Trust the Doctor

“Friendship- my definition- is built on two things. Respect and trust. Both elements have to be there. And it has to be mutual. You can have respect for someone, but if you don’t have trust, the friendship will crumble.”
― Stieg Larsson, The Girl with the Dragon Tattoo

I met him thirty years ago, back in the days when primary care was my major source of patients.  I think a neighbor had referred him to my office.  He was in his mid thirties.  He worked in manufacturing.  He was married; had three kids; loved sports and an occasional night out with his wife.  One could look for weeks without finding such a “typical” patient.  Something made him stand out, however.  He was one of the sweetest, gentlest souls I’ve ever met.

It didn’t take me long to come to this conclusion.  It seemed like his first thought on awakening every day was how he could make others feel better.  There was always a (meaningful) good morning, and he listened when people responded to his “How are you today?”s.  I eventually got to meet his wife and children, and much later I dealt with his supervisor at work.  Everyone agreed that this was an unusual man indeed.  A truly nice guy.

In the early nineties he came down with a cough.  After routine measures failed, a chest X Ray was done.  We found a large lung cancer.  After the usual testing the decision was made to operate.  Part of his right lung was removed.  He had a brief course of chemotherapy: I don’t remember if he needed radiation.  He missed a total of ten days of work.

I never heard him complain of pain, or nausea, or discomfort of any kind.  He approached his illness as if it were a temporary inconvenience that soon would disappear.  What impressed me the most (even alarmed me a bit) was his complete lack of concern about the possibility of a negative outcome.  I would have expected “fear of death” to be expressed in capital letters all over his questions and conversations.  Nothing.  One day I asked him if he felt that he needed to make plans for any contingency that may come up.  All he said was: “You know what you’re doing.  I trust you.”

I began to explain that things can go wrong no matter what the doctor’s preparation is, but something in his look; his smile; the total conviction in his tone of voice made me decide to skip this part of the conversation.

He did well for close to a decade, then his world began to fall apart.  A serious autoimmune disease gave him pain on a daily basis.  He had to take expensive, potentially toxic medicine to ameliorate his symptoms.  Again, he missed little work and again, he had minimal questions and even fewer complaints.   Within a year he had a stroke warning.  He recovered all function and went back to work.  There were bowel issues, likely related to his medication, and his prostate began to act up.  He continued to show up for his visits.  Within two years the casual observer would not have been able to notice that he had many serious medical problems.

Then his cancer came back.  Or he developed a new one; hard to tell.  Another round of testing.  It was felt that he could not afford to lose more lung tissue.  He received high dose chemotherapy and radiation.  He did not tolerate it so well this time.  His major, maybe only concern: when could he get back to work.  “My family needs me, doc.”

Again I tried to impress upon him how tenuous his grip on life was.  He didn’t allow me to go beyond two sentences.  “You’ll figure it out, doc.  You’ve always done good for me.”  He flashed his incredibly sweet, honest, meaningful smile.  I switched the conversation to sports and family.

To my amazement, he recovered.  The lung CT scans showed a persistent mass, but since it showed no sign of growing and it did not impinge on any major structures we decided to leave him alone.  We called it “scar tissue.”  He went back to work; he continued to show up for his routine visits; he never lost his smile or his good intentions.  This went on for four years.

Three years ago I had just returned from vacation when the covering physician told me that he had to be admitted to the hospital.  The next morning I got up early to be able to review his hospital record without having to rush.  He was in a truckload of trouble.

His cancer had recurred.  The lung mass may not have been a scar, or he could have developed a third tumor.  This time he had metastases to his brain, bones, and abdomen.  His kidneys were tightly in the grip of the tumor, so he could not urinate.  They were failing.  He had seizures.  He was terribly anemic.  The oncologist had no newer medicines to try.  The Medical School did not have any ongoing research protocols that dealt with this kind of cancer.  He was out of options.  The nephrologist had mentioned dialysis as a stopgap measure, but it was clear that this intervention would prolong his life without affecting the cancer.  My friend was going to die.

I walked in his room feeling unusually anxious.  He looked wasted; tired; his eyes were dull and expressionless.  Yet I got the same smile.  Of course he asked about me; my family; my vacation first.  After ten minutes I could wait no longer.  I held his hand.  I asked him if anyone had explained what was wrong with him.

Yes; of course.  He knew there were problems with brain and kidneys.  He knew they were serious.  He understood the cancer was back.

I felt some relief.  I reiterated how serious his condition was.  That there were no more medicines to try; that kidney and brain involvement was just too much for a body to bear.

“That’s why I was so eager for you to get back, doc.  You’ll get me out of this.”

I was just about ready to faint.  I felt grateful that I was sitting.

“I’m sorry.  I can’t help you any more.”

Another smile.  Of course I could come up with something; make a phone call…  The nephrologist had mentioned dialysis; for sure this would help!

I looked straight into his eyes and squeezed his hand.

“I’m sorry.”

His mouth opened a bit.  A gesture that told me that he was beginning to believe me.

“You mean you can’t help me?”  A few tears rolled to his cheeks.

I nodded.  There was silence for a few seconds.

“It’s OK, doc.  You’ve done your best.  Don’t worry about me.  You’re a good doc.”

Incredible courage and kindness; so much like him.  He wants to make sure that I’m OK; that I won’t let my failure be too hard on me.  Another beautiful smile; the last one I’ll ever see.

I stood up and I hugged him.  He decided to stop all treatment.  I spoke to his wife and children; I wrote the orders to make sure that my friend would have some peace and no pain.  Within a few hours he passed away.

I’ve never had a patient who believed in me so much.  Sometimes I feel that this was part of his defense mechanism.  That he would have not remained functional for so long if he had allowed his mind to harbor any doubts.  He let me do the worrying about his health, and he could devote what energy he had to his work and family.  This combination worked for a long time.

I still keep in touch with his wife.  We both miss him.