"I just wanted to say thank you. . . ." *

*written/posted with permission from patient's family

This is the text message I received yesterday at 9:27 p.m.

"I just wanted to say thank you. . . ."

I looked at it for a few moments before it registered who it was from- the 22 year old daughter of one of my patients from the inpatient service last month. She'd gotten my number after we'd had a really difficult discussion about her ill father--my patient. Her dad . . . . a prince of a man who'd suffered a severe anoxic (lack of oxygen) brain injury after a complicated procedure three years ago. Repeated infections caused him to come in and out of the hospital. Nonverbal and nonresponsive, the quality of his life was questionable at best. I spoke to his wife at length that Sunday morning and still remember her face; a solid mask of pain. In the family waiting room, she sat meekly in a wicker chair; hands wringing a tattered piece of tissue. The soft fabric of her hijab camouflaged the tears that rolled down her cheeks. "Please call my daughter," she said in a soft and heavily Amharic-accented voice. "Please call and talk to her about all of this. She is in college and studying to be a doctor. Please talk to her."

*67 (or "star six seven")
That's what you dial before you return a page or call a patient from your personal phone. It blocks your number on caller ID and ensures that you won't be getting any random calls from random people later. *67. That's what I dialed before I called my patient's daughter. I'd promised her mother I would call her, and that is exactly what I did.

To be honest, my recollection of the conversation is that it wasn't too great. Who wants to tell a twenty-two year old college student that her formerly healthy patriarch has little to no chance of meaningful recovery? Who wants to bring up ominous words like "hospice" or the dreaded "do not resuscitate" order between study breaks? I would have much rather asked her what she thought of Beyonce's latest video or, if she is the worldly type, a chat about the Obama administration's health care proposal or North Korea shooting missles. Anything but this discussion. Let me tell a sixty seven year old woman this about her octagenarian parent. Not a twenty-two year old girl about her daddy.

"I want to honor my father. Letting him die is not honoring him."

"We want the same thing. We do. I want to honor my patient. Your father is my patient."

Usually these heavy conversations don't happen through an iPhone earjack on Ponce de Leon Avenue. We teach our students to pull up a chair, sit at eye level, and to show empathy. She wasn't even in the state of Georgia, so I didn't have that option. There was no quiet room I could lead her to, away from the beeping machines and overhead speakers. I couldn't touch her hand or furrow my brow to indicate that I was indeed listening to her every word. No small box of too- rough facial tissue to hand her should she cry. No home court advantage at all. It was weird.

There were these periods of silence where I was sure the call had dropped. By the end of the chat, I couldn't tell if I had horribly offended my patient's daughter, confused her, or completely turned her off to the medical field altogether.

"Hospice is a death bed," she'd said boldly.

"Let me teach you more about hospice," I countered.

That was all I could think to say. I was careful with my words--and my tone. Even over the phone it was obvious that she wasn't afraid of doctors, especially me and my iPhone earjack several hundred miles away.

But she did let me teach her a little more about hospice. In fact, she asked me great questions and let me teach her a little more about a lot of things. And even though the conversation did not end with a firm decision to pursue hospice care, it did seem to be a healthy dialogue. She asked to have a number to contact me should she need to ask more questions.

"What is the best way to reach you, Dr. Manning? Your number was blocked."

"My cell phone."

I decided to tell her the truth, the whole truth, and nothing but the truth-- since this had been the theme of our entire phone call. Against everything I constantly preach to the residents and students, I gave my personal cell phone number to a patient. (Well, technically not a patient, but you get the idea.)

Fortunately, there were no random phone calls. No inappropriate crossing of lines or entering of personal space. Just an occasional question here or there leading to more opportunities to explain things better. Mostly in the form of very respectful text messages.

On August 31, my month on the wards ended. That meant I was no longer caring for her dad--but I still thought about him--and her. None of her text messages ever told me what they'd ultimately decided to do, and that was okay. I wondered how he was, and how they were all coping with it. How was my patient's daughter doing in her pre-med coursework? Was she able to concentrate on Organic Chemistry? Was she able to laugh out loud and do the things college kids do? How was his wife? Was she weeping in the bathroom during her lunchbreaks? Was she really okay? Did those conversations I'd had with them make a difference at all. . .or did they just make matters worse. . . .

Multiply these swirling thoughts and burning questions by all the patients who touch you, and now you know how dizzying this job can be. At some point, I guess you just get used to it. . . .learning to accept that sometimes you never get that closure you want. . . . . .

9/9/2009 9:27 p.m.

"I just wanted to say thank you. . . . ."

. . . . but. . . .sometimes you do.