Travels (9 page)

Finally, his physical manner was rough and harsh. He’d yank and pull at people in their beds, shoving them around, yelling at them, “No, no, not like
that
, just stay the way I had you!”

In retrospect, Tim was a frightened man trying to hide his own sense of inadequacy behind a façade of bullying sarcasm. But at the time I thought he was outrageous. All of the house staff had witnessed his behavior; more than once, glances were exchanged at the bedside. I felt Tim ought to be taken aside. I felt he needed psychiatric help. But nobody was doing anything about Tim, and it wasn’t my position to suggest that a member of the house staff needed a shrink. I was just a medical student,
the lowest of the low. And at the end of three months, Tim was going to give me my grade.

But now Tim was planning to do a punch biopsy on Emily’s hipbone, a painful and, I believed, unnecessary procedure. I felt he wouldn’t dare to do it if Emily weren’t an old woman without friends or relatives, a woman no better than an alcoholic bum, a woman who had been lousy on admission.

“I’m doing it at one o’clock,” he said. “Want to assist?”

“No,” I said.

“I’ll let you do it, if you want.” A bribe.

“No,” I said.

“Why not?”

I’d already registered my protest, so all I said was “I have clinic follow-ups all afternoon.”

“Okay,” Tim said. “You missed your chance. I’ll get the nurse to help me.”

I still hoped he wouldn’t go through with it, but he did. The test was negative. Emily’s marrow was fine.

Still, they kept Emily in the hospital. She had been there two weeks now. There was an unspoken rule about old people, which was that you discharged them from the hospital as soon as possible. Emily had gained strength steadily during the first week, but now she was starting to decline, to drift into a vague passivity.

At rounds the next day, the house staff discussed further tests for Emily. More exotic blood chemistries. Another EEG. A series of brain X-rays, a pneumoencephalogram. These tests would take at least another week.

I was already feeling guilty about the bone-marrow biopsy. Now I felt I had no choice. I spoke up.

I said that, while Emily was clearly a strange person, her health now seemed basically good. There wasn’t any compelling reason to do further tests. If she was senile, as everyone thought, then these tests wouldn’t benefit her. There was no advantage to diagnosing an incurable disease. True, we had never found out what had put her in a coma, but we had been trying for two weeks and there was no reason to think we would succeed in a third week. Meanwhile, Emily was in noticeable decline. I argued we should discharge her, and do any further tests on an outpatient basis. And I suggested that if Emily had a family, they would now be pushing us to let her go, and that by keeping her around, we were open to a charge of exploiting her as learning material.

I was sweating by the end of my speech. Everybody stared at me. The chief resident said nothing. He turned to Tim, and asked when the tests would be scheduled.

Tim said the tests would be scheduled all during the coming week.

The chief resident said, Fine. Go ahead.

And that was that.

We went on to the next patient.

“What do you people think is wrong with me?” Emily said later, when she and I were alone.

“We’re not sure,” I said.

“Nothing is wrong with me,” Emily said. “I feel fine. I don’t want any more tests.”

“I can understand that feeling,” I said.

“Well, then, why do I have to have them? He hurt me,” she said, pointing to her bandaged hip.

I was on dangerous ground now. I had to choose my words carefully. “If you want to leave the hospital,” I said, “no one can stop you.”

“You mean I can just walk out of here?”

“No, you have to be discharged. But if you insist on it, they have to discharge you.”

“They do?”

“They’ll try to talk you out of leaving, but they can’t make you stay.”

“Good,” Emily said. “I’m sick of all you fucking doctors and your fucking tests.”

“Guess who checked out?” Tim said that night in the cafeteria. “Emily.”

“Oh yes?”

“Yeah. Discharged herself against physicians’ advice.”

“When?”

“Tonight. Screaming and swearing, nobody could talk any sense to her. They had to let her go. I think somebody put the idea into her head.”

“Oh, really?”

“Yeah. Somebody talked to her.”

“I wonder who?”

“I think somebody from Accounting. They’re not sure if she’s covered by Medicare, you know, and I think Accounting got nervous about the expense and decided to get her out.” He sighed. “But you wait. She’ll be back in a few weeks, covered in lice, just like before. Crazy old bitch.”

* * *

Two months later, I was walking through the lobby of the outpatient department when I felt a pain in the ribs. Somebody had banged into me. I grunted and kept going.

“Hey! Doctor!”

I stopped and turned. A rather elegant woman stood there, wearing a green cape and a beret set at a rakish angle. She smoked a cigarette from a long ivory holder. She carried a cane in one hand. She was staring at me expectantly.

“Don’t you say hello, Doctor?”

Patients never understand how many people you see, how many faces pass before you, particularly in the outpatient clinic. You may see fifty in an afternoon. “I’m sorry,” I said, “but do I know you?”

She cocked her head, and seemed amused. “Miss Vincent.”

I hadn’t a clue. “Miss Vincent?”

“Emily.”

I stared, still not recognizing her. I tried to dredge up anybody named Emily Vincent. And suddenly it all fell together. Emily! The lady who was lousy on admission!

Seeing her now, her stance, her dress, her manner, I understood. Emily was a bohemian. In the 1920s, she had been one of those rebellious, independent, artsy women. Of course she knew all about artists and writers. Of course she had never married. Of course she swore and smoked and was fiercely independent and advanced. Of course she was contemptuous of the doctors around her. Of course she liked to say shocking and outrageous things. As the years went on, Emily would have been in turn a flapper, then a wartime riveter, then an aging beatnik. Of course she said things like “Daddy-oh.” Emily was a hipster.

“Emily,” I said, “how are you?”

“Quite well,
Dottore
. You may call me Miss Vincent.”

“You’re coming to the clinic?”

“They say I have a little something with my thyroid, and I take pills,” she said, puffing on her cigarette. “Frankly, I think it’s crap, but my doctor is so handsome, I indulge him.”

“You look wonderful, Miss Vincent,” I said, still trying to adjust to what I was seeing.

“You, too,” she said. “Well, I must be off.
Ciao
.”

And, with a dramatic wave, she turned, cape flying, and was gone.

Heart Attack!
 

A major disaster befell the medical wards of the Beth Israel Hospital. All the interns and residents went around shaking their heads. The disaster was that, by some quirk of fate or statistics, two-thirds of the patients on the ward had the same illness. Heart attack.

The residents acted as if all the theaters in town were playing the same movie, and they’d seen it. Furthermore, most of these patients would be here for two weeks, so the movie wasn’t going to change soon. The home staff was gloomy and bored, because, from a medical standpoint, heart attacks aren’t terribly interesting. They are dangerous and life-threatening, and you worry about your patients, because they may die suddenly. But the diagnostic procedures were well worked out, and there were clear methods for following the progress of recovery.

By now I was in my final year of medical school, and I had decided I would quit at the end of the year. So my three months at the Beth Israel were going to be all the internal medicine I would ever learn; I had to make the best of this time.

I decided to learn something about the feelings the patients had about their disease. Because, although doctors were bored by myocardial infarcts, the patients certainly weren’t. The patients were mostly men in their forties and fifties, and the meaning of this illness was clear to them—they were getting older; this was a reminder of their impending mortality;
and they would have to change their lives: work habits, diets, perhaps even their pattern of sexual relations.

So there was plenty of interest for me in these patients. But how to approach them?

Some time earlier, I had read about the experiences of a Swiss physician who, in the 1930s, had taken a medical post in the Alps because it allowed him to ski, which was his great passion. Naturally, this doctor ended up treating many skiing accidents. The cause of the accidents interested him, since he was himself a skier. He asked his patients why they had had their accidents, expecting to hear that they had taken a turn too quickly, or hit a patch of rock, or some other skiing explanation. To his surprise, everyone gave a
psychological
reason for the accident. They were upset about something, they were distracted, and so on. This doctor learned that the bald question “Why did you break your leg?” yielded interesting answers.

So I decided to try that. I went around and asked patients, “Why did you have a heart attack?”

From a medical standpoint, the question was not so nonsensical as it sounded. During the Korean War, post-mortems on young men had shown that the American diet produced advanced arteriosclerosis by the age of seventeen. You had to assume that all these patients had been walking around with severely clogged arteries since they were teenagers. A heart attack could happen any time. Why had they waited twenty or thirty years to develop a heart attack? Why had their heart attack happened this year and not next, this week and not last week?

But my question “Why did you have a heart attack?” also implied that the patients had some choice in the matter, and therefore some control over their disease. I feared they might respond with anger. So I started with the most easygoing patient on the ward, a man in his forties who had had a mild attack.

“Why did you have a heart attack?”

“You really want to know?”

“Yes, I do.”

“I got a promotion. The company wants me to move to Cincinnati. But my wife doesn’t want to go. She has all her family here in Boston, and she doesn’t want to go with me. That’s why.”

He reported this in a completely straightforward manner, without a trace of anger. Encouraged, I asked other patients.

“My wife is talking about leaving me.”

“My daughter wants to marry a Negro man.”

“My son won’t go to law school.”

“I didn’t get the raise.”

“I want to get a divorce and feel guilty.”

“My wife wants another baby and I don’t think we can afford it.”

No one was ever angry that I had asked the question. On the contrary, most nodded and said, “You know, I’ve been thinking about that.…” And no one ever mentioned the standard medical causes of arteriosclerosis, such as smoking or diet or getting too little exercise.

Now, I hesitated to jump to conclusions. I knew all patients tended to review their lives when they got really sick, and to draw some conclusion about why the illness had happened. Sometimes the explanations seemed pretty irrelevant. I’d seen a cancer patient who blamed her disease on a lifelong fondness for Boston cream pie, and an arthritis patient who blamed his mother-in-law.

On the other hand, it was accepted in a vague way that there was a relationship between mental processes and disease. One clue came from timing of certain illnesses. For example, the traditional season for duodenal ulcers was mid-January, just after the Christmas holidays. No one knew why this should be, but a psychological factor in the timing of the disease seemed likely.

Another clue came from the association of some physical illnesses with a characteristic personality. For example, a significant percentage of patients with ulcerative bowel disease had extremely irritating personalities. Since the disease itself was hard to live with, some doctors wondered if the disease caused the personality. But many suspected that it was the other way around: the personality caused the disease. Or at least whatever caused the bowel disease also caused the personality.

Third, there was a small group of physical diseases that could be successfully treated with psychotherapy. Warts, goiter, and parathyroid disease responded to both surgery and psychotherapy, suggesting that these illnesses might have direct mental causes.

And, finally, it was everybody’s ordinary experience that the minor illnesses in our own lives—colds, sore throats—occurred at times of stress, times when we felt generally weak. This suggested that the ability of the body to resist infection varied with mental attitude.

All this information interested me enormously, but it was pretty fringe stuff in the 1960s in Boston. Curious, yes. Worthy of note, yes. But nothing to pursue in a serious way. The great march of medicine was headed in another direction entirely.

Now, I was getting these data from the heart attack patients. And what I was seeing was that their explanations made sense from the standpoint of the whole organism, as a kind of physical acting-out. These patients
were telling me stories of events that had affected their hearts in a metaphorical sense. They were telling me love stories. Sad love stories, which had pained their hearts. Their wives and families and bosses didn’t care for them. Their hearts were attacked.