Sometimes I do it all wrong. One minute I'm encouraging a resident to apply sound evidence-based guidelines; the next minute I'm sitting with Serafina.
![Figure](https://www.cmaj.ca/content/cmaj/167/7/786/F1.medium.gif)
Figure. Photo by: Art Explosion
Serafina is a paradox. She seems to have lived a lot longer than the 74 years that her birth date would indicate. When I first met this short, obese, semiedentulous Old World woman, I made the mistake of trying out my very limited Italian and immediately became her confessor. To endear me further she asked about my Sicilian pronunciations and found out that I had learned from someone she'd known in the old country. We were now practically related. At the very least, I had become someone who could understand her and would look after her — body, soul and spirit. In her view, at least.
She comes with fifty complaints, forty-eight of which I can't understand and two that are nonspecific. The list of medical conditions goes on ominously: CAD, CHF, asthma, type-II diabetes, hypercholesterolemia, osteoarthritis, osteoporosis, GERD, obesity, chronic UTIs, depression, anxiety … . What I hear from her is:
“My eyes are pulling.”
“The back of my head is coming over the front of my head.”
“All the muscle in my back is fire.” (She demonstrates by poking the corresponding spots on my back.)
“Everything goes black because of the pain in my chest and my head.”
“My mouth is burning all the time.”
“My stomach makes a pain and a bad noise from here to here.” (She points from mid-sternum to her knees.)
When I try to ask the clarifying questions she gets frustrated, says “Come si dice” and then explains it to me in Italian, not believing for a moment that I can't understand. Even the translator I enlist on occasion is baffled by her turn of phrase.
I grope for something objective to hold onto. Bring all of your medications so I can see what you are using. And your glucometer so I can see what your sugar has been like. She brings a shopping bag of bottles with a mixture of current and past drugs. As we go through them she tells me about each.
“The yellow one makes me dizzy.”
“The blue one is my blood pressure pill, I take it when my blood pressure up.”
“The brown one is my stomach pill; I take sometime one, sometime three.”
“This pill and these patches give me a headache, I don't take them.”
“This capsule I take when I have burning pee.”
“The orange puffer when I can't breathe, the blue one only sometime.”
When I try to set her straight she looks at me condescendingly and says that she knows how her body feels and how to take her medicine.
This elderly woman manipulating her glucometer with the dexterity of a ten-year-old kid with a GameBoy seems incongruous to me. Her records show her blood glucose ranging from 3 to 26. She says she only really feels good when it is around 10 or 15. Whenever she feels unwell in any way, it helps to eat — maybe a piece of homemade sausage or basil pesto on bread, a bowl of the soup that is always on the stove or maybe some cookies. She feels unwell most of the time.
The nonmedical issues are just as numerous. She lives in her own house with a middle-aged son who doesn't work, doesn't help her and is on disability because “he's not right.” She is estranged from her daughter. She was separated from her husband many years ago (maybe she kicked him out) after a marriage that was dominated by alcohol and abuse. Serafina is depressed and wonders why God would make her keep suffering for all these years if all she wants to do is die.
She loves me. How can she? I can't do anything for her. I sit by and watch her suffer with her heart disease, diabetes and hypertension, powerless to apply my clinical practice guidelines. She brings small statues of Mary or Jesus to remind me to pray for her: “Aska God to take me home.” She also brings food — pesto, lentil soup or homemade sausages — all of which smells of a pungent combination of body odour, garlic and olive oil. I am her confessor and confidant.
Serafina is strong, capable of going against church and society to do things the way she needs to. She doesn't need me to do anything at all. I want to deal with her diseases; she wants me to understand her illness.
So I find myself trying to justify my inaction to my colleagues as they look at her HbA1C in the teens. Somehow it doesn't seem right to give patients what they want when we know what they need. Somehow it doesn't seem right to receive from patients, but when Serafina shakes my hand and gives me her blessing, “Pace e bene,” I know I cannot refuse it.
The oath doesn't say, “Do the right thing,” but only “Do no harm.”
Chris Giles Family physician Hamilton, Ont.