Mrs. D was my last patient. I retired several months ago, and for some time prior I informed my patients so as to give them time to decide where they would like their follow-up care.

Mrs. D was an elderly lady who I first met in the ER several years prior after a fall resulting in a displaced ankle fracture. She was pleasant and alert, understanding everything I was explaining after discussing what was wrong and the treatment options. Given the type of fracture, bone quality, and her activity level, surgery was recommended, and she accepted.

Since she was alone, I asked her if she had any family she would like me to call. She told me she was a widow with no children of her own, no family nearby, and her POA belonged to a grandniece who lived three states over. I placed the call and after explaining what happened and the proposed surgery, the niece said that she did not trust the hospital and wanted her aunt transferred someplace else.

After asking if she had anywhere in mind she said no but wanted me to “find somewhere else.” I said I would be happy to transfer her aunt wherever she would like but it was not my job to find another hospital and surgeon. Reluctantly, the niece said she would do that. After splinting and icing the fracture, I explained to Mrs. D what had happened. She said she had no problem staying but would do whatever everyone else wanted.

I explained to the ER staff what was happening and asked them to keep Mrs. D there until they heard back from the niece. I then went to the OR to do another case, all the while receiving phone calls from the ER wanting me admit Mrs. D because they were getting in trouble from Medicare for keeping patients in the ER for too long. I told them I did not want to admit because I was told that the hospital was getting in trouble for admitting and immediately transferring patients. I asked the ER to document everything that was happening and please leave her there until we heard back from the niece.

After finishing my case I returned to the ER to find them about to admit Mrs. D. At that moment we finally heard back from the niece, stating they she “could not find someone, but had checked on me and decided that her aunt could stay.”

No problem, I said, and proceeded to admit, get the appropriate medical follow-up, and operate the next morning.

Mrs. D’s surgery went well. However, since she lived alone and could not walk, she could not be discharged home. She was not a candidate for home care. Social services got involved but her discharge from acute care was delayed. She could not go to inpatient rehab because the empty beds there were reserved for CVA patients. There were four — count ’em, four — empty beds. That left short term nursing home care that the niece was adamantly against.

That meant Mrs. D had to stay on the acute care floor for ten days while there were discussions back and forth between me, the internist on the case, the hospital, social services, and the niece. Every day I got a call from the hospital wanting to know why Mrs. D was still on the floor because the care she was receiving could be done on an outpatient basis and they would not be paid.

Eventually, Mrs. D was transferred to an inpatient rehab bed where she spent two weeks before she was well enough to be transferred to home care. Her post-op outpatient course was benign except for her outpatient PT that took longer then expected. I spent three times as much time answering insurance inquiries and the numerous calls and letters from the hospital explaining why Mrs. D was in the ER for so long and why she had a prolonged stay on the acute care floor then I did actually caring for Mrs. D. I never heard again from the niece.

Months later, Mrs. D plateaued out with her recovery with a mild limp, mild pain and swelling. She was happy with the result and I was willing to discharge her from care but she wanted to come back and see me every couple of months “just in case.”

This went on for a couple of years, our interactions becoming more social then medical. When I told her I was retiring she burst into tears. I told her if she would like I will transfer her care to one of my partners and she was fine with that. On my last day, Mrs. D was my last patient. She handed me an envelope and inside was card thanking me for all the care I provided and apologizing for all the trouble she caused. I had to fight back my own tears.

I am now retired. There are many things I will miss but many things I will not.

I will miss Mrs. D.

Thomas D. Guastavino is a physician.