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Volume 3, Issue 2
Summer 2007:

Last Words

Michael A. LaCombe

Cell 2 Soul. 2007 Summer; 3(2):a2

Some time ago I was called to Richmond to the bedside of an elderly physician. The old doctor was near death and his family had asked whether I would come, would I attend him, was there anything I could do — that sort of thing. I went out of duty more than anything else I guess, that kind of responsibility you have to a colleague.

The man lay in the bedroom of the house where he had lived alone for the past sixty years. Through some minor disappointment — a broken heart or similar tragedy — he had never married. But he was loved nevertheless. Even while I attended him, the constant visits from neighbors and patients were impressive. How could I be of help, I asked the old doctor. His glance and raised eyebrow told me at once that I should know the answer. But if I insisted on staying, he said that I could listen to his story.

And so he began:

"You get to this point, to the end, and all the extraneous stuff of your life just melts away. The picture you are left with all of a sudden gets pretty clear. It's like when you go to the seacoast, you know. You see the boats bobbing in the shallows and the searchlights coming in and out of the fog. There are gulls darting and diving everywhere. And suddenly the fog lifts and there's this leviathan just offshore, right there in front of you for you to see, as honest as the day. Well, that's what this dying does for you. It shows you the leviathans in your life — what was most important to you, what made you who you are. And just as important I suppose, it shows you what has amounted to just so much driftwood through the years.

"I'm lucky I guess. I've had more than my share of leviathans, even more than most doctors I would say. There was that first bright sunny day in medical school on the way to lecture. That's one tremendous leviathan all of us doctors have. And there's the day we all stood on the grass and we were just as green as grass ourselves and we took the Oath together. That's a hell of a leviathan, I'll tell you. And there's your first patient you care for as a full-fledged doctor, and your first life saved, and the first baby you deliver all wriggling and wet and screaming and healthy."

At this point the old doctor's housekeeper entered the bedroom, bustled about, and sent a stare in my direction which said to me in an instant that I was meddling, had no business being there, and should be getting along soon. The housekeeper was either severely kyphotic or a hunchback. I preferred to think of her as a hunchback, possessing magical qualities sometimes bordering on evil and infinitely more interesting. At any rate, the old doctor intercepted her look, dismissed it with a wave of his hand, and nodded to me reassuringly.

"You learn so much in this life," the old doctor said, "if you only bother to take the time. Only after thirty or forty years of experience is a physician really any good at what he does, and by that time he's ready for retirement. That's the great dilemma in medical teaching, how to transmit what the old doctor has learned in those forty years to the young student. It's uncommon these days that medical students and young residents are even put in the hands of experienced clinicians, much less retired practitioners. And it's the uncommon retired practitioner who is any good at teaching anyway. To compound the problem, often the knowledge that he or she has acquired in forty years of experience is often of the ill defined nature: the smell of disease, the nearness of death, the legitimacy of a patient's physical complaints, the pathognomonic constellation of signs and symptoms immediately apparent. How can you teach this?"

I began to speak, to give him an answer, but he waved me off, as though there wasn't time, and he had much more to say.

"My God, you'd like to be able to tell them things, like, be an incrementalist. If you take life in small daily bites, in a lifetime you can master French, Shakespeare, and fly-fishing. A day in the doctor's life metaphor for life. You have to learn to plan your day and set priorities, always aware that emergencies, and life, will have quite different plans for you.

"I'd like to be able to tell them that they should choose consciously whether they wish to be a doctor or a businessman. Being a doctor is a calling and requires self-sacrifice, devotion, love and tenderness to your fellow man. If only a kid just starting out could be a doctor without living like one. Keep your overhead low, as the saying goes. Don't become trapped in a lifetime focused on material things. Belief in science, medical knowledge, honing clinical skills, facility with patients, a sensitivity to suffering, a deep love of non-medical literature, a few close friends — these are the important things. The beachfront property, the summer home, the tony private school for your children, the prestigious address, the academic title, membership in exclusive clubs — these are just driftwood, rather silly, if you only stop to think.

"In houses, automobiles and spouses, avoid trophies, I'd tell 'em; you can select a partner who happens to be a trophy, but don't make the selection because of it."

The housekeeper left the room, and the old doctor eased back and became reflective, soft. It was as though he had been filibustering until she left the room.

"Let me tell you what occupies my mind most these days," the old doctor said.

"There is this one particular leviathan bigger than the rest that just wants to occupy my mind.

"It was a long time ago. I had only been in practice for ten or fifteen years maybe. They had a case of diabetic coma over in the hospital in Phippsburg and they called me in to help out. Diabetes was difficult to treat back then. You would administer huge doses of crystalline insulin. All of the fluids you gave were by stomach tube or retention enema, mostly. Oh, sometimes in desperation you'd give a saline solution by clysis, but that never seemed to work. You had only urine tests for sugar and acid to guide you...none of the blood testing you have now. You followed the urines. You looked at the clinical signs. You did your best and prayed. And it seemed that you killed a diabetic just as often as you had one die on you.

"Well this patient, a young woman, was pretty sick. I had to stay with her the better part of a week, walking the thin line between hypoglycemia and ketoacidosis, pouring fluids and alkali into her, injecting the insulin myself. Eventually she responded — youth itself is a great help in treatment, you know. As soon as it was obvious she was going to make it, I turned the case back over to her physician so I could get back to the practice I had left.

"Oh, I'd drive back evenings to see how she was. After office hours I'd like to drop in on her. Her room was always dark. I'd tap at the door and whisper my name and she'd sit right up and ask me to come in. She was a 'good case,' if you know what I mean. You didn't save many diabetics in coma in those days. I guess when you save a life like that you want to bask in it. Well, I'd sit and talk with her for a while and then I'd go out and kid with the nurses and leave.

"After she was discharged I stopped seeing her. I didn't think about her for a while, except maybe to remind myself when I lost a child with meningitis, that I had saved a young woman in diabetic coma."

The hunchback at this point came in with a supper tray, and since there was only one tray, and another more piercing stare, I hastily excused myself.

"Hoyos," said the old doctor. "Come back tomorrow. Get some Hoyo de Monterrey cigars. Excaliburs, if you can find them, 1066's. We'll have a cigar together. I'll supply the Port."

In fact it was several days before I could return to Richmond and to the old doctor's house. The duties of practice, family life and hospital committees had claimed my time at a moment in my life when I was beginning to doubt my own priorities. Nevertheless, he was waiting for me. I had the Hoyos, and he already decanted the Port, a Taylor Fladgate '64. At this point he wasn't about to skimp. The hunchback was in his bedroom, finding things to keep her there, and the old doctor was patently aware of her, yet given to expound again.

"Have you ever noticed how many people envy us?" said the old doctor. "How many people are pretenders to the throne of physician? How many play at being a doctor and yet, consumed by the worst sort of envy, attack us for being so? Have you ever thought about the burden of expectation American society places upon us? I'd like to tell young doctors not to be seduced by it, not to buy into it. Being a good doctor doesn't make you a skillful politician, nor a statesman, nor a gifted teacher, barrister, or philosopher."

I leaned forward to light his cigar — the Hoyos were not easily found, I can tell you — and then sat back in the overstuffed chair next to the sofa he lay upon, and lit my own cigar. Soon the small room was filled with the fragrant clubby haze of tobacco, pungent enough to drive anyone not so inclined from the room, even a hunchback with magical powers.

The old doctor waited until the housekeeper had closed the door behind her, and then his aged face sprang to life.

"The diabetic girl, the one in the coma that I was telling you about the other day," he said, pointing his cigar at me.

"One day she's in my office. She had made an appointment. There she was, sitting in my examining room, just as big as life. Well, I rushed in and we exchanged pleasantries, and she said she had come to thank me for saving her life. Just like that. I said something stupid like it was a thrill for me to manage such a sick patient or something equally sensitive like that. Then I got called out abruptly for a delivery. My nurse gave her another appointment and she was back again the next week.

"'Doctor,' she said just as cool and level-headed as you or I, 'Doctor, do patients ever fall in love with their doctors?'

"Well, I gave her the standard reaction to this, you know, the talk about gratitude and worship and the patient's awe of a doctor's power. I allowed as I could understand any feeling she might have in that regard. I assured her that this was all normal, these feelings she had, and I appreciated it and all that. I think I rambled on quite a bit because she laughed and said,

"'I don't mean to make you nervous, Doctor, but I'm not talking about worship or grateful patients and forgive me for saying this, but I just feel this great love for you.'

"Well, I mean to tell you, I hunted up Freud and ran for cover! I tried to explain to her about father figures. She'd shake her head and say she already had a wonderful father. So I'd bring in transference theory and point out that maybe she had a need for a big brother who could be protective and understanding, and she'd shake her head no again and tell me she didn't need a brother. So I'd say that perhaps I represented qualities that she had been missing in other aspects of her life. She'd smile and nod and agree and I'd see she missed my point entirely. She could have given Susan B. Anthony lessons in persistence!

"Finally I said,

"'Look, you're fifteen years younger than I am. I'm an old man. Look at me! You're a young woman. I mean, just look at me.'

"And that's when she hit me with the ton of bricks. She just looked up at me, or really past me with these innocent brown eyes of hers and said,

"'Don't you know, Doctor?'

"Well, I didn't know. I mean, I didn't know until that very moment. She'd been in a coma after all and then after that, whenever I had visited her in the hospital, it had been at night and her room was dark, so I really didn't know until that very moment that she was blind.

"'I'm sorry,' I said. And she smiled and said that I needn't be sorry, that maybe because she was blind she was more sensitive to people than most and she could pick up things others seemed to miss. She said that she had grown to know me by the sound of my voice and knew just by hearing me talk to her what kind of person I was. She had fallen in love with me, she said, through the sound of my voice."

The old man became quiet, introspective, and visibly upset. I didn't press him. He took a long drag on his cigar, gulped down his port, held his glass to me for more, and said nothing. I was old enough to know better, and so changed the subject.

"Suppose," I said, "Suppose that you were asked to give a lecture to some medical students or young doctors, a sort of Last Lecture. What would you say to them?"

It worked. The old doctor shifted on the sofa, took several quick puffs of his cigar, setting aglow its business end, and literally drowned me in a torrent of seeming nonsequiturs. I only wish now I had tape-recorded it.

"Answer Socrates," he said. "Know yourself. Examine your life. Spend a part of each day in the pure luxury of thinking. Believe in luck. In the role of the cosmic dice, it is pure luck that you were born American and not Bangladeshi, that you hold a blue-chip education, and can move freely in society, rather than having been chained to a system of caste. Be a champion of the downtrodden, the underdog. Don't buy into the specious arguments of high-rollers and certain politicians. The poor and poorly educated do not deserve it. They have not brought it upon themselves.

"And this," he said firmly. He pointed his cigar at me for emphasis. "your family comes first. Not the patient, not your profession, not your career and most certainly not material goods. The secret of a happy, productive physician is the happy, supportive family he or she enjoys. Such support requires an investment in kind. Make no assumptions in this regard. Nor should you postpone love. Tomorrow is never the better time for intimacy." There was a catch in the old man's voice at this last bit of wisdom, and I felt we were close to the diabetic patient once again. I left it alone. There were long minutes of silence. We sat quietly drawing on our cigars, sipping the Port, saying nothing. Then he began again:

"What are hospitals without its plumbers, its maids and laundry personnel, without its maintenance men and janitors, without pharmacists, or aides who empty bedpans, without the compassionate nurses and technicians who believe 'stat' means what it says," said the old doctor. "Without them our university hospitals would grind to a halt. We should recognize them, thank them, bother to know their names. Yet we don't. We should deflect praise rather than searching for it, avoid the limelight. In teaching, it's better to display the brilliance of others, and in caring for patients, I've always tried to give the referring doctor all of the credit — praising him or her to the patient, to the family, and to the referring doctor herself. And along those lines, you should praise publicly, but criticize privately. There is always something good in everyone. Find it, and praise it. And never embarrass a student. Never attempt to show how positively brilliant you are."

The sun was setting behind the expanse of pasture and mountain. The hunchback braved the smoke-filled room with the supper tray. It was time for me to leave, and that moment of what I sensed might be confession was not to come, not today at least.

When I returned in a few days, I discovered I had unwittingly stumbled upon a way to dispel the housekeeper's evil curse. I should have known better. It was her deformity that had thrown me off, but the housekeeper was a woman, after all, and all women love flowers. I had brought a huge bouquet of cut fresh flowers for her, and a box of Hoyos and a bottle of Port for my old friend. "It's a Fonseca," I said, "1976. The clerk said it was the best they had."

"Crack it," said the old doctor. "Life is too short for cheap wine."

"Where were we?" I said.

"I forget," said the old man. He hadn't forgotten, and we both knew it. But he was not about to tell me about the diabetic patient who loved him.

"Your Last Lecture," I advanced.

"Oh, yes," he said, "advice to the young and all that. Well, let's see, here's a passage from my favorite book." He reached over to the low bookshelf, extracted a book, and opened it to where there had been placed a bookmark.

"Here it is," he said, beginning to read.

"'The best thing for being sad.' replied Merlyn, beginning to puff and blow, 'is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins, you may miss your only love, you may see the world about you devastated by evil lunatics, or know your honor trampled in the sewers of baser minds. There is only one thing for it then — to learn. Learn why the world wags and what wags it. That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust and never dream of regretting. Learning is the thing for you. Look at what a lot of things there are to learn — pure science, the only purity there is. You can learn astronomy in a lifetime, natural history in three, literature in six. And then, after you have exhausted a milliard lifetimes in biology, medicine and theocriticism and geography, history and economics — why, you can start to make a cartwheel out of the appropriate wood, or spend fifty years learning to begin to learn to beat your adversary at fencing. After that you can start again on mathematics, until it is time to learn to plough.'"1

"That's beautiful," I said. "Where…?"

"Yes, it is beautiful," said the old doctor, "yes it is. You know, you should never forget what it was like to be a student, how you looked at those senior to you in medical school, what you thought of residents, attendings, seasoned clinicians. We should never forget the power we have over the young people in our profession, a power that can shape lives for good or for evil. And believe me, there is evil in the world.

"Live your life as a Jean Valjean rather than an Edmond Dantès. Seize the opportunity to do The Good Thing. No other profession will give you so many chances. Don't become selfish.

"Selfishness. You know, when I have been racked with guilt, when my soul is as thin and dry as a chip of wood, when I feel worthless and have nothing left to give — when, in short, I have become too selfish, too self-absorbed, I've turned to the cure for these feelings — generosity. I've tried to find someone less fortunate and then was generous to a fault."

I walked into his next diatribe as though he had been lying in wait for me. "You know, only yesterday," I said, " I saw this fabulous movie on television…"

"Instead of one hour before the television set," the old man said, "you could memorize a poem. Think of it. Poetry is the quickest, most efficient way into the thoughts and feelings of a culture or a country. The best words in the best order, as they say. Be careful of that television set," he said, admonishing me, shaking his cigar at me. "Life is what is happening to you while you're getting ready for something else.

"Your favorite poem?" he asked.

" 'Dover Beach' I guess," I said. "Yours?"


'Sometimes things don't go, after all
from bad to worse. Some years, muscadel
faces down frost; green thrives; the crops don't fail;
sometimes a man aims high, and all goes well.
A people sometimes will step back from war;
elect an honest man; decide they care
enough, that they can't leave some stranger poor.
Some men become what they were born for.
Sometimes our best efforts do not go
amiss; sometimes we do as we meant to.
The sun will sometimes melt a field of sorrow
that seemed hard frozen: may it happen to you.'" 2

"Who…?" I asked. But he was ahead of me. The approach of death heightens the senses, as they say.

"The accessible poets, that's what I'd suggest. Dickinson, Frost, Wilbur. And set aside time each day to think. Philosophers do this. You should too. Thinking is not daydreaming. Learn how to think. Your training has taught you how to memorize, and, one hopes, how to learn. But rarely does medical school teach anyone how to think. It requires solitude, thinking does, and you can't find solitude in front of a TV set or at one of your health clubs, or when you're distracted on a busy commute. You need real solitude, and this can teach you focus and concentration, which are vital to thinking."

It was two weeks before I could get back to visit the old doctor again. I have chastened myself since, believe me, over what in my absence I might have missed. Nevertheless, when I went back to see him, the housekeeper greeted me with what vaguely resembled a smile, accepted her flowers, led me hastily to his room, and left us alone. He began to talk about his diabetic patient, as though he had never left off, as though it were the next sentence of his story.

"She stood in my office and just wouldn't leave it alone," said the old doctor. "She said to me, 'I know you, Doctor. I know you very well and I love you with my whole heart. I really do.'

"Lucky for me, I could get called away again and think this thing out. I twisted and turned the whole business around to look at it every way I could. I was her doctor, for God's sake, and I had saved her life after all. Why shouldn't she feel some affection for me? And besides, here I was married to medicine. That's a contract just like any other contract, with rules to follow. You just don't break those rules. You don't allow this kind of thing to happen. You keep your distance. We believed that back then just as you do now. I explained all of this to her and she would just stare off with that wide-eyed innocence of hers and smile and say, 'Why can't I just love you?'

"Well, I didn't give her a return appointment. And she didn't come back to the office again, but something made me drive to her home to see her. I don't know what it was. Or did I? I called those trips house calls at first, but who was I kidding? She was very beautiful, in fact, in a fragile sort of way. I remember being amazed at myself that I hadn't noticed her beauty when I had been treating her disease. Now it seemed that all I could see was her beauty. That, and feel this unwavering love she had for me.

"Okay, I wanted to see her. I had to see her. I was breaking all the rules, cheating on medicine, breaking the Oath. I couldn't help myself. I drove over to see her every chance I could get. I'd take her for walks when there was time...or when her disease would let her.

"I didn't know what had come over me. I would be in my office examining a patient and all of a sudden I'd find myself thinking about her. Or I'd be talking to a family in the hospital and I might be trying to explain to them about this disease their Aunt Martha had and suddenly I'd stop and pause and I'd be off in a daydream again, imagining myself walking in the woods and kicking the leaves with her. I would get irritated with my secretary if she scheduled patients in at the end of the day because it would mean I'd only get a later start driving over to see her.

"My guilt really bothered me. I don't want you to misunderstand that. It was more than just nice to be with her. It was wonderful to be with her, and I felt almost like I had to be with her, that it was something I lived for, something that was keeping me alive. But I still felt that she was my patient, that I had medicine, that I was married to medicine, that medicine came first, that I had crossed a line I shouldn't have crossed. I would tell her these things. I would tell her that I felt guilty, that this was wrong, that I really shouldn't be doing this, but that I couldn't help myself. She would simply ask me what could possibly be wrong with two people loving each other.

"Her disease didn't just go away. You realize that. She had some pretty bad episodes — imagine what it was like having diabetes before we had any antibiotics. Whenever she was hospitalized, I'd go over and take care of her because there wasn't anyone else qualified to manage her disease and because...she wouldn't have allowed anybody else to take care of her anyway.

"And she became a different kind of patient for me then, I'll tell you! She would teeter on the brink and I would pace and swear...and pray mostly." His voice caught. He swallowed hard, and I could see the tears.

"Isn't it curious that doctors don't believe in God?" he asked me. "But if there is no God, who do you speak to when your patient is doing poorly? And who is it you are whispering to when you are about to stick the subclavian vein, or send home the LP needle, or spark the lifeless heart? If there is no God, then why is it that patients who are prayed over seem as a group to do better? If there is no God, why is there beauty in the world? If I have learned one thing in forty years of medicine, it is that there is a higher power, and great things unknown to me."

The housekeeper entered with two trays for dinner.

I had arrived.

She left and hastily arrived with a third, joining us for dinner without invitation, without fanfare. She had vased the flowers I had brought her that day and had set them on the sideboard. The fragrance of the paperwhites would not, alas, cut through the cigar smoke. But the housekeeper seemed not to mind. For his part, the old doctor had a full audience now, and although he would refrain from talking about his love, he did not hold back his wisdom.

"How was that meeting you went to?" He gave me no time to answer. "By the way, beware of organizations. Organizations should exist for the common good. But too often they don't. They get caught up in two things. First they try to preserve the monolith above all else; that is, the organization becomes its own first priority. And the second thing, the principal aim of its members becomes self-promotion, when really the members should be working to do The Good Thing."

There it was again, that Good Thing of his. He went on. "To that end, if you find yourself in the unhappy circumstance of belonging to a committee, strive to do The Good Thing, avoid at all costs self-promotion, oppose evil large and small, and in all forms. Speak out, stand for what you believe, fight for the unfortunate, the disenfranchised. In these efforts, be a renegade, a loose cannon, an individual. To become politically adept, a company man, a silent vote for the majority, is to have failed. Oh, you may win titles and position and advancement in the organization, but what have you gained? Remember, there is power in debate and in difference of opinion — in democracy in other words. In 'group-think' there is only death of the soul.

"These organizations that you subscribe to are made up of physicians. And you are a physician so you may have the privilege of caring for others, and of teaching others. For no other reason. Not for some imagined life as a doctor. Not for show, nor ostentation, nor social privilege and position, nor the acquisition of material things. Millions on this earth would give everything they have to trade places with you, for the immense opportunity to do The Good Thing which they now find themselves powerless to do. Don't squander this opportunity.

"Fail one hundred times," he said, nodding to me, "but keep trying. Strive for this on your tombstone:

"'He tried.'"

The housekeeper had left the room abruptly in mid-sentence and was now returning with coffee. Since I had consumed three glasses of Port, smoked two cigars, and was heady with the old doctor's wisdom, I could convince myself that the hunchback had added something to my cup, giving my mind this remarkable clarity. She left again with the dinner trays and dishes, and as I rose to leave in her wake, the doctor motioned for me to stay. He knew, as I did not, that this would be our last evening together.

"You're wondering what became of her," he said to me. "How it all ended, with me and the diabetic girl. Well, that first winter she was in and out of the hospital all the time, but in spring she was ready for her walks again and I'd drive over to see her every evening. I'd look at my office nurse for some sign of disapproval from her and I knew that all my patients knew something was going on, and I expected the same disapproval from them, but it didn't matter to me.

"We took long walks that spring. She would hold my arm in both of hers and lean on me as we walked. I loved every minute of it. We would talk about the War, about the Brits, about how they were holding out, about how I felt that it was my duty to help them out. I remember the day when I stopped abruptly and turned to her. I held her shoulders in my hands and told her I had to do this thing, I had to go overseas, and I had to do this duty but I would be back, and when I came back I would marry her. If she would have me. I was trying to be all serious and formal and get it right, if you know what I mean. But she just widened her eyes and looked in my direction and threw her head back and laughed and said,

"'Have you? Have you? Of course I will have you!'

"They sent me to a station hospital outside Birmingham. I knew as soon as I got there that I should have married her before I left. War is like dying, you know. It brings everything into focus. It shows you what's important and what's senseless. And what was senseless, I'll tell you, was my worrying about this stupid 'marriage contract' I had with medicine. I mean, lives were ending all around me and the world was falling apart and I wanted nothing else but to be with her. I could only think about her.

"We were very busy at the hospital. I don't think I slept a full night in two years. I managed catnaps whenever I could. They evacuated the wounded over to us — those wounded that survived the trip — and we would patch them up. Believe me, there were plenty of wounded.

"But she never left my mind. I would live for the letters from her, letters she dictated to me, written in her mother's hand.

"We were experimenting with Prontosil, the sulfonamide, you know, treating wound infections with it. The Huns had discovered it a few years before and the Brits had gotten very interested in it. We were using it and having some incredible successes."

He half-turned to me and looked at me and then turned his face and his shoulders to the wall and went on with his story.

"Well, it was ironic that we were using Prontosil, creating all of these miracles with the wounded GI's, and then I get the letter from her mother. It was sepsis. She had died of sepsis.

"Do you know how I felt? I raged at myself! I didn't want to live. I couldn't think. I blamed myself. If I had only married her, if she had been my wife they would have sent me back when she got sick. I could've taken the Prontosil back and saved her life. And she would still be with me. I blamed myself for her death. I should've married her when I had the chance. They'd have sent me back to the States because of a sick wife. But they won't evacuate you for a sick patient.

"I didn't want to go on. All around me the world was fighting for survival and I just wanted to die. I remember walking onto the wards and seeing the GI's lying there, missing a limb or an eye, all wrapped up in their pain, yet managing a smile for me and saying, 'Hi Doc,' and 'Thanks Doc' and...

"I just went on with my life. It wasn't any major decision. I didn't say to myself that well, I'm a doctor and I have Medicine, even though I don't have her. I didn't assume that my decision was made for me, or anything like that. I just put one foot in front of the other and did my job. That's what you do. You just do your job."

I didn't know what to say to the old doctor. After all, he had enough wisdom for three lifetimes. What could I tell him? Oh, I said that I understood, that it was human nature to be cautious, to procrastinate. I talked about all the people in my life whom I had wanted to open up to...be open with...whom I had wanted to understand me. I told him about all of the intended "somedays" in my life when I would relax my guard, would allow myself to feel — those "somedays" that never seem to come. I sympathized with him, about how circumstance has a way of slamming the door on you.

I rose, put a hand on his shoulder, and murmured a goodbye. I was never to see him again. When I returned, with flowers, a few days later, there was a black wreath on the door. I handed the flowers to the housekeeper. She nodded a thanks to me silently, and backed in to the darkened house, closing the door in front of her. I was left alone.

I am now given to long walks, and it is at these times I can be with him again — the old doctor who seemingly broke the rules, and so became human. I walk until the hike exhausts me, and I am flooded by the memory of his words, which are these:

"A physician's professional life is threatened by three enemies: arrogance, greed, and intellectual laziness. Hubris is arrogance dignified. Karl Menninger, the great psychiatrist and doctor of doctors once said that he had successfully treated doctors for every manner of illness - substance abuse, marital discord, depression — but had never been able to cure a physician of greed.

"Never ignore a sign or symptom you can't explain.

"Honesty is fitting words to the actions. Integrity is fitting actions to the words. Our actions define us; not principles, not goals, not titles nor academic rank.

"Approach each patient with this thought in mind: I will learn one single new thing from this person.

"Travel. You must visit other universities, other medical centers, other countries, if only to gain an idea of medicine's differences and its commonalties. To remain provincial is to become both arrogant and ignorant.

"Study medical history. Find your place in it.

"Cultivate your teachers well. Have them teach you how to learn, not spoon-feed you. Cultivate your consultants as well. Do not abuse them. Send them the baffling case you cannot diagnose by your own wit. Do not, out of sheer laziness or crunch of time, send headaches to the neurologist, chest pain to the cardiologist, or arthritis to the rheumatologist. Finally, cultivate your students. Do not try to make them into your own image for purposes of self-affirmation. You will harm them in doing so. Bother to find out what they need and want to do, and what they are capable of. For students, as for children, quality time is all that is required.

"Just as you cannot cure all disease, you cannot be a doctor to all patients. For your own piece of mind and for the well-being of patients, you must learn to say "no", and "I am sorry I cannot help you" and "I think it is time you saw someone else". These may be the most difficult things for a physician to say, reared as she is in a world of omnipotence and endless possibilities.

"Communicate. Imagination is the great demon of marriages, partnerships, universities.

"Be on time. Never punish the prompt.

"If you cannot make a diagnosis, make a decision.' A corollary to this is that most things get better by morning. And its antithesis is this: that if you cannot do something, order a test.

"When in doubt, return to first principles. Take a history. Examine the patient. Talk to the family. Ask the nurse.

"Simplify your life. Thoreau was right. Material possessions will possess you. Acquire an object for its utility, not for its appearance. Measure your worth not in things, but in knowledge and in kindness to others.

"Remember this: 'All that is required for evil to triumph is for good people to do nothing.'

"There is too much to know. Learn what you love and leave the rest to others. Libraries are repositories of knowledge. You are not and cannot be, so don't try to be.

For God's sake, stop pitying yourself. The Great Plague of our ancestors killed doctors. Ours does not. Likely you will never be exposed to the Ebola virus. You are not at the mercy of a despotic king. You are neither bound by class, nor diminished by poverty. You have great science as a tool, not leeches. The excellence of your pharmacy dwarfs arsenic, antimony, belladonna. Your citizenry in the richest, most advanced country in the history of the world is no more than sheer good fortune. You do not live in Uganda. You enjoy more than an ox for transportation. Your children will almost certainly reach adulthood.

"Do not waste your time. Be sensitive to anything that threatens to waste your time, and avoid it. Friends are not a waste of time. Nor is family. Nor is thinking. Nor are matters of the spirit and soul.

"Let your children, your spouse, your colleagues, partners and students, overhear you praising them.

"Stay in shape. This means more than mere diet and exercise. You need a diet of poetry and literature, and stiff exercise in thinking and spiritual contemplation.

"Being a doctor requires quick reflexes. The occasion is instant. Hone your reflexes by a regular habit of exposure to patients, talking to them, touching them, taking a history and doing a physical examination.

"Learn how to listen. You cannot understand another, nor take a meaningful history, by talking.

"Avoid arrogance. In the great panoply of human history, what have you to be proud of?

"We exist for each other. Teach others, care for them. Generosity, that's the key.

"When you begin to become overly proud, when you begin to strut and show, ask yourself this: With the tools available at the time, would you have been capable of the observation and description of Hippocrites, the precision and analysis of Sydenham, the auscultatory skill of Laennec?

"Whatever did we do without evidence-based medicine? How did the giants of medicine practice, after all? Well, I believe this: they were inclined to think."

These were great lessons for me. On my long walks, recalling those hours with him, I can begin to believe myself capable of owning a mere portion of them. Even if only a very small portion.

But if there is one certain lesson I have learned from my days spent with the old doctor and his housekeeper, it is this: Commonly, when I return home to my wife, who is a trophy, but whom I did not marry because she is a trophy, I bring her flowers. A lot of them.

Presented as the James M. Moss Lecture, Virginia Chapter ACP 2001


1 TH White The Once and Future King Putnam, Chapter XXI, pp 185-6

2 Sheenagh Pugh "Sometimes" from Selected Poems Dufour Editions, 1990

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