A patient's first name.

I often debate whether I should be calling patients by their first name or last name. The gregarious part of me that wants to create a personal family atmosphere thinks first names are better. The professional, respectful part of me sticks to using Mr. or Mrs. The age of the patient also affects my decision. I'm 34, and will not hesitate to use first names with patients younger than me. With a rapidly aging population, most of my patients are much older, and formal salutations are the norm. For middle aged patients, I'm usually torn. Sometimes they'll just tell me to use their first name. If the issue never comes up, I arbitrarily will switch between formal and informal, depending on my mood, my recollection of their personality, the lunar phase or potentially any other random irrelevant thought process.

Mrs. Silva (name changed) , who despite efforts to hide her age wearing bright ill fitting outfits and loud hats, was definitely 68 years old. No matter how hard she tried to look younger, I always used formal salutations.

"Mrs. Silva, what's going on with the diabetes?"
"Well Dr. Hossain, I gotta be honest with you, I've been cheating more this past month."

"Mrs. Silva, How's Mr. Silva doing?"
"Oh he's good. I keep telling him to make an appointment here. He won’t listen to me."

"Mrs Silva, did you get your mammogram done?"
"Oh yeah! it's not due until next month. I've already got it scheduled."

"How's the breathing Mrs. Silva?"
"It still stinks. I'm still always short of breath and no I haven't stopped smoking yet Dr. Hossain. But I'm really gonna try these next few months."

"Mrs. Silva, are you still coughing up a lot of junk?"
"Yeah Dr. Hossain. I can't seem to shake this cough, even after the antibiotics. And I could've sworn I thought I saw a spot of blood in it."

Soon after mentioning the last complaint, Mrs. Silva was diagnosed with Non small cell Lung cancer. Shortly after, it was discovered she had metastasis to the brain. Because of the myriad of oncology, surgery, neurology, neurosurgery, radiation oncology appointments, and 2 hospitalizations, she wasn't able to make it for an appointment to my office. A few times she tried to schedule an appointment but cancelled. Throughout the process, we spoke on the phone a few times, and she remained delightfully optimistic and didn't express any specific needs from me.

Finally, after 6 months, Mrs. Silva made it our office at the urging of her oncologist.. She had lost a great deal of weight and gave up the makeup and bright outfits for more demure, darker and simpler clothing. She lost all her hair but had a closet full of hats for this occasion. Since she was a resident clinic patient, the case was presented to me and I was well aware of all these details even before I walked in the room. I knew I would not be seeing the same Mrs. Silva.

I knocked on the exam room door and with a lump in my throat, ready to discuss some difficult issues.

"Hi. Dr. Hossain."

I don't recall what exactly went through my mind when I saw Mrs. Silva in front me, a shell of her former self. But I remember beginning the visit by trying to smile and saying,

"Hi Lily, how are you doing?”