Tuesday, April 22, 2008

In another's control

Today's Continuity Clinic had a theme, sort of. We had two patients (both very nice) who talked at some length about the stresses placed in their lives by other people. Their reactions to their situations, however, were much different I think.

The first--she was at the visit for something unrelated, but started talking about her mother. She actually started to say "I wouldn't have normally brought this up" (getting ready to tell me the reasoning why she did bring it up--but she was interrupted and never finished the thought--to my disappointment). She talked about how her mother intrudes on every aspect of her life, from how she shops, who she has over in her home, and how she pays her utility bills. She is a 44 yo AAF with one child who is getting ready to graduate high school. She felt overwhelmed by her mother's insistence to be so involved that she actually had seen a counselor before about it, but never went back because the counselor was a white male, and she felt that he wasn't empathetic and couldn't connect to her as an African American and as a female. She went on to say that she was having to hide things around her home, such as liquor and martini glasses to keep her mother from commenting. She was worried that her mother was pumping her 17 year old daughter for information about the goings on in her home. She felt guilty that she was kinda expecting her daughter to lie to her mother about things. She described multiple instances where her mother had called to say "I just went ahead and paid your water/electric/gas whatever bill for you" or said, "I was shopping today and got you this" but would expect her (the patient) to pay her back for the things she didn't necessarily want, need, or like. Our patient told us that this stressed her out so much, because she wanted to tell her mother to back off, but wasn't sure that it would be effective. She talked about the strain it was causing on her relationship with her two sisters, how she couldn't tell them anything for worrying that they would tell her mother. This lady seemed to feel extremely guilty about how all of these familial relationships were arranged, and I honestly feel that her self esteem suffered for it.

Our next patient--when I walked in the room, I was struck by her extreme appearance. Not extreme as in piercings everywhere with tattoos and goth, but extreme in that it was clear that she was a runner and wanted everyone to know. In her early 50s, with salt and pepper hair, I think I could have almost identified every muscle in her upper extremities and torso, along with their attachments. She wasn't anorexic thin, but definitely someone who seemed very focused and set on maintaining herself to look a certain way. She was wearing pants with leg warmers on her calves...on a day that was pretty warm anyhow. She and the doctor had a bit of a disagreement on the plan how to manage some possible tendon strain she was experiencing. The doctor required her to be seen by sports medicine before PT to get cleared for treatment, however, she insisted that she thought she could just go straight to PT without the Sports Med visit. The discussion and discourse went on for about 10 min of the visits. Interspersed throughout this was that she was having tons of trouble with her contacts, wasn't able to drive really, and one more appointment would not be good. But then finally, she said, "Well, you see, I've never been the one controlling the household finances." From there, she talked about how for 26 years, she had to wait to finish the education she so desperately wanted, raised 5 children only allowed to use 25 hours per week of childcare, and tried to take multiple courses throughout that time. Her husband also eventually prevented her from taking her dream job at Cornell. She said her children were great kids, and that's what had kept her in the marriage. What was notable during the interaction with her though was her need to exert herself as a person to us. She talked about her running and being thin, and after we left the room for a short time and came back, she had pulled out this Alumni Feature magazine from her Alma Mater school which featured her.... in the Fall of 2004. I read the article and in it, it mentioned how for 25 years she had to wait to finish to fulfill herself. I was just in awe how this woman, through being repressed by wife and motherhood had to use any way possible to validate herself within the world. She wasn't dislikable, but I pitied/had sympathy for her.

Lesson Learned--My attending said that the above interaction "wasn't that great of a medical learning case, and you'll get plenty of that (psychosocial) in residency"--I tend to disagree--We never know who's controlling the lives of those around us and how it colors their interactions with the environment.

What it's Worth--The worth of the context of the patient and how they deal with problems/people, whether externalizing or internalizing their problems is probably invaluable, and something I won't forget.

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