He was referred to me for an evaluation of atrial fibrillation, a chaotic beating of the upper chambers of his heart which caused him to become markedly short of breath when climbing stairs.
When I first saw him, I learned that he had been a smoker all his life - at least two packs a day for 48 years. His clothes had smelled like smoke, his fingers where stained that familiar yellowish stain from holding his filterless cigarettes, and his dentition was poor. Remarkably, his lung function had never been tested. I was concerned that his rapid heart rhythm was secondary to an as yet undiscovered lung disease, and referred him (after an appropriate cardiovascular evaluation) for pulmonary function tests. I also eventually prescribed a heart rate controlling medication and the blood thinner, warfarin, for him. Most of our visit was spent discussing the issues about smoking at length. He thanked me and felt renewed to try to stop smoking again.
He seemed appreciative and left after our first visit to return to his world. I was not overly optimistic that much would change.
He returned the other day, a bit to my surprise, for follow-up and review of his test results. He had shaved but was wearing dark glasses. He again smelled of smoke and there were his hard-pack of Marlboro cigarettes in his front pocket. He acknowledged that he had not been successful at quitting his smoking habit, but had been given some Zyban by his internist.
"I can walk better upstairs," he told me. "My heart doesn't race as much. I started an exercise regimen and don't get so short of breath."
"I'm glad to hear you're feeling better," I said, but he sensed by disappointment.
"I've always wondered what you doctors' think when a patient fails to do what you want them to do," he said. "You must get really pissed off."
I paused and was surpised by his statement. And then I thought about it.
"I used to," I told him. "When I was younger and more idealistic, I used to get upset at my patients. I'd lecture them for countless hours about how they were poisoning their bodies with countless known poisons, radioactive substances, and heavy metals known lethal to the human body. I'd tell them about the physiologic effects of smoking, review the costs involved, and even offer then $100 (I even showed them the money!) if they could name ONE thing (besides social acceptance) that smoking does that's good for you. No one ever came up with anything. I was always right. Pompous, pompous, pompous. But you know what? It never worked."
"So why don't you do that now?"
"Because I'm older and a bit wiser to the bigger world out there. I realize that this 45-minute visit means little in your overall life experience. I cannot begin to understand all of the forces that have led you to this addiction of smoking. I cannot control all of the minute triggers that you associate smoking with - like lighting up while driving, or having a cigarette while reading the paper with your coffee each morning. Those are POWERFUL relationships and habits that I cannot begin to break. But I can do one thing for you."
"What's that?" he asked.
"I can be your advisor. I can suggest some things. I can show you the effects of your smoking as it relates to these tests and translate what these tests MEAN so you can understand them. But YOU, my friend, have to quit. YOU have to decide this is important enough in your life. YOU have to understand that I believe your heart rhythm disturbance was directly a result of your bad lungs. YOU have to believe you can quit. I just don't want to sit here and watch you decline on the inexorable course you're surely going to have if you don't. Before long, at your current rate of decline, I'm concerned you'll need continuous oxygen."
"My Dad needed oxygen. He had bad emphysema." His eyes welled up with tears as he looked away.
"It's not too late to quit," I said.
"Thanks for not giving up on me."
"I'll see you in a month."