Doctors (47 page)

Hadn’t Laura always chosen his shoulder to cry on? Didn’t he derive enormous satisfaction from what he accomplished with little Marvin Amsterdam at summer camp? (Where are you, Marvin? Are you well and happy?) And he’d lost count of the classmates who had sought assistance from him at both college and Med School in their times of desperation. Yeah, I’m like some magnet for the melancholy.

And yet the first thing a psychiatrist must be is honest with himself. So, come on, Livingston, try to analyze your own decision. You already know what you would do for others, but what would psychiatry do for
you
?

Come on then, this is the hardest part.

The “equilibrium” that people see in me is really an illusion. I am as flawed as anyone. It’s only that I seem to have the knack of hiding it. Psychiatry would help me, first of all, to heal myself. Because let’s face it, Livingston, you’re nearly twenty-five years old and haven’t ever had relationships with women that transcend the superficial. And surely something’s wrong with that.

Besides, the mere fact that you want to be the man dispensing wisdom is a way of self-protection. Be honest, you’re afraid to look inside yourself and see what’s going on.

Yeah, the choice of specialty is often a reflection of the doctor’s inner need. I want to understand myself. I want to know
the reason why I allow myself to act as everybody’s father figure. Could that be a way of hiding something deeper—like the fact that what I want to be is just a father?

Having decided on psychiatry, Barney thought it sensible to take an extra neurological rotation to get a better idea of how the brain functions organically.

He found himself once more performing literally what he would spend his life trying to accomplish with mere words: probing the human brain.

Bennett Landsmann, whose eye was fixed upon the gleaming scalpel, took an extra round of surgery and filled out applications for a surgical internship in the Boston area.

“Hey, look, Ben,” Barney tried to tell him diplomatically, “be honest with yourself. Even if your name were Bennett X and you had all the Black Power in the world, it wouldn’t help. There’s never been a black surgical intern at any of the Boston biggies.”

“There’s never been a woman either,” Bennett countered, “but Grete Andersen’s applying.”

“Hey, listen, my friend, you may be as handsome as Sidney Poitier, as great a jock as Jackie Robinson—and even more Jewish than Sammy Davis—but to those guys you’re still a horse of a different color. And as far as Grete is concerned, for once she’s gonna learn that she can’t wiggle her way into a male closed shop. Anyway, that’s her problem. Why don’t you wise up and apply for an internship with me in New York?”

“I have a sentimental attachment to Boston, Barney. The Symphony runs rings around the New York Philharmonic. Even the art museum—”

“Don’t give me any of that cultural bullshit when I’m trying to tell you facts, Ben. These surgery departments are not about to break tradition—they’ll only break your heart.”

“But what about you, Barn?” Bennett said, turning the tables. “What attraction could New York possibly have for you now that your mother’s sold the ancestral mansion and moved to the land of sun, fun, and skin cancer?”

“Well, my brother Warren’s at Columbia Law.…”

“But he’s living with some girl, right? He didn’t invite you to play
Jules and Jim
, did he?”

“Come on, Ben, New York is the capital of the world. It’s certainly as good for psychiatry as Boston, and besides—”

“Besides—it’s two hundred and fifty miles away from Laura Castellano.”

“What does that have to do with anything?”

“Come off it, Barn. You’ve been in a lousy mood ever since she got officially engaged.”

“He just isn’t
worthy
of her, dammit!”

“All guys feel that way about their sisters—and I suppose, some day, their daughters. No one’s ever good enough for them. From everything I hear, Mr. Talbot is very cool.”

“He is,” Barney confessed, “there’s nothing I can say against him except he’s wrong for Laura.”

“And you feel so strongly about it that you don’t want to hang around and watch her suffer when the bubble bursts.”

Barney poised to retort and then paused. A wan smile crossed his face. “Christ, Landsmann, it hurts me to say it, but you’ve sort of hit the nail on the head.”

“Well,” Bennett allowed, “I guess I was being selfish. I thought if we were both in Boston we could share an apartment and maybe change our foul-shot competition into something more elevated—like numbers of damsels seduced. Hell, I don’t wanna lose you to New York.”

Barney looked up and grinned. “Then marry me, Bennett.”

“I can’t, Barney. You’re not Jewish.”

Barney felt certain he was having a heart attack.

Then the psychiatrist in him made him realize that death was merely a wish-fulfillment fancy.

The truth is he was petrified. For this morning he was about to deliver his first neurological “presentation,” the write-up of his examination, analysis of symptoms, and “differential diagnosis” of a real patient. And it would be before, of all people, Professor Clifford Marks, world-renowned neurologist and a ruthlessly demanding teacher.

Barney was certain from the various symptoms he had been analyzing so intensely that the patient he was about to present would survive. Barney’s only question was, would
he
?

He reached the fourth floor just as Marks, the portly, gray-templed professor, was marching from the elevator, surrounded by a cluster of students and interns.

They exchanged perfunctory salutations as the senior consultant led them down into the Neurology ward. It was not a pleasant place. Those lying in their beds seemed to be divided
into opposite extremes: They were either twitching and convulsing or else paralyzed.

At last they reached the bedside of Mr. Aldo Moretti, a balding, middle-aged man, who at first appeared out of place in this ward. For though his hands and feet were bandaged, he was apparently able to move his limbs without paralysis or palsy.

Moretti was delighted to see so many doctors coming to pay homage to his fascinating symptoms and warmly welcomed these new pilgrims.

When all were gathered around, Professor Marks nodded to Barney. “All right, Livingston, let’s hear the problem.”

Barney turned to the group and opened the manila envelope containing official forms, as well as the copious notes he had made for himself.

As he was about to begin, his subject interposed with a cheery greeting, “Hi there, Barney. Howdja feel this morning?”

“Fine, fine. Thank you, Mr. Moretti,” he muttered. And then he went back to his prepared text.

Again Moretti interrupted, this time addressing all the other white coats. “This kid was so tired last night when he admitted me he could barely keep his eyes open. If I hadn’t felt so lousy, I’d have gone back home and let him sleep.”

“Hmm, yes,” the professor remarked. And then he added, “Proceed, Livingston.”

Barney cleared his throat and then recited, “The patient is a forty-two-year-old male business executive—”

“I’m in trucking, actually,” Moretti footnoted. “I own a fleet of trucks.” At which he turned to Barney, urging, “Go on, kid. Go on.”

Barney continued. “Last Sunday he was entertaining his in-laws for dinner and was cooking a large pot of spaghetti—”

“How many times do I have to tell you, Barney, it was
vermicelli.
”

Barney worked up the courage to talk sternly to a man nearly twice his age. “I’d be grateful if you’d just let me finish this, Mr. Moretti. Then if you’ve got anything to add, you can do it afterwards.”

Determined not to give Moretti another chance to hold the floor, Barney barreled on, “As he was carrying the boiling pot to the sink, he suddenly dropped it, causing extensive second-degree burns to his hands and lower extremities.”

“I can’t understand it,” Moretti apologized. “I mean, nothing
like this ever happened to me before. And what the hell I’m doing with all these spastics, I don’t know.”

Barney took a deep breath and continued. “When admitted to the E.R., the patient was in a confused state and couldn’t recall even dropping the boiling water on himself.”

“Yeah, I was in a real fog,” Moretti commented.

“He was admitted because of the extent of his burns and put on I.V. hydration. At this point he presented no focal neurological signs.

“This morning he developed a high fever—probably secondary to his burns—had temporary loss of consciousness, smacked his lips, and kept turning his head to the right. He had a tonicoclonic seizure lasting less than a minute. When Neurology was called in, he had been groggy for over half an hour.”

“The kid hasn’t missed a thing,” said the voice from the pillow, which Barney pretended not to hear.

“What was your initial impression?” the professor asked.

“Well,” Barney suggested—trying to sound as if it had just come to him rather than being the result of frantic research—“it’s just possible that the high fever he spiked may have caused a seizure. There’s also the possibility that he could be septic from an overwhelming bacterial infection introduced by the burns.”

Following protocol, Barney then offered his “differential diagnosis,” one based on a comparison of Mr. Moretti’s signs and symptoms with those of other diseases with which they could be confused. In addition to the obvious possibility of a tumor, there was AVM, a circulatory malformation that causes similar problems. There was even the possibility of multiple sclerosis. Encephalitis could not be ruled out unless they did a spinal tap—

There was a sudden bellow, “
No way!
Nobody’s sticking a needle in my spine. A friend of mine had it and it hurts like hell.”

Barney was now beyond rage, on a transcendental level of calm, as he replied to the latest outburst, “We’ll keep that in mind, Mr. Moretti.”

Then he turned back to the white coats. “Anyway, Professor, as you keep reminding us, seizures are only signs, not diseases in themselves. As far as I could tell, the patient has no family history of seizure disorder except for one incident he mentioned in conversation—that his grandfather fell off a horse and sustained what was obviously a post-traumatic seizure.

“The neuro exam was normal, including assessment of the
twelve cranial nerves. The examination of sensory and motor nerves fails to reveal any abnormalities. Tendon reflexes are normal and there was no Babinski sign. Mental status is within normal limits.”

At which point the bedridden commentator shouted, “Bet your sweet ass I’m not loony.”

“In conclusion, sir,” said Barney, sensing relief was just a few syllables away, “the patient’s seizure seems to be … idiopathic.”

Idiopathic
—the most useful word in the medical vocabulary. Any doctor who is unable to diagnose a patient’s ailment can always employ that valuable adjective “idiopathic,” which is simply Greek (related to “idiot”), meaning of unknown origin. In other words, the physician is telling the truth but keeping the patient from understanding his confession of ignorance.

The professor nodded. “Excellent presentation, Livingston, your family history thorough, your differentials were all relevant, and your neurological work-up complete. I congratulate you.”

“Hey, what about me?” roared the indignant patient. “Give me some credit, huh? I mean I’m the guy that told that stuff to Barney. He just wrote it down.”

Unruffled, Marks continued to address his student. “Can you tell me why you ruled out TLE?”

“Well, sir,” Barney began, frantically excavating his brain, “temporal lobe epilepsy would have been a possibility except he didn’t suffer from déjà vu or micropsia—the classic symptoms you associate with TLE.”

To which the eminent neurologist replied, “Hmm.”

Marks then bent over to make a long and careful study of Moretti’s face. At last he turned to address his acolytes. “Gentlemen, if you look carefully at the patient’s face you will note a very slight asymmetry. You will also note that his left eye is slightly higher than the right. We call this a ‘soft’ neurological sign.”

The students were duly impressed but could not see where Marks was leading.

“Now, if I may ask Mr. Moretti a few questions.”

“Me?” the patient said, his ego doing cartwheels. “Ask me anything.”

“Can you remember your birth?” the professor inquired.

“Of course,” Moretti answered, “the twelfth of February.”

“No,” Marks interrupted. “I mean the circumstances of
your birth. Do you recall your mother saying there were any difficulties?”

Moretti thought for a moment and then offered, “Actually, she did. I think they had to pull me out with those tongs.”

“I suspected so,” said Marks, with a little smile of satisfaction. And then to the students, “Forceps birth, facial asymmetry …” He pointed to the left side of the patient’s head. “Since he turned to the right when he seized, the lesion in the brain would be here. I think that, with due respect to Livingston’s conclusion, we are still dealing with a temporal lobe epilepsy, which can be confirmed by EEG.”

He then turned to his resident and said, “George, take the ball from here. If it checks out, we’ll get Moretti started on Dilantin.”

As Marks and his group of worshipers moved on to the next neurological enigma, he commented to Barney, “That was a tough one to call. You did a splendid job. Too bad you’re opting for psychiatry. You should become a real doctor.”

Pharmacology, though given relatively short shrift among the last of the preclinical courses, is in fact a discipline that can help determine the success or failure of a medical career.

It is not just that students learn about the composition of innumerable drugs, their actions, uses, and contra–indications. For all this can be found in the various expensively bound reference books behind a doctor’s desk. Rather, it is the physician’s ability to write a really good prescription and thereby win hearts and influence minds.

No patient will feel comforted unless he receives some sort of prescription—that little document with cryptographic scrawl—that proves his physician really
cares.