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Krithika Kavanoor ~


When I first met Ms. Ruiz, I was barely three months into my first year as a family-medicine resident. I was working harder than I'd ever worked before, and continually facing new challenges. I knew that I was learning, and so I persevered, but opportunities for self-doubt were abundant.

Maybe that was why Ms. Ruiz made such a big impression on me.

A middle-aged woman with a small frame and short black hair, she'd been admitted to the hospital overnight for severe abdominal pain and jaundice. Resting quietly in her bed, she listened intently to my colleague's presentation of her case, her sharp eyes fixed on his face. I too listened carefully, and gathered that she would be with us for some time for the CT scans, blood work and other tests needed to pinpoint the cause of her symptoms.

As the intern assigned to her care, I saw Ms. Ruiz often during her two-week stay. I quickly discovered that she was intelligent, practical and hard-working, and I grew to admire her grit and determination. She gave the impression that there was no challenge she couldn't overcome, including ill health.

"The people at home need me," she said. "I have to get back."

Neediest of all, apparently, was her boss, who for twenty years had depended on her to run his dental practice. "That place is probably falling apart without me right now," she explained matter-of-factly.

As her abdominal pain worsened, and her skin grew yellower, she awaited her diagnosis with remarkable patience. Her husband, Tony, visited daily, offering tenderness and concern mixed with a wry humor that seemed to delight and uplift her.

"He's a nut," she'd say affectionately, "but he keeps me going."

Although Ms. Ruiz's fortitude made her a nearly ideal patient, she quickly became one of my most challenging cases. With each day, our certainty grew: She probably had cancer, likely widespread, and she might not have long to live. I dreaded the day when I'd have to deliver this cruel news.

On the evening before her biopsy, my attending physician and I sat down with her.

"As you know," he began gently, "there's a real possibility that the results will reveal some kind of cancer." While we talked, she listened attentively, interjecting only a few questions. When she finally spoke, she sought to reassure us.

"I'm tough; I'm a survivor," she said. "And I'm already feeling better now that you put that stent in my gallbladder. You'll see, I'll be out of here soon." We didn't argue; indeed, we wanted to agree.

The biopsy results arrived on a Sunday--my day off. Ms. Ruiz had metastatic pancreatic cancer.

I'd dreaded this moment, but when it finally came, I regretted that I hadn't been there when she learned her diagnosis.

She's my patient, I chided myself. I owed it to her.

When I came in the next day, she looked surprisingly composed. The oncologist had visited and told her that she could receive the rest of her treatment from home. She was eager to leave and reassured me again: "I'm feeling better, Doc. I'll do whatever I have to do to fight this."

Before leaving, she needed only two things: her pain-medication prescriptions and an appointment with a new primary-care doctor, her previous one having retired.

My heart sank.

Of course, she should follow up with a doctor who knows her--with me, I thought. I knew that she lived near my primary-care practice. But I didn't feel prepared to be the primary-care doctor who would see her die--possibly within months.

She'll die as my patient, I thought miserably, someone I'll see often and get to know well.

I longed to escape the responsibility I felt. But, ultimately, I gave Ms. Ruiz the option of seeing me or going to another doctor, and she readily chose me. That evening, she went home, appearing remarkably well.

Weeks later, she came to my clinic, looking a little tired but otherwise the same. True to form, she waited calmly while I dealt with another patient, less sick, but also less stoic.

When we finally sat down together, I found our visit inexpressibly satisfying. I didn't care how long it took; it was good to see her. We needed to catch up. As we talked, she shared details about her life--things she'd been unable to share during our brief interactions in the hospital.

"My daughter is having a really hard time with all of this," she admitted. "It's hard to watch."

She spoke lovingly of her husband and sister, "my rocks." She spoke of a younger son with whom she'd recently reconnected after being separated for years by circumstances neither could control. She spoke of chemotherapy--the pain and weakness it caused.

"I can't believe this is the best you doctors have come up with," she joked.

She cursorily acknowledged the seriousness of her condition, but quickly moved on to other subjects.

"Tony is always so shocked when he sees me happy and singing," she said, laughing. "I can't help it."

I was struck by how differently I felt now about being Ms. Ruiz's doctor. In a single hour, we'd cemented a relationship that went far beyond the routine doctor-patient exchange; it felt deeply personal and human.

I was in. I was ready to take on the responsibility of being her physician during the last months of her life. Indeed, I now recognized it as an honor and a privilege rather than a burden.

As it turned out, Ms. Ruiz lived far longer than expected. I took care of her throughout my three-year residency and for several months afterwards. Under her eyes, I transformed from a tentative new doctor into a capable physician. In turn, I came to know her husband and sister well and developed a sense of belonging and connection with her whole family.

As time passed, she grew thinner and weaker and lost her hair, then regained some. Her pain, initially sporadic, came to stay. Despite this, she stayed out of the hospital until my last year of residency, when her advancing disease led to a series of hospitalizations.

The last time I saw Ms. Ruiz, she was in the hospital, close to death and under the care of the palliative-care service.

She knew what was coming. For the first time, I saw plainly that she was terrified--terrified of death, terrified for her children's future in an uncertain world--and not ready to yield.

"I don't want to die, Dr. Kavanoor!" she cried out with a deep anguish that pierced me.

Nothing in my medical training could have prepared me for this moment. Ms. Ruiz and I had had many conversations about what to expect. It was heart-wrenching to acknowledge her death not as some imagined future but as a palpable, immediate reality.

I squeezed her hand and grasped at the few things I knew to be true: "So many people love you so much," I said. "And you've given so much love in your life."

It felt inadequate. Given her severely weakened state, I wasn't even sure that she heard me.

I had still been trying to be a doctor who had something to give. Now, finally, I had no choice but to acknowledge that I had nothing more to give--not as a doctor, anyway.

And so I sat silently with her for a while longer, until I finally had to go.


About the author:

Krithika Kavanoor is an attending family physician in the Department of Family and Social Medicine at Montefiore Medical Center, in the Bronx. As part of her job, she sees patients at the Montefiore Family Health Center and supervises residents in family medicine. This is the first piece of writing she has submitted for publication. "I started writing this story in my second year of residency and completed it a few years after I graduated. Caring for Ms. Ruiz was one of the most formative experiences of my years in training. I appreciate having had the opportunity to know and learn from her."

Story editor:

Diane Guernsey

Comments   

# Susan Boyko 2019-02-02 11:48
You did more than many...

Sometimes all we can do is to be present, and to be kind.

Thank you.
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# Pris Campbell 2019-02-02 05:27
I was so moved by this story. Thank you for sharing it with us.
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# Viviana S Martinez-B 2019-02-01 20:29
I just tweeted a link to your beautiful story. Thanks for sharing your vulnerability. My tweet said "A beautiful story of the importance of a continuous relationship. The author did give. Her presence, care & support. And with this article, a beautiful rendition that makes for Ms Ruiz to never be forgotten #Familymedicine strong "
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# Margaret Tryforos 2019-02-01 19:47
"Now, finally, I had no choice but to acknowledge that I had nothing more to give--not as a doctor, anyway." But you did- your presence, your attention, and something that I'll call your love, but is more complicated than that.... perhaps your shared humanity. I think we "give" our patients our skills, but we share ourselves, as they do with us.
Beautiful story. I also teach family medicine residents, and find myself reminding them that we always have something to "give" them, even if we cannot solve their problems.
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# Judy G 2019-02-01 18:51
Very touching. Thanks so much for sharing this story.
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# Mary B 2019-02-02 08:22
As a doctor who is about to enter a palliative medicine fellowship, I disagree that you did not have a lot to give. You gave her plenty, your trust and compassion. A wonderful story and something you will always remember.
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