I saw a young looking kid in the office the other day. She had what looked like inflammatory acne to her face a forehead, oily skin, hair tied down for ease, thick glasses, zipped up dark colored jacket with poor eye contact. My office manager said she had booked an appointment for a skin rash. I greeted her as usual, with and open heart and mind, but something was wrong. I figured she was a teen to college student, so the possiblity of some social apprehension was normal. I slowed down my health interview so as not to frighten her and tried to give some non threatening, open ended questions to engage eye contact. (My mind took me back to highschool- freshman year I was very shy; when everyone witnessed the speed and agility I had in gym class, I got recognized; then I got identified as the kid who knew Karate; then it backfired as John Travolta came out with Saturday Night Fever and mimicked my hair style resulting in a branding as "disco-boy"....back to square one) So I compassionately engaged her interests and interjected questions of why she was there today.
Her reason for visit was right, she was unhappy with her previous doctors just seeing her face and prescribing steroid ointment. She brought forth knowledge of "injections" for psoriasis as a next step and said she was here to come up with "other alternatives" and felt that from our website, we had a nice mix of western and alternative medicine. I was able to finesse a good basis to her chief complaint without presenting myself as an average doctor she had been to in the past. So crucial is the way doctors ask questions and not the questions we ask.
I felt my history taking and physical was successful enough to have a working diagnosis. In the fast paced life of getting patients in and out, once a diagnosis is attained with confidence....of course a treatment plan is already known since the existence of the AMA, western medicine has proven that if there are "these symptoms" then most likely they can be controlled with "this treatment".....and the current fast paced treatment will be.......prescription medicines!!! Hurray for drug companies allocating billions of dollars just for the sake of improving the way humanity is suffering from disease-then educating the doctors on how to treat disease. Any way......I was set and ready to start writing her prescriptions and start thinkng wow, this was an easy diagnosis and I was able to break through the typical shy demeanor of a teen/young adult....all in 15 minutes! But something was still uncomfortable with me. My teachers from medical school called it a "Gestalt Awareness" that something inside you is sensing a message that isnt being addressed in the obvious. Deepak calls this the Law of Pure Potentiality where everything in the universe exists as one so inner intelligence if given the opportunity for expression will yield all the answers to life.
I decided to query a little more. Turns out she is actually 30 years old, has "angry thoughts" that continue since teen years. "When i stress, the rash gets worse"-easy and obvious. SO I PROBED FURTHER. What is this anger and where did it come from. Seems she has no family support and they actually avoid her when the rash is so prominent. (Typical dynamic with a dysfunctional family); maybe this is a conversion reaction she is manifesting from some poor coping skills in communication. I was able to find out there was an associated joint pain issue with the first few episodes of rash. AAHA! sounds like psoriatic arthritis.....I'll confirm this with blood tests! But wait, no joint deformity now.....fever? infection? traumatic event? It was now passed the usual 15 minute time for a visit designated as Rash, infact it was now touching on the next patients time....but still something wrong. I opened up the proverbial can of worms to define what her interpretation of family dysfunction was......suddenly her head drifts to the floor, she covers her eyes, the tissue she had hidden in her fist goes to catch the tears.
Turns out the joint swelling/rash began after she suffered a rape/physical abuse by another family member. The abuse continued nightly for a year. She wanted to get help but comes from a family where they "dont believe" in seeing doctors or letting strangers know about relationships. She is still living with the family member. Doctors she has seen for the last few years of worsening rash have quickly treated her for the same diagnosis the previous doctor gave but just with a stronger steroid since treatments are becoming less effective, thus prompting the last doctor to suggest injections of a Rheumatologic agent known to halt white blood cell activity. A saviour for people truely suffering from debilitating disease but with terrible side effects including turning off your defenses to any and all infections.
Ultimately, I immediately got her an appointment to our behavioral department for a full psychological assessment and gentle establishment of safety/sanctuary; I introduced her to my Naturopathic doctor to look for solutions in controlling these flare ups and help with allergies to environment and food and try homeopathic whole system approaches to "cooling down" this emotional fire she is dealing with. I started the thought process of using acupuncture to control future flare ups that may occur in the next few weeks with the holidays coming around and the obvious conflict ofintentional family gatherings with the person that may still be threatening her. Most importantly I gave her time to express herself in her own way with her own time. The medical business model tells me I cant spend gobs of time with everyone that walks in for evaluation....but....my heart has a healer says the answer to the patients suffering is already the patients expression, it is my job to help find his/her answers amidst the confusion and pain.....even if it means going over the average 15 minute office visit.
