Rewards in Medicine

As I was going through some of my stuff the other day, I came across this medal. 

On the last clinic day of my fellowship, as I just finished seeing my last patient for the day, our clinic secretary approached me to tell that one of my patients was waiting outside to see me. I stepped outside to the lobby to meet this patient. She was a patient very well-known to me. In her hand, she had a gift bag. From that bag, she pulled out a medal. It was a marathon finisher medal. She told me, "I got this specifically for you after I finished the marathon because you made me able to do this." 

Initially, she came to us, referred by her primary care doctor, for overactive thyroid gland. A woman in her 40s, she was tense and irritable. I vividly recall her sighing constantly while I was trying to get a detailed information about her problem, as if she was bothered by my questions. I gathered she was an avid runner, physically very active. With the overactive thyroid, she was not feeling herself. She was very vague about what exactly was happening. As I was prodding her to get text book descriptions of symptoms associated with overactive thyroid, she was half-heartedly throwing out statements. I went through her laboratory investigations. It was a classical overactive thyroid disease called Graves' disease. I drew a picture of pituitary and thyroid in a piece of paper and started explaining her what was happening to her, a routine for me for this kind of disease. After that I told her that we had three options to treat: medications, radioactive iodine treatment and surgery. We discussed about each of them. She was interested to know what will make her feel better the soonest. I told her medications would be able to do that. But they would not cure the disease. We have to constantly monitor labs and adjust medication dose because the disease activity fluctuates. So it might be a reasonable option to treat the symptoms immediately but generally we do a definitive treatment: most commonly, destroy the gland with radioactive iodine or rarely, remove the thyroid gland surgically and replace thyroid hormone which is a much steadier treatment modality. She was desperate to get symptoms controlled, she opted to go for the medication.

She was one of my needy patients. After each test result, we would have a lengthy conversation on what it meant and what she should do. She was feeling much better with the medication but was worried about the return of the symptoms in the future. At a point, she started questioning if she should actually have radioactive iodine treatment. 

In radioactive iodine treatment, radioactive isotope of iodine is given to the patient. Since the thyroid gland preferentially and avidly takes iodine, it gets concentrated primarily in thyroid. It emits radiation there which destroys the thyroid gland. It is extremely safe. Resulting thyroid hormone deficiency is easy to replace; once the proper dose is determined there is not much fluctuation and does not require frequent monitoring. 

Her main concern was how long it would take for the radioactive iodine to completely destroy the thyroid gland. Because until it is completely destroyed, there may be fluctuation of hormone levels and she was scared about having the previous symptoms. She asked me, how long will it take before hormone levels stabilize? Will it affect her ability to do physical activities? Being active was very important to her. She was planning a marathon. Will she be able to do it? I explained to her the response is very variable and generally takes months. It's hard to predict. We discussed it at length. By this time, we had established a good rapport and trust. Stepping the boundary of objective discussion, almost patronizingly, I told her, it will be OK, because there are many patients who have this without much problem. She agreed to have radioactive iodine treatment, she had a very good response, and she reached steady thyroid hormone dose smoothly. She was able to complete her much planned marathon.

For an endocrinologist, it was a routine disease. It was a routine treatment. It was a routine interaction. 

But here she was in the lobby of my clinic with a gift bag, marathon finisher medal and a gift card. She must have asked my clinic staff when my last clinic day was. She wanted to make it special. I was much overwhelmed. I thanked her and gave her a hug. Later I emailed her: 

Dear _(first name),

I was profoundly moved by your visit and thoughtful gift today. Of all the gifts and awards I have received in my professional life, this is the one I am going to cherish the most. I hope I can live up to the standards you have attributed me and be of service to the ones with illnesses and ailments.

Thank you,

My first name.

It was a strong lesson for me, how a routine mundane illness can be a gargantuan issue in the patient's life. These days, it distresses me when my colleagues speak of interesting case. I tend to think there is nothing interesting about these illnesses. They are irksome at the least and sinister at worst. I have yet to find a patient who is tickled by an interesting illness. 

Furthermore, this humbles me to realize the special platform the creed of doctoring offers. Each patient who comes to us with suffering offers us an opportunity to help her. A reward of incomparable substance. We are offered an opportunity to reap rewards with each patient. It just seems so cruel to brush off any of these patients, ignore and neglect any of these patients.