“Thank you for standing by my bedside in the critical care unit”

 

Mr. V had not come to the clinic in a while. He was otherwise a regular fortnightly visitor. An octogenarian, with a hearty and reverberating laughter, he always brings with him the sunshine when he enters the clinic. The white hair, thick white moustache and the wrinkles on the skin on his hands are the only signs that this man is aging, otherwise he is a young lad of 18. He comes to our clinic to get his prescription refill for diabetes, hypertension and a chronic skin condition. Yesterday even before he came in, one of our staff, Mr. V’s daughter in law, dropped by my room to say, “Sir, my father-in-law has come. He recently had a heart attack and was admitted in the hospital. He got discharged day before yesterday and insisted that he will come to see you today. Shall I bring him in?” I requested her to bring him in and stood up to receive him. 

 

As Mr. V walked into the room, I noticed that the usual skip in his step was missing. He was wearing a monkey-cap and had a blue shawl wrapped around him. The usual bright smile on his face was missing. He walked very slowly and came to my table. I was standing and he held my hand and smiled at me. We both sat down. He was silent for a bit and then said, “It was a terrifying few days in the hospital doctor. Somehow, I bargained for some more time from the God of Death and have come back. I am sitting here with you!” and he smiled. I smiled back and asked him how he was feeling. Then I went about the clinical encounter enquiring about his symptoms, examining him in detail, and reviewing his hospital discharge records. Mr. V had suffered a heart attack, which had been quite severe. The heart had stopped for a few minutes, and they had done electrical cardioversion to revive it in the CCU. Since the heart was weak, and given that he was 85 years old, they had held off on any aggressive procedures like angioplasty or surgery and discharged him on medications after he had stabilized. Mr. V had been in the critical care unit of the hospital for a week and then in the general ward for 4 days. He seemed to be recovering reasonably well from this traumatic ordeal. 

 

“You know something? Throughout those fitful days in the critical care unit, all alone, I kept seeing you frequently standing by my bedside holding my hand, like how you usually do and reassuring me! I saw you and my wonderful wife, God bless her soul” 

Mr. V’s wife had passed away many years ago due to breast cancer complications. I am a primary care physician, and my entire work is limited to the two rural clinics where I see patients. I haven’t stepped into a critical care unit as a physician in the past 20 years.  So, I was not there in the critical care unit that Mr. V was admitted it. Both Mr. V and I understood that he was talking about a hallucinatory experience. Both of us acknowledged it for what it is and went on with the clinical encounter. I reviewed his current prescription, adjusted the refill and after talking for a bit he left. 

 

I could not take what Mr. V had told me, out of my mind. It kept ringing in my head, “What does it mean if I am part of the hallucinatory experience of a patient? It must mean something for the kind of bond that Mr. V and I share. How blessed I am to have such a rich patient-doctor relationship?” I thought these things and even wrote about it to my sister and a friend. But then other patients came in and there was no time to delve on it any further. Late last evening after I got home, finished household chores and settled to read, my mind wandered and landed on what Mr. V told me. 

Mr. V experienced a very traumatic episode during his heart attack and critical care unit admission. During such traumatic life altering moments, the mind searches for safety and security. It looks for anchors who provided such safety in the past, for instance, parents, teachers, authoritative figures, spouse and any caregiver. The mind conjures them up to experience that safety. Mr. V had hallucinated his wife and me. This must mean that I have provided him the kind of familiarity and safety through our therapeutic alliance. It was a deeply humbling realization. Mr. V had internalized me as someone who provides him a zone of comfort and our clinic as ‘coming home’. That is why he had decided to come to the clinic as soon as he could, after he was discharged from the hospital. In Mr. V’s mind coming from the critical care unit to our clinic was a metaphor for coming from a traumatic place home. His mind needed that homecoming experience to reconcile and process the trauma. 

 

What Mr. V was experiencing was a kind of transference. Transference is the phenomenon where the patient transfers their feelings, emotions and behaviors from past experiences into the current patient-physician relationship. For example, some patients see their physician as a ‘parent figure’ who has a concern for them, cares for them and regulates their behaviors. They expect the physician to chastise them for missing doses of their medicines or going off track from lifestyle changes that were recommended. In case of Mr. V, he went through what is referred to as ‘idealizing transference’ which means going to a child-like state during traumatic times and viewing the physician as an authority figure from earlier in their life who stands for safety, security and care. Mr. V’s saw a nurse standing by his bedside and hallucinated that it was his wife. He saw another physician visiting him there and hallucinated that it was me. His mind transferred his wife and me on to the people who were there in the critical care unit. Such instances of positive transference can be immensely therapeutic to patients. 

 

This realization really humbles me. I had never thought of this kind of an impact that a patient-physician interaction can have. How deep and strong our therapeutic alliance must be that I feature as an object of Mr. V’s hallucination? If a primary care physician can have this impact on their patients, what a huge responsibility is it to stand up to such a position? In addition to giving me a sense of immense satisfaction in doing what I do, this also makes me nervous! It is the ‘good kind of nervous’ which makes me want to be more caring, more competent as a primary care provider and up to date in doing the right kind of primary care for my patients.