Eight

“Dr. Martin.”

“Dean Thomas, what a pleasant coincidence.”

Lyle Martin nodded with a tight smile and kept up the slick steps at a trot, passing by the pantsuited woman under the umbrella.

“Dr. Martin,” Dean Jane Thomas called after him. Mix of plaintive and displeased. A tone no one likes to hear but she clearly liked to use. Next to her stood a man in a purple-checked gingham shirt and a blue suit a quarter size too small, the fabric tugging at his back and shoulders. The dean, exhaling audibly, walked after Lyle. In her non-umbrella hand, a phone cocked like a weapon. “I need to talk to you.”

“You know I cherish our meetings,” Lyle said without turning. “I’ve got lecture.”

“It started ten minutes ago, Dr. Martin.”

Now, reaching the tall glass doors of Genentech Hall, he turned. He looked at her, then the man in the suit, seemed to consider saying something about the dean’s cheap shot, half smiled, and turned back to the door. On the other side, Lyle’s assistant held a gray cardboard coffee tray, watching the scene unfold. “It’s cold,” she said to Lyle. “They’re lining up outside.”

“Lyle!” Dean Thomas called.

“Emily, can you arrange for me to chat with the dean,” Lyle said, taking the coffee too briskly, a wave spilling over the side and cascading onto the beach of his tan sweater. This completed the picture, the contrast between Dr. Martin, hair matted by sleep and drizzle, and the majesty of the nearly half-million square feet of marble and glass science hall at the University of California, San Francisco medical school. One of the world’s gems.

“Let this be a lesson to you, Emily. If you’re late for class, the dean will show up brandishing an umbrella.”

“I think she’s here for a different reason,” the young lady said, and then, realizing that Lyle knew that, reddened, a look that measured on the dial beyond humiliation and well into schoolgirl crush.

At the door, the dean lowered her chin, shook her head.

“You warned me,” said the man in the suit. His firm tone was a touch undone by the singsong of a southern Tanzanian accent, the mixed influence of Swahili, Portuguese, and military training. Hand at his side, he involuntarily made a fist and then unclenched it. “How long is this class?”

“Asshole,” the dean muttered, referring to Lyle, and followed the scientist and his intern. She had given up on catching him. She turned to the man. “Michael, I think I’d like to hook you up with Dr. Sanchez instead. She’s not . . .”

“An asshole?” Michael said.

The dean, in spite of herself, laughed bitterly. “Dr. Martin is not . . . He’s, how do I describe it?”

“Someone who drinks himself to sleep?”

This paused the dean in her tracks. “Actually, I don’t think so—the drinking part. I’m not sure where you got that information.”

“In any case, my government is not negotiable on this one. He’s the best and it’s got to be him. And soon. How do you say it: yesterday? This can’t get across the border.” Michael paused. “Or into the news.”

 

Half a hallway away, wet shoes squeaking on smudgy tile, Lyle arrived at the auditorium entrance. “Good morning,” he said to the handful of students standing outside. “I’m sorry I’m late. I wrestled my alarm clock to the death, and I won.”

It got an adoring laugh that Lyle didn’t seem to be asking for, or even particularly notice. “Dr. Martin,” called a med student in the clump, clutching a biology tome to his chest. “Will you hold office hours today?”

“He’s got an hour scheduled,” responded Emily.

She trailed him through the wooden doors of the spacious auditorium, clamoring with small talk, clacking of keys on gadgets, and, as Lyle made his way down the aisle, the brushing of backs on chairs. A capacity crowd filled the 268 seats, with a handful of others plopped on the ground in front of the stage. The popularity of these twice monthly lectures owed in no small part to Lyle’s little rivaled capacity for mixing war story with substance. Some academics come off like orchestra conductors, prim and distant, others like the Beatles, brilliant but singular and unapproachable. Lyle more like Keith Richards, an everyman with serious licks. Or maybe a thirty something, Harrison Ford, the disheveled version, but hunting for disease and not treasure. The kind of things students loved—but some colleagues resented because it didn’t fit their scholarly mold.

“If it makes them feel any better, you’re totally inaccessible emotionally,” Melanie had told him in the previous night’s version of toe to toe.

No response from Lyle on that.

“At the risk of repeating myself, you weren’t always like this, Peño.” That was her nickname for Lyle, “Peño,” short for Jalapeño, reflecting the sizzle nature of their relationship the first few years.

Lyle hiked the four stairs on the right side, strode to the podium, looked up and then . . . full stop. He gazed out at the audience, now come almost fully to attention, and he seemed to have lost all momentum. Many onlookers assumed he was centering himself, and the place. The ones near the front of the room, though, they wondered if it was something else. Were those tears in Lyle’s eyes?

It crystallized into such a particular moment that it was impossible to ignore the pop when someone near the left side of the auditorium broke a gum bubble. This yanked Lyle back from wherever he was visiting in his mind. He cleared his throat, reached into his back pocket, and pulled out notes. Unfolded them onto the lectern.

“Where were we?” His voice projected over the microphone. A piercing screech followed from the microphone. Lyle tapped it, and the interference receded. He glanced at his notes.

From the audience, a woman shouted, “Saudi Arabia!” The voice rang just at the same moment Emily was saying the same thing—“Saudi Arabia”—from behind the curtain to Lyle’s left.

“Saudi Arabia,” Lyle said. “That’s right. Hickam’s dictum.”

He looked up.

“Hickam’s dictum,” he repeated. “We’ve talked about Occam’s razor.”

Occam’s razor, a key principle in medicine, says that when there are competing theories to explain a medical condition, the doctor should favor the simpler one. Or, as Sir Isaac Newton restated the fourteenth-century logic: “We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances.”

Lyle glanced at the group. “It can be tempting to look for complex causes and diagnosis. But that often is a form of self-deception, the seeds of imagination, vain hope. Often, things are just as simple as they might appear, much as we are inclined to dupe ourselves.”

Again, he paused, something odd. Where exactly was he going with this?

Dr. Martin, Emily mouthed inaudibly, wishing she could whisper in his ear.

The silent admonition seemed to make its way to him through the ether, or maybe he realized he was getting off track. “As a clinician, it is not necessary to overcomplicate things, Occam’s razor. Much as we’d like to discover something extraordinary, it’s usually, I’m sorry to say, just a head cold.” Some laughter. “Bed rest and fluids will do the trick.

“But then, along came Dr. John Hickam. He gave us permission to get our money’s worth out of medical school.” Lyle explained that Hickam’s principle allows that multiple symptoms often can be explained only by multiple diagnoses—not just a single disease or pathology but, in fact, several. This comes into play, in particular, when you have a patient with a compromised immune system.

Lyle scanned the auditorium. “There’s a great phrase to describe Dr. Hickam’s dictum. It goes like this: the patient may have as many diagnoses as he damn well pleases.” Laughter. “Which brings us to Saudi Arabia.” He told them previously that he’d done some early training in the Epidemiology Outbreak Office for the Centers for Disease Control. After doing a stint like that, the government would occasionally ask Lyle, or others in the program, to visit a place or person in need of a specialized medical consult.

“A guy in the State Department called and asked me if I’d go visit a government minister in Riyadh,” Lyle told the audience. He said the State Department officer told him that the guy had MERS and wasn’t responding to treatment. First class ticket, three-day turnaround, Lyle could stay at a palace.

Lyle seemed not to notice how much he had his audience rapt. He did, though, notice the dean, standing in the aisle near the back, and, more than her, he noticed the man next to her, wearing the too-tight suit. The man stood solidly, not rocking back and forth impatiently like the dean, watching Lyle, studying him.

“I’m sure you’ve read up on MERS,” Lyle addressed the students. “But as a refresher . . .” He told them about Middle East respiratory syndrome coronavirus. It reared its head in 2012 in Saudi Arabia, thought to originate in camels. Symptoms include severe cough, gastrointestinal issues, kidney failure. It can be fatal. Lyle flew to King Khalid airport in Riyadh, got whisked past to a midlevel palace and an opulent bedroom turned medical suite with a man in his seventies prone in a gold-posted bed under a canopy. The minister.

Next to the bed stood a bodyguard in telltale fatigues, and a nurse with ice for the old man’s lips and, cross-armed, his doctor, looking grave. The doctor gave Lyle an update: a CT scan showed a nodule on the lung, consistent with a MERS diagnosis, diarrhea, mostly consistent with it, and also stiff neck, light sensitivity, bouts of confusion.

“What’s lesson number one?” Lyle asked his audience.

Voices from the audience in dystonic harmony: “Take a history.”

So much of infectious disease diagnosis comes from taking a careful patient history. That was the thing Lyle told this class, and every class, on day one. Get a pet history, food history, sexual history, ancient history, and new history. Frontline doctors, in the emergency room or even at clinic, can see symptoms consistent with a pathology, make a fairly reached conclusion about diagnosis but one that is at odds with history.

“I pulled up a chair next to the minister. People need to feel you are the same level that they are on. Never forget the power of your white coat to unnerve; there’s almost nothing you can do to diminish it. So find the humblest place you can. The less arrogance you communicate, the more likely that most patients will share a real history with you. In the case of the minister, the second that I sat down, he dismissed everyone in the room with a wave of his hand. The bodyguard didn’t move and then the minister swatted him out as well.” Lyle then explained that he had asked the minister basic questions to establish a baseline of communication and gauge cognition. How old was he (seventy-one); where was he born (outside Medina); what was he a minster of (domestic police); did he have a family (yes, wife, two sons, and a daughter); did he have much interaction with animals (no); what was his diet like?

“Are you a doctor?” the minister asked Lyle.

“Yes.”

“Then get on with the doctoring,” the man said. He had a white beard and he had been heavy once. Sleeplessness tore at his eyes and left cracked skin at each corner of his mouth. Fear and inner ugliness trickled out in his voice, the sound of a powerful person unaccustomed to feeling helpless.

“The minister’s comment that I should get on with the doctoring was an important moment,” Lyle explained to the students. “It told me that this might be one of those people who actually preferred me to be in a position of authority, rather than one of mere expertise. I don’t want to make more of bedside style than necessary, but I also want to tell you how essential the role of listening, really listening, is. In this case, he was telling me I didn’t need to be so humble after all.” He paused. “So I could just go ahead and be the arrogant jerk my wife tells me that I am.”

There was a smattering of laughter but not so much. Lyle continued with the story. Next to the minister’s bed, Lyle cleared his throat.

“May I examine you?”

The man struggled to pull himself up on his bed.

“Just turn over,” Lyle told him. “Please, pull off your shirt.”

The minister removed the body-length nightshirt, his back exposed. Lyle ran his hand along wrinkled skin over depleted back muscles. He spent some time moving the skin around on the man’s neck.

“Right-handed, played a sport. You have slightly more developed muscles and scar tissue on the right.”

“Hound hunting.”

“You’ve had some hearing loss.”

“Yes.”

“Did the hunting cause your hearing loss?”

“No. How can you tell about my hearing?”

“Small mark on the skin around your ear. Sometimes, that area can get itchy if the nerves get irritated from a hearing aid. Behaves like dry skin.”

“My hearing loss is a state secret. I have to pretend I’m listening to the king.”

“Of course. Doctor/client privilege. How long have you been married?”

“Sixty-one years.” The minister was starting to relax. That was the goal. Yes, Lyle was looking for any unusual external markings, bites or lesions, signs of infection. Mostly, he was getting the man to relax. This was a veritable backrub.

“You are monogamous—with your wife?”

“The only woman for sixty-one years.”

An hour later, Lyle had been over the man head to toe. He’d looked at the chart, read the CT scan. He’d looked in the man’s eyes, causing the minister to recoil, confirming the light sensitivity. He cocked his head back and forth, like a metronome, lost in rhythmic thought.

Back in the auditorium at UCSF, the audience hung on his story, much like Lyle had the minister caught up in the examination. It had been an act of trust building.

“I explained to the minister that I thought we needed one more test,” Lyle told his audience of med students. “Would anyone like to guess what that test was?”

Lots of looks down by students at their laps. Even in an audience this big, many students felt like they’d not like to let down Dr. Martin with a flier, a wrong guess. From the back, a hand rose.

“Yes,” Lyle said. “No hands needed here. Just let ’er rip.”

“An MRI of his brain,” said a woman’s voice. “With contrast, I’d guess.”

“Very good.” Lyle nodded approvingly. “Just what I told the minister. Almost my exact words.”

The minister said, “Sure, yes. If you say so. What will that tell us, Dr. Martin?”

“The MRI is going to show us your brain. I suspect, strongly, it will show us a fungal infection. Crypto meningitis.”

“So that’s what I have? Meningitis?” The minister pushed himself up on his bed, his gown back on, his face strained with pain he struggled to hide.

“Yes and no.”

“Which is it: Yes or no?”

“The fungus is a by-product.”

“Of what? Of the MERS?”

Lyle felt it had gone on long enough. “I’d like to talk about your sexual history.”

“I told you already. I’m married.”

“And you’ve never been with another woman.”

“You are testing me?”

“You’ve been with a man.”

“Excuse me?”

“I believe you’ve got HIV, on top of MERS. It would be simple enough to give you an HIV test to prove it. But I bet your doctor wouldn’t even allow himself to think about such a test. It would insult you and even be dangerous. I hear they flog people here for that sort of behavior.”

“What sort of behavior.”

“Homosexual.”

“I flog people for that sort of behavior.”

“Well, Minister, I think you’re going to want to change your policy or your own practices.”

“You’re a quack!” His words exploded in a hacking cough. He doubled over.

“Minister, let me add it up for you. You haven’t responded fully to MERS treatment. You’ve got cognition issues and light sensitivity. Pronounced stomach issues, a lung nodule. All of that says to me that your immune system is compromised. On top of that, you sent your people out of the room when it was time to talk to me—”

“So.”

“Maybe nothing. Maybe that you wanted privacy. And I can see why, given the marks.”

“What marks?”

“You’ve got several areas of light purple skin on the back of your neck.”

“I’m getting older. It’s my skin.”

“You know the term quack, Minister, so I’m guessing you are also familiar with the term ‘hickey’?”

The minister glared at him. “This is a joke. Are you the best that the United States has to offer me?”

“I’m definitely not the best. But I have had my share of hickeys, and I’ve given a few too. I know what they look like. And I have seen my share of men die terrible deaths from HIV. Most of them contracted it through sex with other men.”

The minister clenched his jaw, now seemingly to calculate.

Back in the auditorium, Lyle leaned on the lectern. “Nothing special about the diagnosis. In fact, I suspect his personal doctor knew what it was and was looking for someone from the outside to take the fall. In the end, they left the official diagnosis as meningitis and gave the minister an antiviral cocktail that just happened to be the same thing they give for HIV.

“The minister died nine months ago. His condition wound up being widely speculated about. He also spent the last few years of his life intensifying his attacks on homosexual behavior. His rage at his own condition, his hypocrisy, amplified. I mention this, and the story, to impart a particular idea about pathologies, diseases. They are, in their own way, straightforward. They aim to kill an otherwise healthy body. They have a deadly agenda but they don’t hide it. Pathology is not duplicitous. It does not discriminate. It doesn’t choose. It is precisely what it represents itself to be. The same cannot always be said of people.”

At the edge of the stage, Emily, Lyle’s intern, tensed. Dr. Martin was out on that Dr. Martin ledge again, heading to parts unknown. In the back of the room, Dean Thomas had a similar but less generous version of the thought: The asshole is going to get rave reviews again, and for what, storytelling?

“Hickam’s dictum,” Lyle continued. “Patients can have as many diseases as they damn well please. Implicit in the phrasing is that people choose illness. This, of course, is utterly false on its face. They don’t choose. But they can reveal. Even inadvertently, often, in fact, inadvertently. I urge you, when you sit at the bedside, to think about the person, the individual. Consider his or her history, habits, as well as the larger context of culture, constituency, demographic. Think about what makes a person tick. What separates a good doctor from a great doctor, in my opinion, happens outside the pages of the book.”

In the back of the room, the man in the too-tight suit smiled. He thought, Dr. Martin is brilliant, just as advertised.

“Dr. Martin,” Emily called quietly. He turned to the side. She pointed to her watch. He nodded and turned back to the stage.

“Having said all that about going beyond the book, I’d like if everyone could read the next three chapters of infectious disease principles and practices. If there are any questions, I think we’ve got some office hours set up in the lounge.” A smattering of applause accompanied the sound of students standing, packing up, hustling on. Lyle could feel his heart working double time with the pulse of dehydration and still metabolizing sleep drugs, and from stress toxins left over from his fight with Melanie. He let his eyes wander to the dean and her guest. Whatever they wanted to talk to him about, he’d seen enough to know. Someone was dying.