Four-Wheel-Drive Medicine R. Landry, MD, MPH Late Friday afternoon. The Northeast. It's been a week of two-hour committee meetings, a statistically significant number of walk-ins, and a pair of anniversary dinner candles burned down to stubs by the time I got home. So why should I expect that the last patient of the day (and of the week, for mercifully, the weekend is all mine) will be routine? Mrs Vest. Chief complaint: chronic back pain. She has earned a record two inches thick and diagnoses that reek of frustration: failed back syndrome, facet syndrome, rule out fibromyalgia. She is, this evening, as I hear the office staff going about their closing ritual outside the treatment room door, what we used to call in medical school "sticky." With every statement of disengagement: "Well, hopefully this will do the trick." Or: "So we'll see you in three weeks" Or: "We'll see what these tests show." Mrs Vest completely ignores her medical-social requirements and continues to provide a free-flowing account of her symptoms. Finally, I resort to the last refuge of the harried physician. I stand, even while she is in mid-sentence, and hand her the prescription while expressing hope that this will make her feel better. Leaving the clinic out the back door, as she exits the front, I button the rarely used top button of my coat to keep out the wind-driven sleet that has surprised some weather forecasters and that penetrates even the warm glow of freedom and expectation I feel about the two days ahead. There is something profoundly world-shattering about an engine that fails to start. Perhaps the capricious nature of the event; or the removal of power; or the ultimate threat in we doctor types: the loss of control. A friend of mine once called times like these "the conspiracy of machinery." They are capable of reducing we clever, response-for-everything gurus to a passive, childlike being, sitting in cold automobiles, out of ideas, and near the edge of tolerance. At last accepting the reality that the faithful Jeep is not going to cooperate, I once again slip into my problem-solving role. I could call the auto road service and wait the requisite hour, and with this weather perhaps two. Across the street there is still a light on at McCarthy's, where in the past I have had work done on the Jeep. Worth a shot at least. "Hi, Doc," greets me as I drip on McCarthy's floor. "What's up?" Maintaining a veneer of familiarity with the nature of the internal combustion engine, I relate to the mechanics the symptoms of my ailing auto. It's Friday, it's late, and they are closing up. I have little expectation of resolution. "Well, Doc. We could go over there and take a look at it for you, but . . ." Here it comes, I thought. " . . . that's not what you need now. Let me get one of our cars for you. We'll work on yours tomorrow, but you use ours for the weekend." This angel of mechanics then looked outside at the worsening weather and added, "You'll need a four-wheel drive in this mess." And then, as if that were not enough, he disappeared outside, without a coat, and soon drove up with an Explorer. Leaving the engine running just outside the front door, he reentered the room with a flourish of brushing and shaking the sleet from his clothes. "Better give it a few minutes, Doc. It'll heat up nicely." Driving home, equanimity restored, I thought about the evening's events. Is not medicine, like auto mechanics, a service profession? In that service, are we not obligated to meet the needs of our patients, even if at times these needs are poorly articulated, are even disguised? What was it that Mrs Vest wanted from me? Did I deliver? Janet, our receptionist, had told me some time ago that Mrs Vest was a widow, her husband having succumbed to melanoma with bone metastases several months ago. Her oldest son, she had told Janet, had injured his back and was out of work. Analgesics, platitudes, and half-hearted optimism did little to ease the loneliness, fear, and emotional suffering she must have been feeling. She, like me, did not have unrealistic expectations. She couldn't or wouldn't ask for what she needed. How is it that now it was clear what Mrs Vest came to get, at our clinic, in my treatment room, so late on Friday afternoon? Did I deliver? Did I deliver the four-wheel-drive version of my profession's care, which today amounted to an attentive, understanding ear? I think not. I could lay the blame on a system in which productivity is the currency of the realm. I could, but I know that to accept that as absolution is to throw off all those reasons why I chose to be a physician. I was callous. I can forgive myself this time. I think Mrs Vest will forgive me. But Neil, the mechanic, will haunt me forever if it happens again.