Between patient encounters and interpretation of test results, I estimate I make at least 50 significant decisions a day. Even if I’m right 98 percent of the time (a near-impossibility in clinical medicine), that still means I make one mistake per day. That’s a minimum of five a week, or roughly 250 per year.

All of these mistakes are incubating in an increasingly hostile milieu in which highly-informed patients are demanding perfection. Practicing medicine in North America in the 21st century is like juggling hand grenades – no matter how good you are, eventually one of them is going to go off in your face.

Humble Pie

Buried within the classifieds of our local biweekly newspaper is a small “Thank You” column. In it community members thank one another for various acts of kindness. I receive a handful of these notes every year. Jan and I have a running gag – whenever the latest paper arrives, if there are no messages in it for me she jokes that the “Dr. Gray Thank-You Supplement” must have fallen out again. Pretty droll, but it always makes me laugh.

On those occasions when she mentions there’s a note for me, I like to try to guess who sent it before I read it. Over the years I’ve learned there is surprisingly little correlation between the acuity of the illnesses I treat patients for and subsequent thank-you notes (or lack thereof). Most times it is not patients I literally snatched from the jaws of death who send a note to the newspaper, it’s people I assisted in more mundane ways. I never expect to receive thank-you notes, so it brightens my day whenever one comes along. They serve as a reminder that I really am making a difference out here in the trenches.

Mr. Anderson was an 80-year-old patient of mine. He had an acerbic wit and a flawless memory. Although he tended to be fairly cranky with most other health care providers, he always had a good yarn and a devilish wink for me. Unfortunately his body wasn’t quite as resilient as his mind, and over time his internal organs began to fail. Despite our best attempts to quell the escalating mutiny, he eventually succumbed to multi-system failure. His death saddened me.

A few days after Mr. Anderson’s funeral I was scanning the paper when I came across a thank-you note submitted by his family. It was a long one. In it they thanked several friends of the family, some hospital and Home Care nurses, a couple of ambulance attendants, their minister, the funeral home and the florist. In short, everyone but me.

I’d like to pull a John Wayne and say that the apparent oversight didn’t bother me, but it did. I kept thinking: “All those years I worked so hard at trying to keep him healthy and the florist gets thanked? Now there’s gratitude for you.” I grumbled about it all evening. I was still muttering to myself that night as I fell asleep.

When I got to my office the next morning there was a beautiful gift basket waiting for me on my desk. The card attached to it read: “Thank you for your wonderful care of Dad over the years. From the Anderson family.”

I felt like a jerk.

Every Breath You Take

Molly was a slightly anxious 40-year-old woman whom I had seen in my office a few times for minor health issues. One morning she presented to the ER intensely short of breath. Her oxygen saturation was only 70 percent and her chest was full of crackles. It took a high-flow oxygen delivery mask to bring her sats back up into the normal range. A chest x-ray was done to help rule out congestive heart failure and pneumonia. To my surprise, it showed extensive scar tissue consistent with a diagnosis of severe pulmonary fibrosis. I admitted her for further investigation.

Pulmonary fibrosis is usually an insidious process. Over the next few days I searched for a reason for her abrupt decompensation. No cause was found. Despite quitting her five-cigarette-a-day smoking habit, she wasn’t able to maintain her sats above 90 percent without supplemental oxygen. Arrangements were made for her to have home oxygen as well as an urgent consultation with the nearest available lung specialist. When everything was in place, I discharged her from hospital.

Over the next several months Molly made a number of trips to the respirologist. A lung biopsy revealed progressive pulmonary fibrosis of unknown origin, so she was started on high-dose corticosteroids.

Although she was a pleasant person, Molly had always been a loner who pretty much kept to herself. She was single and had no living relatives. As her shortness of breath worsened, so too did her anxiety. With nowhere else to turn, my office gradually became her main source of support.

The steroids failed to halt the progression of her disease, so immunosuppressants were initiated. When it became obvious that they, too, weren’t helping, she was referred further south to a transplant unit in Toronto. The team there reviewed her case carefully and concluded she was a good candidate for their program. There was only one catch – she would have to move to Toronto. This was not an unreasonable request. Due to the logistics involved in harvesting and transplanting lungs, patients on the waiting list must be able to get to the surgical centre on short notice. Our town was 800 kilometres away from Toronto.

The idea of moving petrified Molly. She agonized over the decision for a long time, but in the end she opted to go. She had no choice, really – to remain at home in our isolated town would have meant certain death.

Packing up and moving to Toronto when you can hardly breathe is no easy feat. It’s even more difficult when you have limited savings and no family. True to the spirit of the North, our town came through for Molly. After a lot of searching, a suitable place for her to stay in Toronto was found. A community member whom she barely even knew volunteered to go live with her and provide general assistance. In addition to that, a local service club held a fundraiser to help offset her mounting expenses. Eventually everything was organized and a departure date was set.

A couple of weeks before she was scheduled to leave, Molly came in for an office appointment. Her shortness of breath had worsened and she was feeling overwhelmed. She asked if I could admit her to our hospital until she left for Toronto. I called the medical ward and let them know she’d be coming in.

A fresh battery of tests failed to turn up any new problems. Even so, I didn’t think she was well enough to handle a commercial flight. I spoke to the transplant team and they agreed to a direct hospital-to-hospital transfer by jet in one week.

For the next six days I made a point of dropping in and chatting with her for as long as time permitted. If there was no longer anything medical I could do for her, at least I could listen.

At 5:30 on the evening before the transfer a nurse on the medical floor called me at my office to say Molly wanted to speak to me. Apparently she needed to tell me something important. It had been a long day and I was tired. I had already spent 15 minutes with her during my lunch break and I just didn’t feel like doing it again. I asked the nurse to tell her I’d see her first thing in the morning before the jet arrived.

Molly died in her sleep at 6:00 a.m. on the morning of her scheduled transfer.

Sometimes at night I lie in bed and wonder what it was she wanted to tell me.

Thank You

It’s hard to figure out where the expression “thank you” fits into the practice of modern medicine. Are people obliged to thank me when I help them? Of course not. Would it be nice? Why, yes, it would. Most people do say thanks when I help lighten their load, but a surprising number do not. When I stay up all night struggling to keep a family’s loved one alive, I obviously don’t expect any sort of material reward, but I don’t think it’s unreasonable to expect a thank-you.