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Message in a Bottle

Kheirbek, Raya, Elfadel, MD

doi: 10.1097/ACM.0000000000002009
Teaching and Learning Moments

R.E. Kheirbek is associate professor of medicine, George Washington University School of Medicine and Health Sciences, and geriatrician and palliative care physician, Washington DC VA Medical Center, Washington, DC; e-mail:; Twitter: @raya_kheirbekMD.

An Academic Medicine Podcast episode featuring this article is available through iTunes.

Author’s Note: The names and identifying information in this essay have been changed to protect the identity of the individuals described.

“Would you refill these medications, please?”

A nurse handed me a list. “Mr. Bowen just moved to town and ran out of medicine. You don’t have to see him. I scheduled an appointment in two weeks,” she said. I had already seen several patients that day and had more waiting, along with secure messages, the medical advice line, and phone appointments to finish. Filling out a list of medications was not a priority. But I faked a smile and said, “Yes, of course.”

At a glance, the list included usual medications patients take for blood pressure, depression, allergies, eczema, and pain. I tossed the paper on top of a pile of folders and followed up on a phone appointment with another patient, Ms. Cordell, who was upset that I was late in calling. Chronically ill and lonely, she loved to talk. While listening to her, I looked up Mr. Bowen’s remote records and reviewed his medications. They were accurate—he had visited his Veterans Affairs primary care physician less than a month ago and his labs were fine. As I was placing the orders for his refills, I heard a knock on my door. My next patient was ready. I wrapped up my phone call with Ms. Cordell and walked out into the waiting room.

With his list of medications in my hand, I called Mr. Bowen’s name. No response. I asked the clerk if he was still there. She shook her head and shrugged her shoulder. I thought about having the clinic pharmacist enter the refills to save time, but he wasn’t available either so I went back to my office and quickly entered his medications.

My next patient was Mr. Robinson, an elderly man accompanied by his daughter. They had visited oncology to follow up on his lung cancer. He was told that chemotherapy was not an option given his frailty. “Life is precious,” he said. We agreed to work towards realistic goals in promoting his function, dignity, and comfort and supporting his caregivers. When Mr. Robinson and his daughter left, I began responding to urgent messages in my alert box. I saw that Mr. Bowen’s medications were ready for window pickup.

It was nearly noon by then. While passing by the waiting room to get lunch, the clerk alerted me that Mr. Bowen was back. I contemplated asking her to let him know that his medications were ready and that he should come back to see me in a couple weeks. With a few minutes to spare before my next task, though, I found myself walking toward him.

A man in his early thirties, he stood up. I extended my hand and greeted him. “Thank you for waiting. Let’s verify your medicine and we’ll get you out quickly.” He followed me quietly; he walked straight, his face held forward in a steady gaze. It was a bit awkward, but I assumed this was the way he always looked.

We sat in my office. I turned to my computer and started reviewing his medications. His responses were muted, but he had a decent understanding of his illness and treatment. Then silence ensued. “How did you end up running out of medicine?” I casually asked without looking at him.

“I swallowed all my pills last week. I was in pain and did not want to live.”

His voice penetrated my psyche. My heart sank, cold sweat swept over my body, and my hands shook. I reached out to him and touched his hand. Perturbed, I kept hearing myself repeating the few words I could. “I am so sorry.”

A combat Marine, Mr. Bowen had recently separated from the service after two tours of duty in Iraq. He was having a hard time keeping a job. Nightmares and frequent panic attacks became his constant companion. Mr. Bowen had started taking depression medication but did not want to bear the stigma of mental illness. He stopped seeing his psychiatrist and started drinking heavily. Already buried in a sense of shame and guilt, Mr. Bowen swallowed all his pills in an effort to end his life. His wife found him lethargic at home and called 911. He was transferred to an area hospital outside the VA system. He survived and decided to leave town. This information never made it into his VA records.

Mr. Bowen still had thoughts of self-harm, albeit no specific plan. Away from his family and relatives, he was willing to admit himself into a psychiatry program. We both walked to mental health and I ensured a warm handoff to the team.

Back in my office, I collapsed in my chair and cried. Over time, our senses become dull and our capacity for listening tends to wane with the constant intensity of our experiences. My encounter with Mr. Bowen taught me that we listen at different levels. At the highest level, we can hear the most profound sounds, calling on us to connect. I have come to understand that my patients need my absolute focus on being present in the moment. After all, the present moment is all we have.

© 2018 by the Association of American Medical Colleges