I recently encountered a dying man. There was little to do. It saddened me to see this kind gentleman, whom I have known for many years, wilting on the cart. The signs of neglect were clear. He was but a shadow of his former robust figure. He barely opened his sunken eyes when I grasped his frail hand. The end of my day was near, so I sat with him until he drifted into a carbon dioxide slumber and finally asystole. No family came to visit. Because of our previous relationship, I felt compelled to write a letter to his parents.

Dear Mr. and Mrs. ADMIT,

I regret to inform you of the death of your son DIRECT. I’m sure this is a shock to you because not long ago he was vibrant and full of energy and usefulness.

I know that, of late, fewer doctors were calling on him for his services, and I, for one, feel that is a shame. He provided a great service for many years. He saved countless health care dollars and provided a seamless entry to the hospital that the patients enjoyed greatly.

Unfortunately, DIRECT was not able to do everything for patients, and the doctors were required to actually become involved in the process. Apparently speaking on the phone and giving admission orders has become particularly onerous these days.

DIRECT understood that he could not assist every patient. He knew those with unstable vital signs and those who require immediate assessment of dangerous conditions need emergency care. He would be the first to say he was not the one for that kind of work.

I did notice lately that DIRECT had become despondent because he was being passed by. I’ve been feeling the same way about his situation. Uncomplicated fractures, chronic conditions, and nursing home patients with an abnormal lab result from 2 days prior all used to be taken care of by DIRECT. It hurt him to sit on the sidelines while others played his game.

I tried to intervene on his behalf on numerous occasions, but success came infrequently. I did learn a few things in the process. I’ll bet you did not know that a patient with a low-grade temperature and otherwise normal vital signs might have sepsis. You may also be unaware that a patient who falls from standing and suffers a displaced wrist fracture but denies other injury might have severe occult injuries that require consultation with the trauma service. I am shocked that my prior medical training had not addressed these complex management issues.