A History of the Present Illness

by Louise Aronson

  It was the birth of medical modernism, when a subset of doctors finally acknowledged that not all patients could be cured, and then they went one step further, admitting that in fact not just some or many, but all patients—and also, eventually, their doctors and nurses and everyone else would die. The movement’s leaders declared that if patients were to find meaning at the ends of their lives, medicine could no longer countenance the traditional and up to that point supremely dominant narrative in which cure alone constituted therapeutic success. Moreover, they argued that there should be no singular approach to patient care at the end of life. Each person should be viewed as his or her own text—complex, contradictory, playful, ironic, ambiguous, and absurd—and not all stories would have the benefit of happy and tidy endings.

  By the time I came along nearly a decade later, death had become a fashionable specialty in medicine. But it wasn’t until my locums year that I had what could be called my Chekhovian realization or Joycean epiphany: I wanted to be right there when people died—in the trenches, as we doctors like to say, as if battling disease and death in others is a first person experience.

  Good medical stories capitalize on the myriad opportunities for imagery, analogy, and metaphor offered on a daily basis in medical encounters and settings. In the spring of my year doing locums, I was sent to a large nursing home on the southern edge of town where I watched two chatting young women in baby-blue scrubs wheel a body draped in a single white sheet from one building down a long glass corridor to another, then wait in the main lobby among the potted plants and Easter decorations and a crowd of visitors and residents for an elevator down to the morgue. Walking by, I thought of those old brokerage commercials in which mention of the famous broker’s name caused immediate silence: all movement and conversation stopped.

  I had seen enough by then to know where people went after death. Nowhere. They remained in bed, wearing death like a face-lift, an orgasm, a new persona, the change obvious from the doorway. The afternoon of Rogelio’s death, for example, the aide and I watched as the paramedics rolled him down the darkened hallway in a black rubber sleeve, like a giant garment bag for his ultimate journey.

  Sometimes, when it was over, when the coroner and the funeral home had been notified, you didn’t know what to do. The more you wanted to leave, the longer you stayed. In those moments, setting became all important: a shiny black rotary phone that wasn’t ringing, though you’d left a message for the daughter; the acrid smell of urine from a diaper in need of changing; the faded green recliner you didn’t sit in, because you’d never seen anyone sit there but Rogelio; the painting of the Cerro Negro volcano erupting over the city of León, painted by Carina from a photograph long after they’d moved away.

  One warm Sunday evening in mid-May, as the grass on the city’s unmanicured hilltop parks faded from green to the golden brown hues that signal summer in San Francisco and shortly after my new husband and I had driven ourselves up to Reno and tied the knot, I scrolled down the document I’d been working on for the better part of that year. It consisted of a series of anecdotes, each describing a patient I’d seen or a “story” I’d heard from another doctor. Each anecdote had a beginning, middle, and end but felt incomplete on its own. They shared themes and locations in San Francisco and occasionally a character who appeared in more than one anecdote. I knew they belonged together but hadn’t figured out how.

  Looking up from his Sunday Times, our obese feline fluff ball comfortably ensconced in his lap, my husband asked, “Have you considered that progress is slow less because of what you’re trying to say and more because how you’re saying it needs to be completely different?”

  “Meaning I need to choose between personal essay and fiction?”

  “No. Meaning none of that matters. Meaning you keep trying to seduce your reader with setting and synonyms, humor and allusion and allegory, and maybe all you need to do is just be straight up about how much your patients mean to you and how difficult these situations are and how lost you feel when you don’t know what to do. Meaning forget the fancy footwork and ironic remove, and just tell the damn story!”

  At the county hospital where the neighborhood health center admitted its patients, the residents called admissions hits, unless they called them hurts. Hits were just work, while hurts were admissions made especially painful by either the amount of work required or the certain knowledge that one’s efforts were ultimately useless. Carina was a hurt. Obese and demented, she kept getting sick. At each admission, she seemed weaker and more disturbed by the hospital sounds and smells and people, the IVs and breathing treatments and everything else. I offered to try managing the crises at home and explained about alternatives to 911, up to and including hospice. But Carina’s daughter, who had moved her entire family across the country and into the Martin Luther King apartments in the week after her father’s death, insisted on hospitalization. “But I thought—” I began, recalling that she had seemed disappointed when I’d cured her mother’s pneumonia a few months earlier, and then I let it go.

  Carina’s daughter had become her official caretaker, work that came with a small but reliable paycheck from the state. Between hospitalizations, she hand-fed her mother small bites and spoonfuls of her favorite foods. From what I could tell, Carina’s diet consisted of tortillas and bananas and ice cream, only some of which made it to her stomach. The rest went down her trachea, and a few days or weeks after her most recent admission, I’d receive a call saying she was back in the hospital. With each hospitalization, the residents would talk to the daughter about Carina’s obvious suffering and apparent distress, but the daughter said that Carina was happy at home, and it was true that on my visits she sat smiling in her wheelchair between bites of strawberry ice cream or lay in her bed smiling, her grandchildren lying beside her doing their homework and watching TV. But it was also true that Carina’s ongoing existence and care needs secured for her family a low-rent apartment and a regular paycheck. When my locums year ended, this was Carina’s life: tortilla hospital home tortilla hospital home tortilla hospital.

  As is the case for all medical stories, with the exception of things I’ve altered in obeisance of the Health Insurance Patient Protection Act and, at my husband’s insistence, for reasons of esthetics and art, everything I’ve written here is true. For their sakes, I had to change patients’ names and biographical details. For my sake, I had to downplay some aspects of my professional and personal lives. The heartbreak and incredible sex, for example, but also the joy. In real life, there was more of it. In real life, if you’re as lucky as I have been—with work that is long on characters, drama, and significance—there’s always more joy. But that doesn’t make for much of a story.

  Acknowledgments

  In medicine, the “history of the present illness,” or HPI, is the critical first portion of the medical note that describes the onset, duration, character, context, and severity of the illness. Basically, it’s the story, and without it, you can’t understand what’s going on with your patient. Similarly, to really understand this book, you need to know that its onset occurred decades ago, that the symptoms have waxed and waned over time but have been increasingly prominent in recent years, that it’s been a wonderfully messy business full of emotional highs and lows and legions of supportive, generous characters, and that I am hugely grateful to each and every one of them.

  In retrospect, the symptoms started shortly after my birth at one of the hospitals described in this book. The context was the parents to whom I was born: I am a writer because my mother talked to me from before I could answer her, taught me the rules and beauty of language, and provided me with endless recommendations of good books; and I am a doctor because my father modeled the excitement of science, the importance of evidence and logic, and the thrill of making a difference in the world. My parents have supported my every venture and interest, and a person doesn’t get much luckier than that.

  Within weeks of completing my medical training, I b
egan taking writing classes from talented and dedicated writer-teachers. I thank Shelly Singer, Paul Cohen, Tom Jenks, and Carol Edgarian for their wise instruction and forbearance in the face of my early efforts, and Judith Grossman, Peter Turchi, Debra Spark, David Shields, Adria Bernardi, and the rest of the faculty at the Warren Wilson Program for Writers for teaching me all I needed to know to continue developing as a writer long after I’d earned my M.F.A.

  For some people in medicine, fiction writing is a foreign and questionable activity. I have been fortunate to work for people whose open minds and flexibility allowed me to take on a second career not only without compromising my medical career but in a way that enriched both. Jay Luxenberg was the first to invest in me, and I will be forever grateful for his unwavering support even as months bled into years and there was no outward sign that I was actually doing what I claimed to be doing. Like the best of bosses, Seth Landefeld let me follow my unique and unconventional trajectory, offering sage advice and financial support at key moments when many others would have offered neither. Molly Cooke, David Irby, Nancy Ascher, Paul Volberding, Brian Dolan, David Elkin, Patricia O’Sullivan, Talmadge King, and many others at UCSF expressed interest and confidence in my efforts and helped me blend my passions for medicine and writing into UCSF Medical Humanities and a better book.

  My job is sufficiently demanding that stretches of months often passed during which I did no writing. What saved me, and the book, during those years were opportunities to go to beautiful places where I was provided with the space, time, fellow artists, and good food required to make otherwise impossible leaps of progress. I thank Ucross, Ragdale, and Hedgebrook for giving me just what I needed to move forward.

  Critical to the development of these stories has been the feedback and community I have had from my writing groups: Lindsey Crittenden, Rachel Howard, Ken Samuels, Adrienne Bee, and Frances Stroh in the early years, and more recently the Grotto group extraordinaire: Natalie Baszile, Bora Reed, Suzanne Wilsey, Katherine Ma, Susi Jensen, and Catherine Alden. Thank you all for putting up with this long, slow process and for having the courage to give honest, constructive feedback.

  The fact that this book is appearing in print at all is a testament to the generosity of three writers who responded quickly and enthusiastically to an acquaintance who had the audacity to ask if they’d send the manuscript to their agents. Thank you to Peter Orner, Chris Adrian, and Bill Hayes.

  So much of success is luck, and my next lucky break came in the form of Emma Patterson, a young agent who started reading my manuscript and told her boss, Wendy Weil, to read the book immediately. I knew from the start that I was in good hands with Wendy and Emma at the Wendy Weil Agency, and it became even clearer when they led me to my editor, Nancy Miller, at Bloomsbury. Nancy’s keen eye and gentle questions have done much to improve the book, and it has been a total pleasure working with a team that understood what I was trying to do and believed that others might enjoy it too.

  I am particularly grateful to the friends who read, reread, and re-reread these stories. Each offered insights I lacked and needed, and their faith in me and the work kept me going and inspired me to further improve the book. I cannot thank them enough: Kathleen Lee, Annette Huddle, Gina Solomon, and Shawn Behlen.

  Finally, there is one person without whom this book would not exist. Jane Langridge makes anything possible and everything better. This book is for her.

  Footnotes

  1After sixteen phone calls and hours of research; this isn’t exactly a transparent process, is it??

  2Yes, this is the third time I’ve sent this proposed diagnosis because I have yet to receive even a standard-issue form letter by way of reply, and although I realize you’re both at that post–traumatic stress disorder conference in the Caribbean, I checked online and know for a fact that your hotel has Internet access. The recent unjust and all-too-publicly exaggerated charges against me notwithstanding, I keep asking myself how an entire committee can simply ignore a well-articulated, life-and judgment-disrupting diagnosis? A diagnosis, I might add, that bears both accurately and acutely on the suffering of an undervalued and often unfairly penalized segment of the population, namely those almost invariably female and often also otherwise marginalized people who are and always have been disproportionately overrepresented in poorly remunerated and oftentimes dangerous jobs that require enormous emotional and temporal investments at equally enormous and not infrequently devastating personal costs. (Costs, I might add, that may explain why this majority segment of the population is represented on your committee only by Drs. Georgia Brown and Ethel Liu—there’s a word for their role, the noun of which used to get a person onto ferries and buses.)

  3Noemi Kadish-Luna, B.S., M.D., M.A., M.P.A./H.S.A.(c)

  4I’m not sure cluster is the best word choice here, given that when the average American hears that word, she or he will likely have a mall-and/or holiday-based association to that increasingly ubiquitous and tooth-decay-inducing bite-size morsel, the pecan cluster, which, if you think about it, is what? Well, a cluster of nuts, of course, which I know is not the message you want to be sending, to say nothing of the other sort of cluster that might appear in people’s (especially women’s) minds when confronted with the image of a group of mostly middle-aged, mostly white, mostly male doctors sitting around a meeting room in some fancy hotel casually critiquing and summarily pathologizing people, many of whom are not middle-aged, not white, and not male, and most of whom are (for unclear reasons) not present while, between sips of Seattle’s Best and bites of poached salmon with endive salad, the aforementioned middle-aged, mostly white males discuss nothing less than the very personhood of the un-and underrepresented absent majority. (Hint: it’s a two-word phrase and the second word is fuck.)

  5Final digit dependent on number of new diagnoses accepted (see other potential Cluster B additions in footnotes 15 and 16 below). And in case you’re wondering how one person comes up with so many apt solutions to the DSM’s glaring (if publicly unacknowledged) deficiencies, the answer is simple: I don’t just drop into the real world from my ivory tower for one or two half-day sessions a week; I actually live there.

  6I wish!!

  7I often find it helps to put a face to a diagnosis, so let me just mention here that for several years I practiced primary care psychiatry at the South of Market Community Health Center here in San Francisco, working fourteen-hour days while meth heads (active clients and a former employee, according to the police reports) broke into our on-site pharmacy, depleting our already inadequate supply of cold medicines and painkillers, and other criminals (guys who were probably also our clients) took apart my car, a maroon secondhand ’86 Honda Civic with VOTE VEGAN / GIRLS RULE / DIVERSITY / NOT EVERY SPERM NEEDS A NAME / DOGS FIRST! stickers artfully arrayed on the back bumper. The Civic was all I could afford on what they were paying me at SMCHC and certainly wasn’t much to look at even prior to its broad-daylight dismantlement, and yet its loss precipitated the single instance in which I wondered whether, rather than pursuing a life in the world of mental illness, I instead should have followed the leads of my friends who went into specialties like dermatology, pathology, radiology, and cosmetic surgery and who, since finishing training, have wed, slept late on weekends, traveled, and had children. Actually, to be perfectly accurate, while all the men have enjoyed these myriad fruits of their well-chosen professions, only some of the women have, and they were either those perfect ones who could do everything well, or the slimy types who gave up their careers without a single backward glance upon the first sign of their successful impregnation, as if doctoring had been for them nothing more than a loop in the holding pattern of their trajectory toward marriage and motherhood. (I can’t resist digressing a bit here to comment on the irony that it was the members of what I think of as the M.D.-Mrs. contingent who criticized me most strenuously when that whole business between me and a certain postdoctoral pharmacy student—not under my direct supervision, not even from th
e medical center with which I have an affiliation—made the papers, even though easily two thirds of the published account was an obvious and blatant distortion of the facts conjured by the press to justify their lurid, bold-type headlines and sell this first-rate city’s second-rate rag.)

  8I must admit here to not only the expected psychic Sturm und Drang but also to actual physical pain (occipital, primarily) when I learned I hadn’t been invited to participate in the diagnostic revision process, particularly since (recent events notwithstanding) no current committee member has credentials remotely equal to my own.

  9You’re so pretty, Mike Reed, M.A., Pharm.D., said to me his first day at the SMCHC, as if looking at me were akin to gazing upon the idyllic (and perhaps imaginary) Hanging Gardens of Babylon or some other largely inaccessible and supremely exotic global trea sure and he felt fortunate beyond his (admittedly limited) powers of verbal expression to have the opportunity to gaze upon my corporeal self while clarifying one of my orders or less than optimally legible prescriptions. And the next week, just after my supervisor suggested (using his favorite deceptively quiet but devastatingly harsh voice) that I try a little harder to stay on schedule, Mike added, You’re so sexy. And then, I’ve never met anyone like you. And also, You know you’re the smartest doctor I’ve ever met, don’t you?

  10C’mon, Mike said later that same day (and on several subsequent occasions in the weeks prior to our discovery, his firing, my suspension, etc.), I really, really want you and there’s no one in the med room.