“Wherever the art of medicine is loved, there is also a love of humanity”. Hippocrates
I spent 4 years in medical school plus an additional 4 years of residency and fellowship training learning the Science of Medicine. It was not until I was practicing medicine on my own that I finally began to learn and appreciate the Art of Medicine. It is through my patients and my relationships with them that this is so.
It was 10 years ago when I first met one of my most favorite patients; for privacy purposes, I will call her Ms. Lilly. Ms. Lilly was only 74 years old at the time that she entered my nursing home. She came over to me as a patient on hospice (which means that her life expectancy was anticipated to be only 6 months or less). After reviewing her medical records, I could see why she was on hospice. She suffered from severe rheumatoid arthritis, a condition that ultimately led her to become immobile and bed bound. This in turn resulted in her developing a large, stage 4 bedsore (which means that it was a very deep pressure sore that was unlikely to ever fully heal). The pain from her rheumatoid arthritis and from this deep pressure sore was very difficult to control and she required very high doses of pain medication. When I first walked into the room to meet her, I expected to find a nonverbal, debilitated and frail old lady lying in bed. Instead, what I found was a smiling, pleasant and completely alert lady who greeted me. As expected, she was lying in her bed, but other than that, she knew exactly where she was, why she had moved to the nursing home and why it was that she was on hospice. She had previously been residing at a board and care home and this was where she developed her bedsore and that was why she was moving to a nursing home. In most instances, board and care facilities are not licensed or equipped to care for people who have any skin issues or sores that extend beyond a Stage 2 level ulceration and thus, patients must be moved out.
The first thing that I discussed with Ms. Lilly as her new doctor was what her “goals of care” were for herself. She indicated to me that she had a strong desire to continue living and to attempt to heal the wound. Her pain was not well controlled at the time and as a result she required high doses of narcotic pain medication. Over the following 6 months, the staff at the nursing home worked hard and was able to eventually heal her bedsore and I was also able to get her pain under better control. She was then discharged/released from hospice and arrangements were made for physical therapy to work with her until she was strong enough to transfer herself from her bed to a wheelchair.
Over the next many months, Ms. Lilly became a visibly prominent member in the nursing home. She could be routinely found sitting in her wheelchair in one of the main hallways of the nursing home greeting anyone who passed by. Most of the staff (and even visitors and family members of other residents) got to know her by name and would greet her in return. When she wasn’t greeting people, she could be found in the activities room enjoying music or in the courtyard visiting with her family. She also spent many hours in her room reading. After 4 years of living at the nursing home, however, Ms. Lilly started to become somewhat discouraged. When I asked what was bothering her, she mentioned that her vision “was going”. She was afraid that she would not be able to read anymore as this was one of her most favorite pastimes. Upon examining her, I discovered that the cause of her visual problem was that she had cataracts. As a result, she underwent an uneventful cataract surgery and was immediately able to READ AGAIN!
Her time at the nursing home over the last 10 years was not without any incidents, however. During her stay, she was treated for pneumonia a couple of times, several bladder infections and even one episode of influenza. Surprisingly, she managed to recover quite uneventfully through each of these medical hurdles. There was one time, however, that I thought I would lose Ms. Lilly.
As I entered the nursing home one morning, a nurse told me that Ms. Lilly wasn’t feeling too well. I immediately went to her room and found her looking quite ill. She had a fever and was nauseated with no appetite. When I examined her, I found that she had significant tenderness on the right side of her abdomen. “Is it another urine infection doctor?”, she asked. Unfortunately, I knew that it was not. As I recalled, several months earlier, she had had an episode of abdominal discomfort and a low appetite then. At that time, I had diagnosed her with gallstones, but that episode ended up resolving spontaneously. Given her age and existing medical conditions, both she and her family decided not to pursue any aggressive medical intervention (such as surgery for removing the gallbladder). We all knew that it was possible that Ms. Lilly could have another “gallbladder attack” at anytime, but she was willing to roll the dice, as she did not want to undergo any elective surgeries.
As I sat by Ms. Lilly’s bedside, I told her that her condition was much more serious this time; I suspected that she had cholecystitis (inflammation of the gallbladder). This illness occurs when the normal flow of bile out of the gallbladder becomes blocked and as a result, the gallbladder becomes inflamed. For those of us who are younger and healthier, this condition can be treated relatively easily and predictably. For Ms. Lilly, however, given her advanced age and the fact that she was on many medications (for her rheumatoid) that suppressed her body’s natural immune system, her gallbladder situation became a much more serious and life-threatening condition. Although, Ms. Lilly and her family had previously wanted to avoid any elective procedures for chronic conditions, the circumstances had now suddenly changed. The family asked me what I thought we should do. I walked them through “goals of care” again. I discussed the options and risks associated with treating (or not treating) her current condition. Ultimately, we all agreed that her current quality of life at the time was GREAT…and was worth trying to preserve. She decided that since there was a definitive treatment for her condition that she would want to proceed with that treatment option. Ms. Lilly was subsequently admitted to the hospital and was treated initially with intravenous antibiotics. When her condition did not improve on antibiotics alone, she proceeded with the surgery to remove her gallbladder. To everyone’s relief (and surprise)…she survived the surgery! One week post surgery, she returned to the nursing home and began the recovery and rehabilitation process. It took her about one month to finally resume her well-established position in the hallway of the nursing home….but she did it!
Patients like Ms. Lilly really highlight to me the importance of listening to people. It also reminds me that the true practice of medicine is a mix of both SCIENCE and ART. In simple terms, science allows doctors to heal by preventing, diagnosing and treating disease. But the ART of medicine is that intangible process of using that knowledge to deliver a customized treatment plan for each patient as an individual. It is the relationship that exists between physicians and their patients that is at the core of healing. This begins with hearing and understanding. If I had not taken the time to sit down and listen to Ms. Lilly when she was first admitted into the nursing home, then I may not have been blessed with such a wonderful physician-patient relationship. Ten years after checking her into the nursing home as a hospice patient….I now look forward every day to seeing Ms. Lilly’s precious smile and wave as I enter the nursing home.
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