The Practice of Remembering


Facing a patient’s door, my hand poised to knock and enter, I felt a hand on my shoulder. I turned to face an emeritus professor. He said to me, “Practice what you will say before you go in. They will remember every word you say years from now.” I, a third year medical student, solemnly nodded in agreement, paused, and formulated my delivery. Then I went into the room to give my three year old patient and her family the test result: good news--she did not have strep throat! The encounter went well, the news hardly dire, surely by now long forgotten by the family. Years later it is I who remembered the words of that professor. What if the news had been worse, I wonder, more akin to the type that my adult patients now hear from me and my medical team: “You have cancer,” or complications of diabetes, or a heart attack, or little time left? Perhaps even more memorable than the presentation of a diagnosis itself is what you say and do for patients and their families in its aftermath.

Patients often sense their prognosis, pre-empting the medical team’s delivery of bad news. Mrs. S knew her illness well; she was an expert in angina. The pain had been occurring more frequently over the past month. She did not even need to tell her family when it was coming on, because her daughter would see her stop and hold a hand to her chest. Clearly, calmly, she refused all procedural intervention, accepting medicine alone. With tears in her eyes, the daughter translated from Spanish what I already understood: “I am ready to die.” With tears in her eyes, the daughter whispered to me, “I am going to try to convince her,” but her mother had already made a decision about her illness. I reflected on her options, but there was little that I could do to improve upon her already optimized regimen. Ultimately, it was not the patient who needed me at the bedside, but her family, in crisis about what to do next.

The stress of serious illness evokes strong emotions in patients and families. I have seen overwhelmingly beautiful unification of families, as well as overwhelmingly negative reactions that unmasked tension, revealed agendas, and exposed long-standing conflicts. Patients’ best interests sometimes get lost in the whirlwind, especially when they are unable to speak for themselves. I recall a dying patient who, at the eleventh hour, was the center of a battle for the title of health care proxy, with brother pitting against brother in a futile argument about what care to give or withhold. The situation deteriorated daily, as the medical team held many family meetings to focus attention on the patient’s continuing care, until he died. As distressing as the situation was for the family, it was equally disturbing for the medical team, thwarted in our efforts to enact a rational plan. It raised an interesting question--who supports the medical team in these types of scenarios? Our colleagues do. Other physicians from the Ethics Committee heard the case, offered observations, appreciated the complex emotional arguments, acknowledged the frustration of the primary care providers. Formal peer involvement in difficult decisions is affirming. Interns try to support one another, but we find ourselves working alongside each other in our universe of notes and checkboxes, barely stopping long enough to trek across the hospital for lunch. Occasionally we pull one another aside to vent, then continue on. While patients and families rely on us for reassurance, we rely on each other. The long-running joke about internship is: “What can I do except replete K and Mag?”

The answer is: much more. Axel Munthe, physician to the Swedish royal family and contemporary of Charcot and Pasteur, mused in his memoirs about his early years in practice: “What is the secret of success? To inspire confidence…where does it come from, from the head or from the heart?” Likely, it comes from both.

In truth, patients and families do not distinguish among members of the team when seeking emotional support, and sensitivity can establish a bond as much as status. A tearful patient, in pain, ill and scared, can derive comfort from a familiar face at midnight. While patients may not always remember our words in times of stress, they will remember how you made them feel. At the end of a busy day at the Faulkner, I looked into a patient’s room before going home. There he was, sitting in the dark, twisting his sheets, looking extremely anxious. He always knew my face, but never my name. The encephalopathy from his heart failure was getting worse, and he was going to inpatient hospice. He told me that his estranged daughter had come that day to see him. He looked at me and said, “Tell me again what you said yesterday that made me feel better.”

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January / February 2006