Sometimes, my primary care encounters teach me far more about the complexities of being human, and about life, than any psychotherapy session.
I look at the name on the chart before walking into the examination room. It’s Mr. Carlson, and the nurse has noted that he has had pain in his abdomen for the last 2 days.
“Mr. Carlson, how are you?” I shake his hand. His wife’s face is buried in a recent issue of Good Housekeeping, and she doesn’t look up. From where I am standing, I can see that she is looking at the horoscope page. “What’s your forecast say, Mrs. Carlson?”
“I’m looking at my husband’s,” she answers quickly, as if uncomfortable to be the focus of attention even for a moment. She looks at her husband and smiles. She always looks sad, and somehow, her smile makes her look even sadder. “He’s such a typical Leo, you know.”
“Go back to reading, Emma.” He rolls his eyes. “Star signs, can you believe it? Anyway, Doc, I got this terrible pain in my side. Makes me tired all the time. I can’t go to sleep. Can’t go fishing or hunting. I ain’t worth a damn.”
“What kind of pain is it?”
“I don’t know what kind of pain.” He makes hacking motions with his right hand.
“It hurts like someone’s taken a big cleaver to my side.”
Mrs. Carlson flips the pages of her magazine.
“Christ, Emma, can you stop swishing those pages around! I’m trying to talk to Doc over here, a’right? I don’t know why I bring you here anyway.”
“How has your mood been recently, Mr. Carlson? I mean, are you feeling more irritable?” I ask, somewhat redundantly.
“What are you trying to say, Doc? Yeah, I am irritated because all she can do is talk, talk, talk, when I’m hurting like this. Damn right, I’m irritated, but I ain’t crazy.”
Mrs. Carlson sits quietly, looks into her lap, breathing softly.
“I am not saying you’re crazy or anything like that, but sometimes when we are feeling stressed, we feel irritated. I’m trying to see if there is anything that can help you feel better.”
“I don’t know what you mean by we, Doc. I know I don’t want none of those happy pills you fellows throw around these days. I watch TV, and I know I don’t want nothing messing with my head. You just help me with this pain.”
I decide to pursue this at a later time. I try to get some more meaningful information about his pain, but he is unable to tell me anything of use other than “It hurts all the time, Doc.” I ask him to lie down on the table. I listen to his heart and lungs. All fine.
I lift up the hospital gown and look at his belly.
“Show me again where it hurts.”
He points vaguely to an area below his ribs. I push around, trying to feel for an en-larged liver or spleen. Nothing. The rest of the physical exam is normal as well.
“Mr. Carlson,” I say, “I think the pain might be from constipation. I am going to give you some laxatives to see if that helps.”
“Doctor, how much water should he be drinking?” Mrs. Carlson asks suddenly from the corner.
“Shut up, Emma,” Mr. Carlson sits up, his belly hanging, and frowns at his wife.
“I know how much water to drink. Jesus!”
“How much water do you drink, Mr. Carlson?” I ask the question more to prove him wrong than for the information.
“I get enough, Doc.”
“How many glasses of water or liquids do you get on an average day?”
He pauses and glares again at his wife.
“Don’t know. Three or 4, I think.”
“You should get 6 or 7 at least, Mr. Carlson. Your wife is right.”
Mrs. Carlson looks very uncomfortable now, fidgeting in her chair and trying not to meet the gaze of her husband.
“She is right, huh? Guess I’m going to have to listen to you now, Emma? Do I got to listen to you?”
“No,” she laughs nervously. “You know you don’t. . . .” she trails off looking down.
“Six or 7 glasses,” I repeat. “That will get your bowels moving.”
“It’s not the bowels that have to move, Doc. We been married 50 years and Emma, over there, can’t hardly move her lazy behind to get me a glass of water. She takes all day to do the dishes. I get her the best washer, and she’s still in there all day messing about with the switches like she don’t know what she’s doing.”
Three days later, I see his name on the list again. My nurse tells me that Mr. Carlson had her on the phone earlier, shouting about the pain and “that Doc who didn’t do nothing for me.”
I walk into the room. “Hey, Mr. Carlson.”
He is sitting on the exam table and his wife is in her customary place by the door in the corner. I am not sure if I am imagining this, but she does not seem as sad today. As her husband sits on the examination table, his eyes lusterless and his skin pale, she actually seems happier, even stronger. Her shoulders are squarer, she is sitting up straight, and she actually looks me in the eye and says, “Hi, Doctor,” before her husband shouts, “Shut up, Emma, and let me talk. Doc, the pain is real bad. Those pills you gave me, they didn’t do a damn thing, and I’m drinking near 7 glasses of water a day, even though I want to throw it up as soon as it goes down my throat.”
The physical exam is unremarkable again, but I am worried about him. I tell him I need to run some tests right away. “I would like to get a CT scan of your abdomen today, Mr. Carlson,” I tell him. “Let me set that up so we can take a look and make sure this isn’t anything serious.”
“Serious? You don’t think I have cancer or something, do you?”
“It’s possible,” I say, “but I don’t think so.”
Mr. Carlson looks a little relieved. “Yeah, I don’t think I got no cancer, Doc. I don’t smoke, don’t drink, don’t do nothing except take care of my old woman here, hey Emma?” He laughs in her direction, and she tries to smile.
“OK, let’s get the CT scan done and, as soon as I have the report, I will let you know.”
I get the report from the radiologist the following day. Mr. Carlson has a big mass next to the duodenum. Metastatic cancer of the pancreas. He will probably be dead in less than 6 months.
I call him on the phone and tell him I want to see him as soon as possible.
“Bad news, Doc?”
“Let’s discuss this when you are at the office,” I tell him.
He smiles briefly when I enter the room. I notice he has new dentures on, which somehow make him look older.
I place the CT scan films on the viewing box, and Mrs. Carlson begins to hum a tune, showing an uncharacteristic insensitivity.
“Stop that,” Mr. Carlson snaps, but she carries on humming. He looks like he is about to shout at her, then stops, and turns to me.
“So, tell me, Doc. Is it bad?”
I try to break the news gently, but he wants to know immediately. I tell him he has advanced cancer of the pancreas. I point to the big mass on the scan that even to the untrained eye looks like an intruder.
“How long do I have, Doc?”
“It’s impossible to say. It depends on—,” he cuts me off.
“Will I die from this?”
“Let’s wait until we get more information. I am going to get you an urgent appointment with a surgeon, and a cancer specialist, and—”
“Will I die from this, doc?” he repeats and looks into my eyes.
In the years that I have seen him in my clinic, I have grown to dislike him, his attitude toward his wife, his meanness. But in this moment, as he confronts his mortality, as he looks at me with raw fear, I feel ashamed for having sat in judgment, for not having been more empathetic. In this instant, he is not Mr. Carlson, the difficult patient, and the abusive husband, but a fellow human being who is facing the profound and yet universal reality of death.
But all I can say is, “The prognosis for this stage is an average of 4 to 6 months’ survival, Mr. Carlson. I am sorry.”
“You hear that, Emma?” he says. “I am going to die.”
“Yes, dear,” she says.
“Yes, dear,” he mimics her voice and then continues. “If I hadn’t worked so hard to bring money home while you sat on your fat behind doing nothing, this would’ve never happened.”
She has a strange look on her face.
“Are you OK, Mrs. Carlson?” I ask.
“I’m fine,” she says. She turns to look at the films of her husband’s cancer. “I am just fine,” she says again with half a smile, as if holding on to something warm and comforting.