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PATIENT-DOCTOR RELATIONSHIP
Year : 2009  |  Volume : 10  |  Issue : 4  |  Page : 188-196 Table of Contents     

Sketches from a surgeon's notebook


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Date of Web Publication17-Jun-2010

Correspondence Address:
George S Bascom
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Bascom GS. Sketches from a surgeon's notebook. Heart Views 2009;10:188-96

How to cite this URL:
Bascom GS. Sketches from a surgeon's notebook. Heart Views [serial online] 2009 [cited 2020 May 31];10:188-96. Available from: http://www.heartviews.org/text.asp?2009/10/4/188/63692

Medicine is science and narrative, reason and intuition. Empathy underlies the qualities of the humanistic physician and must frame the skills of all professionals who care for patients. But what is empathy? Merriam Webster defines empathy as the "action of understanding, being aware of, being sensitive to, and experiencing the feelings, thoughts, and experience of another . . . Etymology: Greek empatheia, literally, passion, from empathes emotional, from em- + pathos feelings, emotion." Empathy then is the ability to establish trust and connection with others. To be empathetic is to make another person feel secure to open up and share his experience. An empathetic person can sense not only what is presented but also what is behind what is presented or the things that the speaker may not verbally say. Empathy is not the same as sympathy.

The narrative below deals with and illustrates issues of empathy in the dance between patient and doctor. - The Editors

When I came home to practice, the first patient I saw was Orville Burtis. He was a weathered cattleman and an old family friend who had chosen a complete physical exam as a way of welcoming me. I occupied a pair of rooms on the second floor of a fine old pressed-brick home. Below was a busy waiting room and the offices of my father and Willard Schwartz and John Fairchild. They were primary care physicians, G.P's. Each had a different slant. Willard was an internist of volatile mood, and John was a cigarette-smoking anesthetist of very few words. My father's particular interest was surgery and obstetrics. But each doctor offered general care to families. My father was good at what he did. He had a Ph.D. in anatomy and a lively intelligence, and he was devoted to his patients.

Ours was a small town where the distinction between patient and friend was blurred. This had its drawbacks. Orville's office appointment was his way of greeting me and expressing his confidence in my skills. I understood that and did not charge him for the service, though I think he finally insisted on paving me five dollars. Friendship can make negotiations like this complicated. I had noticed my father's faithful but privately exasperated responses to hypochondriacal friends. It was unthinkable he should be haughty or cavalier. He accepted the fact that he was stuck with them.

But it had advantages, too. People understood his need for rest and leisure. They were generous and considerate in turn. So the practice atmosphere I grew up with and expected to enjoy and sometimes suffer was one of friendship.

Certainly other styles are open to a surgeon. Some are autocratic, some prayerful, some patronizing, some overbearing, some punctilious, some exceedingly formal. Some styles are appropriate, some inappropriate, but many serve to minimize personal involvement. In managed health care systems, the surgeon may have only a brief operative and postoperative exposure to the patient. It is efficient. It saves time and emotion.

But allow me to mourn the loss to both the patient and the doctor. Let me mourn the dance of the anesthetized surgeon over the anesthetized patient. Remoteness reduces the patient to a problem and the surgeon to a robot. Both miss the reward that often follows the venture of illness in which both patient and doctor are vulnerable and both need understanding. The surgeon misses a rich and various symphony, the unheard music Orville Burtis brought to the examining room-remembered stories by fire and lamplight, potluck suppers at his ranch, the death of his boy Dave, shingling his barn on a perfect day. The stories are wonderful. Stories wait on both sides of the examining room door. Sure, there is a medical problem to be addressed. But there are other issues, too.

Trust

Joel was a college professor, a writer, and a dramatist. He had a duodenal ulcer with recurrent pain and trouble enough to justify a vagotomy and pyloroplasty. He had tried everything in the way of conservative management and now was ready to consider surgery. But he was uneasy. How competent was I? How safe and effective was the procedure? More than that, and unspoken- perhaps even unconscious-was the matter of trust in my goodwill. Could he put his life in the hands of a stranger? As a man of imagination, he must have wondered who lived behind the features of my face. I could feel the struggle going on in Joel. It took time and several talks during which he covered some of the same questions more than once. After weeks of deliberation and careful thought, he decided on surgery.

I was impressed with his courage. Recognition of his struggle laid a heavy responsibility on me. His question became my own: Was I to be trusted? It made me more careful when Joel went to sleep and lay under the drapes and operating room lights. That question surfaces again and again, especially in cases where indications are blurred or risks and benefits nearly balanced. Joel's struggle to trust led to a reciprocal effort to be worthy of it.

Layla was another lesson. She had had multiple Caesarean sections and a failed hernia repair in Baghdad. Now a graduate student at Kansas State, she wanted the recurrence repaired. But, as I came to learn, she was incapable of trust. Her first two preoperative visits were a year apart. I suspect she spent the intervening time nourishing dark suspicions to help them grow. Why she elected me as her surgeon I cannot fathom. Probably it was because of my brother's kindness and courtesy to international students. Charlie was a physician in student health at Kansas State.

The surgery was scheduled after I called two Iraqi physicians in distant places, San Diego and Dallas, at her insistence. She demanded they be fully informed and concur with the operation. One was a dermatologist and the other a plastic surgeon, so the reassurance they offered had less to do with their competence than with their national origin. It was annoying to make these calls, but I thought it reasonable in view of her alien status and our unfamiliar customs. I explained the indications, recited the plans, and received heavily accented approval from her consultants.

By the time Layla reached the operating room I had the strong presentiment a recurrence would result in formidable turmoil. As an extra precaution, I decided to use Marlex mesh. It lay beautifully beneath the peritoneum when I had finished placing a ring of mattress sutures around the defect. The abdominal wall closed over the mesh without tension, and I was very pleased with the procedure. But Layla did not do well. She began to vomit, became increasingly uncomfortable and increasingly suspicious that I had done something wrong. I assured her she was getting all the fluids she needed intravenously. I apologized for the nasogastric tube and tried to make it as comfortable as possible. But Layla's suspicion was like obsidian, hard and impenetrable.
"Call my doctors," was her sullen response to my attempts at reassurance.

So I made call after call to faraway cities-Washington, D.C., New Orleans, even London. Some of these Middle Eastern consultants were surprised to get my call and were cordially supportive of what we were doing. Others acted as if they had been briefed by Layla, muttering noncommittal responses that breathed the same deep doubt about my judgment.

Layla got worse. Finally there was no question she was totally obstructed and needed reexploration. I proposed it to her and explained with all the patience I could command.
"Call my doctors," she said, handing me the names of two new ones.
"Mrs. A.," I said. "There is no doubt in my mind about this. We do not need more advice. You need the operation now. If you are not satisfied, I want to turn your case over to a surgeon in whom you have confidence."

She stared at me. She and her husband, a large, rough-looking man, said they would let me know. In a few minutes the nurse gave me the word that they agreed and wanted me to carry on. So Layla came back to surgery. When I opened her abdomen, I found bowel stuck up against the mesh. It was distended proximally, collapsed distally. We freed it, interposed omentum between the mesh and her viscera, and Layla made an uneventful recovery. I saw her at the usual intervals after surgery. Each visit was an ordeal of few words. Her unshaken conviction remained that I was both negligent and incompetent. Her ingratitude was uncompromising, her dissatisfaction unwavering. When she was dismissed, I felt a great weight lift from my soul. I wanted never to see Layla again. And if, as some suggest, our feelings are a mirror of the patient's, she was glad to be rid of me.

Absurdity

Absurdity is no stranger to the patient-doctor relationship. Occasionally, I was asked to make a house call on a sorority girl. I remember as a college boy being acutely aware of the inviolate barrier between the first floor of the sorority house and the rooms above. No man dared breach that line between the public activity of the young women and the private-and richly imagined-activity above. Enough of that feeling lingered that some effort was needed to act casual when I arrived with my black medical bag. I marched up the carpeted stairs accompanied by the housemother and one or two of the senior sorority girls. "Man on second," someone called. I tried not to blush. Heads poked out the doors along the corridor and a bevy of young women in curlers and pajamas gathered behind us as we proceeded to the room of the patient. A drama suddenly mushroomed.

The young girl had gastroenteritis and a stomachache, but she threw herself into suffering. The slightest touch to her discreetly bared abdomen elicited a cry of anguish and a writhing withdrawal. Her sisters, appreciative of her histrionics, reciprocated with cries and moans of sympathy. Surrounded by nubile loveliness and emotionally inundated, I examined and questioned her with increasing embarrassment, an embarrassment heightened by their hanging so on every word. It became opera bouffe. Yes, I should have cleared the room and taken charge. But I was young, and the part was new to me. I had never before been the man on second.

And there was the matter of informed consent. Kansas State University with its excellent agriculture and engineering departments attracts many international students. One cannot help feeling a lot of sympathy for them when they get sick or need surgery. Here they are, thousands of miles from home in an alien culture, often short of funds and having to fend for themselves in a strange tongue. So I take particular pains to be respectful and to answer questions.

The young Iranian graduate student in engineering was yellow as a pumpkin. A work-up revealed gallstones. The presumption was that one had slipped into the common duct, blocked it, and was now causing his jaundice. He was a clean-shaven, intelligent, handsome young man. The whites of his dark brown eyes were deep yellow.

I sensed his English was imperfect, so I resolved to take particular care to explain everything, not fearing a lawsuit for failure to inform but out of the nobler impulse of Christian charity. I confess to feeling rather good about myself as I sat down with him at the nurse's station.
"Your surgery is scheduled for tomorrow morning," I began. "As your surgeon it is my duty to answer all your questions and explain hilly what you can expect. Do you understand?"
"Yeah, sure. Sure."
"O.K. Do you know what the gallbladder is?"
"Sure. Sure."
"Well, your gallbladder contains stones which have formed from elements of your bile. You understand?"
"Sure."
"The gallbladder is a side arm, a reservoir off the main bile duct. It stores bile between meals and thickens it like syrup on the stove." I noticed his brow wrinkle a bit and thought perhaps I was going a little too fast. "Do you understand what I mean?"

He nodded. "Yeah. Sure."

Feeling a little doubtful, I explained that a stone had slipped into the main bile duct and blocked it. "That is why your skin and your eyes have turned yellow. The bile is backed up in your system. It can empty adequately only through the common duct." I looked at him again. "You understand?"
"Sure, sure."
"Now," I said, taking a deep breath, "An infection has developed in your bile ducts. Do you know what I mean by infection? Do you know what bacteria are?" I wondered if I was being a bit condescending. He nodded. Did he look faintly bored?
"Well, this infection will come back again and again until the stones are removed from your common bile duct. We plan to remove the gallbladder and also remove the stones from your main bile duct. That will relieve the yellow jaundice and prevent more infections. Okay?"
"Yeah. Okay."
"Now I am required to tell you about problems or complications that you might have. Surgery doesn't always turn out perfectly. Sometimes an infection will occur inside the abdomen or under the skin. It doesn't happen often, but it can make you stay in the hospital longer." He looked a little troubled. "If it does happen, we can take care of it. Okay?"
"Sure." He nodded again.
"Any time we operate we can have some unexpected bleeding. Not often, of course. But it can happen. I have never had this trouble with a gallbladder."

He continued to meet my eyes and nod.
"Now, I must inform you that you could even die as a result of the surgery." He seemed to look more intently. I hurried on. "It is very unlikely. Very unlikely. About as risky as driving to Topeka. You know, anytime you drive to Topeka you could have a fatal accident. Sometimes people are killed on the highway, but it is so unlikely we don't worry about it. That's about the risk of your surgery."

He continued to look at me intently. "Do you have any questions?" I asked.
"Yeah," he answered, "when I go Topeka?"

Anger

Like absurdity, anger can dominate the relationship. Years ago while making rounds I was called to the emergency room. It lay at the end of a long corridor leading from the surgical floor. Wild with anger, a man's voice came racketing down the hall as I walked toward it. "Let go of me you f…… bitches. Goddamn you . . . , get away from me!" And on and on. In the background was the sound of voices trying to pacify him. I saw a tangle of bodies when I entered. He was a large, lean young man with a scalp laceration. Ambulance attendants, nurses, and a policeman were trying to keep him on his back. He was bucking and cursing, trying to fling them away. He spat at one of the nurses, and I felt fury rise in me. "You lie still," I shouted at him.
"F… you, you son of a b….," he screamed. I could smell the liquor on his breath.

A friend had shown me a judo hold that involved grasping the ringers of the hand and separating them forcefully. He assured me it would pacify anyone. He had applied it to me, and I agreed. It was very painful.

Infuriated, I grasped the fingers of his right hand and separated them hard. And with pleasure. I expected him to quiet down, but he writhed around on the table until his bloodshot eyes were inches from mine. "Go ahead," he shrieked, "break them, you f…… bastard."

Shocked by my own savagery, I dropped his hand and stepped away. I was ashamed, humiliated. I felt others in the emergency room looking at me. "You'll have to jail him," I told the policeman. "We can't treat him this way. Bring him back when he sobers up."

I walked away as his cursing and yelling continued. He may have come back. Maybe someone more skilled in managing a berserk drunk came along and sutured his cut. I was glad to get away from him and from myself.

On another occasion anger broke out. It was one or two in the morning, a hot summer night, and I was tired from busy days and nights, lots of surgery and heavy office schedules and, of course, the damned emergency room. Theoretically we took emergency call in turn. But some cheated. Others of us, perhaps self-righteously, took up the slack, felt abused and rather noble, and sincerely hoped the community and hospital staff would notice and give us our due in terms of respect and loyalty. That is, we hoped the other lazy bastards would pay in the end.

So when the phone rang, even before I picked up the receiver, I was groaning inwardly. "Dr. Bascom," I answered.
"This is Memorial E.R., Dr. Bascom. We have a twenty-four-year-old male with a black widow spider bite on the arm."
"A black widow?"
"That's what he says."
"All right," I agreed reluctantly. "I'll be up."
"Thank you, Dr. Bascom." I hear real relief in the nurse's voice. It occurs to me I may be the fourth or fifth one she has called. By then it is too late to ask, and I find it easier just to get up and go.

I walk into a brightly lit ER and find a young man in dirty work clothes lounging against the examining table in the center of the tiled room. "What's the problem?" I snap. In the car I had asked myself if a black widow spider bite is really a surgical disease. I began to suspect a few primary care physicians had turned it down.
"A black widow spider bite," says the young man already offended by my tone. He looks fine. I detect the odor of beer.
"Are you sure it was a black widow?"
"It was black and had a red dot on its belly."

Suddenly his companion speaks. He is an equally scruffy, unwashed type who has been fidgeting as he leaned against a stainless steel counter. "It was a bee," he declares, responding angrily to my unsympathetic manner.
"A bee," I explode. "Well, what is it? A spider or a bee?"

They answer simultaneously-"spider, bee"-each positive he is right.
"Well, let me see the bite."

He holds out his dirty forearm. On the back I see a tiny mark. No swelling. No redness. "This?" I ask.
"Yeah, that."
"When did it happen?"
"About noon."
"About noon! You got me out of bed to see something like this? It happened at noon?"
"Hey," his friend calls out. "We're paying good money for this. We didn't come here to get insulted."
"Yeah," the patient adds. "We don't need this."
"There's nothing wrong with you," I shout. "And don't worry. I wouldn't think of sending you a bill." I stalk out full of fury and righteous indignation.

I suppose they had talked it over in a tavern as they drank their beer, argued about it, and finally decided the way to settle the quarrel was to have a doctor check it. They looked like laborers and must have led tough lives. Kansas heat can make an ordeal of summer work outdoors. I feel more sympathetic now. I wonder how they feel about the hot-tempered son-of-a-b…. doctor.

Sudden anger can destroy even long-standing relationships. Bonnie had many problems but was now hospitalized with mysterious epigastric distress. She was demanding and insisted on relief in a loud, querulous way. I had no explanation for her bellyache and other symptoms even more difficult. We had to rely on the cholecystogram for a positive diagnosis of gallbladder disease, and it was misleading sometimes. Bonnie's cholecystogram was negative and so, despite a strong suspicion that she was suffering biliary colic, I felt we ought to follow her rather than operate. Once she was better, I prepared to discharge her. Hospital census was high that week, so Bonnie was on the medical rather than on the usual surgical floor.

It was a Friday. I was off. My associate knew I had discharged Bonnie, but just before leaving she had another attack and on somebody's orders stayed in. He did not see her Saturday or Sunday. I did not see her Monday or Tuesday. In the middle of Tuesday afternoon, Bonnie called the office. Her message was simple: If I was not in her hospital room in five minutes, she would sue me for malpractice.

I flew to the hospital. Bonnie and her husband were furious at my neglect. I was furious at their threat. We exchanged angry words. I felt coldly unconcerned with their problems. I resented the ingratitude, and said I could no longer work with them.

Later I learned she had gallstones. She relented enough to ask me to do the surgery. I declined, feeling rather mean about it. The angry exchange in her room that Tuesday afternoon had lingering effects. Though I no longer felt angry, I knew surgery would be too great an effort. If, as Origen believed, the purpose and end of creation is reconciliation, then Bonnie and I still have some work to do.

Money

Among the topics avoided in medical education is the love of money. Its importance is affirmed by our unwillingness to talk about it. But it erupts into medical practice willy-nilly and is part of the patient-doctor relationship.

Art was a short, dark journeyman plumber whose wife died of breast cancer after a long illness. She was an appreciative patient, and we became good friends over the course of several years. Art was there as much as he could be, also grateful and friendly.

Art had diabetes and developed a blood-starved left leg that improved after my associate performed a bypass procedure. He was grief stricken after his wife's death and took poor care of the diabetes. One Saturday afternoon he was brought to the emergency room unconscious and with a large scalp laceration. The highway patrol said he had had an inexplicable rear-end collision with a moving vehicle on the open road. Art's right leg was hurting, too, and appeared pale and starved for blood. I was assailed by a number of considerations. Was this a concussion? A fresh stroke? Could he have an intracranial clot? Might he have had an acute cardiac arrhythmia? A heart attack? Low blood sugar? And what about his damned leg? Where did it fit in?

We did not have in-house computed tomography scans at the time. Our practice was to follow the patient's neurologic status and refer if localizing signs appeared. I thought his painful leg was less important than the puzzle of his unconsciousness. My colleague would be back Tuesday, and by that time I felt the situation would stabilize sufficiently to permit an X-ray of his arteries and surgery. Art seemed to understand, though his leg hurt a lot. Something angered him, though, as he waited for definitive care for the leg. Tuesday arrived, Tom saw him and operated, fishing clot and debris out of his femoral artery and improving blood flow to his foot. In another month, however, the vessel clotted again, and Art had an amputation below the knee.

Then in an apologetic way, Art announced he was suing me. He was angry with one of our partners, but his lawyer insisted he had to sue me, too. "Somebody owes me a leg," he said.

Shortly thereafter an accusatory letter arrived from his lawyer. It was insulting and contained a peremptory demand for damages. Then the familiar waltz began. A consultant thought I should have referred him sooner. Art's lawyer threatened the malpractice carrier with immediate suit. The insurance company settled without asking my opinion, and I felt completely victimized.

When I protested, the representative said, "Well, it's our money."
"Yes," I stormed. "But my reputation." Come to think of it, it was also my money. We sent a letter to Art telling him we would not be his surgeons in the future. All our interactions, conversations, affection became a pile of smoking rubble.

The arrival of laparoscopic cholecystectomy revealed that the love of money is not confined to patients and their lawyers. General surgeons have watched the domain of their craft shrink steadily for the past three decades. Orthopedic surgeons claim fractures and hand trauma. Ear-nose-throat specialists are doing thyroids and parathyroids. Maxillofacial surgeons claim the tongue and salivary glands, the larynx and epiglottis. Oral surgeons do fractured jaws. Endoscopists retrieve common duct stones. And so on.

That is why a threat to our claim on the gallbladder aroused such an abrupt and energetic reaction across the country. Be damned if they were going to take the gallbladder away from us.

Now, in retrospect, it is clear that laparoscopic cholecystectomy has a great advantage in reducing postoperative pain and speeding the recovery. True, we give up the chance to feel abdominal organs, and we do not control things as well as with open cholecystectomy. In the beginning, the risk-benefit ratio was not at all clear. But before it could be carefully defined, the technique was adopted by surgeons driven by publicity and patient pressure and, alas, by the love of money. In a confusion of terms, patients wanted the new "laser" operation that many presumed would be painless and risk-free.

Economic considerations helped precipitate the adoption of a technique that did represent real progress in competent hands, I believe, but that might not have. There was feverish and unseemly competition on the part of hospitals and surgeons alike to attract patients. Risks and disadvantages were glossed over.

So when I, finally climbing on the bandwagon, proposed laparoscopic cholecystectomy to a young woman, I felt a real conflict. True, I had assisted on a large number. My assistant was skillful at it. But I had not done one before. Was I being fair to her? I explained the situation. She consented, and I did the procedure. Though I was anxious and sweating, it went well. It served my self-interest to do the procedure. But was it in her best interest to have me do it? This ripple of concern enters the relationship between all but the most self-assured doctors and their patients. There is always a better surgeon somewhere, a more experienced internist or obstetrician. If I am not the best, is it enough to be reasonably good?

Guilt and Absolution

Guilt is an ingredient of medical failure. One of the great defects in our peer-review system is that it makes no provisions for absolution. The legal system seems merciless, too. Mistakes in judgment and technique always seem unforgivable when looked back on. Certainly we knew better. Of course we should have checked for that bleeder or ordered that test or taken that precaution. The event casts a blinding light on our fallibility. We are tired, distracted, hurried, overconfident, careless, unprepared, or panicky and a patient suffers, perhaps dies. If there is to be healing, it has to come from the patient or family. The clucks of sympathy from one's colleagues fail to reach the very heart of the sorrow.

Glenda's mother was a strong old farm woman who presented with cancer of the left colon. I resected it. She had an uncomplicated course but complained of mild, vague abdominal pains for years afterward. I suppose I attributed them to adhesions. They did not disable her. She accepted the discomfort and lived with it. Then her pain changed character and became obstructive. I ordered a film of the abdomen. To my horror it revealed a steel clamp in her left gutter, large and brilliant against the softer shadows of her tissue. One powerful impulse was to hide the film. Yet her daughter Glenda was a nurse on the third floor. She would see the report. But another impulse was to be honest, not just because there was no other choice but because it was the decent thing to do. Were I Glenda's mother, I could forgive the clamp but not the deception about it. With my heart in my throat, I went up to her room and told her.

She and her husband and Glenda were wonderful to me. Their forgiveness was instant and unqualified. My relief was enormous, of course. But more than relief was involved. Forgiveness had an affirmative effect, a powerful strengthening of the bond of brotherhood between us. Their kindness and compassion enlarged my soul.

We operated the next day, found recurrent cancer in her abdomen, and removed the clamp that lay behind the colon we had brought down to the anastomosis. I have not forgotten that generosity about the clamp. It healed me when I could not heal Glenda's mother.

On another occasion early in my practice, I encountered an old man with a perforated ulcer. In those days I took the recovery of my patients for granted. So with little anxiety, I took him to surgery and sewed up the hole in his stomach. But he did not do well. I puzzled over his lack of progress for two or three days and finally re-explored him. His perforation had reopened. A couple of silk sutures had cut through the wall of the stomach and it lay open, dribbling bile-stained gastric juice into his abdominal cavity. I closed it impatiently with bigger sutures and another tag of omentum and just as impatiently waited for him to get well.

But he did not. His family showed increasing concern. I could not understand why. He just ought to get over a perforated ulcer. One evening I entered his room and found his family gathered there. I saw no reason for alarm. Nevertheless he took my hand. "Doctor," he said, "I forgive you. I know you did everything you could."

Well, I felt annoyed. Of course I had. Wasn't I an expert surgeon? I responded politely and assured him he would be getting well soon.

The next morning he died, no doubt of sepsis. Only then was the generosity of his act revealed to me - and the shallowness of my response to him.

Barbara was a piano instructor whom we were sure had abdominal carcinomatosis. She had been vomiting off and on, but her upper gastrointestinal tract showed no obstruction. I was not concerned enough to order a nasogastric tube preoperatively. Her surgery was scheduled late in the morning. It was a busy day, and the anesthetists traded assignments. As anesthesia was induced, I stood by her side. It did not occur to me or to the anesthetist to prevent regurgitation with a Selleck maneuver. Suddenly she vomited and aspirated. He quickly intubated and suctioned her, but the damage was done. After a miserable week, she died of respiratory failure. She was doomed with far advanced cancer but that made me feel no better. The aspiration added greatly to her suffering. I found it very hard to visit her when making rounds.

A month after her death her son sent me a note of thanks with a snapshot of Barbara. She stood near her piano and gazed into the camera with a joyful smile. Tears welled up in my eyes and gratitude in my heart. The patient-doctor relationship does not end with death.

Humor

Sometimes the relationship is full of humor. Lon is in his eighties, I guess. He could pass for younger. He is lean and likes to bicycle. Once a year he pedals from Riley to Clay Center to visit a cousin who is always horrified and urges him to quit. I believe he enjoys her expostulations about as much as the ride. Lon's hobbies include photography and gardening. But his chief delight is language, specifically polysyllabism. He will come in more for conversation than for anything serious. He has had a few little skin cancers, so I always check his skin. But he likes to josh me and Lylah, my nurse.
"Doctor," he will say with a perfectly deadpan manner, "I have inadvertently apprehended an epithelial excrescence prominently and progressively enlarging within the epidermal lamination which overlies the cartilaginous and osseous substructure of my olfactory protuberance."

Or, "If you will diligently investigate the pilar projections rising sparsely from the vertex of my cranial ossification, you will detect a macular callosity which may have malignant potential."

Some people, he complains, call him verbose, some loquacious, though he strictly limits verbalization to what is positively pertinent and necessary.

Laverne was a big, sunburned farmer who always brought a gust of cheerfulness in when he showed up for his follow-up exams after we removed a villous adenoma from his colon. It takes savoir faire to maintain dignity during a proctoscopy. Laverne was good-natured about it. During a procto one day, he told us about a recent adventure he and his lifelong friend ValGene had. It happened during the Iran hostage crisis. Feeling was high, and the presence of Iranian students at the college made some people uneasy, particularly, as it turned out, in the northern part of Riley County where Laverne and ValGene live.

That uneasiness escalated one morning when an abandoned automobile was found on a county road north of Riley. Someone-no one recalls precisely who-reported that two dark-complexioned males left the car and disappeared into the fields.

That night Laverne and ValGene attended a Swine Council meeting in Riley. The appearance of Iranians on the back roads of Riley County was the chief topic. By then, it was pretty well agreed that they were Iranians and probably terrorists. Folks felt pretty vulnerable. If terrorists could take an embassy guarded by marines, what was to prevent assault, hostage taking, and God knows what else in Leonardville and Riley.

About this time Laverne remembered his Japanese hand grenade. An uncle brought it back after the war and gave it to Laverne. When Laverne's aunt died, she left her farmstead to him, and Laverne, thinking of safety, decided to store the hand grenade in the loft of her garage. It occurred to him it would be a dangerous thing in the hands of a terrorist. ValGene agreed, of course. They agreed on just about everything.

So, when the Swine Council broke up, they piled into Laverne's pickup and headed for his aunt's abandoned farm. They parked and doused the headlights. Together they crept into the garage and up to the loft where to their great relief they located the Japanese hand grenade.

While they were looking for it, an elderly neighbor and his wife, returning from church, noticed the pickup in the shadows of the garage. Word of the Iranians and their abandoned car had earlier reached them through the grapevine, so, at the next crossroad, the old gentleman turned around. He told his wife to get into the back seat. Then he crept back toward what they supposed might be them, paused, noted the license number, and took off.

Laverne and ValGene, descending from the loft, noticed the suspicious slowing and accelerating of the passing car. Leaping into the pickup, they careened off in pursuit. Laverne and ValGene were as determined to catch the terrorists as their neighbor was to escape. He told his wife to lie down in the back seat-he expected gunfire-and headed for Riley in a cloud of dust.

Laverne and ValGene could not quite head him off. The two vehicles roared into the sleeping community where the old gentleman pulled into a friend's driveway, doused his lights, and ducked. Laverne and ValGene lost him but went on hunting up and down the streets of Riley. The old fellow called the Riley County police department reported his breathtaking escape and the license number of their maniacal pursuers.

It is safe to assume the police department was puzzled. Both Laverne and ValGene were respectable. They had a streak of fun and unconventionality, but chasing harmless old folks at high speed was totally out of character. Nevertheless, the police checked with Laverne's wife, found her husband was, in fact, unaccounted for and when last seen was driving a pickup answering to the description furnished by the breathless old couple. An all-points bulletin went out even as the pickup lurched through the back alleys of Riley.

That accounted for Laverne's reception when he finally arrived home. His wife emerged from the front door before the truck stopped rolling and long before Laverne could launch into an account of his harrowing evening. "Now what have you done!" she demanded. "The police are looking for you!"

His proctoscopy was negative, and my day greatly improved by the story.

Affection

The sustaining force in the patient-doctor relationship begins with the doctor's affectionate commitment to the patient's welfare. A successful operation is appreciated, but that appreciation can be transformed into fury if the surgeon is uncaring. If a surgeon is affectionate, friendship will spring naturally out of the interaction. Friendship works both ways and enriches both patient and doctor. It makes a successful outcome more pleasing, and it alone has the power to redeem tragedy.

Friendship takes care, though. It can become inappropriately intense, particularly under the impulse of sexuality. I am not talking about the seductive patient or doctor. I am referring here to the surge of feeling that may hit a doctor or a patient in the necessary intimacy of the examining room. We read about instances in which overt sexual interaction occurs. Given the hungers and dissatisfactions of human beings, it is remarkable that it so rarely does. One reason, of course, is that a patient appears because of concern about a health problem. The mood is not romantic. It is my experience that sexuality evaporates when the complaint and treatment are the focus. Sexuality is a hurdle, and clearing it with the patient enriches the friendship with vulnerability recognized and respected.

The care of prominent or unusually wealthy or powerful people can be complicated by egotistic or financial temptations. Conversely, money and power can intimidate the doctor. They make me uneasy. Perhaps that is why I have found caring for a dying patient so satisfying. Ulterior motives are at a minimum. The affection is simple. Often it is all we have left to offer.

Teresa died of breast cancer. She helped found a support group for cancer patients that has met twice a month for the past seventeen years. When she became too weak to leave her home, the group came to her. She was very open about her faith and feelings. She simply could not accept trinitarian Christianity, although she was a loyal Baptist. Her belief in the mercy of the Almighty God allowed her this heresy and her gentle affection made it inoffensive even to the Methodist minister among us. Her husband died suddenly during the last stages of her illness, a cruel surprise that she was able to accept without bitterness. When her pain became too severe to control at home, she came to the hospital. A day or two before she died, she stopped me as I turned to leave her room. She looked directly into my eyes. She said she wanted to thank me for everything I had done. It was spoken calmly but with deep feeling.

We both knew this was goodbye. It was a fine moment, an act of surpassing affection. For her it was closure on the right note. For me it was a reward that renews itself each time I think of it.

Old Harry was about ninety. I had operated on him two or three times, and we always hit it off well. Prostate cancer and arthritis caught up with him. He slipped into a nursing home where I had visited him a few times. One fall afternoon I was called to the hospital where Harry lay in considerable pain with a perforated ulcer. We reviewed his options together. The following poem sums up the moment and the affection, which was painful.


   Old Harry Top


But like broken redbud,

just as dry,

old Harry met his last catastrophe

calmly, grimly,

not unnerved by pain.
"No surgery," he said,
"I'm old. It's time to go."

Then with real affection

he took my hand and held it in

the brittle branches of his own.

Wounded by such fearless love,

I yearned for shelter in the shiny hall.

The feelings of friendship are not confined to dying. I have practiced here for more than thirty-four years. The young man sacking my groceries had a complicated appendix. My friend in the office chair, looking up with quick interest, had a colon cancer. The young woman in Wal Mart - what a saga! - a survivor of multiple operations and hemorrhagic pancreatitis. She smiles a greeting, and what a history is in that smile! Frank is a retired veterinarian. In our kitchen, having returned a book, he rolls up his pant leg to show me how well he healed from the incision through which we evacuated a huge hematoma. He embraces me with tears in his eyes. He has heard about the recurrence of my prostate cancer. Such bonds are the fabric of community. To a large extent, they are the reason and the reward for a life in medicine.

I hope these vignettes suggest the variety and unexpectedness of the patient-doctor relationship. There are, to be sure, some constants: the doctor's desire to solve the medical problem, the patient's to have it solved as painlessly, quickly, and inexpensively as possible. But if we think about it in those terms alone, our mood gets overly serious and our conversation grows dull. Seen fully and without hindrance of preconception, the relationship between doctor and patient is totally and unpredictably rich that one should expect from the encounter between incalculable, irreducible personalities. Often, the business of diagnosis and treatment is the least of it.




 

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