

### Healer's Choice

### Michael Costello

Healer's Choice

Copyright © 2014 by Michael Costello.

Smashwords Edition

All rights reserved. No part of this book may be used or reproduced in any manner without written permission except in the case of brief quotations embodied in critical articles or reviews.

This is a work of fiction. All of the characters and events portrayed in this novel, while entirely plausible and medically intended to be possible, are not real.

To those young people who would be healers—students of medicine, nursing, physical therapy, chiropractic and pharmacy. To those would seek to teach them. To those who love them as family and those who fall in love with them.

### Contents

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Chapter 13

Chapter 14

Chapter 15

Chapter 16

Chapter 17

Chapter 18

Chapter 19

Chapter 20

Chapter 21

Chapter 22

Chapter 23

Chapter 24

Chapter 25

Chapter 26

Chapter 27

Chapter 28

Chapter 29

Chapter 30

Chapter 31

Chapter 32

Chapter 33

Chapter 34

Chapter 35

Chapter 36

Chapter 37

Chapter 38

Chapter 39

Chapter 40

Chapter 41

Chapter 42

Chapter 43

Chapter 44

Chapter 45

Chapter 46

Chapter 47

Chapter 48

Chapter 49

Chapter 50

Notes and Acknowledgements

"In large part, we are teachers precisely because we remember what it was like to be a student. Someone inspired us. Someone influenced us. Or someone hurt us. And we've channeled that joy (or pain) into our own unique philosophies on life and learning and we're always looking for an opportunity to share them—with each other, our students, parents, or in our communities."

―Tucker Elliot

Chapter 1

My _abuela_ always told me that gambling was risky and that by engaging in it there might be unforeseen life-altering consequences.

I'm not sure about the risky part but she couldn't have been more right about the consequences.

My name is Carlos Ramon Sanchez y Vega and here is my story:

_Abuela's_ warning was the farthest thing from my mind as three of my fellow students and I took a rare break at the start of our fourth year of medical school. Poker was a great way to relax because you could play for thirty minutes or three hours, you couldn't lose much money (twenty five cents maximum bet and no more than three raises per card) and we spent much of the time discussing erudite intellectual matters like girls, sports and...did I mention girls?

It would not be an exaggeration to say that this poker group featured some of the stud members of our class at Midcentral State University College of Medicine. At my left, Tyler Fitzhugh Simmons IV came from a long line of high-profile doctors. I think there are actual cave paintings with one of his ancient blond-haired blue-eyed ancestors performing a Paleolithic surgical procedure and driving the primitive equivalent of a Lexus. Tyler went to Yale and had Hopkins medical school in his sights but he became infatuated with a very hot classmate and his grades slipped quite a bit. He was waitlisted initially at Midcentral but finally got the call and spent every waking moment since convincing everyone that he was a _Simmons_ , by God, and he was going to be the best neurosurgeon since Ben Carson.

At my right sat Gomedalu Adeyei. "Gomey" was from Africa and was barely visible behind the enormous stack of quarters that he seemed to amass at every game. He absorbed information like one of those infomercial sponge mops but more importantly could apply everything he learned so quickly that I think the professors stayed up late at night trying to stump him—and rarely succeeded. At well over six feet tall with studiously handsome features, Gomey was enormously popular, was elected class president and eventually wanted to do transplant surgery.

Across the table was Courtney Schwartz. Courtney did undergrad at Amherst and expected to go to one of the big gun medical schools like U Penn in her home state, but her dad died after a long and very expensive illness and the funds dried up so she wound up at Midcentral to avoid deep debt. As with so many women I had met in medicine, she was very attractive but didn't want to let you know it. Courtney had perfected the art of wearing the least flattering glasses, clothing and make-up possible and even adopted postures and expressions which continuously broadcast the message, "I am a serious professional, boys, get any other thought completely out of your heads." At this, she had considerable success. In her academic work, she was a laser beam. Courtney was the nuts and bolts blood-and-guts type in the group and she was bound and determined to be an orthopedic surgeon specializing in joint replacement.

It was Courtney who, after raising the bet on what appeared at best three of a kind, asked the big question, "So, Vega, what rotations have you planned for this year?"

"Schwartz, you need to learn to bluff better," I chided her as I called her raise. "Actually, I am doing Neurosurg at Mayo, Emergency Medicine at Georgetown, Plastic Surgery at Hopkins, Orthopedics here at Midcentral and Trauma at Metro Health."

Tyler called her bet, then reminded me with undisguised sarcasm, "Hey Vega, don't forget about the highlight of your fourth year, the best two months of your life, Excitement City..."

"Oh grow up, Simmons, it's called Family and Community Medicine and in case you forgot, it's a _requirement_ for graduation at our fair university so we all have to complete it".

Gomey folded his cards which meant he probably had a straight flush but just didn't want to show off. "I have heard there is one preceptor for that rotation who isn't a complete waste of time..."

"Oh sure," I interrupted, "I've heard about that guy...what's his name? Greco? Isn't he retired and or more likely fossilized yet?"

Schwartz showed her cards, "You're all calling me---can anyone beat four jacks? Actually, Greco is still precepting and I've heard he's decent. Why don't you sign up for his rotation, Vega? Or are you afraid you might get too tempted by wiping runny noses and holding old ladies' hands for the rest of your career when he talks you into taking over his practice in family medicine?"

I only had a ten high straight in my hand. So not only was this woman taking my very valuable loose change, she was questioning my honor. There was no way some small-town rinky-dink family doc was going to talk me out of my dream of a career in something heroic like trauma surgery. I could still remember the day I decided to be a doctor. I was volunteering at my local hospital and one of the oncologists who knew my Dad offered to let me "shadow" him for a day. We saw one little girl who was finally turning the corner after a number of rounds of really nasty chemotherapy for her leukemia. She had seen so many doctors and nurses that she didn't know who was who. She looked up at me from her bed and said, "Are you the doctor who saved my life?" As I blinked back tears, I told her I wasn't, but I vowed then and there that someday, I would be someone who could.

But I didn't know any heroes in the nose-wiping business.

"Okay Schwartz. I accept your challenge. I will call Greco tomorrow. And on Match Day you will all eat my dust when I accept a position at a more prestigious residency than any of you clowns could even dream about—and no hand-holding will be involved!"

Chapter 2

And so it was that at the start of my fourth year of med school, I found myself driving into the foothills of central Maryland to a small city to spend two months with Albert Greco, M.D. Dr. Greco was sixty-five years old and my hastily compiled brief dossier (based on interviews from students who worked with him previously) was as follows: Reasonably smart guy who knows something about all facets of medicine but can't (or won't) use electronic medical records. Went to Swarthmore undergrad graduating _summa cum laude_ , got his M.D. from Midcentral State U Med School, did family practice internship and residency then served in the Army for a few years and then practiced family medicine ever since in the same town.

Now as I pulled into the parking lot of his modest office, I was figuring the old guy was probably something in the early Pleistocene period, but by now my knowledge base should pretty much allow me to academically run circles around him. I mean, how could he possibly keep up with even the basics of internal medicine, pediatrics, gynecology, orthopedics, dermatology and geriatrics much less the more in-depth specialties like cardiology, infectious diseases and so on?

Unfortunately, my first day had a rough start. As I finished navigating my way to his office, my attention was glued to my GPS instead of the ancient Honda Civic in his parking lot and sure enough I rear-ended the vehicle. Fortunately, I was only going about 3 MPH and the damage to both cars was minimal. I was more embarrassed than anything else to have started the day with a collision with one of the doctor's patients. All I could think of was, "wouldn't it have been awful if I had hit one of the _doctor's_ cars?" But of course a physician's ride would be a BMW or Infiniti or something, right? The car I hit was clearly owned by someone of more modest means.

At that point, I saw the driver was a distinguished older gentleman who seemed neither impoverished nor wealthy and was plainly dressed and not the slightest bit intimidating. I started to chuckle to myself as I realized there was nothing to worry about. I had a simple fender-bender with a nice senior citizen who did not seem prone to road rage. What possible consequences could this simple lapse in concentration have?

The driver of the car got out and was remarkably calm. We exchanged insurance information and everything was going well until with a start and a sinking feeling I recognized the name on the insurance card:

Albert J. Greco, M.D.

Chapter 3

I waited in Dr. Greco's office while he made us both a cup of coffee. I was convinced that my promising career in medicine was coming to a premature and humiliating end. He returned with the file from my first 3 years of school and studied it intently.

"It says here that you have top grades in every course and rotation since you got to Midcentral," he noted, "Good thing they don't have a driver's education rotation," he added with a twinkle in his eye.

"Uh, yes sir, I placed out of that," I tried to joke back.

"Well, this rotation is a little different than what you've had up until now. I don't expect to convince you to choose family medicine as a career. I do expect you to learn how to diagnose and treat patients with your eyes and ears and hands as much as with lab tests and CT scans. I also expect you to learn that gaining a patient's trust is as powerful a tool in healing as any medicine or surgery. I expect you to respect a patient's choices even when they wouldn't be the ones you would make. Finally, I want you to learn that it isn't what you don't know that can trip you up in medicine, _but what you don't know that you don't know"_.

Wow. "Okay, Sir, I can handle that," I ventured.

"Great", he replied, "here's our schedule. At 6:30 AM we meet at the newborn nursery at Memorial Hospital to see any babies. By 7:30 AM we arrive back here at the office to review morning lab and imaging results like xrays, CT scans, ultrasounds and so on. At 8:30 AM the first patient arrives. You will see some patients with me in the beginning. Once you see how our office operates, you will interview and examine some patients then present them to me and tell me what you think is wrong and what you propose in terms of testing and treatment. We eat lunch from 12:30 to 1:30PM although much of that time will be spent reviewing phone messages that have accumulated while we were seeing patients. From 1:30PM until 4:30PM we will continue to see patients. From 4:30PM until about 6PM we will review the afternoon phone messages, labs and xrays etc. All patients will be advised that you are a doctor-in-training and asked if they mind seeing a student doctor under my supervision. Any questions?"

"No sir", I replied.

"Alright then," Dr. Greco said approvingly. "Here is your ID card for the rotation. You will notice it has the same photo as your med school ID and is labeled 'Dr. Vega Physician in Training'. I have lots of students that come through here and my patients know what that means. You will be addressed as 'Dr. Vega' because I want you to understand that you are a part of the team and not just an observer. Is that clear?"

"Absolutely."

"Good. Now that the 'bumper cars' and introductory portions of the rotation are completed, let's go over to the hospital to check on the newborn nursery, shall we?"

As I felt a hot red blush creep over my face yet again I wondered if I was ever going to get to live that that down...

Chapter 4

On the short drive to Memorial Hospital, Dr. Greco showed me some of the highlights of the town I would call home for the next two months. The old main street featured bustling sidewalks filled with restaurants and shops. The Civil War era town hall and even older historical buildings in the town center were nicely preserved. I was impressed with how vibrant and alive everything was. I was not so impressed with the less-than-historic Honda Civic he owned. How could this prosperous physician drive such a hunk of junk?

We parked in the garage and headed directly into the newborn nursery. Dr. Greco had explained that over time he had turned over the care of most of his hospitalized patients to specialists called hospitalists who spent 100% of their time doing inpatient care—a national trend in all but the most rural areas. He continued to see patients in the newborn nursery in order to not lose his skills with younger patients. As for me, I had done a required pediatric rotation as a third year medical student but our experience was very high-tech and therefore was centered on the neonatal intensive care unit where the babies were very sick or premature. I think I examined one or two normal newborns for about five minutes before being hustled off to a 500 gram infant that I could barely recognize for all the monitors, tubes and IV's attached to it.

I was very relieved to have what I anticipated would be an idyllic experience with a normal newborn and his or her mother. I expected to walk into a pink wallpapered hospital room filled with flowers and balloons overseen by a proud beaming mother holding a sleeping peaceful infant with harp music in the background watched over by an ecstatic father maniacally snapping an endless series of photographs.

Well, that didn't exactly happen.

We were greeted by a very no-nonsense nurse with a furrowed brow who said in a concerned voice, "Dr. Greco, you're going to _have_ to have a word with Mr. and Mrs. Katz. They are not adjusting well, if you know what I mean.

We entered the exam room after reviewing the records, scrubbing and gowning to see a red faced newborn at full screaming volume and two terrified parents.

Dr. Greco strode into the room and said, "Hello Mr. and Mrs. Katz. So good to see you again. This is student Doctor Vega. Congratulations on your new addition. What is her name?"

"Dr. Greco, I am so glad you're here," Mrs. Katz literally sobbed, "her name is Elizabeth and I am afraid I am a complete failure as a parent on the very first night!"

"Oh, Mrs. Katz, I'm sure it isn't as bad as it seems. What makes you feel that way?"

"Well, Elizabeth is our first, as you know. I have gone to all the classes and read all the books. I am absolutely determined to breast-feed. And yet she was up all night crying because she is so miserable and hungry and not getting anything. Look at her!"

I had to admit that was one angry-looking newborn. However, even with as little experience as I had, my inner voice was telling me that she wasn't really suffering either.

Dr. Greco walked over to the bassinet and did the first of what I would later call "Greco Scans". It was as if he was observing and processing a thousand different pieces of data just by intently looking at a patient for about 10 seconds. I had the sense he had concluded that this was not an ill infant.

Then, he casually picked up the child in a way I had never seen before. He scooped her up first in the usual way but then draped her over his right arm with her chin cupped in his palm and her cheek bones supported by his thumb and index fingers. She was literally lying over his forearm on her tummy with her legs and feet pointed toward the crook of his elbow. Dr. Greco completed the effect by gently rubbing her back with his left hand.

He was carrying her like a _football._

And she had stopped crying completely. Elizabeth had her eyes wide open and was about as awake, content and alert as a newborn can be.

Everyone in the room relaxed, especially Mr. and Mrs. Katz.

"Mrs. Katz," he said softly, "babies are designed to get absolutely nothing by mouth until your milk comes in, no matter what people tell you. She was crying as a signal to get you to nurse her again. The more you nurse—to a point—the faster your milk will come in. You should nurse her as the nurses instruct on each side. In between times, she can suck on the pacifier and be rocked and held and comforted in the way I just showed you or other ways until the next feeding in two hours. Is it possible that you won't produce enough milk or that there will be some other barrier to breast feeding? Sure. But the great majority of the time, if you just nurse frequently and have faith in the process, you will be successful. Elizabeth is a fully mature healthy newborn."

"But what if I _can't_ do it? What if I give up and feed her...dare I say it...FORMULA?"

"Then Elizabeth will grow and develop into a wonderful woman and you will feed her formula but it will remain our little secret."

After an exhausted but nervous laugh was elicited from Mr. and Mrs. Katz, Dr. Greco completed his admission exam of baby Elizabeth and showed me all the wonders of the normal newborn physical. We answered a slew of typical first-time parent questions and did some more reassuring before letting them know we would return the next morning.

Before we could leave the hospital, Dr. Greco had to enter his encounter with the Katz family into the electronic health records system. I could tell this was something he wasn't looking forward to (something about the comment he made under his breath about computers being the "devil's spawn", I think?). Anyway, I offered to enter the findings since I was familiar with the same EHR software system from my last rotation. He gruffly agreed that if I insisted, I could do so, even though it was technically against hospital policy. As I tapped away on the keyboard I was almost certain I detected a sigh of relief when he was able to step away from the computer...

Chapter 5

Back at his office, Dr. Greco and I began to see the daily schedule of patients. My first surprise was how much more complicated they were than I would have predicted. My fellow students certainly had never worked with Dr. Greco when they commented on the runny nose aspect of his practice. We were combing the literature with almost every patient to make sure that we were considering every possible cause for a given symptom, every conceivable treatment for a given disease and innumerable interactions between different medical conditions and medications—since all of his patients seemed to have endless numbers of medicines and diseases!

After lunch, my esteemed preceptor was ready to turn me loose to see a few patients on my own. I wasn't nervous, not only because I knew he would be reviewing everything and was the final decision-maker but in the end I was still convinced that my fund of knowledge was as good as it got. I wasn't going to let some dinosaur who was intimidated by a simple computer get the best of _me_.

My first patient was a slam-dunk, I figured. She was a 22 year old waitress with a urinary tract infection. She came into the office having already been seen at an urgent care center for pain with urination. They gave her an antibiotic called macrodantin and sent her on her way. Three days later, she was no better. No problem, I figured. Just give her a prescription for something stronger like ciprofloxacin and move on to a real challenge. I even noted that she had a 101 temperature so she probably had pyelonephritis, a _kidney_ infection. No wonder the macrodantin didn't do the job. I did a quick exam and while she had no tenderness over the kidneys and a urinalysis showed no white blood cells and no other chemical indicators for infection, I wrote that off to the antibiotic being in her system. I couldn't quite explain one other finding either. Why was she complaining of swollen glands in her groin?

I excused myself from the exam room and presented my findings to Dr. Greco. He did not give me a congratulatory high-five. He did not teach me the secret family medicine handshake. Instead, he said, "Dr. Vega, what other symptoms of urinary tract infection did this patient complain of? Did she have frequency or urgency?"

"Um...I didn't ask"

"And how often is urinary tract infection associated with inguinal adenopathy? Did you consider examining those nodes with me and a nurse to take that into account in your final diagnosis?"

"Well...not exactly"

"What other disease entities might present with urinary pain, inguinal adenopathy and fever?"

"I don't know"

"THAT, Dr. Vega is the BEST part of the presentation you've given so far," Greco opined as he marched me back into the exam room.

He introduced himself to the waitress who had just become a lot more clinically interesting. Her history went something like this: "Well it hurts, ahem, down there pretty much all the time but a lot more when I pee. I told the doctors at urgent care that but they were convinced so fast that it was a urine problem that they had me out of there pretty quick. The lumps in my groin and the fever came on at the same time. I'm embarrassed to say this but it hurts even to wear underwear because when it touches near where my urine comes out it _really_ hurts."

"What do you think we should do next, Dr. Vega?" came the inevitable query from the man who was making me look like I should re-do my third year rotations.

"A pelvic exam, sir?" I squeaked.

As expected, the ensuing pelvic exam revealed white ulcers with red borders indicating a prime grade A case of genital herpes.

"Any thoughts on treatment, Dr. Vega?" Finally, he was giving me a big juicy fastball over the middle of the plate.

"Valtrex 800 mg three times daily for 7 days for the patient. A little more review reading for me, Sir."

Dr. Greco allowed me a very slight approving nod.

I finally hit one into the gap for extra bases.

Chapter 6

I drove back to the medical student housing at Midcentral that night after 7PM. It had been a long day. As I glanced over the steering wheel at the sun setting over the farms and fields along the way, I thought about how I got here in the first place.

My story might sound much more romantic if I were the son of struggling immigrant parents and the first of my family to go to college. Romantic, but not true. My father is a mechanical engineer who graduated from Purdue and my mother a very good music teacher and accomplished musician in her own right who might have made it as a performer if she hadn't decided to be a stay-at-home mother to take care of yours truly. I do speak decent Spanish but mostly at the insistence of my mother's mother, _mi abuela. Abuela_ did emigrate to the U.S but she didn't struggle either. Her husband had a very successful fruit export business in central America, thank you very much, and they were happy and wealthy until the ruling party of that country decided that the members of my grandfather's political party should not have a measurable pulse or blood pressure and my grandparents felt that maintaining their business was less important than maintaining their vital signs. So one night they gave it all up to come to the U.S.

I grew up in a typical American suburb and went to a typical public high school and got typical straight A's. I chose Dickinson College because I wanted a high level liberal arts school with lots of flexibility in choices of study. Translation: I thought I was pretty smart but I didn't have a clue what I actually wanted to do. During my second semester freshman year, my roommate Jim did what many college frosh have done before him-he got mononucleosis. Unfortunately, he got it with all the trimmings including liver and spleen involvement and took weeks to get better. Frankly, I didn't like Jim all that much but I didn't get mono and I was the only one around that wasn't afraid to help him with meals, bring him his assignments and go with him to doctor visits. As time went on, I became fascinated with his disease process and that's how I started to get interested in the idea of going to med school.

Once in med school, things went pretty easy for me. I don't mean to sound arrogant here—I was just fortunate that my academic strengths were well-suited to the study of medicine. My knowledge of Spanish made learning medical terminology much simpler because a lot of that is Latin. I was never a math whiz but most of medical school science isn't quantitative so you don't need much math beyond algebra (though you are expected to know calculus for reasons I could never figure out). The first two years of med school are a lot like college. You study Anatomy, Physiology, Pharmacology, Biochemistry and other basic subjects. You read. You take notes. You take a test. You move on. The third year is required rotations involving hands-on patient care that everyone has to take like Medicine, Surgery, Pediatrics, Ob-GYN, Psychiatry, and things that introduce you to the broad world of medicine. The fourth year you take electives because that is when you are narrowing things down to which specialty you will study during residency. Residency is when you REALLY learn your craft. You emerge from medical school with the title _doctor._ But only after three to five or more years of additional training are you ready to be anything from a family doctor to a pediatric neurosurgeon.

Midcentral _required_ a fourth year unit in family and community medicine because there was such a shortage of family docs that they were hoping that by making us slog through this purgatory that a few of us might get Stockholm syndrome and actually _choose_ Family Practice as a residency/career.

After my first day with Dr. Greco, I was convinced by turns that family medicine could be awe-inspiring, incredibly challenging, humiliating and exhausting. Those impressions turned out to be correct, correct, correct and correct. I couldn't wait to get back to the comfort of a surgical subspecialty.

Chapter 7

The next day my alarm went off at 5:30 AM and I was off to the races again. Since I had never come up against an academic challenge that I couldn't master, I decided to view Dr. Greco and my family medicine rotation as exactly that: a mountain that I would climb and conquer—no matter what.

After we got back from the newborn nursery at Memorial, we started in with patients again. My first patient was a thirty year old plumber who had been seen a week earlier at the emergency room with "the worst headache of my life". For doctors, this phrase ranks up there with "elephant sitting on my chest". In medicine, there are certain key phrases that get you the big work-up no matter what. In this case, the plumber's complaint made us worry about bad things going on inside his head, like bleeding, aneurysms, that sort of thing. Well, he had that evaluation in the ER, including a CT scan and even a spinal tap and the only abnormality that was found after all the expensive tests was on the CT scan: "normal intracranial findings. Mucosal thickening of the maxillary and frontal sinuses bilaterally but no air fluid levels". This meant that his brain looked okay, but there were some possible sinus abnormalities.

The emergency physician diagnosed the plumber as having sinusitis and gave him an antibiotic. A week later, his headache was not much better. Enter the fourth year medical student. I asked him about his headache. "Actually," he admitted, "I've had sinus headaches since I was a teenager at least once a week especially when the weather changes. I take Sudafed for sinuses and they get a little better. My mother has bad sinuses, too. I wind up going to the doctor at least 2-3 times per year and getting antibiotics which help sometimes. The headaches get so bad they sometimes make me throw up. I've missed some work because of my sinuses and my boss is starting to get ticked off, to tell you the truth." I did notice he was massaging his right temple as we spoke and when I came into the exam room the lights were off. His exam was entirely normal including no yellow mucus in the nose and no sinus tenderness.

I presented the case to Dr. Greco and asked him how he usually managed chronic sinus headaches. Dr. Greco looked at me for a moment and said, "Dr. Vega, are you certain this is a sinus headache?"

I thought for a moment. Now I was early in my training, but I figured I had a 50-50 shot on this question and I was the student and he was the preceptor. So, I made the logical choice. With confidence I certainly did not feel, I gave my response:

"No", I stated with authority.

"Good answer, Dr. Vega," he replied with a barely perceptible smile, "I would suggest that you go back in the room and start over taking a history of this patient's headache as if you knew nothing about the evaluation that has already transpired. Forget the CT and the diagnosis that was made previously. Start fresh. Then come back to talk with me."

I went back to see the plumber, who seemed a little impatient by this time. I asked the questions the way I was taught from the beginning. Describe the headaches. Where are they located? How long do they last? Are there associated symptoms? What makes them worse? And so on. Pretty soon, a picture emerged.

He had throbbing right sided headaches in the temple that made him nauseated and got worse with bright light and loud noise. On a scale of 10 they were as severe as 8. The reason this headache was the worst of this life was that it was 9/10 and it lasted a day longer than usual. He always assumed they were sinus headaches because his nose got congested during the headache, they got a little better with Sudafed, they got worse with changes in the weather and his mother—who had the same type of problem--always referred to _hers_ as "sinus headaches"

I returned to Dr. Greco feeling a bit embarrassed once again but at least confident that I now knew the diagnosis. "Dr. Greco," I announced with what remained of my professional dignity, "This patient has migraine headache."

"Absolutely correct, Dr. Vega," he nodded with approval

_Damn I'm good._ The little voice of rebuilding ego said inside me. I then went on to outline my plan of treatment which Dr. Greco helped me refine. He wrote the prescriptions and I wrote the note for the record. Most importantly, the patient was really impressed that our little office figured out what the big shiny emergency department couldn't.

"Dr. Greco," I ventured, "I am curious about one thing. I don't mean to sound critical, but why is it that you and I in this office were able to make this diagnosis and some very smart doctors in the ER went off in a totally different direction?"

"Dr. Vega, that is a very good question. First of all, the atmosphere in the emergency room is very fast-paced. They are trained to 'rule out disaster' first and then look for the mundane later. Sometimes, they simply don't have as much time as we do here. And finally, they get a little technology-centric over there. So they did the evaluation, saw a mild abnormality on the CT and figured they would focus on that since the exam was otherwise normal. That is why you must always start with the patient and finish with the technology, not the other way around."

I had a lot more climbing to do on that mountain.

Chapter 8

It was day number three of what was supposed to be Wiping Runny Noses 101 and yet was turning out to be one of my most difficult rotations yet. I spent my evenings reading up on the subjects that I felt I wasn't as proficient in as I wanted to be and somehow I always fell asleep before I could complete my reading.

A little after lunch I went in to exam room 2 to see eighty-six year old Norman Weinkopf with progressively bizarre and disturbing behavior. Dr. Greco had known him for many years and his previous notes reflected a man who lived in an apartment which was attached to his son's home. This allowed him to have a measure of independence but allow for support from his family. He had demonstrated gradual memory loss over time and had stopped driving a few years earlier but still played bridge twice a week and did his own cooking, cleaning, laundry and other daily activities.

Unfortunately, according to the family member who was accompanying him today, in the last few months the old gentleman had become increasingly confused, agitated and unreliable. He had left the stove on all night on several occasions. And once he had gone for a walk around the block and had to be guided home by a neighbor because he got lost. He became suspicious of delivery trucks thinking that people were coming to rob his home. He thought he saw his wife on the front lawn (she had died several years earlier). All of this information was discreetly placed in a note to be read by the doctor before entering the exam room so as not to embarrass the patient.

This was a clinical picture with which I was familiar from my medicine rotation so I felt prepared. I smoothed my shirt and tie, put on my best professional expression of empathy ready to make the most astute clinical observations when I opened the exam room door and _ohmigod can you believe the girl who is sitting with the old guy she is the most beautiful creature I have ever seen in my life must pull myself together must concentrate on most likely causes of mental status changes can you believe that sundress her legs go on forever must not lose my composure that can't be sweat running down my forehead okay okay you can do it..._

"Hello Mr. Weinkopf. My name is Carlos Vega and I am a physician in training working with Dr. Greco. How are you today?"

"There is nothing wrong with me young man but my granddaughter here and the rest of my family are convinced that I'm crazy or something just because I forget a few things".

"Dr. Vega, I'm Jillian Weinkopf and I guess you read a little about my grandfather...?"

"Yes, thanks for the heads-up. Mr. Weinkopf, since it's been 6 months since you saw Dr. Greco, there are some standard questions we often ask our older patients just to catch up on their health. Would that be okay with you?" _concentrating concentrating, if I look right at him, I can almost forget her sparkling eyes and light up the room smile..._

"Well, if it's just something _standard_ , I guess it couldn't hurt. But I tell you, there's nothing wrong with me".

"Great, you yourself mentioned that you 'forget a few things'. Now at this point in your life, that would hardly be considered surprising..."

"Right, I'm no spring chicken."

"Okay, so I'm going to ask you a few other questions that involve memory, just to explore that a bit further, would that be alright?" _auburn silky hair, smooth skin mean nothing to me..._

"Sure. Go right ahead."

"Right. So can you tell me what year it is?"

"That's an easy one, it's nineteen....well ninety something. You know, since I retired, I don't pay much attention to the year. It's not really important to me."

"Fine. What season is it?"

He looks for a window (but there isn't one). "Well, I'd say it's fall".

"Next, what month is it?"

"Let's see...I'd say it's around March".

The interview progressed in much the same way. When asked where he was, he named the town he had lived in 15 years ago, not the town we were in now. He got some questions right but many others wrong. This is called a mini mental status exam and while some patients with memory problems such as Alzheimer's can do okay on it, if you score poorly, there is a definite problem. Fortunately, he had no other 'red flag' symptoms such as falling, weakness, loss of bladder or bowel control and so on. His physical exam was otherwise pretty normal, except that he clearly hadn't showered and his clothing was stained and dirty.

I presented the case to Dr. Greco and this time we were in complete agreement. The underlying problem was the progressive global brain deterioration we refer to as dementia, probably Alzheimer type. However, there might be other problems accelerating the process such as vitamin deficiencies, chronic infection, thyroid problems or other chemical imbalances. We would run the standard tests and bring the patient back in two weeks for follow-up _. I could only hope that the same caregiver would accompany him_. We also hinted that the family should begin to think about meeting to discuss what might be the most safe living environment for Mr. Weinkopf in the future. I could tell right off the bat that Jillian was not happy about bringing _that_ news home to her parents...

And so the day passed without further vehicular accidents, clinical humiliations or other revelations of gaps in my medical knowledge. Dr. Greco seemed satisfied and with a wave said,

"You've done enough for today, why don't you take off a bit early and do something besides medicine?"

I didn't have to be told twice. I packed up my laptop, said thank you and "see you tomorrow" to the staff, strode out the front door to the parking lot and...

Holy crap.

There she was. Jillian Weinkopf. A million thoughts went through my head as I wondered what she was doing in the parking lot. _She's here because she couldn't get her mind off me she wants to go out with me life is good I'm the luckiest guy on earth I wonder if Abuela will like her maybe I can get a residency in this area..._

"I want to talk with you about my grandfather." She did not have the look of love in her eyes.

"Um, Okay. I mean, Hi. What did you want to ask me about?" I stammered.

"Can we sit down somewhere?" She continued to look intent, not romantic.

The office seemed somehow impersonal and if we sat in one of our cars that would seem...well...not to allow enough space for two people who had just met.

"Look I've just had a long day and I was just going to get some Italian ice," I offered hopefully. "Do you mind if we meet at that place in the center of town that serves flavored ice in cups?"

"Okay, but don't get any ideas. We're going there to talk about my grandfather. You're not my type, and besides, I already have a boyfriend."

The PFFFFFT sound I heard at that moment was the air going out of my balloon.

Chapter 9

I arrived at the Italian ice stand to order my favorite flavor, but they didn't make a size large enough to take the sting out of my bruised ego.

As I turned from the service window, I looked across the street to the park where I somehow knew she'd be sitting. I noticed that she was drinking only bottled water. Maybe she thought I'd take her less seriously if her tongue and lips were colored brilliant red from cherry water ice.

"So, what did you want to talk about?" I asked as I cautiously took a seat next to her at a respectfully professional distance on the park bench.

Her demeanor softened a bit as she turned her gaze directly at me. It was as if she was assessing whether to take me into her confidence. I must have passed the test, because she got right to the point.

"Dr. Vega, you said..."

"Hold on a minute, we're sitting under a tree in a park and I'm not even a doctor yet. How about if you call me Carlos?"

"Very well, _Carlos,_ you explained a lot about my grandfather's problem today and took a lot of time with us and I do appreciate that. But you didn't say much about what it would take to get him better or how long it would take. You also implied that he might have to live someplace else. Did you mean like a nursing home?"

I was hoping we could answer these questions after I got the test results back, but I decided to give it my best shot.

"First off, may I call you Jillian? Ms. Weinkopf is hard to say with my tongue half frozen from the ice."

She shrugged. _Tough audience but I'll take that as a yes._

"Okay, first of all, there are two pieces to this problem. First, your grandfather likely has underlying Alzheimer's Disease. This means his brain has started to have a gradual overall functioning problem in terms of memory, processing, perception and judgment. There are medications to treat this that can help improve or at least stabilize his ability to remember and process information. We are usually successful in reducing things like his worries that he is going to be robbed by cable repairmen and keep him from seeing or hearing things that aren't really there. These medicines can have side-effects, however, and we need to take some time going over all of them in detail."

"And the second piece?" she really wanted to keep me moving.

"The second piece is actually the best part, and that is that he seems to have gotten worse more quickly recently. That may sound bad, but it implies that something outside of the Alzheimer's is happening too. Those kinds of things, anything from infections to vitamin deficiencies to thyroid problems to other chemical imbalances, are more quickly correctable and could help him faster."

"But you have to wait for the test results?"

"Right. That won't take long, though"

"You still haven't answered my question about the nursing home. Do you really believe he can't live in the little apartment attached to my parents' house?"

_I really hate trying to answer this question._ "The honest answer is that it's too early to tell. If we correct some deficiencies, treat the Alzheimer's, have Memorial Hospital Home Health come in for a consult to design some features to improve home safety for Mr. Weinkopf, he might be okay. What do _you_ think about his safety right now? If nothing changes, do you think it is safe for him to be by himself during the day?"

Jillian's response was not what I expected. She had been so direct and sure of herself up to this point that I thought she had an agenda. I was sure she had some specific demands of me and Dr. Greco.

Instead, she started to cry.

Chapter 10

When she looked up at me again, Jillian's eyes were rimmed with red and I knew then and there I was going to find out why she had waited for me in the parking lot earlier in the day.

"Carlos, my grandfather retired as a violinist with the Philadelphia Orchestra. He started teaching me to play when I was four years old. I am in my fourth year at conservatory and now I am hoping to land a job as a professional musician as well. He may not know what month it is, but he still can coach my technique and play practically every part in every concert he performed in since his career began."

"To this day, he and a group of his retired musician buddies get together every Saturday to play in a string quartet. They do not perform for anyone—only for the pure joy of the music. They have played so often that most of the time they can play from memory without sheet music. If he had to go to some type of _home_ , I am certain it would literally _kill_ him. Is there any way we can keep him in our house for as long as possible?"

Wow. This was a plea that I desperately wanted to grant. And yet even with my limited experience, I knew somehow that it had little to do with my skills as a health care provider, the tests I could order or the medicine I could prescribe. So, I turned to the ultimate source of help that healers have called upon from the dawn of time.

Dear God, I know I haven't been to church in ages, but I swear if just this once you will help me pull this miracle off, I will never EVER ask for anything else as long as I live and I will be there for holiday masses with Abuela...Amen

Then, I took a deep breath and said, "I can't promise anything but I can tell you that Dr. Greco and I will do our absolute best." I managed what I hoped was a reassuring smile and continued, "Now, are you allergic to Italian ice or do they just not serve any flavors you like? Allergy to Italian ice is clinically quite rare you know, but we could pre-medicate you with antihistamines if you have been known to develop hives after consuming it."

She wiped her eyes with a tissue (why do women always seem to have those and men never do?—I remember, it's because we have sleeves) and allowed me just the slightest smile.

And my heart went right up to the sky.

Chapter 11

Each day at Dr. Greco's office brought new challenges. I still wasn't sure I was living up to his expectations. In the second week of the rotation, I finally had a chance to show that I was learning what he was teaching. Do it from the beginning. Use the fundamentals. Don't take anything for granted.

I saw a 40 year old high school teacher as a follow up from the emergency room. He had been diagnosed 3 days earlier with pneumonia and had the chest xray to prove it—right sided infiltrate with pleural effusion (fluid around the lung)—but wasn't feeling any better. He was being treated with an appropriate antibiotic and had enjoyed very good health all his life prior to this.

"I still have sharp pain right here when I take a deep breath," he said, pointing to the lowest ribs on the right side of his chest. "And I get short of breath when I walk from one side of school to the other".

I examined the patient and noted as expected that he had decreased breath sounds over the right lower lung. He did not have a fever. I was about to go talk to Dr. Greco...

Hold on a minute. Do it from the beginning. Use the fundamentals. Don't take anything for granted.

"Sir, can you tell me how this problem all started?"

"Sure," he winced, "About a week ago I woke up with this pain in my side every time I took a deep breath. If I'm just sitting, my breathing isn't so bad, but if I get up and walk for more than a short distance I feel short of breath".

"Any other symptoms?"

"No, that's really it", he assured me

"No cough, no fever, no leg swelling."

"None of the above, Dr. Vega."

Then, I crossed the hall to Dr. Greco and presented the case. "Sir, this just doesn't add up. He's being treated for pneumonia, his chest x-ray kind of looks like pneumonia, but his symptoms don't _sound_ like pneumonia and he isn't getting any better on antibiotics."

Dr. Greco looked at me with an expression that told me I was dead-on.

"So what do you propose, Dr. Vega?"

"I think he needs a CT angiogram, to rule out a pulmonary embolus. But I don't want to start a wild goose chase".

"You're not chasing geese Dr. Vega, you're closing in on a blood clot in that man's lung. Congratulations."

It's a long fly ball to deep center field, way way back, it's outtta heeere.

Chapter 12

Clinical challenges came in all shapes and sizes during my family medicine rotation, and I soon learned that the difficulty of the case didn't always have to do with the complexity of the disease. A prime example was three-year-old Jonah Fogle. Jonah came in with a four day history of nasal congestion, cough, fever to 101 and right ear pain. He had a history of ear infections in the past. I was practically gleeful as I walked into the exam room. All I would have to do was ask a few more questions, look into his ear, calculate an antibiotic dose and the visit would be successfully completed.

I greeted Mr. Fogle and turned my attention to Jonah. His body language should have warned me from the start. The corners of his mouth turned down into something between a skeptical glare and a determined frown. His arms were crossed in front of his chest. He was the picture of pre-school defiance.

As if further explanation were needed, Mr. Fogle noted, "Ah, sorry Doc, but Jonah has never liked anyone looking in his ears."

I tried to turn on my best impersonation of charm and reassurance, "Oh, Mr. Fogle, I'm sure we'll get young Jonah here to help us out, won't we Jonah?"

The boy's angry stare did not waver for an instant. If he had been willing to talk, he would have said, "Bring it on, junior doctor."

"C'mon Jonah," I cajoled, "Won't you let me take a quick peek into your ears?"

The reply was a silent slow side to side motion of the blond curly head.

The father walked over to the exam table with hands extended as if to try to hold Jonah's head. This elicited an even worse response. Jonah began to kick his legs and cry with his hands held firmly over _both_ ears.

"Excuse me a moment, Mr. Fogle," I said as I escaped into the hallway leaving the sobbing child and the embarrassed father. I couldn't believe it. I had come so far in solving difficult clinical issues in my training and I was about to be defeated by the inability to examine the ear of a three year old!

There was nothing else to do but make the humiliating walk down the hallway to Dr. Greco's office. As I presented the case, he just smiled and shook his head.

"Dr. Vega, remember what we said about trust being a powerful tool in healing? Well, that applies to all ages. Let's go see Jonah and I'll show you some things I've done to gain trust with children his age. Only once he trusts you will you be able to examine him."

We entered together and I saw Mr. Fogle relax right away but Jonah remained fearful and visibly tense.

"Hi Jonah," said Dr. Greco as he took a seat on the stool and motioned for me to sit beside him. "You sure are getting big. How old are you?"

Jonah wasn't going to let him off that easy. He just shook his head and stared in another direction. But Greco wouldn't give up.

"Are you this many?" Greco inquired, as he held up two fingers.

Our pre-schooler made a face and shook his head as if insulted that anyone would think he was a mere _two_ year old.

"Are you this many?" Greco now held up four fingers.

Jonah, now realizing there was a game going on, almost let himself smile before he remembered he was supposed to be uncooperative. He shook his head again.

"Are you this many?" Greco tried one more time holding up three fingers.

This time Jonah looked at his father who was gently smiling. Jonah started to smile too and nodded his head.

" _THREE!"_ Greco made a big show of learning Jonah's age. "You can't possibly be three. Are you sure you didn't skip two?"

Jonah knew you didn't _skip_ any years and he began to giggle and shake his head no.

Dr. Greco then asked Jonah, "Your daddy says you're here because your ear hurts. Can you point to which ear hurts?"

Jonah pointed to the right ear.

"Well," Greco continued, "Jonah, I can help your ear stop hurting but I need to look into it first. Which ear should I look at first?"

Jonah was about to choose an ear when he remembered he wasn't going to let anyone look in his ears. So he shook his head. Remarkably, Greco took this in stride.

"Okay, should I look in _this_ ear?" and he pointed to Jonah's knee.

Jonah giggled again and shook his head.

"Why not?" asked Greco.

Jonah finally spoke, "'cause that's not a ear" and he laughed again at what he thought was Dr. Greco's anatomic confusion between the knee and the ear.

"Alright, then which ear _do_ I look in?"

That's when Jonah turned his head and pointed emphatically to his right ear, "That one."

Greco looked in the right ear and then Jonah automatically turned his head so the left could be examined. The remainder of the exam passed without incident. We reviewed my antibiotic calculations and gave instructions for pain relief.

As Jonah and his father started out the door, Mr Fogle said, "Thank you for having so much patience with Jonah. How can I get him to be less fearful at the doctor's office?"

Greco reassured him, "In time the fear will pass on its own. But there are some things that can speed things up a bit. Do you have pets?"

"Yes, we have 2 cats."

"Okay, then, the next time you bring your cat to the veterinarian, bring Jonah, too. Tell Jonah that you're bringing him so the kitty won't be scared at his check-up. It may help Jonah to be less scared at the doctor's office."

"That's a great, idea, Dr. Greco. We'll try that. Thanks again."

As they left, Greco looked at me. "Your instincts were very good, you know. You could have forced the situation and you didn't. Many is the time when I have come running down the hallway to see a student who has directed a parent to actually hold down a screaming child for an exam. That should be the very last resort. No matter the age of the patient, never forget the value of establishing trust, Dr. Vega."

Later, after the Fogles left, I was feeling pretty good and ready for the next challenge—and it wasn't long in coming, but the results would prove to be not nearly as satisfying.

Mrs. O'Malley was a 45 year old overweight woman who had noted for months that after eating she would have episodes of pain in the right upper side of her abdomen. Her mother, aunt and sister had all had gall bladder surgery before her, so she felt she was just putting off the inevitable until she had more time for the operation and recovery process.

One morning, she looked in the mirror after a shower and was shocked to discover that her skin looked yellow. Even the whites of her eyes were yellow.

She came to Dr. Greco's office early enough in the morning that I was able to schedule blood testing and an ultrasound almost immediately. I felt pretty confident that one of her gall stones had gotten stuck in the main drainage tube from the liver. This would cause the yellow bile fluid to back up into her blood and turn her skin and eyes yellow—a dramatic but not particularly grave outcome.

We got the call about an hour later and Dr. Greco put it on speaker so we both could listen:

"Sorry to break this to you boys," Dr. Patel said from the radiology suite, "but your patient has a 3 centimeter obstructive mass at the head of the pancreas with both extra- and intra-hepatic biliary ductal dilation. There are also multiple masses in the liver suggestive of metastatic disease. I would advise a CT scan for further clarification." In other words, instead of the impacted gall stone we had expected, poor Mrs. O'Malley not only likely had a particularly nasty form of cancer, but it had already spread. We would refer her to a cancer specialist. She would get treatment. We would all hope for the best. But the truth was that her chances didn't look very good.

Dr. Greco and I looked at each other. I could see from his pained expression that no matter how often he had heard news like this, it didn't make it any easier to break it to a patient.

"Dr. Greco," I finally ventured, "This is something they don't teach us in medical school. How do you tell someone about something like this? And how do you express to the patient that you care but also keep enough emotional distance that you don't feel like crap to the point that you are ineffective for the other patients that you will see that day?"

Well, Dr. Vega," he answered after a pause, "In answer to the first question, you make sure you bring the patient in with a family member. Yes, they will know just by that suggestion that something is up, but in a way that begins the preparation. You start at the beginning, Mrs. W, you will remember that you came to us with X and we ordered Y test. We suspected Z medical problem. Well, the results came in and they showed....etc. If at all possible you do NOT do this on a Friday because then the patient will worry all weekend and can do nothing about the bad news. And if at all possible, you have already called the appropriate specialist and made the patient an appointment for the next step of care in the next day or so that they won't have to wait very long to get started on treatment.

"That makes sense," I observed.

"As for the second part of your question, Dr. Vega," he breathed a heavy sigh, "You never stop feeling like crap when you fear that a patient may die or otherwise have a bad outcome. But you do learn to live with it because the next patient needs you just as much."

After work that night, Dr. Greco and his wife invited me out for dinner. I'm pretty sure he wanted to cheer me up after an emotionally exhausting day. We drove to a little restaurant on the outskirts of town that looked out over a golf course and was known for views of the setting sun. A very attractive older woman with silver hair sat on the terrace in a yellow dress with a blue knit sweater. She stood and held out her hand.

"Hello, you must be Carlos. I'm Delores Greco. It's so nice to meet you. Albert says you're quite the gifted student."

"Very nice to meet you, Mrs. Greco," I replied, "and thanks for the compliment but I'd better be a good student because it's clear I've still got a lot to learn." I winced at Dr. Greco.

Greco laughed, "Carlos is pretty modest. He knows a great deal—particularly for his level of training."

We sat down and ordered some cold drinks. After answering Mrs. Greco's questions about me, I had a few of my own for her.

"Mrs. Greco, my med school friends and I are getting ready to choose a specialty to study after we graduate. What has your life been like with a family doctor as a husband?"

"Well, you need to realize that we got married 40 years ago, so things have changed a lot. When Albert was in residency, family medicine was in its infancy. He practiced medicine in the army for a few years and then went into solo practice. For many years he saw patients in the hospital almost every morning and did procedures like vasectomy. He even resuscitated newborn infants who had been born in distress. Over time he began to share call with some other solo practitioners in town so we could get away more often. I do recall that despite his long hours he always seemed to get to our son's baseball games and band concerts. And we avoided over-extending ourselves financially, so he didn't feel compelled to make huge amounts of money to support an over-inflated lifestyle."

"Ah yes," I interjected, "That explains his passion for luxury automobiles."

"You noticed, did you? Well, that serves several purposes. First of all, we'd rather spend our money on travelling than on a car. Second, no sooner do you buy an expensive car then someone hits it and you feel terrible. Oops, no offense, dear."

"None taken," I lied. I realized I would forever be known as the "bumper car" med student at Greco Family Medicine.

"And finally," Dr. Greco finished for her, "as a family doc, I would rather appear financially normal rather than wealthy. I want to relate to my patients, not rule over them."

Financially 'normal'. That made me think of something else. "Dr. Greco, did you ever have second thoughts about your career choice? You could have made two or three times the money you earned if you had chosen a subspecialty. You could have been famous or rich or enjoyed greater prestige. Do you ever think about that?"

He seemed to ponder his answer carefully before responding. "Honestly, the answer is no. As a family doctor in this town, I see my patients on practically every corner and in every aisle in the supermarket. I take care of three generations of some families. I am respected and my advice is sought on all kinds of problems--many of which have nothing to do with medicine. As for money, if you can't live comfortably on what I earned then I'm not sure what you're looking to buy. Finally, while I wish I could have had even more time with my family, if I had picked a subspecialty, I might have spent lots more time away from home. No, Dr. Vega, I have no professional regrets," he paused and grinned evilly, "until I had to take on electronic health records".

"Where is your son now? What does he do?" I inquired further.

Mrs. Greco answered this time. "Jordan is a chef in San Francisco. He was always a great student and Albert had high hopes that he might one day grow up to be a doctor and take over his practice but Jordan had absolutely no interest in studying medicine. He can't stand the sight of blood unless it comes from a chicken or a pig." She and Dr. Greco laughed at what must have been an oft-repeated joke.

"One of the best things for me," Mrs. Greco added, "is that Albert's work and income allowed me to stay home with Jordan as he grew up. I am an attorney by trade and could have gotten a job but I'm glad that I could be there for my son."

I thought about all they had said as our meal was served on the terrace and the sun sank into the surrounding hills. We all ate quietly for a few minutes and just enjoyed the sound of crickets chirping and the sight of the deepening pink horizon.

"So how did the two of you meet?" I asked.

Dr. Greco was the one to answer this time. "We met in college in a drama group. She was the prettiest pre-law student at Swarthmore," he said with a sentimental smile.

Mrs. Greco wagged a finger at him and laughed, "Albert, there were only a handful of pre-law women at Swarthmore!"

"And you were the only one I dated."

She uttered a loud "humph" but nonetheless kissed him on the forehead and I saw a look pass between them that I could only hope I might share with someone after forty years of marriage.

I certainly had no hope of sharing it with Jillian Weinkopf.

Chapter 13

I drove home for the weekend after my first week of the family medicine rotation. I had learned a great deal, but I remained convinced that family medicine was most assuredly not for me. There were too few opportunities to make a big "save". I wanted to be a hero, after all. In Dr. Greco's world, many of the patients had problems that couldn't be fixed. His patients had ailments like alcoholism, chronic pain, unemployment, poverty, loneliness and dementia _._ Often, all he could offer was comfort, empathy and understanding. Where was the heroism in that? I wanted to cure disease and repair broken structures in a clean and defined way. Very little of Dr. Greco's practice worked like that.

I ate supper at the kitchen table in the home where I had grown up. I hugged my mother and father and went to bed where I slept the sleep of the exhausted.

The next morning, I drove across town to visit _Abuela._ It was a ritual I looked forward to every time I came home. _Abuela_ was my father's mother and despite her age of 84 we connected on a level that was very different from anyone I have ever known. It seemed as if she could just look at me and tell exactly what was going on.

I knocked on the back door and looked in the window to see her gesturing excitedly as she spoke on the phone as if the person she was talking to could actually see her. She then waved to me to come in and I heard her finish the conversation.

"Manuel, you know I can't do the altar flowers the 2nd and 4th Sundays because I am at the soup kitchen those days...Yes, I can still do 1st and 3rd Sundays...Well, the breast cancer walk is organizing something on that day but I'll see if I can clear some space, why don't you email me? Okay, well I have to go because my grandson has finally remembered that his _abuela_ is all alone spending days and nights pining away for him. Give my love to Rosa, will you? Bye"

"CARLITO", she enveloped me in an enormous hug, "how dare you abandon your _abuela_ for such a long time with no card, no phone call, no..."

" _Abuela",_ I smiled, immediately falling into our old game, "I saw you two whole weeks ago."

She wagged her finger at me, "Don't change the subject just because I am old and sometimes forget details."

I loved this game. _Abuela_ forgot about as many details as a top of the line computer. "I am so sorry for neglecting you, my dear old grandmother."

"At least you can show _some_ respect", she pretended to scold me, "Now sit down with some _café con leche_ and tell your old _abuela_ all about your newest adventures in learning to become a fine doctor."

And so I did. I told her all about how I impressed Dr. Greco with my driving skills and then how at first I didn't impress him much with my medical skills. I told her how great it felt to finally show him I could figure out a difficult case. I told her about how bad it felt to not be able to do much for a woman with metastatic cancer of the pancreas. Finally, I told her how much I wanted to be able to help Mr. Weinkopf and especially how much I wished I could get to know Jillian Weinkopf better—which would be easier if I was her type and she didn't already have a boyfriend. Finally, I confided that this whole two months might really be a waste of time after all if what I really wanted was to be a trauma surgeon.

_Abuela_ took all of this in all the while nodding very sagely. When I was finished, she asked,

"Why do you want to be a trauma surgeon?"

I gave her all the usual reasons, the cool equipment, the fast-paced atmosphere, the opportunity to make an immediate and real difference in people's lives, the technical and intellectual challenge...

"Carlito, when you were little, you wanted to be a fireman. Then you wanted to be a policeman. Then you wanted to be an Army Ranger. Now you want to be a trauma surgeon. Do you see a pattern here?"

"It's no secret, _Abuela,_ that if I'm going to spend this many years studying to do something and get really good at it, I wouldn't mind doing something that makes me feel..."

"Like a hero?"

"Si, Abuela". _There was absolutely nothing getting past this woman._

"All right then. What do you think defines a hero?"

"Wow. I guess I never thought to try to give it a formal definition."

"I'll give you one. A hero is someone who makes a sacrifice or takes a risk to do something for someone else with no thought of gain for him or herself. The only gain involved is the deed itself and that is done for love and love alone. Love for a person, for an ideal, for a country or what have you."

She went on, "So why do you think you need to be a surgeon with fancy equipment and technology to be someone's hero?"

I absolutely could not answer that question.

That is when she delivered the kicker. "Carlito, you need to learn to read women better. Jillian does _not_ have a boyfriend."

Chapter 14

I returned to my clinical rotation pondering all the things _Abuela_ had said to me. I was just starting to wonder if maybe Jillian really _didn't_ have a boyfriend when I decided to check my voicemail. There was a single message from Dr. Greco's receptionist telling me to show up at the office dressed "very casually" on Monday.

I arrived to meet Dr. Greco the next morning and was more than a little surprised to see him dressed in tennis shoes, a checkered shirt and blue jeans. What was going on? Fortunately, I had taken the advice I had been given and was dressed in older khakis, a polo shirt and not-too-shabby sneakers.

"No babies in the newborn nursery today," Dr. Greco noted as we went directly into the office. He rifled through a stack of phone messages and prescription requests in record time and then ushered me back out to his stately Grecomobile—the decrepit Honda Civic that I had so graciously tagged on that fateful first day. He opened the passenger door with a grand gesture,

"Getting in?" he inquired.

"Um, sure," I replied hesitantly, "but where are we going?"

"It's County Fair Day," he announced. "No one works today if they can possibly help it. We are going to have a completely unhealthy breakfast and then we are going to spend the day at the Fair."

"Unless you'd rather see patients..." he added.

"But who _will_ see the patients?" I entreated.

"First of all, most of them will be at the Fair. Anyone who is too sick to go to the Fair will probably need to be in the Emergency Room. And as for everyone else, that's why I hired a nurse practitioner."

Our first stop was at the Waffle House. Now you have to understand just how far off the beaten track 'ol Doc Greco was going here. Every morning since I first met him I saw him eat fruit, low sugar oatmeal sprinkled with trail mix and a glass of skim milk to keep his cholesterol and blood pressure down.

So this morning I about fell out of my chair when I heard him order.

"I'll have the Triple Play Special please—three scrambled eggs, three sausage links, three pieces of bacon, three pancakes, hashbrowns, orange juice and coffee."

It was my duty to order something that complemented _his_ order so I quickly added,

"I'll have the intravenous nitroglycerin and an automatic defibrillator with a side of CPR."

While Dr. Greco glared at my review of his dietary indiscretion, the waitress was clearly not ready for medical humor at eight o'clock in the morning.

"I'm sorry, I don't think I caught all of that," she squinted at her order pad.

"How about if I just go with the bagel and cream cheese, orange juice and a decaf coffee?"

"Okay, that should be out in about 5 minutes".

Before there could be further commentary about his choice of cuisine, I decided to ask instead about our itinerary for the day.

"So tell me about the Fair."

"Well, you know the history of this town. It's an old German farming community going back over 200 years. Every year there's a fair for each farmer to show off produce, livestock and so on. There are rides and games so you can spend a lot of money to win a stuffed animal you could probably buy for half a buck if it were for sale. You can play bingo or see a country band. You can buy homemade pies and crafts. You can watch competitions involving horses or other animals. At the end there are fireworks. It's a big party and everyone in town comes out."

Our breakfast arrived and we dug in. When Dr. Greco had sopped up the last of the syrup with a final piece of pancake and washed it down with a swig of coffee, he paid the check and out we went into the sunshine towards the Fair.

Arriving so early, we got a chance to see a lot of things as they were being set out for display. There were gleaming green tractors ("Nothing Runs Like a Deere"), children getting ready for 4-H and FFA competitions, horses being unloaded from trailers and untold pounds of meat sizzling on grills leaving smoke trails lazily ascending towards a puffy-clouded sky. Amusement rides were already turning awaiting riders who would no doubt be playing hooky from school.

The fairgrounds were already pretty crowded by the time we had made our first circuit of the barns and tents before noontime. As a city boy, this was a completely different experience for me and I tried to take it all in.

Just before noon, I heard the unmistakable sound of a barbershop quartet. Sure enough, approaching us were four gentlemen in pressed black trousers, white shirts, red bands around their upper arms and red, white and blue banded straw hats. As they sang they all had broad smiles and looked like there was no place they would rather be than strolling around the fairgrounds singing close harmony.

Goodbye my Coney Island baby, fairwell my own true love, true love (my honey)...

The leader of the group immediately recognized Dr. Greco and made a motion with his hand that halted the singing in mid-phrase, "Albert, c'mon over here and do a number with us!"

Greco laughed, "You guys are doing just fine without me."

"Nonsense, Ralph's gotta hit the can again because he keeps forgetting to take the prostate medicine you prescribed. Come on, just one number..."

"Okay, Okay," Greco capitulated, "Everybody remember _Lida Rose_ from _The Music Man_?"

There was a murmur of agreement and the leader got out a pitch pipe to give a starting note.

Lida Rose, I'm home again Rose, to get the sun back in the sky...

And so the happy ensemble sang and paraded around the picnic tables to the delight of the early lunchtime crowd.

_Lida Rose oh won't you please be mine..._ concluded the old tune and everyone applauded as I got a glimpse of my mentor's life outside the practice of medicine. The barbershop group had no sooner moved on when we heard other voices directed at Dr. Greco.

"I told you he'd forget"

"Good thing we found him"

"Dr. Greco, it's time for you to judge the apple pie contest. It's noon and the pies are all set out in barn 3, did you forget?"

"Oh my, ladies, I am so sorry, let's get going. Can you show me a short-cut?"

We half-jogged over to barn #3 where Dr. Greco composed himself and made his entrance as a leading citizen in town should. After greeting the eagerly waiting bakers, I walked behind Greco as he made a complete circuit of the long table with no less than 16 delicious-looking (and smelling) apple pies. He then drew me aside out of earshot and said with the gravity he would use for discussing a deadly global public health crisis, "Carlos, we must get this right. There are serious bragging rights at stake for a full year. You must pay attention to three primary criteria: First, overall appearance—see the one pie over there with the lacy overcrust—that is a thing of beauty. Second, crust characteristics—crust should be flaky with just the right amount of sweetness and crisp texture. Third, filling—the apple filling should be moderately sweet and any cinnamony overtones or other added spice flavors are a bonus if they blend well."

"Where did you learn this stuff?" I whispered back thinking about all the years he must have done this.

"The truth is that this is the first time I've judged a pie in my life. George Crum bowed out at the last minute when his back went out. So I did an online search for the criteria for pie judging." He winked at me and I barely managed to keep from ruining the atmosphere by laughing out loud.

Dr. Greco pronounced "each and every pie here better than any I have ever tasted" but "we are here to award blue, red, yellow and honorable mention ribbons" and he did a very diplomatic and credible job of bestowing the coveted prizes. He thanked the competitors and we slipped out of the tent quickly before any of the post-competition trash-talking could begin.

Soon after a lunch whose nutritional value was just as suspect as breakfast, I heard a voice call,

"Dr. Vega...Dr. Vega!"

I turned around and there was the plumber I had seen with the "sinus" headaches that turned out instead to be migraines. He quickly walked toward me pulling a very nice-looking blond woman along by the hand.

"Dr. Vega, I don't mean to intrude, but I just wanted to thank you for all you did for me. This is my wife, Barbara. Barb, this is the doctor who figured out my headaches after all these years!"

"That is very kind of you to say..." I began.

His wife was even more effusive. "Dr. Vega, I don't know what we would have done without you. George was about to lose his job because of those headaches. He had missed so much work that they were about to fire him. Now that you started him on that medication, he is in line for a _promotion_ to supervisor. We....well... we're thinking about starting a family now..." She trailed off smiling and blushing and looking up lovingly at her husband all at the same time.

"The bottom line, Dr. Vega, is that if you ever have a plumbing problem in this town, you call _me_ and that problem is fixed. Immediately," he stated with conviction. "Anyway, we've taken up enough of your time, Doctors. Thanks for everything and have a really great time at the fair."

The plumber and his wife disappeared quickly into the crowd.

I glanced over at Dr. Greco a little sheepishly, "I'm not sure I deserved that, considering you were leading me by the hand all the way."

"First of all, you made the diagnosis and planned the treatment, Dr. Vega. I just made sure you didn't jump to a premature conclusion. Second of all, take your kudos where you can get them. Patients don't hand them out lightly."

I wouldn't get to enjoy the glow of the plumber's praise for very long, because there was another visitor to the fair whose presence would bring me right back to earth. As dusk settled on the grounds and families sat on the picnic benches with their fried chicken and barbecued beef, I saw a woman walk by whose skin was an otherworldly shade of yellow. I knew instantly it was Mrs. O'Malley, the woman with the pancreatic cancer. She walked slowly and tried to smile with her children but I knew at a glance that she was both sad and in pain. Would this be her last fair? Should I walk over and say 'hello'? And if I did, what would I say? "I'm sorry"? In the end, I left her to the privacy of her moments with her family.

Night fell and Dr. Greco and I sat watching the fireworks without speaking. I thought about all I had seen and felt today. The fair was such a great celebration of all that life had to offer. It reminded me of this town and beyond that the kind of professional life that Dr. Greco had found so fulfilling all these years. But could such a life be enough for me?

Chapter 15

The day after Fair Day brought me back to earth. The newborn nursery was uneventful and so the first challenge of the day awaited me back at Dr. Greco's office.

Sandra Kramer, age 40, came for follow up of iron deficiency anemia. She was frustrated because no matter how much iron she was given as a supplement, her iron levels stayed low and her red blood cell count would not come up into the normal range. Up until now, she had been treated primarily by her gynecologist. The theory was that her anemia and iron deficiency were due to loss of blood from heavy periods. She denied abdominal pain, blood in the stool or black stools. She had been tested for blood in the stool and the test was negative. Iron-deficiency anemia was very simple really. For a woman, you were either losing blood through the stomach and intestines or from the uterus/vagina. Since the GYN had not found blood in the stool, they concluded her periods were the cause.

I asked Mrs. Kramer to describe her periods.

She replied, "They are very heavy. My periods come every 28 days and last 4 days. The first few days I go through about 3-4 pads per day and the last day 1-2 pads."

Bells were starting to go off in my head. I was early in my career but I had spoken to a lot of women on my GYN rotation and those did _not_ sound like heavy periods. And if she was not having heavy periods, then we had _not_ really explained where the blood loss was coming from.

After I examined the patient, I made my presentation to Dr. Greco.

"Sir, we could send this patient for intravenous iron and that would normalize the iron levels and the blood count. But I don't think we have fully ruled out the GI tract as a source of blood loss. She could have an ulcer or worse, a cancer of some type"

Greco gave me a thumbs-up and said, "I concur, Dr. Vega, now go and sell the idea to the patient."

I went back to the exam room with a feeling of triumph. All I had to do was gently explain to the patient that she needed a couple of very simple painless tests and we might really save her from a serious disease!

Unfortunately, Mrs. Kramer had other ideas.

"I really don't want to undergo those tests Dr. Vega. When doctors start looking into your body with tubes there's no telling what could happen. I could have a hole poked in my stomach or intestine. I could have a complication from the sedative. And I know deep in my heart that my anemia is from my periods. So thank you, Dr. Vega, but I would rather just have the iron intravenously and be done with it."

I excused myself one more time and went back to Dr. Greco.

"Dr. Greco, what do I do when I know what a patient needs a test but they refuse? Once I'm a doctor, what if a patient refuses a procedure and later dies because they didn't have the procedure. Could I get sued for malpractice?"

"Dr. Vega, this is where you must protect both the patient and yourself. You've heard of informed consent—which is where the patient has a right to know the purpose of a procedure with the alternatives to and possible complications of that procedure _before giving consent_. Well, there is also something called informed refusal. That is when the patient listens to all that you have suggested and _declines_ what you advised. If you carefully document everything, especially that the patient understands and accepts the consequences of the refusal, you are doing everything you can for the patient and the chances of a lawsuit are pretty small."

He concluded, "And if you present everything in a way that is kind and non-judgmental, the patient may even change her mind later."

I went back to the exam room with Dr. Greco in tow, and we got our informed refusal. I was very careful not to do anything which would convey disappointment in Mrs. Kramer's decision.

And later that afternoon I got a phone message.

Mrs. Sandra Kramer called back. She changed her mind and would like the name of the gastroenterologist you wanted to refer her to.

It turned out that I wouldn't have long to enjoy my feeling of accomplishment in the Kramer case. I would now have to decide what to do with my confused elderly gentleman Mr. Weinkopf. His blood tests showed no treatable cause of memory loss. There would be no easy way to way to halt the distressing hallucinations of his deceased wife or quiet his suspicions that the mail carrier might burglarize his home. With Dr. Greco's help, I advised an anti-depressant which showed promise in reducing agitation in patients with dementia and another medication to help stabilize his memory. Jillian came with her grandfather once again, but she was all business. No emotion of any kind flowed between us. Any connection we had made at the park eating Italian ice seemed long forgotten—at least by her. I succeeded in feeling detached and professional that day—but that seemed like a rather small victory in the grand scheme of things. We agreed to see Mr. Weinkopf again in four weeks.

After that, I was feeling a little low, but Dr. Greco came to me with an idea that made me feel a _lot_ better _._

"Dr. Vega," he enquired, "May I ask your advice about something?"

_My advice? That's a switch._ "Sure, Dr. Greco, what did you have in mind?"

"Well, you know I'm not exactly a technical genius..." he began.

Yes, and the Edsel was not exactly a Porsche.

"And I need to choose an electronic health record," he continued.

Oh, no. My mentor, the electronic equivalent of a graying kindergartner, was contemplating making a leap directly into tech graduate school. Recently, the government had made it clear that it would be mandatory to start keeping medical records on computer with very specific kinds of software. This was not, as was popularly imagined, a result of recently passed health care legislation, but rather an outgrowth of mandates that had been evolving for years.

And so Dr. Greco was faced with adopting this software or facing stiff penalties.

"And", he continued finally, "since you have worked with a number of different EHRs, I wondered if you might help me choose one that I could...maybe...figure out?"

"Dr. Greco," I smiled, "I would be honored"

"I hoped you might," he let out his breath with a relieved whoosh of air. "I have lined up three companies which were highly ranked by _Family Practice Management_ for next Monday. Your job is to prep me for exactly what I should look for in a user-friendly system and then take me through the essential features of each system as they are presented to us. I want you to help me ask very probing questions. Then, you will advise me as I choose a system. If you feel that none of the above is a good choice, you will so state and tell me why. In return, I have something to offer you".

"Liquidable securities? Numbered account in the Caymans? Super bowl tickets?"

He smiled. "Nothing so grand as that. You must have noticed that I have been in this business for an awfully long time. I have been incredibly happy and fulfilled, but I can't do it forever. I need to retire while I am healthy enough to enjoy it. I am going to need someone to take over for me...someone whom I can trust and moreover someone who my patients will get along with."

Is he saying what I think he's saying?

"Dr. Vega... _Carlos..._ I know you haven't even chosen residency yet, much less completed it. I'm not even sure you want to pursue family medicine as a career. Yet you are the most accomplished, dedicated compassionate student I have ever worked with. More importantly, I have never had a student that my patients instantly took such a liking to. Provided you successfully complete a family practice residency and pass board certification, I would like to hand over my practice directly to you."

Chapter 16

We both said more that day, but that was the gist of it. He was kind enough to make it clear that he wouldn't be offended or upset if I turned him down, and that whatever happened he would be giving me a top grade for the family medicine rotation.

I had to admit that I was tempted. He wasn't just offering me a practice, he was offering me a whole life in a town that was both vital and historic. The range of patients and medical challenges was enormous and ever-changing.

But there was one thing that family medicine in the country couldn't offer that trauma medicine could and I was embarrassed to acknowledge it.

Money.

Now before you think that we doctors go into this profession to get rich, hear me out.

In the early 2010's the average medical student graduated with $160,000 in debt between college and medical school loans, so the need to make some serious money early wasn't so much about avarice as it was about paying the note. Remember that same student won't start a career until age 28 and many may be 31 or even 33 years old. So hopefully it doesn't seem quite so greedy when a young doctor takes into account monetary compensation when choosing a specialty.

Anyway, I had some significant student debt built up between Dickinson College and Midcentral State U even if the latter wasn't Johns Hopkins when it came to tuition. And I still loved the idea of the gleaming tower of healing that trauma medicine represented with its vast array of gizmos and no issues (at least for me) with insurance or filling out forms.

I was more confused than ever about what to do with my life.

Chapter 17

On Monday morning I briefed Dr. Greco in detail with the "Electronic Record Gospel According to Not-So-Saint Carlos". I explained that the great thing about these systems is that everything you put it these systems you can get back out. The bad thing is that learning how to put it in without spending your life doing it is a neat trick. I showed him how quick it is to send a prescription by computer (and how much the patients like it). I alerted him to many pitfalls of the systems and which ones were most avoidable. I told him point-blank that he would lose a bunch of money the first few months while he got used to the system and he should prepare for that.

We then interviewed all the vendors and took each system for a test drive using simulated patient visits. Dr. Greco rapidly came to a scientifically sound conclusion (with which almost all reviewers before him have resoundingly agreed) and made a sage pronouncement:

"They all suck."

"My dear Dr. Greco," I proclaimed with mock seriousness, "when it comes to electronic health records, the issue is not whether or not a certain system sucks but to what degree it sucks and whether its "suckability quotient " is high enough to render it completely unusable".

At that, Dr. Greco finally broke up in a huge belly laugh. "Alright, Dr. Vega. You've seen the systems, which do I choose?"

I didn't want to choose _for_ him. In the end, based on his needs and comfort with the software, he was able to choose a system that seemed reasonable. I prayed that he would be okay with it.

During the implementation phase, we saw half the usual volume of patients while Dr. Greco got introduced to the system—I didn't say "comfortable" with it. It would be a little like getting comfortable with chickenpox.

The amazing thing was the inversion in our relationship. Now, I was the teacher and he was the student. Remarkably, it wasn't awkward at all.

Chapter 18

Soon after we were up and running (or maybe crawling) with the electronic records, we got a call from a none-too-pleased Jillian Weinkopf. Her grandfather's agitation was worse, he wasn't sleeping and the burglary threat from the Domino's Pizza deliveryman was greater than ever.

Dr. Greco and I met the evening before the scheduled appointment with Mr. Weinkopf and it was clear who was the student and who was the teacher now.

"You know the drill," he said to me without preamble, "increasing agitation in a patient with Alzheimer's who has no other treatable cause and didn't respond to the anti-depressant/anticholinergic combination. We even did an MRI last week just in case his recent deterioration was due to unrecognized stroke and that came up normal also. Remember the next step?"

"There is debate," I noted, "because a common next step is to use atypical antipsychotic medications, even though they are not FDA approved for this problem and even though some studies have shown a trend towards increased mortality".

"So what you might have to say in English to the patient and family is this," Greco advised, "At this point we have few options. If we don't do anything, Mr. Weinkopf's life becomes increasingly frightening for him--not to mention placing him at increasing risk for injury or worse in the event he decides to act upon any of his delusions or hallucinations. On the other hand, we can treat him with a medication which could make him feel a lot more comfortable, allow him to sleep, make it easier to stay at home in a family environment and so on but with which there is a theoretical increased chance of dying somewhat earlier."

"Wow," I said, "this is definitely not a conversation I am looking forward to."

"This, my boy," said Greco, "is where you learn the art of medicine. Whatever they decide, we need to be one hundred percent supportive."

Chapter 19

As the sun poured in through the window blind in the exam room the next afternoon, Mr. Weinkopf, Jillian Weinkopf, Dr. Greco and I finished discussing the scenario that Greco and I had rehearsed the day before. I was prepared for many potential responses—irate, angry, frustrated or tearful seemed among the most likely.

Imagine my surprise when Jillian said, "Well I don't know what we're waiting for, let's have that medicine called into the pharmacy and get started as soon as possible."

I couldn't help making sure she had understood what we had proposed, "so you're okay with this even with the...risks...we discussed".

Jillian immediately gestured with her thumb toward the door. Even with my Y chromosome and confirmed case of chronic cluelessness with women, I was able to divine what this meant.

Once outside the door she said, "my parents and I have already discussed this. We love my grandfather and this is no way for him to live. If he could just get some sleep and some peace, what does it matter if there's a risk that he might not live quite as long? What kind of life is this?"

"Okay, then let's try him on a very low dose. Please call me in a week with a progress report. We can very gradually increase as needed. Call me sooner if there are unacceptable side effects."

She nodded silently and we re-entered the room.

"So we are all in agreement?" Dr. Greco asked.

I'm definitely going to church with Abuela on Sunday.

Chapter 20

A few days later, I was surprised to get a message in my electronic inbox about Mr. Weinkopf. It read simply,

"Patient's granddaughter says patient slept thru night"

By the end of the week, I had received another message,

"Patient's granddaughter says patient no longer hallucinating and UPS delivery man no longer conspiring to break into the home."

_I really am going to need some dress shirts and ties for Sunday mass,_ I thought and I said a silent prayer of thanks right then and there.

After that, things got busy for a while. I saw my first case of shingles, my first patient with Lyme disease, my first case of Bell's palsy and so many other firsts. It was like I opened my brain every morning, crammed it full of new material all day and could barely shut it down for sleep for a few precious hours every evening.

It turned out that I would soon have a diversion from all that intensity. One afternoon there was a small envelope on my desk and inside was a hand-written invitation.

RETIREMENT WITH STRINGS ATTACHED PLAYERS  
INVITES YOU TO A CONCERT FEATURING SELECTIONS FROM VIVALDI'S  
_The Four Seasons_

I had a feeling that I already knew who the performers were going to be and where the concert was going to be held. I just hoped that a certain young violinist would be in the audience.

Chapter 21

I arrived at the Weinkopf house on a warm early autumn Saturday afternoon. There were a surprising number of other cars already parked on the cul-de-sac in front of the house and other concert-goers headed around to the backyard. There, I saw rows of folding chairs, a few tables with bottles of soda and plates of cookies and about 30-40 very friendly looking people of various ages milling about and looking like they all knew one another. At that moment, a middle-aged nicely-dressed couple stepped toward me and extended their hands.

"You must be Dr. Vega," the gentleman of the pair said, "Jill has told us a lot about you and your special way with older patients. I am Martin Weinkopf and this is my wife, Annette."

"It is such a pleasure to meet you, Dr. Vega," his wife greeted me, "Thank you so much for what you've done for Norman."

"Mr. and Mrs. Weinkopf, I am very honored to meet both of you but please call me Carlos. I won't even officially be a doctor until next spring."

"Carlos it is, then, but hurry up or you'll miss the beginning of the concert."

I looked around and saw Jillian conferring with her grandfather as he prepared to play. Their conversation was animated and intense. I wondered if that was what Greco and I looked like when we were discussing a patient with a challenging disease. It was at that moment that she glanced up, saw me and smiled warmly. She started to walk towards me but was stopped by someone who needed to ask her a question. She looked a bit frustrated.

"Can we talk after the concert?" She called out to me.

I nodded quickly and enthusiastically.

We sat down in a hushed silence as four elderly men with their instruments walked towards their places in the front. And then disaster struck. One white-haired violinist tripped and pitched forward landing on his outstretched hand. I jumped up and ran over to him to assess the damage. The codger was holding his swollen wrist against his chest and moaning.

"Sir, I am a medical student, may I have a look?" I asked.

"You can look, but can you fix?" he replied with growing trepidation.

Unfortunately, there was already significant swelling and point tenderness over the wrist bone on the thumb side of his wrist. While there was no gross deformity and no obvious nerve or blood vessel damage, he would not be performing at this concert.

I looked up to see a trio of very concerned but also very disappointed musicians.

"Will Charlie be okay?" asked Norman Weinkopf.

"He'll be okay," I reassured him, "but he needs to go to the emergency room for an xray and a splint. And he won't be playing this afternoon. I'm really sorry."

"Won't be playing?" he echoed, "but everyone is here to listen to the concert!"

Charlie had heard enough. "We are NOT going to cancel the concert. There must be a way. Wait a minute...where's Jillian?"

"Hey Uncle Charlie," Jillian said from the back of the crowd of concerned onlookers, "What do you need?"

"I need you to take my place in the concert".

"Uncle Charlie, that is _not_ happening."

"Jillian, please. Norm and the rest of us haven't performed for an audience in years. Who knows when we'll get another chance. You're a conservatory violinist and you know this music as well as we do. Why not give it a shot and play with your old Grandpa?"

Jillian got up and stormed off. She returned with three items which I later learned were not all standard stringed quartet equipment. She had a violin, sheet music for _The Four Seasons by Antonio Vivaldi_ and an ice bag.

"Uncle Charlie," she gestured to the ice bag, "put this on your wrist and elevate it above your heart. We're going to play _Vivaldi_ like he's never been played before and then YOU are going to the emergency room, is that clear?"

"Yes ma'am", said a chastened but happy old geezer.

Chapter 22

After the lilting strains of _Vivaldi_ had long faded away and most of the guests had started to make the short walk back towards their cars, I finally got the nerve to approach Jilllian. She had been busily playing hostess in addition to being an unexpected featured performer so I wondered if she would be pretty tired by now.

"Can I help you put away the chairs and tables?" I offered.

"Oh sure, thanks for offering," she smiled warmly and gestured with a hand to where things were being stacked up.

"I just wanted to say that I'm really sorry your Uncle Charlie got hurt, but I'm not sorry I got to hear you play. I know I'm no music expert, but I thought you were just amazing."

Jillian actually laughed. "Charlie has wanted my grandfather and me to play together for years. He probably planned the whole trip and fall thing just as a set-up to get his wish." She continued, "As for the nice compliment, in the music business, you take a good review wherever you can get one, so thank you, kind sir..." her eyes danced with another dazzling smile and then she bowed formally.

Then, she said something I'll never forget.

"If I play for a living, it will mean going from audition to performance to review and back again. You know, you got a pretty good review yourself from my family in the role of 'retired musician's doctor'. In fact, in the business, we'd say you pretty much 'killed' that audition."

"Now, it's my turn to say thank you, kind lady", I bowed in an exaggerated parody of formality.

She almost giggled at that one. "Are you too busy at this time for another try-out, Dr. Vega?"

"Is there someone else in your family who needs a physician in training?"

"Well, there might be," she winked, "but she isn't sick. Are you up for some more Italian ice?"

I tried to contain the enormous grin spreading across my face, "How about dinner instead?"

"I'll get my bag".

Chapter 23

We chose a casual restaurant in the center of town with a small outdoor patio garden bordered with geraniums overlooking the sidewalk and its happy cargo of shoppers and passers-by. I frankly couldn't believe my good fortune.

After some small talk and some fried mozzarella sticks, she decided to answer the obvious question without me having to ask it.

"You're probably wondering why I'm here with you if I already have a boyfriend and you're not my type".

"The thought had crossed my mind." _But I was so deliriously happy that I was willing to dismiss it in a heartbeat just to be here with you._

She continued, "Well, that day in the parking lot, I was telling the truth for the most part. At the time, I was seeing someone, but it was about over. I don't see him anymore. The fib I told was about you not being my type. The truth is, I could feel something between us the minute you walked into the exam room but I couldn't let that get in the way of my goal which was to make sure my grandfather got what he needed. I hope you won't hold that against me too much."

You could be an axe murderer and I wouldn't hold it against you.

"I can understand that your grandfather would be your top priority at that moment," I admitted, "and I don't hold it against you at all."

"His memory is still pretty terrible, you know. What the medicine has mostly done is allow him to sleep and to help him feel less paranoid. He doesn't see things that aren't there and he just feels a lot more at peace. But believe me, we are all very grateful for that."

I felt a little uncomfortable with all the adulation and I wanted to get to know her better so I said,

"Now that my head is so swelled it won't fit through the door of the restaurant, can we please talk about you?"

"Well, you met my parents. My dad is a pharmacist and my mother is an accountant. I have two older sisters who have disgustingly practical careers in business and are married and have moved out west. I have always been the dreamer in the house. I discovered music early and have been in love with it ever since. At the conservatory the first day they said to us, 'look to your right and look to your left and realize that two out of three of you are going to be music teachers someday so don't think that just because you were admitted here you're automatically going to make it as a performer.' I heard that and became all the more determined that I would play music for a living—with a major symphony if possible."

We finished our dinner and strolled down the main street of the town. I realized that I had been consumed with learning medicine for so long that I had almost forgotten what it felt like to be really content. We turned the corner to look at some brightly colored Victorian homes when I felt her hand slip into mine. It just felt so natural to be walking like that—like we'd done it a hundred times before. And yet there was a rising feeling of excitement in my chest.

It wasn't long before we arrived back in front of her house. I barely had time to look down at her when she was suddenly in my arms kissing me.

"So how did my audition go?" I asked, suddenly a little breathless.

Her eyes flashed brightly and she pulled me down towards her again. "You've definitely earned a call-back, Dr. Vega. My people will be in touch."

Chapter 24

As I drove back to Dr. Greco's office the next day, I couldn't have been more confused about my future. I had no idea what medical specialty I would choose to study. I had been offered a great practice in a beautiful town—but might have to decline. And to make matters worse I had finally found someone who might be truly special—but both of us were headed in different directions in less than two weeks.

So I did what any red-blooded American male would do in a similar situation. I hit the denial button. I absolutely put off any decision-making whatsoever. I worked long hours with Dr. Greco soaking up every morsel of medical wisdom he could give me. Then I spent every spare moment with Jillian like there was no tomorrow. For all I knew, for the two of us, there might not be.

The last day of my rotation was a Friday and Dr. Greco called me to his office.

"Dr. Vega, you've done all you can here and I've taught you about everything I can convey in the time we've been given. A little birdie told me you've got some non-medical unfinished business to take care of before you leave our little town. Why, don't we shake hands and part now so you can do that? You already know what your evaluation for this rotation will look like. Congratulations and good luck in whatever direction your career takes you."

I wasn't sure what to say.

"Dr. Greco," I finally replied, "I want to thank you so much for everything. This has been far more than a medical rotation. It sounds like a cliché to say so, but it has truly been a life-changing experience. Whatever happens, I will never forget you, Sir."

And at that moment, we actually embraced. I don't think either of us expected that.

I drove over to Jillian's house where she was packing for her last year at the conservatory. Up until then, it was like an unspoken agreement that we hadn't discussed the future. Now, we had no choice.

She ran over immediately to give me a hug but her eyes glistened with tears she was trying not to show.

"Carlos, you know we barely know each other, so it's not like I have some claim on you. You have more rotations, a residency to complete and then a medical practice to begin. And who knows where I'll catch on with a symphony? So I'll understand if you..."

I was not going to let her finish the speech, "Jillian, sometimes it doesn't take a long time to figure out that someone might be 'the one'. You're right, I don't know for sure if you are the person I'm going to spend forever with, but I certainly know that right now, I can't think about anyone else but you. We have something here. I know I don't want to lose you. I'm willing to work to keep you in my life, even if there is some time and distance involved. Does that make any sense at all?"

She threw her arms around my neck and gave up trying to keep the tears from flowing down her face, "Damn it Carlos Vega, here I am trying to let you go gracefully and you insist on making it completely impossible!"

"Not this time, Jillian Weinkopf, you're going to have to work a lot harder than that to get rid of me."

Chapter 25

So there I was, back at my Midcentral State U apartment playing poker as my friends and I took a quick breather between rotations. We were the same players, playing the same nickel ante, quarter maximum bet games, still wondering where life would take us.

"Let me get this straight," began Courtney the future joint replacement specialist, "it took you six weeks to make your move on this babe and after a fourteen day whirlwind courtship, you're _hoping_ to hold onto her while she plays the violin among the rich-boy society types in Philly and you disappear during your shock trauma sub-internship at Metro Health?"

"Show us the picture again," Tyler said.

Gomey was not optimistic as he examined the photo on my phone, "In my village, you would need to offer three elephants and two Land Rovers to her father, and still you would need to keep bidding."

"Thanks for the votes of confidence, everybody", I said, exasperated, "Why does everyone think you have to have spend years with someone before you know they could be 'the one'?"

"We're not betting against you, Vega," Courtney said in a much softer tone, "We just don't want to see you hurt. You know what a shock trauma sub-I is like. You go in there and you don't come out until it's over. Jillian isn't going to see you. Are you going to be able to get through that for six weeks?"

I let that question hang in the air.

Tyler hated long silences so he waded in with another question, "So did Dr. Fossil offer you his practice with a complimentary lifetime permit to hold little old ladies' hands?"

"You're not going to believe this, but he actually did," and I told them about how different the whole experience was than I expected it to be.

"Well, Vega," said Courtney, "then you'd better start winning at the poker table, 'cause you sure aren't getting rich from the hand-holding concession. I'm dealing. The game is Night Baseball, do you all remember the rules?"

Chapter 26

The rules at the Metro Health Shock Trauma Sub-internship say that the fourth year medical student who participates must follow the same schedule as the regular interns including sleeping overnight at the hospital every third night and being available for the same grueling schedule. I was to be supervised by a junior resident who was also overseeing actual interns (those who were in their first year of training after medical school).

I wanted the full shock trauma experience—stabilization in the emergency department, surgical procedures in the operating room and experience in the surgical ICU with managing everything from machine-assisted breathing to unstable blood pressure to post-operative infections to kidney, heart and liver failure as well as what happens in the special situations when the brain and spinal cord are injured. I also wanted to see the reconstructive side of things and work with burn trauma.

Furthermore, I had heard that surgery training programs could be pretty physically and psychologically brutal. Even with less ridiculous working hours than in years past and with the advent of a much larger female contingent, surgery training continued to have the reputation for being like a football training camp. Lots of yelling and humiliation and extra laps if you didn't perform as expected. I wanted to see what it was like close up and if I had what it took to endure it and hopefully thrive.

My junior resident introduced herself as Althea Johnson. She shook my hand firmly and immediately showed me around. She didn't seem to beat or starve the interns and that seemed like a good sign. In fact, she spent a lot of time making sure they knew the inside track to impressing the senior residents and attending physicians.

We got through the orientation stuff and right away got called to the Trauma ED (emergency department) for a new case: an unfortunate motor vehicle accident victim who was not wearing a seatbelt. They let me just watch the first time. I marveled at how quickly each part of the team took care of a specific aspect of the case. Neck stabilized and fractures ruled out with imaging. Airway assessed and breathing tube was quickly passed into the patient's windpipe. Two large diameter intravenous lines were started. Arrangements were made for CT scans or xrays of other injured parts. Blood was drawn for testing and to prepare for possible transfusion. I knew that in a very short time I would be participating with all of these teams and hopefully one day learning to manage one.

I felt the familiar adrenaline surge of the emergency room and the special sensation in my brain as it prepared to go into overdrive for fast decision-making. This was the situation I felt I had prepared for over the past few years. I had read a lot of articles and rehearsed many scenarios in preparation for this specific rotation. Now it was time to put my textbook knowledge into action.

Chapter 27

The next day I arrived in time for morning report and my first official day as part of Trauma Team Three. Team Three was headed up by a senior resident named Royce Cunningham. I saw Royce's bio in the catalog and it was impressive. Harvard Medical School, Alpha Omega Alpha honorary medical fraternity, all-world everywhere he went. I think he invented his own molecule in third grade that cured cancer and baldness and just missed a Nobel Prize. He wasted no time in getting things started.

"Before we hear case presentations, I want to welcome fourth year student Carlos Vega to our team. Carlos just completed his sub-I in flower-arranging...I mean family medicine. Let's all show him what real medicine is, shall we? Carlos, since you've been working...say...three hours a day for the past 2 months? We don't want to tax you too much while we get you up to speed. So, we're going to start you with mainly post-op patients. This will allow you to review the histories of complicated trauma patients who are in the recovery phase while you get your feet wet. You will be expected to know _everything_ that happened to them from the moment of their mishap to the time you present them. I want to know how many times they farted on the way to physical therapy, is that clear? When you have mastered that, you will be given progressively more challenging decision-making responsibilities with the appropriate monitoring from a resident. Do you have any questions?"

Minus the condescending language, this was about what I expected. "No, Sir," I replied.

"Good. After morning report, see Dr. Althea Johnson for your patient list. I have custom compiled it for your special skills," was it just me or was there a twisted evil grin on his face?

I listened to the war stories of the interns and residents of Team Three. Those who had been on call overnight presented pretty grim stories of car accidents, gunshot wounds, stabbings and other assorted tasty morsels of trauma for an audience of doctors in various stages of training. Each presenting physician was quick to point out in the driest terms possible how completely gruesome the situation was. Each was equally eager to nonchalantly highlight how his or her cool mastery of the situation had led to the best possible outcome. Occasionally, a good outcome was not possible and when that was the case, the presenter was obligated to make it clear that God Himself could not have saved the unfortunate victim. The senior staff equally delightedly attempted to poke holes in the narratives of the presenters—either to suggest that a simpler more elegant solution was available or that the answer could have been arrived at more quickly. This was a game I had seen played at medical rounds countless times before, but it seemed that these players considered it blood sport—no pun intended.

I walked out of the room an hour later sweating—and I had not even had to present a patient! I was glad it wasn't me at the podium waiting for someone to rip my carefully prepared presentation to smithereens. Dr. Johnson handed me a computer printout of my patients.

"Carlos," Dr. Johnson said, "Watch out for Royce Cunningham. He's not as warm and fuzzy as he seems." She raised her right eyebrow, which I later learned was her equivalent of an ironic smile, and continued,

"One other piece of advice: The last patient on your list is an HIV positive heroin addict named Wasserstein who was in a car wreck two days ago. He did pretty well in surgery, although he lost his spleen and they thought he might have a bowel perforation but he didn't. Today in addition to any other problems, he is jittery, nauseated, anxious...you know the drill. The nurses have him on withdrawal precautions but you need to keep a close eye on him."

"Thanks for the heads-up, Dr. Johnson."

I looked at the list and logged onto the hospital computer to review the latest data on all of them, taking notes as I went. I made a judgment call. The Wasserstein dude was clearly potentially the most ill of the bunch. In my third year rotations the rule of thumb was, "see the sickest and the quickest first". That meant you went to the ICU first because those patients were most likely to be changing for the worse. Then you discharged the patients that you knew were ready to go home—this made room for new admissions and that made the hospital administrators happy. After that you saw everyone else last.

Wasserstein was the most likely to crump (translation: go down the tubes in a hurry without warning) so I went straight to his floor.

When I arrived to see my newest and sickest patient, things at first didn't seem so bad. I wasn't surprised that his pulse was a bit fast or that his breathing rate was higher than normal because, after all, I had been told that he was in narcotic withdrawal. He had a low grade fever and that, too, wasn't uncommon in the first days after surgery because of a phenomenon in which the lungs don't completely expand and give rise to a mildly elevated temperature. I went into the room and started to ask him a few questions.

"Mr. Wasserstein?" I began, "I am Carlos Vega, a student doctor with Trauma Team Three. How are you feeling today?"

It was then that I noticed that he was very sweaty and pale and not focusing on me as he spoke.

"Who the fuck are you, man? I don't know who you are but you need to keep the people with the black masks from looking in at me through the window."

At first, I thought he was referring to the observation window from the hospital hallway and maybe he was just sick of the every 15 minute neurologic checks that came with someone on withdrawal precautions. However, it quickly became apparent that he was referring to the outside window which not only looked over an alley but was _nine stories up_.

I did a quick exam but something was clearly wrong here. I thought about what Dr. Greco would have said.

Hold on a minute. Do it from the beginning. Use the fundamentals. Don't take anything for granted.

I called Dr. Johnson immediately.

"Dr. Johnson, I'm sorry to bother you. I know everyone thinks Wasserstein is acting oddly because he's withdrawing from narcs but I think it could be from infection. I think he's septic". I gave a fast summary of my findings.

The reply came back rapid-fire, "Vega, you're the doctor now, order the tests you think need to be done and I'll co-sign."

The test results I needed came back STAT and confirmed my suspicions. Wasserstein was an addict but he also had an infection that had gotten into his blood. I ordered antibiotics to cover the two most common groups of intestinal bacteria given his history of possible bowel perforation since his chest xray and urine tests ruled out pneumonia and urinary tract infection. He was transferred to the intensive care unit and had further evaluation to see if more surgery might be needed.

I then finished the transfer orders to the ICU and quietly faded into the background. This was no longer my problem and I had other post-op patients to take care of. My ICU colleagues took over care of Mr. Wasserstein. I was too concerned about making sure I finished my other duties to give the episode another thought.

Chapter 28

The day after the Wasserstein incident, I arrived early to make sure I knew everything about my remaining patients. I looked up Wasserstein and noted that he had been stabilized in the ICU and was doing better now. I dutifully collected every scrap of information and counted every fart from my post-op patients and prepared to be grilled to my eternal humiliation by Royce Cunningham.

When I got to morning report, many of the residents were looking at me and nodding. Ohmigod, I was sure my fart count was completely inaccurate. Sweat poured down my back. Royce Cunningham ascended the podium and looked directly at me with an inscrutable gaze and then addressed the room.

"Yesterday, I introduced our newest team member and gave him a bit of a hard time. I assumed because he had been getting massages and pedicures on the family medicine rotation that he might not know how to do real medicine."

He looked at me and actually smiled. Well, it was kind of a smile. I don't think he really knew how to smile. Maybe he looked it up in the _Journal of Facial Musculature._ Anyway, that was what he was trying to do.

"Well, my fellow surgeons and wannabes, I _may_ have been premature in my judgment. Dr. Vega here evaluated a patient that everyone had assumed to be withdrawing from narcs and instead figured out the guy was septic. He ordered the right tests, chose the right antibiotics and transferred the patient to ICU. From now on, Vega, you better be ready to chip those manicured nails and skip those massages. We're going to start you on your way to learning to be a trauma surgeon."

Now it was my turn to look nonchalant-even if inside me a little voice was saying _ididitididitididit!_

Chapter 29

My first full day of clinical duties completed, I knew that there were two women who needed to hear from me ASAP. I started by calling the one whose wrath was mightier.

" _Abuela_ , how are you doing?" I asked as meekly as possible.

"Don't 'how are you doing' with me young man," came the reply. "Now that you are Doctor big hero doing fancy operations and riding helicopters and forgetting your old _abuela..."_

"Untrue," I countered, "I have not ridden a single helicopter since I got here."

"Hmph," she muttered in a less severe tone, as if my lack of opportunity to leave the earth's surface made my transgression less heinous. "Well, have you saved any lives yet?"

"Not exactly," I replied, "but I did diagnose an infection that everyone else seemed to think was withdrawal from heroin."

"That's my Carlito," it was amazing how quickly she could go from angry at me to proud of me, "and what about that nice young lady you met in Maryland?"

"I haven't even had a chance to call her yet. I called you first, Abuela _."_

"Are you _loco?_ " she erupted, "You are on the phone with an old woman when that lovely girl is waiting for you, where are your priorities, Carlito? Get off the phone at once! Call me tomorrow." And she hung up.

The second phone call was trickier. Jillian and I still hadn't worked out this long-distance relationship thing. We were only 90 minutes apart by car, but our chances of seeing each other seemed remote for the next month and a half. Jillian was intensively working on her senior recital and preparing auditions for the next step in her career. We talked for about 15 minutes while she was between rehearsals. I hung on every word and every inflection, trying not to over-interpret each nuance of what she was saying. She was her usual self. Yet I couldn't help worrying. I hoped that didn't come through in what I was saying.

What if she meets someone else?

Chapter 30

It's amazing how something random can set the tone for an entire piece of your life. What if Royce Cunningham hadn't decided to give me a patient he felt would be a useless waste of my time? What if I hadn't taken a few extra seconds to question the diagnosis someone else had made? What if I had just been viewed as the usual surgical subintern instead of someone who had been lounging in family medicine for the previous two months? Then I might have anonymously gone through Metro Health Shock Trauma, done my time and had an adequate but uninspiring experience.

Instead, after the Wasserstein incident, it was as if everyone put out the red carpet for me. I don't mean they made things easy for me—in fact, they continued to test me all the time. It's just that the residents and staff had made a quick judgment—and they had decided that I was someone who _belonged_ and therefore could be included in some of the best experiences at Metro.

So as the rotation progressed, I felt as if someone was always tugging on my arm to show me something they thought was clinically cool. And I made the most of it. I helped out with burn care, spent days at the wound clinic, got an awesome tutorial at the hyperbaric chamber (where very high concentrations of oxygen are used to help heal wounds among other things) and in general got pulled to every type of trauma situation anyone could find for me to see and participate in.

Unfortunately, this meant I was almost always at the hospital, even when I was not officially on-duty. Visits to _Abuela_ were out of the question. Jillian did her best to understand my situation but one day she called me and I knew it wasn't going to be good.

"Carlos?" she said in a voice that I knew was wavering with tears, "my grandfather died this morning."

"Oh, Jillian, I'm so sorry..."

"You know how close we were, but also that he inspired my love of music—and especially the violin."

"Sure, you've said that many times," I agreed.

"Well, his funeral will be Saturday...can you please...come be with me?"

I wonder what Royce Cunningham would say to this one?

"Jillian, I will be there."

"Thank you so much, Carlos. And...I can't believe I'm saying this...but there is one more favor I need to ask. My first big recital is Sunday. With Grandfather gone, I'm going to be a mess. But if I don't play well, I'll be third chair at the East Nowhere Symphony. Would it be possible for you to attend the recital...you know, for moral support?"

I no longer wonder what Royce Cunningham would say—something about "whipped".

"Can I get an autographed program?" I said with a twinkle in my eye that I wished she could see.

Chapter 31

Getting permission to miss a day of a sub-internship would require an act of congress. Asking to miss two consecutive days might involve a human sacrifice at the altar of Royce Cunningham. I just didn't want that human to be _me._

I decided to talk first with Dr. Johnson. She seemed very helpful and encouraging.

"You want to _what?_ You pulled off the coup of the century by impressing his imperial majesty Cunningham the First on your second day here and now you want to turn all that goodwill to crap in a single act of desperation for a girl?"

Actually, two acts of desperation but who's counting?

"Look at it this way," I offered hopefully, "This is a former _patient's_ funeral and then I'm going to console a family member by attending her recital. Isn't that just good medicine? A kind of closure thing?"

Dr. Johnson looked at me like I had grown three heads and lost the minds of all of them.

"Vega, please don't load up all that family practice bullshit like you think Cunningham's gonna buy it 'cause you know he's not. Tell you what, I'm going to tell him I overheard your phone conversation and that you said you couldn't possibly come there but that _I_ convinced you to go. After all, I'm a woman and he already thinks I'm chromosomally weak."

"Dr. Johnson, you do _not_ have to do that..."

"I know I don't _have_ to do it, Vega, but I'll be damned if I'll let Cunningham wreck a perfectly good sub-intern who has real potential in this specialty. Now get your sorry ass out of here before I change my mind!"

"I owe you big-time Dr. Johnson" I yelled as I ran from the room.

I could have sworn I heard her mutter, _you bet your sweet ass,you do._

Chapter 32

On the drive to the Weinkopf house, I thought a lot about the last months of the life of Norman Weinkopf. I hoped they had been happy and peaceful. But I couldn't help but wonder if the medication we had given him to help his agitation might have hastened his demise. He was eighty-six years old and had multiple medical problems including high blood pressure and high cholesterol, so dying of a heart attack or simple old age was not out of the question. Yet it was impossible not to worry about the studies that showed a trend to increased mortality rates in elderly patients who took those medications.

I parked in front of Jillian's house and started up the front walkway but she met me halfway before I could even reach the door. She ran to greet me, gave me a tight hug and pulled me by the hand,

"Can we take a walk before we go in to meet everybody?" she asked.

I was a little curious who "everybody" was, but I was definitely up for a walk so I agreed and off we went.

We spent some time catching up and before long she found a way to reassure my insecurity about her grandfather's death.

"Carlos, I know we haven't known each other long but there's one thing I'm pretty sure about and that is that you're worried that the medicine you gave Grandfather might have contributed to his death. First of all, my whole family is in agreement that he was a very old man and it was just his time to go. Second, the past few months were really great. He was playing the violin almost every day, he could sleep, he had a great appetite and he was seeing his friends. He was at peace, Carlos. He was at the dinner table with my mother and father every night and he didn't have to be in some nursing home. So if you are worried about whether you did the right thing by recommending that medicine, please _don't,_ okay? "

I tried not to make my sigh of relief too obvious and then observed, "How is it that I am supposed to be here to comfort you and the first thing that happens is that you reassure me?"

One of those unbelievable smiles that I was falling in love with flickered across her lips and she said,

"I guess you'll have to keep hanging out with me to find out, won't you? We better go in the house now or everyone will think we're making out in the car."

Not a terrible idea at that but I suppose we should be sociable.

We walked in the front door, through the front hallway and to the left into the dining room where a surprisingly large group of people sat. There were plates with the last bites of chocolate cake and dark blue ceramic cups of coffee. In addition to Jillian's parents, Martin and Annette, there were two other couples whom I did not recognize.

"Everyone," Jillian began, "This is my friend Carlos. Carlos, you know my parents. On the left is my sister Morgan and her husband Jim. On the right is my sister Regan and her husband Brad. Regan and Brad have a son Daniel who is 2 years old and is asleep with his favorite teddy bear right now."

The two husbands stood and gave typical broad masculine smiles and shook my hand. I was offered cake and coffee which I gratefully accepted. Once everyone had exchanged a few pleasantries, the conversation turned to memories of Norman Weinkopf. It seemed that everyone had a story that was by turns hilarious or heart-warming.

"Why don't you share your story, Regan?" asked her father from the end of the table.

"Daaaad. I am not going to tell that story."

"Then I will," offered Annette helpfully. "It was near the end of Norman's career with the Philadelphia Orchestra. He had been the featured player in a violin concerto at the Philadelphia Academy of Music and the performance had been a particularly good one. Regan was, what would you say Martin, 5 years old? Anyway, it was her first concert and she was so excited to be there. We had tried to prepare as best we could but apparently she hadn't quite understood the whole concert etiquette thing entirely. So naturally after the concerto, Norman rose to take his bows and we all stood to give him an ovation. Suddenly, I realized that Regan wasn't there. At first, I was terrified but then I was both relieved and embarrassed to discover that she was onstage _hugging her grandfather_."

Everyone else at the table had been regaled with this story countless times before so they all chuckled predictably, but I had to hold in some pretty serious laughter as I envisioned the little girl who didn't realize the _faux pas_ she was committing in the middle of the very serious grown-up concert.

"I'm sure she was just so proud of her grandfather," I ventured in an attempt not to make too much fun of someone whom I really did not want to offend. Regan blushed in spite of how many times the story had been told.

"No, but it gets better," Annette continued as she took a sip of her coffee, "Regan somehow found a live microphone that she could reach and said for the entire Academy of Music, 'that's my Grampa'. The entire audience gave HER a standing ovation."

"Thus ended my stage career and began my exciting vocation in the insurance business," concluded Regan helpfully.

After everyone had finished laughing at Regan's expense, Morgan decided to pose a direct question to me.

"Just exactly what are your intentions towards my sister?"

I thought the question was a bit presumptuous, and I thought she was at least half-joking, so I tried to deflect it.

"Well, I thought that Regan and I would just gradually get to know one another, maybe exchange Christmas cards, hopefully one day be good friends".

She wasn't going to let me off the hook, "No, I didn't mean Regan, I meant _Jillian_."

"Oh, sorry about that. Well, you know we just met a short time ago. But I will admit that I've never met anyone who has made me feel like Jillian has. On the other hand, both of us have pretty uncertain career paths right now, so we just have to take it one step at a time.""

Morgan was unimpressed with what I thought was a pretty heartfelt but diplomatic answer and she turned her commentary towards the object of my affections.

"You know, Jill, doctor's wives have to get used to being pretty lonely. Their husbands work nights, weekends and holidays. On the other hand, they make quite a bit of money, so I guess that makes up for it to some degree..."

I could tell that Jillian and Morgan had been sparring partners in the past since Jillian was ready to swing right back,

"Morgan, I don't remember announcing an engagement. When I do, I'm fairly certain there will be standing room for you at the back of the church."

"Now, Jill, there's no reason to get angry, I'm your oldest sister and I'm only looking out for your future happiness..."

"MY FUTURE HAPPINESS? Now there's a laugh. If you were interested in my future happiness, why did you set me up with that dork Harvey Fishwell?"

"Harvey," Morgan bristled, "is a respected entrepreneur in this community and has had tremendous economic success.."

"He has a small chain of drycleaners, thinks that McDonald's is gourmet cuisine and smells like the laundry his clients bring him _before_ he cleans it."

"Beggars can't be choosers, Jill. When I saw that you were spending so much time chasing rainbows with that silly music thing that you weren't finding a decent man, I thought I should step in and assist."

"Thanks but no thanks for your assistance, Morgan. Dad, Mom, I'm going to show Carlos where his room is and then get some sleep. The funeral is early tomorrow and I'm really tired."

"Nice to have met you all," I announced brightly as I was led from the room.

Chapter 33

Jillian showed me the guest room and stuck out her tongue in a sisterly gesture of affection toward Morgan who was not in close enough proximity to appreciate it.

"Well, that went well," I observed sarcastically, "I'm hope I'm not being graded on that part of the audition."

She leaned in and kissed me with surprising fervor for someone who was grieving.

"I alone will judge your auditions, Sir. As for my sister, Morgan is married, gainfully employed and pregnant," she said ticking off each accomplishment on her fingers, "to her that is the life experience trifecta. I, on the other hand, have an impossible dream of orchestral performance, I am single and have no prospect of producing a legitimate child in the forseeable future. She therefore feels sorry for me."

"Ah, but she is mistaken," I countered, "thou art beautiful, destined for greatness as a violinist and frankly I don't see why guys haven't fallen for you all the time."

"Well, she is right about one thing, in my single-minded pursuit of success, I have neglected my romantic life a little." She looked pensive for a moment and continued. "There is something that Morgan said that bothered me a little, though. Is it true what she said about doctor's wives? I mean, I know it sounds really random to ask so early in a relationship but I was just wondering, you know, _hypothetically..."_

I laughed a little then pondered that one for a moment. "It is true that physicians are not 9-5 type workers because illness and injury tend to happen kind of inconveniently. It depends on the specialty but from what I've seen so far, pretty much everyone at least works some evenings, some Saturdays and at least takes telephone call on some Sundays and holidays. Specialties like the emergency room or surgery tend to work all day on certain Sundays or holidays. In fact, lifestyle realities like that are part of how we choose a specialty."

I continued, "Your sister is wrong about one thing, though."

"Oh, really? What is that?"

"It isn't money that comforts the spouses of physicians during those long hours apart."

"What is it then?"

"Well...let's just say that given our prowess as lovers, we're worth waiting for."

Jillian said in mock exasperation, "You did _not_ just say that."

I encircled her waist and drew her towards me with what I hoped was a devilish smile, "This is all evidence-based with double blind randomized clinical trials to prove it. I would be more than happy to provide a demonstration..."

"Carlos, my parents and my sisters are right downstairs. If I don't go down and say good-night in a few minutes it's going to be pretty embarrassing."

"I don't think they would want to stand in the way of your scientific enlightenment," I whispered, as I gently closed the door.

Chapter 34

Saturday dawned cool and rainy. I got up early and dressed in grey trousers, a white starched shirt, navy blue blazer and tie and black polished wing tip leather shoes. I didn't even own a black suit to wear to the funeral. I had breakfast in the kitchen with Jillian and her parents, but I made up an excuse to drive my own car to the church for the funeral mass. I felt like I was intruding at an intensely personal family time as they prepared to lay her grandfather to rest.

As I drove into the parking lot of Trinity Episcopal Church, I was surprised to see so many cars already there. I was early, but could barely find a seat in the last row of pews at the back of the historic stone edifice. Right away I recognized my old mentor Dr. Greco holding hands with his wife. Also present were the surviving members of the _Retirement With Strings Attached Players_ whom I had heard play Vivaldi with Jillian at the Weinkopf house—it seemed so long ago now.

The funeral service proceeded according to a format not unlike the Roman Catholic mass I knew so well, but there were also interludes for commentary by friends and family members. One oddity was that sitting on the (thankfully closed) casket was a single object—a violin which the mass bulletin noted was an authentic instrument crafted by a violin-maker from Naples, Italy named Nicolo Gagliano in about 1761. Initially, I wasn't sure if the violin was actually meant to accompany Norman Weinkopf into the afterlife like a pharaoh of ancient Egypt or whether its presence was somehow symbolic.

It wasn't long before Martin Weinkopf stood and strode to the lectern to explain:

"It was the final wish of my father that his favorite violin be placed on the casket at his funeral and that, just prior to his interment, I read this letter to all assembled. No one except my father and his attorney has seen what he has written herein until this moment."

"To my family and friends: If this letter is being read to you by my son Martin, I must presume that I have passed on to glory and it is the day of my funeral. On the other hand, Morgan and Regan, if you are snooping around my desk again and I am still alive, please put the letter back in the envelope immediately and place it back in my desk until I am fully and properly dead."

A nervous chuckle went around the church.

"I have had a marvelous and full life but I was never blessed with a conventional faith. I have always believed that the life energy of my being was and is music. That is why my _Gagliano_ is on the casket today. I would have bought a _Stradivarius,_ but Martin insisted on four years at Haverford instead of a more economical college so I could only afford the _Gagliano._ "

A little more laughter erupted.

"I have known the great love of a too-soon departed wife, a wonderful son and daughter-in-law and three granddaughters of whom I am proud beyond words. Since I have no true religion to guide me, I believe that beyond the memories held by those I love, any life eternal for me lies in music. And so, my dear dear Jillian, it is clear that it has always been you who understood that a soul might be transported by music. From the moment I taught you to hold the violin, handle the bow and place your fingers upon the strings, I hoped to create a legacy that would live in you through the magic and wonder of music. If my soul lives on anywhere, it is in that _Gagliano_ violin."

At that moment, Martin looked up and directly into Jillian's eyes.

"And that is why, Jillian, you must go now and claim that violin as your own."

A murmur went through the church and her eyes brimmed with tears as Jillian started, almost reluctantly, to walk down the aisle toward the casket. Martin concluded the letter as she held the beautiful polished heirloom instrument and her eyes shone bright and sad and determined.

"Jill, inasmuch as I can ever believe in an afterlife, you may now hold my very soul in your hands. Please do not feel I am pressuring you into performing on the stage. Whether the music you play is a lullaby for your children, a few notes to enjoy by yourself or a concerto for thousands of adoring symphony-goers, every melody and every arpeggio means that I truly live on. I love you always. Grandfather Norman."

Chapter 35

After the interment and a luncheon, Jillian and I had only a few moments to pack and then get on the road to Philadelphia. She gave her family a hug and a kiss and before long we were on our way. We drove northward on US 15 out of Maryland and then turned east on the Pennsylvania Turnpike. For a while we sat in silence. At one point she reached over and covered my right hand with her left one and I was again amazed by the emotion she could stir in me with a simple gesture.

"Thank you so much for coming to the funeral," she finally said, "it meant a lot."

"I was honored to be there for you," I replied and added, "and _you_ must have felt pretty honored when your grandfather bequeathed you his violin. Will you actually play it someday?"

"I might," she mused, "because the tone is amazing. But you don't just pick up someone else's instrument and start performing with it. It's more than just a tool. It's more like a partner. You have to figure out if the two of you really fit with one another. Plus, it's a little intimidating to play a violin that's worth over $150,000."

The car nearly swerved onto the shoulder of the road as I tried not to react to that little revelation.

"Are you serious? For one violin?"

"Sure," she smirked at my show of musical ignorance. "The _Stradivarius_ my grandfather joked about in his letter would have been worth at least 2 million since there are only about 650 left worldwide."

Now that I knew I was going out with a rich girl, I decided to change the subject. "You've had a really long day. Are you sure you're going to be up for this recital?"

She actually laughed, "Are you kidding? After Grandfather's equivalent of a 'win one for the gipper' speech from the afterlife could I do anything else? Seriously, Carlos, Grandfather was right. He's with me and I feel his energy inspiring me forward. This is something I've wanted all my life. Besides, you're going to be in the audience. If you can't rise to the occasion to impress your boyfriend, you're in serious trouble."

We parked near the recital hall and Jillian grabbed her instrument case and ornate performing gown to change into while I headed inside to see the auditorium. It was pretty impressive. There was red velvet carpet everywhere, crystal chandeliers and various performers looking dashing in tuxedos or sequined formal dresses. Evidently other students were giving recitals this evening also and some of their friends and families were in attendance. For a moment, I felt bad that Martin and Annette couldn't come but it was simply too soon after the funeral—there would be other recitals. Jillian said that there were other types of visitors and evaluators on hand but didn't explain much more about what that meant.

There was a palpable buzz of excitement in the audience as each performer was introduced. Then he or she would turn to the audience, give a brief nod to any accompanying musician, and begin to play. I looked around the audience at the faces of those who, like me, were here to support someone up on stage. Each of us was hoping that our particular loved one was going to make it big—either as an ensemble player in a major orchestra or even as a featured solo performer. The combined expressions of worry, hope, faith and sheer determination were something to see.

When Jillian walked on stage it seemed as if she was gliding. She gave the audience one of her trademark melt the room smiles and gave a polite bow acknowledging the welcoming applause. She positioned her instrument and her bow and began to play.

Now I'm no music critic, and there's no doubt I was totally biased, but I was completely blown away by her performance—and I couldn't even tell you what she played that day. The good news is that the ensuing thunderous applause suggested that the audience and evaluators had a similar opinion.

Afterwards, the performers came out to greet the audience and I saw Jillian quickly beckoned by a group of rather serious-looking well-dressed men and women. They gestured for her to sit down and spoke to her for about 15 minutes. They smiled but nothing particularly overwhelming seemed to be going on. Then they shook hands and parted ways. Jillian then walked over to me and gave me a hug with a completely unreadable expression.

"Wait a minute," I blurted out, "What just happened over there?"

"Carlos, I need to congratulate the other performers and then I'll tell you."

"Don't I even get a hint?"

"You need to _wait"_

Jillian then went and congratulated every one of the other recital students for what seemed like an eternity. When asked by her fellow performers what the impromptu meeting was all about she deferred and made some noises about some "future opportunities".

It was only when everyone had filed out, she had changed into street clothes and I think the custodial staff was vacuuming the acres of red velvet carpet that she finally told me.

She looked from side to side in an exaggerated pantomime of determining we were truly alone and then began jumping up and down.

"Carlos, I did it, I did it!"

"What exactly did you do?"

"Well, the first man to talk with me is the musical director of the Philadelphia Orchestra. One of the violinists is going out on maternity leave and they need someone to sub in for her. I'm one of three students selected to take a two week gig!"

"Ohmigod, congratulations!" I said as I hugged her right off the ground.

"Actually, Carlos, it isn't that uncommon for fourth year conservatory students to substitute in for concert instrumentalists in the Symphony. In fact, that isn't even the BIG news."

"You mean there's bigger news than that?"

"Yep. The bigger news is that I've been selected for a violin competition in Vienna, Austria. The winner gets a big leg up on a career as a soloist."

"That's so amazing! But why didn't you want to tell me earlier?"

"Carlos, those students worked so hard for that recital. They may one day be stars or they may take jobs outside of the music field entirely. The one thing I did not want to do was brag on _their_ big night."

"Jillian, your grandfather would be really proud—and not just of the music."

"Aw shucks, Dr. Vega. Now don't you need to get back to Baltimore before they bust your butt back to orderly or something?"

"Now you are showing your lack of knowledge of the medical field. 'They' cannot demote me like that unless I do something really irresponsible—like fail to give you a truly memorable kiss good night."

It was at that moment that she kissed me—and I realized that I would be doing the remembering for the rest of the night.

Chapter 36

When I returned to Metro after the funeral and the recital, I found out that I wasn't going to escape Royce Cunningham's wrath completely for missing two days of my sub-internship. As I worked feverishly to catch up prior to morning report on Monday, I passed by Althea Johnson in a dimly lit hallway before dawn.

"Well, Loverboy," she began, "I was able to protect you from a full-blown encounter with Hurricane Cunningham, but your little excursion over the weekend is still going to cost you."

"Oh, no," I imagined all sorts of draconian punitive assignments I might be forced to undertake, "what penance will be required for forgiveness of my sins?"

"He's going to take you to dinner."

"What?" I replied. "He's going to punish me by taking me to dinner?"

"Well remember he likes you, Vega. So this particular retribution will be more subtle. We have come to know it by another name—'torture by sushi'".

"You're talking about raw fish?"

"I ain't talking about no New York Strip Steak. He will order for you and expect you to love every bit of it. And don't even think about calling at the last minute and saying you're sick. He'll just courteously reschedule."

"I'm dead. I _hate_ fish and the thought of raw fish makes me want to jump off a pier."

"You should've thought of that when you took two days off of this sub-internship without a properly completed death certificate— _yours_. Your only saving grace is that I told Royce that you've always wanted to try the sushi in this area and you would be looking forward to having dinner with him at _Kiku Sushi_ restaurant _._ "

"I don't know a thing about sushi except that I'd rather eat spent nuclear fuel rods."

"Then you'd better start studying up on that little delicacy or your career in trauma surgery could be over before it starts."

* * *

Royce and I met at the restaurant at around 8 PM after evening rounds. He seemed relaxed rather than angry and I thought maybe this would be a low-key evening after all.

"Welcome to _Kiku Sushi_ , Vega," he gestured grandly around us as if he was the proud owner rather than just another diner. "I hope you're ready to appreciate one of life's greatest culinary experiences."

I was, but I knew I was going to be subjected to uncooked seafood instead.

"I am absolutely prepared," I replied, "although I have always wondered why the modern dish is still called 'sushi'. Sushi, as I'm sure you know, literally means 'sour-tasting', which harkens back to the days when it was prepared in fermented rice. Modern sushi is not prepared that way and yet we still call it 'sushi'.

Royce's eyes flashed with recognition. "Vega, I see I underestimated you again. Not all Midcentral U students are complete hayseeds, after all. You do indeed have an appreciation for fine food."

He turned his attention to the menu. "I was going to order some simple 'beginner' stuff for you, seeing that it might be your first time eating this exotic cuisine. But now that I see that you are a fellow connoisseur, I think we need to really do things up right, don't you?"

He motioned to the waiter and my heart sank as I realized my little bit of research had gotten me in even worse trouble. Maybe I would get lucky and have a severe allergic reaction to one of the first courses.

"Waiter," Royce began with nauseating enthusiasm, "We'll have two orders of the seaweed salad, then one order of _unagi,_ one order of _ika_...hmmm..oh, yes how about an order of the _tako_ and an order of the _ikura._ We'll also have some green tea. Also some _shoyu, wasabi_ and _gari._ "

My senior resident had just ordered eel, squid, octopus and salmon eggs with some delicious sauces to accompany them. And there was no way out.

"Dr. Cunningham, those are some of my favorites. I don't know how you could have known."

"I'm pretty perceptive that way. You know, Vega, some students and residents come onto my team and think I'm sadistic or that I don't care about people. Nothing could be further from the truth. Actually, I test everyone pretty hard because I'm afraid that if I don't, they'll fail at the next level. If one of my students or interns didn't succeed because I was too easy on them, I would feel responsible, you know what I mean? So if I ride someone's ass really hard, it's because I want them to make it."

I couldn't believe it. In some small way, Royce Cunningham felt like he had to justify his methods to a fourth year medical student.

He went on, "The truth is, Vega, you have the technical tools and the rapid decision-making ability to be a surgeon. Your patients also genuinely like you and bond with you, even in the short time they spend on the trauma service. Most physicians are not gifted both technically and humanistically to the degree that you are."

Our food arrived and Royce attacked it with his characteristic zeal—it reminded me of one of those old National Geographic films we watched in high school where the lions munched down on a wildebeest.

I took a sip of my tea and tasted each of the rolled slimy morsels of raw fish flesh in front of me. Waves of nausea broke through the effects of the anti-nausea pill that I had gotten one of the residents to prescribe for me.

Royce came up for air and looked at me with a penetrating gaze.

"Well, what do you think, Vega? Does it come up to the standards of sushi you've had in the past?"

I thought very hard. There was no way I was going to be able to finish my meal. I had come to a crossroads with Royce Cunningham. I could work _my_ butt off in his rotation but I had to stop kissing _his_. There was a risk, but I was going to have to tell him what I really thought.

"Dr. Cunningham, the truth is...well...I have never really cared for fish and sushi doesn't do anything for me." I waited for the storm from Royce that would end any hope of my becoming a trauma surgeon.

He stood up and threw down his napkin.

Here it comes.

"Son of a bitch, Vega, you _do_ have a backbone. You're the first sub-intern I took out for sushi that had the gonads to tell me straight up that they didn't like what I liked. I don't impress easy, Vega, but being willing to take chances when you feel strongly about something is what sets great trauma surgeons apart from merely good ones. You let me know when you need a recommendation, even if it's for a candy-ass family practice residency, alright?"

The rest of my trauma surgery rotation went really well. Maybe even extraordinarily well. I saw and assisted with just about every type of procedure associated with trauma that I could hope to experience. Burns, penetrating trauma, blunt trauma, gunshots, inhalational injuries, reconstructive surgeries and wound care/rehabilitation were all thoroughly covered on my curriculum. I came away with newly acquired knowledge of and even greater respect for the men and women who practiced this branch of medicine. The only thing that was missing in this highly sophisticated field of practice was an ongoing month to month or year to year relationship with patients and their families. The encounter with a trauma patient was a very brief and intense one compared with other specialties of medicine. There was much opportunity to save lives and make a difference but not much chance to forge a lasting relationship or even communicate beyond very short snippets. I came away from Metro still unsure as to where my professional future lay.

And so I found myself once again at the poker table with my old friends Courtney, Gomey and Tyler. It was now November and in two short months we would be submitting our preferences for the National Residency Matching Program. The NRMP is a system by which graduating medical students are matched with training programs where they will further develop their skills for a particular medical specialty. The student specifies a list of programs in rank order that he or she wants to attend and the programs rank the students that they want to accept. The result is referred to by both parties as "the match".

Tyler dealt the cards while everyone waited to see who would be the first to state what they wanted to do and where they wanted to do it. But before that moment came, Gomey blurted out a little news:

"I have an announcement, everyone. I'm getting married."

"Congrats, Gomey," Tyler said from behind his cards, "who is she and when the hell did you have time to actually _date_ during the killer rotations you've done so far this year?"

"The answer to both your questions is that she is a pharmaceutical representative named Chloe that I met at my general surgery sub-internship in New York so she was making sales calls to the hospital. Take a look at these pictures," he said as he passed around his smart phone.

I made some impressed noises as I looked through the pictures of a woman who was clearly wasting her time hawking medications to doctors when she could be on the cover of _Vogue._

"Okay Gomey," I said as I remembered his comments about Jilllian, "these pictures make it clear that there is only one more question to ask. How many Land Rovers and how many elephants did you have to offer her father?"

Gomey answered in the most serious tone imaginable, "My friend, we are not in Africa. Her father asked for a much greater price."

Courtney was now on the edge of her seat, "What was that?"

"He demanded that I do everything in my power to make her happy."

Tyler was highly indignant, "The nerve of that bastard!"

Gomey nodded solemnly, "That is not the worst of it."

I looked incredulously at him, "You mean, that wasn't all?"

Gomey shook his head, "In fact, he made it clear that if I hurt her, he would cause me to part with my testicles without anesthesia and outside of an operating room. This caused me to question the American legal system, the American health care delivery system and American marriage customs all at the same time."

The poker table dissolved into peals of laughter at poor Gomey's expense although the twinkle in his eye told me that he knew all along that his fiancee's father would not carry out the threat. I also knew the guy was so smitten with his lady love that he had nothing to worry about—he would do everything possible for her happiness.

A few hands later, we knew it was time to discuss the inevitable. Tyler began the discussion.

"We all know that why we're really here tonight, aside from our pathologic need to play a game which is really nothing more than a ritualized manner of donating to the Gomey Honeymoon Fund. It's time to lay our REAL cards on the table, so I will start. You all know that I intended to become a neurosurgeon, but I changed my mind. My neurosurgery rotation was just not what I hoped for—a lot of egos and not much opportunity for me to learn and get involved. My next rotation was vascular surgery and during that time I got involved with interventional cardiology and vascular procedures—like opening up narrow blood vessels and sticking stents in and stuff. Now you guys know that next to poker, my favorite thing is video games. Well, endovascular procedures are just like video games! You make a little incision, you thread in a little catheter, you look up on the screen and move the thing around. Then you open an artery up and stick in something to keep it open—all essentially by remote control. You can stop a heart attack while it is happening! And best of all they pay you big bucks to do it. I figured, THIS is what I was made to do. So, I am going for a general surgery residency at Duke University and later I will do a fellowship in vascular surgery followed by an endovascular fellowship. I'll be 34 years old when I finish but it will all be worth it."

The whole table applauded and whooped. When the ovation died down, Courtney spoke. "Well, my story isn't as entertaining as Dr. Video Game over there but I'm just as committed. My ambitions haven't changed one bit. I want to do Orthopedics plain and simple. It's a surgically challenging specialty and there's limited interruption for a bunch of silly documentation. You know what they say about an orthopedic surgeon's note in the medical record: 'Bone broke. Me fix.' There's really no need for anything more than that."

"Wait a minute," I challenged her, "Now with electronic health records, won't even orthopedic specialists be expected to write longer more comprehensive notes?"

"Oh, well you've got a good point, Vega. In the future, the note will say 'Bone Broke. Me Fix. Then Me Buy Mercedes-Benz.'"

"That sounds so much better," I said with a sarcastic sigh. I turned to Gomey, "Please tell me a more heartwarming story of the journey to your chosen medical specialty."

Gomey looked pensive. "I must tell you there has always been a little voice inside me saying, 'Gomey, your little village in Africa is poor and underserved. The people need you. Go back there and heal those who cannot afford the care that you have learned to provide.'"

"Now see everyone, there is the heartwarming story we have been longing to hear," I beamed with pride.

Gomey then continued, "And then there is a much louder voice saying, 'You know you want a two story stone colonial in Greenwich Connecticut and a summer house in the Hamptons and your children to go to the best prep schools money can buy so who are you kidding about going back to Africa?' I then realize how much I want to do transplant surgery and I let the louder voice drown out the little voice."

Another round of laughter seized the table and I joined in too even though I wish Gomey hadn't given up on the little voice quite so easily. Then I realized it was my turn and I took center stage.

"You all know that I am one of the few senior medical students who is actually trying to choose between family medicine and trauma surgery. In many ways, the two specialties couldn't be more different. Each offers unique challenges and rewards but both have potential limitations. The truth is that I still can't decide. I may wind up making the decision the day I send off my preferences to the NRMP."

Courtney was the first to chime in with a less-than-supportive reply, "Vega, that is so LAME. You are never going to be a surgeon if you can't be more definitive than that. You know what they say about surgeons, 'often wrong, never in doubt'".

Had she been a man, I might have displayed the central finger of ultimate respect at that moment. As it was, I just shrugged and dealt another hand of cards. I wasn't sure how long it would be until we would play again.

Chapter 37

The rotation that would lead to the winter holidays was Orthopedics back at Midcentral which had a pretty nice referral hospital even if it was in a rural area. It was also near my hometown which was a plus. The best thing about ortho was that there were some _awesome_ physical therapists who taught me how to diagnose everything from anterior cruciate ligament tears to tennis elbow. The surgeons were more interested in having me take out skin staples or evaluate post-operative fevers so they could catch up on sleep uninterrupted.

Things were going swimmingly until I got an unexpected call from my Dad telling me _Abuela_ had been admitted to Midcentral. This threw me for a loop since I hadn't known her to be sick since I was little. _Abuela_ didn't believe in sickness. Unfortunately, illness found her anyway. She got a bladder infection like many elderly women do and tried to ignore it until it turned into a kidney infection. The kidney infection spread into her blood and she was very sick in a hurry. She wound up in the ICU on intravenous antibiotics and despite the best preventive efforts developed a blood clot in her leg and bleeding from her stomach (ICU patients often get stress ulcers). To top it all off, she never told me she'd been treated for high blood pressure and diabetes for years and wasn't very cooperative with medications and follow up visits with her doctor prior to this hospitalization.

By the time I came to her room in the ICU, she was on the aforementioned IV antibiotics, was getting a blood transfusion, intravenous acid blockers, oxygen and insulin among many other medications. I approached her bed with trepidation.

"Now I see what it takes to get you to visit me," she said with the slightest hint of a smile.

"Don't joke like that _Abuela_ , you know I would have come even if you had just been in a regular hospital room. Going to the ICU was going over the top, don't you think?"

"Okay, next time, I do it differently. Carlito, you must explain things. No one here is telling me anything. They just poke and prod and give me medication. There must be 10 different doctors that have seen me. What is going on? When can I go home?"

I carefully explained everything I had read in her chart-which the ICU resident was kind enough to let me read. I concluded with a procedure that was planned.

" _Abuela,_ you have a blood clot in your leg because you didn't move around much for a few days. Normally, they would give you blood thinning medication. But they can't do that, because you are having bleeding in your stomach. So instead, they are going to put a filter in the big vein in your abdomen to make sure the clot in your leg doesn't go to your lungs. This is necessary because a blood clot in the lungs could be fatal."

"Okay," she agreed, "If you say it is the right thing to do, I do it." We then got one of the nurses to bring the consent form and she signed. Then, I gave her a quick kiss on the forehead and they pulled the curtain and brought in a special table and equipment to do the procedure right there in the ICU.

I went out to the waiting room of the ICU and greeted my parents with a hug. They both looked pretty exhausted. I wrote down each of _Abuela's_ problems, the medicine that was used to treat it and what I thought might need to happen before she could be sent to a regular hospital room or eventually home. My dad was appreciative.

"Carlos," he said fighting off a yawn, "the doctors here actually seem pretty nice, but when they talk, they speak a different language. They use words we don't understand and _Abuela_ actually got angry at one point. I know they are trying to help. But we can't even tell which specialist takes care of which part of her body."

It occurred to me that he was absolutely right. Doctors, nurses and hospitals had moved into the 21st century with digital lightning fast communication. But patient communication was still confined to a few words on 6AM rounds. The average patient was elderly, in pain, frightened and sleep-deprived and there was no way he or she could access information about care at times when a nurse or doctor was not present. Furthermore, we as medical students and doctors were given little or no training in the art of communicating with patients. I was amazed that no-one seemed to have developed a software application for this purpose—especially since a large percentage patients were now coming into the hospital with their own tablets or laptop computers.

I promised Mom and Dad that I would keep them updated each day and returned to my duties on the Orthopedics rotation. But _Abuela's_ experience as a patient left an impression on me as I decided how I would conduct myself as a doctor over the course of my career.

Chapter 38

_Abuela_ gradually recovered and I tried to be there every morning when her doctors rounded. It really hit home how complicated it must have seemed to her. Even once she got out of the ICU, she had a hospitalist overseeing her care, a gastroenterologist for her stomach issues, an endocrinologist who had been consulted about her diabetes (which was pretty badly out of control since she had been neglecting it for years), the radiologist who had performed the placement of the clot blocking filter, numerous nurses, technicians, blood drawing personnel and no way of keeping track of who was who and what was what. Everyone I saw talk to her was actually very personable, but they didn't seem to understand how to speak in words that could be understood by people that didn't have a medical background. I wound up having to give a line by line translation after each doctor left. And I gave the same explanations to my parents. What did people in the hospital do who didn't have someone to provide this service? I remembered so many times working with Dr. Greco when I would ask a patient who had recently been hospitalized, "so what did they tell you was causing your abdominal pain?" They would too often reply, "They didn't tell me anything". Now I understood why the patients saw it that way.

As I mused about the difficulties of keeping hospital inpatients informed, I felt a vibration in my pocket and looked at my cell phone. _JILLIAN,_ it read.

"Hey beautiful" I said as I wondered if they made a violin ring tone I could download.

"Hey, Dr. Vega, don't forget you have a big concert in Philadelphia on your calendar tomorrow."

I had definitely not forgotten. In fact, I had thought of little else. This was Jillian's last weekend on her two week fill-in assignment for one of the violinists with the Philadelphia Orchestra who was on maternity leave. I had never seen her play with any orchestra, much less with one of this caliber. I was really looking forward to it.

"You did score me front-row seats, right?" I joked.

"Absolutely, the front row of the Amphitheater, Dr. Big-Spender," Jillian returned facetiously. The Philadelphia Academy of Music is said to be the oldest known continuously operating opera house in the United States. It is a magnificent building constructed in 1857 and I was going to see my girlfriend play her violin there with about a hundred or so fellow musicians. Unfortunately I was going to watch from the Amphitheater—the section highest and farthest from the stage.

"I hope you didn't have to pull too many strings to get _that_ ticket," I said with thinly-veiled sarcasm.

"Actually, I did," she assured me, "it's a celebration of the conductor's anniversary with the orchestra and tickets were hard to get."

"Oops, sorry for the sarcasm. I didn't realize that," I mumbled apologetically.

"Why don't you hurry up and get here and we'll see what you can do to make it up to me?" she said in a way that made me believe that she might have time for me before the performance.

That afternoon I completed my rounds in record time.

Chapter 39

I arrived at the Academy of Music a little early to take in the atmosphere. Jillian had asked me to wear a tie and jacket and I was glad I did because my fellow concert goers were certainly turned out for the occasion. We filed in as the lights flickered on and off to inform us that the music was about to start. I wondered if Jillian was nervous or just happy to be performing or some combination of the two. I thought about what the life of a performer must be like compared with the life of a doctor—they were very different worlds, that was certain, I concluded. I climbed a number of flights of stairs and took my seat. There was near-silence as the music began.

Down on the stage my eyes were immediately drawn to Jillian. She was far away and still I saw her so well—her gaze intense and professional and yet her body seemed to be floating with the music. It was an indescribable feeling to see her thriving in the world she had chosen as her life's work.

When the music ended and the audience went out into the night, Jillian found me and led me to a room in a private area of the concert hall. I was surprised to see that a party was in full swing.

"Is this for the conductor's anniversary?" I practically shouted over the din of voices.

"No, this is to welcome back the woman I was subbing for," she explained.

Jillian took my hand and pulled me over to a somewhat tired-appearing but very pretty blonde holding an infant, "Gina, this is my boyfriend Carlos Vega. Carlos, this is Gina DiGiacomo, the extremely accomplished violinist who courageously allowed me to occupy her chair over the last two weeks."

Gina laughed, "Nice to meet you, Carlos, but don't let Jill play the humble young musician too much. Our conductor can't stop saying how happy he is to have a Weinkopf back in the orchestra."

Jillian was not going to let that one go, "I might be _a_ Weinkopf but I'm not _the_ Weinkopf. It takes more than an antique violin to fill my grandfather's shoes—or yours for that matter, Gina. I have a lot more to learn."

"Maybe so," countered Gina, "but I bet you're going to learn a whole lot competing at the _Kreisler._ "

Jillian crossed her fingers, "I hope so. Thanks for the vote of confidence. Take care, Gina."

Gina was quickly overrun with other well-wishers so I took Jillian aside for a moment.

"What is the _Kreisler_?"

She explained, "The _Fritz Kreisler Young Strings Competition_ is held in Vienna in early December every year. Fritz Kreisler was an Austrian-born violinist and composer—one of the greatest violinsts of all time. Violin players from all over the world come together to compete. The winner gets a scholarship to study and tour for a year with one of the world's great violin masters."

I must have looked truly stricken as I said, "Wow. It would be great if you could win...but I don't know how I would feel about the year apart..."

She laughed then gave me a hug and whispered in my ear, "It's okay Carlos, I know you're rooting for me. But the truth is that I'm a ridiculous long shot. I'm not really soloist material. I'm shooting for an orchestra, like Grandfather." She added, "I _am_ flattered that you like my playing enough to worry I might win."

I looked her straight in the eye. "When you're in that competition, you better only have one thing on your mind, Jillian Weinkopf, and that is kicking serious international violin butt."

"You have my word on it, Dr. Vega."

Chapter 40

I drove her to the airport the next day for her flight to Vienna. She would be gone for two weeks because the _Kreisler_ wasn't just a competition but also a series of workshops for aspiring string performers. They would also be doing some sight-seeing and going to regional dance and music festivals. I desperately wished I was going with her.

"Break a leg," I said lamely as I gave her one last hug.

"Carlos, I'll be back in _two weeks_ ".

"Videochat me every chance you get." I urged.

"I'll call you whenever I'm not out with Hans or Klaus."

"That is _not_ funny."

"Would you prefer I said I'll call you whenever I'm not in the arms of Brigitte or Helga?"

"Well you could at least send me video."

"CARLOS!"

"Just kidding," I laughed long enough to stop feeling sad.

"Pick me up here in two weeks, okay? Because I miss you already."

Then she kissed me and turned and walked away to check in for her flight.

Chapter 41

After I dropped Jillian off at the airport, I felt truly lost. I really didn't know what to do so I literally just started driving. Before long, I found myself back in the town where I had done the family medicine rotation—it probably wasn't an accident. It was Sunday, and on an impulse, I called Dr. Greco. He sounded happy to hear from me and actually invited me to come by his home for a chat and some hot chocolate.

I found his house without difficulty with my GPS. His neighborhood was predictably nondescript full of two-story colonial homes with two car garages on small lots with well-manicured lawns which were now dormant for the winter. I knocked on the door and immediately recognized the handsome smiling white-haired woman who answered wearing an apron embroidered with snowmen and reindeer.

"Come in, come in Carlos," she hustled me through the doorway, "It's cold out there. I hope you remember me. I'm Albert's wife Delores and I am so very glad to see you again."

The smell of cinnamon and coffee wafted through from the kitchen and I was ushered back into a large two-story family room with huge windows that let in the late afternoon sunshine.

I noticed that Dr. Greco stood from his chair very stiffly and moved very slowly but he gave me a big grin and stuck out his hand enthusiastically, "Carlos my boy, it's so good to see you again."

"I'm sorry to impose on the both of you like this on such short notice," I began.

"Impose?" Dr. Greco said incredulously, "Carlos, you are welcome any time of the day or night. I enjoy all of my students but our collaboration was the highlight of my teaching career and I mean that."

"Thank you, sir. I feel exactly the same way about my time with you. I think that's why I'm here now. I came because I'm more than a little adrift right now..." and out tumbled a little of everything. I didn't want to disappoint him since he had offered me his practice, but I wanted to be honest about my dilemma regarding what kind of training program to choose after medical school. I also let him know that my relationship with Jillian had developed into something special and that given recent events I was really worried about what would happen to us as a couple as she matured into the accomplished musician she was destined to be.

Greco got up and walked stiffly to the fireplace. He dropped in a fresh log, poked it around until it seemed to catch fire to his satisfaction and closed the screen. Then he turned around and looked at me.

"Carlos, as a budding physician, you are one of the few who can flourish in family medicine or surgery. The profession of medicine and the patients will benefit either way. What you need to decide is which practice environment will make _you_ happy both on the job and outside of it."

He then made his way slowly and painfully to his chair and sat down in a heap.

Gladys Greco took over from there, "I don't mean to butt in here, dear, but I saw Jillian with you at Norman's funeral, there was a look in her eyes that told me all I needed to know about the second part of your worry."

I looked at both of them and I was suddenly feeling better, even though we hadn't actually solved anything. Then it dawned on me that I had never known Dr. Greco to have problems getting around before.

"Dr. Greco, I'm not sure how to bring this up, but you seem pretty stiff and sore today."

Mrs. Greco looked at her husband disapprovingly and said, "Albert, are you going to tell him or am I?"

Greco looked at his wife wearily and then back to me. "Carlos, your observations are correct. I have been feeling achy and tired for months."

I looked questioningly back at him, "So are you seeing someone about it?"

He didn't respond immediately.

" _Albert,"_ his wife prompted.

"Okay, okay. Let's just say I'm not the best patient in the world."

"You can't be any kind of patient if you don't make an appointment," Gladys noted sarcastically.

"Alright, Dr. Greco, let's get this over with. Are you taking any medicine to lower your cholesterol?"

"No," he replied.

"Have you had red or swollen joints?"

"No."

"Any skin rash? Sores in the mouth?"

"No."

"Can you tell if the pain is more in your muscles or joints or both?"

"I'm pretty sure it's in my muscles."

"Dr. Greco, you know what this is, don't you?"

His wife answered for him, "He doesn't know because he's been too busy denying that he has any symptoms."

"Dr. Greco, you are 66 years old and you've been stiff and sore all over for months, not to mention exhausted. Why didn't you see your doctor?"

He looked at me from the corner of his eye and for the first time I wondered if I saw...fear?

"To tell you the truth, I was a little nervous about what she might tell me. I have had many patients with fibromyalgia and while some have had good response to treatment, the road to recovery can be a long one."

"Sir, you almost certainly have polymyalgia rheumatica," I blurted out, "Surely you must have suspected that. Just have your doctor order an erythrocyte sedimentation rate. I will bet you it is through the roof. You could be feeling better in a week with twenty milligrams daily of Prednisone!"

I will never forget the expression on Dr. Greco's face as he realized that his fears were probably for nothing. He let out a huge sigh of relief and smiled at me knowingly.

"Blast it, Carlos, you are absolutely right. Here I've been trying to teach you to start from the beginning and never assume anything and now you're the one teaching me."

"I've been learning from the best, sir."

Gladys Greco came into the room with a tray containing three steaming aromatic cups.

"I don't have prednisone in my kitchen, but will hot chocolate do for the moment?"

We watched the rest of the football game and Dr. Greco promised to make an appointment first thing Monday morning.

Chapter 42

After my impromptu visit to the Greco household, I turned my attention to the last weeks of the orthopedics rotation and getting ready for Christmas. Orthopedics remained low-key and I admit I wasn't very aggressive about pursuing the subject but at the same time the attending physicians didn't seem like they were that interested in welcoming me to their world, either.

That left me with plenty of time to help my parents decorate our house for Christmas and a chance to contemplate my next rotation, Emergency Medicine. Everyone still calls the Emergency Department the "ER" from the days when a hospital had a single "Emergency Room" although many hospitals have fifty or more rooms in their emergency departments nowadays. The ER is a good place to see a lot of different kinds of medicine in a short time—it can be anything from boring to terrifying. You learn to deal with everything from heart attacks to poisonings to broken bones to suicide attempts. As an aspiring surgeon, you can learn a lot diagnosing surgical disease in the ER. For example, you learn to decide whether a patient has appendicitis versus a disease which doesn't go to the operating room. The ER rotation is useful no matter what specialty one eventually chooses.

After I put the star on the top of the Christmas tree and turned on the lights, Dad brought me a glass of egg nog and lit the fire in the fireplace. Mom turned on some Christmas music by Harry Belafonte and I decided to do some online Christmas shopping. It was then that I felt the familiar buzz in my pocket—a text message from Jillian. "Go to the Philly.com website". That was all it said.

I booted up my laptop and went to the site. I wasn't sure what I was looking for until...

Holy crap.

Local student stuns world in violin competition

Vienna (Special to the Inquirer) In a shocking upset in the music world, local conservatory violinist Jillian Weinkopf, granddaughter of now-deceased long time Philadelphia Orchestra violinist Norman Weinkopf, has captured the coveted Fritz Kreisler Young Strings Competition championship in Vienna, Austria. Ms. Weinkopf has been a local favorite for years, but was frankly never considered to be a true contender for this honor. However, here in Vienna the judges were said to have been overcome by the "sweet tone and expressive phrasing" of her performance. One judge said, "Fritz Kreisler himself would have been impressed by this young woman."

The Kreisler prize includes 10,000 euro, a one year fellowship to the University of Music and Performing Arts in Vienna, and a special tutorial with world renowned violin master Wei Lin Chen who will be a visiting professor from the Shanghai Conservatory of Music.

I wanted to text her so many things. "Congratulations!" "I'm so proud of you!" "I'm so happy for you!"

But all I could think of was: _She's leaving me for a whole year._

Chapter 43

Okay, I thought, this is no time to panic. Jillian and I are adults and we can handle this situation. She wasn't coming home for a few days, so I had time to get advice. It was time to consult my relationship guru, _Abuela._

I drove on the highway through the leafless cold landscape to see the person who somehow always had the answers. I knocked on the door and got a well-needed hug and a tour of the lovingly placed holiday decorations in red and green and gold strewn about the house. _Abuela_ poured us each anegg nog and we ate a few Christmas cookies as she pondered my dilemma at her kitchen table. Then she asked me a question.

"What do you think you should do, Carlito?"

"Well, it would be really hard not to see Jillian for a whole year. But the honest answer is that she is pursuing her dream and I am going after mine. This is the opportunity of a lifetime for her. The man who loves her can't possibly be a man who would for one minute make her feel guilty about chasing her heart's desire—no matter how much it hurts him. So, I guess the only thing I can do is tell her that I love her and support her one hundred percent and hope that she will come back to me when the year is over." Honestly, I was a little surprised to hear those words coming out of my mouth. I hadn't put the thoughts together until just a few moments before.

I looked over and saw a tear run down _Abuela's_ cheek.

" _Abuela,_ are you okay?"

She turned to me with her eyes full of love and pride. "Carlos, you are so grown up now. These are not the feelings of an infatuated teenager, but a man who is truly in love. However, you must know that even with those noble intentions—yours and hers—there are no guarantees. In a year, she might meet someone else. You might meet someone else. There would be no betrayal or dishonor in that. You are both human beings and to be alone for a whole year might be asking too much of one or both of you."

"I guess we'll just have to work that out," I concluded. "Maybe I'll just go to mass every night," I joked gently.

"Carlos," she chided me, "Don't make promises you cannot keep. How about another cookie? There is a PBS Christmas special we can watch together."

Chapter 44

After my talk with _Abuela,_ I felt a lot better prepared when I picked up Jillian at the airport. I was the very picture of cheerfulness as I lifted her off her feet with a welcoming hug and kiss and practically skipped to the car carrying her bags.

Jillian regaled me for quite a while with stories of her adventures in Vienna. She made fun of the hyper-competitive musicians. She waxed eloquent about the art and architecture of the city. She described the cuisine in intimate detail. It was quite a while before she addressed the 400 pound year abroad gorilla in the room.

"Carlos, I hope you don't think I'm happy at the prospect of being away from you for so long next year," she began.

I replied with a script that I had rehearsed in my head a million times, "Jillian, you have never questioned my professional aspirations and how my medical training could affect our relationship. God knows that the long hours of medical residency and fellowship aren't always kind to couples. I am incredibly thrilled that you won the competition and will have this amazing chance to go to the next level in your profession. You're the best thing that's happened to me in a long time. How could I possibly think of throwing a wet blanket on your dream?"

That is when she asked me to pull over to the shoulder of the road.

She looked hard into my eyes and said, "Okay then Dr. Vega, but know this: I tried to let you go once before because we hardly knew each other and it seemed like we were heading separate ways. We stayed together and our relationship was strong enough to grow even with some time apart. Two different continents is a whole different story. I love you but I can't ask you to wait a whole year for me. It just isn't fair..." That's when she sobbed for the first time since she had contemplated the thought of her grandfather in a nursing home without the comfort of his family and his music.

"Jillian," I said quietly in her ear as I held her close, "Go to Vienna and find out where your dream takes you. I only know that I love you, too".

Chapter 45

The Christmas holidays flew by and I spent every moment I could with Jillian—even _Abuela_ didn't give me a hard time about it. Right after the glow of our New Year's Eve celebration, I found myself back at the airport dropping Jillian off for her flight back to Vienna because her fellowship was to begin right away. They had worked something out so that it could satisfy her remaining graduation requirements at the conservatory.

I don't remember the details of that farewell very much—maybe because I was already trying to resign myself to an existence without Jillian. I think I was subconsciously trying to detach myself. I knew that we would write and videochat and that my feelings deep inside were unchanged, but if I dwelled on those emotions too much I knew I would be too much of a mess to function. So I created a little wall to protect myself.

That January was important professionally for me in two ways. First, I needed to focus my attention on my Emergency Medicine rotation. Second, by mid-month I was expected to submit my choices for the National Residency Matching Program.

The ER rotation was great in that in got me back in the groove medically. The teaching physicians were eager to answer my questions (even if I found their personalities a bit callous at times) and get me involved in every way possible. I helped with everything from airway management to cardiac arrests to severe burn injuries to automobile accident victims. One great thing about the ER was you had to stay organized. ER docs take care of three or four patients at once all with very complicated critical problems and keep everything straight. This was a very handy skill for later in my training. I even briefly toyed with the idea of becoming an ER physician because it not only has the kind of immediate and dramatic opportunity to make an impact on patient's lives but also the chance to get paid full-time for working three 12 hour shifts per week which would leave more time to spend with a wife and family. The downside is that there is even less time than in surgery to create an interpersonal bond with people that you take care of because you usually get one encounter one time with the patient and that is it.

A particular encounter in the ED stood out for me above all the others. It was early on in the rotation and I was just getting my feet wet. One of the attending physicians was trying to give me an easy case to get started.

"Vega," he said, "there's a drunk in room 21 with a simple head laceration. Ask one of the Physician Assistants to go in with you and they'll give you any help you need with the repair, okay?"

I had done simple skin closures as part of my surgical rotations, so this sounded like the perfect way to begin my orientation to emergency medicine. I talked to Sarah, one of the PA's, and she and I entered the room to begin the encounter.

Inside we found a disheveled middle-aged man with a several day growth of beard smelling of alcohol and urine. I looked at Sarah who was already wrinkling her nose.

She whispered to me, "Hurry up and sew this guy up so we can get out of here."

Do it from the beginning. Use the fundamentals. Don't take anything for granted.

"Mr. Smolenski," I began, "I'm student Dr. Vega and this is PA Trachtenberg. We're here to help you with that nasty cut on your forehead. Can you tell us how you managed to get it?"

When he spoke, Mr. Smolenski didn't _sound_ intoxicated at all. "The funny thing is, I can't remember all of it. I know I smell like alcohol right now, but the truth is that I'm not much of a drinker. In fact, it was kind of stupid for me to drink anything because I get migraines so I usually stay away from the stuff. But I lost my job as a software developer six months ago and I've been kind of depressed. Finally, two friends from my old job invited me out unexpectedly for my birthday so we had two beers. But I swear to you, that's all it was. Next thing I know, we're leaving the restaurant, they drop me off at my house and drive off, I start to walk up the steps to my town house and that's the last thing I remember until I wake up with this cut on my head and a monster headache."

"Tell me about other headaches you've had."

"Well," he continued, "I've had headaches for the last six months. They've steadily gotten worse. I often wake up in the middle of the night with one and throw up. After I've been up for a while, they get better and I can go back to sleep."

"Did you have any other injuries in the fall?" I pressed on.

"When I got up, I realized I had bitten my tongue and—this is really weird and embarrassing—I think I peed myself. I'm also very achy all over, but maybe that's just because I fell."

"Mr. Smolenski, would you excuse us for a moment while we assemble the materials to close your wound?"

"No problem."

We exited the exam room and I looked at Sarah. "Pretty interesting story, huh?"

She wasn't entirely convinced, but didn't object to me phoning the neurologist on call.

I presented the case with my impression, "Sir, I don't think this man passed out in a drunken stupor, I think he had a seizure and with the prior history of worsening headache, I'm worried about a brain tumor. He's in CT right now getting a scan of the brain and an MRI will come later but I think he will need an admission and we would like to consult you."

The neurologist agreed. "Tell your supervising ED attending that I concur with everything you've said and I'll be arriving shortly. The patient can be admitted to the hospitalist service. We'll get an EEG in the morning. Nice work, son."

And thank you again, Dr. Greco.

That's when Sarah said to me, "Way to turn a 15 minute case into a two hour marathon, Vega. Now are you going to close the head wound or not?"

As for choosing a specialty, I was probably the last student in my medical school class to pick a field of medicine and location for training after medical school. I literally sat at my computer at the deadline comparing the benefits and drawbacks of being a family doctor like Dr. Greco versus being a trauma surgeon. High-tech or low-tech? Definitive interventions or long-term gradual changes? Brief focused encounters or being assimilated into families with all their joys and tragedies? Emphasis on procedures with state-of-the-art equipment or emphasis on diagnosis and medications? Huge income or merely comfortable income? With one hour to spare before the deadline, I pushed the 'send' button which would transmit my ranked list of training programs.

I hoped I had made the right choice.

Chapter 46

At the close of the Emergency Medicine rotation, I traveled back to Midcentral for another poker game with the old gang. We were all on edge for the results of the Match, which would be released in two weeks, but no-one really wanted to talk about that. Instead, we focused on the preparations for Gomey's wedding after graduation in June.

We were at Courtney's apartment and, sensing our anxiety, she prescribed an all-natural vegetable based remedy for our nerves—Coors Light. The quality of the poker playing deteriorated quickly but the conversation was as entertaining as always.

"Invitations to the wedding are going out very soon," Gomey began as he dealt the cards, "but all of you are, of course, invited--along with a date."

"How many of your relatives are coming from Africa to attend the wedding?" Courtney wanted to know.

"My parents, 2 brothers and 3 sisters will all be coming. I have some aunts and uncles who already live in the U.S. and they will come, too. But, according to custom, Chloe and I will have another ceremony in my home country so the whole village can attend."

"That is a really cool custom. What about you, Tyler," I asked the confirmed bachelor, "Will you be bringing a date?"

"Well, there is a girl I've been seeing for the past four weeks..."

"Four whole weeks!" Courtney exclaimed "Isn't that three weeks longer than your previous record?"

"Actually, she might be something special. She thinks my apartment decorations are cute."

All of us broke up in laughter over that one.

"Decorations?" I blurted out. "You mean the old pizza cartons and take-out containers from the Chinese restaurant combined with posters of your favorite NASCAR heroes?"

"I don't understand it either," he agreed, "she saw all that stuff and still wanted to keep dating me."

"You know the rules," Gomey said, "let's see the picture."

Tyler took out his phone and passed it around to everyone, "I've only got two pictures" he explained sheepishly.

I don't know what we were expecting, but this was one cute girl—kind of girl-next-door pretty with a really friendly smile.

Courtney summarized what we were all thinking. "Tyler, I didn't know you had it in you."

Tyler actually blushed, "She's a nurse on 6 North Telemetry at Midcentral Hospital."

Gomey smiled admiringly and said, "Save up for a Land Rover and an elephant or two."

"How about you, Courtney?" I inquired, "Will you bring a date for the wedding?"

"Um, I don't know, I hadn't thought about it," she replied evasively.

I don't know if it was the beer or whether we were just becoming more comfortable around one another over the years but I was feeling pretty bold.

"C'mon Courtney, tell us what's up with _your_ love life. We know we're not supposed to notice, but you are way too pretty to have been unattached for this long."

"Do you really want to know?" she said, looking at each of us around the table.

Three heads slowly nodded up and down.

"Okay, but this is a secret, and what I'm about to show you stays in this room, understood?"

Three heads nodded much more quickly this time.

Courtney got up and left the room. When she returned, she was wearing only a one piece bathing suit. My first impression was that she had a very nice trim body. As she got closer, I saw the point she was trying to make.

Her beautiful body was absolutely covered with scars.

"Not a turn-on, is it guys? If you're wondering what the point of this little show is, I fell out of a tree when I was a small child and broke way too many bones to count. The orthopedic surgeons put me back together, but I have these horrible scars to prove it. Everything works, but I'm not exactly eager to get to the point in a relationship where you have to undress. Everyone thinks I dress conservatively because I'm modest or because I'm too dedicated to medicine to look for a guy. The truth is, I would love to show off my body a little more—but who would want to look at this?" and she pointed to herself despondently.

Tyler, Gomey and I were quiet for a moment. Finally, I figured I should say something since she was responding to my question.

"Courtney, I'm so sorry. I didn't know."

"It's okay, Vega. I just thought you guys ought to know the truth."

After she changed back into jeans and a surprisingly sexy tank top, the game continued, but the humor and the conversation were a lot more subdued. Gomey even took less of our money than usual. Around 11 PM we called it an evening and helped her clean up. Gomey and Tyler walked out into the night leaving me and Courtney to say goodbye.

I was still shaken by her earlier revelation and I wasn't sure what to say.

"Courtney, I just want to say that I think you are really beautiful, no matter what you are wearing."

A smile slowly spread across her face and before I knew it she was hugging me. I looked down into her eyes and we kissed. Then we kissed again with a lot more intensity than one would expect between poker buddies. I took a crazy chance and traced one of the scars on the upper part of her chest with my index finger. She froze and took a step back.

"Carlos, please. You are a terrific guy and it would be so easy to go to bed with you right now. But I know that we are both a little drunk and you are missing Jillian big-time. I can't be your consolation prize even if it would feel great for a little while. Please go home before we do something we'll both regret, okay?"

She was right and I looked down at my feet as I blushed miserably. I felt completely embarrassed but somehow the next time I looked up we were both laughing hysterically.

"Courtney, you are so amazing. You deserve someone so much better than me. Please tell me that when that someone asks you out, you won't be afraid to say yes."

"Alright Vega, I think I can promise you that. Now get your ass home. Please?"

She pushed me out the door and I walked home.

Chapter 47

My next rotation was Plastic Surgery at Johns Hopkins Hospital in Baltimore. While I certainly didn't mind learning about facelifts and tummy tucks, I was most interested in reconstructive surgery after trauma or cancer. I wanted to know just how much one could do to restore the human body after it had been marred by severe injury or the radical surgery sometimes required to remove a tumor. To me, such surgeons were the artists of the medical profession and I wanted to learn all I could from them.

I continued to hear from Jillian throughout the winter as much as videochats, texts and phone calls allowed. She was thrilled with all she was learning and seeing in Vienna. And I was thrilled for her. Still, it was hard to stay close in the way we were before, though we tried very hard.

And then I met someone.

I didn't mean for it to happen. I certainly wasn't looking for anyone else. I still felt completely committed to Jillian in every way.

At least I thought I did, until one day in early March when I got an unexpected call from Tyler.

"Hey Vega," he greeted me, "How are things in boob job land?"

"C'mon Tyler," I cautioned, "I'm here to see a lot more than cosmetic stuff. There are a lot of patients with awfully disfiguring deformities here that need treatment."

"Yeah, right," he scoffed back, "Nothing more disfiguring than an A cup when what you really want is a double D."

"Thanks for the show of sensitivity, Dr. Video Game."

"Touche, Vega," he allowed, "anyway, I'm calling to ask a favor. My cousin Emily is coming to a teacher's convention in Baltimore and she is new to the area. She's kind of shy and doesn't know anyone. Would you be willing to show her around a little bit? I know it's asking a lot but you're honestly the only one I know in the area."

"I don't know, Simmons, this sounds way too much like a blind date."

"Relax, Vega," he assured me. "Emily is not looking for a boyfriend and I know you're still carrying a torch for Jillian. This is strictly a friendly couple of hours as a tour-guide thing."

I thought about that for a minute. A little companionship wouldn't hurt me either, come to think of it. And with the rules so clearly outlined as Tyler stated, what could go wrong?

"Okay Tyler, what's her number?"

Chapter 48

I decided to meet Emily on a Saturday afternoon after she had completed a half day of sessions at her convention in the morning. I picked her up at the Renaissance Hotel downtown across from the Pavillions of the Inner Harbor and we decided to embark on a little driving tour. We started at the shops and restaurants of Fell's Point then moved on to a late lunch in Little Italy at Sabatino's. We then drove past the Science Center and the National Aquarium. We then took a little walk through the Federal Hill neighborhood before driving to Mount Vernon and took a quick stroll past some of the wonders of the Walters Art Museum. By then, it was dinner time and I asked if she was hungry.

"I'm a little hungry and a little tired," she admitted, "Do you mind if we get something to eat?"

"Not at all," I replied, "Is it okay if we go back by the Inner Harbor? The views out over the water are really something to see this time of the evening."

She had no problem with that so off we went. We found a nice little restaurant looking out over the water taxi stop with enough passers-by that everything seemed somehow quite festive.

It was only once the hostess sat us down and took our drink orders that I had a real chance to take in Emily's appearance. Up until then I was concentrating hard on making things interesting during her "tour". What I saw now was a very earnest pleasant-looking girl in her mid-twenties with brown hair and brown eyes who smiled easily and chatted amiably in a way that was not nearly as shy as Tyler had led me to believe. After we ordered our meals, she told me she had been teaching middle school science for the past 3 years and liked it very much despite the challenges of the developmental stage of the students she was working with.

"Middle school science?" I said with mock incredulity, "Don't they give you combat pay or something for that?"

She tried to give me a reproving glare but it quickly dissolved into a smile which told me she had heard my lame joke about a thousand times before.

"Middle schoolers are much more sophisticated beings than we give them credit for. Contrary to popular belief they are not completely ruled by emerging hormones and the pursuit of social interests."

I wasn't sure that was the way I remembered it, so I asked her a more concrete question.

"So inquiring minds want to know: Just how teachable are they?"

Without hesitation, she replied, "In my class they learn exceptionally fast."

Remembering the semi-contained anarchy that was my middle school, I was really interested to know what pharmaceutical was being used to bring about this outcome.

"So are you going to divulge the formula for your success or is it patented?"

"It's not a secret formula. I believe my students achieve their goals for one primary reason: I _presume_ they will succeed."

"And that's all there is to it." I said with now with something dangerously close to sarcasm.

"Almost," she assured me, "but there is a great deal of preparation and work underlying the simple principle. Here's how it works. Let's say I'm teaching IPS—Introduction to Physical Sciences—to a class of eighth-graders. I know what they're supposed to learn—that's called the curriculum. What I need to find out is what they know before we start. So I spend a week or two assessing their knowledge of what they've learned before they got to my class. I don't give quizzes or formal readings or anything like that. Instead, I choose situations that are relevant to fourteen year olds to illustrate physical science questions and use the student's approach to the problem to informally assess their strengths and weaknesses. With luck, it seems to the students like we're just talking about life. In reality, I am carefully analyzing what they seem to be ready for. Then, I tailor my initial lesson plans so they _will_ succeed on whatever level they can. They quickly gain confidence because they become accustomed to doing well. Then I can ratchet up the degree of difficulty and they don't even notice because they believe they're going to accomplish whatever I put in front of them."

I gave a low whistle. I was so impressed that I had to ask her, "How did you put all this together so early in your career? Did someone teach you to think this way?"

She shrugged. "Not formally. At least, it wasn't something I learned in college. But it was something that I observed from elementary school onward when I had really good teachers. One thing they all seemed to have in common was that they _believed_ in us as students."

That sounded like a good credo for a teacher at any level of education.

After dinner, we walked the short distance back to her hotel and through the lobby to the elevators.

"It's very nice of you to take me around like this," she continued, "I hope my cousin didn't badger you too much to take me on as a tourist."

"He assured me that you don't decorate you apartment with old pizza boxes and NASCAR posters."

Unexpectedly, she giggled at that. "He really is a slob, isn't he? I'm kind of the opposite, actually. Maybe that's what people expect from teachers—neatness and organization."

I almost surprised myself with the forwardness of my next question, "What should I expect from you?"

"I don't know. Maybe I'll surprise you. Would you like to find out?"

"I think I would. Is there a chance you might need further tour-guide services?"

She then gave me my first surprise—an impetuous and very enthusiastic kiss.

"Does that come under the category of neatness or organization?" I asked, taken aback more than a little.

"It comes under the category of 'expect the unexpected'. The convention ends after the morning sessions tomorrow. Is there anything left to see in Baltimore before I go home?"

"Baltimore is a great town and there is always more to see," I assured her.

"If you pick me up at noon, you may find out more of what to expect from me," she said coyly and strode into the elevator.

Chapter 49

On the drive home, I found myself in a bit of a quandary. I had just pole vaulted my tour guide gig over the line into a date. Across the North Atlantic, I still had a girlfriend. Or did I? What would I tell Emily? What would I tell Jillian? Given that Jillian had given me a sort of "unconditional release", was I even obligated to tell her? I was tempted to call Emily and give her an excuse for not being able to see her. But I _wanted_ to see her. There was one thing of which I was completely convinced. Tyler was to blame for all of this.

I video chatted with Jillian that night. She seemed very happy. In fact, the more we talked, the more I was convinced she didn't miss me at all. She talked about music and museums and Viennese restaurants and people that I would never meet. She broke off our conversation to go to a rehearsal. We didn't talk about _us_ at all. I went to bed that night feeling a little less guilty about my plans with Emily for the next day.

Sunday morning dawned cold and bright. I went for a run, showered, shaved and dressed like I cared what I looked like. I drove down toward the Inner Harbor after reading some articles about ER diagnosis and treatment. Emily was waiting in front of her hotel—her cheeks a rosy pink from the chilly wind.

"This tour guide service is very convenient," she pointed out, "if the doctor thing doesn't work out, you could always make this a career."

I gave her an ironic thank you as we drove towards our destination. I decided to take her for a nice brunch and spill once and for all on the subject of my current status. I would take my medicine now and see what happened.

So, after some small talk, croissants, fruit, omelets, Belgian waffles and coffee, I decided to get right to the point.

"Emily, I have something I need to tell you."

"You mean, you're not really an AAA approved tour guide?" she tried to joke but was looking worried.

"It's a little more serious than that." And I gave her a diplomatically worded summary of my status. I had just been in a brief but pretty intense relationship. My girlfriend had given me my freedom but we hadn't officially broken up. She would be away until next January. We were starting to grow apart—which was true—but I couldn't say that I didn't still have some pretty strong feelings for her. In short, I wasn't really free but I wasn't really in a functioning relationship either.

"So It's a confusing situation and I wanted to come clean before anything else 'unexpected' happened," I said, fidgeting in my seat at this point.

_Here it comes,_ I thought. _The brave expressionless face. The folding and refolding of the napkin. The suggestion for a rapid return to the hotel. The end of what might have been. Why did things have to be so complicated?_

"Carlos," she finally said, "You're not engaged. Your girlfriend is away and told you she doesn't expect you to wait for her." She took a sip of her coffee and paused as she let a little smile spread slowly across her sweet and forgiving face. "Besides, there is no way I am going to find a decent tour guide on a Sunday on short notice. The way I see it, why don't we just spend the day together and see what happens?"

"Emily, you are 'unexpected' in a whole lot of ways." I said as I realized I was breathing again.

We set off from the restaurant and stopped off here and there in little spots across Baltimore until it was time for her to leave for home. We spent much of the time sitting in the car as the sun warmed us. We looked out over the water and talked for hours. It turned out that her town and school were in a county in northern Maryland so she was not all that far from Baltimore.

"Emily," I said as I dropped her off at her car, "this is all in your hands now. I have had a great time. You are so much fun to be with. I'd love to get to know you better. But I'll understand if you decide that I have too much baggage to invest in right now."

She gave me a hug and appeared to consider that for a moment. "Carlos, there are a lot of things in this region that I have never seen and you seem fairly knowledgeable. I would be pretty silly to give up such a competent and accessible tour guide over a little baggage, don't you think?"

I was beginning to feel warm all over.

She continued with light in her eyes, "Would you be available to show me a little bit of Washington DC next weekend?"

"Vega Tours is at your service," I replied quickly with a bow.

Chapter 50

The winter proceeded with my rapidly accelerating education in emergency medicine and my more gradually but happily developing relationship with Emily. She wasn't the kind of girl that you fell in love with at first sight. Rather the more I was around her, the more I wanted to be around her. She also quietly intimated that as a science teacher, she could get a job just about anywhere. _Anywhere._ Like if she needed to leave to go somewhere else to be with someone she was serious about, it wouldn't be a big deal for her...That was the thing about Emily, she made everything about our relationship so simple. I felt like I could announce suddenly that I wanted to do experimental oncology on Mars and she would say, "Mars! That sounds great. When do we leave?" Given that our relationship was progressing, it wasn't long before I got a phone call from Tyler.

"I can't believe you're hitting on my cousin!"

"Relax, Tyler. We're getting to know each other slowly. Besides this was _your_ idea, if you'll recall."

"Well, you've got a point there. At least Emily says you've been a gentleman."

"We tour guides have a strict code of ethics," I said with as much gravity as I could muster.

"Just make sure her _tour_ has a happy ending." He continued, "Speaking of happy endings, are you ready to meet up with Gomey, Courtney and me for the Match results?"

The results Tyler was referring to were for the National Residency Matching Program. They can be released depending upon the preferences of the individual medical school. So in March, Midcentral University School of Medicine chose to bring our senior class back to the same auditorium where we had been welcomed as first-year students. I guess it was a kind of closure. The names of the students would be read in alphabetical order and each student would be given an envelope with the location and type of training program that had accepted him/her. The result itself would not be announced but most students would make clear what had happened with a shout or wail as the case might be.

Courtney, Tyler, Gomey and I decided to change our usual routine. The night before Match results were to be announced, instead of our usual poker game, we opted for dinner out. As I changed into something presentable, I booted up my laptop to check my email—and immediately spotted a message from Jillian. I debated whether to read it right away or save it for later, but curiosity got the better of me. I took a deep breath and clicked on the link to the message.

Carlos,

I'm pretty sure that tomorrow is when you find out where you'll be going for specialty training after med school. I really wish I could be there to hear the news with you. It didn't hit me until just now that I don't even know which specialty you requested...Well, whatever you wanted, I hope with all my heart that you get it.

I can't believe that we've already been apart for two months. It seems like two years. Here in Vienna, I am learning so much and meeting so many people and experiencing so many new things. Yet there are times when I am still very lonely. So often I have considered just forgetting the whole thing and coming home just so I could see you.

But I can't do that. You know that, don't you? I just can't be one of those women who abandons all of her dreams for love—no matter how strong that love is. If I am going to be a whole person in a relationship someday I can't be wondering in the back of my mind about what I might have done. I have to know that I pursued my dream to the fullest, just as you are doing. I hope you understand...

By now, you may already be seeing someone else. Or maybe you aren't. I'm not sure which would hurt more. Knowing that you were unhappy and alone, or knowing that you were happy with someone else...In any event, I don't want to know.

Anyway, I didn't write to be a downer or depress you. I wrote to wish you good luck and to tell you that no matter what happens, I will always love you and wish you all that your heart desires...whether you wind up with me or someone else.

All my love,

Jillian

I pondered Jillian's note as I walked from my apartment to the restaurant. It was impossible not to compare my relationships with the two women in my life. My feelings for Jillian were overwhelming and intense but circumstances seemed to have conspired so much to keep us apart. My affection for Emily was more of a gently building wave and at the same time everything in our lives was making it so easy to become increasingly involved with her. I could work for the next ten months to hold things together with Jillian long-distance and then find that things weren't the same between us when she returned. Meanwhile, there was Emily—close and warm and so eager to make me happy.

Inside the restaurant, my chums had already arrived. A frosty pitcher of beer sat on the table in the darkened room amid the noise and laughter of a crowd that was all too ready to blow off steam.

Tyler spoke first, "Hey Vega, nice of you to make an appearance. Still working on seducing my cousin?"

I glared at him and then smiled and shook my head. Tyler was intellectually brilliant, but emotionally he was just slightly more evolved than a Neanderthal. "Tyler, you are incorrigible. Emily and I are in a _relationship._ "

Tyler drew me in close and whispered in my ear, " _Relationship,_ huh? Does that mean you haven't..."

Courtney, who had obviously overheard, decided to save me by interrupting, "Tyler, chill, will you? If you're so interested in people's love lives, would you like to hear about mine?"

The darkened room was suddenly transformed as Gomey, Tyler and I turned to Courtney with bright and inquisitive smiles.

"Who is the lucky guy?" Gomey inquired.

Courtney passed her smart phone around with the requisite show and tell photos. "His name is Sean Maloney. I met him at Stanford doing my Orthopaedics sub-internship. Unfortunately for him, he blew out his right knee anterior cruciate ligament tackling an opposing player as a fifth year senior on the football team. Fortunately for me, I was assigned to his case on sports medicine as he was being rehabbed after the ACL repair. His football career may be over, but he already graduated summa cum laude from Stanford and is getting credits toward his MBA. He has a job lined up with a major financial firm. He is also hot beyond belief and is about the sweetest guy you'd ever want to meet."

I looked up from his picture, "Courtney, he must be 6 feet 10 inches 280 pounds. His hands look like they could palm a sofa. Be careful or he might injure you just by accident!"

Courtney leaned over and whispered in my ear with a gleam in her eye, "Carlos, if I weren't such a demure lady I would tell you it isn't his hands that could injure a girl."

"COURTNEY!"

"I'm not sayin', I'm just sayin," she laughed and blushed a little.

Then she went on in a more serious tone, "You know, I don't think I would be with Sean today if it wasn't for you".

I was completely confused by that. "What are you talking about?"

"Remember the night at my place after the poker game?"

It took me a moment before the light bulb went on. "Courtney, surely I am _not_ the first guy to tell you how beautiful you are."

She brushed a tear from the corner of one eye. "Well, maybe not. But that was the first time I started to believe it could be true."

"Courtney, I am unbelievably happy for you."

"So am I," Tyler appeared from over my shoulder conspiratorially, "why are we whispering?"

Gomey raised his glass and the rest of us did the same, "To love. It may cost elephants, land rovers or tears. But once found, we are never the same afterwards."

"Hear, hear," came the reply and we drank deeply and laughed loudly.

* * *

The next morning came quickly and at the appointed time we began to gather at the auditorium. As we waited for the Dean and other bigwigs of the faculty to arrive, I reflected that I had always resented the alphabetical order thing for obvious reasons---my last name is Vega. So ever since pre-school I was used to having to wait until the very end of any given ceremony. However, when it came time for the envelopes to be distributed, the Dean of our medical school announced that there was a change in plans. We would be called up in _reverse_ alphabetical order!

So there I was with very little time to prepare. Zbiegniew, Arnold; Yeltzer, Denise; Yates, Brody; Vondelman, Rachel; _Vega, Carlos_ ;

Holy crap, here we go.

I walked to the front of the auditorium on the big day with my hands absolutely shaking. The Dean gave me my envelope and he flashed me a big smile. What did that mean? Was that a "too bad, nice try" consolation grin? Then I realized he probably didn't know the results yet either. I returned to my seat to sit with Courtney, Tyler and Gomey. We had agreed to wait until everyone had an envelope and open them simultaneously. Tyler had brought a talisman—a box of tissues to ward off the evil spirits. The theory was that if one had tissues, there would be nothing to cry about.

So then we waited, Simmons then Schwartz and naturally almost at the very end Adeyei (darn you Gomey for having a last name at the beginning of the alphabet!). Many of the students had already left before we even opened our sweaty envelopes.

Courtney reacted first. "University of California San Diego ORTHOPAEDICS!! Woo Hoo! Gonna get me an education and a tan!"

Gomey followed, "Massachusetts General Hospital GENERAL SURGERY!! Next stop transplants. Maybe I can find a donor to give Tyler a neatness transplant!"

Tyler went next, "Duke University GENERAL SURGERY!! More to follow but I'm on my way to playing video games for money!"

I swallowed and opened my letter very slowly.

"Johns Hopkins University General Surgery. Guys, I'm going to be a trauma surgeon and fix bodies and save lives by the boatload," I said proudly with a deep sigh of relief.

We all embraced and laughed and even cried a little. We made plans for graduation and Gomey's wedding and vowed to stay in touch with one another forever no matter what.

And there it was. I had everything I ever wanted. This was truly the end of the rainbow.
Epilogue

It is five years later. I am awakened in the middle of the night by the sound of a baby crying. In just a few seconds the events of the past six years pass rapidly before me: The rotations, the friendships, _Abuela,_ Dr. Greco, Jillian, Emily, the results of the Match, my residency, my wedding and now my first child.

I gaze with overwhelming love at my wife who surprisingly has not yet been awakened by our daughter's cries. _She must be exhausted--she really needs to rest._ I quickly arise and pad over to the crib, which is just a few feet away. I scoop up the little one and bring her downstairs so my wife can sleep. I feed her and change her, but the wails continue. I then smile as I remember learning the hold Dr. Greco taught me years ago. Gently, I flip our daughter over, her face cradled in my hand, her body supported over the inner surface of my forearm like a football, with my other hand gently rubbing her back and...

She keeps right on crying.

From behind me there are footfalls on the steps and there is my wife smiling and shaking her head at the two of us—bawling child and crestfallen husband.

"I'm sorry. I was trying so hard to let you sleep," I say. Somehow, I feel like I have failed a big exam.

"Don't worry, we'll just have to break out the secret weapon."

A few seconds later, I hear the lilting melody of an eighteenth century violin as Jillian comes strolling back down the stairs.

And the baby falls right to sleep.

Jillian carefully puts down the beautiful and ancient instrument and sits down next to me.

"Don't you have to be up in a few hours?" she whispers.

"Yep. You know, the usual routine. I start at the newborn nursery at 6:30 then office hours at Greco and Vega Family Medicine."

She slowly shakes her head and smiles, "Sometimes I can't believe how it all worked out. Who knew that you would leave a high-profile surgery residency after a year and switch to family medicine after all?"

I nod and say, "I really needed to be a part of this type of medicine and this practice and this town. What I can't believe is that you decided to come back from Europe and your solo violin career to play with the National Symphony."

"Remember that it's my town too. And did you think I was going to leave the hottest family doctor in Maryland to some school teacher? Easy decision," she laughs and gives me the kind of kiss that suggests that our daughter might not turn out to be an only child. "How much sleep do you need before the alarm clock goes off?" she asks with a gleam in her eye.

Sometimes it's not getting to the end of the rainbow that counts. Sometimes it's more important just to really enjoy the colors.

NOTES AND ACKNOWLEDGEMENTS

_Healer's Choice_ is a story intended to portray a crucial formative year in the lives of four medical students. All the events described _could_ have happened and are medically accurate to the best of my ability. Carlos, Courtney, Gomey and Tyler are composites of doctors-in-training that I have known as are the more senior Drs. Althea Johnson, Royce Cunningham and, of course, Charles J. Greco. However, none of these characters ever actually existed. Lest anyone think that this story is even remotely autobiographical, I assure the reader with all sincerity that Carlos is a far more gifted student that I ever was and Dr. Greco is the teacher of medicine that all of us wanted to have but I could never hope to be. Similarly, Midcentral State University is made-up as is Metro Health Trauma Center. I did not name the conservatory that Jillian attends-- although the reader familiar with Philadelphia is free to speculate on its true identity.

The details regarding the history of Gagliano violins are as accurate as I could make them—I considered having Norman Weinkopf play a _Stradivarius_ but, as Jillian points out to Carlos, such a violin is worth millions and I concluded that it would not likely be possessed by a violinist playing in an orchestra. Hans Kreisler was a famous Austrian violinist as the book states but there is no competition in Vienna named after him to my knowledge. There is a University of Music and Performing Arts in Vienna but the visiting professor from China with whom Jillian was to study is entirely fictional. I did work hard to paint an accurate picture of the kind of path a young violinist might follow and Jillian is the result of that effort.

I wrote this book because, while there are numerous accounts of the clinical experiences of medical students, there are fewer stories about how young doctors feel and interact and develop as people. What is hopefully not fictional is the atmosphere this book attempts to create—for students in training, for doctors in the exam room and physicians at all levels of experience in their communities.

I have many to recognize for their help in writing this book. First, I thank my professors at Milton S. Hershey Medical Center of Penn State University College of Medicine, who taught me to think and practice the way that Dr. Greco does. Also, my gratitude to the faculty of the family medicine residency at Andrews Air Force Base, who encouraged me always to _... Do it from the beginning. Use the fundamentals. Don't take anything for granted._

My thanks also go to Jason, a fine young doctor who reviewed the manuscript, and to Keri, a close friend and veteran educator who looked over the book early on and encouraged me that the story might be remotely interesting and comprehensible to those without formal medical training.

Finally, I would like to thank my wife Laurie, who was patient and kind as I hammered out the story over many months. She took much time hearing every word and vignette and made important suggestions to flesh out the characters. Without her patience and encouragement, these characters and their stories could never have come to life.

