Thanks for the orange juice

Geneviève L’Écuyer

My biggest challenge, when I started my family medicine residency, was managing my insecurity. This was a challenge all the time, but it was particularly hard during on calls. When the phone rang at 3 in the morning and it was the nurse calling to say that she needed me to certify a death, I felt incredible relief. And when the family was not present and I could be back in the on-call room within 10 minutes, I felt relief mixed with guilt.

Having said this, I never felt that I was a bad resident. It was just that handling emergencies and working for long stretches of time had not been part of my career aspirations. Mental health and providing patients with follow-up care were more what I had in mind; I liked to think that I had good relationships with my patients.

And then, at 1 o’clock one March morning on the last night of a really grueling week of on calls, it all fell apart. I was called to the side of a patient in cardiology: the attending physician had prescribed metoprolol IV while she was still at home for rapid atrial fibrillation. The patient was an 83-year-old woman who had been admitted for a massive left-sided stroke, with AF de novo and urosepsis. I opened the patient’s record and scanned it for the information I would need for my note. Then my eye was drawn to the upper right-hand corner of the most recent entry. Mrs Masson—my Mrs Masson!

I had been visiting this patient at home for 8 months, following a stroke that had left her with major left-sided hemiparesis. Prior to her stroke, she had been in perfect health. She was kindly, somewhat frail, and very engaging. Because I was still working on my interviewing skills, within 3 visits I knew the history of her life and her family and had anecdotes for each of the “portraits” that hung on the walls of her home. In November, she had written “Happy Birthday, Dr L’Écuyer” on her calendar, after I mentioned, jokingly, that my birthday present to myself would be to visit her on my birthday in December. She insisted on giving me a glass of orange juice, apologizing profusely for not having a present for me. Her husband and daughter were there and I lingered for a while.

For 2 months, Mrs Masson had been complaining of an atypical, vague burning sensation when she urinated. All the test results and examination findings had been normal, and her symptoms appeared to be improving without treatment. The week before the fateful call, she was doing very well, with rock-solid vital signs—“better than my own,” I had told her—and the examination was most reassuring.

And now, before me, was a woman I hardly recognized. Not only did she have “double hemiparesis” but her facial features had completely changed. She now had the look that all patients, regardless of their pathologies, have when they are hours away from death. I asked her if she recognized me. Although her voice was unrecognizable, she said yes. When I asked her if she was comfortable, she said that she was. As I left the room, the nurse turned to me and said, “She answers yes to all of our questions.”

One of the notes in the file left me stunned: “Talked with family. Patient has had urinary symptoms for 2 months that have not been treated by the family physician. Urosepsis, secondary AF, and embolic stroke.”

Still in shock, it was not until the next day that I questioned my judgment. Was I a bad resident? Had I done a poor job of assessing her condition? I pictured a heated discussion with the family—even a lawsuit. I pictured my supervisor criticizing my lack of attention. Without being able to say exactly why, I felt helpless in the face of her rapidly deteriorating condition.

When I returned to the office on the Friday after my on call, there was a note saying that Mrs Masson was in palliative care. With a knot in my stomach, I picked up the phone to call her daughter. I was not sure whether I was afraid of reprisals or whether I felt inappropriate sympathy for this gentle old lady with whom I had shared a glass of juice. As it turned out, her daughter’s voice was warm, almost overly so. She was very happy with her mother’s care and relieved that her mother was no longer suffering. I was puzzled, yet I was beginning to understand the value of the relationship of care that I had created with the patient and her family over the months. They trusted me. There was nothing I needed to criticize myself for. I had not overlooked anything.

The following Monday, there was a note saying that Mrs Masson had died. Without quite knowing why, I thought of the resident who would have been called to certify her death. Had she been disappointed to see the family around the deathbed, as I would have been? Was she disappointed that she would have to sympathize with them? Would she have preferred to hurry back to her warm bed? And here was another lesson for me: it is easier to keep a distance. It takes time to transform one’s sensitivity into professional empathy.

Just before I wrote this, I called Mrs Masson’s husband. He was calm and glad to hear from me. He asked me to be his home physician and to fill the void left by his spouse. And then he started to talk about the weather. I now understood that Mrs Masson and her family had already grieved, after her first stroke. I understood something that my medical training had not enabled me to grasp: people can become serene when faced with death. How lucky I was to have treated this woman. Thank you for these lessons, Mrs Masson. And thanks for the orange juice!