Tres Mujeres

Dr. Chang – 6:18pm, Wednesday evening

The click of my office door opening startled me, although not as much as I startled the kind-eyed man who had come to empty my trash and turn my light off. 

“Hey doc I’m sorry, didn’t think anyone was in here,” he purred while backing out of the doorway.

“Oh no, it’s ok, I didn’t mean to scare you,” I answered, smiling. After a moment of basking in the warm glow of automatically being called “doc” after years of being called “the nurse” or, worse, “the Asian girl”, or worse still by one memorably outdated patient a the VA “the oriental one”, I turned back to the mammogram images open on my second monitor. It was nearing the end of my first year in practice, and even though I had been told that my physician assistant could help with preparing my clinic notes, I felt more comfortable when I looked through the records myself at least a day before clinic. 

At that moment I was looking at the images for Maria, scheduled for 9:30am the next day, up on my monitor. She had a large tumor in her outer left breast and abnormal lymph nodes in her armpit. Based on the tumor biomarkers, she would need chemotherapy before surgery, which was often a hard sell in patients who insisted that the cancer just needed to be physically removed as soon as possible. I scribbled a few notes on her cover sheet “MRI, schedule port placement, insurance?, CT chest/abdomen/pelvis, bone scan, oncology” just to make sure I didn’t forget anything when I talked to her about the overwhelming number of next steps. As I was closing her images, my eye caught on the notes at the top of the mammogram report, which mentioned that she had first felt the mass six months ago. SIX months? Maybe she thought she was too young? Or was scared to come in because she didn’t have insurance?

The other new patient, scheduled for 8:30am, was Sasha, a 42 year old woman whose entire right breast was peppered with calcifications, with the biopsies of two areas showing in-situ or stage zero disease. It was a little surprising because her screening mammogram 7 months ago had been clear, and unclear to me why it had been repeated before one year had passed, but lucky for her that it had been. She would need to have the entire breast removed but would be fine long-term. Half of the woman I saw were eager to have an excuse to get implants covered by insurance, I wondered if she would be one of these patients. “MRI for contralateral disease, plastics referral” I wrote on her cover sheet.

Sasha and Maria were in addition to the 43 year old and 46 year old new cancer patients I had seen on Tuesday – since when were all of my newly diagnosed patients under 50? Cancer was supposed to be a disease of the elderly, especially somewhere like Santa Monica, where everyone was focused on “clean” eating (a term I hated because of the reciprocal implication of “dirty” eating) and at least the plastic-surgery-assisted illusion of wellness. Breast cancer in premenopausal women had actually been a focus of my fellowship research, but since starting my first “real” job and having a partner quit abruptly three months in, I hadn’t had time to do anything except swim upstream against the floodgates of new referrals. One of these days I would get efficient enough to leave work before the night cleaning crew passed through, but apparently not this week. 

Sasha – 8:15am, Thursday morning

“Get out of the way!” I snarled at the small sedan as it slowed in front of me. The combination of being up half the night with the baby (who at 13 months should definitely be sleeping more than he was) with the anger hangover from the fight I had with Alan about why he couldn’t skip one single preproduction meeting to come to the most important appointment of my life with me had left me completely on edge. Fortunately, my white Lexus was a nearly completely soundproofed cocoon of soft buttery leather, well suited to absorb my misplaced rage. 

After parking, I followed surprisingly informative signs through the maze of hallways, and arrived at the peaceful, tastefully decorated waiting room of Dr. Chang’s office. I checked in with the lovely Japanese woman at the front desk and was immediately taken back to an exam room. Monday, as soon as I hung up the call from the radiology saying that the biopsy had showed cancer, I had called Dr. Reese, my plastic surgeon, who had recommended Dr. Chang and helped get me in to see her. My hands were trembling as I undressed. Never in my deepest nightmares did I imagine I would be diagnosed with cancer – it was alcoholism and suicide that ran in my family – but I trusted that he had put me in good hands.  Yesterday, when the initial shock had worn off a tiny bit, I had started reading about breast cancer to know what questions to ask her, but gave into the constant interruptions from the baby, and my three- and five-year-old daughters. Once the nanny got them under control, I settled for just reading Dr. Chang’s biography page and reassuring myself that she must be good if Dr. Reese recommended her and she had trained at hospitals that even I had heard of.

Just as I was about to take my phone out to distract myself, Dr. Chang breezed into the room. She looked incredibly young. She must not have three little kids and a husband who came home from work dinners smelling like cheap perfume, I thought bitterly before I could stop myself.

“I know this is a scary diagnosis, but you’re going to be ok,” she said warmly and confidently. “We’re going to get through this together.”

She reviewed and confirmed my medical history and recent imaging, obviously having prepared for the visit, which was reassuring. After examining me, she stepped out for a minute to let me get dressed, making me grateful for the opportunity to cover my post-pregnancy belly pooch before confronting my mortality head-on. 

Calmly, she began discussing the biopsy results. I tried to stay with her, catching phrases like “early-stage” and “completely curable”. Maybe this wasn’t as bad as I thought. Couldn’t they treat breast cancer with pills now? It seemed like all of my friends had been Racing for the Cure in college, maybe they were well on the way to finding it. “Mastectomy, which means removal of the whole breast.” I caught her say, suddenly flashing back into the conversation.

“I’m sorry, what? The whole breast?” I ask incredulously.

Her rational explanation made sense, that it was early-stage disease but over a large area, and I knew I wouldn’t refuse life-saving treatment, but it was hard to focus when my mind kept jumping to Alan. For a while I could brush off his late nights at work as necessary, with a touch of hiding from the chaos of the children at home (it made me jealous he even had that option). Unfortunately, I had been blessed with the nose of a bloodhound and could smell a dirty diaper from across the living room, and could also smell the tacky perfume on his beard as he climbed into bed last night. If he was cheating now, or thinking about it, as I almost had my size 2 pre-baby body back, what would he do when I was disfigured with surgery? Involuntarily, I teared up, then flushed with embarrassment. I wasn’t even crying about having cancer, I was crying over a stupid man! 

Maria – 9:40am, Thursday morning

The bus moaned to a stop and Jose grabbed my hand, pulling me up from the hard blue plastic seat and out the back door. I couldn’t believe how bad the traffic had been this late in the morning, when it seemed like everyone should be at work already, and hoped the doctor would still see me. I hated being late and blamed Jose for insisting on eating breakfast but didn’t say anything to him. He had downplayed it when I asked but I knew it had been difficult for him to get off from

Cautiously opening the door, I almost collided with a tall, beautiful woman on her way out. I bet she was never late for things, no one who looked that put together could be.  The waiting room put me on edge. It had the same ambiance as the formal living room in the house I had cleaned until last month, when the gross husband had accused me of stealing a watch after I spun away from him when he grabbed my breast in the kitchen one afternoon.  Shaking off the memory, and the rage that ebbed behind it, I grabbed Jose’s hand and was relieved to have my name called quickly. I asked if he could come back with me and the sweet receptionist said sure, but I might want to have him wait outside the room for the initial exam. I nodded gratefully and Jose gave me an encouraging smile.

Waiting alone in the room in the gown, I tried to focus on the diagnosis and relief that would come with the certainty of a treatment plan and not worry about the money. I wished I had taken the hotel job instead, maybe if I had I would have health insurance now. I was short sighted though, finding it impossible to pass up the larger amount of cash the man and his wife had offered for just cleaning and occasional errands, and now leaving me unemployed and without a way to pay the bill for even this initial visit. 

As soon as she entered Dr. Chang put me at ease. There was a vague scrappiness about her, like she too had to deal with disgusting men and constant underestimation from her peers.  I liked her immediately. She had obviously read my chart thoroughly, and after the exam made sure to bring Jose in for the discussion of treatment. It sounded like a lot to do – chemotherapy which would require the placement of a port into a large vein, followed by major surgery with probable removal of the whole breast and an undetermined number of lymph nodes, with the possibility of radiation after that. Jose took notes for me and asked a few questions, making me wonder when in the world he had found time to read about breast cancer. I was lucky to have a son who was responsible. Given how much trouble I had been having with my two-year-old daughter recently, I couldn’t fathom how I had done so well raising Jose and his twin brother when I had only been a teenager myself. 

Finishing up with her plan, Dr. Chang asked if I had any questions. I hesitated, suddenly choking on my breath and feeling like I forgot how to speak English. “Will…will…will this cost lots of money? I don’t have health insurance, I’m sorry,” I stuttered.

Her face fell, and she reached out and grabbed my hand. “Maria, no, don’t worry about that. We can get you insurance. I already filled out the paperwork, our social worker Heather will go over it with you and have you sign it.”

I liked her so much, I didn’t want to ask the next question, but couldn’t stop myself. “Will it matter for my treatment? The fact that I don’t have fancy insurance?”

Dr. Chang met my eyes, holding my gaze. “Absolutely not,” she said with startling force. “You’ll have the same doctors and get the same care as everyone else. I promise. We will take great care of you.”

Trusting her, I nodded and snuffled, embarrassed that the emotion had overtaken me. If only I could explain that it wasn’t because I didn’t want to work, I had been applying for new jobs nonstop since getting fired.  She was a busy doctor though and I didn’t want to take up any more of her time.

Dr. Chang – 7:00pm, Thursday evening

Talking to my mother on the drive home on Thursdays had become a routine ever since we discovered it worked well with her surprisingly packed retirement schedule of volunteering and socializing. She didn’t know anything about medicine but had still supported me through years of self-doubt, frustration, stress, and loneliness during medical school and residency, so I liked to tell her about life now that I was finished. Every time I was about to enter the room to have a new cancer talk with a patient I paused before I knocked on the door, paying reverence to the fact that I was about to temporarily ruin her life, but overall my work was rewarding. Every compliment I received from a patient at the completion of treatment felt like it should pass through my pores and stick on my parents, who had given up themselves for years to put my brother and I in positions to succeed in the country that was foreign but full of potential to them. 

I said goodbye to her as a walked into my kitchen, dropping my purse to pour a glass of wine from the merlot bottle on the counter. Flopping down on the couch next to my cat, I tried to think about what I wanted for dinner and not worry about Maria and Sasha. Sasha had surprised me with her breakdown in the office – I could never predict the criers – but I sensed an undercurrent of strength in her.  Maria had aggressive cancer with a poor prognosis, but incredible family support if her son was any indication. We would be able to get her public assistance insurance without delaying her starting treatment, but it made me furious that despite her scary diagnosis, the American healthcare was rigged so that money would be her biggest concern. Silently toasting them both, I reassured myself that they would get through treatment, probably surprising me with their resilience as grace as many of my other patients have.   

Maria – 9:00pm, Thursday night

As Jose and his brother cleaned up after dinner, I snuck into my daughter’s room. My father said she had been good all day, but I didn’t believe him. Recently she had been enthusiastic about the word “no!” as only a two-year-old can be, and I had no doubt she had been a bit of a terror. Although I missed my mother every day, I was incredibly lucky that my father, who had watched her during the day while I was working still came over so that I could apply for jobs and run errands. Watching her twitch gently in her sleep, I realized that I would have to rely on him even more in the coming months and knew that he would be there for us. The cancer could take my hair and my breasts and my energy, but not my family.   

Sasha – 10:30pm, Thursday night

I often hated having another adult around during the day, hovering and making me feel inadequate for being unable to simply take care of my own family despite not having gone back to work as I had planned. The division of labor was awkward as she tried to earn her generous, tax-free salary, and I tried to do enough to justify my position as matriarch and meet my own internalized “involved mother” standards. Today however, she took one look at my face when I opened the door, and immediately put the baby down for a nap, started a Disney movie for the three-year-old, sent the five-year-old to play in the backyard, and hugged me while I sobbed.

Now, eight hours later, Alan opened the door, surprised to find me on the couch and not already in bed. 

“Hey hun,” he said, not looking at me. “What are you doing up? What’s for dinner? I missed lunch because the director couldn’t get his head out of his ass and we had to waste a bunch of time….” He blathered on about work. Was it possible that not only had he refused to come with me, but he didn’t even remember that I had the appointment today? I couldn’t believe it, but simultaneously had expected it. My resolve hardened. I was practical enough to know I couldn’t get through surgery and the possible radiation treatment without his money to keep paying the nanny, but as soon as treatment was over, I was taking the kids and leaving him. I couldn’t imagine he would fight me for custody, but if he did, I would leave the country, start over, work two minimum wage jobs, whatever it took. I wouldn’t stay with a horrible, selfish man the way my mother had.