F. Perry Wilson - How Medicine Works and When It Doesnt: Learning Who to Trust to Get and Stay Healthy

I LOST MS. MEYER twenty-five minutes into her first visit.

Doctors are often a bit trepidatious meeting a patient for the first time. By the time we open the door to the exam room, weve read through your chart, looked at your blood work, and made some mental notes of issues we want to address. Some of the more sophisticated practices even have a picture of you in the electronic medical record, so we have a sense of what you look like. I usually take a beat before I open the door, a quick moment to forget my research lab, my paperwork, a conversation with a coworker, to turn my focus to you, the patient, waiting in that room. It is my hope, standing just on the other side of an inch of wood, that you and I will form a bond, or, more aptly, a therapeutic alliance. Ive always liked that termthe idea that you and I are on the same side of some great war, that together we can overcome obstacles. But that alliance doesnt come easily. And lately, it has been harder to forge than ever.

Ms. Meyer was standing in the center of the room, arms crossed. Smartly dressed and thin, she lived in one of the affluent Philadelphia suburbson the Main Lineand it showed, in her subtle but clearly expensive jewelry as well as her demeanor. She looked out of place in my resident-run medical clinic, which primarily catered to less wealthy inhabitants of West Philadelphia. But what struck me most was the emotion that radiated from her. Ms. Meyer was angry.

What brought you here today? I asked her, using my standard first question. Later in my career, I would learn to replace that line with something more open: How can I help you? or even Tell me about yourself. But it hardly mattered.

She was exhausted, she said. Almost no energy. So drained she could barely get out of bed. Unable to focus during the day, she tossed and turned all night and repeated the cycle day in and day out. It was, she said, simply untenable. I asked how long it had been happening.

Months, she said. Years, actually. You are literally the sixth doctor Ive seen about this. Her anger broke to reveal desperation.

Second opinions are common enough in medical practice. Third opinions, for difficult cases, are not unheard of. But I had never been a sixth opinion before, and I felt immediately uncomfortable. Not because I wasnt confident in my diagnostic abilitieslike all young doctors I hadnt yet learned how much I didnt knowbut because I was worried that whatever thoughts I had about her possible ailment would not be enough. What could I offer that all these others couldnt?

I kept my poker face firmly intact and waited.

Eleven seconds. Thats how long the typical doctor waits before interrupting a patient, according to a study in the Journal of General Internal Medicine. Determined to not be a typical doctor, I let her talk, in her own words and in her own time. I thought my attentive listening would frame our relationship differentlythat she might see me as a physician who was conscientious, methodical. But it backfired. It was clear she resented the fact that she had to relay the same information to me that she had already told to the five doctors that came before me.

One of the most important skills a doctor has is to read the room. So I switched from respectful listening to diagnosing. I tried to troubleshoot symptoms of possible thyroid dysfunction, anemia, sleep apnea, lymphoma and other cancers. I asked about her family history, her history of drug or alcohol abuse, her sexual history. I even made sure I didnt miss questions pertaining to pregnancy, because (this one comes from experience) you should never assume someone isnt pregnant. I reviewed her lab work: Pages upon pages of blood and urine tests. Even CT scans of the head, chest, abdomen, and pelvis. Nothing was out of order. Nothing that we can measure in a lab or in the belly of a CT scanner, at least.

But her affect was off, and her mood was sad. Ms. Meyer seemed, frankly, depressed. There is a formal way to diagnose major depressive disorder; a patient must display five of nine classic symptoms (such as loss of interest in activities they used to enjoy, fatigue, or weight changes). Ms. Meyer had eight of nine, a clear-cut case of major depression, according to the diagnostic manuals. But was it depression? Or was it something else, and the frustration of living with that something else had led to depression?

The nine classic symptoms are far from the only way depression can manifest. As a disease that lives in the brain, the symptoms can be legionand can lead doctors and patients on costly, and often fruitless, wild-goose chases.

Listen, I said, not everything is super-clear-cut in Medicine. I think part of this might be a manifestation of depression. Its really common. Maybe we should try treating that and seeing if your energy improves.

Right there. Thats when I lost her.

I could tell from the set of her jaw, the way her eyes stopped looking directly at mine and flickered off a bit, centering on my forehead. I could tell from her silence, and from the slight droop in her posture, that she had lost hope. We talked some more, but the visit was over. There would be no therapeutic alliance. I asked her to call the number on the back of her insurance card to set up a consultation with a mental health professional and made her a follow-up appointment with me in a month, which she, unsurprisingly, missed. My rush to a diagnosisin this case a diagnosis that comes with a stigma (unwarranted, but a stigma nonetheless)drove her away from both me and from conventional medicine. And had she even heard a diagnosis at all? Or had she heard, like so many women have about so many concerns over so many years, Its all in your head?