12 H A S T I N G S C E N T E R R E P O R T November-December 2007

“You lied to me.”No one had ever said that to me in

the hospital before.“Why did you lie to me?”Why, indeed?

I’d met her the previous day, when shebrought her son to Coptic Hospital

in Nairobi, Kenya. I was a fourth-yearmedical student doing an infectious dis-ease elective at the hospital.

Her son was eight years old andHIV-positive. He had a fever and wasbreathing fast. Jason, the infectious dis-ease fellow, listened to the boy’s backand looked at his X-ray. “Pneumonia,”he said.

While the son slept with an oxygenmask on, Jason spoke with the mother:“He is very sick. The first forty-eighthours are the toughest. We can’t behopeful until they’re over.”

Jason excused himself to go to ameeting. I didn’t have a meeting—Ibarely had a white coat. I sat at the footof the sleeping boy’s bed, across from hismother, where the sheets were stamped“CH” in large, faded blue letters. Themother put a thumbnail between herteeth; folded and unfolded her arms;looked at me and then away. She wore aflowery print dress with lace at the neck,as though she’d been suddenly calledaway from a garden party.

“What will happen if he can survivethis one?” she said to me.

“Well,” I said, hesitating, “it de-pends. He may be developing resistance

to the antiretroviral medicines, in whichcase we would need to switch him.”

She looked confused. “You give himnew medicines?”

“Maybe. It depends on—”“Better medicines?”“Well, just different. He won’t be re-

sistant to them.”“The new medicines, they will make

him healthy?” She leaned forward.“Well, his viral load should drop,

and maybe his CD4 count will rise—”She tossed off my jargon. “They will

make him better?” Her eyes carried notjust a question, but a plea.

I paused.“Yes,” I said. “They will make him

better.” With new medicines, I contin-ued, her son wouldn’t get sick as often.He wouldn’t need to take prophylacticantibiotics every day. I told her aboutother children I’d seen, just as sick ashers, who had made complete recover-ies. I described their weight gain, theirincreased energy. How they played soc-cer in the playground after school, justlike the other children.

Her smile was a tiny burst of joy, likethe hug of a small child.

When I left, she squeezed my hand.“You are a good doctor,” she said.

The boy died later that night, while Iwas treating myself to a dinner withfriends at a Korean barbecue restaurant.

The next morning she was waitingfor me. Her face told me more than

the empty bed did. Her eyes tore at mewith unfocused rage, and despair.

When she called me a liar, I thoughtof defending myself—reminding herthat she had asked me to speculate. I’donly responded to her hypotheticalquestion. But I kept my mouth closed,not wanting to tell another lie. Thetruth was I had indulged in the fantasy,too. I had taken comfort in imaginingher son’s long, happy life. Our bedsidechat was as much for my benefit as hers.

She yelled in my face: What aboutthe weight gain? What about the soccerin the playground? She wanted me toaccount for every misleading statementI’d made. Her body trembled with theforce of her fury. But a thousand fits ofrage would not bring her son back, andshe suddenly seemed to realize that. Herhands dropped to her sides. She wept.

She’d asked me to comfort her, andI’d built that comfort from the only ma-terial I had: hope. I had done it un-thinkingly, instinctively. I had not con-sidered that hope is a shaky scaffolding,and that when it collapses, the fall toearth can be long and the landing hard.

To reach for a straightforward solu-tion is tempting: Be accurate and

objective at all times. Tell the wholetruth and nothing but the truth. Giveyour patients a precise dosage of hope,measured out in milligrams, calibratedexactly to the medical circumstances.But one patient might benefit fromhearing the worst-case scenario, whileanother could use the emotional boostof a more optimistic prognosis.

And this, perhaps, is where the art ofmedicine lies: in sensing what will helpyour patient through her crisis, anddoing your imperfect best to give it toher. In adapting to the needs of your pa-tient, even when she herself may notknow exactly what those needs are.

In the end, all I said to her was “I’msorry.” I said it over and over. I was sorryfor her son’s death. I was sorry that Iwasn’t there when he died. I was sorry Imisled her. Ultimately, I was sorry that Ihadn’t yet learned how to be a doctor—one who understood the power of hope.

Hope

by Cameron Page

in practice