Chapter 6: Nepenthe

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It is a false alarm. We, the half-drunk and ornery, wander around the entrance to our apartment building like aimless dogs. As is our custom, we do not greet or look at each other, even though we are neighbours. Instead, we peer into the abyss of our phone screens, scrolling to the symphony of cricket chirps. For my part, I sit cross-legged on the cool grass of the church lawn across the street from my walkup, observing, in the still tenebrous night, the lackadaisical firefighters, who waddle into the building only to shut off the wailing alarm. 

With a curt wave, the oldest of the firemen, a potbellied man with a bristle brush moustache, ushers us back inside, where we clog the stairwells and plod miserably up to our apartments. A woman wearing pyjama bottoms adorned with multicoloured bananas mutters to her partner.

“If it’s those fucking degenerates in 201, I’m going to be so mad. Every time there’s a party, one of their shithead friends pulls the alarm. So over this.”

I doff my shoes on the mat in the entryway of my apartment and stagger into the bedroom, where I allow myself to fall onto the firm mattress. 

Some hours later, I awaken with the sun, which pours through the diaphanous green curtains of my small bedroom window. My phone flashes with a QuidNunc message alert. Ben has sent me a curated list of podcasts to sample on my commutes. 

Ben T [07:05:12]: For the weekday slog. See you in a bit! Cheers

It is a nice gesture, perhaps a bit zealous, but I thank him for his thoughtfulness. Tomorrow is, indeed, looming. Back to work and the tilting, laggard orbit of a life interrupted. I am fortunate that my reentry is as close to a perigee as possible, the beginning of a new clinical rotation. Besides, I have been a resident-in-mourning once before, I remind myself. The sheer turbulence of day-to-day training seemed to provide a buffer against the cloister of anguish, which I suppose I will defer once more. I simply will not have time for grief—or turnings, for that matter. 

I do my best to ensure I am ready for Monday. Lunch containers are packed and stacked in the fridge. I wipe my stethoscope and pack my backpack with my trusty pocket clinical handbook, so worn now that it no longer has a cover. Medicine is not like riding a bicycle. If you don’t use it, you will most definitely lose it. And so I spend much of the morning flipping through Harrison’s Principles of Internal Medicine and a pile of rumpled medical periodicals. During my monthlong hiatus, the mail carrier made herculean efforts to stuff my mailbox long after it was full, so I have to straighten the accordioned pages as I read.

While I make lunch, I send a dispatch to Rhiannon. 

Karina [12:45:50]: T minus 24 hours until clinic

Karina [12:46:06]: I met someone at the MOTH

She replies a few hours later, and a QuidNunc exchange ensues. 

Rhi L [14:58:11]: Hey. O yah? Like a friend or a guy??

Rhi L [14:59:08]: Slo day today thank god. U r good at clinic. It will be a piece o cake.

Karina [15:02:24]: His name is Ben. 

Karina [15:02:52]: He wants to get together later this week. Maybe we should double-date?

Rhi L [15:03:22]: Ow owwwwwww!

Rhi L [15:03:48]: Yah ok. Sila and I are taking things slow but I can ask her. We could do something wacky like axe throwing

Rhi L [15:04:04]: How r u? Must be hard to go back to a busy medical life

Karina [15:05:02]: I’m OK. Trying to prep. I feel like I’ve lost all my medicine.

Rhi L [15:05:40]: It will come back. O shit just got a page for an epidural. Talk soon girl

Karina [15:06:10]: OK, good luck. I miss your face. Let’s get together soon, with or without Ben and Sila

Rhi L [15:06:32]: <3 . I’m off next wknd.

Karina [15:07:05]: Yes!

I am tempted also to send a note to Ben, but I resist it. I do not want to come off as overeager, especially this early on, when everything seems so touch and go. Like a prissy child at a lakeshore, I am dipping my toes into the water with a mixture of wariness and suppressed longing. For his part, he seems neither confused nor discouraged. Or perhaps I simply cannot parse the vagaries of post-date texting, which permits me, a drifting, reticent echo, to ping and retreat. 

Ben does write to me once more at the tail end of the afternoon, while I am preparing a very vinegary kale salad to eat for dinner.

Ben T [17:45:23]: Psyched for dinner on Friday. The restaurant is called Graceful Phoenix. 

Karina [17:55:12]: Haha thanks, Ben. Me, too.

Ben T [17:56:26]: If you have some free time earlier let me know. I’m free most nights.

Karina [17:59:02]: OK, will do, Ben. I’ll get a sense of things tomorrow and let you know.

Ben T [18:00:12]: Nice sounds good. OK, have a great night!

I turn in early, but spend much of the fitful night on the couch, trying, in vain, to read myself to sleep. I feel like I am on call, awaiting a page, vigilant and uneasy in the early hours of morning. Maybe I drift off at some point, trapped in the outer darkness of pseudo-sleep, dreamless and sweaty, but I doubt it. Even though I know better, I droop my antsy torso over the side of my couch to check the flashing red clock-face on the phone screen. I should be fast asleep, I think sourly, but creeping anticipation has me bound and gagged, dangling from the second hand, which ticks along inexorably under my insomniac weight. 

My alarm sounds, but I am already awake. It does not take long for the stony, desperate grogginess that greets the two-hour sleeper to settle like a fog over my awareness. I creak and groan my way through my ablutions. I wind my wild hair into a tight silver bun and hover over a bowl of oatmeal, which I spoon into my reluctant mouth in great heaps. Yesterday, I pre-prepared my coffee, which I reheat in the microwave and pour into a thermos to sip throughout the morning. Ever mindful of spills, I slide my lunch container into the frontmost pocket of my backpack, which I heave over my shoulder with a loud groan. 

I chose my apartment primarily due to its proximity to the Hillside Community Health Centre, a drab building shaped like a car battery, which I can see from my window on a clear morning. The walk is quiet and placid, as usual, and aside from a few harried business types speed-walking with their briefcases smacking their thighs, I am alone on the sidewalks. 

I arrive at HCHC early to prepare for the day. In my absence, the staff has apparently redecorated. Bright, educational posters span the walls of the waiting room alerting patients to the availability of HIV pre-exposure prophylaxis and short-term counselling for “those of us who find ourselves down in the dumps.” Since I am the earliest bird, I flick on the lights in the horseshoe-shaped charting area and open the doors to the stuffy little exam rooms to let them air out. Then I sign into the electronic medical record at my usual computer and comb through the charts of today’s patients. 

I can hear my supervisor, Dr. Fossal, before I see her. She is exclaiming to the sycophantic Dr. Stilton, with whom she walks to clinic each day. From my computer facing the contoured entryway to the charting room, I greet the dyad. The diffident Dr. Stilton, a thin, wide-eyed brunette woman of uncertain age, stands back to allow Dr. Fossal to sweep into the room. 

“Oh, hello, Karina,” she says in her loud and astringent voice. She is short and plain, with a prominent snaggletooth, which protrudes from her permanent sneer when she deigns to convey a human smile. “Someone had mentioned that you would be coming back for this block.”

I nod and smile at her deferentially. “Morning, Dr. Fossal,” I say. “Home again. Ready to get back into the swing of things.”

Dr. Fossal and Dr. Stilton hang their purses on the coat rack and take their usual places at the computers near the semi-translucent back wall.

“We have a busy day,” Dr. Fossal says. She clacks her index fingers loudly on the keyboard and squints at the monitor. “Have you had a chance to check the schedule?”

“I have,” I say. “Do we have any other learners with us today?”

“A medical student,” she says. “Jenica or Jessilyn or something. When she arrives, I’ll give you a rundown of the morning. Do not assign yourself to patients before that.”

Dr. Stilton whisks over to my computer. She clasps my elbow softly, and I turn to her. Close-up, I can see that her dove grey irises are speckled with the palest of pale blues.

“It’s so good to see you,” she says softly, each word enunciated. “I am so sorry about your father, Karina. Do let me know if there is anything I could do to help you today.” 

As though my lacrimal glands were primed, a runnel of tears drips onto my shirt, which I quickly draw up to wipe my eyes. Characteristically, Dr. Fossal is neither paying attention nor reading the room. Without looking up from her screen, she calls to Dr. Stilton, who squeezes my elbow once and returns to Dr. Fossal with a simper.

“And isn’t that just like my husband, Karen,” she says and gestures to her phone. “He forgot the kids’ lunches again. I love him, the big dork, but two times in one week? I might as well have the dog do it.”

Dr. Stilton cackles at this bit of schtick, which Dr. Fossal would like to believe is her longsuit. Fellow residents and other staff doctors trickle in. Everyone greets me cordially, but no one asks about my month-long absence, which I chalk up to “training blinders.” I continue to review the day’s charts and conjure tentative plans for each patient, whom I will have just fifteen short minutes to assess and treat. This is the “price of access,” Dr. Fossal is fond of saying.

Last to arrive is a very young, mousy woman wearing a low-cut blouse. She checks the placard on the door twice before shuffling in. I deduce that this is the med student, so I intercept her.

“Are you Jenica?”

She smiles and inspires with a faint whistle. “Hi!” she exclaims. “Yep, I’m Jenica, the CC3. You’re doctor—?”

“Karina,” I say. “I’m an R2 in family medicine. You’ll be with us today, me and Dr. Fossal.”

Jenica bounces enthusiastically on her forefeet. “Yay, that’s great!” she says. 

I wave her over to Dr. Fossal, who squints at us with obvious disinterest. “OK, girls,” she says. “Or, I should say, ladies. We’ve got a full list.” She gestures lazily at Jenica and mumbles a greeting. “I’m Dr. Fossal. You’re a, what, third year?”

Jenica nods. “So good to meet you, Dr. Fossal,” she says.

Dr. Fossal pauses to offer an exaggerated tight-lipped smile. “Pleasure,” she says and clasps her hands at the bottom lip of the keyboard. “And how is everything going?”

Jenica’s head bobs with every obsequious word she overpronounces. “Oh, so good, Dr. Fossal. I am absolutely loving clerkship. Family medicine is just so wonderful, and I have been looking forward to this block so much.”

Dr. Fossal cocks her head and squinches her nose with barely concealed impatience, but she says nothing. “I did want to let you know about some of my learning goals for today and the next six weeks, if that’s OK, Dr. Fossal,” Jenica continues. “I have a passion for underserved populations, especially those of our patients who have been marginalized in some way. So if there are any patients with challenging social determinants of health, like living with homelessness or problematic substance use, that would be such a great learning opportunity for me.”

Dr. Fossal pauses for a moment before delivering a clipped response. “OK, Jenica. We’ll see what we can do. Now, are you comfortable with histories and physical exams?”

“Oh, yes,” she says. 

Dr. Fossal drags her finger down the screen. “OK, then this morning, you can see Kaur at eight-thirty, Toews at nine-thirty, Muggleston at ten-thirty, and Zhou at eleven-thirty. Can you handle that?”

While Dr. Fossal is talking, Jenica whips out a pen to write on her outstretched palm. “Yes, that’s just perfect,” she says. 

“And Karina,” Dr. Fossal drones. “You can see the rest.” She spreads her hands and allows her eyelashes to flutter theatrically. “I’ll be here, as usual, just living the dream.”

I turn to Jenica. “Do you know how to use the EMR?” I ask. “And do you have a login?”

“Yes to both,” she says. “I’m all set, thank you so much, Karina. I did an elective here after pre-clerkship, so I’m good to go.”

We return to the bank computers along the front wall. I pat the seat next to mine to signal to Jenica where she should settle. 

“OK, all set?” I ask. She bobs her head with such gusto that her headband slips forward. She adjusts it with her delicate, nervous hands. 

“Don’t hesitate to ask me if you need anything,” I say. “Really, I’m here to help you.”

“Thank you so much, Karina.”

This medical student overeagerness is pro forma, I know, a bulwark against paralyzing anxiety, but I still want to shake her. Before I see my first patient, who will need a monthly vitamin B12 shot, I swing by the nursing room a few rooms down the hall. Ciera, one of our pod’s regular nurses, is listening to R&B on her phone speaker while wiping down a blood pressure cuff. She is tall and rotund, with sleek black hair that she wears in thick braids. 

“Oh, hello, Dr. Bergson,” she says.

“Hi, Ciera. Would you mind giving Ms. Borsuk her Vitamin B12 shot this morning? She’s due.”

Ciera’s shaped eyebrows bridge in apparent confusion. “Her what?”

“Oh, she just needs B12.”

“She had it last time, Dr. B.”

“Oh, did she?” I know better than to take Ciera’s word on this. In my first month, she “forgot” to give one of my intractable schizophrenic patients his court-ordered injectable antipsychotic. This was not discovered until he was re-hospitalized a few weeks later after breaking into a church to tack up his very own, new-and-improved 95 Theses. 

“You know,” I say to Ciera. “Let’s give it again today.”

“OK, doc,” says Ciera. 

In preparation for what I suspect will be a tumultuous patient encounter, I use the washroom and make sure to swig some water from my water bottle. Vera Borsuk is an abrasive, cantankerous woman in her late sixties who has longstanding, total-body chronic pain with no diagnosed source. In the words of my old supervisor, who has since taken a teaching job somewhere in Tunisia, Vera has received “a million-dollar workup.” She requires a walker, even though there is nothing demonstrably wrong with her trunk, hips, or legs, and books weekly appointments to castigate whoever is unlucky enough to see her as payback for the system’s failure to cure her. 

Before I enter the small exam room in which I know she is stewing, I take ten deep belly breaths, steeling myself for a duel. Vera has a habit of unloading a dozen health concerns rapid-fire, and in the past, entire clinic days have been pushed back as a result of callow capitulations.

Today, she is following up on a recent diagnosis of lichen sclerosus, an autoimmune condition that causes itchy, puckered white patches around the external genitalia. According to his excellent note, my fellow resident, Antoine, saw her last week and prescribed a round of strong topical steroids, which is the gold standard initial treatment. Today, I have a simple goal, which I rehearse in my head. By the end of the appointment, we will determine, together, whether the steroids are working. If not, I will offer her a referral to see a dermatologist for further management. 

I wait by my monitor until the appointment slot flashes green to indicate the nurse has given the injection and left the room. I linger at the exam room door for just a moment before knocking.

Vera is sitting primly in one of the chairs beside the exam table with a paperback book in her hands. She is diminutive and lumpy, with a kyphotic posture that ages her twenty years. Like many of my chronic pain patients, she wears a permanent, anguished glower. It is a warning to hapless residents like me, a message embedded in the crimped skin of her upper lip and blowsy, ash grey hair. Her walker is parked in the centre of the room, so I have spread my arms akimbo to slide onto the stool beside the computer. Her limp, dangling feet swing gently as she speaks.

“Hello, Ms. Borsuk,” I say. 

“The pain is the same,” Vera replies flatly. “And that stupid cream the boy gave me doesn’t work. I’m completely miserable here.” She drops the book on the orange padding of the adjacent clinic chair and tilts her chin to glower at me. With patients like her, I have learned to ignore the surliness and set a clear agenda.

“So you’re hoping we can talk about the lichen sclerosus today?”

Vera is well aware of my intentions. She scoffs and shakes her head. “Are you telling me I can only discuss one thing? I have a list.”

“Let me sign in quickly,” I say and swivel toward the monitor. “And Vera, we have fifteen minutes today, so I’d like to keep it to one big thing or two small things.”

Vera flings both her hands up in indignation. “I came all the way down here for an appointment, and you residents always want to rush me. Do you know what it’s like to live with pain?”

“I know, Vera,” I say. “And I’m sorry we don’t have more time today.” 

“Well, let’s get to it then,” Vera snaps. “You’re wasting my time talking about procedure and what have you.”

I turn to face her. “Now, Dr. Williams prescribed clobetasol for the discomfort, the lichen sclerosus, last week. How is it working? It’s a pretty strong steroid.”

“It still itches,” she says. “And with my back pain—which is worse, if you care—it’s driving me bananas.”

“Would you like me to take a look?” I ask.

“There is no need,” Vera replies. She groans as she repositions herself on the chair. “Good God, why do you have such horrible chairs?”

I ignore this gripe, which she echoes in some form every time I see her. “OK, well, I think I’d give the steroid a bit more time. Some of the discomfort might be from the biopsy. Is it still healing?”

Vera scoffs and rolls her eyes. “After a month? No, there is no wound. You must have got the diagnosis wrong.”

“Lichen sclerosus is what the pathology report indicates, Vera,” I say. “It’s a fungal skin condition.”

“A fungus?”

“Sorry,” I say. “I misspoke. It’s a chronic autoimmune skin disease.” 

Vera folds her arms. Her lips pucker, which crinkles the skin around her eyes into deep seams. “You what?”

“Sorry, Vera,” I say. “You’re right. It’s not a fungus. It’s autoimmune.”

“Wow,” says Vera. “I can’t believe it.”

“What’s that?”

“How can I trust you? You just provided me with wrong information.”

“Oh, Vera,” I say with a forced smile. “It was just a slip of the tongue.”

“Well, my confidence has been shaken,” she says. “You’re not actually a doctor, anyway, and now it’s become clear you don’t know what the hell you’re doing.”

A feverish anger begins to snake up my throat. “Everybody makes mistakes, don’t you agree?”

“My confidence has been shaken.”

“Well, again, Vera, I’m sorry about that. Can we move on?”

Vera slaps the orange pad of the chair beside her with a petulant hand. “I don’t trust you. I don’t trust the information you’ve given me.”

Little cracks are spreading in my composure. I fold my hands in my lap and eye her cooly. “OK, Vera, what do you want me to say?”

She snorts at me, which provokes a chorus of hacking coughs. “Shouldn’t you reassure me that you know what you’re doing?” she chokes scornfully. “Are you at all competent? I don’t believe you’re competent.”

My equanimity shatters at this last salvo. Much like clueless the word competent crackles with electricity. “Vera, I don’t like the way this is going,” I say through clenched teeth. “Respect is a two-way street. I have been considerate to you throughout this appointment, and I would appreciate it if you could do the same.”

Vera’s desiccated sneer drops. Her thin, wispy eyebrows rise with exaggerated fear. “What did I do?” she asks meekly.

“We can continue,” I say. “But there are boundaries here. We do not treat each other with disrespect in this teaching clinic.”

Vera is quavering now. Her exposed upper arms are mottled and pendulous. They, too, tremble with evident chagrin. “Are you going to help me?” she asks in a babyish tone. 

“I’ll help you,” I say. “Look, let’s get back to the reason you’re here. OK?”

She nods solemnly with her lips curled into a puerile pout. 

“Do you want to continue with the steroid?” I ask. “Or would you like a referral to dermatology to discuss other kinds of treatments?”

“What?” says Vera hollowly. She straightens in the chair. “Are you firing me?”

“No, of course not,” I say quickly. “I’m offering you options for treatment.”

“I have been coming here for eight years,” she says. Her voice rises in a sharp crescendo. “Are you getting rid of me because I told you I didn’t believe you knew what you’re doing?”

I clasp my hands in my lap. “Vera, our time is running out,” I say. “I’m going to have to go to my next patient in a moment. Would you like to give the steroid another week? I can also send a referral to derm, the skin doctor.”

Vera’s puffy, florid face begins to quiver. She opens her mouth to reveal a row of small, mossy teeth and howls. “How dare you?” she cries. “I was abused for nine years! Nine years. Do you understand? Do you understand?”

My hands raise in instinctual placation. “Vera,” I say. “I want you to take a deep breath.”

She emits a strident, childlike scream. “You triggered me,” she bleats. “This is in my chart!”

“I’m sorry,” I say quickly. “What a terrible thing. I’m so sorry. I can’t imagine. But Vera, you need to stop screaming.”

She begins to smack the bit of chair pad protruding from her lap. “You should ask questions and not make assumptions!” she mewls.

“Vera, please,” I plead. “Let’s breathe together.”

She pauses to gulp as large a breath as she can muster. Then, like a banshee, she shrieks wordlessly once more.

I begin to panic. Typically, if a patient has a meltdown, they will respond to my de-escalation strategies. “I can go grab Dr. Fossal,” I say. “Would you like to talk to her?”

Vera claps her mouth shut and fixes me with an expression of pure rancour. “You’re a little bitch,” she barks. 

“OK, we’re done,” I say. I rise and exit before I can retaliate with a barb of my own. My heart is beating in a juddering, thunderous rhythm, perfusing my whole body with blood and fire. I stalk into the chartroom.

Dr. Fossal is stooped over her keyboard, mouth slack, gawking at a close-up photo of button-up shoes on her monitor. She pivots slowly in her swivel chair and blinks thrice.

“Yes, Dr. Bergson?”

“I have Vera Borsuk in three. She’s having a freakout.”

Dr. Fossal rolls her eyes and glosses her teeth with a lazy tongue. “First day back and problems already?”

I stare at her for a moment to gauge her mood. She motions for me to continue, so I recount the deranged encounter in the exam room with what I hope is neutrality and professionalism. Dr. Fossal does not interrupt, but she rolls her eyes at regular intervals and scoffs when I report that Vera called me a bitch.

“So what do you want to do?” she asks. “You’re six months from the end of training. How are you going to conclude the appointment?”

“Well,” I say, wondering which of the myriad appropriate actions will be perceived as the correct one. “It’s one thing to be unhappy and out of sorts, but patients cannot verbally abuse staff. I think I should end the appointment and give her a warning.”

Dr. Fossal eyes me impassively. “And then what?”

 “I mean, I don’t know, Dr. Fossal,” I say. “It’s obvious she’s acting out like this because she thinks she can mistreat residents with impunity. I think it would be helpful if you backed me up on this one.”

Dr. Fossal shakes her head. “No, I wasn’t there, Karina,” she says. “It would be inappropriate for me to reprimand a patient for something I did not observe.”

“I guess I can’t see how I can recover here,” I say. “Our therapeutic relationship has been compromised.”

“In what way?”

“She just screamed at me and called me a bitch.”

“Well, sometimes we have tough patients,” she says blithely. “If I complained every time an old man called me “sweetheart” or young lawyer unloaded on me because I wouldn’t prescribe Ativan for their plane rides, I’d have quit twenty years ago.”

“In other words,” I say quietly. “You’re telling me to suck it up.”

She steps back from her monitor and cocks her head like a seagull. “Excuse you, Karina,” she says. “I’m not sure I like your tone.”

We stare at each other for a long moment before I make a hollow capitulation. “OK, I’m sorry, Dr. Fossal,” I say. “I’ll take care of it.”

I return to my desk to collect my addled thoughts, ears humming with indignation. I tear an appointment reminder card from the dispenser on the wall and assign Vera an appointment slot on my academic day, when I will not be in clinic. I am already several minutes late to see my next patient, so I quickly head to Vera’s room to conclude the appointment.

She is sitting stone-faced and scowling, hands clasped in her lap. In anticipation of appointment end, she has packed her overlarge pleather purse and drawn her walker near.

“You will have to come back to follow up,” I say. “Continue to use the steroid. I will make a dermatology referral on your behalf. If you decide you don’t want it, you can cancel it when the office calls you to schedule your appointment.”

I hand her the card, which she takes gingerly. “Will I be seeing you next time?” she asks in a honeyed tone.

“I don’t know,” I tell her. “Give the card to the secretary on the way out.”

Without waiting for her response, I exit the room and shut the door, whose reverberant slam evidently scares the hell out of Jenica, who emits a squeaky gasp.

“Sorry, you frightened me,” she says, brushing her throat with her fingertips.

“Oh, sorry,” I mutter. “I didn’t see you there. Were you waiting for me?”

Jenica scrunches up her lips and fiddles with the bell of her stethoscope, which hangs like a pendant around her neck. “Actually, if you have a moment, could you show me how to use the elephant ear? I have an elderly gentleman with some new hearing loss, and I can’t see anything with the otoscope. There must be a big cerumen plug in his right ear canal.”

I motion for Jenica to follow me, and we speed-walk to the nursing room, where Tanis, a fifty-something, prickly veteran nurse, is pecking at her keyboard. 

“Yeah?” she says.

“Hi, Tanis,” I say quickly. “I’m just looking for the elephant ear so I can show Jenica how to use it. She’s a senior medical student.”

Jenica offers an enthusiastic greeting and a circular wave. “Hi there! I’m Jenica.”

“OK,” says Tanis. She turns to me and motions toward the far cabinet. “Ear stuff is in there,” she says. “Don’t forget to wash everything out.”

We head to the clinic sink, where I demonstrate how to assemble the modified spray bottle and situate the narrow tip in the ear canal to dislodge and flush out nuggets of impacted ear wax. 

“Oh, I get it, Karina,” Jenica says sweetly, head bobbing. “It’s like a squirt gun, yeah? I can do it. Thank you so much. I know you must need to see your patients. I’ll check in with you when I’m done. Is that OK?”

“Sure,” I say. “Let’s meet back in the chartroom after you finish. I should be done with my next patient after that.”

“Perfect!” chirps Jenica. 

Before I enter the next patient room, I snag a mobile computer terminal parked along the hallway wall. My next patient is an elderly woman one year post-heart attack. I see that we’ve been doing serial electrocardiograms every time she comes in, just to make sure she hasn’t slipped into an abnormal heart rhythm. She’s been waiting in the exam room for about ten minutes, and it does not appear she has had her ECG yet. I return to the nursing room, where Tanis and Ciera are giggling loudly at a viral video of a dog throwing a temper tantrum in a bathtub. 

“Hi, guys,” I say. “Would either of you have a moment to do an ECG on the woman in four? Ms. Halfpenny?”

Tanis glares at me through lids held at half-mast. Her sandy bob is cut jaggedly, and the ends are dyed a limey green. “You need me to do it?”

“That would be helpful,” I reply. I do my best to keep my face blank, but I can’t imagine my exasperation is well-hidden. 

Tanis crosses her arms across her expansive chest. “Well, you could do that, you know.”

I allow my gaze to linger on Tanis for a moment. Then I turn to Ciera and repeat the request. “Could one of you please help me with the patient in four?”

“Sure thing, doc,” says Ciera quickly. She edges past Tanis and pulls the ECG cart out from its niche by the long speckled desk. She unplugs it and quickly stuffs the cord into a depression on its side. 

I follow her out of the room and return to the hallway computer to quickly chart on my incident with Vera. Over the years, I have learned to lean into the frenetic pace of clinic, the mayhem of it all, especially when I’m under duress. Even flashes of red hot rage can be soothed by the salve of chaotic frenzy, which acts as a nepenthe. There, in the dry, refrigerated air of the teaching clinic, my hairline is damp with perspiration. 

Residents and medical students scurry back and forth, knocking on doors and offering solicitous greetings to their patients. I record the events of the fiasco with Vera in the standard bloodless, mechanical tone, quoting, where I can remember, both her words and mine. At the end, I note that I spoke with Dr. Fossal, and then detail our plan, which is for me to make a referral to dermatology and Vera to continue her trial of topical steroids for one more week. 

I omit my decision to schedule her on a day I will not be in clinic. It is irrelevant to her care, and besides, in any other clinic, and with any self-respecting staff doctor, she would have been roundly dismissed years ago. Somehow, such things never seem to happen in teaching clinics, where patients are keenly aware of the liminal position of residents, whose vulnerability makes them the perfect target for the aggrieved and sadistic alike. That is not to say that I work under constant duress. Most of my patients are lovely and gracious. But Vera is certainly not the only rotten apple in the bunch. 

If Dr. Fossal were not such a miserable pill, she would have gone to bat for me. Most physician teachers would have a zero-tolerance policy for patient vituperation, but as the year has unspooled, I have become increasingly aware of Dr. Fossal’s peculiar brand of roundabout spite. When she transferred from another teaching clinic, ebullient with nervous energy and compensatory wisecracks, I suspect I did not ingratiate myself abjectly enough. Unlike the fawning Jenicas of the medical world, who reflexively adulate and flatter, I ignored Dr. Fossal’s inane jokes and kept my eyes fixed on the monitor screen. For this sin, and my ongoing refusal to kiss her ass, I have paid with isolation and humiliation.

Presently, I check the nursing note for Thea Halfpenny, one of Dr. Stilton’s overflow patients we see every now and then. She is seventy-five, otherwise healthy, and one of the unfortunate few people whose heart attack was not occasioned by plaque buildup in her arteries. Rather, she had a MINOCA, which evidently was caused by a spontaneous tear in one of her coronary arteries.

Once the appointment slot flashes green on the EMR screen, I swing my stethoscope around my neck and knock softly on the exam room door. The sound resonates uncannily in the empty clinic hallway and the air around me starts to thin. My perception shifts ever-so-slightly, and I have a sort of felt sense that here and there have transposed. I squeeze my eyes shut and hum faintly to try to keep myself grounded. Not now, I almost say aloud. It can’t happen now. An image appears on my inner tableau, grainy under the strain of my defiance. 

My father is standing cross-footed in a cavernous room. A dim yellow light illuminates the space, which is filled with floor-to-ceiling metal shelving and meticulously labeled boxes. This Perry of perhaps twenty years past slides out one of the boxes and draws a manila envelope from its mouth. 

I hum more loudly and will the scene to dissipate. Not now, not now, not now, I plead with myself. A door opens beside me in clinic, and one of my fellow residents, Luis, flicks my shoulder softly through a diaphanous perceptual mesh hanging over the scene like a dense spiderweb. 

“You OK, Karina?” he asks.

His voice snaps me back. I shudder once and look around. The hallway’s eggshell walls and orange doors seem to breathe slightly, perhaps with vicarious relief. 

“Yeah, just a little tired,” I reply, somewhat breathless. 

He gives me a thumbs up and jogs into the chartroom, his badge bouncing against his navy slacks. I take a moment to breathe and chase away queasy, frantic thoughts of unmooring and lost marbles.

A voice calls out sweetly from inside the room. “I heard a knock. You can come in if you like. I’m ready when you are.”

I enter to find an elderly woman with long, straight cotton-white hair pulled into a ponytail the thickness of a bundle of spaghetti. She is wearing a bright pink tracksuit. 

“Hi, I’m Dr. Bergson, but you can call me Karina,” I say.

She smiles and extends her hand. “Pleasure to meet you. I’m Thea, but you can just call me Minnie.”

A scintillating wave of dread causes me to shudder, but Minnie does not notice. “Well, OK, then,” I say. I plop onto the wheeled stool and swing over to the computer. “Was the nurse able to do the ECG?”

“Oh, yes,” she says. “I’m an old pro now. I’ve had so many of those darned things.”

“That means we’re taking good care of you,” I say. 

She nods. “I’m very fortunate, I know. This heart attack was so unexpected. I don’t know if you read in my chart, but I’m a runner.”

I gesture at her tracksuit. “I can see that. How have you been doing?”

“On the runs? Well, I’ve only been doing about seventy kilometres a week.”

My jaw drops. “No, I meant in general. But seventy?”

She winks at me. “Don’t tell my cardiologist. He doesn’t think I should be running anymore,” she says slyly. “Hard on the heart, I guess. Don’t want to blow out a vessel.”

I can’t help but chuckle at this robust septuagenarian, who doubtless is in better shape than me. “Any chest pain when you run?”

“I’m a bit slower than usual,” she replies. “But no. No more marathons, probably, but I’m being honest when I say, Karina, that I feel pretty good for an old horse.”

I open the door just a crack to grab the ECG reading from the wall-mounted tray. I scan it quickly and compare it with a scanned reading from a few months prior, when she followed up with her cardiologist.

“This all looks good,” I say. “I have to say, Minnie, you’re making me feel like I should get outside more.”

“Are you a runner, too, then?”

“Not since high school,” I say. “I was on the track team, but I think my role was to fill a seat on the bus rides to the meets.”

“Oh, I’m sure you’re exaggerating,” she says. “I didn’t start running until after I had my first child. I was a schoolteacher before Asa was born. And one day, I thought to myself, ‘Minnie, it’s now or never. Do you want to spread out on an office chair like those admin ladies at the school?’ Before my heart attack, I was training for a steeplechase.”

“Well, it’s a shock that you had that MI,” I say. “The heart attack. You’re one of those people who did everything right.”

“Tell me about it,” clucks Minnie. “The cardiologist says my arteries are clean as a whistle. It’s rotten luck, that’s what that heart attack was. But I’m better now. Taking my medications like a good girl.” She grins wryly. “And I just had my shingles shot, too.”

I scan her chart for any outstanding preventive health checkboxes. “Well, Minnie, I don’t know if there’s anything more we can do for you. I’d say you’re a model patient.”

“You’ll keep my little secret,” she says. “Those cardiologists are so anal, aren’t they? Mine would have me sit on my duff for the rest of my life.”

I laugh again. “Did he explain why you should stick to walking for the time being?”

“Oh, I know the risks, dear,” she says. “But time is so precious. You’ll see that yourself when you get to be my age. The moments pass so quickly. For me, life just wouldn’t be the same if I wasn’t running through it.”

We conclude the appointment, and I return to the chartroom to report back to Dr. Fossal. Even from down the hall, I can hear echoes of Dr. Stilton’s reverberant laugh. When I open the door, Dr. Fossal eyes me sidelong and then delivers what must be the punchline of an elaborate joke.

“And then my husband, the big galoof, he says, ‘Polly, I’m really stuck.’” 

Dr. Stilton throws back her head and crows at the ceiling. The medical student, Jenica, also laughs fawningly, but it is rendered pantomime in the cacophony of Dr. Stilton’s hysterical cackle. 

“Anyway,” says Dr. Fossal, turning to me, face impassive. “You missed the joke.”

“Sorry,” I reply. “But it sounds like Dr. Stilton appreciated it enough for two people.”

Dr. Fossal raises a sardonic eyebrow. “Well, what’s going on? Any more fights with patients?”

I ignore this slight and report on Minnie. While I talk, Dr. Fossal lazily scrolls through her chart in the EMR. Jenica bustles over and hovers at my shoulder. 

“So what did you do for her?” Dr. Fossal says.

“I went through her preventive health checklist. She’s up on everything, but I did look. This was just a check-in for her. Cardiology was pleased with her a few months ago, too.”

“OK, and what did you do about Vera?”

“Well,” I say. “We made a plan. I’ll fax a referral to derm. She’s on clobetasol topical, and I figure she could try it for another week to see if the lichen sclerosus starts to clear up. I wouldn’t want to go much beyond that without derm guidance.”

Dr. Fossal flaps her hand and rolls her eyes in annoyance. “Yeah, yeah, that’s all fine. But what did you do about the behaviour?”

“I left it. The therapeutic relationship is already compromised. What would be the point?”

Dr. Fossal crosses her arms across her loose-knit sweater. With a finger, she gesticulates toward Jenica. “Surely, there’s a lesson here.”

I sense the heat of more than one gaze on my neck. The chartroom is small and cramped, and I know that my thin, reedy voice can be heard clearly even at the far bank of computers. My cerebral engine sputters and coughs as I scramble to marshal a satisfactory shibboleth in a discussion befogged with bad faith.

“In family medicine, you get people as they are,” I say to Jenica. “If they’re having a bad day, you share it. If there’s something going on at home or at work, you might be witness to the fallout.” 

Jenica bobs her head in agreement. I try to communicate with furtive squints, but I realize I don’t know what I want to say. Read between the lines, maybe. There is subtext here. Remember the hidden curriculum. But she is ever-attuned, hanging, or pretending to hang, on to my every word. I continue.

“To be honest, Jenica, this was a situation I’ll have to think about tonight. This patient of mine is suffering, but you can’t have a relationship without mutual respect. Wouldn’t you agree, Dr. Fossal?”

Dr. Fossal’s lips are pursed in an inscrutable expression, which is likely a variant of general discontent. “I think you should think about it. Thinking is always good.”

I try to keep my face slack to preserve the illusion of equanimity. In my periphery, I can just make out the lumbering, arrogant Dr. Cannardi, who has positioned himself obliquely on his stool, which always seems to strain under his considerable bulk. I know better than to keep this charade going, so I simply wait for Dr. Fossal to move on. 

She asks me to have Jenica tag along for the rest of the morning’s appointments, which are mercifully uneventful. Together, we assess a new cough, complete an elderly driver assessment, and provide light counselling to a down-and-out engineer and a neurotic teenager. I am patient with the junior trainee, who is keen and eager, and I try to hang back to permit her to practice taking histories and performing pertinent physical exams. 

We return to Dr. Fossal for morning debrief. She asks her usual question: “What are you taking away from this morning?”

Jenica pipes up first. “Honestly, this was such a good first morning in family medicine. I learned so much, and Karina was such a good teacher. She taught me that when you’re doing an otoscopic exam, it’s easier to adjust the bed than your eyes, so you have to make sure to use your angles so you can get the clearest view.”

Dr. Fossal lets her head loll and then shrugs. “Sure,” she says. “That’s a first principle, OK. And what about you, Dr. Bergson? What pearl of wisdom do you have to share with us?”

I ignore this barely concealed jibe and take a moment to think. It would be wise to elide the Vera debacle altogether, but much of the morning was workaday family medicine, so I struggle to pinpoint anything particularly illuminating. I settle on something anodyne, a fart in the clinic windstorm.

“You know, I think the thing that’s sticking with me is something my second patient, Ms. Halfpenny, said to me. She told me she still runs daily in spite of her MI last year. And we went through the risks of strenuous exercise, and she knew them all. She said she couldn’t imagine the remainder of her time on Earth not involving running. It was a good reminder that life narrative can be a critical ingredient in patient-centred care.”

Dr. Fossal blinks slowly to communicate muted displeasure, but she does not challenge me. Instead, she claps her hands on her thighs and declares “All right, team. Go to lunch.”

With a silent groan, I realize I did not refrigerate my quinoa melange, which is probably pickling in my backpack. Jenica swings a large taupe purse over her shoulder and casts a timid smile in my direction. 

“Why don’t we head to the caf?” I say. “It’s a little lunch space down the hall. Do you need to use the microwave?”

“Oh,” she says. Her smile softens, and her tone shifts into a more adult register. “I have some leftover pasta, so a microwave would be great.”

We amble into the corridor and wend our way through the maze of exam rooms and miscellaneous offices. Jenica heels closely, and I greet passing colleagues and staff, most of whom respond with curt waves. My program director, an extremely hirsute and schlubby man shaped like a bowling pin, eyes us creepily as he passes.

“Hello, Dr. Papadopolous,” I say.

As usual, he ignores this normal human salutation and continues to stare at us, hard, as he passes with a swish of his bulging chinos. 

“Is that the program director?” asks Jenica.

“Yep,” I say.

“Oh.”

We swipe into the lunchroom and I hang my backpack over a chair at a four-top table. Jenica draws her pasta container out of her backpack, and the two of us heat our lunches in adjacent microwaves. 

“So, how’s everything going?” I ask her.

“Good, I think,” she says. “I’m coming off of ortho, so I’m still a little tired.”

“No call on this rotation,” I say. 

“Thank God,” she sighs. “That was my first one-in-four. And—.” She puffs out her cheeks and shakes her head. “I mean, wow.”

My microwave dings. I gather a wad of brown paper tissue from a wall-mounted dispenser and gingerly pull my steaming, and startlingly stinky, quinoa from the interior and place it on the table. Jenica follows suit.

“Any questions from the morning?” I say. “Anything you were reluctant to ask in front of Fossal?”

She shakes her head as she blows on a forkful of creamy pasta. “No, I don’t think so, Karina.”

In my periphery, I spot a hunched, quick-moving shape flitting into the lunchroom. I recognize her immediately as Eunice, the clinic’s gawky, somewhat retrognathic chief resident, whose very tiny glasses float above her nasal bridge. 

“Hey, Eunice,” I say. “Long time, no see.”

She sweeps over to our table and knocks its surface in greeting. “Bergson.” 

Like a good medical student, Jenica thrusts out her hand, and her voice modulates up an octave. “I’m Jenica, the medical student on with Karina.”

“Eunice is one of our chief residents,” I say.

“Good to meet you,” says Eunice jocularly. “And welcome, welcome. We’re a friendly bunch here, Jenny, so don’t hesitate to fire off all those burning questions.”

She plops down beside me and flicks me hard in the upper chest, which stings briefly before giving way to focal numbness. “I’m sorry to hear about your Dad,” she says solemnly. 

“Thanks, Eunice,” I say. “First day back.”

“Well, we’re here for you,” she says. “Resident sisters and stuff.” She glances at Jenica, whose shaped eyebrows are knitted inquisitively, but I offer no further details. Eunice rests her face in her hands and taps her temple in an adagio tempo. 

“Who’re you with today?” she says to Jenica.

“Dr. Fossal.”

“Oh, wow,” says Eunice. She snorts and pulls back to flick me on the chest once more. “Well, on the plus side, usually they have you rotate from week to week.”

I shift in the stiff plastic chair, and my bladder, which has surreptitiously filled without my awareness, brushes the steel frame of the table. I almost leap out of my seat.

“Back in a bit,” I say. “Have to pee.”

I half-jog to the staff washroom and swipe in with my badge. While I meticulously lay down toilet paper on the off-white toilet seat, I check my phone for the first time since I arrived in clinic. The screen is teeming with QuidNunc notifications.

Rhi L [09:04:23]: Morning gurl. Hows the first day back? Fossal still a turd?

Rhi L [09:04:51]: I checked w/ sila and saturday is good. Ask your boyfriend. We’ll throw axes

Ben T [10:05:28]: Hey how are you? Just a quick hi. I read an article this morning with my coffee about the ‘grey tidal wave’ that’s going to kill healthcare. It made me think of you. The boomers strike again.

Aunt D [11:06:12]: Good morning, Karina. I am just writing you a quick text message to check in and to let you know that I am thinking about you. I know you are busy with a hectic medical schedule, but when the clouds part and there is a clearing in your days, I hope you will think of me. Sophia, Prateek, and the boys have been on vacation in Montana, where Prateek’s family has a ranch home. I wish she would call more, but the reception there is dismal. You do not need to reply, OK? I just wanted to send you a short note. XOXO Aunt Didi 

I reply to this raft of communiques while I sit on the pot.

Karina [12:32:42]: It’s a shitshow, Rhi, as always. And yeah, Fossal’s still Fossal. Let me ask Ben. I’ll get back to you. Do I need to make a res?

Karina [12:33:15]: Morning, Ben. It’s always the Boomers’ faults. That’s rule number one :)

Karina [12:33:45]: I know we have a dinner on Friday, but could we maybe move it to Saturday? My friend and her date want to go axe throwing. You and I could join them after. Feel free to say no.

Karina [12:35:09]: Aunt Didi, I’m so sorry I’ve been incommunicado! It’s so nice to hear from you. I should have called. I’m sorry. Can we grab lunch soon? Maybe Sunday? I would like to hear about you, Sophie, and everyone. Love, Karina

I return to the lunchroom to find Jenica texting one-handed while finishing her pasta. Eunice has left, and aside from a nurse fiddling with the coffeemaker, the room is now empty.

“Take your time,” I say to Jenica. “We can head back in ten minutes or so to prep for the afternoon.”

When we return, Jenica joins me for my appointments, in which I again give her the reigns. In her histories, she never misses a pertinent positive or negative symptom. Her physical exams are complete to the point of superfluity. The upshot of this division of labour is that I can chart while she does the medical grunt work, which gives us just enough of a time buffer to keep pace with the clinic’s unyielding schedule. 

For her part, Dr. Fossal just slouches over her monitor all afternoon reading, or pretending to read, a middle-brow essay on the rise of “lean-in physician women leaders,” who adroitly balance the demands of clinical life and parenthood while claiming their place at the table. She is lackadaisical about our plans, which she endorses with blasé, lazy-lidded nods or the monosyllabic command, “do it.”

Jenica is indefatigably engaged. She even performs egophony during a respiratory exam, a maneuver that requires the auscultator to discern a tonal change in lung resonance through her stethoscope. The patient, a ten-year-old girl with a typical cold, is unusually compliant with the young trainee, who tells her to say “ee-ee-ee-ee-ee-ee” while she presses the bell of her stethoscope at various points on her thorax. 

I resist the pedantic urge to inform Jenica that this is among the least sensitive respiratory exams in the old pneumonia repertoire. She is thorough and conscientious, and her fidelity should be lauded, so I diligently record her exam results. Only when she asks me for the child’s oxygen saturation do I tell her it is 100%.

At the end of the day, we dutifully report what we’ve learned to the ever-aloof Dr. Fossal, who yawns and nods.

“OK, girls,” she says and then smiles wryly. “I mean, OK, ladies. Day’s over. Go home. See you tomorrow.”

The rest of the week passes in a flash. To my delight and relief, the fiasco with Vera does not come up again, and so, by midweek, I figure I am in the clear. With each day that passes, Dr. Fossal becomes more and more apathetic and subdued. 

“You’re almost an independent doc,” she repeats in response to my perfunctory patient presentations. “What would you do if I weren’t here?”

For her part, Jenica does not need much more mentoring, and after one more day of tag-team patient care, she embarks on her own, seeing patients and reporting to Dr. Fossal. 

There is only one further incident of note. Bright and early on Friday morning, one of my patients, an elderly and irascible man who insists in spite of our remonstrations on riding his bicycle to clinic, gives me quite a scare. As I enter the room, he lurches forward to show me a new mole and promptly faints in my twiggy arms. His enormous bulk nearly floors me, but somehow I manage to remain upright and quaking. I yell for help while trying, in vain, to haul him over to the exam room bed. We make it only a few shuffling steps before I slink to the tile floor under his girth and cradle him in my lap until one of my fellow residents, Nico, hears my bleating calls and heaves the old man off my body. 

It turns out Mr. Nahdi did not eat breakfast before hopping on his Schwinn.

*Note: The illustrations accompanying this story were generated using AI technology

Chapter 7: By the Axe