Market Dynamics
Clayton Dalton on being a physician and writer.
Robert Coles and William Carlos Williams are two men each known for two things: they were both physicians, and both writers. Coles first met Williams, a pediatrician and poet, when Coles interviewed him for his undergraduate thesis in literature. That experience so moved Coles that he became a physician rather than a professor, as he had intended. The two men maintained a lifelong friendship and correspondence, and Coles became an esteemed advocate for the power of story, both in medicine and in life. He fulfilled both original ambitions through a long career as a practicing psychiatrist and as a renowned teacher of the humanities at Harvard.
I suspect, if either were able to speak to their being known as physician-writers, that both men might bristle. Coles visited Williams regularly while he was in medical school, sometimes accompanying him on home calls. On one such visit, Williams dispensed a jewel to student Coles as he expounded on the nature of the relationship between doctor and patient. “Their story, yours, mine—it’s what we carry with us on this trip we take.” What he was trying to say, I think, is that story is integral to everything. It’s how each person makes sense of themselves, and of their life. It’s how we relate to each other. Oliver Sacks, the neurologist and writer, had this to say about the importance of story: “We have, each of us, a life-story, an inner narrative — whose continuity, whose sense, is our lives. It might be said that each of us constructs and lives a “narrative,” and that this narrative is us, our identities.” And, especially important for those two men, story is the most important diagnostic tool that a physician has. Taking a history from a patient helps us gather a sense for what ails them, and is critical in guiding our evaluation and treatment.
Sometimes, the story saves the life. One afternoon a few years ago, I took care of a woman with asthma. She had come to the hospital because she thought her asthma was flaring up. She was short of breath, and her inhaler hadn’t been helping. If I had been moving quickly, I might have settled on asthma as the most likely diagnosis, and ordered her a breathing treatment. But I spent a few extra minutes at her bedside, and asked a few more questions. I asked if she had felt any other symptoms in addition to her shortness of breath. She remembered that she had almost fainted earlier that day, and that her right arm felt numb. Those weren’t typical asthma symptoms. Her story led me to suspect that something much more dangerous might be at hand, and I went looking for it. Sure enough, I found that she had a massive blood clot in her lungs. If I hadn’t been attentive to her story, I might have treated her “asthma” and sent her home, where she surely would have died.
Coles and Williams might bristle at being known as physician-writers because, in truth, there is less distinction between mastery of medicine and mastery of story than you might suppose. It’s all braided together. In Coles’ The Call of Stories, he relates a formative experience from his medical training. “The people who come to see us bring us their stories,” an elder physician tells him. “They hope they tell them well enough so that we understand the truth of their lives. They hope we know how to interpret their stories correctly.” Coles, reflecting on this moment, writes that “he simply wanted to remind me that I was hearing stories all day long, and that when I came to him for supervision I was bringing stories to him—telling him a story at second hand.”
Writing, to me, exercises the same faculty of mind as the practice of medicine, but to a different end. In the hospital, I use story to help me reach a diagnosis and take good care of my patients. I use story to make sense of suffering, so that I might alleviate it. And in writing, I use story to help me make sense of the world, so that I might in some small way illuminate it for myself, and, if I’m lucky, perhaps for others as well.
Market Dynamics, a story by Clayton Dalton
Pick the right seam and the whole round of timber will open up before you. Use a maul, not an axe. Unless you find a knot, then use a wedge. The outer rings are softer. Start there and work your way in.
He swung the maul through a tall arc and cut a two foot round down to the block. The sound of wet sinew split quick by the steel rang off the metal siding of the wood shed. The morning was quiet enough to pick up a second, fainter echo as it came back off the maple stand across the yard to his right.
He set up another round, stepped back, and muscled the fiberglass handle around and down again.
Two, three more like that. He stood back and leaned on the maul to breath.
He watched the vapor spread and fade after each exhalation. Not so different from what’s laid down in the rings of these rounds, he thought, except permanence.
Squatting, he flipped one on end and contemplated the wound skeleton of the tree.
When is a tree dead?
He considered that something slow to grow might also be slow to die.
Thirty seven rings, he counted.
Longer than he’d owned this property.
He set the round atop the block and split it through.
The ritual of it was important. It brought him back from that knot that sometimes spun and grew behind his eyes, casting itself over every mental turn like some terrible veil. Generalized anxiety disorder, the doctor had said, and prescribed Xanax. That’s bullshit, he thought to himself, but he had filled the prescription.
That first pill bottle sat unopened behind the mirror in the bathroom for three weeks. Each morning he would consider it as he took down his razor and brush. Not the prospect of taking them himself. No, it was the other thing that rose in his mind. Soon it was other times too, stopped at a traffic light, or in line at the super market. Then it was in the middle of conversations or telephone calls.
It took three weeks to talk himself into it, or rather for him to give up talking himself out of it.
He hated himself for it, but what other choice did he have? Social security plus whatever he brought in from mapling wasn’t coming close, especially with Suz in the home. And they hadn’t figured on the medical expenses the way they had turned out. He hadn’t told anyone that the retirement account had only about eighteen months left in it, the way it was going now. There wasn’t really anyone to tell.
He took down the orange bottle from its shelf behind the mirror and he got into his truck and he knew where to go.
—
You can’t imagine what it was like for him to pull in behind the Circle K and tell the kids behind the dumpster that he had pills for sale. Weirdly, he remembered the smell better than anything else—wet cardboard and citrus. Not the sweet punch of a fresh orange but the chemical odor of a syrup.
The space was sheltered on two sides by the brick walls of adjacent buildings and on the third by the flank of a large metal dumpster. The open end of the enclosure stood twenty feet across from the back of the Circle K. There was a door there but it stood bolted and was never used.
Five kids were arranged among looming stacks of wooden freight pallets and milk crates. A large whiskey handle sat atop its own central crate and was crammed full of cigarette butts. Several inches of collected rain water sat in the bottom of the handle, ocherous from the leaching color of the macerated butts there.
The kids looked unbelievably young, thin as birds and not yet rid of the feminine countenance of youth. Except Francis, who was the oldest at probably eighteen and had begun to grow into the thickness of adulthood. He was the only one that ever spoke.
Despite their youth, there was a disturbing edge that shone hard in their eyes. It reminded him of something that he couldn’t place at first. It took him some weeks before he realized that they reminded him of feral dogs.
He had been careful to close the truck door hard, that first time, to announce himself in the back parking lot. The gravel seemed loud under his boots as he rounded the squat hulk of the dumpster. It was getting on toward early evening, and the sun was already low in the sky. It came across the top of the dumpster and clove the space behind nearly in half on the diagonal. He could just barely make out two adolescent forms sprawled under the dumpster’s gloom. Two others leaned against the opposite wall and were etched by the light. Francis sat on the edge of two stacked pallets in the middle of the space, the glass handle of cigarette butts on its crate in front of him like an icon. The angle of the light coming over the dumpster lit him crosswise like a spotlight from shoulder to knee.
The red prick of a cigarette cherry hung in the shadows between his legs, its laze of smoke catching the light as it rose.
Hi John, said Francis.
The cigarette came up from the shadows and he took an exaggerated drag. He held it not between forefinger and middle but between middle and thumb, the flare of the lit end covered by the cup of his palm.
John had known the father of this boy before his death from alcoholism two years before. He had been the father’s manager at the paper mill. He knew Francis from the five or six dinners the two families had shared before the father’s addiction had made him unemployable. He knew also of the boy’s inveterate interest in the abuse and distribution of pills of all kinds. As the father’s mistakes at the mill became ever graver, as he came to work ever drunker, he would descend in John’s office into a sopping apology and exculpation that laid blame on his son’s addiction, on his own addiction and transmission of addiction and thereby failure, that bemoaned his inability to do better but swore to do better next time, etc. It wasn’t much more than two months after his inevitable termination that Francis had found him dead at home, apparently having choked on his own vomit or blood. Or so went the rumors.
Francis had never called him John before. The adolescent pursed his lips and blew the smoke out toward him in a thin and reaching stream.
John held up the bottle of pills, a tangerine blush in the evening light.
Francis looked from John to the bottle and back again, and a thin smile began to spread slowly across his face like a malignancy.
—
They started to squeeze him once they saw how they commanded him. To them, at least, he had something to lose. Every month a little less per pill. Market dynamics, they told him. It took everything he had to hold it together until he was back in the truck.
He thought of the round, and of its tree.
Thirty seven years.
Things had been different then. The family still together, house full of sound and life, his wife’s mind not yet dead. The process had begun with her reading glasses, insidiously. Have you seen my glasses? Always with her glasses, at first just a bit more than you might expect from anyone her age, but then more. Daily, hourly. By then it was other things too, familiar people, familiar objects. Darling, have you seen the what-is-it, the kitchen thing that’s flat? For cooking? Scraper-like, you know? He would move slowly into the kitchen, pull the spatula from its drawer, press it to her hand. Kiss her on the ear.
He avoided the internist with Suz, putting off six month visits, too busy at the farm. Can’t you just call in those refills again? We’ll make it to the office next time around.
We’re doing alright.
When they finally did go, it was every bit as bad as he had known it would be. Suz introduced herself to the doctor, who had delivered their three children, and said that it was very nice to have met him, and when did he move to town? The doctor’s face was ashen—there had been no idea. He looked to John but John couldn’t meet him, and instead looked away into the corner of the room, and further.
He drives the twelve minutes to the home every day, at a quarter to six, to feed her. He never listens to the radio in the truck except when he drives there. Sometimes in winter the sky-wave interference brings AM stations from all over the state through the dusk onto a single frequency. All those voices, all at once—makes the quiet white fields seem a little less empty as they roll by his window. He’s never missed a day.
There are three women who sit behind the reception desk. He knows their names and smiles as he enters. They grin and say Hi, John! and ask how he is, and he wonders how they can stay bright when they share a roof with such human decay.
He hates it, but how can he not go? How abandon this woman with whom he made life for so long?
There is a body, yes, but is this his wife? Is this body Suz?
When is a person dead?
He thought again of the round, and of its slow and imperceptible death.
Her eyes are dim and empty. She doesn’t seem to see him anymore. There is no recognition. She doesn’t know his name, or her own. She almost never speaks. When he feeds her, she chews as if in half-remembrance of how it should be done. Creamed corn or soft carrots dribble on her chin like a toddler, and she is incontinent. And so life comes around on itself, again. He dies a little each time to see his beloved as such. There is no indication that she would know if he were not ever to return.
—
He mounted another round and swung too hard. The impact of the blade on the block stung his hands. A wind came on, raising a racket of dry leaves. Bare limbs scattered and scratched on the metal siding of the wood shed.
Remarkable how divorced the body and mind really are. Seems like people these days are always talking about how they’re connected. Body and mind! Teach those people how to swing a maul, let them practice awhile. Then ask them where their mind is while they heave that tool and land it on a seam. It’s not anywhere. It’s not to be found while the body tends itself. Once you get a feel for it, the body stands back where it should, a handle length and some. Hands set on the fiberglass grip just right. Eyeball your mark and start the arc back and up and easy to the top, then let the weight bring it down hard and fast.
The ritual was almost anti-thought—why he needed it. Better than a goddamn pill.
He hefted up a round of elm and set it on the block.
The doctor’s voice came into his head—John, I need to talk to you about something.
He felt his heart quicken and his palms start to sweat in his gloves a little. It was coming on again. He hated the way his body went dumbly with the wayward spiral of that corner of his mind. He so often took solace in his body, his physicality, against the apparitions of his thoughts. He hated how it followed when that knot took to turning, defying him.
He swung hard on the round but it too defied him, the maul not even setting.
Harder now, this time barely opening a narrow line.
A knot.
He tossed the maul into the soft dirt and collected the wedge and a sixteen pound sledgehammer from against the wood shed. With one hand he held the wedge in the small seam he had opened with the maul. With the other, choked up all the way on the hammer, he set it with a few short raps.
He stepped back and swung the heavy tool. A heavy tchink rang out, smithy-like. Barely a nick of progress at the wedge.
John, there’s a database that tracks prescriptions in the state. I see you’re filling another prescription for Xanax over in Cobleskill?
He had fumbled with a bad excuse, eyes set on the back corner of the florescent exam room as he tried to lie. Not a word from the doctor and he couldn’t stop himself from looking over and what he saw was terrible. The doctor’s face was set hard at the jaw but his eyes looked spoiled. They had known each other for nearly forty years. He had cared for Suz before they moved her to the home. John looked back to the corner. After a long silence the doctor got up and left the room without a word.
When he reached his truck in the office parking lot he had a hard time fitting the warm metal key to its slot in the cold door. When he got inside the arid smell of dust and old upholstery in the cab settled heavily upon him. He brought his head down and he put his forehead on the hard sewn leather of the wheel and he cried.
He swung again on the elm and still no progress with the wedge. Rather than reset the wedge or turn the round he swung again. Maybe a centimeter there.
Again—sparks off the wedge.
The doctor had called three days ago and left a message on his machine asking him to bring in his pill bottle so they could review his prescription. It was the 12th, which meant he should have thirty four pills left for the month. Of course he didn’t have them. He hadn’t called back to schedule. The doctor had called again yesterday and left another message but he hadn’t checked it. The machine was in there now, in the kitchen, its small red light blinking.
His thoughts were now turning faster, the regular linearity of his mind feeling bent and pulled like warm caramel. His leather gloves were wet and the cold cut hard through them.
He swung with everything on the wedge again and again, smashing the iron and raising sparks and a hellacious din but the elm stood whole against him.
The red light of the machine in the kitchen blinked in his mind and the impossibility of this, his life, its unraveling, cut into him like he had swallowed something terrible and sharp.
He swung over and over on the elm, and the sparks skittered and died in the cold dirt and the wind rose up around him and spun dust and leaves and it shook the boughs of the maple stand until they moaned and cracked.
His arms were weak and his vision a little dark and his aim faltered, landing the face of the sledgehammer at a glancing angle to the wedge. The blade, still set shallow in the wood, leaned over and drove sidelong and down and out of the round completely. The wayward tool let fly a sizeable hunk of elm, with power enough to cover the twelve feet or so to the woodshed and shatter the lower right pane of the shed window.
The sudden rescission of the wedge as a counterpoint to his hammer blow threw him off balance, and he stumbled forward and came down to his knees in front of the block. The round had rolled off when the knot threw the wedge, and the block was bare. He let go the shaft of the sledge and it fell softly to the ground beside him. His arms hung down by his sides and he leaned forward and placed his head temple down on the block. He felt the damp earth on his knees, through his jeans. He closed his eyes and rested like that, and he felt empty.
He wondered to himself how long the mind survived after a beheading, and imagined the awful perspective of a head spinning free of its body as it dropped away into the basket.
When he opened his top eye, the ugly shattered pane leered back at him.
He turned his head to the other temple and switched eyes.
The maple stand stood twenty or thirty feet off. The wind was dying out now and the tops of the boughs swayed just a little. A few straggler leaves glittered. The sun shone dimly behind a high layer of late winter cirrus, and he noticed the way the light limned the hard edges of the naked branches like a lattice, and he saw that it was extremely beautiful.
A filament of spider’s silk swung into view and caught the light under a patch of open sky. It shimmied and flashed about in a slow arc and advanced on him tentatively until a gust pushed it over, laying the delicate fiber across his brow. He made no move to brush it away. He thought of the high end, lithe and free in the wind above him, and of its spider.
He let his focus back out to the maples. With the mapling lines running among them they looked like a group of children in a park, strung all together by the hand. Soon with spring they would begin again, growing outward, becoming large.
It had been a cold night. A coat of frost had lain crisp on the grass at first light, but the sun would soon burn off the high clouds and the day would be warm. Sap would flow in the lines by afternoon.
He stood up from the block and turned to walk back toward the house. The spider’s silk held fast to his brow, and he made no move to brush it away.
Clayton Dalton is a resident physician in the emergency department at Massachusetts General Hospital, as well as a writer. His work has appeared in Wired, The New Yorker, and The Guardian.