Originally published in the New England Journal of Medicine
Everywhere I turned during my clerkships and in-ternship at a county hospital in southern California, I heard Spanish. My classmates and I came from places like Long Island and Kentucky and often had terrible pronunciation, but we spent entire days speaking only Spanish: Spanish on rounds, Spanish to nurses, Span-ish with patients.
We learned much of our Spanish from patients who were hospitalized for long periods, especially those who had a high tolerance for bumbling med students with pitiful accents. My own best teacher was a young woman named Julia Gonzalez, who was admitted in October of my internship year with acute myeloid leukemia. Younger than I was, she insisted that I call her Julia, and during several months of chemotherapy, she taught me considerably more than Spanish nouns and verbs.
The oncology team showed me how to manage her treatment and its toxic effects. When side effects bloomed, the team taught me what orders to write and how to use my new medical language, while I told Julia in Spanish what the medications were called and what they did. I’d often add that the doctors promised she would rally (“se mejoraría”), even when neither of us believed it.
And she did get better. In December, after four rounds of chemo and what I’d learned we called “a stormy hospitalization,” Julia left the hospital, bald and beam-ing, without a single leukemic cell in her marrow.
I felt fantastic about Julia — and really good about my Spanish. Back in med school, I’d gradually gotten better at using various past tenses while taking his-tories, and I’d begun to fall in love with, of all things, reflexive verbs. I loved the concept of a verb that made the self the object of its action. In my primitive under-standing of this new language, I routinely translated every word into English in my head, and it somehow pleased me to hear patients include themselves in their activities. A young man might say, “Yo me lavé la llaga,” and I would hear, “I myself washed my wound,” or when an elderly woman said, “Me caí de la silla,” I would translate, “I myself fell out of the chair.” The Spanish felt so warm, somehow, so whole-person.
Reflexive verbs also gave me what I perceived as a kinder, gentler way of speaking to patients in those early, awkward days of training. It felt so much more graceful to say to a stranger, “You can redress your-self ” rather than “Put your clothes back on.” And
I much preferred asking a rumpled patient, “How did you yourself sleep?” rather than “How was your night?” I doubt any patient ever noted the difference, but reflexive verbs gave me comfort in an uncomfort-able time.
But the cancer ward had brought me up against the limits of my high school Spanish. I’d often found myself at a loss for words, even in English — what was this myelosuppression? Apoptosis? Pyridines? And patients’ questions became so much more complex or loaded: once when a tiny Argentinian grandmother asked about her cancer, “Va a matarme?” (Is it going to kill me?), all my Spanish vanished. So in my last summer of med school, I’d enrolled in a language-im-mersion school in Queretaro, Mexico.
I had taken formal Spanish classes in the mornings and learned slang from my host family at night. I’d learned more Spanish in that month than in an entire semester at school and was ridiculously proud of my-self for saying, “Me voy a vomitar” (I am myself going to vomit) seconds before I threw up, mid-migraine, on my host mother’s feet.
In May of my internship year, Julia was readmitted, and I read her blood smear. I blinked in astonishment at the wide blue field of distorted cells; the slide itself looked incompatible with life. “This is a classic exam-ple of a blast crisis, a really bad leukemic relapse,” the pathologist commented and then added, “It’s a death sentence: maybe a week or two.”
I went to Julia’s room and found her feverish and sob-bing. She kept mumbling, “Me voy a morir” (I am my-self going to die) until her Ativan kicked in, at which point I paced the halls, helpless and horrified. Finally, I called my old mentor, Bob Figlin, an oncologist I’d shadowed in med school. I told him Julia’s story and asked him how the hell this could be. How could our treatment have failed so completely and so fast?
“It’s the biology of these tumors,” he said. “It gets around us; we don’t know why.”
I feel bad for him now; I know how hard it is to watch a young doctor get smacked by the realities of the failures of medicine, but at the time I felt only fury. I couldn’t bear to let him tell me about tumor resistance or chemosensitivity. I kept thinking, “It is Julia herself who is dying, not a mass of cells.” I could almost hear him shrug his shoulders; he could sense me wringing my hands — both of us feeling helpless in the face of this horrid disease.
I stood in the hallway trying not to weep. Then some-thing Bob said broke through: “Now, you concentrate solely on her comfort.” I automatically translated it into Spanish, with its reflexive verb: “Ahora nos con-centramos en su comodidad” (Now we concentrate ourselves on her comfort). We, ourselves, all of us.
So every day, we concentrated entirely on her comfort. On morning rounds, we juggled her pain meds with her sedatives and antiemetics, and Julia’s eyes began to clear. I started spending my evenings with her. I was her only visitor; her family lived deep in Mexico, almost to Guatemala, in tiny houses with no phones, on dirt roads, “muy pobre,” she explained.
I can’t know what it meant to her, but to me it felt soothing to sit and speak Spanish in this quiet space with this dying patient. I consciously endeavored to bring me myself into the room as we sat murmuring outside the normal flow of procedures and results and the hot, crowded hallways. Sometimes I tried to describe what had happened to her, how the marrow in her bones had filled with cells that couldn’t func-tion, though we didn’t know why. Mostly she spoke of family and her life, always in the past tense, some-times weeping. I held her hand and rubbed her wrists and used my reflexive verbs. We were both speaking a foreign language.
I promised her and myself that I would be with her until the end. But one broiling June day, I arrived at 6:15 a.m., hot and distracted, and learned Julia had died at 5:30, alone, before the California red-wine dawn. In her bed, I found the ex-Julia; Julia herself had evaporated. I gazed at her, thinking of her suf-fering, her loneliness, the orders I’d learned to write, thinking about all the distorted white cells that had poured in and out of her marrow, thinking about the phone call I would have to make to her mother, sleep-ing somewhere deep in southern Mexico.
I tried to figure out what to say. I’d never told a family about a loss. How do you tell someone a life is gone, and how do you do it in Spanish?
I pictured my Spanish teacher in Querétaro, standing in front of us on the hot July day when she’d taught us to conjugate the reflexive verb “to die” — morirse. “I myself died, you yourself died,” we’d intoned in desultory unison. But suddenly the word’s import had clicked, and I’d sat straight up, red hot and alert, whispering fiercely, “He himself died, she herself died . . . .” I will need to know this verb someday, I remem-ber thinking, this needs to stick.
It took most of the day to reach Julia’s mother. When she finally called from the shared village phone, her “Hola?” was questioning and guarded. I explained that I was one of Julia’s doctors, and then I stood stock still, unable to speak, choking on images: Julia’s blasts, our chats, her mouth sores, my orders, her wrists on the bed in the dawn. Finally, I pulled myself back to the hospital hallway and just said it. I said it as I’d been taught in Quereta-ro, with grammatical perfection but no true prepara-tion: “Se murio” — “She herself has died.” And then I listened to the wailing of a woman in a village deep in Mexico who sounded as if her own marrow was being ripped from her bones, and it needed no translation at all.
The patient’s name and identifying characteristics have been changed to protect her privacy. Disclosure forms provided by the author are avail-able with the full text of this article at NEJM.org.
The original article was published at NEJM.com.