It was an event that I knew had to happen. The aphorism told me that it was as inevitable as taxes; the brief candle must extinguish. Despite the inescapable nature of the event, I never considered a course of action, or more importantly a course of thought, that I would take in the situation. I never treated the subject with the appropriate gravity that true preparedness would have required; instead, I mistakenly awaited it with nothing more than the mild dread that a child has while waiting in the dentist's chair, expecting the ineluctable pulling of that first tooth. The less I was prepared for the situation, however, the more I learned when it happened. I was two weeks into my clinical rotations when a patient died under my care.
To cure sometimes.
I walked into the ED examining room. Marie was sitting upright in bed with a pillow propping up a head of neatly curled milk-white hair. Her only living kin, a son, was at her side. “Are you the doctor?” he asked. I had a prepared self-deprecating answer for that question that I had heard so many times previously. “No, I'm just a medical student, but a doctor will also be in to talk to her.” An unusually active 92-year-old, she told of an itchy, scratchy throat beginning three days ago, which progressed to a cough and difficulty breathing within two days. Decreased breath sounds on exam; heterogeneous opacity in left lower lobe on x-ray—I was piecing together the picture. This was pneumonia and could be treated. I was confident; after all, I had recently received a PowerPoint lecture on this affliction. So this is what it feels like to be a doctor¡
To relieve often.
Marie was admitted that night, and over the next three days I learned that my optimistic take on the situation was perhaps mistaken. Her oxygen saturation steadily, slowly dropped, as if it were a clock ticking off her remaining hours. I spent more time in her room. I learned about Henry, her husband of 50 years, now deceased. When Marie became too breathless to speak, her son would pick up the story. When she declined to eat for two days, we discussed foods that she missed the most. Her favorite was chocolate milk; her son asked me if it would be possible to get her some. Locating chocolate milk on the ward was a task I had never before faced, and I had no PowerPoint slide to direct me on this one. When I finally found a carton and returned to the room, Marie accepted it readily. With his mother now content, her son told me that he was going home for the evening, leaving her side for the first time since admission. He had barely slept in the past days, and now he needed relaxation, respite, rest—relief. Perhaps he was finally assured that someone would still be there who would compassionately care for his mother; perhaps he knew what was coming and wanted to prepare.
To comfort always.
That night I could not sleep. I was disturbed by the fact that what I once thought was impossible was now clearly inevitable. A bacterial pneumonia, and yet all the -cillins and -micins had done nothing. If it was the 21st century and an almighty arsenal of antibiotics still failed to cure pneumonia, what was the point of being a doctor? Since I could not sleep, I decided to start prerounding early and went to visit Marie. The sun was not out yet; the only light in her room came from the soft glow of a muted television, a weakened lambent spotlight on her face. She smiled at me. “Hello, Henry, I have problem,” she quietly said, in a voice that was high and scratchy and not her own. Calling me by her husband's name, an acute decline in cognition, this was delirium. Possible causes include infection, metabolic derangements.t… Stop.
“Tell me your problem, and maybe I can help,” I responded.
“I'm thirsty. I'd like some chocolate milk,” she informed me. Out of all that would happen that morning, this was one event that I had prepared for; a carton was in my hand. I placed it in her grasp. She was too weak to lift it. I put a straw in it and brought it to her mouth. She was too confused to form a tight seal around the straw. I unwrapped the plastic spoon that lay next to last night's untouched dinner, and dipped it into the carton. With an unsteady hand I brought the half-filled spoon to her cracked lips. I was not good at this, and most of the liquid spilled into the wrinkles around her mouth. The milk that did make it in was gulped down hungrily. As I repeated the act, I got better at it; halfway through the carton she declined any more. “Thank you, Henry,” she said. I placed a hand on hers, and to my surprise she gripped back tightly. We sat together in silent darkness for a while, not staring at each other but not looking away either, each aware of the other's presence.
I think that it was here that I first came to understand the doctor's job. To cure sometimes. Diagnosis and treatment of disease are cornerstones of the profession, though they are neither always possible nor always necessary. To relieve often. By the nature of the job, physicians often encounter people when they are experiencing a rough patch on the path from birth to death, and it is our duty to make that path easier to tread. This could involve, for example, curing ailments, but could also include clearly explicating diseases to patients, or using humor to ease patients' anxiety. The above narrative illustrates that such duties also extend to families, who partially bear the distressing burden of a person's disease. Even Marie's steadfast son needed sleep.
To comfort always.
The roots of the verb convey a simple meaning: “con fortis”—to be with strongly. It is the physician's assignment, but also our aspiration, to be with the patient. This does not require constant physical presence; rather, the patient should never feel alone. Even if unable to treat the disease, even if unable to lighten suffering, physicians can always be there for the patient, ensuring a caring companion for whatever the future holds.
Marie died the next night with her son at her side. When I arrived at the hospital the following morning, her room was already empty. Her son contacted me through the hospital operator later that day. When I spoke to him, he gave me the closure for which I ached. “Thanks,” he said, “thanks for being her doctor.”
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; Benjamin Lampson's appears here, and the other two second-place essays can be found on pages 1110 and 1114 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).