The Lesson of Francis S.

by Dr. James W. Van Hook

I have been thinking about Francis S. a lot lately. Maybe it is this confounded virus! Maybe it is because of my ill-fitting mask or my now-moribund plans for department expansion, the challenges our students face, or the uncertainties our residents feel. Perhaps it is because I am internalizing the horrible events that I sometimes see on television which suggest rampant racism and social injustice. Maybe it is simply because I am old, discouraged, and often tired. Whatever the reason or reasons, I have begun to think about Francis again.

I took care of Francis a long time ago while I was a medical student. However, when the memory reaches my consciousness, it does not seem like that long ago. The medical school I attended was, for the time, unique in that third and fourth-year students maintained a primary care practice of their own during the entirety of their clinical years. Francis was my patient from nearly the beginning of my third year until I graduated.

Francis and I first met during my Internal Medicine third year clerkship rotation while I was part of the team that cared for her during one of her many admissions. A 70ish, rale thin, lively, pistol of a woman, Francis suffered the consequences of lifelong smoking. Her problem list included cor pulmonale, chronic obstructive pulmonary disease, and asthma. When not hospitalized, Francis lived a borderline existence at a small bait camp on a local lake. She cared for her invalid brother who lived with her. When discharged from the hospital, Francis “requested’ my services as her outpatient “doctor”. The overworked medicine housestaff were more than happy to send her my way for outpatient care.

Later in my career I successfully completed an Obstetrics and Gynecology residency, became fellowship trained in more than one area, and seem to have been just good enough and/or lucky enough to work in several great places with amazingly smart colleagues. However, the third-year medical student “Me” was an awkward mess. I was an average student. Additionally, during medical school, I suffered two significant personal tragedies that at the time affected me deeply. I was not particularly confident, talented, or self-assured. So, why would she want to see me after she was discharged?

At Francis’ first outpatient visit, she announced that she wanted to see me because she felt I needed a good patient to help train me to be a better doctor! Furthermore, she indicated that she would be the best patient for the job! During the subsequent 18 months, Francis was MY patient. I must have seen her at least twice per month while she was an outpatient. When she was hospitalized, I would round on her and meet with the residents caring for her. I probably wore out the community volunteer family doctors and the one poor cardiologist that attended the medical student clinic. I researched the literature and tried various treatments. Francis was MY patient.

During the latter part of my fourth year, Francis took a turn for the worse. She developed a mediastinal mass. Her medical status was deemed too risky for surgery. In addition, the day was soon coming when I was to leave medical school and begin residency in another state. I clearly remember the last time she saw me. Oh, I had arranged a follow up for her and she was to see an underclassman that I knew. I am sure I performed a handoff, affected a transfer of care, and made all the appropriate arrangements. Yet, on that last day, both she and I knew that her time in this world was not long. I will always remember that her parting words to the nurse helping me see her were that “She’d done a good job on me!”

Francis died approximately 2 weeks after I last saw her…

So why is it important for me to write about this now? Every one of us as physicians have probably had a similar experience or story. Given the social injustices, crime, sickness, and other bad things we see in the world every day, why would a long-ago story about one patient be so important to write about? I would contend that the importance lies in the lesson Francis endeavored to teach me.

At the time I cared for Francis, I came to some realization that she was trying to teach me something. What I thought she was trying to teach me was how to be a caring, empathetic, knowledgeable, thorough, and patient-centric physician. While it is true that those lessons were given, what she really was trying to accomplish was to teach me how lucky I should feel that I could care for people who really needed me! By our interactions with Francis and others like her, physicians and other healthcare providers receive a unique gift every day. The recognition of the gift was what Francis really was trying to teach me. Only recently has the lesson been impressed upon the student.

Right now, in healthcare, effort is diffused and obfuscated. Healthcare providers are sometimes part of the problem rather than the solution. Amazing variability exists in the cost of pharmaceuticals and treatments. In some situations, a heart transplant for heart failure is easier to obtain than a mental health evaluation for depression. The underserved use our emergency rooms because access is disproportionate. Physician and nursing burnout are rampant. There are many negatives to consider insofar as the practice of medicine is concerned. However, we do have a secret weapon in the fight for better healthcare and for a happier and more meaningful existence. That weapon is the simple remembrance of why we are lucky to be physicians!

Medicine is on one hand altruistic while on the other corporate. However, at the nexus of what is a sometimes cross-purposed intersection, there exists the joy of relief of suffering! As physicians, each day we need to look for the joy in practicing our craft. For when we look for the joy in helping others, the joy becomes within us and we then reflect the joy on others. Reflected joy and gratitude are the inexorably powerful weapons we can use to fight sorrow and suffering.

I now truly believe that somehow Francis is watching me. I seem to feel her presence more and more now. I hope she thinks I was worth the effort. I truly believe that each of us has our own Francis. We simply need to look outside of ourselves to see our Francis and be open to the lesson.