Mr. Smith is a heavyset man with an expansive, jowly face, and when I walked into the exam room, my first thought was that he resembles my late grandfather. I greeted him and sat down and slowly began to draw out his story. It had been hard for him to get to the free clinic that cold winter morning. He had recently been fired from his job for drinking, and he failed all of the subsequent preemployment health screenings. He was no longer managing his long-standing diabetes. He was living with his daughter, but her heat had been turned off and her phone disconnected, so he had no way of calling for help when he got the increasingly frequent crushing pains in his chest. Yes, he had thoughts of hurting himself, and yes, he had a plan in mind. Though his voice remained flat, his face glistened with tears in the late afternoon. I passed him a box of tissues and stared mutely at my notepad, not knowing what to do.
When I first received my white coat, I was anxious to get into the wards and begin my life's work of caring for patients. Brimming with the enthusiasm of a first-year medical student, I told myself that while we may not yet have conquered disease, we could, with enough kindness and hard work, mitigate any illness. Yet it was also around this time that I was plunged into closer proximity to human misery than I had ever known. I shadowed senior physicians in emergency rooms, burn clinics, and intensive care units. I conferred with patients in HIV clinics and bundled up against the cold in homeless outreach vans, and I watched silently from the wings as families huddled in hospice care. All the while I jotted terse notes to myself, determined to preserve my outsider's shock lest my later training inure me to such suffering: Mr. E—assisted with failed attempt to insert line. Held head. Pt had trach. Screamed silently. Feel awful.
Confronted with these new clinical experiences, I took refuge in the oft-quoted Hippocratic wisdom advising doctors that, while they can cure sometimes, and perhaps relieve often, they can comfort always. While the Hippocratic adage is often invoked in the context of palliative care, when curative intervention is no longer possible, I noted all around me caregivers at various stages of training embodying this doctrine of comfort. One of my classmates sat with a dying man until his family arrived, so that he wouldn't face the prospect of dying alone. A resident appeared, unannounced, at her indigent patient's home with armloads of groceries. And a peerless intensivist kept watch over his patients at all hours of the day and night, his face etched with concern but his words carrying solace for anxious families. There was no shortage of compassionate and dedicated role models.
But I felt utterly defeated on that pale winter afternoon, betrayed by the Hippocratic aphorism that had previously seemed to organize and give meaning to my clinical experiences. Mr. Smith was trundled off for an emergent psychiatric evaluation, and I was left to reflect on how his repeated encounters with thoughtful and caring health care providers over several years had come to naught. I wondered what comfort I could possibly give him to take back to his daughter's cold, dark apartment, where he drowned daily in depression and alcohol.
Mr. Smith's story lingered in my mind long after I left and rotated on subsequent electives. The common diseases I saw in the free clinics and county wards—hypertension, diabetes, depression—are all treatable illness in other settings, but the problems of homelessness confound even basic interventions. Earlier in my medical training I would have been tempted to argue that Mr. Smith's predicament was an artifact of inadequate funding or poor public health policy. These barriers certainly do exist and frustrate the best intentions of caregivers.
But I suspect that I dwelt on Mr. Smith's case for deeper and more personally unsettling reasons than health policy. Only now, with the benefit of hindsight, do I realize that my fleeting encounter with Mr. Smith was the first time it dawned on me that even the most compassionate and skilled care could, in some cases, fail to illuminate the dark recesses of crushing poverty and addiction. While poverty, mental illness, and substance abuse can be treated independently, together they form a constellation of misery that our current models of health care delivery fail to remedy. It is only now, as my undergraduate medical education draws to a close, that I can begin to appreciate the extent to which destitution and despair undermine even this most basic of medical imperatives: the drive to comfort.
I don't know what happened to Mr. Smith, who remained at the psychiatric facility even as I completed my rotation. I don't know whether he found the care and support he needed, or whether he is alive at the time of this writing. The events of that afternoon continue to linger, though not as a reminder of failure. I used to believe that my principal obligation to my patient was one of rescue. If I couldn't rescue my patient from his disease, perhaps I could emotionally rescue him with compassion. But I erred in conflating comfort with rescue. Instead, I've learned that comforting a patient can mean advocating on his behalf, and winning small victories, one at a time. We may not have soothed Mr. Smith's pain, but I believe we averted a suicide that day. Yet the simplest form of comfort is also its most profound manifestation: staying present with the patient throughout his ordeal—if not as a rescuer, than as a guide or at least a companion. Meditating on his own cancer, Anatole Broyard observed that “the physician is the patient's only familiar in a foreign country.… My ideal doctor would be my Virgil, pointing out the sights as we go.”1 We would do well to heed his advice.
The Francis A. Velay Humanism in Medicine Essay Contest Presented by the Arnold P. Gold Foundation
The Arnold P. Gold Foundation is a not-for-profit organization founded in 1988 to nurture and sustain the time-honored tradition of the compassionate physician. Today, students, residents, and faculty participate in at least one Gold Foundation program at 93% of our nation's medical schools and at schools abroad. Its programs and projects are derived from the beliefs that compassion and respect are essential to the practice of medicine and enhance the healing process; the habits of humanistic care can and should be taught; and medical role-model and mentor practitioners who embody humanistic values deserve support and recognition.
In 1999, the Gold Foundation instituted the annual Humanism in Medicine Essay Contest as a way to encourage medical students to reflect on their experiences in writing. Since the contest's beginning, the Foundation has received close to 2,000 essays from more than 110 schools of medicine and osteopathy.
Contestants for the 2006 Humanism in Medicine Essay Contest were asked to respond to the following quote from Hippocrates: “To cure often, to relieve sometimes, to comfort always.” Winning essays and honorable mentions were selected by a distinguished panel of judges. For the sixth year in a row, Academic Medicine is pleased to publish the winning essays from the contest. Although their essays will not appear in the journal, the Gold Foundation would like to recognize third-place winners Kelly Doran and Kate Nyquist. This year, three essays share the second-place honor; Ari Reichstein's appears here, and the other two second-place essays can be found on pages 1110 and 1112 of this issue. The first-place essay will appear in the December 2007 issue of Academic Medicine.
Winning essays are also published on the Foundation's Web site: (www.humanism-in-medicine.org) and in the Foundation's DOC newsletter. For further information, please call the Arnold P. Gold Foundation at (201) 567-7999, or e-mail: (firstname.lastname@example.org).