While taking down the Christmas tree on Saturday, I reflected (as I always do) on the origen of each ornament. Some I can't recall, some are a bit generic ("I bought that box to go on my first tree after medical school") but many more than you'd imagine have specific memories associated with them.
Most of my grandmother's have been broken or gone missing, but there are real pinecones with glitter that were maybe hers? Or Mom made them because they were like hers? There are at least a dozen made by hand by my children over the years. There are gifts from college friends, long gone from my life but not my heart. There are ornaments that move me from far past to present, each a memory of love and caring: Gifts like gentle voices from Christmas past.
There is one that always makes me pause each year, both in placing it on the tree and removing it. It's a sweet little gray tiger china cat, sitting on a real satin pillow - odd for a Christmas ornament, really. It was given to me by a patient more than 25 years ago. He was the first of my patients to die entirely in my care.
Robert had suffered from severe depression his entire life in the era before Prozac. Treatments were limited to medications so sedating that people sometimes drooled; or to electroshock therapy. Long-term hospitalizations were common. He had done these things, and survived them all.
I asked him how he managed. His answer remains one of the most haunting I have ever heard.
"Well, Doc: Every morning, the first thing I do is decide whether or not today is the day I am going to kill myself. When I decide it isn't, I put it out of my mind and get on with my day."
What kind of courage is required to look yourself in the eyeball every single day of your life and make a conscious decision to keep fighting a lifetime of accumulated despair?
He died at home only a few days after a cardiac workup. I'll never know if I failed to find the problem that was causing his symptoms, or if his having symptoms gave me a way to put 'natural causes' on his death certificate for his family when he maybe made a different choice. Those who found him found no reason to suspect that he had taken his own life. I know he was intelligent enough to not leave evidence behind.
I've given it more thought as years have gone by than I did at the time. This is very complicated: Am I uncomfortable because I might have missed a treatable cardiac problem (I certainly was at the time!)? Or because I think I could have helped more with his depression? Or because I might be happier thinking he harmed himself than that I might have missed something?
Uncomfortable thoughts indeed, for a young doctor. No less uncomfortable for time passed.
Doctors in general are realists. We know that things happen, we know that we have the barest illusion of control, we know that our patients' lifestyles matter more than what we do much of the time. I am good at compartmentalizing: Separating home from work, head from heart.
But Robert thought well enough of me to give me a gift. So each Christmas I spare a thought and a prayer for my many patients like Robert, who make the choice daily to live against the forces of despair. And I remember those who haven't survived my care but whose courage lives on in my heart, inspiring me to always, always try my best for the rest.