I miss Alba. I don't know why, but I do. She was the most challenging patient I've ever had. I dreaded seeing her in the office--and yet, somehow, she won me over.
Alba was fifty-nine, with short, silver hair, a deep, gravelly voice from decades of smoking, and an attitude. She had lung disease, heart disease, depression, arthritis and HIV. She also had a complicated social situation. She'd used cocaine and heroin until her husband had died of HIV. She'd then moved in with her elderly mother and cared for her until her mother died of a stroke. Now Alba lived in a shelter right around the corner from where her father had been shot years before.
The biggest joy in Alba's life was her granddaughter; but her estranged daughter wasn't letting Alba see her.
Alba frequently missed appointments or, just as often, walked in without notice, demanding to be seen. She was always in crisis--and she generally took out her frustrations on me.
But when she wasn't crying or yelling, Alba was charming and funny. She would tell me amusing stories about her family. She described how she helped care for a disabled neighbor. No matter how sick she felt, she was always well put together, with full makeup and a fashionable outfit. I couldn't help but admire her for putting on a brave face to the world.
Alba was singlemindedly determined: She would zero in on a goal–-a medication or procedure she wanted--and pursue it relentlessly. On the rare occasions when I went along, we'd enjoy a pleasant visit. But most of the time, talking to her felt like playing tug-of-war.
She began every visit with the same dejected "Hey, ma." Then she'd launch into a tirade about her current issue.
Early on in our relationship, Alba insisted that she needed an electric scooter because her arthritis was making it hard for her to walk. For weeks, I heard about nothing else. Finally, after many phone calls and letters to her insurance company, I succeeded in getting Alba the scooter.
The next time I saw her, instead of thanking me, she demanded opioid medications. Given the chronic nature of her pain, and her history of drug abuse and depression, I felt reluctant. There was too much risk of abuse or overdose. But when I tried to explain this, she cursed at me and shouted, "You're not listening to me, ma!"
I offered her an appointment with pain management, but she said they hadn't helped her in the past. I suggested a referral to orthopedics to plan surgery for her arthritis, but she angrily declined. Finally, I agreed to a very mild narcotic.
Alba threw the prescription in my face. It was Percocet or nothing.
As she rolled away down the hallway, she screamed over her shoulder, "You never want to help me!" On the back of her scooter I saw a "For Sale" sign. I didn't know whether to laugh or cry.
I thought I would never see Alba again.
A few weeks later she walked in, leaning on a cane.
"I'm sorry about how I acted last time," she said. "I was just giving you some tough love."
"What happened to your scooter?" I asked casually.
"It got stolen," she replied without batting an eye.
I kept trying to get her surgery for her arthritis. Somehow, between her missed appointments and the surgeons' reluctance to operate while she was taking blood thinners for her heart condition, it never happened.
One day Alba called me in frustration.
"I'm in so much pain, ma!" she sobbed. "I can't take it anymore! I've been staying clean, but all this pain is making me wanna use again!"
When I tried to discourage her from doing that, she hung up on me.
After several days of soul-searching, I came up with a plan. I called her on a Friday afternoon.
"Hey, ma," she answered, sounding exhausted.
"Hi, Alba!" I replied in my perkiest voice, certain that she'd feel better once she heard my plan. "I have an idea. I can give you small amounts of narcotic pain medications, but just until you see orthopedics again and have your surgery. All you have to do is stay clean. As long as your urine screens show only the drug I've prescribed, I can give you the pain medicine."
"You don't get it, ma!" she cried. "I'm in so much pain! No one understands what I'm going through! I can't deal with this right now!" And she hung up.
I was flabbergasted. I'd been so sure that she would agree--that she'd be grateful. I spent the weekend wondering, What did I do wrong? What did I miss? What more could I possibly offer?
I decided to call Alba first thing Monday morning and give her some "tough love" of my own.
"Alba," I would say, "I've worked so hard to help you, and I'm at my wit's end. Nothing I do seems to satisfy you, and you refuse to follow my recommendations. You need to stop hanging up on me, and you need to tell me exactly how I can help you. If there's nothing I can do, then maybe this therapeutic relationship isn't working. Maybe you need to see someone else."
On Monday morning I opened the medical record to look up Alba's number. But the first thing I saw was a message from the medical examiner.
"Your patient deceased" the subject field read.
The message could have referred to any of my elderly or sick patients, but somehow I was sure that it was about Alba. Maybe it was because I was thinking about her at that moment, or maybe it was some kind of sixth sense.
I read the message and found that I was right.
I phoned the medical examiner.
"She collapsed at a friend's house," he said. "EMS was called, but they couldn't resuscitate her. Multiple drugs were found on the scene and in her system."
I spent the rest of the day in a daze. Was this why Alba didn't like my pain medication plan? Because she knew the drug screen would be positive? Would she have admitted to active drug use if I'd said the right thing? Should I have tried some tough love on her earlier, or would that have driven her away? Was an overdose her way of permanently stopping the pain? Am I partly to blame for her death?
Despite her drama and all that she put me through, Alba wormed her way into my heart, and I feel a real sense of loss. I spent so much time worrying about her, it seems strange not to be doing that anymore.
And I can't shake the feeling that if only I pick up the phone and dial her number, I'll hear her voice saying, "Hey, ma."
About the author:
Maria ("Masha") Gervits is a family physician in the Bronx, where she grew up and attended Albert Einstein College of Medicine and Montefiore Medical Center's Residency Program in Social Medicine. "It was at Einstein that I heard a professor read a story about one of his patients. He encouraged us to keep a journal to honor and remember our patients and reflect upon our clinical experiences. I took this advice to heart and have been writing ever since."