Grand Rounds

Chris Adrian

Thank you, Kate, for that really nice introduction. I don’t think anyone but my mom has ever said such kind things about me, and she only says them when she’s drunk. I’m kidding! She stopped drinking a couple days ago. I’m sorry I’m late and that I kept you waiting. I know very well you all have a lot of work to do.

But it’s really neat to be here, having grown up at UCSF as a resident and now as a fellow. I used to fall asleep in those same seats during lectures just like this one. That is to say, I won’t hold it against you, residents, if you fall asleep this morning. Though I find myself becoming curmudgeonly about work-hour revisions and glorifying the good old bad old days of training when we still worked thirty-six hours straight compared to your twelve. OK, twenty . . . but still . . .

I change the title of this talk a lot. Today it’s called ‘The Teddy Bears’ Picnic’, but sometimes I call it ‘Why Stories Matter’, and sometimes I call it ‘The Worst Year of My Life’, and sometimes ‘Theory and Practice at the Intersection of Art and Medicine’. So I’ll start by reviewing what people in academic settings say when they talk about stories and medicine and then I’ll talk about how and why people I respect and trust insist that a facility in telling and listening to stories makes for a better practice of medicine. After that I want to read you this story I wrote about sick teddy bears and the rebel angels and the hospital staff who have to try to take care of the teddy bears and the angels and themselves after they all get caught in a shrink ray. And then I’ll tell you a little bit about the worst year of my life, as it related to that story, and you won’t be surprised to hear that that worst year coincided with my first year of a Pediatric Oncology Fellowship. So, that’s what’s behind the title. More about that later.

My slides are out of order. I’m sorry. I came here right from the airport, hence the lateness. It was a family emergency.

So. What do we do with stories in medicine? Oops . . . out of order again. My mom was sick. That was the family emergency, or I would have had these in order. Here we go. ‘Narrative Medicine’. What does that even mean, ‘Narrative Medicine’? I’m never totally sure what that means, but I think that’s part of the point, that it means different things to different people, and that, just because the phrase ‘Narrative Medicine’ contains the word ‘medicine’ you can’t expect it to mean the same thing to everyone like some words or phrases do, like ‘bezoar’ or ‘Munchausen’s syndrome by proxy’. I think being ambivalent about what it means is OK – this is a little cartoon I found with Cerberus the dog. Believe it or not I had a toy poodle named Cerberus when I was a kid. We had him trained so if you said, ‘Cerberus, kill!’ he would jump up on someone’s lap and lick their face. My mom thought that was hilarious. The slide didn’t come out very well but you can see he’s sitting on his therapist’s couch and the therapist is asking him how he feels. And one head says ‘Good!’ and one head says ‘Bad!’ and the middle head says ‘Ambivalent!’ And then in the next panel they’re both just sitting there and in the last one the therapist says, ‘It’s good to see that you’re getting in touch with your feelings.’ And I put it in there just to underscore this idea of ambivalence or to show that it’s OK to be ambivalent. As if such things were proved by cartoons. But maybe they are. Sorry, that seemed like such a great slide when I was throwing this together. But the point is that this stuff is all very confusing from the time you open your mouth to start talking about it, and that in most ways that’s OK – if what people talk about when they talk about Narrative Medicine was easy to say they wouldn’t need stories to say it. But in some ways I think that, for me as a writer, trying to explain or understand this is like one of Jane Goodall’s chimps trying to give you a lecture on Clifford Geertz. I am more of a practice person than a theory person. Not that there’s anything wrong with theory people. I love theory people. My ex is a theory person.

In any case, I think what most of the theory people are saying is just that they want us to listen to our patients, to get some intimation of the shape and scope of their lives, and that stories – writing them, telling them, listening to them – can help us do that. And of course we listen to our patients. But then again, we don’t. To borrow a phrase from this guy – sorry, that’s not him. Sorry, I am a bit of a mess from this family emergency and am functionally more than a little post-call. This was supposed to be a joke, that I prefer this Paul – McCartney – to this Paul – there we go – who was Saul of Tarsus before he was Paul of Rome by way of Damascus, Ephesus, Corinth and elsewhere. To borrow a phrase from him: ‘God gave them a spirit of stupor, eyes so that they could not see and ears so that they could not hear, to this very day.’ What I mean – what people who talk about this mean – is that the dispiriting ordinary and extraordinary everyday transactions of medicine give us a spirit of stupor, and some conscious discipline is required to shake it off.

Yes, Kate? What? The teddy bears? Oh yes, they’re coming. I’m getting a bit short on time already, but I’ll read fast. And it’s a pretty short story.

So what do you do with this notion that we ought to listen to our patients’ stories, when it’s hard to actually listen, when there are a whole lot of reasons why it’s hard? Well, here is a lady I met at a conference on writing and medicine, in Oregon. I was late to that too, actually also because my mom was sick. I missed Dr DasGupta’s talk, but she very kindly let me see her slides. I watched them all alone in the auditorium, very late at night, and thought about them for rather a long time there in the dark. I couldn’t sleep anyway.

This is a little chart from an article in Academic Medicine that Dr DasGupta wrote. She’s talking about what they do at Columbia with this – what they do when they try to teach their students to tell stories and listen to stories. They have a whole department of Narrative Medicine there, which kind of blows my mind every time I think about it. Can you imagine being able to call that consult?

But this chart is about a class they run for the second years. A required class – where they spend six weeks in a humanities seminar. You can see from the chart what they’re doing with their six weeks. They come to class with some idea for an illness narrative, a story of illness. It can be their own, but it doesn’t have to be. In fact, they are encouraged to use someone else’s story. My mom was sick for weeks this last time, but I could only get away to see her recently. There’s an illness narrative for you.

So you can see that Dr DasGupta has them try different things with the story. She sets up some hoops and asks them to jump through, as it were. Try writing from the point of view of the patient’s body or even a body part. Try switching up the genre – write the story as a poem or a regular essay or a TV show or a commercial or a play. We had an interesting discussion about how her students sometimes only discover what they want to tell, how they discover what part of the story really matters, as they switch it or carry it from form to form and find which part stays the same amid all the changes. I told her I was working on something that started as a story and became a novel and then an essay before it was finally a graphic novel about the demon that possesses Linda Blair in The Exorcist, but that it was really about my mother. And Dr DasGupta said, ‘Exactly!’ It’s about a lady who keeps having sex with this demon, so her kids are all half demon, and they have to sort of figure that out and deal with that. It’s called Pazuzu because that was the demon’s name. Everyone always thinks it’s supposed to be Satan who possesses Linda Blair, but it’s Pazuzu. Poor Linda Blair. There’s an illness narrative for you, too.

So you can see that in Dr DasGupta’s course there’s a kind of schedule of mutation and permutation to the story the students are telling. Yes, Kate? What’s the difference between mutation and permutation? Never mind. In the last week of the course, the syllabus says, ‘Try to reconcile these different versions of the story that you’ve told.’ Which leads, as you might imagine, to a whole discussion about what ‘reconcile’ means in this context. Kate’s about to start a chant, ‘Teddy bears! Teddy bears!’ They’re coming, I swear. One more slide. OK, two more slides.

This is a ‘Theory of Empathy’. I’m not totally sure what I think about this. I suppose I included it because I needed a fancy slide. This gentleman is from NYU – Martin Hoffman. I think he’s a social psychologist or a developmental psychologist. This is just a short extract from a book called Empathy and Moral Development. So he defines empathy as involving a psychological process that makes an individual have feelings which are more congruent with another’s situation than his or her own. That’s reasonable, I think. But what psychological process?

[thirty-second silence]

Sorry. Suddenly this slide doesn’t make very much sense to me. I think I already told you I . . . that I’m functionally post-call. But I wonder if it would make sense even if the past few days had not been the past few days. I may just be resistant to theories of empathy. So you see these terms up there. ‘Empathic Distress’ and ‘Mediated Association’ and ‘Role-Taking’ and ‘Sympathetic Distress’. And empathic distress is what you get when you see someone suffering and it makes you uncomfortable. The psychological distress, as Mr Hoffman calls it. And mediated association involves feeling that same sort of discomfort even though you’re not right in front of the person – you’re just hearing their story somehow, or you’re listening to ‘We Are the World’. Role-taking involves adopting that person’s point of view, whether on your own initiative or because someone tells you to do it or makes you do it. And then sympathetic distress is what you get when you’re uncomfortable and it’s more about them than about you. I think that’s what he’s saying. The ‘motive to comfort oneself’, he says, ‘is transformed into a desire to help’. So it’s a process. Empathic distress becomes sympathetic distress by means of mediated association. I don’t know. That all sounds perfectly reasonable, but I guess it leaves me cold. It seems kind of like saying that a Volkswagen pulled up in your driveway and forty-five people got out but neglecting to mention that they were all clowns. Or saying your daughter is ill and neglecting to mention that she is possessed by Pazuzu. Or saying that your mom died and neglecting to say that she starved herself to death and you let her do it. I mean, I think it’s very important to try to approach these nebulous mysterious processes systematically and reductively to understand what’s actually going on with them, but something in me always feels a little deflated and unconvinced by the results. Maybe because it seems like you always have to throw out the mysterious part or just ignore it in order to make your reduction or systematization successful. I didn’t read the book, though – Empathy and Moral Development. I didn’t read it. And I should admit to you that, the picture of Mr ‘of Tarsus’ notwithstanding, I’ve never read the whole Bible. Which is one of my problems, I guess, that I never read the book, or the whole book. And I’m just sort of winging it, in the ethics and morality department.

We’re only about three minutes away from the teddy bears now.

This is the last slide, which talks about the University of Michigan’s FCE programme.

[forty-five-second silence]

Sorry. I’m sorry again. I’m trying to remember what FCE stands for and for some reason all I can think of is Fancy Cat Entrepreneur. But that’s not it. Fostering Clinical Empathy? Family Clinical Education? Something like that. The Michigan folks – they’re doing something a little different than Dr DasGupta, pairing their narrative enterprise with a patient encounter. They send their students out to families for a sort of preceptorship. The students visit patients in their homes and ask them questions like, ‘What’s it like to only have one foot?’ You can see the programme there: six visits over two years – not that many, I suppose. Small groups with a clinician facilitator. They’re evaluated on the basis of essays and on the feedback from the patients, so it goes in their file if they are good at visiting, or good listeners, or make friends with their patients. And likewise a patient can report, ‘This person has got the personality of a hibernating lizard,’ and it gets recorded. This stuff is all from an article in Academic Medicine from July of 2008 by one of the architects of the Michigan programme, Dr Kumagai. The last bit is an extract from the discussion section, where authors of the papers support their pedagogical strategy with educational theory. ‘The physical presence of, and interactions with, another human being whose life is profoundly affected by chronic illness, as well as the story he or she tells, may foster an interpersonal link in affective, cognitive and experiential domains. This, in turn, will enhance perspective taking, and serve as the basis for a hot cognition for empathic feelings between the learner and another individual.’

Yes, Kate? What’s a hot cognition? Well . . .

[forty-second silence]

I don’t think I remember the exact definition. It sounds very sexy though, doesn’t it? But I believe it’s about your thought process becoming emotionally charged. And that charge makes the learning stick. I suppose in this context it would go something like, ‘Oh my gosh, this patient whose home I’m currently visiting has no feet and that makes me remember the time that my mother broke my ankle with a hammer and how awful that was,’ and so the bonds of empathy are formed. It’s not that simple, of course. I mean, I’m making it sound like they’re oversimplifying the whole process because I don’t understand the theory they’re deploying, and just because I’ve lost my faith in such endeavours and ideas doesn’t mean they’re not useful or good or true. I think what they’re saying is . . . I mean, the reason I meant to talk about this in the first place is that they are flinging stories around in this programme because they believe that their students will respond to them in a way that will foster their native empathy. The students will meet these people and hear these stories and have a hot cognition flash and take someone else’s role and move from empathic distress to sympathetic distress. What they’re describing is beautiful, if you can believe it, that you can learn to care about people by listening to their stories, and that the problem in the world of medicine and the world of the world is not a dearth of caring but a shortage of stories. I like to think about that being true, but I have a hard time with it. I have a hard time believing that stories ever make that kind of difference, and most of the time it’s easier to believe that despite appearances nobody ever really hears what anyone else is saying, and that there are no listeners in the world of stories, just a dispiriting over-abundance of tellers, and everybody is ululating in some very private language that sounds to anybody else like alien hiccups. And maybe that is all just another way to say that no one really knows how to listen to these stories.

Which brings us to the teddy bears. Finally! I’m almost out of time, I know. I wanted to read you this whole story, but I’ll just do part of it. So there is this one last slide, which is a picture of my mom. There she is. This is from a long time ago, from back when she was a hot cognition, so to speak. She’s wearing a flight attendant’s uniform because she used to be a flight attendant, before I was born. Except she never liked it when people said flight attendant. She preferred to be called a stewardess. Flight attendants are old and have turkey wattles, she said, but stewardesses are beautiful and forever young. I’m showing this picture of her because this was her story, in a sense. The Teddy Bears’ Picnic was this episode from her hot young adulthood that involved two heroin-addled jazz musicians and my Aunt Chris, who wasn’t her sister, just a friend from childhood with whom she had young-adult adventures. I don’t know exactly what happened on this picnic – she would never tell, but from the hints she gave my sister and me, we constructed a story of roly-poly jazz druggies and a lot of wine and a semen-stained picnic blanket. So that’s where this story starts, with my mom. And I won’t set it up any more, but I’ll talk more in a few minutes about the other ways it came together, how it’s about my dead patient and my own life at the time I wrote it. So.

‘It was time once again for the Teddy Bears’ Picnic.’

[a full minute of silence, then tentative applause]

Wait, wait, sorry! Sorry. That’s not it. Not the end, I mean. That would be pretty silly, if that were the whole story. It must sound like I don’t know what comes next, but I have it right here written out. This is going to sound very strange, but I was trying to decide whether or not I should tell you that my mom died yesterday, and then I was trying to decide if I had already told you. I suppose that’s how post-call I am. Anyway, it seemed very important to the story that I tell you that. Like I was being dishonest or disingenuous somehow by not saying that. Did I tell you already? I didn’t think so. Is it weird for me to tell you? I guess it is weird, but it felt equally weird not to tell you. I know more than half of you by name, after all, and you know me. It’s why I was so late, because she was dying, and then she was dead. And since this story starts with her, it was important for you to know. And now we’re almost out of time. I’ll start again.

‘It was time once again for the Teddy Bears’ Picnic.’

[dr kate matthay rises from her seat and offers the speaker a tissue]

Thank you, Kate. Sorry. You know, I don’t think I should read this story. I’ll do another one. As much as I have of it, anyway. I was working on this new story on the plane. You’ll probably say, you should have been working on this horrible talk. But I couldn’t sleep. I was exhausted, but I couldn’t sleep. So I’ll just tell you about the teddy bear story. I’ll sum it up. It’s not that great, anyway. There are these bears and a little girl and some aliens and a shrink ray. And her doctors get shrunk and have an adventure inside her body and there are some magic ponies who are ultimately responsible for all the sickness and confusion and unhappiness in the girl and the hospital and in this country. I guess you have to read it or hear it to really make sense of it, for it not to sound totally ridiculous. But the important part is that there was something about this story that I once thought married my own troubles with the troubles of my patient, this poor doomed six-year-old girl with a brain tumour. I was away in Boston stalking my ex-boyfriend the last time she got sick, and I happened to get back on the night she died. I went from the airport right to her room but she had been dead for hours. I said something to her parents about how I believed they had made the right decisions on her behalf and how much I respected them and admired them, and how much I would miss her, and these were all true statements. And walking home I bawled my head off, but I didn’t know if I was crying because this little girl had died or because my ex had told me to stop stalking him, that dogs would marry cats before he consented to get back together with me, that Pat Robertson would have a snowball party in hell before he wanted to get back together, that he wanted me to go away and never come back, so I kept hearing him say that, like Good Gollum says to Evil Gollum in The Lord of the Rings when that poor creature is having his psychotic break. Go away and never come back! Go away and never come back!

And while I was walking home I kept asking him to come back, calling his name out loud, except intermittently I was using this little girl’s name instead. Even as I said it, over and over, I thought, How strange, and What am I doing? I got home and made a sort of rehearsal of a suicide. I sat around for a while with a telephone cord around my neck, not tied to anything. Oh, I tied it to the shower rod for a while and I tied it to a pull-up bar for a while but I also tied it to my ankle, and to a teapot and to the cat. I even tied it to my balls, and how was that supposed to put me out of my misery? After that night I sort of had a nervous breakdown for the next few weeks. A relatively functional one, I suppose, though poor Dr Lauchle, who was stuck on service with me, would probably disagree since she was the one doing the work all day while I was crying in the bathroom. But the point of this story is not that I was crazy, which I suppose I am in many ways, or that a Heme/Onc Fellowship makes you want to kill yourself, which I suppose it does in many ways, but that for a few moments there I didn’t know who my heart was breaking for. And I was going to tell you – when I give this talk I usually tell people – that the story, with the teddy bears and the aliens, was somehow about those few moments, that it made some kind of useful sympathetic noise. But now . . . today . . . in this last hour, actually, that seems like the wrong thing to say, and the wrong story to tell.

The other story . . . the new story . . . goes something like this: ‘When I was a child I wanted to be sick. This was partly because my mother, who was not always nice to her children, was always nice to me when I was sick. She was often sick herself, though almost never actually unhealthy, the important exception of course being that she had breast cancer while she was carrying me and was treated with a mastectomy just a few weeks before I was delivered. But it was also because sick people – and especially sick children – were special, and I wanted to be special.’

That’s all I have. And I’m out of time. I know. Kate is pointing at her watch. I’m almost done. There’s no more of that story written down, but I can tell you what happens in it . . . I can sum up the important parts. In this story the narrator’s mother breaks his ankle with a hammer and takes him to the emergency room when he’s three. It’s the first of a bunch of treatments. I mean, that’s what she calls them. She says she is making him better, which in some twisted sense she is, since he actually likes being sick. He gets a fever in the hospital, and they think he has osteomyelitis, but it’s his mom pooping in his IV or whatever, and this whole thing starts, this whole long thing starts, where she puts him in the hospital again and again.

And then . . . this is where before, in the old story, the evil magic ponies would usually come in, because what kind of child could ever conceive of such an action, or plan it out, or take any satisfaction in it? This kid, who is eight or nine at this point, walks into his mother’s bedroom one night and breaks her ankle with a baseball bat. And she shrieks and writhes in her bed – how she cried and cried with her pillow clutched over her face! It was like she was smothering herself. But when she can talk she says to the kid, ‘Go call the ambulance. Mommy’s fallen down the stairs.’

So it goes on that way, years and years more of it, though there’s a father intermittently in the house and a sister. They’re not oblivious, but they’re powerless, like they always are – we’ve met these people in our practice, we know this, we forgive them for being powerless as a matter of course. It escalates and wanes and escalates and maybe it gets stranger. Like, when he’s thirteen she makes him a strawberry shortcake, though he’s developed a horrible strawberry allergy, with full-blown anaphylaxis, and he sits down quietly in the kitchen and forks it up. And he has gotten in the habit of making her morning tea when his father is away, and one day he cuts it half and half with silver cleaner, and she sips it nonchalantly, reading the paper in bed while he stands in her door, watching. Years and years this goes on! His chart is 859 pages long. Hers is over 1,000.

And then it stops. I can’t even remember when exactly, and he doesn’t even remember why. At some point, much later, he’ll think it’s like falling out of love with someone, when you look at them and think, ‘Why did I ever go out with that person?’ and you think of what you did with them and ask yourself, ‘Why did I ever do that?’ It’s like that. Why did I ever do that? Probably she’s saying the same thing. Why did I ever do that to my child? Years pass again. Years and years and years, and I suppose they have a relatively normal relationship. OK, not really, but it’s civil, and no one goes to the hospital until after his father dies, and his mother gets sick all by herself. She stops eating, more or less, and he goes home a few times to try to turn things around, and yes there is silver cleaner under the kitchen sink still but that is neither here nor there. It doesn’t mean anything. He looks at it but doesn’t really even see it. He tries to make her better. He, a paediatrician now, has adventures in adult medicine. She goes home from the hospital. Years pass again. Not many, though. Barely two, when she’s back in the hospital.

Now she’s very ill. She might not have gotten quite so ill if someone had come to help her again. He was very busy in his first year of Oncology Fellowship, and having a nervous breakdown et cetera, et cetera. His sister couldn’t go help, though it really was her turn, because she has a terrible aversion to their mother. In the past few years she’s conveniently manifested a paralysing compulsion to avoid anything to do with the lady. She can’t even get letters from her any more – they are filthy. They are contaminated. She’d have to be wearing a moonsuit to handle a letter from her mother. She can’t even touch the postman any more. In fact, she can’t even tolerate the idea of their mother any more, so it’s very hard to talk about her when he calls to say, she’s quite sick. His sister tells him that’s a terrible tragedy. And then she tells him how she can’t even be near sexy stewardesses, or witty mean old ladies who smoke a lot. Even her name – Margaret – is hard to tolerate. She has so many friends named Margaret, and they’re all wondering what they’ve done to drive her away, but they haven’t done anything.

He goes back to Florida – horrible old Florida. Has anything good ever come out of Florida? He probably landed just as she was being transferred to the ICU, and when he arrives in the hospital she is already having blood-pressure issues. They had allowed her to refuse antibiotics and most diagnostic interventions, though she was clearly septic, and though she was depressed out of her mind, but once she was no longer responsive they got it all started up, so she’s on triple antibiotics when he arrives and there has been a nice little workup, and they are just starting inotropes. He thinks that is a little odd, that they let her refuse all those things, but what does he know? He is a paediatrician, used to overpowering toddlers so he can look in their throats for diphtheria. He arrives in the ICU and the doctor says to him, Welcome, welcome, next of kin! What shall we do?

He gets into bed with his mom, and thinks of his sister. This would be terrifically horrible for her, to hold their mother when she’s barely clothed, and smelly in that funny way that people get smelly in the ICU, when you can appreciate the careful and attentive washing of the body that the clinical assistants perform, but then under that, sometimes subtle and sometimes strong, is a horrible rotten stench. She looks awful too, like she’s already dead, like she ought to be cold as a corpse, though in fact she is putting off a terrible heat. She looks just like the Crypt Keeper, if you remember him, the host of Tales from the Crypt, and he very much expects her to sit up and say, in that characteristic cackling shriek, ‘Welcome, kiddies! Would you like to dance to the death?’ But she doesn’t say anything of the sort. She opens her eyes and looks at him but does not seem to see him, and when he says, ‘I love you, Mom. What do you want?’ and ‘I love you, Mom. What should I do?’ she doesn’t reply, except he thinks it’s possible that she sneers at him a little, as if to say, Why are you bothering to ask? You know what I want. The same thing that you do. You’ve always known.

So he gets out of the bed and tells the doctor, I’m ready now. And they call in the team which includes the respiratory therapist and a nurse and a chaplain and some lady with black hair swept back from her face like the wings of a raven, and huge, dark soul-sucking eyes, dressed like a nineteenth-century Jesuit missionary to Canada, who may be a figment of his imagination or may be a representative from the palliative care team. And even beyond the curtain and the room it’s like he can feel the whole hospital and hear them singing ‘Kill her! Kill her!’ as sweetly as the Whos in Whoville ever sang ‘Fah who foraze! Dah who doraze! / Welcome Christmas, Christmas Day!’ And he is thinking that this is a perfect ending, and a perfect story, that they both should get what they want, and that everyone should approve, and then everyone should be so very happy about it. ‘Shall I write the order?’ he asks the doctor, and the doctor says, ‘I have already done it.’

As a child, after he had been hospitalized a few times, he started to state his ‘chief complain’ in the emergency room. The triage nurse would say, ‘And what’s bothering you today?’ and he would say, ‘My chief complain is osteomyelitis’ or ‘My chief complain is a small bowel obstruction’ or ‘My chief complain is intractable pain’ or even, when he was a snarky teenager, ‘You are bothering me. You are my chief complaint.’ And the nurse would smile or grimace or frown but always, whoever she was, unless he had insulted her, she would say something like, ‘Oh my, you’re going to be a doctor one day, aren’t you?’ And he would say, ‘Of course.’

After his mother is dead. After he has written back to his sister, who kept texting him over and over, ‘Is she dead yet? Is she dead yet?’ After the terrible heat has left his mother’s body, he gets out of her bed and, ignoring the condolences and questions of the nurse, he leaves the ICU bay and the ICU and leaves the hospital to walk in the merciless Florida sunshine in a short loop through the parking lot to the Emergency Room entrance. He sits until they call him out of his chair and the triage nurse sizes him up with a sweeping glance and says, ‘What’s the matter, honey?’ He stares at his feet and she asks again, but he doesn’t answer. ‘What can we help you with?’ she tries and ‘What brings you in today?’ but he’s still silent. She gets slightly frustrated, though never stops calling him honey. It’s like she senses that it is hard to say, or hard to know. It’s her, he thinks suddenly. She is the good thing that is finally going to come out of Florida. She asks again, What’s wrong? What is it? How can we help you? What’s your complaint? And finally, when the other nurses have begun to watch curiously and the security guard has come hovering closer and closer, he looks up and says to her perm, ‘I don’t know.’

So that’s a better story. That’s better than magic ponies and teddy-bear picnics and whatever else that other one was about – I can’t even remember any more because this one is better. This one is perfect. Do you understand why it’s perfect? Not because it’s true. You can never know if it’s true or not. It’s because the story and the life that it’s based upon are the same thing. Because the story and the troubling thing that gave birth to it are the same thing. Because the story and the trouble are the same thing.

Does this make any sense at all? Kate is shaking her head no. Thank you for staying, Kate. Thank you, everybody. I know you have places to be. I know that the people who left have places to be. I’m grateful that nobody’s called a chaplain code on me and that the psychiatrists in the audience have remained seated with their Thorazine injectors safely contained even though you probably all think I’m having a nervous breakdown up here, which maybe I am. I keep saying I’m functionally post-call but I guess it feels more like I’m post-everything, like there’s this state of post-ness that the extreme difficulty of the past few days has allowed me to enter, and it’s not about fatigue or being fed up with things but more about the advent of a kind of clarity. Maybe a hallucinatory clarity, but probably a transient clarity. All the way back here on the plane I kept thinking, this is the story. This is the story to tell them. Because it is perfect and because those other stories – everything I’ve written, everything I’ve seen written, though keep in mind I never finish books and I quote from the Bible without having read it – are the wrong stories to tell because they are not perfect. But what do you do with that perfect story, that starts the first time your mother breaks your bones and ends when you kill her? Do you empathize with it? Can you empathize with it? Do you sit down with the whirlwind and say, ‘That must be very difficult for you. That whirling. It must make you feel ungrounded. I empathize with your terrible, terrible whirliness’? Or do you cower? Or run away? Or say nothing but silence?

What do you say? I wish somebody . . . I wish one of you would tell me. Kate? Rob? Mignon? Clay? Anu? You in the back, with the Coco Chanel hair. I don’t know your name but I know your face and I will never forget your hairdo. I’ve seen you moping around the ICU all year and never learned your name, but every day I thought to myself, ‘That lady is the very avatar of sympathy,’ because every time you come out of a room you look like it’s your mother in the bed. Will you tell me? No? Then you, behind her, with the bolo tie. I don’t recognize you at all. Are you an oncologist? Are you even a paediatrician? You don’t have to be, don’t worry. And of course sometimes it’s the mysterious stranger who shows you the answer you’re looking for, cupped like a spider between his two hands. Will you tell me what to say? Open your hands? Not you either? O Stranger! O Patient! O Self! Won’t one of you tell me what to say? Won’t anybody? Please, tell me?

[two minutes of silence. the speaker is led away from the podium by dr matthay.]



Illustration © Simon Fowler


Error, group does not exist! Check your syntax! (ID: '2')