She smiled fetchingly and threw her arms around me. She was so happy to have someone to hug. She was large, obese, kyphotic and almost bent double while edging slowly with her walker toward the examining room. She had sent a Christmas card and a birthday card, and I thanked her for them, while secretly praising myself for remembering she had sent them.

She was diabetic and hypertensive and 88 years old, and had just stopped driving altogether, having made a judgment of her own that it probably wasn’t safe. She had all her marbles. It was her son who took care of her, both of them all that was left of a family, but he was as immobile as she was, already elderly himself and in need of bilateral hip replacements.

Her blood pressure was too high, despite what I had thought was a good regimen, though her diabetes was in fair control, and she said, “Well I’m on so much medicine, and it’s still high, so I guess it’s just going to be high all my life — and I am 88 you know.”

I thought about all the bean-counting going on these days, and how “quality” is being judged, by what’s easy to count and metrics that might not matter. Many of us physicians wonder, from examples in our daily practice, if maybe most of the real quality in the “doctoring” we do isn’t subject to numerical measurement.

As I questioned her in minute detail about her several blood pressure medicines after I noted foot and ankle edema, I noticed that she had quite a few pills left in her diuretic bottle. It turned out that she would never take the diuretics when she planned to “go out,” meaning leaving the house for any reason, which was often.

And when she returned to the house, she didn’t take them either. And at night she didn’t take them because she didn’t want to be up urinating. We had had this conversation before; with me trying to impress on her that if she peed it was because she needed to, to reduce her blood volume and thus her pressure. She did get the connection, but she didn’t care to make the effort, yet she always denied depression, and never would accept medication or non-drug methods offered for depression. She admitted to cooking with salt like she always did — indeed, to liking salt — a lot, and to not paying attention to what she knew she should be doing. She was vying for the title of my nicest, but most non-adherent patient.

I asked about her activities: She used to sing in the church choir, and since I also sing in a civic choir, I was interested. Last year I had noticed some fresh energy and new vigor in her demeanor, her dress, her affect. When I asked her why she was so upbeat, she had mentioned, blushing, that the young man who ran the choir had complimented her several times, and that she thoroughly enjoyed her rehearsals and her interaction with the organization. I could see that she had become quite enamored of this young man, and at one point, even began to believe that he had some feelings for her.

Then one day, she came in, dejected, and trying to hide it. But I knew her well by then and could tell something was up. She came clean, with tears in her eyes. “He’s leaving, and I feel just awful.”

She couldn’t believe he could just leave when he had — in her mind — become so close to her. She had told me that — no — she wasn’t interested in singing in the choir anymore.

Now she said she had bought herself a harmonica and was learning to play it, and she brought out a small harmonica and began to pump air into it, attempting a tune.

“Oh, yes,” I said. “What my father used to try to play. He made a good effort. He used to love one song especially.”

“What was that?” she wanted to know.

I said, “You’ll probably know it, though none of the younger people would. It’s ‘There’s a long, long trail a’ winding … into the land of my dreams,'” and I started singing the first line, not intending to give a concert.

But she took it up, singing with me, and in a second, neither one of us could stop, each filling in the gaps of memory of the words to that ancient, plaintive ballad, until the last wistful line, perfect for harmonizing, and then hanging on the final steady, perfect third — in true barbershop style. Our eyes met, in a communication that can only be had through music. We laughed like schoolgirls and hoped the rest of the office hadn’t been listening through the walls.

This time, when I asked her if she could make the effort to comply with what we both knew was good for her, she actually said, “Yes — I’m really going to try this time.”

As she left the office, she said, “Maybe I should go back to the choir.”

“Yes,” I replied. “Maybe you should.”

Pepi Granat is a family physician.

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