Cases and Stories

The narratives in medicine

He Said/She Didn't

The answer to her mysterious symptoms was one question away.

I was new in practice. They were young - even younger than I. Yet they seemed as attached to one another as a much older couple. Certainly he couldn't have been more attentive to her. He came to every visit and sat by her side, stroking her arm or her hair as she described her symptoms. Sometimes she barely held back tears as he translated her words patiently from their language into mine. There were many symptoms. It seemed we had barely gotten the headaches under control when the heartburn arrived. Then followed the joint aches, insomnia, shortness of breath, and dizziness. Symptom after symptom, like dandelions in mid summer. I became frustrated but he never did. Anytime she felt poorly he took off work to bring her in to see me, to bring her to the invariably inconclusive medical tests I ordered, to escort her to the pharmacy for the drugs I prescribed that I knew wouldn't relieve her. She needed his support, after all. She needed him to speak for her.

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Then the visits stopped.


A year or more passed and she came back to my office, this time without symptoms - just for a regular check up...alone. She looked different than before. Her hair and her skin were shinier. Her eyes were clear and dry. "Where is your husband?" I asked, slowly, enunciating each syllable for her benefit. "I left him," she declared, in accented but unhesitant English.


"I couldn't take him hitting me any more."


In the last decade or two there has been a quiet movement in medicine - it doesn't have a name of which I am aware - in which clinicians are urged to ask certain questions routinely, regardless of who the patient seems to be. It's a reversal, really, of the longstanding notion that a seasoned doctor or nurse's intuition about a patient will lead him or her to focus on the right problem. Now, particularly in primary care, we supplement intuition with pre-printed checklists of issues that may affect our patients' health, safety, and quality of life. This may seem mechanical, but it works. We now ask nice, middle class people about drug use, seventy year olds about sexual satisfaction, and seemingly happy couples about domestic violence.


I finished the physical and found my patient in good health. "How come you never told me he beat you?" I asked her. "Or that you spoke English all along?"


She replied, quite sensibly: "You never asked."

 

 

 

Suzanne Koven practices at Massachusetts General Hospital and teaches at Harvard Medical School.

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