Closure: looking back, one year later

The last patient arrived at 3:30 p.m. on August 31, 2020. This was my 50th year in practice. The circumstances surrounding this visit were far different than way back in ’71, the logistics “unprecedented.” The call from the parking lot heralded the arrival, an early warning signal not unlike Norad. The screening questions, reiterated, answers unchanged from a day earlier when the initial phone contact had been made for a face-to-face visit. Mask up. Elevator limited to three passengers. Office door locked. Knock three times, the secret knock, announce your name, a speakeasy methodology. The doctor will open the door and escort you to your table, in this case, of the examining ilk. The elbow was swollen, bulbous over the tip of the olecranon. No pain, doc. No tenderness, Ralph? Ice it, Advil it as required. Don’t rest it on or against hard surfaces, including your truck’s side window. No, sticking a needle in isn’t a good idea. I’ve seen cellulitis and septic joints, the result of overzealous and intrusive therapeutic insults. It’s just bursitis, self-limiting. Thanks, doc. And by the way, Ralph, you are the last patient I will be seeing for any medical reason, ever! September begins the following morning, reserved for a month’s-long of goodbyes during which patients can drop by, respecting pandemic protocols, and have an opportunity to bid their farewells before my scrub top is retired. There is no reserved seating, standing room only. The idea came to me during the innumerable virtual calls generated following receipt of my infamous retirement letter. There appeared to be a need for some and I was more than willing to satisfy that need, after all, I had been limiting direct office visits to 8-10 per day for several months, a scheduling outlier compared to an earlier life. I had the luxury of time. The month was built and they definitely came. I was humbled by the words, the sentiments and the heartfelt wishes. Emotional displays were an equal opportunity response. Feigned hugs and handshakes were comically enacted, restrained by epidemiological edict and replaced by air gestures and fist bumps. Charlie was booked for 4:00 p.m. He phoned from a congested stretch of the 401 and informed that his ETA would be delayed, the result of a multi-vehicle altercation several kilometres ahead. The commute from Ajax was always unpredictable and he generally tried to accommodate for our respective schedules. No problem Charlie. The doctor will be here. Where was I going? This was September 30. Tomorrow, my retirement would officially begin. Charlie arrived unscathed and apologetic. He had been on the road for one and a half hours, was in no apparent distress and was here to simply say goodbye. Charlie was a scrawny 10- year-old when I saw him in the office for his initial visit in 1973. He shadowed me thereafter as I moved from the strip plaza to the hospital medical centre to my final resting place just across the street. He is a licensed welder, a married father of two, his eldest son challenged developmentally. Charlie attended public school near the old office and some of the young teaching staff at his school stalked Charlie to my office. Marlene was in her second year of teaching when she sought my assistance for a range of inexplicable and troubling symptoms. She had the classic triad of polydipsia, polyuria and polyphagia. At age 24, she met the criteria for the diagnosis of Type 1 diabetes. She was referred to an endocrinologist, started on Insulin and once stabilized, continued under my care, it seems, forever. Somehow, she was spared the end-organ ravages of this disease despite entering the diabetic fray 50 years earlier. In retirement, she and her husband moved, summering in the Georgian Bay area and snow-birding in Florida. We conducted many a virtual consultation over the years, long before it would go mainstream. The “annual” was always done at the office but most everything else lent itself to the more convenient phone visits to consult, review results and arrange her ongoing polypharmacy. Marlene called that final week to say goodbye, reminisce and thank me for all the long-distance calls over the years. The card arrived from Sick Kids Hospital a few days later. A donation had been made in my name, a token of lifelong appreciation. Ken was a teaching colleague of Marlene’s who found his way to my office around the same time. He worked his way up the ladder, topping out as principal some years later. His primary issues related to workplace stress, major depressive disorder and alcohol abuse. He would struggle with this burden for the foreseeable future. Once retired, he moved east, about an hour and a half away, but never wanted to change doctors simply for convenience. On one of his clinical commutes, he complained of some weight loss and central, recurring abdominal pains. Dr. Google opined “ulcer.” After ultrasound, CT and MRI, I confirmed pancreatic ductal carcinoma! He survived his Whipple and lives to tell the story which is far more complex and life-changing than he ever anticipated. We visited by phone regularly during his lengthy convalescence and he never failed to apologize for taking up my time. He called me in that final week of September. “Doing well, just wanted to wish you the best for the retirement, and, don’t worry about me.” Building a practice can be daunting. Sitting at your desk and waiting for patients to walk in the door is a waste of valuable time. Supplementing my idle time, I worked emerg, assisted in the OR, cultivated an obstetrical practice and began a fledgling occupational medicine practice. Patients from the ’hood started to arrive, referred by the bank manager, pharmacist, lab techs, dentist, even the local police division. Most of their referrals were constables and sergeants, not perps. Word of mouth, however, was the primary pathway to the office. Sharon had seen my window shingle when she went shopping in the plaza one morning. She dropped by to see if we had any openings. We were most accommodating. For several years, her visits were sporadic, episodic. I encouraged her to have a “general checkup,” repeatedly, but these suggestions were generally and politely deferred. Finally, checkup day arrived and as with all these visits, we sat in my consulting room and talked, gathering historical information about the patient, their story. After a comprehensive history was obtained, and just prior to moving across the hall to the examining room, Sharon asked if she could extend the conversation. And then she revealed a story that had been suppressed for decades. She was a survivor of a residential school program in Western Canada. This was 1976. It would be 45 years later when Canada and the world would learn of the shocking atrocities and inhumanity committed against the Indigenous people, unearthed at several “school” sites, the result of The Indian Act of 1876! Sharon booked a visit in the final weeks of September. She never forgot our conversation that day so many years before when she finally had to opportunity to talk to someone who had not endured the unspeakable trauma of her youth and who would forever be a valuable resource in her quest for restitution. Harry and his brother owned a manufacturing plant in Downsview, Ont. He was referred in those early years by an employee who had seen me on a referral from a friend of a friend. During the visit he mentioned the difficulty the company was having with WCB, the acronym of the day. Workplace accidents were frequent, and once the employee was seen in the emergency department, they were lost to followup, not seen back on the job for far too long. WCB assessments were very costly. He didn’t trust their personal physicians who he felt could be manipulated in their objectivity and give far too lenient a recovery prognosis. I suggested that I could see his workers in the event of an accident, on-demand, but with the exception of catastrophic injuries. We started a program of workplace injury management and expanded it to include medical surveillance exams to meet the Provincial requirements related to the “designated substance” exposure in this particular industry. This was the beginning of a beautiful friendship. The occupational business expanded as did Harry’s abdominal girth. He was seen regularly to manage blood pressure, IBS and obesity, the latter being most resistant to all manner of intervention. Over the years, the business was sold but as expected, Harry would maintain an oversight responsibility, not wanting to relinquish the family ties. His visits remained limited to singular problems, his annual checkups, however, relegated to a corporate medical provider. He enjoyed spending $2,500 for the convenience of one-stop shopping but always returned with his 30-page comprehensive report for me to translate, review, advise and act upon. When we discussed my impending retirement he was distressed. “Who would take this old fart on as a patient, put up with my mishigas ( craziness), and rarely follow doctor’s orders?” I thought about it, discussed some of the options open to him, including several physicians with whom I had consulted regarding patient transfers of care. He demurred and said he had decided the best fit. He intended to “sign up” with a concierge medicine practice and willingly pay the $5,000 yearly stipend. He figured it was worth it seeing as I had provided all his years’ services pro bono and, really, how many more years did he realistically have left? I wished him well for the future. He thanked me “for putting up” with him for so long and, totally out of character, tearfully exited the office. Charlie talked about his first visit to my office. He had not seen another doctor in 45 years. Neither of us could account for the passage of time that now culminated in this visit. He said he considered me “family” and that tomorrow would be different, past tense, ancient history. The conversation stopped abruptly. We smiled through our masks, our eyes speaking volumes. And Charlie walked away. September 2020 was a month of long goodbyes. It was the consolidation of five decades working as a GP and a lifetime of caring. The final months, although anything but routine, brought a sense of cohesiveness to all those years. So much shared for so long, unconditionally and respectfully with so many. And exactly one year ago, for all the patients that called, sent cards, wrote notes or visited the office that one last time, we all had the opportunity of closure, an act of completeness that will satisfy for the rest of my life.

Closure: looking back, one year later

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HOWARD GOLDSTEIN

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