Dr. Julie England, PGY-3by Dr. Julie England, PGY-3

In my free time, I find it therapeutic to reflect on my memorable patients, and sometimes I write them letters. I never send the letters. I never include lab results or appointment reminders. I simply include the thoughts and experiences my patient and I shared together. Usually, I write these letters for myself, but today I would like to share one of the letters with you.

Dear Mr. M.,

Do you remember that time you saw me in clinic and you were such a grouch? I called your name in the lobby, and you groaned as you stood and walked slowly into my clinic room. You eased into the corner chair.

“Is there anything you want to be sure we talk about today?” I asked.

You frowned up at me. "Just the usual stuff," you grumbled.

The usual stuff was a slew of problems: hypertension, diabetes, migraines, enlarged prostate, and more. I started at the top of the list. “Well, your blood pressure has been high the last few visits –”

“Don’t change my blood pressure medicine,” you interrupted. “Last time they tried that, I nearly passed out.”

I checked your chart and saw the last change to your blood pressure medicines was over three years ago. I mentioned things might be different now.

“I’m not changing my meds.” You remained firm in your decision. I moved on to the next problem.

We marched through the visit, and with each new problem, you refused to change anything or try anything new. I suggested a preventative medicine for your persistent migraines. You weren’t interested. I offered a prostate medicine to help with your urinary symptoms. You didn’t want a new medicine. I brought up your diabetes, which wasn’t well controlled. You crossed your arms and looked away.

“I’m fine just like this,” you murmured. You had refused all of my suggestions. I looked back at your chart, unsure how to proceed.

Finally, you opened up. “No one listens to me here!” you burst out. “I keep coming here, and no one ever helps me. No one ever does anything to make me feel better.”

I figured it was not the right time to point out I had spent the last half hour listening and trying to help you feel better.

“I just hurt all the time,” you continued, “I am always in pain, and I can’t do anything.” You sounded frustrated and hopeless.

I nodded. “Where do you hurt?” I asked.

“My back, my knees, my ankles - everywhere! And I’m angry all the time. And I know I’m angry because I’m just hurting all the time.”

You were right of course - chronic pain and mood symptoms are closely linked. We talked about your pain. I examined your back, knees, and ankles. I told you your pains were most likely from arthritis, and we could get X-rays to make sure nothing else was going on. You refused - absolutely not. Physical therapy? You didn’t have time for that nonsense. Knee or back braces? Those would never work. How about a medicine for chronic pain like duloxetine? You didn’t trust those mental medicines. Mental health referral? Never. Diclofenac gel, tylenol, or ibuprofen? No. No. No.

With all my options exhausted, I brought the visit to a close. “Just let me know if you want help with your pain,” I offered. I stifled a sigh when I handed you a patient satisfaction survey. Goodness, what a day to hand out patient satisfaction surveys. I finished placing orders on the computer as you filled out the survey. You stared at the floor as you handed it to me. “I don’t know if I spelled it right,” you said quietly before shuffling out the door. I glanced down at the paper. It was blank, except for the bottom section, where you had written: “She listened.”

I had a professor in medical school who often said, “in medicine, we cure sometimes; we treat often; we comfort always.” My visit with you had left me feeling helpless and frustrated. I felt like I hadn’t cured, treated, or comforted at all. With your words, you gave me hope that maybe I could make a difference. I even hope that you might let me help you someday. But I won’t get greedy. You have a clinic appointment with me in a few months. We probably won’t change any of your medications. But it will be good to see you. And to listen.

See you soon,

Dr. England