Cookbook Medicine

by Bradeigh Godfrey

She started out as just another admission on an already busy call night. My senior resident paged me with the information as well as a tip that could save me some time:

85 year old female with rectal mass and fecaluria. She’s headed to CT, so run down to the ED now, and you might catch her.

I dropped my pager back into the overstuffed pocket of my white coat. It was 11pm, the night just beginning. Another admission meant I was one patient closer to meeting my cap for the night, which meant I was one patient closer to meeting my bed in the call room—if I was lucky. Might as well get it over with.

I took the stairs down to the emergency department, as usual; no time to exercise when you’re an intern. My footsteps echoed through the silent stairwell and darkened halls. The only person I passed was a janitor with a floor waxing machine, tracing concentric circles around an empty foyer. I could do that job, I thought. Just me and a floor to wax.

This was the dreaded intern year, the first year post-medical school, the mountain I looked forward to putting far behind me. I was one of a cohort of transitional interns at a teaching hospital on the north side of Chicago. We would spend the year rotating between various specialties like foster children moving from house to house, never feeling at home. We all looked forward to next year, to being adopted into our forever family, our specialty of choice. When we start our real residency, things will be better, we told each other. But before that, we had to get through internship. Keep your head down, get your work done, and it’ll be over before you know it.

The lights were on in the emergency department; this was their busiest time of night. My senior resident was standing by a computer, chatting with a nurse and munching on a protein bar. He waved and pointed me in the direction of my admission. I headed toward the row of curtained-off spaces defining the examination rooms, already imagining her frail body, white hair, and frightened face. Perhaps a family member sitting with tired eyes, dreading the long night to come. I hoped she was coherent, could understand questions and follow directions. It would make the H&P much simpler.

A week earlier I had been paged about another elderly woman who had just been admitted to medicine. She was sliding steadily into unresponsiveness and I panicked when I saw her listed as a “Full Code.” I briskly discussed code status with the patient’s middle-aged son, trying to keep the urgency out of my voice. He called his siblings; their anguished disagreement was apparent as I listened to his side of the conversation. Eventually they reached a consensus: no heroic measures. She died a few hours later, and I filled out my first death certificate. Not long after, the patient’s primary care doctor arrived. He sat at the bedside, talking quietly with the son as dawn lightened the room. I sat outside, wondering how I fit into this situation. I had never met the patient before, never met her family. I finished my note in time to realize that I wouldn’t be getting any sleep that night; time to start prepping for the next morning’s rounds. Beneath the fatigue, I recognized another emotion: relief. One less patient to worry about.

But now it was time to meet my new patient. Outside the curtain, I took a deep breath to steady myself. Before I could enter, I heard a clear, confident, and coherent voice rising over the murmur of medical activity: “Come on in dahling, join me for a martini!”

I pulled back the curtain to reveal a pair of bright blue eyes underneath a beautifully coiffed head of white hair, set on a fine-featured, intelligent face. She held a cup of milky white contrast liquid, her hand poised as if toasting at a society event, ready to drink the liquid that would highlight the destruction within her abdomen. I introduced myself, the ever-present pressure of internship easing, just a bit, as I smiled.

We went through the standard history and physical examination, questions about her current problem, how long it had been going on, what associated symptoms she’d had. She described several months of weight loss as “looking more and more fabulous, sweetie—I never lost weight that easily in my life.” Night sweats? “Figured I must be getting a good workout during my dreams.” For months she had vague abdominal pain and constipation but nothing specific until she noticed stool when she urinated. That worried her enough to bring her into the emergency room. “Haven’t seen a doctor in years, honey, that’s why I’ve stayed so sharp.”

More questions about her past history, her family, and where she lived. “Gold coast, baby. High-rise apartment left to me by my sweet husband. Lost him ten years ago, God rest his soul.” Any family nearby? “Oh, my sweet boys are grown and moved away. They don’t need to be worrying about me.”

On to the physical exam. I started with the portions of the examination I was sure would be normal, dreading what I knew I would eventually find. I finished with the rectal examination, where a hard mass greeted my gloved finger. Even in my inexperience, it was clear something was wrong.

After another couple hours of note writing and order entry, she was officially admitted and moved up to her room on the medicine floor. There would be consultations from general surgery and urology and a biopsy of the mass. We would ensure that she was medically stable, then she would discharge home and start treatment. It would be a short stay, an easy admission for our medicine team. I wrote a list of tasks on my notepad, each with a tiny square box to check off as I completed it. We all knew she had cancer, probably fairly advanced, but it wasn’t our job to deal with that.

At rounds the next morning, the team shuffled in: med student, intern, senior resident, attending. We all crowded into her tiny section of the room, a thin curtain separating her from the patient on the other side. She sat erect in the bed, holding court with a regal smile.

“Don’t worry about a thing,” the attending assured her as we finished. “You are in excellent hands.”

“Oh, what I wouldn’t give to be in your hands, Doctor,” she said with a wink.

He continued without missing a beat. “You’re all set up for your biopsy tomorrow morning.”

“What is it, then, this thing inside me?” Her voice quavered before she fixed the smile on her face again.

“Well that’s what we will find out with the biopsy, won’t we now?” he said as we all exited the room.

I felt a slight discomfort, a splinter of doubt, that we weren’t addressing her questions. That she didn’t really understand what was happening. Outside her room, the attending quizzed us on stages of colorectal cancer, on presenting symptoms, diagnostic workup, and treatment options; we used words like metastatic and malignant fistula formation. But inside her room, neither my attending nor my senior resident even used the word “cancer,” so I didn’t either.

Later that afternoon I found myself in her room. I usually would have stayed focused, checked off my tasks and left as soon as possible. But something drew me back. She kept me laughing as I tried to keep up with her in conversation.

“Oh, I have a crush on that doctor!” she said. “I’ve always had a thing for Italian men.”

I wondered if I should tell her that he was Indian.

She told me about her husband, about raising her two boys, about living in her apartment overlooking Lake Michigan. She didn’t want to be anywhere else but there. Her apartment was filled with beautiful things, she said, that her husband had given her.

“It’s like the song,” she whispered, then broke out in the familiar melody. “Whatever Lola wants…Lola gets.”

I was trying to formulate a response when she changed subjects again. “Do you want a baby someday?”

“Actually, I have one already. He’s six months old.” I showed her a few pictures I always carried with me, tucked behind my hospital badge.

“Well look at you! You are a New Woman for sure. A real woman of the new century, right? Doing it all, having it all. Good for you!” She paused. “Now stop sitting here chatting with me and go finish up your work so you can get back to your sweet baby.”

The days ticked by; her biopsy was completed and she drew closer to discharge. We rounded each morning and I continued to visit her each afternoon. Still no one said anything to contradict her description of her hospital stay: “Like a four-star resort! Meals at the ready, good-looking doctors everywhere. All that’s missing is a pedicure.” She would wiggle her toes inside the non-skid hospital socks that were much too large for her tiny feet.

My unease became more urgent, and after rounds I had a question for the attending. “When do we tell her it’s cancer?”

He smiled down at me. I almost expected him to pat me on the head. “She’s going to find out eventually, and she’ll hear that word often enough in the days to come. Who are we to rush that?”

I stayed silent. But later that day, all my other patients seen and my work wrapped up, I went back to her room. Normally I would have rushed home to see my baby, but the nagging doubt had grown and I couldn’t ignore it anymore. She was standing when I came in, reaching for something on her bedside table, the hospital gown loose and billowy on her tiny frame. Out of bed, she looked small, frail, and even more alone.

“I want to talk to you about something,” I said. She sat on the bed next to me, her eyes searching my face. I took a deep breath and told her it was very likely that the mass in her rectum was cancer.

She drew her knees up under the gown like a teenager at a sleepover.  “Oh,” she said, her mouth forming a small circle. “How bad is it?”

“We don’t really know yet. The biopsy will give us some of that information. But we do know that it’s advanced enough that it has spread from your rectum into the other structures inside your pelvis and abdomen. You’ll have more tests, and you’ll see an oncologist at the cancer center after discharge.”

“What kind of treatment is there?”

“I’m sorry,” I said. “I don’t know a lot about this type of cancer or the possible treatments, but I wanted to tell you what I do know.”

She sat quietly for a moment. “I have to be honest, I wasn’t expecting that.” Then she laughed a little too brightly. “I have so many question marks in my head right now, I can’t think straight.”

She spent the new few minutes firing questions at me, her blue eyes fixed on my face. I tried my best to answer them, but kept running into the limits of my knowledge and experience. Maybe I had made a mistake by talking to her—what was I thinking? I would be out of here in a year and probably never see another patient with colorectal cancer for the rest of my career. After a few minutes, she changed the subject. We chatted a little longer before she shooed me out the door, telling me I needed to go cuddle that cute baby of mine.

I was ready to go home. It had been an easy day; tomorrow I would be on call again, so this was my opportunity to leave at a decent time. I was counting on taking the baby on a walk and eating a real dinner with my husband. But I didn’t feel like I could leave yet.

I jumped on a computer and searched for patient information about colorectal cancer. After a few minutes I found a national cancer website with several patient information booklets. They looked like they would do an excellent job of answering her questions. I ran back into her room and asked for permission to submit her address so that the pamphlets could be sent to her home. She readily agreed, and I hit the keys rapidly, hoping that this would help make up for my lack of knowledge.

She was discharged the next morning, and I never saw her again.

A few weeks later, I was paged by the office of graduate medical affairs; something had arrived for me. There was a package for me in the office with a familiar return address. Inside was a rectangular gift, beautifully wrapped in thick gold paper, accompanied by an embossed white card.

A quick glance at the graceful, looping script on the card and I knew who had sent it. She wanted to let me know that the pamphlets had arrived and she was seeing an oncologist at the hospital’s cancer center. “She’s very pretty, but not as nice as you,” she wrote. “I suppose I’m in for some changes in my life soon. I may be moving to Phoenix to live with my oldest boy.”

I unwrapped the package; it was a Marshall Fields cookbook. That venerable Chicago department store, a fixture of the city for so many years, had recently been engulfed by Macy’s. I blinked away the tears threatening to creep into my eyes and returned back to work, bringing the cookbook with me.

Ten years later, I recognize that experience as a turning point. It wasn’t profound; just a simple decision to spend time explaining and connecting, rather than checking off tasks and moving on. But that decision marked the moment I began to develop into the physician I always wanted to be.

I now have my own patients to see and my own residents to teach. There are days when it would be easier to keep my head down, get my work done, get out of the hospital and get home to my family. But I find that my patients come home with me, are carried in my thoughts no matter where I go. That is the burden and the blessing of this profession.

And if I ever forget this, I only need to look on the shelf in my office where, stuffed between textbooks and journals, I also keep a cookbook.

 

Bradeigh Godfrey is an assistant professor in Physical Medicine and Rehabilitation at the University of Utah. Her writing has appeared in The Examined Life, The Intima, Hektoen International, and Litro Magazine.

 

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