Bedside Manners Read online

  She expected me to call personally and arrange this appointment—and soon, very soon.

  I seriously do not know, Doctor Watts (and I was conscious how she landed squarely on my name with all her weight as she spoke), how much longer I can hang on.

  We ordered laboratory tests, X-rays, scans. There was a plethora of phone calls attached like collateral roots to these seemingly mundane events — time of day, transportation, dietary implications. The usually quiet had raised their voices in a chorus of conditions to be met.

  Colonoscopy was scheduled three times. And three times changed. Then, at the last moment, canceled altogether because she, it now appeared, required two days’ hospitalization beforehand. I explained that in these days of cost containment it was a request that Medicare would never approve, but that we would help her arrange to stay near the hospital the night before.

  Things were moving slowly.

  And she was growing impatient. Very impatient.

  The calls grew longer, her tone more strident. It seemed that no amount of talking about test results (which were, in fact, normal) could satisfy her. She said I had not called her soon enough. She had been victimized. She wanted copies of her tests. We sent them.

  You are in possession, she said, of my laboratory tests of July 2, and you for two weeks have not called me about the sedimentation rate, which is twice the normal value.

  Actually, I had. Reassuring her at the same time that this test was not very specific or useful, especially in the elderly, and it generally didn’t mean very much. But I assured her we were taking it seriously and would pursue it. I mentioned it could be elevated during infections or as a result of a rheumatologic condition.

  It is reprehensible, she said, to have let this information go so long uncommunicated. After all, it could be a sign of serious infection or rheumatologic condition.

  I got a call from Patient Relations. They said she had complained about the length of time it took to receive the results of her lab tests.

  In that moment— finally — I realized what I was dealing with.

  My mind clicked. Suddenly she crossed the plane from just a troublesome, demanding, and worried old lady, the likes of which I have seen before and can usually manage, crossed over to one who intends to do harm.

  Sickness brings out the worst in people. It makes us worry excessively. Many of my patients exhibit neurotic behavior. The problems they generate are frustrating, but understandable and manageable. And I have found it worth remembering that the most miserable person in the process is the patient himself. But generally, their basic attitude is that of prayer— an almost desperate pleading for mercy at the hands of illness. Hers was more malignant. She intended to make trouble for me and use trouble as a weapon to get what she wanted. Whatever that was.

  I was ready to abandon ship, but as a final effort, I called her, beseeching her to be kinder to my secretaries, who, after all, were only trying their best to help her.

  If your secretaries — and she screwed her voice around the word sec-re-tarie-s, distorting each syllable until it simmered in nastiness — if your secretaries would come down from their high horse and do something for a change . . .

  I did not respond. I requested that if she had problems with the way we were handling her case, to work it out with us. Directly. Not by complaining to Patient Relations, which only served to inflame the situation. I discussed her sedimentation rate with her. Again. That was Friday evening.

  By ten o’clock Monday morning she had blown away both my secretaries, one right after another, like ducks at a shooting gallery. They came to me as one, saying they had had it. Incidentally, she wants to talk to you immediately about her sedimentation rate. At noon I called her. She did not answer. By four o’clock I got a call from Patient Relations, a message I picked up on the bus on my way home.

  Then I made a mistake. I called her up in anger. I asked what the hell had happened to my request to give my secretaries a little slack, what had become of goodwill in our attempts to solve differences without calling in Patient Relations.

  She wound up like a siren beginning its crescendo, Doctor Watts . . . I will tell you once and for all . . .

  An image flashed in my head. It was from a movie about a kidnapping, in which, against police advice, the father, over the phone, threatened the kidnapper. Whereupon the kidnapper fired his gun just over the head of the child and then hung up the phone. Just so.

  I hit the wall. Time to stop. Past time. She had to go.

  Sorry, I said, I have another call.

  And I concentrated on the flicker the sunlight made, dropping through tree branches onto our bus motoring down the highway.

  I was at my word processor that evening when the telltale message came in, ringing on my message tape like a monotone bell. Doctor Watts . . . you have not begun . . . to see . . .

  I was writing the letter. The letter I needed to write without anger or frustration. This must not be an emotional decision but a professional one. My letter would have no effect upon her— I knew this — but it was a teaching exercise for me, laying out from her perspective the areas where we had disappointed her and how we apparently were unable to provide the services she required. It was to be a letter not of rejection but of withdrawal, acknowledging we would not be able to serve her, giving her other options for medical care as I did so. You come away from medical school believing you can serve anyone, can administer to even the most unusual and difficult of patients — an idea that makes you hang in there longer than you should sometimes.

  Doctor Watts . . . it . . . is . . . piling . . . up . . .

  With each syllable the pitch increased, the volume increased, until the tight tremolo of fury rattled like a bee in a box.

  And in the calm that followed, I knew that, like little smoking meteors dropping on the surface of the brand-new earth, the calls and letters would come, from committees, from medical societies, maybe even from a congressman or two, maybe from a lawyer with a glint in his eye, come like a wave of rage that reverberates many times before the echo dies away . . . dies away . . . dies away.

  I just needed to step aside.

  THE TWO STORIES

  You’ve got an add-on this afternoon, my secretary says. It’s your friend Henry. He sounds really sick.

  There’s always a struggle between the schedule as it is and the schedule as it wants to be. Illness doesn’t happen by convenience, I know that, but the day would never finish if we let everybody come in. So there’s a little startle that runs through me every time I hear the word add-on.

  On top of that, it’s my last day in the office before leaving on a ten-day combination conference and visit to the grandchildren back East. Everybody seems to know instinctively when I’m about to leave town, and the office goes berserk.

  I hold my tongue. Even though I have asked her not to add on unless she clears it with me, something about the tone of her voice tells me he needs to be seen.

  He’s in the back, she says. He doesn’t get up as I enter the room. He’s frozen to his chair. His face is ashen and his hand clammy when I shake it. I am thinking anemia, GI bleed. Hemolysis of red cells, maybe.

  What’s wrong? I ask.

  I don’t . . . know. Don’t know.

  Any pain?

  No . . . no . . . um, what? . . . oh, no pain.

  Bleeding?

  What?

  Bleeding. Passing blood or dark stool.

  Yeah. Yeah, maybe. No. No bleeding. No.

  How do you feel?

  I feel . . . it’s . . . ah . . . it’s something . . . aaah . . . ummm . . . what is it?

  Holy shit, I think. He can’t even complete a sentence.

  Seems like you’re a little fuzzy, I say.

  Yeah. Something’s . . . ah . . . not working.

  This highly intelligent former president and general manager of a TV station, now head of a worldwide production company, can’t finish his thoughts. I’m thinking pneumonia. Oxygen shortage i
n the brain. Anemia.

  I grab the pulse oxymeter and clothespin it to his finger. Ninety-six percent. Not bad. I pop my stethoscope to his chest. Clear. No pneumonia. I think meningitis. Do you have headache? I say.

  No.

  I ask him to touch his chin to his chest. He does that. No meningitis.

  I call his assistant in, the one who brought him here. He’s having trouble piecing things together, I say.

  Listen, she says. When your boss is lying on the couch with his shirt off in your presence, not able to get up for four hours, you know something’s way off. And then, of course, I had to force him to come in.

  How did all this start?

  He was okay in India last week. He started showing signs of fatigue on the way back. Slept a lot.

  I think of wild tropical diseases — malaria, maybe, or blackwater fever, in which the red corpuscles are shattered by the invading organism and the urine darkens with debris. His skin was cool, but fever can be off and on.

  Any fever? I ask him.

  No.

  Black urine?

  No.

  My mind races to the time he got a urinary tract infection in New York and it disseminated. Ended up in a hospital with blood poisoning—I remember his telephone calls to make sure they were doing everything right. I think of gout, kidney stones. It wasn’t pulling together.

  I check his belly. Soft. No pain. Nothing unusual.

  I call for a wheelchair. I’m going to send you to the emergency room for tests, I say, and I expect we’ll hold on to you a few days until we find out what this is.

  His assistant wheels in the chair.

  Your chariot is waiting, I say.

  He laughs and nods.

  Encephalitis comes to mind as the assistant wheels him out. I think of my children at home and wash my hands. Twice.

  I call the ER to discuss his case with the attending physician. After office hours I go by to see him.

  He’s sedated, his assistant says. His wife’s coming back from Albuquerque late tonight. I can wake him if you want.

  No, thanks.

  We’re just waiting for a bed.

  I check the chart. Hematocrit of 12. Good God! That’ll do it every time. No wonder he couldn’t spark two brain cells together. No oxygen in the stratosphere.

  I read on. White cells low. Platelets, too. Bad sign. Some kind of general failure of the bone marrow. Time will sort this out. He’s in the right place.

  My plane leaves with me on it. A day later I call. He is in isolation. The nurse says they still haven’t figured out what’s going on. Three days later— same thing.

  The day of my return, he is in my office. No information about his hospitalization has come to me yet, but he looks a lot better.

  That was quite a deal, he says.

  You’ll have to tell me what happened. Play like I just set foot on the planet.

  Well, they never found the infection, though they think I had one. He’s smiling. Rather than showing remorse, he’s the old friend glad to see me, a mood more as if we’re about to sit down to discuss a network project we both have great interest in. I can detect no sense of tragedy.

  They must have transfused you.

  Oh, many times. And my count kept going down, so they had to do it again and again.

  What did they think it was?

  Well, they don’t know. They did a bone marrow and there’s some kind of problem there. There’s a word for it. Myelo . . . umm . . .

  Myelophthisic anemia?

  Yeah. Yeah, that’s it. I think so. Basically it’s leukemia. There’s no pause, no hesitation before the word that so many have stumbled over.

  Looks like I’m going to get a marrow transplant.

  He looks rosy, energetic. Still smiling.

  You’re taking it very well.

  Laughter bursts forth—as if it has been sitting behind a little retaining wall for a long time, as if the moment for laughter has now come and it is happy to be released.

  Look, David, I’ve had a great life. I’ve been everywhere, done everything I wanted to. I’ve got a wonderful family . . . what more could I want?

  There is a little pause in which I wonder about nominating him for the Poster Child of the Society of Great Attitudes. I want all my patients to meet him.

  My two brothers have already stepped forward. They said they’d donate for me. If I survive that . . . I guess there’s a fifteen percent chance I won’t make it through the transplant process . . .

  . . . you know, I’ve known about this large spleen I have for twenty years . . . twenty years before it finally decided to do something. Not too shabby.

  You’re at peace.

  I’m at peace.

  We walk out of the office more like golf buddies than like a doctor and his patient with leukemia, more like grateful parishioners, blessed by something invisible.

  It was one of those moments that sneaks up on you and elevates you, suddenly, like an unexpected lift in the road. And in that moment I knew I wanted to tell people about this, to write about it. And so I do.

  And as I arrive at the point where we walk out of the office, the story is not over yet. The rest hasn’t happened. Even so, because writing sometimes has the power to tell what comes next, I can see the difference between what might happen and what should happen. But this is risky business. The story wants to go in a direction that asks for something more, something daring, something I might otherwise think about. Can I trust the artifice of a story to advise real life? A chill rattles through me that says I had better be sure.

  I know that writing has the power to see clearly, to raise possibility, to introduce compassion where the arching momentum of ritual doesn’t pause long enough to recognize such opportunities . . . but can it be trusted to direct what hasn’t happened yet? The wisdom that reservoirs in stories results from repeated experiments in the life of the real world with all its foibles. Can a story not finished inform a decision not made?

  I have decided. It feels right. I will call him up and ask how it is going. He will say, Fine, I sure feel a lot better with all that blood in me. Then I will say, Look, I just want you to know that if anything goes wrong with your brothers as donors, you can put me on the list.

  And there will be a pause in our conversation. And something will pass between us that is neither tissue nor spirit. More like flowing waters. And I will remember how I was not able to do anything for my brother when he was dying.

  Well, that’s how I thought it would be. How the story would have written it. It wasn’t that way.

  I did make the offer: I found him in New Mexico.

  You know, I really feel pretty good, he said.

  It helps to have a few blood cells in your body.

  Yeah, I guess it does. Probably helps a lot of things.

  What’s happening about the transplant?

  I’m weighing being down for two months, he said, putting that up against feeling pretty good right now with transfusions.

  I guess you can’t be transfused forever.

  Yeah, that’s what they tell me. But I’ve got time. I’m thinking about going to Mayo’s to see what they have to say. Always good to have another opinion.

  I thought so.

  And if you need it, you can put my name on the list.

  What?

  In case your brothers fall through . . .

  There was a pause in which I wondered if he knew what I was talking about. He did. Well, aren’t you nice, he said.

  Maybe. But you have to consider you might have a violent reaction against all that Texan blood inside you, being from New Mexico and all.

  He laughed. Yeah, I might at that. I’ve got to tell you I can figure out a lot of things, but I can’t figure out Texans.

  They don’t want to be figured out, I said. They’re coyotes. As soon as you start to understand them a little bit, they’ll change something just to throw you off.

  And that was all there was to it. The story had been ri
ght on the concept but needed real life to set a few details straight. And there were some surprises. There was none of the fear I anticipated clotting in a ball at the volunteer desk, no experience of spiritual epiphany or mystical brotherhood. Just the secure feeling that when it finished, all was as it should be.

  Just that and nothing more.

  I write the story and the story writes me. And the story was right. It gave directions to the freeway, even if it took us somewhere we didn’t expect. And from here . . . well, everything will play as it wants.

  The story and the reality benefited from each other, and the two stories — the one in the life and the one about the life, which had touched and mingled, leaving inside each other little tracers, like enzymes of transformation that change ideas and shift outcomes — could now, without ceremony, move us on to the next day.

  MALADY MÉNAGE

  Because all during the interview the new wife kept interrupting the stepdaughter’s recital of symptoms with an almost desperate need to edit minor details and offer her own herbal or spiritual remedies, and because in the elevator I had noticed that the daughter stood very close to the father, nuzzling his upper arm, not minding if her newly formed breast grazed him lightly, what I saw was two women in competition for the same man.

  My patient, the daughter, had a simple problem, common to transitional stages of life: heartburn, belching, burning—the hallmarks of reflux esophagitis, except that she also yorked up a little something from each meal—not much, I assumed, because she wasn’t losing weight and looked perfectly healthy.

  But the usual remedies did nothing. Heavy artillery did nothing: acid suppressors, pro-motility agents, surface-protective agents . . . she just smiled with a look that said, I’m not better, fix me. Simple problems often have complex overtones.

  Things weren’t adding up. So I did what I often do in such circumstances: go for the objective data. At endoscopy nothing much was found, just a very mild esophagitis. Which left an unaccountable discrepancy between the magnitude of the symptoms and the paucity of findings.

  I told her the problem should have resolved by now. Was there anything else I needed to know?

  She struck me as keenly intelligent, almost eccentric in her nonconformist adornments — sleeves below her fingertips, well-placed rips in her jeans, nose ring. I was certain if I looked for it I would find a small, tastefully discreet tattoo somewhere on her body.