Coming out of my exam room on a Monday morning, I saw two overweight police officers standing in my waiting room. From past experience, I knew that they were there to tell me that one of my patients had died and to collect information for the coroner's report. Even as I geared up to hear the impending bad news, the doctor in me couldn't help wondering how they'd passed their department physicals.
"Do I need to call a lawyer?" I joked, trying to guess which of my patients it could be.
"Michael Freund died on Saturday," said Dalia, my office manager.
It was a shot to my gut. Mike was seventy-three years old, but one of my healthiest patients for his age. He neither smoked nor drank, took no medicines except for the occasional Viagra and played tennis with a passion. He was fit and trim, and I couldn't imagine what had done him in.
I hadn't seen Mike in the months since he'd come in for his annual exam, which had raised no red flags. Then I remembered that he had called me the previous Thursday with some vague complaint that I couldn't recall. I'd set him up for an appointment the next day, but he'd called to cancel, telling Dalia he was feeling better.
Now, three days later, he was dead.
The police weren't much help, except to say that he'd had collapsed while doing something or other, and that an autopsy was pending. They copied what they needed from his chart and walked out, leaving me to ponder the cause of death--and awash in emotions.
In addition to being my patient, Mike was my friend. He had come to me six years earlier as a Bay Area refugee looking for a life in the country. Learning that he was both a handyman and an artist, I had him do some repair work around my office. My building has joists cantilevering out to support a deck, and they'd been attacked by rot from the deck. I'd thought that the whole deck would have to be torn down and rebuilt, but Mike had Sawzalled away the bad wood, like a surgeon debriding a wound, and scabbed on good wood using lots of glue and paint. Another time, when a putrid odor permeated the office, he'd squeezed through a crawl space to see if there was a dead critter under the floor. Not finding any, he'd concluded that something had died in the walls; we simply had to wait for it to dessicate until the smell finally went away. Not many patients would get down and dirty for you like Mike did.
I couldn't wait to get the autopsy report--what had I missed?--so I called the county coroner for a preliminary read. The secretary was helpful; the cause of death, she said, was "cardiac ischemia," meaning an insufficient blood supply to the heart.
That struck me as odd, but odder still was to get the report a few days later and find no internal exam results. It was as though the pathologist's "autopsy" had consisted of simply glancing at Mike's body. Nothing had been checked beneath the skin--no body cavity explored, no organs weighed or examined. Surely they'd accidentally omitted the internal exam from the transcript; could the pathologist actually have neglected to do it? This procedure wouldn't even pass for an autopsy on television, where they get all the medical stuff wrong. My calls to the coroner went unreturned, and I was left wondering if this was their standard operating procedure or just an aberration.
Mike's newspaper obituary mentioned that a celebration of his life was to be held at his home the next Saturday. I don't go to many of these affairs; if someone dies, I worry that people will hold the doctor responsible. Maybe I was responsible--maybe I should have paid more attention to a patient who was likely minimizing his symptoms in an effort to fool himself.
Try as I might, I couldn't remember why Mike had wanted to see me. His call had come as I was leaving for the day; I'd scheduled him without even noting his complaint, probably because it didn't sound serious. And when he didn't show, I hadn't thought much of it. Was that negligent of me? I would have given anything to have recorded that last conversation. Anyhow, I decided to go to Mike's celebration.
Arriving at his house, I met Vicki, his girlfriend of two years, who lived in a nearby town.
"Mike told me he'd canceled his appointment with you," she said. "He was having bad reflux, but then he felt better. He came over on Saturday, then he went to play tennis while I went shopping. He played three hard sets with younger players and beat them all. After the match, he collapsed. They say he had a heart attack. His father died of one when he was forty-six, but his brother is still alive at eighty-two, so Mike figured he hadn't gotten the bad genes."
I didn't remember Mike's family history quite that way. As I recalled, his father had died of congestive heart failure at sixty-two. But I wasn't going to argue the point. Besides, he'd had no other cardiac risks or complaints.
I walked around Mike's house, looking at all his artwork. He was prolific; there were abstract paintings everywhere. Several tennis rackets lay on the floor of his bedroom. Once, he'd given me one to get me to play with him. Sadly, that had never happened....
As his tennis-playing and art-world friends began to arrive, I left.
I didn't want to be introduced as Mike's doctor.
About the author:
Sandy Brown practices family and preventive medicine in Fort Bragg, CA. For more than six years he wrote the column "Practice Diary" for Family Practice Management. He now writes the "Family Medicine Practice Diary" for Medscape Family Medicine as well as facilitating their family medicine and internal medicine discussion boards. When not writing or seeing patients, he enjoys dirt and mountain bike riding and counseling premeds about how to get into medical school.