Internal Medicine: A Doctor's Stories Read online

  THEY SAY THAT TIME assuages, and time was, for once, something we had to give. This was Friday; we had an entire weekend before the breakneck rhythm of the hospital took hold of Mr. Jenkins and clutched him to itself. The pieces of aberrant flesh that were snipped from his mass in the GI-procedures suite spent the weekend absorbing stains in the pathology lab. On Monday, Tuesday at the latest, we would have the definitive diagnosis. In the interim there were some things we could get done despite the weekend, and we went ahead and did them—CT scans, chiefly, looking for possible metastases. The goal was to assess the spread of his disease—to “stage” him—and to assemble every other relevant bit of data in time for the multidisciplinary oncology conference that met in the cancer center every Wednesday. There, about two dozen representatives from medicine, surgery, pathology, radiology, pharmacology, and probably theology reviewed the dozen or so new cancer cases that had come up in the previous week, with the goal of arriving at a consensus and a plan.

  But for now, Mr. Jenkins had time, a quiet weekend in a room with a view of Fall descending over the Piedmont.

  Having been on call on a Thursday, I was facing my Golden Weekend—the once-a-month privilege accorded interns: two consecutive days off. I spent them with my family. Sixty hours together. On my return early Monday morning to the upper floors of the hospital I had a sensation of having been out of the action a very long time. Many of the patients I had been taking care of on Friday were gone, having been discharged by my resident over the weekend. Mr. Jenkins, naturally, was not one of those. I found him in his room, sleeping, a towel wrapped carefully around his head.

  One of the things I passionately hate about my job is that it requires me to disturb people’s sleep, sick people who have managed, against the odds, to achieve some measure of oblivion. As I’ve grown older in the profession, I have become less conscientious—I often let patients sleep—but in those days I was conscientious to a fault. I roused each patient so that he or she could bear witness to the events since I had seen them last.

  It was no different with Mr. Jenkins. I called his name from the doorway, softly, then as I moved to the bedside called again, using the same tone I use when waking my children. I pressed briefly on his shoulder and called his name again. This time he stirred and peeled himself a peephole in the towel.

  “Whazzat?”

  “Hi, Mr. Jenkins,” I said softly. “It’s Dr. Harper.” I paused to let that sink in. “How was your weekend?”

  The eye goggled around the room in the same odd stock-taking I’d seen the first morning, before returning to settle on me.

  “Okay,” he said softly. Then the eye inspected again. It seemed to be looking for something.

  “Did you get any visitors?”

  “No.” The eye was still, some small creature sulking in its hole.

  “I’m sorry,” I said, and I meant it, too, thinking about him spending the weekend with nothing to think about but his dismal prognosis. If there’s any time you want family around, it’s when you’re looking at something like that.

  I said as much to Mr. Jenkins. I can’t remember the exact words I used. I don’t suppose they mattered, because I found that eye of his staring at me and growing rounder until the towel came off his face and he was lying there looking at me with horror everywhere in the bed around him.

  “You say what?”

  Then it was my turn to stare back at him, and maybe there was a little horror in my face, too. All I know was that for a long time we stared at each other as if each found the other completely incomprehensible.

  But it was up to me to break out of it first, and I did.

  “Your . . . cancer,” I said.

  He tried to say something but it strangled to a whisper.

  “Do you mean you don’t remember?”

  He shook his head.

  “Well.” I stopped short, at a loss for words. “There are some things the brain just doesn’t want to hold on to,” I said finally.

  He was simply staring at me. Clearly I wasn’t connecting.

  “Would you like me to tell you again?”

  After a long pause he nodded. I took a breath, and with a fugitive sense that this wasn’t getting easier with repetition, I told him the story again. He seemed to take it in. He asked the same terrible questions. I had the same terrible lack of answers. And we left it at that.

  I walked out of the room feeling shaken. It was partly the sheer rigor of it, having to tell again the story I’d never wanted to tell the first time. Or, okay, had wanted to tell, but only once. Was I being punished by some obscure hospital devil, forced for my sin of pride to experience again and again just what we do when we give bad news? I had a brief vision of myself as some kind of Kübler-Rossian version of the Flying Dutchman, doomed to wander the hospital forever in an unending struggle with denial. But that wasn’t it, not really. Mr. Jenkins wasn’t playing by the rules. Say what you want about denial, there was something else going on.

  I tried to convey this on rounds, when we arrived at Mr. Jenkins’s door. I made a hash of it, of course, trying to wedge in between the morning’s lab results and the scheduled pulmonary function tests some ghostly aperçu I couldn’t articulate even to myself.

  The attention span of a team on rounds is short at the best of times. I could tell I’d lost the interest of the resident. The other intern, scheduled for clinic in the afternoon and desperate to be done rounding, looked at me with something that fell just short of hatred. The med students stood apart in some shared goofiness. Only the attending was still looking at me, his expression a tolerant mixture of amusement and minimal curiosity.

  “What do you think it is?” he asked me.

  “I don’t know,” I confessed, feeling miserable that I was making an ass of myself. But Mr. Jenkins wasn’t playing by the rules.

  What were the rules? I found myself wondering later. I had reached one of those random dead spells in the admitting day. I was at the workstation, going over sign-out sheets left by the three other interns whose patients I was covering overnight. Cx if spike; lasix 80 for SOB; Call VIR if HCT: I had several pages of helpful hints from my peers on how to manage their patients’ likely misadventures. But there was no similar advice for how to deal with Mr. Jenkins. Give him the bad news until he finally believes it, because he has to. Make him do it until he gets it right. Isn’t that right? Wasn’t I doing it right?

  Naturally, the next morning I saved Mr. Jenkins’s room for last on my early rounds, and knocked on the door with dread. I heard him hawk up something wet, spit, and then say, “Come in.” At the sound of his voice—a little guarded but otherwise sprightly—my heart sank.

  He was sitting up, looking around him as if puzzled by his surroundings.

  I stood in the doorway, a profound reluctance holding me.

  “Hi,” he said. I was suddenly aware that Mr. Jenkins was shy.

  “Hi,” I said back. I am usually shy too. This morning more so.

  We held our positions for a long minute.

  “Do I know you?” he asked.

  The question hit me hard. The room took a sudden surge toward me, settling in a series of uneasy swells as I tried to absorb what he’d said. Not that I expect all my patients to know my name, or even recognize me for the most part—all those white coats. In most cases the acquaintance is all too brief, too casual. But Mr. Jenkins and I had accumulated some history.

  I eased into the room, moving carefully as one might around a nervous beast, keeping my eyes on his as they followed my progress toward the bed.

  “Don’t you?” I said as I crouched beside him.

  He stared at me with a slowly dawning recognition that as I watched grew into horror.

  “You know me, don’t you?” I said quietly. What was this? Some kind of conversion disorder? A hysterical amnesia? “You’ve seen me before, haven’t you?”

  Jenkins’s head wobbled uncertainly between yes and no.

  “I’m Dr. Harper,” I said quie
tly. “And you’re here because—”

  Jenkins suddenly whipped his bedsheet over his head, clutching it there like a Halloween ghost. The ghost shook its head emphatically and let out a low moan.

  “Oh, God. It happened. It happened, didn’t it.”

  “What happened?” I asked.

  He threw off the sheet, and his gaze scattered around the room, taking in the surroundings one more time. “I knew it,” he sobbed. “I knew it.”

  This was progress, I thought, triumphantly—and felt immediately guilty as I realized how stricken he looked, staring around at the walls as though he expected them to fall on him.

  But I was making progress. Carefully, I prodded him. “Knew what?”

  He moaned. “It’s the crazy house. It’s the crazy house, isn’t it?” He buried his face in the sheet again.

  Whatever I’d been planning to say up to that point vanished in an instant, leaving me flat-footed. “Did I”—the voice came muffled through the sheet—“do something?” The face appeared, eyes reconnoitering nervously above the sheet as the voice dropped confidentially. “It wasn’t murder, was it? I didn’t—”

  “No,” I said, a little louder than I’d intended. “You didn’t—”

  “Oh, thank God,” he said. “Thank God. As long as I didn’t—you don’t know,” he said soulfully.

  “Don’t know what?” There was a lot I didn’t know, but Mr. Jenkins seemed to have something particular in mind. As for me, my head was swimming.

  Jenkins had recovered some of his usual equanimity. The look he was giving me now was downright cagey.

  “Don’t you know?” he said.

  I shook my head. “No, Mr. Jenkins. I don’t know. What?”

  “What it’s like. Waking up every day.”

  I took a wild guess. “With cancer?”

  He turned on me. “What?”

  “With cancer,” I said, perhaps a little more brusquely than I’d intended. “Waking up every day with cancer. Knowing about it, I mean. Waking up that way. Knowing. With cancer.”

  The expression he gave me had nothing to do with my stumbling delivery.

  “What?”

  “Cancer.” Repressing panic, I might have been shouting. “You’ve got cancer.”

  A long silence, broken by the sound of his breathing. It was getting louder and louder.

  “What kind of doctor are you?” He was half out of bed, shaking a double-handful of bedsheet in my face. I started to back away.

  “What kind of doctor are you?” he demanded again. “Coming in here and telling me something like that? Is that how you tell somebody that kind of thing? You’re lying! You don’t tell me that! You don’t come in here and tell me that kind of shit! Get out! Get out of here!”

  By that time I was already out the door. I could hear his shouting all the way down the hall.

  How I got through rounds that morning, I’ll never know. Maybe the rest of the team attributed my zombie-like demeanor to the rigors of a rough call night, I don’t know. All I remember was that I watched, as if from an indefinite distance, as the knot of us worked our way around the floor, measuring with growing dread the approach to Jenkins’s room and the moment when I was going to have to face him again. I was listening, too, for the sound of shouts from that direction, wondering if there was any way I could avoid going in that room again. Perhaps I could simply make a run for it, before the moment when the patient reported that I had come in that morning and abused him. What kind of doctor was I?

  Helpless in the grip of forces I did not understand, there I stood again finally, at the door of Jenkins’s room, reciting by rote his vital signs that morning, exam findings, the results of yesterday’s tests. I ground down. There was a pause.

  “And?” the attending said mildly.

  I might have jumped.

  “Any progress?”

  “Progress?”

  Impatience. “You were going to work with him. On his diagnosis. I thought he was having trouble with it. Any luck?”

  I shook my head dumbly.

  The attending didn’t wait, only nodded and swept open the door to Jenkins’s room. I took a deep breath and followed.

  Jenkins was back in bed, looking peaceful enough. The television set was on. Katie Couric was interviewing a woman who looked just like Katie Couric. Mr. Jenkins was rapt.

  We all stood for a moment looking at Mr. Jenkins. As the interview cut to a commercial, Jenkins’s gaze turned slowly to us, widening to take in the small crowd wedging into his room. I recognized his expression—the same cagey inventory, twice around his surroundings, the same poker face settling down.

  “Hi,” he said shyly.

  “Good morning, Mr. Jenkins,” the attending said.

  We all stood and looked at each other some more.

  “Mr. Jenkins?”

  “Yeah?”

  “Would you mind if we asked you some questions?”

  “Uh-uh.” The commercials were over. Mr. Jenkins’s vision was starting to stray again.

  “Can you tell us why you’re here?”

  A brief inner consultation. “Sure.” He leaned over and spat into the wastecan. “This,” he said. “It’s been going on for a while.”

  “And?”

  “Tastes nasty.” He made a face.

  “Anything else?”

  “Well, yeah. I got this sore throat.” He laid a hand on his chest. “It really doesn’t feel good. I was wondering if maybe I got some kind of ulcer. You know? ’Cause my brother, he’s got ulcers bad. I was wondering if maybe they run in the family? ’Cause if they do, maybe that’s what I got.”

  “You’ve got a brother, Mr. Jenkins?”

  It was news to me. It was news to all of us. As we left the room, the attending muttered to me, “Call psych. And call the brother.”

  Easier said than done, of course. When asked for his brother’s phone number, Mr. Jenkins agreeably recited a string of digits that connected me with a fax machine. When asked again, he wanted to know why I wanted to talk to his brother. “It’s about your ulcers,” I said simply. I was tired. He gave me another string of numbers, which offered the mechanical advice that the number was not in service. On my third trip back I got as far as Jenkins’s door before I realized that the two numbers he’d given me were in different area codes. I spun on my heel, went back to the nursing station, and pulled his chart.

  “MR. JENKINS,” I ASKED, “where do you live?”

  “Lumberton.”

  His chart gave an address in Fayetteville.

  “How long have you lived there?”

  The expression went cagey again. The eyes narrowed. “Fifteen years. Yeah. Fifteen. Right out of high school.”

  I gave that some thought. This was a forty-three-year-old male with pneumonia. Somewhere along the way Mr. Jenkins had misplaced a decade.

  “Mr. Jenkins,” I asked slowly. “Can you tell me what year this is?”

  “Sure.”

  We looked at each other for a minute.

  “What year is it?”

  “What year? Hmm. It’s—I’m not too good with numbers. It’s a leap year, isn’t it?”

  It was in fact a leap year.

  “Can you tell me who the president is?”

  “I don’t follow politics. It’s a dirty business. But sure.” He looked cagey again. “It’s Bush. George Bush.”

  I looked at him, feeling beaten. He looked back at me. A brief standoff, then he coughed self-consciously. The cough turned into a real one, and when he’d recovered his breath, he looked at me again. “What were we talking about?”

  We did consult psych. They came by and gave the diagnosis of Wernicke-Korsakoff dementia. He’d completely fried his short-term memory with too much alcohol. By that time, I’d managed to track down the brother, who confirmed what I’d finally recognized, and a little bit more. It had been several years since Charles Jenkins had seen his brother, but he gave the essential outlines of the story. Mr. Jenkins had been in
the Navy. He was in fact forty-three years old. But between the ages of eighteen and thirty-eight, he’d hadn’t been sober more than three days at a time. The brother said this with a weary resignation in which I tried but failed to hear a trace of bitterness. I wanted to hear the rest of the story, but Charles Jenkins cut it short.

  “When can he come home?”

  TWO DAYS LATER. Mr. Jenkins, his cancer thoroughly staged and determined beyond any hope of cure, sits peacefully in the recliner in his room. He is dressed in street clothes. Sunlight is streaming in over his shoulder, he’s breathing comfortably, and the television set is tuned to one of the two hospital channels, which is showing a locally produced documentary about dialysis. When I go in to see him one last time, Mr. Jenkins is watching, rapt. I realize I’m almost looking forward to introducing myself again, if only to say goodbye. And for a moment I watch him, and find myself equally rapt at the sight of him: sick, dying, and eternally unaware. For a moment I am almost envious.

  The feeling passes, replaced by a kind of nostalgia. He’ll forget me again as soon as I’m gone. I’ll never learn from his account of me what kind of doctor I am. But that’s not it: I am tantalized by the sense that I’ve missed something here. I thought I was giving him bad news. The bad news wasn’t his, but mine.

  Out at the nursing station, I pick out of the general hubbub a nurse’s voice speaking my name and the words “over there,” and through the doorway see a man looking my way.

  The family resemblance is strong. “I’m Charles Jenkins,” the man says. He looks past me into the room. At my back I hear a sudden cry.

  The reunion is a happy one. I leave them there, edging out of the room as I’ve edged out of so many, leaving the family to gather up the plastic bags of personal belongings, medications, paperwork with discharge instructions. My last memory of Thomas Jenkins is of him looking up from the chair, sunlight surrounding him, his face alight in the recognition of one of the few faces in the world he can still remember.