Anecdotally Speaking

The superfluous, a very necessary thing. --voltaire

Tuesday, February 20, 2007


The Complete Check Over

Reducing my office schedule to two days a week, because of my new medical director responsibilities, is creating problems from a sometimes-overbooked appointment list. I am finding that I need to adapt to time pressures I have not experienced before during the coarse of a busy session. Regardless, the problems people are presenting to me are not correspondingly less complex or less time-consuming.

On a recent day, a full schedule revealed the name of an established 12-year-old male patient in a ten-minute appointment slot with a reason for the visit noted as "knee pain - track starting." I had four other patients scheduled that same hour and five in the next with a cornucopia of ailments, but this patient's visit did not look threatening, at least it did not as it was booked on the schedule.

The visit began to take on a different flavor when I picked up the chart from the chart holder outside the room and looked at the patient sign-in slip clipped to the front of the chart. Scrawled out by the patient's own hand next to the question "reason for visit" were the words "complete check over."

I entered the room and found the 12-year-old boy sitting in the patient throne at the end of the exam table and his mother sitting in a side chair next to my little writing desk. I assume my position on the circular rolling stool, that object of great fun and delight for many youngsters that visit my domain, until I arrive and wrest it from them and claim it for myself.

I know this boy's mother well. We go back many years. Though I do not know him as well, I have known him since he was an infant and we have meet on several occasions for minor problems and the occasional ubiquitous sports physical.

I will not go through the entire history and details of the medical problems. Suffice it to say, there turned out to be a significant interplay between subtle, but real pathophysiology, and profound psychosocial overtones, not the least of which was this families strong evangelical religious beliefs.

The precipitating event that ultimately leads to this appointment, it appears, was a well-intentioned lecture at school, followed by intense Internet browsing, on the subject of testicular cancer. My poor fearful young patient was terrified of dying from cancer, thus the reason for "complete check over."

As our encounter progressed, I became aware of four things. One, his exaggerated fearful anxiety over having cancer was appearing to be the tip of the iceberg. I was discovering an underlying pathology, perhaps an affective disorder, anxiety or depression, or a mood disorder, these were common enough but other possibilities could be explored as well, this being a complex and convoluted area of medicine. Any approach in this direction needs extremely careful and skillful handling, considering this young man's fearful and impressionable nature and the family's faith beliefs, which can sometimes affect attitudes towards mental health issues in challenging ways.

Second, I was soon aware that a quick word of reassurance on my part would be inadequate to set my patient's mind at ease, maybe because he did not trust me sufficiently, yet. Maybe because he did not trust the word of a doctor alone, but needed something else besides, something more thorough, some type of evaluation or work-up that would go far enough to suitably satisfy his sense of certainty, maybe then he would be reassured. However, I sensed that not even that would do. I sensed that I could do nothing that would set his mind at ease completely. I thought, "He's bright." I must keep that in mind.

Third, I was aware that everything that was said or was done during our encounter had potentially profound significance, the slightest gesture, a raised eyebrow, a hesitation when answering a question, a frown. These things could be interpreted by the anxious and fearful to represent dire portent. Therefore, I was aware, careful and deliberate in everything I said and did, because I was aware how much it all mattered. This might be just another visit in the day for me, but for my patient, this is a significant moment in his life. He will remember details of this visit for many years to come.

And finally, I realize that to do what I need to help my patient I need to summon all of my skill to understand how this family views health in the context of their overall worldview, so that I can then help them integrate my scientific medical model in a way that they can embrace with integrity. I will fail if I just throw a solution at them that is the antithesis of their faith system. However, if I can help them learn how to incorporate a scientific solution into their belief system, then we will both succeed.

This visit required subtlety and poise and I pulled it off very well but it took longer than the ten minutes that was allotted to it. But hey, that's the nature of Family Practice. Incidentally, he still had track coming up and had a problem with his knees hurting. Hah! Did I think I'd get out of that one? Ha, Ha, Ha! It's Family Practice, no way.

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