Sometimes, Doctors Find Answers Far Off the Charts

by Danielle Ofri

New York Times.

Thick, silky black hair slid out from the sides as she shyly removed the hat to show me the crusted scabs on her head. Carmen came to my clinic because of a scalp condition. She was 37 years old, slender, casually but fashionably dressed, with the broad bill of a red baseball cap obscuring her face.

Carmen’s hands were well manicured and her makeup carefully applied. It was clear that she was embarrassed, and she slapped the cap back on as soon as I had examined her head.

I reassured her that this was a common fungal skin infection and was easy to treat. To give her some distance from this, I quickly moved onto the other parts of the medical interview — past medical history, past surgical history and so forth.

 During the course of my questioning, Carmen mentioned offhandedly that she had been having aches and pains on her left knee, her right shoulder, the back of her head and on her stomach. She described pins-and-needles sensations in these areas for the past six months.

I performed a thorough physical exam, but found nothing amiss: there was no swelling in the joints, there was normal sensation in the skin, there was no sign of trauma or injury. I could find nothing to link these symptoms to any known disease.

“It’s probably just the routine aches and pains of life,” I said. “You are perfectly healthy.”

Carmen smiled a tight smile, and we talked for a few minutes about general steps to maintain good health: Pap smears, balanced diet, exercise.

I gave her a prescription for a lotion to treat her scalp, and then we shook hands and said goodbye. I turned back to my paperwork as she let herself out of my office.

“Oh doctor,” she said, as she was walking out.

I looked up from my writing. Carmen was already outside the office, with her hand on the doorknob, getting ready to pull it shut. “Can I ask you a question?”

 “Sure,” I said, putting down my pen.

Carmen paused, and from under her baseball cap she seemed to focus on a spot beyond me. Her voice grew more tentative. “Do you think … ?”

 She hesitated again, her eyes drifting, as if searching for another, perhaps safer, spot upon which to rest.

“About the parts that hurt me …”

Her lower lip retreated ever so slightly under her front teeth. Her question came out as one of genuine curiosity.

“Do you think it’s at all important that these are the same spots where my boyfriend shot me with a dart gun?”

The “hand on the doorknob” phenomenon is well known in medicine.

A physician can proceed assiduously through a complete history and physical with a patient, but it is only when the patient is halfway out the door that the important information spills out.

I often wonder why this happens, why the crucial information so often waits until after the visit has finished. Perhaps it is because the formality of the standard doctor-patient visit precludes revealing such personal, vulnerable details.

 Or maybe such details simply seem out of place, or unimportant, because they aren’t about livers, spleens or cholesterol levels.

Maybe only when patients are fully dressed and standing upright, somewhat removed from the medical setting, if only by a few feet, do they regain enough humanity and strength to reveal such things.

Whatever the reason, there is something about that moment — halfway out the door, hand on the doorknob — that is critical.

There was a long pause as Carmen’s dark eyes finally settled on mine. I wanted to kick myself; how could I have missed it? Why weren’t my antennae alert to domestic violence, something that is so frighteningly common that every single day, I should have at least one patient who has experienced it?

I stood up and extended my hand to Carmen, to invite her back in from the outside, to pull her back from across the threshold.

Now it was time for the real visit to begin.

(from the New York Times.)