No Apparent Distress: A Doctor’s Coming of Age on the Front Lines of American Medicine

Pearson does a three-month rotation in internal medicine. She works with a medical assistant named Sara who immediately tells her that Dr. Houston will give her a free Brazilian wax if she asks. The complications in private practice are simpler than what Pearson is used to—“high blood pressure, low thyroid, flu” (181). It’s a relief to be in a place where everyone is well tended and can afford the best care.

On her second morning, a woman in her 50s tells Pearson that she would rather not speak with a medical student. This happens almost every day in Dr. Houston’s office, and it always makes Pearson feel bad. It is strange to her that these affluent patients with minor problems are the first who have ever acted as if she might harm them with her inexperience.

Dr. Houston does not allow her to participate in his Botox procedures, even though she has done things far more invasive: “It was a pure luxury transaction: patients paid to have a professional—a doctor—manage their beauty. There was no place for a student in the transaction” (183).

Pearson knows that excess and luxury in medical care are not always benign. In 2000, Pearson’s mother learned that she had contracted Hepatitis C during a past blood transfusion. She joins a study during which she will be treated with an experimental medicine. During the first year of treatment, she is exhausted and loses her hair. After a year, the drugs have not worked. Pearson’s mother went through the ordeal of the treatment for nothing.

Pearson will later learn that in the 1980s, prisons were a frequent source of blood donations. Hep C was rampant in the prisons and could be spread both sexually and through shared needle use: “There’s no way to know for sure, but the blood that infected her very likely came from the prisons” (188). Pearson views the brutality of the prison system as unjustly punishing her mother, as well as many inmates.

Her mother’s second round of treatment is also experimental. She takes two medicines for nine months; medicines that make her lose weight, weaken her, and make her nauseated. She becomes anemic and her immune system cannot resist germs. Her father’s life begins to revolve around her mother’s care, and it is obvious to Pearson and Matt that her parents are not as close as they once were.

Matt calls Pearson from a hospital. Their mother’s heart had stopped briefly after she fainted and he had taken her to the emergency room. When she leaves, she has a pacemaker implanted. After doing bloodwork during a follow-up, Pearson’s mother learns that her treatment failed. Pearson asks her if she hates medicine and doctors. Two years of failed treatments must have left her bitter, she thinks. But her mother won’t say anything negative about the profession.

When she gave birth to Pearson, she received the blood transfusion, a procedure that is now seen as unnecessary: “An excess of care, even though she was uninsured at the time” (191). When Pearson sees patients receiving excess, unnecessary treatments from Dr. Houston, it no longer feels benign to her: “Everything that had happened to my mother felt so unnecessary: the transfusion, the failed treatments, the pacemaker, the fear of death that had fallen over everyone in our family and which we could not shake. Medicine had caused this” (192).

In 2016, her mother visits the Mayo clinic, where she is told that she does not have hepatitis. Not only that, the doctors say that they would not have treated her back in 2000. They say that they could have confidently assured her that she would be fine, even with the more limited medical knowledge back then. Pearson says her mother has now been disease free for a year, although Pearson remains suspicious. No one has an explanation for why the original blood work indicated a virus that her mother no longer has, if she ever did. 

After her third year of medical school, Pearson returns to Galveston for courses at the Institute for Medical Humanities. She also becomes a junior director at St. Vincent’s. One of her new duties is to try to connect patients with reduced-cost medications. She begins working with a patient named Vanessa. Vanessa had been hit by a truck and could no longer work the labor jobs she was used to, now that her back was injured. She and her husband Jimmy are uninsured, but have just enough money to get by. When Vanessa tells Pearson lengthy stories about her mortgage difficulties, Pearson finds her mind wandering. She realizes that she wants to escape from situations in which she hears about problems that she can’t solve.

Pearson becomes a student director and continues to see Vanessa. She always makes an effort to listen especially hard when Vanessa communicates personal details that are irrelevant to her health care. One night she calls Pearson to tell her that Jimmy has cancer. Pearson knows that a low-dose CT scan is what Jimmy needs, but it can’t be recommended to someone without insurance. Pearson asks Vanessa to meet her at St. Vincent’s the next day and to bring her financial papers: “My own response, too, had become bureaucratic. This could be a time for me to learn how to support a patient through fear and grief, but instead I would learn how to apply for financial assistance. Could this be what good doctoring is about?” (200).

Weeks later, without having undergone any substantial treatment, Jimmy dies after Vanessa is forced to choose to ask the doctors to remove his ventilator, since nothing else can be done. Vanessa receives medical bills in excess of $300,000. She gets two jobs and is able to stay in her house, but she has to work hard. She says that she does not believe Jimmy would have been better off if he had not been a St. Vincent’s patient. She knows the cancer was aggressive and that maybe no one could have caught it in time. Pearson isn’t sure: 

More than anything else, I wish Vanessa and Jimmy had had a more experienced advocate than me. Not because I did a bad job. I did a good job for someone at my level. But I was just a student and there were many things I did not know. They deserved, as everyone does, a doctor(204). 

During a dermatology rotation, Pearson learns that it is mostly cancer prevention and care, not cosmetic or aesthetic concerns, that take up most of her time. She helps a lower-level student perform a biopsy on the leg of a woman who has a history of skin cancers and moles that must be removed. The woman tells them that students have made mistakes on her before. She begins to cry and says: “This is what it’s like when no one gives a shit about you” (206). Pearson wants to protest, but she knows that she does not know what it is like to rely on a free patient clinic for medical care. She knows the woman has reason to be wary of students, because mistakes do happen. The biopsy goes smoothly. The woman grabs Pearson’s arm and whispers a thank you. Pearson understands why she says it: “If you are a patient at a private clinic—as I am myself—you can be pretty sure that most of your doctor’s mistakes have already been made. They were made on the bodies of the poor” (210). 

As a student director, Pearson’s primary job is to keep the clinic running. She is 1 of 10 directors, and all are volunteers. This meant discussing which procedures could be performed and which were too dangerous or cost-prohibitive, given the clinic’s ever-changing financial situation. She finds that she is well suited to the work of arranging schedules, managing logistical details, and checking in on other students. At night, she enjoys walking through the hospital corridors after things are quiet. Every night, she gets a beer on the way home and drinks it on her porch: “Sometimes I would look at the hospital tower and wonder why my St. Vincent’s patients couldn’t just be let in” (215). 

A man named Malachai comes into the clinic and requests a testicle exam—although he says he doesn’t need one. He just wants one to go off his schizophrenia medication and says he is worried about a bump on his head. An attending doctor Googles Malachai and finds something disturbing enough for him to tell them that they have to send him somewhere else. He says Malachai has a serious criminal record. Pearson reaches a compromise with the doctor: they will see Malachai on psychiatry night and deal with his schizophrenia care. Only directors will be allowed to see him.

When they meet with him, he tells them that he would like to learn how to make friends, and that he wants to go off of his medication. Pearson goes to Mr. Jackson to discuss her discomfort at the perception that Malachai cannot be treated at the House. Michael Thomas Jackson is the director of St. Vincent’s House while Pearson is there. He is also a lay Presbyterian minister and is proud of his African heritage. For a time in the 1960s he worked in groups similar to the Black Panther Party but says that “loved saved him” (219) when he met a woman whose circle of friends were all interested in nonviolent methods of change.

He tells Pearson that Malachai is welcome there, and that his finding St. Vincent’s is a miracle. But he admits that they will not be able to give him everything he needs, and Pearson will have to accept that as he does. He says that anything they can do is better than the zero that Malachai will receive otherwise: “He always said that one is better than zero, and I always said that one is still an injustice when somebody needs five” (222). For Mr. Jackson, what St. Vincent’s does best—which is at the heart of medicine—is recognize when another human being is suffering and do what can be done, even if it is not enough. He tells Pearson: “You transcend into healing. You realize you are a medium for the whole process. It isn’t you” (222).

Pearson meets with Malachai and a psychiatrist, and Malachai agrees to stay on his medication. The psychiatrist says that she will be his friend. The psychiatrist tells Pearson afterwards that she believes Malachai has mild mental retardation and cognitive disabilities. He seems so gentle that Pearson looks him up on the Internet one night and then wishes she hadn’t. He had been arrested for stalking a woman in a frightening way, although he had never hurt anyone. One night he asks if he can be Pearson’s friend, and she declines: “I will be your medical student, and I will do my best care for you here in the clinic” (224). 

A man named Jacob gives Pearson the chart of Ms. Blair, a 39-year-old African American woman. She has an abdominal mass that is probably cancer. She had been at a hospital, whose doctors had sent her to the free clinic since she was uninsured. Jacob looks shaken. He says that he thinks he accidentally told her that she has cancer. They did a CT scan at the hospital without explaining its purpose or its results, which was to detect a cancerous mass. Jacob assumed that they had told her why she had the scan.

Jacob has been at the House for several months. A patient named Mr. Klein arrives. He has painful throat cancer. Dr. McCammon examines him and says that he needs opiates, which they are not allowed to prescribe at St. Vincent’s. Jacob is determined to get Mr. Klein chemotherapy and radiation treatment. He helps Mr. Klein with the paperwork and continues after several hospitals deny him. After eight months, he is accepted into the Galveston County indigent care system. His brother buys him a trailer so that Mr. Klein can live within walking distance of the hospital. The County rules that because he has a trailer, he is too wealthy for the indigent care program, so Mr. Klein does not have the throat cancer removed. Jacob never learns what happened to Mr. Klein.

A patient named Ms. Blair needs a biopsy through her abdominal wall, which has never been done at St. Vincent’s. Dr. Black, Pearson, and Jacob discuss the potential complications: “Nothing about this was going to be easy, or simple. We were in over our heads” (234).

A month later, Dr. Black performs the biopsy and finds masses consistent with uterine cancer. St. Vincent’s can diagnose her, but cannot perform the surgery. Ms. Blair’s family pools the money for the surgery and it turns out that the mass, although it needed to be removed, was neither cancerous nor life threatening. Jacqueline, a resident who assisted on the biopsy, wonders if anything they did was worth it. She asks Pearson if it would be wrong to call Ms. Blair and check on her. They discuss the boundaries of appropriate contact between residents and patients and decide that the call would be fine.

Jacqueline gives a woman named Gloria a cervical exam and sees a cancerous mass. Cervical cancer is not as dangerous as other forms, but Latina women like Gloria are more susceptible to it than other racial groups. They begin trying to find charity funding for her medical care. Several hospitals rejected them in quick succession.

Pearson describes Jacqueline as not wanting to be “well-rounded as a doctor” (242). Jacqueline wants to find meaning in her work, not to achieve an ideal life/work balance, and Pearson wants to warn her that she is missing out on real life.

Gloria is accepted to Houston Methodist for charity care. She and Jacqueline stay in touch on the phone, even though Gloria now has her own doctors: “Sometimes when you push and push and push, and you don’t give up—when you become that obsessive doctor who can think of nothing else—you actually save your patient’s life” (243).

Pearson is on a porch talking with another fourth-year medical student named Julian, who is going to be a military doctor. She tells him about Cicero, a Roman who could not remain stoic when his daughter died. This was seen as weakness, and he retired to the country rather than display his grief publicly. She tells Julian that this sort of detachment can serve a purpose in medicine: “Your life is actually not about your own experience. It’s about serving this other thing” (246).

Pearson explains how medicine became her entire identity. She thinks of Jacqueline’s insistence that a doctor should derive meaning from their work, and she agrees: “The trick is to give up, and let medicine become you” (248). Seven years after the hurricane, little has changed for Susan McCammon. She continues to visit patients she cannot care for but refuses to abandon them. Pearson finishes her year of directing at St. Vincent’s and gives the keys to Jacqueline, who is overwhelmed by her coming responsibilities. Pearson tells her that she understands, but that she’s going to be fine.

Pearson dreams of Mr. Rose sometimes. In her dreams, she makes no mistakes. Sometimes she is able to cure him, or take away his pain. She manages to feel compassion towards her younger self in these dreams as well: “I know now that returning to be with those who are suffering is no easy thing. I also know that it is my job” (251).