Query

Clare was 300 pounds, middle-aged and short of breath. She was a longtime smoker who looked as if she'd puffed in the womb. She suffered from a crippling emphysema and was noncompliant with her medication regimen. She regularly missed appointments. In short, she was one of my sickest and — Why do they usually go together? — most recalcitrant patients.

She wouldn't come to the office mildly short of breath. No, I would see her only when she was in extremis, her chest taking great heaves in flabby, fluttering attempts to move itty bits of breath. Like last night, when she rolled into the emergency room, hacking and horking up balls of phlegm between rapid, jiggling respirations. It's always the same story with her.

When did you last use your puffer?

Ran out. Last week. Forgot. To. Refill.

When did you start getting short of breath?

Days. Ago. Maybe. Not. Sure. Hungry.

A sad fact: she comes to the hospital only when she gets so dyspneic that she can't eat.

As her doctor, I initially tried to save her. I hinted at weight-loss strategies, scheduled once-weekly appointments to reinforce compliance, encouraged her to stop smoking. Over the course of many months I was patient and consistent in urging her in a healthy direction.

I failed, for she ended up in hospital repeatedly. So I changed tack and became blunt, delivering morbid verdicts with a grim certainty:

You will die if you don't lose weight.

You will die if you don't take your medication.

You will die if you don't stop smoking.

This didn't work either, even though what I said was true. She had pathetic spirometry parameters: each additional fat cell and cigarette shrank her chest's ability to move air. Last night she came close to death. I was about to intubate her when, miraculously, she pinked up and her SpO₂ increased. She was so sick that there was no opportunity to go through our usual routine, in which I ask questions to which I already know the answers.

Sometimes I wish medicine would develop a cure for stupidity. But when this evil thought passes, I purposely turn introspective and recognize that even the most intransigent and oblivious patients can teach me something.

I admitted Clare as per usual, wrote the orders that were by now rote. Masks, steroids, spirometry ad nauseum. The next day I visited the great heap of her during my rounds. What I saw cured me of my arrogance: Clare's little boy, who had probably heard me browbeat his mother a dozen times, was pulling at her arm, trying to get her out of bed. Over and over he tugged, repeating, Exercise, Mommy!

Clare couldn't. She could barely sit up, let alone take a few steps. The little kid had clearly listened to me give Clare hell in the past.

Who was I to presume that I knew this woman? Medically, I knew she might die if she didn't adhere to my advice; personally, I didn't know what her life was like. Instead of concentrating on last night's vital signs and oxygen saturation values, I sat down on the bed beside Clare, ready to relate to her. Not to lecture, but to start building a relationship that would help me solve the puzzle as to why Clare was the way she was, seemingly wanting to die.

— Dr. Ursus