On Gently Laying Aside the Stethoscope

As physicians, we are often asked to assume many roles in our service to our fellow humans. Sometimes it can be hard to take a role we had not planned. At times, it can be difficult to even know what exactly we are being asked to do. A case I remember may serve as an example.

Some years ago, I met a gentleman when asked by a primary care physician to consult on an extremely ill patient in the intensive care unit. This gentleman had suffered a stroke and I was being called to evaluate the possibility that he had an autoimmune disease. During my initial evaluation, he was pleasant although aloof. He asked few questions. At the conclusion of my exam, I discussed with him my impression and offered suggestions regarding tests that would help both confirm his diagnosis and assist in management planning. He said this sounded reasonable and he completed all this without much more comment.

A few days later, I met with him before his discharge to discuss the findings and their significance. He indeed had a significant and potentially life-threatening disorder. I emphasized, however, that this was treatable and that he had a good chance of full response. Again, he seemed thoughtful and listened. I asked him if he had questions but he said no, although I had the distinct feeling that there was a good deal of thinking going on which he was not sharing with me. I outlined the treatment and ordered the initial drugs before he was discharged. I planed to see him just a few days after discharge.

He arrived in clinic on time. He always looked a bit disheveled to me but he was appropriate in his answers to my questions. When I asked him how he was doing with the medication, however, he told me he had not taken any. That came as quite a surprise to me. I asked him why not and he declined to elaborate. I was puzzled...I asked him if he had questions or concerns about the medicines I had ordered or felt uneasy about the diagnosis, etc. He said no, that was not the case. I started to feel a bit frustrated at this point. Why didn't he take these medicines? I started to expound on the possible dire consequences for him if he did not take them. He looked mildly amused but said he would consider it. Somehow, I felt it wouldn't be a lot of consideration. I set up a follow up appointment.

At the next appointment, he again arrived on time but it was clear that he was not feeling so well. The exam confirmed that things were changing. Still, he had not taken the medicines. Again, I asked him why not...again, he declined to comment. I remember that I began to feel a bit angry at this point...why was he coming to see me if he was unwilling to follow my advice? I asked him gently if there were some problems at home; no, there weren't. I knew he lived alone but had family in the area. I asked permission to contact them and he said OK. I chatted a bit about his activities...it seemed he led a rather lonely life and I inquired as to whether there was some depression that we should address. He said no, that was not the case and did not wish to pursue this. I suspected it was indeed very doubtful that this avenue would be fruitful. I decided to explore the nearby family connection...we were running out of time.

I called his family, a daughter in the area, and she actually was of little help. It seems that he was somewhat estranged from his family, largely because of alcohol use in the past. He had been well-trained and was a professional in his field. He had not worked in several years. I informed the daughter of the severity of the situation and she agreed to talk with him. I also called a psychiatrist to discuss the case...what were my options, my legal avenues to get treatment to him. Apparently, they were few. I had to admit that he was not incompetent. I pondered what to do at the next appointment. I began to think about this case a lot. It started to bother me more and more. There was something I was missing here with this man, but what? I was feeling a bit desperate.

Next appointment, things were getting gradually worse. He still didn't want to discuss his decision not to take my medicines but somehow he also seemed more at peace with this decision. I began to sense that the decision had already been made, that there was little chance of changing this. I still didn't have the faintest idea why. He had indeed spoken with his daughter. His daughter had told me that he had simply said he did not wish to pursue that treatment. I asked if there was another type of treatment he would prefer or another physician with whom he would feel more comfortable. He seemed concerned that I had brought these ideas up and I regretted it as soon as I had said them. He said he did not wish another treatment or another physician. I back-pedaled and suggested that we set appointments a bit more frequently, given his condition. He seemed content with this. I was beginning to understand. I took a deep breath.

Next appointment, I gently set aside the stethoscope, my old friend, and began an uncharted journey for which there are no textbooks or flow sheets. Over the coming weeks, I listened a lot and talked little. We shared ideas about many things...he was insightful and quite intelligent. We discussed the common threads of life. Periodically, I explored the issue of his treatment and my concern for him. I offered palliative therapy, which he accepted. Emotionally, I held hands. One visit he didn't show up. I saw his obituary in the paper. He had died at home.

As physicians, we are trained to preserve life. It is hard to do anything less than that. Often, I see physicians respond with indignation at the thought that their control be relinquished. It can be a battle of wills. Yet, at times, our patients ask us to serve them in other ways. How should we respond? How fit are we to address their spiritual journey when our science fails us, or as in this case, we are denied the use of our expertise in chemistry, physics, etc.? More importantly, will we hear them when they call us?