Acne

I am not her regular physician. At this clinic, she has no regular physician because of high turnover and a chronic shortage of physicians. I myself am just a “temp,” a hired hand deposited only briefly into this small New Mexico town.

I ask my patient what brings her here. She quietly lays out her litany of symptoms: fatigue, headaches, stomach pains, and her worsening skin condition. I leaf through her clinic chart as she speaks, and I can see that over the years, acne has been her major problem. It is repeatedly noted that she cannot afford to see a dermatologist for specialty treatment.

Almost perfunctorily, I ask my usual question about the presence of stress in her life. Almost as perfunctorily, she replies that her husband hanged himself 2 months ago. One month prior, he had made a first suicide attempt. Their 12-year-old son discovered him hanging and untied the rope. The father was furious and beat the boy. Four weeks later, the father found the rope his son had dutifully hidden and hanged himself again, this time successfully.

My patient remains impassive as she relates this tale to me. “This is where he hit me the first time,” she says, raising her sleeve above her elbow. “The beer bottle was already broken when he hit me, so it left a scar.”

I lean over to look where she is pointing—the purple scar is jagged and raised. It has pulled the skin around it into an ugly pucker. The harshly engraved lines remind me of the craggy desert landscape that I see in the morning as I drive to work. I can feel a dry heat emanating from where she points.

“It doesn’t show on the stomach,” she says in her unembellished monotone, “but I still get pains here.” She pulls her shirt up, and I see golden skin with faint stretch marks. “When I was pregnant, I tried not to let him kick me there, but it was hard sometimes.”

I don’t see scars, but my ears pound with screams.

“I had my tubes tied,” she says. “But he was mad; he wanted more kids. I thought two was enough, but he wanted more—‘a real Navajo tribe , ’ was what he said.” She intertwines one finger in an ebony lock of hair. Her voice continues—flatly, plainly. “He got drunk a lot more then. He wanted me to get another operation. To untie them. It’s not that I don’t like kids—I love my boys—but I wasn’t sure if we should have any more. Kids are expensive.” She rotates her fingers, and the hair twists with it, glistening under the office lights. I am beginning to perspire in this overly air-conditioned room.

“Almost a year we argued about it,” she says. “We had some bad fights. But I finally decided to do it, untie them. I do like kids. I made an appointment at the hospital for the surgery, but he was mad because it wasn’t soon enough. Then he killed himself.”

I try to respond matter-of-factly, wanting to put her at ease, but I am assaulted by the vision of a man hanging and a young child stumbling into the room. Was the body writhing in agony? Was the face exploding with hypoxic torment? What did it look like from 12-year-old eyes? What could it feel like to unhitch a rope from a dying man’s neck?

“What about my acne?” she asks. “Can’t anything be done?”

For a moment I can only blink dumbly at her, fixated on the web that extends far beyond this office and the capabilities of the medical profession. I hunger for powers to untangle the knots, but medical school has not made me a healer of all pains. The illusion of omniscience blithely promised by my residency training is easily deflated by the unadorned actualities of life. Her acne is all I can attack, although I see that physicians here before me have waged this war without success.

Surveying the medical history chronicled in her chart, penned by so many different hands, I observe that she has already tried most of the basic acne medications. There is one, however, that she has not taken. It is rarely prescribed for women of childbearing age because of its toxic effects on fetuses—each individual capsule brandishes the image of a pregnant woman with an ominous “X” slashed through the swollen belly—but my patient’s plans to reverse her tubal ligation were aborted by circumstance.

This medication is not available in our clinic pharmacy and my patient does not have the means to obtain it on the outside. I have been told that drug companies will occasionally provide medications without charge. The bureaucracy can be arduous, and there is no guarantee of success, but I think we should try. My patient agrees.

I observe in her chart that she has not had a recent Pap smear. I offer her the option of seeing the gynecologist, but she prefers that I perform it, at our next visit. I am honored.

I watch her padding silently down the hall. Weakly, I retreat to my office. The stout medical textbooks and cabinets overflowing with equipment are stifling, mocking. Where did I get the absurd notion that I might be a healer?

When my month at the clinic is up, I will move on. Just one in a stream of physicians, I, too, will abandon this young woman, bequeathing her only a bottle of pills. I scribble a note to call the drug company and then tape it to my bag. I cannot afford to forget.  (from the Annals of Internal Medicine)