History of Present Illness:
“The greatest disease in the West today is not TB or leprosy; it is being unwanted, unloved, and uncared for.” Mother Teresa
In the stark cold sterility of a clinical exam room--at a time when like scenarios were being replicated with distressing similarity in comparable settings across America, a nation perhaps overly pampered by the spoils of its natural and historical riches and living too lavishly off the fat laid down by the hard work and sacrifice of previous generations--a doctor and his patient squared off against each other.
The placid, wooden composure of the doctor’s demeanor belied the quaking unrest which fermented, as always, inside him. Long practiced, he was able to suppress it. As always, and especially before the patient, he had to appear imperturbable. “You’ve had pain like this before, Cindy. I don’t think another MRI is going to make it any better.”
The piteous desperation of the reply thus provoked would have been heart wrenching to one uninitiated to the game. “But Doc, it’s not just the pain! I crapped myself last night! I couldn’t help it! I can’t even feel anything down there!” Strands of newly frosted hair, like platinum waves of wheat, quivered over the patient’s face, which she pushed away with fingers provocatively adorned by acrylic caps of sultry ruby red. The gesture was dramatic enough to dislodge her new smartphone from her purse, almost detaching it from the mischievously nymph-like Hello Kitty plastic skin which encased it.
Being in arrears several thousands of dollars to Rocky Mountain Brain and Spine, none of his patient’s pricey embellishments were lost on Darren Campbell. Or, that is, Dr. Darren Campbell, MD, FAANS, FACS, esteemed product of 13 years of primary and secondary education, high school valedictorian of the Glendale Preparatory Academy, summa cum laude graduate of 4 more years of dedicated premedical grind surrounded by backbiting, curve-inflating Asian whiz kids at UC San Diego, Honors graduate of another 4 at Northwestern University School of Medicine, and finally of 7 grueling, every-third-night-call years at UCLA’s neurosurgical residency, capped by the ultima Thule of the overachiever, Chief Residency. All of which now earned him only the dubious honor of being addressed familiarly as “Doc” by the disabled yet alluringly tinseled Cindy Straughton, still working on her GED.
This undercurrent of iniquity meant his measured rhetoric now had to mask outright contempt as well. “I thought you told me you had sex with your fiancé this morning. Why would you do that if you can’t feel anything ‘down there’?” For the prestigious brain surgeon professional triumphs were often reduced nowadays to teasing out such historical inconsistencies, more like being a cop than a healer.
No less practiced, the patient easily pushed the misplayed contradiction aside. “Dr. Campbell, all I know is it just hurts. That stuff, the Tramadol you gave me, it just isn’t cutting it! It doesn’t even touch this pain! Can’t you just give me enough oxycodone to get by until the end of the month?” Now, Darren noticed, it was Dr. Campbell. As well, all concern that something wrong, something ”seriously wrong, Doc,” had been brushed aside. Now they were down to the nitty-gritty.
Which again gave the brain surgeon, ironically not nearly as meticulously coifed as his patient, a feeling of validation. It helped wash away for awhile that perseverant anxiety that maybe, just maybe, having become benumbed by a perpetual cloud of exasperated irritation over such patients, he really was overlooking something bad, and that despite years of false alarms, of complaints by Cindy of her legs giving out, of peeing on herself at a bar, of pain that somehow is different from “my chronic pain”, of 3 previous surgeries that somehow never brought an end to her relentless suffering, that maybe this time her saying she “crapped herself” might really be the red flag waving, a harbinger of real disease. That might be a sign warranting yet another unpaid four figure bill for still another MRI, one that wouldn’t get him audited by his group for naively ordering yet another in a long line of non-diagnostic studies. Something that, fear of all fears, might get him sued, let alone possibly alleviate the misery of the pitiably distasteful patient in front of him, who he was seeing for the fourth time in three months. Now, for once, his confidence wasn’t feigned; victory, it seemed, was his.
“You’re on a pain contract with Dr. Virio. You’ll have to go through her to get any additional pain medication. But if you want to try another course of steroids, I can do that for you.” This last Darren said as if coloring a blank space inside a line; he had no faith that the proffered therapy would be helpful, or accepted. Even so he was a doctor; he had to do something.
“Dr. Virio won’t see me anymore,” Cindy lamented, fidgeting anxiously despite her ten out of ten pain, restlessly rustling the sterile exam paper now sullied in cat hair and faux fur from her thrift store leopard print coat. “I need to find another pain doctor.”
Fortunately for Darren, he could parry this thrust with his own, armed as he was with the new online prescription drug site the state of Colorado had recently started. “That’s probably because of these prescriptions for Percocet it says here you got from Riverbend Urgent Care earlier this month,” he recited triumphantly, trying not to appear smug as he read from his screen. “Don’t you have any of those left?”
Without shame, entirely unabashed at being shown up, Cindy’s tone transformed seamlessly from agony to scorn. “No, someone stole them. My boyfriend’s ex came over to pick up their kid last week. I think it was her boyfriend who stole them from my purse.”
So silly had all this become that Darren could only smile inside with sordid curiosity. Was the ‘boyfriend’ she was talking about the same as ‘the fiancé’? Who knew? All that mattered was that Dr. Campbell could confidently end this encounter, which had boiled down to what so many in what he once thought was a lauded profession had become: a pathetic appeal to him as a supplier of legalized dope.
“Cindy, I’m sorry, I can’t keep giving you Percocet. You’ll either have to find another pain doctor or make an arrangement with your primary care doctor. I’m sorry about your pain, but your last MRI 2 months ago looks unchanged from the one from 6 months ago. I don’t think we’ll find anything new if we repeat it. I don’t find any evidence of cord compression on your exam, so I’m not sure why you had the problem with fecal incontinence. I’ll leave the script for a Medrol pack out front.” So debased had visits like this made him that he snickered slightly delivering the coup de grâce to his lowly combatant. “You can pick it up when you pay your bill.”
At this point Cindy Straughton, veteran of 3 laminectomies, provider to 2 children born from 2 different fathers (neither of whom was ’the fiancé’), smoker of Red Band Tribal cigarettes, regular customer of Satin Touch Beauty College, and whose above the table income derived entirely from the largesse of regularly delivered checks from the US government and the good state of Colorado, recovered her remarkably intact sense of self-esteem. She didn’t even bother to dignify her stupid doctor’s last statement with a reply. Haughtily she swept up her purse and, with no discernable demonstration of pain at this point, stormed out of the exam room.
Deflated, Darren’s feeling of triumph soon evaporated. He shook his head morosely before trailing her out into the hall. Another depressing end to another morning clinic. His only gratification was that lunch, and not the prospect of more similarly ludicrous encounters, loomed. After that, he had two microdiscectomies scheduled; at least he wouldn’t have to deal with those patients face to face.
But here again, the naive belief of his younger self in the magnanimity of being The Doctor, noble provider of cures, of wielding the intricacies of his painstakingly honed craft to dexterously erase patient suffering as a white-coated knight of healing, had been beaten down by bitter experience. The relief of avoiding more potentially unpleasant personal interactions today would likely only be delayed; in his experience it seemed he could count on at least three-fourths of his microdiscectomy patients eventually returning, their relief only temporary, their pain returned (“It’s even worse now, Doc!“), little accomplished beyond the collection of another insurance payment. Over time the look in their eyes transformed, from hopeful trust to frustrated scorn, each visit part of a depressing procession down the litanies of unsatisfying options for the legions suffering from one of the evolving maladies of modern day man: a worn out spine.
Sullenly, Dr. Campbell shuffled out of the clinic area to the part of his group’s building where the administrative spaces were. Slumping down the hall towards his office, he crossed paths with one of his younger colleagues, Brian Shipley.
Involuntarily Darren cringed. Only a few years removed from his training, Dr. Shipley hadn’t yet been disavowed of the God-like feeling of power his surgical skills endowed to him, so his manner was still that of the cocksure healer. Darren’s long lost confidence wilted under the swagger of his brash younger partner.
“Nice shoes, Darren,” Brian blurted sarcastically as they passed each other. Appropriately, the comment did nothing to bolster the older surgeon’s spirits. Almost fawningly, Darren dropped his gaze down to the item his junior so maligned. The scuffed, off-name footwear, essentially black-colored tennis shoes, were indeed a sorry reflection of their wearer’s professional couture. Yet they matched the rest of Darren’s lackluster wardrobe, so that it was unclear why Dr. Shipley chose to single them out as a target for ridicule. And since Darren’s ensemble always projected a similar frumpiness, it was unclear why such a barb was directed at him today.
Hastening his retreat to his office, Darren picked up his pace as he brushed by Dr. Shipley, who himself looked as if he’d stepped from a Nordstrom’s Rack catalog. “Yeah, well, some of us have kids getting ready to go to college, Brian” he mumbled lamely as he passed, fortuitously missing the derisive smirk his response elicited.
Hoping to duck further humiliation, Darren winced when Brian queried to his retreating back, “Hey, aren’t you going to the Medtronic rep’s presentation? He has a new implantable pump they’re pushing.” As the older partner breached his office door seeking solitude and his Tupperware with last night’s casserole, his upbeat junior, knowing what the response would be anyway, still tempted him mockingly. “Medtronic lays out great spreads, Darren. Last month they put out some killer tapas. None of that cheap Subway crap like Miller Orthotics gives us.”
Midday hunger almost made this enticing, but Darren had other needs. Still, he knew his hermetic instinct cast him out as strange to others in the group, so he sheepishly muttered in reply, “Maybe after I finish a few charts I’ll head over.” Embarrassed by the obvious suspended realization that he’d do no such thing, his eyes remained downcast as he ducked hastily into his small sanctuary and practically slammed the door.
Aaaahhh. The dim silence of his modest office space enveloped him. Within his refuge, his shoulders slackened and his facial lines eased. Here at least was one benefit of his long affiliation with Rocky Mountain Brain and Spine he could truly appreciate; he’d been here long enough to warrant being granted his own office, instead of the shared space of some of the newer arrivals.
Yet even this made him feel awkward; most of the older partners, even with their own spaces, tended to hang out in the community office anyway, sharing barbs and swapping cases in the heady atmosphere of youthful fervor radiated by more recently graduated neurosurgeons, reveling in the aura of professional collegiality that festered there. Just like Darren used to do.
Nowadays, though, nothing short of a ruptured aneurysm or uncal herniation could pull Dr. Campbell from his noontime retreat. Buffeted during his days in storms of apathetic professional inadequacy, he needed his insular cloister to recalibrate for an afternoon’s deluge. Unfortunately, rather than helping recharge his overdrawn batteries, his lunchtime confinement tended instead to be a self-imposed downer, serving not to muster dwindling reserves of faltering enthusiasm but to cast him wallowing in a swamp of self-pity and remorse, leaving him to dwell unproductively yet again on how, just how, things had gotten so rotten.