Sunday, October 10, 2010

the gift

sometimes a patient will give a thank you gift to me. sometimes they want to give more. i'm always a bit awkward with this.

the casualty officer called me and told me he had admitted a patient with an acute abdomen. this is surgical jargon pretty much meaning that the patient needed a laparotomy, most likely as a life saving procedure. i immediately went to see him.

the abdomen was supremely tender and i agreed that it looked to be a case for theater. but then the patient told me that twice before in his life he had presented at different hospitals with the same pain. the surgeons on both occasions had rushed him off to theater and found nothing. these two operations had then indirectly given rise to a multitude of other operations for obstruction. he even volunteered the information that the last surgeon who had operated him told him he had a frozen abdomen (a frozen abdomen is the condition when all your intestines are adhered to each other because of multiple previous operation. it is a nightmare to operate and associated with a high chance of injury to the bowel). red lights were going off in my mind. i decided to see if we could avoid an operation.

the ct didn't show any calamity in the abdomen but there were signs of partial obstruction which was consistent with frozen abdomen. i approached the patient and explained that we were going to try to avoid an operation, but if his conditioned worsened, then we would have no choice. i also explained that an operation in his case held a very high risk of complications. combined with his advanced years, these could be serious.

he recovered well without surgery. i was relieved. every day we would chat less about his medical condition and more about him as a person. it turned out that he worked in one of the fancy private lodges in the kruger and he was keen for me to visit. i said thank you but in myself i sort of knew i wouldn't take him up on his offer. i mean after all i hadn't necessarily gotten him through his ordeal yet.

when he left the hospital again he told me i must visit him in the kruger. again i thanked him but soon forgot about it.

some time later he presented again with abdominal pain. again the ct showed pretty much the same partial obstruction, but with impressively dilated small bowel (worryingly so). he informed me that he lived with a constant degree of abdominal pain and felt he could not go on. once again i told him that an operation would be risky but it could be considered. he felt there was nothing to consider. according to him anything was better than his present life of pain and misery. at that time he told me that i could do with him whatever i liked. he thought i was the greatest seeing that i so far was the only surgeon who didn't rush him off to theater and rip him open from stem to stern. i wanted to mention that we both had been a bit lucky, but i sort of liked the adoration so i just smiled. we decided to proceed.

just before theater the patient reminded me to visit him in the kruger and then the penny dropped. i realised the reason i was reluctant to accept is sometimes my patients die. i can't always predict who is going to die and who is going to make it. to accept such a wonderful gift from this man seemed wrong, especially in the light of the fact that i was not convinced the overall outcome would be favourable. it seemed a bit too much like taking advantage. i suppose in a way i was keeping myself at a distance from the humanity of the man in order to better do my job. i suppose i was also thereby denying myself my own humanity.

the operation was tense but it went well. he recovered and afterwards once again swore i was the best surgeon in the world. i was just glad things didn't go wrong. i didn't really feel that i could take either credit for the good outcome or his gracious gift of time in a fancy lodge in the kruger.

we parted company and i'm happy to say i never heard from him again. happy because that meant things were probably going well.

then some years later i was asked to see another patient. it was a case of severe abdominal sepsis. once again this is a condition that in certain cases can be the event that ends the patient's life, but i was confident i'd be able to pull her through. early on in the management there was talk of a private game lodge and once again i sort of brushed it aside. i pushed through the operation and the post operative period.

but as time went on, it quickly became apparent that survival was assured and i even started hoping for complete recovery. finally she went home in good health. then and only then did i questioned my usual approach of not accepting these sorts of gifts from patients. i mean in the end it was offered in good faith and with pure intentions. and it did seem unlikely that she would complicate at this late stage. i started considering it. after all i have often said my job is to return people to their humanity. now that she was back to a point where she could go on with her life and be herself again, wasn't i now stopping her from doing something that is quite human, ie the heartfelt giving of a gift. also it had something to do with my own humanity. so often when i'm treating patients i need to separate myself to a certain degree to keep perspective and to allow myself to do my job without being too clouded by human emotions. and yet essentially i am human and i do have human emotions and i do want to get to know people as they are and not just as the patients that lie before me.

so in the end, more in attempt to try to restore my own humanity, i accepted. it was a magical place with wonderful people and a real balm for my soul. m and b, thank you very much for allowing me to find my humanity again.


Unknown said...

Maintaining one's humanity is the secret for being areal physician ; as opposed to merely a technician.

Blaz said...

None of my colleagues (or I for that matter) would dare to dream to accept anything patients wish to give us. Firstly, it is widely accepted as wrong (inequal positions when the patient is sick and thereafter when overwhelming gratitude kicks in etc.) and secondly - it is forbidden by law and is classified as corruption (there is an upper limit of 50€ that is not considered criminal, though). Anyways, people can be very persuasive so in my ER we have come up with a plan - when someone has really, really set his/her mind, we channel that into sending us a postcard from where they live and tell us how they're doing. It's a win-win situation - nice people get the feeling someone really cared (we did!) and we get a glimpse into our patients' personalities... And I absolutely understand your dilemmas and I do know how human you felt afterwards (had an interaction including a basket of hand-picked blueberries once from a person who was constantly confused and physically lost before we met - the best blueberries I ever had!).

Dr. Rob said...

Agree that it's a hard line to draw. People want to treat you like a hero when doing otherwise would have been neglecting your job. Still it is important for people to be able to show gratitude.

I usually get cookies, though. No fancy lodges here.

Nicholas Fogelson, MD said...

Sometimes I think that medicine has changed for the worse. There was a time when doctors came to people's houses and knew their families. They made incredible connections on a daily basis.

And in those days, doctors would be far more likely to accept such gifts.

Now we have big organizations that tell us what the new morality is, and that we cannot be corrupted by such influences. Its such hogshit. Giving an accepting a gift is one of the most human and intimate things we do. Given without promting and accepted without expectation, there is nothing wrong with it.

I think doctors should be able to decide what's right and wrong without some organizing body telling is what it is. If it feels good for the patient to offer, and it feels fine to accept, then by all means say yes.

Bongi said...

nicholas, you make a very good point and in a sense that is what this post is about.

it is a bit of a controversial topic and i suppose thar is why i am usually reticent to accept such things. however, in my life, this was an exception and in this situation i am sure in myself that i was not unethical.

i also wonder if the ethics of such a thing may also be culturally bound. maybe our culture is still in a sense old fashioned and this is not quite so frowned upon as it would be in a place like the usa.

anyway, it was a fulfilling experience for me and i have no regrets about accepting such a gesture from this specific couple.

Amanzi Down Under said...

I always politely decline any gift as a rule.

Although I have found the odd bottle of wine "turn up" in my office with a thank you note.

Recently a lady promised me a place on her whale-watching boat and then delivered a free ticket to the hospital. I justified it by taking 2 full paying guests along.

The best gift I got was a thank you letter written in terrible handwriting from a fellow doctor who was involved in a horrific car accident that I treated in ER some months ago. She is only now regaining the use of her arm.

Cams said...

People are not perfect same as doctors. They cure and save life cos that is their mission but despite that mission in life they all are humans. Allow me to say this doctors also they also need time to be humane again. Their task is very challenging. A patient would die because of them. And a patient would have long life also because of them.