Friday, October 26, 2012

Oh, simple thing.

I walked across an empty land
I knew the pathway like the back of my hand
I felt the earth beneath my feet
Sat by the river and it made me complete

Oh simple thing where have you gone?

I'm getting old and I need something to rely on
So tell me when you're gonna let me in
I'm getting tired and I need somewhere to begin

~ from Keane's "Somewhere Only We Know"


Your body was squirming. I couldn't help but notice the ways your eyelids fluttered open and shut and the way you kept wringing your hands. I'd already introduced myself, shook your tremulous hand, and tried to calm it by covering it with my other one. None of that worked.

I sifted through what I'd just heard from the resident doctor about you. Young. Healthy. Labs drawn last week all normal. You'd been told the results so I was expecting to see someone who had been anxious before but not anymore. But that's not who I saw.

We asked questions that doctors ask. Things like, "How are things at home?" or "Are you sleeping okay?" Those foot-in-door queries that start us digging toward mood disorders and such. Things at home were mostly fine for you. Sleep was fair, but mostly unchanged and not something you considered a problem.

I nodded in acknowledgment and quickly thought some more. Me, the senior doctor, standing beside my intern. Her watching to see what I would say next, do next and me wondering the very same thing. Because there was a disconnect. A disconnect between me, your doctor, and you, the patient. Something that had you squirming in your seat with hands trembling on your lap.

"Was there. . . . something that you were specifically worried about? Perhaps something you were concerned about that we should look into or address?"

"Beg pardon?" you asked.

See, this? This was called "the explanatory model." That's this maestro move that good doctors should have in their arsenals that almost always gets at the patient's real agenda. It also gets at the real diagnosis more often than not. It's the "what do you think is going on?" question. The one that pulls the patient into the team of diagnostic super sleuths and allows them a crack at the final diagnosis.

Yeah. So I, the senior doctor, had brushed off my shoulders and pulled this from my pocket. As what I thought would surely get to the bottom of your jitters and also leave my intern with a teachable moment.

"What were you thinking might be going on with you?" I repeated myself. "I want to be sure that we covered all of the things that you were thinking of. Plus patients are often very helpful in helping us not miss things."

You blinked in that same kewpie doll way. I saw you swallow and I felt sure that this was the money question. Two seconds left on the clock, all net. Swish! 

"Uhh. . .I wasn't really . . . .I thought you pretty much checked everything. Was there, like, something else I should have been concerned about?"

Damn. Rebound. No, I didn't have anything in mind. As far as I was concerned you were a young, healthy dude who'd come to us asking to be "checked out." Not "checked out" for any particular thing, but just "checked out" in general because you have a little son and a doting girlfriend who love and need you. No specific symptoms you wanted looked into. No particular issues, either. And I wasn't there for the first full visit; I was only here for the follow up part where you'd received all of your lab results. And those results had been normal. So, no. I wasn't holding anything back. I was just trying to get to the bottom of this vibe you were giving me.

"No, sir. Your labs and physical examination were perfectly normal. I don't have anything else I'm concerned about."

You nodded hard and exaggerated when I said that. "Okay, then." Hands were still trembling. I could see your chest rising and falling and now you were alternating between licking your lips and biting your jaw in efforts to look calm. It wasn't working.

I was out of senior doctor maestro moves. All I knew was that something was up with you and that I hadn't asked the right question to find out what it was. My intern hadn't either and I could tell from the eyes I felt on the side of my face that she was hoping I would.

Then I thought of something. The truth. Why not just come clean and ask him what was on my mind?


"Yes, ma'am?"

"I hope you don't mind me being completely transparent with you here. . . .but something is making me wonder if I'm missing something. You seem really, really nervous. . . and kind of worried. . . and I'm concerned that there's something causing all of that that we haven't asked about."

"Do I really look that nervous?" You smiled for the first time. Next you wiped your face with your hand and shook your head. "I tried so hard not to."

"Really? I'd be lying if I said you didn't."

You let out a big sigh after I said that, then looked toward my intern with a raised eyebrow to get her take on it. When she, too, nodded in agreement you sighed again.

We had carefully screened you for things like major depression and anxiety disorders. I had personally asked you about any kind of substance use whatsoever and you vehemently denied them all. My intern had even explored causes of post traumatic stress disorder and specifically asked you all about symptoms of panic attacks or panic disorder. And none of those things applied to you.

"Your hands are shaking. You're breathing fast and for a minute there I thought you were going to pass out on me." I gently chuckled to lighten things up. "Is everything okay? We want to take good care of you, Mr. Casey. Please, if there's something we should know about this is a safe place, okay?"

You were noticeably more relaxed already. You took in a big drag of air and pressed the heels of your hands into your eyes. My intern and I stood by with baited breath as you shook your head slowly.

Pulling your hands from your face, you looked me straight in the eye. "Real talk?"

I knew what that meant. That was code for "permission to speak freely" and was exactly what we wanted to hear from you. "Real talk," I replied.

"Real talk. . . . I just. . . .I HATE going to the doctor." You released a nervous laugh that I could tell had been bottled up for the whole visit. With a groan you added, "It freaks me out. The poking and the stethoscopes. People mashing on your body and looking all down your throat. I always feel like you might find something-- especially when you start checking the blood tests. My girl was on my back to get a check up so, you know, I did."

"That's good that you did."

"Yeah, but I hate being in this position, you know? Then at Grady first you see one doctor, then that doctor come back in with another older doctor. That shit freaks me out even more." You covered you mouth. "Excuse my French."

I waved my hand to let you know that you definitely had permission to speak freely. French and all.

"So that's why you seem so anxious?"

"Hell yeah. I'm scared you 'bout to come in here all senior doctor swagged out and find something on me that she didn't. Like you gonna look over at her and say, 'Ah hah!' Like that dude on that t.v. show House."

Everyone in the room laughed at that one. And finally, I got it. You relaxed, I relaxed, we all relaxed because all of us got it.

"You know what? I absolutely hate being a patient, too," I said. "It scares the crap out of me."

"Me, too," the intern chimed in with her hand raised for emphasis.

And you seemed to genuinely appreciate those confessions. You really did.

I shook your hand and noticed that it was no longer shaking. "It was good taking care of you and meeting you."

"Yeah, I hope I never see you again." You laughed at your own joke. I did, too.

As I moved toward the door, I looked back at you and smiled. You returned the favor and said this:

"You know, doc? Sometimes what's going on with somebody ain't even that deep. You know what I'm saying?"

I paused with my hand on the door handle and thought for a moment. About your pristine physical examination, your perfectly normal lab tests and your nervousness about being in the vulnerable position as a patient. I quickly reflected on the times that I'd felt the exact same way and probably looked anxious, too. Then I thought about all of the things I worried I could be missing before simply asking you exactly what was on my mind. I let your words replay in my head once more:

"Sometimes what's going on with somebody ain't even that deep. You know what I'm saying?"

"You know what? I know exactly what you're saying."

Happy Friday.

Now playing. . . .


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

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