The young resident presented the patient in the usual dry terms we use for such things.

"The patient is a 42 year old woman recently hospitalized for cirrhosis due to alcohol use. Her cirrhosis has been complicated by esophageal varices, encephalopathy, and refractory ascites."

In other words, the woman has drunk herself nearly to death.

"Is she still drinking?" I asked.

"She says not. She says she stopped about six months ago when she first got sick."

"What did GI say? Did they refer her for transplant evaluation?"

"No," she said, a bit disappointedly, "they said she wasn't a candidate."

I pulled up the GI consult in the computer:

In summary, Mrs. Polascyki is a 42 year old alcoholic with end-stage liver disease and unclear duration of sobriety. Given her severity of illness, lack of a permanent residence, and recent drinking, she is unlikely to survive long enough to qualify for transplant.

"What do you think?" I asked her.

"They said she's not a candidate."

"I know. I read it. What do you think?"

"She's stopped drinking. She wants to get better. She's shown up for two appointments in a row. She's trying."

"OK, finish up her paperwork for this visit. Let me make a quick call."

I paged one of the GI fellows. She had been both a student and resident of mine in the past and I knew she had a good head and a good heart. I ran the case by her.

"Why didn't they refer her for transplant eval?" she asked me.

"Why do you think? What can we do next?"

"Ask the secretary to overbook her with me next week. I'll get the workup going and make the calls."

We sat there afterward, the resident and I, her pained look fading.

"You know," I said, "she's probably going to die before she gets a liver." Her eyes teared up a little.

"But she's trying," she said, not quite sure if it was a question or not.

"Yes, but just as important, you're trying. You're giving her hope. Whether she lives or dies matters, of course, but either way, for maybe the first time ever, someone cares enough to go to bat for her. She sees that, you know."

The young doctor nodded.

"Whatever else happens, today was the day someone believed her and tried to help her. If she doesn't make it, she's going to die knowing someone cared. That matters."

At the beginning of the year, I tell my residents that I understand their outpatient clinics are challenging. "It's service," I tell them. "We're taking care of people who have nowhere else to go. No one wants them."

I was wrong.

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I was wrong.

Isn't it amazing how many of the most important sentences have three words?

By D. C. Sessions (not verified) on 27 Oct 2009 #permalink

This, to me, is what the practice of medicine should look like.

It's also an excellent piece of writing: bravo on all fronts, palMD!

re: how

Completely seconded. Kudos, Pal.

Writing through my tears.
Bravo, and brava to the resident.
Good luck to the patient.

This is why I'm going into medicine. Thank you.

I choked up too.

I'm an MR tech, and I often do expensive scans on uninsured patients who seem to be useless wastes of space--drug users, alcoholics, obese diabetic smokers who refuse to take care of themselves. But I try to give everyone the same respect and good care, because I remember something from my youth.

When I was young and naive and volunteering for the local United Fund, I visited a local residential care center for abused children. The counselors told us the horrific stories of the physical, sexual, and emotional abuse these children had experienced and how disturbed they were as a result. At the time I couldn't even have imagined that such horrors existed. Now when I have to care for one of life's losers, I think--he or she could have been one of those kids. What would I have become?

Good luck to all of you.

Thank you, PalMD, for your care and compassion and thank you for being the teacher of new doctors.

By Anneliese (not verified) on 28 Oct 2009 #permalink

Thank you. She could have been me in 1974. Next week I will celebrate 35 sober years. I'm one of the lucky ones.

By Anonymous (not verified) on 28 Oct 2009 #permalink

Either everyone counts or nobody counts.

By CanadaGoose (not verified) on 28 Oct 2009 #permalink