Adrienne

I met Adrienne as an intern, when I admitted her to the hospital. She was an attractive, engaging woman, a junior faculty member at a nearby liberal arts college. She spoke with an Australian accent in a low voice that was serious, earnest, and playful all at once. She had done some camping a few weeks before and strained her back. She was sure that carrying heavy packs had caused the strain, but since it hadn't gotten any better, her physician felt that she should come into the hospital.

I guess I wasn't a very good interviewer back then. Somehow I had failed to elicit the fact that she had a mastectomy.

I was still at a stage when I felt uneasy examining young women. When it was time for the breast exam, I raised her gown to below her ribs and hesitantly began to examine her breasts. I was shocked that her left breast was missing. Oh that, she responded cheerfully, I had cancer a few years ago but the mastectomy cured it. I don't give it much thought anymore. I was instantly saddened, knowing that the cause of her back pain might be a metastatic lesion. I stumbled through the rest of our conversation. I agreed with her that the heavy pack had probably caused her back strain and that with a little conservative care, she would be better in no time.

The following afternoon I looked at her spine films with my resident. I remember him saying, She's got it, all right. She'll need to be checked for other mets. She'll need castration, radiation, chemo, the works. I didn't go back to see her. She was a private patient, after all, and I was superfluous to her care. Besides, I couldn't face her. I knew she would ask me about her prognosis. I knew she would be afraid of death. I couldn't talk to her about it. So I spent the next couple of days being angry with myself for not going back and talking to people about how you talk to patients with metastatic cancer. Finally one of my psychiatric colleagues gave me the best advice.

Why don't you just go in and say, Hello?

Damn, I thought, he's right, and went up to her room. She had been discharged.

I didn't see Adrienne again for about 6 or 8 months. Then, her oncologist approached me.

Do you remember Adrienne S? she asked. She has quite a lot of feelings about what it's like to have cancer and is very articulate. She wants to speak to a small group of physicians to help them understand how to better care for their patients with cancer. I said that I would be glad to organize such a conference and called Adrienne, arranging to meet her for lunch.

That lunch was extraordinary. We spent a couple of hours talking, about her experiences mostly. I felt moved and told her that her insights and feelings were too precious to share with only a few physicians. She agreed to be part of a panel discussion that also included her oncologist, a nurse, a minister, and me. I advertised it for all hospital personnel.

About 200 people attended. There was a good deal of anger in Adrienne's initial remarks, mostly about physicians' lack of empathy and avoidance of her and about the hospital's lack of attention to the little things. (For example, she couldn't wash her hair in the hospital and, for a woman who cared about her appearance, she found this degrading). She talked about what the cancer had done to her and for her, about her feelings of disconnectedness from her past and from normal life. She talked about how hospital personnel simply called her Adrienne without asking how she preferred to be addressed. She talked with appreciation about the student nurse who had naively inquired about her life. She spoke about her prognosis. Clearly her oncologist's honesty and respect had helped her cope. What a remarkable woman, a friend said later. It's hard to understand how people believe there is a just and merciful God out there. If there were, how could He let a woman like this die?

I saw Adrienne often after that. My wife and I had dinner with her; I met her for lunch a couple of times; but mostly I saw her during her repeated admissions to the hospital.

I remember one Saturday, when I was on call and having a slow night. I had been feeling sad about Adrienne's increasing disability. Around 9 pm, I brought my guitar up to her room. She was sharing the room with another young woman about her age who I had cared for when she was in the ICU. Karen had been septic and quite sick but was now on the mend. I remember thinking about the contrast between the two young women, one getting better and one getting worse. I played my guitar and we all sang folk songs. Adrienne sang all of the lyrics to On Top of Old Smokey. I had never actually heard all of the verses before or realized until then that it was the song of a jilted lover. It has been hard for me to sing that song ever since. As I left to go, Adrienne called me over and gave me a friendly kiss.

On another occasion I passed by her room around midnight and saw that she was awake. I walked in and sat and talked with her for awhile. Adrienne spoke with me about her former husband. Not wanting to take care of an invalid, he had left her after her cancer was diagnosed. We talked about her social life, which had been pretty drab recently. I remember her comment: Doctors don't pay attention to your real needs. We sat in silence after that and then changed the subject.

Inevitably her cancer spread to her brain. She had trouble walking. I had lunch with her one day before she went to radiation therapy. Adrienne was infuriated with her Dean who had canceled her teaching for that semester. She was too weak to go to class but not too weak to hold class in her apartment, which she had fully intended to do. Damn it. I'm alive until I die, she said, and had resumed teaching.

On another occasion, I asked her why she cared for me, as she had been recently telling me. I felt I hadn't really done anything for her. She told me she cared for me not for what I was able to do but for who I was. But, I thought, isn't who you are assessed by what you do? Still, I was touched that she cared for me and felt I had made a difference in her life.

Near the end of my residency, she was admitted just as I was leaving for a vacation. I went up to see her before I left and stood beside her while her sister, who had flown in from Australia, sat by. I held her hand and talked with her a bit. She was now somewhat confused. She talked in medical terms about her disease and I remember saying sadly, So many words you have had to learn. I wanted to tell her I loved her, and kiss her goodbye, but I didn't, not wanting to admit to her, and myself, that she was dying. I left for the sun. When I came back, Adrienne was gone, her body shipped back to Australia, the memorial service days earlier. I had missed it all.

Adrienne was the firstand the lastpatient to become my friend, although a number of patients have called me friend since. I never again became so emotionally involved with a patient but, in the end, I was grateful for the experience. Adrienne deepened my understanding of patients' experiences of terminal illness and helped me overcome my fears of relating to these patients. She also made me aware of the potential for love between doctors and patients: What are the meanings and implications of attraction and caring between doctor and patient? How do clinicians work out the conflicting emotions that sometimes arise?

• Copyright 2004 by the American College of Physicians