Dr. McGregor wore a surgical cap patterned with great white sharks and gnashing jaws on the last day of my neurosurgery elective. For three weeks, jalapeño peppers, hula-dancing natives, and neon green aliens had supervised as I assisted him to bore holes in the skulls of patients. Dr. McGregor was the youngest chief of neurosurgery in the history of my medical school. He wore black horn-rimmed glasses that were either exorbitantly outdated or dismayingly chic; it was rumored that he in fact had 20/20 vision.
“Good job, Eric. You should go into surgery,” he said as he watched me knot a line of stitches along his incision. I stifled an eager grin, even behind a surgical mask and plastic face guard. The guard was a clear sheet of plastic that became a greenhouse on my face. My eyeglasses were in danger of fogging over. “Finish up. I’ll see you in clinic.” I watched him push out both swinging doors as he strolled away from the operating room.
Every Friday afternoon, Dr. McGregor ministered to his patients for twenty minutes of follow-up in his clinic. It was my duty to start interviewing the patients. I plucked the chart from the slanted shelf on the door to Examination Room #1. John Osenger (age: 44, race: white, #8081974) waited behind the closed door. I flipped through his thin chart. A classmate, Kerry, had seen Mr. Osenger previously. Kerry's slender handwriting was rushed, but legible. Low grade astrocytoma. Remission. History, exam non-focal. Return 3mo. Dr. McGregor's hand had scrawled everything else but his notes were indecipherable. Reading any doctor's handwriting was like listening to the lyrics of a song in a foreign language; knowing the jargon still left comprehension a toss up. I understood the major thrust; the patient was here for follow up of a brain cancer, cured by resection almost fourteen months ago.
I knocked on the door and entered the room, not waiting for a response. Mr. Osenger was sitting on the examination table. As medical students, we were taught that the examination of a patient begins as soon as we walk into the room. He looked up and gave a polite smile (lower facial nerve intact) and half stood up. His dark brown hair was thinning, but still obscured the right parietal scar I supposed he had. His wife sat with her arms crossed in the corner of the room. She was small, with auburn hair just alighting onto her shoulders. Neither looked surprised to see a medical student.
Howdy! My name is Eric and I'm a student doctor working with Dr. McGregor. I'm going to talk to you folks some and Dr. McGregor will be in shortly. Sometimes I sprinkled words like “y’all” and “folks” into my script. I even could lapse into a Southern accent, though I had moved from North Carolina to Vermont when I was three. Colloquialisms seemed to make doctors appear friendlier and less dangerous.
Handshakes exchanged (right grip: full strength, no tremor), I went to business. Other than the exam table and Mrs. Osenger's chair, the only furniture in the room was another blue chair and a small desk. I calculated the hassle in retrieving a third chair so that he might descend from the table: not worth it. I sat and started inquiring about his recent health.
Early in medical school, the professors graded me on person-to-person interactions by videotaping my interviews with mock patients. There was even a mnemonic for how to be empathetic. I named. I understood. I respected. I supported. I NURSed out a high honors in that class. However, once I started meeting real patients, I gave up on the formulas. I let things roll in a natural conversation. That was probably why my interviews took too long.
Ten minutes had passed into the appointment and I hadn't even started the physical examination. He had lacked worrisome findings such as vision changes or headache. He had confessed that he had stopped trying to quit smoking ever since his diagnosis.
I performed a cursory examination of his heart and lungs and then examined his neurological function. I asked him to follow my finger with his eyes, show his teeth, lift his big toes, pretend to play castanets with his thumb and each finger. I tested each cranial nerve, his strength, his sensation, his cerebellar function and his reflexes. I asked him to tramp up and down the small room. The standard battery of neurologic tests was a ritual that tried to winnow dysfunction to a certain nerve or muscle or dermatome. It was a meditation between doctor and patient.
Having uncovered a normal history and physical exam, I took from Mrs. Osenger a stack of MRIs. I impatiently waited for the lightboard to come on. It winked on and off, like an approaching car twittering its fog lights. His films were in disarray and I struggled to put them in order. First by date, searching for the little yellow sticker placed on each black placard. The next step was harder—arranging by anatomy. His MRIs were a series of photographs of his head sliced in multiple directions: ear to ear, chin to crest, nose to nape. I righted the confusion of his brain, systematically following the progression of the hollow spaces called ventricles and sinuses.
Each film gave a satisfied snap as it fixed into the lightboard's grip. I was anxious to fill the silence, even though the Osengers appeared quite content to watch me perform the role of a doctor. I imagined how perplexing the jumble of grey wrinkles was to them. I only began to understand the normal architecture of a human body after three long months with a cadaver. Staring at the MRIs, I knew the splotches that marked both sides of Mr. Osenger's brain were not normal. They had a respectable symmetry, like the circular markings of a moth's wings.
I was still staring at the lambent moths when Dr. McGregor entered the room. Dr. McGregor had adopted a crimson blazer atop his blue surgical scrubs. I suddenly blended into the brown wall, a taupe chameleon.
“Hello John, Liz! How are things? Any problems?” Dr. McGregor went through some of the questions I had already asked. With many patients, I felt like a drama coach, helping them prepare their lines for the big show. I fought annoyance when they would get their lines wrong. To my relief, Mr. Osenger repeated the same answers he had given me. After receiving a similar, but much abbreviated, version of normalcy that I had acquired, Dr. McGregor glanced to me. I gave him an affirming smile as I fumbled to turn the lightbox on again.
I searched his face as he scrutinized the brain images. There was recognition, but little surprise. I had hoped that the splotches were only artifacts of my inexperience but Dr. McGregor circled the two areas with a red wax pen. He asked Mr. Osenger to come down from his mount on the examination table. Dr. McGregor swung around the chair I had vacated and placed it next to the wife's seat. He let out an exaggerated sigh as I inhaled a quiet deep breath. The Osengers held theirs.
“So—bad news. It's back and it's the worst possible.” Dr. McGregor did not say much more. He explained that the tumor had returned in a vengeful, more lethal and progressive form called glioblastoma multiforme. No surgical interventions could help. Though Dr. McGregor did not say so, I knew there wasn't much the medical oncologists could do either. Mr. Osenger, who looked and felt so well, would be dying soon. My ears burned. I was in a scene from a television drama, but somehow the comfort of my sofa had abandoned me.
Mr. Osenger was stoic, letting the information seep into his head. His nerve fibers carried the word “glioblastoma” around his brain, past the balls of blighting mutation, into his consciousness. Mrs. Osenger had spoken very little during the whole encounter. She finally squeaked, “So how long are we talking about? Months?” Dr. McGregor answered: “Well, yes.” She became ashen and her lips turned purple. A glint of anger crossed her face.
“I'm not—so much afraid of dying as—I just feel sorry for my family,” Mr. Osenger spoke dully. I was astonished by his show of strength. The four of us waited for something else to arrive, some deus ex machina to appear from the cabinets or the small sink by the door. I searched for something to do other than stare at him. I dismantled the procession of black films from the lightboard and sealed them back into their envelope.
“One of my girls will get you some information. This must be very difficult.” I looked up and saw that Mr. Osenger did not hear the doctor's words. His wife had produced a packet of tissue and had stood up to cradle him. I could not see his face, buried in her breast. Her right hand reached over him and cupped the angle of his jaw. Dr. McGregor looked at his watch. “We’ll give you some time. Stay as long as you need.” She looked up and silently nodded at Dr. McGregor. Then, she looked at me, pulling me out from invisibility. I could no longer deny that I too had a role in this drama. There was little she could have wanted from me; there was little I had to give. “I'm sorry,” I whispered.
“Really, quite a great case,” Dr. McGregor growled as I walked behind him through the hallway. I murmured in obligatory agreement. Both he and I pumped the liquid sanitizer into our palms and rubbed until they were dry. It anointed my hands with a filmy residue. He went through the routine to which I had been accustomed. He marched to his office to dictate a summary of the appointment. On his way, he darkened in holes on a form for medical billing. He would meet up with me in the next patient's room.
I lingered outside of Mr. Osenger's room, hoping he or his wife would call for something that I could do. The door muffled any sound. A knot grew in my stomach as I pondered his word “family.” How many children did he have? How would he tell them? I felt frustrated, helpless and unhelpful.
Yet, despite all that I mourned for the Osengers, I could feel a wave of accomplishment settle through me. I guiltily sensed my heart swell with exhilaration. In that small examination room, my life had intertwined with a stranger's at one of the most important moments of life. This was a station on my path to become a physician. I marveled at the terrible privilege of my vocation.
To the side, I heard the drone of Dr. McGregor's monologue into his black handheld recorder. He was professional and efficient, but I was unsure if he had not lost something. I considered how many times he had performed the same scene as we had with the Osengers. He had lost his wonder. Perhaps he found the NURS mnemonic useful.
I grieved for Mr. Osenger, just as I did two months later for the woman who died at night in a code blue. But I felt almost triumphant energy dance in my hands as I knelt beside her and performed CPR. It reached exultation six months later when I coaxed a newborn out from his mother's womb. I vacuumed his mouth for amniotic fluid that was stained tar-green with his feces. I tingled with religious awe.
Focus, I commanded myself. It was already three minutes into the next patient's appointment. I jotted down a few lines in the chart concerning Mr. Osenger's new diagnosis. I don't know how long the couple stayed in the room or if anyone else entered. I surveyed the next patient's blood pressure and, gripping her chart by my side like a revolver, knocked on Exam Room #2.
AlbertH. Khine, MD
New Haven, CT
albertkhine@hotmail.com
—Judge's Comments—
On the surface, this short story tells about a young medical student, Eric, and his neurosurgery elective with the famed Dr. McGregor. Praised by the surgeon, Eric stifles “an eager grin”—like all students, he's struggling to learn a craft and become proficient at a set of skills. One of these skills is successful patient interaction. In fact, Eric has memorized a mnemonic for “how to be empathetic,” and he often peppers his almost-scripted patient interviews with colloquialisms that “seemed to make doctors appear friendlier and less dangerous.” Eric's education takes an unexpected turn when he must interview and examine a healthy-looking man whose MRI reveals the return of an aggressive brain tumor. It's here that this story takes off, becoming a right-on description of the panoply of emotions, realizations, fears and insights that make up the most important part of Eric's training. The author shows us how a student might feel grief at a patient's situation and, at the same time, elation that their lives “had intertwined . . . at one of the most important moments.” Eric and the author recognize that this double-edged emotion is the “terrible privilege” of a caregiver's vocation. In this story, grief is balanced with the “triumphant energy” of working over a patient's body, trying to save; the joy at saving is intermingled with “religious awe”; and the achievement of efficiency is understood to be nothing without “wonder.” The final line of the story contains a startling image, revealing the twin potentials of caregiving and how like avenging angels we must appear to patients as we stand before them, like Eric, who “gripping her chart by my side like a revolver,” knocks on the exam room door.