks of August, getting a skull film here and an LP there, she got worse, much worse. Given the stress of the dementia work?up, every organ system crumpled: in a domino progression the injection of radioactive dye for her brain scan shut down her kidneys, and the dye study of her kidneys overloaded her heart,, and the medication for her heart made her vomit, which altered her electrolyte balance in a life-threatening way, which increased her dementia and shut down her bowel, which made her eligible for the bowel run, the cleanout for which dehydrated her and really shut down her tormented kidneys, which led to infection, the need for dialysis, and big?time complications of these big?time diseases. She and I both became exhausted, and she became very sick. Like the Yellow Man, she went through a phase of convulsing like a hooked tuna, and then went through a phase that was even more awesome, lying in bed deathly still, perhaps dying. I felt sad, for by this time, I liked her. I didn't know what to do. I began to spend a good deal of time sitting with Anna, thinking. The Fat Man was on call with me every third night as backup resident, and one night, searching for me to go to the ten o'clock meal, he found me with Anna, watching her trying to die.
"What the hell are you doing?" he asked.
I told him.
"Anna was on her way back to the Hebrew House, what happened?wait, don't tell me. Jo decided to go all?out on her dementia, right?"
"Right. She looks like she's going to die."
"The only way she'll die is if you murder her by doing what Jo says."
"Yeah, but how can I do otherwise, with Jo breathing down my neck?"
"Easy. Do nothing with Anna, and hide it from Jo."
"Hide it from Jo?"
"Sure. Continue the work?up in purely imaginary terms, BUFF the chart with the imaginary results of the imaginary tests, Anna will recover to her demented state, the work?up will show no treatable cause for it, and everybody's happy. Nothing to it."
"I'm not sure it's ethical."
"Is it ethical to murder this sweet gomere with your work?up?"
There was nothing I could say.
"Well, then, there you are. Let's eat."
During the ten?o'clock meal I asked Fats about Jo. He became somber and said that Jo was terribly depressed. He thought of her as he thought of the Fish and the Leggo and many other Slurpers: terrific medical texts lacking in common sense. They all shared the belief that disease was some wild and hairy monster to be locked up in the neat medical grids of differential diagnosis and treatment. All it took was a little superhuman effort and all would be well. Jo had dedicated her whole life to that effort, and she had little energy for anything else. Her whole life, Fats said, was medicine:
"It's real sad, and everybody knows it. Jo's been preparing for this moment as ward resident for years, and now it's arrived and she's bound to make a hash out of it. She needs these patients so badly to fill up the emptiness of her life that she comes in on Sundays and on her nights off. She never feels needed except when she imagines that her terns or her patients need her, which they don't, because she's such a klutz when it comes to practical?medicine and human contact. The most important treatment for Anna O. would be to find her lost eyeglasses. Jo should go into research, but she knows that if she did, it would confirm what everybody else knows already?she can't deal with people."
Thinking of Berry, I said, "You sound like a male chauvinist."
"Me?" asked Fats, genuinely surprised. "How?"
"You're saying women like Jo make lousy doctors because they're women."
"Nope. I'm saying women like Jo make lousy people because they're doctors, just like some men do. The profession is a disease. It doesn't care what sex you are. It can trap us, any of us, and it's pretty clear that it's trapped Jo. It's awful. You should see her apartment?it's like no one lives there. She's been there over a year, and she still hasn't unpacked her stereo."
We sat in the gloom of Jo's trapped life, each chewing on it, until, finally, it went down, and Fats, brightening again, said, "Hey, did I ever tell you about this dream of mine, the Invention?"
"Nope: "
"Dr. Jung's Anal Mirror: the Great American Medical Invention."
"Dr. Jung's Anal Mirror? What the hell is that?"
"Don't you remember in medical school during the gastroenterology course they told you to 'examine your own anus with the aid of a small mirror'?"
"Yeah."
"Were you able to do it?"
"Nope."
"Of course you weren't. It's impossible. But not with the aid of Dr. Jung's. Anyone can examine his or her very own anus in the comfort and privacy of the home."
"What the hell is it?" I asked, caught up in the joke.
He showed me what it was. On a napkin he drew a complex and intricate combination of two reflecting mirrors and a large focusing lens all fastened together on adjustable stainless?steel rods. He drew the pathways of the light rays from the anus to the eyeballs and back, splitting it into colorful rainbows and sophisticated spectra which he elaborated with multivariate complex equations and graphs. Finishing, he said, "Do you know how many Americans each day have painful bowel movements and blood on their toilet paper or in the bowl? Millions."
"Why just Americans?" I joked. "Why not the world?"
"Exactly. The only problem is translation. If it's millions in America, it's billions in the world. The anus is a great curiosity to almost all mankind. Everyone would like to see it, but no one can. Like darkest Africa before the missionaries. The Congo of the body."
The hairs on the back of my neck tingled as I started to think that this might not be a joke, and I said, "You're joking."
The Fat Man did not reply.
"This is the most ridiculous idea I've ever heard."
"It's not. And besides, that's always what they say about great inventions. It's like those vaginal mirrors that gynecologists are passing out?oh, by the way, you can adjust the Anal Mirror to look in there too-women are using the vaginal mirrors to get to know their vaginas. This is a unisex device. GET TO KNOW YOUR ASSHOLE." Spreading his hands apart as if reading a bumper sticker or a marquee, Fats said, "ASSHOLES ARE BEAUTIFUL. FREE THE ASSHOLES. The potential in human and financial terms is immense. Big fortoona."
"This is outrageous."
"That's just why it will sell."
"But it's a joke, right? You didn't actually make an anal mirror?"
The Fat Man looked distractedly out into thin air.
Feeling
queasy, I said, "Come off it, Fats," and I pleaded with him to tell me the truth. It was so preposterous that it might just be real, and over the past ten years whenever?I'd estimated what was fantasy in America?from Jack Ruby's blasting Lee Harvey Oswald's guts all over the insides of the TV tubes of America, to the brown paper bags of money delivered to Spiro Agnew in his vice?presidential chambers?I'd been wrong, dead wrong, and had always underestimated, falling far short of the absurd, which had inevitably turned out to be the real. "Come on, Fats," I shouted, "tell me the goddamn truth! Do you mean it or don't you?"
"Do I?" Fats seemed to awaken from his reverie, and composing himself, said, "Oh, of course I don't, do I? I mean, no one would think seriously of anything as crazy as that, would they? Just remember, Basch, about Anna and the other gomers: BUFF the charts, and hide it from Jo. See you later."
I tried it. I decided to go all out on Anna O. and do my best to do nothing. Teetering on that barren precipice above the long leap down to death, Anna was put into a holding pattern governed by LAW NUMBER ONE: GOMERS DON'T DIE. Finally, one day, as I passed by her room I heard a healthy demented ROODLE! and my heart swung around on its apex with pride and I knew that Anna was back and that I had proved scienterrifically that, just as Fats had said, to do nothing for the gomers was to do something, and the more conscientiously I did nothing the better they got, and I resolved that from that time on I would do more nothing on the gomers than any other tern in the House of God. Somehow I'd find a way to hide my doing nothing from Jo.