When I was a final year medical student in 1981, I did an elective term in USA. While I was there, I was introduced to “The House of God”. This irreverent novel about the life of interns and residents in a big teaching hospital became my bible for my first years as a doctor. I have continued to find some of the “Laws of the House of God” to be helpful as I navigate the rocky path of being a human being and a doctor.
“The aim of good medical care is to do as much of nothing as possible,” and “If you don’t take a temperature, you’ll never find a fever” have been particularly helpful signposts in general practice. But the law which I have tried to follow most closely is “Always remember, the patient is the one with the disease.” As someone with a tendency to over empathise, holding these simple words in my mind has been extremely helpful.
But as another law states, “They can always hurt you more,” and sometimes, despite my best efforts to remember who is the patient, I become fond of the people I care for. Dare I say it, but there are times when I think that I may have fallen in love with my patients. Not in an inappropriate romantic way. But to love them as I might a friend or a neighbour. I have known some of my patients for over 20 years. I am not a robot. I do have feelings for them.
Over the last decade or so, I have learnt a simple way of managing uncomfortable or disturbing feelings that arise from my work. The sort of feelings or thoughts which might keep me awake at night. Or as I have sometimes said to my registrars, “the sort of patients I take home to bed” (in a purely metaphorical sense, of course). I write stories. About my thoughts. About my feelings. About our conversations. About my reactions to their suffering.
Much to my surprise, I have found writing in this way to be extremely helpful. It seems to whisk the uncomfortable thoughts or feelings away, taking them out of my heart or mind and transforming them onto the page or the computer screen. Challenging patients become interesting people. Difficult situations become opportunities for reflection and learning. It’s like magic.
Most of my patients are elderly, one of the rewards of having worked in this area for so long. And they are dying. Not because of poor treatment or lack of care, but because they are old. Recently, three of my patients died in quick succession. It made me wonder what the future held for me and my other patients. This thought kept pestering me. It wouldn’t leave me alone.
Until I wrote I wrote a story about it.
And here it is:
The blank death certificate sits in front of me. Housed in its bland beige pad. No matter where a life starts, where it journeys, the Medical Certificate of Cause of Death is the concluding punctuation mark on a person's medical narrative.
I approach the completion of the death certificate with reverence. My final task in the care of a patient. A moment to pause. To reflect. To say goodbye. To honor their life within the rigid confines of a bureaucratic document.
This ritual is becoming increasingly frequent.
As a GP in a rural area for thirty years, my patients have grown older with me. Despite medicine's advances and my best efforts, they are dying. It is their time. As my wise grandmother taught me before she died, Mein lieber Gott vergisst niemanden. My dear God forgets no one.
I'm losing my patients.
Just last month, I lost three.
Lilly was an elegant matriarch. She was my oldest patient. Each of her frequent visits to me ended with her gently touching my arm and saying Bless you, Hilton. I had cared for her husband Don before his death. Now it was Lilly's turn. Her heart was failing. I hope that one night I will go to sleep and wake up dead. Like Don did, she once told me. Her wish came true a few weeks ago. Who is going to bless me now?
Len had been a child during the bombings of London during the war. I had once ruined his Christmas by advising that he go to hospital to have a heart pacemaker inserted. He would have died without it. He wasn't ready for that. The pacemaker kept him going for another decade. Not always easy years. But better than the alternative, as he’d say. Len was a poet. Each visit to me was accompanied by the gift of a poem, from when the muse was upon me. The last time I saw him he told that he was feeling better than he had for years. Another gift. He woke up dead a few days later.
Reg's children and grandchildren were patients of mine. When Reg moved to our town with his wife, they became my patients too. Reg was a lovable rogue with a wicked sense of humor. He was fiercely independent and loyal to his wife, who had advancing dementia, constantly shielding her from interfering do-gooders. Reg dropped dead at home without warning. Out of sight beside his bed. It took two days for his family to discover what had happened, as in his wife's mind, he was just having a long session at the pub. I am haunted by the memory of seeing him lying face down on the floor, so very very dead.
I finish writing the death certificate. I walk out to greet my next patient. The waiting room is full. Many familiar faces look my way. I am troubled by a nagging thought. A persistent pestering question.
I wonder who will be next?