With Appreciation

I thought this was a truly special story and wanted to share it.

If only we had alot more Drs. like this.

A Piece of My Mind

Vol. 303 No. 18, May 12, 2010

With Appreciation

Ram Y. Gordon, MD
Flourtown, Pennsylvania
ram.gordon@gmail.com

JAMA. 2010;303(18):1790-1791.

I was in practice only three months when I met him. I had just finished my cardiology fellowship and, insecure about my lack of experience, strove for a serious, professional demeanor. My tie was straight, shirt pressed, white coat starched and buttoned. Above all, I sought to establish and maintain the boundaries of the patient-physician relationship.

"Mr M is an 82-year-old male with hypertension, hyperlipidemia, and chronic Lyme disease who presents with dizziness." His blood pressure was high and his ECG showed an asymptomatic atrial tachycardia. His stress test revealed ischemia and I referred him for cardiac catheterization.

He wrote me a note:

I am clear that you recommended I go ahead with the procedure. I "heard" that and paid attention. Yet I am making the decision not to go ahead based on what I feel I can do right now. I value and trust and feel comfortable with you, professionally and personally, and hope you will not write me off because I could not do what you recommended I do. I need to count on you for ongoing advice, expertise, help, and perspective. I will endeavor to be a good patient even though this decision will seem to you a mistake on my part. Yet I feel right about this decision.

I was surprised by his choice and was touched that he had written me with such eloquence. It was the first of many letters I would receive from him.

Mr M eventually acquiesced and underwent catheterization, which revealed coronary disease. We elected to treat it medically. Shortly thereafter, a letter arrived:

As has happened each time, I left you yesterday with added confidence, trust, zing, and a feeling that things-are-going-to-be-all-right. I know the cautions, but I also know the feeling and I am grateful to you for it.

Several months later, another note read:

I look forward to my appointments with you. Our conversations are good for my morale and good cheer, as well as my physical health.

Fifteen months after his initial visit, his blood pressure and lipids were controlled. His supraventricular tachycardia, which we called his "friend," as in "your friend was here, but now he's gone," had not affected his left ventricular function. He had chronic kidney disease and his legs were occasionally wobbly, but he otherwise felt well. A brief note from him read:

As you’ve known for quite a while now, I look to you with confidence and trust, an ace pro who cares and heartens, someone who is good news in this world.

Several months later, after an inpatient stay for a respiratory tract infection, he wrote:

I like reminding you of how much I value and honor your genuine commitment, the feeling you give of really seeing and hearing and caring. It's the other end of perfunctory. I am grateful you chose the career you did, and I, among surely so many, are grateful to be "in your light."

Mr M always wore a suit, even if our appointment was the only one on his agenda. His words were measured and he spoke in a deep baritone, as if he were giving a lecture. He had a long and distinguished career as an educator, teaching English at a local high school before becoming a nationally renowned advocate of teaching reform. He had published almost 20 books and had been featured in Time magazine. He reminded me of John Keating, the inspirational English teacher in the film Dead Poets Society. I looked forward to his appointments.

One day, he asked to learn more about me. I felt uncomfortable. He was my patient, not my friend. Our relationship, while cordial and warm, was one of physician and patient, and I was fairly certain that this line should not be crossed. But this request, from this particular patient, felt somehow different. On his next visit we discussed his stable cardiac disease and then spent 40 minutes talking about me. He was an expert interviewer and sought details of my life, my interests, and my choice of medicine as a career. I let him in.

I told him about my blue-collar Pittsburgh roots and the influence of my father, an ophthalmologist, who was the first person in his family to go to college. I told him that, like all children of physicians, I felt a constant unconscious pressure to go into medicine and was unsure of that decision until I saw patients with my father when I was 21 years old. On that day, I fell in love with the patient-physician interaction, and the marriage of science, art, and interpersonal relationships that defines clinical medicine. I told him about my mother's nurturing and about my gold-hearted grandfather, who should have been a social worker, but instead pumped gas for a living. I told him about meeting my wife in college and about my three children. When the conversation was over, and other patients were waiting, we parted. I felt that I had shared something special, something of myself, with a "friend."

I received a handwritten note several days later:

I have played through that wonderful conversation we had again and again in my mind—it's the scene from a joyous movie—us there in your office, you visiting with your father's patients for the first time, the extraordinary relationship with your grandfather and mother, your clarity from each, in what your work was going to be, and your joy in it. Often, people are moved most by stories of sadness or frustration or struggle. What was so moving to me about that conversation was that it was a story of extraordinary happiness. You were and are blessed, and so are the many of us who visit your orbit.

As a physician, I have always felt an obligation "to try and reach" every patient. Now, with Mr M, our relationship had grown closer.

Thereafter, his appointments became joyous reunions. Neuropathy had affected his fine motor movements, and I helped him button his dress shirt and adjust his tie. We would part with a hug, and his visit would lift my spirits for the rest of the day.

Although he was modest, I eventually persuaded him to share more about himself. He had a son and daughter, and two beloved granddaughters. He lived locally but had been born in his parents' bedroom in New Hampshire. He was valedictorian of his class and a champion tennis player in high school and had majored in French at a top liberal-arts college.

And, early in our discussions, it became obvious that he loved classic films. One visit, we discussed Frank Capra's It's a Wonderful Life, one of my favorite movies. He nonchalantly mentioned that he and Capra were good friends, and we talked for several minutes about their relationship. A few days later The It's a Wonderful Life Book by Jeanine Basinger was waiting for me on my desk. In it, the inscription read:

To my distinguished cardiologist, princely fellow, valued encourager, and friend. Like George Bailey, you are "the richest man in town."

I once mentioned that I shared a birthday with Fred Astaire and that my 5-year-old daughter loved his classic film Top Hat. Several days later, the complete Fred Astaire DVD series arrived on my desk with a warm note. Other movies followed and with each, a note highlighting some of the classic scenes, dances, and songs. Although I was deeply moved, I begged him on several occasions to stop giving me gifts. He insisted that it gave him great joy to think of me watching some of his favorite movies with my family. I felt he was sharing part of himself with me and accepted the films, knowing he would not take no for an answer.

Recently, I saw him for the final time in my office. A note followed:

I wonder how many people walk out of an appointment with their doctor feeling healthier, happier, more affirmed, more zesty, than when they went in. I look forward as much to the conversations—they are pure gold as far as I’m concerned. I am grateful I know you. With appreciation, Mr M.

Two months later, he developed a fever and chills but delayed going to the emergency department so that he and his wife could finish watching The Ghost and Mrs Muir on a Sunday afternoon. He was admitted and quickly transferred to the ICU. His last words to me before being intubated were "There's my fine, princely fellow." He spent the final two weeks of his life sedated and on hemodialysis. Finally, his family could bear it no longer and withdrew care, giving him the peaceful and dignified death he deserved.

His death hit me like a ton of bricks. I felt as though I had lost a grandfather. I was his physician, and his cardiac issues always came first. But his office visits, telephone calls, and letters were special gifts. I could not deny their importance to me. My medical training had imprinted on me the principle that evenhanded distance is the appropriate relationship between physician and patient. I wondered if we had crossed any lines that reduced my medical objectivity. Had I served him well as his cardiologist? Had I become too close to a patient?

Ultimately, I found peace in the realization that medicine is an art and that interpersonal relationships are at its core. Mr M was an exceptional person. To deny his proffered "friendship" would have been to miss out on an amazing relationship with a fellow human being. Understanding his nature also made me a more effective physician. On some level, I used these insights to build trust, gain his approval, and improve his adherence to a complicated medical regimen. His survival as a patient was built partially on his belief in me. I never met him socially nor did I share any activities with him outside the professional office setting. Nevertheless, I was deeply moved when his family invited me to sit with them during Mr M's memorial service. Shortly after his death, I received a beautiful bouquet of flowers and a note, written in an unfamiliar hand:

Dear Dr Gordon,
How do you tell someone they make a life difference to you?
You are, and have been, such a "special" light in our lives.
Please know that Mr M and I love you dearly.
Sincerely, Mrs M

With Mr M's passing and my reaction to it, I felt compelled to address a question: What did this relationship mean to me? The answer did not come easily and required some earnest soul-searching. In the end, I realized that his many medical problems challenged me to grow as a young physician; his remarkable character and life story inspired me to grow as a person.

Acknowledgment: I thank Jerold, Elizabeth, and Assaf Gordon and Rachel Ledewitz Gordon for their thoughtful comments and review of this essay. I am also deeply indebted to Mrs M and her family for their kindness in allowing me to share Mr M's story.

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor

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