One thing that has been a constant in all my years of medical school, training and the practice of medicine is the patient list, the daily printout of the patients I am taking care of in the hospital. The list is always sorted by room number so physicians can use it as a road map, of sorts, for their day’s journey. It includes the patients’ name, birth date, age, sex and attending physician. The shortened version of it looks something like this:
The room numbers always start at the top floors of the hospital and go down. Most physicians set up their lists in this way, as we make what are referred to as “gravity rounds.” We take the elevator to the top floor, where the ICU is usually located, seeing the sickest patients first early in the morning, and then we work our way down the list, walking the stairs, going from the top floor to the next floor, and so on, seeing our patients, writing notes, consulting nurses and social workers and other physicians… until we get to the bottom floor and the cafeteria for a break.
This list has always been much more than a map for me; it is the repository of all the significant reminder notes that I make in between patient visits. In my system, I put a billing code to the left of the room number so I could submit accurate billing at the end of the day. I circled the name of any patient who was not in their room when I went by on my morning rounds as a reminder that I needed to head back and see them later. I wrote my to-do list after the attending physician’s name: check chest X-ray; check labs; call family… whatever it was that I needed to do later in the day was scrawled there. In fact, since the advent of the Electronic Medical Record (EMR) system, writing on my list is the only time I use a pen. If I lost my list during the day, I was truly lost. I would have to backtrack until I found my list. Did I inadvertently leave it in the last patient’s room that I visited? At the nurses’ station next to the computer? In a pocket I had forgotten I even had? Where was it? I spent a lot of time looking for that list, and I almost always found it, but when I didn’t, it cost me a lot of time, energy, and effort. My list, for that one day, was the most important piece of paper I owned. And the next day, I tossed it into the shredder. Yesterday’s old news. It is this list, in my pocket every day of my career, that contributed the most amount of internal pressure to my eventual decision to retire this past December. This list has been a constant reminder to me of mortality, my patients’ as well as my own. Typically about one-third of the patients on my list would not be alive in six months.
I don’t know much about how other physician’s feel about their own mortality; that is a subject that rarely comes up in the physician’s cafeteria, at morning conference, or at a dinner party. As physicians, we almost never discuss our own mortality. You might not think that’s so odd since most people usually don’t talk much about death, their own or anyone else’s, unless they are going through a crisis at a particular time. But as physicians, we deal with people dying every day. We talk to other physicians and other medical personnel about our patients’ end of life care, we talk about patient’s lives we have and have not been able to save, and we talk about the difficult decisions we may have made that contributed to the death of a patient. We talk about death all the time, but the one death we never, ever talk about is our own.
How physicians have felt about death has changed considerably over the past forty years. When I was in training, Internal Medicine physicians were called “fleas.” A flea is the last thing to jump off a dying dog. An internist was the last, final physician to treat a dying patient. The surgeon would declare a patient too sick for surgery and refuse to operate, but an internist could, and often did, treat a patient right up until the moment of death. When a patient died, the implication was that the physician had somehow failed. Hospice treatment was not readily available back then, and end-of-life discussions were frequently delayed until imminent death was obvious and impossible to ignore. We rarely “gave up” on a patient as that was tantamount to admitting defeat. Death was the enemy and, while we always inevitably, finally, lost, we always fought long and hard to win. Today, the whole concept of death is more accepted as a part of the spectrum of human experience. Physicians today certainly do whatever can be done to prolong quality life, but most physicians are also much better at accepting the eventuality of the death of certain patients, and they plan and prepare better for it. End-of-life care is no longer “fighting” against the “defeat” of death, but it is seen as making the end stages as comfortable and bearable as possible, both for the patient and for the family.
So what does the patient list have to do with my feelings about my own mortality? It is because of the close personal relationship I had with my list and the important data that was on it. I saw, at a glance, every morning, how old my patients were. Some days were good, and I would look down and see that everyone on my list was over 80 years old. Some days I would look down and see that I had an unusually large number of patients under 40. But most days, there was a mixture of ages, a few younger, but most were older. The natural order of life. And serious illness. And death.
When I started in practice at the age of 28, the ages and birth dates of the patients on my list were of special interest, and I found it mildly amusing when one of my patients had the same birthday as me. Upon meeting them in their hospital room, I always asked those patients if they knew which president was born on our birthday. My very Republican mother’s family made me aware at a very early age that I shared a birthday with Herbert Hoover. Not one patient born on August 10th ever knew this fact until I told them. But at age 28, mostly what I saw on this list was a bunch of old people. I was young, and I never had a thought for my own mortality. As a physician, I spoke to patients and their families about death and dying almost every day, but when I was young I never thought of death in personal terms, in terms of me. But what did become very clear to me is that everybody dies. I was reminded of this every single day, every time I looked down at my precious list. Over the years, I learned that for people who died at an old age, the final few years were often lived with limited mobility, intense pain, decreased mental capacity, or loneliness and depression from having lost spouses and friends, and their lives were often interrupted by hospitalizations. This is certainly not the case for everyone; my own grandfather retired from his job at the age of 88, and he was completely functional until the week before he died at 95. He had a great life, and he had a great end of his life. But this is not what most of us can expect in these days of advanced, life-prolonging medical care. And the kicker is, you never know which group you will be in until you are smack in the middle of it.
As time went on, the patients on my list did not really get that much older. They were different patients, but their ages were similar to what they always were. While medical care certainly can extend the lives of elderly patients and, with early diagnosis, cure younger patients of previously-considered fatal diseases and add years to their lives, all of us have a “use by” date, and the vast majority of us will not see our 90th birthday. As the years went on, every morning I looked down at my list and saw that the ages on my list were getting closer and closer to my own. It began to wear on me.
One morning, while making rounds in the hospital, I stopped to talk with Reza, an excellent oncologist who is much younger than me. Reza and I have enjoyed many philosophical discussions about life and death, the future of medicine, politics, and other topics that always made my day more interesting, even though our impromptu conversations often put both of us way behind schedule. That morning, we spoke about my upcoming retirement in terms of the effect my list was having on me. His response was, “John you are a good physician, and we need to keep doctors like you working. Take a Prozac and get over it!” I had to admit, he had a point, but only up to a point. Facing my own mortality was depressing, but I was not depressed. I was, in fact, pretty realistic and pragmatic. I don’t know the number of years I have left, but I do know that number is a finite one. From my years of experience, I know there is a good chance the last years of my life might not be great. So I plan to maximize my remaining good years, the ones I am living right now, and minimize those last few terrible ones down the road. While my passion for medicine has always been a primary factor in my life, there are a lot of other things I very much like doing. I have a limited number of years to focus on these things and an even smaller number of years in which I will have the health and fortitude to be able to fully participate and actively enjoy those activities. Now that I have been retired for six months, I find it’s good not having to look down at my list and see people my age dying regularly. Even though today is, indeed, the first day of the rest of my life, I enjoy it just being another day. I am a planner, and while I still can’t get Ruth to go shopping for cemetery plots with me, I know we will eventually need to get around to doing this. I am certainly not ready to die, and I have a lot of things to do, and I hope plenty of time to do them. Death is no longer considered a doctor’s failing or a topic to be avoided, but something to be planned for, so when it is my time, I will have done – and enjoyed — the things I wanted to do. Today, I am content, and I am having fun with my lakeside medical musings. And travel, my grandson, my yard. And golf. Have I told you how much my handicap has come down? To my surprise, there is a lot of life beyond the patient list, and I hope my name is not on some other doctor’s list anytime soon.
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