Cage

Trigger Warning: Themes of alcoholism, grief, and terminal illness.

Sometimes I worry I’ll be struck off the medical register. It's a constant threat to my self-belief, a nagging doubt. Make a mistake, struck off. Be unprofessional, struck off. And if you are lucky enough to avoid that fate, then you still get the pleasure of a disciplinary process where you're treated like a criminal. It’s why I am so clinical and keep my emotions under control. Be the perfect human-robot and you conform. It’s no way to live. But perhaps it helps us deliver quality patient care. 

These are my thoughts the morning I meet Greg for a consultation. He’s not my usual patient. He is normally under the care of another GP in the practice, Dr. Turner, who tapped me on the shoulder the day before to tell me Greg’s neighbour thought he was an alcoholic. “His bin is always full of beer bottles, apparently,” Dr Turner said, “Consider doing the CAGE questions.” 

I sit in my consulting room and type the shortcut into the software. It populates the notes with reminders of the questions. I press the button for Greg to be called. I know his name will be flashing in the waiting room. As he is only 42 years old, it'll probably take him half a minute to appear at my door. Some of my elderly patients can take three or four minutes. Sometimes they get lost and I go find them.

Greg stands in my doorway, right on time. His brown eyes, a Freddie Mercury moustache, and olive complexion give him a distinct, almost Mediterranean look. He’s in a shirt and jeans, slim but with solid shoulders. I can’t help staring—he looks like a younger version of my father.

He looks at me expectantly and the silence grows as I am lost for words.

“Greg,” he says, offering his hand.

I get up. “I’m Graeme,” I say and shake his hand.

“Dr. Peterson?” 

“Yes, that's right. Please take a seat.”

We both settle into our chairs and I stay silent, giving him space to speak. It's a technique they taught me at med school. However, in this case, I'm still stunned to be looking at an almost carbon copy of my father.

“I need to renew my sickness benefit,” he says.

I review his case and ask appropriate clarifications. He’s unemployed, and on the sickness benefit because of a long-standing back injury. He’s tried to get back to work but it's impossible. Whether it's a genuine issue or not, I tend to take people at their word unless proven otherwise and supply a three-month certificate. 

“At the moment I’m doing routine screening around alcohol. Can we run through it today?” I say.

“Fine,” he says. He sits back against his chair and looks at the ceiling.

CAGE: Cut Down

“Have you ever felt you needed to cut down on your drinking?”

He shrugs. “Yeah, sometimes,” he says.

I knew my dad needed to cut down, the moment I flew home. I walked towards the sliding doors having retrieved my bags and caught a glimpse of him in the arrivals area of the airport. I made the diagnosis in an instant, 100 yards away. He was gaunt in his face, strikingly so, like a corpse, it was shocking. And his abdomen was round and big. No way it was fatty tissue given how gaunt his face was. Must be ascites—fluid. A common reason—liver failure from excessive alcohol consumption. 

I shake away the intrusive thought and note again Greg is slim. He is not in the same situation yet. 

CAGE: Annoyed by criticism

I look at the computer screen and read the next question to Greg. “Have people annoyed you by criticising your drinking?”

“My neighbour annoys me. She says I drink too much.” He laughs. It’s a short exhale of air as if some involuntary joy is being shunned.

His laugh reminds me of how my father used to laugh. He’d laughed like that the day I told him he had to stop drinking, laughing away criticism.

We were sitting in his back garden, the afternoon after he’d collected me from the airport. We drank a beer each—father and son bonding. A sunshade provided gloom on an otherwise sunny day. Wayward butterflies disrespected the march of time by lazily drifting here and there. Neighbours played nearby, splashing in a paddling pool with toddlers, their whoops of joy punctuating our laboured conversation.

“Dad, you've got liver failure,” I said.

He nodded casually as if I'd told him it was nearly bedtime. 

“I tried so hard to lose this weight. It wouldn't shift.”

I looked at him. Of course he couldn’t lose it. It wasn’t adipose tissue. It was fluid brought on by his failing liver. His tanned white skin shined yellow in the shade and his eyes were brighter still. The bilirubin was doing that. Staining his skin, and the sclera of his eyes. 

“You must stop drinking. Every remaining liver cell is precious.”

“Nothing at all?” he said, and laughed with a quick exhale of air, as if stopping was a ridiculous notion.

“Not a drop.” 

“Not even a wine every now and then?”

“It's life or death.”

He looked into his bottle, swirling the beer around. He took a swig. And then poured the remainder into the dirt. “Okay,” he said.

CAGE: Guilt

I type in Greg's response and ask him the next question.

“Have you ever felt guilty about drinking?”

“Guilt?” he says, frowning. “Why would I feel guilty?”

His answer confuses me because his look-alike did express guilt.

Dad was on his deathbed. He hugged a teddy bear he’d asked for, and was hooked up to drips and monitors, a clinical prison. He was generally irritable, the liver failure irritating his brain. But then he had a moment of clarity.

“I’m sorry,” he’d said, “I’ve been a terrible father.”

“I love you, dad,” I said. 

I remember I was proud I said that. But I didn’t truly feel it. 

CAGE: Eye-opener

Greg taps his foot on the ground and grasps his palms. He's agitated, I realise, but I need to press on. These questions are important. I’ve got a second chance to ask Dad the questions needed to save his life.

“Only one more question, Greg,” I say. “Have you ever felt  you needed a drink first thing in the morning as an eye-opener to get rid of a hangover?”

He frowns. “I’m not an alcoholic,” he says and stands suddenly, scraping his chair backward, red appearing in his cheeks. “I’m going to see my own doctor next time,” he says, opening the door abruptly and exiting.

I notice the small timer on-screen is still green and only at 5 minutes. I might run on time today. 

I do my notes. 

Impression: (1) Chronic lumbar pain, requiring sickness benefit (2) Likely excessive ethanol consumption as evidenced by a score of 2 on interrogation with CAGE questions. 

Plan: Certificate done. Patient left before alcohol advice given. Suggest further discussion by usual GP in three months.

I save my notes, swivel in my office chair, and look through the doorway at the fluorescent-lit corridor wall. 

My dad probably had problem drinking too. More accurately, he was certainly an alcoholic. I’m sure he needed eye-openers. He’d come home drunk, any time of the day, drive up to the house, car swerving, and over the limit. It never bothered us kids. He was an adorable drunk. He never hit anyone. He was just a fool. It didn’t teach me self-esteem.

Would Dad have left before hearing advice? Would some detached emotionally-retarded clinician put it down to his denial or personality? Maybe I could’ve done more, taken time out of my busy schedule to ask simple questions like: are you okay? Or the CAGE questions. Maybe I could have saved him? But probably not. He was in denial, beyond help, trapped in a dopamine cage of addiction: withdrawal and reward.

Greg’s response hurt, more than it should, and intellectually I know it's transference. But I can’t help it.

My breath catches in my throat and a sob bolts from nowhere. And then I’m crying. I try to stop myself. I can’t let my colleagues catch me crying, what would they think? I shut the door and lean up against it. I focus on sobbing quietly. 

I let the tears come. My emotions, bottled up for too long in a cage of their own, liberated. I did love my father. I can feel the love now. And I forgive him for dying too young.

The room remains comfortingly cold and clinical. There are disinfectant wipes next to the bed, hand sanitiser attached to the wall, and a sink where I wash my hands. I go to the sink and put on the warm water. I let it run over my hands and splash my face with it, washing away my tears. I run my hands through my hair to smooth it out and return to the desk.

After a few minutes of counting my breaths and regaining my composure, I’m ready to see my next patient. I press the button to call them.