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BEFORE I WENT AWAY to college, I sat with my grandmother while she polished silver. “Don’t you want to stay home and make things beautiful?” she asked me. No, I did not.

When I finished graduate school, unsure of what to do next, I signed up with a clerical temp agency, a stopgap until I found a real job. I was sent to work at the largest teaching hospital in Boston. Ten years later, when I received a service pin and a rose, I realized that I still thought of myself as temporary. During this time, I had made no effort to be promoted up the clerical ladder. For many years, I didn’t make contributions to the retirement annuity the hospital offered, because I didn’t intend to be there long enough to make it worth my while. I left the hospital only after a secretary in the cardiology office where I worked shot one of the doctors four times and then put the barrel in her own mouth.

She had come to us as a temp. She announced immediately that she was not a secretary. We’d heard that before. In fact, she really wasn’t a secretary. She didn’t know how to type or transcribe dictation. She was, as she told us, a professional. She had worked for a number of years as a pediatric social worker. She told us she was temping while she looked for a job in hospital administration.

Strangely, as the skills required for office work become less particular—the portability and fidelity of dictating machines leaving shorthand an almost dead language; word processors and spell checkers outdoing the accuracy of old-time typists—the requirements for employment are becoming more rigorous. Secretarial jobs in the hospital are posted with a college degree as “required” or “preferred.”

Who goes off to college aspiring to be a clerk? Reading the classified ads, I am amused by the attempt to get the pink-collar class into suits. During the years I worked in an office, the title “secretary” fell from favor and was replaced by “administrative assistant,” and, more recently, “assistant.” I don’t know if there is a secretary left at Harvard since the clerical workers unionized there.

Mine was not what they called a “front office” job, and did not require that I dress professionally. From time to time, I would admire a suit on a store mannequin and try it on, the store clerk dressing me up with accessories. Looking in the mirror, I knew I could get my resumé together and get a better job. When I was younger, I would sometimes buy the clothes and bring them home, where they would hang in my closet. The better tailored the dress, the more I felt I was wearing someone else’s clothes.

When I spilled spaghetti sauce down the front of my white blouse one day and asked to go home, my boss sent me to the laundry to get a pair of scrubs. After that, when I didn’t have a clean blouse, I would wear a scrub top. Patients and visitors sometimes had trouble distinguishing between the physicians, nurses, technicians, and janitors, all of them rushing through the halls in their scrubs (aquamarine in my hospital). The uniform covers a rigid hierarchy of expertise. The physician touches the patient. The office worker does not assist.

I held on to my title. I was a secretary. The first requirement of my job was secrecy. I had to cultivate disinterest, detach myself from the papers that crossed my desk and keep the patient’s history confidential. I was saved because it was impossible to type and read at the same time. If I paused over a patient’s medical record, I began thinking in lifetime narratives rather than words per minute, and lost a good part of my day.

The larger secret we were hired to keep is that hospitals are businesses. Between the insurance companies and the patients, the doctors are middle managers. The secret is so well  kept that many come out of medical school without knowing it. Many leave the profession when they find out how much of the job is paperwork. This is where she stood out. She was a problem solver, adept at scheduling for the physicians and getting insurance issues resolved. After a month in our office, she became the go-to person for administrative issues. After two months, she accepted an offer to stay on as one of the clerical staff.

She became one of us. She joined in with the office gossip. She gasped at the story of the surgeon who had screamed at his secretary for taking the last Coke in the refrigerator, and commented, “Well, I guess no one died.” She reassured the young woman whose husband had started getting manicures that this was not a sign he was gay. She offered to use her discount at the bookstore where she had a night job to buy me books.

Most of us chattered about our families: the irritable child who was finally diagnosed with diabetes; the husband who had fifteen years’ of Scientific American stacked in the basement; the mother who never cleaned her refrigerator. She didn’t talk about her family, except to worry about her parents’ health. She talked about the families she had dealt with as a social worker. She told us about the crack babies she had to take away from their parents, and the battered children she had to place in foster homes. Later, I wondered if her obsession with a married man who had children was social work slipping into sociopathy. She was trying to place herself in the ideal family.

§

Why did she stay on as a secretary? Why did I? We were both Irish Catholics and had both come up in Catholic schools where, from grammar school on, we didn’t prepare for an occupation, but listened for a vocation. The promised call might come as a shout, but more often as a whisper. It always came as a question, an invitation, never an answer. The special would be called to religious life, but if we listened, we would all find a path in the world. As a child, I felt that once I knew my way, the work would be over and my life would begin.

I thought it a great blessing, having been taught by religious sisters, to get through school without hearing a call to join them. At the same time—and I don’t know if those not raised in my tradition will understand this—I was miffed at the silence. That left the old truth: unless you are gifted with extraordinary talent, your work is usually in the family business.

Medicine was my family’s business. My father was a neurosurgeon, my mother an operating-room nurse. My sisters and I had bandage scissors in our art box and protected our hands like surgeons. Even now, when I close a car door, I hear my father’s voice: “Watch your hands.” When my mother died last August, my sisters and I each chose pieces from her jewelry box. I took her nursing pin—Royal Victoria Hospital, Montreal, 1942.

I have four sisters: none of us went into medicine. We knew the costs. My father had a clear vocation, literally being called at all hours. He was precise, hyper-vigilant, and often irritable, pacing from his study to the kitchen and back. “Like a caged animal” was the cliché I knew then. Like a surgeon, I know now. Still, carried in the wake of our parent’s mission, three of us worked in hospitals.

Why does anyone stay? I know I was addicted to the urgency, the constant crises and resolutions. My mother used to tell the story of the nurse’s aide who visited the hospital chapel at the end of each day to undo the work of her eight-hour shift by praying for the death of those in pain. Like her, I sat on the sidelines of life and death, feeling I was in the game.

My colleague’s father was a retired FBI agent who had worked in New York City, another constant vigil. I imagine that it was from him she inherited the tropism of looking behind herself every few minutes, ready (hoping?) for the encounter. Social work had confirmed for her that the world was made up of the ruthless and their victims. She told me that her father had taught her and her sisters to use a gun to protect themselves. Later, we wondered how long she had been carrying it in her backpack.

§

My father, who was old school, made a distinction between medical and surgical thinking. Surgeons consider what they can remove to cure the patient. Physicians consider what they can add to the regimen to promote healing. He once speculated that if every patient walking into the emergency room was taken off of all medication, half would leave cured and half would die.

The surgeon’s main contact with the patient is from the other side of a mask. The physician sees the patient regularly and follows his history for years, making notes about headaches, back pain, constipation, and then, suddenly, acute heart failure or inoperable cancer. In the hospital, the surgeons walk through the halls in scrubs and clinic coats. The senior physicians wear suits. The caricature of a cardiologist is a man in a suit, signing his records with a fountain pen.

The physician she murdered was a world-renowned consultant on cardiac arrhythmias. He was Irish, with that peculiarly Irish mix of personal reserve and great wit, seemingly the least likely victim in the office. He was a great diagnostician, and not simply within his own specialty. He was able to find an early brain tumor in one of his patients, endocrine problems in another. His special talent was auscultation, listening to the heart, a dying art in these days of cardiac ultrasound. He did not simply read a printout of the rhythm; he could hear the music. And he listened to his patients, taking their complaints seriously. To the irritation of all of us secretaries, his patients began to treat him as a primary care physician, calling him to report colds, depression, and stomach problems. He had the largest practice in the department.

§

In the years since, I have tried to find my way back to the detachment I felt when it was over. I was able to give all my attention to my feet, stepping around the blood, walking on my toes toward the policeman at the office door. We needed to protect the crime scene. Someone sent for the professionals. We needed to let go, one muscle at a time. We could sit on a rock in the middle of the river dangling our feet in the current. We could return to a place where we felt safe, or travel to a place we had never been. Driving down Sixth Avenue in my mother’s station wagon, my sisters and I would watch for the pools of water on the road ahead. We all tried to be the first to shout “mirage.”

They should have sent in the philosophers. After the murder, gossip in our office gave way to speculation about first and final causes. We talked about it all day, every day: where we stood, what we saw, how she got into his office, how many gunshots we heard, the awful smell of gunpowder. Every day we came up with new theories about motive. He had complained that someone had broken into his computer and viewed private financial information. Maybe he caught her trying again and confronted her. Maybe, doing his own investigating, he had broken her cover and found out something about her past. Maybe he finally realized she was stalking him. The counselors who haunted our office urged us to stop dwelling on the details, give up trying to make sense. We couldn’t. We had a vocation.

§

The medical record includes two kinds of narrative. There is the story of the patient, and the much more interesting story of the doctor trying to make sense of it all, ruling diagnoses in and out by symptoms, clinical testing, and empirical trials. If the patient has trouble breathing and bending down to tie his shoes, he probably has problems with his lungs, but if he needs to sleep on several pillows to breathe at night, he more likely has problems with his heart. If the poor man who has trouble bending down to tie his shoes is fat, he may have trouble with either his lungs or his heart, or maybe both. If his lungs wheeze, he probably has lung disease; if they crackle, he probably has heart disease. And all God’s children got algorithm.

The principal is Occam’s razor, a kind of surgical thinking: prefer the simplest diagnosis that explains all symptoms. The tricky part is that the real problem can change its cover, appearing as new symptoms. Anxiety is the most common diagnosis made by cardiologists. In our office we had calls every day from patients who had researched their symptoms on the internet and were sure they had a medical emergency or a fatal disease. Because they had had dangerous aberrations in their heart rhythms in the past, our patients had their fingers on their wrists, and were conscious of every extra beat. After the first diagnosis, subsequent symptoms made a “sticky wicket,” as the Irish doctor would say. Which disease was the face, and which the mask?

I am still haunted by the history I had to type of the woman my age bitten by a dog while trekking in Nepal. She flew to Australia, where a doctor advised her to get the full series of rabies shots. Rabies has never invaded the island continent, so the serum would have had to be flown in. She began to feel foolish. The bite was healing, and she had no symptoms. She decided to fly home without waiting for the serum.

Once home though, she must have had second thoughts, because she looked rabies up in the encyclopedia. She knew herself to be a hypochondriac. When she began to feel numbness and tingling in her hand and moving up her arm, she convinced herself that she had frightened herself with the reading and was having an anxiety reaction, surely the simplest explanation for her symptoms. Even when her boyfriend brought her into the emergency room because she was so terrified of water that she would no longer drink or shower, she was embarrassed, and told the admitting physician that she thought she might be creating the whole syndrome in her head.

§

The razor can slip even in the hands of the professional. An answer is simply the place we stop investigating, a diagnosis is the place we stop cutting. The end result of the differential diagnosis is sometimes an “occult” syndrome. As the nuns taught us, the enemy is sometimes disguised as Legion. There was no simple connection for the multiple diseases caused by AIDS until the HIV virus was discovered.

Outside of our office in the hospital, the assumption was that the two of them had had an affair; he had made promises, broken them, and backed off, rejecting her. The story is, as my grandmother would say, “old as dirt,” and would seem the simplest explanation. In our office, we did not accept it.

Simplicity is not an icon in medical thinking. The patient is accepted in all her complexity. At the Neurological Institute in Montreal where my parents met, there was a copy of a nineteenth-century French sculpture, a bronze woman of goddess proportions pulling some drapery off her shoulders: Knowledge Unveiling Herself before Science. Once, lingering in the halls, my mother heard one of the janitors explain to a visitor, “This is the lady undressing for the doctors.”

In medical thinking, the physician does not start by counting symptoms, but by looking at the patient, listening to his story, then going to the place where the picture does not make sense and asking what it would have to mean in order to make sense—like Jimmy Stewart in Rear Window.

In fact, in his retirement, my father diagnosed a neighbor’s condition by watching his house through our dining-room window. He knew when the man left for work in the morning, and knew what cars were usually parked in the driveway and on the street in front of the house. The man left the house at seven in the morning and always drove the black car. When neither he nor his car left the house one morning, and cars of all colors started coming and going from the house, my father reckoned he was in the hospital. Because of his age (over sixty) and occupation (stockbroker), my father diagnosed him with a myocardial infarction, a heart attack.

Then, by some calculation of the number of cars on the street and the frequency of their comings and goings, my father intuited that his condition was not so serious that it required open-heart surgery, and he had likely undergone cardiac catheterization and angioplasty. My sisters and I were mortified that my father had nothing better to do in his retirement than look out the window at neighbors, but when the man came home, he confirmed that my father was right on all counts.

§

There was the matter of their comings and goings. There was no time for an affair. The physician saw patients from ten in the morning until five in the afternoon, taking a short break for lunch in his office. He spent one day each week consulting for the arrhythmia unit at a hospital in another city. He had a family, including two young girls, and took his turn carpooling them to school.

After she worked nine-to-five in our office, she went directly to her night job in a bookstore downtown. She knew his schedule. Looking around for him when he didn’t keep it, she was always surprised to learn that he was out of town on vacation.

And there is the anti-razor, the famous dictum of the physician John Hickham: “Patients can have as many diseases as they damn well please.” In fact, she had an eating disorder, which, in a fifty-one-year-old woman, was likely end stage. Starvation that had gone on that long must have taken its toll on her brain. How could someone critically ill work around doctors for nine months without anyone intervening?

Like many with the disease, she talked about appetite and eating all the time, implying that her weight was a metabolic problem. On Ash Wednesday, when some of the staff came in with dark smudges on their foreheads, she announced that she could not think of fasting, even for a day. Behind her back, we would talk about her thin, frizzy, we thought over-processed hair. I found out only after she died that this, and the facial hair she covered with thick makeup, were symptoms of advanced disease. The truth is that her energy, efficiency, and effluent cheerfulness belied the moveable fast.

The truth is—and this is something she never understood—the doctors weren’t looking. In a hospital, the secretary is invisible. We work behind the scenes. No one of us is marked by skills that are particular or indispensable to the institution. We move in and out of these jobs, giving two weeks notice, learning the details of a new job in a few more weeks. In my years in the hospital, I worked in five different departments.

A few months before the murder, she became increasingly edgy and aggressive. She began speaking loudly in an officious voice: officiousness for the sake of officiousness. She told us that she had been offered a significant raise and implied that she would soon be our manager. When I reminded her that she was a secretary like the rest of us, she stopped talking to me and later tried to make peace by telling me that she knew I hadn’t meant to say what I had. The day of the murder, she announced that someone had to “take care” of a secretary who had rearranged the EKG schedule.

When they searched her apartment, the detectives found a to-do list including a reminder to clean the gun, a box of ammunition, and two different kinds of antidepressants. We learned that her family had committed her to a psychiatric hospital a number of years earlier, but she had signed out against medical advice. At about the same time, right before Christmas, she had gone down to Virginia, where she could buy a gun with just a driver’s license, and bought a snub-nosed revolver at a pawnshop. Nothing found in the apartment revealed any connection to the physician or shed light on her motive.

Scientologists picketed the hospital for a number of days, blaming her violence on the prescription for antidepressants. For a few months after the murder, a psychiatrist from the emergency room would stop in to see how we were doing. Every time he came around, we pressed him on the subject of what kind of mental illness could have made her snap. He told us that everyday he was called upon to evaluate people, to see if they might be harmful to themselves or others, and everyday he interviewed suicidal patients. The homicidal did not knock on his door.

The nuns had warned that the enemy, too, would call. The way to recognize this vocation would be the offer of an answer, a sudden enlightenment, a simple and elegant solution. The seduction of easy answers, they told us, was a common sign of mental illness, and a defining tactic of evil. In our office we were afraid to say “evil.” We said: “We’ll meet her in hell.”

§

My father had a story he never stopped laughing at. As a medical student, he was on rounds with an attending physician who stopped on the staircase, sniffed, and asked the students if they smelled it. Smelled what? Cholera. He thought he smelled cholera. When they got to the floor, the attending approached a nurse and asked her if there were any patients with cholera on the floor. Yes, she told him, the one he had admitted the night before.

She set herself up. The undercover work doomed her. If she had only gotten to know him instead of becoming intimate with his personal details—breaking into his computer, interviewing his secretaries, investigating and tailing him—she wouldn’t have been duped. She used the wrong edge of the razor. Believing he understood her and shared her feelings, she took every gesture or word as confirmation.

She never spoke to me about her crush. She did admit to being charmed by his brogue. We all were. He could say hello or thank you and it sounded personal. She was second generation and should have known better: the Irish will never dishearten a stranger. “A little way down this road” can mean fifty miles.

§

After my father died, I met a woman who had worked at the hospital where he had had his surgical practice. She told me she had never seen him out of his scrubs. I was jealous: I had never seen my father in his scrubs. When I conjure him now, I think of his wonderfully expressive upper face. He could wiggle his ears, wink with either eye, move his whole forehead up and down, raise one eyebrow, or two, in a startled expression that was characteristic of him—all this, while holding his mouth closed.

It occurred to me years later that this exaggerated expression must have served him in communicating above the mask he wore in the operating room. Strangely, or not so strangely, my sisters and I all mimicked his expressions. “Body screaming,” my husband calls it.

It was staged. She played both the victim and the killer. The day before, she asked each of us individually if we would be in the office the next day. She needed a chorus. She arrived dressed all in black and went into the bathroom several times that morning to comb her hair. He was the last to come in: it was his day to carpool his daughters to school. Moments later, she went into his office and began shooting.

So I am living the life my grandmother imagined for me. I can sit at my desk grateful that a typo, unlike the slip of a scalpel, cannot kill. Still, there is some moment in every day when the panic sneaks up on me. I can be washing the dishes and, suddenly, smell the gunpowder. Even more distressing is the compulsion to look back, the idea that if I could figure out exactly what happened and why, I would never have to go there again.

The doctors told us that there are those with personality disorders, seemingly born without conscience, unable to empathize with others, without a chance. I can’t accept that. This is what I believe: She, too, was looking back when she turned into a pillar of salt.


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