Chapter 1: Makayla
Oh no! No, no, no, no!
I stared at the faint line on the pregnancy test I’d just taken in the bathroom at work. I tilted the stick and looked at it from a different angle. And then another. The blue vertical line remained visible.
I gripped the pedestal sink hard as the reality of the situation hit me like a sucker punch to the gut. The possibility that I might be pregnant had entered my mind about a week ago, even though I was on the pill and hadn’t missed my period yet. A woman who’s been pregnant before knows such things, never mind a doctor.
But this was not supposed to happen. Not now. This was not part of the plan.
“Damn it, Makayla,” I whispered accusingly to my reflection.
You can do this, she shot back.
I wasn’t so sure I could, but I had no doubt she could. The woman in the mirror was formidable. With her flawless makeup, expensive ivory silk blouse, tailored black skirt, and high heels she’d be wearing for at least the next eleven hours, she would handle this as if it were nothing more than a tiny hindrance designed to challenge her. She loved challenges. She ate challenges for breakfast. Even her wild mane of curly black hair had been tamed into a low bun with no more than twelve pins and four combs. Determined dark-brown eyes in a rich caramel face stared back, reminding me of how much we had already come through, and I exhaled. We could do this. We would do this.
I let go of the sink and straightened up, pausing a moment to let the wave of nausea pass. I wrapped the pregnancy test in a paper towel, but before I could toss it into the trash can, I felt my phone vibrate where I’d clipped it to my skirt. I unclipped it and, glancing at the screen, saw a message from my husband, Jason.
Jason: Hi, hon, I hope you haven’t forgotten about Kiara’s belt test. Are you coming home first or meeting us at the dojang?
Instantly annoyed, I threw out the pregnancy test and typed a quick reply. There was nothing wrong with my memory. If I had missed Kiara’s last two tae kwon do belt tests, it was because I was busy with work.
Me: I blocked off my last appointment slot to make sure I finish on time. I’ll meet you there.
I returned the phone to its clip. I left the bathroom and walked to the break room where I poured the rest of my coffee into the sink. I couldn’t stomach the pungent smell, and it tasted like cardboard.
“Dr. Jackson, this is your medical student, Elizabeth.”
I whirled around, instantly putting on my professional face as my receptionist, Jessica, ushered a young woman into the room and then promptly returned to her duties. The student appeared to be in her early twenties. She wore a black sweater dress under her short white student-doctor coat and clutched a large black doctor’s bag. The bag gave her away as a first-year student. As students progressed in their training and increased their knowledge and confidence, they clung to fewer and fewer manuals and cheat sheets until their tools fit around their neck and in their pockets.
One of my many duties as an assistant professor of medicine at Harvard Medical School was teaching students as they shadowed me in my office. Teaching was key to my career goals, and I normally enjoyed it, but given how I felt and the shocking confirmation of my pregnancy, I feared today might require extra patience.
“It’s nice to meet you, Elizabeth.” I summoned a smile and stepped forward to shake her hand. “Please have a seat.” I indicated one of the chairs at the small round table in the middle of the break room and then sat myself.
“Would you like a doughnut?” I asked, gesturing toward the box on the table. I always picked up treats on Monday mornings for the staff, but today I had been unable to stomach the glazed doughnuts.
Elizabeth declined. Was that a disapproving look? She looked fit. Probably ran five miles every day and was likely wondering why a doctor, someone charged with preserving health, had doughnuts in her office. She had no clue yet what it took to get through a day in a medical office.
“How about coffee? Tea? Water?” I offered, praying she wouldn’t choose coffee.
“Nothing, thank you.” She seemed quite nervous. It was May, so she’d been in medical school for nine months already, but this was likely her first venture outside the classroom.
“So, tell me a little about yourself, Elizabeth.” I forced thoughts of my unexpected pregnancy to the back of my mind and looked my newest trainee over.
Elizabeth shifted in her seat. “I’m in my first year at Harvard, and I’m starting to explore various fields in medicine before I have to select my clinical rotations next year,” she said. “Thank you for letting me spend the month in your office. My housemate, Aya, really enjoyed working with you last year.”
“You’re welcome. It’s no hardship at all working with such bright students.” I glanced at my watch. “We’d better get going. It’s almost time to see the first patient.”
I led Elizabeth out of the break room and down the hall to my office.
“Here we are.” I sat in my chair, directing Elizabeth to the seat on the other side of the desk. “We have a full day today: twenty-two patients scheduled and room for sick patients to schedule same-day visits. Monday is usually our busiest day.”
Elizabeth nodded and glanced around my office. “You have a beautiful office,” she said.
I had invested time and money to decorate my office and make it comfortable given how much time I spent in it. During a light week, I only spent about sixty hours at the office. But in the last two months since the dean of students at Harvard Medical School had mentioned that three associate professor positions had become vacant, I had doubled the time I spent teaching students and writing about my asthma research for publication in peer-reviewed journals. I served as chair of the Student Clinical Rotations committee at Boston General Hospital, a Harvard teaching hospital. Now I was averaging about seventy hours a week at work, to my husband’s great displeasure.
I looked around the office now and tried to see it through Elizabeth’s eyes. I’d chosen an African theme, inspired by a rotation I did as a medical student at the Albert Schweitzer Hospital in Gabon in central Africa. Beige zebra-pattern curtains hung at the single window, and were currently pulled back to let in the spring sunshine and the soft sounds of distant cars. A beautiful desk lamp with an African-inspired base sat on my desk. I had also picked up a few sculptures made by a local Gabonese artist, and these now stood scattered between my “vintage” medical textbooks on the bookshelf. I’d hung my framed medical license on the wall directly across from my desk where I could see it every day and so I would never forget what it had taken to get it and what it would take to forget the shame and humiliation that came with it.
I leaned toward Elizabeth, hands clasped on my desk. “Before we start, I want to make two important points about doctoring that I make to all medical students.” I paused as Elizabeth shifted her gaze from the artwork around my office to give me her full attention.
“Tell me,” I asked, “what’s a doctor’s most important tool?”
Elizabeth answered quickly. “Her stethoscope.”
I shook my head. “Try again.”
“An intelligent doctor is a given. You don’t graduate from medical school and residency without a high level of intelligence. And, of course, a stethoscope is an important tool, but it’s not the most important one.”
She waited for me to reveal the answer.
“Show me your hands.”
She raised them up dutifully. She’d been blessed with solid, utilitarian hands. Maybe a future orthopedic surgeon, I thought.
“Those are your most important tools.” I looked intently at Elizabeth. “Touch is a vital thing. Babies die without it. Your patients and your career as a doctor will not thrive without it. Touch heals,” I continued. “I’m not talking about anything supernatural. You just have to touch your patients. It might be a handshake, or a hand on a knee or shoulder. A medical exam involves a patient letting you into their personal space, even though you’re often a stranger to them. You must reassure them that you’ll take care of them.” I paused. “Does that make sense?”
I stood and came around the desk to sit in the chair beside her. The touchy-feely part was over. My gaze and voice became hard.
“The second point is this: Medicine is hard. Not hard like you have to stay up late studying complicated physiology and pathology until your head feels like it’s going to explode. Not hard like you’ll have to work ridiculously long hours when you start on the wards, and you won’t get enough sleep, or exercise, or see your friends and family.” Elizabeth’s eyes were growing wider as I spoke, but I pressed on. “Medicine is hard because people will die if you mess up. It’s your job to study hard and work your tail off.” Because it’ll be your fault if they die because you didn’t do your job. My daily self-reminder did double duty today, also making a point to the medical student.
There was silence. I felt bad. My words had come out harsher than I’d meant, but it was my duty as Elizabeth’s teacher to instill this important mindset. And if she couldn’t handle it, if she wasn’t tough enough, then now was the time to walk away. I had learned that the medical field did not tolerate weakness.
Before I could say anything else, my nurse appeared at the door. “Mr. Pierce is ready,” he informed me.
“Thank you, Oscar.”
He nodded and left.
I returned to my chair and pulled up Mr. Pierce’s electronic chart on my computer. “Mr. Pierce has had recurrent bladder infections,” I explained to Elizabeth after quickly skimming the notes from his last visit. “That’s not normal at any age for a man and is especially concerning given that he’s in his sixties, so I sent him to a urologist. Let’s go see how he’s doing.”
I grabbed my white coat and stethoscope from the hook behind the door, slipped the coat on, and draped the stethoscope around my neck.
We walked to exam room one, and I pushed open the door, smiling at the thin, balding man who stood as we walked in.
“Hello, Frank,” I said.
“Well, hello, Doctor. And how are you this morning?” he asked as he took the hand I extended and held it in both of his.
“I’m good, thanks. This is Elizabeth.” I stepped aside to introduce her. “She’s a medical student at Harvard. I hope it’s alright with you if she shadows me.”
“I don’t mind one bit.” To Elizabeth, he added, “I have to warn you. She’s probably going to make me pull my pants down.”
Elizabeth smiled, embarrassed, as he chuckled.
“Hush now, Frank, and have a seat,” I said.
He opted to sit in one of the pair of chairs rather than on the exam table, and I took the stool by the computer stand but remained facing him. Elizabeth stood by the door.
“What did you think of the specialist I sent you to?” I asked Frank.
“He was a nice guy. He wasn’t as gentle as you are when he checked my prostrate.”
I winced. “Your prostate,” I corrected absently. “Have you been back to see him for your biopsy results?”
“Nah, I just got back from Lowell. My son just had another boy.”
“Congratulations! What is it, his fourth?” I shook my head in wonder.
“That’s right. His wife quit her job with AT&T. It’s going to take all her time to keep up with those four boys.”
“Bless her heart. Is your son still with the pension administration plan?”
“Yes, he is. You got a good memory, Doc.”
“I listen, even when you try to talk my ear off.” I laughed.
Frank reached into a reusable grocery bag at his feet. “Judy baked banana bread this weekend. She made an extra loaf since she knew I was coming to see you today.” He pulled out something wrapped in a red-and-white-checked kitchen towel and handed it to me. I unwrapped a loaf of banana bread and got a whiff. Normally, I loved banana bread, but today my stomach revolted, and it took every ounce of self-control not to let it show on my face.
“Please tell your wife I said thank you,” I managed to respond.
I paused, bracing myself for what I had to say next. I hated this part of my job.
“I got a letter from the urologist, Frank. I’m afraid it’s not good news.” I rolled my stool closer and set a hand on Frank’s knee, at the same time as I handed the loaf to Elizabeth. “The biopsies show you have prostate cancer.”
In any other setting, it would have been comical how quickly and completely Frank’s expression changed.
“It’s cancer, Frank.”
He still looked confused, even as his eyes began to tear up. He took several deep breaths, trying to compose himself. “How bad is it?” he finally asked.
I chose my words carefully. “All prostate cancers aren’t the same. Some get bad very quickly and spread, while others don’t do much and eventually the patient dies of old age or something else. We try to make an educated guess about which way the cancer will go based on what we see on the biopsy. Yours has a low Gleason score, meaning we don’t think it’s going to be aggressive.”
“But we’re not sure.”
“No, there’s no way to know for sure.”
“So, what should I do, Doc?”
I sighed. “I can’t make that decision for you, Frank. You need to talk it over with Judy. But here’s what you need to know. We have two main options. One, we can do surgery and remove your prostate, and this will virtually eliminate any chance that the cancer will spread, but the surgery often causes the bladder to leak and difficulty having an erection.”
Frank’s eyes widened, and he swallowed hard.
“Or two,” I continued, “we can monitor you closely. I’ll see you every three months to do a prostate exam and check your prostate antigen blood level. If everything holds steady, we continue monitoring. If the exam or your levels get worse, then you can go for surgery. But it’s up to you.”
He nodded. He was quiet for a while, and I let him process. After a minute or two, he asked some specific questions about the treatment options and I answered as best I could, given the inherent uncertainty.
When Frank seemed to run out of questions, I made a suggestion. “Why don’t you come back later this week with Judy after you’ve had a chance to digest the news. We can all talk some more then.”
He nodded once again. He took a big, shaky breath and visibly made himself sit taller. “We’re gonna fight this, Doc.”
“I’ll be right there with you. Come on, I’ll walk you to the front.” With a final pat on Frank’s knee, I stood and led him out of the exam room.
After seeing Frank off to the lobby, I glanced at my watch and realized we’d spent close to half an hour with him, a little over the twenty minutes I allotted for each appointment. My patients appreciated me taking my time with them, and in return, they didn’t mind waiting on occasion.
Elizabeth and I walked back from the lobby to the work area in the center of the cluster of exam rooms. I stopped in front of my computer workstation and shook the mouse. My large monitor sat on a long counter, and I worked standing, which allowed me to move quickly between patients. Oscar worked directly across from me at a lower counter so he could sit and handle phone calls and paperwork. A few feet away was an identical setup for Soraya, the nurse practitioner, and her nurse, Cindy, although the area currently sat empty as Soraya was on vacation in India for the week making plans and purchases for her wedding in a few months.
Once my computer came on, I saw the next patient was ready for me. I opened her chart and read my previous notes on her.
The rest of the morning flew by in a blur of physicals, high blood pressure and diabetes checks, sinus infections, lab results, X-ray reports, and consult notes while fielding constant questions from my nurse and the front office staff regarding patient phone calls. Despite the busywork, the pregnancy was never far from my mind. I was distracted trying to figure out how to work it into my career plans, and, more than once, Oscar caught mistakes I almost made.
By one p.m., I was ready for a break. I sent Elizabeth to get herself some lunch, and after grabbing my salad bowl from the refrigerator, I escaped to my office and shut the door.
The nausea had thankfully resolved by now. I took a bite of crispy greens, carrots, and nuts in a light sesame dressing and closed my eyes to enjoy it. I hoped that food would tame the relentless pounding that had started behind my right eye two hours ago. Since my residency training, I had suffered from frequent migraines. I didn’t know if this headache was from the pregnancy, caffeine withdrawal, or just one of the many headaches that came from practicing medicine. There was always so much to do: patients to see, continuing medical education to do, families to support, careers to preserve and advance. I’d almost lost it all once before, and I couldn’t let it happen again.
I opened my eyes and looked out my window. I’d jumped at the chance to work in this office after finishing residency four years ago at the age of twenty-eight. The handful of square miles that comprised the Longwood Medical and Academic Area arguably housed the greatest hub of scientific and medical centers of excellence in the world and the gifted individuals who worked there: Harvard Medical School, four teaching hospitals, a diabetes research center and clinic, several colleges and graduate schools, and biomedical firms. My office, located in the Fenway Park neighborhood, was one of a dozen in the area operating as Partners HealthCare, which was owned by Boston General Hospital, a large, prestigious tertiary care hospital.
I fished out a bottle of extra-strength acetaminophen from my purse. I took two pills and washed them down with a glass of water. Hopefully, the headache would be gone by the time I had to face screaming kids and their overzealous parents at the tae kwon do school.
In light of my frequent headaches, I had set up my office to be as relaxing as possible. Even now, I could smell the very faint scent of gardenia oil gently diffusing throughout the small space. The overhead fluorescent light was too jarring, so the lamp on my desk was the only source of additional light beyond that which came through the window.
After a few minutes, the headache dimmed as a glimmer of a plan began to pierce the fog I’d been enveloped in all morning. If Jason knew about the pregnancy, he would undoubtedly try to stop me from going for the promotion. There was no doubt that becoming an associate professor would increase the demands on my time. It was a good thing Jason was a stay-at-home dad. He’d complain even more about me not being home enough, but I knew he could handle Kiara and the new baby.
Jason was a wonderful dad and a great spouse, even if he didn’t fully understand what it took to have a successful career in medicine. Lately, we seemed to be arguing all the time about my work. I would spare us both another argument and tell him about the pregnancy after I had secured the promotion. And who knew? There might not be anything to tell. A number of pregnancies were lost within the first few weeks. I forcibly pushed back the morbid thought. I just couldn’t pass up this opportunity.
I finished my salad and glanced at my watch. I really didn’t have the time, but I needed to make a phone call.
After the usual automated message and a mercifully short wait, a customer service agent picked up the call.
“Thank you for calling FedLoan Servicing. This is Deepak. May I have your name please?”
I provided the necessary information to identify my student loan account.
“I’m calling regarding the last statement I received. I noticed I was assessed a fee of thirty-five dollars, and I’d like to figure out why.”
“It’s ‘Doctor.’ This title is why I owe so much money.”
“I’m sorry, Dr. Jackson. You were assessed that fee because we didn’t receive a payment from you last month.”
“That can’t be.” I was meticulous when it came to all things financial. I handled all the household accounts and paid the bills myself. “I’ve paid every month on time for the last four years.”
“Except for last month. Now, I don’t see any previous penalties on your account, so as a courtesy, I will remove this charge. Would you like to go ahead and make the overdue payment?”
“Yes, I would.” While Deepak navigated to the payment page, I racked my brain for what could have happened. I had a fleeting recollection of a headache so bad a couple of Sundays ago, I’d had to abandon my paperwork and go to bed. The next morning, I’d forgotten about the bill I’d been in the process of paying but apparently never actually did.
Deepak’s voice penetrated my thoughts. “How would you like to pay?”
I gave him my bank details.
“Thank you, Dr. Jackson.” Deepak processed my payment. “Your remaining balance is now $215,182.35.”
I winced. My income was good, but between the loan payments, a Boston mortgage, and being the sole breadwinner, I couldn’t afford to slack off at work. I thanked Deepak for his assistance and hung up.
A few minutes later, Elizabeth returned from her lunch break, and we got on with the afternoon session. By four forty, we were done seeing patients. I signed off on the last of the medication refill requests and set it in my outbox for Oscar with a sigh of relief. I sent Jason a text to let him know I was leaving the office. As I hung up my white coat behind my office door, the phone on my desk rang. I debated for a moment not answering. I really didn’t want to miss Kiara’s belt test, but it was technically still business hours. I sighed, leaned over my desk, and picked up the receiver.
“Dr. Jackson, Dr. Smith here.”
I groaned internally. The chief medical officer calling was never a good thing.
“I wanted to let you know that I’ve e-mailed you your metrics report for the month, and you’re not at target for several items,” he said. “Please have a look at the report. We’ll discuss it during our meeting tomorrow.”
I sighed. I had thought graduating from residency meant the end of getting grades, but I was wrong. Over the last several years, physician practices had been coming under increased oversight via measurements meant to ensure that physicians were practicing quality evidence-based medicine. Essentially, it was a way of micromanaging the doctor-patient relationship and left many physicians—myself included—frustrated. I was perfectly capable of providing excellent care to my patients without someone looking over my shoulder, ready to slap my knuckles with a plastic ruler for the slightest oversight or if I deviated from “guidelines.” I’d had enough of being supervised.
“I’ll take a look at the report,” I said reluctantly.
“See you tomorrow, then.” He hung up.
I came around my desk, sat back down, and fired up my computer. As I perused the report, I became increasingly embarrassed. I had been a straight-A student in college and had graduated summa cum laude from medical school. I’d gotten derailed during residency in spectacular fashion, and I had been working very hard since to make up for it. Failing to meet all the criteria for the quality metrics was unacceptable.
Before long, I was immersed in the report, analyzing where I had come up short, and making notes about how to address the deficits. Rather than embarrassed and apologetic for my nonperformance, I intended to show up tomorrow at the meeting with Dr. Smith ready to prove to him just how committed I was to my work, my patients, and the organization. This meeting with Dr. Smith was an important one. In addition to discussing my annual bonus and salary increase, I needed to secure Dr. Smith’s support. Without a strong recommendation from my department chief, my application for associate professor was dead in the water.
I became aware of a persistent vibrating sound coming from my purse. I pulled out my phone and noticed with a start that an hour had passed. There was a text message.
Jason: Where are you?