5 The Power of Her Fragility

nothing which we are to perceive in this world equals

the power of your intense fragility: whose texture

compels me with the colour of its countries,

rendering death and forever with each breathing

—e e cummings, “somewhere i have never traveled, gladly beyond,” 1959

“I’m warning you Anthony, cool it!” A woman’s voice.

“Listen to your mother, Anthony!” Deeper, a man’s voice.

I paused, my hand raised to knock on the exam room door, on my way to see Ms. Badway in the new cancer building. A couple of weeks had passed since she was discharged from the hospital, and I had already heard from her outpatient nurse, Jackie, that she had filled her prescription for the imatinib and had been seen in the high-risk OB clinic for what would become her weekly visits there.

The dynamic in the exam room sounded like one that might have emanated from any of my own family’s outings. I knocked and entered.

Ms. Badway was walking to the trashcan to throw out some paper towels. A boy who looked to be about 4 years old, presumably the now-famous Anthony, was sitting on a stool across the room wearing a green shirt with the Hulk on it. He clutched a juice box. A couple of empty gummy bear packages were strewn nearby.

“Sorry doc, cleaning up a spill,” she said, shooting a look at the boy. “This is my son Anthony and Joe, my husband.”

Joe looked to be in his late 30s and wore loose jeans with a wine and gold Cavalier’s T-shirt that read “The Land.” He gave me a broad smile and a bone-crushing handshake, and then also shot a look over at his son.

“Anthony, what are you doin’? Get out of the doctor’s chair!”

It reminded me of the time my wife and I took my children to their doctor’s appointment, when my older son was 8 years old. As we waited for the doctor, he bopped around the exam room, as I’m sure Anthony had just been doing, while we sat in the available chairs. He suddenly stopped and looked around.

“Where can I sit?” my son asked.

I motioned to the doctor’s stool. “Why don’t you sit there?”

“I can’t,” he said. “That’s where the doctor sits.”

“Well, what do you think happens when I walk into a room to see my patients and someone is sitting on the doctor’s stool?”

His eyes widened as he imagined the catastrophic fallout from this extreme breakdown of the rules governing social etiquette in his father’s exam room. “I don’t know, what do you do?”

I shrugged my shoulders. “I sit somewhere else.”

I made my way to hop up on the exam table and told Anthony he could stay where he was. He opted instead to jump into his mother’s lap as she sat down in a chair near Joe.

“Anthony, Jesus, be careful of your mother’s stomach!” Joe barked at him. The kid couldn’t catch a break. I tried to imagine the stress they were under, with three children at home, one on the way, a bunch of new doctor’s appointments now added to their schedule, and the first time walking into a building that had the words “Cancer Center” on it.

“How’s it been going Ms. Badway?” I asked. She laughed.

“Mrs. Badway is Joe’s mother. Call me Sarah.” I make it a point to never call my patients by their first names unless invited, wanting to be respectful of those who prefer the formality of a professional relationship. Those are mostly my older patients, and some of them still came dressed to the nines for their doctor’s appointment. But I don’t make assumptions about my younger patients.

“Fine, good to be out of the hospital, though I miss the peace and quiet of that place,” Sarah continued.

“You doing okay with the pills?”

“Yeah, thank God we have insurance!” she answered, as Joe whistled.

“Wow, 12,000 bucks a month those cost! We only had a copay of $50. But 12,000 bucks? What do people do if they don’t have insurance?’ Joe marveled.

We had checked to make sure her insurance would cover the pills before she left the hospital. The cost of Gleevec, the brand name for imatinib, has risen steadily since it first came on the market in the United States in 2001. At that time, it was priced at around $2,500 per month. And while $30,000 per year isn’t cheap, it’s almost understandable given the exigencies of the time: although there was no competition for this miracle drug that made it unnecessary for most patients with CML to have bone marrow transplantation (a procedure that, all in, could run $500,000), there was some need to recoup research and development costs—both for imatinib, and for similar drugs that never made it to market.

What happened subsequently to its pricing, however, is unconscionable.

As with other specialty drugs, the cost of Gleevec rose at an approximate rate of 15 percent per year, and then skyrocketed to its current levels for the two years prior to the drug coming off patent, which occurred in 2015, and just afterward. This is a common practice among pharmaceutical companies, to squeeze every last ounce of profit from a drug before there is adequate competition from generic versions of the same drug. Another common practice is to stonewall the requests of generic drug companies to obtain brand drug samples from which they can develop a generic version.1

Celgene, which manufactures the drug lenalidomide, or Revlimid, to treat multiple myeloma and myelodysplastic syndromes, has been lambasted for this practice—and for increasing the price of lenalidomide 145 percent over time.2 Having to pay for the resources necessary to bring a drug to market might explain some pricing inflation at first, but that justification doesn’t hold much water a decade after the fact. After all, when you buy a Ford Focus, even years after its introduction to the marketplace, are you also paying for every version of a Ford car that never reached a showroom floor?

One estimate places the number of people in the United States living with CML at 30,000. At the initial pricing of imatinib, the annual revenue from sales would have been almost $900 million—more than enough to recoup research and development costs within two years. Yet the price continued to climb.

It should come as no surprise that other drugs in the same class of tyrosine kinase inhibitors (the second- and third-generation TKIs that followed imatinib) have been priced comparably, rendering moot any decision-making based on economic efficiency for drugs with similar efficacy and toxicities. Unfortunately, generic competition has not impacted that pricing as much as was anticipated.3

Groups of hematologist-oncologists (myself included) have protested these types of wanton pricing of cancer drugs, with one scientific publication authored by more than 100 of us decrying the average escalation in cancer drug prices of $8,500 per year over the first 15 years of the millennium.4 The drug cost for each additional year lived for a cancer patient, which was $54,000 in 1995, skyrocketed to $207,000 in 2013.

In other words, 18 years later cancer patients are paying almost four times as much to live one year more than they would have without chemotherapy. And on average, 20 to 30 percent of that cost is paid out of pocket by those same cancer patients.5

Until there is federal legislation to rein in drug costs (as is done in parts of Europe, where pricing is part of the regulatory approval process), it is unlikely that the industry will respond to even a large group of well-meaning physicians unless there are cheaper alternatives that work just as well with a similar side effect profile. Pricing reform of cancer drugs will require changes from FDA and government regulators, in legislation, patent laws, reimbursement approaches, drug purchasing practices, and insurance and pharmaceutical companies.6

At the end of the day, we still need to treat our cancer patients, and continue to prescribe expensive drugs while we grind our teeth at the individual and societal cost of doing so.

“There are some patient assistance programs that help out,” I told Joe. “And some patient organizations that will help with a limited amount of costs. Some folks even sign up for Medicaid to help cover their treatment.”

“But there are also people who still can’t afford their medicines,” Sarah said. I nodded as she and Joe shook their heads, as if incredulous that people in this country and in this day and age still had to forgo cancer treatment.

“Any side effects to the pills that you notice?” I asked her.

“I get a little nauseous, like during my first trimester, but that’s about it.” I suggested she take the imatinib with the biggest meal of the day, which often helps with the nausea.

“Have you missed any pills?” I followed up.

Before coming into the exam room, I had noticed that her white blood cell count had decreased from 330,000 to 248,000, and that her platelet count had come down a bit, from 470,000 to 420,000—an improvement from where she started, but not as much as I usually see after a couple of weeks of imatinib. Anthony had started to get restless and was banging a matchbox car on the desk that held the computer. Sarah held his arm steady and he started to squirm: Hulk strong.

“Only a couple,” she answered. Anthony slid down from her lap and was sitting on the floor. He seemed to be calculating his next move: Hulk free.

“How many is ‘a couple’?” I persisted.

“A few,” she said. That couldn’t have left many days in the past week when she did take them. “But it’s hard to remember, what, with everything else I have to do around the house.”

“You haven’t been taking your chemo?” Joe asked.

“Get off my back, Joe. How ’bout you do the laundry and I’ll take the chemo?”

When all of those people with CML were enrolled in those large studies that led to imatinib’s approval, in the years from 1998 to 2000, almost all had blood counts that returned to normal, and most had at least a reduction in the amount of Philadelphia chromosome that could be measured. Many even had complete elimination of the genetic abnormality.

Over time, some patients “lost their response”—their CML returned. A group of investigators from Belgium wondered what had happened, what could have caused this miracle drug to fail.7 So they designed a study that included more than 200 CML patients treated at 34 centers, and administered adherence questionnaires to both the patients and their doctors. A pill count was then performed to confirm questionnaire responses. Approximately one-third of patients were non-adherent for the 30 days prior to the study and for the 90-day study duration. Interestingly, of those who were non-adherent, most (71 percent) took less of the drug than they should have, but almost 15 percent took more—either through an honest misunderstanding of how much to take, or because of a belief that taking more would work better to eliminate the leukemia. Of those with suboptimal responses to imatinib, 23 percent reported missing doses of the drug, compared to 7 percent of those with optimal responses. Patients whose CML returned were significantly more likely to have missed doses than those who maintained their response to imatinib. And the likelihood that the CML returned increased with the more pills that were missed.

Medication adherence is a problem in any chronic medical condition. One study of more than 30,000 patients taking statin medications for high cholesterol estimated that only 43 percent were taking their pills as directed after six months.8 A study of almost 8,800 women taking hormonal therapies for breast cancer found that they were adherent only about 50 percent of the time.9

Another study conducted in the United Kingdom at Hammersmith Hospital provided 87 CML patients with pill bottles that contained their imatinib prescription, but didn’t tell patients that the investigators had installed a microelectronic monitoring system—a computer chip—in the bottle’s cap.10 The chip recorded every time the patient unscrewed the bottle to remove an imatinib tablet, thus measuring their medication adherence.

The results? Medication adherence was better among these dedicated patients, at almost 98 percent. Those with adherence rates less than 90 percent, however, were significantly less likely to achieve a remission than those with better adherence rates. To put this in perspective, as imatinib is a once-a-day pill, a person would only have to miss four pills per month—one per week—to compromise the chance of entering a remission.

Not surprisingly, when people like Sarah have busy lives that get busier, they are more likely to forget to take their imatinib. At one presentation at a medical conference in Chicago one of the study authors, Dr. Jane Apperley, showed a slide of one man’s adherence during December and January. As the frantic pace of the holidays approached, his pill taking fell off, and he missed multiple doses of imatinib. Then, starting January 2 (and probably as a result of a New Year’s resolution), his adherence improved markedly, and he became a model patient.

I’m terrible at remembering to take pills, so to me this is completely understandable. I have other CML patients, though, to whom such behavior is incomprehensible.

“Miss a dose?” they have responded when I ask the same question of them that I did of Sarah. “It’s cancer and this is my chemo. I would NEVER miss a dose!”

The problem—and it’s a good problem to have—is that people with CML who take a drug like imatinib and who have restoration of their blood counts start to feel so good, like they don’t have leukemia at all, that they forget that it’s the pill that’s making them feel so good, and then they start dropping doses. This is the same phenomenon that occurred among HIV-positive patients who started taking anti-retroviral medications, many of whom rose like Lazarus from the near dead.11 This happens particularly when people are on the medication for months, or even years.

Others stop taking their medication because they don’t like the daily reminder that they have cancer, and that this cancer could kill them if not for these pills. Call it denial, or the subconscious going rogue. Some people do have significant side effects and take matters into their own hands to avoid them.

And still others skip doses, or cut tablets in half, because they can’t afford the pills or their insurance copay. At $50, Sarah’s copay was not low enough to qualify as negligible, but it was not terribly high. Some patients have told me that their insurance companies disingenuously agreed to cover the $12,000 monthly cost of imatinib, as long as my patients agreed to the $8,000 monthly copay.

“It’s really hard to remember to take these pills, and everyone forgets some,” I reassured Sarah. Joe seemed to relax a bit. Anthony got up from the floor and started to roam around the room.

I explained the importance of sticking to her schedule, and methods she could put into place to help remind her to take her pills—setting a daily alarm on her phone, placing the pill bottle in a location she will see, even associating taking the pills with another daily activity, like brushing her teeth. Anthony threw his car against the wall. Hulk smash.

“Is it okay for her to keep the pregnancy with the chemo?” Joe asked.

I turned to Sarah. “Are you worried about birth defects? Is that maybe affecting how many of the pills you’re taking?” I knew we had discussed this in the hospital and that she had said that her health had to come first. But people can have second thoughts.

She stared down at her hands, clasped over the bump of her belly. “Maybe a little.”

“Sarah, you didn’t tell me that,” Joe said, almost tenderly.

It reminded me of a similar interaction I had with another patient who had CML, a man, in the same exam room.12 I had prescribed imatinib for him, too, but for some reason he hadn’t done as well as most on the drug. His blood counts never quite reached normal values, and his Philadelphia chromosome stubbornly persisted.

His wife became pregnant while he was taking imatinib, and she accompanied him to an appointment with me. When she told me she was pregnant, it was without joy, and she quickly added that she was considering getting an abortion. When I asked why, my patient jumped in.

“We’re worried about birth defects.”

I told them what I wound up repeating to Sarah and Joe. That a National Toxicology Program publication (from the National Institutes of Health) reported rates of major congenital malformation for women exposed to chemotherapy during their first trimester of pregnancy to be 14 percent, but only 3 percent for exposure during the second or third trimester.13 I tried to put these data in context of how difficult it is to determine, sometimes, if chemotherapy caused specific birth defects, given the background rate of 3 percent birth defects in the general population, according to the Centers for Disease Control and Prevention. Data on birth defects from men exposed to chemotherapy at the time of conception are even harder to come by.

My patient exhaled, relieved that the risk of birth defects in their unplanned pregnancy was low, despite his having taken the imatinib.

“That’s good news.” He smiled and held his wife’s hand. Her face remained troubled, though, with worry etching dark lines in her young forehead.

“But what happens if I have this baby and he’s not here to be its father?” She stared at me, unblinking, as tears streamed down her face. My patient stared across the room at neither of us, considering the brutal honestly of her question.

I acknowledged the uncertainty of my patient’s future, as we struggled to find a drug that would get him into a remission. I also recognized the burden it would place on her, to have a newborn and a sick husband. There was another aspect to this terrible situation, though, that I’m sure she was also considering.

“If the worst happens, you’ll still have a part of him that will live on,” I told her.

They sat silent, holding hands, considering a world with him as a doting father, and one without.

And so it often goes in my exam rooms, where cold truths, moments of elation and despair, and people’s deepest worries are revealed, sometimes for the first time. Sterile, unadorned, and bare as they may be, these rooms are also safe havens where people feel they can be honest, with me and with each other, and where they can be heard.

“Okay, I’ll take the pills,” Sarah said, now resolved.

“Really?” Joe asked.

“Yeah, I’ll do it. I’ll really do it,” Sarah reassured him. And me.

Anthony stooped to pick up his car, stood back up, and whacked his head on the corner of the counter. He started wailing. Hulk done with doctor visit.

Afterward, Rachel met me in the outpatient clinic and we walked to the hospital together, to see Joan.

“She’s better,” Rachel said as we headed over, smiling and nodding every so often at people we knew who were walking in the opposite direction, good Midwesterner that I had become. “Her FiO2 is 21 percent”—the same oxygen percentage as the air we breathe, so that’s as low as the ventilator will go. The highest is 100 percent, which can’t be sustained for too many days, as it can damage the lungs—“and they’re going to extubate her today.” Remove the breathing tube. “The steroids really worked.”

“I’m glad the differentiation syndrome is resolving. Is she awake?” I asked.

“Oh yeah. Writing her questions on a pad of paper by her bed, making sure the ICU nurses know what they’re doing.” I smiled, remembering an old joke: What’s the difference between a surgical/ICU nurse and a bulldog? Fingernail polish. She was tough.

“Have her kids been in to see her?”

Rachel nodded as we entered the stairwell to walk from the third to the sixth floor. I force myself (and, by default, the residents and fellows I work with) to take the stairs if the distance we have to travel is within three flights up or five flights down. Otherwise, I’d never get any exercise.

It was once suggested to me, by a female resident, that perhaps I should invoke this rule only after having to follow it myself wearing heels. A fair point, but I wonder if she’s come around yet in her career to the proverbial advice, “Wear sensible shoes.”

“They’ve been by every day. The ICU was a wake-up call.” Rachel answered.

Family members, too, go through the Kübler-Ross stages after a cancer diagnosis. I’m glad her kids had come around.

Rachel flashed her badge by the reader outside the ICU and the doors swung open. The noise from the unit struck us like a brusque wind. It took me right back to my first day of internship, when I met the woman who would convince me to become an oncologist.

That day would turn into the longest one of my life.14 I met my junior resident, Dave, the person who would share my call nights, at 7 a.m. in the ICU. When I walked through the automatic doors that first time, the noise level surprised me: a constant garble of voices coming from the central nurses’ station which was made even more indecipherable by the constant humming of floor buffers used by environmental services workers nearby; above all that, alarms sounded from breathing machines or cardiac monitors every time a patient’s oxygen saturation dipped, or someone’s breathing didn’t sync with the ventilator, or when someone else’s heart beat too fast or too slow. I walked by the bloated, wrecked bodies of the patients, feeling like a bystander on a World War II movie set when, after the battle, the camera pans slowly over the fallen troops so the viewer can better absorb the horror of the carnage.

Before my internship at Massachusetts General, the largest hospital in New England, I had never before seen people this sick. I would later learn that patients cared for in other hospitals’ ICUs often came directly to the regular patient floors at Mass. General, so you had to be remarkably sick to make it into the ICU there. (The same is true at Cleveland Clinic, which is almost twice the size.) The sobering effect of such concentrated illness gave me pause. I then headed toward the narrow conference room at the far end of the unit.

When Dave and I arrived, there were three other intern–junior resident pairs sitting or standing around a thick, honey-colored wood table that dominated the room, along with a third-year (“senior”) resident, a pulmonary and critical care fellow, and a couple of Harvard medical students. Two white boards, with what looked like oxygen-saturation curves and respiratory-flow equations written in red marker, hung on the walls, and a manikin was propped up on a side table with a breathing tube stuck in its mouth. There were also a couple of guys sitting at the end of the table who looked rough—hair disheveled, two-day growth of beard, light-blue scrubs untucked beneath their dirty white coats. They held heavily wrinkled paper lists of patients in front of them, clutching them like sacred scriptures. This much hadn’t changed between my residency then and John’s now. I realized they were post-call—they had just spent the night taking care of all of these horribly sick people. Dave and I would be sitting in their seats in 24 hours. Looking like them.

“You guys ready for sign-out?” the post-call duo asked the rest of us in the room.

“Let’s do it. You’ve got other services to pick up,” answered the senior resident, Ben, with a laugh. It was true—after finishing with us, this disheveled pair would leave to care for patients elsewhere in the hospital.

One of them smiled, his eyes tired. He seemed to be forcing himself to respond with confidence.

“Yes we do! But you know what? At least we won’t be spending the next month in the Deathstar!” Wow, was that crass. This is what they called the ICU. I wondered if I would become as jaded.

I looked around the room at my co-interns. We laughed with the rest of the crowd, but much more nervously.

“In bed 2 is Mr. Yankowicz, a 58-year-old guy with obesity, and a 60-pack-year history of smoking.” I remembered from medical school how to quantify the amount a person smokes in the course of his lifetime: multiply the number of cigarette packs he smokes per day by the number of years he has smoked. So, 60 pack-years could mean someone smoked one pack per day for 60 years, or two packs per day for 30 years. During my training, I would meet people whose pack-years number reached triple digits.

The post-call junior resident stopped for a second, looked up from the Holy Grail papers on which this information appeared, and continued. “He likes Marlboros—for anyone who’s interested—and he’s got diabetes. He came in yesterday because of severe groin and leg pain and on ultrasound and CT scan was found to have a dissecting aorta down the femoral artery. Surgery said it wasn’t bad enough yet to operate so they’re holding off, he needs his pedal pulses checked every hour. We have him on Lopressor, his BP is 102 over 56, heart rate 74 . . .”

Dave was writing down this information quickly on his own patient lists, and drawing small, open boxes next to the tasks we’d have to perform that day, so as not to forget what had to be done. Check pedal pulses—at the feet. Follow blood pressure to keep the systolic less than 110, to minimize the chance that Mr. Yankowicz would continue to dissect his arteries. Call the surgeons to see when they would be ready to take him to the OR. Once each task was completed, he’d fill in the box and move on to others.

“Mrs. Flannigan, 68-year-old woman with COPD, coronary artery disease, 70 pack-years of smoking, admitted with pneumonia, total white-out of her right lung, on triple antibiotics and 2 pressors, vent setting with an FiO2 of 60 percent and climbing, pressure support of 20, PEEP of 10 . . .”

Dave was writing furiously. I didn’t understand most of what this guy had just said, but I would within my first week. On a chest X-ray, air and fat look black, whereas bone, some fluids, and infection look white. So a “white out” of her lung meant that on her X-ray, her right lung was entirely filled with either fluid or infection, which was why she required a ventilator. Her FiO2 was closing in on that maximum of 100 percent. Pressure support was how forcefully the machine was getting the oxygen into the lungs, and PEEP—positive end-expiratory pressure—had to do with keeping the airways open to get the oxygen. She was also on pressors—medications to keep the blood pressure up. Ben interrupted him.

“Has anyone called a family meeting? This sounds like it’s getting pretty futile.”

“Yeah, we tried that,” the post-call junior resident said. “They’re a full go.”

Ben shook his head, clearly bothered by the news that the patient’s family wanted “everything done” to keep her alive. “I’ll call them together again to talk it over. Maybe I can convince them otherwise.”

I soon learned that these types of momentous family discussions were a daily ritual in the ICU for one or another patient’s loved ones. At a certain point, the docs and nurses caring for a patient would recognize that the person’s chance of ever making it out of the unit alive had become vanishingly small, and it was time to withdraw care and let nature take its course. A family meeting would be called, the gravity of the situation discussed, and most of the time the family would agree, particularly if they recognized, along with the medical staff, how aggressive the intensive care had already been. The docs and nurses would then stop further interventions—even checks of blood pressure or heart rate—and reduce the amount of blood pressure or ventilator support they were providing, until a patient died, ideally with the family by the bedside.

But occasionally a family would not agree with this assessment and insist that everything still be done—even as the ventilator and blood-pressure support was maxed out, and patients started to require kidney dialysis. Unfortunately, such interactions could even get hostile. Some families lost faith in the medical staff for wanting to withdraw care, while medical staff became resentful that patients were being subjected to care with little potential to help but high likelihood of harm—a violation of the Hippocratic oath. Now I can see both sides of these situations, as families hope for a miracle, and in truth I have seen patients recover against all odds. But I have also seen patients, at the behest of their families, who undergo procedures I would never want to have myself if I were living my last days.

Back then—during my internship and the remainder of my residency—I was “young and stupid,” to quote my father-in-law’s buddy. I hadn’t lived enough of life to appreciate its preciousness, to have sustained decades-long relationships with another person to understand the devastation of their loss, or to have seen enough of the against all odds cases, particularly among my leukemia patients, who survived their stays in intensive care units. Back then I was more likely to invoke futility.

Sign-out took 45 minutes, and then Dave and I, and the other intern-junior pairs, went off to round on our patients. No point in mincing words: I was completely and utterly useless. I didn’t know how to use the computers to look up lab results. I didn’t know how to read the flow sheets at the patients’ bedsides to document extremes and averages of blood pressure, heart rate, temperature, systolic arterial pressures, wedge pressures, or pulmonary arterial pressures. I didn’t even know how to write an order yet, and thank God a nurse was nearby to tell me how to prescribe potassium—my first prescription as a legit doctor. At the very least, I was able to sign it without her assistance. I didn’t know how to fight the tubes and wires draped over my patients’ chests so I could listen to their hearts or lungs with my stethoscope. It was completely demoralizing. After an hour of this, I actually checked my own hospital badge to make sure “MD” really and truly followed my name. It was, though I assumed it stood for “Major Disappointment.”

Next came rounds with the whole team, including the staff doc, a guy named Dr. Thompson. Staff docs at Mass. General were called “visits” because in the nineteenth century, if you were wealthy and living in Boston, doctors would visit you in your home and not the other way around. Only poor people actually came to a hospital. Thompson was kind. He was decisive. He stopped rounds to teach us about lung dynamics. He was brilliant. And I felt totally out of my league. I again looked sheepishly at my co-interns, and was grateful that they seemed to have the same deer-in-the-headlights look as me. We interns would grab the green charts from the rack and hand them over the juniors. They were the ones who presented the patients while we shifted our weight from one leg to the other during the four hours until rounds were done. This was in the pre-WOW days. So Dave did all the work of summarizing what had happened with our patients over the past 24 hours, all the work of writing notes, of making decisions about patients, and of planning our day. I held the green charts.

We spent 30 minutes after rounds that day doing the most urgent tasks on Dave’s list—he now had small open boxes that went all the way down three pieces of paper—and then we broke for lunch in the conference room as we were taught, once again, by the indefatigable Dr. Thompson. We spent the rest of the afternoon placing invasive lines, ordering tests, calling for consults, and speaking to family members. Well, to be clear, Dave did all of that while I held the green charts. I did run a couple of errands for him and was thrilled when I could successfully locate an X-ray in the catacombs of the radiology department! Nowadays, of course, X-rays and medical records are all on computers, so I can’t imagine what first-day interns in the intensive care unit actually do with their time.

Most of that day is a blur, though I did notice Ben in Mrs. Flannigan’s room, standing by the window with his arms crossed as he was talking to what I assumed were her family members, who were sitting across the room. One older man stood by the patient’s bedside, holding her hand and crying.

As night fell, we rounded out, during which the other intern-junior pairs told us about their patients. We heard about a couple of new admissions, another old guy with a lot of medical problems, and now with a pneumonia, who might need to be intubated, and a woman with metastatic ovarian cancer who was having trouble breathing and might also need to be intubated. Dave scribbled a lot more notes on the same pieces of paper that had been our bible for the day (now with most of the small boxes filled in). Then, the other residents took their leave, a scene straight out of that same World War II movie that started my day. We had now arrived at the part in which the company is forced to abandon two guys whose legs got shot up, and leave them with a certain amount of ammunition to fend off the advancing Germans. The departing troops always say goodbye and promise to come back to retrieve the guys the next morning—if the two survive the night, which everyone knows is highly unlikely.

So, instead of the 6 patients we cared for during the day, we were in charge of 20. I was hoping that disease recognizes the need for sleep, too, and we would have an easy night, but it was not to be. The overnight bag I packed, including replacement contact lenses, glasses, a set of scrubs, toothbrush and toothpaste, a comb, and a change of underwear, would remain unopened.

Dave and I rounded, just the two of us, on all the patients so we could get to know them, at least by sight. At about 8:45, Dave told me to go get us some dinner.

“Where?” I asked. The cafeteria closed at 7 p.m.

“Down at the cafeteria. They have a special meal at 9 for the interns and residents. One of us has to remain in the unit in case a patient crashes, so if you’d like I can go instead and you can stay here.” He smiled, knowing the suggestion that I remain alone with 20 sick patients would terrify me to the point of near incontinence.

I walked out the doors to the ICU and realized it was the first time I had exited in 14 hours. I then took the elevator to the basement and looked down the hall toward the cafeteria entrance, which was blocked by a garage-door gate that was pulled down tight. A gaggle of people were standing in front of it, waiting—interns and residents in internal medicine, surgery, pediatrics, psychiatry, emergency medicine, and pathology. The pathologists were standing closest to the gate. I recognized some co-interns from our orientation, and we shared a couple of war stories from the day.

At precisely 9 p.m., a cafeteria worker came over to slide up the gate. As soon as it was three feet off the ground, the pathology residents bent down and scurried under, making a beeline for the desserts. Really? Were they that delicious? Soon everyone pressed in. I grabbed a tray to scope out the selections.

It took me a few nights on-call to figure out how best to game the nighttime food selections. The “special meal” for residents represented what was left over from the day’s selections—obviously, the least popular meal choices. Dessert consisted mostly of fruit-flavored Jell-O, but occasionally a couple of chocolate puddings would remain, and that’s what the pathology residents were gunning for. We joked that by the end of residency, having eaten all of that Jell-O, we probably had the strongest fingernails of any internists in the continental United States. The leftover entrée selection was always nondescript white fish or the vegetarian special. For vegetables, we were treated to waxy green beans or the occasional wilted lettuce with Thousand Island dressing. I loaded up the tray and headed back up to the unit, glancing over my shoulder wistfully at my co-interns, who had the luxury of remaining in the cafeteria and sharing a meal together. It took me a little longer than others to get to know all the members of my intern class, because the ICU would be so isolating that month.

Back upstairs, I set the tray on the conference room table and found Dave. Almost immediately, the disasters began. Mr. Yankowicz cried out from Room 2. We ran in.

“What’s going on, buddy?” Dave asked, cool as a cucumber. My heart was in my throat.

“My leg! My goddamn leg!” He was holding his right thigh. Dave grabbed a Doppler machine, which has a probe that you place over someone’s pulse so that you can actually hear the whoosh, whoosh of blood coursing through an artery, and placed it on Mr. Yankowicz’s foot. We heard his pulse only faintly, even when Dave turned the Doppler’s volume all the way up.

“We better call the surgeons,” Dave said. “I think he’s dissecting his artery even further, and he’s no longer getting any blood to the lower part of his leg.”

Dave paged them and a couple of minutes later two guys in scrubs came into the unit, grabbed the Doppler, and put it on Mr. Yankowicz’s foot. We again heard the same faint pulse.

“We’ll operate tomorrow. As long as he’s getting some blood to that foot, he’s okay,” the older surgeon said. The younger one looked about as terrified as me, and I assumed his internship had started that same day, too. Twice more that night, Mr. Yankowicz would cry out, and we’d go through the same procedure with the Doppler, verifying he still had a pulse. Early the next morning, he was whisked away to the OR.

As we were leaving his room, one of the nurses, Janet, came over to us.

“The new admission in bed 10 . . .”

“What’s his name?” Dave interrupted her. A lot of docs and nurses had gotten into the habit of referring to patients by their bed numbers. The point was really to avoid using their names in public and thus violating the privacy guaranteed to every patient under the Health Insurance Portability and Accountability Act (HIPAA), which was just being passed by Congress and signed into law by President Bill Clinton that year.15 But Dave believed they had gone overboard and in the process dehumanized people even further. He insisted on hearing everyone’s name—a practice I would follow throughout my career, as well. The nurse rolled her eyes.

“Mr. Wilson, 78. Married. He likes long walks on the beach, quiet nights by the fire, and occasionally he likes to cuddle with his sweetheart.”

Dave laughed. “I got it, I got it. Is there anything else he likes? Maybe a breathing tube?”

“Precisely,” Janet answered.

“Alrighty then. We’re a full-service hospital. Let’s give the man his money’s worth.”

We followed Janet into Room 10. An elderly man with a white, grizzled growth of beard was lying in bed with a face mask plastered over his mouth and nose. He was breathing quickly, maybe 40 times per minute. His eyes looked anxious, and his hands were grabbing the bed sheets, as if he were trying to brace himself while he breathed. Dave stared at the monitor over his bed, and I followed his gaze to see it registering an oxygen saturation of 78 percent and a heart rate in the 120s.

“Mr. Wilson!” Dave shouted at the man. “We’re going to have to put a tube down your throat to help you breathe! You can’t keep going like this without one! Is this something that you want us to do?”

Mr. Wilson locked eyes with Dave and nodded quickly. Janet had already rolled a cart into the room with plastic tubes and some metal instruments on its surface. Dave moved behind Mr. Wilson’s bed and lowered the head of it until it was flat. This did not help Mr. Wilson’s breathing, and he shut his eyes. Dave spoke calmly but with authority as he took the mask off Mr. Wilson and sprayed an anesthetic into his mouth. It smelled faintly of oranges.

“Can I have a Mack and a 7.5 French tube.” The Mack, short for Mackinaw, was one of the metal instruments on the cart. Dave pulled on the Mack’s lever and a light came on. He stuck the lever into Mr. Wilson’s mouth, deep, the light helping him to see where he was going, to press down on Mr. Wilson’s tongue while the nurse handed him a plastic breathing tube. Dave slid the tube over the lip of the lever, then even deeper, past the vocal cords, and removed the Mack. He took a syringe and injected air into a port that came off the tube—this would inflate a collar around the tube that would keep it anchored in Mr. Wilson’s throat. He attached the end of the tube, sticking out of Mr. Wilson’s mouth, to the large tubes leading to the ventilator. Finally, he took his stethoscope and listened to Mr. Wilson’s lungs, and in the area of his stomach, to make sure he successfully placed the tube into Mr. Wilson’s trachea, and not his esophagus. We would get an X-ray to confirm the placement soon after.

“Sounds like a winner to me!” Dave said, as he cleaned up the packaging from the tube and instruments, and we left the room. Within the next week, I would learn how to do this myself, and eventually would place more breathing tubes in patients than any other intern in my class. But at that moment, I just stood in the room with my mouth open. I think I had just witnessed Dave saving this guy’s life.

“You ready for some grub?” Dave asked me. I looked at my watch. It was almost midnight. He went ahead to the conference room as I lagged behind, glancing into the rooms of these patients I was now officially helping to care for.

I stopped as I passed the room of Mrs. Abrams, the woman with ovarian cancer whose lungs were filling with fluid. She was a pediatrician from a nearby hospital. Initially, she was to be intubated and placed on a respirator, but she had changed her mind, deciding instead to live her last hours breathing air on her own, unassisted. She was in her early 40s, and her appearance in our unit had ruled our team’s emotions that day. It didn’t help matters when her son and daughter, ages 10 and 8, came in to say goodbye to her in the evening—we all knew this would be the last time they would see her. Each of us in turn, doctors and nurses, sought refuge off the main floor to check the hitch in our breathing or cry outright in private. I had never been witness to this kind of family drama up close, and it was heart wrenching.

Just before we had rounded out with the rest of the team, her husband escorted their children away and returned a couple of hours later with her best friend, now carrying a bag from CVS. As I was doing my rounds, checking vitals on patients to dutifully report back to Dave, I glanced in her room and saw her husband standing, hunched over her bed, holding a clipboard while she struggled to write something. I made it back to our conference room.

“Hey Dave, what’s going on in there?” I asked, gesturing to her room. By this point in the day I had proven myself to be so utterly helpless that I no longer even worried about asking Dave completely idiotic questions. He was my lifeline, my only source of truth. Even if I’d had time to use the bathroom, I probably would have needed his assistance there too. He looked at me blandly, but without prejudice.

“She’s writing out cards.”

“You mean 3×5 cards?” I asked. I had a pocket full of them, each with a different patient’s information written down. When I was in medical school, this was how we kept track of our patients, though it was clear that in residency people used printed-out patient lists. These were the only cards I could picture.

“No, birthday, holiday cards—those types.”

Birthday, holiday cards, graduation cards, cards for every occasion she could imagine. Cards for bar and bat mitzvahs. Cards for Halloween. Cards for the next ten years for her son and daughter. Cards so she could be a part of their lives. Cards because she was so proud of them. Cards so she could live those years with them over the course of her last night on earth. Cards so they would never forget her.

I was up for the rest of that night, caring for others and watching her stay up all night, writing, her eyes intent on the cards in front of her, sometimes her husband holding the clipboard, sometimes her friend. As she finished, and as her breathing became more labored, she asked that her morphine dose be increased.

Of course, there were other emergencies. Mr. Wilson’s breathing did not get much better even after Dave intubated him, so we had to increase the amount of oxygen and pressure support he received. Mrs. Flannigan passed away at 4 a.m., just after her husband had left her to go home and catch a couple of winks. Throughout my career, I would see the same thing occur, a person dying just a few minutes after his or her spouse had departed, as if giving them one last gift, of sparing them the lasting image of their departure from this earth. Dave walked with me into the room.

“Have you ever pronounced anyone before?” he asked. I admitted that I had not.

“It’s easy. Come over here.” I walked next to him, by the lifeless body’s side. “Lift up her eyelids and shine a light in her eyes, to see if the pupils react.” I did what he told me. It was creepy, touching the dead woman’s face. The pupils remained fixed.

“Great. Now check if she’s breathing. Put your ear near her mouth and listen, and then listen to her lungs with your stethoscope.” Only then did I noticed that the nurse had removed her breathing tube before we came in the room, and had shut off her ventilator. I did what Dave told me to do. Again, nothing. Eerie silence.

“Okay. Now listen with your stethoscope to her heart. You need to listen for one minute without hearing a beat.” I watched the second hand on the wall clock make an entire revolution as I listened again with my stethoscope, this time to the heart. A minute is a long time to be crouched over a body that is quickly getting cold to the touch. All for naught. I looked up at Dave and shook my head.

“Great job, champ. You took a life out of this world. Now we just have to work on teaching you to keep them here,” he joked. I half smiled, too tired to come up with a snappy response, or to argue. At least I had done one thing right in the past 21 hours.

The sun soon rose over the Charles River. Dave beckoned me to a sink, which had one of those boiling water dispensers you could use to make tea quickly, or even hot cocoa. He turned the handle, and soaked a couple of washcloths under the steaming water. He then wrung them out, handed me one, and placed the other over his face, barbershop style. I did the same. It felt amazing, instantly rejuvenating. We stood with our washcloths by the sink for a minute or two before Janet came up to us.

“Mrs. Abrams just passed. Her husband and friend are in the room.”

I looked at Dave hesitantly. I had just learned how to pronounce a person dead, but wasn’t sure I could handle this in front of other people. He divined what I was thinking.

“I’ll take care of it,” he said.

More than two decades have passed, and I still think about Mrs. Abrams and the cards she wrote to her children. The power of her intense fragility—or was it strength? I wonder if I would do the same for my children, now that I have them, or how I would deal with this cache of missives from another world if I were her husband. I also think of her son and daughter—did they look forward to getting these cards every year, or did they dread them? Did they save them? As a parent, I would hope so. But maybe her uncertain handwriting during her final hours reminded her kids of the time when she was sick, so they rejected the cards for earlier, happier memories.

It’s rare in life that we can pinpoint one moment that causes a seismic shift in our thinking that leads to our careers veering completely off course from what we imagined. Right then, I decided to become an oncologist. And though I can provide perfectly compelling reasons for my choice—including the fascinating biology of the diagnoses, the opportunities for research, or the prospects for conducting clinical trials of novel drugs—in reality I made the choice so that I could have even a glancing connection to the people who face these terrible cancers with dignity, and in so doing, give value to the lives of everyone around them. All because of Mrs. Abrams, who wanted to have a say after her death.

The rest of the team straggled in at 7 a.m. My co-interns, especially the guy who was to be on call next, looked horrified at my appearance. He handed me a coffee and a muffin—one of our many traditions—the on-call intern always brought in breakfast for the post-call intern.

“How was it?” he asked, not sure if he wanted to hear the answer. I paused before responding.

“Oh, great!” I said. “Sorry, I’m just a little slow on the uptake right now because of all of the sleep I got.”

Dave had been listening in. “That’s my boy!” he exclaimed. “Now you’re catching on!”

Dave and I checked on our patients and joined the team for rounds with Dr. Thompson, who had so much energy he nearly bounded from one patient to the next. I almost fell asleep, twice, while standing up. We got together for lunch in the conference room and for another teaching session, this time courtesy of the pulmonary/critical care fellow, and then Dave and I were free to go home.

Years later, when I was a hematology/oncology fellow at the Dana-Farber Cancer Institute in Boston, my pager went off, and I saw a number with a Boston area code, but one that was unfamiliar. I called the number, and on the other end of the line I heard Dave’s familiar voice. He had become a pulmonary/critical care specialist at another Boston hospital and had just joined their staff. I suspected that Mrs. Abrams and his experience in the intensive care unit had influenced his career choice, too.

“Hey champ! What’s cooking?” he asked loudly. There was something forced about the way he said it, though. I asked him how he was doing.

“Not so well, actually. I’m kinda in the hospital, as a patient.” He paused, as if he wasn’t quite used to saying the next words out loud. “Yeah, I kinda just got diagnosed with lymphoma, and I need to figure out what to do next.”

We chatted for a few minutes and I helped arrange for him to see one of the lymphoma specialists where I was training. Things had come full circle, to the point where I was finally able to help Dave. He was treated and cured of his cancer, and even went on to become a nationally prominent medical educator.

I wondered if perhaps that, too, was all part of Mrs. Abrams’s plan.

Joan was lying in bed, almost sitting upright, with four or five pillows propping her up. An oxygen mask covered her face. A used breathing tube lay on her bedside table next to some bloodstained gauze. I glanced up at the monitor over her bed, which showed an oxygen saturation of 94 percent. Joan’s kids, not as coiffed as in the photo from her room, were there: Her son, a thin guy with closely shaved blond hair, black leather jacket, and a cut-off T-shirt with a marijuana leaf on it, sat in the one chair in the cramped room. Her daughter, who looked to be about 17 and had the same hair color as Joan, stood next to him. She had multiple piercings in each ear and one in her nose. As before, when I saw them in Joan’s other hospital room, the worry on their faces belied their hardened appearances.

“How you feeling kiddo?” I asked, loud enough to be heard over the ambient noise. Joan gave me a thumbs-up sign. “I think this is going to be the worst of it,” I told her. She locked eyes with me, just as she had prior to being intubated, and nodded, tired. “You made it through. Once the ICU team feels you’re stable enough, we’ll welcome you back to the leukemia service with open arms,” I promised her. The irony, of a leukemia floor being a step in the right direction, escaped neither of us. She mouthed the words “thank you” then closed her eyes and drifted to sleep. I reassured Joan’s kids that she was getting better and asked if they had any questions, but they both just shook their heads.

Joan did transfer back to our service later that day. Over the next week and a half, with the help of physical therapy she slowly recovered her strength, and with the help of her healthier bone marrow her blood counts returned to normal. Becky, the resident working with John, discussed her on rounds late one morning.

“I think she’s getting better,” Becky announced to the team.

“What makes you say that?”

“Well, her white blood cell count is 2,300, which isn’t that different from the past few days, but the blasts”—the bad guys—“are gone from her blood stream. And her neutrophils”—the white blood cell subtype that fights bacterial infections—“are over 1,200.” Joan had endured the terrible differentiation syndrome brought on by the vitamin A drug, ATRA, but the drug had done its job: the immature blasts had developed into functional neutrophils. With a neutrophil count below 500 or 1,000/µL, Joan was considered “neutropenic” because the quantity of those important neutrophils was considered insufficient to fight life-threatening infections. But with a neutrophil count of 1,200/µL, we considered her immune system competent, and she could potentially go home.

“What about her platelets?” I asked.

“Also normal. She hasn’t needed a platelet transfusion in a few days.”

“If we discharge her, will her insurance cover the ATRA?” She would need to continue on the drug for another week or two, and intermittently over the next few months. For a vitamin, it was outrageously expensive, at thousands of dollars per month—quite a bit more than the vitamins for sale at our local GNC store—but still a bargain compared to imatinib.

“Yup, her copay isn’t bad.” Becky reassured me.

“How’s she getting around? Is she eating?” I persisted. The basic rules for discharging patients from the hospital include making sure that they can function independently or with minimal assistance at home and sustain themselves nutritionally. Otherwise, we would need to consider a rehabilitation facility.

“She’s been walking in the hallway, and she tells me every day that the hospital food is terrible.”

“So, you’re saying she has insight?” I joked.

The quality (or lack thereof) of hospital food is routinely one of the greatest patient dissatisfiers. Some explanation for this comes from trying to mass-produce meals for 1,400 people at roughly the same time every day—the taste is going to be compromised whether it’s at a hospital or a convention. Food also doesn’t taste as good because of competing smells, such as those from bleach or other antiseptic interventions required to minimize the spread of germs in the hospital, and from the filtered air on the leukemia floor. Analogously, on an airplane food tastes bland because the dry air at altitude dulls our sense of smell, which compromises our sense of taste.16 Finally, the drugs we prescribe can change the sense of taste. After receiving chemotherapy, my patients frequently tell me they are more focused on texture than taste, like toddlers. They prefer moist foods, like melons, and can’t stand steak or some types of bread. One patient, a former schoolteacher, ate Chinese lo mein for a month because he liked the greasy noodles.

We entered Joan’s room. She was sitting at a chair by the window. Her sister Connie, who must have just arrived, was taking off a puffy jacket and slinging it over the back of another chair. Winter was coming, with a dusting of snow forecast for the evening. A bag from Slyman’s Deli sat on top of Joan’s bedside table, now pulled close to her chair.

“That smells delicious, did you bring enough for all of us?” I asked. Connie smiled.

“I’m going to try the hot pastrami. I usually have the corned beef, but for some reason, it just didn’t appeal to me,” Joan said.

“I bet that would taste even better in the comfort of your own home.”

Joan had been opening the bag from Slyman’s and hesitated. “Seriously? I heard rumblings from your posse that I might get out of here. When?” We were a gaggle, but I didn’t correct her.

I shrugged my shoulders. “You can finish your sandwich so it doesn’t get cold, but any time after that would be fine.”

“Is she in a remission?” Connie asked.

“Probably, but we won’t know for sure until we perform another bone marrow biopsy, which will happen in a week or so in clinic.” Joan had dodged the bullets of infection, bleeding, and differentiation syndrome that kill people with APL during their induction chemotherapy, so she was almost certainly on the good side of the binary outcome, and in a remission.

Joan blinked a couple of times, absorbing the news. Recent events had transpired in a time warp that seemed like a split second and a lifetime all at once: from the moment she sat across the desk from her colleague, the surgeon, who first used the word leukemia to describe her condition; to the long drive to Cleveland and her bone marrow biopsy; to watching the red chemotherapy enter her body from the syringe manipulated by Janey’s steady hands; to entering the ICU and the horror of the breathing tube (the ICU was a blur, a crazy dream); to the past week of slowly regaining her strength.

Connie started to cry. The enormity of the experience began to hit her too. A golem had attacked her sister—dragging her to that awful ICU for days where she was dehumanized with a breathing tube and multiple intravenous lines, making her use a walker to take just a few steps, and reducing her gustatory range to that of a toddler. But this golem had been defeated, at least temporarily. She rushed over to me and hugged me hard, whispering “thank you” over and over. I hugged her in return, trying to both comfort and reassure. I felt disingenuous at receiving this outpouring of affection.

“All we did was write for chemotherapy and a couple of other drugs. The two of you did all the heavy lifting,” I told her and Joan.

“We’ll be back to go over your discharge instructions and medications. You’ll see us in clinic in a few days,” Becky told them, matter-of-factly.

Joan nodded, still stunned, and managed a small smile.

“Home” was all she said.

David Sweeney was the final patient of the day we needed to discuss on rounds. As our gaggle settled back behind our WOWs, Becky updated us on his progress.

“His counts are still in the basement. Whites are 190, hemoglobin 7.8, platelets 7. He’s basically requiring either a bag of blood or platelets, or both, every day,” she said.

“What day is he?” I asked. We track how long it’s been since the first drop of chemotherapy is given (Day 1) to better predict what complications to expect in people with AML, and when their bone marrow will wake up.

The Ara-C finishes infusing on Day 8, the bone marrow biopsy to determine if the leukemia persists occurs on Day 14, and most people recover their blood counts by Day 28, with the first signs of that occurring around Day 21. For those, like David, who need a second course of chemotherapy, it is infused from Days 14 to 19, and blood counts often recover between Days 35 and 42. Bacterial infections can strike at any time, while fungal infections are more likely to hit after Day 10. Breakdown of the tissue linings of the mouth and throat from the chemotherapy (a condition called mucositis) occurs in a minority of patients starting around Day 10 or 12, while the same phenomenon can affect the colon around Day 18 (called neutropenic enterocolitis). For people with APL receiving ATRA or arsenic, the risk of differentiation syndrome peaks at Days 7 to 10.17

“He’s Day 27, Day 13 from re-induction chemo,” Becky answered.

“Are his fevers gone? How’s his diarrhea?” I asked. David, lucky guy that he was, had developed both a fungal infection in his lungs and neutropenic enterocolitis following his terrible bouts of vomiting.

“Tmax 37.8”—his maximum temperature in the past 24 hours, in Celsius, where a temperature of 38, or 100.4 degrees Fahrenheit, is considered febrile—“and he’s down to only four or five bowel movements a day. It’s better with the immodium.” At his worst, he had 10 to 12.

I nodded as I charted all of this in his notes on the computer. Then we went into David’s room to see him. He was lying in bed on his side, with the sheets pulled up tight near his head, now bald. The chair by the window was empty. Betty must have gone down to the cafeteria for lunch. He had lost weight, and his cheekbones were more prominent, accentuated by the waxy appearance of his skin. Hard to have much of an appetite on antibiotics and with frequent diarrhea. A bag of packed red blood cells hung on his IV pole, as did IV fluids. I sat down gently at the edge of his bed and lightly placed my hand on his leg.

“David? Hey, sorry to wake you. How are you doing?”

He opened his eyes but wasn’t startled. “Groundhog Day,” he said softly, alluding to the movie in which Bill Murray plays a weatherman who relives the same day over and over again. One day on the leukemia service can be pretty similar to the next.

“Our goal is to make this as boring a stay as possible for you. Busy night?”

David nodded. “Visited the john a bunch of times. Then the nurse hung the platelets around 6 this morning. She said the counts haven’t budged.”

“Not yet, but it’s still early. I’m hoping to see some signs of life in the next week,” I told him.

“God willing,” he said. I glanced up to the wall over his bed, where a new plaque hung, decorated with an image of St. Christopher and the words “Protect Us.” A couple of angel figurines sat by the window, near the photo of the family tailgating. “He’ll get me through this. Through you.” David’s face was tranquil, without the worry that I had seen a couple of weeks earlier, when I broke the news to him about the persistent leukemia.

Medicine and religion can appear to operate on opposing principles. Whereas most religions are based on faith in an unseen, almighty being, the practice of medicine is empirical. To make a diagnosis, doctors rely on what they observe during an examination (for instance, Joan’s petechial rash and persistently bleeding bone marrow biopsy sight indicating low platelets and DIC) and on the supporting laboratory results (a platelet count of 18,000 and abnormal clotting factors).

During my training, my own mentors would go so far as to tell me, “Tumor is a rumor. Tissue is the issue.” Even a mass on a CT scan that looks for all the world like cancer isn’t called cancer until a piece of it has been removed from the body and examined under a microscope by a pathologist.

There’s a joke that emphasizes this principle (and at the same time pokes fun at the priorities of different specialists): Four doctors—an internist, a radiologist, a surgeon, and a pathologist—are out on a boat, duck hunting. They see an object fly across the sky.

Says the internist: “Well, that looks like a duck, but my differential diagnosis for what it could be would include a goose, a hawk, a pterodactyl, and a flying saucer.”

The radiologist weighs in: “The image appears to be one of a duck, but I cannot exclude duck-like clouds, scar tissue, or an artifact in how the digital CT scan produces the image.”

The surgeon, impatient, grabs a gun, takes aim at the flying object, and shoots it out of the sky. He then scoops it out of the water, hands it to the pathologist, and says, “Tell us what it is.”

I struggled for years trying to bring into harmony the factual basis of science and medicine with the faith basis of religion, particularly with what I knew about the bargaining stage of the Kübler-Ross theories, in which an increased focus on religion (“God, if you help me get into remission, I will be a better Christian”) might be used as a coping mechanism. I wondered (perhaps unfairly) if that truly represented faith or just desperation, a means to an end.

Then I met a young woman who had endured even more side effects to chemotherapy than David. She retained her generosity of spirit, equanimity, and poise throughout, relying frequently on her faith even when she was at her worst, always pointing out to me that there were others in more need.18

Soon after completing her treatment, she and her husband, who were childless, started fostering some at-risk children as a way to give back what she considered the blessing of her good health.

“I’ve prayed about it,” she told me.

When the young woman became pregnant, we celebrated her joy at being able to bring another child, one they had conceived, into their home. But then, during our next appointment, she shared the news she’d learned from her obstetrician just a day earlier: her baby had a rare congenital syndrome that would make it highly unlikely for him to achieve developmental milestones beyond infancy and to live long enough to see his tenth birthday.

I consoled her, as her tears flowed unfettered, and told her what a lucky guy he was to have her as a mother.

She smiled at me, reassuringly. “We’ll love him no matter what. It’s all part of a greater plan.”

Her face became tranquil, just as David’s had. With her calm, her strength through such adversity, I finally saw God.

It wasn’t until Day 38 that David’s neutrophil count—the white blood cells that fight bacterial infections—crested 500, rendering his immune system competent enough to face the outside world. Rachel, Becky, John, and I entered his room to tell him the good news, but Janey must have beaten us there: He was sitting in a chair, dressed, across from Betty, who was also in a chair. The photos, plaque, and figurine were all put away, and his suitcase was packed. Their daughter Susan stood by the window. They were all smiling broadly, though David’s expression looked more weathered.

“The team and I took a vote, and we decided you’re taking up some bed space that sick people need, so we’re politely asking that you leave,” I joked.

“We’ll take him!” Susan volunteered.

I turned to Betty. “You’ll have to clean up all of those beer cans and pizza boxes before David gets home.”

“Nah. If I did that, he wouldn’t recognize the place,” she countered. We all laughed.

“In all seriousness, Janey will go over your medications and follow-up appointments. You have a bunch of them.” David could go home because his immune system was recovering, but he still needed blood and platelet transfusions every couple of days. He also needed to continue his antibiotics for the fungal infection. He was far from being out of the woods, and the delay in recovery of his platelet counts nagged at me.

“We’ll do whatever it takes to get him outta here,” Susan said. “Even if it means an appointment every day, as long as we get him in his own bed every night.”

“My own bed.” David shook his head, marveling over this most basic of creature comforts denied to him for almost six weeks. Then he looked over to me. “I am grateful, to you and to Him,” David said, pointing toward the ceiling.

“Me too,” I told him.