The kindness of strangers

Kendall A. Noel

Patients—that is, people—appreciate kindness—whether it be from a friend, a stranger, or a family physician. During my medical training, the ability to maintain one’s distance from the patient was emphasized as a highly regarded aspect of professionalism, but is it really so important? We teach it to our students, we teach it to our residents, but how does it fit with the principles of the patient-centred clinical method and the many years of continuous care that practitioners of family medicine provide to their patients?

Mr and Mrs L. entered into my practice together, having transferred from one of my colleagues. They were formidable individuals, God-fearing salt-of-the-earth jokesters who could read you in a second and then, if they felt the need, share exactly what they thought of you for the next 2 hours.

Mrs L. was, by her own admission, both vertically challenged and horizontally gifted, but she liked it that way. Oh, we would discuss her concerns about her diabetes and her struggles with her weight, although she confided that she loved her evening snacks, fully aware that they didn’t help her glucose control. We also talked about her family. Her daughter had passed away a few years earlier, and we talked about the pain known only to parents who have had to bury a child, the unnaturalness of it all, and of how she would have given anything to have let it be her, and not her daughter, on that day.

And we talked about her son, her worries about him and his relationship. She was proud of him, wishing only that he could see as much in himself as she did. And, of course, we would talk about her husband, Jean, about her love for him and her concerns about his health and family history, and about how he was relating to his son. She was the “preparer,” briefing me for my visits with her husband. “You are going to see Jean next week,” she would say. “Be sure to ask him about the pain he has been having. He probably won’t tell you about it, but it is driving me nuts hearing him complain about it.” Mr L. was in good hands.

Many of us entered into medicine with a burning desire to help people—sick people, sick children, pregnant women, the elderly, people not happy with how they looked, people unable to see—all people. And yet, once we started medical school, much time was spent putting a divide between us and the patient. Despite our grandmother’s illness being one of the reasons we chose to become a doctor, we learned that we should not care for family members. Despite our own battles with disease and illness being our call to medicine, we were quickly taught about the importance of the physician not healing thyself. Despite our willingness to give the shirt off our back to assist people, to go to any lengths to help, we were told that there was an important professional boundary that we had to place between ourselves and the patient. This boundary was important not only to maintaining our objectivity but also to preventing us from inadvertently harming a patient.

During a short absence of mine from the office, Mrs L. presented with what looked like an abscess in her buttock. Attempts to drain it proved unhelpful. She was sent to the emergency department and eventually to general surgery for more extensive debridement. The surgeon had just as much trouble and sent a tissue sample to Pathology. The results reported evidence of a sarcoma. Upon my return from holidays, the results were in, and it was my responsibility to share them with Mrs L.

Mrs L. sat there, stricken and yet unsurprised. Mr L. let me know that this was like getting a kick in the teeth, a real shocker, but that he was prepared to do anything to help his wife. Mr L., nearing retirement, had been dealing with problems at work and feeling pressure to make a move. His wife’s diagnosis moved these issues to the shadows. There would be no husband more devoted than Mr L.

Days turned to weeks; weeks turned to months; and eventually Mrs L.’s cancer proved to be both inoperable and incurable. I made a few home visits, during which Mrs L. and I talked again about the unnaturalness of it all. We talked about what she would miss most, what least, what she would not miss at all, and what she was looking forward to—being reunited with her daughter. I would ask her how her husband was doing. “Not too good,” she would reply, as the stress of their situation was overwhelming.

I spoke with Mr L., who confirmed his wife’s impression. “Doc, it is like getting a kick in the teeth.”

So, how do you take the burning desire to help and the willingness to go to any lengths to do so, which a type-A medical student sees as an inherent part of his or her character, and teach that student to look at it differently? You break it and tear it apart, insisting upon a strict definition of professionalism, one that requires cool, calculating objectivity, and then trust that with time the caring individual will rediscover how best to help people within the confines of their new-found profession.

The last time I saw Mrs L., she was semicomatose, lying in a hospital bed at the palliative care hospital. Her care had become too much to handle from home. Her room was noisy because the grandchildren were visiting, but she was exhibiting signs of Kussmaul breathing and her eyes were glazing over. In a moment of privacy, I leaned over and whispered to her, “Rest, dear friend, you are a remarkable woman and you have lived a good life.” I then looked her in the eyes, held her hand, and said my goodbye. There would be no more conversations between us, this much I was sure. I then spent some time speaking with her husband. He had many questions and I had very few answers, and yet we both understood. In the end, I did not want to take up too much of his time—we both knew that she had so little time left. It was important that he and the family spend as much of it with her as possible.

Mrs L. passed away, and shortly thereafter, Mr L. came to my office and thanked me for the visits to their home and to the hospital to see his wife. He commented on how so few physicians seem to do these things these days, but I could only think about how unfortunate it was that I was not able to be the physician caring for his wife in her final days, the kind of physician I wanted to be when I entered into medicine. We spent a good 30 minutes speaking during that visit, about the past and about his plan for the immediate future: “I’m going to fix up my bike and go for a ride—I need to clear my mind.”

The longer one is in practice, the more one comes to know one’s patients, and in many ways, our patients come to know us too—often times better than we think, coming to see us as a part of the family, a trusted friend, a dependable neighbour, a good doctor. After 12 years of practice, I am no longer a stranger to my patients, in particular to those whom I have had the honour to care for since I started out, and that is perhaps a good thing. The importance of the professional boundary, and the understanding that caring for one’s patient is not sine qua non a crossing of it, is a lesson that family doctors learn during the course of their careers. This thing of ours, the patient-doctor relationship, is a mutual, multilateral investment that pays out its dividends in trust, the intangible aspect of a relationship that allows our patients to follow our advice and lets us feel comfortable providing it. And building that trust starts with the kindness of individuals not willing to remain strangers. Goodbye, Mrs L. Rest peacefully.