Room with a view.

As a Medicine chief resident at Johns Hopkins Bayview Medical Center in Baltimore, one of my roles each month is to orient the medical students who rotate with our ward teams. After reviewing the basic structure of the rotation, I take the students on a tour, beginning with the first floor and culminating with the wards on the fifth floor. On the wards I make a special point to show them the view: a few miles to the south, the “bay” after which the hospital is named (it’s actually the Patapsco River, which empties into the Chesapeake Bay) and, to the west, the downtown Baltimore skyline. These views helped me get through residency. Most of the patient rooms face either the river or the city. During the times of day when I was most exhausted—dawn, dusk, and the middle of the night—these views were at their most vibrant, offering a moment of aesthetic rejuvenation. From some rooms, at dawn, I could see the Patapsco River slowly emerge out of the darkness, as if the many cargo cranes along its shores were unloading into the sky brilliant hues of blue, orange, and pink off a ship from the Far East. From other rooms, at dusk and beyond, I could see the city’s skyscrapers blacken in the foreground of the setting sun and then shimmer like smoldering embers throughout the night. From the room in which I took care of Mr. G, I could see neither. It looks out on the sides of several nondescript brick buildings clustered around a drab traffic circle. I can still remember when I first heard about Mr. G. It was only a few weeks after I had transformed, overnight, from being a third-year resident to a chief resident, without any change in my appearance. I was preparing to attend on the wards, with the outgoing attending giving me sign-out over the phone. “The next case is a really fascinating one. Mr. G is a 35-year-old Spanish-speaking man with a new diagnosis of AIDS and pulmonary TB. He’s a transfer from the ICU….” Oh, great, I thought as an image of an N95 mask flashed before my mind’s eye. There goes the beard. The following morning, two medical students, an intern, a resident, and I were outside Mr. G’s room, donning masks. Walking in, I was immediately reminded of how, as a resident, I had found nothing redeeming about the view from this room. The buildings it faces are largely brick and reflect little light, and the traffic circle sits in front of a rehab center. The only thing I had ever seen glancing out of that window was a truck making a delivery, or a person with a walker ambulating to the beat of a waiting car’s blinkers. No figurative shipment of brilliant colors from the Far East; no smoldering embers shimmering in the night. Just a few years my senior, Mr. G looked older than I had expected but, for someone with unbridled AIDS complicated by TB so severe that he had almost required intubation, he also looked better than I had expected. His hair was black and short, punctuated by strands of gray, and his skin was a healthy bronze. He lay in bed, with his arms and legs extended, motionless, as if he was afraid that by moving he would break something inside himself. “Buenos dias. Me llamo Doctor Possner,” I said, a bit haltingly, each inhalation as I spoke passing crisply over my freshly shaven skin underneath the mask. It takes very little for someone’s English to trump my Spanish, and unfortunately Mr. G didn’t speak any English. Among the team, we cobbled together just enough Spanish words to cover the bare essentials. Breathing okay? Eating okay? Pain? To all of this, with frequent, polite smiles and a simple “yes” or “no,” Mr. G assured us that he was okay. Later that day, while reviewing his chart, I learned that Mr. G was in the US illegally from Honduras, where he had a wife and child. Before getting sick, he had worked in construction. He shared an apartment in Baltimore with several other migrant workers. Beyond that, as best as I could tell, no one in the hospital knew anything about him. Here was a man who had just been diagnosed with AIDS. At the very least, what did he know about his disease? Everyone had been so focused on saving his life that no one had yet tried to understand his view of the situation. For a few days, my team and I continued this course of ignorance, except now with a translator’s assistance. Each day was the same. The first thing we would see walking into the room was the window, with its bland snapshot of the buildings and traffic circle. Then we would see Mr. G. Any pain? Breathing okay? Okay, all okay, he would say, smiling. We would push on his belly and listen to his heart and lungs. And then we would leave. We were just waiting for him to receive enough anti-TB meds so that we could send him home, after which the Health Department would continue his treatment. In the meantime, with a note of concern, the nurses said that Mr. G would never ask for anything. He rarely had any visitors. He didn’t have any family pictures or “Get Well” cards. Mr. G would simply spend his days in bed, staring for hours at a time at the window in front of him. What he saw, I couldn’t imagine. One day, after asking him the usual questions about pain, breathing, etc., we told him we wanted to talk about his AIDS diagnosis. For the first time since I had met him, his face darkened, like a mask of forced serenity had been lifted. His eyes drifted away from mine, to the window, looking far off. His questions came haltingly, as if he himself had to first translate them from a voice deep within himself. Am I going to die? How do I tell someone I have this disease? Do I need to keep my food separate in the refrigerator? In these questions, I suddenly understood what Mr. G saw staring at the window. In his mind’s eye, he saw having endured considerable danger and sacrifice to get to the Land of Opportunity only to discover that he was worse off than when he had started, and that the end was near. He saw the dilemma of having to tell his wife and child that he has AIDS, or having to live with the secret the rest of his life. He suddenly saw himself as being an alien in his own community, not just in his adopted society. Looking at his window, he couldn’t see the river or the city, and he didn’t see a group of buildings or a traffic circle. He saw only darkness. That day, and over the coming days, we explained to Mr. G that AIDS is neither a death sentence nor a reason for shame. The key, we told him, is getting treatment. The Health Department would provide pills for the TB, but not for the AIDS. Mr. G didn’t have any identification or proof of residence, so getting him AIDS continuity care and medication would be challenging, but not impossible. We found a clinic where he could follow up. We arranged for the chaplain to visit. We gave him the translation service number through which he could contact us, at any time and for any reason, after discharge. Finally, the day arrived when the team no longer had to wear masks and Mr. G could leave. He had confided in us some of his deepest fears, and yet this was the first time he fully saw our faces. “First there is God, then there are doctors,” he told us through the translator, shaking each of our hands with a vibrancy that was in stark contrast to the stoicism he had shown when we first met. “Thank you for taking care of me, and thank you for giving me hope.” And with that he was gone, out into the world on the other side of the window. It’s been several months since I took care of Mr. G. I’ve attended on the wards a few more times, during which I’ve taken care of other patients in that room. I still don’t like the view from the window. However, standing at the doorway, I now see something much different. In my mind’s eye, I see a man in bed looking out on the rest of his life with a little bit more hope, and I see several doctors early in their careers realizing that although they didn’t invent light, they should never overlook their ability to brighten the view.