Saturday, July 28, 2007

Beautiful and important - A brief patient encounter

Not the patient discussed below, but similar in age. (FYI: Heart sounded fine.)

The baby the mother carried in her arms was almost unrecognizable.

He had rolls of fat where once there were once skin-veiled ribs, plump cheeks where there had been cheek bones. He had a lardy tummy where once there had been a taut, protruding abdomen, an abdomen filled not with age-appropriate pudge but an oversized liver and spleen.

On does not require a healthcare background to know that the ribs of a baby should not protrude from the flesh around them. When they do, they are reminiscent of neglected, scavenging canines, drastic famine and chimney-topped concentration camps.

Any layperson will recognize that an infant without cheeks looks oddly aged. The concavities give the impression of a shrunken elder. The eyes sink tiredly into the sockets, as if completing life’s journey rather than just beginning.

When the sharp, defined angles of the infant skeleton are juxtaposed with a belly that looks and feels like a volleyball, the visual effect is grotesque. The proportions are similar to a miniaturized pregnant woman at term, the baby a crude caricature of his own recent birth.

The mother entering my exam room cradled the chubby, full-faced baby in her arms. Her face held the glowing, humane expression of a loving mother holding her beloved baby.

If a cosmetics company could manufacture and package that glow, it could name any price.

“How are things going?”, I asked the glowing woman.


Even before medical school, I learned the value of open-ended questions. They allow the person asked to answer without being limited by the intent of the question. In a way, it allows the person asked to choose a question, and then answer it.

In the doctor-patient encounter, potential answers to the question “how are things going?” include: “good”; “oh, not too good, doctor”; “it is very cold outside”; “my husband lost his job”; “the baby is too too sick”; “I don’t know”; “you tell me”; etc.

By far, the three most common answers are “I am fine”, “she is fine” and “he is fine.”

This is the benefit to asking open-ended questions when your HIV positive patients have been receiving appropriate antiretroviral therapy. The Baylor clinic has been open a year and a half now, and most all of our previously “too too sick” patients are quite “fine”, indeed.

Alternatives to open-ended questions are many, and include “Does the baby have fevers?”, “Your chart says you are just here for a refill. Is that correct?”, “Is there anything about the child that I should know?”

These questions hasten the visit, corners the parent into giving narrow responses, and ensures that the doctor will miss things, usually the important things.


“How are things going?” I asked the glowing woman.

This was her answer, in translation:

“Well, Doctor. Before, I did not want to bathe my child in the homestead because his skin was bad and his belly was sticking out. People did not like to look at him. They did not come near us.”

“Now I bathe the baby outside as much as I can. Everyone wants to come up and touch him. They want to tell me that he is beautiful.”



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