The Empowerment of Fear.

I bawled so loudly in the bathroom this morning that I woke up my roommate (a medical student in the class above mine, presently keeping the awful hours of a surgery rotation -- who demonstrated how outstanding a physician she's going to be: so thoughtful and caring, even under these circumstances). She calmed me down enough to focus on being proactive (of which bawling in the bathroom is not an example) -- and enough to appreciate that the single-most important act I can take right now is to write about this. So that I never ever ever ever forget what it's like to be this afraid.

I entered an essay contest a few months ago, where I wrote from a patient's perspective about how it feels when a doctor does not attempt to "inhabit one's existence" -- to translate the 'review of systems' checklist into the practical experience of what it is like to actually go through life with those symptoms. I was pretty graphic, and actually too embarrassed of my crudeness to even share the essay with my own mother or several of even my closest friends. It's ironic that, six weeks later, I've decided to write THIS on a blog read by hundreds of people a week. But I've decided to do it because it'll keep me honest.

Part of seeing the world as a fusion of interconnected parts is that, even in the midst of pure frightfulness, I can see that my experiences this week, appreciating different forms and perspective of fear, have all led up to this moment.

Yesterday at the clinic, I saw a trooper in the hallway. I chalked this up to just another 'thing that happens' -- much like the experience of seeing a random horse outside the window of my preceptor's office. Yes. A horse. A horse that had never been there before. This is my world. Turns out, the trooper wasn't as random. He was there investigating a case of alleged child abuse. 19 year old developmentally disabled woman, charging that her foster mom had split her lip. My preceptor and I were microwaving dinner in the kitchen chatting about heart rate monitors (obviously...) and suddenly, there was this girl telling us this story. I felt helpless. I expected my preceptor to step in and save the day -- to make all of the world's wrongs right, to magically transform fear into peace -- because that's what he does. Turns out, he's human -- who knew? I felt even more helpless.

"I'm scared," the girl said. "They're going to make me go back there, and I'm scared about what's going to happen to me."

We walked away, leaving her with the trooper. We later heard that thorough police investigation had yielded a history of false accusations and secondary motivations, I questioned my ability to discern genuine fear and its implications.

After dinner and an IMMENSELY rewarding discussion with my preceptor about the study I am conducting about heart-rate monitor use and self-efficacy (if you've ever worn a HRM, you can participate here), we saw a patient who again prompted me to ponder how fear/uncertainty translates into the details of everyday functioning.

We saw a woman in her late 20s who had been experiencing freakish distortions of physiology. More than 20 times a day, right before our very eyes, her entire leg would intensely contract and jerk off to one side -- unable to relax for 10+ minutes. When these contractions took place, her face distorted in pain. The same happened to her hands, her arms, her shoulders, even a portion of her abdomen. On the schedule, her chief complaint had been written: "muscle spasms." How understated! This girl couldn't walk, couldn't drive, couldn't sit up or stand up. Couldn't function. I ransacked the pathetic data bin in my brain on muscular spasms, and came up empty for anything that could possibly contribute to this girl's world. One advantage to knowing relatively NOTHING is that my brain is not "cluttered" by extensive knowledge of all the things that SOMETHING could be. So I thought it looked like MS, just because it's a) the only thing I know anything about that resembles this, and b) because I'd just learned about it 48 hours prior. I asked her questions about her vision and her balance. I hated that her responses matched my expectations, even though that's theoretically why I asked the questions.

My preceptor left the room, leaving us alone in the exam room. My 'first-year-medical-student arsenal of questions' had been exhausted. Awkward silence. But it occurred to me that, just maybe, she would feel better to be asked about what it was like to live with these "muscle spasms."

I watched as her eyes widened, softly glossing over as she spoke.
"I'm so scared," she said. "I'm so scared to have no control over my own body. I'm just so scared about what's going to happen to me."

Almost the same exact words as the earlier exchange, except fearing an internal attack as opposed to external.

I asked her to tell me about how she has been managing -- how does she get around, what's it like to wake up and fall asleep and everything in between. What it's like to interact with her family. Her descriptions were awful, and I felt guilty that I had NOTHING to contribute other than an acknowledgment that her descriptions were awful. She told me that she's started to believe that her symptoms are like magic, to indicate to her that a person or a situation is "bad news." She didn't call it divine intervention but that's kinda how she described it. How fascinating to tap into someone's innermost schema that underpinned her coping mechanisms for basic functioning. How fascinating that, had I had more legit medical questions, I would never have had the "space" to learn this about her. And whether it has any bearing on medical management or not is irrelevant: I watched as a wave of peace, almost brightness, spread across her face. I'd given her a forum to tell 'someone in a white coat' about how she saw the world -- and no matter how little I did to earn the privilege of hearing that expression, I was grateful and proud.

Truth be told, I felt on top of the world last night. I didn't say anything stupid, didn't bumble any major exam skills, didn't otherwise embarrass myself. Nice. And best of all, my preceptor (my most recent HRM convert) spontaneously advocated HRM use to one of his patients who was trying to lose weight. I felt like I'd truly accomplished something awesome.

That's not how I feel right now.

Now, I feel scared. I'm scared that I have no control over my body. Just so scared about what's going to happen to me.

The point of this post isn't to document the gorey, crude details of my symptoms (a GI bleed unlike any that I have experienced before). The point is to hold myself accountable to internalizing what it means to look down at something that came from one's own body -- and to detach from any rational mechanism for processing reality. This has happened before, though not to this extent. Years of managing unambiguously abnormal, chaotic experiences and developing coping mechanisms for fitting them into a chaos-free existence has afforded me great insight, into both my own motivations/truths and to those of other people. Every episode has meant something, something powerful and positive -- something that's going to make me "get it" when someone needs me to "get it." Something that's going to make me a better doctor.

What made this morning's episode worse, I think, was that it seemingly exhausted my knowledge base. I was no longer the #1 expert of my body. My threshold for "knowledge exhaustion" is higher, both because of my professional training and in the time invested in developing an awareness of the specific anatomical and physiological aspects of my symptions. Nothing within my "life schema" could possibly explain what was happening; it was above and beyond my threshold at which "things that make sense" become "things that do not." The experience of crossing that threshold was tremendously disempowering for me. Processing that 'process' has been helpful, and I need to remember that when I see the opportunity to prompt other people to take that time for their own processing.

They taught us in our earliest training sessions about medical history-taking that the questions "What do you think this is?" and "What is your greatest concern about this?" are tremendously important. When phrased exactly like that, these questions always sound tremendously awkward -- but they really are important. Above and beyond the utility of learning from the #1 expert in the diagnostic issues at hand, these are the questions that prompt these experts (patients) to appreciate that they are experts. To empower people to take a proactive role in their own wellness, to act as their own advocate.

Time for me to do the same.