January 3, 2013
On Thursdays, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.
Beth Mazyck, MD, clinical associate professor of family medicine & community health, vice president of medical services at Community Health Connections Family Health Centers and staff physician at Fitchburg Community Health Center, informed me that her story was not exactly one about a clinical success. I would argue that her success is in wrestling with the death of a long-time patient, meeting with the family, and finding grief in her heart as her doctor. Each of us has likely had a similar event—I can remember mine. First year in practice, patient died a week after I saw her and I scanned the file over and over, even gave it to a colleague to review. Even when we offer our best care, patients die. Medicine (as we know it) has no answers in some cases. However, humanity always does.—Hugh Silk, MD
I saw her Monday afternoon. Early Wednesday morning she died in her sleep at home.
What did I do wrong? What did I miss?
She had been my patient for 15 years. Over that time, she had a heart attack and developed congestive heart failure and chronic obstructive pulmonary disease, and had always been morbidly obese. She had a cardiologist. She had a pulmonologist. But on Monday she came to see me, her primary care provider, because she had a cough that was keeping her up at night.
Her vital signs were normal. Her exam was essentially normal. I ordered a chest X-ray, told her to take extra Lasix for the mild ankle edema. I offered to see her back in one week, but she thought that two weeks would be fine. I had one of our medical assistants take her down to radiology by wheelchair for the X-ray, then wait with her for the taxi that would take her home.
Wednesday evening, when I finally had time to review the message that she had died early that morning, I called her daughter, expressed my shock, and gave her my condolences. I arranged for a visit the next day for her daughter and her husband, both of whom are also patients of mine.
I reviewed my note, the chest X-ray results. I missed nothing. There was no indication that she needed to have gone to the emergency department. Intellectually I know there was nothing more that I could have done.
So, why do I still feel that I should have done more? That I should have known somehow?
What did I miss?
I miss her.