After close to 20 years of practicing internal medicine, I have a reasonably sound knowledge of the work done by internists and family medicine physicians. I am also very aware that practicing medicine is not a solo activity, but a team event requiring the expertise of many disciplines. As the years go by, I grow ever more impressed with the unique and interdependent contributions made be all members of the team.
Professionalism, n. The status, methods, character, and standards of a professional.
We physicians are all members of the medical profession. We are not members of a medical club, a medical special interest group, or a medical fraternal order. As members of a profession, we are expected by society — not to mention each other — to act like professionals. This expectation is simultaneously a burden and a badge of honor and grace. To comport ourselves as professionals, we live by a code of conduct loftier than that which governs many other honorable fields of work. For clinicians in the medical arts and sciences, this is our blessing and our curse.
When my final patient of the week came in on a Friday afternoon in May, I was exhausted. It had been a long week with too many patients who were much too sick. It did not help that spring had not yet arrived in Vallejo, California. Clouds and fog clung to the land with gritty determination.
It came down to one last patient, Kenneth, a 43-year-old intellectually disabled man who lived with his mother. I had taken care of Kenneth for 10 years. He was massive, 6 foot 3, and he carried his 300 pounds close to the earth. Despite an intimidating appearance, he was a gentle man of few words. During a decade of taking care of him, I had never heard him say more than an occasional “yes,” “no,” or “fine.”
One of the most important, yet most difficult and most mysterious tasks we face as physicians is helping patients and their families approach an impending death. No matter how much practice I have had carrying out this role, it still takes every ounce of emotional and professional reserve I possess. And it is never routine, never the same, from one patient and family to the next. Unlike the management of hypertension or diabetes, here is no practice guideline to follow. For the physician, it takes equal measures of empathy, sympathy, and objectivity, leavened with ample doses of wisdom and intuition.
It was a Wednesday, early afternoon, and I was running 25 minutes behind. Actually I shouldn’t call it running behind. More accurately, I was creeping along, 25 minutes behind. I just could not keep up. Every patient had more things on his or her list than any human doctor could possibly deal with in the time allotted. The tide of patient messages coming in from the Call Center was rising steadily, green message sheets washing over my desk. In addition, walk-up patients flowed in all day, a stream of people unable to get through on the phone, people so desperate to connect with their personal physician they were willing to risk a long wait in the waiting room.
Physicians are commonly exposed to events more unusual and heart-rending than the most inventive Hollywood screenwriter could possibly devise. There are days when I think back over the stories patients have told me, the crises and turning points I have witnessed, and I can hardly believe they actually happened. One such episode took place several months ago on one of our hospital wards. Let me say in advance that you will find this story hard to believe. But I vow, with one hand on my Harrisons’ medical textbook, that what you are about to read did actually take place. Exactly as I will describe it.
Deep inside the human brain, in crevices and channels invisible to MRI scans and high-resolution CTs, lie reservoirs of memory that never run dry. They may overflow occasionally in a current of tears of happiness or sorrow — sometimes in a trickle, sometimes in a torrent — these subcortical pools are invariably replenished from uncharted wellsprings even deeper inside the brain, in regions known only to a few. After two decades practicing medicine, I am still amazed that no passage of years, no accumulation of decades, diminishes the freshness of this water. It is always clean. It is always clear. And it is timeless.
Sometimes the challenge is too difficult. Sometimes there is less than nothing a physician can do to help his or her patient. Sometimes it is best to hoist the white flag and walk off the field. One morning in clinic several years ago brought this truth home with a hammer.
It was a Wednesday morning in April. Spring was two weeks old, but you would not know it if you looked outside. Rain, morning fog, a chill wind off the bay. I drove into Vallejo the back way that morning, on Lake Herman Road, sipping my French Roast, gearing up for the day.
Physicians are supposed to be healers extraordinaire. It is our burden and our curse. Society holds us to lofty standards. We are expected to regularly perform miracles, or at least to pull reasonably healthy rabbits out of somewhat tattered hats. And do so with compassion and consistency. And to perform this role for several decades of our lives.
For over three decades, I practiced adult primary care medicine in various settings in California. I worked in a U.S. Public Health Service clinic, an Emergency Department, two different medicine departments in Kaiser Permanente, and a community clinic in Vallejo, California. I retired from clinical practice in 2016.
Practicing medicine was never quite what I expected when I went to medical school. During tens of thousands of patient interactions, I often found myself surprised — surprised by what patients were saying and experiencing, surprised by what my colleagues were doing, and surprised by my own reactions to patient encounters.
As I was going through this process, I decided to write about some of my experiences. Many of my reflections were published in the professional staff newsletter of The Permanente Medical Group in Vallejo. I recently re-read these pieces, and in doing so I recaptured the surprise and the evolution of my understanding of the doctor-patient relationship.
This website contains many, though not all, of the articles I wrote over a 15 year period. The intended audience at the time I wrote them was my fellow clinicians, but I think my reflections may also help others understand a little better what is going through the mind of their personal physician. All of the stories are true. In every case, I have changed the name to protect the privacy of the patients I am discussing.
Some of the articles obviously reflect a different time than the present, such as references to economic crises, watching DVDs, and other phenomena. To place each piece in context, I have included the date it was written at the end of each one. But the observations made during these earlier years still reverberate today.
I hope you enjoy reading these, whether you’re a clinician, or a patient, and I welcome any comments or feedback. Thank you.
Richard Fleming, M.D.
Benicia, California