There is a conversation I replay in my head since you died 3 years ago. In it, I tell you I’m sorry about your death and express my gratitude to you. Nobody knows what your final moments were like. However, I know they were unexpected as you had been at dialysis just the day before plugging yourself into a machine that you hated, being poked by a needle that we had conditioned you to fear beyond reason, just so that your rather poorly functioning heart could keep on ticking for another day. I hope you passed painlessly, but I suspect that was not the case, knowing we had planned to turn off your defibrillator but that your cardiology appointment to do so had not yet occurred.
When I came to work the Monday after you died, I learned of your passing in a way that illuminated the less humanitarian side of medicine—a message in my inbox from a call center representative I had never met, stating I must call the coroner’s office to discuss your death and complete the necessary paperwork. I stared at the screen, paralyzed for a good minute, then realized I had 10 patients on my schedule ahead of me, buckled down my heartache, saw them, called the coroner, and drove home letting myself mourn your death in the privacy of my car.
I am sorry, because you shouldn’t have died alone. About 2 years after you had become my patient, you had come to see me for what had become chronic, intermittent chest pain. You had previously had a coronary bypass and we knew your bypass vessels were obstructed. You were already on the best medications possible to help your heart. I drew a picture of your heart and labeled your blocked, rerouted arteries. Then I pointed to the nitroglycerin on your medication list, and tried to let my face show how sorry I was. I let you know there was nothing more I could do, waiting as the translator relayed each of these messages in Spanish. I felt like a failure, notifying you of this truth. You understood my disappointment, replying in English, “It’s okay. You all take good care of me, more than my family.” Most people die with their families beside them if they can. I knew you wouldn’t, but I hadn’t pictured you dying alone, and for that, I am so sorry.
Mr C, the other thing I want to say to you is thank you. Many hands helped shape me into the doctor I am today, and many of them were highly trained and educated. Despite having only a sixth-grade education, you were one of my greatest teachers. When you first became my patient during the intern year of family medicine residency, you taught me so many lessons important to the early resident—how to manage diabetes, heart failure, end-stage renal disease, sick versus not sick, the value of provider-patient continuity.
As I became a better doctor, your lessons became more sophisticated. Your PHQ-9 was 11. Could I trust that you really wanted your defibrillator turned off, or was that depression talking? When you asked about your prognosis, I gave you a straight answer. You had taught me that patients are entitled to the whole truth, especially when the news is bad, granting me the confidence to turn the unrealistically optimistic “there’s a slight chance” of intern year into the more respectable “what is most likely” of third year.
You taught me how to work with my team. Our social worker helped you find housing. Our psychologist helped you talk about your mood and gave you exercises to reduce your fear of needles. After months of your pharmacy mysteriously not receiving the refills I was signing, our pharmacist discovered I had been sending them to a different Walmart several blocks down the same street from the one you you were going to. In fact, when staff around the clinic learned that you died, it was the front desk staff that took it hardest.
You taught me to be an advocate, asking your specialists to step outside of their guidelines to cater to your individual medical needs that I alone knew. You taught me to look deeper when I realized that your improved diabetes control was actually the result of you eating less because of worsening depression and dwindling money for food.
Above all, you helped me start to learn what it means to be a family doctor. I say start to learn because now, 2 years postresidency, I can see that understanding what family medicine is takes more time than a 3-year residency. Because of you, I know that continuity means better care, that lack of financial resources supersedes recommended care, and that sometimes my job is about making a troublesome problem disappear, but mostly it’s about helping patients live with problems that don’t go away.
I know that you appreciated me being your doctor, because you thanked me at the end of each visit. I’m sorry I didn’t thank you back. I think you deserved to know how much I appreciated what you taught me over the years, and I think you deserved to have died with dignity. I know that you will never read this letter, but other patients might, and I hope that in doing so, they get a glimpse of the profound effect you can have on us, even if we forget to say thanks.
Sincerely,
Dr Aimee English
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