More than 20 years ago I moved back to my home town to take up an internship in a large teaching hospital. Although I had grown up in the community, the medical system and the hospital were strange to me. Tests were ordered differently from the way I'd become used to in my training so far, and the roles of the nurses and residents were somewhat unexpected. I was frightened and anxious. I felt inadequate, as though I weren't up to the task of being a physician, and I was bewildered by all that was happening around me. About three weeks into this turmoil I met Roy, a 71-year-old farmer from a nearby community who'd never been sick a day in his life. Until now. He came to be investigated for jaundice (in those far-off days it was still possible to be admitted for such things) and I was assigned to "work him up." Roy was more confused and frightened than I was, and for good reason. He had no experience at all of illness and not much with the medical system. The jargon made no sense and the implications of his symptoms weren't at all clear to him. My feelings of uncertainty and insecurity were trivial compared to what he was dealing with, yet I felt a kinship with him. I wasn't sure how I could help him, given my limited knowledge and skill. But there was one thing that I knew I could do pretty well: I could talk, and talk we did. I interpreted the results of the tests, all of which were ominous, and the plans of the consultants. He told me about his family and shared his fears and sense of unfairness about what was happening to him. He made me feel like I was helping, and I think I gave him the feeling that he was important. I was no older than his grandchildren, and still uncomfortable with the label of "Doctor," so I enjoyed his nickname for me: Little Pal. I didn't worry about boundaries or professional dignity; I just knew that we both needed the trust and comfort that we provided for one another. On morning rounds with the consultant, the head nurse and various levels of residents and medical students, it was reassuring to hear him greet me. "There's my little pal!" he'd say. FIGURE
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Figure.
Things didn't work out well for Roy. The tests all indicated that he had metastatic cancer, and the consultant recommended that he stay in hospital for chemotherapy. Roy was hopeful at first, and I felt terrible. Although none of the experts were explicit about it, I realized that he likely had little time left. Was it a betrayal of trust to hope along with him? Would a good doctor be very clear about the prognosis, or would he or she encourage belief in the miracles of science? I didn't know what was right, so I just kept visiting and answering Roy's questions as they came up.
One day the whole team of consultants, residents, nurses and students swept into Roy's room on rounds. Ignoring them all, he looked directly at me.
"Little Pal," he said, "this chemo isn't doing me any good, is it?"
Oh, Lord, what would a good doctor say? What would the oncologist say? But Roy was looking at me, so I answered with my own belief.
"No, it's not," I said.
"That's what I think, too. So I'd like to stop it now. Can I do that?"
I had no experience with patients refusing treatment. What were the rules? Was it up to me to decide?
"Yes, we'll stop it, if that's what you want," I said.
"And I'd like to go home, where my friends and family can visit me more easily. Can I do that?"
I had no idea how to go about arranging a transfer to the small hospital in his community, but I knew that I would make it happen.
"Yes," I answered, but my voice was shaking and tears were pouring down my face.
"Thanks, Little Pal."
Then I left Roy's room, with the team following behind me.
I stood in the corridor of the big teaching hospital and wept. Not for Roy, really, because he was so obviously prepared for what lay ahead and so at peace with his decision. I wept for the inevitability of the death of a good and gentle man, for my own loss, and for the beauty of his grace and acceptance. As I cried I wished desperately to be able to stop, because I had never seen a physician cry about a patient before, and because I felt so unprofessional, so human. The doctor who began telling me about the latest pain control strategies was of no help to me. But the resident who put his arm around me and gave me a squeeze was. So was the one who silently handed me a tissue. It was the first time I shed tears in the course of my professional work, but it certainly wasn't the last.
Roy was transferred to the little hospital, where he died several weeks later. I continued my training as a physician, a role in which I now feel comfortable as I never could have imagined I would. I never think of Roy without a few tears, and never without gratitude. From him I learned that sometimes caring is the most important thing a patient can be given. He showed me that death could come with grace and acceptance, and gave me the confidence that comes from being the person that a patient looks to for help, even when there are more experienced experts on hand.
Thanks, Pal.