On Being a Doctor |

Them and Us FREE

Elisha H. Atkins, MD
[+] Article, Author, and Disclosure Information

From MGH-Chelsea Healthcare Center, Chelsea, Massachusetts.

Requests for Single Reprints: Elisha H. Atkins, MD, 151 Everett Avenue, Chelsea, MA 02150; e-mail, eatkins@partners.org.

Ann Intern Med. 2003;138(6):515-516. doi:10.7326/0003-4819-138-6-200303180-00019
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At the small city hospital where I trained, “they” were us. As rumpled, sleepless interns, most of us living just a walk away, our patients were our neighbors, like the loud old man whose radio and opinions I could hear on baseball nights, and whose blood pressure I stopped by to check after a heart attack. Or the teenagers who came to the emergency room with lacerations and sprains, and who knocked on my apartment door for suture removal and a sheepish question about sex.

The nurses, our friends and party-mates, brought reluctant uncles for checkups. Retired professors, admitted for an arrhythmia or pneumonia, could have been our fathers, or the graduate student with the worrisome pleural effusion, one of us. Even the wilder ones, raving in restraints from alcohol or angel dust, reminded us of friends on the edge or the black sheep in our families.

The line between work and leisure was blurred. We were never anonymous, never truly off duty. Passing through the cafeteria line, we would be told of symptoms and asked for advice by those serving the potatoes. Stopping by a neighborhood bar to catch the late innings on TV one night, I noticed, with mutual awkwardness, a patient just discharged from the detox ward.

The pity of it all could not be missed. We pumped red cells into the chief of pathology as his ulcer bled, sped him to surgery, watched his slow return to work and health, gaunt over the microscope. Sometimes the closeness was almost unbearable—feeling a stab of guilt at the unexpected death of a patient who had brought cakes at Christmas, hearing the love and despair in the voice of a senior resident admitting his own depression-struck father.

This small world, looking after its own, could give limitless support and comfort. But there was no room for secrets, no matter how shameful. It even seemed sometimes to shelter those past competence—the stooped physician shuffling through intensive care to encourage bananas on his gravely ill and hypokalemic colleague, the tipsy nurse never confronted because everyone was her friend.

So it was with the nostalgia and relief of one leaving a small town that I went to work in a health center in another, poorer city. The world on which it drew seemed larger—immigrants from all corners and longer-term residents whose lives looked raw and exotic.

There were no physicians or professors among my new patients. They were cared for in private offices or on reserved, wood-paneled hospital wards. Rarely I would get a glimpse in—once in a misrouted call from a visiting nurse, worried about a revered consultant who had discharged himself, febrile and hypoxemic. I immediately understood his pride and stubbornness.

Understanding of my own patients didn't come as quickly. Now better off and with children, I lived several towns away; I no longer passed my patients in the grocery. My new colleagues and I made every attempt to establish common ground, but it required work, extrapolation, straining across a growing gap of language, culture, and circumstance.

At first, no one required more work than Nora and her family. A retiring friend and colleague had left meticulous notes describing her and her ancient mother Helen, and Helen's diminishment by a series of strokes. Through calls and letters from a variety of agencies, I also learned of an addicted son, an unstable and angry daughter-in-law, and an ugly custody battle over an adolescent grandson.

Nora's blood pressure was high, and she was short of breath, but she didn't want tests or pills. (“I'm too fat,” she would say. “That's the problem.”) But she did start asking for painkillers for her mother. A cautionary Medicaid printout showed too many such prescriptions from too many other doctors to be just for an old woman's aches. Maybe they were for Nora. More likely, she hoped they would keep her son from buying on the streets, if only for a day.

Nora thought that her ancient mother's condition was getting worse, though that was hard to tell. She would call, distraught. “My mother is leaning more to the left,” she would say, but she usually declined offers for an office evaluation as too taxing. During rare visits, Helen seemed much the same, immobile and wheelchair-bound, mute except for an occasional murmured “okay.”

Then things fell apart in a way we could all see. Nora's mother had pains in her abdomen and blood in her stool, and lost weight. In the hospital, she became delirious as her bowels were prepared for endoscopy, and she had to be restrained. Her skin, smooth under Nora's care, now grew sores. If this was painful for me to see, it was an impossible agony for Nora. She took her mother home.

There, Helen was less agitated, but wouldn't eat, and became harder and harder to arouse. Nora tried everything. She called, beside herself with worry and indecision. Should she take Helen back to the hospital, try again for a painful and surely only partial and temporary cure, or let her slip away? I said I'd be over.

Nora's son, on his way to a methadone program, waited in the snow to direct me in, down an alley, past an abandoned car, and into a cluttered apartment, windows taped against the cold. On a bed in an alcove lay Helen. Examining her—her neat white curls, her fine features and translucent skin, her stillness—I felt a shock of recognition. She could have been my own grandmother.

Granny P.'s generosity and dotty enthusiasm had buoyed our family, and many beyond. The spareness of this apartment was far from her earlier world, a vanished one of piano lessons in Paris, Manhattan parties, then summers by the shore, grandchildren happily in tow. But her last failing years had been much closer, filled by repeated hospitalizations with nothing clear to mend, frantic calls from multiple family members to her beleaguered internist, and conflicting demands for intervention and palliation.

Finally, my wife, a nurse, had visited, found her weak in her new assisted-living unit, nothing familiar but the half-unpacked boxes of photographs, and bundled her home to my mother.

There, Granny P. slipped into a coma. A kind medical school colleague of my father's visited and allowed us to cede the physician's role. He said that we could hospitalize her, but the course would be hard and long, and the chance that she would return to the person that we remembered and that she would want to be had faded.

We decided to keep her at home. My wife chose supplies for the sickroom and gave us the small tasks of comfort and attention. An IV line hung from an old lamp as aunts and uncles kept vigil. My stoically grieving mother called us at the end.

Nora decided to keep Helen at home. A visiting nurse gave order to her daily care. Nora slept on a couch beside her mother's bed; Nora's son helped bathe and turn her; Nora's grandson stroked Helen's hand. Talk turned from diagnosis to memories of who she was before all this, her kindness, her wry and anarchic sense of humor, her companionship, all that had formed the bonds that were now so hard to release.

A small band of us planted a rosebush, in the pale sunlight by the shore, for Granny P. Sorting her belongings, we found a film my grandfather had made of her, dancing in the woods at that summer place, naked but for a long red scarf.

At Helen's wake there were six of us. She didn't have life insurance, but her family had pooled enough money for a pink silk burial gown. She looked a princess.

Nora is still not easy. After one relapse too many, she had to have her son arrested, but was desperate when his health gave out in prison. She comes for visits sometimes, listens distractedly, and doesn't follow my advice. We talk mostly of how she misses her mother and, yes, also her son, of how difficult it is to raise a teenager, and of how long and at what cost she had tried to keep hope alive on that hard ground.

I get notes, concerned that she has not come for a scheduled x-ray. I try to call, but rarely get an answer. As the phone rings and rings, I look at the stack of unanswered messages. It is late, and I am tired, but still waiting are other daughters or stepsons or girlfriends or uncles, waiting with yet another question about a failing loved one. None of the questions will be easy, and no answer will seem enough. Wearily, I wonder why these people are so difficult.

But the estrangement is brief. If death makes us equal, then partners too are all we who fret, and later mourn. I put down the phone, read the next message, and, with less effort, no strain, they once again are us.

Elisha H. Atkins, MD

MGH-Chelsea Healthcare Center; Chelsea, MA 02150





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