internist, Herb Katz—an old friend and medical school classmate—had just completed
his examination and, as always, told Julius to dress and come to his office for a
debriefing.
Herb sat at his desk, rifling through Julius`s chart. «On the whole, you look pretty
good for an ugly sixty–five–year–old man. Prostate is getting a little swollen, but so is
mine. Blood chemistries, cholesterol, and lipid levels are well–behaved—the meds and
your diet are doing their job. Here`s the prescription for your Lipitor, which, along with
your jogging, has lowered your cholesterol enough. So you can give yourself a break: eat
an egg once in a while. I eat two for breakfast every Sunday. And here`s the prescription
for your synthyroid. I`m raising the dose a bit. Your thyroid gland is slowly closing
down—the good thyroid cells are dying and being replaced by fibrotic material. Perfectly
benign condition, as you know. Happens to us all; I`m on thyroid meds myself.
«Yes, Julius, no part of us escapes the destiny of aging. Along with your thyroid,
your knee cartilage is wearing out, your hair follicles are dying, and your upper lumbar
disks are not what they used to be. What`s more, your skin integrity is obviously
deteriorating: your epithelial cells are just plain wearing out—look at all those senile
keratoses on your cheeks, those brown flat lesions.» He held up a small mirror for Julius
to inspect himself. «Must be a dozen more on you since I last saw you. How much time
you spending in the sun? Are you wearing a broad–brimmed hat like I suggested? I want
you to see a dermatologist about them. Bob King`s good. He`s just in the next building.
Here`s his number. Know him?»
Julius nodded.
«He can burn off the unseemly ones with a drop of liquid nitrogen. I had him
remove several of mine last month. No big deal—takes five, ten, minutes. A lot of
internists are doing it themselves now. Also there`s one I want him to look at on your
back: you can`t see it; it`s just under the lateral part of your right scapula. It looks
different from the others—pigmented unevenly and the borders aren`t sharp. Probably
nothing, but let`s have him check it. Okay, buddy?»
«Probably nothing, but let`s have him check it.» Julius heard the strain and forced
casualness in Herb`s voice. But, let there be no mistake, the phrase «pigmented
differently and borders aren`t sharp,” spoken by one doc to another, was a cause for
alarm. It was code for potential melanoma, and now, in retrospect, Julius identified that
phrase, that singular moment, as the point when carefree life ended and death, his
heretofore invisible enemy, materialized in all its awful reality. Death had come to stay, it
never again left his side, and all the horrors that followed were predictable postscripts.
Bob King had been a patient of Julius`s years ago, as had a significant number of
San Francisco physicians. Julius had reigned over the psychiatric community for thirty
years. In his position as professor of psychiatry at the University of California he had
trained scores of students and, five years before, had been president of the American
Psychiatric Association.
His reputation? The no–bullshit doctor`s doctor. A therapist of last resort, a canny
wizard willing to do anything he had to do to help his patient. And that was the reason
why, ten years earlier, Bob King had consulted Julius for treatment of his long–standing
addiction to Vicodan (the physician–addict`s drug of choice because it is so easily
accessible). At that time King was in serious trouble. His Vicodan needs had dramatically
increased: his marriage was in jeopardy, his practice was suffering, and he had to drug
himself to sleep every night.
Bob tried to enter therapy, but all doors were closed for him. Every therapist he
consulted insisted that he enter an impaired physician recovery program, a plan which
Bob resisted because he was loath to compromise his privacy by attending therapy groups
with other physician–addicts. The therapists wouldn`t budge. If they treated a practicing
addicted physician without using the official recovery program, they would place
themselves at risk of punitive action by the medical board or of personal litigation (if, for
example, the patient made an error of judgment in clinical work).
As a last resort before quitting his practice and taking a leave of absence to be
treated anonymously in another city, he appealed to Julius, who accepted the risk and
trusted Bob King to withdraw on his own from Vicodan. And, though therapy was
difficult, as it always is with addicts, Julius treated Bob for the next three years without
the help of a recovery program. And it was one of those secrets that every psychiatrist
had—a therapeutic success that could in no way be discussed or published.
Julius sat in his car after leaving his internist`s office. His heart pounded so hard
the car seemed to shake. Taking a deep breath to quell his mounting terror, then another
and another, he opened his cell phone and, with trembling hands, called Bob King for an
urgent appointment.
«I don`t like it,” said Bob the next morning, as he studied Julius`s back with a large
round magnifying glass. «Here, I want you to look at it; we can do it with two mirrors.»
Bob stationed him by the wall mirror and held a large hand mirror next to the mole.
Julius glanced at the dermatologist through the mirror: blond, ruddy faced, thick
spectacles resting on his long imposing nose—he remembered Bob telling him how the
other kids taunted him with cries of «cucumber nose.» He hadn`t changed much in ten
years. He looked harried, much as when he had been Julius`s patient, huffing and puffing,
arriving always a few minutes late. The Mad Hatter`s refrain, «Late, late for a very
important date,” often had come to mind when Bob rushed into his office. He had gained
weight but was as short as ever. He looked like a dermatologist. Whoever saw a tall
dermatologist? Then Julius glanced at his eyes—oh oh, they seemed apprehensive—the
pupils were large.
«Here`s the critter.» Julius looked through the mirror as Bob pointed with an
eraser–tipped stylus. «This flat nevus below your right shoulder under your scapula. See
it?»
Julius nodded.
Holding a small ruler to it, he continued, «It`s a shade less than one centimeter. I`m
sure you remember the ABCD rule of thumb from your med school dermatology—”
Julius interrupted, «I don`t remember squat from medical school dermatology.
Treat me like a dummy.»
«Okay. ABCD.A for asymmetry—look here.» He moved the stylus to parts of the
lesion. «It`s not perfectly round like all these others on your back—see this one and this
one.» He pointed to two nearby small moles.
Julius tried to break his tension by taking a deep breath.
«Bfor borders—now, look here, I know it`s hard to see.» Bob pointed again to the
subscapular lesion. «See in this upper area how sharp the border is, but all around here on
the medial side it`s indistinct, just fades into the surrounding skin.C for coloration. Here,
on this side, see how it`s light brown. If I magnify it, I see a tad of red, some black,
maybe even some gray.D for diameter; as I say, perhaps seven–eighths of a centimeter.
That`s good–sized, but we can`t be sure how old it is, I mean how fast it`s growing. Herb
Katz says it wasn`t there at last year`s physical. Lastly, under magnification, there is no
doubt that the center is ulcerated.»
Putting down the mirror, he said, «Put your shirt back on, Julius.» After his patient
finished buttoning up, King sat down on the small stool in the examining room and
began, «Now, Julius, you know the literature on this. The concerns are obvious.»
