The Doorknob

 

 “And oh, um, I feel like I’ve been gaining weight,” I said hesitantly.  The doctor was about to exit, her hand on the doorknob, “But it’s just in my belly.”  

After the usual questions and admonitions, a brief listen to my heart and lungs, a feel of my neck, and orders for a few screening labs, my annual physical was nearly over.

 “Well, if you’re not pregnant, your metabolism may be slowing down with age – that can happen in your mid-twenties,” she answered, slightly exasperated, “So just up the exercise to 30 minutes a day and watch your diet – cut out alcohol and fatty foods.”

She advised follow-up in a few months and left the room.

I was puzzled, since my recent move into the city for graduate school allowed me to eat better and be more active.  I felt healthier than ever.  But she’d expressed the plan with such certainty – I felt awkward contesting it.  And we were out of time.  So I changed back into my clothes, walked to the local market for a kale smoothie and signed up for a yoga class.

I didn’t know it at the time, but I had just unwittingly uttered what doctors call the “doorknob complaint” – a new problem brought up at the last moment of an appointment.  My expanding waistline was somewhat embarrassing, and quite unexpected. I was unsure of its significance and wondered if I should have brought it up.  One can have all sorts of pangs and lumps and slight uneases that the doctor quickly assures are nothing dangerous.  I didn’t yet have the training to know whether to worry.  

Now, after treating thousands of my own patients, I understand my doctor’s frustration.  Doctors are trained to think logically.  We learn how to eliminate diagnostic possibilities in a methodic and sequential way.  Most of us appreciate order, control, a smooth flow.  When patients have multiple concerns, we are taught to help manage their expectations, prioritize complaints and see them over multiple short visits.

However people, and their illnesses, are rarely so neatly packaged.  Their doorknob complaints can frustrate us.  They counteract our forward motion, prolonging an appointment, inhibiting the patient-every-15-minutes speed often dictated by hospital administrators and insurance companies.    

With the next patient waiting in the neighboring exam room, it’s tempting to dismiss or defer, to assume a fairly simple symptom – gaining weight or occasional headaches or not sleeping well – has a straightforward cause.  We hear in medical school –  “common things are common” and “when you hear hoofbeats think horses, not zebras, unless you’re in Africa.”  We can rely on the common instead of searching for the unusual, especially when time is constrained.

Later that year I returned to my doctor’s office; I needed a physical for a new job.  Busy with graduate school midterms, I pleaded with the receptionist to just give me a form.

“Sorry – it’s been nearly 6 months since your physical so you need to be seen – it’s policy,” she insisted.

So I sat, chilly in my underwear and oversized gown, waiting for the physician’s assistant.  I thought again about my abdomen; after a shower recently, its reflection in the bathroom mirror had an asymmetry – the left side protruding more than the right.  I decided to bring up this oddity just after the physician assistant came in.  

“Hmmm, well let’s take a look,” he said.          

He began pushing gently, starting right of my belly button, moving leftward, then stopping abruptly.  The change in his expression was sudden – from relaxed concentration to slight awe, then to definite concern.  He suddenly left me, lying on the exam table, bare belly exposed.  He returned with two doctors, who pressed in the same areas, resulting in the same faces of restrained unease.  

Despite it being 5 pm on a Friday, they sent me straight to the CT scanner.  I sensed an urgency, but was given little explanation – just concern for a “mass.”  I was familiar with the mass in physics – masses falling and resisting and attracting.  I knew my body already had mass, but had no idea what this particular mass could be. I did not yet know that in medicine, “mass” almost always means cancer.  

The scan showed a tumor huge and unwieldy, just larger than a football, one that had pushed nearly all of my left-side organs to the right.  It was a one-in-a-million cancer, a liposarcoma, a tumor made up of fat cells gone awry.  There was no way diet and exercise would help; this fat was malignant.

The mass upended my life’s schedule.  Time was suddenly distorted, feeling limited and circumscribed, while also agonizingly drawn out.  The mass suspended my life’s laws of physics. It decoupled cause and effect. It shattered my trust in my own body.  

I wondered if it could have been found sooner.  I’d asked the doctor about my weird weight gain months before; did my concern inconveniently interrupt the flow of her busy day?  Was she distracted?  Why did she assume rather than investigate?  But most weight gain isn’t the result of a huge tumor; her assumptions may have been reasonable.  But why was her exam incomplete?  And even if she had felt my belly then, would she have found the mass?  Was it already there and overlooked, or, as a cancer known for being insidious and slow-growing, would it have escaped undetected?  If it had been found early, would there be any difference?  Would that have prevented my tumor from recurring?

A life in medicine thus far has shown me that in the end, there is only so much one can control.  Doctors and patients are fallible.  We can be tired, overscheduled, irked by disorder, biased by experience, lulled by pattern.  We can tire of the messiness of illness.  We can become frustrated when life is not able to be packaged up with tidy bows.  We can be disappointed when time is not ours to control.  

The relentless volume of the ER or the clinic develops its own momentum.  We rush at a constant velocity, resisting any change in our forward movement.  But when a patient exerts a force – the unexpected and often inconvenient doorknob complaint  – we are wise to accept this change in momentum.  By its nature, revealed late and requiring effort to disclose, it unmasks a patient’s deeper concerns – their confusion, embarrassment, anxiety, misunderstanding or outright fear.  This is why, despite our hand on the doorknob, such moments require attention, respect and investigation.

I have since asked myself, am I the patient who speaks up?  Who advocates for myself?  Who views a doctor’s misstep with a forgiving lens? Am a doctor who pauses, thinks thoughtfully, listens actively?  Can I resist the culture put upon us by a system that often prioritizes productivity over health?  The one who treats people with all their imperfections instead of numbers and diagnostic codes?  Such self-inquiry helps me to take a pause, ask another question and lay on a hand, with the hope of finding someone else’s tumor early.

 

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5 Comments

  1. Dear Dr. Julia,

    The “doorknob” was an amazing piece of work. I was truly moved by your personal story, as well as your perceptions about how medical care is delivered.
    I too have been a frequent flyer- with two autologous stem cell transplants under my belt, and I am currently undergoing OP chemo therapy. I have noted missteps along the way.

    I wish you well!

    Please keep writing, as I am inspired by your work. I would like to start journaling myself.

    Thanks again, for for sharing your gift with the rest of us.

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