Tough and tender at the same time, Linda is a woman with a broad smile, the kind who likes to “fish all weekend at the lake, a place where I don’t think about anything. Or, anyone.” I often smelled cigarette smoke on her, and she has the raspy voice that comes from a lifetime of stepping outside on the porch to light up. She embodies the physical strength that comes from doing a job of legitimate labor and carries her taut and tanned frame with confidence.

2024, it turned out, was a pivotal year in our relationship, her annual wellness visit that, for some reason, departed from its previous predictability when she mentioned, “I want you to know that I drink vodka after work.” Despite my questions for years—I ask everyone—this admission—confession?—had never come up. “I know it’s too much and I am trying to cut down.” There was that smile again, a glimmer of vulnerability buried in her strength.

I’m not saying that is where we left it, but, in a way, that’s where we left it. I never get to chase down all the loose ends generated by “Oh, by the way…” and “I just want you to know…” statements patients make, often as we are standing up and heading to the exam room door. Sometimes I wonder if my patients say these things in this manner with the intention of letting me hear, but, in a calculated way, preventing further discussion.

Linda said, “4–6 shots in the evening after work—I’m being honest with you,” an admission that seemed like some kind of breakthrough. I was grateful that she had opened up. A lifetime of patient care had taught me that this was a fleeting moment, and it might not come again.

After she left, I wondered if there was a future where we would talk more about this. We hugged, and I felt her powerful shoulders, ones which stood in contrast to her choice to be vulnerable. Was she beginning to trust me on a different level? I wondered what she was “treating” with her alcohol abuse. My patients who drank in this manner had their reasons and, I have learned, you shouldn’t assume anything about how, or why, this came to be.

Sometime in the coldest and darkest part of the winter of 2025, Linda came to the ER in the ravages of alcoholism, begging for rehab, help—anything. Jaundiced, gaunt, hallucinating, matted hair, and eyes that indicated demons had moved off the back burner and were cooking on the front of the stove. Whatever her previously organized life was, it had sprung a leak and was now resting on the bottom of the lake. Taking it all in, I was left wondering what I actually knew about Linda. I had seen her a few months before, and this did not—honestly—seem to be the same woman. What, exactly, happened?

After a dreadful 48-hour stay in an uncomfortable bed in the busiest emergency room in West Virginia, the Berkeley Medical Center, Linda was lucky. She got a spot in an inpatient rehab on the far side of the state. I made a mental note to keep tabs on her—you know how these things go. By the beginning of the following week, I was wrapped up in other matters and—to be honest—forgot about Linda. When she arrived at my office earlier this week, months had passed. I was thrilled and surprised in equal parts to see her, and ashamed that she hadn’t crossed my mind. How could I be so damn “busy” that I had forgotten her pain and suffering?

We stared at each other, unsure where we were picking things up. My shame felt like a sunburn across my face, and I assumed she could see it. As I often do, I went first. “Are you going to any meetings?” I asked her, my traditional sobriety ice breaker. “No, I am not,” was her firm reply, her tone unclear. “I don’t want to talk to anyone about this.” She raised her eyes, and we stared some more. For a moment it was quiet to the point that the only thing I could hear was my tinnitus.

“Ice cream is my new vodka. I can’t stop eating it.” She laughed that hoarse laugh and pinched a new roll of belly fat with both hands, shaking it up and down. As she did this, I guessed that she had gained 30 pounds, and her eyes were crystal clear without a hint of jaundice. Normally, people don’t look good when they gain weight, but Linda was an exception. I saw a clarity in her physiology, one that was full of promise, one that was not there before.

“My last drink was eighty days ago,” she said with a big smile and a weight that told me this was a declaration, not a question. Her body language indicated I should not follow up, so I just sat there. As I processed this information, Linda drifted away, and her vision rested on a point somewhere far off in the distance behind me. For the first time in our relationship, I admired the pale blue tones on the inner rim of her eyes.

I could see that Linda was transported to someplace else entirely. With her gaze locked on that same point, she recounted in a no-nonsense manner how she was no longer drinking and was “trying so hard” to focus on her grandbabies. I moved my seat forward and made my body language indicate that she had my full attention, none of which she seemed to notice. I wondered what on earth could have possibly happened to have set up this destructive behavior, one that she maintained for so long before it wrecked her life and almost killed her. Our previous conversations had me asking so many questions.

Then she turned her gaze directly at me. “When you’re in high school and you lose your virginity to your biological father it’s not a good situation.”

Ryan McCarthy is an internal medicine physician.