Cleveland, Ohio, United States
I could hear him as he rounded the corner from the lobby. He seemed to know almost everyone in the office; they cooed over him and he fawned at each and every one of them. My day was already busy with a full office schedule, a lecture to the residents later that afternoon, and a medical student working with me all day long. Bustling days like this one seemed to move on auto-pilot with the computer chirping repeated and mostly relevant directives at me regarding patient care.
His personality seemed to round the corner before his body and when I saw his person I was amazed. I noted the age in the chart: the personality of this ninety-three-year-old man seemed to boil over like an erupting volcano. It was impressive that his only medical problem was hypertension. Svelte and trim, I could almost envision the young, fervent man he had been seventy years earlier.
A fall at home leading to rib pain was the reason for the visit. I could hear his jovial and boisterous refrain behind the closed door. The electronic health record (EHR) stated he was in need of a cholesterol check and that the ibuprofen he was using may be contraindicated.
The medical student and I entered the room together. With a gaping smile, he extended a strong hand, stating, “Call me Sylvester!” He then expressed that he was glad to take me on as his new primary care doctor. I could tell I would get along with this affable character.
Turning to the computer I looked over the pre-visit note describing his fall at home. The nurse practitioner had already ordered an x-ray, confirming two fractured ribs, but aside from an occasional wince, his calm expression made me wonder if I was viewing the correct image. He told us how he still lived alone save for his trusty dog, and with a proud exclamation indicated he still did all his tasks himself. He did not lack the money to pay someone else, he just had too much pride to relinquish such duties. In the course of emptying his lawn scraps he had fallen onto metal garbage cans. He eventually dragged himself to his house and after making it inside, his first remedy was a cold beer he shared with his dog. While Sylvester shared his story, the EHR interjected that he was overdue for a pneumonia vaccine.
I remarked on his resolve given the rib pain, but he shook off any such notions. Instead he began to relay his dramatic landing on D-day on Omaha Beach in Normandy. He was captured by Nazi forces, endured savage hardship as a prisoner of war, and lost nearly eighty pounds. “Now that was tough,” he demurely remarked, although the change in his face seemed to indicate he was reliving all those horrendous nightmares again. Having seen this stark change in demeanor, I tried to shift the mood in the room.
We discussed recovery from his current injuries, though I could tell that the camaraderie in the office was probably better than any medication I could prescribe. I tried to get an idea of what his diet consisted of at home. With a smirk, he described how he did not eat many vegetables, as he had been given only green pea soup and vegetable stew accompanied by a robust helping of bugs and dysentery when he was in the POW camp. “I hated vegetables when I was a kid and now I still hate them, but for much different reasons!” he proclaimed. In the midst of this, the EHR then registered that Sylvester was, not unsurprisingly, a fall risk. I cursed the electronic chart that was not “smart” enough to look at the entire patient picture and yet still screamed directives at me during visits.
During moments like these, medical training feels antiquated and you fall back on your instincts as a human being. There was no abdication of physician responsibilities by not ordering a test that was clearly unnecessary, or waiting until the next visit to address vaccinations. The low probability that a lipid screen would even be worthwhile made me harken back to Sir William Osler, who stated that “medicine is a science of uncertainty and an art of probability.”1 Sylvester had already beaten all the odds. While I did provide an analgesic medication for his rib fractures and some help around his home, by listening I also provided a valuable medicine. And in a reversal of roles, it was the healthy dose of reality and humanity he gave me that was likely more potent and powerful. The electronic health record could not take into account the savageness and brutality he had endured, or the horror of seeing those around him maimed or killed. These elements of a patient’s story ensure that the physician will never become obsolete, even with advancing technology.
- Bean WB. Sir William Osler: Aphorisms, 129.
T. COLIN KILLEEN, DO, is a general internist and a Clinical Assistant Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. He was born and raised in Michigan and now works in Cleveland with medical students and residents.