Some things happen for a reason

“We’ve got one more patient coming in,” the medical assistant calls down the corridor.

The words sting in my ears. From where I sit behind my desk, I can see the clock on the credenza: 6:50 PM. By rights, in ten minutes we should be closing up shop and heading home. The last thing I want to hear at this juncture is that I will have to stay past posted office hours to see a straggler.

“The father called at 6:15 PM,” the receptionist tells me. “He said he would be here in fifteen minutes. I don’t understand why he’s late. According to the chart, he lives in town, just a couple of streets over.”

I stare out the front window. The few remaining cars in the extensive lot are covered with snow. Despite several passes by the plough there’s still a good bit of slush on the pavement.

“The temperatures were supposed to drop this evening,” I say. “Maybe the roads are beginning to ice up.”

I retire to my office and finish the last of the charts from a busy day. I’m tired and spent. I would like to go home and have my dinner. I wonder why people always seem to wait until the last minute to call.

The cleaning crew arrives. The father and son team begins to collect the trash from the examination rooms and wipe down the counters with disinfectant. I look up at the clock and shake my head: 7:00 PM.

At 7:05 PM the father stumbles through the front door with a diaper bag and his infant son in the car seat carrier. “Sorry I’m late,” he mutters. “I just got a new car, and already it’s acting up. It quit on me twice on the drive over.”

The medical assistant escorts the father and infant to an exam room. I hear her ask him the reason for the visit. The father starts in, describing the onset of nasal congestion one week ago. Evidently, the child didn’t eat well today. He’s vomited several feedings. Perhaps he needs an antibiotic to kick the cold, the father says. Everybody else at home is sick.

The medical assistant hands me the child’s chart. “There’s no fever,” she says. “98.8.”

I open the slender file. The child is just three weeks old. The father brought him in for the congestion last Saturday. From the note it appears as though the baby might have had conjunctivitis. The father has been putting an antibacterial ophthalmic ointment in the baby’s eyes. I close the record and ease to my feet. It’s now 7:10 PM. With a little luck, I might be out of the office by 7:30 PM.

I recognize the father immediately when I see him. He was in fact a former patient in our pediatric practice, an intellectually limited young man.

“I’m sorry I’m late,” he starts in. “My car is acting up. I can’t understand it, I just got it last week. I had the baby in to see the other doctor a couple of days ago. He told me to come back if the baby got worse. He didn’t eat much today. The little he did eat he threw up. Maybe he needs some kind of medicine to help him get better. What do you think? Does he need a antibiotic?”

While listening to the father’s words, I observe the infant on the exam table. His respiratory rate is in the 80s, he’s retracting with each breath. The area around his mouth looks dusky. I place my stethoscope on his chest and count the heart rate: 180 beats per minute.

I pull the stethoscope from my ears. “I think we’ve got to get him down to the hospital,” I say. “He’s having difficulty breathing. At the very least he needs a chest x-ray and some oxygen.”

The father looks at me and then at his son. “He wasn’t this bad earlier today,” he says. “Honest, he wasn’t.”

I place my hand on the father’s shoulder. “Little babies can get sick quickly over a short period of time,” I tell him. “You did the right thing bringing him in.”

“I don’t think I can take him to the hospital in my car,” the father says. “It quit on me twice driving over here. The roads are slick—”

“Don’t worry,” I tell him. “We’ll get an ambulance to take him down. You can ride along with him.”

“Can I call my mother? Maybe she can meet me at the hospital.”

“Go ahead. We’ll arrange for the ambulance in the meantime.”

I walk out to the front desk and ask the medical assistant to make the emergency call. Our receptionist turns beet red.

“I’m so sorry,” she says. “If I had known he was going to be this late…”

“Forget it,” I say. “If you hadn’t had him come in when you did, he might not have lasted the night.”

A new used car that is on the blink. An intellectually limited father. Icy roads in the aftermath of a winter storm. A belated telephone call at eventide.

Sometimes a string of events portending disaster can lead to a satisfactory outcome.

The ambulance arrives to collect the infant and his father. Soon they disappear into the night. The cleaning people have taken out the last of the trash.

I turn out the lights, step through the side door into the chilly air and throw the deadbolt.

Some things happen for a reason, I think, as I slide in behind the wheel of my car. I hit the switch, and the engine roars to life.

Literary medical weblogs

Dear J.B.,

Your comment on my blog posting The stories we tell came in just as I was re-reading the first chapter of James Joyce’s Ulysses on the front porch.  Previously, I hadn’t run across the Joyce line you quoted about all novelists having only one story, which they tell again and again; but it certainly rings true.  Hemingway said that in crafting a piece of writing he could “cut the scrollwork or ornament out and throw it away and start with the first true simple declarative sentence” he had written. In my book, anyone who takes writing seriously has to start with a desire for truth and the stamina to pursue it, no matter where it might lead.

You also mentioned Dr. Robert Coles.  I too was fortunate to hear Dr. Coles speak two decades ago at a conference on medicine and the humanities.  I recently read Handing One Another Along, a collection of lectures from an undergraduate course which Coles taught at Harvard on literature and social reflection. (The title of the book comes from a line in Walker Percy’s The Moviegoer, one of Coles’ favorites.) Dr. Coles, of course, is an excellent resource for many good works on medicine and literature as well.

Decades ago I got interested in the idea of using story as a vehicle to explore the doctor-patient relationship.  Throughout my medical training (I am a practicing physician assistant) I was appalled at the insensitivity which many clinicians demonstrated in dealing with patients in their time of suffering.  I struggled to understand the source of this coarseness in bedside manner.  Had these clinicians always acted this way, or through years of training had their medical education squelched whatever empathy they might have once had?  Was this perhaps a defense mechanism they had developed over time to shield themselves from the suffering that they witnessed daily in practice?  If so, what could be done about it?  (It certainly wasn’t helping the patient to heal.)  Could empathy be taught, or was it an innate trait possessed by only a minority of individuals who opted for a career in medicine?

As I began to craft narratives of patient encounters, I discovered that the act of writing itself enhanced the way I related to patients.  Somehow writing the story down served to hone an empathetic response.  It also served to help me deal with my own emotions, guilt and grief which I experienced in encounters with patients.  As my perspective developed, I was fortunate to find several like-minded souls in the social ether along the way.  Over the years I worked with other colleagues to create several online sites which continue to function as forums for clinicians and patients alike, Cell2Soul and Dermanities among them.  After reviewing my book Patients Are a Virtue, Dr. Howard Spiro asked me to consider submitting a monthly piece—“Notes from a Healer”— for the Yale Journal for Humanities in Medicine; and I was also invited to write a bimonthly Humane Medicine column for the Journal of the American Academy of Physician Assistants.  I established this weblog to serve as a repository for my writings.

My hope has always been that with ongoing exposure to these sorts of narratives, more and more medical colleagues might come round to recognizing just how intimate and profound the doctor-patient relationship truly is, and come to an understanding that there is much more to the art of healing than just closing a surgical incision, dressing a wound or writing a prescription.  Medical practice is after all the stuff of life; and because literature historically has been an attempt to capture the essence of what it means to be alive, it is small wonder that the two complement each other so beautifully.  As you so aptly put it, medicine and storytelling go hand in hand.

None of us can be all things to all men; but we can certainly make some fumbling attempts to alleviate suffering in the world and bear one another’s burdens as best we can.  As Rilke so aptly put it, perhaps if we learn to love the questions themselves, we can one day live on into the answers.