Room 21

Dear patient in room 21,

I know you've dreaded this visit for years.  I see the 6 foot man walking ahead of you, assessing the room, looking for his seat.  He is not nervous.  In fact, he is quite talkative, inquiring about my training, where I came from. How long I've been doing this, and that we have some issues to address. What you don't know is that I have him pegged, and have since he marched into the room. The less I say, the more I can observe.  The nurse comes in, asks you a series of questions answered by him.   She then presents you with a gown and a paper towel and you wait.

What you don't know, dear patient, is that I am outside the door.  I'm listening to you interact when no one is watching because I fear that the family I am about to meet is not the family that you experience.

I enter with an outstretched hand and a warm smile to him.  "He's got her snowed", you think, and I see your shoulders slightly slump in defeat.  I sit down, put my feet up and ask what brings you in, to which he answered "decreased libido, too tired and having a hard time keeping up (with what?), she's cranky and she just doesn't listen very well."

I instantly notice him jump out of his seat to watch me perform a routine breast exam.  I say nothing about the bite marks on your chest. I see the bruises on your forearms, in the exact area you would use to protect your face.  Not bruises around the wrists consistent with creative sexual exploration. He's quick to tell me about your fall last week, except these are fresh bruises.

I ask you to follow my pen. Not because I am concerned about your cranial nerve function, but I need to look in your eyes.  Vacant.  Looking at the floor.  And your husband is quick to tell me that he's just started a church.  You smile right on cue, with a nervous laugh. "Yeah, she has NO idea what kind of man he his...", you think.

What I notice first is your pounding heart, anxious breathing pattern ..."Oh she hates these things!", he exclaims.  I lighten the mood talking about your children and that surely a routine gynecological exam can't be worse than an 8 pound baby, right? "Oh, they weren't  mine," I hear your husband say.

Then, I have him breathing at the back of my neck... Your legs clamp tightly, a barely audible sob fell out completely out of your control.  Your breathing is fast, uncontrolled, and tears roll down your checks.  It's fairly obvious at this point that someone, somewhere, has violated you, emptying you of your dignity and self worth leaving a void now filled with a controlling and  potentially abusive  husband.

"I can't see in there!  Do you see anything?  Does she have anything?"  I smile politely and state that her gynecological exam appears normal.  Except for the fact that he had to mark his territory immediately prior to the visit today, like a tomcat.  What I didn't tell him is that while her pelvic area is perfectly groomed,  her legs have yet to see the 3 minutes of attention they have deserved this month.  I also notice her $700 Coach bag, but 6 month old pedicure.  I see the big bruise on her knee... From the fall "last week" I assume.  I see him aggressively trying to look over my shoulder, and I'm doing my best to preserve what's left of your dignity.  Why won't he leave you alone for 90 minutes for a pedicure?

I continue to engage him, attempting to earn his trust.  Offer to draw labs as a biochemical explanation for your perceived shortcomings.  I believe none of it, but I want to have him think he's got me fooled.  Fooled enough that he will let you come alone next time, so I can really look into the window of your soul and extend my hand as a safe rope .

My student emerges and I ask her what she noticed about you.  "Pretty, thin, quiet and very polite."

"Why is she here today?", I ask.

"Just for an annual. No issues."

"None?", I inquire?
"Tell me about her hands, her forearms.  Did she wear nail polish?  What does she do for a living?
Where was that dysplastic looking mole?"

"Well...I was typing her info. She's v70.0 and 627.2, needs screening Mammogram."

I ask, "What color is her hair?  Tell me something about her husband."

Awkward silence...

And, so now, I spend the next 20 minutes teaching a medical student how to look at her patient, and how to manage controlling husbands, identify signs of abuse, and how to delicately document these observations in a computer medical record that will be eventually accessed by the world at whim.

My patient did come back. He stayed in the lobby on wifi.  She said, "It's not happily ever after, but it's what I signed up, for." I then gently asked if he was always that protective when she went to the doctor. I told her that I knew her bruises were recent and not a result of last week's ice storm. Through tears, she said, "I thought he had you fooled.  He set you up to never believe some of the crazy stuff I could tell you."

I assured her we will check in once a month to address her "hormones".  I also assured her that violence only breeds more violence.   And, that maybe it was time for her 16 year old to come in for a visit as well.

She needed her pap done, but it was about much more than that.  I know that I can't save anyone that doesn't think they are worthy of a better life, but I pray as we build a relationship, she will slowly learn that not only is she worthy of respect, but that her children are learning by their examples how to treat others and what kind of behavior is acceptable.  The cycle of violence and control has to stop, and I will fight it as long as God gives me the grace and the guts to do what it takes so that no one else ever has to experience the gut wrenching anxiety every time they turn the knob at the back door.

I had an attending tell me more than a few times, "God gave you 2 eyes, 2 ears, 2 legs to get to 'em and 2 arms to hold them, you've only got 1 mouth, so listen more, hug more, do more and talk less."  What you give to your patients daily is your vocation, their trust in your care is your salary.