The Things I Carry

For years a worn black leather bag sat on a shelf in the rear of my closet. It is a doctor’s bag, and my grandfather carried it for nearly 20 years, caring for his patients in their homes. Although he died before I was born, the stories of his small general practice, one in which accounts were kept in an old shoe box and bills were often paid by barter, were handed down to me like family heirlooms. The leather is dry and cracked, and the key to its tarnished brass buckle was lost long ago. My father used to keep spare electronic odds and ends in it. If you ever needed a speaker wire or a camera battery, chances were you might find it in the bag.

When I went away to medical school, my father cleaned the bag and gave it to me. I accepted the gift with gratitude, but in my mind I categorized it with the faded antique copy of Gray’s Anatomy on my bookshelf: both seemed relics of a time gone by, of interest to a historian but not very relevant to medicine today.

So that summer the bag took up residence in my closet, and it stayed there through all medical school, while I memorized biochemical pathways and struggled to bring myself to violate the flesh of a cadaver with my first halting incision in my Gross Anatomy laboratory. The bag never moved through my third year of studies as I woke at 4:00 am to check in on patients before surgical rounds or as I experienced my first delivery on the obstetrics service.

One afternoon in my last year of residency, I was busily reviewing job opportunities (1 to 6 call ratio, salary guaranteed for 24 months) when a local gastroenterologist paged me. He had just diagnosed advanced, inoperable squamous cell carcinoma of the larynx in a patient who had no primary care physician. Would I see her in the hospital and assume responsibility for her?

Then he told me a little bit about the patient. She had schizophrenia with paranoid delusions that kept her from seeing a physician about her multiple medical problems. She smoked three packs of cigarettes each day and had visited the emergency department 5 days earlier when the pain in her throat became unbearable. The emergency department physician referred her for laryngoscopy, but the police had to be called to cajole her into keeping her appointment because she so feared leaving her home. The more I heard, the more impossible my task seemed. How could I possibly help this woman?

I first met her that day in the hospital. She was still groggy from the anesthesia but seemed far different from her description. Instead of being the hostile psychotic I had expected, she spoke to me softly and helpfully discussed her condition with me. She was gentle, mild, and grateful. We agreed that she would come to my office in a week.

I asked one of my faculty mentors about her. I described her cancer and her poverty. He looked at me quizzically when I told him she would be in to see me later. “Why don’t you just plan to visit her at home?” he asked. I was so accustomed to the residency’s office-focused practice that it had not occurred to me to offer a home visit.

My patient arrived later with her caseworker, and I described that plan to them. She, too, was surprised. “You mean you could just come to my house and see me for checkups?” she asked, incredulous. “Really?” She turned to her caseworker inquisitively, as though she thought we might be making a joke. Finally, she accepted my offer. “That would be wonderful,” she sighed. That night I retrieved my grandfather’s bag from the closet and filled it with things I might need for a house call.

I went to her home a week later. She lived on the top floor in a small house behind the YMCA. I ascended a staircase that managed the seeming impossibility of being simultaneously vertiginous and claustrophobic. Finally, I reached her door: 5B. I knocked.

She greeted me warmly, and I followed her up another staircase, this one even narrower than the one in the hall. A snow globe sat proudly at the top of the stair on a low wooden box. Inside the glass was a miniature replica of the Statue of Liberty, and a small brass plaque on the base was inscribed with the words “New York City.” I looked around the room, taking in a living area with a single chair, a tiny television, and a battered red milk crate upended and in use as a footstool. The apartment, claustrophobic as it was, spoke of neatness and order.

Grace led me to her kitchen table. First we talked about her pain, discussing analgesic options. Later she told me about her family and about her new caseworker. She brought out her photograph albums, telling me about her estranged family. Grace offered me coffee and then demonstrated how she could prepare food in her tiny kitchen without ever leaving her seat at the table. She smoked constantly while I was there. I noticed her hands trembling as she brought the cigarettes to her lips.

During the next few weeks we became friends, and I learned about the rhythms of her life. I followed her to the drug store around the corner and watched as she bought an entire weeks’ supply of groceries from the Revco’s sole snack aisle. Each visit she told me even more about herself, and she never tired of chiding me for not drinking her coffee. “It tastes too strong!” I always protested. These kinds of interactions, the insights into her daily life, were new and wonderful for me. I had never learned about a patient in those ways.

One night that spring I was finishing up with Grace when she put her cigarette down. She looked over the rims of her glasses at me, and I saw her mouth tremble. “I know that I will die soon,” she said. “I’m really not afraid. It seems like the right thing for me now.” She laughed softly. “Someday you’ll understand.”

Grace was right; she died in her sleep the next week. The hospice worker called me to Grace’s apartment that morning to certify her death. As I walked up the stairs to her tiny home for the last time, I carried my grandfather’s bag in my hand. Inside it, jumbled with the stethoscope and the reflex hammers, lay a connection to my past and a promise for my future. Grace had taught me that my grandfather’s kind of medicine was still alive and well in the homes of my patients. I needed only to get out of my office, away from its sterile lights, machines, and procedures, to experience it. Home visits were not antiquated, I learned. They are as alive as our patients. As I pondered this realization, I looked around again at Grace’s apartment, now still and empty. Then I sat down at her table and drank a cup of coffee to her memory, black.

• Received for publication November 20, 2002.
• Revision received November 20, 2002.