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REFLECTIONS Home MRS. J HAS BEEN MY PATIENT for five years. She is a 66-yearold woman with hypertension, diabetes, and degenerative j o i n t disease. Slowly, s h e is g o i n g d o w n h i l l , a n d s h e is in t h e office f r e q u e n t l y . Mrs. J is a w i d o w a n d lives w i t h h e r g r o w n c h i l d r e n ; t h e y h a v e r e a c c u m u l a t e d in h e r h o u s e after failing o n t h e i r o w n . H e r c h i l d r e n o f t e n b r i n g u p o l d u n r e s o l v e d issues w i t h Mrs. J a n d p o i n t o u t h e r deficiencies. Her office visits are filled w i t h n u m e r o u s c o m p l a i n t s , t i r e d a n d d e f e a t e d sighs, a n d lots of self-pity. W i t h v e x i n g regularity she reminds me of the pain she must endure and h o w little m y m e d i c a t i o n s s e e m to d o for her. M u c h o f t h e time she spends lamenting her problems, her children, a n d t h e u n h a p p i n e s s t h a t is h e r life. D u r i n g h e r a p p o i n t m e n t s I a m q u i e t a n d n o n c o m m i t t a l for t h e m o s t part, f e e l i n g r e s i g n e d to failure a n d full o f n o d s a n d " H u m m h s . " W h e n s h e leaves I u s u a l l y feel as sad as she. Mrs. J n e v e r misses a s c h e d u l e d a p p o i n t m e n t . This was a great m y s t e r y to me. I k n o w I am h a v i n g little i m p a c t

o n t h e n a t u r a l h i s t o r y o f h e r p h y s i c a l a i l m e n t s , a n d an o u t s i d e o b s e r v e r w o u l d c e r t a i n l y c o n c l u d e s h e i s n ' t satisfied w i t h m y a t t e m p t s to d i m i n i s h h e r suffering. So w h y d o e s s h e c o n t i n u e w i t h me, m o n t h after m o n t h ? T h e o t h e r day s h e c a m e i n t o t h e office q u i t e w o r r i e d a b o u t A l z h e i m e r ' s disease. It s e e m s s h e f o r g o t a f a m i l i a r t e l e p h o n e n u m b e r . This was a n i s o l a t e d e v e n t , b u t h e r d a u g h t e r c a l l o u s l y s u g g e s t e d Mrs. J was " c o m i n g d o w n w i t h A l z h e i m e r ' s . " She was c l e a r l y t r o u b l e d b y t h e possib i l i t y o f this h a p p e n i n g to her. I a s s u r e d h e r s h e w a s n o t crazy o r d e m e n t e d , a n d in fact was c o p i n g w i t h c h r o n i c disease a d m i r a b l y , as b e s t s h e c o u l d . Mrs. J was i m m e d i a t e l y r e v i v e d a n d grateful b e y o n d m y e x p e c t a t i o n . At t h a t m o m e n t it b e c a m e c l e a r to m e t h a t s h e d o e s n ' t e x p e c t m e to c u r e h e r ills o r solve t h e p r o b l e m s w i t h h e r family. All s h e w a n t s is for m e to listen t o h e r a n d n o t f l i n c h a n d fret, o n e h a n d a n x i o u s l y p u l l i n g at t h e d o o r k n o b o f t h e e x a m r o o m door. DANA FREDERICK HOCH, MD

Department o f Medicine Santa Clara Valley Medical Center San Jose, CA