I don’t mean to be the town crier of bleakness, here, but it is increasingly hard to avoid the facts. The longer my tenure in the field of general internal medicine, the more ill and infirm become my panel of patients. The measure of my success as an internist is whether I keep my patients alive to travel further along the deeply-trodden path of aging. And lo, that way is fraught with peril: withering rose bushes whose pretty petals litter the ground but whose thorns remain pointy-sharp, greasy patches guaranteeing skids and mishaps galore, and a deepening twilight which darkens the trail ahead. The better I perform and the more people I send along that road, the further down the path they must trudge.
The profession of the general internist is so different from that of the surgeon, who wields her knife to excise disease and cure the grateful patient. Or the obstetrician, who ushers bouncy new souls into this wondrous world. Oh, how I envy the pediatrician, who finds fulfillment helping young humans navigate the comparatively easy road to adulthood. And, truth be told, I’m a might resentful of the psychiatrist, who now provides patients better living through chemistry, leaving the time-consuming unearthing of psychodynamics to me, the primary care physician, in 15-minute office visits.
So, as a general internist, wherein do I find my satisfaction?
Let’s paint this picture with precise brush strokes. Every day that passes, my panel ages collectively by almost four years. Each month that goes by, my patients as a group grow 120 years older. In the course of my practice so far, my patients have aged 30,000 years. Have I done my job, or what?
Don’t get me wrong. I’m all into patients thriving. Healthy, happy, self-reliant? I brook no issue with those concepts. They are honorable goals for the first seven, maybe eight decades of life. I strive to help patients thrive. But for an increasing proportion, thriving is a distant memory. For a steadily growing number on my panel, even surviving is a stretch goal. Mind you, it is not my intent to promote disease, despair, and disability as the lofty aim of my life’s work. But reality trumps hope and the more successful my practice, the more disease, despair, and disability I create.
Sometimes I reflect on my practice of medicine and wonder if I am at odds with the mission of Kaiser Permanente. The organization promotes “thrive” as its vision, which I’m scrambling to get my patients just to make it through the coming season. I acknowledge my professional aspirations would not make for a good marketing campaign: “Kaiser Permanente — Survive!” Can’t you just see the images on these “survive” billboards along I-680? Wheelchairs! Walkers! Bags of IV fluids cinched into the arms of ventilated patients! Wow, what a way to recruit new members. Join Kaiser Permanente and this can be your future.
Sooner or later my patients finally grasp the hard truth of what lies in store and come to realize that each visit to my office brings them closer to their destiny. “Cure” is not a word that frequents my exam rooms. In fact, I sometimes feel I should refer to my office visits as “disappointments” rather than cling to the oh-so-neutral word “appointments.” At the end of the afternoon, I reflect back on the day’s 20 or so disappointments. The next morning, I anticipate the 20 or so disappointments to come.
But let’s pause and examine the dialectic of disappointment. As I said in opening this soliloquy, I do not intend to be a bleak herald. There are very good aspects to the profession and practice of general internal medicine. Some of the greatest rewards on earth come from shepherding patients through the aging process. While no one enjoys the inexorable march into infirmity and ill health, something remarkable occurs when a patient is accompanied down that fearsome path by a physician, a doctor who can help illuminate the road ahead, fend off some of the hurtful blows, and resonate with the patient’s experience of growing old. No one should have to navigate that difficult course without a guide. Physicians in the field of adult primary care can play that role. In doing so, we may gain a trove of benefits which both accompany and transcend the reality that we physicians are here, on this earth, to help people grow as old as they should, as aged as they are meant to be, with a humble measure of dignity and grace.
Over the years, I have had myriad experiences with my aging patients which simply took my breath away There was the day I informed Mr. Gonzalez, a chronically anxious retired electrician, that not only did he have cancer, but it had metastasized and would be cured. For the first time in our 20 years together, and almost immediately, his face assumed a peaceful look. He thanked me and said how nice it had been to be friend for so many years. And there was Mr. Smithson, also dying of metastatic cancer after a long and meaningful life, who opened each of his final five office visits with the words, “I can’t complain.”
So many aging patients. So many patient patients.
Mr.s Giovanni, who shared cute stories of greatgreatgreatgrandchildren. Or Mr. Sebastian, who ran half-marathons when I first became his doctor years ago, but whose arthritis won the race. He ended up hobbling along with the aid of a walker, a hip fracture waiting to happen, expressing gratitude that I had taken the edge off his pain. I loved the chat I had with the elderly woman starting a new relationship after years of widowhood, who sought some personal and intimate advice on how to proceed.
Most profound and moving are my interactions with those patients who know we’re nearing the end of our association and who are genuinely, whole-heartedly grateful for our years together, for the deep bonds forges through trials and tribulations, and for the unimpeachable trust which underpins our relationship. There are times, in the too-brief exam room encounters, when the words unsaid are more powerful than those spoken aloud. It is during these precious and moving moments that I find my finest reward. Herein lies the magic of medicine.
Yes, my job is to further the aging process. But my profession is to try to ease the way, to seek a temperate path into an uncertain future. It is through transforming disappointment into acceptance that I can best accomplish my mission, my vision. I never achieve this consistently. Many are the patients who dwell in the land of disappointment, despite my best efforts.
But when I do succeed, the rewards can be profound. For the patient. And for myself.
So here I stand, sturdy at the the crossroad amid the yellow leaves. Each of my patients approaches, often a bit nervous, hoping I will direct them down the path less-traveled. But I chat with them a while, exploring their hopes, appreciating their fears. Soon they understand that I must direct them down the path well-worn instead. They may pause briefly, but soon they proceed, as they must, every one. I tell each that I will help show the way, and that if they are lost or scared they can always call on me. Yes, the thorns are sharp and the journey hard. But having a guide provides a measure of comfort. That, plus knowing that so many have gone that way before, and so many more will follow on. And as we talk, and if they listen, my patients will also contemplate the words unspoken. They will understand that I too will one day join them on that same path, following their same footsteps, not as a guide, but as a time traveler just like them.
Yes, my time will come. As will yours. One day we will each enter those woods, lovely, dark, and deep. And when that time comes, we will each, hopefully, have a knowledgeable yet empathetic guide to lean on when our progress falters, ease our fears when shadows cross the sky, point out the stars which sparkle through the lowering twilight, and remind us how beautiful is the last rose of summer.
(July 2010)