We are born, and we find ourselves thrown into the ring of life. And it’s quite a prize fight. And there are many punches thrown at you in a medical life. Internship. Peer Review. Medicare audits. Recertification. Malpractice. Maybe those make up the big prize fights, the headliners, but sometimes it the smaller bouts on the undercard, the quiet struggles of patients and their doctors, that are the real stories, the ones that touch your heart and knock you out cold.
Who wins these medical exam room battles with disease and aging? Does the patient always lose or is it sometimes the doctor’s soul that leaves bruised and beaten? There are 15 long rounds of a career if you keep stepping in to the fight. And what higher power is the referee? Is the reward a personal Heaven or Hell? I don’t know that answer. For today, I’m stepping out through the corner ropes and just being the ringside announcer. For today, I’m just telling a story about one of those bouts.
It started with my daily card of patients on an ordinary day. I walked into an exam room harried with a doctor’s time pressures. I’m behind. The schedule always wins. On the daily appointment log, it says the patients will cross the finish at 5PM. I usually reach the end at 6. I lose. On my desk, there are mounds of prescription requests and lab results. I look over at the phone nurses who are furiously scribbling to churn out more requests like a robotic assembly line. It is an ordinary day.
When I entered exam room 2B, it was still the same ordinary day – the nurses, the paperwork, the clock. But it would all look different when I came out. When I went in, I was just part of this self-absorbed medical machine. When I came out, I would be disconnected, and for a long while, I would not be connected again.
My patient began her history. “My father called me.” Not what I expected my patient to start talking about, since I knew she had suffered an abusive childhood. “He died. He was in the hospital for a heart attack and he died.”
“I’m sorry to hear that.” I said something like that in my best professional voice. She had me a little off balance.
“Oh, he’s OK.” I just remember she said he was OK. In truth, I’m telling you what happened was 25 years ago. It’s hard to remember exactly what she said. Her father had been resuscitated. He was back. He was OK. And she was going to go see him. I guess she would have to do that. And she said he was being nice.
Nice. A big change. This was the guy who was abusive her whole life. And it was a HARD life without much grace. Fifty long years had brought my patient thinned hair and cracked hands. Having four children had brought urinary incontinence. Working endless shifts as a waitress had brought low back pain and sciatica. Love had brought divorce. But maybe life hadn’t brought her a broken spirit yet. She still had some fight left in her. She still had hopes.
“He says he’s changed.”
Well, maybe. I suppose these afterlife experiences really have an impact on people. See your ancestors in the beautiful light and you get slapped with the mother of all wake-up calls. Ring, ring, ring. Better change where you’re going with your life.
“He went to hell.”
Now I felt like I’d taken one in the gut. I hadn’t seen that one coming. I was knocked back and staggered. My professional guard had been down. We think we had seen it all before. I had never seen this. I remember fumbling for words. She went right on. She told me all about Hell; and it was horrible. Her father had said that he needed to change. He didn’t want to go back there. She paused and continued.
Hell was cold, he had said. And not the temperature. It was the coldest place he’d ever been. The loneliness is what made it cold. The complete black emptiness. She went on to describe the complete loss of everything. A past where you couldn’t know if you really remembered anything real. A forever present without anybody. A future of nothingness. A blackest black, an emptiest emptiness, an endless end. Somehow, in her words, I felt like I was being pulled down into Hell with him. I remained stunned. Of all the lines she could have delivered, I wasn’t ready for Hell.
Again, I said something like, “I’m sorry to hear all that.” I might have been talking to her or I might have been talking to myself. I felt so naïve. There was so much I thought I knew, but now my professional confidence was shaken. And she could see that, too. I was a bit diminished. How many times can patients see right through us? See clearly that we are just so much medical bluster, thinking we know more than we do. And yet, in her eyes, I also saw some forgiveness. Whatever I was doing, she wasn’t here to fight with me or make me look bad. There was no fight between us. Only a fight against the brutal barrage of life’s afflictions.
She was going to visit her father. It would be hard. He was very ill and she was already over-burdened. We were back in the here and now. Back in a thankless world of families on the ropes, where toil and care are obligatory and rewards are not. No miracle comebacks today. Apology or not, she now had one more thing on her plate. I had one more prescription to fill. These amazing stories from patients. Too often, they end with a small white square prescription pad scrawled with my signature, and then an awkward shuffle out the exam room door.
I continued to struggle with this story of Hell. I’m Jewish. We don’t cotton too much to Heaven and Hell. Oh, they’re sometimes part of the theology, but mostly not. Our judgment is here on Earth. In Hebrew, “hee-nae-ni” means “here I am Lord”. When we say this word, we recognize that God is watching us now, here, today. We must choose the right choice every single moment. And Heaven is here for us to build on Earth. Our life’s duty is “Tikum Olam” – meaning “Heal the world”. We see ourselves as the worker angels that raise the floors for the edifice of Heaven. Jews must leave this world lifted closer to a higher plane than when we arrived. There is no Hell, but there is the daily weighty glare upon us from a seriously expectant Father.
But this current Hell was finally explained to me by a young devout Christian. “Of course that is Hell. Hell is the absence of connection to God”. And that was all she had to say, so seemingly obvious. Yes, the absence of connection to God, and with it, the absence of connection to all of humankind. It made a certain, perfect, religious sense; it was the true opposite of the beautiful welcoming light.
At this point, you might ask yourself whether you are comfortable with the reality of this seemingly celestial story. Well, I will assure you, I still regard this as a secular narrative of medicine. It is the tale of a doctor and a patient and a 25 year relationship through good times and bad, through some deep professional connection and some callous professional disregard, my own manifestations of good and evil. And perhaps I am not describing the afterlife of Heaven and Hell anyway, but merely a momentary sojourn to the so-called “collective unconscious”, buried deep in the limbic system, too deep a tremor for the seismic EEG, too dark a sulcus for the magnetic light of the MRI. Perhaps this is a primordial zone from an ancient emotional goo that has always bubbled forth with what we struggle to name as rapture and ecstasy or terror and devastation.
But let’s go back to the story. The patient leaves; the page turns. The patient has shuffled through many hard visits and many white squares of prescription paper.
The patient’s father did not stay a good man. His repentance was revoked. It took four years, but he reverted back to his old and terrible ways.
The father’s original heart attack and cardiac arrest were of his own doing. He had put a gun to his own head and sent a bullet up through his neck and out his jaw. What could you expect from a man “who never went anywhere without carrying two knives and two guns”? I don’t know why he did it, and I don’t really care to know. One could say he deserved it for all the abuse he laid upon his loved ones. In the end, he finally laid his judgmental abuse upon himself. There were many long hospitalizations on the road to his eventual, inadequate recovery, and several cardiac arrests as well. During one of them, he went to Hell. As one nurse said, “It would have been better if he never came back.” Maybe he never did. His ultimate facial reconstruction was hideous.
But for a while he DID reform. Then he turned. “He would beat me, even in his condition. He would hit me and punch me.” There were always vicious family fights with my patient as the scapegoat for all his discontent. He went on to disown her, along with her children, and even his great-grandchildren. “The last time I saw my father he was going to get his gun. That was the last time I saw him. I had finally said, ‘This house has too many secrets. And it would do some good if I would just say them.’ Yeah, he was looking for his gun. He was looking for his gun so he could shoot me.” She barely got out.
We learn in the science of patient education, that motivation through fear is ephemeral. You cannot scare a patient into compliance anymore than a visit to Hell could scare this wretched father into becoming a compassionate man. Nor can the vision of a breathless Hell of emphysema move many a smoker to put down a cigarette for good. For the wounds of an average day rarely find adequate human solace, and as one smoker has said, “Somedays a cigarette’s the only friend I have”. And I suppose anger was the only retreat for the daily humiliations of my patient’s father.
Many years pass. My patient has metastatic cancer. In her solitude and suffering, she had long been asking, praying, begging for an end to her pain. And so her prayers would now be answered. There would be a final end to her pain. And she was OK with that. It seemed OK.
So let’s take a final metaphysical summation. Patients go round after round with life. Knocked down and getting back up. Knocked down and getting back up. What awaits them when they take the final 10 count; when the ultimate Referee calls the bout to an end? Will it be the angels of Heaven that ring the final bell or will they walk out alone into the black silent back alley of Hell? For me, if I had the chance to be St. Peter, I would surely open the Pearly Gates for all of them, and lift away the shackles of suffering. However, I share a weary ordinary mortality, and my 40 years of medicine has transferred some scarring of its own. I no longer have the clear self-righteous eye of a rookie medical intern; only the puffy-eyed, cloudy vision of an aging physician struggling between the daily Heaven and Hell of my endless medical workday. Yet in the end, I find myself still the medical pugilist, still standing on these wobbly legs, still right there in the ring with my patients. But sometimes, when I get a pause between the rounds, I get to stop and tell you a story.
Larry Kravitz