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Dartmouth Medical School Dartmouth-Hitchcock Medical Center

At Home

For over 40 years, family physician Bill Toms has processed the emotions of medicine by writing what he calls "short stories in verse." Now retired from Dartmouth-Hitchcock, he shares here some insight into his relationship with a patient with whom he's always felt at home.

By William B. Toms, M.D., M.P.H.
• Illustrations by Bert Dodson

His all-over smile? His droll wit? His durability? His understated courage? His trust? Our time-honed relationship? What was it that I found so appealing about Bob G.?

Bob was a man who considered smiling (as well as working) to be like breathing. He just did it. He didn't ask many questions beyond a few well-placed "whys?" We typically met in a medical setting—a sterile exam room—but at each visit the space would quickly fill with nonmicrobial connections. Early on in our relationship, we each recognized in the other a funky accent and discovered that we had grown up in the same area. It was now far away in both miles and years, but we knew the same streets, the same gyms, the same hangouts.

Toms practiced family medicine in New Hampshire for more than 30 years, retiring in 2005 as the medical director of Dartmouth- Hitchcock Keene; the same year, he was named New Hampshire Physician of the Year by the New Hampshire Hospital Association. He still practices part-time in rural Maine and sees home-bound patients in Keene. Dartmouth Medicine also published some of what Toms calls his "short stories in verse" in the Summer 2008 issue.

As we talked over time, we became friends. We talked often of the old days but reluctantly snuck in a little medical talk as well. There was the metastatic prostate cancer that had been haunting him for 26 years, the recurrent small-bowel obstructions, the ureteral stents that needed periodic changing by his grumpy urologist, the chemo that his oncologist was more in favor of than Bob himself was. Medical stuff.

Over the years, we met and talked. I ordered the usual tests, changed a few medications, referred him for more than a few consultations. Some people might have called it chronic care management. Some might have called it a "patient-centered medical home." But it was just what we did.

It used to be that nobody except those of us in primary care seemed to understand the importance of continuity of care. The episodic, fee-for-service model seemed to suit the health-care business just fine. Then the medical societies for the primary-care specialties endorsed the "medical home" concept—the idea that a patient does best having a personal physician who coordinates all care the patient receives. But it was not until recently that the medical home concept began being widely touted as a potential savior for health care. Maybe it will be. Maybe it won't.

But the reason we primary-care physicians have long provided what amounts to a medical home is because it's the right way to practice medicine. It's right for our patients; it's right for us. It's right to come to know our patients over time—to listen closely for what they want, not what we decide. It's right to guide them and protect them from some of the crazy aspects of the health-care system. It's right to focus on what's important to them, not just on lab reports and MRIs. It's right to understand that we're there to serve them and that it's our privilege to do so. It's right that many of our patients consider us trusted friends, and that many of us value, honor, and reciprocate those friendships. Such friendships strengthen us for the hard times when our patients don't do well, when medicine doesn't do well, when we don't do well. They allow us to say, "Yes, despite all the hard stuff, I'd do it all over again. How lucky I am to have all of these friends."

Yes, Bob and I shared a friendship. Though the setting for that friendship was initially exam rooms, later on we met at his home and in a hospital hospice room. The topics of our conversations changed a little at that point—we began to address pain, paralysis, talks with God—but we still managed references to the old days, too.

And through it all, to the end, Bob retained his droll wit and his all-over smile. Yes, that was it. That smile. And that friendship.

The pieces on the following pages describe some of our talks during Bob's last year, 2010. They are shared with the permission of his family and with the knowledge that Bob himself would have been comfortable with their inclusion here. They are about a medical home. About a friendship.

We talk a few more pills but mainly a plan. Yes, that's a decent plan, we agree.

Knowing

Sun streams against newly yellowed clinic walls.
A skeleton sulks in the corner, his cranium disjointed,
tipsy, anatomically incorrect.

We meet again. We shake the clasp of old friends—
no need for introductions, perfunctories.
We skip talking about Camden and St. Joe's.
We don't even mention Sonny Sunkett's jumper,
smooth as silk, way back when.
We get on with the whats, the whens, and a few whys.

You know your body well: 73 years will do that.
You know the damn cancer well: 26 years will do that.
You know about chemo, how it sucks your good self
while it tries to convince the chunky little invader
to leave your ureters, your renal pelvices—the parts you need.
You know the fatigue, the weariness, the "why go ons"
that we pathologize as chemo-induced anemia.
You know the back pain, which might be your stomach,
maybe your heart, maybe the stupid cancer, maybe getting old.
You know the uptight, precise oncologist
who knows her stuff—but why can't she hear you?
You know the grouchy, insensitive urologist
who's maybe a little nicer since he had that surgery.
You know you're not going to live forever—26 years
with cancer is a hell of a long time, isn't it?
You know you're not ready to cash in . . . yet . . .
but you know you don't want this chemo right now.
You decide you're going to ask the oncologist for a vacation,
and if she can't hear you . . . well . . .

We talk a few more pills but mainly a plan.
Yes, that's a decent plan, we agree.
We agree to meet next week, with the tipsy skeleton,
within these sun-streamed newly yellowed walls.

Big Picture

Doc, I'm confused by all this:
The specialists, the drugs, the chemo.
They don't seem to hear what I'm trying to say.

What are you trying to say?

Well . . . I don't want to be in pain,
and I'd like to enjoy the time I have left as much as I can.
Is that unreasonable? Am I asking too much?

Doesn't sound like too much to me. Sounds pretty reasonable.
Just say it like that to your specialist docs.

I know they mean well, but they don't get it.
They don't get that my little case and its puny statistics
are the only picture that I see,
and that it's a really big picture to me.
They probably think I'm confused
and don't understand what's really happening.
I know what's happening. I'm dying.

Anything else you want?

Yes, there's something else I want:
I want to feel like I'm in control
of how I'm living and how I'm dying.
Sometimes they feel like the same thing.
Anyhow, I'd like to be in charge.

You sound like you know what you want.
You don't sound confused.
You sound in charge.

I do.
I'm not.
I am—and I'm going to be.

Conversation

Yeah, the pain's holding up.
Oxycodone, 10 milligrams, every four hours.
Oxycontin, 20 milligrams, three times a day. I hate the stuff.
Yeah, I take the Ensure. I have no appetite.
Yeah, I'm still working, 40 hours a week.
What else would I do—stay home and watch TV?
No, I don't want any more chemo: Carboplatin, Taxol.
No, no thanks.
Yeah, I'm willing to do more radiation
because you said it might help the pain.
No, I don't have a living will. You think I should?
Yeah, yeah, I do want to be in charge:
Is that what these papers are about?
Yeah, getting up on that MRI table was awful pain;
took an hour and 20 minutes, lying on that cold, hard table.
Yeah, I had a serious conversation with God
on that hard table—a real serious conversation.

We discuss the usual, the expected.
No, you aren't in pain right now.

The Living Room

You holler "Come on in" from your living room,
while your old dog offers an obligatory bark,
then happily welcomes an ear scratch.
Your sofa dwarfs you, though maybe the wheelchair
next to you puts the word "smaller" in my mind.
I always considered you my height,
though you say I've got you by six inches.

This is your house; we talk about what you want to.
We talk of Camden, Campbell's Soup, the shipyard,
how nobody'd want to live there now.
We offer a little memorial service to the old city,
right here in your living room, just by remembering.
You recall everything: City ghosts live on.

You talk of how you used to hunt up here,
of how, one day, you and your wife said "Why not?"
So you left a dying city and brought a smile to a lake town.
You talk of this house, the beams of this living room
that you ripped apart. The sawdust between the walls.
The pride in every part of this old house, redone room by room.

Mostly, you talk of family. You're so proud of them.
You describe them with the brogue of a loving father,
tinged with the South Jersey twang even they still carry.
Everything you tell, you tell with a smile.
After a while, it feels like it's the smile talking,
and you've just given it a place to work out of.

The pain is gone. That's good. "So are the legs," you add.
"But that's okay—the new wheelchair is great."
The smile seems a little tired, so I shake your hand,
scratch the old dog's ear, and find my way out
of this, your living room, with the sawdust in the wall.

What Did I Expect?

The hallway is shiny, antiseptic clean. And quiet—
a Sunday morning hospital quiet that no one wants to disturb.
I find the hospice room brighter, roomier
than I expected. But what did I expect?
You lie in bed, flashing your familiar grin.
"Hey, Doc, come on in." The room is warm.
We discuss the usual, the expected.
No, you aren't in pain right now.
Yes, everybody's been great.
No, not much appetite. No, no Ensure.
"You know, come to think of it, I'd like some.
Chocolate, if you could."

You converse with a self-effacing joviality
I don't expect in this room. But what did I expect?
Your grandson points to you, saying, "He's a hoot."
Gary asks you to tell "the hunting story."
Seems a few years ago, back in Camden,
you decided to go hunting down to Atco.
Had no car, so you took the White Horse Pike bus,
complete with your shotgun. No one asked any questions.
Couldn't do that now, sure couldn't. But back then,
you know, times were different, yes they were.
"Where's that chocolate drink?" you wonder out loud.

We chat some more, but nothing as good
as the shotgun-on-the-bus story.
We discuss some practicalities, like letting go.
We agree to meet when you get home.
"Where's that chocolate drink?"
You smile in that casual, keep-it-short way of yours.
But what did I expect?


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