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Dialogue and diagnosis
This is a story so typical of general practice that you could almost use it to help medical students decide whether or not they want to be GPs. (I have, as always, altered some details in order to make the person involved anonymous.) The patient is a woman in her late thirties, childless. The story began about two months ago, when I saw her with some peculiar neurological symptoms. I was vaguely aware that she had had a miscarriage about a year previously, but this was not at the front of my mind when I saw her: she normally sees another doctor in the practice anyway, and the presenting, acute symptoms were too worrying to think about anything else.I called up the duty neurological registrar to describe the symptoms. He thought I was right to worry and offered an urgent out-patient appointment. He saw my patient a week later and was concerned enough to do some imaging. This turned out to be entirely normal. When he saw the patient a month afterwards to tell her the results, the symptoms had in any case changed. They had become far less specific and more suggestive of general muscular fatigue. He sent her back to me with a letter raising the possibility of a chronic fatigue syndrome and suggesting that I should send her to a rheumatologist or someone with a particular interest in such states.
So I saw her again and went back to square one. This time I got an entirely different story. The symptoms were now mainly aches and pains and exhaustion. She had more or less forgotten the numbness and parasthesiae that had brought her to me in the first place and caused such concern. (I wonder if they were amplified from the original consultation onwards as a result of seeing doctors, and then dispelled by the normal scans. We sometimes forget that we make our own contribution to the construction of symptoms.) When I asked her to date her problem, she told me this time that she had had them about a year—considerably longer that she had said at first. This timing took us back precisely to her miscarriage.
Miscarriage. Childlessness. Late thirties. Suddenly I knew that I was going to hear quite a different story from the clipped, clinical one that I had elicited and possibly promoted at our previous meeting. And indeed, an entirely new story now came to light. The miscarriage had been, in effect, a cruel caesura in her life. Until she had come to the doctor with heavy bleeding, she told me, she had never even dreamed she might be pregnant. By the time she knew that she was pregnant, it was already over. It was the only pregnancy of her entire life—a much longed-for one that she believed would never happen. But she had lost it before there had been any chance to celebrate her fertility for even one minute.
She began to cry, and then she told me more. Five years previously, when she was still in her mid-thirties, she had gone with her husband for some fertility tests. She was told she needed IVF, but in the same breath she was told she did not qualify for this unless she went private—which in no way could she afford. She described, word for word, the consultation with the gynaecologist. I have heard too many such stories to discount them as exaggerations or misunderstandings. The local ‘rules’ by which the gynaecologist had excluded her from treatment made no sense, in logic or humanity, but she and her husband clearly had neither the education nor the emotional resources to challenge them. They had walked out of the clinic, and never requested or even thought of a second opinion. When she had grieved her miscarriage a year ago, she had relived every minute of the earlier rebuff, and felt its injustice bitterly. She recognized the cruel pattern in both events: the tantalising possibility of parenthood, coupled instantly with its extinction. Her consequent numbness had not been neurological but existential.
It was clear that she did not have chronic fatigue syndrome, nor did she need to see a rheumatologist or fatigue specialist. What was evident was that she needed someone to ask for and tolerate a narrative that was entirely different from the one in which we all colluded, perhaps necessarily, the first time round. She also needed to tell someone who was capable of hearing both kinds of story—the biological and the biographical one—and who did not find it at all surprising that human beings live in both worlds at the same time, and may not know which of these worlds to talk about, in order that things might change.
I am sure that encounters like this also happen in hospital and psychiatric out-patient clinics. But as GPs we work permanently on the knife edge, as it were, between the diagnosis of illness and the interpretation of experience. I know few GPs who cannot tell of such transforming conversations on a weekly or even daily basis. And I wonder how on earth one could ever quantify the outcome of these entirely private and unique exchanges: the time, money and endless frustration that are saved when people are headed off from further referrals, further tests, and further futile ‘treatments’; and the healing that starts when a story like this has been told.
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