The Symptoms Begin

My name’s Erik, I’m a physician—a doctor—doing my residency in a Southern town. When I got here I found I had a pre-filled role to play—or not—as a doctor. I thought I was getting the role down pretty well, when things took some strange turns several months ago…

A few days later I’m waiting for the elevator in the central elevator bay, which I usually avoid. I’m using the central bay because the west bay is not working today, which is—unfortunately—not unusual.

The central bay was built as part of the original hospital in the nineteen-forties. As you travel up, it feels like the elevators move by a series of connected rubber bands. You can feel variations in your speed and watch passengers grab the handrails, nervously glancing at one another. When your floor is reached, the elevator car will slow, stop, lower, and then raise a bit. The effect can be compared to motion of a Slinky as it finds its hanging point. They usually stop within a foot or two of the floor. Often not the floor you requested, but close enough that you only have to take the stairs up or down a single flight.

On each of the floors the elevator bay is equipped with phones so when you walk by the hall and hear the screaming of people trapped in between floors you can let elevator maintenance know. I have that phone number programmed into my cell phone. I also have a fair number of friends I made while trapped between floors.

The newer elevators in the west bay do not trap you (much) and don’t move with rubber band motion, but they’re frequently broken.

So I am at the central bay, waiting.


A smiling, thin, middle-aged black man joins me. He presses the up button, though it’s already lit, to announce that he—also—is waiting for the elevator. He then asks me if I am a doctor.

I’m looking at my shoes when he asks this, so in my field of vision I can see my white coat, my stethoscope, and the embroidering—cheap embroidering—of my coat that spells out the word ‘Doctor’ before my name begins.

He’s friendly enough and I haven’t been able to immediately glean his angle, so I just say yes.

‘Awesome job you have, man.’

Though awesome’s meaning is rather specific—either awe inspiring or excellent—it can be pronounced many ways, and the pronunciation very specifically communicates which meaning is intended. His meaning was clearly not the Bill & Ted variety of ‘great job with golf and cash and seeing naked chicks.’ His was of the church going variety with ‘vocation and mission and helping the afflicted.’

‘Sometimes,’ I said, a bit flatly but punctuated with a—hopefully—pleasant nod.

‘Well, I think it’s an awesome job,’ he said and began talking about why he thought so.

I pressed the call button again.

He kept talking when we got on the elevator.

‘I have a friend who’s a doctor,’ he said, ‘and he says that when he sees the complexity of the human body, the hormones and the way they’re regulated, he says its clear we’re designed by an awesome God.’

I knew doctors like his friend in medical school. They were the kids who confused landscape design’s approximation of natural beauty with its reversal: natural beauty’s approximation of landscape design.


Granted, the simplified flow charts and regulatory pictogram that recall electrical schematics and circuit diagrams can be misleading. Illustrations that explain the way something works can be mistaken for the why something works.

These people revealed themselves with their confusion when the way and the why were at odds with each other, when elements had no obvious use, or no discernable why: the molecular equivalents of an appendix.



I don’t join the religious fervor of people who mock creationists. They often have less understanding of the history and details of evolution than a twelfth-century peasant understands paganism yet rails against the Holy Roman Empire.

I tried to make eye contact with him, to be friendly, but what I was really thinking was that his friend was probably loved by his patients—because, contrary to popular opinion, you don’t have to be a great thinker or possess great understanding to be a good doctor: For the most part you can get by with memorized algorithms and lists. That kind of doctor is loved by his patients because he refers everything out to specialists. The patients think they are special, why else would they go to a specialist? But that kind of doctor doesn’t truely understand what he’s observing.

To be a great doctor you have to kill your own awe. You must be willing to defy god, to tinker with his creation, to alter and change the way the human body functions to keep it alive until it can resume homeostasis.

I am not awed by man’s body. There is no dread in my soul. When a patient is dying before me, he’s a mathematical equation that must be solved, a brain teaser, an Encyclopedia Brown Mystery whose clue needs to be discerned. I have no time or stomach for awe and wonder.


People wonder why doctors think they’re gods; I can explain it quite easily. Place you fingers on a cold, pulseless wrist. Say words that serve as an incantation that send women in white scurrying to administer agents of your choosing. Feel the pulse return to the wrist. Watch the eyes open.


It’s a simple parlor trick.

But go out and talk to the brain teaser’s daughter, the equation’s wife, the mystery story’s mother. You’ll have to avoid their eyes. Their eyes are full of the awe and wonder and dread that you have tried to kill. If you were in awe, if you felt the wonder of what you were doing, you would crumble. You would not be able to function in those crucial moments. And their watering eyes praise you. Their hands clasp around yours in gratitude. They tremble as they give you thanks.

You then—as I now, in the elevator—won’t know what to do with such praise.

The smiling, thin, middle-aged black man in the elevator has almost reached his floor. It has stopped just shy of it and, after I help him step the eighteen inches up, he turns to me and says, ‘God loves you.’

‘Yes,’ I say, pressing the door close button, ‘I’m aware.’

Chicago utters the words ‘I love reggae.’

Not Bob Marley—or even Jimmy Cliff—he loves reggae music in general.

Stockholm comes over after a difficult night at work. We’re in bed and she’s lying with her head in my lap while I stroke her hair.

She’s telling me about a customer who was an asshole, but she’s not explaining what he did that made him an asshole. Eventually she explains it was a joke he told that she didn’t like.

After much needling, she tells me the joke.

It’s a bad idea to laugh when someone’s head is in your lap and repeats a joke that defined its teller as an asshole. I know this. Unfortunately, when someone’s head is in your lap stifling laughter is obvious. When her head is shaking because of your laughter and she gets up and starts putting on her clothes, you have to turn on major game.

There were many I’m sorry’s and baby’s, cooing and softly rubbing her forehead and cheek with your thumb. You know you have to make her stay. If she leaves like this, she won’t be coming back. This is not the time to make her laugh. Laughing will remind her of your laughter.

This is the hard sell.

This is, after the cooing and apologies, after the thumb rubs and baby, baby come here, put down your keys, after she softens when you kiss her neck, but stiffens again and looks for her shoes, after you crouch beside her as she slips them on, after another don’t go, don’t leave, stay here, stay with me, that’s when it just slips out, and you haven’t been drinking so you have no excuse.

It just slips out and it’s there and there it is, and she looks at you, after you’ve said it, and you see her surprise and your chest is throbbing and feels waterlogged.

You can feel yourself breathe.

‘I should go,’ she says, but she’s softened. She steps toward you and kisses your cheek. You don’t move. You feel yourself blinking, a series of fast blinks one after the other. You’re trying not to twitch. She’s already facing the door, but turns to you for the briefest of moments.

‘Call me tomorrow,’ she says, ‘if you meant that.’

I’m staring at the door handle she has just used to leave me.

Fuck.

I hear her engine start and see the garage silhouetted by her headlights. The car revs and then fades as she drives away from my house.

I can feel the weight of my body shift from my heels to the pads of my feet.

Fuck. Fuck, fuck fuck.

I stop staring at the door. I wonder around the house, moving from couch to computer desk to kitchen and to bed.

I get up and put in Costello’s My Aim Is True on the stereo.

I go back to bed. I fidget. I get the phone and open it, scrolling through the names. Once, before phonebooks were digital, I told someone ‘every time I go through my phonebook, my fingers always seem to land on you.’

Tonight they land on ‘send,’ and I press it, though it’s after midnight.

I hear the voice inhaling as the phone picks up, and hear the last half of a groggy hello.

‘Hey there,’ I say, ‘what are you doing?’

‘Nothing’ Birmingham says.

‘I didn’t wake you, did I?’ I ask, but head off my own question. ‘I was just thinking about you.’

‘That’s nice,’ he says, still half-asleep. ‘You wanna come over?’

‘Tomorrow?’

‘Okay,’ he says.

‘Are you going to remember this or should I remind you?’

‘Better give me a reminder.’

‘Sleep well,’ I say and hang up. I lay down with happy anticipation for tomorrow night.

‘That boy has no game,’ I’m saying to Dr Merteuil about Dr Pasteur. ‘You want to see his idea of game?’

As a radiologist friend—a cute blonde—walks by, I grab her hand.

‘Play a game with me,’ I tell her, ‘Pretend I’m Pasteur for a sec.’

She smiles and shows some teeth.

‘Hi,’ I say in my Dr Pasteur voice, ‘what’s your name?’

‘You know my name,’ she says, still holding my hand and giving it a little squeeze.

‘No,’ I say, back in my own voice, ‘Pretend I’m Pasteur and you don’t know me.’

She looks at Merteuil and then agrees.

‘Hi,’ I say in my Dr Pasteur voice, ‘what’s your name?’

‘Sara.’

‘Sara,’ I say, still in my Dr Pasteur voice, ‘can I have your phone number?’

The three of us laugh and Sara yanks her hand out of mine dramatically. She walks away shaking her head as Merteuil and I continue to laugh.

‘I’ve seen him try that shit fifteen times,’ I say. ‘Not in bars either—with other doctors.’

‘You know that blonde Ob/Gyn,’ she asks, laughing. I nod. ‘She agreed to go out with him. So he takes her to Outback Steakhouse.’ She starts laughing so much she stops talking for a moment. ‘He tells her he chose the restaurant because he knows she’s Australian.’

I’m laughing too, but I’m confused.

‘But she isn’t Australian,’ I say. ‘She’s South African.’

‘I know,’ she says, laughing so hard she’s crying.

‘What a tool,’ I say, laughing, glancing out the window when I think I see Pasteur coming in from the patio entrance, but it’s just a reflection and a trick of the light.

Stockholm picks up as the fifth ring begins.

‘I waited for your call.’

‘I’m sorry,’ I apologize, ‘work ran late.’

There’s another moment silence.

‘I’m sorry about last night,’ I say, ‘also.’

‘Sorry for what?’ she asks.

‘Sorry for laughing,’ I say.

‘But not for finding it funny.’

‘No,’ I admit, ‘not for finding it funny.’

‘Then I’m not sure we have anything to talk about…’

I can hear the sounds of the restaurant kitchen in the background and hear the sound of her lighter: she’s in the back alley. And lighting a cigarette. I quickly run through seven different algorithms for lighting a cigarette after making that statement. Of the plausable terminal boxes, none involve trying to get off the phone. She’s only trying to play it cool; she wants me to move things forward.

‘There are always hipsters to make fun of,’ I offer, recalling a previous conversation we had.

‘You know, I’m starting to realize that it’s hating hipsters that makes someone a hipster,’ she says. This sounds like she’s challenging me, but she’s not. She’s moving the conversation forward. We talk and banter as she finishes her cigarette.

‘Can I take you out Sunday?’ I ask. ‘Someplace nice?’

‘Only if I choose the wine,’ she says. I can hear her smile through the phone.

‘Deal,’ I say, smiling.

My dad’s called me from Iowa and asks how things are going.

‘Really well. I’m meeting interesting people for the first time in a while. It’s nice,’ I say, ‘this past year I’ve been alone. Going from work to studying and reading, not much interaction with other people, except for a few out-of-town friends. I feel like I’m coming out from a dark period of my life.’

As I finish the last sentence he begins laughing, really loud.

I don’t say anything.

‘I’ve never seen this commercial before,’ he says, ‘it’s really funny. This guy just got smashed through a wall.’

Birmingham and I end up drinking Crown & water at a dive bar. Walking back to his house drunk, we fall asleep on top of each other, clothes still half on.

I wake at 5:45, driving directly to the hospital, showering in the O.R. suite and putting on a pair of scrubs.

One advantage of being a doctor: you get to work in what is essentially a comfortable pair of pajamas.

After last night’s overindulgence with Birmingham, the plan tonight with Chicago is low key: pizza and sharing a pitcher of Peroni.

When I drive to Chicago’s house, his roommate’s sitting on the front porch. I turn off the ignition and the sound of The Smashing Pumpkins’ Siamese Dream, which was playing loudly, abruptly stops. As I get out of the car, his roommate says, ‘Are you sure you’re gay?’

‘Look who’s talking,’ I say, walking past him, ‘patchouli boy.’

‘I don’t wear patchouli,’ he objects.

‘You listen to reggae, close enough,’ I say.

I knock on the screen door, call out Chicago’s name, and walk into the house.

‘Hey, boy,’ he says, coming out from the kitchen with two beers in his hand. ‘Want one?’

I take the beer and kiss his cheek.

He shows me around the house. I politely ignore the bong next to his reggae couch. And then the unexpected: when I see his bookshelves I have two virgin experiences.

The first virgin experience is finding a doppelganger of my own library. He has the requisite Hurston, Hemmingway and Marquez, but also Gaitskill, The Safety of Objects, & Winterson. Of course he has that early 1960’s New Directions edition of Ferlinghetti’s A Coney Island of the Mind, but a copy of Tyrannus Nix? sits next to it. He’s got a nice size dictionary and bible with a sizable grouping of Camus, Orwell, Gertrude Stein, C.S. Lewis and WCW. He doesn’t have any cyberpunk or Jim Thompson, but he’s got at least eleven cool ass titles that I’d been meaning to read for fifteen years.

The second virgin experience followed from the first: I became aroused looking over someone’s bookshelf—I mean really aroused. To distract him while I readjust my jeans, I ask if he has any Patchen.

He’s leaning with his hand outstretched against the wall and looking down for the book, looking relaxed and intelligent. I lean into him and kiss the side of his neck, right where the sternocleidomastoid muscle bisects the unshaven scruff from the smoothness of the rest of his neck.

Constantly risking absurdity, indeed.

At the pizza joint, Chicago and I share a pizza and a pitcher of Peroni.

He’s telling me about the cadre of kids he takes care of at the Boys & Girls Club. I’d forgotten the way his eyes lit up when he talked about them, and I’m swayed by this. He’s excitable now because of the topic, and while he talks I eat the lion’s share of the pizza—it’s called the T-Rex and it’s got a whole lotta meat.

We’re making plans for going to the kickoff game against the Bengals and talking about our post-college rogue years. He asks me about the picture on my refrigerator. It’s of me in my scrubs with the family of one of my patients. I tell him the patient’s story. Things are good up till now.

That’s when he asks me what kind of medicine I want to practice, and I tell him that I love infectious disease.

I talk about how bacteria in certain towns, or even within certain hospitals, develop resistances to antibiotics and how the choices we make as physicians effects those resistances. I talk about plasmids and spontaneous mutations, vectors and fomites. About the excitement of watching a microscopic diorama of evolution at work.

I talk about the enjoyment I get working with HIV and virulent strains of hepatitis, and about the way the field is changing, incorporating genomics and DNA probes as well as the challenge of genotyping for resistance patterns and potential vaccines.

I again say how much I love infectious disease.

I guess I’m a bit carried away because he’s looking at me—not quite but—almost in horror.

‘I don't love infectious diseases,’ he says, before looking down at the table and adding, ‘I hate them.’

And something’s changed. I try to clarify that I mean I love treating infectious disease rather than the diseases themselves, but it does not seem to sway him.

When we finish the pizza, he says he needs to turn in early.

When he tells me how to get to his house, I try to show him a shortcut, but there’s a dead end where I thought there was a pass-through and it ends up taking us a little out of our way. He doesn’t say anything after that.

When I kiss him goodnight, he removes my hand from his neck. I watch him walk from my car until he is in his home.

I’m on the elliptical machine at the gym and Oprah Winfrey’s on television talking to Charlize Theron. I unplug my earphones from my Rio and plug them into the television outlet, hoping she might talk about the upcoming AeonFlux flick, but they’re talking about Monster and North Country. Oprah’s asking Charlize why she has this amazing asset of her beauty but picks roles that make her appear unattractive.

Charlize says that it isn't something she seeks out, that the appearance comes naturally as she gets into the character. Then she says she believes that outer beauty is simply a reflection of our inner appearance. When she says this even Oprah’s impressed and can’t say anything for a moment. Kind of stunned, Oprah says, ‘I’m having an a-ha moment right now.’

In the mirror, I check my posture and adjust my hair.

The HIV gosling improved at first, but for the past four days his white blood cell count’s been dropping and he’s now neutropenic.

His breathing’s slowly worsened also. A blood gas today finds he’s developed a methemoglobinemia. This is certainly from the trimethoprim/sulfamethoxazole we’re using to treat his Pneumocystis pneumonia. I suspect it’s also causing his neutropenia. Unfortunately, it’s one of the few drugs that will treat his infection. There’s a few other drugs I can try, but when I see his X-ray, I’m less enthusiastic.

His X-ray looks like shit. I suspect his initial improvement was from the steroids and not the antibiotics. Pneumocystis, if you’ll recall, kills about 20% of people who get it. If you change antibiotics because of their side effects, it doesn’t change survival rates. But if you change them because of a treatment failure, his odds of dying increase to somewhere between 75 and 100%. And his X-ray looks like a treatment failure.


Explaining things are looking bad without removing hope is, as far as I can tell, an impossible tightrope act. Each family has their own length of despair, their own thickness of denial, and you have no idea what kind of rope you’re dealing with until you’ve lost your balance.

‘You’re always giving me such fucking horrible news,’ the gosling says to me, angrily, ‘can’t you even give me one good thi—’ but he’s coughing too badly to finish his sentence.

‘Your kidneys are doing okay,’ I offer.

‘Oh, well, that’s something,’ one of the younger geese says, ‘isn’t it?’

She’s ignored by the others, who are, in their usual manner, trying to stare me down.

‘I think we need to discuss what you’d want done if things continue to get worse,’ I say.

‘No, Doctor, we don’t,’ says one of the older geese, I think it’s the one named Sheri, ‘because what’s making him sick is your pessimistic attitude. My brother’s going to get better and just because one drug didn’t work doesn’t mean that the next one won’t.’

I don’t say anything for a moment. I don't want a rapid back and forth. I allow silence to serve as a pressure valve to dissipate some of her anger.

‘I hope you’re right and he responds,’ I say, slowly, ‘but if—god forbid—he doesn’t, I don’t want you to have to make decisions in the heat of the moment. I’d like you to be able to talk about things.’

‘Doctor,’ another of the geese says, in a way that John Grisham would probably describe as steely, ‘he’s going to get better.’

I run a quick algorithm of the different possible conversations that could follow from this point. None of them lead to a good outcome. Sheri and the other geese are too powerless. Unable to hate God, I have become their enemy. They need a small victory, so I acquiesce and give them some control over the situation: I ask them if it’s okay to start the new antibiotic. I spell the name so they can look it up on the internet later. They give me permission to start it.


At the nurses’ station, I’m calling the ID fellow and asking her to see the patient, while trying to figure out how I can salvage some therapeutic relationship with this family.

I continue to think about their flightless form into the late afternoon when I run into the ID fellow. She tells me she was thrown out of the room entirely and the geese were refusing to let her come back.