Prior Authorization: From Writer to Doctor and Back Again


On January 8th, 2012, my mother died and I was freed. My novel, Divided Eden, flew out as if released, a pent-up expression so ready to fly I could barely type or scribble fast enough to let it out. I wasn’t freed because I’d been a caregiver, seeing to my mother’s needs 24/7. No, my father had done that. I wasn’t freed because she’d disapproved of my writing, because she hadn’t. She’d even challenged me to write, years before she got sick. Told me if I didn’t like the book I was reading, I could write a better one. That I should write a better one.

But long before telling me to write, my mother had given me a different task. A task, a path that had defined and confined me for so long I wasn’t fully aware of its bindings. When I was seven years old, I came home from career day with a plan. I would become a nurse. When I told my mother this, she snorted, cigarette in hand and said, “Become a doctor instead. Then you get to give the orders.” From the age of seven I chased, and caught, a dream that had never been mine. A worthy dream, a path of hardship and reward, sacrifice and service. I path I sometimes loved and sometimes hated with a bleak sadness. But the whole time I spent studying to be and becoming a doctor I wasn’t the one giving orders, I was taking them. Always taking them.

Divided Eden turned out to be about mothers and daughters, and grief, and the shifting of shapes. Of who you become when you are pushed by outside forces and whose voice you listen to in the quiet, terrifying moments of self-doubt. For E.J., these forces are at first very much beyond her control. These forces ask her to make decisions and choices she cannot fully understand. But E.J. needs to understand. She needs to find her own voice.

When my mom died, I was freed in a way that made no sense to me at first, as if something integral inside me had changed shape overnight. A role I had been playing ended that day. The dutiful, informed daughter, the dedicated patient advocate, her always-on-duty doctor—these parts of me disappeared and another self emerged. I don’t know all of her moods and colors yet, because I am still getting to know this new self. But I know with certainty that she is not a nurse, or a doctor. She is a writer and she is finally free.

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Part of Me

Part of me wanted to be a doctor. Part of me liked the attention. Adults were pleased with my ambition, my peers were dubious but impressed. I studied Latin, anatomy, chemistry. I volunteered at the local hospital, wearing a red and white apron. I did everything you were supposed to do “to get into medical school”. And I wrote stories.

When I was eleven I wrote about a robot with feelings. A robot with longings and regrets, my first official entry into the world of speculative fiction. The contest was Scenario Writing and I won second place in the state of Ohio. I’d met the girl who took first place two years before, at a fifth grade debate. I was the girl who’d cleaned out the library of books about cloning and she was my opponent—shy, stumbling, unprepared. I stomped her in the debate and I enjoyed it. Part of me liked being the best and the smartest. But part of me felt ashamed.

When we were reunited on the bus taking us to the award ceremony, I didn’t remember the debate or having met Janine before. I didn’t know at first that she remembered me. She had no reason to be nice. No reason to stay up all night talking with me about movies and comic books and sisters. No reason to challenge me to a video game marathon in the dimly lit arcade of a Best Western in Solon, Ohio. But she did. On the surface, in terms of temperament and drive and family life, we couldn’t have been more different. On the inside, in the part of ourselves where we were fully weird, fully awake, and fully known, we were the same.

Janine has hair like in a classical painting—down to her waist, thick and wavy and more golden than red. Eyes gray-blue or blue-gray depending on the sky, and an elfin smile. She is a soothing breeze when I am a tempest. She is a poem when I am a rant.

You know when someone is your best friend because she is a part of you. Her thoughts as familiar as your own, her moods a song you know by heart. Her triumphs your triumphs, her disappointments felt as keenly as your own. In high school, in our advanced creative writing class, her work was singled out. Her prose, lyrical, her characters, haunting. A part of me cringed with envy. But the far greater part of me glowed with pride. My best friend was a writer. And I was going to be a doctor.

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A Good Soldier

If you’ve ever felt like the doctor taking care of you seems cold or detached or even a little bit angry, I have an idea why. We learned to be that way in the same way we learned to read an X-ray or perform surgery. We were taught by those more skilled at it than us.

I once sat next to a young Marine on a plane, a helicopter pilot with a biting sense of humor and a quick smile. He was curious about my training, wanting to compare boot camp to medical school and residency. In the end we discovered far more similarities than differences. “In boot camp they break you down,” he said, “so they can build you back up. So then you can break the next guy down.”

In my first month of surgical wards as a third year medical student, fresh off two years of book learning, I stopped in a room to help a patient who was vomiting all over herself. I brought her a basin and a rag, I called for the nurse. And for that simple act I was berated in front of the whole group. Told off for interrupting rounds and doing a nurse’s job. Did I regret helping that woman? Absolutely not. Did I learn how to behave? Yes, I learned. I learned that compassion was weakness and weakness was to be hidden. I learned to hide. I learned to shove down the softest parts of myself and build up walls. But living behind walls changes a person.

In Divided Eden, E.J. is angry. E.J. is trapped. E.J. is hiding the best parts of herself to make it through. But hiding those parts doesn’t help you survive. It only makes you start to hate yourself. In medical training I became a good soldier. I kept my head down and my mouth shut. I did what I was told, acted as I was expected to act. Was I cruel to the students who came after me? Did I treat them as I had been treated, did I punish them for tears or emotions or doubts? I hope not, but I honestly don’t remember. Living behind walls makes you forget.

Once as a fourth year, I was sick. Feverish, dizzy, exhausted. I asked a kind nurse if I could check my temperature and then got caught by my supervising resident, digital thermometer still in hand. She glanced down at the number, 101 degrees, and made a point. A teaching point. “It’s not really a fever until greater than 101.5 degrees,” she said. “You’re not that sick.”

No, I wasn’t “that” sick. Not like our patients, some moaning, some so miserable in their beds I could barely force myself to make eye contact. Some scared, some healing, some dying. No, I wasn’t “that” sick. But I was ill. I felt terrible. I needed sleep, I needed hot soup and kindness. Instead I stayed put on the wards and did my job until I was told to go. As I think back I wonder what gentleness would have cost her, a resident doctor as tired and unhappy as I was. What would have happened if she had just said, “Sorry you don’t feel great. Maybe we can get you out of here a little bit early today.” What was lurking behind her wall? Maybe she would have crumbled.

At the time, instead of falling apart, I added another layer to my armor and placed more bricks into my wall. I was a good soldier, I didn’t fall apart until much later. But I stopped writing.

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The needle tip, shiny and curved and bloody, winked at me. After 36 straight hours of helping deliver babies and sewing women up, I had stuck a needle all the way through my thumb and I felt nothing. Well, not nothing. Just not physical pain. Despair at the idea of having to go to the ER to get my blood tested for HIV and hepatitis. A numb disbelief that it would be an extra hour before I could drop down into blessed, dreamless sleep.

Getting stuck is actually what woke me up. I was an intern and I was drowning. There were always a few residents who actually thrived under the pressure, hardening into brilliance like diamonds. I admired them, of course. I just couldn’t relate. Some of us exercised or drank to excess. Some ate for comfort, some barely ate at all. There were addictions and affairs and divorces, families ripped apart.

I learned who to turn to, and it wasn’t my family. I’d called home weeping, thumb throbbing. Thinking of quitting, with visions of liver failure dancing in my head. My mother told me to suck it up. My father said I’d known what I signed up for. I got the message. Failure was not an option.

In Divided Eden, E.J. doesn’t have a family to turn to, either. All of the adults in her life are either dead or just gone. And as much as she loves her sister, there are secrets between them. Secrets on both sides that hold them at a distance from each other. So E.J. does what I do—she turns to books. To read is to escape. To feel weightless as you turn the first page, waiting for the hard yank of acceleration taking you out of yourself. She knows that as long as you have a book to read, you have a home.

I survived medical training on candy bars and Diet Dr. Pepper and stories. I became known as the resident who had novels in her bag instead of medical texts. The strange one who went to the movies alone.

After a needle stick they test your blood every few months for a year, to make sure you’re free of disease. Every time a needle went in because the needle had gone in, I thought about sitting alone in a theatre, breathlessly waiting for the screen to go dark. Or cracking the spine of a new book and for a moment being exactly where I wanted to be, stuck inside someone else’s story.

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Once during residency, I called my mother just to talk. A young woman had died from an amniotic fluid embolus hours after giving birth, leaving a newborn baby girl, a shattered husband, and an oblivious two-year old. I wanted to talk about the cruel injustice of death. My mother wanted to talk about wallpaper.

I tried. I tried to talk about the color scheme for the upstairs bathroom and her latest trip to the gambling boats. I murmured replies, I hung up the phone and I got angry. Wallpaper. The world I dwelled in was bloody and unfair and full of all kinds of pain. I didn’t give a crap about wallpaper. And if my own mother couldn’t talk to me about what I needed to talk about, then I didn’t give a crap about her. That’s how I felt and that’s how I treated my parents and even my old friends, the ones who weren’t doctors. I thought our worlds were too far apart to connect, so I stopped trying. And after a while, they stopped trying.

In Divided Eden, E.J.’s world is confining. As a fetisher living in Old Town with a family just as corrupt as the cops, she has no future and no hope. At first glance, Lance’s world is everything hers isn’t. He has money, security, and loving, successful parents. She doesn’t think their worlds could be farther apart. Until she looks deeper, she doesn’t see the cracks. The weight of expectation Lance lives under, the pressure to become his parents. The fake life of a fetisher stripped of his talism and unable to use his gift. E.J. has to see through Lance’s cracks to find someone just as in need of hope as she is. Just as trapped, on the other side of the Gate.

My mother didn’t know how to talk to me about anything real in my life–or maybe she didn’t want to. Regardless, she had nothing real in her own life to talk about either. The years and the hurt on both sides that it took for me to figure this out still haunts me. The way I pushed away the friends that loved me and wanted to understand what I was going through haunts me.

My mother had two daughters who’d moved as far away from her as possible and called only out of duty. A husband caring for her with a distant, perfunctory kindness. A small life in a dingy town that she hated. A life filled with all kinds of pain and no words to define or express her rage, her disappointment, or her loneliness. So she talked about what she saw in front of her, or about what she did to fill the gray hours. Now that it’s too late, I see through her cracks. And to hear her voice one more time, I would spend as much time as she needed talking about wallpaper.

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Tea and Sympathy

My residency savior–how fitting–was named after a star. Aldee was my intern, technically my student, but she taught me how to be human again. Aldee began her intern year much like the rest of us, in wild-eyed, mute shock. She just didn’t stay quiet.

Aldee loves listening to jazz in smoky nightclubs, wearing leather catsuits, and practicing yoga. She makes jewelry and a mean cup of tea. When it hit her, what residency was all about, she protested. Maybe it was her years of waitressing, serving cocktails to handsy men while wearing fishnets, that gave her such a voice. Maybe it was just innate wisdom, pouring forth. She spoke out. She spoke up. She said, “We can’t be treated this way. We need lives, we need to breathe. We need to be human to be doctors.” No one listened–at least, no one in charge. Nothing changed except inside me.

We became a club of two, the be-more-human club. At my first yoga class, scrunched and sweating, uncomfortable in lots of ways, I watched her lithe limbs bend. I watched her calm face, I noticed her smile. I was not smiling. I almost cried as my limbs and joints protested. Yoga was not my happy place. Being with a friend was. And for the first time in more than a year, I felt like a person again. We spent long afternoons hunched over her kitchen table, stringing beads and drinking tea, hearing each other. Long nights in cramped wine bars and jazz dives, dancing until we couldn’t stand. We broke the silence of our own unhappiness, together.

In Divided Eden, E.J. keeps silent about the horrors of her past. I have no tale of woe, sir. She refuses to see herself as a victim. E.J. knows only how to move forward, not how to look back. When she meets Lance and his mother, two fetishers who treat her with respect and compassion, she finally lets her truth come out. She learns that holding the pain inside does not make it go away. E.J. breaks her own silence and starts to heal.

The addition of tea and sympathy didn’t change residency. The hours were just as long, the months I didn’t see my husband just as lonely, the exhaustion as soul-numbing. Tea and sympathy didn’t change my circumstances, they changed me. Speaking my truth to a friend changed me forever.

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The Red Couch

Sitting on the red couch of the Grandview Heights Public Library I wrote longhand on yellow legal pads, sometimes for eight hours with barely a pause for a snack. For the first time in seven years, I had the time. I’d been fired.

My first official job as a physician ended before it even started, when the practice I was supposed to join decided not to hire anyone, including me. I’d finished residency, moved back across the country, taken a road trip, and settled myself, a cat, and a husband into a rental house before the news hit. Then for two months I had mountains of time. Blissful, lazy, stretched hours where the only buzzing in my head came from words flowing onto the page. I was a world-building, mythology-crafting, character-creating machine. I had never been so happy to fail.

People kept trying to tell me how sorry they were that I was jobless and drifting, with no paycheck to cover my student loan bills and a grumbling husband still working long hours as a fellow. But when they saw my face and heard my laugh, the sympathy stopped. Some thought I’d gone crazy. Wasn’t I supposed to want to work? To use those skills I’d sacrificed so much to gain? Didn’t I feel rejected, scared, lost?

I didn’t feel lost for a moment. On the contrary, I’ve never felt so found. On that red couch, hour after hour, month after month, I was becoming myself again. I was re-learning how to breathe, to think, to dance, to be silly. For the months I was jobless and then working part-time, I was the truest me I’d ever been. A me that I hope to find again.

Non-writers always ask how I find the time to write. They don’t understand and I don’t know how to explain: writing finds me. Writing saves me. Writing lifts me up and splashes joy in my face and helps me find the reason for my day, the way nothing else in my life can quite do. The happiest place I’ve ever been is on a red couch in a quiet library, pen crawling across the paper, nothing else to do but write, dreams becoming reality.

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Gertrude, Not Sam

Gertrude was unable to speak, frail, dying. I’d stepped into her room, knowing she couldn’t speak after a devastating stroke but not expecting to see such lively, crackling eyes in a superbly wrinkled face. I spoke her name, offered gentle words, performed my simple exam. And then she glared at me. Ferociously, with so much spirit and so much to say behind those tight lips I stood frozen and ached for her.

When her family arrived hours later, she was deeply comatose. I greeted them at bedside, noticing tears and smiles, a room already filled with flowers, cards, a balloon and a half-eaten box of donuts. They were here for the duration. I sat down, hoping for stories. But not expecting the reaction I got when I said, “Tell me about Gertrude.”

The room burst into laughter. The kind of laughter that bends grief into a manageable shape, if only until the silence descends.

“You didn’t call her that, did you?” her daughter asked, horrified and somehow delighted. “She went by Sam. Only by Sam.”

And then, stories. The family filled the room with cackles and “do-you-remembers” and hugging and sobbing, shared memories from ninety years of a life often wildly lived. At last they produced a faded Polaroid of Sam slumped in a lawn chair, a bottle of beer balanced on one knee and a hand over her eyes as she peeked at the stripper in a Speedo in front of her. He was golden blonde and muscular, posing with a hand on his hip. She was celebrating her 70th birthday.

We laughed until tears ran down our cheeks: they because of how much they would miss her, me because I was so grateful. Honored, humbled, and touched to receive the gift of knowing her.

When asked how I am able to bear the grief of caring for the dying, I think of Sam. I think of how if feels to be in the presence of the dying with no cure to give, only my attention. Only my time and an open heart. I think of how much I am given every day.

The name on a plastic band around her wrist said Gertrude. I stopped to look at a faded Polaroid and I was given a story. If I hadn’t paused, if they hadn’t shared, something immeasurable and precious would have been lost. I would have known only Gertrude, not Sam.

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