Many of my notes begin something like this:
Forty-five year old white female, who looks older than her stated age, presents with symptoms of depression, hopelessness, and suicidal ideation.
I was discussing with a fellow worker in the mental health field yesterday the fact that we are all well-trained in observation. We must be, to do our jobs properly. I have written posts in the past, and have even taught medical students, about how to do a fairly complete or at least serviceable mental status examination on a patient who never says a single word to you. It is not optimal, but it can be done.
We notice what our patients look like the moment they walk in the door. How is their hair done? Are they wearing makeup? Is it tasteful? What kind of clothing are they wearing? Is it appropriate for the season? Do they have jewelry on? As they walk down the hall toward the office, we can see if there is any disturbance of gait or balance. When they sit down, body language, abnormal movements, and eye contact are all readily available markers of what might be going on that brings them to see us. All this before we have said much more than good afternoon to each other.
What we forget to remember sometimes (for we knew it all along; we just don’t want to acknowledge that it is true) is that our patients also notice us. They notice how tired we look one day, or the bags under our eyes if we have not been sleeping enough. They notice if we wear new clothes or have new glasses or a new wristwatch. They may have a mental illness, but that does not mean that they are not concerned about the welfare of the person who is treating them.
Most of the time this is harmless, but sometimes it can be telling in a very important way that impacts good patient care. Like the time that I hired a temporary doctor to help with coverage in a rural clinic. Shortly after she had met some of my longtime patients at the office, I received a message that one of them wanted me to call him about something important. Now, this patient never called me and left a message like that unless it was truly important to call him back. I did so, promptly. (As background, please know that I had already heard grumblings from the staff at the main mental health center office where this doctor was also spending some time.)
“Dr. Smith?” my patient began on the other end of the line, his southern drawl so thick it took him days to tell a story.
“Yes, Bill?” I answered, wondering now what was up. He sounded good, calm, together.
“You know that lady doctor you sent down heah to see us until you can git sumbody else hired to help you out?”
“Yes, I do. What about her, Bill?”
“Well,” he hesitated.
“It’s okay. You can tell me whatever you need to tell me. It’s all right.”
“Well,” he began again, “Dr. Smith, you’ve known me a long time. I may have a bad mental illness, but Dr. Smith, that lady is one of the craziest doctors I think I’ve evah met.”
He went on to tell me details of some inappropriate behaviors that impacted care in the center, consistent with the feedback I had already been getting from others.
I fired the doctor the next day.
I saw a young patient in clinic recently. He had not been in to see me in well over a year, maybe two. He greeted me this way:
“Well, I guess we both got older, Doc. A little gray there since I last saw you.”
Just a few years ago, this might have bothered me. No more.
I’ve come to like my rapidly whitening goatee, the touch of gray-white at my temples. Badges of experience. Signs of (hopefully) wisdom gained in the struggle? I’m not as skinny as I was in the ninth grade in high school. My hairline has receded a bit, but at least I still have hair! Some days, I’m sure my patients notice me sitting down with an audible groan or struggling for a half-second to get up when my polymyalgia has flared. I’m sure they notice that I forget things, parts of their history that I know and have known for years, but that get swept away downstream in a modern-day torrent of electronic medical records, red tape and sheer volume of information coming at me from a dozen different pipelines.
I think my patients give me the benefit of the doubt, because they know I care.
We grow old together, my patients and I.
I am treating the fourth generation in some families now, seeing first hand the living textbook of mental health genetics that is a family plagued with substance abuse, depression, or schizophrenia. I have always said that I am privileged beyond words to be let into a patient’s life and circumstances on such an intimate level as this. I mean it. It is an honor.
Aging gracefully is a skill. An art.
In this age when we value beauty and youth, we sometimes forget how important it is to revere and respect our elders. They hold priceless memories. They have seen things we have not had to see. They have picked us up when we have fallen and protected us from untimely hurt. They have known that they could not forestall the inevitable painful education that life bestows on us all, long before the first gray whisker or arthritic joint visit us and take up permanent residence.
Yes, my patient pointed out the gray. He reminded me that, like my patients, I grow older with each passing year. Not a bad thing, given the alternative.