Your Voices

On loneliness

"A 76-year-old widower, a retired miner, appeared at my office every Saturday afternoon with some minor complaint that seemed not worthy of medical attention. He was always dressed in a fresh shirt, tie, and suit, his shoes brightly polished.

He was rather shy and very polite. He particularly enjoyed talking with the nurses and would bring them little gifts. Although it appeared he had plenty of money and always insisted on paying, I felt guilty about taking his money for services he apparently did not need.

In an effort to detect anything I might have missed, I set aside two hours one Saturday for a thorough exam and review of his history. I found him in perfect general health. Since his wife had died two years ago, I asked if he had ever considered taking up with any of the single women in the community. He smiled and demurred.

I didn't know what to make of this patient. My nurses suggested that he was 'just lonely.' We considered a diagnosis of depression, although he showed no overt signs. Still not satisfied, I set up another appointment a week later to go over the results of his lab tests. He came and had his usual pleasant interaction with the nurses. I suggested that he didn't need to return for another six months. That evening he hanged himself.

In retrospect, the diagnosis was clear. His wife had died, he had no family, his working life was over, and he felt useless. The only thing that had kept him from falling off the edge was his weekly visit to our office. I had pulled his security blanket away from him.

I was never threatened with a malpractice suit, although an ambitious attorney might have seized on the situation. I endured my punishment in my own personal purgatory. I have been more vigilant about depression ever since."

—Roy T. Rapp, general surgeon, Quincy, IL

On listening

"The current climate in medicine is disappointing, but not without hope. We need to raise our expectations of ourselves and strive to do what we do best—communicate with our patients. We need to re-examine our motivation for choosing our careers in the first place. And we need to regain our sense of self-respect.

Instead of feeling threatened by a patient who brings me information from the Internet, for instance, I try to compliment her for taking such a proactive interest in her health. I let her know that my job is to work in partnership with her to maximize her health. I remind her that I am trained to evaluate all the available information about her condition, and that together we will devise a plan tailored to her unique needs. Sometimes I copy the information the patient brings me and put it in the chart. I make it clear that I keep up on the latest developments and always appreciate additional sources of information.

I find that my most rewarding moments are those in which I take some extra time to listen to my patients. Their lives are filled with many difficult and complex issues; I hear about their jobs, children, parents, and spouses. It never ceases to amaze me that I often learn as much when patients tell me what is going on in their lives as I do from their lab tests or sonograms.

I'm getting better at not having all the answers. Surprisingly, these interactions leave me feeling very content and proud to be a doctor."

—Neeta Ambe-Crain, gynecologist, Thousand Oaks, CA

Almost dying helps me to live

"As a busy solo internist, working 70-plus hours per week and taking call every other weekend, I paid little attention to symptoms of gradually increasing shortness of breath. I thought I was just getting older, so I increased the intensity of my workouts. I was a healthy nonsmoker, an avid hiker and jogger, and I saw no reason not to do one of my favorite treks—14 miles to the 10,000-foot summit of Haleakala, a volcanic mountain on Maui. As our party began a 3,000-foot descent from the summit to the floor of the crater, I felt strangely lightheaded and dizzy. And as the day progressed, I became increasingly short of breath.

Approaching our final rest stop, I felt a dreadful sense of impending doom that seemed to rise out of the earth and ascend my aching legs. I told my wife I probably had some altitude sickness. While others ate their lunch, I collapsed a few feet away in a clump of grass.

I had the sudden feeling that I was dying. Strangely, I felt no panic or fear. I looked up at the sun and saw beautiful ribbons of color, coalescing to form a tunnel. In the next instant I felt transported into an indescribably beautiful place that shone with blinding, but not painful, white light. I remember thinking, 'Well, you've just died, and this is what happens.' I had no sorrow or regret but felt bathed in love and the 'peace which passeth understanding.'

After a while I sensed the murmurs of people nearby. I felt pain and sharp disappointment at being thrust back into my body and pushed back into life. I knew I wasn't going to die that day and didn't have the physical or mental nerve to make sense of what had just happened. Numbed and overwhelmed, I kept the experience to myself.

I felt good enough to go to work the next day, but when I saw a cardiologist at my lunch break, my ECG was flagrantly abnormal. An echocardiogram revealed severely elevated pulmonary artery pressures and a nearly paralyzed right ventricle, all due to a massive pulmonary embolism. It was the most abnormal lung scan I'd ever seen—and it was mine!

I was devastated not only by the bad news but also because I didn't think living was worth it, not after the ecstasy of my near-death experience. A psychiatrist friend who had an interest in such things told me my despair was a typical reaction. I read accounts of NDE and was surprised how much of what I'd experienced followed rather predictable patterns.

What followed was a prolonged, sometimes painful and difficult process of reaccepting life and learning to cope with my disability. After two years of Coumadin therapy, when my pulmonary hypertension and abnormal lung scan persisted, it appeared that I'd been forming silent emboli for years.

But I feel I've gained more than I lost from my illness. As a physician I'd been trained to keep going, to take care of patients despite personal stress or fatigue. Now I'm partially disabled and can no longer jog or hike at altitude. But I can swim and do yoga for conditioning and relaxation. I've taken on an associate and now have a part-time practice with no emergency call. I spend more time with my family and loved ones.

Sure, if I'd been diagnosed and treated earlier, I might have suffered less permanent damage. But I've learned not to grieve over past mistakes, that living in the present is wonderful and precious.

I'm also more keenly aware of, and responsive to, the suffering of my patients, and less irritated by the hassles of paperwork, more willing to help others who might need me. I have become a strong advocate for patients, especially with recalcitrant health insurers, and serve in an advisory capacity to our local IPA and a physician-directed health plan.

I have been humbled by my experience, forced to scrutinize my values, my limitations, my own fragile mortality, and my commitments to career and family. Finally, I have been taught not to fear death."

—Ronald C. Kwon, internist, Wailuku, HI

 

Your Voices. Medical Economics 2001;8:103.