10

A few minutes later, as Sam waited, I walked down the hall to an office labeled PIC. Inside the room, a fifty-something man with a page-boy haircut was reading the latest issue of The Journal of the American Medical Association.

“Hello,” I said softly, “I’m one of the new interns.”

He put down the journal and looked up at me, beaming. “Welcome!” he said. “Please take a seat.” The PIC, whose name was Moranis, was wearing khakis and a blue Ralph Lauren button-down with a red tie, the unofficial uniform of an academic physician.

“I want to apologize for running late. My first patient is a bit complicated.”

Moranis shook his head. “Never begin any presentation with an apology. It’s your first day in primary care,” he said, quickly blinking his sea-green eyes, “and they’re all complicated.”

I took out my notebook. “Where should I begin?”

“You tell me. I’m just here for guidance.”

I gazed down at the sun-faded notebook—a tempest of composition—and felt unsteady. “Well, I made a problem list.”

“Good way to start. What’s at the top of the list?” It was clear he’d been coaching young physicians for years, and I felt a bit more at ease. But that might’ve been just because I was no longer dealing face-to-face with a patient.

“Top of the list is high blood pressure,” I said. “His blood pressure is a bit elevated today.”

“Is he on a diuretic?”

I scanned the medication list looking for Lasix—the only diuretic I could think of. A day earlier, I’d mentioned on rounds that Lasix gets its name from its duration—“(la)sts (six) hours.” Baio had one-upped me, detailing the way Lasix found its way into horseracing after it was noted to prevent horses from bleeding through the nostrils during races. Hence the term “piss like a racehorse.”

“No Lasix,” I said. “But he is on a bunch of other medications.”

“Is he on hydrochlorothiazide? And do you know why I ask?”

“No. And no.”

“Several years ago a large trial called ALLHAT showed that patients with high blood pressure should be started on a thiazide diuretic if single therapy is being initiated and another medication is not indicated.”

“Gotcha.” I quickly wrote down ALLHAT.

“However, you said this patient is complicated, so a different medication may be indicated. Perhaps Lisinopril if he has kidney…”

I tried to transcribe his thoughts but couldn’t keep up.

“…However, if he has heart disease a beta-blocker may be indicated.”

How would I ever remember all of this? Did I have to go back and explain it to Sam? Maybe this was why the previous physician hadn’t told Sam he had kidney disease—because it was just too complicated to explain.

As the waiting room continued to fill up, Moranis went through each of the issues on the problem list and explained the rationale behind each diagnosis and treatment. Despite the boyish haircut, he had the unmistakable patina of age and authority, and he spoke with a kind of joyfulness as he turned over each piece of information to examine the possibilities as they related to Sam. I tried to absorb it all but caught myself zoning out, watching his lips move while wondering if a lifetime spent memorizing journal articles and acronyms would turn me into someone like him. Someone who seemed to know more about my patient than I did without ever having examined him. Or would I become a creature so consumed by minutiae that I’d be incapable of interacting with patients on even the most basic level? Would it all just become a tangled skein of factoids?

“Let’s go see your guy,” he said finally, rising to his feet. “The best part.”

When Moranis stood up, I realized that I could rest my chin on his head. This man whom I found so intellectually imposing was nearly a foot shorter than I was. As we walked back down the hall, I noticed that his eyes sparkled a bit the way Baio’s did. I was with yet another doctor who felt squarely in his element. Would I really ever get to the point where any of this might seem pleasurable?

“This is my boss,” I said to Sam as we reentered my office, “the physician-in-charge.”

“Sam,” he said, extending his right hand. “Your liege was just telling me all the things that are wrong with me.”

Moranis turned his head toward me and frowned. “I understand you two covered a lot of ground.”

“Dr. McCarthy mentioned that I have more than fifteen problems. Never thought of myself like that, but I guess it’s good to be aware of it all.”

“Let me offer an alternate hypothesis,” Moranis said, holding up an index finger like his kid-shrinking namesake, as if about to introduce a tween-condensing laser beam. “You were told you had high blood pressure at a young age.”

Sam wrinkled his brow, and Moranis nodded gently.

“Perhaps. That sounds right,” he said.

“And I’ll bet you were offered a medication for it.”

“I don’t remember, honestly.”

“And you didn’t take that medicine.”

Sam flashed a mirthless grin. “You’re right about that. I didn’t take anything until I turned fifty. And then it apparently all went to shit.”

“Your untreated high blood pressure led to kidney disease, which further exacerbated your hypertension. This, in turn led to heart disease.” Moranis glanced at his belt and silenced his pager. “The heart disease,” he continued, “led to liver disease, which in turn contributed to your erectile dysfunction. And the erectile dysfunction contributed to your insomnia.”

“Great,” Sam said, “so what’s the answer? Treat the blood pressure and it’ll all go away?”

Moranis held his finger up to his lips so he could listen to Sam’s heart and lungs with his stethoscope.

“It’s not that simple,” I said, eager to contribute. “These are all chronic conditions that will likely need to be managed, not cured.”

My pager went off, and Sam covered his eyes with his right hand. “You know it seems like I see a different doctor every time I’m here. Every few months I start from scratch with someone. Can you be my permanent doctor?”

We had made a small connection. “Of course I can be your permanent doctor. I’m here for the next—”

“No,” Sam said, motioning toward Moranis, “him.”

Moranis removed the stethoscope from his ears and moved toward the door. “We’re a team here. You’re in good hands. It was a pleasure to meet you.”

“There’s one other thing I didn’t mention to your boss,” Sam said meekly once we were alone. “I guess I was embarrassed. But I ran out of Viagra a few weeks ago and was wondering if I could get a refill.”

The Viagra commercial popped in my head—an attractive baby boomer sailing on a lake—with the voice-over “Do not take Viagra if you take nitrates for chest pain.”

“Do you take nitrates for chest pain?” I asked.

“You tell me, Doc.”

I scanned his medication list. “No.” I imagined Sam trying in vain to get an erection. “Of course, I can get you a refill.”

We wrapped up our session a few minutes later. On my way to give paperwork to the receptionist, I stuck my head into Moranis’s office.

“Thank you,” I said, “for that. All of it.”

“It’s why I’m here.”

“Well, thank you.”

“Meant to ask,” Moranis said, putting down his journal. “Did you notice that he’d been incarcerated?”

I was shocked. “Uh, can’t say that I did. I suppose I got caught up in—”

“Quick tip. You can’t just go through the most recent notes to understand your new patients.” Moranis must’ve combed through the older notes while I was examining Sam. But there were dozens of notes in the chart. How did he know which ones to read?

I considered Sam, the adorable sheepdog. “Did you ask him why he was in jail? Did I miss that?”

A smile crept onto Moranis’s face. “Why do you think?”

“I guess I’d be curious.”

“Why?”

“I don’t know—if he was a pedophile or serial killer or something?”

“Why?”

“You’re asking me why it would matter if he’s a sex offender? Or a wife beater?”

“Sure. Would that change anything about the way you treated him?”

The question sent my mind back to Boston three years before, to a seminar I once took at Harvard. One afternoon per week, a small group of students would get together to discuss prejudices in and out of medicine in a course called Emerging a Culturally Competent Physician. At the end of the seminar, we were asked to divulge one prejudice to the group.

“I think fat people are lazy, sometimes,” a young woman said.

“When I hear a Southern accent, I kinda think the person might not be too bright,” said another.

We continued in this manner until we reached Ben, an aspiring trauma surgeon like Axel, who was gently shaking his head.

“Frankly, I think we should all cut the bullshit,” he said.

The professor raised an eyebrow. Ben possessed a swagger not seen elsewhere on campus; his was an intelligence we would never quite understand or possess. And he was one of Charlie McCabe’s favorites.

“I think it’s great that we’re all sharing today,” Ben continued. “I am friends with Matt,” he said, pointing in my direction. “I like him and I look forward to hearing about his prejudices. And there’s no doubt Matt here thinks fat people are lazy.”

Heads spun toward me; I was mortified. I shook my head and mouthed “no.”

“But I also have no doubt Matt would care for a fat person the same as anyone else.”

I enthusiastically nodded.

“So who cares?” Ben said. “I’m more interested in the…the bad people in this world. What about a child molester? Should I operate? Should I try my damnedest to save the life of a monster?”

“Well,” a petite future surgeon named Marjorie said, “I think we all bring certain values to the table that are inescapable. I know I won’t treat every single person exactly the same.”

“Oh?” Ben said.

“I…” She glanced down at her desk. “I couldn’t treat a Muslim, for example.”

Her Orthodox Judaism was no secret to the class.

Ben smiled. “Go on.”

“But I know enough not to put myself in that position,” Marjorie continued. “I would recuse myself.”

“And what if you don’t have that luxury?” Ben asked. “What if you’re in a small hospital and you’re the only surgeon?”

“I wouldn’t let that happen.”

“We’re being trained to put people back together again,” Ben said, scanning the members of the room. “We’re not here to be a judge. Or to be a jury.”

Marjorie shook her head. “I am just being honest.”

“But perhaps,” Ben said lightly, pointing an index finger at Marjorie, “perhaps an executioner.”

“That’s not fair, Ben. As I said, I was just being honest.”

“I’m gonna go out on a limb,” he continued, “and suggest you weren’t this honest in your med school interviews.” She did not answer. Ben turned to me. “Somehow, Matt, I bet it didn’t come up.”

I took a step toward Moranis and said tepidly, “Do you know why Sam was in prison?”

“I do.”

“And?”

“It’s in the chart.”

“I might take a look.”

“Feel free.”

“I also wanted to mention that after you stepped out, he asked me to refill his Viagra. Didn’t see any reason not to. I think he was a little embarrassed to bring it—”

“Sam was convicted of sexual assault eleven years ago.”

I took a step back. What I knew about Sam after an hour in his file was almost nothing. But there was no way to discuss his personal life when I was still trying to wrap my head around the acronyms that spelled out his medical history. What if Sam was convicted of a crime, served his time, and was now married with a family? Or what if he was a monster?

“So,” I said softly, “should I not refill the Viagra?”

Moranis smiled. “That’s your call. He’s your patient. I’m just here for guidance.”

“Right. So…”

“So.”

“How would you guide me?”

He stood up, put an arm on my shoulder, and said, “I would advise you to think about it and make the decision on your own.”

I hung my head. This scenario must’ve come up before. What was the right answer? Was there a right answer? Why wasn’t it all as simple as “Don’t give the sex offender hard-on pills” or “Hey, that was a long time ago, of course it’s probably fine”? And in any case, how could I be expected to make snap judgments on moral questions that might take days to sort through when I couldn’t even manage to keep track of the patient’s symphony of actual medical ailments, the stuff he truly needed me to be on top of?

I opened my mouth, but Moranis cut me off.

“The waiting room is filling up,” he said. “You better get moving.”