Paper

This post reflects a real encounter, but it has been heavily anonymized.

"There's someone coming in for anxiety," Dr. H said. "You want a challenge?"

That didn't sound like a challenge to me. Challenges are chief complaints with differential diagnoses that are full of conditions with long names and specific treatment regimens and prognoses and diagnostic techniques...none of which I know! And most conditions patients have, and most new ones I learn about in clinics (salpingitis isthmica nodosa?) prove my disastrous lack of knowledge. But anxiety? That's not like "headache," or (heaven forbid) "chest pain," which have are important, enshrined, carefully-built differential diagnoses. But anxiety is not something I know nothing about. All you have to do with "anxiety" is talk to the person. And that, I can do.

"Sure," I said happily to Dr. H. Maybe he thought I was being a good little aggressive medical student, because he smiled and chuckled, nodding me toward the exam room.

Dr. H's office uses electronic medical records, but because I don't know the system, I just bring in sheets of the same lined paper I use to take notes in lecture. (It has AMDG and JMJ printed at the top, but no one notices because it's very faint.) This has turned out to be a blessing: I can sit and face the patient and ask them questions without the computer as a third wheel. I was especially glad to have paper this time, because it allowed me to really pay attention to the person in front of me.

I walked in and saw that she "looked her stated age, appeared non-traumatic and well-nourished," to use some stock descriptors from presenting clinical cases.

But I noticed that she moved very little and her face was not very expressive, although I shifted my weight occasionally during the conversation. And while the layout of the room placed my stool at an angle to her chair, she did not rotate her body to face me, just her head. Her voice was more monotonic than most persons'.

Her eyes were loaded with questions. I don't know all of them, but I wondered whether some were "Will you listen? Will you believe me? Will you judge me? Am I broken? Am I in trouble? Can something help me?"

I was struck this time more than usual that this was a person of great value, perhaps because she seemed very fragile. I softly introduced myself and asked her to tell me about what brought her in.

And she did. Although I remained calmly empathetic and did my job, her story moved me very much. Undeniably, I was moved largely because she and I were so similar. She was very close to my age. Her life was like mine in a few little ways (although hers had been much more crushing, in terms of pressure and tragedy). And later she said, "It's funny that you're a medical student. That's...what I wanted to do before...this."

So although I didn't even unpack these thoughts until I sat down to type this, I was struck by the kind of identity I found between us. She could have been in my place, and I could have been in hers. How was it decided, and why, that she would suffer and submit to describing all this to a stranger? How was it decided, and why, that I would ask another self "have you ever thought about harming yourself"?

Providence is a mystery to me this time.


I left the room promising to return shortly with Dr. H. I presented the case to Dr. H in his office, starting with the typical formula, "Ms. ____ is a __-year-old female with a _____ year history of anxiety...." I wove an abbreviated version of the story, distilling details and finishing with the patient's goal for the day, which was "to find some way to start to get better."

Dr. H leaned back in his chair. He asked a few more questions about her that I didn't think were terribly relevant ("how did she look?"). Then he mused, "you always have to watch out for drug seekers."

The eyes of my mind shot open. What? Drug seekers? Her? Not possible. Her story was so moving, seemed plausible, human, deserving of even pharmaceutical help.... But was I being naive? No, I told myself. This was a genuine case. Was she putting out bait I'd bite? Not possible. Not her.

In this mental back-and-forth (which was really all simultaneous confusion) I finally decided that Dr. H was the one who remembered that "drug seeking" is in the differential diagnosis of anxiety, so he should be the one to decide whether that was the case. We walked back to the exam room together and went in.

From my position in the corner of the room (a place specially designed in every medical institution
for medical students) I tried to guess what Dr. H was thinking about this patient. He asked questions I hadn't asked ("have you ever tried any medicine before?") and her answers made me wince internally—they sounded like they were pointed toward a goal—a benzodiazepine.

Just as I was beginning to think, "he was right!" Dr. H began discussing doses and prescriptions with the patient, in an earnest tone that implied that he badly wanted to help her. She left with everything she needed. After she was gone, Dr. H remarked (almost apologetically, as if to clear his name to me) "well, that was a case of clearly-the-opposite-of-what-I-thought." I was relieved that what I originally thought was true.

But it was a time to think about how impressionable and influenceable I am. I might be pushing the paper metaphor too far, but it's another instance of the fragility I started to think about with the patient and I earlier.We're sometimes strong, but still easy to crush, easy to reshape.