I click on the third chart of the morning—carpal tunnel surgery with regional anesthesia. A man in his late seventies. Mental checklist of a few things to delve into: his pacemaker and cardiovascular disease.

Knock, open the door with a big smile. Warm greetings are essential in the preop clinic; patients size up your demeanor right away to calculate any obstacles to surgery. He is quiet, sitting a bit stiffly in a slightly rumpled blazer, but his greeting is warm as we confirm some details about the surgery. An activity history reveals that he is busy as the primary caregiver for his wife. Anesthesia history is good; he has done well with recent surgeries.

“But they used a skylight to take out my tonsils.”

I raise my eyebrows as he describes an awake version of events as a child. I've learned not to gloss over these reports. They can be deeply emotional snippets of memory that sometimes weave seamlessly with the present. His body language tells me he is not worried about this now and I address it with some levity, joking about the lack of skylights in our ORs.

The tone of the conversation abruptly changes as we talk about his pacemaker. The computer shows a recent visit for his pacemaker interrogation, but no report. I ask questions to ascertain if he is pacemaker-dependent. He stiffens more, redness flooding his lined face.

“You know, I was a lawyer...and this is so inefficient for the customer. Why don't you know this?”

My placating response about the real (and imagined) inefficiencies in medicine is hardly adequate. So many patients feel that the questioning by my medical assistant, then myself, and later by the anesthesia team and surgeon are an endless interrogation. I try one last time.

“What did the cardiologist say about your pacemaker on the visit?”

“He was pretty, well...rude.”

I chide myself. I could have handled the conversation better.

I confess, “There is a lot of room for improvement in how we do things. I appreciate your patience with me.”

He makes a comment about being old-fashioned and spends a minute more on the foundations of good customer service. Treading lightly, we round out the remainder of the history, coming back to his wife. His shoulders visibly slump; his gaze drops to the papers on the table.

“I wake her up, cook food, bring her food.”

I ask about helping her with bathing or dressing.

“Sometimes her feet don't work.”

His role for the past 3 years.

“I have some help coming.”

I respond with some positivity. He will need help to rest his hand.

“Maybe you can do something for yourself,” I say.

“That would be wonderful. Maybe I can play some of my CDs. I haven't played any.”

There is a pause, and my heart opens to him. I watch his face as he considers, but it is clear he doesn't believe it.

Physical examination, preoperative instructions, anesthesia consent; all feel perfunctory as he seems not at all the patient I opened the door to greet. I try to catch his eye, and almost manage to finally do so when we address taking it easy after surgery. He nods; this was the advice with his last hand surgery.

As I escort him out, I can't help feeling I am missing something important. Was it his music? His journey with his wife? Maybe a fear I did not uncover? It is the downside to my clinic: always a snapshot, never the whole story. Even when I can follow a patient a bit longer, I never get satisfaction. I allow myself a minute to ponder a change in practice. Perhaps a setting where I would get more of the story. Ah, but the paper on my desk signals the next patient has arrived. I am reminded that I also love the evergreen mix and challenge of where I am.