From a Week in Practice
Am Fam Physician. 2005 Sep 15;72(6):1034-1035.
This is a momentous time for me. After 14 years, I’m leaving my current position at St. Joseph’s. As much as I love my job and my relationships here, I’m being drawn by the chance to work with another fine group of faculty and to do something I’ve dreamed of—start a magazine that will use physicians’ personal stories to look at health care and our health care system. I’ll still be seeing patients and teaching residents and will write in this column about the challenges of starting over. Luckily, my new job isn’t far, a few miles across the New York City border in the Bronx, so our family won’t need to relocate. I’m excited, scared, and also sad, particularly when I think about my patients, many of whom I’ve cared for since the early ’90s. I wrote them a heartfelt letter a few weeks ago and since then have been going over the news in person. Today, I see Lorena, a funny, 55-year-old woman who underwent a liver transplant in 1997 because of sarcoidosis. She also suffers from recurrent foot pain. “I need a new foot,” she’s said. “And while you’re at it, how about a new brain for my husband?” Today, Lorena calmly asks a few questions about my leaving—when? where? why?—and I relax, until I notice her jaw trembling, mouth twisting, and eyes welling. Ouch. Heart sinking, I reach for the tissues. This isn’t easy.
When Jessica comes in complaining of abdominal pain, my ears prick up. Jessica is a 12-year-old girl, who at age seven developed a puzzling fever that took several cultures to diagnose as a urinary tract infection (UTI). In the course of subsequent UTIs, she was found by our pediatric urologist to have severe bladder dysfunction. Now, after a long period of therapy—prophylactic antibiotics, laxatives, a bladder relaxant and, most recently, biofeedback—she’s been doing better. Still, I worry. Jessica tells me that she became weak and dizzy coming home from school today and nearly fell. She has pain around her navel but no fever or urinary symptoms. Her physical examination is remarkable for suprapubic and left lower quadrant abdominal tenderness, with rebound but no guarding. A heel strike is negative. Her urine dip shows blood but no leukocytes. The family looks at me expectantly while I rub my chin. “Has Jessica had her first period yet?” I ask. “No,” her mom answers. Jessica denies seeing blood in her underwear. I send her urine off for culture and prescribe an antibiotic, just in case. “Looks like you were right,” Jessica’s dad says when I call the next day. “Her period started after we got home. She never took the antibiotic, but she’s feeling better.” I’m relieved, and pleased that one of several guesses earned me credit for a bull’s-eye.
In my letter to my patients, I wrote the following: “It is with mixed feelings that I leave. You, my patients, often feel like family to me. I treasure the times we’ve shared, the trust and kindness you’ve shown me, and the relationship we have. I’ve felt honored to be your doctor.” Today, I’m greeted with smiles tinged with sadness and reproach. “I’m sad that you’re going,” says Estela, a melancholy 81-year-old woman whose husband died several years ago from the complications of parkinsonism. She smiles bravely and says, “if this is good for you, then we must be happy for you.” I find myself impressed with my patients’ practical strength. Many acknowledge the difficulties of trying to follow me into the Bronx, which would be a mere 20 minutes away—if only they had cars. Because mass transit and Medicaid managed care plans don’t easily cross county lines, I might as well be starting practice in another country. Ernesto, whom I diagnosed with kidney failure and then acquired immunodeficiency syndrome when he was injecting heroin 13 years ago, hugs me and starts to cry.“You’re the best doctor in the world,” he says. I’m touched and wish I could agree. I do know that bearing witness to this man’s epic turnaround—away from drugs and back to nurturing his family—has awed and humbled me.
Two weeks ago, I sent a second letter to my patients inviting them to come to the family health center this afternoon if they wanted to say good-bye. (“Please don’t bring gifts,” I wrote, “but I’m bringing a camera and will want to take your picture.”) Today, at 1:40 p.m., the first patients arrive, and by 2:30 p.m., our small family therapy room is jammed with patients, relatives, and a few health center staff sitting in chairs and wheelchairs around a small table laid out with fruit, vegetables, and cheese and crackers. I keep introducing people to one another, half expecting them to know each other already. (They don’t.) We take photos, and the chatter ebbs and flows. “Tell me about my next doctor,” Mrs. Sanchez says, and I consult my list. “I’ve assigned you to Dr. Bligh. A good doctor and muy guapo—very handsome,” I tell her. “What about me?” asks Mrs. Gerson. “Dr. Ringstad. You’ll like her. Very nice and muy buena doctora (very good doctor),” I tell her. I’m glad to hear them thinking about the future. It reminds me of an old joke, in which a wife tells her husband, “If one of us died, I’d move to Paris.” When I’m gone, I hope all my patients move on, and with the efforts of my colleagues and our new residents, I know they will.
“Change is a good thing,” a colleague said to me not long after I announced my leaving. She joined our faculty after more than a decade in private practice, so she’s intimately acquainted with the ache, and the growing, that comes with moving on. One thing that my departure has already taught me is that I often miss the forest for the trees while practicing medicine. That is, I spend large parts of office hours worrying: Am I missing anything? Doing it smart enough? Fast enough?Now, as I listen to my patients express their appreciation, I realize that our time together has been filled with gifts: the concern and care I showed them; the trust and fondness they returned to me; and the way we’ve taken root in each others’ lives. “You’ve been like a father to me,” says 75-year-old Mrs. Saunders. Like a father to her! Why, I wonder, didn’t this monumental aspect of practice enter my consciousness until now? Where have I been? Luckily, I’ll be able to keep in touch with patients via my colleagues, who will provide medical and personal follow-up. And when I begin seeing new patients, I hope to reflect more often upon the special privileges of my work. Change is a good thing, if it awakens this preoccupied doctor to his own life.
Medicine has its yearly rituals: the Pap test, the mammogram. So does family life. Today, my wife and I drive our daughters to sleepaway camp. After two years of hearing her older sister, Ariel, describe camp in nearly mythical terms (including the performance of rousing songs and elaborate hand gestures), Nikki, who is nearly 12, decided that the time had come. Her trepidation grew as the big day drew nearer, but today she awakens looking resolute. Fourteen-year-old Ariel, meanwhile, is despondent at having to leave her boyfriend behind. It’s a sure thing that someone will require major consoling on the long ride up, but who? We soon learn that separating from one’s true love is far more traumatic than the thought of kissing Mom and Dad good-bye. After the inevitable melt-down, both girls arrive at camp possessed of a fragile stability that, outwardly at least, passes for calm. We deposit Ariel and Nikki in their respective cabins, where their counselors are friendly and eager, whereas their bunkmates seem a bit disoriented. Before driving off, we make a ritual stop at the nearby post office to write the girls letters. How aptly this weekend of family adjustments and new beginnings mirrors my own professional transition and the new job that begins on Monday.
To preserve patient confidentiality, the patients’ names and identifying characteristics have been changed in each scenario. Any resemblance to actual persons is coincidental.
Copyright © 2005 by the American Academy of Family Physicians.
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