A History of the Present Illness

by Louise Aronson

  A little while later, since they were the only other people awake at that hour of the morning, I told the story to the doctors and nurses in the emergency department downstairs. I knew it was disrespectful of the patient, but I couldn’t help myself. He was so dead. We had a good laugh, then went back to work.

  Of course, what most doctors call stories aren’t really stories at all. They’re anecdotes, which my Webster’s dictionary tells me are “usu. short narrative(s) of an interesting, amusing, or biographical incident.”

  Here’s an example of one I’d forgotten until I was sent to Chinese Hospital for a two-week stint and it turned out that what they needed was a surgeon, not an internist:

  As a medical student, I cut off a woman’s foot. I was doing my required surgery rotation, and one night, around midnight, I was told to go down to the emergency department to see a woman whose foot hurt. All these years later, I can’t remember her exact age, though I remember that she looked decades younger than what it said on the chart. Her foot was gangrenous; it must have been hurting for weeks. Her brother had brought her in and said she’d probably hurt herself gardening. Or maybe that was just how she liked to spend her time. She was unmarried, lived alone in the family home where she’d been born the better part of a century earlier, and had never seen a doctor. No childhood vaccinations, no broken bones. “She never even catches colds,” said her brother.

  She was overweight, so probably she’d been diabetic for years.

  I could easily picture her in one of the many similar small houses in Ingleside near the 280 freeway. A well-kept but worn house, everything faded, its contents exactly as they had been when her parents were alive and slowly filled their home with furniture, commemorative plates, and children. Everything left just as it had been when the parents died. A dark, quiet place with a pervasive odor of age and dust, of mildew and microwave dinners and the fresh flowers she sometimes brought in from the garden.

  This was toward the end of my two months on surgery, so I did the admission without much help. There was no question of what needed to be done.

  The next morning, the surgery resident offered me the foot.

  His exact words were, “If you want it, it’s all yours.”

  I thought, Why not? When will I ever get another chance to cut off a foot?

  Many doctors would call that a story, though it’s not: no conflict, no crisis, no resolution. It is, as we like to say in medicine, necessary but not sufficient that the description is vivid and detailed and true. Nor does learning more about me, a key character and potential protagonist, guarantee the transformation of anecdote to story. Case in point: my first day on surgery, as the attending and residents worked for more than six hours to remove and reattach parts of a man’s intestine, I marveled that anyone could survive an operation, their innards exposed to the air for all those hours, cut and rearranged, sewn and stapled like cloth or paper or aluminum siding, and then wake up, groggy to be sure and in some discomfort, but basically fine—better, in fact, than prior to the operation. But the second day of the rotation, standing through a few quickie surgeries (one appendix, one gallbladder, and one hernia) and then another six-hour intestinal procedure, I felt like Ronald Reagan on his visit to the Redwoods: seen one, seen ’em all. I realized then that I wanted to take care of patients, not parts, wanted conversation and connection, not instrumentation, resection, and redecoration. Though I couldn’t have articulated it correctly at the time, what inspired me most in medicine was the opportunity to go beyond everyday exposition to life’s trigger problems and rising action, its culminations, turning points, and denouements.

  In contrast to anecdote, story—at least in the literary sense—offers so much more: narrative arc, movement, unification of action, irrevocable change. Meaning.

  It seemed that in the process of becoming a doctor, I’d also become quite literal, unable to bend fact for the sake of drama or significance. Or perhaps I’d always been that way, and that was why I’d become a doctor in the first place. In any case, having come up short in my attempts at advocacy journalism, I decided to try to exercise my creative muscles by writing fiction, in the hope that it would help me move beyond my own myopic and overly anecdotal point of view to some larger truth with a capital T.

  To my surprise, most of my earliest stories contained a protagonist who could invariably be described as a young female doctor who was always having to adjust to new hospitals and patients and couldn’t quite figure out what she wanted to do with her life. Nevertheless, I avoided the first person unless the “I” was so certifiably crazy that no one could possibly mistake her for me. Most of the time I chose a classical, all-knowing, and thus appropriately doctorly narrator. Physicians, we learned in medical school, should function as objective interpreters of other people’s behaviors, confidently providing reflections, judgments, compassion, and truths at key moments as the action unfolds. In theory, as in great eighteenth-century novels, that stance made good sense; in real life, unlike in fiction, I sometimes found it hard to manage.

  This is an old story; most doctors have one that’s more or less the same.

  I’d been sent to a large group practice near the old Mount Zion Hospital. Two hours into an overbooked clinic of patients I didn’t know, Rose Fong walked in off the street with a funny feeling in her chest. The nurse said she didn’t look good and put her into a room right away. Rose said she’d never had the squeezing feeling in her heart before and also that she wanted a sandwich. “Please,” she said to me in precisely articulated, very slightly accented English. “I am so hungry.” The T waves on her EKG, normally tiny upside-down U’s, looked like tombstones, tall and broad and evil. Tombstones is the actual medical term, not a word I slipped into my story for dramatic effect.

  As we waited for the ambulance, Rose said, “I don’t care what kind—ham, tuna, cheese, even peanut butter.” Her EKG went up down, up down, slithering like a snake—a pattern even more distressing than tombstones.

  “Just a glass of milk,” she begged as the paramedics arrived. Then she mentioned nausea, and her EKG became a line, straight as an arrow, and it stayed that way for the next forty-five minutes as we tried unsuccessfully to save her.

  Among us locums docs, the joke went: the good patients died and the bad ones stuck around to torment you. A lie. Both died, at least now and then. What was true was that deaths were easier than primary care. Fewer phone calls. No prescriptions.

  If you were a nice locums, a team player, you’d fill out all the appropriate forms before finishing your placement so all the doc you were covering for had to do on his or her return was send a note to the family.

  In other words: no epic account of an impoverished provincial childhood, young love, migration halfway around the world, pursuit of the American dream, invisible illness, sudden death, and small, orphaned children—just a condolence card.

  The night of her death, I told my boyfriend that all I’d been able to think about for the rest of the day was how I wished I’d given Rose a sandwich.

  Some medical stories never get told in quite the right way. Such stories almost always involve a doctor behaving badly according to certain widely accepted though rarely articulated codes of physician conduct. This is the sort of story you tell one way if you’re its protagonist, unconsciously but quite understandably suppressing and internalizing, then forgetting certain details while exaggerating and elaborating others. If, on the other hand, you were a secondary player, such as—hypothetically speaking, of course—a senior doctor who owned a large group practice and did nothing more than peer over shoulders during a prolonged and unsuccessful resuscitation, you are free to tell the story in a completely different way, making modifications for the sake of humor and misplaced sympathy and, most important by far, to discourage future lawsuits against the practice by relatives of the deceased, and you are free to do so whether or not such alterations occur at the expense of the facts, such as the poor prognosis associated with tombstones on an
EKG, the patient’s accented but actually entirely intelligible pronunciation of the names of certain types of sandwiches, and a somewhat inexperienced junior colleague’s well-meaning but perhaps ill-advised—possibly even lethal—decision to get an EKG before calling 911.

  Some people believe this means the story has been told. Those same people, while fluent in the languages of shame and humiliation, of ass kicking and ass covering, lack even the most rudimentary understanding of point of view.

  Once upon a time, Rogelio and Carina had four children. The oldest died in Nicaragua of what sounded like cancer but might have been the sort of infectious disease we don’t see much in the United States. The third and fourth died in a school bus accident in El Paso; they were nine and ten at the time. Their only surviving child, a daughter, married a man who moved a lot for work. She lived in Chicago when I met her parents, but soon thereafter she moved to Raleigh-Durham, then Orlando. I gathered that there were grandchildren but also that there wasn’t money or time for visits.

  Sometimes in medicine, entering a story in medias res can be problematic. In those instances, you wonder what you’re missing and assume the worst: that frail Rogelio used to cheat on Carina, and his current kindness stemmed from guilt and retribution; that, frustrated by failures at work, the inability to save enough for a down payment on a house, or the death of his sons, he ignored, abused, or disparaged his daughter, who consequently wanted little or nothing to do with him; that the son-in-law’s frequent moves stemmed not from a quest for more lucrative work, but from a need to escape the law; that the daughter wanted her mother dead so she could inherit the earrings, necklace, and bracelet bought in better times and worn even now, day and night, over cornflower-blue flannel pajamas and floral housedresses.

  The possible backstories, limitless and nefarious, can make you question a patient’s or family member’s every plea or explanation and search the subtext of even the most straightforward comments. Such as when Rogelio and Carina’s daughter said, “You’re too kind,” in reference to my having gone out of my way to make sure her mother got the right antibiotic for the pneumonia that might otherwise have killed her, when what she might have meant was I wish you hadn’t.

  It’s rare but not unheard of for a medical story to start as an anecdote but—because it appears to be about one thing when really it’s about something else entirely—end up one step closer to being an actual and successful story, one with what might almost qualify as an Aristotelian reversal. In that sort of story, you get to the end and it changes everything. Such as the story I told my increasingly serious boyfriend about Svetlana Kamenetsky, a patient I cared for in the large clinic near Mount Zion, where I ended up working for more than six months, covering first the regular doctor’s preterm labor and then her three-month maternity leave.

  Respecting Russian tradition and the family’s well-documented requests in the chart, I didn’t mention bone marrow failure to Svetlana. She went for transfusions and never asked why. Words like Chernobyl and mortuary were spoken only furtively, in the tiny hallway outside my exam room, whispered over the screeches and whoops of the children running in and out of the waiting area shared with the pediatrics clinic next door. One afternoon, when I put Svetlana last on my schedule and asked that the entire family be present so we could discuss the few remaining options for treatment, she said never in the Soviet Union did they have a doctor so nice. She said, “We are very thank you,” and the entire family—Svetlana, sunken and swollen, gray and dying; her ancient parents; her husband and brother; even the teenage children—were all smiles.

  Hearing the story to that point, my beloved boyfriend was also all smiles. But then I told him how sometimes at work I felt like a fraud, pulling options and assertions with the bright colors and plasticity of Play-Doh from the empty pockets of my long white coat. Right away, my boyfriend stopped smiling, which was good, because boyfriends, like patients, sometimes get confused. Too often they think a nice doctor is a good doctor. Too often, they notice the affection but not the brutality, the gratitude but not the obvious, unspoken question. For example: Cultural tradition aside, what kind of doctor lies to a dying woman?

  Not infrequently, medical stories tend toward sentimentality or humor, as if outrage at the injustice of illness and the necessary violence of medical care are downers better left to novelists and bloggers.

  “That’s interesting,” said my new fiancé on the Saturday morning after the cloudless Friday night atop Twin Peaks, the lights of the city and bridges sparkling below, when he dropped to one knee and asked me to marry him. A few hours later, naked, his curly hair wild from the wind on the hilltop and the burrowing of my fingers, he was reading the titles of the books on my writing desk.

  “What is?”

  “Your books. They’re all about war.”

  It was true. As models for writing about medicine, the war books came closest to achieving what I was after. They had stories of good deeds and bad, but no heroes or villains. They had descriptions of horror and obscenity and crazy things that should never have happened but did, again and again, and so struck me as profoundly and irrevocably true. In other words, they were honest. I wanted to be honest, too.

  To ensure objectivity and accuracy, doctors’ notes avoid the first person pronoun. Instead, they are written in the style of textbooks, using the dispassionate third person with lots of jargon and a relative paucity of the sort of telling detail that might allow a patient to transcend the page and emerge a fully formed and unique human being in the imagination of the reader. Mostly made up of something called history (which shouldn’t be confused with story), the best such notes contain quotations (dialogue, if you will) in the actual voice of the patient. These conventions, particularly the avoidance of the subjective and responsible “I,” may partly explain why, when describing certain emotional events in my writing, I do so by using the second person. But rest assured that whenever I use the word you, I am not referring to you, the reader, but to myself. This is a common literary usage of the second person but also, I’ve found, a common usage in real life as well. So often, when a person says you, they mean me.

  “You’re too easily upset,” I said to my fiancé one night when he appeared on the verge of tears at the end of one of my patient anecdotes. Then I reminded myself that he worked in a world in which young, healthy college-educated men and women spent their days debating pressing issues such as whether the villain should be a lion or a bear in their latest animated children’s video game, and I softened my tone. “It’s my work, you know. Somehow, you’re going to have to get used to it.”

  When Rogelio talked about his life, games were a recurrent theme. He’d been a player of bridge and dominoes and loba, seeking out games on the weathered green or gray picnic benches in the concrete parks that punctuated the Mission District. This was back when Carina managed every aspect of their household, before his world shrank to the confines of their most basic needs and the two rooms of their government-subsidized apartment. The games had brought him friends and fun and, on occasion, a little extra spending money. But he’d given all that up the day Carina put an entire bag of unopened tortillas on the stove’s open flame and walked away. His life ended that day in so many ways, yet it also went on and on, the years that followed an excruciating expanse of structured, hollow time, the only game around the game of life, a game at which he considered himself hopelessly and unequivocally a loser.

  His death was abrupt. I’d visited them just two weeks before. At that time he’d had some vague symptoms that he said weren’t important, telling me instead about the aide he’d fired because she would change Carina’s diaper only twice a day. I suggested doing some tests, but Rogelio said he felt good enough—“Regular,” he said in Spanish with a shrug and his usual wan smile. He said he’d call if the symptoms continued. His exam was normal, and he looked the same as always, so I didn’t insist.

  That was the worst: when you didn’t know whether you’d killed them, when yo
u wondered whether, if a certain hand had been played a slightly different way, maybe the whole thing would have gone in another direction and there would still be dominoes standing in their usual neat lines at the end of the long hall on the fifth floor of the Martin Luther King apartments. Maybe Rogelio would still be in the game, making sure his wife lived and died in her home with the best of care to the very end, her hair neatly brushed, and every inch of her skin clean and rich with the scents of baby powder and cooking oil and love. But there was no way to know, so you stayed awake nights wondering, and then sometimes, for the next several patients, you ordered every test imaginable, careful to miss nothing. You tortured them and found that some got better and some didn’t, and you were no closer to a definitive answer about what constituted good care and enough treatment and what was too much.

  This next medical story, though an official chapter in the history of medicine in America, is considered sacred by some and blasphemy by others. It all depends on people’s biases when it comes to plotlines in medicine: Are the only legitimate scenarios the archetypal classics Man v. Disease, Man v. Man, and Man v. Death, or might tales that lack metaphors for battles and quests—scenarios such as Man with Man, Man accepts Fate, or Man with God—have a place in the canon as well?

  Way back in the mid-1990s, when mostly no one besides doctors on call carried cell phones and Internet skills weren’t essential for keeping up to date with the latest scientific developments, a new species of medical conference emerged and spread across the country like an epidemic. From the enthusiasm of certain doctors and nurses, one might have thought there’d been a major medical breakthrough. The conferences had sessions with such titles as “Giving Bad News,” “The Good Death,” and “The Spiritual Lives of Patients.” During the breaks between lectures, multicultural pain scales with selections ranging from smiley faces to frowns and plastic pocket cards listing useful phrases to use when breaking bad news were snatched from display tables as quickly as free wine or cookies.