Note: Certain details in this entry have been omitted or changed to protect the identity of those involved.
During my pediatrics rotation, the thing that many students grew tired of was performing well checks. It's a short visit during which we measure height and weight, inquire about any past illnesses or active symptoms, assess milestones and healthy development, and provide guidance on measures for safety — like wearing seatbelts, drinking milk, or locking away guns at home.
Intellectually, the well check was a quick exercise. Once we got a sense for the range of normal childhood growth, the expected markers of verbal, social, and motor development, and the signs and symptoms of puberty, the rest was a process in applying common knowledge. Here there were no diagnostic mysteries, no evidence-based prognosticating, no clinical exams where the purpose was to unearth a subtle finding. The goal was to be thorough, quick, and uniform. However, the stellar clinicians who mentored me quickly proved that the well check was a prime opportunity for connection, counseling, and change.
One memorable experience in a pediatric clinic involved a thirteen year-old and her mother. The girl was from a family of Christian faith; her mother had a warm, hearty laugh and seemed involved in her daughter’s life, unlike some of the other teenage patients who came to the clinic alone. We talked about grades (hers were excellent) and extracurricular activities (choir, model UN, and track team).
I listened to her heart and lungs, looked under her eyelids, felt for any lumps in her neck, palpated her abdomen, and spent some time examining her knees which hurt after long runs. Then, despite one eye on the ticking clock, I did what I do with all adolescent patients: politely asked her mother to step out, so I could examine and speak with her alone.
After her mother left, I talked about puberty and asked her if she had any questions. She was shy, and said she had none. I inquired gently about other social situations, as I had watched my mentors do. Does she have friends she can count on? Have her friends started being more interested in dating? Do other students drink alcohol or do other drugs at parties? Is she interested in, or has she tried, any of those things? She admitted that the dynamics have changed a bit in high school, but that she has not been in situations where she felt pressured to do anything.
Wondering where to go next in the conversation, I slowly asked her about her own romantic interests. “Do you think you might like boys, or girls, or both?” It is a clinical question that always looks silly on paper—“Men, women, or both?”—as if the spectrum of experience can be reduced to a multiple choice question: a), b), or c) both and b. But when asked non-judgmentally, it is sometimes the most open-ended way to normalize sexual preferences in a heteronormative world, and it can be a starting point to discuss the nuances of identity, orientation, and desire.
This is when she mumbled to me, “Both.” I told her, “OK, have you shared this with anyone before?” She said no, not even her friends. Then she expressed that this is something she is afraid of, and even quite stressed out about. I tried to support her, saying that what she is feeling is not wrong and that it is completely normal and healthy to be attracted to people of the same sex or the opposite sex, despite what society sometimes tells us. She agreed with me.
“I know that, that’s not the problem. It’s my mother. My family is very religious. We go to church all the time. My pastor talks about how homosexuality is wrong. I’m afraid that if my parents found out about this, it would ruin my relationship with them. When I think about this, I feel worried and sick to my stomach.”
At this moment it clicked for me. Sure, on a quantitative level my patient was well: Her body-mass index was appropriate, her physical exam was normal, her development was in line with her age. But in this particular facet of her life, she was not all well. I certainly didn’t solve all of her problems. But I gave her a safe place where she could talk about them, reassured her that anything she told me would remain between only us — unless, of course, she was in imminent danger of harming herself or someone else.
A well check, then, is an opportunity to think broadly about what it means to be well. Sometimes the things that wear us down are physical — lack of nutrition or too much of the wrong kind; diseases we inherit or that are triggered by our environment. Often they are social — economic disparities that manifest in differential education, employment opportunities, or access to healthcare. Frequently they are emotional or psychological — exploring one’s identity, feeling at odds with one’s family or culture, feeling sad or anxious, feeling conflicted by competing priorities.
Another patient in the same clinic, a six-year-old girl, described during her well check that she had frequent nosebleeds. A routine problem, caused by allergies, easily fixed by an antihistamine and training on how to curtail the bleeds. But when I spoke with her after the exam about what worried her, she expressed a fear of dying — a little girl in a dotted dress, with an uneasy awareness of her own mortality. Only when she articulated the fear could I reassure why nosebleeds were ultimately harmless, and that even if she had one again she was at no risk of death.
To promote wellness is to use the clinic visit to find the kernel that disrupts wellness for a particular patient at a particular point in time. Finding this thing —sometimes buried, sometimes strikingly apparent on the surface — allows for partnership, and leads to opportunities for connection, change, and healing.
Illness, and wellness, are not a what but a why, a how. The currency of wellness is not numbers but questions, thoughts, doubts, and fears. In a world of increasingly quantified and personalized medicine, we must also remember to measure wellness beyond increments of measurement, to ask our youngest and oldest patients what makes them happy, or sad, or content, or stressed. To explore why or how a person achieves wellness is a key art of medicine.
Stanford Medicine Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the Stanford Medicine Unplugged category.
Amrapali Maitra is a sixth-year MD/PhD student at Stanford studying medical anthropology. This academic year she is based in Kolkata, India, conducting dissertation research on women’s health, poverty, and gender-based violence. She is a 2013 Paul and Daisy Soros Fellow.
Photo by jasleen_kauer
