MR ROBERTS came in faithfully for checkups. He was a mild-mannered working man, a bit compulsive perhaps, with routine medical issues. He took an active interest in his health, and it was always a pleasure to see him.
One winter, Mr Roberts began to lose weight. The history was unremarkable, as were the results of the physical examination. He hadn't been eating as much, and some weight loss was not unexpected. When the weight loss began to accelerate, I ordered the appropriate serological tests and asked about new symptoms. Test results were normal, and the examination results were unchanged. Mr Roberts was concerned by the continued weight loss, but reassured by my lack of findings. I was not entirely reassured.
Mr Roberts worked the night shift as a guard at a local warehouse. He led a very private life, with very few friends or hobbies. But he was satisfied with his somewhat reclusive lifestyle, and there were no recent mood changes or major life events.
He lost more weight. Could this be an undetected malignancy, human immunodeficiency virus infection, tuberculosis, thyroid disease, depression? I reassessed his situation, but there was nothing new on the tests, history, or examination. The chest radiograph was normal, and psychosocial factors did not seem to be involved. I began to think zebras.
During one of the ensuing visits, Mr Roberts told me matter-of-factly that the tests were becoming too expensive. He was running down his life savings: one thousand dollars. In addition, he feared that his job would be among the next wave of layoffs at the warehouse. Mr Roberts had been earning the minimum wage at his job of many years and had no health insurance. And I, as his physician, never even knew.
I arranged for his testing to be done at the lowest cost or as a courtesy. Our social worker investigated and arranged appropriate services. Unfortunately, Mr Roberts' paltry wages were just enough to preclude his eligibility for the usual sources of aid. What he did not clearly need to have done, I did not order. This was "cost-effective" medicine in the trenches. It reminded me that most health care was once routinely "rationed" by how much a patient could afford to pay. Meanwhile, my patient began to appear ill, and I was losing the war on his weight loss.
Mr Roberts was a thin man to begin with and now was rapidly wasting away. His body looked like a stick frame with a cloth blown onto it by a gust of wind. I consulted with my colleagues, sent him to specialists, and pursued appropriate workup, all to no avail. In spite of our frugal approach, we repeated many tests. He was only 50 years old, led a very modest lifestyle, and had no significant risk factors. However, he was becoming very ill; it didn't seem fair.
Mr Roberts looked at me and asked why he was losing weight. This was the technology-driven 1990s. Yet, my years of training in the temples of technology could not give me and Mr Roberts an answer to his simple question. He nonchalantly accepted my explanation about continuing the search for a cause, but I could feel that he knew something was seriously wrong.
Following one office visit, I called to tell Mr Roberts about a specialist consultation I had arranged. There was no answer, but I knew he never went far from his apartment. After 3 days of unanswered calls, I decided that more active intervention was needed. My social worker called the apartment building's office and asked that they check on Mr Roberts. They soon called back and asked that we urgently come to the building.
I entered the building's atrium. Several policemen were milling about. My worst fears had come true: Mr Roberts had been found dead in his room. Resuscitation had not been attempted. When I asked why, one policeman beckoned and said, "I'll take you up there." His sergeant handed him a cigar, smirked, and said, "It always works for me." I was puzzled.
We rode the elevator to the 11th floor, my mind racing with a mixture of apprehension, sadness, guilt, and curiosity. As the elevator door opened, the intense odor of decay hit us. The reasons for the cigar and lack of resuscitation became painfully clear. The policeman hastily lit the cigar as we walked down the dim hallway to Mr Roberts' apartment.
I could not believe that the figure slumped over in the chair was my patient, Mr Roberts. They reassured me it was. I glanced around his home. A naked lightbulb hung from the ceiling of the single-room apartment. A thin mattress lay in one corner, and a small table stood in another. There wasn't much else. It struck me how the bare apartment mirrored his barren life.
Mr Roberts sat in the lone chair at the table, facing a brick wall. A half-empty cup of coffee and snack cake sat on the plate in front of him, as if he were suddenly going to sit up and finish his meal. Perhaps an arrhythmia secondary to the severe wasting, I wondered. How cruel: not even a diagnosis, and then suddenly struck down in the middle of a meal. But maybe the underlying disease would have brought much more misery.
I was not yet ready to give up the battle. I moved closer in search of clues to his demise. It became apparent that nature had dealt one more cruel blow. The lone window was wide open, but had no screen. Free to come in along with the busy sounds of the city traffic below was the common housefly. The scavenger flies came in search of a place to lay their eggs. They found one. The leathery face that once respectfully looked into mine for answers was now a writhing mass of thousands of white maggots. My last visit with Mr Roberts was finished.
He didn't have local family or a significant other. At the office, I found Mr. Roberts' medical record and located a telephone number, probably written on his first visit to our office years earlier. I called. His sister told me that he had always been a loner. He had left their Midwest farm 20 years ago, in search of a better life in the big city. I imagined, for a moment, what his life may have been like had he remained on the family farm.
His 3 sisters and mother thought that he had a well-paying job and had made it big in the city. After all, he regularly sent his mother some money. I could not bring myself to tell them how different his life had actually been. Despite his minimum-wage job, he had somehow managed to send a portion of his meager earnings back home. The contrast between his life and their perceptions made the City of Brotherly Love suddenly feel desolate and cold.
That last image of Mr Roberts slumped in his chair and the unanswered questions haunted me. Maybe it was amyloidosis, an atypical presentation of anorexia nervosa, or even something obvious that had been overlooked. The medical examiner found no significant pathological characteristics on autopsy. If only I had ordered a couple more tests; the answer surely was near. My colleagues reassured me that I had done all that I could, but the thought held little comfort. Although I had been there as his physician and also provided emotional support, scientifically I had failed. While I realized there was no other test to order, my emotional tug-of-war continued. I could not find piece of mind, knowing that tomorrow there could be some new technology that would lead to a quick diagnosis and cure.
One day, several months later, I pondered Mr Roberts' fate. As one of my mentors had so eloquently taught me, sometimes the telling of a story is therapeutic in itself. This one was, for me at least. While I had been frantically searching for a medical answer to Mr Roberts' fate, I gradually learned more about his life and became one small part of it. A sad story was being painted while I was frustrated and absorbed in the baffling medical details. As I silently saluted his courage in face of the ominous signs, I realized that I now saw a bigger picture of his life. His life was one of stark contrasts between his hopes and dreams and the realities of his life: his puritan lifestyle, yet an early demise; his idealistic vision of a better life in the big city vs the harsh realities of the working world; and his hope for an answer to his illness, yet the inability of medical science to give him one. With the telling of the story and the passing of time, I saw his life from a different perspective. Mr Roberts hadn't run out of tests. He ran out of dreams.
