by David Watts
Table of Contents
Title Page
Dedication
Epigraph
Praise
PREFACE
PART - ONE
WHITE RABBITS
THE DOCTOR WITH FOOD ON HIS SHIRT
ADVANCE DIRECTIVE
SYLVESTER
LOVE IS JUST A FOUR-LETTER WORD
CIRCUS
SURGICAL WOUND
TELEPHONE TREE
STRICTURE
ATTRACTION
MONOLOGUE MILLIE AND THE SYSTEM OF CARE
PART - TWO
WAITING TO BE SERVED
FLU SHOT
THE MORBIUS MONSTER
LIVING IT UP AT THE TOP OF THE MARK
NOT WAVING BUT DROWNING
ANNIE’S ANTIDOTE
MRS. ROBINSON EYES
ECTOPIC
ME AND THE HEC
PALOOKA
HER LANGUAGE
EVENING IN THE - TWO WORLDS
PART - THREE
WHEN CRAZY GETS SICK
JOKE MAN
THE GIFT OF NOTHING
THE GIRL IN THE PAINTING
LUNCH AT THE STEREOTYPE CAFÉ
LOST IN TRANSLATION
CODGER
ABOUT MONEY
IF YOU SAW IT, IT WOULD LOOK LIKE A TREE BURNING
THE HMO AND THE RENEGADE IN ME
THE STALKER’S BRIDEGROOM
HOSPITAL DU JOUR
RITUAL
HOME REMEDY
PAIN AND HEROES
PART - FOUR
AILERONS
MOTIVATION
THE PATIENT NAZI
THE TWO STORIES
MALADY MÉNAGE
PROTECTION
CONSULTATION
THE THIRD SATISFACTION
TWO DYINGS
PIANO LESSON
Acknowledgments
About the Author
Copyright Page
For my patients . . . . . . and for Joan
You can observe a lot by watching.
—YOGI BERRA
Praise for BEDSIDE MANNERS
“Dr. Watts is a healer in the truest sense. Reading these stories will change lives. They just might change your life, too.”
—Melanie Austin, M.D., in Cell 2 Soul
“Undeniably compelling.”
—Kirkus Reviews
“Both empathetic and practical, Watts relates encounters that have informed his ability to understand, diagnose, and treat sickness. . . . All of the incidents related here, whether sad, frustrating, or inconclusive, are unfailingly compelling.”
—Publishers Weekly
“David Watts is a gifted storyteller with a sense of the poetic, macabre, ironic, and surreal. He combines eloquence, erudition, and an ear for the gritty vernacular of the examining room and ER—a thoroughly satisfying read.”
—Leonard Shlain, author of The Alphabet Versus the Goddess and Sex, Time and Power
“These encounters with his patients by a wise, kind doctor are finely wrought in language that is always clear and compassionate. They are a welcome addition to the growing body of literature from the experience of medicine.”
—Richard Selzer, surgeon and author of The Whistlers’ Room
“A moving, eloquent insight into what a sensitive physician feels and thinks encountering a variety of patients and problems. A must-read for doctors and patients alike.”
—Paul Ekman, Ph.D., author of Emotions Revealed
PREFACE
Can you tell me a growing-up story?
The request came from my son, Duston, as I was tucking him into bed. I am familiar with this request. He makes it mostly when he is troubled. Maybe another child has said something mean to him. Maybe he’s having to deal with the unthinkable idea of war or capital punishment. Growing up is not easy or fair.
Yet what puts things in place for him and makes him feel better is stories, especially about times past. Instinctively he knows that something is to be found there that will teach or reassure or lull. And I realize that by this ritual he will come to know my relatives, living and dead—to know them by how they come alive and speak and drive cars and take apart tractors for him in the late evenings.
I never intended to be a storyteller. I came to writing because I was looking for something. I was in a difficult transition and I wanted to find a way to say what was going on inside me — or maybe just to find out what was there. I was drawn first to poetry because of its traditional subjects: love, loss, longing . . . the complex and rich and sometimes painful interactions of the family . . . There was stuff there to work with.
As I wrote, I became aware of this niggling little tap, tap, tapping on my shoulder. And a voice that said, Shouldn’t you write on the subject you know the most about?
I didn’t want to write about my work. But I had to admit that medicine had a rich and beautiful language, and there was a music to the words one could get lost in. And there exists within the doctor-patient relationship this rarest of conditions, which gives the people involved permission to engage in instant, profound human interaction. It’s like stepping suddenly into a clearing. Even so, writing about medicine was for someone else.
Well, I finally gave in. My first efforts at writing about the doctor-patient relationship sounded more like articles for the New England Journal of Medicine than anything remotely related to art. The cold, distancing language of medicine had crept in and locked out feeling. It was not until I became ruthlessly honest in my treatment of my subject and, by the same token, of myself as a doctor that the language of academics disappeared and the music began to return.
The real turning point came when a young violinist with cancer became my patient. Her struggle and her bright spirit were so inspiring that I just had to find where that passion was coming from. Writing about her taught me how to find what lay underneath. Writing about her allowed me to be deeply moved by other patients with other stories.
Life has a certain irony. My grandfather says that sometimes you just have to go where the horse wants you to go. My horse apparently wanted prose, and wanted it to speak of the struggles of doctors and patients.
Then another surprise: The subjects I was attracted to, the ones that had brought me to poetry in the first place, were to be found quite at home within the heart of medicine. And perhaps to greater effect, for here the tension between the professional and the personal, the locus of these strong emotions within the hard reality of medicine, gave them a certain fresh architecture, a scaffolding to hold on to. And as I learned more clearly from writing about it, the office visit, with its urgency and compression, its precise language and powerful emotions, is itself a poetry.
The stories in this book are true. What I wanted most to celebrate by writing them were the wonderful and inspiring qualities of my patients: their courage, their inventiveness, their quirkiness, even the admirable way they are sometimes irascible and defiant. There is wisdom in the particulars of these characters. Like reflections on the surface of a complex gemstone, these sparkles of personality are what makes the medical experience so interesting, so human, and so impossible to predict.
Something happens when we sit down face-to-face in the spirit of mutual trust and talk about vital issues of health and mortality. Lives open up. We see things we had passed by day after day and never recognized about ourselves. Moreover, this information opens out onto balconies of change, sometimes radical ones. I’ve seen patients go out and divorce their spouses or change their careers based upon what they learn about themselves. Much of the mysterious action of the human spirit comes forth when we finally relinquish our hiding places. That’s what this book is about—what we do about our lives when confronted with mortality.
&n
bsp; There are situations and syndromes here that, to my knowledge, have not been described before—or at least I had not known about such things: the man who had to stay awake to stave off his demons during endoscopy, the woman who used poetry to get through a frightening procedure, the doctor who made his living saying yes to insurance companies, the doctor who finally learned how to find value caring for a thankless patient . . .
It turns out, as I wrote deeper and deeper into my subject I revealed more and more about myself. That, I guess, is what literature does. Makes us set aside inhibitions. Makes us find a pathway to the interior. “I write the story, the story writes me.”
Some of what I wrote was too painful or specific to include here. The doctor-patient relationship is a sacred and fragile covenant. Patients have a right to their privacy. When writing about my patients I have always asked their permission and with rare exception they would say something like, Oh, that’s wonderful. Please do. I think they were genuinely honored to be so recognized. Some names I could not remember. Some people I could not find. But I always tried to disguise my subjects well enough so as to honor the unspoken agreement. Some may recognize themselves. Some may only think they do. The circumstance of literature is specific to us all.
Sometimes, writing these stories late at night, I have become weary with pleasure. Sometimes, reading them again brings the pleasure back. There is a wisdom in stories that goes beyond the circumstance of their creation, and there is a comforting sense of continuation and resilience. Perhaps that is what my son has found there. Gratitude, then, to those who have given us their stories, those who taught me what I now know, and made me a better doctor because of it.
My son is asleep. And bless him. I know that he feels safe now, sleeping in a complex world.
He will need more stories. So will I. There is time for this.
PART
ONE
WHITE RABBITS
Frank is in my waiting room, which means I’m going to be spending a lot of time chasing rabbits — little questions he brings on small crumples of paper that skitter around on my desk, issues he’s researched on the Internet and gotten emotional about that usually don’t have anything to do with his own circumstance. What’s worse, he’s about to have an operation, which means he’s really going to be worked up.
I’m remembering that he’s the guy with too many colonoscopies. “Well, something might have gone wrong since the last one,” he’ll say. True, but mostly not true. Still, you can resist that argument only so long and then you find yourself torquing another scope through the colon.
And it’s not a trivial deal. He goes vagal in the mid-transverse colon, drops his blood pressure, looks like the life force is beating it out of town on the lam. We haven’t killed him yet, but we may have come pretty close. And it probably doesn’t do a lot of good for his oxygen-starved brain cells that his blood turns to molasses like that. Besides, watching him go shocky sends my coronaries into spasm.
I made him sign a release before the last one. That was after the cardiologist told him no more colonoscopies until he got his carotid arteries fixed. Even the S word, stroke, couldn’t deter Frank.
I’m not going to have a stroke, he said.
It struck me that he has one set of evaluators for a real disease that could do real harm and another set for the harmless imaginary one.
He wrote a long letter releasing everyone this side of Kansas from any kind of liability connected with colonoscopy. This is a man who knows what he wants even if it doesn’t make sense. We did it, but not before I secretly cleared it with the cardiologist. And we survived. All three of us. But I told him no more nonsense until he got a little more blood flow to his critical body parts.
Now the time has come. ’Bout time, I say. The vascular surgeons are ready to ream out his carotids, but he wants to ask me a few questions first. I knew that. And I know what’s coming—so here we go.
I understand you can get a stroke from this operation.
That’s true.
How common is it?
I don’t know. Not very common. It’s a question you should ask the vascular surgeons.
They don’t hold still as long as you do.
Tie them down and ask them. Meanwhile, they don’t do the surgery unless the risk of waiting outweighs the risk of the surgery itself. It’s a complicated formula, and I’m sure it’s only partly accurate, but that’s the intent. It has to do with the extent of stenosis.
What’s that?
Narrowing.
How narrow is mine?
Ninety percent, both sides.
Is it safe to say it’s small?
What’s small?
The risk of stroke.
It’s small. Smaller than if you didn’t have surgery.
How long will I be in the hospital?
Don’t know. These days, probably not long.
Three days?
Thereabouts.
I read that they will put me on something to thin my platelets.
Yeah, probably.
What’ll that be?
It’s up to the cardiologist and the vascular surgeon.
What are the side effects?
And I’m thinking to myself, This is an example of how questions get asked for the sake of asking. Fueled by their own passion, they spring from a point beyond the platform of knowledge. How would I know the side effects if I don’t know the drug?
I can’t answer that.
A long silence.
The rabbits were moving from one pile to another.
Well, I have some questions about these bor . . . I can never say it.
What?
Sounds in my abdomen.
Borborygmi.
Yeah, that. I keep getting these loud noises.
You always have that.
Yeah, but I don’t believe it’s normal.
I know you don’t believe it’s normal, but you’ve always been normal. Every colonoscopy has been normal. We’ve studied you from teeth to toenails and there’s nothing in there. Nothing.
What do you listen for if you think you’ve got cancer?
Now we’ve come to it, I thought. This is the root of the multitudinous colonoscopies, the driving force for the unseen locomotive: failure to believe negative data. Failure to temper the fear that something is wrong somewhere.
I am careful to speak the truth. But truth comes in many packages and it looks different to different people. For Frank I will speak it in a way that wants to bring him back to earth. Just somewhere along terra firma. It would be a mistake to lay out all the variables. That would give him too many openings to hang himself on yet another obsessive rope of worry. So I overstate.
You don’t have cancer.
How can you be sure?
You don’t have cancer. Since he cannot shut that door, I shut it for him.
He acts like he didn’t want to hear this. He looks uneasy, fumbling with his notes as if they, by their meticulous preparations, will ride him over this unpleasant hiatus. They do not. He is forced to accept and move on.
Well, what do abnormal bowel sounds sound like?
I could be offended by that question. Layered into it is distrust of my ability, my training and experience to listen and report, as if only he, with his untrained ear, can decide what is normal. I conclude it is an accident of distraction. Of obsession. He is blinded by his worries.
I indulge him; I’m not sure why. But I can feel that I’m getting close to my limit.
Bowel sounds are abnormal if they are absent for one minute in all four quadrants of the abdomen, if they are high-pitched and occur in rushes as they do during a dynamic obstruction, or if they are amphoric, meaning that they sound cavernous, like water dripping in a very wet cave—
He interrupts: Can you be more specific?
No.
No?
No. End of lesson.
Well, I want you to hear—
I’ve listened to your belly a hundred times.
No, I mean—
And he brings out a little velvet pouch, something you might see holding a family heirloom, a watch perhaps, the lovingly engraved kind, made of gold and wound by a tiny gold key. He lays it on the table and starts clumsily trying to extricate whatever it is that is wedged inside.
And with a straight face he says, I made a recording of these bo . . . bo . . . bobo . . . rygeums, or whatever. I want you to listen to it.
By now he has the recording device out on the table and is fumbling with it, trying to get it to play. It’s not cued to the proper place and he is madly forwarding and rewinding. I realize I am most amazed not by the weirdness it takes to record one’s own bowel sounds, not by his solipsistic assumption that I will find this of such great and compelling interest as to arrest my whole practice while we await the multimedia presentation, but that I will tolerate his time-consuming fiddlings with this bowel-noise recording device of his while patients fully deserving my attention wait their turn. Were it not so humorous, it would be maddening.
Without thinking, my body has stood up and is leaving the room. I babble something polite like I have to see someone down the hall, and am gone before I can laugh or burst out with something I’d be sorry for. I am tempted to relate this story to those in the hallway, but who would believe that there’s a guy in my office playing a recording of his own bowel sounds?
When I return, he’s found it. He plays me ten seconds of static, mike noise, adventitial sounds. And in the background, harmless bowel mumblings.
Normal, I pronounce.
Are you sure?
Sure.
He is incredulous, but I leave him no openings. I am not in the mood for encores.
He is quiet for a moment. Then he rallies. I was reading about fistulae, he says.
Oh no.
Yeah, and how do you know if you’ve got a fistula?
Frank, I say. Cut it out. You’ve got a real problem in your carotids and you’re out there trying to invent something in your gut you’d rather talk about. We’ve been there. Done that. Checked you out, first class. All is well in loop-de-loop land.
I have stunned him to silence. Even so, I know I’ve not heard the last of this. When he is away from me and my slaps in the face of the disease he believes in so furiously he almost wants it, doubts will filter in along the periphery and eventually, because they are welcome there, occupy again the pathways to the center of his being. He will build them up meticulously, like a young man smitten with a model airplane project, with the same concentration and enthusiasm of one whose grand vision is somehow tied to what he is building, all energies now turned in the same direction, recruiting evidence, plotting how to convert the heathens who refuse to see the obvious. Oh, for someone to share his vision.