Start reading We Are All Perfectly Fine by Jillian Horton
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Funny, fresh, and deeply affecting, We Are All Perfectly Fine is the story of a married mother of three on the brink of personal and professional collapse who attends rehab with a twist: a meditation retreat for burned-out doctors.
1. The Curse of Knowledge
I know how I’m going to die.
It’s in a tin can of a plane at an altitude so low that birds will see the whites of my eyes as I go down screaming. Whichever nondescript great-lake abuts Toronto and broaches Rochester —okay, Lake Ontario—that’s the lake I’m dying in, today, on this plane.
The whine of the motor is deafening. The low-pitch pulsing sounds like the apocalypse. Just after takeoff, I snapped a photo of an ominous dent on one of the wings and I’m wondering whether it will upload to the cloud if I’m in airplane mode when we crash. Then the Transportation Security Administration investigators will praise me: “One passenger had the presence of mind to give us the photographic evidence that unlocked this case for us. In her final act, sensing something amiss, she took a photo of the plane’s wing.”
But that was stupid. A better final act would have been to alert the pilot before takeoff, and then maybe it wouldn’t have been a final act. And my final final act should have been texting my husband to tell him and the kids how much I love them. Or at least going into efficient doctor mode to remind him the youngest is due for a dentist appointment, and please follow up with the roofing company to patch the outrageously massive hole a squirrel chewed in the side of our chimney. Lest we get more squirrels.
By the way, I loved you.
I’m a general internist, the kind of doctor who looks after people with medical problems that sound made up. Typhilitis. Neurocysticercosis. Ankylosing spondilitis. I also look after people with less exotic problems but lots of them at once. Heart failure and liver disease and sick kidneys. Stroke and pneumonia and severe mental illness. I work in an inner-city hospital, a rambling facility in need of a paint job, built on unceded Treaty 1 land in a part of Canada Truth and Reconciliation seems to have forgotten, a hundred miles from the town where I grew up. I look after people who are sick enough to be in the hospital. Some of them are dying. Many of them are homeless. Many are Indigenous and have been subjected to gross, almost unfathomable injustice, racial oppression and intergenerational trauma. They struggle to escape its legacy, which often comes in the form of the scourge of drug and alcohol addiction.
I’m heading to a place in New York called Chapin Mill. Nobody’s sending me. I’m going of my own volition, unsure as to why, doubtful it will make any difference. In the only-in-my-mind major motion picture movie version of my life, either Hawkeye Pierce or the soulful doctor played by George Clooney on ER have staged an intervention, since it’s so painfully obvious to viewers that I’m floundering emotionally and need to go away somewhere for at least part of one season.
Interventions don’t happen in medicine, in my experience. When they do they’re a late-stage measure, akin to chemotherapy for advanced-cancer patients who have no hope of cure. Most doctors look fine, perennially, until the day they don’t. That’s because doctors are excellent at compartmentalizing. We are also compliant and conscientious and rigidly perfectionistic, characteristics that put us at risk for choking to death on our own misery – or more specifically, overdosing on the perfect fatal combination of pills, throwing ourselves off just tall-enough tall buildings, or slitting open the large arteries we studied so carefully when we were undergraduates, with just the sleight of hand to bleed out quickly - if all goes well, in approximately five minutes.
I talk about death a lot; wouldn’t you? I’m surrounded it. I’ve signed more death certificates than checks, and I pay for everything by check. Doctors have a delusional relationship with death. We trick ourselves into the professional assumption that death is reasonable. Not benevolent, but not unpredictable, nothing psycho about it. Birth is a Hitchcock film on a good day; death is often quiet, understated, like dealing with your accountant. So when it shows up on our doorstep, whether for us or one of our family members, suddenly this “reasonable” death that seemed so calm and inevitable when it was happening to other people turns out to be a real handful, and we’re often woefully unprepared to deal with it.
But we also talk and think so much about death because medicine is so fucking hard.
I know many jobs are hard. Try being a soldier deployed in Afghanistan. Try being a police officer on the frontlines of the meth crisis. My friend Al is a pharmacist. Believe me, pharmacists have their problems too. All that working with doctors, some of them notorious jerks. All that worrying, missing interactions between the red pill and the yellow, or the blue one and the white. All those drugs, spread out in front of you like Dylan’s Candy Bar minus the carbs. One pill might take the edge off. Just the edge. What if it found its way into your pocket? What if you slipped it under your tongue? Just one. What’s the harm? That’s why they call it the edge, of course. Nothing begins in medias res. Every addiction, every dysfunctional behavior – all of it starts somewhere.
Al and his wife came with us to the beach this past summer. We watched the kids wade out a mile into the shallowest side of Lake Winnipeg, far enough that they were dots halfway to the horizon but the water was still only up to their knees. It was so hot that it made Al think of his first summer job. He worked at a grill, cooking meat. Behind the grill was hotter than any beach. Sometimes Al got assigned to onions. He would stand next to the sink, slicing them, working his way through an entire mesh bag. For the first ten minutes, tears would pour down his face and his eyes would burn. Every minute was worse than the one before it. Just when he thought he couldn’t stand it anymore, even though he hadn’t finished cutting, the burning stopped. His face was wet with tears. He couldn’t feel anything. He didn’t even know he was crying.
I think Al cutting those onions was like me and medicine. In the first few years, everything burned. Then one day the pain just stopped. That was a warning sign, and I missed it. Pain tends to serve a purpose in our lives, sending messages to keep us out of danger. When we ignore those messages, or when our nerves have been damaged by some prolonged toxic exposure and we no longer feel any pain, we mistake our insensibility for infallibility. And that’s when we can end up in serious trouble.
I didn’t know what I was in for when I decided to go to medical school. I couldn’t have known what I was getting myself into. I knew there was risk; I didn’t know the degree. Nobody would climb Mount Everest if they knew unequivocally once they were up there they’d freeze their face off and be left with a hideous chunk of black flesh where their face used to be.
And yet, I love being a doctor. There is something so intimate, so fateful between me and medicine. Itzhak Perelman picks up the violin and knows it belongs in his hand. When I sit down at a bedside with a person in pain, there’s a moment of deep resonance and grace: everything in my life has led me to that chair. But relationships have undertones, just like instruments. Perelman plays a concert, and it’s easy to forget he spent his life making what he just did look effortless. And we have no idea what happened in rehearsals.
Why did I go to medical school? I went because of my sister, Wendy. She was the first of four siblings, twelve years older than the youngest (me), an age gap that would normally mean I might have been babysitting her kids before I was out of high school. But six years before I was born, Wendy was diagnosed with a brain tumor. Surgeons cut her head open and took the tumor out. If it had been diagnosed earlier, or if that had been the end of it, she might have recovered and had a good life. Instead, just a few days after surgery, her skull still wrapped in Frankenstein bandages, she got post-operative meningitis, an infection of the thin, glistening tissues that encase the brain like a tough layer of Saran wrap. That infection caused swelling, and scarring, and left her with the most complex cluster of disabilities imaginable. It made her the world’s most cantankerous disabled person, but also one of its funniest. She was a martini of a human you could never mix again. But her disabilities were so profound that all the doctors advised my parents to stick her in an institution that wouldn’t even pass for an animal shelter by today’s standards. My mom remembers a doctor, famous in these parts when he was alive, drawing a pie graph on a chalkboard, with a single narrow line representing the one child out of a hundred who survived pediatric anaplastic astrocytoma, then thrusting Wendy’s scans up on a lightbox and screaming at my Mom and Dad, who had asked about her prognosis, “Can’t you people get it through your heads? There problem is there’s no brain left.”
But the problem had nothing to do with my parents, or their heads. Doctors were the ones who screwed up my sister’s case at the beginning, middle and end. There was an unfathomable two-year delay until her diagnosis. Trip after trip to the clinic, my mother’s panic rising, because she knew, as mothers often do, that something wasn’t right. Wendy’s head in those photos from before the surgery, big as a dandelion gone to seed. Vomiting in the morning, bile travelling in an arc across the room, bits of her breakfast stuck to the walls. We learn early in medical school that this is called projectile vomiting. It’s a classic sign of raised intracranial pressure, along with headaches, balance problems, and deep, intractable nausea, a syndrome you should be able to describe if not diagnose by the time you’re in your third year of medicine. Wendy had all of these signs. Doctor after doctor missed them. Then, after the diagnosis and the surgery, other doctors had the audacity to yell at my parents that they were the ones with something wrong with their heads, despite the fact that my sister, who had gone into the OR looking like a dandelion but otherwise a perfectly regular six-year-old, ended up coming out of that operation with a head full of scrambled eggs. My mom always said she could write a book, but who could bear to read it?
And yet, my parents came across some good people, and there were a few doctors scattered among them too. The kind pediatric neurologist in another city who made the correct diagnosis in a few minutes with a simple, thorough physical exam, hardly able to conceal his horror at what his colleagues had somehow missed. A surgeon at the Children’s Hospital, empathetic and skilled, who probably saved her life. And Wendy’s last family doctor, a woman who treated Wendy and my elderly parents with compassion and love, offering care in the tradition of the Greek God, Asclepius, healing as art.
That narrow line on the pie graph that doctor had drawn for my parents – it wasn’t the survival of one child out of a hundred. That line was really a crack my mother and father found or made, then pried open, then somehow managed to just barely squeeze my sister through. My grandmother once said to me, in a voice that didn’t belie whether she thought it was a good thing, “Wendy lived by your mother’s will alone.” Nobody thought she would live. And when she did live, nobody thought her life was worth anything, that it served any purpose, and it was as if the entire medical system was angry at my parents for exposing its shortcomings, angry at Wendy, first for evading diagnosis and then for having the nerve to live when they declared it impossible with, as that one doctor had so eloquently put it, no brain left. So much of her was hidden from view, or clouded by fits of intense, uncontrollable rage. But then Wendy would emerge, hilarious, original, mesmerizing, and you were reminded she had always been there and you could forget she had been pulverizing you a few minutes earlier having been pissed that you put mayonnaise in her sandwich, because to her mayonnaise was the most disgusting substance on the planet—although I am pretty sure she never had bubble tea—and any anger you had felt would be replaced by love and forgiveness. And grief for everything she had lost through no fault of her own, and, maybe as an afterthought, for everything you had lost too.
Later on, once she was an adult, a lot of “experts” told my parents she should just be in a nursing home. They didn’t really consider that she had nothing in common with World War II veterans, or grandmothers who like to knit afghans, or people with dementia who care for rubber dolls as if they’re real babies. And her brain injury, specifically the damage to her frontal lobe, the part of the brain that sanitizes thoughts before they come out of your mouth, meant Wendy was liable to say, in a slow but intelligible voice, “Why is that idiot (your sweet grandmother with dementia) carrying that stupid doll,” or, “Why is that moron (your adorable grandfather, the World War II Veteran) smoking that disgusting cigarette?”
Life with her was a trial, infinitely harder than medical school, harder than the hardest moments of having a baby. It was difficult because it was uncertain, and because there was no end in sight. That tumor decimated so many important parts of her and, worse still, left her with the memory of what it had been like to look and move and eat and talk like everybody else. Most people only saw what was gone, and they didn’t understand anything about her, or about the reality of living with a person who was so profoundly disabled in such unique ways.
I didn’t understand that reality either. When I was eight or nine, one day at recess, with the air of a child’s confessional I blurted out to a teacher: “My family isn’t normal.” The teacher sniffed, and blew her whistle at a pair of boys who were rolling on top of each other like kittens. Before she went to pull them apart, she looked at me and sighed. She said: “Show me a normal family in this day and age!”
She must have thought she was helping, but that day I started thinking it must be normal to feel like a gaping hole had been blown in your heart. My sister’s propped up shell in a wheelchair, her constant screaming at night, the blaring tv, the cranked up radio, the complex toileting, the holes in the wall where Wendy’s head had gone through the plaster because she couldn’t remember that her balance was too poor to walk, the lack of respite, the lack of appropriate medical care, , the lack of a single person of any stripe coming to let my parents lie down or take me and my other sister and brother out to a movie or to the mall, the little extended family we did have too far away or too busy with their own lives to tend to the chronic emergency of ours. I have a haunting memory, from when I was five, of my mom at the end of the hall, crying that she couldn’t take it anymore, my dad telling me in a firm voice to go away, that everything was fine. Even when my brother developed a febrile illness and a sudden-onset psychosis at the age of fifteen and went permanently to the psychiatric hospital, even when my other sister, Heather, listened to the same depressing record all night with her bedroom door locked, even if I felt like I lived in a Salvador Dali painting, there wasn’t cause for alarm. My teacher had told me: there were no normal families in this day and age.
Years later, I would spend an inordinate amount of time seeing a psychologist. But she would tell me exactly two useful things. She would tell me: your sister was your first patient. And she would tell me that the worst part about what happened to my family is there was nobody to be angry at, because it was nobody’s fault.
But she was wrong. I found somebody to get angry at. I had enemies and decided to hold them close, closer than anyone, so close I became one of them, infiltrated their ranks in order to make them pay for what they had done to our family.
I became a doctor.
Now, all these years later, I’m on a plane with a phone full of potential forensic evidence, bracing for the impact that has already happened in my mind. The last year has been hard and dark, thumbnails of the same day sketched over and over with a black crayon. Everything has been an effort. The bitter cold all winter. The interminable drive to the hospital. The long, windowless hallways. Colleagues I’ve worked with for ten years who don’t even say hello when we pass in the corridors. Going to the ward, finding the right charts. Then, logging into yet another new electronic health record platform, trying to remember which massive drop-down menu is hiding the discharge note I want to review. Choosing which patients to see from a list that is already too long to be safe. Finding forms to fill out, ordering tests, four calls coming in on my pager. Five nurses and two students asking me questions, giving me information I can’t process because I’m still trying to find the drop-down menu that will yield the note summarizing the three-month community hospital admission of a woman with fifteen medical problems. Six emails when I dare to check my phone, three about improving the learning environment. The learning environment! What about the teaching environment? There was a time when I loved teaching so much I couldn’t wait to get to work. A time when the Hippocratic Oath was almost as precious to me as my marriage vows. I will gladly share such knowledge as is mine with those who are to follow. Now I am drowning in this water and I don’t want anyone to follow me into it. Sometimes I just want the students and Hippocrates and everybody else to leave me the fuck alone.
Once a month, if our schedules align, my friends Frank and Len and I go for coffee in the glass atrium. We watch the wind picking up, leaves gathering by the glass. We are all in or near our forties, parents of little boys, internists of some stripe, sleep-deprived and struggling with an amorphous discontent that has become medicine’s secret ailment. We’re good doctors; we care about our patients. But there’s a force bigger than us pushing us to the brink, and some days I’m afraid one of us is going to tumble over that edge.
I don’t tell my friends what’s going on with me at this point. They’re basically in the same boat. I don’t burden them with the fact that I’m not sleeping enough, that a constant weight on my chest like a barbell is making it hard to get through not only rounds but also supper and playdates and grocery shopping. The radio in my head is set to perpetual glum, Nespresso pods strewn across my desk as if they are drugs and paraphernalia I am relying on to get me through the week on call. Between clusters of patients I curl up like a caterpillar in a stained armchair in the corner of my office, swallowing against the lump in my throat. There’s a tingling behind my eyes, a feeling I get in my mouth, an ache in the teeth like winter or an empty parking garage. Still, silent, heavy. Boiling the kettle for tea, momentarily comforted by the smell of chai, a whiff of spice, the hint of a kitchen at Thanksgiving. My office has a thin, high band of windows, and they face a brick wall; the effect is like looking up from the bottom of a well. I am at the bottom of that well, but Doctors look fine until the very end. This is a silent emergency, and even if the people around me can smell something burning, none of us have made the connection that the thing on fire is me.
The morning before I left for Chapin Mill, I dropped my sons off at school. A little girl came running down the hallway, wisps of hair stuck in her mouth. Her face was alive with important news.
“The egg hatched!” she shouted at us. “There’s a baby dove!”
My boys went wide-eyed. They kicked off their boots at the lockers and ran in their socks down the hallway towards the classroom. Children were gathered around a birdcage. A male dove sat up top, perched on a little trapeze, sounding guttural, excited notes. Below him, a female was sitting on a miniscule body.
The teacher was peering into the bottom of the cage, craning her neck for a good look at the littlest bird. “I don’t know if it’s alive,” she said. But a second after she had spoken the baby dove turned its head to the side, eyelids fused shut, extending its translucent neck. The mother nipped at its hairless body. The children huddled around the cage, transfixed and silent.
On my way back out to the car, I saw geese lined up in a lazy V overhead, their two-tone honking reminding me of the rubber horn I had on my bike when I was a little girl. I felt a pressure in my chest, like a small hand squeezing my heart. The bird was barely moving. Of course it was going to die. The mother didn’t have a coach or a public health nurse or a doula, and the father was thinking about how soon he could knock her up with another egg. Soon there would be a latex glove, the teacher moving the mother aside as she pried the little dove’s body out from under her.
It’s a burden, knowing what’s going to happen to that little bird when everyone else is still ten steps back, saying “ooh” and “ah” and calling it a miracle. It makes it so hard to be hopeful.
That’s the curse of knowledge.
So how did I really end up on this plane? A friend who is a social worker invited me to a talk by another friend of hers, a doctor she had invited to speak about mindfulness. I went because my friend phoned me twice, and I wanted to show her that I was open minded, even if I really wasn’t. I sat in the back row with my jacket over my shoulders. I said it was because I was cold but really I was waiting for a chance to slip out of the room.
Except it was actually kind of an interesting talk. The doctor’s name was Mick Krasner. He was bald and looked more like a beat poet than a doctor. He and his colleagues had published a study in the Journal of the American Medical Association showing that their mindfulness program made doctors feel happier and more able to handle the stress of medicine. I had expected him to be a hippie or a freak, but Mick seemed like a lighter, happier version of me from a time before a connection between necessary pieces of myself got severed.
When the talk was over, my friend walked me up to Mick.
“This is the colleague I told you about,” she said to him.
Mick smiled. He gave me his card. He told me he thought I might like to come to spend a few days with him and one of his colleagues at a retreat for doctors. There was one in April. He said they still had room at Chapin Mill. He hoped I could join them.
“Is it like, a padded room?”
Mick laughed. “No, but it’s a Zen Retreat. Lots of cushions.”
“I don’t think it would help me.”
He winked at me. “Only one way to find out.”
Normally, this exchange would have irritated me, but that day Mick’s words hung in the air, stayed with me on my way home and that night as I was getting ready for bed.
I lay there in the dim light and I knew: this was my Hawkeye/Clooney moment. Mick and my friend were throwing me the only intervention I was ever going to get. A week later I surprised my husband by booking a ticket to Rochester and marking the whole week unavailable in my calendar.
I’m not burnt-out. I am on fire. That’s why I’m going to Chapin Mill.