Internal Medicine: A Doctor's Stories Read online

  By the time I was done, the hospital had come to life around me. The intern who had signed out Mrs. B to me scratched the name off her patient list.

  Keith, the resident, appeared on the floor just before rounds got under way. “How was your night?”

  I told him. He listened to the story, pulled his lower lip, shook his head.

  “You should have called me.”

  I flinched. “What would you have done?”

  “Nothing,” he said. “Just like you. There was nothing to do. But at least we could have done it together.”

  GIVING

  BAD

  NEWS

  IT’S ONE OF THOSE ICONS OF MEDICAL TRAINING, something you spend an afternoon discussing in the preclinical years and then gratefully forget, like community health or Medicare billing requirements. I don’t remember anything we learned that day. All that stayed with me was a vague solemnity, a sense of having spent the afternoon in the middle of an Emily Dickinson poem—not one of the cheerful ones—and coming out of it about as wise for the experience. And so, as is inevitable with the lessons we tune out, it wasn’t long before I learned this one the hard way.

  He was a forty-three-year-old with pneumonia. I was an intern on the infectious-disease service. He belonged there only slightly more than I did. He did have pneumonia, but pneumonias aren’t really all that infectious (most of them), and on a service crowded with HIV his presence was anomalous, more an accident of ER timing than a reasoned assignment from admissions. He had come up from the ER around two in the morning, admitted by the night float resident and placed on my service. His story was unremarkable. He had developed a cough, then fevers and shaking chills that bought him a five-day course of azithromycin from his primary MD. When he’d failed that, the primary had tried him on levofloxacin, a reasonably big gun. When he’d failed that, the primary had sent him to the hospital “for further eval.”

  It’s part of the nature of the hospital where I trained (as it is with most teaching hospitals) that patients arrive without a great deal of documentation. In the typical community hospital, if you’re unlucky enough to find yourself hospitalized you at least have the consolation of knowing that your own doctor, who presumably knows your medical history, is going to be treating you. But admitting privileges at this facility are reserved for faculty of the medical school, who divide their time between laboratories, clinics, and the floor. When patients come here from what we generally call “outside docs,” they usually arrive without any more medical information than the patient can recall.

  If the patient is well educated, articulate, and interested in his health, that information can be complete—sometimes too complete. But usually the patient is none of the above. I wouldn’t have had it any other way, but at times this complicated my attempts to understand what was going on. As with this time. The history and physical on the chart didn’t say very much: the acute pneumonia, no other medical history (not unusual in a forty-something man), a high school education, and a smoking habit. Not employed, living with family. No meds.

  As for the patient’s current state of health, that was somewhat more complex. In addition to the pneumonia, which had him coughing up “bad phlegm” these past two weeks, he had reported some difficulty swallowing and a weight loss he could only quantify by saying that he’d taken in three notches on his belt since last Spring.

  The resident said immediately, “That’s not good.”

  I looked at him.

  “Weight loss, difficulty swallowing, resistant pneumonia in a middle-aged male smoker,” he said.

  “Ah,” I said, scanning the rest of the chart for a clue. The orders left by the night float resident included not the chest CT and bronchoscopy I had expected but an EGD—one of those gastrointestinal procedures where they stick a lighted tube down your throat and examine the inner lining of your stomach. “Ah,” I said again.

  The patient, an amiable, clueless fellow whose chief complaint when I met him after rounds was the absence of breakfast, looked better than his story sounded. Weight loss is a relative thing, after all, and until you get into the absolute end of the range, it usually doesn’t show. He was a skinny man, who coughed once or twice with the weary, pained expression of a person who has coughed too much recently, and obligingly deposited the product in the plastic jar he’d been given for the purpose. The contents of the jar looked nasty, but then they always do. “When am I gonna eat?” he said, when he had finished screwing the lid back on the jar.

  We explained about the EGD, and how he needed an empty stomach for the test. “Okay,” he said. “And when’s that gonna be?”

  We told him that it was hard to say. It’s always hard to say. This is more than usually distressing because most of the people waiting for the call are waiting with empty stomachs, and despite the low quality of the hospital food, breakfast is by far the best of it. Even dinner starts to smell pretty good when your roommate is being served and you’re still waiting for your call to GI. So we’re used to explaining to people why they can’t eat: it’s the kind of bad news that takes a while to sink in.

  Mr. Jenkins spat disconsolately, as if he had a bad taste in his mouth, and we excused ourselves, promising to let him know as soon as we heard anything. Which of course we didn’t, because we got busy with new admissions and no one ever tells the house staff anything anyway.

  So when the number for GI procedures showed up on my pager it took me a moment to remember Mr. Jenkins. But that was all right because when I dialed it and heard the phone say, “GI procedures,” they put me on hold before I could give my name.

  Orville Shayne picked up. Orville, known universally as “Awful,” was a first-year GI fellow from Chicago who had earned his nickname by being the most abrasive personality in the entire hospital. He was not averse to lessoning his betters now and then, and was entirely too eager to lecture the rest of us whenever possible.

  “Who is this?” he demanded.

  “It’s Harper,” I said. “You paged me.”

  “Harper. What are you going to do about your Mr. Jenkins?”

  “What?” I replied, perhaps unwisely.

  “Jenkins! Your Mr. Jenkins! The one you sent down here with”—he searched for a word sufficiently scathing—“pneumonia.”

  “Look, Orville,” I said, enunciating carefully, “is there a point to this? ’Cause I’ve got an admission down in the ER, and—”

  “And you don’t care about your Mr. Jenkins, is that it?”

  This was starting to get me mad. “Do you want to tell me something, Orville?”

  He snorted. “I suppose I’ll have to, since I doubt you could interpret the pictures, which are in Mr. Jenkins’s chart, by the way. Tell me,” he said, “do you know what cancer is?”

  What everyone wishes you’d get, I thought, but said nothing.

  “As I suspected,” Orville sneered. “Well, it’s what your Mr. Jenkins has growing in his esophagus. Which is why he can’t swallow, which is why he’s losing weight, which is why he’s got your pneumonia.” And then the line went dead.

  Mr. Jenkins had esophageal cancer. It made sense. As Orville had so helpfully spelled out, it was the unifying explanation.

  But what a nasty explanation it was. As it happened, I did know something about cancer, enough to know that esophageal cancer is an especially bad thing. It’s not all that common; smoking and alcohol are probably risk factors. By the time it’s diagnosed it is usually, as the oncologists say, out of the barn. Your odds of being alive five years after diagnosis are less than one in twenty. Starvation, hurried along by metastatic disease in the lung, liver, and brain, is the usual mode of death. You can try to put a rigid liner in the esophagus to hold it open. You can try radiation. And, for the optimistic, you can try chemotherapy. It was a dismal future Mr. Jenkins had in store. And it was up to me, I realized as I turned from the phone, to tell him.

  It wasn’t, really. It wasn’t, technically, up to me. The service I was on had a number o
f doctors with more knowledge and experience than I had. There was the resident, of course, still in-house. There was the attending, now gone home for the night, but he could certainly break the news in the morning—a lot better than I would, since he’d had the experience before.

  I hadn’t had the experience. And I needed it. And, to be strictly truthful, I wanted it. This was how we were supposed to learn. He was my patient, and I felt responsible for him. But, also, I wanted to be the one to tell him. It’s something I can’t explain—didn’t understand then and perhaps would rather not understand about myself now. I hadn’t had the experience, and I wanted to get it. So I squared my shoulders and marched down the hallway to Mr. Jenkins’s room.

  He was the only occupant of a double on the west side of the tower. Here on the sixth floor the view out the window was a sweep down the hill to the town, garish under sodium-vapor streetlights. The yellow glow from the street was the only light in the room. Mr. Jenkins was in bed, asleep. He was snoring unevenly, a little puddle gleaming darkly on the pillow beside his open mouth.

  I stood at his bedside, listening to him breathe. Regular, unlabored, a little rattly, but basically the automatic tidal motion of a man in the middle of his life, the rhythm he had been maintaining from the moment of his birth. I stood there and listened to it, unconsciously holding my own breath for a long time until I realized what I was doing and drew a ragged breath out of the dark.

  “Mr. Jenkins?” I said softly.

  No answer.

  “Mr. Jenkins?” I said again. This time I reached down and pressed his shoulder slightly. He stirred, and abruptly he was wide awake, astounded, raised on his elbow staring around the room.

  “Wha’?” he said, or something to that effect. He was starting to pull back from me. In the darkened room, his eyes were enormous.

  “Easy, Mr. Jenkins,” I said in what I doubted was a reassuring tone. “You’re in the hospital. Remember? I’m Dr. Harper. We met this morning.”

  Mr. Jenkins continued to stare at me as if I were a ghost, but he gradually subsided, muttering something I didn’t catch beyond the tone of ebbing shock.

  “Are you awake, Mr. Jenkins?”

  He nodded, perhaps a more polite answer than the question deserved. And he lay there, still propped up on one elbow, waiting.

  I realized that I had no idea how to proceed. I tried to think of something, but all I could come up with was the tune to “The Yellow Rose of Texas.” It kept repeating itself unhelpfully, scattering my thoughts: beyond that, all of the advice from that long-ago dreary afternoon with Emily Dickinson had evaporated. And Jenkins was waiting. As if aware of my uneasiness, he was starting a shy, reassuring smile.

  “Mr. Jenkins,” I began.

  He nodded at me encouragingly.

  “I’m afraid I’ve got some bad news.”

  For a horrible ten or twelve seconds, the smile lingered on his face while the rest of his features abandoned it until it hung there in empty air.

  “That test we did this afternoon?”

  He nodded.

  “It found a—a mass.”

  This wasn’t right, I realized. I should just name it.

  “They found cancer, Mr. Jenkins. That’s why you’ve been having trouble swallowing. That’s why you’ve been losing weight.”

  I stopped for a moment, unable to go on. In the silence that lay between us I recalled dimly that I was supposed to do this, supposed to give the patient time to grasp the news. Reassured by this, I let the silence grow.

  Finally, his voice coming with effort, Mr. Jenkins said, “What’s it gonna do?”

  Patients have this terrifying ability to ask the question, the one of all others you don’t want laid at your feet. I could feel myself start to choke. The easy answer, the immediate one, was I don’t know, but I couldn’t bring myself to say it—it would be too palpably a lie. Because I did know. We both knew. But I couldn’t say that either.

  I was wrestling with all of this, starting to hyperventilate, when I heard Mr. Jenkins sigh. “That’s a bad question,” he said. The ghost of a smile shimmered in the dim light. He settled back against his pillow, ran the back of a thin hand across his forehead. “Ain’t nobody knows, do they.”

  “That’s right,” I said fervently. “But, Mr. Jenkins, I do know this. There are a lot of people in this hospital who can help you. The next thing that will happen is we’ll present your case”—no, I thought, too legal—“we’ll present you”—too formal—“we’ll bring in a lot of specialists”—that was it: “specialists” had a reassuring ring—“and we’ll help you fight this thing.” Unless, of course, fighting wasn’t what he wanted. What if he didn’t want to fight it? I was just about to babble, I realized. “Would you like to see the chaplain, Mr. Jenkins?”

  Mr. Jenkins lay back on his pillow with his left arm beside his head, fingers curled delicately as if waiting for something to fall into his palm. He closed his eyes.

  “Maybe tomorrow,” I said.

  I don’t know if Mr. Jenkins slept that night. I didn’t, of course, being a green intern on call, prone to jump bolt upright at the sound of my pager, and feeling the need to go see every patient I heard about, whether the situation warranted it or not. But if I had been allowed to lie down for more than fifteen minutes at a stretch, I doubt I would have fallen asleep without Mr. Jenkins’s expression hovering in the dark above me. I had nothing constructive to think about, nothing really to do about him. The machinery of oncology would be unleashed on Mr. Jenkins tomorrow, there would be a routine series of studies to go through, and his pneumonia would undoubtedly respond to the IV antibiotics he was getting every six hours. There was nothing in particular to think about at all. So it was only his smile that might have haunted me, if I had been available for haunting.

  The next morning I was up and moving around, having gotten perhaps forty-five minutes of jumbled sleep and short-term memory disturbance somewhere between five and the sounding of my alarm at six in the morning. Rounds began at seven-thirty, and I had nine patients to see before then, giving me about ten minutes per patient, which even in my first week of internship was more than I needed to check the vitals, wake the patient, and do a quick exam. But I had set my alarm early with a thought to Mr. Jenkins, feeling that I would probably need more than ten minutes to see him this day.

  I left him for last, of course, walking into his room with fully thirty minutes to go before rounds. The sun had risen by then, the world below his window blazing with color, each red leaf on the far hills distinct in the clear air. Mr. Jenkins was asleep, his pillow blotched with pink, green, and brown, his mouth slack, the same regular rising and falling of his chest.

  “Mr. Jenkins,” I said gently.

  He roused more easily this morning, his eyes opening sleepily but without the terror of the night before. They opened, then opened wider, scanning the room quickly with an odd, stock-taking motion, as if he were in the habit of cataloging, every morning, the contents of his room.

  He finished his survey with me, eyeing me with what I can only describe as a mild surmise. As he looked at me, uncertain, perhaps a little curious, I realized how deeply miserable I was to be standing before him. Not that I could think of any particular thing I’d done wrong. Just that it was miserable to be there, having to enter into it again.

  “How are you?” I said gently.

  “I’m not bad,” he said. “Been coughing up a bit, not so bad.”

  “Good,” I said. I moved to the bedside, sank down in the chair, and took a breath.

  Mr. Jenkins regarded me, and his gaze as I looked back at him took another one of those curious sweeps around the room, returning to me. His expression was open, friendly, almost perky.

  “So tell me,” I began. “Have you been thinking?”

  Jenkins looked puzzled. “Thinking,” he said noncommittally.

  I waited, but he had nothing more to add.

  “Yes,” I said. “About . . .”

  He ele
vated his eyebrows helpfully. “About?”

  “You know.”

  “Oh,” he said. The eyebrows settled, pressed down by a pair of deep furrows. “I don’t know,” he added after a while.

  “I understand,” I said. “It’s a lot to take in.”

  “Yeah,” he said. And then: “A lot.”

  “Yeah,” I agreed.

  We sat there for a little while longer, thinking about a lot together.

  “What do you think?” he said finally.

  “Me?” I squeaked. I was suddenly aware of the time. “It’s not really what I think,” I began. “Is it?”

  If I was thinking he was going to help me out, I was wrong. Mr. Jenkins stared back at me across his bedclothes, his hands lying on top of the cotton blanket as inert as old socks, the expression on his face an open blank. Open and blank. Not frightened. Not worried. Not remotely comprehending what had me so solemn and upset.

  “Mr. Jenkins?” I said finally.

  The eyebrows lifted a half degree.

  “You do know what we’re talking about, don’t you?”

  No change at all. For an instant I hoped wildly that this was cultural, this was some strange thing that came from class or poverty that I wasn’t getting, and I shouldn’t mess with it. But it was too late for that.

  “We’re talking about your diagnosis,” I said slowly. “You remember, don’t you?”

  Now the eyes did begin to widen, the whites showing between the irises and the upper lids.

  “What I told you last night? About the cancer?”

  The face went stricken.

  “I’ve got cancer?” It was a hoarse whisper, twisting upward at the end.

  “It’s in your throat,” I said, pointing to mine. “It’s why you’re having so much trouble swallowing.”

  He blinked at that. “I got cancer,” he mumbled, looking inward for a moment, nodding again. Then back at me. “What’s it gonna do?”

  I told the story on rounds. After the recitation of vital signs and exam findings, I added a brief anecdote describing his reaction to the news. The attending nodded and shook his head. “You’ll get used to this,” he told me. “We get so hardened to other people’s bad news. It’s hard to remember what a shock it is to them. Give him time to get used to it.”