The Patient Was…

The patient was a woman in her seventies, married to a man of some renown in a specialized area of art.

She was referred to me by her primary care internist who shared her Asian ethnicity. He pointed out that she, like many of his patients, regularly saw many other Asian physicians, but that she had great respect for “Western” doctors.

Her medical problems were straightforward: mildly elevated blood pressure and blood cholesterol levels, for which she readily accepted commonly prescribed medications. She was also taking a variety of herbal remedies, composition unknown, that had been suggested by other people she consulted. She often brought jars of strangely colored liquids to my office that she swore were of great benefit and tried to get me to try them. I always said I would take them home and share them with my wife; I did take them home and my wife and I would share a smile as we discarded them.

The patient always had health-connected questions for me, many of which had no relation to her own situation. Some, she hinted, were related to family members who would not consult a non-Asian doctor, while others seemed to be just part of her inquisitive mind. I enjoyed our discussions, but I could not convince her that I didn’t have reliable information to answer some of what she asked. She refused to accept that: “Doctor Henry,” she would say, “you know everything.” It was flattering, but uncomfortable.

She liked to come to the office every two or three weeks, despite my insisting it was unnecessary. One day, she announced that I would not see her for several weeks, since she was going to accompany her husband on a working trip to several Asian countries. I made sure she had a sufficient quantity of the medications I prescribed for her, and wished her well.

A couple of weeks later, my secretary interrupted me while I was with a patient to tell me I had a telephone call from Manila, in the Philippines. I had a general office rule that I should not be interrupted by phone calls while I was with a patient unless it were an emergency, another physician, or long distance because I didn’t want people to run the expense of having to calling back.

I wasn’t surprised to hear the patient on the phone since I knew of no other of my patients who were traveling in the region at the time. She proceeded to tell me that everything was going well, she was feeling fine, but she had a big problem that only I could solve.

It seems that by direction of another practitioner she had been taking a coffee enema every day for the last few weeks. Now, coffee enemas have a long history of use as a colon cleansing technique to “detox” the body. They have been particularly recommended as an “alternative” treatment for cancer patients. It’s important to know that there is no good scientific evidence of either benefit or significant harm from coffee enemas.

The patient’s problem, as she described it, was that the hotel she was staying in did not have brewed coffee; they mostly served tea and relied on the instant variety for their guests who insisted on coffee. She needed to know how many enemas of instant coffee it would take to match the effects of brewed coffee.

There was no way I could say that I didn’t know, because she was convinced that I had the answer to any health-related question. To say I didn’t know would be to dismiss her concern and that, in turn, would damage the delicate relationship we had developed.

I told her to hold on the phone for a time. I knew that holding on would be expensive for her, so the answer would seem more valuable. Holding on also meant I was giving her question due attention. And it would solidify that I respected her concerns. There was no information to research, no data on this. So, I used the next brief period to finish my examination of the patient whose call she had interrupted. Then I went back to the phone, still with no information but with a brainstorm.

“Here is what you need to do,” I said, making it up on the spot. “If there is no brewed coffee and you have to use instant, but it’s regular instant coffee, you need two enemas instead of one.” After pausing briefly to let that sink in, I added what was planned to seem a brilliant insight. “But if it’s decaff you need four!”

When she returned to the office after her trip, she looked really well, and said she never felt better. She gushed her appreciation for my advice when she was in Manila. “As I always say, Doctor Henry, you know everything.”

Sometimes, so long as you do no harm, improvisation is a great strategy.