The exam room bears an odor; it’s a musty sweetness, not unpleasant, but one that I know well–fetor hepaticus, a sign of severe liver disease.
My patient, Ms. Atkins, slouches on the exam table, brooding. She’s thirty-four years old, and an alcoholic. She is joined by her mother and her five-year-old daughter, Mari, who skips to my side, long braids bouncing off her shoulders.
“Hi, Doctor!” Mari reaches for my stethoscope, then turns to her mother, straightening her posture. With fierce concentration, she places the stethoscope against her momma’s belly. It’s become our routine during her mother’s office visits.
Ms. Atkins slowly raises her eyes to meet mine, and I am struck by the apathy in her gaze. It feels painfully familiar. I force down the aching in my chest and try to focus on my patient. Slowly, I register her shallow breaths, her distended abdomen, her swollen ankles spilling over her Crocs, the thickened, discolored skin telegraphing the chronicity of her condition.
Three weeks ago, she was admitted to the hospital for alcoholic hepatitis. She developed severe abdominal swelling and confusion, and then an overwhelming infection that landed her in the intensive-care unit for two weeks.
“I almost died,” she says, nonchalantly.
I’ve reviewed her hospital notes: Several times, as she recuperated, her care team offered her inpatient or outpatient chemical-dependency treatment; but she always declined.
Now, when I ask, she admits to drinking since she’s returned home.
“Not a lot. Just a couple of drinks.”
“Just a couple of drinks….” The words are familiar.
They weigh heavily in the air. Grandma’s eyes dart back and forth between us; I feel as if she’s silently pleading with me to help her daughter. Ms. Atkins, however, remains distressingly calm.
“I can quit on my own!” That’s what I used to tell myself–and I failed repeatedly.
I review her recent lab results. They’re worrisome, pointing to liver failure.
“I am very concerned about your drinking,” I tell Ms. Atkins, “and that you are advancing to alcoholic cirrhosis.” I see no comprehension in her eyes–just the vacant stare.
Eventually, the blinding realization hits me that I’m flailing. Standing in the bathroom early one morning, I struggle to meet my bloodshot eyes in the mirror. I am full of self-hatred and hopelessness.
“Well, I’m not drinking anymore,” Ms. Atkins says. When I ask, she admits to some cravings. I again offer her resources: medication, outpatient treatment, support groups.
“I’m not going to AA. That program is all about God and religion.”
I cry through my first AA meeting; big, powerful, heaving sobs. I can’t stop. It’s the first time I’ve said the word “alcoholic” and my name out loud in the same sentence. “Don’t get caught up on the Higher Power,” they say. “It can be the Universe, or other people in the program. You just have to be willing.”
I’m willing, but I am so ashamed. I am an alcoholic physician–a disgrace to my profession. That “A” is my scarlet letter.
I drag my attention away from my own memories and back to Ms. Atkins.
“AA is a support group intended to help you maintain sobriety,” I say.
She shakes her head. “No.”
Feeling conflicted, I don’t press further.
I have not told any of my patients about my own battle with alcohol use. Early in recovery, admitting it out loud to anyone, including myself, was a struggle. I shared it with a few colleagues, which fueled the rumor mill and led to intense feelings of shame. As time passed, I became comfortable sharing with others openly, but I felt that patients were different.
Now, with more than three years of sobriety, I’m trying find the courage to share my experience with Ms. Atkins, to let her know that I understand.
It was so hard. There were days when I didn’t think I would make it. “One day at a time.” I remember counting the hours, or just the minutes, when seeking to ease the mental anguish, but it got easier. Over time, I found hope, forgiveness and grace for myself. I found a resilience that I never knew I was capable of, followed by healing and joy.
I’m tiptoeing along the boundary between professional discretion and personal vulnerability–a mysterious and dangerous place. When I was a student, several of my mentors told me never to share personal details with patients. Most of the time, I don’t.
I used to smoke, though, and I often share that fact with patients who are trying to quit, as a way of acknowledging their struggle and letting them know that I understand how difficult it can be. As a primary-care physician, this kind of self-disclosure feels familiar and valid.
My patients ask often about my family and hobbies. They share pictures of grandchildren smearing cake on their face on a first birthday, of spouses at family reunions, of legions of children and memories. Sometimes I’m privileged to hear their fears about their health, and about the impact of new laws and policies on their lives. Sharing something from my own life, with the goal of helping a patient, seems safe.
More urgently, Ms. Atkins is going to die if she doesn’t get help. It feels like an obligation to extend this branch of hope.
Despite that, my fear persists. Looking at Ms. Atkins, I can feel the inner boundary line opening into a chasm that threatens to swallow me whole, and I’m terrified. I open my mouth, but my shame pulls me deeper into the pit, silencing me.
We finish our visit, and I schedule Ms. Atkins for an outpatient procedure to drain the fluid in her abdomen. We plan a follow-up visit within a month.
There’s nothing else I could do, I tell myself.
One month later, I’m sitting in clinic and reviewing discharge summaries. As I scroll through the list, a name appears on my screen: Ms. Atkins.
It’s a Death Summary.
My mouth goes dry. Shaking, and feeling my heart pounding, I click on her chart.
She was admitted again to the ICU, developed a rare lung complication and died two weeks later. She never sought treatment for her alcoholism.
Tears prickle my eyes. My throat tightens, and I’m overcome with an unexpected wave of grief. I’ve lost patients over the years, but this one feels more personal. It could have been me. Could I have made a difference? I reflect on our last meeting, my anxiety a weight in the pit of my stomach.
I call Ms. Atkins’ mother to share my condolences. I want to apologize for my cowardice, for my failure to reach out to her daughter, but I don’t have the words.
“How will I care for my granddaughter?” she asks, her voice full of anguish. As I hang up, my guilt and sorrow are suffocating.
I remember Mari running into the room and crawling into my lap, and the scent of her baby shampoo as she draped my stethoscope around her neck. In my mind, I wrap my arms around her.
I’m so sorry, I tell her. I failed.
I make a promise to myself, and to her: Next time, I will try to cross that invisible boundary–I will share my own personal story, so that my patient knows that I really do understand how hard it is, and will feel supported in the struggle.
I will try.