NEVER SMOKER | Jonathan Bock
The CDC doesn’t care if you’ve smoked ninety-nine cigarettes; the magic number is a hundred. The CDC doesn’t care, so I don’t care. Once you’ve smoked a hundred, you’re in trouble. Your medical record changes from “never smoker” to “former smoker” and your differential diagnosis list gets a lot longer. Make sure you keep track of how many cigarettes you smoke, because someday I might ask you if you’ve smoked a hundred or ninety-nine. Or, if you’re like me, just answer “never” because a few cigarettes as a teenager doesn’t make you a smoker, and it’s really not worth explaining that at every doctor’s visit.
I looked through the chart of a 68-year-old woman the night before seeing her in the office. In my clinic prep template, I typed “never smoker” next to the social history heading. In sixty-eight years of life and annual trips to the doctor, through three pregnancies, a diagnosis of high cholesterol and two shoulder surgeries, she had been asked multiple times about a history of tobacco use, and every time she had said, “no, never.” Previous notes written by generalists, orthopedists, cardiologists, obstetricians and gynecologists all said the same thing: “never smoker.”
I ask her again today, as a formality, even though my printed clinic prep tells me what she’s going to say. Today she says “no” and then “well” and then “yes,” because five weeks ago she felt a growing fullness in her belly, four weeks ago she went to her doctor for an ultrasound, and three weeks ago she heard she has stage 3 ovarian cancer. Today she looks a 25-year-old medical student in the eyes (even though his eyes are looking at his paper and pen) and confesses to him and to her husband and to God that she smoked a few cigarettes in high school.
She has a happy marriage and three grown children, one of whom is a few months away from providing the first grandchild. She loves to ski and hike and eat good food. Her sixty-eight years have made her wise, but they have not made her frail, despite the scars left behind by surgeons. Her family and friends know she would never smoke, she barely even drinks after all. They know that no one deserves cancer, but if anyone really doesn’t, it’s her.
Her husband is in the room with us. He’s bored by the question but leans forward and frowns when he hears her answer. She shakes her head and says that this is the first time she has remembered those cigarettes out loud, and we know that means she’s afraid. Afraid enough to make her confession. Afraid that she’ll miss the family ski trip in a few months; that she won’t meet her first grandchild; that she’ll be gone before that child makes it to high school and says yes or no to their first cigarette. She’s scared enough to tell me, because maybe it changes things for her. Maybe this broken confession is her only hope of absolution. Maybe the graphs she saw when she Googled “ovarian cancer life expectancy” don’t apply to her because she smoked a few cigarettes fifty years ago. What if the chemo regimen is different if you’ve tasted a cigarette?
The doctor is in the room now, and the wheel of the mouse is noisily clacking through the woman’s CT scan. There’s the belly button, and just to the right is one of your tumors. Her cancer has silently spread through various parts of her abdomen like smoke crawling under a closed door. She cranes her neck to get a better look, and her husband leans forward even farther to see around her, frowning deeper at the black and gray images that look nothing like his wife. Her strong hands slip beneath her shirt, and she feels just to the right of her belly button. She pushes hard in silence, trying to feel the imperious cancer cells, trying to place her hands right where the images say they’re growing. She doesn’t say if she feels anything, and we don’t ask.
Cancer lurks in the void and often strikes out at random, leaving no one and nothing to blame. Google will tell you that smoking cigarettes increases your risk of ovarian cancer, making it seem as though one of the seven cigarettes you smoked when you were eighteen is the reason your grandkids will learn how to ski without you. Perhaps this misplaced guilt is more comfortable than resigning to the randomness of the unknown.
Jonathan Bock is a third-year medical student at the Mayo Clinic in Rochester, Minnesota. Originally from a small town in Kansas, Bock studied philosophy and biochemistry as an undergraduate. His eventual medical specialty is undetermined, but he hopes to use his educational background to incorporate the power of storytelling and the varied contributions of the world's great thinkers into his future practice.