A fictional column. All patients are composites. This is reflection, not medical advice. Full disclaimer at the end.
Tuesday. 8:39 AM. Clinic was supposed to start at 8.
The patient is a man in his sixties. He has been on the same small pill for nine years. He has come, today, to tell me that he does not believe in it.
He does not say so straight away. He arrives in the chair the way men of a certain age arrive in chairs, which is, by their own description, slowly. He places a folded piece of paper on the desk between us. It is, I see, the printed information leaflet that came inside the medication box.
"I’ve been reading."
"Yes."
"It says here." He points to a paragraph. "It says here it can cause everything."
I look at the leaflet. The leaflet does, in the legal sense, say it can cause everything. The leaflet for water would, if water were a medication, say similar.
I do not say this. I have, over the years, come to understand that the leaflet has a kind of authority that no doctor sitting across the desk can match. The leaflet is paper. The leaflet was in the box. The leaflet has, by implication, been written by people who know.
"Which symptom worries you most?"
He pauses. He turns the leaflet over. He folds it back to its original shape, which I notice is precise, as though he has folded it many times.
"I don’t have any symptoms."
"You don’t have any of the symptoms in the leaflet."
"No."
"You’ve been on the medication for nine years."
"Yes."
"And no symptoms."
"No."
I sit. I drink the coffee, which is, by now, warm in the way coffee is warm when no one has been watching it. He waits. He is a polite man. He has prepared this conversation in his living room and is now, in the actual room, going through the prepared version of it.
We talk for twenty minutes. He has read, on a website his nephew sent him, that the pill is, in some quiet way, doing harm he cannot yet feel. The nephew is a kind man with a marketing degree. The website is run by people who sell other pills. I do not say this either. I draw, instead, a small diagram of the body part the pill is helping. I draw a slow process. I draw an arrow.
He looks at the arrow.
He says, "So if I stop it."
"If you stop it, the arrow goes the wrong way."
"How wrong."
"Wrong enough that, in a few years, you would come back."
He folds the leaflet. He puts it in his shirt pocket. He stands. He says, "I’ll think about it."
I write the follow-up for eight weeks. I write, in the margin of the chart, a small note for myself. The note says, patient still on medication, for now. I do not know, yet, if the for now is hopeful or sad.
11:21 AM. A woman in her forties, on three medications. She has come to ask if she can stop one of them.
"Which one."
"The small one."
The small one is the one most likely to be quietly keeping her alive.
"Why that one?"
"It’s the one I forget."
I sit with this for a moment. The answer is honest. The medication that is easiest to forget is, almost always, the medication that has decided to do its work without making a fuss. The medication that asks for nothing is the one she has noticed least, and the one she has come to think she does not need.
We talk about the small one. I tell her what it is doing. I tell her what would, slowly, change if it were gone. She listens. She does not, I think, fully believe me. She believes, instead, in the version of herself who feels fine, and who is told, by that feeling, that everything is fine.
I do not stop the small one. I make it the easiest of the three to take. I move it to the morning. I write the new schedule on a card. I hand her the card.
She looks at it.
She says, "It’s still three."
"Yes."
"I just wanted it to be two."
"I know."
She puts the card in her bag. She does not put it carefully. She puts it the way you put a thing you suspect you will lose.
At 1 PM I do not eat. I think about the man who does not believe in his medication, and the woman who would prefer to take less of hers. They are, in their own ways, the same patient. They have, each of them, decided that the version of their life that includes the pill is a slightly smaller version. They would like the larger one back.
I think about the leaflet, folded in his shirt pocket, and the card, somewhere in the bottom of her bag. Both are, today, doing their work. Tomorrow is harder to know.
The coffee is cold. The afternoon clinic begins at 2.
Disclaimer
Doctor’s Diary is a work of fiction. All patients, conversations, clinical findings, laboratory values, treatment decisions, and outcomes described in this column are invented composites. They do not depict any real individual, living or deceased. Any resemblance to a specific person, encounter, or institution is coincidental and unintended.
This column is published for reflection and literary purposes only. It is not, and is not intended to be, medical advice, a clinical opinion, a diagnosis, a treatment recommendation, or a substitute for professional medical evaluation, examination, or care. Nothing in this column establishes a doctor-patient relationship between the author and any reader.
Do not start, stop, change, or interpret any medication, test, diet, lifestyle measure, or clinical management on the basis of anything written here. If you have a clinical concern, consult a qualified healthcare professional in person. In an emergency, contact your local emergency services immediately.
The author writes anonymously. The views expressed are personal literary reflections and are not official guidance from any institution, regulatory body, hospital, university, professional society, or government agency. Information may not reflect the most current medical consensus, guidelines, or evidence and is provided "as is" without warranty of accuracy, completeness, or fitness for any particular purpose.
The author, Hormone Insight, and its operators accept no liability for any action taken, or not taken, on the basis of content published in this column. By reading this column you acknowledge and accept these terms.