Relationships are at the core of the helping professions: teaching, medical practice, psychotherapy, nursing, and social work. Yes, expertise is important and skills are essential but the bond between student, patient, client and the professional is crucial for improved health, solving problems, understanding one’s self, and learning. Joel Merenstein, M.D., understands this at the core of his being. Merenstein has written posts for this blogs before. His most recent (see here) is about relationship with patients after he retired in 2010.
This post–taken from his recent co-authored book, The Human Side of Medicine: Three Generations of Family Physicians Share Their Stories—underscores the centrality of the doctor-patient relationship. Obviously, there are differences among the helping professions but what draws them together is precisely this relationship, a bond that too many health, social policy, and educational policymakers seeking efficiency, increased productivity, and faster, and better outcomes, too often forget or ignore.
Mary Ann and I had a long and intense relationship as patient and doctor. She was bright, resourceful, and determined. She had her own ideas about medical management and did not hesitate to share them with me. We usually disagreed–until she was dying.
Actually, for many years our conflicts centered around her role as mother rather than patient. I believe, and still do, that both the doctors’ and the parents’ responsibility for children should be to aid and encourage independence. Mary Ann believed in total protection and guidance. So many of her phone calls would start, “I know that you think I’m an overprotective mother, but ….”
Real crises were no problem for her. When the second of her four daughters had acute glomerulonephritis [serious inflammation of the kidneys], she did not panic or become hysterical but remained calm. supportive, and caring. However, despite her daughter’s complete recovery, Mary Ann would forever ask, “Shouldn’t we check again to be sure her kidneys are still all right?”
As the girls grew older and less controllable, more of Mary Ann’s questions and concerns focused on her own symptoms. Once again we had our disagreements. She was not a bothersome patient. In fact she would often wait weeks or months with a particular set of symptoms before calling or making an appointment; but when she did call or come in, she would always want more answers than I had, more explanations than I was capable of–and at the same time, she offered more suggestions than I knew how to handle.
She recognized some of her symptoms as depression and would start medication, only to discontinue the visits and the therapy before they could be effective. At other times she would request tests to evaluate her joint and muscle pains and then want to know why they were normal when she was so uncomfortable.
She never criticized me personally for the lack of answers but was often hard on herself. She came in for an urgent visit with severe ear pain. When I found a small furuncle [a boil] in the external canal, she was upset that she had overacted and that the visit was unnecessary.
Whenever I recommended some referral or alternate form of therapy, she would counter, “That’s not the answer,” or “Do you really think that it will work?” When she finally agreed to see a rheumatology consultant, it seemed to be more to prove no one could diagnose her than to really get an answer. She was vindicated when the consultant could find nothing wrong.
Then a markedly elevated sedimentation rate was reported [blood test that shows inflammation in the body]. This prompted an extensive hospital evaluation, but again no answers. Six weeks later she developed chills, fever, and lymph nodes so large that it was hardly necessary to biopsy them to diagnose her lymphoma.
As she began to do battle with the first of two oncology groups, the strengths of our relationship surfaced. In response to the oncologist’s complaints, I noted that she had always been difficult. I told her and her husband that the oncologist should have been more open and informative. I was being truthful in both instances.
The second oncologist provided a little better communication but not much improvement or satisfaction. She failed to show any response to all of the radiation or chemotherapy.
There was much for me to deal with too: the lack of communication by the oncologists and their difficulty with her demands to know everything, a period of blaming her husband and then herself, and the oldest daughter’s guilt over her independence battles with her mother.
The oncologist reported that there was nothing more he could offer. Mary Ann accepted this and prepared herself.
Then came the house calls. We talked about the home visits I made when the girls were younger and we were all just starting out. We reminisced and bantered, and then she nodded toward her husband and said, “You have to make him understand.” So we stopped talking about the past and concentrated on the future.
Other home visits were to meet the visiting nurses and set up a regimen for pain medication and to see how things were going. There were no complaints and no disagreements. She made suggestions regarding adjustment of her medication and how the nurses might help. She was usually right, or at least she seemed to respond. There were no calls outside the regular visits until the end.
It was a cool but bright Sunday morning in March,and her husband called and asked if I could be there by noon. Her blood pressure had dropped,and they were afraid to give her the narcotic injection that was due then.
She was quiet but seemingly comfortable when I arrived. She said the priest had been there and given her the last rites and “everything was set.” I asked one of the girls if perhaps they had last comments to discuss with their mother. She informed me her mother had already taken care of that.
Her daughters, her husband, and her sister were all around in the large master bedroom. We all talked together almost lightheartedly. She seemed to doze,and I said to the family, “Maybe she doesn’t need the shot.” We all laughed when she immediately admonished me,”You said the wrong thing.”
I gave the morphine and reminded her husband that the injections were not killing her but relieving her pain. I told her to put in a good word for me in heaven and said goodbye. At the front door I wanted to hug her husband but was only able to put my arm around his shoulder.
As I drove away I had a sense of loss but yet felt good that it went well. Then I had an uneasy feeling and pulled the car off the road and thought maybe it had gone well because we did things her way this time. She died at 6:00 AM the next day, quietly and peacefully at the age of 48.