coda: a passage at the end of a composition that brings it to a formal close
Physicians’ days are filled with codas. These finales to office visits, hospital visits, and procedures can be the most significant, moving, and revelatory moments in our profession of healing. I am continually impressed by the power of the coda for both the patient and the physician, though this power is often unrecognized. The brief, closing moments can cover more ground and unveil more about the patient’s situation than everything that came before. The wise physician pays heed to the coda. It often provides the key to the patient’s real concerns and the true nature of the illness. It can forge or damage the trust between patient and healer.
The coda is easy to overlook. Our encounter with the patient unfolds over 15 to 30 minutes, sometimes longer, sometimes shorter. We proceed in orderly fashion through the opening movement: the warm handshake, the pleasantries, the inquiry into how the patient is doing and identifying the issues for today’s encounter. Then we move into the next stage, a more detailed history-taking. Next comes the examination, followed by the last movement: reviewing what has been found, what steps we recommend, and what to expect next. It is time to wrap things up and make a graceful exit, knowing we are now even further behind schedule for all the patients to come.
But as we get up to leave, it is not uncommon for the patient to mention one last subject, sometimes in an off-handed, dismissive way as we are headed for the door, pressed for time, with the next patient’s problems beginning to intrude on our thinking. Since we are finished with the current patient, it is easy to overlook the coda. But to do so ignores the risks and rewards the coda can bring.
The risks can be overwhelming. I still remember the 64-year-old woman who, as I was walking out the door after an uneventful physical with no symptoms presented, said, “Oh, doc, I’ve been kind of tired lately. Does that mean anything?” I reassured her and was out the door. Two hours later, she was dead from a massive myocardial infarction. Could I have anticipated this by paying attention to the coda?
Then there was the middle-aged man who glibly mentioned some chest pain as I was leaving the room. He gave me an easy out, saying, “I’m sure it’s nothing.” Why did I stope by exodus, re-enter the room, and spend another five minutes with him? I’m still not sure, but had I not done so, his left main coronary lesion would have been diagnosed post-mortem rather than the following day in the cath lab.
The comments patients make in the closing moments can be astonishing. Seemingly uneventful office visits have ended with patients telling me their only child has just committed suicide. Their mother has died. Their spouse was found to be unfaithful. No matter how far behind I am, I retreat from my exist to talk a little more with the patients who offer these comments. In the next 100 seconds, my relationship with the person on the exam table is ofen galvanized into an unbreakable bond that will last a lifetime.
Sometimes the coda reveals something the patient is particularly proud of. “My son is graduating from West Point this year,” or “My daughter just got into Harvard.” Sometimes patients say things they want me as their physician to be proud of. “You talked me into quitting those damn cigarettes. Thanks, doc.” And, “My nephew just got into medical school.” In such encounters, the minute it takes to validate the patient’s achievement or pride is priceless. I fight my tendency to toss off a brief, barely audible, “That’s nice,” as I escape through the door. Instead, I make myself return to the room, even though I often continue holding the door handle, and warmly acknowledge the patient’s success. Again, strong bonds can be built in these precious seconds. Or they can be lost. Not acknowledging the success can humiliate the patient and make him or her feel that their doctor doesn’t really care.
Sometimes the coda is a small plea for help. I have lost count of the times a 50-something-year-old man has interrupted my exit with a clearing of the throat and a, “Hey, doc,” followed by a pause. Each time this happens, I release the door handle, reach for my prescription pad, ready to write up a prescription for Viagra. This can be the most important 40 secondsin health care.
Codas are not just beneficial for patients; they can reward the physician as well. Recently, I was out in the hall after a routine appointment with one of my 84-year-old patients. WE had completed our visit and agreen to reconvene in six months. I was closing the door when I heard him say, “Hey, doc.” I paused, stuck my head back in the room, and he said, “You’re my hero.” This was a stopped all right. I returned to the room in disbelief and asked, “Mr. McDonald, what are you talking about?”
“Well, doc, I’ve been with you for 15 years now, and you helped me stop smoking. You got me off booze. You took care of my heart problem. I’m doing OK now, and it wouldn’t have happened without you.” Then he repeated, warmly, sincerely, honestly, “You’re my hero. Thanks.”
I was speechless. Here was a man from the greatest generation, a World War II vet, old enough to be my father, saying these words. Deep inside, I knew I could claim little credit for his situation. I had played the part assigned to me over the years, and he had been the sometimes-compliant patient. We’d had our ups and downs. Nonetheless, his comment made me glow inside, and it more than made up for the fact I was falling further behind in my clinic schedule.
I do not mention this vignette to toot my own horn. I am confident that everyone reading these words has had similar encounters with patients during the closing moments of a visit. Maybe the words varied, but the heartfelt appreciation was there. Hopefully, you heard the words for what they were and internalized their magic. Hopefully you turned around to acknowledge the gift as warmly as it was given.
Codas. They crystallize the profession of medicine — profound and healing moments, for patient and clinician alike.
(June 2002)