Bedside Manners Page 11

  There came a little silence in which I could not say good luck, because I knew she wasn’t going to have any. We stayed on the line awhile, holding on to our silence, letting it run a few saturated seconds . . . then broke the connection as we knew we must.

  LUNCH AT THE STEREOTYPE CAFÉ

  Orthopedists are jocks, she said. Football players.

  That’s why they love pain. Then she took a bite from her breadstick.

  I remembered my orthopedist twisting my injured knee until I yelped. It’s the “Oh Jesus” sign, he had said. When they yell “Oh Jesus,” we know we’ve found the right spot.

  Okay, okay, I said, and neurosurgeons are basketball players, thinking of the admissions committee member who looked for that on the applicant’s record. Even better if they’re All-State, he’d said.

  She was ready for me. Psychiatrists need therapy, she said. I said, Pediatricians are short. She laughed. Surgeons are action figures with their power switch stuck in the “on” position, she said, and she brushed a few crumbs from the table.

  Marty leans over from the next table. Cardiologists are distant, he said. It’s because of their stethoscopes. Gastroenterologists, she said, are intimate. It’s because of their scopes.

  Marty was thinking. I was reaching for ammunition.

  Drug reps are good-looking, I said. And they wear short skirts.

  Neurologists play chess, she said.

  Internists are contemplative and would smoke pipes if it wasn’t so bad for them.

  Marty leaned over again. That’s why they drive surgeons crazy.

  I said, Radiologists wear sunglasses and stay indoors.

  Fat doctors wear sloppy clothes, she said.

  Urologists play with it. Gynecologists . . . We paused and looked around.

  Heather came up and leaned over the table. Breast surgeons are mama’s boys, she said. Then she winked and walked away.

  Everybody was out of breath.

  The bill came. We left it for the plastic surgeon.

  LOST IN TRANSLATION

  Do you remember the woman I was telling you about with the weight loss and the crazy stools, the one who would call at all hours with her questions of forgetfulness about her medications, the same one who eventually showed up with a bump on her navel?

  A story is a story . . . and later a different story. Or maybe it’s one story because it has a life where it stops midsentence and takes a deep breath. That place. That breath place was where we were . . .

  . . . which had opened like an updraft on the smooth surface of the ocean, a place where chaos falls together and seems to make sense. That was the first story. And then . . .

  The kids had gone off to the living room to play a little dominoes before homework. So, I’m interested, she said. What happened?

  It was the Sister Mary Joseph sign, the abnormal liver enzymes . . . I’d been thinking—no actually, I felt pretty certain it was pancreatic cancer. There is a triad for that diagnosis: weight loss, abdominal pain, depression. She had two out of three and maybe half credit for the third if you consider that a little toxic brain muddling from the metabolites of her cancer might account for her being so bad at telling us things.

  My wife made a little rolling sign with her hands, which, in television biz, means, Come on, fella, wrap it up.

  The CT scan of her abdomen was normal.

  The one you were sure would show some cancerous mass?

  No masses, no liver metastasis, no nothing. Clean as a whistle.

  And the liver abnormalities?

  Went back down.

  How do you account for that?

  I don’t.

  And that little Sister Mary whatever-her-name-was sign, the “ditzel”?

  Everybody worried about that one. My cancer specialist even agreed. The one strange thing about it was that it was tender. Cancers are not supposed to be painful to the touch. First time I saw it I tried to reduce it back into the abdomen, thinking that if it was a hernia it should go. It didn’t. And she said it hurt.

  So?

  Well, sometimes hernias can be stuck pretty hard, stuffed in there so tight it might feel as firm as a little stone of cancer. It didn’t help that it wouldn’t slip back in the hole it came from.

  How’d you find out?

  Things change. She came back and I examined her again, and when she lay down on the table, the little “ditzel” slipped back inside.

  To where?

  To the empty space under the surface of the abdomen where it lives.

  My wife looked at me like she thought I couldn’t make up my mind.

  Exactly, I thought, then I continued out loud: I saw her primary physician at lunch and told him about the normal CT and the disappearing mass and how that pretty well shot down our suppositions.

  I still think she might have a little cancer at the head of the pancreas, he said, one that is leaning on the bile duct just enough to make the liver enzymes go up.

  They went away, I told him.

  The LFTs?

  Yup.

  Are you sure?

  Sensing his conviction had not been undone, I said we would try to needle the place where the mass was and see if there were any abnormal cells there.

  So they found none? My wife was back on the trail.

  Well, I sent her over there and the doctor called me in the middle of the procedure to say there was nothing to needle.

  My wife was beginning to look like I was trying to confuse her.

  I did my best to represent there might be a little bump there because I didn’t want to miss the opportunity, but I didn’t get anywhere.

  So they didn’t needle it?

  They’re very experienced. If they can’t find anything to needle, there’s probably nothing there.

  Good for her, said my wife, then laughed softly. But I guess that’s bad too, I mean, not knowing what’s going on. I get the feeling things are not adding up.

  Bingo.

  I paused to remind myself how often the diagnosis serves the doctor’s desire to wrap up all disparate problems into one amazing Oslerian pronouncement of wisdom and grace . . . and then, dusting one’s hands in self-satisfaction, move on.

  Now’s the time to recomb the bushes for evidence, I said. Remember how I pointed out she was so happy when all the attention burst forth?

  Sure.

  Anybody would be, I suppose, but in retrospect it’s a small clue. At this point any small clue is a large clue.

  What next?

  I decided to scan her brain.

  What for?

  Well, she still could have had some kind of growth up there that accounted for her behavior and a few other things.

  Meanwhile, you may recall that I sent her back to the psychiatrist, a decision that I later regretted, thinking she probably had some horrible cancer eating her up from the inside out, and here I was falling into the “it’s all in your head” trap.

  Seems to me you had plenty of reason.

  Probably, and maybe I overreacted to the trap business. Anyway, the psychiatrist put her on Klonopin.

  Don’t tell me that cured her.

  She stopped calling six times a day. And she told me her anxiety went way down.

  So at least part of it’s psychiatric.

  It almost always is. The problem is determining the weight of each part. In this case we had a few red herrings.

  Next evening I called my patient to see how everything was going.

  Actually, fine, she said.

  Fine?

  Yeah. I feel pretty good. I’ve been sleeping through the night. The bowel moments are coming without effort. I’m not as anxious as I was.

  Sounds damn good to me.

  I’d say so. That medicine that the psychiatrist put me on . . . Why, it’s been miraculous. But I’ve got this . . . seven thirty Monday . . . is that right? . . . test.

  Right.

  I guess I still need to do that.

  Yes, you need to do that. And
I was thinking that this case had done so many reversals that if that pattern was any indication of where we were headed, I, for one, didn’t want to be off the train.

  Okay, well, I guess that’s it. Thanks for calling.

  I was stunned. She practically hung up on me. She was so difficult to get off the phone before it was as if I’d been talking to someone else.

  It was someone else, my wife would have said.

  So what happened to that lady with the vague feathery stools? It was after dinner. The boys in the living room again, this time turning a Pilates mat into a conveyer belt for their dump truck.

  She disappeared from the surface . . .

  My wife looked quizzical.

  . . . when she got that perfect-for-her-psychosis drug on board.

  Stopped calling?

  Stopped calling.

  Whatever it was about the stools . . . ?

  Went away.

  Everything better?

  Absolutely.

  My wife had that look that said that if she could have thought of any more questions to dispel what she was hearing, she would.

  And the brain scan came back?

  No tumor. No growth. Just a few age-related changes — probably the blood supply waffling down a little.

  And that’s normal?

  Pretty much. I even called her up again. Sounded like she didn’t need to talk to me.

  So it was waving.

  Yup.

  Waving, not drowning.

  Waving, not drowning. Or maybe drowning a different way.

  And I thought of symptoms rising from her like flags of discontent, the body the last semaphore signal in a language of anguish she could not speak, the body a mirror of the soul’s distress.

  And I wondered how the body could know to string together sentences that way, sentences that would carry the heavy weight of alarm, as if it understood so well how to get our attention . . .

  Waving, she said like an echo.

  And after a little adjustment in the brain’s sacred chemistry, not even waving.

  My wife raised an eyebrow.

  Don’t worry, I said, and now it was my turn to raise an eyebrow, I’m not letting her out of my sight.

  CODGER

  We almost hung it up a couple of years ago. The Codger had been my patient since my mentor died and left him to me. Before that, his patient for God knows how long.

  The Codger wears a hat with a soiled brim tilted off to one side, walks stooped, partly, I suspect, for effect—he is always muttering about the goddamned doctors and the goddamned secretaries and the goddamned clinic where no one gets any service — and stooped partly, to be fair, because of his rare spinal arthritic disease, often unshaven, looking like he just wandered out of a tree trunk.

  I decided I shouldn’t take all his goddamns seriously. Besides, I had plenty of stories of my own about the medical system’s numerous faults — so we formed, in this manner, a common ground of reckless, humorous, totally irresponsible cynicism.

  It was refreshing. Few survived his acerbic knife. He had, as he constantly reminded me, grown up in Brooklyn, a runt of a Jew-boy who was beat up daily by the spics and krauts, and if it wasn’t for his older brother’s best friend, the full-back from Villanova—a strapping brute built like a boxer, who set him on his knee and sang folk songs, and at other times knocked the blocks off anyone who picked on his little friend—he would never have survived childhood. His brother was no help. He was six years old when I was born, he said, and he’s been trying to kill me ever since. Goddamned older brothers. You’re one, aren’t you? You know how you are.

  Misanthrope, he said of himself. But he had his favorites and they were golden. One of them was Ol’ Doc Simpson, who diagnosed his Schmorl’s disease. Codger would rock his whole stiffened body and slam the desk with his open hand, eyes squinched shut in laughter as he described how Ol’ Simpson delivered the news: You’re going to live a long time, he said— then he looked up and smiled with gleeful satisfaction—but you’re going to suffer a lot.

  Peals of laughter. And with the first breath he caught between them: That sorry son of a bitch.

  And of Dr. Carbone and his famous response when Codger delivered the taunt from the dermatologist after his rash had disappeared: Well, we’ve cleared up the problem in our department. Tell Carbone to clear up his.

  Carbone was writing in the chart. His eyes flashed over his half-moon glasses, his bald head swayed slightly as if winding up to a detonation of nuclear proportions, and he said, I want you to deliver this message to the dermatologist. There was a slight pause, then Carbone lurched his full body weight into the fist-up-the-ass-to-the-elbow gesture, and Codger cracked up. Cracks up again as he tells the story to me the fifth, or perhaps fifteenth, time.

  His visit would take hours if I allowed it. He could randomly land on a small island in the vast archipelago of subjects he knew something about in his colorful life and build an elaborate castle upon it: how he knew Myrna Loy through some friends in Hollywood and went backstage just in time to see her goose a celebrated stage director, then wink and walk away. He knew for sure that P. G. Wodehouse was the most insightful and intelligent writer ever born, and one of the few who showed proper cynicism about the human race. He was convinced of the untrustworthiness of Arabs, the astonishingly low IQs of American presidents . . . I found myself weighing in like a ballast on a hot-air balloon just to keep him in the park.

  How’s the gastritis? I might say, out of nowhere.

  He’d look at me with disdain, realizing what I was doing. The worst, he said. You goddamned doctors . . .

  How much Carafate are you taking?

  And so it went. Probably less than 10 percent of the visit was spent on medical subjects in an exercise that might loosely be called diagnosis and treatment. But then I figured that about matched the proportion of real disease we were dealing with. The rest? Well, when I finally chased him out of the office with subtle little hints — standing up midsentence from my chair, deflecting with sidelong glances and courteous nods his frantic efforts to marshal a new and compelling subject from thin air, my feet marching their disciplined march to the door . . . little violent spell-breakers to unroot us to the waiting room where other patients, losing their patience over his long visit, were already sending waves of displeasure —when I’d finally almost chased him out, he’d open his Neiman Marcus shopping bag and fill it with samples from my medicine cabinet. You go on, he’d say, waving me away with his hand. I’ll just help myself.

  When he reached the outer office, he’d settle in a chair opposite my secretary and engage her in conversation for an hour or more. She had learned to listen, or seem to, while answering the phone, renewing prescriptions, filling out referral forms —seem to listen, I say, with enough legitimacy to satisfy what was missing from his life. It gave pleasure. He was Solomon at his finest, making pronouncements to an adoring court. It was a cynic’s delight.

  And I, passing through the outer office, dispensing quickly with three or four patients in the time he remained there, would see him eventually rise, doff his hat, and say, with recognizable sarcasm, Well, David, it’s been a little slice of heaven.

  I liked that. It had layers to it. I’d say it, too. Even try to beat him to the punch, which never failed to break him into spasms of laughter.

  How was he doing? About as well as any old curmudgeon, living alone, never married, an entertaining, playful misanthrope of a guy whose best form of recreation was repartee with his doctors — about as well as could be expected. Maybe better. Which is to say he was still alive, with no serious complications, rare hospitalizations, standing almost upright on the surface of the earth. A man who took too many medications and had ailments that would not kill him but just make him miserable. That well.

  But we almost hung it up. One day, in his most acerbic and critical of moods, railing against this and that, he hit upon how I was taking care of him, comparing me to his beloved and charismatic Dr. C
arbone, implying that no doctors in the current generation, including myself, knew anything about medicine, or, for that matter, how to be good doctors, familiar territory, when somehow the conversation, without warning, swung full force upon my family. He called my son a muppet-headed little idiot of a child, and I rose out of my chair on the updraft of a fiery wind, and I didn’t care about courtesy, or the etiquette of the doctor-patient relationship, or anything else. I stood, pointed my finger hard into the surface of the desk, and said, Criticize me all you want, but one word about my family and your sweet ass is out of here.

  I don’t think he even knew he’d said it. It was part of the dynamic repartee that had suddenly swelled out of bounds. At that moment his rhythm was thrown, and he stumbled for words, not wishing to recant, yet not wishing to lose his doctor.

  It was a shock to him that his words could have that effect. As if words were vaporous, aromas to be inhaled, particles of humor and gamesmanship.

  I didn’t care. I was defining my limits. For emphasis I waved my finger. Not my family, I said.

  Next visit he brought a picture.

  In addition to his profession as a pharmacist, he had a little side business collecting, and sometimes, when lucky, selling a few pieces of art. Most of it looked to me like discards from the low tables of kindergarten, but he saw value in it.

  So he brought me a thing of value, a pen-and-ink drawing of his grandfather the rabbi. You can have him, he said. Don’t you have a daughter who married one of the tribe? Give it to her. She’ll need it, those goddamned conservative Jews.

  Weeks later my secretary nabbed me as I was trying to escape the endoscopy unit. It’s his niece on the phone, she said. She wants to know if you’ll visit him in the convalescent home.

  Codger had been found on the floor, beat up perhaps, not clear, somehow crumpled without memory, and had been taken to St. Mary’s Hospital, where they determined he had a small subdural hematoma. I went to see him. He was mumbling something about Ohrdruf, not making much sense. He got better, but not well enough to go home. Therefore the extended-care facility that now was the subject of the phone call.