Bad News

T.E. Holt

8 It’s one of those icons of medical training, something you spend an afternoon discussing in the preclinical years and then gratefully forget, like community health or Medicare billing requirements. I don’t remember anything we learned that day. All that stayed with me was a vague solemnity, a sense of having spent the afternoon in the middle of an Emily Dickinson poem—not one of the cheerful ones—and coming out of it about as wise for the experience. And so, as is inevitable with the lessons we tune out, it wasn’t long before I learned this one the hard way.

He was a 43-year-old with pneumonia. I was an intern on the infectious-disease service. He belonged there only slightly more than I did. He did have pneumonia, but pneumonias aren’t really all that infectious (most of them), and on a service crowded with HIV his presence was anomalous, more an accident of ER timing than a reasoned assignment from admissions. He had come up from the ER around two in the morning, admitted by the night float resident and placed on my service. His story was unremarkable. He had developed a cough, then fevers and shaking chills that bought him a five-day course of azithromycin from his primary MD. When he’d failed that, the primary had tried him on levofloxacin, a reasonably big gun. When he’d failed that, the primary had sent him to the hospital “for further eval.”

It’s part of the nature of the hospital where I trained (as it is with most teaching hospitals) that patients arrive without a great deal of documentation. In the typical community hospital, if you’re unlucky enough to find yourself hospitalized you at least have the consolation of knowing that your own doctor, who presumably knows your medical history, is going to be treating you. But admitting privileges at this facility are reserved for faculty of the medical school, who divide their time between laboratories, clinics, and the floor. When patients come here from what we generally call “outside docs,” they usually arrive without any more medical information than the patient can recall.

If the patient is well educated, articulate, and interested in his health, that information can be complete—sometimes too complete. But usually the patient is none of the above. I wouldn’t have had it any other way, but at times this complicated my attempts to understand what was going on. As with this time. The history and physical on the chart didn’t say very much: the acute pneumonia, no other medical history (not unusual in a 40-something man), a high-school education, and a smoking habit. Not employed, living with family. No meds.

As for the patient’s current state of health, that was somewhat more complex. In addition to the pneumonia, which had him coughing up “bad phlegm” these past two weeks, he had reported some difficulty swallowing and a weight loss he could only quantify by saying that he’d taken in three notches on his belt since last spring.

The resident said immediately, “That’s not good.”

I looked at him.

“Weight loss, difficulty swallowing, resistant pneumonia in a middle-aged male smoker,” he said.

“Ah,” I said, scanning the rest of the chart for a clue. The orders left by the night float resident included not the chest CT and bronchoscopy I had expected but an EGD—one of those gastrointestinal procedures where they stick a lighted tube down your throat and examine the inner lining of your stomach. “Ah,” I said again.

The patient, an amiable, clueless fellow whose chief complaint when I met him after rounds was the absence of breakfast, looked better than his story sounded. Weight loss is a relative thing, after all, and until you get into the absolute end of the range, it usually doesn’t show. He was a skinny man, who coughed once or twice with the weary, pained expression of a person who has coughed too much recently, and obligingly deposited the product in the plastic jar he’d been given for the purpose. The contents of the jar looked nasty, but then it always does. “When am I gonna eat?” he said, when he had finished screwing the lid back on the jar.

We explained about the EGD, and how he needed an empty stomach for the test. “OK,” he said. “And when’s that gonna be?”

We told him that it was hard to say. It’s always hard to say. This is more than usually distressing because most of the people waiting for the call are waiting with empty stomachs, and despite the low quality of the hospital food, breakfast is by far the best of it. Even dinner starts to smell pretty good when your roommate is being served and you’re still waiting for your call to GI. So we’re used to explaining to people why they can’t eat: it’s the kind of bad news that takes a while to sink in.

Mr. Jenkins spat disconsolately, as if he had a bad taste in his mouth, and we excused ourselves, promising to let him know as soon as we heard anything. Which of course we didn’t, because we got busy with new admissions and no one ever tells the house staff anything anyway.

So when the number for GI procedures showed up on my pager it took me a moment to remember Mr. Jenkins. But that was all right because when I dialed it and heard the phone say “GI procedures” they put me on hold before I could give my name.

Hoffal Shayne picked up. Hoffal, known universally as “Awful,” was a first-year GI fellow from New York who had earned his nickname by being the most abrasive personality in the entire hospital. He was not averse to lessoning his betters now and then, and entirely too eager to lecture the rest of us whenever possible.

“Who is this?” he demanded.”

“It’s Holt,” I said. “You paged me.

“Holt. What are you going to do about your Mr. Jenkins?”

“What?” I replied, perhaps unwisely.

“Jenkins! Your Mr. Jenkins! The one you sent down here with”—he searched for a word sufficiently scathing—“pneumonia.”

“Look, Hoffal,” I said, carefully aspirating the H, “is there a point to this? ’Cause I’ve got an admission down in the ER and—”

“And you don’t care about your Mr. Jenkins, is that it?”

This was starting to get me mad. “Do you want to tell me something, Offal?”

He snorted. “I suppose I’ll have to, since I doubt you could interpret the pictures, which are in Mr. Jenkins’s chart, by the way. Tell me,” he said, “do you know what cancer is?”

What everyone wishes you’d get, I thought, but said nothing.

“As I suspected,” Hoffal sneered. “Well, it’s what your Mr. Jenkins has growing in his esophagus. Which is why he can’t swallow, which is why he’s losing weight, which is why he’s got your pneumonia.” And then the line went dead.

Mr. Jenkins had esophageal cancer. It made sense. As Hoffal had so helpfully spelled out, it was the unifying explanation.

But what a nasty explanation it was. As it happened, I did know something about cancer, enough to know that esophageal cancer is an especially bad thing. It’s not especially common; smoking and alcohol are probably risk factors. By the time it’s diagnosed it is usually (as the oncologists say) out of the barn. Your odds of being alive five years after diagnosis are less than one in 20. Starvation, hurried along by metastatic disease in the lung, liver, and brain, is the usual mode of death. You can try to put a rigid liner in the esophagus to hold it open. You can try radiation. And, for the optimistic, you can try chemotherapy. Itwas a dismal future Mr. Jenkins had in store. And it was up to me, I realized as I turned from the phone, to tell him.

It wasn’t, really. It wasn’t, technically, up to me. The service I was on had a number of doctors with more knowledge and experience than I had. There was the resident, of course, still in house. There was the attending, now gone home for the night, but he could certainly break the news in the morning—a lot better than I would, having had the experience before.

I hadn’t had the experience. And I needed it. And, to be strictly truthful, I wanted it. This is how we were supposed to learn. He was my patient, and I felt responsible for him. But, also, I wanted to be the one to tell him. It’s something I can’t explain—didn’t understand then and perhaps would rather not understand about myself now. I hadn’t had the experience, and I wanted to get it. So I squared my shoulders and marched down the hallway to Mr. Jenkins’s room.

He was the only occupant of a double on the west side of the tower. Here on the sixth floor the view out the window was a sweep down the hill to the town, garish under sodium-vapor streetlights. The yellow glow from the street was the only light in the room. Mr. Jenkins was in bed, asleep. He was snoring unevenly, a little puddle gleaming darkly on the pillow beside his open mouth.

I stood at his bedside, listening to him breathe. Regular, unlabored, a little rattly, but basically the automatic tidal motion of a man in the middle of his life, the rhythm he had been maintaining from the moment of his birth. I stood there and listened to it, unconsciously holding my own breath for a long time until I realized what I was doing and drew a ragged breath out of the dark.

“Mr. Jenkins?” I said softly.

No answer.

“Mr. Jenkins?” I said again. This time I reached down and pressed his shoulder slightly. He stirred, and abruptly he was wide awake, astounded, raised on his elbow staring around the room.

“Wha’?” he said, or something to that effect. He was starting to pull back from me. In the darkened room, his eyes were enormous.

“Easy, Mr. Jenkins,” I said in what I doubted was a reassuring tone. “You’re in the hospital. Remember? I’m Dr. Holt. We met this morning.”

Mr. Jenkins continued to stare at me as if I was a ghost, but he gradually subsided, muttering something I didn’t catch beyond the tone of ebbing shock.

“Are you awake, Mr. Jenkins?”

He nodded, perhaps a more polite answer than the question deserved. And he lay there, still propped up on one elbow, waiting.

I realized that I had no idea how to proceed. The advice from that long-ago dreary afternoon with Emily Dickinson had evaporated. And Jenkins was waiting. As if aware of my uneasiness, he was starting a shy, reassuring smile.

“Mr. Jenkins,” I began.

He nodded at me encouragingly.

“I’m afraid I’ve got some bad news.”

For a horrible ten or 12 seconds, the smile lingered on his face while the rest of his features abandoned it until it hung there in empty air.

“That test we did this afternoon?”

He nodded.

“It found a—a mass.”

This wasn’t right, I realized. I should just name it.

“They found cancer, Mr. Jenkins. That’s why you’ve been having trouble swallowing. That’s why you’ve been losing weight.”

I stopped for a moment, unable to go on. In the silence that lay between us I recalled dimly that I was supposed to do this, supposed to give the patient time to grasp the news. Reassured by this, I let the silence grow.

Finally, his voice coming with effort, Mr. Jenkins said, “What’s it gonna do?”

Patients have this terrifying ability to ask the question, the one of all others you don’t want laid at your feet. I could feel myself start to choke. The easy answer, the immediate one, was “I don’t know,” but I couldn’t bring myself to say it—it would be too palpably a lie. Because I did know. We both knew. But I couldn’t say that either.

I was wrestling with all of this, starting to hyperventilate, when I heard Mr. Jenkins sigh. “That’s a bad question,” he said. The ghost of a smile shimmered in the dim light. He settled back against his pillow, ran the back of a thin hand across his forehead. “Ain’t nobody knows, do they.”

“That’s right,” I said fervently. “But, Mr. Jenkins, I do know this. There are a lot of people in this hospital who can help you. The next thing that will happen is we’ll present your case”—no, I thought, too legal—“we’ll present you”—too formal—“we’ll bring in a lot of specialists”—that was it: “specialists” had a reassuring ring—“and we’ll help you fight this thing.” Unless, of course, fighting wasn’t what he wanted. What if he didn’t want to fight it? I was just about to babble, I realized. “Would you like to see the chaplain, Mr. Jenkins?”

Mr. Jenkins lay back on his pillow with his left arm beside his head, fingers curled delicately as if waiting for something to fall into his palm. He closed his eyes.

“Maybe tomorrow,” I said.

I don’t know if Mr. Jenkins slept that night. I didn’t, of course, being a green intern on call, prone to jump bolt upright at the sound of my pager, and feeling the need to go see every patient I heard about, whether the situation warranted it or not. But if I had been allowed to lie down for more than 15 minutes at a stretch, I doubt I would have fallen asleep without Mr. Jenkins’s expression hovering in the dark above me. I had nothing constructive to think about, nothing really to do about him. The machinery of oncology would be unleashed on Mr. Jenkins tomorrow, there would be a routine series of studies to go through, and his pneumonia would undoubtedly respond to the IV antibiotics he was getting every six hours. There was nothing in particular to think about at all. So it was only his smile that might have haunted me, if I had been available for haunting.

The next morning I was up and moving around, having gotten perhaps 45 minutes of jumbled sleep and short-term memory disturbance somewhere between five and the sounding of my alarm at six in the morning. Rounds began at 7:30, and I had nine patients to see before then, giving me about ten minutes per patient, which even in my first week of internship was more than I needed to check the vitals, wake the patient, and do a quick exam. But I had set my alarm early with a thought to Mr. Jenkins, feeling that I would probably need more than three minutes to see him this day.

I left him for last, of course, walking into his room with fully 30 minutes to go before rounds. The sun had risen by then, the world below his window blazing with color, each red leaf on the far hills distinct in the clear air. Mr. Jenkins was asleep, his pillow blotched with pink, green, and brown, his mouth slack, the same regular rising and falling of his chest.

“Mr. Jenkins,” I said gently.

He roused more easily this morning, his eyes opening sleepily but without the terror of the night before. They opened, then opened wider, scanning the room quickly with an odd, stock-taking motion, as if he were in the habit of cataloging, every morning, the contents of his room.

He finished his survey with me, eyeing me with what I can only describe as a mild surmise. As he looked at me, uncertain, perhaps a little curious, I realized how deeply miserable I was to be standing before him. Not that I could think of any particular thing I’d done wrong. Just that it was miserable to be there, having to enter into it again.

“How are you?” I said gently.

“I’m not bad,” he said. “Been coughing up a bit, not so bad.”

“Good,” I said. I moved to the bedside, sank down in the chair, and took a breath.

Mr. Jenkins regarded me, and his gaze as I looked back at him took another one of those curious sweeps around the room, returning to me. His expression was open, friendly, almost perky.

“So tell me,” I began. “Have you been thinking?”

Jenkins looked puzzled. “Thinking,” he said noncommittally.

I waited, but he had nothing more to add.

“Yes,” I said. “About . . .”

He elevated his eyebrows helpfully. “About?”

“You know.”

“Oh,” he said. The eyebrows settled, pressed down by a pair of deep furrows. “I don’t know,” he added after a while.

“I understand,” I said. “It’s a lot to take in.”

“Yeah,” he said. And then: “A lot.”

“Yeah,” I agreed.

We sat there for a little while longer, thinking about a lot together.

“What do you think?” he said finally.

“Me?” I squeaked. I was suddenly aware of the time. “It’s not really what I think,” I began. “Is it?”

If I was thinking he was going to help me out, I was wrong. Mr. Jenkins stared back at me across his bedclothes, his hands lying on top of the cotton blanket as inert as old socks, the expression on his face an open blank. Open and blank. Not frightened. Not worried. Not remotely comprehending what had me so solemn and upset.

“Mr. Jenkins?” I said finally.

The eyebrows lifted a half-degree.

“You do know what we’re talking about, don’t you?”

No change at all. For an instant I hoped wildly that this was cultural, this was some strange thing that came from class or poverty that I wasn’t getting, and I shouldn’t mess with it. But it was too late for that.

“We’re talking about your diagnosis,” I said slowly. “You remember, don’t you?”

Now the eyes did begin to widen, the whites showing between the irises and the upper lids.

“What I told you last night? About the cancer?”

The face went stricken.

“I’ve got cancer?” It was a hoarse whisper, twisting upward at the end.

“It’s in your throat,” I said, pointing to mine. “It’s why you’re having so much trouble swallowing.”

He blinked at that. “I got cancer,” he mumbled, looking inward for a moment, nodding again. Then back at me. “What’s it gonna do?”

I told the story on rounds. After the recitation of vital signs and exam findings, I added a brief anecdote describing his reaction to the news. The attending nodded and shook his head. “You’ll get used to this,” he told me. “We get so hardened to other people’s bad news. It’s hard to remember what a shock it is to them. Give him time to get used to it.”

Time was, for once, something we had to give. This was Friday; we had an entire weekend before the breakneck rhythm of the hospital took hold of Mr. Jenkins and clutched him to itself. The pieces of aberrant flesh that were snipped from his mass in the GI-procedures suite spent the weekend absorbing stains in the pathology lab. On Monday, Tuesday at the latest, we would have the definitive diagnosis. In the interim there were some things we could get done despite the weekend, and we went ahead and did them—CT scans, chiefly, looking for possible metastases. The goal was to assess the spread of his disease—to “stage him”—and to assemble every other relevant bit of data in time for the multidisciplinary oncology conference that met in the cancer center every Wednesday. There, about two dozen representatives from medicine, surgery, pathology, radiology, pharmacology, and probably theology reviewed the dozen or so new cancer cases that had come up in the previous week, with the goal of arriving at a consensus and a plan.

But for now, Mr. Jenkins had time, a quiet weekend in a single room with a view of fall descending over the Piedmont.

Having been on call on a Thursday, I was facing my Golden Weekend—the once-a-month privilege accorded interns: two consecutive days off. I spent them with my family. Sixty hours together. On my return early Monday morning to the upper floors of the hospital I had a sensation of having been out of the action a very long time. Many of the patients I had been taking care of on Friday were gone, having been discharged by my resident over the weekend. Mr. Jenkins, naturally, was not one of those. I found him in his room, sleeping, a towel wrapped carefully around his head.

One of the things I passionately hate about my job is that it requires me to disturb people’s sleep, sick people who have managed, against the odds, to achieve some measure of oblivion. As I’ve grown older in the profession, I have become less conscientious—I often let patients sleep—but in those days I was conscientious to a fault. I roused each patient so that he or she could bear witness to the events since I had seen them last.

It was no different with Mr. Jenkins. I called his name from the doorway, softly, then as I moved to the bedside called again, using the same tone I use when waking my children. I pressed briefly on his shoulder and called his name again. This time he stirred and peeled himself a peephole in the towel.

“Whazzat?”

“Hi, Mr. Jenkins,” I said softly. “It’s Dr. Holt.” I paused to let that sink in. “How was your weekend?”

The eye goggled around the room in the same odd stock-taking I’d seen the first morning before returning to settle on me.

“OK,” he said softly. Then the eye inspected again. It seemed to be looking for something.

“Did you get any visitors?”

“No.” The eye was still, some small creature sulking in its hole.

“I’m sorry,” I said, and I meant it, too, thinking about him spending the week with nothing to think about but his dismal prognosis. If there’s any time you want family around, it’s when you’re looking at something like that.

I said as much to Mr. Jenkins. I can’t remember the exact words I used. I don’t suppose they mattered, because I found that eye of his staring at me and growing rounder until the towel came off his face and he was lying there looking at me with horror everywhere in the bed around him.

“You say what?”

Then it was my turn to stare back at him, and maybe there was a little horror in my face, too. All I know was that for a long time we stared at each other as if each found the other completely incomprehensible.

But it was up to me to break out of it first, and I did.

“Your . . . cancer,” I said.

He tried to say something but it strangled to a whisper.

“Do you mean you don’t remember?”

He shook his head.

“Well.” I stopped short, at a loss for words. “There are some things the brain just doesn’t want to hold on to,” I said finally.

He was simply staring at me. Clearly I wasn’t connecting.

“Would you like me to tell you again?”

After a long pause he nodded. I took a breath, and with a fugitive sense that this wasn’t getting easier with repetition, I told him the story again. He seemed to take it in. He asked the same terrible questions. I had the same terrible lack of answers. And we left it at that.

I walked out of the room feeling shaken. It was partly the sheer rigor of it, having to tell again the story I’d never wanted to tell the first time. Or, OK, had wanted to tell, but only once. Was I being punished by some obscure hospital devil, forced for my sin of pride to experience again and again just what we do when we give bad news? I had a brief vision of myself as some kind of Kubler-Rossian version of the Flying Dutchman, doomed to wander the hospital forever in an unending struggle with denial. But that wasn’t it, not really. Mr. Jenkins wasn’t playing by the rules. Say what you want about denial, there was something else going on.

I tried to convey this on rounds, when we arrived at Mr. Jenkins’s door. I made a hash of it, of course, trying to wedge in between the morning’s lab results and the scheduled pulmonary function tests some ghostly aperçu I couldn’t articulate even to myself.

The attention span of a team on rounds is short at the best of times. I could tell I’d lost the interest of the resident. The other intern, scheduled for clinic in the afternoon and desperate to be done rounding, looked at me with something that fell just short of hatred. The med students stood apart in some shared goofiness. Only the attending was still looking at me, his expression a tolerant mixture of amusement and minimal curiosity.

“What do you think it is?” he asked me.

“I don’t know,” I confessed, feeling miserable that I was making an ass of myself. But Mr. Jenkins wasn’t playing by the rules.

What were the rules? I found myself wondering later. I had reached one of those random dead spells in the admitting day. I was at the workstation, going over sign-out sheets left by the three other interns whose patients I was covering overnight. “Cx if spike”; “lasix 80 for SOB”; “Call VIR if HCT ↓”: I had several pages of helpful hints from my peers on how to manage their patients’ likely misadventures. But there was no similar advice for how to deal with Mr. Jenkins. Give him the bad news until he finally believes it, because he has to. Make him do it until he gets it right. Isn’t that right? Wasn’t I doing it right?

Naturally, the next morning I saved Mr. Jenkins’s room for last on my early rounds and knocked on the door with dread. I heard him hawk up something wet, spit, and then say, “Come in.” At the sound of his voice—a little guarded but otherwise sprightly—my heart sank.

He was sitting up, looking around him as if puzzled by his surroundings.

I stood in the doorway, a profound reluctance holding me.

“Hi,” he said. I was suddenly aware that Mr. Jenkins was shy.

“Hi,” I said back. I am usually shy too. This morning more so.

We held our positions for a long minute.

“Do I know you?” he asked.

The question hit me with a force. The room took a sudden surge toward me, settling in a series of uneasy swells as I tried to absorb what he’d said. Not that I expect all my patients to know my name, or even recognize me for the most part—all those white coats. In most cases the acquaintance is all too brief, too casual. But Mr. Jenkins and I had accumulated some history.

I eased into the room, moving carefully as one might around a nervous beast, keeping my eyes on his as they followed my progress toward the bed.

“Don’t you?” I said as I crouched beside him.

He stared at me with a slowly dawning recognition that as I watched grew into horror.

“You know me, don’t you?” I said quietly. What was this? Some kind of conversion disorder? A hysterical amnesia? “You’ve seen me before, haven’t you?”

Jenkins’s head wobbled uncertainly between yes and no.

“I’m Dr. Holt,” I said quietly. “And you’re here because—”

Jenkins suddenly whipped his bedsheet over his head, clutching it there like a Halloween ghost. The ghost shook its head emphatically and let out a low moan.

“Oh, God. It happened. It happened, didn’t it.”

“What happened?” I asked.

He threw off the sheet, and his gaze scattered around the room, taking in the surroundings one more time. “I knew it,” he sobbed. “I knew it. This is the crazy house, isn’t it?”

Whatever I’d been planning to say up to that point vanished in an instant, leaving me flat-footed.

“It is, isn’t it?” Jenkins urged. “Did I do something?” His voice dropped confidentially. “It wasn’t murder, was it? I didn’t—”

“No,” I said, a little louder than I’d intended. “You didn’t—“

“Oh, thank God,” he said. “Thank God. As long as I didn’t—you don’t know,” he said soulfully.

“Don’t know what?” There was a lot I didn’t know, but Mr. Jenkins seemed to have something particular in mind. As for me, my head was swimming.

Jenkins had recovered some of his usual equanimity. The look he was giving me now was downright cagy.

“Don’t you know?” he said.

I shook my head. “No, Mr. Jenkins. I don’t know. What?”

“What it’s like. Waking up every day.”

I took a wild guess. “With cancer?”

He turned on me. “What?”

“With cancer,” I said, perhaps a little more brusquely than I’d intended. “Waking up every day with cancer. Knowing about it, I mean. Waking up that way. Knowing. With cancer.”

The expression he gave me had nothing to do with my stumbling delivery.

“What?”

“Cancer,” Repressing panic, I might have been shouting. “You’ve got cancer.”

A long silence, broken by the sound of his breathing. It was getting louder and louder.

“What kind of doctor are you?” He was half out of bed, shaking a double-handful of bedsheet in my face. I started to back away.

“What kind of doctor are you?” He demanded again. “Coming in here and telling me something like that? Is that how you tell somebody that kind of thing? You’re lying! You don’t tell me that! You don’t come in here and tell me that kind of shit! Get out! Get out of here!”

By that time I was already out the door. I could hear his shouting all the way down the hall.

How I got through rounds that morning, I’ll never know. Maybe the rest of the team attributed my zombie-like demeanor to the rigors of a rough call night, I don’t know. All I remember was that I watched, as if from an indefinite distance, as the knot of us worked our way around the floor, measuring with growing dread the approach to Jenkins’s room and the moment when I was going to have to face him again. I was listening, too, for the sound of shouts from that direction, wondering if there was any way I could avoid going in that room again. Perhaps I could simply make a run for it, before the moment when the patient reported that I had come in that morning and abused him. What kind of doctor was I?

Helpless in the grip of forces I did not understand, there I stood again finally, at the door of Jenkins’s room, reciting by rote his vital signs that morning, exam findings, the results of yesterday’s tests. I ground down. There was a pause.

“And?” The attending said mildly.

I might have jumped.

“Any progress?”

“Progress?”

Impatience. “You were going to work with him. On his diagnosis. I thought he was having trouble with it. Any luck?”

I shook my head dumbly.

The attending didn’t wait, only nodded and swept open the door to Jenkins’s room. I took a deep breath and followed.

Jenkins was back in bed, looking peaceful enough. The television set was on. Katie Couric was interviewing a woman who looked just like Katie Couric. Mr. Jenkins was rapt.

We all stood for a moment looking at Mr. Jenkins. As the interview cut to a commercial, Jenkins’s gaze turned slowly to us, widening to take in the small crowd wedging into his room. I recognized his expression—the same cagy inventory, twice around his surroundings, the same poker face settling down.

“Hi,” he said shyly.

“Good morning, Mr. Jenkins,” the attending said.

We all stood and looked at each other some more.

“Mr. Jenkins?”

“Yeah?”

“Would you mind if we asked you some questions?”

“Uh-uh.” The commercials were over. Mr. Jenkins’s vision was starting to stray again.

“Can you tell us why you’re here?”

A brief inner consultation. “Sure.” He leaned over and spat into the wastecan. “This.” He said. “It’s been going on for a while.”

“And?”

“Tastes nasty.” He made a face.

“Anything else?”

“Well, yeah. I got this sore throat.” He laid a hand on his chest. “It really doesn’t feel good. I was wondering if maybe I got some kind of ulcer. You know? ’Cause my brother, he’s got ulcers bad. I was wondering if maybe they run in the family? ’Cause if they do maybe that’s what I got.”

“You’ve got a brother, Mr. Jenkins?”

It was news to me. It was news to all of us. As we left the room, the attending muttered to me, “Call psych. And call the brother.”

Easier said than done, of course. When asked for his brother’s phone number, Mr. Jenkins agreeably recited a string of digits that connected me with a fax machine. When asked again, he wanted to know why I wanted to talk to his brother. “It’s about your ulcers,” I said simply. I was tired. He gave me another string of numbers, which offered the mechanical advice that the number was not in service. On my third trip back I got as far as Jenkins’s door before I realized that the two numbers he’d given me were in different area codes. I spun on my heel, went back to the nursing station, and pulled his chart.

“Mr. Jenkins,” I asked, “where do you live?”

“Burlington.”

His chart gave an address in Greensboro.

“How long have you lived there?”

The expression went cagy again. The eyes narrowed. “Fifteen years. Yeah. Fifteen. Right out of high school.”

I gave that some thought. This was a 43-year-old male with pneumonia. Somewhere along the way Mr. Jenkins had misplaced a decade.

“Mr. Jenkins,” I asked slowly. “Can you tell me what year this is?”

“Sure.”

We looked at each other for a minute.

“What year is it?”

“What year? Hmm. It’s—I’m not too good with numbers. It’s a leap year, isn’t it?”

It was in fact a leap year.

“Can you tell me who the president is?”

“I don’t follow politics. It’s a dirty business. But sure.” He looked cagy again. “It’s Bush. George Bush.”

I looked at him, feeling beaten. He looked back at me. A brief stand-off, then he coughed self-consciously. The cough turned into a real one, and when he’d recovered his breath, he looked at me again. “What were we talking about?”

We did consult psych. They came by and gave the diagnosis of Wernicke-Korsakoff dementia. He’d completely fried his short-term memory with too much alcohol. By that time, I’d managed to track down the brother, who confirmed what I’d finally recognized, and a little bit more. It had been several years since Charles Jenkins had seen his brother, but he gave the essential outlines of the story. Mr. Jenkins had been in the Navy. He was in fact 43 years old. But between the ages of 18 and 38, he’d hadn’t been sober more than three days at a time. The brother said this with a weary resignation in which I tried but failed to hear a trace of bitterness. I wanted to hear the rest of the story, but Charles Jenkins cut it short.

“When can he come home?”

Two days later. Mr. Jenkins, his cancer thoroughly staged and determined beyond any hope of cure, sits peacefully in the recliner in his room. He is dressed in street clothes. Sunlight is streaming in over his shoulder, he’s breathing comfortably, and the television set is tuned to one of the two hospital channels, which is showing a locally produced documentary about dialysis. When I go in to see him one last time, Mr. Jenkins is watching, rapt. I realize I’m almost looking forward to introducing myself again, if only to say goodbye. And for a moment I watch him, and find myself equally rapt at the sight of him: sick, dying, and eternally unaware. For a moment I am almost envious.

The feeling passes, replaced by a kind of nostalgia. He’ll forget me again as soon as I’m gone. I’ll never learn from his account of me what kind of doctor I am. But that’s not it: I am tantalized by the sense that I’ve missed something here. I thought I was giving him bad news. The bad news wasn’t his, but mine.

Out at the nursing station, I pick out of the general hubbub a nurse’s voice speaking my name and the words “over there,” and through the doorway see a man looking my way.

The family resemblance is strong. “I’m Charles Jenkins,” the man says. He looks past me into the room. At my back I hear a sudden cry.

The reunion is a happy one. I leave them there, edging out of the room as I’ve edged out of so many, leaving the family to gather up the plastic bags of personal belongings, medications, paperwork with discharge instructions. My last memory of Thomas Jenkins is of him looking up from the chair, sunlight surrounding him, his face alight in the recognition of one of the few faces in the world he can still remember.

I like to think of him that way. That way, and no other. I only wish I could hold myself so finally aloof from time. <

T.E. Holt practices medicine at a major medical center in the South. His short fiction has appeared in Zoetrope and Tin House.

Originally published in the July/August 2006 issue of Boston Review