At one point in The Recovering, her remarkable new book on addiction and recovery, Leslie Jamison recalls being diagnosed with an arrhythmia and undergoing catheter ablation to correct the abnormality. After the procedure fails, her cardiologist keeps her in the hospital to load her on a powerful anti-arrhythmic therapy, sotalol. When Jamison is ready to leave the hospital, she notices a sticker on the bottle of sotalol, a cartoon martini glass with an overlying X. Do I really need to abstain from alcohol, she asks her cardiologist? The cardiologist answers yes without any follow-up, missing a crucial opportunity to screen for alcohol abuse. Jamison eventually “fails” sotalol therapy, although it’s hard to truly label this treatment failure as she doesn’t take the drug whenever she drinks, which is often. The cardiologist prescribes her a second line anti-arrhythmic therapy. Again the prescription bottle advises not to take the pills with alcohol, and again the physician doesn’t react when Jamison asks about whether alcohol really needs to be avoided with the new medication. Not surprisingly, the second line agents “fails” in the same vein as sotalol.
At a recent dinner with some other physicians, having just read this section of The Recovering, I shared Jamison’s arrhythmia story and asked the group, “Is this a particularly bad cardiologist, or do you think most doctors would have failed to pick up their patient’s alcohol problem?” The consensus from the group was yes and yes. “When you’re a hammer,” one physician explained, “all you see is a nail. So the cardiologist is focused on the arrhythmia. He’s not there to do alcohol screening. His job is to fix her heart, and all he cares about is having his patient follow his instructions so he can succeed.” This rationale seemed reasonable if not laudable.
And yet, while reading this episode and later discussing it with other doctors, I self-righteously held fast to the idea that I would not have made the same mistake as Jamison’s cardiologist. “Why do you ask?” I pictured myself saying to Jamison as she clutched her medication bottle. “How much do you drink?” I’d ask in quick succession. I’d have been able to help her, in other words.
And yet, when I read Jamison’s previous book, The Empathy Exams, I was moved enough by her essays to write about them in two publications, covering “In Defense of Saccharin(e)” for Hobart and the collection’s title essay for Essay Daily. I was dumbstruck by her essay (“Morphology of the Hit”) recounting the night of her 24th birthday, spent in Nicaragua. Walking home alone from a bar, an unidentified man runs up to her and punches her square in the face, breaking her nose and shattering her confidence in the decision to live and teach and be bold in that country. I loved the journalistic essays in the collection, including her coverage of an ultramarathon in Tennessee and a follow-up piece on visiting one of its runners in jail, as much as the personal essays. And I can’t listen to Joni Mitchell without thinking of Jamison’s essay on Morgellons disease. Never once reading and re-reading these essays did I think about the author’s alcohol use, but many of these events are retold in The Recovering under the umbrella of her addiction (the Nicaragua attack) or her attempts at sobriety (the ultramarathon reportage). I now felt guilty about how oblivious a reader I was of The Empathy Exams, about how I missed some key clues in her stories – why is a young woman walking home alone from a bar in a remote Nicaraguan village? When you’re a hammer, all you see is a nail, I reminded myself. I’d picked up the book as an essay lover, not a doctor.
And yet, when one of my closest friends from college called me up to let me know he was in a rehab facility, seeking treatment for alcoholism, I was surprised when I shouldn’t have been. Peter and his wife had stayed with me a few months earlier, sharing the basement of my house with their infant son in a Pack-n-Play. Every day they took the train into New York City, and every night they returned home to my suburban town for dinner with me and my family. One night, Peter headed back into the city after dinner, without his wife and child, to meet up with some friends from law school. At two in the morning, Peter’s wife knocked on my bedroom door. “Sorry to wake you,” she said, “but when is the last train home from Manhattan? Peter hasn’t come back yet, and he’s not answering his phone.” Eventually we located him. He’d fallen asleep on the train home and missed our stop. He was about 20 miles north of us, but he’d already called an Uber that was on its way. “He sounds so drunk,” I said with a smile after getting off the phone with him. “Typical Peter,” I added. His wife said, “I’m worried about him.” I responded, “Don’t worry. Uber is really good around here. He’ll be home soon.”
In both The Empathy Exams, specifically in the “In Defense of Saccharin(e)” essay, and in The Recovering, as she unravels the efficacy of Alcoholics Anonymous, Jamison argues that clichés serve a purpose by highlighting the common elements in our stories, the tropes that bind us together as fellow humans (it is hard to write a sentence about clichés without employing clichés, it turns out). In her saccharine essay, which is mostly about nostalgia, Jamison quotes Milan Kundera in The Unbearable Lightness of Being: “Kitsch causes two tears to flow in quick succession. The first tear says: How nice to see children running on the grass! The second tear says: How nice to be moved, together with all mankind, by children running on the grass!” And in both her essay collection and her newest book, she is focused on this idea of being moved, thinking and feeling and connecting, “together with all mankind” even if the only route to such connection is via clichés.
That night discussing Jamison’s failed antiarrhythmic therapy and her cardiologist’s inability to pick up on her alcohol abuse wasn’t the first time I’d heard a doctor say, “When you’re a hammer, all you see is a nail.” Doctors often throw this phrase around when we explain missed diagnoses or a surgeon’s refusal to consider non-operative therapies or even a patient’s insistence that her headache is due to a brain tumor. But we’ve also employed this cliché to describe how we don’t turn off our doctoring outside the hospital or clinic. We wonder aloud if our neighbor has a pituitary tumor. We tell our uncle he will die of a heart attack before he retires if he doesn’t lose fifty pounds. We comment on the salt or fat or carbohydrate content of meals. We speculate on why some of our kids’ friends are always covered in snot.
And yet, and yet, and yet. I failed to recognize my friend’s drinking problem, and I completely blew off his wife’s attempt to enlist my help. I was no better and likely far, far worse than Jamison’s cardiologist. I can only take comfort in another cliché – he wasn’t ready then to ask for help, which is what Peter’s wife told me when I apologized about my behavior that night he’d passed out on the train. I hope she’s right.
We teach medical students to ask patients whom they suspect of alcoholism a series of questions called CAGE: Have you ever felt you needed to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about drinking? Have you ever felt you needed a drink first thing in the morning (Eye-opener)? Two affirmative answers on this questionnaire are usually indicative of significant alcohol abuse. The problem with CAGE, though, is that we leave it up to the medical student, and the doctor he or she eventually becomes, to have enough clinical suspicion to launch into the questions. This is probably why so many missed opportunities arise, whether it’s Jamison asking questions about sotalol or my friend’s wife being reassured about the efficiency of Uber in Westchester County. Our clinical suspicion is not that trustworthy.
Requiring every patient to undergo substance abuse screening is a possible answer. In fact, most electronic medical software now obliges the physician, filling out a note on his or her patient, to check off boxes indicating whether there’s any misuse of tobacco, alcohol, or illicit drugs. Still, there are obvious pitfalls to this system, including patients concealing their use and physicians so busy that they don’t press for further details if a patient says “rarely” or “socially” to questions about alcohol use. When I was a medical student, we were encouraged to attend AA meetings, to experience the variety of ways alcoholism can present. If I were running a medical student course, I’d continue this tradition and also encourage the students to read The Recovering, which (as Jamison points out in her Acknowledgments) is constructed to work like an extended AA meeting in its provision of so many individual tales of addiction and recovery.
But I’d also bring in as many doctors as I could find who’d be willing to share their own stories of not recognizing alcohol abuse in patients, friends, and family members. I’d want the students to hear story after story of doctors failing sick people who needed their help. When the last doctor had concluded telling his or her tale of failing a patient, I’d get up in front of the lecture hall and close the session with arguably the most important cliché in all of medicine: We learn more from our mistakes than our successes. It turns out this cliché is not unique to doctors. Towards the end of The Recovering, when Jamison visits a lawyer in recovery, she sees a piece of framed calligraphy hanging on his wall: “Alcoholics anonymous is not a history of our personal success stories. It is, rather, a history of our colossal failures.” I’d argue that the “our” in that last sentence applies not just to the addicts but everyone in the addicts’ orbits, including doctors.
Andrew Bomback is a physician and writer in New York. His book, Doctor, will be released from Bloomsbury this September.