To Comfort Always

June 24, 2018
by Mark David Siegel

Hi everyone:

“To cure sometimes, to relieve often, to comfort always.” These words call out to us from the late 19th century, the sentiments and aspirations of Edward Livingston Trudeau, founder of the famed tuberculosis sanitarium at Saranac Lake in New York’s Adirondacks.  Decades before the advent of anti-tuberculous drugs, Trudeau treated patients with fresh air, nutritious food, and a regimented lifestyle.  A patient himself, Trudeau knew cure wasn’t guaranteed, but he also knew that as a physician, he had much to offer.

His words resonate today—especially today—in an era replete with treatments Trudeau couldn’t have imagined.  In the 21st century, we can eliminate infections with antibiotics and defeat some forms of cancer with surgery, radiation, and chemotherapy, but the truth remains that most ailments are beyond cure.  

Unfortunately, these few tantalizing successes can push physicians to focus disproportionately on pursuing elusive cures while neglecting opportunities to relieve and comfort.  Palliative medicine offers a panoply of tools to alleviate pain, nausea, dyspnea, and anxiety, but too many patients suffer needlessly while seeking cures that will never come.  We must continue to explore new treatments, but we’ll have no cause to celebrate if we fail to relieve suffering in parallel.

And what of the mandate to comfort?  Do we always give patients what they so desperately need from us?  In our frenetic, high-tech clinics and hospitals, we physicians come and go in unpredictable shifts.  Visits are fleeting.  We work down the hall from patients’ rooms, facing screens instead of faces.  We offer sophisticated medications and diagnostic modalities but withhold an essential element of care.  Patients complain that they rarely see us after rounds, or that we are rushed and have no time to sit and listen.  Where’s the comfort in that?

In my clinic, I care for many patients with emphysema, an incurable disease.  I can relieve symptoms with inhalers, oxygen, and exercise programs, but the clinical impact is modest.  I’ve cared for some of these patients for more than twenty years, and sometime I’ve wondered why they keep coming back. 

I used to question the point of these visits.  Was I accomplishing anything?  I used to worry I was missing something, like a mysterious transformative treatment I wasn’t smart enough to find.  Patients trudged into my office, lips pursed, chests heaving, hearts racing, eyes worried.  What could I offer?   

The drama replayed itself year after year in endless loops of small talk: 

Me: “It’s cold out there!” “How was your niece’s graduation?” “Did you make it to Italy?” “Has it really been six months?” 

The patients: "HOw old are the girls now?" "Did I see your wife on TV?" "You're busy today!"

The dance replayed itself too. Shirt up in the back.  Fingers percussing. The stethoscope marching up and down the back.  Inhaling and exhaling.  X-rays and PFTs reviewed.  I explain: “This is why you need oxygen” or “Here’s the spot we’re watching.”  I render judgment:  “I like what I’m hearing today.” “With lungs that good, you’re going to put me out of business.” Or “A few days of antibiotics and prednisone and you’ll be feeling better.”  

For most patients, nothing much changes between visits.  If they’re lucky, they stay out of the hospital.  They celebrate birthdays and go out to dinner.  Cure isn’t an option.  

At some point, I began to realize my patients were getting more out of these visits than I’d recognized.  By the end of the sessions, they weren’t breathing so hard.  They seemed less worried, sometimes even content as they gathered up their sweaters, handbags, walkers, and oxygen tanks: 

Me: “It was good to see you.” “Give the slip to the ladies at the front desk.”  “We’ll give you a flu shot next time.” “Call me if you need anything.”  

In response: ‘Thanks doc, enjoy your family, see you in the fall.” 

More than a century later, we face the same challenges Trudeau faced in the sanitarium.  We have more treatments, but we still cure only a minority of our patients.  We can usually relieve suffering, but only if we prioritize doing so.  And we can always comfort.  A kind word, a friendly smile, a gentle touch, a reassuring presence.  We all have enough time.  Whether we’ve been doctors for thirty years or thirty days, we all possess the skills.  It’s up to us to use them.  

Warmly,

Mark  

PS Edward Livingston Trudeau was the great grandfather of a famous cartoonist. Can you be first person to name him? Let me know!

M

Submitted by Mark David Siegel on June 24, 2018