Big Jake's Little Secret

As I waited in line at our favorite burger restaurant, I was approached by a large – a very large – man, who sported a wide, toothless grin and was built like a weight lifter. My kids stared wide-eyed, as the man and I carried on a conversation. I knew their minds were racing and that they were anxious to find out who he was.

His name was Jake, and he was no stranger to me. He had experienced periodic bouts of chest pain and had been in our hospital numerous times.

"Well, "Jake said proudly, "Mrs. Lowe, 'tis not me heart!"

"Oh, really, what is it then?" I asked casually, as I juggled a tray of food and tried to disengage somehow. I knew this could be a long conversation.

"It's all in me a-sausages!" Jake announced. And he was so elated. His pain was the result of a gastrointestinal problem and not cardiac.

I spoke a few more words and got back to my family. The questions came fast and furious, so I explained to my two pre-teenage children that he was a man who had been sick, but that he was OK and was telling me so.

That seemed to satisfy them and that was that. But in my mind, I was silently chuckling over the 'a-sausages' comment and couldn't wait to tell my co-workers at the hospital. Jake always had a new twist on an old theme, and he just would not say 'esophagus.' We didn't know why. That's just the way it was.

Jake was around 55 or so at the time. He was absolutely and totally non-compliant when it came to his diabetes, and consequently, other problems. He worked around town doing small errands and jobs for the merchants, and lately had managed to get a part-time job as a delivery van driver for the flower shop.

This big, easy-going man did not have an untroubled life though. Poor, and a member of a large family, he picked apples, picked up garbage, delivered newspapers, and did any job that nobody else would do. But with every job he took great care to perform the tasks well.

As the years went by, and Jake aged, his health problems increased. His wife had left him. He had developed a cardiac problem, a result of the diabetes and the improper lifestyle he had led. The diabetic clinic nurse could not get him to comply with the diet sheet; he got his medications mixed up; he forgot or lost appointment cards; and, as time when on, he became an increasingly difficult management problem. But he continued with his flower deliveries and told me it was wonderful to be able to give a lady flowers and see her smile. The owner of the flower shop kept a good eye on him, helped him remember appointments, and generally showed she cared about him – which was, indeed, what he needed.

Not once did any of us ever hear Jake use bad language. Not once did he ever complain about nurses or doctors. And not once did he put himself first. Despite his huge, unkempt appearance, Jake was a quiet, unassuming, and friendly character.

Then disaster struck. Jake had a myocardial infarction, a heart attack, and a major one at that. He was treated in our emergency department and then brought to our medical unit, where he did as he was asked. He had many tests to undergo in the weeks ahead. Preparations were underway to transfer him to the major hospital in our region, and he was prepped to go. He had procedures explained to him, and we gave him a load of material to read and study. We even gave him pamphlets that walked a patient through the procedure. Every time we walked by his door, Jake could be seen with his head in the books and the material.

And up until the day the lady from the flower shop called to inquire about him, we were all very proud of how well our non-compliant Jake was coming along. She was his only contact in the outside world, and seemed to be the only one who cared. We told her the details of what was going to be happening to her favorite delivery van driver, and I described how seriously he was reading and studying all the books and material he had been given.

But then came the shock. "No, he isn't reading anything." The lady said, "He cannot read or write at all. He has his driver's license through a special program I arranged and he learned how to sign his name years ago, and that is all he can do. He is fooling you because he is so ashamed."

We were totally stunned. How could this have happened? How did we let this slip through our fingers during all those admissions that Jake had to our hospital? Why did we not notice something awry?

Nobody had guessed, because he was so skilled at covering up his illiteracy. Jake knew the town so well, he didn't need street names. He remembered all his numbers, addresses, medications, but he couldn't read or write. Obviously his memory was his secret weapon.

So, diplomatically, we let Jake know that we knew his secret, and taught him with those wonderful audiovisual aids. The stress of keeping the secret was over. He went for his surgery, recovered well, and went back to delivering his bouquets.

Because of Jake, our nursing team learned to listen more carefully, and to ask more casual questions to determine the facts regarding a patient's ability to understand and communicate. We also learned not to take it for granted that everyone understands what we do.

But the memory of Jake, sitting on his bed, with his head in a cardiac teaching manual, will stay with me always. How we take so much for granted. And how fortunate we are to have the ability to read!

Well done Jake! You taught us so much and made us better listeners. A bouquet to you for that, and I would love to be the one to deliver it!

This issue has been studied, for example, in Influence of Patient Literacy on the Effectiveness of a Primary Care-Based Diabetes Disease Management Program , published in the October 13, 2004 issue of The Journal of the American Medical Association.

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