“I mean, ever since it happened, I just don’t feel safe anymore … they come out of nowhere … my heart will be pounding and pounding … they can get me at night, even if I’m in my mom’s house. I haven’t worked this whole month, and don’t know how I’ll go back.”
Ms. Smith is a young white woman who is presenting with panic attacks.
“Doctor, the pain is so bad I can’t sleep, I can’t eat, and it still feels like someone’s stabbing me every time I breathe.”
She also complains of insomnia, anorexia, and pleuritic chest pain, secondary to her having been beaten by her boyfriend, and raped by a stranger.
She’s weeping now.
“Will I ever be normal again? Every day I wish I could die … I don’t wanna take those drugs, because I’ve been down that road before and know how much of a slippery slope it is.”
Ms. Smith has a history of drug addiction and chronic pain syndrome, treated with gabapentin.
“What’s wrong with me? Shouldn’t my ribs be better by now?”
She was found lying unconscious and naked on a park bench, with abrasions on her legs, and bruises on her chest and face. She was taken to the ER where chest X-rays were performed, negative for costal fractures.
My preceptor listened to Ms. Smith with empathy and concern. He spent an hour with her — a rarity in his busy family practice — trying to determine the best treatment for her panic attacks and ongoing pain.
It doesn’t take six months of medical education to realize that even after her injuries heal, she, in all likelihood, will never heal. Health, remember, is not simply the absence of disease. The tragic conditions that led her to be admitted to that ER in the first place are still present, and still injuring her spirit.
Now, those of you more astute readers may think, “But Jacob, ‘broken spirits’ don’t show up on any diagnostic imaging! Nor can they be measured with a Coulter counter or blood pressure cuff! How can you even code for them?! — They’re not in the ICD-10.”
I’ll answer your question with another question: Why haven’t prospectively randomized control trials of the efficacy of parachutes for skydivers ever been performed?
I learned in school that good medicine is a science, based solely on clinical research. Excellent medicine, on the other hand, is a scientifically informed art, understanding the uniqueness of every person and situation, and utilizing answers to questions that science often lacks the tools to ask.
An injured spirit leads to an injured body. The two are as intertwined as the thyroid and pituitary glands. Unfortunately, unlike an injured body, an injured spirit will rarely ”spontaneously remit.” Painful self-work and strong support is required for any improvement to occur.
Thus, at first glance, it seems that Ms. Smith’s fate is obvious: She lacks the access and insight to pursue psychological therapy, the education and skills to climb out of poverty, and the motivation and knowledge to make healthier choices. She is condemned to sickness, pain, misery, and a premature death.
This fatalistic and callous attitude is easy to develop, and even glamorized on many TV shows. It shields doctors, nurses, and other care associates from accepting the responsibility that they can have a meaningful impact on their patients’ spirit.
For patients like Ms. Smith, one kind word, one hug, one truly genuine motivational interview, or one more minute spent thinking of a creative solution, can mean the difference between life, and an imperceptibly slow death. Yes, obviously, many patients like her will never improve beyond a cheap simulacrum of health. However, many others can only find their way through the darkness of their broken spirit because of the kindness of their health team, family, and friends.
Outside, my window frames the starless black of an Ohio winter night. Were it not for the Christmas lights adorning some homes, nothing would be visible. In my house, as a Jew, I’ve lit a menorah, accomplishing the same effect: Banishing a great deal of darkness with a little light.
Jacob Chevlen is a medical student.
Image credit: Shutterstock.com