Fall 2016

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The Doorknob Complaint

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Julia Michie Bruckner ’02, a pediatrician and writer, lives in Boulder, Colo., with her husband and daughter. She blogs at juliamd.com.

Tell us what you think. E-mail comments or questions to the editors at letters@northwestern.edu.

Sometimes the last thing a patient mentions to a doctor at the end of an appointment is the most important one.

by Julia Michie Bruckner

“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, you’re not pregnant, so your metabolism may be slowing down with age — that can happen in your mid-20s,” she answered curtly. “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. My recent move to New York City to start a master’s degree 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 questioning 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 it was even worth mentioning. One can have all sorts of pangs and lumps and slight feelings of unease that the doctor quickly assures are nothing dangerous. I didn’t yet have the medical 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 methodically and sequentially. Most of us appreciate order, control, a smooth flow. When patients have multiple concerns, we are taught to 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 pace often dictated by hospital administrators and insurance companies.

He began pushing gently, starting to the 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.

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 come to 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 six 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 and thinking 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 to the 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 the time — 5 p.m. 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 mass from pre-med 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 the tumor have escaped undetected? If it had been found early, would there be any difference? Would that have prevented my tumor from recurring years later?

A life in medicine has shown me thus far that, in the end, there is only so much one can control. Both 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.

Too often 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 take heed. By its nature, revealed late and requiring effort to disclose, it unmasks a patient’s deeper concerns — his or her confusion, embarrassment, anxiety, misunderstanding or outright fear. This is why, despite our hand on the doorknob, such moments require respect, attention 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 I a doctor who pauses, thinks thoughtfully, listens actively — the one who treats people with all their imperfections instead of numbers and diagnostic codes? Can I resist a system that often prioritizes productivity over health? Such self-inquiry helps me to take a pause, to dig a bit deeper, to take my hand off the doorknob and listen to the patient.