Box of Chocolates

A JAMA article by Lealani Mae Y. Acosta, MD
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Patients often come to see the physician with hope, and we do our best to help. When our best efforts may not feel like much to us, they may make an immeasurable difference to the lives of patients and their families. Their gratitude is similarly difficult to quantify, even when embodied in a box of chocolates.

As per the initial visit, he came pushing his wife of many decades in her wheelchair, only this time he additionally came bearing a bright smile and a distinctive box of chocolates. It actually was Valentine’s Day.

“I am so happy we are seeing you again, Dr Acosta! She has done so much better since her first visit with you and the suggestions you’d made!” This was a difficult concept to grasp, because she had been quite challenging to examine when I initially evaluated her.

A wheelchair-bound octogenarian with kyphosis and presbycusis, she had been brought by her husband to clarify the diagnosis of dementia. I had reviewed her medical record ahead of the visit and had mentally prepared myself. Her primary care physician (PCP) was a good historian and had carefully documented her multiple medical diagnoses, although the best that could be said for her cognitive status was “dementia.” The physical examination results included in the notes ran the gamut of standard organ systems typical for a general physical examination. The patient sitting before me was a perfect reflection of those encounters, which documented a patient who had tremendous difficulty following commands and could only communicate very little. Given that so much of my examination as a behavioral neurologist relies on language and cooperation, I was unsure what to expect from the encounter. To quote Dr McCoy from Star Trek, “I'm not a magician, Spock, just an old country doctor.” With any referral, much like Gump’s proverbial chocolates, you never know what you’re going to get.

True to form, her initial examination left me rather discomfited because almost every kind of cognitive question was left unanswered. I practically shouted in her ear with every question, to which the patient responded either with, “What?” or silence. I typically ask the spouse about the existence of hearing aids, which inevitably are either forgotten at home, too expensive, or the patient refuses to wear them. The best response I garnered directly from her was her first name.

Her neurological examination was more informative. Extreme kyphosis had her practically staring in her lap, so I had to crouch down on the floor to peer up at her to meet her steely gaze (this was no mean feat with my center of gravity shifted from pregnancy, as I was 6 months along at the time). She maintained good, if not glassy, eye contact, so by moving my face in the cardinal directions I was able to assess extraocular movements; at the very least, there were no signs of limited vertical gaze indicative of progressive supranuclear palsy. She had paratonia and a mild resting tremor, which are not exactly textbook for a Parkinson plus syndrome, but a nod in that direction. Her reflexes were symmetric and within normal limits. At best she was able to move all limbs antigravity, as formalized strength testing was difficult to direct. We discussed trying to get her out of the wheelchair for a gait evaluation, but she had reportedly been wheelchair-bound for months, so I deferred, in part because of my protruding belly and also because I was not eager to chance her potentially falling.

As far as recommendations, I offered some tentative suggestions regarding medication changes. I recommended checking her blood work results for common endocrinological and vitamin abnormalities that can contribute to cognitive impairment to see if there was anything that needed correction. She had been taking an acetylcholinesterase inhibitor and N-methyl-d-aspartate–receptor antagonist in the past, both of which had been discontinued sometime in the past year; there would be no harm and likely limited, but some possibility for, benefit by their resumption. As best as I could tell from her spouse and medical record, there had been no trial of carbidopa levodopa, so this could be beneficial for her tremor and mobility. I outlined a staggered course of medication reintroduction or trial for them to discuss with her PCP; they were hesitant to make any changes without the PCP’s approval. I felt like I had contributed little to her treatment, so I instructed as-needed rather than scheduled follow-up. I was exhausted after the visit had taken nearly twice as long as the allotted time.

Hence I was surprised to see her name on my schedule again a couple of months later, right before I was due for maternity leave. She didn’t appear that much different on paper when I reviewed the PCP’s interim note; of all the medication changes I had proposed, they had only ventured one.

Yet I was amazed that she looked more alert: brighter, better eye contact. Despite her kyphosis, she was even sitting a little more upright. When I asked her questions, she actually understood what I was saying and was able to respond relatively appropriately, even though she was still without hearing aids. Granted, she remained completely disoriented as to date and location, but she could engage some pleasantries, tell me how she was feeling, and identify her husband, which was much better than our initial encounter. I was floored.

“We weren’t sure if we were going to see you again,” her husband gushed. “The changes you recommended have really made a difference! Even the staff at the nursing home has noticed. This is the best she’s been in months.” I felt a rush of emotions, reflecting my prior frustration at not being able to do more. Apparently, I’d done enough.

He gratefully handed me the box of chocolates, and I jokingly commented that I couldn’t say no to sugar “for the baby.” Ah, pregnancy cravings.

She died several weeks after I had seen her. I met with her husband months later and he spoke glowingly of his wife. He showed me pictures of her sitting relaxed and smiling with a perfectly coiffed bouffant. He brought me samples of jewelry that she had hand-painted with delicate flowers: a filigreed ring with tiny strawberries, a pendant with a spray of violets, a bracelet with tiny daffodils and irises. She had won “teacher of the year” awards at several schools where she worked, no mean feat for a school librarian. I read through samples of her writing that illuminated her faith, including a reimagining of Psalm 23. I held back my own tears as he choked up while narrating her final hours, including holding her hand as she died. Beyond the patient, I saw her as a cherished wife, teacher, and artist: kyphosis, from bowing her head in hours of prayer and poring over books; hands, wizened by age, arthritis, and a lifetime of grasping a paintbrush; and eyes shining with love for her husband.

I realized that all my lamentations represented frustration at not being able to do something that I had perceived as substantive for her. As physicians, we are used to having the answer, diagnosis, or treatment. Those brief minutes (or hours, as the case may be) we spend with patients in the clinic may take only a fraction of our day but can create lasting memories for those whom we treat, and ourselves as well.

I never remembered chocolate tasting quite so sweet.