American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, November 5, 2015


“It was a gift I ain't never seen coming. But as special and precious to me as being raised by her.”
—Ms. Ables

I saw this Grady elder 1 day in clinic on an ordinary weekday. It was a simple follow up for diabetes and high blood pressure and high cholesterol and not much more. She was adherent to her medication regimen, kept appointments, and was up to date on all of her age-appropriate cancer screening. It seemed that she was in good shape.

Even though Ms. Ables (*names, details changed to protect anonymity) was in her seventies, from looking at her smooth brown skin you couldn't tell. Her crop of silver curls was the only tell-tale sign that she probably earned a senior discount in Publix and Kroger. She had a beautiful smile, too. It was big and vibrant; so wide that you could see the gold edges of the partials she wore. But somehow it all just made her more pleasant to the eye. I liked her immediately.

“Is there anything you're particularly concerned about today?” I asked. Of course, the resident physician seeing her with me had already asked her this same question but I thought I would ask again for good measure.

“Well … hmmm.” She twisted her mouth for a moment and chose her words carefully. “I feel like I lost a lot of weight over the last 3 years. And I guess it's good for my medical conditions but I just thought I'd mention it since I ain't been doing nothin’ to lose that much weight.”

As soon as she said that, I clicked into the weight flowsheets in her chart. The last 3 visits appeared to be pretty much 2 to 3 pounds in the same range. She saw me doing that and added, “It's been gradual. Nothin’ real, real obvious. It's only when I run into somebody who ain't seen me and they say, ‘Dang! You lost a lot of weight!’ or ‘Girl, you look good! What you do?’ I don't even have the heart to tell them that I ain't done nothing.”

I nodded at her and, following that prompt, moved back a few years to see what she'd previously weighed. Sure enough, I saw what she meant. Three years ago, she was 228 pounds. And now? She was a solid 180 soaking wet. “Wow. You have lost weight.”

“Told you.”

I looked up at her and pressed my mouth into a straight line. I mean, her screenings were all without evidence of cancer. Her blood work was pristine, too. Her address hadn't changed nor had her medication list. This was weird. “Have you been on any diets? Or given anything up since then?”

“No, ma’am.”

I leaned my chin into my hand and squinted an eye. “Well, you're definitely right that it's been gradual. And it obviously started somewhere around 2012. Can you think of anything that has happened since then that could explain this?”

“In ‘12? Hmmm. No. Not as I know of.”

“Okay,” I responded. And honestly, I wasn't sure what else to say. I mean, anything life threatening that would cause weight loss of this amount would have fully been declared by now. But more than 40 pounds was a lot of weight to be losing without trying.

A whole lot.

Her mood and affect were light and normal. She definitely didn't strike my resident or me as depressed, but I've paid enough attention to some very strong people affected by depression and anxiety to know that this means nothing. Out of necessity people find their best “game face” and strap it on for moments such as this. And so. I went ahead and did a simple screen for depression which, for the most part, came up negative.

For the most part.

When asked her the question about changes in her appetite, she said, “It's there, but I just don't eat as much these days.”

I didn't beat around the bush and came right out and asked. “Why is that?”

I needed to know. I mean, was it a money thing? Or an access thing like living in a food desert or not having transportation? Was it a dental issue, which is super common in indigent populations, requiring her to get a tooth pulled or to be fit for dentures? I wanted to know.

Turns out, it was none of those things.

“I eat to live now and that's it. But I used to live to eat.” The side of her mouth turned up and some inexplicable emotion washed over her face. She cleared her throat and went on. “My mother and I used to have dinner together every night. She was a great cook and taught me all she knew.”

I just stayed silent, nudging her to go on. She did.

“When Daddy passed on about 15 years back, Mother came to live with me. Not ‘cause she couldn't do for herself or nothing. Just because she liked being with people and such. Mother was like that. She liked people and company.”

“That's great.”

“Yeah, it was good for both of us. My kids' dad and I split a long time back and my kids were all grown and on they own. I was glad to have her move on in.”

“Sounds special.”

“You know? It was. It sho’ was. And Mother? Whew-weee, she loved food.” Ms. Ables shook her head then swallowed hard. “Jest loved it. Everythang about it. And nawww, she ain't never got real heavy or anything. But food was her thing. And a good meal with everybody together enjoying it? Now that was her favorite.” Her eyes had already begun welling up with tears that she blinked back as hard as she could.

I decided not to overthink it and bit with the obvious question. “Did your mother pass?”

“Yes, ma’am. She went home jest before Christmas in leb'm.” I liked the way she and many of my Grady elders pronounced the word “11” as “leb'm.” And I also liked the way death was described as “going home.”

“I'm sorry.”

Ms. Ables sighed hard. “Yeah, baby. Me, too. Once Mother moved in, it was just us for some time. We was both up in age so look like we was jest two peas in a pod, me and her. And since she loved food and cooking so much, we made dinner side by side in the kitchen and ate together every night.”

“Wow,” I said. At this point Ms. Ables was sweeping tears off of her cheeks. I pushed a box a hospital-grade Kleenex in her direction. Watching her cry made me feel this dichotomous mixture of sorry I'd asked about her mom and yearning to hear more about her. Now that I know how good it feels to talk about someone you love, especially when they're no longer alive, I stuck with embracing the latter. “What kinds of things did your mom like to eat?”

Ms. Ables placed her hand on her bosom and laughed hard and deep at that question. Immediately I felt glad I'd asked. “Chile,” she sucked in a big drag of air and chuckled again. “Mother liked it all. And see, since she was one of them old school cooks, she knew how to make everything from scratch. But the reason I'm laughing is ‘cause later on she got into them cooking channels. And I tell you she'd have me in the store and down by that curb market with her looking for all sorts of stuff. I mean anythang you name, Mother and me tried it out. Right there in my kitchen.”

Shit. This is the kind of thing that always makes me want to cry. I mean, I can't even type it well without crying so you can only imagine what I was like when I was there. But surprisingly, I held it together. That is, until she said this:

“And no matter what, Mother had me set that table jest like I did as a girl. And you know? I would. I set it just like she taught me every single ev’nin. And Mother believed in eating on your good plates. We ain't never had no china or nothing. But we had some nice stuff and we used it every day, me and Mother. We sure did.”

And that? That did me in. Man. I tried my best to smile at her as the fat tears rolling down my cheeks mirrored the ones that had been sliding down hers. Because now? Now, I got it. I got why this woman, who used to live to eat now only eats to live.

“I'm sorry,” I finally whispered while patting my eyes with tissues from the same box I'd just handed to her a few moments before. And I said that because I was sorry. “It's just … that … it's just a beautiful image, Ms. Ables. You and your mother dining together like that. I can see it.”

She froze and closed her eyes for a moment. Her breath hitched briefly, then she gave her throat a clearing. Ms. Ables' eyes were somber when she opened them to look at me again. “So guess it do make sense why my weight fell off, don't it? ‘Cause now I just eats to live and that's it. I mean … “ Her voice faded off and crackled a bit. I could tell these words hurt but she pressed on. “Now I just like to get meals on over with, you know? I picks something real simple to make, too. ‘Cause a real complicated recipe make me miss my mother too much.” She looked frustrated when the tears started to return.

All I could do is sit there. Sit there with my eyes on her and not flinching as she honored her mother and told her story.

Ms. Ables looked skyward and then dropped her head. “Lord Jesus. Mother, I miss you so much. I mean every single day, Lord knows I do.”

Now she was weeping. And let me tell you, it broke my heart into a thousand tiny pieces. I reached for her hand and she let me hold it. “Take your time, Ms. Ables.”

And you know what? She did.

“You know? I still eat on the good plates, you know? Jest ‘cause I know Mother would want that. And my life a good life. I go places and do stuff and enjoy my life, too. But it's just that meal time. Something about sitting down to a meal that I believe is probably gon’ hurt my heart until I take my last breath. ‘Cause that? That I associate with Mother. And I doubt I'll ever reach a point where I don't feel that way. And that's okay with me.”

I decided it was okay with me, too.

So there you had it. This is why my patient had lost more than 40 pounds in 3 years without trying. And you know? I'm realizing more and more how much you can learn about people by asking the right question and then—the real key part—by actually listening to what they say in response.

More discussion revealed that Ms. Ables was indeed enjoying a very good quality of life outside of meal time. We completed a PHQ-9 depression assessment, too, and she didn't meet criteria for depression with that 1 either. Ms. Ables just missed her mother. Plain and simple.

We wrapped up the end of the visit and tied up the loose ends. I reached over and gave Ms. Ables a big hug and she hugged me right back. And all of it was authentic and good. Truly it was.

I thanked her for introducing me to her mom and that made her smile. Then, one of the last things she said before I left was this:

“This probably sound silly to a lot of folk. I mean, look at me, 74 years old and crying over losing my mama like she ain't never get a chance to grow old. Mother made 94. Ninety-four! And she was in her right mind that whole time, even up until her last days when she just fell on asleep one day in her chair and didn't wake up.” I stepped away from the door and sat back on the edge of the chair when she said that part. Then Ms. Ables rested her eyes on mine and finished. “But here's the thing: Mother wasn't just my mama. She was my friend. And I loved growing old with her. It was a gift I ain't never seen coming. But as special and precious to me as being raised by her.”

And that? That I knew I'd have to place on a post-it note in my heart to come back to later. Because until then the idea of living long enough to become an elder with your parent was something I'd never even thought of. I guess because it calls for planets and birthdays to be aligned just so, but still. I now know that hearing that will surely change the way I view loss in those who get the chance to experience that uniquely special phase together.


See this? This is Grady. A world of people and lives and lessons and love. Of Ms. Ables and mothers and so much more. And me? I'm just glad to be here, man. So, so glad.


And thank you, Ms. Ables, for showing me yet another dimension of love between mother and child.

This reminded me of this poignant word that Billy Bob Thornton shared on the show “Master Class.” Some piece of me relates to this, too.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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