Query

Ms. Ste-Marie smoked and drank most of her life. Many entries in her chart attested to expensive stints in detox; she even had an extended stay at the Betty Ford. Her wealthy family had long since abandoned her; her ex-husband provided her with a divorce settlement exhausted long ago, and her three daughters no longer spoke to her. Liver ultrasounds, enzyme counts and skeletal x-ray reports told the sorry medical tale of the alcoholic: at first an absorbent sponge, her liver was now a shrunken pumice stone, and her osteoporotic bones were cobbled from many drunken falls.

Figure. Photo by: Anson Liaw

I had just assumed care of Ms. Ste-Marie, an orphan patient. Notes made by previous physicians commented on her relentless decline; over a period of twenty years all remarked on her general good cheer and willingness to forswear booze altogether — for as long as she was in the office. The strategy of her last few doctors had been simply to listen, they coming to the realization that any attempt to arrest her descent would be futile. The net effect of this strategy was that over the past two years her appointments were whittled down to fifteen minutes apiece. They were documented only very briefly, always using the same billing code.

Ms. Ste-Marie had begun to grow depressed. She longed to renew contact with her ex-husband, who never remarried, and whom she read about in the business section of the newspaper. She had tried to locate her daughters, but they skillfully avoided her. She was lonely and hopelessly addicted; the most sober moments in her life, she told me, came when she abstained for a few hours in anticipation of a doctor's appointment.

I'm not sure my predecessors appreciated this fact. In her chart there were records of referrals made and lab tests ordered, but no mention of the sacrifice she made in order to converse with her doctor.

“I'm an old drunk,” she told me, “and I've been drinking longer than you've been alive!”

It was hard not to believe her. Alcohol had taken its toll: her complexion was sallow, and she shook as she sat. Her birthdate lied about her age: she looked eighty, not sixty-five. I asked, “Why do you stop drinking before you come to these appointments?”

She said, “Ever try to talk when you're drunk? I've had doctors carry me out of here and order a taxi to take me home. Women have taken their children to the other side of the waiting room because they smelled me and were scared.”

I looked at the last billing code: Supportive Psychotherapy.

“Is that the only reason you stop for a few hours?”

— Dr. Ursus