Normal-people problems

We're not supposed to pick favorites among our patients, but I have one. We'll call her Brenda.

Brenda heard about our clinic through a friend of hers, a guy she used to smoke crack with. She'd been off drugs and booze for almost a year when she came to see me. Now that she was sober, she said, she realized she had "normal-people problems"--joint pain, high blood pressure, obesity--and needed a normal-person doctor. She had anything but a normal-person mouth, however, and from the moment I met her, said anything she wanted to, any time she wanted. She never held back the many, many things that most people think but never actually say to their doctors, and it is for this reason that she quickly became of my favorite patients in the practice.

From her first visit at the start of my intern year, I adored Brenda, but feared her illness. Addiction is a formidable foe that I didn't know very well, and I'd always felt that what I could personally bring to a patient's struggle with addiction would be woefully inadequate. Still, my affection for Brenda only increased as I got to know her beyond her mouth. All of her brashness couldn't hide her almost childlike generosity, nor her pain from the losses she'd sustained, nor the depths of her self-hatred.

She'd like herself a lot better, she said, if she weren't such a fat cow. She is a big lady, a finger's breadth shy of 6 feet and bulky in places where it is unpopular to be bulky. After our first conversation about diet, she stood up to leave, and grinning broadly, told me to go fuck myself. "I'm going to go get a doughnut. See you in a month." Despite her frustration with my advice, she made some positive changes. But her weight stayed the same, and her frustration grew. Being fat was one of her greatest sources of concern, alongside the instability of her employment, her living situation, and her family dynamic.

At a clinic visit a few weeks ago, Brenda burst into tears the moment I walked into the room. Nothing was right, she sobbed. She'd put on two pounds; she didn't have enough money to do laundry or buy food; she was on the verge of being evicted; and she was less certain than ever that a new job would come through.

Then came the most worrisome admission of all: "I had a beer last night, and it felt great."

In that moment, I realized that what used to scare me about addiction was my mistaken assumption that a patient's success at beating it hinged on my abilities as a clinician. A year wiser and a few addicted patients later, I now know that it's not always the medical model--or even the medical resident--that does the healing.

I spent ten minutes more with Brenda, most of it reassuring her that I was still proud of her for making some healthy choices. I also told her that I was worried about her drinking, and that I wanted to find some better solutions to her feelings of desperation. I then went straight to our clinic's social worker. Within an hour, Brenda had a box full of used clothing, an emergency food supply, and an appointment to come back the following week.

When I saw her at her follow-up appointment, Brenda said we had shown her exactly what I'd hoped we would: that we thought she deserved a shot at success. And although the verbal support was nice, the tangible evidence of it was what had fed her and clothed her. It is also, I suspect, what decelerated her slide toward a relapse.

If Brenda is able to stay clean, it won't be because of my clinical judgment, or my medical knowledge, or really, anything I did at all. Although I practiced very little medicine during her clinic visit, the course of her disease might still have been changed.

I was right about addiction: there's no way I could treat it on my own.