You’ve Got 3 Months To Live

I had always been skeptical of stories about patients who were cured of cancer by eating a certain root or drinking an extract of elderberries, or such.  I would feign interest while to myself I would say, “idiocy.”  Life subsequently made me less of a scoffer.  In Love, Medicine and Miracles Bernie Siegel states that every doctor has a cancer patient who experienced an unexplained cure.  In fifty years of practice I encountered two; each was puzzling and humbling.

The first was Nick, a retired steelworker, who came to my office because of abdominal pain.  Reluctantly he consented to being hospitalized.  When routine tests failed to turn up any cause for his pain, I performed a nuclear scan of his pancreas. This was my first attempt at such a scan, as I had just returned from three days of studying the procedure in Cleveland.  To my unabashed and disgraceful joy the scan showed a tumor.  How proud of myself I was with my newly discovered talent.  A subsequent biopsy demonstrated malignant cells, confirming a diagnosis of cancer of the pancreas, a death sentence since almost all such patients at that time died within one year.  Nick refused to undergo surgery, which seldom helped anyway).  I told Beth, Nick’s wife, that there was no other treatment (these were the days before chemotherapy, fortunately for Nick as it turned out) and that his days were numbered in months, not years.

To my surprise and chagrin Nick never returned to my office.  Periodically I kept in touch by phone, hearing only that he was well.  I remember one particular phone conversation with Beth.  “Can I speak with Nick?”

“He’s out in the garden.”

“How’s he feeling?”

“Fine.”

“How much weight has he lost?”

“None.”

“How’s his pain?”

“He doesn’t have any.”

Desperately seeking to elicit one little symptom, I pleaded, “Does he burp?”

“No. He’s just fine.”

In disbelief I had eminent pathologists review the microscopic samples taken from Nick’s pancreas.  Always the same answer: “cancer.”  And my Cleveland mentor confirmed my interpretation of the nuclear scan. My isotope scan of Nick’s pancreas was even published in a textbook of nuclear medicine as a proven case of cancer of the pancreas!

Five years after my prediction of an inevitably early demise, an ambulance brought Nick to my office parking lot for the formality of my pronouncing him dead.  At my urging Beth agreed to an autopsy.  Knowing what the pathologist had to find, I prevailed upon him to be more meticulous than usual.  Lo and behold the cause of death was an acute myocardial infarction, a common heart attack; there was no cancer to be found.

With no other hypothesis to fall back on, I’m left with believing that perhaps Siegel’s thesis is correct, that a proper attitude on the part of the patient can positively influence the course of his cancer.  I now, at least, recommend gardening.

Helen, my second miracle case, was a nurse at my hospital and a personal friend.  How proud I was of myself, and yet wretched (in that order), when I diagnosed colon cancer from a barium enema I performed in my office.  I had to remind myself that I hadn’t put the cancer there.  On Thanksgiving Day that a cancer surgeon operated on Helen.  I watched as he deftly removed the cancer and one cancerous lymph node. 

Three months later while I was out of town, Helen experienced renewed pain in her abdomen. I received a phone call from a surgical colleague.  “Dave, I just opened Helen’s belly.  It was sprinkled with tiny metastases everywhere.  Oh, yes, I did splash in some nitrogen mustard (the only chemotherapy drug at that time) before I closed her but you know that can’t do much good.”  The surgeon told Helen’s husband that she had three to six months to live.  I concurred.

Against all odds, Helen continued to live in good health defying my prediction, just as Nick had.  Questioing my initial diagnosis, I sent tissue samples from both of her surgeries to two university pathologists who confirmed the diagnosis of metastatic cancer.  Not one of the many oncologists I consulted would credit the nitrogen mustard for her remission.

In the ensuing years Helen remained symptom-free with occasional checkups disclosing absolutely no abnormal findings.  Her husband would ask, “Doctor David, how do you explain our good fortune?” 

At a loss for words on each occasion once I did offer, “Well, you know that the night before Helen’s first operation, I attended a Brotherhood meeting with Bishop John Wright (later Cardinal Wright) and he agreed to offer a special prayer for her.”

 Helen lived thirteen years, after the second surgery, continued nursing (not gardening), until death came from a massive stroke.  It was not surprising to me at that point that the autopsy showed no evidence of cancer. 

Whatever the reason for these miracle patients, it is incumbent on me, and all physicians, to be truthful and humble; that includes not setting rigid limits on the projected life span of any patient.  I only wish that when I used to estimate the amount of time “left,” I could have been wrong an additional time or two or three ….

(Abstracted from my memoir, By All Means, Resuscitate)

Love Is Color-blind; Doctors, Not.

What a prim and proper image both husband and wife projected sitting across the desk from me: she, a tiny woman with a silvery-white coiffure, every hair in place, and he, appearing twice her size, with tweed jacket, buttoned, starched shirt collar, and paisley print tie.  Though she was the patient, he did the talking after my introductory remark, “What can I do for you?”

“Priscilla has been having dizzy spells.  Can you give her something to stop them?” 

“Hold on!  I need first to obtain much more information from Priscilla and then examine her before coming to a correct diagnosis.  It may be that I will need to carry out blood tests and a battery of other procedures before confirming a diagnosis.”

“Her problem is really simple.  She’s just nervous and needs something to calm her down.”

“If that is the case, (I looked at Priscilla) why did your doctor send you to me?”

Again her husband answered.  “He really wanted to send her to a cardiologist at the University but I asked for you.  I know that you Jewish doctors are usually the best.  Give Priscilla some pills and if they don’t work, then we’ll see.” 

My initial discomfort at first meeting this couple was vindicated.  He was an arrogant racist, an abusive, tyrannical husband; she, a submissive wife without any apparent spark of discomfort with the scene that was unfolding.  Maintaining a professional bearing, I suggested that they go home and reconsider returning under my terms.  Feigning sincerity, I said I would be happy to see Priscilla again.  In the years to come I would grow to marvel at this remarkable lady.

Franklin, the husband, was indignant as he stood, pulling Priscilla’s arm. “There is no point in continuing the interview.  Doctor, if I owe you any money, please send me your bill.”  Not one word from Priscilla during the short encounter, though I noted that she sighed frequently, a tip-off that this could be the cause of her “dizzy spells.”

There was nothing in my years of training to suggest that I had the prerogative to select which patients I would treat and which I would not.  Any adult with a medical problem came within my purview. The only baby I delivered after my internship took place on the floor of the admitting office of our recently opened hospital.  Being the only doctor available at that moment, I had no choice.  With ten thumbs, I managed to keep out of the way of the exiting future president.  I did subsequently however, propose a routine of having all women in labor by-pass the admitting office and proceed directly to the obstetrical suite. 

Having been raised in a multi-ethnic town and having friends from many classes, nationalities, and religions, I seldom displayed a negative reaction when facing a patient for the first time.  This was in contrast to my first encounter with a Japanese roommate in 1944 at Harvard; I failed that time but hopefully never again. 

Take the alcoholic who sat disheveled, glassy-eyed, reeking of cheap gin, his fingers nicotine-stained.  He was referred to me because his doctor heard a heart murmur indicating a leaking valve.  Was I permitted to feel repelled?  Well, permitted or not, I was.  Managing a cursory examination while avoiding contact even with his clothes, I made a decision to admit him to the hospital where he would be bathed and clothed in freshly laundered hospital garb.  There he dried out without withdrawal events.  He turned out to be medically exciting, for his heart problem was due to vitamin B deficiency, called Beri-Beri.  I hadn’t seen a case since third-year medical school on the wards of Boston City Hospital.  More to the point, under the alcoholism lay a bright, inquisitive, sensitive human being.  If I had rejected him after an initial glance, I would have missed the thrill of managing a rarely seen illness, of rehabilitating a sinking soul (with the help of Alcoholics Anonymous), and of making a new friend.

Franklin and Priscilla fell into another category of problematic first encounters.  Their haughty demeanor, expressionless and humorless, evoked no special curiosity or interest on my part.  I would have had to work hard to construct a working rapport.  Accordingly I had to rebuke myself as this relationship failed so quickly.  Couldn’t I have used an approach different from one that resisted intimidation?   Couldn’t I have delved into some historical data, taken her pulse, and checked her blood pressure?  If the diagnosis were quickly apparent -- I did not doubt that over breathing was the basis of her symptoms --, I could have prescribed appropriate management, maybe made a friend and, again maybe, inspired Priscilla to return, hopefully without her husband.

It was a month later that Priscilla called me at home to request an urgent appointment.  “I want it to be at a time when no other patients are there, not even your nurse.”  I indicated that the absence of other patients could be arranged but my nurse would have to be in the office although not in the room with us. 

“But she used to work in an office near my husband.” 

“My nurse is bound to the same code of secrecy as I.  You can trust her.”   

“Then, at least, I don’t want her to see my chart.”

“That’s impossible.  She types my records.  I am afraid you will have to trust us.”

Priscilla relented.  An appointment was arranged for the next day after the usual working hours.  My nurse wasn’t happy but I was able to convince her to put on a professional face when Priscilla arrived.

We shook hands, that is, if touching the ends of the offered fingers can be called that.  In response to my “How are you?” Priscilla lost all composure.  She blotted her tears as fast as they descended her cheeks. 

“How am I?  I’m miserable.  I can’t take it anymore.  I’m terrified of my husband.  I don’t know what he would do if he knew I’d come to you on my own.”

“It doesn’t sound like much of a marriage.”

“Would you be appalled if I said, ‘he forces me to have sex’ after which he locks me into the bedroom until he returns from work?”  And when he’s not abusive in physical ways, he treats me like a puppet.  He makes every decision for me, what I do, where I go, whom I can see or not see.  He takes me shopping and picks out my clothes.  He does give me money for grocery shopping but otherwise he pays all the bills.  I can’t sign checks.  Our daughter hates her father and is fed up with my inability to pull myself loose from him.  She moved out, as far as she could get.  California.  I never see her.”

As this tirade of fear, frustration, and anger spewed from the apathetic woman I had seen on the initial visit, I was excited to find grounds on which we could now commence treatment.  I also knew that I was unqualified to embark on the psychotherapy she required.  Yet there was more I could do. Firstly I had to explore the urgency of her situation.  “Has he ever struck you?”

“No, not really.  He has pushed me around.  How many times I saw my father hit my mother!  So, early in my marriage I felt I was lucky; I had a husband who didn’t beat me.”

Next I asked about insomnia and constipation, symptoms that might suggest depression.  “No” to each of these.  And then I leaped in with the most confrontational of questions, “Have you ever contemplated suicide?”

Not once in my career has a patient responded in anger or chastised me for such an absurdity.  Priscilla’s response was the usual one.  She hesitated.  “To tell you the truth, maybe once or twice, never seriously.  The first time Franklin locked me in the bedroom, I thought that I could get even with him with the embarrassment of having his wife found in a pool of blood with her wrists slashed.  I didn’t have the nerve to do it.”  I was satisfied that I didn’t have to worry over that possibility.

I proceeded to take a lengthy medical history although with each question she kept trying to get back to her marriage.  As I delved more deeply into her dizziness, it was clear that light-headedness more accurately described her symptoms.  She nodded “yes” to each question regarding sighing, burping, not being able to get a deep enough breath, and periodic numbness and spasms in her hands.  She obviously had “hyperventilation syndrome.”

How could I ever miss that diagnosis, having suffered from it myself as I began my first days away from home entering medical school?  Unlike the idiot of a doctor who compounded my problem by ordering a skull x-ray, I finished a physical examination and quickly gave her my diagnosis.  Treatment of her symptom would be easy.  Once she was reassured that she didn’t have a brain tumor or high blood pressure, her fears abated.  She could elect to ignore the symptom or make efforts to breath more shallowly and refrain from sighing.  Furthermore, for the hand symptoms she could breath into a paper bag.  I was satisfied that this problem would dissipate and told her so.

“But, we have to attack the problem which caused this symptom.  It’s lucky for you that more disturbing psychoneurotic symptoms haven’t occurred.  I want you to consider having a psychiatric consultation with a colleague of mine.  In the meantime I will arrange a urinalysis and a few blood tests.  I’ll see you again next week.”  After Priscilla left, my nurse told me she paid in cash and rejected a receipt.  Without a checking account she had no other recourse.  Without a receipt she could deny that the visit ever took place. 

A week later, under the same private conditions, Priscilla entered the office.  There was such a difference in her appearance or was I just seeing the person I had missed during the first two visits?  Her hair, her dress were less severe and she actually offered me twice the amount of flesh I had noted with our initial handshake.

“Doctor, Franklin was right. You Jewish doctors are the best. (Her smile told me she was facetiously quoting her racist husband.)  I’ve stopped burping and I no longer carry a paper bag in my purse.”

I complimented her for having done her homework. After I Indicated that her laboratory studies were normal, I asked if she had noted any other differences. “Well, I’m less edgy.  Even Franklin commented on this. And as for your suggestion regarding my seeing a shrink, let’s hold off for a while.”

We spent the rest of this visit and two more discussing primarily her early rearing and her self-image. As we parted on her final visit she took my whole hand in hers and said, “You can’t appreciate what you’ve done for me. More than all our discussions and your medical advice, you listened to me. You didn’t criticize me or indicate that you found me a silly person. I now like myself better and you know what? Franklin likes me more. I even confessed that I had been seeing you. And you know his answer? ‘Maybe I should too’.” He never did.

All of this has been just the preamble to Priscilla’s story.  Four years later Priscilla was a widow.  Franklin had fallen from a very high crane and had died instantly.  Two months after this tragedy Priscilla asked to see me for a check-up.  Her sadness on losing Franklin was evident; they had become increasingly “good friends” in those intervening years. Now in her late fifties, she found herself quite alone. To her sorrow she discovered that her financial situation was bleak. Her meager savings and a widow’s social security were insufficient to maintain her sixty-year-old house. She sold it and rented a three-room apartment. At the same time she found a part-time job babysitting and during the Christmas holiday, work as a gift-wrapper in a department store.  Priscilla was uncomplaining.

She thought that she would benefit from pills for “depression.”  I was quite confident that, though she was sad, she was not depressed and reassured her that she was managing her grief well. 

Within another two years Priscilla moved to a low rental multi-racial senior citizens’ home, into a one and a half room efficiency apartment. This constituted a striking social comedown considering the lower-class residents and neighborhood. Yet she was quite cheerful now that she had financial security and could even afford to visit her daughter. I was proud of her, wondering how I would fare under similar circumstances. I verbalized this to Priscilla at which point she became the doctor, reassuring me that I would do what I had to do.

A few months later we met in the hospital where she was visiting a sick neighbor. We had a lovely chat in the cafeteria. I mentioned to her that a hospitalized patient of mine lived in her apartment house. It just so happened that this patient, a very dark-skinned African American, and I had become good friends in the course of his treatment for heart trouble. On almost every visit we ended up discussing local and national politics as well as race relations (this was during the racial unrest of the late 60s and early 70s.) He was a well-read, astute analyst of our times. I was shocked when Priscilla said, “Are you talking about Isaac Rose?”

“Why, yes, I am,” I said, trying to mask prejudicial thoughts.

When A Doctor Tries To Be Robin Hood

It was not one of my better days when Don came to see me.  I had agreed to his request to see him after office hours when no one else would be present.  He sat heavily into a chair opposite my desk.  Saying nothing, within seconds his eyes watered.  I had absolutely no idea what was to follow.  As fellow internists Don and I had been friends for over ten years, frequently substituting for one another on weekends and extended vacations.  He was devoted to his patients and they, to him.  Though generally passive, he could be counted on to support any hospital policy innovation that would improve patient care. 

I waited for him to begin the conversation.  “Dave, you know I’m a good family man.”

“Oh, my,” I thought.  “He’s having an affair.”  I really didn’t think of Don as having much libido.

“And I go to church every Sunday.”

Again to myself, “that could mean all kinds of sins.”

“I’m in trouble, big trouble.”

Now I knew the answer.  Though I wasn’t his doctor, he had mentioned his being a diabetic.  This plus the fact that he was a heavy smoker and a sedentary chubby added up to coronary heart disease.  Surely he was going to tell me that he had developed angina pectoris, chest pain typical of that diagnosis.

Was I wrong!  “You know I’m a political conservative.”  How well I knew that!  A year after I started my practice in Aliquippa, Marcia and I invited Don and his wife to our home to watch the Democratic Convention on television.  Adlai Stevenson to our delight was to be nominated.  Don thought him to be a liberal “egghead.”  Within minutes we politely, though reluctantly, shut off the TV.  “And you would be right to think that I agreed with our medical society which opposed doctors being involved with Medicare.  Once we had little choice but to go along with their fee schedules, I knuckled under.  But it annoyed me that there was a significant deductible fee that patients had to pay out of their own pockets.”

“Don, I’m at a loss to know what’s upsetting you.”

And then came the confession.  “I got caught trying to beat the system.  I’m being accused of committing fraud.”

I was still in the dark.  “Well, did you commit fraud?”

“Yes and No.  When I did an electrocardiogram, I billed Medicare for two examinations which compensated me enough that the patient didn’t have to pay me anything.”

I was irate but managed a poker face.  I had to keep remembering that Don had come to me as a friend, as a confidant.  I couldn’t turn on him.  “But, Don, even if your reasoning might be politically understandable, in a climate where doctor after doctor is being found guilty of bilking the government for services never supplied, how could you be so naïve to think that you could get away with it?”

How well I knew the paranoia of the system. Only three months before, I had received a letter requesting (that is, requiring) chest x-ray films of ten specific patients for whom I had billed Medicare.  In addition I was asked to send for each of the ten patients the indication for the x-ray study and a copy of my written report.    Subsequently, my x-ray films were returned with a note thanking me for my participation.  Not all doctors were similarly praised.  A few received court summons; either they were unable to produce the requested films or chest x-rays were fraudulently produced as proven by testimony of patients who denied under oath of having x-ray studies performed.

Don had no answer for me.  Instead he anticipated the shame of having his crime sensationally disclosed in large print in the local newspaper.  “Can you imagine how the newspapers will rake me over the coals?”  A defense that he tried to help protect his patients’ finances would be ridiculed.

And then Don spewed one catastrophic scenario after another.  “Will I be put in jail?  Will there be an open court trial?  Will my kids be ashamed of me and will their classmates taunt them?  Will I go bankrupt?”  And finally, with chin touching his chest, “Maybe I should just kill myself.”  At that moment my anxiety took on a new dimension.  With Don’s permission I called his wife, Beverly, and asked her to come to my office; she had been too humiliated and terrified to accompany Don. 

“Do I have to, Dave?”  It was obvious that she was crying.

“I’m sorry, Bev.  You don’t have much choice.”  Then to Don I began proposing a plan of action.

“Is your friend, Lionel, also your lawyer?”

“Yes.”

“I suggest that I call him now and arrange an urgent meeting today.  OK?”  With resignation, Don nodded approval.  “Then I think you should set up a meeting with your tax consultant.  If he’s also your financial advisor, so much the better.  I think you have to sit with him with a sharpened pencil and see exactly what you have to worry about in case your income should drop.  And don’t hide any assets from him.”  I made both calls.

By the time all was arranged, Beverly arrived.  In contrast to Don, Bev was slender, looking even thinner as she sat in the chair, a twin to Don’s.  There was no question that their ordeal, which was just beginning, had taken its toll.  She was wearing a wrinkled housedress and no make-up; her hair hadn’t felt a comb since the court summons had arrived early that morning; normally every hair was in place.  She sobbed continuously.  “What are you feeling,” I asked?

“I wish I were dead.”  It was quickly made evident that Don would have no support from this quarter.  All I needed was a double suicide.  A vision of their two orphaned children flashed through my mind.  I needed help.

I knew that Don and Beverly were active members of their church.  Furthermore I admired their Pastor, enough so that he had been a guest at our Passover Seder the previous year.  “If you feel up to it, I would like Reverend Walters to see you now while you are waiting for your appointment with Lionel.  He could see you in the privacy of my office or his, whichever you prefer.”  The idea pleased them.

“Call Reverend Walters and we’ll do whatever he wants.”  As it turned out, Reverend Waters was free and chose to have them come immediately to his study.  For the time being I felt that I had covered the major components of the support system that Don and Beverly would need.  Surely psychiatric help would come later.

Don rose first and helped Beverly stand; there was almost no tone in her body.  Don and I embraced, but distantly.  Beverly gave me a limp hand handshake.  They shuffled to the door and departed.

Predictably, the next day a front-page headline read, “Government Accuses Local Doctor of Fraud.”  The reporter raised cogent criticisms: “Why didn’t the good doctor just absorb the loss of the deductible himself?”  (“The good doctor” is always spoken with derision.)   Or, “If he didn’t approve of Medicare, why did he participate in the first place?”  (Doctors had the option of billing patients directly and letting them collect what they could from Medicare.  The guaranteed payment, albeit partial, was too tempting to ignore.)  The writer had done his homework, choosing to link Don with the growing number of doctors convicted of lining their pockets with money by fraudulent Medicare claims.  There was no defense on Don’s behalf or any mention of his stellar medical training or professional skills.  There were no quotes from his loving patients, only comments of townspeople anxious to spew their contempt for doctors and their inflated incomes.  Don had been warned in time by his lawyer not to speak to the press. 

When I went to the hospital that morning, I inquired of the nurses if any of Don’s patients needed help from me.  They informed me that he had made rounds at 5:30 AM.  That was a good sign.  As soon as I had finished tending my hospital patients, I called Don’s office.  The secretary informed me that Don had her cancel all his appointments for the day.  I then called his home.  After at least twenty rings, I hung up. I couldn’t blame him for not answering.

I drove to his house. A television station vehicle was pulling away as I approached.  The only indication that Don was home was a car parked in his driveway with a clerical symbol on its windshield.  I knocked. After a brief delay, a child’s voice asked, “Who is it?”

“Dr. Chamovitz,” I replied. There was another pause before the door opened. Reverend Walters was the first to greet me. 

“I’m so glad to see you. Don’s not feeling very well. He wouldn’t let me call you.”

Don was sitting in an easy chair, smoking a cigarette, “to soothe my nerves. Dave,” he said apologetically.  Beverly sat next to him, her hand on his.  “I’m OK. Just a little indigestion from all the turmoil. The phone never stops ringing.”

“Then take the phone off the hook,” I said for starters. “Now tell me about the indigestion.”

“Oh, it’s nothing new. I’ve had it before. Maybe too much to drink before I went to bed. I just couldn’t get to sleep.”

“Don, please stop being your own doctor and tell me your symptoms.”

“Well, you know. I just had this vague feeling in the middle of my chest last night. A few good burps after Alka Seltzer and I felt better. It came back a couple of times but I’m feeling alright now.” I paid attention that Don did not run his fingers up and down the middle of his chest as he described his discomfort; that would have reassured me that his problem was related to his esophagus and not his heart.

“Don, I know you don’t want to be seen in public but I’m taking you to the hospital now for an electrocardiogram and blood tests.”  He followed me without protest; Reverend Walters remained with Beverly who just stared into space.

Suffice it to say that Don spent the next two weeks in the hospital recovering from a mild heart attack, doubtlessly precipitated by the stress of the impending criminal investigation.  A “No visitors” sign on the door of his private room shielded him from casual spectators wanting to gloat over the downfall of a pillar of the medical community.  I did permit members of his professional support system to visit freely but no one from the prosecutor’s office.  I was pleased that his minister didn’t interpret the heart attack as divine retribution for Don’s “indiscretion” though Don did. And he knew full well that this wouldn’t be the end of his punishment.  “Maybe since I’m recovering from my heart attack, I’ll manage with whatever else is thrown at me, God willing, not a jail sentence.” 

And survive he did. An out-of-court settlement imposed a fine of triple the amount of money Don had received illegally from Medicare and a one-year ban from Medicare payments. A few of his very loyal Medicare patients paid his fees out of their pockets; most transferred to the care of other doctors.  Fortunately, I never benefited from Don’s loss; had I done so, our relationship might have been tainted.

Although not outgoing by nature, Don thereafter avoided all social contacts. He fulfilled his medical obligations and came only to mandatory meetings. No one asked him to prepare conferences or to give a lecture, not wishing to impose upon his flagging energy level.  He did give up cigarettes and took walks late at night, timed to avoid his neighbors. He declined a psychiatric consultation. For the next five years before leaving town for good, he continued to express to me his feeling of having been abused by the community he was committed to help. “After all,” he persisted, “all I did was try to protect my patients from an abusive payment system.” 

Robin Hood to the very end.

More Than Linen In The Closet

It was two o’clock in the morning when an unrelenting knocking on our front door awakened Marcia and me.  Half awake, I hoarsely vocalized, “Who can that be at this hour?”  I thought, maybe someone to alert us that our house was on fire or maybe a drunk, who mistook our house for the hospital, half a minute up the road.

The wooden floor was freezing as I inched around in the dark for my slippers.  Not wanting to waken Marcia further I waited until I got downstairs to put on a light.  I peered out the window framing the front door and identified the intruder as a hospital colleague.  I unlocked the door and motioned him in.  “Charlie, what’s the matter?”

“The matter?  Nothing’s the matter.  I was in the neighborhood and I just thought I’d drop by and consult with you about a case I saw today.”  (His use of the word “case” instead of something more personal typified his lack of empathy for his patients.)

"How inappropriate was his response," I thought. And that wasn’t all that was inappropriate.  His necktie was hanging out of a jacket pocket and his shirt looked as though it hadn’t seen an iron since it was washed.  The usual compulsively accurate part in his hair was awry.

“Charlie, you look awful.”

He once had criticized me for being too confrontative during a patient interview.  His expression at this point registered the same disapproval.  Apparently I hadn’t given him enough time to compose an answer for his mouth tensed until it finally offered an answer, not the answer, I was certain.  “I had a flat tire on my way.  When is the last time you changed a tire?”  “Not good enough,” I said to myself.

“C’mon in the kitchen while I make us some coffee.”

“No, thanks.  I just changed my mind.  I can talk to you tomorrow. I'm sorry to have bothered you. I didn’t realize how late it was.”  As he opened the front door he lowered his gaze and said, “Don’t hesitate to tell anyone who asks that I spent time with you tonight.”  Not risking any probing from me, he rushed away.  I knew that I was being used and was infuriated at the thought.

When I got back in bed, Marcia mumbled, “I heard Charlie’s voice. What did he want?”

“Oh, I think he just lost track of time after changing a tire.”  Marcia was asleep before I finished.  But for me, sleep was slow in coming.  “What a jerk!  What a transparent subterfuge he had designed!  I wonder what really happened tonight?”

Charlie was about fifty years old, tall and all-American in appearance, married to a D.A.R.  They had two sons and three daughters.  A family doctor, whom I would rate as a five on a scale of one to ten, he wasn't that smug not to recognize when he needed a consultant.  The nurses deprecated his patient management and rapport while nevertheless flirting openly with him and therefore, I assumed, harmlessly.  When we were at staff parties, I was uncomfortable with his display of affection for his wife.  Marcia had once commented that Charlie’s grip on her while dancing was “problematic.”  “So,” I asked myself, “was he with another man’s wife tonight and had to make a hasty retreat from her house?  Or were the police after him for a criminal offence?”  Already I imagined myself in the witness chair.  Fortunately I was asleep before contemplating perjuring myself.

I can’t attest to Charlie having a strong moral character.  A couple of years before, there had been a house party for doctors, all-male, that is, except for three very attractive young women who appeared to be “the life of the party.”  Within an hour the women were nowhere to be seen but soon after, it became obvious that one after another some of my colleagues were retiring to the upstairs bedrooms.  I was flabbergasted and angry to be corralled into such debauchery.  I do believe that the hosts' parent were of the philosophy that "boys will be boys." During my hasty departure with two fellow dupes I noted Charlie walking down the stairs, buckling his trousers belt.
 

Nor was Charlie among the stalwarts whose vote for enforcing professional standards could be taken for granted.  He alone had voted against a resolution mandating that a particular staff member undergo an educational program even when dismissal from the staff would have been more appropriate.  The interpretation by some was the fear that maybe he's be next.

In the morning I was making rounds on my patients in the Critical Care Unit when the Head Nurse informed me that a surgeon had written a consultation request to me.  “Any urgency?” I asked the nurse.

“No.  The patient is stable but she does have chest pain, most likely from rib fractures. A fractured femur has already been casted. I’d better check her now.”  Perusing her chart moments later, my knees became weak as I read the initial entry by the Emergency Room doctor. “This twenty-eight-year-old woman is a victim of a hit-and-run driver.”  I noted the time of arrival, “1:45 AM.”  The courtroom scene flashed before my eyes.  “Guilty!”  With such thoughts could I be an objective doctor for this patient?  Apparently I assumed I could.  My secret information was irrelevant. And any responsibility would cease once I ruled out internal injuries, in particular, injury to her heart.  I subsequently did my best to avoid emotional involvement with the patient, which probably wasn’t noticed by her as she lay under moderate sedation.

Of course the police visited her and, during varying degrees of somnolence, she was questioned for details about the accident.  “Can you identify the car?  Did you get a look at the driver?”   She shook her head from side to side with each question.  The police presumably interrogated the attending surgeon but fortunately not a word to me.

On the second day of the patient’s hospitalization Charles walked right past me without so much as a nod.  I noted that he also walked past his victim’s room without any sideward glance.  "Was there any doubt? A cool character,” I reasoned.
   

In three days I was able to sign off her case and in another day or two she was discharged with a walking leg cast and a chest binder to diminish the pain from fractured ribs.

I slept fitfully the first couple of nights.  What course of action should I take?  Didn’t I have a responsibility to report my suspicions?  Wasn’t it almost as though I had witnessed the accident?  Finally on day three during lunchtime, I called Charlie and asked if we could meet in the hospital parking lot.  “Sure.  What’s up?”  He didn’t sound defensive.

As soon as he got into my car, I lashed out. “What went on the other night?”

“What are you talking about?”

“C’mon, Charlie. You came to my house soon after the hit-and-run woman was admitted and you looked like hell.  Were you or were you not the driver?  ‘Cause I have to decide … .”

Charlie stopped me with boisterous laughter.  “Boy, have you got it all wrong?  My favorite square doctor and so naïve.  I thought my reason for barging in at your home was pretty obvious but now you accuse me of being a criminal?  Shame on you.”

“So, set me straight.”

“Well, you know this gorgeous blond nightshift nurse … .”

“Spare me her identity.”

“We were going at it in the linen closet, fortunately with the lights out, when in came a janitor.  He heard a flurry of our repairs and backed out.  So, what’s the problem?  My wife has had me on a sort of probation.  If she got wind of the incident, I’m out on the street.  When I got home that night and she asked, ‘Where were you?’ it was easy.  ‘Oh, I was at Dave Chamovitz’s house reviewing a couple of patient records that had been pulled by the Quality Care Committee’.”

“But maybe you hit the woman as you sped from the hospital.”

“On my word, Dave.  You have reason to think I’m a scoundrel but I would never do that.  If you don’t believe me, I’m willing to have my car checked by the police.”

“Suit yourself, Charlie but I guess I buy your story.”

The next day the police found the guilty youngster who had been driving without a license.  I immediately called Charlie.  The maid answered and said that he and his wife had just left for a cruise in the Bahamas.  My problems would be resolved if the boat drifted into the Bermuda Triangle.  Just kidding.

The Cookie Jar

“Doctor, why are you staring at my breast?  Is something wrong?” Darlene spoke free of embarrassment or admonishment.

Her questions interrupted my concentration as I listened intently to her heart murmur.  As a fledgling doctor for the first time away from the protective network of a teaching hospital, it was difficult to quell my excitement.  I was so thrilled to be diagnosing rheumatic heart disease that I gave no thought to the person or the body that lay before me.  Let me put the event in context to allay any doubts the reader may be entertaining.

During my final year of internal medicine training in Boston, my wife and I were living on a tight budget.  Having trouble making ends meet, I responded to a request sent to all members of the Massachusetts Medical Society for volunteers to make house calls on indigent residents of Boston.  Actually “volunteer” wasn’t quite the correct word for each patient would be required to pay the sum of seven dollars.  Nominal or not, the payment would feed us for two days.  I signed up.

Actually I faced the potential new responsibility with trepidation.  From the moment of my first involvement with a patient eight years before as a second-year medical student in 1946, I had always the security of a backup of a huge cadre of teachers and more highly placed residents, and indeed, the vast support system of one medical school or another.  Now for the first time I would be out in the cold unforgiving world on my own.  I and I alone would be prescribing for a patient with no one looking over my shoulder to monitor my decisions.  It was scary.

Lo and behold on the following Saturday afternoon came a call from the dispatch center asking about my availability.  Receiving a positive reply, they gave me the address and directions to a run-down section of Back Bay, Boston.  I remember that my heart was pounding as I contemplated my mission.

Twenty minutes later I arrived at a two-story clapboard house.  Four warped steps led to the front porch.  Faded yellow paint was peeling around the door.  The doorbell made no sound so I knocked.  A six-year old girl answered and led me up one flight of stairs.  The sparse furniture was shabby.  The mother, who was obviously the patient, reclined listlessly in a cotton nightgown on a couch.  I gestured to her not to get up; she appeared grateful.  I shook her moist, flaccid hand.  She forced a near-motionless smile.

My first dilemma was where to sit.  I pulled a metal chair from the kitchen and sat opposite my patient, a comfortable and yet not unfriendly distance away and began my history taking.  Her daughter sat at a nearby table with a coloring book.

The patient, Darlene, was an attractive twenty-three-year-old, a single parent.  She worked in a laundry; her hands were red presumably from contact with strong soaps.  She had called “the service” because of a severe sore throat and fever.  Aspirin had done little for her.  Inquiring further I learned that twelve years before, she had been hospitalized for rheumatic fever.  She was unaware of any after effects and had no cardiac symptoms.  I spent another quarter of an hour compulsively documenting a complete history.  Her family had rejected her when she had become pregnant out of wedlock.

My next problem was where to examine her.  I could have done so as she sat on the couch but this was in front of a bare window.  Instead I helped her into a disheveled bedroom.  She sat on a double bed and started to take off her nightgown; I indicated that this wasn’t necessary.  I placed my medical bag next to her and started the physical examination.  The first abnormal finding was an inflamed throat with patches of pus on her tonsils, an obvious “strep” throat.  So far so good.  My training was paying off.  As I took out my stethoscope, again she started to raise her nightgown.  “Oh my!” I thought.  “This is far different from a hospital setting with a nurse in attendance or at least nearby.”   I began listening to her heart sounds.  Within a couple of minutes Darlene interrupted my routine with the question that started her story.

If I was embarrassed, this was not the explanation of my excitement for I had heard a loud heart murmur indicative of rheumatic mitral insufficiency, in lay terms, a leaking valve.  Such a great teaching case!  I wanted only to demonstrate my findings to the medical students working in the ward but, of course, this wasn’t a ward and there was no one around to teach.

I compulsively performed a fairly complete physical examination, but certainly no pelvic exam.  I couldn’t help wondering if Darlene pondered what a breast exam had to do with a sore throat or even a heart murmur.  I was relieved to return to the living room.  

“You have a strep throat,” I said.  I doubt if I weighed the impact of my medical jargon as I continued, “You have rheumatic heart disease.  We have to treat your streptococcal infection especially so to prevent the streptococci from spreading to your heart valves.  You must take penicillin pills four times a day for ten full days in order to do that.  Don’t interrupt the medicine even though you ought to be feeling normal within thirty-six hours.”  I was in high gear as though I were confidently completing the last question of a medical school exam.   I wrote out a prescription for forty penicillin tablets, which she could obtain for a minimal fee.

As I rose to leave, Darlene went to the kitchen where she took a cookie jar from a closet.  She reached in and extracted its contents, seven, crumpled dollar bills.  So many thoughts flashed through my mind.  “Was this all the money she had?”  “Could I take three?  Would that humiliate her?”  And finally, “Had I already not been amply rewarded by the validation of my years of training? Wouldn’t taking money from her tarnish our relationship”?  Never before having received a fee from a patient, I was at a loss for an answer.

I put the seven dollars in my pocket, and after an approving glance at the stick-figure drawings by the little girl, I departed.

I’ll never know if Darlene followed my instructions or whether in later years she had her valve successfully replaced or whether her daughter went on to become a famous artist.

What! You're still alive?

It was an inauspicious beginning. The patient lying on my examining table confounded me.  "George, when did you get that telangiectasia on your belly?" He recognized the medical term for an array of dilated capillaries in the skin that was present over a large area encompassing a surgical scar.

"Oh, that began to appear a few months after my radiation treatment."

I was ashamed of myself. Somehow I had failed to elicit a history of either the operation or the radiation therapy. Had I really forgotten to ask about previous operations or had the patient tuned out the memory of an obviously life-threatening illness?

George took me off the hook. "Since I came to you with a breathing problem, I didn't think the belly thing would be of any importance."

George had come to the USA from Yugoslavia in the early 1920s at age ten. His schooling never went beyond the eighth grade; he quit to work on the railroad. As the oldest of seven brothers and sisters, his paycheck was crucial to keep the family from losing their home, for his alcoholic father worked only sporadically. By the time he was twenty, George had been promoted to foreman of a thirty-man crew, laying and repairing tracks for the railroad. By the time he was twenty five he married, had one child and was financing his wife Mary's college education. Mary became a highly respected school teacher. As a political scientist she was frequently called upon to address fraternal and church groups in the evenings. At the time I was learning about George they had celebrated their twentieth wedding anniversary. Regarding their marriage he answered, "Successful. Mary and the three kids are healthy and we all like sports. I have no problem keeping myself occupied while Mary does her thing – and the money she earns makes a big difference."

Does her thing is usually a condescending comment but he appeared to take his wife's academic achievements in stride. Yet, it all seemed a bit too pat. My suspicions would prove to be warranted.

"When did you have the surgery?"

"Oh, about ten years ago; I was thirty-five."

"What was the reason for the operation?"

He hesitated as though trying to find the right words:"My doctor found lump in my belly and asked a surgeon to take a look inside." George wasn't offering any more information than what I requested.

"And?"

"Well, he said it was not possible to remove it all. So he just took out enough to send to the laboratory."

"And what did the biopsy show?"

"Hold it a minute. I never can remember." He reached for his wallet and took out a crumpled piece of paper. "Here, you read it."

I flattened out the note. I couldn't believe my eyes. Sarcoma. "What! You're still alive! That's impossible, George. That's a very malignant tumor.  If it were true, you would have died years ago. And it's obvious you aren't dying now. I've got to speak to the pathologist." At that moment the mild pulmonary symptoms for which George sought m examination paled in importance. A mystery was unfolding before me. I was ebullient.

Within two days our hospital pathologist got back to me. His excitement mirrored my own. He began."Because the patient was operated on here, I was able to retrieve the original microscopic slides and I was even able to make new slides from the original paraffin blocks. The tissue diagnosis not recognised at the time of the surgery is a benign tumor. Non-malignant fibrotic tissue encircles the ureters sometimes even closing them off. More often the tumor recedes spontaneously with no need for treatment. There's no evidence that the that the radiation therapy did him and good or any harm. Let's write an article!" (This we did; it was published in the The American Journal of Medicine.)

I invited George to return with Mary;  I was too narcissistic to convey the glad tidings over the phone. George broke into broad smiles as I unfolded my report. He took Mary's hand and asked her, "Should we buy the pathologist a bottle of liquor?" Mary just stared out the window. I said to myself, "there is something phoney going on here." As George went out the door Mary tarried a bit, and whispering, asked if she could make an appointment for herself without George's knowledge.  "Of course" I said, though I was wary of playing games with my patients.

A week later she entered my consultation room wearing sunglasses. "Very chic," I thought. Wrong. Mary removed the glasses to reveal a black eye.

She began. "You can't imagine what your diagnosis of my husband's condition has done for me. (I was fleetingly complimented.) True he had shoved me around a few times before his surgery, but after he was told that he had a fatal illness he began hitting me more and more. I assumed he was taking out his anger and fright on me; I thought it was my duty as a wife to let him. So many times I wanted to leave him but I was too ashamed beside I knew it would end soon. Hadn't the doctor told me his days were numbered? Then it was no longer days or months but years.  I just didn't have the energy to do anything about my predicament. Whenever I threatened to leave, he would pull out his "But I'm dying card". That won't work anymore. I am so grateful to you. I have been to a lawyer and I'm filing for a divorce."

Mary's two-minute declaration exhausted me. She had put me on an emotional roller coaster. George's story was another of so many examples of doctors making snap decisions from inadequate knowledge. Bernard Lown at Harvard Medical School taught his students to interview a patient with the spouse present. I always thought the patient deserved to be seen alone during the initial interview.  Had I followed Dr. Lown's advice, I might well have sensed negative vibrations and, exploring them, I might have prevented Mary's last beating. If she, herself, hadn't taken the initiative to consult a lawyer, she might have ended up on a coroner's slab.

Needing nothing more from me, Mary left. I was content that I had resolved a major medical problem for George and by so doing, enabled Mary to free herself from a life-threatening marriage.A month later, George returned to my office, crying. "Mary moved out. I'm lost without her." With a little probing he admitted that he had hit Mary "maybe once or twice but she made me mad." I gave him the name and phone number of a psychiatrist but I don't know that he ever saw him. Since he had survived one potentially catastrophic problem, doubtlessly he would survive this one as well. But would his next spouse?