The personal side of medicine
How conducting research on a rainy day removed the clouds
Mr D, from New York
The sky was grey. The raindrops scattered amongst the medieval buildings in the old town of Zutphen in the east of The Netherlands. My student and I carried two heavy bags with groceries and a backpack full of equipment to be installed at the home of our first patient.
At noon precisely, we rang his doorbell. His wife opened the door and warmheartedly welcomed us. We mounted the stairs and entered a house completely stacked with paintings, pencils and canvasses.
While she was making tea, he ensured us to make ourselves comfortable. Mr D, 80 years old, quietly sat in a flowered chair. He wore thick rain trousers, two fleece sweaters and a hoodie with some paint spots here and there. Although his mouth missed half of its teeth, the words coming out of it were as bright as his eyes.
It was about 1,5 years ago, I started my PhD in surgery. The major question to investigate: how to define whether patients with cancer of the intestines are fit enough to operate? We started out with a traditional approach, investigating cohorts of previously operated patients and looking at what had been done before by other research groups. The conclusion so far: we don’t really know what’s best for the frail elderly patient.
In order to put our concepts into a clinical experiment, we sought to combine the scientific evidence and the growing market of addictive online products such as Facebook and Instagram. First, we asked physiotherapists and dietary specialists what kind of exercise and diet would be best to prepare a cancer patient for an operation: in short, daily bouts of strength training and a portion of around 40 grams of protein. Second, we assessed the most important motivational triggers for elderly people: social support and having a purpose while preferably maintaining daily habits and routines. After profound research and dialogue both with experts and patients, we developed a small, user-friendly old fashioned television that could be installed at home.
While I was installing the small device that would help him to get fit the coming weeks prior to surgery, my colleague asked him some questions about his daily diet and physical performance. Surrounded amongst the most surreal but craftsmen’s worthy paintings, the nature of medicine to assess the pure rational and pragmatic perspective felt rather one-dimensional.
“Did you feel desperate or depressed the last month?” It was another question of the so called ‘geriatric depression scale’. The contrast of an intelligent artist who has travelled and lived and the blunt question summarising the interpretation of daily life into a yes or no question, was a precise reflection of the current struggle of daily medicine. The human scale at which we try to deliver care is caught in forced systems of randomised controlled trials and precisely standardised protocols.
More than once he paused, partly to catch a breath due to some serious restrictive lung function, partly to look at us and to say something important. My own tendency to keep busy betrayed the uneasily awareness of that it had been a long time since I had had the possibility to truly listen to a patient. A patient, though not yet weakened by a hospital bed or sedative medicines which apparently always makes me take their words more like those of a poor child than of an equal human being.
Meanwhile, with serious dedication, he performed the hand grip strength test and spelled the word bacon backwards to ensure his cognitive functioning. In between, we talked about art, love and other matters of more importance than whether or not he experienced a bloated feeling due to his tumor.
He spoke without ego, embraced emotion without the dramatic sauce: he was real. And likewise, he complimented his treating surgeon, my boss, for the same straightforwardness. After I was done installing all that had to be measured the coming weeks, I sat down in front of him.
He looked at me and said: “You are a doctor? And you want to be a surgeon?” I nodded. He paused. “The thing is. I admire the Dutch painters: Van Gogh, Mondriaan, Vermeer.” He looked out of the window. The rain had stopped and a typical Dutch sky presented itself, clouds mixed with the brightest of lights. “Your boss is like the Dutch painters. Not woozy, straight forward, sticking to the topic. His trust gives me trust.” Again, there was a silence. “However, do not mistake clarity with bluntness, it’s all a matter of subtlety.”
The 2-hour visit vanished as if they were mere moments. I left the apartment as if somebody had just given me a new pair of eyes. We walked back to the train station. We were unsure what to say. But if it were like Hippocrates once said: “Medicine is entertaining the patient while he is getting better.” Than today I would have to add to that: “The patient can teach the doctor while he is being entertained.”