Reflections in a Head Mirror

I am truly fortunate today … I had an essay published in JAMA entitled “Listening to Leviticus,” in which I wrote about the emotional turmoil I went through in the process of caring for a wonderful patient with a large goiter who was a member of the Jehovah’s Witnesses. Long story short: Everything turns out fine.  

As if that wasn’t great enough, the article was picked up by the New York Times Health Blog and has generated a number of comments. I usually receive two or three comments for each blog post; I’m not used to this much attention.  

For those who are interested, I had another essay published in JAMA a few weeks ago entitled, “The Book.”  

Thanks for reading these entries! I appreciate your comments and suggestions.

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The following is feedback received for this blog: Congratulations on your multiple publications in JAMA. The Leviticus one was very well written. You have inspired me to submit to them as well. Got any tips to share? I will probably link to this post and the JAMA article in a upcoming Pallimed post. - Christian Sinclair www.pallimed.org I have to say, the praise is well-deserved. I very much enjoy reading everything you write. - Rob Lamberts http://distractible.org Congratulations! Both stories are thought-provoking and very well written (as all your writings). "The Book" really left me puzzled. - Oystein Horgmo http://sterileeye.com Congratulations, Bruce, on your fine work. Reminds us that there is a very real human side to our interactions with our patients. Many of us feel as you do but don't have the gift of expressing it so eloquently. Please continue your writing! - Thomas Kidder, M.D. I really enjoyed reading your JAMA essay entitled "Listening to Leviticus." Great piece of work! - Wook Lee

“Always write angry letters to your enemies. Never mail them.”
-James Fallows    


“He should never have agreed to treatment! It was the worst thing he could ever have done! I can’t believe you doctors did this to him!”  

My patient’s cousin, whom I had never met before, was very angry and I was her target. Unfortunately, she chose his funeral as her opportunity to unload on me.  

At one level, it was hard to disagree with her. He had been a gentle, hardworking, and quiet man. I had actually met him on occasion before he had developed cancer since his profession brought him into the hospital on a regular basis. In his mid-40s, a large cancer had developed in the sinuses that extend between his eyes. Despite aggressive surgery and radiation, the cancer had recurred just a few months after its initial treatment. Chemotherapy had been unhelpful, and, in the weeks before he died, he had been miserable. His vision had deteriorated, his cancer had a penetrating, noticeable odor, and it had been very difficult to find a balance between pain control and over-sedation. He told me more than once that he was ready to go.  

Still, the cousin’s diatribe had taken me by surprise. I tried to think of a response, but could not. “I’m so sorry,” I said. “He was a wonderful person.”  

She glared at me and said nothing.  

I thought to myself …Would we have done anything differently had we known ahead of time that his tumor would be so unresponsive? I was uncertain. By searching the medical literature, we can predict how groups of similar patients will do, but there are wide differences in individual outcomes. He might just as easily have sailed through treatment and had a complete response.    

One of his sisters, whom I had known well throughout his ordeal, saw what was happening and stepped in just as the angry cousin stormed off.  

“We know you did all you could. Thank you, Doctor.”  

“I’m so sorry,” I repeated.  

She, too, said nothing at first. Then, “We all will need some more time to heal.”   

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The following is feedback received for this blog:

Another great post from you. It is hard all around when things go like this. You were good to go to the funeral. I feel sure you did your best. It's tough (and often hard to accept) when that is not good enough. - rl bates   http://rlbatesmd.blogspot.com/

“Take care of all of your memories. For you cannot relive them.”
- Bob Dylan  


For a 1958 Saturday Evening Post cover, Norman Rockwell created a painting of a young boy standing on a chair and facing the wall in the doctor’s office. The boy stares at the large diploma directly in front of him, his hands securely holding onto his unbuckled pants. While he waits, the distinguished, white-smocked doctor, working across the room, unhurriedly prepares an injection. The image, “The Doctor’s Office,” brings back vivid memories for me.  

I grew up in the 1960’s. I can recall the tinge of anxiety as I held my mother’s hand in the lobby of the Medical Arts Building. I can remember anticipating the jolts as the operator clanked the internal metal cage shut before the elevator lurched into action. I can see the heavy dark varnish covering all of the woodwork in the corridors and hear the rattle of the frosted glass-paneled doors as they opened and closed down the hallway. I can smell the mercurochrome, taste the thermometer that had been soaked in disinfectant, feel the cotton ball soaked with alcohol on my arm, and taste the sugar cube impregnated with the polio vaccine. I can hear the crinkling paper sheet under my legs and feel my legs swinging as I sat waiting forever for the doctor to come into our room.    

Mostly I remember the doctor exploding into the room, greeting my mother, and telling me how big I was getting. He smelled of cigarette smoke in a time when that was just fine. His stethoscope was cold but his hands were large and warm as he moved through the exam, felt my belly, checked my reflexes, and tousled my hair. I remember the relief if the doctor grinned at me and announced, “No shot today, Sonny Boy!”  

Years later, I learned that my pediatrician had been on an academic faculty earlier in his career, publishing papers on the effects of war on children and authoring a book on normal pediatric growth and development. But as I was growing up, he was the unhurried, reassuring man in the white smock with the booming voice and ready smile who worked in a building with a really cool elevator.

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The following is feedback received for this blog:

Hi! Loved your last Reflections. Do you know that Dr. [XXX] was your first pediatrician? He was awful. I was doing everything wrong; He bawled me out! [My friend] got the same treatment. She brought little Mike in and when Dr. XXX stepped out for something, Mike asked "Has he gone to get a gun?" You can see why I switched pediatricians! Keep Reflections coming! Love, Mom Dear Mom, Thanks! Love, Bruce

“It is a wise father that knows his own child.”
-Shakespeare      



Once upon a time, many years ago, my family was visiting for the holidays. On several occasions, I had tried, with only intermittent success, to explain to my father what I did for a living. On this day, I casually invited him to make rounds with me; he readily agreed.  

When we got to the hospital, we headed to the inpatient floor. One of the patients that day was Mr. Johnson, a young man who had undergone cancer surgery to remove part of his cheekbone the day before. He had done well overnight and was recovering. I stuck my head into his room.  

“Merry Christmas!” I said. “I have my father with me this morning to make rounds. He is not a doctor but he would like to meet you. Do you mind if he comes in with me?”  

“That would be fine,” Mr. Johnson responded.  

I returned to the hallway and retrieved my father. We entered and stood by the bed. If my father was surprised by my patient’s early post-operative appearance, he did not let on.    

“Good morning, Mr. Johnson! How are you doing today?”  

Despite his obvious swelling, Mr. Johnson replied, “I’m doing very well, thanks.” The young man was lying in bed with his one eye  nearly shut and his cheek full of packing material. His fresh facial wounds were still healing and his skin graft donor site on his leg was tender. As I checked his surgical sites and looked at the chart, the patient spent a few minutes addressing my father and describing his initial symptoms, his treatment, and his recovery. My dad, a distinguished looking gentleman with graying temples, stood and listened, intermittently nodding and smiling, all the while absorbing the story.  

“How long do you think I will be in the hospital?” asked my patient. My dad glanced at me.  

“I think you are doing great,” I said. “I predict you will be home the day after tomorrow.”  

“Thanks again, Doc. I’ll let my family know.”  

Over the subsequent years, I didn’t remember many details of the visit, but my father certainly did. Several times during the remainder of his life, my dad reminded me about that day and inquired about the patients he had met. Those few minutes had given him insight into my life that I could never have provided by just telling him what I do.      

Many years later, I received a Christmas card from Mr. Johnson, marking the anniversary of his hospitalization. “I remember you even came to see me on Christmas Day with your Dad. I will never forget that,” he wrote.  

As I read the card, I was surprised how that brief encounter many years before had clearly impacted both my father and the patient. The shared experience of illness had affected both of them, sharpening their senses. Later, when I responded to Mr. Johnson’s card, I realized that I was grateful not only to have cared for the patient, but that I was particularly grateful to have shared that moment of insight, healing, and presence both with Mr. Johnson and with my father. It was a holiday gift I will always remember. 

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The following is feedback received for this blog:

This is one of my favorite posts of yours. Incredibly touching. Reminds me of how my mom used to send my surgeon a Christmas card each year, to let him know how I was progressing (he saved my life as an infant). And each year he'd write back a hand written card. Those little human touches mean a lot. - Val Jones www.revolutionhealth.com/blogs/valjonesmd  I love this one. - selim firat What a great post! I've had moments like these, and it never ceases to amaze me how much impact we have on the lives of our patients, and how things that seem so little to us can mean so much. And, conversely, how much of an impact our patients have on us. - David Loeb http://doctordavidsblog.blogspot.com/