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.
I myself was feeling increasingly sluggish. I felt I was not providing very good care or service to my patients that day. I knew I would not finish my final 5:00 appointment until well after 6:00, at which point I would try to deal with the sea of phone messages covering my desk.
Just as I finished another chart, I sensed Joanne, my medical assistant, standing in the doorway. She had that look on her face, the one I could read immediately without her uttering a word. After working with Joanne for 13 years, nonverbal communication goes a long way. Her expression told me there was another walk-up.
I gave Joanne that look, which she also could read immediately, a silent plea for her to please deal with the patient somehow, some way, so I didn’t have to fall even further behind.
“It’s Mrs. Sidhu,” said Joanne. “She’s out there in a wheelchair. She’s moving back to India, and she stopped by to say goodbye. Can you please come out for just a minute?”
I glanced down at the elephant sculpture Mrs. Sidhu had given me. It had avoided being covered by patient message sheets and was perched precariously at the far edge of my desk, ready to fall off. Thoughts of what Mrs. Sidhu and I had gone through flashed through my mind.
I adjusted the elephant to a safer perch on my desk and said, “OK. I’ll be out in a minute.”
Joanne smiled slightly, then left to deliver my message.
Mrs. Sidhu had been on an arduous journey with me over the past several years. I had been caring for her for a decade, treating her diabetes and an episode of typhoid fever six years earlier. She was one of those patients who never felt she was in good health. Her symptoms, reported in a determined fashion at each visit, always exceeded whatever I could find in repeated workups. Mrs. Sidhu was chronically frustrated with me, feeling I was missing any number of serious diagnoses.
This dynamic continued for eight years, but two years ago, at age 56, her symptoms began to escalate. Having been through this pattern with her for our entire time together, I temporized. I tried to reassure her, as I had before. Over the next couple of months, her visits increased, and I ran a few tests, hoping this might reassure her. Nothing major turned up. She was very slightly anemic, but a battery of tests for anemia and other conditions was normal. She kept calling. She was tired. Her appetite was gone. I ordered some x-rays of her chest and abdomen and more blood tests, but they still showed nothing notable.
Then family members started calling. A second cousin, a physician who lived in Kansas City, called to suggest other tests to order. Another physician relative, even more distant, called with other recommendations. They were only a little pushy, and I was only a little annoyed.
Three months later, Mrs. Sidhu returned again, and this time she did look a bit ill. Her husband accompanied her, and he stared at me silently when I asked Mrs. Sidhu if there was any stress in her life or if she was feeling depressed.
I ordered some more tests. Her anemia had worsened just slightly. Despite negative serum and protein electrophoreses, I referred her to hematology to do a bone marrow. It was there that her diagnosis resided. Mrs. Sidhu had an unusual variant of multiple myeloma. She was started on chemotherapy, roughly four months after her symptoms began to escalate.
The next several visits were unpleasant. Mrs. Sidhu was very angry with me, feeling I had taken too long to make the diagnosis and that her prognosis was worse as a result. Her husband took me to task as well.
Repeatedly, I tried to explain that her prognosis was unlikely to be affected, and that unusual diagnoses can take time to sort out. No physician would have referred her for a bone marrow after her mild anemia first showed up. It seemed my words fell on deaf ears.
Mrs. Sidhu’s care was increasingly taken over by the hematologist, and months went by when I didn’t see her. She did come in that autumn, six months after starting chemo, for a routine diabetes check. Her chemo was not working, and she was steadily declining. At this appointment, she had little to say. For the first time in 10 years of visits, she voiced no major complaints. Her responses to my questions were monosyllabic. I looked at her face and saw nothing but depression. The appointment lasted only ten minutes.
A few months later, at Christmas, Mrs. Sidhu dropped off a bamboo elephant cart sculpture. She did not ask to see me, but told Joanne, my medical assistant, that the elephant was to thank me and give me good luck. I was surprised, both because she was Hindu and did not observe Christmas, and because it was the first present and first thanks she had given me.
These were the images that crossed my mind as I gathered myself to go say goodbye to my patient.
Mrs. Sidhu was sitting in her wheelchair, looking wan, but she smiled broadly when I approached. Her face looked more peaceful than I had ever seen it.
“I’m going home to India for a while,” she said. “Maybe I’ll come back this summer. Or maybe I’ll stay in India a little longer.”
I stood next to her, trying to smile, but inside I felt both sad and uncomfortable.
“It’s very nice of you to come by,” I said. “I have your elephant cart on my desk, and I think of you every time I look at it.” Though I frequently deliver platitudes, these words were actually true.
“Thank you for everything,” said Mrs. Sidhu. “You’ve been so kind to me and taken good care of me. I just wanted to see you for a minute before I leave. I won’t keep you, because I know how busy you are.”
As I stood there looking at Mrs. Sidhu, all I could think was that we both knew we would never see each other again. This was our final visit, and we were saying our final goodbyes. I thought to myself, how do I say goodbye to his lady? What words should I use? Does she want some kind of final closing statement? Or do we pretend this is but a temporary separation in a continuing journey?
My uncertainty was resolved by Mrs. Sidhu, who said, “This is the last time I will see you. You’ve taken good care of me, but now my people will take over. There are people at home who will watch me.” Her smile deepened, and reassured me more than any words she may have chosen. And then she said, “I just wanted to see you one last time.”
There was little left to say, and little left to do. Our journey together was at its end. I decided there was no point in trying to be profound, or insightful, or therapeutic, or wise. Not that I even could. No, there was only one thing left.
I bent down and gave Mrs. Sidhu a heartfelt hug and said, “Mrs. Sidhu, thank you for coming by. Please have a safe trip home. Goodbye.”
I think this was all she needed or expected. At least I hope so, because that was all I could find to say. I reflected briefly on how I felt very inadequate in the care I had provided Mrs. Sidhu. Though I don’t think I made any mistakes, it had seemed Mrs. Sidhu felt I kept dropping the ball. At least until today. Our brief hug ended, and it then struck me that the doctor-patient relationship can be deeper and more complex than almost any other human relationship.
I then stood up, we smiled at each other, and a few moments later our paths separated, forever.
(July 1999)