by David Watts
I called the bookkeeper and she says we can’t see him, my receptionist says. She is being responsible.
I have no hesitation. I have seen this man. I know that we are in this together. Put him in a room, I say, and then I go about finishing what I have to do so I can squeeze him in.
When I enter, it is his wife who speaks. Five times a day, she says. Just like water. Irish brogue, I think. Ten years off the boat.
He looks up at me, puffs a little smile on his pursed lips, then glances back at the spot just above the floor where his eyes have rested since I came into the room, as if the glance he gave took great energy, rising from somewhere near stupor to acknowledge what is moving toward him.
Thank you for seeing us, she says.
I know they’ve overheard the discussion that sounded like rejection in the making. Now the poverty of his disease shows through, and with it something that looks like gratitude. He is humble, quiet. He reminds me of my father in the last days of his cancer treatments, with his unspoken, undemanding attitude: whatever you can do for me, I’d be most grateful.
To think, my bookkeeper and I had the power to refuse this man.
I say that clearly he needs to be seen, and I’m glad to do what I can.
Now the exam is over. Nothing dramatic. That’s good news, I say. But I want a couple of his new medications stopped or changed, a couple of tests done, and if, after the recommendations I will give him, nothing improves, we might need to look at his colon with a scope.
He nods with the kind of supplication so complete that doctors have to be wary not to overdo their ministries.
One step at a time, I say.
Would you do me a favor? his wife asks.
Sure.
Talk to my daughter. She can translate all the difficult words for us. It would mean so much.
She fumbles with the cell phone, nervous that she is taking too much of my time. Comes up with three wrong numbers in her haste. Don’t hurry, I say, and I’m struck, almost amused, by this awkward coming together of old-world charm and modern technology.
The daughter comes on the line. I recite the history, what to look for, the tests I plan. I mention the possibility of ischemic bowel disease, since his diabetic arteries may not be bringing enough oxygen to the tissues, but reassure her I want to stick to the simple things first. There is an immediacy of understanding that cuts through the brain’s propensity to cloud when dealing with loved ones. Professional. I appreciate that.
We’re set but for one thing. If it comes to colonoscopy, I say to the daughter, and by overflow to the parents as well, you probably don’t want me to do it. I’d be glad to, and I could even do it without charging you anything, but since I’m not in the HMO anymore, they would make him pay richly for the hospital and facilities fees. The parents look a little disappointed. It could be thousands, I say.
I feel the daughter’s nod pushing through the microwaves.
. . . But I’m more than happy to get him started on the right track . . .
The daughter breaks in: We’ve got an appointment later this week with one of your colleagues who is still in the HMO.
Exactly right. Good.
We are done. Except that if I don’t derail the paperwork monster, a lot of low-reimbursement time and effort will be spent, and when it’s done, this couple might be out a hunk of valuable change. Nothing about that process appeals to me. I write no charge on the front of the chart.
My receptionist will be embarrassed, my bookkeeper angry. They’ll have to get over it. We’re all supposed to give away our services sometimes. The problem with the HMO is that it makes you feel like you’re giving it away all the time. Stifles your generosity. Makes you a different person. And, paradoxically, it takes away a big part of why most of us go into this profession in the first place. I like this arrangement better. I get to make the choice and feel the pleasure.
Yet I am about to lose these people, people I’ve already become attached to. I want their stories, their language, the little wisdoms that lie in the cracks between opportunity and hardship. It isn’t just I who am giving something here. Lying within the exchange of stories and wisdoms they so willingly bring to me, the gifts and trades that make us larger than ourselves, is what elevates what I do from a profession to a calling.
I say good-bye and leave quickly. I want to escape their overly gracious thank-yous and the imbalance of power they suggest. I will call the cardiologist and make him promise to tell me how they are doing . . . just like I’m the doctor who’s still following them . . . just like real patients.
Just like family.
IF YOU SAW IT, IT WOULD LOOK LIKE A TREE BURNING
I have a daughter, she said.
This, in the little pause that comes at the end of the office visit, a stillness in which subjects like the latest sculpting project, the triathlon, the arrogance of politicians, the unexpected and interesting you’d never think to ask about, come forward.
You’d like her, she said. Pretty. Intelligent.
I’m sure I would, I said. And I thought to myself that I have always loved how this moment fears nothing, as if it knows the hard work is done and it’s time for what the mind is really thinking.
She’s a great scientist. She just got a million-dollar grant to study cancer of the bone marrow and is moving to Switzerland. They put together a lab for her there.
That’s great, I said. Quite an accomplishment. Then I raised my eyebrows, or rather, they raised themselves, as if they knew to ask for something more. Silence more than any question brings out the right stuff. Silence knows what to ask.
You know, she said, she works in a medical lab but can’t go near a hospital.
What do you mean, can’t go near.
She freaks out.
Her mother was puzzling over something, something that had another side to it perhaps, something she’d not yet seen, or now was looking at more clearly, like the side of a face in a certain quality of light.
She was born with a patent ductus arteriosis, you know.
I didn’t know, but what I did and did not know was not the issue. So I just nodded.
And they operated on her when she was two months old.
I folded my stethoscope into my pocket.
Nowadays, I guess they don’t even repair those things, she said. They grow shut or something. Well, they operated on her, and it was in that famous hospital, you know the one, where the chief of surgery made the cover of Time magazine . . .
. . . and when they finished they came out and told us . . .
. . . well, they came out . . .
Her head drooped a little and her fingers occupied themselves with a piece of lint.
. . . and told us they hadn’t used any anesthetic. That’s what they said . . . after the surgery.
My voice was in the tank. She went on.
They said a two-month-old baby doesn’t feel pain. They said children who don’t anticipate pain don’t feel pain.
The shock and astonishment was settling in like penetrating oil. I sighed. What part of this tragedy to address first? I paused. When there is no conversation in these little caesuras, I often think of October and imagine briefly that quality of wind that passes through trees . . . how the trees seem to move with it . . . And I don’t even remember what I said when she told me her story, but somehow the image of that tree rushed back into my brain, and the wind that moves through it.
My baby cried for three days, she said. All that time she was in restraints so she couldn’t tear out the IV lines and stuff. Then she just withdrew. I’ve never seen anything like it. She wouldn’t look at anyone. She wouldn’t even look at me.
The piece of lint, squashed and rolled, fell to the floor.
We spent a lot of time with her and she got better. But afterward she would trigger.
What do you mean, trigger?
Something would set her off. Maybe I would pick her up wrong and she would be inconsolable. Or a stethoscope. A stethosc
ope would make her go through the roof.
The moment was wide and slow. I tried to imagine what the surgeons had been thinking. They could not have believed that a baby doesn’t feel anything. Come on; if you pinch a baby, it jumps. And the business about anticipation—you only have to look at infants to know they are absolutely present in this world: They understand what’s going on in the room, they sense the slightest change in emotions, they identify their mother and their father and watch their eyes for subtle signals only they understand. They even regulate their heartbeat by imitating what they sense from the parent lying near them. They are wise and intelligent. They just don’t have the language to tell us what they’re doing.
The infant doesn’t feel anything . . . was just a fiction they used to explain themselves.
I thought of my own children, the wonder of their unfolding complexity. And my mind went back to the morning, early, when my three-year-old son, Gabriel, looked up at me from the bathtub and said, Dad?
Yeah?
There are three brains. Did you know that?
No, I didn’t. What are they?
There’s the volcano brain. Get it? Volcano Brain?
Well, sure, I think so. Then what?
There’s the brain in the head, he said, pointing authoritatively to his fingers as if to articulate the list.
I couldn’t wait for the next one. Okay, I said. What else?
He paused for a moment, then said, It’s the brain in the heart. Didn’t you know that?
Exactly, I said. Exactly. Even my three-year-old has a construct for emotion and intelligence in the body.
I remembered the moment Gabriel was born, two months premature, and how, when I saw him lying in his incubator, I could feel compassion and wisdom moving through the room like a blessing.
And I knew what the surgeons had done.
Did she ever get over it? I asked.
Never did. Even now just looking at a bandage — a little Band-Aid — she faints on the sidewalk. Last week she went to have her blood drawn. She had to lie down and cover her head with a towel, and still her legs were shaking so bad I had to give her pressure points.
I pictured a baby on the operating table, four months older than my Gabriel at birth, her chest open, alive and awake. That baby was aware. That baby knew what was being done to her, and by whom. And that unimaginable experience would mark her at every level of consciousness as long as consciousness exists.
The story was told. My patient brushed her pant leg as if there were other pieces of lint neither of us could see. She was right. I did want to meet this person.
And I wanted to stand with her
without saying anything.
And I must have mumbled something like that
because her mother
said she was grateful,
and then we just stood there awhile and I
could only think of that tree
with all the wind inside it.
THE HMO AND THE RENEGADE IN ME
Well, I got this letter from the HMO thanking me for cooperating with the Re-Credentialing Medical Record Review Inspection. I must have dropped my guard. Shame on me to let them sneak in while I wasn’t watching.
They said a minimum score of 80 percent was required. And the doctors who scored less than that would be required to submit a “strategy for corrective action” within thirty, and then the little (30) in parentheses like they always do, days.
It bothers me when I hear words like strategy and corrective action. They’re the kinds of words people use when they don’t want you to know what they’re up to. Strategy. A good strategy, it seems to me, would have been to lock up my charts.
Yes, and one thing more. They said subsequent review would be conducted one—and then the (1) in parentheses again—year later just to see if I’d improved upon myself. Kind of reminds me of Big Brother and all that.
Well now, there are certain things I could improve. I’m sure about that. I’m just not sure the HMO and I would agree which things.
For instance, they want me to put all the medications the patient is taking in the front of the chart. It’s not a bad idea. Except for anybody who changes medications frequently. You get so many scratch-outs and overwrites you can’t read a damn thing. So I put that information along with the notes for the most recent visit. That way I know what’s what. And when it’s what. The HMO didn’t see it my way, and I got a zero on that one.
And then there’s this little matter of the return visit. Doctors always say when we’d like the patient to come back and see us again. You have to follow people up to find out what’s going on. Well, I put that information on the front sheet, outside the chart, right where the secretary can see it. No hassle. No mistakes. Been doing it that way without any problems for twenty years.
But the HMO wants me to put it at the bottom of the note that’s inside the chart. Never mind that it works better for all concerned to do it my way. Zero on that one, too.
Then they want me to record a physical exam each time the patient comes into the office. I don’t do a physical exam each time. It’s a waste of time and money. The best policy is to address the problem at hand with your full attention and do your complete physical exams periodically, according to age and necessity. Since the HMO doesn’t pay for it, I guess they feel free to request it.
Brings out the renegade in me.
Oh, and I forgot to tell you they said if I don’t comply with the demands of this review, they can haul me before a “committee of my peers” and fine me $1,000. For one thing, anybody who would sit on a committee like that isn’t any peer of mine.
The letter told me my score was 72.73 percent, which I thought was pretty good considering they didn’t even look in the right place for the information. Must have been that 100 percent I scored on all those other little things like blood pressure, physical exam, mammograms, cholesterol, PSA . . .
But the guy in the letter didn’t think it was so hot. And didn’t show any sense of humor when I called him up and suggested that they should send someone out who knew how to read. I told him in any case I wasn’t going to change my charts around for the convenience of the inspector who didn’t know how to find things.
He was not amused. He suggested I prepare myself to appear before that “committee of my peers.” And I said they were his peers, not mine, and if I thought by doing battle with his committee I could make the system work any better . . . well, you know the rest. He stuck to his committee thing and I stuck to my no-committee thing and I tendered my resignation.
Now, you may wonder why all this fuss about charts. Well, they think they can measure that elusive little butterfly, quality, by looking at the charts. It’s true there are things doctors are supposed to be doing to screen for cancer, diabetes, and the like. I agree. And I do that. And I put it in my charts. But quality doesn’t reside where you put your return visit or your medication list. I’ve always thought it had more to do with a thorough knowledge of the craft, compassion, close attention to your patients, and maybe that openness which allows the doctor and the patient to work together. I haven’t figured out a way of looking at a chart and measuring that.
Maybe they haven’t either.
THE STALKER’S BRIDEGROOM
The treatment isn’t working, she said.
Her accent was Eastern European, her hair short-clipped, tapering to the top of her neck like phosphorus to the head of a match. Middle-aged, stony-eyed, she asked about my family and looked at me as if I was to do what was expected, no questions asked. I spoke into the magnet of her gaze. Things aren’t great, I said, recent divorce . . . Suddenly I felt strangely inappropriate. I shook it off and turned sharply to the business of the day: which diet to choose, how much fiber to add, which laxative was not habit-forming. She went away. And came back, saying, It isn’t working . . . and what was that about your needing company?
I said I didn’t. And I hadn’t said so. But my protests weren’t working. I was off balance
, on the defensive without knowing how I got there. She said I hadn’t answered her question correctly, but it was all right, she understood what I meant to say.
She bought my book of poetry, quoted lines to me. She came to one of my readings, then wrote to me saying she could tell my eyes were looking for her. I wrote back to say that they weren’t and that I wasn’t interested in anything but a professional relationship. I told her that if that didn’t work for her, she’d have to find another doctor.
She missed her next appointment. Then the gifts started coming: Swedish strudel, a CD of Christmas carols played on a German-Swiss music box, a hand-carved statue of the Virgin Mary. I returned the statue, gave the strudel to my secretary, put the CD on the shelf. Then I sent a message: NO GIFTS.
My home phone rang . . . no voice, no dial tone . . . It rang evenings when I walked in the door, at midnight when I turned out the light, mornings as I walked out the door to go to work. The apartment manager asked if I knew a woman in a dark coat who was hanging around.
I began to imagine tapping at the window, footsteps around the hedge. My mail wrinkled in its box. I asked my secretary to get in touch with her, but the number had been changed. Letters we wrote trying to set things straight came back with no forwarding address.
The situation was out of control. There was no meaning but her meaning, no idea outside the tight kernel of her idea. The look she had given me when she didn’t like my answers began to haunt me. I had never seen a look like that. It had rejection and demand mixed into something that was both absolute and powerful. There was no possibility I was going to change this vision of hers, but, more important, there was an almost hypnotic power bearing down on me, requiring the answers she was looking for.
Should I have seen this coming?
Christmas passed. Then Valentine’s Day, and the day after a young woman calls and asks, Are you in love with my mother?