“You always have a green light at the end of your dock.”
-F. Scott Fitzgerald in The Great Gatsby

I sat alone at my desk surveying the scene of a video visit necessitated by COVID-19. At first, I saw the wallpaper, a distinctive pattern of intertwined vines, but this was quickly rendered invisible as the screen went nearly black, save a brilliant orange light near the center. Slowly, other details became visible again. Eventually, the outline of a window, a pair of glasses almost hovering in mid-air, and then a person’s face came into focus - but still, the orange light commanded the room. I realized that the patient had a lit cigarette in her mouth that she then proceeded to smoke throughout the duration of the visit, fittingly one for characterization of a respiratory chief complaint. The “Orange Light” I saw has come to serve as something of a personal trope for the sometimes-apparitional reality of tobacco use in our society. As primary care physicians, we know that many people smoke, but rarely glimpse it with our own eyes.

It's no secret that success in achieving smoking cessation is elusive to many primary care physicians. One study even demonstrated that surgeons, who can use the carrot/stick of not performing an elective surgery, are the best at bringing about this change.1 As I reflect on the “Orange Light” and the massive societal and global health burden of smoking, a similar light, albeit from a different end of the color spectrum comes to mind. In F. Scott Fitzgerald’s novel, The Great Gatsby, the “Green Light” that the protagonist sees across the water serves as a representation of all Gatsby’s work up to that point and all that he still wishes to achieve as he attempts to lure a married woman away from her husband.2

If this comparison seems to be a stretch, one need only Google divorce rates and smoking cessation success rates in the U.S. to see that Gatsby’s venture may have been less daunting than that of the physician. We as primary care physicians hope to affect an outcome with our own “Green Light” and the lingering specter of lifestyle factors that are modifiable, but also beyond our control. Patients find themselves in the position of Daisy as she vacillates between loyalty to a husband of many years (40-years of loyally smoking) and a young upstart who seeks to have them run away (their tiresomely persistent primary care physician who never fails to ask about abandoning cigarettes).2

While I did not achieve the goal of smoking cessation with this patient, it is important not to underestimate the window into a patient’s daily life that a video visit can bring and its value to the therapeutic alliance. Although a few steps short of adding a complimentary bar room and smoking lounge to our clinic, the brief video visit brought to the foreground something as otherwise subtle and yet imperious as the “Orange Light.” In contrast to the narrator’s abandonment of New York after seeing what the “Green Light” did to Gatsby, a physician must still persevere in his or her efforts and embrace the times patients allow us inside their daily lives.

“So we beat on, boats against the current, borne back ceaselessly into the past.”
-F. Scott Fitzgerald in The Great Gatsby

References

  1.  Rao, B. M., Moylan, D. D., Sochacki, K. R., Kollmorgen, R. C., Atwal, L., & Ellis, T. J. (2020). Mandatory Nicotine Cessation for Elective Orthopedic Hip Procedures Results in Reduction in Postoperative Nicotine Use. Cureus, 12(12), e12158. https://doi.org/10.7759/cureus.12158
  2. Fitzgerald, F. S. (1995). The Great Gatsby. New York: Scribner Paperback Fiction.