Each Thursday, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.
This week, Katrina Austria, MD, a second-year resident at the Family Health Center of Worcester, writes a wonderful piece based on a few encounters with different patients, all who share the same mark—a scar. While the skin wounds may appear similar, each story behind the scarring is very different. Katrina shows how simply asking about these superficial marks can lead to a profound change in the patient-doctor relationship. –Hugh Silk, MD
April, it seems, was a month filled with scars. As a physician, you're trained to identify and describe scars in an attempt to determine how they happened. As a family medicine physician, you're trained to ask "Can you tell me about that scar?"
FT is a patient I had met this past fall through a few acute visits for vertigo. She is this eccentric Nicaraguan woman with meticulously applied makeup that matched her trendy outfits. She had asked me to be her PCP and I gladly accepted. She came back for a physical in mid-April. We talked about her past medical history, social background and other concerns she had about her health. Other than lingering vertigo symptoms and concerns about hot flashes, FT said she felt great.
During the physical exam, I noticed a raised branch-like flesh colored scar on her right wrist and palm. I became concerned about a history of self-mutilation or suicide attempts and visions quickly swirled in my mind.
"How did you get this scar? It looks painful."
FT smiled. "I was working on the 4th floor of a building back home in Nicaragua. On the day of the earthquake in the 1980s, the 6th and 5th floors crashed down, and my hand was sandwiched in between the walls." She showed me her index finger, which appeared slightly narrowed and deformed. "My finger was hurt, but it's ok. It's better now."
CH is a warm-hearted Malawian woman (I inherited from another resident) who had hypertension secondary to hyperaldosteronism. She never had any children, and adopted me as her "daughter." "Tell your mother that you have a black mother here in Worcester!" We shared the same frustrations of not being understood by Americans, even though we were taught and spoke proper English, albeit draped by an accent of our mother tongues.
Her sweet face is marred by linear dark scars on her cheeks.
"Tell me about these scars, CH."
"Oh, this?" She touched her scar. "When I was only months old, I took sick. My grandmother was a healer, and she made this cut. She rubbed some herbs in it to heal me, and now I am here, alive. Everyone in Africa has these scars."
GL is a Nigerian gentleman whom I first met during a team precepting session. He was scheduled for a complex appointment. A review of his chart revealed that he was recently diagnosed HIV positive and arrived in America last year. I entered the room and was met with a very fit looking man who extended his hand towards me. "I'm sorry that I'm late. I had to take care of my insurance and was directed to many different people."
We began to talk about the events that led him to America. GL was a paramedical provider in Nigeria. He had contracted HIV and had a positive test back home, but he "did not dare pursue treatment because [he] would get killed." His partner was murdered when it was revealed that he was gay. GL had to leave his family behind as well.
GL complained about polyuria and nocturia for the past month and was very concerned about his recent blood tests. He and I reviewed lab work that was drawn during a previous visit with the HIV clinic. His fasting glucose was in the high 200's but his HBA1c was under 6.5. I gently explained to him that given his blood test and his symptoms, it appears that he has diabetes. GL lowered his head and began to cry.
"I cannot have diabetes. This is terrible. HIV and diabetes together is terrible. I have seen men in my country with diabetes who had their feet and legs amputated. I just cannot have this disease."
Scars come in different shapes, sizes and reveal different places of hurt. I have met patients with physical scars that recall a traumatic event or remind us of a moment of nurture, and emotional scars that evoke the deepest hurt that no one should suffer. Regardless of how the scars were inflicted, the greatest reminder is that they are a sign of survival. I appeal to you to continue to ask your patients about their scars, and you will get stories about people fighting the good fight.