Chapter 73: Hypothetical Questions

December 5, 2000, Mayo Clinic, Rochester, Minnesota

“I had a good time last night,” I said. “I was surprised you invited a friend!”

Mary laughed as we walked into the exam room, “Naomi had a good time as well. You know what a Resident’s life is like.”

I nodded, “No social life.”

“Exactly. You guys seemed to hit it off pretty well.”

“Yes, but I’m not here for that!”

“You’re everywhere for that, and you know it!”

I couldn’t help but laugh.

“Let’s just say that you hit the sweet spot - red hair, green eyes, and a perfect athletic build. But given my mental state, I just didn’t feel right flirting.”

“You don’t have to flirt, and you know it! Those goddamn bedroom eyes and your disarming charm are all it takes!”

“I’m here for an exam and tests, Doc!”

“She told me to tell you she’s free tonight if you want to have a drink.”

“Tests,” I replied firmly.

“Just relaying the message. And it wasn’t a setup.”

“Right,” I chuckled. “You bring a single girl, a perfect Steve type no less, knowing what happens with me, and you say it wasn’t a ‘setup’? Who are YOU kidding, Doc?”

“She might have complained to me about the lack of action and the fact that male doctors are so full of themselves that she’s not interested.”

“But quiet, boring accountants curl your toes.”

“Perhaps! Now, assume the position! I’ll be back in a moment with my MALE medical student!”

I laughed and after she left the exam room, I stripped down to my briefs and put on the stupid hospital gown. Mary was back two minutes later with a young black man named Laurent, who was originally from Côte d’Ivoire.

“This is Laurent’s second day of his third rotation,” Mary said, “so he’ll take your history, but observe the exam.”

“You’re the teacher, Doc,” I said. “Whatever you feel is best. I’m OK with dual exams.”

“Hint taken,” Mary said. “Laurent, Mr. Adams has mentored several medical students, including a doctor he’s married to, and he’s insistent that they be allowed to do things, so, despite Mayo’s protocols for your first two weeks, you’ll get to actually put hands on a real live character, I mean, patient!”

I chuckled, “She was right the first time.”

“Laurent, go ahead and take his history, but I’ll warn you, this is a complex case, and Mr. Adams knows how to answer what you ask, not what you might have meant, and he’ll be reticent to volunteer anything you missed.”

I chuckled, “You assume I treat all med students the way I treated you?”

“Yes!”

Laurent was a bit tentative, and I had to pay close attention to what he was asking because of a strong accent, though his English was otherwise superb, far better than my Spanish by a long shot without Jorge around, and probably better than my Swedish, as I didn’t use it all that often these days, except for occasionally talking to Sofia and my monthly letters with Tina. Not to mention I would be hopeless in French, which I was sure he spoke fluently.

Laurent did a very good job, and I suspected at least one of his earlier rotations had involved taking medical histories. He did miss something, which I was sure Mary had expected him to miss. He’d asked me about what had brought me to Mayo and I said I was feeling a bit off. He’d pursued physiological causes, but had mis-phrased a key question that might have tipped him off - he’d asked me what physicians I was seeing besides Mary, and I’d listed them. But Doctor Mercer wasn’t a physician, so I hadn’t mentioned her. He’d also asked about recent medical treatment, but she wasn’t an MD, so I’d left that out, too.

“Laurent,” Mary said when he finished, “you did an excellent job, but you missed perhaps the most important point, mainly because you didn’t listen to what I said.”

“Excuse me, Doctor Whittaker,” he replied, “but I was careful to probe his answers.”

“Steve?” Mary asked.

“When you asked about physicians, I gave you the list of MDs I’m seeing. When you asked about medical treatment, I told you about all the treatment I’ve received from medical doctors and medical facilities.”

“Yes.”

“But not mental health professionals.”

“I totally missed it,” he said dejectedly.

“Don’t get down,” Mary said. “Mr. Adams purposefully hid information from you. But that’s the lesson. Patients will do that even if they aren’t cooperating with a training plan as Mr. Adams is.”

“You knew?”

“He did it to me,” she said. “It’s because he’s married to a trauma surgeon and he likes to give her a really hard time about the medical profession.”

“So it was a trap?” he asked.

“No, more like an example, in a controlled situation, of what can happen in an uncontrolled situation. I know the answers, as does Mr. Adams. But you will, for sure, run into patients who know the answers and won’t give them to you.”

“But why?” Laurent asked, sounding very confused.

“Any number of reasons or even no reason. Patients aren’t always rational, and even when they are, they’ll omit important information because they don’t think it’s relevant or because they’re embarrassed or because they simply don’t want to. Now, without concerning yourself with his mental health issues, what would you propose?”

“Based on what I learned, a complete blood series, including hormone levels; a complete metabolic panel, including a glucose tolerance test; an EKG; and an EEG.”

“Very good. But given his issues with metabolizing glucose and fructose, we’re going to skip the glucose tolerance test and do a cardiac stress test instead. Now, back to his mental health issues, his comment about feeling ‘out of sorts’ is a clue, and you did a very good job of deducing the physiological issues. What this should teach you is that mental health issues are often omitted because in many ways, those are the diagnoses patients fear most. Even a cancer diagnosis, so long as it’s not end-stage, gives a patient some hope despite scaring them. Mental illness just scares them. And that includes people like Steve who are fully cognizant of their issues.”

“But he seems so comfortable discussing his concerns.”

“His physiological problems don’t worry him; his bipolar disorder scares him to death.”

“May I ask the diagnosis of the physiological problems?”

“Yes, because you’ll hear it before we get the test results back. Our working diagnosis is that he has a congenital defect in his hypothalamus which creates a significant hormone imbalance and causes him to have difficulty metabolizing complex sugars. As you deduced, he’s on a ketogenic diet, and I suspect, in the back of your mind was some form of insulin-related disorder.”

“Yes, and that would be explained by your working diagnosis, and by the fact that he’s seeing a research endocrinologist!”

Mary laughed, “Good point. You had a very good clue there. Overall, you did a good job, just watch out for the mental health issues.”

“Yes, Doctor Whittaker.”

“I’m going to do the exam,” Mary said. “At certain points I’ll ask you to repeat what I’ve done.”

“Yes, Doctor Whittaker.”

Mary led Laurent through the physical exam, and when she was satisfied, she called the phlebotomist to take blood.

“I always expect you in a black cape and fangs,” I said to the young woman who came to take the four tubes of blood.

She laughed, “I tried that on Halloween and the Hospital Director suggested I select a different costume!”

“Talk about ‘no fun’!” I chuckled

“TELL me about it! He has NO sense of humor!”

She quickly and expertly drained me of a near-fatal amount of blood, or at least it felt that way, then quickly went on her way to take the vials to the lab. Next, I had the cardiac stress test, and then the three of us had lunch with Doctors Alston and Ross and basically rehashed the conversation on the conference call that had led to my visit.

After lunch I had my EEG and EKG, and then Mary and I returned to her office.

“No Laurent?” I asked.

“In your case, because we’re going to probably discuss your unique family situation, I thought it best to send him to see a patient with another Resident.”

“What about your Attending position?”

“Next summer. It’s basically a lock. You see Doctors Ross and Alston simply letting me do my thing. That lunch was their ‘case review’.”

“Congratulations. Does that mean you and Don will start your family?”

“That’s pretty much it - once I’m an Attending, taking the time off doesn’t cause any trouble in any way, and doesn’t interfere with or delay advancement. So, how are you feeling?”

“OK, I think. That said, the most stressful thing I’ve done in the past four days is the cardiac stress test. I’m glad we didn’t do a glucose tolerance test, because those always mess me up.”

“Which is why we didn’t. At this point, doing that test would be risky. You told Laurent you were following your near-zero carbohydrate diet and that you were exercising and getting enough sleep. What about Saturday night and Sunday morning?”

“I took a nap after Birgit got her cuddles and we had breakfast, because of Guys’ Night and walking Jess to work.”

“I’m going to tread a bit on Doctor Mercer’s turf here - any thoughts of self-harm or suicide?”

I shook my head, “No. I haven’t had an obvious depressive episode in quite some time. But that conforms to what I could find about bipolar I versus bipolar II. Mostly I have the markers for bipolar I because I’ve had numerous manic episodes but few, in any, truly depressive episodes. But I know the risk of having one is real.”

“Again, treading a bit on Doctor Mercer’s territory, for you, self-harm will come from inappropriate risk-taking, not intentional self-harm.”

I chuckled, “I avoid married women, Doc. It avoids the potential for serious harm from annoyed husbands.”

“What about annoyed parents?” she asked with a smirk.

“I’m not going to stop being a subversive!”

“If you did, I’d be very concerned!”

“I think all that’s left for me is to get the test results, which I am positive will tell me exactly nothing we don’t already know or assume, and then to speak with Doctor Barton and Doctor Mercer. I’m not putting any restrictions on you besides the diet. I’m encouraging exercise and proper sleep, and I want you to continue taking the mix of vitamins and supplements I sent you. The jury is out on those, but there’s no downside other than a few bucks you might have spent on something else. That said, I’m more and more convinced Vitamin D is one key to fending off your depression, especially the possibility of seasonal affective disorder.”

“I follow that list religiously.”

“I did have to refrain from laughing when you answered the questions about sexual health. ‘I have a healthy sex life’ doesn’t even begin to describe it!”

“It’s true. It’s also true that I’ve never had an STI and that I practice ‘safe sex’ as they’re calling it these days.”

“I got the drift that it was that which was making you uneasy.”

“Sort of. I just had plenty of opportunity and took advantage of the opportunities, which I hadn’t done for nearly eighteen months before January. I think part of it was the changes in my relationships with Liz and Maria Cristina.”

“I missed something.”

“Ah, yeah, I didn’t say it on the call because of Al, but both of them are seeing someone, which meant our relationships had to be intimate, not sexual.”

“Thus confirming what I was trying to teach Laurent - you withheld information because of the circumstances.”

“You, Al, and Doctor Mercer all know, at varying levels of specificity, how I live my life. Al has a good idea, but we’ve purposefully left it at him being jealous of the freedom I have.”

“I’m sorry about Naomi.”

“Why? I didn’t feel you pushed her on me and the four of us had a great time. I have nothing to complain about and don’t feel you did anything improper.”

“What are your plans for this evening?”

“I didn’t have any,” I said. “But you’d suggest dinner with Naomi if I hadn’t pushed back, right?”

“Yes, but again, not from a standpoint of setting you up, or playing the role of procurer. She just needs to get out.”

“I’d be happy to have dinner and a drink with her,” I said. “But I’m going to bed, alone, at the end of the evening.”

Mary laughed, “You are too funny! You are the freest person I know when it comes to sex, and the most open-minded, but you get into these moods where suddenly it’s a bad thing. Have you tracked them?”

I shook my head.

“Include that in your food and glucose testing diary, please. Make it -1, 0, +1, where -1 is what you’re saying to me now; 0 is neutral; and +1 is active desire. That should be sufficient to plot a chart against everything else.”

“OK. You’re looking for patterns, or perhaps some biometric rhythm?”

“I try not to look for specific things in my research, because that can lead to what your Navy friends would call target fixation, and you can miss what the data is trying to tell you.”

“A good strategy, and one I support. But what I suggested is the likely outcome, right?”

“Yes.”

“Do you want me to keep a sex diary?” I smirked.

Mary laughed, “I could probably use that to write scripts for erotic movies! But unless you want to participate in one of Clara’s studies, I don’t need that detail!”

“Understood.”

“How about the kids’ health?”

“All of the kids have low body temperatures and low resting heart rates, but they’re all very active. You know the girls are in karate, Jesse plays hockey, Matthew acts and plays soccer, Michael is in the robotics club which is very hands-on and plays soccer, and Albert is in Scouting and is learning to fly. None of them have shown any areas of concern in their metabolic panels, but Jesse is fourteen, so he’s about at the point where I started seeing the very first symptoms of the metabolic disorder.”

“You were an athlete then, too, right?”

“I swam every day and rode my bike quite a bit. I ran when I lived in Sweden, and ice skated, too. That was all before karate.”

“It’s something to keep an eye on with your boys, though as we discussed, if it’s the flawed ‘X’ from your mom, then none of them will have the symptoms. It’s interesting that all your girls have the lower temperatures, but that’s a question for a geneticist.”

“My sister has the low temp and low resting heart rate as well. She’s active, but not an athlete. She does Jazzercise or something else very active three times a week.”

“Keep an eye on your boys and if you see any signs, give me a call and I’ll arrange for you to bring them here. Are any of the boys besides Albert on Jessica’s health plan?”

I shook my head, “No. I could put all seven of them on mine, but given Jennifer’s benefits are like mine, she’d prefer to keep Jesse on her plan. Matthew and Michael are on Elyse’s plan through NIKA. Kara’s daughters are on the University plan which is almost as good as Jessica’s. Jessica’s kids and I are on the hospital plan because it’s as good as NIKA’s plan, though it’s much less expensive. If we run into issues, we can move Jesse to my plan, but I’m pretty sure M&M’s plan matches ours.”

“OK. And I do have my research money to offset any excluded expenses, deductibles, or co-pays if you need it.”

I shook my head, “No. We’re very well off so you can save that money for someone who needs your expertise but can’t afford it.”

“Thanks. Anything you want to ask?”

I shook my head, “Not until after I talk to Doctor Mercer.”

“OK. Do you want me to call Naomi?”

Besides being the epitome of a ‘Steve type’, Naomi had been fun and engaging, and she had, for want of a better description, soaked up the attention I gave her. I knew the struggles of a first-year Resident, and I felt I could help her relax and enjoy herself for a few hours. I also didn’t feel like Mary was pushing me to be anything other than a friend or a friendly ear, so I decided dinner and drinks couldn’t hurt.

I grinned, “Oh, sure. Why the hell not?”

Mary laughed softly and picked up the phone. She dialed an outside line and let Naomi know that I’d have dinner with her, suggested a restaurant to which Naomi agreed, set the time, then hung up.

“Got it,” I said. “It obviously didn’t come up last night, but what exactly does she know?”

“That you’re in an open relationship. I was careful so she knew you were married, but also that you had enough freedom to enjoy yourself.”

I chuckled, “That’s an interesting way to put it.”

“It’s true, isn’t it?”

“As true as my answers to Laurent!” I grinned.

“I think we’re done. I’ll see you in February, and then for your usual visit in August.”

“February in Minnesota. Oh, joy!”

“Says the man who lived in Sweden for a year!”

Mary and I both stood up, hugged, and then I left her office and walked out of the hospital and to my rental car. I drove back to the hotel where I took a short nap, showered, and then dressed for dinner. I had a bit of time to kill, so I picked up A Storm of Swords which I was struggling to finish because it was so bad, but having started it, I’d decided to see it through, despite taking a break to read Cryptonomicon. One thing was sure, I was done with anything by George R. R. Martin. After about twenty minutes of slogging through the book, I tossed it on the desk and headed to the restaurant to meet Naomi.

“Hi!” Naomi gushed when I walked into the lobby of the restaurant.

“Hi!” I replied, accepting the quick hug she offered.

The host led us to a table for two, and a waitress arrived immediately to take our drink orders.

“How did it go today, if it’s OK to ask?”

I nodded, “It’s OK. It went about like you’d expect any exam to go. We didn’t talk details of the case last night because Don was there, but given Mary’s theory about it being a congenital defect of the hypothalamus, all the tests are going to do is show more of the same, so to speak. What she’s obviously concerned about right now is long-term management of an unknown ailment. If you are part of the diagnostic group, you’ll get the details.”