Motke

Most of us have at least one candidate for my most unforgettable patient; the more fortunate may even have several. Mine is Motke and I am not sure if it would have been any easier to forget him had I not been his doctor. He was one of those people who embody a whole way of being; he stood over and against the materialistic, communal idealism of those among whom he lived. There was an air of saintliness about him but he would have laughed at the description, for he was an agnostic. He walked with a limp from childhood polio. The defect made him unfit for the occupations involving sword or ploughshare through which men established themselves as useful members of kibbutz society.

When a doctor feels affection for his patient, the outcome of any interaction between them may be improved. There was no way not to show warmth to Motke, but I do not flatter myself that what must have been obvious to him in all our dealings had anything to do with the surprisingly long time this story covers. By way of more explicit and clinical introduction, let it be said that he was destined to outlive some of his coronary arteries and most of his myocardium by a score of years.

My first encounter with Motke took place in 1965 when I was an intern in the department of medicine at a 300-bed peripheral hospital in the Jezreel Valley. He lay there with a great shock of white hair spread around his delicate features, a veritable halo of dishevelment, looking unwell but resigned to his circumstances. One of the senior physicianswe were making roundsshowed me his cardiogram with its towering QRS complexes, its giant T-waves, and its S-T segments depressed 5 mm or more below baseline. It had, of course, been taken at rest and eloquently expressed the chest pain for which he had been admitted. Although nothing more than a streamer of slick paper, checkered gray and black, the cardiogram appeared to me a death warrant. After rounds, the senior physician told me to do an admission history and physical examination on Motke and, as if to warn me not to draw too close emotionally, added that he thought the patient was not long for this world.

Motke and I hit it off quite well, perhaps because I was a full decade older than most of the other junior staff members and had spent 9 years farming. I have no recollection of the anamnestic details he gave in reply to my questions. I do remember his thin, wiry physique and the heaving ventricle, not only palpable but also visible. The point of maximum impulse, too, showed how far it could wander from its appointed place when things went wrong.

Somehow, Motke made it through the week and was discharged home to his kibbutz in the Beisan Valley, 25 miles away, with a diagnosis of coronary artery disease. I learned that he was a horticulturist with an international reputation who specialized in growing rose bushes. Letters asking for advice were delivered from all over the world to his room, which resembled a monk's cell. The duties of an intern made me forget him and we did not meet again until nearly 4 years had passed.

When my residency was completed, I looked for suitable work in ambulatory medicine. The health maintenance organization that insured almost all of the denizens of the Jezreel and Beisan Valleys and also ran the regional hospital assigned me to five border settlements, one of which was Motke's home. After a quarter of a century of backbreaking labor by its pioneers, who withstood unimaginable hardships, the area was now quite green. It lay some 700 feet below sea level, and noontime summer temperatures hovered around 40 C but had been known to climb as high as 53 C. It was under intermittent mortar and small arms fire from across the Jordan River, and military prowess and resourcefulness in repairing damaged machinery were more in demand than expertise in horticulture. In particular, there was no money in rose bushes and younger members of Motke's kibbutz cast an envious eye on the little parcel of land, just inside the perimeter fence, where his nursery was located.

It took some time for me to adjust to the prevailing, war-like atmosphere that was to persist for 2 years. I am afraid that during those heroic days I had a tendency to regard wounds from shell fragments as the only significant medical condition and to look down on patients who were troubled over trivial complaints. I certainly wasn't much good at eliciting their concerns beyond the occasional confession of feeling uptight because of the situation. However, for Motke I always had time, possibly because I could really do so little for him and because he stood out as unique and refined in comparison with the rough-and-ready surroundings. He came to the clinic infrequently and on each occasion it turned out that he had stopped taking the pills I had so optimistically prescribed on his previous visit. Beta-blockers were now available but Motke didn't like being medicated, although he was far too tactful to reveal this to me. He seemed to know the secret of living without health at a safe distance from medicine. He believed that disease and death are part of life, which goes on without regard to quality. I often felt that with some knowledge of homeopathy or nature cures I could have done him far more good.

Motke spoke an elegant although somewhat archaic Hebrew, quoting freely from Scripture not out of belief but because he liked a well-turned phrase. I am surprised today that I know nothing of his origins in Poland. He seemed faintly anachronistic, yet so much a part of the present that it was difficult to connect him with siblings or parents. He was definitely not happy; the kibbutz had reached a stage when family life was becoming ever more central. A confirmed bachelor, he radiated a certain inner peace despite spending most of every 24 hours alone. He withstood all blandishments to retire honorably and surrender his few acres to something more profitable. Every year, with several of the young women, he would put on a floral show in the spacious hall where cultural activities usually took place. Dozens of varieties of roses were then on display and people came from the neighboring settlements to a defiant demonstration of the beautiful and the transient, briefly preserved from an environment that seemed hostile in every way. Many volunteers passed through the kibbutz in those days, looking for a taste of communal life and the occasional surge of adrenalin that the odd mortar shell could provide. Over the years, I would meet one or another of them, always hearing that the most memorable aspect of his or her kibbutz experience was being assigned for a day to work in Motke's nursery.

One morning I awoke to the realization that I had been working in the Beisan Valley for 17 years! My wife and I took stock, and, since our nest was on the verge of emptying, decided we should move on. Perhaps, too, we feared the day when I would have to attend to the last illnesses of people to whom we were bound by ties of a shared fate and similar ideals. Once a year thereafter a New Year's card would arrive from Motke, but we never saw him again. We heard later that, some 20 years after my first encounter with him, he was found dead between the rows of his beloved rose bushes with a peaceful look on his face. He had exceeded the three-score and ten allotted us by the ninetieth Psalm and even outlived the average Israeli male.

When I wondered what impelled me to write of him at this particular time, two answers suggested themselves. The first has to do with one of Jerusalem's loveliest parks that I happened into just a few days ago. It comprises lawns, trees, a small lake, and a network of moats spanned here and there by a rustic bridge, along with thousands of rose bushes about to flower. Two or three of the varieties Motke perfected grow there, identified by little metal signs.

The second answer is concerned with the term modern medicine. When Motke was admitted to the hospital 27 years ago, we believed fervently that our practice was current and that our patients were benefiting from the best the profession could offer. Indeed, in historical perspective 1965 definitely belongs to the modern era. In the very shadow of Mt. Gilboa where, 3 millennia earlier Saul and Jonathan had perished, the department of medicine had just received a Lown DC cardioverter. Various antibiotics were available, as were powerful new diuretics and hypotensive agents. Our general surgeons were doing splenorenal shunts for portal hypertension and sophisticated workups for Hirschprung disease. We read the latest journals avidly, knowing that it would take a few years until the dazzling new technologies reported there reached us, but feeling that they were already within our grasp. As always, the advances were uneven rather than across the entire front, and I mention some of the measures we took against ischemic heart disease with a sense of embarrassment because they now seem hopelessly crude. We used nitrates, still standbys for angina pectoris, with no appreciation of tolerance. We administered dipyridamole because even 5 years later a respected textbook said it might improve collateral circulation. We prescribed monoamine oxidase inhibitors believing that, in addition to their sedative influence, they might have some direct effect on the ischemic myocardium. Finally, we gave propylthiouracil for intractable angina in the hope that the hypothyroid state would make fewer metabolic demands on the heart.

Could we have done more for Motke had all that is written here happened 2 decades later? Could we have added years to life, or life to years as the saying goes? Would he have allowed us angiography, percutaneous transluminal coronary angioplasty, bypass, or transplantation? I seriously doubt it. Imperfect from childhood, he did not pursue any ideal of health, nor could longevity, in and for itself, ever have been a good in his eyes. He wrested a score of summers from the absurd, confronting it clear-eyed but with some bemusement and, when it was enough, he simply let go.

• Copyright 2004 by the American College of Physicians