Half Day Clinic & What Should I Feel?

“This latte is too sweet” I think to myself as the foamy hotness lights up the sweet receptors of my tongue. I stop and try to remember how many pumps the nice lady at the coffee shop slammed into my cup and think it’s somewhere around three or four — will have to go down to one tomorrow. I sigh and spin in my office chair breathing deeply and looking around. Black Dell computer, corded office phone, a chair next to mine and an automated bed with thin, crumply paper covering it — my half day clinic.

Like so many of my peers I chose internal medicine for the inpatient experience — the steady stream of data that requires an immediate reaction, multiple adjustments of treatments throughout the day and making sure their intended effects are taking place before discharging. To me the clinic was a slow burn and sending people home with medication changes while not being able to see the result until a few weeks via phone was challenging. Moreover seeing patients who were in relatively good health as outpatients demanded a more intricate and finessed approach trying to tease out problems that hadn’t had time to truly manifest. The patient with pneumonia in clinic was quite different than the one breathing 25 times a minute on 4L of oxygen in the ED — often times the former would become the latter and it was up to me and my burgeoning clinical foresight to stop that in its tracks before it became too late.

I hear a knock at my door which interrupts my office chair olympics “Come in” I say.

“Doctor, good morning! We have our first patient waiting” my clinic nurse tells me. I nod in response and try to place her accent. Unsuccessful and momentarily realizing my ignorance of sociolinguistics I clear my thoughts and begin to type furiously on the dusty keyboard in front of me — clinic is a sprint and knowing about your patients beforehand makes all the difference between a comfortable lead and a photo finish when the clock strikes five.

“Hmm, looks like Mr Davids is due for another check up” I think to myself. A mental image of him quickly formulates in my head, a gift I’ve developed somewhere at the intersection of obsessing over my patients and anxiously trying to keep their needs at bay. Bald head, clean shaven and stubborn.

“The perfect combo” I mutter out loud.

I think of all our past visits and laugh in spite of the growing knot in my stomach — I couldn’t even count the times we disagreed over treatment plans and had to change them because Mr Davids had a difference in opinion.

“At least he keeps it interesting” I say through a sigh.

The door signals its opening with a slow, drawn out squeak and I feel the warm hospital air against my right cheek. “Mr Davids! Long time no see, how are we doi–”

My nurse, cheerful a few moments ago, stands under the door frame now appearing sullen.

“Dr Bhatty, it looks like Mr Davids passed away and won’t be making his appointment” she says quietly.

I take in her demeanor for a moment. “That’s a shame, he had a lot of issues going on — do you know what happened?”

“I think he had some kind of infection, the son called and talked to one of the other nurses, it should be in the chart” she says now with what appears to be an empathetic  smile.

She begins to turn away and I swivel my chair back to the computer screen, now decorated with bright flowers replacing the list of lab results that were there a few minutes ago. I shake the mouse and the screensaver quickly disappears. It’s my second year of my residency and admittedly I’ve lost patients in more traumatic ways than a few sentences shared in a clinic on a Wednesday afternoon. I’ve spent so much time trying to figure out what next medication, lab test or image I should order that knowing what and how to feel when they pass away has fallen by the wayside. I  think I’ve stopped asking that all together.

“Is that wrong?” I think to myself. Sitting here I honestly have no idea — no one talks about these kinds of things. To be honest, sometimes I focus on whether I should feel anything at all.

“You’re crazy” I say shaking my head. At the same time I know that I’m not; too many conversations with colleagues at conferences and even in other disciplines have led me to believe that our journeys, however different, are in many ways the same.

I stare hard at the black frame outlining the Dell computer and let my thoughts drift to old patients of the past. The first time I ran code, the patient’s whose respiratory rate could easily be confused with their heart’s….all these memories blur together and I let out a deep breath. The ability to control what and how much you feel is useful when you’re by yourself at midnight and the only one with the power to do anything.

“Feeling less, helps me think more” my inner voice demands. Yet, like most days when I reach this conclusion, I am not satisfied. After several med reconciliations, progress notes and cheerful “see you in six months” I am done for the day. I put on my black jacket and place the shoulder strap to my bag over my head. As I walk slowly towards the brown double doors that lead to the rest of the hospital I feel a soft tap on my shoulder.

“Dr Bhatty, this came in the mail from you” my nurse says.

I take the yellow crumpled envelope from her hand and see the messy writing over it — misshapen o’s and barely crossed t’s adorn it’s face.

“I think it’s from one of the patient’s, you should read it” she quickly says before walking away.

I continue my march to the parking lot while tearing the top of the envelope to reveal a white paper inside. I stop as I exit the hospital to the cold air outside.
Dear Dr Bhatty, 
 
Thank you for all your help this year — if it’s wasn’t for you I think I would have died a long time ago. 
 
Mr David 
 

The cruel irony twists itself into a ball in my stomach and I stand glued to the spot as the letter dances with the breeze. Suddenly I feel everything all at once — the pain of loss, the sense of hopelessness and feeling of letting someone down. I recognize these feelings all to well; I swallow my saliva and neatly fold the paper into my back pocket and begin to walk towards my car. My jaw is clenched and yet with each step I feel a new, stronger feeling rising. The space inside me spinning with what I mentioned before makes way for something else — humility, motivation and determination. I turn my bronze car keys in my ignition and hear my engine churn to life.

Feelings are a double edged sword in medicine — many times they can shake you or beat you down. After two years I know this, that the answer isn’t to shut close the door to your heart. As painful as it is that door must remain open, because if you stick around and survive the pain the dust often settles and what takes its place is more beautiful than anything that existed there before.  A wise professor once said “Love the patient, hate the disease”. As the trees hanging over the long black road become a blur I let my thoughts linger on whats occurred for a few more seconds before taking one last breath and turning on the radio. But not before saying out loud the mantra

“Love the patient, hate the disease”.

Details of the story including people, places and time have been altered for storytelling purposes and identity protection. 

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