18 January 2017

Webster was much possessed by death
And saw the skull beneath the skin; 
And breastless creatures under ground 
Leaned backward with a lipless grin.

T. S. Eliot, “Whispers of Immortality”

I flipped through the CT scan images, the diagnosis obvious: the lungs were matted with innumerable tumors, the spine deformed, a full lobe of the liver obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my final year of training. Over the last six years, I’d examined scores of such scans, on the off chance that some procedure might benefit the patient. But this scan was different: it was my own.

I wasn’t in the radiology suite, wearing my scrubs and white coat. I was dressed in a patient’s gown, tethered to an IV pole, using the computer the nurse had left in my hospital room, with my wife, Lucy, an internist, at my side. I went through each sequence again: the lung window, the bone window, the liver window, scrolling from top to bottom, then left to right, then front to back, just as I had been trained to do, as if I might find something that would change the diagnosis.

We lay together on the hospital bed.

Lucy, quietly, as if reading from a script: “Do you think there’s any possibility that it’s something else?”

“No,” I said.

We held each other tightly, like young lovers. In the past year we’d both suspected, but refused to believe, or even discuss, that a cancer was growing inside me.

About six months before, I had started losing weight and having ferocious back pain. When I dressed in the morning, my belt cinched one, then two notches tighter. I went to see my primary care doctor, an old classmate from Stanford. Her sister had died suddenly as a neurosurgery intern, after contracting a virulent infection, and so she’d taken a maternal watch on my health. When I arrived, however, I found a different doctor in her office—my classmate was on maternity leave.

Dressed in a thin blue gown on a cold examining table, I described the symptoms to her. “Of course,” I said, “if this were a boards exam question—thirty-five-year-old with unexplained weight loss and new-onset back pain—the obvious answer would be (C) cancer. But maybe it’s just that I’m working too hard. I don’t know. I’d like to get an MRI to be sure.”

When Breath Becomes Air

“Of course,” I said, “if this were a boards exam question—thirty-five-year-old with unexplained weight loss and new-onset back pain—the obvious answer would be (C) cancer.”

“I think we should get X-rays first,” she said. MRIs for back pain are expensive, and unnecessary imaging had lately become a major national point of cost-saving emphasis. But the value of a scan also depends on what you are looking for: X-rays are largely useless for cancer. Still, for many docs, ordering an MRI at this early stage is apostasy. She continued: “X-rays aren’t perfectly sensitive, but it makes sense to start there.”

“How about we get flexion-extension X-rays, then— maybe the more realistic diagnosis here is isthmic spondylolisthesis?”

From the reflection in the wall mirror, I could see her googling it.

“It’s a pars fracture affecting up to five percent of people and a frequent cause of back pain in the young.”

“Okay, I’ll order them, then.”
 “Thanks,” I said.
 Why was I so authoritative in a surgeon’s coat but so meek in a patient's gown? The truth was, I knew more about back pain than she did—half of my training as a neurosurgeon had involved disorders of the spine. But maybe a spondy was more likely. It did affect a significant percent of young adults—and cancer in the spine in your thirties? The odds of that couldn’t be more than one in ten thousand.

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