Thursday, November 14, 2013

What I Know Now

My patients, they do not leave me.  We exist now as a group, I feel them stringing along behind me when I walk to class or to my car, they hover over my head when I lay down and try to sleep.  Their voices echo in small phrases, glimpses swim in front of my tightly shut eyes while I rub the now permanent line that is etched between my eyebrows.  I struggle to recall faces, instead my mind is filled with a collage of body parts that I try to piece together - clenched hands on the exam table, the paper crinkling under their white knuckles, pale inner thighs that shrink away from my touch, chapped lips that answer my questions in whispers, eyes that won't meet mine.

Sometimes my patients are like the horses I grew up drawn to.  They size me up as I walk into the tiny exam room, the whites of their eyes following my every move.  I sit and lean back against the wall - I have no agenda, I want them to know.  I have tamed the single-minded eagerness to explain, to educate, to inform, to counsel that often fills us as we learn.  I know so little, it seems, I have been trusted with so much, I want to impart every speck of what I can offer, because even that is not enough.  Instead, I sit down and say hello.  I smile.  I ask how they are, and what brings them to me.  I set my pen down and listen.  I nod, and they seem unsure if they should continue to speak when I don't interrupt them immediately with questions.  I've stopped trying to have all the answers, but sometimes the questions still make my heart pound with anxiety.  I ask them anyway, my voice soft, the walls are thin, do you feel safe at home, where are these bruises from, how many partners in the last year, can you tell me how often you're shooting up, are you planning on becoming pregnant at this time, have you ever had symptoms like these before, how long have you had this pain?  I say, I'm so sorry that happened, that sounds really difficult, you don't need to apologize, ever, can you let your legs fall out just a bit more, you're in charge here, okay?, will you tell me if this hurts, let's use the other arm for this blood draw, let me know when you're ready.

I think back to a before time, when it felt important to do it all perfectly, to remember the order for collecting a Pap and how many centimeters into the cervix to insert the cytobrush in order to extract a sufficient sample, to perform a breast exam so flawlessly that no inch of tissue went unexamined by my probing fingers.  I think back to when I would recite my pelvic exam "lines" in my head on the drive to clinical, terrified of forgetting our textbook's directions for the best way to elicit cervical motion tenderness and what that would mean.  The words fall out of my mouth now, scoot all the way down, this is my hand on your leg, these are my fingers, this is the speculum, lots of pressure now, cervix looks good, little crampy now while I take a sample for the lab, you might have some spotting today, no need to worry, speculum coming out now, we're almost done, these are my fingers again, I'm going to press on your belly, any pain while I do this?, I'm making you have to pee, I know, okay, you are all set, you can scoot on back and up.

I know now that a sufficient sample and a smoothly performed exam do not erase the bruises on her inner thighs.  I know that my ability to rattle off the medication regimen for gonorrhea, chlamydia, pelvic inflammatory disease, and herpes does nothing for the woman whose trust has been shattered by a disease she did not give herself.  I hand her tissues and say, again, I'm so sorry.  I hope, maybe, that this tiny exam room with the fake wood paneling and the ancient posters on the walls can be something more than a bizarrely furnished box.  This tiny space we share where I ask them about their day, their dogs, their children, where I admire their socks and listen to what they say and even harder for what they do not say.  It is in this place I think, maybe, that in spite of all my weird and deeply probing questions, in spite of my hands inside them and my far from perfect technique, even in spite of all that I fumble and trip over and the answers I do not have, it is my hope that they feel safe.  That she sees that when the door shuts, I am with her and that is all that there is.  That I am long past the point of ever batting an eye no matter what she may ask or tell me, and that I will do my best to answer her questions but will tell her frankly if I cannot.  And maybe for five or ten insignificant minutes, maybe that is enough.

I've stopped trying to be right.  I only try to be kind.


The Nanny said...

love this.

Anonymous said...

Beautiful. I admire you.