Appearances Are Revealing, Even As They Are Deceiving

Patients often seem to come in themed waves. One day it will be low back pain, another day it will be allergies, the next might be digestive problems. Yesterday was dedicated to shen disharmonies, or at least odd people.

My first one of the day was an older man who grunted through his new patient paperwork for about 15 minutes. He seemed a little crotchety, but we get a lot of pain patients, and pain can make you pretty grumpy and not-your-usual-sunshiny self, so ok. I came back out to get him after going through his intake forms and transferring the information to mine, and he was gone. The receptionist pulled me aside and told me quietly to be sure and gather as much info as possible about prior treatments because apparently he has been to the clinic before but used different names. So I took him back to my room, and did the workup/history which yielded your basic garden-variety neck/shoulder tension, but it did give me a chance to practice some of the history-taking techniques I learned in Fred's class last weekend. I'm feeling better and better about those. But he had a strange, reticent kind of energy--like he just wanted to cut to the chase or something. I went back and presented the case to my attending, and told him about the prior visits. We looked compared the files: same SSN, same address, but he was 4 years older this time, identical handwriting, etc. Even the chief complaint was the same. What was interesting to me was that on his first file he signed the arbitration agreement but put the word "duress" in parentheses (he is a retired lawyer--does that trick actually work?) and then initially refused to sign the current agreement until the receptionist told him we couldn't treat him without it. We had a good discussion about how if this patient had come into our private practices we likely would have referred him out right away for that reason--everyone knows the profile of patients who become huge, litigious headaches.

After his treatment my attending and I went in with his files and set them side by side in front of him, and asked what was going on. And it was just a question of money, it turns out--he wanted to make sure he got the senior discount, even though he was technically a couple of years shy. We ended up giving it to him anyway, and explained that we were happy to try to work with him and make sure he got the care he needed, but that we needed him to deal honestly with us, and he agreed. So that's a story to file away for the next time it comes up.

My next patient was a woman I remembered from when I was an observation intern, who was still wrestling with the same issues of consolidating her mental energy and concentration and making a commitment to end a relationship with a much younger man whose company she enjoyed but who made it clear that he was not ready to settle down with anyone for a long time. Which is a sucky situation, and I've been in a version of it, and I totally get it 'cuz making clean cuts is still painful even though in the long run it ends up being better than the alternative.

Segue to my afternoon, where Steph and I have been co-treating a 45Y woman who initially was trying to get pregnant even though her life and emotional state are such that the last thing she needs is another child right now. So that dialogue has been ongoing, trying to approach her from the standpoint that she needs to be healthy physically and otherwise in order to give optimal chances to a new child or the 4-year-old daughter she already has. She's so invested in and identified with the drama she creates however that it's slow and uneven progress. I want to just ask point-blank why she wants another child, and see what she says. My attending is much more patient with her than I am--she is the perfect sort of person for me to challenge my practice of tonglen, I guess. I want to write another post exploring what happens or doesn't happen when patients become so attached to the identity of being sick or in pain or whatever that they don't really want to move on and get better, and what to do about that, how best to help them. Is being too patient enabling? Is it better to be compassionate but straight-up look-here's-what-you-gotta-do-no-matter-how-painful-to-look-at? Obviously, it depends on the patient and what they can take in, but still. How to evaluate even that?

Fast forward to my last patient of the night. A beautiful woman who is used to being a beautiful woman, but who is aging and has (at least temporarily) lost her mojo so to speak and is having a hard time mustering the will to get back up on top of it and impose disciplined structures like diet and exercise. And the thing is, she's totally identified those things not with health and feeling good from the inside, but with vanity and looking conventionally sexeh hawt. I was asked for a facelift and lipo a few times (joking but kind of not). Underneath it all were undercurrents of livery, livery energy because she's frustrated by her job, relationship, etc. How true that underneath every excess lurks deficiency, that underneath brash confidence underlies cringing insecurity. It is so easy for me to take people who seem so sure of themselves at face value, when really I should be wondering: what is this hiding, and why?