Last Friday, as I sat finishing up notes on the last of my almost 30 physicals (this number is never any surprise for us pediatricians this time of the year, it’s back to school week, so every Thomason, Dickinson, and Harrison is lining up for sports physicals and regular physicals and all sorts of clearance and medication forms that need to be filled out and turned in “yesterday.”) I took a deep breath and exhaled, my mind filled with the events of the day. As is customary, my beloved patients often postpone their physicals all summer, in search of sandy beaches and clear blue vacation skies, so it’s usually a mad rush the first week of school.
I found myself reflecting on the patients I had seen that day as I often do at the end of my day. Most of them were mundane well-baby and well-child checkups, nothing really of note, a few of them had minor issues to clear up before returning to play … but one of them stood out clearly like a lily in a field of carnations … a 16-year-old we shall call “Maya.” I have met Maya only a couple of times in the past, and I have known her to be a troubled teen, plagued with depression and anguish, never really smiling, not much eye contact, not much of an effect — just sad. I have tried to manage her depression the best I can with counseling in the office and referral for proper psychotherapy. My good friend and child psychiatrist sees her regularly and has placed her on an appropriate dose of antidepressants. And she reportedly goes to counseling regularly, all with little or no change in her mood.
She came in that day in the company of her mother and her older 17-year-old sister. I sensed something wrong right away, but I continued my usual intros and salutations. Her mom could not stop fidgeting, with the characteristic continuous knee shaking. Her sister’s face was buried in her mobile device for pretty much the duration of the visit, except when I inquired about her. It turned out her sister was also to be seen that day.
Both mother and child proceeded to explain to me that her sister needed to be seen for “stomach problems” that only happen at her high school, stemming from her “unique eating habits,” and her lunchtime not being fixed at a particular time of the school day. This apparently never happens at home or during the holidays or vacation, when she reportedly “has her own eating schedule.” She wanted a note from me to the school nurse authorizing her to eat her lunch at the exact time she wanted, or she would develop abdominal cramps, nausea, and headaches and “get so sick” she would end up being sent home from school. This storyline and request struck me as bizarre, I recognized a familiar thread of possible anxiety in her sister, and maybe some codependency in her mom, but I digress.
Maya, on the other hand, wore a thick black sweatshirt and jogging pants. Mind you, it is 105 degrees outdoors in San Antonio in July!
I somehow am a magnet for depressed and suicidal teens, and Maya was no different. She made absolutely no attempt to engage with me, no eye contact, shoulders drooped over, melancholic and flat affected. She appeared pale, ashen and sullen with dark circles around her eyes; she simply looked like she could use a long-warm-heart-filled-hug. During the physical exam, she hesitated to take off her sweatshirt, but I insisted, eventually, her mother ordered her to do so. She did so very reluctantly and immediately pronated both forearms. I gently supinated them, and to my horror, it revealed numerous, clearly visible, freshly carved cuts all over her forearms, extending from her wrists all the way to her elbows, on her left and right forearms respectively. I said nothing, gently turned them back to her preferred position, completed her examination, and walked back to my seat.
I then calmly asked her mom about Maya’s depression, and how her cutting behavior was fairing. She hurriedly replied, “Oh, a lot better, she is receiving counseling, and has not cut in two years.” Two years!? I thought to myself, more like two days. Her response immediately made me stop typing on my laptop EMR, I looked up at her, made sure my words came out clearly and as gently as my rapidly beating heart could muster, as I said, “No ma’am, I am afraid, but I have to tell you that Maya has fresh cuts on her forearms and wrists, that are probably not more than two days old.”
The rest of the visit was a bit awkward. Her mom asked to see the cuts, Maya vehemently refused, and an uneasy silence set in after I explained to mom that, she would probably do better waiting until they got home to approach her alone in her bedroom. Meanwhile, we should probably revisit her counseling sessions, and explore the possibility of an in-house facility if possible, especially since her self-completed PHQ-9 score that day was a total of zero.
I write this story today to remind myself of my “why.” To urge each one of us doctors to remember our “why.” Never lose sight of the reason you went into medicine, no matter what. We are a special breed, a unique set of like-minded individuals who choose service to humanity above all. We choose to make a difference in our patients’ lives regardless of all the administrative, legislative, personal and sometimes insurmountable difficulties we face daily in the field. I was reminded that day of my reason for leaving my beloved 9 to 5 job to follow a passion of fighting to end teen depression and teen suicide. I was reminded to follow my heart and believe in my dream. I was reminded to stay the course, because, for every Maya in my office, there are a hundred or even a thousand more out there, so, I must go forth.
“The harvest is plenty, the laborers, few …”
– Luke 10:2.
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