I almost missed her

E was a former patient and a labor-delivery nurse, the little sister of one of my best friends from high school. That early spring day in 2003 I would say former patient because she fired me. That is right. Two years earlier she became angry with me and requested her records to see another gynecologist.

When I learned she had been diagnosed with acute leukemia I spent a week using the excuse of a bad cold to keep me off the sixth floor where the immunosuppressed heme-onc patients stayed. Finally, on Friday I bought flowers and made my way to E's room. She was sitting at the head of the bed with her knees drawn up to her chest. I remember how thin and pale she looked with shoulder length, straight, blond hair. The oncologist had been there earlier in the afternoon. The diagnosis was ALL, acute lymphoblastic leukemia. The doctor explained that chemotherapy would come first then perhaps a stem cell transplant from one of her four sisters.

E spoke with me about all this while I stood across the room wearing a mask. She looked terrified as she should. The five year survival rate for an adult with her diagnosis was under twenty five percent. As I left one of my physician friends, an oncologist, asked me what I was doing on the sixth floor. Upon hearing that E was a family friend he offered his condolences.

I went back the next day and the next and then many of the days in the next six months as E completed the courses of chemotherapy. She suffered many side effects of the medications and many illness from her lack of an immune system. She lost her hair, her face became as round as the moon and on many days she had ulcers in her mouth that made it difficult for her to swallow. Yet it seemed the sicker she was the more she smiled and joked with me about people and events from our past. E's older sister and I had been extremely close in high school we both knew a great deal of each other's "family history."

The most important thing that happened in these months of battling the leukemia was E's persona changed. She went from that timid, huddling figure on the bed the first week, to someone who smiled easily. Instead of huddling in her bed and making visitor stand across the room she stretched her arms out to give them a tight hug, after they had washed, gowned and masked themselves of course. She was not shy with her physicians either. She demanded information every time one came to her room. One of the hematologists told me she was angry with him at one point and "fired" him. I welcomed him to the club and I also noticed that he continued to come by and see E even when she was on the transplant service and no longer under his care. Like me, he wanted to cheer her on against almost impossible odds.

While I think E knew that the odds of her beating the leukemia were almost impossible that did not seem to deter her from the fight. I had watched as she and her sisters fought growing up. Those battles now seemed like preparation.

Weeks and months stretched out over a period of two years. E's first remission was six months. The second, following the first stem cell transplant was a little longer. E went back to work. Life was a bit more normal for her family. Finally, the monstrous leukemia returned. It was just a couple of weeks before Easter 2005 when E became septic with a overwhelming infection that antibiotics and her body could not handle. She died on a Wednesday morning with two of her sisters, her three children and a close friend at her bedside. I was in my office seeing patients when someone from the hospital called. I ran the three blocks to the hospital but I arrived too late.

I have decided that it was OK that I had missed her that morning. There had been many other mornings, late nights and occasionally a long afternoon when E convinced me of the value of living every day for all that one day is worth. And when I think about how close I came to not going up to her room that Friday afternoon, I shudder. I could have totally missed her. My pride and the rejection that I felt when she went to another doctor might have prevented me from going to visit on that very first week of her illness. I will forever be grateful that I was able to move past that and into the space of friend.

Three conversations

On top the card read, "To Dr. LMD and Staff, for all the nice things you do for me." Underneath the foil wrap were two dozen fresh baked chocolate chip cookies still warm from the oven. As I truthfully exclaimed that these were my favorite, the patient related two stories of other doctors offices. Offices where the staff was in the patient's words, "more interested in my money than they were in me."

Later in the day I saw a patient who had lived in Brussels Belgium for the past six years. As she and I visited about her medical history for the years she had been away she remarked wishfully, "It certainly is different in Europe." I found out later that a member of my front office staff had badgered her for her husbands social security number. It seems that without it we could not file her insurance. Her primary care physician in Brussels was a single physician with his wife as the receptionist/office nurse. My patient had the up most respect for this physician and the care that she received as his patient. The cost of an office visit: forty Euros. A fee the doctor himself accepted after the completion of the office visit.

At the end of the day my office manager wanted to review with me a potential new hire for my office. The point sold my office manager on hiring this young woman was the fact that she had self appointed "goal" of collecting a certain amount of money from patients at check out in the course of each day.

Medicine it seems is a business more so than a generation ago. Many times I am disappointed in myself as well as my colleagues. We spend too much of our time thinking about monetary compensation rather than taking pride in the work we do or realizing how important that work is to the health of our patients.

Showing up

Life is about winning, right?

On a recent call night I found myself watching the movie "Little Miss Sunshine" a comical and poignant story about a family traveling to a beauty contest for six and seven year old girls. The movie shows the family journeying several hundred miles in a yellow VW bus as they struggle with life and each other.

For me the message of the movie is distilled in to a moment when the oldest character, the grandfather, so damaged by life that he resorts to snorting cocaine to cope, calms the youngest character, Olive, the beauty queen contestant as she expresses her fears of failure on the eve of the contest.

"Grand paw, I don't want to be a loser. Dad hates losers." Olive cries.

"Your are not a loser. You know what a loser is?" Her grand paw replies. "A loser is someone who is so afraid of not winning they don't even try. Now you are trying right?"

Olive replies in the affirmative and Grand paw asks another question, "Now we are going to have fun tomorrow, right?" Again affirmation and the plot moves on.1

This scene reveals much about life. The cliche is "winning is not everything" and yet I find myself and those around me living as if being first, being at the top, is the only thing. More often than not in the most important aspects of life showing up and giving the task at hand our best effort possible is the most important part. This is when we become winners regardless of our place in the end.

1. Little Miss Sunshine Twentieth Century Fox Presentation 2006