CHAPTER ONE Introduction VIGILS A monotone pulse penetrates my unconscious, wiggles between the sheets, and rouses me from my bed. I hobble toward the window where the alarm clock rests. With a flick it is silenced, and I gaze out to a billowing gray mist, the cool breath of Belfast Bay as it blows past my window on an early midsummer morning. It is 4:30 A.M., light enough to convince me that day has begun. Cats scampering underfoot, I creak downstairs and begin the morning chores. I grind the coffee and set it dripping, blend the crunchy cat food into raw scrambled egg for the felines, Kitty and Dinky, and choose the morning chants, which today are the Carmelite Vespers of George Frederick Handel, scored in sacred choral polyphony. There is an easy, unfettered satisfaction in these mechanical motions that gently wake me, and peel the sleep from my eyes. I smell the vapors of coffee dripping, hear the faint coughs of my wife and daughter stirring overhead in their gentle dreams, feel the vibration of wooden legs squeaking across the floor beneath me as I slide to my desk and create a time and place for the world opening to my imagination. What I see in my practice shapes my life. And through my writing I return to see it better: bits and strands of everyday medicine woven into one's conscience like a robin nesting, in a place where earaches and bellyaches, "bunches" and "risin's," or some unutterable sorrow provide the day's take in "accomplishment" or "insight" or, not uncommonly, a niggling sense of defeat. It is a world that seems light-years from the glamour, drama, or cutting edge of the university medical center, one where the rewards for your labor are found in the bargain bins and dumpsters of a general practice. The morning vigil to the computer has become my bread and butter, especially when I realize that in two brief hours I will lose control, sacrifice my calm to the chaos and appetites of a busy practice. So I tread here in search of happiness -- happiness in the form of order, peace, and solitude. These only do I need, because in love (from my family and friends) I am secure. For my patients, too, I wish this happiness. Do we share the goal if we should call it, say, "the desire to avert misery"? For what reason would they otherwise come? "Take your pills," I urge them, "quit the booze, lose weight if you hope to escape your father's stroke or his emphysema or his violent end." But these threats are toothless. Every prescription is written with a statistical faith; my orders draw from a tradition that is blind to the doubters and the disinclined, and to those who comply under the pain of death and die anyway. I cannot dispense happiness any more than a parent can hand it down. But I give to my patients a replenished heart and ears that will listen. I can hold up their fears and doubts and dispirited dreams as we strive toward that mutual goal happiness. This does not deny medical science its death-defying feats. But physicians realize that the hardest work begins when the cure is evasive and "the plan" is our only defense--plans fabricated countless times over countless days, by doctors and patients who infuse a diagnosis with different meanings in order to disperse the unknown and light the trail to their recovery; plans to create order; plans to sustain hope. Good planners do not bury those delicate moments. One time in ten or one in ten million, a patient stumbles, the doors of stubborn pride swing ajar, and raw feelings are exposed. Who is this man if not my neighbor, vulnerable yet deserving of God's grace? Only when I embrace him as my brother can I offer him something more than pills, more than companionship, but mercy also, and every intercession against despair. Through the journal, I have come to appreciate what doctors bring to the bedside. Not only skills and training, but also our very lives and needs. The challenge, we suddenly realize, is to give back to our patients more than we receive. And we know that we can succeed only by fostering in ourselves a deep sense of purpose and by sharing whatever blessings we find along the way. Luke makes this clear in his Gospel, "Give, and it shall be given to you. Good measure pressed down, shaken together, running over, will they pour into the fold of your garment. For the measure you measure with will be measured back to you" (Lk 6:37-38). Like the Medieval memento mori, the doctor's work, more than anything else, reminds us that our days are numbered. We are given in abundance what the psalmists craved: a chance to glimpse "the measure of my days, what it is, that I may know how frail I am" (Ps 39:4). The journal, more than anything else, is a compendium of stories that tell of the irrepressible human spirit, refined by adversity and renewed by love. We often hear that God is in the details. But why should He cling to so cluttered a plane? It is rather here--in the empty pages of a journal, and along the backwaters of our big-notioned society--that I seek my Maker. I have come on the counsel of Father Henri Nouwen, who finds "God dwelling where man steps back to give Him room." Of course, we are the ones stuck in the details; they dot our disjointed lives. This journal records the particulars of a life lived on the coast of Maine. Of Belfast and its seven thousand inhabitants, including my wife, Lindsay, and daughter, Clare. It is a story about my work and those who share it: my partner, Tim Hughes; my associates Scott and Mary Beth and Cathy; the countless nurses and office staff and patients who constitute the sublime pleasures of a medical practice. Through my practice I have discovered what Sir William Osler, father of American medicine, once observed: "Nothing will sustain you more potently than the power to recognise in your humdrum routine, as perhaps it may be thought, the true poetry of life--the poetry of the commonplace, of the ordinary man, of the plain, toil-worn woman, with their loves and their joys, their sorrows and griefs." The journal entries are merely bookmarks in a bountiful life. They are sketches from a year in medical practice, a string of facts and circumstances that have moved beyond the mere documentary. It has demanded of me--like the very act of writing--a stepping back, a giving over, a letting go. It has provided me with an awareness that one often reaches in the fifth mile of a run or the tenth year of a medical practice or when infatuation peels from the person you love. In finding my stride, I have found the reasons to run. The vigil is my daily comfort. But rarely do I appreciate it except in its absence, when I grumble at the interruptions or feel the knot of deprivation. It happens all too often, what with the exigencies of a hospital practice, the cries of a patient in labor, or a second glass of wine that follows the evening meal, all of which lie in ambush at the sound of the morning alarm. Then, not even the hunger sirens buried in the bellies of our felines (who expect to be fed by 5:00 A.M.) can rouse me from slumber or settle the cloud that hovers in my brain. Until I can return to my desk, I carry these memories inside me: an aftertaste of strong coffee, etched impressions of a flaming sunrise, the flicker of the computer screen, the touch of varnished butcher block, the click of plastic computer keys beneath my fingertips. They are the accouterments of my sacramental time ... time enough to snatch a handful of pages from a book, jot a letter to a long-neglected friend, or log an entry into my journal. Two hours of silence and solitude, when distractions dissolve, words weld themselves to the page, reminiscences are savored, and the heart heaves with joy and gratitude. Two hours that fold into the morning bustle, as twilight dissipates into the radiance of day, and the mists and fog burn off yet linger in the recesses of the mind. JULY What good will it do us to know merely that such things were said? The important thing is that they were lived. That they flow from an experience of the deeper levels of life. THOMAS MERTON The Wisdom of the Desert On a ridge of Route I, in the orange globe of the rising sun, two ungainly creatures mounted the pavement and ambled to the opposite wood. They were altogether too large for stray dogs, too clumsy for deer, too fearless for the coyotes that roam our rural coastline. Still squinting, and now barely pressing the accelerator, I realized that these beasts were a moose cow and her calf. The cow bent her head toward me, shook it whimsically, then nudged her calf down the opposite bank and disappeared into a stand of pine. I had needed a sign, longed for an apparition--some divine confirmation that I had come to the right place at the appointed time, that my journey was in some way sanctioned and secured and readied in advance. You see, I am a young physician of an older school, one who feels called to his practice and destined to be here. Yet, only a decade into my work, I am riding in the rut of despair. Now these early mornings I will curse less loudly at my inconvenience and offer the road to Elena. Almost six months ago, at the close of my sabbatical year, Elena Moulton was diagnosed with amyotrophic lateral sclerosis (better known as Lou Gehrig's Disease). This was not the first adversity she had faced in life. Elena was born an achondroplastic dwarf and raised by a rigid, overly protective mother. After college and her elopement with Harry, they adopted a son whom they later discovered was mentally retarded and emotionally impaired. But ALS is altogether different. It is a rare and invariably fatal neurologic disorder that whittles away at the body's functional capacities, rendering useless, first the limbs, then the larynx, and finally the muscles of swallowing and breathing. Elena had come to the second stage of her illness when I paid her that first call. I remember watching her struggle, nodding and grunting at a plexiglass message board as she tried to express herself with the remnants of a language. Two letters constructed, then three; a word, then another, until they strung together in a simple phrase. From my vantage I noticed the panic in Elena's eyes, saw the desperation in the wave of her head. Finally she could go no further, her efforts washed away by a flood of tears. The palpable tension between husband and sister (who had been hovering behind Elena) now ignited into petty bickering. At that moment I vowed to get Elena a computer and find a way to make it work. After several phone calls and a long talk with a local computer aficionado a plan was hatched: we would need a Macintosh computer, software that displayed a keyboard on the screen, and a pointing device that responded to head movement and a puff on a straw. How long could Elena maintain the necessary strength and head control, or have the lung capacity for puffing? I didn't know. When the materials finally arrived, I brought my computer to her home temporarily while I hunted for a loaner, just to get her started. And so began my early morning junket to the office in search of a computer from my personal use. Despite telephone calls and a personal visit to the Kodak Center for Creative Imaging in nearby Camden, I could not secure a computer for Elena. A week went by without leads. I lost patience, sunk into despair, imagined myself "The Writer" who had sacrificed his principal means of self-expression for his patient. It was a lovely, romantic, ennobling thought until the reality struck home: my computer was allowing a dying patient, with no use of her limbs or voice, to peck a bare-bones message--nothing but the basics of need and desire--to family and home health aides, who waited with Job-like patience at the computer's side. In a few days, Elena developed a head cold. The abundance of mucous and saliva, difficult to clear or suction from the throat under the best of circumstances, was now audibly gurgling in her chest, and causing her, and those around her, untold mental anguish. Elena once confessed to me, while speaking of her prognosis, her two greatest fears: choking to death and dying alone. Before I could return a telephone call to the family, they had summoned the ambulance and whisked Elena to the hospital, where I would care for her over the next five days. It was a trial run, working out the kinks for the more urgent journey they saw looming ahead; Elena's X-ray, blood counts, vital signs were all normal, and she happily discovered the security and attention that a hospital could offer. The oxygen and IV antibiotics had done little more than justify the necessity of her admission. In the meantime, I seized the opportunity to take my computer back and puttered happily on it for the few days that Elena recuperated in the hospital. As the discharge date neared, I explained to her that I was looking for a larger screen, something easier to work with. True, I admitted to myself, but far-fetched. Three days passed and still no computer in Elena's home. My great pleasure--my mornings at the computer--was now guilt-ridden by the injustice: I had stolen Elena's computer for my own use, solely for the recreation of it. I must give it up Five days after Elena's return from the hospital, I brought back her Macintosh with apology and regret. "Sorry, but I struck out, Elena; I have no larger screen for you, just this homely little Classic." Elena's eyes gleamed as I set up the computer, and she motioned for me to mount the headset. I watched intently as she marched the first eleven letters onto the screen: nice machine. Red-faced, I now felt redeemed by the Elena's quick, accepting smile. For whatever the reason, after the computer, after that trip to the hospital Elena changed. For the first time in months, she asked to leave her home in order to visit her mother in a nursing home. She typed messages to her nurses, a moving account of which was reported to me yesterday. When asked about the most difficult part of having ALS, she listed, first, her inability to speak; second, her struggle to get an itch properly scratched. Now the computer sings sonnets for Elena. And in the past two weeks, there has been new movement, rediscovered strength in those stubby fingers, in her limp and dangling legs, and a growing stamina for holding herself erect, a posture essential for puffing at the computer. But recovery is virtually unknown in ALS. Elena attributes her improvement to the oxygen she received in the hospital, reading somewhere that patients with multiple sclerosis benefit from hyperbaric oxygen. If not from that, then from the antibiotics. What Elena has "recovered" from, at the very least, is the hopelessness of her condition. She has reclaimed a life and the possibility of living, perhaps more fully and for however long, in the good fight against her relentless slide toward that moment when at last she will be stripped clean of all her capacities. In her trip to the hospital, Elena had faced death and flown home again. And she continues to live, ever so convincingly, with the love and attention of her husband, son, and caregivers--and with that homely little box that has given her a voice. After returning from three days of vacation, mounds of charts towered above my desk and clamored for attention: abnormal laboratory tests; requests for disability reports; phone messages from visiting nurses and referring physicians; phone messages from patients needing a clarification of their prescriptions, their diet, their progress, all begging for "only a minute of your time, doctor." Before breakfast with Lindsay and Clare at 7:30 A.M., I must hospitalize a patient with hyperemesis gravidarum who has come here more for the indoor plumbing than a magic cure. No doubt I will disappoint her; my role is peripheral, just a twelve-hour plug in the hospital dike. It promises to be quite a year: I am the reputed age of Jack Benny and will engage my fortieth year in a few fleeting months. But more ominous is the failing health of my mother. She convalesces now in a nursing home, following surgery at University Hospitals to evacuate a blood clot beneath her skull. She had fallen at home, a victim of her drinking and memory loss and poor balance, all of which will continue to plague her after the surgery. She will never return home. Her apartment, in my hometown of Rolfe, Iowa, lies waiting, furnished and heated and hauntingly empty. But Mom is growing accustomed to the security of her new surroundings, the reliability of three square meals and the companionship of her nurses and neighbors. Fortunately, with her poor memory, she does not press the issue of going home. And the chances diminish with each passing day. As her life crumbles, I in turn lose that Maginot Line that separates youth from old age. Is this not the cause of the midlife crisis, rather than what they would have you believe: the slip-sliding away of your youthful dreams, or the discovery that the promise of material success was an empty one? Another momentous decision faces Lindsay and me: will we add to our family, give Clare a sibling, or call it quits in our advancing years? Our four-year-old has raced beyond infancy. Could we recapture it with the life of another, toss the dice once more for a package of healthy genes, brace ourselves for the sleepless nights and endless interruptions, scramble our plans again for God knows how long? I am covering the Fourth of July weekend for family practice. At a moment's notice I could be summoned for a hospital admission, emergency room consultation, obstetrical delivery, medical examiner's case, telephone call from a worried patient, or a surgical assist. The beeper at my waist is the devil's plaything. On most occasions I suffer the "on-call" role gladly. Patients appreciate you more on weekends, especially the tourists passing through. The work is considered "extra," something above and beyond the call of duty, and sets the doctor apart, marks his devotion, elevates his cause, and earns his place at the banquet where the chronically overworked and underpaid are said to feast. A beeper, moreover, provides a convenient excuse for a late arrival or early departure at the Hospital Aide Potluck Dinner. But it cuts both ways; it may equally deprive me of a moment's peace, a quiet run, a warm supper with my family, or an uninterrupted night's sleep. I have, over these last eight years, made peace with the beeper. I now try to erase every expectation from the on-call weekend, and accept whatever morsel of free time falls my way. Before, I resented the burden, hated the patients who abused me, who got sick "stupidly" or at the most inopportune time, or who waited too long and by rights should be forced to wait a day or two longer. The illusion of freedom, the wisp of hope that I could enjoy such a weekend, became my curse and suffering. Cursing and suffrage brought me to the crux of the matter: After choosing this career, could I swallow the responsibility? But only after doing so could I enjoy a life in medicine. The idea sounds saintly--perhaps even dysfunctional, in the way martyrdom has been revisioned--but it is key to a country doctor's survival. One patient of mine is in labor; six others rest comfortably in their hospital beds. I have only a few clinical quandaries left hanging from the workweek: a child, feverish and fussy and eating poorly for three days, whose illness I am calling viral; an emphysematous man with chest pain, right-sided and knifelike. A chest X-ray would be useless in the diagnosis of pneumonia or bronchitis, so I will treat the pain only. I am reassured by the absence of cough, fever, or shortness of breath and suggest that he take ibuprofen. A young woman with abdominal pain has defied my testing; her thick chart suggests an hysterical personality, but she rejects any suggestion that stress or anxiety may be contributing to her pain. And she flaunts the episode when--after eleven days of hospital testing--a surgeon opened her belly and found the adhesions that were responsible for her pain. Now the family is outraged that "these doctors" cannot fix her. I am temporizing, playing for time, hoping to find my patient an honorable out when the tests return negative. She does not need any more surgery, which has already cost her several dispensable organs. But the more tests we perform, the longer the hospital stay, the more inflated the bill, the higher the stakes. And, as I am frequently reminded, tests can be wrong. Maybe this weekend I can turn the compost, mow the lawn, go for a long run, fly a kite with my daughter, treat her to lunch in the hospital cafeteria, or play long enough for my wife to make a hospice visit. But, as is often the case, maybe I can't. It was a dismal showing, yesterday's log. A long and arduous labor ended in cesarean section at 6:00 P.M., and that was the crown jewel of my accomplishments. She had consumed most of the day's worry. She had been laboring for two days, stop and go, when I finally ruptured her bag of waters. There was every good reason to get on with it: she was five days overdue, had a ripened cervix, and was running low on energy and optimism. When a strong contraction pattern did not ensue, I gave her a sedative. She woke up often during the night with irregular pains, and by morning the contractions were still five to eight minutes apart. So Pitocin was started to intensify the pains and narrow their frequency. It worked well enough; the cervix reluctantly widened, and by 2:00 P.M. she was pushing. The deep decelerations that had plagued her earlier continued into the second stage, so I remained close by. Finally, after three hours of pushing in every conceivable position and with no descent of the head, I called for a C-section. These are the worst of labors: hours of intense pain that come to naught under the quick and anesthetized slice of the surgeon's scalpel; fretting over falling fetal heart rates, suffering the cries and moans of the labor bed, hesitating to call for the section despite the mounting need, and finally summoning the OR crew on a sunny holiday afternoon. A doctor learns most about himself in the face of adversity. Coming to the correct diagnosis, initiating appropriate treatment, assuring the cure of a patient through the glorious exercise of science ... a rare outcome, indeed. Most of the time, the patient gets better regardless of what we know or do. After a few years in the trenches, doctors face this truth and adjust accordingly. The more basic need is for companionship in the patient's struggle. Our patients ask us to help them bear the pain, quiet their fears, face the certain diagnosis of cancer or an incurable condition. Often our own bellies tighten as we see ourselves, or our families, in the frantic eyes of the patient, and we shudder at that reality. I cannot sit with a laboring mom without reliving, in some small way, my wife's three hours of pushing before the birth of our daughter. I cannot erase the anger of patients or their families who felt I hesitated too long in ordering a C-section; cannot forget the limp and ghostly babies I have pulled from between their mothers' legs after a series of deep decelerations in the fetal heart rate, or the embarrassment of calling in the surgical cavalry only to have the mother deliver in the wings of the OR. Any doctor can make the right diagnosis and do the right thing; our regimented training secures that claim. But how do we, individually, connect with our patients, knowing when and in what ways they will need our support, our frankness, our heavy-handed opinions? At best, I serve as their guide. Doctors have grown familiar with the terrain of pain and fear. Patients trust us to stare without blinking at their base instincts and unguarded moods, having seen them all, having grown accustomed to our own. We are expected to recognize the truth of their lives without messy revelations. Surprisingly, we sometimes do. But these understandings cannot be taught in the way a skill or technique can be taught. They are not a shamanic gift. They rather emerge slowly over time to those who outlast a million complaints in a thousand stuffy exam rooms, over the wail of toddlers, in the instant before the patient permits your escape. It is a waiting game out there along the parade route of cures and declines. Of the many chores I had hoped to accomplish yesterday, I succeeded in finding only fifteen minutes for the compost. It is now a dense, rich, aromatic mixture of grass clippings, leaves, kitchen scraps, and other organic debris. How satisfying to watch nature digest itself. I enjoy the outdoor, backbreaking work, the steamy stench of it all, the smell of silage wafting from my Iowa boyhood, this tiny token for the environment. Now, if only our manure man would deliver, our compost could attract even fatter worms, which are the gardener's benchmark of good soil. Of course I lay no claim to the title "gardener." It properly belongs to my wife, Lindsay. I am here for the spading, the lugging, the sheer progress of it all. You cannot take the farm out of the Iowa-born boy. The most depressing part of the long weekend was yesterday's endless showers. Lindsay played Leonard Cohen and we ran the furnace to lift the damp and chill; at noon it was fifty degrees out of doors. Last night we celebrated an Olde-Fashioned Fourth by racing around the backyard with jumbo sparklers. Afterward, we hunted for night crawlers. Clare is unabashed about grabbing almost any slithery thing (except slugs, which she prefers to skewer with a stick) and is apprenticing in the art of hunting crawlers. The key, of course, is to search on the eve of a steady rain, shortly after dusk, skimming the beam of a flashlight over the bare earth. First identify the tip of the crawler, then swoop toward the end nearest the hole. Crawlers escape at lightning speed and exert a tremendous pull once they have gained a toehold. A soft approach and quick wrist are the essentials of the art. Yesterday morning I toured the hospital, visiting my convalescing patients in the ICU, OB department, and medical-surgical floor. In the afternoon, I admitted a patient with severe bullous emphysema, saw another with lobar pneumonia (a dwarf known as Yoda in the nursing home) in the emergency room, and consulted on an orthopedic patient with delirium. The hardest part of the weekend was OB. When obstetrics is good, it is very, very good, but when it is bad it is horrid. My patient presented to OB at 7:00 Sunday evening, with a recurrent, irregular backache that had deprived her of sleep the night before. Now her cervix was seven centimeters dilated, membranes bulged with each contraction, and we conspired to rupture them, thus calling labor's bluff. Active labor ensued. By 11:15 P.M. she was bone-tired but fully dilated and ready to push; I watched her nod between the pains. Almost the same history, I recalled, as the patient we sectioned two days ago. We prodded her into a squatting crouch next to the bed, then onto her hands and knees, and finally into an upright sitting position supported by a horizontal bar. She simply could not budge the head beyond the narrows of her pelvis. Stuck, frustrated, exhausted. I stayed with her throughout most of her gymnastics, coached and supported her in labor, tried not to show my concern when two hours had elapsed, then another half hour, then another. Finally I approached her with the options, waited for her nod of approval, met the eyes of that wide gentle face now drained of all vitality and dotted red from pushing. Labor wound down to this moment of truth, when the patient and her doctor abandoned hopes for a "natural" birth. It had been a good, hard, well-managed campaign. Why a baby cannot pass is almost never known, hence the vague alibi "failure to progress." The patient and the operation cry for a more satisfying explanation. Questions gnaw in the minds of the doctor, the mother, her family: why did we fail; should we have persevered longer, intervened sooner, tried one more maneuver or an aliquot of Pitocin? I return to the medical-surgical floor at 4:00 A.M. after the section, only to learn of another admission waiting for me down the hall, moaning quietly beyond the darkened doorway. I owe my mother a telephone call. It has been put aside for two weeks as one day's duties have spilled into the next. But her forwarded mail--volumes of Medicare and Blue Cross "explanations of health care benefits"--jogs my memory. As Mom's power-of-attorney, I also collect her interest earnings and dividend checks, money that offsets the high cost of convalescence. On my last visit to Rolfe I finally looked squarely into her finances. She had been after me to do it for years, wedging her requests into the first fifteen minutes of every visit home. "When I die," she would insist, "everything is in the safety deposit box at the bank. Mary and Rosella (my aunt and uncle, our closest relatives) will take care of the funeral arrangements, pick out the dress, see to the obituary. Just don't you kids fight." I spent two hours in a stuffy cubicle at the Rolfe State Bank sorting through legal documents from the family estate. It was, in ways I could not have imagined, a nostalgic time. Here was material proof of my father's hard work and devotion, the evidence to support his claims. I was twelve years old the year before he died. How clearly I can remember the five of us seated around the supper table, listening to my father's declaration, while his hand hit the table like a gavel, "I just want you kids to know that, when I die, you will be well taken care of." How ridiculous to imagine! When I die! We might as well worry, as my mother once did, about being nailed by falling Skylab debris. But there it was, irrefurable proof. After his death, our material lives marched on: we still vacationed at Lake Okoboji, bought a new Chevrolet every third year, pursued our college interviews, received help with mortgage down payments and the much-needed checks at Christmas time and after the arrival of our first child, Clare. And still there was an estate, built by my father during a scant fifteen years in general practice, and preserved by my mother with the motto "Never go into principle." It was, to an older generation, proof of parental love, of family values, of duty and devotion, of a responsibility fulfilled. It sustained my sense of importance, the feeling that I was set apart, endowed, heir to something beyond a tiny farming community and the glory of high school success. I am sure that love and attention and sacrifice were the active agents in the creation of what is now popularly called self-esteem, but accomplished with an impressive sleight of hand. I never knew it then. And what remains is my parents' estate. So now, as I handle my mother's retirement checks, earned on the house calls and home deliveries that took my father from us, I have a greater sense of their love. These are not a substitute for horsey rides on my father's knee, or whisker rubs, or home movies in which I was the star, but they are love just the same, in a different package. Today is electric with anticipation. At 5:00 A.M. the air is sweet and warm, and the yolk of a sun is cracking through an absolutely clear eastern sky. My desks at home and office are symmetrically tidy and unfettered by obligation. This morning I will meet with Cathy, our office manager, for the weekly business report, visit briefly with a patient, mow the lawn, buy a birthday gift, and pen a letter to a friend. I will return a dulcimer to Bob Ranney, along with the book he loaned me, and a copy of a reference letter I have prepared for him. Bob grew up across the street from me in Rolfe, Iowa, on a wide and shady thoroughfare lined by elms. The Ranneys and the Loxterkamps, 807 West Elm Street and 808, local dentist and doctor, respectively. Bob, ten years my senior, took an early interest in me, looked me up on Christmas breaks for basketball in the school gym, then invited me to his Walden Pond when I turned college age, a place called Bull Creek in the Missouri Ozarks. It sealed our friendship, those sweet nights of Harry Carey baseball on the St. Louis Cardinals sports channel, unlimited watermelon, sumac lemonade (our marketing strategy would pitch the name Sumade), and stories of my father, dead these half-dozen years, whom Bob knew in a way I hungered for, at Dad's heels on many a home visit. The birthday gift is for my partner, Tim Hughes, who always appreciates a good book or gag gift but not the social obligation that birthdays sometimes impose. We will gather tonight, husbands and wives, for a celebration six days in advance. The ostensible reason will be to report on recent travels: Tim's trip to Disney World and his wife (Cris) and daughter's (Rozy) sojourn to a Friends retreat. I know now that Cris's hopes were not fulfilled. Will we broach the question, raised in recent conversations, of why bright, talented, likable doctors' wives lose their way in search of self or career? Are they attracted to the doctor's iron-clad identity and sense of purpose? Do they take as their own his displaced doubts and uncertainties? Of course, there's the rub, because our roles become polarized and fixed through the daily grind. Lindsay has commented on what a relief it is--almost a pleasure--when I become downcast, when my boundless energy slackens and I lose my competitive edge. Such moments come rarely. I witnessed this once in my partner, during my sabbatical year, when the doubled work load dampened his spirits. But it is far more difficult to detect, or to acknowledge, in myself. Yet here we are in marriage, making do. It does no good to say "girls, buck up, deal with your problems," even if the roots lie in the social or biochemical circuitry of their brains. Mary Beth Leone, the therapist who works our office, has two doctors' wives for clients and knows Lindsay and Cris well. She sees in all of us that peculiar and intriguing equation. But how to understand it, reshuffle it, right the balance that elevates the doctor and subordinates his wife? More on that tonight over dessert and presents. We had a very robust evening together, Tim and Cris, Lindsay and I, in honor of Tim's forty-first birthday. Questions of mood did not arise. Instead we talked of travel. Ever since moving to town eight years ago, we have cultivated a tradition of celebrating birthdays together. Last night we gave Tim an astrologically appropriate pet (a hermit crab whom he dubbed "Hermes"), a worry stone, and a fake rubber hand. He especially liked the package illustration of a hand emerging from a vest pocket, a cargo trunk, and the fly of a pair of trousers. Our final gift was a book on death and spirituality, wrapped in the cover of John Berger's A Fortunate Man. Berger's 1967 account of the life of a country doctor in rural England is still, a decade since I discovered it, my favorite doctor story. Last year I gave Tim a copy for the second time, a gaffe he did not let pass unnoticed. So I created the appearance of giving it a third time. Yesterday, after celebrating Mary Beth's birthday at noon, the room began to spiral with loud chatter and wild gesticulations; suddenly I felt compelled to remove myself to the doctor's room and sit silently with my thoughts and creeping mood. Patients would arrive in a few minutes. If I began late, I would run late and finish even later with each successive patient. So it was imperative that I rock myself out of the rut and begin on time. The tension in my upper back and neck, the heaviness of my eyes, the dullness of my thoughts had suggested to me all morning that something physical was wrong. Then, at the noon staff meeting, I could say nothing that, once beyond my lips, did not twist itself into dark humor, a supercilious statement, or a belabored point. Why not shut up and let the meeting pass as painlessly as possible? The afternoon drained me. I seemed forever on the verge of a yawn. I gazed helplessly out the window, hoping for simple patients with simple needs who would ask nothing more of me than a prescription refill, who would not judge my lackluster performance unkindly. There was nothing in it for me, not an ounce of pleasure. No pull into the lives of my patients, no tolerance or pity for their problems. It was as if the electromagnetic current had been severed. My eyeballs felt like lead shot, the inside of my head was a washing machine. Comments from my partner--innocent on the surface--seemed terse and critical and cutting. The nurses chattered incessantly, aimlessly, hurtfully. I did not trust the advice I was giving my patients, so I ventured nothing beyond the simple, safe, and automatic. Lindsay was working in the office that day. Had she been ignoring my gaze? Had all the affection between us gone? Did I notice a perky employee too conspicuously? Why was everything an annoyance and a distraction? By midafternoon the tide was ebbing, and I recognized depression for what it was. Yet it never feels like depression. It will leave for a week, perhaps a month, and then sweep back in a tempest. Thank God it is brief, lasting a day or two at the most. I can ignore it--even, at times, convince myself that it is the full moon conspiring, or a virus replicating, or pure exhaustion taking its toll. But today I have no clear answer. It is, in some ways, a blessing. It is a peephole into depression, one day's share in what others--my patients, my family, my wife included--battle daily. Will they find happiness or optimism or energy? Or will they travel their whole lives with the sorrowful mysteries strapped to their backs? I feel better today. I am typing, enjoying a flaming-orange sunrise, and listening to chirping birds and Handel's Carmelite Vespers. I hope to enjoy a part of the day with Lindsay. Perhaps I will run this afternoon, or return a letter to Gayle Stephens, who has been my writing mentor for the last fourteen years. We are not friends, I readily admit. If you pushed us onto the open floor at a medical convention, our talk would turn stiff and formal. We are constrained, I suppose, by our manhood, our doctorhood, and differences of a generation. But there is an affection between us, a bond and an abiding respect. Gayle is one of the most admired essayists in family medicine, a moral being whose vitality over the years--I am now convinced--has been maintained by a proximity to his patients, and to their sorrows and ills. Recently he sent me two pieces awaiting publication. Both are very good and a pleasure to read in their raw form, before the publisher has edited them. In his letter he mentions his new role as a retired physician, "an informal consultant to friends, neighbors and former patients." He speaks of his patients, a black women with ALS, a lady in his church whose husband is alcoholic. Gayle is the associate editor of the Journal of the American Board of Family Practice and has, most ardently and patiently over the years, encouraged me to write. Because of him, I have sent a few stories to the JABFP, which, with his editorial help, were accepted. He now tells me that the journal has created a new column called "Reflections in Family Practice" that is ideally suited to the stories I spawn. So I'll enjoy returning Gayle's letter, reporting on my life in Maine, and unveiling my plans for this diary. Standing on the back stoop, I face a cool southerly breeze and its threat of rain, smell the heavenly valerian standing shoulder-height beside me, hear the caw of distant crows and the wheeip, wheeip, chir chir chir chir of our cardinal-in-residence, and ready myself for a run. I look forward to the long stream of purple and pink lupines along the backstretch of Route I, where the goldfinches nest and scatter from me as I churn past. Today is the Feast of St. Benedict, abbot, father of Western Monasticism, writer of The Rule to which all Roman Catholic monks adhere in one form or another. I will make a special point of going to 7:30 Mass. There is much to be thankful for in the fruits of Benedict's labor. I have come inexplicably to his monastic tradition: the Gregorian chant, simple Cistercian architecture, the writings of Thomas Merton, retreats to the Trappist abbeys at New Mellary near Dubuque, Iowa, and St. Joseph's in Spencer, Massachusetts, and New Clairvaux near Vina, California. I love the order of their day: work and contemplation punctuated by common prayer. The offices, as they are called, gather the monks seven times a day to sing the psalms, listen to the Word of God, and celebrate Mass. It is precisely this order that I rebel against in my own chaotic life. Yet chaos is no better. I long for structure that is freely chosen, that strengthens my work and focuses my energy, that liberates me from the zillion dispensable decisions of daily living, that creates a space for the All and helps me sift for the essential and come to terms with my fears and insecurities and loneliness. It is tempting to discard such structure and let life be manipulated, distracted, and deluged by the cornucopia of choices in the Land of the Free. Yesterday Lindsay and I shared a lovely drive to Rockland, where we shopped for shrubs for the front yard. Lindsay's great passion is gardening, the only family trait (other than love of the evening news) that she readily acknowledges. She enjoys nearly all aspects of horticulture--naming the names (for which she has a categorical gift), absorbing sun and wind and dirt, composting and fertilizing the earth, ordering the grounds, picking the wildflower bouquets, and drawing in the fragrance of sweet flowers, only a trace of which can I appreciate. She is forever shouting, on an evening walk or during a tour through a neighbor's garden, "what's that incredible scent?" Then searching wildly for a flowering tree, shrub, or garden row until she has located the source of her delight. I first met Lindsay in Hyde Park while attending the University of Chicago. I was working on a master's degree in the social sciences, she as a clerk in the catacombs of the basement bookstore called Seminary Coop. And though she was seeing someone else at the time (on a daily basis, actually: they were living together), she agreed to meet me for beer and conversation at the Woodlawn Tap, better known on campus as Jimmy's. That was January 26, 1983, a date more secure in my feeble mind than the day of our wedding. We quickly became friends, correspondents, travel companions, paramours. Lindsay found me an easy conversationalist, someone who returned her probing questions as fast as she dealt them. She thought my work "interesting," at least in comparison to tales from the polymer chemistry lab, where her old boyfriend worked. I, on the other hand, liked her looks--fresh, petite, brown-eyed, mysterious, and pretty. I enjoyed her interest in books, films, ideas. I shared her passion for diners, Thai food, strange beer, and old bars, like the venerable Berghoff in Chicago's Loop. I loved her peculiar and active curiosity. I loved, too, her precise, clipped manner of speaking, heavy on the consonants; her languages, French and Latin; and the worldly experiences she had amassed at such a tender age: raised in Washington, D.C., she had traveled in England and lived briefly in New York, Paris, and Chicago. For all the sizzle of courtship, our year and a half together in Chicago had its trials. I felt awkward around Lindsay's friends, with whom she seemed hopelessly entwined. I felt needled by her opinions, which were sharp and plentiful, judging and cajoling, as if she expected me to spar with her, to return them tit for tat. But it was not my nature. I felt it a duty almost to stifle opinion: as a doctor, you are there to support the patient, apprise him of the bare clinical facts only, which often meant overlooking, at least for the moment, his carelessness or stupidity, his inattention to hygiene or good manners. On the other hand, Lindsay was not enamored with my friends either, and she was forced to ignore the poor taste I displayed in what I wore and what I drove, where I lived and how I "accessorized." Her old boyfriend had been a "stylish, young, urban esthete," while I was an apparition out of Middle America, the acrylic-on-velvet big-eyed boy you could find hanging above any living room sofa. Our move to Maine was as much an escape from my belongings as it was our adventure of a lifetime that we would risk together. Lindsay, like all of us, is a strange combination of her parents. She grew up in suburban Washington, the last of three daughters born to a Jack-Mormon journalist and a commanding Presbyterian housewife. From Ray she inherited a love of words and their uses; from Helen, a ticket to perform with the Little Singers of Montgomery County, who exposed her to foreign language through a repertoire of twenty-seven different national anthems. From Ray she acquired a love of gardening; from Helen, an aversion to organized religion. From Ray she derived her relaxed, disarming chuckle; from Helen, her sharp opinions that intensified as they descended in a line from sister to sister. From Ray she got skinny, hairless legs; from Helen, the fear of dying young, as Helen had (of ovarian cancer) when Lindsay was fourteen, and as Helen's mother had when Helen was twelve. But it was this early death that liberated Lindsay during her rebellious teenage years, and it gave us, Lindsay and me, that similar excavation of the heart that distinguishes the child who has lost a parent prematurely. Lindsay also inherited Helen's tortured ambivalence about career and motherhood. When Helen's mother died, Helen assumed the domestic chores of cooking and cleaning for her father and three brothers. But fortune shone when Aunt Emily invited her to come to Philadelphia and attend Girls' High School. She advanced to college, thoroughly enjoyed it, majored in math and physics. After college she took a job with Eastman Kodak in Rochester, New York, where her talents were recognized. Then war broke out, and she was off to the Women's Army Corps as an intelligence officer in charge of aerial photography. During her wartime travels, she met Lindsay's father. When the war ended, they were married and moved to Rochester so that Helen could resume her career with Eastman Kodak. But conditions had changed: the G.I.s flooded home, Helen's desk was moved into the hall, and she was passed over for promotion. Her spirits sagged. Bowing to the advice of friends and the dictates of society, she had a baby. The baby did not adjust to kindergarten, and it was advised that Helen have a second child to support the first. The young family moved to Bethesda, where Ray became employed as a speechwriter on Capitol Hill. Helen's unhappiness deepened, especially after the birth of their last child, Lindsay. Her dreams of career vanished only to resurface as the hopes and ambitions she would fashion for her daughters. I am not sure if this helps to explain the quandary we faced as we contemplated having a baby. Lindsay seemed poisoned by a desire for career that had been force-fed to her as a child. She was afraid of losing herself to play groups, burp pads, and the latest notions in Parent magazine. She had grave doubts about her abilities or worthiness as a mother, especially given the truncated and distorted example left by her mother. Marriage to a physician only complicated matters. Doctors are afforded an instant prestige, instant identity, instant career. And Lindsay worried, "When you're on call, I'm on call, so that I won't have a life, basically. I'll be as tied to a baby as you are to your practice, which is something I don't think most doctors remember or fully appreciate. I'll wait for you to jump and run out the door." But we have a child, thanks to our therapist, Mary Beth Leone, and thanks to Lindsay's courage, and thanks be to God who blew that tiny spark into our lives. I am indebted to Lindsay for her steadfast loyalty; for her affections (sometimes distant or spare) that are, at any rate, more generous and spontaneous than I deserve; for her sensitivity and her gentle tears that fall during a sentimental movie or a sappy poem I pen on a birthday card; for her exquisite taste (and sense of smell); and her own opinions, which have softened through the years to sift comfortably through our conversations in the waning moments of a day. I set out at a trot down the sloping hill toward the Bay, admiring the placid, pale waters before me that stretch toward Blue Hill and Cadillac Mountain. My legs are rubber bands, wound for action, and I feel the firmness of my undercarriage, the sureness of my knees and ankles. There is in me a full-headed, deep-rooted, summer enthusiasm for the call of the road. An offshore breeze billows through my T-shirt and cotton shorts. Within a half block, I turn left on High Street, the town's major artery. Here the streets take a different name in each direction: Northport Avenue to the right, Condon Street ahead, Salmond to the rear; as always, I proceed left along High Street, holding back the horses, tempering the pace for the long run ahead. High Street is canopied by towering black locusts, maples, oaks, beach. I run past old mansions and estates that date from Belfast's era of affluence, the period of the American Greek Revival in the mid-nineteenth century, when she built and sailed vessels the world over. At Peach Street and on through Park, my stride lengthens as I lope down the hill. Here the peeling paint and storefront facades begin to mark what has become the commercial district. On the left I pass a nursing home, the group home, the Belfast Free Library, and finally reach the downtown. We cherish this cluster of large, brick buildings, including the Masonic Temple and the Progressive Age Building, whose faded letters boast of "Steam-powered Printing." Most was rebuilt in brick after the devastating fires of 1865 and 1873, and is listed on the National Historic Register. I sneak under the stop light at High and Main, the only one of its kind in Waldo County. On past the McClintock Block and Phoenix Row, whose upper apartments teem with the Welfare crowd, youths raising youths, where I have thrice visited wearing the coroner's badge. On past Colonial Cinema, City Hall, the Courthouse, and a large, weathered frame structure that once housed U Otta Bowl, a candlepin alley that was still operating when we moved to town. It is an easy run thus far, with time and inclination to let the mind wander and take in the public bustle. But now High Street turns up Primrose Hill, a grouping of eight impressive homes that mirror the historic affluence of Upper High Street. Admiral Pratt's estate is principal among these. This is my first test, the journey's leg that tunes the hamstrings and readies the diaphragm and rectus abdomini for the approaching campaign. In the next mile, I will be leaving Belfast, running past the Gov. Anderson School, the Head Start grounds, the old Waldo Shoe Factory (one of the last to close), and the overpass of Routes 1 and 3, which lead the tourists to Bar Harbor and Acadia National Park. And then, suddenly (even to a runner), the trail drops away, down, down to become City Point Road. The air chills and dampens in the shaded overgrowth. Dilapidated shacks (what the realtors call "camps") peek timidly out from behind the trees; Budweiser packages, bald tires, plastic motor oil quarts, cigarette wrappers are littered along the route. For the next half mile, the Belfast & Moosehead Railroad parallels my path. These tracks once hauled grain and other products to support a thriving poultry industry; it too has failed, and now tourists travel the twenty-five-mile round-trip excursion to nowhere, to the interior where the real Maine, of trailers and junked up dooryards, is stowed away. Out on City Point Road and across the Upper Bridge, Belfast village first rose on its toddling legs. Passage there challenges the runner with a series of steep hills along a twisting, narrow ribbon of road that shoulders the Passagassawakeag River. Finally the terrain levels out, and I cross the bridge to Head of Tide. Here, houses are not as grand or well kept as those closer to village center. But they date from Belfast's beginning, a fact established by a plaque on the homestead of Glenview Farm, "Est. 1798." Capes, federals, gambrels, and saltboxes all intermingle, dogs jerk at their chains, the smell of honeysuckle and the brilliant flash of poppies greet the runner as he glides by. The air warms and sweetens in the open sunlight. It can be stagnant and thick with mosquitoes and black flies, but today a light breeze dries the sweat from my brow. On this half mile, my legs finally stretch to relive the wide-open runs of my youth on the Iowa prairie. I spot an Osprey nest atop the utility pole, dodge red-wing blackbirds who defend their marshy nests, and smell the mud baking in the tidal basin below. Finally I begin the ascent. The next mile is alternately a gradual, then steep, climb away from the sea. I set a pace and cling to it. After a quarter mile, the road turns back toward town, south on the Doak Road, over a gorge where rapids roar and sharp plates of slate jut into the broiling stream. In the spring when the Passy is full, this is the most serene place on earth. But no time to gaze. The road rises menacingly and I focus on survival. Sweat pools in my eye sockets. My legs ache and lungs strain for oxygen. Up past the cemetery where I once paused, rich in sea lore. I remember the captains buried here: F. A. Patterson, Simeon Rider, and Charles Brier, whose son Henry died at sea on October 6th, 1860. Martha J. Mayhew's children honored their mother with poetry etched in stone: Heaven retaineth now our treasure. Earth the precious casket keeps. And we often love to linger where our dearest mother sleeps. As for their father, the Captain Vinal Mayhew, they put it plainly: "To Die Is Gain." Here lie George U. White and his three wives; Eliza Jane, dead at the tender age of thirty; Katie, gone at thirty-eight, and Sarah, who buried her husband and lived twelve years a widow. Here lie the Soldiers of '61, brothers A. F. and F. A. Patterson, Jr., representing Company H of the Eighth Maine Regiment and Company K of the Fourth Maine Regiment, respectively. The latter survived the war only to perish "On the passage from Africa to New York, AE 35 Years." I keep climbing, climbing, hoping to catch my breath as the upward grade slackens. I push past the old Doak homestead, appropriated now by the general surgeon, and the Doak Repair Shop, owned and operated by a direct descendant. Still climbing, I pinch the stinging brine from my eyes and fight to hold the pace. I am always, on this stretch, pierced by the loneliness of the long-distance runner. I speak not of solitude, for that is a welcome companion in my line of work. I have never passed a runner on this route, nor do I nod to cars that rocket by, or wave to the old men mired in their dooryards. I give up intention, all conscious thought. I slip inward to where the question is put in inescapable terms: why do you run? what makes you a runner? It is not for the endorphins or for a longer life, though I would not begrudge a runner these reasons. I, too, am in training. It is the distance that attracts me, the long haul. It is the solitude; it is a challenge in such simplified terms; it is the lure of accomplishment; it is the sense of sole responsibility. I relish, too, the sweat and strain, the responsiveness of muscle and will. I enact, on manageable terms, our lifelong journey through time and space, at a more livable, observable, thinkable speed. For the seventeen-year-old in Alan Sillitoe's novella, "This long-distance running is the best lark of all ... [A]s soon as I take that first flying leap out into the frosty grass of an early morning when even birds haven't the heart to whistle, I get to thinking, and that's what I like. I go my rounds in a dream, turning at lane or footpath corners without knowing I'm turning, leaping brooks without knowing they're there, and shouting good morning to the early cow-milker without seeing him. The long-distance run of an early morning makes me think that every run like this is a life a little life, I know--but a life as full of misery and happiness and things happening as you can ever get really around yourself" (p. 10). Finally I crest the hill and stare a quarter mile down the wooded valley. I know now that I'll have the lungs to finish, though the steepest climb looms ahead. I clear the summit, recover my wind, straighten my drooping frame, and picture the graceful, undulating, two-mile stretch of road home. The race is over. I accept the accolades, the melodramatic finish, the chance to untangle my knotted legs. I sail past the redemption center, legs rebounding; past the new high school, lungs sucking deeply; arrive at the downtown from Waldo Avenue and slide past the Post Office and Customs House, the First Church and William J. Crosby School, and along picturesque Church Street, with houses boasting their considerable age. At last I draw a bead on the stop sign at the end of the road. Just beyond lies the finish, with home but a short walk up the grassy slope of our neighbor's lawn. Home, what I have been searching for, and have finally found. This morning I lay in bed a few minutes after the alarm to enjoy Lindsay's legs interfolding with mine, the cotton sheets drawn snugly against the cool breeze, the catbirds cawing and chickadees chattering outside our window, and, intermixed, the whining of our fat felines who were unwittingly locked outside last night. Truth in fact, our doors never lock, nor do most of those in town. The fear of the city has not yet seeped into our insular community. I don't doubt that it will come. But for now we live with one less fear. Hospital rounds were a breeze: the brushfires in OB and the ER were easily snuffed, and I set off happily for the Belfast Free Library to spend my lunch hour with Joseph Williamson and his double-volume History of Belfast. Then the beeper sang, summoning me back to the ER. Two admissions awaited: a seven-week-old infant with fever and an old man with stroke. I was nearly two hours late to the office, and, even with radical surgery on my afternoon schedule, never caught up. The journal has caused a shift in my thinking, a reordering of priorities. It consumes every free shred of my morning; it occupies my idle thoughts--not in a disturbing way, but constantly and completely. The bookshelf gets fewer glances. My running has slackened to three times a week. I wonder, too, what behavior has changed because of it. I don't want to "freeze" or capture my life over the coming year, nor should I change for the sake of a story. What did Heisenberg say? You cannot simultaneously record the speed and location of a particle in space. You cannot observe without changing. So it is good to paw over my tiresome routines and snap judgments, to extrude doubts and worries and clean out that hog barn ... I think, hmmm, "this would be good topic," or "better resist that temptation." This imaginary audience, like a guardian angel, has become my conscience and changed my approach to the world. Yesterday was Tim's birthday, proper. The office celebrated with a traditional potluck feast. Charlotte's incredible spinach lasagne, Lindsay's tuna pate, Scott's homegrown broccoli with dip, Cathy's tossed green salad, and becandled cakes by Bonnie and Trudy. The staff doesn't miss a trick, laying out a spread for every occasion. The format rarely changes, and is ripe for scrutiny: a birthday card signed by all, the gag "last patient of the morning" (your wife in disguise), a loud chorus of "Happy Birthday" as we pile in close together. But, when your turn arrives, suddenly it is a nice surprise and a warm feeling to have the ten of us huddle around the ping-pony table with too little to say and too much to eat in honor of the day of your birth. Last evening Tim picked me up for a family meeting. After a winding, wooded drive ten miles into the interior, we arrived at a shingled bungalow, the home of Bernitha and Ted Truman. Bernitha is dying of lung cancer that was diagnosed three years ago. Jean Goldfine, the Hospice social worker who lives up the hill from the Trumans, arrived fifteen minutes before us. She's been a regular companion at our recent meetings, and it is comforting to have her along. It is good, too, to be here with Tim. Doctors, especially generalists, operate in relative isolation. What we value most in family practice--dealing in relationships--is often exercised in privacy. The area of obstetrics is a prime example. I have watched only one delivery by a fellow physician since my formal training ended. The family meeting, in contrast, requires a team approach, depends upon it for mutual support, and creates an environment where everyone is a novice, a witness, and a full participant. The family meeting is simply a glorified home visit, an occasion for the doctor to come calling. Today "the doctor" will be two physicians and a social worker. By prior agreement, Tim will lead the meeting and Jean and I will take a back seat. "Family" becomes whomever the patient has identified. Such a meeting provides an invitation for family members to broach a topic they might otherwise ignore, or subvert, or quarrel over without getting to the crux. In a family meeting, everyone is asked to speak and listen. We take an hour to say, or begin to say, what is most important to communicate before the time runs out. Bernitha's house is tiny, a single downstairs room divided by lines of furniture. The five of us fit snugly on the sofa and three chairs that are clustered near the door. Tim and Bernitha share the couch, where she has spent nearly every waking hour (and many nights) listening to the traffic, imagining cars careening through her bay window. "I'd be a goner," she announces matter-of-factly. Portraits and religious calendars, posters in biblical verse, knickknacks of every persuasion hang scatterdash along the walls. A portable TV occupies the center stage, like its dooryard counterpart, the satellite dish. A little dog scrambles from lap to lap and finally nestles between Tim and Bernitha, where it will receive the most affection. Tim's method is uncomplicated, based on the interview style of Michael Murphy, medical director at St. Peter's Hospice in Albany, New York. He will steer back and forth between patient and husband, asking "what is your story, what are your worries. Tell me about when you first learned of your cancer, Bernitha. What were your feelings then, Ted?" Trolling back and forth between them. We learned that Bernitha's doctors had not initially told her of her cancer, and when they finally did, they had said it was treatable. I squirm in my sear because I was one of "those doctors." I remember the tearful visits two years ago when we ordered the chest X-ray for bronchitis and found instead a spot on her lung. I informed Bernitha that it was most likely cancer and packed her off to the specialists. Then I left for sabbatical as Bernitha set out upon her odyssey with the oncologists and radiation therapists. Only months later, after she finally wandered back to Dr. Hughes, did her case move from the back burner. Why the delay? What actually happened then? Bernitha spoke, too, of her emptiness and loneliness when Ted becomes engrossed in the television or trots off to bed. There are strings of days when no one pays a visit. Yet she is happy for the neighbors who drive her to her appointments and take her out to lunch, who walk down the road three times a week just to say hello, fellow parishioners who pray for her and cook the meals and dote over her. And she spoke of a son in Oklahoma whom she has only rarely heard from since his last visit a dozen years ago. Bernitha's fears all stem from loneliness. Her greatest fear is that Ted will go first, what with his emphysema and all, and leave her no choice but to sell the house and move into town. Ted spoke sparingly during our visit. I do recall his offer to sing for Bernitha if she wanted, and his mention of the movies (which he thoroughly loves, except, of course, those "of naked women"). But he never acknowledged that Bernitha was dying--because, as he kept saying, "she looks too well." Copyright (c) 1997 David Loxterkamp. All rights reserved.
