Tears Roll Down by Patrick Smith

The day had started off just like I had expected, with excitement and anticipation.  I finally arrived to my third year of medical school.  After diligently sitting through lecture after lecture, cramming my full head with medical knowledge hoping it would not leak out somehow, it was time to put this information to use and test my diagnostic and patient skills.  It was time to see real patients, the whole reason I had some to medical school. 

I was ready.  I had read up and reviewed my notes.  My white coat (half-sized designating me as a medical student) was glaringly white, perfectly pressed and starched.  I had my pockets filled with books, note cards, ophthalmoscope, tuning fork, reflex hammer, a granola bar and a note from my wife wishing me good luck.  I had even polished my stethoscope and was ready to go. 

On my first day, I was assigned to an outpatient office with an internal medicine physician as my preceptor.  He was en excellent role model and a wonderful teacher.  At first, he had me shadow him as he went in to see his patients.  He introduced me as Student Doctor, which made everyone chuckle.  I listened intently, watched his every move, and tried to do exactly what he did during his examination.  It was thrilling, and my main goal was to do my best to not mess up too badly or say anything too silly. 

About two hours into the first morning, my preceptor turned to me and said, “You got the next one—let me know what you find out,” and he slapped a chart against my chest.  I held it there for a moment or two, possible as a shield to hide my pounding heart.  I slowly looked at the chart, and then nodded and opened it right up.  Perfect!  This was a 56-year old gentleman who was here for a follow-up for high cholesterol.  What a great case as a first patient.  I knew all about this subject.  I was entirely prepared to talk about health risks of myocardial infarction, stroke and vascular disease, the Framingham criteria, prevention and medications.  We could discuss the importance of exercise and proper diet.  I knocked on the door to his examination room and entered with a purpose.  

I found an impressive man waiting.  He was sitting in the chair, elegant in a jacket and tie, his legs crossed.  He appeared to be about fifty, with graying hair.  He was a distinguished looking African American gentleman with a distinctive light in his eyes that seemed at once full of the vigor of youth balanced with the wisdom of the ages.  He was a big man, and as he stood up to greet me he easily passed my six feet of height with broad shoulders and large hands, though his handshake did not crush like I was expecting based on his size.  He was more than willing, as he laughed, to help “teach” the poor medical student how to be a good doctor.   

We exchanged pleasantries and small talk for a minute or two and then dove into the reason he had come in to visit the doctor.  The last time he was here for a check-up, he explained, his blood cholesterol levels had been a touch elevated.  Several members of his family had experienced the same problem, along with some hypertension.  He did not really like the idea of taking medications the rest of his life, though he would if it was really needed.  The last time he had been examined, he and my preceptor agreed to try six months of modified diets and exercise to see if that would reduce his cholesterol levels.  He actually had his blood drawn at the laboratory the week before and had the results to hand to me.  As I glanced at them, I was pleasantly surprised to see that his values actually dropped significantly, down to levels that were enviable for a man ten years younger.  On the inside, I have to admit I was a little disappointed and felt like the wind had been taken out of my sails.  However, I congratulated him on such fine work and we talked about continuing his current diet.  As he had no other concerns to discuss, I kind of stalled out on what to say next, so I thought I would make some friendly conversation for a couple of minutes and then leave to report to my preceptor. 

When I asked him about his family, he smiled.  Both his parents had passed at a ripe old age.  He laughed and said he had been married to the same woman probably longer than I had been around.  He had three children, but was still waiting for one of them to make him a happy grandfather.  When I asked what his children did, he replied that two of them lived in the area and explained their jobs.  I inquired about the third, and he paused before he told me that she had passed away some time ago, a distant look in his expression.  I told him I was sorry.  After an awkward moment, he simply nodded slightly and then stared off through the window of the examination room into the distant woods.  He told me it would be twenty-five years ago this coming month.  I was not sure what to do or say, so we sat there in silence for what seemed an hour.  Finally, in a quiet voice, I asked what happened. 

He did not respond all at once, at least not in voice.  I could see by his slight movements, the way he straightened his back ever so gently, how his hands opened, that he was already thinking about that far away day.  When he did speak, it was in low tones, his deep voice, an enamoring combination of James Earl Jones with the soaring oratory of Dr. Martin Luther King, Jr.  As he told his story, his eyes were directly upon my chest, but his gaze went right through me. 

She was five years old, and she was a daddy’s girl. They had gone to the petting zoo because she loved animals.  She had a fabulous time, running from stall to stall, naming each creature they saw, leaning over the rails to touch each one, laughing when the donkey licked her cheek.  She was an unstoppable bundle of youthful energy, her father and mother barely able to keep up with her pace and exuberance.  Many a time they wanted to sit on the park bench for a minute to catch their breath when she would come bounding down the path to grasp their hands and pull her tiring parents to the next wonderful animal.  The day went on and on full of joy until at last it was time to go. 

On the way to the car, he noticed she was exhausted.  He thought it was just all the running and efforts of the day, another tired child.  But as he buckled her in, he knew something was wrong.  She was more than just tired, she was different.  He walked to the nearby payphone and called her pediatrician to be seen right away.  When the doctor saw her, he said that she had caught some bug, and she just needed to drink lots of fluids and she would be better before they knew it. 

Once they arrived home, however, she looked even worse.  Being the concerned parent, he knew that this was bad, real bad.  He put her right back in the car and drove straight to the emergency department.  He carried her in his big arms through the doors.  They tried to make him wait, but he put his foot down and said no, she needs to be seen now.  The resident who saw her was very nice and examined her quickly.  He said that she had some illness called a gastroenteritis, some viral bug.  The attending physician also examined her and concurred with the earlier assessment.  They told him she probably got a little dehydrated running around all day.  She just needed to drink lot of liquids and she would perk up by the morning. 

Reluctantly he drove her home.  She died two hours later, in his arms. 

An autopsy was performed.  It revealed nothing.  There were no answers.  She was just gone. 

The real kicker came one week later.  They had taken photographs of their visit to the zoo, but had completely forgotten about them until they arrived in the mail.  They were still in shock from what happened when these images were there in front of them.  There were her little pigtails.  There she was in her cute yellow sundress with the stain on the front from her melting snowcone.  There she was on her daddy’s shoulders looking at the goats.  There she was being chased by the silly ducks.  There she was smiling.  There she was with her daddy, her mommy, her brothers.  There she was happy. 

As he told his story, he was no longer in the room with me.  He was back, twenty-five years before, holding his daughter’s hand.  I know he could see her again, as she was in her sundress enjoying life as only little children do.  He was hearing her high-pitched squeals of laughter, and listening to her giggle the way that only little girls around the world can giggle. She was picking her up and throwing her in the air and giving her hugs and kisses and telling her how much he loved her.  You could see how much he loved her still. 

He did not cry.  Maybe he had moved on.  Maybe he had cried all the tears he could cry.  But no, it was obvious that even twenty-five years later, he was still deeply, profoundly affected.  A few years after her death, he became a preacher.  Maybe his relationship with God helped him walk through the valley of darkness and comforted him.  I imagine that he is an amazing preacher.  He has the look.  I am sure that in every prayer he utters, every time he consoles a grieving soul, each time he reads out a sermon in his slow baritone voice, she is right there with him. 

I wondered what I should do.  Should I say anything to him?  Should I stop him?  I was not sure.  This is not something that I had been taught during my first two years of medical school.  It was all about physiology, anatomy, pharmacology and disease processes.  Sure, there was a bit in our classes about showing compassion and listening to your patients, but nothing to be sure that would have prepared me for this situation.  Maybe a hug, a pat on the arm, something. 

Moreover, in our classes we had not once talked about how to handle our own emotions.  I am not sure why his story of something that happened two and a half decades ago affected me so much.  I take that back.  I know exactly why, I have children of my own, and they are the absolute center of my universe.   I completely and totally imagine the devastation and pain this man must have felt, and indeed is still feeling.  I have complete empathy for patients who have young children just as I do. 

He may not have shed any tears as he related his tale, but I certainly did.  While his soft words drifted over me, I felt my emotions rising inside of me.  The tears welled up, and again I wondered what I should do.  I asked myself if it is acceptable for me to feel the way I was feeling.  Shouldn’t I as a future medical care provider be objective and unattached emotionally with the patients’ experiences?  Would it be appropriate for me to cry in front of the patient?  Should I excuse myself and leave the room or at least turn my head so as not to let him see my emotions?  It is a debate I would think that most physicians have.  At some point in their career, I imagine something would confront us, would touch our soft spot and force us to deal with that which most affects us on the deepest level. 

At that moment, I had no idea what was right or wrong or what I should do.  I have thought about it many, many times since, and I still am unsure.  But at the time, I felt it was best to be there with this man as he journeyed back and relived this episode.  I had nothing to say.  I had nothing to offer.  I was simply another soul listening to someone tell their story.  I hope and pray it was sufficient.  As we sat there in silence, on my face the tears streamed down.  The tears streamed down.