It happened on a holiday weekend while I was on call. I had arrived on the floors early, having promised my wife that I would try to get home in time for an afternoon party. I groaned when the admitting clerk told me that I had 12 admissions.

"Eleven," corrected Mike, the second-year resident. He was standing at the nurses' station with Judy, one of the new interns. "One has signed out against medical advice." "Good," I thought, "less work." "What's the story?" I asked.

"His name's John Pagano. He's this high-pressure New York businessman who's in town visiting relatives for the holiday. He came to the emergency room last night with about 8 hours of ‘heartburn.’ He had an abnormal EKG that corrected with nitroglycerin. His initial blood work is abnormal but shows nothing definitive yet. He's probably having a heart attack, but he's felt better since last night and insists on leaving—says he has to be back at work tomorrow. We spent a long time talking to him, Judy especially, but he doesn't listen very well. He's still in his room, getting ready to leave."

"Damn," I said. I wanted to get on with my day. "I'd better go talk to him."

"I doubt you'll have much success," said Judy. "This guy is tough."

He was pacing around the room in his street clothes. He was a tall, overweight man who looked as though he enjoyed intimidating people. I introduced myself, shook his hand, and sat down. "I guess you know why I'm here," I said.

"No, why?" he asked.

"I'm here to talk you into staying with us. My housestaff tell me there's a good chance you're having a heart attack."

He frowned impatiently. "I don't think so. Look at me. Do I look sick to you?" He actually did not look very sick. "I feel fine, and I've absolutely got to get back to New York tonight."

I started to feel anxious. I didn't like him pacing around. "Have a seat for a minute and let me talk to you." He sat down.

"I understand that you feel fine," I said, "but your symptoms, your electrocardiogram, and your initial lab tests all suggest that you may be having a problem with your heart. Do you know what a heart attack is?"

"Yeah, in a general way," he replied.

"Let me explain it to you," I said, taking out my pen and paper. I went through my usual explanations, with drawings of the coronary anatomy, telling him about cardiac ischemia and how it could have caused the pain he had had. I told him that with his positive family history, smoking, and obesity, he was a setup for a heart attack, and I patiently explained why he needed to stay with us and get proper attention. My presentation was clear and convincing. I would have been convinced and worried.

"Look, Doc, I just don't buy it," he answered. "You don't understand. I'm not going to keel over of a heart attack! I'm going to die someday of some endless, miserable illness. Anyway, I've got to be at work tomorrow. All hell will break loose if I'm not there."

"I see," I said, "You're completely indispensable at work."

"Well, yes!"

"You're the one who doesn't understand," I insisted. "This is serious business. You could be putting your life at risk if you leave here. Maybe you don't care if you live or die, but I'll bet there are people in your life that do. Are you married? Any children?"

"Yeah, I've got a wife and a 16-year-old son."

"Don't you want to be around for them?"

"Doc," he said, in an exasperated tone, "I appreciate what you're trying to do. After I get back to New York, I'll make an appointment with a doctor for a checkup. I promise!"

"If you get back to New York," I said.

"Jesus, Doc, all you guys are giving me are suppositions. You tell me I could be having a heart attack. That's not good enough for me. I'm feeling fine now, so ..."

"That's why you have to stay," I broke in, "until the rest of the test results come back. Then you'll at least have the information to make an intelligent decision. If they come back negative, we'll be glad to let you leave."

"When will they be back?" he shot back.

"Well, it's a holiday weekend, so they may not be back till tonight. I'll see what I can do to push the lab."

"Can't do it."

"This is your life on the line," I said. "You really have to stay."

"Can't do it."

"You know," I said, softening my tone, "I'm just telling you what I would want for you if you were my brother. Look, I don't have to sit here and try to convince you to stay. You've already signed out against our advice, and I've got 11 other patients to see. I'm spending the time now because I think it's really important. You owe it to your family, and yourself, to stay. I'd hate to think of anything happening to you that we could easily prevent."

"Hey, thanks for your time, Doc. I'll be all right, really. It was probably just some gas or something. You'd better get to those other patients."

His look and the tone of his voice told me that the conversation was over. I offered my hand resignedly. "Good luck."

"Thanks." He smiled.

Back at the nurses' station, I reviewed his chart while I phoned Mike. "You guys were right," I said. "That guy was tough. I failed. I couldn't convince him to stay."

There was silence at the other end of the line.

"What's the matter?" I asked.

"I just lost five dollars."

"What do you mean?"

"I bet Judy five dollars that if any attending in this hospital could convince him to stay, it would be you."

I couldn't believe it. I had failed my resident, too. "Don't pay her yet," I said. "I'm going back!"

I turned around. Alan Sherwood, a cardiologist, was writing in a chart. "Hey Al," I said, "you got a minute?" I told him Mr. Pagano's story and showed him the EKG. "There's no question this guy's having an ischemic event," Alan concluded. "He also sounds very much like a type A."

I laughed. "You've got that right," I said.

I strode back into Mr. Pagano's room, holding his EKG. "This is a very abnormal EKG!" I said emphatically.

He looked up at me, surprised.

"I just ran into one of the top cardiologists in the hospital and showed him your EKG. He said something is definitely going on with your heart. There's just no way you can leave this hospital!"

He argued with me. I argued back. Finally, he reached for the phone. "Okay," he said, "you're going the extra mile for me. I'll go the extra mile for you. I'll stay until the rest of your test results come back. But only until then!"

"Then, we'll see." I said. I convinced him to take 10 mg of diazepam, telling him it would help take some stress off his heart by reducing the adrenalin in his bloodstream.

The test results returned positive 2 hours later.

I went to Mr. Pagano's room to tell him the results. Before I could begin, his wife and two friends walked in. "What's going on with my husband?" his wife asked anxiously.

"Your husband just had a heart attack." I said.

She burst into tears. "My father died of a massive heart attack."

Suddenly, everybody was talking at once. Mr. Pagano protested loudly that he was fine and that everybody was making a fuss over nothing. His friends and his wife insisted that he stay. His voice was rising.

"You're making an invalid out of me!"

"This is your chance!" I said, "If you stay and let us take care of you, I'll bet we can make you better than you were before."

In the end, he gave in.

I came back later that evening. With 30 mg of diazepam in him, he was mellow. "I've decided to stay and see this thing through," he said. "What the hell."

Several days later I saw him again. He was talking about giving up smoking and changing his diet. He was a model of post-infarction resolution.

I called Mike. "I just wanted to say thanks," I said. "We did good work for Mr. Pagano. I think we saved his life. I hate to think of what might have happened if we had let him drive back to New York. He might have cashed in on the ride back and taken a few people with him."

"You did a great job," Mike said, "He never would have stayed if it hadn't been for you. And," he went on, "I collected my five bucks!"

"That's what made me go back and talk to him again," I said. "I would have given up if you hadn't bet on me. My reputation was at stake! You believed in me, and I really appreciate that."

The whole episode left me shaken. I had thought I had done my best the first time I talked to Mr. Pagano, but I hadn't. I found myself wondering about many things: the essentials of negotiation, the elements of persuasion, and the scope and limits of our responsibility for patients. It also made me think about that borderland between practicing medicine and being a physician, where our attitudes, motivation, passion—and pride—determine our clinical effectiveness.