Missing the Final Act

by Danielle Ofri

Diseases, like dramas, have natural progressions.  Introductions, backgrounds, developments, climaxes, and dénouements. And each disease of each person has its own singular tempo.  Often the rhythms are unpredictable, with sudden overnight developments or stultifyingly dull periods of waiting.  Life in a teaching hospital, however, is paced by the hard-edged specificity of the academic calendar.  I am the attending physician on the medical wards for exactly four weeks at a time.  After twenty-eight days of intense involvement in my patients’ lives, I must abandon the ward to return to my home base in the clinic – irrespective of the progression of their individual dramas.

Today is my 28^th day.  A quiet Sunday morning of rounds.  I arrive early, even before the interns, because there are so many patients to see.   There is, of course, the absurdity of seeing the newly admitted patients today, of introducing myself as the attending physician at the same time as saying that this is my last day and that they will meet new doctors tomorrow.  But it has to be done.  And then there are the patients who have been here for a few days or even a few weeks.  These are the patients whom I’ve come to know, whose dramas I’ve witnessed in the making but will be exiting before the final act.  It all seems so bizarre.  Aren’t doctors supposed to stay with their patients until the bitter end?

Most patients, however, are understanding.  They’ve been in the academic system before and have grown accustomed to—or at least tolerant of—hordes of medical students, interns, residents, fellows, and attendings parading in and out of their rooms.  Most don’t know the distinction between these varying levels of medical hierarchy, and most, frankly, don’t seem to care.   The medical student’s unhurried afternoons of conversation probably mean more to a patient than the fact that the attending physician is board-certified in her medical specialty.

Rishala, a sweet-faced 23 year-old, is stuck in the hospital for six weeks of IV antibiotics for an abdominal abscess.  Our lives crossed during Weeks Two through Five.  I have seen only a bouncy Indian woman eager and impatient to return to her studies as a respiratory therapist.   She seems too healthy to be here, but I have read in her chart what Week One was like, when she was prostrate with a fever of 105°, consumed by abdominal pain, too weak even to walk.  I missed the endless X-rays and CT scans and blood cultures and the various misdiagnoses of pancreatitis and gallstones.  I waltzed onto the scene during Act II, when the broad-spectrum antibiotics had already restored her energy and appetite.  Now she is achingly bored with confinement and my visits have been mainly to cheer her up rather than alter her medical care.  When I told her of a previous patient of mine who studied Italian during his hospital stay, Rishala giggled and whispered that she’d always wanted to learn Spanish.  I brought her one of my basic Spanish books and each day thereafter she has greeted me with “Como está?” and her new vocabulary word of the day.  Now I am leaving the week before her antibiotic course is complete.  We’ve had a month of daily chats about movies, abscesses, and Spanish conjugations, but I will not be able to partake in the climax and denouement of her drama.  I will not be able to celebrate the sweetness of her discharge or her mastery of the past participle.

Anjali is another Indian woman on my service.  She is only 45 but the furrows etched around her eyes bespeak of other forces aging her.  Twenty years ago she had a routine gallbladder operation in India and the doctors recommended a blood transfusion because she seemed a bit weak at the edges.  Along with the oxygen-rich red blood cells, the hepatitis C virus was also transfused into her veins, and decades later her liver began to fail.  Now she is near the end stages, with intractable fluid swelling her petite body.  This time the fluid is infected, and she, like Rishala, requires six weeks of intravenous antibiotics.  Her only hope would be a liver transplant.  She is a perfect candidate: never drank alcohol, never used drugs, young, reliable, no other medical problems, has a supportive family.  Except for one thing…she isn’t an American citizen.

Anjali cried frequently during the month and it was often excruciatingly uncomfortable to remain in her room.  Every day that I saw her we spoke sadly about the situation; it was impossible to make small talk about the weather.  She was an excellent cook, her sons told me.  I brought in an Indian cookbook I’d purchased long ago but never used.  Anjali spent her days examining the recipes and highlighting the ones she thought were tasty and sufficiently uncomplicated for a busy doctor.  I’m leaving before her antibiotics are finished.  I am saying goodbye midway through her drama, and she cries when she returns the cookbook to me.  She stayed up late last night getting through the final chapter on desserts.  After this month the cookbook will sit untouched on my shelf.  I will remain sadly ignorant of the final chapter of her story and it will be too painful to prepare those recipes.

Karolina was admitted to our service less than 48 hours ago.  I barely know her and now I am saying goodbye.  She is 21; our medical service seems particularly young this month.  A frail wisp of a young woman who speaks little English, she nods as I try to say both hello and goodbye in the same breath.  When she was vomiting every day in her native Poland, she was diagnosed with anorexia and bulimia.  An endoscopy of her stomach had been performed, but apparently no biopsies were taken and nothing seemed amiss.  When she arrived in America, she was promptly admitted to the psychiatric ward for severe anorexia.  Another endoscopy was performed, however, and gastric cancer was there, clear as summer, and already Stage IV—metastatic.  I feel guilty leaving so early in the game with Carolina.  There will be long and serious talks in the next few weeks, but I am bailing out.   Though at least she speaks enough English to say goodbye.

Xi-Lang doesn’t speak a single word of English.  Not one.  She is 41 and has Stage IV cervical cancer.  She’s been in the hospital for a week and has already signed a DNR.  Planning for hospice care is well underway.  Since I can’t normally locate the Fukinese interpreter for my daily rounds I simply smile at her and hope my eyes convey my concern.  “Tong?” I ask, using the only word in Chinese that I know.  “Pain?  Tong?” I ask, pointing to her belly.  She shakes her head no; her morphine is adequate.  Her husband comes every evening with their two young children.  It is simply too agonizing to watch, especially without being able to communicate, and often I find myself backing quickly out the door.  I tell myself that it’s because we have nothing to say, but I know it is otherwise.  On this Sunday I say goodbye in the most basic of ways.  I take her hand in mine and shake it slowly.  Then I smile and wave goodbye like a small child would—cheerily and probably too demonstratively.  In the absence of words my gestures feel overly dramatic and I am acutely aware of their awkwardness.  I point from my heart to hers and I think she understands.

I have finished seeing all my patients and am jotting the last of the progress notes in their charts.  My 28 days are drawing to a close.  What a month it has been.  So many young people, it seems, this month.  So many young women this month.  It’s not always like this, and of course there were many patients this month—men and women—who were in and out in a matter of days as their asthma attacks or pneumonias easily resolved.  But it’s the ones with cancer and serious infections who stay for long periods of time.  My canvas of time and their canvas of time will overlap only partially.  For some patients, like Carolina, the overlap will be their Act I.  For others, like Anjali, it will be their Act III.  And there were those this month, for whom I bore witness to their final act.

Why does this leave me so unsettled?  It is of course impossible for me to be here round-the-clock, every day, every month for every patient.  I have to say goodbye at some point.  Three separate months per year of full-time inpatient medicine is all I can handle.  It is exhausting in a way that outpatient medicine in the clinic can never be.  I do enjoy the opportunity of brushing up on my inpatient skills and there is an excitement to caring for critically ill patients.  But the disjointedness gnarls under my skin like a persistent parasite.  In the clinic I have the opportunity to live in parallel with my patients, to meet their children and grandchildren, to celebrate their retirements, to mourn the deaths of their parents or spouse.  I have been with some of my patients for more than a decade.  But whenever I work in the inpatient wards, a shadow of guilt trails behind me with silent, but insistent, footsteps.  I can never be there enough.  I can never be there for the whole story for every patient.

Is this the deal we must make with our patients in academic medicine?  At the end of 28 days I exit abruptly like the annoying theatre patron who squeezes out of her row in the middle of the performance, stumbling over purses and knees and programs, apologizing in a hurried whisper.  The other audience members shake their heads in the wake of her awkward departure and wonder how she could possibly be so oblivious to the riveting drama upon the stage.   (originally published in The Rio Grande Review)