Making Rounds with Oscar

by David Dosa

  “We had the Peking duck, Doctor.”

  “That’s right, the Peking duck.” Ruth seemed pleased with herself, as if she was the one who had recovered the memory. “It was so good. You really have to try it.”

  I smiled and said I would. The conversation, however, was troubling. Despite her preserved social graces, it was becoming increasingly apparent that Ruth had some issues with her shortterm memory at the very least. Though she skillfully hid it by deferring to her husband, the more I continued to isolate her from his coaching, the more apparent it became. The simple memory tests I gave her next only confirmed my suspicions.

  I gave Ruth a piece of paper and a pen.

  “I’m going to ask you to draw me a large circle and pretend it is a clock. Please put the numbers on the clock.”

  It’s a simple task that any grade school student should be able to perform, but Ruth struggled with it. Robbed of her husband’s assistance, she painstakingly placed the numbers on the clock, pausing to consider the position of each one as if her very life depended on it. Perhaps, in a way, it did. After a minute, she looked up at me with a sense of accomplishment. Like a student proudly giving an aced test to a parent, she handed me the piece of paper. I looked down at her work and noted that the numbers one through twelve had been placed correctly on the clock. Then I handed the paper back to her.

  “Now I want you to draw the hands on there at 2:45.”

  My request was met with a concerned smile. Ruth’s eyes drifted up toward the clock above the doorway. She studied it momentarily before speaking.

  “Doctor, I don’t know how any of this has anything to do with me. I’m fine, really. I don’t know what my husband is going on about.”

  “Mrs. Rubenstein, I know it seems silly, but the test can really be helpful to me in figuring out what is going on. Could you just place the hands of the clock at 2:45, please?”

  Ruth sized me up.

  I refused to back down.

  She looked back at her drawing and shook her head, as if frustrated by the inconsequential nature of my request. She considered the numbers on the page.

  “What time do you want?”

  “2:45.”

  Over the next minute, the mental strain of the activity became more obvious. She tapped her pen on the paper. Intermittently she broke the silence with nervous laughter.

  “I was never really good at math,” she announced. I didn’t have the heart to tell her that the task had more to do with visual-spatial skills and executive function than math. The clock test is standard for just that reason: If you can do it, the chances are excellent you don’t have Alzheimer’s. It’s also a highly significant indicator of how you will do on the road. I wish the DMV would give this test along with the eye exam.

  I waited patiently for Ruth to finish. Finally, after several minutes, she drew the little hand pointing to the 2. Then, like thousands of other patients with memory impairment, Ruth placed the minute hand of the clock between the 4 and 5, rather than at the 9.

  Convinced that she had once again aced her exam, Ruth looked up at me with a sense of extreme satisfaction. As I looked over at her husband, it was apparent that he didn’t share her enthusiasm. A tear had come to his eyes, which he quickly wiped away before it could find its way down his check.

  I then launched immediately into another battery of memory tests without saying a word about her performance. She seemed momentarily disappointed by the lack of feedback, but there is nothing much that I can say in that situation—nothing that the patient wants to hear, anyway.

  “All right, Mrs. Rubenstein, I’m going to say three words and ask you to commit them to memory.”

  I recited three words—apple, book, and coat—and asked her to repeat them back to me. She remembered two out of three. Five minutes later, she would almost certainly remember none.

  I asked her to spell a five-letter word, world, forward. She did so, quickly and precisely. A smile that said “I told you there is nothing wrong with me” appeared on her face.

  “Now can you spell it backward?” I asked.

  She looked at me with the sort of lethal stare she gave her husband earlier.

  “Doctor, I don’t understand why any of this is necessary. I’m totally fine.”

  I repeated my request and she continued to struggle; she was finally able to get only two of the five letters in place.

  Switching gears to another memory test, I asked her to write down the names of as many four-legged animals as she could in a minute. Normally, patients can name over ten in this test of executive function. Today, my five-year-old son could probably name twice that, but Ruth named only six that day and wrote cat down twice.

  We finished a few additional tests and I asked Frank to escort me to the waiting area so I could conduct a more thorough physical examination. He seemed reluctant to leave, but did so grudgingly after his wife gave him a reassuring smile.

  “It’s okay, dear. It’s just part of the exam,” she said.

  In the hallway, I used the opportunity to openly ask Frank some harder questions about his wife. I have learned over the years that there are many things family members do not want to disclose in front of the person suspected of having dementia.

  “Has she done anything dangerous?” I asked.

  “What do you mean, Doctor?”

  “Has she left the bathtub running or has she left the stove on?”

  “I suppose she’s burned the meatloaf a couple of times but she was never much of a cook.”

  He attempted a meek smile.

  “Has she crashed the car or been in any fender benders?”

  Patients with dementia have an extremely high rate of car accidents although few are ever reported. Frank shook his head.

  “Has she acted strangely or have you noticed her behavior changing?”

  “She’s a little more suspicious than she used to be. The other day, I went out to a restaurant with a few friends. When I got home, I caught her going through my wallet. When I asked her what she was doing, she accused me of being with another woman. Doctor, you have to understand that I would never ever do something like that!”

  I nodded again and told Frank to sit in the waiting room. I returned to the examination room to complete Mrs. Rubenstein’s physical. She had changed into the paper gown and was sitting on the examination table waiting for me.

  “Doctor, I really think I am okay.”

  She looked at me for any evidence of an opinion to the contrary. I have learned not to give anything away: if I played poker I could probably make a killing.

  “What did my husband say to you out there?” she asked me. “I don’t know why he’s so concerned about me.”

  I smiled.

  “He loves you, Mrs. Rubenstein, and he is concerned about your health. By the way, how long have you been married?”

  She looked at me and then beamed.

  “Too long, Doctor. We met in Europe during the war.”

  “Oh, yeah? What was that thirty, forty, or fifty years ago?” I was pushing her for an exact number.

  She shrugged her shoulders. “Too long, Doctor, too long!”

  I smiled at her, wondering to myself if I would ever get to the point where I wouldn’t remember how long I’d been married. I know that Ruth’s attempt at humor was just a ruse to hide the fact that she really had no idea. She could have been married ten years or a hundred.

  “I have to admit, Mrs. Rubenstein, that I share some of your husband’s concerns regarding your memory.”

  She shook her head and reached over to put her hand on mine as a gesture of reassurance.

  “Oh, Doctor, I’m just tired. I really have a lot on my mind.”

  “That might be the case, Ruth, but I am a little worried that there may be more going on. Would you let me order some more tests?”

  “But, Doctor, why would you want to order more tests? Tests for what?”

  I couldn’t keep beating around the bush.

  “Rut
h, I’d feel better if you’d allow me to order a few more tests.”

  She shrugged and offered grudging approval. “If you think it’s really necessary.”

  “Ruth, how long has your husband been concerned about your memory?”

  She became defensive.

  “I don’t know, Doctor. He keeps telling me that my memory is not as good as it used to be. Well, of course it’s not as good as it used to be.” She pointed at herself, smiling. “Look at me: I’m an old lady!”

  I laughed at her candor. If nothing else, she still had a sense of humor. But it’s a common misconception: Age really has nothing to do with memory, and problems with memory are never normal aging. People assume the two are related because memory problems become more common as we age. Yet memory impairment is always abnormal and should be worked up.

  “You’re not that old,” I said. “You could actually pass for twenty years younger!”

  “Well, thank you, Doctor,” she said, and I think she actually blushed.

  I decided not to make any further comments until I brought Frank back into the room. I finished her physical exam and excused myself to allow her to get dressed.

  By the time I returned with her husband, in a matter of mere moments, her mood had changed. I looked directly at Ruth and could see the quiet desperation in her face.

  “Doctor, all of these memory tests that you did. They’re all silly. I’m okay—right? I just have a lot on my mind these days.”

  But her eyes said something else. She knew there was a problem. People usually do.

  I couldn’t meet the gaze and looked instead at the floor between us.

  Now they knew.

  Sometimes there are tears when I deliver bad news. This time there was only silence. I’d rather have tears. At least you can do something. You can reach over and grab a box of tissues from the counter. You can place a reassuring hand on someone’s shoulder.

  Silence is the worst.

  In medical school, they used to teach you to be detached but empathetic when giving bad news. Listen and support but don’t get involved.

  Easier said than done.

  I’m human and I get to know my patients. I meet their families and hear about their children and grandchildren. I get to celebrate their successes and be there for them during the difficult times. It is the part of the job that I find most intoxicating—working to develop a trusting doctor-patient relationship where my patients can feel comfortable sharing everything. A doctor’s office should feel like a safe place, an arena in which you can bring out your demons or your angels, your deepest fears and most intimate secrets. In return I have to be honest. That can be the worst part of my job.

  “I’m sorry, Mrs. Rubenstein. The memory testing that we did shows there are parts of your memory that are not working as well as they used to. These tests I’d like to run will give us a better sense of what’s going on.”

  The blank expressions on their faces told me they didn’t understand.

  “Mrs. Rubenstein, I think you have a type of dementia, the medical term we use when you have a problem with memory.”

  Silence. No tears. I could hear the second hand tick on the clock over the door, the same clock she glanced at when taking her test.

  It was Frank who eventually broke the silence. “Is it Alzheimer’s, Doctor?” he asked. Suddenly he was the captain of a rudderless ship on an uncharted ocean. He was flying without instruments, driving without a map.

  “I’d like to order a few more tests, Mr. Rubenstein, but Alzheimer’s is the most common form of dementia and the memory tests I’ve performed thus far are consistent with that diagnosis.”

  Frank nodded grimly. Since they had no other questions, I began to tell them about Alzheimer’s disease and how it affects brain cells. I told them the disease would ultimately result in further memory loss and perhaps even behavior changes. I tried to console them by saying that there are a few medications that might delay her symptoms and that her deterioration will be gradual at best. I informed them that she should exercise regularly, something that has recently been shown to improve memory. I concluded by telling them that in all likelihood, she might one day die with dementia rather than of it.

  Small consolation to someone who has just been told her life will never be the same. Their lives.

  The discussion left both husband and wife visibly shaken. A minute passed and I finally broke the spell, asking them if they had any further questions. They shook their heads. I left the room and walked toward my office.

  “Doctor!”

  Frank had followed me down the hall to ask the one question that everyone wants to know.

  “How long does she have?”

  “Truthfully, Mr. Rubenstein, I really don’t know.”

  “But Doctor, surely you have some idea of how long she has.”

  Pressed on the issue, I offered a guess.

  “She has relatively early dementia currently but based on where her memory is today, I suspect that she has perhaps three to five years before she loses the ability to care for herself.”

  My response was met with a look of nonbelief, followed quickly by anger. It was as if I was the one who had brought her the disease rather than the diagnosis.

  All he needed was a gun to shoot the messenger.

  As I said, sometimes I hate my job.

  CHAPTER FIVE

  “One cat just leads to another.”

  ERNEST HEMINGWAY

  A LARGE PORTRAIT OF HENRY STEERE HANGS OVER THE piano in the lobby. It’s a cozy setting, what with the sunlight streaming through in midafternoon. But that wasn’t what I thought the first time I heard the piano playing. When I had wandered into the lobby on my first visit to Steere House, piano music filled the space with a Chopin prelude, but there was no one else in the room. I had looked over expecting to see one of the more able residents or a family member seated before the keys practicing. Instead, there were only Billy and Munchie, the two resident lobby cats, staring back at me from the comfort of an otherwise unoccupied piano bench. The oddness of the scene, two cats seated at a piano bench while music filled the air, was overwhelming—until I realized it was a player piano.

  Today I was stealing a few minutes of downtime before rounds. I had settled myself into one of the lobby’s comfy chairs and was enjoying the music. I guess I was reflecting, too, on the need to soften the reality of a nursing home—the last home most of our patients will know. At Steere House, perhaps we’ve achieved the same effect with a family of cats, an atrium of glass, and the sounds of classical music played by the best pianist you never saw.

  As if on cue, one of the lobby cats rubbed against my legs. It was Munchie. He’s an unusual-looking fellow: grayish-black with spatters of chestnut and brown, like an expressionist painting gone wrong. He meowed loudly, calling out for affection. Cautiously, I reached over and stroked him behind the ears. That flipped the purring switch and he continued to bang against my legs like a bumper car.

  “You’re not so bad,” I said. “At least you don’t attack me, like some cats I could mention.”

  Munchie looked up at me and then curled up over my feet, fully obscuring them from view. As he settled in for a nap, a more ordinary-looking black-and-white cat appeared and jumped into my lap. Billy turned twice before curling up in a ball. Then he looked at me as if to say, “You didn’t think you were going to get away without petting me, too, did you?” My pager rang, and I frowned. How do cats always seem to know when you have to be somewhere else?

  “Sorry, guys,” I said as I stood up. “Mary’s paging me and I suspect that I’ve got to check in on Mrs. Rubenstein upstairs.” Munchie scurried away and Billy leaped off my lap and looked at me with that air of disdain only cats can muster. Feeling guilty for having shortchanged him, I leaned over and gave him some gentle petting. But he lost interest after only a few seconds and wandered off to find his friend. Calling a cat fickle is like saying snow’s wet.

  As I left the lobby I looked
back at the cats in the atrium; they were already engaged in chasing each other, like two kids playing tag. My comings and goings were of no concern to them. They were truly in the now. My life is made of pagers, deadlines, appointments, and responsibilities. At that moment the existence of a cat looked pretty good to me.

  I got on the elevator and, as if by reflex, found myself looking to the back corner, half expecting to see Steere House’s very first cat, Henry, curled up on the floor. It’s Henry and his successors that make Steere House so different from other nursing homes; it’s a menagerie of cats, rabbits, and birds.

  It wasn’t always this way, though. Before the 1980s there was no such thing as pet therapy. Animals didn’t have a place in health care institutions. Why bring a “dirty animal” into a sterile environment? Then some scientists began to espouse the human-animal bond theory—the belief that animals can have a beneficial effect on human health and psychology. Research increasingly began to back up this belief. Nursing home patients in particular—with or without memory loss—were less depressed and lonely with animal companions. I suppose intuitively this makes sense. Most people love animals. Why wouldn’t they want them in their last home?

  I’d like to tell you that Steere House’s acceptance of animals came about as a result of this research, but truth to tell, I think it was all due to a little guy named Henry. He was literally Steere House’s first occupant—and the one the nursing home tried hardest to get rid of.

  Since its foundation over a century ago, Steere House has gone through several incarnations, growing to suit the needs of the community. As the current structure was being built, workers noticed that a stray cat had wandered onto the construction site and was living in the unfinished building. The cat was even known to steal from an unattended lunchbox or two. By the time the building was completed, the cat had seemingly moved on and was forgotten. Shortly after the dedication ceremony for the modern Steere House, however, the cat returned to give the building his own inspection. Early one morning he strolled back into the facility, liked what he saw, and sat down in an easy chair. At first the staff tried to shoo the animal away, to no avail. Each day the cat returned, undaunted, through the lobby’s sliding glass doors. His attitude was one of entitlement. “I was here first,” he seemed to suggest with each wave of his tail.