Reflections on “before”

Duke, Pauline S.

I am the keeper of the old family photos. I have always loved to watch my older relatives smile as I listen to them tell stories and reminisce about the people in the snapshots. They create a window into the past that has helped me know more about my family’s history. From Newfoundland, I also come from a culture that values its past as much as its present.

So it’s a natural consequence that family photos of my patients interest me. But I’ve come to realize that it is more than just a simple interest.

Pictures worth a thousand words

I remember a man I met 10 years ago, Mr J. I knew Mr J’s wife and children well because they were my patients and attended clinic for regular checkups and health concerns, but I had never met him. He was in his mid-50s and, like many men his age, did not come to see a doctor unless he was quite sick.

While I was on maternity leave, Mr J became ill and was diagnosed with a terminal brain tumour. He was cared for by my colleagues, but upon my return I became his family doctor. I cared for him during a hospital admission and then on housecalls. I spent time with his wife and children at home visits but never really got to know Mr J as a person. The tumour had caused terrible disability, and communication was very difficult; he was bedridden and slept most of the time.

From his family, I knew that he was a fine man. I also knew that he was loved by his friends—many visited while I happened to be there. Mr J was a freelance writer. At the time of his illness he received a national award for his work but could not attend the ceremony. His wife decided to construct a beautiful scrapbook of his life that would be shown at the national writers’ conference.

Author’s grandfather, Mr Isaac Duke, who lived in Fox Harbour, Newfoundland, was captain of his own fishing schooner. He fished the Grand Banks of Newfoundland and coastal Labrador. Photo taken in the early 1960s.

Once housecalls became more frequent as his health declined, I watched the progress on this lovingly made book. I saw pictures of him as a young university student, with friends, at his outdoor wedding in the Rockies, at work, and with his children. The photos that brought me to tears were those of him holding each of his 3 children as newborns. He held them and looked at them so lovingly; it was evident from these photos that he adored his children from the time they were born. Now they were young adults and teenagers trying to deal with the sadness of their father’s illness and impending death. The photos were very powerful and helped me to get to know Mr J better. I was privy to important moments in the life of a man whom I met only when his life was ending.

More pictures

For a time, as a family doctor, I provided medical care to our military veterans at a Department of Veterans Affairs long-term care facility. I enjoyed caring for these special men and women. As I went on rounds or visited rooms, I noticed that, above the beds, veterans had photos of themselves in their military uniforms. Some were veterans’ formal military photos, and some were photos taken while at their military jobs. They all showed young handsome men or beautiful women. One could see a lot about them in their faces or perhaps how they held the shoulder of a friend. Although some of them were suffering from the ravages of dementia and could not tell me much about their lives, their photos could. The confident, smiling young man in the pilot seat of his airplane doesn’t know his family anymore. The lovely young woman shown with her friends now finds it difficult to walk.

Teaching students to read them

There is so much “before” in our patients’ lives, so much living before we happen along. We see patients for specific times in their lives, and in fact get to know them well over time, but don’t know all. Yes, we’re an important part of our patients’ lives, especially when they really need our medical care, but we’re along for a short ride compared with what else has happened in their living. We are privileged to be part of their stories at whatever time that we meet. Sometimes we weave in and out of our patients’ lives—seeing them when they really need our form of care or at pivotal moments, and other times we don’t see them for a while.

I teach medical students and family medicine residents. I am often impressed by their knowledge, competence, and caring. They understand the patient-centred clinical method, but they often don’t get the concept of the “before” in patients’ lives, at least not initially. They see the patient in front of them at that point. They treat the congestive heart failure and the other ailments in their patients competently. They understand and practise preventive health care. But the students often don’t see the “before.” Maybe it’s because they are young or that we are getting older and have practised a long time. Maybe it’s something that happens as you mature as a physician. I don’t know. I think patients’ family photos can help our learners understand the “before.”

When I’m on housecalls and am trying to get to know my patient, I’ll ask the patient or caregiver to tell me more about the person and ask if they have any photos of the patient and the patient’s family. While doing home visits with residents, I often ask patients if I can take down a photo from their walls to get a closer look, and I ask our patient to tell me more. Patients are always glad that you have taken the time to be interested. Then, on the ride back to the office in the car or after rounds on the Department of Veterans Affairs ward, I explain the concept of the “before” to residents. Sometimes I can see on their faces that they get it, and that’s a great moment as a teacher.

Theme: Family | Famille

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




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