Four more words

Patey, Paul

"I'm worried about me legs." Ben is a 70-year-old fisherman, still sturdy, but concerned.

I look: the skin between his ankles and his knees is certainly no longer normal. In places there are some crusted spots; a couple have bled, probably from being scratched, but the basic pattern is compatible with a combination of skin changes from years of trouble from varicose veins, and skin sensitivity maybe allergy - to rubber boots.

First I address Ben's concern. 'What did you think it was?"
"I thought it might be TB. When I was a youngster I seen some people get sore legs when they got TB."
"No sir, it's not TB. What else did you think it might be?"
"Cancer. The cancer. You hears a lot about it these days. Radio said I should show the doctor sores that don't heal."
"No sir, it's not cancer."
Ben smiles broadly and says, "What, you mean to tell me it's not TB and it's not cancer! Well doctor that's wonderful! We can handle whatever else it is no trouble for sure."

Ben's fears are lessened. Now we can talk about caring for chronic skin problems.

Maude is 76. I have been her Family doctor for several years. I knew that one of her greatest joys is trouting. She takes her fishing pole, worms, and a tall plastic bucket to her favourite spot on the shore of her favourite pond. Inverted, the bucket becomes a seat: sitting thereon, Maude became a contented fisher, as well as the serene old lady she is.

A week ago I had diagnosed pneumonia: relatively mild this time. The X-ray, blood tests, breathing test and my clinical assessment had all indicated it was safe to treat her at home. If she got worse she would have to go to hospital. Now she is back to clinic for a check up. She has improved.

Certainly, with her years Maude has collected many diseases: severe high blood pressure, chronic obstructive lung disease, mild congestive heart failure, peripheral vascular disease, mild kidney failure, osteoarthritis, cataracts, and recently slight diabetes. She is on a bunch of pills to keep her going and try and defer the many fatal complications for which she is at risk, including strokes and heart attacks. But would she be better dying on her chesterfield at home or on her plastic seat beside the pond? Surely the trouting was more benefit than risk.

"I 'spose I won't get troutin' no more?" says Maude, after I tell her the pneumonia is nearly gone.
"Why not? I think you'll be able to go trouting in a couple of weeks time. You bundle up warm. You don't trout in the rain. Your daughter gets out of your way but stays nearby in the cabin. Is your greatgrandson still around to dig worms for you this year?"
"Yes. Jimmy's 11."
"And you still got your plastic bucket?"
"Then I dare say you'll get trouting again. Your body has lots of troubles but it keeps on going."
Maude's hope is not shattered by the uncertain and unknown future, nor by undue caution from me.

George's words come slowly. His lips move more than necessary. Cerebral palsy has been with him since his Birth 24 years ago. George also has epilepsy.
He walks well. His hands are strong. He has a part time job. He is explaining to me recent episodes, when he felt like he was going to have a seizure, but didn't.

I listen. Part way through his sentences I am often fairly sure what the remainder will be. I wait. I do not finish his sentences for him. I respect his right to be heard. I give him the privilege to be heard. I respect him. It prolongs the interview slightly. It strengthens the doctor-patient relationship substantially. And George's dignity is preserved.

I enjoy being George's Family doctor. Life has given him burdens. He bears them with dignity. I respect and nurture his dignity.

Nancy is concerned about her baby's feet.
"She started walking two months ago. Now she runs, and when she does her right foot turns in and sometimes she falls."

I examine the child, Elaine, in her mother's lap - the most secure place in the world. There is full range of motion of hips, knees and ankles. Reflexes are normal.

"Put her diaper back on. Let's see her walk." We go into the corridor. Nancy holds Elaine's hand and they walk. Then, I hold Elaine, Nancy moves a few feet away, turns, says "come. run," and Elaine does, while I watch her feet.

We return to the room. We discuss the problem. As expected, baby sleeps on her belly with her legs drawn up and toes turned in, and when sitting on the floor often bends knees and turns toes in. At this stage treatment is simple instructions to encourage different sitting and sleeping postures, a reassessment in three months, and informing the mother that if necessary later on "special boots with a bar joining them" for Elaine to wear at night can be obtained.

Then I add. "You are enjoying Elaine?"
To which Nancy replies, "Oh my yes doctor, she's wonderful. Drives me up the wall sometimes, but she's wonderful."
"And Bill, your husband?"
"He thinks the world of her. He really does. He's so gentle and joyful with her."
"So you are both enjoying your child?"
"We sure are."
"Enjoy her. That's the best way to love her. That's the best way to love anybody: enjoy them. You've discovered that."
"We sure have," says Nancy, as she gives Elaine a big hug.
And by this expression, their love is strengthened: Bill's, Nancy's, and Elaine's.

In 1963, during second year medical school I first read this sentence in a clinical skills handbook: "So handle them that their fears are lessened, their hopes not shattered: and their dignity preserved." I underlined it in my book and my life. In the next four decades I added four more words. Now it reads:
So handle them that their fears are lessened; their hopes not shattered, their dignity preserved, and their love strengthened."

Patients, their families, students, colleagues, physicians, teachers, managers -and numerous other health care workers with whom I have worked have shown and taught me dozens of ways to lessen fear, protect hope and preserve dignity. They have taught me hundreds of ways to try to help love grow. What a wonderful parade of caring people they have been. To them all I say "Thank you: you have immensely enriched my life."

Theme: Patients | Patients
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.




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