“Mr. Jones, how are you this morning?” I ask.
A muffled, incoherent reply.
“Are you in pain?”
“No.”
I perform a brief, perfunctory exam — it’s unchanged from yesterday. I then glance at his breakfast tray on the bedside table — still untouched. The plastic mug is still full of watery, lukewarm coffee, the rubbery pancakes on the plate are still intact. This is at least the third morning that my patient — who I am calling Mr. Jones
— has not eaten any breakfast. In fact, I realize, he has not been eating much of anything since he was admitted.
I am rotating for a week on the inpatient geriatrics consult service during my fourth year of medical school. Mr. Jones is one of the patients I have been assigned to follow. He has advanced dementia with lewy bodies and had been admitted to Duke University Hospital following a fall at his assisted living facility that resulted in a few cracked ribs. The trauma service consulted our team after some agitated behavior overnight raised their concern for delirium. At the outset, his story seemed fairly typical. Our team had rounded on him each morning that week and had dutifully attempted to mediate each possible cause of his delirium — pain, occult infection, medication side-effects, etc. However, he is still dwindling, and now he is not even able to feed himself. This does not bode well for him becoming strong enough to leave the hospital, much less return to his assisted living facility.
I am about to leave Mr. Jones’ room, but I stop and check my watch. I still have some time before rounds and am not aware of any emergent issues with my other patients. Sitting down next to Mr. Jones, I ask him if he is hungry. To my surprise, he answers that he is. “Would you like some help eating?” Again, a surprise — he is willing to let me help him eat.
I pull his tray over. “Pancakes?”
No, he doesn’t want pancakes. “How about cereal?”
Cereal is acceptable. I open the miniature box of raisin bran and pour it into a foam cup, then add the milk. I carefully begin delivering spoonfuls of soggy cereal to his open mouth, giving him time to swallow in between. The process reminds me feeding a baby, though without the cajoling and use of “train entering the tunnel” metaphors. I persist until he indicates that he is done. He eats most of the cereal and even drinks a few gulps of orange juice.
I leave his room feeling triumphant. I feel as good as if I have just performed a complicated procedure or confirmed a difficult diagnosis. It seems laughable to consider feeding a cup of raisin bran to an elderly patient with dementia as something noteworthy. I know that what I just did probably made absolutely no difference in the course of his medical treatment. A meager breakfast of cereal and orange juice will not reverse his failure to thrive nor alter the progression of his disease. But perhaps I made some small difference in the comfort of my patient, and for me, this was the most meaningful thing I had done all week.
During my various clinical rotations throughout medical school — as I juggled long lists of differential diagnoses in my mind, scribbled lab values on bits of paper stuffed in the burgeoning pockets of my white coat and tried to feign confidence during morning rounds — I often struggled to feel that I was making a difference. The hospital to me felt like a giant RVU-generating machine that churned through patients like widgets, and I was an awkwardly fitting gear that slowed the process down more than it helped. The moments that mattered, however, were those moments when I was able to connect with patients on a human level and understand what they truly needed. Such moments reminded me how grateful and honored I am to study medicine.
A famous 1891 oil painting by Sir Luke Fildes entitled The Doctor depicts a country physician sitting faithfully at the bedside of young child, while the father stoically looks on and the mother weeps in the background. The painting is powerful and poignant not only because of its portrayal of empathy, but also its portrayal of powerlessness. The doctor’s furrowed brow and hand on his chin seem to convey his intense desire to do more without the means to do so. The only thing he can do is to be present with the patient, mourn with the suffering family and help out in any way he can. I can imagine him wiping the brow of the child with a damp cloth or offering a spoonful of hot broth, whispering silent prayers that Providence will grant the cure he cannot provide.
Medicine has come a long way since The Doctor was painted. Once a profession for the philosophers and poets, medicine is now a profession of engineers and entrepreneurs. Modern medicine is much more focused on procedures, evidence, and results than it is on human interactions and physician gestalt. Of course, this is not necessarily a bad thing. New discoveries and technologies have pushed the limit of possibility. More can be done today to save the lives of patients and prevent disease than at any point in history. The illnesses that plagued humanity during the lifetime of Sir Luke Fildes are virtually nonexistent today.
However, there are many situations — more than we care to admit — when modern medicine does not have any answers or offer any good cure. For my patient with dementia, nothing our team could do would beat back the inevitable advance of his cognitive and functional decline. There are few diseases as cruelly resistant to all forms of treatment as is dementia. To some physicians and trainees, this can be incredibly frustrating. Perhaps for this reason, we conveniently ignore these doomed patients or pass them off to other medical teams, preferring instead to focus on those with more treatable problems. After all, such patients are a disposition nightmare. Perhaps it is inevitable to feel and behave this way in our frenzied health care environment with ever more regulatory pressures and narrower profit margins. Nevertheless, what I have learned during my years in medicine is that sometimes being a good doctor does not entail having all the answers or being able to provide the latest treatments. Sometimes, being a good doctor means sitting down next to a patient and ministering to him or her in their moment of extremity. Feeding a patient, wiping a brow, offering a kind word — these are the interventions that sometimes make the biggest difference. These are the interventions that matter in the end.
Morgan S. Hardy is a psychiatrist.
Image credit: Shutterstock.com
