by David Watts
So I’m telling the son about this. Everything was normal a little while ago, I say. She’s done this several times before, and I know it’s confusing because although it looks serious we almost never find anything wrong. The truth is, these blowups always seem to be connected to some major stress in her life.
But the son says that something’s got to be wrong.
What’s missing from this picture, I wonder. I’ve told him already about the recent negative workup, that I’d make time to see her tomorrow, and I would make certain everything appropriate was done.
He is unmoved. He says that he’s concerned about her taking enemas all the time to keep her bowels moving.
I say that her psychiatric medicines have made her constipated, and if she has to take enemas it’s better than having her go crazy.
But she’s coming off them, he says, because of the constipation.
True. And last I heard, two days ago, she wasn’t constipated at all.
But there’s the pain and the nausea.
I know, I know. And we have to evaluate that. I will do that. But you have to remember she always has pain and nausea. Ever since the first day I knew her, she’s had pain and nausea.
Yeah, but it’s worse.
It’s always worse and we’re always checking into it. But I’m not optimistic we’ll find anything.
Well, you remember my father.
I can’t recall that I do.
The doctors kept seeing him for his complaints over and over and never found anything. Then he died.
I’m tempted to say we all die. We all see doctors. There may not be a connection between the two. But it would only inflame the situation, and by that admission I know now where he’s coming from. This is a cookie from a bad recipe. He has a neurotic mother with a litany of unsubstantiated complaints and the memory of a father who died without a diagnosis. Bad combination. This guy will never be convinced.
And then I realize what has just happened. Responsibility, ker-plunk, has just been placed back in the doctor’s court. Service ace. No return of serve. The son—because his father died undiagnosed, because he grew up with his mother’s pathology and had a blind eye for it— for whatever reason, refuses to take responsibility, refuses to allow that his mother’s neurosis can be generating all this whoop-de-do, and chooses to rely instead upon the notion of a doctor’s oversight.
Then the psychiatrist comes in the picture: I’m worried there’s something serious going on here, he says.
We’ve been here before.
Yeah, but this is different.
How so?
Much more serious . . . somehow.
She’s off her meds. Doesn’t that make her out of control?
Sure. But I think—
Look, we’re already on it. I’ve talked to her with a plan and a map two days ago. Her greatest concern was not the pain or the nausea, but just that she would be allowed to talk to me again. I take that as a sign. And don’t you feel a bit used here? In any case, we’ve got the emergency room if she falls apart.
He’s not convinced my position in the matter is correct. But neither am I convinced of his. Now we have something in common. And I have the distinct feeling the tennis court has just added one more opponent.
And then Geraldine. Her turn on the phone.
Oh, Doctor Watts. Finally!
What can I do for you, Geraldine?
I haven’t eaten in three days. The pain is unbearable. The nausea. Can’t you do something?
Are you constipated?
No. I have diarrhea.
How about the psychiatric meds?
They’re stopped.
Did the medications I suggested do any good?
None whatsoever. I’m in such incredible misery.
Where is the pain?
All over.
In medical school I was taught that unlocalized pain was not likely to be caused by anything physical. Vague abdominal pain is psychosomatic until proven otherwise.
Where is the pain when it’s at its worst?
I can’t tell. It’s so bad it doesn’t even have a location. Why do I have to suffer so?
And I think to myself that these, without a doubt, are the most dangerous patients. They’re never really sick. Almost never, and there’s the rub. It keeps you guessing. The symptoms they have are for the most part not real. They invoke an inordinate amount of perturbation in their lives. The patients develop a support system that includes medical services that reward symptoms with much longed-for attention, family and friends who are all too eager to sympathize and to place the blame on anything but the one explanation that ties it all together. In short, everything falls in place to encourage and reinforce the problem. And in the middle of all that stands the physician who, frustrated by the hopelessness of it all, is apt to become just cavalier enough as to overlook the one time she really does get sick. And that, ladies and gents, would be a real screwup.
You’ll have to come to the emergency room, I say.
Oh, Doctor Watts. The last time I went there I lay around for five hours and they didn’t do anything.
Of course they did. They did what they were supposed to do, Geraldine. They examined you, did tests, X-rays. Made sure you were all right. That’s the whole point.
But I don’t want to go.
Look, Geraldine. If your pain is as real as you say it is, you’d kill for a chance to go.
Will you be in touch?
I always am.
But I don’t like ERs.
I don’t know anyone who does. But in precisely this situation it’s the right thing.
Will you call them?
I already said so.
Is it serious?
What?
Am I going to die?
I can’t help thinking that death in the abstract is a great deal scarier than the real thing.
Not yet, I said.
Will you talk to them?
Geraldine, why do I have to tell you five times . . .
And I realized this was Frustration Central breaking through like WLAC-Nashville on a stormy night. If it were still me, I would know better than to believe any objection of mine would change her behavior.
Okay, okay. I’m going, she said. The taxi is waiting outside. Will you call . . . ?
Wednesday afternoon, my day off. I am watering the garden with my twenty-month-old son, Gabriel. My wife comes to the catwalk with my cell. That’ll be the ER, I say.
Oh, hi, Doctor Watts. It’s Johnny. Let me get Doctor Austin for you.
Dr. Austin comes on. I’ve got Ger . . .
Geraldine McIntyre.
Yeah, that’s right. She’s . . . um . . . something.
How does she check out?
Well, her abdominal exam is completely normal. No masses. No tenderness. No abnormal bowel sounds. There’s nothing to suggest any pathology down there at all. She’s a little dry, probably from the diarrhea and not eating. We thought we’d hydrate her up with a couple of liters of IV fluids. Her labs are normal. No white count. Liver okay. She complains of constant urination, but her urinalysis is normal—no cells to suggest infection, no sugar to make her osmotically diurease. And her blood sugar is okay. I guess we just wanted a little background. How to handle this situation. She’s . . . I want to say . . . umm . . . well, how can I say this and be polite?
She’s crazy.
Yes, that word will do.
I hate to laugh at her expense, I say. But she’s probably the most neurotic person in my practice. She’ll disappear for a long time, six months or so, as if she’s been distracted by something else, and then she’ll show up with a bang and give us thirty calls a week. With the exception of the gall-stones we found and took out three years ago, there’s never been anything wrong. I didn’t want to tell you this in advance so as not to prejudice your workup.
Well, that’s kind of what we thought.
I had planned to see her tomorrow, but things sort of fell apart. I apologize, bu
t I sent her to you. Crazy people get sick, too.
Yeah, but not this time.
Gabriel has been very patient with me. Now he holds up his green watering can and asks for a refill. He is naming things and blessing them with little sprinkles: flower, rock, chair. Can, he says. Toe. Toe.
Bless you, Gabriel, I say.
I will call Geraldine tomorrow. I will work her in between patients, lay my hand on her belly, let her, without showing any criticism I might feel, unravel and reravel again. We will sift through her complaints, which she offers like requests for something lost, filtering and weighing, reserving judgment, looking for the one true sign and wishing that somebody, early in her life, had blessed her, too.
JOKE MAN
The police called to say they found my patient in a motel room with sleeping pills and a bottle of vodka. He left a note of apology and a $50 bill for the maid who found him.
Next day a letter arrived. I never lied to you before, Doc, it said. But I did this time. Sorry. I hope you’ll forgive me. Inside the letter were two $100 bills. Take your wife out for a nice dinner, he said. Go have a good time.
Charlie the joke man, the button salesman, spent his life collecting jokes for his clients. Long since retired with no place to tell them, he brought them all to me. Stacks and stacks of them. So many I kept the recycling man busy.
Now let’s talk about what I want to, he had said on his next-to-last visit. I need some advice. When the time comes I don’t want to be here . . . if you know what I mean.
I had a good idea, but I wasn’t sure. I was always wary of surprises, knowing Charlie.
A friend of mine will get me a gun, but I don’t know the right place to point it. And he made a few gestures at his head and face. Does it bother you to talk like this?
I knew the situation: Charlie had terminal lung cancer. And, on top of that, advanced emphysema from all those years on the road partying and drinking and smoking. You give the client what he wants, he always said to me. If they want poker, you start up a game. If they want girls, you get girls. Lungs so bad the surgeons wouldn’t touch him.
A gun is a hell of a way to go, I said. Painful. Messy. His expression was like a child’s, learning some new constellation in the sky. I leaned over the desk. And think about the person who has to clean it up.
Hadn’t thought of that, he said, and took a deep breath. I could hear the sound of cars passing outside the window, the scrape of a bulldozer down the street.
I’m dying, Doc. It’s not a major deal. Even the red-woods . . . have to die . . . sometime . . .
He was breathing hard just from the effort of conversation. I sized him up. A couple of weeks, tops.
He paused. And in that pause there was no world outside.
Do you know my history?
I do.
Do you? Do you know the condition I was in twenty years ago—just about dead from all that Crohn’s disease stuff? First time I came here, you guys put me in the hospital and changed all my medicines. I should have been dead twenty years ago. I think I got a pretty good deal.
I could feel the unspoken tension of my patients in the outer office, waiting. But I felt no pressure to hurry. This would take as long as it wanted.
Yeah, pretty good, he said. A pretty good deal. And I realized he thought of all those years as a bonus. A gift. To die after he’d cheated death was easy. It was a level of contentment I had to admire.
And that’s about it for me, he said. I guess I had better get going. Oh, incidentally, I’m going to need that renewal on my sleeping pills, you remember.
I didn’t. And suddenly it dawned on me that this was it. There would be no speeches. No good-byes. He was just going to walk out the door and never come back.
He talked about his computer, the e-mail, how there were so many jokes on the Internet these days anybody could be a comedian. I watched him like I was watching a movie with the sound turned off.
And in that moment the room was empty of training and law. There were just the two of us in a quiet place. Even the term each other changed its meaning. Here was a friend when only friendship mattered. And there was nothing else in the world but this, this and the river-rush of understanding that deepened between us.
He leaned over the desk, looked hard into my face, and said, How are you doing?
The question caught me off guard and I couldn’t think of an answer right away. Fine, I said, awkwardly, surprised at the unsteady tone of my voice . . . I’m . . . and then with resolve, knowing it was not an idle question . . . I’m just fine.
That’s good, Doc. That’s good. Oh . . . did you hear the one about . . .
And I had heard this one, and I knew when he turned from the door he was going to tell one of his tasteless, off-color jokes that I would never retell to anyone and five minutes later wouldn’t be able to remember . . . and I laughed, I remember I laughed anyway . . .
Thanks for everything, Doc, he said.
And then, I let him go.
THE GIFT OF NOTHING
You are not a doctor, they told us on the first day of medical school. So don’t go around acting like one.
Then they told us the story of two young people at a carnival. The girl fainted. The medical student, feeling compelled to act, stepped forward. He mistook her for a cardiac arrest. It was in the days before modern techniques of resuscitation, and with his pocket knife he opened her chest. The patient, a healthy teenager, did not survive.
Authority is dangerous. Coupled with ignorance, it can be lethal. Nor is the problem confined to the occasional medical student. On the Autobahn near Würzburg, Germany, I pulled over to help a Middle Eastern man, sitting with his son beside his overturned Mercedes. The son had a broken arm. I’m a doctor, I said. Thank you, said the man. Would you look at my son’s arm?
I was out of my element, an army doctor who ran a dispensary for soldiers and who remembered little about roadside medicine. I recall debating whether to stop in the first place, uncertain what might be required. It made me nervous and cloudy.
Maybe it’s not broken, I said, only glancing at it, choosing foolish optimism rather than confessing I wasn’t sure what to do, missing the boat rather than declining to act or comment. I think it’s broken, the father said. And there was a long silence in which the man and his son were more at ease than I was.
I should have left well enough alone, but I broke the silence: Maybe I could examine your son’s arm again.
The father winced as my thumb flipped the floating radius. Like the medical student, I was acting without reason. Maybe it’s not broken, I said and left. Only miles down the road did I realize I had not even offered to make a splint.
Ignorance dominates. Wisdom is slow in coming. I’d been sucked into the vortex of apprehension and was paralyzed. It would have been simple to break out of it if I’d just confessed that I didn’t know what I was doing.
Action has the appearance of competence. Physicians trained at intervention may lack the courage to do nothing. Yet “nothing” would have saved the young woman and avoided unnecessary pain for the boy at the roadside.
Hippocrates knew about that. Primum non nocere, he said. The first rule of medicine, do no harm.
The more I know, the more I feel my ignorance. And the more I want to make peace with that. So I practice doing nothing a lot these days. I’m getting better at it. I told one of my patients I saw it as my job to build a wall between her and her surgeons. A brick wall. After six abdominal surgeries, the devil we know is better than the one behind the next surgery.
I admire decisive action. It can be lifesaving. But I respect inaction in some ways even more. It takes a different kind of courage to withstand the pressure to do something and abide by your limits. So I’m thinking of hanging a sign where I can see it every day. “Okay, so you’re a doctor,” it might say. “Just don’t go around acting like one.”
THE GIRL IN THE PAINTING
BY VERMEER
Ten o’clock Monday mo
rning and she’s waiting for me, my new patient, a woman who looks younger than her thirty-five years. She almost curtsies as she shakes my hand. She wears a light tweed suit that reminds me of Easter Sunday in central Texas.
She has a quick laugh that juts into conversation with surprising speed and at unexpected places, as if she’s embarrassed to be speaking out loud. She’s a violinist who teaches a large clutch of students and is frequently tired, but blames it on her heavy concert schedule. She’s lost weight. No other symptoms. Oh yes, night sweats, drenching. Another doctor found something in her liver, and she wants to know what I think.
In the exam room she reaches down and pats her belly. Do you see it? Do you see my hemablob? Your what? My hemablob. That’s the name I gave it. She laughs. And there, out her side, a large bump protrudes, lifting the skin over it like a mound of soil over something buried. Holy cow, I think to myself. That thing’s huge. She’s looking up at me. Hemablob, I say. It’s a great name.
We run a few tests. She’s giving a lesson when I call with an update and a plan. She doesn’t ask questions, just says, It’s a mind boggle.
I schedule a colonoscopy. Two seconds in and I find it. The nurse groans as the lens picks up the unmistakable fleshy, crumbling mass, plastered to the side of the rectum like a fungus gone mad. The room grows quiet, as if we were standing around the embers of a house burned down, kicking the cinders aimlessly.
I look down at her lying on the table. She looks young and perfect, relaxed in a posture of grace like a girl in a painting by Vermeer. But I know her body’s ruined, rotting from the inside out.
In recovery I tell her I found it. She says it makes sense. She’s been thinking there might have been a little pain, a little bleeding. I’m sorry for the trouble I caused you, she says.
She decides to move back to New London to be close to her friends. I call her at home the next day. Her voice still has that light lift I heard the first time we met. I say I wish I could have found something nicer. She laughs and thanks me for picking up on her crazy way of communicating. I do violin all day, she says. I’m not very good with words.