“He spiked a fever of 102.3 last night. His brain MRI is unremarkable, his CSF cell counts are inconclusive and his urine culture is negative.” I reported these perplexing findings to my Attending on morning rounds, pondering the next step in this patient’s treatment. As a third-year medical student on my medicine rotation, I was eager to begin learning the art of differential diagnosis and medical management. However, during my time on the wards, I learned not only what it takes to be a great doctor, but also what it means to be a healer.
Mr. Mitchell was an 83-year-old man with a history of mild Alzheimer’s dementia and sarcoidosis. Three days after a simple right inguinal hernia repair, he suddenly became obtunded and non-responsive. Just after his surgery, he was subsequently found to have a large lung mass. Every day, I spent time examining him and trying to get a response, but he had become suddenly nonverbal, unresponsive and unable to follow any verbal commands. I spent countless hours with his wife and three daughters, who at first remained calm and convinced that he would recover soon from whatever had caused his sudden change in mental status. Every day on rounds, I came up with more things to add to my differential diagnosis: listeria bacterial meningitis, urinary tract infection, pneumonia, carcinomatous meningitis, neurosarcoid, hyponatremia, and new worsening dementia with delirium. However, every test came back either negative or inconclusive. I desperately wanted to find the answer. I was convinced that I just hadn’t thought of the right diagnosis, but once I did, I would be able to cure him so he could go home to his family. After a week of fluid repletion, broad spectrum antibiotics and heavy doses of antivirals, he was not getting better. In the next few days, he continued to deteriorate, but I felt that I just needed to try harder. It was a race against the clock.
Each day, his wife sat by his side and held his hand. I saw her cry once, and she asked me if I thought he knew she was present. I told her that of course he knew she was there, and her presence and love was the best medicine. They had known each other since they were 13 and had been married for 67 years. She brought him a beautiful red knit blanket from home so he wouldn’t have to use the hospital blankets, and she hung a picture of their family on the wall from their grandson’s graduation.
On his eighth hospital day, Mr. Mitchell took a turn for the worse. He became hypoxic and started working hard to breath. He remained non-verbal and unresponsive. It was clear: he was dying. I walked into his room, and his whole family–sister-in-law, grandson, daughters and wife–was sitting in chairs around his bed. They, too, knew this was the end and wanted to be there for his last moments. I had never seen a person in the act of dying until that day. As I watched each labored breath, I realized that dying is truly a verb; he was actively dying. I sat down in the room, and I started talking about Mr. Mitchell with his family. We did not discuss diagnosis or prognosis, but rather, I asked them to tell me about what an incredible man he is, and to share their greatest memories. They eagerly explained that when he was just 18, he went to fight a war in Germany. He was one of the few African American solders in his WWII infantry group. However, his wife went on to explain, his greatest accomplishment and his greatest joy was his family, including his three beautiful daughters. I sat there and just listened. I expected to be disappointed in myself because I had not found the right diagnosis or the cure, but I was not. Rather, I found it meaningful to be with the family at this very fragile time.
His wife and I cleaned his face with a damp towel. Before I left, I bent down and kissed his forehead to say goodbye. His wife started to cry. She said to me, “There are so many doctors who are running around, just going through the motions, doing their job. It’s so nice to meet someone who truly cares and understands.” Before that moment, I hadn’t realized the effect I had on the family. They didn’t care about my differential diagnosis, my comprehensive H&P, or the countless orders I had put in for him, but they did notice that I cared, and that was what had meant so much to them.
When I left the room, I cried. I wasn’t even sure why I was crying, but I was embarrassed because I thought doctors weren’t supposed to cry. I quickly ran to the bathroom to dry my tears and maintain my composure. I was always told not to get emotional about my patients. I thought about that advice and realized that I would be disappointed in myself the day I stopped crying. What would that say about me? I realized that I don’t ever want to stop crying for my patients.
Mr. Mitchell taught me about the doctor I want to be, and he helped me discover a little more of myself. He showed me that medicine is not black and white. There’s not always a cure or an answer, but there is always time to be a compassionate healer. When a patient is sick, the whole family is affected. Finding the diagnosis and right medicine is only part of a cure. True healing means helping the whole family to heal. I couldn’t restore Mr. Mitchell’s health, but I could help his family in their healing process.
Ann Intern Med. 16 August 2011;155(4):273