Thursday, May 6, 2010

GUESS WHAT? REAL LIFE ISN’T LIKE TV


Do you remember Dr. Ben Casey? Every week on early 1960s television, this chief neurosurgery resident drained the brain abscess just in time, grabbed the obscure diagnosis that eluded his smug house staff (“Phil, do you mean you didn’t even think of a metastatic pheochromocytoma?”), even found housing and jobs for his indigent patients.

Now, he was a doctor. Actually, he was heir to the honorable lineage that included Dr. Christian and Dr. Kildare, and would serve as a model for Dr. Marcus Welby and today’s hyperactive tele-physicians. These legendary characters are nothing if not problem solvers. Whatever the catastrophe, they somehow deliver heaven from the jaws of hell.

It’s fiction, though. In real life, the Seventh Cavalry hardly ever arrives to save the day. Medical practice is more like trying to hit a moving target in a dark room. We wish patients would present with clearcut, textbook symptoms so we can just cruise down our algorithm and click on the perfect remedy, but that’s an exception. The more typical patient offers a rambling, bewildering narrative that frustrates us to the point that we interrupt (after an average of eighteen seconds, according to studies) in order to nail down something, anything, tangible. It’s not that patients are poor historians; life is simply smudgier than we’d like.

Sure, heart attacks and strokes and intestinal obstructions—life-threatening physical problems—occur, and need immediate physical attention. More often, though, the patient suffers something only she can address, an existential dilemma working its way through her physiology.

When we think of “body language,” we usually conceive it as overt postures, grimaces and gestures, but it occurs at the physiologic level, too. Many organs beside the eyes know how to weep, for example. The lungs can weep, as can sinuses, the gastrointestinal tract, and the skin. Muscles everywhere know how to grip—in the neck, lower back, pelvis, intestines, arteries, and even the heart. Those who live with a great burden of stress are aware of the toll, including even structural change, that these unconscious reactions can take over time.

Several years ago, I saw “Milly,” a woman in her thirties who had a strange arthritis that migrated around her body. Determined to track this down, I examined her thoroughly, read copiously, performed over a thousand dollars worth of tests, and finally nailed down the diagnosis: palindromic rheumatism. I’d never heard of that before, yet here it was, without a doubt. Proudly, I revealed the diagnosis to Milly.

“Well, how do you treat it?”

“Mainly with painkillers and probably steroids.”

She thought a bit. “Tell me,” she said, “do you think this has anything to do with my marriage?”

My medical pride summarily crumbled. Many visits, hours of research, and a fortune in tests, and it came down to this. “What about your marriage?”

She confided in detail, and during the next visit, too. I had no idea what to do or say, so I just listened. At last she said, “Look. Look at my hands. What do you see?”

“Swollen fingers.”

“Look carefully. One finger’s normal.”

Her ring finger. Had she worn her wedding ring anywhere else, she wouldn’t have been able to remove it. There, in the office, she slid it off. She went on to get a divorce. Her symptoms utterly disappeared.

I hadn’t done anything but be a catalyst, a sort of passive lubricant for the changes that needed to occur. As much as I’d aspired to be Ben Casey, my role here wasn’t telegenic at all.

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