SIGNPOSTS | Andrea L. Merrill
My phone vibrates next to me on the scratchy motel sheets. It’s still dark outside as I rouse myself from sleep, my lids heavy from the late flight a few hours earlier. I tap my phone and see Judy’s name glowing dimly on the screen. “I think I want to end my life.” The words sit there, heavy and unmoving. I don’t know what to do; I’m 3,000 miles away. Why am I the one she chose to send this to? When she doesn’t answer my calls or my texts, I call the local police to do a wellness check. I don’t know where she is, if she is using again, or if this is even a real threat. But I keep calling.
***
I met Judy five months into my first job as a surgeon. A hospital gown hung loosely from her body, hiding the left breast mass that had brought her in. I took in her disheveled appearance, her crooked, yellowed teeth contrasting with her dark skin. Her breast cancer was treatable but would require multiple rounds of chemotherapy, surgery, radiation and five years of pills. It was a daunting course for anyone, let alone someone like Judy who was homeless. Judy’s wide, brown eyes looked at me, full of fear and distrust. I hoped my face appeared friendly enough behind the blue mask covering my smile. I hoped she couldn’t sense my own fear and uncertainty as a new surgeon.
Judy started her first cycle of chemotherapy and immediately landed in the emergency room due to a two-day cocaine binge after six years of sobriety. She seemed overwhelmed by the diagnosis and perhaps had turned to an old friend to numb her mind. Several more emergency room visits followed for syncope, drug relapses and a port infection. I never told Judy this, but I blamed myself. I had read about her history of cocaine use in her chart but felt too uncomfortable to ask about it. Maybe she would have told me she was fine and didn’t want help, but I didn’t ask. Instead, I glossed over it, a checkmark on a long list of questions, and focused on what I knew how to treat: her cancer.
As a mea culpa, I threw myself into helping Judy continue her treatment, working with the social workers and even calling her myself with visit reminders. I was still insecure about my skills as a surgeon this early in my career, but communicating with Judy was something I knew I could do, even if it seemed beyond the boundaries of a typical surgeon-patient relationship.
One hospital admission, I visited her every day, pulling up a plastic chair next to her bed as The Food Network projected from the tiny TV on the wall. She spoke in short, emphatic sentences, often going off on tangents I couldn’t quite follow. Her eyes darted discordantly around the room as she shared that she had been the chef at a hotel for eighteen years. “I make the best red sauce, mmmmm,” she reminisced. “You know the secret? Gotta give it time.” Our conversation turned to food as she regaled me with her favorite recipes: jambalaya, chocolate cake, a perfectly cooked steak. Food became our common language, and I could feel her trust in me growing.
The day of her operation finally arrived and just before surgery she told me she needed a few minutes for “my right boob to say goodbye to my left boob.” Judy didn’t know but it was a big day for me too: my one-year anniversary of becoming an attending surgeon. Somehow, we had both made it through the year. My year of insecurities about my abilities as a surgeon were culminating in this moment. The surgery went smoothly and the next week in clinic I gave her incredible news: the chemotherapy had removed all traces of detectable cancer in the tissue I removed during surgery. It was one of my proudest moments of my early career, to be able to get her through months of chemotherapy and surgery, proof to myself that I was a capable surgeon.
However, she soon skipped her appointments for ongoing treatment. I called Judy, texted her and asked her other providers to call. She eventually responded to a text and showed up for an appointment or two, only to disappear again. And then, a few weeks later, as I was catching up with a friend over Sunday brunch, she called me and left a voicemail that she was homeless, kicked out of her cousin’s apartment. I was drinking hot coffee and eating fluffy, decadent pancakes inside a warm, cozy restaurant while Judy was outside in the cold. I felt guilty that I didn’t call her back right away.
I spent hours on the phone on my day off trying to find a shelter but then she was turned away for having too many belongings. I was at a loss. I knew how to cure Judy’s cancer, but I didn’t know how to cure her homelessness or addiction. Would a better doctor have been able to do more? Or was I trying to do too much? Perhaps this was the sign that I had crossed the doctor-patient boundary with Judy. I worried it was taking my attention away from my other patients while slowly exhausting me.
But Judy gave me one more surge of hope. The day before Thanksgiving I received a text “Happy Thanksgiving, gobble, gobble.” She was temporarily living with family and called to tell me about the feast she was cooking for 42. “It’s nothing,” she said. “I used to cook for over a hundred when I was a chef.” She was making sweet potato pie, chocolate cake, a whole smoked turkey, ham, goose and sides. And then she told me about her family Thanksgiving tradition of going around the table to say what each person was grateful for. This year, Judy was grateful for me. I doubt she knew how much I needed to hear those words.
She disappeared again, though, and stopped answering my calls. Just before the social worker was about to call the police for a wellness check, Judy texted me, as if she could sense my worry. “I am homeless again. Let me be. I am going back on my drug of choice.” A part of me felt a sliver of relief. She was letting me off the hook. She was setting the boundary I didn’t yet know how to set. I knew it was time to listen and let her be. And maybe it was time to let myself be, to forgive myself for not being able to do everything for her or the subsequent Judys that would inevitably come along.
***
I thought that would be the last I heard from Judy and that she would stay forever on my “lost to follow up” list. All doctors have one. But she surprised me, occasionally showing up for her mammogram or visit with me. And then one day she presented with a new mass. My fingers rolled slowly over the hard, irregular lump under her armpit. Her clothes hung off her shrinking frame. I helped her schedule a biopsy appointment to confirm the inevitable, but she never showed up. I didn’t hear from her again until her despondent text threatening to take her life appeared on my phone screen in the early hours of the morning.
Twenty-four hours later she finally called and told me she was ok but then she went silent again. When she came back in for treatment several months later, her cancer had metastasized to her bones and lungs. She confessed that she had relapsed and was ashamed. But I had my own secret too: I was moving away in a few months for a new career opportunity. I would be leaving her. I dreaded telling her, worried she wouldn’t get treatment if I wasn’t there, but this was something I had to do for me.
I realize now that I clung to Judy in those early days as a barometer to measure my skills and compassion as a doctor. Judy was my “signpost, my teacher.”[1] She embodied the beginning of my journey as I struggled to understand not just who I was as a surgeon, but who I wanted to be as a doctor. She helped me realize I was a capable surgeon but also one who will never settle for just treating the cancer. She taught me that patient-doctor boundaries are not always clear, and it may be ok to cross them occasionally. Now it is time to take the lessons she has taught me, the confidence she has instilled in me, and for both of us to take our next steps forward.
[1] Berwick DM. “A piece of my mind. To Isaiah.” JAMA. 2012 Jun 27;307(24):2597-9.
Andrea L. Merrill, MD is a breast surgeon practicing in Charlottesville, VA. She is passionate about promoting women in surgery, surgical ergonomics, and narrative writing. She has published in JAMA, Annals of Internal Medicine and Annals of Surgery. Note from author: “I would like to acknowledge Dr. Richard Panush for his helpful insights and feedback which guided me in revising this essay.”