part0013

Dr. Parvinder caught himself sighing as he walked slowly down to the clinic. He remembered hearing someplace about “heartsink„ patients – the patients whose names made your heart sink as soon as you saw them on your appointment list. Although he had met her only once, this described his reaction to Mrs. Gregor perfectly.

Dr. Parvinder’s only previous meeting with Mrs. Gregor was six months earlier – when, like now, he was covering for her usual physician. It was an appointment he remembered clearly. Hers was a memorable story. Five years earlier, at the age of 69, she had been diagnosed with breast cancer. Following a lumpectomy, it was recommended that she undergo adjuvant radiation or chemotherapy. The idea of these cancer therapies terrified her, and she decided against them, holding onto the thin hope that surgery alone had been curative. Eighteen months later, she developed back pain. Eighteen more months passed before she mentioned this to her physician. The X-rays seemed like a formality. The foreshadowing was too strong: metastatic breast cancer. There would, of course, be no chemotherapy.

Since then, she has been haunted by a never-ending combination of symptoms that, for her, were deeply intertwined. Pain. Nausea. Difficulty swallowing. Fatigue. All of these symptoms fluctuating constantly and unpredictably. None responding more than marginally to anything her doctors offered. And all wrapped up in several layers of the anxiety and depression that had plagued her since the birth of her second daughter nearly five decades ago.

All of this ran through Dr. Parvinder’s mind as he flipped through her chart before entering the room. Perusing his colleague’s recent notes, it was apparent that little had changed since their first encounter. A recent CT scan showed stable disease. Medications for pain and nausea had been adjusted up, then down, then up again. He was disappointed, though not surprised, to read that she had not followed through with the psychiatry referral that he had made for her six months ago. He knew that today’s appointment would not be short, and it would not change anything.

He put on a gentle smile and entered the room. Mrs. Gregor mumbled hello, but did not meet his gaze. She behaved as though she were trying to avoid disturbing the air. Dr. Parvinder was relieved that she did not look acutely ill. In fact, she looked no different than she had half a year ago. Mr. Gregor, a retired military officer, rose and shook Dr. Parvinder’s hand firmly. He was a faithful companion at each of her appointments.

The three settled into familiar roles, with Dr. Parvinder listening attentively as Mrs. Gregor described her symptoms and Mr. Gregor occasionally interjecting with his observations. When Mrs. Gregor commented on how difficult she was finding it to cope with everything, Dr. Parvinder took the opportunity to ask about the psychiatry referral. For the first time that afternoon, Mrs. Gregor did not reply. After a pause, her husband responded on her behalf, and said in a surprisingly frosty tone, “Let’s just assume everything from the neck up is taken care of, okay?„ Dr. Parvinder, understanding that there would be no common ground on that issue today, moved on to another topic. He feared that he was implicitly endorsing a destructively false mind/body dichotomy by asking about her pain without discussing her suffering, but what could he do? His colleague’s notes made it plain that she shared the same frustration: everything from the neck up was clearly not taken care of, and hadn’t been for a long time.

During his initial visit with Mrs. Gregor, she told him about when she last felt well. It had been 10 years ago, when she was given a combination of antidepressant medications by a “psychiatrist who made me laugh.„ Then they moved. First to a new city for her husband’s work, then across the country to where her younger daughter lives, and then to yet another city where her eldest daughter lives. The same medications prescribed by other doctors never seemed to do the trick.

Her support system was quite thin. As a military family, they had always moved often, and that pattern evidently continued into retirement. She had acquaintances all over the country, but no close friends. Her daughters were supportive but had families of their own. Her husband was her stalwart, but he openly acknowledged his frustration at the intractable nature of her suffering and the toll that this was taking on him. In fact, Dr. Parvinder was somewhat taken aback by Mr. Gregor’s frank tone. “Dr. Parvinder, I can’t tell you what a strain all of this has been on me. I’m sick of it all. I love my wife dearly, but there are days when I really feel at the end of my rope!„

Almost an hour later, Dr. Parvinder walked out of the examining room. He had assessed each of her symptoms in detail, asking her questions she had answered literally a thousand times before. They had reviewed options – more tests, new medications, more of the old medications. Mrs. Gregor didn’t hold much optimism for any of these, and frankly neither did Dr. Parvinder. In the end, Mrs. Gregor said she preferred to leave everything unchanged.

She’s stuck, thought Dr. Parvinder as he scribbled a note in the chart. She has moved many times, but she’s been stuck for 50 years .

Then he changed his mind. No, not stuck. Stuck implies an attempt to move that is externally constrained. Mrs. Gregor isn’t attempting to move or change. If anything, she seemed to be trying not to. “ She isn’t stuck, „ thought Dr. Parvinder, “ she’s frozen. I wish I could have helped her to begin to unfreeze.„

Mrs. Gregor was still on his mind as Dr. Parvinder climbed into bed that night. “ Perhaps ,„ he thought, “ there are worse things in life than being frozen .„ She may be frozen, but she was managing. In 50 years of anxiety and depression, she had found a way to survive, raise two girls, hold her marriage together, and now, on top of everything else, live with cancer. That was more than many could say. Her coping was clearly fragile, and perhaps she simply understood that choosing to “fight„ her cancer would have overwhelmed her hard-won equilibrium.

“I have my struggles, but I’m still here and I’m still me.„ Maybe that, at the end of it all, was her message. She never gave the impression that she was expecting him to fix things. Maybe she just needed Dr. Parvinder to echo the message back to her: you are in tough straits, but you’re a survivor and will find a way to cope.