Alan

I was Alan’s doctor on the brain injury unit. In September, he’d had a fall, nothing major, just a slip in the rain taking the garbage out. It was nighttime; he didn’t see the puddle; he was wearing worn-out shoes. He got up and pretty much forgot about it. But in October, his family started noticing him forgetting much else: where he’d put his keys, what he’d had for lunch, how frequently he now dropped his fork from his right hand. In November, first his sentences and then his strides grew shorter. And by December, he started falling again, really falling, and now he had neither the strength nor the verbal fluency to resist his family’s insistence on bringing him to the emergency department. Brain imaging explained it all, as expected: a large frontal tumor with considerable mass effect. He underwent urgent neurosurgery, a subsequent intracranial infection, a further operation, postoperative delirium, and at last a transfer to our care: rehab to facilitate neurologic recovery—and me as his doctor to monitor and optimize what I could.

He was 78 and looked perhaps 60. He was sitting up in bed, dressed in blue jeans and a casual flannel button-down. His eyes were intent, his eyebrows thick with wisdom. A long arc of bright staples curved across the left side of his swollen scalp. There was reading material everywhere—on his tray table, on his bed, piled on the window sill: newspapers, magazines, novels, notebooks. Things I recognized and some things I had read: The Economist, Cat’s Cradle, the New England Journal of Medicine. He held a pencil in his hand.

“It’s not that I wish to be perceived as complaining about the service,” he started, before I had a chance to say my name, “but I have significant concerns about the hospital from which I have come. There is in some sense a complete deviation from patient-centredness and personalized care, and an outrageous claim for which I can identify no evidence.”

I offered him the wide-eyed sincerity we all use to be relatable to the impaired: “Can you tell me what they were saying?”

“They think I have a brain injury.”

Alan and I enjoyed our daily chats. We talked about the books he was reading, the trips he was planning, live music. He showed me hundreds of pencil sketches he had made over the years in an aging leather notebook that his wife brought in from home. He was especially proud of his Bob Dylan. And every day we discussed his therapy.

“I was simply not offered therapy today. The occupational therapist? She asked me to draw a clock. I can mobilize without a cane and she asked me to draw a clock.”

“I was asked what I would do if there were a fire. There is no fire and I am waiting for therapy.”

“My goals? To get out of this place and return to my medical practice.”

Alan’s wife, presumably around his age, had his same preserved quality. She walked quickly, stood up straight, addressed me like an old friend. She had unapologetic, straight, gray hair cut at the shoulders, the sort of hair that other people dye and she specifically did not. The sort of hair that drew attention to the absence of other manifest signs of aging. But after taking him home on a weekend pass, there was something in the lines around her mouth that looked sad.

“There were moments that seemed normal. We had a conversation. Watched television. Shared popcorn. But in the morning .… First I thought he was sleeping in, then awake and relaxing. But as the hours passed it was getting … stranger, the way he just stayed in bed, just stayed there, not seeming bothered, but not really relaxing, either. Not so much relaxing, as … just not … well, just not, just kind of missing. I asked him if he wanted to get dressed. He said yes, but didn’t move. Like he was present when talking to me, but not present to himself, not aware that he was the guy who had to be him. I said, ‘OK, time to get dressed.’ He said OK, and didn’t move. I started to negotiate, cajole. Put your left arm in this sleeve, put the toothbrush in your mouth. At times it felt like he was resisting. But at times it felt more like he was too missing to resist.

“When I finally got him ready, I asked what he wanted to do. He said he wanted to go to his office. I led him to the basement, to his office, and he stayed there. For hours. Just sitting in his armchair, staring off. Not relaxing, just sort of … gone. I asked him if he needed help. He said no. I asked him what he thought of Tolstoy. He said Tolstoy was a crazy, dead schmuck. I asked him what he was doing. He had been sitting, just sitting, doing nothing at all, for hours. He said he was working on publishing his recent hospital experience.”

Alan looked at her with a sincere combination of condescension and empathy: “I can mobilize without a cane.”

And he looked at me: “There is in some sense a higher concept of individuality that is completely lacking from your team’s approach to patient care. I am being called on daily to participate in tasks that have nothing to do with patient-centred goals. I am being coerced into experiencing symptoms that I don’t have just for the sake of treating them. I am being institutionalized rather than deinstitutionalized. And, in fact, I am not being offered any treatment to which I, the patient, consent.”

And he meant it. He looked at me and I looked at him and I saw his eyes, so familiar, so personal, eyes that are used to seeing where others cannot see. I thought of the lifetime of patients he had worked with—the anxious, the agitated, the psychotic, the sick. He, too, must have treated people with injured brains and injured minds; he too must have been patient and polite, looking at these weakened humans from our vantage point: third party, bird’s eye, objective, correct. He was so used to it, trained in it, patterned in it, you could almost believe. But it wasn’t real. He was limited by his brain. He only sounded smart: his was an artificial intelligence.

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