Friendship with patients.

I will never forget meeting Ginnie—a Southerner-turned-Northerner, Baptist-turned-Jew, former Miss Georgia with more joie de vivre than a candy shop full of preschoolers. “Well, aren’t you a doll!” she announced, before I could extend my hand and introduce myself. Her warm languid drawl rendered her irresistibly lovable and entirely unforgettable. No patient has ever greeted me in quite the same way. Ginnie first came to see me not long after I finished training and hung out my shingle. She was enthusiastic about life—and too busy for office visits, even if she needed them. Still, I heard from her. She had a knack for gathering her chicks and kicking up the dust, and whether it was her husband’s birthday or the birth of my child, she made it a party. She issued invitations; eventually, I accepted. The first time I attended one of her parties, the guests included everyone from her golf partners to her auto mechanic. Anyone who crossed her path became a potential friend. Ginnie’s husband had been ill for years with cancer, and from her description, I gathered that his disease was quite advanced. One day she called to tell me he had died. I saw her a couple of times after that and then heard nothing more. On occasion, I would pick up the phone to call her but hang up before it rang. The boundaries between doctor and patient perplexed me. Was she a friend or a patient? A patient and a friend? What did it mean when I had no medical reason to call her but wished to know how she was doing? Other patients had invited me to events before, and although such invitations always strengthened our relationships, we remained in our patient and doctor roles. Some eighteen months later, Ginnie contacted me out of the blue. “Well, it has been a while since we have talked, and I am ready for a physical,” she wrote. “I will call your office and make an appointment next week. I am doing OK, lots to talk about. Maybe we should have lunch?” A physical and a lunch. I chuckled. An appointment at my place and an appointment at hers. Ginnie was back, and I was thrilled. Who says doctors don’t love their patients? Routine laboratories obtained after that visit were concerning. I called and asked her to have more blood drawn. This she put off for a month, and when I saw her in the office again, she had lost ten pounds unintentionally and had developed enlarged lymph nodes in the neck. I ordered even more tests and then emailed a friend in the laboratory to ask if she would prioritize what would be Ginnie’s definitive test. Back at my desk the air felt heavy, like when an airplane first takes off. I had plenty of work to do, but instead found myself in the zone that characterizes so much of Generation Text—skimming electronic files absentmindedly. I clicked on Ginnie’s medical record; had her results come back? I clicked my open email folder; had my doctor friend written back? At last, I forced myself to tackle some work. As part of my research, I was taking a class on Augustine’s ethics at the divinity school. We were reading his Confessions, and I had left off where he describes the illness and death of a beloved friend. I turned to the page now. “My heart was black with grief,” he wrote. “Whatever I looked upon had the air of death. My native place was a prison-house and my home a strange unhappiness.” I left work that night unsettled. During a meeting the next morning, it occurred to me that Ginnie’s report might be ready. I mentally logged out of the meeting and logged into the electronic medical record on my laptop. My suspicions were confirmed. Augustine’s strange unhappiness descended upon me. Ethicists and physicians have long debated how doctors should relate to their patients. Should they practice Hippocrates’ benevolent paternalism or defer to the desires of the patient? Should they sympathize and suffer with their patients, or empathize from a distance? My approach has been to try to treat my patients like I would a family member, relating through some combination of guiding, deferring, and being firm. Perhaps that blurs the standard boundaries; perhaps it’s simply a contemporary interpretation of a very old art. When Ginnie picked me up from work to go to lunch the next day, she seemed to be expecting the news. Her matching pants and jacket—a knit grey—silently announced her dread. She had suggested we go to a local dining club, where it would be quieter. During the short drive from my clinic, we stuck to discussing the effects of one-way streets on traffic flow. Having never before delivered a major diagnosis over lunch, I decided to take my cues from her. She couldn’t have been clearer. As soon as we took our seats, she said, “What did the tests show?” “It’s a kind of cancer,” I said softly, so that no one else could hear. She sipped her water. Clearing her throat, she called to the waitress. “A lemon, please. Lemon for my water.” She instantly sounded more Southern and appeared much smaller. She rustled around in her purse, pushed her chair back, and tapped the table with manicured nails. It was as though all of her enthusiasm for life and people had been stuffed back inside, and only a bit of nervous energy could escape. Her eyes darted about the room. An acquaintance walked by, and for a moment the old Ginnie seemed to return. “Hey there!” she sang out. The woman greeted her, but didn’t notice the forced smile or damp eyes. After their exchange, she turned to me again, relieved to be alone with her secret. “Cancer,” she repeated, as if experimenting with the word. “I have cancer.” She paused. “What kind?” We spoke gently of what was to come, of the specialists she would meet, of the testing she would undergo. She cried some, though undoubtedly less than she might have in the quiet but cold privacy of the exam room. We then eased into a more familiar, comfortable banter about travel and movies and our next rendezvous. She drove me back to my office, and as I climbed out of her car, she grasped my arm and said, “Thank you for your friendship. I really mean it.” “Thank you,” I said.