“Tell them something about yourself,” Jim advised that first night as we walked with flashlights, searching for a man known to sleep near a riverbank. “Tell ’em anything. Just be yourself and be honest.” Jim cut a solitary figure as he forged ahead to where water met land, waving his flashlight back and forth like a tiny lighthouse. He spotted a pile of blankets next to the Charles River and motioned me over. There was a shine on the water from distant construction lights, and I could feel my heart thumping with every anxious exhalation. Lifting his index finger to his lips, Jim whispered “All yours” and disappeared in search of others.
“Sir?” I said, staring at the pile of blankets that was gently oscillating like an accordion. “Hello? Hello there? Anybody?” I looked out over the river and frowned. “My name is Matt,” I said, rubbing my hands together. “Just here to check in.” I inched closer and placed my right hand on the pile of blankets. “I’m working with Jim O’Connell and Health Care for the, uh, do you know Jim?”
At that point in medical school, I was several months removed from the banana peel; there was no chance that Axel ever had to seek out patients like this. I began grinding my teeth as McCabe’s voice trickled into my head: Ask yourself a deceptively simple question: Can I imagine myself being happy as anything other than a surgeon? Like a sine wave, the blankets bounced up and down as I considered my words. “Hello? Anyone?”
I was preparing to turn around when a voice emerged. Soon a pair of eyeballs was staring back at me.
“Hey,” I said, “I’m Matt.”
“You work with Jim? Is he here?”
I leaned in, trying to make out a face. “He is. Would you like me to get him?”
“Who are you?”
“I work with Jim,” I said tentatively. “I’m a student. I brought socks and soup.”
“Can I…can I talk to Jim?”
“Yes, I’ll get him.”
“Can he take a look at this?” The man emerged from under the blankets and pointed to an open sore on his left shin. The skin was dark and mottled, with pus weeping from the borders. The stench was overpowering and unforgettable; I fought the urge to turn my head away. “Let me get Jim,” I said softly.
As I headed back to the van, I thought of the material I’d been stuffing in my brain during medical school and compared it with what was floating through Jim’s head. He held in his mind an intricate map of the city’s homeless, a human atlas that few, if any, possessed. Jim O’Connell was undoubtedly the only physician who could tell you why one overpass was preferable to another for a good night’s sleep or why Copley Square was better than Faneuil Hall for panhandling.
And like Axel, Jim was happy to dispense wisdom. “The key,” he said later that night as we walked with flashlights under a condemned bridge, “is to build a relationship. It’s easy to condescend. Resist that urge.” And after a challenging interaction, “The problem is us, not them.” Between stops, Jim and I talked about Whitey Bulger, Boston’s enigmatic criminal, and baseball. “Dennis Eckersley,” Jim said, referring to the former Red Sox pitcher, “his brother was homeless. Who knew?”
I found myself coming back to my apartment in Brookline raving about the experiences. I wanted to be like Jim. I wanted to be Jim: an unconventional, understated, brilliant doctor who played by his own set of rules, engaging patients in ways I’d never seen or considered. His method tapped powerfully into my own self-image as an outsider—the pre-med who was a ballplayer, the Ivy Leaguer in the minor leagues. In medicine, too, I knew I wanted to be something different but I wasn’t sure what that something was until I met Jim.
More than a few times, my roommates were subjected to my theory that Jim O’Connell was doing for Boston’s poor what Paul Farmer, the subject of Tracy Kidder’s book Mountains Beyond Mountains was doing for Haiti. “Do you know what he’s building?” I’d ask Heather, referring to the centerpiece of O’Connell’s oeuvre, a massive medical complex that included a 104-bed inpatient clinic and dental clinic designed for the homeless. “Do you realize,” I’d say, time and again, “just how incredible that is?” My friends quickly tired of hearing about it, but I never tired of telling them.
One morning, I found myself in the corner of Jim O’Connell’s small office at Mass General, looking on as he examined the middle-aged woman with smeared lipstick, the one he’d been speaking with when McCabe introduced us. This time Sheryl was wearing dirty gray sweatpants and a blue Tasmanian Devil sweatshirt. Neon lipstick was smudged across her lips and cheeks.
After removing his stethoscope from her chest, O’Connell sat down in a black plastic chair a few inches from Sheryl and took one of her hands in his. “Everything looks good,” he said. “Very good. Things are trending in the right direction.”
She looked over at me and in a stage whisper said, “I was hoping for great.”
“Everything looks great,” Jim added warmly. “Blood tests, urine test, heart and lungs. I couldn’t be happier.”
I had seen Sheryl at the Pine Street Inn several times and learned from Jim that she’d been living on the streets of Boston for nearly a decade. Sheryl tended to ramble about her ex-husband and occasionally burst into fits of laughter for no apparent reason. She once shouted at me about the television show Designing Women.
Jim gently pulled Sheryl’s hand in his direction to regain her attention. “You know what I’m going to bring up next,” he said. “And just because you say no doesn’t mean I’m ever going to stop asking.”
She leaned toward him and their knees almost touched. “Lay it on me, Jimmy.”
He took a deep breath. “I would like you to speak with one of our mental health professionals.” Sheryl pulled back slightly but left her hand resting in his. “This is not a judgment against you,” he said. “I just think you’d benefit from talking to someone. Someone with more expertise than me.” She closed her eyes as he continued to speak. “We’ve been talking about this a long time and I think it would really help. And the clinic actually has an opening today. You could be seen this afternoon.”
I stared at Sheryl, wondering what was going through her head, as my eyes fixated on the lipstick. Why not talk to someone? What’s the harm? I straightened my freshly starched white coat and folded my arms.
“I understand why you don’t want to go,” Jim said, edging closer to her. “Really. But this is important, and I’m not going to stop bringing it up.”
She shook her head. “I’m not crazy.”
“I know that. I know you’re not crazy. But I still think this could help.”
Sheryl looked down at the floor, and my eyes drifted in the direction of her gaze. What was she thinking? Was she crazy? In our brief interactions, it had kinda seemed like it.
“It’s important,” Jim added. “Really important.”
Sheryl looked over at me, and I gave a gentle nod.
“Please consider it,” he said.
She gave him an exaggerated smile and softly said, “Fine.”
My eyebrows raised, and so did Jim’s.
“I’ll do it, Jimmy. Whatever you want.”
“You will?” he asked.
“I will.” Sheryl looked at me, grinning. “He has been a pain in my ass about this for years. Years! Never shuts up about it. Go see someone. Go talk to someone. Well, I’m talking to you, Jim! I’ll talk all you want.”
I wanted to respond but wasn’t sure what to say. “Is that right?” I muttered.
“I’ll make the referral now,” Jim said, flashing a flicker of a smile. “Right now.”
A moment later the appointment was over. Sheryl grabbed her belongings, gave Jim a hug, and said, “To be continued,” as she sauntered out of his office toward the mental health clinic. When the door closed, I noticed that O’Connell was staring at a blank sheet of paper on his desk.
“Interesting lady,” I said, approaching him. “Really interesting.” I took a seat where Sheryl had been. “Lot going on there.”
Jim sighed and looked a
t me. “That woman has had her life ruined because of mental illness,” he said. “Her marriage, her job, every interpersonal relationship. All destroyed.” His eyes became moist and his voice soft. “I have been trying for six years to get her to see a psychiatrist and she has always refused. Every single office visit for six years. Always said no.”
I studied his face, trying to think of something significant to say. But I could only offer a single sound. “Huh.”
“She has never given herself a chance.” Jim pounded his right hand on his thigh and smiled. “Until today.”
“Incredible.” His eyes bounced from left to right, and I tried to follow them. I could hear voices just outside of the office discussing a new coffeemaker. “Why today?” I took out a pen and a small notebook from the front pocket of my white coat and started to jot down the details of the exchange. “Wonder what changed,” I said.
I waited for Jim to say something about persistence or tact, but he didn’t say anything. He just stared at the blank sheet of paper. As we sat in silence, I tried to imagine what the last six years of encounters with Sheryl had been like. Had she yelled at him? Politely declined his suggestions? Did he ever get frustrated or upset with her?
“Matt,” he finally said, putting a warm hand on my shoulder, “sometimes things that on the surface can seem like small victories, very small victories…”
His voice trailed off, but I wanted him to continue. I put down my pen. “Yes?”
He stood up and shook his head. “Sometimes those things can actually be tremendous victories.”
—
I was so taken with Jim and his philosophy that I convinced Harvard Med to give me course credit for schlepping around with him. Instead of making me learn how to efficiently manage a complex primary care visit with a guy like Sam, the school gave me primary care credit for assisting Health Care for the Homeless one night each week. That’s part of the reason I felt so overwhelmed when I started working in Columbia’s primary care office; I had watched Jim provide primary care out on the streets, but I hadn’t done much of it myself.
Sure, I dispensed clean socks and foot ointment and listened when people wanted to chat, but Jim was the one examining and treating people. He was the one making tough decisions, convincing a reluctant recluse to go to an emergency room or providing reassurance. But it was during those late-night rides that I discovered how important it is to connect with patients. He was the reason, I realized later, that I first went to Benny’s room when Baio asked me to introduce myself to the patients in the CCU. I didn’t gravitate to the most medically complex patients, I went to the guy on the stationary bike—the guy I could talk to and potentially connect with.
From Jim I learned that through medicine it is possible to reach the unreachable—even the ones who most of us forget about or actively try to ignore. This is the power and beauty of our profession. He spent his evenings with Boston’s homeless so they would trust him, so they would come to his clinic when illness struck. And this, I discovered, was no small task for people who lived under bridges or in large boxes near abandoned warehouses—people who were embarrassed by the sores on their legs or the smell of their skin. To walk into a hospital’s lobby in shambles and sit in a waiting room was not something most would even consider. But they did it for Jim.
And I wanted them to do it for me.
17
“Let’s start with the basics,” said a woman holding a marker outside of a patient’s room. I had completed my month in the cardiac care unit, parted ways with Baio, and moved on to the infectious diseases service. My new assignment—tending to patients with HIV, tuberculosis, or viral hepatitis—was widely considered the most fascinating and emotionally taxing monthlong rotation of intern year, which was hard to imagine given what I’d just gone through. The majority of the patients checked in to the infectious diseases wing of the hospital, we were told, were intravenous drug users or had mental illness. They were the unreachable patients who might yell at you or spit at you, the ones with nothing to lose who would exploit any sign of weakness—emotional, professional, or otherwise.
“If a patient shows up in our emergency room and says they have HIV, what six pieces of information must you obtain without fail?” Dr. Chanel, a junior faculty member in the Division of Infectious Diseases, asked of our small group of residents and medical students. She was in her late thirties and had a gently graying side ponytail. Muffled whispers passed around the half circle. We had just emerged from the room of a young woman who had reluctantly come to our emergency room because of a persistent sore throat; Ariel had been the one to inform her that her symptoms were actually due to acute HIV infection while we all looked on anxiously. As tears streamed down the patient’s face, I had been sent out in search of Kleenex. After a few minutes of fruitless searching, I had returned with a handful of paper towels and toilet paper, which the woman had waved away. Then we’d all shuffled out.
Our group now had a brief moment—a thirty-second huddle—to try to learn something from this encounter before we were sucked back in to the maelstrom of buzzing pages and relentless orders. “One,” Dr. Chanel continued, “what year did they contract HIV? Is this someone who has had it for twenty-five years and been through numerous treatment regimens, or is this someone like our last patient, who contracted it a week ago and is struggling to cope with the diagnosis?”
I wondered if this moment would have been better spent counseling the woman who had just had her world upended.
“Two,” Chanel said, as we took notes, “what is the CD4 count. This is the subset of white blood cells that HIV destroys. Three: viral load. This is the quantity of replicating copies of HIV in the blood. The goal, not surprisingly, is for the viral load to be undetectable. Four: risk factors. How did the patient get HIV?”
I half-raised my hand, and Dr. Chanel nodded at me. “Why does it matter how the person contracted HIV?” I asked. “Seems like they’ve either got it or they don’t. Not really our business how they got it.”
She scanned the group. “Can anyone answer Dr. McCarthy’s question?”
Meghan cleared her throat, perhaps in an attempt to suppress her twang. “Well,” she said, “patients who get it from IV drug use are more likely to have hepatitis C or endocarditis. Patients who get it through receptive anal intercourse should be screened for anal cancer.”
Chanel smiled. I wondered if it was the first time that a sentence ending with the words anal cancer made someone do that. “That’s exactly right.”
I quickly jotted this information down, pausing once to consider how poised Ariel had remained while relaying the devastating diagnosis. I couldn’t have done it as easily as she had. I wondered if her time in consulting had prepared her for delivering bad news. Possibly she was used to walking into a room, ruining someone’s life, and walking out.
“Good. Point five,” Chanel went on, “what medications are they on? Does their HIV regimen make sense? And six. What opportunistic infections have they had? HIV patients get bizarre infections. That’s actually how the virus was discovered. Otherwise healthy gay men in the early nineteen eighties were developing—”
ARREST STAT, SIX GARDEN SOUTH! the intercom blared, and my knees buckled. ARREST STAT, SIX GARDEN SOUTH!
I was the only one in our group who visibly flinched. Recently I had resigned myself to the fact that the screeching, electrifying announcement was something I’d never get used to. Two members of the team sprinted away, and I thought of Baio, hustling to revive yet another person. It was strange being separated from him. I wondered where he was and whom he was teaching. The man who’d taught me so much over such a short period of time was now just a guy I passed in the lobby or caught wolfing down a piece of pizza at grand rounds.
“Perhaps we should stop there,” Dr. Chanel said, readjusting her side pony. “Let’s reconvene in twenty minutes.”
A few minutes later, the second-year resident I’d been assigned to work with in this portion of my rotat
ion, Ashley—my new Baio—returned from the arrest. She had impossibly high cheekbones and spoke in clipped, overcaffeinated sentences with one thought emerging in the midst of another. In retrospect, she gave the impression of Jennifer Lawrence on speed, perhaps with more sensible shoes.
Ashley had greeted me that morning by saying, “Don’t do anything without running it by me first. Are we clear?” Before I could respond, she’d launched into the array of tasks that needed to be completed before rounds—rattling off assignments like wheeling a patient to dialysis and transporting a vial of blood to the chemistry laboratory—faster than I could write, and then withdrew the work delegated to me just as quickly, explaining that it was quicker if she just did everything herself. This was becoming a regular routine, and it made me feel expendable and potentially dangerous. It was clear she considered me a liability, someone who still couldn’t enter computer orders related to HIV care or write notes as proficiently as she could. Our brief exchanges were reminiscent of a naughty child and a frustrated babysitter. Her friends called her Ash, but she’d instructed me to call her Ashley. The intentional distance she put between us made me anxious. Even though we were hardly a personality match, I wanted to click with her. I wanted to click with everyone.
“Where were you?” Ashley asked, running her hands through olive oil hair. “You’re supposed to come to these arrests.”
I looked up from my scut. “I didn’t realize.”
She flashed a stiletto stare. “Realize.”
“I didn’t see any of the other interns going so I—”
“I don’t need an explanation. Woman’s dead. Dead on arrival.” Ashley shook her head. Baio must not have been there, I thought.
“We’re reconvening with the attending in about ten minutes,” I said.
The Real Doctor Will See You Shortly Page 10
