themselves at risk of punitive action by the medical board or of personal litigation (if, for
example, the patient made an error of judgment in clinical work).
As a last resort before quitting his practice and taking a leave of absence to be
treated anonymously in another city, he appealed to Julius, who accepted the risk and
trusted Bob King to withdraw on his own from Vicodan. And, though therapy was
difficult, as it always is with addicts, Julius treated Bob for the next three years without
the help of a recovery program. And it was one of those secrets that every psychiatrist
had—a therapeutic success that could in no way be discussed or published.
Julius sat in his car after leaving his internist`s office. His heart pounded so hard
the car seemed to shake. Taking a deep breath to quell his mounting terror, then another
and another, he opened his cell phone and, with trembling hands, called Bob King for an
urgent appointment.
«I don`t like it,” said Bob the next morning, as he studied Julius`s back with a large
round magnifying glass. «Here, I want you to look at it; we can do it with two mirrors.»
Bob stationed him by the wall mirror and held a large hand mirror next to the mole.
Julius glanced at the dermatologist through the mirror: blond, ruddy faced, thick
spectacles resting on his long imposing nose—he remembered Bob telling him how the
other kids taunted him with cries of «cucumber nose.» He hadn`t changed much in ten
years. He looked harried, much as when he had been Julius`s patient, huffing and puffing,
arriving always a few minutes late. The Mad Hatter`s refrain, «Late, late for a very
important date,” often had come to mind when Bob rushed into his office. He had gained
weight but was as short as ever. He looked like a dermatologist. Whoever saw a tall
dermatologist? Then Julius glanced at his eyes—oh oh, they seemed apprehensive—the
pupils were large.
«Here`s the critter.» Julius looked through the mirror as Bob pointed with an
eraser–tipped stylus. «This flat nevus below your right shoulder under your scapula. See
it?»
Julius nodded.
Holding a small ruler to it, he continued, «It`s a shade less than one centimeter. I`m
sure you remember the ABCD rule of thumb from your med school dermatology—”
Julius interrupted, «I don`t remember squat from medical school dermatology.
Treat me like a dummy.»
«Okay. ABCD.A for asymmetry—look here.» He moved the stylus to parts of the
lesion. «It`s not perfectly round like all these others on your back—see this one and this
one.» He pointed to two nearby small moles.
Julius tried to break his tension by taking a deep breath.
«Bfor borders—now, look here, I know it`s hard to see.» Bob pointed again to the
subscapular lesion. «See in this upper area how sharp the border is, but all around here on
the medial side it`s indistinct, just fades into the surrounding skin.C for coloration. Here,
on this side, see how it`s light brown. If I magnify it, I see a tad of red, some black,
maybe even some gray.D for diameter; as I say, perhaps seven–eighths of a centimeter.
That`s good–sized, but we can`t be sure how old it is, I mean how fast it`s growing. Herb
Katz says it wasn`t there at last year`s physical. Lastly, under magnification, there is no
doubt that the center is ulcerated.»
Putting down the mirror, he said, «Put your shirt back on, Julius.» After his patient
finished buttoning up, King sat down on the small stool in the examining room and
began, «Now, Julius, you know the literature on this. The concerns are obvious.»
«Look, Bob,” replied Julius, «I know our previous relationship makes this hard for
you, but please don`t ask me to do your work. Don`t assume I know anything about this.
Keep in mind that right now my state of mind is terror veering toward panic. I want you
to take charge, to be entirely honest with me, and take care of me. Just as I did for you.
And, Bob, look at me! When you avoid my gaze like that, it scares the shit out of me.»
«Right. Sorry.» He looked him straight in the eyes. «You took damn good care of
me. I`ll do the same for you.» He cleared his throat, «Okay, my strong clinical impression
is that it`s a melanoma.»
Noting Julius`s wince, he added, «Even so, the diagnosis itself tells you little.
Most—remember that—mostmelanomas are easily treated, though some are bitches. We
need to know some things from the pathologist: Is it melanoma for certain? If so, how
deep is it? Has it spread? So, first step is biopsy and getting a specimen to the pathologist.
«Soon as we finish I`ll call a general surgeon to excise the lesion. I`ll be by his side
throughout. Next, an examination of a frozen section by the pathologist, and ifit`s
negative, then great: we`re finished. If it`s positive, if it is a melanoma, we`ll remove the
most suspicious node or, if necessary, do a multiple node resection. No hospitalization
required—the whole procedure will be done in the surgery center. I`m pretty sure no skin
graft will be needed, and, at most, you miss only a day of work. But you`ll feel some
discomfort at the surgical site for a few days. Nothing else to say now until we learn more
from the biopsy. As you asked, I`ll take care of you. Trust my judgment on this; I`ve been
involved with hundreds of these cases. Okay? My nurse will call you later today with all
the details about time and place and prep instruction. Okay?»
Julius nodded. They both rose.
«I`m sorry,” Bob said, «I wish I could spare you all, this but I can`t.» He held out a
folder of reading material. «I know you may not want this stuff, but I always distribute it
to patients in your situation. Depends on the person: some are comforted by information,
others would rather not know and just toss it on the way out of the office. Hope after the
surgery to tell you something brighter.»
But there was never to be anything brighter—the later news was darker yet. Three
days after the biopsy procedure, they met again. «Do you want to read this? said Bob,
holding out the final pathologist`s report. Seeing Julius shake his head, Bob scanned the
report again and began: «Okay let`s go over it. I gotta tell you: it`s not good. Bottom line
is that itis a melanoma and it has several...uh...notable characteristics: it`s deep, over
four millimeters, ulcerated, and there are five positive nodes.»
«Meaning? Come on, Bob, don`t talk around this. вЂNotable,` four millimeters,
ulcerated, five nodes? Be straight. Talk to me as if I were a layman.»
«Meaning bad news. It`s a sizable melanoma, and it has spread to the nodes. The
real danger here is more distant spread, but we won`t know that till the CT scan which
I`ve arranged for tomorrow at eight.»
Two days later they continued their discussion. Bob reported that the CT scan was
negative—no evidence of spread elsewhere in the body. That was the first good news.
«But even so, Julius, this adds up to a dangerous melanoma.»
«How dangerous?» Julius`s voice cracked. «What are we talking about? What kind
of survival rate?»
«You know we can only address that question in terms of statistics. Everyone is
different. But for an ulcerated melanoma, four millimeters deep, with five nodes, the
statistical charts show a five–year survival of less than twenty–five percent.»
Julius sat for several moments with head bowed, heart pounding, tears in his eyes,
before asking, «Keep going. You`re being straight. I need to know what to tell my
patients. What will my course be like? What`s going to happen?»
«It`s impossible to be precise because nothing more will happen to you until the