Visiting Germany in the Winter

Affiliation:

Department of Internal Medicine, University of Texas Southwestern, Seton Family of Hospitals, Austin, TX

Abstract: Elderly people often tell stories about their life experiences to a younger audience. Storytelling is a mechanism by which the elderly re-experience notable events of their past, perhaps reminding themselves that they have not always been old and ill. Physicians who treat the elderly should encourage these reminiscences, as they often provide some sense of well-being to the storyteller. When the patient is also a physician, these clinical visits present opportunities for connection between younger and older generations of physicians. This article illustrates a clinical vignette in an internal medicine outpatient practice. The patient is an elderly retired physician who was struggling with ill health and recent loss. The vignette highlights his resilience in the face of adversity. 

Key words: Storytelling, reminiscing.

Robert is one of my favorite people. He’s an 85 year-old retired physician, a family practitioner who had once been chairman of the department of family medicine at a large municipal hospital in the South during the 1960s and 1970s.

I have been Robert’s physician and that of his ex-wife, Alicia, for about 15 years. They divorced 2 years ago. The first 30 or so years of their life together were like many marriages—full of serenely beautiful times, mundane experiences, and tragedy. Alicia, 25 years Robert’s junior, had two children with Robert. Their son Mike is now a grown man. Mike’s older sister, whose name I had never known, died at a young age.

Robert was devastated but not surprised by Alicia’s decision to leave him. Having lived together for more than 35 years, one has to see things like this coming. But among the rubble of their marriage, as the dust began to settle, Robert soon was able to accept things for what they were. They were two people, still in love. But Alicia, for her own reasons, felt that she must make a radical change of direction in her life.

Robert then began making plans for himself. He kissed Alicia goodbye, wished her well, and moved into a semi-independent living center. As he left their home for the last time, he asked Alicia to bring her friend Andrew over for Christmas dinner at his new apartment the following month. He meant it. Never bitter, never sarcastic, Robert was a realist and a gentleman throughout that time of tumultuous change. He loved Alicia and would always love her. To see her happy again at Christmas dinner, even with Andrew and not with himself, would warm the chill of Alicia’s rejection at least a bit.

Christmas came and went without the dinner.

A month after Alicia left him, Robert went to Germany, alone, “because [he’d] never been there before.” I wondered why he had chosen Germany as a destination. Why not Hawaii or Costa Rica? Someplace warm. Germany in the winter is so difficult.

But I think he chose Germany because it was difficult and because he had never been there before. He knew the challenges involved; the icy European January weather, an environment conducive to hip fractures. He would be an elderly stranger in a foreign country, alone. But, thinking back on it, I think he needed difficult hurdles then, difficulties other than the one that was breaking his heart. Perhaps he viewed it as a challenge: to prove to himself that he was still capable, competent, and independent.

Robert had a few mobility problems while there, but nothing of consequence. In fact, he had a delightful time and felt good about his undiminished abilities to manage travel logistics, despite his age and the rigors of a cold, harsh climate. On this European adventure, Robert did not find nor seek a “female Andrew.” He found something much better: confidence in himself and in his ability to live a meaningful life on his own, despite heartache and physical infirmity.

Robert told me all about his travels through Germany during one of his clinical visits. Eighteen months later, Robert visited for another check-up. As usual, he stoically denied pain, decrepitude, or shortness of breath. He spoke rather dismissively of the leg weakness that was only very slowly getting worse. He was still able to walk to the grocer’s, still able to prepare his own meals, able to read his medical journals, as well as a bit of “well written fiction.” He could still socialize casually with the other “inmates,” as he teasingly referred to his neighbors at the assisted living facility.

I performed a cursory physical examination, which revealed nothing unexpected. Robert was doing all right, despite his known afflictions of sleep apnea, coronary artery disease, hypertension, and spinal stenosis. I deemed that he was in equilibrium with his conditions.

I asked him if he would ever consider spinal surgery, if it would offer a chance at improving his leg strength. “Naw,” he rasped. “For now, it’s really not all that bad for the types of things I do in my life.” He then looked down from his perch on the examination table and paused. After a few seconds, he lifted his gaze from the floor, a twinkle in his eye, and said, “Though, I would like to go to Miquelon and Saint Pierre.”

I’m not a travel agent, but I’ve always considered myself pretty good at geography. However, my quizzical look made him laugh. “You don’t know where the hell I’m talking about, do you?”

At that point, something from my ham radio experience popped into my consciousness. Miquelon/Saint Pierre! Of course! “Now wait a minute. Yes! I do know where that is. It’s a small French possession just off Newfoundland in the North Atlantic. Cold, blustery, isolated place. I have tried for years to talk to a ham from there, but no luck.”

At that, his bushy, unruly eyebrows went up in surprise, and we were off on yet another tangent.

“You are a ham? I used to be a ham. YN4GCK was my call sign.”

“That’s Nicaragua, right?” I asked. The first two or three letters or digits in a ham’s call sign usually designate what country he lives in. “What were you doing in Nicaragua?”

“I was on a medical mission in, yes…you’re right, eastern Nicaragua.” Looking down again, he shook his head silently, smiling, then chuckled in remembrance. “We used to do everything there. Even brain surgery.”

I said, “Are you kidding? How does anyone, much less a family practitioner—no offense—do neurosurgery in the bush?”

He looked up and replied, “I did it because if I didn’t, the lady would have died. There was no place to send her. We were ‘it’.”

He shifted around on the examination table, rattling the paper sheets, as he prepared to relate his improbable tale.

“She was a little ol’ woman in her 70s who had been set upon by bandits about 6 miles from our rural hospital. The robbers had machetes. They decapitated the old lady’s grandson and slashed the top of her head with the machete that left her brain cortex exposed. There must have been a 3- by 6-cm [sontameter as he said it, the way many physicians trained in the 1940s and 50s do] piece of cranium missing over the vertex of the skull. They just left her for dead.” 

“Oh my God,” was all I could manage to say.

“Yeah! It was awful. So we carried her to our makeshift operating room inside the hospital. We irrigated the wound for 30 minutes. Then I sewed up the meninges as best I could, pulled the skin tight over the whole thing, and sutured it together. After that, we sent her to the ward and I treated her like she had meningococcal meningitis—16 million units a day of intravenous penicillin for 10 days.”

I blinked a few times, seriously doubting that I would have been up to performing similar heroics in those impossible conditions. Then asked, “So what happened to her?”

Chuckling again, “You’re not going to believe this, but that ol’ gal walked out of there 2 weeks later. She only spoke an indigenous dialect used in rural Nicaragua, so I couldn’t talk to her. One of our nurses translated for me though. She said the old lady seemed pretty much normal to her, though maybe a little forgetful at times.”

I could only shake my head in wonderment.

He then went on to tell me about another miraculous accomplishment, that of a young man with a fractured hip that he pinned without aid of X-ray equipment in the operating room.

Physicians are fascinated by medical “war stories.” They love hearing incredible tales of daring-do as told by colleagues, usually from older, more experienced doctors. These stories tie one generation of physicians to the next, providing a continuum of shared experience that the younger doctors use in their profession as much as the knowledge gained from textbooks or lectures. Such stories are a painless and entertaining way to gain experience, if only by proxy.

As I enter into my mid-60s, the reservoir of older-than-me colleagues seems to diminish every day. There aren’t many war stories left for me to hear anymore. I counted myself blessed to have just heard a couple of doozies from Robert.

During the pause in our conversation, I sensed that I had reached a critical juncture in my office visit with Robert. Should I now make our encounter more conversational (like a social visit) or should I just shut up and see what happened? I sensed that his recitation of events in Nicaragua had had quite an effect on him, but in what way I wasn’t sure. I decided to be quiet.

We continued to sit in silence. He sat there, looking down at the floor for a couple of minutes, shaking his head and smiling to himself as if he were reliving those and many other events for the first time in quite a while. These were his old memories of Nicaragua that were bubbling up, one after another, from deep within. His head would occasionally bob up and down, as if saying “oh, yes!” and then he would quietly laugh, the way old men do, as if he had remembered something else even more remote and more deeply buried than the previous experience he had just recalled. I smiled as well for those few moments, watching him from the sidelines, as he enjoyed his reverie. I wondered what he was recalling now…what other incredible things had happened that he chose to keep to himself.

Then, the smile suddenly faded. “Hmm,” he uttered. A few more seconds passed. Then, he was back in the present, the magical spell broken. There was a barely perceptible shake of the head. He blinked a few times, swallowed hard, then looked me in the eye and suddenly smiled broadly, then cleared his throat a little after a false start, before speaking again.

“Well, I guess I’d better be going. I’ve taken up too much of your time already.” He made an old man’s preparations to get off the examination table, slowly lifting one leg off the paper sheet covering the table, then the other, a rehearsal of sorts, before the actual act of gingerly navigating the distance between table and floor.

I replied “Don’t be silly. I always love visiting with you. You know that.”

He safely got both feet on the floor then turned to face me. He looked a bit wearier than he did earlier, as if he was struggling to drag himself forward to the present.

“Yeah. That’s true. Oh, one thing...do you want to change any of my meds?” His question provided him context that he had returned to “now.” We had resumed our roles of doctor and patient. He slipped off the gown and I handed him his clothes.

“No. No medicine changes,” I said, without elaboration. I knew he didn’t require an explanation. He was a physician. He knew as well as I that the risk-to-benefit ratio of all his therapeutic options had already been optimized. He nodded in reply, expecting my response.

As he got dressed, I considered what had happened over the last 15 minutes. Was there anything that I really gave Robert during that visit? Had he received any value by coming to my office? I decided that, even though I had not done the usual “doctorly” things, such as changing his medications or ordering tests, there was one thing that I was able to do for him during our visit: I was able to talk to him during the appointment, to stray off the usual office visit script and really just talk, and listen, and allow him to relive some of his life’s best moments, with minimum interruptions. In so doing, he was able to remind himself of his past and consider his present, despite its somewhat diminished circumstance. I think he realized that at 85, with much less physical capacity than he had during his younger days, he was still capable and sufficiently girded, physically and emotionally, to handle most things that came his way. Just as he had handled his professional trials in Nicaragua in the spring of his life, he had recently demonstrated his viability by successfully binding the emotional wounds of a ruptured marriage while in his German winter.

“No, Robert. I’ve got nothing for you, except some advice.”

“Which is?” he said with his characteristic wry smile, stopping now his slow shuffle out of the examination room, turning his whole body to face me.

“Go to Miquelon/Saint Pierre. Otherwise, I’ll never be able to make a contact on the radio with anyone up there.”

The smile faded into a look of genuine consideration of a new idea. He blinked a few times, his gaze never leaving me, apparently mulling my tongue-in-cheek recommendation. After a moment, he spoke.

“Yeah! Maybe next winter.”

Disclosures: The author reports no relevant financial relationships.

Address correspondence to: Michael K. Williams, MD, Internal Medicine Office, 313 East 12th Street, Suite 102, Austin, TX 78701; mkwilliams@seton.org