Love Is Color-blind; Doctors, Not.

What a prim and proper image both husband and wife projected sitting across the desk from me: she, a tiny woman with a silvery-white coiffure, every hair in place, and he, appearing twice her size, with tweed jacket, buttoned, starched shirt collar, and paisley print tie.  Though she was the patient, he did the talking after my introductory remark, “What can I do for you?”

“Priscilla has been having dizzy spells.  Can you give her something to stop them?” 

“Hold on!  I need first to obtain much more information from Priscilla and then examine her before coming to a correct diagnosis.  It may be that I will need to carry out blood tests and a battery of other procedures before confirming a diagnosis.”

“Her problem is really simple.  She’s just nervous and needs something to calm her down.”

“If that is the case, (I looked at Priscilla) why did your doctor send you to me?”

Again her husband answered.  “He really wanted to send her to a cardiologist at the University but I asked for you.  I know that you Jewish doctors are usually the best.  Give Priscilla some pills and if they don’t work, then we’ll see.” 

My initial discomfort at first meeting this couple was vindicated.  He was an arrogant racist, an abusive, tyrannical husband; she, a submissive wife without any apparent spark of discomfort with the scene that was unfolding.  Maintaining a professional bearing, I suggested that they go home and reconsider returning under my terms.  Feigning sincerity, I said I would be happy to see Priscilla again.  In the years to come I would grow to marvel at this remarkable lady.

Franklin, the husband, was indignant as he stood, pulling Priscilla’s arm. “There is no point in continuing the interview.  Doctor, if I owe you any money, please send me your bill.”  Not one word from Priscilla during the short encounter, though I noted that she sighed frequently, a tip-off that this could be the cause of her “dizzy spells.”

There was nothing in my years of training to suggest that I had the prerogative to select which patients I would treat and which I would not.  Any adult with a medical problem came within my purview. The only baby I delivered after my internship took place on the floor of the admitting office of our recently opened hospital.  Being the only doctor available at that moment, I had no choice.  With ten thumbs, I managed to keep out of the way of the exiting future president.  I did subsequently however, propose a routine of having all women in labor by-pass the admitting office and proceed directly to the obstetrical suite. 

Having been raised in a multi-ethnic town and having friends from many classes, nationalities, and religions, I seldom displayed a negative reaction when facing a patient for the first time.  This was in contrast to my first encounter with a Japanese roommate in 1944 at Harvard; I failed that time but hopefully never again. 

Take the alcoholic who sat disheveled, glassy-eyed, reeking of cheap gin, his fingers nicotine-stained.  He was referred to me because his doctor heard a heart murmur indicating a leaking valve.  Was I permitted to feel repelled?  Well, permitted or not, I was.  Managing a cursory examination while avoiding contact even with his clothes, I made a decision to admit him to the hospital where he would be bathed and clothed in freshly laundered hospital garb.  There he dried out without withdrawal events.  He turned out to be medically exciting, for his heart problem was due to vitamin B deficiency, called Beri-Beri.  I hadn’t seen a case since third-year medical school on the wards of Boston City Hospital.  More to the point, under the alcoholism lay a bright, inquisitive, sensitive human being.  If I had rejected him after an initial glance, I would have missed the thrill of managing a rarely seen illness, of rehabilitating a sinking soul (with the help of Alcoholics Anonymous), and of making a new friend.

Franklin and Priscilla fell into another category of problematic first encounters.  Their haughty demeanor, expressionless and humorless, evoked no special curiosity or interest on my part.  I would have had to work hard to construct a working rapport.  Accordingly I had to rebuke myself as this relationship failed so quickly.  Couldn’t I have used an approach different from one that resisted intimidation?   Couldn’t I have delved into some historical data, taken her pulse, and checked her blood pressure?  If the diagnosis were quickly apparent -- I did not doubt that over breathing was the basis of her symptoms --, I could have prescribed appropriate management, maybe made a friend and, again maybe, inspired Priscilla to return, hopefully without her husband.

It was a month later that Priscilla called me at home to request an urgent appointment.  “I want it to be at a time when no other patients are there, not even your nurse.”  I indicated that the absence of other patients could be arranged but my nurse would have to be in the office although not in the room with us. 

“But she used to work in an office near my husband.” 

“My nurse is bound to the same code of secrecy as I.  You can trust her.”   

“Then, at least, I don’t want her to see my chart.”

“That’s impossible.  She types my records.  I am afraid you will have to trust us.”

Priscilla relented.  An appointment was arranged for the next day after the usual working hours.  My nurse wasn’t happy but I was able to convince her to put on a professional face when Priscilla arrived.

We shook hands, that is, if touching the ends of the offered fingers can be called that.  In response to my “How are you?” Priscilla lost all composure.  She blotted her tears as fast as they descended her cheeks. 

“How am I?  I’m miserable.  I can’t take it anymore.  I’m terrified of my husband.  I don’t know what he would do if he knew I’d come to you on my own.”

“It doesn’t sound like much of a marriage.”

“Would you be appalled if I said, ‘he forces me to have sex’ after which he locks me into the bedroom until he returns from work?”  And when he’s not abusive in physical ways, he treats me like a puppet.  He makes every decision for me, what I do, where I go, whom I can see or not see.  He takes me shopping and picks out my clothes.  He does give me money for grocery shopping but otherwise he pays all the bills.  I can’t sign checks.  Our daughter hates her father and is fed up with my inability to pull myself loose from him.  She moved out, as far as she could get.  California.  I never see her.”

As this tirade of fear, frustration, and anger spewed from the apathetic woman I had seen on the initial visit, I was excited to find grounds on which we could now commence treatment.  I also knew that I was unqualified to embark on the psychotherapy she required.  Yet there was more I could do. Firstly I had to explore the urgency of her situation.  “Has he ever struck you?”

“No, not really.  He has pushed me around.  How many times I saw my father hit my mother!  So, early in my marriage I felt I was lucky; I had a husband who didn’t beat me.”

Next I asked about insomnia and constipation, symptoms that might suggest depression.  “No” to each of these.  And then I leaped in with the most confrontational of questions, “Have you ever contemplated suicide?”

Not once in my career has a patient responded in anger or chastised me for such an absurdity.  Priscilla’s response was the usual one.  She hesitated.  “To tell you the truth, maybe once or twice, never seriously.  The first time Franklin locked me in the bedroom, I thought that I could get even with him with the embarrassment of having his wife found in a pool of blood with her wrists slashed.  I didn’t have the nerve to do it.”  I was satisfied that I didn’t have to worry over that possibility.

I proceeded to take a lengthy medical history although with each question she kept trying to get back to her marriage.  As I delved more deeply into her dizziness, it was clear that light-headedness more accurately described her symptoms.  She nodded “yes” to each question regarding sighing, burping, not being able to get a deep enough breath, and periodic numbness and spasms in her hands.  She obviously had “hyperventilation syndrome.”

How could I ever miss that diagnosis, having suffered from it myself as I began my first days away from home entering medical school?  Unlike the idiot of a doctor who compounded my problem by ordering a skull x-ray, I finished a physical examination and quickly gave her my diagnosis.  Treatment of her symptom would be easy.  Once she was reassured that she didn’t have a brain tumor or high blood pressure, her fears abated.  She could elect to ignore the symptom or make efforts to breath more shallowly and refrain from sighing.  Furthermore, for the hand symptoms she could breath into a paper bag.  I was satisfied that this problem would dissipate and told her so.

“But, we have to attack the problem which caused this symptom.  It’s lucky for you that more disturbing psychoneurotic symptoms haven’t occurred.  I want you to consider having a psychiatric consultation with a colleague of mine.  In the meantime I will arrange a urinalysis and a few blood tests.  I’ll see you again next week.”  After Priscilla left, my nurse told me she paid in cash and rejected a receipt.  Without a checking account she had no other recourse.  Without a receipt she could deny that the visit ever took place. 

A week later, under the same private conditions, Priscilla entered the office.  There was such a difference in her appearance or was I just seeing the person I had missed during the first two visits?  Her hair, her dress were less severe and she actually offered me twice the amount of flesh I had noted with our initial handshake.

“Doctor, Franklin was right. You Jewish doctors are the best. (Her smile told me she was facetiously quoting her racist husband.)  I’ve stopped burping and I no longer carry a paper bag in my purse.”

I complimented her for having done her homework. After I Indicated that her laboratory studies were normal, I asked if she had noted any other differences. “Well, I’m less edgy.  Even Franklin commented on this. And as for your suggestion regarding my seeing a shrink, let’s hold off for a while.”

We spent the rest of this visit and two more discussing primarily her early rearing and her self-image. As we parted on her final visit she took my whole hand in hers and said, “You can’t appreciate what you’ve done for me. More than all our discussions and your medical advice, you listened to me. You didn’t criticize me or indicate that you found me a silly person. I now like myself better and you know what? Franklin likes me more. I even confessed that I had been seeing you. And you know his answer? ‘Maybe I should too’.” He never did.

All of this has been just the preamble to Priscilla’s story.  Four years later Priscilla was a widow.  Franklin had fallen from a very high crane and had died instantly.  Two months after this tragedy Priscilla asked to see me for a check-up.  Her sadness on losing Franklin was evident; they had become increasingly “good friends” in those intervening years. Now in her late fifties, she found herself quite alone. To her sorrow she discovered that her financial situation was bleak. Her meager savings and a widow’s social security were insufficient to maintain her sixty-year-old house. She sold it and rented a three-room apartment. At the same time she found a part-time job babysitting and during the Christmas holiday, work as a gift-wrapper in a department store.  Priscilla was uncomplaining.

She thought that she would benefit from pills for “depression.”  I was quite confident that, though she was sad, she was not depressed and reassured her that she was managing her grief well. 

Within another two years Priscilla moved to a low rental multi-racial senior citizens’ home, into a one and a half room efficiency apartment. This constituted a striking social comedown considering the lower-class residents and neighborhood. Yet she was quite cheerful now that she had financial security and could even afford to visit her daughter. I was proud of her, wondering how I would fare under similar circumstances. I verbalized this to Priscilla at which point she became the doctor, reassuring me that I would do what I had to do.

A few months later we met in the hospital where she was visiting a sick neighbor. We had a lovely chat in the cafeteria. I mentioned to her that a hospitalized patient of mine lived in her apartment house. It just so happened that this patient, a very dark-skinned African American, and I had become good friends in the course of his treatment for heart trouble. On almost every visit we ended up discussing local and national politics as well as race relations (this was during the racial unrest of the late 60s and early 70s.) He was a well-read, astute analyst of our times. I was shocked when Priscilla said, “Are you talking about Isaac Rose?”

“Why, yes, I am,” I said, trying to mask prejudicial thoughts.