Magnified and Sanctified

It’s been ten years, Den, and only now do I feel I can say goodbye to you.

You were sixty three, I was sixty one. You died on Friday night. Your son brought the news to us at our shabbat table.

We buried you on the Sunday. We laid you to rest at an odd corner of the Jewish burial ground, beneath a young gum tree. I looked at the tree at that time and I remembered Dad’s fear of falling gums. I thought, here you are again, going against Dad’s prudent judgement. And I smiled.

You lie now, beyond the judgement of humans. Many were the people who judged you, fewer were those who tried to walk a mile in your shoes. They were big shoes.  Like everything about you, very big. Magnified, sanctified… People who did understand loved you extravagantly, in proportion to your extravagant life.

And now I can let you go. From the time of our final conversation I dreamed of you. The dreams were dreams of helplessness. You could not help yourself, I needed to help, I tried to help, but in those dreams, I could not. You called me that last time. The phone woke me from a dreamless sleep. Your speech rustled and crackled, the sweetness of your voice ruined by seven days with the breathing tube. You had rallied, they’d removed the tube; now, with your breathing failing, they needed to replace it. Your voice crackled: ‘Doff, they want to put the tube back. What should I say?’

I heard your breathing, a rasping, gasping sound. ‘Do as they say Den.’

‘Is it my best chance?’

‘Den, it’s your only chance.’

They returned you to your coma and they replaced the tube. Three days later you breathed your last.

At the cemetery we said, magnified and sanctified be the holy name.

One evening during the week of shiva my son led the prayers in honour of his uncle. He loved you Den. We loved you.

For ten years I dreamed of you, restless dreams, frantic. I was unable to help. Then I started writing about you and the dreams stopped. Now I sleep without the dreams. Sleep in peace beneath your gum tree, Den.

My Private Knee

After three months of physiotherapy and rest and exercises and anti-inflammatory tablets had failed to fix my injured knee, an MRI explained why: the outer cartilage was torn and the inner was tatty. I saw a surgeon last Wednesday and on Friday he repaired what was reparable and removed what was not.
 
 
The next day I sat on my couch in small pain, enjoying a liberal dose of self-pity. I had time and excuse to sit and live slowly. I read the ‘paper. A fellow citizen wrote to the editor in praise of Medicare, our universal health scheme. Her small daughter fell acutely ill and she hurried to the public hospital, where the waiting area was crowded and the public address announced the arrival of a series of ambulances. The delays would be long. However the sick child was assessed in Triage as urgent, was seen and treated expeditiously and expertly. By morning she was well enough to go home and her mother took up the pen in praise and thanksgiving. ‘How lucky we are’, she wrote, ‘to have such an excellent public health system.’
 
 
A second letter to the editor told the opposite tale. The writer suffered a limb injury and attended a public hospital. His injury was disabling and unremittingly painful. It was rapidly recognised as in need of early surgery. That was two years ago. His case is classified in the category of Most Urgent (elective). Every three months since he has returned to the hospital for routine appointments, where the diagnosis and the urgency are confirmed. His letter ends with a lament: ‘How can we kid ourselves we have a health scheme where Most Urgent can languish for years?’
 

****
 
 
The writer and I both suffered injuries. Both of us received expert advice that surgery was necessary. Mine was performed within days, while my fellow languishes for years. My injury was minor but it did not feel trivial. For three months it hurt too much to run. I turned to the bike and the knee felt worse. Soon I could not walk without pain. I watched the muscles of my thighs wither and I lamented. Those legs had been my pride. I contemplated a life without exercise and I knew I would not know myself.
 
 
How is it my leg improves by the day while a fellow citizen suffers a worse problem and waits interminably? I cannot doubt the sufferer subsists on medication which is neither curative nor safe. By now he is surely addicted to his opiates. Why the disparity? The answer is my private health insurance, which, by dint of thrift and belief, I afford. Not everyone is so fortunate.
 
 
Even an unbleeding-hearted economic rationalist would see the disparity as just that, an inequality. I believe there is a solution which is not a new idea, but a forgotten one. I recall a politician by name of Don Chipp who became Minister for Health in the Liberal Government in the days before Medicare was sanctified, beatified and became untouchable. Facing the disparity, Chipp proposed government would underwrite the private health insurance of the poor. All citizens would be insured, all would enjoy choice of surgeon and hospital, the private health sector would expand and prosper through efficiencies that Public Health can never match, investors would rejoice and the Liberals would be congratulated in the polls. Meanwhile Most Urgent Surgery (elective) would be performed within a humane frame of time.
 
 
That scheme, which bore some resemblance to Obama Care, never came to pass. Labor rejected the necessary Means Test as ideologically repugnant. Chipp moved out of his party and created a third force in politics, which soon became a chronic and disabling pain to Liberal governments. Decades later my fellow citizen, uninsured privately, suffers privately, where he could be cured.
 
 

More Unnatural Medicine 

Following my recent blog post titled ‘Unnatural Medicine’ one correspondent bothered to respond thoughtfully and at considerable length. As you will see from the passage below (excerpted from his comments) he writes insightfully and with strong feeling. I quite understand that intensity; health is both a personal and a universal concern. Further, at the head of its hierarchy and ruling our fate, standing over us, exciting our awe and our resentment, are the doctors.

 …On the other hand we see leaders in western medical practice dismiss Chinese medicine, for example, as quackery and voodoo medicine. Despite clinical trials clearly demonstrating the effectiveness of acupuncture, for example, many Scientists declare that there are no such thing as “meridians” in the human body as their existence has not been clinically demonstrated. The hypothesis is dismissed despite evidence gained from the applied testing that they do. Further, many assert that all forms of Chinese medicine, sometimes including acupuncture, should not be considered “real” medicine. (This includes senior doctors advising government and insurers.) Yet this practice has 4,000 years of accumulated clinical practice, is taught in major teaching hospitals in China and practiced daily by doctors in conjunction with “modern” western practice. Numerous clinical trials of diagnostics, treatments and herbal concoctions have been conducted, which are generally dismissed in the west, often merely because they are not available in English. When they are available, the results are howled down because there is no critical mass of such research available. Yet the Chinese pharmacopeia is yielding impressive results in western labs in the treatment of everything from common infections to malaria and cancer. Why is there such resistance to the science of Chinese medicine?
With the social and economic power of the western pharmaceutical industry we continue to see western medicine practised with an emphasis on the provision of drugs as first recourse in treatment. So pervasive is this that you have written about patients who want the prescription of a drug, any drug, rather than wanting to hear a more complex story of how to achieve health and of some doctors who support this approach. We have a culture of “science” where alternatives can often be dismissed and
where pharmaceuticals are pushed to the frontline of treating almost any and every condition. Incidentally, my father peddled Debendox – among many other drugs- to doctors in the 1960s and ’70s for the treatment of morning sickness and later associated with birth defects. It was given to me as a treatment for travel sickness. Hard science and its practice makes mistakes.
Please forgive my self indulgence in presenting my rant, Howard. I know your musings are often light-hearted and exploratory of deeper things. But I guess my point is this: there is an ideological
spectrum in medical practice, which can be said to range from “natural” to “unnatural”. There is medical practice that works with the “natural” processes of the human, which includes an understanding of diet, exercise, psychology, history, social conditions, the environment, etc all having their effects, good and bad, on human lives. In common parlance “natural” usually refers to seeing patients as people first, human beings subject to and part of nature in never-ending cycle of birth, life, death, repeat (depending on your belief). My experience of your practice puts you in this camp. Do as little harm as possible, be cautious, be curious, respect the person, do not jump to conclusions or easy answers, respect the life process. Sometimes trauma means offering treatment (or not) that may cause damage or harm. A difficult choice.
There is also practice that does not respect the human, does not give value to patient’s experience, knowledge of their body, etc. There is a dominant (moot?) practice of prescribing western pharmaceuticals first and asking questions later in the next 15-minute consultation a week later. This well-documented practice is disease focussed
and knows little of health, except as the “absence” of disease. This “unnatural” practice is characterised by a focus on the disease or condition, of which the “patient” is merely the subject. Treat the disease, not the person.
This spectrum lies at the heart of current debate and power struggles within medicine and in policy regarding human health. It has enormous implications also for all policy that focuses on the human species as somehow separate from “nature”, implicitly subject to different rules, with or without the possibility of divine intervention to protect us from
ourselves.
 
I find myself highly stimulated by my correspondent’s comments. I’m bursting with an accumulation of thoughts and feelings of my own, musings and speculations. I suppose these have gathered and grown within me over a lifetime in medicine. (It has quite literally been a lifetime: born into a household that accommodated my family and my father’s medical practice, I grew up in medicine. I was weaned on milligrams and speculums.)
 
My own feelings about western medicine and doctors are as mixed as anyone else’s. I am old enough to need the services of my doctors quite frequently, while still young enough to be doling out medical services to others. Macbeth cries, ‘Throw physic (medicine) to the dogs. I’ll none of it!’ And in a few cryptic words the Talmud declares: ‘”tuv harofim le’ge’hinnom” – the best of doctors can go to hell.’
Does medicine have an ideology? If an ideology is a system of beliefs or ideals or principles, I believe medicine does have an ideology. In the practice of that ideology I see the best of medicine, and in its abuse, the worst. That worst is the exercise of power for its own sake, a petty parochialism, a readiness to denigrate what it does not understand; and, in budget season, a hypocritical piety.(“No, no, no, Mister Treasurer , you must not cut, peg or regulate our fees – or our patients will suffer.’) The best is seen in your doctor’s service of ‘scientia cum caritas’, knowledge with loving care.
For me it is the ‘scientia’ which is the hard bit. Your good doctor is a scholar: the word means ‘teacher’, ‘master’, ‘wise one.’ That scientific doctor applies himself to the evidence. He suppresses his own human hankerings, his romantic leanings, his wishful thoughts. That doctor brings to his work a rigour, an austerity, a devotion to the pursuit of demonstrable truth. When I am sick I truly need that science; and your good doctor brings that to my bedside.
Let me give you an example. While working in the Emergency Department of Alice Springs Hospital last week I watched while five doctors worked to save a man who had been found at a remote roadside, unconscious and convulsing violently. The man was tall, strongly built, apparently athletically fit. His mountain bike was found lying near him. Unable to tell us how or what or when, his powerful body defied his absent mind as it jumped and threw itself around. I stood, quietly appalled, watching a man fifteen years my junior, disconnected from mind, at the threshold of the void.
The doctors watched him for signs. Acutely attentive to which limb moved, which did not; how his pupils reacted to a pencil beam of light; whether and how strongly he responded to voice (initially he’d stir; later he did not), and to a painful stimulus. Here was a biological organism in a near agonal state. The doctors looked up to study the lines and waves and numerals on the screen. How strong is his heartbeat, how effective his circulation? How much oxygen are his lungs delivering to the circulation and – critically – how high is the blood pressure? The readings were elevated above the norm. I misgave and pointed out the elevation to the Team Leader. ‘That’s good,’ he said. He explained that the damaged brain was much more vulnerable to low blood pressure than high. The outcome, he explained, was worse when pressures were low. ‘The outcome’: two words pregnant with knowledge, with meticulously gathered and tested and scrutinised evidence. Tough minds had obeyed tough rules in the gathering of that evidence; now smart scholars would deploy this in our immediate emergency. I witnessed dry science at the service of hot blood. 
It was imperative to control the seizures and to treat pain. Surely he had pain – he’d had a fall, presumably at speed, his skin was torn from his body, gravel and mud grimed his raw wounds – and he was vomiting forcefully on arrival. He must not be allowed to vomit lest he aspirate and block his lungs.
Next the man’s respirations must be controlled. He’d be paralysed and placed on a respirator. He’d become utterly defenceless. The very doctors who would overcame his defences must become his protectors.
To all these ends, all of them critical, all of the utmost urgency, strong drugs would be used – opiates, benzodiazepines, muscle relaxant drugs, anaesthetic agents, anti-emetics. Doses must be calculated minutely, effects monitored, dosages re-calibrated. The precise numbers of milligrams and micrograms would determine whether this man would live, would walk, would think, would speak, read, laugh or love. ‘Will this man ever get back on his bike?’ All lay in the hands of these scientific doctors.
 But how to calculate dosages? Unable to weigh a stuporose man threshing his own body, the doctors had to guesstimate. Too much opiate would lower blood pressure and endanger the damaged brain. Too much anti-convulsant would do the same. And both classes of chemicals might suppress breathing. The anaesthetic drugs must be adequate to paralyse him (to allow intubation and the use of the respirator), but again these agents can defeat their own purpose.
So the doctors injected morphine, eagle eyes upon oxygen saturation and respiratory rate and blood pressure. They injected metoclopramide to prevent vomiting that morphine so readily triggers. They deployed three different anticonvulsants, in doses nicely titrated, before they were able to control the fitting. Now came the intricate business of intubation, the act of introducing a breathing tube deep into the throat in defiance of every natural reflex and physiological objection; this procedure, a pas de deux of surpassing intensity, saw all present hold their breath in unconscious imitation of the patient, now paralysed, whose breath was held from him by chemical restraint. Now the tube was guided truly, now oxygen supply was resumed, hypoxia reversed. All breathed out.
Our patient would never know how medical science saved him. How doctors had used just enough of every hero molecule, how they had threaded that narrow path between his own injuries and the potential harm of their remedies. How every drug might poison him. And of the race of his life, the literal counting of seconds where every second counted, the quietly hectic passage of time when he arrived as quivering meat and was so soon stable. Safe!
Equally deep was the pool of knowledge that detected the cause of all – no, not head injury, not brain contusion, not spinal cord injury – a heart attack had thrown this athlete, engaged in a mountain bike race in unseasonal heat, into coma and convulsion at the threshhold of death.
So, yes, western medicine has its ideology. Last week I saw that ideology save a human person. Clearly I am in awe of that sort of intellectual discipline which is so far above and beyond my suburban skills.
By way of contrast we who practise by instinct, by intuition, must tread the shallows of organic disease, even as we grope in the deeps of human suffering. You cannot afford to indulge our speculative modes of medicine when your damaged organs call out for science.
In the earliest years of my practice I felt frustrated when patients informed me of the advice they’d received from alternative practitioners. Those healers would declare to my patient her spine was out and they’d put it back; they’d looked in her eyes and found her pancreas was sick and they’d cured her with herbs. Not with drugs, no, never with drugs. Those healers prescribed detox diets for the liver, cheerfully unaware that the liver detoxifies all. They told my patient they knew what was wrong, where I knew I did not, where no doctor could – in any scientific sense – know.
I came in time to respect the achievements of these practitioners. My patients felt better for seeing them, encouraged, confident in their recovery. I wondered how this could be and it came to me that the naturopath gave the patient the gift of an unrushed, attentive hearing. The amplitude of time, the emphasis upon natural healing, the resounding vote of confidence in the forces of the natural body helped the patient materially. I realised how intuitive, how insightful, how respectful was this practitioner. I recognised in the naturopath the healer I wished to be. But there was one difference, ineradicable: I never heard a patient quote the alternative practitioner confess ignorance or impotence. Free of the shackles of constraining science, the practitioner never said three words that I need to use every day. Those three words are: I don’t know.
I am pretty confident I have by now offended some readers. This is always a risk with the trenchant expression of strong opinion, of ideology, if you like. And it is not only western doctors who hold an ideological position. I consider it natural to humans, perhaps universal, to cherish convictions about health and its care. These convictions too encompass values, traditions, emotional needs. Mine are distinctively my own. Every distinct human will differ. Expressing my full thoughts on these subjects might offend seven billion humans.
Nevertheless I propose to write a series of short pieces which might include:
Why some doctors resist and resent alternative medicine;
‘Thou shalt not kiss thy patient’ and other absurdities.
Why I recommended acupuncture for a patient whom doctors could not help.
Why doctors prescribe medicines: Big Pharma, big mamma, bad sicknesses;
My Debendox daughter.
In writing on these matters I expect to relieve myself of strong feeling, long pent. And after all that I will scarcely have responded to my correspondent’s weighty concerns.
 
One final vignette before I let you go. In 1972 I joined a rural practice where I worked happily for almost thirty years. Around that time I met a squat jolly man and his slim jolly wife. The couple had three small daughters and I became their family doctor. They were a devout family, members of a small local congregation of a church which is possibly the most widely respected by the secular majority in this country. They wore their piety tactfully – neither crucifix nor yarmulke nor hijab declared publicly their private faith.
From time to time Mother brought the little girls, slim, elfin presences with smiles that sweetened my day. They’d sit on my knee while I discussed their condition their mum. In time they grew up and left their small home town. One of the three, whom I’ll call Sarah, returned and introduced me to her fiancé, a member of Sarah’s church. The two had decided on a career as ministers to the youth in the service of their church. Soon they would marry and take positions in a distant city interstate.
 
When I saw Sarah next seven years had passed. Her father had died of complications of orthopoedic surgery. Her face shone with grief and pride as she introduced her batch of three small children to me. Slim like Sarah, all with biblical names, they played at our feet as we spoke of their grandfather, that squat jolly man, and of his passing. Sarah and her husband petitioned the church for a posting in Melbourne to be nearer the family.
They settled in an outer suburb on the far side of town and I saw nothing of them for about three years, when Sarah turned up in my waiting room. Delighted and surprised I listened as Sarah told me of the strange and slow development of her second child, a boy. ‘Jeremiah might have autism.’ We talked. I told Sarah I was no expert in that condition. She seemed to know that already. She wasn’t after diagnosis, but counsel and for that it was to her old family doctor she turned.
Years passed. Once again I was delighted one day to discover Sarah in my waiting room. She was the final patient of my morning. By chance I had no more patients to see for the next hour and a half.
‘Hello, Sarah. What brings you here?’
‘Howard, this morning in the shower I found a lump in my left breast.’
‘Does it hurt?’
‘No.’
‘Do you have chills, a fever?’
‘No, it’s not mastitis. I weaned Benjamin a year ago.’
I examined Sarah’s left breast. Her slim body habitus made the lump easy to find. It was a hard lump, a little larger than an almond. I felt the opposite breast: normal. I probed her axillae. There, in the left armpit I felt a second lump, also hard. I tried to hide the dread I felt.
Sally looked up at me, searching my face: ‘Can you feel the lump?’
‘Yes. It’s a worry. Please get dressed and we’ll talk.’
We talked for an hour. We talked of the probable cancer, of its possible spread, of treatments, of specialists – who, where, when? Sarah asked, ‘Do think I’ll be cured, Howard?’ I did not think she would. I said the signs were worrying and I feared the worst. Sarah looked down and rummaged in her handbag for her hanky. She sat quietly, tears rolling down her cheeks. She dabbed her eyes and cried some more. The hanky was a sodden ball in her hand. She blew her nose and said, ‘I’m not frightened for myself. The children… they’re so young.’ Fresh tears followed.
At length it was time to finish. I stood up. On blind instinct, driven I suppose by hard feeling, I said, ‘Sarah, stand up.’
She did so. I stepped forward, took her in my arms and hugged her. She hugged me back, hard. I dropped my arms but she hugged on. And on. At length she released me. She took a deep breath, found a small smile and said, ‘That’s what I crossed Melbourne for, Howard.’
I never saw Sarah again. Her surgeons wrote to me from time to time. Eight years after her doctor took her in his arms and breached medical ethics, Sarah died. 

Health is not a Human Right

I am about to make some shocking suggestions: 

Health is not a human right.

The Morrison-Turnbull budget cuts to Medicare Rebates are not completely bad.
Running in the dark this morning, I noticed the illuminated sign outside the local hospital. It read:

PRIVATE HOSPITAL.

 

I felt unhappy reading that. A hospital is a place where human beings help other human beings with their health. The meaning of a hospital cannot be realised with that label. ‘Private’ tells the reader that some humans will be admitted and others turned away. Privacy as a personal property might well have been eclipsed by the internet, but ‘private’ survives with this message, unkind to some, saying ‘keep out.’

 

If health were a right we’d need to outlaw Down’s Syndrome, premature death and disability. We would legislate and make ourselves ridiculous. The error of language here betrays an error of thinking. We cannot assert a right to health, but we can create a right to equal access.

 

I am a private doctor. I am a public doctor. The public is composed of private persons. I treat one person at a time, privately. That is, personally, confidentially; two humans together, doing what every human does in a lifetime: ordinary transactions of care.

 

Doctors generally share a number of characteristics. We are serious, careful, committed and proud. We are defensive of our liberties, self-righteous and voracious of cures. We are expensive; I mean someone, somewhere, always pays for cures. In its new budget the government has pegged Medicare rebates. This skewers doctors and patients: either the doctor loses or the patient loses. There is nothing new in this.

 

When Hayden-Whitlam introduced Medicare I bulk-billed everybody. I thought it was a wonderful thing that a person, be she rich or poor, might consult a doctor equally. I thought so then and I think so still. To assure doctors they would not lose, the Hayden-Whitlam Government set up a referee who increased the rebate in pace with the rising costs of practice. This was costly. So the government told the referee to stop indexing rebates. And I stopped bulk billing. Often patients found themselves facing a choice – see the costly doctor or feed the family. When this occurred all doctors I know abated their fees so the patient might afford both cure and food.

 

What a government does in tightening benefits is to create the need for a new force to operate in care. The force is not one of rights but of grace. The doctor and the patient gaze upon each other as we did through all history, unmediated by refunds and rebates, freer now of the obscuring presence of the insurer. Two humans in a situation of human need.

 

The words ‘Private Hospital’ jolt me. They remind me that health is not merely a matter of economics or of civil rights, but of civil opportunity.

 

Alone and Palely Loitering

You walk past them at lunchtimes and at smoko, you see them sheltering under eaves in foul weather, you see them in their outcast clusters, you see them and you avert your gaze for fear your concern will offend.

They are many, these persons of all ages, members of an underclass. If they were to unite as voters they’d overthrow governments. If they were to become radicalised we’d tremble in our beds. But no, they do nought to us and all to themselves. These human persons harvest leaves and dry them and chop the dried leaves finely then wrap the product in a cylinder of paper. Carefully, accurately, with practised fingers, they burn the leaves, then hungrily, deeply inhale.

Alone in the animal kingdom these sentient creatures do not flee from smoke.

I see them, I see my friends, who meet my gaze and smile in confession – and I am sorry to see – in embarrassment.

A long time ago my father in law was dismayed when advised by his tobacconist (yes, he saw a specialist, no mere candy vendor) that Chesterfields would no longer be imported to Australia. The tobacconist asked: ‘How many do you smoke a day?’

My father in law told him.

The tobacconist responded: ‘You are a very special customer; we’ll make sure you stay supplied.’

images-4

The very special customer became too breathless to read a bedtime story to his grandchildren. Soon he developed a cough. Suspecting cancer he stopped smoking.

Not long after, the very special customer died of his disease and my children lost their very special grandfather.

Manufacturer Phillip Morris continues to accommodate its special customers. My friends huddle and shelter while I shudder. And I direct my superannuation to alternative investments.

More Mother’s Day Thoughts

After my experience last Sunday I’ve decided I like Mothers Day. I enjoyed sharing vignettes of my old Mum. One of the first that I ever published, appeared in my first book, a memoir which I called “My Father’s Compass”. The vignette, a story about my 92 year old father battling the extinguishment of his great powers, and my mother battling nothing and accepting all, was titled: Falling gums.

“The phone rings at midnight. I walk towards the answering machine and listen for an urgent message. I do not pick up the receiver because it is Friday night, my Sabbath – Shabbat – when my soul visits paradise. When I am in paradise I do not answer the phone. There is no message.

Though puzzled – who would want to speak to me at midnight if it were not an emergency? – I begin to relax, then the phone rings again. Once again my machine offers to take a message, once again the caller is mute. I grab the phone. Dad’s voice says, ‘Mum is on the floor …’

‘I’ll come now,’ I say, and hang up. Dad and I have responded to the situation with the least possible desecration of the Sabbath.

Minutes later I let myself into my parents’ house. There, on the bedroom floor, in a tangle of limbs, is my mother. ‘Hello darling,’ she says. She looks up at me and gives me a grin. Recently, Mum’s front teeth have begun to desert her. Those teeth that remain are a picket fence, stained and in disrepair. Mum’s former serene smile has given way to a seven-year-old’s grin – all mischief and careless abandon.

I peer down at Mum’s legs. They are thin, too thin, except for her ruined knee which is swollen and misshapen. In the half light her skin is ivory. I crouch and put my hand on her leg and feel its cool and its smoothness. I touch my mother’s skin and I am her small child again.

A short time passes. ‘Does any thing hurt, Mum?’

‘No darling.’

‘Can you move your limbs, Mum?’

Dad’s voice breaks in: ‘Mum’s not hurt – she didn’t fall. She was reaching for the commode chair and she pushed it away instead of holding it still … she just slid gently onto the floor … I couldn’t stop her falling …’

Dad’s voice subsides. He sits on his bed and holds his head in his hands.

Mum speaks: ‘I’m quite comfortable, darling. It’s quite a nice floor, really.’ Another grin. I look at my mother. Her limbs are splayed and folded beneath and before her like so many pick-up-sticks. I wonder how I will pick them up.

‘If you like it on the floor, Mum, would you prefer to stay there until the morning?’

‘If you wish, darling.’ She extends a hand and pats my face.

I bend and begin to take her weight, my hands beneath her arms. Dad gets up to help but I knock him back because his heart is worn out and failing.

He recoils, recedes and sits down opposite me, his face wrought of grief and care. I feel a pang for my abruptness.

An in-drawing of breath, a grunt and Mum is aloft, her legs a pair of white flags hanging limply beneath her. Her arms are around my neck and we are locked in our accustomed embrace that has become so familiar since she began to suffer a series of strokes.

We know this moment well; each of us knows the sweetness of this slow dance. Neither of us would readily trade it, not even to make Mum whole again.

A moment later Mum is in her bed, covered up, wheezing, speaking breathily, her voice ravaged by stroke and by time: ‘Thank you, darling, what a treat!’ – and beaming with the simple pleasure of ­being tucked into her bed.

Dad, contrite, distressed, is saying, ‘I am sorry, darling. I hate to disturb you.’ And I am saying how pleased I am to come, and how come he didn’t speak into the machine when he rang. And Dad says, ‘I don’t know.’

‘Shabbat Shalom,’ I say, kiss them both goodnight, and go home.

Back home, but not yet in paradise, I sit a while and recall a conversation my friend Lionel reported to me. While driving with my father in the Flinders Ranges, Lionel asks this indestructible old man a singular question: ‘What are you afraid of in this life, Myer?’

My dreadnought father has fought all his sixty-seven years as a doctor against illness and injury. Of all diseases, I know that cancer and stroke fill him with terror beyond naming. And I recall, too, Dad confiding to me his fears for Mum: ‘I am grateful for every single day that I have her; and I am so frightened of the day that …’ He falls silent, his voice drowning in the grief of his imagining.

When Lionel asks his question, Dad looks up and out and away from inside him, and he sees those silent, massive and beauteous living things, so inviting in the outdoors and so treacherous. He answers, ‘Falling gum trees.’

The day after the ‘fall’ Mum and I are alone in the kitchen when she begins to laugh. The sound has a gasping quality. You have to pay close attention to discover whether she is choking again, or simply amused. She laughs louder then tries to speak at the same time.

Her voice is a concerto for bagpipes and windstorm. I lean close, into the teeth of the storm, and Mum says, ‘When I was on the floor last night, and I couldn’t get up, I started to laugh, and I couldn’t stop … and Daddy was furious!’”

FOBT

Some doctors have too much time on their hands. When you’re feeling quite well they go looking and testing for things you aren’t suffering from. They call that preventive medicine. (I call it preventative medicine.) My wife calls it meddling.

Year ago I advised my wife to have a colonoscopy. I offered to refer her to a bottom surgeon, a lovely bloke, quite exceptional in his trade. She declined.

I persisted: “Look, he’s gentle, kind…”

“I know all that. I’ve known him for longer than you have. I knew him when he was a medical student.”
“Then why not see him as a doctor?”

“No! I had the hots for him back then.”

“So? That’s not a disqualification, is it? Was he your boyfriend?”

“No.”

“Did he know you had the hots for him?”

“No.”

“So, why not see a great surgeon and a nice guy who never knew how you felt?”

“I don’t want someone looking at my bottom whom I felt that way about.”

My wife sacked me as her GP and consulted a stranger who sent her bottom to a second stranger.

What goes around comes around and bites you on the bum.

I reached the age of fifty and saw my own GP for a spot of preventative medicine. She said: “You’re Jewish aren’t you?”

I confessed I was. I had the scar to prove it.

“And you are Ashkenazi. You are in a high risk group for colon cancer. I’ll arrange a colonoscopy.”

I wasn’t keen. My wife had told me about the two-litre laxative drink that preceded the examination.

I bargained and we settled for the faecal occult blood test. She handed me a request slip that read:

Test requested: FOBT

Clinical Notes: 50 y.o. male Ashkenazi Jew.

I pictured myself lugging my specimen back to the lab in a shoebox.

I turns out they aren’t that greedy: two smudges would do.

The instructions and restrictions were detailed and grotesque. Being a doctor I didn’t read the leaflet too closely. Didn’t need to. I knew how to “produce a specimen”.

Next morning I awoke early, took my blood pressure tablets and my 100mg of aspirin and felt the urge for an early morning donation. I fought it off as I applied the Glad Wrap, discovering a happy concordance between the width of the wrap and the diameter of the bowl. (Is that cosmic chance or commercial cabal?)

I emptied my bladder elsewhere. (I don’t know what you are supposed to do if you don’t have a garden. Or if you are female.)  Finally I donated. Then I selected, daubed, closed, sealed, dated.

Then I forgot about the entire project. Three weeks later I got around to Specimen No. 2. I collected this and followed the earlier steps. With a light heart and a sense of virtuous health I delivered my daubs to Specimen Collection. Specimen Collection perused the paperwork, checked the dates. And rejected my specimens. Uncertain whether to be outraged or humiliated I asked why. “Dates too far apart.”

I never knew poo had a use-by date.

Back to the beginning. My specimens were collected in timely relationship and delivered to Specimen Reception. I waited in quiet triumph. Specimen Collection had some questions but wasn’t happy with my truthful and humbly virtuous replies. She asked: Did you eat carrot in the three days preceding each of the dates?

Certainly.

Raw?

Yes.

Did you brush your teeth the evenings prior?

Of course!

I am sorry but the lab cannot accept these specimens. Even a single violation voids the accuracy of the technique. Two violations are quite out of the question.

Look, ma’am – very politely, showing some of those teeth in a sweet smile – I am a doctor. I believe I understand the test. I’ll accept responsibility for any inaccuracy.

Sir, we are dealing here with cancer, with human life. The laboratory cannot compromise.

She handed me a new collection set. I stopped by the supermarket for more Glad Wrap and returned to my squat. Carrotless days and unbrushed evenings dawdled by. My teeth turned brown and my fibre-freed stools tore their way out. I sampled my moon rocks and I collected two specimens, a day apart. And returned to Specimen Collection.

With a lovely smile of her own Specimen Collection thanked me and said, See you next year, Doctor.

Er, thanks. Yes.

Oh, by the way, you aren’t taking aspirin are you?