Tuesday, September 18, 2012

Dat'll do.

*Names, details, and all that stuff that folks worry about have been modified.
Piedmont Park on a Saturday, Atlanta

Last patient of the day on a sunny afternoon. This was back when our Urgent Care center was open on weekends and, no matter how much you love Grady Hospital, being there on a sparkling Saturday is not exactly ideal. So yeah, that's where I was but on this day I was trucking. Running three rooms, working seamlessly with the nurses, and stamping out disease one urgent complaint at a time.

I'd grabbed his chart and read the complaint. "Recurrent hemorrhoids and constipation." Age: twenty-something.

Now. If you are a doctor who has ever worked in a super-busy clinic--especially a super-busy inner-city clinic--you can totally understand why those two words "hemorrhoids and constipation" would make me do the happy dance. Especially at 4:45 P.M. on a weekend when I really wanted to be in Piedmont Park.

I nodded my head smugly and pointed at my colleague who was feverishly charting on his second to last patient of the day. "Yeaaaaah baby!"

"What? A toothache?" he asked. We both knew that a toothache was the motherlode of complaints that were in-and-out for us. As internists, there wasn't much more that we could do other than getting the patient to an area dentist or oral surgeon. Antibiotics in the interim and pain control could be written on a script quicker than you could say "Rumpelstiltskin." Next best thing? Hemorrhoids. Especially recurrent ones.

"Hemorrhoids. And constipation. Recurrent." I smiled a big wide smile.

He squinted his eyes at me and groaned. "I have someone with a headache and a pretty elevated blood pressure. At four forty-five. Awesome." He held up the other chart in his hand. "And this patient needs some stat labs."


"I know, right? So much for finishing up early. But I guess we signed up for this, right?"

"Claro que si," I replied while sifting through the computer to see if my young patient had any old lab work. "No labs or prior visits to the Gradys." I stood up, propped hands on the desk and leaned over toward the window like a tripod. I was looking forward to feeling that sun on my face.

"Rub it in, why don't you!" my colleague teased. I raised my eyebrows and smiled again. Then he offered me a playful warning. "Hey Kim. . . . . nothing is ever as straightforward as it seems."

"Especially at four forty-five on a Saturday!"  I pushed the door open and chuckled again. Quickly I made my way to my last patient of the day.

After a knock on the door I stepped in and introduced myself. "Hey there, sir! My name is Dr. Manning and I'll be seeing you today. You are . . .Mr. Cole?"

"Yes ma'am," he replied while firmly shaking my hand. That handshake was deliberate and masculine. "It's okay if you call me Quentin, though."

"Is that your preference?"

"Sure. That's cool. I mean, yes ma'am, that's what I'm most comfortable with."

I liked the way he autocorrected himself when speaking to me. Almost like he could hear some grandmama in his ear saying, Is that how you speak to people? The Grady elders call that home-training. I could tell he had plenty of it -- from his neatly groomed hair and clothes to the straightness of his spine as he sat. No slack jeans or mumbling voice. He clearly had some quality home-training.

"Okay, Quentin. So . . .are you a student here in Atlanta?"  I couldn't help but ask since he was wearing a t-shirt with big block letters from his university on it. The baseball cap and drawstring nylon bag in the same color palette gave it away. That and his young face. "I see you representing your school with all the paraphernalia!"

He nodded proudly. "Yes ma'am. Proud of it, too!"

"Good stuff," I continued. "What are you studying?"

"Finance. And I'm on an athletic scholarship. Football."

"Nice."  And I said that because I meant that. It was nice that this kid with the home-training was in an excellent four-year institution on a scholarship. I looked back down at his chart and was reminded of his chief complaint. I knew it would be more awkward for him than it was for me  so I did my best to keep things light but formal. "So I see that you have a problem that isn't a new one for you. How about you tell me what's going on?"

"It's kind of embarrassing. But yeah, it's hemorrhoids. And since they are kind of uncomfortable, I think I've been avoiding doing. . . .you know. . . number two."

"Got it." I jotted that down and glanced back up. "Hemorrhoids are so super common. They can be pretty uncomfortable, too."

"Yes, ma'am." He seemed to appreciate that normalizing statement.

"You've had hemorrhoids in the past?"

"Yes, ma'am."

I stared at him for a beat and thought about why a twenty-something year old man would have recurrent hemorrhoids. Most of the time they come from straining--pushing out hard bowel movements, pushing out big babies and pushing through some heavy lifting. Heavy lifting? Aaaah. Yes.

"Do you lift a lot of weights for football? Like squats and stuff like that?" I knew that answer before he could even open his mouth. His percentage of body fat wasn't the kind you get from recreational work outs. He had that two-a-day practice kind of definition clear down to his calf muscles.

"Yes ma'am," he chuckled, seemingly relieved that we had an easy explanation for all of this.

I was relieved, too. Relieved that this was as straightforward as I'd hoped it would be, but also that I was sitting in front of a really charming young person who knew how to talk to other adults. His caramel complexion was almost identical to my own and his facial features even looked like those of people related to me. Something about that made me well with pride. I was glad to be seeing him.

"Is this similar to when you had hemorrhoids before?"

"Pretty much. They hurt a little more last time. Now they're mostly irritating." A wave of embarrassment came over his face. "I'm sorry. This is so weird to be talking about."

"Totally understand."

"I was hoping to get some of the foam and the medicine they gave me last time."

"That shouldn't be an issue."  I wrote down a few more things and then asked him some more obligatory questions. Like, what are you allergic to and do you smoke? Are you sexually active and have you tried any kind of drug? Do you drink and what medical problems besides this have you had in the past? His answers were predictable. No allergies, yuck to smoking, yes ma'am to sex and no ma'am to drugs. A little bit of asthma that he thinks he grew out of. Otherwise uneventful. Yes, this was all very straightforward.


I also asked a little bit more about the constipation and reviewed his diet. Typical crappy college fare, full of refined sugars and fats with a paucity of fiber. Duh.

Next was the physical examination. Habitually, I started with his eyes and oropharynx which didn't yield much of anything. Ears had not even a trace of wax and other than being hidden inside of an uber-ripped container his lungs, heart, and abdomen were pristine.  And then I paused.

Shit. He needs a rectal exam.

I could see his face pleading with me. It was saying, Please, ma'am. Just take my word for this. Please don't ask me to drop trow right here, right now. And you know? I strongly, strongly considered obliging him.

First of all, it meant I'd need to get a nurse to stand in as a chaperone. Since it was late in the shift, we were low on nurses so that would make the whole thing take longer. And seriously? This guy was a good historian with good home-training. Why wouldn't he just tell me like it was? Everything else about him had been easy-peasy. Was it really necessary for me to make this poor guy show this lady doctor his nether region?

I started coming up with arguments in my head. Telling myself that if this were some swanky private practice that this whole encounter could have been a call in to the nurse and that, sure, a prescription could be phoned directly to his local CVS. Or Rite Aid. Or whatever he so chooses.

But that isn't what this was. It was an urgent care visit. With a complaint involving the rectum. What kind of doctor would see someone for a complaint in an ear and not look at it? Grrrr. I could hear my dad in my ear. He calls that being a "dat'll do" kind of person. The kind that cuts corners just because they think they can.  I knew I had to look.

"Well let me just step out and grab a nurse, okay? Go ahead and undress from the waist down and cover your lap with this sheet. I'll be right back."

"Excuse me, Dr. Manning--umm. . . . is it possible to just make the prescription? My mom was saying that sometimes if you've had a problem before like this one -- especially a sensitive thing -- that I should ask."

I held my hand on the doorknob and paused. Good ol' Mama.

"She was saying, like, that her doctor if she has a yeast something she called it. . . . the doctor just calls it in or even takes her word for it. So she won't have to do that whole other part and get checked out all over again when they know what it is."

Damn. This was tempting.

Dat'll do. Dat'll do. Poopdeck wouldn't get out of my ear.

"This will be super quick. It's way easier than doing a pelvic exam. It'll take two seconds, okay? I'm only looking just to be thorough. I'll be right back."

I stepped out of the room before he (or me) could try to convince me otherwise. A few moments later I was back with Charlotte, one of our nurses. She offered a quiet introduction with only a smile and head nod.  Her job was just to be there and nothing else.

I instructed Quinten to put one foot on the step and to lean his body forward on the exam table. I kept reassuring him that this would be "super-quick" so that I could "quickly confirm that his hemorrhoid didn't need to be drained." He wasn't miserable enough to need emergent incision and drainage, but I felt the need to justify this mortifying position I had him in.

I rolled over on my stool to grab the neck of the positionable light and then flicked it on. "These are just my hands looking," I announced. Quentin's voice was quiet and far away as he mumble back an obligatory "Yes ma'am." I gently applied pressure outward to open the cleft and better visualize what was certainly going to be the tell-tale garden variety external hemorrhoid.  Just as I did, the bright light gave me clear view of the source of his complaint.

Or rather sources.

I'd been talking the whole time but now I was quiet. I looked carefully to make certain I was seeing correctly. And I was. Shit.

"Quentin? You said this was a little different than your hemorrhoids before?"

"Uhhh, sort of. I mean just. . .they didn't hurt as much."

"Um, okay." I inspected some more. "So, okay. How long has this been bothering you again?"

"On and off for like some months."

"Did the doctor who gave you the foam and numbing medicine last time do this kind of examination?"

"Like what you're doing?"

"Yes. Like what I'm doing right now."  This was awkward. Talking to someone who had their back--and their backside--to you. But this wasn't what I was expecting. I needed more history.

"No. It was my pediatrician while I was home for the summer. When he heard about me being constipated and the weight lifting he gave me the medicines and they kind of helped."

"Okay. Thanks for clarifying that, Quentin."  I went ahead and examined the rest of his genital region and then stepped on the other side of the curtain that Charlotte had pulled. "Go ahead and get dressed and we can talk about the plan."

"Yes ma'am." Of course. Yes, ma'am.

Charlotte was so busy that she was down the hall and into another task before I could even get out of the room. Moments later I stepped back inside to talk to Quentin about what I'd seen.

So what did I see? Well. It certainly wasn't a hemorrhoid. Instead, found a large collection of perirectal warts coalescing right at the entry. Some were pedunculated and red--I could see how this could be irritating to him.

I was mad at myself. First, I'd strongly considered not examining his rectum. Second, I didn't take a full sexual history. I"d gotten so caught up in making him a bread and butter case that I'd sized him up and forced him into my own story line. I was too experienced for this. To me, this was more the move of an overtired trainee. Not a full fledged attending physician.

Dat'll do. Dat'll do. 

"Quentin," I started carefully, "I didn't see hemorrhoids on your examination. I saw some pretty large genital warts at the opening of your rectum."

His eyes widened and his mouth fell open. "What?"

"It makes sense why you've felt this way. I think the medicines you took before quieted down the irritation but it probably wasn't ever a hemorrhoid."

"How did I. . . I mean, what does this mean?"

"I probably need to have a specialist see you. I can make a referral to help with that. I think since they're kind of big, they may want to remove them, like, surgically."

"Will that mean they're gone for good?"

I sighed because that was a damn good question. "Honestly? These often come back."

"Really?"  Now his eyes were glistening with tears.

"Quentin?" I softened my voice. "I should have asked you this earlier. You told me that you are sexually active. . . but are your partners female, male . . . or both?"

"Female," he promptly responded.

"Condoms? Do you use them?"

"Mostly. I mean, I've slipped a few times but mostly yes."

"Have you. . . .like. . . ever maybe tried sex with someone who wasn't a female?" It felt so lame to ask again but this diagnosis suggested unprotected anal receptive intercourse. We needed to get this out on the table before I could get to any problem-specific patient education.

"I tried it, yeah. Like only a few times, though."

"Okay. There really isn't an issue with whether or not your partners are only girls or only guys or girls and guys. The issue is mostly whether you use condoms. I think maybe one of the times that your partner didn't use a condom. . . .you might have gotten these warts around your bottom."

"Damn it! Really?" Now tears were falling down his cheeks. "So anybody who sees this on me will know, right? Like know that I've done that before?"

"Quentin, look. I know this is a lot and those kinds of questions are really complicated, you know? But to be honest, this can be as private as you keep it. There's probably more to all of this, I'm sure. Like, how you feel about all of  this and even how you feel about who you are."

"Yes, ma'am."

"My impression of you when I first met you is that you seem like a really respectful young man who obviously has been hitting the gym and the books." He offered me a tiny smile. "This is kind of crappy news to get on a weekend, but you're here, you know, and now you'll get the care you need."

"Yes, ma'am." He sighed hard and pressed the heels of his palms into his eyes.

"It's going to be okay, Quentin. Okay?"

He nodded and tried to believe me.

I wanted to say dat'll do and end it there but I knew I had to consent him for an HIV test, further screen him for other sexually transmitted infections, talk about safer sexual practices and arrange some referrals. He was gracious with all of it, and mostly he looked kind of relieved. Almost like I'd rubbed a genie out of it's bottle whose contents had been under pressure.

After all of this was said and done, the encounter was still pretty fast. I was out of the hospital by five thirty and yukking it up with a girlfriend over frosty margaritas on a patio overlooking Piedmont Park by five forty-five.


I never saw Quentin again. I did see that his HIV antibody was negative and there were indications from his chart that surgical follow up was obtained. Otherwise, I'm not sure what ever became of him.

My guess is that he's somewhere working in finance and doing great things. I hope that he's being true to himself and not just saying "yes, ma'am" and "no, sir" because he thinks that's what everyone wants to hear.

But mostly I hope he's happy.

I never, ever forgot the lesson he taught me in not sizing people up with sweeping generalizations and also about fighting the temptation to cut corners. It's all so easy to fall prey to, you know? He also reminded me of how hard it is to be your authentic self in this world. Sometimes life nudges us to walk the seemingly easiest path when doing that really makes things less so.

Dat'll do. Dat'll do. 

No ma'am, no sir, it will not.



  1. As usual- a heartfelt, terrifically written story about something very true and very important.
    You had good home-training, too, Ms. Doctor. And it serves you and your patients and us, too, so very well.

    1. I love when you love a post I've written. Your writing is so beautiful that the compliment feels so amazing. Thank you for your kind words of affirmation.

  2. Just think what would have happened differently if you hadn't taken the time to look. Bravo to you for not cutting corners. And I love the term home-training...never heard that before. We had some home-training when I was growing up, too (to this day I can't slouch for imagining that my grandmother is going to whap me between the shoulder blades, and she's been gone 17 years!) and I'm doing my best to raise some mannered kids too. I keep telling them that their behavior reflects on me and their father and that we don't take kindly to poor representation in public. ;)

    1. Wow! Grandmothers and mothers live forever through our home-training. It's something isn't it?

  3. Such a great relaying of a clinical encounter ! And yes- you can never assume anything about anyone. This much I know, even in my five short years of being a physician.

    Maria, fellow Meharrian

  4. Terrific lesson in there. There're no shortcuts in this field.

    -- Tara

    1. You can try but they come back to bite you on the hind parts. I always feel so relieved that I did look. Just saw another patient last week with symptoms of dysuria that sounded like a UTI--inspection revealed primary HS (herpes simplex virus.)


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

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