Dr. Sanders had been dying a long time. Bald and infected, quiet and cachectic, he was getting his life in order. We were friends. He was dying with a calm strength, as if his dying were part of his life. I was beginning to love him. I began to avoid going into his room. "I understand," he said, "it's the hardest thing we ever do, to be a doctor for the dying." Talking about medicine, I told him with bitterness about my growing cynicism about what I could do, and he said, "No, we don't cure. I never bought that either. I went through the same cynicism— all that training, and then this helplessness. And yet, in spite of all our doubt, we can give something. Not cure, no. What sustains us is when we find a way to be compassionate, to love. And the most loving thing we do is to be with a patient, like you are being with me." -Samuel Shem, House of God
high plains doctoring
The other day I was out on the High Plains, doctoring. In this particular location, the ED isn’t very busy, so I also cover a walk-in clinic at the same time. Usually, this is standard urgent care type stuff.: kids with fevers, ear infections, sinus infections, headaches, bronchitis. Occasionally, I get a follow up from some other practitioner and I have to piece together what was going on, what the plan was, and what is going on now.
I looked at the schedule: follow up rash – not getting better.
This particular patient received one opiate medication as a refill accidentally instead of her usual one and she had developed hives from it (a known personal reaction, apparently). She completed course of montelukast, prednisone, and H2 blocker about 10 days ago and got her opiates straightened out. Initially, she improved, but once she finished the prednisone, she continued to get daily itchy, red, urticarial (hive) rash. It was temporary with no discernable trigger. She did not have a rash in the visit.
Normally, this would be pretty robust hive regimen and, for a single exposure, should have taken care of it. She had no known other exposures or new foods/soaps etc. So, I asked her about stress. I have already seen a few cases of stress urticaria in my short career. People are generally much more willing to talk about stress in their lives than their “mental health” or “anxiety.”
Critical Access Hospital Medicine Truth #1: You are more likely to find artisanal kimchi on the High Plains than adequate mental health resources.
And the flood burst forth! As it happens, she was nearing the 1 year anniversary of the murder of her grandson with whom she was very close and whom she raised as her own child. On top of that, news was slowly coming to her about when the trial would start and, like all of these bureaucratic occurrences, it was start-stop.
Had she seen or talked to anyone about this over the last year.?
Are interested in counseling?
We discussed places for counseling – there is only one mental health service in this area – an hour away – and they have a bad reputation in this community, so she wasn’t interested.
We discussed a pastor/clergyman, this was a possibility. Her grandson had been close with a local pastor, I encouraged her to talk to him about her grandson.
Grief is not a disease, it should not be anesthetized away.
And then she began to talk to me about her grandson, she told me stories, what he was like, how he cut his hair. This is where the “just being with” can be strong medicine. I cannot do anything to bring her grandson back. Grief is not a disease, it should not be anesthetized away. It is a necessary process and part of life. But it MUST be witnessed.
So, I sat and listened – intently. I probably didn’t say a true word, just nodded, for at least 5 minutes. Try truly listening to someone for 5 minutes. It feels unnatural. It takes practice and intention. Doctors are terrible at it – there are studies to prove it. She cried. I didn’t try to make her feel better, those who are grieving need to feel the sadness at times. I was simply being with her while she felt it.
good doctoring can be a drug
After she had told me what she needed to tell me – again, I had never met this woman before – she thanked me for listening. I recommended she meet with the pastor and talk about her grandson and gave her a prescription of cetirizine, to see if that helped – knowing that what she really needed was more people to bear witness to her grief and help her feel it, in a healthy way.
Today, I was able to be that person, because I don’t have productivity targets, because I am payed by the hour to simply “be” at the hospital and do what must be done. That is not the norm in our system.
Even in my current situation, it is simply possible. It is neither encouraged nor supported. For those of us who try to help people heal through our doctoring, that very act of “being with” is now an act of rebellion. “Being with” ill and suffering people, when done frequently enough is now a fireable offense in the American Hospital-Pharmaceutical Complex – a.k.a.: not meeting productivity.
I emerged from that room cloaked in her grief. For a short time, I had wandered the wilderness with her. It felt meaningful and worthwhile; still, I was drained. I had a moment of gratitude, because I hadn’t had to choose between “falling behind” and “being with.” I had the time and energy to give to her and gave it freely, not begrudgingly.
Sadly, this is not included in the “standards of care” in clinics around our country. As I got into my car to start the lonely drive home, I grieved for all people, patients and doctors alike, who are routinely wounded by our system.