The Cancer Finishing School, page 2
4. Crime and self-punishment
Clara, another eighty-something widow, looks distraught as she walks into my consulting room one hot summer afternoon. She sits, shifting uneasily in her chair, unable to meet my eye – always an alarm bell. When I ask what’s wrong she raises the hem of her skirt a few inches and stretches out two swollen ankles, keeping her face averted as if unable to bear the sight of them.
A hoarse whisper: ‘It happened so suddenly.’
I haven’t seen her so troubled since her husband Bert died ten years before, a month after they moved into a retirement village. I examine the offending body parts: pitting oedema, so-called because a thumb pressed into the skin leaves little pits that take time to refill.
‘What is it, Peter?’
Puzzled as much by her agitation as the swelling, I examine her more fully. No signs of heart failure or fluid retention elsewhere in the body.
‘It’s nothing serious,’ I reassure her. ‘I need to do some tests, but it’s probably just a combination of the heat and varicose veins – and gravity.’
She isn’t listening. ‘There’s a new man at the village,’ she interrupts. ‘A widower. Nice enough, but very flirtatious. The hand-kisser type. I would invite him in for coffee once a week, but he kept pestering me for, well, more.’
‘He won’t take no for an answer?’
She meets my eyes for the first time, beseechingly. ‘I loved my Bert very much, Peter. You know that. I had always been faithful to his memory.’
Had? My ears prick up. ‘Of course,’ I say, and wait to hear the real reason for her anguish.
Her eyes are all over the place again. A deep breath, ‘I, um, gave in to him the other night,’ she finally gets out, again in a whisper.
I take her hand. ‘From what I remember of Bert,’ I suggest, ‘he wouldn’t have wanted you to be a nun.’
This also goes unheard. ‘I’ll never do it again. I’m so disappointed in myself.’
Her eyes fill with tears as she stares down at the bloated ankles. ‘I woke up the next morning with . . . this.’
For a moment I’m not sure where this is going.
‘Could the swelling be, well, you know – his, um, discharge?’
I try to hide my astonishment. ‘His semen?’
A slight shudder answers the question. I need to convince her otherwise, but don’t trust my facial muscles. I try to frown them into submission. The last thing she needs is any sign of incredulity, or worse, amusement. My turn to avoid eye contact. Head bent over her ankles, I test their range of movement thoroughly, a clinically pointless exercise that at least buys me a little thinking time.
‘No evidence of seminal fluid,’ I finally pronounce, trying to sound technical. ‘Ejaculate is also not that voluminous.’
I don’t add the stray thought on the tip of my tongue: in my bathtub experience it floats, not sinks.
‘How can you be so sure? Can’t you get rid of it? Aspirate it, or something?’ A pause. ‘I don’t want it there. It keeps reminding me.’
Another stray, farcical thought: is she worried – surely not! – that her ankles might be pregnant? Absurd, but is an ectopic pregnancy in a foot any more unlikely than a sperm bank? I lead her into the other consulting room, help her up onto the examination bench, place a cushion under her feet for elevation, give her a magazine to read and ask Vicki to bring a cuppa.
Half a dozen patients later, I poke my head in to find the swelling has vanished, if only temporarily. She seems reassured, but as I help her down, she immediately finds another outlet for her anxiety.
‘I’ve been lying here worrying, Peter. This is all between us, of course.’
‘Of course,’ I lie, or at least fib, because the story is too good not to share in some more universalised, anonymously fictionalised parable of guilt.
‘If it’s not semen, could it be, um . . .’
I wait for the usual underlying It, the dreaded C-word, but once again she surprises me.
‘He’s rather too popular with the other ladies. You don’t think I could have, um, caught something?’
I assure her otherwise, but she is not convinced, and this explanation being a slightly less implausible displacement of her guilt, and more easily disproved, I decide to run with it. I take bloods, swabs, request a urine sample and make a booking to see her in a week’s time. It’s going to take a lot more persuasion, a lot of reinforcement and some useful take-home hard-copy evidence.
Confessing her sin at least seems to have helped; she is calmer as she leaves my big, brightly lit booth. I know she hasn’t been to Mass since Bert’s death. I raise the possibility; she declines.
I offer my own dubious absolution: ‘Bert would have wanted you to be happy, Clara.’
She offers in return a wan smile and a promise to ring earlier than our appointment if she is struggling, emotionally. Otherwise, another session in the confessional next week.
I sit there in a slightly dazed trance after she leaves. Of course, the jokes crowd into my head, boisterously, cruelly, if only for relief – Congratulations, it’s twins! – but her pain is real, and each time I make myself smirk I feel my own twinge of guilt, although not, I remind myself, as much as she does, and only briefly, mine being more of a business-class guilt-trip, if truth be told.
5. Natural medicine
‘Knock knock.’
‘Who’s there?’
‘Death.’
‘Death wh—’
Did Rowan Atkinson write the ending of this well-known routine first? It came back to me the moment my patient Alan walked out the door, as the best lines always do. I almost called him back to share it, with the thump of a body-double – my family-Bible sized Gray’s Anatomy, perhaps – hitting the floor. I’ve shared the joke with other patients over the years; it was my close friend and occasional patient Andrew Male who first shared it with me.
It’s the ending of all our stories, after all – and always written first, writ in base-pair code, on our DNA scrolls before we are born.
Before our species was born.
The natural medicine of jokes works both ways in the stressful workplace of a doctor’s rooms. I won’t forget Clara’s semen-haunted ankles and anguish in a hurry. I hope I helped her through it in the weeks that followed, but what a gift she left me in return: a story that is both terrible, and terribly funny, and in the telling teaches me something about myself.
Poems and songs rhyme, mostly, but stories like Clara’s also rhyme, more deeply if less obviously, in our heads: we are often not aware of their resonance until we are in their grip. Their emotional trajectories remind us of our own pains, our own fears – and guilts – even if we aren’t quite aware of them, or trying hard not to be aware of them.
Their residue of meaning, their lessons, jolt us, deeply, if not always immediately. They can be slow, sometimes painful homework.
Jokes rhyme with us less painfully. Tell me your phobias and I will tell you what you are afraid of, the American humorist Robert Benchley memorably wrote. My version goes like this: tell me your jokes and I will tell you your worst fears. It works especially well personally: jokes are useful forward scouts when entering enemy territory, especially the no-go areas of my own head, a Balkanised country full of minefields and fortifications.
Sometimes jokes work even when a patient is dying. Deborah, a sophisticated, Sorbonne-educated, Alexandria-born Jew, required regular intravenous morphine for her cancer pain once she reached the point of palliative care.
‘It’s just a little prick,’ I reassured her the first time, swabbing the crook of her elbow.
‘It doesn’t matter, dear,’ she said, deadpan. ‘You have nice eyes.’
How did I keep the needle steady? What exemplary style, what stoic humour, as her own end approached. Perhaps she was just trying to make me feel better; if so, it worked.
But if I’ve improved as a doctor over the decades, and I like to think I have, slowly, it’s not as a would-be bedside comedian, or even through playing straight man to my patients’ gags. It’s due to the lessons I’ve learnt from them, sometimes grudgingly, sometimes uproariously, but almost always accidentally.
Twenty-odd years back, my patient Eric turned a hundred and I was grateful to be invited to his home for the celebration. A compact hobbit of a man, bent even more gnome-like by age, he’d spent the best part of the previous month halfway up a ladder, painting a perfect rainbow across the width of his shed door, along with a couple of Bible quotes, in preparation for the big occasion.
He had also grown increasingly deaf. A few weeks before, Meals on Wheels had rung worried because Eric hadn’t answered the door, or his phone, the day before. His meal had been left on his step; it was still there, untouched, today. I tried raising him on the phone myself, then his next of kin. The receptionists checked the hospital admissions and ambulance calls, also fruitlessly. When I finished consulting I drove to his home and banged on his door, then rattled the windows.
By now it was dark; a cold midwinter evening, with a sprinkle of rain. He might have been tucked up in bed, his hearing aids sitting on the bedside table next to his dentures. He might have been ill, or worse. Twice before I’d discovered bodies by peering through a window crack, but all his blinds were drawn.
Time to ring the police? I couldn’t wait. I removed the glass louvres from the high toilet window, one by one, by torchlight, stacked them outside, pulled over a garbage bin, clambered up on top and squeezed through the gap headfirst, slithering python-like down over the porcelain cistern – a trick I had mastered in childhood when locked out of the house.
As I pushed myself upright I was struck, feebly, by some sort of blunt instrument – and there was Eric, a frail but courageous figure in ghostly white pyjamas in the dim greyness, his walking stick raised to strike again.
I found the light switch just in time.
‘Doctor!’ he exclaimed, tottering backwards. ‘You should have rung!’
After inserting his hearing aids, he accepted my apologies and poured me a brandy. Facing down a cat burglar was small beer for Eric; he’d been gassed in the trenches of Flanders in World War One. Quite possibly he was the oldest living survivor of mustard gas.
At his centenary a few weeks later, after the speeches and the reading of telegrams from the local premier and the distant queen, I sat there sipping the same St Agnes brandy, eating Balfours’ famous frog cakes and feeling highly pleased with myself. I might have scared him half to death recently, but I’d got him through his last years, hadn’t I? The mustard gas had left him with a dodgy chest, but I’d managed to pull him coughing and wheezing across the line.
Why, wasn’t I something of a hero myself?
‘Doctor!’ he called from across the room, rousing me from the warm glow of self-regard. ‘Over here. I’d like you to meet my brother from Sydney. He’s a hundred and three.’
A useful lesson in humility. We are a hardy species. Mostly our patients survive not because of doctors, but in spite of us. Especially if we stick to first principles, such as the properly irreverent, and sceptical, teaching of Hippocrates: ‘First, do no harm.’
6. Cautionary tales
Has my daily habit, or fix, of writing, which I like to think is a way of slower, more thorough thinking (and, yes, feeling), also helped improve me? Less through writing poetry, perhaps, which tends to see the world through one pair of eyes and speak with one tongue, than through writing stories and novels, which demand a more exhaustive, or at least exhausting, attempt to enter other heads.
And to speak, in a sense, with a forked tongue, multi-pronged, giving every character a voice, and the right to be heard.
Perhaps. But being allowed inside the heads of my patients, daily, for decades, has provided the biggest self-improvement, a higher education of a very privileged sort, although it took self-centred me far too long to grasp how lucky I was. I hope I paid proper attention to their symptoms, but I was not always a good listener to their wider concerns. Too often as they told me their stories, their domestic tragedies or comedies, I had one ear cocked for any useful material. The best stories, priceless ore for the smelter of fiction, went into my notebook or was scribbled on the desktop blotting paper even before being entered into the case notes.
‘Sorry to interrupt, Clara – I need to get this down. You did ask if it might be seminal fluid in your ankles?’
Proper listening, I was slow to learn, is a portal into another world, another perceptual dimension, each of which is roughly the same size and shape as mine, near-infinite, but surprisingly different and uniquely flavoured. Our heads are tiny Tardis booths of brain and bone, but each contains an entire, expanding universe of consciousness.
This book began as my story, my cancer journal, but it grew so quickly, so massively, it soon began to fill with stories of the illnesses – and deaths – of others: of my patients, of course, but also of friends and writers and even of fictional characters I hadn’t thought about for years. At least consciously. Often they would pop into my head in the small hours, dragged up by some mysterious connection or narrative rhyme with my illness: cancer stories at first, then stories with differently high stakes, the kind of exemplary or cautionary tales that tell us so much about ourselves.
Are they my stories to tell? My patients’ stories, especially: what about medical confidentiality? I’ve sought permission from the living, but what of those who have predeceased me, like Clara? I’ve changed names, dates, localities, and even gender, but in the end, just as I believe our organs should belong to others who need them after we die, and our bodies are the property of the coroner or medical science, if required, so too our stories. Our biographies belong to history, and the stories we tell to the different forensic science of storytelling. (With some obvious reservations in regard to the feelings of surviving family.)
Might Oliver Sacks offer a model for this? Even the careful, considerate Sacks, author, among numerous other books, of the classic collection of case studies The Man Who Mistook His Wife for a Hat, has been criticised for using his patients’ stories – most memorably as ‘the man who mistook his patients for a literary career’ by the disability activist Tom Shakespeare.
I’m on Sacks’s side in that debate, but I suppose I would be, wouldn’t I? When I was younger I liked to quote the Russian writer Isaac Babel, partly as an excuse, partly as a self-important boast: a writer is someone with spectacles on his nose and ice in his heart. Recently, I learnt I was misquoting him, misremembering his beautiful ‘autumn in his heart’ for my own colder purposes. Not that my icy writer’s heart ever seemed to matter to my patients: a dump-bin of my books has always been available in the waiting room; they still regularly find themselves, fictionalised, between the pages.
‘That’s me, isn’t it!’ many have insisted, even of the least savoury characters, and even when, which is usually, it isn’t.
‘What better education for a writer than the study of medicine?’ W. Somerset Maugham wrote – even though he promptly abandoned it after graduating. Anton Chekhov, who continued to practise, often pro bono, had different priorities. What better higher education for a doctor, I suspect he would have put it, than being one? What better continuing education? What better finishing school?
Being both a patient and a doctor, perhaps? Chekhov lived for many years with the consumption that killed him at age forty-four, but refused to allow it to consume him psychologically. Nor did it slow his work rate, whether literary, medical, philanthropic or sexual. His patients’ illnesses provided more useful material than his own, and were addressed with a compassion that was never sentimental, a humour often dark, and a study of character that was surgically precise. Tough love? He had more than one splinter of ice in his heart, but he was as hard on himself as he was on the rest of the human race. I never grow tired of rereading Anyuta, one of his earliest and shortest stories, which documents, in half a dozen understated pages, the relationship between a young, half-starving seamstress-cum-artist’s model, and the medical student who shares her room and bed. Anyuta supports her lover through his studies, albeit in penury; she is so thin she also serves as an anatomical ‘skeleton’ for him and his fellow students to study. As the end of the story approaches and he is about to graduate and move on to a more affluent life, we realise that hers is a different fate: to be handed on to the next medical student, exactly like a box of bones, just as she was handed on to him years before.
Chekhov doesn’t moralise, he seldom does, but the story is an icepick, with the power to stab even the most frozen heart, as surely and sharply as it must have stabbed his, being at least partly autobiographical, and written out of guilt. Perhaps the quote I was groping for owes more to Kafka than to Babel: ‘A book must be an axe for the frozen sea within us.’
Is cancer the axe that will crack the last ice in my heart? Time will tell. Meanwhile, what lessons might it teach me before it finishes me off? The illness stories of my patients, likewise; what else can I do but get them down too, here, for the same purposes?
7. Cycling
Frank, a plainspoken bloke of my age with similarly sport-ruined joints, chuckles derisively when I mention, creaking up out of my chair, that I need a knee replacement.
‘You told me that, Doc. Three years ago. Remember?’
I don’t, but I have a good excuse. I haven’t seen him since. Frank avoids doctors whenever possible. We’re bad for his health.
I check his file. ‘You’ve had them done?’
Another chuckle. ‘No way. I got on my bike and went for a ride instead.’ He pauses for effect. ‘A long ride.’
‘Where to?’
‘Broome. And back. Took three months. Haven’t had any trouble since.’
Physician, heal thyself? Patient, heal thy physician. I soon tell his story to other ageing, arthritic patients, along with its moral: you can get away with murder in a knee joint if you have strong quadricep muscles. As for telling myself, Broome is a little beyond my range. But having murdered both my knee joints – I had an anterior cruciate reconstruction in my mid-thirties so that I could keep playing soccer, then kept playing for another two decades, which was exactly twenty years too long – on my wife Lisa’s urging I begin cycling to my medical work on weekdays, and to the Central Market or the beach or the hills with her on weekends, trying to postpone the inevitable.
