The cancer patient's book of grammar.
The possessive. The radiologist pushes against the patient's breast with what the patient conceives to be a pestle. "Have you felt anything?" The radiologist doesn't look at the patient--or even at the patient's breast. She looks only at a screen.
In a series. The radiologist examines the screen, pushes the patient's breast again, and reexamines the screen. "Have you felt anything?" "No." The radiologist asks again, "Have you felt anything?" "No." The radiologist leaves the room. The technician says, "You may get dressed and go now."
To denote a parenthetical. A week, perhaps more, passes. The patient hears what the mammogram reveals, not from the radiologist, but from her gynecologist. "You mean the radiologist's office didn't say anything?" "No." "But you need a biopsy. I'm sure they're required to tell you." "They didn't." "I can't believe they didn't say anything." "They didn't."
PUNCTUATION BETWEEN INDEPENDENT CLAUSES:
When joined by a conjunction. The patient lies on her stomach, and her left breast drops through a hole. The new radiologist, a specialist, sits below her. "You'll feel a pop," he says, and his assistant puts her hand on the patient's back. "Do you have a breast surgeon?" The patient answers no, and she remembers how someone told her only five percent come up malignant. The radiologist says, "You're going to need to see a breast surgeon."
When not joined by a conjunction:
Use of the semicolon. The radiologist leaves the room; the patient gets up and dresses. The radiologist comes back; he points out the trails of calcium on the mammogram.
Use of the colon. This radiologist tells the patient what he sees: this radiologist isn't a coward.
Issues in Composition
USE OF THE PARAGRAPH:
Example 1: The radiologist says, "We can't know for sure until we have the pathology report, but what we see on the mammogram is in situ. I want to stress that: what we see is ductal carcinoma in situ." "What stage is that?" "This could be stage zero, but, again, we can't know for sure until we see the pathology report."
Example 2: "I have the pathology report from the biopsy. It's not what we thought, but it's still not bad." "Oh." "There's a little place where the cancer cells have broken through into the adjacent tissue." "What stage is that?" "Probably stage one, but we won't know for sure until the surgeon removes the tumor and gets the pathology report from that."
Use of the active voice. The patient sees the surgeon. The surgeon recommends a lumpectomy. The patient has the lumpectomy. She takes a cab home. She vomits.
Avoiding unnecessary words. The patient waits. An hour passes. The surgeon says he's waiting for the report.
Use of the run-on sentence. That the surgeon says nothing else to her is a bad sign, the patient thinks, and she goes over again what he said, that he's waiting for the report, which she thinks means he's heard orally but doesn't want to say what he's heard, for if there had been anything at all good to say, he wouldn't have made her wait. She remembers, too, how, after being closed up in the cold room, she opened the door, but he came past and closed it again, and she thinks now he did that because he didn't want her to overhear something before he was ready to say it, and her worries are confirmed when, finally, he steps into the room, and, when she asks if the news is bad, he answers, "It's complicated."
Use of tense in summaries. The node has cancer cells. The margin of the tumor from the left breast isn't clean. The risk to the right breast is high.
Word placement. The patient is wheeled into the room and rolled on a bed. She has two rows of stitches where once she had two breasts.
Issues of Form and Formatting
Numbers. The patient has lost count of the time she's spent on hold with the insurance company. She has lost count of the number of times she's had to tell perfect strangers about her condition. She is a private person, and now she must make the most private thing that has ever happened to her public, over and over again.
Quotes, Parentheticals, and Numbers. "I have breast cancer," she says to Brittany, an insurance company representative. (She reaches Brittany only after she's pressed 1, then 4, then 4 again, and listened to the automated voice talk about all the insurance company's friendly automated phone features over and over again. She long ago learned there is no automated answer to any of her questions, and no matter what she wants to ask, only 1, then 4, then 4 again will get her to a person. If she chooses any other combination, there is no way to get back to a "main menu." Instead, she must hang up and start again.) "I need your help to make this process as efficient as possible." (She doesn't want Brittany's help at all: she has no choice.)
Quotes, Parentheticals, and Numbers. The patient says, "I must have chemotherapy. Does that require a referral or precertification?" Brittany answers, "Do you have the CPT codes? I can't tell you what approval process you will need without them." ("CPT" is the acronym for "Current Procedural Terminology." The terminology, which changes every year, consists of five-digit numbers for each of thousands of clinical procedures. The patient calls the oncologist, his nurse practitioner, his administrative assistant, and the finance person at the hospital to which she's been referred, but no one can give her the CPT codes.)
Titling. The patient tries to find the CPT codes on her own. If she is willing to spend $259.95, she can obtain the CPT 2005 Electronic Professional Edition on CD-ROM from the AMA Press Online Catalog. For only $79.00, she can download the CPT 2005 ASCII Data Files Complete Set--Download. If she can understand and is willing to agree to the fine print in the license, she can use the CPT code search license for personal/noncommercial use of Physician's Current Procedural Terminology without making any payment at all. No matter what she chooses, the patient knows she's unlikely to figure out which CPT codes apply.
Quotes, Numbers, and Parentheticals. The patient calls the insurance company again. This time she gets Shawn. "May I have your member ID number please?" (The patient gives it; she knows that, otherwise, she'll not be able to get to the next step.) "May I have your date of birth?" (The patient gives this, too, for the same reason.) "How may I help you?" "May I be transferred to Medical Management, please?" (Shawn, remarkably, complies.) "This is Marie. What is your provider number?" "I'm the patient. I am trying to find out whether I need a precertification or a referral for my chemotherapy treatment, and I can't get the CPT codes from my doctor." Marie (seized unaccountably by the impulse to be helpful) lists the drugs that require precertification by name. The patient calls the oncologist's office to reconfirm the names of the drugs she will be given, and none are on the list Marie gave her. A referral, therefore, will suffice.
Numbers and Parentheticals. Now, three hours of phone calls and three days later, the patient can call her primary care physician (who's had nothing at all to do with the treatment plan), from whom she's required to get the referrals she needs (one for the oncologist, the other for the treatment). The primary care physician's office still isn't sure how to proceed, and the patient spends two more hours in phone calls and waits three more days to get the referral in place for the treatment.
Parentheticals, Quotes, and Numbers. (When the patient spoke with Brittany, she asked about the referral to the oncologist, too.) "You have a referral in place." "Yes, but it's for six visits within six months, and I've seen him twice already. I must see him at least eight more times during the next four months and, thereafter, periodically for the rest of my life." (She tries to remain civil. At this moment, Brittany is the only means she has by which to get the information she needs.) "You can get the referral extended for more visits and more months." "I shouldn't have to keep doing that. If I miscount, the doctor won't get paid, and I'll get billed. I should be able to get a referral that is appropriate to the disease." (She tries even harder to remain polite.) "Perhaps this is something about which I need to speak to a supervisor, someone who might have more familiarity with this." (Brittany hesitates.) "What you need is a standing referral." (It appears to the patient that Brittany knew all along, but chose--or had been instructed--not to offer this information unless pressed.) "What do I need to do to get that?"
Numbers, Quotes, and Parentheticals. After a week of daily follow-ups with no news to report, the primary care physician's office calls. "The insurance company says the standing referral is in place. It's for unlimited visits, but it expires in a year." "Then what?" "Then we have to go through the same process to try and get it renewed." (The patient records the date in the long list of dates and numbers and other things she must remember. She also knows she'd best confirm this directly with the insurance company. She's seen what happens when there's a mistake. She has seen the bill collectors chase after the patient--and no one remembers or cares who got it wrong.) When she goes online, she sees the referral shows one visit, not unlimited. She calls the insurance company; this time she gets Michael. "I'm supposed to have a one-year referral for unlimited visits, but I can't confirm it online." "We can't put a word in the field for number of visits, so for unlimited, we put in the number one." "Then how can I prove I have unlimited visits?" "You can't."
Numbers. She has tried to be efficient--to get the prescriptions filled, the chemotherapy scheduled, the proper approvals ascertained and in place, and her heart scan done--so she could have one last ordinary week between the heart scan and the start of chemotherapy. But now the week is up, and the chemotherapy starts tomorrow.
Problems in Word Choice
Positive Attitude. The patient has been told she has a positive attitude. Usually, the phrase comes wrapped together with a conclusion: "Just keep a positive attitude, and you'll be fine." The patient, however, finds nothing positive about this experience. She would gladly take any means of escape offered her. She is trapped by her circumstances; she is irritable, enraged, and demoralized by turns. The patient finds no solace in a proclamation that her own "positive attitude" or lack of it will determine whether her cancer is stopped or will spread.
You Look Great. The patient has had to have her breasts removed. There are two lines of stitch-shaped scars across her chest. The skin on her chest feels as if it has been ironed flat and creased. People survey her face (which looks no different than it ever did) and say, "You look great."
Percentages. The patient has asked, what are her chances? She is advised that, even without chemotherapy, her chance of no recurrence in five years is 66%. She is advised that chemotherapy will increase her chances by 15%, as will estrogen-blocking medication, if she is a candidate for that. But she is also advised that, if she has chemotherapy and the estrogen blocker, the two 15% figures will not increase her total chances by 30%, but only by 20%. The best the patient can make of all these numbers is that her chances are either l00% or none.
Chemo. The patient's friends, family, and colleagues, whether they have had chemotherapy or not, all refer to chemotherapy as "chemo." The patient herself has done this in the past; at present, however, she does not wish to be on a first- name basis with these drugs to which she has no desire to submit. She will submit, of course, because she cannot argue with the percentages, even if they are not meaningful to her. But she sees no need to enter into this easy camaraderie with "Chemo."
Do You Want to See a Social Worker? The patient apologizes to the nurse. "Guess I'm having a bit of a meltdown here." The nurse is kind and attentive; she wants to help. "Do you want to see a social worker?" (The patient has met one of the social workers. She came to introduce herself before the patient was discharged from the hospital. She was young, pert, and two-breasted. She squirmed in her chair and had no idea what to say.) "Absolutely not."
Prosthesis. The patient tears open the plastic bag. Inside are a cheesy lace-edged bra, two pieces of foam, four small safety pins, and a set of instructions. The instructions show the patient how to anchor the bra to the waistband of her underwear; otherwise, the foam pieces, which are lightweight, will float upward. The patient throws the package in the trash.
I'm Fine. When the patient is asked how she is doing, she often says, "I'm fine," whether she means it or not.
Rules for Writing
Choose a natural style. The patient is surprised at how quickly she has forgotten how she looked before. This is what I look like now, she thinks, as she stands in front of the mirror working Vitamin E into her scars. I will just have to work on my posture, she thinks. (She has always had a tendency to slump.) She is surprised, really, that something as unnatural as crosshatched lines of stitches across her chest is what is natural to her now.
Choose the right design. The nurse tells the patient that, by the second treatment, her hair will fall out in earnest. "Take control of it. Shave your head." She resolves to follow the nurse's advice, but then she doesn't do it. She has the first treatment. As she walks down the street, she is sure she feels chemicals working at her scalp; as she stands in the shower, her eyes are fixed on the drain. She has the second treatment, and the nurse says again, "You know your hair is going to go, now." "Will it go right away?" "Not all at once, but soon." The patient observes the nurse's long, thick hair. "It will be such a long time before I have hair again."
Avoid authorial intrusion. The patient is in a wig shop. A woman shows her around the shop. "We recommend a brush--it's better for the eyebrows." The patient hasn't even thought about her eyebrows. "You won't want to use liner; the brush gives a more natural look." The patient has never worn a shred of make-up. How will she manage this? "We can help with the eyelashes, too." The eyelashes, too.
Strive for accuracy. The nurse holds the patient's hand and taps her veins. She finds the one she wants and inserts the catheter. The patient turns her head and winces. "I'm a wimp." "You're no wimp," says the nurse. "You're sitting in this chair."
Embrace revision. The nurse starts the saline solution, but the machine beeps: the solution isn't flowing. She backs out the catheter part way; the solution flows again. She pushes in the catheter; the machine beeps again. "I hate when this happens." The nurse has no choice. She pulls out the catheter, swabs the patient's skin with alcohol, and tells the patient to press on the gauze. The nurse must find another vein and start again.
Avoid affectation. The patient has decided she will try to be clever: she will make it all into a literary joke. She finds the witch's scene from Macbeth. She lies on the sofa, repeating it: "eye of newt and toe of frog/wool of bat and tongue of dog." She puts it to memory, as best she can, so she can quote bits of it at will. People laugh, and she's pleased with herself. Then someone says to her, "So, you're going for your next eye of newt today?" She doesn't find it funny.
Avoid unnecessary explanations. People are getting tired of hearing about her problems with the insurance company. Next to the cancer, the issue seems trivial to them, and, in any event, no one has time to listen to her blow-by-blow account. The doctor says, "Try to compartmentalize it." A friend says, "But it's resolved now, right?" The patient thinks, but this is something that doesn't need to go badly. She won't give up on it. She writes memos to the doctors and the health department--to anyone who might be able to address the problem--but then she's afraid she'll be seen as a hysteric, and she puts all the memos in a drawer.
Avoid adverbs. Only secondarily is the patient still human. Primarily, she is a stew of chemicals. What is known about the chemicals, ironically, is that they are toxic; what is not known, paradoxically, is whether they will do her any good.
Do not lapse into foreign languages. The patient thought it might be helpful, after all, to see a therapist. "I have a life-threatening disease. I need to figure out how to cope with this--how to incorporate it into who I thought I was and who I am from here. I don't have time to go back into the great morass of childhood and find my way out again. What I need are tools that will help me get through this thing now." But the therapist knows only her own language, and it is not the patient's.
Avoid exaggeration. At first, the patient thought her changes in mood and disposition had complex and nuanced origins. Now she understands that it comes down to this: the drugs make her sick almost half the time.
Avoid melodrama. The newspaper contains yet another report on a prominent person's "courageous battle" against cancer. The patient feels a kinship she didn't expect. She thinks, do not require us to be courageous: it is enough that we have no choice.
Avoid adjectives. A friend asks, "How are you doing?" The patient says, "OK." The patient pauses. "Well, to tell the truth, it's a nightmare." She could also say, but decides not to, that it is humiliating, miserable, and unfair.
Disguise who is speaking. The patient attends meetings and client functions; she talks to colleagues and clients on the telephone. Each time, she becomes someone else. She perpetuates a mirage of well-being: she jokes about her flat chest, her "plucked chicken" head, the witch's brew of chemicals she's required to take. She finds she lies easily, and she finds she feels better when she lies than when she tells the truth.
Avoid complex terminology. Before this, the patient rarely took an aspirin. Now, because of the Adriamycin and Cytoxan she's been given, the patient must take Emend, Aloxi, and Decadron (for nausea), Neulasta and Aranesp (to boost her blood cell counts), and Prilosec and Mylanta (for reflux). Because of the Decadron, the patient must take Ativan (to sleep). Because of the Taxol, the patient must take Benadryl, Decadron, and Pepcid (to stave off an allergic reaction to the Taxol), Neulasta and Aranesp (to boost her blood cell counts), a great deal of Advil (for bone pain caused by the combined effects of the Taxol and Neulasta), Prilosec and Mylanta (to stave off reflux from the Advil), and Ativan (to sleep after the Decadron and through the bone pain).
Avoid dialects. The language the physicians and nurses speak among themselves is that of drugs and dosages and the arcanery of medical terminology. The patient tries to look things up and prepare her questions, but there are too many, and there isn't enough time. The physicians and nurses know what they must do, even if the patient doesn't, and they know that, to make it all efficient for the patient and cost-effective for the hospital, they must move the patients through. If the patient is ready with her questions, and she tries to be, they do their best to answer them. But the gap between the words they have to explain things and the words she understands is too big and can't be bridged in the time allowed.
Avoid seeking untenable opinions. Two months have passed, and the patient is more than halfway through the chemotherapy. Her complaints, taken singly--or even altogether--would probably be considered minor. She has not, after all, had nausea or vomiting. She has lost her hair, of course, but it will grow back when this is over. For countless days and nights, acid rode up her esophagus and burned the back of her throat, and cankers on her tongue prevented her from eating food as benign as bread. Even now, almost every day, her tongue tastes of soap. Once, from the standard dose of Decadron, she had six days when she couldn't work or read or even speak without racing far beyond her hobbled capacity to think and five nights when Ativan boxed with Decadron in what passed for sleep. Even when the Decadron or something else hasn't kept her awake, hot flashes and the constant need to relieve herself have prevented her from sleeping through a single night--and now her legs are stiff, her back throbs, and from time to time small bursts of pain press at random joints or run across the scars on her chest. There is hardly a day when she's not distracted from a sentence in a book or a thought in her head by one or more in a series of small plagues, not caused by the cancer, but by the drugs. She wants their opinion: "Why, again, am I being put through this? What will happen if I stop now?" She knows the doctors and the nurses are doing the best that can be done for her; she knows, too, that now she's come this far, she's not going to stop. But she wants them, nonetheless, to promise her what no one can promise her: because she has gone through this, she'll be all right.
Avoid using shorthand. The nurse's aide takes the patient's weight, blood pressure, and pulse, all the while asking questions in shorthand: "Name? Date of Birth? Nausea? Vomiting? Diarrhea? Constipation? Medications? Anything else?" The patient starts to answer the last question, but the nurse's aide is busy scribbling on her chart. The nurse's aide leaves, and the nurse comes in. The nurse goes through the same litany as the nurse's aide. She listens as the patient identifies the symptoms she's never had before; to each, the nurse responds, "That's normal."
Choose the ordinary. The patient stands at the window. The sky is clear, and blue lines of shadow stripe the snow. The sun etches light on the bark of pine trees; dried seed-heads of sunflowers sport snowy caps. White-throated sparrows skip from branch to branch and dip toward the ground. The patient steps into her boots. An ordinary day, at last.
Seek clarity. The treatment is finished. The patient has no cancer they are able to detect--for now.