The second thing was my brother. He has a way of appearing when I need him. (The “way” is by receiving my panicky, tearful phone calls, buying a thousand-dollar ticket to fly from Alaska to Texas, giving up a couple weeks of work, and installing himself on my couch.) He stayed through two of the worst weeks, quietly cooking Vietnamese food and hanging out with my neighbor, Alyssa.
The final thing, and the thing that actually saved me, was that the school year ended. The year ended, and I turned down a scholarship to go to Colombia and work with a family physician for a month. The professor who had recommended me for the scholarship was shocked when I told her. “You may never have a chance like this again,” she said. “To go abroad with everything paid for. It’s special.”
But I knew I was in no place for that, and I think the decision I made was life affirming. Instead of going to Colombia, I cleaned my apartment as best I could and went to Chicago to stay for a month with my best friends Delaney and Ryan. We would cook together in the evenings, and I started writing again, resurrecting a children’s book project I had begun before medical school. Gradually, I came back into myself. One night I told Delaney what I had realized about death—that my desire to die was durable, not a symptom of depression but a part of myself. She listened quietly, then said, “No. I don’t think that’s right.”
Delaney had known me for many years. I started to insist, but when I reached down into myself to resurrect that conviction, it was gone.
I write about this here because I think it’s important to share. Medical students and physicians have high rates of suicide. Male physicians are about 1.4 times more likely than their nonphysician counterparts to die by suicide, and female physicians are 2.3 times more likely.*Medical students and residents are particularly likely to be depressed; studies have found that as many as 30 percent of medical trainees may screen positive for depression on a questionnaire. But depression is not a thing that we like to discuss—at least not when it comes to ourselves.
To do so, in fact, makes us professionally vulnerable. When you apply for a medical license in some states, you have to report whether you’ve been under psychiatric care. If you’ve been on medications or been seeing a psychiatrist, this admission can delay your licensure. The reporting requirement is meant to protect patients from impaired physicians, but in fact, it works the other way: By discouraging us from seeking psychiatric care, it makes both us and our patients more vulnerable. It drives a suicide-prone population away from the help we may need.
WHILE I WAS IN CHICAGO, Alyssa went over to my apartment twice a week to water my plants. One day she texted me, “Who’s taking the plants?” I told her that I didn’t know, and she sent me pictures: the pots were still there, but my three small basil plants had disappeared.
The next week, my last plant—a three-foot-high pencil cactus—disappeared in the same way. It was a mystery. With the plants gone, Alyssa stopped going over.
When I got back from Chicago, the mystery was solved. I opened the door of my apartment to find that the place was absolutely covered in rat shit. I looked across the nasty floor, and over at the pot where my pencil cactus had stood. My plants have been eaten by rats, I realized.
The apartment smelled rank, and as I walked in I felt a wave of shame. I was back in Galveston, back in the lonely apartment where I had become so depressed. I was no longer a writer, but doomed to be a medical student. I seemed so successful on the outside, but I knew that I was a failure in the one way that mattered most to me as a human being, because I had given up on writing and myself. Now, a plague had come.
I put down my luggage and went straight to bed.
That night, I dreamed of Frank. I was back in the auditorium at Portland State, where our physics class had been. It was the first class I had returned to after he died, and I recognized my Portland friends in the seats. I went from friend to friend, saying hello, grabbing their hands, but they each turned away from me, silent. It was as if they could not see me. I went to sit in the back, and Frank was next to me. I realized why he was the only one who could see me. “How could you do this, Rachel?” he said. “You’ve made a horrible mistake.”
I was awakened from my dream by a loud banging sound. I lay in my bed for a minute, and the banging did not recur. So I got up, because I had to go to the bathroom. I walked through the dark apartment to the kitchen, and when I got there I heard another loud bang. I reached toward the shelf where the light switch was. When it came on, three huge rats jumped off the shelf. As they went, they knocked another can off the shelf—bang. They ran into the bathroom.
Clearly, I could not go to the bathroom. So that is how I began my second year of medical school: barely recovered from depression, pissing in the kitchen sink of my rat-infested apartment.
The dream had done its work, however. Within two weeks, I left that apartment. I started classes again, and began going back to St. Vincent’s. That was when I met Mr. Rose.
* Matthew Goldman, Ravi Shah, and Carol Bernstein, “Depression and Suicide Among Physician Trainees: Recommendations for a National Response,” JAMA Psychiatry 72, no. 5 (2015): 411–412.
CHAPTER 9
AT OUR FIRST VISIT, I LISTENED TO MR. ROSE’S STORYTELLING. He told how he had worked on cars, been on a ship in the Merchant Marines, and how his cousin’s little baby was doing. My life, in comparison—my books, my short white coat, my bike commute from home to the library and back again—felt pretty dry. And anyway, there was plenty of time to talk with him. We sat in one of the exam rooms at St. Vincent’s, hearing the thumps and shouts of a basketball game on the court outside the window as we talked.
I’d picked up Mr. Rose’s chart because he was a first-time patient, and I knew I’d get to do a whole social history and family history and a complete physical. Doing those things is good practice, and you always learn a lot. I was a second-year medical student so I was short on information but long on time, and we could sit in the exam room for a solid hour and a half while Mr. Rose told me about his pain.
The pain was nonspecific—that is, it wasn’t clearly coming from the liver, or the pancreas, or the stomach, or anywhere. He’d had a couple of tarry, black stools—an ominous finding that suggests bleeding in the stomach. And he’d had some constipation, and he felt as if food got stuck in his throat, and he had a few other symptoms. His eyes were yellow, and his urine stank. It seemed everything was wrong, but none of it pointed clearly to anything. I asked about general symptoms—fatigue or weight loss—and he said he wasn’t sure about his weight, but he figured he’d lost some from not eating. He used to weigh four hundred pounds. Then he lost one hundred pounds in one year, his diabetes resolved, and he somehow slid off the patient list at UTMB. He hadn’t seen a doctor since then—four years ago. Somebody at his sister’s church recommended St. Vincent’s.
So I did everything I knew how to do. I did a full physical exam, noting that his belly was taut with fluid. A swollen belly suggests liver problems, so I spent a while asking Mr. Rose about things that can lead to liver disease: IV drug use, foreign travel, sexual activity, and transfusions—all of which can put you at risk for a hepatitis virus. Other drugs, herbs, or medicines. And, of course, alcohol.
Mr. Rose wasn’t much of a drinker. His father had been a lifetime alcoholic who died of cirrhosis of the liver, so he knew what that looked like. “I drink,” he said, “but not like him.” I pressed him on the issue, and he said he’d have two or three beers at a time, once or twice a week. But that was before the pain started. Since the pain began, he hadn’t been drinking at all.
The physical exam was very thorough, because the doctor volunteering that day had told me, “This is your chance to learn. At St. Vincent’s, you need to lay hands on every single patient. You’re going to see things here you won’t see anywhere else.”
I laid my hands—the hands of a second-year medical student—on Mr. Rose. His belly was tender all over, but on the upper left side it was exquisitely tender. Pressing on
it caused so much pain that he moaned and, as if involuntarily, pushed my hands away. So I didn’t press too hard right there. I was too tender myself, at that time, to know that a doctor must steel herself to press the hardest exactly where it hurts.
I checked his blood sugar and his heart rate; I tapped out the span of his liver; I pressed on his ankles and looked at his palms. I took a sample of his blood for labs. It took me three tries with the needle and I raised a bruise on his inner elbow, but he didn’t complain. He just looked at me in that quizzical way, with one eyebrow up, and said, “Doc, you sure are a student.”
On the scale in the hallway, Mr. Rose was shocked to note that he had lost twenty pounds.
“When did you last weigh yourself?” I asked. A month ago, he’d weighed himself on the scale at the liquor store. Now that caught my attention, because he’d told me he never drank much, and hadn’t been drinking at all since the pain began. So I asked him again about drinking. And he said no, he just walked up there with his cousin, and they have a scale you can use for a quarter.
That is one of the moments I think back to, in trying to figure how this story went awry: Mr. Rose standing in the hallway in his socks, talking about the scale at the liquor store. When I reported to the attending, I mentioned it. It introduced a note of skepticism, a nail on which we could hang a little mistrust.
Rapid, unexplained weight loss is a very bad sign, and it should have made us suspect cancer. But in this particular case, the attending physician was led to suspect alcoholism, instead. The detail about the liquor store scale took on more meaning than the weight itself. Even at St. Vincent’s, where our mission is to care for the uninsured, it so happens that medical providers can have a hard time trusting a homeless African American man—a poor historian—when he says he doesn’t drink. Not to mention his swollen belly. Or the scale at the liquor store.
ON THAT FIRST VISIT, I made a mistake. Mr. Rose had said his urine stank. So a fourth-year medical student named Chandler, who was directing St. Vincent’s, told me to get a urine sample and do a urine dip. And I did. A urine dip is the simplest of lab tests. I walked to our little hallway laboratory with the urine sample, and followed the instructions on the bottle of test strips: you dip one in the urine, let it sit for sixty seconds, and then compare the little colored boxes on the strip with the example boxes on the side of the bottle.
When I checked Mr. Rose’s strip after sixty seconds, every single value was abnormal. The strip said there was blood in the urine, ketones, and protein, and the pH was wrong. Surely I had messed up this test? They couldn’t all be abnormal. I wrote down the results, then poured out the rest of the sample.
It stank so badly that I retched over the sink.
And by the time I was describing Mr. Rose to the attending physician, I had forgotten about the messed-up urine sample. I was worried about the pain that had brought Mr. Rose to the clinic, and the exquisite tenderness of his belly. Then there were the black stools. And the fluid in his abdomen, the trouble swallowing, the yellow eyes. There was so much wrong with this patient that I was struggling to tell his story at all, and I forgot about the urine.
AFTER MY FIRST VISIT with Mr. Rose, I took him on as my patient. Attending doctors and the student directors were always backing me up, but I made sure to be present at every one of his appointments. So, I saw him every week for months. He seemed to get a little bit sicker every time, his belly more swollen or his pain worse, but there wasn’t much we could do without the studies we needed to diagnose him. At one point we sent him to the ER at UTMB to see whether he could get admitted to the hospital, but they just told him it wasn’t a proper emergency and sent him back to St. Vincent’s. Although a 1986 law called EMTALA—the Emergency Medical Treatment and Labor Act—requires hospitals with emergency rooms to accept and stabilize patients with emergencies threatening life or limb, patients who are not actively dying may not be accepted. Mr. Rose was clearly sick, but he wasn’t actively dying.
Our working diagnosis was still alcoholic cirrhosis of the liver. So I would ask about alcohol, trying to do what the doctor had recommended, and Mr. Rose would tell me again that he didn’t drink. “Lord no, I am not drinking,” he would say. “I can hardly eat my yogurt.” I stopped asking after I finally felt too embarrassed to push the issue. I believed him.
And what about that pain? St. Vincent’s had a policy of not prescribing narcotics, so those drugs were out. He couldn’t take drugs like ibuprofen because we were worried about bleeding in his stomach. So we didn’t do much, and when Mr. Rose quietly asked me if it was okay that he took his sister’s Norco sometimes, I nodded yes and was grateful he had access to something. It hurt him to stand, to move, to walk.
When the new year of medical school began, my first course covered the heart. Listening closely to Mr. Rose’s heart sounds, I picked up an abnormality: an S3, which sounds like an extra beat. It’s a sign of fluid backing up, and overfilling the heart. “I think he has an S3,” I said to the doctor.
When the doctor double checked and verified the S3, he was so proud of me that he gave me a high-five—right in front of Mr. Rose. Then he explained what the sound meant.
My next class was on the gastrointestinal system, and I learned all about the liver. I learned that, in patients like Mr. Rose, one important study to do is the peritoneal tap. The peritoneum is a thin layer of tissue inside the abdominal wall. In a peritoneal tap, we push a needle through the skin, muscle, and peritoneum to take a sample of the fluid from the belly. In Mr. Rose’s case, the protein content of the fluid could have been analyzed to distinguish between cancer and diseases like cirrhosis.
I started hounding my professors in the halls of the medical school after the lecture. “I have this patient at St. Vincent’s,” I would say. “I think he needs a peritoneal tap.” One professor agreed, but there wasn’t much he could do. He’d never done a peritoneal tap at St. Vincent’s, and he wasn’t convinced it would be safe. What if the needle punctured a loop of Mr. Rose’s intestine? Fecal matter would leak into his abdomen and cause an infection. If the needle hit a vessel that caused rapid bleeding, would we send Mr. Rose to UTMB in an ambulance? And if we did that, what would be the consequences for the clinic? Every procedure has risks, and nobody knew how much risk was acceptable to take at St. Vincent’s.
So Mr. Rose just kept coming back, telling his stories, living with his pain. We got to know each other pretty well. I would wave to him when I came into the clinic. He always showed up early, so he would be seen in the first round of patients. And I always pulled his chart. He started calling me “Doc.” I learned a lot from him, and he believed in me.
ONE EVENING IN EARLY NOVEMBER I opened an e-mail with the subject line “Your Patient.” My patient? I thought. I’m just a second-year student. I don’t have any patients.
The e-mail was from Chandler. She was training in the emergency room in John Sealy that night, and Mr. Rose had come in, desperately short of breath. Chandler and her team checked him into the hospital. They put him on an oxygen mask, took blood samples, and did a CT scan. The results of the CT scan were copied into her e-mail. I held my breath as I read them.
There was a huge mass on one of his kidneys. (Why did I never feel that? Was I too gentle with my abdominal exam?) There were masses in his liver and his lungs. There were small masses in his brain. It could be nothing but cancer, metastasized all over his body. It had been there when he first came to St. Vincent’s, and it had been growing inside him through all the months that I had been trying to care for him.
After reading Chandler’s e-mail, I immediately bicycled the five blocks from the house to the hospital. Chandler met me outside, and walked me up to Mr. Rose’s room. “Well, obviously it’s cancer,” she told me as we walked. “But we don’t know what kind yet. We’ll do the biopsy tomorrow.”
“Oh man,” I said.
“Yeah,” she said. “Rachel, I’m really sorry.” I hadn’t even realized how upset I was until she said
that, and my eyes filled with tears.
Mr. Rose was in the Intermediate Care unit—the IMC—where critically ill patients who are not quite sick enough for intensive care go. Chandler asked if I was ready, then opened his door and said, “Look who’s here to visit you!”
“Hey!” Mr. Rose called out. “There’s my doctor!” He spread his arms, with an IV trailing from one wrist. I walked over to his bed and gave him a hug.
“I’ll leave you two to catch up,” Chandler said. And then, more quietly, she said to me “Let me know if you need anything.”
Mr. Rose had the head of his hospital bed tilted up so he could watch TV, and there was a barely touched dinner tray on the silver table beside his bed. He was on a heart monitor that beeped quietly, and a thin plastic tube blew oxygen into his nostrils.
“Well, sit on down,” he said, and I pulled up a chair beside his bed. And from there our conversation rambled, in and out of sentences that I can rebuild from memory and those that are lost now. I remember that the strange surroundings—the machines, the IVs, the nurses who came and went—made me feel shy. I still felt out of place in the hospital back then. I remember that he was ebullient when he first saw me, but his voice dropped later. He told me that he had been short of breath for days, but then tonight he couldn’t breathe at all, and he felt like he was going to faint. And, well, he knew he was sick, but now they were telling him it was cancer.
“What else have they told you?” I asked. I wanted to know if he knew as much as I did. I did not want to break the bad news; I was not part of the team taking care of him in the hospital, and I didn’t know all the details. I was just a second-year student.
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