Esther: A patient who taught much to a young resident physician

by R. Daniel Braun, MD, OBGYN.net International Representative - U.S.A.

The year was 1965. I was a first year Resident in the Gynecology Clinic at the county hospital. One day a young medical student came to get me. He was having problems trying to examine a patient. She was refusing to allow him to touch her because he wasn't a "Real Doctor". I followed him back to the examining room which was separated from the hall by a curtain.

I pulled back the curtain and laid eyes on her for the first time. She looked just like Fred's Sister-in-law "Esther"from Sanford and Son to me, so I will call her by that name. She was in her early 50's and bigger than life. Big voice, big hat, big makeup, big hair. Her only complaint was slight lower abdominal pain and fullness. Upon abdominal exam, I discovered she had a big, irregular pelvic mass the size of a 24 week pregnancy. It started in the pelvis and went up to 2 inches above her umbilicus.

On pelvic exam, the mass seemed to arise from her uterus and appeared to the medical student and I to be uterine fibroids. We left the room, so she could get dressed and then returned to talk to her. Since I was the "Real Doctor", I informed her of my findings and suggested to her that even though fibroids weren't malignant, surgery would confirm that this was the correct diagnosis and it should probably be removed surgically anyway. Esther did not agree. Out came that big voice at full volume, "You ain't cutting on me!" She repeated this sentiment loudly at least 10 times before I could get her to calm down. I then tried to talk to her again but to no avail.

"You ain't cutting on me," the big voice proclaimed at maximum volume. This time there was no calming her down and things started to get out of hand. I was the doctor but I was quickly losing control of the situation. There with other patients waiting and listening to all the ruckus. I told her that if she didn't quit, I would have to call Security and have her removed. She didn't quit. What should I do? What could I do? She wouldn't listen to reason, so I called Security and they escorted her out of the clinic. The other 30 patients waiting in the lobby slowed down in their fidgeting and edging toward the door.

About three weeks later, I was in clinic and there was Esther again. I have no idea why she returned. She denied any new symptoms and did not want to discuss treatment of her problem. We had the same conversation and ended with the same results. This went on four times over the next six months. I still had no idea of why she was
coming in and upsetting my clinic in this fashion. She denied any new problems, just the same slight lower abdominal pain and pressure. She had no new questions and still the same opinions. Esther was becoming an enigma to me. How could I treat her if she wouldn't listen to and follow my medical recommendation?

Somewhere in the middle of this time span, "Sarge" (Miss Sargent), the clinic nurse, took me aside and said, "You know she gets all dressed up and puts on her best makeup when she comes in to see you." My response was, "You're kidding?" Sarge responded, "No, and she only does when she comes in to see you. When she goes to Medicine clinic she never looks so nice." This blew my mind. I was curious, but had no explanation. Besides that, she was still upsetting "MY" clinic every time she came in.

For some reason, after six months Esther quit coming in to the clinic and I didn't see her again. Then, one quiet afternoon in the Gyn Clinic, about one year later, Bernie, the dermatology resident, tracked me down. "I have a patient that you need to see," he said. I walked over to the dermatology clinic with him as he described the patient and sure enough, there was Esther. Still bigger than life. She had come in because of a discharge from her umbilicus. On exam, it was easy to see that it was most likely a cancer, growing out of her umbilicus (a totally new finding). Unfortunately, biopsy proved me to be correct. It was a very aggressive endometrial adenocarcinoma. Chest X-ray revealed
several lung nodules, which we believed to be metastases.

The staff at the oncology clinic worked out a treatment plan that consisted of radiation and chemotherapy. When this was explained to Esther, her response was that she would only consent to the treatment if I were the one who would start all of her IV's. "Why me?" I thought. This wasn't my job and Esther probably wasn't going to make it easy based on my last experiences with her. But for some reason she felt she needed me. After explaining to her that I might get sick or have to go out of town, I was much relieved when she agreed that under those circumstances, she would allow someone else to do it. I agreed to start her IV's.

For the next 4 weeks, every morning at 7:15, I walked the half mile across campus from the University hospital, my latest rotation, to the county hospital so I could start Esther's IV. Sometimes I did this a little grudgingly. I was very busy. But Esther faithfully kept every appointment and got every treatment. I began to see this big, formidable woman in a different light. I found out more about her as a person. I found out that she could also use her big voice to sing in the local Baptist Choir. She was a regular churchgoer and had a strong faith.

About five weeks after the chemo was completed, Esther returned with a complaint of abdominal swelling. Examination revealed that she had developed "ascites". This is a collection of fluid within the abdominal cavity. It was causing her a lot of pain and shortness of breath. She was unable to sing now, because she couldn't get enough air in. After much discussion amongst us doctors, a treatment plan was established. We would inject a chemical, "Atabrine", into the peritoneal cavity. This would cause a chemical reaction which would result in the obliteration of the peritoneum so that it could no longer produce the fluid. Daily injections for 5 days were required. Esther agreed but again had one stipulation. You guessed it; I had to do the injections. Again, there was consternation on my part (I was young, remember). I had to come across campus during the busiest time of my day to perform an unpleasant procedure. She'd probably end up refusing anyway. The procedure is painful. Why me? Why couldn't one of the staff in Oncology do it? After all it was their job. But for some reason Esther felt she needed me. I relented and we started the treatments together. Esther, quite to my surprise, kept a stiff upper lip and went along with the plan. It wasn't easy for her. I began to admire her. She had a great deal of inner strength that seemed to help her deal with the pain. The treatment worked fairly well, actually. Almost all of her ascites disappeared and she felt much better. She was also now able to sing again.

Three weeks later, she returned with shortness of breath. Chest X-ray revealed a pleural effusion, mostly on the right. This was filling up her chest cavity and collapsing her lung so that she couldn't breathe. The plan now became one of injecting atabrine into the pleural cavity daily 5 times. This would fuse the outer covering of the lung to the inside of the chest wall.

By this time there was no question for me whether I would be involved in the treatment plan. Esther had a strong faith in God that helped her deal with the pain and fear. She was able to tolerate a great deal of pain. She had a realistic outlook on her disease. She realized that we were only doing these things to make her remaining days as comfortable as possible. She also had a feeling about me that was helpful to her. So, I did as she requested and made my daily trek of one mile, round trip, to do her injections.

About four days after the completion of this course, Esther became really short of breath again. So now we had to do the other lung. Then there would be no cavities left for her to collect fluid in. So once again it was atabrine into the chest. Following this course of treatment, she was able to breathe again and felt good enough to go home. She was again able to sing.

Three months later, she was readmitted with shortness of breath and jaundice. Chest X-ray showed her lungs were full of cancer. Lab studies showed that she probably had nearly as much cancer in her liver. She was to be admitted to the hospital. These were the days when that is what you did. There was no hospice. It was obvious to all of us on staff
that she wouldn't last much longer.

I was doing all the lengthy paper work involved in admitting her. Dry business questions with short impersonal answers. Suddenly she changed the subject. She said to me, "Doctor, I want you to know how much I appreciate everything you have done for me. I could not have made it through all those treatments without you being there. You helped me so much and I truly appreciate it." I felt sad, small, and inadequate at that moment. Geez! Here she was thanking me and I hadn't even wanted to do it. I told her that I had not done much. But I had really come to admire her inner strength and great faith. What she said next really blew my mind. She told me she had nearly lost her faith on several
occasions and it was only my presence that had allowed her to keep it. Not once, during her whole treatment had we ever mentioned God or even talked about religion. If I had, we might have had a good argument, because
at that time, my faith development was in a trough.

It would be another fifteen years in the future before I would realize that I even had a faith in God. Even then it would barely stand knee high to Esther's. But somehow she saw some potential in me. Something that I didn't even see in myself and leaned on it.

Four hours later, I was called to her bedside where I officially pronounced her dead. Death had silenced that big voice forever. The bigger than life woman didn't look so big any more. I felt a loss and sadness I had not expected to feel.

Three days later, with great fear and trepidation I attended Esther's funeral. I was the only white person in attendance. This was 1968, only one month after the riots in Watts. Several people came up to me suspiciously and wanted to know who I was and what I was doing there. I explained that I had been her physician for the last couple of years. One woman asked if I were the doctor that Esther always had to be dressed up just right to go see. I remembered what Sarge had told me. "Yes," I said. "That was me." That changed everything and I was made to feel very welcome from that point on. I found out about Esther the mother, the sister. Apparently she had been more than just my patient.
Imagine that.

I learned more from Esther that year than I did from any of my professors or in any textbook. Lessons about life, humility, and faith. At times over the years I often wished that I had been more mature when I had been her doctor. That I had not been so young with all the selfish arrogance of youth. I wished she had had the doctor I was to become and not that young cocky Resident of so long ago. But over time I've come to realize a lot. I realize that she is part of the reason I grew to become a compassionate and caring doctor. That her faith in me helped me to become the kind of
physician the would be worthy of that faith. That in the end, faith and love are all that really matter. Whatever we do as physicians to tinker with death and disease, if we don't have faith and love, we don't help our patients. Thank you Esther for being the one to teach me that most important lesson.