JACQUELINE DOES NOT PARTICULARLY believe in being well-rounded as a doctor. She resents the pressure to treat medicine as a job, to leave it in the hospital. Her father never left his work at the office; he was always on call, always thinking about his patients.
“Part of me doesn’t want medicine to be the way I derive meaning from life,” Jacqueline said, “but that’s just the way it’s going to be. Why is it so bad that I want my life to have meaning from my work?”
Some part of me wanted to stop Jacqueline then, to tell her that life is full of meaning and we do not have to take it all from medicine. For a moment I saw her rushing toward a cliff that only I could see, but I couldn’t stop her any more than I could stop myself. She chose medicine.
So she drove Gloria into Houston, where Gloria’s application for charity care was rejected by the MD Anderson Cancer Center.
Gloria told Jacqueline to trust in God.
“Faith is amorphous,” Jacqueline told me.
The worst day came when Jacqueline and Gloria were trying to figure out if Gloria could move to Houston—or fake an address in Houston—to get indigent care coverage under the Houston hospital district. But Gloria had nothing: no bills, no pay stubs, nothing that showed her address at all.
“Maybe we can get you enrolled in a study,” the doctor at St. Vincent’s said, lightly patting Gloria’s back. Jacqueline translated, and Gloria burst into tears.
“Are you telling me I won’t get care?” she said. “I’m not sure I want to go on. I want to go back to El Salvador and be with my family. I want to go back to El Salvador to die.”
Jacqueline went home and keeled to the floor with guilt.
But like a miracle, the answer came the very next day. Gloria called Jacqueline on her cell phone. Thanks in large part to Jacqueline’s advocacy, Gloria had been accepted to Houston Methodist for charity care. She would begin treatment the next week. She wept on the phone, and Jacqueline wept again. Gloria would not go back to El Salvador; she would stay, and live.
Sometimes medical students and doctors do get too involved with our patients; sometimes we sacrifice our family lives, our art, the things that keep us human. But sometimes when you push and push and push, and you don’t give up—when you become that obsessive doctor who can think of nothing else—you actually save your patient’s life.
Jacqueline and Gloria still talk on the phone sometimes, even now that Gloria has her own doctors and no longer needs to come to St. Vincent’s. Gloria prays for Jacqueline, and Jacqueline meditates. Meditation doesn’t feel quite full enough, though, and so sometimes she prays in a vague, earnest way. She is not quite sure whom she is praying to, but sometimes, she just needs to pray.
* For more background on this, see the 2013 report “Latinas and Cervical Cancer in Texas: A Public Health Crisis,” by the National Latina Institute for Reproductive Health.
CHAPTER 25
ONE FEBRUARY NIGHT, LATE AFTER CLINIC, MY FELLOW student director Julian and I were sitting on his back porch smoking a cigar. Sarah and Dave were asleep on couches in Julian’s apartment. We four directors had all gone dancing that night, and hung out at Julian’s until Sarah and Dave conked out. The three of them were nearly done with medical school: they would match into residency programs the next month, and all of us would wrap up our year of directing. In the last few months, with the incredible stress of learning to be directors and running the clinic finally easing, we had all become close friends.
Julian passed me the cigar, then leaned back against the porch railing and laughed again at the fact that I was smoking. He was a military medical student, set to become a military surgeon, and the occasional fat cigar seemed to suit him well.
“Nice,” he said.
“Yeah,” I said, leaning back.
“So we’re almost done,” he said.
“Yeah,” I said. “Well, I still have to finish grad school. Are you worried about residency?”
“Nah,” he said. “I hope I get Seattle, but if I go to Walter Reed it’ll be okay.”
Then we talked about being a military doctor for a while, and Julian said that he was looking forward to being deployed. He said that other people didn’t understand that, why he would look forward to it, why he wouldn’t just be afraid to get hurt or want to stay home in his regular life. People thought it was crazy, he said.
“Naw, it makes sense to me,” I said, a bit drunkenly. “Let me tell you a story about Cicero.”
Julian smiled. He was a classic military dude: brusque, a bit concrete, the kind of guy who thinks hierarchies are just great and will soon be at the top of many. But he enjoyed how Sarah and I always talked about the medical humanities; it blew his mind a little bit. He leaned back and took the cigar from me, settling in to hear my story.
“Cicero was a Roman,” I began, “who lived around the year 100 BC.” At the time he was alive, the Roman Empire had been in a state of constant civil war for over three hundred years. So a virtuous Roman man was always ready to serve the empire—as either statesman or soldier—and all of virtue was wrapped up in that social duty. The inner life, the emotional life, was not seen as important. In fact, it was a kind of liability. Romans were expected to present a smooth exterior face to society, and not only to outwardly appear emotionally restrained, but to actually not feel perturbed by emotion.*
But Cicero had a crisis when his beloved daughter died. He began to show his grief in public, and he had to retreat to his country estate. There, along with his friends, he wrote the Tusculan Disputations, including “On Grief of Mind,” in which he argues that a virtuous man would suppress the lower, emotional, feminine side with the higher, rational, male side. And medicine has been struggling with this kind of virtue ever since. Like Cicero, we are meant to give up our lives to the service of others. But now, to serve contemporary Americans who see emotional sincerity as a virtue, we are called on to be emotionally engaged. Cicero’s story reminds me that our emotional restraint (which can be mistaken for coldness) has a history and serves a purpose: it is part of the traditional armamentarium of she who would dedicate her life to the service of others.
“So, like, I get that,” I concluded. “I get why you would want to be deployed, and you’re not freaking out about it or trying to stay home. Your life is actually not about your own experience. It’s about serving this other thing.”
Julian leaned over and put his arm around my shoulder. “Thanks, Rach,” he said. “Most people don’t get that.”
AT TIMES, ST. VINCENT’S CLINIC seemed to shamble on without us—we directors would be at loose ends, running from room to room, or sniping at one another, but somehow miraculously all the patients were seen, the volunteers survived, and the faculty kept showing up. I came to respect the chaos of the clinic as a productive kind of chaos. You cannot try to control the thing completely. You have to trust that the clinic, which is older than I am and will endure until the need for it is over, works.
There were, as Mr. Jackson would say, many patients whom we could not get all the way to five. Jacob met a man at the Luke Society clinic one morning who had a bent forearm in a filthy splint. He’d broken his arm and gone to UTMB. The break was not complicated, so they put him in a splint and sent him home. Which would have been fine, Jacob says, if somebody had explained to him that he should not remove the splint. But he took it off to shower, and the broken ends of the bones in his arm slipped out of contact, leaving his forearm crooked and his fingers numb from a pinched nerve. Jacob began “making friends in the orthopedic surgery community,” as he calls his efforts to get this patient care. The surgeons would agree to look at an X-ray, but not to correct the displaced fracture with the surgery he needed. They couldn’t use an operating room without UTMB approval, as Susan well knew. So the man, who used to be a handyman, is now slightly deformed and slightly disabled, and he is a St. Vincent’s patient now. Meanwhile, Jacob is still Jacob, unflappable and good, though I know he feels guilty sometimes, too. He still listens
to Nine Inch Nails.
So often, our goal was to get people out of St. Vincent’s and into something better. Sometimes that happened, and when it did it was often thanks to the Affordable Care Act. Mrs. Theroux, for example, had heart failure and chronic diarrhea and malignant hypertension and chronic pain, and had had two strokes so she was maintained on blood thinners that we had to check the levels on every week. She also cared for her elderly blind husband, who always seemed so joyful when he answered the phone and I said it was me calling from St. Vincent’s. “Thank you so much for all y’all do,” he would say, so that I could feel his smile warming me through the telephone line. Well, Mrs. Theroux finally got insurance. “Thank the good Lord,” she said, and I was grateful, too. She died not long after, but she did not lack love and care in this world.
But the Affordable Care Act never helped us in the way it was supposed to. It never made St. Vincent’s obsolete: first, because it deliberately excluded undocumented people from getting coverage, and second, because Texas did not expand Medicaid. Our patients were mostly the working poor—white, brown, black, whomever—and most of them would qualify for Medicaid if Texas would expand it. At the time of this writing, 17 percent of Texans are still uninsured, including 11 percent of children.†Medicaid expansion would help a lot. It is the low-hanging fruit of health policy, supported by the Texas Medical Association and basically everyone else with common sense. But it still wouldn’t make St. Vincent’s obsolete.
And it was always so pleasant to practice there, even with the pain and the frustration. It was good to do medicine in a place that felt perfectly embedded in the community, as if the clinic were a natural outgrowth of the neighborhood. It was good to know that my patients were all welcome there; indeed, they were expected. It was good to hear all the sounds of life—basketballs thumping, kids on the playground, guys on the street happily shouting back and forth—in that moment at the beginning of a physical exam when I would close my eyes to feel my patient’s heartbeat pulsing up through his or her wrist.
St. Vincent’s gave me so much. The knowledge that the clinic should not exist, that every one of my patients deserved something more, hung always in the background, even as the clinic became the largest piece of my heart.
Once upon a time, I was preoccupied with who I might become in medical school. I thought I was an artist, and I thought I needed to fight against the forces that would try to socialize me into medicine—to deaden me, to numb me, to make me cool and objective. So fight I did, with a haughtiness that nearly cost me some friendships. But ultimately, medicine won.
Medicine changed me, but not in the ways I expected. It became for me what Susan sought when she joined the profession: a total identity. I know that’s probably difficult to understand. But I think often of Jacqueline’s question—“Why is it so bad that I want my life to have meaning from my work?”—and my answer is that it isn’t bad at all. It’s exactly who a doctor should be.
I have a life, of course. I have a dog, I go camping, I plant a pathetic garden every spring that dies in August. I could no more separate my medical identity from my identity as a person or as a writer than I could separate the earth from the sky. And—even with the paperwork and the injustice and the hassle—I could imagine no life more meaningful than the life I have been able to live through medicine and through St. Vincent’s. It is the life I wanted, in the end: It is solid. It is real. The trick is to give up, and let medicine become you.
SEVEN YEARS AFTER THE HURRICANE, Susan tells me that very little has changed. “This is not a happy story,” she says. “This is still not a happy, good story.”
Her house-call bag, the one she carried out to Beaumont so many times, is still on a shelf in her garage. She is still having the same conversations with unfunded patients; she is still doggedly applying to Casebook. Her patients are routinely rejected but she feels that it’s important to try, so that somehow the need, and the need’s refusal, can be documented. More good people have left UTMB, and some in heartbreak, but many remain. Susan tells the St. Vincent’s directors that, if we ever need a faculty member to cover, she lives ten minutes from the clinic and she’ll just drive over.
After her Ike experience, Susan became board certified in hospice and palliative medicine. Having cared for so many dying patients in their homes, she was eligible for the “practice pathway”—that is, she achieved board certification without having to do a fellowship. She never expected to become a palliative care physician, but the work compels her, and now she both practices surgery and cares for the dying.
“I almost can’t remember what I thought doctoring would be like,” she says, “because it has been so different. And it was so characterized by that sudden loss of ability to doctor, when all those patients were lost.”
In April, I passed off my keys to Jacqueline. My year of directing had wound to its end, and it was time for me to go take care of other things. “These were Htin’s keys,” I said. “This is the key to the banana room. This is the key to the chapel. This is the key to the medication closet in the hallway. This is the key to the counseling room.” I went on and on.
“There’s no way I’m going to remember all these,” Jacqueline said.
“I know,” I told her. “It’s totally overwhelming. But you’ll be fine.”
* Robert E. Proctor, Defining the Humanities: How Rediscovering a Tradition Can Improve Our Schools (Bloomington: Indiana University Press, 1988).
† For reasonably up-to-date statistics on insurance coverage in Texas and other states, see the U.S. Census Bureau at www.census.gov or the Kaiser Family Foundation at www.kff.org.
EPILOGUE
SOMETIMES I DREAM OF MEETING MR. ROSE AGAIN. THIS is not a dream I have at night, but a daydream. In it, we are back at St. Vincent’s in the sweltering Galveston summer, and he is himself then but I am who I have become now. In the dream, I get it right. I think clearly and systematically like a physician, instead of being baffled by his illness. I dig deeper, slow down, ask more questions. If in the dream I make a mistake, I am able to explain it and apologize. And if in the dream he is still dying, I stand by his side. I visit him in the hospital; I get to know his family.
In the daydream, sometimes I am so good that I am able to take his pain away, or to finagle a late-breaking, miraculous cure for him. Other times it is more realistic: I cannot make the cup of suffering pass from him. But I am able to sit with him a while longer in that hospital room, to breathe in deeply of his suffering and offer what I can of my compassion. I am able to apologize.
At times I even feel compassion for my poor baffled medical student self. I was early in my training, and I was trying so hard to help. I made a mistake, and I needed—for my own human reasons—to apologize. I lost my chance to do so because I didn’t have the guts, or the grace, to return to visit my patient. I know now that returning to be with those who are suffering is no easy thing. I also know that it is my job.
I can only apologize to the sky now. I am sorry.
ACKNOWLEDGMENTS
I am grateful to, and humbled by, the patients who have so gracefully allowed me to be part of their care. Thanks to Mr. Michael Jackson and the whole community at St. Vincent’s, particularly my crop of directors: Sarah Baker, Toug Tanavin, Julian Vellucci, Roxi Radi, Kelli Gross, Sean Kelly, Lauren Fuez, Samantha Dorer, Jamie Hinderliter, and Suzanne Snow. One of our group, David Gersztenkorn, passed away before this book was published; his death was a loss to us all.
My research mentor Jason E. Glenn opened my eyes to many of the structural and social issues that emerge in this book. I am grateful to him and to all those at the Institute for the Medical Humanities who helped form me as a scholar and humanist.
Many thanks to my first and best mentor in writing, Michael Adams. Also to Forrest Wilder and all the folks at the Texas Observer, for keeping the Great State on its toes. Thanks to my excellent agent, Zoë Pagnamenta, for seeing this work through from scratch. I am grateful for the sharp editor
ial guidance of John Glusman at Norton, and all the folks there who have contributed so much to this book.
I’m grateful to all those who have taught me medicine, but particularly to Susan McCammon, Robert Beach, Patricia Beach, Howard Brody, Michael Boyars, Bruce Russell, Adrian Billings, and Serena Aunon. Thanks as always to the John P. McGovern Academy for Oslerian Medicine, for crucial financial and moral support during my medical education.
And of course my friends, especially Delaney Hall, Caitlin Sweetlamb, Graham Schmidt, Katherine Strandberg, Freddie Joseph, Christina Gomez-Mira, Ryan Kiesler, Amerisa Waters, Katie Ray, Margaret Wardlaw, and Parth Gejji. Thanks to the Historic Pleasure Palace, the Big Yellow House in the Sky, and all the physicians and scientists who shared their homes and years with me.
And of course my family. And Ben Laussade, my lantern on the trail.
INDEX
Page numbers listed correspond to the print edition of this book. You can use your device’s search function to locate particular terms in the text.
Note: Many of the names in the index are pseudonyms.
abortion clinic, 11–20
addiction, 229
Affordable Care Act (ACA), 173, 207, 237, 247
African Americans
and alcoholism, 96
among St. Vincent’s workers/volunteers, 60–61
and cadavers, 67–68
and cervical cancer, 240–41
criminal records and medical care, 217
and diabetes, 130–31
on Galveston Island after Hurricane Ike, 61
and Juneteenth, 37
and medical professionals’ racial bias, 130–33
No Apparent Distress Page 25