Chapter 5

AN END

What we call the beginning is often the end

And to make an end is to make a beginning.

The end is where we start from.

—T. S. Eliot, “Little Gidding” (1942)

Hanover, New Hampshire. February 1985

It was still dark outside our bedroom window when the phone rang. Calls before dawn were always bad news, but ours was a doctor’s house, so we got a lot of them. Typically, it was someone else’s bad news, not our own, but this didn’t make it any easier for Janice, my wife. All those calls meant that bad things were happening to lots of folks out there, decent folks like us, bad things they didn’t deserve and usually didn’t see coming. And, if that’s the way it is, then our turn will come, too, right? So, is this the one? Is this call for us?

Janice sprang out of bed as if she’d been bitten.

Yes? she said anxiously into the receiver, her voice gruff with sleep but suddenly wide awake. She listened for a minute, then exhaled deeply.

No, she said. No . . . wait a minute . . . wait a minute . . .

Who is it?

Your girlfriend.

Which one?

Janice handed me the phone.

Remember, she said sternly, you’re on vacation.

It was warm outside when I went to my car. That detail sticks in my memory now, twenty-five years later—that and the sound of Martha’s voice on the phone. Please come! Please, Brendan! Now! Please! You must come now! She wasn’t shouting. Martha wasn’t a shouter, not even that day, but her whisper was so plaintive, so urgent—so fierce!—I knew I had to go. Martha hadn’t asked for much in the years we’d been together. And she never begged for anything. But that’s what I heard that morning, even more in her voice than her words: She was begging me. Please! Come now! Please!

Snow lay hip-high in the yard and along the road. First light had barely begun to crawl up over the eastern hills—just the gray, not the glimmer—but already, even before sunup, it was warm. I could smell the thaw, hear it trickle. The Volvo’s tires had frozen flat in the driveway every night since Christmas, but I pulled out easily onto Wheelock Street. A pair of bluebirds tweeted in the bare lilac hedges.

Every year, for a day or two, this sudden reprieve in the dead of winter sent the temperature climbing into the fifties. It was always a surprise. And when it came, the whole town felt lucky, jubilant. During our thirteen winters here in Hanover, where I worked at Dartmouth’s medical center, there had been entire months when the mercury never rose above zero, day or night. During those stretches, even the native New Hampshire folks took notice. (Been some nippy out there, ayuh?) But most people here endured the long winter without complaint. Beyond the skiing and Dartmouth’s winter carnival and the fine snow sculptures on the college green, there would be ample compensation for the cold. Here in the north country, spring was triumphal, summer idyllic, and autumn so glorious you almost didn’t care that winter was just around the bend again. Like most everybody else, Janice and I felt lucky to live here, especially on a day like today.

It was a Tuesday. I had taken the week off—it was the kids’ winter school break—and we were all going skiing that day. When I hung up the phone and jumped out of bed to go see Martha, I told Janice, Don’t worry, this won’t take long, we’ll make the skiway before the first lift.

Janice didn’t say anything. She just gave me one of those looks: Again? They come first again?

Martha was eighty. So was her husband, Fred. They had been calling a lot these past few weeks, but we had worked it out, talked it through. We had a plan. But this was a new wrinkle. Martha was so distraught she couldn’t even say what was wrong. Please! Please come! was all I could get out of her. I had been Martha’s doctor for ten years. I liked her, admired her. I couldn’t ask the on-call guy to handle this. He didn’t know Fred and Martha. I did. I knew I could help, whatever this was.

Yet Janice had every right to be pissed about this. It was a different story when I was on call. Then, typically one weekday night per week and one weekend per month, my going would make sense. It was my job. Most of the time I could handle things on the phone—someone’s minor illness that could wait until morning or a discussion with one of the Dartmouth medical residents about an inpatient on the hospital service. But if it sounded serious and uncertain, if it meant going to the hospital or someone’s house even in the middle of the night, that’s what you did, it came with the territory.

Janice accepted this. She knew all about responsibility and hard work. She was raising BJ and Caitie without a lot of help from me, despite having a busy full-time job herself. In her “spare time,” she had just completed a graduate degree from Dartmouth. But there are limits, Janice said, there must be boundaries.

We argued about this and, as I drove down Wheelock Street that morning, I worked through these arguments again. Talking about it—boundaries and all that—is one thing. But what do you do? Some doctors say, I’m sorry, I’m on vacation today, Dr. So-and-so is on call, you don’t know him but he’s very good. Is that what you do? Martha and Fred were people I cared about. It didn’t make any sense to ask another doctor to get involved.

A short way down the hill, I approached the old mansion on the corner of Jackson Road. Reflexively, I ducked, almost hiding under my dashboard as I passed. It was six in the morning and still dark outside but you never knew with Babs. She could appear out of nowhere, always when I least expected her, and start shrieking for attention.

Babs and her husband, Clark, a wealthy couple from New York, had moved into the mansion a couple of years ago. Soon after they arrived, they were invited to a dinner party hosted by a medical professor at Dartmouth, who was constantly courting wealthy donors to support his research. I lived just down the street. The professor apologized when he called me, said he didn’t know if I was on call that night, but one of his dinner guests was having a stroke—or something, he wasn’t sure what it was—and asked could I just come over and take a look at her?

As it happened, I was on call that night and, after asking a few questions, I had a pretty good notion what this “stroke” might be. It’s peculiar, the professor had said, it’s just her face that’s paralyzed but it came on all of a sudden. During dessert, actually. The rest of her seems all right, she has no hemiparesis or headache or anything else. It’s a bit . . . embarrassing, you know? I’ve got a house full of people here . . .

When I arrived a few minutes later, Babs had been secluded in the den with her husband, apart from the other dinner guests. In her forties, fashionably thin in the New York way, Babs would have been attractive had her meticulously cosmeticized face not been so grotesquely contorted. Everything on the left side of her face—her eye and mouth, even her nose—was straining desperately to occupy the right side of her face instead. Her tongue was stuck hard inside her right cheek, making a bulge like a huge wad of chewing tobacco, but the spit dripping down her chin was clear, not brown. Her lips and tongue could barely move at all, her speech was garbled, nearly incomprehensible. The rest of her looked all right but she was miserable, frantic, and she mumbled something about being too young to have a stroke. I tied a tourniquet tight around her arm, slapped the crook of her elbow to find a vein and shot her up with a slug of IV Benadryl from my little black bag. I wasn’t sure myself how long it would take, so we laid her down on the couch and put a pillow under her head, but within less than a minute Babs was sitting up, exclaiming, Oh, Gawd, oh, Gawd, thank you, Gawd, her diction precise, her tongue untied, her face symmetrical and astonished. I hung around only long enough to make sure she wouldn’t need more Benadryl and to explain that her problem was the medication she had taken earlier in the day. She had called her doctor in New York because she had an upset stomach, and he had phoned in a prescription for an antinausea drug, Compazine, which was well known to cause (rare) dystonic drug reactions like this one. After I left, Babs became the life of the party, which itself became a great fund-raising success. Apparently, Babs’s dramatic “cure” became a perfect prop in the professor’s after-dinner spiel about the importance of supporting medical research.

But no good deed goes unpunished. From that night onward, whenever Babs spotted me around town—in the supermarket, at the skiway, wherever—she would shriek and make a huge fuss. There’s my doctor! Dr. Reilly! He’s my doctor! she would shout, He’s my doctor! as if everyone, now gawking at us in the vegetable aisle, would really want to know this.

Babs became a recurring reminder of one of the things I disliked about being a primary care doctor in a small town: the loss of anonymity. The townspeople here all knew me. Or at least they liked to think so. After all, I knew their secrets and their sins. For some of them, I was as much confessor as doctor. True, I didn’t discourage patients from phoning me at home, as Janice thought I should. My patients knew they could reach me if they thought it was important. Most of them were respectful of my time and apologetic about bothering my family at home. It just didn’t feel right to me to abandon them to the guy on call—someone who didn’t know them, hadn’t followed them for years, hadn’t seen them in the hospital and at home, a stranger who didn’t know all that they and their families had been through. Even if the on-call guy took the time and trouble to read through their stacks of medical records, he couldn’t possibly do what I could do. Yeah, Janice would counter when I made this argument, do the other guys do the same for you?

The truth was that some did, but some didn’t. So, for a long time, these “unnecessary” intrusions into our personal life had upset Janice. She began to understand my side of the story only after I told her about Laura Henderson. As I neared the bottom of the hill on Wheelock, I realized that Laura hadn’t called for some time now. I hoped this was a good sign.

Laura didn’t call often, but it was always late at night and always she was crying, saying she really couldn’t talk to anyone but me. Laura lived alone in northern Vermont now, her six kids grown up and moved away. She didn’t know me well—I had been her husband’s doctor, not hers. She had friends, but she couldn’t confide in them, not about this. And she had forbidden me to discuss it with anyone. Ever.

So I was the only one she had. I was the only one who knew.

Two years before, Saul Henderson had been referred to me at Dartmouth by his own internist up north, who knew Saul was seriously ill but couldn’t figure out why. A charming, charismatic headmaster at a prestigious New England prep school, Saul’s months of fever and weight loss had baffled his doctors. He’d had all the tests and empiric treatments they could think of, but he kept going downhill. After I put him in the hospital at Dartmouth it took us a while to figure it out, too, but a new virus had just been identified in Bethesda and Paris, so we asked the NIH people to do their new blood test for HIV—it wasn’t approved yet for general use—because no other diagnosis made sense. This one didn’t make sense either until Saul finally told me about his business trips to New York and visits to the bathhouses in Greenwich Village.

When the blood test came back positive, Laura couldn’t believe it, not even after I insisted that Saul tell her about New York. She refused to be tested herself—This is not possible, she said—and they both instructed me to tell no one. This wasn’t easy. Back then, HIV was rare in small-town America, but Christopher, the Hendersons’ eldest son, was a savvy young guy who asked to meet with me privately more than once.

Talk to your mom and dad, Chris. That was all I could say.

We kept Saul in the hospital until he died about a month later. Under the circumstances—the bleeding, the diarrhea, how combative and confused he became toward the end—there was no way we could send him home to die, no way to protect his family and friends from infection. When the autopsy confirmed the diagnosis, Laura couldn’t continue to deny it to me, but she’d never been able to tell anyone else.

After Saul died, Laura’s entire adult life made no sense to her. They had married young, raised a large loving family. They had been happy, she said.

Do you understand what I’m saying, Dr. Reilly? We were happy.

Now, two years later, it still didn’t make any sense to her. So, on some lonely nights when she’d had a few drinks, Laura would pick up the phone and call the only person who could know why she was crying.

One night when Laura called I had just gotten home from the hospital. It was late. I wasn’t on call but I had missed dinner and hadn’t seen the kids before they’d gone to bed. When I got off the phone with Laura, Janice hit the roof. So I broke my promise to Laura and told someone else about Saul.

I can’t say it made everything better. But after Janice heard the story, she seemed less begrudging about the phone calls—Laura’s and some of the others, too.

This business about boundaries isn’t as simple as it sounds.

My headlights flashed past Kingsford Road, where Janice and I and the kids had lived when I first met Martha ten years before. Even then, at age seventy, Martha was striking, a dead ringer for the actress Jessica Tandy and every bit as vital, witty, and wry. Since I’d known her, she’d been lucky, her arthritis slowly getting worse but the rest of her remarkably well preserved despite her rheumatic heart. Fred, Martha’s husband, had been even luckier. He’d never had any serious medical problems at all. Fred took no pills, had never had surgery, and, with his spry youthful demeanor and full head of white hair, he looked like a poster child for healthy aging. I had been his doctor for about a year now—I took him on after his own doctor retired—and, except for the fainting spell that brought him to me in the first place, he hadn’t needed my help at all.

The phone calls had started a few weeks ago. Always at night. The first time it was Martha who called. She apologized, said Fred needed to talk to me. Then she listened in on the extension as Fred rambled on about this or that, coherent but oddly tangential. It wasn’t clear what was on his mind. When I asked how I could help, Fred paused, then said, That’s a good question, that’s a very good question. But that was as far as I could get.

A few nights after that first call, Fred made the call himself. I could hear Martha tsk-tsking in the background and exclaiming in a loud exasperated whisper: Fred! Leave the poor man alone!

I was wondering, Brendan . . . do you know much about angels?

Angels?

Yes, you know, cherubim and seraphim, all that . . .

Uh, no. Not much. Why?

Well, I’ve been thinking about haloes . . .

Haloes . . . ?

Yeah, you know, the light around the angels’ heads . . .

Uh-huh . . . ?

Well, I think maybe the shape and intensity of the light . . .

Click-click. Martha’s persnickety voice came over the extension line.

Fred? For Pete’s sake, Fred! It’s the middle of the night!

Oh . . . well now, you see, Brendan, that’s interesting, too, don’t you think? I mean . . .

Fred, leave the poor man alone! Hang up the phone!

Well, I just . . .

For Pete’s sake! Brendan, I’m sorry. Fred! Hang up the phone!

The whole thing was bizarre. As far as I knew, this was completely out of character for Fred. So I brought him in and checked him out and he passed with flying colors, just as he had done before. He was the healthiest eighty-year-old I knew—sharp as a tack mentally with a “physiological” age twenty years younger than his chronological age—the kind of elderly patient I liked to ask, only half joking, What’s your secret? Whenever I asked Fred this question, he would just chuckle and say, That’s a good question, a very good question. But he didn’t say much about the phone calls. In fact, he didn’t remember them very well. This concerned me even more. I talked to Martha privately about this. She couldn’t put her finger on anything specific. But, she said, I’ve been married to this man for fifty-five years and there’s something fishy going on—that’s the word Martha used, “fishy”—because most of the time he’s just his same old Fred and then, especially at night but not every night, he’s . . . different . . . I know, I know, but that’s the best I can do, Brendan, he’s just different, I can’t say how exactly.

Finally, Martha and I convinced Fred to see Katherine Armour, a professor of psychiatry at Dartmouth who, in her seventies herself, specialized in geriatric psychiatry. Fred wasn’t crazy about this idea—in fact, that’s exactly the way Fred put it, chuckling—but he went along when I reminded him that Martha was concerned about him. What’s the harm? I said, and he reluctantly agreed. Just last week I’d heard that Dr. Armour hadn’t found much either when she examined Fred. But now she’d begun to receive his phone calls at night, too. Uncertain what was going on, she was debating whether to hospitalize Fred on the inpatient Psychiatry service to observe him around the clock for a few days.

As my old Volvo huffed and shimmied up the next hill, I wondered whether Martha’s frantic call this morning meant Martha wanted me to arrange the inpatient Psych observation, now. It seemed like a good idea, for Martha’s sake as well as Fred’s. As much as I was perplexed about Fred, I was concerned about Martha, too. She was the one with the bad heart.

I would need a plan. I checked the clock on my car’s dashboard. It read 6:05. This was okay. Dr. Armour and her husband were avid bird-watchers, even in winter. They’d be up and about, even at this hour. And I could do my part. Fred and Martha would go along with what I recommended. They trusted me.

This didn’t mean we were friends. I hadn’t let that happen. When friends wanted to become my patients, I talked them out of it. And when patients wanted to become my friends, I put them off. This was awkward, sometimes—and often I wished I didn’t have to refuse the dinner invitations or golf outings or theater tickets—but I didn’t see any other way. Professional objectivity was impossible when caring for a friend or a relative. Love and loyalty, or guilt and regret, just get in the way. But maintaining a distance was a personal defense, too. After all, the “doctor-patient relationship” is a relationship. And, like all relationships, it can get complicated.

Across the road, heat rose from the chimney above Inge’s house. Pale wood smoke danced in the trees, beckoning. Was her husband away? In my mind’s eye, I could see the sleek stone fireplace inside, the lush Scandinavian carpet on the hearth. Was she sitting there now, by the fire?

For a long time, I had seen Inge only at the office. In the beginning, it was usually for stomachaches or insomnia or other vague aches and pains. Soon enough, though, it became clear that she was depressed and lonely and needed someone to talk to. Her husband was a research scientist who studied cold climates in remote places like Greenland and the Antarctic, places too forbidding for a young wife and child. She was alone a lot. For a woman who looked like Inge, making friends in a small town wasn’t easy. The men couldn’t take their eyes off her. The women resented her for it. Antidepressant drugs made her worse. She didn’t trust psychologists or psychiatrists. (They’re all voyeurs, she said, they just get off on other people’s troubles.) So she talked to me.

I hadn’t seen her in several weeks when she called one day. It was winter. She asked me to come see her at home. She said she’d been so tired these past few weeks she hadn’t been able even to leave her house. Her husband was away. Her son was at the babysitter’s. I’m all alone, she said.

It took me a while to find her house. The sun had begun to set when I arrived. No one answered when I rang the doorbell. Soft evening light filled the downstairs rooms but Inge wasn’t there. She was upstairs, lying on her bed. She wore a nightshirt, nothing else. She didn’t get up. She just lay there. Her skin was translucent, white as the snow outside her window. Unnaturally white. When I touched her, her heart was racing. I put pillows under her long, bare legs to examine her. She moaned when I put my finger inside, but was otherwise unresponsive. The stool in her rectum was black as coal. I guessed she’d bled out almost her entire blood volume these past few weeks. I covered her with blankets and called for the ambulance. Had Inge been Martha’s age, that stomach ulcer would have killed her, but within a few days she was well again. Her husband flew back urgently from Hudson Bay. In her white hospital bed she blushed pink and smiled wide when he promised he would be home more often now.

This morning, as the chimney smoke wafted into the gray predawn, I hoped Inge’s husband had kept his promise.

How complicated couples are! In my short career as a doctor, I had become impatient, even contemptuous, of people who gossiped and opined about other couples’ relationships. No one can know what goes on between two people except the couple themselves. I couldn’t even begin to imagine all the water that had passed under Fred and Martha’s bridge. Fifty-five years! They’d been married almost twice as long as I’d been alive. How could I think I could help them?

But I was learning. On every corner in this town, down every street I passed this morning, there were stories like Inge’s. The house calls, like the one this morning, took a lot more time than the phone calls ever did, and they took a bigger piece out of me, too. But I remembered them all and I learned something every time. The word doctor is derived from the Latin root docere—to teach—but, in my experience so far, the patients had taught the doctor at least as much as the doctor taught them.

At the crest of the hill, near the beginning of the Dartmouth campus, the old Westman house stood empty and dark. The path to the front door hadn’t been shoveled all winter. Could it really be ten years since I had spent the better part of three days there, trying to help Ms. Westman die? Back then, I didn’t know much about such things. I was new, fresh out of training, well equipped to deal with the heart attacks, cancers, and infections in the hospital. But helping old folks die at home wasn’t part of the medical curriculum in my day.

Ms. Westman had just had her fourth stroke. Her son, who had run the local pharmacy since her husband died, knew that his eighty-nine-year-old mother didn’t want to go back to the hospital. Ever. After I reviewed her medical records—she had been hospitalized thirty-eight times in the past ten years—I agreed with the son’s request to try to care for Ms. Westman at home. When I arrived, my shiny black doctor bag in hand, the poor woman was lying on her bed, fully clothed, unconscious yet groaning, rolling her head this way and that as if trying to shake off a pain that not even coma could relieve.

I examined her as best I could. But, for the life of me, I couldn’t figure out the source of her suffering. It was painful just to watch. Finally, remembering that I was here not to make a diagnosis but to make Ms. Westman comfortable, I gave her a shot of morphine. To my horror, this seemed only to make her worse. She was so agitated, so distressed!

I was about to give up—tell the son we had no choice but to call an ambulance—when the visiting nurse arrived. Peggy was an older Scotswoman, nearing retirement. She had visited Ms. Westman at home regularly for years. Peggy took one look at her, writhing on her bed, and said, Ah, now, what a shame. Such a fine lady she is.

Then Peggy saw that I was clueless, clearly over my head and at my wit’s end.

Firmly but diplomatically—after all, I was the doctor and she the nurse—Peggy said, Ooh, doctor, yes, let’s get her out of that girdle now, shall we?

I didn’t know what she was talking about. A girdle? Such distress from a girdle? But I didn’t have any better ideas. It took all that we both could do to get Ms. Westman, a large woman and dead weight, out of that brocaded dress and the heavy nylon stockings and the lacy garters with the metal clips and the rubber buttons and the tight elastic girdle and all the rest of it. When we were done, Ms. Westman was stark naked but she was still writhing and groaning.

Peggy looked at me expectantly, awaiting my order.

I didn’t know what to do. I wasn’t at the hospital. I couldn’t just order some tests or X-rays or ask a consultant to see her. What to do?

Her tone deferential but firm, Peggy said simply, Dr. Reilly, she has to pee.

Before I could even register this idea, Peggy spread Ms. Westman’s doughy white thighs and deftly slipped a catheter into her bladder. A torrential stream of urine shot out into a large metal basin, nearly filling it. Immediately, Ms. Westman (who remained peacefully asleep thereafter until her death three days later) let out such a prolonged and exuberant sigh of pleasure and release that she seemed in the throes of ecstasy. She even grinned, her face lopsided by her stroke but utterly satisfied, comatose or not.

Peggy watched her, then smiled and shook her head. She clucked her tongue pensively and said, It’s quite something, is it not, Dr. Reilly?

What?

Well, now! How women of a certain age . . . and breeding, if I may say so . . . just can’t . . . bring themselves . . . to . . . wet their pants! No matter what! Now, isn’t it remarkable, that?

And so it was, at least to me.

This was how doctors learned. This was the people part of doctoring—the part the patients teach the doctors, not the other way around—and it was endless, the stuff of novels, not textbooks. I never did find an authoritative medical reference about how to handle my visit to Mr. Chadwick, an old angler with Parkinson’s disease who asked me to remove a fishhook stuck painfully in his upper eyelid. He refused to go to the hospital. (That suggestion had made his head shake even more.) He apologized for bothering me about such a foolish thing and said that, in the old days, he would have just removed it himself, but his tremor was pretty bad now, both his head and his hands. So he talked me through the procedure, right there on his front porch, easy as pie.

The textbooks hadn’t helped me much when I’d had to figure out what to do for Tim, either. Tim was a good man—orphaned as a five-year-old, he’d taught himself to become a fine auto mechanic—but he couldn’t handle his beer and had been trying to stay on the wagon so he could win back his estranged wife and kids. Taciturn and hardworking, Tim asked me to sew his nose back onto his face at home at his kitchen table, so his wife wouldn’t hear about how he’d passed out, face first on the floor, onto a jagged shard of beer bottle. His nose was hanging off his face, like a flag at half-mast. I’m no plastic surgeon and probably shouldn’t have done what I did, but about a year later a permanently sober Tim, despite his odd-looking nose, was able to reconcile with his kids, if not his wife.

If only there were a book of life, somewhere I could just look up the answers. The intimidating breadth of clinical skill and experience that primary care requires is humbling, but these “people things” were the hardest part. Some involved classic issues in medical ethics; these I could read about and consult with colleagues to help me. But so many others were judgment calls where there was no right or wrong answer, where I couldn’t be sure what was the best thing for my patient or what were the appropriate limits of my responsibility as their doctor. These ambiguities were part of the job.

•  •  •

In the decade immediately preceding my early morning house call to visit Martha and Fred, luminaries in American medicine hotly debated the “boundaries” of our profession. Is medicine strictly a curing science, its purview limited to human biology and disease? Or is medicine a “helping profession” whose boundaries extend beyond biomedical science?

This debate continues today. Its arguments affect not only how our society spends its resources to improve its citizens’ health but also what kind of help its citizens can reasonably expect to receive from the medical profession. Can a medical doctor like me help Laura Henderson, the grieving widow? (Medical doctors are trained to treat disease. Is grief a disease?) Do Fred’s loopy phone calls mean he’s ill? Or is he just getting more eccentric and forgetful in his old age? (If so, what can I do about that? And how can I help Martha, now sick with worry about Fred?) Did loneliness cause the bleeding ulcer that nearly killed Inge? If so, could better doctoring have prevented it?

For the past thirty years, the biomedical side in this debate has clearly held the upper hand. Its argument was articulated most famously by Donald Seldin, a distinguished physician-scientist, in his widely publicized address titled “The Boundaries of Medicine”:

Medicine is a very narrow discipline. Its goals may be defined as the relief of pain, the prevention of disability, and the postponement of death by the application . . . of medical science to individual patients. . . . A heritage which invests medicine with the priestly function of the counselor and comforter of the sick . . . has resulted [in] a tendency to construe all sorts of human problems as medical problems. This medicalization of human experience leads to enormous . . . frustration and disillusionment when medical intervention fails to eventuate in tranquility . . . and happiness.

Human problems . . . are medical problems and medical illnesses only when they can be approached by the theories and techniques of biomedical science.

Seldin argued that a clear boundary can (and must) be drawn between medical care and health care: Medical care is a part of, not a synonym for, health care. Health is affected by many nonbiological factors—social, economic, psychological, and cultural factors—but these issues (including substance abuse, poverty, various forms of mental illness, and the aging process) “lie outside the arena of medicine.” Furthermore, within the arena of medicine, Seldin argued that another boundary must be drawn that separates patients’ problems into those that biomedical science can and cannot solve. In his view, it cannot solve problems like grief, worry, alcoholism, and risky behavior. (Such problems are the “turf” of paramedical professionals, such as psychologists, social workers, and ethicists.) Medicine’s task is not to make people happy. Medicine’s task, in its entirety, is to understand, prevent, diagnose, and treat scientifically definable biological dysfunctions.

This is an enormous task but, as Seldin argued, also a “very narrow” one. Even if Inge’s bleeding ulcer was caused by the stress of loneliness, it’s not her doctor’s job to have prevented it. Like Laura Henderson’s grief, stress and loneliness are not diseases. These afflictions cause patients real suffering—and may eventually lead to “real” diseases such as bleeding ulcers—but they are not, in the biomedical view, medical problems.

The contrary argument holds that this biomedical model works well for researchers (a good fit for their reductionist methodology) and for some practicing physicians (their job made easier by its narrower scope) but not for patients. This view was articulated best by George Engel, a legendary professor of medicine (and a contemporary of Donald Seldin), in the prestigious journal Science:

Despite the enormous gains which have accrued from biomedical research, there is a growing consensus among the public . . . that physicians are lacking in interest and understanding, are preoccupied with procedures, and are insensitive to the personal problems of patients and their families.

Medical institutions are seen as cold and impersonal; the more prestigious they are as centers for biomedical research, the more common such complaints.

In Engel’s view, the biomedical model was winning battles but losing the war. The root cause of this failure was widespread misunderstanding about the difference between illness and disease. Long before medicine was remotely scientific—indeed, before the modern scientific concept of disease even existed—people who felt ill sought help from healers, because they believed that the healer might know why they felt ill and how to make them feel better. For the patient (the literal meaning of the word is “one who suffers”), the illness is everything. No less today than in prescientific times, what matters to patients is how they feel, the impact of their “ill-ness” on how they function, its portent for their future, how they live their life.

But the connection between illness and disease, even today when the explanatory power of biomedicine is so powerful, is tenuous at best. Some patients who feel ill have no definable disease. Other patients, who have definable diseases, don’t feel ill at all. And, when one disease afflicts two different patients, their illnesses—how the disease makes them feel—may be completely different. Such discordance between illness and disease led Engel (and many others) to conclude that a purely biomedical model is inadequate to the goals of medicine. All too often, when doctors tell patients with ambiguous illnesses, “There’s nothing wrong with you,” the doctor really means that “There’s nothing wrong with you that fits within my own, narrow biomedical model of disease.”

But all human illnesses and diseases express themselves through their victim, a person who feels, communicates, and attributes meaning to those experiences in unique ways. The clinical “expression” of disease—the illness—always will vary with the individual characteristics, psychological makeup, and cultural background of the disease victim. Thus, Engel argued, doctors will never be able to diagnose and treat their patients effectively without understanding, and gaining expertise in, these nonbiological domains. To be effective, the physician must accept the responsibility “to evaluate whatever problems the patient presents and recommend a course of action, including referral to other helping professions.”

During a few brief periods in the 1970s, and again in the 1990s, Engel’s “biopsychosocial model” gained some traction in the United States. Young physicians like me embraced primary care medicine because we were inspired to help “the whole patient,” notwithstanding the ambiguity (and hubristic zeal) this implied. Today, however, primary care physicians in the United States are in shorter supply than ever. The biomedical model of medicine is clearly dominant, propelled by its truly remarkable scientific achievements. In fact, the science has shown that some health domains once deemed not “biomedical”—such as substance abuse, mental illness, aging—do, in fact, have important biological underpinnings. Nevertheless, Engel’s fundamental concern remains unanswered today: What happens to patients whose illnesses don’t “fit” the biomedical model? Who helps them?

•  •  •

I stopped for a red light at the corner of Wheelock and Park streets, where the Dartmouth campus began. Hard ice covered the fine red clay tennis courts in front of the new athletic center. Across the street, construction on the new student housing complex had been halted temporarily, a rare concession to the brutal cold and heavy snows of January. These new dormitories would mark the beginning of the Big Change, Dartmouth’s first bricks-and-mortar acknowledgment of societal changes it could no longer ignore. For more than two hundred years, Dartmouth had been a wealthy, world-class institution whose all-male Big Green alumni—“men of granite” who “bled green”—had given generously and fought hard to preserve its traditions. But recently the college trustees had recognized the female sex as a constituency they couldn’t live without, one deserving more respect than it typically received at Dartmouth’s infamous frat parties. Despite fierce opposition from rabid alumni, they had voted to admit women students to Dartmouth.

Women? At Dartmouth?

The first few pioneering females had been housed in temporary quarters, which most of them liked precisely because they weren’t far removed from the men’s dorms. But this advantage soon lost its luster, at least for some, who wound up coming to me. Dartmouth ran an excellent student health service, including an inpatient infirmary, but like the rest of the college it wasn’t ready yet for female problems—or, at least, not the kind of female problems that found their way to me.

The Dartmouth women I saw seemed female analogs of Dartmouth men: clean-cut, athletic, attractive kids from Connecticut and California, kids from good families with bright futures who had had all the advantages and probably always would have. But, behind their practiced smiles and polished social skills, some of these young women were hurting badly, in ways they couldn’t explain. One had intractable headaches. Another couldn’t sleep. A third had constant pelvic pain that defied physical explanation.

The first one, Jennifer, was a tall, raven-haired all-American soccer star whose fine cheekbones, athleticism, and ribald sense of humor would have made her a big man on campus—if she’d been a man. Eventually we got down to why her headaches were happening, how the guys would show her (four or five at a time) what they really thought of her. She couldn’t confide in anyone, including her own family. (That’s why she was here: Her father and older brother and all her uncles had gone to Dartmouth.) She said there was just no way she could talk to them about it. After I’d figured out what was going on with Jennifer, it didn’t take long to get to the bottom of Kylie’s pelvic pains or Samantha’s insomnia.

The traffic light turned green. I drove past the dormant Caterpillars at the construction site—excavators, front-loaders, and cranes glistening with ice. Directly across the street was the modest frame house where Hugh MacNamee and his family lived. A psychiatrist who specialized in adolescent mental health, a kind man with teenagers of his own, Hugh had seen Jennifer and Samantha and some of the other girls at my request. He had helped them. He never said anything to me about it—whatever they discussed was confidential—but I knew he had helped. And I suspected that the location of the new women’s dormitory was no coincidence.

Hugh’s elderly mother, Patty—a wizened, wise, delightful widow in her eighties who had a bad heart—lived in an oxygen-equipped apartment in the attic of Hugh’s house. Sometimes, in the evening on my way home from the hospital, I would stop in to check on her. (Patty never asked for me—she always said she didn’t like being a “nuisance”—but Hugh’s wife would let me know when the swelling in Patty’s legs or shortness of breath seemed worse.) In recent months, whenever I visited her, Patty had developed a conspicuous habit of looking out her attic window at the construction site across the street. With a twinkle in her eye, she would say to me: Isn’t it fine that the Dartmouth girls will finally have a place of their own? Isn’t it fine?

Once, just once, Patty had slipped. (I think. It was hard to tell with Patty; she was an ace poker player.) On that one occasion, Patty had said: your Dartmouth girls. Isn’t it fine, Brendan, that your Dartmouth girls will have a place of their own? I never asked her what she knew, but, like Patty, I was glad for the girls.

My car approached the center of town. There, the Dartmouth green lay empty and white in the lifting darkness. In summertime, the green was a wide expanse of lush lawn bordered by giant leafy elms and grand stone buildings, each named for a wealthy alumnus. The professorial life at Dartmouth, a first-rate institution in a beautiful place, seemed pretty sweet. Its focal point was Baker Library, the stately brick edifice whose iconic bell tower was the north star of academic life here. But this star had begun to dim for some of the Dartmouth faculty, many of whom were my patients. More than a few had become restless and dissatisfied. After they had survived the gauntlet to tenure, they seemed to spend most of their time learning more and more about less and less. As their academic focus shrank, their personal horizons constricted, too. Bored, they poured their energy into hobbies or had affairs or drank too much or paid too much attention to their children (or, in some sad cases, not nearly enough).

Initially, I attributed faculty ennui to the small size and homogeneity of the college population, an insular culture that glorified bits of arcane knowledge that only a handful of people in the world cared about. But, in time, it seemed to me that the cause of their angst—which, in some cases, led to panic or depression and thence to me—wasn’t that their life’s work seemed useless. (They all knew from the start that unearthing new evidence about Shakespeare’s mistress or Lincoln’s sexuality wasn’t useful, not in any practical way.) Instead, the problem seemed to be that the merits of their research, which required great effort and skill, could be judged only subjectively, decided by the prevailing opinion of expert peers like themselves. This was less true in the sciences (and in the business and engineering schools) than the arts, but even the chemists and geologists and economists never seemed sure that they weren’t wasting their time. (These were the days when quantum mechanics and Thomas Kuhn were all the rage: Nothing was certain.) To compensate, many professors found solace in the beauty, if not the truth, of what they taught. Others found meaning in the process, if not the outcome, of their discoveries. But more than a few found neither. Of these, the ones I saw just seemed to feel smaller as they got older.

Medicine, it seemed to me, was different from these other pursuits in both its science and its practice. The science’s power to prolong and improve people’s lives seemed limitless. It was tangible, visible, its value objectively indisputable. A mere five years after HIV, a new disease, had killed thousands of people like Saul Henderson, medical scientists had isolated the murderous piece of RNA that caused it, a stupendous achievement. There was talk about eradicating HIV from the planet entirely, along with smallpox, polio, and other viral scourges. The pace and practical utility of such discoveries were breathtaking.

Although very different from medical research, the practice of medicine was vital, too. If you made the effort, you could find out what really happened. Did my diagnosis prove correct? Did my treatment work? When my patient died, did the autopsy show what I had missed, how I could have done better? Every day as a practicing doctor, I encountered an objective reality—out there, independent of my own wishfulness or bias or ego—actual things that happened to real people in real time, some of them the result of what I did or didn’t do. And, like trees falling in a remote forest where no one can hear them, these things happened whether I knew about them or not. Finding out—actively, even desperately, tracking down what had happened—became an essential part of what I did. Whether the final factual reality proved me a success or a failure, finding out made me better and wiser. But only if I took the trouble—and had the guts—to find out. To look reality in the eye.

Personally, this was a godsend. I had grown up on denial. My own family was beset by many of the same problems (and blessings) that have long bedeviled (and saved) large Irish families: alcoholism (and romanticism); depression (and stoicism); religiosity (and puckishness); inbreeding (and wanderlust). Drink ruined my father’s medical career and nearly killed him when I was eight, the second of five kids then aged one to nine. My mother never spoke about it. None of us kids visited Dad even once during the entire nine months he spent in the VA hospital just three blocks from our home. Afterward, my father had lived the life of a “dry drunk,” working a menial medical job for the Pennsylvania Railroad, punctual and professional at the office but brooding and resentful at home. Mom denied her own alcoholism for years, and Dad, who figured he had no rights in the matter, did nothing about it until others intervened.

So I had seen up close the effects of creating one’s own reality. Then, when I went to medical school, I saw that real shit happens to real people whether you want to admit it or not. And I learned that when you’re trying to help those people, denial just doesn’t cut it.

Fortunately, I married a woman who understood this. Ironically, Janice thought I was in denial, too—about my own habit, an addiction to medicine—and that, as a result, I was in danger of living the life of a “dry drunk” like my father. And, when you got right down to it, there I was, sitting in my car that February morning, waiting for a traffic light before sunup, stealing my precious vacation time from the people I loved most because I needed to find out about Martha and Fred.

The light turned green. As the road began its steep decline down the hill from Hanover toward Norwich, I looked west over the Connecticut River to the high meadows of Vermont. Even in winter, when the maple, beech, and birch are bare and the pastures pale with ice, it is some of the prettiest country in New England. Up there, on the south face of the slope, was an old weathered barn, too far away to see. That’s where John would be now, out of bed hours ago, feeding and milking, tending the machines and the stalls, maybe even birthing a calf.

Compared to John Melby, my family and I knew nothing about denial. Dairy farming was backbreaking work, seven days a week, but John Melby loved it. So did his wife, Shane, until the trouble got out of hand. Ostensibly, the trouble was John’s unshakeable conviction that he had colon cancer—even though two colonoscopies, a sigmoidoscopy, and two barium enema X-rays had proved he had no such thing. To look at him, John was the last person you would expect to be ruminating endlessly, anxiously, about a disease he definitely didn’t have. Six feet three, 220 pounds of pure muscle, with a confident smile, cleft chin, and penetrating brown eyes, he looked, even at age forty, like a recruiting ad for the U.S. Marines, which, as it happened, he once had been. Fresh out of high school, where he’d been the football captain and married the homecoming queen, John had served two tours of duty in Southeast Asia in the early sixties, before Vietnam was called a conflict, much less a war.

Like most doctors, I hadn’t learned how to help hypochondriacs like John, but he kept coming back to see me anyway. I didn’t find out about the real trouble until Shane started coming to see me, too. After she got to know me, she told me about how John spent his nights.

Sometimes it’s the moon, John said, when he tried to explain it.

The moon?

Yeah, somethin’ about the moon, doc. Like . . . when it’s about half full and . . . a little cloudy, you know?

Uh-huh . . .

Wet wood, too. Or wet leaves. When you burn them, you know? It’s the smell.

Okay.

And the chopper. You know, when the helicopters come down over the river sometimes, transporting somebody into the hospital? The sound, you know? It’s the sound of the darn thing.

Yeah.

Those were his triggers. Whenever he saw or smelled or heard those things, John would drop in his tracks. He might be in the barn or the kitchen or out in the field. He might even wake up with it and slip stealthily out of bed, careful not to wake Shane or the kids. Then he would crawl, on all fours, all night sometimes, out in the pastures, around the farm’s outbuildings, on patrol, with a loaded M-60 in his hands and murder in his heart. Usually, Shane wouldn’t even know until she found him in the morning—outside, asleep under the porch, covered in mud and manure, his rifle held tight to his chest.

His were the delayed kind, they had told him at the VA, the kind of flashbacks that don’t start until years later. But he was getting worse and the kids were getting older and they didn’t understand why their dad was the only dad who couldn’t go on overnight field trips or to bonfires the night before a big game. John never said an unkind word about anyone, including the VA doctors (whom he didn’t like) or the Vietnamese. (They were just fighting to keep their farms, you know, doc?) And he didn’t blame the guys. (No, sir, I’m proud of what we did, I’m proud to be a Marine.) And he didn’t blame Johnson. (But Kennedy would have stopped it, don’t you think so, doc?) It was just one of those things, he said, what are you gonna do?

But, uh, doc, about those colonoscopies? I’ve been reading that they can miss the cancer sometimes, you know? So, do you think we should take another look up there, or what?

I drove across Ledyard Bridge into Vermont. Ice floes cracked on the riverbank below. I thought about Maggie, John’s daughter, who had come to see me just last week. She was a lovely, healthy girl who was getting married in the spring. She worried that her father wouldn’t be able to walk down the aisle with her. He couldn’t handle a crowd, not even when it was just family and friends. It would break Maggie’s heart if her dad couldn’t give her away. I promised her I would try again to get John to take some medicine. I didn’t tell her I was pessimistic. The wedding was only a few months away.

As I drove into Norwich, Hanover’s quaint quiet sister town on the Vermont side of the river, it occurred to me that Fred and Martha were John’s temperamental opposites. Martha was uncomplaining to a fault. And when I first met Fred, he’d had a fainting spell at home—passed out cold at his kitchen table—but he didn’t seem concerned in the least. In fact, he was more intrigued by the experience than worried about his health. He’d never fainted before and found it “very interesting.”

Fred was an engineer, a rather famous one. Before coming to Dartmouth to teach at its prestigious graduate school of engineering, Fred had worked for big corporations like Ford and General Motors, inventing (and patenting) all kinds of useful things. Like all engineers, he was fascinated by “how things work.” But Fred admitted that he didn’t know much about how the human body works, so he’d had a grand time in my office with the Dartmouth medical student who examined him before I came in, each of them bouncing ideas off the other about the various “mechanisms” that might cause a person to faint. In the course of their discussion, the medical student had consulted a textbook I had written about the diagnosis and treatment of common medical problems (including fainting), which became grist in their mechanistic musings. In the end, it wasn’t clear why Fred had fainted—he wasn’t injured, his examination was normal, and his many tests turned up nothing—but Fred liked me anyway and, because his own physician had just retired, he asked me to take him on.

I wasn’t accepting new patients—I had too many already—but Fred won me over with his charm. He had returned to see me to review his test results and brought with him a copy of my textbook. (This alone would have won me over; then he said he’d actually read it.) He said he thought we were kindred spirits. He considered himself a “generalist” engineer, and he had the track record to prove it: He had invented everything from disc brakes for cars to navigation systems for airplanes. He’d even designed one of the first heart-lung machines for cardiac surgery. Fred liked the fact that I was an internal medicine doctor whose specialty was not specializing—not limiting my expertise to one bodily organ (like a cardiologist) or one disease (like a cancer specialist)—and whose goal was to take care of the “whole” patient. He had highlighted in yellow magic marker a phrase in my textbook’s Introduction: “We generalists must know our own limitations . . . but we will remain vital in our efforts and proud of our work if we heed our patients’ plea: Be my doctor.” That day in my office, Fred had simply pointed at those yellowed lines and asked, Can you do this for me?

It had been easy—Fred had never once needed my help—until a few weeks ago.

Hello?

Brendan, I’ve been thinking about what you said the other day . . .

Fred?

. . . and I’ve been working on this new idea . . . seems promising . . .

Uh-huh?

Well, when we did the new navigation system for the Electra . . .

Electra . . . ?

. . . it was heavier than the old direction finders. People thought it would eat up too much fuel if the plane had to carry the new, heavier device on long trips . . .

Okay . . . ?

Click-click.

Fred? For Pete’s sake, Fred! Leave the man alone! Hang up the phone!

I turned left on Elm Street and began the climb up to Fred and Martha’s place. Norwich had long been a quintessential Vermont town but change was coming. The town’s public areas still included nothing more than a post office, a grammar school, a swimming hole, and Dan and Whit’s general store. The store’s motto, crayoned on a wood beam above an old-fashioned Coca-Cola-red freezer, read, “If we don’t have it you don’t need it,” and this had been pretty much true for a very long time. But as I downshifted into the hill, I passed the pond and the paddock behind Joanie’s McMansion. Norwich never used to look like that.

I’d been inside the McMansion only once, a few months ago, a weekend house call. Joanie was a divorcée with two little kids who’d moved to Norwich from New Jersey a year ago. She had a mild chest cold. Her father, who was visiting from New York, wanted me to hospitalize her. You can’t be too careful about these things, don’t you agree, doctor? He wore Gucci loafers with gold buckles, a Rolex the size of Staten Island, and a toupee that may have cost more than my house. After I’d examined Joanie and reassured her, he pulled me aside privately to push harder for his hospitalization idea, and waved a wad of fifty-dollar bills at me. He didn’t know what to think when I declined, told him the house call was on the house, and left him spluttering at the front door. This wasn’t New York.

I was paid a salary. No bonus. No incentives. No “skin in the game.” I didn’t make more money the more patients I saw, or the more tests I did, or the more referrals I brought into the hospital. The Dartmouth group was one of the largest multispecialty practices in the United States; we did everything for the people of northern New England from cutting-edge cardiac surgery to neonatal intensive care—and we did it cost-effectively and well. Our heart surgeons and neurosurgeons and orthopedists were paid higher salaries than mine—but not much higher (less than double), a remarkable thing given the fact that I, compared with internists in private practice, was grossly underpaid myself. It was a special group of doctors who had developed this model of medical care and sustained it for decades—one that put patients first, not the doctors or the hospital or the bottom line—and I felt proud to be one of them.

We were a team. My job was to do what I was doing now: be the front man, be available to people who needed help when they needed it, figure out what was wrong with them, and get them to specialists when (but only if) the patients really needed them. Above all, as with Fred and Martha, my job was to be their doctor—the one they could count on, no matter what, over the long haul. From patients’ perspective, what I did was every bit as valuable to them as the great things our specialists did. The insurers didn’t think so, of course; they reimbursed the specialists and surgeons at much higher rates than my services. But this was the genius of the Dartmouth model: The caregivers, as a group, cared more about serving patients well than kowtowing to what insurers valued. None of us was getting rich—I couldn’t even afford to send my kids to private school—but we believed in what we did and we tried to do right by our patients.

This wasn’t socialized medicine. It was medicine that made sense within a particular social context. Rural New England was a place where people were raised to value three things above all else: their independence (New Hampshire’s state motto is Live Free or Die); their environment (Vermont is the Green Mountain State); and their neighbors. You helped other folks and they helped you; it was as simple as that. Ripping them off in the process, or putting a dollar value on everything you did, was a repulsive, foreign idea. To a city boy like me, doctoring and getting to know these folks—farmers and stonemasons, potters and carpenters, lumberjacks and weavers—had been a revelation.

But the change was coming and, as I chugged past Joanie’s place and up the hill to Fred and Martha, I knew the old way wouldn’t survive. New York and New Jersey had discovered New Hampshire and Vermont. Before long, money would gum up the works here, too. But it never occurred to me that one could actually measure the differences in quality and cost between the Gucci-loafers-fistful-of-dollars style of medical practice on Park Avenue and the very different style here.

But that’s what Jack Wennberg was doing at Dartmouth, even way back then. I had last seen Jack a few months before, on a mountaintop. Together with friends from New York, Janice and I had climbed Cardigan Mountain to get an eagle’s-eye view of the spectacular fall foliage down below. At the summit, we met Jack and his wife, who had climbed there many times before. After some small talk, they suggested we descend the mountain by a different route from the way we’d come up. The view is even better, if you can believe it, Jack said. This alternate route down would have left us several miles from where we had left our car at the bottom. But Jack said they were going down the way we had come up and they’d be glad to drive our car around to the other side of the mountain and leave the keys in the car. Delighted, we agreed. Our New York friends were astounded. Leaving your car unlocked with the keys on the front seat wasn’t something people did in Manhattan.

Jack had grown up in Vermont, trained at Hopkins and Harvard, but then returned home to the place he loved most. His area of research at Dartmouth was called “small area analysis,” a term he had invented and that no one else in medicine cared much about. Using data he had collected in Vermont and Maine, he discovered that more women who lived in particular towns in these two states had had a hysterectomy than women who lived in other towns. This did not make the evening news. But Jack cobbled together enough grant funding to investigate these “small area variations” further. He discovered that more men who lived in particular towns had had a prostatectomy—and more children had had a tonsillectomy—than those living in other towns. He also found that hospitalization rates for various medical conditions (like Joanie’s respiratory infection) varied widely for people who lived in different areas. None of these variations seemed to make any sense. They couldn’t be explained by differences in the towns themselves or the people who lived in them. Trained in sociology as well as medicine, Jack became intrigued by the idea that these variations somehow reflected differences in the “culture” of medical practice in these different locales. To understand this phenomenon better, Jack recently had broadened his sights and begun studying differences in physicians’ use of hospital services in Boston versus New Haven.

At the time, I thought small area variations in medical care belonged in the same category of trivial academic esoterica as exciting new discoveries about art history or geology. Others, much wiser than I, knew better.

•  •  •

In 1975, Howard Hiatt, a physician and dean of the Harvard School of Public Health, published a provocative and prescient article titled “Protecting the Medical Commons: Who Is Responsible?” that cited Jack’s work prominently. Using the analogy of a large grazing pasture shared by many dairy farmers, Hiatt argued that, if a single farmer increases his number of cows and consumes more of the pasture, this will have little effect on the overall welfare. However, if all of the dairy farmers do the same, that is, increase consumption of the pasture to maximize their own self-interest, this will destroy the welfare of all. Hiatt contended that U.S. society faced a similar dilemma about medical care.

Hiatt strongly endorsed the traditional principle that a doctor’s primary responsibility was to “do everything possible for the individual patient.” But this principle, applied in an era when costly new medical technologies and treatments were introduced almost daily, raised the specter of our society “reaching a point where marginal gains to individuals threaten the welfare of the whole.” Societal medical resources—the medical commons, like the grazing pasture—are finite. Unconstrained use of those resources by individuals, which inevitably will limit the resources available to the rest of us, “is a luxury we can no longer afford.” What to do? Obviously, priorities must be set. But Hiatt asked: Who is responsible for setting these priorities? Who will make these decisions?

It is surely not fair to ask the physician or other medical provider to set [these priorities] in the context of his or her own medical practice. . . .

To protect the commons from useless, prematurely introduced, or otherwise inappropriate practices, the physician must join statisticians, epidemiologists, and economists to ensure that no practice is widely adopted without prior evaluation.

Hiatt identified several categories of medical practices whose incursion on the medical commons seemed problematic. He cited Jack’s research because it dealt with the most important of these: practices whose value was unknown, negligible, or even negative (more harmful than beneficial). For example, pediatricians had long believed that as many as 90 percent of the one million tonsillectomy operations performed annually in the United States (in 1975) were unnecessary, a waste of medical resources. But this contrarian view was difficult to prove until Jack’s research showed that the rate of tonsillectomy varied tenfold in different New England towns. And, Jack argued, avoiding unnecessary tonsillectomy procedures not only would save precious resources ($360 million in 1975), it would also reduce deaths from (tonsillectomy-related) general anesthesia. Jack’s work had shown that elective, unnecessary tonsillectomies cost hundreds of millions of dollars and scores of kids’ lives every year. In Hiatt’s view, this exemplified the kind of “health services” research (rarely done in 1975) badly needed to help protect the medical commons.

Hiatt didn’t stop there. A fervent supporter of biomedical science and technological innovation, he applauded the discovery of new, potentially valuable practices. In 1975, these novelties included computed tomography (CT scans), intensive care units (ICUs), and “prehospital rescue units” (ambulances with emergency medical personnel on board). But, ever mindful of the endangered commons, he insisted that new technologies and practices not be adopted until they are proven more effective—and more cost-effective—than the status quo.

Regarding CT scanning, for example, Hiatt cautioned that “already there is evidence of its being used for purposes for which much simpler equipment is adequate. Will we be able to establish guidelines for the purchase and use of this machine [1975 cost: four hundred thousand dollars] before it too becomes a prominent and unregulated occupant of the medical commons?” Intensive care units and emergency ambulances no doubt save lives, Hiatt argued, but how many lives—and at what cost? Will “universal implementation” of these promising new practices be cost-effective? Hiatt and others had good ideas about how to answer those questions (using rigorous health services research methods). But who would empower and oversee this process? Again, Hiatt’s essential question was: Who is responsible to protect the medical commons?

In 1975, when Hiatt wrote confidently that “few would question . . . that we are approaching . . . a limit” to the resources our society can devote to the medical commons, health care spending in the U.S. amounted to 6 to 7 percent of the nation’s $1.6 trillion gross domestic product. Thirty-five years later, in 2010, U.S. population had grown 50 percent (from 200 to 300 million) and health care spending had grown more than 2,000 percent (to 17 percent of the nation’s $14.6 trillion gross domestic product). Newfangled curiosities in 1975, intensive care units and CT scanners and emergency medical ambulances are now ubiquitous. Today, there are more intensive care units than hospitals in the United States but their cost-effectiveness is not known. Seventy million CT scans are performed annually in the United States—all of them expensive and many of them unnecessary. (Worse, it is estimated that ionizing radiation from these CT scans will cause fifteen thousand to thirty thousand cancers annually—1 to 2 percent of all new cancers diagnosed.) Fifteen thousand American communities now employ 850,000 emergency medical personnel to staff what Hiatt called “prehospital rescue units.” No doubt these ambulance crews do fine work, but who is tracking their effectiveness and cost?

Since Hiatt’s time, the one person in the United States who has been “tracking” medicine most carefully—and, arguably, doing more than anyone else to protect the medical commons—is Jack Wennberg. Forty years after he started asking questions about the “culture” of medical practice in rural Vermont, Jack’s lifelong research has illuminated medical culture throughout the United States and around the world. His Dartmouth Atlas of Health Care chronicles the irrational variation, inequity, inefficiency, and potential for improvement of the U.S. health care system. Not incidentally, and largely due to Jack’s efforts, many fewer kids today undergo—or die from—unnecessary tonsillectomy.

But if you met Jack today on a mountaintop in Vermont, he would be the first to admit that Howard Hiatt’s urgent question—Who will take responsibility for protecting the medical commons?—remains unanswered. Neither the medical profession nor the politicians have done so. Is the “delivery” of health care in the United States today accessible and efficient? Does it provide a sense of security and continuity of care to all Americans? The national shortage of primary care physicians—the one doctor you and all Americans need—has reached unprecedented, crisis proportions. Countless sick patients are discharged from U.S. hospitals today without a follow-up appointment to see a doctor. Measles and other communicable diseases are on the rise due to spotty delivery of preventive health services. Perhaps naïvely, Howard Hiatt had hoped in 1975 that one day all Americans, when they need “enlightened advice” from a health care professional about an urgent medical concern, could just pick up a telephone “any time, day or night.” How many people today do you know who can do that?

Fred and Martha could.

•  •  •

Rivulets of melting snow crisscrossed the road as my car began the steep part of the climb. I knew every foot of this hill. In the summer and fall I cycled in the Vermont mountains. Sometimes, at day’s end, I would take a spin after work across the river and up this hill to the top where the paved road faded into a dirt path, centuries-old stone walls tumbling across a broad high meadow shaded here and there by copses of birch trees, their medallion leaves twittering green and gold in the evening breeze and urging me on, farther west into the sunset, and then down the back side of the high ridge, flying, heading for home. It was a special place—folks didn’t call this God’s country for nothing—and there at the peak of the hill stood Fred and Martha’s house. Sometimes Fred would be out walking when I passed—Martha didn’t get out much, the uneven ground hard on her arthritic knees and spine—and I would stop to say hello, panting and sweaty, and Fred would shake his head in his kind, avuncular way and say something dry about the folly of youth or offer an engineering suggestion about how to make my bike more aerodynamic and I would ask after Martha and then he would wave me on and wish me well and I would crest the hill past their house and spin across that glorious meadow into the western sky.

For me, the house at the top of this hill wasn’t just Fred and Martha’s place, it was part of a place I loved. During the long winter months, when I dreamed about summer—riding, with the wind at my back and the sun in my face and the river running fast far below—I would dream about the meadow at the top of this hill and there was Fred and Martha’s house, in my dreams.

It was a modern house, flat-roofed and glass-walled, very different from most of the houses in this old Vermont town. Its design was elegant but simple, a sprawling fifties-style split-level specially renovated with two things in mind: convenient, elder-friendly living—and the view. Oh, the view! In every direction: across the river far below, east to the sunrise and the Dartmouth bell tower; north to the White Mountains and the Presidential Range; west to the Green Mountains and the sunset; south across my dreamy high meadow and beyond to Mount Ascutney.

It was a house that said a lot about the people who lived there. Before I’d seen it, Martha had seemed to me like so many other local well-to-do women of a certain age. Impeccably dressed, punctual, and polite—even formal, notwithstanding her martini-dry wit and the mischievous sparkle in her eye—Martha had seemed the type who would greet her guests at the foot of an imposing center-hall staircase just off a chandeliered dining room filled with antiques in the traditional upper-crust Upper Valley way. But Martha’s house was wide-open Mies van der Rohe space with high ceilings, walls of windows, gleaming wood floors, Bauhaus décor. This all made more sense after I met Fred and learned about his accomplishments. But, as it turned out, the house had been Martha’s idea, and after my first house call there, I couldn’t help wondering about Martha, so attractive and youthful even in her seventies. She was more than twice my age and I didn’t remember ever having such thoughts about an elderly woman before. Fred and Martha were a captivating couple wherever they went, in any company, but, in their own house, they seemed one of a kind, enviable, youthful despite their years.

Near the top of the hill the ice had not yet begun to run. I parked my car just below, about fifty yards from the house, and climbed the rest of the way. The sky across the river was beginning to brighten, a penumbra of blue rising up out of the eastern hills. It was going to be a beautiful day—Colorado weather, warm and sunny but plenty of snow—a great day to go skiing with the kids. I looked at my watch. It was 6:30, still plenty of time to get us all out to the skiway for the first run of the day.

In the few minutes it took me to reach the house, the blue had risen still higher in the eastern sky. Or so it seemed; maybe it was just the extra elevation.

In the summertime, two Adirondack chairs sat together here in the front yard, facing southeast, sunflowers all around. I would have liked to eavesdrop on those summer conversations, just the two of them, their memories and their jokes. Now the yard was three feet deep in snow, the triangular tops of tall wooden plant protectors barely breaking through its surface. The stone walkway tunneled toward the front door, walls of white up to my waist on both sides. It had been shoveled but . . . not carefully, not well. A whole section near the front door hadn’t been shoveled at all.

This was odd. Fred was diligent about these things. He and Martha had lived in the north country for a long time now and knew the risks of winter, especially for old folks like themselves. As I approached, I wondered when they had last been out of the house.

The outdoor lamps along the walkway and above the front door were dark. This was odd, too. They knew I was coming. Looking closer now, I could see that the house was dark inside as well. The windows were enormous, the lengthening blue glow from the east reflected there. But I saw no lights inside.

What the hell . . . ?

I stepped over the snowbank at the front door and rang the bell.

No one answered. No lights switched on. Nothing.

I rang again.

Nothing.

I tried the door. It was unlocked. I stepped across the threshold into the foyer, my shoes caked with snow. It took a moment for my eyes to adjust to the dark.

Now, about twenty feet away, at the top of the two stairs that separated the living room from the foyer, I saw a white shadow, hovering.

Martha . . . ?

She didn’t move. She didn’t speak.

Martha, what . . . ?

She wore a long white robe over her nightgown. She held her cane in her right hand. With her left hand she made a gesture as if to wave me away.

I came closer.

What is it? Are you all right?

I could see her face now. She looked me straight in the eye, as she always did, but I wasn’t sure she knew who I was. I saw in her gaze no sign of recognition or greeting. She was staring at me. But I wasn’t sure she was seeing me.

It’s Brendan, Martha.

She didn’t speak. She tilted her head to the left with a weary, fed-up, what-can-you-do look on her face.

Immediately, I felt relieved. I had seen this expression many times before—whenever Martha would comment sarcastically about some hapless politician or an annoying side effect of one of her many medications. Good, I thought. This is Martha, not some shell of herself, suddenly impaired.

What . . . ?

She touched her hand to her lips. But still she said nothing. Then she made that motion again, a dismissive shooing motion that said something like Look-at-that-nonsense-over-there or What-more-is-there-to-say?

I don’t understand . . .

She shooed me again: there, over there . . .

I looked where she pointed. The large open living room was empty. A corridor farther left led to the north wing of the house.

I walked down the corridor. Its walls were lined with family portraits and parchment copies of some of Fred’s patents. Photographs of vintage airplanes and Kitty Hawk. Pictures of Fred smiling chummily with Harry Truman, Charles Lindbergh, Robert McNamara.

The door to the library was open. Sitting at his typewriter, an old black Underwood, Fred was dressed in a handsome green shirt and pressed khakis. His moccasined feet perched confidently atop the surface of his desk. His head leaned back against the chair as he looked out the big window toward the dawn. How long and languid his legs were. How contented he seemed.

Looking out the window, he hadn’t turned to me yet. But I could tell he knew I was there. And his confident posture alone spoke volumes: Fred was sure he was right, whatever he and Martha had been squabbling about this time. His show of confidence made me doubt my own. What if he won’t listen to me? What will I do then?

I braced myself for a difficult conversation.

Fred . . .

He didn’t turn to me right away. Like his posture, this seemed intentional, a silent statement of control.

Fred, look . . . What’s this about? Let’s talk about it.

His eyes were closed. He seemed to be deliberating carefully about how best to begin, how to answer my question, how to stake out his own position on the matter. I was prepared for some of the same things I’d heard him say before, something about simple questions often being the most difficult ones, or about long marriages, or the challenges of old age that most people don’t like to talk about. But he didn’t. He didn’t say any of those things. He had a smug little smile on his face like he knew a secret no one else knew. I looked at the typewriter in front of him but there was just a single blank page staring back at me and I don’t remember which thing I knew first, the fact that he was dead or the fact of how he had died, because at the same time I saw that smile on his face and braced myself for whatever he would say I also saw how awkwardly his right arm was dangling down toward the floor where the gun lay on the carpet just below his limp outstretched fingers. It was a peculiar-looking thing—it might have been a piece of sculpture or a paperweight, something other than what it was, an antique German Luger with a tapered barrel and an elegant curved handle.

I couldn’t see a wound. His clothes were pristine, no bloodstain spreading across his chest or abdomen. His face was unmarked.

Suddenly afraid, I looked quickly around the room, half expecting to see someone else there, lurking.

I don’t know why I noticed it so quickly, such a small inconspicuous spot, no bigger than a pencil eraser. The cream-colored wallpaper was otherwise perfect, maybe that was why I saw it, and after I inspected it I knew where Fred’s wound would be. The wallpaper had lifted up around the bullet hole and the paper’s torn white edges were red and gray. Up close, the red was flat, the bloodstain still wet. But there was substance to the gray—clusters of tiny gelatinous globules, glistening like undercooked risotto, with pink striations of cerebral capillaries running through them. A few other lobules of gray matter were spattered on the wall nearby—they were sticky, not dripping—and as I turned back to Fred I traced the line from the wall to his head where the wound had to be. His hair was fashionably long and thick on the sides and even though it was snow white, still I had to tease it away to see the exit wound above his left ear. There was very little blood, just a small patch of red congealing against his pink scalp. The entry wound was in the same spot on the other side, just above his right ear. He couldn’t have done it more cleanly if he’d used a stereotactic device, the kind neurosurgeons use to make sure they drill into the cranium in just the right place.

It was perfect: mission accomplished; minimal mess. And, judging from that little smile on his face, Fred knew it.

I don’t remember much about the rest of that day. Martha’s knees and back were hurting badly but still she couldn’t sit down. She just stood there in the living room until the sheriff arrived. Norwich was a small town but the sheriff had been around for a while and he looked like he knew what he was doing. He asked Martha terse questions and let her talk, never interrupting but watching her closely as he listened. Occasionally he asked for clarification about this or that, as if he had his own version of what had happened—or maybe more than one version—and he was testing it against Martha’s. She told him today was the day Fred was scheduled to be admitted to the mental health center for a few days of inpatient observation because he’d been acting so strangely lately. But these last few days he’s been fine, she said, better than fine, really, he’s been reminiscing about the kids and the old days and things we haven’t talked about in a long time. He’s been very affectionate, even frisky—that’s the word Martha used, “frisky”—and she didn’t bat an eye when she told the sheriff that she and Fred had made love the night before, something they hadn’t done since she didn’t know when. Fred got up early like he always did but this time he kissed her before he left the bedroom, and that was unusual, too, she said. She didn’t make anything of it until she heard the single sharp sound from down the corridor a few minutes later.

The sheriff asked me if I’d touched anything—the gun, the typewriter, Fred—and I told him what I remembered. He looked at me funny when I told him I didn’t know Fred was scheduled to be admitted to the inpatient Psych unit today. He wanted to know how that could be: You’re his doctor, aren’t you? I told him about the phone calls and the referral to Dr. Armour and how she must have arranged it but still he thought it strange that I didn’t even know about it and he made a note of this on his writing pad. He called the coroner’s office and arranged for the medical examiner to come pick up the body. Autopsies were required, he told us, in all cases like this. I wasn’t sure what like this meant but when he said it to Martha he watched her reaction carefully and he seemed to do the same with me.

Martha didn’t cry. Even after her daughter arrived and became hysterical in the library, Martha didn’t cry. She just took her daughter in her arms and looked at me. I don’t remember what I said to them. I stayed for a while longer, I don’t remember how long. I called Katherine Armour, the psychiatrist. Then I just sat there in the living room thinking about what the sheriff had said. I didn’t know what else to do.

When I left Martha and her daughter to drive home that day, all I could think of was a lecture given by Milton Helperin, the famous medical examiner in New York City, who had taught a class about autopsies in my second year of medical school. He told us a story about a Mafia assassin who had dropped dead on the stoop outside his mother’s brownstone in Little Italy as he left the building after visiting her. He was a young guy with a lot of enemies, not the type who just keels over for no good reason on a sunny day. But after they had examined his heart and aorta and other internal organs, the pathologists doing his autopsy didn’t have a clue what had killed him until they looked more carefully at the top of his skull. There, clean as a whistle, was the small hole where the bullet had entered his cranium and traveled straight down through his brainstem and spinal cord. Whoever had offed the guy from the rooftop of that brownstone—five floors directly above the stoop where the guy had been standing—knew what he was doing.

That’s what I remember best about the rest of that day. I don’t remember whether Janice had given up and taken the kids skiing without me, or whether I went with them. And I don’t remember anything about the rest of my week vacation or how soon the weather turned frigid again. But I couldn’t stop thinking about how clearly Fred had known what he was doing, how carefully he had planned it. Martha’s daughter told the sheriff about the gun. Fred’s father had brought it back from Germany as a souvenir after the armistice in 1919. Fred restored it himself, several years ago, in his machine shop. He wanted to make sure it worked, he had explained. He told Martha and his children that if he ever started to lose his marbles, the old Luger would solve that problem nicely. They all thought this was just talk, Fred’s way of making philosophical banter. I hadn’t known a damned thing about it.

So, for the next few weeks, this was why I blamed myself—for not knowing what Fred had said about his marbles and his gun—especially when his behavior and personality had changed so inexplicably. I should have asked. This was a no-brainer, Psychiatry 101: Have you thought about killing yourself? Have you made a plan? Do you know how you would actually do it?

Who knew what would have happened to Fred if it had gone the other way, if he’d made it into the hospital Psych unit that morning? Something bad was happening—major depression, incipient dementia, something. And whatever it was, Fred was losing his marbles, something he flat-out didn’t want to live with. So I felt guilty about not doing my part better—and I vowed I would never let it happen again—but I didn’t blame myself for Fred’s death. He was the one who pulled the trigger.

So, I got on with my life.

That was the plan, anyway.