“So I heard you’re leaving…”
“I am.”
“When?”
“My last day is February 1st.”
C shrunk into himself as he centered his gaze on his worn hands. After 10 seconds of silence, he finally sighed and looked back at me with eyes that hadn’t known true rest for the last 6 months.
“It’s hard to start over, you know? I don’t know if I can tell someone our story again.”
Nodding my head, I looked over at his wedding ring and felt a familiar pang of regret.
“There’s a lot of history here, C. I understand why it would be difficult to go through this again with someone new.”
“It’s sad for me. You were R’s last doctor. You know, of all the doctors that she went through for her myeloproliferative disease, bone marrow failure and chronic pain – R liked you the most.”
Had she really?
Our story
Over the three years I had taken care of C’s wife R, our relationship had been defined by cancellations and no shows. I recalled the times I “forced” her to come in for an appointment so she could get her medication refills. The cajoling to get labs that she ultimately never had done before her stroke.
I thought she would’ve resented me toward the end, especially when I had told her what we were doing was not optimal care, nor was it safe.
Even after R’s premature death, her story continued on for C and I.
Into the weekend after her death during which I agonized whether or not I had done enough to help prevent the stroke that took her life. If my best was truly good enough.
The first time I saw C in my office after her funeral when everything spilled out despite his baseline stoicism, tears in his icy blue eyes as he told me of the rose plants he couldn’t bear to look at. Purchased to build the garden of her dreams, now wilting away like the future he had envisioned for them. But he couldn’t find the motivation to either water or throw them away.
How the horror of her inability to register him when he found her sprawled out and half paralyzed on their bathroom floor still sent after shocks unexpectedly when he’d brush his teeth. But he couldn’t push out the memory, it being the last time he would ever see her awake.
How the sound of R drowning in her own secretions after she was extubated haunted his dreams and waking moments, occurring randomly during periods of silence – driving a car, sleep, a lull in the chatter.
How he stayed by her side because he couldn’t imagine the thought of his wife of 30 years dying alone in a cold ICU room. Even after the warmth of her hand dissipated into the frigid air, still he stayed. Because he knew once he let her go, he’d have to go and face the world.
Alone.
Life goes on…
Even after 6 months, C continued to relive the death of his wife R as if it just happened yesterday. But he would never again let me peek beyond his armour like he did that first visit after R’s death.
Instead, as a counselor, he’d describe his “grief reaction” academically, using all the right words to shield us from the emotion of his loss. The term passive suicidal ideations would drop from his lips as if it were common place to speak of your wish to no longer be here. He calmly told me of his daughter’s concern for him, compelling her to put up the suicide hotline number on their fridge and program it into his phone.
This was his new normal.
“I guess it’s for the best that you’re leaving, Dr. M. It’s a good reminder for me that life must go on.”
Hollow words of encouragement, recited from one of his scripts no doubt.
How odd to feel the need to support my decision to leave, knowing this would leave a vacuum where one of his support systems once stood. Life continued to move around him, but C’s grief held him paralyzed in the place R left him.
Again, my gaze landed on the gold wedding ring resting loosely on his 4th finger, a sign of his alarming weight loss from his lack of appetite. How long would this ring tether him to this place, to this grief?
You can’t stay here with him, M. This is a story you won’t be able to see all the way through.
“Life does go on. I hope in time you’ll allow yourself to rejoin it. Not just for your daughter or for your sons, but for you, C.”
Keeper of stories
Sitting down to review my progress note at the end of the day, the inadequacies of my handoff to his next provider blared off the screen.
History of Present Illness:
F/u depression – still struggling with death of wife. Seeing counseling qweek. Passive suicidal ideations, no specific plan, no homicidal ideations. Has safety plan. Tolerating cymbalta – helping with neuropathy as well. Poor interrupted sleep, avg 4 hrs/night. Poor appetite – lost 30 lbs so far. Poor motivation, +anhedonia. Returned to work, feels he can complete his tasks.
Physical exam:
General appearance: Well groomed, good eye contact, appropriate speech and thought content, flat affect.
Assessment/plan:
1) Depression – uncontrolled, declines changes in cymbalta today. Trial of trazodone to help with sleep. F/u in 4-6 weeks. Reviewed safety plan, esp with his passive suicidal ideations. Continue counseling.
Struggling with death of wife, as if this fully wrapped in the last 6 months of hell C had been living in.
Flat affect, as if these two words could adequately describe the emotional detachment he was experiencing to help him get through each day.
Lost 30 lbs, like this fully painted the picture of watching this man waste away in front of me, that with every hand gesture the last physical tie to the love of his life threatened to fall off his finger.
Our story would never come through in these office visit notes.
C will never again be able to share the story of R’s last days with someone who took care of both of them.
He will never be able to take comfort in our shared memory, keeping R alive beyond her physical presence here on earth.
But I’ll keep them alive here.
When my best wasn’t good enough, I can still do this.
***
Photo of the moon reflecting off Lake Merwin, WA, taken from the inflatable kayak I made my husband J row to the middle of the lake so I could take this perfect shot!
For more photo adventures including our upcoming New Zealand trip, follow me on Instagram @reflectionsofamillennialdoctor
This is so sad. I’m really tired right now so prone to teary eyes and I just felt my heart drop out at the thought of having this man’s experience.
Sharing in people’s grief like this must be utterly exhausting.
Nearly all the kids I care for get better. The worry and fear is transient and happy diacharges await most making it all a lot easier.
But being part of this suffering…..
The suffering is intense. I had initially thought about dropping my peds practice altogether when I was nearing the end of residency (long story), but I quickly realized I needed the healthy kids to brighten up my day.
Primary care is hard in that you see your patients’ suffering play out over time, rather than the one time encounters in the hospital. It’s hard to keep those emotions from coming home with you… I mean, clearly I fail at that.
Excellent post. As a PCP (Family Doc), I understand exactly about what you are writing here. It is both an enormous privilege to see patients in their moments of need, and also a burden. I try to remind myself daily of this honor. Sometimes the weight of these encounters does really hit you though. Keep up the good work, no matter where you go next!
Thanks for the words of encouragement! You’re absolutely right – it is a privilege and a burden. When it gets too heavy, I have to reframe things in my mind and remember that my emotional response to their suffering can’t even compare to the grief my patients experience. It puts things in perspective for sure.
I honestly don’t know how you are able to handle all these longstanding relationships that you have developed.
One of the benefits of radiology is I have this built in buffer between patient and me. It is much easier to read something bad on an imaging study when you have no personal tie to the patient. Front-line docs have to deal with the breaking of awful news, etc.
These connections you have made clearly demonstrate what kind of doc you have been to your patients. Transitions are hard on both sides of the patient-physician relationship. Hopefully both can recover.
I’ve certainly had a lot of patients cry when I’ve told them I’m leaving my clinic. It’s bizarre, this whole leaving thing. You don’t really realize how much you’re appreciated until you tell people you’re leaving!
It has been difficult essentially breaking up with some patients, but for the most part, my patients have been understanding and supportive, unlike other breaking up stories I’ve read about.
It’s made this transition harder but sweeter than I thought it could be.
M,
Oh man, as you can imagine I have a hundred thoughts on this. As Sean noted above, it is burden and an honor. The fact that it is an honor doesn’t make it any lighter. Often the simplest things are the most difficult. I think doctors like to try and design byzantine solutions to problems because the complexities obscure the hard reality that every patient we see will eventually die – we are bound to lose if death is our stated enemy.
Sadly, so much of our time in medical training is spent accumulating knowledge, and so little spent accumulating wisdom. C needs comfort and wisdom, and we can always give what we have of those two commodities.
One of the most helpful things I learned in my grief was that you NEED to feel bad. It is right and proper and part of the process. Anesthetizing that emotion robs the person of their grief, which is to deny the love they had for that person.
Don’t beat yourself up about C having to tell his story again. I am sure it will be hard for him and I am sure he fears it. But part of coming to terms with loss is the retelling of the story, the building of a narrative that allows for healing and continuing to live. Because eventually, as you retell and retell stories of that person, the love returns to the telling and starts to make the pain smaller.
I love that. I hope in time he will be able to move past the telling of his loss and start reliving the decades of life they had together.
I tell people all the time that they need to sit in the discomfort (another Brene Brown quote I steal). We no longer find pain acceptable though it is a universal experience.
Many people want to just numb away all the hard emotions, but they are so essential for growth and future understanding of ourselves and the human condition.
Attending Physician. Attend from Latin attendeo literally to hold onto, more primitively derived from teneo to hold or possess. The job isn’t to be “good enough” it’s to be there, to allow yourself to be possessed. Yours is not resolution, it’s to encourage the process to manifest. In your case you can no longer be there because it’s untenable, there’s that root again. Do not be confused, It’s your job to attend, it’s C’s job to heal. Sometimes healing is hard.
I often tell my patients they do all the hard work, I just direct them in the path they should go.
It’s their choice to take it.